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Adult Nursing Notes

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Adult
Often times patients on traction are viewed as stable clients with expected outcomes. When getting pt out of bed have open end of chair facing the foot of the bed. Buck’s traction = knee immobility Russell traction = femur or lower leg Dunlap traction = skeletal or skin Bryant’s traction = children <3y, <3 lbs with femur fx. Nephrotic Syndrome leads to proteinuria Glomerulonephritis leads to hematuria.

Respiratory
Rales = !"# Rhonchi = pneumonia Wheezes = $sthma Hemoptysis = %ung cancer or &' Pleural Pain =(ossible () Safe suction ran e* +,,-+., mm"g "The good lung down" &ympanic membrane* pearl grey = normal. /% 0asal !annula is the most you can give, anything above that really doesn1t improve oxygenation. !" N# = .23 #i,. $ " = .43 % " & 3.3 '" & 223 #i,. Herpes simple( incubation = .-+. days.

Neuro)Brain
*emporal lo+e - hearing ,rontal - personality changes -ccipital - visual Brain stem - bladder5bowel Detached retina = floater or sensation of a curtain or veil over the visual field .acular degeneration = middle of vision #ataracts/ loss of red reflex. Do0n1s syndrome/ white flecks in the iris 2ntraocular Pressure 32-P4 = "igher in the morning6 have glaucoma patients schedule appts. early in the morning. .5ni6re’s disease = tinnitus, vertigo, 057, sensorineural hearing loss on the involved side.

Posturin / Decordicate* #lexion 8cord problems9 Decera+ate* )xtention : rotation 8brainstem problems, = 'ad9 Decorticate posturing* flexion of the upper extremities and the extension of the lower extremities. $lso plantar flexion of the feet. Decerebrate posturing: extension of the upper extremities with internal rotation of upper arms and wrists. &he lower extremities extend with some internal rotation noted at knees and feet. deceberate 8brainstem problem9- hands like an ;e;, decorticate 8cord problem9- hands pulled in toward the cord Neuroleptic mali nant syndrome 3N.S4 is like S7./ <ou get hot 8hyperpyrexia9 =tiff 8increased muscle tone9 =weaty 8diaphoresis9 '(, pulse, and respirations go up : <ou start to drool A8*-N-.2# D9SR:,":;2A-triggered by sustained stimuli at &/ or below.

7asodialation above in>ury,8flushed face, increased bp etc9 7asoconstriction below in>ury8pale, cool, no sweating. - =:=* pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension - (lace client in sittin position 3ele<ate H-B4 first +efore any other implementation= *ypes of partial seizures Simple partial* symptoms confined to one hemisphere #omple( partial/ begins in one focal area6 spreads to both hemispheres. *ypes of eneralized seizures • A+scense 3petit mal4/ loss of responsiveness, but continued ability to maintain posture control and not fall. • .yoclonic* movement disorder 8not a sei?ure9 • #lo+ic* opposing muscles contract and relax alternately in rhythmic pattern. • *onic* muscles are maintained in continuous contracted state 8rigid posture9 • *onic>clonic/ 8grand mal, ma>or motor96 violent total body sei?ure • Atonic* drop and fall attack • Akinetic* suddenr brief loss of muscle tone or posture.

-h -h -h *o *ouch And ,eel A Girls ?a ina And Hea<en #N 2* Olfactory @ smell test #N 22/ Optic @ sight #N 222/ Ocularmotor @ =ix-point ga?e, ()AA%$ #N 2?/ &rochlear @ =ix (oint Ba?e, ()A%%$ #N ?/ &rigeminal @ Castication #N ?2/ $bducens @ =ix (oint Ba?e, ()AA%$ #N ?22* #acial @ =mile5=crunch &est. #N ?222/ $coustic @ "earing &ests #N 2;/ Blossalpharangeal @ =wallowing5Bag =ensation #N ;/ 7agus @ Dvula Aise #N ;2/ =pinal $ccessory @ 0eck and shoulder shrug #N ;22/ "ypoglossal @ &ongue movement 8%ight &ight Einamite9

Alzheimers Sta es Sta e 2/ %asts +-3 years. Cemory loss, poor >udgment5problem solving5adaptation Sta e 22/ %asts .-+, years. %oss of memory, communication difficulties, psychosis.

