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www.nclex-tutorial.com
INTRODUCTION
Dear Reader,
Welcome to the 2010 edition of Dr. Karrenberg’s NCLEX-RN® Review Manual.
We are continuing our success proven concept of our previous manuals and of our live
tutorial and review classes by presenting the entire exam relevant content in a
comprehensive but compact format. Based on the latest NCLEX-RN® Test Plan from
April 1, 2010 our new manual meets the requirements of the latest passing standards. In
comparison to previous versions the new exam curriculum is emphasizing clinical
priorities, organizational skills, management of care as well as laws and regulations. A
comparably lesser number of questions is now distributed for the category reduction of
risk potential. This manual allows you to prepare for your nursing board exam with a
detailed review of all exam relevant facts in just one book. Including baseline knowledge
requirements as well as high scoring exam relevant content. It meets the requirements
of U.S. as well as International nursing students for a successful, time and cost efficient
exam preparation.
Based on a review of content, NCLEX-RN® relevant keywords and practice questions
this program enables you to acquire the necessary exam relevant knowledge, skills and
confidence to pass your board exam and to start your career as a RN soon! No question
remains unanswered whether you are sitting for the NCLEX-RN® for the first time or if
you are about to prepare for a repeated attempt.
In comparison to other review systems this program is based on the following three
steps to assist you in acquiring the entire exam relevant knowledge as well as important
test taking strategies.
1. Content Review
The detailed but compact content review allows you to acquire the entire exam relevant
knowledge under special consideration the most high scoring content of pathophysiology,
pharmacology, nursing mathematics and other difficult subject materials that usually are
the greatest challenges for the NCLEX-RN® candidates.
2. Keyword Review
The keyword review outlines the requirements of the minimum knowledge requirements
of the most current official NCLEX-RN® Test plan as issued by the National Council of
State Boards of Nursing (NCSBN).
3. Question Review
The question review of 355 well composed practice questions allows you to repeat and
practice the previously acquired knowledge of the first two steps in the computer
adaptive testing question style that you will encounter in the actual testing situation.
I hope that this unique manual will assist you in a successful preparation for your
NCLEX-RN® exam as it has supported many U.S. Nursing school graduates and
International nurses before. We appreciate your feedback and comments about this
book under [email protected]
Good Luck!
Sincerely,
Dr. H. A. Karrenberg
January 2010
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Table of Content
ADMINISTRATION OF THE NCLEX-RN® EXAMINATION
Categories of the NCLEX-RN® curriculum
Test Taking Strategies
CAT Question item types
CONTENT REVIEW
SAFE AND EFFECTIVE CARE ENVIRONMENT
Management of care
Definitions of Ethics, Morals, Values and legal aspects
Managed Care Settings in the United States
Organizational skills
Basic Principles of Leadership and Supervision
Safety and infection control
Rules and Definitions of Basic Life Support (BSL)
Infection control
HEALTH PROMOTION AND MAINTENANCE
Female Reproductive System
Male internal structures
Infertility Assessment
Treatment options in female infertility
Family Planning and Contraception
Antenatal Assessment and Care
Sexually transmitted infections
Nursing Care at neonatal visits
Physiological changes in pregnancy
Gestational conditions
Labor and Delivery Care
Electronic fetal heart rate interpretation
Process of labor
Pain management during labor
Complicated Delivery and Care
Medication Therapy in Obstetrics and Gynecology
Physiological changes during the postpartum period
Psychosocial changes during the postpartum period
Postpartal nursing care
Newborn Assessment
Physiological changes in the Newborn period
Complicated postpartum care
Complicated newborn care
Birt defects
Milestones of human growth and development
Vaccinations
Health and physical assessments
Elements of a healthy lifestyle
Age related Health Screening Schedules
Age related care of older adults
Common adverse effects of medication in older adults
Common laboratory tests
Common diagnostic procedures
Perioperative nursing care
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Basic client needs
Wound care
Monitoring tubes and drains
Fluid and electrolyte imbalances
Acid base imbalances
Applied Pharmacology
Dosage calculation and medication administration
Intravenous therapies
Red blood cell and blood component administration
Total parenteral nutrition
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NURSING CARE SPECIFICS - PATHOPHYSIOLOGY - MEDICAL TREATMENTS
APPLIED PHARMACOLOGY AND PSYCHOSCOCIAL ASPECTS
OF DISEASES AND DISORDERS
Neurological Disorders and Diseases
Neurological Medication Therapy
Infectious Diseases
Antibiotics
Antiviral Medications
Respiratory Disorders and Dieseases
Respiratory Medications
Cardiovascular Disorders and Diseases
Electrocardiography
Disorders of the veins
Hypertension
Peripheral arterial disease
Cardiovascular Medications
Urological Disorders and Diseases
Urological Medication Therapy
Gastrointestinal Tract Disorders and Diseases
Gastrointestinal Tract Medication Therapy
Endocrine Disorders and Diseases
Musculoskeletal Disorders and Diseases
Musculoskeletal Medication Therapy
Dermatological Disorders and Diseases
Dermatological Medication Therapy
Eye Disorders and Diseases
Ear Disorders and Diseases
Eye and Ear Medication Therapy
Mouth Disorders and Diseases
Blood Disorders and Diseases
Malignant Diseases
Pediatric Oncology
Adult Oncology
Antineoplastic Chemotherapy
Safety requirements for handling chemotherapeutic medication
Common side effects related to chemotherapeutic agents
Immune modulating medications
Cell stimulating medications
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Psychiatric Disorders and Diseases
Psychiatric Medications
Normal reference ranges for laboratory test results
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Baseline knowledge requirements of the NCLEX-RN®
Index of content related keywords
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NCLEX-RN® practice exam questions and answers
Answer Key
Learning Plan Recommendations
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393
KEYWORD REVIEW
QUESTION REVIEW
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Administration of the NCLEX-RN® examination
The NCLEX-RN® nursing licensing examination is offered in a computer adaptive testing
mode only. The duration of the exam is of variable length and depends on the average
performance of the candidate during this exam. Due to its unique setting as a computer
adaptive testing the NCLEX-RN®-Examination regularly starts with a question that
targets knowledge which is slightly below average of the required overall exam base line
knowledge. If the candidate answers this first question correctly then the computer will
automatically pick another, more difficult question. If the candidate answers a question
wrong then the computer automatically chooses a less difficult question and so on. The
minimum amount of questions to be answered by every candidate is 75 within an allotted
time of 6 hours. The allotted time includes any breaks as well as the time for the pretest
tutorial. Depending on the individual test performance the candidate will be offered more
questions but not additional testing time to reach the passing score. The maximum
amount of questions will not exceed 265. Fifteen of the overall amount of questions
asked will not be used for the assessment of the exam candidate since these questions
are included for testing purposes for future exams. The exam stops automatically either
after the minimum 75 questions or once the allotted time is over or whenever the
candidate has proven a consistent satisfying or a non satisfying level of competence. It
typically causes a lot of discomfort for the candidates during the test if the system keeps
asking more than the 75 mandatory questions since this may be a sign of a low
performance level. Although, this does not necessarily mean that the candidate is failing
the overall examination. The most current 2007 NCLEX-RN® test plan includes four
main and six subcategories of client needs in which exam candidates need to prove
minimum competency. Results of the NCLEX-RN examination are scored as passed or
failed only. Exam candidates receive a computerized assessment of their individual
testing performance as well.
Categories of the NCLEX-RN® curriculum
I. Safe, Effective Care Environment
• Management of Care (16-22 %)
•
Safety and Infection Control (8-14%)
II. Health Promotion and Maintenance (6-12%)
III. Psychosocial Integrity (6-12%)
IV. Physiological Integrity
•
Basic Care and Comfort(6-12%)
•
Pharmacological and Parenteral Therapies (13-19%)
•
Reduction of Risk Potential (10-16%)
•
Physiological Adaptation (11-17%)
Test Taking Strategies
General requirements of the NCLEX-RN®:
The NCLEX-RN® is considered to be an assessment test. It is specifically designed to
assess the ability of a graduate nursing student to start employment as a junior RN in a
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hospital or other common type of healthcare setting. All question in this exam are
comprised to expose the exam candidate theoretically with a variety of common
situations and regulations as they occur and apply in daily nursing practice. It is now
necessary to view the question items under consideration of two or more conditioning
factors. The appropriate problem solving approach is defined as “critical thinking” in the
NCLEX-RN® Test plan.
Specific strategies for successful participation in the NCLEX-RN®:
•
Thorough understanding and practice of all six different types of question items
currently used in the NCLEX-RN®.
• Complete and careful reading before answering any question items. A question item
may not always ask for a variety of possible outcomes. (least, most, wrong, usual,
typical outcome, result).
• Use of a problem solving approach that considers all aspects as they are provided in
the question items.
• Time measurement - every 10/20 questions during exam following the “one question
per minute rule”.
• Use of common sense! All answers must also be rationally explainable!
• Focus on recognition of priorities for a client in a particular situation,
(because other answer choices may be correct but not logical in a
particular situation).
Priorities examples:
Maslows Hierarchy of Needs, ABC (Airway, Breathing, Circulation), Identifying and
recognizing least stable /most riskful situation, time as a priority factor, priority among
other clients in need (e.g. patient to be prepared for scheduled surgery).
CAT Question item types:
It is rather important to become familiar with the different types of questions that are
used for the different items in the Nclex-RN examination before the actual exam date.
This allows a faster pace by answering items and reduces insecurity. There are six
alternate item format practice questions to become familiar with:
1. Single response questions (One right answer only)
A single answer question typically starts with a brief description of a common situation in
daily nursing practice. The candidate is then asked to make a decision based on
principles of nursing practice and/or clinical knowledge by choosing one out of four
answers.
Example:
A 40 year old male client is admitted to the hospital for acute abdominal pain.
During the interview he points out to the ER Nurse on duty, that he had severe alcohol
problems for many years but he has been abstinent for 5 years now.
Considering this history which of the following conditions is the most likely cause for this
clients chief complaints? Please select the best response.
A) Ureter stones
B) Pancreatitis
C) Gallbladder stones
D) Gastritis
E) Gastroenteritis
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2. Multiple response questions
Compared to a single response question, test items of this type will provide more than
one correct answer to choose from but it may not tell how many correct answers are
there at all. Therefore, between two to four of the multiple choice answers may be
correct.
Example:
A client who was just admitted to the Emergency Room for acute respiratory distress has
a long standing history of an obstructive pulmonary disorder.
Which of the following conclusions are correct in regards to this clients condition ?
Please select all answers that apply.
1. This client may be suffering from Asthma.
2. The hypoxemia of this client may require respirator treatment.
3. The blood gas analysis may show a respiratory acidosis.
4. The blood gas analysis may show a significantly increased pCO2.
A) 1 and 3 are correct
B) 2, 3, and 4 are correct
C) 3 and 4 are correct
D) None of the above statements are correct
E) All of the above statements are correct
3. Fill in the blank questions. (i.e. solution of a math operation)
This type of question is mainly used for subjects dealing with nursing mathematics,( e. g.
dosage calculation). In this case the testing computer system provides a calculator for
on screen use. There are no anwsers to choose from and the appropriate answer has to
be written in a defined answer field.
Example:
A liquid medication has a concentration of 2mg/ml and is supposed to be applied
intravenously.
The written physicians order states the following dosage advice.
0,5 ml / kg bodyweight / hour.
How much dosage in ml will this particular client receive in 24 hours,
if his weight is 78 kg?
Answer: This client will receive
ml of the prescribed substance.
4. “Hot spot” question
A hotspot question allows you to answer a question by clicking on a correct area within
an image
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Example:
Please use the diagram of the female reproductive tract below to indicate the
anatomical area where the fertilization takes place.
A) Cervical Canal
B) Fallopian tube
C) Uterus
D) Vagina
E) None of the above
5. Chart exhibit question
An exhibit question will provide a specific clinical information, (e.g. a printout of a
complete blood count) followed by a question regarding its interpretation.
Example:
A cient on a ward suddenly develops a severe, acute respiratory distress. One of the
first diagnostic steps is to obtain capillary blood for a blood gas analysis.
Which is the most correct interpretation of the BGA results displayed below?
A) Respiratory alkalosis
B) Respiratory acidosis
C) Metabolic alkalosis
D) Metabolic acidosis
E) None of the above
pH = 7,04
pCO2 = 106 mmHg
pO2= 55 mmHg
BE + 8
Potassium
6. Drag and Drop Question/ Ordered Response Item
Drag and drop questions are mainly used to assess knowledge concerning practical
procedures. Two boxes are provided in this question item. The left hand box contains
statements options for a specific question but in a non orderly manner. The right hand
box is supposed to be filled with these statement options but in an orderly manner.
Since all statement options have to be used to answer this type of question, there should
be no statement option left in the left hand box once this question is answered.
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Example:
To perform a cardiovascular resuscitation it is important to follow an algorithm of
maneuvers. Please put the assessments and procedures described in the left hand box
below in a logical sequence by putting the most basic action on top.
Unordered options
Airway assessment
Circulation assessment
Breathing
Defibrillation
Ordered options
NCLEX-RN® Category I:
SAFE AND EFFECTIVE CARE ENVIRONMENT
1. MANAGEMENT OF CARE
- Definitons of the four Elements of Nursing Practice 1. Nursing Process:
Compoments of the scientific problem solving approach in nursing practice, including:
1.
2.
3.
4.
5.
Assessment of client needs
Analysis of care environment
Planning of care
Implementation of care
Evaluation of care
2. Caring:
Basic requirement for a successful client – nurse interaction to achieve desired client
outcomes are mutual respect and trust.
3. Communication and Documentation:
Verbal and nonverbal interaction has to be maintained with everybody involved in patient
care. Documentation is a professional duty and requires written and/or electronic
recording of activities and events during patient care.
Proper documentation is mandatory in nursing practice and reduces liability!
4. Teaching and Learning:
Goal of Client Education is the akquisition of knowledge, skills and attitudes for the client
to change his behavior.
- Definitions of Ethics, Morals, Values and legal aspects ANA Code of nursing ethics principles:
- Autonomy, - Beneficience, - Paternalism, - Justice, - Fidelity, - Virtues, - Confidentiality.
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Legal regulations of nursing practice:
• General Law
• Good Samaritan Law
• Licensure Requirements
• Nurse Practice Act
(Guidelines, Rules, Regulations, educational, professional standards).
Basic Principles of nursing practice:
• Delivering a holistic and comprehensive care.
• Respecting a clients uniqueness.
• Fostering an open and honest communication.
• Valuing empathy.
• Setting appropriate limits.
• Promoting the independence of a client.
- Definitions of Liability in Nursing Practice Negligence / Conduct = falling short of what a reasonable person would do to protect
another individual from foreseeable risks of harm.= Failure to
take appropriate actions.
Malpractice = Failure in taking appropriate actions by disregarding specific professional
standards.
Assault = Threat causing fear
Battery = Touching without consent
Invasion of privacy = i.e. Violation of confidentiality
Fraud = deliberately deceiving clients for the purpose of unlawful gains
Defamation of character = Damaging a patients reputation
False Imprisonment = Prohibiting discharge and give medications without need
- Principles of Safeguarding Client Rights Informed Consent
Agreement to undergo specific medical procedures. Typically results from a personal
consultation with a healthcare provider and is based on a detailed explanation of the
purpose of the particular procedure as well as of available alternatives.
(exceptions: waiver, minors and legal guardianship)
Confidentiality
Professional obligation that counts among members of a therapeutic team and may even
exclude witness in court of law (except threats to identified individuals or major crime)
Advances directives
Legal documents that allow to convey a clients decisions about end-of-life care ahead of
time and to avoid confusion later on. (copy must be part of medical record)
Health care proxy
A person named in a durable power of attorney for health care document. The proxy is
someone you has earned the clients trust to make health decisions if he is unable to do
so. Decision making authority may also be given to medical staff.
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Organ / tissue donation rules
• Donor must be minimum of 18 years old
• Requires living will or advance directive or donor card
• Decision can be made in advance
• Uniform Anatomical gift Act in all 50 Stated
• 3 Criterias for clinical death have to be present:
1. No brainwaves
2. No spontaneous breathing
3. No sensomotoric reflexes
- Legal Terms and ethical aspects Professional nursing care requires to ensure clients autonomy and liberty at all times as
far as condition allows.
A voluntary Admission to a hospital treatment has to be agreed on in writing by patient.
An involuntary Admission is justified under the Mental Health Act in situations of self –
or public endangerment only.
A Mental Health condition does not generally take the right of informed consent away!
Physicians order
Overall therapeutic guideline. Can and must be questioned in any case of doubt!
Incident reports
Have to be issued and filed for the caregivers and are not part part of the Medical
Record. But incidents need to be mentioned in MR’s.
Risk management
Individual case and client related measures to protect client from physical injury or
aggravation of the underlying condition. Considering age and condition related risks.
Duties of external report are given in the following situations
Communicable diseases
Public Health Department
Evidence of Crimes
Police
Suspected chemical abuse of coworker
Police
Sexual harassment
Police
Unsafe working conditions
Occupational Safety and Health Administration (OSHA)
-
Managed Care Settings in the United States –
All managed systems are designed to control healt care costs and to optimize efficiency
and quality of medical treatments. A managed Health Care Plan delivers and finances
the service instead of paying a third party for it.
This decreases unnecessary services and costs, maintains quality of service,
facilitates management of patient care needs, promotes timely and appropriate care.
Therefore all managed care systems require their own provider netwrok, unlike a regular
health insurance company.
Health Maintenance Organizations HMO’s
Oldest and most typical managed care system among several other types.
Emphasis lies on prevention and quality of care. HMO members pay a periodic fee or
receive membership as a benefit by their employer. Members select a primary care
physician from the list provided by the HMO. This primary care physician coordinates the
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entire medical care for this member. If specialist care is needed, the primary care
physician will refer the member to a specialist, usually within the HMO network.
Members who go to healthcare providers outside of the network without prior approval
may pay all or most of the cost of that care. A HMO is generally more restricted and has
a limited capacity in comparison to PPO Networks. Copays for treatments and
prescriptions may lower the monthly premium.
Preferred Provider Networks PPO
Network of private-practice doctors, healthcare facilities and hospitals. Network works by
contract with insurance companies and PPO providers receive a set rate for their
services. Less restrictive but more expensive for the patients which receive more control
over their own medical needs. They do not need a referral as long as the doctor they
visit is a member of the PPO. Clients may have a deductible to meet before coverage
starts each year. Overall coverage may only be 80 or 90% off all healthcare costs. PPOs
hire nurses and medical professionals to handle patient cases and make decisions about
hospital visits and diagnostic tests.
Case Management (focuses on diagnosis)
Follows a guideline based care plan for defined conditions.
Treats all involved professionals as equal. Managing interdisciplinary outcomes.
Promotes continuity of care.
- Nursing Care Delivery Systems -
Functional Nursing
Established in the 1940’s. Client needs are defined by necessary tasks and activities.
Tasks areprovided by RN,LPN,UAP. Head nurse coordinates assignments of duties to
members of the nursing staff. Nurses of different qualifications can work together
therefore costefficient.
Primary Nursing
Nursing System to provide continuity of care for a client. A primary nurse designs,
implements and is accountable for the entire client care, assisted by an associate nurse.
Team Nursing Most common nursing care delivery system in the US !
Team of nurses provides total care to a team of clients. Allows non or less skilled nurses
to be involved. Only one RN team leader is necessary.
Shared governance models of practice
Involving all delegating and supervising nursing personell within a facility.
Underlying principles are partnership, equity, accountability, ownership.
Characteristized by decentralized power sharing and decision making process,
interdisciplinary team building, activities and conferences. Elected committees set
policies and address organizational issues for nursing practice, quality improvement,
education, management of specific areas. The chairperson of an overall coordinating
council elects the nursing staff.
-
Organizational Skills –
General priority schemes in client care
•
•
ABC’s
Maslow’s Hierarchy of Needs
o Physiological (primary) needs
o Safety and security
o emotional and psychosocial support
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•
•
•
•
Agency policies and procedures
o Urgent response policy
o Elective response policy
o Delegating response policy
Time
o Immediate tasks
o Scheduled tasks within 2 – 4 hours
o Scheduled tasks within one shift
Client and family preferences
o Clients and families in distress
o Clients and families concerned about nursing care
o Routine client and family requests
Care related to client acuity
Unstable client first!
o Life threatening condition
o Lifesaving activities
o Essential activities
Priorities in medication therapy
o Medication for acute physical distress
o Preventive Medication
o Maintaining Medication
Time Management
Requires outcome oriented and not task oriented aspect. Goal is to provide quality care
under time efficient conditions instead of caring for a larger number of clients in a
circumscripted time frame.
Time management strategies for nurse leaders
Goal is use time wisely.
Key question: Does it need to be done now / or at all ?
Goal is to use the time primarily for essentials and to delegate appropriate tasks.
Additional factors of efficient time management include an organized work area as well
as recognition and prevention of stressors in personal life.
Symptoms of poor time management
Fatigue, irritability, stress, difficulty concentrating and forgetfulness.
Tools to organize time efficient nursing care
Efficient access to supplies, regarding shift reports, assignments to duties,
shift action plans, client care rounds and self reflection.
-
Basic Principles of Leadership and Supervision –
Obligations that require professional judgement can not be delegated.
Only authority but not ultimate responsibility can be delegated.
Inappropriate delegation
• Underdelegation (“I do it myself.”)
• Reverse delegation (Team member unable to fulfill task)
• Overdelegation (“You can do it all”)
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NCSBN’s five rights of delegation
1. Right task
2. Right circumstance
3. Right person
4. Right direction/communication
5. Right supervision
Assigment making requirements
• Clear concise directions
• Delegation of responsibility
• Delegation of authority
• RN retains accountability
• RN ensures skills are commensurate with the assignment
Leadership definition
Personal trait, exercise of power, influence and responsibility. Attempt to change
behavior of another person. Art of getting others to do what one deems important.
Coping with change. Mentoring towards higher levels. Flexible in various situations.
Leadership must earn trust and respect of another!
Leadership is responsibility rather than an honor!
Formal leadership (Supervisor position) - Informal Leadership (Leadership by skills)
Nurse Leaders first objectives:
Put client first
Focusing on Client Safety
Enhancing care quality
Improving client care outcomes
-
Leadership types and theories in nursing –
Autocratic leader:
Makes all the decisions autonomously, is uncongenial, motivates by power and
punishment.
Democratic leader:
Believes team members are motivated by internal drives, promotes participation and
majority ruling.
Laissez faire leader:
Democratic leadership without direction or facilitation. Based on trust in team members
to act responsibly. Everyone can operate freely as long as the expected outcome arrives.
Bureaucratic leadership:
Believes in external power, relying on policies and standardized procedures.
Benevolent leadership:
Kind to followers but not involving them in the decision making process.
Consultative / participative leadership:
Seeking employees advice about decisions.
Contingency theories
Leader adjusts leadership to the individual situation.
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Examples:
a) Fiedler contingency theory: Task oriented or relationship oriented leadership
b) Situational leadership
Qantum leadership theory
Contemporary.
Building partnerships with followers. Leader is an influential facilitator.
Transactional leadership
Built on social exchange and rewards.
NCLEX-RN® Category I:
SAFE AND EFFECTIVE CARE ENVIRONMENT
2. SAFETY AND INFECTION CONTROL
- Protecting Client Safety Age specific and general safety requirements.
Basic Rules of Infant Safety
• Supine position after eating and for sleeping.
• Motoric development increases injury and accident risk.
• Rear facing restraint system to be placed in middle of backseat of car.
(for children of up to 1 year or 20 pounds)
• Heated devices to be placed out of reach.
• All infant furniture have to meet safety standards.
• Caution for lead poisoning on antique furniture and house paint required.
Lead poisoning
Normal lead serum level < 10 mg/dl.
Treatment with (D-Penicillinamin) from 19 mg/d required.
Basic Rules of Toddlers Safety
• Toddler must not be in touch with potentially poisonous substances at any time.
• Car restraint system for toddlers has to be placed in the back seat until shoulders are
above harness or ears have reached top of the seat.
After child outgrows the system a booster seat with shoulder / lap belt is required.
• Toddlers are endangered by swallowing, electricity and drowning.
Basic rules of School age safety
• Children have to be taught pedestrian and bicycle safety.
• Children under 12 years and 4’9” have to be placed in rear seat with shoulder / lap
belt.
• Children have to be taught fire safety (“stop, drop and roll”) and water safety.
Basic rules f Adolescent safety
• Drivers education.
• Alcohol and substance abuse education.
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•
•
•
•
Sports injury prevention.
STD information.
Birth control awareness.
Reviewing water safety.
Basic rules of Adult safety
• Occupational Health Injury Prevention Programs.
(musculoskeletal dysfunctions are the most common work related injuries)!
• OSHA Education for hazardous conditions and toxic substances.
• 40% of MVA’s are related to DUI (Community Programs)
• Firearm education.
Basic rules of Elderly safety
• Generally increased accident risk due to reduced vision and hearing.
• Risk of falling.
• Increased risk to become crime victims.
Awareness of the most common Medical errors and risks
Application of wrong medication or dosage to the wrong client.
Adverse reactions.
Toxic effects, side effects.
Idiosyncratic (individual) reactions.
Common Allergies
Fish
Iodine
Contrast Fluids!
Medical history awareness.
- Rules and Definitions of Basic Life Support (BSL) -
* 2005 International Consensus Conference on Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care Science with Treatment Recommendations
Signs of cardiac arrest
Rescuers should start immediate cardiopulmonary resuscitation (CPR) if the victim is
unconscious (unresponsive), not moving, and not breathing. Even if the victim takes
occasional gasps, rescuers should suspect that cardiac arrest has occurred and should
start CPR.
Airway and Ventilation management
Opening the Airway
Rescuers should open the airway using the head tilt-chin lift maneuver. Rescuers should
use the finger sweep in the unconscious patient with a suspected airway obstruction only
if solid material is visible in the oropharynx.
Foreign-Body Airway Obstruction (FBAO)
Chest thrusts, back blows/slaps, or abdominal thrusts are equally effective for relieving
FBAO in conscious adults and children >1 year of age, although injuries have been
reported with the abdominal thrust. These techniques should be applied in rapid
sequence until the obstruction is relieved; more than one technique may be needed.
Unconscious victims should receive CPR. The finger sweep should be used in the
unconscious patient with an obstructed airway only if solid material is visible in the
airway. There is insufficient evidence for a treatment recommendation for an obese or
pregnant patient with FBAO.
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Mouth-to-Nose Ventilation
Mouth-to-nose ventilation is an acceptable alternative to mouth-to-mouth ventilation.
Mouth-to-Tracheal Stoma Ventilation
It is reasonable to perform mouth-to-stoma breathing or to use a well-sealing, round
pediatric facemask.
Tidal Volumes and Ventilation Rates
For mouth-to-mouth ventilation with exhaled air or bag-valve-mask ventilation with room
air or oxygen, it is reasonable to give each breath within a 1-second inspiratory time to
achieve chest rise. After an advanced airway (e.g., tracheal tube, Combitube, laryngeal
mask airway [LMA]) is placed, ventilate the patient'
s lungs with supplementary oxygen to
make the chest rise. During CPR for a patient with an advanced airway in place, it is
reasonable to ventilate the lungs at a rate of 8 to 10 ventilations per minute without
pausing during chest compressions to deliver ventilations. Use the same initial tidal
volume and rate in patients regardless of the cause of the cardiac arrest.
Chest Compressions
Hand Position
It is reasonable for lay people and healthcare professionals to position the heel of their
dominant hand in the center of the chest of an adult victim, with the nondominant hand
on top.
Chest Compression rates, Depth, Decompression and Duty Cycle
It is reasonable for lay rescuers and healthcare providers to perform chest compressions
for adults at a rate of at least 100 compressions per minute and to compress the
sternum by at least 4 to 5 cm (1-1/2 to 2 inches). Rescuers should allow complete recoil
of the chest after each compression. When feasible, rescuers should frequently alternate
"compressor" duties, regardless of whether they feel fatigued to ensure that fatigue does
not interfere with delivery of adequate chest compressions. It is reasonable to use a duty
cycle (i.e., ratio between compression and release) of 50%.
Firm Surface for Chest Compressions
Cardiac arrest victims should be placed supine on a firm surface (i.e., backboard or floor)
during chest compressions to optimize the effectiveness of compressions.
Alternative Compression Techniques
CPR in Prone Position
CPR with the patient in a prone position is a reasonable alternative for intubated
hospitalized patients who cannot be placed in the supine position.
Effect of Ventilations on Compressions
Interruption of Compressions
Rescuers should generally minimize interruptions of chest compressions.
Compression-Ventilation Ratio During CPR
A single compression-ventilation ratio of 30:2 for the lone rescuer of an infant, child or
adult victim is recommended.
Chest Compression-Only CPR
Rescuers should be encouraged to do compression-only CPR if they are unwilling to do
airway and breathing maneuvers or if they are not trained in CPR or are uncertain how
to do CPR.
Recovery Position
It is reasonable to position an unconscious adult with normal breathing on the side with
the lower arm in front of the body.
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Cervical Spine Injury
For victims of suspected spinal injury, additional time may be needed for careful
assessment of breathing and circulation and it may be necessary to move the victim if he
or she is found face-down. In-line spinal stabilization is an effective method of reducing
risk of further spinal damage.
Airway Opening
Maintaining an airway and adequate ventilation is the overriding priority in managing a
patient with a suspected spinal injury. In a victim with a suspected spinal injury and an
obstructed airway, the head tilt-chin lift or jaw thrust (with head tilt) techniques are
feasible and may be effective for clearing the airway. Both techniques are associated
with cervical spinal movement.
Drowning
CPR for Drowning Victim in Water
In-water expired-air resuscitation may be considered by trained rescuers, preferably with
a flotation device, but chest compressions should not be attempted in the water.
Removing Drowning Victim From Water
Drowning victims should be removed from the water and resuscitated by the fastest
means available. Only victims with risk factors or clinical signs of injury (history of diving,
water slide use, trauma, alcohol) or focal neurologic signs should be treated as a victim
with a potential spinal cord injury, with stabilization of the cervical and thoracic spine.
EMS System
Dispatcher instruction in CPR situations
Providing telephone instruction in CPR is reasonable.
Improving EMS Response Interval
Administrators responsible for EMS and other systems that respond to patients with
cardiac arrest should evaluate their process of delivering care and make resources
available to shorten response time intervals when improvements are feasible.
Risks to Victim and Rescuer
Risks to Responders
Providers should take appropriate safety precautions when feasible and when resources
are available to do so, especially if a victim is known to have a serious infection (e.g.,
human immunodeficiency virus [HIV], tuberculosis, hepatitis B virus [HBV], or severe
acute respiratory syndrome [SARS]).
Risks for the Victim
Rib fractures and other injuries are common but acceptable consequences of CPR given
the alternative of death from cardiac arrest. After resuscitation all patients should be
reassessed and reevaluated for resuscitation-related injuries.
If available, the use of a barrier device during mouth-to-mouth ventilation is reasonable.
Adequate protective equipment and administrative, environmental, and quality control
measures are necessary during resuscitation attempts in the event of an outbreak of a
highly transmittable microbe such as the SARS coronavirus.
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-Infection ControlFactors for the development of an infection
1. Etiologic agent: Bacteria, Virus, Fungi, Protozoa, Rickettsiae, Helminths
2. Reservoir: inmate (organism) or inanimate: food, water, soil, equipment
3. Portal of exit from a reservoir
4. Method of transmission: a) direct contact (within 3ft) , b) Indirect contact ,
c) Airborne
5. Portal of entry to susceptible host
6. Susceptible host: Individual at increased risk for infection
Standard precautions in accordance to first tier of CDC Guidelines to be used in all
cases and for all clients to reduce risk of transmission. Applies to blood, body fluids,
excretions, secretions, except sweat, visble or not visible, with and without intact skin
and mucous membranes.
Hand Hygiene
To be performed before and after each contact, immediately after exposure and before
and after donning gloves. Washing hands with plain soap or using waterless alcohol
based hand rub has equal effect.
PPE priority order: Gloves
Gown
Mask
googles
Gown
mask
googles
gloves at last
Order of applying PPE: Hand hygiene
Order of removing PPE: Gloves
mask
gown
googles
hand hygiene
Medical Asepsis (Clean technique)
Includes hand hygiene and use of PPE. Considers “clean” and “dirty” designated objects.
Disposal of contaminated equipment
Linens: Handle as little as possible, contain in bag before removal from clients room.
Dishes: No special considerations are needed.
Syringes, needles, sharps: Avoid recapping or detaching needles, and dispose
immediately in a rigid, puncture resistant container.
Equipment: Discard disposable items immediately!
Non disposable items have to be cleaned and decontaminated
immediately after use.
Lab specimens: To be placed in leak proofed container with biohazard label and placed
in a sealed plastic bag.
Transport of clients with infections: masks for patient, cover of wounds,
information for receiving staff.
Surgical Asepsis (Sterile technique)
= Procedures to maintain objects and areas free of microorganisms.
Considers “sterile” and nonsterile” objects. Used in any invasive treatment.
Principles of surgical asepsis:
• Items to be sterilized by chemicals, dry or moist heat, radiation.
• Sterile packages to be checked for intactness, dryness, expiration date.
• Sterilized items to be stored in clean,dry places, off the floors, away from sinks.
• Check of sterile indicators.
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Any unsterile contact to be avoided.
Areas where sterile procedures are performed need to be cleaned regularly.
with damp cleaning or with detergent germicides.
Hair to be kept clean and short.
Surgical caps to be worn in Operating rooms, delivery rooms, burn units.
Avoid sneezing and coughing. (Germs travel 3ft (= 1m))!
Nurse with mild upper respiratory tract infection to refrain or wear mask when
carrying out sterile procedures.
Minimum conversation over sterile fields or avert the head.
Sterile items ready to use have to be in view.
Nursing staff not supposed to turn backs on any sterile item.
Sterile part of Gown: 2 inches above elbow and front. (waist to shoulder)
Sterile draped tables are sterile only at surface level.
Sterile becomes unsterile by prolonged exposure to airborne microorganisms.
Sterilized areas require closed doors, minimum traffic, avoidance of moving air.
Do not move unsterile objects over a sterile field.
Hold forceps down if no gloves are worn.
Hold hands up during surgical handwash.
Moisture drafts bacteria.
Use sterile barrier on moist surfaces.
Edges (2.5 cm) of a sterile field are considered unsterile.
Skin cannot be sterilized (Wash hands prior to handscrub).
Set up sterile field close to its use.
Report any contamination.
Questionable sterility means unsterile!
Unattended items are unsterile !
Transmission based precautions.
Limiting the spread off pathogenic microorganisms
Airborne precautions
• Special air handling and ventilation are needed.
Examples: Rubeola, TBC, Varicella.
• Place client in private, negative air pressure room w. 6 – 12 air exchanges per hour.
• Air to be discharged outside or undergoes high efficiency filtration.
• Close doors when entering or leaving the room, clients remains in room at all times.
Only cohort patients with same airborne infections but no other!
Droplet precautions
Examples: Diphtheria, M. Pneumonia, Rubella, Pertussis, Streptococcus.
• Standard precautions: Mask within 3ft.
• Private room or cohorted rooming.
• Door may remain open.
Contact precautions
• Affects contact with client or contaminated items
• e. g. skin infections: Scabies, Pediculosis, Herpes, Hepatitis A, Wounds including
MRSA and VRE. (Vancomycin resistant Enterococcus)
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Standard precautions: Gloves
Private room or cohorted
Door may remain open
Limit transportation
Dedicate equipment to client care
MANAGEMENT OF POST-EXPOSURE PROPHYLAXIS
AFTER NEEDLESTICK INJURIES
Needlestick or sharps injuries or exposure to blood or other body fluid of a patient during
the course work must lead to the following steps:
- Wash needlesticks and cuts with soap and water.
- Flush splashes to the nose, mouth, or skin with water.
- Irrigate eyes with clean water, saline, or sterile irrigants.
- Report the incident to your supervisor.
- Immediately seek medical treatment for prescription of antiretroviral medications
- Prophylaxis should begin as soon as possible after exposure and within 72 hours.
- Treatment should continue for 4 weeks, if tolerated
NCLEX-RN® Category II:
HEALTH PROMOTION AND MAINTENANCE
-The Female Reproductive System -
Anatomy of female internal structures
Vagina (birth canal)
Muscular, membraneous tube. Side walls covered with rugae. Connects external
genitalia and cervix.
Cervix
Neck of Uterus. Consists of fiber tissue. Distending during labor.
Uterus (womb)
Hollow muscular organ. Sheds endometrium periodically. Holds fetus. Superior part:
fundus, lower part: cervix.
Fallopian tubes
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Connects either ovary with uterus. Ciliated to transport ovum (zygote). Isthmus = part
towards to the uterus. Ampulla = middle section. Indundibulum = ending
Ovaries
Almond sized endocrine functioning glands. Producing and secreting estrogene and
progesterone. Release one mature follicle per menstrual cycle.
Function of female genital structures.
Oogenesis
Oocytes present at birth.
FSH (follicle stimulating hormone) stimulates meiosis to develop an individual ovum
LH (luteinizing hormone) transforms follicle into corpus luteum
Corpus luteum
produces progesterone and maintains a pregnancy
Estrogene and Progesterone
are produced by ovaries with or without pregnancy.
Ovulation
FSH stimulates maturation of a follicle during follicular phase into Graaf Follicle which
ruptures on the surface and becomes corpus luteum under influence of LH and FSH.
Minimum body fat percentage of 14% is needed to have an ovulation!
Corpus Luteum either degenerates if no fertilization occurs or produces progesterone in
case of fertilization.
Conception
Requires a 23 Chromosom containing Spermatozzoon to meet a 23 Chromosom
containing Ovum to produce a 23 Chromosom containing diploid zygote. Conception
takes place in the ampulla of the fallopian tube.
Development of a Pregnancy
Cleavage (rapid miotic division of zygote) leads to blastocyst which develops into the 16
cell Morula
Morula divides into trophoblast to be implanted into endometrium.
Cervical secretions become stratified during ovulation to facilitate sperm transport
Endometrial Secretions are rich in glycogen to nourish developing embryo until Placenta
has developed/
Menses
Begins during puberty and is stimulated by alternating estrogene and progesterone
secretion.
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Menstrual cycle
A menstruation occurs if the ovum is not fertilized and the corpus luteum disintegrates.
Estrogen and progesterone levels drop in last week of menstrual cycle. Leading to
sloughing of endometrium.
Menstrual cycle:
Follicular Phase: Day 1 – 14 of cycle
Consists of menstrual phase and proliferative phase
Length of follicular phase varies and can change length of
the entire cycle!
Luteal Phase: Day 15 – 28 of cycle
(Always 12 – 14 days in length)!
Consisting of secretory Phase (Endometrium secrets
glycogen) and ischemic phase (Endometrium breakdown)
Cervical mucus as a fertility indicator
• During ovulation more plentiful, thinner and of stretchy consistency
• Forms columns to facilitate sperm transport
• Production can be impaired by surgical treatment for abnormal Pap smears
Female sexual and reproductive hormones
Estrogene characteristics
• Produced by ovaries and ovarian follicles during ovulation.
• Expresses secondary sex characteristics at puberty.
• Peaks in follicular phase of menstrual cycle
• Inhibits FSH and LH secretion.
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Progesterone characterisitics “ The Pregnancy Hormone”
• Produced by Corpus luteum.
• Peaks in luteal phase.
• Stimulates LH and FSH.
• Thickens endometrium.
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FSH
Anterior pituitary hormone, matures one ovarian cycle each cycle.
LH
Anterior pituitary hormone, completes maturation of ovarian follicles and stimulates
ovulation which occurs 10 – 12 hrs after LH Peaks.
Menopause
Defined by 1 year of amenorrhea, occurs on average around 50, leading to thinning and
atrophy of internal and external genital structures.
- Anatomy of male internal structures -
Testes: two lobular, oval glands, conducting spermatogenesis via Meiosis
Epididymis: duct from top of testis ending in vas deferens
Vas deferens: connects Epididymidis and Prostate Gland
Prostate Gland: encircles Urethra, producing alkaline secretion, released during
ejaculation.
Seminal vesicles: superior to the prostate gland, producing seminal fluid, released
during ejaculation to support sperm metabolism and motility.
Urethra: between Bladder and urethral meatus
Semen: 2 – 5ml , spermatozoa and secretion
Spermatogenesis takes place in testes
Epidydimidis stores Spermatazoa until Ejaculation occurs.
b
- Male sexual and reproductive hormones and fertility parameters -
Semen: 2 – 5ml , spermatozoa and secretion.
Sperm Count
Normal: > 20 Million Sperms / ml.
50% must have normal form and motion.
Testosterone
Directs libido, sperm production, building and maintenance of erection, ejaculation.
Male Puberty
Characterized by increased levels of Testosterone which enlarges and thickens penis
testes and scrotum.
Spermatozoacount and quality decrease from middle age.
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- Infertility Assessment Parameters Primary Infertility = never conceived
Secondary Infertility = not conceiving after previous pregnancy
BBT Basal Body Temperature
Morning oral temperature dips one day prior ovulation.
Rises by 0.5 to 1.0 F indicate ovulation.
Cervical mucus
During ovulation more plentiful. Thinner and stretchy consistency.
Forms columns to facilitate sperm transport.
Production can be impaired after surgical treatments for abnormal Pap smears
(e. g. Coniotomy).
Uterine structure
Abnormalities present ? (i. e. fibroids)
Fertility awareness method
BBT and cervical smear monitoring to detect ovulation
FSH and LH Levels
Assessment of ovarian function
Postcoital exam of vaginal secretion
10 – 12 hours after iintercourse, 1 or 2 days before expected ovulation
Endometrial Biopsy
To check for luteal phase defect (lack of progesterone)
Client placed in lithotomy position under speculum adjustment. Cervical block, vaginal
bleeding will occur. Vasovagal response possible.
Hysterosalpingogramm HSG
Detecting abnormalities within the uterus and fallopian tubes. Filling uterus with iodine
based radio opaque dye via catheter. In general anaesthesia.
Laparascopy
Insertion of instruments in peritoneum at umbilicus and symphysis pubis to assess
fallopian tubes and ovaries.
Male semen analysis
Sperm antibody evaluation of cervical mucus. Ejaculate testing for Agglutination with
mucus.
- Treatment options in female infertility -
ART Assisted Reproduction Technologies
Hormonal Therapy to induce ovulation and induction of ovulation with medication.
(Clomiphene Citrate (Clomid, Serophene), single dose hCG)
Side effects: multiple birth, ovarian cysts,
Intrauterine Insemination (IUI) requires centrifugation to obtain spermatozoa
concentrate. Sperm collection from Uterus for IUI has to occur within 3 hours after coitus
via catheter.
IVF In – vitro fertilization
Multiple ova harvested transvaginally with large bore needle after stimulation with FSH.
Harvested ova is mixed with Spermatozoa
Implantation of 3-4 embryos 2-3 days later
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Cryoconservation of remaining embryos.
Clients remain under observation for 2 hours post procedure limited activity for 24 hours
Prescription of progesteron supplement necessary.
Variations of IVF
• Gamete intrafallopian transfer (GIFT) after 42-72 hours
• Tubal Embryo Transfer (TET) after 42 – 72 hours.
• Zygote Intrafallopian Transfer (ZIFT) after 18-24 hours.
• Micro Epididymal Sperm Aspiration (MESA).
• Percutaneous Epididymal Sperm Aspiration (PESA).
-Family planning and contraceptionNot every state allows provision of contraception to minors without parental consent!
Termination of pregnancy (TOP)
Informed consent and documentation of counseling is required in all cases.
Mandatory counseling has to include:
Benefits, Risks, Alternatives, Inquiries, Decisions, Explanations, Documentations.
Some states require approval of spouse for a termination of pregnancy (TOP) and for
sterilization procedures.
Fertility awareness methods
Abstinence
Coitus interruptus (considered as safe)
Calendar method:
Least safest fertility awareness method! Based on the following facts:
Ovulation occurs 14 days prior to next menses (+/- 2 days)
Sperm is viable for 5 days !
Ovum is capable for fertilization for 24 hours.
Method requires to maintain a menstrual calendar for 6 – 8 month to assess shortest
and longest cycle
• Fertile period = Between the date 18 days from the first day
of the shortest cycle and the date that is 11 days from the beginning of the longest
cycle.
Example: 25 – 18 = 7 / 29 – 11 = 18
Conclusion: abstinence between 11th and 18th day of cycle.
BBT method:
Requires to keep chart. Daily measurement of morning temperature prior activity.
No intercourse for 3 days when temperature rises significantly by 0.5 to 1.0 F.
Cervical mucus method: (=ovulation or Billings method)
As effective as BBT. Assessment of mucous daily for amount, color, consistency,
viscosity. Abstinence for 4 days once mucuos becomes more clear, elastic, slippery.
Mucus can be affected by hygiene procedures and intravaginal applications.
Symptothermal method:
Involves BBT and cervical mucus assessment as well as secondary indicators of
ovulation = libido increase , abdominal bloating, ovulatory pelvic pain, breast and pelvic
tenderness, pelvic and vulvar fullness, lightly dilated and softened cervical os.
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Mechanical contraceptions methods
Condoms
No oil based lubricants can be used alongside latex condoms.
Female condoms
Made of polyurethane and can be used with Latex allergy.
To be inserted up to 8 hours prior to intercourse.
Can be used with oil based substances.
Spermicides
Foams, films, suppositories.
Most commonly used substance is nonoxynol-9 and octoxynol-9.
Must be applied before each intercourse.
Does not protect against STI.
Diaphragm
Needs to be inserted 4 hours before intercourse.
To be replaced annually and after pregnancies and weight gain over 15lbs. Device may
supports recurrent urinary tract infections due to urine retention and urethra compression!
Cervical Cap
Needs to be applied a minimum of 20 minutes but no longer than 4 hours prior
to intercourse; Can be left in place for up to 48 hours. Spermicide does not need to be
reapplied.
Contraceptive Sponge
Polyurethane, effectiveness highest in nulliparous women. To be moistened with water
Protects for 24 hours and does not need to be reapplied within this time.
Intrauterine Device IUD
Immobilizing sperm on their travel into the fallopian tube, unknown how this works.
Hormonal or coppered devices, Progesterone T ( Progestasert ) to be changed annually
Copper T380A (ParaGard) can stay for 10 years
Women should be monogam, no PID, Pain may occur for 2 – 6 wks after insertion
Irregular menstruation during the first few cycles has to be expected,
Follow up after 4 – 8 weeks,
Self check for string once weekly in first month, then monthly after menses.
Increased risk for PID in first 3 weeks
TSS Toxic shock syndrome
May be caused by Caps, Diaphraghms, Sponges, IUD’s.
Early warning signs and symptoms are:
101.4 F, sore throat, weakness, achiness, sunburn rash, UTI symptoms, abdominal/
pelvic symptoms, foul smelling vaginal discharge.
Hormonal Contraception
Variety of effect due to inhibiting release of ovum, blocking release of gonadotropin
releasing hormone, changing cervical mucus and paralyzing the fallopian tubes.
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Oral contraceptives:
Combined
= estrogen + progestin for 21 or 28 days
Progestin only = “mini pill”
= No Estrogen and less progestin than combined pills.
Preferrably used in lactation, mild hypertension and in case of Estrogene side effects.
To be taken first on the first day of a new menstrual cycle but no later than the following
Sunday after the onset of menstruation. (= max. 7 days delay)
Missing the Mini Pill
continue Pill and use extra contraceptive.
Missing a Combined Pill
same procedure but no extra precaution necessary
if only one pill is missed.
Side effects:
Thromboembolic disease, headache, fluid retention, nausea = estrogen related
Acne, HDL increase, depression, hirsutism, ectopic pregnancy = progestin related
Combined BC Pill Benefits:
Decreased Risk of Ectopic Pregnancy, fibrocystic, breast disease, ovarian and
endometrial cancer, improvement of acne, protection against functional ovarian cysts.
Birth control pill effect decreased by Phenytoin, Tegretol, Primidone, Topirimate,
Griseofulvin, Rifampin /Ampicillin, Tetracyclines and other antibiotics.
Contraindications for combined Pill:
> 35 years of age, lactation, headaches and neurological problems, decreased mobility
BP > 160 / 100, Diabetes, > 20 years of vascular disease.
Subdermal Implants (e. g. Norplant ®)
Six silastic capsules containing levanorgestrel, Subdermal implantation in upper inner
arm in first 7 days of cycle, Prevent ovulation, thickening mucous, causes bleeding
abnormailites, weight gain, moods and depression.
Long acting progestin injections
Methoxyprogesteroen (Depot Provera)150 mg, long acting progestin blocks luteinizing
hormone, prevents ovulation, thickens cervical mucous. May cause bleeding
abnormalities, weight gain, tenderness, depression,
Intramuscular injection to be repeated after 80 – 90 days necessary.
MAP Morning after pill (Mifepristone RU 486)
Progesterone antagonist, prevents Implantation of ovum.
X
X Surgical Contraception
Vasectomy
Resection of Vas deferens. Postoperatively minimal activity for 48 hours, light activity for
1 week. Ice packs help to reduce swelling, No baths until stitches are removed.
Requires up to 3 semen exams prior unprotected intercourse and after the 6th and 21st
month.
Tubal ligation
Interruption of Fallopian tubes by laparascopic surgical procedure.
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-Antenatal Assessment and CareEstimation of Date of Birth (EDB)
Naegeles Rule
1st day of Menstrual Period – 3 Month (=84 days) + 7 days
Rule applies in regular menstruation and in woman not being on hormonal birth control.
McDonalds Method
Measuring fundal height from symphysis pubis to uterine fundus. Distance correlates
with weeks of gestation between 22 and 34 wks. To calculate as follow distance in cm x
8 = weeks of gestation. Not reliable in abnormal weights, multiparous and abnormal
amniotic fluid.
Obstetric Definitions
Quickening
Feeling of fetal movements between 16 and 18 weeks of gestation.
Gravida
Term to describe number of pregnancies = Number of infants delivered after 20 wks of
Gestation, dead or alive Multiple Birth count as one.
TPAL Assessment
Number of children born in Term after 37 wks.
Number of Preterm infants born between 20 and 37 weeks.
Number of spontaneous or therapeutic Abortions prior to 20 wks.
Number of Living children.
Pregnancy signs, symptoms and assessments
Presumptive signs
Amenorrhea, nausea and vomiting, Fatigue, increased urinary frequency, breast
changes and quickening.
Propable signs
Enlargement of abdomen, pigmentation changes, striae, ballottement, positive
pregnancy test, palpation of fetal outline.
Positive signs
Fetal heartbeat, fetal movement palpable by examiner, visualization of fetus in
ultrasound.
Maternal pregnancy examination parameters:
Vital signs, height, weight, thyroid, heart and breathing sounds, pelvic musculature,
pelvic seize and uterus size.
Laboratory pregnancy assessment parameters:
Hematocrit and hemoglobin, Blood type, Rh factor, irregular antibodies, Rubella titer,
tuberculin skin test, renal function tests, Urin analysis and culture , STD Screening, PAP
Test, and Offer! of a HIV Test.
Psychosocial pregnancy assessment parameters:
Feelings about pregnancy, available support systems, stability and functional level in
clients family, economic support and cultural preferences.
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Collaborative Antenatal Nursing Management:
Client has to be instructed about physical exam, prenatal care program, setting,
personnel, physiological changes and danger signs. Client has to be able to verbalize
relevant knowledge from these instructions.
Blood group examination:
Further testings are necessary if mother is type O or Rh negative (means she carries
antibodies against A, B and RH factor). May cause Erythroblastosis fetalis or
Hyperbilirubinaemia which may compromise fetus in a later pregnancy.
Urinalysis:
Performance and interpretation:
Collection from mid stream urine, clean catch specimen.
An urine culture for microbiological examination is necessary if contamination is current
with a number of > 100.000 bacteria / ml. Normal urine has a clear to amber color.
A low Urine ph < 7 most commonly indicates Ketonbodies in fasting conditions or
Diabetes. Urine glucose appears from a Blood Glucose of 160 mg/dL due to impaired
renal reabsorption. The specific gravity of urine is increased in dehydration.
Caused by excessive vomiting and Hyperemesis gravidarum. Proteine urine traces to +
1 in dipstick may occur in pregnancy physiologically.
Higher Levels may indicate hypertension or preeclampsia. Evidence of Nitrite and
WBC’s causes suspicion of an urinary tract infection. UTI in pregnancy increases risk for
preterm labor!
T-O-R-C- H Infection Screening
Toxoplasmosis
Caused by toxoplasma gondii protozoe due to consumption of undercooked, raw meat,
poor hygiene after handling cat litter/ Fetus is affected if mother gets infected after
conception. IgG > 1:256 = recent infection / IgM > 1:256 = acute infection
Maternal symptoms:
Flulike symptoms, Fetal and neonatal effects: Miscarriage, CNS defects, Hydrocephaly,
Microcephaly, Chronic Retinitis, Seizures.
Rubella ( = German measles, = 3 day measles)
Caused by Rubella Virus. Spread by droplet infection.
IgG > 1:10 = Immunity, IgG </= 1:8 = No Immunity
Maternal signs:
fever, rash, mild. Lymphoedema
Fetal neonatal effects:
congenital abnormalities, death
v
Cytomegalievirus CMV
Caused by respiratory droplet, (Most common), semen, cervical and vaginal secretions,
breast milk, placenta tissue, urine and feces.
Special risk for health care workers in contact with mentally challenged!
Diagnosis via viral culture most effective.
CMV antibodies show recent infection, a fourfold increase within 10 – 14 days an acute
infection.
Maternal symptoms: Sore Throat, Splenomegalie, cervical discharge
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Herpes Simplex Virus (HSV)
Caused by HSV Virus.
Hepatitis A / B
HAV and HBV infections are the most common in a fetus.
HAV spreads by Droplets or hands supported by poor hand washing
HBV is transmitted to fetus via placenta but usually during labor and delivery
Diagnosis of Hepatitis A:
RIA for HAV Antibodies, IgG without IgM = chronic stage
IgM without IgG = acute stage
Diagnosis of Hepatitis B: Hepatitis B surface antigen (HbsAg)
Maternal symptoms:
Flu like, Fever , malaise, nausea, abdominal discomfort, liver failure.
Fetal / neonatal symptoms:
Preterm birth, hepatitis, intrauterine fetal death
HSV II:
STD, contracted via vesicular lesions on genitals.
Infant gets infected in Birth Channel.
Diagnosis by viral culture, Serology not accurate.
Maternal symptoms: Fever, malaise, nausea, Headache,
Fetal/neonatal effects:
preterm, stillbirth, IUGR, (intrauterine growth restriction)
Vaginal delivery indicated if no obvious lesions detectable.
Sexually transmitted infections (STI’s)
= STD’s = venereal diseases
HPV (Genital warts)
Diagnosed by inspection
Maternal symptoms:
Genital lesions, chronic vaginal discharge, pruritus, cervical dysplasia, some strains are
asymptomatic.
Juvenile symptoms:
Juvenile laryngeal papillomata.
HIV
Transmission through all body fluids inclusive breast milk.
Transplacentar transmission less likely if mother receives treatment during pregnancy.
Diagnosis by EIA and positive Western Blot.
P24 antigen capture assay diagnoses neonatal HIV as soon as 2 – 6 wks after infection
and before seroconversion.
Cultures are best diagnostic tool fo neonates but expensive and take 4 – 6 wks.
Maternal symptoms:
Opportunistic infections (p. carinii pneumonia) , candida oesophagitis, wasting syndrome,
HSV, CMV. Seroconversion associated by flu like symptoms, Lymphadenopathy,
nausea, diarrhea, weight loss, rash.
Fetal / Neonatal symptoms:
At birth asymptomatic, later as above, Hepatosplenomegalie, failure to thrive,
Informed consent must be obtained prior to any HIV testing !
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Group B Streptococccus (GBS)
Vertically transmitted through vaginal colonisation of 10 – 30 % of healthy women.
Mandatory screening in all pregnant women between 36 – 37 weeks gestation with GBS
culture.
Maternal symptoms:
preterm labor, chorioamnionitis, premature rupture of membranes, UTI, postpartum
infections.
Fetal neonatal symproms: meningits, sepsis, septic, shock, death
Syphyllis
Caused by Treponema pallidum, a motile spirochete bacteria.
Transmitted through microscopic abrasions on subcutaneous tissue and via placenta
at any time during pregnancy.
Diagnosis:
Lesion tissue analysis, Serology not positive in acute infections, but in late infections.
Screening in first prenatal visit and possibly again in 3rd trimester. With VDRL (Venereal
Disease Research laboratories) or the RPR (Rapid plasma regain). Confirmation of
positive test with fluorescent treponemal antibody absorption test (FTA ABS)
Maternal symptoms:
(acute) chancre on skin near infection lymphadenopathy, rash on palms and soles.
Latent stage up to 5 years. third stage can affect CNS, cardiovascular system, ocular
signs, miscarriage, premature labor.
Fetal / neonatal effects:
CNS damage, hearing loss, death.
Gonorrhea
Caused by infection with neisseria gonorrhea. (aerobic gramnegative diplococcus) via
sexual activity and in birth canal. Screening at 1st prenatal visit.
Women at risk also at 36 wks of gestation.
Diagnosis:
Thayer-Martin culture from smears of the endocervix, rectum and pharynx.
Maternal symptoms:
Asymptomatic to purulent discharge, irregular menstruation, pelvic pain
Premature rupture of membranes (PROM).
Fetal/ neonatal symptoms:
Preterm birth, neonatal sepsis, IUGR, opthalmia neonatorum
Chlamydia
Caused by infection w. Chlamydia trachomatis via sexual contact.
CDC recommends screening in asymptomatic high risk women.
Cultures expensive , special transport required, results take up to 10 days.
Maternal symptoms: Mostly asymptomatic, also bleeding, purulent discharge,
PID, Dysuria.
Fetal/neonaltal effects: Conjunctivitis, Opthalmia neonatorum, pneumonia.
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Complete Bloodcount alterations in pregnancy:
Parameter
Normal Results
Pregnancy related alterations
RBC Count
4.2-5.4 million/mm3
5-6.25 million/mm3
Hemoglobin
12-16 mg/dl
> 11 grams/dl
Hematocrit
37-47%
> 33%
Mean corpuscular
80-95/mcm3
(no changes in Pregnancy)!
Volume MCV
Mean corpuscular
27-31 picogram/ml
(no changes in Pregnancy)!
hemoglobin MCH
Mean corpuscular
32-36 grams/dL
(no changes in Pregnancy)!
Hemoglobin concentration MCHC
WBC Count
5000 – 10000/mm3
5000-15000 / mm3
Polymorphynuclear
55–70% of WBC’s
69-85% of WBC’s
Cells (Neutrophils)
Lymphocytes
20-40% of WBC’s
15-40% of WBC’s
Platelet Count
150000 – 400000/mm3 postpartal changes
- Nursing Care at neonatal visits Antenatal assessments
• Psychological well being
• Weight gain
• Vital signs
• Nutritional status
• Urine Status for Proteines/Glucose/ WBC/Nitrite w. clean catch collection.
• Monthly hemoglobin.
• Fundal height
• Fetal movement and heart rate,
• AFP Levels at 16 – 18 wks.
High AFP = Defects of neural tube, body wall, threatened abortion, fetal distress,
death = Triple Screen Test. Ultasound, AFP Levels in amniotic fluid.
Low AFP = s/o Trisomie 21 or fetal wastage, Glucose at 24 – 28 weeks.
Frequency of Visits
Every 4 weeks during first 28 weeks
Weekly until delivery.
2nd – 9th month every 2 weeks until 36 wks.
Teaching of physiological changes (Colostrum, quickening etc.)
and danger signs is an essential part of the neonatal visits !
Triple Screen Test = AFP, hHCG, unconjugated Estriol UE 3
Glucose Tolerance Test GTT
50 g oral glucose load at any time of the day even with prior meals.
Normal result if 1 hour venous blood glucose < = 140 mg / dl.
Abnormal result: 3 hour oral glucose tolerance test.
Oral Glucose Tolerance Test OGTT
High Carbohydrate Diet over 3 days prior test
After 8 hour fasting overnight fasting serum glucose obtained
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100mg oral glucose administered
Venous blood glucose readings after 1,2,3 hours
1 or more abnormal findings
gestational Diabetes
1 abnormal fiding = borderline result = repeat in one month
Abnormal OGTT Results
Fasting > 105 mg/dL, 1hour > 190mg/dL,
2hour > 165 mg/dL, 3hour > 190 mg/dL
Ultrasound
Assesses gestational age, anomalies, fetal well being.
Transvaginal Ultrasound:
Primarily used in first trimester to assess fetal and maternal structures, fluids, bones.
No full bladder needed.
Contraindications: Embarassment and Latex Allergy.
Viability:
Assessment of fetal heart rate at 6 – 7 weeks of gestation with real time echo scan.
Fetal death
Absence of heart activity, scalp edema, maceration.
Assessment of gestational age via ultrasound can best be established during first 20
weeks of gestation because of fairly consistent fetal growth rate during this period.
Crown - rump measurement 7 – 14 weeks. Biparietal Parameter BPD + Femur length >
12 weeks of gestation. (= serial assessments for determination of fetal growth)
Abdominal Ultrasound:
Requires full bladder for best results.
Warning signs in pregnancy
Gush of fluids from vagina = Rupture of Membranes
Vaginal bleeding = Abruptio placentae, Placenta praevia, Bloody show
Abdominal pain = premature labor, abruption placentae
Temperature = > 100.4 degrees Fahrenheit / 38 degrees Celsius = Infections
Persistent vomiting = Hyperemesis gravidarum
Visual disturbances = Hypertension Preeclampsia
Severe headache and hypertension = Preeclampsia
Epigastric pain = Preeclampsia
Dysuria = UTI
Decreased fetal movement = Compromised fetal well being
Childbirth Education Needs by Trimester
Trimester
First
Educational topic
- Physical and psychosocial changes
- Self care
- Protecting and nurturing the fetus
- Choosing a care provider and setting
- Prenatal exercise
- Relief of common early pregnancy discomforts
Second
- Planning for breast feeding
- Sexuality in pregnancy
- Relief of common later pregnancy discomforts
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Third
- Preparation for childbirth
- Development of a birth plan
Exercise in pregnancy
Women have to be encouraged to participate in regular exercise three times weekly.
(pelvic tilt, partial sit ups, Kegel exercises, stretching of inner thigh muscles)
Common natural birthing methods
Lamaze
The most widely known natural childbirth method used to be recognized for teaching of
specific breathing methods which were supposed to distract the women in labor from
pain.
After going through several changes within the last decades this method is now founded
on several other techniques that have in common to focus the attention of the women in
labor elsewhere.
The basic contemporary Lamaze rules of natural childbirth are as follow:
•
“Let Labor Begin on Its Own”
•
“Walk, Move Around, and Change Positions Throughout Labor”
•
“Bring a Loved One, Friend, or Doula for Continuous Support”
•
“Avoid Interventions That Are Not Medically Necessary”
•
“Avoid Giving Birth on Your Back, and Follow Your Body’s Urges to Push”
•
“Keep Mother and Baby Together
– It’s Best for Mother, Baby, and Breastfeeding”
Bradley
This method teaches natural childbirth and views birth in general as a natural process.
Based on proper education, preparation and the help of a loving, supportive and
educated coach the women can be helped to give birth naturally.
Woman and coach play an active part by increasing self-awareness and teaching of how
to deal with the stress of labor by tuning in to her own body. The Bradley Method
encourages mothers to trust their bodies using natural breathing, relaxation, nutrition,
exercise, and education.
Kitzinger – Stanislavski
This method is based on the ideas of English anthropologist Sheila Kitzinger and
promotes birth as a natural sexual event. In addition to education and coping skills
learned in specific classes, there is a strong emphasis on the positive interaction of the
parents who have conceived this baby together. Therefore this method requires an intact
parent relationship since the father is supposed to “coach” the women in labor.
Early Pregnancy discomfort awareness
Nausea and vomiting, Breast tenderness, Urinary frequency, Fatigue, Ptyalism,
Nasal stuffiness/bleeding.
Late Pregnancy discomfort awareness
Heartburn, constipation, hemorrhoids, backache, leg cramps
varicose veins, ankle edema, faintness and flatulence.
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•
•
•
•
•
•
•
•
•
•
•
•
•
Physiological changes in pregnancy
Hypertrophy of Uterus = (increase in size of cells)
from 10 mL to 5 Liter due to estrogen stimulation.
Cervical secretion of thick mucus to plug opening of the cervix
Goodell’s sign = softening of the uterus
Chadwicks sign = bluish color of cervix during pregnancy
Vagina mucosa and secretion thickening. Fiber tissue relaxing pH 3.6–6.0.
Breasts: Increase in size and number of glands.
Colostrum secretion, bluish white, last trimester.
Cardiovascular changes:
Cardiac output increases by 30- 40%. Pulse by 10–15 beats/minute.
Cardiac problems most common around 28 wks.
Decrease of pulmonal and peripheric vascular resistance decreases by 40–50%.
BP 1st and 2nd Trimester 3rd Trimester.
Vena Cava Syndrome
Reduced blood flow to right atrium from midterm pregnancy leads to BP decrease and
collape. Client needs to choose positioning on left side.Respiratory changes:
•
•
•
•
•
•
•
•
•
•
•
Respiratory changes:
Decreased airway resistance. Increased air volume by 30–40% due to
progesterone.
Intrathoracic Volume remains unchanged!
Musculoskeletal changes:
Relaxation of pelvic and ISG Joints, Hyperlordosis Diastasis recti.
Gastrointestinal:
Hyperemesis gravidarum commonly occurring in 1st Trimester due to hcG
production
in placenta. Progesterone relaxes all smooth muscles, causing constipation.
Renal:
Urine frequency increased in 1st and 2nd Trimester.
GFR by 50% from 2nd Trimester.
Skin:
Estrogen = Pigmentation in areola, nipples, vulva. Choasma in women of
color around eyes and forehead aggravated by sun exposure. Linea nigra dark
pigmentation from umbilicus to pubic area. Striae gravidarum. Increased activity
of sebaceous glands.
Endocrine changes in pregnancy:
Weight gain:
3–5 lbs in first trimester , 12-15 in each following trimester (35lbs
altogether) = 10–13 lbs in first 20 weeks and 1 pound weekly in last 20 weeks.
Weight gain results from growth/increase of fetus, placenta, amniotic fluid, uterus,
blood volume increase and breast size.
Water retention
due to increased levels of sexual hormones and decreased serum protein.
hCG production
human chorion gonasdotropin, secreted by Trophoblast in early.
Pregnancy, stimulates Estrogen and Progesterone production. Urine ELISA
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•
•
pregnancy tests are developed to detect hCG in Urine.
Human placental lactogen hPL = chorionic somatomammotropin.
Estrogen and Progesteron. Produced by Corpus luteum for first 7 weeks.
Estrogene: stimulates uterine development and lactation of breasts.
Progesterone: Maintains Endometrium, relaxes uterus and smooth muscles.
Relaxin: Corpus Luteum Hormon, relaxes uterus, collagen fibers, softens cervix.
Prostaglandines: contribute to onset of labor
Maternal Nutrition
Healthy pregnant normal weight woman require additional 3000 calories per day.
Proteins, Folate (Vit B 6), Vitamins, Minerals, Trace elements.
Lactose Intolerance
Lactase deficiency leads to a failure to break down lactose to glucose and galactose.
Results in nausea, vomiting, and. Cramping and diarrhea.
oral replacement via supplement before consuming dairy products
(cheese, yogurt and cooked dairy products maybe tolerated)
Vegetarian diet in pregnancy requires Vitamin B12 supply from whole grain fruit,
legumes and nuts.
Complicated antenatal care
- Identification of high risk prenatal clients.
Prenatal Diagnostic tests: Biophysical profile BPP
= 5 factors (Score: 0 -10
8-10 normal, 4-6 possibly abnormal, < 4 abnormal)
•
Fetal breathing movement
•
Body movements
•
Muscle tone
•
FHR
•
Amniotic fluid volume
Doppler blood flow analysis
Noninvasive determination of blood flow and resistance in placental circulation to detect
IUGR after 15th week of pregnancy. Assessment of a systolic/diastolic pressure ratio
from umbilical/uterine arteries. Ratio > after 30 weeks are considered abnormal if
persisting = IUGR
Nonstress test NST
Assessment of FHR Velocity under provocation of fetal movements. Movement should
increase FHR at least twice by min 15 bpm over min 15 seconds within 20 minutes.
Contraction stress test CST
Measurement of FHR Assessment under breast stimulation or IV oxytocin to stimulate
uterine contractions. Indicated in situations where an IUGR is already diagnosed to find
out if fetus can withstand decreased blood supply due to uterine contractions in labor.
Late decelerations must not occur at all within 3 contractions in maximum 10 minutes.
Amniocentesis
Withdrawal of max 20ml of amniotic fluid after 14-16 wks of gestation through abdominal
wall. Procedure requires Rh–neg clients to receive Rhogam following procedure.
Recommended for clients over 35 years of age.
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Tests to perform from amniotic fluid samples:
•
Lecithin to Sphingomyelin ratio (L/S ratio) for assessement of lung maturity.
Ratio must be > 2:1
•
Phosphatidylglycerol (PG)
Presence indicates presence of surfactant = lung maturity
•
Karyotype
Assessment of genetic chromosomal disorders
•
AFP level
Indicator for spina bifida
•
Chorionic villus sampling
-Gestational conditions-
Hyperemesis gravidarum
Severe vomiting in first 20 weeks of pregnancy. Risk of Dehydration, Electrolyte
imbalance, Ketosis, Acidosis, weight loss. Client may require hospitalization for I. V. fluid
supply and I & O control. Treatment is symptom oriented, mainly based on small meals,
psychological support. Pharmacological treatment with Phenothiazines and and
antihistamines possible in severe cases.
Ectopic pregnancy
Most common site are the fallopian tubes as well as other regions within the abdominal
cavity. Risk factors are PID, IUD contraception.Unilateral lower abdominal pain, radiating
with abdominal tenderness. May cause uterine or abdominal bleeding. May require
shock treatment. Treatment requires surgery. Preoperative test of CBC, B-HCG, Blood
group and type, RhoGAM prophylaxis for rh negative mothers.
Hydatiform mole (Gestational trophoblastic disease)
Abnormal growth of placenta in first trimenon of pregnancy without fetal development
Can result in chorioncarcinoma. Most common in Japan. May show brownish vaginal
bleeding. May cause hemorrhage. For one year close follow ups for possible
chorioncarcinoma (20% transformation rate!) Client to avoid pregnancy for 1 year.
b
Incompetent cervix
Painless cervical effacement and dilation due to previous cervical injuries or
infections.May cause preterm labor. Treatment may involve strict bedrest for remaining
pregnancy and/or cerglage which has to be removed at onset of vaginal birth.
Spontaneous abortion / Miscarriage
Unintended loss of pregnancy within first 20 weeks of gestation = spontaneous abortion.
After 20 weeks = miscarriage. Most commonly indicated by bleeding in first trimester
Classifications:
Threatened abortion: Vaginal bleeding, cervix closed, mild cramps
Inevitable abortion: Cramping, bleeding, dilation, membranes may rupture
Incomplete abortion: Tissue remains in uterus
Complete abortion: Cervic closed uterus contracts
Missed abortion: Tissue remains in utero because of risk for DIC
Clots, pads and tissues may be used in all cases for further examination.
RhoGAM Prophylaxis has to be considered after abortions/miscarriages.
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Placenta praevia
Abnormally implanted placenta near to or over cervical os. Vulnerable to cervical dilation
commonly causing bleddings in early pregnancy. Incidence increases with multiparity
and multiple gestations. Client usually requires caesarean section. Vaginal delivery only
in advanced preterm labor. Typically increasing painless bleeding after 20th week of
pregnancy. Diagnosis is made by ultrasound scan. Suspicion of placenta praevia
prohibits vaginal examination. All clients require bedrest with bathroom privileges. DIC
risk increased. (assessment platelets, fibrinogen, fibrin degradation products, PT, PTT).
Abruptio placentae
Partial or full separation of the placenta from the uterine wall. More or less painful and
bleeding depending if a full or partial separation occurs. Periodical Aassessment of
abdominal girth at umbilicus level for baseline size to evaluate baseline size.
Premature rupture of membranes PROM
= Membran rupture before labor begins.
Preterm rupture of amniotic membranes prior to term gestation or before 38 weeks of
pregnancy. Prolonged rupture more than 12 hours before birth may require induction of
labor to avoid ascending infections. (Chorioamnionitis) All membrane rupture prior to
start of labor increase risk of umbilical cord prolaps. Amniotic fluid may be clear, gush or
meconium filled. Differentiation to urine with nitrazine paper and microscopically
detectable ferning pattern.
Pregnancy induced hypertension (Preeclampsia)
Refers to hypertension over 140/90 mmHg after 20 weeks of gestation. May be
associated by mild to severe proteinuria, and edema depending on severity of stades.
HELLP Syndrome (Hemolysis, elevated liver enzymes, low platelet count) and/or
Eclampsia (includes seizures) are the eclipse of preeclampsia characterized by
additional maternal tonic-clonic seizures. Commonly occurring in third trimester.
Laboratory routine assessments include: haematocrit, BUN, ALT, AST, RBC and
platelets Bedrest in quiet and calm environment. High protein,salt restricted diet required.
Magnesium sulfate increases the seizure threshold. Condition can only be cured by
labor.
- Labor and Delivery care -
General considerations
Consider psychological safety for mother. Primigravida mostly experience longer labor.
Maternal history must be assessed for abuse. Cultural awareness necessary.
Education about laboring process important.
Electronic fetal monitoring
Used for surveillance of heart rate FHR and uterine contractions UC.
External monitoring is placed over fetal back, can be disturbed by maternal obesity
Internal monitoring (cervix at least 2cm, membranes ruptured)for direct ECG.
Electronic Fetal heart rate interpretation
Baseline fetal heart rate
= heart rate between contractions, normal: 120 – 160- bpm.
Short term variability
Can only be evaluated by internal monitoring = jaggedness, zickzack appearance in
baseline FHR as an expression of changes in FHR between two beats. Expression of
parasympathetic/sympathetic nervous system decreased by fetal tachycardia,
prematurity, heart and CNS anomalies.
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Long Term variability
Same cause. Rhythmic fluctuations of FHR 2–6 x/minute. Increased by movement,
decreased by sleep. FHR may also vary spontaneously and with contractions.
FHR Accelerations
Nonperiodic, spontaneous. Response to fetal movement, indicate in general fetal well
being.
FHR Decelerations
Early decelerations
Starts and ends with contraction, mirrors contraction activity. Generally benign finding as
long as fetus is descending and contractions do not become ineffective.
Late decelerations
Begin after start and end after end of contraction. Always considered ominous s/o
uteroplacentar insufficiency.
Order of appropriate actions in cases of suspected uteroplacentar insufficiency:
1.
2.
3.
4.
5.
Oxygenation via mask 7 – 10 L/ min.,
Positioning of client to left lateral side,
Fluid by increased IV rate to correct hypotension.
Stop Oxytocin supply.
Report of incident.
Variable decelerations
Sudden occurrence. Varying in duration and intensity in relation to contractions.
Resolve spontaneously. Caused by umbilical cord compression! Categories: mild,
moderate, severe bases on lowest FHR reading. Ominous when prolonged, recurrent,
more severe, slow return or overshoot of baseline = s/o fetal asphyxia.
Order of appropriate actions in cases of suspected umbilical cord compression:
1. Immediate oxygene supply necessary.
2. Repositioning client to relief cord compression.
3. Vaginal exam to assess if umbilical cord has prolapsed.
Intrauterine Amnio infusion of warmed saline to cushion umbilical cord may be required.
Severe variable deceleration pattern
deceleration of FHR to 90 bpm or less for at least 60 seconds.
Uterine contraction monitoring parameters are
Frequency, Duration, Intensity.
External fetal monitoring:
Tocodynamometer to be placed on abdomen, close to fundus.
Only accurate for frequency and duration.
Sensitivity of instrument depends on BMI of client.
Internal fetal monitoring:
Via intrauterine pressure catheter
(IUPC) (pressure gauge or saline filled tube)
Measures IUP in mmHg.
x
x
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-Process of labor-
Initiating factors
•
Distention of the uterus
•
Release of
o
Prostaglandines
induce mild contractions for cervical dilation.
o
Oxytocine
induces strong uterine contractions for labor.
o
Fetal Cortisol
increases muscular fetal activity during labor.
o
Estrogene
levels increase towards labor.
o
Progesterone
levels decrease towards labor.
True labor is characterized by cervical effacement and dilation.
Definitions of the female pelvic anatomy:
gynecoid, 50% , occiput anterior most common,
android, 20% , slow descent, arrest, operative birth common
anthropoid, 25% , occiput anterior or posterior, vaginal delivery not favorable
platypelloid, 5%, occiput posterior, vaginal delivery not favorable
(type of pelvis determines delivery)
False pelvis (large pelvic cavity)
True pelvis (small pelvic cavity)
Pelvic anatomy
Obstetrics terminology:
Passenger = fetus
Attitude = positioning of fetal parts to one another. Normal attitude is flexion.
Lie = positioning of longitudinal fetal axis to longitudinal axis of mother
Types: Vertex (head first) most common lie!
Breech (buttock first)
Transverse / Shoulder (laterally across uterus)
Oblique (diagonally across uterus)
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Presentation = description of fetal part entering pelvis first during labour.
Types: cephalic (most common) , breech , shoulder presentation.
Landmarks: acromion process, mentum, occiput, sacrum
Position = position of presenting part to the pelvis.
(posterior, anterior, transverse)
Most common: ROA (right occiput anterior, LOA (left occiput anterior)
Engagement = largest diameter of presenting part reaches pelvic inlet.
Floating Engagement = part directed to pelvis but easily moveable.
Ballotable Engagement = part directed to pelvis but moveable with manual pressure.
Engaged Engagement = presenting part fixed, cannot be displaced.
Station
Position of presenting part to sciatic spines of pelvis.
Measured in cm as follow:
- = fetus below spines
+ = fetus above spines
Forces of labor
uterine contractions stimulated by uterine pacemaker.
Contraction phases: Increment (building up phase)
Acme (peak)
Decrement (letting up phase)
Nadir (resting phase),
(necessary to facilitate perfusion and oxygenation)
Frequency of contractions
Intensity = strength of contraction at acme (assessed by palpation)
Mild, moderate, strong palpable
Duration of contraction in seconds from increment to decrement
Contractions produce effacement = thinning and drawing up of internal os.
Effacement may precede cervix dilation in Primigravida.
Occurs simultaneously w. dilation in Multigravida.
Cervical dilation is measured from 0 – 10 cm!
Psychological influences birth due to muscular contractions.
Fear
muscular contractions
increased pain.
Education about childbirth essential to reduce fear!
x
x
x
x
x
x
xx
x
x
x
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-Stages of laborFirst stage
From onset of true labor to complete dilation of cervix.
Divided in three phases: latent, active, transition.
Latent phase:
Dilation of cervix 0 - 3 cm , Little descent.
Contractions every 30 minutes, from irregular to regular with increasing intensity.
Average Duration: 8.6 hours for nulliparas, 5.3 hours for multiparas.
Assessments:BP, Pulse, respirations once/hour if normal.
Temperature 4 hourly with intact membranes, 2 hourly with ruptured membranes.
FHR hourly in low risk, per 30 minutes in high risk women.
Active phase:
Dilation 4 – 7 cm
Effacement and descent progressive.
Contractions every 2 – 3 minutes, of about 60 s duration, strong intensity.
Client experiences increased pain.
Average duration: 4.6 hours for nulliparas, 2.4 hours for multiparas.
Assessments:
Same as latent phase
FHR per 30 min for low risk, per 15 min for high risk
“Bloody mucus show” due to progressed cervical dilation.
Transition phase:
Dilation 8 – 10 cm.
Contractions every 1.5 – 2 minutes, for 60 - 90 seconds.
Communication impaired.
Nausea and vomiting common.
Increased anxiety, loss of control and helplessness.
Average duration: 3.6 hours for nulliparas, 30 minutes for multiparas.
Assessments:
BP, Pulse, Respirations every 30 minutes, Contractions + FHR/15 minutes.
Collaborative Management
Orientation about progress and assessments.
Encourage ambulation if presenting part is engaged.
Provide comfort.
Encourage voiding every 2 hours!.
Monitoring progress and fetal well being.
Ice chips, clear liquids against dehydration.
Teach, reinforce breathing and relaxation.
Encourage rest between contractions.
Analgesia as requested and prescribed.
Documentation.
Second stage
From full dilation of cervix to delivery of fetus.
Opportunity to “press” voluntarily with contractions!
0.5 – 3.0 hours of duration.
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Cardinal movements:
1.
2.
3.
4.
5.
6.
7.
8.
Engagement
Descent
Flexion
Internal Rotation
Extension of fetal head under maternal symphysis.
Restitution neck turns 45 degrees to untwist neck after head is delivered.
External rotation further 45 degrees to bring lateral diameter of fetal
shoulders in line with AP dimension of pelvis.
Expulsion shoulders slip over symphysis.
Crowning
Expulsion of perineum and opening of vagina due to forward pressing fetal part.
Assessments
BP, Pulse, Breathing every 5-15 minutes.
Continous palpation of contractions.
FHR every 15 minutes at low risk, every 5 minutes at high risk.
Monitoring of fetals descent cardinal movements and crowning.
Collaborative management
Urinary catheter may be necessary!
Episiotomy = Perineumincision
To ease birth in fetal distress or to protect perineum damage.
Due to tearing which is harder to repair.
Perineumlaceration
1st degree, only in epidermis, no repair necessary if no bleeding occurs.
fascia
muscle = suturing necessary.
2nd degree, epidermis
3rd degree, extension into rectal sphincter = surgical repair necessary
4th degree, extension through rectal mucosa = surgical repair necessary
Third stage
From birth of newborn to delivery of placenta on average within 30 minutes
Maternal Assessment:
BP,Pulse,Respiration/5minutes.
Uterus tone remains increased and umbilical cord is lengthening until placenta is
delivered.
Fourth stage (postpartal)
First 1 – 4 hours after delivery.
Client usually remains in nursing suite.
Repair of episiotomy or lacerations as soon as possible.
Ice administration to perineum if injured or sutured.
Initiation of breast feeding.
Fluid supply, resuming regular diet.
Assessments:
BP, Pulse, Respirations, fundus, lochia, perineum
(after 15 minutes, 30 minutes, 1st hour, 2nd hour)
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- Pain management during labor Nonpharmacologic methods
Position changes, Hydrotherapy, Breathing techniques and Relaxation techniques.
Pharmacological methods
All systemic drugs cross the placenta barrier!
Analgesia during birth is not to be administered to early or too late since this may cause
prolonged labor.
Most commonly used Intravenous narcotics:
•
Nalbuphine Hydrochloride (Nubain®) = narcotic agonist – antagonist !
Not to be used for opioid dependent clients !
•
Butorphanol tartrate (Stadol®)
Rapid onset, short term duration, used in active phase or first phase of labor!
Antidote Naloxone (Narcan) has to be available at all times!
Effect and therapeutic use:
Effectful pain relief during labor.
Not to supply in early labor.
Side effects:
May prolong labor.
Nubaine + Stadol may cause withdrawal in women committing Morphin abuse.
Respiratory and cardial depression, hypotension, miosis, constipation, urinary retention
and sedation. Newborn respiratory depression if birth 1 – 4 hours after administration.
Intrathekal narcotics:
Substances: Morphin sulfate or Fentanyl citrate.
Subarachnoid administration at L4/L5 or L5/S1.
Sudden effect, neonatal depression rare.
Easier and faster than epidural administration.
Spinal headache, muscle spasms and urinary retention are common side effects.
Lumbar epidural block
Injection at same spinal location.
Substances:Bupivacaine Hydrochloride, (Marcaine ®)
or Lidocaine Hydrochloride ( Xylocaine ®)
Excellent pain relief, longer lasting, no neonatal respiratory depression.
Decreasing pelvic floor muscle activity and uterine contraction.
May lead to failure of fetus to accomplish internal rotation
caesarean section
Hypotension is most considerable side effect.
Meningeal anatomy of the spinal chord
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Paracervical Block
Local anaesthesia to lateral aspect of cervix during active or transition phases
Relatively easy administration, quick onset, rapid onset, no neonatal effects
May lead to decreased or absent urge to push
Systemic effect by infection through vascularized cervix = FHR !!!!
Decreased sensation in lower extremities
Pudendal Block
Local anaesthetic injected into lateral walls of vagina to anaesthetize pudendus nerve.
Administered in 2nd stage during preparation for episiotomy.
Eliminates urge to push.
Decreases sensation in lower extremities or ability to urinate.
Monitoring of Morphine side effects
respiratory depression may occur up to after 8 hours,
nausea and vomiting after 4 hours,
itching within 3 hours,
urinary retention, constipation, somnolence at any time.
- Complicated delivery and care Significant risk factors for intrapartal complications are
high catecholamine levels due to stress, fear and labor!
Factors contributing to difficult labor or dystocia
Hypertonic and hypotonic uterine dysfunction
Assessment with labor graph (Friedman curve)
(comparing descensus and dilation of cervix over time)
Malpositions and Malpresentations
Fetal malpositioning (Correct position is Occiput anterior position)
Occiput posterior position (OP)
Occiput anterior position (OA)
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Fetal malpresentations
•
Vertex presentation
•
Brow presentation
•
Face presentation
•
Sincipital presentation
•
Breech presentation (require caesarean section!) three types:
1.
Frank breech (presenting sacrum)
2.
Incomplete (footing) breech
3.
Complete breech (presenting anus and buttocks)
Shoulder presentation (transverse lie) requires caesarean section.
FHR monitoring electrodes must not be placed on presenting part !
Extraction methods
Vaccum delivery
( may cause cephalohematoma, retinal hemorrhage, intractranial hemaorrhage)
Forceps delivery
( may cause fetal ecchymosis, edema of face)
Signs and symptoms of breech positions.
Fetal distress , (insufficient oxygen supply)
Meconium stained amniotic fluid.
FHR Tachycardia > 160, FHR Bradycardia < 110.
Reduced or absent variability of HR.
Late decelerations of FHR following contraction.
Necessary actions
Positioning mother on left side. Oxygen supply.
Cephalopelvic misproportion requires caesarean birth!
Shoulder dystocia is considered an obstetric emergency.
-
Induction of labor-
Treatment methods:
•
Prostaglandines for cervical administration (PGE2 Gel) or oral, intravaginal
Misoprostol.
•
Amniotomy/Artificial Rupture Of Membranes (AROM)
•
Oxytocin for intravenous use over infusion pump to stimulate contractions.
(Until contractions are frequent, following closer than 2 minutes and longer than
90 seconds)
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Contraindications for the induction of labor
•
Abnormal pelvic structure.
•
Prolapsed umbilical cord.
•
Active genital herpes.
•
Invasive cervical cancer.
•
Prior uterine incision.
•
Malpresentations of fetus.
Causes of prolonged labor:
Prolonged latent phase:
> 20 hrs. for nulliparous parent, > 14 hours for multiparous parent.
Protracted active phase:
Dilation < 1,2 cm / hour in nulliparous or less than 1,5 in multiparous client.
Protracted descent:
< 1 cm/hour in nulliparous client, < 2cm in multiparous client
Secondary arrest of cervical dilation:
Cessation of dialatation for > 2 hours in nulliparous client and for > 1 hour in multiparous
client.
Arrest of descent:
No fetal descent for > 1 hour.
Premature labor
Contractions between the 20th and the 37th week of gestation!
Signs of labor
Contractions frequent, every 10 minutes or less.
Low abdominal cramping, with or without diarrhea.
Pelvic pressure.
Urinary sensation.
Low backache.
Increased vaginal discharge.
Leaking amniotic fluid.
Immediate actions to be taught to a pregnant client in case of uterine contractions:
Empty bladder.
Lay on left side.
Administer fluids.
Assess uterine contractions by abdominal palpations.
Continue activity 30 min after contractions stop.
Management of preterm uterine contractions:
Administration of tocolytic agents. (Terbutaline (Brethine), Magnesium sulfate, Ritodrine
(Yutopar).
Administration of betamethasone or dexamethasone to stimulate lung maturity.
-
- Complications in labor -
Precipitous (unattended) labor
Rapid, under 3 hours.
Injury in birth channel tissue may occur.
Fetal risk for hypoxia, intracranial hemorrhage and birth injuries.
Client not to be left alone at any time!
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Client blowing decreases urge to push.
Support perineum with sterile towel when crowning occurs.
Apply gentle pressure on fetal head to decrease velocity of delivery.
Suction infants mouth first, then nose with bulb syringe.
An umbilical cord around infants neck must be clamped twice and cut before delivery!
Once infant is delivered assess for separation of placenta.
(gushes of bright blood and lengthening of umbilical cord)
Hemorrhage prevention with fundus massage or by putting infant to clients breast.
Uterine prolapse
May be caused by intense fundus massage and pulling on umbilical cord.
Uterine inversion = inside out uterine prolapse.
May occur complete or partial.
Requires immediate reposition to stop blood loss!
Uterine rupture
Rare complication. Associated with previous caesarean or augmented birth,
overstimulation of uterus resulting in intense contractions. Main symptoms are sudden
cessation of uterine contractions, FHR , strong abdominal pain and massive
haemorrhage. Full rupture requires hysterectomy, a partial rupture can be repaired.
- Caesarean delivery Mainly indicated by CPD, fetal distress, breech presentation, previous caesarean birth.
Maternal risks
Injury to bowel and bladder, Hemorrhage, Thrombophlebitis, Pulmonary embolism and
Aspiration.
Fetal risks
Prematurity, Injury at birth, Respiratory problems.
Skin incision usually performed at pubic hair border (Pfannenstiel incision) or
by vertical incision. Uterine incisions may be performed through upper or lower uterine
segment. Common routine Pre – and postoperative care
Contraindications
Inadequate pelvic or fetal size (> 4000g)
Any circumstances that may require a repeated caesarean section.
A previous classical uterine incision.
Any fetal position that may require augmented birth.
Any other than hospital birth setting.
Risks
Uterine rupture, especially in early period of labor. Labor failure.
Benefits
Experience of natural delivery for mother and child. Economic benefits.
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Medication Therapy in Obstetrics and Gynecology
Uterine Stimulants
Oxytocin (Pitocin®)
Effect and therapeutic use:
Short lasting effect over 2 – 3 minutes after administration
Stimulates uterine contraction
Used as labor inducing medication in:
maternal diabetes, preeclampsia, eclampsia, erythroblastosis fetalis
May be used carefully to support labor process after cervix has opened and presentation
has occurred.
Stimulates lactation by increasing let down reflex
Causes post partal uterine involution
Controls postpartum hemorrhage
Requires dilution prior to intravenous administration
Magnesiumsulphate needs to be immediately available for IV administration.
May be administered as nasal spray to promote milk ejection.
Side effects:
Increased uterine contractions,
(< 2 Minutes apart, > 90 seconds duration, around 50 mmHg in strength)
Pelvic pain, Hypotension, Cardiac Dysrhythmias
Ergot Alkaloids
Ergonovine (Ergotartrate® )
Methylergonovine (Methergine ®)
Effect and therapeutic use:
Control of postpartum hemorrhage due to induction of uterine contractions.
Side effects:
Causes rebound uterine relaxation, hypertension, decreases milk production and
allergenic potential.
Contraindications:
Pregnancy, hypertension, coronary artery disease, smokers (increased Vasoconstriction)
Overdose causes Ergotism:
Nausea, vomiting, weakness, muscle pain, insensitivity to cold and paraesthesia.
Prostaglandines
Dinoprostone (Prepidil ®, Cervidoil ®):
Prostaglandin E2, Approved to support cervical opening.
Carboprost promethamine (Hemabate ®):
Prostaglandin F2, Approved to control postpartal bleeding
Effect and therapeutic use:
Stimulation of uterine myometrium
To induce labor or control of postpartal bleeding
Also effect to terminate pregnancy from the 12th week until the 6th month.
Client to remain in supine position after administration.
Side effects:
Nausea, vomiting and hypertension.
Uterine cramping, - tetany and rupture.
Contraindications:
Pelvic Inflammatory Disease (PID), Asthma and Hypertension.
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- Uterine Relaxants All substances may lead to postpartal uterine hemorrhage if used shortly before delivery
and may require client to receive Oxytocin as soon as possible.
Terbutaline (Brethine ®)
Beta-adrenergic substance. Most commonly used, not FDA approved for preterm labor.
Can cause nausea and vomiting. Neonate may be delivered with Hypoglycemia.
To be diluted in 1000 mL D5W for IV administration. (= 5 mcg/mL)
Ritodrine (Yutopar ®)
Beta-adrenergic substance. Only FDA approved substance for preterm labor!
But increased risk for pulmonary edema.
Nifedipine (Procardia ®)
Calcium – Antagonist.
Second commonly used, not FDA approved for preterm labor.
May cause Oligohydramnion.
Consuming Grapefruit can interfere with effect.
Hypotension or othostatic Dysregulation may occur.
Indomethacin (Indocin ®)
Non-steroidal anti-inflammatory drug.
Third choice, Most commonly used.
Short – term treatment for up to 3 days.
May cause Oligohydramnion.
May cause premature closure of ductus arteriosus and/or Foramen ovale.
Effect and therapeutic use:
Inhibition of uterine contractions.
For delay of threatened preterm labor until EDD.
or until induction of surfactant with corticosteroids took effect.
To allow intrauterine fetal rescuscitation during labor.
Magnesium Sulfate
Effect and therapeutic use:
Used in treatment of preeclampsia.
Reduces contractility and reliefs cramping in smooth, skeletal and cardiac muscle.
Also reduction of nerve velocity in central nervous system.
Common parenteral dose is 4 gram over 30 minutes via infusion pump.
Antidote for side effects of Oxytocine treatment.
Side effects:
Generalized muscle weakness, hyponatremia, fluid and electrolyte imbalance
Respiratory depression and respiratory arrest!
(At risk if Patella reflex is depressed)
Increased risk of pulmonary edema if used along with beta – adrenergics
Contraindications:
Renal failure, Pulmonary edema, Chronic heart failure, CNS disease
Fetal anomaly/death.
Special considerations:
Infusion rate is adjusted by urine flow of at least 30 – 50 mL/hour
Breathing rate has to be at least 16/min. prior to application of additional dosages
A breathing rate < 12/min. requires physician to be notified.
Serum magnesium level have to remain in normal range 4 – 7 mEq/L
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Antidote calcium gluconate has to be available at bedside at all times!
-RH0(D) Immune Globulin (RHOGAM) -
Effect and therapeutic use:
Avoidance of Anti – D Antibody in Rhesus negative women giving birth to Rhesus
positive infants. To be administered within 72 hours prior to potential contact of both
blood types (labor) and at any time of a new potential contact unless mother has build up
Rh – antibodies meanwhile.
Contraindications:
Allergies against human immunoglobulines.
-Lung SurfactantsBeractant (Survanta®), Olfosceril palmitate (Exosurf®)
Effect and therapeutic use:
Lowering alveolar surface tension in preterm neonates to prevent respiratory distress.
Applied by intratracheal tube. Procedure may lead to brief reduction of oxygene
saturation and bradycardia.
Betamethasone (Celestone ®)
Effect and therapeutic use:
Indution of surfactant synthesis to prevent RDS in neonatal preterm children.
Administered between 28 – 32 weeks of gestation if labor can be delayed by 48 hours.
Ice daily i.m. injections. Typical steroid side effect pattern.
Phytonadione Vitamin K1 (PROPHYLACTIC TREATMENT)
Used for Induction of the synthesis of coagulation factors II, VII, IX, X in newborn liver to
prevent neonatal hemorrhage prior to onset of own synthesis. IM injection at time of
delivery.
-Physiological changes during postpartum period-
Involution
Reduction of uterus due to ongoing contractions occluding inruterine blood vessels.
Puerperium
Timeframe of 6 weeks after delivery in which the uterine involution occurs under normal
circumstances.
Boggy uterus
Interrupted contractions make it soft and relaxed, likely to cause hemorrhage.
Lochia
Blood and debris following delivery. Increased by exertion or fetal distress. Undergoes
physiological color changes as follow:
•
•
•
Rubra: 1 – 3 days, musty odor, red, small clots, , nickel size), contains blood,
mucus, decidua cells, epithelial cells, leukocytes, meconium, lanugo and
vernix caseosa.
Serosa: 4 – 10 days, watery, pink – brownish, odorless, also containing bacteria
Alba: 11 – 21 days (up to 6 wks in lactating women)
Yellow to white, slightly stale odor. Contains Cholesterol
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Involution enhancing factors:
Breast feeding, uncomplicated labor and delivery, early ambulation, complete expulsion
of placenta and membranes.
Involution inhibiting factors:
Prolonged labor and delivery, anaesthesia, grand multiparity, retained placenta
fragments and membranes, full blader, infections, overdistended uterus.
Reoccurrence or increase of Lochia rubra is generally abnormal!
Afterpains
Caused by intermittent postpartal uterine contractions. More intense in multiparous and
breast feeding women.
Cervix
soft, irregular, edematous, multiple small lacerations of 2-3 cm after 1 week, touchable
after 1 week by fingertip permanent change from round, dimplelike to lateral slitlike.
Vagina
Smooth, edematous, multiple small lacerations. Perineal pain to resolve after 2 weeks
Estrogen postpartum = lubrification = painful intercourse.
Abdominal wall
Soft, flabby, increased muscle tone, striae, diastasis recti.
Cardiovascular system
Due to Diuresis and increased GFR the first 48 hours postpartum bear the greatest risk
for clients with heart diseases. BP usually remains unaltered. Temporary bradycardia
occurs within first 6-10 days. Increased fibrinogen for 1st postpartal week! = ESR =
DVT Risk . Temporary increase of WBC up to 30.000/mm3 considered as normal,
unless fast developing (within 6 hours) or accompanied by signs of infection.
Hemoglobin normalizes within 4 – 6 weeks. Hematocrit decrease indicates an increased
blood loss.
Urinary tract:
Generally increased UTI risk during pregnancy and postpartal period.
5 lbs weight loss due to 2000 – 3000ml diuresis within 1st 12 – 24 hours.
Full bladder increases risk of failure of uterine involution and postpartal hemorrhage.
Fluid loss also due to diaphoresis and increased perspiration.
Gastrointestinal:
Hunger, Thirst, Constipation (fear of defecation), Hemorrhoids.
Endocrine:
Delivery of Placenta causes drop of Estrogene and Progesterone.
Menstruation:
Mens resumes within 7 – 12 weeks . First postpartal cycle maybe anovulatory.
Ovulation and Menstruation resumes after 2 – 18 month in lactating women.
Lactation process:
Nipple stimulation
Oxytocin release
Prolactin release
production of milk and let
down reflexes (expression of milk by contractions of Alveoli of breast)
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Colostrum, first milk secreted, rich in protein and immunoglobulins
Engorgement (“Pre – milk”) on 2-3rd day after delivery as supply of blood and lymph in
the breast is increased and transitional milk is produced.
Mature milk after 2 weeks, watery, bluish, like skim milk
-Psychosocial changesBonding (Attachment) process: (3 phases)
1. Taking in phase ( 3 days)
2. Taking – hold phase (3-10th day)
3. Letting go phase (10 days – 6 weeks postpartum)
Engrossment (fathers absorption, preoccupation, interest in infant)
Postpartum blues maternal adjustment reaction.
Transient depression within first 2 weeks postpartum.
Related to hormonal changes. Experienced by majority of women to some extent.
-Postpartal nursing care-
Postpartal Assessments
Temp. > 100.4 F after first 24 hrs indicates infection.
Pulse 50 – 80 bpm. Tachycardia of 100 bpm or higher needs to be reported.
Respirations 16 – 24/min. BP, orthostatic Hypotension possible.
Breasts
Engorgement ?, tenderness ?,nipples intact ?
Uterus
Firmness, height of fundus, position of fundus in relation to midline of abdomen.
Wound inspection after episiotomy or caesarean section:
Redness, edema, ecchymosis, discharge, gap?
Bladder
Voiding within 8 hours mandatory, dysuria ?, bladder palpable ?
Bowel
Passage of flatus ?, distension ?, auscultation ?
Lochia
Type ?, Quantity ?, Amount ?, Odor ?
Haemorrhoids?
Present, aggravated ?
DVT?
Homan’s sign positive ? (dorsiflexion of foot) Pedal edema ? redness ?, warmth ?
Emotional status?
Bonding ? Maternal depression ?
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-Collaborative Management•
•
•
Keep bladder empty to ease uterine involution!
Massage / self massage boggy uterus.
Administer medication to support uterine involution:
Oxytocin (Pitocin), Methylergonovine maleare (Methergine), Ergonovine
maleate (Ergotatrate)
•
•
•
•
•
Apply ice to perineum wounds after episiotomy or perineum lacerations.
Encourage warm or cool bath within first 24 hours, as required from second day.
Teach perineal care.
Administer dermal anaesthetics or analgesics as required.
Advice on patient controlled aneasthesia or morphine epidural for caesarian
patients. Encourage stool observation and regulation.
Encourage nursing on demand, alternating 10 – 15 min per breast until infant led.
Assist with positioning for breastfeeding.
Assist with suppression of lactation.
•
•
•
(snug bra/breast binder continuously for 5 – 7 days,
avoid heat and stimulation, apply ice for 20 minutes four times daily)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Support awakening through the day.
Observe cultural specifications.
Gradual return to daily activities over 4 – 5 weeks.
Muscle strengthening
(Kegel exercises, chin to chest, knee rolls, lifting of buttocks)
Adequate nutrition (additional 500kcal./day for lactating mothers)
Administer prepregnancy diet if bottle feeding.
Encourage fluid intake of 2000 mL/day.
Ensure iron supply, improved with Vitamin C.
Encourage and praise self and child care
Encourage rooming in and presence of family members.
Advice that sexual activities can resume after lochia stopped, episiotomy healed.
Arrange contraception counseling prior discharge.
Advice that estrogen supply interfers with lactation.
Advice that refitting of mechanical contraceptives may be necessary.
Rhesus Prophylaxis to prevent sensitization of a Rh negative mother
Requirements:
•
Rh negative mother not sensitized.
•
Negative indirect Coombs Test due to lack of antibodies in maternal blood.
•
Rh positive newborn not sensitized.
Procedure:
•
RhO(D) Immunglobuline (i. e. Rhogam) once to prevent Rh sensitization.
•
300mg IM within 72 hours after delivery
In an acute hemolysis neonatorum an exchange transfusion
with 0 neg. blood may be considered.
