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HI there....welcome To test visual acuity, the nurse should ask the patient to cover each eye separately and read the eye chart with glasses and without, as appropriate. Fundamental of Nursing Before teaching any procedure to the patient, the nurse must first assess the patient’s willingness to learn and his current knowledge. Fundamentals of Nursing A blood pressure cuff that is too narrow can cause a falsely elevated blood pressure reading. Fundamentals of Nursing When preparing a single injection for a patient who takes regular and NPH insulin, the nurse should draw the regular insulin into the syringe first because it is clear and can be measured more accurately than the NPH insulin, which is turbid. Fundamentals of Nursing Rhonchi refers to the rumbling sounds heard on lung auscultation; they are more pronounced during expiration than during inspiration. Fundamentals of Nursing Gavage refers to forced feeding, usually through a gastric tube (a tube passed into the stomach by way of the mouth). Fundamentals of Nursing According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority. Fundamentals of Nursing Checking the identification band on a patient’s wrist is the safest and surest way to verify a patient’s identity. Fundamentals of Nursing A patient’s safety is the priority concern in developing a therapeutic environment. Fundamentals of Nursing The nurse should place the patient with a Sengstaken-Blakemore tube in semi-Fowler’s position. Fundamentals of Nursing The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery; hand and finger spasms during occlusion indicate Trousseau’s sign and suggest hypocalcemia. Fundamentals of Nursing For blood transfusion in an adult, the appropriate needle size is 16 to 20G. Fundamentals of Nursing Pain that incapacities a patient and can’t be relieved by drugs is called intractable pain. Fundamentals of Nursing In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic transmission. Fundamentals of Nursing Decibel is the unit of measurement of sound. Fundamentals of Nursing Informed consent is required for any invasive procedure. Fundamentals of Nursing A patient who can’t write his or her name to give consent for treatment must have his or her X witnessed by two persons, such as a nurse, priest, or doctor. Fundamentals of Nursing The Z-track I.M. injection technique seals medication deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle that is 1’’ (2.5 cm) or longer. Fundamentals of Nursing A registered nurse (RN) should assign a licensed vocational nurse (LVN) or licensed practical nurse (LPN) to perform bedside care, such as suctioning and medication administration. Fundamentals of Nursing The therapeutic purposed of a mist tent is to increase hydration of secretions. Fundamentals of Nursing If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention. Fundamentals of Nursing The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity. Fundamentals of Nursing To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2” (5 cm) to that measurement. Fundamentals of Nursing Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies. Fundamentals of Nursing The appropriate needle size for an insulin injection is 25G and ⅝" (1.5 cm) long. Fundamentals of Nursing Residual urine refers to urine that remains in the bladder after voiding. The amount of residual urine normally ranges from 50 to 100 ml. Fundamentals of Nursing The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation. Fundamentals of Nursing Planning refers to the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan. Fundamentals of Nursing Implementation refers to the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions. Fundamentals of Nursing Evaluation refers to the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan, making the nursing process circular. Fundamentals of Nursing In the event of fire, the nurse should (1) remove the patient, (2) call the fire department, (3) attempt to contain the fire by closing the door, and (4) extinguish the fire, if it can be done safely. Fundamentals of Nursing Before administering any as need pain medication, the nurse should ask the patient to indicate the pain’s location. Fundamentals of Nursing Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people. Fundamentals of Nursing When providing oral care for an unconscious patient, the nurse should position the patient on the side to minimize the risk of aspiration. Fundamentals of Nursing During assessment of distance vision, the patient should stand 20’ (6.1 m) from the chart. Fundamentals of Nursing The ideal room temperature for a geriatric patient or one who is extremely ill ranges form 66º to 76º F (18.8º to 24.4º C). Fundamentals of Nursing Normal room humidity ranges from 30% to 60%. Fundamentals of Nursing Hand washing is the single best method of limiting the spread of microorganisms. Hands should be washed for 10 seconds after routine contact with a patient and after gloves are removed. Fundamentals of Nursing To catheterize a female patient, the nurse should place her in the dorsal recumbent position. Fundamentals of Nursing A positive Homan’s sign may indicate thrombophlebitis. Fundamentals of Nursing Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent equals the number of milligrams per 100 milliliters of a solution. Fundamentals of Nursing Metabolism takes a place in two phases: anabolism (the constructive phase) and catabolism (the destructive phase). Fundamentals of Nursing The basal metabolic rate represents the amount of energy needed to maintain essential body functions. It is measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment. Fundamentals of Nursing Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains adequate intestinal motility, and helps establish regular bowel habits. Fundamentals of Nursing Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs. Fundamentals of Nursing Petechiae refers to tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage. Fundamentals of Nursing Purpura refers to a purple skin discoloration caused by blood extravasation. Fundamentals of Nursing Glucose-6-phosphate dehydrogenase (C6PD) deficiency is an inherited metabolic disorder characterized by red blood cells that are deficient in G6PD, a critical enzyme in aerobic glycolysis. Fundamentals of Nursing According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse shouldn’t recap needles after use because most needle sticks result from missed needle recapping. Fundamentals of Nursing The nurse administers a drug by I.V. push by delivering the dose directly into a vein, I.V. tubing, or catheter with a needle and syringe. Fundamentals of Nursing When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied. Fundamentals of Nursing A nurse should have assistance when changing the ties on a tracheostomy tube. Fundamentals of Nursing A filter is always used for blood transfusions. Fundamentals of Nursing A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide. Fundamentals of Nursing The patient should carry a cane on the unaffected side to promote a reciprocal gait pattern and distribute weight away from the affected leg. Fundamentals of Nursing A good way to begin a patient interview is to ask “What made you seek medical help?” Fundamentals of Nursing The nurse should adhere to standard precautions for blood and body fluids when caring for all patients. Fundamentals of Nursing Potassium (K+) is the most abundant cation in intracellular fluid. Fundamentals of Nursing In the four-point gait (or alternating gait), the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot. Fundamentals of Nursing In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg. Fundamentals of Nursing In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch. Fundamentals of Nursing Vitamin B complex, the water-soluble vitamins essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12). Fundamentals of Nursing When being weighed, an adult patient should be lightly dressed and shoeless. Fundamentals of Nursing Before taking an adult’s oral temperature, the nurse should ensure that the patient hasn’t smoked or consumed hot or cold substances in the past 15 minutes. Fundamentals of Nursing The nurse shouldn’t take a rectal temperature on an adult patient if the patient has a cardiac disorder; anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery. Fundamentals of Nursing In a patient with cardiac problems, rectal temperature measurement may stimulate a vagal response, leading to vasodilation and decreased cardiac output. Fundamentals of Nursing When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3 indicates a bounding pulse (readily palpable and forceful); +2, a normal pulse (easily palpable); +1, a thready or weak pulse (difficult to detect); and 0, an absent pulse (not detectable). Fundamentals of Nursing The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia recovery unit. Fundamentals of Nursing On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water, has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have taken and recorded. Artificial limbs and other prostheses are usually removed. Fundamentals of Nursing Comfort measures, such as positioning the patient, performing backrubs, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness. Fundamentals of Nursing A drug has three names: its generic name, which is used in official publications; its trade name or brand name (such as Tylenol), which is selected by the drug company; and its chemical name, which describes the drug’s chemical composition. Fundamentals of Nursing The patient should take a liquid iron preparation through a straw to avoid staining the teeth. Fundamentals of Nursing The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon). Fundamentals of Nursing An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin. Fundamentals of Nursing In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma. Fundamentals of Nursing To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if indicated; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet. Fundamentals of Nursing The diaphragm of the stethoscope is used to hear high-pitched sounds such as breath sounds. Fundamentals of Nursing A slight blood pressure difference (5 to 10 mm Hg) between right and left arms is normal. Fundamentals of Nursing The nurse should place the blood pressure cuff 1'' (2.5 cm) above the antecubital fossa. Fundamentals of Nursing When instilling ophthalmic ointments, waste the first bed of ointment and then apply from the inner canthus to the outer canthus; twist the medication tube to detach the ointment. Fundamentals of Nursing The nurse should use a leg cuff to measure blood pressure in an obese patient. Fundamentals of Nursing If the blood pressure cuff is applied too loosely, the reading will be falsely elevated. Fundamentals of Nursing Ptosis refers to eyelid drooping. Fundamentals of Nursing A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position. Fundamentals of Nursing To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle. Fundamentals of Nursing To move the patient to the edge of the bed for transfer, follow these steps: (1) Move the patient’s head and shoulders toward the edge of the bed. (2) Move the patient’s feet and legs to the edge of the bed (crescent position). (3) Place both the arms well under the patient’s hips and straighten the back while moving the patient toward the edge of the bed. Fundamentals of Nursing When being measured for crutches, a patient should wear his or her shoes. Fundamentals of Nursing The nurse should attach a restraint to a part of the bed frame that moves with the head, not to the mattress or side rails. Fundamentals of Nursing The mist in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory pattern. Fundamentals of Nursing To administer heparin subcutaneously, the nurse should follow these steps: (1) Clean, but don’t rub, the site with alcohol. (2) Stretch the skin taut or pick up a well-defined skin fold. (3)Hold the shaft of the needle in a dart position. (4)Insert the needle into the skin at a right (90-degree) angle. (5)Firmly depress the plunger; but don’t aspirate. (6)Leave the needle in place for 10 seconds. (7)Withdraw the needle gently at the same angle it was inserted. (8)Apply pressure to the injection site with an alcohol pad. Fundamentals of Nursing For a sigmoidoscopy, the nurse should place the patient in a knee-chest or Sims’ position, depending on the doctor’s preference. Fundamentals of Nursing Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort) safety and security, love and belonging, self-esteem and recognition, and self-actualization. Fundamentals of Nursing When caring for patient with a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness. Fundamentals of Nursing During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube. Fundamentals of Nursing In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage, for example, “10 mm of brown mucoid drainage noted on dressing.” Fundamentals of Nursing To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as thumbnail. Fundamentals of Nursing In a positive Babinski’s reflex, the great toe dorsiflexes and the other toes fan out. Fundamentals of Nursing When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis. Fundamentals of Nursing The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours. Fundamentals of Nursing Antiembolism stockings decompress the superficial blood vessels, thereby reducing the risk of thrombus formation. Fundamentals of Nursing The most convenient veins for venipuncture in a adult patient are the basilic and median cubital veins in the antecubital space. Fundamentals of Nursing From 2 to 3 hours before beginning a tube feeding, the nurse should aspirate the patient’s stomach contents to verify adequate gastric emptying. Fundamentals of Nursing People with type O blood are considered to be universal donors. Fundamentals of Nursing People with type AB blood are considered to be universal recipients. Fundamentals of Nursing Herts (Hz) refers to the unit of measurement of sound frequency. Fundamentals of Nursing Hearing protection is required when the sound intensity exceeds 84 dB; double hearing protection is required if it exceeds 104 dB. Fundamentals of Nursing Prothrombin, a clotting factor, is produced in the liver. Fundamentals of Nursing If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory slip. Fundamentals of Nursing During lumbar puncture, the nurse must note the initial intracranial pressure and the cerebrospinal fluid color. Fundamentals of Nursing A patient who can’t cough to provide a sputum sample for culture may require a heated aerosol treatment to facilitate removal of a sample. Fundamentals of Nursing If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first. Fundamentals of Nursing When leaving an isolation room, the nurse should remove the gloves before the mask because fewer pathogens are on the mask. Fundamentals of Nursing Skeletal traction is applied to a bone using wire pins or tons. It is the most effective means of traction. Fundamentals of Nursing The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use because delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction. Fundamentals of Nursing Medication isn’t routinely injected I.M. into edematous tissue because it may not be absorbed. Fundamentals of Nursing When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice. Fundamentals of Nursing When cleaning dentures, the sink should be lined with a washcloth. Fundamentals of Nursing A patient should void within 8 hours after surgery. Fundamentals of Nursing An EEG identifies normal and abnormal brain waves. Fundamentals of Nursing Stool samples for ova and parasite tests should be delivered to the laboratory without delay or refrigeration. Fundamentals of Nursing The autonomic nervous system regulates the cardiovascular and respiratory systems. Fundamentals of Nursing When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion. Fundamentals of Nursing A low-residue diet includes such as foods as roasted chicken, rice, and pasta. Fundamentals of Nursing A rectal tube should not be inserted for longer than 20 minutes; it can irritate the mucosa of the rectum and cause a loss of sphincter control. Fundamentals of Nursing A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum. Fundamentals of Nursing When lifting and moving a patient, the nurse should use the upper leg muscles most to prevent injury. Fundamentals of Nursing Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal. Fundamentals of Nursing During occupied bed changes, the patient should be covered with a black blanket to promote warmth and prevent exposure. Fundamentals of Nursing Anticipatory grief refers to mourning that occurs for an extended time when one realizes that death is inevitable. Fundamentals of Nursing The following foods can alter stool color: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown). Fundamentals of Nursing When preparing a patient for a skull X-ray, have the patient remove all jewelry and dentures. Fundamentals of Nursing The fight-or-flight response is a sympathetic nervous system response. Fundamentals of Nursing Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia. Fundamentals of Nursing Wheezing refers to an abnormal, high-pitched breath sound that is accentuated on expiration. Fundamentals of Nursing Wax or a foreign body in the ear should be gently flushed out by irrigation with warm saline solution. Fundamentals of Nursing If a patient complains that his hearing aid is “not working,” the nurse should check the switch first to see if it’s turned on and then check the batteries. Fundamentals of Nursing The nurse should grade hyperactive biceps and triceps reflexes +4. Fundamentals of Nursing If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart. Fundamentals of Nursing In a postoperative patient, forcing fluids helps prevent constipation. Fundamentals of Nursing The nurse must administer care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy. Fundamentals of Nursing The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1º C. Fundamentals of Nursing As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion. Fundamentals of Nursing The body metabolizes alcohol at a fixed rate regardless of serum concentration. Fundamentals of Nursing In an alcoholic beverage, its proof reflects its percentage of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol. Fundamentals of Nursing A living will is a witnessed document that states a patient’s desire for certain types of care and treatment, which depends on the patient’s wishes and views and quality of life. Fundamentals of Nursing The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as needed with normal saline solution to maintain patency. Fundamentals of Nursing Quality assurance is a method of determining whether nursing actions and practices meet established standards. Fundamentals of Nursing The five rights of medication administration are the right patient, right medication, right dose, right route of administration, and the right time. Fundamentals of Nursing Outside of the hospital setting, only the sublingual and transligual forms of nitroglycerin should be used to relieve acute anginal attacks. Fundamentals of Nursing The implementation phase of the nursing process involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities. Fundamentals of Nursing The Patient’s Bill of Rights offers guidance and protection to patients by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization. Fundamentals of Nursing To minimize the omissions and distortion of facts, the nurse should record information as soon as it is gathered. Fundamentals of Nursing When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present. Fundamentals of Nursing Drug administration is a dependent activity. The nurse can administer or withhold a drug only with the doctor’s permission. Fundamentals of Nursing The nurse shouldn’t give false assurance to a patient. Fundamentals of Nursing After receiving preoperative medication, a patient isn’t competent to sign an informed consent form. Fundamentals of Nursing When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms. Fundamentals of Nursing A nurse may clarify a doctor’s explanation to a patient about an operation or a procedure but must refer questions about informed consent to the doctor. Fundamentals of Nursing The nurse shouldn’t use her thumb to take a patient’s pulse rate because the thumb has a pulse of its own and may be confused with the patient’s pulse. Fundamentals of Nursing An inspiration and an expiration count as one respiration. Fundamentals of Nursing Normal respirations are known as eupnea. Fundamentals of Nursing During a blood pressure measurement, the patient should rest the arm against a surface because using muscle strength to hold up the arm may raise the blood pressure. Fundamentals of Nursing Major unalterable risk factors for coronary artery disease include heredity, sex, race, and age. Fundamentals of Nursing Inspection is the most frequently used assessment technique. Fundamentals of Nursing Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a homey atmosphere. Fundamentals of Nursing The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication. Fundamentals of Nursing Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidosmastoid muscle use during respiration. Fundamentals of Nursing When patients use axillary crutches, their palms should bear the brunt of the weight. Fundamentals of Nursing Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially. Fundamentals of Nursing Normal gait has two phases: the stance phase, in which the patient’s foot rests on the ground, and the swing phase, in which that patient’s foot moves forward. Fundamentals of Nursing The phases of mitosis are prophase, metaphase, anaphase, and telophase. Fundamentals of Nursing The nurse should follow standard precautions in the routine care of all patients. Fundamentals