RNnetwork

Study Guide

© RNnetwork 2012/5 RNN-675 V-5

 TABLE OF CONTENTS

Table of Contents
General Objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Specific Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
I. Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Headaches (Migraines) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Parkinson’s disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Alzheimer’s disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Stroke (CVA – Cerebral Vascular Accident) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Muscular Dystrophy …. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Epilepsy/Seizure Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Increased Intracranial Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Subdural Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
II. Respiratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
COPD (Chronic Obstructive Pulmonary Disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
III. Cardiac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ACS (Acute Coronary Syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
ECG Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Electrical Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Coronary Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Waves and Intervals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Six Critical Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Basic Rules for ECG Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Practice Strips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Answer Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
IV. Gastrointestinal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
GERD (Gastro – Esophageal Reflux Disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
IBS (Irritable Bowel Syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Gastro – Intestinal Bleed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Colon Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

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 TABLE OF CONTENTS

V. Genitourinary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Cystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Enlarged Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Renal Calculi (Kidney Stones) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
VI. Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Phases of Wound Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Staging Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Ulcer Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Wound Cleansing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Dressings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
VII. Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Type I DM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Type II DM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
VIII. Burns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
IX. Labor and Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3 Stages of Labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
X. Obstetrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
XI. Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Growth and Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Common Childhood Illnesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
XII. Orthopedics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
XIII. Drug Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Systems of Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Systems of Measurement Quiz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Common Conversions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Methods of Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Practice Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

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Objectives
 OBJECTIVES

General Objective • Gastrointestinal: Hemorrhoids, Constipation,

The objective of this study guide is to provide the GERD (Gastro-Esophageal Reflux Disease), IBS
RNnetwork Nurse with: (Irritable Bowel Syndrome), Gastro-Intestinal
Bleed, and Colon Cancer.
1. An overview of common disease processes
with associated medications and treatments • Genitourinary: Cystitis, Enlarged Prostate, and
seen in the current patient population. Renal Calculi (Kidney Stones).

2. A review of the physiological evolution of • Wounds: Phases of Wound Healing, Staging

common disease processes and classes of Pressure Ulcers, Ulcer Care, Wound Cleansing,
drugs or procedures used in their treatment. and Dressings.

3. A review of critical clinical issues requiring • Diabetes Mellitus: Type I & II DM.
immediate intervention. • Burns: First, Second, and Third Degree Burns.
Specific Objectives • Labor and Delivery: 3 Stages of Labor, Pain
management, and complications
These are the objectives that the RNnetwork Nurse
would like to achieve. • Obstetrics
• Neurological: Headaches (Migraines), • Pediatrics: Growth and development,
Parkinson’s Disease, Alzheimer’s Disease, Stroke Common Childhood Illnesses
(CVA - Cerebral Vascular Accident), Muscular • Orthopedics: Fractures, Osteoarthritis, and
Dystrophy, Multiple Sclerosis, Epilepsy/Seizure Devices
Disorder, Increased Intracranial Pressure, and • Drug Calculations: Systems of Measurement,
Subdural Hematoma. Common Conversions, Methods of
• Respiratory: Asthma, COPD (Chronic Calculations, and Practice Problems.
Obstructive Pulmonary Disease), and
Pneumonia.
• Cardiac: ACS (Acute Coronary Syndrome),
Hypertension, Medical Devices, Mitral Valve
Disease, and Peripheral Artery Disease.