Sta e 222/ %oss of all mental abilities and ability to care for self. .uscle Biopsy confirms muscular dystrophy. *actile fremitus* normal = not palpable below 3-2th intercostal. :chocardio ram = used to assess heart valves.

:r+s point = 3rd % F!=6 pulmonic and aortic murmurs are best heard there Hemophilia = is x-linked. Cother passes disease to son. S2ADH = concentrated urine, dilute plasma, common cause = lung !$

#ardiac
Ri ht>sided heart failure* edema, ascites, and hepatomegaly. ?entricular allop* is the earliest sign of heart failure ;O; is the universal donor 8remember @[email protected] in donor9 &he "eart secretes $0( 8atrial natriuretic peptide9 a cardiac hormone causing sodium excretion. +. $ctions of $0( oppose those of the renin-angiotensin-aldosterone system. .. $0( decreases blood pressure and reduces intravascular blood volume. 3. $trial stretching increases the amount of $0( released. Parkland ,ormula 2cc x Gg x 3 '=$ 'urned = &otal 7olume 0ecessary +st 4hrs @ H total volume .nd 4hrs @ I total volume 3rd 4 hrs @ I total volumes 2nfecti<e :ndocarditis/ OslerJs nodes and splinter hemorrhages. S!> Systole> heard best at ape(- %D' - tricuspid and mitral valves close =.- Eiastole- heard best at base8think top9- ED' - aortic and pulmonic valves close

$usculate S% and SA extra heart sounds by turning pt on the left side and using the bell of stethoscope to listen at apex. $ mitral murmur can best be heard at the ape( 8bottom9 of the heart Bruit = use the bell side of the stethoscope S! = !losing of mitral5tricuspid 8$79 valves heard at the beginning of systole and heard best in the mitral region S$ & !losing of aortic5pulmonic 8semi lunar9 valves heard best over aortic region at the end of systole S% & 7entricular gallop @ start of diastole, ventricles filing SA & $trial gallop @ end of diastole Dse D2S*RA#*2-N method s with toddlers and manic patients only. -n the :#G or :BG/ ( wave = atrial depolari?ation (-A interval = represents atrial,$7 node, : (urkin>e depolari?ation K wave = septal depolari?ation A wave = apical depolari?ation = wave = depolari?ation of lateral walls KA= complex = spread of excitation through the muscle of the venticles & wave = venticular repolari?ation .enieres Disease = low sodium diet

G2)G8
<ogurt, buttermilk and beets often reduce the smell of colostomies Ascites mana ement @ $lbumin, pulls fluid back. Eiuretic = removes fluid *o(ic Amonia le<els = asterixis 8flapping hands9 .ost o+structions = small bowel. Cost lar e +o0el o+structions = cancer 8lcerati<e colitis/ 3-3, stools per day WF&" blood and mucus. (ain in %%K* relieved by defecation. #rohns disease* 0O obvious blood or mucus in stool. (ain* Aight lower Luadrant pain that is

steady or cramping...or pain could be in periumbilical area, tenderness and mass in the A%K. Di<erticulitis/ no corn or popcorn. "aennec’s #irrhosis/ Aelated to alcoholism. Gastric "a<a e/ preformed before adiminsitration of activated charcol. A liver that is tender on palpation is suggestive of viral hepatitis. Acute lomerulonephritis - follows streptococcal infection :dema > mild, usually around the eyes Blood Pressure - elevated 8rine - dark, tea colored 8hematuria9, slight5mod proteinuria Blood - normal serum protein, M $=O titer Nephrotic Syndrome - usually idiopathic :dema - severe, generali?ed 8rine - dark, frothy yellow, massive proteinuria Blood - decreased serum protein, - $=O titer