Awareness of Neomycin Allergy if clients requires rubella vaccination!
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Rhogam and Rubella Vaccine need to be separated for at least 6 weeks to 3 months
if both are necessary (Danger of ineraction and reduced activity of Rubella vaccine)
Rhogam comes first!
Clients have to avoid pregnancy for 3 months after active Rubella Vaccine !
Warning signs of the postpartal period
•
•
•
•
•
•
•
•
•
•
•
Increasing or recurrent lochia rubra with clots
Temperaure > 100.4 F
Chills
Strong pain
Redness of breast
Redness of Episiotomy
Offensive smelling lochia
Dysuria, Urine retention
Calf pain, tenderness, redness or swelling
Chest pain
Breathing difficulties
-Newborn AssessmentApgar Score
Criteria for the adaptation of a newborn after 1 and 5 minutes.
Criteria:
1. Color
2. Heart Rate (Pulse)
3. Reflex Irritability (Grimace)
4. Muscle Tone (Activity)
5. Respirations
The expression of each criteria is described by a score of 0 – 2!
Results:
10 = no findings,
8,9 = nasopharyngeal suction, oxygen exposure needed.
4,5,6,7 = oropharyngeal suctioning, tactile stimulation, oxygen supply needed.
Collaborative Management
Maintain skin Temperature at 97.7 – 98.6 F = 36.5 – 37.0 C, Flexed position
decreases surface area,Temperature to be taken axillary and from skin.
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Vital signs
•
HR 120 – 160 bpm, irregular.
•
Average blood pressure is 80/40 mmHg.
•
Functional murmurs possible.
•
Assessment of heart rate by palpating apical pulse for one full minute.
•
Respirations 30 – 60 breaths/minute, (more or less indicate a problem!)
•
Temp. 97.7 – 98.6 F = 36.5 – 37.0 C
•
Heat loss occurs due to
o
convection
loss to cooler air currents
o
radiation
from body to cooler surface
o
evaporation
from wet skin through sweating
Head
Size:
one quarter of body surface with molding fontanels.
FOC Frontal occipital circumference:
32 – 27 cm (12.5-14.5 inches) = 2 cm > chest circumference.
Caput succedaneum:
Birth trauma, swelling under scalp (disappears in days)
Cephalhematoma:
Blood between cranial bone and periosteum (disappears in 6 weeks)
Fontanel closing:
Posterior at 8 – 12 weeks, anterior at 18 months.
General assessment:
Symmetric movement of face present as a sign of a facial nerve lesion?
Subconjunctival hemorrhage ? (Will spontaneously disappear in weeks)
Eyelids edematous ?
Tear glands do not become active prior to 2 month of age.
Chest clear and symmetric?
Nose: Clear with flat bridge ?
Mouth: Hard palate intact ?
Heart
Auscultation
At border of left sternum. Murmurs present? Heart rate?
Point of maximum pulse lateral to midclavicular line at 3rd to 4th intercostal space.
Breast
Nipples must be symmetrically located.
White discharge or extra small nipples possible as a normal finding.
Abdomen
Movement with respirations? Bowel sounds present?
Umbilical cord
Clamped?, no foul odor?
Genitalia
Labia majora should cover labia minora and clitoris.
Testes should be palpable in scrotum.
Location of urethral meatus must be centrally located on surface of glans penis.
Vernix caseosa on labia minora is indicator for term gestational age.
Pseudomenstruation due to maternal hormones possible.
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Hips
Barlow’s maneuver
Adduct leg over hip leads to a snap when femur leaves actabulum
Ortolani’s maneuver
Hip abducted and lifted leads to a click if femur enters acetablum
Arms
Grasp reflex: Grasping of object placed in hand
Non movement = s/o Erb-Duchennes paralysis or Erb’s palsy.
Nails present?
Legs
Pulses present?
Back
Scoliosis? Pilonidal Dimple?
Skin
Acrocyanosis may be present as a physiological finding.
Milia, obstructed secretions of sebaceous glands may be present.
Mongolian spots, bluish pigmentation buttocks in Asian, African and Hispanic children.
Lanugo, fine hair on shoulders, forehead, cheeks develops from 20th gestational week.
Harlequin’s Sign = one side of body red, other pale due to vasomotoric disturbance.
Gestational age assessment “Ballard Tool”
Based on six physical and six neuromuscular signs:
Outcomes:
Small, appropriate, large for gestational age SGA, AGA, LGA
Neuromuscular assessments may need to be repeated after 24 hours since
neuromuscular system may be unstable due to labor and birth.
Physical maturity is always stable from birth.
Lanugo is less the higher gestational age is, minimal at term birth.
Plantar surface covered by 2/3 in crease in first 12 hours.
Breast tissue 5 – 10 mm between forefinger and middle finger.
Nipples aised above skin level?
Testes descended ? Scrotum pendulous, covered w. rugae?
Labia majora cover labia minora and clitoris between 36 – 40 weeks of gestational age.
Newborn reflexes
Rooting reflex: infant turns to stimulated side to suck
Sucking reflex: starts when lips get stimulated
Epstein’s pearls: small white specks, cysts, tongue not protruding
Tonic neck reflex: On turning of head, extremities on same side extend,
opposite extremities flex.
Moro reflex: Arms are extending brisk and symmetrical when newborn is loosing
support in neck in a supine, vertical position.
Babinski Reflex: Fanning and extension of toes if sole is stroked,
disappears at 12 month. May reoccur in adults with CNS damage.
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-Physiological changes and needs in the newborn periodCardiovascular
lungs expand
decreasing pulmonary vascular resistance.
First breath
Clamping of umbilical cord
increase of systemic vascular resistance
increasing aortic blood pressure
closure of ductus arteriosus of fetal circulation
between pulmonary artery and arch of thoracic aorta.
Foramen ovale between left and right atrium functionally closes in 1 – 2 hours and
anatomically in few weeks to 1 year.
Ductus venosus closes and forces perfusion of liver
Low 02 , high PCO2, low pH immediately after birth common due to a
temporary peripartal Asphyxia.
Newborns are obligatory nose breathers !
Signs of respiratory distress
(increased breathing rate, audible grunting, nasal flaring, intercostal retractions)
color of skin, oral area, extremities ?
Neurological
Three Periods of reactivity
1.
2.
3.
First period of reactivity:
30 – 60 minutes after birth, awake and alert, nursing and attachment behaviours.
sleep phase , sleeps minutes to 4 hours.
2nd period of reactivity: awakes from sleep, lasting 4 – 6 hours, close observation
for changes of color, heart rate and breathing necessary.
Musculoscelettal
Extremities with full range of symmetrical motion?
Gastrointestinal
Digestive enzymes active from 36 weeks of gestation
No pancreatic enzymes present at birth = poor absorption of digestion and fat
No proper saliva production until 3 month of age
Regurgitation, spitting up due to immature lower oesophagel sphincter
Meconium
First stool, excreted within 24 hours. Contains bile, epithelial cells, amniotic cells.
Kidney
Low GFR
high urinary production
Redish diaper stain from uric acid.
lower metabolism of drugs.
Hepatic
Excess of unconjugated Bilirubin derives from hemoglobin from broken down blood cells.
Permeates to extravascular tissues. Binds to albumin and is eliminated in stool.
Increased feeding is helpful.
Collaborative care:
Assessment of output (weigh diapers 2 – 4 hourly)
Monitor adequate Hydration (Specific gravity, turgor of skin)
Mask for Phototherapy
Bili stool 6 times in 24 hours
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Skin
Plethora = red skin = s/o Hematocrit > 65 , should be evaluated,
Polycythemia = at risk for Hypoglycaemia , cyanosis, resp. distress, jaundice,
bright red, akrocyanosis due in case of immature capillary system
Immune System
Only IgG crosses Placenta and provides passive Immunity from mother !
Own Antibody production starts from three month of age
IgA is only available in breast milk, own production starts at 4 – 6 months.
Breast fed children are protected from influenza, mumps and chickenpox !
Newborn Nutrition
90 – 120 kcal/kg/24 hr food supply
140 – 160 mL/kg/24 hr fluid supply
8 – 10 wet diapers daily
Formula milk does not have immunologic properties and digestibility of human milk
The American Academy of Pediatrics recommends to feed
breast milk or formula until 12 month of age.
Soy formulas are necessary if cow milk and lactose intolerance is present!
Preparation of Formula
Aseptic sterilization: Supplies boiled in water for 20 minutes
Terminal sterilization: poured in unsterilized bottles and sterilized together
for 25 minutes
Bottles are not meant to be warmed in a microwave because of hotspots
and change of nutritional composition through heat !
Do not lay infant down with bottle!
Breast feeding
Steady milk supply until 4th postpartal week.
Lactating breast never empties if stimulated continuously.
Supply only increases through feedings if transfer is successful (swallowing occurs)
Feeding on demand when hunger cues are displayed
(rooting, sucking on fists, clenched fists, crying is last expressed sign of hunger)
Night feedings necessary through first 6 – 8 weeks.
Sore nipples caused by incorrect position.
Foremilk produced and stored between feedings.
Hindmilk produced at the end of feedings.
Weight development
Normal daily weight gain 0.5 – 1 ounces per day.
Weight doubled by 6 month of age.
Weight triples by 1st birthday.
Eye prophylaxis
Erythromycin 0.5 % and tetracycline 1 % ophthalmic ointment to be administered
immediately within 1st postpartal hour to prevent ophthalmia neonatorum caused by
Neisseria gonorrhea and Chlamydia trachomatis.
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Hemorrhagic disorder prevention
0.5 – 1.0 mg Vitamin K IM once (Aqua-Mephyton)
Phenylketonuria (PKU) Screening
Child has to be fed for at least 24 hr prior to testing.
Test prior discharge and within 7-14 days.
Cord care - Cord care practices vary and are not evidence based!
Keep dry
Remove clamp after 24 hours
Do not cover in diaper and submerge in water (do sponge bath)
Falls off in 7 -14 days
Clothes
To be worn in layers and washed separately.
Foreskin
Does separate from Glans until 3-5 years of age
Do not force for cleansing
Daily retraction once separation has occurred
-Complicated postpartum carePostpartum haemorrhage:
Early postpartum haemorhage with over 500ml blood loss within first 24 hours due to
•
Uterine atony
Lack of contraction and descend of uterus after birth.
Predisposing factors are circumstances that provide overdistention of uterus e.g.
augmented birth, use of tocolytics, oxutocin induction, general anesthesia.
Requires immediate intervention with Oxytocin (Pitocin) IV , Ergonovine
(Methergine), Prostaglandines (Hemabate)
•
Lacerations of birth channel.
•
Vaginal, vulva hematoma
•
Disseminated intravascular coagulopathy DIC
Typically related to circumstances which contribute to a delayed labor as well as
to placental damage in utero.
Late postpartum hemorrhage
1-2 weeks after childbirth may be caused by:
•
Subinvolution = Failure of uterus to regain previous size and position.
Marked by a persistent lochia rubra.
Assessments of vaginal bleeding, shock signs, amount of blood loss, bladder function,
quarterly within first hour then every 30 minutes !
Postpartum infections
Multiple risk factors, most common after caesarean section, PROM and any intravaginal
manipulations
Endometritis
Parametrial cellulites
Peritonitis
Septic pelvic thrombophlebitis Bacteremia and septic shock
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Summary of possible clinical findings
Temperature elevation up to 105 F, abdominal pain, uterine tenderness, subinvolution,
HR , BP , offensive smelling lochia, Ileus / subileus, excessive thirst, backache, chills
WBC Count, ESR, CRP , renal output
Wound infections
Assessments 8 -12 hourly, especially after episiotomy:
Redness, edema, ecchymosis, discharge, approximation of wound edges.
Breast infections (Mastitis)
Most commonly caused by Streptococcus species, Staphylococcus aureus, Escherichia
coli bacteria, Candida albicans along with cracked nipples, poor hygiene and tight
clothing.
-Complicated newborn care-
Characteristics for high risk newborns
Maternal Diabetes, Opiod analgesics during labor, fetal asphyxia (urges fetus to pass
meconium into amniotic fluid), difficult labor, multiple gestation pregnancy, preterm or
postterm delivery, congenital anomalies and infections.
Small for gestational age SGA
Birth weight below 10th percentile = < 2500 grams or 5 pounds and 8 ounces
loose, dry skin, little scalp hair, hypoglycemia and weak cry.
Large for gestational age LGA
Birthweight above 90th percentile = > 4000 grams or 8 pounds and 13 ounces
Primarily infants of diabetic mothers, Hyperbilirubinaemia (> 13 – 15 mg/dL)
birth injury, clavicle fracture, shoulder dytocia, Erb – Duchenne paralysis,
Hypoglycemia (Blood Glucose < 30 – 35 mg/dL) Hypocalcemia, RDS
Apgar Score < 6 at 1st minute, or 7 at 5 minutes.
Preterm signs: Lanugo, Vernix caseosa, fused eyelids, crease over soles
General care setting for high risk newborns include:
•
UVL umbilical venous line
•
UAL umbilical arterial line
•
ABG arterial blood gas analysis
•
Gavage tubes 5 – 8 Fr.
Maturity Problems
Minimum gestation for survival is 23- 24 weeks of gestation.
Respiratory distress syndrome.
Maternal risk factors: smoking and placental damage.
Fetal risk factors: multigestation and infections.
Poor lung maturity due to surfactant deficiency.
RDS within 24 – 48 hours after birth
Bronchopulmonary dysplasia
(substernal retractions, inspiratory grunting, nasal flaring)
Poor thermoregulation due to underweight and muscular weakness.
Liver immaturity
Immune incompetence
Feeding problems
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Renal impairment
Liver impairment with lack of coagulation factors and fragile cerebral capillaries
leading to intraventricular hemorrhage IVH.
Cardiovascular weakness
Retinopathy of prematurity ROP due to high concentrations of O2
Prophylaxis by maintaining minimum PaO2 of 50 – 70 mmHg
Necrotizing Enterocolitis NEC, because of blood shunt due to neonatal distress
Apnea and bradycardia due to immature circulatory regulation.
Postmaturity problems
For infants born after 42 weeks of gestation
Caused by placental insufficiency increases risk of intrauterine asphyxia and meconium
aspiration syndrome MAS
Birth Trauma
Facial paralyis, commonly self resolving.
Erb-Duchenne paralysis
Affecting brachial portion of upper arm.
Infant holds arm rotated inwards with stretched elbow, Moro reflex on affected side
negative and grasp reflex intact. Requires immobilization to reduce additional stress on
damaged structure.
Fractures, most common in descending order. (clavicle, skull, humerus, femur)
Heal without surgery
Asphyxia
Inadequate tissue perfusion due to decrease of FHR.
Signs: pH in labor < = 7,20, Apgar score 4-7, meconium passage.
Requires inflation of 100 % O2 at a breathing rate of 40 – 60/min.
HR hast to be minimum 60 – 80 or requires compressions.
Withhold oral feeding in RDS if breathing rate is 60 or more.
Position neonate supine or side lying to suction meconium from airways.
Cerebral palsy
Altered body movement due to a spastic paralysis of skeletal muscles.
Most commonly caused due to a fetal intra – or peripartal trauma causing, fetal
hypoxemia or hemorrhage. Paralysis may be mildly expressed and not detectable from
the beginning. Severe cerebral palsy typically shows uncontrolled athetotic (“snake like”),
movements of the affected limbs. Condition appears hemiplegic, diplegic or tetraplegic
and can involve swallowing difficulties as well as speech problems. Mental retardation
occurs in 25 % of children with CP. Condition is not progressive. Treatment focuses on
improvement and assistive treatment of impaired functions.
Congenital “TORCH” infections
Toxoplasmosis, Others (Hepatitis), Rubellla, Cytomegalie and HIV
Common STD’s
Syphillis, Gonorrhea, Chlamydia, Candidiasis and HIV
Neonatal Sepsis
Mainly due to Beta hemolytic streptococcal vaginosis.
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-Birth Defects-
Hypospadia, Epispadia
Meatus of urethra in boys is not centrally located at the end of the penis but either on top
(epispadia) or underneath (hypospadia) of the penile shaft. Surgical intervention is
mostly performed by using praeputium kin to cover initial needs to take place prior to
development of urine continence and before 18 months of age.
Bladder exstrophy
Exposure of urinary bladder due to a missing lover abdominal and anterior bladder wall.
Commonly accompanied by an epispadia in boys.
Surgical correction is immediately necessary after birth to avoid intraabdominal
infections. Other defects of comparable origin are:
Omphalocele
Peritoneum with intraabdominal content herniates through umbilical cord due to failure of
abdominal wall to close in embryonic period.
Gastroschisis
Bowel herniation without peritoneal sac parallel to abdominal rectus muscles.
Surgical repair may not be possible in all cases.
Chordee
Downward curvature of the penis, mostly accompanied by a hypospadia of the penis.
Treatment required prior to 18 months of age to ensure timely development of urine
continence.
Cryptorchism
Delayed or absent descensus of testicle at term birth. Most cases require observation
only and resolve spontaneously within first year of life. If persisting sexual maturity and
fertility are delayed or insufficient. Clients also have a higher risk for testicular torsion.
Surgical treatment is performed by orchidopexie, a ligation between the lower testicular
pole and the inner lining of the scrotum.
Biliary atresia
Progressing inflammatory stenosis of intra – and extrahepatic bile ducts starting from
birth. Cholestasis leads to liver cirrhosis over time. Symptoms and prognosis are
identical to primary biliary cholangitis. Surgical biliodigestive anastomosis between the
common bile duct and the duodenal wall may lead to a temporary bile drainage.
Medication treatment is not available. Only achievable cure is liver transplant.
Aggravating factor is a possible early brain damage due to a constant hyperbilirubinemia.
Cleft palate
Birth defect of hereditary of teratogenic origin. Midline defect caused by failure of fusion
of tissues in late embryonic development period. Defect may be involving or reduced to
upper lip, soft palate, hard palate and nasal distortion. Condition may be uni - or bilateral
expressed. Surgical correction has to take place no later than 18 months. Clients require
feeding in strict upright position prior to correction to avoid aspiration of fluids and food.
Postoperatively clients must not have any oral feeding, pacifiers, tooth brushing or
straws. Drinking from a cup is tolerable.
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Congenital diaphragmatical hernia
Protrusion of abdominal organs through an abnormal diaphragmatical opening into the
thoracic cavity. Clinical symptoms correlate with the intensity of organ protrusion from
mild to severe. Clients may appear almost asymptomatic in early childhood but will
develop cardial and respiratory symptoms by further growth or failure to thrive. Main
complication of an undetected CDH is a compression of heart and lungs and / or a
possible life threatening bowel incarceration. Clinical outcomes can include cardail and
respiratory failure as well as peritonitis. Surgical correction may require a simultaneous
laparatomy and thoracotomy.
Pyloric stenosis
Congenital hypertrophic gastroduodenal sphincter inhibits gastric emptying.
Symptoms mostly arise or worsen by increase of intake of breast or bottle milk increases
and occur as sudden imperative, projectile vomiting shortly after feeding.
Affected childen quickly develop dehydration and metabolic alkalosis due to repeated
vomiting. Hypertrophic pylorus may be palpable through abdominal wall. Surgical
sphicterotomy is required. Oral feedings can resume 6 hours after surgery.
Congenital megacolon / aganglionosis (Hirschsprung’s disease)
Lack of ganglion cells of the parasympathetic nervous system of the colon rectosigmoideum. Absent autonomous innervation results in partial bowel paralysis with stool
accumulation and disability to defecate. Surgical treatment is usually performed in two
steps. Starting with an initial colostomy soon after diagnosis is made and a
reanastomosis after resection of the aganglionic segment by the age of 2.
Hypopituitarism
Failure to thrive caused by a deficiency of growth hormone from pituitary gland.
Affected children will appear with a growth retardation below third percentile by the age
of 1 year. Symptoms depend on agents age at onset and severity of GH Deficiency.
Primary appearance is determined by delayed or permanently interrupted physical
development.
Infants: Micropenis, no descend of testicles, hypoglycemia due to compensating
hyperinsulinemia and jaundice.
Children: Obese, hyperglycemic, retarded musculoskeletal development.
Proof of diagnosis by assessment of low levels of IGF – 1 ( insulin – like growth factor )
Treatment requires supplemental therapy with subcutaneous growth hormone injections.
Psychological support of children and parents.
Phenylketonuria (PKU)
Inherited autosomal recessive deficiency of the liver enzyme phenylalanine hydroxylase.
Required to metabolize phenylalanine into tyrosine. Healthy appearance at birth, Musty
body and urine odor, blond hair, blue eyes and fair skin. Failure to thrive, mental
retardation, seizures.
Laborarory findings: Phenylalanine level Tyrosine level
Melanine deficiency
Dopamine and Tryptophan
Mandatory preventive Guthrie Test for all newborns in the United States performed after
the first 24 hours of breast milk or formula nutrition but within the first seven days after
birth. Main treatment is a phenylalanine free or restricted diet to keep phenylalanine
blood level below 2 mg/dl.
Muscular Dystrophy (MD)
Inherited sex linked progressive muscular weakness from birth.
Different types affect diverse muscular areas. Most common form is MD Type Duchenne.
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Intellectual development may not be necessarily impaired. Abnormal muscular
weakness of skeletal muscles. Altered muscle tension also leads to a deforming skeletal
growth.
(e. g. bowed legs, hyperlordosis, hyperkyphosis) Delayed motoric development.
Depending on severity of physical impairment main goal is to increase physical activity
by regular physical therapy and supply of appropriate orthopedic devices. Corrective
orthopedic surgery may be involved in treatment plan as well in some cases. Lethal
outcomes prior to the onset of puberty are common, mostly due to affection of auxiliary
breathing muscles.
Clubfoot
Inherited uni – or bilateral congenital foot deformation of unknown cause but strong
familial occurrence.
Defect may appear with one or a combination of several of the following deformities:
•
Plantarflexion
•
Dorsiflexion
•
Varus deviation
•
Valgus deviation
First line treatment is serial dressing with castings starting from newborn period over 8 –
12 weeks. Active and passive supportive physical therapy to improve ROM. If
unsuccessful, a surgical realignment of the foot bones is required.
Congenital hip dysplasia
Mostly unilateral congenital deformation of the acetabulum. Cause is unknown bur
condition may be influenced by intrauterine breech positions or increasing size of the
child. Screening examinations are performed in well child examinations in newborn
period. Single sided shortened leg, inward or outward rotation of hip joint, limited
abduction of hip, Ortolani sign to be assessed and positive between 2 – 3 month of age,
clicking sound during abduction of hips indicates dislocation, delayed start of walking
Positive Trendelenburg’s sign:
If affected hip is bearing the full body weight while client is standing on one leg only,
the pelvis will tilt towards the healthy side due to insufficient gluteal muscles on the side
of the affected hip.
Abduction casting (Pavlik harness) for newborns and toddlers up to 3 months of age
over several months to support the development of an acetabulum impression in the
pelvic bone. Older childrem may require surgical intervention to rotate hip bone in an
anatomical correct position towards the acetabulum space. While correcting treatment is
performed motoric development of upper extremities should be supported.
Untreated or undiagnosed hip dysplasia may lead to delayed and / or disturbed motoric
development and early osteoarthritis of the hip.
Osteogenesis imperfecta
Inherited autosomal dominant congenital defect of bones and connective tissue due to
an insufficient synthesis of collagen.
High occurrence of pathological fractures even from birth.
Clients appear with blue sclera of eyes, highly vulnerable soft skin, Highly flexible skin
and joints, conductive hearing loss.
Condition is incurable.
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Medication includes Biphosphonates, calcitonin and growth hormone to increase density
and growth of bones. Main importance has avoidance of fractures by handling affected
children with special care.
-Milestones of Human Growth and DevelopmentPattern of Growth and Development
Cephalocaudal Development, Proximodistal Development and Differentiation.
Factors influencing Development
Genetics, Nutrition, Prenatal factors, Family and Community and Cultural conditions.
Developmental Milestones
Milestones of fetal development (Prenatal Development)
4 wks: fetal heatbeat detectable
8 weeks: all organs formed
12 wks: fetal heart sounds audible by Doppler
16 wks: gender detectable
20 wks: heart audible with fetoscope, quickening, hair, eyebrows, eyelashes developed
24 wks: 1lbs 1 oz, increasing activity, respiratory movement
28 wks: Surfactant production, two thirds of final size
32 wks: finger and toenails formed
38 wks: fills uterus, gets maternal antibodies
Infant Growth and Development
Neonatal period ( 1Month )
Weight: 6 to 8 lbs, gaining 5 – 7 oz weekly in first 6 months.
Height: 20 in, growth 1 inch monthly for first 6 month. Head circumference: 33 – 35 cm
Growth during infancy (1 – 12 month)
Weight doubles in 6 month, triples in 1 year. Height increases 50 % 1st year
Head circumference 33 – 35 cm , greater than chest circumference
Newborn Reflexes
Moro (elicitated by loud noise or sudden change of position), Tonic neck (fencing
position). Gag, cough, blink, papillary reflex, Grasp reflex, Rooting reflex(side of mouth
touched = infant turns to this side), Babinski reflex, Parachute reflex
Landau reflex,Labyrinth reflex, Body righting reflex
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Piaget’s Theory on cognitive development (4 stages)
1. Sensorimotoric development (birth – 2 years)
Infant learns through senses and motor activity, Progress reflex activity
simple
repetitive behaviors
imitative behaviors Develops sense for cause and effect,
curiosity, experimentation, exploration result in learning process, Object permanence
is fully developed.
2. Preoperational (2-7 years)
Forms symbolic thoughts, exhibits egocentrism, language development, does not
understand conservation becomes more social. Concentrates on only one
characteristic of an object at a time.
3. Concrete operational (7-11 years)
Thoughts increasingly logical and coherent ability to concentrate on several things
simultaneously (decentralization), concrete thinkers, right or wrong, no “gray” areas
problem solving skills, conservation skills.
4. Formal operations (11 years to death)
Ability to logically manipulate and abstract unobservable concepts with a scientific
problem solving approach.
Erikson’s theory of psychosocial development
Trust v. mistrust (birth – 1 year)
LOVE AND CARE
Autonomy v shame and doubt (1-3 years) FREEDOM
New skills used for autonomy, symbolizing independence
Leads to upbuild of willpower and self – confidence or self doubt if critized.
Initiative v guilt (3-6 years) ENCOURAGEMENT
Initiative is demonstrated by carrying out a plan or an action
Leads to direction and purpose or guilt if inhibited.
Industry v inferiority (6-12 years) INTRODUCTION
Development of new interests and involvement in activities. Develops confidence and enjoys
learning, being compared to others may lead to feeling inadequate and inferior if expectations are
too high.
Identity v role confusion (12 – 18 years)
Marked by puberty changes. Peer group very important. Self definition, definition of family, peer
group and community. Leads to self identity and optimism or role confusion.
Intimacy vs Isolation (early Adulthood)
Strong sense of self accomplishment. Searches for meaningful relationships
Generativity vs stagnation (middle Adulthood)
Sense of productivity. Reaches and attains goals. Critical self – review.
Lack of success leads to stagnation.
Ego integrity vs despair (older Adulthood)
Acceptance that life has passed and of current stage. At peace with self.
Identity apart from work and acceptance of death.
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Gross motor development
4 months: controls head
rolls from back to side
5 months: rolls from abdomen to back
6 months: rolls from back to abdomen
8 months: sits alone without support
9 months: stands holding on
10 months: crawling
11 months: creeps
12 months: cruising, walking while holding on and sits down from upright position
Fine motor development
1 month: hand predominantly closed
3 months: grasping desire
5 months: two handed grasping
6 months: holds bottle, grasps feet,
7 months: transfer from hand to hand
10 months: pincer grasp
12 months: neat pincer grasp
Sensory development
Birth: Hearing and touch well developed. Prefers human phase
2 months: locating sounds and smiles
6 months: taste preferences
7 months: responding to own name
1 year: four words
Nutrition
6 months: starting solids, sooner start make allergies more likely.
Start with iron fortified rice cereal.
Eruption of lateral incisors.
Weaning from breast to bottle.
Introduction of 1 : 1 diluted juices, fruits, meats,vegetables, one food each week.
Solids only by 12 months
No more than 32 oz of formula per 24 hours for infants to avoid iron deficiency !
Toddler Period from 1 – 3 years of age
Physical Development
4 times birth weight by 2 ½ years
50 % of adult height by 2 years
Head circumference 10.5 – 20 inches by 2 y
90 % of adult size brain by 2 years
Anterior fontanella closes by 18 month !
Gross motor development:
15 months: walks without help
18 months: jumps in place
24 months: goes upstairs (2 feet per step), Runs fairly well
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Fine motor development:
15 months: uses cup well and builds tower of blocks
24 – 30 months: holds crayon with fingers
30 months: good hand finger coordination
36 months: copies a circle
Sensory development:
15 months: binocular vision well developed
12 months: knows own name
2 years: follows simple directions
18 months: identifying geometric forms
18 – 24 months: short sentences
3 years: remembers and repeats three numbers
2 years: speaks 300 words
Object permanence = knowledge that a person or an object continues to exist when not
seen or heard.
Ritualism, toddlers need to maintain sameness and reliability.
Nutrition
Growth slows at 12 – 18 months
Picky and ritualistic eating habits
Avoid large pieces of food
Ability to feed self completely by 3 years
About 20 deciduous teeth by 2.5 – 3 years
Teach good dental practice
Play
Imaginative, self belief play (i.e. imitation of an adult)
blocks, wheels, toys, puzzles, crayons.
Repetitive stories and short songs with rhythm.
Preschool Period from 3 – 5 years of age
Physical Development
Weight + 5 lbs/year
Height + 2-3 inches / year
Motor Development
3 years rides Tricycle
4 years skipping and hopping on one foot
5 years throws and catches ball, balancing on alternate feet, 2100 words,
increased strgth and refinement
Nutrition
Similar to Toddler
Food preferences, influenced by others
90 kcal/kg/day
Good dental hygiene
Safety
Belt positioning booster seat
Teach safety measures
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Play
Imitating same sex
Toys to promote motor and coordination skills
Sing along songs with rhythm
Schoolage Period from 6 – 12 years of age
Physical Development
Weight + 5 lbs/ year
Height 1-2 inch / year
20/20 vision by 7 years of age
Nutrition
Obesity Risk
Loosing first deciduous teeth at the age of 6.
All permanent teeth but the molar teeth are present at the age of 12.
-Vaccinations-
Active Immunity
Vaccine from live, attenuated or dead and inactive viruses or bacteria induces antibody
production but no infection. Not indicated for pregnant women or those who are likely to
get pregnant within 3 months after vaccination. May not be indicated in HIV.
Passive Immunity = administration of immunoglobulines.
General considerations
Vaccines have to be stored on center shelf of body of fridge to establish stable
temperatures between 2 – 8oC / 35 – 46o F. Simultaneous vaccinations are administered
contralaterally either in vastus lateralis ( newborn to preschool age) or deltoid muscle
(schoolage to adulthood). Documentation necessary. Be aware of adverse reactions
now and in history (VAE Report) Do not vaccinate if client is moderately or severely ill or
prior to one month after immunosuppressing therapy. Delays of up to 90 days are
necessary if corresponding hyperimmunglobulin has been administered. Common
vaccination side effects are malaise, achiness, temperature and redness of injection site.
Hepatitis B
Minimum Distances of injection: 0 = Birth – 1 Month – 3 Months (minimum distance)
3rd dose not to be administered before 6 months of age. Intramuscular injection.
Infant born by HbsAg positive mother requires simultaneous Hepatitis B Immunglobuline.
Do not administer Hepatitis B vaccine in cases of Bakers yeast allergy!
DPT (Diphtheria, Pertussis, Tetanus)
Diptherie, Tetanus (“lockjaw”) = inactivated (killed) vaccine
Pertussis = acellular vaccination
6 injections from 2 months to 6 years. 1 booster for adolescents and adults.
Intramuscular injection.
Management of acute anaphylactic reactions
Epinephrine 1:1000 and resuscitation equipment has to be in reach for immediate
availability. Administration of 0.01ml/kg body weight per single dose once order was
obtained. To be repeated every 10 – 20 minutes.
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Haemophilus influenzae Type B
Used to be most common cause of meningitis in children < 1 month of age.
Also causing Epiglottitis, sepsis,septic arthritis.
Vaccination at 2-4-6-12-15 months of age. Intramuscular injection.
Not needed over 5 years of age unless client has special health risk.
Inactivated Polio Vaccine IPV
Trivalent vaccine, containing all three components of Polio.
Inactivated, killed vaccine, therefore requiring frequent boosters due to a less intense
immune response. Vaccination at 2-4 (6-18) months and 4-6 years of age. Intramuscular
injection.
Do not administer IPV to clients with allergies against
Neomycin, Streptomycin and Polymyxin B!
MMR Vaccine
Live, attenuated vaccine! Intramuscular injection.
Vaccination at 12-15 months + 4-6 years of age. Yellow fluid.
Advice client to avoid pregnancy for 3 months after vaccination.
!Active vaccination are not supposed to be administered if immune serum globulin or
blood products were administered 3-11 months earlier!
Do not administer to clients with allergies
against neomycin, eggs and gelatine!
Varicella Vaccine (Varivax)
Live, atennuated vaccine ! Vaccination at 12-18 months once or as postexposure
prophylaxis. Intramuscular injection.
Pneumococcal Vaccine PCV
Vaccination at 2-4-6-12-15 months of age. Intramuscular injection.
Active against Streptococcus pneumoniae leading cause of meningitis in the U.S !
Recommended for all children from 2 – 23 months of age. Clear colorless liquid.
Highly recommended for children in daycare, children with immunosuppression, cardiac
illness, diabetes, sickle cell anemia and asplenia.
Not to be administered to clients with a hypersensititivity against Diphtheria toxoids!
Hepatitis A Vaccine
Inactivated, killed vaccine.
Can also be used as a postexposure Prophylaxis along with immune globulin.
2 doses after 24 months of age and 6 months apart.
Administered by intramuscular injection.
Dosage for clients < 18 years: 0.5 ml, > 18 years: 1.0 ml
Influenza, trivalent inactivated vaccine
Inactivated, killed vaccine.
Vaccination effect lasts 1 year.
To be administered once yearly in early autumn by intramuscular injection.
Inranasal vaccine available for children from 5 years and older.
Intramuscular 0.25 ml from 6-23 months, 0.5 ml > 3 years.
For children younger than 12 years of age dosage has to be splitted
in two injections 4 weeks apart.
Do not administer to clients with allergy to eggs !
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Meningococcal vaccine
Respiratory infection can lead to meningitis, DIC, septic shock and death.
No experience on safety in pregnant women.
Vaccination at 2 years and at 11-12 years of age for clients at special risk due to
asplenie, immune deficiencies, entering risk countries, colleges and universities.
Duration of effect unknown. Intramuscular injection.
Recommended Immunization Schedule for Persons aged 0 – 6 Years
United States 2010
Birth:
1 Hepatitis B
1st Month:
nd
2 Hepatitis B
2nd Month:
st
1 Rotavirus, Diphtheria, Pertussis, Tetanus, Pneumococcal vaccine,
Inactivated Poliovirus
4th Month:
nd
2 Rotavirus, Diphtheria, Pertussis, Tetanus, Pneumococcal vaccine,
Inactivated Poliovirus
6th Month:
rd
3 Rotavirus, Diphtheria, Pertussis, Tetanus, Pneumococcal vaccine
12th – 15th Month:
th
4 Hepatitis B, Diphtheria, Pertussis, Tetanus, Pneumococcal vaccine,
2ndInactivated Poliovirus,
1st Influenza (yearly), Mumps, Measles, Rubella, Varicella, Hepatitis A (2 doses)
From 2nd to 6th year:
th
5 Diphtheria, Pertussis, Tetanus, Inactivated Poliovirus,
2nd Mumps, Measles, Rubella,
1st Varicella
st
Recommended Immunization Schedule for Persons aged 7 – 18 Years
United States 2008
11 – 12 years:
6th Diphtheria, Pertussis, Tetanus
1st Human Papiloma Virus HPV (3 doses),
1st Meningococcal vaccine,
1st Hepatitis B series,
Inactivated Poliovirus series, Mumps, Measles, Rubella series, Varicella series.
13 – 18 years:
7th Diphtheria, Pertussis, Tetanus,
1st Human Papiloma Virus HPV (3 doses),
2nd Meningococcal vaccine.
x
x
x
x
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H1N1 Vaccination
CDC Recommendations as of January 2010
•
•
•
All people from 6 months through 24 years of age
Persons aged 25 through 64 years with health conditions associated with
higher risk of medical complications from influenza.
-Health and Physical AssessmentHealth History
Health History Components
Biographical data, chief complaint, symptom analysis, history of present illness,
past health history = past history = medical history. Childhood and adult Immunization,
incl. last Tetanus and Influenza shots, childhood illnesses, prior hospitalizations,
surgical procedures, allergies, pregnancy history and current medication.
Family Health History
Increased expression of certain diseases present in family history?
Known hereditary conditions?
Personal/Social History
Diet, activity and exercise, sleep and rest, tobacco use, substance use, living
arrangements, family relationships/friendships, psychological data (stressors,
appropriateness of behavior and communication style), occupation (hazards, commuting
and amount of sick leave), travel (Travel abroad, Military service abroad, length, data)
and healthcare resources utilized so far.
Health History of Children
Parent’s perception and observation vs childs perception may be different !
Birth History
Length of pregnancy, mothers prenatal health and care, medication, substances taken
during pregnancy, duration of labor, type of delivery, APGAR - Score, birth weight,
length and head circumference.
Medical History of the child
Allergies, immunizations, boosters, habits and behavior, nutritional data (eating habits
and diets), Family History = Genogram
Family structure, community environment, occupation, education of family, cultural,
religious factors and child’s personality.
Preparation for Physical Examination
Basic Equipment
Blood pressure cuff, clean disposable gloves, penlight, stethoscope, tape measure,
thermometer, watch with a second hand and weight scale.
x
Additional Equipment
Cotton ball, Doppler, goniometer, neurologic hammer, lubricant, nasal speculum, near
vision charts, skin calipers, Snellen test for visual acuity, strabismoscope, tongue
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depressor, tuning fork, tympanometer, vaginal speculum, Setting: privacy, comfortable
temperature, minimum distractions and adequate lighting.
Systematic Physical Examination
General considerations
Swellings, asymmetrical, built, atypical coloration, signs of inflammation ?
Skin
Color, texture, wounds, scars, moles, petechiae < 0.5 cm, purpura > 0.5 cm
Temperature, nails, coloration (blanch test = capillary refill < 3 s.), white bands = ?
melanoma, darkening = malaria medication, hematoma,
signs of fungal infection ? soft, lose, breaking skin ?
Head and Neck
Symmetrical features ?
Conjunctives, Sclera: color, swelling, discharge, inflammation ?
Nose (Nasal speculum inspection), mouth, tongue, thyroid gland (shiftable, enlarged,
nodular) and lymph nodes.
Eye Test
PERRLA examination
Extraocular movements, Pupil size, Equality, Roundness, Light, Accommodation.
Fundoscopy via Ophthalmoscope (red reflex , optic disc, blood vessels, retina)
Ears
Otoscopy for ear canal and tympanic membrane (moveable intact, pearly white gray in
colour) Rinne and Weber test for bone and air conduction.
Breasts and Axillae
Sitting position, symmetrical contour, skin coloration, inflammation, swelling, detect
retraction by instructing client to raise arms above head, push hands together w. flexed
elbows and to press hands on hips). Areola masses ? Nipples masses ? Axillary,
subclavicular, supraclavicular lymph nodes. Points of palpation: lateral edge of m.
pectoralis major, thoracic wall in midaxilla, upper portion of humerus, anterior edge of m.
latissimus dorsi. Breast masses + tenderness present ?
Chest
Inspection, palpation (crepitus ?), assessing respiratory expansion normally 3 – 6 cm
Tactile fremitus “ninety – nine”,“blue moon”, decreased fremitus = effusion,
pneumothorax, Increased fremitus = consolidation of lung tissue.
Percussion
Tympanic = drum = high pitch = i.e. gastric bubble
Resonant = hollow = low pitch = i. e. healthy lungs
Hyperresonant = booming = very loud = i. e. Emphysema
Dull = Thudlike = soft to moderate pitch = substance (liver, spleen and heart)
Flat = very dull = high pitch = muscle bone
Auscultation
From apical to base, from lateral to medial.
Normal: vesicular, bronchovesicular, bronchial breathing sounds.
Carotid arteries, jugular veins
One at a time (contour and Amplitude)
Palpation, auscultation, jugular vein distention ?
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Heart
Auscultation sounds:
S1 = Apex = closure of interventricular valves
S2 = Base = closure of aortic and pulmonic valves
(S3) = Apex = ventrcicle filling
(S4) = Tricuspid or Mitral area = resistance to ventricular filling
Pericardial friction rub = Left sternal border
Cardiac auscultation scheme:
Accurate heart size assessment is performed via Chest X – Ray.
Abdomen
Positioning with pillow under knees, arms over chest.
Contour, symmetry, bumps, bulges, masses, scars, striae, movements.
Examination of all 4 quadrants singularly.
Auscultation of bowel sounds before palpation and percussion for 2 minutes.
(Sounds absent, present, increased, decreased ?)
Do not palpate pulsating structures.
Rebound tenderness ? (Peritonitis and Appendicitis signs)
Groins
Palpable lymph nodes and pulses.
Extremities
Pulsation, perfusion, motoric and sensoric nerves and muscular symmetry ?
Edemas and spine curvatures ?
Muscular strength: 0 = no contraction 5= Full ROM against resistance.
Straight leg raising (Lasegue sign) normally not painful
indicator for NP Prolaps.
x
Cranial nerves (CN)
C I = Olfactory nerve Sense of smelling.
C II = Optic nerve Visual acuity.
C III , IV, VI Abducens, trochlear, occulomotorius nerve
Extraocular movements.
Nystagmus ? (rapid horizontal oscillating eye movements)
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CV Trigeminal nerve
Motor function of masseter and temporal muscles, sensitivity of face, corneal reflex.
C VII Facial nerve
Function of facial muscles (smile, frown,eyebrows)
Sensory function of tongue for salty, sweet and sour.
C VIII Vestibulocochlear nerve
Hearing ability assessment by whispering from 2 ft distance.
Weber Test:
Tune fork in middle of scull. Is sound heard equally in both ears ?
Let client indicate when sound is disappearing, then place fork on mastoid bone until
sound is no longer heard.
Outcome: ‘Lateralization” to bad ear in case ofconductive hearing loss and to good ear
In case of sensoric hearing loss. No lateralization means no problem.
Rinne Test:
Sound heard twice as long by air conduction AC than by bone conduction BC.
If AC is less or equal than BC it means conductive hearing loss.
AC/BC ratio normal but overall reduced = sensorineural hearing loss.
CIX and X Glossopharyngeus and vagus nerve
Yawning and “aah”: Innervation of uvula, soft palate and tonsilar pillars to center, gag
reflex, voice quality, swallowing.
C XI Spinal accessory nerve
Innervation of sternocleidomastoideus and trapezius muscle. Shrug shoulders, turn head
against resistance.
C XII Hypoglossal nerve
Protruded tongue stays centrally, “Light, dynamite, tight” shows lingual speech.
Cerebellar function
Walking gait observation. Step length 15 inch ? heel – heel Heel on toe on a straight line
balance ?, Romberg Test, rapid alternating movement tests.
Assessment of Mental Status
Orientation to time, place and person. Adequate behavior, interaction and judgement.
Assessment of Levels of consciousness LOC
Consciousness = client is fully oriented and able to communicate
Confusion = disorientation, unable to interact adequately
Lethargy = slow but adequate verbal and motoric response
Obtundation = brief adequate response to stimulation during sleep
Stupor = poor physical response to external stimulation
Coma = Loss of consciousness.
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Glasgow Coma Scale (Scores)
Diagnostic tool used for assessment of LOC via
Best verbal response
Adequate and oriented = 5, Confused = 34, Inappropriate = 3
Not understandable = 2, No response = 1
Best motor response
To commands = 6, To pain = 5, Flexion = 4, Atypical flexion = 3,
Atypical extension = 2, No response = 1
Eye opening
Spontaneous = 4, To commands = 3, To pain = 2, No response = 1
Best outcome = 15 (fully awake and oriented)
Worst outcome = 3 (coma or death)
Sensory system assessment
Discrimination of pain (sharp and dull), temperature, vibration, discrimination of pain,
sharp and dull. Temperature and vibration?
Stereognosis present ?
Grapheshesia
Two point discrimination
Deep Tendon Reflexes DTR
Biceps = C5/C6, Triceps = C7/C8, Brachioradialis = C5 / C6, Quadriceps = L2/L4,
Achilles=S1/S2
Superficial Reflexes
Abdominal Reflexes , T8-T10 upper,T 10- T 12 lower
Cremasteric Reflex L1-L2
Babinski Reflex (stroke on lateral sole and across ball of foot) Dorsiflexion of big toe
and fanning of other toes. Only in infants until 12 months of age.
In healthy adults negative response = Flexion of toes / foot
Genital/ Rectum examination
Gloves required! Blood, fissures, scars. Prolpse, hemorrhoids, discharge and blisters.
Rectal exam: masses, blood ? Left testicle with longer spermatic cord.
Postexamination responsibilities
Assistance in cleaning, redressing, removing of dressing gown. Assure comfortable
position. Immediate documentation of data. Handle specimens.
Mental Status Assessment
Short Assessment
Mental Distress present yes or no ?
Tools: Mini Mental State (Folstein), 5-10 minutes, highest score 30, average 27
Key areas of Mental Status Assessment:
1. Appearance
2. Behavior
3.Level of consciousness LOC
Awake, alert, responding, aware of external and internal stimuli, or
lethargic, drowsy, stupurous, unresponsive
Glascow Coma Scale
4. Speech
Aphasia (receptive Wernicke ; motoric Broca), mood and affect.
x
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5. Cognition
Orientation to time, place, person, events, attention span, recent memory, remote
memory, new learning (four unrelated words test), judgement.
6. Thought processes
Thought content (logical, consistent), client’s perceptions (congruent reality based)
absence presence of suicidal thoughts.
Specifications of children examinations
General considerations:
Easy understandable language, involving parents. Reassurance, distress and intrude at
last, prepare for painful procedures. Assure comfortable and secure position, gentle
restraint.
Awareness for signs of child abuse is mandatory !
Tonsils are physiologically enlarged in children !
Epicanthal fold = Asian child or Down Syndrome.
Visual acuity tests:
Snellen letter chart, Snellen symbol chart and Faye symbol chart.
Extraocular muscle tests
Cover – uncover test for strabismus
Hirschberg test:
Light shining pupils should symmetrically reflect in center of pupils or there is
strabismus. Opthalmoscopic examination for PERRLA and red reflex (should be present)
Permanent eye color is present at 9 Months of age!
Ears
Performance of otoscopy in infants requires to pull pinna down and back.
In older children and adult clients pinna has to be held upward and straight.
Cerumen ? Foreign bodies ? Tympanic membrane intactness, effusion.
Audiometry mandatory prior school age.
Heart Ausculation in children
To be performed as soon as possible during encounter !
Apical pulse = 4th ICS until 7 years, 5th ICS after 7 years
Sinus arrhythmia, (breathing activated) is a normal finding in children!
Abdomen
Prominent and supine in infants and children.
Umbilical hernias common, spontaneously resolving.
True and false deformities.
True deformities
Metatarsus varus = forefoot turned in
Talipes varus = adduction of forefoot
Talipes equinovarus (clubfoot) = adduction of forefoot, inversion of entire foot,
Pointing downward of entire foot.
Medial tibial torsion
Medial femoral torsion
Assessment for congenital hip dislocation
To be assessed until 1 year of age several times
(birth, 6weeks, 6-8 months, 15-21 months.)
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Ortolani sign = Child supine, flex knee and hip to 90
degree, Abduction of hip by pulling femur downwards. Click noise
indcates a dislocation is present.
Barlow’s maneuver = Same position but adduction of legs until thumbs touch.
Equal length of legs ? Equal gluteal folds ? ROM of hips normal ?
Toddlers are usually bowlegged. 2- 7 years old may be mildly knock kneed
Scissoring gait ?
cerebral palsy.
Autonomic infant reflexes
Stepping reflex
Takes walking steps when feet touch ground. Disappears at 2 months of age.
Moro reflex = startle reflex = parachute reflex
Loud noise or sudden vertical descent in a supine or prone position lead to
Flexion and abduction of legs. Lateral extension of arms while forming a C with thumb
and forefinger and fanning other fingers. Immediately followed by anterior flexion and
adduction of arms. Disappears by 3 months.
Rooting reflex
= touch of cheek or lip = infant turns head towards stimulation and opens mouth
disappears by 4 months.
Palmar grasp reflex
Disappears by 4 months.
Tonic neck reflex
Child supine, head passively turned to the side = extension of arms and legs on side to
which head is turned opposite extremities will flex. Appears at 2 month disappears by 6
months.
Plantar grasp reflex
Disappears by 10 months.
Sucking reflex
Disappears by 12 months.
Babinski Reflex
Disappears within 2 years.
Persistence of newborn reflexes is suspicious for neurological disease!
Hand preference develops during school years!
-Elements of a healthy lifestyle-
Breast self exam (BSE)
Breast cancer appears in women and men.
BSE monthly for males and females, women from first gyn exam or age 20.
Women > 40
yearly mammogram recommended.
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x
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Breast self exam BSE:
Premenopausal women should perform BSE 5-7 days after menses each month.
Standardized Instructions on how to perform a BSE:
1. Look in mirror: Arms to side, overhead and on hips = retractions ?
2. Lie down arm underhead, free arm examines opposite breast including axilla
and nipple region.
3. Press tissue firmly against chest wall, from outer to inner areas, circular
approach.
4. Instruct client to memorize an individual ‘baseline’ touch.
Menstruation, breast feeding, pregnancy enlarges the breasts naturally.
“Personal baseline” also has to be assessed in cystic breasts.
Testicular self exam TSE
Highest risk < 40 years of age.
Normal finding if one testis appears larger, hanging lower with a smooth and shiftable
surface. TSE during shower to assess epididymis, testis and spermatic cord.
Exercise
Aerobic exercise 30 minutes 3 - 5 x weekly. Maximum Heart Rate = 220 – client age
Target Heart Rate = Maximum HR – resting HR. Walking, weight bearing prevents
Osteoporosis. Physical examination prior start of exercise if chronic illness is preexisting
or likely.
General Recommendations* for daily nutritional supply:
* www.mypyramid.gov”
Six ounces of grains
2.5 cups of vegetables
2 cups of fruit
3 cups milk products
5.5 ounces of meat /adult
2 grams of sodium
Low fat, low sugar, balanced diets
ADA Diet for diabetes patients and patients with Hyperglycemia.
Vegetarian diet
Vegetarians may choose Dairy products.
Strict vegetarians require B12 Supplements and choose soy, tofu, dry beans, nuts for
protein supply. Orange and green vegetables = Vitamins A,C,D,E and K, 8 glasses
water/d. (1 ml for each kcal consumed = on average 2000 kcal/d.).
Necessary dietary supplements
Folic acid for childbearing women.
Iron during pregnancy.
Calcium after Menopause 1500 mg/d + Vit D.
Religional dietary practices
Orthodox Judaism
Fish with scales and fins, cloven – hoofed animals, animals that eat vegetables or
slaughtered in a ritualistic manner. Milk and meat cannot be combined.
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Roman Catholicism
No meat on Ash Wednesday and Fridays during lent. Fasting on Good Friday and Ash
Wednesday optional for the rest of the lent.
Russian Orthodox
Meat and dairy prohibited Wednesdays and Fridays and during Lent. Fasting during
Advent.
Buddhism
Vegetarianism, no alcohol or drugs.
Hinduism
Beef and veal prohibited for all.
Islam
Pork and meat that is not slaughtered ritually. No alcohol and drugs.
Jehovah’s Witness
All meats to be drained of blood, no foods to which blood has been added.
Cultural dietary practices
Mexican Americans
Mainly corn, dried beans, rice, chilli peppers. Reduced meat, papaya and mango.
Hispanic / Latino
Similar to Mexican diet. Dried codfish, meat, milk, vegetables used less often.
Viandas, plantains, green bananas.
Native American
Fish (Alaskan), game, chicken, pork, mutton (Navajo)
Native Alaskan
Tortillas, bread, blue corn bread, corn meal mush, eggs, corn,
potatoes, green beans, tomatoes and fruit.
African American
Breads and cereals, cooked with corn and oats, eggs, cheese, less milk. Leefy greens,
okra, sweet potatoes, potatoes, corn, beans and rice. Pork, poultry, fish, organ meat,
less beef and fried food.
Asian American
Chinese: Rice, vegetables, eggs, soybeans, tofu, small amounts of meat and green tea.
Japanese: Also sushi, seafood,steamed vegetables and fresh fruit.
Southeast Asian: plus chicken, duck, pork, nuts and legumes.
-Age related Health Screening SchedulesHealth Screening for Children General Recommendations* for daily nutritional
supply:
* www.mypyramid.gov”
Recommendation by the US Preventive Services Task Force
Yearly dental checks to start at age 4.
Denver Development Assessment used from infancy to age 6.
Height and weight charted annually.
Well child exam schedule
Birth, 1,2,4,6,9,12,15-18 month
Age 2,3,4,5,6,8. Annually 10 – 17 years.
Blood Pressure = Age 3,4,5,6,8 annually 10-17 years.
Vision = Age 3,4,5,6,8,10,12,15 years.
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Hearing = 4,5,6,8,10,12,15 years.
Hereditary metabolic screening Birth to 1 months of age.
Lead screening as required.
Hemoglobin and Hematocrit at 12 month of age.
Urinalysis: Age 5
Screening for Adults
BP, BMI, Cholesterol yearly from age 20.
Blood Glucose yearly from age 45.
Recommendations for early cancer detection
Seven warning signs as published by the American Cancer Society.
1. Altered bowel and bladder habits
2. Bleedings of unknown cause
3. Delayed healing of sores
4. Thickening tissue at any location
5. disturbances of the gastrointestinal tract
6. Skin alterations
7. Voice alteration and persistent cough
Recommendations and Guidelines for early cancer detection
Breast: Breast self examinations (BSE) from age 20.
From age 20 – 39 years. Gynecologic breast exam once every 3 years.
From age 40 yearly mammogram and breast exam.
Uterus: Yearly Pap smear from age 18.
Prostate: Yearly digital rectal exam from age 50 plus.
Yearly PSA test (Prostate specific antigen)
Colon: From age 50 yearly stool test for occult blood.
Digital rectal exam and flexible sigmoidoscopy once every 5 years.
Colonoscopy with barium enema once every 10 years.
-Age related care of older adultsMost Common Health Disorders in adults > 65 years.
(Dept. of Health and Human Services 2003)
1.
2.
3.
4.
5.
6.
Hypertension
Osteoarthritis
Heart Diseases
Cancer
Sinusitis
Diabetes
Characteristic age related physical changes of older adults
Skin, hair and connective tissue:
Loss of elastic fibers and subcutaneous tissue (affecting skin, lungs and heart)
Lentigo, loss of pigmentation, thinning of hair, slower and thicker growth of nails.
x
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Eyes:
Presbyopia (Loss of Accommodation), weakening of color vision, delayed adaptation to
light and darkeness (night lights !), increased risk of falls, cataract development, Arcus
senilis of iris and dryness of eyes.
Ears:
Presbyacusis due to calcification of ossicles, obturating cerumen, loss of high pitch
hearing , (especially w. consonants).
Shouting does not help when communicating with a hearing
impaired person but speaking slowly and clearly and using direct eye contact!
Nose and olfactory system:
Olfactory bulb decreases (Anosmia), gustatory buds decrease.
Central nervous system:
Decreased sensitivity to touch, temperature, slower motoric activity, requiring mind
exercises, sleep decreases, proprioception (awareness for movement and position)
decreases, generalized muscular atrophy, intervertebral disc atrophy, cartilage atrophy,
osteoarthritis and osteoporosis risk increases.
Pulmonary system:
Coughing effectivity and lung expansion , oxygene diffusion decreases.
Circulatory system:
Heart murmurs due to stiffened valves. Blood vessel elasticity = BP
Kidneys and urinary tract
Renal output of minimum 30 ml/hr, GFR , Creatinine clearance
BPH Syndrome may occur, Urine retention, UTI’s may occur more frequently.
Metabolic and endocrine system
Thirst and appettite decreasing, TSH + Thyroxine , Insulin , Insulin sensitivity .
General considerations
ADL = activities of daily living, IADL = instrumented activities of daily living impaired.
Infections may be indicated by a fall. Shingles reoccurrence likely.
Nutritional aspects in older adults
BMI 20 – 24.9 = healthy in an elderly Person. Sodium max. 2300 mg / d.
Deficiencies of Vitamin A, B6 , C, E, Calcium, iron, zinc and folic acid common
Potassium sources (potato, banana and fortified orange juice)
Urinary incontinence
Urinary incontinence is a pathologic finding at any age and not an age related finding !
25 % of affected clients are older than 65 years. Women are more commonly affected
than men.
Continence requires a healthy lower urinary tract, cognitive ability, usable toileting
environment, motivation. Causes of transient Incontinence may be delirium, restricted
mobility, retention, infection, inflammation, impaction, polyuria, pharmaceuticals.
Chronic constipation
Most common cause is overuse of laxatives over years leading to an atonic colon
impaction.
Dehydration
Hydration status may be assessed by skin tenting on abdomen, forehead and moisture
of mucous membranes. Tenting on hands is normal age related process !
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Mental alterations of older adults
Dementia
Gradually developing over years. Remains with alert consciousness. Appears w.
personality changes, client becomes easily agitated. Tries to follow instructions but
shows an impaired memory, looses knowledge, language and judgement. Dementia is
an irreversible condition despite the underlying cause.
Delirium
Acute onset and brief course. Client is unable to concentrate. Poor attention and
fulfillment of simple tasks. Fluctuations in memory and thoughts. Reversible.
Depression
Sudden or gradual development. Client appears self absorbed, apathetic, worthless
but is able to follow instructions. Selective memory loss. Reversible.
- Common adverse effects of medication in older adults General considerations for medication therapies in older adults:
•
•
•
•
•
Iron is not absorbed with Calcium.
Green vegetables counteract Warfarin treatment.
Fluid deficiency increases orthostasis under beta – blockers.
Ciprofloxacine and Tetracycline will chelate with dairy products.
Amiodarone, Lovastatin, Buspirone levels increase drastically when taken with
Grapefruit juice.
Inadequate Medications for older adults:
( due to a highly anticholinergic profile)
Analgesics: Propoxyphene (Darvon) and combination products, Meperidine (Demerol)
Hypnotics: Diazepam, Barbiturates (Phenobarbital (Luminal) is tolerable)
Antiplatelet agents: Dipyridamole (Persantine)
Anticoagulant: Ticlid (Ticlodipine)
Antihypertensive: Methyldopa (Aldomet)
Other common substancespecific side effects
Delirium = acute confusion
My be caused by Diazepam, Clonidin, Levodopa, Isoniazid.
Monitor for oto - and nephrotoxicity
Aspirin + Aminoglycosides
Decreased sexual desire
Antipsychotics, Ketoconazole, SSRI.
Priapism
Sildenafil, Alprostadil, Trazodone and Antipsychotics.
-Common Laboratory TestsAdequate specimen collection:
Fasting = withholding Food and Fluids for 8 – 12 hours. (NPO Status)
Observation of hygienic and antiinfective precautions. Identification of specimen with
name, DOB, date of specimen, time and type of specimen. Laboratory requisition slip
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requires information on diagnosis and requested tests. Shaking of vials induces
hemolysis. All Specimens generally require prompt processing. Critical (panic) results
have to be reported immediately.
24 hour Urine:
Container may need to be stored on ice. Reminder on patients bed not to discard urine.
Patient to empty bladder prior to start and at the end of the sampling period.
Glucose Levels
FBG Fasting Blood Glucose. (Reference range 70 – 110 mg / dL = 3.9-6.1 mmol/l)
Fasting (including medication) time 8 – 12 hours prior sample. Assessment for Diabetes
and Hypoglycemia. Antidiabetics, insulin have to be paused prior to sample.
RBG Random Blood Glucose. (Reference range 60 – 110 mg / dL = 3.3-6.1 mmol/l)
Diagnostic Value: Assessment in a nonfasting state for diabetes screening and
surveillance purposes of diabetes treatment.
OGTT Oral Glucose Tolerance Test.
Diagnostic Value: Diabetes Screening and diagnosis tool. Assessment of baseline
glucose and after consumption of glucose at defined times. Requirements: High
carbohydrate diet (200 – 300 mg) for 2 days prior to the test. Avoidance of alcohol,
caffeine and nicotine for 36 hours, fasting for 10 – 16 hours. No antidiabetics or insuline
for 12 hours and no exercise for 8 hours prior to test.
Reference ranges:
30 minute sample 110 – 170 mg/dL = 6.1 -9.4 mmol/l
60 minute sample 120 - 170 mg/dL = 6.6 – 9.4 mmol/l
90 minute sample 100 – 140 mg/dL = 5.5 – 7.7 mmol/l
120 minute sample 70 – 120 mg/dL = 3.9 -6.6 mmol/l
Glycosylated hemoglobin A1c
Diagnostic Value: Assessment of average blood glucose levels over 6 – 12 weeks
Does not require fasting sample.
Normal 3.5 – 6 5; Good diabetic control 7.5 % or lower ;
Fair diabetic control 7.6 – 8.9 %
Poor diabetic control 9% or higher.
Arterial Blood Gas Analysis Normal Reference Ranges
Serum pH 7.35 – 7.45
Oxygen PaO2 80 – 100 mmHg
Carbondioxide (PaCO2) 35 – 45 mmHg
Bicarbonate 22-26 mEq/L
Base excess BE +3 - -3
Serum Electrolytes Normal Reference Ranges
Sodium 35 – 145 mEq/L
Potassium 3.5 – 5.1 mEq/L
Chloride 98 – 107 mEq/L
Bicarbonate (venous) 23 – 29 mEq/L
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Prothrombin time PT / INR International Normalized Ratio
Measurement of time of fibrin clot development from prothrombin in extrinsic coagulation
pathway. Interferes with Vitamin K metabolism.
Diagnostic value: Assessment of effectiveness of oral anticoagulants (Warfarin type).
Diagnosis of disseminated intravascular coagulopathy DIC. Vitamin K deficiency, Liver
dysfunction.
Normal Reference Ranges:
9.6 – 11.8 seconds for adult females (+/- 2 seconds)
9.5 – 11.3 seconds for adult males (+/- 2 seconds)
Warfarin Therapy = 1.5 – 2 times control value
Normal: 2.0 – 3.0 ; High dose: 3.0 – 4.5
High values increase bleeding risk, low values show inefficient therapy.
INR is considered as a standardized PT.
Partial Thromboplastin Time PTT
Assessment of time for fibrin clot formation over the extrinsic pathway.
Normal: 60 – 70 seconds.
Activated Partial Thromboplastin Time aPTT
Time needed for recalcified, citrated plasma to clot after adding activated thromboplastin
reagent. Normal: 30–45 seconds.
Diagnostic Value:
Assessment of effectiveness of Heparin Therapy,
Assessment of clotting factor deficiencies (except VII and VIII),
Assessment of DIC.
Sample to be taken from contralateral arm for venipuncture,
if sample is taken under ongoing heparin infusion!
Clotting Time
Assessment of extrinsic and intrinsic clotting system. Normal 8 – 15 minutes.
Intrinsic coagulation pathway: Initiation of blood coagulation due to contact with
foreign surfaces.
Extrinsic coagulation pathway: Initiation of blood coagulation due to tissue damage.
Bleeding Time
Assessment of thrombocyte function. Normal 1 – 4 minutes.
Fibrinogen
Plasma Protein required for clotting. Normal range: 150 – 400 mg/dL. Deficiency in
disseminated intravasal coagulation DIC).Increase in infections, estrogen treatments,
pregnancy and hepatitis.
Fibrin Degradation Products FDP
Increased in FDP, fibrinolysis, thrombolysis and DIC. Normal value is 10 mcg/mL.
Fibrin D-Dimer
Assessment for differentiation between DIC and fibrinolysis. Most sensitive laboratory
parameter for deep vein thrombosis and pulmonary embolism. Normal range is 0 – 0,5
mcg/mL
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Clotting cascade
Complete Blood Count CBC
Hematocrit (Hct)= RBC Volume in percent of blood volume
Normal reference range: 40 – 50 % in males , 38 – 47 % in females
Diagnostic value: Assessment of hemodilution and hemolysis.
Hem – o - globin (Hgb) = CO2 and O2 binding protein of RBC’s
Heme = Porphyrin and Iron ; Globin = Carrier Protein. HCT usually 3 times higher than
Hgb. Nomal reference range: 13.5 – 18 g/dL in males, 12 – 16 d/dL in females
Red Blood Cell Count RBC
RBC derive from bone marrow and get eliminated by the reticulo - endothelial system
RES of spleen, liver and kidneys within 120 days. Carrier of hemoglobin molecules.
Nomal reference range:
4.0 – 5.5 million cells/microliter in females, 4.5 – 6.2 million cells/microliter in males
Abnormal in anemia and blood dyscrasias. Increase in environment with low oxygen
concentration.
RBC Indexes
MCV (mean corpuscular volume)
MCH (mean corpuscular hemoglobin)
MCHC (mean corpuscular hemoglobin concentration)
x
x
x
x
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Platelet Count
Platelets initiate clotting process if traumas establish contact to body surface or altered
intravascular structures such as ateriosclerotic plaques. Platelets produce
Prostaglandines. Function can be inhibited by Prostanglandin synthesis blocking
medication. (i.e. Aspirin)
Normal range is 150.000 – 450.000 /ml ; Life span is 10 days. Platelets decreased in
bone marrow depression, leukemia, massive blood losses, infections, sepsis and uremia.
Increase under Steroid treatment or as an idiopathic process.
White Blood Cell Count WBC
= Agranulocytes (Monocytes & Lymphocytes)
+ Granulocytes (Neutrophils, eosinophils, basophils)
WBC’s provide humoral and cellular immune system. Normal range is 5000 – 10000 /
mm3. “Left shift WBC” occurs in massive lymphocytic immune response in viral or fungal
infections or inflammations as well as in leucemias with an increased number of
immature WBC’s or lymphocytes. “Right shift WBC” is defined in an increased number of
neutrophil granulocytes due to underlying bacterial infections, liver diseases, Down
Syndrome,megaloblastic anemia. Eosinophilic increase indicates allergic or parasitic
reponse. Basophilic increase indicates healing process.
B Lymphocytes
Stored in lymph nodes, contact with antigen
Immunglobulines = antibody producing plasma cells.
leads
to
transformation
into
T Lymphocytes
Mature in Thymus, stored in lymph nodes, spleen and overall lymphatic tissue.
Cadiovascular Function Studies
Serum Lipids
= Total cholesterol < 200 mg/dL ; LDL Cholesterol < 130 mg/dL ;
HDL Cholesterol < 30 – 70 mg/dL ; Triglycerides < 200 mg/dL
LDL + Total Cholesterol increase
increase of cardiovascular risk
HDL increase has cardiopotective function
Cholesterol blood test requires 12 hour fasting and 24 hours withholding of alcohol.
Creatinekinase CK = creatinephosphokinase CPK
Muscular enzyme with specific subtypes for skeletal and cardiac muscles and brain.
Total CK rises 4-6 hours after cardial or skeletal muscle damage.
Males 55/170 U/L, Females 30 – 135 U/L.
CK – MM = originates from skeletal muscle, 94 – 100 % of total CK ,
Peak 18 – 24 hours after tissue damage.
CK – MB = originates from cardiac muscle, 0- 6 % of total CK, Increase 6 hours after
tissue damge. Normalization within 3 - 4 days.
CK – BB = Brain tissue, 0-5 of total CK
Alcohol to be withheld 24 hours before sample.
Injections, bruises, contusion, cuts, strong physical exertion
can cause false elevation of total CK.
CK and LDH monitoring in MI provides additional information on progress and severity.
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Lactic Dehydrogenase LDH
140 – 285 U/L, Increased from 24 hours after MI.
Peaks in 48-72 hours. 5 Subtypes. Evidence for MI if LDH2 rises / flips over LDH1.
Normalization in 7 – 14 days.
LDH1
LDH2
LDH3
LDH4
LDH5
14 – 26%
29 – 39%
20 – 26%
8 – 16%
6 – 16%
Troponine
Proteine of cardiac and skeletal muscle cells.
Troponin I < 0.1 - < 1.0 ng/ml.
Rises within 3 hours after cadial muscle damage. Nomalization after 5 – 9 days.
Troponin T < 0.2 - < 1.0 ng/ml.
Rises 3 hours after cadiac muscle damage. Normalization after 10 – 14 days
Thyroid Gland Function Studies
Assessment of Hypo– and Hyperthyreosis.
Thyroxine T4 : Normal reference range 4.5 – 11.5 mcg/mL T4 (1.0 – 2.3 ng/dL free T4)
Triiodothyronine T3 : Normal reference range 80 – 200 ng/dL
Thyroid stimulating Hormone TSH:
Released from anterior pituitary gland by negative feedback loop due to low T4 Levels.
Normal reference range: 0.35 – 5.5 mU/mL.
Enables differentiation between thyroid gland and pituitary gland disorders.
Low TSH and low T4 indicates pituitary gland disorder.
Renal Function Studies
Blood Urea Nitrogen (BUN)
Product of hepatic protein catabolism.
Normal reference range 8 – 25 mg/dL = 2.9 -8.9 mmol/l.
Increased in: Reduced GFR, Increased protein uptake, Starvation, Crush injuries,
Feverish infections, Hemoconcentration.
Decreased in: Overhydration, Poteine deficient diet.
Failure of liver to convert ammonia to urea.
Serum Creatinine
Product of creatine metabolism in skeletal muscles. Increase indicates renal
insufficiency. Sample requires withholding meat for 24 hours and leave physical exercise
for 8 hours. Normal reference range is 0.6 – 1.3 mg/dl.
Urinanalysis
Nitrites
Presence indicates but does not proof UTI due to transformation of physiologically
excreted nitrate into nitrites by gram negative bacteria. (i.e. E. coli).
False negative results if urine was stored in bladder > 4 hours.
No sensitivity for UTI caused by gram positive bacteria.
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Leucocyte Esterase
Test to be done on a voided urine sample i.e. diaper. Positive results if urine contains
bacteria. UTI diagnosis requires a minimum of 100.000 colonies of bacteria perhigh
powerded field.
Normal Urinalysis
Color
Pale yellow – amber = normal
Pale – water clear = Diabetes insipidus and excessive water intake
Reddish – RBC
Burgundy – Porphyria
Orange – Phenazopyridine HCl and Rifampin (Rifadin)
Green – bile
Black – brown: mercury poisoning
Milky – pus and fat globules.
Clarity
Clear on excretion = normal
Cloudy = infection and phosphate precipitation
Odor
Faintly aromated = normal
Sweet = acetonuria
Strong = drugs and asparagus
Ammonia = produced by urea slitting bacteria in standing sample over time
alkaline transformation.
Specific gravity
1.005 – 1.030 = nomal
Increased = diabetes mellitus, hypovolemia, liver disease, heart failure,
i.v. contast medium.
Decreased = diabetes insipidus, diuretics, excessive water intake
pH
4.6 – 6.0
Acidity due to presence of ketone bodies = Diabetes, fever, starvation and dehydration.
Alkaline due to citrus, salicylates, bicarbonate, uti, after standing > 4 hours.
Protein
Trace to none = normal
Transient = Fever, stress
0.5 mg/d = chronic pyelonephritis
0.5-4.0 mg/d = multiple myeloma and diabetic nephropathy
5.0 mg/d = nephrotic syndrome and glomerulonephritis
Glucose
None = Normal
Present = Diabetes mellitus
Ketones
None = Normal
Pesent = Diabetes, fever, starvation and dehydration
Sediment:
0-3 RBC, 0-4 WBC, occasional casts, occasional urothelial cells = normal
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RBC casts: glomerulonephritis,
Blood: renal bleeding, malaria, hemolysis, aanemia, transfusion reaction.
WBC casts: UTI
Pus: Glomerulonephritis
Stool Examinations
Stool samples are commonly asservated and tested for:
Occult blood:
Paper stripe based test retrieves pseudoperoxidase reaction of Hemoglobin.
Clients have to avoid nutritional ingredients that may cause false positive
results, such as fish, meat, iron, iodine, boric acid and NSAID.
False negative results may be caused by: Vitamin C supply, beets, melons and
horseradish.
Gastrointestinal infections:
Stool samples are cultivated to assess bacterial and parasitic gastrointestinal infections
as well as clostridial toxins.
Fecal fat
Diagnostic parameter and assessed in malabsorption syndromes caused by hepato –
biliary and pancreatic gland disorders.
Liver Function Studies
Alanine aminotransferase (ALT)
= Serum glutamic pyruvic transaminase (SGPT)
Found in liver > heart, kidney, skeletal muscle. Normal reference range: 10-25 U/L
Elevation > 300 U/L common in liver diseases. Sample can be obtained non-fasting.
Aspartate aminotransferase (AST)
= Serum glutamic oxalacetic transaminase (SGOT)
Found in liver and heart muscle > skeletal muscle, kidneys and pancreas.
Unspecific. Normal reference range: 8-38 U/L, Rises up to 10 times in case of liver injury.
In MI rise less high in 6 – 10 hours, peaks in 24 – 48 hours, normalization in 4-6 days.
Sample can be obtained non-fasting.
Bilirubin
Product of hemoglobin breakdown in liver, spleen and bone marrow. Conjugated (direct)
bilirubin excreted over GI tract. Unconjugated (indirect) in blood circulating bilirubin.
Normal reference ranges:
Total bilirubin
0.1 – 1.2 mg/dL = 1, 71 – 20,52 micromol/l adults
1 - 12 mg/dL = 17.1 – 205 micromol/l newborns
Direct bilirubin 0.1-0.3 mg/dL = 17 - 51 micromol/l I
Indirect bilirubin
Difference between direct and total bilirubin.
Elevation of total bilirubin over 2.0 mg/dL causes jaundice. Specimen is light sensitive.
Sample taken fasting for 4 hours prior to test.
Levels influenced by yellow vegetables if consumed 3 days prior to test.
Ammonia
End product of nitrogen breakdown in protein metabolism in liver. Excreted via kidneys.
Normal reference range 35-65 mcg/dl. Indicator for liver disease. Increase can cause
brain damage and hepatic coma. Sample to be taken fasting for 8 hours before test and
after withholding nicotine for 8 hours.
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Pancreatic Enzymes
Amylase
Product of pancreatic and salivary glands. Required for digestion of Carbohydrates.
Normal reference range: 25 – 151 U/L. Increase in pancreatitis 3 – 6 hours after pain
starts. Peak after 24 hours. Normalization in 2 – 3 days.
Lipase
Product of pancreatic gland. Required for breakdown of fatty acids and glycerol.
Normal reference range: 10-140 units/L. Increased in pancreatic disorder from 24 hours
after onset of disorder. Normalization in 14 days.
Gastrointestinal Function Studies
Albumin
Normal reference range 3.4 – 5.0 grams/dL
Plasma protein. Maintains oncotic pressure. Transport of water insoluble substances (i.e.
hormones, fatty acids, drugs, bilirubin). Indicator of nutritional status and protein
synthesis in liver.
Alkaline Phosphatase
Present in intestines, liver, bones, placenta. Rise indicates bone growth, liver disease,
bile duct obstruction. Reading may be affected by hepatotoxic drugs. Sample requires
12 hours fasting prior test.
Total Protein
Overall proteins functioning as carriers, hormones, coagulant factors, enzymes,
tissue growth and repair. Normal reference range is 6.0 – 8.0 grams/dL. Decreased in
malnutrition, severe injuries and burns, liver disease and renal failure. Increased in
Myeloma and due to all forms of dehydration by causing hemoconcentration.
Uric Acid
Product of purine metabolism. Affected by diet and renal function. Increase causes gout
disease and kidney stone formation.
Normal reference range is 3.5 – 8.0 mg/dL in adult males and 2.8-6.8 mg/dL in females.
Sample does not require fasting but withholding of high purine food.
(organ meat, sardines and scallops)
-Assessment of therapeutic drug levelsSamples to be taken before daily dose or as peak and though levels.
(peak = 30 minutes after intake or administration, through = next to scheduled dosage)
Most commonly assessed therapeutic drug levels
Carbamazepine (Tegretol) 5-12 mcg/mL
Digoxin (Lanoxin) 0.5 – 2.0 ng/mL
Lithium (Lithobid) 0.5 – 1.3 mEq/L
Phenytoin (Dilantin) 10-20 mcg/mL
Theophylline (Theo-Dur) 10-20 mcg/mL
Valproic acid (Depakene) 50 – 100mcg/mL
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- Immune Function Studies -
The immune system responds to contact with antigens with its humoral and/or cell
mediated immunity.
The Humoral Immune System
Main function is the synthesis of antibodies once an antigen has entered the system:
Mediator cells are B – Lymphocytes.
1. B Lymphocytes recognize antigen and bind it to their surface
2. B Lymphocytes differentiate into plasma cells
3. Plasma cells secrete immunoglobulins to support an antigen/antibody reaction.
Lymphocytes also develop memory cells to enable the immune system for an enhanced
and faster immune response once an antigen reenters the organism again.
The Cell Mediated Immune System
The cell mediated immune system elicits a primary immune response against viral,
bacterial, parasitical, and fungal infections as well as in cases of a transplant rejection
reaction (e. g. Graft versus host). The cellular immune response gets activated once BLymphocytes have bound to an invading antigen.
This antigen/antibody complex is presented to the cellular immune system by expressing
a specific major histocompatibility complex. (MHC). This newly build complex of BLymphocytes and antigens then bind to a specific CD receptor on the surface of a TLymphocyte.
IgA
IgD
IgE
IgG
IgM
Types of Immunoglobulins
“sessile” Antibody, not circulating in plasma. Located on all body surfaces.
bound to surface of lymphocytes for antigen capture and presentation.
bound to interstitial mast cells, facilitating allergic reactions
circulating in entire systemic circulation. Activates systemic immune response
and is able to pass placenta barrier!
Immediate and primary immune response. Activates systemic immune response.
Types of Hypersensitivity reactions
Type I, Anaphylactic reaction
Characteristics:
Immediate immune response due to binding of activated IgE Immunoglobulines
to mast cells leading to an allergic response. Local responses target the areas where the
reaction takes place. Systemic reactions may lead to a generalized allergic reaction such
as an anaphylactic shock.
Symptoms and diagnostic findings:
Symptoms include a variety of allergic symptoms such as wheezing, bronchospasm,
hypotension, allergic dermatitis, glottis and tracheal angioedema, asphyxia, shock and
death.
Treatment:
If possible, suspected allergen has to be eliminated instantly. Acute, life threatening
anaphylactic reactions require immediate treatment with epinephrine, airway placement,
oxygen and circulatory support. Further medication therapy include antihistamines and
mast cell stabilisators for immediate cessation of further histamine production and
release. Corticosteroids are applied to minimize immune response.
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Type II, Cytotoxic reaction
Characteristics:
Systemic humoral immune response triggered by IgA and IgM antibodies in cases of
autoimmune diseases and transfusion reactions due to A,B,O incompatibility.
Symptoms and diagnostic findings:
See manifestation of autoimmune disorders. (e.g. Graves disease, Goodpasture
Syndrome and Myasthenia gravis) Activation of hemolysis in cases of A,B,O blood
incompatibility. Coombs and Gellen test positive.
Treatment:
Prevention of A,B,O incompatibility by thorough checks of patient identity and
surveillance of transfusion for at least 15 minutes.
Type III, Immune complex reaction (“Serum sickness”)
Characteristics:
Precipitating antigen – antibody complexes lead to a systemic immune response with
complement activation that targets specific tissues or causes a generalized unspecific
immune response.
Symptoms and diagnostic findings:
Examples of clinical manifestations are rheumathoid arthritis (RA)
systemic inflamed
synovial tissues and joint cartilages. Systemic Lupus erythematodes (SLE)
Generalized inflammation of internal organs and bone marrow.
Sclerodermia
systemic skin fibrosis.
Serum sickness is characterized as generalized body ache, fever and swollen lymph
nodes. Arthus reaction describes a local, only one organ targeting reaction.
Treatment:
Symptomoriented treatment, surveillance until reaction is exhausted.
Type IV, Delayed hypersensitivity reaction
Characteristics:
Slow immune response of T – Lymphocytes to substances and allergens that do not
trigger a humoral immune response. Symptoms may not arise before 72 hours after
allergen contact has taken place.
Symptoms and diagnostic findings:
Examples are positive tuberculin test reactions, contact dermatitis and graft and
transplant rejections.
Treatment:
In order to underlying cause.
Allergy testing procedures
Scratch test (In vivo)
Intradermal application of one or several defined testing allergens at a time. Leads in a
positive testing to an immediate erythema, swelling and itching at the site of the injection
due to activation of mast cells.
Radio-Allergen-Absorbent-Test (RAST) (In – vitro)
Incubation of clients blood with a defined allergen leads to an accumulation of IgE
antibodies in a positive case. IgE concentration can be measured by radioactively
marked IgE antibodies.
-Common Diagnostic Procedures-
Biopsy
Removal of organ tissue for the purpose of microscopical (histological) examination.
Usually performed in cases of suspicion of malignant tumors.
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Bronchoscopy
Endoscopic examination via Pharynx, Larynx and Bonchioles to reveal pathologic
changes. May require premedication and general anesthesia or local anesthesia.
Local anesthesia suppresses swallowing reflex which requires withholding of food until
anesthetic effect wears off due to danger of aspiration !
Pulmonary function studies
Assessment of physiological pulmonary function as well as of restrictive and obstructive
pulmonary diseases. Main parameters are vital capacity, lung volume loop, diffusion
capacity assessment, provocation studies, bodyplethysmography, pulse oximetry,
ecercise studies. Clients to avoid any food and nicotine 4 – 6 hours prior to the test.
Ventilation scan
Assessment of pulmonary ventilation via scan of inhaled radioactive isotopes.
Used to differentiate between anatomical and cardiovascular causes of a pulmonary
dysfunction.
Angiography
Assessment of the perfusion of the arterial and venous system via transcutaneous
injection of radioactive contrast fluids. Procedure may cause allergic reaction and
requires client to fast 8 – 12 hours prior to the procedure. As any examination under
administration of contrast fluid an IV access has to be maintained throughout the
procedure. Angiographies on arterial blood vessels need to be observed in regards to
accidential punctures or prolonged bleedings.
Cardiac catheterization
Angiography of the coronary arteries. Catheter device is inserted via the brachial or
femoral artery and used for injections of contrast fluids into the coronary arteries.
Echocardiography
Ultrasound based method for examination of cardiac heart valves. May be used for
transthoracic and transesophageal examinations. Transesophageal examinations are
performed to assess the atrial regions of the heart. This procedure may require
intravenous sedation and a fasting period of 4 hours prior to the procedure.
Electrocardiography (ECG, EKG)
Assessment of the autonomous electrical activity of the heart.
Used to detect dysrhytmias as well as acute and chronic ischemic myocardial reactions.
Commonly performed as a 12-lead ECG. Electrodes are placed on limbs and chest in a
specific order
Unipolar electrodes: aVR, aVL, aVF
Bipolar electrodes: I,II,III
Chestwall electrodes: (C) V1 – V6
Reliable examination results require client not to move during procedure. Body hair in
areas of electrode placement has to be shaved.
Holter-monitoring
24-hour ECG examination under normal daily activities to assess periodical dysrhytmias.
Stress / exercise tests
Cardiac monitoring under physical exercise or medication induced tachycardia. Methods
of assessment are treadmill and ergometer ECG’s, myocardial perfusion imaging test
and dobutamine stress test. Method to establish exercise induced myocardial ischemia
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and dysrhytmias. Clients are supposed to maintain NPO Status after midnight and to
avoid caffeine and nicotine prior to the exam. Client instruction about acute warning
signs like chest pain and dyspnea prior to the exam is mandatory. Resuscitation
equipment has to be available at all times during the examination procedure. Test results
may be influenced by medication, i. e. Beta-Blockers. Monitoring has to be continued for
5 – 10 minutes after exertion has stopped and heart rate and blood pressure are
normalized.
Computer tomography (CT) scan
Narrow X-Ray based scan of circumscripted anatomical regions for abnormalities and
lesions in soft tissue, central nervous system and musculoskeletal system. May be
performed with or without contrast dye. Contrast medium may cause an allergic reaction
and requires assessment of kidney function prior to the examination. Use of contrast dye
requires patient to dink sufficient amounts of water after procedure. Not to be performed
in pregnancy.
Fluoroscopy
X-Ray examination of organs in motion under administration of contrast dye.
(i.e. Barium Enema, coronar angiography). Contraindicated in Pregnancy.
Magnetic Resonance Imaging (MRI)
Imaging examination with similar results as in computer tomography. Not based on
ionizing radiation. Underlying principle is the creation of a high energetic magnetic field
which accelerates protones of body fluids and translates the resulting electromagnetic
rays into picture producing signals. Procedure is contraindicated in any case of metal
device implantation. (e. g. pacemakers). Gardolinum as a nonallergenic substance is
used for contrast fluid administration and may interfere with calcium absorption for the
next 24 hours. Procedure may cause claustrophobic reactions and is noisy.
Nuclear scan
Scan is based on the administration of radionuclides and and the assessment of their
distribution into specific organs. Imaging is peformed under use of a Gamma - or
scintillation camera.
Radioisotopes used for these examinations are technetium 99m, iodine 123,iodine 125,
thallium 201, xenon, indium 111, gallium. Client requires administration of thyroid gland
blocking agent (Lugol Solution, potassium perchlorate) and san iodine restricted diet
prior to the examinaton. Radionuclides are naturally discharged within 24 hours without
risk of contamination for other people.
Positron emission tomography (PET)
Noninvasive procedure to assess perfusion and transformation of the central nervous
system and within the heart muscle. Imaging is based on measurement of the density of
administered positron emitting isotopes of a previously administered radionuclide.
Commonly used substances are radioactive glucose, rubidium 82, oxygen 15 and
nitrogen 13.
Ultrasonography
Ultrasound transducer produces and receives echoes from body tissues and cavities
and transforms the returned echo signals into pictures. Method can detect any
anatomical alterations of inner organs. Diagnostic value increases with density of the
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examined tissues. Preparation usually requires fasting for abdominal examinations.
Pelvic examinations have to be performed with partially filled bladder.
X-ray examinations
Screening and diagnostic examinations. Standard examinations are: KUB (kidneys,
ureter, bladder), Flat plate (chest, heart, abdomen), skeletal and skull. Patient is required
to wear protective garb for protection of reproductive organs. Contraindicated in
pregnant women.
Vasography (Phlebography)
Flouroscopy or X-Ray of deep leg veins via intravenous injection of contrast dye.
Performed for detection of deep vein thrombosis. Requires NPO Status for 4 hours.
Assessment of vital signs before, during and after procedure. Client has to be handled
as a DVT case until ruled out. Previously first line diagnostic tool in cases of DVT before
duplex sonography was available.
Cystoscopy and Cystography
Direct endoscopic visualization of the bladder. May include retrograde filling of the
bladder with radiopaque contrast dye. Blood tinged urine and temporary burning
sensations during urination may be observed in postprocedure care within the first 2
days. Gross haematuria indicates complication. Minimum urine output has to be 200 ml /
8 hrs.
Intravenous Pyelography (IP)
Synonymous term for excretory urography for radiologic visualization of the entire
urinary tract. Requires intravenous injection of of radiopaque contrast dye. X-rays are
taken at 3,5,10,15 and 20 minutes after injection and after client has voided. Client has
to remain in NPO status for up to 12 hours prior test. Preparation procedures requires a
laxative in the evening and an enema in the morning.
Retrograde Pyelography
Not commonly used alternative for IP in cases of clients with kidney dysfunction.
Contrast dye is administered via catheterization into the ureter.
Barium enema
Assessment of the entire large intestine (colon) to determine pathologies. Performed
under use of Barium sulfate only or in combination with air as a contrast fluid. (= double
contrast) Procedure requires bowel preparation with fluids, and a low residue = low fiber
diet 2 – 3 days prior to the test. Postprocedure care includes prolonged use of laxatives
until barium is removed from bowels.
Cholangiography
Fluoroscopic and radiologic assessment of biliary ducts. Access to administer contrast
fluids may be performed intravenously or via transabdominal and transhepatic puncture
of biliary ducts in liver. Intraoperative cholangiography uses a t-shaped bile duct catheter
(T-Tube). Assessment of LFT’s before and after procedure is mandatory.
Cholecystography (oral)
Orally administered contrast media concentrates in gall bladder after 12 hours. Clients
are supposed to remain in NPO status for 12 hours prior to the test. Procedure requires
assessment of LFT before and after.
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Gastrointestinal GI series
Fluoroscopic and x-ray examination of the gastrointestinal tract after administering
barium contrast medium. Pictures are taken over 1 – 6 hours depending on examined
area of the gastrointestinal tract. Care comparable as for other contrast media involving
procedures. Lightly coloured stoll may occur for a few days after the procedure.
Upper gastrointestinal tract = Mouth
Intestines
Lower gastrointestinal tract = Colon and Rectum
Mammography
X-ray examination of breasts to detect cysts or tumors. Sensitivity to detect malignancies
is about 90%. Current guidelines recommend an examination every two years for every
woman between 35 and 40 and yearly for women oer 40 years of age. Test does not
require any specific preparation but client is supposed to avoid any external lotions or
crèmes on the day of the examination. Procedure may cause discomfort but no actual
pain. Films are usually developed instantly.
Bone Densitometry
X-ray based investigation to determine mineral content of the skeletal bone. Test is noninvasive and takes 30 – 60 minutes.
EEG - Electroencephalography
Method to measure electrical impulses produced by brain cells. Mainly used to diagnose
seizure disorders and brain death. Electrodes are placed on scalp, impulses are
recorded on moving paper comparable to an ECG. May be performed und all stages of
consciousness. Patient must not use oil or gels but shampoo only on hair prior to the test.
Client must not remain fasting. Sedating medication has to be avoided or interrupted.
Myelography
Flouroscopic and radiologic exam of the subarachnoid space (spinal canal) after
injection of air or contrast fluids. Procedure may require sedation of client and recurrent
change of positions on the examination table. Loss of spinal fluid requires compensation
with increased fluid intake. Client have to maintain bedrest for at least 8 hours after the
procedure to avoid headaches due to the loss of cerebrospinal fluid.
Arthroscopy
Endoscopic transcutaneous surgical examination and treatment procedure for joints.
May include therapeutic intervention in the same setting and / or arthrography via air or
contrast media injection. Appropriate to diagnose cartilage, tendon and synovial
structure damage. Most commonly used to assess and repair knee and shoulder injuries
but also used for other joints.
Colonoscopy
Endoscopic examination of the large intestine via an rectally inserted fiberglass optic
instrument. Procedure allows to perform biopsies and to remove polyps from examined
tissues. Therefore medication which increases the risk for bleeding needs to be stopped
1 week prior to the procedure. Preparation requires a bowel cleansing procedure which
is performed 24 hours prior to the scheduled examination and includes intake of large
amounts of osmotic laxatives (i.e. GoLytely, Colyte Solution and Fleet Phosphosoda)
until clear watery discharge from anus appears. Positioning of client during the
examination is either on left side of body or in Sims position. Care includes monitoring of
vital signs and precautions as in a surgical procedure under sedation.
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Esophagogastroduodenoscopy
Direct visualization of the gastrointestinal tract via insertion of a fiber glass endoscope.
Requires NPO Status for 8 -12 hours prior to the test or gastric lavage in case of an
emergency procedure. Biopsies can and may be taken during procedure. Examination
includes esophagoscopy, gastroscopy and duodenoscopy.
Oral anaesthesia must loose effect before patient is allowed to eat or drink !
Endoscopic retrograde cholangiopancreatography ERCP
An orally inserted endoscope is guided to the duodenal papilla where radiopaque
contrast medium is injected to identify abnormalities and pathologic findings of the biliary
and pancreatic duct. Preparation requires NPO status for 8 hours prior to test and
insertion of an IV line. Care includes monitoring and precautions as in a surgical
procedure under sedation.
As for any orally or transorally performed procedure dentures have to be removed !
Gastric analysis
Examination of gastric acid secretions via an inserted nasogastric tube.
May be performed with or without stimulation. Increased production indicates peptic
ulcers or Zollinger Ellisons Syndrome. Decreased acid production indicates pernicious
anemia, gastric malignancy or atrophic gastritis. Examination usually requires four
subsequent specimens every 1 minute. NPO status 8 -12 hours prior testing especially
avoiding acid provocating food and coffee.
Fetal Non-stress Test
Used for assessment of fetal heart rate (FHR) when fetus is moving. Accomplished via a
transducer. Desired rate is 15 beats per minute over 15 seconds. Test requires client to
shift transducer to area where fetal movement is experienced. Fetal movement may be
provocated by external stimulation. Normal outcome requires an increase of the FHR
when Fetus is moving.
Hysteroscopy
Visualization of the uterine cavity via an endoscopic procedure. Procedure allows to take
biopsies and to perform removals of polyps and other abnormal findings.
Contraindicated in any case of external genital infections including cervix infections.
Procedure should be undertaken in first of menstrual cycle. After menstruation and prior
to ovulation. Examination is performed in Lithotomy position and on an empty bladder.
Carbon dioxide is inflated to widen the uterine cavity. Care is comparable as for any
surgical intervention. Client to avoid sexual intercourse and any kind of transvaginal
treatment or hygienic procedure for two weeks to avoid an infection.
Papanicolaou Smear (PAP Smear)
Cytological smear taken from the cervix to identify atypical cells, malignancies as well as
viral, fungal or bacterial infections. May also be used to evaluate effect of an ongoing
radiation or chemotherapy treatment. Test does not require any specific preparation but
client is supposed to avoid sexual intercourse or any transvaginal irritation 24 hours prior
to the examination. Procedure requires client to lay in a lithotomy position in a gown with
all clothes removed. A breast exam is typically performed after the smear.
Tuberculin skin test
Screening test for tuberculosis. Only for clients who were tested negative before.
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Not to be performed in clients with previous positive test results
due to the risk of an anaphylactic reaction !
Tests are containing a purified protein derivative which is applied to the skin in two
different ways.
a)
b)
Tine test (= Mono Vac test)
Multipuncture stamp needle used for mass screening purposes.
Mantoux-test requires strict intradermal injection of PPD using a tuberculin 1ml
needle with a 25-27 gauge needle.
Results are to be read within 48 – 72 hours. Most accurate after 72 hours. Positive test
indicates contact or infection with Mycobacterium tuberculosis. Further testings include
sputum cultures, gastric acid cultures and chest x-rays.
Skin tests are also performed for Blastomycosis, Coccidioidomycosis, Histoplasmosis,
Trichinosis and Toxoplasmosis.
-Perioperative Nursing CarePreoperative Phase Checklist
•
•
•
•
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•
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•
•
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Client identification
Client assessment
Identifying health problems
Beginning of Postoperative teaching
Interview
Completion of diagnostic procedures
Ensuring about availability of complete reports
Reporting any abnormal findings
Ask client for consent of autologous or directed blood transfusions
Obtain informed consent
Physical assessment
Physical preparation
Intraoperative phase (surgical period) Checklist
(= clients transfer to operating table until admission to postanesthesia care unit PACU)
•
•
•
•
•
•
•
•
•
•
•
•
•
Client requires preparation for induction of anesthesia
Maintaining aseptic conditions
Assisting in providing a hazard free environment
Sufficient and timely supply with materials
Administering IV medications and infusions
Positioning of client
Applying grounding device
Provide physical and emotional support
Apply monitoring devices
Monitor clients reaction to procedure and medications
Identify nursing roles
Circulating nurse = non – sterile
Scrub nurse = surgeons assistance = sterile
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Postoperative phase Checklist
(= Discharge from PACU until follow up evaluation)
•
•
•
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•
•
•
•
•
•
Requires assistance in physical adaptation, orienting back to
consciousness, communication with other nursing units
Assessment of effect of procedure and applied medications
Monitoring of vital functions
Providing comfort and pain relief
Appropriate positioning
Maintain hydration
Monitor renal output
Suctioning
Wound care
Education
Types of treatments and procedures
•
•
•
•
•
Diagnostic = to establish a diagnosis
Curative = to remove pathological cause
Ablative = to remove a diseases structure
Reconstructive = to repair a dysfunction
Palliative = to reduce pain
Classification of surgical procedures
•
•
•
•
•
•
•
Major surgery = prolonged, larger blood loss, vital organs involved,
postoperative complications possible
Minor surgery = few complications to be expected, typical for outpatient setting
Emergent = immediate treatment for life threatening or dangerous condition
Urgent = treatment promptly required, within 24 hours
Required = treatment within weeks to month
Elective = to avoid an aggravation ahead of time
Optional = A non surgical treatment option exists
Anesthesia
Conscious sedation
= minimal depression of consciousness by IV narcotics and anxiolytic medication.
Regional anesthesia:
1. Accomplished by use of local anesthetics.
Stages1: Drowsy,dizziness and depressed pain sensation.
Stage 2: irregular breathing, involuntary movements.
Stimulation may cause vomiting.
Stage 3: Muscle relaxation, miosis and absence of eye lid reflex.
Stage 4: Medullar depression, mydriasis, rapid pulse, decreased breathing.
Factors of preoperative assessment
•
Clients history
•
Physical assessment
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Diagnostic preoperative laboratory examination screening routine
Urinalysis
Chest x-ray
ECG
CBC
Blood typing
Cross matching
Serum electrolytes Na, K, Ca, Mg, Cl, HCO3
Fasting blood glucose
BUN
Creatinin
ALT
AST
LDH
Bilirubin
Serum Albumin
-Care specifics for surgical clients-
PACU Nursing care
Postanesthetic clinical assessment factors Checklist
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Adequacy of airway
•
Oxygen saturation
•
Adequacy of ventilation
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Cardivascular status
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LOC
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Presence of protective reflexes and motoric activity.
•
Skin color
•
Fluid status
•
Condition of operative site
•
(purulent = pus, serosanguineous (serum and blood),
•
Patency, amount, character of drainage,
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Discomfort and safety.
PACU unit discharge criteria
1. Vital signs sufficient,
2. Breathing spontaneously
3. Gag reflex present
4. Client easily arousable
x
x
xx
x
x
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Postoperative nursing management duties on clinical units
Assessment of:
Encourage
•
Breathing
•
deep breathing, leg exercising
•
Vital signs
Provide
•
i.v. sites and drains
•
Pain management
•
Wound conditions
•
Call light
•
Temperature
•
Emesis basin
•
Tubes
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Ice chips
•
Pain
•
Bedpan and urinal
•
Positioning
Communicate with family.
•
IV fluid monitoring
Promote
•
Urine output monitoring
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GI status
•
Discharge planning participation.
Discharge instructions shall include:
Diet, activity, medications, wound care and follow up care.
Most common postoperative complications include
•
Respiratory distress due to pulmonary embolism
•
Hemorrhage and shock
•
Thrombophlebitis
•
Paralytic ileus, constipation,
•
Urinary retention
•
Wound infection
•
Wound dehiscence and evisceration.
-Postoperative care after abdominal surgery-
Gastrointestinal tract:
Partial gastric resection and total gastrectomy
Partial or total removal of stomach for neoplastic or ulcerous diseases. Modifications of
the gastrectomy procedure are:
a)
b)
c)
d)
Billroth I gastrectomy
( = Gastroduodenostomy)
Billroth II gastrectomy
( = Gastrojejunostomy)
e)
Removal of lower portion of stomach including gastrin and acid / pepsinogen
secreting cells with subsequent connection to the duodenum (B I) or jejunum
(B II). Common complication of these procedures is a Dumping
syndrome, caused by a sudden movement of indigested food into the
duodenum or jejunum. Leading to a non-resorption situation in the duodenal
part as well as a sudden fluid shift into the renal cells which may cause
immediate severe flushes, sweats, pallor, palpitations. Hypoglycemia may
arise out of a sudden instead of a gradual insulin response.
Postoperative clients after Gastrectomy and gastric resection require suctioning via a
nasogastric tube which is typically placed during the procedure. Tube placement
requires regular monitoring since an improper suction may lead to an overdistention of
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the remaining stomach and endangers the anastomotic sutures. Tubes should not be
corrected or changed blindly either. Gastrectomy procedures may also require lifelong
parenteral folic acid and vitamin B12 supply due to absence of parietal cells.
Clients need to be instructed how to overcome limited or absent gastric space
by selecting a specific low carbohydrate, high protein and high fat diet
with 4 – 6 meals per day !
Ileostomy
Stoma care requires skin protection by use of sufficient barrier systems. Special
consideration has to be given to the prevention of dehydration and electrolyte
imbalances of the stoma including advice on fluid and electrolye enriched diet.
Colostomy
Special attention has to be given to the possibility of a blockage by constipation. In
general stool will appear more solid the lower the colostomy is placed. e. g. stool from a
descendostomy is more solid then from an ascendostomy. Clients require education with
bowel irrigation.
Basic client needs
-Nutritional needs-
General Guidelines on Diets
All current recommendations by the U.S. Department of Health and Human Services
and the U. S. Department of Agriculture are valid for the NCLEX-RN® and can be viewed
online at www.mypyramid.gov.
General dieting recommendations include a balanced eating pattern, consumption of
basic food groups as much as possible while keeping consumption of trans – fats,
cholesterol, added sugars, salt and alcohol low.
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Main nutritional elements
Carbohydrates
Key source of energy, providing 4 kcal/gram, mainly carried in fruits, vegetables, milk
and grain. Sufficient supply of carbohydrates prevents proteine waste and muscular
atrophy.
Fats
Concentrated sources of energy, providing 9 calories/gram. Required for absorption of
fat soluble vitamins. Physiological cushion and isolation function. Sources are eggs,
yolks, meats, butter, cheeses and various oils. Differentiation of fats considers
Cholesterol content and molecular structure of fat acids as follow:
•
Saturated fats
Contain more carbon atoms per molecule.
Carbon content is higher the more solid this fat is, e. g. butter vs. sunflower oil. Over
alimentation with fats, especially saturated fats, leads to obesity, heart disease and
cancer.
•
Mono – or polyunsaturated fats
Contain less carbon atom per molecule and are mainly of herbal origin.