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I. Neurology
 1. Neurology

A. Headaches (Migraine): These are often caused channel blockers and anti-hypertensive
by stress, allergies, or environmental factors. medications are also very effective in
Sufferers can have auras (a warning sign that a decreasing the frequency, intensity and
migraine is imminent). Symptoms can include duration of the headache. Anti-depressants
light sensitivity, nausea, vomiting, and severe such as tricyclic anti-depressants (Pamelor)
throbbing pain. and SSRI’s (Effexor) are another treatment
• Medications and Treatments: The two choice for migraine headaches. Research
main categories of drugs used to treat has shown that these medications are
migraine headaches are for pain-relief and effective due to affecting the levels of
prevention. Medication management of serotonin and other neurotransmitters.
migraine headaches requires factoring the Medication management is guided by the
frequency, severity, and degree of disability effectiveness of the treatment. The goal
caused. is to reduce the frequency, intensity and
duration of the headache. The physician will
• Pain relieving drugs: NSAIDS (Advil, often combine the different medications, in
Motrin, and Aleve) are commonly used for order to eradicate or greatly minimize the
pain relief as well as tryptophans (Imitrex signs and symptoms of migraine headaches.
and Axert) which also help with nausea
and light sensitivity. Ergots (Migergot B. Parkinson’s Disease: Parkinson’s disease is a
and Cafergot) are not as effective as deterioration of the central nervous system
the NSAIDs and tryptophans; however and loss of dopamine production in the brain.
they are most effective in treating pain Early signs include shaking, tremors, and difficulty
lasting longer than 48 hours. Anti-nausea walking. As the disease progresses, it begins to
medications (Phenergan or Compazine) affect behavior and cognitive function. Dementia
are commonly used in conjunction with occurs late in the disease. Severe muscle spasms
the pain relieving medications as part of can cause difficulty sitting, standing, and severely
the treatment regimen. Opiates are used impact the ability to walk.
to manage pain and can be habit-forming, • Medications and treatments: There is
placing a patient at risk of addiction. no known cure for Parkinson’s disease.
Current studies show that opiates often The current approach for this disease is
cause rebound headaches, despite their use directed at treating the symptoms that are
for pain control and therefore is often used most bothersome. Dopaminergic drugs are
as a last resort. used to help replenish dopamine levels in
• Preventative Medications: Cardiovascular the brain or mimic the effects of dopamine
drugs have been found to be effective to reduce muscle rigidity, improve speed,
for decreasing frequency and intensity and coordination, while decreasing tremors.
of migraine headaches taken on a daily/ Carbidopa/Levodopa (Sinemet) is the
long term basis. First line treatments with primary medication used for treating
cardiovascular drugs are beta blockers. Parkinson ’s disease. The brain converts
These drugs have been found to be levodopa into dopamine, thereby increasing
extremely effective in reducing the severity the dopamine levels in the brain. Due to
and frequency of headaches. Calcium increased levels of dopamine, the patient

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experiences a decrease in tremors, muscle memory loss occurs and the patient can
rigidity and improved ability to walk. When no longer recall important events such as
starting this medication, it is important anniversaries, birthdates of children, graduation
for the pharmacy to check for drug from high school, etc. Eventually the patient
interactions or incompatibilities with the no longer has the ability to recall events
medications the patient is currently taking. that occurred only minutes ago. Once the
Medications are one part of the treatment diagnosis is confirmed, the life expectancy is
plan for patients with Parkinson’s disease. approximately 7 years.
Surgical procedures are available, but are • Medications and treatments: In the
reserved for patients who, after exhausting early stages of Alzheimer’s disease,
all medication treatment regimes, still have cholinesterase inhibitors are prescribed.
symptoms that are not well controlled These drugs, Razadyne (galantamine),
with medication. The goal of surgery is to Exelon (rivastigmine) and Aricept
decrease the most debilitating symptoms of (donepezil), are used in hope of preventing
Parkinson’s disease such as tremors, rigidity, or delaying the worsening of symptoms as
slowed movements and walking problems. well as help control behavioral symptoms.
The most common surgery performed, These drugs work by either blocking the
if needed, is Deep Brain Stimulation. A toxic effects of neurotransmitter build- up
neurostimulator device is implanted in the (glutamate) or prevents the breakdown
brain which sends electrical stimulation of acetylcholine in the brain. These
to targeted areas that control movement medications lessen symptoms such as
thereby blocking abnormal electrical signals memory loss and confusion for a limited
that cause tremor and other Parkinson’s period of time. Namenda (memantine)
symptoms. Patients may still need to take is a medication used to treat moderate
some medications, but the side effects to severe Alzheimer’s disease helping
(dyskinesia) from the medications are to delay the progression of symptoms,
dramatically reduced because the patient thereby allowing the patient to maintain
needs less medication. certain daily functions for a period of time
http://www.medicinenet.com/parkinsons_ (6 to 8 months). The disease continues to
disease/article.htm destroy brain synapses, leading to complete
C. Alzheimer’s Disease: This is the most common dependence on others with no ability or
form of dementia in older Americans. Onset comprehension for self-care. Patients lose
is usually after 65 years of age, but early onset their ability to recall events and eventually
of the disease occurs in some individuals. The do not recognize family members and
first symptoms are often mistaken for usual friends they have known their entire lives.
signs of aging. The individual begins to have http://www.mayoclinic.com/health/alzheimers-
difficulty recalling recent events. There is an disease/DS00161
inability to acquire new memories. As the http://www.ncbi.nlm.nih.gov/pubmedhealth/
disease progresses, changes occur in mood PMH0001767/
and behavior, with an increase in aggression,
confusion, irritability. The start of long term

