Pi Nclex Module Review

Mental health
- is a state of emotional, psychological, and social wellness

evidenced by satisfying interpersonal relationships, effective behavior and
coping, positive self-concept, and emotional stability.
Factors:
 Autonomy and independence

 Maximization of one’s potential
 Tolerance of life’s uncertainties
 Self-esteem
 Mastery of the environment:
 Reality orientation
 Stress management
Mental Illness/Mental disorder - a clinically significant behavioral or

psychological syndrome or pattern that occurs in an individual and that is
associated with present distress (e.g., a painful symptom) or disability (i.e.,
impairment in one or more important areas of functioning) or with a
significantly increased risk of suffering death, pain, disability, or an important
loss of freedom – (American Psychiatric Nursing)
General characteristics:
 dissatisfaction with one’s characteristics, abilities, and accomplishments

 ineffective or non-satisfying relationships
 dissatisfaction with one’s place in the world
 ineffective coping with life events
 lack of personal growth
 Self-concept is distorted
 Perception of strengths and weaknesses is unrealistic.
 Thoughts and perceptions may not be reality-based

Mental Health Mental
Illness
The Diagnostic and Statistical Manual of Mental Disorders (4th Edition,

Text Revision; DSM-IV-TR)
 published by the American Psychiatric Association

 describes all mental disorders, outlining specific diagnostic criteria for
each based on clinical experience and research

Multi-axis Classification System
 Axis I is for identifying all major psychiatric disorders except mental

retardation and personality disorders. Examples include depression,
schizophrenia, anxiety, and substance-related disorders.
 Axis II is for reporting mental retardation and personality
disorders as well as prominent maladaptive personality features and
defense mechanisms.
 Axis III is for reporting current medical conditions that are potentially
relevant to understanding or managing the person’s mental disorder as
well as medical conditions that might contribute to understanding the
person
 Axis IV is for reporting psychosocial and environmental
problems that may affect the diagnosis, treatment, and prognosis of
mental disorders. Included are problems with primary support group,
social environment, education, occupation, housing, economics, access
to health care, and legal system.
 Axis V presents a Global Assessment of Functioning (GAF), which
rates the person’s overall psychological functioning on a scale of 0 to
100.
Type of Mental Health Admission
1. Voluntary admission
- The client (or the client’s guardian) seeks admission for care.
- The voluntary client is free to sign out of the hospital with physician
notification and prescription.
- Detaining a voluntary client against her or his will is termed false

imprisonment.
2. Involuntary admission
- Involuntary admission may be necessary when a person is mentally ill, is a

danger to self or others, or needs psychiatric treatment or physical care
- The client loses the right to refuse treatment when he or she poses an
immediate danger to self or others, requiring immediate action by the health
care team.
II. Communication
Therapeutic Communication
 Broad openings—allowing the client to take the initiative in introducing

the topic
“What would you like to work on today?”
“What is one of the best things that happened to you this week?”
 Giving recognition— acknowledging, indicating awareness
“I notice you are wearing a new dress. You look very nice.”
 Exploring—delving further into a subject or idea
“How does your girlfriend feel about your being to the hospital?”
“Tell me about what was happening at home just before you came in the
hospital?”
 Clarifying - To check whether understanding is accurate, or to better

understand, the nurse restates an unclear or ambiguous message to
clarify the sender’s meaning.
“I’m not sure I understand what you mean by ‘sicker than usual’, what is
different now?”

 Focusing—concentrating on a single point
“Could we continue talking about you and your dad right now?”
“This point seems worth looking at more closely.”
 Encouraging the formulation of a plan of action
“What do you think you can do the next time you feel that way?”
“How might you handle your anger in a non-threatening way?”
 Giving information— making available the facts that the client needs
“My name is . . .” “Visiting hours are . . .” “My purpose in being here is . . .”
 General leads—giving encouragement to continue
“Go on.” “And then?” “Tell me about it.”
 Making observations— verbalizing what the nurse perceives
“You appear tense.” “I notice that you’re biting your lip.”
 Reflecting—directing client actions, thoughts, and feelings back to

client
Client: “Do you think I should tell the doctor . . .?” Nurse: “Do you think you
should?”
Client: “My brother spends all my money and then has nerve to ask for more.”
Nurse: “This causes you to feel angry?”
 Restating—repeating the main idea expressed
Client: “I can’t sleep. I stay awake all night.” Nurse: “You have difficulty
sleeping.”
Client: “I’m really mad, I’m really upset.” Nurse: “You’re really mad and upset.”
 Suggesting collaboration— offering to share, to strive, to work with

the client for his or her benefit
“Perhaps you and I can discuss and discover the triggers for your anxiety.”
“Let’s go to your room, and I’ll help you find what you’re looking for.”
 Summarizing—organizing and summing up that which has gone before
“Have I got this straight?” “You’ve said that . . .”
“During the past hour, you and I have discussed . . .”
 Voicing doubt—expressing uncertainty about the reality of the client’s

perceptions
Client: Zombies inside me are eating my flesh”
Nurse: “Isn’t that unusual?”
“That’s hard to believe.”
Blocks to therapeutic Communication

 Advising—telling the client what to do
“Why don’t you . .”
“I think you should ..”
 Agreeing—indicating accord with the client
“That’s right.” “I agree.”
 Belittling feelings expressed—Misjudging the degree of the client’s

discomfort
Client: “I have nothing to live for . . . I wish I was dead.”
Nurse: “Everybody gets down in the dumps.” OR “I’ve felt that way myself.”
 Challenging—demanding proof from the client
“But how can you be President of the United States?”
“If you’re dead, why is your heart beating?”
 Defending—attempting to protect someone or something from verbal

attack
“This hospital has a fine reputation.”
“I’m sure your doctor has your best interests in mind.”
 Disagreeing—opposing the client’s ideas
“That’s wrong.” “I definitely disagree with . . .” “I don’t believe that.”
 Disapproving—denouncing the client’s behavior or ideas
“That’s bad.” “I’d rather you wouldn’t . . .”
 Giving approval— sanctioning the client’s behavior or ideas
“That’s good.” “I’m glad that . . .”

 Introducing an unrelated topic—changing the subject
Client: “I’d like to die.” Nurse: “Did you have visitors last evening?”
 Making stereotyped comments—offering meaningless clichés or trite

comments
“It’s for your own good.”
“Keep your chin up.”
 Probing—persistent questioning of the client
“Now tell me about this problem. You know I have to find out.”
“Tell me your psychiatric history.”
 Reassuring—indicating there is no reason for anxiety or other feelings

of discomfort
“I wouldn’t worry about that.”
“Everything will be all right.”
 Rejecting—refusing to consider or showing contempt for the client’s

ideas or behaviors
“Let’s not discuss . . .” “I don’t want to hear about . . .”
 Requesting an explanation— asking the client to provide reasons for

thoughts, feelings, behaviors, events
“Why do you think that?” “Why do you feel that way?”
III. Therapeutic Nurse-Client Relationship
A nurse-client interaction that focuses on client needs and is goal-specific,

theory-based, and open to supervision.

Components:
 TRUST and RESPECT

 GENUINE INTEREST
 EMPATHY
 ACCEPTANCE
Phases of a therapeutic nurse-client relationship
1. Pre-interaction phase
 The pre-interaction phase begins before the nurse’s first contact with
the client.
 The nurse’s task in the pre-interaction phase is to focus on his or her
own preconceived ideas, stereotypes, biases, and values that may
impinge on the nurse-client relationship.
2. Orientation or introductory phase
 Acceptance, trust, and boundaries are established.

 Expectations and the time frame of the relationship are identified
(establishing a contract).
 Client-centered goals are defined.
 Termination and separation of the relationship are discussed in
anticipation of the time-limited nature of the relationship.
3. Working phase
 Exploring, focusing on, and evaluating the client’s concerns and

problems occurs; an attitude of acceptance and active listening assists
the client to express thoughts and feelings.
 Encouraging independence in the client facilitates recovery and leads to
readiness for termination.
Client transference is the unconscious process of displacing feelings for
significant people in the past onto the nurse in the present relationship.
Counter-transference is the nurse’s emotional reaction to clients based on

feelings for significant people in the past.
4. Termination or separation phase
 Prepare the client for termination and separation on initial contact.

 Evaluate progress and achievement of goals.
 Identify responses related to termination and separation, such as anger,
distancing from the relationship, are turn of symptoms, and
dependency.
 Encourage the client to express feelings about termination.
 Identify the client’s strengths and anticipated needs for follow-up care.
 Refer the client to community resources and other support systems.
References:
Saunders Comprehensive Review for the NCLEX-RN Examination, LINDA

ANNE SILVESTRI, PhD, RN
Psychiatric Mental Health Nursing, Sheila L. Videbeck, PhD, RN
Basic Concepts of Psychiatric–Mental Health Nursing, Louise Rebraca

Shives, MSN, ARNP, CNS

Prepared by: Nurhaya Asuncion Moctal, USRN – International NCLEX
Educator
0020
Defense Mechanisms, Crisis Intervention, and Suicide
I. COPING AND DEFENSE MECHANISMS
1. Coping mechanisms
 Coping involves any effort to decrease anxiety.

 Coping mechanisms can be constructive or destructive, task-oriented in
relation to direct problem solving, or defense-oriented and regulating the
response to protect oneself.
2. Defense mechanisms
 As anxiety increases, the individual copes by using defense

mechanisms.
 A defense mechanism is a coping mechanism used in an effort to
protect the individual from feelings of anxiety; as anxiety increases and
becomes overwhelming, the individual copes by using defense
mechanisms to protect the ego and decrease anxiety
Types:
1. Compensation - over-achievement in one area to offset real or perceived

deficiencies in another area
 Napoleon complex: diminutive man becoming emperor • Nurse with low

self-esteem works double shifts so her supervisor will like her
2. Denial - Failure to acknowledge an unbearable condition; failure to admit

the reality of a situation, or how one enables the problem to continue
 Diabetic eating chocolate candy • Spending money freely when broke •
Waiting 3 days to seek help for severe abdominal pain
3. Displacement - Ventilation of intense feelings toward persons less

threatening than the one who aroused those feelings
 A person who is mad at the boss yells at his or her spouse. • A child
who is harassed by a bully at school mistreats a younger sibling.
4. Identification - Modeling actions and opinions of influential others while

searching for identity, or aspiring to reach a personal, social, or occupational
goal
 Nursing student becoming a critical care nurse because this is the

specialty of an instructor she admires.
5. Intellectualization - Separation of the emotions of a painful event or

situation from the facts involved; acknowledging the facts but not the emotions
 Person shows no emotional expression when discussing serious car

accident.
6. Introjection - Accepting another person’s attitudes, beliefs, and values as

one’s own
 A person who dislikes guns becomes an avid hunter, just like a best
friend.
7. Projection - Unconscious blaming of unacceptable inclinations or thoughts

on an external object
 Man who has thought about same-gender sexual relationship but never
had one, beats a man who is gay.
 A person with many prejudices loudly identifies others as bigots.
8. Rationalization - Excusing own behavior to avoid guilt, responsibility,

conflict, anxiety, or loss of self-respect • Student blames failure on teacher
being mean. • Man says he beats his wife because she doesn’t listen to him.
9. Reaction Formation - Acting the opposite of what one thinks or feels
 Woman who never wanted to have children becomes a super-mom. •

Person who despises the boss tells everyone what a great boss she is.
10. Regression - Moving back to a previous developmental stage in order to

feel safe or have needs met
 Five-year-old asks for a bottle when new baby brother is being fed.
 Man pouts like a four-year-old if he is not the center of his girlfriend’s
attention.
11. Repression - Excluding emotionally painful or anxiety-provoking thoughts

and feelings from conscious awareness
 Woman has no memory of the mugging she suffered yesterday. •

Woman has no memory before age 7 when she was removed from
abusive parents.
12. Sublimation - Substituting a socially acceptable activity for an impulse that

is unacceptable • Person who has quit smoking sucks on hard candy when
the urge to smoke arises. • Person goes for a 15-minute walk when tempted
to eat junk food.

13. Substitution - Replacing the desired gratification with one that is more
readily available • Woman who would like to have her own children opens a
day care center.
14. Undoing - Exhibiting acceptable behavior to make up for or negate

unacceptable behavior
 A person who cheats on a spouse brings the spouse a bouquet of

roses. • A man who is ruthless in business donates large amounts of
money to charity
II. Crisis Intervention and Suicide
Crisis is a temporary state of severe emotional disorganization caused

by failure of coping mechanisms and lack of support.
 an experience of being confronted by a stress in which the individual is

unable to cope/problem-solve
 self-limiting; usually exists for 4 to 6 weeks.
 The ability for decision making and problem solving is inadequate.
 Anxiety and tension accompany the experience, making it more difficult
to cope
 Hopelessness and/or helplessness results in a state of disorganization
where previous experience and coping fail to enable the individual to
problem- solve
Types of Crisis:

 Maturational crises (sometimes called developmental crises), are
predictable events in the normal course of life such as leaving home for
the first time, getting married, having a baby, and beginning a career.
 Situational crises are unanticipated or sudden events that threaten the
individual’s integrity such as the death of a loved one, loss of a job, and
physical or emotional illness in the individual of family member.
 Adventitious crises, (sometimes called social crises), include natural
disasters like floods, earthquakes, or hurricanes; war; terrorist attacks;
riots; and violent crimes such as rape or murder.
 Cultural crises accompany culture shock while adapting or adjusting to a
new culture or returning to one‘s own culture after being assimilated into
another
Crisis intervention – “Here and Now Therapy”
1. Treatment is immediate, supportive, and directly responsive to the

immediate crisis.
2. Interventions are goal-directed.
3. Feelings of the client are acknowledged.
4. Intervention provides opportunities for expression and validation of
feelings.
5. Connections are made between the meaning of the event and the crisis.
6. Assist the person in crisis to reestablish equilibrium by using previously
effective coping techniques
7. The client explores alternative coping mechanisms and tries out new
behaviors if former coping techniques are no longer effective
The process of crisis intervention contains four steps:
 Assessment
 planning of therapeutic intervention
 implementation of therapeutic intervention
 resolution of the crisis with anticipatory planning and evaluation

Psychopharmacology as Treatment during Crisis
A crisis is not a psychiatric illness, nor a prolonged condition, therefore

pharmacologic interventions are not the intervention of choice.
Pharmacologic agents may be used to treat target symptoms that interfere

with the client’s ability to function:
 Anxiolytics of the benzodiazepine group such as alprazolam (Xanax),

clonazepam (Klonopin), diazepam (Valium). lorazepam (Ativan), etc.
may be used to treat anxiety, panic, and sleep disturbances that
accompany a crisis
 Antidepressant trazadone (Desyrel) may be used for the management
of insomnia
 Neuroleptic medications: the atypicals, such as olanzapine (Zyprexa),
risperidone (Risperdal), quetiapine (Seroquel) and typical agents such
as haloperidol (Haldol). etc.). may be used to treat psychotic symptoms
that emerge
SUICIDE
SUICIDE
 is the intentional act of killing oneself.

 common in people with mood disorders, especially depression.
Nursing Diagnosis: Risk for injury directed to self; Ineffective coping

Suicidal ideation - means thinking about killing oneself.
Risk Factors:
 A history of previous suicide attempts; the first 2 years after an attempt

represent the highest risk period, especially the first 3 months
 Those with a relative who committed suicide; the closer the relationship,
the greater the risk.
 Adolescents
 Older adults
 Disabled or terminally ill client
 Clients with personality disorders
 Clients with organic brain syndrome or dementia
 Depressed or psychotic clients
 Substance abusers
 antidepressant treatment
The single most predictive psychiatric disorder for suicide is the presence of

a mood disorder
Warning signs:
 changes in personal habits such as appetite, sleep patterns, personal

appearance and personality
 use of alcohol and other drugs
 bodily complaints
 self-depreciating comments
 making wills and/or giving away personal/meaningful belongings
 decline in academic/occupational performance
 decreased interactions with peers and friends
 Client statements indicating an intent to attempt suicide
 Sudden calmness or improvement in a depressed client
 Client inquiries about poisons, guns, or other lethal objects

Suicidal Client: Assessment
Plan
Does the client have a plan?
What is the plan, how lethal is the plan, and how likely is death to occur?
Does the client have the means to carry out the plan?
Client History of Attempts
What suicide attempts occurred in the past and what harm occurred?
Was the client accidentally rescued?
Have the past attempts and methods been the same, or have methods
increased in lethality?
Psychosocial Factors
Is client alone or alienated from others?
Is hostility or depression present?
Do hallucinations exist? Is substance abuse present?
Has client had any recent losses or physical illness? Has client had any
environmental or lifestyle changes?
Interventions
1. Initiate suicide precautions.

2. Remove harmful objects.
3. Do not leave the client alone.
4. Provide a nonjudgmental, caring attitude.
5. Develop a contract that is written, dated, and signed and that indicates
alternative behavior at times of suicidal thoughts.
6. Encourage the client to talk about feelings and to identify positive
aspects about self.
7. Encourage active participation in own care.
8. Keep the client active by assigning achievable tasks.
9. Check that visitors do not leave harmful objects in the client’s room.
10. Identify support systems.
11. Do not allow the client to leave the unit unless accompanied by a
staff member.
12. Continue to assess the client’s suicide potential.
!!! Provide one-to-one supervision at all times for the client at risk for
suicide.
III. Milieu Therapy
Description
1. The milieu refers to the physical and social environment in which an

individual is receiving treatment.
2. Milieu therapy uses a safe environment to meet the individual client’s
treatment needs.
3. Safety is the most important priority in managing the milieu.
4. Milieu therapy is staffed by persons educated to provide support,
understanding, and individual attention; all encounters with the client
have the goal of being “therapeutic.”
5. All members of the treatment team contribute to the planning and
functioning of the milieu; the team generally includes a registered nurse,
social worker, exercise therapist, recreational therapist, psychologist,
psychiatrist, occupational therapist, and clinical nurse specialist or nurse
practitioner.
6. All members of the treatment team are viewed as significant and
valuable to the client’s successful treatment outcomes.
7. Focus of milieu therapy
 The focus of milieu therapy is to empower the client through
involvement in setting his or her own goals and to develop purposeful
relationships with the staff to assist in meeting these goals.
8. The physical and social environment is used to effect a positive change

directed toward accomplishing the client’s treatment goals.
9. Community meetings, activity groups, social skills groups, and physical

exercise programs are used to accomplish treatment goals.
10. One-to-one relationships with staff are used to examine client behaviors,
feelings, and interactions within the context of the therapeutic group activities.
References:


Prepared by: Nurhaya Asuncion Moctal, USRN – International NCLEX

Educator
I. Overview
Somatoform disorders
 are characterized by persistent worry or complaints regarding physical

illness without supportive physical findings.
 client focuses on the physical signs and symptoms and is unable to
control the signs and symptoms. - physical signs and symptoms
increase with psychosocial stressors
 anxiety is redirected into a somatic concern
 client may unconsciously use defense mechanisms: internalization and
somatization
Internalization - keeping stress, anxiety, or frustration within self rather than

expressing them outwardly
Somatization - expressing these internalized feelings and stress through

physical symptoms
Primary vs Secondary Gains
 contributes to continuance of symptoms
Primary gains are the direct external benefits that being sick provides such as
relief of anxiety, conflict, or distress.
Secondary gains are the internal or personal benefits received from others

because one is sick such as attention from family members and comfort
measures (e.g., being brought tea, receiving a back rub).
II. Etiology
 Physical symptoms have NO ORGANIC BASIS; objective diagnostics

tests do not reveal structural or functional damages
 Physical symptoms for which there is NO ORGANIC BASIS allow
clients to meet dependency needs without admitting such needs exist
 Clients may be admonished to be “mentally strong” and to not express
emotional needs or problems

III. Specific Disorder
A. Somatization disorder
 The client has multiple physical complaints involving numerous body

systems - The cause of these complaints is presumed to be
psychological
 New symptoms arise with increased emotional distress
 Frequently goes from provider to provider, seeking relief
Special Interventions:
 Client requires long-term management, often in a medical setting ✓

Treat physical symptoms conservatively, matter-of-factly
 Antidepressants may be prescribed if depressive symptoms present
 If anxiety present, focus should be on nonpharmacological treatments
B. Conversion Disorder
 involves unexplained, usually sudden deficits in sensory or motor

function
 is an expression of a psychological conflict or need and has NO
ORGANIC CAUSE
 most common conversion symptoms are blindness, deafness, paralysis,
and the inability to talk.
 KEY FEATURE: La Belle Indifference - seemingly lack of concern or
distress despite of the symptoms being experience
Assessment

o
 “La belle indifference”: Unconcerned with symptoms
 Physical limitation or disability
 Feelings of guilt, anxiety, or frustration
 Low self-esteem and feelings of inadequacy e.
Unexpressed anger or conflict
 Nurse must treat the symptom as “real”, as the client experiences the
symptom
 Use problem-solving approaches for dealing with conflicts and stressors
C. Pain Disorder
 primary physical symptom of pain, severe prolonged pain with NO

ORGANIC/NO PHYSIOLOGIC BASIS - preoccupation with pain which
generally is unrelieved by analgesics
 greatly affected by psychological factors in terms of onset, severity,
exacerbation, and maintenance
 Teach client how stress increases muscle tension, which creates

increased pain (stress-tension-pain cycle)
 Acupuncture, biofeedback training, transcutaneous nerve stimulation ✓
Specific exercise programs, physical therapy
 Visualization, and relaxation training
 Education about pain management techniques
 Note: analgesics and anti-anxiety agents may be ineffective for pain,
and addiction is possible
D. Hypochondriasis
 Physical symptom is interpreted as severe or life-threatening, resulting
in exaggerated worry and preoccupation
 Physical symptoms may begin with sensitivity to vague physical
sensations or mild physical symptoms that most people would not notice
 misinterprets bodily sensations or functions
 causes significant distress or impairment in role function - No evidence
of physical illness exists
Assessment:
 Often seeks information from clinicians or data sources (i.e. internet) to

substantiate concerns
 With history of multiple visits to multiple practitioners
 Concerns persists in spite of negative findings and clinician
reassurances
 Experiences significant anxiety
 Extensive use of home remedies or nonprescription medication
 Teach rational interpretation of body sensations

 Assists resolution of family conflict over medical treatment and client
distress ✓ Non-pharmacologic treatment of anxiety
E. Body Dysmorphic Disorder
 Preoccupation with a defect in appearance, either an imagined defect or

excessive concern over a minor anomaly
 Varies from “flaws” of face or head (complexion, hair thinning,
asymmetry) to abdomen, extremities or body shape/size
 causes significant distress or impairment in role function, and often
leads to social isolaton - embarrassed about defects so may express
them vaguely (“ugly”)
 may frequently checks defects, avoid reminders (removing mirrors),
seek reassurances from others, or attempt to improve the defect
 disorder is persistent; client has repeated surgeries, dental work or
dermatological treatment for defects
 emotional distress may be severe enough to lead to depression and
suicidal ideation
Special interventions:
 respect preoccupation; avoid challenging the validity of client

perceptions ✓ focus on coping techniques
 contract with client to increase social activities and relationships
IV. General Nursing Interventions
1. Obtain a nursing history and assess for physical problems.