Insufficient intake of fats leads to increased risk of infection, skin lesions, amenorrhea,
hormonal imbalances and increased cold sensitivity.
Minerals (Micronutrients)
Part of cells, bones and hormones. Enhance cellular function and catalyze multiple
physiological processes. Mainly calcium, potassium, sodium, magnesium, chloride,
phophorus, zinc are required and may become deficient due to health conditions.
Trace elements are required in a significant less quantitiy. Significant trace elements
are iodine, copper, zinc, selenium, manganese, fluoride, chromium and molybdenom.
Vitamins (Micronutrients)
Vitamins function as coenzymes to support metabolic processes. Sufficient vitamin
supply can be obtained by regular diet alone. Vitamin supplements are not generally
necessary. The main differentiation among vitamins considers water soluble (B + C) and
fat soluble (E,D,K,A) vitamins.
Overview over Vitamin sources and function
Thiamin = Vitamin B1
Coenzyme. In Pork, wheat and cereals.
Deficiency common in chronic alcohol abuse leads to neurological symptoms.
= Beri – Beri Syndrome , Wernicke – Korsakoff Syndrome.
Riboflavin = Vitamin B2
Coenzyme. In milk and enriched grains. Deficiency = Ariboflavinosis
Niacin = Vitamin B3
Coenzyme. In peanuts, legumes and grains.
Defiency = Pellagra, Dermatitis, Dementia and Diarrhea.
Panthotenic Acid = Vitamin B6
Coenzyme. In meat and whole grains.
Deficiency = Rash and fatigue
Pyridoxine = Vitamin B6
Coenzyme. In pork, organ meats, whole grains and wheat germs.
Deficiency = Nutritional anemia.
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Cobalamin = Vitamin B12
Coenzyme. In pork, beef and poultry protein.
Deficiency = Pernicious anemia
Folic acid
Coenzyme.In Orange juice, meat and leafy green vegetables.
Deficiency = Nutritional Anemia.
Neural tube defects if deficiency is current during pregnancy.
Biotin
Coenzyme. In eggs, yolks and liver.
Deficiency = Dermatitis
Ascorbic acid = Vitamin C
Antioxidant, wound healing and hormone synthesis. Main source are Citrus fruits.
Deficiency = Scurvy (bleeding gums).
Vitamin A
Vision, bone and tissue growth, immune + reproductive function. In animal foods, fruits,
vegetables and fortified milk.
Deficiency = Night blindness, Xeropthalmia. Toxicity possible.
Vitamin D
Facilitates calcium and phosphor metabolism. In dairy products, fortified food sources.
Also produced by human body in kidneys and skin under the influence of sunlight.
Deficiency = Ricketts, Osteomalacia. Toxicity possible.
Vitamin E
Antioxidant, immune function. In vegetable oil, peanuts and margarine.
Deficiency = Hemolysis. Interferes with Vitamin K if taken in excess.
Vitamin K
Coenzyme for synthesis of clotting factors II, VII, IX, X.
Deficiency = Hemorrhagic disease. In green leafy vegetables.
Antidote, antagonist to warfarin. Toxicity possible.
Phytochemicals
Phytochemicals have no nutritional function. They are considered as functional food
since their consumption appears to correlate with health benefits. Proven or suspected
function as antioxidants in prevention of cancer, cardiac disease, macular degeneration
and alleviation of menopausal symptoms.
Types of Phytochemicals
Carotenoids
In colorful fruits, classified in beta–carotene and lycopene (in tomatoes and – products)
Pro – and antioxidant function.
Indoles
In broccoli and cabbage. Reduce estrogen effect (less risk of non-hormone depending
breast cancer). Protective against carcinogen development by influencing DNS activity.
Isoflavones
In soy foods, black and green tea. Cancer, osteoporosis, protection, reduction of
menopausal symptoms.
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Phenolic acids
In beans, fruits, vegetables, green tea, wine and soybeans. Binds metals to increase
excretion of carcinogenic substances. Cancer protection and glycemic control.
Terpones
In citrus peel and menthol oil. Carcinogen protective effect.
Phytoestrogens
In multiple plants, especially whole grain, soy beans and berries. Breast cancer
protective effect and reduction of menopausal symptoms.
Catechins
In teas. Rich in phenolic acid. Antioxidant activity, prevention of cancer and
antihypertensive effects.
Weight management and physiological nutrition
The basic principle of weight management is to balance calories consumed with calories
expended. Prevention of weight gain as well as weight loss therefore basically requires
decrease of calorie intake and increase of calorie loss due to physical activity. Basic
recommendations for adequate nutrition include the following guidelines.
Vegetables
Per 2000 kcal/d diet = 2 cups of fruit and 2 ½ cups of vegetables per day.
Equal consumption of vegetable subgroups necessary (dark, green, orange, legumes,
starchy).
Whole grains
Three or more ounces of whole grain product equivalents per day.
Milk
3 cups low fat or fat free milk daily.
Fats
Consumption of less than 10 % of daily calories from saturated fatty acids.
Consumption of less than 300 mg cholesterol / d.
Trans fat consume as low as possible.
Total fat intake should not over exceed 20 – 35 % of daily calories.
Preferably use of mono – or polyunsaturated fats from fish, nuts and vegetable oils.
Trans fats
Trans fats are unsaturated vegetable oils which are chemically enriched with hydrogen
to achieve a more aromatic taste and calories comparable to more expensive saturated
fats from animals. Trans fats recognized as risk factors for diabetes, obesity, cancer and
heart diseases. Widely used in fast foods and sweets although already banned in some
countries and states.
Carbohydrates (CHO’s)
Consumption of fiber rich fruits, vegetables and whole grains often. Limit added sugar
and caloric sweeteners. Practice of good oral hygiene.after consume of CHO is
mandatory.
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Sodium
Max 2300 mg / d (1 teaspoon)
Potassium
Choose Potassium rich food. Excess Potassium intake will be neutralized in kidneys.
BMI
Assessment of BMI:
Asessment of nutritional status
BMI = weight in kg (1kg = 2.2 lbs)
Height im meters 2
Healthy = 18.5 – 25 , Grade I Obesity= 25 – 29.9, Grade II Obesity = 30 – 40
Grade III Obesity = > 40.
Basal Metabolic Rate (BMR)
Increases with amount of lean muscle. Decreases by 2 % each decade after age 30.
Hip Waist Ratio
Differentiation between Truncal obesity (‘apple’) = increased health risk and
Pelvic obesity (‘pear’) = reduced health risk.
Skin fold measurements (calipers)
Triceps skin fold (TSF) , Mid arm Muscle circumference (MAMC)
Albumin Level
Normal = 3.5 – 5.5 g/dl
Mild depletion = 2.8 – 3.4 g/dl
Moderate depetion = 2.1 – 2.7 g/dl
Severe depletion = < 2.1 g/dl
Tranferrin, Albumin, Prealbumin (TPN)
Parameters to check response to parenteral nutrition.
Transferrin drops more rapidly than Albumin.
Total Lymphocyte count depletes if protein count becomes depleted
(carrying Antibodies) !
Nutritional needs across the lifespan
Calorie supply in pregnancy and lactation
Pregnancy = + 300 calories / d, Lactation = + 500 calories / d
Weight gain in pregnancy is determined by BMI prior to the pregnancy as follow:
< 19.8 = + 28 – 40 pounds
19.8 – 24.9 = + 25 – 35 pounds
25 – 29 = + 15 – 25 pounds
> 29 = + 15 pounds
Infancy
Weight doubles in first 6 month of life and triples by first year.
Cow milk is deficient of fatty acids, iron, zinc, Vitamin E, C
and has to be avoided in first year!
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Flouride supply to be started generally from 6 months of age,
unless water supply is fluoride deficient!
Solids from 4 – 6 months by introducing one new food every week, starting with a small
amount. Food has to be cooked well and cut in tiny pieces.
Childhood
Ritualistic and erratic eating patterns, strong food preferences in Toddlers and
preschoolers. Daily multivitamin may be considered.
Adolescence
Male growth spurt from 12-13 , peak at 14, continue until 19. Female growth spurts at 11,
peaks at 12, continues until 15.
Therapeutic diets
Clear liquid diet
for abdominal surgery and gastroenterologic diseases.
Fluid water, 500 – 100 kcal, simple sugars, electrolytes and fiber free.
To be pursued over 1 - 3 days. Only foods and fluids that are liquid at room temperature.
Full liquid diet
for patients with non – neurological dysphagia or for short term postoperative, post –
surgery diet. Water calories, proteins and minerals, vitamins and dairy products.
Pureed diet
for patients unable to chew or swallow properly.
Food has to be prepared in a way that avoids aspiration of solid particles.
Dysphagia diet
Thickened liquids, requires at least 30 – 45 degrees head elevation.
Soft diet
for people with chewing difficulties due to oral problems as a transition diet.
Mechanical soft diet
Tender, soft textured, chopped foods are included in this diet.
Bland diet
avoiding food that stimulates the GI tract and the production of gastric acids. e. g. Spices,
sweets, fat, alcohol, pepper, caffeine and fried food.
High residue / high fiber diet
to regulate bowel function, fat and blood sugar metabolism.
20 – 25 g of fiber daily to add bulk to stool. Vegetable, fruits, legumes and whole grains.
Low residue / low fiber diet
for gastrointestinal obstruction, chronic inflammatory bowel diseases, enteritis, diarrhea.
High CHO (pasta, white bread, cerals), avoiding fibers.
Restricted or enhanced diets
Carbohydrate controlled diets
in Diabetes, Obesity, Hypoglycemia and Galactosemia, Dumping Syndrome,
Consists of 55 – 60 % CHO’s, 10 – 20 % proteins, 10 % or less saturated fat. 20 – 35 g
fiber.
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Fat controlled diet
in malaborption syndromes, pancreatic- , bile duct diseases and Gallbladder stones.
Medium chain triglycerides (MCT) are utilized in diet because they are easily digested
along with high intakes of CHO’s and proteins. Saturated fats are sparingly used.
May require enzyme replacements.
Gastric bypass diet
Small meals several times daily with sufficient amounts of liquids in between.
Multivitamin supplements may be necessary.
Low fat and high protein, No carbonic acid, simple sugars and no high fiber food.
Protein controlled diet
in progressed liver and kidney diseases.
Avoiding excess amounts of protein because of diability to metabolize and to excret
metabolic products properly. Up to 0.8 g/kg of dry weight, max. 40-60 mg /d. 1.5 – 2.0
g/kg in excess for additional need due to dialysis and liver repair. Minimum amount of 50
– 100 grams CHO / d.
Food allergy diets (Elimination diets)
Gluten – restricted diet for clients with Aprue or Coeliac’s disease.
Avoidance of any prepared and commercially prepared food with sources of wheat
including beer. Allowed: Cornmeal, corn flakes, popcorn, hominy, potato chips, potatos,
rice, soybeans and flour.
Lactose Intolerance diet
Avoidance of dairy products including casein, may need supply of lactase tablets.
Lactose may be part of oral medication ! Yogurt is allowed! Clients may need supply of
Calcium, Vitamin B6 (Riboflavin) and Vitamin D.
Purine controlled diet
Indicated in gout, tumor lysis syndrome, multiple myeloma. Increased purin
accummulation leads to uric acid increase. Restriction of dairy products, alcohol,
anchovies, meats and seafood.
Sodium controlled diet
Indicated in hypertension, cardiovascular disease and heart failure. Sodium intake as
low as 500mg / d. Salt restriction increases risk for potassium elevation especially under
use of potassium sparing Diuretics ( e. g. Triamterene). High sodium content in canned
foods , breads and salted snacks, Meats, sauces, spices, instant drinks and commercial
mik.
Tyramine and dopamine restricted diet
Indicated in MAO treatment. Foods to avoid are cheeses, bananas, chocolate, smoked
fish and meats, soy sauce and flava beans.
Low Potassium diet:
Indicated in renal failure and use of Potassium saving drugs. Food sources to avoid are
apricots, avocados, bananas, cantaloupe, raw carrots, dried beans, dried fruits, melons,
oranges and orange juice, peanuts, potatoes, prune juice, spinach, tomatoes and winter
squash.
High Calcium diet
Indicated in osteopenia, osteoporosis, endocrine abnormalities, kidney failure. Sources
are dairy products, milk and green leafy vegetables.
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High protein diet
Indicated for severe burns, liver disease, athletes. Preference of meat, fish, poultry and
dairy products.
High calorie diet
Immunodeficiency, burns and wounds. Nutritious snacks and proteins.
High iron diet
Indicated in anemia. Iron supply, bread, egg yolks, dried fruits and legumes.
x
Vegetarian diet
Vegan: (strict vegetarian), Ovovegetarian, Lactovegetarian and Ovolactovegetarian
Lab monitoring parameters of dietary treatments
Relevant parameters: TLC, BUN, Albumin, Prealbumin, Creatinine and Electrolytes.
Tube feeding specific considerations
To check placement of tube assess pH of aspiration fluids and auscultate stomach.
Formulas must be supplied as ordered. (isotonic
hypertonic) Tubes have to be
assessed for remaining food particles at the end of the feeding procedure and need to
be flushed regularly. Feeding supplies have to be checked for best before date.
Documention of lab findings and weight is required.
Obesity
Starts from weight > 22 % of normal body weight in young men and > 25 % in older men
or from > 35 % in women. Morbid obesity = 100 % than normal body weight. Most
common cause is dietary: high fat diet and sedentary lifestyle. Rare causes: Prader willi
syndrome, cushing syndrome, polycystic ovary syndrome, hypogonadism and
insulinoma, growth hormone insufficiency. Supported by medication: antidepressants,
estrogene, corticosteroids, antiepileptics, antihypertensives, nsaid and phenothiazines.
Social and psychological factors.
Nursing assessment
BMI? Type of Obesity? “apple or pear ”? Type of body? endomorph (stocky) ectomorph
(tall) mesomorph (middle range). Assesment of obesity complications: Lab findings,
ECG and BP.
Obesity treatment
Normal safe weight loss under dietary treatment is 1 – 2 pounds per week. Exercise
should be at least 30 minutes of an aerobic activity/d. Behavioral therapy is part of the
treatment as well. Surgery may be indicated in BMI > 35 and no response to other
treatments, always in BMI > 40. Procedures are: gastroplasty (most common), intestinal
bypass, maxillomandibular fixation and esophageal banding. Medication therapy is
controversial, only in BMI > 30 or 27 with comorbidities along with diet and exercise.
Anorectic medications are contraindicated, pregnancy and lactation. Liver -, kidney -,
cardiac diseases.
Treatment for underweight clients:
Correction of underlying cause is of primary importance.
1 pound weight gain per week requires 500 additional cal./d ! = 3500 kcal per week
Supportive medication therapy includes Megestrol acetate (Megace), Dronabinol
(Marinol) which may be used as appettite stimulants. Treatment includes eating plans
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with steady increase portion sizes and nutrient dense food. Physical activity to increase
muscle tone and metabolism is part of the treatment. Supplemental feedings, tube
feedings, may be necessary.
Proteine deficiency in significant underweight situations may lead to:
•
•
•
•
•
•
•
Immunodeficiency
Fluid shifts to the third space (extravasal room)
Ascites (Kwashiorkor) and Edema (dependant and periorbital)
Electrolyte imbalances
Skin, nail and hair changes
Delayed wound healing
Mouth sores, oral cavity changes and decreased dehydration
-Hygiene needs-
Common skin problems
Flaky, dry, itchy skin, Abrasion of epidermis, ammonia dermatitis (diaper rash)
contact dermatitis, erythema and pressure ulcers (Open lesion over bony prominences)
Specific hygiene measures
Partial bed bath, complete bed bath, perineal care, nail and foot care
Document skin conditions!
Oral care, hair and scalp care, care of eyes, ears and nose. Care of an eye Prosthesis.
(wipe from inner to outer canthus)
Always document ability to self care !
-Oxygenation needs-
Function of the cardiorespiratory system
Conditions affecting oxygenation:
Altitude
Increases Respiratory rate, cardiac rate, respiratory depth.
Heat
Causes peripheral vessel dilation, increased blood flow to skin decreased
resistance to blood flow, CO , BP , HR Increase of breathing rate and depth.
Causes Vasoconstriction, BP , reduced need for oxygen, HR
Cold
Air pollution
Causes coughing, choking and difficulty breathing.
Narcotics (Morphines)
cause central nervous depression of breathing rate.
Premature infants
immature lungs, respiratory center, gag and cough reflex.
Infants and toddlers
are primarily endangered by aspiration.
Older adults
Emphysema development.
Hyperventilation:
increased rate , reduced depth of inspirations.
Hypoventilation:
inadequate alveolar ventilation.
Hypoxia:
(acute) rapid pulse, rapid shallow respirations, dyspnea, flaring nostrils,
restlessness, intercostals / substernal retractions and cyanosis.
Cyanosis:
blue discoloration of skin, mucous membranes and nails.
Orthopnea:
Breathing difficulties while lying down
Dyspnea:
Difficulty breathing to air hunger.
Wheezing:
caused by narrowed bronchus (bronchoconstriction)
Chest pain accompanied by breathing diificulties and cyanosis
may be a sign of an acute pulmonary or cardial damage !
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Nursing interventions to promote oxygenation
1.
Providing oxygene supply
2.
Suctioning of trapped mucous from airways
3.
Positioning of client in Fowler’s position
4.
Assessment of oxygenation with pulseoxymetry and blood gas analysis
5.
Decrease of anxiety by verbal intervention
6.
Turn clients with emphysema from side to side 1 – 2 hourly
7.
Chest physiotherapy: percussion, vibration, postural drainage
8.
Place client in lateral position if unconscious
Oxygen delivery systems
Nasal cannula = 1 – 6 l/min of 23 – 42 oxygen concentration
Oxygen mask = most effective, delivers low or up to 100 % of oxygen,
Simple face mask = treatment of CO2 retention, 6-8 L / min, 40 – 60 %
Partial rebreathing mask = retains parts of exhaled air from trachea and bronchus
Non rebreathing mask = fits tightly over face and designed for 80 – 100 % oxygen
supply.
Oxygen tent = mainly used in infancy. Flow rate is 20 L/min, 60 %
Ventimask Venturimask = for chronic alveolar hypoventilation and CO2 retention.
-Meeting the need for sleep-
General requirement is to assure circadian synchronization to avoid inadequate day
tiredness. Stages of sleep are NREM and REM sleep. NREM sleep (non – rapid eye
movement) is deep and restful sleep, leading to decreased physiologic functions.
The 4 Stages of NREM sleep:
Stage 1: very light sleep, sleeper is relaxed and drowsy, floating sensations eyes roll
from side to side, every few minutes.
Stage 2: light sleep and easily awaken.
Stage 3: medium depth sleep: less easily awaken, muscles relaxation and reflexes
decrease.
Stage 4: delta sleep. Deepest sleep stage, sleeper difficult to awake, rarely moving,
muscle, relaxation, and dreaming.
REM sleep (rapid eye movement)
Every 90 minutes for 5 – 30 minutes. Active, memorable dreaming occurs, vital signs
remain regular. Hard or easy awaken. REM sleep decreases to about 20 % of overall
sleep in adolescence.
Changes of sleep patterns during childhood development.
Neonates:
16 – 18 hours of sleep / d, 50 % NREM Stades III + IV, 50 % REM sleep.
Infants:
12 – 22 hrs. of sleep / d, wakeful periods increase with age, at 4 month sleep through
the night can be expected with naps during the day, first year, sleep 14 of 24 hours, half
of time infant have light sleep and 20 – 30 % REM sleep.
Toddlers:
Normal sleep – wake cycle is established by 2 – 3 years. Toddlers generally sleep for 10
– 12 hours / d. Requires midafternoon nap. 20 – 30 % REM sleep.
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Preschoolers:
11-12 hours sleep /d., fluctuates due to activity and growth spurts and 2 – 30 REM sleep.
School age:
8 – 12 hours without daytime naps. REM sleep decreases to about 20 %.
Adolescents:
Sleep declines to 8 – 12 hours / d.
Adults:
6 – 8 hours / night, 20 % REM sleep.
Older adults:
On average 6 hours of sleep a night, 20 – 25 % REM, decrease in stage IV NREM
sleep, sleep disorders are more common.
Factors interfering with sleep
Illness, drugs and substances, caffeine, nicotine, lifestyle, emotional stress, environment,
various prescribed drugs, exercise, fatigue and food / calorie intake.
Sleeping disorders and modes of treatment
Insomnia
Sleep inducing and sleep maintaining behaviors. Short term sedatives and correction of
underlying cause.
Sleep apnea
Periodic cessation of breathing during sleep. From 1second to 2 minutes. Accompanied
by snoring, hypertension, heart diseases, especially elder obese men. May also be
caused by Adenoids and enlarged tonsils. Improvement under nasal cPAP. (continous
positive airway pressure).
Narcolepsia
Uncontrollable desire to sleep. Treatment with stimulants (amphetamines).
Parasomnias
Abnormal behaviors associated with sleep.
•
Somnambulism
Episodic sleepwalking in stages III + IV NREM and 2 hours after falling asleep.
•
Sleeptalking
Occurs during NREM sleep.
•
Nocturnal enuresis
Bedwetting common in male children > 3 years of age, when arousing from
stage III to stage IV NREM sleep.
•
Nocturnal erections
Start around adolescence and occur during REM sleep.
•
Bruxism
Clenching and grinding teeth during stage II NREM.
Sleep deprivation
REM sleep deprivation, caused by alcohol, shift work, jet lag, extended ICU
hospitalizations. REM sleep deprivation has same causes as well as hypothroididm,
depression, sleep apnea and age.
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Sleep improving factors
Adjustment of environmental factors, bedtime routines, comfort promotion, activity
promotion (exercise reduces stress), medications should be last resort and used on a
short term basis.
-Urinary elimination needs-
Normal urine output is 1500 ml/d, 30 - 60 ml / hr.
Characteristics of normal urine specimens (MSU):
• Contains 96 % water as well as urea, ammonia, uric acid, creatinine, inorganic
solutes sodium, chloride, potassium, sulfate, magnesium, phosphorus.
• Sterile (no bacteria included)
• pH 4.5 – 8 (normal H+ ion concentration in plasma and extracellular space).
• Specific Gravity 1.010 – 1.025 (reflects normal concentration ability of kidneys)
• Glucose not present (presence indicates Diabetes, Blood Glucose > 180 mg/dl)
• Ketone bodies not present.
(traces of breakdown of fat cells, indicates fasting or in higher concentrations
poorly controlled Diabetes)
• Blood if present indicates inflammation, uti,damage of glomerular membranes.
• Aromatic odor
Protein are not present in normal urine specimens. !
Traces of protein may occur as orthostatic proteinuria in tall slim people.
Larger amounts of proteins, esp. Microalbumin
indicates damage of glomerular membranes. !
Abnormal urination symptoms:
Urgency
strong unavoidable desire to void
Dysuria
painful voiding
normal once / 3 – 6 hours
Frequency
Hesitancy
delay in initiating urination
large volume per urination
Polyuria
Oliguria
100 = 500ml / 24 hr
excessive and sleep interrupting urination.
Nocturia
Hematuria RBC’s in Urine
Common urinary elimination problems
Urinary retention
(i.e. in cases of BPH syndrome,Urethra strictures, neoplasms, medications:
anticholinergic, antidepressants, antipsychotics, antiparkinsonian and antihypertensives)
Urinary tract infections
Incontinence: involuntary urination
Urine and urinary tract examinations
Urine culture / Antibiogramm
To assess number and type of bacteria and their sensitivity towards antibiotics in
contaminated urine over 24 – 72 hours.
Intravenous pyelogram or urogram (IVP/IVU)
Injection of radiopaque contrast media to assess kidneys, ureter and bladder.
Renal Scan
Radio traces or isotopes injected IV. Shows renal size, perfusion, function and position
under scintillation camera.
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Ultrasound
Imaging of the urinary system by reflected high frequency ultrasound waves.
Cystoscopy
Assessment of urethra and bladder via endoscopic magnifying tool with possibility to
take biopsies.
Bedside bladder scan
Ultrasound examination tool to assess filling of bladder.
Health Promotion for urinary elimination
Adequate hydration of minimum 1500mL / d, proper personal hygiene, emptying bladder
completely (Kegel exercises), cotton briefs for women for UTI prevention, acidification of
urine for UTI prevention (cranberry juice and vitamin C products), avoidance of excess
intake of dairy products.
-Bowel elimination needs-
Infant and toddlers have immature control of bowel function. Daytime control should be
present by 2 ½ years with toilet training. School age children may delay elimination.
Older adults are prone to constipation. In general a regulated bowel function requires
adequate amount of fibers and fluids and physical activity. Constipation may be caused
by Codeine, Morphine, antipsychotic, antiparkinson, antidepressant medication and any
medication with anticholinergic effect. Also after abdominal surgery and general
anesthesia.
Bowel function disorders
Constipation, impaction, diarrhea, incontinence, flatulence and hemorrhoids.
Diagnostic tests
X-Ray Abdomen in standing or lying position (laying on left side), upper GI barium
swallow barium enema, endoscopy (EGD = esophagogastroduodenoscop, colonoscopy,
proctosgmoideoscopy).
Bowel diversion ostomies
Terminology considers part of diverted bowel segment. Commonly performed
procedures are ileostomy, cecostomy, ascending colostomy, transverse, colostomy,
descending colostomy and sigmoidostomy. Ostomies may be performed in a single, loop,
divided, double or barreled form.
Colostomy care
Colostomies rather tend to obstruct than ilestomies due to a naturally increased
thickness of the stool. Adequate colostomy care requires awareness for:
Odor causing food: garlic, onions, fish, eggs, beans and asparagus
Gas producing food: cabbage, onions and beans.
Stool thickening food: yogurt, cheese, tapioca, applesauce and bananas
Stool lossening food: spices, fruits, vegetables and dried food
Ileostomy care
Stool is typically soft and moist. Obstructions can be solved with warm fluids, warm
showers, knee chest positioning and massaging of the peristomal area. Pouch has to be
removed if stoma is swollen. Clients generally require a low residue diet, limit high fiber
foods. Clients with ileostomies tend to have a limited ability to digest due to a deficiency
of bile acids.
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-Wound Care-
Layers of Epidermis
Epidermis: Five layers of squameous epithelial cells deriving from basal cell layers.
Dermis: Elastic cells with nerves and blood vessels, glands and hair follicles
Subcutaneous tissue: Adipose tissue that provides support and blood flow to epidermis.
Skin glands: sebaceous glands, soporiferous glands, cerumenous glands and
secreting earwax.
Wounds
Break in skin or mucous membranes due to physical means. May be superficial and
affecting the skin surface only or deep, involving blood vessels, nerves, fascia, tendons,
ligaments and bones.
b
Classifications of wounds
1. Open wounds e. g. cut, lacerations, abrasions
2. Closed wounds e. g. contusion or ecchymosis
3. Full thickness burn or injury that reaches until subcutaneous tissue
4. Partial thickness burn or injury reaches epidermis and dermis
5. Noninfected / infected
6. Surgical wounds
Pressure ulcers
Skin lesion by unrelieved pressure. Caused by immobility, cachexia, moisture, friction,
shearing, dry skin.
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Norton and Braden Scale for assessment of Pressure ulcer Risk
Stage 1: skin intact, erythema possible, tingling or burning sensations, edema,
Induration, hardness as indicators.
Stage 2: superficial partial thicknes skin loss, blister, abrasionlike appearance
Stage 3: full thickness skin loss, extending to fascia,
Stage 4: damage beyond fascia, affection muscles, bones, tendons,\. May also build
Fistulas.
Phases of wound healing
1.
Inflammatory phase
RBC and proteines build fibers of fibrin. Increased blood perfusion of the area to
assure adequate nutritional supply. Healing ends with a scab from fibrin and other
proteins. Skin heals in 3 – 4 days.
2.
Proliferative phase
Fibroblasts grow to form granulation tissue with new capillaries and epithelial cells.
Connective tissue builds scar tissue. Excession build up of granulation tissue forms
keloid.
3.
Maturation / remodeling phase
Weeks – years of reorganization of collagen fibers, wound remodeling, tissue
maturation.
Factors affecting wound healing
Age, nutrition (Vitamin C!, Proteines), Condition of injured tissue (Grade of destruction,
contamination), efficiency of circulation, rest, anxiety, stress, medications.
(Immunosuppressant, Cyclooxigenase inhibitors)
Wound closure is either caused by primary intention (surgical repair)
or by secondary intention ( scarring)!
Dehiscence and Evisceration of tissues require urgent surgical repair!
Wound assessment
Signs of infection
Redness, swelling, increased tenderness, temperature, WBC, disruption of wound edges.
Treatment with wound cleaning Saline – or diluted antimicrobial solutions. Gauze
squares.
Dressing types
Gauze
Sterile, nonsterile, antimicrobial, absorbs drainage
Transparent
Impermeable to bacteria and fluids, supporting autolytic debridement
Composite dressing
Absorbent and adhesive cover. May only require 3 changes weekly. Hydrocolloids –
Adhesives made of gelatine. Occlusive to microorganisms. Enhances autolysis of wound
bed.
Hydrogel
Water or glycerine is primary component. Maintains moist, oxygenated surface.
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Calcium alginates
Made of seaweed fibers to absorb larger amounts of drainage.
Exudate absorbers
Semiperneable polyurethane foam that absorb large amounts of exsudatives while
keeping wound moist.
-Monitoring of Tubes and Drains-
Tracheostomy
Surgically created opening in the cricothyroideum ligament between cricothyroideus
cartilage and 1st tracheal cartilage. May be temporary or permanent. (Jackson tube)
Variations include double or single lumen (with or without inner cannula),cuffed or
cuffless, fenestrated and not fenestrated.
Any procedures performed on a trachestoma require that there is a manual resuscitation
bag available at all times. Replacement tracheotomy set has to be in reach in case
tracheostoma is accidentialy removed and fistula opening collapses!
Tracheostomy care
1.
Respiratory assessments 4 hourly.
2.
Suctioning prn.
3.
Frequent assessment for signs of infection.
4.
Tracheostomy care required every 8 hours including assessment of cuff pressure.
5.
Change of tracheostomy ties daily, if soild.
Change requires to have tracheostomy held in place by assistant during the
procedure since patient may cough and accidentially loose it.
Ensure alternate communication with patient if tracheostomy has a cuff inflation.
Accidental removal of a tracheostomy tube is a medical emergency,
especially if trach was inserted within the last 72 hours!
Management of accidential tracheostoma tube removal
hold stoma open by grasping retention sutures or using curved clamp
insert obturator, insert tube, remove obturator, if problems occur call rapid response
team.
Long Term complications of Tracheostomy
Tracheomalacia
Tracheoesophagel fistula
Tracheal stenosis through scar tissue
Tracheal innominate artery fistula (Life threatening condition)
Endotracheal tube
Required for mechanical ventilation up to 14 days. Orotracheal or nasotracheal insertion.
Assessment of correct placement of an endotracheal tube
Ventilation with manual resuscitation bag and auscultation of epigastric area.
Use of CO2 analyzer
Portable Chest X-Ray (tip of tube to be placed to 1–2 cm above bifurcation (carina))
Respiratory assessments 4 hourly
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Suctioning prn
Oral care 2 hourly
Reposition tube daily
Inflating cuff by minimal leak technique or minimal occluding volume technique
Removal of airway tube
1.
Suction trachea,
2.
Adjust client to semi–fowlers or fowlers position
3.
Deflate cuff
4.
Remove tube at peak inspiration
5.
Close monitoring for 30 minutes
6.
Expect sore throat and hoarseness
Closed Chest Systems
Chest tubes are placed to remove air or fluids from pleural cavity by producing a
vaccuum. Commonly a 3 Chamber system with water seal (vacccum), suction and
collection.
Management of closed chest systems:
1.
All tubing connections have to be secured from dislocating with tape.
2.
Collector needs to be positioned below chest.
3.
Milking of the chest tube can cause organ damage.
4.
Clamping of chest tube requires Physicians order.
5.
No clamping when patient is mobile. Clamp must be in reach at all times.
6.
Monitor drainage 1 – 4 hourly.
7.
Maintain – 2cm water level suctioning.
8.
Water level must fluctuate.
9.
Continuous water bubbles indicate leak in the system.
10.
Light permanent bubbling in the suction control chamber is to be expected.
11.
Intermittent inspiratory water bubbles in a Pneumothoax indicate normal function.
12.
Reposition client twice hourly.
13.
Encourage deep breathing, and coughing.
14.
Daily Chest X Ray may be necessary.
15.
In accidential dislocation or damage of system insert chest tube into sterile water
to maintain water seal, then replace system.
16.
Accidential removal of chest tube requires immediate cover, closure of insertion
wound and surgeon to be contacted. Scheduled Removal under Valsalva
maneuver.
Renal and urinary tract tubes
Nephrostomy or ureteral tube
Minimum output is 30 mL/hour. Drainage should occur at least every 15 minutes. Irrigate
only if ordered with 5 ml sterile saline under sterile precautions. Action necessary if
irrigation does not restore tube.
Indwelling urinary catheter
Specifications: Retraction foreskin in men while cleaning with soap and warm water.
Repositioning after removal mandatory. Remove during exhalation.
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Nasogastric tubes
Salem tube (common) = double lumen allows continuous suction.
Levin tube (less common) intermittent suction only otherwise tube collapses.
Insertion of a nasogastric tube
Position client upright in Fowlers position.
Measure distance tip of nose – earlobe – xiphoid process and mark with tape on tube.
Lubricate tip with lidocaine gel or water soluble gel.
Insert slowly while client swallows small sips of water.
Coughing, choking indicates tracheal insertion
Fixate when end of insertion is reached.
Confirm placement by injecting air and auscultation of epigstric area.
Chest X – Ray prior to use with food and fluids (most reliable).
Aspiring fluids for pH testing every 4 hours.
(should be 4 or less in correct placement. Higher pH indicates intestina placement)
Be aware of increased mouth dryness since client needs to inhale though mouth.
Nasoenteric - (intestinal) tubes
Miller – Abbott or Cantor tube with tungsden weight at the terminal end. Tube forwards
through peristaltic and gravity, may take hours to reach desired position. Requires X-Ray
to confirm correct position. Positioning of client with head of bed elevated, laying on right
side.
Combined esophageal and gastric tubes
Sengstaken-Blakemore tube
3-lumen tube for treatment of bleeding esophageal varicosis. Gastric and esophageal
balloons with 25 – 45 mmHg pressure. Intermittent suction tube. Needs to be maintained
under traction. Can not be used if patient has esophagus lesion on history.
Minnessota tube
Additional 4th lumen for suctioning fluids from esophagopharyngeal area. Scissors have
to be available at bedside at all times to cut tubes rapidly in case of respiratory distress.
Risk of ongoing bleeding and esophagus rupture.
Gastric Lavage tubes
For removal of indigested toxins from stomach.
1.
Ewald tube:
Single lumen for one time use.
2.
Lavacuator tube:
Two lumen, for irrigation and suction.
Unconcious clients are generally at increased risk for aspiration!
Under these conditions gastric lavage tubes can only be
inserted after endotracheal intubation!
Wound drains
Closed wound drainage system
Commonly used are Jackson – Pratt Drain, Hemovac Drain under electric or
mechanical device suction. Collection chamber needs to be squeezed to reestablish
suction after emptying the system.
x
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Penrose drain
In cases of excessive serosanguineous drainage. Inserted via stab wound a few inches
from surgical incision. Drains onto gauzes, lightly dressed, secured by suture. Usually
removed after 3 – 4 days.
-Fluid and Electrolyte imbalances-
Definitions:
Intracellular space (ICS)
Contains intracellular fluids which represents > 2/3 of body fluids.
Extracellular space (ECS)
Intravascular space and intercellular space.
Constant fluid and electrolyte exchange between ics and ecs occurs by osmosis.
Osmosis
Shift of fuids and small particles from compartments of lower concentrations to
compartments of higher concentrations through a semipermeable membrane until the
concentrations of both solutions are equalized. Concentrations of solutions are defined
by Osmolality and osmolarity which are determining the osmotic pressure of a fluid
within a compartment. Characterizing the strength of a solution to draft water from
another fluid filled compartment.
Osmolarity (per liters of fluid)
osmolality (per kilograms of fluid)
= osmotic pressure = water intake
Osmolarity and osmolality are of equal size if the solvent solution is water (1 liter = 1
kilogram). The osmolality of serum is 275 – 295 mOsm/L.
Isotonic solutions have eqal osmolarity as serum (e.g. 0,9 % NaCl, Ringers Solution,
D5W) and remain in the extracellular space.
Hypotonic solutions have lower osmolarity than plasma and get shifted as free water
into the intracellular. (e.g. 0.45 % NaCl, 0,225 % NaCl)
Hypertonic solutions have a higher osmolarity than plasma and remain in ecs to draft
water from cells (e. g. 10 – 50 % dextrose, 3 – 5 % NaCl, 5 % dextrose + hypotonic
sodium chloride solutions).
Diffusion
Shifting of particles (e. g. electrolytes) from solutions of higher concentrations to
solutions of lower concentrations through a semipermeable membrane.
Forces to facilitate movement of fluid through capillaries:
Hydrostatic pressure is created in the vascular capillary system and in interstitial
system by amount of intravascular fluids, cardial output and blood pressure.
Oncotic pressure or colloidosmotic pressure
Exists in the capillary and intersititial system. Colloids are large particles (proteines) that
remain in the intravascular system and draft water into ecs) Deficiency of colloids leads
to fluid loss into the third space. (e. g. Kwashiorkor, Ascites) Hydrostatic and oncotic
pressure in the interstitial space are normally lower than in ecs to allow fluids to shift into
the interstitial system.
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Hormonal regulation of the fluid and electrolyte distribution
Antidiuretic Hormone ADH
Increases renal water reuptake.
Synthesized in hypothalamus released from the posterior lobe of the pituitary gland.
ADH deficiency leads to Diabetes insipidus.
Aldosterone
Increases renal natrium and water reuptake and potassium excretion.
Produced and excreted by adrenal glands. Activated by activation of Renin - Angiotensin
System RAA once blood pressure decreases. ADH and Aldosterone release activates
thirst if changes on plasma concentrations are noticed in hypothalamus.
Corticosteroids
Promote natrium and fluid retention in kidneys.
Produced and excreted by adrenal glands. Further physiologic effects of corticosteroids
include hyperglycemia, increase of blood pressure, thrombocytosis and leucopenia.
ANP(F) Atrial natriuretic peptide (factor)
induce reduction of blood pressure,
increase of GFR, inhibition of RAA - system and ADH secretion.
Cardiac hormone released by cardiac overload.
Average physiological daily fluid losses:
Renal 1500 ml/day
Skin (perspiration, sweat) 500ml/day
Lungs 350ml/day
Feces 150mL/day
= 2500 mL/day
Dehydration conditions in regards to changes of the ECF:
Isotonic Dehydration
Most common due to loss of ECF. (e. g. bleedings)
Hypertonic Dehydration
Fluid loss requires shifting of electrolytes to recompensate ECF. Typical for any
condition that mainly leads to fluid loss (e. g. sweats).
Hypotonic dehydration
Fluid loss is recompensated by fluid shift from ICS only. Typical for chronic ongoing fluid
loss i.e. due to a chronic illness with loss of proteins (e. g. Ascites).
Fluid loss into the third space
Effusions of pleural space, pericard, abdomen and peripheral edema.
Fluid loss into the third space is caused by any condition that leads to a loss of proteins
which keeps the colloidosmotic pressure stable (e.g. trauma, burns, ulcers, sepsis,
abdominal surgery, cancer, malnutrition, liver failure). Or any condition that leads to an
increased vascular hydrostatic pressure due to a fluid overload that overcomes the
colloidosmotic pressure (e. g. heart and renal failure).
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Signs and symptoms of Dehydration
•
• Reduced urine output:
< 2mL / kg / hour (children)
< 30 mL / kg / hour (adults)
• Urine specific gravity > 1.035
• Serum osmolality > 300mOsmol/kg
• BUN,HCT,Creatinine
• Hypernatremia > 150 mEq/mL
• Dry skin and mucous membranes
• Sunken eyeballs
• Hypotension
• Flattened peripheral veins
• Hypotension
• Tachycardia
• Desorientation
• Neurologic defincincies (TIA, PRIND)
Weight loss (Scaling more realiable than I&O)
Fluid Volume Excess (FVE)
Isotonic FVE due to renal failure, heart failure, excess fluid intake, high corticosteroid
and aldosteron levels.
Hypotonic FVE due to medical procedures (e. g. rinsing during endoscopic
examinations), excessive intake of hypotonic fluids and syndrome of inadequate ADH
secretion (SIADH).
Hypertonic FVE due to excessive salt intake.
Symptoms of fluid volume excess
Edema, Bulging fontanels, CVP , pulmonary edema, fluid loss into third spaces, weight
gain, HCT , BUN , Serum Osmolality < 275mOsm/kg, Serum Sodium < 125 mEq/L
Treatment:
Increase of diuretic activity, puncture of third spaces and restriction of fluid intake.
Elecrolyte imbalances
Hyponatremia
Sodium < 135 mEq/L
Main causes are fluid excess and hemodilution as well as sodium losses through burns,
trauma, surgery, open wounds.
Symptoms and diagnostic findings:
Symptoms are equivalent to FVE symptoms. Also neuromuscular dysfunction, agitation,
weakness, headache, confusion, seizures, lethargy, dizziness, gastrointestinal nausea,
vomiting, diarrhea, cramps.
Treatment:
Treatment of underlying cause. Diuretics or sodium supplementation as required.
Hypernatremia
Sodium > 145mEq/L
Sodium excess can occur in any volemic filling stade but occurs most commonly in
dehydration. “Natrium (sodium) always follows the water!”
Symptoms and diagnostic findings:
Symptoms are similar to symptoms in a dehydration stade. Tachycardia, hypertension,
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dry skin and mucous membranes, increased urine output, diarrhea, neuromuscular
contractions, muscle fasciculations, tremor, hyperreflexia, halluzinations. Hypernatremia
can also be induced by a sodium rich diet although this appears to be a rare cause.
Symptoms and diagnostic findings:
Salt restrictions from 3g to 0,5 g/day, loop diuretics and fluid supply.
Hypokalemia
Serum Potassium < 3,5 mEq/L
Caused by hyperaldosteronism, adrenal adenoma, cirrhosis of the liver, heart failure,
hypertensive crisis, Cushing’s syndrome, diabetes insipidus and renal dysfunction. Also
possible side effect of medication therapy with loop and thiazide diuretics, corticosteroids,
cardiac glycosides, penicillines, amphotericin B, gentamycin, theophyllin and tocolytic
medications. Physical conditions leading to hypokalemia are vomiting and diarrhea,
ileostoma, colon adenoma, laxatives, enema, sweating (Diaphoresis), dialysis, and
potassium restricted diets.
Symptoms and diagnostic findings:
ECG: ST-Segment depression, flattened T-Wave, U Wave phenomenon, dysrhytmias,
Increased Digitalis intoxicity, shallow, weak, breathing, polyuria, nocturia, urine specific
gravity , anxiety, depression, confusion.
Treatment:
Treatment of underlying causes. Supply of Potassium under constant monitoring of
serum potassium levels. Minimum urine output for supply is 0,5 mL/kg/hour. Maximum
infusion rate for parenteral supply is 10mEq / hour. Potassium is to be diluted in a
concentration of max. 1 mEq/10mL Higher dosages require constant ECG monitoring.
Paravasation causes tissue damage. Phlebitis, veinous irritation possible. Gastric
irritations possible due to oral supply, therefore supplementation after meals required.
Potassium Food sources:
Bananas, apricots, raisins, oranges, spinach, broccoli, green beans, carrots, tomato
juice, potatoes, dairy products, meat, nuts, whole grains and legumes.
Hyperkalemia
Serum Potassium > 5,1 mEq/L
Causes are excessive consumption of potassium rich food, decreased K+ excretion (M.
Addison, renal failure, potassium sparing diuretics, ACE - inhibitors (stop aldosterone
secretion), excessive hemolysis or tissue damage (K+ is mainly concentrated in the ICS),
metabolic acidosis, insulin deficiency, digoxin use, blood transfusions.
Symptoms and diagnostic findings:
ECG: peaked T Waves, widened QRS complexes, prolonged PR Intervals, flattened P
Waves, heart rhythm disorder including asystolia. Hypotension, bradycardia, respiratory
failure due to generalized muscular weakness, muscular fascilations, twitching, anxiety,
cramps, irritability, diarrhea and nausea.
Treatment:
Decrease of potassium supply and increase potassium output due to Diuretics
or Insulin – Dextrose 50/50 per infusion, Calcium Gluconate IV, Sodium bicarbonate IV.
x
x
X
x
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Hypocalcemia
Serum calcium < 8,5 mg/dL = <
Causes are dietary calcium deficiency and avoidance of dairy products. Excessive intake
of oxalates which limit the intestinal calcium absorption. Post thyroidectomy/
parathroidectomy, hypoparathyroidism, crohn’s disease, laxatives, excessive use of
phosphorous supplements, hypomagnesemia, blood transfusions and blood products.
Diuretics, hypoalbuminemia, vitamin D deficiency, renal diseases, sepsis, burns,
massive trauma, pancreatitis, corticosteroids, contrast media, biphosphonates, antacids,
anticonvulsants and heparine.
Symptoms and diagnostic findings:
ECG: QT – and ST - segment prolongation and cardiac arrest.
Hypotension, laryngospasm, paresthesias, muscle spasm, tetany, Chvostek’s sign
positive, Trousseaus sign positive, hyperreflexia, depression, amnesia, delusion,
hallucinations, convulsions, diarrhea, abdominal cramping, cataracts, brittle nails and
hair, increased vulnerability for fractures and bleedings.
Treatment:
Ca supply, treatment of underlying cause, Ca-Gluconate, Ca-Chloride, IV infusion or
emergency push, oral dosages 1,0 – 3,0 grams / day, calcitriol, vitamin D, phosphorous
binding agent based on need, thiazide diuretics.
Special monitoring under Ca – supply if client is under digitalis effect because of
enhanced cardiac output and contractility !
Temporary Hypocalcemia due to an induced respiratory alkalosis in a hyperventilation
will be treated with sedation, verbal intervention and CO2 breathing only!
Glycoside treatment under unregulated calcium and potassium levels
Hypokalemia and hypercalcemia increase the toxicity of Glcosides !
(= Digoxin and Digitoxin)
Hyperkalemia is rather leading to a cardiac arrest under treatment with Glycosides.
As a consequence glycosides have to be withdrawn in these conditions.
Hypercalcemia
Serum calcium > 10,5 mg/dL = >
Causes are osteolytic or other metastasis in cancer, hyperparathyroidism,
hyperthyroidism, calcium rich diet (Milk alkali Synrome), sarkoidosis, thiazide diuretics,
vitamin D intoxication, hypophosphatemia, lithium therapy and OTC antacids containing
CaCarbonate.
Symptoms and diagnostic findings:
ECG: decreased ST segments, shortened QT interval, dysrhytmia, cardiac arrest.
Hypertension, headache, confusion, psychotic symptoms, fatigue, increased DTR’s,
amnesia, lethargy, coma, anorexia, nausea, vomiting, constipation, abdominal cramps,
polyuria, polydipsia and kidney stones.
Treatment:
Calcium restriction, corticosteroids to limit intestinal absorption, loop diuretics, fluids
4000 mL/d, preferably high acidity juices (orange and cranberry). Parenteral fluid
replacement with 0,9% NaCl in dehydration or 0,45 % if fluid volume is restored.
Biphosphonates to limit Ca resorption from bone, calcitonin and dialysis.
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Hypomagnesemia
Serum magnesium < 0,75 mmol/L
Causes are alcoholism, prolonged parenteral nutrition, decreased absorption due to
intestinal conditions, chronic inflammatory bowel diseases, pancreatitis, ileostomy,
aminoglykosides, prolonged diarrhea, vomiting, burns and excessive trauma.
Symptoms and diagnostic findings:
Quite similar to hypocalcemia and hypokalemia ! Laryngeal Stridor.
ECG alterations: P Wave deformation, inverted T waves, ST segment depression,
Prolonged QT Interval, U waves, premature supraventricular and ventricular
tachycardias “Torsade des pointes” and ventricular fibrillations.
Concurrent hypokalemia, increased digitalis toxicity, nausea, vomiting, anorexia,
Chvostek sign, Increased DTR.
DTR sensitivity is the most reliable sign to monitor the clinical improvement
after supplemental magnesium therapy!
Treatment:
Oral replacement with Magnesium sulphate containing antacids, up to 350 mg daily.
Whole grain products, cereals, nuts, green vegetable, seafood, bananas and oranges.
Parenteral replacement requires at least 30ml urine output/hour.
Hypermagnesemia
Serum magnesium > 0,95 mmol/L
Causes are decreased renal output due to renal failure, increased intake, (Antacids,
enemas, parenteral nutrition), diabetic ketoacidosis, Addisons disease, lithium therapy
and dehydration.
Symptoms and diagnostic findings:
Symptoms comparable to hyperkalemia, decreased DTR, decreased muscular tonus,
hypotension, bradycardia and cardiac arrest.
ECG: Peaked T Waves, widened QRS complexes, prolonged PR Intervals, flattened P
Waves, heart rhythm disorder incl. asystolia and somnolence.
Treatment:
Limitation of Mg+ intake, diuretics, rehydration to increase urine production.
Calcium gluconate intravenously is an emergency treatment in cases of cardiac and
respiratory symptoms only!
Concurrent shifts of electrolytes
Magnesium, potassium, sodium and chloride deficiencies and overloads
occur concurrently and predict each other!
Hypochloremia
Serum chloride < 98 mmol/L
Causes are comparable to the causes of hyponatremia, hypokalemia and FVE since
hypochloremia is mainly an accompanying symptom of both conditions and rarely
occurring as a single finding. Other causes include increased chloride excretion in case
of elevated bicarbonate levels during a respiratory acidosis in clients with COPD or other
chronic pulmonary conditions leading to an increased pCO2. Diabetic ketoacidosis
(increased anion gap) vomiting, diarrhea, trauma, high pitch fever, sweating, SIADH and
Addison’s syndrome.
Symptoms and diagnostic findings:
Muscular twitching, tremor, decreased breathing rate and hypotension.
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Treatment:
NaCl or KCL supply (salt) , Cl- rich food are dairy products, eggs, seafood, processed
and canned food. Treatment of underlying causes e.g. hypervolemia, ABG monitoring in
case of acid base imbalance.
Hyperchloremia
Serum chloride > 106 mmol/L
Causes are dehydration, hypernatremia, metabolic acidosis, NaCl supply, Diabetes
insipidus, hyperaldosteronism and acute renal failure.
Symptoms and diagnostic findings:
Hyperventilation, dysrhythmia, accompanying hyperkalemia and hypernatremia,
metabolic acidosis.
Treatment:
Limitation of Cl- intake, diuretics, rehydration w. hypotonic 0,45 % NaCl or D5W and
correction of Acid Base imbalance.
Hypophosphatemia
Serum phosphorus < 2,5 mg/dL = < 0,81 mmol/l
Causes are hypercalcemia, malnutrition, vitamin D deficiency, excessive use of Mg+ and
Ca+ containing antacid medication due to complex building chemical reactions with
phophorus, oxalate (e. g. spinach and rhubarb) or phytate (e. g. whole grains). Other
causes are vomiting and diarrhea, ketoacidosis, alcoholism, hyperparathyroidism,
diuretics, renal failure, hypomagnesemia, hypokalemia, glykolysis (moves phophorus
into cells) respiratory alkalosis and total parenteral nutrition.
Symptoms and diagnostic findings:
Hemolysis (increased instability of Erythrocytes), Granulocyte dysfunction
(immunosuppression), paresthesia, tremors, spasms, tetany, confusion, seizures,
dysrhythmias, heart failure, shock, muscular hypoventilation, respiratory acidosis,
respiratory failure due to muscular weakness and reduced gastrointestinal motility.
Treatment:
Oral or parenteral supplement. Phosphorus rich food (e. g. meat, dairy products,
legumes and nuts) Avoiding calcium or magnesium containing antacids. Monitoring of
muscular strength (hand grasps). Monitoring of neurological status.
Parenteral nutrition generally requires phosphorus supply!
Hyperphosphatemia
Serum phosphorus > 4.5 mg/dL = > 1,45 mmol/l
Causes are dietary reasons, renal failure, hypocalcemia, hypoparathyroidism (= low
calcium), Vitamin D excess, blood transfusions and rhabdomyolysis.b
Symptoms and diagnostic findings:
Symptoms are determined by corresponding decreased Ca levels. (Hypocalcemia)
Calcification of soft tissues and organs (e. g. kidneys) and constipation.
Treatment:
Phosphorus restriction, phosphate binding agents, calcium supply, fluid supply, antacids
and stool softeners
Calcium and phosphate shifts always occurs in opposite directions.
e.g. Hypercalcemia = Hypophophatemia
- Acid – Base Imbalances -
Definitions:
Acid = releases all H+ Ions in dilution with water. Weak acids only release some H+ Ions.
Base = binds fast to H+ Ions if diluted in water. Weak base reacts delayed with H+ Ions.
Buffer = stabilizes pH between 7.35 – 7.45 by either adding or releasing H+ Ions
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Physiological buffer exist in all tissues and compartments:
•
•
•
•
Protein buffers
Phosphate buffers
Hemoglobin – oxyhemoglobin system buffer
Bicarbonate NaHCO3- (=renal) + carbonic acid H2CO3 (= respiratory) buffer
The bicarbonate and carbonic acid buffer system
The average ratio between NaHCO3 and H2CO3 is 20 : 1 ratio if pH is in normal range.
All buffer systems can be activated by pH alterations of renal and respiratory causes.
H2CO3 can be utilized by respiratory system for dissociation into carbondioxide CO2 for
exhalation and water.
HCO3 - will be excreted or retains H+ Ions from kidneys:
= CO2 + H2O
H2CO3
HCO3- + H+.
Pulmonary pH regulation:
Quick onset but not longlasting.
Hypoventilation creates CO2 increase = respiratory acidosis
Hyperventilation creates CO2 decrease = resp. Alkalosis
Renal pH regulation:
Slow onset but longlasting.
Ecxretion of acidic or alkaline urine.
Reuptake or diuresis of H+ amount regulates amount of HCO3- available as well as
reaction between ammonia (NaH3) and hydrochloric acid (HCl) to build ammonium
chloride (NH4Cl-) for excretion via urine.
A metabolic pH dyregulation is primarily regulated by resiratory system.
A respiratory pH dysregulation is primarily regulated by metabolic system.
Monitoring of acid base status
pH = negative logarithm of H+ ion concentration in mEq/ml
Physiological pH range 7,35 – 7,45
high pH = low H+ concentration, low pH = high H+ concentration
Acidosis = pH < 7,35 = CNS depression ; Alkalosis = pH > 7,45 = CNS excitation
PaCO2 = 35 – 45 mmHg (partial pressure of carbon dioxide in plasma)
< 35 mmHg = respiratory alkalosis = Hyperventilation
> 45 mmHg = respiratory acidosis = Hypoventilation andprolonged exspiration
(e.g. COPD)
HCO3- = 22-26 mEq/L
< 22 mEq/L = Acidosis
> 26 mEq/L = Alkalosis
Base excess (BE) = - 3.0 - + 3.0 (available amount of HCO3- available in ECF)
> + 3.0 = metabolic alkalosis
< -3.0 = metabolic acidosis
Serum anion gap (AG) = 10-12 mEq/L
= Na + - (Cl- + HCO3-)
> 12 mEq = metabolic acidosis
< 10 mEq = metabolic alkalosis
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PaO2 = 80-100 mmHg (partial pressure of oxygen in plasma)
SaO2 = (percentage of hemoglobin saturation with O2 )
Acidosis decreases affinity of oxygen to hemoglobin and eases its release to
the peripheral tissues. = right shift of oxygen dissociation curve
Alkalosis increases affinity of oxygen to hemoglobin which results in a tighter
oxygen binding to hemoglobin = left shift of oxygen dissociation curve
K+ ions exchange with H+ ions in case of alkalosis and acidosis
In acidosis K+ shifts to ECF and H+ to ICF
In Alkalosis K+ shifts to ICF and H+ to ECF
Analyzing an ABG
Deciding parameters
1.
pH
2.
pCO2
3.
HCO3Interpretation:
Primary imbalance always matches the direction of change of the pH!
Secondary imbalance shows compensating mechanism.
pCO2 and HCO3- never show acidosis or alkalosis simultaneously!
Aquiring an ABG specimen from a radial artery
Vital signs
Allen Test
Heparinized syringe
Ice in collection bag
Labeling
Note Temp, O2 Sat, ventilator settings, clients activity
Aquire sample
Pressure on punctured site
Immediate testing of sample required
b
Respiratory acidosis
Causes:
CO2 retention due to hypoventilation > 45 mmHg.
pH decrease < 7.35
Symptoms and diagnostic findings:
Hypotension, tachycardia, delayed cardiac conduction, decreased cardiac output, warm
red skin, dyspnea, muscle twitching, confusion, decreased level of consciousness,
hyperkalemia.
Compensation:
Increased breathing activity, H+ elimination and HCO3- retention in kidneys.
Treatment:
Any procedure that improves ventilation.
Upright positioning. Medication as required to treat underlying causes (i. e.
Bronchodilators).
The breathing activity of the respiratory system is stimulated by the PaCO2 levels and not
by oxygene levels. Therefore the oxygene supply to clients with chronic obstructive
diseases can lead to a decreased repiratory stimulation and respiratory failure and has
to be administered slowly and in low doses.
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Respiratory alkalosis
Causes:
pH > 7,45, paCO2 < 35 mmHg, caused by hyperventilation
Symptoms and diagnostic findings:
Heart rate , palpitations, hyperventilation, tetany, tingling sensations in extremities,
convulsions, anxiety attack, hypokalemia, hypocalcemia, urine pH > 6 due to HCO3excretion, HCO3- , Renal H+ retention.
Treatment:
Rebreather mask, calm approach to client, oxygen as required, monitoring.
Metabolic acidosis
Causes:
pH < 7,35, HCO3- < 22. Loss of HCO3- , Accumulation of acids in ECF due to starvation,
diabetic ketoacidosis, malnutrition, prolonged diarrhea, sepsis, shock and trauma.
Symptoms and diagnostic findings:
Abdominal pain, signs of shock with peripheral vasodilation, hypotension, dysrhythmias,
cold, clammy skin, deep rapid Kussmaul’s breathing to release CO2, confusion,
drowsiness, hyperkalemia, BE decrease, AG increases, Renal HCO3- retention leading
to acidic urine pH < 6. Cardial conduction disturbances leading to dysrhythmias.
Treatment:
Treatment of underlyibg cause, fluid supply, alkalotic IV fluids (NaHCO3-, Cl-HCO3-)
carefully and slowly, to restore reduced HCO3- levels below 18mEq/L. Monitoring of ABG,
I&O, vital signs, LOC and electrolytes.
Metabolic alkalosis
Causes:
pH > 7,45, HCO3- > 26 mEq/L, loss of H+ ions due to prolonged vomiting, indigestion of
alkalotic antacids (e.g. calciumbicarbonate).n
Assessments:
Tachycardia, hypertension, dysrhytmias, hypoventilation to increase pCO2 may lead to
respiratory failure, agitation, tremor, muscle twitching, tetany, hyperreflexia, seizures,
paresthesia, hypokalemia, hypomagnesaemia, hypocalcemia (increase of pH increases
Ca binding affinity), nausea and vomiting, paralytic ileus, increased renal HCO3excretion and urine pH > 6.
Treatment:
Supply of Cl- to enhance renal absorption of Na and excretion of HCO3- rehydration and
potassium supply. Ranitidine, Famotidine Antacids to reduce secretion of H+ ions from
gastrointestinal tract. Acetazolamide to increase renal HCO3- excretion. Supply of
deficient electrolytes.
Acidosis causes CNS depression, alkalosis stimulates the CNS !
Digitalis toxicity increases in alkalosis, hypokalemia and hypocalcemia!
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-Applied PharmacologyDosage calculation and medication administration
General considerations
Generic names:
Reflect chemical substance of a drug and do not change by manufacturer.
Brand names (trade name):
Proprietary name given by manufacturer.
Any medication order has to be handwritten, signed and dated.
Always assure correctness of illegibly written prescriptions by calling prescriber.
Nurses are responsible for their own actions by law.
Telephone orders must be co-signed asap.
Verbal orders are only acceptable in an emergency situation.
Pharmacokinetic movements
Absorption,
Uptake from medication from digestive tract into the bloodstream.
Distribution
Movement to the specific organs where medication takes effect.
Metabolism
Enzymatic fragmentation of a drug into molecules (metabolites) with less effect which
are soluble for excretion through the biliary and urinary system.
Excretion
Elimination of metabolites.
Principles and process of medication administration
Checklist
1.
Orders have to be complete, accurate and legibly written.
2.
Allergies against prescribed medication have to be ruled out.
3.
Clients condition needs to correspond with order?
4.
Awareness of:
•
Interactions with other medications
•
Side effects
•
Adverse effects
•
Toxic effects
5.
Calculation of dosage, if necessary
6.
Check of expiration date
7.
Labeling of medications
8.
Discarding any partially used single dose containers at the end of the day
Six rights of administering medication:
1.
Right drug
2.
Right dose
3.
Right route
4.
Right time
5.
Right Client
6.
Right documentation
Do not administer medication if client is questioning correctness !
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Dosage calculation medication administration
Metric system
Uses gram for a unit of weight and liter for an unit of liquid volume.
Conversion within the metric system
From a lower to the next larger unit of measure move decimal point three places to the
right.
e. g. 1.5 grams
1500 miligrams
From a larger to the lower unit of measure move three places to the left
e. g. 1000 ml
1.0 Liter
Dosage calculation schemes
Formula 1 “Desired over have”
Dose ordered (desired) x Amount available = Amount to give
Dose on hand (have)
Example: Metoclopramide 15 mg is ordered, Medication is available in 10 mg/2mL
15 mg x 2 mL = 3 mg
10 mg
Formula 2: Ratio and Proportion
Step 1:
Dose ordered (desired) = ____Dose required ____
Dose on hand (have)
Amount available (have)
15 mg
10 mg
=
X_
2
Step 2:
Result of left Division x Amount available = Amount to have
1.5 mg x 2 = 3mg x = 3
Formula 3: Dimensional Analysis
Equation:
X = Amount available x Dose on hand
Dose ordered
X = __20__
15
X=3
Each of these formulas works for all dosage calculation operations.
Use the formula which is best for you !
Identification of extended length oral medication by additional abbreviations
CR, (controlled release), CRT (controlled release tablet), LA (long acting), SA (sustained
action), SR (sustained release), TR (time release) XL, XR (extended length of release)
Do not crush extended length oral medication !
x
x
x
x
x
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Enterally administered medications
For tube feeding purposes stop tube feeding 30 – 60 minutes prior and after
administering medication. Administer one medication after another. Flush tube with 30
mL water after each single dosage. Discontinue any suction for 30 minutes after
administration. Maintain client for at least 30 minutes in a semi fowlers position.
Injections
Checklist
1.
Withdrawing medication from an ampulle
2.
Tap neck to move solution downwards
3.
Break ampulle with a pad at marked area
4.
Hold ampulle by the bottom
5.
Insert filter needle
6.
Dislodge air in syringe
7.
Eject air in syringe
8.
Recheck amount of medication in Syringe
9.
Replace with appropriate injection needle
Withdrawing medication from a vial
Checklist
Remove vial cap
Cleanse rubber top with alcohol
Take syringe with needle or needleless syringe
Inject amount of air to be withdrawn from medication above surface of medication
Invert vial and withdraw medication
Only touch vial barrel and plunger
Remove air while syringe is attached to vial
Remove syringe once filled with desired amount of medication
nn
Sites, Syringes and Needles for injections
Intradermal injections
Used for antigen and skin testing from inner aspect of forearm or scapular area, upper
chest, medial thigh. 25 – 27 gauge needle, 10 – 15 degree angle.
Subcutaneous injections
Used for slow or sustained absorption from abdomen, lateral and posterior aspects of
upper arm and thigh, scapular area of back, upper ventrodorsal glutaeal area, 25 gauge
needle , 45 – 90 degree angle, depending if tissue can be grasped or not grasped.
Intramuscular injections
Used for rapid absorption. Ventro–and dorsogluteal injections, deltoideus, vastus
lateralis for children < 7 months. Inject at 90 degree angle.
Modes and sites of intramuscular injections
Anteroglutaeal
Patient lies on one side.
Use right hand for left hip or left hand for right hip.
Place palm over Trochanter major.
Index finger pointing to anterior superior spine of the iliac crest.
Spread other finger to form a “V”.
Inject in 90 degree angle into the “V”.
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Dorsogluteal
Side lying position, upper knee flexed in front of lower knee.
Imiginary line between greater trochanter and posterior superior spine of the iliac crest.
Inject in 90 degree angle lateral and superior to this line.
Vastus lateralis
Place client in supine position.
Antero lateral middle third of thigh between greater Trochanter and lateral femoral
condyle. Inject in 90 degree angle.
Deltoid
2 inches below acromion. Inject in 90 degree angle.
Z-track injection
Displacement of skin prior intramuscular injection to reduce loss of medication into
subcutaneous tissue.
Push i. v. = Bolus i. v. Injections
Medication has to be injected within one minute or within the adequate injection time for
the particular substance.
“HOW TO…”
inject IV Bolus (IV push)
1. Prepare 1 Syringe with medication, 2 Syringes with physiological saline to flush.
2. Wash hands, use gloves.
3. Clean infusion port with alcohol swab for 30 seconds.
4. Administer IV saline through needle less IV access device to flush system.
5. Administer IV Medication in recommended IV push rate.
6. Flush IV access device again.
n
If client has a running infusion:
Stop IV Infusion while performing a bolus injection.
“HOW TO…”
administer a “Piggyback” Infusion without interrupting an IV infusion
1. Ensure compatibility of medication that is about to be added with currently infused
medications.
2. Hang existing infusion lower than “Piggyback”.
3. Clean infusion port with alcohol swab for 30 seconds.
4. Connect second infusion to preexisting system.
“HOW TO…”
1.
2.
3.
4.
Topical medications
Apply creames and ointments
Use gloves after washing hands.
Remove remaining topical medication from previous applications.
Apply substances from container to skin using tongue depressors.
“HOW TO…”
Apply transdermal patches
1. Remove a previously applied patch.
2. Cleanse skin.
3. Place new patch, possibly on opposite site if indicated.
4. Record date and time of application.
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“HOW TO…”
Apply nasal medications
1.
2.
3.
4.
Use gloves after washing hands.
Client to blow nose and bend neck lightly backwards.
Occlude one nostrile.
Client takes a deep breath.
“HOW TO…”
Apply eye drops
1.
2.
3.
4.
5.
Client to extend slightly backwards.
Eyedropper to be placed ½ - ¾ inch above eyeball.
Pull lower eyelid gently downwards to open conjunctival sack.
Apply prescribed amount of drops
Put light pressure on inner canthus to reduce systemic absorption.
“HOW TO…”
Apply ear drops
1.
2.
3.
4.
5.
6.
Client is laying on his side.
Put on gloves.
Straighten ear canal by pulling pinna gently upward and backward in an adult.
( for a young child downward and backward)
Instill medications.
Cotton may – loosely – be inserted into ear canal.
“HOW TO…”
Apply vaginal suppositories / creams:
1.
2.
3.
4.
5.
6.
7.
Client to be placed in dorsal recumbent or Sims (left lateral) position.
Use gloves after washing hands.
Remove foil wrapper and insert suppository into applicator or amount of cream.
Insert applicator 4 inches into vagina.
Release application.
Remove applicator.
Client to remain laying down for 15 minutes until medication is absorbed.
“HOW TO…”
Apply rectal suppositories:
1.
2.
3.
4.
5.
6.
Client to be placed in dorsal recumbent or Sims (left lateral) position.
Use gloves after washing hands.
Remove foil wrapper from suppository.
Add small amount of water soluble lubricant.
insert suppository with index finger to about 4 inches.
Client to remain laying down for 15 minutes until medication is absorbed.
“HOW TO…”
Apply metered – dose inhaled medications:
1.
2.
3.
4.
5.
6.
7.
8.
Shake canister before each use.
Hold inhaler 2 inches away from mouth.
Exhale through pursued lips.
Depress inhalation device.
Inhale slowly and deeply through mouth.
Hold breath for 10 seconds.
Exhale slowly through pursued lips.
Wait 2 – 5 minutes between puffs.
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•
•
•
•
•
•
•
use with spacer:
Connect MDI Inhaler with spacer.
Release inhaler medication into spacer.
Open mouthpiece.
Client to close lips tightly around mouthpiece.
Inhalation process as with MDI only.
Devices to be cleaned after use.
-Dosage calculation for pediatric clientsAny pediatric medication order always has to be checked against.
the safe dosage ranges of the individual medication.
Dosage calculation either uses Body weight or Body surface area (BSA).
BSA may be more accurate and precise.
Body weight dosage order refers to mg/kg/day or mg/kg/day/order.
Conversion between pounds and kilograms: 2.2 pound lb = 1 kilogram kg
Calculating a single pediatric dose by body weight
Order example:
10 mg of a drug per kilogram of body weight for a child that weighs 23 kg.
= 10 x 23 = 230 mg
The volume of a soluble medication can be calculated with one of the previously
prescribed methods. If this dose is prescribed as a daily dose to be administered in two
separate orders, then the daily dose needs to be divided by two, resulting in 115 mg /
dose.
Calculating a single pediatric dose by body surface area in m2
The size Body surface area in m2 has to be obtained from a nomogram which requires
to assess the exact height and weight of the pediatric client.
Administration of oral medication to children
Children under 5 years may have difficulties swallowing capsules and tablets.
Oral medications can be crushed and administered with juices or applesauce to disguise
taste. Childs mouth has to be checked if medication has been swallowed properly.
Suspensions have to be mixed well prior to administration. In infants small amounts of
liquid medication should be placed around mouth at a time to prevent spitting and
aspiration.
Specifications of subcutaneous injections in children
Usually used are 25 – 25-gauge needles. Volumes are up to 0.5 mL for infants and 2 mL
for older children. For volumes of up to 1 ml a Tuberculin syringe has to be used.
Child needs to be comforted as best as possible and rewarded for any cooperation and
braveness. Since medical encounters in early childhood can be traumatizing and
inducing a phobia against medical treatments which may remain a stressor even into
adulthood.
Specifications of intramuscular injections in children
Volumes are up to 0.5 mL for infants and 2 mL for larger children.
Preferred injection site the vastus lateralis muscle for children up to 5 years.
Dorsoglutaeal injections may be used in children after they have been walking for at
least one year but not as a first choice.
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-Intravenous Therapies-
Indications
Disability to administer sufficient amounts of fluid and nutrition orally. As well as for rapid
access of medication in emergency situations or to avoid repeated intramuscular
injections in a hospital environment. Also used for PPN = Partial parenteral Nutrition and
TPN = Total Parenteral Nutrition.
Needles and catheters are either Over-the-needle catheters or winged needles
“butterflies”.
Infusion pumps and electronic delivery devices control and measure administered
dosages of medication in order to adjustments made. Alarm systems indicate once a
medication has been administered or if there is a blockage or disconnection of the tubing
system.
Regulators and controllers are electronic devices which are designed to sense and
regulate the drop flow from the infusion bags. There are also mechanical devices to
ensure an adequate infusion rate, such as elastomeric ballons which apply a defined
and adjustable pressure to the infusion bag.
Tubing system may be vented for glass bottles or nonvented for plastic bottles.
In a gravity driven tubing system the drip chamber determines the size of the drop which
are rated between 10 and 20 drops per mL for adult clients. Tubing systems mostly carry
filters against bacterial and air contamination. Filters used in TPN require changing
every 24 hours. Filters may also need to be changed at any time after the application of
certain drugs, (e. g. Phenytoin and Pantoprazole).
Types of intravenous infusions
Peripheral Infusion via device in a peripheric vein. To be changed after 3 – 4 days.
Central Infusion via Central Venous Access Devices (CVADs / CVS) or Peripherally
inserted Central venous Catheters. (PCC) Requiring a sterile dressing since catheter tip
will reach into the entry of the right cardial atrium. CVC’s have one to four lumen.
Insertion points are V. Subclavia, V. juguaris interna and the V. brachiocephalica.
Indication for insertion of a CVC
Long Term IV Therapy, need to obtain frequent blood specimens, limited access to or
damaged periphereal veins, necessary CVP (central venous pressure) monitoring and
TPN. Flushing with at least 10 ml syringe since smaller syringes may cause rupture of
lumen.
CVC Catheter types
Open tip catheter: (Hickman catheter)
Tip ends in blood stream and requires frequent flushing with saline followed by heparine
to prevent occlusion. (Broviac catheter is a pediatric version with smaller size of lumen)
Closed tip catheter: (Groshong catheter)
Valve at end of tip prevents backflow of blood. Do not require heparine flush or clamping
but saline solutions.
Calculation of an infusion flow rate
The infusion set has a given drop factor unless it is a pediatric microdrip which always
has 60 drops / mL.
Based on a given drip factor of 10 drops/mL the infusion rate has to be adjusted
following the order.
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Example: An order may request to administer 1000 mL in 8 hours.
The required infusion rate has to be calculated as follow:
Total infusion volume x drop factor
Total time of infusion in minutes
=
1000 mL x 10 = 20.83 drops/minute (21 dr/min)
8 x 60 min
Intravenous infusions always require constant surveillance to detect any dysfunction.
Possible problems in intravenous infusion therapy
Accidential disconnection of tubing system or displacement / loss of catheter.
Damage or dislocation of catheter leading to fluid infiltration of interstitial tissues.
Inflammation / Injection at insertion site. Blockage of catheter or tubing system.
Catheter removal is necessary if infusion stops
and this does not cause any blood return !
Complications of IV Therapy
Air embolism
Caused by air intruding accidentially into tubing system. Volumes from 10 ml may cause
embolism of superior cava vein or pulmonal artery. Can be prevented by strict
surveillance of catheter system and tight closure of all ports of catheter system. Clinical
symptoms are sudden dyspnea, central cyanosis, tachycardia, hypotension, chest pain.
In cases of suspicion for an air embolism clamp the catheter, position client in
Trendelenburg position, administer oxygen and contact physician.
Puncture of a central artery
(e. g. A. subclavia, A. jugularis interna)
Pneumothorax
Due to accidental puncture of the pleural space.
Infections
Most common in TPN. Fever, chills, erythema, WBC , Shock !
Hydrating Solutions used in IV Therapy
Isotonic Solutions
Sodium chloride 0.9 %, Lactated Ringer Solution (LR) (alkalinizing effect to treat
metabolic acidosis) 5 % dextrose in water (D5W) acidifying solution to treat metabolic
alkalosis.
Indication: Fluid replacement after shock, blood loss and dehydration.
Risk: Hypervolaemia
Hypotonic Solutions
0.45 % Sodium chloride, 0.33 % Sodium chloride
Indication: Cellular dehydration
Risk: Administration with tendency of peritoneal or pleural effusion or brain edema.
Hypertonic Solutions
5 % Dextrose in normal saline D5NS, 5 % dextrose in 0.45 % sodium chloride D51/2NS
5 % Dextrose in lactated Ringers D5LR, 10,20,50 % dextrose in water D10,20,50W
Indication: Dehydration, TPN, Hypoglycemia
Risk: Hypervolaemia
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Volume Expanders
Albumin 5 %, 25%, Dextran 40%, Hetastarch (HESI), Plasma Protein fraction
Indication: Hypovolemic shock, Dosage to be adjusted by CVP
Administered through large needle.
-Red Blood Cell and Blood Product AdministrationForms of blood donation
1. Anonymous
2. Designated
3. Autologus
Scheduled blood donation with client 4 – 6 weeks prior scheduled surgery.
Donation may be as frequent as every 3 days as long as hemoglobin level remains > 11
g/dL. Contraindicated in acute infections, leukemia, cardiovascular or cerebrovascular
disease, hemoglobin < 11 grams/dL or hematocrit < 33 %.
4. Blood salvage
Resampled blood during surgery undergoes a “washing” procedure which removes
tissue and cellular debris prior to reinfusion.
Blood group compatibility
Blood group (=RBC surface antigen) / Antibodies present / Can donate to / Can receive
0
A,B
every blood type*
0
A
B
A, AB
0, A
B
A
B, AB
0, B
AB
No antibodies
AB
univ. receiver*
* in regards to A,B,0 but not to Rhesus compatibility.
Rhesus factor compatibility
Unlike the blood group specific antibodies, rhesus factor antibodies in rhesus negative
clients are not present from birth and may never be produced at all as long as a rhesus
negative client does not get in contact with rhesus positive RBC’s. Since about 85 % of
the overall population are rhesus factor positive it can likely happen that rhesus negative
donor RBC’s are not available at the time when a rhesus negative client urgently
requires blood transfusions. In these cases rhesus positive RBC’s will be supplied along
with anti-D antibodies to avoid a sensitization of a rhesus negative client versus rhesus
positive RBC’s. This treatment is comparable to the previously discussed treatment of a
rhesus factor negative pregnant women giving birth to a rhesus positive child. In all other
cases rhesus negative donor blood always has to be preferred if available.
Blood group typing
Involves Antibody Screening for A, B, Rhesus and other antibodies.
Cross match
Is ordered when a transfusion is about to be performed.
Donor cells are added to recipients serum and Coombs Serum to check for agglutination.
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Immediately after blood is drawn for typing, client receives a wrist bracelet with an
unique blood donor number that must match the blood identification tag in the units this
client receives.
Blood products
Red blood cells (RBC’s)
Replacement of lost erythrocytes. Contains 250 – 400 ml per unit. One unit raises
Hemoglobin by approximately 1 gram / dL and hematocrit by 2 – 3 %. Assessment not
prior 4 – 6 hours after transfusion.
Fresh frozen Plasma (FFP)
Replacement of clotting factors and plasma proteins to extend blood volume. One Unit =
200 – 250 mL. Requires Blood typing prior to use ! Does not contain RBC and Platelets.
To be infused within 6 hours after thawing to maintain clotting factors. Assessment via
coagulation studies (PTT, PT).
Platelets
Needed for blood coagulation. Units with variable Volumen from 70 – 400 mL. To be
administered as soon as received from blood bank. Assessment of platelet count after 1
and 24 hours.
Albumin
Expands blood volume and increases colloidosmotic pressure to shift fluids from
interstitial space back into intravascular space. Used to treat hypovolemic shock and
fluid losses into the third space. (e. g. edema). Increases albumin levels by 25
grams/100ml which equalizes amount of albumin found in 500 mL of blood.
Cryoprecipitate
Clotting factor replacement. Prepared from FFP. Has to be administered as soon as
thawed out.
Administration of Blood Products
Checklist:
1.
Asessment of vital signs.
2.
Obtaining clients consent.
3.
Finding and puncturing suitable vein.
4.
Insertion of a 18 – 20-gauge needle catheter.
5.
Start Saline 0.9 % Solution using a Y – Set.
6.
Check blood from blood bank for donor number and exspiration date.
7.
Compare blood donor number and patient identification with second nurse.
8.
Mix cells and plasma gently by inverting back several times.
9.
Hang blood unit
10.
Start with transfusion rate of 2 mL per minute for first 15 minutes.
11.
Check vital signs every 5 – 15 minutes.
12.
Increase transfusion rate after 15 minutes.
Blood must be hung within 30 minutes of receipt from the blood bank !
Unit must be administered within four hours !
Asses vital signs half hourly until 1 hour after transfusion has stopped !
Transfusion reactions, symptoms and management
Bacterial reactions
Chills, tachycardia, fever.
Obtain blood culture, start antibiotic therapy,
fluid resuscitation, vasopressors, corticosteroids.
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Hypersensitivity
Urticaria, fever, anaphylactic reaction.
shock treatment, oxygen.
Diphenhydramine,
Hemolytic reaction
Nausea, back pain, tachycardia, hypotension, hematuria
shock treatment, oxygen.
Diphenhydramine,
Febrile reaction
Nonspecific if not accompanied by additional physical symptoms. Most
common transfusion reaction, may require premedication with
Acetaminophen or Aspirin.
Circulatory overload
Transfusion speed to fast. Leading to tachycardia, pounding pulse,
hypertension, distended neck veins, crackles upon lung auscultation,
dyspnea and coughing.
Procedure
slow transfusion rate, maintain an upright position,
supply oxygen and notify physician.
Blood – borne infection
Specific risks are CMV, HIV, Hepatitis B + C, Malaria.
Electrolyte imbalances
Hyperkalemia, due to intravasal hemolysis.
Hypocalcemia caused by citrate from blood
products.
Iron overload
Delayed complication after multiple transfusions. Treatment with
desferoxamine (Desferal) subcutaneously or intravenously which will
eliminate iron via kidneys (red urine !)
-Total Parenteral Nutrition (TPN)-
Total parenteral nutrition via an intravenous catheter is indicated in conditions that
interfere with a regular function of the gastrointestinal tract. (i. e. intestinal blockage or
recent abdominal surgery) This form of treatment may be provided in a hospital as well
as in a home care setting. Main goals of a TPN are prevention of weight loss, protein
loss and adequate Fluid and Electrolyte supply.
The TPN solutions typically consist of a mixture of amino acids and dextrose as well as
electrolytes and vitamins in an amount of 2 – 3 liters which are usually administered over
24 hours. Depending on the duration of this treatment it may be necessary to supply
additional lipids, vitamins and minerals. Lipids are usually not given on a daily basis
unless the primary formula solution with carbohydrates and aminoacids also includes
lipids in a small concentration. Such solutions are called total nutrient admixture TNA.
Single fat emulsions to be added to the TPN are called linoleic, linolenic, oleic, palmitic
and stearic acids.
Access sites for TPN
A peripheral vein is used for up to 7 days but no longer than two weeks to administer
parenteral nutrition. Access via a peripheral vein does not allow to administer dextrose
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solutions of more than 10 % concentration since higher concentrated solutions cause
sclerosing and phlebitis of the peripheral veins. A central vein access allows the
administration of dextrose concentration of more than 10 %. TPN via a central vein
access requires a catheter with at least 3 lumen where one lumen has to be reserved for
administration of the TPN only. A vein catheter inserted directly into a central vein can
be used for up to 4 weeks. If a TPN is required for a longer period of time, then a
peripherally inserted central catheter (PICC) may be used since it can remain inserted
for a longer period of time.
Management of a TPN:
Checklist:
1. Ensure correct function and insertion of peripheral or central vein catheter.
2. Blood glucose monitoring prior to the start of a TPN as well as every 6 hours to
detect Hyperglycemia / Hypoglycemia.
3. Daily weight measurement to determine fluid balance as well as accurate 24 h
input / output records.
4. (A sudden and significant increase of i.e. 1 kg per day may be rather fluid
retention while a slower less significant weight of 1 – 2 pounds weekly is rather
caused by weight gain
5. Regular laboratory assessments of liver function, TLC, BUN, creatinine, albumin,
prealbumin, total protein and serum electrolytes.
6. Ensure that type, concentration and amount of any ingredients of a TPN solution
are complying with physicians order.
7. Assure that TPN solution has a homogenous light color and concentration
without any solid particles.
8. Adjust TPN flow rate to individual conditions (usually 50 mL/hr – 125 mL/hr).
9. Lipid concentration flow rates start from 1 mL / min.
10. Maintain Normoglycemia by using Dextrose 10 % Solution if TPN is temporarily
not available.
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NCLEX-RN ® Category III,IV,V:
NURSING CARE SPECIFICS
PATHOPHYSIOLOGY - MEDICAL TREATMENTS
APPLIED PHARMACOLOGY
AND PSYCHOSCOCIAL ASPECTS
OF DISEASES AND DIORDERS
NEUROLOGICAL DISORDERS AND DISEASES
Anatomy and physiology of the nervous system
Microanatomy of the nervous system
The nervous system contains specific structural nerve cells (= neurons). These cells are
designed to produce and process electrical impulses along the nerval fibers (= nerve
axons). Each neuron communicates with an average of 1000 other neurons via
functional connections which are described as synapses and dendrites. Neurons are
the basic information processing units of the entire nervous system. The main cell types
of the connective tissue of the central nervous system are astrocytes and
oligodendrocytes.
Myelin sheats
Central and peripheric nerves can be differentiated in myelinated and unmyelinated
nerve fibers. Myelin layers of peripheric nerves are build by specific connective tissue
“glia” cells, (“Swann’s cells”) and designed to increase the speed at which nerval
impulses are progressing along the myelinated fiber. Along unmyelinated fibers,
impulses move continuously as waves, but, in myelinated fibers, they hop or "propagate
by saltation." Myelin increases electrical resistance across the cell membrane by a factor
of 5,000 and decreases capacitance by a factor of 50. Myelination also helps to prevent
the electrical current from leaving the axon. When a peripheral fiber is severed, the
myelin sheath provides a track along which regrowth can occur.
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The compartments of the nervous system
The human nervous system is functionally and anatomically divided into the following
three compartments:
1.
2.
3.
Central Nervous System CNS:
Brain and spinal cord.
Peripheric Nervous System PNS:
Peripheral nerves between the spinal cord and the innervated tissues.
Autonomous Nervous System ANS:
Parasympathetic and enteric nervous system PSNS / ENS
Sympathetic nervous system SNS
The central nervous system CNS
The brain and its spinal cord recognize all consciously and subconsciously received
sensations that are affecting the human body. The brain transforms them into adequate
responses by innervating motoric actions, inducing thought processes and memorizing
important facts and experiences. The sensoric “receiving” cell areas of the brain are
characterized as white matter due to their anatomical appearance while the motoric
“responding” cell areas are considered as grey matter for the same reason. All intended
human actions are generally caused by sensations affecting the sensoric cortex of the
brain and transformed into motoric responses that are carried out by neurons of the
motoric cortex.The brain has the highest demand of oxygen and carbohydrates of all
organs. An absence of oxygene for more than 3 minutes can cause an irreversible cell
death of neurons. The metabolic supply of the central nervous system occurs via the
blood brain barrier only, to assure that only substances of low molecular weight and
lipophilic substances can be exchanged. The blood brain barrier consists of gliacells
which can be considered as the connective tissue of the CNS.
The peripheric nervous system PNS
The PNS combines all nerval structures that are originating from the CNS to connect to
the peripheral tissues. A peripheric nerve consists of multiple individual nerve fibers with
afferent = sensitive, efferent = motoric and autonomous qualities. The nerval endings are
classified as chemical synapses and enable nerves to connect with other nerval
structures and non – neuronal cells. Chemical synapses are designed to transform
nerval
signals
into
chemical
signals
by
expressing
neurotransmitters.
Neurotransmitters are synthesized and stored in presynaptic vesicles and get
discharged upon receipt of an electrical nerval stimulation. Once released
neurotransmitters connect to specific receptors within the postsynaptic membrane of the
chemical synapsis which is recognized as an activating or inhibiting signal by the
innervated organ. In case of the PNS the main activating neurotransmitter is
acetylcholine and the main inhibiting transmitter glycine.
The autonomous nervous system ANS
The ANS controls every willingly uncontrollable organ by specific innervation of smooth
muscle cells, glandular tissue and cardiac muscle cells. Main areas of innervation are
therefore the digestive and urinary tract as well as the cardiovascular and respiratory
system. The ANS is functionally divided in two components with counteracting effects:
The parasympathetic nervous system PSNS and the sympathetic nervous system SNS.
As a descriptive characterization the PSNS is supporting every body function that
supports “rest and breed” while the SNS is aimed to control “fight or flight” reactions.
Thorough understanding of the function of the different wings and qualities of the ANS
function is mandatory to understand and memorize the pathophysiology of neurologic
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disorders as well as characteristic side effects of medication therapies. Atropine
antagonizes acetylcholine effects only on muscarinic receptors.
Neurotransmitters of main importance
Acetylcholine
Main neurotransmitter within the entire parasympathetic nervous system but also within
the PNS and CNS. Its activating or inhibiting effect depends on the quality and
distribution of muscarinic and nicotinic acetylcholine receptors within an organ tissue.
Summary of parasympathomimetic = “cholinergic” and sympathomimetic effects :
Activating “breed” effects on:
Inhibiting “rest” effects on:
Alpha-1 Receptors
Noradrenaline (Norepinehrine)
Beta-1 Receptors
Adrenaline (Epinephrine)
Alpha-2 Receptors
Noradrenaline sensitive:
Beta-2 Rceptors
Adrenaline sensitive:
Digestive tract
Urinary tract
Diaphragm
Glandular functions:
Salivation
Enzymatic digestion
Tears
Hormonal glands
Sexual functions
Heart rate
Blood Pressure
Miosis
Induction of sleep
Bronchoconstriction
sensitive:
Smooth muscle contraction
Skelettal muscle contraction
sensitive:
Heart rate
Kidney function
Lipolysis
Digestive tract motility
Urinary tract motility
Glycolysis
Dilation of Bronchioles
Arterial vasoconstriction
Uterine relaxation
Pancreatic Insuline release
Adrenergic effects induced by medication are described as “sympathomimetic”.
Glutamat, Dopamine
Stimulating Neurotransmitter in the CNS
GABA
Main inhibiting neurotransmitter within the CNS.
Injuries and diseases of the central and peripheric nervous system
Spinal cord injuries and disorders
Symptoms and severity of a spinal cord injury correlate with the location of the actual
damage. Typical injury patterns after spinal cord injuries are:
Tetraplegia
Damage of the cervical spinal cord.
Total paralysis from upper extremities downwards.
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Paraplegia
Damage of the thoracic or lumbar spinal cord. Paralysis of lower extremities up to the
pelvic area.
Spinal shock
Loss of autonomous and motoric reflexes in an area below the spinal cord injury
immediately after damage has occurred. Skeletal muscle paralysis, flaccid, hypotension,
bradycardia, hypesthesia for pain, temperature and touch. Bladder and bowel
incontinence, autonomic dysreflexia in cases of spinal cord injury from T6 and higher.
Treatment:
Primary stabilization for transport with appropriate devices (e. g. halo extensions)
Steroid treatment in initial injury stadium to limit spinal cord edema. Surgical
stabilizations of vertebral fractures.
Long Term Care: Physiotherapy, ergotherapy, bladder and bowel training,
psychotherapy and supply of orthopedic devices
Guillain Barre Sydrome
Ascending inflammation of spinal nerves commonly starting from lower extremities
resulting in a progressive motoric and sensoric paralysis. Autoimmune disorder with
antibody production against myelin sheet of nerval fibers. Destruction of myelin results in
loss of conduction ability of nerval fibers.
Symptoms and diagnostic findings:
Progressive general muscular paralysis and paresthesia, body achiness, respiratory
failure due to muscular weakness, hypotension due to dysfunction of the autonomous
nervous system and elevated proteins in a CSF sample.
Treatment:
Plasmapheresis for separation of Plasma from blood cells to eliminate autoimmune
antibodies. Immunoglobulin supply and corticosteroids. Symptomoriented treatment of
repiratory failure, cardiovascular problems, bowel and bladder dysfunction.
x
Myasthenia gravis
Autoimmune disease of the peripheral nervous system. Characterized by an
autoimmune disorder with antibody production against acetylcholine receptors. Results
in an inhibition and destruction of the neuromuscular chemical synapses. Most cases are
accompanied by autoantibody production against thymus glands. Progress can be
enhanced by multiple factors such as infections, vaccinations, physical exhaustion,
stress, thyroid gland disorders, menopausal hormonal disturbances and alcohol
consumption. Medications with effects or side effects towards the peripheral nervous
system are sedatives, anesthetics, analgesics, opioids and quinidine.
Symptoms and diagnostic findings:
Slowly progressing muscular weakness up to a development of a complete muscular
paralysis. Diplopia, swallowing and breathing difficulties and respiratory failure.
Myasthenic crisis = Respiratory failure & Aspiration. Cholinergic crisis = Overdose of
cholinesterase inhibitors.
Diagnosis is made via Tensilon test (leading to a temporary improvement of symptoms if
positive) and Electromyography (EMG) test (poor stimulation of motoneurons if positive).
Treatment:
Cholinesterase inhibitors:
Need to be supplied 45 minutes prior to meals, when peak concentration is needed!
Neostigmine, Pyridostigmine.
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Immunosupressants:
Corticosteroids, Azathioprin, Cyclosporine.
Precautions against aspiration. Eye care/eye patch.
Brain Disorders and Injuries
Brain contusion
Brain tissue damage due to parenchymal bleedings caused by blunt trauma. May be
accompanied by a more or less significant bleeding.
Brain concussion
A brain contusion which leads to a temporary confusion or a loss of consciousness.
Grade 1: Stade of confusion for up to 15 minutes and no loss of consciousness.
Grade 2: Transient confusion for more than 15 minutes and no loss of consciousness.
Grade 3: Loss of consciouness for up to several minutes.
Treatment:
Self limiting conditions with spontaneous improvement within hours to days if no
significant brain tissue damage occurs. Clients usually require hospitalization for clinical
observation for at least 24 hours. Depending on severity clients may complain of
headaches, dizziness, light sensitivity, poor concentration and retrograde amnesia in
regards to the circumstances prior to the trauma.
Epidural Hematoma
Caused by acute rupture of a meningeal artery.
Leads to rapid development of a hematoma between skull and dura within minutes to
hours.
Subdural Hematoma
Slowly developing hematoma between pia mater and dura mater over days and weeks.
Caused by a rupture of small connecting bridge veins.
Treatment:
An epidural hematoma is a life threatening condition and always requires an emergency
neurosurgical intervention via a craniotomy procedure to relief the increased intracranial
pressure and to stop the intracranial bleeding. Subdural hematomas require surgery
depending on their size and severity. Small circumscripted subdural hematomas may not
require surgical treatment.
Meningeal Anatomy
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Seizures
Seizures are spontaneous events of unregulated electrical potentials in neurons of the
brain and occur either in specific areas or generalized over the entire brain.
Seizure disorders occur as idiopathic seizures with no known cause as well as related to
another disorder such as hypoglycemia, acute alcohol or substance withdrawal or brain
tumors. Another typical cause can be a history of severe head or brain injury or surgery
because of brain irritating intracranial scar tissues. Seizures may be preceeded by a
temporary specific aura stade of lethargy, lack of concentration and abnormous
tiredness.
Symptoms and diagnostic findings:
•
Grand mal seizures (= tonic clonic seizures)
Most common expression of a seizure. Appearance of repeated muscular tonic and
clonic contractions of entire skeletal muscles, tongue bites, spontaneous uncontrolled
urination and defecation, temporary cessation of breathing and loss of consciousness.
Typically expression of head and muscle aches, retrograde amnesia, confusion,
tiredness once client has regained consciousness. ( = Postictal period)
A Status epilepticus can occur if a grand mal seizure is not improving spontaneously or
remains untreated. Clients in a status epilepticus are in a potential life threatening
situation, endangered by hypoxia, hypoglycemia and exhaustion.
•
Complex partial seizures (petit mal seizures)
Localized, non purposeful, unspecific movements in combination with a temporary
impaired or total loss of consciousness.
•
Simple partial seizures
Expression of either motoric, sensoric, autonomic symptoms or psychic alterations but
not in combination.
•
Absence seizures
Short lasting seizures for up to 30 seconds of duration. Expressed by a sudden psychic
alteration and a brief cessation of motoric activity.
Diagnostic tests used to detect seizure sensitivity and causes are
Electroencephalography (EEG) to detect abnormous electrical activity of neurons.
Skull X – rays in search for fractures or abnormalities, CT scans, lumbar puncture and
blood tests.
Treatment:
Most simple partial or absence seizures cessate spontaneously and do not require any
acute intervention. In acute grand mal and complex partial seizures the main priority is to
secure the client in a side lying position for airway maintenance and to avoid aspiration.
Clients with breathing difficulties may require oxygenation. Bite sticks may be used but
are not generally recommended to avoid tongue bites. Provide a safe environment by
removing potential sources for injury.
Drug treatment:
Acute treatments may be performed via injections of short – and midterm acting
benzodiazepines such as diazepam, lorazepam or clonazepam or with phenobarbital.
Long term drug treatment with phenytoin, valproic acid and carbamazepine is used to
increase the seizure threshhold. Long term treatments require the ongoing daily intake of
the appropriate medication at a given time to secure a sufficient blood level. Therapeutic
blood levels have to be assessed on a regular basis via blood samples. In rare cases
seizure disorders may not respond to drug treatments and require neurosurgical
intervention.
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Multiple sclerosis - MS
Autoimmune disease with destruction of myelin fibers and neurons of the entire central
nervous system. (brain and spinal cord).
The clinical course of multiple sclerosis can vary as follow:
•
•
•
•
Benign (asymptomatic destruction)
Relapsing – remitting (temporary destruction)
Primary progressive (repetitive destruction)
Secondary progressive (permanent destruction)
Production of autoantibodies against myelin and axons may be linked to viral infections.
Symptoms and diagnostic findings:
Earliest symptoms are visual disturbances which can be verified by neurophysiological
examinations using evoked potentials. (EP’s) Gradual or sudden muscular weakness of
limbs. Progressing muscle spasticity in advanced stades. Bladder incontinence,
dysphagia and constipation. Appropriate diagnostic procedures and their outcomes are:
Lumbar puncture (IgG bands in CSF), MRI and CT Scans (plaque formation in white
matter, brain nerves and spinal chord).
Histologic characteristics are Astrocytes which function as a scar tissue to replace
destroyed nerve fibers.
Treatment:
Multiple sclerosis is primarily incurable. Treatment is mainly symptom oriented.
Medications used to suppress a rapid development in stages of acute flares are
immunosuppressants such as interferon – alpha.
Further treatment focuses on physical therapy, supply of orthopedic and assistive
devices , adequate fluid supply, PEG – supply to secure nutrition, assistance in ADL’s,
infection control by preventive use of antibiotics and antiviral medication and
psychological support.
Medication therapy:
Multimodal anti-inflammatory effect to the myelin structures of the central nervous
system. Medications for treatment of MS are:
Methylprednisolone /oral Prednisolone = Reduces exacerbation rate and severity.
Interferon Beta 1a + 1b = Long term treatment to decrease severity of exacerbations.
Azathioprine (Imuran) = Decreases severity of symptoms and progression of MS.
Cyclophosphamide = Reduces exacerbation rate and severity.
Glatiramer = Prevents destruction of brain and nerve tissue.
Cyclosporine = Reduces severity of exacerbations.
Morbus Parkinson / Parkinson’s Disease
Degenerative neurological disease caused by a loss of the dopamine producing
substantia nigra in the hypothalamic area of the brain. Older adults from 50 years of age
are mainly affected.
Symptoms and diagnostic findings:
Classical symptom trias results in: Rigor, Tremor and Akinesia. Slow onset of general
muscle tremor at rest along with increasing muscle rigidity. Altered walking pattern with
short stepped and shuffling gait, slurred speech, slow eye movements, dysphagia,
constipation, depression, sweating of face and neck only.
Treatment:
Treatment depends on stage of disease. Treatment options include: Physical therapy,
assisted and self exercise of ROM as early as possible. Supply of orthopedic mobility
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devices to prevent falls. Supply of assistive devices to overcome loss motoric skills.
Logopedic treatment by speech pathologist. High fiber and fluid diet and psychological
support. Drug treatment options include: L-Dopa, MAO – Inhibitors, dopamine agonists,
anticholinergics, antidepressants, propranolol.
Stroke/Cerebrovascular Accident CVA
Definition of transient and permanent ischemic attacks to the brain:
Types:
1.
TIA = Transient Ischemic Attack
Neurologic deficits resolve within 24 hours.
2.
PRIND = Prolonged Reversible Ischemic Neurological Deficits
Neurological deficits resolve within after 24 hours up to 7 days.
3.
CVA = Cerebrovascular Accident
Permanent neurological deficit due to either an occlusion of a cerebral artery
by thrombosis or embolism or by intracranial hemorrhage.
Ischemic attacks are mostly caused by arteriosclerotic degeneration of the supplying
blood vessels. Other common causes include cardiac embolism, uncontrolled
hypertension and aneurysms of cerebral arteries.
Symptoms and diagnostic findings:
•
Occlusion of internal carotid artery and middle cerebral artery:
Paralysis and loss of sensitivity of contralateral body hemisphere.
Aphasia = client unable to talk.
Apraxia = client unable to perform motoric tasks.
Agnosia = client unable to recognize environment.
Uni or bilateral Hemianopsia = loss of half of visual field.
•
Occlusion of vertebral artery:
Dysphagia = client unable to swallow.
Multiple other circumscripted losses of sensitivity can occur due to occlusion of other
brain supplying arteries.
Treatment:
Thrombotic CVA
Heparin treatment and thrombolytic drug treatment.
Lysis of clot with tissue plasminogen activator within 3 hours.
Hemorrhagic CVA
Surgical treatment in cases of severe intracranial bleedings.
Correction of blood pressure and intracranial pressure.
General treatment options:
Early rehabilitation, psychological support, management of underlying vascular risk
factors and oral Anticoagulation.
Common affections of facial nerves
Bell’s Palsy
Unilateral paralysis of facial nerve. Cause unknown. Over 90 % experience spontaneous
recovery within several months.
Symptoms and diagnostic findings:
Unilateral paralysis of facial muscles.
Loss of taste over anterior portion of tongue.
Loss of corneal reflex on affected side.
Increased tearing from lacrimal gland on affected side.
Treatment:
Antiviral medication, steroids, eye patch, facial nerve stimulation and physiotherapy.
Regular follow up examinations.
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Trigeminus neuralgia
Nerve induced chronic recurrent or permanent pain of one half side of the face.
Cause unknown. In some cases linked to underlying ear or dental disorders or tumors.
Also after blunt injuries to the face.
Symptoms and diagnostic findings:
Unilateral pain in one, two or all three innervation areas of the trigeminus nerve
branches. Most commonly occurring as a pulsating pain. Triggers of onset may be touch,
light, eating or other facial an cervical movements. A paralysis of facial muscles is not
involved.
Treatment:
Avoiding specific triggers, if known. Analgetic treatment on demand with common pain
relief. In cases of recurrence in a high frequency a prophylactic treatment with
carbamazepine or other antiepileptics may be tried. Surgical intervention if nerve is
trapped in its compartment.