:ndocrine
A+d 8ltrasound = Ex for cholecystitis Beta cells = produce insulin Pancreatitis = increased $mylase and lipase and glucose levels, decreased serum !a levels .yasthenia Gra<is* worsens with exercise and improves with rest. .yasthenia #risis* a positive reaction to &ensilon--will improve symptoms #hronic alcohol use is the most common cause of hypoCg, which may result in cardiac arrest #holiner ic #risis/ caused by excessive medication-stop med. Biving &ensilon will make it worse Boch)Bock Pouch* is continent, doesnJt nec need a drainage bag, use absorbent dressing on it. Erain with catheter K 3-2. Pa et1s disease is characteri?ed by excessive bone destruction, skeletal deformities, and cortical thickening. Rheumatoid arthritis* (ain and stiffness is on arising, lasting less than an hour...can also occur after long periods of inactivity. Noints red, hot swollen, boggy, and decreased AOC. -steoarthritis/ (ain and stiffness occurs during activity. Noints may appear swollen, cool, and bony hard.

#rohns = small intestine 8lcerati<e colitis = large intestine Blurred ?ision is indiciative of Hyperglycemia Dou+le <ision is indicative of Hypoglycemia Aisk factors for "e ionnaires disease advanced age, immunosuppression, end stage renal disease, and diabetes &ransmission* !ontaminated showers Rheumatoid arthritis/ Swan-neck deformity and ulnar deviation. (ain and stiffness is on arising, lasting less than an hour...can also occur after long periods of inactivity. Noints red, hot swollen, boggy, and decreased AOC. -steoarthritis* Heberden’s and ouchnard’s nodes (ain and stiffness occurs during activity. Noints may appear swollen, cool, and bony hard. Pheochromocytoma* hypersecretion of epi5norepi - persistent "&0 - increased "A - hyperglycemia - diaphoresis - tremor - pounding "$ !ursing "onsiderations* avoid stress, freLuent bating and rest breaks, avoid cold and stimulating foods, surgery to remove tumor

Addisons <s #ushin s Addisons = up down, down down down #ushin s= down up up up up GM5!aMO '( O 7olume O 0aM O Blucose O )verything else wouldnt be hard to remmenber* moon face, hirsutism, buffalo hump, obesity &hyroid storm is "O& 8hyperthermia9 Cyxedema coma is !O%E 8hypothermia9

Gra<es disease/ &heir hyper and run their self in the grave #onn1s disease- retention of sodium and water and over secretion of aldosterone PARA*H9R-2D PR-B":.S hyperparathyroidism= hypercalcemia=hypophosphatemia hypoparathyroidism=hypocalcemia=hyperphosphatemia

#ancer
9o urt has live cultures- dont give to immunosuppressed pt 2nternal radium implant = low residue diet *N. classification/ *=primary growth.+-2 with increasing si?e6 &+s indicates carcinoma in situ N=lymph node involvment.,-2 indicates progressively advancing nodal disease .=metastasis.+ indicates presence of metastasis Sta es C>2?* all cancers divided into stages incorporating si?e, nodal involvement, and spread Breast #ancer Risk ,actors/ • P , years of age • #FA=& child born after 3, years of age • Brandmother, Cother, =ister has it • (ersonal history of breast cancer Dia+etic Betoacidosis = donJt give GM until the patient has been hydrated and urine output is adeLuate. .enorrha ia @ "ypothyroidism Dollin er>:llison syndrome = Aeport promptly to his5her healthcare provider any finding of peptic ulcer 8night time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite9 We+er1s hearin test

Fn the Weber tuning fork test, the nurse places the vibrating tuning fork in the middle of the clientJs head, at the midline of the forehead, or above the upper lip over the teeth. @ - 0ormally, the sound is heard eLually in both ears by bone conduction. Ff the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. - Ff the client has a conductive hearing loss in one ear, the sound is heard in that ear.