2. Explore the needs being met by the physical symptoms with the client.
3. Assist the client to identify alternative ways of meeting needs.
4. Assist the client to relate feelings and conflicts to the physical
symptoms.
5. Convey understanding that the physical symptoms are real to the client.
6. Assure the client that physical illness has been ruled out.
7. Explore the source of anxiety and stimulate verbalization of anxiety.
8. Encourage the use of relaxation techniques as the anxiety increases
9. Use a pain assessment scale if the client complains of pain, and
implement pain reduction measures as required.
10. Report and assess any new physical complaint.
11. Encourage diversional activities.
12. Provide positive feedback.
13. Assist the client in recognizing his or her own feelings and
emotions.
14. Administer antianxiety medications if prescribed.
NOTE: For a client with a somatoform disorder, allow a specific time period

only for the client to discuss physical complaints because the client will feel
less threatened if this behavior is limited rather than stopped
completely. Avoid responding with positive reinforcement about the physical
complaints.

References:


Dissociative Disorders
 a disruption in integrative functions of memory, consciousness, or

identity.
o Usually consciousness, memory, identity and perception are
integrated function
 Defense mechanisms of dissociation and repression are used
Dissociation is a defense mechanism in which experiences are blocked off

from consciousness, so that affect, behavior, identity, memories, and/or
thoughts are not integrated
Repression is a defense mechanism in which thoughts and feelings are kept

from consciousness
 Client does NOT consciously “decide” to dissociate

 May experience depression and anxiety

II. Etiology/Causes
A. Traumatic Experience (accidents, natural disasters, assault)
1. Strong Emotional response

2. Psychological Conflict
3. Long-term, chronic stressors
B. Severe childhood physical, sexual, or emotional abuse
 Child learns to detach or dissociate from intolerable situation; continues

to dissociate when experiencing stressful (even non-abusive) events as
an adult, which interferes with normal functioning
III. Types
1. Dissociative amnesia
2. Dissociative fugue
3. Dissociative identity disorder (formerly multiple personality disorder)
4. Depersonalization disorder
IV. Specific Disorders
A. Dissociative Amnesia
 Inability to recall important personal information usually of a traumatic or

stressful nature because it provokes anxiety
o Localized amnesia: short time period (hours) after a disturbing
event
o Selective amnesia: amnesia for some, but not all events
o Generalized amnesia: amnesia for whole lifetime of experiences
o Systematized – loss of memory about one specific family member
o Continuous amnesia: forgets successive events as they occur

 Support groups
 Gradual reconstruction of events through talking and listening/reading of
others’ accounts of the trauma
B. Dissociative Fugue
 Characterized by suddenly wandering away or taking a trip away from

one’s usual place, unable to recall important aspects of identity and
assumes new identity
 Old and new identities do not alternate, incomplete new identity
 Typically retains learned skills, and can perform usual mental functions
like writing or calculating while in fugue
 Often a response to psychological stressors
 Usually lasts from hours to days, rarely months; considerable confusion
when returns to pre-fugue state - Once the client has returned to pre-
fugue state, has NO memory for events during the fugue
Special Intervention:
 Assist in developing effective coping skills to deal with problems

 Assist the client to cope with post-fugue confusion
C. Dissociative identity disorder (multiple personality)
 Two or more fully developed, distinct and unique personalities exist

within the client; each personality/identity has own enduring pattern of
perceiving, relating to, and thinking about oneself and the environment
 May present different ages, genders, have different physiological
responses and disorders
 The HOST is the primary personality/identity that holds the person’s
name, and the other personalities are referred to as ALTERS.
 ALTERS may take full control of the client, one at a time, and may or
may not be aware of each other. ✓ The ALTERS may be aware of the
HOST, but the HOST is NOT USUALLY AWARE of the alters
Assessment:
 The client may have an inability to recall important information

(unrelated to ordinary forgetfulness).
 Transition from one personality to the other is related to stress or a
traumatic event and is sudden.
 Dissociation is used as a method of distancing and defending one’s self
from anxiety and traumatizing experience
 “Loses time” when alternate personality is present for a period of time
 No-harm contract and environmental safety if the client is suicidal or

self-mutilating
 Meeting and recognizing alters and their unique experiences and needs
 “Mapping” personality system, noting characteristics of alters
 Individual therapy with therapist skilled in working through trauma
leading to integration (moving together of aspects of all identities)
 Development of new coping skills for clients so that dissociation is either
unnecessary or is under control
 Family therapy with partners and children to help client avoid
dissociation, deal with hostile personalities, understand therapy
process, and to confirm experience with client’s behavior
 Hypnosis
D. Depersonalization disorder
 The client has a persistent or recurrent feeling of being detached from

his or her mental processes or body, as if in a dream-like state
 intact reality testing; that is, the client is NOT psychotic or out of touch
with reality.
 Describes self as “detached from the body” or “being in a dream”, feels
strange or unreal
 Precipitated by stress or anxiety
 Reports distress about experiences and become depressed and
anxious
 Problem-solving to reduce stress in general

 Stress-management techniques
 “Grounding” or focus on discernable, external environment
o Having the client focus on real, concrete things that can be seen
or heard and redirects the client’s attention from
depersonalization, this in turn, interrupts the anxiety response
o Help the client to focus on what he or she is currently
experiencing through senses
 Are you hearing something?
 What are you touching
 Can you see me and the room we are in?
 Do you feel your feet on the floor?
V. General Nursing Management
PROMOTE CLIENT’S SAFETY
 Discuss self-harm thoughts.

 Help client develop plan for going to safe place when having destructive
thoughts or impulses.
HELP CLIENT COPE WITH STRESS AND EMOTIONS
 Use grounding techniques to help client who is dissociating or

experiencing flashbacks.
 Validate client’s feelings of fear, but try to increase contact with reality.
 During dissociative experience or flashback, help client change body
position but do not grab or force client to stand up or move.
 Use supportive touch if client responds well to it.
 Teach deep breathing and relaxation techniques.
 Use distraction techniques such as physical exercise, listening to music,
talking with others, or engaging in a hobby or other enjoyable activity.
 Help to make a list of activities and keep materials on hand to engage
client when feelings are intense.
HELP PROMOTE CLIENT’S SELF-ESTEEM
 Refer to client as “survivor” rather than “victim.”

 Establish social support system in community.
 Make a list of people and activities in the community for client to contact
when help is needed.
Additional Nursing Interventions:
1. Develop a trusting relationship with the client.

2. Encourage verbal expression of painful experiences, anxieties, and
concerns.
3. Explore methods of coping.
4. Identify sources of conflict.
5. Focus on the client’s strengths and skills.
6. Orient the client.
7. Provide nondemanding simple routines.
8. Allow the client to progress at his or her own pace.
9. Implement stress reduction techniques.
10. Plan for individual, group, or family psychotherapy to integrate
dissociated aspects of personality or memory and to expand self-
awareness.
References:



Prepared by: Nurhay
MedProU Logo 2019.gif
I. Overview
Personality
 ingrained, enduring pattern of behaving and relating to self, others, and

the environment; personality includes perceptions, attitudes, and
emotions.
 Develops as individuals adjust to their physical, emotional, social, and
spiritual environments
 Personality traits o patterns are reflected in how individuals cope with
feelings and impulses, see themselves and others, respond to their
surroundings, and find meaning in relationships
Personality Disorders
 diagnosed when personality patterns or traits are inflexible, enduring,

pervasive, maladaptive, and cause significant functional impairment or
subjective distress
 Diagnosis is made when the person exhibits enduring behavioral
patterns that deviate from cultural expectations in two or more of the
following areas:
o Cognition: Ways of perceiving and interpreting self, other people,
and events
o Affect: Range, intensity, lability, and appropriateness of emotional
response
o Interpersonal functioning
o Impulse control: Ability to control impulses or express behavior at
the appropriate time and place
 Are coded under axis II disorders (personality disorders or mental
retardation) using the American Psychiatric Association’s Diagnostic
and Statistical Manual of Mental Disorders, fourth edition – Text
Revision (DSM IV-TR)
II. Categories of Personality Disorders
Cluster A: odd or eccentric
 Paranoid personality disorders

 Schizoid personality disorders
 schizotypal personality disorders
Cluster B: dramatic, emotional, or erratic

 antisocial personality disorders
 borderline personality disorders
 histrionic personality disorders
 narcissistic personality disorders
Cluster C: anxious or fearful
 avoidant personality disorders

 dependent personality disorders
 obsessive-compulsive personality disorders
III. Cluster A: odd or eccentric
A. Paranoid personality disorders
 Pattern of distrust and suspiciousness such that others’ motives are

interpreted as malevolent
 Secretive, hyperalert to danger, argumentative to maintain safe distance
between self and others - May be hostile, aloof
 May be rigid, critical, and controlling of others
 Tendency to look for hidden, demeaning, or threatening meanings and
to respond by criticizing others
 Uses defense mechanism of projection
Special Nursing Intervention:
1. Serious, straightforward approach

2. teach client to validate ideas before taking action c. involve client in
treatment planning
B. Schizoid Personality disorders
 Pattern of detachment from social relationships and a restricted range of

emotions - Neither desire nor enjoy relationship with others
 inability to form warm, close social relationships - Interest in solitary
activities
 Aloof and indifferent
1. Improve client’s functioning in the community

2. assist client to find case manager - The case manager can help the
client to obtain services and health care, manage finances, etc.
C. Schizotypal Personality Disorder
 is characterized by the display of abnormal or highly unusual thoughts,

perceptions, speech, and behavior patterns
 milder form of schizophrenia (NO Hallucinations)
 exhibits odd/eccentric behavior and speech that is coherent but often
tangential, vague, or overelaborate
 Magical thinking
 Odd thinking and speech
 Suspiciousness and paranoia
 Uncomfortable with intimacy and avoid relationships with others; usually
avoided by others because of their odd/eccentric behavior
1. Develop self-care skills

2. improve community functioning
3. social skills training
Cluster A-specific nursing interventions
 approach people in a gentle, interested, but nonintrusive manner

respect client’s needs distance and privacy
 Be mindful of own nonverbal communication as a client may perceive
others as threatening Gradually encourage interaction with others, if
appropriate
IV. Cluster B: dramatic, emotional, or erratic
A. Antisocial personality disorder
 is characterized by a pervasive pattern of disregard for and violation of

the rights of others and with the central characteristics of deceit and
manipulation
 irresponsible and antisocial behavior, selfishness, an inability to
maintain lasting relationships, poor sexual adjustment, a failure to
accept social norms, and a tendency toward irritability and
aggressiveness
 Perceives the world as hostile - Superficial charm and hostility
 No shame or guilt and Self-centered - Unreliable and easily bored
 Poor work history
 Inability to tolerate frustration
 View others as objects to be manipulated - Poor judgment and
impulsive
Special Nursing Intervention
1. Limit-setting
2. Confrontation
3. teach client to solve problems effectively d. manage emotions of anger
or frustration
Consistent limit-setting
 in a matter-of-fact, nonjudgmental manner. Limit-setting involves three
steps:
1. Stating the behavioral limit (describing the unacceptable behavior)

2. Identifying the consequences if the limit is exceeded
3. Identifying the expected or desired behavior
Confrontation
 is another technique designed to manage manipulative or deceptive

behavior. The nurse points out a client’s problematic behavior while
remaining neutral and matter-of-fact; he or she avoids accusing the
client
Helping clients solve problems
 Problem-solving skills include:

o Scenario: a client’s car isn’t running so he stopped going to work
1.
1.
1. identifying the problem - transportation to work
2. exploring alternative solutions and related consequences -
taking the bus, asking a coworker for a ride, and getting the
car fixed
3. choosing and implementing an alternative
4. evaluating the results
Managing emotions
 identify sources of frustration, how they respond to it, and the

consequences
 taking a Time-out – leaving the area and going to a neutral place to
regain internal control
B. Borderline Personality Disorder

 characterized by instability in interpersonal relationships, unstable mood
and self-image, and impulsive and unpredictable behavior
 Unclear identity
 Unstable and intense
 Extreme shifts in mood - Easily angered
 Easily bored
 Argumentative - Depression
 Self-destructive behavior; High-risk for suicide and self-mutilation
because of feelings of emptiness or rage
 Manipulation
 Inability to tolerate anxiety
 Chronic feelings of emptiness and fear of being alone
 Splitting—sees others as all good or all bad; creates conflict between
individuals by playing one person against another
Special Nursing Interventions:
1. Promote safety - seriously consider suicidal ideation with the presence

of a plan, access to means for enacting the plan, and self-harm
behaviors and institute appropriate interventions
2. help client to cope and control emotions
3. cognitive restructuring techniques - used to change the way the client
thinks about self and others
o thought stopping - the client stops negative thought patterns
o positive self-talk - designed to change negative self-messages
o decatastrophizing - teaches the client to view life events more
realistically not as catastrophes
4. structure time
5. teach social skills
C. Histrionic Personality Disorder
 characterized by overly dramatic, intensely expressive behavior, and

attention-seeking
 Lively and dramatic and enjoys being the center of attention
 Has poor and shallow interpersonal relations; exaggerate the closeness
of relationships
 May be sexually seductive or provocative
 Dramatizes his or her life and may appear theatrical
 Overly concerned with appearance
 Easily bored
1. Teach social skills

2. provide factual feedback about behavior
D. Narcissistic Personality Disorder
 characterized by a pervasive pattern of grandiosity (in fantasy or

behavior), need for admiration, and lack of empathy
 increased sense of self-importance and preoccupation with fantasies
and unlimited success - Need for admiration and inflation of
accomplishments
 Overestimation of abilities and underestimation of contributions of
others - Lack of empathy and sensitivity to needs of others
 arrogant, sees self as more important/special than others
1. Matter-of-fact approach
2. gain cooperation with needed treatment c. teach client any needed self-
care skills
Cluster B-specific nursing interventions
 Safety is always the priority of care – protect client from suicide and
self-mutilation until they can protect themselves
 Be patient as clients display emotional and erratic behavior
 Provide a consistent and structured milieu to avoid manipulation and
power struggles
 Set limits as necessary to help clients maintain impulse control in order
to protect themselves and other from injury
 Engage in frequent staff conferences to counteract client’s ability to play
one staff member against the other
 Help clients recognize and discuss their fear of abandonment
 Help clients recognize the presence of dichotomous thinking or splitting,
in which self and others are perceived as all good or all bad
 Encourage direct communication to minimize attention-seeking through
the use of dramatic, seductive behavior
 Help clients who display a sense of entitlement to acknowledge the
needs of others
V. Cluster C: anxious or fearful
A. Avoidant Personality disorders
 characterized by a pervasive pattern of social discomfort and reticence,

low self-esteem, and hypersensitivity to negative evaluation.
 Avoid interpersonal contact and new situations related to fear of
rejection and embarrassment
 Lack self—confidence and are extremely sensitive to rejection; view self
as inadequate and inferior - Fearful of shame, criticism and ridicule; shy
and hurt by criticism
1. Support and reassurance

o explore positive self-aspects, positive responses from others, and
possible reasons for self-criticism
2. cognitive restructuring techniques- used to change the way the client
3. promote self-esteem

B. Dependent Personality Disorder
 characterized by a pervasive and excessive need to be taken care of,

which leads to submissive and clinging behavior and fears of separation
 intense lack of self-confidence, low self-esteem, and inability to function
independently
 the individual passively allows others to make decisions and assume
responsibility for major areas in the person’s life
 the dependent client has great difficulty making decisions
 difficulty of disagreeing with others related to fear of rejection and
abandonment
 anxious when left alone because of fear of being unable to do things for
themselves
1. Foster client’s self-reliance and autonomy

2. teach problem-solving and decision-making skills
C. Obsessive-compulsive Personality Disorder
 characterized by a pervasive pattern of preoccupation with

perfectionism, mental and interpersonal control, and orderliness at the
expense of flexibility, openness, and efficiency
 Overly conscientious - High need for routine
 Inflexible and preoccupied with details and rules
 Extremely devoted to work to the exclusion of leisure activities and
friendships
 Miserly and stubborn; Hoarding behavior – unable to discard worthless
objects; Engages in rituals
 Decreased ability to focus on the major goal of any activity as becomes
overly involved in details
 Difficulty with task completion related to a need for perfection
 Unable to delegate for fear that others will not perform tasks correctly
1. Encourage negotiation with others

2. assist client to make timely decisions and complete work
realistically not as catastrophe
Cluster C-specific nursing interventions
 Point out avoidance behaviors and related losses and secondary gains
 Provide problem-solving and assertiveness training to increase self-
confidence and independence Encourage expression of feelings to
decrease rigidity and need for control
 Help clients recognize any impairment or distress related to their need
for perfection and control
 Help clients acknowledge and discuss their sense of inadequacy and
fear of rejection
VI. General Interventions for a Client with a Personality disorder
1. Maintain safety against self-destructive behaviors.

2. Allow the client to make choices and be as independent as possible.
3. Encourage the client to discuss feelings rather than act them out.
4. Provide consistency in response to the client’s acting-out behaviors.
5. Discuss expectations and responsibilities with the client.
6. Discuss the consequences that will follow certain behaviors.
7. Inform the client that harm to self, others, and property is unacceptable.
8. Identify splitting behavior.
9. Assist the client to deal directly with anger.
10. Develop a written safety or behavioral contract with the client.
11. Encourage the client to keep a journal recording daily feelings.
12. Encourage the client to participate in group activities, and praise
nonmanipulative behavior
13. Set and maintain limits to decrease manipulative behavior.
14. Remove the client from group situations in which attention-
seeking behaviors occur.
15. Provide realistic praise for positive behaviors in social situations.
VII. Psychopharmacology
1. Antipsychotic agents may be prescribed on a short-term basis to

alleviate psychotic symptoms associated with schizotypal or borderline
personality disorders
2. Selective serotonin reuptake inhibitors may be prescribed to diminish
the rapid mood swings, impulsive, aggressive, and self-destructive
behavior associated with borderline personality disorder
3. SSRIs may be prescribed to treat the obsessive rumination associated
with certain personality disorders
Schizophrenia
 Combination of disordered thinking, perceptual disturbances, behavioral

abnormalities, affective disruptions, and impaired social competency
 Disturbances in affect, mood, behavior, and thought processes occur
Major Symptoms:
1. Delusional ideation:a false belief brought about without appropriate

external stimulation and inconsistent with the individual's own
knowledge and experience
2. Hallucinations: false sensory perceptions that may involve any of the
five senses (auditory, visual,tactile, olfactory, and gustatory)
3. Disorganized speech patterns
4. Bizarre behaviors

o At least two of these symptoms must be present for a significant
portion of the time during a 1-month period
o Duration: Continuous signs of the disturbance persist for at least 6
This 6-month period mustinclude at least 1 month of symptoms
Types of Schizophrenia:
1. Paranoid - characterized by persecutory (feeling victimized or spied on)

or grandiose delusions, hallucinations, and, occasionally, excessive
religiosity (delusional religious focus) or hostile and aggressive behavior
2. Disorganized - grossly inappropriate or flat affect, incoherence, loose
associations, and extremely disorganized behavior
3. Catatonic - characterized by marked psychomotor disturbance, either
motionless or excessive motor
4. Undifferentiated - mixed schizophrenic symptoms of others
5. Residual - characterized by at least one previous, though not a current,
episode; social withdrawal; flat affect; and looseness of associations
Related Disorders:
1. Schizophreniform disorder: The client exhibits the symptoms of

schizophrenia but for less than the 6 months necessary to meet the
diagnostic criteria for Social or occupational functioning may or may not
be impaired.
2. Schizoaffective disorder: The client exhibits the symptoms of psychosis
and, at the same time, all the features of a mood disorder, either
depression or
3. Delusional disorder: The client has one or more non-bizarre delusions—
that is, the focus of the delusion is Psychosocial functioning is not
markedly impaired, and behavior is not obviously odd or bizarre.
4. Brief psychotic disorder: The client experiences the sudden onset of at
least one psychotic symptom,such as delusions, hallucinations, or
disorganized speech or behavior, which lasts from 1 day to 1 The
episode may or may not have an identifiable stressor or may follow
childbirth.
5. Shared psychotic disorder (folie à deux): Two people share a similar
The person with this diagnosis develops this delusion in the context of a
close relationship with someone who has psychoticdelusions

II. Etiology
1. Biologic Factors
o overactive basal ganglia
o enlarged ventricles, cerebral atrophy, decreased cerebral blood
flow, decreased brain volume, and reduced glucose metabolism in
the frontal and temporal lobes as seen on imaging studies (CT,
MRI, and PET scans)
o Imbalance between dopamine and serotonin neurotransmitter
systems, usually with an excess of dopamine
o Low levels of the neurotransmitter GABA (gamma-aminobutyric
acid)
2. Genetic Factors
o increased risk for the development of schizophrenia with a
positive family history of schizophrenia
o risk increases for those with first-degree relatives diagnosed with
schizophrenia
o no specific genetic defect identified that causes schizophrenia
3. Psychological Factors
o no specific studies that indicate that stress causes schizophrenia,
but stress does affect relapse and exacerbation to schizophrenic
manifestations
o genetic predisposition + presence of stressful events =
schizophrenia
4. Environmental factors

o exposure to infectious agents such as viruses in early infancy may
contribute to the development of schizophrenia
o association between schizophrenia and complications during
pregnancy or labor such as oxygen deprivation, short gestation
periods, and low birthweights
III. Assessment
1. Positive symptoms indicate a distortion or excess of normal

functioning: they often occur as the initial symptoms of schizophrenia
and precipitate the need for hospitalization:

o Delusions – fixed, false belief
Types of Delusions:

o

 Persecutory/paranoid delusions - involve the client’s
belief that “others” are planning to harm the client
 Grandiose delusions - characterized by the client’s
claim to association with famous people or celebrities,
or the client’s belief that he or she is famout
 Religious delusions - often center around the second
coming of Christ or another significant religious figure
or prophet.
 Somatic delusions - generally vague and unrealistic
beliefs about the client’s health or bodily functions.
 Referential delusions or ideas of reference - involve
the client’s belief that television broadcasts, music, or
newspaper articles have special meaning for him or
her.