of Nursing The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs. Fundamentals of Nursing The nurse can assess a patient’s general knowledge by asking questions such as “Who is the president for the United States?” Fundamentals of Nursing Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury. Fundamentals of Nursing The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers). Fundamentals of Nursing The autonomic nervous system controls the smooth muscles. Fundamentals of Nursing A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. It is developed in collaboration with the patient. Fundamentals of Nursing The optic disk is yellowish pink and circular with a distinct border. Fundamentals of Nursing A primary disability results from a pathologic process; a secondary disability, from inactivity. Nurses usually are held liable for failing to keep an accurate count of sponges and other devices during surgery. Fundamentals of Nursing The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals. Fundamentals of Nursing Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, leafy vegetables, eggs, and whole gains, generally have low water content. Fundamentals of Nursing Collaboration refers to joint communication and decision making between nurses and doctors designed to meet patients’ needs by integrating the care regimens of both professions in one comprehensive approach. Fundamentals of Nursing Bradycardia refers to a heart rate of fewer than 60 beats/minute. Fundamentals of Nursing A nursing diagnosis is a statement of a patient’s actual or potential health problems that can be resolved, diminished, or otherwise changed by nursing interventions. Fundamentals of Nursing During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data. Fundamentals of Nursing The patient’s health history consists primarily of subjective data, information supplied by patient. Fundamentals of Nursing The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation. Fundamentals of Nursing When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign every entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines. Fundamentals of Nursing Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy. Fundamentals of Nursing The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery, which is compressed against the radius to take the pulse rate. Fundamentals of Nursing The normal pulse rate of a resting adult is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults. Fundamentals of Nursing Laboratory test results are an objective form of assessment data. Fundamentals of Nursing The measurement systems most often used in clinical practice are the metric system, apothecaries’ system, and household system. Fundamentals of Nursing Before signing an informed consent, a patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phase; the risk involved; and the possible complications. The patient also should have a general idea of the time required from surgery to recovery and should have an opportunity to ask questions. Fundamentals of Nursing A patient must sign a separate informed consent form for each procedure. Fundamentals of Nursing During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds (that helps determine the size, shape, position, and density of underlying organs and tissues), elicit tenderness, or assess reflexes. Fundamentals of Nursing Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound. Fundamentals of Nursing A foot cradle keeps bed linen off the patient’s feet, which prevent skin irritation and breakdown, especially in a patient with peripheral vascular disease or neuropathy. Fundamentals of Nursing If the patient is a married minor, permission to perform a procedure can be obtained form the patient’s spouse. Fundamentals of Nursing Gastric lavage is the flushing of the stomach and removal of ingested substances through a nasogastric tube. It can be used to treat poisoning or drug overdose. Fundamentals of Nursing During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy. Fundamentals of Nursing Bruits commonly indicate a life- or limb-threatening vascular disease. Fundamentals of Nursing O.U. means each eye; O.D., right eye; and O.S, left eye. Fundamentals of Nursing To remove a patient’s artificial eye, the nurse depresses the lower lid. Fundamentals of Nursing The nurse should use a warm saline solution to clean an artificial eye. Fundamentals of Nursing A thready pulse is very fine and scarcely perceptible. Fundamentals of Nursing Axillary temperature usually is 1º F lower than oral temperature. Fundamentals of Nursing After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions. Fundamentals of Nursing On a medication prescription, the abbreviation p.c. means that the medication should be administered after meals. Fundamentals of Nursing After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment. Fundamentals of Nursing Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which she works. Fundamentals of Nursing Gauge refers to the inside diameter of a needle. The smaller the gauge, the larger the diameter. Fundamentals of Nursing An adult normally has 32 permanent teeth. Fundamentals of Nursing After turning a patient, the nurse should document the position used, time turned, and skin assessment findings. Fundamentals of Nursing PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation. Fundamentals of Nursing When purcussing a patient’s chest for postural drainage, the nurse’s hands should be cupped. Fundamentals of Nursing When measuring a patient’s pulse, the nurse should assess the rate, rhythms, quality, and strength. Fundamentals of Nursing Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair’s footrests to the sides and lock its wheels. Fundamentals of Nursing When assessing respirations, the nurse should document the rate, rhythm, depth, and quality. Fundamentals of Nursing For a subcutaneous injection, the nurse should use a ⅝" 25G needle. Fundamentals of Nursing The notation “AA & O x 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time). Fundamentals of Nursing Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or stool, and perspiration. Fundamentals of Nursing After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results. Fundamentals of Nursing When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle) with the bevel up. Fundamentals of Nursing To obtain an accurate blood pressure, the nurse should inflate the manometer 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure. Fundamentals of Nursing The nurse should count an irregular pulse for 1 full minute. Fundamentals of Nursing A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus. Fundamentals of Nursing Prophylaxis is disease prevention. Fundamentals of Nursing Body alignment is achieved when the body parts are in proper relation to their natural position. Fundamentals of Nursing Trust is the foundation of a nurse-patient relationship. Fundamentals of Nursing Blood pressure in the force exerted by the circulating volume of blood on arterial walls. Fundamentals of Nursing Malpractice refers to the professional’s wrongful conduct, improper discharge of duties, or failure to meet standers of care, which causes harm to another. Fundamentals of Nursing As a general rule, nurses can’t refuse a patient care assignment; however, they may refuse to participate in abortions in most states. Fundamentals of Nursing A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform. Fundamentals of Nursing States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from such assistance. These laws don’t apply to care provided in a health care facility. Fundamentals of Nursing A doctor should sign verbal and telephone orders within the time established by institutional policy, usually within 24 hours. Fundamentals of Nursing A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of this refusal. Fundamentals of Nursing Although a patient’s health record or chart is the health care facility’s physical property, its contents belong to the patient. Fundamentals of Nursing Before a patient’s record can be released to a third party, the patient or patient’s legal guardian must give written consent. Fundamentals of Nursing Under the Controlled Substances Act, every dose of a controlled drug dispensed by the pharmacy must be counted for, whether the dose was administered to a particular patient or discarded accidentally. Fundamentals of Nursing A nurse can’t perform duties that violate a rule or regulation established by a state licensing board even if it is authorized by a health care facility or doctor. Fundamentals of Nursing The nurse should select a private room, preferably with a door that can be closed, to minimize interruptions during a patient interview. Fundamentals of Nursing In categorizing nursing diagnosis, the nurse should address actual life-threatening problems first, followed by potentially life-threatening concerns. Fundamentals of Nursing The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions. Fundamentals of Nursing Standing orders, or protocols, establish guidelines for treating a particular disease or set of symptoms. Fundamentals of Nursing In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostals space near the apex. Fundamentals of Nursing The S1 sound heard on auscultation is caused by closure of the mitral and tricuspid valves. Fundamentals of Nursing To maintain package sterility, the nurse should open the wrapper’s top flap away from the body, open side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body. Fundamentals of Nursing The nurse shouldn’t use a cotton-tipped applicator to dry a patient’s ear canal or remove wax because it may force cerumen against the tympanic membrane. Fundamentals of Nursing A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises. Fundamentals of Nursing The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse liability. Fundamentals of Nursing Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States. Fundamentals of Nursing Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential but have currently accepted medical uses. Their use may lead to physical or psychological dependence. Fundamentals of Nursing Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both. Fundamentals of Nursing Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs. Fundamentals of Nursing Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances. Fundamentals of Nursing Activities of daily living are actions that the patient must perform every day to provide self-care and interact with society. Fundamentals of Nursing Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI. Fundamentals of Nursing The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with stethoscope slightly raised from the chest. Fundamentals of Nursing The most important goal to include in a care plan is the patient’s goal. Fundamentals of Nursing Fruits are high in fiber and low in protein and should be omitted from a low-residue diet. Fundamentals of Nursing The nurse should use an objective scale to assess and quantify pain because postoperative pain varies greatly among individuals. Fundamentals of Nursing Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings. Fundamentals of Nursing The nurse should provide honest answers to the patient’s questions. Fundamentals of Nursing Milk shouldn’t be included in a clear liquid diet. Fundamentals of Nursing Consistency in nursing personnel is paramount when caring for a child, and infant, or a confused patient. Fundamentals of Nursing The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland. Fundamentals of Nursing The three membranes that enclose that brain and spinal cord are the dura mater, pia mater, and arachnoid. Fundamentals of Nursing A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively. Fundamentals of Nursing Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for medication. Fundamentals of Nursing The area around a stoma should be cleaned with mild soap and water. Fundamentals of Nursing Vegetables have a high fiber content. Fundamentals of Nursing The nurse should use a tuberculin syringe to administer an S.C. injection of less than 1 ml. Fundamentals of Nursing For adults, S.C. injections require a 25G 1" needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G ½" needle. Fundamentals of Nursing Before administering medication, the nurse should identify the patient by checking the identification band and asking the patient to state his name. Fundamentals of Nursing To clean the skin before an injection, the nurse should use a sterile alcohol swab and wipe from the center of the site outward in a circular motion. Fundamentals of Nursing The nurse always should inject heparin deep into S.C. tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation. Fundamentals of Nursing If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure. Fundamentals of Nursing The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative. Fundamentals of Nursing If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops; if bruising occurs, the nurse should monitor the site for an enlarging hematoma. Fundamentals of Nursing When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head. Fundamentals of Nursing Frequency of patient hair care depends on the length and texture of the hair, duration of hospitalization, and patient’s condition. Fundamentals of Nursing Proper hearing aid function requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries. Fundamentals of Nursing The hearing aid marked with a blue dot is for the left ear; the one with the red dot is for the right ear. Fundamentals of Nursing A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water. Fundamentals of Nursing The nurse should instruct a patient not to use hair spray while wearing a hearing aid. Fundamentals of Nursing The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy. Fundamentals of Nursing The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown. Fundamentals of Nursing The purpose of heat application is to promote vasodilation, which reduces pain caused by inflammation. Fundamentals of Nursing A sutured surgical incision is an example of healing by first intention (healing directly, without granulation). Fundamentals of Nursing Healing by secondary intention (healing by granulation) is closure of the wound by the granulation tissue filling the defect and allowing reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered. Fundamentals of Nursing Keloid formation is an abnormality in healing characterized by overgrowth of scar tissue at the wound site. Fundamentals of Nursing The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site. Fundamentals of Nursing The ascending colostomy drains fluid feces; the descending colostomy drains solid fecal matter. Fundamentals of Nursing A folded towel (called a scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis. Fundamentals of Nursing When giving an injection to the patient with a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection. Fundamentals of Nursing Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation. Fundamentals of Nursing To insert a nasogastric tube, the nurse should first instruct the patient to tilt the head back slightly and then insert the tube. When the tube is felt curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.) Fundamentals of Nursing According to families whose loved ones are in intensive care units, their four most important needs are to have questions answered honestly, to be assured that the best possible car is being provided, to know the prognosis, and to feel there is hope. Fundamentals of Nursing A double-bind communication when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to. Fundamentals of Nursing A nonjudgmental attitude displayed by the nurse demonstrates that she neither approves nor disapproves of the patient. Fundamentals of Nursing Target symptoms are those that the patient and others find most distressing. Fundamentals of Nursing Advise the patient to take aspirin on an empty stomach with a full glass of water and to avoid foods with acid such as coffee, citrus fruits, and cola. Fundamentals of Nursing For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for that specific problem, and then selecting the intervention from the choices provided that will enable the patient to reach that goal. Fundamentals of Nursing Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient. Fundamentals of Nursing Giving an I.M. injection against the patient’s will and without legal authority is battery. Fundamentals of Nursing An example of a third-party payor is an insurance company. Fundamentals of Nursing On-call medication should be given within 5 minutes of receipt of the call. Fundamentals of Nursing Generally, the best method to determine the cultural or spiritual needs of the patient is to ask him. Fundamentals of Nursing An incident report shouldn’t be made part of the patient’s record but is an in-house document for the purpose of correcting the problem. Fundamentals of Nursing Critical pathways are a multidisciplinary guideline for patient care. Fundamentals of Nursing When prioritizing nursing diagnoses, use this hierarchy: (1) problems associated with airway, (2) those concerning breathing, and (3) those related to circulation. Fundamentals of Nursing The two nursing diagnoses with the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern. Fundamentals of Nursing A subjective sign that a sitz bath has been effective is that patient expresses a decrease in pain or discomfort. Fundamentals of Nursing For the nursing diagnosis Diversional activity deficit to be valid, the patient must make the statement that he’s “bored, there is nothing to do” or words to that effect. Fundamentals of Nursing The most appropriate nursing diagnosis for an individual who doesn’t speak English is Communication, impaired, related to inability to speak dominant language (English). Fundamentals of Nursing The family of the patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him. Fundamentals of Nursing Up to age 3, the pinna should be pulled down and back to straighten the eustachian tube before instilling medication. Fundamentals of Nursing When administering eyedrops, the nurse should waste the first drop and instill the medication in the lower conjunctival sac to prevent injury to the cornea. Fundamentals of Nursing When administering eye ointment, the nurse should waste the first bead of medication and then apply the medication from the inner to the outer canthus. Fundamentals of Nursing When removing gloves and mask, the gloves, which most likely contain pathogens and are soiled, should be removed first. Fundamentals of Nursing Crutches should placed 6" (15 cm) in front of the patient and 6" to the side to assume a tripod position. Fundamentals of Nursing Listening is the most effective communication technique. Fundamentals of Nursing Process recording is a method of evaluating one’s communication effectiveness. Fundamentals of Nursing When feeding the elderly, limit high-carbohydrate foods because of the risk of glucose intolerance. Fundamentals of Nursing Passive range of motion maintains joint mobility whereas resistive exercises increase muscle mass. Fundamentals of Nursing Isometric exercises are performed on an extremity in a cast. Fundamentals of Nursing A back rub is an example of the gate-control theory of pain. Fundamentals of Nursing Anything below the waist is considered unsterile, a sterile field becomes unsterile when it comes in contact with nay unsterile item, a sterile field must be continuously monitored, and the 1" (2.5 cm) border around a sterile field is considered unsterile. Fundamentals of Nursing A “shift to the left” is evident when there is an increase in immature cells (bands) in the blood to fight an infection. Fundamentals of Nursing A “shift to the right” is evident when there is an increase in mature cells in the blood as seen in advanced liver diseases and pernicious anemia. Fundamentals of Nursing Before administering preoperative medication, make sure that an informed consent form has been signed and attached to the patient’s record. Fundamentals of Nursing The nurse should spend no more than 30 minutes per 8-hour shift in providing care to the patient with a radiation implant. Fundamentals of Nursing The nurse should stand near the patient’s shoulders for cervical implants and at the foot of the bed for head and neck implants. Fundamentals of Nursing The nurse should never be assigned to care for more than one patient with radiation implants. Fundamentals of Nursing Long-handled forceps and a lead-lined container should be in the room of the patient who has a radiation implant. Fundamentals of Nursing Generally, patients who have the same infection and are in strict isolation can share the same room. Fundamentals of Nursing Diseases requiring strict isolation include chickenpox, diphtheria, and viral hemorrhagic fever such as Marburg virus disease. Fundamentals of Nursing For the patient abiding by Jewish custom, milk and meat shouldn’t be served in the same meal. Fundamentals of Nursing Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps of the procedure (cognitive domain of learning). Fundamentals of Nursing Developmental stages according to Erik Erikson are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to 3 years), initiative versus guilt (3 to 5 years), industry versus inferiority (5 to 12 years), identity versus identity diffusion (12 to 18 years), intimacy versus isolation (18 to 25 years), generativity versus stagnation (25 to 60 years), and ego integrity versus despair (older than 60 years). Fundamentals of Nursing Face the hearing impaired patient when communicating with him. Fundamentals of Nursing A proper nursing intervention for the spouse of the patient who has suffered a serious incapacitating disease is to assist him in mobilizing a support system. Fundamentals of Nursing Hyperpyrexia refers to extreme elevation in temperature above 106º F (41.1º C). Fundamentals of Nursing