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D. Stroke (CVA - Cerebral Vascular Accident): prevention of blood clots. Patients who
A stroke is caused by the interruption of have had surgery, and/ or restricted to
blood supply to an area of the brain and bed rest for extended periods of time,
can be embolic (blood clot) or hemorrhagic. are given these medications. The most
This causes oxygen depletion to the area common antiplatelet drugs used are Plavix
of the brain with a possibility of irreversible (Clopidogrel), Lovenox (Enoxaparin), ASA,
damage to the area. If symptoms are brought and Persantine (Dipyridamole). These drugs
to the attention of medical personnel within are taken once daily as prescribed by a
a 4 hour window, the possibility of reversing physician.
the symptoms is greatly increased. The four Anticoagulant Drugs are designed to
hour window is necessary for the use of clot prevent clot formation or to prevent an
busting drugs (TPA) which greatly increase the already present clot from getting larger.
chances for recovery and no residual effects. These drugs are given to patients who have
TPA is the front line drug for embolic strokes. had a stroke or a myocardial infarction.
Some hospitals have Brain Attack teams that These patients will be on an anticoagulant
are activated when a patient presents in the medication long term, thereby decreasing
emergency room within the appropriate time the chance of having another stroke
frame. The team will assume responsibility for or heart attack due to a blood clot.
the patient and begin protocol care. Anticoagulant drugs work by either
• Medications and Treatment: If a patient inhibiting clotting factors or blocking the
presents to the emergency room within activity of thrombin. Coumadin (Warfarin)
a 4 hour time period, from onset of is a drug that works by inhibiting clotting
symptoms, then clot busting drugs such as factors. Heparin is a drug that works by
TPA (altase) can be used. The sooner the inhibiting the activity of thrombin. When
drug can be given increases the chances of a patient is admitted due to a stroke or
reversal of symptoms and decrease the risk heart attack, thought to be caused by a
of bleeding into the brain. Blood Thinners blood clot, initial treatment is with heparin.
are also medications used to treat stroke The patient is often given a bolus dose
patients. The medications are used in hopes and then started on a heparin drip. Serial
of improving the patient’s recovery from a blood work (PT, PTT and INR) are checked
stroke and hopefully prevent future ones. at frequent intervals until the PT, PTT and
There are two classes of drugs commonly INR are 1 ½ time greater than the normal
used in the treatment and prevention range. Once the patient’s lab values have
of a stroke, antiplatelet medications and increased 1 ½ times, the patient will be
anticoagulants. Antiplatelet drugs work started on Coumadin and taken off the
by decreasing platelet aggregation and heparin drip. The patient will have a.m. labs
inhibiting thrombus formation. Antiplatelet checking the PT, PTT and INR levels to be
drugs are the only drugs that work in sure that the new values remain elevated.
the arterial system. The anticoagulant The physician will determine the daily dose
drugs work in the venous system. The of Coumadin after receiving the results of
medications are used in hospitals for the a.m. labs. Normal range for a PT test
is 10-12 seconds. Normal PTT values are