o Hallucination – false sensory perceptions, or perceptual
experiences that do not exist in reality
Types of Hallucination:

o

 Auditory hallucinations - the most common type,
involve hearing sounds, most often voices, talking to
or about the client. There may be one or multiple
voices; a familiar or unfamiliar person’s voice may be
speaking.
 Command hallucinations - are voices demanding that
the client take action, often to harm self or others, and
are considered dangerous
 Visual hallucinations - involve seeing images that do
not exist at all, such as lights or a dead person.
 Olfactory hallucinations - involve smells or They may
be a specific scent, such as urine or feces, or more
general such as a rotten or rancid odor.
 Tactile hallucinations refer to sensations such as
electricity running through the body or bugs crawling
on the skin.
 Gustatory hallucinations - involve a taste lingering in
the mouth or the sense that food tastes like
something else. The taste may be metallic or bitter or
may be represented as a specific taste.
 Cenesthetic hallucinations - involve the client’s report
that he or she feels bodily functions that are usually
undetectable. Examples would be the sensation of
urine forming or impulses being transmitted through
the brain.
 Kinesthetic hallucinations - occur when the client is
motionless but reports the sensation of bodily
movement. Occasionally the bodily movement is
something unusual such as floating above the ground.
 Referential delusions or ideas of reference - involve
the client’s belief that television broadcasts, music, or
newspaper articles have special meaning for him or
her. Examples: The client may report that the
president was speaking directly to him on a news
broadcast or that special messages are sent through
newspaper articles.

o Abnormal Motor Activity

 Catatonic posturing - Holding bizarre postures for long
periods
 Catatonic excitement - Moving excitedly, with no
environmental stimuli present
 Echopraxia - Repeating the movements of another
person
 Waxy flexibility - maintaining any position in which
they are placed, even if the position is awkward or
uncomfortable.


o Unusual Speech Pattern

 Clang associations - are ideas that are related to one
another based on sound or rhyming rather than
meaning
 Example: “the train brain rained on me.”; “that
boat hope floats”
 Neologisms - are words invented by the
 Example: Grittiz: “I’m afraid of grittiz. If there are
any grittiz here, I will have to leave. Are you a
grittiz?”
 Verbigeration - is the stereotyped repetition of words
or phrases that may or may not have meaningto the
listener.
 Example: “I want to go home, go home, go
home, go home.”
 Echolalia is the client’s imitation or repetition of what
the nurse
 Example:
 Nurse: “Can you tell me how you’re
feeling?”
 Client: “Can you tell me how you’re
feeling, how you’re feeling?”

o

 Stilted language - is use of words or phrases that are
flowery, excessive, and
 Example: “Would you be so kind, as a
representative of Florence Nightingale, as to do
me the honor of providing just a wee bit of
refreshment, perhaps in the form of some clear
spring water?”
 Perseveration - is the persistent adherence to a single
idea or topic and verbal repetition of a sentence,
phrase, or word, even when another person attempts
to change the topic.
 Example:
 Nurse: “How have you been sleeping
lately?”
 Client: “I think people have been following
me.”
 Nurse: “Where do you live?”
 Client: “At my place people have been
following me.” Nurse: “What do you like to
do in your free time?” Client: “Nothing
because people are following me.”

o

 Word salad - is a combination of jumbled words and
phrases that are disconnected or incoherentand make
no sense to the listener.
 Example: “Corn, potatoes, jump up, play
games, grass, cupboard.”

o Abnormal Thought Processes
 Tangential Thinking - veering onto unrelated topics and
never answering the original question
 Example:
 Nurse: “How have you been sleeping lately?”
 Client: “Oh, I try to sleep at night. I like to listen
to music to help me sleep. I really like country-
western music best. What do you like? Can I
have something to eat pretty soon? I’m hungry.”
 Circumstantial thinking - the client gives unnecessary
details or strays from the topic but eventually providesthe
requested information:
 Example:
 Nurse: “How have you been sleeping lately?”
 Client: “Oh, I go to bed early, so I can get plenty
of rest. I like to listen to music or read before
bed. Right now I’m reading a good mystery.
Maybe I’ll write a mystery someday. But it isn’t
helping, reading I mean. I have been getting
only 2 or 3 hours of sleep at night.”

o
 Flight of ideas - Constant flow of speech in which client
jumps from one topic to another in rapid succession;a
connection between topics exists, although it is sometimes
difficult to identify
 Example: A man starts talking about his business, but
quickly shifts to discussing the economy, the
government, and other countries.

o
 Associative looseness - Fragmented or poorly related
thoughts and ideas
 Example: "The next day when I'd be going out you
know, I took control, like uh, I put bleach on my hair in
California."

o
 Thought blocking - An abrupt stop in the middle of a train of
thought; the individual may or maynot be able to continue
the idea.
 Example: the client may suddenly stop talking in the
middle of a sentence and remain silent for several
seconds to 1 minute

o Illusions: inaccurate perception or misinterpretation of
sensory impressions
o Agitation
o Hostility
o Bizarre behaviors
2. Negative symptoms indicate a loss or lack of normal functioning; they

develop over time and hinder the person's ability to endure life tasks

o Anhedonia - diminished ability to experience pleasure or intimacy
o Apathy - lack of interest, enthusiasm, or concern
o Alogia - poverty of speech
o Anergia - lack of energy
o Avolition - lack of motivation and goals
o Ambivalence - inability to make a decision because of conflicting
emotions
o Affect disturbances
1. Blunted
2. Flat
3. Inappropriate
o Restricted emotion
o Social withdrawal
o Dependency
o Lack of ego boundaries
o Concrete thought processes
o Lack of self-care
o Sleep disturbances
IV. Nursing Responsibilities
A. Implementing Interventions for Delusional Thoughts
Be sincere and honest when communicating with the client

o Delusional clients are extremely sensitive about others and can
recognize
Avoid vague or evasive remarks.

o Evasive comments or hesitation reinforces mistrust or delusions.
Be consistent in setting expectations, enforcing rules, and so forth

o Clear, consistent limits provide a secure structure for the client
Do not make promises that you cannot

o Broken promises reinforce the client’s mistrust of others
Encourage the client to talk with you, but do not pry or cross-examine for
information

o Probing increases the client’s suspicion and interferes with the
therapeutic relationship
Explain procedures, and try to be sure the client understands the procedures
before carrying them out

o When the client has full knowledge of procedures, he or she is
less likely to feel tricked by the staff
Give positive feedback for the client’s successes

o Positive feedback for genuine success enhances the client’s
sense of well-being and helps to make non-delusional reality a
more positive situation for the client
Recognize the client’s delusions as the client’s perception of the environment

o It is important to recognize the client’s environmental perceptions
to understand the feelings he or she is experiencing.
Initially, do not argue with the client or try to convince the client that the
delusions are false or unreal

o Logical argument does not dispel delusional ideas and can
interfere with the development of trust
Interact with the client on the basis of real things; do not dwell on the
delusional material

o Interacting about reality is healthy for the client
Engage the client in one-to-one activities at first, then activities in small

groups, and gradually activities in larger groups.

o The client who is distrustful can best deal with one person
Gradual introduction of others when the client can tolerate it is
less threatening.
Recognize and support the client’s accomplishments (activities or projects

completed, responsibilities fulfilled, interactions initiated).

o Recognition of accomplishments can lessen the client’s anxiety
and the need for delusions as a source of self-esteem.
Show empathy regarding the client’s feelings; reassure the client of your
presence and acceptance

o The client’s delusions can be Empathy conveys your acceptance
of the client and your caring and interest.
Do not be judgmental or belittle or joke about the client’s belief

o The client’s delusions and feelings are not funny to him or The
client may feel rejected by you or feel unimportant if approached
by attempts at humor.
Never convey to the client that you accept the delusions as reality

o You would reinforce the delusion (thus, the client’s illness) if you
indicated belief in the delusion
Directly interject doubt regarding delusions as soon as the client seems ready
to accept (e.g., “I find that hard to believe.”) Do not argue with the client, but
present a factual account of the situation as you see it.

o As the client begins to trust you, he or she may become willing to
doubt the delusion if you express your doubt.
Attempt to discuss the delusional thoughts as a problem in the client’s life; ask
the client if he or she can see that the delusions interfere with his or her life.

o Discussion of the problems caused by the delusions is a focus on
the present and is reality
B. Implementing Interventions for Hallucinations
1. Help present and maintain reality by frequent contact and

communication with client.
o focus on what is real and to help shift the client’s response toward
reality
2. Elicit description of hallucination to protect client and The nurse’s
understanding of the hallucinationhelps him or her know how to calm or
reassure the client.
o Initially the nurse must determine what the client is experiencing—
that is, what the voices are saying or what the client is seeing
3. Engage client in reality-based activities such as card playing,
occupational therapy, or listening to music
o this technique of distracting the client is often useful
4. Identify certain situations or a particular frame of mind that may precede
or trigger auditory hallucinations
o Intensity of hallucinations often is related to anxiety levels;
therefore, monitoring and interveningto lower anxiety may
decrease the intensity of hallucinations
5. Teaching the client to talk back to the voices forcefully
o Being able to verbalize resistance can help the client feel
empowered and capable of dealing withthe hallucinations

C. General Interventions for Schizophrenia
V. Pharmacology
Antipsychotic Medications

 Improve the thought processes and the behavior of the client with
psychotic symptoms, especiallyclients with schizophrenia
 Affect dopamine receptors in the brain, reducing the psychotic
symptoms
 Typical antipsychoticsare more effective for positive symptoms of
schizophrenia, such as hallucinations, aggression, and delusions;
typical antipsychotic medications also block the chemoreceptor trigger
zone and vomiting center in the brain, producing an antiemetic
 Atypical antipsychoticsare more effective for the negative symptoms of
schizophrenia, such as avolition, apathy, and
 The effects of antipsychotic medications are potentiated when given
with other medications acting onthe
Side effects:
1. Anticholinergic Effects
o Dry mouth
o Increased heart rate
o Urinary retention
o Constipation
o Hypotension
2. Extrapyramidal Side Effects
o Pseudo-parkinsonism or neuroleptic-induced parkinsonism

 symptoms usually appear in the first few days after
starting or increasing the dosage of an antipsychotic
medication

o
 Tremors
 Mask-like faces
 Rigidity
 Shuffling gait
 Dysphagia
 Drooling

o Dystonia - appear early in the course of treatment and are
characterized by spasms in discrete muscle groups such as the
neck muscles (torticollis) or eye muscles (oculogyric crisis)
 spasms also may be accompanied by protrusion of the
tongue, dysphagia, and laryngeal/pharyngeal spasm that
can compromise the client’s airway, causing a medical
emergency
 Acute treatment consists of diphenhydramine (Benadryl)
given eitherintramuscularly or intravenously, or
benzotropine (Cogentin) given
o Akathisia - restless movement, pacing, inability to remain still, and
the client’s report of inner restlessness

o
 usually develops when the antipsychotic is started or when
the dose is increased
 Betablockers such as propranolol have been most effective
in treating akathisia

o Tardive Dyskinesia - irreversible once it has appeared, but
decreasing or discontinuing the medication can arrest the
progression
 Protrusion of the tongue
 Chewing motion
 lip smacking
 blinking and grimacing
 involuntary, choreiform movements of the limbs and feet
3. Neuroleptic Malignant Syndrome
 potentially fatal syndrome that may occur at any time during therapy
with neuroleptic (antipsychotic) medications
 more commonly occurs at the initiation of therapy, after the client has
changed from one medication to another, after a dosage increase, or
when a combination of medications is used
 characterized by muscle rigidity, high fever, increased muscle enzymes
(particularly CPK), andleukocytosis (increased leukocytes)
 Dyspnea or tachypnea; Tachycardia or irregular pulse rate; Fever; High
or low blood pressure; Increased sweating; Loss of bladder control;
Skeletal muscle rigidity; Pale skin; Excessive weakness or fatigue;
Altered level of consciousness; Seizures
Interventions for Neuroleptic Malignant Syndrome

o Notify the physician.
o Monitor vital signs.
o Initiate safety and seizure precautions.
o Prepare to discontinue the medication.
o Monitor level of consciousness.
o Administer antipyretics as prescribed.
o Use a cooling blanket to lower the body temperature.
o Monitor electrolyte levels and administer fluids intravenously as
prescribed.
4. Agranulocytosis
 failure of the bone marrow to produce adequate white blood cells,

potentially fatal side effect of Clozapine
 develops suddenly and is characterized by fever, malaise, ulcerative
sore throat, and leukopenia
 drug must be discontinued immediately
Note: Clients taking this antipsychotic must have weekly white blood cell
counts. Currently, clozapine is dispensed every 7 days only, and evidence of
the white cell count is required before a refill is furnished.
5. Other Side Effects
 Drowsiness
 Blood dyscrasias
 Pruritus
 Photosensitivity
 Elevated blood glucose level
 Increased weight
 Impaired body temperature regulation
 Gynecomastia
 Lactation
General Interventions for Antipsychotic Medications
1. Monitor vital signs

2. Monitor for symptoms of neuroleptic malignant syndrome (can occur
with antipsychotic medications).
3. Monitor urine output
4. Monitor serum glucose level
5. The client taking an antipsychotic medication may require long-term
medication for parkinsonian symptoms.
6. Administer the medication with food or milk to decrease gastric irritation
7. For oral use, the liquid form might be preferred because some clients
hide tablets in their mouths to avoid taking them.
8. The absorption rate is faster with the liquid form of oral medication.
9. Avoid skin contact with the liquid concentrate to prevent contact
dermatitis
10. Protect the liquid concentrate from light.
11. Dilute the liquid concentrate with fruit juice.
12. Inform the client that a full therapeutic effect of the medication
may not be evident for 3 to 6 weeks after initiation of therapy; however,
an observable therapeutic response may be apparent after 7 to 10 days.
13. Inform the client that some medications may cause a harmless
change in urine color to pinkish to red-brown.
14. Instruct the client to use sunscreen, hats, and protective clothing
when outdoors
15. Instruct the client to avoid alcohol or other CNS depressants
16. Instruct the client to change positions slowly to avoid orthostatic
hypotension
17. Instruct the client to report signs of agranulocytosis, including sore
throat, fever, and malaise.
18. Instruct the client to report signs of liver dysfunction, including
jaundice, malaise, fever, and right upper abdominal pain.

VI. Psychotherapy
 Milieu therapy: a method of psychotherapy that controls the

environment of the client to provide interpersonal contacts in order to
develop trust, assurance, and personal autonomy
1.
1. Provide for the client's safety and the safety of others in the milieu
2. Provide a supportive environment that is structured and
predictable
3. Collaborate with the multidisciplinary team regarding the client's
plan of care
4. Collaborate with the client regarding his or her plan of care
5. Encourage the client to participate in milieu groups and activities
that promote socialization
6. Assist client with ADLs as needed, but encourage independence
as client progresses

References:

ANNE SILVESTRI, PhD, RN Psychiatric Mental Health Nursing, Sheila L.
Videbeck, PhD, RN

Cognitive Mental Disorders
 disruption or impairment in any of the cognitive abilities of the brain

 cognitive abilities include reasoning, judgment, perception, attention,
comprehension, and memory

Primary Categories
1. Delirium
2. Dementia
3. Amnestic Disorder
II. Specific Disorders
A. Delirium
 Acute, usually reversible brain disorder characterized by clouding of the

consciousness (decreased awareness of the environment) and a
reduced ability to focus and maintain attention
 Develops over a short period of time (usually hours to days) and tends
to fluctuate during the course of the day
 Evidence from history, physical examination, or laboratory findings
suggests that the disturbance is caused by the direct physiological
consequences of a general condition
 May have sensory disturbances such as illusions, misinterpretations, or
hallucinations
 May also experience disturbances in the sleep–wake cycle, changes in
psychomotor activity, and emotional problems such as anxiety, fear,
irritability, euphoria, or apathy
Etiology:
 Delirium almost always results from an identifiable physiologic,

metabolic, or cerebral disturbance or disease or from drug intoxication
or withdrawal:

Assessment Findings:
 Delirium has sudden onset and an identifiable cause
Signs and Symptoms:
 Fluctuating levels of consciousness (alternating periods of coherence

with periods of confusion); with disorientation that worsens at the end of
the day – Sundown Syndrome
 Alternating patterns of Hyperactivity (typical of drug withdrawal) to
hypoactivity (typical of metabolic imbalance)
Hyperactive Behaviors

o
 Rambling, bizarre, incoherent, rapid, pressured, or loud
speech
 Restlessness, picking at clothes or bed linen, irritability,
euphoria
 Calling out for help, striking out at others, bizarre and
destructive behavior, combativeness, anger, profanity
Hypoactive Behaviors

o
 Limited, dull patterns of speech
 Lethargy, apathy, withdrawn behavior
 Reduced alertness, awareness of environment
 Cognitive changes: disorganized thinking, diminished ability to focus

attention, disorientation to time and place, impairment in recent and
remote memory
 Visual or auditory hallucinations, frightening delusions
 Sleep pattern disturbances, including vivid and terrifying dreams or
nightmares ✓ Predominant emotion is fear with a high level of anxiety
Treatment and Prognosis:
 The primary treatment for delirium is to identify and to treat any causal
or contributing medical conditions.
 Other Supportive medical treatment
o Intravenous fluids and total parenteral nutrition
o Trazodone (Desyrel) 25 to 500 mg/day
 Note: Can decrease agitation and aggression without
decreasing cognitive performance
o Haloperidol (Haldol) 0.5 to 1 mg
 Note: decreases agitation
o Buspirone (Buspar) 10 to 60 mg/day
 Note: not sedating and fewer side-effects, preferable to
benzodiazepines
o Sedatives and benzodiazepines are avoided because they may
worsen delirium
Nursing Interventions for Delirium
1. Promoting client’s safety

o Teach client to request assistance for activities (getting out of bed,
going to bathroom)
o Provide close supervision to ensure safety during these activities.
o Promptly respond to client’s call for assistance.
2. Managing client’s confusion

o Speak to client in a calm manner in a clear low voice; use simple
sentences.
o Allow adequate time for client to comprehend and respond
o Allow client to make decisions as much as able.
o Provide orienting verbal cues when talking with client.
o Use supportive touch if appropriate.
3. Controlling environment to reduce sensory overload

o Keep environmental noise to minimum (television, radio).
o Monitor client’s response to visitors; explain to family and friends
that client may need to visit quietly one on one.
o Validate client’s anxiety and fears, but do not reinforce
misperceptions.
4. Promoting sleep and proper nutrition

o Monitor sleep and elimination patterns
o Monitor food and fluid intake; provide prompts or assistance to eat
and drink adequate amounts of flood and fluids
o Provide periodic assistance to bathroom if client does not make
requests
o Discourage daytime napping to help sleep at night
o Encourage some exercise during day like sitting in a chair,
walking in hall, or other activities client can manage.
B. Dementia
 A chronic, irreversible brain disorder characterized by impairments in

memory, abstract thinking, and judgement, as well as changes in
personality
 syndrome with progressive deterioration in intellectual functioning
secondary to structural or functional changes
 chronic development of multiple cognitive deficits manifested by
memory impairment and one or more of the following cognitive
disturbances:
o aphasia – a loss of the ability to understand or use language
o apraxia – an inability to carry out skilled and purposeful
movement; the inability to use objects properly despite intact
motor abilities
o agnosia – inability to recognize or name objects despite intact
sensory abilities
o Disturbance in executive functioning, which is the ability to think
abstractly and to plan, initiate, sequence, monitor, and stop
complex behavior
 Memory impairment is the prominent early sign
 Course is insidious and progressive, characterized by gradual onset and
continuing cognitive decline
 experiences a steady decline in physical and mental functioning and
usually requires long-term care in a specialized facility in the final stages
of the illness
 The most common type of dementia is Alzheimer’s disease
Etiology:
The most common types of dementia and their known or hypothesized causes
follow:
1. Alzheimer’s disease - progressive brain disorder that has a gradual

onset but causes an increasing decline in functioning; evidenced by
atrophy of cerebral neurons, senile plaque deposits, and enlargement of
the third and fourth ventricles of the brain.
2. Vascular dementia - has symptoms similar to those of Alzheimer’s, but
onset is typically abrupt followed by rapid changes in functioning, a
plateau or leveling-off period, more abrupt changes, another leveling-off
period, and so on; multiple vascular lesions of the cerebral cortex and
subcortical structures resulting from the decreased blood supply to the
brain.
3. Creutzfeldt-Jakob disease - central nervous system disorder that
involves altered vision, loss of coordination or abnormal movements,
and dementia that usually progresses rapidly (a few months). The cause
of the encephalopathy is an infectious particle resistant to boiling, some
disinfectants (e.g., formalin, alcohol), and ultraviolet radiation.
4. HIV disease can lead to dementia and other neurologic problems; these
may result directly from invasion of nervous tissue by HIV or from other
AIDS-related illnesses such as toxoplasmosis and cytomegalovirus.
5. Parkinson’s disease - slowly progressive neurologic condition
characterized by tremor, rigidity, bradykinesia, and postural instability;
results from loss of neurons of the basal ganglia
6. Huntington’s disease - inherited, dominant gene disease that primarily
involves cerebral atrophy, demyelination, and enlargement of the brain
ventricles.
7. Dementia can be a direct pathophysiologic consequence of head
trauma. The degree and type of cognitive impairment and behavioral
disturbance depend on the location and extent of the brain
injury. Repeated head injury (for example, from boxing) may lead to
progressive dementia.
Assessment Findings:
Dementia is a progressive disease and symptoms can be divided into three

