1

RESPIRATORY SYSTEM

Normal Breath Sounds

1. Broncial

It is heard when air is passing through Trachea & Bronchi.

2. Bronchio-Vesicular

Sound is heard when air is passing through Broncheolus.

3. Vesicular

It is heard when air is passing through Alveoli.

Abnormal Breath Sounds

1. Strider

It is heard when air is passing through completely obstructed airway passage.

It is a medical emergency condition we should intubate the patient.

2. Wheezing

Sound is heard when air is passing through partially obstructed airway passage.
It is a musical sound commonly heard on expiration. Eg.
Asthma

3. Crackles (crepts)

Heard when air is passing through fluid filled alveoli, it is commonly seen in Pulmonary
Edema.

COPD

Include 2disease conditions. ( Respiratory Acidosis )

1. Chronic Bronchitis
2. Emphysema

1. Chronic Bronchitis
Chronic productive cough that last for minimum 3 months in 2 continuous
years.

2. Emphysema
Abnormal permanent enlargement of air spaces at the level of alveoli.
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C/M

 Dyspnoea
 Hypoxia
 Tachypnoea
 Wheezing sound
 Cyanosis

 Barrel Chest :- Anterior-Posterior diameter of the chest wall is increasing this is due to
emphysema.

 Koilonychia :- ( Spoon shaped Nails ) It is commonly seen in hypoxia conditions, like

respiratory conditions, cyanotic heart disease and anemia. Provide vitamin, iron rich food

C/M of Emphysema is called as PINK PUFFERS.

C/M of Chronic Bronchitis is called as BLUE BLOATERS

Management

 Administer low concentrated O2 ( 1-2 Litter )

 Provides Semi Fowlers Position ( fowlers )
 Bronchodilators ( Side effect - Tachycardia )
 Steroids ( Administer first bronchodilator then steroids, But when are stopping stop the
Steroids first then Bronchodilators )
 After the use of Rota caps, advice the patient to do Oral Gargles to prevent Oral
Candidiyasis.

ABG Analysis :- Respiratory Acidosis in COPD Nursing

intervention :- Oral Care

Provide Chest Physiotherapy

Patient teaching for COPD

 Early detection and treatment of respiratory infection.
 Increase fluid intake.
 Influenza Vaccine
 Pneumococcal Vaccine for Old Age
 Provide high Calory - High Protein Diet
 Advice Pursed – Lip Breathing technique to eliminate excessive CO2
 The child may develop Tripod Position, It is a Sign of Laryngeal Edema.

Influenza Vaccine

It is a Yearly Vaccination.
Contraindicated for Infants Below 6 Month.
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Winter months are ideal time for Influenza Vaccine.

Vaccination is Contra Indicated in individual with Egg Allergies. Do not
Administer After 65 Years
Administer Pneumococcal Vaccination After 65 Years.
Pneumococcal Vaccination is an Old Age Vaccination. Administer every 5 year

ABG ANALYSIS

Normal Values

PH - 7.34 - 7.45
PCO2 - 35 - 45
HCO3 - 22 - 26

Common Extra cellular fluid Buffer - Bicarbonate ( HCO3 ) In

DKA and Renal Failure - Metabolic Acidosis
In Vomiting and Hyperemisis Gravidarum - Metabolic Alkalosis

Example

PH - 7.27
PO2 - 95
SPO2 - 98 %
PCO2 - 39
HCO3 - 20

Step of ABG

1. Check the PH if < 7.35 Acidosis Check

the PH if > 7.45 Alkalosis
2. Check PCO2
3. Check HCO3 ( Bicarbonate )

ROME-------Respiratory Opposite Metabolic Equalent

Respiratory Acidosis PH - PCO2

Respiratory Alkalosis PH - PCO2

Metabolic Acidosis PH - HCO3

Metabolic Alkalosis PH - HCO3

Pre procedure

 Explain the procedure to the patient.

 Should check Allens Test before radial ABG to check collateral circulation.
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Allens Test

Involves compressing of both radial and ulnar arteries and asking the client to close and open the
fist. This cause the hand to become pale. The nurse then release pressure on one, artery and
observe if circulation is quickly restore there is sufficient collateral circulation. Repeat the
procedure in remaining artery.
T B ( Tuberculosis )

Causative organism > Microbacterium Tuberculi Droplet Air

born Infection
Acid Fast Bacilli ( AFB ) Breathing
Sound – Popping sound Spread in over
crowding area

C/M

 Productive cough more than 2 Weeks Especially in Early Morning – It is an early c/m
 Hemoptysis
 Wight loss
 Night Fever and Sweating D/E

 Sputum Culture -Early detention and confirm laboratory test –100% confirmatory test Ist
option
 Chest X RAY II nd option
 Mantoux Skin Test > .1 ml PPD (Purified Protein Derivative ) is injecting to the Left
Forarm Intra Dermally. Using 26 G Needle. Check the induration after 48 - 78 Hours

IF induration present 5 mm / more Test is + ve AIDS

pt. 5 mm is + ve
DM pt. 10 mm / more + ve Normal pt.
15 mm + ve

IF pt. Once Mantoux is + ve , the Mantoux will be + ve for Life Long.

Nursing Intervention

Provide Isolation - Negative Pressure Room Management

Antituberculin Drugs - side effect – Hepatic Toxicity

Drugs Side Effects

Iso Niyazide ( INH ) - Hepatic Toxicity, Peripheral Neuropathy

Rifampicin - More Hepatic Toxicity, Orange Colour Body Fluid Urine

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Pyrazinamide - Hepatotoxicity

Check LIVER Function Test Before, During, and After Antituberculin drug treatment

PNEUMONIA

Inflammation of Lung Parenchyma is called as pneumonia

Causative Organism > Pneumococci , Streptococci, Pseudomonas Erieginosa , Microplasma Type

1. Hospital Acquired Pneumonia ( HAP )
2. Ventilator Associated Pneumonia ( VAP )
3. Community Acquired Pneumonia ( CAP)

1. Hospital Acquired Pneumonia ( HAP ) :- Pneumonia occurs after 48 hrs of Hospitalization.

It is a nosocomial infection ( Infection acquired from hospital ). It is an iatrogenic infection
due to lack of aseptic technique.
2. Ventilator Associated Pneumonia ( VAP ) :- causative organism – Pseudomonas
Erieginosa
3. Community Acquired Pneumonia ( CAP ) :- causative organism- Microplasma
Pneumonia.

C/M

 Productive Cough
 Chills
 Fever
 Respiratory distress
 Dyspnoea
 Tachycardia
 Pleural pain
 Decreased Breath sound

D/E

Chest X RAY Sputum Culture

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Management

Antibiotics
Increased fluid intake

CHEST TUBE DRAINAGE SYSTEM ( ICD )

Indication

Pnemothorax :- Air in the Plural Space

Hemothorax :- Blood in the plural space Plural
Effusion :- Fluid in the plural space Emphyma :-
Pus in the Pleural Space

 Intermittent Bubbling or Fluctuation in the Water Seal chamber are the Normal
Function of chest tube
 Continuous bubbling and absence of bubbling indicate malfunctioning chest tube.
( Continues bubbling may be present in pneumothorax )

 Notify the physician if drainage more than 100 ml / more, or it is dry red.
 If the ICD is detached from the chest wall apply Petroleum Gauze Pad dressing over the
area.
 If the ICD tube is detached from water seal chamber. Should dip the distal end is Sterile
Water.
 When the chest tube is removing the client. He is asked to take a Deep Breath and Hold
it , or follow a Valsalva Manneur.

POSTURAL DRAINAGE

Position - Trendelenberg Position.

Drainage of respiratory secretions with the help of Gravity ( Principle of Gravity ) .
If the secretion is present in the Upper Part of Lungs provide Sitting and Leaning Forward. Lower
Part of the Lungs – Lie on Unaffect side with Trendlenberg Position.
Lower Posterior portion of the Lungs - Prone with Trendlenberg position.

CHEST TRAUMA AND THORACIC INJURY

1. Rib Fracture
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Fracture of the rib

C/M
 Pain increases with Inspiration
 Shallow Respiration
 Self Splinting in chest
 Tenderness

Position - Fowlers Position Management

– Analgesics

2. Flail Chest

Multiple Rib Fracture.

C/M
 Paradoxical chest movement ( Inward movement of chest during Inspiration and
Outward movement during Expiration )
 Chest pain
 Diminished breath sound
 Shallow Respiration

Management
 Bed Rest
 Fowlers Position
 Humidified O2
 Coughing and Breathing

3. Pneumothorax

Presence of Air in Pleural Space

1. Open - Open wound is present

2. Close - No external wound is present
3. Tension - Rapid accumulation of air in Pleural Space

It is a Medical Emergency Immediate Treatment required with is Needle Decompression.

C/M
 Decreased chest expansion unilaterally
 Decreased / absent breath sound n affected side
 Sucking sound in Open pneumothorax
 Tracheal deviation towards the unaffected side ( Mediastinal Shift ) in the
Tension Pneumothorax ( Seen in Chest X ray )
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 Hypotension
 Cynosis
 Chest Pain
 Tachycardia

Management
Apply Dressing over the chest ( if it is open pneumothorax )
Administer O2
Fowlers Position
Prepare for chestube placement

CARDIO VASCULAR SYSTEM

ECG

12 leads are present

V 4 :- Apical Area / Vital Area Lt side

Location :- 5 th Intercostal Space, Mid clavicular Line Below the Nipple Line Left to Sternum

Pulmonic Area :- 2 nd Intercostal Space Left to Sternum Pulse

Pressurer :- Difference between Systolic and diastolic BP Normal

Pulse Pressure :- 40 mm of Hg

Pulse Deficit :- Difference Between Apical and Peripheral Pulse Mean

Arterial Pressure ( MAP )

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MAP =

( DP x 2 ) + SP
----------------------
3

( 80 x 2 ) + 120 160 + 120 280

120/80 ------------------- = ---------------- = -------- = 93
3 3 3

Cerebral Perfusion Pressure :- MAP – ICP

Normal ICP :- - 15 mm of Hg Exactly 10

Stroke Volume :- Amount of Blood Pumped by heart in Each Contraction.

Normal :- 70 ml

Cardiac Output :- Amount of Blood Pumped by Heart in Each Minute.

Cardiac Output = Stroke Volume x Heart Rate

BP

Pressure Exerted by the Wall of the Artery Types

New classification

S BP D BP

Normal 90 - 119 60 - 79
Pre HT 120 - 139 80 - 89
HT Stage I 140 - 159 90 - 99
HT Stage II 160 and above 100 and above

Basic Life Support ( BLS )

Check the Response

!
No response
!
Call for Help
!
Get Defibrillator ( AED )
!
Check Pulse Adult - Carotid Pulse , Infant - Brachial Pulse
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!
No Pulse
!
Start CPR Compression

Ratio

Infant 15 : 2
Adult 30 : 2
Compression rate / mt is not < 100 ( 100 – 120 )

Depth

Adult - 2 Inch
Infant - 1.5 Inch

Site of compression
Lower 2/3 rd of Sternum towards the Nipple Line Advance

Cardiac Life Support ( ACLS ) Using Defibrillator Common

difference in ACLS is using Drug Eg. Adrenaline

CHOCKING

Adult Chocking Follow Heimlich Manneur

If we are suspecting chocking make sure that he is chocking by asking are you Chocking. If Yes
Using Abdominal thrust
Stand behind the pt. and fingers locked and give upward and forward thrust at the bottom of
the diaphragm.

C/I

 Obesity
 Pregnancy
 Just post partum
In this case advise the client to Cough Forcefully and Chest Thrust ( Compression in Chest )
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Infant Chocking

Place the Infant on Prone Position on Forarm with Head Down wards and give 5 Black
Blows and Chest Thrust.

Normal Heart Sound

S1 - Clossure of the Atrioventricular Valve ( Tricuspid & Bicuspid / Mitral ) S2 -

Clossure of the Semilunar Valve ( Pulmonic & Aortic Valve )

Abnormal Heart Sound

S3 - It is present in Heart Failure, Valve Abnormality etc. S4

- Present Atrial Systole.

Conducting System Of the Heart

Include :-
 SA Node
 AV Node
 Bundle of His
 Purkinje Fibers

1. SA Node
Pacemaker of the Heart, Located at the Junction of Sup. Venacava & Rt. Atrium.
It initiate heart beat at the rate of 60 - 110 Bpm.

2. Av Node
Located at the Inferior portion of Intra Atrial Septum, Receives impulse from SA
Node. If SA Node fails to initiate heart beat, AV Node initiate the heart beat at the
rate of 40 - 60 Bpm.

3. Bundle Of His
Continuation of AV Node - 2 Branches

1. Rt. Bundle Branch

2. Lt. Bundle Branch

4. Purkinje Fibers
These are network of conducting strands located beneath the Ventricular Endo
Cardium. If SANode & AV Node fails to initiate heart rate, Purkinje fiber will do it at
the rate of 20 - 40 Bpm.

Normal E C G
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P Wave - Rt. & Lt. Atrium Contraction ( Depolarization )

PR Interval - Time taken for the transmission of impulses from SA Node to Purkinje Fibers
( Normal 0.12 - 0.20 Second )

QRS Complex - Ventricular Contraction ( Depolarization )

T Wave - Ventricular Relaxation ( Heart Relaxation / Repolarization ) DYS

ARRYTHEMIA

1. Atrial Fibrillation

 No Definite P Wave
 Irregular RR interval Management -

Cordarone / Amiodarone

2. Atrial Flutter ( AF )

 Saw Tooth Appearance

Management

Digoxin
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3. Ventricular Tachycardia ( VT )

P Wave - Absent
PR Interval - Absent QRS
- Wide

 2 Types

1. Pulse VT - Management - Lidocaine ( Xylocaine )

2. Pulseless VT - Management - Defibrilator It Can

Cause Cardiac Arrest

4. Ventricluar Fibrillation

P Wave - No recognizable T
Wave - No recognizable
QRS - Unable to Determine

It is Most Dangerous Dysarrythmia - Rapidly Fatal

Flat Line Protocol / A systole

 Check the connection between Monitor and Electricity

 Check the connection between Patient and Monitor.
 CPR

Heart Failure / CHF

In ability of the heart to pump adequate blood

1. Rt. Side Heart Failure

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2. Lt. Side Heart Failure

Risk Factors
 Rheumatic Heart Disease
 MI
 Congenital
 Valvular C/M

Rt. Side H.F Lt. Side H.F

Jugular Vein Distension Symptoms are related to Respiratory Problem

Spleenomegaly Tachypnoea
Hepatomegaly Dyspnoea
Wt. Gain Hypoxia
Ascitis Crackles
Increased CVP Use of Accessory Mussels on respiration
( Normal 8 – 10 mm of Hg )

Management

 Semi Fowlers Position

 O2 Administration
 Diuretics
 Digoxin

Digoxin

Heart Failure Drug Of Choice

Action - Cardiac Glycoside - Increased Cardiac Output

Before administering Digoxin should Check Apical Pulse. If the Apical Pulse < 60 Beats With hold
the medication and Inform Physician.
Should Monitor Potassium Level during Therapy
Therapeutic range is 0.5 - 2 nanogram/mt., If it is more than 2 ngrm is called as digoxin Toxicity

S/S of Digoxin Toxicity

 Bradycardia
 Hallo Vision
 Nausea
 Vomiting

While administering Digoxin the client Vomit, We are not supposed to administer. Inform
the Physician.
If Digoxin Toxicity present, give Antidote - Digibind Nursing

Management of H.F
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 Restrict Na+ & Water Intake

 Daily Wt. Checking ( Same Time, Same Machine, After Voiding, Same dress )

MYOCARDIAL INFRACTION

Necrosis of Heart tissue due to decreased supply of O2 to myocardium.

CAD is the reason for MI ( CAD means Athero Sclerosis of Coronary Artery ). Basically all the risk
factors of Atherosclerosis is the reason for CAD and MI . They are -

Modifiable R/F Non Modifiable R/F

Alcoholism Age
Smoking Sex
Diet Family History
DM Race
HTN
Physical Inactivity
Hyperlipidemia

C/M
Chest Pain Radiating to Lt. Shoulder Jaw & back

Management
 Administer O2
 Morphine Sulphate
It is an Opioid Analgesics. That suppress the resp. centre. So after administering
Morphine advice the Pt. to do Deep Breathing and Coughing exercise to prevent Resp.
complication

C/M of Morphine Toxicity

 Decreased resp. rate & Saturation
 Decreased BP
 Decreased LOC
 Constricted and Pinpoint Pupils
If overdose is present, administer the Antidote of Morphine which is
Nalaxone.
The Antidote of all Opioid drugs are Nalaxone

NTG

Route - Sublingual
Action - Vasodilator
If Pt. came to ER with chest pain administer NTG 3 times 5 mg in b/w check BP. After
administering 3 doses, If pain not relived administer Morpine.
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Diagnosis of MI
ECG - St Segment Elevation
The Specific Cardiac Enzyme is Troponin I

Management
 Thrombolization
Break down of clots by pharmacological method. Commonly called Clot busting ,
Streptokinase is the most commonly used Agent.

PTCA

Pre procedure
1. Consent Duty of a Doctor, Nurses Duty is to Witness
2. Ask the client about Iodine Allergy, ( Sea food, Shellfish )
3. Check the Creatinin level if it is increased do not Administer dye.
4. Area Preparation

Post Procedure
1. If Femoral PTCA, Immobilize the Extremity and Elevate the Head End, Not more than
300 .
2. Check the Distal Pulse ( Dorsalis Pedis ) if the pulse is weak & Extremity Cool inform
the doctor.

DVT

Formation of Thrombus in the deep Vein of Lower Extremity

Causes
 Prolonged Immobilization ( Traction, Bed ridden, Unconscious Patient. ) Post OP patient
especially Ortho & Abdominal Surgery including Hystrectomy, LSCS ).
 Fracture risk for Fat Embolism - Orthopedic Surgery
 Heart Failure
 Varicose Vein

C/M
 Edema over affected leg
 Warmth over affected leg
 Pain over the Cuff Muscle – HOMAN’S SIGN :- Dorsiflexion of foot, flexion of foot
towards body may cause pain in Cuff Muscle.

Management
 Strict Bed rest
 Elevated affected extremity
 Anticoagulant
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HEPARIN

Check APTT while giving heparin

Anti dot of Heparin - Protamin Sulphate

WARFARIN / CUMADIN

Check PT INR while giving Warfarin Anti dot of

Warfarin - Vit. K

Instruct the client to avoid Vit. K Rich Food

Treatment of DVT / Prevention of DVT

 Early ambulation and Movement

 Provide active and passive exercise
 Provide Anti Embolism Stocking ( Wear before getting out of bed in early morning no
need to wear on night )
 DVT Pump ( Pneumatic Compression Device )
 Prophylatic Ant Coagulation Therapy

Stop Heparin 5 Days prior to Surgery Stop

Warfarin 3 Days prior to Surgery Aspirin 1 Day
prior to Surgery

Mgt :- Strict bed rest, Not massage the legs

Complication - Pulmonary Embolism

PULMONARY EMBOLISM

Obstruction of Pulmonary artery and its branches due to a thrombus, Usually from DVT

C/M
 Severe Stabbing Chest Pain
 Dyspnoea
 Tachypnoea
 Hypoxemia
If it is Fat embolism, PETECHIAE over the chest and its fade quickly D/E -

Pulmonary Angiography

Management - Embolectomy , Anti Coagulant Therapy

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RHEUMATIC FEVER

It means inflammation at the all layers of heart. ( Pericarditis + Myocarditis + Endocarditis )

RHD is the first complication of Rheumatic fever. ie, inflammation is affecting to the valves
of the heart. Eg. Mitral Valve

Cause
 Group A Beta Hemolytic Strptococci
 Auto immune response - With in 2 – 3 weeks after a streptococcal throat infection body
produces antibody which mistakenly attack healthy tissues in the body.

Risk Factor
 Living in slum area, Crowded area
 Age 5 – 15
 Malnourished

Pathological Change
Pericardium - Pericardial effusion Myocardium -
Formation of Asch off’s bodies
Endocardium - Vegetation formation ( Pus + Fibrin + Micro-organism )

C/F
1. Jone’s Criteria in 1944 T.D Jones describes

Major
 Carditis
 Poly arthritis
 Chorea ( Involuntary movement of face and extremity during mental stress)
 Erythema Marginatum - It is pink color macules seen mainly trunk and
extremities.
 Subcutaneous Nodules – Non tender movable nodules on the bony prominence
especially joint area

Minor
 Fever
 Polyarthralgia
 Increase WBC , ESR
 + ve CRP
 ECG - Prolonged PR interval Disease

identification through Jones Criteria

2 Major + H/O Throat infection 2 – 3 Weeks before

1 Major + 2 Minor + H/O throat infection 2- 3 weeks before

Confirmatory Test - ASO Titer

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Management
 Monitor vital sign
 Complete bed rest for to prevent cardiac complication.
 Hot of Cold application
 Initiate seizure precaution
Eg. Sodium Valproate or carbamazepine
Rheumatic fever - Drug of choice BENATHINE PENICILL Penicillin - If

allergic

Azithromycin or erythromycin - If allergic Then

administer Vancomycin

Nursing intervention when administer Penocollin

 It should be administer after skin sensitivity test,
 If penicillin is allergic, Cephalosporin, Ampicillin and ASmoxycillin become allergic
 Penicillin action cell wall destruction
 Penicillin is administering to prevent the re-occurrence of the disease.
 Penicillin create allergy then administer the antidote - Adrenaline or Epinephrine

Penicillin allergy clinical features

 Coughing, Wheezing, Dyspnea
 Hives
 Itchy watery eye
 Swelling around skin and face

Surgical Management - Mitral Valve Replacement.

ANEMIA

If Hb ( Haemoglobin) < 10 mg/dl, Hematocit is < 30% is termed as Anemia.