Common infections of the Central Nervous System
Meningitis
Severe infection of the meningeal structures of the central nervous system. Most
commonly caused by a hematogenic or traumatic (surgical and accident related) droplet
bacterial infection with
•
Neisseria meningitides (Meningicoccus)
•
Streptococcus pneumoniae (Pneumococcus)
•
Haemophilus influenzae, Type B
•
Diverse viruses (mostly leading to a better outcome)
Symptoms and diagnostic findings:
Severity and duration of infections depend on causative agent. Flu–like symptoms, fever,
chills, bodyache, headaches, light sensitivity, photophobia, nausea and vomiting. Signs
of nuchal rigidity: Brudzinski Sign (Pain on neck flexion in supine position) Kernig Sign
(Pain on hip flexion in supine position), Opisthotonus (Hyperextension of neck and back),
seizures and confusion. Diagnosis confirmed by growth of bacterial culture or
lymphocytosis from CSF sample.
Treatment:
Viral meningitis: Treated by symptoms. No specific medication available.
Bacterial Meningitis: Antibiotic treatment intravenously or intrathekal (=subarachnoideal)
Preventive treatment due to vaccinations. Treatment and isolation of contact persons for
24 hours after onset of prophylactic treatment with Rifampicine. Upright position or LP to
relief increased intracranial pressure.
Encephalitis
Viral infection of the brain. Most commonly caused by Herpes simplex virus type 1
(HSV1) during neonatal period. Other causes are rare.
Symptoms and diagnostic findings:
Symptoms are generally comparable with symptoms of meningitis. Seizures are more
common.
Treatment:
Treatment of causative agent, symptomoriented treatment and psychological support.
Poor prognosis. Clients are likely to remain with neurological disorders.
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Neurological Medication Therapy
Migraine Medication
Ergotamine
Pharmaceutical effect:
Alpha sympathomimetic effect on blood vessels, may lead to vasodilation or
vasoconstriction depending on administered dosage. Prevention of decline of serotonine
levels due to inhibition of reuptake into platelets.
Physiological effect:
Acute and prophylactic treatment of migraine headaches.
Indication:
Migraine treatment and prophylaxis.
Contraindications:
Pregnancy, cardiovascular disease, coronary artery disease and hypertension.
Substances:
Ergotamine tartrate (Ergostat), Dihydroergotamine mesilate (Migranal) and Sumatriptan
(Imitrex)
Medication for preventive treatment of migraines.
Beta – blockers, Ca- channel Blockers, lithium and corticosteroids.
Behavioral measures for prevention of migraine attacks.
Regular life style, avoidance of stress, regular meals, avoiding long fasting periods,
(diets), alcohol and certain types of food (esp. Tyramine containing food, red wine etc.).
Anticonvulsive medication (Antiepileptics)
Diverse group of substances which are inhibiting the induction convulsive impulses of
neurons of the motoric cortex.
Hydantoins (Phenytoins)
Acute treatment and prevention of grand mal seizures, status epilepticus
(Fosphenytoine), psychomotoric seizures. Fosphenytoine is used for intravenous
admnistration only. Oral Phenytoine has to be administered without food due to its high
ability to bind with proteins. Long term Phenytoin treatment requires a regular
assessment of medication blood levels to adjust daily dosages as well as CBC, liver and
kidney function.
Side effects:
Paresthesias, nystagmus, diplopia, gingival hyperplasian (can be prevented by proper
dental hygiene), Stevens–Johnson Syndrome, hepatitis, anemia, leukopenia,
thrombocytopenia and megaloblatic anemia.
Barbiturates and Benzodiazepines
Characteristics discussed under addictive substances. Barbiturates are used for acute
treatment of seizures via intravenous administration, as well as for longterm treatment of
epilepsy. Long term therapy requires regular assessment of therapeutic blood levels.
Benzodiazepines are primarily used for acute intervention in a seizure rather than for a
long term treatment of epilepsy. Longterm therapy requires regular assessment of blood
levels.
Carbamazepine
Carbamazepine is used for acute treatment of seizures via intravenous administration as
well as for long term treatment of epilepsy.
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Central Nervous System Stimulants
Pharmacological effect:
Alpha and Beta Receptor stimulation of the central sympathetic autonomous nervous
system.
Physiological Effect:
Decrease of appettite and overall alertness.
Obesity treatment
Anorexiants
Narcolepsia
Amphetamines
Attention deficit/hyperactivity disorder
Amphetamines
Side effects:
Central sympathetic stimulants of different potencies share a combarable side effect
pattern: hypertension, tachycardia, palpitations, restlessness, dysmenorhea.
Amphetamines may also cause blood dycrasias, libido disturbances and erectile
dysfunction.
Special considerations:
Medication has to be tapered off in any case. Client has to avoid intake of caffeine and
other substances (e. g. Theobromime in tea and chocolate) with stimulating effect.
Substances:
Amphetamine (Adderall)
Dextroamphetamine sulfate (Dexadrine)
Methylphenidate hydrochloride (Ritalin)
Anorexiants:
Benzphetamine hydrochloride (Didrex)
Diethylpropion hydrochloride (Prop/ion)
Sibutramine hydrochloride (Meridia)
Anti Parkinson Medication
Anticholinergic Parkinson medication
Pharmacological effect:
Interference with acetylcholine receptors in the central parasympathetic autonomous
nervous system.
Physiological effect:
Reduction of involuntary movements, especially tremor, in Parkinson’s disease.
Contraindications:
Myasthenia gravis, narrow angle glaucoma and gastrointestinal obstruction.
Side effects:
(Parasympatholytic effects), Mydriasis, dry mouth, constipation, ileus and urinary
retention.
Intoxication occurs even due to lightest overdose!
Substances:
Benztropine mesilate (Cogentine) and Trihexyphenidyl hydrochloride (Artane)
Dopamine-agonist Parkinson Medication
Pharmacological effects depend on individual substance:
Amantadine: Promotion of synthesis and release of Dopamine.
L – Dopa: Physiological precursor of Dopamine increases Dopamine synthesis.
Dopamine agonists Bromocriptine / Pergolide:
Direct stimulation Dopamine of receptors. Comedication to LDopa.
Monoamine oxidase B inhibitor: Increase of Dopamine activity.
Comedication to L-Dopa.
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Special considerations:
Food interactions
Levodopa and selegiline: Reduced absorption with high protein
food.
Selegiline: Tyramine containing food may establish hypertension
Side effects:
Amantadine: Convulsions, congestive heart failure and leukopenia
Levodopa: Mental or personality changes, leucopenia and agranulocytosis.
Extrapyramidal symptoms: twitches, grimacing and tongue protrusion
Myasthenia Gravis Medication
Pharmacological effect:
Increase of acetylcholine in the chemical synapses of the peripheric nervous system.
Therapeutic effect:
Improvement of transmission of nervous impulses from motoneurons to skeletal
muscles.
Special considerations:
Treatment requires a frequent dosage adaptation in accordance to the progress of the
myasthenia gravis but should not be performed more than once every six weeks.
Medication should be administered prior mealtimes.
Atropine sulfate has to be available as an antidote at all times!
Respiratory support equipment needs to be available at all times. An increasing or
recurrent muscle weakness one hour after administration of the medication may lead to
an overdose, resulting in a cholinergic crisis. Recurrent muscle weakness after three or
more hours may be a sign of an undermedication. Medication only causes temporary
relief of symptoms and does not provide a cure.
Side effects:
Correlate with an increased activity of the parasympathetic autonomous nervous system
and can be considered as partially parasympathomimetic: Insomnia, headache,
dizziness, nausea, vomiting, polyuria, diarrhea and miosis.
Substances: (direct and indirect acting parasympathomimetics)
Edrophonium chloride (Tensilon, Enlon), Neostigmine bromide (Prostigmin Bromide)
Pyridostigmine bromide (Mestinon), Ambenonium chloride (Mytelase) (Longlasting
effect)!
Physostigmin (Antirilium) crosses blood/brain barrier!.
Tensilon – Test
If Tensilon is given by an intravenous injection then it leads within 30 – 60 seconds to an
increased muscle tone and increased muscular strength. If this effect lasts for up to five
minutes, then the tested individual is likely to suffer from Myasthenia gravis.
In an already diagnosed patient under treatment receives a positive outcome of this test
then this is a sign for an insufficient dosage of the current medication therapy.
Skeletal muscle relaxants
Pharmacological effect:
Decrease of synaptic afferent response to motoneurons within the central nervous
system, leading to a decreased muscular contraction.
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Therapeutic effect:
Relief and prevention of muscle spasms and pain in musculoskeletal and neurological
diseases.
Indication:
Spinal cord injuries, strokes, cerebral palsy and multiple sclerosis.
Side effects:
Drowsiness, weakness, nausea, eosinophilia and hepatic injury.
Contraindications:
Compromised pulmonary function, compromised cardial function, liver disease, children
< 12 years of age and intermittent porphyria.
Substances:
Baclofen (Lioresal), Dantrolene Sodium (Dantrium), Carisoprodol (Soma),
Cyclobenzaprine hydrochloride (Flexeril) and Methocarbamol (Robaxin).
INFECTIOUS DISEASES
Viral infections
Infectious Mononucleosis (“kissing disease”)
Characteristics:
Viral infection with Epstein – Barr Virus by droplets from oral secretion or blood.
Incubation period up to 6 weeks. Clients may remain contagious for 6 months.
Symptoms and diagnostic findings:
Fever, sore throat, pharyngitis, headache, lymphadenopathy and hepatosplenomegalie.
Severe lymphocytosis in blood count. Spleen rupture may occur as a rare complication.
Treatment:
Symptomoriented treatment and bedrest. Assessment of lymphocytosis and size of
spleen!
Roseola (Exanthema subitum)
Characteristics:
Common viral infection with herpesvirus type 6 in children between 6 months and 3
years of age. Mode of infection is unknown.
Symptoms and diagnostic findings:
Sudden flare of high fever in an otherwise well child. After normalization of temperature
development of maculopapoulos skin rash from trunk towards extremities and face
which is typically self limiting within 24 - 48 hours. Cervical lymphadenopathy may occur
briefly.
Treatment:
Observation and antipyretic treatment.
Poliomyelitis
Characteristics:
Viral infection with polio virus via an oropharyngeal or fecal – oral mode of infection.
Incubation period up to 35 days. Clients may remain contagious for > 6 weeks over
feces !
Symptoms and diagnostic findings:
Unspecific prodromal stade with light upper respiratory tract and / or abdominal
symptoms. After initial recovery progressive paralysis by destruction of motoneurons
which may lead to immobility and respiratory failure.
Not all polio virus species cause paralysis !
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Treatment:
Strict immobilization. Immunetherapy and vaccination. Treatment is oriented on
individual course of infection. Prevention by vaccination from early childhood.
Erythema infectiosum (Fifth disease)
Characteristics:
Viral infection with human parvovirus B19 via droplets from respiratory tract and blood.
Incubation period up to 21 days. Aplastic crisis is most common complication. Duration
of contagiosity unknown.
Symptoms and diagnostic findings:
Maculopapular rash, developing from face downwards over 7 – 10 days before it
disappears. If systemic symptoms such as fever, malaise, headaches and lethargy an
aplastic crisis is likely to occur. Rashes can reoccur after infection has passed if
triggered by traumas or extreme temperatures. If infection occurs during pregnancy
abortion is likely.
Treatment:
Hospital admission may be necessary. Otherwise symptom oriented treatment.
Mumps (Parotitis epidemica)
Characteristics:
Single or double sided infection of the parotid gland caused by droplet infection with
Paramyxovirus. Incubation period up to 21 days. Infection is communicable from
prodromal stade throughout the entire course of infection.
Symptoms and diagnostic findings:
Fever, jaw pain, headaches. Tender swellings of the parotid gland(s).
Accompanying orchitis, myocarditis, hepatitis and encephalitis as rare complications.
Treatment:
Primary prevention via MMR vaccination in order to vaccination schedule or immediately
after exposure. In acute uncomplicated cases symptom oriented treatment with bedrest,
pain and fever relief. Fluid supply, avoidance of chewing and talking in acute stades.
Measles (Rubeola)
Characteristics:
Infection with rubeola virus by droplets from all body excretions after an incubation
period of up to 21 days. Contagiosity over entire course of infections.
Symptoms and diagnostic findings:
Appearance with skin rash, high fever, conjunctivitis and upper respiratory tract infection.
Rash appears in a fine maculo papular expression from head downwards and may also
show a typical enanthema on oral mucous membranes. So called Koplik’s spots.
Complications may occur as pneumonia, otitis media, encephalitis.
Treatment:
Primary prevention via MMR vaccination in order to vaccination schedule or immediately
after exposure. In acute uncomplicated cases symptom oriented treatment with bedrest,
pain – and fever relief.
Rubella (German Measles)
Characteristics:
Viral infection with Rubella virus by droplets from all body excretions after an incubation
period of up to 21 days. Contagiosity throughout the entire course of infection.
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Symptoms and diagnostic findings:
In comparison to measles, a rubella infection shows only low grade fever and a rash with
larger macula but less erythematic. Infection is highly teratogenic in a pregnancy.
Complications may occur as arthritis or encephalitis.
Treatment:
Primary prevention via MMR vaccination in order to vaccination schedule or immediately
after exposure. In acute uncomplicated cases symptom oriented treatment with bedrest,
pain and fever relief.
Chickenpox (Varicella zoster)
Characteristics:
Viral infections with Varicella zoster virus by droplets of oropharyngeal and respiratory
origin or skin vesicules. Incubation period up to 14 days. Contagiosity persists until all
skin vesicles have dried off and scarred.
Symptoms and diagnostic findings:
Sudden general malaise. From 2nd day maculo – papulous rash over entire body which
develops into vesicles. Vesicles rupture spontaneously and build crusts and scars. All
expressions of this rash exist simultaneously and build a characteristic “star sky
phenomenon” Rash usually disappears within 7 – 10 days.
Treatment:
Primary prevention due to vaccination possible. Also immediately after exposure.
Clients require bedrest and isolation. Treatment involves relief of temperature and
pruritus as well as skin care with calamine lotion or other soothing substances to prevent
scratching and bacterial infection.
Bacterial infections
Scarlet fever
Characteristics:
Bacterial infection with group A beta – hemolytic streptococci by droplets of
oropharyngeal and respiratory origin as well as foodborne. Incubation period up to 5
days. Contagiosity over entire course of infections.
Symptoms and diagnostic findings:
Acute swollen, tender tonsils with a white to gray exsudation that also covers the tongue
which shows swollen papillae. (“Strawberry tongue”) Clients may also suffer from high
fever, body achiness, abdominal discomfort, nausea, vomiting and diarrhea.
Within first 24 hours development of a pinpoint like maculous rash that covers the entire
body but spares the face, which appears with an obvious perioral pallor. Rash
disappears under scaling of the skin, especially on palms and soles. Courses without
rashes are occasionally observed as well. Complications are otitis media,
glomerulonephitis and endocarditis.
Treatment:
Immediate abticiotic treatment with penicillin or erythromycin over 14 days.
In acute uncomplicated cases symptom oriented treatment with isolation, bedrest, pain
and fever relief.
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Diptheria
Characteristics:
Bacterial infection with corynebacterium diptheriae by droplets of oropharyngeal,
integumetary and respiratory origin . Incubation period up to 5 days. Symptoms are
caused and triggered by amount of diphtheria toxin.
Symptoms and diagnostic findings:
Light fever, sore throat , foetor ex ore, hoarseness, progressing cover of naso and
orophanrynx covered with grey – white membranes that may cause airway obstruction.
High rate of complications due to Myocarditis, Neuritis, Sepsis and respiratory failure.
Treatment:
Infection requires urgent hospital admission and isolation ! Treatment is accomplished
with antibiotics to reduce causative bacteria and diphtheria antitoxin. Hospital discharge
requires 3 negative bacterial cultures over 4 weeks to rule out persisting contagiosity.
Pertussis (Whooping cough)
Characteristics:
Bacterial infection with Bordetella pertussis by droplets of oropharyngeal and respiratory
origin. Incubation period up to 21 days. Symptoms are triggered by pertussis toxin.
Contagiosity over entire course of infections.
Symptoms and diagnostic findings:
Stage 1: Catarrhalic stade. (1 – 2 weeks)
Symptoms of an unspecific upper respiratory tract infection with low fever and
conjunctivitis..
Stage 2: Paroxysmal stade. ( approximately 4 weeks)
Daily, mostly nocturnal episodes of persistent heavy cough with a whooping sound of the
intermittent inspirations.
Treatment:
Primary prevention possible with pertussis vaccine.
Antibiotic treatment with Erythromcin. Pertussis immunoglobulin against toxin effect.
Humidity inhalations, fluids and bedrest.
Rocky Mountain Spotted Fever
Characteristics:
Bacterial infection with Rickettsia ricketsii via tick bites. Incubation period up to 2 weeks.
Infected humans are not contagious.
Symptoms and diagnostic findings:
Acute fever and overall body achiness, nausea, vomiting, headaches and confusion.
Petechial rash, developing from extremities towards trunk.
Treatment:
Antibiotic treatment with Tetracycline. Preventive hospitalization due to increased risk of
sepsis and multi organ failure.
Borreliosis (Lyme Disease)
Characteristics:
Infectious bacterial disease caused by Borrelia burgdorferi in the
several of its subtypes in Europe. The infection is transmitted by
species Ixodes rhizinus.
Symptoms and diagnostic findings:
Early symptoms include fever, headache, fatigue, depression,
(erythema migrans). Chronic courses occur if the primary infection
United States and
tick bites from the
and a skin rash.
was not diagnosed
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and treated in time and may include joint pain, myocarditis, inflammation of the central
nervous system.
Treatment:
Antibiotic treatment with ceftriaxone or doxycycline. In cases of ongoing infections
treatment may need to be prolonged over month.
Sepsis (Blood infection)
Sepsis is usually caused by an overwhelming bacterial infection which leads to an
overstimulation of the immune system. This can potentially lead to the sudden and
uncontrolled development of the following symptoms:
Rapid decline of blood pressure – Tachycardia – Tachypnea - Confusion, - Disorientation, Agitation – Diziness - Reduced urine production – Rashes - Joint pain
- Thrombcytopenia – Leucocytosis - CRP and ESR Elevation - Disseminated
intravascular coagulation - Multi organ failure
Treatment requires an ICU setting and includes i. v. antibiotic therapies based on the
results blood cultures, as well as support of the circulatory symptoms with
katecholamines.
Antiinfective Medication Therapy
Antibiotics
Aminoglykosides
Bactericid and antiprotozoal effect.
Indications:
Serious gram negative infection and sepsis. Bowel sterilization prior sugery and in cases
of liver cirrhosis with hepatic encephalopathia. ( Reduction of ammonia levels)
Destruction of urease producing bacteria in bowels to reduce ammonia absorption in
cases of hepatic encephalopathy.
Spectrum:
Gram negative infections, Gram positive cocci: Acinetobacter, Citrobacter, E. coli,
Klebsiella pneumoniae, Proteus, Pseudomonas, Providencia, Salmonella, Serratia and
Staphylococci.
Special considerations:
Intravenous and intramuscular administration. Oral administration only for preventive
treatments. Suitable for intrathecal/intraventricular injection. Topical periocular
treatments. Assessment of therapeutic levels via peak and through drug levels. (Blood
level assessment 30 minutes after and immediately before intravenous administration.)
Monitoring of WBC and kidney function. May be started as empiric therapy in
combination with cephalosporines in cases of sepsis prior microbiological examinations.
Side effects:
Ototoxicity
Potentially irreversible loss of auditory and vestibular function due to
affection of 8th cranial nerve.
Nephrotoxicity
Risk increases by co-medication, age, preexisting renal condition.
Neurotoxicity
Neuromuscular blockade due to inhibition of acetylcholine release.
Candida infections. Skin rash, fever, paresthesias. Pseudomembranous colitis due to
infection with Clostridium difficile
Contraindications:
Renal diseases, combination therapy with other potentially nephrotoxic substances,
pregnancy and lactation
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Substances:
Amikacin (Amikin®), Gentamicin (Garamycin®), Kanamycin (Kantrex®), Neomycin
(Mycifradin®), Netilmicin (Netromycin®), Paromomycin (Humatin®), Streptomycin
(generic) , Tobramycin (Nebcin®)
Cephalosporines
Bactericidal. Chemically related to Penicillins. Identical in effect, side effects and
pharmacological attributes. Cross sensitivity may occur.
Spectrum:
1st Generation: Gram negative bacteria and anaerobic bacteria. 2nd Generation:
additional effect against Haemophilus influenzae, Staphylococcus aureus amd
Streptococcus pneumoniae. 3rd Generation: Increased effect against Beta Lactamase
producing gram negative bacteria including Neiserria gonorrhoea. 4th Generation:
increased activitiy against Gram positive cocci and gram negative bacilli.
Indications:
Bacterial sexually transmitted diseases. Upper and lower respiratory tract infections,
otitis media, skin infections and Lyme disease. Prevention of postoperative bone
infections (Cefazolin).
Special considerations:
Cefoperazone and Ceftriaxone are only cephalosporins excreted through bile.
Cefuroxime passes blood/brain barrier in general. All other third generations
cephalosporines only if meningeals are inflamed. Creatinine clearance under treatment
is not supposed to be less than 50 mL/min. All cephalosporines cross placenta.
IM injections are painful and should be avoided (except for expected Non - compliance
in clients with STD’s) Medication has to be administered separately from iron and
antacid medication. Treatment for streptococcal infections should be proceeded for at
least 10 days. Monitoring of WBC, RBC kidney and liver functions required !.
Contraindications:
Pregnancy and lactation. Liver diseases (for Cefoperazone and Ceftriaxone)
Side effects:
Rash, allergic reactions, lethargy, hallucinations, anxiety, depression, nausea, diarrhea,
liver enzyme elevation, bone marrow depression, cross sensitivity with penicillins
Serum-sickness-like-illness
Erythema multiforme or other skin rashes, arthralgia,
fever. Treatment with corticosteroids and antihistamines. Seizures, Vitamin K deficiency,
pseudomembranous colitis and alcohol intolerance for up to 72 hours after last
administration.
Substances:
•
1st Generation:
Cefadroxil (Duricef®), Cefazolin (Ancef®), Cephalexin (Keflex®), Cephapirin (Cefadyl®)
and Cephradine (Velsoef®)
•
2nd Generation:
Cefaclor (Ceclor®), Cefmetazole (Zefazone®), Cefonicid (Monocid®), Cefprozil (Cefzil®),
Cefotetan (Cefotan®), Cefoxitin (Mefoxin®), Cefuroxime axetil (Ceftin®), Cefuroxime
sodium (Zinacef®) and Loracarbef (Lorabid®)
•
3rd Generation:
Cefixime (Suprax®), Cefotaxime (Claforan®), Ceftriaxon (Rocephin®), Cefdinir
(Omnicef®), Cefditoren (Specracef®), Cefoperazone (Cefobid®) and Ceftibuten
(Cedax®)
•
4th Generation:
Cefipime (Maxipime®)
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Fluoroquinolones
Bactericidic broad spectrum activity against gram positive and gram negative infections
in lower respiratory tract, sinuses, bones and joints, skin and connective tissue,
abdomen and urogenital tract. Oral and parenteral administration reaches same plasma
levels. Treatment requires frequent and recurrent administration to secure sufficient
blood levels. Medication to be separated from antacids, iron, zinc and sucralfate. May
potentiate warfarin and antiepileptic medication by increasing their blood levels.
Monitoring of kidney function as well as of INR, PT and drug levels of antiepileptic
medication under antiepileptic treatment.
Side effects:
Rash, allergic reactions, lethargy, hallucinations, anxiety, depression, nausea, diarrhea,
liver enzyme elevation, atrioventricular conduction impairment under sparfloxacin and
moxifloxacin. Also increased light sensitivity. Adverse effects more common in elder
clients.
Contraindications:
Impaired Kidney function. Lactation and Pregnancy. History of seizures.
Substances:
Ciprofloxacine (Ciprol®)
Macrolide Antibiotics
Bacteriostatic effect, used in lower respiratory tract infections, skin and soft tissue
infections caused by Streptococcus or Haemophilus organisms as well as gonorrhea,
chlamydia, syphilis, borreliosis, mycoplasma, corynebacterium and helicobacter
infections. Substances are highly bound to proteins. Administration under high protein
diet necessary. Zithromax used for short term treatments only.
High potential for drug interaction.
Side effects:
Nausea, vomiting, jaundice, diarrhea, thrombophlebitis, pseudomembranous colitis,
candidiasis, hepatotoxicity, ototoxicity and nephrotoxicity.
Contraindications:
Pregnancy and lactation, hepatic dysfunction, kidney dysfunction and hearing
impairment.
Substances:
Azithromycin (Zithromax®),Clarithromycin (Blaxin®), Dirithromycin (Dynabac®),
Erythromycin (Erythrocin®), Troleandomycin (Tao®), Clindamycin (Cleocin®),
Lincomycin (Lincocin®), Telithromycin (Ketek®)
Penicillines
Bactericid beta-lactam inhibition in synthesis of cell wall. Sensitivity mainly against
Gram-positive bacteria. (streptococci, pneumococci, meningococci, staphylococci and
treponema pallidum). Endocarditis prophylactic treatment is preferrably performed with
amoxicillin or ampicillin. Penicillins have to be taken on empty stomach, except for
Amoxicillin. Strong hepatic first pass effect (
loss of effect during liver passage)
requires high oral dosage. Intravenous administration is reserved for serious infections
only. Monitoring of liver and kidney function necessary. Buttermilk and yogurt helps to
restore destroyed colon flora in cases of diarrhea. Urine glucose may present false –
positive results. Oral suspensions of penicilline can be used for up to 14 days.
Side effects:
Skin rashes of diverse expressions are the most common penicillin side effects.
Maculopapular rashes under ampicillin and amoxicillin are not a true allergic reaction
and not necessarily a contraindication for repeated treatment!
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Other side effects include nausea, vomiting, diarrhea, bone marrow depression, anxiety,
depression, hypokalemia/hyperkalemia, serum sickness-like reaction and high risk for
acute anaphylaxia.
Contraindications:
Serum sickness, exfoliative dermatitis and blood dyscrasias.
Substances:
Amoxicillin (Amoxil®), Amoxicillin/clavunate (Augmentin®), Ampicillin (Omnipen®),
Mezlocillin (Mezlin®), Methicillin (Staphcillin®), Penicillin G (Pentids®) and Penicillin V
(V-Cillin®)
Sulfonamides
Bacteriostatic treatment of urinary tract infections caused by E. coli bacteria, also
treatment of infectons with chlamydia trachomatis, toxoplasmosis (Pyrimethamine) and
nocardiosis. Oral preparations have to be administered with food. Cross sensitivity with
cephalosporines and penicillins possible. Sufficient fluid supply or urine alkalization
required to avoid crystallization. Substance has to be stored in light resistant container.
Side effects:
Rash, nausea, vomiting, diarrhea, abdominal pain, jaundice, headache, depression
crystalluria, peripheral neuritis, tinnitus, hepatitis, anemia and Stephens Johnson
Syndrome (
exfoliative dermatitis)
Contraindications:
Pregnancy, lactation, children < 2 months unless treated for toxoplasmosis, porphyria
blood dyscrasias, hepatic impairment, kidney impairment, glucose 6 phosphate
dehydrogenase deficiency and asthma.
Tetracyclines
Bactericidal treatment of infections caused by chlamydiae,(PID) rickettsiae, (rocky
mountain spotted fever) vibrio cholera, propionibacterium acne, shigellosis, brucellosis,
mycoplasma, helicobacter pylori and typhus. Limited activity against protozoa
(amebiasis). Prophylactic treatment of travelers diarrhea. Syphillis and gonorrhea
treatment in cases of penicillin allergy. Sclerosing agent in pleural or pericardial
effusions. Malaria treatment in combination with quinine. Inhibition of Antidiuretic
Hormone. STI Prophylaxis for rape victims. To be taken on empty stomach with fluids.
Dairy and calcium products decrease absorption. Not to be administered intravenously
only intramuscular. Topicyclin for topical treatment can cause systemic reactions. To be
stored in light resistant container.
Side effects:
Tooth hypoplasia, bone growth inhibition, dysphagia, nausea, vomiting, photosensitivity
rash, teeth discoloration in developing teeth, nail discoloration and hepatotoxicity.
Fatty liver degeneration = jaundice
azotemia
increased nitrogen retention
hyperphosphatemia
acidosis.
Nephrotoxicity, pancreatitis. Decrease of cholesterol level. Allergies, blood dyscrasias
Headaches due to increased intracranial pressure.
Contraindications:
Pregnancy and lactation. Children , < 8 years of age. Severe liver and kidney diseases.
Substances:
Doxycyline (Vibramycin®), Minocycline (Minocin®), Tetracycline (Achromycin®),
Oxytetracycline (Terramycin®) and Demeclocycline (Declomycin®)
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Antibiotics for specific indications “Reserve antibiotics”
Vancomycin (Vancocin®)
For treatment of bactericid Methicillin resistant Staphylococcus aureus infections
(MRSA) Pseudomembranous colitis caused by Clostridium difficile Staphylococcal
enterocolitis. Oral administration for colitis treatment, poorly absorbed. Parenteral
treatment via infusion over 60 – 90 minutes.
Side effects:
Nausea, Diarrhea, Ototoxicity, Nephrotoxicity, Thrombophlebitis if administered
intravenously
CVAD preferred, Bone marrow depression and hypotension (“red man
syndrome”).
Contraindications:
Severe Liver and kidney dysfunction.
Imipenem/Cilastatin (Primaxin®)
Bactericid serious infections of any location. Only Meropenem (Merrem®) is able to pass
the blood/brain barrier and can be used for treatment of meningitis. Administration
intravenously or intramuscular and diverse preparations.
Side effects:
Headaches, dizziness, confusion, somnolence, tremor, nausea, diarrhea, vomiting,
hyperkalemia and hypernatremia.
Contraindications:
Penicillin and Cephalosporine allergy.
Quinupristin/Dalfopristin (Synercid®)
Bactericid treatment of Vancomycin Resistant Enterococcus Faecium. (VREF),
Vancomycin resistant Staphylococcus aureus and Streptococcus pyogenes.
For parenteral administration via CVAD only.
Side effects:
Myalgia, Arthralgia and Thrombophlebitis.
Antituberculines
Bactericid due to inhibition of cell wall synthesis and protein synthesis.
Treatment and prevention of Mycobacterium tuberculosis, Mycobacterium avium,
Mycobacterium leprae. 3rd line therapy for infections with multi resistant staphylococci,
pneumococci. Antituberculines are mostly used in combination with other
antituberculines to increase efficiency and reduce the risk of resistance development.
Treatment requires co - administration of Vitamin B6 and B12! (rich in meats, liver
soybeans, potato skin and avocado)
Contraindications:
Severe liver and kidney damage and pregnancy.
Side effects:
Generally well tolerated., Rifampicin and Rifabutin may change color of excretions,
secretions of urine, tears, feces and sweat.
Optic nerve neuritis, nausea, vomiting, Disulfiram-like effect (= alcohol intolerance),
nephrotoxicity ,ototoxicity, hepatotoxicity (INH) and blood dyscrasias.
Commonly used substances:
Rifampin (Rifadin®)
Also used for for eradication of Neisseria meningitides and Haemophilus influenzae
from Nasopharynx for infection prevention in Meningitis outbreaks!
Streptomycin, Rifabutin (Mycobutin®), Ethambutol HCL (Myambutol®) and Isoniazid INH,
Kanamycin (Kantrex®)
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Antiviral Medication
Antiviral medication treatment has to be started as soon as possible in cases of an acute
viral infection or reoccurrence of acute flares in a preexisting viral infection. Virostatic
effect due to implementation of artificial nucleotides within the DNA chain.
Termination of viral infections in acute phases of HSV-1, HSV-2, VZV and Eppstein-Barr
Virus possible. May be used for preventive treatment only in situations of immune
suppression. Treatment requires sufficient hydration and has to be started as soon as
possible in case of infection. Course of treatment has to be completed to avoid
development of drug resistance. Treatment of Herpes genitalis requires sexual inactivity
for duration of the treatment. Medications do not cure for HSV and CMV infections.
Contraindications:
Hepatic or renal dysfunction, pregnancy and lactation.
Side effects:
Blood Dyscrasias, electrolyte dysbalance, nephrotoxicity, thrombocytopenia and
pancreatitis.
Commonly used substances:
Aciclovir (Zovirax®)
HSV 1 and HSV 2
Ganciclovir (DHPG®)
CMV infections only
Famciclovir (Famvir®)
VZV infections
Trifluridine (Viroptic®)
HSV keratokonfjuntivitis
Valacyclovir (Valtrex®)
Drug of choice for genital herpes
Penciclovir (Denavir®)
topical herpes infections
Cidofovir (Vistide®)
CMV retinitis in HIV infections
Influenza specific antiviral substances
Amantadine, Rimantadine limit duration and intensity of Influenza infections.
Leukopenia is most significant side effect.
RESPIRATORY DISORDERS AND DISEASES
Anatomy and Physiology of the respiratory system
The anatomical structure of the respiratory system is divided in the upper and lower
respiratory tract. The upper respirartory tract is designed to clean, moisturize and warm
the breathing air while the actual gas exchange takes place in the lower respiratory tract.
Inspiration is innervated and synchronized by the autonomous nervous system which
triggers the contraction of diaphraghm which pulls lungs downwards and increases of
negative intrapleural pressure, while in expiration the intrapleural pressure decreases
due to an upward movement of the lungs after relaxation of the diaphragm.
The intrahoracic pressure is generally negative.
Diagnostic tests
Spirometry
Pulmonary function testing and spirometry are diagnostic tests used to measure lung
volumes and capacities. The interpretation of the test results allows to identify
obstructive and restrictive functional pulmonary disorders by assessment of the following
parameters:
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• Vital Capacity (VC)
- maximal amount of air exhaled steadily from full inspiration to maximal expiration. Not
time dependent.
• Forced vital capacity (FVC)
- volume of lungs from full inspiration to forced maximal expiration. Expressed as a
percentage of the predicted normal for a person.
Interpretation:
SVC should be >80% predicted, reduced in restrictive disease.
FVC is reduced in restrictive disease and also in obstructive disease if air-trapping
occurs.
• Forced expiratory volume in one second (FEV1)
Volume of air expelled in the first second of a forced expiration.
Interpretation:
Reduced in both obstructive and restrictive disease.
• Forced expiratory ratio (FER) %
(FEV1/FVC)x100
Percentage of FVC expelled in the first second of a forced expiration.
Interpretation:
• Forced expiratory flow between 25-75%(FEF 25-75%)
Also known as MMEF (maximum midexpiratory flow)
Definition:
Average expiratory flow rate in the middle part of a forced expiration. Is a sensitive
indicator of what is happening in the middle and lower airways but is not as reproducible
as is happening in the middle and lower airways but is not as reproducible as FEV1.
Interpretation:
Normal in restrictive disease.
Example of a normal, obstructive and restrictive pattern in a spirometry graph
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Chest X–ray
Commonly anterior posterior and lateral view to inspect pulmonary structures and pleural
cavity.
Computer Tomography (CT)
Cross sectional radiological examination of tissues with higher sensitivity for
abnormalities than Chest X-ray.
Magnetic Resonance Imaging (MRI)
Cross sectional examination using proton signals of body fluids in a high energy
magnetic field. Does not allow metal in range of scanner or as implant in client.
Pulmonary angiogram
Injection of radio active contrast media via a CVC into right side of heart.
Pulse oxymetry
Assessment of oxgen bound to hemoglobin (= oxygen saturation) in peripheric blood.
Normal arterial oxygen saturation is 95% or higher in healthy clients. Method uses a light
spectroscopy and can be influenced by dark skin, coloured nails and bright lights.
Thoracocentesis
Puncture of pleural cavity to aspire pleural fluids or effusions for diagnostic and/or
therapeutic purposes.
Arterial blood gas analysis “Astrup – Test”
Aspiration of arterial blood from a capillary or an artery to assess oxygenation and acid –
base status.
Sputum analysis
For asservation of material for microbiological and cytological examination.
Skin testing
Intradermal testing. To measure induration from 48 – 72 hours after injection.
Indurations of 5mm diameter or greater and indicate recent tuberculosis exposure or
possible HIV infection. Indurations of >10mm in diameter are significant for active
tuberculosis. A positive result does not proof the diagnosis of an infection but is evidence
for a previous antigen contact by the tested individual.
Airway management
Oropharyngeal Tubus (Guedel Tubus).
Preventing posterior tongue displacement in an unconscious client.
Nasopharyngeal Tubus
For semiconscious clients or in situations where oropharyngeal tube is not tolerated or
fittable.
Endotracheal intubation
Long term airway management in connection with a respirator.
Tracheostomy
Surgical transtracheal placement of an airway for prolonged mechanical ventilation.
Cricothyrotomy
Surgical placement of an intratracheal airway in an emergency situation by incision of
the cricothyroid membrane between the cricothyroid cartilage and the 1st tracheal
cartilage ring.
Suctioning
Performed to clear any patent airway from obstructive mucous. Must not be performed >
10 seconds in adults and > 5 seconds in children.
Positioning
Adequate positioning in a respiratory distress situation is an important factor to decrease
the airway resistance.
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•
•
•
In any respiratory failure body position must be at least 45 degrees elevated.
In a single sided pulmonary dysfunction the client may be placed in a side lying
position with the affected lung upwards to improve the ventilation/perfusion
matching of the damaged lung.
In an Adult Respiratory Distress Syndrome ARDS the patient may need to be
positioned alternating on sides and back to improve the ventilation/perfusion
matching of the remaining functional pulmonary areas.
Oxygen administration methods
Nasal cannula:
Allows 1–6 L/min O2/min provides 24–44% oxygen concentration of inspiratory volume.
O2 Administration has to be performed cautiously in clients with COPD to avoid
respiratory failure due to the decrease of paCO2 or under use of Venturi mask which can
be adjusted to deliver exact concentrations of O2.
Methods of mechanical ventilation
Types of ventilators differ by trigger
•
Positive pressure time cycled ventilator
•
Positive pressure volume cycled ventilator
•
Positive pressure pressure cycled ventilator
•
Positive pressure jet ventilator
•
Negative pressure ventilator (Iron lung)
Modes of ventilation
•
Intermittent Mandatory Ventilation IMV
•
Assist Control Ventilation ACV
•
Controlled mandatory Ventilation CMV
•
Synchronized Intermittent Mandatory Ventilation SIMV
Ventilator settings
1.
PEEP positive end-expiratory pressure
2.
FiO2 fraction = amount of O2 inhaled via ventilator
3.
Tidal volume VT
4.
Breathing rate per minute
Indications for ventilator respiration:
•
O2 Saturation < 80%
•
pH < 7,35
•
PaCO2 > 50mmHg
•
VT < 5mL/kg Bodyweight
•
Minute volume < 10 L/min
Client care after lung surgery
After lobectomy an equal alternating positioning on back and either side is necessary to
avoid atelectasis and to optimize the ventilation – perfusion ratio for the remaining lung.
After segmental resection a positioning on side of surgery can cause damage to the
surgical wound.
After pneumonectomy client is to be preferably positioned on back and halfway turned to
side of resected lung.
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Obstructive pulmonary diseases
Emphysema
Emphysema is caused by ongoing destruction of alveoli leading to a decrease of
functional pulmonary tissue surface. An emphysema is typically the terminal outcome of
a long history of progressive COPD where a chronic obstruction of airways leads to a
limited ability for sufficient air exhalation. Trapped air distenses the airways and leads to
their systematic collapse over time which increases the airway resistance. A hereditary
but rare Alpha 1–antitrypsine deficiency may also cause the development of an
emphysema. Commonly occurring with emphysema are frequent pulmonary infections.
A ‘barrel chest’ can be observed after a long lasting development of an emphysema due
to the total loss of the pulmonary elastic structures. Clients may need to use auxiliary
breathing muscles and pursed lip breathing.
Symptoms and diagnostic findings:
“Pink puffer” appearance in advanced stades of emphysema characterized by pursed lip
breathing and barrel chest. The ability for physical exertion gradually decreases with a
progressing emphysema. PO2 , PCO2 in ABG normal or elevated depending on stages.
Compensatory erythrocyosis. Chest X-ray shows clear, enlarged lungs, flattened
diaphraghm. VC and FEV1 Wheezes, crackles or silent chest are audible findings.
Pneumothorax due to overdistended and rupturing alveoli.
Treatment:
Treatment or removal of underlying cause. (e. g. smoke withdrawal) Medication therapy
with oral and inhalative bronchodilators. Also chest physiotherapy, intermittent positive
pressure breathing (e.g. cPAP) in acute respiratory problems. Surgical removal of
destructed pulmonary areas. Long term oxygene home therapy. Client education.
Condition is incurable. Therapeutic goal is to slow and limit progression.
Chronic Bronchitis
Chronic airway inflammation. Defined by a history of chronic cough over a period of 3
consecutive months within 2 years. Mainly caused by smoking. Recurrent respiratory
tract infections. Development of COPD, emphysema and pulmonary hypertension in
advanced stages.
Symptoms and diagnostic findings:
Chest X-ray: enlarged right heart, congested lung fields and flattened diaphraghm.
Pulmonary function decreased: VC , FEV1 , FEV1/FVC ratio
Treatment:
Smoking cessation. Otherwise comparable to emphysema treatment.
Chronic Obstructive Pulmonary Disease COPD/COLD
Chronic pulmonary obstruction that is not fully reversible by medication therapy.
Commonly caused by a chronic inflammation of the airways of the lower respiratory tract
such as a chronic bronchitis or an emphysema.
Asthma
Chronic recurrent obstructive lung disease with sudden onset of dyspnea. Multiple
intrinsic and extrinsic causes. Flares occur unpredictably and from a variety of triggers.
Generalized bronchospasm leads to ventilation perfusion mismatch under excretion of
thick mucous.
Symptoms and diagnostic findings:
Severe breathing difficulties. Client may be unable to move or speak. Prolonged
expiration. Agitation, tachypnea. Either audible wheezes or silent chest in case of
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atelectasis or trapped air. Eosinophilia. Pulmonary function: RV , VC , FEV1 , peak
expiratory flow . Chest X – ray may be unsuspicious
Treatment:
Bronchodilators, corticosteroids, oxygen therapy in acute dyspnea. Treatment of chronic
asthma involves use of
short acting bronchodilators on demand as well as
corticosteroids and theophylline. Client may require intravenous medication and
mechanical ventilation in acute flares that do not respond to regular medication therapy.
Desensitization in cases of allergic asthma. Relaxation techniques.
Pleural effusion
Fluid accumulation in pleural spaces may occur for multiple reasons. Depending on the
consistency pleural effusions are characterized as follow:
Transudate
due to protein deficiency and increased hydrostatic pressure in renal and liver
diseases and chronic heart failure. Contains small amounts of proteins.
Exsudate
Contains large amounts of protein and appears in malignancies and infections.
Empyema
Pus in pleural space due to underlying pneumonia, abscess, tuberculosis.
Chylothorax
Accumulation of lymphatic fluids in pleural space due to disease or surgery related
damage of lymphatic vessels.
Hemothorax
due to bleeding in intrapleural space after rib fractures, lung injuries or due to lung
malignancies.
Symptoms and diagnostic findings:
Dyspnea, limited movement of lungs, decreased breathing sounds and dull percussion
over affected side. Fluid accumulations visible in pleural space ultrasound examination
and chest x-ray. Chylothorax will cause malabsorption of fat from gastrointestinal tract.
Treatment:
Treatment of underlying cause. Acute treatment for depressurization of pleural space
may involve loop diuretics and thoracocentesis as well as oxygen supply. Acquired
specimen has to be asservated for microbiological and laboratory examination and for
differentiation between transudate and exsudate.
Pneumothorax
Air filled pleural space, most commonly due to spontaneous rupture of emphysematic
bullae. Affected clients are mostly slim tall young males. Other causes are trauma or
pulmonary emphysema. Traumatic pneumothorax occurs due to a lung rupture or a
rupture of the chest wall. Pneumothorax may lead to an intrapleural tension causing a
life threatening shift of the mediastinum to the opposite side of the injury and mostly
requires emergency treatment by placing a chest tube for intrapleural pressure relief. A
smaller spontaneous pneumothorax may heal spontaneously and does not require any
intervention.
Symptoms and diagnostic findings:
Dyspnea, affected side with absent breathing sounds or crepitation, dull percussion,
limited chest expansion, X-ray shows collapsed lung, PO2 .
Treatment:
Small air accumulations in cases of spontaneous pneumothorax may not cause
significant symptoms and heal without further intervention since air will be absorbed in
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interpleural space. Placement of a thoracic drainage or tube is required in cases of more
significant air accumulations or in a tension pneumothorax.
Atelectasis
Collapse of parts of pulmonary tissue or of a complete lung caused by bronchial
obstruction. Typical causes are tumors, hypoventilation and longstanding COPD. An
existing atelectasis is susceptible to develop pneumonia or bronchitis. Clients after
immobilizing operations require chest physiotherapy for atelectasis prevention.
Symptoms and diagnostic findings:
Fever, Leukocytosis if accompanied by a pulmonary infection. Dyspnea, depending on
size of unventilated lung tissue. Hypoxemia, diminished breathing sounds and altered
percussion. Marked area of unventilated lung tissue in chest x-ray study.
Treatment :
Treatment of underlying cause, Treatment of hypoxemia as needed and prevention of
further atelectasis.x
x
Pneumonia
Inflammatory disease of pulmonary alveoli and bronchioles as the actual pulmonary
tissue. Causes of bacterial infections are classified by community and hospital
acquired infections. Streptococcus pneumoniae is the most common infectious
causative agent for pneumonia overall. Community based bacterial pneumonia also
arises from infections with Escherischia coli, Pseudomonas aeruginosa, Haemophilus
influenzae, Klebsiella pneumoniae and influenza viruses. Also viral and fungal infections
possible as well as atypical bacterial infections. Other causes include aspirations of
food particles in uncontrolled vomiting or swallowing difficulties as well as inhaled
chemical agents or foreign bodies.
Symptoms and diagnostic findings:
Fever (moderate in viral, high in bacterial infections), dyspnea, unproductive cough,
leucocytosis and chest X-ray with more or less infiltrates depending on cause.
Almost clear chest x-rays in cases of atypical pneumonia!
Treatment:
Antibiotic and fever treatment, analgetic medication, oxygen supply, upright positioning,
fluid supply, mechanical ventilation as required.
Tuberculosis
Specific bacterial infection of pulmonary tissue. Causative agent is the gram positive
Mycobacterium tuberculosis. Diagnosis is made by proof of acid fast bacteria in sputum
sample or samples from fasting gastric secretion. Transmission occurs via airborne drop
infection from infected individuals. Infection of otherwise healthy people usually requires
a more frequent contact. Clients with immune compromising other conditions, alcoholism
and / or in stades of malnutrition are at a significantly higher risk for infections. Lungs are
most common sites of infection but other body tissues can be affected as well. Infection
induces the upbuild of Granulomata after activation of cell mediated immune response.
Symptoms and diagnostic findings:
Coughing from unproductive to productive with pink sputum, weight loss, anorexia, night
sweats and positive skin testing. Ghon tubercle in chest x-ray marks newly developed
infection. Proof of diagnosis via acid-fast bacillus sputum samples or samples of fasting
gastric secretion over three consecutive days.
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Treatment:
CDC standards and airborne precautions: Isolation in private room, negative air room
pressure, 6–12 full air exchanges per hour, personnel and visitors to wear fitted mask in
patients room, client to wear mask when transferred to other departments, antimicrobial
therapy and oxygen supply as needed.
Antibiotic exposure prohylaxis with Isoniazid over 6 months with no clinical evidence of
infection and for 12 months with clinical evidence of infection. Treatment of active
disease by following one of four CDC treatment plans.
Pulmonary Embolism
Pulmonary embolism is caused by a sudden partial or total blockage of the pulmonal
artery or multiple pulmonal arterioles by blood clots, fat or air. Blood clots mostly arise
from a deep vein thrombosis or from another thrombosis and get shifted through the
veinous circulation. Air or fat embolism occurs more frequently after trauma or major
surgical treatments. Pulmonary embolism in general is a life threatening condition,
especially if clots block the main pulmonal arteries leading to pulmonal infarction. Risk
factors are comparable with risk factors for deep vein thrombosis and include
immobilization, hypercoagulability, trauma and major surgery, especially joint
replacement and gynecological surgery.
Symptoms and diagnostic findings:
Sudden chest pain, hemoptysis, hypotension, decrease of S02 and PaO2, tachycardia,
anxiety, restlessness, agitation, loss of consciousness, cyanosis and lung crackles.
Chest X-ray may be unsuspicious in early stages. Diagnosis is made via pulmonary
angiogram or ventilation perfusion scan.
Treatment:
High volume oxygene supply, intravenous line, circulation support, if available
thrombolytic therapy or emblectomy and sedation. Cava filter placement in vena cava
inferior to prevent additional emboli.
Bronchopulmonary Dysplasia BPD
BPD is a chronic obstructive pulmonary dysfunction in infants which typically occurs after
prolonged periods of oxygen therapy or mechanical ventilation. Commonly occurring in
premature children with a history of respiratory distress syndrome at birth because the
bronchial epithelium suffers damage from air pressure and high oxygen concentrations.
As a consequence a generalized pulmonary fibrosis occurs and limits the gas exchange
surface area.
Symptoms and diagnostic findings:
Hypercapnia and respiratory acidosis, hyperventilation, chronic hypoxia, poor feeding,
failure to thrive, increased respiratory tract infections.
Treatment:
Clients require mucolytic, bronchodilating and corticosteroid medication, prophylactic
antibiotic treatment may be necessary. Strict infection control practices among hospital
staff and family members is mandatory as well as CPR training for parents. If children
are discharged with tracheostoma precautions have to be met.
Mandatory precautions for clients requiring tracheostoma care:
No handling of small items in front of tracheostoma.
Appplying a loose cover over tracheostoma during meals.
Showering not allowed.
Bathing under precautions to assure that no water is entering tracheostoma.
Tracheostomy tie change with assistance only.
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Laryngotracheobronchitis LTB/Croup
Inflammation of the upper respiratory tract due to viral infections with respiratory
syncytial virus (RSB), influenza, parainfluenza and mycoplasma pneumoniae causing
swelling of mucous membranes in upper airways. Typical clinical expression is an
inspiratory stridor. May cause respiratory acidosis and failure.
Symptoms and diagnostic findings:
Barking cough, inspiratory stridor, thick bronchial secretions, increased and exhausting
respiratory effort, low grade fever, muscle and body achiness and headaches.
Treatment:
Creating a calm environment by keeping parents at bedside. If possible accomplish cool
and humidified breathing air. Oxygen supplementation. Upright positioning,
bronchodilating medication. Corticosteroids to reduce airway edema. Be aware of
sudden relapse after initial improvement !
Epiglottitis
Most commonly caused by infection with haemophilus influenzae leading to a bright red,
severe and tender swelling of the epiglottis. Mainly occurring in chidren from 2–8 years
of age. Sudden onset , full obstruction within 1 to 6 hours possible.
Symptoms and diagnostic findings:
High fever of up to 102 F, pale facial expression, drooling saliva, altered voice,
severe tender dysphagia and agitation. Proof of diagnosis via lateral neck x-ray
revealing a thickened and displaced epiglottis cartilage.
Treatment:
Creating a calm environment, client may require intubation or tracheotomy, antibiotics
antipyretics, corticosteroids, hydration and maintaining an NPO Status.
Bronchiolitis
Inflammation of bronchioles triggered by infection with Rhino-syncytial virus RSV. Most
commonly occurring in children up to 2 years of age. Slowly developing from an upper
respiratory tract infection. RSV is able to spread via airborne and drop infection.
Symptoms and diagnostic findings:
Low grade fever, labored breathing, severe tachypnea with nasal and thoracic
retractions, thick secretions from nose and upper respiratory tract. Auscultation of
wheezes and crackles.
Treatment:
Suctioning of secretions, rest, upright positioning, bronchodilators and steroids, fever
relief with acetaminophen or ibuprofen and fluid supply.
Respiratory Medication Therapy
Bronchodilators
Beta-agonist sympathomimetics
Pharmacological effect:
Sympatomimetic bronchodilators connect with beta–2 receptors on bronchial
membranes and lead to release of cAMP (cyclic adenosine monophosphate) which will
leads to a dilation of bronchi and bronchioles.
Indication:
Acute Asthma attack, acute Dyspnea in a Chronic obstructive lung disease (COPD),
Long term Asthma and COPD treatment.
Special considerations and side effects:
•
The therapeutic effect of Beta-2 mimetic medication decreases with increase of
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administered dose and frequency.
Side-effects increase with increased dosage.
Once Beta-2 receptors are saturated with Beta-mimetic medication there is no
further therapeutic effect until the substance is released from receptor.
•
This process can be enhanced by intermittent use of inhalatory corticosteroids.
•
Increased dosage may also lead to stimulation of Beta1-sympatomimetic
receptors leading to tachycardia, hypertension, palpitations, tremor and anxiety.
•
These effects may be increased under caffeine consume which should be
avoided during the treatment.
•
Sympatomimetics have to be used with caution in patients with cardiovascular
disease.
•
Symptomimetics are contraindicated in combination with Monoamine oxidase
inhibitors. (MAOI’s)
•
Administration of inhalatory Sympatomimetics requires adequate patient
education.
•
There should be between 1–5 minutes of waiting time in between dosages
•
If administration of a maximum dosage does not lead to a relief of the
bronchospasm within minutes a physician has to be contacted.
•
Diabetes patients may respond with hyperglycemia.
•
During treatment of an acute dyspnea due to a flare of asthma or COPD it is very
important to remain calm and reassure the patient about a positive outcome.
Substances:
Albuterol (Proventil®), Bitolterol mesylate (Tornalate®), Formoterol (Foradi®)
Isoprotenerol (Isuprel®), Metaproterenol sulfate (Alupent®) Pirabuterol acetate
(Maxair®), Salmeterol (Serevent®), Terbutaline sulfate (Brethine®)
•
•
Salmeterol and Formoterol is not indicated for an acute treatment
since its effect starts after 20 minutes and lasts for 12 hours!
Albuterol, Bitolterol, Metaproterenol and Terbutaline is
not indicated in children under 12 years of age!
“How to ..”
use a metered dose inhaler
1. Insert medication cartridge into inhaler.
2. Remove cap from mouthpiece and hold inhaler upright.
3. Shake inhaler for 3 – 5 seconds.
4. Hold inhaler upright with mouthpiece downwards.
5. Tilt head lightly backwards.
6. Close lips tightly around mouthpiece.
7. Release dosage while taking a deep, slow breath for 3 – 5 seconds.
8. Hold breath for 10 seconds.
9. Exhale.
10. Rinse mouth and blow nose.
11. Clean mouthpiece with mild soap.
12. Store inhaler at room temperature.
Anticholinergic Bronchodilators
Pharmacological effect:
Blocking Acetylcholine receptors of the PNS on bronchial membranes.
Indication:
Acute Asthma attacks
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Acute Dyspnea in a Chronic obstructive lung disease (COPD)
Special considerations and side effects:
•
Lower potency than sympathomimetics.
•
Immediate but short lasting effect.
•
Can be used in an acute bronchoconstriction even in combination with
sympathomimetics.
•
May cause anticholinergic effects: dryness of mouth, tachycardia, hypertension,
palpitations, tremor, anxiety, urinary retention, diarrhea, nausea and vomiting.
Substances :
Ipratropiumbromide (Atrovent® and Combivent®), Tiotropium (Spriva®)
Xanthines
Pharmacological effect:
Inhibition of the enzyme phosphodiesterase (PDE)
Increase of cAMP in smooth muscle cells to achieve a bronchial dilation.
Increase of catecholamine levels.
Inhibiting synthesis of Prostaglandines.
Inhibiting release of cellular mediators Prostaglandin, Histamine, Thromboxane, from
leucocytes and mastcells.
Indication:
Status asthmaticus, mild and moderate Asthma attacks, pulmonary edema.
Special considerations and side effects:
•
Long term treatment requires monitoring of blood levels.
•
Therapeutic range: 10 – 20 mcg/mL
•
Slower onset of effect than inhalers, especially if administered orally.
•
Same stimulating effects, side effects to the cardiovascular system and central
nervous system as Sympathomimetics.
•
Euphoric effect, comparable to and increased by caffeine.
•
Overdose may cause irritability, insomnia, restlessness, palpitations,hypertension.
•
Not FDA approved for other pulmonary obstructive diseases than asthma.
Substances:
Aminophylline (Truphylline®), Theophylline (Theo – Dur®)
Inhalatory topical corticosteroids
Pharmacological effect:
Antiinflammatory effect on bronchial membranes. Probably due to inhibition of release
and production of inflammatory mediator substances from leukocytes.
Indication:
Obstructive pulmonary diseases
Special considerations and side effects:
•
Used either in combination with short or long term effective bronchodilators or as
a monotherapy to prevent bronchoconstrictions.
•
Dosage has to be limited if client takes systemic corticosteroids as well.
•
Client is supposed to rinse mouth after each use.
•
Medication has to be tapered off, over 2 weeks. No sudden termination.
•
Careful use in the following conditions:
o
Glaucoma
o
Congestive heart failure
o
Myasthenia gravis
o
Seizures
o
Inflammatory bowel diseases
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•
•
o
o
o
o
Hypertension
Thromboembolic disorders
Esophagitis
Inflammations
o
o
o
o
o
Opportunistic infections
Aquired immunodeficiency syndrome (AIDS)
Tuberculosis
Children < 2 years
Thrombocytopenia
o
o
o
o
o
o
o
Risk of reduced bone growth in children
Pharyngeal irritation
Diarrhea, nausea and vomiting
Headaches
Adrenocortical suppression and Addison’s Disease
Cushing’s Syndrome
Weight gain
Contraindications:
Side effects:
Substances:
Beclomethasone (diproprionate) = fewest side effects, greatest anti-inflammatory effect.
Budesonide (Pulmicort®), Flunisolide (Aero-bid®) and Triamcinolone (Azmacort®)
Inhalatory mast cell stabilizers
Pharmacological effect:
Inhibition of release of inflammatory mediator substances from mast cells.
(= sessile lymphocytes).
Indication:
Preventive treatment of inflammatory airway diseases.
Special considerations and side effects:
o
May help to decrease dosage of steroids and bronchodilators.
o
Effect may not be noticeable for treatment but flares may be rare
( = 3rd wheel of treatment).
o
Not suitable in acute exacerbations and breathing difficulties.
o
Dosage adaptation in renal or hepatic diseases necessary.
o
Propellants of Aerosols may aggravate symptoms of a CAD or Dysrhytmias!
o
Client to rinse mouth after each use.
o
If prescribed, bronchodilators administered 30 minutes prior to the use of
inhalatory mast cell stabilizers may incease their effect.
Substances:
Cromolyn (Intal®) and Nedocromil (Tilade®)
Leukotriene modifiers
Pharmacological effect:
Blocking action of leucotrienes which are released from mast cells and lymphocytes
during an allergic reaction.
Indication:
Long term preventive treatment of Asthma in children and adults.
Special considerations and side effects:
Leukotriene modifiers work specifically in pulmonary tissue. Onset of effect may take up
to one week. To be prescribed to children from 12 years of age and adults. May be used
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singularly or in combination with corticoteroids. May cause headaches, nausea, diarrhea
and dyspepsia.
Substances:
Montelukast (Singulair®), Zafirlukast (Accolate®), Zileuton (Zyflo®)
Antihistamines
Pharmacological effect:
Blocking action of histamines by competitive block of histamine receptors.
Indication:
Prevention and treatment of allergic reactions, cough and sneeze relief in common colds.
Therapeutic use:
Prevention and relief of common allergic symptoms: (Urticaria, Quincke edema, allergic
rash, itching, bronchospasm and sneezing), inhibition of oral, nasal, lacrimal,
gastrointestinal and saliva glands. Not indicated in an acute asthma attack. May be
given prior administration of blood products as a precaution. Onset of effect usually
within 15–60 minutes, lasting for 6–12 hours.
Side effects:
Anticholinergic: Dry mouth, mydriasis, urine retention, constipation, nausea and vomiting.
Bone marrow depression, pancytopenia and agranulocytosis.
Sedation, light to deep especially in antihistamines of the 1st generation.
Special considerations:
Antihistamines as well as corticosteroids interfere with any diagnostic skin testing for
allergies and should not be taken 72 hours prior such testing.
Substances:
•
First Generation, sedating
Diphenhydramine (Benadryl®), Brompheniramine (Dimetane®), Chlorpheniramine
(Chlor-Trimeton®), Dimenhydrinate (Dramamine®), Clemastine (Tavist®), Promethazine
(Phenergan®)
•
Second Generation, non – sedating (can be used in children over 6 years)
Loratadine (Claritin®), Cetirizine (Zyrtec®), Fexofenadine (Allegra®)
Nasal Decongestants
Pharmacological effect:
Nasal decongestants are sympathomimetics and stimulate specifically alpha1-receptors.
Symptomimetic effect causes downswelling of nasal mucosal membrane due to
vasoconstriction in supplying arteries.
Indication:
Rhinitis in upper respiratory tract infections and allergic reactions.
Therapeutic use:
Relief from nasal congestion.
Side effects:
Rebound decongestion if used longer than 3 days or repeatedly. Addictive potential
leading to privinism. Sympatomimetic stimulation may lead to hypertension, tachycardia,
dysrhymias. Restricted use in clients with history of cardiovascular disease.
Special considerations:
Nasal congestion inhibits sucking in infants. Therefore decongestant should be applied
30 minutes prior to bottle feeding. Clients have to be taught about addictive potential and
very temporary benefits and alternatives (i. e. steam inhalations). Cardiovascular side
effects may also occur in children.
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Substances:
Phenylefrine (neo – Synefrine), Pseudoephedrine (Sudafed), Ephedrine (Vicks Vatronol)
Naphazoline (Privine), Oxymetazoline (Afrin), Tetrahydrozoline (Tyzine) and
Xylometazoline (Otrivin)
Expectorants
Pharmacological effect:
Not fully inestigated and questionable.
Indication:
Fluid secretion in respiratory tract infections.
Therapeutic use:
Dilution and increased secretion of fluids in repiratory tract infections of questionable
effectiveness. Medication requires an adequate fluid intake.
Substances :
Sodium chloride solution, Acetylcyteine (Mucomyst) and Dornase alfa (Pulmozyme – for
clients with cystic fibrosis only).
Antitussiva
Opioids = (Codeine) and non-opioid antitussives are available. Direct inhibition of cough
reflex center in brain stem. Dry, hacking unproductive cough. Non-opioid antitussiva
dextrometorphan is first choice since it does not cause CNS depression.
Side effects:
Dependency, CNS depression with codeine. Dry mucous membranes with
dextrometorphan.
Oxygene therapy
Pure oxygene can be directly administered in a flow rate of 1 L/min.–6 L/min. Oxygen
dries mucous membranes and needs to be applied with humidifier. Prolonged supply of
high concentrations of oxygene can cause damages of lung tissue. First symptoms of
oxygene toxicity are cough, chest pain and gastrointestinal symptoms.
Side effects:
Atelectasis, alveolar collapse due to oxygene supply at a concentration of 60% over 36
hours or of 90% over 6 hours. ARDS Adult respiratory distress syndrome may occur due
to 80–100% of oxygen for more than 24 hours. Outcome may be pulmonary edema and
pulmonary hemorrhage. COPD patients may develop respiratory depression under
supply of oxygene in rates >2 L/min. Diagnostic parameter for efficiency of oxygene
supply is SaO2. Oxygene therapy must be administered under strict protection from
electric sparks, friction or fire.
Oxygene applications masks:
Venturi–mask: max. 10 – 100 % oxygen administration.
Nonrebreather mask: 60 – 100 % oxygen administration
Partial rebreather mask: 70-90 % oxygen administration
X
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CARDIOVASCULAR DISORDERS AND DISEASES
Anatomy and Physiology
Great vessels and Coronary arteries
Circulatory system
Cardiac cycle
•
Diastole:
1.
Simultaneous filling of the right atrium by return of venous oxygen
deficient blood via the superior and inferior cava veins and of the left
atrium by return of oxygenated blood via the pulmonary veins.
2.
Opening of the atioventricular valves.
3.
Simultaneous filling of the right and left ventricle.
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•
Systole:
1.
Simultaneous contraction of atrial chambers.
2.
Closure of atrioventricular valves
origin of 1st heart sound!
3.
Simultaneous contraction of ventricular chambers.
4.
Closure of pulmonalis and aortic valves
origin of 2nd heart sound!
Terms and Definitions
Heart Rate HR = Heartbeats per minute
Stroke Volume SV = amount of blood that the myocardial chambers pump per single
heart beat. On average 60 – 70 ml in healthy adults.
Cardiac output CO = Heart rate (HR) x Stroke volume (SV)
Contractility = Strength of the myocardial contraction
Preload = Maximal ventricular enddiastolic relaxation.
Afterload = Resistance caused by blood pressure in peripheric vascular system.
Components of the cardiac conduction system
The myocardial cells within the cardiac conduction system are also described as
“pacemaker cells” since they a are specialized in conducting and progressing an
electrical innervation of the myocardium. The pacemaker cells of the different
compartments of the cardiac conduction system differ in the rate and strength of the
electrical innervation they can induce. Pacemaker cells of the Sinus node elicite the
most frequent and strongest electrical impulses.
1. Sinoatrial node
Main and natural pacemaker which regulates normal heart rate between 60 – 100 bpm.
2. Internodal conduction pathway
Connecting SA node with AV node.
3. AV node
Replacement pacemaker with 40 – 60 depolarizations/minute.
4. His’ bundle
Connecting AV node with intraventricular nerve conduction fibers.
(Left & right branch bundle)
5. Purkinje fibers
Terminal ending of intracardial conduction system.
Electrocardiography
Technical principles:
Graphic recording of the electric myocardial activity.
Obtainable cardial information:
Myocardial perfusion and ischemia, heart size, heart position, hypertrophy and
dysrhythmias.
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Placement of 12 lead ECG Electrodes
Chest: V1 = red, V2 = yellow, V3 = green, V4 = blue V5 = orange, V6 = violet
(V and C leads are equivalent)
Right Arm: = White
Left Arm: = Black
Right leg: = Green
Left leg: = Red
Placement of electrodes (3 – lead ECG):
One below center of each clavicle bone as well as over lowest rib in left
medioclavicular line.
Placement of electrodes (5 – lead ECG):
Placement of additional leads over lowest rib right medioclavicular line.
As well as in one position of V1 – V6.
The standard electrocardiogram (ECG) is a representation of the heart'
s electrical
activity. It consists of recordings from each of the 12 electrodes on the body surface. The
use of 12 recording leads is a convention and has little logical or scientific basis.
The basic ECG waveform ( Regular Sinusrhythm, 60-100 bpm)
The basic ECG waveform consists of three main recognizable deflections which are
described as "P wave", "QRS complex" and "T wave". The P wave represents the
spread of electrical activation (depolarization) through the atrial myocardium. Normally, it
is a smooth rounded deflection preceeding the QRS complex. The QRS complex
represents the spread of electrical activation throughout the ventricular myocardium. It is
usually (not always) the largest deflection on the ECG and is "spiky" in shape.
Deflections resulting from electrical activation of the ventricles are called QRS
complexes, irrespective of whether they start with a positive (above the baseline) or a
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negative (below the baseline) deflection and whether they have one or more
recognizable deflections within them.
The various components of the QRS complex however, are named on the basis of the
following convention:
a) The first positive wave (above the baseline) is called r or R.
b) Any second positive wave is called r'or R'
.
c) A negative wave that follows an r or R wave is called a s or S wave.
d) A negative wave that precede an r or R wave is called a q or Q wave.
e) An entirely negative wave is called a qs or QS wave.
f) LARGE DEFLECTIONS are named CAPITAL letters, small waves by small letters.
The T wave represents electrical recovery (repolarization) of the ventricular myocardium.
It is a broad rounded wave following the QRS complex.
The U wave may appear due to a slow replolarization of the papillary muscles. Some
causes include: Bradycardia, hypokalemia and digoxin therapies
Interpretation of common ECG findings
Normal 12 lead ECG
Variations of normal ECG findings
Sinus arrhytmia
R-R Interval changes depending on respirations. Does not require treatment.
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Sinus tachycardia
HR > 100 – 150 bpm. May be caused by fever, hypovolemia and pain.
Treatment due to relief of underlying cause.
Sinus bradycardia
HR < 60 bpm. Treatment is indicated if patient experiences symptoms.
Atropin for immediate intervention.
Premature Atrial Contractions (PAC)
Usually unaltered normal atrial and ventricular heart rate. Caused by early atrial
contractions leading to a compensatory break until the following contraction. Mainly
caused by stress or overuse of stimulating substances like caffeine, alcohol or tobacco.
Paroxysmal Supraventricular Tachycardia (PSVT)
Atrial contractions > 100 - > 200 bpm. May not significantly alter the ventricular rhythm.
Treatment by stimulation of the autonomous nervous system via carotis sinus stimulation,
valsalva maneuver, oxygen supply, adenosine, verapamil, cardio selective beta –
blockers and ecg-triggered cardioversion.
Atrial Flutter
Atrial contractions between 240 and 360 bpm, regular. Ventricular response does not
overexceed 150 bpm, regular. Treatment with cardioversion or drug treatment with
calcium–channel blockers, beta–blockers, quinidine, amiodarone or flecainide to reduce
ventricular response.
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Atrial Fibrillation AF
Atrial contractions > 300 bpm, irregular. Ventricular response maximum 180 bpm and
irregular (arrhythmia absoluta). Treatment with cardioversion or digoxin, verapamil, betablockers. Unresolvable atrial fibrillation requires anticoagulation to avoid upbuild of
intracardial clots.
Junctional Escape Rhythm
40–60 bpm, regular. Stimulation of myocardial tissue originates from conducting
atrioventricuklar fibers. Typical replacement rhythm due to irregular or absent sinus node
activity. Does require pacemaker treatment if accompanied by symptoms or if heart rate
decreases.
Premature Ventricular Contractions (PVC)
Irregular and variable heart rate. Typically marked by a deformed widened QRS –
complex with no corresponding P – wave. Followed by a compensatory pause. May
occur singular, monotop or polytop. PVC’s can be caused by stress, overuse of
stimulating substances like caffeine, alcohol or tobacco or underlying myocardial
problem. Drug treatment may be performed with lidocaine, propranolol, procainamide
and phenytoine. Serial PVC’s can develop into ventricular arrhytmias and ventricular
fibrillation which is functionally equivalent to a cardigenic shock. Formations of triplet and
quadruple premature ventricular contractions are possible as well.
Ventricular Tachycardia (VT)
100 - > 200 ventricular, regular bpm. P – waves undetectable, multiple and deformed
QRS-complexes. Treatment necessary in unstable circulatory condition. Includes
lidocaine, procainamide and defibrillation.
x
Ventricular Fibrillation (VF)
Heart rate not detectable. Functional cardiac arrest. Client requires immediate
defibrillation.
x
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Atrioventricular Conduction Blocks
1st degree AV Block
Prolonged P-Q interval > 0.20 seconds. Regular sinus rhythm and normal heart rate. No
treatment necessary.
2nd degree AV block, type I (Mobitz I, Wenckebach)
Pattern of a gradually prolonged PR – Interval until ventricular response fails.
Normal heart rate. May be a transitional stade after myocardial infarction. Therapeutic
intervention is not immediately necessary and depends on symptom development. Drug
therapy includes atropine or isoproterenol.
2nd degree AV block, type II, (Mobitz II)
Pattern of 2:1 or higher P:QRS ratio, resulting in less than 60 ventricular regular
contractions per minute. Clients require pacemaker. Intermediate drug treatment with
Atropine or Isoproterenol.
3rd degree AV block
Atrial and ventricular contractions are completely unlinked due to total block of the
atrioventricular conduction. Ventricular heart rate regular and as low as 15 – 60 bpm.
Clients require immediate pacemaker therapy.
Intraventricular conduction blocks
Interruptions of the intraventricular conduction pathway may lead to an altered
innervation of the ventricular myocardial innervation, which can be identified as left or
right bundle branch blocks in an ECG. The affected clients may be asymptomatic in
regards of clinical symptoms of heart failure or coronary heart disease. Bundle Brunch
Blocks appear with a prolonged or deformed QRS complex as an incomplete or
complete block in order to the following criterias:
QRS complex duration < 0.12 sec. = incomplete BB /
QRS complex > 0.12 sec. = complete BB
Affected leads (C) V1 – V3 = Right bundle branch block /
(C) V4 – V6 = Left bundle branch block
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Left bundle branch block LBB
Right bundle branch block RBB
Coronary Artery Diseases CAD
Arteriosclerosis of the coronary arteries causes a decrease of the coronary bood flow
and the nutritional and oxygen supply for the mocardium. Cinical complaints may not
occur until the vascular diameter is reduced by at least 50%. Typical symptoms of
coronary artery disease include congestive heart failure, dysrhytmias, Angina pectoris or
myocardial infarction.
Common appearance of Angina pectoris:
Stable Angina pectoris
Chest pain under exertion spontaneously ending when client is resting.
Unstable Angina pectoris
Chest pain occurs independently from physical activity.
Prinzmetal Angina
Benign vasospasm with no underlying cause and danger for the myocardial tissue.
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Symptoms and diagnostic findings of a Myocardial infarction
Nitroglyzerine resistant chest pain, which may radiate to substernal, clavicular or
submandibular region.
Nausea, vomiting, cold sweats, dyspnea, dysrhythmias and anxiety.
ECG findings in acute stades:
ST – elevations, T-Inversions. Q – waves in post - infarction stades. Elevated
myocardial enzymes in early stades: CK – MB over 6 % of total CK. Troponine Test
positive.
Treatment:
Monitoring of vital signs, ECG holter monitoring and 12-lead ECG, oxygen supply and
creation of a calm environment.
First line medication treatment includes:
Nitroglycerine, Heparine supply under PTT monitoring, Aspirine, Morphine,
Fibrinolytic therapy if applicapble, PTCA and CABG (if applicable).
CAD specific ECG alterations
Typical ECG Alterations in cases of subacute Coronary Artery Disease are ST Segment
Depressions.
Typical ST Depression in leads II, III, aVF in a client with Coronary Artery Disease.
Heart failure (Congestive heart failure) HF
Heart failure occurs as a chronically developing myocardial weakness resulting in
inefficient blood supply for the cardiovascular system due to a reduced cardiac output.
Heart failure typically starts as left or right sided heart failure. Contralateral sides are
typically affected over time which results in a global heart failure. Common causes for
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heart failure are cardiomyopathy, coronary artery disease or valvular diseases. An acute
left sided heart failure mainly occurs due to a myocardial infarction. Right sided heart
failure is described as cor pulmonale and develops predominantly after pulmonary
diseases such as COPD, Asthma or Emphysema which cause pulmonary
hypertension. Pulmonary embolism causes typically causes an acute right sided heart
failure.
Pathophysiology of left sided heart failure
reduced cardiac output of left ventricle
dilation of pulmonary veins
pulmonary congestion = (“pulmonary backup”)
pulmonary edema
diminished gas exchange
moderate to severe dyspnea due to a “fluid lung”
hypoxia
hyperkapnia
peripheral and/or central cyanosis
deficient metabolic supply and gas exchange in peripheral tissues
general physical weakness
chronic fatigue
Pathophysiology of right sided heart failure:
fluid retention into systemic venous circulation “venous backup”
peripheral edema
pleural effusions
aszites
fluid congestion of internal organs ( i.e. Liver, spleen)
jugular vein distention in upright position.
Treatment:
Constant monitoring of blood pressure, heart rate and blood gas analysis, upright
positioning, oxygen supply, monitoring of input/output balance, serum electrolytes, fluid
restriction and weight assessment.
x
Pharmacological treatment of congestive heart failure:
Angiotensin converting enzyme inhibitors (ACE inhibitors)
Blood pressure = afterload .
Diuretics (Loop and Thiazide Diuretics)
cardiac preload
pulmonary congestion .
Diuretic medication therapy requires frequent monitoring of serum potassium levels !
Nitroglycerine
cardiac preload
Morphine
Sedation
Blood pressure .
pulmonary vasodilation
hypotension.
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Glycosides (Digoxine Digitoxine)
heart rate
myocardial contractility
cardiac output .
Digoxin is contraindicated in cases of renal failure and needs to be replaced with
Digitoxin which is metabolized through a hepatic pathway only.
Frequent monitoring of potassium and calcium levels under glycoside treatment is
necessary throughout the course of treatment.
A heart rate < 60 bpm under glycoside treatment may require physicians attention.
Cardiomyopathy
Dysfunction and degeneration of the heart muscle due to multiple underlying causes.
Mostly fatal outcome. Common as a secondary development in alcoholism, diabetes,
kidney diseases, infections or autoimmune disorders.
Classifications:
Dilated cardiomyopathy
Myocardial degeneration leads to a weakened contractility and widening of the heart.
Hypertrophic cardiomyopathy:
Myocardial tissue thickens and decreases cardiac output due to a reduced stroke
volume.
Restrictive cardiomyopathy
Loss of elasticity of the myocardial tissue which also results in a reduced stroke volume.
Symptoms and diagnostic findings:
Cardiomyopathy symptoms are comparable with symptoms of a left sided heart failure.
A slow to rapid progression may occur. Generally poor prognosis.
Treatment:
Condition is incurable. Treatment is focused on underlying cause and on severity of
resulting heart failure. Heart transplant may be indicated in some cases.
Hereditary heart defects
Rare hereditary heart defects may affect the atrial and/or ventricular cardial function but
can also remain asymptomatic. Main criteria for the severity of hereditary heart defects is
if the pulmonary blood oxygenation is limited leading to cyanosis. Such right
left shunt
heart defects result from circumstances where the intraatrial or intraventricular pressure
of the right heart significantly overcomes the intracardial pressure of the left atrium or
ventricle. The incidence of hereditary heart defects is significantly higher in premature
children or in cases of malnutrition throughout the early childhood.
Symptoms and diagnostic findings:
Heart defects with left-to- right shunt:
Atrial and Ventricular Septum Defect (ASD and VSD)
Persisting Ductus Arteriosus Botalli. (DAB)
Clients may be asymptomatic. Systolic murmur is a common significant finding.
Advanced stades may lead to a global heart failure. Cyanosis unlikely.
Treatment:
ASD, VSD and persisting DAB may close spontaneously. Otherwise surgical treatment
by insertion of a patch. DAB closure can be induced with oral administration of acetylic
salicylic acid (
inhibition of prostaglandine synthesis).
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Heart defects with right-to-left shunt:
Transposition of the great vessels
Aortic vessel originates from right ventricle and pulmonal artery from left ventricle.
Fallot’s Tetralogy
Combination of pulmonary stenosis, ventricular septum defect, right sided ventricular
hypertrophy and overriding aorta. (
Aorta “rides” over VSD which results in mixed
aortic perfusion with oxygenated and unoxygenated blood)
Symptoms and diagnostic findings:
Cyanosis, “ squatting child” (reduction of venous return by squatting), severe hypoxia
compensatory polyglobulia.
Treatment:
Surgical correction.
Valvular cardiac disorders
Destruction and deformation of cardiac valves caused by underlying atherosclerotic
degeneration, rheumatism or endocarditis. Defect results in limited opening (stenosis) or
insufficient closure (regurgitation/ insuffiency) of heart walves. Most commonly affected
are aortic and mitral valve.
Symptoms and diagnostic findings:
•
Aortic walve regurgitation (insufficiency):
Left sided backward heart failure, diastolic murmur, enddiastolic overload of
left ventricle, Palpitations and premature ventricular contractions possible.
•
Aortic valve stenosis:
Left sided forward heart failure, systolic murmur, cardiac output
BP , possible angina pectoris due to insufficient diastolic filling of
coronary arteries.
•
Pulmonal valve regurgitation (insufficiency):
Right sided backward heart failure, diastolic murmur, insufficient lung perfusion
leading to insufficient blood oxygenation for the entire systemic circulation and
enddiastolic overload of right ventricle.
•
Pulmonal valve stenosis (occurs mostly as birth defect):
Right sided forward heart failure, systolic murmur and severely impaired lung
perfusion.
•
Mitral prolapse:
Left sided forward heart failure, systolic murmur, mostly asymptomatic
May cause palpitatons and premature ventricular contractions.
•
Mitral regurgitation (insufficiency):
Left sided backward heart failure, systolic murmur, atrial fibrillation due to
developing overdistention and increased enddiastolic pressure of left.
ventricle common.
•
Mitral stenosis:
Left sided forward and backward heart failure, diastolic murmur and
increased enddiastolic pressure of left ventricle.
•
Tricuspidal regurgitation (insufficiency):
Right sided backward heart failure, diastolic murmur, increased enddiastolic
pressure of right ventricle and decreased lung perfusion.
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•
Tricuspidal stenosis:
Right sided forward and backward heart failure, systolic murmur,
decreased lung perfusion and fluid retention in venous system.
Treatment:
Treatment options include medications to improve cardiac output or to restore regular
heart rhythm as well as surgical valve replacement.
Every client with a valvular cardiac disorder requires prophylactic antibiotic treatment
before and after valve replacement to avoid endocarditis if procedures or diseases or
infections of the oropharyngeal or gastrointestinal tract are current. Materials used for
valve replacement are either from a biological source (pigs) or mechanical valves made
from titanium which require lifelong anticoagulation treatment with warfarin.
Endocarditis
Rapidly or chronically developing inflammation of the endocardial tissue due to a
bacterial infection which results in a destruction of the endocardial tissue and commonly
also in a damage of cardiac valves, mostly of the left sided heart.
Starting point is either a predisposition and/or an abnormous high amount of bacterial
toxins circulating in the blood stream. A predisposition is usually given by a preexisting
cardiac valve disorder or another structural myocardial disorder such as a persisting
foramen ovale. These anatomically altered surfaces function as breeding grounds for
circulating bacteria. High risk clients are intravenous drug users who mostly acquire
defects of the tricuspidal walve and/or the pulmonal walve.
Symptoms and diagnostic findings:
General malaise, fever and weakness. Elevated inflammatory parameters in blood
sample ( ESR, CRP and WBC). Cardial symptoms vary from signs of moderate to
severe heart failure to audible murmurs especially if valve destruction has already begun.
Examination involves blood culture sample to identify type of underlying bacterial
infection for specific antibiotic treatment. Acute infections are mostly caused by
Staphyloccocus aureus.
Treatment:
Clients require strict bedrest until infection is cured. Cardiac treatment is symptom
oriented and depends on severity of involvement of cardial structures. Main aspect is
cure of underlying infection with intravenous antibiotic therapy. A severely damaged
valve may require surgical replacement.
Pericarditis
Inflammation of the protective pericardial sac. Mostly caused by viral infections such as
Coxsackie-, Influenza- or Ademovirus after repiratory infections. Other common causes
include Dressler’s syndrome after myocardial infarction, uremia, tuberculosis and trauma.
Symptoms and diagnostic findings:
Symptoms of viral illness with fever and elevated inflammatory parameters along with
substernal pain. Pericardial effusions may cause cardiac tamponade. Limited cardiac
output, symptoms of global or single sided heart failure. ECG may show elevated ST
and T waves. Audible friction noises may occur. Chronic stages lead to a restrictive
heart failure due to scaring tissue.
Treatment:
A cardiac tamponade due to a significant pericardial effusion requires urgent pericardial
puncture (Pericardiocentesis) as an emergency treatment if it leads to a restrictive heart
failure. Other treatment options include pain management, oxygen supply and
supportive treatment of heart failure. Anti inflammatory treatment involves non steroidal
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antiinflammatories and corticosteroids. Also, if possible treatment of underlying cause.
In a tuberculotic pericarditis the pericardial sac may require surgical fenestration and
partial removal.
Disorders of the Veins
1. Deep Vein Thrombosis DVT
Sudden inhibition of blood flow in the deep vein system due to formation of an
intravenous blood clot. Most commonly occurring in lower extremities.
Significant risk factors for development of a DVT are:
Immobility (e. g. postoperative) leading to inactivity of calf muscles, dehydration, surgical
procedures, (total hip joint replacements and pelvic gynecological procedures involving
the uterus), hormonal birth control, smoking, varicose veins and previous DVT in clients
history. Also hereditary thrombophilia (APC resistence, Antithrombin III deficiency and
thrombocytosis), diuretic medication. Paraneoplastic DVT’s in presence of a malignancy,
typically in cases of pancreatic gland cancer.
Symptoms and diagnostic findings:
Painfull swelling of affected leg at rest and due to movement of ankle, (Hohmans sign)
blue discoloration, edema, calf and thigh tender to touch. Diagnostic imaging techniques
to reveal disturbed venous circulation include Doppler duplex sonography, radiologic
venogram with contrast dye and MRI. Full inhibition of arterial and venous perfusion of
affected leg. (Phlegmasia caerulea dolens)
2. Postthrombotic syndrome
Symptoms and diagnostic findings:
Chronic veinous dysfunction resulting in persistent swelling of affected leg.
Treatment:
Treatment has to start when a DVT is suspected. Pain relief. Strict immobilization in
upright position of upper body. Elevation of affected leg and pressure bandaging
(Improvement of veinous return via collateral unaffected veins) Initial administration of
Heparine (e. g. 5000 IE UFH) to avoid further blood coagulation on top of existing clot. If
confirmed continuation of anticoagulation with oral anticoagulants. Continuation of
compression therapy with stockings. Prevention and elimination of DVT causes.
3. Thrombophlebitis
Blood clot formation in superficial vein system. Most commonly due to injuries after
medical vein punctures or due to varicose veins. Also common under intravenous drug
users. May include a bacterial infection with Staphylococcus aureus of Streptococcus
viridans bacteria if skin is injured.
Symptoms and diagnostic findings:
Circumscripted painful red discoloration. Affected area tender and warm to touch.
Clot in superficial vein may be palpable, skin injury or puncture in affected area.
Treatment:
Temporary rest and limited muscular activity of affected limb. Local application of
heparine gel or cool packs and pain relief. Antibiotic treatment if bacterial infection is
suspected.
Thrombophlebitis almost never leads to an embolism within the deep venous system!
Hypertension
The American Heart Association AHA defines hypertension as a blood pressure from
readings of over 140/90 mmHg after ten minutes of rest, if assessed at repeated
measurements on at least two different examinations. Readings from 120/80 mmHg to
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139/89mmHg are classified as a prehypertension. Readings below 120/80 are
unsuspicious and should be targeted in a antihypertensive therapy. Primary
hypertension mainly occurs as an essential hypertension due to a primary vascular
disorder of unknown cause.
Secondary hypertension is less common and develops due to other underlying disorders
or diseases including alcoholism, obesity, hormonal and kidney diseases. Any
hypertension aggravates due to smoking, high salt intake and uncontrolled diabetes.
Symptoms and diagnostic findings:
Hypertension mostly develops slowly over several years without causing any physical
complaints. This diagnosis is typically made by routine blood pressure measurements at
rest. Other manifestations occur as a hypertensive crisis with sudden acute head or
chest pain. Further assessments can reveal signs of left ventricular hypertrophy in an
ECG,chronic kidney failure or retina detachments (
Fundus hypertonicus). Routine
assessments in newly diagnosed clients are necessary to rule out the following most
common underlying causes of secondary hypertension:
•
Renal artery stenosis (assessed via duplex-sonography)
•
Catecholamine producing tumors (catecholamines in 24 hour urine sample)
•
Hyperthyreosis (TSH assessment in blood sample)
Malignant hypertension is defined as hypertension that has already caused organ
damages such as a MI, a stroke or kidney damage.
Treatment:
For primary hypertension treatment consists of usually lifelong medication therapy with
single use or combination of
o
o
o
o
o
ACE - Inhibitors
(Thiazide) – Diuretics
Beta – Blockers
Calcium channel blockers
Angiotensin 1 – inhibitors
A strict cardiovascular risk factor assessment and management is necessary to control
serum lipids, bodyweight, salt intake, blood sugar and kidney function. Secondary
hypertension will be treated by resolving the underlying cause first.
x
x
Periphereal Arterial Disease PAD
PAD develops due to atherosclerotic damage of one or several peripheric arteries. Main
risk factors are hyperlipidemia, diabetes, smoking and hypertension. Most commonly
affected vessels are the aortic artery, inguinal arteries and the arteries of lower
extremities. An arterial stenosis develops slowly and does not show any symptoms
before the diameter of an artery is narrowed to 25% of the former diameter.
Severity of a PAD - Fontaine stades I - IV:
I: Narrowing arteriosclerotic process present, but no clinical symptoms.
IIa: Intermittent claudication after more than 100 meters
IIb: Intermittent claudication after less than 100 meters
III: Pain at rest
IV: Ulcers and tissue necrosis due to permanent hypoxygenation of tissues.
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Symptoms and diagnostic findings:
Claudication pain in the affected leg is the most typical symptom observed in a PAD.
Also cool and pale extremities, weak or vanished peripheric pulses, cyanosis, disturbed
nail and hair growth. PAD may also lead to an acute arterial embolism where an
atherosclerotic thrombus may block suddenly an artery which shows the following
characteristic “six p” symptoms.
Pain, Pallor, Pulselessness, Paresthesias, Paralysis and Poikilothermia
Thrombi may also develop due to irregular myocardial contractions in cases of atrial
fibrillation or after a myocardial infarction. Assessment of location and severity of an
arterial stenosis is performed via color duplex ultrasound sonography, digital subtraction
angiography (DSA) or plethysmography.
Aortic Aneurysm
Separation of the intima and externa layer of the aortic wall. Typically caused by
atherosclerosis. Most common site is the infrarenal abdominal aorta and the ascending
thoracic aorta. Aortic aneurysms may remain asymptomatic for a long time. Diagnosis is
then usually made by coincidence during abdominal ultrasound examinations. Acute
pain along with signs of poor arterial perfuision indicates an impending rupture and
requires emergency surgical intervention with insertion of an alloplastic graft to bypass
the aneurysm. Elective Surgery is performed in cases of aneurysms with more than 4 cm
in diameter. (normal max. diameter is 2 cm)
Treatment:
Regulation of all relevant risk factors as a secondary prophylactic treatment.
•
•
•
Medication used to inhibit aggregation of platelets:
Ticlodipine (Ticlid®), Clopidogrel (Plavix®) and Aspirin
Vasodilating medication: Pentoxifylline (Trental®)
Analgetic medication.
Daily repeated walks until pain occurs will help to stimulate growth of collateral arteries
in Fontaine stades up to II b.
x
Surgical treatment options:
Catheterization angioplasty, homologous or autologous bypass grafting, endarterectomy
/embolectomy. In cases of acute arterial emboli also thrombolysis within 6 hours to avoid
rhabdomyolysis and kidney damage. Any interventional treatment will be performed
under temporary heparine therapy and requires postoperative observation of the
activated partial thromboplastine time aPTT. After arterial embolism a warfarine
treatment may be necessary to avoid upbuild of further thrombi.
Diabetic Angiopathy
Clients with a history of untreated or undiscovered Diabetes may develop comparable
symptoms due to a destruction of the small arteries and capillaries only while main blood
vessels may not show any evidence of advanced destruction.
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Cardiovascular Medication Therapy
Nitrates
Pharmacological effect:
Dilation of blood vessels due to relaxation of smooth muscles.
Physiological systemic effect:
•
Dilation of coronary arteries
•
Dilation of venous system = cardial preload (blood volume to return to the heart)
= venous “pooling”
•
Dilation of arterial system = cardial afterload
(resistance of arterial system to blood ejected from heart) BP
•
Reduction of myocardial oxygen demand.
Indication:
Coronary artery disease, pulmonary embolism and chronic heart failure.
Therapeutic use:
Acute intervention in Angina chest pain. Can be administered as a spray to oral mucous
membranes. (most common) Also intravenous, oral (tablets) and transdermal
administration (patches and paste).
Special considerations:
•
Patients with angina pectoris must have medication available at bedside for
immediate treatment or self administration in case of an acute angina pectoris
attack.
•
Administration of Nitrate capsules and tablets requires adequate moisturization of
oral mucous membranes.
•
Intravenous administration is always performed as an infusion never as a bolus
injection.
•
Nitrate infusion requires dilution of medication in Sodium chloride 0.9 % or D5W.
•
Regular PVC IV tubing may absorb up to 80 % of Nitroglycerides, especially
•
under exposure to light.
•
Manufacturer supplied special, darkened IV tubing and bottles may be used
instead.
•
Intravenous application requires constant monitoring of heart rate and blood
pressure (every 15 Minutes).
•
Nitrate IV solutions and aerosols can be absorbed transcutaneously.
•
An acute angina type chest pain in a patient with a known coronary artery
disease that is not improving under nitrate treatment is suspicious for a
myocardial infarction.
•
Patients with NTG Patch are allowed to swim and to take a bath.
•
Medication has to be stored in a cool dry place.
•
Patients with a permanent nitrate treatment must have a 12 hour administration
free period within 24 hours. Otherwise the nitrate receptors of the vascular
smooth muscle cells are overstimulated and become insensitive towards the
medication.
Contraindications:
Hypersensitivity/allergies against nitrates. Combination with phosphodiesterase inhibitor
medications used for treatment of erectile dysfunction (i. e. Sildenafil). May cause severe
hypotension.
Side effects:
Nitrate related headaches, hypotension, vertigo, dizziness, nausea, vomiting, reflex –
tachycardia due to sudden hypotensive effect.
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Substances:
Nitroglycerin, (Nitro-Tab®, Nitrstat®, Nitrogard®
Isosorbide mononitrate (Imdur®, Monoket®) and Isosorbide dinitrate (Isordil®)
Beta-Adrenergic Blockers
Pharmacological effect:
Blockage of cardial Beta1 receptors of the Sympathetic Nervous system (SNS).
In higher dosages also blocking pulmonal Beta2 Receptors.
Physiological systemic effect:
•
HR ( = negative chronotropic effect)
•
Cardial force of contraction (= negative inotropic effect)
•
Intracardial conduction velocity (= negative dromotrop effect)
•
Cardial automaticity (Ability of own stimulation)
•
Depression of sympathetic autonomous nervous system
Indication:
•
Angina pectoris
•
Acute myocardial infarction
•
Long term treatment after myocardial infarction
•
Hypertension
•
Supraventricular Tachycardia
Special considerations:
•
Treatment requires frequent monitoring of HR, BP and heart rhythm.
•
Treatment needs to be reduced or interrupted if HR is < 60 bpm and
systolic blood pressure is < 90 mmHg.
•
Any combination with other hypotensive medication increases hypotensive effect.
•
Combination with calcium channel blockers may increase bradycardia as well.
•
Treatment can not be discontinued abruptly and must be tapered off.
•
High dosages may cause bronchoconstriction.
•
Beta blockers may disguise hypoglycemic symptoms in clients with Diabetes and
may cause a limited insulin production in the pancreatic glands.
•
Beta-blocker may cause heart block in a pre-existing Wolff-Parkinson White
Syndrome.
•
An exercise tolerance electrocardiogram may show a false negative test result
under beta-blockers and should not be performed with clients receiving this
treatment.
Contraindications:
•
AV – heart blocks from first degree
•
Valvular cardial disease
•
Obstructive airway disease
•
Combination with psychotropic substances
•
During MAOI Treatment and two weeks after
•
Severe allergic reactions
(
Beta blockers would inhibit adrenaline treatment in case of anaphylaxia)!
Side effects:
Hypotension, dizziness, depression, psychosis, laryngo – and bronchospasm, dry mouth,
eyes, glands, agranulocytosis, hypo and hyperglycemia.
Substances:
Atenolol (Tenormin®), Betaxolol (Kerlone®), Bisoprolol (Zebeta®), Metoprolol
(Lopressor®) Nadolol (Corgard®), Propranolol (Inderal®) and Timolol (Blocadren®)
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Calcium channel blockers
Pharmacological effect:
Inhibition of calcium ion influx of myocardial and arterial smooth muscle cells avoids their
stimulation.
Physiological effect:
•
Dilation of coronary arteries and arterioles
•
Decrease of peripheric vascular resistance = decrease of afterload.
•
Dilation of peripheric arteries
•
Hypotonic effect
•
Increase of myocardial O2 delivery
•
Prevention of angina pectoris
•
Decrease of intracardial conduction velocity (negative dromotropic effect)
•
Reduction of heart rate (negative chronotropic effect)
Indications:
•
Essential Hypertension
•
Prevention of Chronic stable Angina pectoris
•
Treatment of vasospastic (Prinzmetal’s) Angina
•
Atrial fibrillation, Atrial flutter and supraventricular Tachycardia
(Verapamil + Diltiazem only)
Special considerations:
•
Not to be administered if BP is < 90/60 mmHg
•
No alteration of serum calcium level occurs
•
Initial BP and ECG examination prior start of treatment required
•
Administer Verapamil and Diltiazem with food
•
IV administration of Verapamil and Diltiazem only via infusion pump
•
Monitoring of hepatic and renal lab test results
•
A combination of Verapamil or Diltiazem with Beta – blockers may lead to a
cardiac arrest and is contraindicated
Side effects:
Hypotension, dizziness, nausea, vomiting and heart blocks (Diltiazem and Verapamil)
Hyperglycemia in clients with diabetes, ankle edema and reflex–tachycardia due to
hypotensive effect.
Substances:
Amlodipine (Norvasc®), Felodipine (Plendil®), Isradipine (Dynacirc CR®), Nicardipine
(Cardene®), Nifedipin (Adalat®) and Nisoldipine (Sular®).
Angiotensin Converting Enzyme (ACE) Inhibitors
Pharmacological effect:
1. Inhibition of angiotensin-converting enzyme which catalyzes conversion of angiotensin
I to angiotension II.
2. Inhibition of Renin-Aldosterone-Angiotension system RAA. Aldosterone production .
Physiological effect:
Hypotension due to limitation of angiotensin II.
Indications:
Hypertension, especially in diabetic nephropathy. Post myocardial infarction blood
pressure management.
Special considerations:
Treatment requires ongoing monitoring of liver function, bilirubin, electrolytes, creatinine,
BUN. Avoid potassium containing or elevating drugs and foods. To be taken with food,
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except for Captopril and Moexipril. Medication must be tapered off to avoid rebound
hypertension.
Contraindications:
Pregnancy and lactation, hypersensitivity and allergy.
Side effects:
Hypotension, palpitations, persistent nonproductive cough and dyspnea, angioedema
leukopenia, agranulocytosis and thrombocytopenia. Altered taste in beginning of
treatment (Dysgeusia) and rash. Impotence, Hyperkalemia and Hyponatremia.
Substances :
Benazepril (Lotensin®), Captopril (Capoten®), Enalapril (Vasotec®), Fosinopril
(Monopril®), Lisinopril (Privinil®), Moexipril (Univasc®), Perindopril (Aceon®), Quinapril
(Accupril®), Ramipril (Altace®) and Trandolapril (Mavik®).
Angiotensin II Receptor Blockers (ARBS)
Pharmacological effect:
Blocking Angiotensin II receptor on smooth vascular muscle cells.
Physiological effect:
Prevention of peripheral vasoconstriction, decrease of blood pressure.
Indication:
Essential hypertension
Special considerations:
Careful use in clients with renal or hepatic diseases.
Potency is higher than potency of ACE inhibitors.
Side effects:
Hypotension and related disorders, hyperkalemia and neutropenia.
Less coughing and gastrointestinal effects than ACE inhibitors.
Contraindications:
Pregnancy and lactation.
Substances:
Candesartan (Atacand®), Eprosartan (Tevetan®), Irbesartan (Avapro®)
Direct acting Vasodilators
Pharmacological effect:
Direct vasodilation due to direct interaction with smooth vascular muscle cells in various
ways.
Physiological effect:
BP , HR , Cardiac Output CO
Indications:
Essential Hypertension and vascular dysfunction (i. e. Raynaud’s disease).
Special considerations:
All substances need to be tapered off slowly to avoid rebound hypertension.
IV administration requires strict monitoring of HR and BP.
Nitroprussidnatrium for IV administration requires monitoring of serum thiocyanate and
dilution to 200mcg/mL.
Hydralazine can be administered undiluted and by bolus of 10 mg/min.
IV Solutions can not be mixed with other substances and need to be stored in a light
resistant container. Smoking negates effect of medication!
Hot bath and hot shower may increase hypotensive effect.
Side effects:
Reflextachycardia, hypertension due to baroreceptor reflex, angina, palpitations
nausea, vomiting, diarrhea and pancytoepenia.
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Thiocyanate intoxication may be caused by sodium nitroprusside!
(profound hypotension, tinnitus, atigue, pink skin color,metabolic acidosis, loss of
consciousness)
Systemic lupus erythematodes – like syndrome due to Hydralazine
Excessive growth of body hair under Minoxidil
Substances :
Minoxidil (Loniten®), Diazoxide (Hyperstat®), Hydralazine (Apresoline®)
Nitroprusside (Niprid®e) and Trimethapahan (Arfonad®)
Central and Peripheral Alpha Receptor Blockers
Pharmacological effect:
Centrally acting alpha-adrenergic blockers stimulate Alpha2 receptors, leading to a
lowered stimulation of the central nervous sympathetic system with an inhibition of the
cardio accelerator and vasoconstrictor centers of the brainstem.
Peripherally acting alpha-adrenergic blocker decrease catecholamine stores in
peripheric synaptic vesicules leading to peripheric vasodilation.
Physiological effect:
BP , HR , CO
Special considerations:
Guanabenz: 1-2 weeks before maximum response and adjustment of dosage.
Guanfancine: 3-4 weeks before maximum response and adjustment of dosage.
Methyldopa: 2 days before maximum response and adjustment of dosage.
If given orally medication should be administered without food. Methyldopa is not meant
to be administered i.m. or s.c. Drowsiness may occur under centrally acting medication
Regular monitoring of liver and kidney function including uric acid.
Side effects:
Sedation, dry mouth, nose, pharynx, parkinsonism, involuntary choreoathetotic
movements, nausea, vomiting, diarrhea, peripheral edema, hepatic necrosis, myocarditis
and weight gain.
Cardiac Glycosides
Pharmacological effect:
Interaction with potassium receptors on cardial muscle cells as well as on cardiac
atrioventricular conduction cells between the Sinus node and the AV node.
Physiological effect:
Positive inotrope and negative dromotrope.
Indications:
Chronic heart failure, dysrhytmia, especially absolute arrhythmia in an atrial fibrillation.
Special considerations:
For parenteral use, glycosids can only be administered intravenously as a push injection
of the individual dose over 5 minutes. Full effect of the medication requires to establish a
glycoside blood level first. Treatment requires special attention in hypokalemia, renal
impairment, hypothyroidism, lung disease, cor pulmonale, heart block, organic or
valvular heart diseases and coronary artery disease.
Frequent assessments of glycoside
and electrolyte blood levels as well as ECG – examinations are mandatory!