(3) stages:
 Stage 1 (Mild dementia) – typically lasts 1 to 3 years

o memory loss of recent events
o personality changes, such as becoming more subdued or
withdrawn
o getting lost or misplacing objects
o difficulty with problem-solving and complex tasks, such as
managing finances
o trouble organizing or expressing thoughts
 Stage 2 (Moderate dementia) – lasting approximately 2 to 10 years

o increasing confusion or poor judgment
o greater memory loss, including a loss of events in the more
distant past
o needing assistance with tasks, such as getting dressed, bathing,
and grooming
o significant personality and behavior changes, often caused by
agitation and unfounded suspicion
o poor impulse control with frequent outbursts and tantrums
o changes in sleep patterns, such as sleeping during the day and
feeling restless at night
o wandering or aggressive behavior, hallucinations, delusions
o Confabulation – the filling in of memory gaps with imaginary
information in an attempt to distract others from observing the
deficit
o Agnosia
 Auditory Agnosia – inability to recognize familiar sounds
such as ringing doorbell or telephone
 Astereognosia – or tactile agnosia, inability to identify
familiar objects such as a comb or pencil when placed in the
hand
 Alexia - or visual agnosia, inability to identify an object or its
use by sight such as a toothbrush or telephone
 Agraphia – inability to read or write
 Stage 3 (Severe dementia) – lasting 8 to 10 years before death occurs

o Progressive decrease in response to environmental stimuli
leading to total nonresponsive or vegetative state
o Severe decline in cognitive function, losing ability to recognize
others or even self
o a loss of the ability to communicate; may scream spontaneously
or be able to say only one word; frequently becomes mute
o a need for full-time daily assistance with tasks, such as eating and
dressing
o a loss of physical capabilities, such as walking, sitting, and
holding one’s head up and, eventually, the ability to swallow, to
control the bladder, and bowel function
o an increased susceptibility to infections, such as pneumonia
Treatment and Prognosis:
 For degenerative dementias, no direct therapies have been found to

reverse or retard the fundamental pathophysiologic processes.
 Acetylcholine Replenishment therapy – can slow down progression of
mild to moderate dementia (acetylcholine precursors, cholinergic
agonists, and cholinesterase inhibitors)
o Tacrine (Cognex) effects can be seen in 6 weeks
 Note: can cause elevation in liver enzymes, discontinue
therapy if occurs; liver function test every 1 to 2 weeks
o Donepezil (Aricept), slows deterioration without serious liver
toxicity attributed to Tacrine ▪ rivastigmine (Exelon)
o galantamine (Reminyl)
 Other medications for symptomatic relief:
o Antidepressants are effective for significant depressive symptoms
o Antipsychotics such as haloperidol (Haldol), olanzapine (Zyprexa),
risperidone (Risperdal), and quetiapine (Seroquel) may be used to
manage psychotic symptoms of delusions, hallucinations, or
paranoia
o Lithium carbonate, carbamazepine (Tegretol), and valproic acid
(Depakote) help to stabilize affective lability and to diminish
aggressive outbursts.
 In Vascular Dementia, appropriate treatment of the underlying vascular
condition is towards improvement of cerebral blood flow
o changes in diet, exercise, control of hypertension or diabetes
Nursing Interventions for Dementia
1. Promoting client’s safety and protecting from injury

o Offer unobtrusive assistance with or supervision of cooking,
bathing, or self-care activities.
o Identify environmental triggers to help client avoid them.
2. Promoting adequate sleep, proper nutrition and hygiene, and activity

o Prepare desirable foods and foods client can self-feed; sit with
client while eating
o Monitor bowel elimination patterns; intervene with fluids and fiber
or prompts.
o Remind client to urinate; provide pads or diapers as needed,
checking and changing them frequently to avoid infection, skin
irritation, unpleasant odors
o Encourage mild physical activity such as walking.
3. Structuring environment and routine

o Encourage client to follow regular routine and habits of bathing
and dressing rather than impose new ones
o Monitor amount of environmental stimulation, and adjust when
needed.
4. Providing emotional support
o Be kind, respectful, calm, and reassuring; pay attention to client.
o Use supportive touch when appropriate.
5. Promoting interaction and involvement

o Plan activities geared to client’s interests and abilities.
o Reminisce with client about the past.
o If client is nonverbal, remain alert to nonverbal behavior.
o Employ techniques of distraction, time away, going along, or
reframing to calm clients who are agitated, suspicious, or
confused
Nursing Interventions specific to Issues related to Alzheimer’s Disease
 Wandering
o Provide the client with a safe environment.
o Prevent unsafe wandering.
o Provide the client with close supervision.
o Close and secure doors.
o Use identification bracelets and electronic surveillance.
 Communication
o Adapt to the communication level of the client.
o Use a firm volume and a low-pitched voice to communicate.
o Stand directly in front of the client and maintain eye contact.
o Call the client by name and identify self; wait for a response.
o Use a calm and reassuring voice.
o Use pantomime gestures if the client is unable to understand
spoken words.
o Speak slowly and clearly, using short words and simple
sentences.
o Ask only one question at a time and give one direction at a time.
o Repeat questions if necessary, but do not rephrase.
 Impaired judgment
o Remove throw rugs, toxic substances, and dangerous electrical
appliances from the environment.
o Reduce hot water heater temperature.
 Altered thought processes

o Call the client by name.
o Orient the client frequently.
o Use familiar objects in the room.
o Place a calendar and clock in a visible place.
o Maintain familiar routines.
o Allow the client to reminisce.
o Make tasks simple.
o Allow time for the client to complete a task.
o Provide positive reinforcement for positive behaviors.
 Altered sleep patterns

o Allow the client to wander in a safe place until he or she becomes
tired.
o Prevent shadows in the room by using indirect light.
o Avoid the use of hypnotics because they cause confusion and
aggravate the sundown effect.
 Agitation
o Assess the precipitant of the agitation.
o Reassure the client.
o Remove items that can be hazardous when the client is agitated.
o Approach the client slowly and calmly from the front, and speak,
gesture, and move slowly.
o Remove the client to a less stressful environment; decrease
excess stimuli.
o Use touch gently.
o Do not argue with or force the client.
C. Amnestic disorders
 characterized by a disturbance in memory that results directly from the
physiologic effects of a general medical condition or the persisting
effects of a substance such as alcohol or other drugs
 memory impairment characterized by inability to learn new information
or inability to recall previously learned information
 Confusion, disorientation, and attentional deficits are common
 Clients with amnestic disorders are similar to those with dementia in
terms of memory deficits, confusion, and problems with attention. They
do not, however, have the multiple cognitive deficits seen in dementia
Etiology:
1. Amnestic Disorder due to a general medical condition

o stroke or other cerebrovascular events, head injury,
2. Substance-induced persisting amnestic disorder amnestic disorder

o carbon monoxide poisoning, chronic alcohol ingestion, and
vitamin B12 or thiamine deficiency
Treatment and Prognosis
 focuses on eliminating the underlying cause and rehabilitating the client

and includes preventing further medical problems
Note: Nursing interventions are similar to those used when dealing with the
memory loss, confusion, and impaired attention abilities of clients with
dementia or delirium
References:


Prepared by:
restorative therapy, and the phase continues until

wound closure is achieved.
Rehabilitative Phase:
Goals is to gain
Overlaps acute phase of care independence and achieve
maximal function.
Extends beyond hospitalization
Note: Urinary output is the most reliable and most sensitive noninvasive

assessment parameter for cardiac output and tissue perfusion.
 Major Burn Management

1. Evaluate the degree and extent of the burn
2. Ensure a patent airway; administer 100% oxygen oxygen
(nonrebreather face mask)
3. Monitor for respiratory distress
4. Assess the oropharynx for blisters and erythema
5. Monitor arterial blood gases and carboxyhemoglobin levels.
6. For an inhalation injury, administer 100% oxygen via a tight-fitting
nonrebreather face mask until carboxyhemoglobin level falls below
15%.
7. Initiate peripheral IV access
8. Assess for hypovolemia
9. Monitor vital signs closely.
10. Insert a Foley catheter as prescribed
11. Manage fluid resuscitation; goal to maintain urine output at 30 to
50 mL/hour.
12. Maintain NPO (nothing by mouth) status.
13. Insert a nasogastric tube as prescribed
14. Administer tetanus prophylaxis as prescribed.
15. Administer pain medication as prescribed.
 Minor burns
1. Administer pain medication as prescribed.

2. Instruct the client in the use of oral analgesics as prescribed.
3. Administer tetanus prophylaxis as prescribed.
4. Administer wound care as prescribed
5. Instruct the client in follow-up care
Pain management
1. Administer opioid analgesics as prescribed by the IV route.

2. Avoid administering medication by the oral route.
3. Medicate the client before painful procedures.
Carbon monoxide poisoning Carbon monoxide is a colorless, odorless, and

tasteless gas that has an affinity for hemoglobin 200 times greater than that of
oxygen.
Oxygen molecules are displaced and carbon monoxide reversibly binds to

hemoglobin to form carboxyhemoglobin.
Tissue hypoxia occurs.
Blood Level (%) Clinical Manifestations

1-10 Normal level
Headache, Flushing, Decreased visual
11-20 (mild poisoning) acuity, Decreased cerebral functioning,
Slight breathlessness
Headache, Nausea and vomiting,

Drowsiness, Tinnitus and vertigo,
Confusion, and stupor Pale to reddish-
21-40 (moderate poisoning) purple skin, Decreased blood pressure,
Increased and irregular heart
rate, Depressed ST segment on
electrocardiogram
Coma, Seizures, Cardiopulmonary
41-60 (severe poisoning)
instability
61-80 (fatal poisoning) Death
Physiologic Integrity
Musculoskeletal System
Diagnostic Tests
Radiography and magnetic resonance imaging (MRI) are commonly used

procedures to diagnose disorders of the musculoskeletal system.
Nursing Interventions:
 Handle injured areas carefully and support extremities above and below the joint.
 Remove any radiopaque and metallic objects, such as jewelry.
 Shield the client’s testes, ovaries, or pregnant abdomen.
 NO to pregnant or expecting mothers.
 Inform that the radiation from radiography is minimal and not dangerous.
 *Administer analgesics as prescribed before the procedure.
Arthrocentesis is used to diagnose joint inflammation and infection; involves aspirating

synovial fluid, blood, or pus via a needle inserted into a joint cavity.
 Obtain informed consent

 Apply an elastic compression bandage post procedure
 Use ice to decrease pain and swelling.
 Administer analgesics as prescribed.
 Pain can continue for up to 2 days after administration of corticosteroids into a
joint.
 Instruct the client to rest the joint for 8 to 24 hours post procedure.
Arthroscopy provides an endoscopic examination of various joints; articular cartilage

abnormalities can be assessed, loose bodies removed, and the cartilage trimmed.
 Fasting: 8 to 12 hours before the procedure.

 Obtain informed consent.
 Assess the neurovascular status of the affected extremity.
 An elastic compression bandage should be worn post procedure for 2 to 4 days.
 Instruct the client that walking with weight bearing usually is permitted after
sensation returns but to limit activity for 1 to 4 days.
 Instruct the client to elevate the extremity as often as possible for 24 hours post-
op.
 Place ice on the site.
Dual-energy x-ray absorptiometry measures the bone mass of the spine,

wrist and hip bones, and total body.
Quantitative ultrasound evaluates strength, density, and elasticity of various

bones, using ultrasound rather than radiation.
 Inform the client that the procedure is painless.

 All metallic objects are removed before the test.
Bone scan is used to identify, evaluate, and stage bone cancer before and
after treatment; it is also used to detect fractures.
 NPO prior to the procedure.

 Remove all jewelry and metal objects.
 Increase OFI after the procedure to eliminate excess isotopes
 1 to 3 hours after the injection, have the client void before the scanning
procedure is completed.
Bone or muscle biopsy may be done during surgery or through aspiration or
punch or needle biopsy.

 Monitor for bleeding, swelling, hematoma, or severe pain.
 Elevate the site for 24 hours following the procedure.
 Apply ice packs.
 Monitor for signs of infection.
Electromyography (EMG) measures electrical potential associated with skeletal

muscle contractions.

 Instruct the client that the needle insertion is uncomfortable.
 Do not take any stimulants or sedatives for 24 hours before the procedure.
 Inform the client that slight bruising may occur at the needle insertion sites.
Injuries
Strains are an excessive stretching of a muscle or tendon.
 Apply warm and cold compress

 Limit activity
 Medicate for pain and muscle relaxants
Sprains are characterized by pain and swelling.
" R-I-C-E "
 Rest the affected site

 Apply Ice compress
 Apply Compression bandage
 Elevate legs
 *Casting may require
Rotator cuff injuries is characterized by shoulder pain and the inability to maintain
abduction of the arm at the shoulder (drop arm test).
 Apply ice to heat compress.

 Apply arm sling.
 Administer NSAIDs as prescribed.
Fractures a break in the continuity of the bone caused by trauma, twisting as a result of

muscle spasm or indirect loss of leverage, or bone decalcification and disease.
Signs and Symptoms:
" BROKEN "
 Bruising with pain and swelling

 Reduced movement
 Odd appearnace
 Kracking sounds
 Edema and erythema on sites
 Neurovascular impairment (decrease in sensation, temperature changes, loss of
function etc.)
Types of Fractures:
Closed or Simple: Skin over the fractured area remains intact.
Comminuted: The bone is splintered or crushed, creating numerous fragments.
Complete: The bone is separated completely by a break into 2 parts.
Compression: A fractured bone is compressed by other bone.
Depressed: Bone fragments are driven inward.
Greenstick: One side of the bone is broken and the other is bent; these fractures occur
most commonly in children.
Impacted: A part of the fractured bone is driven into another bone.

Incomplete: Fracture line does not extend through the full transverse width of the bone.
Oblique: The fracture line runs at an angle across the axis of the bone.
Open or Compound: The bone is exposed to air through a break in the skin, and soft
tissue injury and infection are common.
Pathological: The fracture results from weakening of the bone structure by pathological

processes such as neoplasia;also called spontaneous fracture.
Spiral: The break partially encircles bone. Transverse: The bone is fractured straight
across.
 Immobilize the affected extremity with a cast or splint.

 Assess the neurovascular status of the extremity.
 Interventions for a fracture: Reduction, fixation, traction, cast
Link
Traction is the exertion of a pulling force applied in 2 directions to reduce and

immobilize a fracture; provides proper bone alignment and reduces muscle
spasms.
" TRACTION "

 Temperature (infection, extremity)
 Ropes hang freely
 Alignments
 Circulation check
 Type and location of fracture
 Increase OFI
 Overhead trapeze
 No weight on bed or floor
Types of tractions:
Skeletal traction is applied mechanically to the bone with pins, wires, or

tongs; typical weight for skeletal traction is 25 to 40 lb (11 to 18 kg).
 Monitor color, motion, and sensation of the affected extremity.

 Monitor the insertion sites for redness, swelling, drainage, or increased
pain.
 Provide insertion site care as prescribed.
Skin traction is applied by using elastic bandages or adhesive, foam boot, or

sling.
Cervical Skin Traction relieves muscle spasms and compression in the upper
extremities and neck.
 Uses ahead halter and chin pad to attach the traction.

 Use powder to protect the ears from friction rub.
 Elevate the head of the bed 30 to 40 degrees.
 Attach the weights to a pulley system over the head of the bed.
Buck’s(extension) skin traction is used to alleviate muscle spasms and immobilize a

lower limb by maintaining a straight pull on the limb with the use of weights.
 Apply boot appliance to the attach to the traction.

 Not more than 8 to 10 lb (3.5 to 4.5 kg) of weight should be applied as
prescribed.
 Elevate the foot of the bed to provide the traction.
Pelvic Skin Traction is used to relieve low back,hip,or leg pain or to reduce
muscle spasm.
 Apply the traction belt snugly over the pelvis and iliac crest and attach to
the weights.
 Use measures as prescribed to prevent the client from slipping down in
bed.
Balanced Suspension Traction Used to approximate fractures of the femur,

tibia, or fibula; produced by a counterforce other than the client.
 Position the client in a low Fowler’s position on either the side or the back.
 Maintain a 20-degree angle from the thigh to the bed.
 Protect the skin from breakdown.
 Provide pin care (if pins are used with the skeletal traction)
 Clean the pin sites with sterile normal saline and hydrogen peroxide or povidone-
iodine.
Casts are used to immobilize bones and joints into correct alignment after a fracture or
injury using plaster, fiberglass, or air casts.
 Keep the cast and extremity elevated.

 Allow a wet plaster cast 24 to 72 hours to dry (synthetic casts dry in 20
minutes).
 Handle a wet plaster cast with the palms of the hands (not fingertips)
until dry.
 Turn the extremity every 1 to 2 hours, unless contraindicated.
 A hair dryer can be used on a cool setting to dry
 Monitor closely for circulatory impairment (compartment syndrome)
 Maintain smooth edges around the cast to prevent crumbling of the cast
material.
 Monitor for signs of infection such as increased temperature, hot
spots on the cast, foul odor, or changes in pain.
 Instruct the client not to stick objects inside the cast.
 Teach the client to keep the cast clean and dry.
 Instruct the client in isometric exercises to prevent muscle atrophy.
Link
Caution! Monitor a casted extremity for circulatory impairment such as pain,

swelling, discoloration, tingling, numbness, coolness, or diminished pulse.
Notify the HCP immediately if circulatory compromise occurs.
Complications of Fractures:
Fat Embolism
1. Notify the health care provider (HCP).

2. Administer oxygen.
3. 3. Administer intravenous (IV) fluids
4. Monitor vital signs and respiratory status.
5. Prepare for intubation and mechanical ventilation if necessary as
6. Follow up on results of diagnostic tests such as chest x-ray or CT)scan.
7.
7. Documentation
Pulmonary Embolism is caused by the movement of foreign particles (blood

clot, fat, or air) into the pulmonary circulation.
Signs and Symptoms:
 Restlessness and apprehension

 Sudden onset of dyspnea and chest pain
 Cough, hemoptysis, hypoxemia, or crackles
 Notify the HCP immediately
 Administer oxygen, intravenous(IV), anticoagulant therapy.
Compartment Syndrome occurs when pressure increases within 1 or more

compartments, leading to decreased blood flow, tissue ischemia, and
neurovascular impairment.
Note: * Neurovascular damage may be irreversible if not treated within 4 to 6

hours .
Signs and Symptoms:
" 5Ps "
 Pain (increasing) in the limb.

 Pale, dusky, or edematous distal tissues.
 Pain with passive movement
 Paresthesia
 Pulselessness (late sign)
 Notify the HCP immediately

 Elevate the affected extremity.
 Fasciotomy to relieve pressure and restore tissue perfusion.
 Loosen tight dressings or bivalve restrictive cast as prescribed.
Osteomyelitis (inflammatory response in bone tissue) can be caused by the

introduction of organisms into bones leading to localized bone infection.
Signs and Symptoms:
 Tachycardia and fever

 Erythema and pain in the area
 Leukocytosis and elevated ESR level
 Notify the HCP
 Prepare to initiate aggressive, long-term IV antibiotic therapy.
Avascular necrosis occurs when a fracture interrupts the blood supply to a

section of bone, leading to bone death.
Signs and Symptoms:
 Pain
 Decreased sensation
 Notify the HCP if pain or numbness occurs.

 Prepare the client for removal of necrotic tissue.
Crutch Walking
*This video includes all the things you need to learn regarding the use of
crutches.
Please click the " Link " below to watch this video.
Link
 The distance between the axillae and the arm: 2 to 3 fingerwidths in

the axilla space.
 The elbows should be slightly flexed, 20 to 30 degrees, when the client
is walking.
 When ambulating with the client, stand on the affected side.
 Look up and outward when ambulating and to place the crutches 6 to
10 inches (25.5 cm) diagonally in front of the foot.
 Instruct the client to stop ambulation if numbness or tingling in the
hands or arms occurs.
Remember! Going up and down stairs:
GOOD -up; BAD -down

Hemicanes or quadripod canes are used for clients who have the use of
only 1 upper extremity.
 Position the cane at the client’s unaffected side, with the

straight,nonangled side adjacent to the body.
 Position the cane 6 inches (15 cm) from the unaffected client’s side.
Walker
 Stand adjacent to the client on the affected side.

 Instruct the client to put all 4 points of the walker flat on the floor before
putting weight on the hand pieces.
 Instruct the client to move the walker forward, followed by the affected
or weaker foot and then the unaffected foot.
Fractured Hip
Types:
1. Intracapsular (femoral head is broken within the joint capsule); Femoral

head and neck receive decreased blood supply and heal slowly.
 Skin traction is applied preoperatively to reduce the fracture and

decrease muscle spasms
 Treatment: Total hip replacement or open reduction internal fixation
(ORIF) with femoral head replacement.
 To prevent hip displacement postoperatively; avoid extreme hip flexion.
2. Extracapsular (fracture is outside the joint capsule) fracture can occur at

the greater trochanter or can be an intertrochanteric fracture.
 Preoperative treatment: Balanced suspension or skin traction

 Surgical treatment: ORIF with nail plate, screws, pins, or wires.
 Postoperative treatment: Monitor for signs of delirium and institute
safety measures. Prevent internal or external rotation; avoid extreme hip
flexion.
 Elevate the head of the bed 30 to 45 degrees for meals only.

 Avoid weight-bearing on the affected leg.
 Keep the operative leg extended, supported, and elevated (preventing
hip flexion)
 Monitor for wound infection or hemorrhage.
 Use antiembolism stockings or sequential compression stockings.
 Avoid crossing the legs and activities that require bending over.
Total knee replacement is the implantation of a device to substitute for the

femoral condyles and tibial joint surfaces.
Post-Op Care:
 Monitor surgical incision for drainage and infection.

 Prepare the client for out-of-bed activities as prescribed; avoid leg
dangling.
 Weight-bearing with an assistive device is prescribed as tolerated.
 Administer antibiotics if prescribed.
Joint Dislocation injury of the ligaments surrounding a joint, which leads to

displacement or separating of the articular surfaces of the joint.
Subluxation incomplete displacement of joint surfaces when forces disrupt

the soft tissue that surrounds the joints.
Signs and Symptoms:
 Asymmetry of the contour of affected body parts.

 Pain, tenderness, dysfunction, and swelling
 X-rays are taken to determine joint shifting.
 Focus of treatment: pain relief, joint support, and joint protection.
 Open or closed reduction is done with a postprocedural joint
immobilization.
 Initial activity restriction is followed by gentle range-of-motion activities
and a gradual return of activities to normal levels.
Cervical Disk Herniation occurs at the C5 to C6 and C6 to C7 interspaces;

causes pain radiation to shoulders, arms, hands, scapulae, and pectoral
muscles.
Signs and Symptoms:
 Paresthesia
 Numbness
 Weakness of the upper extremities
 Bed rest
 Immobilize the cervical area with a cervical collar or brace.
 Apply heat to reduce muscle spasms and apply ice to reduce
inflammation and swelling.
 Maintain head and spine alignment.
 Administer analgesics, corticosteroids, sedatives, and antiinflamatory
medications as prescribed.
 Avoid flexing,extending,and rotating the neck.
 Avoid the prone position; maintain in neutral position
Lumbar Disk Herniation most often occurs at the L4 to L5 or L5 to S1

interspace. Pain is relieved by bed rest and aggravated by movement, lifting,
straining, and coughing.
Signs and Symptoms:
 Lower back pain radiating to lower limbs down.

 Muscle spasm to lower extremities.
 Apply heat to decrease muscle spasms and apply ice to decrease
inflammation and swelling.
 Instruct the client to sleep on the side, with the knees and hips flexed,
and place a pillow between the legs.
 Apply pelvic traction as prescribed to relieve muscle spasms and
decrease pain.
 Begin progressive ambulation as inflammation, edema, and pain
subside.
 Instruct the client about application techniques for corsets or braces to
maintain immobilization and proper spine alignment.
 Instruct about proper body mechanics.
Lumbar Disk Injury
Link
Disk Surgery is used when spinal cord compression is suspected or

symptoms do not respond to conservative treatment.
Pre-Op Care:
 Monitor for respiratory difficulty from inflammation or hematoma.

 Encourage coughing, deep breathing, and early ambulation.
 Monitor for hoarseness and inability to cough effectively.
 Assess the surgical dressing; monitor the surgical wound for infection,
swelling, redness, drainage, or pain.
 DIET: Soft diet
 Monitor for sudden return of radicular pain; may indicate cervical spine
instability.
Post-Op Care:
 Assess the surgical dressing; bleeding, drainage, and surgical drains.