Common Surgical Procedure

  • appendectomy
    An appendectomy is the surgical removal of the appendix, a small tube that branches off the large intestine, to treat acute appendicitis. Appendicitis is the acute inflammation of this tube due to infection.

  • breast biopsy
    A biopsy is a diagnostic test involving the removal of tissue or cells for examination under a microscope. This procedure is also used to remove abnormal breast tissue. A biopsy may be performed using a hollow needle to extract tissue (needle aspiration), or a lump may be partially or completely removed (lumpectomy) for examination and/or treatment.

  • carotid endarterectomy
    Carotid endarterectomy is a surgical procedure to remove blockage from carotid arteries, the arteries located in the neck that supply blood to the brain. Left untreated, a blocked carotid artery can lead to a stroke.

  • cataract surgery
    Cataracts cloud the normally clear lens of the eyes. Cataract surgery involves the removal of the cloudy contents with ultrasound waves. In some cases, the entire lens is removed.

  • cesarean section
    Cesarean section (also called a c-section) is the surgical delivery of a baby by an incision through the mother's abdomen and uterus. This procedure is performed when physicians determine it a safer alternative than a vaginal delivery for the mother, baby, or both.

  • cholecystectomy
    A cholecystectomy is surgery to remove the gallbladder (a pear-shaped sac near the right lobe of the liver that holds bile). A gallbladder may need to be removed if the organ is prone to troublesome gallstones, if it is infected, or becomes cancerous.

  • coronary artery bypass - Most commonly referred to as simply "bypass surgery," this surgery is often performed in people who have angina (chest pain) and coronary artery disease (where plaque has built up in the arteries). During the surgery, a bypass is created by grafting a piece of a vein above and below the blocked area of a coronary artery, enabling blood to flow around the obstruction. Veins are usually taken from the leg, but arteries from the chest may also be used to create a bypass graft.

    Anatomy of the heart following coronary artery bypass surgery
    Click Image to Enlarge

  • debridement of wound, burn, or infection
    Debridement involves the surgical removal of foreign material and/or dead, damaged, or infected tissue from a wound or burn. By removing the diseased or dead tissue, healthy tissue is exposed to allow for more effective healing.

  • dilation and curettage (Also called D & C.)
    A D&C is a minor operation in which the cervix is dilated (expanded) so that the cervical canal and uterine lining can be scraped with a curette (spoon-shaped instrument).

  • free skin graft
    A skin graft involves detaching healthy skin from one part of the body to repair areas of lost or damaged skin in another part of the body. Skin grafts are often performed as a result of burns, injury, or surgical removal of diseased skin. They are most often performed when the area is too large to be repaired by stitching or natural healing.

  • hemorrhoidectomy
    A hemorrhoidectomy is the surgical removal of hemorrhoids, distended veins in the lower rectum or anus.

  • hysterectomy
    A hysterectomy is the surgical removal of a woman's uterus. This may be performed either through an abdominal incision or vaginally.