Therapeutic levels:
Digoxine:0.5 – 2.0 ng/mL
Digitoxine 10 – 40 mcg/mL
Glycoside intoxication occurs with the following symptoms:
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(Flu-like symptoms, Nausea, vomiting, diarrhea, visual disturbances)
Digoxine Antidote: digoxine immune fab (Digibind)
Hypokalemia through diet and medication has to be avoided.
Digoxin effect increases in Hypokalemia and decreases in Hyperkalemia.
Digoxin is excreted via the kidneys and should be replaced with Digitoxin in clients with
an impaired kidney function.
Digitoxin is excreted via the biliary system only.
Heart rate assessment has to be performed via apical pulse rate over 1 minute.
Side effects:
Dysrhytmias, hypotension, A-V heart block, fatigue, muscle weakness, disorientation
hallucinations, visual disturbances (blurred, green, yellow vision) and halo-effect.
Substances :
Digoxine (Lanoxin®), Digitoxine (Crystodigin®)
Antidysrhytmics
Class I A Antidysrhythmics
Fast sodium channel blockers.
Pharmacological Effect:
Blocking sodium ion channels in cell membranes of cardial pacemaker cells.
Prolongation of the myocardial refractory period.
Depression of spontaneous depolarization in myocardial pacemaker cells.
Physiological Effect:
Depression of contractility excitability of myocardial cells.
Depression of ectopic excitability.
Indications:
Ventricular and supraventricular dysrhythmias,
premature ventricular and supraventricular contractions.
Ventricular tachycardia.
Long Term treatment or treatment prior electric cardioversion.
Special considerations:
Assessment of blood glucose and electrolyte levels mandatory prior to and during
treatment. Different types of dysrhythmic medication should not be combined.
If treatment switches to another dysthythmic medication or to a contolled release formula,
an appropriate time of 6 -12 hours has to elapse.
Frequent ECG and BP monitoring in first days of treatment mandatory.
Signs of delayed conduction that require intervention are:
Prolonged QT – Interval, QRS more than 35 % widened. HR < 60 bpm or > 120 bpm.
Assessment of apical pulse prior administration of drug.
Contraindications:
Second–and third degree heart block, cardiogenic shock, severe heart failure and
hypotension.
Side effects:
Hypotension, chest pain, dysrhythmias and cardiogenic shock.
Headache, fatigue, muscle weakness, paresthesias, nervousness, psychosis,
peripheral neuropathy, uterine contractions and onset of myasthenia gravis.
Allergic reactions, tinnitus, disorientation, drowsiness, euphoria, difficulties swallowing
and speaking.
Substances :
Disopyramide (Norpace®), Procainamide (Pronestyl®) and Quinidine (Quinaglute®)
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Class III Antidysrhythmics
Local anaesthetics
Pharmacological effect:
Decrease of refractory period.
Elevation of diastolic ventricular electrical stimulation threshold.
Suppression of Replacement Rhythm by the His-Pukinje fibers.
Physiological effect:
Prevention of ventricular dysrhythmias.
Indication:
Ventricular dysrhythmias.
Special considerations:
Lidocaine has to be manufactured for intravenous use!
First dose applied as a bolus, continuation via infusion of 1g Lidocaine to 250 – 500mL
of D5W, flow rate maximum 4 ml/min.
Treatment can be discontinued as soon as normal heart rhythm occurs.
Assessment of blood level of medication and creatinine necessary.
Side effects:
Comparable pattern as Class I a Antiarrhythmics, including parasympatholytic side
effects.
Substances :
Lidocaine (Xylocaine®) and Tocainide (Tonocard®).
Class I C Antidysrhythmics
Strong sodium channel blockers
Pharmacological effect:
Down regulation of conductivity in AV node and ventricles.
Physiological effect:
Prevention and treatment of ventricular dysrhythmias
Special considerations:
Oral administration. Dosage adaptation every 4 days.
Substances:
Flecainide (Tambocor®) and Propafenone (Rhytmol®).
Class II Antidysrhythmics
Beta – blockers (as previously discussed)
Class III Antidysrhythmics
Potassium channel blockers
Pharmacological effect:
Prolongation of repolarization due to limited potassium uptake into cardial pacemaker
cells.
Physiological effect:
Decrease of intraventricular conduction.
Indication:
Ventricular tachycardia, ventricular fibrillation and supraventricular tachycardia.
Special considerations:
May aggravate hypo and hyperthyroidism. Leads to increased sensitivity of iodine.
Dosage depending Gastroenteritis symptoms. Long half life of up to 55 days. Requires
regular assessments of blood levels of medication including liver, kidney function
parameters as well as CBC. CNS triggered tremor may occur one week after start of
treatment. Requires regular ophthalmic examinations, every 6 months to 1 year.
Hypersensitivity to sunlight.
Side effects:
Corneal microdeposits of medication. Reversible stale-blue pigmentation and rash of
skin after one year. Motoric and sensoric neuropathy. Hypotension, Chest pain,
Dysrhythmias and cardiogenic shock.
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Substances:
Amiodarone (Cordarone®), Bretylium (Bretylol®), Dofetilide (Corvert®) and Sotalol
(Betaspace®)
Class IV V Antidysrhythmics
Calcium channel blockers as previously dicussed.
Class V Antidysrhythmics
Adenosin (Adeonocard, Adenoscan)
( Digoxine, Digitoxine, as previously discussed)
Pharmacological effect:
Interruption of myocardial conductivity and reentry mechanisms.
Physiological Effect:
Regulation of supraventricular dysrhythmias.
Indication:
Supraventricular dysrhythmias and identification of heart rhythm.
Specific Considerations:
Applied intravenously with a bolus injection under permanent ECG montoring.
Contraindications:
Atrial flutter and fibrillation, hypotension, chest pain, dysrhythmias and cardiogenic shock.
Sympathomimetic Antihypotensives
Pharmacological Effect:
Stimulation of alpha – and beta adrenergic receptors.
Physiological Effect:
Vasoconstriction and increases systemic BP.
Increase of heart rate and myocardial contractility.
Indication:
Shock treatment
Specific considerations:
Requires dilution and administration via infusion pump.
Constant monitoring of Input & Output, vital signs and ECG necessary.
May cause hypertensive reactions in clients under MAOI or TCA treatment.
Requires correction of depleted blood volume prior to administration.
Paravasal infiltration may cause tissue necrosis. To be treated with local injection of
diluted Phentolamine mesilate (Regitine).
Sympathomimetics are light sensitive are incompatible with sodium bicarbonate.
Contraindications:
Arrhytmias, blood volume deficit, hypoxia and vascular thrombosis.
Side effects:
Palpitations, bradycardia, tachycardia, hypertension, arrhytmias, cardiac arrest,
bronchospasm, anxiety, restlessness and tremor.
Substances :
Dobutamin (Dobutrex®), Dopamine (Intropin®), Isoproterenol (Isuprel®), Metaraminol
(Aramine®) and Norepinephrine (Levophed®)
Oral Anticoagulants
Sodium warfarin (Coumadin®)
Pharmacological effect:
1.
Prevention of conversion of Vitamin K to induce an insufficient production of the
clotting factors II, VII, IX and X.
2.
Vitamin K deficiency leads to the inhibition of fibrin formation within the extrinsic
pathway of the clotting cascade.
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Physiological effect:
Prevention or delay of blood coagulation.
Special considerations:
Coumadin has a high affinity to plasma proteins, especially Albumin and is therefore
prone for drug interactions. Medication takes on average one week to reach its
therapeutic effect. Daily average dosage varies between 1 and 15 mg.
Effect of medication for dosage adjustment is performed by frequent assessment of the
prothrombin time PT which is transferred into the international normalized ratio INR.
Therapeutic INR levels: (based on indication)
Average: 2.0 to 3.0
Mechanical cardiac walve replacement: 3.0 – 4.5
Although Vitamin K is a Coumadin Antidot in urgent cases (strong bleedings) a client
under warfarin treatment requires FFP (Fresh Frozen Plasma) or prothrombin
concentrate. To maintain a secure therapeutic effect client has to be advised on Vitamin
K containing food as a part of a general education on how to maintain this treatments
and how to avoid and handle bleedings. All patients under prescribed anticoagulation
medication have to avoid any medication containing acetylsalicylic acid and ibuprofen,
diclofenac or any other nonsteroidal antiinflammatories.
Contraindications:
Pregnancy
Side effects:
Bleedings, rash, nausea, hair loss and hepatitis.
Direct thrombine inhibitors
Rivaroxaban (Xarelto®), Dabigatran (Pradaxa®)
Altough the FDA approval of these substances is pending at the time as this manual is
produced we would like to mention them since it is very likely that these medications will
be part of NCLEX – Pharmacology questions in the near future.
Pharmacological effect:
1. Inhibition of Thrombin (Dabigatran, Pradaxa®)
2. Inhibition of Factor Xa to interrupt the intrinsic and extrinsic coagulation pathway of
the blood coagulation cascade as well as the inhibition of the formation of thrombi.
Rivaroxaban (Xarelto®).
Physiological effect:
Prevention or delay of blood coagulation.
Indication:
Prevention of DVT’s after knee and hip surgery.
Anticoagulation in atrial fibrillation.
Specific considerations:
In comparison to Warfarin these substances do not require monitoring of coagulation
parameters.
Contraindications:
Comparable to Warfarin.
Side effects:
Comparable to Warfarin.
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Heparine
Pharmacological effect:
Inhibition of the intrinsic, fibrin forming pathway of the clotting cascade by inhibiting the
conversion of fibrinogen to fibrin and inhibiting the synthesis of thrombin.
Physiological effect:
Prevention or delay of blood coagulation.
Special considerations:
First choice of treatment and prevention of DVT, PE and embolism resulting from atrial
fibrillation. Intravenous or subcutaneous administration. Antidot is Protamine sulfate, to
be administered intravenously only.
Low molecular weight heparin (LMWH) and unfractioned heparine (UFH) are differing in
their molecular weight and bioavailability (higher in LMWH).
Effect of Heparin therapy is monitored by frequent assessment of the
activated partial thromboplastin time. (aPTT) Normal value = 25 – 40 seconds.
Common Heparin treatment schemes:
Low dose UFH therapy for DVT prevention (not aPTT relevant)
5000 U Enoxaparin s.c. every 8 -12 hours or three postoperative dosages.
High dose UFH therapy with alteration of the aPTT.
Therapeutic goal is to prolong the aPTT 1.5 – 2.0 times under intravenous infusion.
The average dosage for an adult client is 20,000 – 40,000 Units/24 hrs.
Administration of subcutaneous heparin injections in a 90 degree angle by rotating the
sites and without rubbing the injection areas, using a 25 – 27 gauge needle.
Side effects:
Bleedings. Heparine induced platelet aggregation HITT, resulting in severe
thrombocytopenia.
Typically after 3rd day of treatment.
Osteoporosis under long term therapy (> 6 months).
Substances:
Heparin (Liquaemin®) , Enoxaparine (Lovenox®), Dalteparin (Fragmin®) , Tinazaparin
(Innohep®) and Danaparoid (Orgaran®)
Antiplatelet Agents
Pharmacological Effect:
Inhibition of platelet aggregation.
Physiological Effect:
Prevention of blood clots.
Specific considerations: Available medications use different biochemical pathways.
Acetylic Salicylic Acid (Asprine®)
Therapeutic dosages for blood clot inhibition between 81–325 mg/d.
Contraindicated in Asthma, COPD, gastritis, gastric ulcers and gastrointestinal bleedings.
Contraindicated in children because of risk of Reye Syndrome.
Side effects include: Hemorrhage, blood dyscrasias, gastrointestinal bleedings, and
ulcers.
Ticlodipine (Ticlid®)
Alternative to ASA if contraindicated or not tolerated.
Main side effect is serious agranulocytosis and neutropenia.
Used for platelet aggragation and cardiac stress testing.
Can cause gastrointestinal complaints and headaches.
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Clopidrogel bisulfate (Plavix®)
Secondary prevention after strokes and MI’s,
Can cause flu – like symptoms, chest pain, edema and hypertension.
Abciximab (ReoPro®)
Used after PTCA interventions.
Administered intravenously.
Platelet aggregation inhibitors are generally contraindicated in children, pregnancy and
lactation and have to be cessated 7 days prior a scheduled surgery.
Fibrinolytics
Pharmocological effect:
Activation of the fibrinolytic system.
Conversion of plasminogen to plasmin helps to digest fibrin and degrading fibrinogen.
Physiological effect:
Breakdown of an already established thrombus or blood clot.
Special considerations:
Usually administered in an emergency treatment setting due to an acute MI, PE and
DVT. Requires strict cardiac and coagulation monitoring during administration.
Effect of streptokinase or urokinase can be restricted or stopped with antidote
aminocaproic acid (Amicar). In an uncontrolled bleeding administration of FFP or packed
cells may be necessary.
Contraindications:
History of CVA, Hypertension, Pregnancy, Neoplasm, recent trauma or major surgery.
Side effects:
Hemorhage, allergic reaction, nausea, vomiting, cardiac arrhythmias and hypotension.
Substances:
Strepptokinase and Urokinase
Antihyperlipidemics
HMG-Coenzyme A reductase inhibitors (Statins)
Pharmacological effect:
Inhibition of Cholesterol synthesis.
Physiological effect:
Reduction of LDL – Cholesterol and light increase of HDL Cholesterol.
Special considerations:
Medication to be taken at bedtime.
No effect on amount and synthesis of lipoproteins.
Requires frequent assessment of LFT and CK under treatment.
Lipid assessment not until 2 weeks of treatment have passed by.
Side effects:
Muscle achiness, rhabdomyolysis, elevation of liver enzymes and gastrointestinal
symptoms.
Substances:
Atovastatin (Lipitor®), Fluvastatin (Lescol®), Lovastatin (Mevacor®), Pravastatin
(Pravachol®), Rosuvastatin (Crestor®) and Simvastatin (Zocor®)
Bile Acid Sequestrants
Pharmacological effect:
Synthetic bile acids bind cholesterol in the gastrointestinal tract.
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Physiological effect:
Increased amounts of bile acids binding Cholesterol in the gastrointestinal tract lead to
decreased Cholesterol serum level.
Special considerations:
Administration as powders and tablets 2–4 times/day.
Tablets are not meant to be crushed and need to be taken without any other medications.
Serum cholesterol starts to reduce 48 hours after start of the treatment.
LDL-Cholesterol levels lower after 1 month.
Contraindications:
Cholestyramine is contraindicated in Phenylketonuria.
Side effects:
Loss of fat soluble vitamins A,D,K,E and folic acid, rash, pruritus, steatorrhea,
hemorrhage after long term use and gastrointestial complaints.
Substances:
Colestyramine (Questran®) and Colestipol (Colestid®).
Fibric Acid Derivatives
Pharmacological effect:
Decrease of very low density lipoproteins VLDL and Chylomicrones, leading to a
decrease of Triglycerides.
Physiological effect:
Lowering of Triglyceride Levels.
Less intense effect on HDL and LDL levels.
Special considerations:
Admininistered in divided dosages twice daily.
Therapy may be discontinued after three month of treatment if no improvement is
detectable.
Side effects:
Abdominal and epigastric pain, jaundice, blurred vision, elevation of liver enzymes,
cholecystitis, hypokalemia and acute appendicitis.
Substances :
Clofibrate (Abitrate®), Fenofibrate (Tricor®) and Gemfibrozil (Lopid®)
Nicotinic Acid (Niacin, Vitamin B3)
Pharmacological effect:
Lowers lipoproteine levels unspecifically. Increases HDL levels.
Physiological effect:
Improvement of Hyperlipidemia. Peripheric vasodilation.
Specific considerations:
Normal dose is 500 mg/d.
Cholesterol lowering effect from 300 mg/d.
Niacin food sources: eggs, dairy products, meat and tuna.
Side effects:
Flushing, hypotension, hyperglycemia, elevation of liver enzymes, uric acid and blood
glucose, dark colored urine and cardiac dysrhythmias.
Contraindications:
Liver disease, Peptic ulcer disease and severe hypotension.
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Hemostatics
Pharmacological effect:
Inhibition of Fibrinolysis
Therapeutic effect:
Inhibition of bleedings
Specific considerations:
Aminocaproic acid:
Indicated for treatment of hemorrhage due to hyperfibrinolysis and hematologic
disorders. Antidote to thrombolytic medication. (Heparine, Streptokinase and Urokinase)
Tranexamic acid:
Indicated in hemophilia, 1 day prior and 2 – 8 days after dental surgery.
Menadiol sodium diphosphonate, Vitamin K4: Antidote to oral anticoagulants.
UROLOGICAL DISORDERS AND DISEASES
Kidney and ureter stones
Stone formation in the urinary tract has mutiple causes. The most common types are
calcium-oxalat stones. Other types include uric acid, cystine and struvit stones.
Formation of stones usually requires a chronic fluid deficiency and dehydration of the
affected individual. Other common causes are excessive intake of dairy products and
vitamin D, hyperparathyroidism, chronic recurrent urinary tract infection, obstruction of
urinary tract and delayed oxalate metabolism or high oxalate intake.
Symptoms and diagnostic findings:
Kidney stones can remain asymptomatic for a long time. Sudden discharge of
concrements into the ureter leads to an acute fluctuating severe flank pain. Mostly
accompanied by excessive nausea and vomiting and hematuria. Pain radiates typically
from flanks into scrotal area in male and labia majora area in female clients. An urinary
tract infection after an ureter colic can occur. Urinalysis typically shows micro or
macrohematuria, and large concentration of crystals. Routine diagnostics include
assessment of blood samples to assess creatinine, BUN, calcium, phosphate and uric
acid levels. 24-hour urine samples are used to assess calcium, uric acid and oxalate
levels. Diagnostic procedures include intravenous pyelography, renal ultrasound and
cystoscopy to localize and remove stones and possible obstructions of the ureter which
may lead to a hydronephrosis.
Treatment:
Acute treatment is focused on pain and nausea relief. About 80% of ureter colic causing
stones are discharged spontaneously. Remaining stones require intervention by an
urologist surgeon for the following methods.
•
•
•
•
ESWL (extracorporal shock wave lithtripsy);
transurethral uroscopy with basket catheter,
percutaneous nephrostomy,
surgical nephrolithotomy, pyelolithotomy and ureterlithotomy.
Dietary treatment for recurrence of ureter stones requires restriction of causative agents
along with an alkaline – ash diet by an increased intake of legumes, milk, green
vegetables, rhubarb, fruits. Increase of fluid intake up to 3.5 liters/daily is required in all
cases under consideration of pre-existing renal or heart failure.
Urinary incontinence
Urine incontinence is classified in the following subtypes in order to the individual causes
and symptoms.
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Stress incontinence caused by increased intraabdomonal pressure.
Reflex incontinence Ionvoluntary urination due to bladder distention.
Urge incontinence shortly after urge to void appears.
Functional incontinence, urgent and unpredictable.
Total incontinence due to permanent urination.
Symptoms and diagnostic findings:
Urinary incontinence may occur temporarely or permanent and is commonly expressed
as a symptom of one of the following underlying disorders.
•
•
•
•
•
•
•
Weakened pelvic diaphragm in women
Enlarged uterus
Prostate gland enlargement in men
Urinary tract infections
Neurological diseases
Tumors of the urogenital tract
Menopausal vaginal atrophy
Treatment:
Treatment of underlying causes may include, Kegel exercises to increase muscular
stability of pelvic floor, hysterectomy, prostatectomy, treatment of urinary tract infections,
anticholinergic medication to support detrusor muscle, antihistamines to improve smooth
muscle contractions and estrogen supply in cases of atrophic vaginitis.
Urinary tract infections (UTI)
Urinary tract infections are typically caused by infections of gram negative bacteria from
bowel colonisation, mostly Escherischia coli. . UTI’s are more common in women than
men. Infections are supported by dehydration, incontinence and urinary obstruction. A
beginning UTI will start as a cystitis and may turn into a pyeolnephritis if treatment starts
delayed. Pyelonephritis causes a risk for the affected kidney and for a lifethreatening
urosepsis.
Symptoms and diagnostic findings:
Polyuria and Dysuria with burning sensations during voiding are most characteristic
findings for a cystitis. Urinary retention may occur as well. Fever, chills and flank pain
are indicators for an ascending urinary tract infection into a pyelonephritis. Urine
samples usually appear cloudy and of strong odor. Urinalysis may show an increased
count of WBC, RBC and Nitrite. Blood samples are usually showing an elevated WBC
and increased inflammatory parameters in case of infection in cases of pyelonephritis
but remain unsuspicious in a cystitis.
Treatment:
Symptom relief with analgetic and antispasmodic medication. Antibiotic treatment and
increase of fluid intake up to 3 l. daily. Chronic recurrent UTI’s may require prophylactic
antibiotic treatment and further diagnostic procedures to rule out other underlying
pathologies of the urinary tract or systemic immunodeficiencies (e. g. diabetes mellitus).
Benign tumors of the urogenital tract
In most cases benign urogenital tumors arise from parenchymal tissue.
Common types are kidney tumors and cysts, bladder polypes and benign prostate gland
hyperplasia.
Symptoms and diagnostic findings:
Benign urogenital tumors may cause an acute urinary obstruction but are usually
asymptomatic.
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Treatment:
Most benign urinary tumors show a characteristic formation in the imaging diagnostic
procedures and will be usually monitored in appropriate time frames, mostly every 3 – 6
months. Invasive treatments apply in cases of suspected malignancies.
Acute renal failure (ARF)
Loss of kidney function. Mostly due to a shock.
Three phases: Initiation
Recovery
Restitution.
Reversible over months but also progression into terminal renal failure possible.
Causes of acute renal failure:
Depending on the cause three types of acute renal failure can be differentiated:
Prerenal, “shock kidney” by loss of blood volume or sudden blood pressure decrease.
Intrarenal, due to a parenchymal kidney damage.
Postrenal, due to an obstruction of the urinary tract, e. g. stones, BPH syndrome.
Pathophysiology of acute renal failure:
Oliguria
Anuria = urine output < 400 mL / 24 hours
0
Hypervolemia due to ECF fluid excess
blood count: WBC , Platelets , RBC due to erythropoietin deficiency
muscle weakness
hypernatremia
hyperkalemia
hypermagnesemia
hyperposphatemia
hypocalcemia
metabolic acidosis
Vitamin D deficiency
SG and Proteinuria
Loss of consciousness Neurological symptoms
NOT all symptoms are expressed from the beginning of an acute renal failure!
Treatment:
Intrarenal failure: Assessment of fluid retention by daily assessment of weight, input and
output. Management of electrolyte imbalances. Protein, potassium and sodium restricted
diet. Dialysis and medication treatment.
Loop diuretics, ACE Inhibitors and Antihistamines (gastric ulcer prevention).
Acute prerenal and postrenal failure will be treated by correction of underlying cause.
(e.g. fluid supply in a prerenal failure caused by dehydration)
Chronic renal failure (CRF) / End Stage Renal Disease (ESRD)
End stage of a chronic renal failure CRF. ESRD is defined by a GFR of less than 20%
than normal. Creatinine clearance and BUN rise when > 90% of nephrons are destroyed.
Typical systemic causes are hypertension, diabetes and SLE.
Important renal causes of CRF and ESRD are:
1. Polycystic kidney disease,
Autosomal dominant and autosomal recessive hereditary disease. Causes a cystic
transformation and enlargement of both kidneys in adulthood or even already in early
childhood in cases of autosomal recessive inheritance. Early, asymptomatic stades are
mostly discovered by routine ultrasound examinations. Symptoms occur in advanced
stages with hematuria and dysuria. Cystic organ alteration causes increased resistance
for renal blood supply which results in a systemic hypertension by activation of the renin
– angiotensin mechanism RAA.
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2. Glomerulonephritis.
Autoimmune inflammation of the capillary linings of the renal glomeruli. Caused by a
antigen – antibody reaction in a bacterial or viral disease. Most common cases are
induced by an infection with group A-beta-hemolytic streptococcus. Acute
Glomerulonephritis may lead untreated to a severe acute renal failure. Diagnosis
requires renal biopsy. Progression leads to a damage of the glomerular membranes and
to rapid a loss of plasma proteins including coagulation factors and antibodies which is
considered to be a
nephrotic syndrome.
End stage of renal failure is considered as uremia.
Pathophysiology of end stage renal disease / chronich renal failure
Kidneys become unable to concentrate urine
specific gravity stays 1.010, equivalent to plasma
fluid retention
hypernatremia
hypermagnesemia
hyperposphatemia
hypocalcemia
metabolic acidosis
vitamin D deficiency
SG
proteinuria
general weakness and fatigue
nausea and vomiting
Treatment:
Nutritional restrictions:
•
Sodium, Potassium max. 2g daily.
•
Proteines max. 60g daily.
•
Fluids as needed.
Monitoring of input, output and weight.
Bicarbonate buffering of acidosis. Monitoring of kidney parameters and electrolytes.
Dialysis and Assessment for kidney transplant.
Medication treatment includes diuretics, ACE inhibitors, electrolyte replacement,
phosphate binding agents, erythropoietin and folic acid.
Urological Medication Therapy
Diuretics
Diuretic medications are categorized in five different groups concerning their
pharmacological effect within the renal tubular system.
1.
2.
3.
4.
5.
Thiazide diuretics
Loop diuretics
Potassium sparing diuretics
Carbonic anhydrase inhibitors
Osmotic diuretics
Characteristics of Thiazide diuretics, Loop diuretics, Potassium sparing diuretics:
Indications:
Chronic heart failure with fluid retention, acute and chronic renal failure
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(not potassium savers)! peripheric edema, pulmonary edema, hypertension.
Common diuretic side effects:
Polyuria, hypotension, reflextachycardia, orthostatic dysfunction, electrolyte imbalance,
hyperglycaemia, dehydration, constipation, dizziness, vertigo, abdominal pain, nausea,
vomiting and blood dyscrasias.
General considerations for diuretic treatment:
Regular monitoring of fluid intake and output, regular weight assessment and monitoring.
Diuretics should be administered between morning and lunchtime to avoid excessive
Nykturia. Diuretics shall not be taken during pregnancy and lactation. A regular
assessment of the kidney function including GFR rate is part of every diurtetic treatment.
Thiazide Diuretics
Pharmacological effects:
Inhibition of reabsorption and increase of sodium and water in the renal proximal tubuli.
Physiological effect:
Increase of urinary output, increase of sodium output.
Special considerations:
Effect requires a minimum creatinine clearance of 30mL/min. No immediate
antihypertensive effect; Requires regular assessment of serum electrolytes as well as
assessment of body weight, fluid intake and oputput. Requires potassium
supplementation and sodium restriction. (elevated sodium levels support fluid retention)!
Client has to avoid habits which lead to further dehydration (i.e. alcohol consume).
Specific side effects:
Hyperglycemia, hyponatremia, hypokalemia, headaches and photosensitivity.
Contraindications:
Allergies against Sulfonamides.
Substances:
Hydrochlorothiazide (Esidrix®), Chlorothiazide (Diuril®) - increasing duration effect.
Bendroflumethiazide (Naturetin®), Benzthiazide (Exna®), Hydroflumethiazide
(Diucardin®) Metolazone (Zaroxylin®), Quinethazone (Hydromox®), Chlorthalidone
(Hygroton®, Thalitone®), Indapamide (Lozol®), Methylclothiazide (Enduron®),
Polythiazide (Minizide®, Renese®)
Loop Diuretics
Pharmacological effect:
Promoting excretion of sodium, potassium, chloride and water in ascending loop of
Henle within the renal tubular system.
Physiological effect:
Sodium , Potassium , Chloride , Fluids
Special considerations:
IV infusions to be mixed with Sodium chloride 0.9 %, Dextrose5W, Ringer Lactat. Strong
and urgent onset of urination. Hypokalemia may occur. Surveillance of potassium levels
required.
Contraindications:
Anuria, (Output < 400mL)
Specific side – effects:
Systemic vasculitis, thrombocytopenia, agranulocytosis, photosensitivity and ototoxicity.
Substances:
Bumetanide (Bumex®), Ethacrynic acid (Edecrin®), Furosemide (Lasix®) and
Torasemide (Demedex®).
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Potassium-sparing diuretics
Pharmacological effect:
Increase sodium and decrease potassium secretion within the distal convoluted tubulus.
Physiological effect:
Na , Potassium
Special considerations:
(Spironolactone) also prescribed in liver cirrhosis, primary hyperaldosteronism and
premenstrual syndrome. To be taken with food or milk. Requires potassium restriction.
Contraindications :
Serum Potassium > 5.5 mEq/L, anuria, acute and chronic renal insufficiency.
(diabetic nephropathy), impaired hepatic function (=Diminished Aldosterone breakdown)
Not to be combined with other potassium saving medications.
Specific side effects:
Hyperkalemia = Potassium Level > 5.1 mEq/L, abdominal cramps, nausea, vomiting,
tachycardia
bradycardia. Hyperaldosteronism and suppression of adrenal cortex.
Impotence, gynecomastia, breast soreness and muscle cramps.
Substances:
Spironolactone: (Aldactone®), Amiloride (Midamor®) and Triamterene (Dyrenium®)
Carbonic Anhydrase Inhibitors
Pharmacological effect:
Reversible, noncompetitive block of the enzyme Carbonic Anhydrase.
Physiological effect:
Inhibition of renal excretion of Bicarbonate, Sodium, Potassium and water.
Indications:
Glaucoma, epilepsy, metabolic acidosis, chronic heart failure
Special considerations:
Can not be administered by intramuscular injection. Further dosage increase does not
lead to increased Diuresis!
Side effects:
Bone marrow depression, pancytopenia, sulfonamide reaction
Stephens – Johnson Syndrome
toxic epidermolysis, hepatic necrosis and death.
Contraindications:
Allergies against sulphonamides. Narrow and wide angle glaucoma
Liver and Kidney Dysfunction. Relatively contraindicated in COPD.
Substances:
Acetazolamide (Diamox®), Dichlorphenamide (Daranide®) and Methazolamide
(Neptazane®).
Osmotic Diuretics
Pharmacological effect:
Increase of osmotic pressure in proximale tuble and loop of Henle.
Physiological effect:
Inhibiting re-absorption of water and electroytes but promoting diuresis.
Indication:
Prevention and treatment of acute renal failure in an intensive care setting.
Glaucomtherapy (Mannitol) decrease of intracranial pressure.
Special considerations:
All osmotic diuretics require intravenous administration. Mannitol crystalizes at low
temperatures. Urea turns to ammonia over time.
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Antibiotics for urinary tract infections
Pharmacological effect:
Bacteriostatic and bactericid effect to bacteria causing urinary tract infections. Main
mode of effect is to antagonize folic acid in the replication process.
Physiological effects:
Treatment of bacterial infections.
Indications:
Urinary tract infections.
Special considerations:
Prescribed course needs to be completed to avoid development of antibiotic resistance
and recurrent infection. Medication generally requires normal liver and kidney function.
Nitrofurantoin administered orally can lead to discoloration of teeth and requires rinsing
of mouth immediately after dose is taken.
Acidification of urine due to oral administration of vitamin C or cranberry juice is of
support in treatment of an UTI. Milk, fruit juices, bicarbonate alkalizes urine and supports
an urinary infection. Encourage client to drink normal amounts of fluid (eight glasses of
water / d.). Highly increased fluids weaken medication due to dilution. Pyridium may be
prescribed as a local analgetic medication. ( changes color of urine into orange)
Side effects:
Abdominal discomfort, diarrhea, leukopenia, thrombocytopenia, angioedema,
drowsiness, weakness, headaches, pruritus, rash and arthralgia.
Contrainidications:
Folate deficiency and megaloblastic anemia
Substances:
Trimethoprim (Proloprim®), Trimethoprim / Sulfamethoxazole (Bactrim®),
Sulfamethoxazole (Gantanol®), Sulfamethizole (Thiosufil forte®), Sulfisoxazole
(Gantrisin®), Methenamine (Hiprex®) and Nalidic acid (NegGram®)
Urinary Tract Spasmolytics
Pharmacological effect:
Relaxation of smooth muscles in bladder and ureter due to peripheral anticholinergic
effect.
Physiological effect:
Spasm relief in urinary tract.
Indications:
Incontinence, dysuria and nocturia.
Side effects:
Urine retetion, constipation, palpitations, dry mouth, hypertension and mydriasis.
Contraindications:
Glaucoma, COPD and Asthma, gastrointestinal obstruction, myasthenia gravis, paralytic
ileus, urinary tract obstruction, cardiovascular disease and drowsiness.
Substances:
Oxybutynin chloride (Ditropan®), Hyoscyamine (Cystospaz®) and Tolterodine tartrate
Bladder Stimulating Medication
Pharmacological effect:
Parasympathomimetic stimulating effect on detrusor and bladder muscle.
Physiological effect:
Initiation of voiding.
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Indications:
Neurogenous bladder (MS and spinal cord injuries).
Special considerations:
Atropine as antidote treatment must be accessible at all times. Clients have to be
monitored one hour after administration of parasympathomimetic medication.
Side effects:
Hypotension, blurred vision, miosis, nausea, vomiting, diarrhea and hypersalivation.
Contraindications:
COPD, gastrointestinal and urinary tract obstruction, peptic ulcer disease, bradycardia
Parkinsonism, hypotension and AV Blocks.
Substances:
Bethanechol chloride (Urecholine®)
Dopamine
Pharmacological effect:
Peripheric vasodilation in the gastrointestinal, urogenital and mesenterial circulatory
system.
Physiological effect:
Increase of blood flow in kidneys.
Indication:
Treatment of acute renal failure.
Special considerations:
Effect changes by dosage. Low dosages between 2 – 5 mcg/kg/min cause increase of
renal perfusion. Widening of QRS complexes may occur.
Hematopoetic Growth Factor
(Erythropoetin)
Pharmacological effect:
Stimulation of RBC production in cases of a primary or secondary renal anemias without
bone marrow defects. (i. e. Chronic renal failure, HIV, Chemotherapy)
Physiological effect:
Increase of RBC, Hemoglobin and Hematocrit
Indications:
Renal anemia and anemic conditions without bone marrow disease.
Special considerations:
To be administered as a bolus injection or subcutaneously. Normal HCT raise is up to 4
points in 2 weeks. Seizures may arise within first three months of treatment.
Side effects:
Hypertension, headaches, seizures, iron deficiency, thrombocytosis and hematocrit .
Immune Suppressant Medications for treatment after kidney transplantats
Cyclosporine
Pharmacological effect:
Suppressor of immune mediators produced by T-Lymphocytes: Interleukin-2, Gamma
interferon and other cytokines.
Physiological effect:
Suppression of T–cell mediated immune reponse.
Indications:
Prevention of organ rejection after allogenic transplantation.
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Special considerations:
Patients under treatment have limited immune response against infections.
Grapefruit juice can raise Cyclosporine levels. Medication is administered orally and
diluted in juices or milk.
Prednisolone may be administered concurrently to limit immune suppression to the
desired therapeutic effect.
Client requires special education on detection of early transplant rejection symptoms,
especially about the importance of fever.
Clients should avoid environments that cause contraction of communicable diseases.
Cyclosporine levels are affected by other medications with strong protein binding abilities
and have to be assessed regularly.
Side effects:(common for immune suppressants)
Nausea, vomiting, increased rate of infections, bone marrow depression.
(specific side effects of Cyclosporine).
Hypertension, tremor, hirsutism, depression and anaphylactic shock.
Substances:
Neoral®
Azathioprine
Suppressor of cell mediated and humoral immune system.
May be combined with Cyclosporine. Also used in rheumatoid arthritis.
Bone marrow depression is main side effect. Available as Imuran®.
Mycophenylate mofetil
Used with Glucocorticoids and Cyclosporine.
Available as CellCept®.
Tacrolimus
Concurrently used with glucocorticoids. Can cause renal damage.
Available as Prograf®.
Daclizumab (Zenapax®), Basiliximab (Simulect®), Muronmonab-CD3 (Orthoclone
OKT3®)
Antibodies to prevent rejection after allogenic transplant. Intravenous administration.
Basiliximab for immediate treatment after transplantation.
xx
GASTROINTESTINAL DISORDERS AND DISEASES
Gastritis
Acute or inflammation of the gastric mucosa by external agents or causes e. g. NSAID
food excess, alcohol excess, caffeine, stress, corticosteroids, gastroenteritis,
gastroesophageal reflux disease (GERD), autoimmune diseases (Pernicious anemia),
bile reflux from biliary system into the stomach and Helicobacter pylori infection.
Symptoms and diagnostic findings:
Acute or chronic epigastric pain, aggravating by eating, foetor ex ore, nausea, vomiting,
lack of appetite and bad taste in mouth. Diagnosis in acute cases is made by physical
examination. An endogastroduodenoscopy is performed in severe or recurrent cases or
in cases with recurrent complaints after treatment.
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Treatment:
Treatment of underlying cause.
Medication: Antiemetics, Histamine H2 - antagonists, Proton pump inhibitors, Mucosal
protective agents, Antacid and Eradication therapy for helicobacter pylori.
Gastroesophageal Reflux Disease GERD
Reflux of stomach content and gastric acids due to a decreased lower esophageal
sphincter tonus. Condition may be caused idiopathic or by a hiatic herniation as well as
obesity and external agents e. g. nicotine, caffeine, fat and fried food, estrogenes,
anticholinergic drugs, calcium channel blockers and others.
Long standing GERD leads to a tissue alteration of the inner mucosa from epithelial into
columnal “ Barretts epithelium “ cells which can cause esophageal cancer. Cancer risk
increases over time.
Symptoms and diagnostic findings:
Recurrent heartburn, aggravating in supine positions or while client is bending over as
well as in long term fasting conditions or immediately after a meal.
Long standing GERD may lead to a chronic inflammatory process with thickening of the
esophageal mucosa causing dysphagia, regurgitation and horseness.
Onset of Asthma in adults is commonly associated with GERD.
Main diagnostic evidence is provided by 24h–pH monitoring.
Treatment:
Extinction of causative agents including: Weight management, smoking and caffeine
cessation, upright positioning in bed and small meal nutrition pattern.
Medication: Histamine H2 - antagonists, Proton pump inhibitors, Mucosal protective
agents and Antacids.
Peptic Ulcer Disease (PUD)
Peptic ulcers appear in about 90% of all cases within the duodenum and in 10% as
gastric ulcers. Esophageal peptic ulcers are rare. Duodenal ulcers are typically caused
by an infection with Helicobacter pylori. Gastric ulcers have the same causes as seen in
cases of gastritis but are strongly associated with NSAID medication which inhibit
prostaglandins as the main acid protecting factor for the gastric mucosa. The severity of
a PUD increases with any coexisting factor that supports a gastritis as well.
Symptoms and diagnostic findings:
Strong epigastric pain. Pain in duodenal ulcers aggravating especially in fasting
conditions. In comparison to gastritis and gastric ulcers the intake of food provides pain
relief. Helicobacter pylori test positive in > 90% of all cases of duodenal ulcers. In both
cases diagnosis is made by EGD only. Perforation of ulcers can lead to acute peritonitis.
Treatment:
Basic treatment to decrease acid production as in cases of GERD and Gastritis.
Medication: Histamine H2 - antagonists, Proton pump inhibitors, Prostaglandin analogons
as mucosal protective agents, Antacids, treatment of a H. pylori infection.
Chronic inflammatory bowel diseases
The two most common types of chronic inflammatory bowel diseases are Crohn’s
Disease and ulcerative colitis. Both diseases have in common that they are suspected to
be caused by underlying autoimmune disorders. Other supporting causes like stress and
infections are suspected as well. Both diseases show a chronic recurrent course and
mainly start in young adulthood. Severity, intensity and recurrence rate vary individually.
Extraintestinal manifestiations are linked to both types of IBD, especially arthritis and
uveitis. Treatment for both types of IBD is identical. Corticosteroids in high dosages are
prescribed to terminate acute flares. Depending on the affected intestinal or bowel
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segments the mode to administer medication may vary from oral and intravenously to
rectal suppositories. Medication for preventive treatment consists of acetylsalicylic acid
compounds (e. g. sulfasalazine) or immunomodulators (e. g. azathioprine). Adequate
nutrition should consist of a low fiber, high protein and high calorie diet. The
psychological impact of both conditions is immense since acute flares interfere strongly
with a functioning social life of the affected individual.
• Crohn’s disease
Crohn’s disease is also described as regional enteritis which mainly affects the terminal
ileum. Although this condition can potentially affect the entire gastrointestinal tract.
Symptoms and diagnostic findings:
Increased defecation frequency of 5 to 10 stools daily turning into a semiformed diarrhea.
Severe abdominal cramping mainly in the right lower abdomen. Fever, weight loss, body
achiness, intraabdominal abscess and fistulas to other segments of the intestines and
bowels and other intraabdominal and intrapelvic organs. Diagnosis is made by
colonoscopy which reveals a typical “cobblestone” type of lesions which are interrupted
by healthy areas of the mucous membranes, so called “skip lesions”. Histological
examination of biopsies typically reveals granuloma type formations of lymphocytic cells.
Bowel obstruction and rigidity due to a scar tissue development after recurrent flares is
common. Bowel perforations can occur as well but lead mostly to conglomerate tumors
with other bowel segements. Blood examination shows elevated inflammatory
parameters (WBC, ESR, CRP).
Treatment:
Surgical treatment is indicated if medication therapy fails or complications like bleedings
or bowel perforations arise. Surgical treatment of choice is a circumscripted resection of
the affected bowel area with a consecutive end – to end anastomosis of the resection
margins. A temporary Ileostomy may be necessary in cases where the acute
inflammation has not come to a standstill by the time of the surgical intervention.
• Ulcerative Colitis
Inflammation of the mucosa and submucosa from rectum over the entire colon. Other
parts of the gastrointestinal tract are usually not affected.
Symptoms and diagnostic findings:
Sudden onset of up to 20 diarrheas per 24 hours, even nocturnal, typically with blood
and mucous. Abdominal cramping, fever, weight loss and body achiness. Flares can
cause acute severe intestinal bleedings, obstructions and perforations. Colon cancer risk
is increased in individuals with ulcerative colitis. Diagnosis is made by colonoscopy
showing an inflammated, edematous, bleeding mucosa with cryptic abscess formations.
Fistulas are rarely observed in ulcerative colitis.
Treatment:
Surgical treatment is performed as a proctocolectomy in combination to a temporary
ileostomy or colostomy.
Diverticulitis
Outpouchings of the intestinal wall are considered Diverticula and appear increasingly by
age. Main affected area in 95% of all cases is the sigmoid colon. Diverticula do not
necessarily become symptomatic. Clients with a chronic constipation tend to retain stool
and bacteria within the diverticular pouches.
Symptoms and diagnostic findings:
Classical appearance of an acute diverticulitis is an acute pain in the lower left quadrant
of the abdomen. In accordance to the clinical symptoms this condition is also called a
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“left sided appendicitis”. Fever, chills and increasing abdominal pain are indicating a
developing perforation of the sigmoid colon as the most common complication of
diverticulitis.
As in cases of a Crohn’s Disease, a perforation can also occur “covered”, leading to
conglomerate tumors with other bowel segments and intraabdominal abscedic infections.
Recurrent flares may lead to a fast growth of intraluminal fibrotic scar tissue which can
cause a stenotic condition. Diagnosis is made by abdominal ultrasound and barium
enema.
Ileus
An ileus describes the situation of an intestinal obstruction and is usually classified as
either a mechanical or nonmechanical (=paralytic) ileus. Common causes for a
mechanical ileus are tumors, incarcerated and trapped hernias, fibrotic rigidity after
intraabdominal inflammations, adhesions, volvulus or fecal obstructions. A
nonmechanical (= paralytic) ileus is caused by a disturbance of the muscular bowel
function, the nerval bowel innervation or perfusion. Common causes are situations after
abdominal surgery, anesthesia, peritonitis, spinal cord lesions as well as insufficient
blood flow in the mesenterial arteries. A colon ileus can occur but the most common
location is the terminal ileum due to its natural narrowness.
Symptoms and diagnostic findings:
Abdominal pain, absence of defecation, nausea, vomiting, alteration of bowel sounds
from high pitched to absent, hypotension, shock due to fluid loss into bowels, signs of
peritonitis, elevated inflammatory parameters, LDH and lactate elevation in blood
samples. Diagnosis is made by x-ray examinations of the abdomen where dilated bowel
loops with fluid entrapment can be seen.
Treatment:
Primary action is the insertion of a nasogastric or nasointestinal tube to reduce
intraintestinal pressure. Fluid supply, analgesia under restriction of ileus supporting
opioid analgetics and parenteral nutrition. Monitoring of input and output, renal function,
inflammatory parameters, bowel sounds and X-ray’s. Surgical treatment by partial bowel
resection and temporary or permanent ileo – or colostomy is required if condition is not
improving spontaneously or if complications arise.
Acute Appendicitis
The vermiform appendix is the terminal structure of the small intestines located at the
end of the coecum. The appendix is a lymphoid organ and functionally comparable to
tonsils and lymph nodes. Due to its anatomical configuration it is vulnerable to be
obstructed by undigested food particles, hardened stool or microorganisms which can
cause an acute appendicitis. The local conditions allow this inflammation to develop fast
into an abscess which can potentially cause a life threatening perforation and peritonitis.
Symptoms and diagnostic findings:
Acute and increasing abdominal pain in the right lower abdominal quadrant. McBurney –
Trigger point, located in the center of a direct line between the umbilicus and the Crista
iliaca anterior superior. Fever, chills, nausea, vomiting and anorexia. WBC count up to
20000 cell/mm3, elevation of ESR and CRP.
Treatment:
Acute appendicitis requires immediate appendectomy to avoid or limit a developing
peritonitis. Which is an acute bacterial infection of the peritoneal cavity. Mostly caused
by abdominal wall trauma or rupture of intestinal organs. Residential bowel bacteria
spreading into the blood stream and leading to a septic shock by release of endotoxins.
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Food intolerance syndromes
•
Celiac disease/Sprue
Gluten sensitive food intolerance syndrome. Affected clients are unable to digest wheat
products containing the proteins gliadine and gluteine. If condition is present from birth it
is considered Celiac’s disease. A second form starts during adulthood and is described
as Sprue.
Symptoms and diagnostic findings:
After a frequent exposure for several weeks the digestion of gluten containing products
suddenly leads to an acute inflammatory reaction within the intestinal mucosa. Clients
experience massive vomiting and diarrhea of fatty stool along with severe abdominal
cramps. Diagnosis is made by stool analysis revealing an increased concentration of fat.
Duodenal biopsies proof an acute inflammatory reaction with mucosal damage and
degeneration. Antigliadin and reticulin antibodies are positive in blood samples.
Treatment:
Clients generally require lifelong gluten – free diet which is accomplished by a total
elimination of any sources of wheat.
•
Lactose intolerance
Caused by a steadily decreasing activity of lactase throughout childhood and early
adolescent age. Clients will remain with a very limited or no lactase activity and are
unable to digest lactase into glucose and galactose. Treatment requires to maintain a
lactose free diet or to substitute oral lactase prior to indigestion of dairy products. Aged
cheeses (e. g. camembert) and yogurts are mostly tolerated.
Irritable bowel syndrome
The cause of this functional disorder of the gastrointestinal tract is unknown. Affected
clients experience mostly a completely disturbed bowel function.
Symptoms and diagnostic findings:
Cramping abdominal pain predominantly over the entire lower abdomen.
Unexpected diarrhea and bloatedness especially shortly after meals.
Constipation also possible. No relevant findings in routine abdominal diagnostic
procedures. Mainly treated as a psychosomatic disorder after other possible causes are
ruled out.
Treatment:
Symptom oriented treatment focuses on high fluid – high fiber diet regulations,
avoidance of stimulating substances (sweets, caffeine and
processed food).
Symptomatic treatment of constipation and diarrhea. Psychological support (e. g. Stress
Management).
Cystic fibrosis
Hereditary and not primarily tumorous, malignant or cancerous disorder following an
autosomal recessive trait. A chromosomal defect on chromosome 7 leads to non –
expression of the cystic fibrosis transmembrane regulator CFTR (a chloride channel).
This results in a disability to move water across cell membranes and disables the Na+Clchannels as well. As a result the secretory function of any glandular cell of the body is
disabled leading to a retention of glandular fluids due to thickening which is caused by a
lack of water and chloride within the ICF and an increased chloride concentration in the
ECF. Main symptomatic areas are the respiratory and the digestive tract. The production
of large amounts of thickened mucous within the respiratory tract leads to occlusion of
bronchioles which can not be cleared by coughing.
Main affected organ in the digestive tract is the pancreatic gland where essential
digestive enzymes can not be discharged into the duodenum. Deficiency of pancreatic
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enzymes causes malabsorption of fats, proteins carbohydrates and fat soluble vitamins.
Cystic fibrosis is incurable and usually causes clients to pass before the age of 40.
Symptoms and diagnostic findings:
Recurrent atypical respiratory infections. Growth retardation and malnutrition in children
and young adults. Prenatal diagnosis via amniocentesis reveals a reduced intestinal
alkaline phosphatase. Meconeum ileus is a common first sign in newborns. Diagnosis
via pilocarpin induced sweat test shows an increased Cl- concentration of at least > 60
meq/L. Fatty stools in 72 hour stool sample. Chest X-rays with signs of mucous
infiltrations within the parenchymateous lung tissue. Clubbing nails as a sign of chronic
hypoxemia
Treatment:
Sincere pulmonary hygiene, Postural drainage, specific antibiotic treatments in cases of
bacterial infections. Bronchodilators. High calorie and high protein diet with
prefermentized ingredients or parenteral supply. Avoidance of exposure to respiratory
tract infections. Frequent physical exercise to increase pulmonary function and secretion
of trapped mucous.
Disorders and Diseases of the Liver
Hepatitis A
Caused by a fecal - oral droplet infection with Hepatitis A-virus mostly from contaminated
food sources or water in an non-hygienic environment. Symptoms may start after an
incubation period of 15 – 50 days. Infected clients remain infectious throughout the
course of the disease, especially about two weeks prior to the onset of symptoms.
Symptoms vary from minimal gastrointestinal complaints to a massive jaundice.
Hepatitis A is usually a self limiting infection in otherwise healthy individuals. Treatment
is oriented on symptoms. Infection leads to a lifelong immunity against Hepatitis A.
Hepatitis A is vaccine preventable. Acute epidemic infections can be interrupted by mass
treatments with Hepatitis A immunglobuline.
Hepatitis B
Caused by blood borne (= parenteral) infection with DNS containing Hepatitis B Virus.
Infection requires contact between body fluids and occurs regularly either sexually or by
common use of needles amongst intravenous drug users. Other sources of infection are
surgical procedures with contaminated instruments, blood transfusions and dialysis
treatments. Health care workers are generally endangered by accidential infections as
well. The incubation period is estimated between 30 and 180 days. Clients remain
infectious as long as anti – Hbs is traceable in blood. 70% of otherwise healthy infected
individuals will experience spontaneous healing within a period of 6 months. About 30%
of all cases will lead to a chronic hepatitis where the virus persists in the liver parenchym,
causing a more or less progressive ongoing hepatitis. In these cases anti – Hbs, anti –
Hbe and HBV-DNA remain as diagnostic markers for the ongoing infection and its
activity. Clients with a chronic persisting hepatitis b have an increased risk for the
development of liver cirrhosis and liver cell carcinoma. The rate of progressive liver
destruction by liver cirrhosis is 20% and 15% for the development of liver cell carcinoma.
In cases of suspected fresh hepatitis b infections it is recommended to administer
hepatitis b vaccine as a postexposure prophylaxis. A possibly developing chronic
hepatitis will be treated with a combination of interferone and ribavirin for up to 48 weeks
depending on the persistence of the infection markers.
Hepatitis C (Hepatitis non–A / non–B)
Hepatitis C is in regards to modes of infection and incubation period comparable to
hepatitis b. Main difference is a comparably much more aggressive course of infection.
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75% of infected individuals develop a chronic hepatitis with an increased risk for liver
cirrhosis and liver cell cancer. Treatment of a chronic persisting hepatitis c is comparable
to the treatment of a chronic persisting hepatitis b.
Hepatitis D
An infection with Hepatitis D virus requires the presence of a hepatitis b virus capsule
which is needed to allow a proper replication of the hepatitis d virus. Modes of infection
are comparable with hepatitis b. Acute Hepatitis with a healing rate of 95% can be
observed in cases of a simultaneous infection. Superinfections in cases of an already
developing course of acute hepatitis b lead to a poor prognosis with high rates of
terminal liver failure.
Hepatitis E
Hepatitis E virus infections occur comparable to hepatitis a infections and show an
almost identical outcome. Hepatitis E is currently not endemic in the United States but in
South America, Africa, Asia and the Middle east.
Cirrhosis of the liver
Liver cirrhosis is defined as a stade of destroyed and dysfunctional liver parenchym and
its replacement by connective fiber tissue. Common causes of liver cirrhosis are
alcoholism, (laennec’s cirrhosis) chronic persisting hepatitis b and c, biliary diseases,
autoimmune hepatitis and metabolic diseases. Course and severity of liver cirrhosis are
determined by the persisting presence of its cause. Liver cirrhosis is primarily incurable
but its progress can be interrupted or significantly delayed if its cause can be controlled.
Total liver failure due to a cirrhosis may not occur until 90% of the organ is affected but
multiple complications can derive from a reduced liver function.
Symptoms and diagnostic findings:
Disturbed protein synthesis and an increased blood pressure in the portal vein. Physical
exhaustion, fatigue, jaundice, pruritus, weight loss, malnutrition, anorexia and enlarged
liver. Delayed blood coagulation, hematomas, spider angiomata, teleangiectasia, clay
colored acholic stools, altered bowel habits, pleural effusions, breathing difficulties,
immunodeficiency, delayed wound healing, palmar erythema and dark urine. Umbilical
caput medusa, edema, respiratory distress due to sub-diaphragmatical ascites,
disturbed menstrual cycle in women, gynecomastia and erectile dysfunction in men.
Testosterone/Estrogene deficiency.
Pathophyiology of liver cirrhosis
Portal vein hypertension
Caused by an increased pressure within the portal vein due to growing resistance
caused by fibrotic liver tissue as the most common cause. Other causes are portal
vein thrombosis, liver vein thrombosis (Budd Chiari Syndrome), right sided heart
failure.
The increased pressure in the portal vein causes large connecting veins to expand,
leading to the following characteristic symptoms:
- Hemorrhoids
- Esophageal and gastric varicosis with potential risk of hematemesis
- Umbilical vein dilation “caput medusa”
- Hepatospenomegaly
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Ascites
Plasma rich fluid accumulation in the peritoneal cavity.
Caused by proteine deficiency and decreased oncotic pressure.
Aldosterone increase leads to sodium and water retention.
Hepatic encephalopathy
Neurological disorder caused by increased ammonia levels due to an altered hepatic
protein metabolism. Symptoms include confusion, altered consciousness, flapping
tremor and disorientation.
Hepatorenal syndrome
Acute renal failure in an ongoing and advanced liver failure. Oliguria, hyponatremia
and fatigue. Increased creatinine and BUN parameters. Client may require dialysis to
treat fluid excess and hyperkalemia. Liver transplantation is the only possible cure.
Laboratory findings
Bilirubin
Cholinesterase
Albumin
Blood coagulation factors
Pancytopenia
Serum ammonia levels ,
Aldosterone leve
Sodium
Gamma – globulines
Fat soluble vitamines
Blood Glucose due to Gycogene deficiency
The final diagnosis of a liver cirrhosis always requires liver biopsy
which has to be obtained by a blind liver puncture or laparascopy!
Ultrasound examinations typically reveal a more or less unevenly shaped liver surface,
diminished liver veins and widened portal vein.
Treatment:
Treatment is generally focused on resolving underlying causes.
General treatment:
Small frequent meals, anorectic clients require strict prevention of pressure sores,
Monitoring of liver function parameters, Vitamin K supply to enhance remaining
production of coagulation factors and life style change (e. g. avoiding alcohol).
Ascites treatment:
Paracentesis to drain ascites.
Portal vein bypass by surgical procedure or catheter placement (LeVeen/TIPS)
to treat portal hypertension and avoid recurrence of ascites.
Fluid, sodium and protein restriction.
Daily monitoring of weight, input and output.
Diuretic treatment with Spironolactone and Furosemide
Hepatic encephalopathy treatment:
Lactulose treatment to reduce inrestinal ammonium levels produced by intestinal
bacterial flora. Neomycin for bowel sterilization.
Hematemesis treatment:
Intervention in cases of hematemesis from a varicose esophageal bleeding by
sclerotherapy or esophageal tamponade via Sengstaken – Blakemore or Minnesota tube.
Vasopressin or beta blocker intravenously (under cardiac monitoring) to cause
vasoconstriction of portal vein collaterals.
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Gall bladder and biliary duct stones (Cholelithiasis)
Gall bladder and biliary duct stones are the most common disorders of the biliary system.
Gallbladder stones consist in more than 80% of all cases of cholesterol. The underlying
dysfunction for the formation of these stones is mostly a disproportion between bile salts
and the amount of indigested cholesterol. A deficiency of bile salts can be caused either
by their disturbed hepatic production or inhibited reuptake from the terminal ileum in the
digestion process. A deficit of bile salts leads to limited digestion of fats. Another
possible source for cholesterol stones is a long lasting high cholesterol diet which can
overcome the fat digesting capacity of the gastrointestinal tract.
Multiple risk factors for the development of gallstones have been described:
Obesity, hyperlipidemia, age > 40 years, caucasian ethnicity, female gender, family
history of gall stones, pregnancy and estrogen supply. Affections and dysfunction of the
terminal ileum (e. g. Crohn’s disease and tumors),type I diabetes.
Stone formation of pigment stones occurs from a combination of hardened unconjugated
bilirubin with calcium. These stones occur more often within the biliary system, mostly
after a bile duct inflammation (cholangitis) or conditions of increased destruction of blood
cells (e. g. leukemia).
Symptoms and diagnostic findings:
Gallbladder and biliary duct stones can be asymptomatic for a lifetime. Once a
gallbladder got filled with gall stones its natural function as a reservoir for bile acids is
limited or lost which typically results in digestive problems after fatty or spicy meals as
well as larger amounts of food. A biliary colic occurs if a gallbladder stone moves into the
narrow biliary duct system and gets trapped in there. As a result the affected client
experiences severe fluctuating abdominal pain in the right upper quadrant. Mostly
accompanied by severe nausea and vomiting. Physical examination typically reveals a
sharp pain when client performs deep inspiration while examiner is palpating the RUQ.
(Murphy’s sign) Jaundice, grey stools, dark urine and elevated bilirubin serum levels
occur if colic leads to a total blockage of the common bile duct. Diagnosis is routinely
made via abdominal ultrasound as well as by abdominal x-rays. Laboratory findings
include an elevation of GPT and GOT as well as GGT and AP as cholestasis indicating
parameters. WBC, ESR and CRP may be altered in cases of a developing inflammatory
process.
Treatment:
Clients with asymptomatic gallbladder stones do not require any curative treatment.
Frequent follow up examinations along with a cholesterol restricted diet are
recommended. Main priority in an acute biliary colic is symptom relief with common
analgetics and spasmolytics. Opiod analgetics are relatively contraindicated since they
increase spasms in smooth muscles.
Symptomatic cholelithiasis usually requires surgical treatment via cholecystectomy and/
or ERCP (Endoscopic Retrograde Cholangio Pancreticography). ERCP is commonly
indicated in cases of bile duct blockage prior to a cholecystectomy. Cholecystectomy is
usually performed as a minimal invasive laparascopic transabdominal surgery and
requires a clear biliary passage. Conventional cholecystectomy via laparatomy may be
indicated if a larger part of the biliary duct system has suffered damage from a colic or if
biliary stones can not be captured via ERCP. In these cases surgery involves temporary
placement of a T–Drain which leads biliary fluids through the abdominal wall until the
biliary system has healed. Drain will be removed when bile flow subsides. Flow should
not over exceed 500 mL within the first 24 hours and should gradually decrease in the
following days. Other forms of treatment are Extracorporal Shock Wave Lithotripsy
(ESWL). Oral Ursodesoxycholic acid (UDCA) to dissolve gall stones of less than 2cm in
diameter. Treatment lasts up to several years. High recurrence rates.
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Cholecystitis
An acute or chronic inflammation of the gall bladder. Mostly of lithogenic cause due to an
obstruction of the cystic duct or the common bile duct due to an inhibited flow of biliary
and pancreatic fluids as well as other digestive enzymes. Other causes are a previous
gallbladder or biliary duct surgery as well as a vast overproduction of biliary fluids in
cases of hyperalimentation with fats.
Symptoms and diagnostic findings:
Symptoms of an acute cholecystitis mostly occur during an acute biliary colic and show
comparable symptoms. Advanced inflammations can lead to peritonitis. Laboratory
findings are irregular liver function tests, especially elevated cholestasis parameters and
inflammatory parameters. Abdominal ultrasound examination reveals an edematous gall
bladder wall. Proof of inflammation in chronic stades via nuclear scans. (HIDA–
Hepatobiliary Imino Diacetic Acid).
Treatment:
Acute inflammation needs to be cured prior to any surgical treatment of underlying cause!
Clients remain in NPO status under intravenous antibiotic treatment and analgetic
medication until acute infection is under control. Emergency cholecystectomy may
become necessary in case of peritonitis.
Primary Sclerosing Cholangitis (PSC)
Incurable autoimmune inflammatory process which leads to a progressive destruction of
the entire biliary system.
Symptoms and diagnostic findings:
Repeated cholestasis, jaundice, abdominal pain in upper right quadrant and anorexia.
Proof of diagnosis via assessment of pANCA antinuclear antibodies. Otherwise elevated
GGT, AP and inflammatory parameters. Progress leads to biliary cirrhosis of liver. Up to
10% of affected individuals experience cholangiocarcinoma or colorectal cancer.
Diagnosis is made by liver biopsy.
Treatment:
Symptom oriented treatment of cholestatic episodes including dilating procedures of
biliary ducts. Only curative treatment is liver transplantation.
Pancreatitis
Increased amount of pancreatic enzymes in pancreatic duct leads to pancreatic
inflammation and autodigestion. Inflammatory swelling of pancreatic duct occludes
Sphincter oddi and ampulla Vateri and inhibits flow. Hemorrhagic organ destruction may
lead to retroperitoneal hematoma.
Major causes of pancreatitis are:
Obstructive biliary stones leading to a reflux of digestive pancreatic enzymes.
Alcohol and alimentary excess causing hypertriglyceridemia with an increased
production of pancreatic enzymes lipase and amylase. Rare causes are side effects of
medication e. g. NSAID, Thiazides and abdominal traumas.
Symptoms and diagnostic findings:
Acute epigastric abdominal pain and tenderness, increasing in supine position,
Hematoma in both flanks and/or around umbilicus (Grey – Turner sign/Cullen sign).
Hemorrhagic ascites, pleural effusions, hypovolemia and shock. Also nausea, vomiting,
diarrhea and fever. Abdominal ultrasound and CT–scans reveal inflammatory pancreatic
edemas and bleedings, gall and biliary duct stones, ascites and pleural effusions.
Laboratory findings: Blood Glucose, Lipase, Amylase , Urine Amylase , Hypocalcemia,
CRP and Leucocytes .
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Recurrent episodes of acute pancreatitis may lead to chronic pancreatitis with a resulting
exocrine pancreatic insufficiency. Main symptom is a food intolerance against fat.
Treatment:
Depending on the severity of an acute pancreatitis treatment includes, pain relief,
antibiotic treatment, antispasmodic treatment, nasogastric tube to drain excess digestive
fluids, parenteral nutrition, correction of hyperglycemia, adjustment of electrolyte status
and fluid supply. Curative treatment of underlying cholelithiasis is performed after acute
episode of pancreatitis is controlled.
Gastrointestinal Medication Therapy
Antispasmodics
Pharmacological effect:
Antagonizing effect on the acetylcholine receptors of the smooth muscles of the
gastrointestinal tract.
Therapeutic effect:
Relaxation of smooth muscles to increase gastrointestinal motility.
Indications:
Gastrointestinal dysfunction, cramping, pylorospasms and inflammatory bowel disease.
Special considerations: Medication should be taken about 30–60 min. prior mealtimes.
Side effects:
Dry mouth, nausea, vomiting, constipation, mydriasis,, urine retention, impotence,
tachycardia, palpitations, dysphagia, hyperthermia due to inactivity of sweat glands,
allergic rash and urticaria.
Substances:
Hyoscyamine sulfate (Levsin®), Dicyclomine hydrochloride (Bentyl®), Chlordiazepoxide
hydrochloride (Librax®) and Glycopyrrolate (Robinul®).
Antidiarrheals
Pharmacological effect:
Reduction of bowel motility by interaction with intestinal motoric nerves.
Therapeutic effect:
Diarrhea relief
Indications:
Diarrhea
Special considerations:
Self treatment with OTC Medications is tolerable for 2 days in a case of diarrhea. Main
concern is the development of dehydration, especially in elderly or pediatric clients.
Adequate fluid supply and an easy digestable diet. (i. e. BRAT Diet = Banana, rice,
applesauce, tea, toast is also a part of the treatment) Dairy products aggravate diarrhea.
Pregnant and lactating women need to seek medical attention early!
Contraindications:
Bloody diarrhea, bacteria induced Diarrhea (E. Coli and Shigella), bowel obstruction.
Difenoxine: Not indicated for children < 2 years and in combination with MAOI
medication.
Substances:
Loperamide (Imodium®)
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Categories:
•
Stimulant laxatives
•
Bulk forming laxatives
•
Stool softeners
•
Hyperosmotic laxatives
•
Lubricants
•
Saline Laxatives
Laxatives
Laxatives are indicated in the treatment of constipation only. The individual pattern on
how often a human being defecates can differ widely between individuals. Therefore the
individual regularity of bowel movements is of greater importance for judging about a
constipation than the actual frequency. An exception from this rule is the abrupt and
ongoing alteration of bowel habits which should always be further investigated since this
could indicate a suspicion of bowel cancer or another intestinal or systemic disease.
The main factors which regulate a normal bowel function are a fiber rich diet, daily
physical activity and sufficient amount of fluids. Therefore constipation is of great
concern for clients who are lacking sufficient mobility. A constipation also may occur as a
side effect of certain medications and is most common for opioid analgetics of all
potencies. Long term use of laxative and laxative abuse weakens the muscular bowel
function and can lead into a state of bowel immobility (carthatic colon) due to a chronic
ulcerative colitis. A general contraindication for laxatives are any mechanical bowel
obstructions i. e. due to a tumorous or inflammatory or stenosis. Administration of
laxative agents should take place separately from any other medication.
Stimulant laxatives
Pharmacological effect:
Stimulation of parasympathic bowel innervation due to mucosa irritation.
Special considerations:
Effect to be expected 6–12 hours after oral administration and within 2 hours after rectal
administration. Not to be taken with milk or antacids.
Contraindications:
Abdominal colics, pain, nausea, vomiting, rectal bleeding, gastroenteritis and intestinal
obstruction. Castor oil can cause premature labor.
Senna is excreted in breast milk.
Side effects:
Hypokalemia, hypocalcemia, abdominal cramping and colicky pain.
Substances:
Bisacodyl (Dulcolax®), Castor oil (Neoloid®, Purgo®), Senna (Senokot®) and
Casanthranol (Pericolace®)
Bulk forming laxatives
Pharmacological effect:
Non-absorbable polysaccharide molecules increase in size by binding water. The
resulting bulk formation is distending the colon wall as an adequate trigger to release
peristaltic action.
Special considerations:
Slow onset of effect within 12 hours to 3 days. Strictly requires sufficient fluid supply! Pat
is otherwise endangered of bulk forming process in upper gastrointestinal tract.
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Substances:
Calcium polycarbophil (Fibercon®), Methylcellulose (Citrucel®) and Psyllium
(Metamucil®)
Hyperosmotic laxatives
Pharmaceutical effect :
Equivalent to bulk forming laxatives, orally or rectally administered disaccharides absorb
water which leads to a softening effect without bulk formation.
Special considerations:
Onset of effect may be delayed by 2 – 4 days.
Substances:
Lactulose (Kristalose®), Polyethylene glycol (Miralax®) and Glycerine (Glycerol®)
Stool softeners (emollient laxatives)
Pharmaceutical effect:
Anionic surfactants diluted in water penetrate into dry formations of stool.
Special considerations:
Effect is delayed by up to 3 days from first dosage. Main indication is the prevention of
strainous defecation in clients at special risk for constipation (i. e. elderly and immobile
clients with limited fluid intake).
Substances:
Docusate sodium (Colace®), Docusate potassium (Dialose®) and Docusate calcium
(Doxidan®)
Saline Laxatives
Pharmacological effect:
Non-absorbable Magnesium sulfate or citrate salts or Sodium phosphate salts lead to a
fast defecation.
Special considerations:
Onset of effect between 30 Minutes and 6 hours after administration.
Side effects:
These laxatives may get partially absorbed.
(Relative)Contraindications:
Renal impairment: Magnesium salts.
Chronic heart failure: Sodium salts
Antiemetics
Antihistamines
Most commonly used for treatment of motion sickness. Antiemetic effect due to
anticholinergic side effect.
Substances:
Cyclizine HCl (Marezine®), Dimenhydrinate (Dramamine®), Diphenhydramine
(Benadryl®), Hydroxyzine (Vistaril®) and Meclizine (Antivert®).
Phenothiazines and Butyrophenone:
Antiemetic effect due to dopamine receptor blockade.
Substances:
Metoclopramide
(Reglan®),
Perphenazine
(Phenazine®),
Prochlorperazine
(Compazine®) and Promethazine HCl (Phernergan®).
Cannabinoids
Mechanism unknown. Used as an antiemetic in cancer chemotherapy.
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Substances:
Dronabinol (Marinol®) and Nabilone (Cesamet®)
(also used in AIDS treatment for appetite enhancement)
Benzodiazepines and Glucocorticoids
Antiemetics in cancer chemotherapy. Used in combination along with Metoclopromide.
Substances:
Diazepam (Valium®) and Lorazepam (Ativan®)
Serotoninantagonists
Antiemetic effect is part of the Serotonin antagonism.
Substances:
Dolasetron mesylate (Anzemet®), Granisetron (Kytril®), Ondansetron (Zofran®),
Palonosetron (Aloxi®)
Antacid medication
H2 Histamine Blockers
Pharmacological effect:
Selective blockage of H2 - Receptors in gastric, duodenal and pancreatic secretory cells.
Reduction of acid release in gastric, duodenal and external pancreatic cells. Peptic ulcer
disease, reflux esophagitis and Zollinger-Ellison’s syndrome.
Physiological effect:
Reduction of gastric acid production.
Special considerations :
Reduced dosages in hepatic or renal impairment. Successful treatment requires dietary
and life-style regulations. Normal oral dosage is administered once daily at bedtime.
NSAID and ASA may interfere with therapeutic effect.
Side effects:
Dysrhytmias and blood dyscrasias.
Substances:
Cimetidine (Tagamet®), Famotidine (Pepcid®), Ranitidine (Zantac®) and Nizatidine
(Axid®)
Protone pump inhibitors
Pharmacological effect:
Blockage of acid producing gastric parietal cells by inhibiting H+-K+ ATPase and
removing protons from acid building process.
Physiological effect:
Reduction/elimination of gastric acid.
Indication:
GERD, gastric and duodenal ulcers.
Special considerations:
Used for long–and short term treatment depending on underlying conditions.
Lansoprazole and Esomeprazole capsules can be crushed and administered pelletwise.
Omeprazole, Rabeprazole and Pantoprazole capsules can not be opened. Medication
has to provide full symptom relief. Otherwise dosage increase or change of medication is
required. Intravenous administration has to be performed slow over 15 minutes.
Requires reduced dosage in case of a liver impairment. Ongoing Assessment of
laboratory parameters is mandatory.
Contraindications:
Children, pregnancy and lactating women.
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Side effects:
Disturbed digestion due to absence of gastric acid, resulting in nausea, flatulence,
constipation, diarrhea, increased liver enzymes, hepatic failure, liver necrosis, toxic
epidermal necrolysis, Stevens Johnson Syndrome and Agranulocytosis.
Substances:
Pantoprazole (Protonix®), Esomeprazole (Nexium®), Lansoprazole (Prevacid®)
Rabeprazole (Aciphex®) and Omeprazole (Prilosec®).
Pantoprazole (Protonix), Esomeprazole (Nexium), Lansoprazole (Prevacid)
Mucosa protecting substances
Misoprostol (Prostaglandine)
Pharmacological effect:
Prostaglandine effect on gastroduodenal mucosa cells:
Inhibition of gastric secretion,
increase of gastric bicarbonate,
increase of mucus production
decrease of pepsin cells.
Physiological effect:
Gastric acid relief and mucosa protection.
Indications:
Mucosa protection
Special considerations:
Misoprostol has to be taken with food. Strict contraception under Misoprostol is required
for up to 1 month after treatment has ended.
Side effects:
Dizziness, nausea, vomiting, laryngospasm, seizures, dysmenorrhea and
postmenopausal bleeding.
Sucralfat
Pharmacological effect:
Formation of a pepsin absorbing coating from albumin and fibrinogen on an
gastroduodenal ulcer site.
Physiological effect:
Gastroduodenal ulcer protection.
Indications:
Gastrodudenal ulcers
Special considerations:
Medication to be taken 1 hour prior or 2 hours after meals and 2 hours after medication.
Antacid medication
Pharmacological effect:
Anionic magnesium and aluminum molecules to neutralize gastric acids.
Therapeutic effect:
Gastric acid relief.
Specific considerations:
Used for symptom oriented treatment on demand only.
Magnesium has to be used cautiously in cases of renal impairment !
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Side effects:
Magnesium may cause diarrhea, aluminum may cause constipation and
hypophospatemia.
Contraindications:
Lactating women.
Magnesium: Severe renal impairment, Ileostomy, Colostomy.
Substances:
Magnesium trisilicate (Gaviscon®), Magnesium hydroxide and aluminum hydroxide
(Maalox®) and Calcium carbonate (Tums®).
Helicobacter pylori treatment schemes
Lansoprazole + Amoxicillin + Clarithromycin (Prepak®) most effective!
Bismuth salicylate + Metronidazol + Tetracycline (Helidac®)
Omeprazole + Clarithromycin (Prilosec/Biaxin®)
Ranitidine + Bismuth citrate + Clarithromycin (Titrec/Biaxin®)
Special considerations :
Course has to be completed within one week.
Clarithromycin and bismuth can not be administered to pregnant women!
Bismuth is contraindicated in children (Danger of Reye-Syndrome) and may change
color of tongue and stool.
x
Gallstone-Dissolving Agents
Pharmacological effect:
Bile acid, inhibiting hepatic synthesis and secretion of cholesterol.
Therapeutic effect:
Removal of gall stones.
Indication:
Gallbladder stones
Special considerations:
Treatment requires 12–24 months and must show gradual improvement in 6 monthly
frequent ultrasound investigations to be continued.
Side effects:
Rash, nausea, vomiting, abdominal pain, photosensitivity and anxiety.
Contraindications:
Calcified stones, obstruction of biliary system and liver disease.
Substances:
Urosodiol (Actigall®)
Pancreatic Enzymes
Pharmacological effect:
Replacement of pancreatic enzymes lipase, amylase and protease.
Therapeutic effect:
Restoration of excretoric pancreatic function.
Indication:
Chronic pancreatitis
Special considerations:
Medication has to be linked to meals. No combination with other substances.
Side effects:
Nausea, diarrhea and hyperuricemia.
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Substances:
Pancrease and Viokase (Creon 5®)
Antiprotozoal Medication
Therapeutic effects:
Treatment and prevention of Gardiasis, Threadwom infections, Cestodiosis and
Malaria infections.
Special considerations:
Quinacrine:
Used for treatment of tapeworm giardiasis and cestodiosis. As a sclerosing agent for
injection into the pleural space used to prevent recurrence of pneumothorax. To be
taken after food. Substance may cause reversible yellow blueish coloration of ears,
nasal cartilage and nail beds.
Chloroquine:
Used for giardiasis and amebiasis treatment. To be taken with food. Prophylactic
treatment once weekly during current risk and for 10 weeks afterwards. May cause
bleaching of body and scalphair, bluish black skin coloration, rusty yellow or brown urine
and photophobia.
Side effects:
Decreased visual acuity, dizziness, vertigo, headaches, nausea, vomiting, diarrhea,
confusion, delirium, insomnia, cardiotoxicity, bone marrow suppression, hypotension,
blackwater fever and interaction with anticonvulsive agents.
Commonly used substances:
Chloroquine (Aalen®), Mefloquine (Lariam®), Primaquine, Pyrimethamine (Daraprim®)
Quinacrine (Atabrine®), Quinine sulfate (Quinamm®), Pentamidine isethionate (Pentem
300®) Pneumocystis carinii infection.
Anthelmintic Medication
Treatment of infection with Ascaris lumbricoides, trichostrongylus, enterobius
vermicularis, ancystoma duodenale and necator americanus.
Commonly used substances:
Mebendazole (Vermox®), Piperazone (Antepar®), Pyrantel pamoate (Antiminth®),
Thiabendazole (Mintezol®)
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ENDOCRINE DISORDERS AND DISEASES
Hormonal regulation cycles
Hypothalamic
hormones
Gonadotropine
releasing hormone (Gn-RH)
Dopamine
Thyreoidea releasing hormone
(Thyreotropin, TRH)
Growth hormone releasing
hormone (GH-RH)
Corticotropin releasing hormone
(CRH)
Pituitary gland
hormones
Peripheric
hormonal glands
Peripheric
hormones
Follicle Stimulating
Hormone
Testicles
Testosterone
Ovarian Glands
Estrogene
Testicles
Testosterone
Ovarian Glands
Progesteron
None
Thyroid Gland
Prolaktin
Thyroxin (T4)
Growth hormone (GH)
Liver
Trijodthyronin (T3)
Somatomedine
Adrenocorticotropic
hormone (ACTH)
Adrenal cortex
Glukocorticoids
(FSH)
LH - Luteinizing Hormone
(LH)
Prolaktin
Thyreoidea stimulating
hormone (TSH)
Mineralocorticoids
Androgenes
Antidiuretic Hormone (ADH)
Oxytocin
ADH,released by pituitary
gland.
Oxytocin, released by
pituitary gland.
None
None
None
None
Adrenal cortex
Adrenalin,
Noradrenalin
Kidney
Erythropoetin,
Calcitriol
Pancreatic gland
Somatostatin,
Glukagon, Insulin
Parathyroid gland
Parathormone(PTH)
Thyroid gland C-Cells
Calcitonin
Hormones initiate and support specific functions of the human body. The secretion and
production process of each hormone is triggered by an endocrine feedback process.
Hormonal levels are continuously measured by specific receptors within the central
nervous system. Depending on the demand the hormonal production and secretion will
either be halted, increased or reduced.
Hypopituitarism
Failure to thrive caused by a deficiency of growth hormone (GH) from pituitary gland.
Affected children will appear with a characteristic growth retardation below the third
percentile within the first year.
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Symptoms and diagnostic findings:
Symptoms depend on clients age at onset of this disorder and on the severity of the GH
deficiency. The primary appearance of the affected individuals is showing a delayed or
permanently interrupted physical development.
Infants: Micropenis, no descend of testicles, hypoglycemia due to compensating
hyperinsulinemia and jaundice.
Children: Obese, hyperglycemic and retarded musculoskeletal development.
Proof of diagnosis by assessment of low levels of IGF–1 (insulin – like growth factor).
Treatment:
Supplemental therapy with subcutaneous growth hormone injections. Psychological
support of children and parents.
Growth Hormone (GH)
Physiological function:
Pituitary gland hormone. Regulating growth of all human tissues.
Therapeutic use:
Supplementation in children with GH deficiency.
Indication:
Growth retardation.
Special considerations:
Only effectful by parenteral administration via subcutaneous or intramuscular injection.
GH stimulates all growth specific metabolic functions epecially the protein and blood
sugar metabolism. Treatment requires regular x-ray assessment of epiphyseal plates for
signs of closure. Treatment has to be discontinued once epiphyseal plates are in
process of closing. Treatment in first year may result in 3–5 inches additional growth but
result will decrease later. Therapeutical goal is reached when normal adult height has
been reached.
Contraindications:
Shortness of height due to other causes. Closure of epiphyseal plates. Intracranial
tumors.
Side effects:
Glucose Intolerance, hypothyroidism, deficiency of ACTH (Adrenocorticotropic hormone).
Hypercalcuria, allergies, diabetes, organ enlargement, akromegalie and hypertension.
Substances :
Somatrem (Protropin®), Somatropin (Humatrope®), Sermorelin = stimulating GH
release (Geref®), Bromocriptine = GH suppressor (Parlodel®), Octreotide = suppressor
of intestinal peptide hormones, insuline, glucagon and growth hormone. (Sandostatin®)
Hyperpituitarism (Gigantism/Acromegalie)
Abnormous physical growth by inadequate secretion of growth hormone (GH).
Commonly caused by benign pituitary gland tumors. Gigantism with unlimited physical
growth occurs if disorder takes place during childhood prior to the physiological
epiphyseal closure. Adult hyperpituitarism results in Acromegaly.
Symptoms and diagnostic findings:
Abnormous enlargement of musculoskeletal system, organomegaly, hypertension and
early degenerative osteoathritis.
Treatment:
Causative treatment is the surgical transsphenoidal removal of GH producing
hypophyseal adenoma or of the entire pituitary gland. Patients who are at high risk for
surgery may be treated with radiation first.
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Hyperthyroidism
Inadequate production and secretion of thyroid gland hormones. The most common
cause is an autoimmune disorder, also called Grave’s disease which leads to production
of TSH Receptor autoantibodies. Hyperthyreosis is also caused by autonomous
dysregulation of parts or of the entire thyroid gland. A rare cause is a dysfuntional
release of the thyroid stimulating hypothalamic hypophyseal hormones TRH and TSH or
an accidential overdose of thyroid gland hormones.
Symptoms and diagnostic findings:
Regardless of the underlying cause the following symptoms indicate hyperthyroidism.
Struma (enlarged thyroid gland), tremor, nervousness, weight loss, tachycardia,
hypertension, psychomototic restlessness, anxiety, panic attacks, sweats and
inadequate temperature adjustment. Symptoms depend in occurrence and severity on
the actual thyroid gland hormone levels. An intoxication with thyroid gland hormones can
occur in severe cases and is considered a thyroid storm or thyroid crisis.
This condition is a life threatening emergency, characterized by tachycardia with > 150
bpm, commonly associated by atrial fibrillation. Temperature > 102 F, nausea, vomiting
Diarrhea. Clients with Grave’s disease may also develop exopthalmus (“Betty Davis’
eyes”).
Laboratory findings:
T3, T4 , TSH , TSH receptor auto antibodies (Grave’s disease).
Imaging diagnostic methods include thyroid gland ultrasound as well as technetium
radionuclide uptake scan in cases of suspected thyroid gland autonomy.
Treatment:
Thyreostatic medication with Ethionamide to reduce secretion of thyroid gland hormones.
Radioactive ablation therapy with Iodine 131. Substance is administered orally as a fluid
by using a straw. Thyroid gland will be partially destroyed over six weeks time.
Radioactive precautions are necessary until radiation is below 30 mCi. Partial or total
thyroidectomy. Main complications of thyroidectomy are: surgical injury of the nervus
laryngeus recurrens leading to a horseness, accidential removal of epithelial bodies of
the parathyroid gland, leading to hypocalcemia and tetania. Special eye care may be
necessary in case of exopthalmus.
Hypothyroidism
Comparable to the causes of hyperthyroidism the underlying problem is either a deficient
TSH secretion by the pituitary gland or a primarily insufficient thyroid gland which is
mainly caused by an antibody activated autoimmune disorder. (Hashimoto’s disease).
Symptoms and clinical findings:
Weight gain, depression, intellectual retardation, hypothermia, hypotension, bradycardia,
fatigue, constipation, myxedema in severe cases, not shiftable, predominantly periorbital
and pretibial.
Laboratory findings: (variable to cause)
T3, T4 , TSH
Treatment:
Supply of thyroid gland hormones, mostly life long weight management.
Thyroid gland medication
Physiological function:
Stimulation of growth, development and protein synthesis. Supplementation Treatment
in hypothyroidism. Administration may be performed intravenously, intramuscular,
subcutaneously or oral. An acute hypothyreosis or hyperthyreosis requires regular
assessments of vital signs, mood and vigilance. Supplemental treatment requires regular
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assessments of thyroid gland hormones and blood sugar levels. Supplemental treatment
is in most cases life long.
T3 does not cross blood brain barrier like T4
and is not useful for infantile Hypothyroidism!
Side effects:
Severity and characteristics of side effects depend on dosage, hypertension, weight loss,
palpitations, angina pectoris, anxiety, nervousness, depression, hyperglycemia.
Common substances:
Levothyroxine = Tetrajodthyronine T4 (Levothroid®, Levoxyl® and Synthroid®)
Liothyronine = Trijodthyronine T3 (Cytomel®), Liotrix = T3/T4 Mixture (Thyrolar®)
Protirelin = TRH Hypothalamic thyroid gland releasing hormone for diagnostic use.
Thyrotropin = Pituitary TSH (Thyroid gland stimulating hormone) for diagnostic puposes.
Antithyroid medication
Pharmacological effect:
Inhibition of synthesis but not of release of thyroid hormones.
Therapeutic effect:
Treatment of Hyperthyreosis and Thyreotoxicosis (Grave’s disease).
Specific considerations:
Relevant laboratory studies under treatment with antithyroid medication.
Serum T3, serum T4, serum fT3 ( “free” = not bound to Albumine), serum fT4
T3 resin uptake, serum thyroid uptake of radioiodine, thyroid gland suppression test.
No immediate onset of effect. Routine blood tests may be performed weekly. Medication
is to be taken in circadian rhythm.
Side effects:
Hypothyroidism and related symptoms, bone marrow depression
Agranulocytosis. anemia, infections, neuropathia, metallic taste
Common substances:
Methimazole: (Tapazole®) Inhibiting thyroid hormone synthesis but not hormone release.
Propylthiouracil (generic) Inhibits synthesis and peripheral breakdown of T3 to T4.
Hyperparathyroidism
Primary hyperparathyroidism is mostly caused by a tumor or a hyperplasia of the
parathyroid gland. Secondary hyperparathyroidism occurs in cases of hypocalcemia.
Physiological PTH function is to restore decreased calcium levels by influencing three
modalities
Increasing the calcium resorption from bones, the renal calcium reabsorption and the intestinal calcium reabsorption.
Symptoms and diagnostic findings:
Serum calcium
, Serum phosphate , nephrolithiasis, polyurie, osteopenia –
osteoporosis and gastrointestinal ulcers.
Treatment:
In cases of tumor or hyperplasia the first line treatment is surgical removal as early as
possible in the course of disease. Medication treatment loop diuretics under sufficient
fluid supply is indicated if surgical solution is not achievable or not indicated. Thiazide
diuretics and digitalis are contraindicated in hypercalcemia!
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Hypoparathyroidism
Main cause of hypoparathyroidism is the accidental surgical removal of the parathyroid
gland.
Symptoms and diagnostic findings:
Hypocalcemic tetany: Paresthesia, hoarseness, headaches, tremor and muscle spasms.
Chvostek sign positive
pressure on facial nerve leads to elevation of mouth angles.
Trousseau sign positive
inflation of blood pressure cuff leads to cramps of forearm
muscles. Laboratory findings: PTH , Serum calcium , Phosphate .
Treatment:
Calcium and Vitamin D supply.
Parathyroid Gland Medication
Calcium Supplements
Pharmacological effect:
Supply of calcium to meet metabolic needs.
Therapeutic use:
Calcium replenishment in hypocalcemia due to hypoparathyroidism. Also antacid
treatment for gastric problems due to hyperacidity.
Indication:
Hypoparathyroidism and alimentary calcium deficiency.
Special considerations:
To be taken separately from dairy products and other medications with large amounts of
water, with meals or after meals. Spinach, whole grain, beets, bran reduce intestinal
calcium absorption due to their high concentration of oxalates. Long term treatments and
severe hypocalcemia requires weekly assessments of serum and urine calcium levels.
Side effects:
Constipation, flatulence and hypercalcemia.
Common Substances:
Calcium acetate (PhosLo®), Calcium chloride (generic), Calcium carbonate (Tums®)
Vitamin D
Physiological effects:
Controlling the calcium absorption and interaction with the skeletal calcium metabolism.
Therapeutic use:
Treatment and prevention of Vitamin D deficiency.
Indications:
Rickets, osteomalacia, hypoparathyroidism.
Special considerations:
Administration orally or intramuscular. Therapeutic effect requires presence of sufficient
calcium serum levels. Monitoring of kidney function and electrolytes is mandatory under
treatment of vitamin D deficiency.
Side effects:
Hypercalcemia
(Constipation, gastrointestinal dysfunction, abdominal pain, hypotonia,
seizures, ataxia, fatigue, somnolence, dysrhytmias and hypercalcuria)
Hypervitaminosis D
(Hypercalcemia, hypercalciuria, tissue calcification, lower level of
consciousness.
Common substances:
Calcifediol (Claderol®), Calcitrol (Calcijex®), Dihydrotachysterol (Hytakerol®),
Ergocalciferol (Calciferol®) and Paricalcitol (Zemplar®).
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Anti-Hypercalcemia medications
Pharmaceutical effect:
Renal excretion of calcium , Decrease of duodenal calcium absorption , decrease of
calcium mobilization from bone , complex building of free calcium ions in peripheric
blood.
Therapeutic effect:
Normalization of calcium levels.
Indications:
Hypercalcemia
Special considerations:
Administration intravenously, intramuscular, subcutaneously or oral.
Intravenous preparations require dilution. Supervision of renal function required.
Sufficient fluid supply under treatment is mandatory.
Contraindications:
Renal impairment and ongoing calcium supply.
Side effects:
Mainly caused by Hypercalcemia, facial flushing, increased effect of cardiac Glycoside
medication, nausea, vomiting, diarrhea. Venous irritation, thrombophlebitis and
nephrotoxicity due to IV administration.
Common substances:
Calcitonine (Miacalcin®) = Inhibition of calcium resorption into bone tissue.
Cinacalcet (Sensipar®) = Increases parathyroid sensitivity to increased extracellular
calcium and to decreased PTH secretion.
Epedate disodium (Disotate®) = Building calcium chelate complexes.
Etidronate (Didronel®), Zoledronic acid (Zometa®) and Pamidronate (Aredia®)
= Inhibiting bone resorption.
Gallium nitrate (Ganite®) = Malignant hypercalcemia.
Plicamycin (Mithramycine®) = Inhibition of malignant bone resorption.
Cushing’s Syndrome
Inadequate secretion of cortisol from adrenal cortex or of Adrenocorticotropic Hormone
(ACTH) from pituitary gland. Also caused by long term cortisol treatment in high dosages.
Symptoms and diagnostic findings:
Abnormal distribution of fat tissue over entire body leads to characteristic appearance
including moon facies, truncal obesity, fat neck, diabetes, edema, weight gain,
thin and sensitive skin with delayed wound healing. Immunodeficiency causes recurrent
infections.
Laboratory findings:
Cortisol , ACTH decreased or increased, depending on course, natrium ,
glucose , 17 – Ketosteroids in Urine
Treatment:
Treatment of underlying adrenal or hypophyseal dysfunction by radiation or surgery.
Physical cushingoid symptoms that are established are not reversible. Clients require
strict injury and infection prevention. Slow steroid dose reduction in cases of cortisol
overdoses.
Addison’s Disease
Mainly caused by a sudden insufficiency of the adrenal cortex due to an autoimmune
disorder with antibody production against the adrenal cortex. Also due to insufficient
production and release of hypophyseal adrenocorticotropic hormone (ACTH). Most
commonly after severe shocks and infections. Also due to a sudden cessation of steroid
treatments.
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Symptoms and diagnostic findings:
Abnormal muscular weakness and fatigue, pigmentation of skin and mucous
membranes, weight loss , dehydration, low blood pressure, abdominal pain,
hyponatremia, hyperkalemia, Cortisol , ACTH (adrenocorticotropic hormone).
Treatment:
Supply of corticosteroids.
Treatment of Gluco – and Mineralocorticoid Metabolism Disorders
Mineralocorticoids
Physiological effect :
Retention of sodium and water. Release of Potassium via kidneys as part of the Reninangiotensin blood pressure regulating system.
Indication:
Replacement therapy in dysfunction of the adrenal glands (Morbus Addison).
Special considerations:
Requires permanent assessment of Serum electrolytes, weight, input and output.
Potassium rich and Sodium poor diet. Trauma, infections and stress require dosage
adjustment.
Side effects:
Delayed wound healing, unusual response to infections, thromboembolism, nausea,
acne and hypokalemia.
Substances:
Fludrocortisone (Florinef®), Hydrocortisone (Cortef®) and Cortisone (Cortone®)
Glucocorticoides
Physiological effects:
Metobolic effect by stimulation of the carbohydrate, protein and fat metabolism.
Anti inflammatory effect, immunosuppressive effect and thrombocytosis.
Indications:
Replacement in cases of disturbed or absent synthesis (i.e. M. Addison).
Inflammatory diseases, allergic diseases, anaemia, thrombocytopenia, dermatological
disorders and autoimmune diseases.
Specific considerations:
Form of administration depends on underlying indication and can be intravenous,
imtramuscular, topical, oral, nasal and optical. Long Term treatment suppresses
negative feedback trigger of own synthesis within the hypothalamic – pituitary – adrenal
system. (HPA). Acute withdrawal after steroid long term treatment is contraindicated and
can cause permanent depression of the entire adrenal cortex. Even in non systemic
treatments. No vaccinations should be performed under treatment and three months
there after. Patients under steroid treatment require thorough assessments even for
common infections like colds. Each Clucocorticoid has a defined borderline dosage
which is supposed to not be overcome in patients with long term steroid treatment. (e.g.
the borderline dosage for Prednisolone is 7.5 mg/d). Every Glucocorticoid (besides
Triamcinolon) has also mineralocorticoid effects and vice-versa.
Side effects:
Cushingoid appearance: moonface, weight gain, hypertension, hyperglycemia,
hypertrigleridemia, striae, change of skin pigmentation, vulnerability against opportunistic
infections, gastroduodenal ulcers and diabetes.
Substances:
(None to little mineralo corticoid action)
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Triamcinolone
(Aristacort®),
Betamethasone
(Celestone®),
Dexamethasone
(Decadron®), Prednisone (Deltasone®), Methylprednisolone (Medrol®), Prednisolone
(Deltasone®), Cortisone (Cortone®) and Hydrocortisone (Cortef®).
Adrenocorticotropic Hormone ACTH
Physiological effect:
Mediator hormone excreted by the pituitary gland. Direct stimulation of adrenal cortex for
production of adrenal steroids.
Indications:
Diagnostic testing for adrenal and pituitary insufficiency. Treatment of steroid sensitive
diseases but much less therapeutic potency than adrenal glucocorticoids.
Specific considerations:
Administration intravenously, intramuscular, subcutaneously or oral.
Contraindications: (comparable to Glucocorticoids)
Opportunistic infections, systemic infections and recent surgery.
Substances:
Corticotropin (Acthar®), Cosyntropin (Cortrosyn®), Metyrapone (Metopirone®)
Diabetes mellitus
Caused by an insufficient function or total inability of the pancreatic gland to produce and
release insuline.
Diabetes Type 1
Starts from birth or until the age of 40 with a sudden or slowly developing total loss of
pancreatic insulin production. Mainly caused by an autoimmune destruction of the
pancreatic beta cells which can be induced by previous unspecific viral infections.
Diabetes Type 2
Characterized as a slowly developing insulin resistence which leads to a
hyperinsulinemia first and later to an exhaustion of the pancreatic insulin production.
Intermediate stages are considered as decreased glucose tolerance.
This type of diabetes strongly correlates with obesity and can occur from adolescence
but mainly after the age of 40.
Symptoms and diagnostic findings:
Early stages:
Abnormal weakness and fatigue, polydipsia, polyuria, ketonuria, polyphagia
Fluid and electrolyte dysbalance, Diabetic Ketoacidosis (DKA).
Advanced stages:
Immunodeficiency,
recurrent
infections,
delayed
wound
healing,
diabetic
macroangiopathy (coronary artery disease and peripheral arterial disease), diabetic
microangiopathy (Diabetic foot syndrome and diabetic retinopathy), diabetic nephropathy
(Microalbuminuria) and diabetic neuropathy (Paresthesia).
Life threatening diabetes related conditions
•
Diabetic ketoacidosis
•
Hyperglycemic hyperosmolar nonketotic syndrome
Laboratory findings:
Hyperglycemia (Fasting blood sugar), > 126 mg/dl (= 7.0 mmol/l)
Diabetes
100 – 125 mg/dl (= 5,6 – 6,9 mmol/l)
Impaired fasting glucose IFG
< 100 mg/dl (5,6 mmol/l)
normal fasting glucose
Glucosuria
appears from blood glucose of > 180 mg/dl blood glucose levels!
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Treatment:
Prior to any medical treatment a successful diabetes therapy requires a strong
motivation of the client to learn self administration of insulin and blood glucose
monitoring as well as compliance to follow dietary guidelines and to attend regular check
ups to prevent or control late developing diabetes symptoms. Clients with an insuline
therapy require further teaching about appropriate.
Physical exercise
endurance activities
Foot care
daily inspection of soles, avoid walking barefoot and wear appropriate
Footwear.
Emergency treatment of hypoglycemia 15 g Carbohydrate snack or Glucagon injection.
Weight management
General diet recommendations as for general public.
Diabetes mellitus medication therapy
Insulin
Pharmocological effects:
Correction of blood glucose levels due to enhanced uptake in skeletal muscles and liver.
Support of the lipid synthesis and inhibition of the Glucagon secretion.
Therapeutic effect:
Maintaining normal blood glucose levels.
Indications:
Diabetes Type 1 + 2
Special considerations:
Parenteral injection only via syringes, pumps and pen injectors. Mainly subcutaneous
injection to abdomen, thighs, arms. Injection sites need to alter regularly.
Only regular insulin can be administered intravenously!
Suspension free Insulins are regular and Lispro.
All others require to be dispersed prior injection. Not all insulins are compatible with each
other. Unopened vials have to be stored in refrigerator. Vials in use can be stored at
room temperature for up to one month.
Insuline therapy schemes:
1.Conventional therapy:
Injections of short acting and intermediate acting insulin as a combination twice daily at
defined times.
2.Intensified therapy:
Long acting insuline in the mornings and evenings in combination with short acting
insuline prior to each meal.
Use of Beta adrenergic Blockers can disguise hypoglycemic symptoms.
Effectfulness of treatment requires frequent daily glucose monitoring as follow:
•
•
For conventional therapies fasting and prior to bedtime.
For intensified therapies fasting, prior each meal and at bedtime.
Also whenever client experiences any physical discomfort.
Assessment of glycosylated hemoglobin A1c allows judgement about adequate long term
results. This assessment is most conclusive if it is performed every 3 months since
renewal of RBC’s occurs within this time frame (+/- 120 days). Repeated assessments
within 6 weeks provide no additional information. Required insulin dosage increases
over time due to development of insuline tolerance. Clients with infections, fever
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especially gastrointestinal disturbances require dosage adjustments since hypo – and
hyperglycemia can occur.
Clients who are undergoing general surgery require temporary adjustments to regular
insulin only. Any antidiabetic therapy but especially insulin therapy requires thorough
and detailed patient education. Brand and type of insulin can not be changed without
notification of client and prescriber. Vials for insulin pens contain a higher concentrated
insulin than vials to be used for syringes and can not be exchanged.
Pregnant and lactating clients with a diabetes that can not be maintained by dieting
receive treatment with regular insulin only. Other insulin types and oral antidiabetic
medication types are contraindicated in pregnancy and lactation.
Side effects:
Hypoglycemia ( = Blood Glucose < 50 mg/dL / 2,8 mmol/l )
cold sweats, palpitations, hunger, reduced level of consciousness, headaches,
muscle weakness, seizure and coma.
Allergic reactions
Lipodystrophia
degeneration of subcutaneous fat tissue after repeated insulin injections leads to a
disturbed absorption. Weight gain due to the anabolic effect of insulin.
Common Substances:
Rapid acting insulin:
Onset within 5 minutes, peak after 30–60 minutes, duration 2–4 hours.
Types: Insulin lispro (Humalog®), Glulisine (Apidra®) modified human type.
Fast acting insulin:
Onset within 30 minutes, peak after 1–3 hours, duration 3–5 hours.
Types: Aspart (Novolog®) modified human type.
Regular insulin:
Onset within 30–60 minutes, peak after 2–4 hours, duration 5–7 hours.
Types: Regular Insulin, (Humulin R®, Novolin R® , Velosulin BR® , human type, beef,
pork insulin.
Intermediate insulin:
Onset within 1–2 hours, peak after 6–12 hours, duration 18–24 hours.
Types: NPH®, Humulin®, Novolin®, Human type, beef and pork insulin.
Long acting insulin:
Onset within 4 – 6 hours, peak after 16 – 18 hours, duration 20 - 36 hours
Types: Lantus®, Humulin U®, Ultralente®, Novolin L®, Human type insulin.
x
Oral antidiabetic medication
Sulfonylureas and Meglitinides
Pharmacological effect:
Stimulation of pancreatic beta cells for release of insulin.
Therapeutic effect:
Supplementation of reduced insulin production for maintenance of blood glucose levels.
Indications:
Diabetes mellitus type II
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Special considerations:
Treatment is indicated when diabetes management with diets and exercise alone is not
sufficient. Treatment with beta-adrenergic receptor blockers can weaken insulin release
from pancreatic cells and the effect of sulfonylurea medication. Alcohol intolerance under
treatment is likely to happen. Alcohol increases risk for hypoglycemia. Metabolites of
sulfonylurea medication also have hypoglycemic effect and may lead to a delayed
hypoglycemic reaction up to 6-12 hours after administration if no sufficient amounts of
carbohydrates were consumed. Medication has to be taken 15 – 30 minutes before
meals. Available substances have equal potency.
Substances:
Gibencamide (Euglucon®), Glipizide (Glucotrol®), Glyburide (Diabeta®), Glimepiride
(Amaryl®),Tolbutamide (Orinase®)
Metiglinides
Differ to sulfonylureas in rapid onset and short duration of effect. Therefore they are
better tolerable and less likely to cause side effects.
Side effects:
Hypoglycemia, allergies (Skin reactions), gastrointestinal disturbances and weight gain!
Contraindications:
Pregnancy and lactation, severe hepatic and renal dysfunction.
Substances:
Nateglinide (Starlix®) and Repaglinide (Prandin®)
Nunsulfonylurea oral antidiabetics
Alpha-glucosidase inhibitors
Delay absorption of carbohydrates from intestinal tract.