C/M
 Weakness ( Main C/M of Anemia ) Fatigue
 Tachycardia
 Tachepnoea
 Gidiness
 Hepatosplenomegali

Types
1. Iron Deficiency Anemia
2. Pernecious Anemia
3. Sickle Cell Anemia / Vasoocculsive crisis
4. Aplastic Anemia
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1. Iron Deficiency Anemia

Iron stores are depleted, resulting in decreased supply of iron for the manufacture of hemoglobin
in RBC

Causes
 Blood Loss
 Malabsorption
 Decrease iron intake

Clinical Features
 Weakness and fatigue
 Paleness
 Koilonychias / Spoon Shaped Nail

Diagnostic Evaluation
 Sr. Ferritin Level
 CBC
 Peripheral Smear - Hypo chromic and microcytic cell

Management
Severe Deficiency
 Blood Transfusion
 IV or IM iron injection
 For IM injection practice Z track method

Mild Deficiency
 Instruct the client to take iron rich food
Eg. Green leafy Vegetable, dry fruits, Liver,etc

Moderate Deficiency
 Administer iron supplements
 Give iron supplements between Meals or One Hour before Meals for
maximum absorption.
 Instruct the client should take the tablet along with Citrus Fruits Juice for
maximum absorption.
Eg. Lemon or Orange
 Avoid take along with Milk and Antacid.

Iron Tablet Side Effect

GI upset - Eg. Foul alter taste, Constipation, Black Color Stool
 Oral Syrup can cause Tooth Stain – For prevention instruct the client should take
the medication through straw or after medication clean the mouth with water.

2. Pernicious Anemia ( Vit. B12 Deficiency / Syanocobalamin Anemia ) It is

also known as Vitamin B12 deficiency or Vegetarian anemia.
Intrinsic Factor - Secretion form the stomach if any infection or inflammation present in stomach
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or after gastrectomy. The secretion of intrinsic factor will decrese. Intrinsic factor will required for
the absorption of Vit. B12. Also called extrinsic factor

Etiology
Gastritis, Peptic ulcer, Gastrectomy Low
intake of vit. B12
Dietary sources of Vit. B12 :- Meat, Liver, Brewers East, Citrus Fruits, Dried Beans, Nuts So risk
for developing pernicious anemia in Pure Vegetarians.

Vitamin C increase the absorption of Iron

D/E :- Shilling Test, Peripheral Smear - Normochromic, Macrocytic Cell

C/M
 Smooth Red Beefy Tongue
 Paleness
 Gait problem
 Slight Jaundice
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Complication
 Stomach Cancer/ Gastric cancer
 Gastric Cancer
 Brain damage
 Nerve damage
 Heart problem

3. Sickle Cell Anemia

Autosomal recessive disorder in which RBC’s are Sickle Shaped. Normal life span of RBC’s
is 120 Days. But here life span is 15 – 20 days. It may lead to Iron overload. So administer
deferaxone which an iron chelating agent.

Complication
 Sickle Cell crisis / Vasoocculsive crisis
Commonly due to dehydration
Sickle cell RBC are obstruct the low of blood lead to tissue hypoxia

C/M
 Generalized body pain
 Abdominal pain
 Cynosis
 Hypoxia
 Swelling of the hands, feet and joints
 Hypersplebism

Management
 Priority to treat pain:-
 Maintain adequate hydration and blood volume with normal Saline or Oral Fluid.
( Without adequate hydration pain will not be controlled )
 Oxygen administration and blood transfusion
 Administer Analgesics
 Antibiotics
 Blood Transfusion
 Genetic Counselling
To treat complication provide good Hyderation

4. Aplastic Anemia
Anemia due to bone marrow suppression. It is a drug induced anemia. Commonly Chemotherapy.
So before during and after Chemo should check CBC.
Chloraphnicol ( Anti Malarial drug ) will cause aplastic anemia which lead to bleeding Decrease

RBC, WBC, Platelet

Type/Cause
 Congenital – Due to Chromosomal alteration As an
autoimmune disorder
 Acquired - Due to Bone Marrow Suppression
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1. Drug
 Chemotherapy
 Chloramphenicol ( Drug of Choice in Typhoid )
 Antimetabolites
 Anti – Seizure
2. Radiation
3. Infection
Hepatitis Biliary
TB
4. Chemical Agent eg. Arsenic, Benzene, Gold

C/F
 Pancytopenia
 Petechiae
 Purpura
 Weakness
 Risk for infection

D/E
 Bone marrow Biopsy
Site – Adult – Sternum , Vertebra , ileac crest Child -
Sternum , Tibia
 CBC

Management
 Whole Blood Transfusion
 Bone Marrow Transplantation
 Corticosteroid
 Colony stimulating factors may be prescribed to enhance bone marrow production.

Iron Rich Food

Liver , Meat, Brocholi , Dry Beans , Spinach

Patiennt with CHF and Valvular disease should take Warfarin life Long Basalic
Vein - Forarm – Medial aspects
Cephalic Vein - Lateral aspect of the Arm

GASTROINTESTINAL SYSTEM

Functions
 Process food substance
 Digestion and absorb the product of digestion in to the blood
 Excrete un absorbed material
 Absorption of the water from the large intestine
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 Provide an environment for micro-organism to synthesize nutrients such as

vitamin K

Anatomy
 Upper GI Tract
Mouth to Stomach ( it include lip,teeth,tongue palate,pharynx. Salivary gland ( saliva
contain ptyalin enzyme Epiglottis )

 Stomach ( J shape, Capacity 1.5 Ltr )

 It producing HCL ( amount - 1.5 ltr , PH - 3.5 )
 Function of Hcl breaking food in to paste and kill the organism present in the
food. Chief co enzyme present Pepsin that convert protein to protease and
peptones.
 Parietal cell of stomach is producing the intrinsic factor that helps for the
digestion and absorption of Vitamin B12
 Mucous membrane present inside the stomach and duodenum that protect from
acidity.

 Lower GI Tract (duodenum to rectum )

 It include small intestine ( duodenum,jejunum,and ileum ) function
absorption of nutrients.
 Large intestine ( Function excretion of waste and absorption of water )
 Appendix - n location near the ceecum.

 Liver – largest gland in the body . Weight 3 – 4 pound.

 Function - Liver contain Kupffers Cells, which remove bacteria in the portal
venous blood ( Detoxification )
 Stores and filters blood ( 200 – 400 ml )
 Helping for blood coagulation and protein metabolism
 Produce bile - Daily 500 – 1000 ml the function is helping for fat
metabolism
 Store vitamin A, D, B & Iron

Position for liver Biopsy – During – supine or left lateral, After – right lateral

 Pancreas - Partially endocrine and partially exocrine

 Head and body is exocrine. Is producing pancreatic juice ( Amylase + Lipase
+ Tripsinogen )

 Daily 1.5 ltr production helping for CHO , FAT , Protein metabolism . PH – 8
 25

ABDOMINAL EXAMINATION ORDER

1. Inspection
2. Auscultation
3. Percussion
4. Palpation - Palpate the right lower quadrant first and palpate the painful area at last

1. Inspection

 Stool Character

 Melena - Dark bleeding

 Hematochezia – Bright bleeding
 Fecal Occult Blood ( Guaiac Test ) – to rule out occult blood.
 Red Currant Jelly Stool - Intussuception
 Ribbon Like Stool – Hirschpung’s disease
 Steatorrhea – Fat in the Stool
 Blood and Mucosa
 Gray or Clay
 Rice Water - Cholera
 Pea Soup - Typoid

 Asterixis ( Flapping Tremor ) – Liver Cirrhosis

 Xanthelasma ( is a deposition of yellowish cholesterol rich material that can appear
around Eye )
 Xanthoma ( It is a deposition of yellowish cholesterol rich material thatcan appear
anywhere in the Body )
 Caput Meduca - Dilated Veins in abdomen
 Spider Angioma ( Spider Naevus )
 Gynecomastia
 Palmar Erythema
 Jaundice
 Cullen Sign - Ecchymosis in peri umbilical area
 Turner’s Sighn - ecchymosis in Flank area
 Edema

2. Auscultation

 Bowel Sound ( Normal 5 – 35 times / mt. )

3. Palpation

 Blumberg Sign or Rebound Tenderness

 Pitting Edema
 Organomagaly

4. Percussion
 26

 Dulness , Tympanic

RYLES TUBE INSERTION

 Purpose - To decompress stomach, gastric lavage ( Wash ). Gastric Gavage ( Feeding ),

to decrease the risk of aspiration and a diagnostic evaluation purpose.
 Tube Measurement - From tip of Nose to Ear Lobe, Earlob to Xyphoid Process to
sternum
 Contra Indication - Obstruction, TEF , Nasal bone fracture, CSF - Rhinorrhoes
 Position of the client – High Fowlers or sitting upright position with head tilt forward
the chin flexed position. This position will assist to close the trachea and open the
esophagus.
 During tube insertion if any cough or cyanosis occur immediately remove the tube
and administer oxygen.
 During tube insertion if resistance occur - Instruct the client to take deep breathand
same time the nurse rotate tube at 180 0 and reinsert. If not passing then remove and
report to the doctor.
 Tube position Confirmation - 1. X-Ray , 2. Aspirate the content and analyze the PH, 3.
Auscultate the Sound.
Should check PH of aspirated content if PH < 3.5 , can confirm that content from stomach.
Because of presence of HCL.
 Tube Feeding Position
 For intermittent feeding - High Fowlers Position
 Continuous Feeding - Semi Fowlers Position
 Before tube feeding aspirate the content, if the amount is more than 50% of the
previous feed or more than 100 ml with hold the feed more over aspirated content re
insert to the client.
 Tube feeding complication – Fast feeding can cause abdominal distention and
diarrhea.
 CLOGGED Tube – Any kinking or obstruction in to the tube due to feed content inside
the tube, Prevention, Before and after feeding apply Luke Warm Water in to the tube.
 For long term feeding practice use PEG (Percutaneous Endoscopic Gastrostomy )

RT Feeding Position :- Provide semifowlers for continuous , High Fowlers for intermittent Feeding

ENEMA

 Administration of solution in to the rectal area

 Purpose – Laxative, Nutrient, Analgesic, Antipyretic, Sedation.
 Position - Left Lateral Position with hperflexion of Rt Knee / Left sims position
( Purpose is to drain the enema fluid by its gravity
 Self Enema Position – Lithotomy ( Supine with Hip and Knee flexed ) / Semi Prone
 27

Position.
 Oil enema position - Trendelenberg position
 Enema solution temperature ( Adult = 40 – 43 degree, and Infant 37 degree )

LARGE VOLUME ENEMA ( Maximum 100 – 250 ml at a time )

 The rectal tube should insert 6.6 – 8.8 cm ( 3 – 4 inch ) 1 inch – 2.54 cm
 The enema bag should be hang at a heright of 18- 22 inch ( 45 – 55 cm )
 During enema if pain / abdominal cramp occur – 1. Reduce the height of enema
solution. 2. Stop or clamp the enema tube.
 After subsiding pain restart with slow rate.

BODY MASS INDEX ( BMI )

BMI =

Weight in KG
------------------------------------
Height in Meter Square
 28

Normal BMI = 18.5 to 25 - Healthy Person

Under Weight = Less than 18.5
Over Weight = 25 to 30
Obesity = More than 30

ABDOMINAL QUADRANTS

1 2 3

4 5 6

7 8 9

Sr No. Name of the Quadrants Organs Occupied

1 Right Hypochondrium Liver, Gall bladder, Rt. Kidney & Small Intestine
2 Epigastrium Stomach, Liver, Pancreas, Duodenum, Spleen,
Adrenal Glands
3 Left Hypochondrium Spleen, Colon, Lt. Kidney, Pancreas
4 Right Lumbar Gall Bladder, Liver, Right Colon or Ascending Colon
5 Umbilical Jejunum, Ileum, Duodenum
6 Left Lumbar Descending colon and Lt. Kidney
7 Right Ileac Appendix and cecum
8 Hypogatrium Urinary Bladder, Sigmoid Colon, Female
Reproductive organs
9 Left Ileac Descending Colon & Sigmoid colon

PANCREATITIS

Inflammation of the Pancreas Causes

 Alcoholism
 Abdominal Injury / Trauma
 Biliary ( Chololothiasis induced )
 Drugs - Steroid, HIV drugs, Valporic Acid
 Hypertriglyceridemia
 Idiopathic
 Scorpion sting
 Viral & Bacterial infection
 29

C/M
 Nausea
 Vomiting
 Anorexia
 Fever
 Pain :- Epigastric pain or Left upper quadrant pain radiating to Back Because of
retroperitoneal position of Pancreas. This pain Increase after consuming Fatty Meals/Food,
Alcoholism and client maintains Supine Position ( Recombinant Position
)
 CULLEN Sign :- Echymosis / Bluish discoloration in the Peri Umblical Area.
 TURNER’S Sign :- ( grey turnal spot ) :- Echymosis / Bluish discoloration in the Flank
Region
These 2 Signs are due to Vit.K Deficiency
 Steatorrhoea ( Ecessive Fat in the Stool )
 Clay Colored stool
 Deficiency of Fat Soluble Vitamin ( A, D, E, K )

Management
 Diagnosis ( Serum Lipase )
 High Protein Diet. Avoid Heavy Meal
 Administer Pancreatic Enzyme with Each Meal
 NPO
 H2 Receptor / PPI

P - PAIN :- Morphine, Dilaudid A -

Antispasmodic Drug
C - Calcium Replacement
R - Replacement of Fluid and Electrolyte
E - Endocrine ( Insulin ) Exocrine ( Amlyase and Lipase with food ) replacement A -
Antibiotics
S - Steroids during acute attack

Surgical Management :- Pancreactectomy and

WIPPLE procedure :- Complication - Hyperglycemia Radical
Pancreatodeodinogastrectomy
Indication - Ca Pancreas Complication -
Hyperglycemia

APPENDICITIS
 30

Inflammation of Vermiform Appendix

Causes
Kinking or Obstruction in to the Appendix
Srangulation of Appendix
Foreign bodie

C/M
Nausea Vomiting
Anorexia
Pain :- Kochers Sign :-Initial stage Pain – Peri Umblical area, that pain descend to Rt. Lower
Quardrant, Pain more Severe in MC Burney’s Point. – ( 1/3rd Distance from the Anti- Superior
Iliac Spine to Umbilicus )
Rebound Tenderness :- Pain after reliving the Fingers Rovsing’s
Sign :- Pain in Rt. Side when Palpating Lt. Side Psoa’s Sign :-
Forceful extension of Thigh lead to severe Pain
Aviod hot Application because it may lead to rapture of appendix if rapture occur lead to Peritonitis
Positive Dunphy Sign :- Coughing can causing abdominal pain.
Hamberger Sign :- Physician provide favourite food for the patient, if patient consumes the food it
is consider other than appendicitis, a positive sign indicates patient decline the food

D/E
History collection & Physical examination, CT Scan, USG , CBC
Management
Maintain Right Later Position with Semifowlers ( if rupture occurs ) Avoid
hot Application, enema, bowel wash ( chance of rupture ) Provide Cold
Application
Antibiotics
Monitor Complication :- Peritonitis
Antibiotics :- Broad spectrum antibiotics – Ampicillin, Amoxycillin except Streptomycin. Surgery :-
Open Laprotomy

PERITONITIS

Inflammation of peritoneal cavity. It may cause from rupture of appendix or rupture of

intestine due to appendicitis, ulcerative colitis, chrons disease, diverticulosis, if rupture occur
ride for peritonitis

C/M
 Severe fever
 Chills
 Abdominal Pain
 31

 Abdominal Distension
 Tachycardia
 Tachypnoea

Intervention
If peritonitis present, place the client in semifowlers position otherwise risk to spread the
infection in to the thoracic cavity

CHOLECYSTAITIS

Inflammation of the Gall Bladder

Etiology
Cholelithiasis ( Stone formation in the gall bladder )

C/M
 Fever
 Nausea
 Vomiting
 Pain :- Rt. Upper quadrant pain, radiating towards Rt. Shoulder pain increases after
consuming Fatty Diets.
 Jaundice
 Clay Colored Stool ( Stratorrhoea )
 MURPHEY Sign :- Palpating Rt. Lower Liver boarder Pt. shows breathing
difficulty

Management
 NPO
 Antibiotics
 Vitamin Replacement ( Vit. K injection )
 Avoid Fatty Food
Surgical Management - Choleycystectomy

Diagnosis :- USG , CT

Early mobilization is required either cholecystectomy. Pt. has come to his normal activities
after 1- 2 weeks of open Cholecystectomy, & 4 – 7 days Laproscopic sugery

Post OP
Close monitoring Respiratory status advise the client to take deep breathing & Coughing
exercise.

Quadrant Pain & Disease :-

Rt Upper :- Cholecytaitis
Rt. Lower :- Appendicitis
Lt. Upper :- Pancreatitis
 32

Lt. Lower :- Diverticulitis

GASTRITIS

Inflammation of the mucous membrane of the stomach

Causative Organism :- H. Pyloric Bacteria

 Contaminated food / Spicy Food

 Drug induced – NSAID , aspirin, ibuprofen
 Radiation therapy
 Smoking & alchohol
 Diet – coffee, carbonated drinks
 Stress
 Gastrinoma – tumor in the pancreas or duodenum that secretes excess of gastrin leading
to ulceration of duodenum, stomach and GI
 Zollinger – Ellison Syndrome – Gasrin - secreting tumor of islets cells in the
pancreas causing overproduction of gastric acid resulting in peptic ulcer
 33

C/M

 Abdominal Pain / Epigastric pain

 Abdominal distention
 Hemetemesis ( Blood in Vomiting )
 Maleena ( Black color stool due to blood )
 Malnutrition
 Pyrosisi / Heart burn
 Hiccups
 Dehyration

D/E
 Endoscopy

Left Later position

Administer atropine and glucagon priorly
After procedure before giving to mouth check the gag reflex

Managementt
 NPO
 After symptom subside initially administer clear water
 Avoid administer stimulants to the client
 Antibiotics - Clarythromycin and Metrogel
 Adminster syrup sucrafen – it work as a mucosal barrier protectant
 H2 receptor ( Rantac ) or PPI ( Omiprazole ) both drug will help to decrease the
prodection of HCL or administer antacid ( Gelucil ) it will neutralize the gastric
secretion.
 Bismuth salt or pepto – bismol

Complication :- Pernecious Anemia

Surgical Site for Gastrectomy is from the Epigastrium to the Umblicus.

Surgical Management
1. Gastrectomy
2. Billroth I / Gastrodeodinostomy ( 2nd half of the stomach will removed )
3. Billroth II / Gastrojejunostomy ( 2nd half of the stomach + deodinum )

Pre Op Teaching :- Teach Spiro meterExercise before Gastric Surgery

Complication After Gastric Surgery

1. Pernecious Anemia

2. Dumping Syndrome
 34

Rapid emptying of gastric content in to small intestine that occurs following gastric
surgery

C/M
 Weakness
 Sweating
 Feeling of Fullness
 Dizziness
 Nausea
 Bor – Borygmi ( Loud gargles indicating hyperperistalsis )

Treatment of Dumping Syndrome

 Avoid Sugar / Salt and Milk
 Provide high – protein, high fat, low carbohydrate food
 Eat small meals, avoid consuming fluids with meals
 Lie down after meals ( Supine )
 Provide small and frequent meals

STOMA CARE

Normal Color - Pink to bright red

Cynosis - Bluish discoloration
Necrosis - Black
Infection - Red, Swelling, Painful
Fungal Infection - White Color ( Bleach Color ) Low
HB & Hematocrit Value - Pale Pink Stoma
Blanching Color - Cynosis

 Empty stoma bag if 1/3rd fill.

 Inspect the stoma and surrounding skin
 Should not apply Antibiotics directly to stoma
 Wash the stoma with mild soap and water
 Irrigate the stoma with mild warmed tap water. ( Temp 106 - 110 0 F ) for all
irrigation fluids
 More skin protection is needed in illeostomy due to fluid stool. Because of risk of
Infection. Due to watery stool
 Apply Karaya gum Powder ( Is a synthetic skin barrier ) around the stoma to
prevent leakage.
 Client can resume his normal daily activity following Ostomy including swimming
 Sigmoid colostomy take 6 – 8 wks for its maturity
 Avoid gas producing ( Potato, Apple ) food and odour producing ( Egg, Meat ) etc.

Nursing Diagnosis - Body Image disturbance ( For Amputation, Colostomy, Skin disorder,
Mastectomy, etc )
 35

Stoma Stool consistency Stoma site

1. Illiostomy Watery Rt. Lower quadrant

2. Ascending colon Semi Fluid Rt. Upper quadrant
3. Transverse colon Mushy Fecus ( Mud ) Epigastrium
4. Descending colon Semi Solid Lt. Upper quadrant
5. Sigmoid colon Solid ( Close to Normal ) Lt. Lower

HYPERTROPHIC / PYELORIC STENOSIS

Narrowing of Pyeloric spincher

C/M
 Projectile Vomiting ( Forcefull Vomiting )
 Olive Shaped / Mass over abdomen
 Visible ways of peristalsis
 Non Villous Vomiting ( With out Bile content )

Surgical Management :- Pyloromyotomy

GERD ( Gastro Esophagal Reflex Disease )

Incompetent of Cardiac Sphincter lead to regurgitation of food in to the oesophagus

C/M
 Vomiting
 GERD lead to aspiration and client with GERD may suffer from frequent respiratory tract
infection while collecting h/o ask about the frequency of respiratory tract infection.
 Heart burn / Pyrosis
 Globus ( Something in throat feeling )
 Regurgitation
 Hypersalivation
 Odenophagia ( Painful Swallowing )

Management
 Burp after feeding
 Avoid spicy food
 Small and frequent meal
 Elevate head end of bed after feeding
 Avoid coffine ( coffee, milk, chocolate, carbonated )
 Low protein and low fat with easily digestible CHO
 Avoid stimulant food
 Take water between meal and maintain up right position after meal
 Avoid antichollinergic which delay stomach emptying
 36

Medical management :- Protron Pump Inhibitors Surgical

management :- Fundoplication
Nursing Diagnosis :- Fluid Volume Deficit

TRACHEO ESOPHAGIAL FISTULA AND ESOPHAGICAL ATRESIA

Abnormal connection between Trachea and Esophagus – Tracheo Esophagial Fistula Esophagial

Atresia - Esophagus terminate before reaching to the stomach

C/M
 Respiratory problems after feeding
 Abdominal distension
 Frequent drooling of frothy saliva through the mouth

Management
 Corrective surgery
 Provide Gastrostomy feeding - PEG feeding

CELIAC DISEASE

Intolerance of Glutton containing diet – Glutton Entropathy

C/M
 Severe Diarrhea
 Vomiting
 Abdominal Cramp
 Vitamin Deficiency
 Malnutrition
 Electrolyte imbalance

Endoscopic examination shows Villous Atrophy Avoid

Glutton Items

Avoid BROW Foods :-

B - Barley
R - Rye
O - Oats - Processed Oats Glutton free W -
Wheat

HIRSCHPRING DISEASE (Congenital Aganglionic Megacolon )

 37

Ganglions are normal nerve cells which are present in the Rectal Area. With helps for the
movement of rectum.
Congenital absence of the ganglionic cells at the distal part of intestine lead to intestinal
obstruction and enlargement of distal colon.