  • hysteroscopy
    Hysteroscopy is a surgical procedure used to help diagnose and treat many uterine disorders. The hysteroscope (a viewing instrument inserted through the vagina for a visual examination of the canal of the cervix and the interior of the uterus) can transmit an image of the uterine canal and cavity to a television screen.

  • inguinal hernia repair
    Inguinal hernias are protrusions of part of the intestine into the muscles of the groin. Surgical repair pulls the intestine back to its original location.

  • low back pain surgery
    Low back pain can have various causes, including abnormal development of the backbone, stress on the back, injury, or a physical disorder that affects the bones of the spine. Usually, surgery is not considered until other options have been exhausted, including rest, medication, and mild exercise. The type of surgery performed on the back depends on the diagnosis.

  • mastectomy
    A mastectomy is the removal of all or part of the breast. Mastectomies are usually performed to treat breast cancer. There are several types of mastectomies, including the following:

  • partial (segmental) mastectomy, involves the removal of the breast cancer and a larger portion of the normal breast tissue around the breast cancer.

    Illustration of a partial mastectomy

  • total (or simple) mastectomy, in which the surgeon removes the entire breast, including the nipple, the areola (the colored, circular area around the nipple), and most of the overlying skin, and may also remove some of the lymph nodes under the arm, also called the axillary lymph glands.

    Illustration of a total mastectomy

  • modified radical mastectomy, in which the surgeon removes the entire breast (including the nipple, the areola, and the overlying skin), some of the lymph nodes under the arm, and the lining over the chest muscles. In some cases, part of the chest wall muscles is also removed.

    Illustration of a modified radical mastectomy

  • radical mastectomy, involves removal of the entire breast (including the nipple, the areola, and the overlying skin), the lymph nodes under the arm, and the chest muscles.

    Illustration of a radical mastectomy

  • partial colectomy
    A partial colectomy is the removal of part of the large intestine (colon) which may be performed to treat cancer of the colon or long-term ulcerative colitis.

  • prostatectomy
    The surgical removal of all or part of the prostate gland, the sex gland in men that surrounds the neck of the bladder and urethra - the tube that carries urine away from the bladder. A prostatectomy may be performed for an enlarged prostate, benign prostatic hyperplasia (BPH), or if the prostate gland is cancerous.

  • releasing of peritoneal adhesions
    The peritoneum is a two-layered membrane that lines the wall of the abdominal cavity and covers abdominal organs. Sometimes, organs begin to adhere to the peritoneum, requiring surgery to detach them.

  • tonsillectomy
    The surgical removal of one or both tonsils. Tonsils are located at the back of the mouth and help fight infections.

SOURCE: http://carefirst.staywellsolutionsonline.com/Library/Encyclopedia/85,P01392
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COMMON LAB TESTS FOR HEMATOLOGIC DISORDERS

1. Blood

* Complete blood count (CBC)

* Differential blood count

* Sickle cell trait

* Laboratory tests for Anemias and Leukemias

* Transferrin saturation

* Serum ferritin

* Serum folic acid

* Serum iron

* Serum total iron-binding capacity

* Vitamin B12 assay

* Reticulocyte count

2. Laboratory tests for hemolytic disorders

* Serum haptoglobin

* Hemoglobin electrophoresis

* Osmotic fragility

* RBC enzyme assays

* RBC survival time

3. Laboratory tests for bleeding disorders (illustration )

* Platelet count

* Bleeding time

* Partial thromboplastin time or activated partial thromboplastin time

* Prothrombin time

* Thrombin time

* Prothrombin consumption time

* Platelet aggregation

* Fibrinogen level I

* Fibrinogen degradation

* Antithrombin III

* Coagulation factor assays
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COMMON LAB TESTS FOR THE GENITOURINARY SYSTEM

1. Urine

* culture and sensitivity

* pregnancy

* osmolality

* WBC

* RBC

* casts

* specific gravity

* ketones

* esterase

* nitrates

2. Blood

* serum electrolytes, creatinine, BUN

* osmolality

* CBC

* uric acid

* ESR

* CRPp

* serum mucoprotein

* serum complement

* pregnancy

* estrogen and progesterone levels

* RPR

* HIV assay - ELISA

* antibody responses: ASO, ASKase, AHase, ADNase-B

* prostate-specific antigen
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COMMON LAB TESTS FOR THE RENAL SYSTEM

1. Blood

* CBC

* Serum chemistry

* Serum electrolytes

* Serum osmolality

* Lipid levels

2. Urine

* pH

* Osmolality

* Specific gravity

* Sodium

* Creatinine

* Sediment

* Creatinine clearance

* Casts

* Culture and sensitivity
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COMMON LAB TESTS FOR ENDOCRINE AND HORMONAL DISORDERS

1. Blood or serum

  • 1. Serum electrolytes
  • 2. Plasma Fasting ACTH

*8 AM <60 pg/ml
*4 PM 10-50 pg/ml
  • 3.Plasma Aldosterone Concentration (PAC)

* Supine 10-160 ng/liter
*Upright 8.9-58 ng/dl
  • 4.Plasma Renin Activity (PRA)
  • 5. Plasma Cortisol
  • 6.Catecholamines
  • 7.Thyroid hormone levels: TSH 0.35-6.20 µU/ml
  • 8.Fasting Blood Sugar
  • 9.Blood insulin levels
  • 10. Growth hormone

* Male: <5 ng/dl

* Female: <10 ng/dl

  • 11.Cosyntropin
  • 12.ESR
  • 13.CRP
2.Urine
  • 1. 17-hydroxysteroids
  • 2.Free catecholamines
  • 3.Osmolality
  • 4. Glucose tolerance test
  • 3.Karyotyping
  • 4.Water deprivation study
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COMMON LAB TESTS FOR INTEGUMENTARY DISORDERS

1. Blood

* CBC

* Cultures

* IgE

* Eosinophils

* Titers

* IFA

* ELISA (Enzyme-linked immunosorbent assays)

2. Skin/wound

* Cultures

* Scrapings, smears

* Patch testing

* Microscopic exam
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COMMON LAB TESTS FOR MUSCULOSKELETAL DISORDERS:

BLOOD TESTS

1. ESR

2. C-reactive protein

3. CBC

4. Serum cultures

5. Serum Calcium

6. ANA

7. Creatinine
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COMMON LAB TESTS FOR NEUROLOGICAL DISORDERS: CEREBROSPINAL FLUID

1. Appearance colorless, clear

2. Pressure 50-180 mm H2O

3. Protein

  • 1. Lumbar 15-50 mg/dl
  • 2. Cisternal 15-25 mg/dl
  • 3. Ventricular 6-15 mg/dl

4. Cell Count

  • 1. RBCs negative
  • 2. WBCs 0-5

5. Glucose 50-80 mg/dl

6. Gram stain negative for organisms

7. Culture and sensitivity: no grow
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COMMON LAB TESTS FOR RESPIRATORY DISORDERS


1. Blood

1. arterial Blood gases

2. blood cultures

3. hemoglobin

4. hematocrit

5. CBC

6. serum electrolytes

7. RAST

8. immunoglobulins

9. cultures Profile II

2. Urine

1. UA

2. culture and sensitivities

3. casts

3. Throat: sputum culture and sensitivites

4. Skin

1. PPD
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COMMON LAB TESTS FOR CARDIOVASCULAR DISORDERS

1. Serum Chemistry

2. Serum Electrolytes

3. Alanine aminotransferase (AST) 5-40 IU/L

4. Creatine kinase CK

* Male 55-170U/L

* Female 30-135 U/L

5. CK - MB (isoenzyme) 0-7 U/L

6. Lactic dehydrogenase (LDH)

* LDH1 22%-36%

* LDH2 35%-46%

* LDH313%-26%

* LDH4 3%-10%

* LDH5 2%-9%

7. CBC

8. Lipid levels

9. Prothrombin time

10. Alkaline phosphatase

11. ESR

12. Arterial Blood Gases

13. Troponin
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COMMON LABORATORY TESTS FOR GASTROINTESTINAL DISORDERS

1. Blood

1. CBC

2. Serum electrolytes

3. Serum chemistry

4. Enzyme-linked immunosorbent assays (ELISA)

5. Serum amylase

6. Differential blood count

7. Prothrombin time

8. ALT, AST, Alanine aminotransferase, LDH

9. Serum bilirubin

10. Glucose

11. Ammonia

12. Serum lipase

13. Alkaline phosphatase

2. Stool

1. Occult blood

2. pH

3. Ova & parasites

4. Qualitative fat

5. Reducing substances

6. Bacterial cultures

7. Vital pathogens

8. Leukocytes

3. Urine

1. Osmolality

2. Sodium

3. Potassium

4. Nitrogen

5. Urobilinogen

6. pH
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Common Laboratory Tests according to Systems and Disorders

COMMON LABORATORY TESTS FOR GASTROINTESTINAL DISORDERS

COMMON LAB TESTS FOR CARDIOVASCULAR DISORDERS

COMMON LAB TESTS FOR RESPIRATORY DISORDERS

COMMON LAB TESTS FOR NEUROLOGICAL DISORDERS: CEREBROSPINAL FLUID

COMMON LAB TESTS FOR MUSCULOSKELETAL DISORDERS: BLOOD TESTS

COMMON LAB TESTS FOR INTEGUMENTARY DISORDERS

COMMON LAB TESTS FOR ENDOCRINE AND HORMONAL DISORDERS

COMMON LAB TESTS FOR THE RENAL SYSTEM

COMMON LAB TESTS FOR THE GENITOURINARY SYSTEM

COMMON LAB TESTS FOR HEMATOLOGIC DISORDERS
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Compilation of previous board exam downloads


DEC 2006 Nursing practice tests 1 to 5

JUNE 2007 Nursing practice tests 1 to 5

DEC 2007 Nursing practice tests 1
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MS: GASTROINTESTINAL SYSTEM

I. Anatomy and Physiology
A. Upper gastrointestinal tract
B. Lower gastrointestinal tract
C. Accessory digestive organs
D. Process of digestion
II. Disorders of Stomach and Colon
A. Pernicious anemia
B. Peptic ulcer disease
III. Disorders of the Intestines
A. Inflammatory intestinal diseases
B. Diverticular disease
C. Constipation
D. Diarrhea
E. Bowel obstruction
F. Colon cancer
IV. Disorders of the Liver
A. Hepatitis
B. Hepatitis B
C. Cirrhosis
D. Portal hypertension
E. Ascites
F. Hepatic encephalopathy
V. Disorders Pancreas and Gallbladder
A. Acute pancreatitis
B. Cholecystitis
Points to remember
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MS: RESPIRATORY SYSTEM

I.Quick Review of Anatomy and Physiology of Respiratory System
  1. General Respiratory Anatomy and Physiology
  2. Upper Respiratory
  3. Lower Respiratory and Accessory Muscles
  4. Physiology
II.Disorders of Upper Respiratory System
IIIDisorders of Lower Respiratory System (LRS): Obstructive
IV.LRS Disorders: Restrictive
V.LRS Disorders: Infectious
VI.LRS Disorders: Miscellaneous
>>>>Points to remember
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GIT Bullets

• Most obstructions occur in the small bowel.
• Most large bowel obstructions are caused by cancer.
• Onset of cirrhosis is insidious with symptoms such as anorexia, weight loss, malaise, altered bowel habits, nausea and vomiting.
• Management of cirrhosis is directed towards avoiding complications. This is achieved by maintaining fluid, electrolyte and nutritional balance.
• A client with esophageal varices must be monitored for bleeding (e.g., melena stools, hematemesis, and tachycardia.)
• The rupture of esophageal varices is life threatening and associated with a high mortality rate.
• Pancreatitis is often associated with excessive alcohol ingestion.
• Pancreatic cancer is an insidious disease that often goes undetected until its later stages.
• Diverticula are most common in the sigmoid colon.
• Clients with diverticulosis are often asymptomatic.
• A deficiency in dietary fiber is associated with diverticulitis.
• Colostomies: an ascending colostomy drains liquid feces, is difficult to train and requires daily irrigation; a descending colostomy drains solid feces and can be controlled.
• Frequent liquid stools can be indicative of a fecal impaction or intestinal obstruction.
• Bowel sounds tend to be hyperactive in the early phases of an intestinal obstruction.
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Disorders of Pancreas and Gallbladder