Biguanide medications
Reduce glucose production from glycogen storages in liver and skeletal muscles by
enhancing the anaerobic glycolysis. Does not cause weight gain and is primarily
indicated in obese clients.
Glitazones / “Insulinsensitizer”
(Thiazolidinediones) reduce peripheric insulin resistance and gluconeogesis in liver.
Treatment in combination with biguanides or sulphonylureas.
Special considerations:
Medication therapy is generally indicated when diabetes management with diets and
exercise alone is not sufficient. Medication has to be administered with meals.
Alpha-glucose inhibitors:
Used for monotherapy and in combination with insulin or sulfonylureas.
Biguanides:
Used for monotherapy and in combination with sulfonylureas. Alcohol increases risk of
hypoglycemia and lactic acidosis.
x
Thiazolidinderivates:
Only for therapy in combination with sulfonylureas or biguanides if they can not be
combined with each other. Treatment requires strict surveillance of liver function.
Side effects:
Alpha-Glucosidase Inhibitors:
Abdominal cramps, flatulence, diarrhea, decreased absorption of iron
Anemia
Biguanides:
Decreased appettite, nausea, diarrhea, hypoglycemia and lactic acidosis.
Thiazolidinderivates: Liver damage
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Contraindications:
All substances: Pregnancy and lactation.
Biguanides:
Cardiorespiratory diseases, clients > 65 years, renal insufficiency and cachexia.
Thiazolidinderivates:
Liver diseases, insuline therapy.
Substances:
Alpha glucosidase inhibitors: Acarbose (Precose®) and Miglitol (Glyset®)
Biguanide: Metformin (Glucophage®)
Thiazolinediones: Pioglitazone (Actos®) and Rosiglitazone (Avandia®)
Bromocriptine (Cycloset®)
Dopamine agonist medication.
Also used for treatment of Parkinson’s Disease.
Stimulates production of Dopamin in the CNS.
The substance is indicated in Diabetes Type II only and has to be taken orally in the
morning with food. Either as a monotherapy or in combination with Sufonylurea and / or
Metformin.
Gliptines
Sitagliptin (Januvia®), Vildagliptin (Galvus®)
Ora antidiabetics for treatment of Diabetes type II which do not cause hypoglycemia,
weight changes or any significant side effects.
Can be used as a monotherapy or in combination with Metformin, Thiazoline (“Insuine
sensitizer”) Sufonylurea medication and insuline.
Injectable non – insuline antidiabetics
Liraglutide (Victoza®), Exenatide (Byetta®)
Injectable GLP 1 - receptor agonists.
Increases insulin production of the pancreatic gland in clients with Diabetes Type 2.
Used as first line therapy after failure of treatment with diet, exercise and weight loss.
Substance has to be injected subcutaneously once daily (Liraglutide) or twice daily
(Exenatide).
Anti Hypoglycemic Medication
Glucagon
Pharmacological effect:
Promotes glucose synthesis by stimulating the breakdown of glycogen.
Therapeutic effect:
Correction of hypoglycemia.
Indication:
Emergency treatment for hypoglycemia in an unconscious client or lack of dextrose,
glucose supply.
Special considerations:
Administration via IM, IV or subcutaneous injection. Effect expected within 5–20 minutes.
Glucose/dextrose infusion has to be added under consideration of effect and
measurable levels of blood glucose. Glucagon effect requires efficient glycogen storage.
Every client under treatment with insulin or oral antidiabetics has to be instructed about
symptoms of hypoglycemia and advised to carry oral dextrose and a glucagon kit at any
time.
Side effects:
Nausea, vomiting, hyperglycemia and hypokalemia.
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MUSCULOSKELETAL DISORDERS AND DISEASES
Osteoporosis
Osteoporosis is the most common bone disease among the elderly. Most common
cause in > 90% of all cases is a postmenopausal osteoporosis in women. In rare cases
osteoporosis may be induced by a longer lasting immobility or steroid treatment.
Dietary deficits of calcium, smoking, lack of physical activity and anorexia also apply.
Symptoms and diagnostic findings:
Osteoporosis remains asymptomatic until the sudden occurrence of a spontaneous
fracture due to an inadequate trauma, unspecific skeletal pain or reduction of body
height. Most common osteoporosis induced fractures are related to spine, femur and
radial bones. Preventive BMD (bone density measurements) may diagnose osteoporosis
prior to the appearance of pathological fractures or other symptoms.
Laboratory findings:
Indicators of increased bone resorption: Serum alcalic phosphatase (AP) , calcium and
phosphate levels are mostly in normal ranges.
Treatment:
Preventive treatment includes:
Dietary daily intake of 1200mg Calcium/daily in combination with Vitamin D. Regular
physical exercise and estrogene replacement therapy in postmenopausal women.
Paget’s disease
Second most common skeletal disease beside osteoporosis. Starts with a rapidly
developing bone resorption of single bones and a hypertrophic and deforming formation
of weak bone tissue.
Symptoms and diagnostic findings:
Diagnosis is made via x-ray. Symptoms include: Slowly increasing pain in single bones
followed by a deforming bone growth. Pathological fractures due to weak new bone
tissue. Arthritis, headaches and hearing loss.
Laboratory findings:
Increased alkaline phosphatase.
Treatment:
Medication therapy includes biphosphonates and calcitonin.
Osteomyelitis
Bacterial infection of the bone marrow. May be caused by a direct bacterial
contamination in an open fracture or a surgical intervention. Other causes include a
hematogenic infection from other infected tissues via the blood stream. Most common
causative germ is staphylococcus areus.
Symptoms and diagnostic findings:
Acute, mostly feverish infection accompanied by a severe circumscripted pain of the
infected area. Warmth, swelling and redness of surrounding soft tissues.
Symptoms and diagnostic findings:
ESR , Leucocytosis, CRP,
, Imaging diagnostics via X-ray, MRI or CT scan reveals
location and extent of inflammatory affection of infected bones.
Treatment:
Immediate high dose antibiotic treatment required. Substances with an improved
resorption by bone tissues are makrolides, aminoglycosides, cephalosprines and
flourchinolones. In cases of hematogenic osteomyelitis the choice of antibiotics depends
on the character of the primary infections. Osteomyelitis caused by direct contamination
mostly requires surgical therapy for wound debridement and local antibiotic treatment.
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Osteoarthritis
Mostly age related degenerative joint disease. Early onset may be caused by previous
joint injuries or after fractures which have healed in an anatomically deviated position.
Condition causes painful progressing degeneration of joint cartilage with loss of function
and deformation of the surrounding bone tissue. Every joint is affected over a life time
but does not necessarily become symptomatic. Less common types of osteoarthritis are
specifically effecting the distal interphalangeal finger joints (Heberden’s nodes) or the
proximal interphalangeal joints (Bouchard’s nodes).
Symptoms and diagnostic findings:
Osteoarthritis pain in early stages typically appears as a walking through pain which
starts after a resting period and gradually improves the more ROM has been performed.
In later stages this condition causes ongoing pain and limits function of affected joints.
Specific laboratory findings are not existing. Diagnosis is made via x-rays.
Treatment:
Treatment is oriented on symptomatic pain relief along with physical therapy to maintain
a functional ROM of the affected joints. Medication therapy used are non-steroidal anti
inflammatories and analgetics (e.g. acetaminophen). Intraarticular steroid injections are
performed in acute inflammatory exacerbations. In advanced stages joint replacement
surgery may be considered. Clients need to be encouraged for regular physical activity
and weight management.
Medication therapy for Osteoporosis and Paget’s disease
Pharmacological effect:
Reduction of skeletal calcium release by slowing bone resorption and remodelling
process down.
Therapeutic effect:
Reduction of bone destruction. Prevention of Hypercalcemia
Indications:
Osteoporosis (disturbed bone metalbolism), Paget’s Disease (idiopathic bone
destruction)
Special considerations:
Administration intravenously, intramuscular, subcutaneously, orally and intranasal.
Interaction with calcium, vitamin D, antacids, assessments of 24 hour urinary
hydroxyproline provides information on activity and speed of bone resorption. As well as
bone mineral density BMD in hip , vertebrae and forearm. Reassure sufficient calcium
and vitamin D supply.
Side effects:
Nausea and vomiting, diarrhea, dyspepsia, gastrointestinal ulcerations, gastritis,
esophagitis, facial flushing due to shifting serum calcium and muscle spasms. Dry
mucous membranes. Venous irritation, thrombophlebitis, nephrotoxicity due to IV
administration. Hypocalcemia and hypercalcemia (temporary).
Common substances:
Calcitonin (human or salmon i. e. Cibacalcin), Etidronate (Didronel) and Pamidronate
(Fosamax).
Gout
Caused by significantly increased uric acid blood levels. Most commonly caused by an
excessive intake of purine containing food along with a deficient renal elimination. Rare
causes are metabolic disorders with a reduced activity of the enzyme hypoxanthin –
guanin - phosphoribosyltransferase. (Lesch – Nyhan Syndrome, Kelley – Seegmiller
Syndrome). Triggers for acute flares of gout disease are sudden alterations of uric acid
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levels which can be caused by weight loss, fluid deficiency, renal insufficiency, alcohol
intake or excessive consumption of purine rich food (meat and fish).
Symptoms and diagnostic findings:
Kidney Stones (Nephrolithiasis)
Gout arthritis (Arthritis urica) mostly affecting single joints (Gonagra, Podagra)
“Gout tophi” (Deforming joint crystallizations of uric acid and visible x-rays)
Acute flares appear with significant elevations of WBC’s and ESR.
Treatment:
Medication therapy in acute stades is performed with non steroidal anti-inflammatories.
Preventive antihyperuricemic treatment is performed with allopurinol and includes
appropriate daily fluid intake, diet changes and a reduction of alcohol consume.
B
Perthe’s Disease
Perthes Disease describes an acute aseptic necrosis of the femoral head which affects
children between 2 and 7 years of age only. 90% of all cases occur unilateral. The cause
is unknown. This condition is generally self limiting and heals within 2–4 years if
appropriate treatment takes place. The course of Perthes disease includes 4 stages:
I: Avascular stage
II: Revascularization stage
III: Reparative stage
IV: Regeneration stage
Symptoms and diagnostic findings:
Acute aggravating hip pain of moderate to intense severity under physical activity.
Limited range of movement in affected hip joint, weakness of gluteal muscles evident by
a positive Trendelenburg sign. Diagnosis is made via X-ray which show a progressing
destruction of the femoral head.
Treatment:
Depending on the stade of an aseptic necrosis of the femoral head treatment is mainly
conservative and includes strict avoidance or limitation of weight bearing while
maintaining an adequate range of movement. Tutors, cast and other orthopedic devices
may be necessary to avoid a luxation of the femoral head since an anatomical correct
regeneration of the femoral head can only take place if the hip joint remains intact. A
surgical treatment option is a rotating osteotomy of either the femoral bone or the
acetabulum to ensure that the femoral head is covered by the acetabulum.
Dislocation of the femoral epiphysis
This condition typically occurs prior to epiphyseal closure of the longitudinal bones
during puberty. During a usually slow developing process the proximal eiphyseal plate of
the femoral head slips off the distal epiphyseal plate. A definite cause is unknown.
Clients prone to a femoral epiphysis dislocation are usually either fast growing or show
tendencies of obesity.
Symptoms and diagnostic findings:
Acute or gradual onset of hip pain at rest and while weight bearing, along with a
developing limited range of motion. Diagnosis is made by X-ray.
Treatment:
Surgical treatment is mandatory. Clients require strict preoperative immobilization to
avoid further damage to the epiphyseal gap which may result in a growth inhibition of the
affected limb. Surgical treatment is aimed to reposition and fixate the slipped epiphyseal
plate. Sporting activities which include a stop and go mechanism or contact sports have
to be avoided until the skeletal growth is completed.
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Scoliosis
Lateral deviation of the spine from its longitudinal axis.
Primary cause is an idiopathic structural growth disturbance of the spine of unknown
cause which mainly starts from childhood. Secondary scoliosis due to a musculoskeletal,
neurological disease or osteomyelitis of the spine is comparably rare.
Symptoms and diagnostic findings:
A spine deformation becomes obvious during its development and is mostly not
associated with pain from the beginning. Low grade scoliosis may be overlooked but are
subject to the well child and school examinations. Points of orientation are equal heights
of shoulders and both sides of the pelvic bone. Depending on the actual severity of the
deformation internal organs may be compromised which can result in additional
symptoms such as respiratory or digestive problems. Scoliosis also leads to an
imbalance of the entire musculoskeletal system which may include dysfunction of limbs
as well as an early developing osteoarthritis.
Treatment:
Treatment options are conservative or surgical depending on the actual angle of
deviation. As a common rule, a scoliosis with less than 40 degrees of deviation can be
treated with conservative methods which includes an intensified physical therapy to
strengthen the spine and to stabilize the paravertebral muscles. Supporting braces my
be used for cases of advanced scoliosis or after surgical intervention took place.
Rheumatoid Arthritis RA
Autoimmune disease with destructing effect to the cartilage and connective tissues of
the musculoskeletal system. Inflammatory flares are triggered by environmental factors
in clients with genetic predispositions. The course of the disease typically shows variable
stades with exacerbations and remissions.
Symptoms and diagnostic findings:
Clinical manifestions mostly occur in middle aged clients but condition can be present at
any age. Onset with acute flares of symmetrical inflammation of small joints, preferrably
on hands and feet (PIP and DIP). Main clinical symptoms are swelling, effusions,
stiffness, pain and loss of function of the affected joints. Uncontrolled flares lead to joint
destructions.
Symptoms and diagnostic findings:
ESR , WBC , CRP , rheumatoid factor positive (in majority of cases), anemia and
deformations on hands and feet.
Treatment:
Multimodal anti-inflammatory medication therapy.
Musculoskeletal Medication Therapy
Non-Ateroidal Anti-Inflammatory Drugs (NSAID’s)
Indicated in early stages of rheumatid arthritis.
See discussion under musculoskeletal system.
Disease Modifying Antirheumatic Drugs (DMARD’s):
Auranofin (Ridaura®) + Aurothiglucose (Solganal®)
Reduction of rheumatoid factor and immunoglobulins to suppress arthritic symptoms.
Side effect: Nephrotoxicity
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Gold Sodium Thiomalate (Myochrisine®)
Inhibition of inflammatory prostaglandin effect.
Side effect: Nephrotoxicity
Etanercept (Enbrel®)
Tumor necrosis factor from chinese hamsters which causes inhibition of lymphocytic
inflammatory reaction.
Side effect: Infections due to induced immunodeficiency
Hylan G-F 20 (Synvisc®)
Preparation of hyaluronic acid from chickens which is injected in affected joints to
provide lubrification.
Side effect: Allergy
Methotrexate (Amethopterin®)
Inhibition of DNA synthesis, causing interruption of proliferation of inflammatory tissue.
Side effects: bone marrow suppression, pulmonary fibrosis, gastrointestinal ulcerations.
D-Penicillinamine (Depen®)
Reduction of IgM - Rheumatoid factor. Side effect: skin reaction and rash.
Sodium hyaluronate (Hyalgan®)
Supposed to provide improved lubrification of joints and support repair of joint cartilage
tissue. IV only as infusion no push. Monitoring of inflammation parameters as well as
kidney and liver function required. May or may not be taken with meals but always with
sufficient amounts of fluids.
Non – opioid pain management in musculoskeletal disorders
Prostaglandin sysnthesis inhibitors - Nonsteroidal Anti – Inflammatory Agents
Pharmaceutical effect:
Inhibition of cyclooxygenase, the key enzyme for the synthesis of the inflammation and
pain mediator prostaglandin.
Physiological effect:
pain relief, anti inflammatory effect, inhibition of platelet aggregation, antipyretic effect
Indications:
Treatment of musculoskeletal pain and dysmenorrhea.
Side effects:
Gastric irritation, prolonged bleeding, tinnitus, hepatotoxicity, allergies, bronchospasms.
Contraindications:
Children, due to danger of Reye Syndrome, (Encephalopathy and fatty liver
degeneration) asthma, peptic ulcer disease, history of gastrointestinal bleedings,
anticoagulant therapy, hepatic diseases, kidney disease.
Treatment should be pursued for up to one month at a time or as required!
Substances:
Celecoxib (Celebrex®), Diclofenac (Voltaren®), Ibuprofen (Advil®), Indomethacin
(Indocin®), Ketoprofen (Actron®), Naproxen (Naprosyn®), Piroxicam (Feldene®)
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DERMATOLOGICAL DISORDERS AND DISEASES
Eczema (Atopic Dermatitis)
Circumscripted superficial inflammation of the skin, typically related to a wide range of
allergic reactions against food, pollen or other unindentified allergic agents. Inherited
sensitivity mostly occurring from childhood ages. x
Symptoms and diagnostic findings:
Suddenly developing superficial and itching inflammation of the skin. Mostly dry and
scaly and predominantly distributed by a certain pattern over stretch or flexing sides of
the limbs.
Treatments:
Main treatment is the elimination of the causative agent to avoid an increase and
recurrence of eczemas. Mostly the causative agent is unknown and can not be revealed
in an allergic test. Possible causes may be identified by stepwise elimination of any
external agents other than soap and water. Possible underlying food allergies may be
identified by an elimination diet. Acute medication therapy in acute cases is performed
with topical steroid crème such as hydrocortisone 1%. Antihistamines are used to
control itching.
Contact Dermatitis
Acute or delayed skin reaction due to an individually specific irritating substance or
allergen. An allergic reaction can also be mediated by presence IgE alone while the
epidermal reaction is caused by T–lymphocytes! Reaction may appear acute or
chronically.
Symptoms and diagnostic findings:
Expression varies from acute erythema to an eczema like and thickening skin reaction in
direct range to the point of contact of the causative agent.
Treatment:
Main treatment is the identification and elimination of the causative agent, if possible.
Skin reactions will be treated with topical steroid cremes. Smoothing external agents or
systemic antipruritic medication may be used for itch relief.
Urticaria
Acute maculo–papulous skin transformation due to an unspecific allergic reaction or
triggered by cold or hot temperature followed by an IgE mediated histamine release from
mast cells.
Symptoms and diagnostic findings:
Raised, blanched exanthema surrounded by a red margin. Severe pruritus. May affect
any area of the body. Allergic urticaria mostly appears generalized.
Treatment:
Medication therapy for severe allergic urticaria includes Antihistamines + corticosteroids,
+ epinephrine 1:1000 s. c. Any observed allergic urticaria requires an acute intervention
to prevent a possible ongoing life threatening anaphylactic reactions, although an
allergic urticaria may also be self limiting without any medical intervention. Treatment of
other forms of urticaria depends on their underlying causes.
Psoriasis
Chronically recurrent eczematous skin disease which is suspected to be caused by an
autoimmune disorder, mediated by T–Lymphocytes.
Symptoms and diagnostic findings:
Psoriasis appears with a characteristic dry rash of white –grey scales which are typically
located over knee caps, elbows, scalp, palms and soles. Nails typically develop white
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circumscripted dots. Psoriasis may also cause arthritis.
Treatment:
Medication therapy is mainly based on topical steroids in combination with systemic
antihistamines. Long term treatment also includes frequent exposure to ultraviolet light
under simultaneous use of psoralene containing medication to increase the light
sensitivity of the skin (PUVA Therapy).
Seborrhoic Dermatitis
Circumscripted erythematous scaling inflammation of the skin. Acute flares mainly occur
in a climate with low humidity and a lack of sunlight. The definite cause is unknown.
Symptoms and diagnostic findings:
Circumscripted, red (erythematic), scaly skin lesions, spreading all over the body areas
which are rich of sebaceous glands: scalp, eyebrows, neck, axils, back, glutaeal and
genital region, palms and soles.
Treatment:
Medication therapy consists of coal tar, steroids and selenium sulfide for local use only.
Bacterial skin infections
Acne
Chronic recurrent inflammation of the sebaceous glands that are surrounding the hair
follicles, commonly accompanied by a bacterial super infection with proprionibacterium
acne. Course is triggered by multiple factors, such as androgen stimulation, skin type
and amount of sebaceous production. Main common occurrence can be observed in
male puberty.
Symptoms and diagnostic findings:
Lesions occur accordingly to the natural distribution of the sebaceous glands over
forehead, cheeks, nose, neck, back and chest. Acne lesions follow through the following
stages: Closed comedones
open comedines
papules
pustules.
Acne may heal in severe cases with extensive scarring but not necessarily.
Treatment:
Clients are supposed to avoid any manual destruction of lesions which could cause
unnecessary scaring and to avoid any cosmetics on affected skin.
Medication therapy includes:
Topical scaling agents
topical retinoids, benzoyl peroxide, topical antibiotics and
azelaic acid.
Systemic medication therapy in severe cases
Oral tetracycline based antibiotics,
isotretinoin 0,5–1,0 mg / kg daily.
Acne caused by a hormonal overproduction of sebrum
Cyproteroneacetate and
estrogene supply.
Impetigo
Contagious bacterial skin infection with Staphylococus areus or beta hemolytic group A
streptococcus. Infection occurs mainly in children through a minor injury of the skin.
Symptoms and diagnostic findings:
Mostly multiple erythemic vesicles which are spreading around a skin lesion and become
crusted in later stages. Fever and chills are possible.
Treatment:
Antibiotic treatment is required. Preventive treatment requires proper hygiene.
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Folliculitis
Bacterial infection of a hair follicle with staphylococcus areus or pseudomonas
aeruginosa. Contributing factors are sweating, shaving and generally hairy skin. As in an
Impetigo fever and chills can occur.
Symptoms and diagnostic findings:
A single follicle appears as an erythematic, very tender swelling surround a body hair.
Predominant areas of infection are rich on sebacceous glands. Inflammation may
progress into the following stages:
x
Furuncle (pus producing single inflammation of a hair follicle)
Furunculosis (multiple furuncles in different areas of the skin)
Carbuncle (multiple carbuncles confluating into one)
Treatment:
A general treatment in all forms of hair follicle infections is to apply moist heat to ease
the swelling and pain. A systemic rather than local antibiotic treatment may be
prescribed if pus production takes place in advanced stages. Because of the increasing
pain furuncles and carbuncles may require incision and drainage to depressurize and
eliminate pus. Spontaneous eruptions may occur as well.
Cellulitis: (Erysipel)
Bacterial infection of the subcutaneous tissue spreading along the lymphatic system.
Most common cause is the invasion of Streptococcus pyogenes and Staphylococcus
aureus mainly via a minor laceration of the skin. Commonly affected areas are the
pretibial areas of the legs.
Symptoms and diagnostic findings:
Acute circumscripted and tender red discoloration of the skin. Fever, chills, malaise and
body achiness may occur in severe cases. A regional tender lymphadenopathy is
common.
Treatment:
Cellulitis requires an antibiotic therapy with penicillin. Hospitalization is required if client
is endangered by a septic course of this infection which becomes more likely if the
infection involves a central location in the head or neck area or another comparably
large area. Supportive measures are the application of moist heat, elevation of the
affected body part and analgetic treatment.
Viral skin infections
Herpes simplex virus infection (HSV)
Target tissue of herpes simplex virus type I is the oral mucosa while herpes simplex type
II is targeting the genital mucosa. Infection occurs via droplets of contaminated body
fluids on the intact skin. In otherwise healthy individuals an acute flare is mostly self
limiting but the infection typically takes a chronic recurrent course in all cases. An intact
immune system avoids active flares by inhibiting the replication and keeping the virus in
a dormant stade. New flares occur in presence of other light or severe health problems
which are stimulating the immune system (e.g. common colds and gastroenteritis). HSV
viruses remain in the body for life. Contagiosity of infected individuals is likely in acute
flares.
Symptoms and diagnostic findings:
After an incubation period of an average of two weeks the outbreak occurs as a tender
blister of the affected mucosa. Fever and chills may occur as well.
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Treatment:
Rest, fluids, pain and fever relief. Prevention of spreading is accomplished by avoiding
close physical contact and/or use of condoms. Acute flares can be limited in their
duration and severity by medication therapy with anti retroviral agents such as aciclovir,
famciclovir and others if started within 48 hours after onset of symptoms.
Herpes zoster
Reactivation of a previous varicella zoster infection appears as a cutaneous infection
which is affecting motoric nerves. Seniors or immuno compromised individuals are at
high risk. Affections of cranial nerves can endanger the eyesight.
Symptoms and diagnostic findings:
Circumscripted papulo – vesicular rash, accompanied by strong pain and itching of the
affected area. Overall signs of infection like fever and malaise may be present.
Treatment:
Treatment is directed to dry the skin lesions with superficially active substances. (e. g.
Burrow’s solution). Pain and fever relief may be required. Clients have to be separated
from individuals at risk, especially pregnant women, children and adults without immunity
against varicella virus infection. Antiretroviral medication needs to be prescribed within
the first 48 hours to limit the severity and duration of the infection. Contagiosity is current
until the skin rash has completely healed. Complications may arise from a bacterial
superinfection and from a neuropathy which may turn into a chronical condition as a so
called “Zoster neuralgia”. Zoster infections in otherwise healthy individuals should lead to
further investigations of possible underlying causes for an immunodeficiency.
Warts
Warts are typically caused by a cutaneous infection with human papilloma virus. (HPV)
Infected areas are typically palms and soles, especially in children.
Symptoms and diagnostic findings:
Warts do not necessarily become symptomatic and appear as flesh colored hard
nodules of different forms and sizes.
Classical appearances are:
•
Plantar wart
•
Filiform wart
•
Flat wart
•
Common wart
Treatment:
Treatment is required if wart produces symptoms like pain or aesthetical problems.
Treatment options are electrotherapy, cryotherapy and surgical removal as well as
external treatment with concentrated acetylic salicylic acid.
Fungal skin infections
Fungal infections mostly occur on grounds of an altered skin as well as due to
immunodeficiency syndromes. Common supporting causes are moist, warm skin areas,
antibiotic treatments, immunodeficiency in pregnancy, diabetes, steroid treatments or
consuming diseases. Main fungal infections of clinical relevance are caused by
Candidiasis vulgaris and Tinea corporis.
Candidiasis
Symptoms and diagnostic findings:
Areas of infected skin appear tender, bright red, macerated and scaling. Common
manifestations of cutaneous candidiasis are:
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Diaper rash, Balanitis, Paronychial infections, Otitis externa and Scalp infections.
Mucosal candidiasis appears typically as
Vulvovaginitis and oral candidiasis.
Diagnosis is made from a scaling sample or smear.
Tinea corporis (“Ringworms”)
Lesions of a ring – like form in with an elevated border and typically spreading all over
the body but spare palms and soles. Infection is caused by a number of different fungal
species and can be transmitted from animals and soil. Diagnosis is made from a scaling
sample or smear which requires preparation in a potassium hydrochloride for
microscopic examination.
Tinea pedis (“Athlete’s foot”)
Erythematic, scaly lesions of soles caused by dermatophytes which target the epithelial
keratin containing layer of the skin.
Treatment:
Overall recommendation is to keep affected skin dry and to change underwear and linen
daily to avoid reinfection.
Medication therapy:
Candida infections: Nystatin
Tinea corporis: Ketoconazole
Tinea pedis: Nystatin, Ketoconazole for topical treatment,
Griseofulvin, Fluconazole and Terbinafine for systemic oral treatment.
Parasitic skin infections
Pediculosis = Lice
Head lice: Common among school age children and not depending on social
Background. In severe cases eye lashes are affected as well.
Pubic lice: Sexually transmitted affection of the pubic hair.
Lice reproduce by laying eggs (nits).
Symptoms and diagnostic findings:
Main symptom is an ongoing and severe itching of the affected area.
Diagnosis is obvious if either lice or white sesame corn size nits can be observed. Nits
are typically attached to the hair roots.
Treatment:
Medication therapy used for Pediculosis capitis and pubis:
Permethrine, Lindan shampoo for head lice.
(Lindan can only be used once a week. Neurotoxicity!)
External medication therapy requires an intact and uninflamed scalp!
Preventive measure include washing clothes and linen of all family members of an
affected individual.
Scabies
Infestation of the skin by scabies mites. Occurrence is increased in individuals who
maintain a poor physical hygiene or do not have access to bathing facilities.
Symptoms and diagnostic findings:
Severe rash and pruritus. Infestation may spread over hands, wrists, elbows, axils,
breasts, abdomen and genitals. Characteristic thread - like red lesions from ridges
made by mites.
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Treatment:
Prevention of spreading and reinfection by washing and hot drying of all clothes, towels
and linen or by separation of clothes from host in an airtight bag for seven days.
Medication therapy: Permethrin or Crotamiton cream (two treatments/48 hours from
head to toe.) Lindan 1% cream (One treatment / weekly. Not for children or nursing and
childbearing women).
Vitiligo
Acquired circumscripted white macules of different shapes and sizes due to a lack of
melanocytes.
Symptoms and diagnostic findings:
Non - dermatomal and dermatomal form. Itching and increased UV sensitivity of the pale
areas.
Treatment:
Not available. Progression may be stopped by oral steroid treatment. Depigmentation of
normal skin for cosmetic reasons may be achieved by use of hydroquinone cream. In
general strict protection from sunburns is required.
Pressure ulcers (Bedsores and Decubitus ulcers)
Ongoing inhibition of blood and lymphatic circulation in skin areas due to external
pressure results in an ischemic ulcerous destruction of the skin and the subcutaneous,
connective and muscular tissue. Pressure ulcers are a common problem for clients
suffering from immobility and typically develop over prominent bone structures with little
covering subcutaneous tissue such as elbows, spine, pelvic bone and heels. Supporting
factors for the development of pressure ulcers are malnutrition, anorexia, low body
weight, incontinence, dry or edematous skin, Vitamin C deficiency and long term steroid
treatments.
Symptoms and characteristic findings:
Classification of pressure ulcers
Stage 1: Erythematous, warm and tender
Stage 2: Loss of epidermis, excoriation, erythema and swelling.
Stage 3: Subcutaneous ulcer
Stage 4: Ulceration beyond deep fascia
decayed wound
Laboratory findings: WBC , ESR , Albumine
Treatment:
Frequent pressure relief by repositioning client every two hours. Active and passive
ROM exercises to increase circulation and muscular tonus. Supply of high protein diet,
Vitamin A, C and Zinc to improve collagen sythesis. Frequent wound care including
change of dressing, drainage of secretions and surgical removal of necrotizing tissue.
Incontinence control. Wound assessment, classification and documentation every 12
hours.
Wound care:
Granulomatous and necrotizing wounds requiring topical enzymatic debriding with
collagenase, fibrinolysin – desoxyribonuklease or papaine. Secreting wounds require
absorbent hydrocolloid dressings and moisture barriers. Antibiotic wound treatment:
General antibiotic treatment options for Osteomyelitis are Clindamycin and Gentamycin.
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Burns
Burns are considered as a destruction of tissues due to:
•
Heat (open fires or contact to hot substances)
•
Chemicals (Acids and bases)
•
Electricity (Electrical voltage, lightning)
•
Radiation (Ultraviolet rays and radiation)
Symptoms and diagnostic findings:
Assessment of burn injuries:
Burns may be accompanied by respitory problems due to smoke intoxication with
pulmonary edema.
Possible Laboratory findings:
Hemoglobin , hematocrit , sodium , potassium , creatinine , BUN
Possible clinical findings: Respiratory failure, hypotension, tachycardia and shock.
x
Treatment:
Resuscitation following the ABCD rule.
Removal of rings and braces is mandatory to avoid tourniquet effect. Immediate
excessive cooling of burned area with regular water may limit the after burn amount of
destructed tissue significantly. Fluid resuscitation and high protein supply remains
necessary until wound exsudation stops.
Rule of 9’s
•
•
•
Method to assess the approximately affected body surface area in %.
In children the head is more than 9%.
Description of burned body surface area equivalent to the child'
s palm (= 1%)
o
Face & Scalp 9%
o
Back 18%
o
Perineum1%
o
Arm each 9%
o
Front18%
o
Lower leg each 9%
Major burns are all burns involving the trunk!
Classification of burn injuries by the American Burn Association
epidermic painful erythema, no blisters, scarfree healing
within five days.
Superficial partial thickness
subtotal epidermic destruction, moist, read and white
areas, blisters, no loss of sensoric function, heals
within 28 days with some scarring.
Deep partial thickness
loss of entire epidermis, dry, waxy, white wound. Skin
transplant may be performed but spontaneous healing
within 1 month is possible.
Full thickness
Destruction of more or all remaining subepidermal tissues
Superficial thickness
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Criteria for hospital admission of burn unjuries
Any burn injury that affects over 10% of BSA
Burns in special areas face, neck, hands, feet, perineum
Electrical burns any burn with history of smoke inhalation
Chemical burns Full thickness burns where grafting is indicated.
Burns may be accompanied by respitory problems due to smoke intoxication with
pulmonary edema.
Laboratory findings:
Hemoglobin , hematocrit , sodium , potassium , creatinine , BUN
Possible clinical findings: Respiratory failure, hypotension, tachycardia and shock.
v
Treatment:
Resuscitation following the ABCD rule.
Removal of rings and braces is mandatory to avoid tourniquet effect. Immediate
excessive cooling of burned area with regular water may limit the after burn amount of
destructed tissue significantly. Fluid resuscitation and high protein supply remains
necessary until wound exsudation stops.
Fluid resuscitation following the Brooke formula
2 mL/kg/%TBSA burned (3/4 crystalloid + ¼ colloid)
plus maintenance fluid of 2000 mL D5W within 24 hours.
TBSA = Total Body Surface Area
Fluid resuscitation following the Parkland/Baxter formula:
4 mL/kg/% TBSA burned (crystalloid only – lactated Ringer)
plus maintenance fluid of 2000 mL D5W within 24 hours.
Medication therapy includes Opioids, Antibiotics, Tetanus booster and Albumin supply.
Wound care involves use of silver ion/sulphonamid based cremes or gazes to avoid
bacterial infections (e. g. Sulfadiazine). Change of dressings typically requires strong
analgesia or temporary anesthesia. Escharectomy (removal of scarring tissue) may be
required if wound healing results in ROM of limbs or limited thoracic or abdominal
mobility. Psychosocial support may be required as well.
Dermatological Medication Therapy
Soaps
True soaps are used for mechanical skin cleansing from bacteria, sebum and pollution.
Medicated soaps and shampoos are used for skin conditions such as psoriasis or
chronic dermatitis.
Cleansers
Preparations with bacteriostatic or bactericidal effect for preoperative skin cleansing and
wound treatment. Commonly used substances are:
Iodine – cleansing effect.
Povidone-iodine – bactericidal ( i. e. Betadine and Betadone).
Alcohol – bactericidal.
Hydrogen peroxide – Germicidal and cytotoxic. Can destroy newly grown cells.
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Chlorhexidine – cleansing effect.
Hexachlorophene – cleansing effect.
Oxychlorosene sodium – cleansing effect.
Benzalkonium chloride – bacteriostatic (Benza)
Can support growth of pseudomonas bacteria!
Lotions
Liquid emulsions of thin consistency. Require thorough shaking prior to administration.
Commonly used lotions are Calamine lotion (Calamox®), Zinc stearate, Zinc oxide.
Emollients
Occluding and hydrating effect with skin repairing and protecting character.
Ingredients are silicone oils, isopropyl palmitate, octyl stearate, petrolatum, lanolin and
cacao butter. Common preparations are: Eucerin crème, white petrolatum, lac-hydrin
cream.
x
Protectants
Ointments, creams and powders to accomplish skin protection from wetness. Prevention
of rashes. Commonly used substances are lanolin, zinc oxide, petrolatum, cod liver oil.
Soaks and wet dressings
Weeping and crusting skin lesions respond well to aqueous drying solutions. Soaks are
applied three times daily for 20 minutes at a time or continuously depending on
thickness of crust. Commonly used preparations are:
•
•
•
•
Self prepared salt solution for wetting purposes.
Self prepared 1% acetic acid solution for pseudomonas contaminated wounds.
Potassium permanaganate for antifungal treatment.
Burrow’s solution (5% aluminum acetate) used in exudating wounds.
Topical Antipruritics
Topical treatment of pruritus may include any neutral cream or lotions as well as oral
antihistamines. Examples for commonly used external anti - pruritus medications are:
Aveeno lotions, creams or hydrating bath, Eucerin cremes and lotions, Zonalon cream
Hydroxyzine hydrochloride (Vistaril®) and Chlorpheniramine (Chlor-Trimeton®).
Topical Antibiotics
Antibiotic for dermatological infections may be absorbed and can cause substance
specific side effects. The clients history of previous allergic reactions due to medication
must be taken carefully.
Antibiotics used for bacterial skin infections
Tetracyclines
Gram positive and gram negative bacterial skin infections.
Neomycin
Prevention of wound infections (e.g. Mycifradin® topical)
Mupirocin
Impetigo caused by Staphylococcus aureus, Streptococcus
pyogenes andbeta-hemolytic Streptococcus (e.g. Bactroban®)
Metronidazole
Broad band antibiotic treatment
Meclocycline sulfosalicylate
Gram positive and negative bacterial skin infections
(i.e. Meclan® topical).
Gentamycin sulfate
Prevention of Pseudomonas aeruginosa infection after ear
surgery (e.g. G-myticin® topical).
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Erythromycin/Benzoyl peroxide
Acne vulgaris (i. e. Benzamycin)
Clindamycin phosphate
Vaginal infections and treatment of Acne (e.g. Cleocin®).
Chloramphenicol
Broad spectrum antibiotic treatment. Can cause bone.
marrow depression due to internal absorption (i. e. Chloromycetin®)
Bacitracin, PolymyxinB, Neosporin
Bacterial superinfection in other underlying skin
problems (i.e. Mycitracin® topical).
Topical antiviral medications
Aciclovir 5% Ointment.
Solely used for Herpes simplex infections and Herpes zoster infections in early stages.
Antifungal Medication
Systemic antifungal medication
Pharmaceutical effect:
Fungicidal, fungistatic effect depending on applied dosage.
Therapeutic effect:
Treatment of candida, cyptococcus, blastomycosis, histoplasmosis, aspergillus fumigate
and tinea.
General considerations:
Surveillance of liver function since elevation of liver enzymes is the most important side
effect of oral antifungal medications. Regular laboratory assessments are required under
treatment.
Side effects:
Fever, chills, headaches, nausea, vomiting, myalgia, insomnia, confusion,
photosensitivity, hypokalemia, hypomagnesemia and bone marrow depression.
Amphotericin:
Ototoxicity and nephrotoxicity. Amphotericin therapy requires premedication with
hydrocortisone, antipyretics, antihistamines as well as sufficient hydration. Substance
precipitates in any sodium chloride solution. Administration has to be performed under
protection from light.
Ketoconazol:
Gynecomastia and sexual impotency.
Substances:
Amphotericine B (Fungizone®), Amphotericin B Liposomal Complex (Ambisome®) ,
Clotrimazole (Mycelex toche®), Fluconazole (Diflucan®), Griseofulvin (Grifulvin V®),
Ketoconazole (Nizoral®) and Nystatin (Mycostatin®).
Topical antifungals
Therapeutic effect:
Treatment of fungal skin infections (e. g. athlete’s foot “jock itch”).
Special considerations:
Topical antifungal treatment may be useful in limited infections of hairless skin only. All
other areas of fungal skin and nail infection require systemic treatment. Usually topical
antifungal medications do not cause any systemic side effects due to a low resorption
rate. Topical medication always has to be administered with gloves. Nystatin spray for
treatment of athlete’s foot can be applied to shoes and stockings. Vaginal suppositories
can be administered during pegnancy and require to restrain from sexual intercourse or
to use condoms. Infected areas are not supposed to be covered with tight clothes or
dressings. Clothing with contact of infected areas require washing after treatment.
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Side effects:
Local hypersensitivity reactions.
Commonly used substances:
Amphotericin B (Fungizone®), Ketoconazole (Nizoral®), Miconazole (Monistat®),
Nystatin (Mycostatin®), Clotrimazole (Mycelex®), Terbinafine (Lamisil®).
d
Topical antiparasitic medication
Main indications are Scabies and Pediculosis capitis (Lice). Common treatments:
Scabies:
Crotamiton (Eurax® cream and lotion)
Pediculosis capitis:
Malathion (Ovide® lotion)
Pediculosis capitis, corporis and pubis:
Pyrethrin and piperonyl butoxide.
Scabies and Pediculosis capitis:
Permethrin (Elimite® cream, Nix liquid), Lindane
(Kwell® cream, lotion)
Special considerations:
Scabies treatment:
Permethrin and Lindane has to be left on skin for 8–12 hours.
Crotamiton has to be applied twice and each time for 24 hours.
Pediculosis capitis treatment:
Lindan lotion stays on for 12 hours
Lindan shampoo stays on for 4 minutes
Side effects:
Lindane may cause dizziness and seizures. Not to be used in infants and children.
Topical Corticosteroids
Pharmacological effect:
Anti-inflammatory effect due to the inhibition of prostaglandin activity. General
immunosuppressive effect.. Antiproliferative effects, vasoconstriction of epidermal
capillaries.
Therapeutic effect:
Healing of inflammatory skin eruptions.
Indications:
Unspecific, non infectious skin eruptions, psoriasis, atopic dermatitis, seborrhoic
dermatitis and intertrigo.
Special considerations:
Topical corticosteroids get absorbed systemically and can cause systemic corticosteroid
side effects including suppression of adrenal cortex. Absorption rate depends on skin
site and potency of the administered medication and duration of treatment. Duration of
treatment should not exceed 21 days for low and medium potency agents and 14 days
for high potency agents. Highest absorption occurs on face, axilla, groins and perineum
where only low potency agents should be administered.
Side effects:
Skin atrophy, hyperpigmentations and striae.
Potency of topical corticosteroids
Highest potency
Betamethasone Diproprionate 0.05%, Clobetasol proprionate 0.05%, Diflorasone 0.05%,
Halobetasol proprionate 0.05%
High potency
Betamethasone diproprionate 0.05%, Desoximethasone 0.25%, Flucinolone 0.05% - 0.2
%, Halocinonide 0.1% and Triamcinolone acetonide 0.05%
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Intermediate potency
Betamethasone benzoate 0.025%, Betamethasone valerate 0.1%, Desoximethasone
0.05%, Flucinolone acetonide 0.025%, Halocinonide 0.025%, Mometasone 0.1%, and
Triamcinolone acetonide 0.1%
Low potency
Betamethasone valerate 0.025%, Clocortolone 0.1% , Fluocinolone acetonide 0.01%
Flurandrenolide 0.025%, Hydrocortisone valerate 0.2% and Triamcinolone acetonide
0.025 %.
Lowest potency
Alclomethasone 0.05%, Desonide 0.05%, Dexamethasone 0.04%, Hydrocortisone 1%
Hydrocortisone 2.5%, Methylprednisolone acetate 0.25% and Methylprednisolone
acetate 1%.
Topical acne medication
Pharmacological effect:
Diverse substances with antiseptic, antibiotic and keratolytic effect.
Indication:
Control of minor and early stages of acne.
Overview:
Retinoids with keratolytic effect.
Tazarotene (Tazorac®), Tretinoin (Retin – A®) and Isotretinoin (Retinoic acid derivative)
Antibacterials
Benzoyl peroxide (Benzagel®) + keratolytic effect, Clindamycin (Cleocin T®), Sodium
sulfacetamide (Klaron®), Tetracycline (i.e. Monodox®), Erythromycin (i. e. Emgel®) +
anti inflammatory effect.
Contraindications:
Retinoid medication has to be strictly avoided in pregnant women because of its high
teratogenic toxicity. Women under retinoid treatment must maintain strict contraception
and perform repeated pregnancy tests before and while under treatment!
Retinoids, a Vitamin A metabolite, can not be combined with Vitamin A supplements to
avoid intoxication. Tetracycline and Clindamycine may induce photosensitivity.
Side effects: Local skin reactions.
Topical Medication for Burns
General considerations:
Burns have to be considered as open wounds and must be treated under sterile
precautions. Changing of topical substances may require administration or even
sedation prior to the procedure. Regular assessment of inflammatory parameters as well
as of albumine levels and kidney and liver function must be maintained in cases of larger
burn wounds.
Overview:
Nitrofurazone (Furacin®)
Adjunctive antibacterial effect. Contains polyethylene glycol. Use restricted in kidney
impairment.
Silver sulfadiazine (i. e. Silvadene®)
Toxic antibacterial effect of silver absorption rate 10%. Precaution in G6PDH Deficiency.
May cause leukopenia, skin necrosis and Erythema multiforme.
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Mafenide (Sulfamylon®)
Bacteriostatic activity against Pseudomonas aeruginosa and Clostridia. May cause
metabolic acidosis in clients with impaired renal function.
Wound cleaning (debriding) medications
A delayed or secondary healing process of skin wounds and pressure ulcers may be
interrupted by cell debris, fibrinogen, damaged tissue and dirt. Substances with
debriding activity contain enzymes which are able to breakdown and digest such cellular
debris to facilitate reepithelisation of the wound base and further healing.
Overview over commonly uses substances:
Trypsin, peru balsam, castor oil (Granulex®), papain, urea, chlorophyllin (Panafil®),
fibrinolysin and desoxyribonuclease (Elase®), sutilains (Travase®) and collagenase
(santyl®)
EYE DISORDERS AND DISEASES
Myopia (Shortsightedness)
Condition in which light is focussed in front of the retina, resulting in a blurred vision by
focusing on distant objects. Shortsighted people can often see reasonably clearly at
short distances.
Symptoms and diagnostic findings:
Characterisitic symptoms of a myopia include the exertion of eyes to see distant objects.
Affected pupils commonly experience difficulties in reading the blackboard at school. In
advanced stages a limited visual - motoric coordination may lead to a lack of interest in
playing outdoor games after repeated falls and accidents.
Treatment:
Glasses, contact lenses and refractive surgery are the currently available treatment
options.
Hyperopia (Farsightedness)
Farsightedness or hyperopia, occurs when light entering the eye focuses behind the
retina, instead of directly on it. This is caused by a cornea that is flatter or an eye that is
shorter than a normal eye.
Symptoms and diagnostic findings:
Hyperopia can be usually well compensated during early childhood because of the
compensatory lens accommodation. Clients experience primarily difficulties by focusing
on close objects. In advanced stages a blurred distance vision may develop as well.
Under usual circumstances the affected clients experience a severe eye fatigue when
reading which may result in eye strains, headaches, pulling sensations and burning.
Children may be observed with an intermittent strabism.
Treatment:
Glasses, contact lenses and refractive surgery are the currently available treatment
options.
Presbyopia
Presbyopia is a physiological condition and caused by the decreasing elasticity of the
eye lenses which results in a reduced ability to focus on close objects. This process is
expected to develop slowly between the ages of 40 to 65 years.
Symptoms and diagnostic findings:
Affected clients experience difficulties to focus on close objects. Holding close objects
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like a newspaper or a telephone book further away makes focusing easier.
Treatment:
Presbyopia is corrected by the wearing of a correct pair of glasses. Bifocal glasses allow
to have one pair of glasses to improve close and farsightedness.
Strabismus
Affected client is unable to align eyeballs due to an uncoordinated movement of the eye
muscles. Mostly inherited occurrence.
Symptoms and diagnostic findings:
Client appears with more or less obvious crossing eyeballs while focusing on an object.
Strabismus screening is performed by cover – uncover testing
One eye is covered
while client is focusing on a distant object. An unaligned eye will deviate once the cover
is taken away in an attempt to readjust to the focus. Strabismus can also be detected by
examining the corneal light reflex. If an examination lamp is held 12 inches away from
the nasal bridge while client is focusing on a distant object the corneal light reflex is
supposed to occur on symmetric spots of both eyes.
Treatment:
Since strabismus mostly occurs congenitally, successful treatment needs to be
accomplished within the first two years to avoid amblyopia of the affected eye.
Conservative treatment is based on disabling the better eye with patches to force the
weaker eye to strengthen its ocular muscles. Surgical procedures can readjust the eye
muscles and correct strabismus if conservative treatment is not successful.
Glaucoma
Pathologically increased intraocular pressure due to an overproduction and/or
decreased drainage of aqueous humor. In order to the width of the anterior chamber
angle between the iris and the cornea an open angle glaucoma appears to be the most
common form of glaucoma. Open angle glaucoma occurs due to an obstructed canal of
Schlemm. Angle closure glaucoma becomes symptomatic during mydriasis or when
client is focusing on close objects which leads to a complete closure of the anterior
chamber angle.
Symptoms and diagnostic findings:
Open angle glaucoma leads to a gradual slow increase of the intraocular pressure while
an acute flare of angle closure glaucoma leads to acute eye – and headaches with
blurred vision, nausea and vomiting. Diagnoses is made via assessment of the
intraocular pressure and the width of the anterior chamber angle.
Treatment:
Acute glaucoma is considered a medical emergency and requires immediate medication
therapy with thiazide diuretics and carboanhydrase inhibitors to reduce the intraocular
pressure. Miotic eye drops are used to keep the anterior chamber angle open while beta
– blocker containing eye drops reduce the production of aqueous humor. Surgical
interventions are made by an iridotomy or trabeculoplasty to enhance drainage from the
anterior chamber.
Cataracts
Gradual loss of vision due to an increased opacity of the eye lenses or lense capsules.
Causes are multifactorial. Common are alcoholism, smoking, uncontrolled diabetes,
steroid treatment, previous eye injuries and extended exposure to ultraviolet light.
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Symptoms and diagnostic findings:
Vision disturbances occur independently from accommodation. Increasing blinding
sensations due to light are typical first signs of cataract as well as a disturbed color
vision.
Treatment:
Surgical replacement of eye lense with or without capsule. Retention of lens capsule
provides better stability to lens implant.
Retina detachment
Detachment of the retina from underlying chorioid membrane. Commonly caused by age
related degeneration of the vitreous humor. Less common causes are traumas and
postoperative surgical complications.
Symptoms and diagnostic findings:
Clients produce increasing visual disturbances such as floating spots, blurred visions
and gradual losses of the visual field in a way of a downing curtain or other
phenomenons. Diagnosis is made via opthalmoscopy.
Treatment:
Treatment is mainly by performed by laser coagulation or cryotherapy in an attempt to
reattach the retina after it has been repositioned and to protect the remaining retina from
further detachment. Other surgical treatment options are gas or air injections into the
shrinked aqueous vitreum space or “buckling” the sclera beyond the area of detachment.
Acute and postoperative treatment involves supine positioning to avoid increased
hydrostatic pressure to the detached area.
Macular degeneration
Localized degeneration of the retinal area with the most sensitive visual acuity. Age
Related Macular Degeneration AMRD is considered to be the most common cause of
blindness in individuals over 65 yeas of age and the most common form of macula
degeneration. The exact cause of this condition is unknown. The most common form of
macula degeneration is considered to be the atrophic or dry form which occurs bilaterally
and leads to a gradual and significant loss of vision but only in a low percentage of all
cases to a legal blindness. The exudative or wet form of macula degeneration is more
aggressive and leads more often to a full legal blindness since it causes a faster
degeneration due to subretinal bleedings and exudation.
Symptoms and clinical findings:
Characteristic symptom for a macula degeneration is a sudden and progressing loss of
central vision while the peripheric vision remains intact. Other signs include distortion of
objects and blurred vision. Diagnosis is made via fundoscopy which typically reveals
yellow retinal spots so called “Drusem” which appear around the degenerated retinal
area.
Treatment:
Curative treatment is not available for either one form of the macular degenerations. Dry
macular degeneration is untreatable. Wet macular degeneration can be limited in its
progress by laser coagulation or photodynamic therapy. Photodynamic therapy is a
combination of laser coagulation with a light activated drug which will be injected.
Eye infections
Summary of characteristics and symptoms:
Blepharitis
Painful infection of the eye lash follicles and eye lid glands.
Hordoleum (“Sty”)
Painful infection of the sebaceous gland of eyelid.
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Chalazion
Granulomatous, cystic, nodular and painless inflammation of conjunctival
Tissue (chronic course of a Hordeolum).
Itching and tender infection or allergic reaction of the conjunctiva.
Conjunctivitis
Corneal ulcer
Painful corneal ulcer due to infections and trauma.
Keratitis
Painful inflammation of the cornea.
Uveitis
Severly painful inflammation of the uvea with reactive papillary constriction.
Treatment:
Infection of the eyelids and conjunctives are treated with topical antibiotics and analgetic
medication. Regular eye cleansing from bacteria and debris is mandatory. Allergic
conjunctivitis is treated with local or systemic antihistamines. Topical cortisone fluids are
contraindicated for use on the cornea. Suspected corneal lesions require immediate
bedrest in supine position and supply of sterile dressings prior to emergency surgical
repair.
c
EAR DISORDERS AND DISEASES
Otitis externa
Inflammation of the external auditory canal due to bacterial infection in a humid and
moist environment or as an allergic reaction.
Symptoms and diagnostic findings:
Acute pain, swelling and red discoloration of the external auditory canal. May also lead
to temporary hearing impairment.
Treatment:
Application of topical or systemical antibiotic treatment and pain relief medication.
Preparations may also include topical steroids to alleviate the swelling.
Otitis media
Inflammation and infection of the middle ear (tympanic cavity). Most common causative
bacteria in children is Escherichia coli. Other causes are infections with Streptococcus
pneumoniae, Neisseria catarrhalis and Haemophilus influenzae.
Symptoms and diagnostic findings:
Moderate to severe ear ache. Fever. Otoscopy reveals bulging and inflamed tympanic
membrane due to an effusion of the middle ear. Spontaneous rupture of the tympanic
membrane can occur. In complicated courses a further development into a mastoiditis
with affection of the cochlear and the vestibular organ as well as the meningeal
membranes may occur.
Treatment:
Oral systemic antibiotic treatment is mandatory to avoid a further development into a
mastoiditis with affection of the cochlear and the vestibular organ. Puncture of the
tympanic membrane may be performed to avoid a spontaneous rupture. (Myringotomy)
Abscedic mastoiditis requires mastoidectomy to avoid a further spreading into a
meningitis and mastoiditis. Nasal decongestants may be administered briefly to ease
pressure relief by dilating the Eustachian tubes.
Meniere’s Disease
Flares of vertigo, nausea and vomiting caused by a disturbance in the membranous
labyrinth of the inner ear, where a deficient re-absorption of endolymphatic fluid causes
an endolymphatic hydrops. The etiology of this condition is unknown. Flares may be
triggered by stimulating substances such as caffeine or nicotine and sodium rich diets.
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Symptoms and diagnostic findings:
Acute unilateral vertigo, accompanied by nausea, vomiting, headaches, tinnitus and
partial hearing loss. Autonomous nervous symptoms may be hypotension and
nystagmus. Diagnosis is made by electronystagmography with caloric testing. Ear
examination and audiogram may be unsuspicious.
Treatment:
Atropine leads to a reduction of the parasympathetic response. Diuretics and
antihistamines may be used for treatment of acute episodes. Surgical treatment options
include endolymphatic decompression, vestibular neurectomy, labyrinthectomy, or
cochlear implant.
Epistaxis
Acute bleeding of nasal mucous membranes. May occur due to a rhinitis of infectious or
allergic cause or by mechanical irritation in small children or due to a trauma. Some
cases are caused by abnormally located superficial blood vessels of low mechanical
resistance.
Symptoms and diagnostic findings:
Bleeding severity varies from tissue stains to hemodynamic relevant fast and severe
blood losses.
Treatment:
In most cases bleeding stops spontaneously by applying manual pressure to the
nostriles. Clients have to bend head forward during acute bleedings while cooling pack is
placed over neck. In case of prolonged or massive bleedings intranasal administration
of epinephrine or thrombin may be required. Other treatment options include
electrocautherization and packing of the nose (Belloq’s tamponade).
Eye and Ear Medication Therapy
Glaucoma Medication
Beta-adrenergic antagonists (“Beta – Blockers”)
Pharmacological effect:
Decrease production of the intraocular aqueous humor.
Therapeutic effect:
Reduction of intraocular pressure.
Indication:
Chronic primary open angle glaucoma.
Special considerations:
Beta Blocker for glaucoma treatment will be absorbed into the circulatory system and
cause systemic side effects, cross the placenta and appear in breast milk. Special
precautions are necessary for patients with obstructive lung diseases, renal failure,
diabetes, hyperthyroidism, heart blocks. Adverse effects may occur in combination with
antihypertensives and antidysrhythmics. Baseline vital signs and current intraocular
pressure must be obtained prior first time administration. Medical history must be
explored carefully regarding cardiovascular and pulmonary diseases as well as for
diabetes and hyperthyroidism. Medication of choice for treatment of open angle
glaucoma in patients with obstructive pulmonary diseases is the Beta1 selective blocker
betaxolol (Betoptic) Beta – blocker medication may have to be withdrawn 48 hours prior
cardiac stress testing or general surgery.
Side effects:
Local eye and conjunctival reaction and irritation.
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Allergies, hypotension, dizziness, depression, psychosis, laryngo – and bronchospasm,
dry mouth, eyes, glands, agranulocytosis, hypo – and hyperglycemia.
Contraindications:
Hypotension, dizziness, depression, psychosis, laryngo – and bronchospasm, dry mouth,
eyes, glands, agranulocytosis, hypo – and hyperglycemia.
Commonly used substances:
Betaxolol (Betoptic®), Metipranolol (OptiPranolol®), Timolol (Timoptic®)
Adrenergic agonist medications, mydriatic
Pharmacological effect:
Decrease of production of the intraocular aqueous humor, Mydriasis and ocular
vasoconstriction
Therapeutic effect:
Reduction of intraocular pressure.
Indications:
Open angle glaucoma secondary to an uveitis. Artificial mydriasis for eye examination
purposes. Hemostasis during open eye surgery.
Special considerations:
Adrenergic agonist medications for glaucoma treatment will be absorbed into the
circulatory system but cause rarely systemic side effects. All substances cross the
placenta and appear in breast milk. Baseline vital signs and current intraocular pressure
must be obtained prior first time administration. Medical history must be explored
carefully regarding cardiovascular and pulmonary diseases as well as diabetes and
hyperthyroidism. If epinephrine is administered with miotic medication, miotic medication
must be administered first.
Side effects:
Blurred vision, photophobia, headache, hypertension, difficulty with night vision, rebound
miosis due to phenylefrine.
Contraindications:
Narrow angle glaucoma, corneal lesions and abrasions.
Commonly used substances:
Phenylefrine (Neo – Synephrine®) and Hydroxyamphetamine (Predrine®)
Sympathomimetic agents, non - mydriatic
Pharmacological effect:
Decrease production of aqueous humor and increase its outflow.
Therapeutic effect:
Reduction of intraocular pressure.
Indications:
Treatment of open angle glaucoma.
Special considerations:
Adrenergic agonist medications for glaucoma treatment will be absorbed into the
circulatory system but cause rarely systemic side effects. All substances cross the
placenta and appear in breast milk. Baseline vital signs and current intraocular pressure
must be obtained prior first time administration. Medical history must be explored
carefully regarding cardiovascular and pulmonary diseases as well as diabetes and
hyperthyroidism. If epinephrine is administered with miotic medication, miotic medication
must be administered first.
Epinephrine: Onset of effect after 1 hour, peak effect after 4–8 hours.
Dipivefrin: Onset of effect after 0.5 hours, peak effect after 1 hour.
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Side effects:
Blurred vision, photophobia, headache, hypertension and difficulties with night vision.
Contraindications:
Narrow angle glaucoma, concurrent treatment with mono amino oxidase inhibitors MAOI.
Commonly used substances:
Dipifevrin (Propine®) and Epinephrine (Epifrin®)
Cholinergic agents
Pharmacological effect:
Increase of outflow of aqueous humor by induced miosis. Leading to a decreased
resistance of aqueous flow.
Therapeutic effect:
Reduction of intraocular pressure.
Indications:
Treatment of open angle and angle closure glaucoma.
Special considerations:
Cholinergic agents for glaucoma treatment will be absorbed into the circulatory system
and cause systemic side effects, cross the placenta and appear in breast milk.
Baseline vital signs and current intraocular pressure must be obtained prior first time
administration. Medical history must be explored carefully regarding cardiovascular and
pulmonary diseases as well as diabetes and hyperthyroidism. Cardiovascular reactions
likely if used while under beta – blocker medication.
Side effects: (Parasympathomimetic)
Blurred vision, myopia, irritation, brow pain, abdominal pain, bronchoconstriction,
hypotension, ataxia, seizures, respiratory failure, bradycardia and retinal detachment
after prolonged use.
Contraindications:
Acute Iritis and severe cardiorespiratory diseases.
Commonly used substances:
Carbachol (Carboptic®), Physostigmine sulfate (Eserine sulfate®), Pilocarpine (Isopto
Carpine®)
Carbonic Anhydrase Inhibitors (CAI’s)
Pharmacological effect:
Decrease of aqueous humor production.
Therapeutic effect:
Reduction of intraocular pressure.
Indications:
Oral preparations: Treatment of open angle, angle closure and secondary glaucoma.
Ophthalmic preparations: Treatment of open angle glaucoma and ocular hypertension.
Special considerations:
Carbonic anhydrase inhibitors are chemically sulphonamides without antibiotic effect.
Oral preparations are not indicated in acute glaucoma but for maintenance treatment.
May cause diuretic effect and should be therefore taken in the morning. Client has to
maintain adequate fluid supply and a high potassium/low sodium diet unless otherwise
indicated.
Side effects:
Topical agents: Local allergic reaction, keratitis and photosensitivity.
Oral agents: Diuresis, diarrhea, nausea, vomiting, lethargy, weakness, paresthesia,
bone marrow depression, blood dyscrasias, Stephens Johnson syndrome
and hypokalemia.
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Contraindications:
Sulphonamide allergy.
Commonly used substances:
Oral agents:
Acetazolamide (Diamox), Methazolamide (Neptazane) and Dichlorphenamide (Daranide)
Topical agents:
Brinzolamide (Azopt®), Dorzolamide (Trusopt®)
Prostaglandin agonists
Pharmacological effect:
Increase of aqueous humor outflow.
Therapeutic effect:
Decrease of intraocular pressure.
Indications:
Open angle glaucoma and ocular hypertension
Special consideration:
If prescribed, Pilocarpine has to be administerd 1 hour after prostaglandin agonist eye
drops. Frequency of administration in all cases only once daily. Contact lenses have to
be removed for 15 minutes after use of medication.
Side effects:
Allergic reactions, thickening, elongation and pigmentation of eye lids.
Contraindications:
Allergies against Latanoprost and Benzalkonium
Commonly used substances:
Bimatoprost (Lumigan), Latanoprost (Xalatan), Travaprost (Travatan) and Unoprostone
(Rescula)
Mydriatics and Cycloplegics
Pharmacological effect:
Anticholinergic paralysing effect to ciliary muscle.
Therapeutic effect:
Mydriasis
Indications:
Uveitis, keratitis and preparation for intraocular surgery and fundoscopy.
Special considerations:
Ointment needs to be applied several hours before the examination or procedure.
Cholinergic agents for glaucoma treatment will be absorbed into the circulatory system
and cause systemic side effects, cross the placenta barrier and appear in breast milk.
Baseline vital signs and current intraocular pressure must be obtained prior first time
administration. Medical history must be explored carefully regarding cardiovascular and
pulmonary diseases as well as diabetes and hyperthyroidism. Intraocular pressure
needs to be monitored over full course of therapy.
Side effects:
Blurred vision, mydriasis may last 3 (Scopolamine)–12 days (Atropine), photophobia,
tachycardia, hypertension, dry mouth.
Commonly used substances:
Scopolamine hydrobromide, Atropine sulfate, Tropicamide, Homatropine and
Cyclopentolate.
Non steroidal anti inflammatory drugs (NSAID)
General description under musculoskelettal and neurological medications. If absorbed,
substance can cause same side effects as under oral or parenteral administration.
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Indications in Ophthalmology:
Ketorolac = (Acular) Treatment of Conjunctivitis , ophthalmic pruritus.
Diclofenac = (Voltaren) Treatment of postoperative inflammations.
Antibacterial eye medication
Various antibiotics with topical activity against common eye infections:
Conjunctivitis, blepharitis, keratitis, uveitis and hordeolum.
Commonly used substances are:
Bacitracin (Baciquent®), Chloramphenicol (Chloroptic®), Ciprofloxacin (Ciloxan®),
Erythromycin (Ilotycin®), Gentamicin (Garamycin®)
Antiviral eye medication
Indicated in treatment of herpes simplex keratitis and keratokonjunktivitis.
Commonly used substances are:
Idoxuridine (Stoxil®), Trifluridine (Viroptic®) and Vidarabine (Vira – A®).
Anaesthetic eye medications
Indicated prior IOP assessment via tonometry and during removal of foreign bodies.
Commonly used medcations are:
Proparacaine hydrochloride (Ophthetic®), Tetracaine hydrochloride (Pontocaine®)
Rapid onset for 15–20 minutes duration! Eye protection necessary until anaesthetic
effect has worn off.
Corticosteroid ear medication
Mainly used in combination with antibacterial, antiviral or antifungal agents.
Special considerations:
Contraindicated in perforations of tympanic membrane.
Commonly used substances are:
Betamethasone, Hydrocortisone, Hydrocortisone with acetic acid, alcohol, benzethonium
and Dexamethasone.
MOUTH DISORDERS AND DISEASES
Pharyngitis
About 90% are caused by viral infections in school children. Rarely caused as a single
manifestation of an infection with A beta-hemolytic streptococcus.
Symptoms and diagnostic findings:
Soar throat with swallowing difficulties, drooling and dry cough. Tonsils and cervical
lymph nodes are mostly simultaneously enlarged as a characteristic sign of an
accompanying immune response. Fever may occur. Assessment includes smears for
throat cultures and strep – testing to identify a possible bacterial infection.
Treatment:
Viral Pharyngitis: Pain and fever relief and smoothing of pharynx with acid free fluids.
Antibiotic therapy for bacterial infections.
Tonsillitis
In comparison to a pharyngitis tonsillitis is typically a bacterial infection of the posterior
pharyngeal tonsils.
Symptoms and diagnostic findings:
Symptoms are equal to symptoms in acute Pharyngitis. Throat inspection typically
reveals highly enlarged tonsils with exsudation of pus. Inflammatory parameters may be
elevated. Complications include paratonsillar abscess (Quinsy’s).
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Treatment:
Antibiotic treatment is mainly required. Abscedic infections may require incision for pus
relief. Cool drinks and ice cream alleviate pain.
cv
BLOOD DISORDERS AND DISEASES
Iron Deficiency Anemia (IDA)
Iron deficiency anemia is a characteristic finding in cases of acute and chronic blood
losses as well as in a disturbed iron metabolism or a decreased intake.
Symptoms and diagnostic findings:
Most clients are elderly and may not show any significant physical symptoms if IDA has
developed slowly enough for the client to adapt to it. Symptoms are determined by poor
oxygenation due to a gradual loss of oxygen binding erythrocytes. Clinical findings
include abnormous fatigue, physical weakness and shortness of breath. Common
causes of IDA are also chronic gastrointestinal bleedings or tumor bleedings. The
investigation of an IDA of unknown cause must always rule out tumors or ulcers of the
gastrointestinal tract.
Characteristic development of hypochromic microcytic anemia =
Hemogobin, erythrocytes, MCV, MCH, MCHC , Serum iron , Serum iron binding
capacity , Serum ferritin (Most significant diagnostic parameter for IDA)!
Treatment:
Identification and treatment of the underlying disorder. Supply of iron orally as ferrous
sulphate in a dosage of 1000mg daily for six months or until normal ferritin level is
established. Increase of reticulocytes occurs quickly and allows a reliable assessment of
this treatment. Iron supply should be taken prior to meals with an acidic fluid. Parenteral
supply in severe causes with iron dextran IV solution. Oral iron supply changes stool
color into black.
Megaloblastic anemia
Anemia due to a deficiency of Vitamin B 12 leads to a limited proliferation of red blood
cells and a low hemoglobin saturation. Vitamin B 12 deficiency is most commonly
caused by a defect or a lack of the intrinsic factor producing parietal cells of the stomach
due to pernicious anemia or after gastrectomy.
Symptoms and diagnostic findings:
Vitamin B 12 deficiency anemia is typically accompanied by defects of other fast growing
tissues such as the mucous membranes. Visible alterations are a glossitis with a red and
sore tongue and cracked lips (Cheilitis). Other mucous membranes may become
dysfunctonial as well. Neurological complications are a disturbed proprioreception and
parestesias. Laboratory findings: RBC , HCT , MCV , MCHC
Achlorhydria in gastric acid analysis = pH 3,5
Diagnosis is made via Schilling test from a 24–hour urine sample to assess vitamin B 12
intake after radionuclide labeled viramin B 12 was administered.
Folic acid deficiency anemia
Common causes are alcoholism, malnutrition, methotrexate treatment, antiepileptic
medication, oral contraceptives, parenteral nutrition and hemodialysis.
Symptoms and diagnostic findings:
Megaloblastic anemia without neurological symptoms. Clinical and laboratory findings
otherwise comparable with Vitamin B 12 deficiency. Fragile gums and mucous
membranes occur as well.
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Treatment:
Supply of folic acid from dietary sources like fish, citrus fruits, vegetables, dried beans,
green leafy, grains and liver.
b
Aplastic Anemia
Deficiency of erythrocytes, leukocytes and platelets.
Mainly caused by a toxic reaction of the bone marrow and its stem cells to external
triggers such as medication, radiation, infections or toxic substances.
Symptoms and diagnostic findings:
Signs of anemia, infections, spontaneous bleedings, Pancytopenia in blood and no cell
activity in bone marrow.
Treatment:
Elimination of underlying cause, General
bone marrow transplant, Anemia
RBC,
transfusions, (leukocyte free). Thrombopenia
splenectomy, leucopenia
Infection
precautions, Mediation therapy: Antilymphocyte globulin, antithymocyte globulin,
cyclosporine, prednisone and cyclophosphamide.
Neutropenia
Neutrophil count of less than 2,000/mm3 due to a primary hematological disorder or
caused by medication therapy, radiation or chemotherapy. Neutropenia results in a
reduced phagocytotic activity for the immune system which leads to significantly higher
susceptibility for bacterial infections.
Symptoms and diagnostic findings:
Clients in neutropenic stades may be completely asymptomatic but remain at high risk
for severe bacterial infections. Neutrophil count reveals absolute amount of available
cells.
Treatment:
First line treatment is the elimination of the underlying cause. Clients should be isolated
for the duration of the immunodeficiency. Strict hygiene procedures have to be followed
by clinical staff and visitors. Steroid treatment may elevate the WBC count in
autoimmune related neutropenia. In decreased production due to a bone marrow
suppression leucozyte stimulating growth factor may be used. Microbiological therapies
should be based on specimen exams and antibiograms.
Aquired Immunodeficiency Syndrome AIDS
AIDS is the clinical manifestation of an infection with the Humane Immunodeficiency
Virus HIV after a mostly asymptomatic latency period of up to 20 years. HIV is a RNA
retrovirus which specifically targets T–lymphocytes which are expressing the CD 4
antigen and disable the cell mediated immune response. T4 cells also boost B cell
mediated reactions due to inceased immunoglobulin production. HIV infections occur
parenteral via blood and body fluids only. High risk sources of infection are intravenous
drug use, sexual contacts and blood transfusions.
Symptoms and diagnostic findings:
Initial infection may lead to unspecific flu – like symptoms like malaise, body achiness
and low grade fever. Symptoms typically increase along with virus progression until
latency period ends with the initiation of an aquired immunodeficiency syndrome.
Additional symptoms include anorexia (unexplained “wasting syndrome”) and an
increased susceptibility for HIV encephalopathy, Kaposi Sarkoma and lymphomas.
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Opportunistic infections typically facilitated by HIV infections are:
Tuberculosis, Pneumocystis carinii pneumonia, Toxoplasmosis, Mycobacterium avium
pneumonia, Cryptosporidiosis, Cryptococcosis, Candidiasis and Cytomegalievirus
infection.
Diagnosis is made by detection of HIV antibodies via an enzyme–linked immuno
absorbent assay (ELISA). Positive ELISA test results for HIV antiboides have to be
confirmed by a Western blot examination to detect antibodies along with viral
components. Significant markers for the couse of the infection are the CD4 count and
the viral load. Unspecific markers are all inflammatory parameters.
Parameters for individual risk evaluation:
CD4 T cell counts
T4 cells boost B cell reactions due to inceased immunoglobulin production.
Normal reference range: 500-1600 cells/microliter.
200–499 cells / microliter = increasing risk
< 200 cells/microliter = severe risk
CD4/CD8 ratio
= Helper / Suppressor cells ratio. Normal: 2:1
Ratio decreases with CD4 count if clients condition worsens.
Treatment:
Main importance has the continuing care and assessment of prognostic values to detect
any progression or complication in time before severe further health damage can occur.
Further a high protein, high calorie diet with frequent small meals is required to combat
further weight loss and protein deficiency.
Medication therapy:
Main importance has the anti retroviral therapy to avoid a further virus replication.
Substances commonly used are protesase inhibitors and nucleoside analogue
medications. Additional medication therapy is based on accompanying medications.
Protease inhibiting medications
Pharmacological effect:
Antiviral effect due to inhibition of protein synthesis.
Therapeutic effect:
Decrease of viral load in HIV infections and manifestations of AIDS and aids related
complex including opportunistic infections. Increase of CD 4 count.
Special considerations:
Administration requires specific considerations:
Saquinavir, Ritonavir
to be taken with meals and milk.
Indinavir
to be taken prior or in between meals.
Contraindications:
Pregnancy and lactation
Side effects:
Nausea, vomiting, diarrhea, hyperbilirubinemia, nephrolithiasis, hepatotoxicity and blood
dyscrasias.
Commonly used substances:
Ritonavir (Norvir), Indinavir (Crixivan) and Saquinavir (Invirase)
Reverse transcriptase inhibitors:
Pharmaceutical effect:
Inhibition of virus replication and growth. Penetration of blood brain-barrier.
Therapeutic effect:
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Treatment of HIV infections in clients with a CD4 count < 500/mm3. Prevention in cases
of exposure and risk of maternal transmission.
Special considerations:
No alteration of blood cells. Substances include Nucleoside Reverse Transcriptase
Inhibitors (NRTI) and Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI). Mostly
used in a combination Therapy.
Side effects:
Neuropathy, insomnia, tremors, dizziness, diarrhea, pancreatitis, hypomagnesiaemia,
discoloration of skin and nails, blood dyscrasias and dermatological side effects.
Commonly used substances:
NRTI’s: Zidovudine (AZT, Retrovir), Lamivudine (Epivir), Didanosine (DDI)
NNRTI’s: Efavirenz (Sustiva), Nevirapine (Viramune) and Delaviridine (Rescriptor)
Sickle cell disease
Sickle cell disease is considered an inherited hemoglobinopathia and hemolytic anemia
which is caused by the synthesis of an atypical hemoglobin S due to a mutation in the
beta chain of the hemoglobin molecule. This results in both chains of the molecule for a
substitution of the aminoacid valine instead of glutamine. Sickle cells disease follows a
autosomal recessive inheritance and mainly occurs in clients of African origin.
Symptoms occur only if the oxygen saturation of the blood declines. This leads to an
immediate change of the shape of the red blood cells which interferes with proper blood
flow capabilities. As a result multiple painful tissue infarctions can occur and lead to a
sickle cell crisis.
Symptoms and diagnostic findings:
Pallor, jaundice to hemolysis, swollen joints, priapism, generalized body pain and
multiple ischemic lesions throughout the entire body.
Laboratory findings:
Sickle cell shaped RBC’s on blood smear, hemoglobin electrophoresis shows and
assesses Hemoglobin S, Bilirubin levels , Reticulocyte count .
Treatment:
Blood transfusions, Hydroxyurea to increase Hemoglobin F concentration.
Nifedipine for priapism, hydration to decrease blood viscosity. Management of individual
organ complications. Preventive vaccination against influenza, hepatitis B and
pneumococcus pneumonia.
Thalassemia
Inherited autosomal recessive hemoglobinopathy leads to the synthesis of a fragile
hemoglobin molecule which causes early hemolysis of RBC’s. Condition can be
expressed in three different grades of severity:
Thalassaemia minor, intermedia and major.
Minor form may not require treatment but indicates a trait of the disease for the carrier.
Likelihood of transmission is 25% if both parents are carriers. Mostly but not solely
occuring in Mediterranean clients.
Symptoms and diagnostic findings:
Thalassaemia causes a progressing hemosiderosis as a result of the iron overload due
to the permanent hemolysis. Affected children suffer from chronic anemia, chronic
hypoxemia and failure to thrive. Hemosiderosis causes splenomegalie, cirrhosis of the
liver, cardiomyopathy, diabetes, hypertrophic and increased fragility of the marrow
containing bones.
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Treatment:
Depending on the severity the main treatment includes blood supply and iron chelation
therapy. Cure requires successful bone marrow transplantation.
Polycythemia
Polycythemia can occur as a primary disorder of the bone marrow or secondary as a
reaction to another underlying disease. Polycythemia of the red blood cells is also an
adaptation phenomenon that occurs during chronic hypoxia in clients with chronic
pulmonary and cardial diseases or due to prolonged exposure to a low oxygen
saturation, e. g. in mountain areas. Polycythaemia may affect all three cell rows of the
bone marrow or only the red blood cells in cases of a polycythemia vera rubra. Main
complication of a polycythemia is a significant increase of the blood viscosity which may
lead to disturbed circulation and metabolism of internal organs.
Symptoms and diagnostic findings:
Anemia, immunodeficiency, spontaneous multiple bleedings, plethora (
red
discoloration of the skin preferrably on the chest), itching and pains due to ischemic
body tissues. Multiple organ failures. MI, CVA. Blood cells produced in excess are
mainly dysfunctional. Diagnosis is made by bone marrow puncture.
Treatment:
Correction of underlying cause. Phlebotomies for multiple blood drawings to decrease
hematocrit. Isolation and infection prevention for leukocytopenia. Medication therapy for
myelosuppression: Melphalan, Hydroxyurea and radiation therapy. Gout prevention with
Allopurinol. Thrombosis prevention with antiplatelet agents
Thrombocytopenia
Thrombocytopenia is defined as a platelet count of less than 100,000/mL blood.
Possible causes are: Inherited autoimmune destruction of thrombocytes
Idiopathic
Thrombocytopenic Purpura (ITP) or conditions causing thrombocytosis (e.g. thrombosis
of the liver). Increased consumption due to infectious diseases, sepsis or medication
side effect. Immediate danger for spontaneous bleeding from is given from thrombocyte
counts of less than 20,000/ml.
Symptoms and diagnostic findings:
Overall increased hemorrhagic diathesis: Pinpoint size petechial bleedings. Menorrhagia,
hematuria, gastrointestinal bleedings and epistaxis.
Laboratory findings:
RBC , HCT , Thrombocytes
(anti–platelet antibodies), bleeding time ,
Megakaryocytes in bone marrow absent or deficient.
Treatment:
Platelet transfusion if client is bleeding or at severe risk to bleed. Strict avoidance of any
invasive procedures. Avoidance of NSAR medication due to risk of gastrointestinal
bleedings. Steroid – and immunosuppressant treatment in ITP.
Hemophilias
Hereditary coagulation disorders with a gonosomal recessive trait that leads to a
prolonged bleeding time. Hemophilias are classified by their underlying genetic defect as
follow:
Hemophilia Type A
Hemophilia Type B
Deficiency of coagulation factor XIII which stabilizes fibrin clots.
Most common type of hemophilia.
Deficiency of coagulation factor IX, which triggers the synthesis
of tromboplastin in the intrinsic system.
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Deficiency of von Willebrand factor vWF as a co - factor
to factor VIII.
Symptoms and diagnostic findings:
Sudden bleedings at multiple locations. Typical are hemarthros due to joint bleedings
and ecchymosis due to subcutaneous bleedings. Recurrent hemarthros leads to
cartilage damage = hemarthrosis. Internal compartment syndromes.
Laboratory findings: Bleeding time , aPTT in von Willebrands disease.
Treatment:
Supply of deficient coagulation factors which are stored and delivered as cryoprecipitiate.
Von Willebrand’s disease
Disseminated Intravasal Coagulation (DIC)
Onset of a massive, unspecific and unregulated coagulation activity along the entire
vascular system which leads to a deficiency of clotting factors with consecutive
hemorrhage. Multiple underlying causes such as intoxications, sepsis, polytrauma,
tumors, burns, prosthesis, medications and other health conditions.
Symptoms and diagnostic findings:
Clinical symptoms due to underlying causes and DIC. Start with a gradual decrease of
platelets and fibrinogen. Elevation of PTT, aPPT, Thrombin time. Increased fibrin
degradation products. Consumption of coagulation factors V, VII, VII, IX, XIII. D-Dimer
increased.
Treatment:
Main aspect is the identification and treatment of the underlying cause. Controlling of
severe bleedings via platelet transfusion and supply of coagulation factors (e. g. FFP).
MALIGNANT DISEASES
General considerations
TNM Classification
Tool for grading and staging of malignant tumors in regards to the therapeutic options.
T = Tumor size
N = Affection of lymph nodes
M = Presence of metastases
Scale reaches from 0–3.
A rating of 0 indicates no presence of a criteria while a rating of 3 indicates its maximum
development.
Tumormarkers
Tumormarkers are physiologically occurring substances which show alternating
increasing or decreasing serum concentrations accordingly to a progression or
regression of various defined types of cancer. The presence of a tumormarkers alone is
not a diagnostic criteria for the presence of a tumor. Diagnosis of a malignant tumor can
only be made from histology examinations of tumor biopsies. Therefore tumormarkers
assessments are used as a diagnostic monitoring tool for ongoing cancer treatments.
Treatment options
Cancer treatment options include surgical tumor removal, radiation, chemotherapy. Main
side effects of chemo and radiation therapies are the simultaneous but mostly reversible
destruction of other physiologically fast growing tissues of the body such as hair follicles,
mucous membranes, germ cells, blood and bone marrow cells.
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Clinically, these conditions are typically expressed as stomatitis, alopecia and bone
marrow suppression with immunosuppression. Many more pathologies are possible and
require additional treatment. Bone marrow transplantation is a treatment option
specifically for leukemia and other incurable disorders of the hematopoetic system. It
may also be performed if radiation or chemotherapy have destroyed healthy bone
marrow irreversibly. Immunological therapies are based on substances that are able to
modify the immunological response of an organism towards an antigen. Common
biological reponse modifiers are:
x
Monoclonal antibodies
artificially induced by a group of identical lymphocytes
which are sensitized towards a specific antigen of a tumor.
Colony stimulating factors
induce proliferation of immune competent cells to
achieve an enhanced immune response.
Pain Management in malignant Diseases
Analgesics
Choice of pain medication should depend on results of pain assessment on a pain scale.
Opioids
Depending on their interaction with the opioid receptors of nerve cells, opioid pain
relieving medications are either pure opioid agonists or mixed agonists and antagonists.
The main difference between those two groups is that pure agonists show a steady
increase of their analgetic effect as long as the dosage increases as well.
Opioid agonist-antgonists or partial anatagonists have a limited range of effect. Even if
the dosage increases further and further
ceiling effect.
Pure Morphin agonists
Codeine (Paveral), Dihydrocdeine (Vicodin), Oxycodone (Oxycontin), Propoxyphene
(Darvon), Morphine sulfate (Duramorph), Fentanylcitrate (Duragesic), Oxymorphone,
(Numorphan), Hydromorphone (Dilaudid), Meperidine (Demerol) and Methadone
hydrochloride (Dolophine).
Mixed agonist-antagonists
Pentacozine (Butorphanol), Butorphanol (Stadol), Dezocine (Dalgan) and Nalbuphine
hydrochloride (Nubain)
Opioid antagonists
Naloxone (Narcan), Naltrexone (ReVia), Reverse effects of opioids
Induction of opiate
withdrawal symptoms:
Tremor, convulsion, labile blood pressure, tachycardia, hyperpnea, nausea and vomiting.
Need for opioide agonists depends on assessment vital signs, level of consciousness,
level of respiratory and cardial depression. Assessment includes ECG and arterial blood
gas analysis to assess pO2 and pCO2.
Indicator for an opioide overdose is the symptom trias of
Miosis, Coma and Respiratory depression!
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PEDIATRIC ONCOLOGY
The most common malignant tumors of Toddlers and Preschool Medication
Nephroblastoma (Wilms Tumor)
Malignant tumor, originating from kidneys, uni or bilateral. Main occurrence from 2 years
of age.
Symptoms and diagnostic findings:
Symptoms occur comparably late in the course of this disease since tumor is primarily
encapsuled. Children appear with abdominal pain, nausea, vomiting, hypertension,
hematuria and a palpable abdominal mass. Clients under suspicion for having a Wilm’s
tumor have to keep strict bed rest and should receive no abdominal palpation to keep
tumor capsule intact. Primary metastasizing organs are lungs and liver. Diagnosis
requires intravenous pyelogram and renal ultrasound. Prognosis is generally poor due to
silent, asymptomatic growth of tumor.
Treatment options:
Nephrectomy, radiation and chemotherapy.
Neuroblastoma
Most common extra cranial tumor in childhood, originating from neural crest cells.
Located around the abdominal and or the thoracic paravertebral sidestring of the
sympathetic autonomous nervous system. Prognosis is generally poor due to a silent
and asymptomatic growth of this tumor.
Symptoms and diagnostic findings:
Abdominal pain , fever , weight loss , fatigue , palpable abdominal masses. Respiratory
problems occur if tumor is expanding within the thoracic cavity. Diagnosis is made by
thoracic and abdominal CT scans. Specific laboratory findings: Increased breakdown of
catecholamines in some cases leads to excess amounts of vanillylmandelic acid (VMA)
and homovanillic acid (HVA). Primary metastasis occurs in bones and bone marrow.
Treatment :
Nephrectomy, radiation and chemotherapy.
Bone cancer in children
The osteogenic sarcoma and the Ewing sarcoma are the most common osteogenic
types of cancer of the childhood period and in general.
•
Osteogenic sarcoma
Tumor is typically originating from metaphyseal part of long bones but rapidly expanding
in to the epiphyseal parts. Most common primary locations are femur, humerus, tibia,
pelvic and jaw bones. Most common time of onset is puberty and adolescent age.
Prognosis is generally poor due to the generally rapid growth of this tumor.
Symptoms and diagnostic findings:
Acute tender swelling with a solid and dense palpable mass. Primary metastasis occurs
in lungs, often prior to diagnosis and onset of treatment. Diagnosis is made by X-rays,
MRI and CT scans.
Treatment:
Treatment options are radical surgical resection, chemotherapy and radiation.
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•
Ewing sarcoma
Tumor occurs in children from 4 years until young adulthood. Sarcoma is primarily
originating from diaphysial part of limb bones and ribs.
Symptoms and diagnostic findings:
Symptoms and mode of diagnosis are comparable to osteogenic sarcoma. Primary
metastasis occurs in lungs, often prior to diagnosis and onset of treatment.
Treatment:
Mainly radiation and chemotherapy since tumor is mostly too far advanced or clients
condition already too far declined for major surgery once diagnosis is made.
•
Testicular cancer
Most common form of cancer between 15 and 35 years of age. Possible risk factors are
previous cases of testicle infections (orchitis) as well as a history of maldescensus testis
and cryptorchism. Tumors are mainly detected by self examination. Metastasizing
occurs predominantly through the lymphatic system into the retroperitoneal lymph nodes.
Symptoms and diagnostic findings:
Affected clients typically experience symptoms of dull pain in one side of the scrotum
along with asymmetric enlargement of one testicle.
Diagnosis may also be made by assessing testicular infections or distortions with
hemorrhage. Systemic symptoms include typical B-Symptoms as well as gynecomastia,
lumbar back pain.
Specific laboratory findings:
Significant increase of Alpha – Feto – Protein (AFP), Beta – human –
choriogonadotropin (Beta – HCG), Lactatdehydrogenase (LDH).
Diagnosis is made by testicular ultrasound. Metastasis is detected by CT scan.
Treatment:
Surgical treatment is performed by unilateral orchiectomy. In presence of signs for
an advanced metastasis the surgical procedure includes retroperitoneal
lymphadenectomy as well, combined with chemotherapy. Clients may preserve sperm
prior to treatment for future IVF treatments. Monthly testicular self exam is mandatory on
remaining testicle. Prognosis is generally well due to an usually early diagnosis.
ADULT ONCOLOGY
Hepatom (Hepatocellular carcinoma) and Liver metastases
Primary hepatocellular carcinomas are much less common than liver meteastases.
Primary liver cancer in general has a poor prognosis. Main causes are chronic
progressive hepatitis b and c infections as well as alcohol induced liver cirrhosis. Tumors
arise either from hepatocellular or cholangiocellular origin.
Symptoms and diagnostic findings:
Beside a severe pain the main symptoms are comparable to an advanced liver failure
due to a cirrhosis as previously discussed. Main diagnostic tumor marker is Alpha – Feto
Proteine AFP. Diagnosis is made by imaging rechniques and biopsies.
Treatment:
Partial liver resection or liver transplant if indicated and client’s condition does not
interfere with these treatments. Otherwise palliative chemo and/or radiotherapy.
Treatment of liver metastases is focused on underlying primary tumors.
Surgical resection of single metastases may be pursued.
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Pancreatic cancer
Adenocarcinoma, originating from the ductal epithelium of the pancreatic gland. Most
commonly occurring in ages > 45 years. Possible risk factors include chronic pancreatitis,
cigarette smoking and hereditary factors. Metastasis occurs mostly over the
gastrointestinal lymphatic vessels into stomach, small intestines, biliary system and liver.
Mostly of poor prognosis due to late diagnosis.
Symptoms and diagnostic findings:
Abdominal discomfort and lighter abdominal pain in early stages. Newly developing
maldigestion especially of fats. Altered stool habits with infrequent diarrhea. Anorexia,
diabetes and jaundice. Appropriate imaging diagnostics includes abdominal ultrasound,
CT and MRI scans. Diagnosis is made via biopsy.
Treatment:
In rarely diagnosed early stages of the disease a total pancreatoduodenectomy
(Whipple’s procedure) may be indicated. Due to the late diagnosis a palliative treatment
is more common. Procedures include stent implantations into the biliary and pancreatic
duct system to facilitate biliary and pancreatic secretion. Specific medication or
chemotherapy is not available or of limited effect. Pain control is mandatory.
Malignant tumors of the urogenital tract
The most common urogenital malignancies derive from urothelial cells, which build the
inner lining for the entire urogenital tract. An excemption is the prostate gland cancer
which derives from a glandular parenchymal tissue alteration. Urogenital cancer may
therefore occur as follows:
1.
2.
3.
Urothelial kidney cancer (Hypernephroma)
Urothelial cancer of the ureter and bladder
Prostate gland cancer
Symptoms and diagnostic findings:
As an early symptom urothelial gland cancers typically present through a painless
macrohematuria which usually is a turning point for the affected individual to see the
doctor for further investigations. Cytologic examinations for urine samples may show
cancerous epithelial cells. Pain and obstruction of the urinary tract typically occurs later
in the course of the malignant disease and indicate an already advanced stade. Further
investigations regularly performed in cases of suspicion of urothelial cancer are: Cysto
and ureteroscopic examinations ultrasound examinations, CT, MRI scans and cytologic
examinations of urine.
Treatment:
Main therapeutic option is the resection of the affected part of the urogenital tract if no
metastasisis has been detected. Radiation and chemotherapy will be applied as an
adjuvant chemotherapy in cases of an increased tumor size or metastasis. Urogenital
tumor resection mostly requires an urinary diversion postoperatively. Common surgical
methods of urine diversion are:
•
Cutaneous nephrostomy and ureterostomy
Ureters (or pelvic pyelon) are leading through the abdominal wall and discharge
continuously into a bag.
•
Ileal & Colon conduit
Ureters are inserted into a segment of ileum or colon as an urine reservoir which can be
catheterized as they end as an urostoma in the abdominal wall.
•
Kock pouch
A conduit operation where the pouch has a valve formation in the entry and the outlet
which avoids dripping. Pouches and conduits require self catheterization.
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Ileocystoplasty
Formation of a neo bladder which is still connected with the urethra and allows client to
void.
Prostate Gland Carcinoma
The adenocarcinoma of the prostate gland is the most common type of prostate cancer.
Clients are usually from 50 years of age or older at the time of diagnosis. Main
metastasizing locations are the pelvic bone and the vertebral bones. Androgen
production has stimulating effect towards the tumor growth. A second rare type of
prostate cancer is a squamous cell carcinoma which typically follows a very aggressive
course with predominantly hematogenic metastazition.
Symptoms and characteristic findings:
Early stages often remain asymptomatic. Vague symptoms include Dysura, urinary tract
infections and urine retentions which can also be caused by the common benign
Prostate Gland Hypertrophia (BPH) syndrome in this age group.
Diagnosis is made by rectal digital examination which typically reveals a dense, enlarged
and unshiftable prostate gland. Accordingly an increased PSA reading may be assessed.
Proof of diagnosis occurs via transrectal biopsy.
Treatment:
Main surgical treatment is the prostatectomy along with orchiectomy for androgene
withdrawal. Types of procedures compared by complication rate:
Radical prostatectomy
Removal of entire prostate gland and surrounding capsule,
lymph nodes and neck of bladder. Leads to urine incontinence
and impotence.
Continence and potence may be maintained
Suprapubic (ransvesical) prostatectomy
but bladder may retain functional problems.
Retropubic prostatectomy
No bladder injury and least postoperative complications.
Perineal prostatectomy
Most minimal surgical trauma but increased risk of infections.
Laser treatment may be an alternative procedure since it causes the least complications
but removal of tumor tissue may remain subtotal. Hormonal ablative therapy is
performed along with prostatectomy or as a single mode treatment. Prognosis of the
adenocarcinoma of the prostate gland is generally well since tumor is slow in progress
and rarely causes severe damage to vital organs. Clients require strong educational and
psychological support to manage incontinence, self catheterization and coping with
impotence and castration symptoms. Pain due to bone metastasis usually requires
opioid treatment.
Bronchogenic carcinoma
Lung cancer arising from bronchoepithelial tissue. Cancer with highest lethality among
all cancers. Main cause is cigarette smoke, especially in combination with other
carcinogenic inhalatory agents and genetic predispositions. Carcinogenic agents are
arsen, asbestos and aromatic hydrocarbons. Histologic classification differentiate small
cell and non small cell carcinomas. Metastasing occurs hematogenic and lymphogenic.
Mostly upper lobes are affected.
Symptoms and diagnostic findings:
Onset of symptoms typically occurs in advanced stages. Prime suspicion is given in a
persistent productive or unproductive cough over three months. Other symptoms include
chest pain, dyspnea , anorexia and swelling of cervical lymph nodes.
Diagnostic tests that are revealing tumor build up are CT, MRI and X-Ray. Cytologic
sputum samples are obtained from bronchoscopic washings.
Therapeutic management:
Surgical resection of the affected pulmonary tissue up to the entire lung
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( wedge resection, segmentectomy, lobectomy and pneumonectomy).
Chemotherapy, radiation, laser, immunotherapy, pain management and palliative care.
Laryngeal cancer
A squamous cell carcinoma is the most common histological type of laryngeal cancer.
A high incidence can be found in smokers and clients with a history of chronic
alcoholism. A pre-existing chronic recurrent laryngitis of any etiology may be a risk factor
as well by contributing to precancerous leukoplakia and erythroplakia. Metastasis mainly
spreads into lungs.
Symptoms and diagnostic findings:
A sudden developing and persistent hoarseness or voice alteration of unknown cause is
the primary suspicious finding. Swollen, nontender cervical lymph nodes and
unexplained ear achecmay occur as well. Diagnostic tests: MRI, CT, X-ray and contrast
paque x-ray visualization.
Treatment:
Laryngectomy with neck dissection of cervical lymph nodes, chemotherapy, radiation,
trachestomy and patent airway supply. Oxygen supply. Pain management as required,
palliative care, nutrition and hydration maintenance. Frequent suctioning of
Trachesostoma especially in first postoperative period. Clients require teaching of
esophageal speech by supraglottic swallowing for voice production.
Colorectal carcinoma
Colorectal cancer typically develops from polypes of the colorectal mucosa.
Metastasizing occurs via the lymphatic system or by expansion to other organs.
Symptoms and diagnostic findings:
There are no specific symptoms in the early development of colorectal cancer.
Unspecific signs are diffuse abdominal complaints, weight loss, altered bowel habits,
rectal bleedings (“tar stools”) positive hematest. Advanced tumors may cause
obstructions, severe rectal bleedings and bowel perforations. Diagnosis is made via
biopsies obtained via colonoscopy.
Treatment:
Primary treatment is the surgical resection of the tumor with consecutive colostomy or
end to end anastomosis. Chemotherapy may be applied preoperatively to reduce tumor
size or postoperative as an adjunct preventive chemotherapy to erase possible
undetectable micrometastasis.
Cervical cancer
Most common type of cancer ot the female reproductive system. Onset commonly
between 30–50 years of age. Mainly squamous cell carcinoma which shows early
lymphogenic metastasis. Occurrence is strongly linked with previous Human Papilloma
Virus (HPV) infections.
Symptoms and diagnostic findings:
Early stages are asymptomatic. Coincidential diagnosis by two consecutive abnormal
results of a Papsmear. Advanced stades may show irregular but painless bleedings,
especially contact bleedings or atypical cervical discharge. Diagnosis is made by biopsy
from a colposopic cervical coniotomy.
Treatment:
In early stages surgical removal including postoperative radiation and chemotherapy.
Fistulas between intrapelvin organs are common complications from radiation therapy.
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Prognosis is poor due to usually late diagnosis. Successful curative treatment is rare.
Good response to chemotherapy and radiation therapy which results in significant life
prolonging effect.
Ovarian Cancer
Adenocarcinoma, usually deriving from ovarian parenchyma. Mostly asymptomatic in
beginning stages. Since no routine screening program is available diagnosis almost
always occurs coincidential or after onset of symptoms. Risk increases significantly from
age 40. Mainly lymphogenic metastasis.
Symptoms and diagnostic findings:
Clients usually experience abnormal pelvic heaviness or abdominal distention as a first
symptom. Examination typically reveals a single sided palpable pelvic mass. Diagnosis
can only be made by biopsies taken during an explorative laparatomy. Supporting
diagnostic criteria is a significant increase of Carcinoembryonic antigen 125 (CA 125) as
the only relevant tumormarker.
Treatment:
Surgery, radiation and chemotherapy. Prognosis is generally poor in regards to a cure
but treatment has significant life prolonging effect.
Breast cancer
Adenocarcinomas are the most common histological type of breast cancer. Growth of an
adenocarcinoma in females is generally hormone dependent. Other types (e. g.
squamous cell carcinoma) may not be hormonsensitive. Multiple significant risk factors
have been identified for the development of breast cancer, such as:
Caucasian race, menarche <12 years of age, late menopause, after 50 years of age,
maternity after 30 years of age, family history of breast cancer, hormonal supplemental
therapy, obesity and family history of breast cancer.
Most common location of occurrence is the upper, outer right quadrant of the breast.
Symptoms and diagnostic findings:
Asymptomatic tumors are mostly detected by a regular Breast Self Exam (BSE). Early
stages are usually not tender. Corresponding enlarged axillary lymph nodes may also be
detectable by affected women. Unspecific symptoms are occasional nipple discharge
and unilateral tenderness. Growth are detectable by mammography, ultrasound, CT and
MRI scans. Suspected tissues will be identified under application of radionuclides during
PET examinations. Diagnosis is made by sentinel lymph node biopsy.
Treatment:
Treatment options include surgery, radiation and chemotherapy.
Modes of mastectomy:
Segmental
only involving the tumorous tissue and the immediate surrounding area.
Simple
removal of breast without lymph nodes.
Modified radical
removal of breast and axillary lymph nodes.
Radical mastectomy
removal of breast, axillary lymph nodes and chest wall muscles
Medication therapy for hormone receptor positive breast cancer
Estrogene receptor blocker (Tamoxifen) for premenopausal women, leads to
menopausal symptoms.
Aromatase inhibitors for post menopausal women (Arimidex and Femara) blocks
the aromatase enzyme which catalyzes the synthesis of estrogenes from its androgen
precursor molecules within the adrenal cortex. Three types of aromatase inhibitors are
currently used for treatment.
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Arimidex (anastrozole)
Prescribed for early stage disease right after surgery.
Femara (letrozole)
Prescribed for women who have completed a five year treatment with tamoxifen.
Aromasin (exemestane)
As a permanent blocker of the aromatase enzyme it is prescribed for early stage
diseases once three years of treatment with tamoxifen are completed.
All aromatase inhibitors can be prescribed in metastatic breast
cancer as an adjunct therapy.
As in other malignant diseases the prognosis of breast cancer generally depends on the
tumor stage that is present at the time of the diagnosis. Hormone sensitive tumors
typically show better remission rates.
Malignant neoplasms of the skin
Malignant melanoma
Highly malignant melanocytic tumor of unknown etiology. Risk factors are inceased
exposure to sunlight, naturally pale skin and a history of multiple sun burns. Malignant
melanomas can affect mucous membranes of the respiratory and digestive system as
well.
Symptoms and characteristic findings:
Melanomas share the following characteristics of any suspected integumentary
malignancy in comparison to common types of naevi (“ABCD – Rule”).
•
•
•
•
Assymmetric and fast growth.
Border lacks of a surrounding clear margin to the neighboring tissue.
Color changed within the same naevus.
Diameter > 5mm.
Diagnosis is made by histological examination of biopsy materials of suspected areas.
Treatment:
Surgical excision is the treatment of first choice.
Chemotherapies and radiation are performed in case of metastasizing melanoma.
Basal cell carcinoma (Basalioma)
Slow growing malignant tumor that derives from the epidermal basal cell line.
Occurrence is directly linked to a history of intense UV exposure. Most affected areas
are face and head. Therefore this tumor is mostly seen in farmers and construction
workers. Basaliomas mostly occur from 60 years of age and show a slow invasive
growth without metastasis.
Symptoms and diagnostic findings:
Early stages appear as a papulous growth of skin like coloration. In advanced stages
development of a keratocytic wall with a central ulceration.
Treatment:
Surgical excision. Alternative treatment options involve radiation or cryotherapy since the
mainly elderly clients are often inoperable.
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Sqamous cell carcinoma
Most common type of skin cancer. Likely to metastasize. Malignant skin tumor which
develops from keratinocytes in areas that are frequently exposed to sunlight. Other
supportive causes are exposure to chemicals and previous traumas.
Symptoms and clinical findings:
Early stages may appear as a basalioma but turn fast into an erythemic papule which
easily starts bleeding.