D/E :- Rectal Biopsy ( Absence of Ganglionic cells ) C/M :-

Abdominal pain, RIBBON Like Stool

Management :- Removal of affected part and Anastamosis

Disease Stool

1. [Link] - Loose stool , Low Grade Fever

2. Vibrio cholera - Rice Water Stool
3. Hirschpring Disease - Ribbon like Stool
4. Intussupseption - Current Jelly like Stool
5. Ulcerative colitis - Watery Stool with Blood & Mucous
6. Crohns Disease - Semi solid diarrhea with pus & Mucous
7. Hemaroid - Bright red bleeding with defecation
8. Esophagial Varices - Black Tarry Stool

DIVERTICULOSIS

Herniation or outpouching of intestinal mucosa

Diverticulitis - Inflammation of the diverticulam.
 Pain at the left lower quadrant

Nursing Intervention :- Avoid food with contains seeds ( Cucumber ), Peanuts, Cornflakes

HEPATITIS

Inflammation of the liver parenchyma

Types
1. Hepatitis A
2. Hepatitis B
3. Hepatitis C
4. Hepatitis D
5. Hepatitis E

1. Hepatitis A
 38

Also called as infectious hepatitis

Commonly seen in Young Children
Mode of transmission - Feco Oral Route Incubation
Period - 2 – 6 Wks ( 14- 42 days )
Treatment
1. Hand washing ( For all Hepatitits)
2. Stool and Needle Precaution
3. Hepatitis A vaccine available

2. Hepatitis B
Transmission - Blood & Blood Product - Same as like AIDS
Incubation - 6 – 24 Wks ( 42 – 168 Days )
HbsAg ( Hep. B Surface Ag )
High risk for Haemodyalisis Patient
Treatment
Hand washing, All Preventive method of AIDS, Vaccine
 39

3. Hepatitis C
Same as like AIDS
Purely Blood born Hepatitis
More risk to spread through breast milk
Incubation Period - 5 - 10 Wks ( 35- 70 Days )
Treatment
Hand Washing, All AIDS prevention
 Vaccine Not Available for Hepatitis C

4. Hepatitis D
Occur as a complication of Hepatitis B
HbsAg is required for the growth of Hepatitits D Virus
Transmission and prevention same as Hep. B
Hepatitis B Vaccine available
Incubation period - 7 – 8 Wks (49 – 56 Days)

5. Hepatitis E
Water Born Hepatitis
Prevalent in areas where sewage disposal inadequate.
( Travelers to countries India, Burma, Pakistan, Mexico Mode of
transmission - Feco oral route
Incubation period - 2 – 9 Wks
 Vaccine is Not Available for Hepatitis E

Vaccine is not Available for Hepatitis C and Hepatitis E

Hep.A & Hept.E :- Feco Oral Route

Hep.B & Hep. C & Hep. D :- Blood & Blood product More
risk to spread through breast milk Hept. C

ACUTE PEPTIC DISEASE

Causes :- Same as gastritis

Classification
 Gastric
 Duodenal
 Esophageal
 Curling Ulcer ( It is an acute gastric erosion resulting as a complication of burn. Due to
decreased plasma volume lead to ischemia and necrosis )
 40

 Cushing Ulcer. ( Due to increased ICP ) Gastro Duodinal ulcer

Features Gastric Duodenal

Age Above 50 Below 50

Common 20 % 80 %
Pain After 30 mts of food intake After 2 hrs of food intake
( Food ingestion increase pain ) ( Foood ingestion decrease Pain )
Relieved by Vomiting Food intake
Weight Loss Gain
Bleeding Hematemesis more common than Malena
Malena and rigid board like
Abdomen
CA Yes No
Location At the antrum Duodenum

Diagnosis
 Endoscopy, Urea breath test ( UBT ), CBC
 Biopsy
 CEA

Management
Medical and nursing management same as gastritis
Surgical Management ( Surgical site from epigastria to umbilicus )
 Total gastrectomy
 Vagotomy – cutting of vagus nerve because it stimulating for the production of HCL
 Antectomy
 Billroth 1 - Also known as gastroduedenostomy
 Billroth 2 Procedure - Gastro Jejunostomy

Post Operative Intervention after abdominal Surgeries ( Both Adult ands Child ) Most

commonly surgery is perform under general Anesthesia

 After General anesthesia the priority assessment order.
1. Airway/ Spo2 / Respiratory system
2. Cardiovascular system
3. Nervous system
4. Surgical site
 Put the client for NPO till bowel sound return. Usully 1 – 3 days
 Insert NG tube and keep it open. For gastric decompression.
 Before giving oral feed monitor the bowel sound or ask the client are you passes the flatus
 41

( Mainly in Adults )
 Once bowel sounds return initially administer clear water.
 Exercise – Deep breathing or coughing exercise / use spirometer. Whenever coughing
perform splint the incision.
 Monitor complication
Bleeding – clinical feature is pain and abdominal distention.

 Gas accumulation - Cliniccal feature is pain and abdominal distention and pain. But this
occur at 2nd post operative day

Management :- Instruct the client to ambulate

 Infection
 Monitor the complication of surgical wound.
1. Wound dehiscence – Rupture of suture due to increased pressure in the surgical site.
2. Wound Evisceration – Protruding of internal organs through ruptured suture site.
Management :- Apply sterial socked dressing Special

Attention In Adult

First 24 hrs complete bed rest. After that the client can ambulate.

Use anti embolism stockings. Complication of

Gastric Surgeries
 Bleeding, Diarrhoea, Hypoglycemia
 Pernicious Anemia ( Vitamin B12 Deficiancy )
 Dumping Syndrome :- The rapid emptying of the gastric content in to the small
intestine leads vertigo, palpation and giddiness
Clinical Features :- Syptoms occur after 30 mts meal
 Borborgymi
 Abdominal cramping, feeling of abdominal fullness

Patient Education Tips

Share these tips with your patients who have dumping syndrome to help manage their
symptoms.
 Avoid food high in simple carbohydrate ( candy, Cookies, Cakes, Fruit juices,
sweetened drinks, ice cream, canned fruits in heavy syrup, sugar alcohols ).
 Eat protein with each meal and snack ( eggs, Cheese, Meat, Fish, Poultry, Legumes, low fat
milk )
 Avoid drinking liquids with meals, instead, drink 30 to 45 nts before and 1 hr after the
meal.
 42

 Limited the use of caffeine, Tea, and alcohol. These beverages can stimulate gastric
motility. Discuss the appropriate intake of alcohol with your healthcare provider.
 Eat five to six small meals a day to avoid overloading the stomach.
 Lie down for about 15 mts after eating to help slow gastric emptying.
 Avoid very hot or very cold foods and liquids, they can increase the severity of DS
 Choose high fiber foods to decrease the risk of late dumping

Bariatric Surgery :- It is a Cosmetic surgery Mainly using for the Treatment of an Obesity

Types:-
1. Total Gastrectomy
2. Billroth 1 & 2 Surgery
3. Vertical banded gastroplasty
4. Panniculectomy - Removal of pannus ( excessive adipose tissue in stomach )
5. Circumgastric banding
6. Gastric Bypass

LIVER CIRRHOSIS

Nodule formation and scaring of the Liver

Cirrhosis 4 Types
1. Alchoholic ( Laenner’s )
 Long term ETOH abuse
2. Post Necrotic – Massive Hepatic Cell Necrosis
 Post viral Hepatitis
 Toxic Exposure
 Autoimmune process
3. Billiary
 Chronic biliary obstruction
 Bile stasis
 Inflammation
4. Cardiac
 Severe RHF
 Corpulmonale
 Constrictive pericarditis
 Tricuspid Insufficiency
C/F
 Asterixis
 Fetor hepaticas
 Spider angioma
 43

 Oedema

Complication
 Hypertension , Portal Hypertension
 Pleural effusion
 Ascitis
 Metabolic acidosis
 Bleeding
 Anemia
 Caput Meducae
 Esophageal Varicies ( C/M - Black Tarry Stool )
 Hemorrhoids
 Hepatic Encephalopathy due to peak ammonium concentration.

C/F
 Hepatomegaly
 Jaundice
 Ascites
 Circulatory changes - Spider telangiectasia, palmar erythema, cyanosis
 Endocrine changes :-
-Loss of libido, hair loss
-Men:- Gynaecomastia, testicular atrophy, impotence
-Women:- brest atrophy,irregular menses, amenorrhoea
 Haemorrhagic tendency- bruises, purpura, epistaxis, menorrhagia
 Portal Hypertension – Splenomegaly,collateral vessels, variceal bleeding, fetor
hepaticus
 Hepatic (Portosystemic) encephalopathy
 Other features – pigmentation, digital clubbing D/E
 Hypernatremia
 Hyperkalemia
 Hypercalcemia
 Incrase bilirubin
 Increase ammonium
Management
 Treat the cause
 Antihypertensive, diuretics
 Avoid hepatotoxic drug – PCM, acetaminophen, barbutarates
 Diet – high CHO, caloric, low fat and moderate protein
 Syp. Lactulose/ defolac to prevent hepatic encephalopathy or bowel wash
 Thorasentesis and parasentesis
 44

 Administer albumin

Cirrhosis
Treatment :- dietary and fluid management
1. Fluid ad sodium restrictions based on response to diluretic therapy, urine output,
electrolyte values.
2. Protein - 75 – 100 grms per day- unless client has hepatic encephalopathy (elevated
ammonia levels) then 60 – 80 grm/day
3. Diet high in carbohydrates,moderate in fats or as TPN
4. Vitamin & mineral supplements- deficiencies often include B Vitamin & A,D,E
magnesium

HEMORROIDS

Dilated varicose vein of the anal canal

Cause :- Portal Hypertension, Constipation, Pregnancy
Clinical Features :- Bright Red rectal Bleeding with defecation, rectal pain and itching Management

Encourage high fiber and fluid

Administer stool softeners Avoid
prolonged sitting
Surgery :- ( Hemorrhoidectomy, sclerotheraphy, minimally invasive procedure of hemorrhoids) -
during surgery provide Lithotomy Position

Post Operative Intervention

 Position – Prone or Lateral and avoid Supine Position
 First 24 hrs cold application
 After 24 hrs hot sits bath ( temperature 430 or 1100 Fahrenheit )
 Instruct the client to limit sitting for a short period

INFLAMATORY BOWEL SYNDROME

An ulcer formation any where in intestine occur from distal to proximal.

Type
1. Ulcerative Colitis ( ulcer present in to the large intestine – starting in rectum
extending up to Cecum )
2. Chrons Disease ( Ulcer present in to the small intestine especially terminal ileum )

Clinical Feature
 45

Ulcerative Colitis Chrons Disease

Bloody / forthy diarrhoeas Semi soild diarrhea which may contain mucous and pus Severe
dehydration Malnutrition or malabsorption syndrome
Abdominal tenderness Electrolyte imbalce, Vitamin deficiency and
cramping
Bleeding due to deficiency Right lower quadrant cramp like and colicky pain after meal of
Vitamin K
Anaemia, Electrolyte Fever, Anorexia, Weight loss
imbalance
Colon Become Oedematous Disappearing abdominal mass

Features Crohn’s Ulcerative Colitis

Cause Infection Autoimmune

Site Any Site ( Ileum – Cecum ) Rectum Sigmoid
Depth Trans mural Mucosa
Lesion Skipped lesion Continuous
Stool Bloody Blood and Mucosa
Weight Loss More Less
Fistula Common No
Pain Site Right Lower Left Lower
Tenesmus No Yes

Rectum Involvement Many 100 %

Barium String sign Lead pipe sign
Treatment Antibiotics Surgery

Management
 Drug – Anti Diarrheal, Antibiotics, Antispasmodic
 Maintain NPO
 IVF + Electrolyte, Complete bed rest
 Total parenteral Nutrition (TPN) – always on IV controller, and frequently monitor
Hyperglycemias. Tubing use single use ( Maximum 24 hrs)
 Following acute phase diet progress from clear liquids to low fibre, instruct the client to
avoid gas forming food, milk products, whole wheat, grains, nuts, raw fruits, vegitable,
pepper and alcohol should be avoid
 Diet elementary diet – It means diet containing all micronutrients and easily
absorbing
 46

 Monitor compli9cation - Bowel perforation leads to peritonitis ( for detail refer

appendicitis)

COLOSTOMY AND ILEOSTOMY

An stoma create in to large intestine is known as colostomy in to the small intestine is known
as ileostomy.

Pre operative intervention

 Administer laxative or enema.
 Instruct the client to eat a lower fiber diet for 1 – 2 days before surgery
 Administer intestinal antiseptic and antibiotics (Metrogel) as prescribed to clean the bowel
and to decrease the bacterial content of the colon. ( continuous antibiotic administration
can cause bleeding in post operative period due to damages of the intestinal flora )

Post operative intervention

Stoma Abdominal site Stool Character
Ileostomy Right Lower Liquid of Fluid
Ascending Colon Right Upper Semi Liquid
Transverse Colon Epigastrium Mushy or Mud fecus
Desending Colon Left Upper Solid fecus
Sigmoid colon Left Lower Normal stool
 47

ENDOCRINE SYSTEM

Function of Endocrine system

 Maintenance and regulation of vital functions.
 Response to stress and injury
 Growth and development
 Energy Metabolism
 Reproduction
 Maintain fluid electrolyte and acid base balance

Hypothalamus :- ( Master of Master gland ) is producing all type of releasing and inhibiting
hormone

Pituitary ( Master Gland )

Pituitary Gland – Is the master gland in our body

2 Parts :-

Anterior Pituitary ( Adenohyposis ) Posterior Pituitary

( Neurohypophysis )
 48

Anterior Pituitary Hormone

1. Growth Hormone :- It enhances body growth Increased

GH in child is called as Gigantism Increased GH in
Adult - Accromegali Decreaed GH - Dwarfism

Dwarfism in children associated with hyperactive behavior.

2. TSH ( Thyroid Stimulating Hormone ) T3 T4 Hormone It

enhances Thyroid Hormone

3. ACTH ( Adreno Corticotrophic Hormone )

Increased secretion of ACTH leads to Primary Cushing syndrome

4. FSH ( Folicle Stimulating Hormone )

Production Ovum from Ovary

5. LH
Release of ovum from ovary

6. Prolactin
Milk production and secretion Posterior

Pitutery

2 Hormones :-
Vasopressin ( ADH Anti Diuretic Hormone)
Oxytocin

1. Vasopressin ( ADH )
Help for water reabsorption from renal tubules to maintain fluid balance.

2. Oxytocin
Help for uterine contraction during delivery and milk ejection. Disorders of

ADH

Diabetes Insipidus SIDH ( Symptom Of Inappropriate ADH )

It is a condition due to Hypo secretion It is a condition due to Hyper secretion of ADH of

ADH
Decreased ADH Increased ADH
Polyuria Increased water re absorption
Polydipsia Hypervolemia
Decreased Urine Specific Gravity HTN
( normal 1.010 - 1.020 ) Tachycardia
Hypotension
 49

S/S S/S
Excessive Thirst Water intoxication
Dehydration – Hyotension Delirium
Tachycardia Tachycardia
Passing of diluted urine Passing concentrated urine
Low urine Specific gravity High Urine Specific gravity
High Serum Osmolarity Low Serum Osmolarity
Hypernatremia Hyponatremia D/E

D/E

Water Deprivation Test. Water Loading Test

Management Management

Safety
Increase The Fluid Intake Restrict the Fluid Intake
Administer ADH / Vasopressin Hypophysectomy
( Decrease urine output and to increase DEMENCOCYCLINE The
BP )

Nursing Diagnosis :- Fluid Volume Deficit HYPOPHYSECTOMY :-

Surgical removal of Pituitary gland

There are 2 Approaches :-

1. Craniotomy ( More risk for Increased ICP and Infecction )

2. Transphenoidal ( Through the Nostrils with the help of Endoscopy )

Complication
CSF Rinorrhoea :- Post operatively if rhinorrhoea is present sent secretion to the lab for
identifying the presence of glucose. Because CSF contains glucose if present inform physician
If Bloodish drainage occur receive the secretion in a White surface such as gauze piece etc.
If CSF present in it blood will accumulate in centre and an Yellowish Ring form

around blood is called Halo Ring Sign / Concentrated Ring Sign

THYROID GLAND ( situated at the anterior part of the neck )

It produces :-
T3 ( Tridothyronine ) T4
( Tetra Idothyronin ) Calcitonin
T3 and T 4 which help in regulating BMR. The by product of metabolism is heat.
Thyrocalcitonin - which help in deposition of calcium in bones.
 50

Thyroid Disorders :-

HYPOTHYROIDISM HYPERTHYROIDISM

Condition due to hypo secretion of thyroid Condition due to Hyper secretion of Thyroid
Hormones ( Decrease BMR ) Hormones ( Increased BMR )
Types Type
Primary – Decrease T3, T4 & Primary – Increase T3, T4 &
Increase TSG , TRH Decrease TSH , TRH
Secondary – Decrease T3 , T4, TSH & Secondary – Increase T3, T4, TSH &
Increase TRH Decrease TRH
Tertiary – Decrease T3, T4, TSH, TRH Tertiary – T3, T4, TSH, TRH

Causes Causes
Auto immune or hashimotor Thyroiditis Manipulation during Tyroidectomy Use of
lithium & Aminodarone Tyroid tumour
Iodine Deficiancy

S/S S/S
Decrease T3 & T4 Increase T3 & T4
Increase TSH Decrease TSH
Decrease BMR Increase BMR
Intolerance to COLD Intolerance to HEAT (Provide
additional sheet and Blanket) (Provide AC room / cold )
Hypotension & Bradycardia & Bradypnoea Hypertension &Tachycardia&Tachypnoea Dry
coarse hair Insomnia, goiter

Myxoedema ( Puffiness over face and around Exophthalmous ( Abnormal Protrusion of Eye
ball ) Eye ball )

Management Management
Administer synthetic Thyroid Hormone ` PTU ( Profile - Thiouracil - PTU Eg.
Levothyroxine sodium (Give early morning Iodine 131 it is a radio active iodine
Before Food /empty stomach) Provide cool environment
Provide warm environment Decrease the fiber intake

Increase the fiber Intake Thyroidectomy

Administer warmed IV isotonic solution Administer Iodides, Beta blocker, PTU &
Glucocorticoids before thyroidectomy Before
 51

starting thyroid hormone replacement therapy Check Cardiac Function Long term use of

Thyroid Hormone Causes Osteoporosis

Complication
Myxoedema Coma – Severe form of hypothyroidism with shock & coma , life threatening
due to extreme low thyroid hormones
MR
Thyroid Storm - life threatening due to extreme high thyroid hormones.

Thyroidecctomy
Permanent management of Hyperthyroidism Surgical
removal of Thyroid Gland
Severe form of Hypothyroidism is called myxedema coma
Manipulation of thyroid gland cause excessive secretion of T.H & result in severe hyperthyroidism
in prepare to administer anti Post op period

Complication
1. Thyroid Storm
2. Laryngeal Nerve Damage
If it occur sound changes occurs (absent of sound mute sound )
3. Hypoparathyroidism

Position
Thyroidectomy - Head end elevation Position
Laryngectomy - ,, ,, ,, ,, ,, Tonsilecctomy
- Side line / Prone Position
Adenoidectomy ,, ,, ,, ,,

PARATHYROID GLAND

It produces Hormone - Parathormone

Function - Calcium Balance in the blood (increase blood calcium )

A. Hypoparathyroidism

Most commonly occur as a result of Accidental removal of parathyroid gland During tyroidectomy
leads to decrease Secretion of parathyroid – parathormone hormone

 Severe form of Hypo Calcemia lead to TETANY

Causes :- Thyroidectomy
 52

S/S

 Hyocalcemia
 Hyperphosphetemia
 Hypotension, bradycardis
 Bronchospasam, laryngospasam
 Seizure
 Numbness and tingling sensation in face
 Seziure
 Positive CHVOSTEK’S Sign :- Facial contraction while tapping infront Earlobe
 Positive TROUSSEAU’S Sign :- Carpel Spasm occur when inflating the BP cough above
systolic BP
Management
Administer Calcium Gluconate
Increase calcium and decrease phosphorus. Increase the
fluid intake

B. Hyperparathyroidism

Condition due to hypersecretion of parathormone hormone (maintaining calcium blalance in

blood)

Causes :- Tumor
 53

S/S

 Hypercalcemia
 Hypophosphatemia
 Excessive thirst
 Bone destruction
 Renal stones

Management
 Decrease calcium and increase phosphorus
 Increase the fluid intake
 Administer calcitonin – route intra nasal

Pancreas :- The only one Gland which is partially Endocrine and Exocrine Function

ADRENAL GLAND

Situated top of each Kideny 2

Parts :-
1. Outer cortex / adrenal cortex - Corticosteroids
2. Inner Medulla / Adrenal medulla

Corticosteroid
1. Glucocorticoids – Increased blood glucose Level (cortisol,cortisone,corticosterone)-
Regulate carbohydrate, protein metaboloism.
2. Mineralocorticoids – Retention of Na+ in blood (aldosterone) – retention of sodium and
water and excretion of potassium
3. Androgens / Sex Hormone – regulate secondary male sexual characteristics.