    1. Acute pancreatitis
      1. Definition/etiology - inflammation of the pancreas
        1. alcohol ingestion
        2. gall stones
        3. drug ingestion
        4. viral infections
        5. trauma
      2. Pathophysiology
        1. autodigestion from premature activation of pancreatic enzymes
        2. proteases and lipases, normally active in small intestine, are activated in the pancreas
        3. phospholipase A digests adipose and parenchymal tissues
        4. elastase digests elastic fibers of blood vessels, producing bleeding
        5. amylase digests carbohydrates
        6. inflammation response occurs from enzyme release
      3. Findings
        1. left upper quadrant abdominal pain
        2. pain worsens after eating and when lying flat
        3. nausea and vomiting
        4. fever, agitation, confusion
        5. hypovolemia and shock
        6. hemorrhage into retroperitoneal space may produce ecchymosis in flank or around umbilicus
        7. tachypnea, pulmonary infiltrates, atelectasis from circulating enzymes

      1. Diagnostics
        1. elevated enzymes: serum amylase, serum lipase, and urinary amylase
        2. elevated WBCs, decreased hemoglobin and hematocrit
        3. elevated LDH and AST (SGOT)
        4. hyperglycemia
        5. hypocalcemia
        6. chest x- ray, CT scan, ultrasound, ERCP

Endoscopy helps diagnose and treat many abdominal (and other) disorders. Here are two endoscopic procedures designed for the abdomen:

Endoscopic retrograde cholangiography (ERCP) outlines the common bile duct and helps diagnose pancreatitis. (If it helps, think of the P in ERCP as pancreatitis and "picture" because ERCP pictures the duct.)

Endoscopic retrograde catheterization of the gallbladder (ERCG) helps diagnose cholecystitis. (Think of the G in ERCG as gallbladder.)

      1. Complications
        1. respiratory problems - atelectasis, pneumonia from the immobility imposed by pain
        2. tetany from decreased calcium levels
        3. abscess or pseudocyst
      2. Management
        1. treat cause
        2. pain relief - meperidine (Demerol)
        3. fluid maintenance to prevent shock
        4. insulin for hyperglycemia
        5. calcium replacement
        6. decrease stimulation of pancreas
          1. NPO-TPN (nothing by mouth; total parenteral nutrition)
          2. NG tube
          3. anticholinergics
          4. h2-receptor antagonists
      3. Nursing interventions
        1. manage pain
        2. monitor alteration in breathing patterns
        3. monitor nutritional status
        4. oral care when NPO
        5. if eating is allowed, diet high in proteins and carbohydrates and low in fat
        6. monitor fluid and electrolyte balances

PANCREATITIS

  • Acute pancreatitis can become chronic
  • Morphine sulfate is not used to treat pain since it can cause the sphincter of Oddi to spasm
  • Pain may be relieved by side-lying
  • If clients lose pancreatic function, they may have to take pancreatic enzymes and bile salts with meals.
  • With pancreatitis, avoid stimulation of the pancreas: do not use enteral feedings
    • Cholecystitis
      • Definition/etiology - inflammation of the gallbladder
        • usually due to gallstones (Cholelithiasis)
        • types
          • cholesterol - most common
          • pigment - unconjugated bilirubin
        • bile is blocked, and infects tissue
        • more common in women, especially those over 40 and those who use birth control pills
      • Pathophysiology
        • common bile duct is obstructed by a gallstone
        • bile cannot be excreted, some is reabsorbed
        • remaining bile distends and inflames gall bladder
        • may scar gallbladder, resulting in less storing of the bile from the liver
        • can perforate gall bladder

      1. Findings
        1. colicky pain in right upper quadrant with possible radiation to right shoulder and back
        2. indigestion after eating fatty foods
        3. nausea and vomiting
        4. jaundice (if the liver is involved or inflamed or the common duct obstructed)
        5. low grade fever
      2. Diagnostics
        1. endoscopic retrograde cholangiography (ERCP)
        2. endoscopic retrograde catheterization of the gallbladder (ERCG)
        3. ultrasound

  1. Management
    1. rest
    2. low-fat diet
    3. removal of stone in common duct by endoscopy
    4. to dissolve cholesterol stones
      1. chenodeoxycholic acid (Chenodiol) - side effects are diarrhea and hepatotoxicity
      2. ursodeoxycholic acid (UDCA)
    5. control pain - meperidine (Demerol) is drug of choice
    6. replace vitamin K if bleeding time is prolonged
    7. extracorporeal shock wave lithotripsy - may have hematuria after procedure, but not longer than 24 hours
    8. choledocholithotomy - to remove or break up stones
    9. laparoscopic laser cholecystectomy
    10. cholecystectomy
  2. Nursing interventions
    1. monitor vital signs
    2. monitor pain and medicate as needed
    3. teach client - dietary restriction of fatty foods
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STRESS RESPONSE

A. Local responses to stress: Local Adaptation Syndrome (LAS):
1. Examples
a. Blood clotting
b. Wound healing
c. Reflex pain response
d. Inflammatory response
2. Characteristics
a. Localized response
b. Adaptive (that is, requires a stressor)
c. Short-term
d. Restorative

B. Whole-body response to stress: General Adaptation Syndrome (GAS)
1. Involves primarily nervous and endocrine systems, in 3 stages



2. Stage 1: Alarm reaction - exposure to adverse stimulus; body mobilized to resist in form of compensatory behavior
a. Fight or flight response
1. Increased cardiac output
2. Increased heart rate
3. Increased respiratory rate
4. Pupils dilate
5. Increased mental alertness
b. Sympathetic Nervous System response
1. Increased epinephrine
a. Increased heart rate
b. Increased oxygen intake
c. Increased blood sugar
2. Increased norepinephrine
a. Increased blood flow to skeletal muscle
b. Involves increased arterial blood pressure
c. Posterior Pituitary: Increased ADH
1. Increased water reabsorption
2. Decreased urine output
d. Anterior Pituitary: Increased ACTH
1. Increased cortisol secretion
a. Body turns fat and proteins into glycogen
b. Increased protein catabolism
c. Increased fat catabolism
2. Increased aldosterone secretion:
a. Body reabsorbs more sodium, more water
b. Kidneys produce less urine
c. Kidneys secrete more potassium
3. Stage 2: Resistance - When stimulus is excessive or prolonged, alarm and mobilization give way to resistance
a. Stabilization
b. Hormonal levels return to normal
c. Parasympathetic nervous system activates
d. Body adapts to stressors
4. Stage 3: Exhaustion - If stressor continues, energy wanes and body weakens
a. Physiological response as noted in alarm reaction
b. Decreased energy levels
c. Decreased physiologic adaptation
d. Death
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Stress Management

A. Stress: a universal phenomenon, stress requires change or adaptation so that the person can maintain equilibrium
B. Stress can be internal or external
C. Nature of stressor involves:
  • 1. Intensity
  • 2. Scope
  • 3. Duration
  • 4. Other stressors: their number and nature
D. Categories of stressors - and examples
  • 1. Physical - drugs or alcohol
  • 2. Psychological - such as adolescent emotional upheaval, or unexpressed anger
  • 3. Social - isolation, interpersonal loss
  • 4. Cultural - ideal body image
  • 5. Microbiologic - infection
E. The greater the stressor as preceived by the client, the greater the stress response

F. Stress response involves both localized and general adaptation


G. Factors affecting stress response
1. Personal: heredity, gender, race, age personality, cognitive ability
2. Sociocultural: finances, support systems
3. Interpersonal: self-esteem, prior coping mechanisms
4. Spiritual: belief system
5. Environmental: crowding, pollution, climate
6. Occupational: work overload, conflict, risk

H. Physiologic indicators of stress
  1. Increased Blood Pressure
  2. Tachycardia
  3. Tachypnea
  4. Sweaty palms
  5. Cold Hands and Feet
  6. Decreased urine output
  7. Dilated Pupils
  8. Change in appetite
  9. Gastrointestinal changes: nausea, vomiting, diarrhea
  10. Headache
  11. Restlessness
  12. Insomnia
  13. Muscle tension

I. Emotional/behavioral indicators of stress
  1. Behavior Patterns
    1. Substance use/abuse
    2. Changes in eating habits
    3. Changes in activity
  2. Mood
    1. Loss of self esteem
    2. Feelings of inadequacy
    3. Increased irritability
    4. Crying
  1. Cognitive
    1. Lack of motivation
    2. Forgetfulness
    3. Tendency to make mistakes
    4. Decreased productivity
    5. Poor judgment
    6. Inability to concentrate
    7. Preoccupation


J. Stress can cause a variety of emotional and physical disorders
  1. Hypertension
  2. Ulcers
  3. Skin Disorders
  4. Cardiovascular disorders
  5. Increased cholesterol
  6. Migraines
  7. Eating Disorders
  8. Depression
  9. Substance Abuse
  10. Asthma
  11. Cancer
  12. Rheumatoid Arthritis
  13. Anxiety disorders
  14. Dysrhythmias
  15. Muscle tension/aches
  16. Sleeping disorders
  17. Gastrointestinal upset/disorders
  18. Endocrine disorders


K. Stress management strategies

L. The non-compliant client does not cooperate with the treatment plan
1. Behavior characteristics
a. does not take prescrived medication
b. continues activities restricted by provider of care, such as smoking
c. does not follow prescribed activities, such as exercise
2. Nursing interventions
a. explore the reasons for non-compliance
i. lack of understanding - reinforce teaching
ii. lack of family support - involve family and support groups
iii. side effects - refer to provider of care
iv. finances and access - refer to Social Services
v. negative attitude toward treatment - encourage expression
b. express genuine concern for client
c. discuss imporvement potential
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FOUR THEORETIC MODELS OF GRIEF

A. Elizabeth Kubler-Ross: Five Stages DABDA
1. Denial
a. Unconscious avoidance which varies from a brief period to the remainder of life
b. Allows one to mobilize defenses to cope
c. Positive adaptive responses - verbal denial; crying
d. Maladaptive responses - no crying, no acknowledgement of loss
2. Anger
a. Expresses the realization of loss
b. May be overt or covert
c. Positive adaptive responses - verbal expressions of anger
d. Maladaptive responses - persistent guilt or low self esteem, aggression, self destructive ideation or behavior
3. Bargaining
a. An attempt to change reality of loss; person bargains for treatment control, expresses wish to be alive for specific events in near future
b. Maladaptive responses - bargains for unrealistic activities or events in distant future
4. Depression and Withdrawal
a. Sadness resulting from actual and/or anticipated loss
b. Positive adaptive response - crying, social withdrawal
c. Maladaptive responses - self-destructive actions, despair
5. Acceptance
a. Resolution of feelings about death or other loss, resulting in peaceful feelings
b. Positive adaptive behaviors - may wish to be alone, limit social contacts, complete personal business
B. John Bowlby: Four Stages of Separation and Loss
1. Shock
2. Despair
3. Detachment
4. Resolution
C. E. Lindemann
1. Shock
2. Acute mourning
3. Resolution of grief
D. J.W. Wooden
1. Accepting the reality
2. Experiencing the pain
3. Adjusting to the changed environment
4. Withdrawing and reinvesting emotional energy
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Grief

A. Loss
1. A universal phenomenon; it occurs across the lifespan
2. There are many types of loss
a. loss of external objects
b. loss of significant other: through death, divorce
c. loss of environment: by moving, taking a new job, hospitalization
d. loss of an aspect of self: may include a body part, physiologic or psychologic function
3. Response to loss depends on
a. one's personality
b. culture
c. previous experience with loss
d. one's values
e. perceived value of loss
f. support system