Treatment:
Surgical removal as soon as diagnosis is made. As for other squamous cell carcinomas
there is no causative medication or chemotherapy available.
Mycosis fungoides (T – cell Lymphoma)
Most common lymphoma of the skin. Arising from T-lymphocytes (“helper cells”).
Classified as a Non – Hodgkin lymphoma of low malignancy. Slowly progressing and
mostly over decades.
Symptoms and diagnostic findings:
Main characteristic is a strong pruritus of the affected area which is mainly localized at
the trunk or in the glutaeal region.
Early stages start as large erythematic maculae with a sharp border to the surrounding
tissue. In advanced stages the surface becomes scaly and moist. Metastasing
throughout the lymphatic system into inner organs can occur in late stages. Lymph node
swelling is likely at this stage. Diagnosis is made via histological examination of a biopsy
or of the entire growth after surgical resection.
Treatment:
In early stages topical treatment with steroids, PUVA radiation and interferon may be
prescribed. In advanced stages radiation therapy of the lymphatic tissue will be
performed.
Kaposi Sarcoma
Malignant tumor that arises from endothelial cells of the vascular system. Most common
in clients with HIV infections. May occur simultaneously in different areas of the body but
does not metastasize. Mostly diagnosed as a skin lesion which typically occurs in the
urogenital area from where it invades the integumentary blood and lymphatic vessels.
Internal organs may affected as well.
Symptoms and diagnostic findings:
Single or multiple 5–20 mm sized unspecific erythematous macula or papula.
Treatment:
Single lesions are treated by excision, cryotherapy and radiation therapy. Interferon
treatment is considered in advanced stages and multiple affected areas.
Leukemias and Lymphomas
The different types of leukemia have in common that they start with an unregulated and
overwhelming proliferation of immune incompetent white blood cells within the entire
bone marrow as well as in liver and spleen. As a consequence the affected clients are in
a highly immunocompromised situation. The synthesis of red blood cells and platelets
also becomes significantly deficient since the functioning bone marrow gets further and
further eliminated throughout the course of the disease.
Leukemias are classified by the origin of their underlying malignant process as follow:
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Acute Lymphocytic Leukemia (ALL): Occurring in childhood and most aggressive type!
Chronic Lymphatic Leukemia (CLL): Occuring from 50 years of age and most benign type!
Acute Myeloic Leukemia (AML): Occurring in all age groups.
Chronic Myeloic Leukemia (CML): Occurring from young adulthood.
Symptoms and diagnostic findings:
Leukemia symptoms are anemia, thrombopenia and immunodeficiency caused by a total
damage of the three main bone marrow functions. Clients appear with bleedings,
infections, shortness of breath and cardiovascular symptoms.
Laboratory findings: WBC or in normal ranges, depending on presence of current flares
of acute leukemias, anemia and thrombopenia. Diagnosis is made by bone marrow
biopsy which typically reveals irregular stem cells or an inadequate amount of premature
WBC blast cells. Specific diagnostic finding for a CML is the presence of a genetic cause
(Philadelphia Chromosome).
Treatment:
Depending on the individual leukemia classification the main treatment options involve
chemotherapy and bone marrow transplantation. Deficiencies of RBC’s and platelets
require transfusion therapy. A CLL may remain in remission for a long time and only
requires therapeutic intervention in cases of acute flares.
Malignant Lymphomas
Uncontrolled proliferation of lymphocytes within the entire lymphatic system leads to a
progressing immunodeficiency and a systemic destruction of inner organs. As in
leukemias the actual cause is not known. Acute infections may trigger the onset of
lymphomas. Malignant lymphomas are mainly classified as Hodgkin and non – Hodgkin
lymphomas. Differences between these two groups exist mainly in their diagnostic
criterias but generally show a quite similar course.
Characteristics of Hodkin – Lymphomas
•
Typical originating from T–lymphocytes.
•
Main primary affection is an altered lymph node which is mostly cervical.
•
Biopsy reveals multinuclear Sternberg – Reed cells as proof of diagnosis.
Symptoms and diagnostic findings:
Affected lymph nodes typically appear enlarged, firm, nontender and not shiftable!
Abnormous physical weakness, B–Symptoms
nightsweats, fever, weight loss,
jaundice, pruritus, lymphoma pain due to indigestion of alcohol, hepatosplenomegalie
and mediastinal lymphadenopathy.
Treatment:
Invasive staging via thoracotomy and laparatomy.
Treatment in order to stages I–IV by radiation and chemotherapy.
Characteristics of Non – Hodgkin Lymphomas
•
Typical onset from B–lymphcytes within the lymphatic tissue of one organ
•
No initial noticeable alteration of a lymph node
•
No presence of Sternberg–Reed cells
Symptoms and diagnostic findings:
Abnormous physical weakness, B – Symptoms: Nightsweats, fever and weight loss.
Hepatosplenomegalie, neurological deficiencies, neuropathy and lymphopenia.
Diagnosis is made via lymph node biopsy.
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Treatment:
Combination of radio – and chemotherapy. Rituximab (monoclonal) antibody against CD
20 surface antigen of malignant lymphcocytes. Interleukin and Interferone.
Antineoplastic Chemotherapy
Alkylating agents
Pharmacological effect:
Cell cycle unspecific interference with DNA replication.
Therapeutic effect:
Destruction of neoplastic tissue.
Indication:
Chemotherapy in malignant neoplastic diseases.
General considerations:
Treatment requires strict contraception and is contraindicated in lactation and pregnancy.
General side effects of chemotherapy include bone marrow depression, pancytopenia,
blood dyscrasias and increased susceptibility for infections. Main cytotoxic effect occurs
in tissues with high mitotic activity.
Contraindications: Gastrointestinal tract diseases, hematopoetic system diseases,
reproductive system, childbearing age and serious infections. Regular laboratory
assessments under treatment required: Leukocyte count, platelet count, hematocrit, liver
and kidney function initially and at least 2 weeks after completion of treatment.
Neurological assessments and audiograms prior and during treatment because of
neurotoxicity and ototoxicity.
Substances:
1. Cyclophosphamide
Administered orally on an empty stomach.
2. Busulfan
Administered orally on an empty stomach. Needs to be stored in light resistant container.
Myelosuppression, pancytopenia for up to 2 years after treatment, ovarian suppression,
amenorrhea, nausea, vomiting, pulmonary fibrosis “Busulfan lung”, hepatic dysfunction,
diffuse hyperpigmentation and alopecia.
3. Cisplatin
Pretreatment ECG required because of possible myocarditis. Pretreatment audiometric
examination because of possible ototoxicity. Minimum urine output has to be
100mL/hour. Minimum specific gravity has to be greater than 1.030.
4. Carboplatin
Store protected from light. Avoid contact with aluminum surfaces.
5. Mechlorethamine
Severe tissue necrosis if extravasation occurs. Antidot for extravasation is isotonic
sodium thiosulfate.
6. Procarbazine
Requires avoidance of tyramine containing foods, due to danger of hypertension and
hemorrhage. Causes alcohol intolerance.
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Antimetabolites
Pharmacological effect:
Cell cycle specific inhibition of DNA and protein synthesis by supplying alterated
dysfunctional metabolites for the protein synthesis.
Specific considerations:
Regular assessments of CBC, WBC, Differential – and platelet count. Regular
assessments for infection and bleedings. Side effects: Hyperpigmentation of IV sites,
including nail, veins and mucous membranes. (Rotate frequently!), myelosuppression,
stomatitis, diarrhea.
Substances:
Flourouracil (5-FU)
Side effects:
Cardiotoxicity, photosensitivity, cerebellartoxicity, maculopapulous skin rash, no fever,
myalgia , bone pain, malaise, , cerebellar toxicity, hepatotoxicity.
Substances:
Cytarabine, Methotrexate, Thioguanine, Fluouracil and Fludarabine.
Antitumor Antibiotics
Pharmacological effect:
Cell cycle unspecific interference with RNA and DNA synthesis.
Special considerations:
Severe vesicants in case of extravasation. Requiring antidot treatment. Strong
surveillance of infections and infusions required. Punctured veins should not be located
close to nerves and blood vessels. Catheters have to be changed every 48 hours.
Administration by push injections. Arterial, venous and lymphatic perfusion must not be
compromised on limb chosen for injection.
Substances:
Doxorubicin (Adriamycin), Bleomycin (Blenoxane), Plicamycin (Mithramycin)
Mitoxanthrone and Mitomycin.
Side effects:
Irritant on injection site, blue–green coloration of sclera and urine, myelosuppression,
hepatotoxicity, renal toxicity and cardiotoxicity.
Treatment of accidential paravasations
Vesicant therapy antidotes and treatment
Thiosulfate – Nitrogen mustard
Dactinomycin – Apply ice
Doxorubicin – Cold pack
Vinblastine – Hyaluronidase + Warm pack for 24 hours
Paclitaxel – Hyaluronidas + Ice for 24 hours
Mitose inhibitors
Pharmacological effect:
Inhibition or arrest of mitosis during M-Phase. Not to be used with PVC containing
devices but with nitroglycerine tubing. Extravasation can cause tissue necrosis. Requires
strict Anaphylaxis prevention by premedication with dexamethasone, diphenhydramine,
cimetidine or ranitidine. Assessment of vital signs under treatment
Side effects:
Transient bradycardia, peripheral neuropathy, myelosupression and anaphylaxia.
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Substances:
Vincristine (Vesicant)
Hyaluronidase to be used as a vesicant antidote in cases of paravasation.
Frequent assessment of achilles tendon reflexes
for signs of polyneuropathy required!
Nitrosureas
Pharmacological effect:
Interference with DNA replication and repair.
Cell cycle non specific Crossing blood – brain barrier.
Hormonal antineoplastic therapy
1. Corticosteroids
Pharmaceutical effect:
Lysis of lymphoid malignancies.
Special considerations:
Slow intravenous infusion or oral administration with food. Requires frequent
assessment of CBC, 2-hour postprandial glucose, kidney parameters, electrolytes,
weight, I & O balance, mood and sleep pattern.
Side effects:
Euphoria, insomnia, psychosis, edema, muscle weakness and hyperglycemia.
1. Estrogens
Pharmaceutical effect:
Suppression of testosterone in male clients.
Special considerations:
Oral administration after meals. To be taken with water one hour before meals and
requires that no milk, dairy products or calcium containing products are used.
Side effects:
Thromboembolism, nausea and severe hypercalcemia.
3. Progestins
Pharmacological effect:
Tumor cell regression in breast cancer.
Special considerations:
Palliative use. Assessment of weight, allergic symptoms, oral administration and not
related to meals. Contraindicated in pregnancy, lactation, cardiac arrhythmia and
combination with calcium channel blockers.
Side effects:
Vaginal bleeding, breast tenderness, abdominal pain and increased appetite.
4. Anti - Estrogene
Pharmacological effect:
Competitive blockage of estrogen receptors of malignant cells.
Special considerations:
Frequent CBC assessment required. Dosage may require adaptation to alleviate severe
side effects.
Side effects:
Menopausal syndromes, thrombosis and discharge from breasts.
5. Androgens
Pharmacological effect:
Stimulation of androgen receptors.
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Special considerations:
Palliative use for suppression of estrogen receptor positive neoplasia. Oral
administration. Assessments of calcium levels is essential. Sufficient fluid supply
necessary.
Side effects:
Virilization and hypercalcemia.
6. Anti – androgens
Pharmacological effect:
Blockage of androgen receptors.
Special considerations:
Used in metastatic prostate gland cancer. Frequent assessment of liver function test.
Side effects:
Gynecomastia, gastrointestinal disturbances and hepatitis.
Unspecific antineoplastic medication
Asparaginase
Pharmacological effect:
Depletion of asparaginic acid for DNA protein synthesis.
Special considerations:
Every medication therapy that includes aminoacids and proteins
carries a high risk for anaphylactic reactions!
Intradermal skin testing prior to treatment with asparaginic acid is mandatory!
Administration requires immediate access to emergency anaphylaxia treatment!
Crash cart needs to be available at all times!
Anaphylaxia occurs commonly within 30–60 minutes after administration.
Mandatory assessments include kidney and liver function, clotting tests, CBC, amylase,
calcium, ammonia and uric acid. Fiberlike particles in solution are common after
reconstitution. Treatment is contraindicated in pregnancy and lactation.
Side effects:
Anaphylaxia, hyperemesis, hemorrhagia and pancreatitis.
Hydroxyurea
Pharmacological effect:
Inhibiting incorporation of thymidine into DNA.
Special considerations:
Assessments of kidney, liver and bone marrow function, fluid input and output.
Treatment is contraindicated in pregnancy and lactation.
Side effects:
Bone marrow depression, stomatitis, maculopapular rash and hyperuricemia.
Common side effects
related to chemotherapeutic agents
Neutropenia
Defined by Neutrophil count < 1500/mm3.
Nadir most common 7–14 days following administration.
Frequent assessment of Body temperature mandatory.
Fever > 38.0 o C/100,4 o F is most significant symptom.
Limit amount of visitors, avoidance of contact with individuals suffering from infections.
Advice patient on good personal hygiene. Advice visitors to wash hands before touching
patient. Avoid exposure to potentially contaminated fresh fruit or homemade food from
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unknown sources. In case of infection determination of the infectious location involves
cultures of urine, blood, tip of intravenous catheter and chest X-ray. Administration of
filgrastim (Neupogen) stimulates regrowth of neutrophil colonies. (G-CSF) Substance
may induce bone pain and can be self – administered via subcutaneous injection.
Thrombocytopenia
Defined by platelet count < 50.000 mm3. Lifespan of Thrombocytes is 10 days.
Clients are at risk for hemorrhage, prolonged bleeding time, bruising, petechiae,
hypotension, tachycardia and intracranial bleedings. Advice to minimize risk of
accidential injury due to falls and cuts etc. Administering stool regulators to ease
defecation. Monitoring of pad count in menstruating women. Client to avoid nose blowing.
Treatments with non steroidal anti-inflammatory medication or acetylic salicylic acid is
contraindicated. Frequent urine and stool test for blood necessary. Hemorrhage may
require platelet transfusion.
Nausea and vomiting
Can occur acute or delayed in clients under chemotherapy. Avoid strong aromatic odors.
Encourage small frequent meals and sufficient fluid supply. Antiemetics may be
administered parenteral (i. e. Metoclopramide, domperidone and ondansetron).
Anticipatory nausea can be prevented with dexamethasone. Monitoring for dehydration
is mandatory. Replenishment of fluids and electrolytes as required.
Diarrhea
Monitor client frequently for dehydration. Replenishment of fluids and electrolytes as
required. Administering antidiarrhea medication. Elimination of sweets, processed
sugars, caffeine and cold drinks. Avoiding milk and chocolate. Serving low fiber, high
protein and high calorie diet. Client may require liquid diet or temporary fasting. Perianal
area may require application of moisture barrier
Constipation
May occur due to intestinal polyneuropathy caused by chemotherapy.
Requires monitoring of defecation frequency. Encouraging a fiber rich diet and sufficient
fluid supply. Preventive treatment with stool regulators may be indicated. Sufficient
regular exercise in order to clients overall physical condition. Laxatives may be used
reluctantly due to side effects.
Stomatitis
Caused by destruction of epithelial cells of oral cavity during chemotherapy.
Condition causes hypersensitivity to hot and cold temperatures, spices and alcohol.
Assure thorough oral hygiene to prevent secondary infections. Antifungal/antiviral
preventive treatment may be indicated.
Alopecia
Typical onset 2 weeks after administration of chemotherapeutic agents.
May continue for up to 5 months. Condition requires careful care of persistent and
regrowing hair until full consistency is achieved again. Clients may require emotional
support to cope adequately.
Cardiotoxicity
Developing immediately or within 4–5 weeks after drug administration. Onset of
symptoms requires immediate cessation of chemotherapy. Assessment parameters are
the decrease of the cardiac ejection fraction, ECG – changes, dysrhyhmias, hypotension,
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chest pain, pulmonary congestion and peripheric edema. Reversibility depends on
amount of administered dosage.
Pulmonary toxicity
More common in clients >70 years of age. Toxic reaction of alveoli and capillary
endothelium. High oxygen supply increases toxicity of Bleomycin. Regular assessment
of pulmonary function studies and oxygene saturation in peripheric blood required.
Onset of dyspnea is the primary symptom. Management with low dose opioid medication,
oxygen supply and instruction on appropriate breathing techniques.
Hemorrhagic cystitis
Due to damage of urothelial lining and induction of inflammation of bladder wall.
Caused by acrolein, metabolit from cyclophosphamide and ifosfamide. Symptoms
comparable to an urinary tract infection. Treatment with a chelatbinding agent (mesna)
may lead to excretion of acrolein from bladder. Client is required to maintain adequate
hydration.
Hepatotoxicity
Caused by metabolism of toxic chemotherapeutic agents in liver. Manifestation includes
jaundice, pruritus, abdominal pain in upper right quadrant, hepatomegaly,
hyperpigmentation, acholic stool and beerbrown urine.
Assessment via regular liver function test. Management involves avoidance of other
potentially hepatotoxic substances.
Nephrotoxicity
Caused by damage of nephrons leading to an obstructive nephropathy. Symptoms
include elevated levels of creatinine and urea in serum and urine as well as decreased
albumin levels and glomerular filtration rate. Urine specific findings are proteinuria,
hematuria and hypomagnesemia. Medication may need to be cessated if BUN is >
22mg/dL and/or creatinine > 2 mg/dL. Prevention of nephrotoxicity requires hydration
with minimum 3000mL fluids daily and prescription of Allopurinol to control uric acid
levels. Also alkalization of urine with bicarbonate and strict avoidance of NSAID required
to prevent further kidney damage.
Neurotoxicity
Mainly caused by cumulative dosage of vinca alkaloids passing through the blood/brain
barrier to cause direct damage on cells of the central nerous system. Requires frequent
neurological assessments. Neurological deficiencies allow conclusion on the affected
CNS areas as follow: Confusion or impaired level of consciousness
Cerebrum
Tinnitus, hearing loss
Auditory cortex. Digestive and urogenital dysfunction
Autonomous nervous system. Paresthesias and impaired deep tendon reflexes
Sensoric cortex.
SAFETY REQUIREMENTS FOR HANDLING CHEMOTHERAPEUTIC MEDICATION
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Personnel should be specially trained for this task.
Dosages have to be calculated in relation to body weight or body surface.
Treatment courses are mainly intermittent and sometimes combine two or more
chemotherapeutic agents.
Preparation of dosages has to occur in a well air vented area with restricted
access.
Personal safety requires wearing of leak proof gown, disposable gloves and eye
protection.
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Safety regulations do not allow pregnant women
to get in contact with chemo – therapeutics !
Immune modulating medication
1. Colony – stimulating factors
• Granulocyte Colony-Stimulating Factors (G-CSF)
• Granulocyte and Macrophage stimulating factors (GM-CSF)
Pharmacological effect:
Reduction of neutropenia.
Special considerations:
Allergic reactions may occur.
2. Sargramostim (Leukine®)
Special considerations:
To be applied not any earlier than 21 days after completion of bone marrow
transplantation or 11 days after completion of chemotherapy. Necessary assessments
iclude CBC, liver and kidney parameters twice weekly. Thorough assessments of
remaining leucemic cells are mandatory. Suspension can be reconstituted with
physiological saline.
Contraindications:
Hypersensitivity to yeast products or E. coli products. Pregnancy, lactation.
Impaired renal or hepatic function. Remaining leucemic cells in bone marrow.
3. Filgrastim (Neupogen®)
Special considerations:
Not to be administered within first 24 hours after a dose of cytotoxic chemotherapy.
Necessary assessments: CBC, liver and kidney parameters twice weekly. Reconstitution
in Dextrose 5%.
Contraindications:
Hypersensitivity to yeast products or E. coli products. Pregnancy and lactation.
Impaired renal or hepatic function. Remaining leucemic cells in bone marrow.
Side effects: (Substance unspecific)
Headache, myalgia, malaise, stomatitis, nausea, vomiting, diarrhea, constipation,
alopecia, gastrointestinal hemorrhage, renal and hepatic dysfunction, supraventricular
dysrhythmias and tachycardia. Adult Respiratory Distress Syndrome (ARDS).
Myocardial infarction (MI).
4. Erythropoetin
(Increases RBC count only, as discussed under renal medications)
Cell stimuating medication (Interleukines)
Pharmacological effect:
1. Increase specifically thrombocytes, lymphocytes and T-cell immunity
in peripheric blood.
2. Antitumor activity by causing cells to change to a non-proliferative type.
General considerations:
Frequent assessment of CBC, including differential and platelet count,
electrolyte balance and vital signs.
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1. Aldesleukin (Proleukin®)
Indications:
Renal carcinoma, severe thrombocytopenia.
Special considerations:
Treatment is administered over two times 14 single doses and requires hospital setting
with availability of an ICU.
Side effects:
Myalgia, lethargy, fluid retention and cardiac dysrhythmias.
2. Levamisole (Ergamisol®)
Indications:
Colon cancer Duke stage C. Increase of activity of B and T cells and macrophages.
Specific considerations:
Treatment to be started 7–30 days after bowel resection. May be combined with 5 Fluouracil.
Side effects:
Flulike symptoms, bone marrow depression and gastrointestinal disturbance.
3. Oprevelkin (Neumega®)
Indications:
Treatment of myelosuppression following chemotherapy due to an increase of
megacaryocytes and thrombocyte production.
Specific considerations:
Treatment for 21 days or until thrombocyte count reaches 100.000 cells/mm3.
To be reconstituted in physiological saline.
Side effects:
Cardiac dysrhytmias and fluid retention.
PSYCHIATRIC DISORDERS AND DISEASES
General Definitions
Therapeutic Communication and Environment
Elements of Communication
1.
Sender initiates conversation.
2.
Message is submitted.
3.
Channel one of the five senses used to submit the message.
4.
Receiver individual who this message is directed too.
5.
Environment (context) conditions under which this message is submitted.
6.
Feedback (response)
Levels of communication
Intrapersonal, interpersonal and public.
Forms of communication
Verbal and nonverbal, non–therapeutic and therapeutic.
Influencing factors of communication
Pacing, intonation, clarity and brevity, timing and relevance.
Factors of nonverbal communications
Facial expression, eye contact, gestures, posture and gait, territoriality and personal
space and personal appearance.
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Communication blocks
(Blocks and avoids expression of clients feelings) Communication must be client
centered and goal oriented. Self disclosure, inattentive listening, overuse of medical
terms and personal opinions. Probing or prying questions (unless in a Mental Health
Setting). Changing the subject, challenging or being defensive. False reassurance.
Therapeutic relationship phases
1. Pre - interaction phase (analyzation of information prior to contact)
2. Orientation phase (pre - helping phase), opening the relationship, clarifying a problem,
structuring and formulating the contract.
3. Working phase (exploring and understanding thoughts and feelings) transference and
countertransference may occur and the client makes a decision.
4. Termination phase (prepare early in process, may include follow up procedures,
feelings of loss and ambivalence on both sides).
Health Risks under consideration of ethnicity
African Americans
Lactose intolerance and lactase deficiency, hypertension, sickle cell anemia, cancers,
coronary heart disease, coccidioidomycosi and diabetes.
Asian Americans
Thalassaemia, lactase deficiency, G6PD Deficiency, hypertension, cancer (stomach and
liver) and coccidioidomycosis.
Latino/Hispanic Americans
Diabetes, hypertension, pernicious anemia and childhood obesity.
Native Americans
Alcoholism, accidents, arthritis, COPD, diabetes, hypertension, heart diseases, HIV,
influenza, cancer, malnutrition, maternal and infant deaths, obesity, suicide and
tuberculosis.
Coping Strategies and Defense Mechanisms
Adaptive (healthy) coping
Sustaining general homeostasis
Maladaptive (unhealthy) coping
General homeostasis not preserved
Compensation
Making up for a deficit.
Denial
Refusing to acknowledge an unacceptable fact.
Displacement
Directing feelings against a big threat towards a smaller threat.
Identification
Attempt to change oneself to please somebody else.
Intellectualization
Excessive reasoning to avoid or minimize distressing experiences.
Introjection
Internalizing somebody elses feelings in one self.
Minimization
Refusing to acknowledge the significance of somebody elses behavior.
Projection
Transfering unacceptable feelings to another.
Rationalization
Justifying unacceptable behavior by applying a false logic or applying false but
acceptable motives.
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Reaction formation
Behaving contrary to personal feelings.
Regression
Returning to an earlier less well developed stage of functioning.
Sublimation
Displacing motivation for unacceptable behavior into acceptable behavior.
Substitution
Replacing an unobtainable goal or unacceptable object with a less satisfying but
acceptable and available one.
Undoing
Trying to repair previously made damage.
Personality traits and response to medical illness
Type A:
Unhealthy response to medical illness. Irritabile, impatient, unable to relax, time
conscious, low self – esteem and highly depending on approval from others.
Type B:
Healthier response. Laid back, goal directed, relaxed and easygoing
Behaviors that increase likelyhood of medical illness
Pessimism, repression, limited social interactions, hostility and despair.
Behaviors that decrease likelyhood of medical illness
Energetic, questioning, humorous, inspirational and good interpersonal skills.
Crisis
Confrontation by a stressor a person is unable to cope with. Always time limited (4 – 6
weeks) accompanied by: Threat to individuals well balanced self (equilibrium)
Characterized by an overall hopelessness and helplessness.
Crisis either leads to personal growth or increased psychological vunerability.
Maturational Crisis = Developmental Crisis due to normal life transitions.
Situational crisis = Due to external factors. i.e. loss and change.
Adventitious crisis = Due to catastrophies or disasters.
Cultural crisis = Due to being in a new cultural environment.
Nursing Assessment
Focus on immediate problem, determine clients perception of problem and identify
current changes, assess coping mechanisms, assess support systems and assess
potential for self harm.
Treatment:
Verbal intervention strategies. Psychopharmacological treatment during crisis.
Anxiolytics: Alprozolam (Xanax), Clonazepam (Klonopin), Diazepam (Valium) and
Lorazepam (Ativan)
Sedatives: Zolpidem (Ambien) and Zaleplon (Sonata)
Neuroleptics: Olanzapine (Zyprexa), Risperidone (Risperdal), Quetiapine (Seroquel) and
Haloperidol (Haldol). Psychotic symptoms are not typical for crisis but
crisis may excerbate underling Psychosis!
Anger and Aggression
Violence typically follows aggressive behavior of any kind. Risk factor is an appropriate
history. Violence may be provocated by staff in a clinical setting. Intervention rules
similar to crisis intervention!
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Psychosis
Disorder of organic or emotional origin characterized by gross impairment in reality
testing.
Psychotic symptoms
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Delusions
false beliefs that can not be altered by evidence or local reasoning.
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Hallucinations
sensations with no real existing external stimulus.
( related to sight, sound, smell, taste or touch)
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Self neglect
difficulty in caring for oneself.
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Thought disruptions
Assessment of individual stress reaction
Assessment of psychological factors to a clients health:
Factors to explore:
Source, number, duration of stressors, full mental status examination, coping strategies,
adaptive and maladaptive behaviours, pre-existing psychological illness, drug,
substance and alcohol abuse.
Biological Assessment
Assessment of impact of biological factors to a clients health.
Factors to explore are:
Recent and past health conditions, physical examination, neurological status, laboratory
results, current physical ability, sleep pattern, nutritional pattern and pharmacological
assessment.
Social assessment
Client history, life changing events, lifestyle patterns, cultural practices, family
communication pattern, support network, spiritual concerns, occupational assessment
and economic status.
Anxiety Disorders (Neurosis, Psychoneurosis)
Anxiety is defined as fear of the unknown and is experienced by all human beings.
Anxiety is not necessarily an unhealthy reaction and it is needed to alert an individual to
danger and stressors.
Symptoms:
Tremor, increased muscle tension and increase of BP, HR.
Depression, irritability and anger. Inability to concentrate and to function on a cognitive
level.
Social withdrawal, excessive communication, self–isolation and suicidal ideas.
Spiritual signs, hopelessness, despair, fear of death and no meaningful aspects in life.
Classification:
Acute anxiety = State anxiety.
Chronic anxiety = Trait anxiety.
Primary anxiety = Anxiety due to psychological factors.
Secondary anxiety = Response to physical health problems.
Fear = A reaction to a specific danger.
Stress = Imbalance between demands and fulfillment of demands.
Stressor = Internal or external event that leads to feelings of anxiety.
Experienced on an individual basis, but health problems are commonly an
underlying stressor.
Burnout = Physical and/or mental exhaustion due to prolonged stress.
Anxiety levels:
Mild
Alert, tensed but otherwise not impaired.
Moderate
Focus on immediate concern, fear and tension, Perceptual field is narrowed.
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Severe
Focus on specific details, focus directed on specific anxiety,
sympathetic nervous system aroused and severe emotional distress.
Reaction to dread and terror, individual is unable to function adequately. Details get
blown out of proportion and overwhelming emotional reaction.
General adaptation syndrome
Automatic physical reaction to stress by the sympathetic nervous system.
1.
2.
3.
4.
Stress = response to the demand
Alarm = hormonal activity triggers fight or flight reaction
Resistance = moderate to severe anxiety, psychosomatic symptoms, functioning
on a suboptimal level and implementation of a coping strategy.
Exhaustion = occurs when adaptational resources are depleted, disorganized
functioning, hallucinations and delusions may occur. Severe
anxiety to panic.
Phobic Disorders
Fears of specific objects, activities, situations, e.g. Agoraphobia (fear of being trapped
in crowds). Frequently associated with a panic disorder. Treated with behavioral therapy.
Generalized anxiety disorder GAD
Triggered by common daily activities. Treated with Benzodizepines on demand and
Buspirone. Client has to be taught to rethink perception of stressor (behavioral therapy).
Panic Disorder
Reaction to dread and terror. Individual is unable to function adequately. Details get
blown out of proportion, overwhelming emotional reaction.
Symptoms include desire to escape, chest pain, hot flushes and other physical
symptoms. Accompanied feelings of hopelessness and despair.
Obsessive Compulsive Disorder OCD
Recurrent obsessive thoughts and uncontrollable compulsive behavior.
Issues about controlling oneself, others and the environment.
Obsessions
Unwanted thoughts, impulses, images about objects, contamination, questions, sex and
unacceptable impulses.
Compulsions
Unwanted behavioral patterns or acts i.e. counting, praying, washing hands, repeating
words, controlling and seeking reassurance.
Interruption of obsessive thoughts and compulsive behavior leads to increased anxiety.
Treated with relaxation and cognitive behavioral techniques like flooding and thought
stopping. Teach immediately after client has completed ritual. SSRI (i.e. Sertraline
(Zoloft) Selective Serotonin Reuptake Inhibitors are most effective medication therapy.
Electroconvulsive Therapy ECT has been used to treat depressive symptoms associated
with OCD successfully.
Posttraumatic Stress Disorder PTSD
Associated with an extremely traumatic event.
Symptoms:
Apathy, social withdrawal, isolation, loss of interest, depression, hopelessness,
restlessness, irritability, intrusive and unwanted memories (flashbacks).
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Coping with denial, repression, suppression of unwanted thoughts and impulses.
To be explored about feelings of guilt, shame and grief and taught new coping strategies.
Mood Disorders
Mood
A prolonged emotional state that affects someones life and personality.
Changes of mood are generally normal.
Affect
Present feelings and moods
Mood disorders are changes in mood ranging from depression to elation.
Dysthymic Disorder
Chronic disorder in which a low level depressed mood frequently fluctuates with normal
mood for at least 2 years plus 3 of the following symptoms:
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Depressed mood daily or every 2nd day
Poor appetite or overeating
Insomnia or hypersomnia
Low energy
Low self esteem
Unable to make decisions
Feeling of hopelessness
Therapeutic management
Assure client’s safety towards potential for self harm as a first priority since client may
have limited judgement ability(self harm is more likely in phase of regaining hope)!
Warning signs are a history of violence, signs of hopelessness, self–neglect and
malnutrition. Malnutrition generally requires a frequent examination of the protein
metabolism including assessment of serum prealbumin, albumin, glucose, electrolytes,
and nitrogen balance.
Bipolar Disorder = manic depressive disorder
Depression and Elation appear alternating as a Bipolar I and Bipolar II disorder.
Major depression (unipolar disorder)
Generally described as an overall loss of interest in life, transforming from mild to severe
in at least 2 weeks. May be accompanied by delusions and hallucinations in severe
stades. Suicide rate is 15%! Clients show a significantly decreased desire to participate
in any social setting. Low self-esteem, feeling of incompetence, decreased motivation,
“Why bother?“ attitude, social withdrawal, sense of sadness and anhedonia.
Guilt “Why do I feel like this?”, difficulties making decisions and self perception as
unattractive. Clients may develop hallucinations. Loss of libido, altered eating pattern,
increased or decreased appetite and lack of personal hygiene.
Mania
Clients in acute manic phases appear with high energy and productivity. Decreased
ability to concentrate, increasing frustration and irritability, shortened attention span,
unrealistic self confidence, poor judgement and financially risky transactions. Inadequate
social behavior, increased talkativeness, cheerful to euphoric mood, irritable,
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disrespecting attitude, hyperactivity, grandiosity ideas, flight of ideas. Believe to be very
attractive, hallucinations possible, increased sexual activity, promiscuity, insomnia,
eating disorder, constipation, exaggerated, overdressed and colorful clothing.
Cyclothymic Disorder
Depressive and hypomania phases last for at least 2 years each. No “normal” stage.
Seasonal Affective Disorder SAD
Depression in fall and winter due to reduced sunlight. Correlating with a reduced
production of Melatonin and Serotonine.
Schizoaffective Disorder
Mood disorder accompanied with manifestations of schizophrenia.
Occuring in flares of 15-20 minutes at a time. Assessment of current affect reveals
restlessness, nervous anxiety and disability to concentrate. Client is socially withdrawn
with dysfunctional support system and showing no personal interests. Hallucination and
delusion may be present. Also signs of self–neglect, alcoholism or drug abuse. Suicidal
ideas or attempt may be revealed in medical history. Calm, respectful, honest and
realistic therapeutic feedback to maintain a safe therapeutic environment.
Psychotherapeutic treatment options
Biologically based therapies
Consider mental health problems are as biochemically induced and can be repaired with
medications and other methods (i. e. ECT).
Cognitive therapy
Distorted conceptualization and dysfunctional beliefs will be reintegrated by reality
testing.
Activity therapy
Considers that mental health problems are caused by social deficits. Group activity to
increase self – esteem and promote socialization.
Family therapy
Considers that mental health problems are caused by family problems. Members are
lacking sense of “I” and the problem of the affected individual serves a specific function
in the family. Treatment therefore involves the entire family to gain sense of one self for
each family member.
Group therapy
Relationship problems can be solved by learning new coping skills in a group setting.
Group has to have a leader.
Milieu therapy
Therapeutic environment to increase self awareness of feelings and increase of
reponsibilty. Setting is determined by patients leaving a high extent of autonomy.
Play therapy
Therapeutic setting to assist children to express thoughts and feelings unable to
verbalize in play.
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Psychoanalytical therapy
Conflicts between identity and ego lead to anxiety and ineffective and inappropriate
defense mechanisms. Therapy is designed to discover unconscious thoughts, feelings,
defenses and correcting them.
Electro Convulsion Therapy ECT
for treatment of depression in case of failure of antidepressants. Not widely used.
Psychotic Disorders
Schizophrenia
Difficulty to think clearly, being realistic, managing feelings and relating to others in any
way.
Classification:
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Paranoid = Hallucinations.
•
Catatonic = Stupor, Echolalia and Echopraxia.
•
Residual = No plus symptom present but schizophrenic episode in the past.
•
Disorganized = In speech, behavior and affect.
•
Undifferentiated type
Positive schizophrenia symptoms “Plus–Symptoms”
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Hallucinations (mostly auditory)
Delusions (false beliefs)
Loose associations
Overactive affect
Disorganized speech pattern
Bizarre behaviors.
Thought broadcasting = believe others can know personal information
Thought insertion = believe others can put thoughts in a persons mind
Psychosis = difficulty to differentiate own perceptions from reality
Illusions = inaccurate perception or misinterpretation of sensory impressions
Agitation and hostility
Association disturbances
Clang associations (rhyming words in a nonsense way)
Illogical thinking patterns
Neologisms and Word salads
Negative schizophrenia symptoms “Minus Symptoms”
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Absence of healthy mental behavior
Purposeless and ritualistic behavior
Bizarre facial or body movements
Ineffective social skills
Isolation
Lack of self care
Concrete thought process
Lack of ego boundaries
Dependency
Ineffective social skills and social withdrawal
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Affect disturbances
Ambivalence
Avolition = lack of motivation and goals
Anergia = lack of energy
Alogia = poverty of speech
Anhedonia = diminished ability to experience pleasure or intimacy
Sleep disturbance
Intervention strategy rules in cases of acute psychosis
1. Honest supportive and consistent approach.
2. Do not argue.
3. Maintain a clear and directed communication.
4. Do not confirm hallucinations or delusions.
5. Encourage expression.
6. Do not force rest.
7. Protect from self harm.
Undifferentiated psychotic disorders
1. Schizophreniform disorder
Abbreviated course of schizophrenia.
2. Delusional disorder
Non- bizzare delusions for at least 1 month.
3. Brief psychotic disorder
One positive schizophrenia symptom for 1 day – 1 month.
May occur under specific stressor.
4. Shared psychotic disorder (folie a deux)
Delusions occuring between two individuals.
5. Substance induced psychosis
Psychosis induced by substance abuse or medication therapy.
Personality Disorders
Personality disorder patterns are inflexible, enduring, pervasive, maladaptive, causing
significant functional impairment and stress. May be experienced as comfortable
(egosyntonic) or uncomfortable (egodystonic) by the affected client. Condition does
not cause clinical problems but problems in daily living. Commonly more than one
personality disorder present at a time.
Characteristics exist in four areas:
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Behavioral manifestations
Affective manifestations
Cognitive manifestations
Sociocultural manifestations
Personality disorders are caused by a dysfunction of the limbic system and CNS
irritability. Serotonin (5 HT) levels are decreased. Norepinephrine levels are increased
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(NE). Abnormal levels of Dopamine and genetic factors. Also hostility towards oneself,
living up to perfectional standards, super ego rules, unsatisfied basic needs, anxiety and
social oppression.
Classification:
Cluster A personality disorders
Paranoid personality disorder
Distrust and suspiciousness
Schizoid personality disorder
Social detachment and restricted emotions
Schizotypal personality disorder
Discomfort in close relationships, cognitive or
perceptual distortion and eccentric behavior
Cluster B personality disorders
Antisocial personality disorder
Disregarding others
Borderline personality disorder
Instability in personal relationships and
impulsivity
Histrionic personality disorder
Excessive emotionality and attention seeking
narcissistic personality disorder, grandiosity
pattern and need for admiration
Cluster C personality disorders
Avoidant personality disorder
pattern of social inhibition, feeling of inadequacy
and hypersensitivity to negative evaluation.
Dependent personality disorder
need to be taken care of and submissive
Obsessive – compulsive personality disorder
pattern of preoccupation with
orderliness, perfectionism and
control.
Assessment guidelines
Client with personality disorders are mostly not aware of this problem. Assessment
includes functioning in areas of affect, cognition, behavior and sociocultural
adaptation.
Intervention strategy
Clients may or may not change! Mirror behavior to motivate them for a more adaptive
life style. Focus on a small step improvement in role functioning and decreasing
distress.
All clients have potential to change. Awareness of own emotional responses required!
Cluster A
Cluster B
Cluster C
requires gentle, interested and non–intrusive approach.
Patient approach when agitated and erratic. Set limits as necessary!
Direct communication diminishes attention seeking behavior.
Address fears of inadequacy.
Treatment of personality disorders
Any therapeutic intervention requires that client is aware of its need. Medication therapy
include SSRI as needed to equalize mood swings. Behavioral therapy for impulse
control training, setting limits (clearly stated, necessary and enforceable) and behavioral
modification. Psychological comfort promotion. Encouraging independence and decision
making.
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Dissociative Disorders
Sudden disruption in client’s consciousness, identity or memory. Using dissociation and
repression as defense mechanisms. Caused by trauma (wars, natural disasters, abuse,
and crime) and genetic predisposition.
Dissociative Amnesia
Client cannot remember personal information.
Amnesia can be localized, selective, generalized and continuous.
Dissociative fugue
Client flees from personal environment. Unable to remember upon return.
Dissociative identity disorder (Split personality)
Alterating from one personality to another (“Dr. Jekyll and Mr. Hyde”). May alter
physiological characteristics of one personality as well. Client may or may not be aware
of the coexisting personality.
Host personality disorder
Hosting other personalities than the one that is identified with persons name.
Depersonalization disorder
Experiencing detachment from one self as in a dreamlike state.
Somatoform disorders
Increased perception of physiological signals by impaired inhibitory CNS function leads
to psychophysiological responses in form of physical symptoms with no underlying
cause. May be reinforced by secondary gain due to increased attention within the family
or cultural environment. Treatment by client education. No Psychopharmaceuticals.
Somatization disorder
Prior to age 30. Multiple physical complaints.
Conversion disorder
Client is indifferent about the loss of a motoric, sensoric or visceral function without an
underlying organic cause. Clients mood may not be adequately affected.
Pain disorder
No organic cause but client experiences ongoing severe physical pain.
Hypochondriasis disorder
Development of multiple organic symptoms without an underlying cause leading to a
very concerned personality.
Body dysmorphic disorder
Preoccupation by an imagined effect or excessive concern about a minor defect.
Cognitive Impairment Disorders
Delirium
Acute, usually reversible brain disorder. Leading to reduced consciouness.
Developing within hours to days. Caused by an underlying medical condition,
intoxication or alcohol withdrawal( Delirium tremens).
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Dementia
Chronic, irreversible brain disorder. Gradually developing. Leading to loss or weakening
of memory, abstract thinking, judgement and personality. Including aphasia, apraxia and
agnosia. Loss of ability to function in an organized manner.
Classification:
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Alzheimers Type dementia
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Vascular dementia
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Substance induced dementia
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Multiple etiologies
Amnestic disorders
Unable to recall previously learned information or to learn new information.
Multiple causes.
Dementia screening Tools
Folstein Mini Mental State Examination. Score of 9-12 indicates organical illness.
Cognitive Performance Scale. Subscale from nursing home minimum data set
0 = cognitively intact 6 = cognitively impaired.
Geriatric Depression Screening Tool. 0-10 = mild, 21–30 = severe depression
Alzheimers Disease
Stage 1:
Forgetfulness and loss of higher executive functions. Losses in short – term
memory.Use of Memory Aids. Client concerned and frightened about condition.
Depression worsens symptoms.
Stage 2:
Confusion. Progressive short term memory loss. Memory gaps (Confabulation)
Performance of ADL’s seriously impaired. Social withdrawal. Inappropriate appearance.
Lack of ability for adequate verbal response. Poor impulse control.
Stage 3:
Loosing order in ADL. Wandering and hallucinations
Aphasia
Stage 4:
Hyperorality. Perseveration disorder and repetitive behaviors.
Agraphia, Agnosia, Auditory impairment and Astereognosia (= tactile Agnosia)
Alexia (=visual Agnosia). Hypermetamorphosis. Need to touch and examine every object
Progressive motor deterioration. Progressive decreased response to stimuli. Progressive
decline in cognitive function. Mute, scream and continous repetition of one word.
Medication Therapy for Alzheimers Disease
Pharmacological effect:
Inhibition of the enzyme cholinesterase leads to an increase of the acetylcholine
concentration in the chemical synapses in neurons of the central parasympathetic
autonomous nervous system.
Therapeutic effect:
Progress of Alzheimers dementia slows down.
Side effects:
Correlate with an increased activity of the parasympathetic autonomous nervous
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system and can be considered as partially parasympathomimetic: Insomnia, headache,
dizziness, nausea, vomiting, polyuria, seizures and hepatotoxicity.
Substances:
Donezepil hydrochloride (Aricept®), Galantamine (Razadyne®), Memantine (Namenda®)
SSRI are better tolerated in older adults than TCA!
Antipsychotics hacw potential to cause tardive dyskinesia!
Non–pharmacological treatment options include behavior modification, review of life
therapy, validation therapy and SCU special care units.
Eating Disorders
Anorexia nervosa
Life threatening condition. Affected clients maintain minimum nutrition to avoid obesity.
Onset commonly in teenagers and triggered by life events. Mostly eager, success
oriented personalities.
Symptoms and diagnostic findings:
Weight Loss, electrolyte imbalances, BP, Temp., HR decreased, peripheric cyanosis,
constipation, tooth and gum degeneration, dry scaly skin, numbness of extremities, bone
degeneration, amenorrhea over min. 3 cycles and insomnia.
Bulimia
Clients are concerned on body size, appearance, low self esteem, poor relationships.
Overeating large amounts of low nutrient food followed by purging through vomiting,
laxatives, enemas, diuretics and amphetamines.
Symptoms and diagnostic findings:
Weight may be normal. Electrolyte imbalances, cardiac diseases, hypertension, tooth
decay, gastritis, ulcers, Boerhave Syndrome (esophagus rupture) and rectal bleedings.
Pseudodementia = Depression that appears as dementia.
Treatment:
Main aspect is to protect client from self harm or harm to others by securing a safe care
environment, assessing specific needs, building partnerships with family and finding
community resources.
Dependency and Addiction
Substance abuse
Purposeful recurrent use of a substance despite evidence of adverse consequences to
oneself or others.
Substance dependence
Drug use is no longer under control and is continuously used despite adverse effects.
Addiction
Illness with compulsion, loss of control, continued pattern of abuse despite experience of
negative consequences.
Treatment always focuses on Abstinence.
Types of addiction:
Substance abuse disorder and process addiction ( i.e. gambling and shopping)
Accompanied by intoxication, withdrawal, abuse, dependence and tolerance.
Jelinek’s four phases of Alcoholism
(Can be generally applied to Substance abuse and process addiction)
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• Prealcoholic symptomatic phase
Drinking to cope with emotions not realizing that drinking causes tension.
• Prodromal symptomatic phase
Six months to 5 years. Drinking in secret. Gulps first sips. Diminished emotional
response. Plans activities under consideration of access to Alcohol. Feels guilty.
• Crucial phase
Build tolerance. Disease process and psychological dependence. Loss of control
during consume. Preoccupation with use. Craving triggers. Defense Mechanisms.
Environment expresses concerns. ADL’s affected. Anger and alienation of non–
drinking environment.
• Chronic phase
Drinks to blackout, passout and incapacitation. Cognitive, physical, emotional and
deterioration. Reverse tolerance. Loss of control.
Model of process addiction
Contact phase
Serendipitous phase (discovers stress relieving effect of pursuing with
addictive behavior)
Instrumental phase
Dependant phase.
Etiology of Dependence and Addiction
Addiction = chronic brain disease with a dysfunction of the brain reward system.
CNS affecting substances or engaging in addictive behaviors causes increased
availability of Dopamin, Serotonine, Opioid peptides and Neurotransmitters.
Leads to a short term euphoric response generated by this activity. Cravings for readministration. Development of tolerance. Physical Dependence and withdrawal.
Psychological Dependence.
Genetic/biologic risk
Developing out of multiple underlying risk factors. Hereditary tendency.
Psychosocial risk for addiction development
Personality traits: Antisocial, introversion and impulsiveness.
Developmental failures:
Abuse survivors lack of nurturance in childhood. Coping skills deficit and lack of positive
coping skills.
Dual disorder risk
Pre-existing psychiatric disorder in clients with an alcohol or substance addiction causes
an increased risk of suicide.
Environmental risk
Social learning theory (addiction as a learned behavior) Normalized behavior under peer
pressure.
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Assessment of clients with addictions
CAGE Question assessment for addictive behavior
Have you ever tried to cut back on Alcohol?
Have you ever been annoyed by comments about your drinking?
Have you ever felt guilty about drinking ?
Have you ever had an eye opener in the morning?
2 x yes = further assessment necessary
Other Assesssment tests: Michigan Alcoholism Acreening Test (MAST).
Addiction Severity Index (ASI)
Physical Assessment:
Changes in bowel function. Liver problems, including Wernickes Encephalopathy and
Korsakoff’s Psychosis. Weight loss or weight gain. Sleep disturbances. Chronic pain?
Functioning social network?
Psychosocial Assessment
Substance use Assessment
Substance abuse in history?
Medication Assessments
Overuse of prescription medication?
Outcome
Multi specialty approach. Prognosis is mainly determined by compliance of client.
Treatment:
Detoxifications and Abstinence medications
Disulfiram (Antabuse)
Daily average dosage 250mg/d orally. Prevents breakdown of alcohol. If still consumed,
appearance of severe gastrointestinal problems. May increase liver enzymes.
Naltrexone (ReVia)
Daily average dosage 50mg orally. Prevents and diminishes cravings/euphoric effect.
Used in alcohol and opiate dependency. May increase liver enzymes.
Antidepressants/Anxiolytics
Enhance and stabilize mood . Gradual dosage reduction prior cessation necessary.
Components of psychotherapeutic intervention
Group framework key elements
1.
acceptance (there is no effective cure)
2.
surrender
3.
processing
4.
grief
5.
higher power
6.
power of the group
Cognitive behavioral model
Develop and use of positive coping skills. Identifying euphoric recall.
Relapse prevention model
Identify situations and factors that contribute to relapse.
Components of motivational Enhancement and stages of change
Reflective listening. Development of discrepancy to help clients to see themselves the
way they really are. Assessments of client’s stages of change.
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Substance Abuse
Alcohol
Effect is dose dependent and biochemically induced due to enhancement of GABA
synthesis. Medication therapy for alcohol withdrawal treatments includes:
Chlordiazepoxide (Librium), Diazepam (Valium) and Lorazepam (Ativan)
In conjunction with Atenolol (Beta–blocker) and Disulfiram.
Disulfiram effect:
= Alcohol dehydrogenase enzyme inhibition leads to an increase of acetaldehyde when
client consumes alcohol. Results in sudden onset of nausea, vomiting, dizziness,
hypertension and flushing. Long half life of Disulfiram requires up to two weeks time to
elapse before alcohol can get consumed after the last dosage of Disulfiram.
Opioids
Signs of toxicity and overdose are Miosis, coma and respiratory depression.
Opiod antagonist Naloxone (Naran) antagonist must be administered carefully and
maybe repeated because of short half life. Sudden reversal of opioid symptoms may
lead to withdrawal. Nalmefene (Revex) is an opioid antagonist with a long half life and
does not require repeated dosage. Methadone as a partial opioid antagonist is
prescribed for withdrawal purposes only.
Cocaine
Stimulant, instant but short active. Depletes Norepinephrine and Dopamine by blocking
its reuptake. Highly addictive, psychological and physical addiction. Treatment requires
restoration of neurotransmitters by using Tyrosine and phenylalanine as amino acid
catecholamine precursors as well as tricyclic antidepressants and Bromoctiptine
(Dopaminagonist).
Cannabis
Delta–9–tetrahydrocannabinol (THC). Produces euphoria, sedation and hallucinations.
Increases sensitivity to visual and auditory stimuli. Enhanced sense of touch, taste and
smell. Increased appetite. Distortion of time.Therapeutic use as an antiemetic in cancer
chemotherapy. Used to stimulate appettite in HIV patients. Mainly psychological
addiction and no severe physical withdrawal symptoms.
Suicide
Eleventh leading cause of death among all age groups. Third leading cause of death
between 10 years and adolescence. A common pattern is low self esteem and isolation
or a life situation that is regarded as hopeless. White, gay, male individuals are
statistically at highest risk.
Mood disorder is most predictive psychiatric disorder for suicide!
Suspicion of suicidality requires further specialized assessment!
Suicide assessment
Always address any suspicion of self–harm or suicidal tendencies directly!
Ambivalence may be present. Very sudden “improvement’ may indicate that client is
about to carry suicide out. Suicide watch is mandatory in case of suspected suicidal
plans. Suicide watch needs to be provided in a safe environment with 15 min checks for
24 hours, if possible with roommate.
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Psychopharmaceutical Suicide Prevention Treatment
Selective Serotonine Reuptake Inhibitors SSRI
are first choice of treatment in a suicidal depression because of low risk of OD and low
side effect profile.
Substances:
Citalopram (Celexa®), Paroxetine (Paxin®), Fluoxetine (Prozac®), Sertraline (Zoloft®)
Tricyclic Antidepressants TAD
Can be self administered in a lethal overdose. Treatment of suicidal patients requires a
reliable supervision.
Substances:
Amitryptiline (Elavil®), Clomipramine (Anafranil®), Desiramine (Norpramin®), Doxepin
(Sinequan®), Imipramine (Tofranil®), Nortryptiline (Pamelor®) and Trimipramine
(Surmontil®)
Atypical and tetracyclical Antidepressants
Bupropion (Wellbutrin®), Venlafaxine (Effexor), Mirtazapine (Remeron®), Duloxetine
(Cymbalta)
Monoaminoxidase Inhibitors MAOI’s
Clients need to comply to Tyramin – free diet as previously discussed. Otherwise risk of
hypertensive crisis.
Substances:
Tranylcypromine (Parnate®), Phenelzine (Nardil®) and Isocarboxid (Marplan®)
Mood stabilizers
Prescribed in Bipolar disorders.
Lithium, Valproic acid (Depakote®), Carbamazepine (Tegretol®), Lamictal
(Lamotrigene®), Gabapentin (Neurontin®), Topiramate (Topamax®) and Olanzapine
(Zyprexa®).
Suicidal risk increases at first improving, euphoric effect of AD!
End of Life Care
Goal is to create an overall positive experience for client and family by accomplishing
personal goals even with suffering and loss. Caregiver led advocacy with a meaningful
and dignified death.
Core principles for professional end of life care
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Respect and dignity for client and caregiver.
Sensitive and respectful approach to clients and relatives wishes.
Appropriate measures that are consistent with clients choices.
Highest priority is alleviation of pain and other physical complaints.
Continuity of care.
Providing of any therapy that realistically improves clients condition.
Providing access to palliative care and hospice care.
Respect right to refuse treatment.
Respect physicians professional judgement and recommendation.
Recognition that dying is a profoundly personal experience and part of life cycle.
Principles of autonomy, privacy and veracity are fundamental to nursing practice!
(Veracity = determination to be truthful)!
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Basic ethical principles for end of life care:
Beneficience = ethical principal of doing good
Nonmalefficience = first do no harm
Justice = being fair
Advance directives
Based on the 1990 Client Self Determination Act.
Enables client to make decisions about their end of life care before they come in to a
situation where they might be unable to enter a decision making process.
Euthanasia
Deliberate end to life intervention; No appropriate action in accordance with the Code of
ethics for Nurses and the American Nurses position statement.
A consent decision to withdraw food and fluids and to discontinue life support to let a
disease take its natural course is acceptable in accordance to the American Nurses
Association, The Hospice and Palliative Nurses Association and the National Hospice
and Palliative Care Organization.
Physiological end of life care
Management of symptoms
Rest periods, light exercise to support circulation, treatment of anemia and
fluid supply.
Recognition of physical symptoms of nearing death
Changes in neurological function
Weakness and fatigue
Increased drowsiness and sleeping
Decreased oral intake
Dehydration
Hypernatremia
Uremia
Weakened swallow reflex
Terminal restlessness and agitation
Fever
Bowel alterations
Incontinence
Providing psychosocial support
Provide listening, understanding and communication to patient and family members.
Postmortem care
Close eyes, place dentures in mouth.
Clean from any fluids and secretions released at time of death
Remove tubes and drains
Bathe body and pad drainage areas
Apply gauze pack to anal orifice
Align body and fold hands
Pull a sheet over the body until family leaves, Keep ID in place
Documentation of time of death, depositon of the body and personal belongings.
Kubler Ross stades of Bereavement
Denial
Anger
Bargaining
Depression
Acceptance
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Rando’s Process of Bereavement
1. Recognize loss and death
2. Expression of separation and pain
3. Reminiscence
4. Relinquish old attachments
5. Readjust to adapt to the new role
6. Reinvest
Psychiatric Medication Therapy
Antipsychotics
Are divided in two subgroups: Phenothiazines and atypical antipsychotic drugs.
Phenothiazines: ( = “typical” antipsychotic agents)
Effect and therapeutic use:
Phenothiazines are also called neuroleptic medication and were the first drugs used for
treatment of different types of schizophrenia. These very complex drugs are used for
treatment of other psychotic disorders as well. Some Phenothiazine types also have an
antihistaminic and antiemetic effect. In general Phenothiazines rarely induce a tolerance
and treatments can be pursued for many years if necessary and if no side effects occur.
Neuroleptic medication has to be administered in defined dosages and punctual over a
circadian rhythm to establish a significant blood level of the particular substance.
Phenothiazines are Dopamine antagonists as well as anticholinergic drugs. The different
types of antipsychotic drugs differ in their antipsychotic and sedating effect. The weaker
the antipsychotic effect is, the stronger is the sedating effect.
Side effects:
Anticholinergic effects
- Dry mouth
- Urine retention
- Photophobia
- Constipation
- Tachycardia
- Hypertension
- Blurred vision
Extrapyramidal side effects “ESPE’s”
Akathisia
Dystonias
Disability to sit still.
Torticollis, tongue and pharyngeal cramps,
oculogyric crisis.
Parkinsonism
Picture of symptoms equivalent to Parkinson’s disease
(Tremor, rigor and akinesia)
Tardive dyskinesia
abnormal involuntary movements
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Neuroleptic malignant syndrome
Rigidity - Labile blood pressure
- Hyperthermia – Sweating - DyspneaIncontinence – Agranulocytosis –
Gynecomastia – Galactorrhea –
Sedation – Tradive diskinesia –
Seizures - Galactorrhea
Special considerations:
Occasional lack of compliance among clients with psychotic disorders may
require surveillance to assure that medication is being taken. Otherwise
intramuscular depot injections may be indicated. Clients also require frequent
laboratory studies and neurological examinations. Antipsychotics administered as
Depot injections may stabilize clients condition over long time frames.
Establishment of full effect may take up to 6 weeks. Orthostatic Hypotension may
occur. Urine color may change into light pink. Oral phenothiazine medication can
be administered with food, milk or water. Avoid skin contact with injectable
phenothiazine medication. Do not supply large amounts of medication because
of possibility of lethal overdose.
Substances:
Chlorpromazine (Thorazine®), Triflupromazine (Vesprin®), Fluphenazine
(Prolixin®), Perphenazine (Trilafon®), Trifluoperazine (Stelazine®), Thiothixene
(Navane®), Haloperidol (Haldol®), Molindone (Moban®) and Loxapine
(Loxitane®)
Atypical antipsychotic drugs (Clozapine, Risperidone and Olanzapine)
Effect and therapeutic use:
These medications block Serotonin as well as Dopamin receptors of the cenral
nervous system and show effect against positive and negative treatments of
schizophrenia. Especially in early stages, as well as against other psychotic and
mood disorders.
In comparison to typical antipsychotics these substances show little or no
extrapyramidal side effects at all!
Special considerations:
Olanzapine (Zyprexa®)
Induces significant weight gain. Moderate anticholinergic side effects.
Max. dosage = 15 mg/d.
Clozapine (Cloxaril®)
Agranulocytosis! Clients require weekly CBC! Maximum dosage = 900 mg/d.
Seizures.
Risperidone (Risperdal®)
Hypotension, Insomnia, Agitation, Headache, Anxiety and Rhinitis.
Antidepressants
Tricyclic Antidepressants (TCA)
Effect and therapeutic use:
TCA’s block the reuptake of stimulating monoamine Neurotransmitters.
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Therapeutic effect may take up to 3 weeks.
Indicated in depression, attention deficit disorder, panic disorder and chronic
insomnia.
Increase appetite, regulate sleep pattern, elevate mood and increase of physical
activity.
All TCA substances have equal potency and effect but differ concerning their
side effects.
Common duration of treatments is up to 12 months. TCA can not be combined
with Monoamine oxidase uptake inhibitors or with direct acting
sympathomimetiscs (i. e. epinenephrine and norepinephrine).
Side effects and special considerations:
Orthostatic hypotension, sedation due to blockade of CNS histamin receptors,
anticholinergic effect, cardiotoxicity (slowing intracardial conduction), lowering of
seizure threshold, hypomania and sexual dysfunction.
TCA’s weaken effect of indirect acting sympathomimetics (Ephedrine and
Amphetamine)
Combination with direct acting sympatomimietics (i. e. epinephrine and
norepinephrine) or Monoaminoxidase Inhibitors (MAOI’s) can lead to a severe
hypertensive reaction.
Suicidal patients need to remain under surveillance in an inpatient setting,
especially in the beginning of the treatment with TCA’s.
Substances:
Amitryptiline (Elavil®), Clomipramine (Anafranil®), Desipramine (Norpramin®),
Doxepin (Sinequan®), Imipramine (Tofranil®), Trimipramine (Surmontil®),
Nortryptiline (Pamelor®).
Monoaminoxidase Inhibitors MAOI’s
Effect and therapeutic use:
Monoaminoxdase inhibitors can cause severe side effects by food and drug
interactions and are therefore not a first choice of medication. Prescribing
requires a detailed instruction of the client on dietary regulations. Effect is caused
by inhibition of Tyramine and other biogenic amines and monoamine transmitters.
Indications are treatment of depression, bulimia, obsessive–compulsive disorders
and panic disorders. Combination with other sympathomimetic medications may
lead to a hypertensive crisis.
Patients under treatment with MAOI’s are required to avoid Tyramine containing
food
Aged cheeses: e. g. Roquefort, camembert, blue and brie cheese; aged and
cured meat and fish, tofu, soy, draft beer, chianti wine, sauerkraut, yeast extracts
and canned soups.
Medication to avoid under MAOI treatment:
Nasal decongestants, other antidepressant medication, antihistamines, asthma
medication, narcotics, (mepridine), epinephrine, cocaine and amphetamines.
Food to consume with caution under treatment with MAOI’s:
Mozzarella, cottage, ricotta, cream, processed food, liver, meats, herring,
raspberries, bananas, avocado, spinach, wine, glutamate, pizza, chocolate,
caffeine, nuts and dairy products. Insulin, oral Antidiabetics, oral anticoagulants,
thiazide diuretics, anticholinergic agents and muscle relaxants.
Substances
Phenelzine (Nardil®) and Tranylcypromine (Parnate®)
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Selective Serotonine Reuptake Inhibitors (SSRI)
Effect and therapeutic use:
Shorter duration (1-3 weeks) until onset of therapeutic effect and less side effects
than MAOI and TCA Antidepressants. SSRI block reuptake of Serotonine.
Indications are Depression, obsessive-compulsive disorder, panic disorder and
bulimia nervosa.
Special considerations:
Contraindicated in hepatic or renal disease. SSRI have a high tendency to bind
to plasma proteins. Interaction with other medication with same characteristics
have to be expected. Especially Warfarin levels may be affected. Frequent CBC
and bleeding time assessments are required. Changing from SSRI to MAOI
requires at least 2 weeks to elapse, before medication can be started. Changing
from MAOI to SSRI require at least 5 weeks to elapse. SSRI and MAOI can not
be combined since their synergetic effects may cause a Serotonine syndrome.
Suicidal patients need to remain under surveillance in an inpatient setting
especially in the beginning of the treatment with SSRI.
Substances:
Citalopram (Celexa®), Escitalopram (Lexapro®), Fluoxetine (Prozac®),
Fluvoxamine (Luvox®), Paroxetine (Paxil®) and Sertraline (Zoloft®)
Other Antidepressants
Bupropion
Effect and therapeutic use:
Chemically related to amphetamines. Blocks reuptake of Dopamin in CNS.
Suppressing Appetite. Well suitable for elderly patients due to less anticholinergic
side effects in comparison to other antidepressants. Used for smoking cessation
therapy as well.
Side effects/special considerations:
Agitation and insomnia are most common side effects. Especially in clients with a
history of bipolar disorder. Dose related seizures also common. Dosage
adaptation by age and renal or hepatic impairment necessary.
Trazodone
Effect and therapeutic use:
Second line treatment for depression, mainly used in combination with other
antidepressants. Slow onset of antidepressant effect by altering effect of
Serotonin in CNS.
Side effects/special considerations:
May cause Dyrhytmias, cardiac assessments prior and during therapy are
frequently necessary. Trazodone may cause gastrointestinal side effects and
therefore has to be taken immediately after meals. Patients under Trazodone and
Bupropion have to be carefully assessed for suicidal tendencies in early phase of
the treatment.
Antimania Medications
Lithium
Effect and therapeutic use:
Long Term prophylaxis in recurrent manic depression. Control of manic episodes
in bipolar disorders. Altering stimulating neurotransmitters in a not fully explored
way. The Antimania effect appears after 5–7 days and full effect after 3 weeks.
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Contraindications:
Dementia, dehydration, elderly clients. Preexisting hepatic or renal failure,
cardiac disease, thyroid gland disorder and diabetes mellitus.
Side effects/special considerations:
Treatment requires close monitoring of blood level, every 1-2 month and as
required.
Normal Level: 0.8–1.4 mEq/L. Levels alter with sodium excretion. High sodium
excretion leads to an increased lithium excretion. Loss of sodium through
dehydration may cause lithium toxicity. Treatment requires at least 2000–3000
mL fluids/d. and input/output monitoring.
Missed doses to be taken as soon as remembered unless 2 hours prior next
dose (6 hours if MR). Clients > 40 require ECG Assessment.
High amounts of Caffeine have to be avoided because of diuretic effect!
Lithium toxicity
Mild toxicity: (from 1.4 mEq/L) lethargy, muscle weakness, tremors, ataxia.
Moderate toxicity: (1.5 – 2.5 mEq/L) Gastrointestinal symptoms, blurred vision,
tinnitus.
Severe toxicity: (> 2.5 mEq/L) Nystagmus, hyperreflexia, impaired LOC,
hallucinations, renal failure and death.
Sedatives, Hypnotics and Anxiolytics
Benzodiazepines
Effect and therapeutic use:
Inhibitory GABA Receptor–Agonists.
Medication has pharmacological active metabolites which ensure a longlasting
effect.
Indications:
anxiety, insomnia, seizures, alcohol withdrawal and skeletal muscle relaxation.
Contraindicated in lactation and pregnany as well as in any condition that causes
hepatic impairment. Addictive potential. No abrupt withdrawal after long term
treatment. Can cause paradox effects especially in elderly clients.
Substances:
Alprazolam (Xanax®) , Chlordiazepoxide (Librium®), Clonazepam (Klonopin®)
Clorazepate (Tranxene®), Diazepam (Valium®), Flurazepam (Dalmane®),
Lorazepam (Ativane®), Midazolam (Versed®), Triazolam (Halcion®), Oxazepam
(Serax®) and Temazepam (Restoril®)
Benzodiazepine Antagonist
Flumazenil (Romazicon®)
Reverses all effects of Benzodiazepines but the respiratory depression.
Substance becomes immediately active after intravenous administration.
Sedation can reoccur for up to two hours after administration. May cause acute
Benzodiazepine withdrawal syndrome, including seizures, confusion, agitation,
nausea, dizziness and paresthesias.
Barbiturates
Unspecific CNS Depression. Used for sedation, seizure treatment and general
anesthesia. Addictive potential. Not to be administered by intramuscular because
of the danger of muscle necrosis due to alkaline solution! Effect is depending on
dosage in the order of sedation
sleep
general anesthesia. Cardiovascular
depression due to effect on heart muscle and smooth vascular muscle. Overdose
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symptoms are similar to Morphine overdose = Coma, Miosis and Respiratory
Depression. Women require nonhormonal birth control during treatment. Can
cause pain syndromes and paradox effects, esp. in elderly clients.
Substances :
Amobarbital (Amytal®), Butabarbital (Butisol®), Pentobarbital (Nembutal®)
Phenoparbital (Luminal) ® and Secobarbital (Seconal®)
Buspirone
Anxiolytic medication. Binds to Dopamine and Serotonine Receptors.
Increases Norepinephrine metabolism in the central nervous system.
Nonsedative character. No abuse or addictive potential. No CNS Depression.
May cause dizziness, nausea, headaches, nervousness and dystonia.
Zolpidem
GABA Agonist. Used for short term and on demand treatment of insomnia. Rapid
onset of action. Comparable to Benzodiazepines.
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Normal reference ranges for laboratory test results
UNITS:
Mass concentration (g/dL or g/L) is the most common measurement unit in the
United States. Liters are usually given with dL (decilitres).
Molar concentration (mol/L) is used to a higher degree in most of the rest of the
worldincluding the United Kingdom and other parts of Europe and Australia.
Laboratory Test
Normal Range in US Units
Normal Range in SI Units
ALT (Alanine
aminotransferase)
W 7-30 units/liter
M 10-55 units/liter
W 0.12-0.50 µkat/liter
M 0.17-0.92 µkat/liter
Albumin
3.1 - 4.3 g/dl
31 - 43 g/liter
Alkaline
Phosphatase
W 30-100 units/liter
M 45-115 units/liter
W 0.5-1.67 µkat/liter
W 0.75-1.92 µkat/liter
Amylase (serum)
53-123 units/liter
0.88-2.05 nkat/liter
AST (Aspartate
aminotransferase)
W 9-25 units/liter
M 10-40 units/liter
W 0.15-0.42 µkat/liter
M 0.17-0.67 µkat/liter
Basophils
0-3% of lymphocytes
0.0-0.3 fraction of white blood
cells
Bilirubin - Direct
0.0-0.4 mg/dl
0-7 µmol/liter
Bilirubin - Total
0.0-1.0 mg/dl
0-17 µmol/liter
C peptide
0.5-2.0 ng/ml
0.17-0.66 nmol/liter
Calcium, serum
8.5 -10.5 mg/dl
2.1-2.6 mmol/liter
Calcium, urine
0-300 mg/24h
0.0-7.5 mmol/24h
Cholesterol
200 mg/dL
5.0 mmol/liter
Cholesterol, LDL
190 mg/dL
4.91 mmol/liter
Cholesterol, HDL
> 60 mg/dL
> 1.0 mmol/l
Creatine kinase
W 40-150 units/liter
M 60-400 units/liter
W 0.67-2.50 µkat/liter
M 1.00-6.67 µkat/liter
Eosinophiles
0-8% of white blood cells
Erythrocyte
sedimentation rate
W<=30 mm/h
M<=20 mm/h
W<=30 mm/h
M<=20 mm/h
Folate
3.1-17.5 ng/ml
7.0-39.7 nmol/liter
Glucose, urine
<0.05 g/dl
<0.003 mmol/litro
Glucose, plasma
70-110 mg/dl
3.9-6.1 mmol/liter
GGT (Gamma
glutamyl
transferase)
W <=45U/L
M <=65 U/L
W <=45U/L
M <=65 U/L
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Hematocrit
W 36.0% - 46.0%
M 37.0% - 49.0%
of red blood cells
W 0.36-0.46
M 0.37-0.49
fraction of red blood cells
Hemoglobin
W 12.0-16.0 g/dl
M 13.0-18.0 g/dl
W 7.4-9.9 mmol/liter
M 8.1-11.2 mmol/liter
LDH (Lactate
dehydrogenase)
(total)
<=270 U/L
<=4.5 µkat/liter
Lactic acid
0.5-2.2 mmol/liter
3
3
0.5-2.2 mmol/liter
4.5-11.0x109/liter
Leukocytes (WBC)
4.5-11.0x10 /mm
Lymphocytes
16%-46% of white blood
cells
0.16-0.46 fraction of white blood
cells
Mean corpuscular
hemoglobin (MCH)
25.0-35.0 pg/cell
25.0-35.0 pg/cell
Mean corpuscular
hemoglobin
concentration
(MCHC)
31.0-37.0 g/dl
310-370 g/liter
MCV (Mean
corpuscular volume)
W 78-102 µm3
M 78-100 µm3
W 78-102 fl
M 78-100 fl
Monocytes
4-11% of white blood cells
0.04-0.11 fraction of white blood
cells
Neutrophils
45%-75% of white blood
cells
0.45-0.75 fraction of white blood
cells
Phosphorus
2.5 – 4.5 mg/dL
0.81-1.45 mmol/L
Platelets
(Thrombocytes)
130 – 400 x 10 3µL
130 – 400 x 10 9L
Potassium
3.4-5.0 mmol/liter
3.4-5.0 mmol/liter
RBC
W 3.9 – 5.2 x 106/µL3
M 4.4 – 5.8 x 10 6/µL3
W 3.9 – 5.2 x 1012/L
M 4.4 – 5.8 x 10 12/L
Sodium
135-145 mmol/liter
135-145 mmol/liter
Triglycerides
40-200 mg/dl
0.45 - 2.26 mmol/liter
Urea, plasma (BUN)
8-25 mg/dl
2.9-8.9 mmol/liter
Urinalysis - pH
Specific gravity
5.0-9.0
1.001-1.035
5.0-9.0
1.001-1.035
WBC (White blood
cells, leukocytes)
4.5-11.0x10 3 /mm 3
4.5-11.0x10 9 liter
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KEYWORD REVIEW
Baseline knowledge requirements of the NCLEX-RN®
Index of content related keywords
Safe and effective care environment
Management of care
p. 9 - 14
Advance Directives
Advocacy
Case Management
Client Rights
Collaboration with interdisciplinary Team
Concepts of Management
Confidentiality / Information Security
Consultation
Continuity of Care
Delegation
Establishing Priorities
Ethical Practice
Informed Consent
Information Technology
Legal Rights and Responsibilities
Performance Improvement
(Quality Improvement)
Referrals
Resource Management
Staff Education
Supervision
Safety and infection control
p. 15 - 21
Accident Prevention
Disaster Planning
Emergency Response Plan
Ergonomic Principles
Error Prevention
Handling Hazardous and Infectious Materials
Home Safety
Injury Prevention
Medical and Surgical Asepsis
Reporting of Incident/Event/Irregular Occurrence/Variance
Safe Use of Equipment
Security Plan
Standard/Transmission-based/Other Precautions
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Health Promotion and Maintenance
p. 21 - 74
Aging Process
Ante/Intra/Postpartum and Newborn Care
Developmental Stages and Transitions
Disease Prevention
Expected Body Image Changes
Family Planning
Family Systems
Growth and Development
Health and Wellness
Health Promotion Programs
Health Screening
High-Risk Behaviors
Human Sexuality
Immunizations
Psychosocial Integrity
p. 294 – 312
Abuse / Neglect
Behavorial Interventions
Chemical and Other Dependencies
Coping Mechanisms
Crisis Intervention
Cultural Diversity
End – of – Life Care
Family Dynamics
Grief and Loss
Mental Health Concepts
Psychopathology
Religious and Spiritual influences on Health
Sensual / Perceptual Alterations
Situational Role Changes
Stress Management
Support Systems
Therapeutic Communications
Therapeutic Environment
Physiological Integrity
p. 105 - 177
• Basic Care and Comfort
p. 105 - 117
Assistive Devices
Complementary and Alternative Therapies
Elimination
Mobility / Immobility
Non – Pharmacological Comfort Interventions
Nutrition and Oral Hydration
Palliative / Comfort Care
Personal Hygiene
Rest and Sleep
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•
Pharmacological and Parenteral Therapies
p. 133 - 144
Adverse Effects / Contraindications and Side Effects
Blood and Blood Products
Central Venous Access Devices
Dosage Calculation
Expected Effects / Outcomes
Medication Administration
Parenteral / Intravenous Therapies
Pharmacological Agents / Actions
Pharmacological Interactions
Pharmacological Pain Management
p. 46; 249;277
Total Parenteral Nutrition
•
Reduction of Risk Potential
p. 74 - 105
Diagnostic Tests
Laboratory Values
Monitoring Conscious Sedation
Potential for Alterations in Body Systems
Potential for Complications of Diagnostic Tests
Potential for Complications from Surgical Procedures and
HealthAlterations
System Specific Assessments
Therapeutic Procedures
Vital Signs
•
Physiological Adaptation
p. 15 – 21
Alterations in Body Systems
Fluid and Electrolyte Imbalances
Hemodynamics
Illness Management
Infectious Diseases
p. 157 - 166
Medical Emergencies
Pathohysiology
p. 145 - 319
Radiation Therapy
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QUESTION REVIEW
NCLEX-RN® practice exam questions and answers
1. Which of the following characteristics is not part of the elements of nursing
practice as defined by the National Council of State Boards of Nursing?
A)
B)
C)
D)
E)
Caring
Communication
Teaching
Documentation
Consideration of treatment options
p. 9
2. A 30 year old female client is admitted to a hospital for a controlled alcohol
withdrawal treatment. Prior to the supply of the appropriate oral medication the
nurse has forgotten to collect urine for a pregnancy test. Which of the
following legal terms describes this situation most accurately?
A)
B)
C)
D)
Negligence
Malpractice
False imprisonment
Battery
p. 10
3. Ethics, Morals and Values of nursing practice are based on which of the
following principles?
A)
B)
C)
D)
E)
Autonomy
Beneficence
Justice
Confidentiality
All principles apply
p. 9
4. A client is admitted to the Emergency Room because of a sudden severe chest
pain. The attending nurse considers his complaints as not being typical for a
serious condition and delays routine diagnostic assessments. Later this client
experiences a massive myocardial infarction.
Which form of liability applies under the described circumstances?
A)
B)
C)
D)
E)
Negligence
Malpractice
Assault
Battery
Invasion of privacy
p. 10
5. A client files a complaint against a nurse because of an inappropriate approach
in an examination setting. He states that the nurse started a physical
assessment without obtaining the clients consent first. Which form of liability
applies in this case?
A)
B)
C)
D)
E)
Battery
Invasion of privacy
Fraud
Defamation of character
False Imprisonment
p. 10
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6. A nurse rejects maintaining standard infection precautions prior to the start of
an intravenous therapy. The client later suffers from a severe systemic
infection. The nurse may face legal charges because of:
A)
B)
C)
D)
E)
Defamation of character
Malpractice
Battery
Negligence
Assault
p. 10
7. A doctor starts a physical examination without obtaining the patients consent
first. Which form of liability applies in this case?
A)
B)
C)
D)
E)
Defamation of character
Malpractice
Battery
Negligence
Assault
p. 10
8. Which of the following principles of professional nursing does not apply?
A)
B)
C)
D)
E)
Empathy
Open and honest communication
Personal statement about clients condition and prognosis
Promotion of clients independence
Holistic care
p. 9
9. An unconscious adult client is admitted to a surgical unit with a life threatening
injury which requires immediate surgical intervention. Which of the following
statements describes the performance appropriately?
A) No treatment can be performed without an informed consent from this client.
B) It is necessary to find this clients relatives to obtain an informed consent
prior to any treatment.
C) Informed consent is not a requirement in this case.
D) No treatment is necessary if this clients condition results from a suicide
attempt.
E) Informed consent is not required for surgical procedures.
p. 10
10. Which of the following individuals in a therapeutic team is obligated to
maintain confidentiality about a client’s condition?
A) Psychotherapist
B) Physiotherapist
C) Nurse
D) Doctor
E) All of these professionals
p. 10
11. Which of the following statements about a health care proxy is correct?
A) A competent client who has filed a health care proxy should still make healthcare
decisions.
B) A health care proxy requires an agent to execute the decisions that are stated in
the health care proxy.
C) The legal term of a health care proxy is power of attorney.
D) A health care proxy has to be followed once the client loses his or her ability to
communicate.
E) All of the statements are correct.
p. 10
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12. In which of the following cases does a healthcare professional violate a clients
right for confidentiality?
A) Discussing a clients physical complaints with another healthcare professional
who is also involved in this clients treatment and care.
B) Telling a visiting colleague who is not involved in this client’s treatment personal
details about a client.
C) Sharing clinical observations with other healthcare professionals on the ward
during a nursing round.
D) Reporting suicidal ideas of a client to the health care provider.
E) Transferring a clients medical record to another department of the hospital where
this client will receive treatment.
p. 10
13. Please choose the statement which identifies the criteria of clinical death
accurately.
A)
B)
C)
D)
E)
No brainwaves, no spontaneous breathing and no sensomotoric reflexes
No spontaneous breathing, miosis and lack of bowel sounds
No brainwaves, flat line ECG and mydriasis
No arousable to any stimulus, absence of DTR’s and hypoxemia
No audible heart sounds, no spontaneous breathing and midriasis
p. 11
14. Which of the following statements concerning safeguarding a clients autonomy
and liberty applies?
A) An involuntary hospital admission under the Mental Health Act is only justified
in cases of self–or public endangerment.
B) Informed consent must not be obtained at all from a client who was
involuntarily admitted to a psychiatric unit.
C) It is generally impossible for the average client to choose from different
treatment options.
D) A clients autonomy is generally restricted in a healthcare setting.
E) A client is not allowed to leave a hospital without approval of the
healthcare provider.
p. 10
15. Which of the following incidents in a healthcare setting must not be reported to
external agencies?
A) Lack of health insurance coverage of a client
B) Sexual harassment
C) Evidence of communicable diseases
D) Unsafe work conditions
E) Evidence of crimes
p. 11
16. A Healthcare management system offers healthcare coverage and delivers a
defined package of medical services. The voluntary enrolled members are
required to make periodic payments to maintain health insurance coverage and
are only eligible to receive treatment within this network. Services that can not
be offered within this network require a referral or can be denied. This type of
health care setting is considered as a:
A) Preferred Provider Organization (PPO)
B) Health Maintenance Organization (HMO)
C) Case Management
D) Private Health Insurance
E) Point of Service System (POS)
p. 11/12
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17. Which of the following nursing care delivery systems is considered as the
most cost efficient and therefore most widely used?
A) Shared governance models of practice
B) Primary Nursing
C) Team Nursing
D) Functional Nursing
E) All of the above named nursing care delivery systems have equal
cost efficiency.
p. 12
18. Which of the following situations requires the most immediate attention of an
attending nurse?
A) A client complaints about shortness of breath.
B) A surgical client appears with an acute postoperative bleeding.
C) A client is complaining of dysuria.
D) Administering of an intravenous therapy at a defined time as ordered.
E) Providing essential discharge instructions to a client with previously
uncontrolled diabetes.
p. 12/13
19. Please identify the activity with the least urgency.
A)
B)
C)
D)
E)
Providing preventive medication therapy.
Following specific agency procedures.
CPR treatment.
Comforting a client in acute emotional distress.
Assessment of a client with acute chest pain.
p. 13
20. Which of the following priority of care schemes can be considered as the one
with the highest priority?
A) ABC
B) Care related to client acuity.
C) Time
D) Priorities in medication therapy
E) Maslow’s Hierarchy of needs
p. 13
21. Maslow’s Hierarchy of Needs considers which of the following priorities in
client care?
A) Safety and security
B) Immediate tasks
C) Medication for acute physical distress
D) ABC’s
E) Agency specific urgent response policy
p. 12
22. An obese male client with a severe and ongoing gastrointestinal bleeding is
admitted to the Emergency Room. He is awake and responding on arrival.
Which of the following tasks of the attending nurse has the highest priority.
A) Assessment of vital signs.
B) Administering intravenous fluid supply.
C) Assessment of hemoglobin level.
D) Obtaining informed consent for an EGD.
E) Providing emotional support.
p. 13
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23. The nursing staff on a surgical ward suddenly experiences an unexpected
amount of admissions due to a mass accident. The team leader nurse has to
delegate the staff to meet which of the following priorities under any
circumstances?
A) Meeting the physiological needs of all clients on the ward.
B) Routine client and family requests.
C) Administering and maintaining medication.
D) Fulfillment of scheduled tasks within one shift.
E) Providing emotional and psychosocial support.
p. 13
24. Which of the following clinical situations has the highest priority in terms of
urgency?
A)
B)
C)
D)
Insertion of an urinary catheter
Administering total parenteral nutrition
Bleeding from a surgical wound
Pain of a fractured leg
p. 13
25. Which of the following examples for the delegation of nursing care duties,
applies most appropriately to the rules of delegation?
A)
B)
C)
D)
Delegating nursing rounds to nurse’s aids
Delegating client education to relatives
Delegating the care for a client with acute pain to an intern
Delegating the review of medical records to a newly qualified RN
p. 14
26. A female and otherwise healthy client on a gynecological ward experienced a
spontaneous abortion in the 9th gestational week and was admitted to the
hospital. The attending nurse would consider which of the following care
specifics as the most appropriate in order to the priorities of care for this client
in an acute emotional distress?
A) Providing emotional support.
B) Instructing the client that an unhealthy lifestyle is the most common cause
of spontaneous abortions.
C) Assessment of the clients health history.
D) Instructing the client about the further procedure.
E) Preparing the client for immediate surgery.
p. 13
27. Which of the following needs is considered as the one with the
highest priority in a client care setting?
A) Oxygenation need
B) Nutritional need
C) Bowel elimination need
D) Need for sleep
E) Urinary elimination need
p. 13
28. Which of the following statements about appropriate delegation of
nursing duties is correct?
A) Delegation must reduce responsibility of the delegating nurse.
B) Supervision is generally unnecessary once a task is delegated.
C) Any RN is able to perform any task that a team leader RN delegates.
D) Delegation requires clear and directed communication.
E) Delegation includes authority and ultimate responsibility for the delegated
task.
p. 13/14
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29. Which of the following criteria is not defined as one of the five rights of
delegation in nursing care?
A) Right client
B) Right task
C) Right supervision
D) Right directions
E) Right circumstances
p. p. 14
30. Which of the following conditions of a client is considered
mandatory to start a cardiopulmonary resuscitation (CPR) immediately?
A)
B)
C)
D)
E)
Shortness of breath and chest pain
ECG wave suspicious for a myocardial infarction
BP 50/80 mmHg, HR 45 bpm
Unresponsiveness, weak pulses and shallow breathing.
Unconsciousness, not moving, not breathing or taking occasional gasps
p. 16
31. Which statement about correct airway management in a CPR situation
is correct?
A) Prior to the start of a CPR the rescuer should always perform a finger sweep
of the oropharynx to detect a possible foreign body airway obstruction.
B) The head tilt-chin lift maneuver is the appropriate method to open the airway of
the victim.
C) Mouth to Nose Ventilation is unacceptable and ineffective.
D) Chest thrusts, back blows/slaps, or abdominal thrusts are appropriate to
perform at any age to remove a suspected foreign body from the airways.
E) Mouth to Mouth Ventilation is considered as effectful as ventilation via an
advanced airway.
p. 16
32. Which of the following statements about chest compressions in a CPR
situation is incorrect?
A) During chest compressions any position of the compressing hand is equally
effective as long as the procedure leads to a significant compression of the
sternum.
B) Dominant and non-dominant hand should be placed in the center of the
sternum.
C) Victims should be placed on a firm surface.
D) The effectiveness of chest compressions can be verified by palpation of the
femoral pulses of the victim, if two rescuers are available.
E) A compression – ventilation ratio of 30:2 in a CPR is recommended.
p. 17
33. Please check the following statements on cardiopulmonary
resuscitation (CPR) for correctness and mark the appropriate correct
answer.
A) A CPR victim can receive chest compressions in a prone position if a supine
position can not be accomplished.
B) An unconscious client with normal breathing should be positioned on the side
with the lower arm in front of the body.
C) During CPR rescuers should limit any interruptions.
D) It may be necessary to move a victim in need of CPR into an adequate position
even if there is a suspicion of a spinal cord injury.
E) All statements are correct.
p. 17
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34. Which of the following conditions requires the immediate start of a
cardiorespiratory resuscitation treatment? Select all that applies.
1.
2.
3.
4.
Pulselessness
Unresponsiveness
Weak but adequate response
Occasional gasps of an unresponsive individual
A)
B)
C)
D)
E)
1, 2 and 3 are correct.
1 and 4 are correct.
Only 4 is correct.
All statements are correct
None of these situations require an immediate CPR treatment.
p. 16
35. Which of the following factors is not a mandatory requirement for the
development of an infection?
A)
B)
C)
D)
E)
Infective agent
Reservoir
Transmission
Portal of entry
Previous antibiotic medication therapy
p. 19
36. Which of the following procedures is not required to maintain standard
hand hygiene in order to the first tier of CDC Guidelines of infection
control?
A)
B)
C)
D)
E)
Hand hygiene before and after each contact
Hand hygiene immediately after exposure
Repeated hand hygiene every ten minutes
Use of waterless alcohol based hand scrub
Use of plain soap
p. 19
37. Which of the following orders of using personal protective equipment is
correct?
A)
B)
C)
D)
E)
Hand hygiene first
Gown
mask
googles
gloves at last
Gown first
mask
googles
hand hygiene
gloves at last
Gloves first
mask
hand hygiene
gown
googles at last
Hand hygiene first
Gown
mask
gloves
googles at last
None of the above orders are correct. p. 19
38. Depending on the cause of infections personal protective equipment
for infection control is required in the following order:
A)
B)
C)
D)
E)
Gloves
Gown
Mask
Googles
Gown
Mask
Gloves
Googles
Gloves
Mask
Gown
Googles
Mask
Gloves
Gown
Googles
Googles
Gloves
Gown
Mask
p. 19
39. Which of the following orders of removing personal protective
equipment are correct?
A)
B)
C)
D)
E)
Gloves
mask
gown
googles
Mask
gown
googles
gloves
Googles
gown
mask
gloves
Gloves
hand hygiene
googles
None of the above orders of removing
p. 19
hand hygiene
hand hygiene
hand hygiene
gown
mask
personal protective equipment are correct?
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40. Which description does not apply to the term of medical asepsis?
A)
B)
C)
D)
E)
Differentiation between “clean” and “dirty” objects.
Donning of gloves only in cases of infectious diseases.
Hand hygiene before and after using gloves.
Invasive procedures require additional sterile precautions.
None of these descriptions apply for medical asepsis.
p. 19
41. Which of the following statements about disposal of contaminated
equipment is correct?
A)
B)
C)
D)
E)
Detached needles need to be recapped prior to their disposal.
Any medical equipment has to be considered as a potential biohazard.
Linens have to be collected in a bag prior to their removal from a clients room.
Used medical equipment does not have to be discarded immediately.
Used, non-disposable medical equipment can be collected throughout a shift and
then cleaned and decontaminated.
p. 19
42. A client on a surgical ward was diagnosed with MRSA colonization.
Which of the following statements of infection control are correct?
A) Prevention of contaminating nursing scrubbs with moist, wet body substances as
well as with secretion from wounds and mucous membranes is of highest priority.
B) Hand washing is not a primary precaution since nasal carriage is the most
common mode of MRSA contamination.
C) A MRSA colonized client can be placed in a room with a non–colonized client
with an open wound if no other room is available.
D) Infection and Colonization with MRSA lead to identical therapeutic consequences.
p. 20
43. Which of the following statements describes the term “medical
asepsis” most appropriately?
A) Sterility indicators are required.
B) Procedures consider “clean” and “dirty” objects.
C) Equipment can be used for invasive treatment.
D) Surgical caps are mandatory to be worn.
E) Using personal protective equipment is not required.
44. Principles of surgical asepsis include.
A)
B)
C)
D)
E)
p. 19
Any unsterile contact has to be avoided.
Moisture drafts bacteria.
Report of any contamination of sterile objects
Sterile items ready to use have to be in view.
All principles apply.
p. 19/20
45. Airborne infection precautions apply in which of the following cases?
A)
B)
C)
D)
E)
Clients with Rubeola, TBC and Varicella infections
Any bacterial infection
Hepatitis B infections
Cohorting of clients with different airborne infections
Airborne precautions also include contact precautions
p. 20
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46. Please identify the anatomical structure where the fertilization of an
ovum takes place.
A)
B)
C)
D)
E)
Uterus
Cervix
Ampulla of fallopian tube
Infundibulum of fallopian tube
Ovary
p. 22
47. Which of the following statements about the oogenesis is correct?
A)
B)
C)
D)
E)
Oocytes are entirely present at birth.
FSH stimulates differentiation of an oocyte into an ovum.
LH supports the development of the corpus luteum.
The Corpus Luteum produces progesteron.
All of the above statements are correct.
p. 22
48. A sexual hormone is produced and excreted by ovaries. It reaches its
peak levels in the follicular phase of the menstrual cycle and inhibits
the secretion of luteinizing hormone and follicle stimulating hormone.
This description applies to which of the following hormones?
A)
B)
C)
D)
E)
Estrogene
Progesterone
Testosterone
Gonadotropine releasing hormone
None of the above named hormones
p. 23/24
49. A 29 year old women was diagnosed with a Corpus Luteum
insufficiency. This condition leads to a reduced production of which of
the following hormones?
A)
B)
C)
D)
E)
Estrogene
Luteinizing hormone
Follicle stimulating hormone
Progesterone
Prolaktin
p. 23
50. Which of the following characteristics describes the function of the
Corpus luteum most accurately?
A)
B)
C)
D)
Supply of estrogene
Termination of pregnancy
High levels of FSH throughout the entire menstrual cycle
Maintaining an early pregnancy
p. 22
51. Which of the following conditions have to be met for the development
of an erythroblastosis fetalis?
A)
B)
C)
D)
Mother: Rhesus negative, Child: Rhesus positive.
Mother: Rhesus negative, Child: Rhesus negative.
Mother: Rhesus positive, Child: Rhesus positive.
Mother: Rhesus negative, Father: Rhesus negative.
p. 30
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52. A 36 year old and otherwise healthy women is expecting her first child.
Which of the following recommendations should the attending nurse
make in a first antenatal assessment?
A)
B)
C)
D)
Recommendation for an Amniocentesis between in the 16th gestational week.
No recommendations at all since the client is healthy.
Recommendation for a Caesarean delivery under any circumstances.
Recommendation to treat even severe bacterial infections during pregnancy
without antibiotics.
p. 37
53. Which of the following female sexual hormones is expected to produce
its peak levels at the time of an ovulation?
A)
B)
C)
D)
E)
Luteinizing hormone
Progesterone
Prostaglandine
Estrogen
Follicle stimulating hormone
p. 23
54. Please identify the most accurate description of the physiological
function of the Corpus Luteum.
A) The Corpus Luteum provides the production of progesterone and supports a
pregnancy.
B) A functioning Corpus Luteum is not mandatory for the survival of an early
pregnancy.
C) The persistence of the Corpus Luteum is not depending on the fertilization of an
ovum.
D) A Corpus Luteum weakness does not interfere with fertility.
E) None of the statements describe the physiological function of the Corpus Luteum
correctly.
p. 22
55. Which of the sequences below describe the most immediate
developments after fertilization of an ovum?
A)
B)
C)
D)
E)
Cleavage
blastocyst
morula
trophoblast
implantation
Blastocyst
morula
trophoblast
conception
Trophoblast
morula
blastocyst
implantation
Conception
trophoblast
morula
cleavage
blastocyst
Implantation
cleavage
conception
p. 22
56. Which of the following statements about the normal menstrual cycle is
incorrect?
A) A menstruation occurs if the ovum is not fertilized and the Corpus Luteum
disintegrates.
B) Estrogen and progesterone levels drop in the last week of the menstrual cycle.
C) Day 1 – 14 of the menstrual cycle is considered as the follicular phase.
D) Day 15 – 28 of the menstrual cycle is considered as the luteal phase.
E) The luteal phase can drastically vary in length and determines the overall
duration of the menstrual cycle.
p. 23
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57. An amenorrhea for more than one year in a women of 50 years of age is
suspicious for which of the following conditions?
A)
B)
C)
D)
E)
Uterine cancer
Menopause
Hypothyroidism
Ovarian cysts
Diabetes
p. 24
58. A 27 year old man underwent a semen analysis to assess his fertility.
The results are as follow:
•
•
•
Semen 2,6 ml
8 Million Sperm /ml.
50% of normal form and motion
Which of the following conclusions can be drawn from this information:
A)
B)
C)
D)
E)
The results show an abnormal amount of Sperm and Semen.
These results are characteristic for an untreatable infertility.
No relevant statement about this client’s fertility can be made from these results.
The client can be assured about a normal result of his semen analysis.
This client probably produces a significant amount of estrogen.
p. 24
59. Common methods of fertility assessment do not include:
A)
B)
C)
D)
E)
Basal Body Temperature
Cervical mucus monitoring
Laparascopy
Male semen analysis
Fallopian tube biopsies
p. 25
60. Mandatory counseling as a legal requirement prior to a termination of
pregnancy has to include:
A)
B)
C)
D)
E)
Benefits
Alternatives
Explanations of medical term
Documentation
All above named factors are required to be addressed
p. 26
61. Which of the following statements about contraception methods is
correct?
A)
B)
C)
D)
E)
All available contraceptives have the same Pearl–Index.
Female condoms can be used in cases of latex allergy.
Diaphragm and cervical caps protect reliably against STI’s.
Copper intrauterine devices have to be changed once yearly.
All statement are incorrect.
p. 26-28
62. A toxic shock syndrome can most likely occur due to the use of which
of the following contraceptive methods?
A)
B)
C)
D)
E)
Condoms
Cervical sponges
Birth control pill
Fertility awareness method
Hormonal implants
p. 27
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63. A female client has forgotten to take her combined birth control pill for
two consecutive days. Which is the most appropriate advice to give to
this client?
A) After missing more than one pill this client should pause the pill until a withdrawal
bleeding occurs and then start a new pill cycle. Until then extra contraceptive
precautions have to be met.
B) Missing a combined pill for two days does not compromise its birth control effect.
C) A pregnancy test should be performed immediately.
D) A temporary dosage increase of the combined birth control may make up for this
mistake.
F) None of this advice is correct.
p. 28
64. A 39 year old female client is requesting information on contraception
methods. The attending nurse assesses the following relevant data:
•
•
•
•
•
•
Weight: 164 lbs
Height: 5’7”
Non–smoker
Regulated menstrual cycle
History of a deep vein thrombosis at the age 22
A recent mammogram has revealed no pathology
Based on the information provided which contraceptive method would be the most
appropriate for this client?
A) Intrauterine device
B) Cervical sponge
C) Cervical cap
D) Combined birth control pill
E) Female condom
p. 27/28
65. Which of the following statements describe the main benefits of a
progesterone – only “mini pill” in comparison to a combined birth
control pill?
A) A mini pill can be prescribed to women over 35 years of age as well as during
lactation and in cases of mild hypertension and estrogen side effects.
B) The main benefit of the mini pill is a reduced estrogen concentration.
C) There are no major differences between a combined and a progesterone only
birth control pill.
D) A mini pill can also be used as a hormone replacement therapy in menopausal
women.
E) A mini pill makes an extrauterine gravidity less likely to occur.
p. 27/28
66. A female client receives a positive result of a pregnancy test in an
encounter with a nurse. The client states that her last period of her
usually regulated menstrual cycle started on August 12. Please state
the estimated time of delivery by using the Naegeles rule.
A)
B)
C)
D)
E)
May 19
April 10
June 12
March 2
April 19
p. 29
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67. Which of the following descriptions of the McDonald’s method is
correct?
A)
B)
C)
D)
E)
The McDonald’s method requires an ultrasound examination.
The McDonald’s method can be used in every pregnant women.
The McDonald’s method can be used from the 2nd gestational week.
The McDonald’s method is most reliable from midterm pregnancy.
The McDonald’s method is more reliable than Naegeles rule.
p. 29
68. Which of the following factors are of importance for a first antenatal
examination?
A) Number of children born in term after 37 weeks of gestation.
B) Number of preterm infants born between 20 and 37 weeks of gestation.
C) Number of spontaneous or therapeutic abortions prior to the 20th gestational
week.
D) Number of living children.
E) All of the above named factors have to be assessed at a first antenatal
examination.
p. 29
69. Please identify the positive signs of a pregnancy from the symptoms
stated below:
1)
2)
3)
4)
5)
Fetal heartbeat
Fetal movement palpable by examiner
Visualization of fetus in ultrasound
Morning sickness
Amenorrhea
A)
B)
C)
D)
E)
Only 4 and 5 are correct.
Only 1, 2 and 3 are correct
All of the above named symptoms are positive signs of a pregnancy.
Only 3 is correct.
Only 2 and 3 are correct
p. 29
70. Parameters that are routinely assessed in a maternal pregnancy
examination do not include:
A)
B)
C)
D)
E)
Vital signs
Height
Weight
Tetanus vaccination status
Blood type
p. 29
71. Laboratory pregnancy assessment parameters are:
A)
B)
C)
D)
E)
Rh factor and irregular antibodies
Rubella titer
Tuberculin skin test
Renal function tests
All of the above parameters are assessed in a pregnancy
p. 29
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72. Which of the following maternal blood type constellations can
potentially lead to an erythroblastosis fetalis?
A)
B)
C)
D)
E)
Rh negative
Rh positive
A, B and A/B
A/B only
None of these blood types
p. 30
73. A pregnant client undergoes a routine examination at her first antenatal
assessment. Her urinalysis shows the following results:
•
•
•
•
•
•
> 100.000 bacteria/ml
Urine ph < 7
Glucose of 160 mg/dL
Specific gravity increased
Protein urine traces
Evidence of Nitrite and WBC’s
Which of the following conclusions can be drawn from this examination result?
A)
B)
C)
D)
E)
Physiological finding and no action necessary.
Suspicion of urinary tract infection, dehydration and gestational diabetes.
Suspicion of a nephrotic syndrome in an end stage renal disease.
Metabolic alkalosis.
This client is at high risk to develop a HELLP syndrome.
p. 30
74. Which examination is described as the TORCH Screening.
A)
B)
C)
D)
E)
Assessment for gestational diabetes
Assessment for blood type incompatibility
First gestational ultrasound examination
Newborn assessment
Maternal antenatal assessment for infectious diseases
p. 30
75. Pregnant women have to avoid consumption of raw undercooked meat
as well as contact with cats to minimize the risk for an infection with:
A) Mumps
B) Measles
C) Rubella
D) Toxoplasmosis
E) Diphtheria
p. 30
76. Which of the following infections carries the highest risk for congenital
abnormalities if acquired during pregnancy?
A)
B)
C)
D)
E)
Tetanus
Hepatitis A
Mumps
Rubella
Diptheria
p. 30/31
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77. Please identify the most common cause of congenital fetal infections
from the list below.
A)
B)
C)
D)
E)
Toxoplasmosis
Hepatitis A and B
Cytomegalievirus
Herpes simplex virus
Diphtheria
p. 30/31
78. Please verify which of the following statements about sexually
transmitted diseases are correct.
1.
2.
3.
4.
5.
Hepatitis B is not primarily classified as a STI.
HIV testing does not require informed consent from client.
Syphillis is a viral infection.
Partner treatment is not necessary in STI’s.
Chlamydia infections are generally harmless.
A)
B)
C)
D)
E)
Only 1 is correct.
Only 2 and 3 are correct
Only 1, 2 and 3 are correct
1, 2, 3 and 4 are correct.
All statements are correct
p. 31/32
79. Which of the following statements about antenatal assessments are
correct?