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30-45 seconds. Normal INR values are 1-2. • Medications and treatments: There is no
These patients will be followed by their current medication used to treat this illness.
primary care physician on a periodic basis Physical and occupational therapy are
to be sure that the medication remains in used to help the patient maintain strength
therapeutic range. and coordination as well as learning
Warning: Patients taking anticoagulant modifications for activities of daily living.
and antiplatelet drugs need education Modifications for bathing, grooming, and
regarding side effects. Patients should be other activities allow the person to remain
taught about increased bruising, epistaxis independent.
(nose bleeds), and hematuria (blood in http://www.ncbi.nlm.nih.gov/pubmedhealth/
urine). If the patient sustains a cut or a PMH0002172/
puncture wound, pressure needs to be F. Multiple Sclerosis: This is an autoimmune
applied longer due to increased bleeding response of the body causing problems
times. If a patient has a nosebleed in the brain and spinal cord. The myelin
(epistaxis) or blood in the urine sheath covers nerves and helps to conduct
(hematuria), the patient should report electrical signals to the brain and spinal
this to their physician. If unable to stop a cord. MS causes deterioration of this sheath
nose bleed, the patient should go to the by inflammation, thereby affecting nerve
nearest emergency room. conduction. Researchers are not clear as to
Patients who have gastrointestinal ulcers what causes this disease. Current theories
may not be able to take these medications are viral or a genetic defect. The illness has
or will need to be monitored very episodes of activity and then, the person may
closely for any signs of bleeding. NSAIDS go into remission. There is no way to predict
should not be used when taking these the length of time the person will be sick vs.
medications due to the increased risk of the amount of time the remission may last.
gastrointestinal bleeding. Some of the more common symptoms include
http://www.ncbi.nlm.nih.gov/pubmedhealth/ loss of balance, difficulty with speech, problems
PMH0001740/ with co-ordination and muscle weakness.
http://www.mayoclinic.com/health/stroke/ • Medications and treatments:There is
DS00150 no known cure for multiple sclerosis.
Treatment is aimed at getting the patient to
E. Muscular Dystrophy: This disease is inherited return to functional activity after an attack.
and diverse. The basic issue is with muscle The goal is to prevent new attacks and
weakness and muscle loss. There are many prevent disability.
types of muscular dystrophy, each having their
own unique symptoms. When a physician http://www.mayoclinic.com/health/multiple-
completes a thorough physical and runs sclerosis/DS00188
various tests, they will be able to identify the
type of dystrophy present. There are no known
cures at this time. The key is to remain active
as long as possible in as much as inactivity
causes the disease to progress faster.

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 1. Neurology

G. Epilepsy/Seizure Disorder: Episodic abnormal H. Increased Intracranial Pressure: This is caused

electrical activity in the brain. Epilepsy is more by a rise in the pressure inside the skull, often
likely to occur in children and adults over 65. the result of an injury to the brain. Increased
• Seizure activity is categorized into two pressure can also be caused by an increase
basic categories: Generalized and partial. in cerebrospinal fluid, a mass in the brain, or
Generalized seizures are caused by just the swelling of the brain itself. Prolonged
abnormal electrical activity throughout increase in the intracranial pressure crushes
the brain. Partial seizures are localized in the brain tissue (brain herniation) and often
a particular area of the brain. The most is fatal if not treated aggressively. The most
common seizures are: common causes of increased intracranial
pressure are:
• Grand Mal/Generalized Tonic-Clonic:
Unconsciousness, convulsions and muscle Aneurysm
rigidity. Do Not Place anything in the Encephalitis
mouth when this person is seizing. The Hydrocephalus
most important thing is to keep them
from hitting any objects that could cause Meningitis
additional injury. Patients have a “postictal Severe head injury due to some type of
state where they have stopped seizing but trauma
remain semi-conscious. They may foam at Subdural Hematoma
the mouth due to inability to swallow saliva
Status Epilepticus
during the seizure.
Stroke
• Absence: Brief loss of consciousness.
• Myoclonic: Sporadic (isolated) jerking
movements often isolated to a limb.
• Clonic: Repetitive jerking movements.
• Tonic: Muscle stiffness, rigidity seen in all
muscular areas.
• Atonic: Loss of muscle tone. Often results
in the person falling.
http://www.ncbi.nlm.nih.gov/pubmedhealth/
PMH0001714/
http://www.webmd.com/epilepsy/guide/
understanding-seizures-and-epilepsy