ADDISON’S DISEASE CUSHING DISEASE

Condition due to hyposecretion of Adrenal Condition due to hypersecretion of adrenal Cortex

hormone. cortex hormone.

Cause Cause
Removal of Pituitary or Adrenal Pituitary Tumor

S/S S/S
Decreased Corticosteroid Increased corticosteroids
Hyponatremia Hypernatremia
 54

Hypoglycemia Hyperglycemia
Hypotension Hypertension
Hyperkalaemia Hypokalemia
Hypercalcemia Hypocalcxemia – Tetany
Bronze pigmentation of skin Hypervolemia -oedema
Menstrual irregularities in female & Pendulous abdomen
Impotence in men Weight Gain
Weight Loss Moon Face
Buffalo Hump
Truncal obesity or centralised obesity Hirsutism
Plethora (Redness in Cheeks)

Management Management
Administer Steroid Hormone ( side effect- Hypophysectomy / adrenalectomy.
Hyperglycemia, cataract, osteoporosis ) Stop steroids
Diet – high calorie, protein,CHO Antihypertensive, diuretics
Protect the client from infection Special skin care Avoid
sedatives, anesthetic, barbuterates
Should not stop steroid suddenly

Complication :- Addisonian crisis ( Absolute Nursing Diagnosis -Impaired skin integrity

Deficiency due to surgery,infection,sudden Disturbed Body Image
Stoppage of steroids )

Clinical features – Shock

Management :- Administer IV Fluid NS ( RL contra indicated) Administer
IV hydrocortisone

Type of CUSHING syndrome

1. Primary – Due to over secretion of ACTH Mgt -
Hypophysectomy
2. Secondary - Over secretion from adrenal cortex / over use of steroids.

ADRENAL MEDULLA ( inner core of adrenal gland )

It produces catecholamines ( Epinephrine and Norepinephrine ) it is the part of sympathetic

nervous system which helping for increase HR & BP and which helps in regulating vitals
Adrenal medulla produces Epinephrine and Norepinephrine Hormone

PHEOCHROMOCYTOMA
 55

Tumor of adrenal medulla which lead to excessive secretion of Epi & Norepinephrine lead to
uncontrollable HTN & HR

Causes
Adrenal Tumor
S/S

 Paroxysmal sustained hypertension

 Tachycardia
 Hyperglycemia
 Palpitation

D/E
 VMA urine test ( Vanilly Mandelic Acid ) in 24 hrs urine ( normal value 14
mcg/100ml)
 Biopsy is contra indicated
 Can take CT,MRI

Management
 Avoid Beta Blockers
 Administer Calcium channel blocker and alfa adrenergic receptor blockers
 Adrenalectomy

PANCREAS

Partially endocrine and partially exocrine

 Endorine cell of pancreas is islets of langerhans
 Alpa Cells -0 secrete glucagon ( gluco – neogenesis is the function ) the function pf
glucagon is the production of glucose from glycogen, protein or fat or non CHO sources.
( release during hypoglycemia period)
 1 grm CHO = 4 kilo calories
 1 grm Protein = 4 kilo calories
 1 grm Fat = 9 kilo calories
 56

 Beta Cells – Secrete insulin ( function – it decrease blood glucose level by shifting blood
glucose in to cell. Shift potassium in to cell. It helps for glycogenolysis – conversion of
glycogen in to glucose)
 Delta Cells – produce somatostatin – which suppresses alfa cell and beta cells

DIABETES MELLITU

It is a metabolic disorder due to decrease ot absence of production of Insulin by the Pancreas.

Type
1. Type I DM ( IDDM ) / Juvenile DM
Auto immune disorder mainly occur less than 13 yrs. In this absolute deficiency of
insulin.
2. Type II DM ( NIDDM ) - Mainly occur after 35 yrs
3. Gestational DM ( 26 – 28 wk )

R/F type II DM
 Obesity
 Family History
 Pregnancy
 HTN

S/S

 Polyurea
 Polydispsia
 Polyphagia
 Delayed wound healing & decreased circulation to the feet
 Blurred vision
 Recurrent infection
 Fatigue
 Wt. Loss in Type I DM
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D/E
 FBS & PPBS
 HBA 1C – to detect at least 3 month of glucose control level
 Normal for DM patient – below 7%
 Above 6.5 DM

Management
 Exercise at least 3 times in a week - More beneficial for Type II DM
 Diet ( Low CHO, Fat and adequate protein )
 Oral Hypoglycemic agent ( OHA – Eg. Metformin, Orinase, Tolbutamide )

Contraindication of OHA- Type I, GDM, Chronically ill Pt., Post Op Pt.

Complication Of DM Type 1
 DKA
Type 2
 Retinopathy
 Nephropathy – micro albuminuria is present in Diabetic Nephropathy
 Neuropathy
 CAD
 Cholilithiasis
 HGHNKS

INSULIN

 Store insulin at 2 – 8 degree

 If less than 2 degree or more than 30 degree discard it
 Once vial is opened can use for 28 days

Type Brand Name Onset Peak Duration how

Works long Rapid
acting Humalog 10 – 30 mts 1 – 3 hrs 3 – 5 hrs
Novolog Apidra
Short acting Regular ( R ) 10 - 30 mts 2 – 4 hrs up to 12 hrs

Intermediate NPG ( N ) 1.5 – 4 hrs 4 – 12 hrs up to 24 hrs Acting

Long Acting Lantus 0.8 – 4 hrs Minimal up to 24 hrs
Levemir Peak
 58

 We can give regular & NPH insulin in same syringe. But first load regular insulin then
NPH - is cloudy

Problems with insulin therapy

 Hypoglycemia
 Allergic reaction
 Lipodystrophy

DIAETIC FOOT CARE

 Daily inspection of foot

 Should not wash with hot water because diabetic neuropathy cause loss of sensation and
cause burns
 Keep the foot dry socks
 Should not apply emollients in between the toes
 Cut the toes nails as straight

DIABETIC KETO ACIDOSIS ( DKA )

It is a Life threatening complication of Type I DM . It is due to lack of insulin production by

pancreas leading to hyperglycemia, dehydration and ketoacidosis.

Causes
 Illness, infection
 Lack of insulin intake
 59

S/S

 Hyperglycemia ( 300 – 800 mg/dl )

 Dehydration
 Ketosis
 Acidosis
 Metabolic acidosis, Dry skin
 Hyperkalemia
 Fruity Smell on Breath
 Kussmaul’s Respiration :- It is a deep and labored breathing pattern ( Hyperventilation ) that
often associated with severe metabolic acidosis particularly DKA but also in Renal Failure it is a
form of Hyperventilation which is any breathing pattern that reduces CO2 in blood due to
increased rate of respiration.

 Nursing Diagnosis - Fluid and Electrolyte imbalance

 Management
 IV Fluids ( NS )
 Insulin ( IV regular Insulin )

 Complication of Type II DM
HHNS ( Hyperglycaemic,Hyperosmolar,Non-ketonic Coma ) Can
occur when the action of insulin in severely inhibited Seen in Pt. W/
NIDDM, Elderly persons W/NIDDM

 Monitor Potassium level of the patient

GENITO URINARY SYSTEM

FUNCTIONS

 Maintain homeostasis of the blood and acid base balance

 Excrete end product of protein metabolism
 Control fluid& electrolyte balance
 Excrete bacterial toxins, water soluble drugs
 Secrete rennin and erythropoietin(rennin is produced from juxta glomerular kidney cell &
erythropoetinin is produced by fibroblast in the kidney)
 60

IMPORTANT POINTS

 Nephrons is the functional units of the kidney

 The totalbladder capacity-1 litre
 Normal adult urine output-1.5 litre/day
 The inner lining of urinary bladder is covered by transitional epithelium
 Creatinine is the end product of protein & muscle metabolism. Increased level in the blood
Indicate renal failure (normal value-0.5-1.5 mg/dl)
 BUN by product of proten metabolism in liver
 Normal urine specific gravity-1.010 to 1.030
 Normal urine color-amber
 Urine specimen collect early [Link] 10-20ml
 For urine culture sensitivity collect midstream urine specimen in a sterile container
 Cystole-prolapsed urinary bladder, management kegel exercise
 Catheterization
 Position (male - supine. Female - lithotomy)
 Over foleys catheter pseudo membrane occur, it's a fungal infection. Drug of choice
fluconazole,cotrimoxazole
 24 hour urine sample any one sample is missed again restart the procedure
 Renal biopsy position- Prone ( after procedure-s upine position )
 SPASTIC BLADDER/OVER ACTIVE BLADDER
 A problem with bladder function that causes the sudden need to urinate
 RISK FACTOR-obesity, constipation, poorly controlled DM, catheter related infection Over
activity of detrusor urinary muscle

 Management - Antimuscarinic & Intermittent catheterization

 Cancer bladder clinical feature-painless hematuria

TYPES OF URINARY INCONTINENCE MANAGEMENT

 61

STRESS  Anticolinergic
Leakage of small amounts of urine during Example-
physical movements such as coughing, laughing,  Atropine or benztropine
sneezing.  Kegels exercise
URGE
Leakage of large amounts of urine unexpectedly;
associated with strong urge to void.
MIXED
Combination of Stress and Urge Incontinence
OVERFLOW
Unexpected leakage of small amounts of urine because
of a full bladder; due to blockage or ineffective bladder
contraction.

DIALYSIS PRINCIPLES

OSMOSIS movement of solvent from

lower concentration to
higher concentration.
DIFFUSION diffusion movement of
solute from higher High Concentration , Low concent.
concentration to lower DIFFUSION
concentration
ULTRA Pressure needed for
FILTRATION shifting the fluid

 Maximum No of dialysis in week-3

 Complication of dialysis-disequilibrium syndrome, air embolism, dialysis encephalopathy

GLOMERULO NEPHRITIS
 Destruction, inflammation, and sclerosis of glomeruli of both kidney occurs
 CAUSE-group a beta hemolytic streptococcus.
 Clinical features
 Proteinuria,edema
 Hematuria (dark smoky cola colored red brown urine )
 Per orbital edema
 H/Othroat infection 2-3 week before
 COMPLICATION-pleural effusion, CHF, pulmonary edema,
 Management
 Anti-biotic
 Fluid restriction-500-600 ml
 62

 Daily weight and l/O charting

 Diet - high calorie, low protein, low sodium, low potassium

Nephrotic Syndrome

NEPHROTIC SYNDROME MANAGEMENT

Clinical complex characterized by a
number of renal and extra renal -Low Sodium Moderatly High Protein
features. The most prominent being. -Penicillin
 Proteinuria of > 3.5 g/d -Prednisone
 Hypoalbuminaemia -Lasix
 Oedema -Weight Check.(same time, scale,
 Hyperlipidaemia -Special skin care
 Hypercoagulability.

RENAL CALCULI

Calcium Stones
 Commonest type of kidney stones.
 Occur due to excess calcium in diet, high dose of vitamin D, intestinal bypass
surgery, etc.
Uric Acid Stones
 Generally found in people who don’t take enough of fluids nor lose too much fluid
 Also seen in people having high – protein diet and those who suffer from Gout
Struvite Stones
 Struvite stones are formed in response to same kind of urinary tract infection.
 These stones are known to grow quickly and become quite large.
Cystine stones
 These stones usually form in people with a hereditary disorder that causes kidneys
to excrete too much of certain types of amino acids called cystine in urine resulting
in cystinuria.

MANAGEMENT
1. Priority of pain management
2. Increase fluid intake
3. Avoid massage over the flank area
 63

4. Dietary - alkaline stone provide acidic ash food. If acidic stone provide alkaline ash food

URINARY TRACT INFECTION

 [Link], pseudomonas
 More common in girls because urethral opening is short and near to rectum

Clinical Features
UTI Symptoms MANAGEMENT

-pressure in the lower pelvis -Additional symptoms that ANTIBIOTICS -

-dysuria may be associated with this SULFONAMIDE
-frequent need to urinate disease: -CITRUS JUICE
（frequency) -Sexual intercourse, painful -INCREASE FLUID
-urgent need to urinate -Penis pain -CLEAN PERINEUM FROM
（urgency) -Flank pain FRONT TO BACK
-Nocturia -Fatigue -USE COTTON UNDERWEAR
-Abnormal urine color -Fever
-Chills
（cloudy urine)
-Vomiting
-Hematuria
-Mental changes or
-foul or strong urine odor
Confusion (Note:in elderly
-Young children with UTIs
may only have a fever, or people, mental changes or
confusion often are the
even no symptoms at all.
only signs of a possible
urinary tract infection .)
 64

Causes

BENIGN PROSTATE HYPERTROPHY / HYPERPLASIA

 AGE ABOVE 60, HIGH DHT, OBESITY, DM.

Clinical features
 Frequency
 Urgency
 Hesitancy
 Acute retention of urine
 Chronic retention of urine
 Hematuria
 Terminal Dribbling
 Difficulty micturation with weak stream
 Infections: Cystitis, Urethritis
 Stone formation and residual urine.

 DIGNOSIS - PSA ( prostate specific antigen more than 4 nanogram/dl )-blood sample

 MANAGEMENT
 alpha adrenergic receptor blocker ( tamsulosin )or terazocin
 anti antrogen ( finasteridin )

 S/M-TURP
Risks/Complications of TURP

 Risks : incontinence(<1%), impotence(5-10%), retrograde ejaculation(75%)

 Complications : bleeding, urethral stricture or bladder neck contracture, perforation

of prostate capsule with extravasation, and if severe, transurethral resection
syndrome

Nursing Care of the TURP Patient

 Continuous bladder irrigation with warmed solutions from the top shelf of the blanket/
solution warmer. Follow the directions on the front of the warmer regarding labeling and rotating
the solutions. Observe for signs of urinary compromise. Expect red-tinged urine that fades to pink
 65

within 24 hours.
 Observe for signs of vascular compromise: rapid pulse and decreasing blood pressure.
 Weights: daily including upon arrival to the unit
 1&0: Accurate. Check every 1-2 hours. Track the amount of irrigation fluid that is instilled
on the white board and subtract this volume from the amount that is measured from the
catheter bag to obtain urine output.
 If blood clots impede adequate catheter drainage, gentle irrigation is performed with saline
solution after completing bladder scan for residual.
 Dressings: May place a gauze dressing loosely over the end of the penis to absorb bloody
discharge. A large amount of bleeding or urine leakage may indicate obstruction of the catheter.

RENAL FAILURE

Clinical features
 Hypertension
 Uremia- nausea/vomiting, pericarditis,
 encephalopathy, neuropathyy
 Pruritis, easy bruisability
 Hyperkalemia- arrythmia
 Anemia, due to erythropoietin deficiency
 Fluid overload- edema, pulmonary edema
 Hyperphosphatemia&hypocalcemia
 Metabolic acidosis
 66

 Accelerated atherosclerosis

MANAGEMENT - DIALYSIS & RENAL TRANSPLANTATION

Complication Of Peritoneal Dialysis

1. Peritonitis ( cloudy outflow )

2. Pain
3. Exit site and tunnel infections
4. Poor dialysate flow
5. Dialysate leakage
6. Monitor color of out flow Cloudy
( Peritonitis )

NERVOUS SYSTEM

CLASSIFICATION

 Central Nervous System

 Brain

 Spinal cord
 67

 Peripheral Nervous System

 Spinal nerves (31 pairs)

 Cranial nerves (12)

 Autonomic Nervous System

 Sympathetic nervous system

 Parasympathetic nervous system

Central Nervous System

1. Brain
2. Spinal cord

1. Brain

a. Cerebrum
b. Brainstem
c. Cerebellum

a. Cerebrum:

 Frontal lobe- Thinking, Problem Solving, Decision making, speech

production, ipsilateral motor, reasoning, judgment, concentration
 Temporal lobe - Hearing, memory, speech perception
 Parietal lobe - Pain & Perception, primary somatic sensory area
 Occipital lobe - Vision, colour / visual perception
 Broca's area - motor speech
 Wernicke's area - auditory comprehension
b. Brain system: / Medulla

 Medulla oblongata - regulate sneezing, coughing, vomiting, swallowing,

controlling vitals
 Pons - regulation of respiration
 Midbrain- reflex centre for papillary reflexes and eye movements

c. Cerebellum: Is responsible for equilibrium and posture, BALANCE

 For assessing the function of cerebellum , 2 tests

1. Romberg Test ( walking )

 68

2. Finger to nose - Cordination test

Diencephalon -- Thalamus (controls emotions) and hypothalamus (critical role in temperature

regulation)

Autonomic nervous system

 Sympathetic nervous system (fight or flight response)

 Parasympathetic nervous system (conserves, restores function)

2. Spinal cord

 It is the pathway of spinal nerves

 Total 31 pairs ( cervical — 8, thoracic — 12, lumbar — 5, sacral — 5, coccyx —1 )
 Much more synapse junction present ( the junction between two neurons )

Meninges

 Covering of brain and spinal cord

 Three layers ( duramater. Arachnoids space, pia mater )
 Arachnoids space contain CSF present
 CSF is produced from choroid plexus and absorbed by sub arachnoids willi
 Normal amount ( 120- 150 ml )
 Normal CSF Pressure 5-15 mm of hg or 36-180 cm/h2o

Blood supply — circle of willis ( normal 750 to 1 litere per minute )

Neuro Transmitters

 Acetylcholine
 Dopamine
 Nor-epinephrine
 Polypeptides
 Serotonin
 Amino acids

NEUROLOGICAL ASSESSMENT - Cranial Nerves Assessment

[Link] Cranial nerves Type Functions Clinical

significance
1 Olfactory Sensory Smell
2 Optic Sensory Vision eye pain

3 Occulomotor Motor Movement of Eyeball inability to

Upper eyelid elevation pupillary open eye
reaction
 69

4 Trochlear Motor Upward and downward movement

of eye, Movement of eye Muscles
5 Trigeminal Mixed Sensory- Touch perception of face, Toothache,
oral and cornea motor-chewing facial pain
&swallowing
Lateral movement of eye /Movement
6. Abducent Motor
of upper eye lid
7 Facial Mixed Sensory - Taste perception of
anterior two-third of tongue (sweet
and salt)
motor- facial movements
8 Vestibulo Sensory Hearing & balance hearing loss
cochlear(Acoustic)
9 Glossopharyngeal Mixed Sensory- - Taste perception of
posterior one-third of tongue Gag
reflux
chewing and swallowing
10 Vagus- it is Mixed parasympathetic function decrease inability to
parasympathetic heart rate produce
nerve decrease BP sound
phonation.
Gag reflux
production of HCI in stomach
sensation behind ear
11 Spinal Accessory Motor movement of shoulder, trapezius
muscle, sternocleidomastoid muscle

12 Hypoglossal Motor Chewing & swallowing Tongue

movement

“ One Of Our Training Teacher Asked For Very Good Vada And Halwa ”

GLASCO COMA SCALE ( GCS )

Maximum - 15
Minimum - 3
Score < 8 - Pt. in Coma Score
13 – 15 - Normal
Score < 3 - Death / Deep Coma
 70

Spontaneous 4
Response to call 3
EYE Opening Response to Pain 2
No Response 1

Well Oriented 5
Confused 4
Verbal Inappropriate Words 3
Incomprehensible Sound 2
No Response 1

Obey Command 6
Identifying pain area 5
Withdrawal to pain –normal flexion 4
Motor Decortications – abnormal flexion 3
Decerebration - extension 2
No Response 1

HYDROCEPHALUS

Accumulation of CSF in brain tissue

Type
1. Obstructive
2. Non obstructive

C/M
 Increased Head Circumference
 Bulging Frontanalle
 High Pitched Shrill Cry and Seizure
 Decreased LOC

Late Sign :- High Shrill Cry , Seizure

Management :- VP Shunt ( Ventricle Peritoneal Shunt )

 Daily measurement of Head circumfrance

 Normal ICP :- Supine Position

 Increased ICP :- Semi Fowlers Position
 71

 Recurrent Shunt revision cause Latex Allergy to the body

 Health care worker and patient undergone Multiple Surgery have a high risk to get Latex
Allergy.
 Some Nuts may trigger allergic cross response in people with Latex Allergy

Cushing’s Triad
It is a sign of Increased ICP ( Normal ICP 5 – 15 )
 Cheyne Stoke Respiration ( Rhythamic Respiration a period of Apnoea )
 Bradycardia V
 Vident Pulse Pressure ( Increased Systolic BP )
B C

Macewens Sign
Cracked Spot Sound on Percussion MULTIPLE

SCDLEROSIS

Demyelination of Neurons or CNS

Causes :- Auto immune disorder, Viral infection, Usually occur 20- 40 Yrs Triggering
Factor - Exposure to Hot

C/M
 Fatigue
 Weakness
 Muscle Spasam
 Dysphagia
 Optic Neuritis ( Inflammation of Optic Nerve )
 Diplipia :- Double Vision
 Nystagmus :- Rapid involuntary movement of Eye Ball
 Shimmering :- A feeling of flash of light in to Eyes
 Dysarthria :- Difficulty in articulating words it is late stage C/M
 Constipation
 Incontinence of bladder

Diagnostic evaluation
 EEG
 Lumbar Puncture indicate Increased Gama Globulin but S. Globulin normal

Management
 Baclofen - Anti Spasmodic - drug of choice – Reduces Spasdicity
 Side Effect - Muscle Tremor
 72

 Drug during exacerbation - Steroid - eg. IV Prednisone

MS have exacerbation stage ( severe form ) exacerbation the drug of choice is Steroids . Hot
Climate / Temperature exacerbate the condition

Place the Eye patches for Diplopia

MYSTHINENIA GRAVIS

It is a Auto immune disease characterized by weakness, abnormal fatigue of voluntary

muscle due insufficient secretion of Acetylcholine due to excess of Cholinesterase

C/M
 Drooping of Eye lied
 Weakness
 Fatigue

 Dysphagia
 Diplopia
 Respiratory Failure
 Difficulty in Chewing

Test
 E M G - Electro Mayo Gram

Intervention
 Monitor respiratory status closely
 Administer Anti – Cholinesterase medication
 Neostigmine
 Pyrostigmine
 Instruct the client to avoid stress, infection and importance of follow up otherwise it lead to
complication of Mystenia Gravis wich is mystaenin crisis

Mysthenin Crisis
Severe from of M.G due to inadequate amount of medication infection, fatigue, stress,
HTN
Management :- Anti – Cholinesterase Medications

Cholinergic Crisis
Due to over medication with Anticholinestrace
C/M
 73

 Fatigue
 Weakness
 Abdominal cramp
 Nausea
 Vomiting
 Late C/M - Hypotension
Management :- withhold Anticholinstrace medication
Administer Antidote of Anticholinestrase wich is Atropine Sulphate.