1. Elevated AFP levels in the amniotic fluid are suspicious for neural tube defects.
2. The triple screen test includes assessment of AFP, hHCG and Estriol
concentrations in the amniotic fluid.
3. A GTT result of 162 mg/dl of venous blood glucose after 1 hour is considered as
normal.
4. Antenatal visits have to be scheduled daily after the 36th gestational week.
5. A transvaginal gestational ultrasound can be performed at any time during a
pregnancy.
A)
B)
C)
D)
E)
1,3 and 5 are correct
1 and 2 are correct
Only 1 is correct
All statements are correct
None of the statements are correct
p. 33
80. A nurse has to instruct a female client about warnings signs during
pregnancy. Which of the following statements from this client, causes
doubts that the instructions are fully understood?
A) I understand that only painful vaginal bleedings indicate danger for the intactness
of my placenta.
B) From now on I will see the doctor whenever I experience symptoms of an
urinary tract infection.
C) During the first 28 gestational weeks my routine antenatal assessments take
place every 4 weeks.
D) The spontaneous movements of my child should not decrease significantly
during this pregnancy.
E) Excessive vomiting may occur temporarily especially in the first trimester.
p. 34
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81. A female client is in her 30th gestational week. During an antenatal
routine assessment she complaints about increased backache,
heartburn, ankle edema and visual disturbances. What should be the
most appropriate immediate action of the attending nurse?
A) The nurse should assure this client that all of the described symptoms are typical
discomforts in a late pregnancy.
B) The nurse should take a blood pressure reading and asses this client for
proteinuria.
C) The nurse should give advice to limit the daily fluid intake because of the edema.
D) The nurse should encourage the client to take OTC pain relief medication
E) The nurse should arrange an immediate MSU exam to rule out an urinary tract
infection.
p. 34
82. A female client is in her 14th gestational week. During an antenatal
routine assessment she complaints about recurrent nausea and
vomiting, breast tenderness, increased urinary frequency, fatigue, and
ptyalism. What should be the most appropriate immediate action of the
attending nurse?
A) The nurse should assure this client that all of the described symptoms are typical
discomforts in an early pregnancy.
B) The nurse should advice this client to see an ENT doctor.
C) The nurse should arrange a mammogram because of the sudden breast
tenderness.
D) The nurse should encourage the client to take antibiotic medication since she
has symptoms of an urinary tract infection.
E) The nurse should arrange an immediate MSU examination.
p. 38
83. Which of the following findings are considered to be physiological changes
in pregnancy?
A)
B)
C)
D)
E)
Goodell’s sign
Chadwick’s sign
Hypertrophy of uterus
Increase heart rate at rest
All findings are considered as physiological changes during pregnancy p. 36/37
84. Which of the following statements about maternal nutrition and weight
development during pregnancy is correct?
A) Pregnant woman require additional 3000 calories per day as well as proteins,
folate, vitamins, minerals and trace elements.
B) An average weight gain of 35lbs during the entire pregnancy can be considered
as normal.
C) The amount of weight gained during a pregnancy is not of significance since it is
mainly caused by the growing fetus.
D) A significant lower weight gain during pregnancy is suspicious for gestational
diabetes.
E) Pregnant vegetarian women require Vitamin B12 supply from whole grain, fruits,
legumes and nuts.
p. 36
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85. Which of the following statements about the biophysical profile is not correct?
A) The BPP is a reliable tool to identify prenatal clients at high risk.
B) The BPP assesses fetal breathing movement, body movements, muscle tone
FHR and the amniotic fluid volume.
C) A BPP score of 10 is considered as abnormal.
D) The BPP score would be altered in cases of an esophageal atresia.
E) A BPP score < 15 leads to further antenatal diagnostic procedures.
p. 37
86. An Amniocentesis is suggested to a 37 year old nulliparous women in her first
pregnancy. Diagnostic information about which of the following systems and
conditions can be obtained from this procedure?
1.
2.
3.
4.
5.
A)
B)
C)
D)
E)
Lung maturity
Chromosomal disorders
Spina bifida
Congenital hip dysplasia
Neurological status
1, 2 and 4 are correct.
1, 2 and 3 are correct.
Only 4 is correct.
All statements are correct.
None of the statements are correct.
p. 37
87. A 27 year old women is is 24 weeks pregnant when she suddenly experiences
an acute painful vaginal bleeding. Vaginal examination reveals a dilated cervix.
Which is the most likely diagnosis that the receiving nurse has to consider?
A)
B)
C)
D)
E)
Inevitable abortion
Placenta praevia
Ectopic pregnancy
Incompetent cervix
Abruptio placentae
p. 39
88. A 31 year old women arrives for her routine antenatal assessment in the 30th
gestational week. During the encounter the nurse reveals the following
findings:
• BP 175/90 mmHg
• Proteinuria
• Thrombopenia
• Headache
Which is the most appropriate action to take for the further care of this client?
A)
B)
C)
D)
E)
Advise client to go home and rest.
Immediate assessment of liver enzymes.
Immediate referral for a transvaginal ultrasound.
Immediate referral for an ECG examination.
Immediate referral for a chest X-ray.
p. 39
89. A 42 year old pregnant women in her 30th gestational week is referred to the
obstetrics department. She is concerned that she suddenly experiences much
less fetal movements than before. Further examination reveals that the cervix
is closed. Uterine bleedings and contractions are not present. The fetal heart
rate shows a severe variable deceleration pattern with heart rates as low as 70
bpm for more than 60 seconds. What is the most likely cause for this
condition?
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A)
B)
C)
D)
E)
Uteroplacentar insufficiency
Inevitable abortion
Placenta praevia
HELLP Syndrome
Abruptio placentae
p. 40
90. Which of the following statements about fetal heart rate monitoring are
correct?
A) Short term variability of the fetal heart rate is not necessarily an abnormal finding
and can only be assessed by internal monitoring.
B) Long Term variability of the fetal heart rate is caused by autonomous cardiac
innervation.
C) Nonperiodic spontaneous accelerations indicate fetal well being.
D) Early decelerations are considered as normal as long as uterine contractions do
not become frustraneous.
E) All of the above statements about the interpretation of fetal heart rate monitoring
are correct.
p. 39/40
91. The first stage of labor includes which of the following steps?
A)
B)
C)
D)
E)
Latent, active and transition phase.
Complete cervical dilation to a maximum width of 10 cm.
Effacement and descent.
Frequency of uterine contractions from 1/30 minutes to 1/2 minutes.
All of the above steps occur in the first stage of labor.
p. 43
92. Which of the following statements about the collaborative management
during the second stage of labor is correct?
A) It may be necessary to insert a urinary catheter and to assess the clients vital
signs and the fetal heart rate every 15 minutes.
B) There is no difference in the outcome if an episiotomy is performed or if a
perineum laceration occurs.
C) The uterine contractions during this stage are so strong that it is unnecessary to
tell the client to “push” voluntarily.
D) A 1st degree perineum laceration requires surgical repair.
E) The 2nd stage of labor is expected to last at least five hours.
p. 44
93. What are potential complications that have to be expected during the third
stage of labor.
1.
2.
3.
4.
5.
Atonic uterine bleeding
Retention of placental parts
Breech position
Prolonged duration over 30 minutes
Hypovolemic shock
A)
B)
C)
D)
E)
1, 2 and 4 are correct.
1, 2 and 3 are correct.
1, 2 ,4 and 5 are correct.
All statements are correct.
None of the statements are correct.
p. 44
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94. The fourth stage of labor is defined as follow:
A)
B)
C)
D)
E)
Initial postpartal period
Full uterine involution
Beginning of the lactation period
Discharge of white lochia
A fourth stage of labor does not exist
p. 44
95. Which of the following statements about pharmacological pain management
during labor are correct?
1. Intravenous morphine based narcotics are most widely used.
2. The appropriate antidote in cases of a morphine overdose is naloxone.
3. Substances used for subarachnoideal administration are Bupivacaine or
Lidocaine.
4. Lumbar epidural blocks are performed with morphine based analgetics as well.
5. Pharmacological pain management during labor may reduce the force of the
uterine contractions.
A)
B)
C)
D)
E)
1, 2 and 4 are correct.
1, 2 and 5 are correct.
1, 4 and 5 are correct.
All statements are correct.
None of the statements are correct.
p. 45
96. What is considered to be a normal fetal position during labor?
A)
B)
C)
D)
E)
Occiput posterior position
Occiput anterior position
Occiput transverse position
Breech position
Face presentation
p. 46
97. During the crowning process in the second stage of labor the presenting fetal
part appear to be the buttocks. Which of the following terms describes this
form of fetal malpresentation correctly?
A)
B)
C)
D)
E)
Complete breech presentation
Incomplete breech presentation
Frank breech presentation
Sincipital presentation
Transverse lie
p. 47
98. Which is the most immediate action to take in a breech presentation with
decelerations of the fetal heart rate?
A)
B)
C)
D)
E)
To apply any positioning that relieves pressure from the umbilical cord.
Oxygen supply
Amnio-infusion
Creating a calm environment
Sedating the laboring client
p. 47
99. Which of the following procedures are appropriate to induce labor?
1.
2.
3.
4.
5.
Applying Prostaglandine gel to cervix
Amniotomy
Intravenous Oxytocin therapy
Transvaginal stimulation of the uterus
Intravenous Terbutaline therapy
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A)
B)
C)
D)
E)
1,2 and 4 are correct.
1,2 and 3 are correct.
1,2,4 and 5 are correct.
All statements are correct.
None of the statements are correct.
p. 47
100. Premature labor is defined as
A)
B)
C)
D)
E)
Contractions between the 20th and the 37th gestational week.
Contractions between the 28th and the 37th gestational week.
Any labor prior to the 40th gestational week.
Birth of child small for date of delivery.
Labor prior to an established lung maturity.
p. 48
101. Reliable signs for the onset of labor are:
A)
B)
C)
D)
E)
Frequent contractions every 10 minutes or less.
Low abdominal cramping, with or without diarrhea.
Pelvic pressure.
Leaking amniotic fluid.
All of the described symptoms are reliable signs for the onset of labor.
p. 43
102. The most common indications to perform a caesarean delivery are:
A)
B)
C)
D)
E)
CPD
Fetal distress
Breech presentations
Previous Caesarean birth
All of the above
p. 49
103. Which of the following descriptions of uterine stimulants is correct?
A) Oxytocin stimulates uterine contractions as well as lactation but is only of short
lasting effect.
B) Ergotamines are widely used for the induction of labor.
C) Prostaglandines are only used to control postpartal bleedings.
D) There is no major difference between the different types of uterine stimulants.
E) All descriptions are correct.
p. 50
104 Which of the following substances is the most widely used uterine relaxant
medication?
A)
B)
C)
D)
E)
Magnesium sulfate
Indomethacin
Terbutaline
Nifedipine
Ritodrine
p. 51
105. A 23 year old and otherwise healthy woman experiences a spontaneous
abortion. Which of the following steps is the most reasonable to detect a
possible cause of a spontaneous abortion.
A) To investigate a possible Rhesus incompatibility.
B) Checking the clients family history for abortions.
C) Questioning if the client has maintained a healthy lifestyle throughout the
pregnancy.
D) Telling the client to be more careful in her next pregnancy.
E) To rule out underlying physical disorders.
p. 52
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106) A 33 year old nulliparous pregnant women experiences premature
contractions in her 32nd gestational week. The attending gynecologist
prescribes Terbutaline to delay the labor for at least 48 hours. What would be
the appropriate answer of the attending nurse if asked by the client why this
procedure was chosen.
A) This treatment is necessary to have enough time to induce the lung maturity of
your child.
B) This is a routine procedure to see how long we can possibly delay the labor.
C) We are just trying our best to save your child.
D) This is one of our routine procedures.
E) This is to make sure that nothing will happen to your child.
p. 51
107. Which statements about the prophylactic treatment of newborns with vitamin
K are correct?
A) Vitamin K induces the synthesis of the coagulation factors II, VII, IX, X.
B) The appropriate treatment mode is an IM injection at time of delivery.
C) Newborns are generally endangered by neonatal brain hemorrhage due to a
deficiency of coagulation factors.
D) Vitamin K will be synthesized later by colon bacteria.
E) All of the above statements are correct.
p. 52
108. A nurse prepares to discharge a female client and her newborn boy. Which
of the following statements is not a correct discharge instruction.
A) It will take about 6 weeks until your uterus goes back to its normal size.
B) You will experience some vaginal discharge for a few weeks which changes its
color from red to white back and forth.
C) You may detect hemorrhoids.
D) There is sometimes a few days of a delay between the labor and the actual
production of the breast milk. During this time it is important that you have your
baby suck at your breasts. Because the stimulation of the breast nipples will help
to produce the milk and your child will learn how to suck correctly.
E) Please make sure you drink sufficient amounts of fluid because you may
experience an urinary tract infection easier as long as the lochia production goes
on.
p. 54 – 56
109. 24 - hours after a client gave birth to a healthy newborn the nurse observes
the following findings during a routine postpartal assessment.
•
•
•
•
Temperature 101.0 F
Redness, edema and yellowish discharge from a caesarean section wound.
HR 100 bpm, regular
BP 125/70 mmHg
Which of the following actions should the nurse take immediately?
1. To contact the healthcare provider since this client seems to have developed an
infection of her surgical wound.
2. To apply an icepack to the wound.
3. To order an urgent ECG.
4. To administer antihypertensive medication.
5. To keep observing this client for further aggravation of the described symptoms.
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A)
B)
C)
D)
E)
1,2 and 4 are correct.
1,2 and 3 are correct.
Only 1 is correct.
All statements are correct.
Only 1,4 and 5 are correct.
p. 56 – 58
110. A postpartal assessment 2 hours after a vaginal delivery reveals the following
findings:
•
•
•
•
T 100.0 F
Homan’s sign negative
25 ventilations/minute
Occasional lighter and lower abdominal cramps
Which of the following statements are appropriate to make based on these findings?
A)
B)
C)
D)
E)
Everything is fine.
We may have to watch you a little closer.
I am really concerned about you.
We need to run a few test as soon as possible.
Cramps are really unusual for this situation.
p. 56 - 58
111. A client who gave birth to a healthy newborn experiences ongoing significant
vaginal bleedings one hour after delivery of the placenta. Which is the
most appropriate medication therapy to administer to this client.
A)
B)
C)
D)
E)
Amoxicillin
Ergot alkaloids
Oxytocin
Terbutaline
None of these medications
p. 50
112. A newborn assessment reveals the following findings:
•
•
•
•
•
Flexed position
HR 160 bpm
T 98 F
BP 85/40 mmHg
Head circumference 30 cm (12 inches)
Which of the following statements are correct?
A)
B)
C)
D)
E)
All findings are considered as normal for a newborn assessment.
The heart rate indicates a hereditary heart failure.
This newborn appears to have an infection.
A hydrocephalus is likely. Further investigation is necessary.
All findings are abnormal
p. 56
113. Which of the following findings are regularly assessed in newborns as an
evidence of appropriate development for the gestational age.
A)
B)
C)
D)
E)
Completed descent of testicles into the scrotum at birth.
Labia minora covered by labia majora.
Thickness of breast tissue.
Presence and distribution of Lanugo.
All of the above findings are criterias of the Ballard tool for assessment of the
gestational age of a newborn.
p. 58
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114. A newborn suddenly develops the following symptoms:
•
•
•
•
increased breathing rate
nasal flaring
inter-costal retractions
changing of color
These symptoms are specific findings in which of the following conditions?
A)
B)
C)
D)
E)
Acute respiratory distress
Congenital heart failure
Fever
Malnutrition
These symptoms do not correlate to any specific findings.
p. 59
115. During a newborn assessment the examiner holds the newborn vertically by
stabilizing the neck and then suddenly removes the hand that is supporting
the neck. The newborn responds with a sudden forward directed extension of
both arms. This reaction is characteristic for which of the following newborn
reflexes?
A) Moro Reflex
B) Babinski Reflex
C) Tonic neck reflex
D) Rooting reflex
E) None of the above reflexes
p. 58
116. Which of the following statements about newborn care is correct?
A) Newborns are nose breathers. A newborn that needs to open the mouth for
respiration purposes is in respiratory distress.
B) A Guthrie Test must be performed immediately after delivery.
C) The remains of the umbilical cord need to be removed.
D) Feeding should be pursued after a fixed schedule.
E) A yellowish skin color of a newborn is a normal finding.
p. 59 - 67
117. The nurse assesses the vaginal blood loss of a client at 800 ml within the first
24 hours after labor. Which should be the most immediate conclusion
regards to this finding?
A) A postpartal blood loss of up to 1000 ml within the first 24 hours does not require
any attention.
B) This client may have taken aspirin during the pregnancy.
C) The described finding only requires attention if the bleeding contains clots.
D) The hemoglobin level of this client should be assessed.
E) Further investigation is immediately necessary to rule out a severe injury of the
birth channel, a coagulation disorder and an atonic uterus.
p. 61
118. A newborn is assessed with the following findings:
•
•
•
•
Birth weight: 4lbs, 4 ounces
Blood glucose 30 mg/dl
Dry skin
Weak cry
Which of the following conclusions are correct?
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A)
B)
C)
D)
E)
Abnormal birth weight, otherwise normal findings.
Maternal Diabetes likely
Juvenile Diabetes Type I likely
Small for gestational age
Renal Diabetes likely
p. 62 - 63
119. A newborn is assessed with the following findings:
•
•
•
•
Birthweight 4620g
Bilirubin level 20 mg/dl
Shoulder Dystocia
Apgar score 6 at 5 minutes
Which of the following conditions are likely to be present in this case?
A)
B)
C)
D)
E)
Inherited liver failure
Hypothyreosis
Large for gestational age
Respiratory distress
Abnormal birth weight and other findings normal
p. 62 - 63
120. The minimum gestational age a fetus must have to survive preterm labor is
A)
B)
C)
D)
E)
23 weeks of gestation
20 weeks of gestation
30 weeks of gestation
36 weeks of gestation
28 weeks of gestation
p. 62
121. Which of the following newborn conditions can typically occur after
preterm labor?
A)
B)
C)
D)
E)
Growth retardation
Respiratory Distress
Hemorrhage
Retinopathy
All of the above findings
p. 62
122. Please review the following statements about complicated newborn care for
correctness?
1.
2.
3.
4.
5.
Newborn with asphyxia and a breathing rate over 60 should not be fed orally.
A heart rate of less than 60 bpm may require chest compressions.
A newborn with asphyxia may have aspired meconium.
A facial paralysis may require immediate treatment.
Cerebral palsy has hereditary causes.
A)
B)
C)
D)
E)
1, 2 and 4 are correct.
1, 2 and 3 are correct.
Only 1 is correct.
All statements are correct.
Only 1, 4 and 5 are correct.
p. 62 – 63
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123. A newborn assessment of a boy reveals that the urethral opening is not
located on the end but on the top of the penis. Which of the following medical
terms describes this birth defect correctly?
A)
B)
C)
D)
E)
Epispadia
Hypospadia
Bladder exstrophy
Gastroschisis
Omphalocele
p. 64
124. Which of the following birth defects is of poor prognosis?
A)
B)
C)
D)
E)
Chordee
Epispadia
Cryptorchism
Cleft palate
Biliary atresia
p. 64 - 67
125. Two days after delivery a newborn has recurrent projectile
vomiting and dehydration. These symptoms are typical for which of the
following birth defects?
A)
B)
C)
D)
E)
Congenital diaphragmatical hernia
Pyloric stenosis
Down’s syndrome
Cleft palate
Phenylketonuria
p. 65
126. Typical symptoms of muscular dystrophy do not include:
A)
B)
C)
D)
E)
Hypertrophic calf muscles
Hyperlordosis
Hyperkyphosis
Bowed legs
Mental retardation
p. 65/66
127. The parents of a 21 month old girl are concerned since their daughter does
not make any attempt to walk. Which of the following signs and symptoms
indicate a congenital hip dysplasia?
A)
B)
C)
D)
E)
Positive Ortolani sign
Positive Barlow’s maneuver
Positive Trendelenburg’s sign
Gluteal muscle weakness
All of the above findings indicate a congenital hip dysplasia
p. 66
128. Which of the following findings are expected to be observed during a routine
prenatal assessment in the 16th gestational week?
1.
2.
3.
4.
5.
All organs formed
Gender detectable
Finger and toes formed
Weight: 1lb
Fetal heart sound detectable
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A)
B)
C)
D)
E)
1, 2 and 4 are correct.
1, 2 and 5 are correct.
Only 4 is correct.
All statements are correct.
None of the statements are correct.
p. 67
129. Quickening describes the onset of spontaneous fetal movements from which
gestational week?
A)
B)
C)
D)
E)
8th week
12th week
20th week
30th week
40th week
p. 67
130. Piaget’s theories of development are focused on:
A)
B)
C)
D)
E)
Cognitive development
Physical development
Psychosocial development
Preterm maturity
None of the above
p. 68
131. Erikson’s theories of development are focused on:
A)
B)
C)
D)
E)
Child–parent relationship
Intrauterine psychological development
Social development of siblings
Identity development
Psychosocial development
p. 68
132. Piaget’s theory defines the stages of cognitive development in the following
order:
A) Sensomotoric
preoperational
concrete operational
formal operations
B) Preoperational
concrete operational
formal operations
sensomotoric
development
C) Formal operations
concrete operational
postoperational
D) Physical development
psychosocial development
coping with stressors
E) None of the above
p. 68
133. In accordance to Erikson’s theory, the stages of psychosocial development
appear in the following order:
A) Trust vs. mistrust
autonomy vs. shame and doubt
Initiative vs. guilt
Industry vs. inferiority
Identity vs. role confusion
B) Inferiority vs. Isolation
generativity vs. stagnation
ego integrity vs. despair
C) Trust vs. mistrust
industry vs. inferiority
identity vs. role confusion
generativity vs. stagnation
ego integrity vs. despair.
E) Initiative vs. guilt
industry vs. role confusion
generativity vs. stagnation
intimacy vs. isolation.
D) Erikson’s theories are not based on psychosocial development.
p. 68
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134. Which of the following newborn reflexes should not be present in a 10
month old child?
1.
2.
3.
4.
5.
Moro reflex
Landau reflex
Parachute reflex
Babinski reflex
Body righting reflex
A)
B)
C)
D)
E)
1, 2 and 4 are correct.
1, 2 and 3 are correct.
1, 2, 3 and 5 are correct.
All statements are correct.
Only 1, 4 and 5 are correct.
p. 67
135. Which of the following summaries of skills describe an average
developmental stage of a 12 month old child?
A) Walking while holding on, sitting without support, neat pincer grasp, ability to
speak up to four words and eating solids.
B) Crawling, transferring an object from hand to hand and responding to their name.
C) Walking without support, uses a cup well and builds a tower of blocks.
D) Following simple directions, holding crayons and birth weight tripled.
E) Identifying geometric forms, speaks short sentences and jumping.
p. 67 - 69
136. Which of the following summaries of skills describe an average
developmental stage of a 6 month old child?
A) Rolling from back to abdomen, holding bottle, taste preferences and starting
solids.
B) Standing while holding on, pincer grasp and Babinski reflex present.
C) Sitting without support, and binocular vision well developed.
D) Slowing growth and weight gain and 50% over birth weight.
E) None of the descriptions are describing a normal developmental stage of a 6
month old child.
p. 67 - 69
137. Which of the following vaccinations has to be administered on the day of the
childbirth?
A)
B)
C)
D)
E)
Hepatitis B
DPT
Hib
IPV
MMR
p. 71
138. The PEERLA–examination does not include which of the following criteria?
A)
B)
C)
D)
E)
Pupil size
Red reflex
Equality of pupils
Redness
Light reflection
p. 75
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139. A percussion sound of healthy lungs is considered to be
A)
B)
C)
D)
E)
Tympanic
Resonant
Dull
Flat
Hyperresonant
p. 75
140. Which of the following statements about auscultation sounds of the heart are
correct?
1.
2.
3.
4.
5.
S1 indicates the closure of the interventricular valves.
S2 indicates the closure of the aortic and pulmonal valve.
S2 indicates the start of the diastolic filling of the ventricles.
An aortic stenosis produces a murmur at S1 + 2.
Auscultation of the tricuspid and mitral valve is performed at the left sternal
border.
A)
B)
C)
D)
E)
1, 2 and 4 are correct.
1, 2 and 3 are correct.
1, 2,3 and 5 are correct.
All statements are correct.
Only 1, 4 and 5 are correct.
p. 76
141. The Weber and Rinne Tests are used to detect:
A)
B)
C)
D)
E)
Sensorineural hearing loss
Conductive hearing loss
Sensorineural and conductive hearing loss
Dementia
Cerebrovascular diseases
p. 77
142. The examination for congenital hip dislocation includes:
A)
B)
C)
D)
E)
Ortolani’s sign
Barlow’s maneuver
ROM Test
Gait pattern analysis
Equality of gluteal folds
1.
2.
3.
4.
5.
1, 2 and 4 are correct.
1, 2 and 3 are correct.
1, 2, 3 and 5 are correct.
Only 1, 4 and 5 are correct.
All answers are correct.
p. 80
143. Which of the following newborn reflexes may persist in a healthy child
until the age of 1 year?
A)
B)
C)
D)
E)
Moro reflex
Rooting reflex
Plantar grasp reflex
Palmar grasp reflex
Babinski reflex
p. 80
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144. Which is the most common health disorder among adults in the US?
A)
B)
C)
D)
E)
Sinusitis
Hypertension
Diabetes
Osteoarthritis
Coronary artery disease
p. 83
145. An older client was admitted to the hospital for the treatment of an ureter
colic. During the treatment this client suddenly develops an acute confusion,
is unable to concentrate and is not oriented. The situation is fully reversible
within a few hours without any further treatment. What is the most likely
cause of this condition?
A)
B)
C)
D)
E)
Pre-existing mental health disorder
Delirium after a brief treatment with Benzodiazepines
Stroke
Hypertensive crisis
Delusion in an underlying dementia
p. 85
146. Food sources that contain high levels of potassium are:
1.
2.
3.
4.
5.
Potatoes
Milk
Bananas
Fortified orange juice
Dried fruits
A) 1, 2 and 4 are correct.
B) 1, 2 and 3 are correct.
C) 1, 2, 3 and 5 are correct.
D) Only 1, 4 and 5 are correct.
E) All answers are correct.
p. 85
147. A repeated FBG sample was taken from a client over several days
The results are as follow:
•
•
•
•
Day 1: 126 mg/dl
Day 2: 130 mg/dl
Day 3: 140 mg/dl
Day 4: 155 mg/dl
Which of the following conclusions can be drawn from these results?
A) Normal findings and no further investigation necessary.
B) The results prove the diagnosis of a Diabetes.
C) This client requires an insuline therapy.
D) Diabetes of this severity does not require any treatment.
E) The findings are related to a high carbohydrate diet.
p. 86
148. A nurse is instructing a client on how to perform a 24–hour urine sample.
Which of the following client statements prove that he understood the
procedure?
A) I understand that I need to collect as much urine as possible within the next 24 –
hours.
B) I will collect all urine within the next 24–hours.
C) I need to collect as much urine as needed until the container is filled up.
D) I can start collecting the urine at any time and without any preparation.
E) All statements show that the client did not properly understand the instructions.
p. 86
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149. A client receives an intravenous therapy for treatment of an acute DVT. Which
of the following coagulation parameters has to be checked frequently under
this treatment?
A)
B)
C)
D)
E)
aPTT
PTT
Clotting time
Bleeding time
Prothrombin time
p. 87
150. Which of the following laboratory values is a significant parameter for the
treatment of an acute myocardial infarction?
A)
B)
C)
D)
E)
LDH
CK – MB
CK – BB
CK – MM
AST
p. 89/90
151. A 25 year old women has a history of recurrent UTI’ s. She is currently not
experiencing any symptoms. The result of an urinanalysis shows the
following results:
•
•
•
•
Nitrite negative
50.000 colonies of bacteria per high powered field
pH 4,8
Specific Gravity 1.020
What advise should the attending nurse give?
A) At this time no treatment is necessary but please keep drinking sufficient amounts
of fluids daily.
B) Another course of antibiotic medication needs to be prescribed.
C) You must have terrible bladder pain.
D) Any bacterial contamination of the urine is very dangerous.
E) An emergency referral for a kidney examination is necessary.
p. 91
152. A client is admitted to the hospital with acute abdominal pain. After reviewing
the first results of a routine blood test the nurse reports to the attending
physician that this client appears to have an acute pancreatitis. This
statement is based on which of the following findings?
A)
B)
C)
D)
E)
Total Bilirubin 1,4 mg/dl
ALT 25 U/L
Lipase 300 U/L
Ammonia 55mg/dl
Uric acid 7,0 mg/l
p. 92 + 225
153. Which of the following immunoglobulines is able to pass the placenta barrier?
A)
B)
C)
D)
E)
IgA
IgD
IgE
IgG
IgM
p. 60
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154. A 62 year old female client is admitted to the hospital after taking a new
medication for the first time. She appears to be in an acute respiratory
distress and produces a strong expiratory stridor and a significant
hypotension. Which of the following immune reactions is causing these
complaints?
A)
B)
C)
D)
E)
Type I
Type II
Type III
Type IV
All of the above reactions can apply.
p. 94
155. A nurse undergoes a routine tuberculine skin test with the Occupational
Health Service. The evaluation after 72 hours shows that the injection area
appears significantly red and swollen. Which of the following conclusions in
regards to this finding is correct?
1. The reaction does not prove an acute Tbc reaction.
2. It is possible that the nurse recently was in contact with a client with Tbc.
3. Further investigations include chest x-ray, sputum sample and gastric acid
analysis.
4. The described finding does not require any further action.
5. Anti-tuberculotic treatment is immediately necessary.
A)
B)
C)
D)
E)
1, 2 and 4 are correct.
1, 2 and 3 are correct.
1, 2, 3 and 5 are correct.
Only 1, 4 and 5 are correct.
All answers are correct.
p. 100/101
156. Which of the following examination procedures is not routinely performed as
part of a pre-operative assessment.
A)
B)
C)
D)
E)
Chest X-Ray
Physical examination
24 – hour blood pressure monitoring
Blood typing and cross matching
Serum electrolyte assessment
p. 101 – 104
157. A client underwent major surgery. Which of the following criterias must be
met to discharge this client from the postanesthetic care unit?
1.
2.
3.
4.
5.
Vital signs must be sufficient
Breathing spontaneously
Gag reflex must be present
Client has to be easily arousable
Client has to be able to maintain his personal hygiene
A)
B)
C)
D)
E)
1, 2 and 4 are correct.
1, 2 and 3 are correct.
1,2,3,4 are correct
All statements are correct.
Only 1, 4 and 5 are correct.
p. 104
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158. Which of the following statements about a dumping syndrome after
abdominal surgery is correct?
A) A dumping syndrome is mostly caused by a Billroth I and II procedure.
B) Treatment involves the adaptation of the dietary habits to the limited gastric
space.
C) Symptoms include palpitations, sweats, hypotension and hypoglycemia.
D) A lifelong vitamin B 12 supply is most likely necessary.
E) All of the above statements are correct.
p. 104
159. A client with coronary artery disease underwent coronary artery bypass
surgery. One of his discharge instructions is to maintain a low cholesterol
diet. Which of the following statements shows that this client has
understood the dietary regulations in regards to his supply with fats.
A) Fats are essential for the body to maintain important metabolic functions but my
diet should avoid saturate fats as they come in butter, milk and meat.
B) Basically I can eat whatever I want as long as I do not gain any weight.
C) Daily pure butter on bread and an egg does not make a difference.
D) I can eat everything but fast food.
E) Fats of herbal origin are not as nutritious as fats from animal sources.
p. 106
160. The BMI is correctly calculated as follows:
A)
B)
C)
D)
E)
Weight in kg (1kg = 2.2 lbs)
Height in meters 2
BMI = Height in meters
Weight in kg
Weight
in kg (1kg = 2.2 lbs)
BMI =
Body surface area in m2
BMI = Weight in kg (1kg = 2.2 lbs)
Bone density
p. 109
BMI = Weight in kg – 100
BMI =
161. A female client is 5’6” tall and weighs 190 lbs.
These dimensions are relating to the following BMI.
A)
B)
C)
D)
E)
23
20
30
32
24
p. 109
162. Which of the following nursing interventions is not appropriate to assist a
client with orthopnea?
A)
B)
C)
D)
E)
Positioning the client in a Fowlers position
Positioning the client in a Trendelenburg position
Providing oxygen supply
Performing a blood gas analysis
Providing chest physiotherapy
p. 113/114
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163. An Urinalysis shows the following results:
•
•
•
•
•
•
Sterile
pH 4.5
Specific Gravity 1.010
Proteinuria
Ketones negative
Glucose negative
The specimen was obtained from a client with an urinary output of 400 mg/d.
Which of the following interpretations are correct?
1. Nephrotic syndrome
2. Urinary tract infection
3. Diabetes
4. No relevant findings
5. This client is in an oliguric stade of renal failure.
A) 1, 2 and 3 are correct.
B) Only 1 is correct.
C) 1, 4 and 5 are correct.
D) 1,2,3,4 are correct.
E) None of these interpretations are correct.
p. 90
164. Nursing instructions for a client with a colostomy should not include which of
the following advice.
A)
B)
C)
D)
E)
Spices, fruits and vegetables tend to loosen the stool.
Garlic, onions, eggs and beans should be consumed sparingly.
A client with a colostomy does not require any dietary limitations.
Cabbage, onions and beans may cause colicky pain.
Beside a few limitations it is possible to maintain a healthy and well balanced diet.
p. 117
165. Which of the following facts should be part of the nursing discharge
instructions for a client who recently underwent an ileostomy procedure?
A) An ileostomy produces generally very soft and moist stool.
B) Warm fluids or the temporary use of a hot water bottle may help to improve an
obstruction.
C) High fiber foods should be generally limited.
D) Lifelong parenteral supply of fat soluble vitamins may be necessary.
E) All of the above instructions should be provided.
p. 117
166. A client lives in a nursing home and is bed bound after multiple
cerebrovascular accidents. The nurse notices a wound around this clients
sacral area and documents it as follow: Superficial partial thickness, skin loss,
blistering and abrasion - like appearance. This finding correlates to which of
the following stages of the Norton and Braden scale:.
A)
B)
C)
D)
E)
Stage 1:
Stage 2:
Stage 3:
Stage 4:
The described wound is not a typical pressure ulcer.
p. 117
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167. A client has accidentially removed his tracheostoma tube.
Which is the most urgent intervention necessary in this situation?
A)
B)
C)
D)
E)
To call for help
To hold stoma open with a curved clamp or by using the retention sutures
Oral suctioning
Oxygen supply via face mask
No urgent intervention is necessary but a new tracheostoma has to be supplied.
p. 120
168. What is the correct anatomical position of an endotracheal tube?
A)
B)
C)
D)
E)
In between the voice membranes.
In the upper half of the trachea.
2 cm above the carina.
In one of the main bronchioles.
Any position below the epiglottis is correct.
p. 120
169. Which of the following descriptions of the osmotic process is correct?
A)
B)
C)
D)
E)
Shift of fluids and small particles through a semipermeable membrane.
Shift of particles through a semipermeable membrane.
Osmosis can only occur between two isotonic concentrations.
Osmosis is not driven by any forces.
None of the above statements describe the process of osmosis correctly.
p. 123
170. Please identify the correct attributes of the hormone Aldosterone from the
statements below:
1.
2.
3.
4.
5.
Increases renal natrium and water re-uptake and potassium excretion.
Decreases renal natrium and water re-uptake and potassium excretion.
Secretion is inhibited by the renin – angiotensin – mechanism.
Secretion is increased by the renin – angiotensin – mechanism.
Aldosterone is excreted by the pituitary gland.
A)
B)
C)
D)
E)
1 and 3 are correct.
1 and 4 are correct.
2 and 3 are correct.
4 and 5 are correct.
Only 5 is correct.
p. 124
171. Typical symptoms and diagnostic findings of Dehydration in adults do not
include:
A)
B)
C)
D)
E)
Urine output: < 30 mL / kg / hour
Urine specific gravity > 1.035
Serum osmolality > 300mOsmol/kg
BUN,HCT,Creatinine
Pulmonary edema
p. 125
172. Signs and symptoms of a hyperkalemia do not include:
A)
B)
C)
D)
E)
Serum Potassium of 4,5 mEq/L
ECG alterations
Hypotension
Bradycardia
Respiratory failure
p. 126
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173. Concurrent findings in cases of a metabolic acidosis are:
1.
2.
3.
4.
5.
Hyperkalemia
Hypokalemia
Shift of H+ ions into intracellular space
Shift of H+ ions into the extracellular space
Hypoventilation
A)
B)
C)
D)
E)
1 and 3 are correct.
1 and 4 are correct.
2 and 3 are correct.
4 and 5 are correct.
Only 5 is correct.
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174. An arterial blood gas analysis shows the following results:
•
•
•
pH = 7,25
PaCO2 = 55 mmHg
HCO3- = 24 mEq/L
A)
B)
C)
D)
Respiratory Acidosis
Respiratory Alkalosis
Metabolic Acidosis
Metabolic Alkalosis
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175. An arterial blood gas analysis shows the following results:
•
•
•
pH = 7,50
PaCO2 = 35 mmHg
HCO3- = 36 mEq/L
A) Respiratory Acidosis
B) Respiratory Alkalosis
C) Metabolic Acidosis
D) Metabolic Alkalosis
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176. Which of the following conditions applies in a case of isotonic dehydration?
A)
B)
C)
D)
E)
Sudden blood losses
Profuse sweating
Ascites
Pleural effusion
None of the above
p. 124
177. Symptoms of Dehydration due to a fluid deficiency do not include:
A)
B)
C)
D)
E)
Serum osmolality > 300mOsmol/kg
BUN,HCT,Creatinine
Hyponatremia < 125 mEq/mL
Dry skin and mucous membranes
Sunken eyeballs
p. 125
178. Which of the following statements about hypercalcemia are correct?
1. A possible cause is hyperparathyroidism.
2. Affected clients will show increased DTR.
3. Kidney stones can be caused by hypercalcemia.
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4. Clients under treatment with digoxin will not experience symptoms of
hypercalcemia.
5. Hypercalcemia induces hyperphosphatemia.
A)
B)
C)
D)
E)
1 and 3 are correct.
1, 3 and 4 are correct.
1, 2 and 3 are correct.
4 and 5 are correct.
Only 5 is correct.
p. 127
179. Please verify the following information about the acid – base regulation.
1.
2.
3.
4.
5.
Respiratory alkalosis is caused by a retention of CO2.
Metobolic alkalosis is defined as a CO2 > 45 mmHg.
Acidosis causes CNS depression, and alkalosis stimulates the CNS.
In an acidosis K+ shifts to ECF and H+ to ICF
Hyperventilation does not alternate the systemic pH value.
A)
B)
C)
D)
E)
1 and 3 are correct.
1, 3 and 4 are correct.
1, 2 and 3 are correct.
3 and 4 are correct.
Only 5 is correct.
p. 129 - 132
180. A physician’s order states that the appropriate dosage of an intravenously
administered drug is 450 mg per 24 hours. The daily dosage has to be
divided and administered in three equal daily dosages. The medication
is available in a concentration of 5 mg/ml. How many ml of this medication
has to be administered with one single dosage?
A)
B)
C)
D)
E)
30 ml
45 ml
60 ml
120 ml
150 ml
p. 133
181. A single dosage of the above described substance has to be administered
exactly within 30 minutes. Which of the parameters below describes the
adequate hourly flow rate in ml that has to be adjusted on the infusion pump?
A)
B)
C)
D)
E)
60 ml/hr
90 ml/hr
125 ml/ht
150 ml/hr
200 ml/hr
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182. A pediatric medication is prescribed in a dosage of 125 mg/m2 BSA/day.
The patient is a 30 month old boy. His height is 3’2”and his weight is 28 lbs.
In order to this information, this client is supposed to receive a daily dosage
of how many mg of this medication?
A) 250 mg
B) 375 mg
C) 450 mg
D) 600 mg
E) The information provided is not sufficient to answer this question.
p. 139/140
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183. Which of the following statements about infusion flow rates are correct?
1. A pediatric infusion set has a drop factor of 60 drops/ml
2. An adult infusion set has a drop factor of 60 drops/ml
3. An infusion rate has to be calculated as follows:
Total infusion volume x drop factor = 1000 mL x 10
Total time of infusion in minutes
8 x 60 min
4. The required infusion rate depends on the administered substance
A) 1 and 2 are correct.
B) 1, 2 and 3 are correct.
C) 1, 3 and 4 are correct.
D) 3 and 4 are correct.
E) All statements are correct.
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184. Administering a hypotonic infusion may lead to which of the following
side effects?
A) Hemolysis
B) Dehydration
C) Hyperkalemia
D) Metabolic Alkalosis
E) Hypertension
p. 140
185. Which of the following statements about the compatibility of blood groups
are correct?
1.
2.
3.
4.
5.
A Rhesus factor incompatibility has to be disregarded in cases of an emergency.
Clients with blood group 0 are universal receivers.
Clients with blood group AB are universal receivers.
Blood group A occurs most commonly.
Clients with blood group A can receive blood group 0 and A.
A) 1 and 2 are correct.
B) 1, 2 and 3 are correct.
C) 1, 3 and 4 are correct.
D) 3, 4 and 5 are correct.
E) All statements are correct.
p. 141 - 143
186. Regular routine laboratory assessments for a client who receives total
parenteral nutrition do not include which of the following parameters?
A) Liver function test
B) BUN
C) Creatinine
D) Albumin
E) C – reactive Protein
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187. A cholinergic effect does not cause which of the following symptoms?
A) Constipation
B) Stimulation of the urinary tract
C) Miosis
D) Bradycardia
E) Hypotension
p. 147
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188. Nicotinic and muscarinic receptors are located on a chemical synapsis to
interact with which of the following neurotransmitters?
A) Adrenaline (Epinephrine)
B) Noradrenaline (Norepinephrine)
C) GABA
D) Dopamine
E) Acetylcholine
p. 147
189. Which of the following synaptic neurotransmitter receptors are sensitive to
adrenaline (Epinephrine)?
A)
B)
C)
D)
E)
Acetylcholine receptors
Dopamine receptors
Beta 2 receptors
Alpha 1 receptors
Alpha 2 receptors
p. 147
190. A paraplegia was diagnosed in which of the following cases?
A)
B)
C)
D)
E)
Sensomotoric deficite in right arm
Paralysis of left arm and leg
Plexusparalysis Erb – Duchenne
Disc injury of the cervical spine
Paralysis of lower extremities up to the pelvic area.
p. 148
191. Which of the following statements about the Guillain–Barre Syndrome are
correct?
1. The underlying cause of this disorder is an autoimmune disease.
2. The affected structures are the myelin sheets of the spinal nerve fibers.
3. The diagnosis requires a spinal tab.
4. Clients may require respirator treatment.
5. A specific medication therapy does not exist.
A) 1 and 2 are correct.
B) 1,2 and 3 are correct.
C) 1,2, 3 and 4 are correct.
D) 3 and 5 are correct.
E) All statements are correct.
p. 148
192. Please verify the following statements on intracranial bleedings.
1. An epidural hematoma requires urgent neurosurgical treatment.
2. Small subdural hematomas may not lead to physical complaints.
3. An epidural hematoma typically develops below the pia mater.
4. All intracranial bleedings are potentially life threatening.
5. Epidural hematomas are caused by a rupture of the meningeal artery.
A) 1 and 2 are correct.
B) 1, 2 and 3 are correct.
C) 1, 3 and 4 are correct.
D) 1,2,4 and 5 are correct.
E) All statements are correct.
p. 149
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193. A 23 year male old client was admitted to the hospital with a sudden loss of
consciousness. Accompanying friends have observed a repeated involuntary
uncoordinated muscle contraction. After recovery the client is embarrassed
by discovering an involuntary urination.
Which of the following diagnosis is the most likely in this case?
A)
B)
C)
D)
E)
Grand–mal Seizure
Petit–mal Seizure
Multiple Sclerosis
Grave’s Disease
None of the above
p. 150
194. Which of the following medications may be included in the treatment of
multiple sclerosis?
1.
2.
3.
4.
5.
Methylprednisolone
Interferon Beta
Azathioprine
Cyclophosphamide
Morphine sulfate
A) 1 and 2 are correct.
B) 1, 2 and 3 are correct.
C) 1 2, 3 and 4 are correct.
D) 3 and 5 are correct.
E) All statements are correct.
p. 151
195. Which of the following structures are targeted in cases of Myasthenia gravis?
A) Synaptic Acetylcholine receptors
B) Skeletal muscle fibers
C) Beta 2 receptors
D) Smooth muscle fibers
E) None of the above
p. 148
196. A TIA is defined as follows:
A) Neurologic deficits resolving within 24 hours.
B) Neurologic deficits resolving within 7 hours.
C) Neurologic deficits resolving within 7 days.
D) Recurrent neurologic deficits.
E) Neurological deficits of unknown cause.
p. 152
197. Which of the following medications is not indicated for the treatment of
seizure disorders?
A)
B)
C)
D)
E)
Phenytoine
Clonazepam
Carbamazepin
Magnesium Sulfate
Ergotamine Alkaloids
p. 150
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198. The therapeutic effect of Amantadine is defined as follows:
A) Promotion of synthesis and release of Dopamine.
B) Blockade of Alpha 1 receptors in the CNS
C) Relaxation of skeletal muscles
D) Migraine relief
E) None of the above
p. 156
199. Which of the following statements about Scarlet fever are correct?
1. The infection is caused by beta – hemolytic streptococci
2. The contagiosity persists over entire course of the infection
3. Scarlet fever is caused by a viral infection
4. Koplik’s Spots are typical symptoms
5. A vaccination is recommended
A) 1 and 2 are correct.
B) 1, 2 and 3 are correct.
C) 1, 2, 3 and 4 are correct.
D) 3 and 5 are correct.
E) All statements are correct.
p. 160
200. Which of the following statements about Rocky Mountain Spotted Fever are
correct?
A) It is caused by a bacterial infection with Rickettsia ricketsii.
B) The infection is transmitted via tick bites.
C) Antibiotic treatment with Tetracycline is required.
D) The infection may require hospitalization.
E) All statements are correct.
p. 161
201. The four generations of Cephalosporines differ in the following way:
A) Increasing effect against gram positive cocci in latest generations.
B) Increasing effect against gram negative cocci in latest generations.
C) Increasing effect against anaerobic bacteria in latest generations.
D) Increasing antiviral effect in latest generations.
E) Less cross sensitivity with Penicilline in latest generations.
p. 162
202. Characteristics of Diphteria include the following symptoms:
A) Light fever
B) Sore throat
C) Halitosis
D) Grey – white membranes in nasopharynx may cause airway obstruction
E) All of the above
p. 160
203. A treatment with Tetracyclines is contraindicated in which of the following
cases?
A) Intravenous treatment of a Cholera infection.
B) Treatment of acne of a 17 year old boy.
C) Treatment of a Chlamydia infection in an adult female.
D) Treatment of Malaria.
E) Treatment of Rocky Mountain Spotted Fever.
p. 165
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204. Please assess the following statements about pulmonary function testing for
correctness.
1. The Vital Capacity (VC) is defined as the maximum air volume available for
exhalation after a maximum inspiration.
2. The Forced Vital Capacity(FVC) is the total amount of air that can forcibly expired
after full inspiration and measured in liters.
3. The Forced Expiratory Volume in 1 second. (FEV1) is defined as the Amount of air
that can forcefully expired in one second and measured in liters
4. The FEV1 / FVC ration in healthy adults should be approximately 75-80%.
5. The FEV1 is increased in an obstructive pulmonary disorder.
A) 1 and 3 are correct.
B) 1, 3 and 4 are correct.
C) 1, 2 and 3 are correct.
D) 1, 2, 3 and 4 are correct.
E) Only 5 is correct.
p. 167
205. The diagnosis of an emphysema can include which of the following findings?
A) “Pink puffer” appearance
B) Pursed lip breathing
C) Barrel chest
D) VC and FEV1
E) All of the above findings correlate with a pulmonary emphysema.
p. 170
206. Which of the following descriptions of pleural effusions is not correct?
A)
B)
C)
D)
E)
A Transudate contains small amounts of proteins.
An Exsudate contains large amounts of proteins.
An Empyema describes the accumulation of air in the pleural space.
A Chylothorax describes the Accumulation of lymphatic fluids in the pleural space.
A Hemothorax may be caused by bleedings into the intrapleural space.
p. 171
207. Which of the following statements about pulmonary tuberculosis are correct?
1. Diagnosis is made via intrautaneous skin testing.
2. Diagnosis is made by proof of acid fast bacteria in sputum sample.
3. Tuberculosis is mostly accompanied by other diseases or disorders.
4. Exposure to clients with tuberculosis may require antibiotic prophylactic treatment.
5. All of the above statements are correct.
A) 1 and 3 are correct.
B) 1, 3 and 4 are correct.
C) 1, 2 and 3 are correct.
D) 2, 3 and 4 are correct.
E) Only 5 is correct.
p. 173
208. The treatment of clients with an inhalatory Beta 2 - mimetic has to
include the following considerations.
A) The therapeutic effect of Beta-2 mimetic medication decreases with increase of
administered dose and frequency.
B) Sympathomimetics have to be used with caution in patients with cardiovascular
diseases.
C) Sympathomimetics are contraindicated in combination with Monoamine Oxidase
Inhibitors(MAOI’s).
D) The use of inhalatory Sympathomimetics requires adequate patient education.
E) All of the above facts apply under treatment with Beta-2 mimetic medication.
p. 175/176
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209. Specific requirements of nursing care for clients after lung surgery have to
consider the following facts:
1. After lobectomy an equal alternating positioning on back and either side is
necessary to avoid atelectasis.
2. After segmental resection a positioning on the side of surgical intervention can
cause damage to the surgical wound.
3. After pneumonectomy client is to be preferably positioned on back and halfway
turned to side of resected lung.
4. Clients should maintain a Tredenlenburg’s position.
5. The pulmonary function changes significantly after a segmental pulmonary
resection
A) 1 and 3 are correct.
B) 1, 3 and 4 are correct.
C) 1, 2 and 3 are correct.
D) 1, 2, 3 and 5 are correct.
E) Only 5 is correct.
p. 170
Which of the following ECG examinations shows the following findings?
210. Paroxysmal supraventricular Tachycardia
211. Atrial flutter
212. 1st degree AV – Block
213. Ventricular fibrillation
p. 182 - 188
214. 3rd degree AV – Block
A)
B)
C)
D)
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E)
215. Diagnostic criterias of a myocardial infarction include which of the following
ECG - alterations?
1.
2.
3.
4.
5.
ST – Segment elevation
Q – waves
ST – Segment descent
R – Waves
S - Waves
A) 1 and 2 are correct.
B) 1, 3 and 4 are correct.
C) 1, 2 and 3 are correct.
D) 1, 2, 3 and 5 are correct.
E) Only 5 is correct.
p. 189
216. Which of the following symptoms does not typically occur in a left sided
heart failure?
A)
B)
C)
D)
E)
Pleural effusion
“Fluid lung”
Congestion of pulmonary veins
Dilation of the left atrium
Hypotension
p. 190
217. Characteristic findings in a right sided heart failure include which of the
following symptoms?
1. Tibial edema
2. Jugular vein distention in an upright position
3. Jugular vein distention in a supine position
4. Pleural effusion
5. Fluid volume excess
A) 1 and 2 are correct.
B) 1, 3 and 4 are correct.
C) 1, 2 and 3 are correct.
D) 1, 2, 3 and 4 are correct.
E) All anwers are correct.
p. 190
218. The medication therapy of a congestive heat failure includes which of the
following pharmacological substances?
A)
B)
C)
D)
E)
Nitroglyzerine
ACE – Inhibitors
Loop Diuretics
Glycosides
All of the above substances may be used for treatment of a
congestive heart failure.
p. 190
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219. The levels of which of the following electrolytes are of most significant
importance for clients under a medication therapy with Glycosides:
1.
2.
3.
4.
5.
Natrium
Potassium
Chloride
Calcium
Phosphate
A)
B)
C)
D)
E)
1 and 2 are correct.
1, 3 and 4 are correct.
1, 2 and 3 are correct.
1, 2, 3 and 4 are correct.
Only 2 and 4 are correct.
p. 191
220. A dilation of the left cardiac atrium is most likely to occur due to which of
the following heart valve defects?
1.
2.
3.
4.
5.
Pulmonal valve stenosis
Mitral prolapse
Mitral stenosis
Mitral insufficiency
Tricuspidal insufficiency
A)
B)
C)
D)
E)
1 and 2 are correct.
1, 3 and 4 are correct.
1, 2 and 3 are correct.
1, 2, 3 and 4 are correct.
Only 3 is correct.
p. 192/193
221. Which of the following statements about endocarditis are correct?
1.
2.
3.
4.
5.
Common causes are bacterial infections with streptococci.
An antibiotic treatment with penicillin is mandatory.
An immediate antibiotic treatment with tetracyclines is mandatory.
A sudden destruction of heart valves is likely to occur.
An endocarditis is generally a benign infection.
A)
B)
C)
D)
E)
1 and 2 are correct.
1, 2 and 3 are correct.
1, 2 and 4 are correct.
1, 2, 3 and 4 are correct.
Only 4 is correct.
p. 193
222. Which of the following statements characterize the main difference between a
thrombophlebitis and a deep vein thrombosis correctly?
A.
B.
C.
D.
E.
A Thrombophlebitis occurs within the superficial vein system.
Both terms describe an identical pathology.
A Thromboplebitis commonly leads to a pulmonary embolism.
A Thrombophlebitis requires an oral anticoagulation therapy.
None of the above statements describe the main difference between a
thrombophlebitis and a deep vein thrombosis correctly.
p. 194
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223. An arterial embolism is typically accompanied by which of the following
symptoms?
A.
B.
C.
D.
E.
Pain
Pallor
Pulselessness
Paresthesias
All of the above named symptoms can occur in an acute arterial embolim
p. 196
224. Which of the following pharmacological substances is not a calcium channel
blocker?
A.
B.
C.
D.
E.
Amlodipin
Nifedipin
Felodipine
Verapamil
Captopril
p. 199
225. The pharmacological effect of an ACE – Inhibitor is based on a direct
interference with which of the following biochemical systems?
A.
B.
C.
D.
E.
The renal renin – angiotensin – aldosterone system
The adrenal catecholamine synthesis
The hepatic protein synthesis
The pituitary synthesis of antidiuretic hormone
The thyroid gland hormone synthesis
p. 199
226. Which of the following statements about the medication therapy with cardiac
glycosides is correct?
A. Digoxin has to be replaced with digitoxin in cases of renal dysfunction.
B. Frequent assessments of the serum glycoside levels are mandatory.
C. Irregular serum potassium and calcium levels may cause severe glycoside
side effects.
D. Glycosides increase the myoacardial contractility and decrease the
atrioventricular conduction.
E. All of the above statements are correct.
p. 201
227. Kidney and ureter stones do not cause which of the following symptoms.
A.
B.
C.
D.
E.
Macrohematuria
Microhematuria
Colicky flank pain
Nausea
Glomerulonephritis
p. 209
228. Please state which of the following statements about urinary incontinence are
correct.
A.
B.
C.
D.
E.
An age related urinary incontinence is not considered as an abnormal finding.
Stress incontinence is caused by an increased intra-abdominal pressure.
Urge incontinence occurs shortly after the urge to void appears.
Postmenopausal estrogen deficiency may cause urinary incontinence.
All of the above statements are correct.
p. 209
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229. Please identify the most common cause of acute renal failure among the
following conditions:
A.
B.
C.
D.
E.
Hypovolemia
Ureter stones
Glomerulonephritis
Urinary tract infections
Polycystic kidney disease
p. 211
230. Which of the following statements about the medication therapy with
diuretics are correct?
1.
2.
3.
4.
5.
Thiazide diuretics are first line medications in cases of an acute renal failure.
Loop diuretics are administered in renal failure and congestive heart failure.
A diuretic treatment requires a regular assessment of serum potassium levels.
Loop diuretics are considered as antihypertensives.
An uncontrolled therapy with diuretics can lead to dehydration.
A) 1 and 2 are correct.
B) 1, 2 and 3 are correct.
C) 1, 2 and 4 are correct.
D) 2, 3 and 5 are correct.
E) Only 5 is correct.
p. 212
231. A client has received a kidney transplant. Which of the following medications
are expected to be part of an immunosuppressant treatment?
1.
2.
3.
4.
5.
Cyclosporine
Azathioprine
Tacrolimus
Daclizumab
Interferone
A) 1 and 2 are correct.
B) 1, 2 and 3 are correct.
C) 1, 2 and 4 are correct.
D) 1, 2, 3 and 4 are correct.
E) Only 4 is correct.
p. 216
232. A Gastroesophageal reflux disease typically appears with which of the
following symptoms?
A)
B)
C)
D)
E)
Flatulence
Diarrhea
Vomiting
Heartburn
Lactose intolerance
p. 218
233. Which of the following statements describes the primary difference between
an ulcerative colitis and a Crohn’s disease most accurately?
A)
B)
C)
D)
E)
Ulcerative Colitis is primarily curable by total colectomy.
An ulcerative colitis typically causes constipation.
Crohn’s disease affects the large bowels only.
An ulcerative colitis causes a short bowel syndrome
Crohn’s disease is an autoimmune disorder
p. 218/219
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234. Typical laboratory findings in an acute appendicitis include which of the
following symptoms?
A)
B)
C)
D)
E)
Leucocytosis
Increased erythrocyte sedimentation rate
Increased c – reactive protein
Increased BUN
Decreased hemoglobin
p. 220
235. Which of the following statements about cystic fibrosis are correct?
A)
B)
C)
D)
E)
Cystic fibrosis is a hereditary disease.
Cystic fibrosis causes a systemic glandular dysfunction.
The condition is incurable.
A heart and lung transplant may be inevitable in the course of this disease.
All statements are correct.
p. 221
236. A client was recently diagnosed with Hepatitis A. Which of the following
statements about the expected course of this disease are correct?
A)
B)
C)
D)
E)
A Hepatitis A remains contagious throughout the entire course of the infection.
Hepatitis A is acquired by a parenteral infection.
Liver cirrhosis is likely to develop.
Hepatitis A infections are of poor prognosis.
Hepatitis A commonly develops into a chronic persisting hepatitis.
p. 222/223
237. Which of the following descriptions of typical complications of a liver
cirrhosis are correct?
A) Ascites is primarily caused by a decreased colloid osmotic pressure in the
extracellular space.
B) A hepatic encephalopathy is caused by increased ammonia levels.
C) A portal vein hypertension may cause esophageal varicosis.
D) A portal vein hypertension may cause hemorrhoids.
E) All of the above descriptions are correct.
p. 223/224
238. Relevant laboratory diagnostic parameters in diseases and disorders of the
biliary system are:
A)
B)
C)
D)
E)
GGT + AP
AST + ALT
Only AP
Only AST
AST + BUN
p. 225/226
239. The pharmacological effect of antiemetics can be described best as:
A)
B)
C)
D)
E)
anticholinergic
parasympathomimetic
sympathomimetic
sympatholytic
adrenergic
p. 229/230
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240. Which of the following substances is considered as a stimulant laxative?
A)
B)
C)
D)
E)
Bisacodyl
Methylcellulose
Lactulose
Docusate sodium
Magnesium sulfate
p. 228/229
241. Protone pump inhibitor medication is commonly prescribed in which of
the following conditions?
A)
B)
C)
D)
E)
Gastroesophageal reflux disease
Gastroeteritis
Crohn’s disease
Diverticulitis
Diarrhea
p. 230
242. A client was diagnosed with Gardiasis. Which of the following medications
will be most likely described as an appropriate medication therapy?
A)
B)
C)
D)
E)
Chloroquine
Clotrimazole
Amantadin
Trimethoprim
Mebendazole
p. 235
243. The synthesis and release of which of the following hormones is directly or
indirectly induced by Gonadotropine?
A)
B)
C)
D)
E)
FSH
LH
Estrogene
Testosteron
All of the above
p. 234
244. Ethionamide is frequently prescribed in which of the following
endocrimologic disorders?
A)
B)
C)
D)
E)
Hyperthyreosis
Hypothyresosis
Hypopituitarism
Addison’s Disease
Hyperparathreoidism
p. 236
245. A secondary hyperparathyroidism is caused by which of the following
conditions?
A)
B)
C)
D)
E)
Renal failure
Liver failure
Dysfunction of the adrenal cortex
Hypercalcemia
Hypophophatemia
p. 237
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246. Which of the following conditions is a typical cause of Addison’s disease?
A)
B)
C)
D)
E)
Auto-immune disorder with antibody production against the adrenal cortex.
Over production of Cortisol.
Overdose of orally administered corticosteroids.
High levels of adrenocorticotropic hormone ACTH.
All of the above conditions may cause Addison’s disease.
p. 239
247. Which of the following symptoms is a characteristic finding of Diabetes
mellitus Type I?
A)
B)
C)
D)
E)
Hyperosmolar non – ketotic syndrome
Obesity
Hyperinsulinemia
Diabetic keto – acidosis
Delayed Glucose tolerance
p. 241/242
248. Please identify the main difference between sulfonylurea and non –
sulfonylurea oral antidiabetics among the following statements:
A) Sulfonylurea medication stimulates the insulin release in the pancreatic gland.
B) Non – sulfonylurea medications stimulate the insulin release in the pancreatic
gland.
C) All non – sulfonylureas show a similar effect.
D) The hypoglycemic effect of sulfonylurea medication is weaker.
E) None of the above statements are correct.
p. 243 - 245
249. Symptoms of an advanced stage of a diabetes type II do not include which of
the following findings?
A)
B)
C)
D)
E)
Polydipisia
Diabetic nephropathy
Diabetic neuropathy
Diabetic angiopathy
Diabetic retinopathy
p. 241/242
250. A client with a pre-existing insulin dependent diabetes mellitus type II
suddenly looses consciousness. An instant blood sugar monitoring reveals a
blood glucose level of 30 mg/dl. Which is the most immediate and appropriate
action among the following available options?
A)
B)
C)
D)
E)
To administer an intramuscular glucagons injection.
To call for help.
To inject 10 units of regular insulin subcutaneously.
To wait until client regains consciousness.
To administer a dextrose lozenger orally.
p. 245
251. Which of the following statements about Paget’s disease are correct?
1.
2.
3.
4.
5.
Symptoms include pathological fractures, headaches and hearing loss.
The medication therapy is comparable to the treatment of an osteoporosis.
Affected clients may experience severe musculoskeletal pain.
A relevant diagnostic laboratory parameter does not exist.
Paget’s disease typically results in osteomyelitis.
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A) 1 and 2 are correct.
B) 1, 2 and 3 are correct.
C) 1, 2 and 4 are correct.
D) 1, 2, 3 and 4 are correct.
E) Only 4 is correct.
p. 246
252. Which of the following musculoskeletal diseases develop typically during
puberty?
A)
B)
C)
D)
E)
Rheumatoid arthritis
Osteoarthritis
Dislocation of the femoral epiphysis
Osteoporosis
Gout
p. 248
253. Which of the following substances are indicated in the treatment of a
rheumatoid arthritis?
A)
B)
C)
D)
E)
Gold Sodium Thiomalate
Etanercept
Hylan G-F 20
Methotrexate
All of the above named substances
p. 249/250
254. A client has to be educated about which of the following warning signs of
common side effects of non–steroidal anti-inflammatory medication?
A)
B)
C)
D)
E)
Epigastric pain
Symptoms of anaphylaxia
Prolonged bleeding in cases of injuries
Hypertension
All of the above side effects
p. 250
255. A client appears with a skin rash in the Emergency Room that was caused
by a limited acute allergic reaction due to medication. The exact diagnosis
of this condition is most likely described as:
A)
B)
C)
D)
E)
Contact Dermatitis
Psoriasis
Erysipel
Urticaria
Seborrhoic Dermatitis
p. 94/95 + 251
256. Which of the following dermatological disorders is not considered as a
bacterial infection?
A)
B)
C)
D)
E)
Impetigo
Folliculitis
Acne
Shingles
Cellulitis
p. 159
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257. Topical treatment with Nystatin is commonly prescribed in which of the
following skin infections?
A)
B)
C)
D)
E)
Impetigo
Acne
Tinea corporis
Candidiasis
Shingles
p. 259
258. Which of the following descriptions of a superficial partial thickness burn
wound is correct?
A) Epidermic painful erythema, no blisters and scar free healing within five days.
B) Subtotal epidermic destruction, moist, red and white areas, blisters, no loss of
sensoric function and heals within 28 days with some scarring.
C) Loss of entire epidermis, dry, waxy and white wound. Skin transplant may be
performed but spontaneous healing within 1 month is possible.
D) Destruction of more or all remaining subepidermal tissues.
E) Total tissue necrosis.
p. 257
259. Which of the following laboratory parameters are relevant towards the
treatment and care of burn wounds?
A)
B)
C)
D)
E)
Serum albumin level
BUN
Hematocrit
Serum potassium level
All of the above
p. 257/258
260. In order to the rule of 9’s a burn wound of the entire abdomen and chest
applies to an estimated body surface area of:
A)
B)
C)
D)
E)
9%
13.5%
18%
22.5%
36%
p. 257/258
261. A gradual loss of visual acuity due to an increased opacity of the eye lenses
is a characteristic finding in which of the following conditions?
A)
B)
C)
D)
E)
Strabism
Cataract
Glaucoma
Amblyiopia
Conjunctivitis
p. 264
262. A client appears in the Emergency Room. He complaints about sudden and
increasing visual disturbances such as floating spots, blurred visions and
gradual loss of the visual field. Which of the following diagnoses is the
most likely in this situation?
A)
B)
C)
D)
E)
Retina detachment
Macular degeneration
Eye infection
Glaucoma
None of the above
p. 265
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263. A nurse has to instruct a client who has just received a laser treatment for an
acute retina detachment about the specifics of the post-operative treatment.
Which of the following statements are correct?
A)
B)
C)
D)
E)
You have to remain in a supine position for the next 24 hours.
We will give you a mild laxative to prevent a constipation.
Even after discharge you will have to avoid heavy lifting for at least 6 weeks.
You may remain without any visual impairment if this treatment was successful.
All of the above statements are correct.
p. 265
264. Which of the following laboratory findings in an iron deficiency anemia are
typically altered in an iron deficiency anemia?
A)
B)
C)
D)
E)
MCV
MCH
MCHC
Serum iron
All of the above parameters are altered in an iron deficiency anemia.
p. 272
265. Which of the following statements about a pernicious anemia are
correct?
1. Pernicious anemia is caused by an auto-immune reaction against parietal gastric
cells.
2. Pernicious anemia causes a deficiency of intrinsic factor.
3. The absorption of Vitamin B12 causes a microcytic anemia.
4. Neurological symptoms can be caused by a deficiency of Vitamin B12.
5. Diagnosis is made via the Schilling – Test.
A) 1 and 2 are correct.
B) 1, 2 and 3 are correct.
C) 3 and 4 are correct.
D) 1, 2 and 4 are correct.
E) 1, 2, 4 and 5 are correct.
p. 272
266. Which of the following statements about Thalassaemia are correct?
1.
2.
3.
4.
5.
Thalassaemia occurs in a major and a minor form.
Thalassaemia is classified as a hemoglobinopathy.
Humans of mediterranean ethnicity are immune against Thalassaemia.
Thalassaemia is a synonymous term for sickle cell disease.
Thalassaemia minor usually does not require any treatment.
A) 1 and 2 are correct.
B) 1, 2 and 3 are correct.
C) 3 and 4 are correct.
D) 1, 2 and 4 are correct.
E) 1, 2, 4 and 5 are correct.
p. 275
267. Haemophilia Type A is classified as follows:
A)
B)
C)
D)
E)
Deficiency of coagulation factor VIII
Deficiency of coagulation factor IX
Deficiency of von Willebrand factor vWF
Low platelet count
Microcytic anemia
p. 276
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268. Which of the following characteristics of a disseminated intravasal
coagulation are correct?
A) Common causes are intoxications, sepsis, polytrauma and other health
conditions.
B) PTT, aPPT and Thrombin time are elevated.
C) Increased consumption of coagulation factors V,VII, IX and XIII.
D) Increase of D-Dimer.
E) All of the above findings are typical for a disseminated intravasal coagulation.
p. 277
269. Please verify the following statements about prostate gland tumors for
correctness:
A) Diagnosis is made via biopsy.
B) Benign tumors of the prostate gland are generally more common than
malignancies.
C) Prostate gland cancer typically develops bone metastasis.
D) Prostate specific antigen is used as a Tumormarker for malignancies of the
prostate gland.
E) All of the above statements are correct.
p. 282
270. A client is admitted to the hospital. His chief complaints include enlarged,
firm, non - tender and non – shiftable lymph nodes. Further diagnostic
procedures reveal a hepatosplenomegalie and a mediastinal
lymphadenopathy. Which is the most likely diagnosis in this case?
A)
B)
C)
D)
E)
Hodgkin Lymphoma
Non–Hodgkin Lymphoma
Chronic Lymphatic Leukemia
Acute Lymphatic Leukemia
None of the above
p. 287
271. Which of the following side effects is not typical for a chemotherapeutic
therapy?
A)
B)
C)
D)
E)
Bone marrow depression
Nausea
Vomiting
Hepatotoxicity
Hypertension
p. 289 - 293
272. Which of the following statements about aromatase inhibitors are correct?
1.
2.
3.
4.
Aromatase inhibitors are indicated in hormone receptor positive breast cancer.
These substances are mainly indicated in premenopausal women.
Aromatase inhibitors do not replace a necessary treatment with tamoxifen.
Women with hormone receptor negative breast cancer show similar therapeutic
effects.
5. Aromatase inhibitors do not change the prognosis in cases of a hormone
receptor positive breast cancer.
A) 1 and 2 are correct.
B) 1 and 3 are correct.
C) 3 and 4 are correct.
D) 1, 2 and 4 are correct.
E) 1, 2, 4 and 5 are correct.
p. 284
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273. Which of the following definitions of psychiatric symptoms is incorrect?
A)
B)
C)
D)
E)
Delusions = false beliefs that can not be altered by evidence or local reasoning.
Hallucinations = sensations with no existing external stimulus.
Self neglect = difficulty in caring for one self.
Thought disruptions = difficulty in concentrating on a defined topic.
Anhedonia = loss of social competence.
p. 298
274. Which of the following definitions of psychiatric symptoms is incorrect?
Characteristics of a major depression are defined as follows:
1.
2.
3.
4.
5.
Decreased desire to participate in any social setting.
Low self-esteem
Feeling of incompetence
Decreased motivation
Sadness
A) 1 and 2 are correct.
B) 1 and 3 are correct.
C) 3 and 4 are correct.
D) 1, 2 and 4 are correct.
E) All criteria are correct.
p. 298
275. Which of the following psychopharmaceutical substances is also used as
an anti-emetic medication?
A)
B)
C)
D)
E)
Phenothiazine – type antipsychotic medication
Diazepam
Tricyclic anti-depressants
Zopiclone
Citalopram
p. 313
276. Which of the following ECG – findings can be caused by a coronary
artery disease (CAD) ?
1.
2.
3.
4.
5.
A)
B)
C)
D)
E)
Descending ST – Segments in leads II, III, avF.
Shoulder shaped ST Elevations
Left Bundle Branch Block
Atrioventricular blockage 3rd degree
Atrial fibrillation
2,3, and 4 are correct.
1,3, and 5 are correct
Only 1 and 2 are correct
None of the findings is typically caused by CAD
All findings can be caused by a CAD
p. 188/189
277. Which of the following rules and regulations apply for the decision
making rules in nursing practice ?
1.
2.
3.
4.
5.
Institutional regulations
Federal law
Priorities of urgent care
Insurance coverage of client
Power of Attorney
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A)
B)
C)
D)
E)
2,3, and 4 are correct.
1,3, and 5 are correct
1,2,3 and 5 are correct
None of the statements apply.
All statements apply
p. 8 - 11
278. Which of the following conditions of clients in an emergency room requires
the least urgent medical attention ?
A) Stabbing chest pain
B) Suicidal ideas
C) Hyperventilation
D) Urinary retention
D) Bleeding from a cut
p. 12/13
279. Parkinson’s Disease is caused by a deficiency of which the following
neurotransmitters ?
A) Dopamine
B) Norepinephrine
C) Epinephrine
D) Serotonine
E) GABA
p. 152
280. Which of the following brief descriptions applies to the term HMO most
accurate ?
A)
B)
C)
D)
E)
Preferred Provider Organization
Limited services
Welfare based health insurance
Primary Care referrals not required
Most expensive health insurance system
p. 11
281. Beta – 2 receptor stimulating medication is most commonly used in which
of the following conditions. (Select all answers that apply)
1.
2.
3.
4.
5.
Expected preterm labor
Hypertension treatment
COPD
Depression
Failure of uterine involution
A)
B)
C)
D)
E)
2,3, and 4 are correct.
1 and 3 are correct
Only 1. is correct
Only 3. is correct
All statements apply
p. 51/176
282. Which of the following stades is not part of the Kubler Ross stages of
Grief ?
A)
B)
C)
D)
E)
Denial (this isn'
t happening to me!)
Anger (why is this happening to me?)
Bargaining (I promise I'
ll be a better person if...)
Depression (I don'
t care anymore)
Suicidal ideas (Life does not make anymore sense)
p. 312
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283. In comparison to other common birthing methods the Bradley method is
based on which of the following requirements ?
A)
B)
C)
D)
E)
Augmented vaginal delivery
Hospitalisation
Distraction from pain
Intact parental relationship
Reduction of fear
p. 35
284. Which of the following ECG Patterns is of least clinical importance ?
A)
B)
C)
D)
E)
Premature ventriclar contractions
Premature atrial contractions
Atrial fibrillation
Ventricular fibrillation
Shoulder shaped ST – segment elevation
p. 182 - 188
285. Which of the following criterias have to be considered by a shift leading RN
who has to delegate duties to other staff members ?
1.
2.
3.
4.
5.
Years of experience
Qualification
Skills
Personal relationship
Workload
A) 2,3, and 4 are correct.
B) 1,3, and 5 are correct
C) 1,2,3 and 5 are correct
D) None of the criterias above apply.
E) All criterias apply
p. 13/14
286. Which of the following conditions is best described as a primary restrictive
pulmonary disorder ?
A)
B)
C)
D)
E)
COPD
Asthma
Emphysema
Tuberculosis
Whooping cough
p. 167/168
287. Which of the following symptoms are common extrapyramidal side effects
(ESPE’s) of an antipsychotic medication therapy ?
1.
2.
3.
4.
5.
Akathisia
Incontinence
Diarrhea
Miosis
Oculogyric crisis
A) 2, 3 and 4 are correct.
B) 1, 3 and 5 are correct
C) 1 and 5 are correct
D) None of the symptoms are common expressions of ESPE’s
E) All criterias apply
p. 313
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288. Which of the following recommendations apply for the care of a client
with Diabetes ?
1.
2.
3.
4.
5.
Weight gain has to be avoided
Insulin treatment is mandatory
Delayed wound healing is expected
Gestational diabetes may heal after delivery
Lack of treatment leads to Hypoglycemia
A) 1, 3 and 4 are correct.
B) 1, 3 and 5 are correct
C) 1 and 5 are correct
D) None of the statements apply
E) All criterias apply
p. 241 - 245
289. A nurse assesses the outcome of a tuberculine skin test a client has received
48 hours ago and recognizes a significant induration of the skin. Which of the
following statements is correct ?
A) 48 hours are not a sufficient time frame to allow any statement about the outcome.
B) The induration is a reason to hospitalize this client instantly.
C) A possible reason for this outcome is a previous BCG vaccination that this client
may have received.
D) The test has to be repeated.
E) All statements are correct.
p. 100
290. Which of the following actions in the acute care for a client with an acute
pulmonary edema has the highest priority ?
A)
B)
C)
D)
E)
Semi Fowler’s position
Oxygen supply
Administering Sodium chloride 0,9%
Performing an emergency ECG examination
All statements are correct.
p. 190
291. A nurse explains to a client the anticholinergic effects of a psychiatric
medication that was prescribed to him. Which of the following symptoms have
to be expected by this client ?
A)
B)
C)
D)
E)
Ptyalism
Bradycardia
Polyuria
Diarrhea
None of the above symptoms are anticholinergic side effects
p. 313
292. Which of the following statements about psychiatric conditions are
correct ?
1.
2.
3.
4.
5.
rrrrr
Delusional ideas are common and generally harmless
Self endangerment may require hospitalization against clients will
Addictive behaviour has to be anticipated and assessed
Psychopharmaceutical treatment is generally mandatory
Monoamineoxidase Inhibitors may be combined with trycyclic antidepressants.
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A) 1, 3 and 4 are correct.
B) 1, 3 and 5 are correct
C) 2 and 3 are correct
D) None of the statements are corrrect
E) All statements are correct
p. 302
293. Which of the following statements about Myelin sheets are correct.
1.
2.
3.
4.
5.
Myelin is the connective tissue of the nervous system
Myelin sheets increase the velocity of an electrical nerval innervation
All neurons are covered in myelin sheets
Myelin sheets are damaged in Myasthenia gravis
Myelin sheets are damaged in Multiple sclerosis
A)
B)
C)
D)
E)
1,3, and 4 are correct.
3,3, and 5 are correct
Only 1, 2, 4 and 5 are correct
None of the statements are correct.
All statements are correct.
p. 145
294. Which of the following conditions and procedures can lead to a metabolic
alkalosis.
1.
2.
3.
4.
5.
Myocardial infarction
Hyperosmolar non – ketotic diabetic coma
Insertion of a nasogastric tube
Hyperventilation
Frequent use of calcium carbonate based antacids
A)
B)
C)
D)
E)
1,3, and 4 are correct.
1,2, and 3 are correct
Only 3 and 5 are correct
None of the statements are correct
All statements are correct
p. 132
295. A patient has been hospitalized with pyelonephritis and is about to be
discharged. A nurse provides discharge instructions to a patient and his
family. Which misunderstanding by the family indicates the need for more
detailed information?
A) The patient may resume with normal home activities as tolerated but should
avoid physical exertion and get adequate rest.
B) The patient should continue to drink sufficient amounts of fluids on a daily basis.
C) The patient may discontinue the prescribed course of oral antibiotics once the
symptoms have completely resolved.
D) Recurrent bladder or flank pain as well as fever require immediate assessment.
E) Pyelonephritis is more complicated than cystitis.
p. 210
296. Which of the following signs and symptoms is not likely to occur in cases
of a left sided chronic heart failure ?
A)
B)
C)
D)
E)
Pulmonary edema
General physical weakness
Hypotension
Increase of BUN
Ankle edema
p. 190
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297. An unconscious client is admitted to the Emergency room. He carries the
following prescription drugs.
1.
2.
3.
4.
5.
Amitryptiline
Ramipril
Hydrochlorothiazide
Glimepirid
Pantozole
Which of the following assumptions can be made regarding the medical history of this
client ?
A)
B)
C)
D)
E)
This patient may suffer from schizophrenia
This patient may suffer from cancer
This patient may suffer from hypothyroism
This patient may suffer from diabetes
This patient may suffer from COPD
p. 145
298. Which of the following rules apply to a priority based clinical
decision making process of a team leader RN ?
1)
2)
3)
4)
5)
Acute care first
Rules of delegation
Oral medication first
Consideration of ethnical and religious needs
Institutional rules
A)
B)
C)
D)
E)
1,2, and 4 are correct.
1,2, and 3 are correct
Only 4and 5 are correct
None of the statements are correct
All statements are correct
p. 12/13
299. Which of the following infection is transmitted via an enteral pathway?
A) Influenza
B) Hepatitis B
C) Hepatitis C
D) HIV
E) Polio
p. 157
300. Appropriate education of a client with primary hypertension should include
which of the following statements.
2. A special diet is not required
3. A frequent blood pressure monitoring is recommended
4. Hypertension treatment includes frequent assessments of the kidney function
5. Smoking increases the risk to develop arterisclerosis
A)
B)
C)
D)
E)
1,2, and 3 are correct.
1,2, and 4 are correct
1, 3, 4 and 5 are correct
None of the statements are correct
All statements are correct
p. 194/195
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301. A client in a psychiatric unit is frequently observed with an overeating habit,
self induced vomiting, low self esteem and abuse of laxatives.
Which of the following conditions may be current in this case ?
A) Anorexia
B) Substance abuse
C) Bulimia
D) Schizophrenia
E) Depression
p. 307
302. A client on a surgical ward complains about a reddened, warm and tender
area on his left leg. The area is right above a wound that this client has
suffered from a car accident. Which of the following medications are most
likely to be included in this clients further care.
A) Erythromycin i.v.
B) Doxcyclin p.o.
C) Sulfamethoxazol p.o
D) Prednisolone i.v.
E) Ketoconazole i.v.
p. 253
303. Which of the following conditions are common risk factors for the
development of a deep vein thrombosis.
1. Estrogene therapy
2. Varicose veins
3. Immobilisation
4. Smoking
5. Major surgical procedures
A)
B)
C)
D)
E)
1,2, and 3 are correct.
1,2, and 4 are correct
1, 3 and 4 are correct
None of the statements are correct
All statements are correct
p. 194
304. Which of the following rules only applies in an environment of surgical
asepsis ?
A) Hair has to be kept clean and short
B) Designated area has clean and dirty objects
C) Use of personal protective equipment required
D) Hand Hygiene mandatory
E) Water and soap and alcohol based hand rub are of equal effect.
p. 19
305. Medical aseptic precautions apply to which of the following procedures ?
A) Insertion of a Ventral veinous catheter
B) Cholecystektomy
C) Spinal tap
D) Pleurocentesis
E) Colonoscopy
p. 19
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306. A client complains about a sudden onset of vertigo, nausea and vomiting. The
underlying condition is most likely which of the following ?
A) Epistaxis
B) Menieres Disease
C) Uveitis
D) Otitis externa
E) Glaucoma
p. 266
307. A client has received a lobectomy for lung cancer and is transferred to the
surgical observation unit. Which of the following statements describes the
appropriate positioning of this client ?
A) No specific rules apply.
B) Equal alternating positioning is required
C) Client needs to be positioned on the side of the surgical wound
D) Client is preferably positioned halfway to the side of the remaining lung
E) Client is preferably positioned on back
p. 170
308. Which of the following statements about a Dumping syndrome is correct ?
A) It is caused by a Billroth I procedure
B) It is caused by a Billroth II procedure
C) It causes hypoglycemia
D) It causes hot flushes and sweats
E) All of the statements are correct
p. 104
309. Which of the following physiological functions is a typical sympathomimetic
effect ?
A) Smooth muscle relaxation
B) Reduction of heart rate
C) Bladder stimulation
D) Miosis
E) Bronchoconstriction
p. 147
310. Appropriate nursing care for a client with a Tracheostomy includes which of
the following procedures ?
1. Respiratory assessments three times daily
2. Suctioning as required
3. Tracheostomy and Cuff pressure assessment three times daily
4. Change of soiled Tracheostomy strings asap
5. Frequent assessment of respiratory tract infections
A)
B)
C)
D)
E)
1,2, and 3 are correct
1,2, and 4 are correct
2, 3,4 and 5 are correct
None of the statements are correct
All statements are correct
p. 174
311. Which of the following actions has to be performed first when an airway tube
is removed ?
A) Deflation of cuff
B) Adjusting client in a Fowlers position
C) Suctioning of the trachea
D) Removal of tube
E) None of the above
p. 121
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312. A client receives Ergotamine for treatment of a chronic migraine. Which
behavioral measures should this client be instructed on ?
1. Avoidance of stress
2. Regular meals
3. Regular life style
4. Avoidance of long fasting periods
5. Avoidance of red wine
A)
B)
C)
D)
E)
1,2, and 3 are correct.
1,2, and 4 are correct
3,4 and 5 are correct
None of the statements are correct
All statements are correct
p. 154/155
313. Which of the following criterias have to be met to diagnose a substance
addiction ?
A)
B)
C)
D)
E)
Recurrent use of a substance despite negative consequences
Controlled use
Consume can be interrupted for days to weeks
Compulsive use of a substance
All of the above criteria are met in case of a substance addiction
p. 307/308
314. Which of the following statements about Flumazenil is correct ?
A)
B)
C)
D)
E)
Flumazenil is administered orally.
Flumazenil is an antidepressant
Flumazenil may be used to treat symptoms from a Diazepam overdose
Flumazenil an antipsycotic medication
All statements are correct
p. 317
315. Which of the following considerations apply in maintaining a central venous
catheter (CVC) ?
A)
B)
C)
D)
E)
A closed tip (=Groshong) catheter can be flushed with physiological saline only.
Flushing a CVC should be performed with a 20 ml syringe
A sterile dressing of the insertion site of a CVC is not necessary
A CVC only has to be inserted in cases of poor peripheral veins
The tip of a CVC has to reach into the left atrium
p. 139
316. Which of the following characteristics apply to Crohn’s Disease ?
1. Curable
2. Incurable
3. Infectious disease
4. Bloody diarrhea
5. Affecting the large bowels only
A)
B)
C)
D)
E)
1,2, and 3 are correct.
1,2, and 4 are correct
Only 2 is correct
None of the statements are correct
All statements are correct
p. 218
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317. In palliative care setting the following physical symptoms are considered to
be signs of a nearing death:
1. Drowsiness
2. Dehydration
3. Restlessness and agitation
4. Incontinence
5. Pain
A)
B)
C)
D)
E)
1,2, and 3 are correct
1,2, and 4 are correct
Only 2 and 3 is correct
1,2,3 and 4 are correct
All statements are correct
p. 311
318. A pressure ulcer of a client reaches deep into the subcutameous tissue.
Which of the following treatments provides the most effective support for a
healing process ?
A)
B)
C)
D)
E)
Pressure relief
Drainage of secretions
Surgical debridement
Frequent wound assessments
Supply of zinc
p. 256
319. A blood count of a female client shows the following findings:
Hb 11,3 g/dl
MCV 68 fL
MCH 20 pg
Which of the following conclusions are correct ?
A)
B)
C)
D)
E)
This is a normal finding
This client has to e assessed for a folic acid deficiency
This client requires an immediate RBC transfusion
The lab results show characteristic findings for an iron deficiency anemia
No statement can be made without a complete blood count
p. 272
320. Which of the following findings proofs the diagnosis of a Hodgkin –
Lymphoma ?
A)
B)
C)
D)
E)
Enlarged, tender, shiftable lymph nodes
Enlarged, nontender, non – shiftable lymph nodes
Massive production of B – Lymphocytes
Presence of Sternberg – Reed cells in a Biopsy
Weight loss
p. 286
321. Which of the following criteria defines characteristics of a malignant process ?
A)
B)
C)
D)
E)
Enlarged, tender, shiftable lymph nodes
Enlarged, nontender, non – shiftable lymph nodes
Fever
Prolonged Diarrhea
Weight loss
p. 286
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322. Which of the following actions are appropriate steps to take after a
needlestick injury where the client is suspected to be infected with Hepatits
and HIV ?
A)
B)
C)
D)
E)
Decontamination of the wound by cleaning the skin with soap and water
Administering Hepatitis B – Immunoglobulines
Administering a Hepatitis B vaccination
Starting an antiretroviral treatment within 72 hours
All of the above actions are appropriate
p. 21
323. Typical symptoms of a Hyperpituitarism are:
A)
B)
C)
D)
E)
Gigantism
Akromegaly
Cushings Syndrome
Hyperthyroidism
All of the above symptoms can occur
p. 237
324. Which of the following symptoms are expected to occur in
Hyperparathyroidism ?
1.
2.
3.
4.
5.
A)
B)
C)
D)
E)
Elevated blood glucose
Elevated serum calcium
Increased serum phosphate
Increased risk of fractures
Polyuria
1,2, and 3 are correct
2,3 and 4 are correct
Only 2 and 3 is correct
1,2,4 and 5 are correct
All statements are correct
p. 237
325. Which of the following medications takes effect by blocking the
Prostaglandine synthesis pathway ?
A)
B)
C)
D)
E)
Nitrendipine
Promethazine
Acetylic salicylic acid
Erythromycin
Metoclopramide
p. 89
326. Expected complications in case of a clinical sepsis include which of
the following ?
1.
2.
3.
4.
5.
Fever (>38oC)
Hypotension (systolic pressure<90 mm Hg)
Oliguria (<20 ml/hr)
Hypertension
Disseminated intravascular coagulation (DIC)
A)
B)
C)
D)
E)
1,3, and 4 are correct.
1,3, and 5 are correct
1,2,3 and 5 are correct
None of the statements apply.
All statements apply
p. 161
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327. Which of the following functions is not supported by an innervation of
the trigeminal nerve ?
A) Biting
B) Chewing
C) Swallowing
D) Coughing
E) Facial sensation
p. 76/77
328. Which of the following calls made to an outpatient clinic should have the
highest priority for medical intervention?
A) A home health patient reports, “I am running out of meds today.”
B) A patient who received a forearm cast yesterday reports, “I have terrible pain and
numbness in my left arm.”
C) A female client reports, ”I think I sprained my ankle about 2 weeks ago.”
D) An older patient reports, ”My knee is still hurting after the surgery 2 weeks ago.”
E) A mother of a 2 year old girl reports that her daughter is having fever since the
morning.
p. 12/13
329. A patient on a surgical ward is experiencing sudden shortness of breath,
chest pain and calf pain. Which of the following actions has the first priority in
the further care for this client ?
A) Positioning in a Fowler’s position
B) Positioning in a supine position
C) Assessment of vital signs
D) Oxygen supply
E) Request for an emergency ECG
p. 12/13
330. Which of the following tasks necessary for the care of a client with a
previously excerbated COPD is appropriate to delegate to a nursing
assistant ?
A) Transfer within the clients room
B) Adjusting the flow rate of oxygen supply
C) Examining the client
D) Educating the cleint
E) Providing discharge instructions to relatives
p. 13/14
331. Which of the following patients should the nurse on duty check on first?
A) A 55 year-old male who is scheduled for an EGD in 10 hours.
B) A 44 year-old male who is scheduled for back surgery the next day and who has
experienced an onset of urinary incontinence in the last hour.
C) A 21 year-old male who had a lower extremity amputation two days ago.
D) A 27 year-old female who has received a RBC transfusion two days ago.
E) A 33 year-old male with headaches
p. 12/13
332. A 14 year old teenager is admitted to the ER with acute lower right
abdominal pain. The admitting nursing should take which the following
measures first?
A) Administer pain relief.
B) Preparing for a blood sample
C) Preparing for insertion of a central venous catheter.
D) Schedule a X-Ray examination
E) Assessing the menstrual cycle
p. 12/13
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Dr. Karrenberg’s 2010 NCLEX-RN® Review Manual
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333. Which of the following criterias have to be met to take a client with
pulmonary tuberculosis off isolation restrictions ?
A) Negative TBC sputum cultures
B) 1 Month of tuberculostatic therapy
C) Symptom relief
D) Absence of fever
E) Weight gain
p. 173
334. An older male patient suddenly experiences abdominal pain, absent pedal
pulses, chest pain, lower back pain. The attending nurse also notices a
hypotensive blood pressure. Which of the following actions has the first
priority in this case ?
A)
B)
C)
D)
E)
Scheduling an abdominal ultrasound examination
Requesting an emergency ECG
Oxygen supply
Administering Morphine orally
Inserting one or more i. v. lines
p. 196
335. Which of the following actions has the highest priority in the care for a client
with an acute asthma attack ?
A)
B)
C)
D)
E)
Administering Salbutamol by nebulizer
Administering oxygen
Assessment of the medical history
Administering Prednisolone i. v.
Administering Theophylline i. v.
p. 171
336. Which of the following actions has the highest priority in the care for a client
with an acute myocardial infarction after the diagnosis has been made via an
ECG?
A)
B)
C)
D)
E)
Discussing the therapeutic options with this client
Administering oxygen
Administering Morphine
Administerintg Metoprolol
Preparing for a left heart catheterization
p. 188/189
337. A client with Diabetes Type 2 receives an oral antidiabetic therapy. When he is
scheduled for surgery which of the following changes of this therapy are
appropriate ?
A) Maintaining the pre-existing therapy throughout the surgical procedure and
recovery period.
B) Prescribing long acting Insulin instead of oral antidiabetics throughout the
surgical procedure and recovery period.
C) Cessating the oral antidiabetic therapy and replacing it with regular insulin on
demand under frequent blood sugar monitoring.
D) Cessating the oral antidiabetic therapy without replacement since the client will
not eat as much as usual throughout the surgical procedure and recovery period.
E) Reducing the dosage of the oral antidiabetic therapy by 50% throughout the
surgical procedure and recovery period.
p. 241 - 245
388
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338. A client is likely to report that he feels euphorized and that he recognizes an
increased pulse after taking which of his following medications ?
A)
B)
C)
D)
E)
Bisoprolol
Candesartan
Naproxen
Nystatin
Theophylline
p. 176
339. After taking the medical history of a client the admitting nurse schould be
concerned about which of the following combinations of prescribed meds ?
A)
B)
C)
D)
E)
Metoprolol and Verapamil
Diclofenac and Pantoprazole
Metoclopramide and Morphinesulfate
Terbutaline and Prednisolone
Ciprofloxacine and Acetaminophen
p. 199
340. Which of the following clients can be cohorted ?
A)
B)
C)
D)
E)
A client with HIV and a client with pneumonia
A client with Meningitis and a client with pneumonia
A client with a pyelonephritis and a client with cellulitis
Two clients with pulmonary tuberculosis
A client with MRSA and a client who had an Appendectomy
p. 20/21
341. Which of the following conditions may require treatment with Azathioprine ?
A)
B)
C)
D)
E)
Rheumatoid Arthritis
Osteoarthritis
Fibromyalgia
Chronic heart failure
Lyme disease
p. 249
342. A female client is concerned about the need to receive antibiotic medication
therapy and asks the attending nurse for possible side effects. The nurse
should inform this client about which of the following possible side effects ?
A) Diarrhea
B) Cystitis
C) Head cold
D) Coughing
E) Alopecia
p. 161
343. Which of the following blood dyscrasias are likely to be observed in a client
under treatment with cyclophospamide ?
1. Leukopenia
2. Anemia
3. Disseminated intravascular coagulation (DIC)
4. Thrombocytosis
5. Eosinophilia
A) 1 and 2 are correct.
B) 1,3, and 5 are correct
C) 1,3 and 5 are correct
D) 2,4, and 5 are correct
E) 3,4,and 5 are correct
p. 291
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Dr. Karrenberg’s 2010 NCLEX-RN® Review Manual
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344. Ascites is directly caused by
A) Loss of colloidosmotic pressure
B) Liver enlargement
C) Portal vein hypertension
D) Alcoholism
E) Congestion of the common bile duct
p. 224
345. Pleural effusions can be caused by
A) Trauma
B) Tumors
C) Pneumonia
D) Chronic heart failure
E) All of the above named conditions
p. 171
346. Which of the following patients in an emergency room has the most urgent
need for medical attention ?
A)
B)
C)
D)
E)
A pregnant female patient with sudden vaginal gosh of fluids
A male patient with a BP of 195/100 mmHg
A three year old child with a temperature of 100 degress Fahrenheit 38 C)
A male patient with back ache and a history of an aortic aneurysm
All described cases are of equal priority
p. 12/13
347. Which of the following findings on a maternity ward should raise the most
concern of the attending nurse ?
A) A woman who has been admitted 6 hours earlier after uterine contractions have
started ?
B) A woman who has been admitted for her fourh vaginal delivery.
C) Early decelarations of the FHR.
D) Late decelarations of the FHR.
E) A woman who has just competed the third stage of labor.
p. 39
348. Which of the following observations of psychiatric symptoms are considered
as warning signs of a psychotic disorder ?
A)
B)
C)
D)
E)
A client who appears to be depressed due to a job loss last year.
A client who has a 10 – year history of alcohol abuse.
A client who is suffering from frequent mood changes.
A client who has problems to interact socially.
A client who reports to hear frequent voices.
p. 302
349. Which of the following medications would be administered in an
Opthalmology Department to induce a Mydriasis for an eye exam?
A)
B)
C)
D)
E)
Latanoprost
Atropine sulfate
Hydrocortisone
Acetazolamide
Timolol
p. 268
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Dr. Karrenberg’s 2010 NCLEX-RN® Review Manual
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350. Hashimoto’s disease requires a medication therapy with which of the
following subtances ?
A)
B)
C)
D)
E)
Growth hormone
Prednisolone
Calcitonine
Thyroxine
None of the above named substances
p. 236
351. A client with an endstage renal disease requires a potassoium restricted diet.
Which of the following food sources should be limited ?
A) Beans
B) Dried fruits
C) Melons
D) Tomatoes
E) All of the above
p. 126
352. Which of the following conditions is the most common health disorders in
clients above 65 years of age ?
A) Cancer
B) Coronary Heart Disease
C) Osteoarthritis
D) Diabetes
E) Hypertension
p. 83
353. Which of the following statements about maintaining a central veinous
catheter is incorrect ?
A) The catheter can remain unchanged as long as necessary if no obvious signs of
infections occur.
B) A sterile dressing is not required.
C) Insertion can be made via any visible vein.
D) Correct placement of the tip of a CVC is the superior cava vein.
E) All statements are incorrect.
p. 139
354. Following the current 2010 CDC vaccination schedule which of the following
vaccinations has to be administered at birth?
A)
B)
C)
D)
E)
H1N1
Influenza
Tetanus
Pneumococcal vaccine
Hepatitis B
p. 71
355. Which of the following criteria does not allow discharge from a PACU unit ?
A)
B)
C)
D)
E)
Vital signs sufficient
No gag reflex present
Spontaneous breathing
Client easily arousable
Immobility
p. 103
391
Dr. Karrenberg’s 2010 NCLEX-RN® Review Manual
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ANSWER KEY
1
E
47
E
93
2
E
3
E
4
B
C
139
B
185
D
231
D
48
A
49
D
94
A
140
D
186
D
232
D
95
G
141
C
187
A
233
A
50
D
96
B
142
E
188
E
234
E
5
A
51
A
97
A
143
E
189
C
235
E
6
B
52
A
98
A
144
B
190
E
236
A
7
C
53
A
99
A
145
E
191
E
237
E
8
C
54
A
100
A
146
E
192
D
238
A
9
C
55
A
101
E
147
B
193
A
239
A
10
E
56
E
102
E
148
B
194
C
240
A
11
C
57
B
103
A
149
A
195
A
241
A
12
B
58
A
104
C
150
B
196
A
242
A
13
A
59
E
105
A
151
A
197
E
243
E
14
A
60
E
106
A
152
C
198
A
244
A
15
A
61
B
107
E
153
D
199
A
245
A
16
B
62
B
108
B
154
A
200
E
246
A
17
C
63
A
109
C
155
B
201
B
247
D
18
A
64
A
110
D
156
C
202
E
248
A
19
B
65
A
111
B
157
C
203
A
249
A
20
A
66
A
112
A
158
E
204
D
250
A
21
D
67
D
113
E
159
A
205
E
251
B
22
B
68
E
114
A
160
A
206
C
252
C
23
A
69
B
115
A
161
C
207
D
253
E
24
D
70
D
116
A
162
B
208
E
254
E
25
D
71
D
117
E
163
B
209
D
255
D
26
A
72
A
118
D
164
C
210
A
256
D
27
A
73
B
119
C
165
E
211
B
257
D
28
D
74
E
120
A
166
B
212
C
258
B
29
A
75
D
121
A
167
B
213
E
259
E
30
E
76
D
122
B
168
C
214
D
260
C
31
B
77
D
123
A
169
A
215
A
261
B
32
A
78
A
124
E
170
B
216
A
262
A
33
E
79
B
125
B
171
E
217
E
263
E
34
B
80
A
126
E
172
A
218
E
264
E
35
E
81
B
127
E
173
B
219
E
265
E
36
C
82
A
128
B
174
A
220
E
266
E
37
A
83
E
129
C
175
D
221
C
267
A
38
A
84
E
130
A
176
A
222
A
268
E
39
A
85
E
131
E
177
C
223
E
269
E
40
A
86
B
132
A
178
C
224
E
270
A
41
A
87
A
133
A
179
D
225
A
271
E
42
A
88
B
134
C
180
A
226
E
272
B
43
B
89
A
135
A
181
A
227
E
273
E
44
E
90
E
136
A
182
E
228
E
274
E
45
D
91
E
137
A
183
C
229
A
275
A
46
C
92
A
138
D
184
A
230
D
392
Dr. Karrenberg’s 2010 NCLEX-RN® Review Manual
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289
C
303
E
317
D
331
B
345
E
290
A
304
A
318
A
332
B
346
D
291
E
305
E
319
D
333
A
347
D
292
C
306
B
320
D
334
E
348
E
293
C
307
B
321
B
335
A
349
B
294
C
308
E
322
E
336
B
350
D
B
295
C
309
A
323
E
337
C
351
E
282
E
296
E
310
C
324
D
338
E
352
E
283
D
297
D
311
A
325
C
339
A
353
E
284
B
298
B
312
E
326
C
340
C
354
E
285
C
299
E
313
A
327
D
341
A
355
B
286
C
300
C
314
C
328
B
342
A
287
C
301
C
315
A
329
A
343
A
288
A
302
A
316
C
330
A
344
A
276
E
277
C
278
C
279
A
280
B
281
Learning Plan Recommendations
Depending on how soon after your college graduation you are intending to start your
NCLEX-RN exam preparation process we recommend the following 3 individual learning
plans below. We also recommend to schedule the exam date before you start your
preparation process. Depending, if you are a full or part time student you may adapt the
following time lines to your individual situation.
Content
Review
Keyword
Review
Question
Review
Graduating
Students
Graduation 6 – 12
months ago
10 days
20 days
Refresher /
Returner /
Retaker
30 days
2 days
4 days
8 days
3 days
6 days
12 days
Preparation periods over 50 days in length should be generally avoided since it becomes
more difficult to retain the particular specific knowledge requirements over a longer
period of time.
For the individual situation you may focus on retaining as many exam relevant facts as
possible instead of focusing on practice questions only. This method enables you much
rather to aquire a sufficient and broad knowledge of the NCLEX-RN curriculum, which is
essential to meet the passing standards.
The NCLEX – RN curriculum consists of a well defined pool of knowledge areas which
we have introduced you to entirely in this manual. The challenge of passing this nursing
board exam is to recognize as many known facts in the actual exam situation.
393
Dr. Karrenberg’s 2010 NCLEX-RN® Review Manual
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for one of our upcoming classes in your area!
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