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• Medications and treatments: The most

important issues are oxygenation and
decreasing the pressure in the brain.
Hyperventilation using a ventilator or
bag valve mask can help decrease ICP by
decreasing CO2 levels. Increased CO2
levels causes increases in ICP. This solution
is immediate but temporary. Keeping the
mean arterial pressure low can also help
decrease intracranial pressure. Physicians
may use common antihypertensive
medications such as beta blockers to keep
the mean arterial pressure below 60.
Analgesia and sedation are used to keep
restlessness and struggling to a minimum,
thereby keeping the ICP lowered. If
sedation does not keep the patient quiet
enough, then the use of paralytics may be
used.
http://www.ncbi.nlm.nih.gov/pubmedhealth/
PMH0001797/
I. Subdural Hematoma: Caused by a tearing of
the venous blood vessels causing hematoma
to form between the Dura mater and the
arachnoid mater. This is often caused by a
traumatic brain injury to an individual or seen
in the elderly due to a fall. There are two types
of subdural hematomas-acute and chronic. An
acute subdural hematoma is often fatal if not
treated emergently. Blood rapidly accumulates
in the dural space causing an increase in
intracranial pressure and the risk of brain
herniation due to the rapid accumulation in a
fixed space.
http://www.bettermedicine.com/article/
subdural-hematoma
http://www.mayoclinic.com/health/intracranial-
hematoma/DS00330/DSECTION=causes

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II. Respiratory
 II. RESPIRATORY

A. Asthma: Airways narrow, swell, produce extra help prevent asthma symptoms
mucus, making breathing difficult. The most for up to 24 hours. In rare cases,
common asthma signs and symptoms are these medications have been linked
coughing, wheezing and shortness of breath. to psychological reactions such as
For some people asthma symptoms are a agitation, aggression, hallucinations,
minor nuisance. For others, they are a major depression, and suicidal thinking.
problem that interferes with daily activities. • Long-Acting Beta Agonists (LABAs):
Severe asthmatics can be at risk for a life- These inhaled medications include
threatening asthma attack. Asthma cannot be salmeterol (Serevent Diskus) and
cured, but symptoms can be controlled. formoterol (Foradil Aerolizer).
• Medications and treatments: The right LABAs open the airways and
medication depends on a number of reduce inflammation. However, they
things including age, symptoms, and have been linked to severe asthma
triggers. Preventive, long-term control attacks. LABAs should be taken
medications reduce airway inflammation only in combination with an inhaled
leading to symptoms. Quick-relief inhalers corticosteroid.
(bronchodilators) quickly open swollen • Combination Inhalers: These
airways that are limiting breathing. In some include fluticasone and salmeterol
cases, medications to treat specific allergies (Advair Diskus) and budesonide
are needed. and formoterol (Symbicort). These
– Long Term Control Medications: medications contain a LABA
• Inhaled Corticosteroids: These along with a corticosteroid. Like
medications include fluticasone other LABA medications, these
(Flovent Diskus, Flovent HFA), medications may increase your risk
budesonide (Pulmicort Flexhaler), of having a severe asthma attack.
mometasone (Asmanex), flunisolide – Quick Relief Medications: Quick-relief
(Aerobid), beclomethasone (Qvar) (rescue) medications are used as
and others. They are the most needed for rapid, short-term symptom
commonly prescribed type of long- relief during an asthma attack.
term asthma medication. You may • Short-Acting Beta Agonists: Inhaled,
need to use these medications quick-relief bronchodilators rapidly
for several days to weeks before ease symptoms of an asthma
they reach their maximum benefit. attack. They include albuterol
Unlike oral corticosteroids, these (ProAir HFA, Ventolin HFA, others),
corticosteroid medications have a levalbuterol (Xopenex HFA) and
relatively low risk of side effects and pirbuterol (Maxair Autohaler). These
are generally safe for long-term use. medications act within minutes and
• Leukotriene Modifiers: These oral effects last several hours.
medications include montelukast
(Singular), zafirlukast (Accolate)
and zileuton (Zyflo, Zyflo CR). They