 Monitor lower extremities for sensation, movement, color, temperature,
and paresthesia.
 Monitor for urinary retention, paralytic ileus, and constipation.
 DIET: High fiber diet; increase oral fluid intake (OFI)
 Administer opioids and sedatives as prescribed to relieve pain and
anxiety.
 Assist regarding the use of back brace or corset and to wear cotton
underwear to prevent skin irritation.
 Position: Lie in supine; place a pillow under the neck and slightly flex the
knees.
 Avoid spinal flexion or twisting and that the spine should be kept
aligned.
 Avoid extreme hip flexion when lying on the side.
 Following disk surgery, instruct the client in correct logrolling
techniques for turning and repositioning and for getting out of bed.
Corset Application
Link
Amputation is the surgical removal of a limb or part of the limb.
Post-Op Care:
 Monitor for signs of complications ( hemorrhage, infection, phantom limb

pain, neuroma, and flexion contractures)
 Mark bleeding and drainage on the dressing if it occurs.
 Evaluate for phantom limb sensation and pain; medicate immediately.
 Do not elevate the residual limb on a pillow.
 First 24 hours: Elevate the foot of the bed to reduce edema; then keep
the bed flat to prevent hip flexion contractures,
 After 24 to 48 hours: position the client prone to stretch the muscles
and prevent hip flexion contractures.
 Maintain surgical application of dressing,elastic compression wrap, or
elastic stump.
 Massage the skin toward the suture line to mobilize scar and prevent its
adherence to underlying bone.
 Provide emotional support for the loss of body part.
Interventions for below-knee amputation:
" NAPE "

 Not to hang residual limbs over the edge of the bed.
 Alignment: Discourage long periods of sitting and knee flexion.
 Prone position
 Edema prevention
Interventions for above-knee amputation:
" 2Ps "
 Position in prone
 Prevent internal or external rotation of the limb; use sandbag, rolled
towel, or trochanter roll along the outside of the thigh.
Rheumatoid Arthritis (RA) is a chronic systemic inflammatory disease

(immune complex disorder); the cause may be related to a combination of
environmental and genetic factors; leads to destruction of connective tissue
and synovial membrane within the joints.
Signs and Symptoms:
 Inflammation, tenderness, and stiffness of the joints

 Morning stiffness lasting longer than 30 minutes.
 Spongy, soft feeling in the joints
 Low-grade temperature, fatigue, and weakness
 Elevated ESR and positive rheumatoid factor (Reference interval:
Negative or < 60 units/mL)
 Synovial tissue biopsy reveals inflammation
 Provide range-of-motion exercise.

 Splints may be used during acute inflammation to prevent deformity.
 Apply heat or cold therapy as prescribed to joints.
 Avoid weight-bearing on inflamed joints.
 Identify and correct safety hazards in the home.
 Encourage the client to verbalize feelings.
 Assist the client with self-care activities and grooming.

Pathophysiology of RA VS OA
Link
Osteoarthritis (OA) is marked by progressive deterioration of the articular

cartilage; causes bone buildup and the loss of articular cartilage in peripheral
and axial joints.
Signs and Symptoms:
 Joint pain that diminishes after rest and intensifies after activity.

 Pain occurs with slight motion or even at rest.
 Aggravated by temperature change and climate humidity.
 Difficulty getting up after prolonged sitting.
 Presence of Heberden’s nodes (high) or Bouchard’s nodes (below)
 Administer medications as prescribed, such as acetaminophen or

topical applications, NSAIDs and muscle relaxants.
 Position joints in function position and avoid flexion of knees and hips.
 Prepare the client for corticosteroid injections into joints as prescribed.
 Provide a bed or foot cradle to keep linen off of feet and legs until
inflammation subsides.
 Avoid large pillows under the head or knees.
 Immobilize the affected joint with a splint or brace until inflammation
subsides.
 Apply cold applications as prescribed when the joint is acutely
inflamed.
 Instruct the client to balance activity with rest and to participate in an
exercise program.
Gout is a systemic disease in which urate crystals deposit in joints and other body
tissues; results from abnormal amounts of uric acid in the body.
Pathophysiology
Link
Types:
Primary gout results from a disorder of purine metabolism.
Secondary gout involves excessive uric acid in the blood caused by another disease.
Phases:
1. Asymptomatic: Client has no symptoms but serum uric acid level is elevated.

2. Acute: Client has excruciating pain and inflammation of 1 or more small joints,
especially the great toe.
3. Intermittent: Client has intermittent periods without symptoms between acute
attacks.
4. Chronic: Results in deposits of urate crystals under the skin, within major
organs, such as the kidneys, leading to organ dysfunction.
Signs and Symptoms:
 Swelling and inflammation of the joints,leading to excruciating pain.

 Tophi: Hard, irregularly shaped nodules in the skin containing chalky deposits of
sodium urate
 Low-grade fever, malaise, and headache.
 Pruritus from urate crystals in the skin
 Presence of renal stones from elevated uric acid levels
 DIET: Low-purine diet; avoiding foods such as organ meats, wines, and aged
cheese.
 Encourage a high fluid intake of 2000 mL/day.
 Encourage a weight reduction diet.
 Avoid alcohol and starvation diets because they may precipitate a gout attack.
 Increase urinary pH (above 6) by eating alkaline ash foods (i.e., green beans,
broccoli).
 Monitor joint range-of-motion ability and appearance of joints.
 Provide heat or cold for local treatments to affected joint as prescribed.
 Administer medications such as analgesic, antiinflammatory, and uricosuric
agents as prescribed.
 Position the joint in mild flexion during acute attack.

Osteoporosis occur post menopausal or as a result of a metabolic disorder
or calcium deficiency; most commonly in the wrist, hip, and vertebral column.
Pathophysiology of Osteoporosis
Types:
Primary osteoporosis
a. Most often occurs in postmenopausal women; occurs in men with low

testosterone levels
b. Risk factors include decreased calcium intake, deficient estrogen, and

sedentary lifestyle.
Secondary osteoporosis
a. Causes include prolonged therapy with corticosteroids, thyroid-reducing

medications, aluminum-containing antacids, or antiseizure medications.
b. Associated with immobility, alcoholism, malnutrition, or malabsorption
Risk Factors for Osteoporosis
▪ Cigarette smoking
▪ Early menopause
▪ Excessive use of alcohol
▪ Family history
▪ Female gender
▪ Increasing age
▪ Insufficient intake of calcium

▪ Sedentary lifestyle
▪ Thin, small frame
▪ White (European descent) or Asian race
Signs and Symptoms:
 Back pain that occurs after lifting, bending, or stooping.

 Pelvic or hip pain, especially with weight-bearing.
 Decline in height from vertebral compression.
 Kyphosis of the dorsal spine, also known as “dowager’s hump”
 Safety measures
 Clear walkway at home.
 Use side rails to prevent falls.
 Instruct in use of assistive devices such as a cane or walker.
 Use of a firm mattress.
 Move the client gently when turning and repositioning.
 Provide gentle range-of-motion exercises..
 Apply a back brace as prescribed during an acute phase.
 DIET: high in protein, calcium, vitamins C and D, and iron
 Maintain an adequate fluid intake to prevent renal calculi.
Musculoskeletal Medications
Medication Nursing Considerations
Skeletal Muscle Relaxants: Safety is a primary concern
when the client is taking a
▪ Baclofen ▪ Carisoprodol ▪ Chlorzoxazone ▪ skeletal muscle relaxant
Cyclobenzaprine ▪ Dantrolene ▪ Diazepam ▪ because these medications
Metaxalone ▪ Methocarbamol ▪ Orphenadrine ▪ cause drowsiness.
Tizanidine
Baclofen causes CNS effects
such as drowsiness, dizziness,
weakness, and fatigue; and
nausea, constipation, and
urinary retention.
Carisoprodol take with food to

prevent gastrointestinal upset.
Chlorzoxazone cause the urine

to turn orange or red.
Cyclobenzaprine is
contraindicated in clients who
have received monoamine
oxidase
inhibitors (MAOIs) within 14
days of initiation and cardiac
disorders; caution in clients
with a history of urinary
retention, angle-closure
glaucoma, or increased IOP.
Dantrolene is hepatotoxic;
cause gastrointestinal bleeding,
urinary frequency,
impotence, photosensitivity,
rash, and muscle weakness.
Methocarbamol is nephrotoxic;
cause hypotension,
bradycardia, anaphylaxis, and
seizures, especially when the
medication is given too
rapidly; *cause the urine to turn
brown, black, or green.
Tizanidine and metaxalone ar
e hepatotoxic.
Orphenadrine caution in clients
with a history of urinary
retention, angle-closure
glaucoma, or increased IOP.
Antiarthritic: Adalimumab has been
associated with neurological
▪ Anakinra ▪ Adalimumab ▪ Azathioprine injury (numbness, tingling,
▪ Cyclosporine ▪ Etanercept dizziness, visual disturbances,
▪ Hydroxychloroquine ▪ Infliximab ▪ Leflunomide ▪ weakness in the legs); can
Methotrexate ▪ Penicillamine ▪ Rituximab cause PTB reactivation
▪ Sulfasalazine
Azathioprine toxic effects
include hepatitis and blood
dyscrasias.
Cyclosporine can cause
nephrotoxicity.
Etanercept has been
associated with CNS
demyelinating disorders and
hematological disorders.
Hydroxychloroquine associat
ed with retinal damage and
visual disturbances.
Leflunomide side and adverse

effects include diarrhea,
respiratory infection, reversible
alopecia, rash, and nausea;
medication is hepatotoxic.
Methotrexate bone marrow
suppression, gastrointestinal
ulceration, and pneumonitis.
Penicillamine can cause bone

marrow suppression and
autoimmune disorders.
Infliximab can cause infusion

reactions (fever, chills, pruritus,
urticaria, chest pain);
medication is hepatotoxic.
Sulfasalazine can cause
gastrointestinal and
dermatological reactions, bone
marrow suppression, and
hepatitis.
Calcitonin monitor for
hypocalcemia.
Bisphosphonates administere
d in the morning before eating
or drinking with a full glass of
water; the client must then
Antiresorptive
remain sitting or standing and
postpone ingesting anything for
▪ Calcium and vitamin D ▪ Raloxifene ▪
at least 30 minutes (60 minutes
Calcitonin ▪ Bisphosphonates
with ibandronate).
Raloxifene contraindicated in
clients who have a history of
venous thrombotic events .
Peripheral Vascular Disorders
Arterial Disorders "Think of a Dying Garden"
When your patient suffers from arterial disease, blood return is not the issue.
Instead, we have a problem with the flow – blood that can’t get down to the
area in question. As a result, the surface will look more like a “barren
wasteland.” Think of it as a garden: if you can’t transport water and nutrients
to the plants (in this case, tissues), everything will dry up and die.
Causes: partial stenosis or complete occlusion (Atherosclerosis)

Signs and symptoms:
 Intermittent claudication
 Dusky, purplish (gray-blue) discoloration of feet (dependent)
 White/pale (elevated)
 Lower back, buttock discomfort
 Loss of hair, shiny skin (lower ex)
 Low BP on lower ex
 Thickened toenails
 Ulcers on legs
Deep, pale (common: toes, feet, other skin areas)
 Venous refiling (dependent)

 Decreased or absent pedal pulse
 Numbness, cold, tingling in extremity
Interventions:
 Elevate the feet at rest (not at the level of the heart)

 Severe cases (edema) – sleep with affected limb hanging or sit upright
(s leg elevation)
 Individualized exercise program
 Avoid crossing legs
 Avoid exposure to cold
 NEVER apply direct heat
 Inspect daily – report signs of breakdown
Procedures:
 Percutaneous transluminal angioplasty
 Laser-assisted angioplasty
 Atherectomy
 Bypass surgery
Venous Disorders "It’s About Pooling Blood"
When your patient has venous insufficiency, what’s going on? It’s not a
problem with blood flow, it’s a problem with blood return. When the blood can’t
get back up to the heart, it pools in the lower leg.
Causes: Thromboembolism, varicose, chronic venous insufficiency
Signs and symptoms:
 Discoloration of the lower extremity, stasis dermatitis

 Edema over the tibia
 Ulcers
 Tenderness in legs
 Positive Homan’s sign
Arterial vs. Venous
Arterial Venous
Pain Intermittent claudication Aching: cramping
Pulse Assessment Diminished or absent Present
Deep, pale (toes, feet, other Superficial, pink (inner/outer

Ulcer
skin areas) ankle)
Dependent rubor/dusky red;
Thick and tough, brawny
pallor upon elevation; dry,
Skin pigment, normal temp, may
shiny, skin; cool or cold
have edema
temperature, mild edema
Medications:
 Pentoxifylline Trental: Decrease blood viscosity and increase

microcirculation.
 Vasodilators prostaglandins
 Anticoagulant/thrombolytic therapy
 Antiplatelet drugs: cilostazol (Petal)
Risk reduction:
 Management of body weight

 Physical exercise
 Smoking cessation
 Others…
Sclerotherapy
 A solution is injected into the vein, followed by the application of a

pressure dressing.
 Incision and drainageofthetrapped blood in the sclerosed vein is
performed 14 to 21 days
after the injection, followed by the application of a pressure dressing for
12 to 18 hours.
Laser therapy: A laser fiber is used to heat and close the main vessel
contributing to varicosity.
Vein stripping: Varicose veins may be removed if they are larger than 4 mm

in diameter or if they are in clusters; other treatments are usually tried before
vein stripping.
Raynaud’s Disease
Vasospasm of the arterioles and arteries of the upper and lower extremities.
Assessment:
 Blanching, followed by cyanosis

 Reddened tissue (relieved vasospasm)
 Numbness, tingling, swelling, and a cold temp
(primarily fingers, toes, ears, and cheeks)
Interventions:
 Monitor pulses
 Vasodilators
 Avoid precipitating factors
 Avoid smoking
 Wear warm clothing
 Avoid injuries to fingers and hands
Buerger’s Disease (Thromboangiitis Obliterans)
Assessment:
 Intermittent claudication
 Ischemic pain at rest
 Cool, numb, tingling
 Diminished pulse in distal extremities
 Cool and red in a dependent position
 Loss of hair, shiny skin
 Thick nails
Reynaud's vs. Buerger's
Reynaud's Buerger’s
Inflammatory occlusive vascular
Constriction of small arteries disease mid-sized arteries and
Definition and arterioles of the fingers veins
and skin
Common: feet
Cause Autoimmune Smoking
Population Young women Asian, Jewish, Smokers, <40
Red-white-blue syndrome of Pain at rest, intermittent
digits, normal pulse, pain, claudication, rubor and cyanosis,
Signs and symptoms
sensory changes, pallor and decreased/absent pulse, loss of
cyanosis, thick nails hair/shiny extremities, think nails
Exercise, long-term exposure Smoking, cold, stress, has
Triggers
to cold, stress remissions and exacerbations

Aortic Aneurysm
 An aortic aneurysm is an abnormal dilation of the arterial wall caused by

localized weakness
and stretching in the medial layer or wall of the aorta.
 Can The aneurysm can be located anywhere along the abdominal
aorta.
 Goal of treatment: limit the progression of the disease by modifying risk
factors, controlling
the BP to prevent strain on the aneurysm, recognizing symptoms early,
and preventing rupture.
 Saccular: Distinct localized outpouching of the artery wall

 Fusiform: Diffuse dilation that involves the entire circumference of the
arterial segment
 False (pseudoaneurysm): Occurs when the clot and connective tissue
are outside the arterial
wall as a result of vessel injury or trauma to all 3 layers of the arterial
wall.
 Dissecting: Created when blood separates the layers of the artery wall,
forming a cavity between them
Assessment:
Thoracic aneurysm
 Pain extending to neck, shoulders, lower back, or abdomen

 Syncope
 Dyspnea
 Increased pulse
 Cyanosis
 Hoarseness, difficulty swallowing (pressure from the aneurysm)
Abdominal aneurysm
 Prominent, pulsating mass in the abdomen, at or above the umbilicus

 Systolic bruit over the aorta
 Tenderness on deep palpation
 Abdominal or lower back pain
Rupturing aneurysm
 Severe abdominal or back pain

 Lumbar pain radiating to the flank and groin
 Hypotension
 Increased pulse rate
 Signs of shock
 Hematoma at flank area
Interventions:
Monitor vital signs.
b. Obtain information regarding back or abdominal pain.
c. Question the client of the pulsation in the abdomen.
d. Check peripheral circulation, including pulses, temperature, and color.
e. Observe for signs of rupture.
f. Note any tenderness over the abdomen.
g. Monitor for abdominal distention.
6. Nonsurgical interventions
a. Modify risk factors.
b. Instruct the client regarding the procedure for monitoring BP.
c. Regular HCP visits to follow the size of the
aneurysm.
d. Severe back or abdominal pain or fullness, soreness over
the umbilicus, sudden development of discoloration in the extremities, or a
persistent
elevation of BP? notify the HCP immediately.
Instruct the client with an aortic aneurysm to report immediately the

occurrence of chest or back pain, shortness of breath, difficulty
swallowing, or hoarseness.
Pharmacological interventions:
1. Antihypertensives
2. Instruct the client about the purpose of the medications.
AAA resection
Surgical resection or excision of the aneurysm; the excised section is replaced

with a
graft that is sewn end to end.replaced with a graft that is sewn end to end.
Preoperative AAA resection:
 Assess all pulses (baseline for postop comparison)

 Coughing and deep breathing exercises
Postoperative AAA resection:
 VS
 Monitor peripheral pulses (distal)
 Graft occlusion: changes in pulses, cool to cold extremities below the
graft, white or blue extremities
 Limit elevation to 45 degrees
 Monitor hypovolemia, kidney failure, respiratory complications
 Monitor urine output, serum creatinine, and BUN daily
 No heavy lifting – 15 to 20 lbs for 12 weeks
 Do not to drive a vehicle until approved by the HCP.
Thoracic aneurysm repair:
 Thoracotomy or median sternotomy approach

 Total cardiopulmonary bypass: excision of aneurysms in the ascending
aorta
 Partial cardiopulmonary bypass
Postoperative Interventions
 VS, Neuro and renal status

 Monitor for signs of hemorrhage
 Monitor for increased in chest tube drainage, bleeding, separation at the
graft site
 Assess sensation and motion of all extremities: notify the HCP if deficits
are noted (lack of blood supply in the spinal cord during the surgery)
 Monitor respiratory complications
 Encourage turning, coughing, and deep breathing while splinting the
incision.
 Discharge instructions regarding pain management, wound care, and
activity restrictions.
 Not to lift objects heavier than 15 to 20 lbs for 6 to 12 weeks.
 Avoid activities requiring pushing, pulling, or straining.
 Not to drive a vehicle until approved by the HCP.
Venous Thrombosis
 Thrombophlebitis: inflammation
 Phlebothrombosis: without inflammation
 Phlebitis: associated with invasive procedures
 Deep vein thrombophlebitis: more serious due to respiratory
compromise
 Venus stasis, HF, immobility
 Hypercoagulability disorders
 Injury to the venous wall
 Post ortho and abdominal surgery
 Pregnancy
 Ulcerative colitis
 Use of contraceptives
 Certain malignancies
 Fractures, injuries of the pelvis or lower ext
Risk factors:
 Venus stasis, HF, immobility

 Hypercoagulability disorders
 Injury to the venous wall
 Post ortho and abdominal surgery
 Pregnancy
 Ulcerative colitis
 Use of contraceptives
 Certain malignancies
 Fractures, injuries of the pelvis or lower ext
Phlebitis
 Red, warm area radiating up the vein and extremity
 Pain
 Swelling
Interventions:
 Apply warm, moist soaks

 Assess for signs of complications such as tissue necrosis, infection, or
pulmonary embolus.
Deep Vein Thrombosis
 Calf or groin tenderness, pain with/without swelling

 Positive Homan’s sign
 Warm skin, tender to touch
Interventions:
 Bed rest
 Leg elevation 10 to 20 minutes every few hours
 AVOID using knee gatch or pillow under the knees
 Do not massage
 Antiembolic stockings (knee-knee, thigh-thigh)
 Moist compress (intermittent or continuous)
 Monitor for warmth and edema
 Measure/record circumference of thighs and calves\
 Monitor for shortness of breath and chest pain
 Thrombolytic therapy - initiated within 5 days after the onset
 Heparin therapy – monitor APTT
 warfarin when DVT resolves – monitor PT and INR
Client education:
 Hazards of anticoagulation therapy

 Recognize bleeding
 Avoid constrictive activities
 Elevate extremity 10-20 mins every few hours
 Progressive exercise program
 Inspect legs for edema, measure
 Antiembolism stockings
 Avoid smoking
 Avoid OTC
 Medic-Alert bracelet
Varicose veins
Distended, protruding veins that appear darkened and tortuous are evident.
Vein walls weaken and dilate, and valves become incompetent.
Assessment
 Pain in the legs; dull aching after standing

 A feeling of fullness in the legs
 Ankle edema
 Stasis ulcer
 Trendelenburg’s tests:
a. Place the client in a supine position with the legs elevated.

b. When the client sits up, if varicosities are present, veins fill from the
proximal end;
veins normally fill from the distal end.
Interventions:
 Antiembolism stockings
 Elevate legs
 Avoid constrictive clothing, pressure on legs
 Prep for sclerotherapy/vein stripping

Embolectomy
Removal of an embolus from an artery, using a catheter. Patch graft may be

required to close the artery.
Preoperative Interventions:
 Obtain a baseline vascular assessment.

 Anticoagulants as prescribed.
 Thrombolytics as prescribed.
 Place a bed cradle on the bed.
 Avoid bumping or jarring the bed.
 Maintain the extremity in a slightly dependent position.
Postoperative Interventions:
 Assess cardiac, respiratory, and neurological status.

 Monitor affected extremity for color, temperature, and pulse.
 Assess sensory and motor function of the affected extremity.
 Monitor for signs and symptoms of new thrombi or emboli.
 Administer oxygen as prescribed.
 Monitor pulse oximetry.
 Monitor for complications caused by reperfusion of the artery, such as
spasms and swelling
of the skeletal muscles.
 Monitor for signs of swollen skeletal muscles: as edema, pain on
passive movement, poor
capillary refill, numbness, and muscle tenseness.
 Maintain bed rest initially, with the client in a semi-Fowler’s position.
 Place a bed cradle on the bed.
 Check the incision site for bleeding or hematoma.
 Administer anticoagulants as prescribed
 Monitor laboratory values related to anticoagulant therapy.
 Instruct the client to recognize the signs and symptoms of infection and
edema.
 Instruct the client to avoid prolonged sitting or crossing the legs when
sitting.
 Instruct the client to elevate the legs when sitting.
 Instruct the client to wear antiembolism stockings as prescribed and
how to remove and reapply the stockings.
 Instruct the client to ambulate daily.
 Instruct the client about anticoagulant therapy and the hazards
associated with anticoagulants.
Vena Cava Filter and Ligation of Inferior Vena Cava
Insertion of an intracaval filter (umbrella) that partially occludes the inferior

vena
cava and traps emboli to prevent pulmonary emboli
Ligation: Suturing or placing clips on the inferior vena cava to prevent

pulmonary emboli; done
via abdominal laparotomy
Preoperative Intervention:
 D/C anticoagulant (may cause bleeding)

Postoperative interventions:
 Administer oxygen as prescribed.