B. Types of Grief
1. Anticipatory grief: person learns of impending loss and responds with processes of mourning, coping, interaction, planning, and psychosocial reorganization
2. Disenfranchised grief: person experiences a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported
3. Mourning: process used to resolve grief
4. Tasks of mourning (common to the models of grief) spell R-E-A-L
a. Real: accept that the loss is real
b. Experience the emotions associated with the loss
c. Adjust or re-adjust to life and activities
d. Let go: move on with one's own life
5. Grief theory models

C. Nursing care in grief
1. Support client's effective coping mechanisms
2. Don't take client's responses personally
3. Listen attentively
4. Help client with problem solving and decision making as indicated
5. Encourage the client and/or significant others to ventilate
6. Utilize therapeutic touch as appropriate
7. Assist in discussions of future plans as appropriate
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Therapeutic Communication

- Characterizes the Nurse-Client Relationship

A. Nurse-client relationship: a therapeutic professional relationship in which two people interact
1. The nurse who possesses the skills and ability to provide counseling, crisis intervention, health teaching, etc. and
2. The client who seeks help for some problem

B. Phases of the nurse-client relationship
A. Initiating or orientation
1. Sets time, place and duration of sessions
2. Establishes boundaries of the relationship
3. Identifies the problem and expectations-that is, goal setting
4. Usually an anxious time for both client and nurse
a. Client may be late for the session
b. Client may exhibit anxious mannerisms
c. Nurse's own anxiety may prompt nurse to use techniques that block communication
B. Working
1. Boundaries of the relationship are accepted by the client and the nurse and a therapeutic relationship is established
2. Nurse uses interpersonal skills to communicate with the client
3. Client identifies problems, develops insights to the problems
4. Client learns adaptive coping skills and problem solving
C. Termination
1. Actually begins with the first session and ends when identified treatment goals are met
2. Anticipate problems of termination
a. Client may become too dependent on nurse
b. Client may recall previous separation experiences, and feelings of rejection, depression, and/or abandonment
3. Client and nurse summarize and evaluate work
4. Client and nurse express thoughts and feelings about termination

C. Five characteristics of nurse-client relationship
1. Mutual definition: together, nurse and client define relationship
2. Goal direction: purpose, time, and place are specific
3. Specified boundaries: in time, space, content, and confidentiality
4. Therapeutic communication: nurse eases trust and open communication by these interpersonal techniques
5. Nurse helps client toward resolution
(many Good Scholars Take Nursing)

D. Therapeutic communication
1. Consider the developmental level, culture, and physical condition of the client
2. Focus not on subjective inferences but on actual objective behaviors
3. Focus not on judgment but on description
4. Instead of offering advice and solutions, share information and explore alternatives
5. Focus not on "why" but on how and what
6. For confused or disoriented clients, focus on reality orientation
7. Ask open-ended questions and seek information
8. Focus on nursing interventions
9. To ease this process, use specific techniques
10. Certain techniques block therapeutic communication

THERAPEUTIC COMMUNICATION TECHNIQUES

Not Necessarily Verbal
1. Acceptance - Recognizing the other person without inserting your own values or judgments. May be verbal or nonverbal; with or without understanding
2. Listening - Consciously receiving the client's message. Includes listening actively, responsibly, and seriously
3. Empathy - Experiencing another's feeling temporarily; truly being with and understanding another through active listening
4. Silence - Suspending talk for a therapeutic reason
5. Neutral response - Showing interest and involvement without saying anything else
6. Eye contact - As appropriate to the client's culture
Verbal
7. Self-disclosure - Sharing personal information at an opportune moment to convey understanding or to role model behavior
8. Clarification - Putting into words vague ideas or unclear thoughts of the client. Purpose is to help nurse understand, or invite the client to explain
9. Restating - Repeating to the client the main thought he has expressed to indicate the nurse is listening and interested. May encourage the client to elaborate
10. Refocusing - Picking up on central topics or "cues" given by the client
11. Open-ended questions - Asking questions that cannot be answered "yes" or "no." Used to broaden conversational opportunities and to enable the client to communicate.
12. Incomplete sentences - Encouraging the client to continue with phrases such as "Go on…"
13. Focusing - Helping the client to explore a specific topic
NINE INEFFECTIVE COMMUNICATION TECHNIQUES

1. Giving advice - Telling the client what to do. Giving an opinion or making decisions for the client. Implies the client cannot handle life decisions and that the nurse is accepting responsibility for client.
2. False reassurance - Using clichés, pat answers, cheery words and comforting statements as an attempt to reassure client.
3. Changing the Subject - Introducing new topics inappropriately. May result from poor listening skills
4. Social Response - Responding in a way that either focuses attention on the nurse instead of the client, or is not goal-directed on behalf of the client.
5. Invalidation - Ignoring or denying the client's thoughts or feelings.
6. Overloading - Talking rapidly, changing subjects or asking for more information than can be absorbed at one time; for example, asking two questions at once.
7. Underloading - Remaining silent and unresponsive, not picking up cues and failing to give feedback.
8. Incongruence - Sending verbal and nonverbal messages that contradict one another; often called a double message.
9. Value Judgments - Giving one's own opinion, evaluating , moralizing or implying one's own values by using words such as "should," "ought," "good," or "bad."


E. Other types of therapeutic interventions
1. Group therapy
2. Family therapy
3. Milieu therapy - A method of psychotherapy that controls the environment of the patient to provide interpersonal contacts that will develop trust, assurance, and personal autonomy
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Coping Mechanisms

(also called defense mechanisms)
A. Definition: psychological techniques that the personality develops to manage anxiety, aggression, hostility, etc.

B. Coping mechanisms represent conflicts between the id and superego

C. Used by both mentally healthy and ill individuals

D. May be used consciously, but are usually unconscious

E. Types of coping mechanisms
1. Compensation - extra effort in one area to offset real or imagined lack in another area
o Example: Short man becomes assertively verbal and excels in business.
2. Conversion - A mental conflict is expressed through physical symptoms
o Example: Woman becomes blind after seeing her husband with another woman.
3. Denial - treating obvious reality factors as though they do not exist because they are consciously intolerable
o Example: Mother refuses to believe her child has been diagnosed with leukemia. "She just has the flu."
4. Displacement - transferring unacceptable feelings aroused by one object to another, more acceptable substitute
o Example: Adolescent lashes out at parents after not being invited to party.
5. Dissociation - walling off specific areas of the personality from consciousness
o Example: Adolescent talks about failing grades as if they belong to someone else; jokes about them.
6. Fantasy - a conscious distortion of unconscious wishes and need to obtain satisfaction
o Example: A student nurse fails the critical care exam and daydreams about her heroic role in a cardiac arrest.
7. Fixation - becoming stagnated in a level of emotional development in which one is comfortable
o Example: A sixty year old man who dresses and acts as if he were still in the 1960's.
8. Identification - subconsciously attributing to oneself qualities of others
o Example: Elvis impersonators.
9. Intellectualization - use of thinking, ideas, or intellect to avoid emotions
o Example: Parent becomes extremely knowledgeable about child's diabetes.
10. Introjection - incorporating the traits of others
o Example: Husband's symptoms mimic wife's before she died.
11. Projection - unconsciously projecting one's own unacceptable qualities or feelings onto others
o Example: Woman who is jealous of another woman's wealth accuses her of being a gold-digger.
12. Rationalization - justifying behaviors, emotions, motives, considered intolerable through acceptable excuses
o Example: "I didn't get chosen for the team because the coach plays favorites."
13. Reaction Formation - expressing unacceptable wishes or behavior by opposite overt behavior
o Example: Recovered smoker preaches about the dangers of second hand smoke.
14. Regression - retreating to an earlier and more comfortable emotional level of development
o Example: Four year old insists on climbing into crib with younger sibling.
15. Repression - unconscious, deliberate forgetting of unacceptable or painful thoughts, impulses, feelings or acts
o Example: Adolescent "forgets" appointment with counselor to discuss final grades.
16. Sublimation - diversion of unacceptable instinctual drives into personally and socially acceptable areas.
o Example: Young woman who hated school becomes a teacher.
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Psychiatric Nursing

I. Coping Mechanisms
II. Therapeutic Communication
III. Grief
IV. Stress Management
V. Schizophrenia
VI. Mood Disorders
VII. Anxiety Disorders
VIII. Borderline Personality Disorder
IX. Suicide Prevention
X. Crisis Intervention
XI. Substance Abuse
XII. Autism
XIII. Abuse Syndromes
XIV. Eating Disorders
POINTS to Remember
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CRANIOCEREBRAL TRAUMA (ACUTE REHABILITATIVE PHASE)

Craniocerebral trauma, also called head or brain injury (open or closed), includes skull fractures, brain concussion, cerebral contusion/laceration, and hemorrhage (subarachnoid, subdural, epidural, intracerebral, brainstem). Primary injury occurs from a direct or indirect blow to the head, causing acceleration/deceleration of the brain. Secondary brain injury results from diffuse intracerebral axonal injury, intracranial hypertension, hypoxemia, hypercapnia, or systemic hypotension. Cerebral concussion is the most common form of head injury.
Consequences of brain injury range from no apparent neurological disturbance to a persistent vegetative state or death. Therefore, every head injury must be considered potentially dangerous.
CARE SETTING
This plan of care focuses on acute care and acute inpatient rehabilitation. Brain injury care for those experiencing moderate to severe trauma progresses along a continuum of care, beginning with acute inpatient hospital care and inpatient rehabilitation to subacute and outpatient rehabilitation, as well as home- and community-based services.
RELATED CONCERNS
Cerebrovascular accident (CVA)/stroke
Psychosocial aspects of care
Seizure disorders/epilepsy
Surgical intervention
Thrombophlebitis: deep vein thrombosis
Total nutritional support: parenteral/enteral feeding
Upper gastrointestinal/esophageal bleeding

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CIRRHOSIS OF THE LIVER

Cirrhosis is a chronic disease of the liver characterized by alteration in structure, degenerative changes and widespread destruction of hepatic cells, impairing cellular function and impeding blood flow through the liver. Causes include malnutrition, inflammation (bacterial or viral), and poisons (e.g., alcohol, carbon tetrachloride, acetaminophen). Cirrhosis is the fourth leading cause of death in the United States among people ages 35 to 55 and represents a serious threat to long-term health.
CARE SETTING
May be hospitalized on a medical unit during initial or recurrent acute episodes with potentially life-threatening complications. Otherwise, this condition is handled at the community level.
RELATED CONCERNS
Alcohol: acute withdrawal
Substance dependence/abuse rehabilitation
Fluid and electrolyte imbalances
Psychosocial aspects of care
Renal dialysis
Renal failure: acute
Total nutritional support: parenteral/enteral feeding
Upper gastrointestinal/esophageal bleeding
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Diabetes Mellitus

* A group of metabolic diseases characterized by elevated levels of glucose in the blood resulting from defects in insulin secretion, insulin action, insulin receptors or any combination of conditions.
* A chronic disorder of impaired glucose metabolism, protein and fat metabolism

BASIC PATHOLOGY : Insulin problem (deficiency or impaired action)
* Insulin is a hormone secreted by the BETA cells of the pancreas
* Stimulus of insulin- HYPERGLYCEMIA
* Action of insulin: it promotes entry of Glucose into the body cells by binding to the insulin receptor in the cell membrane

Insulin Metabolic Functions:
* 1. Transports and metabolizes GLUCOSE
* 2. Promotes GLYCOGENESIS
* 3. Promotes GLYCOLYSIS
* 4. Enhances LIPOGENESIS
* 5. Accelerates PROTEIN SYNTHESIS

RISK FACTORS for Diabetes Mellitus
* 1. Family History of diabetes
* 2. Obesity
* 3. Race/Ethnicity
* 4. Age of more than 45
* 5. Previously unidentified IFG/IGT
* 6. Hypertension
* 7. Hyperlipidemia
* 8. History of Gestational Diabetes Mellitus