TENSILON TEST ( Tedrophonium Test )

Some time use may confuse that M.G , M.C, C.C in such situation to conform diagnosis we
can perform Tensilon injection ( Which is an active from of anticholinstrace )
 If client shows improvement in muscle strength after the administration of Tensilon the
condition is MG.
 After administration if strength improvement the client need more medication -
Mysthenian crisis
 After administration weakness severe - Cholinergic Crisis Here the
Antidot of Tensilon wich is Atropin Sulphate.
Atropin Sulphate is antidote of all anticholinstrace medication and Organo
Phosphrus Poisoning .

STROKE ( Cerebrovascular Accident / Brain Attack C V A )

It is the neurological dysfunction due to decreased blood supply to the brain

especially to cerebrum

Types
1. Thrombotic Stroke - Due to Ischemia. It Constitute 70%
2. Hemorrhagic Stroke - Due to bleeding . It constitute 30 %

Causes
 Ischemia sue to Atherosclerosis
 Cerebral Aneurysm
 Heart Failure
 Valvular Disorders
 Head Injury R/F
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Non Modifiable Modifiable

Age HTN
Sex DM
Race Smoking
Family History Alcoholism
Physical inactivity

C/M
 Dysphagia
 Hemiplegia
 Agnosia :- Inability to Recognize Familiar Objects or person.
 Apraxia :- Loss of ability to execute or carry out skilled movement / Jesters.
 Dyspraxia :- Mild form of Apraxia
 Hemianopxia :- Blindness in half of visual field in one eye
 Homonymus Hemianoxia :- Loss of half of field of view in the same side of both eyes.

Nursing Intervention :- Re Orient the Client

Intervention for Hemi anopxia & Homonymus hemianopxia

 Encourage the client to turn the head to scan the complete the range of vision
 Approach the client in unaffected side
 Provide eye care

C/M - Neglect Syndrome ( Unilateral Neglect )

The client is unaware of the existence of his paralyzed side
Intervention :- Teach the client to touch and use the unaffected side of body.

C/M - Aphasia
It is a communication Disorder
1. Expressive Aphasia :- Patient can understand the things by he can’t express in words.
2. Receptive Aphasia :- Patient can’t understand the things by can express
3. Mixed Aphasia :- Complication of expressive and receptive
Intervention :- Provide Pen and Paper or computer technology or Picture board to communicate.
Diagnostic
CT
Management
 For Ischemic Stroke - Thrombolization Anti Coagulant
 Hemorrhagic Stroke - Craniotomy
 75

Nursing Management
 Prevention of Aspiration
 Refer the patient to Speech Therapist to learn swallowing technique
 If dysphagia - RT feeding
 Change position 2 hrly to treat Bed Sore and DVT
 Passive Exercise

Transient Ischemic Attack ( TIA )

It is a mini stroke with no dead brain tissue. It the warning sign of stroke and it is a
temporary focal loss of neurological function caused by ischemia of one of the vascular territories of
the brain. Symptoms last for 24 hour and minimum for 5 minutes

ASSESSMENT

F - Fascial dropping
A - Arm weakness
S - Slurred speech
T - Don't waste time

Right side brain stroke — Left side Body Paralysis

Left side brain stroke — Right side Body Paralysis , High risk for Suicide / Depression

TRIGEMINAL NEURALGIA

Problem with 5th Cranial Nerve, Painful face pain increased with during intake of hot or
cold food.
Causes :- Compression of blood vessels, herpes virus infection, infection of teeth

C/F :- Dysphagia, Sharp facial pain / gums, nose, across the cheeks, situations that
stimulate symptoms like Cold, Hot, Face washing.

Management
 Avoid Hot or Cool Foods and administer fluids
 Drugs :- CARBAMAZIPINE - Antispasmodic

Instruct the patient to Chew with the Unaffected Side

BELL’S PALSY

Temporary paralysis of one side of the face due to injury to the seventh cranial nerve ( 7th )
cranial nerve - facial nerve

Cause — birth injury, trauma, meningitis

 76

Clinical features — dysphasia, inability to close the eyes, Unilateral Eye movement, loss of taste

Management
 The major complication of bell's palsy is keratitis (corneal inflammation) which results
from incomplete eye closure on the affected side.
 DARK ROOM
 STEROID & Facial Exercise

GUILLAIN- BARRE SYNDROME ( DEMYELINATION OF PNS )

The major concern in GB syndrome is difficulty breathing, monitor respiratory status

closely
 H/ 0 respiratory or GI infection
 Ascending to descending paralysis
 Diagnosis nerve conduction velocity

Management - IV Immune Globulin IgG, PLASMAPHERESIS, INTUBATE

ALZHIMER’S DISEASE

Irreversible form of dementia / delirium Brain

degenerative disorder
C/M :- Pt loss Resent memory first then the Remote Memory Sun
down Syndrome
Common inFemale gender. Having genetic history Drug
of choice :- DONEPEZIL
Management :- Safety Measures

PARKINSON’S DISEASE

Disease of the Basal Ganglia due to deficiency of Dopamine

C/M
 Regidity
 Bradykinesia
 Pill Rolling Tremor :- Tremor increases during rest and decrease during activities
 Dysphagia
 Dysarthria
 Postural Deformity - Khyposis
 77

 Bladder incontinence ( Urge incontinence ) Pt. has sensation for urination, but fastly occur
before reaching toilets
 Masked Face
 Blank Facial expression

Management
 Bladder training exercises
 Anticholistrase
 Prevent aspiration
 Safety
 Increase fluid intake
 Antiparkinsons Medication
Eg. LEVODOPA, CARBIDOPA
 High energy exercise in Morning
 Keep suction apparatus and urinal in bed side
 Avoid pillow

High Risk for Aspiration

MENINGITIS

Inflamation of Covering of Brain / Meninges

Types
1. Bacterial / Payogenic - Streptococcus, neisseria, hemophilus influenza type B
2. Viral / Aseptic - Entero Virus, Variccella Zoaster
3. Fungal and Protozoal

R/F
 Craniotomy,
 Skull fracture, those who are living in crowded areas. Eg. Dormitory and Prison Mode

of transmission :- Bacteria ( Airborn/droplet) , Virus ( direct Contact )

C/M
 Fever
 Head ache
 Photophobia
 Nuchal rigidity
 + Ve KERNING Sign :- Loss the ability of supine pt to straighten the leg completely when it
is fully flexed at knee and hip indicated meningial irritation
 78

 +Ve BRUDSKINSKI Sign :- Involuntary flexion of hip and knee when the neck is
passively flexed

Diagnostic evaluation :- C S F Analysis

Bacterial Meningitis
 C S F is cloudy with Increased Protein , Increased WBC, Decreased Glucose count

Viral Meningitis
 Clear C S F with decreased Protein, Decreased W B C and Increased Glucose

Management
 Droplet precaution for Bacterial
 Proper handling of fecus for Viral

Meningococal Menigitis Cause :- Septic Shock

SEIZURE

Abnormal electrical discharge of the brain from the cerebral hemisphere

Type
1. Generalized seizures (Tonic Clonic) Adult.
2. Absent Seizure(Children) Stages

1. Pre-ictal ( aura) - before develop seizure the client body produce warning symptoms
( mainly in sensory form )
2. Tonic spasm phase — stiffness of the body. the C/M are — client fall the ground from
sitting or standing position, opisthotonous posture, frothy discharge from mouth,
cayanosis, cease the breath,
3. Clonic spasm phase — jerking of the body C/M are — involuntary passage of urine and
stool, tongue or cheek bite with loss of consciousness
4. Post ictal phase - one sleep like stage , headache present

Intervention
 Sideline position
 Elevated side rails
 Suction airway
 Administer O2
 Loosen dressing MANAGEMENT

— during seizure
 79

 Priority for airway clearance

 If the client having a seizure, maintain a patent airway. Do not force the jaws open or place
anything in the client's mouth, and avoid suctioning.
Maintain left LATERAL POSITION

SAFETY
 Place a pillow under the head
 Loosening the cloth
 The drug of choice is Phenytoin. – S/E – Hypertrophy and bleeding from Gums.
 An adverse effect of Phenytoin (dilation) is gingival hyperplasia , hypotension,
bradycardia, purple glove syndrome
 Therapeutic level of Phenytoin in blood — 10-20 mg/dl more than 32 toxic
 Phenytoin antidote — Activated Charcoal
 Other drug of choice- lorazepam, diazepam , sodium valporate,carbamazepine
 STATUS EPILEPTICUS continuous Seizure administer Diazepam / Vallium
 Anti ndot of Vallium ( Diazepam ) - Flumazenil
 Phenytoin - Need oral Care Because to Prevent Dental Decay

Nursing diagnosis- during seizure — 1. Ineffective airway clearance 2. Risk for injury

AUTONOMIC DYSREFLEXIA

Sudden increase in ICP a patient with Spinal Cord injury above the level of T6 Vertebrae is
called autonomic dysreflexia

C/M
 Urinary Retension ( Full Bladder )
 Severe thrombing head ache

Intervention
 Administer Foleys’s Catheter

SPINAL NERVES

C8
T 12
L5
S 5
C1
C1 - C4 - Cardiac and respiratory problem C5 - C8
 80

- Problem in upper extremity

L1 - L4 - Check patellar reflex OPISTHOTONIC

POSITION

Arging towards the back flexion of neck and upper extremity and extension of lower extremity. It
is a Sign of Increased I C P especially cerebral palsy.
Abduction - Away from Body
Adduction - Towards the Body

MUSCULOSKELETAL DISORDERS

OSTEOPOROSIS

Demineralization of bone is known as osteoporosis.

 Osteoporosis is characterized by decreased bone mass and increased bone fragility.
 Most commonly occur in to the wrist, hip, and vertebral column.
 The condition same as hypercalcemia.

Types / Causes
 PRIMARY - the causes are decreased calcium intake, poor vitamin D , old age (males due
to deficiency of testosterone and in menopausal women due to deficiency of estrogen).
 SECONDARY - the causes are alcoholism, drug induced ( steroids, LevoThyroxine Sodium,
anticonvulsants, aluminum containing antacids ) , malabsorption syndrome.

Clinical features
 Back pain occurs after lifting or bending.
 Back pain that increases with palpation
 Decline in height from vertebral compression
 Dowagers hump.( kyphosis).
 Hypercalcemia
 Pathological fracture
 Renal stones

Management
 Drug of choice — calcitonin
 Bisphonates — example alendronate.
Action- it inhibit osteoclast mediated bone resorptionthere by increasing total bone mass.
Side effect — esophagitis, ocular problems.
 81

Contra indication — esophageal disorder, person who do not sit or stand.

Nursing responsibility- should be administered in empty stomach with one glass of water and
should remain sitting or standing and can take food after 30 minutes.
 Instruct the client to perform weight bearing activities for to reduce weight .eg
walking exercise.
 Diet high calcium , protein and vitamin D .

PLANTAR FASCITIS

Inflammation of plantar skin commonly seen in marathon runners due to prolonged use of
heal of the foot

Management - leg stretching exercises, use cushion shoes

GOUT ( NORMAL URIC ACID 3.5 — 7.5 mg/dl )

Gout is a systemic disease

Cause
 PRIMAY GOUT - result from incomplete purine metabolism ( acidic + protein food)
 SECONDARY - result from another disease. example psoriasis

Pathology - increased uric acids in the blood can converted to crystal form and deposited in
to the soft tissue can cause renal calculi and deposited in to the joint can cause gauty arthritis.

Clinical features
 Pain and inflammation of one or more small joints
 Tophi
 Pruritis from urate crystsls in the skin.
 Joint pain and swelling.
Diagnostic test - synovial fluid aspiration is confirmation test
Management
 Drug of choice - Allopurinol ( zyloprim ) and colchicines
 NSAID
 Provide low purine diet. Take alkaline ash food.
 Take much more water. it will help to excrete the uric acids through urine and to
prevent stone formation.
 Avoid excessive movement of the joint.
Complication :- Uric Acid Kidney Stone - to treat these increase Fluid Intake RHEUMATOID

ARTHRITIS
 82

Inflammatory disease leads to destruction of connective tissue and synovial membrane.

Mainly affecting peripheral joints and knee joint.

Cause - Auto immune disease, genetic factor.

Clinical features- CROSS CHECK THE PICTURE FROM NET

TYPICAL FEATURES OTHERS

Early morning stiffness [Link],tenderness &stiffness of joint
lasting more than
30mts.
B/L symmetrical
[Link] ,soft feeling in the joint
arthritis
Ulnar drift [Link] ESR
Swan neck [Link] ROM
Hamer toe

Diagnostic Test
 X — ray ( joint deterioration )
 Blood test — RA factor
 Synovial tissue biopsy ( showing pannus tissue or granulation tissue)
Management
 NSAID, steroid, methotrexate ( methotripsin)
 Monitor medication related blood loss through GUAIAC TEST ( stool for occult blood ).
 Surgery — synovectomy , TKR .

OSTEO ARTHRITIS

It is progressive degeneration of the joint. Marked by progressive deterioration of the articular

cartilage in peripheral and axial joints.

Causes - [Link]. Infection

Assessment - CROSS CHECHK THE PICTURE FROM NET

 Initially pain during activity and will be relieved by rest.
 Difficulty getting up from prolonged sitting.
 Heberdens node- a hard or bony swelling that can develop in the distal inter
phalangeal joints.
 Bouchards node- are hard bony outgrowth on the proximal interphalangeal joints.

Management
 83

 Corticosteroid directly in to the joints.( intra articular) . after medication continues hot
application.
 NSAID and muscle relaxants.
 Immobilize the affected joints.
 Maintain weight within normal range with a normal well balanced diet.

DEVICES USED IN MUSCULO SKELETAL DISORDERS CRUTCH

CRUTCH

 Indication — amputation
 Hold the crutch on the unaffected side and during ambulation the nurse should stand on the
affected side
Measurement-
 Walking up the stairs- first move unaffected leg then affected leg and crutch.
 Down the stairs- first crutch, then affected leg and then un affected leg. CANE
 Indication- weakness in to the lower extremities
 Hold the cane on the unaffected side, so that the cane and weaker leg can work
together with each step.
 During ambulation the nurse should stand on the affected side.

WHEEL CHAIR AND STRETCHER

 Place this material on the unaffected side.

 The nurse should stand on the affected side.

ROLLER WALKER

 Indication- those who are weakness in to the upper extremities

FRACTURE

 It is a break in to the continuity of the bone.

Types
 Closed or simple
 Comminuted- the bone crushed with three or more fragments.
 Compression- a fractured bone is compressed by other bone
 Depressed — bone fragments are driven inward.
 Green stick— common in children .one side of the bone is Brocken and the other part is
bent.
 84

 Impacted — a part of the fracture bone is driven in to another bone.

 Incomplete
 Oblique — the fracture line runs at an angle across the axis of the bone.
 Open or compound fracture — the bone is exposed to air. Sterile dressing is needed
 Spiral- the break partially encircles bone
 Transverse
 Pathological fracture

Management
 Immediate intervention is immobilization ( for to prevent further damage and
immobilization is basic requirement for bone healing)
 SPLINT & SLINGS
 Reduction — it restores the bone to proper alignment. Types open and closed.
 Fixation - it provide immediate bone strength. And [Link] internal and
external.
 CAST- Nursing intervention
 Keep the cast extremity elevated.
 Monitor the distal area — if having poor peripheral pulse, numbness, tingling sensation,
cyanosis, and swelling occur that means cast compression present .the best nursing
intervention is immediately report to the doctor or cut the cast
 Instruct the client to keep the cast clean and dry. And avoid stick any object inside the
cast.
 If any foul discharge, smell occur from inside the cast or hot spot over the cast
indicate inside the cast infection is present
 EXERCISE- during cast — isometric exercise or passive exercise. After cast removal
— active assistive range of motion exercise.
 TRACTION- traction provides proper bone alignment and reduce muscle spasm.
 Nursing intervention- maintain proper body alignment.
 Ensure that the weight hang freely and do not touch the floor.
 Do not remove or lift the weight without a physician order.
 Ensure that pulleys are not obstructed and ropes in the pulleys move freely.

TYPES :
 Skeletal traction — priority pin site care with chlorohexidine
 Skin traction
1. Cervical skin traction - it relieve compression and muscle spasm of neck & extremity.
2. Bucks extension — use fracture in to the lower limbs or tibial bone.
3. Russels or brayands traction- use fracture in to the femur.
4. Dunlops traction- horizontal traction is applying to clear humorous fracture.
 85

COMPLICATIONS OF FRACTURE

[Link] bed rest can cause bed sore

[Link]
[Link]
[Link] embolism.
 A fat embolism originates in the bone marrow and occurs after a fracture when a
fat globule is released in to the blood stream.
 Client with long bone fracture are at the risk for the development of a fat
embolism.( femur, pelvis, humorous, vertebra, ribs )
 It occurs within the first 48-72 hours following injury
 Clinical feature - petechial rash or ecchymosis should be present at the side of the
neck or upper chest. Hypotension ( remaining features and management same as
pulmonary embolism )
Management
 Notify the physician
 High fowlere position
 Administer Oxygen.
5. Pulmonary Embolism ( refer adult respiratory)
6. Compartment Syndrome
 It occurs when pressure increases within one or more compartment leading to tough
fascia surrounds muscle group.
 Assessment- 5P ( Pain, paleness , pulselessness, parasthesia, paralysis) and edema.
 Management — notify, fasciotomy
7. Disuse Syndrome - Is the generic name for a physical state caused by bed rest ,
immobility or a lack of physical activity.
8. Avascular Necrosis - When a fracture interrupts the blood supply to a section of bone leading
to bone death.

AMPUTATION

It is the surgical removal of a lower limb or part of the limp

Classification : —
1. Traumatic amputation .
2. Surgical amputation. Types
—
1. Above knee amputation,
2. Below knee amputation,
3. Syme amputation,
4. Mid foot amputation,
5. Toe amputation.
 86

Post OP Intervention
 After surgery first 24 hour elevate the extremity to prevent hip contracture.
 After 24 hour to provide supine position to prevent hip contracture
 After 24 hour every day 20 minutes to provide prone position to prevent hip
contracture
 The second post operative day onwards massage toward the site to make as cylindrical
shape to prepare for prosthesis. It will help to decrease pain and mobilizing the scar.
but the massaging is performing the 15th day for prosthesis preparation.
 Use triangular pillows inside and out side the thigh to prevent internal and external
rotation of the thigh.
 After 24 hour avoid hip flexion.
 Use anti embolism stockings or TED HOSE.
 Monitor complications.
1. Bleeding — if occur first mark the area and report to the doctor.
2. Neuroma
3. Infection
4. Phantom limb sensation pain — it is a neurogenic pain treated with high dose
analgesics ( both pre and post operatively ) or with the help of an mirror box
therapy . mirror box therapy will help to convert the sensory perception to visual
perception.
 Prepare for prosthesis
Nursing Intervesion :- Place Mirror at the bed side TOTAL

KNEE REPLACEMENT

 Post operatively 24-48 hours as prescribed to exercise the knee and provide
moderate flexion and extension.
 Administer analgesics before passive range of motion to decrease pain.
 Post operatively initially perform crutch walking.
 Avoid leg crossing and hip flexion post operatively.

TOTAL HIP REPLACEMENT

 Always maintain leg abduction with pillow between the legs

 Avoid adduction and leg crossing.
 Post op exercise- isometric quadriceps exercise.

SPRAIN MANAGEMENT - PRICE

 87

P - Protection.
R - Rest
I - Ice
C - Compression.
E - Elevation

EYE DISORDERS

ANISOCORIA

It is a condition characterized by an unequal size of the pupils.

 88

Cause-

1. Physiological — it is normal
2. Mechanical -- previous trauma or eye surgery or inflammations
3. Oculo motor nerve palsy
4. Pharmacological agent — anticolinergic example atrophine sulphate.

Management- administer miotics

ADIES SYNDROME

It is a neurological disorder characterized by a tonicaly dilated pupil that reacts slowly to

light but shows a more definite response to accommodation

Cause — damage of post ganglionic fibers of the parasympathetic intervention of the eye.
Pilocarpine drugs for constrict pupil.

REFRACTIVE ERRORS

MYOPIA — a condition in which close objects appear clearly. But far ones don't.
Management — Concave Lens.

HYPEROPIA — long site present . Management

use convex lens.

PRESBYOPIA - vision loss due to aging. Due to decreasing elasticity in the lens. To check refractive
errors with the help of ansnellens chart.

CATARACT

Opacity of the lens Types /

Causes
 SENILE CATARACT- due to aging process
 INHERITED — congenital
 TRAUMATIC — due to ant other eye injury
 SECONDARY— due to another eye disease or drugs eg long term use of steroids C/F

 Early features: blurred vision (floaters) and decreased color perception

 Diplopia, decreased color perception, presence of white pupil, redness of eye ( only in senile )
 89

Management - Administer mydriatrics - to dilate the pupil eg: atropine. S/E- dry mouth, constipation,
tachycardia

Surgical management:
 Extra capsular extraction of the lens ( phacoemulsification is the principle )
 Intra capsular extraction ( total lens and capsule are removed ) Post
operative intervention
 Elevate the head of the bed at 45 degree and turn the client from supine to non
operative side.
 Avoid getting strain to the eye.
 Clean the eyes from inner canthus to the outer canthus.
 Monitor complication. Decreased vision and pain
 The final best vision will not be present until 4-6 week following cataract removal
because this is the time should take for wound healing

Nursing diagnosis : disturbed sensory perception related to ocular lens opacity.