 Maintain a semi-Fowler’s position.
 Avoid hip flexion.
 Provide activity as prescribed.
 Check the insertion site for bleeding or hematoma and signs or
symptoms of infection.
 Assess for peripheral edema.
 Maintain antiembolism stockings as prescribed.
 Monitor laboratory values related to anticoagulant therapy.
 Instruct the client to recognize the signs and symptoms of infection and
edema.
 Instruct the client to avoid prolonged sitting or crossing the legs when
sitting.
 Instruct the client to elevate the legs when sitting.
 Instruct the client to wear antiembolism stockings as prescribed and
how to remove and reapply the stockings.
 Instruct the client to ambulate daily.
 Instruct the client about anticoagulant therapy and the hazards
associated with anticoagulants.
Review: Hypertension and Hypertensive Crisis
Sources:
 Saunder's NCLEX Comprehensive 7th edition.

 http://blog.wcei.net/2017/07/venous-vs-arterial-ulcers-whats-the-
difference
 www.youtube.com RegisteredNurseRN
Immune Disorders

Immune Response
Laboratory Studies
1. Antinuclear antibody (ANA) determination is a blood test used for the

differential diagnosis of rheumatic diseases and for the detection of
antinucleoprotein factors .
2. Anti-dsDNA antibody test monitors disease activity and response to
therapy, and establishes a prognosis for SLE.
3. Human immunodeficiency virus (HIV) testing monitors the
progression of HIV.
 Normal Value: CD4+ T-cell counts higher than 500 cells/L, < 200cell/L
= Immunocompromised
4. Viral culture involves placing the infected client’s blood cells in a culture

medium and measuring the amount of reverse transcriptase activity over a
specified period of time.
5. Viral load testing measures the presence of HIV viral genetic material
(RNA) or another viral protein in the client’s blood.
6. P24 antigen Assay quantifies the amount of HIV viral core protein in the
client’s serum.
7. Oral testing for HIV uses a device that is placed against the gum and
cheek for 2 minutes.
8. Home test kits for HIV a drop of blood is placed on a test card with a
special code number.
9. Skin testing administration ofan allergen to the surface of the skin or into

the dermis.
Preprocedure interventions:
 Discontinue systemic corticosteroids or antihistamine therapy 5

days before the test
 Ensure that informed consent was obtained.
Postprocedure Interventions:
 Record the site, date, and time of the test.

 Have the client remain in the waiting room or office for at least 30
minutes after the injections
 Inspect the site for erythema, papules, vesicles, edema, and wheal
 Measure flare along with the wheal, and document the size and other
findings
(Normal: <0.5 cm in diameter)
 Provide the client with a list of potential allergens, if identified.
Anaphylaxis a serious and immediate hypersensitivity reaction that releases histamine

from the damaged cells (localized or systemic).
Pathophysiology
Cause:
 Food
 Latex
 Medications
 Chemicals
 Cosmetic products
 Environmental factors
Signs and Symptoms:
" Hypo- Tachy- Tachy- Diz - Hoarse- Head- *Pruritus "
 Hypotension
 Tachycardia
 Tachypnea
 Dizziness
 Hoarseness
 Headache
 *Pruritus
PRIORITY NURSING ACTIONS!
1. Respiratory status and maintain a patent airway

2. Call the Rapid Response Team
3. Administer oxygen
4. Start an IVF (PNSS)
5. Prepare to administer diphenhydramine and epinephrine
6. Documentation
Immunodeficiency is the absence or inadequate production of immune bodies.
Goal: Protection against infection.
Autoimmune Disease
1. Systemic lupus erythematosus (SLE) chronic, progressive, systemic

inflammatory disease that can cause major organs and systems to fail.
"NO CURE"
Cause: Unknown
Target Organ: Integumentary, GI, Renal
Signs and Symptoms:
 "Butterfly rash"
 Skin: Dry, scaly, raised rash
 Fever
 Photosensitivity
 Joint pain
 Erythema of the palms
 Monitor skin integrity

 DIET: High Vitamins and Iron, High Protein (Renal: OK)
 Monitor intake and output and daily weight
 Early detection: Lupus nephritis
 Provide emotional and supportive therapy
 Monitor BUN, Creatinine closely
Scleroderma (Systemic Sclerosis) characterized by inflammation, fibrosis,

and sclerosis.
Target Organ: Connective tissue, skin, synovial membranes, esophagus,

heart, lungs, kidneys, and gastrointestinal tract.
Signs and Symptoms:
 Stiffness and muscle weakness

 Pitting edema of the hands and fingers
 Taut and shiny skin
 Decreased ROM
 Joint contractures
 Encourage activity as tolerated.

 Room temperature: constant
 DIET: Small frequent meals; AVOID: Spicy, Caffeine, Alcohol
 Advise the client to sit up for 1 to 2 hours after meals
Polyarteritis Nodosa is a form of systemic vasculitis that causes

inflammation of the arteries in visceral organs, brain, and
skin. Prognosis: Poor
Signs and Symptoms:
 Severe abdominal pain

 Bloody diarrhea
 Weight loss
 Elevated ESR
Cause of Death: Renal Impairment
 Monitor skin integrity

 DIET: High Vitamins and Iron, High Protein (Renal: OK)
 Monitor intake and output and daily weight
 Early detection: Lupus nephritis
 Provide emotional and supportive therapy
 Monitor BUN, Creatinine closely
Pemphigus is a rare group of blistering autoimmune diseases that affect the

skin and mucous membranes.
Signs and Symptoms:
 Fragile, partial-thickness lesions

 Nikolsky’s sign: Separation of the epidermis caused by rubbing the skin
 Malaise, pain, and dysphagia
 Provide supportive care

 Provide oral hygiene and increase fluid intake.
 Assist with soothing baths
 Administer corticosteroids and cytotoxic agents as prescribed
Goodpasture Syndrome autoantibodies are made against the glomerular

basement membrane and alveolar basement membrane.
Target Organ: Lungs and Kidneys
Signs and Symptoms:
 Shortness of breath
 Hemoptysis
 Decreased urine output
 Hypertension and tachycardia
 Corticosteroid therapy and plasmapheresis

 Provide supportive therapy for pulmonary and renal involvement.
Lyme's Disease caused by the spirochete Borrelia burgdorferi, acquired from a tick

bite.
Signs and Symptoms:
 First Stage: Bullseye rash; it may occur anywhere on the body. Flulike symptoms

 Second Stage:Joint pain
 Third Stage: Arthritis
 Gently remove the tick with tweezers

 Wash with soap and water
 Perform a blood test 4 to 6 weeks after a bite
 Avoid areas that contain ticks, such as wooded grassy areas
Posttransplantation Immunodeficiency is a immunosuppression caused by

therapeutic agents.
Signs and Symptoms:
 Assess for signs of opportunistic infections.

 Assess nutritional status.
 Assess for signs of rejection
 Strict aseptic technique is necessary

 Provide psychosocial support
 Provide client teaching about immunosuppressants

Oncological Disorders
Cancer a malignant neoplastic disorder that can involve all body organs with
manifestations
that vary according to the body system affected and type of tumor cells.
Effects:
1. Impaired immune and hematopoietic (bloodproducing) function

2. Altered gastrointestinal tract structure and function
3. Motor and sensory deficits
4. Decreased respiratory function
Cancer classification
1. Solid tumors: Associated with the organs from which they develop, such as breast
cancer or
lung cancer
2. Hematological cancers: Originate from blood cell–forming tissues, such
as leukemias, lymphomas, and multiple myeloma.
Factors that influence cancer development
1. Environmental contributor
a. Chemical carcinogen: Industrial chemicals, medications, and tobacco.

b. Physical carcinogen: Ionizing radiation and ultraviolet radiation
c. Viral carcinogen: Epstein-Barr virus, hepatitis B virus, and human
papillomavirus (HPV).
d. Helicobacter pylori infection increased risk of gastric cancer.
2. Obesity and dietary factors
3. Genetic predisposition
4. Advancing age
5. Immunosuppressed individuals (e.g. HIV-AIDS, and organ transplant
recipients)
Warning signs: " C A U T I O N U S"

▪ Change in bowel or bladder habits
▪ Any sore that does not heal
▪ Unusual bleeding or discharge
▪ Thickening or lump in breast or elsewhere
▪ Indigestion
▪ Obvious change in wart or mole
▪ Nagging cough or hoarseness
▪ Unusual anemia
▪ Sudden weight loss
Diagnostic Tests
1. Biopsy is the definitive means of diagnosing cancer and provides histological proof
of malignancy.
Common types:
a. Needle: Aspiration of cells
b. Incisional: Removal of a wedge of suspected tissue from a larger mass
c. Excisional: Complete removal of the entire lesion
Frozen Section (Cryosection) Permanent Paraffin Section

> Time: Fast result (minutes) > Time:Takes about 24hrs for the result
> Quality: Clearer details can be
> Quality: Lower quality result
obtained
a. Prepare the client for the diagnostic procedure
b. Obtain informed consent.
c. Provide post procedure instructions (*Pain management).
Causes of pain:
c.1. Bone destruction

c.2. Obstruction of an organ
c.3. Compression of peripheral nerves
c.4. Infiltration
c.5. Inflammation, necrosis
c.6. Psychological factors, such as fear or anxiety
"Assess the client’s pain. Do not undermedicate the client with cancer who is in pain."
*Pain Management:
Severity of Pain Pharmacologic Tx Nonpharmacologic Tx

 Salicylates,  Relaxation (e.g.Deep breathing
 Acetaminophen exercises, meditation, yoga)
 Paracetamol  Guided imagery
Mild to Moderat
 Nonsteroidal  Biofeedback
e
Antiinflammatory  Massage
Drugs (NSAIDs)  Heat-cold application
 Codeine sulfate
 Monitor V/S
 Morphine sulfate
 Collaborate with other
 Methadone
Severe healthcare team members and
 Hydromorphone
HCP
hydrochloride
2. Bone marrow examination (particularly if a hematolymphoid malignancy is

suspected)
3. Chest radiograph
4. Complete blood count (CBC)
5. Computed tomography (CT)
6. Cytological studies (Papanicolaou test)
7. Liver function studies
8. Magnetic resonance imaging (MRI)
9. Proctoscopic examination (including guaiac test for occult blood)
10. Radiographic studies (mammography)
Treatments
Sugery indicated to diagnose, stage,and treat certain types of cancer.

Decreases the number of cancer cells; therefore, it may increase the chance
that other therapies will be successful.
Types:
Prophylactic surgery: performed in clients with an existing premalignant

condition that strongly predisposes to the development of cancer.
Curative surgery: All gross and microscopic tumor is removed or destroyed.
Control (cytoreductive or “debulking”) surgery:consists of removing a large
portion of a locally invasive tumor.
Palliative surgery: performed to improve quality of life during the survival time.
Reconstructive or rehabilitative surgery: Performed to improve quality of life by
restoring maximal function and appearance, such as breast reconstruction
after mastectomy.
Adverse effects of surgery
1. Loss or loss of function of a specific body part

2. Reduced function as a result of organ loss
3. Grieving about altered body image
4. Pain, infection, bleeding, thromboembolism
Chemotherapy kills or inhibits the reproduction of neoplastic cells and kills

normal cells.
Common side effects:
 Immunosuppression
 Mucositis
 Fatigue
 Alopecia
 Nausea and vomiting
*General Nursing Interventions:
Physiological Integrity Safe and Effective Care Psychosocial Integrity

Environment
Instruct the client about the Dia
Prepare IV chemotherapy in an
Monitor CBC, BUA, electrolytes possibility of temporary hair hig
air-vented space
loss are
Initiate bleeding precautions Wear personal protective

Discuss the purchase of Ca
if thrombocytopenia (PC <50,000 equipment; gloves, gown, mask,
a wig before treatment starts hyg
mm3) occurs. eye shield
Avoid intramuscular injections Discuss the potential effect

Monitor for phlebitis with IV Av
and venipunctures as much as of infertility,
administration sic
possible which may be irreversible.
Monitor for fever, sore throat,
Instruct the client about the need Ble
and signs and symptoms Monitor for skin breakdown
for contraception me
of infection
Reduce IV site pain by altering Co
Monitor for nausea and vomiting
IV rates or warming the injection rec
DIET: high-caloric, high protein
site vac
Administer antiemetics several
hours before
Notify the HCP if symptoms
chemotherapy and for 12 to 48
persist
hours
after as prescribed
Increase OFI; at least 2L/day
Treatments:
Types Positive Negative

Radiation Therapy  Destroys cancer cells, with  Local skin changes
minimal exposure of normal irritation
cells to the damaging effects of  Alopecia (hair loss)
radiation.  Fatigue (most comm
side effect of radiat
 Altered taste sensa
 Effective on tissues directly

within the path of the radiation
beam.
 For a period of time
 The radiation source comes into
client emits radiatio
direct, continuous contact with
Brachytherapy and can pose a haz
tumor tissues for a specific time.
to others
 Not confined
completely to one b
area, and it enters
Subtype: fluids and eventual
------ eliminated via vario
Unsealed Brachytherapy excreta, which
are radioactive and
harmful to others.
Sealed Brachytherapy  Temporary or permanent  The client emits

radiation source (solid implant) radiation while the
is implanted within the tumor implant is in place,
target tissues. the excreta are not
radioactive.
------ ------ ------
 The actual radiation source is

external to the client.  Burn injuries
External beam radiation  The client does not emit  Skin breakdow
(teletherapy) radiation and does not pose a  Erythema on sit
hazard to anyone else.
Bone marrow transplantation (BMT) and Peripheral blood stem cell

transplantation (PBSCT) procedures that replace stem cells that have
been destroyed by high doses of chemotherapy and/or radiation therapy.
Types of donor stem cells

1. Allogeneic: Stem cell donor is usually a sibling, a
parent with a similar tissue type, or a person who
is not related to the client (unrelated donor).
2. Syngeneic: Stem cells are from an identical twin.
3. Autologous most common type.
a. The client receives his or her own stem cells.
b. Stem cells are harvested during disease remission and are stored frozen to
be reinfused later.
Procedure
1. Harvest

o Apheresis or leukapheresis (the blood is removed through a
central venous catheter and an apheresis machine removes the
stem cells and returns the remainder of the blood to the
donor). Length of time: 4-6hrs
o Harvested through multiple aspirations from the iliac crest.
o Filtered for residual cancer cells.
o Allogeneic marrow is transfused immediately; autologous
marrow is frozen for later
use (cryopreservation).
2. Transplantation

o Administered through the client’s central line (IV infusion or by IV
push) in a manner similar to that for a blood transfusion.
4. Engraftment

o Occurs when the white blood cell (WBC), erythrocyte, and
platelet counts begin to rise.
o Engraftment process takes 2 to 5 weeks.
Complications
 Infection
 Bleeding
 Neutropenia (Decrease neutrophil count)
 Thrombocytopenia (Decrease platelet count)
 Graft-versus-host disease
 Hepatic veno-occlusive disease occlusion of the hepatic venules by
thrombosis or phlebitis. S/sx: Right upper quadrant abdominal pain,
jaundice, ascites, weight gain, and hepatomegaly.
Leukemia
A group of hematological malignancies involving abnormal overproduction of

leukocytes, usually at an immature stage, in the bone marrow.
Major types:
1. Lymphocytic (involving abnormal cells from the lymphoid pathway)

2. Myelocytic or myelogenous (involving abnormal cells from the
myeloid pathways).
Classification of Leukemia
1. Acute Lymphocytic Leukemia

▪ Mostly lymphoblast present in bone marrow
▪ Age of onset is younger than 15 years.
2. Acute Myelogenous Leukemia

▪ Mostly myeloblast present in bone marrow
▪ Age of onset is between 15 and 39 years.
3. Chronic Myelogenous Leukemia

▪ Mostly granulocytes present in bone marrow
▪ Age of onset is in the fourth decade
4. Chronic Lymphocytic Leukemia

▪ Mostly lymphocytes present in bone marrow
▪ Age of onset is after 50 years

Signs and Symptoms:
Headache
Bone pain and joint swelling
WBC count (normal, elevated, or reduced)
Decreased hemoglobin and hematocrit levels, platelet count
Anorexia, fatigue
Anemia
Overt bleeding
Positive bone marrow biopsy identifying leukemic blast–phase cells
Interventions:
1. Initiate protective isolation procedures.

2. Ensure frequent and thorough hand washing by the client, family, and
HCPs.
3. Visitors with known infection should avoid contact with the client.
4. Use strict aseptic technique for all procedures.
5. Place the client in a room with high-efficiency particulate air filtration or
a laminar airflow system if possible.
6. Initiate a bowel program to prevent constipation and prevent rectal
trauma.
7. Auscultate lung sounds, and encourage the client to cough and deep-
breathe.
8. Instruct the client to avoid activities that expose the client to infection,
such as changing a pet’s litter box or working with house plants or in the
garden.
9. Reduce exposure to environmental organisms by eliminating fresh or
raw fruits and vegetables
(low-bacteria diet) from the diet; and avoid leaving standing water in the
client’s room.
10. Monitor for signs of bleeding tendencies.
11. Emphasize safety measures and precaution.
12. Emphasize the importance of a healthy lifestyle modification.
Lymphoma: Hodgkin’s Disease is a malignancy of the lymph nodes that

originates in a single lymph node or a chain of nodes.
Involvement:
 Lymph nodes
 Tonsils
 Spleen
 Bone marrow
* Reed-Sternberg cells
Risk Factors:
 Viral infection
 Combined chemotherapy
Signs and Symptoms:
 Fever
 Sudden anemia
 Presence of Reed-Sternberg cells in nodes
 Night sweats
 Body malaise
Nursing considerations:
 Extensive external radiation of the involved lymph node regions (earlier
stage; 1 and 2)
 Radiation and multiagent chemotherapy (advance stage)
 *Refer to general oncological nursing care
Multiple Myeloma invasion of proliferated malignant plasma cell inside the

bone marrow that destroys the bone.
Signs and Symptoms:
 Bone (skeletal) pain

 Weakness and fatigue
 Recurrent infections
 Anemia
 Urinalysis shows Bence Jones proteinuria and elevated serum protein
level
 *Osteoporosis
 Thrombocytopenia and leukopenia
 Elevated calcium and uric acid levels
Nursing considerations:
 Provide supportive care to control symptoms and prevent complications

 Maintain neutropenic and bleeding precautions
 Increase OFI; 2L/day
 Encourage mobility
 Take medications as prescribed (bisphosphonate, antibiotics,
analgesics, antineoplastic agents)
 Prepare the client for local radiation therapy
Different types of Neoplastic Disease
Age
Type of
Definition variatio Signs and Symptoms Treatment
Cancer
n
Pre-op
 Adm
 Prep
pres
 Prep
 Dis
infor
Post-op
 Mon
infec
 Mon
 Noti
or te
 Early: Painless from
testicular swelling  Instr
Arises from stre
 “Dragging” or “pulling”
germinal  Perf
Testicular sensation
epithelium, sperm- 15 - 40 on t
Cancer  Palpable
producing germ years Orchiectomy mon
lymphadenopathy
cells or from old
 Late: back or bone pain
nongerminal *Gynec
and respiratory
epithelium
symptoms.
Nonsurgical: Pre-op
 Painless vaginal
postmenstrual and ▪ Chemotherapy  Prov
postcoital bleeding ▪ Cryosurgery  Obta
 Foul-smelling or  Iden
Due to the serosanguineous ▪ External radiation
abnormal growth vaginal discharge Post-op
of cells that have 25 - 29  Pelvic, lower back, leg, ▪ Internal radiation
Cervical implants (intracavitary)
the ability to years or groin pain  Mon
Cancer
invade the cervix old  Anorexia and weight ▪ Laser therapy  Ass
and other pelvic loss exer
structures.  Leakage of urine and Surgical:  App
feces from the vagina com
 Dysuria ▪ Conization  Avo
 Hematuria ▪ Hysterectomy weig
▪ Pelvic exenteration * >1 sat

Grows rapidly,
spreads fast, and is  Gastrointestinal  External radiation
oftenbilateral. It has disturbances
55 - 65 therapy
Ovarian a higher mortality  Dysfunctional vaginal 
years Chemotherapy Similar
Cancer rate than any other bleeding
old  Surgery: TAHBSO
cancer of the  Abdominal mass
female reproductive  Elevated tumor marker
system. (i.e., CA-125)
Nonsurgical:
 External or
 Abnormal vaginal internal radiation
bleeding/discharge  Chemotherapy
A slow-growing
Endometri  Late: Low back,  Progesterone
tumor arising from > 60
al pelvic, or abdominal therapy
the endometrial years Similar
(Uterine) pain  Tamoxifen
mucosa of the old
Cancer  Advance: Enlarged
uterus
uterus Surgical:
 TAHBSO
Breast Invasive when it > 40  Nipple retraction Nonsurgical: BSE:

Cancer penetrates the years  Skin
tissue surrounding old dimpling,retraction,  Chemotherapy  P
the mammary duct or ulceration  Radiation therapy d
and grows in an  Peau d’orange skin  P
irregular pattern.  A fixed, irregular, Surgical: c
painless mass
 Irregular in shape  Mastectomy Post-op
(simple, modified
radical)  M
 Lumpectomy  P
p
 U
l
 A
t
 E
 A
s
 A
 P
p
 D
*PROTE
 Dysphagia  M
A malignancy found 40 - 74  Odynophagia  Chemotherapy  I
Esophage
in the esophageal years  Epigastric pain  Radiation therapy m
al Cancer
mucosa old  Surgical resection of d
Link the tumor
Early:
 Indigestion
 Abdominal
discomfort
 Full feeling
 Epigastric, back, or
retrosternal pain
Late:
 Chemotherapy
 Weakness and  Radiation therapy
A malignant growth
> 50 fatigue  Gastrectomy: Total;  Mon
Gastric of the mucosal cells
years  Anorexia and weight Subtotal: Billroth I  DIE
Cancer in the inner lining of
old loss and II
the stomach
 Nausea and
vomiting
 Pressure in the
stomach
 Ascites
 Iron deficiency
anemia
 Dysphagia and
obstructive
symptoms
Link
Pancreati Highly malignant, > 55  Clay-colored  M
c Cancer rapidly growing years stools "Acholic Nonsurgical: (
adenocarcinomas old Stool"  M
originating from the  Glucose intolerance  Chemotherapy
 Radiation therapy
 Abdominal pain Surgical:  D

epithelium of the
 Jaundice f
ductal system
 Whipple
procedure
Intestinal Malignant lesions > 50  Early: Blood in Nonsurgical:  M