CLASSIFICATION OF DM

1. Type 1 DM
* Insulin dependent Diabetes Mellitus
2. Type 2 DM
* Non-insulin dependent Diabetes Mellitus
3. Gestational DM
* Diabetes Mellitus diagnosed during pregnancy
4. DM associated with other conditions or syndromes

Other types of DM
* 1. Impaired Glucose Tolerance
* 2. Impaired Fasting Glucose
* 3. Pre-diabetes






TYPE 1- Diabetes Mellitus

This type of DM is characterized by the destruction of the pancreatic beta cells

Etiology:
1. Genetic susceptibility- HLA DR3 and DR4
2. Autoimmune response
3. Toxins, unidentified viruses and environmental factors

PATHOPHYSIOLOGY
* Destruction of BETA cells--> decreased insulin production --> uncontrolled glucose production by the liver--> hyperglycemia --> signs and symptoms

CLASSIC P’s
* Polyuria
* Polydipsia
* Polyphagia

TYPE 2- Diabetes Mellitus
* A type of DM characterized by insulin resistance and impaired insulin production

Etiology:
1. Unknown
2. Probably genetic and obesity

PATHOPHYSIOLOGY
* Decreased sensitivity of insulin receptor to insulin --> less uptake of glucose --> HYPERGLYCEMIA
* Decreased insulin production --> diminished insulin action --> hyperglycemia --> signs and symptoms
* BUT (+) insulin in small amount --> prevent breakdown of fats --> DKA is unusual

GESTATIONAL Diabetes Mellitus
* Any degree of glucose intolerance with its onset during pregnancy
* Usually detected between 24-28th week gestation
* Blood glucose returns to normal after delivery of the infant
* NEVER administer ORAL HYPOGLYCEMIC AGENTS to PREGNANT MOTHERS!

ASSESSMENT FINDINGS
* 1. Classic 3 P’s
* 2. Fatigue
* 3. Body weakness
* 4. Visual changes
* 5. Slow wound healing
* 6. Recurrent skin and mucus membrane infections

DIAGNOSTIC TESTS
* 1. FBS- > 126
* 2. RBS- >200
* 3. OGTT- > 200
* 4. HgbA1- for monitoring!!
* 5. Urine glucose
* 6. Urine ketones

DIAGNOSTIC CRITERIA
* 1. FBS equal to or greater than 126 mg/dL (7.0mmol/L)
* (Normal 8 hour FBS- 80-109 mg/dL)
* 2. OGTT value 1 and 2 hours post-prandial equal to or greater than 200 mg/dL
* Normal OGTT 1 and 2 hours post-prandial- is
* 140 mg/dL
* 3. RBS of equal to or greater than 200 mg/dL PLUS the 3 P’s

NURSING MANAGEMENT OF DM
* The main goal is to NORMALIZE insulin activity and blood glucose level by:

Nutritional modification
2. Regular Exercise
3. Regular Glucose Monitoring
4. Drug therapy
5. Client Education

The Patient with DM
* HISTORY
* Symptoms and characteristics
* PHYSICAL EXAMINATION
* VS, BMI, Fundoscopy, and Neuro assessment
* LABORATORY EXAMINATION
* FBS, RBS, HgbA1c, lipid profile, ECG, and Urinalysis
* REFERRALS
* Ophthalmologist, Podiatrist, Dietician, etc..

DM Nutritional management

* 1.Review the patient’s diet history to identify eating habits and lifestyle
* 2. Coordinate with the dietician in meal planning for weight loss
* 3. Plan for the caloric intake distributed as follows- CHO 50-60%; Fats 20-30%; and Proteins 10-20%
* 4. Advise moderation in alcohol intake
* 5. Using artificial sweeteners is acceptable

DM Exercise management
* 1. Teach that exercise can lower the blood glucose level
* 2. Diabetics must first control the glucose level before initiating exercise programs.
* 3. Offer extra food /calories before engaging in exercise
* 4. Offer snacks at the end of the exercise period if patient is on insulin treatment.
* 5. Advise that exercise should be done at the same time every day, preferably when blood glucose levels are at their peak
* Regular exercise, not sporadic exercise, should be encouraged.
* 7. For most patient, WALKING is the safe and beneficial form of exercise

Glucose Self Monitoring
* Self-monitoring of blood glucose (SMBG) enables the patient to adjust the treatment regimen to obtain optimal glucose control
* Most common method involves obtaining a drop of capillary blood applied to a test strip.
* The usual recommended frequency is TWO-FOUR times a day.
When is it done?
* At the peak action time of the medication to evaluate the need for adjustments.
* To evaluate BASAL insulin --> test before meals
* To titrate bolus or regular and lispro--> test 2 hours after meals.
* To evaluate the glucose level of those taking ORAL hypoglycemics --> test before and two hours after meals.

Diabetes Mellitus Monitoring therapy
* Testing the glycosylated hemoglobin (HbA1c)
* This glycosylated hemoglobin refers to the blood test that reflects the average blood glucose over a period of TWO to THREE months.
* Normal value is 4 to 6 %
* No patient preparation is needed for this testing
* Done to monitor therapy

Diabetes Mellitus
* Urine testing for glucose
* Benedict’s test
* Urine testing for ketones
* Ketones are by-products of fat breakdown
* Urine testing for ketones
* This is performed whenever TYPE 1 DM have glucosuria or persistent elevation of blood glucose, during illness, and in gestational diabetes

DM Drug therapy

DRUG THERAPY and MANAGEMENT
* Usually, this type of management is employed if diet modification and exercise cannot control the blood glucose level.
* Because the patient with TYPE 1 DM cannot produce insulin, exogenous insulin must be administered for life.
* TYPE 2 DM may have decreased insulin production, ORAL agents that stimulate insulin production are usually employed.

PHARMACOLOGIC INSULIN
* This may be grouped into several categories according to:
1. Source- Human, pig, or cow
2. Onset of action- Rapid-acting, short-acting, intermediate-acting, long-acting and very long acting

* This may be grouped into several categories according to:
3. Pure or mixed concentration
4. Manufacturer of drug


GENERALITIES
* 1. Human insulin preparations have a shorter duration of action than animal source
* 2. Animal sources of insulin have animal proteins that may trigger allergic reaction and they may stimulate antibody production that may bind the insulin, slowing the action
* 3. ONLY Regular insulin can be used INTRAVENOUSLY!
* 4. Insulin are measured in INTERNATIONAL UNITS or “iu”
* 5. There is a specified insulin injection calibrated in units

RAPID ACTING INSULIN
* Lispro (Humalog) and Insulin Aspart (Novolog)
* Produces a more rapid effect and with a shorter duration than any other insulin preparation
* ONSET- 5-15 minutes
* PEAK- 1 hour
* DURATION- 3 hours
* Instruct patient to eat within 5 to 15 minutes after injection

REGULAR INSULIN
* Also called Short-acting insulin
* “R”
* Usually Clear solution administered 30 minutes before a meal
* ONSET- 30 minutes to 1 hour
* PEAK- 2 to 3 hours
* DURATION- 4 to 6 hours

INTERMEDIATE ACTING INSULIN
* Called “NPH” or “LENTE”
* Appears white and cloudy
* ONSET- 2-4 hours
* PEAK- 4 to 6-12 hours
* DURATION- 16-20 hours

LONG- ACTING INSULIN
* “UltraLENTE”
* Referred to as “peakless” insulin
* ONSET- 6-8 hours
* PEAK- 12-16 hours
* DURATION- 20-30 hours

HEALTH TEACHING
Regarding Insulin SELF- Administration
* 1. Insulin is administered at home subcutaneously
* 2. Cloudy insulin should be thoroughly mixed by gently inverting the vial or ROLLING between the hands
* 3. Insulin NOT IN USE should be stored in the refrigerator, BUT avoid freezing/extreme temperature
* 4. Insulin IN USE should be kept at room temperature to reduce local irritation at the injection site
* 5. INSULIN may be kept at room temperature up to 1 month
* 6. Select syringes that match the insulin concentration.
* U-100 means 100 units per mL
* Instruct the client to draw up the REGULAR (clear) Insulin FIRST before drawing the intermediate acting (cloudy) insulin
* 8. Pre-filled syringes can be prepared and should be kept in the refrigerator with the needle in the UPRIGHT position to avoid clogging the needle
* 9. The four main areas for insulin injection are- ABDOMEN, UPPER ARMS, THIGHS and HIPS
* Insulin is absorbed fastest in the abdomen and slowest in the hips
* Instruct the client to rotate the areas of injection, but exhaust all available sites in one area first before moving into another area.
* 10. Alcohol may not be used to cleanse the skin
* 11. Utilize the subcutaneous injection technique- commonly, a 45-90 degree angle.
* 12. No need to instruct for aspirating the needle
* 13. Properly discard the syringe after use.

T-I-E
Test blood--> Inject insulin --> Eat food

COMPLICATIONS OF INSULIN THERAPY

1. LOCAL ALLERGIC REACTIONS
* Redness, swelling, tenderness and induration appearing 1-2 hours after injection
* Usually occurs in the beginning stage of therapy
1. Local allergic reactions
* Disappears with continued use
* Antihistamine can be given 1 hour before injection time
* Porcine and bovine insulin preparations have a higher tendency to produce this reaction.

2. SYSTEMIC ALLERGIC REACTIONS
* Very rare
* Generalized urticaria is the manifestation
* Treatment is desensitization

3. INSULIN DYSTROPHY
* A localized reaction in the form of lipoatrophy or lipohypertrophy
* Lipoatrophy- loss of subcutaneous fat usually caused by the utilization of animal insulin
* Lipohypertrophy- development of fibrofatty masses, usually caused by repeated use of injection site

4. INSULIN RESISTANCE
* Most commonly caused by OBESITY
* Defined as daily insulin requirement of more than 200 units
* Management- Steroids and use of more concentrated insulin

5. MORNING HYPERGLYCEMIA
* Elevated blood sugar upon arising in the morning
* Caused by insufficient level of insulin
* DAWN phenomenon
* SOMOGYI effect
* INSULIN WANING

DAWN PHENOMENON
* Relatively normal blood glucose until about 3 am, when the glucose level begins to RISE
* Results from the nightly surges of GROWTH HORMONE secretion
* Management: Bedtime injection of NPH

SOMOGYI EFFECT
* Normal or elevated blood glucose at bedtime, decrease blood glucose at 2-3 am due to hypoglycemic levels and a subsequent increase in blood glucose (rebound hypergycemia)

* Nocturnal hypoglycemia followed by rebound hyperglycemia
* Due to the production of counter regulatory hormones- glucagon. cortisol and epinephrine
* Management- decrease evening dose of NPH or increase bedtime snack

INSULIN WANING
* Progressive rise in blood glucose from bedtime to morning
* Seen when the NPH evening dose is administered before dinner
* Management: Move the insulin injection to bedtime

ORAL HYPOGLYCEMIC AGENTS
* These may be effective when used in TYPE 2 DM that cannot be treated with diet and exercise
* These are NEVER used in pregnancy!
* There are several agents:
* Sulfonylureas
* Biguanides
* Alpha-glucosidase inhibitors
* Thiazolidinediones
* Meglitinides

SULFONYLUREAS
* MOA- stimulates the beta cells of the pancreas to secrete insulin
* Classified as to generations- first and second generations
* FIRST GENERATION- Acetoheximide, Chlorpropamide, Tolazamide and Tolbutamide
* SECOND GENERATION- Glipizide, Glyburide, Glibenclamide, Glimepiride
* The most common side –effects of these medications are Gastro-intestinal upset and dermatologic reactions.
* HYPOGLYCEMIA is also a very important side-effect
* Chlorpropamide has a very long duration of action. This also produces a disulfiram-like reaction when taken with alcohol
* Second generation drugs have shorter duration with metabolism in the kidney and liver and are the choice for elderly patients