GLAUCOMA

A group of ocular diseases resulting in Increased Intra Ocular Pressure. increase IOP result
from inadequate drainage of aqueous humor from the canal of schlemm or over production of
aqueous humor. So increase IOP will compress the optic nerve and the pupil is dilated that result
blindness.
 Normal IOP Is 10 - 21 mmofhg . - Tonometer is using for measure lOP

Aseesment
 Early features- increase 10P, tunnel vision or decreased accommodation
 Headache, halos around light , loss of peripheral vision

Management
 Vision problem is not corrected with lenses.
 Administer drugs for to decrees 10P. [Link] ,xalatan.
 Administer diamox for to decrease the production of aqueous humor
 Atropine is Contra Indicated in this disease (anti colinergics) or mydriatrics( drugs which
is using for to dilate pupil
 Administer miotics for to constrict pupil eg. pilocarpine S/E- bradycardia,
hypotension
 S/M - Trabeculectomy and Iridectomy
 Eye surgery position — towards the un affected side
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RETINAL DETACHMENT
Detachment or separation of the retina from the epithelial eye wall.
 It occurs when the layers of the retina separate because of accumulation of fluid
between them or tumors.
 When detachment become complete blindness occurs.

Assessment : flashes of light, sense of curtain being drawn over the eye, floaters or black spot

Management
 Provide bed rest. Cover both eyes to prevent further damage.
 Avid jerky head movement
 Cryosurgery : nitrous oxide is injecting into the epithelial eye wall and to freeze the cells
 Vitrectomy : after surgery prone position
 Drainage of fluid from sub retinal space
 Sclera buckling, laser therapy.

EAR DISORDERS

Anatomy and physiology

Function : hearing and maintenance of body balance or equilibrium.

Anatomy
 Outer ear — pinna, mastoid process, auditory canal and anterior portion of the ear
drum .function collecting the sound waves.
 Middle ear - ear drum ,maleus, incus, stapes ( smallest bone in human body),( the bony
ossicles which decrease the amplitude of the sound ) and Eustachian tube ( which allows
 91

equalization of air pressure on each side of the tympanic membrane so that the membrane
does not rupture)
 Inner ear - semicircular canal and cochlea, and the cochlea contain eighth cranial nerve
vestibule cochlear nerve.
 which is helping for hearing and maintain equilibrium of the human body.

EAR ASSESSMENT

 Autoschopic examination — less than 3 year pinna down and back more than 3 year up and
back for to visualize the auditory canal . Normal character of tympanic membrane is grey
color , opaque .
 TUNING FORK TEST
 Webers test -- place the vibrating tuning fork at the middle of the for head or in front of
the nose, if patient get conduction equally in both ears ( normal ). If the conduction is
louder in one ear it denotes conductive hearing loss to that ear. this is performing to
detect conductive hearing loss.
 Rinne test — place the vibrating tuning fork at the mastoid process patient get
vibration to an extent through the bone. after the vibration is stopped place the fork in
front of ear to get vibration through air If air conduction is more than bone
conduction it indicates positive test or normal hearing . air conduction is two times
longer than bone conduction
 Vestibular assessment
 Caloric test -- is a test of the vestibulo-ocular reflex that involves irrigating cold or
warm water or air into the external auditory canal. Ice cold or warm water or air is
irrigated into the external auditory canal, usually using a syringe. If the water is warm
(44 °C or above) is used horizontal nystagmus towards irrigated ear. If the water is cold,
relative to body temperature (30 °C or below) horizontal nystagmus away from irrigated
ear.
 Romberg test -- Romberg's test, Romberg's sign, or the Romberg maneuver is a test used
in an exam of neurological function for balance. Ask the subject to stand
erect with feet together and eyes closed. Watch the movement of the body in relation to a
perpendicular object behind the subject. Romberg'stest is positive if the patient falls
while the eyes are closed.

 Hallpikes maneuver -- The client starts on sitting position, the examiner lowers the client
to the exam table and rather quickly turns the client's head to 45 degree position. If after
about 30 seconds there is no nystagmus, the client is returned to a sitting position and the
test is repeated on the other side.
 Gaze nystagmus evaluation -- Client's eyes are examined as the client looks straight ahead,
30 degrees to each side, upward and [Link] spontaneous nystagmus- an
involuntary, rhythmic, rapid twitching of eyeballs- represent a problem with the vestibular
system.
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TERMINOLOGIES

 Otalgia — ear pain

 Cholesteatoma - tumor of the middle ear and mastoid process that contain
cholesterol.
 Labyrinthitis — inflammation of the labyrinth membrane
 Cerumen — ear vax
 Otosclerosis — a condition characterized by abnormal spongy bone formation around
the stapes .
 Presbycusis -- progressive hearing loss associated with aging process
 Myringitis — inflammation of the tympanic membrane.
 Ototoxic drugs -- aminoglycoside antibiotics( streptomycin, gentamycin, amikacin,
tobramycin. )
 Anti neoplastic( cisplatin vincristine)
 Diuretics eg. Lasix
 Others [Link], aspirin and salicylate.

EAR SURGERIES

 MYRINGOTOMY OR TYMPANOTOMY — Incision in to the tympanic

membrane.
 OSSICULOPLASTY — Surgical re construction in to the three bony ossicles in the middle
ear
 STAPEDECTOMY — removal of stapes ( stapedotomy means incision in to the stapes)
 FENESTRATION — complete removal of stapes and prosthesis insertion
 MYRINGOPLASY OR TYMPANOPLASTY — repairing of the tympanic
membrane.

MENIERES DISEASEOR ENDOLYMPHATIC HYDROPS

It is a disorder of the inner ear. That can affect auditory system and vestibular system. it
refers to dilation of the endolymphatic system by over production or poor reabsorption.
CAUSES : -- Viral or bacterial infection, allergic reaction, long term stress, women more than men,
retention of sodium

Clinical feature
 Typical symptoms — tinnitus , vertigo, sensory neural hearing loss
 Photophobia, nausea and vomiting, severe head ache

Management
 Anti-histamine
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 Diuretics — lasix
 Anti emetics and vestibulosupressants( haloperidol )
 Sedative eg. Diazepam
 Cryosurgery and endolymphatic drainage
 Complete bed rest, provide assistance for walking.
 Initiate sodium and water restriction

OTITIS MEDIA

Inflammation of the middle ear. Mainly occur in children. It is occurring as a result of a

blocked Eustachian tube. It is a common complication of acute respiratory infection.

 Infants and children are more prone to otitis media because their eustachian tubes are
shorter wider and straighter

Cause
 The common cause is streptococcus pneumonia.
 Hemophilus influenza
 Moraxella catarrhalis
 High risk: child not maintain up right position for feeding, bottle feeding baby, acute
respiratory infection.

C/F
 Excessive crying, fever, irritability
 Older children complaint otalgia
 Rolling of head from side to side and pulling on or rubbing the ear
 Otorrhea

Management
 ENCOURAGE fluid intake and avoid chewing because it increases pain
 Position — affected side down.
 Administer analgesics or antibiotic ear drops for 14 days

 Surgery — myringotomy and insertion of tympanoplasty tubes into the middle ear to
equalize pressure and keep the ear aerated. It is a surgical procedure for facilitating
drainage in otitis media.
 Post-operative intervention
 Avoid — Airplane travelling, nose blowing, pinch the nose trills, vigorous
coughing and sneezing, and avoid take water through straw
 Keep the ear clean and dry
 Use ear plug during shampooing
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 Instruct the parents that if the tubes fall outs it is not an emergency but the
physician should be notified.

Prevention
 Maintain Upright Position for feeding
 Promote breast feeding and avoid bottle feeding
 Keep immunization up to date
 Early treat upper respiratory infection

ACOUSTIC NEUROMA

 Benign tumor in the distal portion of the eight cranial nerve ( aquastic nerve)
 Clinical feature - tinnitus, vertigo, and sensory neural hearing loss
 Management- surgery through craniotomy
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DERMATOLOGY

BURNS

Cell destruction of the layer of the skin and the resultant depletion of fluid and electrolyte

Types
1. Thermal Burn
2. Electrical Burn
3. Chemical Burn
4. Inhalation
5. Radiation

Classification

1. 1st Degree ( Superficial )

C/M
 Pain
 Redness
 No Blisters
 Healing 5 – 10 days

2. 2nd Degree ( Partial Thickness )

C/M
 Pain
 Redness
 Blisters

Management for 1st and 2nd Degree Burns

 Analgesics
 Silver Nitrate

3. 3rd Degree Burns ( Full Thicknmess )

Enter distraction of muscle, Vessels, Vein and Nerves

C/O No Pain
Dry and discolored skin Management :-
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Fluid Replacement

4. 4th Degree Burns

Muscle, Bone, Black, Eschar, Dry, Painless, Amputation

RULE OF NINE ( 9 ) IN ADULT ( Used for estimating total Burn Surface area TBSA )

Head - 9%
Ant. Trunk - 18%
Post. Trunk - 18%
Upper Extremity - 9 x 2 = 18%
Lower Extremity - 18 x 2 = 36%
Genitalia - 1%

RULE OF NINE ( 9 ) In Babies & Children ( Used for estimating total Burn Surface area TBSA )

Head & Neck - 18%

Each Arm - 9 x 2 = 18%
Back & Buttocks - 18%
Chest & Abdomen - 18%
Lower extremity - 13.5 x 2 = 27%
Genitalia - 1%

Complication
 Risk for infection so follow strict aseptic technique
 The common Burn in child is Scald Burns ( Liquids and Gases ) can cause Growth
Restriction
 The most risk group for accidental burn injury is Toddler
 There is Vit D deficiency is present in burns because of skin damage
 The most critical burn is in the Chest, Neck, and Face.
 Other body area - Electrolyte imbalance Hyperkalemia, Hyponatremia
 24 – 48 hrs Hypovoemia
 48 -72 hrs Diuresis phase

Cause of Death :- ARDS, Hypovolemia, Septic Shock, Arrithymia, Renal Failure Management :-
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First Aid

R - RESCUE
A - ALARM
C - CONFINE
E - EXTINGUSH
P - PULLED UP
A - AIM AT BASE
S - SQUEEZE
S - SWEEP

 Emergency phase management -- Priority for ABC % calculate the percentage of burn
 Resuscitative phase — Administer fluid to prevent hypovolemic shock .mainly using
Parkland Formula

PARKLAND FORMULA

Fluid Resuscitation  Medication Only IM

 Reverse Isolation / PPI
Parkland Formula  Diet High Protein, Calorie,
 Total Fluid requirement in First 24 hrs = Vit – C , D , Zinc
4 ml x TBSA burn ( % ) x Body Weight
( kg)

 50% given in first 8 hrs from time of

injury
 50% given over next 16 hrs
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 Acute phase - wound care

Wound care steps Types of wound covering

Hydrotherapy ( time 30 min

 Auto graft
Debridement  Homograft
 Mechanical  Xeno graft
 Enzymatic  Cultured skin
 Surgical  Amnion
Wound coverings
Wound closure

 Rehabilitative phase — rehabilitative planning should be done at the time of

admission onwards
Nursing diagnosis
 burn present in face , neck, chest — ineffective airway clearance
 80% burn all over the body — fluid volume deficit
 80% burn priority nursing diagnosis at the time of discharge — disturbed body image
 Management — immune suppressant % plasmapheresis

PHEMPHIGUS

It is an auto immune disease commonly affecting oral cavity .

C/M — it present as oral blisters especially in the buccal and the palate mucosa
 Weight loss, mal nutrition
 It also affect conjunctiva, nose, esophagus, vulva, vagina, pelvis, anus
 Blister can leads to ulcerative lesion
D/E — positive NIKOLSKYS SIGN (RUBBING OF SKIN CAUSES EXFOLIATION)
 Management /- Cortico steroid & immune suppressants

PRESSURE ULCER

Causes - immobility. Mal nutrition, sensory deprivation STAGES;

STAGE 1; NON BLANCHABLE REDNESS. STAGE 2;

BLISTER, RED, SHALLOW CRATER.
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STAGE 3; DEEP CRATER, SUBCUTANIOUS TISSUE AFFECTED STAGE 4;

BONE TENDON MUSCLE.
STAGE 5; UNSTAGEABLE, ESCAR.

Diagnostic Evaluation

Braden Scale - Predicting Pressure SoreRisk

 The Braden Scale score ranks patients according to their level of risk for pressure
ulceration. Lower scores indicate a lower functional status and, therefore, a higher level of
risk:
9 or less = Very high risk
10 – 12 = High risk
13 – 14 = Moderate risk
15 - 18 = Mild risk
19 - 23 = Generally not at risk

 A total Braden Scale score of 18 or below in an adult patient is predictive for the
development of a pressure ulcer unless preventive measures are taken. If the total Braden
scale score is < 18, the patient must have preventive interventions.
 Preventative measures must focus on those Braden subscales in which a patient has a low
score.
 Low subscales indicate risk even if total score >18.
 The intensity of interventions is based on the level of risk.
 Target the reason the scale is low in the interventions you select for your patient.
 All patients who have a Braden Score of 18 or below must have interventions
initiated that will lower the risk for pressure ulcer development.
 Initiate a Plan of Care for Risk for Impaired tissue Integrity and corresponding EMR
Pressure Ulcer Prevention Order Set

COMPONENTS OF BRADEN SCALE.

1. Sensory perception.
2. Activity
3. Mobility
4. Nutrition
5. Moisture
6. Friction/shear
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Management

Preventive Collaborative

Every 2 hourly change the position of the Avoid massage over the red area
client Antibiotics
Use air bed or water bed Skin grafting
Be sheet is wrinkle free Perform hydrocolloid dressing or wet dressing
Keep skin clean and dry DIET HIGH PROTEIN HIGH CALORIE VIT-C
Use cream and lotions to lubricate the skin
ROM every 8 hourly

Risk for impaired skin integrity Impaired skin integrity

ALOPACIA

Type
 Alopecia totalis – no hair in the head
 Alopecia universalis – no hair in the body
 Alopecia acreta – auto immune disease. In which bald spot of any shapes.

Management :- Corticosteroid

TYPES OR WOUND DRAINAGE

Serous - Clear watery plasma

Purulant - Thick, yellow, green tan or brown
Sero sanguineous - Pale, Pink, watery mixture of clear and red fluid.
Sanguineous - Bright red indicate active bleeding.

Stages of Wound Healing

Stage I-------- Hemostasis and inflammatory phase

 Bleeding is stop and area become inflamed. Stage
II Proliferative phase
 Formation of new granulation tissue like cell, nerves and blood vessels Stage
III Maturation Phase
 Formation of Black Crest or Eschar that helps to healing.

TYPES OF WOUND HEALING.

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1. PRIMARY INTENTION- - wound is closed by suturing.

2. SECONDARY INTENTION- - wound is closed by a graft or a flap.
3. TERTIARY INTENTION - - wound is left open for a variable period.

PSORIASIS

It is a long lasting auto immune disease characterized by silverey patches of the skin.

Causes — long term stress, hormonal change, medication. Clinical

features.
 Red dry itchy wound
 Skin scaling lesion - silver colored in center red boundary
 Yellow discoloration, pitting, and thickening of the nail
 Psoriatic arthritis
 Koebner phenomenon — is the development of psoriatic lesion at the of injury. such as
scratched or sunburn area

Management
 Topical medication — coal tar, gluco-corticoid, anthralin
 Systemic medication — 1. Acitretin — slowing cell production 2. Cyclosporine and
methotrexate

SYSTEMIC LUPUS ERETHEMATUS (SLE)

Auto immune disease commonly affect heart, kidney, joint and connective tissue Chronic
progressive, systemic inflammatory disease that can cause major organs and systems to fail.

 Assessment — malar rash or butterfly rashes of the face. Discoid rashes

 Diagnosis — positive ANA test ( anti nuclear anti body )

Management- immune suppressants. plasmapheresis

SKIN CANCER

 BASAL CELL CARCINOMA — this is the most common types. It affect the basal cell of
epidermis and metastasis to other organs. It appear as waxy border with papule with red
centre crater. ( central depression )
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 SQUAMOUS CELL CARCINOMA— it affect the keratinocytes and can metastasis via
lymph nodes. It appear as a oozing, bleeding crusted lesion (a black center like )
 MELANOMA — new unusual growth or changes in the existing mole. The most serious
type of skin cancer. It affect the melanocyte and it is a highly fatal condition. Which
metastasis can occur to the brain, lung, bone or liver .

Assessment.
 Melanoma ABCDEFG ( these characters are used by the dermatologist to classify
melanoma )

A - Asymmetry
B - Border( irregular with edges )
C - Color
D - Diameter (more than 6 mm )
E - Evolving/ elevated
F - Firm to Touch
G - Growing

Management — chemotherapy and radiation therapy.

Prevention — avoid sun exposure from 11am to 3 pm. Apply sun screen lotion with ( SPF- sun
protection factor) 20 to 30 minute before going out

TINEA SKIN INFECTION

Fungal infection of the skin. Mainly affect feet between toes and groin.
Types
 TINEA PEDIS — of the foot between the toes. also known athletes foot
 TINEA UNGUINM — inflammation of toes or finger nails.
 TINEA CRURIS — inflammation to the groin.
 TINEA CORPORIS — inflammation other part of the body.
 TINEA CAPITUS-- fungal infection of scalp presented with loss of hair with
ulceration of scalp

Assessment — redness , itching, a rash that may form blister. More extreme cases oozing is present.

Management - contact isolation. Anti fungal agent — cotrimoxazole.

BEE STING BITE ( give emergency attention to the patient)

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Bee sting ----> histamine release---->bronco construction------ >dyspnoea/wheezing/rashes

 Rashes usually wheel like reaction

Management
 Quickly remove the sting and application of ice packs
 Sting is usually removed by scraping or brushing with the edge of he needle
 If the victim is allergic to venom of bee, there will be swelling of lips, tongue, and rashes
and puritis.
 To prevent anaphylactic shock administer subcutaneous adrenaline

LYME DISEASE

Causative organism - Borrelia burgodeferi

It is caused from a tick bite commonly seen in wooden or grassy area.

Signs / Symptoms

1. Asymptomatic
2. Symptoms appear days to months after bite.
3. A small pimple develops that progress into a ring shape rash ( bullseye rash)
(picture from net )
4. Flu like symptoms.
5. Neurological and cardiac manifestation
Management
 Gently remove the tick with tweezer and flush it in toilet.
 Administer antibiotics
 Avoid wooden and grassy area.
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PAEDIATRICS

GROWTH AND DEVELOPMENT

 Growth -> Increase the size of the body. It can measure in the form of KG, cm, lbs
 Development -> It is defined as progression towards maturity. Thus the terms are used
together to describe the physical mental, and emotional processes associated with the
growing up of children.

New Born Position

Term babies -> Supine position
Pre term babies -> Lateral/ Semi prone

ANTHROPOMETRIC MEASUREMENT OF THE NEW BORN

Birth weight -> 2.7 - 3.9kg Height -
> 45 - 55 cm
Chest circumference -> 31-33cm (it is less than 2 cm of head circumference). Head
circumference -> 33-35 cm

CHANGES OF ANTROPOMETRICAL MEASUREMENT

Birth weight doubled at 6 month and tripled at 1 year. (9kg) Height
increases by 3/4 inch per month
By 1 -2 years of age head circumference and chest circumference are equal after that chest
circumference is increase head circumference comparatively decreasing.

GROWTH PERIODS
New Born Birth — 28 days
Infant 1 month to 1 year
Toddler 1 year to 3 year
Pre-school 4 year to 6year School
age children 6 year to 12 year Adolescence
12 — 18 year

NEW BORN ASSESSMENT

The new born requires through skilled observation to ensure a satisfactory adjustment to
extras uterine life.

ASSESSMENT ORDER IN NEWBORN

Respiratory system, Cardiovascular system, Integumentary system Step I

INITIAL ASSESSMENT - APGAR SCORE

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SIGNS SCORE
0 1 2
RESPIRATION Apnea Slow, irregular or weak cry Good cry or lusty cry

HEART RATE Absent Less than 100 Over 100

MUSCLE TONE Flaccid Flexion of extremities Active body movement

REFLEX No response Grimace Cough or sneeze

IRRITABILITY
COLOR Blue or pale Body pink but extremities Complete pink
blue or acrocynosis

Scoring 7 - 10 normal
4 - 6 mild depression
0 3 severe depression

Note : - Evaluation of all fine categories are made on 1— 5 minutes after birth. Step II

Head to foot examination

1. Skin
 Normally bright red smooth with lanugos and white cheesy substances or vernix caseosa
 Abnormal findings
 Milia
 Mongolian spot
 Erythema toxicum
 Harlequin coloration and mottling
2. Head
 Anterior fontanel or Bregma— diamond in shape close at 18 month.
 Posterior fontanel or lamda-triangular in shape close at 1 1/2 - 3 month.
 Monitor any abnormality
A. Craniosynostosis / Brachycephaly
 It is a condition in which one or more of a fibrous sutures in an infant skull
permanently fuses their by changing the growth pattern of the skull.
B. Caput succedaneum
 It is the edema of the soft tissue over bone
C. Cephalohematoma
 It is swelling caused by bleeding in to an area between the bone and its periosteum.
3. Neck and facial feature
 Bell's Palsy- Temporary paralysis of one side of the face due to injury to the seventh cranial
nerve that is facial nerve.
 Erb's Palsy Upper brachial plexus injury can cause Erb's palsy. It is also called waiters
tip hand
 Klumpke Palsy --> Lower plexus injury can cause Klumpke palsy.
 Neck - Tonic neck reflex present. Abnormalities in neck — Torticollis or torticose neck
 106

syndrome. It may be due to injury to the sternocleidomastoid muscle

4. Chest
 Anterior, posterior and lateral diameter are same
 Abnormalities in chest
 Pigeon chests or pectus carinatum or convex chest
 Funnel chest or pectus exacavatum or concave chest

5. Umbilicus
 Should have 2 artery and 1 vein
6. Monitor any congenital abnormality in another part of the body
 Eg. Heart, Abdomen, Extremities, Genitalia.