Tumors that developing the years stool (most common i
cells lining the old manifestation)  Chemotherapy a
bowel wall or  Anemia  Radiation therapy
develop as  Weight loss Pre-op
adenomatous
polyps in the colon Surgical:  I
or rectum p
 Late: Guarding  Bowel, local  I
behavior, abdominal lymph node b
mass, cachexia resection c
(severe muscle  Colostomy
wasting)  Ileostomy Post-op
 E
 M
s
o
 M
b
 N
i
 A
s
 S
 D
 A
 T
 S
 A
p
 I
n
a
p
Post-op
 H
 P
t
 S
 M
e
Link
Nonsurgical:  M
s
 Chemotherapy  M
 Wheezing
A malignant tumor  Radiation therapy  A
 Dyspnea
of the bronchi and  D
 Hoarseness
peripheral lung Surgical: v
65 - 74  Hemoptysis
Lung tissue.  A
years  Blood-tinged or
Cancer  Laser therapy c
old purulent sputum
Common target for  Thoracentesis  P
 Diminished breath
metastasis from  Pleurodesis  M
sounds
other organs.  Thoracotomy  M
 Lobectomy s
*Priorit
Laryngeal A malignant tumor > 50  Hoarseness Pre-op

Cancer of the larynx years  Painless neck mass Nonsurgical:
old  Feeling of a lump in  D
the throat  Chemotherapy s
 Change in voice  Radiation therapy  E
quality a
 Hemoptysis Surgical:  D
 Foul breath odor n
 Cordal stripping
 Cordectomy Post-op
 Laryngectomy
(partial/total)  M
 Tracheostomy  A
 R
(
 O
n
 M
n
g
 R
c
Link
Nonsurgical:
 Early: Asymptomati  Androgen
c suppression
 Hard, pea-sized therapy
Post-op
nodule (DRE)  Luteinizing
 Gross, painless hormone therapy
 M
A slow growing hematuria  Radiation therapy
 I
malignancy of the  Chemotherapy
> 50  E
Prostate prostate
years h
Cancer gland; common can Surgical:
old  M
cer in American  Late: Weight loss
s
men  Urinary obstruction  Orchiectomy
i
 Bone pain  Prostatectomy
c
(lumbosacral area to  Cryosurgical
the leg) ablation
 Transurethral
resection of the
prostate (TURP)
Bladder A papillomatous  *Painless Pre-op

Cancer growth in the hematuria (most Nonsurgical:
bladder urothelium; common sign)  I
noted malignant  Frequency, urgency,  Chemotherapy m
changes; infiltrates dysuria  Radiation therapy I
the bladder wall.  Clot-induced c
obstruction Surgical: e
 E
 Cystectomy  A
 TURP a
 Ileal conduit
 Ureterostomy Post-op
 Urostomy
 A
e
 M
p
p
 A
 M
p
 I
i
p
 P
Genera
Link
Link
Link
Oncological Emergencies
Sepsis is a life-threatening illness caused by your body's response to an

infection.
Disseminated Intravascular Coagulation (DIC) is a condition in which blood

clots form throughout the body, blocking small blood vessels.
Interventions:
 Early identification of clients at high risk for sepsis and DIC

 Maintain strict aseptic technique
 Administer antibiotics and anticoagulants as prescribed
Priority: Hemorrhage
Syndrome of inappropriate antidiuretic hormone (SIADH) causes the body

to retain too much water by stimulating substances that mimic antidiuretic
hormone.
Signs and Symptoms:

 Weakness
 Muscle cramps
 Loss of appetite
 Fatigue
 Hyponatremia <normal: 115 to 120 mEq/L (115-120 mmol/L)>
 3Cs (coma, confusion, changes in personality)
Interventions:
 DIET: Limit OFI, Increase Na intake

 Administer an antagonist to antidiuretic hormone
 Chemotherapy
Spinal Cord Compression occurs when a tumor directly enters the spinal

cord or when the vertebral column collapses from tumor entry, impinging on
the spinal cord.
Signs and Symptoms:
 Numbness
 Tingling
 Loss of urethral, vaginal, and rectal sensation
 Muscle weakness
Interventions:
 Administer high-dose corticosteroids

 Chemotherapy or Radiation therapy
 Use of neck or back braces
Hypercalcemia a late manifestation of extensive malignancy that occurs most

often with bone metastasis.
Signs and Symptoms:
 Fatigue
 Anorexia
 Constipation
 Polyuria
Interventions:
 Monitor serum calcium level and ECG changes (shortend
QT/ST interval, wide or flat T wave)
 Administer oral or parenteral fluids as prescribed
 Prepare the client for dialysis if needed
 Encourage ambulation
Superior Vena Cava Syndrome occurs when the SVC is compressed or

obstructed by tumor growth (commonly associated with lung cancer and
lymphoma).
Signs and Symptoms:
 Early: Edema of the face esp. the eyes

 Strokes' sign ( tightening of shirt or blouse collar)
 Late: Edema in the arms and hand
 Dyspnea
 Erythema of the upper body
 Epistaxis
 Alarming signs: Airway obstruction
 Hemorrhage
 Mental status change
 Decreased cardiac output
 Hypotension
Interventions:
 Place the client in semi-Fowler’s position

 Administer corticosteroids and diuretics as prescribed
 High-dose radiation therapy to the mediastinal area
Tumor lysis syndrome occurs when large quantities of tumor cells are

destroyed rapidly and intracellular components such as K+ and BUA are
released into the bloodstream faster than the body can eliminate them.
Signs and Symptoms:
 Hyperkalemia
 Hyperphosphatemia
 Hypocalcemia
 Hyperuricemia (acute kidney injury)
Interventions:
 Encourage oral hydration

 Monitor renal function and intake and output
 DIET: renal diet low in potassium and phosphorus
 Administer diuretics and antihyperuricemia meds as prescribed
 Prepare to administer IV infusion of glucose and insulin to treat hyperkalemia.
 Prepare the client for dialysis if needed.
Anaphylactic Reaction an acute allergic reaction to an antigen to which the

body has become hypersensitive.
PRIORITY
INTERVENTIONS
ASSESSMENT SIGNS AND SYMPTOMS
"ABC"
B: Assess respiratory
Obtain an allergy history Dyspnea (Tachypnea)
status
Administer a test dose
Chest tightness or pain Stop the medication
when prescribed
Contact the health care
provider (HCP) and the
Monitor vital signs Pruritus or urticaria Rapid
Response Team if
necessary
Tachycardia B: Administer oxygen
Maintain the intravenous
Dizziness, LOC (IV) access with normal
saline
C: Raise the client’s feet
Anxiety or agitation and legs, if not
contraindicated
Administer prescribed
emergency medications,
Flushed appearance such as epinephrine (Epi-
pen, Prednisone,
Diphenhydramine),
Hypotension Monitor vital signs
Cyanosis Document the event,
actions taken, and the
client’s response
Alkylating agents
Cytotoxic Mechanism of action Adverse effects

Alkylating agent - causes Hemorrhagic cystitis, myelosuppression,
Cyclophosphamide
cross-linking in DNA transitional cell carcinoma
Cytotoxic antibiotics

Bleomycin Degrades preformed DNA Lung fibrosis
Stabilizes DNA-topoisomerase II complex inhibits DNA &
Doxorubicin Cardiomyopathy
RNA synthesis
Antimetabolites

Myelosuppression,
Inhibits dihydrofolate reductase
Methotrexate mucositis, liver fibrosis,
and thymidylate synthesis
lung fibrosis
Pyrimidine analogue inducing cell
cycle arrest and apoptosis by Myelosuppression,
Flurouracil (5-FU)
blocking thymidylate synthase mucositis, dermatitis
(works during S phase)
6-mercaptopurine
Purine analogue that is activated
(Azathioprine is
by HGPRTase, decreasing purine Myelosuppression
metabolized to
synthesis
mercaptopurine)
Pyrimidine antagonist. Interferes
with DNA synthesis specifically at
Cytarabine Myelosuppression, ataxia
the S-phase of the cell cycle and
inhibits DNA polymerase

Acts on microtubules

Vincristine: Peripheral neuropathy
Vincristine,
Inhibits formation of microtubules (reversible) , paralytic ileus
vinblastine
Vinblastine: myelosuppression
Prevents microtubule depolymerisation
Docetaxel Neutropenia
& disassembly, decreasing free tubulin
Other cytotoxic drugs

Ototoxicity, peripheral
Cisplatin Causes cross-linking in DNA
neuropathy, hypomagnesaemia
Inhibits ribonucleotide
Hydroxyurea
reductase, decreasing DNA Myelosuppression
(hydroxycarbamide)
synthesis
Sensory Disorders
Diagnostic Tests for the Eye
1. Fluorescein angiography a detailed imaging study used to assess

problems with retinal circulation, such as those that occur in diabetic
retinopathy, retinal bleeding, and macular degeneration, or to rule out
intraocular tumors after administration of dye.
Pre-op Care:
 Assess the client for allergies to dye

 Administer mydriatic medication; instill into the eye 1 hour before the
test
 The dye is injected into a vein of the client’s arm
 Inform the client about dye discomforts
 Inform client that the urine maybe brightgreen or orange for up to 2
days
 Observe for any untoward signs and symptoms
Post-Op Care:
 Encourage rest
 Increase OFI
 Remind the client that the yellow skin appearance will disappear
 Inform the client that the urine will appear bright green or orange until
the dye is excreted
 Avoid direct sunlight for a few hours after the test; wear sunglasses, if
staying outdoors
 Inform the client that the photophobia will continue until pupil size
returns to normal
2. Computed tomography (CT) is performed to examine the eye, bony

structures around the eye, and extraocular muscles; contrast maybe used if
not contraindicated.
Interventions:
 No special client preparation or follow-up care needed

 Instruct the procedure to the client
 Ask about and document allergies
3. Slit lamp allows examination of the anterior ocular structures under microscopic

magnification.
Interventions:
 Explain the procedure.

 Advise the client about the brightness of the light and the need to look
forward at a point over the examiner’s ear.
4. Corneal staining a topical dye is instilled into the conjunctival sac to

outline irregularities of the corneal surface that are not easily visible.
Interventions:
 Remove contact lenses

 Instruct to blink after the dye has been applied for proper distribution.
5. Tonometry the test is used primarily to assess for an increase in IOP and

potential glaucoma.
 Noncontact tonometry: A puff of air is directed at the cornea to indent

the cornea; less accurate method of measurement.
 Contact tonometry: A flattened cone is brought into contact with the
cornea and the amount of pressure needed to flatten the cornea is
measured; avoid rubbing the eye following the examination.
Note: Normal IOP is 10 to 21 mm Hg

Disorders of the Eye
Refraction is the bending of light rays; any problem associated with eye
length or refraction can lead to refractive errors.
Myopia (nearsightedness): Refractive ability of the eye is too strong for the

eye length; images are bent and fall in front of, not on, the retina.
Hyperopia (farsightedness): Refractive ability of the eye is too weak; images
are focused behind the retina.
Presbyopia:Loss of lens elasticity because of aging; less able to focus the
eye for close work and images fall behind the retina.
Astigmatism: Occurs because of the irregular curvature of the cornea; image

focuses at 2 different points on the retina.

Legal blindness In the client who is legally blind,t he best visual acuity with
corrective lenses in the better eye is 20/200 or less, or the visual field is no
greater than 20 degrees in its widest diameter in the better eye.
 Use a normal tone of voice when speaking to the client

 Alert the client when approaching
 Orient the client to the environment
 Ensure that the client has a clear pathway
 Promote independence
 * Allow the client to grasp the nurse’s arm at the elbow so that the client
can detect the direction of movement.
 Instruct the client in the use of the cane for the blind (straight shape,
white color with red tip)
Cataract is "opacity of the lens" that distorts the image projected onto the

retina and that can progress to blindness.
Signs and Symptoms:
 Early signs: Blurred vision and decreased color perception

 Late signs: Diplopia,reduced visual acuity, absence of the red reflex,
and the presence of a white pupil
 Pain or eye redness is associated with age-related cataract formation.
 Loss of vision is gradual
Pre-op Care:
 Instruct the importance of hand washing and measures to prevent or

decrease IOP (bending over, coughing, straining, and rubbing the
eye)
 Administer eye medications preoperatively, including mydriatics and
cycloplegics as prescribed.
Post-op Care:
 Elevate the head o the bed 30 to 45 degrees

 Turn the client to the back or nonoperative side
 Maintain an eye patch as prescribed; orient the client to the environment
 Position the client’s personal belongings to the nonoperative side
 Use side rails for safety
 Assist with ambulation
 Protective glasses must be worn at all times
 Eye itching and mild discomfort are normal for a few days after the
procedure.
Glaucoma the condition damages the optic nerve and can result in blindness
due to IOP. "Tunneling of visual fields"
Types:
 Primary open-angle glaucoma (POAG): results from obstruction to out

flow of aqueous humor and is the most common type
 Primary angle-closure glaucoma (PACG) results from blocking the
outflow of aqueous humor into the trabecular mesh work
Vision:

Retinal detachment detachment or separation of the retina from the

epithelium; can lead to blindness. "Curtain-like vision"
Signs and Symptoms:
 Flashes of light
 Floaters or black spots (signs of bleeding)
 Increase in blurred vision
 Sense of a curtain being drawn over the eye
 Loss of a portion of the visual field; painless loss of central or peripheral
vision
 Provide bed rest

 Cover both eyes with patches to prevent further detachment
 Speak to the client before approaching
 Protect the client from injury
 Draining fluid from the subretinal space so that the retina can return to
the normal position.
 Diathermy, the use of an electrode needle and heat through the sclera,
to stimulate an inflammatory response
 Laser therapy, to stimulate an inflammatory response and seal small
retinal tears before the detachment occurs
 Scleral buckling, to hold the choroid and retina together with a splint
until scar tissue forms, closing the tear
 Insertion of gas or silicone oil to promote reattachment; these agents
float against the retina to hold it in place until healing occurs.
 Maintain eye patches
 Monitor for hemorrhage
 Prevent nausea and vomiting and monitor for restlessness, which can
cause hemorrhage.
 Instruct the client to limit reading for 3 to 5 weeks
Macular Degeneration caused by gradual blocking of retinal capillaries

leading to an ischemic and necrotic macula; rod and cone photo receptors
die.

Vision:
Signs and Symptoms:
 A decline in central vision

 Blurred vision and distortion
 Initiate strategies to assist in maximizing remaining vision

 Promote independence.
 Laser therapy, photodynamic therapy may be prescribed to seal the
leaking blood vessels in or near the macula

Ocular Melanoma most common malignant eye tumor in adults; found in the
uvealt ract and can spread easily.
Signs and Symptoms:
 Increased IOP
 Blurring of vision
 Change of iris color
 Enucleation (surgical removal of the eye)

 Radiation therapy
Foreign bodies an object such as dust or dirt that enters the eye and causes
irritation.
Visible object: Look upward > Expose the lower lid > Wet a cotton-tipped

applicator (NSS) > Twist the swab over the particle > Remove it.
Not visible object: Look downward > Place a cotton applicator horizontally on

the outer surface of the upper eye lid > Grasp the lashes > Pull the upper lid
outward > Remove it.
Penetrating objects an eye injury in which an object penetrates the eye.
 Never remove the object

 Cover the eye with a cup (paper or plastic) and tape in place
 Do not bend over or lie flat or place pressure on the eye
 X-rays and CT scans of the orbit are usually obtained.
 NO MRI
Chemical burns an eye injury in which a caustic substance enters the eye.
PRIORITY NURSING ACTIONS!

1. Quickly assess the client and visual acuity.
2. Check the pH of the eye (pH: 7.35 - 7.45)
3. Irrigate the eye using lactated ringers solution ( 15-20 minutes)
4. Document the event, actions taken, and the client’s response
Disorders of the Ear
Diagnostic Tests for the Ear
Tomography assesses the mastoid, middle ear, and inner ear structures and is
especially helpful in the diagnosis of acoustic tumors.
 All jewelry is removed.

 Lead eye shields are used to cover the cornea against radiation
 Remain still in a supine position
 No follow-up care is required.
 If contrast is to be used, assess for any allergies
Audiometry measures hearing acuity
 Pure tone audiometry is used to identify problems with hearing,

speech, music, and other sounds in the environment.
 Speech audiometry, the client’s ability to hear spoken words is
measured.
Electronystagmography (ENG) is used to distinguish between normal

nystagmus and medication-induced nystagmus, or nystagmus caused by a
lesion in the central or peripheral vestibular pathway.
 Instruct to remain NPO for 3 hours before testing

 Avoid caffeine-containing beverages for 24 to 48 hours before the test.
 Medications are withheld for 24 hours before testing
 Instruct the client that this is a long and tiring procedure.
 Bring prescription eyeglasses to the examination
 The client’s ears are irrigated with cool and warm water, causes nausea
and vomiting.
 Assist with ambulation
Conductive hearing loss occurs when sound waves are blocked to the inner ear fibers
because of external or middle ear disorders
Sensorineural hearing loss is often permanent,and measures must be taken to

reduce further damage.
Mixed hearing loss also known as conductive-sensorineural hearing loss. The client

has both sensorineural and conductive hearing loss.
Signs of Hearing Loss
▪ Frequently asking others to repeat statements
▪ Straining to hear
▪ Turning the head or leaning forward to favor 1 ear
▪ Shouting in conversation
▪ Ringing in the ears
▪ Failing to respond when not looking in the direction of the sound
▪ Answering questions incorrectly
▪ Raising the volume of the television or radio
▪ Avoiding large groups
▪ Better understanding of speech when in small groups
▪ Withdrawing from social interactions
Cochlear implantation used for sensorineural hearing loss; small computer

converts sound waves into electrical impulses; Electrodes are placed by the
internal ear with a computer device attached to the external ear.
Presbycusis leads to degeneration or atrophy of the ganglion cells in the
cochlea and a loss of elasticity of the basilar membranes.
External otitis infective inflammatory or allergic response involving the

structure of the external auditory canal or auricles; common in children.
Signs and Symptoms:
 Pain
 Itching
 Plugged feeling in the ear
 Redness and edema
 Exudate
 Hearing loss
 Apply heat locally for 20 minutes, 3 times a day.

 Encourage rest to assist in reducing pain.
 Administer antibiotics or corticosteroids as prescribed.
 Administer analgesics for the pain as prescribed.
 Keep the affected ear clean and dry.
 Use earplugs for swimming.
 Avoid the use of hair products or headphones

Mastoiditis results from untreated or inadequately treated chronic or acute otitis

media.
Signs and Symptoms:
 Swelling behind the ear and pain with minimal movement of the head
 Cellulitis on the skin or external scalp over the mastoid process
 A reddened,dull,thick, immobile tympanic membrane
 Low-grade fever
 Tender and enlarged post auricular lymph nodes
 Most common treatment: Simple or modified radical mastoidectomy with

tympanoplasty
 Once infected tissue is removed, the tympanoplasty is performed to restore
normal hearing.
Otosclerosis a genetic disorder of the labyrinthine capsule of the middle ear that

results in a bony overgrowth of the tissue surrounding the ossicles.
Signs and Symptoms:
 Slowly progressing conductive hearing loss

 Bilateral hearing loss
 A ringing or roaring type of constant tinnitus
 Loud sounds heard in the ear when chewing
 Pinkish discoloration (Schwartze’s sign) of the tympanic membrane
 Negative Rinne test
 Weber’s test shows lateralization of sound to the ear with the greatest degree of
conductive hearing loss
Fenestration is the removal of the stapes, with a small hole drilled in the footplate; a
prosthesis is connected between the incus and footplate.
Pre-op Care:
 Prevent middle ear or external ear infections.

 Instruct the client to avoid excessive nose blowing.
Post-op Care:
 Inform that Gelfoam ear packing (if used) may interferes with hearing to decrease
bleeding.
 Assist with ambulating during the first 1 to 2 days after surgery.
 No noticeable improvement in hearing may occur for as long as 6 weeks.
 Administer antibiotic, antivertiginous, and pain medications as prescribed.
 Instruct the client to move the head slowly when changing positions
 Instruct the client to avoid rapid extreme changes in pressure (quick head
movements,sneezing,nose blowing,straining, and changes in altitude)
Labyrinthitis infection of the labyrinth that occurs as a complication of acute or chronic

otitis media.
Signs and Symptoms:
 Hearing loss on the affected side

 Tinnitus
 Spontaneous nystagmus (affected side)
 Vertigo
 Monitor for signs of meningitis most common complication, (headache, stiff
neck, lethargy)
 Advise the client to rest in bed in a darkened room.
 Administer antiemetics and antivertiginous medications as prescribed
Meniere’s Syndrome also called endolymphatic hydrops; it refers to dilation of the

endolymphatic system by overproduction or decreased reabsorption of endolymphatic
fluid.
Signs and Symptoms:
 Tinnitus
 Unilateral sensorineural hearing loss
 Vertigo
 Feelings of fullness in the ear
 Severe headaches
Nonsurgical interventions:
 Prevent injury (SAFETY)
 Provide bed rest in a quiet environment.
 Provide assistance with walking.
 Instruct the client to move the head slowly
 Initiate sodium and fluid restrictions
 Instruct the client to avoid watching television (during acute attack)
 Administer nicotinic acid, antihistamine, antiemetics as precribed
Surgical interventions:
 Endolymphatic drainage and insertion of a shunt

 Labyrinthectomy
Post-op Care:
 Assess packing and dressing on the ear.

 Speak to the client on the side of the unaffected ear.
 Maintain safety.
 Assist with ambulating
 Administer antivertiginous and antiemetic medications as prescribed.
econdary traumatic stress
a boundary violation
compassion fatigue
moral distress
contact isolation with double-gloving and shoe covers
respiratory isolation with positive pressure rooms
enteric precautions
reverse isolation
Final Score: 4/25
Multiple Choice
1)
The nurse is teaching a female client about postmenopausal bone loss. What will the nurse include with
the teaching? Select all that apply.
 Try to limit use of stool softeners.

 Avoid calcium channel blocker medications.
 Swimming and cycling are joint-friendly ways to stay active.
 Be active three times a week with weight-bearing exercises.
 Sun exposure can be beneficial, but sunscreen should be used.
 Stay upstairs when your spouse is smoking in the house.
Score: 0.00
Correct answer(s):
 Try to limit use of stool softeners.
 Avoid calcium channel blocker medications.
 Swimming and cycling are joint-friendly ways to stay active.
 Be active three times a week with weight-bearing exercises.
 Sun exposure can be beneficial, but sunscreen should be used.
 Stay upstairs when your spouse is smoking in the house.
Multiple Choice
2)
The nurse plans to instruct the postpartum client who is breastfeeding about methods to prevent breast
engorgement. Which measures should the nurse include in the teaching plan? Select all that apply.
 Feed the neonate a maximum of 5 minutes per side on the first day.
 Wear a supportive brassiere with nipple shields.
 Breastfeed the neonate at frequent intervals.
 Keep mom and baby together as much as possible.
 Use a breast pump between feedings.
Score: 0.00
Single choice
3)
Which statement by a parent indicates the best understanding of why raisins should be limited as a
snack food in toddlers?
 "Raisins are low in nutritional value."