BIGUANIDES- “ Formin”
* MOA- Facilitate the action of insulin on the peripheral receptors
* These can only be used in the presence of insulin
* They have no effect on the beta cells of the pancreas
* Metformin (Glucophage) and Phenformin are examples
* The most important side effect is LACTIC ACIDOSIS!
* These are not given to patient with renal impairment
* These drugs are usually given with a sulfonylurea to enhance the glucose-lowering effect more than the use of each drug individually

ALPHA-GLUCOSIDASE INHIBITORS
* MOA- Delay the absorption of glucose in the GIT
* Result is a lower post-prandial blood glucose level
* They do not affect insulin secretion or action!
* Side-effect: DIARRHEA and FLATULENCE

* Examples of AGI are Acarbose and Miglitol
* They are not absorbed systemically and are very safe
* They can be used alone or in combination with other OHA
* Side-effect if used with other drug is HYPOGLYCEMIA
* Note that sucrose absorption is impaired and IV glucose is the therapy for the hypoglycemia

THIAZOLIDINEDIONES
* MOA- Enhance insulin action at the receptor site
* They do not stimulate insulin secretion
* Examples- Rosiglitazone, Pioglitazone
* These drugs affect LIVER FUNCTION
* Can cause resumption of OVULATION in peri-menopausal anovulatory women

MEGLITINIDES
* MOA- Stimulate the secretion of insulin by the beta cells
* Examples- Repaglinide and Nateglinide
* They have a shorter duration and fast action
* Should be taken BEFORE meals to stimulate the release of insulin from the pancreas
* Principal side-effect of meglitinides- hypoglycemia
* Can be used alone or in combination

ACUTE COMPLICATIONS OF DM
* Hypoglycemia
* Diabetic ketoacidosis
* Hyperglycemic hyperosmolar non-ketotic syndrome (HHNS)
* Macrovascular complications- MI, Stroke, Atherosclerosis, CAD, and Peripheral vascular disease
* Microvascular complications- micro-angiopathy, retinopathy, nephropathy
* Peripheral neuropathy

HYPOGLYCEMIA
* Blood glucose level less than 50 to 60 mg/dL
* Causes: Too much insulin/OHA, too little food and excessive physical activity
* Mild- 40-60
* Moderate- 20-40
* Severe- less than 20

ASSESSMENT FINDINGS
* 1. Sympathetic manifestations- sweating, tremors, palpitations, nervousness, tachycardia and hunger
* 2. CNS manifestations- inability to concentrate, headache, lightheadedness, confusion, memory lapses, slurred speech, impaired coordination, behavioral changes, double vision and drowsiness

* DIAGNOSTIC FINDINGS
* RBS- less than 50-60 mg/dL level

Nursing Interventions
* 1. Immediate treatment with the use of foods with simple sugar- glucose tablets, fruit juice, table sugar, honey or hard candies
* 2. For unconscious patients- glucagon injection 1 mg IM/SQ; or IV 25 to 50 mL of D50/50
* 3. re-test glucose level in 15 minutes and re-treat if less than 75 mg/dL
* 4. Teach patient to refrain from eating high-calorie, high-fat desserts

* 5. Advise in-between snacks, especially when physical activity is increased
* 6. Teach the importance of compliance to medications

Diabetic Ketoacidosis
* This is cause by the absence of insulin leading to fat breakdown and production of ketone bodies
* Three main clinical features:
* 1. HYPERGLYCEMIA
* 2. DEHYDRATION & electrolyte loss
* 3. ACIDOSIS

PATHOPHYSIOLOGY
* No insulin--> reduced glucose breakdown and increased liver glucose production --> Hyperglycemia
* Hyperglycemia--> kidney attempts to excrete glucose --> increased osmotic load --> diuresis --> Dehydration
* No glucose in the cell--> fat is broken down for energy --> ketone bodies are produced--> Ketoacidosis

Risk factors
* 1. infection or illness- common
* 2. stress
* 3. undiagnosed DM
* 4. inadequate insulin, missed dose of insulin

ASSESSMENT FINDINGS
* 1. 3 P’s
* 2. Headache, blurred vision and weakness
* 3. Orthostatic hypotension
* 4. Nausea, vomiting and abdominal pain
* 5. Acetone (fruity) breath
* 6. Hyperventilation or KUSSMAUL’s breathing

LABORATORY FINDINGS
* 1. Blood glucose level of 300-800 mg/dL
* 2. Urinary ketones
* 3. ABG result of metabolic acidosis- LOW pH, LOW pCO2 as a compensation, LOW bicarbonate
* 4. Electrolyte imbalances- potassium levels may be HIGH due to acidosis and dehydration

NURSING INTERVENTIONS
* 1. Assist in the correction of dehydration
* Up to 6 liters of fluid may be ordered for infusion, initially NSS then D5W
* Monitor hydration status
* Monitor I and O
* Monitor for volume overload
* 2. Assist in restoring Electrolytes
* Kidney function is FIRST determined before giving potassium supplements!
* 3. Reverse the Acidosis
* REGULAR insulin injection is ordered IV bolus 5-10 units
* The insulin is followed by drip infusion in units per hour
* BICARBONATE is not used!
* A serious condition in which hyperosmolarity and extreme hyperglycemia predominate
* Ketosis is minimal
* Onset is slow and takes hours to days to develop
* Lack of insulin action or Insulin resistance --> hyperglycemia
* Hyperglycemia--> osmotic diuresis --> loss of water and electrolytes


HHNS
PATHOPHYSIOLOGY
* Insulin is too low to prevent hyperglycemia but enough to prevent fat breakdown
* Occurs most commonly in type 2 DM, ages 50-70

Precipitating factors
* 1. Infection
* 2. Stress
* 3. Surgery
* 4. Medication like thiazides
* 5. Treatment like dialysis

ASSESSMENT FINDINGS
* 1. Profound dehydration
* 2. Hypotension
* 3. Tachycardia
* 4. Altered sensorium
* 5. Seizures and hemiparesis

DIAGNOSTIC TESTS
* 1. Blood glucose- 600 to 1,200 mg/dL
* 2. Blood osmolality- 350 mOsm/L
* 3. Electrolyte abnormalities

NURSING INTERVENTIONS
* Approach is similar to the DKA
* 1. Correction of Dehydration by IVF
* 2. Correction of electrolyte imbalance by replacement therapy
* 3. Administration of insulin injection and drips
* 4. Continuous monitoring of urine output

MACROVASCULAR CX
Nursing management
* 1. Diet modification
* 2. Exercise

Nursing management
* 3. Prevention and treatment of underlying conditions such as MI, CAD and stroke
* 4. Administration of prescribed medications for hypertension, hyperlipidemia and obesity
* Retinopathy- a painless deterioration of the small blood vessels in the retina, may be classified as to background retinopathy, pre-proliferative and proliferative retinopathy
* Permanent vision changes and blindness can occur
Retinopathy-ASSESSMENT FINDINGS
* Blurry vision
* Spotty vision
* Asymptomatic

Retinopathy: Diagnostic findings
* 1. Fundoscopy
* 2. Fluorescein angiography
* Painless procedure
* Side-effects- discoloration of the skin and urine for 12 hours, some allergic reactions, nausea
* Flash of camera may be slightly uncomfortable

NURSING INTERVENTIONS
* 1. Assist in diagnostic procedure
* 2. Assist in the preparation for surgery- laser photocoagulation
* 3. Health teaching regarding prevention of retinopathy by regular ophthalmic examinations, good glucose control and self-management of eye care regimens
* 4. Maintain client safety

DIABETIC NEPHROPATHY
* Progressive deterioration of kidney function




DIABETIC NEPHROPATHY
* HYPERGLYCEMIA--> causes the kidney filtration mechanism to be stressed --> blood proteins leak into the urine
* Pressure in the kidney blood vessels increases--> stimulate the development of nephropathy

ASSESSMENT findings for diabetic nephropathy
* 1. Albuminuria
* 2. Anemia
* 3. Acidosis
* 4. Fluid volume overload
* 5. Oliguria
* 6. Hypertension
* 7. UTI

NURSING MANAGEMENT
1. Assist in the control of hypertension- use of ACE inhibitor
2. Provide a low sodium and low protein diet
3. Administer prescribed medication for UTI
4. Assist in dialysis
5. Prepare patient for renal transplantation, if indicated
Diabetic Neuropathy
* A group of disorders that affect all type of nerves including the peripheral, autonomic and spinal nerves

* Two most common types of Diabetic Neuropathy are sensori-motor polyneuropathy and autonomic neuropathy

ASSESSMENT findings
* 1. paresthesias- prickling, tingling or heightened sensation
* 2. decreased proprioception
* 3. decreased sensation of light touch
* 4. unsteady gait
* 5. decreased tendon reflexes

Nursing Management
* 1. Provide teaching that good glucose control is very important to prevent its development
* 2. Manage the pain by analgesics, antidepressants and nerve stimulation

Autonomic Neuropathy- ASSESSMENT findings
* 1. Silent, painless ischemia
* 2. delayed gastric emptying
* 3. orthostatic hypotension
* 4. N/V and bloating sensation
* 5. urinary retention
* 6. sexual dysfunction

Autonomic Neuropathy-Nursing management
* 1. Educate about the avoidance of strenuous physical activity
* 2. Stress the importance of good glucose control to delay the development
* 3. Provide LOW-fat, small frequent feedings
* 4. Administer bulk-forming laxatives for diabetic diarrhea
* 5. Provide HIGH-fiber diet for diabetic constipation

RISK FACTORS for the development of foot and leg ulcers
* 1. More than 10 years diabetic
* 2. Age of more than 40
* 3. Smoking
* 4. Anatomic deformities
* 5. History of previous leg ulcers or amputation

MANAGEMENT of Foot Ulcers
* Teach patient proper care of the foot
* Daily assessment of the foot
* Use of mirror to inspect the bottom
* Inspect the surface of shoes for any rough spots or foreign objects
* Properly dry the feet
* Instruct to wear closed-toe shoes that fit well, recommend use of low-heeled shoes
* Instruct patient NEVER to walk barefoot, never to use heating pads, open-toed shoes and soaking feet
* Trim toenails STRAIGHT ACROSS and file sharp corners
* Instruct to avoid smoking and over-the counter medications and home remedies for foot problems



INSULIN

Types of Insulin

1. Rapid Acting Insulin- Ex. Insulin Lispro ( Humalog)
2. Short Acting Insulin- Ex. Regular Insulin (Humulin R)
3. Intermediate Acting Insulin Ex. NPH Insulin ( Humulin N)
4. Long Acting Insulin- Ex. Insulin Glergene ( Lantus), InsulinDetermir
( Levemir)
5. Fixed Combination of N and R- Ex. 70/30%- 70% N, 30 % R
6. Fixed Combination- Ex. Humalog Mix 75/25, 75% lispro protamine,
25% lispro insulin


Insulin
> Enhances transmembrane passage of glucose across cell membrane.
> Promotes conversion of glucose to glycogen.

Common Uses

1. Oral hypopglycemic Agents- Type 2 DM
2. Insulin- Type 1 DM


Common adverse effects: hypoglycemia.


Types

1. Rapid- acting insulin
> Onset: within 15 minutes
> Peak: 30-90 minutes
> Duration: 3-4 hrs

2. Short- acting insulin
> Onset: 30-60 minutes
> Peak: 2-3 hrs
> Duration: 3-6 hrs

3. Intermediate –acting insulin
> Onset: 2-4 hrs
> Peak: 6-10 hrs
> Duration: 10-16 hrs


4. Long-acting insulin
> Onset: 2 hrs
> Peakless
> Duration: 24 hrs

5. Fixed Combination of N and R
> Onset: 30-60 minutes
> Peak: 6-10hrs
> Duration: 10-16 hrs

6. Fixed combination
> Onset: 15 minutes
> Peak: 1-6.5 hrs (average 2.5 hrs)
> Duration: 10-16 hrs
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