#ommunity Health
Disaster Plan/ $ way to remember who to remove first is by using $'! $ - $mbulatory ' - 'ed Aidden ! - !ritical !are E ri hts of dele ation Aight task Aight circumstance Aight communication Aight person Aight feedback Bio*errorism "e<el 2 - local emergency "e<el 22 - regional aid from surrounding counties "e<el 222 - local and regional assets are overwhelmed state or federal assistance is needed

Percutaneous 8m+ilical Blood samplin / ike amniocentesis but cord punctured. &ests for chromosomal anomalies, feta karyotyping, and blood disorders SPA#2NG ,irst spacin - normal distribution of fluid in the intracellular fluid. Second spacin - an abnormal accumulation of interstitial fluid 8edema9. *hird spacin - Occurs when fluid accumulates in a portion of the body from which it is not easily exchanged with the rest of the )!# - is any fluid not where it is supposed to be 8ascites9.

.ental Health

Bohl+er ’s *heory of .oral De<elopment/ Sta e C = )gocentric >udgement 8birth @ . years9, no >udgement of right5wrong Sta e ! = punishment-obedience 8. - 3 years9, view the world in a selfish way. Sta e $ = instrumental relativist 82 @ Q years9, conscience emerges Sta e % = good boy-nice girl 8Q @ +, years9, maintainance of friendships Sta e A = law and order 8+, @ +. years9, following rules. Sta e E = =ocial contracts 8adolescents9, gives and takes and expects nothing in return. Sta e ' = Dniversal ethical principles 8adult9, control of conduct is internal. .unchausen Syndrome is a psychiatric disorder that causes an individual to self-inflict in>ury or illness or to fabricate symptoms of physical or mental illness, in order to receive medical care or hospitali?ation. Fn a variation of the disorder, Cunchausen by proxy 8C='(9, an individual, typically a mother, intentionally causes or fabricates illness in a child or other person under her care. :mphysema/ 'arrel chest, pink color, clubbed fingernails. Huntin ton1s #horea/ ,3 genetic, autosomal dominant disorder =5=* chorea --P writhing, twisting, movements of face, limbs and body -gait deteriorates to no ambulation -no cure, >ust palliative care Gout* $void beets, milk, eggs 'rown pigmentation around the ankles of patient indicates venous insufficeny =tarve a gastric ulcer, feed a duo ulcer Rheumatic ,e<er Si ns and Symptoms Aheumatic fever is a complication of untreated strep throat, caused by bacteria called Broup $ =treptococcus. Ft is potentially life threatening. =ince one of the main symptoms of rheumatic fever is pain in the >oints, use the word, NOF0&= to remember the signs and symptoms. F- Noints are painful -- Over a long period it can damage the heart 2> Fnfection may be too mild to be recogni?ed N- 0ervous system can be affected leading to chorea *- &hroat that is sore S- =wollen >oints

*he .. +and reflects !(G from skeletal muscle. @ )levated in skeletal muscle disease. *he .B +and reflects !(G from cardiac muscle. *he BB +and reflects !(G from the brain. Salem sum tu+e- turn patient every . hours to promote emptying of stomach contents. (acemaker spikes on & wave indicate that the pacemaker is not capturing appropriately and should be ad>usted for this patient. $ patient who is having muscle spasm while in traction should be repositioned to see if the spasms decrease. .ultiple mylomas=increased immunloglobins expected. #eliac Disease* "ant have 'AOWR '- '$A%)< A- A<) O- O$& W- W")$& .iller a++ott tu+e is used for decompressing intestine, which relieves the small intestine by removing fluid and gas from small intestine. #olonoscopy = %eft sims position *hyroid Storm* $brupt onset !"#, delirum, altered clotting, febrile. Bive dig, hydrocorto?one and &ylenol. $ddisonian crisis* n5v, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased '( Brave disease-hyperthyroidism • $nxiety • Frritability • Eifficulty sleeping • #atigue • $ rapid or irregular heartbeat • $ fine tremor of your hands or fingers • $n increase in perspiration • =ensitivity to heat • Weight loss, despite normal food intake