ASSESSMENT OF REFLEXES IN NEW BORN

Landau Reflex
 Seen in horizontal suspension with the head, legs,& Spine extended
 If the head is flexed, hip knees & elbows also flex
 Appears at approximately 3 months, disappears at 12 - 24 months
Clinical Significance
 Absence of reflex occurs in hypotonia, hypertonia or mental abnormality.

1. Sucking and Rooting

 Touch the new born lip, cheek or corner of the mouth with a nipple. The new born turn
head towards the nipple, opens the mouth takes hold of the nipple and sucks. Disappear
after 3 — 4 month old. But persist up to 1 year.
 If sucking is absent, to give spoon feeding

2. Tonic Neck or Fencing Reflex

 As the new born faces the left side, the left arm and leg extend outward while the right
arm and leg flex.
 Disappear 3 — 4 month old

3. Palmar Grasp Reflex

 Light touch of the palm produces reflex flexion of the fingers.
 Disappear 3 — 4 month old.

4. Plantar Grasp Reflex

 Placing object or finger beneath the toes causes curling of toes around the object.
 Disappear 8 — 12 month old

5. Moro's Reflex / Startle Reflex

 Elicited by pulling the baby halfway to sitting position from supine and suddenly let the
head fall back.
 Consist of rapid abduction and extension of arms with the opening of bands, tensing of the
back muscles. Flexion of the leg and [Link] is used to defect hearing in infants.
 107

TEETH ERUPTION

6 - 8 month - lower incisors 8 - 12

month - Upper incisors
13 -19 month - Pre —molars and molars 16 - 23
month - Canine and cuspid
At 28 month - 20 temporary teeth. Oral

care started at - 1 year

Toilet training start at 2 — 3 year (bowel training at 2 year bladder training at 3

year)

Play Therapy

Infancy - Solitary play

Toddler - Parallel play or therapeutic play (child Never share the toys) Pre —
School - Co-operative play (They share the toys)
School age - Competitive play Adolescence -
Games and Athletic Activity

Site of IM injection in Children

Infant or ( less than 3 year ) - Vastus lateralis, Rectus femoralis.

Children ( After 3 year ) - Deltoid

BREAST FEEDING

 According to the WHO and AAP breast feeding is the normal way of providing young
infants with the nutrients they need for healthy growth and development.
 Breast feeding helps defiance against infections, prevent allergies and protect against a
number of chronic conditions.
 BFHI 1991

Physiology of Lactation

1. Mammogenesis - Enlargement of breast and protruding the nipple

Estrogen and progesterone is helping in this stage
2. Lactogenesis - Synthesis and secreting of milk in the breast alveolar cells. Pro!actin is
helping for this stage.
3. Galactokinases --Ejection of milk. Oxytocin is helping to stimulate the breast alveolar cells to
eject the milk.
4. Galactopoesis -*Maintenance of lactation. hormone responsible for this stage is
prolactin and adequate sucking.

Types of Breast milk

1. Colostrums' - First four days

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2. Transitional milk - 4th day to 15 day

3. Mature milk - 15th day onwards Drugs

to Improve milk production

 Metoclopramide -10mg TDS

 Sulpulride
 Intranasal Oxytocin — side effect nasalvasoconstruction

GENETIC DISORDERS

Types
1. Autosomal Dominant trait disorder
 Males and females are equally affected.
 Any one parent or both parentsare affected.
 In dominant trait disorder disease features externally visible in the body.
 If One parent is affected (getting 50% chance of inheritance)or Both parent should
affected(getting 100% chance of inheritance ).
 Eg:-Achondroplacia or congenital dwarfism, Adult PKD

2. Autosomal Recessive Trait disorder

 Males and females are equally affected.
 Parents are only the carriers(sign and symptoms of the disease is externally absent.
it is hidden in the body)
 If only one parent is the carrier getting 25% Chances for the disease affecting to the
child, 25% Chance for unaffected the disease. But 50% chance for again the child is
in carrier stage
 Eg :- Cystic fibrosis, beta thalassemia, PKU, Infantile PKD, sickle cell anemia.

3. X — linked Recessive trait disorders

 Males are affected. But females are the carrier
 Eg :- Hemophilia
 Female child is getting carrier stage from diseased father and the boy become
infected from carrier mother.

Example 1:- Father has no hemophilia. But mother is the carrier. The result is If Boy
child -› 50% the disease is affecting
If female child - 0% chance for the carrier stage

Example 2:- Father hemophilic positive. But mother not in carrier stage the result become If Boy
child — 0% chance for hemophilia.
If female child — 100% chance for carrier stage

NOTE- but rarely the disease is affecting to the female. ( if father is hemophilic and mother is the
carrier situation )
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RESPIRATORY DISORDER

CROUP SYNDROME

It is Laryngeotracheobronchitis
 Risk group 3 month —5 years
 Cause allergy/ Para influenza [Link], respiratory synctyl virus ( droplet
infection )

Clinical Features
 Mild fever
 Barking cough due to laryngeal edema
 Wheezing
 Diaphoresis
 Stridor

Types
 Typical - Symptoms more at night
 Atypical - Symptoms more at day

Management
 Maintain patent airway
 Administer humidified oxygen (02)
 Monitor stridor
 Have resuscitation equipment available at the bed side

Drugs
 Administer Nebulization with Adrenaline. It will help to decrease edema
 Administer corticosteroid to decrease inflammation
 Avoid cough syrup and cold medicine.

Nursing Diagnosis
 Ineffective airway clearance related to laryngeal edema

EPIGLOTITIS

Inflammation of the epiglottis Risk

group 2 years — 5 years

Cause
 Homophiles influenza type B
 Streptococcus pneumonia

Clinical Feature
 High fever
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 Absence of spontaneous cough

 Dysphonic
 Drooling of saliva from mouth
 Child maintain tripod position

Prevention
 Administer Hlb. vaccine —Benefit prevention of meningitis and epiglottitis

Management
 Priority for airway clearance
 Maintain lateral position and avoid supine position
 Provide cool mist oxygen therapy
 Provide NPO till gag reflex return.
 Avoid oral temperature monitoring, and throat swab culture because this can cause spasm
and stridor.
 When monitor oral temperature place the thermometer bulb at the lateral side of the
frenulum of the tongue.

Nursing Diagnosis
 Ineffective airway clearance.

CYSTIC FIBROSIS

It is an autosomal recessive trait genetic disorder

 It is a multisystem, genetic fatal disorder
 The disease is affecting to the exocrine glands
Eg. Pancreas, liver, salivary gland, mammary gland sweat gland etc
 There is thick respiratory secretion which lead to respiratory problems frequently.
 Thick pancreatic secretion that obstruct pancreatic duct lead to deficiency of
pancreatic enzyme.
 Administer pancreatic enzyme with Each Meal and Snacks
 Early C/M in a Newborn is delay in passing Meconium
 There is more loss of Sodium and Chloride through the Sweat
 Males are Sterile
 Infertility is present in Female
 It is an incurable disorder and respiratory failure is a common cause of death.
Clinical features

Diagnostic Test
Sweat Chloride Test - More than 60 meq/l choride in sweat is considered as + ve result for
Cystic Fibrosis
 111

1. Quantitative sweat chloride test (confirmatory test)

Minimum 50 — 75 gm sweat is needed
Apply sweat stimulating hormone in the client body (eg:-Pilocarpine iontophoresis )
 112

Result

Less than 40 meq/dl is normal 40 — 60 meq/dl

doubtful More than 60meg/dl positive.

2. Stool Examination'
3. Chest X-ray

Management
No definitive management only symptomatic treatment.
Respiratory Management

To give Not to give

Much more water 1. Steam inhalation

Chest physiotherapy 2. Cough suppressant
Nebulization with tobramycin
Bronchodilator
Flutter mucous clearance device
Vaccine- Pneumococci and influenza

G.I Management
 Administer Amylase + lipase (Pancreatic enzyme) along with each meal
 Balanced diet — high calorie, high protein and multivitamin
 Ensure adequate salt and water
 Administer dornasealfa medicine it will help to loosening the secretion.

TRANSIENT TACHYPNOEA OF THE NEW BORN (TTNB)

Temporary increased respiratory rate in new born.

 It results from incomplete re-absorption of fetal lung fluid in full —term new born.
 Usually disappears within 24 — 48 hours.
 Risk factor LSCS, preterm

Clinical feature
 Respiration more than 60 times/mt
 Expiratory grunting, crackles, cyanosis
 Chest x-ray shows interstitial edema and pleural effusion( normal after 48 hours)

Management
 02 administration
 Supportive care.
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RESPIRATORY DISTRESS SYNDROME

 Severe breathing difficulty especially in pre-term new born

 Cause :- deficiency of surfactant

Clinical feature
 Nasal flaring
 Tachypnea
 Expiratory grunting
 Decreased breath sound
 Sea saw respiration
 Cyanosis

Diagnostic Evaluation
 Assessment of Severity :- Modified Downe’s Scoring System
 Sliverman Anderson Score :-

 Score > 7 - Respiratory Failure

 Score 4 – 7 - Respiratory Distress

Result - Both score are widely used for the categorization of respiratory distress in
neonates.

Score of 4 or more for at least 2 hur during the first 8 hrs of life denotes clinical RD
and require assessment of the infant by a physician. An RD score of 6 or more is an indication
for ventilator.

Prevention
Administer BETAMETHASONE to the pregnant ladies those who are expecting preterm
labor for early maturity of fetal lung.

Nursing Diagnosis
Impaired gas exchange R/To deficiency of surfactant.
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TONSILITIS

Inflammation of tonsils

Cause
 Group A. Beta hemolytic streptococci
 Pneumococcal, H. influenza

Clinical Feature
 Redness, pain, swallowing difficulty
 Enlargement of lymph nodes
 Mouth breathing and unpleasant mouth odor.

Management
 Antibiotics (eg:- Azithromycin or erythromycin)
 Liquid diet
 Gargling only pre-operatively
 Surgery
 Tonsillectomy (During surgery provide Rose position) Post —

operative intervention

Position :-
Prone or lateral position Avoid
supine position
If breathing difficulty occur to give semi fowlers position
 Child having frequent swallowing it means bleeding from the surgical site.
 Can be seen old dried blood clot in vomits is normal.
 Post operatively give clear cold water or ice chips. It will help to decrease pain and
bleeding.
Post operatively avoid :-
 Milk or milk product
 Ice-cream
 Red color food
 Citrus fruit and carbonated beverages
 Gargling
 Discourage coughing
 Monitor complication

Eustachian tube obstruction

—> Ear pain
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CARDIOVASCULAR DISORDER

HEART MURMERS

Disease Character of Cardiac murmur

VSD Loud holosystolic harsh murmur
TOF Loud holosystolic harsh murmur
PDA A continuous washing machine like murmur
ASD SYSTOLIC EJECTION MURMER

TETROLOGY OF FALLOT

It include 4 defect VSD

1. VSD
2. Pulmonary Stenosis
3. Right ventricular hypertrophy
4. Over riding of aorta

Clinical features
 Hyper cyanotic Spell or Blue Spell (Cyanosis) , Tet Spell (dyspnea) Acute
episode of hypoxia and cyanosis is called Blue Spell
 Koilonychias or spoon shaped nails
 Tachycardia
 Poor growth
 Murmur — Harsh systolic ejection murmur at the upper left sternal border in third space
 Chest x-ray — Boot shaped heart
 Poor feeding, older children maintain squatting position.

Management
1. Priority for to treat hyper cyanotic spell
 Position 4 Knee chest or squatting (INCREASES AFTER LOAD)
 100% oxygen by face mask
 Administer morphine sulfate it will help to decrease the infundibular spasm
 Administer IVF

2. Administer propranolol for to treat tachycardia.

3. REST.
Surgical Management
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 Do the corrective surgery in the first year of life.

 Surgery comes under palliative surgery
 Name - Blalock Thomas Taussing Shunt Surgery

KAWASAKI DISEASE

It is also known as mucocutaneous lymph node syndrome

 It is an autoimmune disease in which the medium sized blood vessels throughout the body
become inflamed
 The disease mainly affecting the endothelium of coronary artery
 Mostly occur in under 5 year children
 Mainly it including blood vessels, skin, mucous membrane and lymph nodes

Clinical Features
 Remittent fever
 Red throat
 Swollen hands
 Bilateral conjunctivitis
 Enlargement of cervical lymph nodes
 Desquamation of skin or peeling of skin.
 Strawberry tongue.
 Thrombocytosis.

Management
 IV immune globulin.
 Salicylate or aspirin may be prescribed
 Do not administer aspirin or aspirin containing product if the child has exposed to viral
infection along with Kawasaki disease for the prevention of Reye's syndrome.
 Symptoms may last 2 months
 Monitor the sign and symptoms of aspirin toxicity Eg:-
Headache, tinnitus, Bruising
 Avoid administer live attenuated vaccine for 11 month after IV immune globulin
therapy Eg:- MMR, Varicella, etc
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NERVOUS SYSTEM

BOTULISM

It is a serious paralytic illness caused by a nerve toxin produced by the bacterium Clostridium
Botulinum.

Mode of Transmission
 Organism are found in the soil.
 Spread through food, air or wound.
 incubation period 12 hour — 72 hour

Pathology
The toxin destroys the Neurotransmitter Acetylcholine that leads to muscle weakness or
paralysis.

Assessment
 Abdominal cramps, diarrhea vomiting
 Ptosis, Blurred vision, Diplopia
 Difficulty swallowing/speech

Management
 Administer the Anti — toxin
 Botulism immunoglobulin
 Injection penicillin
 Induction of vomiting/enema

Special character of the disease

 It cannot spread person to person.
 Disease not affect the level of consciousness.
 Disease not associated with fever.

Prevention
 Vaccine but not widely using.
 Food heat at 100 deg. for 5 minute.

CEREBRAL PALSY

It is a general term for a group of permanent movement problem due to injury to

the extra pyramidal or pyramidal motor system.
 They cause physical disability mainly in the areas of body movement there may also be
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problems with sensation perception and communication ability.

 In this condition according to chronological age physical development present. But there is
no mental and cognitive development.

Causes
1. Prenatal Rubella infection
 Trauma, Genetic factor
2. Intranatal Precipitating delivery
 Fetal distress
3. Post natal cause Head trauma or infection

Clinical Features
 Altered muscle tone ( Stiff and rigid arms or legs)
 Irritability and crying
 Feeding difficulties
 Delayed developmental mile stones
 Persistence of primitive infantile reflexes (eg:- Moros, tonick neck)
 Client maintain Opisthotonos Posture
 Seizure

Management
 Antispasmodic — eg:- Baclofen, Side effect — Tremor
 Symptomatic treatment
 Physiotherapy —for to relieve muscle spasm
 Provide nursing care according to the mental development rather than the
chronological development
 Provide a safe environment
 Position the child upright after meal

SPINA BIFIDA

It is a neural tube defect. ie, failure to close the neural tube during embryonic period.

 Cause — Folic acid deficiency in pregnancy

 Daily intake -200 mcg
 In pregnancy — 400 mcg Types

1. Spina Bifida Occulta

 Posterior vertebral arch fail to close in the lumbosacral area.
 Neurological deficit are not usually present

2. Spina Bifida Cystica

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 Meningocele - Lumbosacral area one protrusion is present. It involves Meanings,

CSF, not involved the Neural Tube, the protrusion is covered with a sac
 Neurological deficit are absent

 Myelomeningocele
 Lumbosacral area one protrusion. The protrusion is covered by as thin membrane
prone to leakage or rupture. The protrusion involves Meninges, CSF, and Spinal
Cord.
 Neurological deficit are present

Clinical Manifestation
 Below the level of protrusion no sensation, no movement, no reflexes.
 Flaccid paralysis of the legs.
 Altered bladder and bowel function

Note: -Perform credes maneuver for to eliminate urine

 Hydrocephalus

Neural Tube Defect - Avoid Supine position , Prone position should given

Management
 Prone or lateral position.
 Avoid supine position.
 Surgical closure should be performed within 24 — 72 hours.
 Perform hydrocolloid dressing or wet dressing over the defect.
 Avoid adhesive dressing.
 Avoid getting the sac is rupture.
 Protect the client from infection and hypothermia.
 Provide ROM
 Increase fluid and fiber rich diet for older children
 Crede's maneuver

Surgical Management
 Laminectomy.

DOWN SYNDROME or TRISOMY -21

It is a chromosomal abnormality

Cause
 Addition of one extra chromosome in the 21st pair.
 Total 47 chromosomes in down syndrome patient.
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Risk Factor
 Women age more than 34.
 Hypothyroidism during pregnancy.

Clinical Features
 Grey spot on iris (BRUSHFIELD SPOT)
 Over curved helix
 Protruding or large tongue
 Single Transverse Palmer Creases ( SIMIAN LINE )
 Low set ears
 Brachycephaly
 Speech delay
 Separated eyebrows
 Poor eye contact during feeding
 High risk for leukemia due to immune dysfunction
 Leg sandle sign (Separated wide gap between big toe and 2")

Diagnostic Evaluation
 Triple test during pregnancy
 Estrogen
 HCG(HIGH)
 AFP
Management
 Positive re-enforcement
 Supportive management and safety and Correcting structural deformities

GENITO URINARY ABNORMALITY

CRYPTORCHIDISM

It is also known as undescended testis- failure to descend the testis in to the scrotal
cavity.

Cause
 Absence of testis
 Prematurity

Management
 Palpate the inguinal area followed by the abdominal area.
 Monitor during the first 12 month of life to determine whether spontaneous descend occur,

WILMS TUMOR

It is also known as Nephroblastoma or kidney tumor of childhood.

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 Peak incidence 3 years of age.

 Boys and left kidney are more affected
 Wilms tumor associated syndrome

W - Wilms tumor
A - Aniridia (Absence of iris) G
- Genito urinary defect
R - Mental retardation

Clinical Features
1. Initially painless, non pulsating abdominal mass. (But later pain present)
2. Increase abdominal girth
3. Anemia due to
 Rupture and hemorrhage
 Decreased erythropoietin
4. Hypertension due to Renin Angiotensin reaction
5. Urinary retention / hematuria
6. Symptoms like dyspnoea, chest pain occur it means metastasis occur in lungs

Diagnosis
1. CT
2. MR1
3. Biopsy is contraindicated

Management
Pre-operative intervention
 Monitor vitals
 Avoid abdominal palpation. because palpation can cause rupture of the tumor
 Measure abdominal girth daily
 Administer antihypertensive medication

Surgical Management
 Nephrectomy

EPISPADIASIS AND HYPOSPADIASIS

It means abnormal urethral opening.

 Epispadias means urethral orifice is located on the dorsal (Upper) surface of the penis.
 Hypospadias is means urethral orifice is located below the glans penis along the ventral
surface.

Management
 Surgery is done before the age of toilet training preferably between 16 —18 month of age.
 Circumcision is not perform on a newborn with epispadiasis and hypospadiasis
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because the fore skin may be used in surgical reconstruction of the defect.

CLEFT LIP AND CLEFT PALATE

Cleft Lip lt result from failure of the maxillary and median nasal process to fuse.

Cleft Palate It is a midline fissure of the palate that result from failure of the two sides to fuse.

Cause
 Genetic / Hereditary
 Rarely folic acid deficiency
 Anti-convulsant during pregnancy
 Maternal smoking
 Teratogenic factor

Management (surgery)

Cleft Lip Cheiloplasty — timing 3 — 6 month (LATERAL) Cleft

Palate Palatoplasty timing 6 -18 month (PRONE)

 But close as early as possible to facilitate speech development

Post operative intervention

 Maintain supine or lateral position and avoid prone position
 Use restraints. eg:- Elbow, mitten, jacket
 Provide lip protector or a metal appliance
 After palatoplasty avoid hard food items orally

Complication
 Otitis media
 Nasal speech
 Difficult feeding

Nursing Diagnosis (In parents)

 Disturbed body image
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INTUSSUCEPTION

Telescoping of one portion of the bowel into another portion. The condition results in obstruction
to the passage of intestinal contents.

Clinical Feature
 Colicky abdominal pain.
 Bilious vomiting (Color greenish yellow)
 If in a new born case delay in passing meconium.
 Tender distended abdomen, possibly with a sausage — shaped abdominal mass.
 Current jelly like stool containing blood and mucous.
 The proximal position of the intestine telescopes in to the distal portion.

Diagnostic Evaluation
 Barium enema

Management
 Antibiotics
 Insert NG tube — It should be open
 Administer hydrostatic reduction enema with barium or NS.
 Monitor for the passage of normal brown stool which indicate that the
intussusceptions has reduced itself.

ABDOMINAL WALL DEFECT

It includes :-

Omphalocele :-
Herniation of the abdominal contents through the umbilical ring. Theprotrusion is covered
by a translucent sac that may contain bowel or otherabdominal organ.

Gastroschisis :-
Occurs when the herniation of the intestine is lateral to the umbilical ring. No membrane
covers the exposed bowel.

Bladder exstrophy or Ectopia vesicle :-

lt is characterized by extrusion of the urinary bladder to the outside of the body through a
defect in the lower abdominal wall.

Management
 The affected area is covered with a saline gauze piece or perform hydrocolloid
dressing or wet dressing.
A layer of plastic wrap is placed over the gauze to provide additional protection against
moisture loss.
 Avoid getting the sac is rupture.
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 Protect the client from infection and hypothermia.

 Surgical management skin grafting.

Care over a grafted area

 The affected side should be elevate.
 Avoid excessive movement or pressure over the grafted area because wound adhesion should
not be present.
 If any discharge occur form the grafted area apply firm pressure over the graft.

Sign and symptoms of graft rejection.

 Pain
 Redness
 Itching
 Fever
 Purulent discharge

DIARRHOEA

Cause

Loose or watery stool.

 Acute diarrhea
 Rota virus
 Antibiotic therapy
 Parasite infection
 Chronic diarrhea
 Malabsorption syndrome
 IBS
 Immune deficiency. eg:- AIDS
Clinical Features

 Abdominal pain or cramping.