 "Raisins can increase tooth decay."
 "Raisins are easy to choke on."
 "Raisins are hard to digest entirely."
Score: 0.00
Correct answer(s):
 "Raisins are low in nutritional value."
 "Raisins can increase tooth decay."
 "Raisins are easy to choke on."
 "Raisins are hard to digest entirely."
Single choice
4)
The nurse is caring for a school-age child, and the parents request anticipatory guidance. What trait will
the nurse account for when explaining the child's cognitive development?
 magical thinking
 transductive reasoning
 abstract thought
 conservation skills
Score: 0.00
Correct answer(s):
 magical thinking
 transductive reasoning
 abstract thought
 conservation skills
Single choice
5)
What response by the nurse would be most appropriate for a mother who voices concern about her 4-
year-old child’s stuttering?
 “This behavior is normal, and the child probably will stop soon.”
 “The child needs to see a speech therapist before school starts.”
 “The majority of children do this until they are about 6 years of age.”
 “You need to help the child complete the words giving him problems.”
Score: 0.00
Correct answer(s):
 “This behavior is normal, and the child probably will stop soon.”
 “The child needs to see a speech therapist before school starts.”
 “The majority of children do this until they are about 6 years of age.”
 “You need to help the child complete the words giving him problems.”
Single choice
6)
After the nurse teaches a primiparous client planning to return to work in 6 weeks about storing breast
milk, which client statement indicates the need for further teaching?
 “I can safely store freshly expressed breast milk at room temperature for 8 hours.”
 “I will be sure to label the breast milk with the date, time, and amount.”
 “I must discard any breast milk stored for more than 3 days in the refrigerator.”
 “I can keep the breast milk in a deep freeze in clean glass bottles for up to 1 year.”
Score: 0.00
Correct answer(s):
 “I can safely store freshly expressed breast milk at room temperature for 8 hours.”
 “I will be sure to label the breast milk with the date, time, and amount.”
 “I must discard any breast milk stored for more than 3 days in the refrigerator.”
 “I can keep the breast milk in a deep freeze in clean glass bottles for up to 1 year.”
Single choice
7)
A nurse implements a teaching plan for a client who's scheduled for discharge. Which client
behavior best demonstrates effective teaching?
 exhibiting a positive change in behavior

 verbally repeating the instruction
 making statements indicating understanding
 exhibiting nonverbal signs such as nodding the head to indicate "yes"
Score: 1.00
Single choice
8)
The nurse is providing prenatal teaching to a 15-year-old pregnant adolescent. The nurse is addressing
the health risks to the mother if appropriate prenatal care is not obtained. Which of the following
statements is most appropriate for the nurse to include in the teaching?
 “Adequate prenatal care helps to prevent a preterm birth.”
 “Adequate prenatal care helps to prevent low birth weight babies.”
 “Adequate prenatal care helps to prevent iron deficiency anemia.”
 “Adequate prenatal care helps to prevent failure to thrive in the newborn.”
Score: 1.00
Single choice
9)
Which position is appropriate for palpating tissues during breast self-examination?
 sitting in a chair with a pillow under both shoulders to elevate the chest
 standing facing a mirror
 flat on the back with a pillow under the head and arms raised over the head
 flat on the back with a pillow under the shoulder of the side being examined
Score: 0.00
Correct answer(s):
 sitting in a chair with a pillow under both shoulders to elevate the chest
 standing facing a mirror
 flat on the back with a pillow under the head and arms raised over the head
 flat on the back with a pillow under the shoulder of the side being examined
Single choice
10)
A client tells the nurse that she thinks her water broke 2 hours ago after she experienced a gush of fluid.
What action should the nurse take first?
 Perform a pH test.
 Assess maternal vital signs.
 Perform a vaginal exam.
 Assess the fetal heart rate.
Score: 0.00
Correct answer(s):
 Perform a pH test.
 Assess maternal vital signs.
 Perform a vaginal exam.
 Assess the fetal heart rate.
Single choice
11)
The nurse performs a gestational age assessment on male neonate born vaginally at 37 weeks’ gestation
according to the mother’s estimated date of delivery. Which physical finding would the nurse expect to
find at 37 weeks’ gestation?
 an anterior transverse crease on the soles
 extensive rugae on the scrotum
 some cartilage in the ear lobes
 coarse and silky scalp hair
Score: 0.00
Correct answer(s):
 an anterior transverse crease on the soles
 extensive rugae on the scrotum
 some cartilage in the ear lobes
 coarse and silky scalp hair
Single choice
12)
The nurse judges that the parent of a 9-month-old infant in a hip spica cast understands how to feed the
child when the parent makes which statement?
 "I can lay my child flat and feed that way."

 "I can borrow a special feeding table to use."
 "I will raise my child's head up and leave the hips and legs on a pillow."
 "It will take two of us, one to hold and one to feed."
Score: 0.00
Correct answer(s):
 "I can lay my child flat and feed that way."
 "I can borrow a special feeding table to use."
 "I will raise my child's head up and leave the hips and legs on a pillow."
 "It will take two of us, one to hold and one to feed."
Single choice
13)
A nurse is assessing the parent-neonate attachment of postpartum clients. Which finding most indicates
a need for further evaluation?
 Parental desire to room-in with the neonate

 Limited parent-neonate contact immediately after birth
 Parental understanding of the importance of parent-neonate bonding
 Previous cesarean birth
Score: 0.00
Correct answer(s):
 Parental desire to room-in with the neonate
 Limited parent-neonate contact immediately after birth
 Parental understanding of the importance of parent-neonate bonding
 Previous cesarean birth
Single choice
14)
A 32-year-old primigravida at 39 weeks’ gestation is admitted to the hospital in active labor. While the
nurse performs Leopold’s maneuvers, the client asks why these maneuvers are being done. The nurse
explains that the major purpose of these maneuvers is to determine which factor?
 fetal presentation
 fetal size
 estimated gestational age
 intensity of contractions
Score: 1.00
Single choice
15)
A parent brings an 8-month-old to the pediatrician's office. When the nurse approaches to measure the
child's vital signs, the child clings to the parent tightly and starts to cry. The parent says, "The baby
used to smile at everyone. I don't know why the baby is acting this way." The nurse begins teaching the
parent about growth and development by stating:
 "Children who behave that way are developing shy personalities."

 "Children at this age begin to fear pain."
 "Your baby's behavior indicates stranger anxiety, which is common at his age."
 "Your baby's having a temper tantrum, which is common at this age."
Score: 0.00
Correct answer(s):
 "Children who behave that way are developing shy personalities."
 "Children at this age begin to fear pain."
 "Your baby's behavior indicates stranger anxiety, which is common at his age."
 "Your baby's having a temper tantrum, which is common at this age."
Single choice
16)
The parents of a 3-week-old healthy newborn ask the nurse why their child is intermittently cross-eyed.
What is the nurse’s best response?
 "An eye patch may be necessary for 6 weeks to correct you child's vision."
 "Your child will likely need an ophthalmology consult."
 "It is normal to have eye crossing in the newborn period."
 "Surgery may be necessary to correct your child's vision."
Score: 0.00
Correct answer(s):
 "An eye patch may be necessary for 6 weeks to correct you child's vision."
 "Your child will likely need an ophthalmology consult."
 "It is normal to have eye crossing in the newborn period."
 "Surgery may be necessary to correct your child's vision."
Single choice
17)
A couple visiting the infertility clinic for the first-time states that they have been trying to conceive for
the past 2 years without success. After a history and physical examination of both partners, what would
be the most appropriate outcome for the couple to accomplish by the end of this visit?
 Choose an appropriate infertility treatment method.

 Acknowledge that only 50% of infertile couples achieve a pregnancy.
 Discuss alternative methods of having a family, such as adoption.
 Describe each of the potential causes and possible treatment modalities.
Score: 0.00
Correct answer(s):
 Choose an appropriate infertility treatment method.
 Acknowledge that only 50% of infertile couples achieve a pregnancy.
 Discuss alternative methods of having a family, such as adoption.
 Describe each of the potential causes and possible treatment modalities.
Multiple Choice
18)
The parents of a preschooler ask the nurse how to handle the child's temper tantrums. Which technique
should the nurse include in the teaching plan? Select all that apply.
 putting the child in "time-out"

 ignoring the child
 putting the child to bed
 spanking the child
 trying to reason with the child
Score: 0.00
Single choice
19)
A primiparous client who will be bottle-feeding her neonate asks, “What is the best position for the baby
to nap after feeding?” Which position should the nurse recommend?
 supine
 on the left side
 prone without a pillow
 upright on the caregiver’s lap
Score: 0.00
Correct answer(s):
 supine
 on the left side
 prone without a pillow
 upright on the caregiver’s lap
Multiple Choice
20)
The nurse is teaching a postpartum client about the prevention of mastitis. Which information should be
included in the teaching? Select all that apply.
 "Refrain from wearing a bra during the day to prevent nipple abrasions."
 "Limit feedings to four times a day to give your breasts a rest between feeding."
 "Breastfeed every one to two hours with position changes at each feeding."
 "Use plastic-lined breast pads so that your nipples don't become wet from leakage."
 "Allow your nipples to air dry after breastfeeding, and avoid using cloths for drying."
Score: 0.00
Multiple Choice
21)
A client has Raynaud’s phenomenon. What information should the nurse include in a teaching plan
about managing an attack? Select all that apply.
 Go to a warm room.
 Move the fingers and toes.
 Place hands under hot, running water.
 Massage the fingers and toes.
 Place hands under the armpits.
Score: 0.00
Single choice
22)
The nurse is delegating care of client with neutropenia who is in isolation to an unlicensed assistive
personnel (UAP). What information should the nurse give the UAP about the care of this client?
 listening and responding to the client’s feelings of concern

 completing the client’s care in a calm, unhurried manner
 completing all of the client’s care for the shift at one time
 instructing the client to dispose of the tissue after blowing the nose
Score: 0.00
Correct answer(s):
 listening and responding to the client’s feelings of concern
 completing the client’s care in a calm, unhurried manner
 completing all of the client’s care for the shift at one time
 instructing the client to dispose of the tissue after blowing the nose
Single choice
23)
A hospitalized preschooler with meningitis who is to be discharged becomes angry when the discharge is
delayed. Which play activities would be most appropriate at this time?
 reading the child a story

 painting with watercolors
 pounding on a pegboard
 stacking a tower of blocks
Score: 0.00
Correct answer(s):
 reading the child a story
 painting with watercolors
 pounding on a pegboard
 stacking a tower of blocks
Single choice
24)
A 10-year-old child visits the clinic for a wellness examination before entering school. The child's parent
questions the nurse about what to expect related to normal behavior at this age. What response by the
nurse is most appropriate?
 "Your child's need to express individuality will begin to increase at this age."
 "Your child will become more independent and will not require close parental supervision."
 "Your child will still need your guidance while exploring individual interests."
 "Peer relationships will be more important to your child than parental influence."
Score: 1.00
Single choice
25)
A student nurse and his/her preceptor are providing care for postpartum families in the home. Which
statements would indicate to the nurse that the student understands the benefits of community health?
 “Home care provides more comfort for people within their own homes.”
 “There is more opportunity to teach self and infant care.”
 “Nurses have more ability to assess the physical and psychological condition of the mother and baby dad.”
 “Home provides more access for families to services within their own community.”
Score: 0.00
Correct answer(s):
 “Home care provides more comfort for people within their own homes.”
 “There is more opportunity to teach self and infant care.”
 “Nurses have more ability to assess the physical and psychological condition of the mother and baby dad.”
 “Home provides more access for families to services within their own community.”
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PI Tutoring 1
Single choice
1)
The client with peripheral vascular disease and a history of hypertension is to be discharged on a low-
fat, low-cholesterol, low-sodium diet. Which should be the nurse's first step in planning the dietary
instructions?
Determine the client's knowledge level about cholesterol.
Ask the client to name foods high in fat, cholesterol, and salt.
Explain the importance of complying with the diet.
Assess the family's food preferences.

Single choice
2)
A 14-month-old client weighing 26 lb (11.8 kg) is admitted for traction to treat congenital hip
dislocation. When preparing the client's room, the nurse anticipates using which traction system?
Bryant's traction
Buck's extension traction
overhead suspension traction
90-90 traction
Single choice
3)
A client tells the nurse that she is concerned because she has not had a bowel movement since the birth
of her infant 3 days ago. Which would be the priority intervention by the nurse?
Encourage bed rest with frequent position changes.
Increase her consumption of fiber to 25 grams per day.
Collaborate with the physician for a laxatives order.
Tell her it is normal not to have a bowel movement for up to 5 days after birth.
Single choice
4)
A client with a new ileal conduit asks what the disadvantages are to this type of stoma. The nurse
explains that the client may experience which disadvantage?
Stool continuously oozes from it.
Absorption of nutrients is diminished.
Peristalsis is greatly decreased.
Urine drains from it continuously.

Single choice
5)
A client with unilateral nerve deafness is admitted to the surgical unit. What is the most important
intervention for the nurse to use when caring for this client?
Talk to the client and allow extra time for a one-to-one conversation to occur.
Be certain the client’s position is considered prior to beginning a conversation.
Convey information to the client through the use of a sign language interpreter.
Speak in a normal tone of voice and also write down all information for the client.
Single choice
6)
The nurse is teaching a client who is taking dexamethasone for cerebral edema about early symptoms of
Cushing's disease. The nurse should advise the client to report which of the following is a symptom of
hyperadrenocorticism?
Hypotension.
Easy bruising.
Increased muscle mass.
Increased urinary frequency.

Multiple Choice
7)
The client is admitted with pneumonia and is receiving intravenous (IV) antibiotic therapy. Which
assessment findings by the nurse indicate that the client is able to start oral antibiotic therapy? Select all
that apply.
tells the nurse, "I am hungry." client is short of breath normal functioning gastrointestinal (GI)
tract good oral (PO) intake oxygen saturation is 80%
Single choice
8)
A client undergoing a bilateral adrenalectomy has postoperative prescriptions for hydromorphone
hydrochloride 2 mg to be administered subcutaneously every 4 hours as needed for pain. Why should
the nurse administer hydromorphone in small doses?
A small dose is:
less likely to cause dependency.
less irritating to subcutaneous tissues in small doses.
as potent as morphine in larger doses.
excreted before accumulating in toxic amounts in the body.

Single choice
9)
The nurse is performing an assessment on an infant with intravenous fluids infusing in the right hand.
Which of the following assessment findings would the nurse recognize as acceptable in the infant?
streaking along the vein
no blood return
erythema around the IV site
edema around the IV site

Single choice
10)
A client is being successfully treated with clozapine. Which statement by the client reflects a need for
further teaching about managing the drug's adverse effects?
“If I eat too many fruits, I’ll get constipated.”

"I need to take the medicine with food to avoid nausea."
“I have to get up slowly so I don’t get dizzy.”
“Sometimes I have to push myself because I’m sleepy.”

Single choice
11)
A newly hired nurse on unit orientation prepares to administer vitamin K to a neonate. The nurse draws
up 1 mg of vitamin K and prepares to administer a subcutaneous injection in the left, lateral anterior
thigh. Which action by the nurse preceptor is best?
Stop the nurse and ask that the injection techniques be reevaluated.
Praise the nurse for accurately preparing to administer the injection.
Distract the neonate by talking in a calm voice.
Stop the nurse and instruct the nurse to administer the vitamin K using the Z-track method.
Multiple Choice
12)
The nurse is caring for a client who is 32 weeks pregnant. The client is started on nifedipine for preterm
labor. Which of the following statements made by the client demonstrate an understanding of the plan
of care? Select all that apply.
“I will check my blood pressure prior to taking my scheduled nifedipine.” “I will move about
frequently to keep my contractions regular.” “I will avoid sexual intercourse until my physician says
otherwise.” “I will drink 2 to 3 quarts (1.9 to 2.8 liters) of water per day.” “I will not take my
scheduled nifedipine if I have a headache.”
Single choice
13)
Upon entering the room, a nurse notes that there is a cap missing on the central venous access device.
The client is experiencing shortness of breath, coughing, and chest pain. What would the nurse
do first after replacing the cap on the open port?
Reassure the client that the symptoms will resolve very quickly.
Place the client in low Fowler’s position to facilitate easier breathing.

Obtain an electrocardiogram (EKG) to rule out possible myocardial infarction.
Notify the health care provider (HCP) of the incident.

Single choice
14)
To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina.
Which observation by the nurse indicates a radiation hazard?
The client is maintained on strict bed rest.
The head of the bed is at a 30-degree angle.
The client receives a complete bed bath each morning.
The nurse checks the applicator's position every 4 hours.

Multiple Choice
15)
The nurse is caring for an unconscious child with Reye syndrome. Which nursing interventions are
appropriate to prevent skin breakdown? Select all that apply.
keeping the arms and legs flexed placing the child on a sheepskin applying lotions on the skin
placing the client in a supine position frequent change of position
Single choice
16)
What should the nurse recognize as the first sign of peripheral arterial disease (PAD) in inactive older
adults?
pain in the extremities
diminished pulses
dry, shiny skin of the extremities
gangrene
Single choice
17)
The nurse is caring for a dysphagic client who is receiving intermittent enteral feedings via a
gastrostomy tube (G-tube). What action for the prevention of aspiration pneumonia will the nurse
include in the plan of care?
Elevate head of bed at 30 degrees at all times.
Perform oral care every 4 to 6 hours.
Change client's position every 2 to 3 hours.
Perform focused respiratory assessment every shift.

Single choice
18)
The nurse is caring for a child with swollen, painful joints. Which nonpharmacologic measure
is most important to implement for pain relief?
Perform gentle passive range-of-motion exercises.
Massage the painful joints.
Provide a bedside commode.
Encourage the child to change position in bed every 2 hours.

Single choice
19)
A nurse reviewing the lateral X-ray report on a child admitted with epiglottitis notes a finding of a
thickened flap. What is the appropriate nursing action?
Continue the current nursing care plan.
Communicate the finding during the hand-off report.
Notify the healthcare provider of the X-ray finding.
Prepare the child for a biopsy of the mass.

Single choice
20)
The parent of a newborn witnesses the nurse gives the baby a vitamin K injection and asks why the baby
received it. What is the nurse’s most appropriate response?
"The medication is given to stimulate growth of intestinal flora."

"The medication is given to promote absorption of fat-soluble nutrients."
"The medication is given to speed conjugation of bilirubin."
"The medication is given to promote synthesis of clotting factors."

Single choice
21)
A young adult is diagnosed with cryptorchidism. What is most important for the nurse to tell the client
about this condition?
The client may require preventive chemotherapy.
The client should use a condom to encourage the testicle to move
The client will be unable to have children.
The client should perform a testicular exam due to increased risk for cancer.
Single choice
22)
Active range-of-motion exercises are prescribed for a client with chronic arthritis. Which should the
nurse identify as the goal for these exercises?
reduce localized joint swelling
increase muscle strength
regain joint range of motion
maintain circulation to the extremities

Single choice
23)
The nurse should include which information in discharge teaching after a client has had nasal surgery?
The client should expect tarry stools for several days at home.
Nausea is an expected outcome of surgery and may persist for several days.
Brief episodes of epistaxis are expected after the surgery.

The pain from surgery should be resolved within 24 hours of the surgery.
Single choice
24)
A client is to take rosuvastatin. What information should the nurse determine prior to administering the
drug?
Can the client swallow a pill, or does the client need a liquid form?
Is the client of Asian descent?
Does the client have a history of cardiovascular disease?
Will the client be able to afford the medication?

Single choice
25)
What is the nurse's priority action for a client experiencing dyspnea, dependent edema, hepatomegaly,
crackles, and jugular vein distention?
Reposition the client so the lower legs dangle off the bed.
Apply supplemental oxygen at 4 L/min.
Administer furosemide 40 mg I.V. as ordered.
Notify the attending physician.

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Mental health

- is a state of emotional, psychological, and social wellness

 Autonomy and independence

Mental Illness/Mental disorder - a clinically signiﬁcant behavioral or

 dissatisfaction with one’s characteristics, abilities, and accomplishments

The Diagnostic and Statistical Manual of Mental Disorders (4th Edition,

 published by the American Psychiatric Association

 Axis I is for identifying all major psychiatric disorders except mental

Type of Mental Health Admission

- Detaining a voluntary client against her or his will is termed false

- Involuntary admission may be necessary when a person is mentally ill, is a

 Broad openings—allowing the client to take the initiative in introducing

“What would you like to work on today?”

 Giving recognition— acknowledging, indicating awareness

 Exploring—delving further into a subject or idea

 Clarifying - To check whether understanding is accurate, or to better

 Focusing—concentrating on a single point

“This point seems worth looking at more closely.”

 Encouraging the formulation of a plan of action

“How might you handle your anger in a non-threatening way?”

“My name is . . .” “Visiting hours are . . .” “My purpose in being here is . . .”

 General leads—giving encouragement to continue

“Go on.” “And then?” “Tell me about it.”

 Making observations— verbalizing what the nurse perceives

“You appear tense.” “I notice that you’re biting your lip.”

 Reﬂecting—directing client actions, thoughts, and feelings back to

 Restating—repeating the main idea expressed

 Suggesting collaboration— offering to share, to strive, to work with

 Summarizing—organizing and summing up that which has gone before

“Have I got this straight?” “You’ve said that . . .”

“During the past hour, you and I have discussed . . .”

 Voicing doubt—expressing uncertainty about the reality of the client’s

Client: Zombies inside me are eating my flesh”

Nurse: “Isn’t that unusual?”

“That’s hard to believe.”

Blocks to therapeutic Communication

 Advising—telling the client what to do

“Why don’t you . .”

“I think you should ..”

 Agreeing—indicating accord with the client

“That’s right.” “I agree.”

 Belittling feelings expressed—Misjudging the degree of the client’s

Client: “I have nothing to live for . . . I wish I was dead.”

 Challenging—demanding proof from the client

“But how can you be President of the United States?”

“If you’re dead, why is your heart beating?”

 Defending—attempting to protect someone or something from verbal

“This hospital has a ﬁne reputation.”

“I’m sure your doctor has your best interests in mind.”

 Disagreeing—opposing the client’s ideas

“That’s wrong.” “I deﬁnitely disagree with . . .” “I don’t believe that.”

 Disapproving—denouncing the client’s behavior or ideas

“That’s bad.” “I’d rather you wouldn’t . . .”

 Giving approval— sanctioning the client’s behavior or ideas

“That’s good.” “I’m glad that . . .”

 Making stereotyped comments—offering meaningless clichés or trite

“It’s for your own good.”

“Keep your chin up.”

 Probing—persistent questioning of the client

“Tell me your psychiatric history.”

 Reassuring—indicating there is no reason for anxiety or other feelings

“I wouldn’t worry about that.”

“Everything will be all right.”