• • • •

'rittle hair )nlargement of your thyroid gland 8goiter9 !hange in menstrual cycles #reLuent bowel movements

*o(ic Shock* =taph $. "igh fever 8+,.M9, diffuse sunburn-like rash, "o&0, orthostatic syncope, di??iness. EesLuamation of palms5soles occurs +-. weeks after initial onset. .enin itis = look for nuchal rigidity, Gernigs sign 8canJt extend knee when hip is flexed9 and 'rudinskis sign 8flex neck and knee flexes too9 petichial rash. .ini .ental Status :(am = Nudgement, Orientation, Cemory, $ffect, !onsciousness, =peech Beratitis is a bacterial or viral infection of the cornea that can lead to corneal ulceration. (hotophobia, pain, and tearing are common symptoms. 2nfecti<e endocarditis = murmur #affine/ can precipitate or worsen fibrocystic breast disease. Acute appendicitis* expect to see pain first then nausea and vomiting. Gastroenitis* you will see nausea and vomiting first then pain. #rutch>0alkin upstairs* Dp with the good, down with the bad. Dp = good food first. #ushin 1s *riad = "&0 8widening pulse pressure, systolic rises9, 'radycardia, irregular resp

.2S#
,A* Solua+le ?itamins/ AD:B G $ - visual acuity E @ 'one !alcificaiton5!acium $bsorbtion ) @ $ntioxidant

G @ 'lood !lotting Water Solui+le/ '+ - &hiamine @ for $lcoholic (atients '/ @ amino acid metabolism @ for &' (atients #olic $cid @ A'! formation @ for (reggo1s '+. @ nerve function @ #or (ernicious $nemia, 7egitarians. ,ull "iHuid* anything liLuid at room temperature 8include oatmeal9 Greek* 'read served w5every meal. "o0>purine diet* N- spinach, poultry, liver, lobster, oysters, peas, fish or oatmeal Pork is good source of thiamine Red .eat ) *urnips ) Hoarseradish may give false M for guaiac. ?it #/ Cay cause false negative for guaiac. Hyper. I 'radycardia, %ethargy, "yperactive E&A1s, "o&0, 057, 'radynpnea Hypo. I Widened KA=, D waves, &achycardia, &etany, !hovstek1s5&rosseau1s, 'abinski H9P- #aI & J#A*SK !-convulsions $-arrythmias &-tetany =-spasms and stridor 8laryingospasm9 H9P:R #aI & JS#RA.L 8K = @ =edation ! @ !onfusion A @ Aeflexes $bsent $ @ $bdominal (ain C @ Cuscle Weakness D @ uncoordinated

H9P:Rkalemia S)S( & .8RD:R

.-muscle weakness 8>urine, oliguria, anuria R-respiratory distress D-decr cardiac contractility :-)!B changes R- reflexes, hyperreflexia, or flaccid H9P-kalemia S)S( & S8#*2-N S @ skeletal muscle weakness 8 @ D wave # @ !onstipation * @&oxicity of Eig 2 @ irregular pulse - @ orthostatis 8di??iness9 N @ numbness or paresthesia

Hyperkalemia #auses/ M.A#H2N:’ Cedicationa 8ace inhibitors, 0=$FE=9 $cidosis 8metabolic : repiratory9 !ellular destruction 8burns, traumatic in>uy9 "ypoaldosteronism, "emolysis 0ephrons, renal failure )xcretion 8impaired9

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