 Electrolyte imbalance. eg:- Hyponatremia
 Metabolic acidosis.
 Character of the stool depending upon the type of infection

 Vibrio cholera - Rice water stool

 Typhoid fever - Pea soup stool
 E-coli infection - Loose stool and low grade fever
 Desentry - Bloody stool
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Management
 Contact isolation
 Monitor skin integrity
 IV F and electrolyte
 Antibiotics

 Prevention - Administer rotavirus vaccine.

DEHYDRATION

It is a common fluid and electrolyte imbalance in infants and children.

 In infants the organs that conserve water are immature, placing then at risk for fluid volume
deficit.

Cause
 Decrease fluid intake
 Burn
 DKA
 Diarrhea
 Diaphoresis
 Diuretic therapy

Clinical Feature
 Weight loss more than 10% — Daily 1kg weight loss indicate 1 litre water loss present
in the body.
 Poor skin turgor (In children check — Abdomen, Adult — Forehead, fore arm)
 Depressed anterior fontanels (Only in less than 18 month babies)
 Absent or decreased tears during crying
 Kussmaul respiration (Deep and rapid)
 Behavior — lethargic
 Sunken eye
 Capillary refilling more than 4 seconds
 Oliguria

Sign and symptoms of dehydrated child become on a Rehydration stage

 Vitals stable
 Urine is clear
 Good skin integrity

Management
 Treat the exact cause
 IVF
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 Administer ORS

PHENYLKETONURIA

 PKU is an inborn error of metabolism involving impaired metabolism of

phenylalanine one of the Amino acid.
 PKU is a autosomal recessive trait genetic disorder that result in central nervous system
damage from toxic level of phenylalanine in the blood.
 Phenylalanine more than 2mg/dI is considered as PKU.
 Phenylalanine present in protein rich food.

Cause
 Deficiency of hepatic enzyme phenylalanine hydroxylase, which convert phenylalanine in to
Tyrosine which is again metabolized in to dopamine and melanin.

Clinical Features
 Digestive problem and vomiting
 Seizure
 If not treating early Mental Retardation MR
 Eczema
 Hypertonic
 Liver cirrhosis
 Fare skin
 Blue eye
 Hypo pigmentation of hair ( Red color ) due to absence of melanin.

Diagnostic Evaluation
 Metabolic Screening or Guthrie test or heal prick test
 The infant should have begun formula or breast milk feeding before specimen
collection.
 First sample should send 48 — 72 hours
 Repeat sample on the 7th day
 Most accurate sample on the 3rd day

Management
 Restrict phenylalanine intake or protein rich food. But not completely avoid because it is an
essential amino acid

THALASSEMIA

It is an autosomal recessive trait genetic disorder

 It is characterized by the reduced production of one of the globins chain in the
synthesis of hemoglobin
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 Increased level of iron in the blood is deposited in to the organs( hemosiderosis or

hemochromatosis ) that can cause organ damage

Clinical features
 Frontal bossing
 Maxillary prominence
 Hepato splenomegaly
 Severe Anemia

Diagnostic evaluation
1. Prenatal — amniocentesis
 Chronic villus sampling

2. CBC
 Peripheral smear- microcytic hypochromic cell
 HB electrophoresis is the confirmatory test

Management
 No specific treatment
 Monthly blood transfusion
 Administer the antidote of iron deferoxamine (working as chelating therapy. And
monitor nephrotoxicity)
 S/M — Splenectomy to relieve abdominal pressure

HEMOPHILIA (royal disease)

It is x-ray liked recessive trait genetic disorder

 It refers to a group of bleeding disorder result from a deficiency of clotting factor

Types
 Hemophilia A or classical hemophilia
It result from deficiency of clotting factor VIII
 Hemophilia B or Christmas disease
It result from deficiency of clotting factor IX

Clinical features
 Abnormal bleeding in response to trauma or surgery — especially after circumcision
 Epistaxis
 Hemarthrosis- bleeding into the joint
 Joint pain, swelling, tenderness, and limited range motion
 Risk of intra cranial hemorrhage
 PT NORMAL PTT HIGH

Management
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 Monitor for bleeding and maintain bleeding precautions

 Administer - Desmopressin Acetate
 Administer - Cryoprecipitate
 Teach the parent regarding the sign and symptoms of internal bleeding
 If bleeding occur apply manual pressure 15 min

Nursing Diagnosis - Risk for bleeding

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OBG

ANATOMY — UTERUS

Parts —

 Fundus ( Upper portion )

 Body ( Middle portion)
 Cervix 9 ( Lower aspect)\

Weight - 50-60 Gram

SHAPE - Pear shape Weight in pregnancy
- 1 kg

FERTILIZATION
It means fusion of sperm ad ovum occurs at ampulla of the fallopian tube.

IMPLANTATION
The zygote is propelled towards the uterus. Fertilization to implantation timing is 7- 10 days
Placenta

 Shape discoid shape.

 Weight 500GM or 1/6 of the fetus
 Placental layer — amnion (fetal surface) chorion (maternal surface) .in between
placental barrier is present.
 Substances will cross to the placental barrier-protein, drugs, amino acids, alcohol, virus,
fatty acids glucose, electrolyte, IgG hormones, and antibodies.
 Substances do not cross to the placental barrier- fat, insulin, bacteria, parathyroid
hormone, calcitonin, IgM.
 Complete development of the placenta occurs at 12 weeks.

UMBILICAL CORD
It contains two artery and one vein. artery carry deoxygenated blood and vein carries
oxygenated blood.

PELVIS
 Gynecoid pelvis-normal female pelvis. most favorable for successful labor and birth.
 Anthropoid pelvis-oval shape, adequate outlet with a narrow pubic arch.
 Android pelvis- heart shaped resembles male pelvis.
 Platypelloid- flat with an oval inlet. wide transfers diameter but short anterior
posterior diameter making labor and birth difficulty.

AMNIOTIC FLUID
 Normal color- early pregnancy colorless. At term pale straw color
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 Normal amount at term- 800-1200m1 (average 1000mI)- more than 2 litter poly
hydramnios less than 200 ml oligohydramnios.
 Abnormal color
 green meconium stain.

 golden —RH incompatibility

 Greenish yellow or saffron-post maturity.
 dark color-accidental hemorrhage.
 Dark brown or tobacco juice color-IUD.

FETAL DEVELOPMENT
 2-3 week. Blood circulation begins and heart is tubular and begins to beat.
 3-5 weeks. Double heart chambers are visible.
 8 weeks. Every organ system is present.
 12 weeks. Kidney begins to form urine. And sex is visually recognizing
 16 weeks. Fetus is 100 grams. lanugo begins to develop. fetal ossification occurs.
 24 weeks. Fetus has ability to hear.
 28 weeks. Fetus is 1.1Kg. brain is developing rapidly and if born neonate can breathe at this
time.
 32 weeks. bones fully developed
 6 weeks. Skin is pink and less wrinkled.
 40 weeks. Weight.3.2KG length 40 CM .skin pink and smooth. testis is in the
scrotum, and labia majora are well developed.

NAGELES RULE-
 This rule is using for estimating EDD.
 Use of Nageles rule requires that the women have a regular 28th day menstrual cycle.
 First day of last menstruation + 7 days — 3month + 1 year = EDD

Eg. 2017 Feb 26 :- 5 March

GTPAL SCORE
 G - GRAVIDITY - it means number of pregnancy.
 T - Number of Term Birth ( delivery occur after 37 weeks completion
considered as term delivery. ie delivery occur at 38,39,40 weeks )
 P - Number of Preterm deliveries. ( deliver occur at after 20 weeks
completion and 37 or before 37 weeks considered as Preterm delivery).
 A - ABORTION ( deliver occur before 20 weeks )
 L - Number of current Living Children.

Eg. Collecting data during an admission assessment of client is Pregnant with twins, client has a
healthy 6 yr old child, who was delivered at 38 wks and tells the nurse that she does not have a H/O
any Abortion using GTPAL what should the nurse document the clients chart
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Ans :- G – 2 , T - 1 , P – 0 , A – 0 , L - 1

POST TERM :- Delivery after 42 Wks of gestation C/M :-

Dry Cracked Skin

Absence of Lanuge
FUNDAL HEIGHT CALCULATION:

Between 18 – 30 Wks of Gestation :- The Fundal height is in CM + 2 CM from the

Gestational Wk ( + / -- 2 Cm )

12th Wk - At the level of Symphsis Pubis

16th Wk - Midway between Symphsis Pubis and Umblicus 20th
Wk - At the level of Umblicus
36th Wk - Xyphoid Process / Xipisternum

Eg. Gestational Week 24 - Fundal height is 22 - 26 Cm

BEST POSITION IN PREGNANCY - Left lateral (especially in second and third trimester) for to
prevent vena cava syndrome

FHR

 Early pregnancy 160-170 beats per minute.

 At term 120-160 beats per minute.

ANTE NATAL DIAGNOSTIC TESTS

 ULTRA SONO GRAPHY

 TRIPLE TEST DURING PREGNANCY

It includes three tests :-
 1 - hcg
 2 - estriol or estrogen
 3 - alfa feto protein sampling-
.
 CHORIONIC VILLUS SAMPING
 AMNIOCENTESIS
 ANOTHER TEST
 Fern test
 Non stress test
 Contraction stress test
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 Hemoglobin and HCT

 GTT

NORMAL LABOR

 EUTOCIA — NORMAL LABOR

 DYSTOCIA — DIFFICULT LABOR

True Labor Pain character:

 Intensity and duration of pain is increased.

 Uterine contraction associated with cervical dilation is present.
 True labor pain associated with show. ( Expulsion of cervical mucous plug mixed
with blood )
 True labour pain is associated with Hardening of uterus.
 Formation of bag of for-waters. ( Bag of Membrance )
 Pain is not relieved by enema or sedatives. False

Labour Pain

 Dull in nature
 Not associated with hardening of utrus
 Usually relived by enema / sedatives

STAGES OF LABOR

 FIRST STAGE - It starts from the onset of true labor pain and ends with full dilatation
of cervix. average duration in primi 8-12 hours and in multi 4-6 hours

 SECOND STAGE - It starts from the full dilatation of cervix and ends with expulsion of
the fetus from the birth canal. Timing 2 hours in primi and 30 minutes in multi.

 THIRD STAGE - It begins after expulsion of the fetus and ends with expulsion of he
placenta. And membranes. is about 15 minutes in both primi and multi.

Sign and symptoms of third stage of labor :-- gush of vaginal bleeding, uterus feels hard to
touch, lengthening of abdominal cord.

 FOURTH STAGE — it is the stage of observation for at least one hour after
expulsion of the placenta.

PHASES IN FIRST STAGE OF LABOR

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STAGE CERVICAL INTERVAL DURATION Monitor FHR

DIALATION

Latent phase 1-4 cm 15-30 minutes. 15-30 seconds Every 60-90 minutes

Active phase 4-7 cm 3-5 minutes 30-60 seconds Every 30 minutes

Transitional 8-10 cm 2-3 minutes 45-90 seconds Every 5 - 15 minutes

phase

NOTE: Early deceleration of FHR, it is due to Head Compression Late Deceleration of FHR indicate
Fetal Distress.
Management give left lateral position and administer Oxygen.

MECHANISM OF LABOR

 Engagement/lightening/dropping
 Descent
 Flexion of head
 Internal rotation of head
 Crowning
 Extension
 Restitution
 External rotation of the shoulder and internal ratation of the body
 Expulsion

POST NATAL PERIOD OR PUPERIAL PERIOD

 It means first 6 weeks after delivery.

 Changes in post natal period
 Involution of uterus- daily 1 CM fundal height is decreasing.
 LOCH IA - it is the vaginal discharge for the first 2 weeks. Initially alkaline in nature
later it is acidic in nature. (normally female vaginal PH is acidic because presence of
doderlian bacillus bacteria is producing lactic acid.)

TYPES OF LOCHIA

 LOCHIA RUBRA- red in color. duration 1-4 days. It consist of blood , fetal
membrane, deciduas, vernix caseosa, lanugo and meconium.
 LOCHIA SEROSA- color yellow ,pink, or pale brown. Duration 5-9 days. It consist less
RBC, more leukocytes, wound exudates, mucous from cervix and micro organism.
 LOCHIA ALBA- pale white in color. Duration 10-15 days. It contains plenty of
deciduas cells leukocytes, mucous, fatty and granular epithelial cells.
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 After LCS Also lochia present. average amount 250 ml

ANTE PARTUM HEMORRAHAGE.

1. PLACENTA PREVIA

 Placenta is situated in to the lower uterine segment

 Cause is unknown

Clinical feature

 Sudden onset of painless, bright red vaginal bleeding occurs in the last half of
pregnancy.
 Uterus is soft, relaxed and non-tender.
 Fundal height is more than the period of amenorrhea.
 Most complicated type of placenta previa is type II posterior

MANAGEMENT.

 Monitor maternal vitals and FHR

 Avoid vaginal examinations
 Provide Trendelenburg position to the mother
 Strict Bed rest
 Monitor the amount of bleeding and fetal distress. administer IV fluid and blood
products.

2. ABRUPTIO PLACENTA

Premature separation of the placenta from the uterine wall after the 20 week of gestation and
before the fetus is delivered

Causes
 Trauma
 Short cord (normal length 45-50 CM)
 Sick placenta
 Cocaine abuse

Clinical features
 Dark red painful vaginal bleeding.
 Severe abdominal pain
 Uterine rigidity
 Sign of fetal distress
 Sign of maternal shock if bleeding is excess.
 DIC
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Management
 Monitor maternal vitals and FHR.
 Administer oxygen, IVF, and blood products.
 Place the client in a extremely Trendelenburg / Side line position.
 Emergency LSCS
 It is a medical emergency

3. PREGNANCY INDUCED HYPERTENSION

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Types :-

1. Pre eclampsia
2. Eclampsia

1. Pre edclampsia

Development of HTN to the extend of 140/90 mm of hg or more with Proteinuria

after 20th Wk of gestation in a previously normotensive and non- proteinuria women.

C/M
 HTN
 Proteinuria
 Edema

Complication
1. Eclampsia
2. HELLP Syndrome

HELLP syndrome

H - Hemolysis ( Distruction of RBC ) EL - Elevated Liver Enzyme

LP - Low Platelet Count

Diet

Adequate amount of daily protein about 100 gm. Increase diatary CHO Usually salt intake is permitted.
But no added extra salt ( Avoid table Salt ) No need to restrict fluid intake
Total calorie approximately 1600 keal for a day

Treatment
1. Nifidipine
2. MgSo4 ( Magnesium Sulphate )
Theraputic level of MgSo4 is 4.8 - 9.6 mg/dl ( 1.5 - 2.5 meq/l )
If the therapeutic level exceeds more than this range lead to toxicity. It is excreted though
kidney. Patient with low urine output is at an increased risk for MgSo4 toxicity.
( Urine out put is 30 ml / hr is the normal expecting output )

S/S of MgSo4 Toxicity

 Depressed deep tendon reflexes
 Absence of knee jerk reflexes
 CNS depression including resp.
 Hypotension , Sweating
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 Hypersomlocence :- excessive sleeping

If these symptoms are present while administering MgSo4. Stop the infusion and
administer the antidote of MgSo4 which is Calcium Gluconate

3. ECLAMPSIA

Pree eclampsia complication with Seizure is Eclampsia.

Drug - MgSo4 ( Magnesium Sulphate ) Nsg

Mgmt - All the intervention of Seizure Provide
calling bell

ABORTION

A pregnancy that end before 20 weeks of gestation spontaneously or electively.

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Types.

 Spontaneous
 Induced
 Threatened - Spotting and cramping without cervical change occur.
 Inevitable - Spotting and cramping occur and cervix begins to dilate and efface
 Incomplete
 Complete
 Missed - Product of conception are retained in utero after fetal death.
 Habitual - Spontaneous abortion occur in three or more successive pregnancies

Clinical feature
 Spontaneous vaginal bleeding.
 Uterine cramping or contractions
 Hemorrhage and shock can result if bleeding is excessive.
Management
 Maintain bed rest and monitor vitals
 Count perineal pads to evaluate blood loss
 Prepare the client for dilation and curettage as prescribed for incomplete abortion
 Rh ( D ) Immune globulin ( RhoGAM ) is prescribed for an Rh-negative woman (within
72 hour)

GESTATIONAL DIABETES MELLITUS

Gestational diabetes occurs in pregnancy during in second or third trimester in client not
previously diagnosed as diabetic and occurs when the pancreas cannot respond to the demand
for more insulin.

 It should be screened for gestational diabetes between 24 to 28weeks of pregnancy.

Cause -- placenta producing hormone HPL (human placenta lactogen - it working as a growth
hormone ). HPL hormone resist the power of maternal insulin. So, hyperglycemia will develop.

Risk factors -- Age after 35 years, obesity, family history

Clinical features --- Polydipsia, weight loss, polyuria, glycosuria, polyhydramnios, recurrent UTI

 Effect to the fetus-baby is MACRO BABY (because glucose molecules shift to the fetus)
 Hypoglycemia for few days
 Lethargic/dull nature
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 Poor cry, sucking reflex

Diagnostic test —GTT

Management
 Dietary modification- low carbohydrate diet
 Exercise
 Inj. Insulin -- Regular Insulin
 Asses for sign of maternal complication such as pre - eclampsia.
 Carefully regulate insulin and provide glucose IV as prescribed because labor depletes
glycogen that cause hypoglycemia
 Regulate insulin needs as prescribed after the first day, according to blood glucose testing.

HYPER EMISIS GRAVIDARAUM

Excessive Vomiting during pregnancy

Complication - Metabolic Alkalosis

Pregnancy is confirmed by Ultra Sound ( USG)

Acetone Smell In Breath

DRUGS

OXYTOCIN

Route - IM / IV , Intra nasal Use

Antinatal Period - Abortion
Late Pregnancy - To induce Labour
Postnatal - To treating PPH

 Intra Nasal administration of Oxytocin help to induce milk production during

Postnatal period.
 Should continue Oxytocin after the delivery of baby & placenta to treat PPH
 If FHR is < 100/mt and duration of contraction is more than should stop Oxytocin

METHERGINE/ERGO METRINE

Directly stimulate uterine muscle and helps in arresting bleeding)

Route :- IM / IV
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Active management of third stage of labor To stop

atonic uterine bleeding

IMPORTANT ANTIDOTE

Universal Antodote- Activated Charcoal

Morphin - Nallaxone
Digoxin - Digibind
Straptokinase - Aminocarpolic Acid ( AMICAR ) MgSo4
- Calcium Gluconate
Heparin - Protamin Sulphate
Warfarin - Vitamin K
Acetaminophen - N acetyl cystine ( Mucomist )
Diazepam - Flumazenil
Tensilon - Atropin Sulphate
Neostigmin - Atropin Sulphate
Organo Phosphrous Poisoning - Atropin Sulphate Insulin
- Dextrose 50%
Cyanide - Sodium Thio Sulphate
Iron - Deferoxamine
Pencillin - Adrenaline
Magnesiumsulphate - Calciumgluconate
OPOIDS - NALAXONE

NEWBIRN CARE

Nursing Diagnosis -
1. Ineffective airway clearance
2. Impaired thermoregulation

APGAR SCORING

Score
0 1 2

Heart Rate Absent < 100 b/mt > 100 b/mt

Breath Absent Irregular / weak

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Strong cry
Reflexes Absent Grimace ,weak cry to
Stimulation
Cries, Pulls away
from stimulation
Muscle Tone Absent Limited movement of
extremity
Movement of all
Extremity - blue
extremity
Colour Pale / Blue
Body - Pink
Pink completely

Score 8 - 10 - Normal
4 - 7 - Mild depression, Gently stimulate and administer O2
0 - 3 - Severe depression need resuscitation

INFANT SKILLS

2 – 3 Months - Social Smile , Hold head in Mid Line 4 – 5

Months - Grasp Objects
6 – 7 Months - Sit with support 8 – 9
Months - Sit Unsupported 10 – 11
Months - Stand alone
12 – 13 Months - Can drink from a Cup 14 – 15
Months - Walks alone
24 Month - Pour water to a cup

3 Years - Stand on a one foot

Piagets Theory of Cognitive Development

Birth to 2 year - Sensory Motor

2 – 7 Years - Pre operational ( Ego ) 7 – 11
Years - Concrete operational 11 –
Adult - Formal operational

Erikson’s Theory of Psychosocial Development

0 – 1 ½ years - Trust Vs Mistrust

1 ½ - 3 ( Todler ) - Autonomic Vs Shame 3 – 5
( Pre school ) - Initiative Vs Guilt
5 – 12 ( School age ) - Industry Vs Inferiority
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PLAY

Infancy - Solitary Play ( Self Play )

Toddler - Parallel Play
( Play with his own Toys, Don’t share with anyone )
Pree school - Cooperative play ( Share with Toys ) School
Age - Competitive play

Teeth Eruption

6 – 8 Month - Lower incissors 8 – 12

Month - Upper incissors
12 – 18 Month - Canines ( cuspid ) / Pre molars, molars 2 ½
Years - 20 teeth

Start oral care at 1st year of life Start

toilet training at 3 years

SPINAL DEFORMITY

KHYPHOSIS :- Convex Curvature of spine ( Back word Curvature ) eg. Parkinsons , Osteoporosis
LORDOSIS :- In ward curvature / forward curvature of spine. Common during Pregnancy and
Obesity.
SCOLIOSIS :- Lateral curvature of spine ( S – Shape )

MASTECTOMY

 Should elevated the affected extremity to treat lymph edema

 Should not take BP, IV, Injections in affected arm
 Should not use razors for shaving under the hair in hand ( Axilla ). But use drimmers
 Avoid wait bearing by affected arm MASLOW’S

HIERARKY OF NEEDS

5. Self Actualization

4. Self Esteem
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3. Love / Belonging

2. Safety

1. Physiological

Physiological - Respiration , Food, Sleep, Water etc. Safety

Love / Belonging
Self Esteem ( Self Confidence )

 Nursing diagnosis - Body Image Disturbances ( Mastectomy , Colostomy )

 Goal of the Body Image Disturbance - Make Accept

Self Actualization - Morality creatively problem solving