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• Ipratropium (Atrovent): Like other • Medications and treatments: Control of

bronchodilators, ipratropium relaxes symptoms, reduce risk of complications,
the airways, making it easier to and exacerbations.
breathe and is mostly used for – Stop Smoking: This is the most essential
emphysema and chronic bronchitis, step in any treatment plan for smokers
but sometimes used to treat asthma with COPD.
attacks.
– Bronchodilators: These medications,
• Oral and Intravenous which usually come in an inhaler, relax
Corticosteroids: Used for the muscles around airways. This can
relief of airway inflammation help relieve coughing, shortness of
caused by severe asthma. Oral breath, and make breathing easier. (Mayo
medications such as prednisone and Foundation for Medical Education and
intravenous medications such as Research, 2011)
methylprednisolone are the front line
drugs used to treat the acute phase – Inhaled Steroids: Inhaled corticosteroid
of an asthmatic attack. Long term medications can reduce airway
usage may cause serious side effects, inflammation and make breathing easier.
so they are used only on short-term Prolonged use of these medications
basis for severe asthma symptoms. can weaken bones and increase the risk
of high blood pressure, cataracts and
http://www.mayoclinic.com/health/asthma/ diabetes. They are usually reserved for
DS00021 people with moderate or severe COPD.
B. COPD (Chronic Obstructive Pulmonary – Oxygen Therapy: The goal is to keep
Disease): This is a group of lung diseases the patient’s pulse oximetry greater
that block airflow as you exhale and make than 90%. In order to maintain this,
it increasingly difficult for you to breathe. supplemental oxygen will be required.
Emphysema and chronic asthmatic bronchitis Devices to deliver oxygen – Nasal
are the two main conditions that make up Cannula (up to 6 l/min) or a Non-
COPD. Many people have both. In all cases, Rebreather Mask (up to 15 l/min) are
damage to your airways eventually interferes choices available to deliver oxygen to a
with the exchange of oxygen and carbon patient. Additional oxygen should help
dioxide in your lungs. COPD is a leading cause reduce work of breathing.
of death and illness worldwide. Most COPD
is caused by long-term smoking and can be http://www.mayoclinic.com/health/copd/
prevented by not smoking or quitting soon after DS00916
you start. This damage to your lungs cannot be
reversed, so treatment focuses on controlling
symptoms and minimizing further damage.

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 II. RESPIRATORY

C. Pneumonia: This is an inflammation of lungs, – Viral - Antibiotics are not effective

usually caused by infection. Bacteria, viruses, against most viral forms of pneumonia.
fungi or parasites can cause pneumonia. It is A few viral pneumonias may be treated
a particular concern to those older than 65 with antiviral medications; however the
or have a chronic illness or impaired immune recommended treatment generally is
system. It is the number three cause of death rest and plenty of fluids.
in those who are 65 or older. It can also occur – Mycoplasma – This is treated with
in young, healthy people. Pneumonia can range antibiotics. In some cases fatigue may
in seriousness from mild to life-threatening and continue long after the infection itself
often is a complication of another condition. has cleared. Many cases go undiagnosed
Symptoms can vary greatly, depending on any and untreated. Signs and symptoms
underlying conditions and type of organism mimic a bad chest cold, so some
causing the infection. Pneumonia often mimics people never seek medical attention.
the flu, beginning with a cough and a fever. The symptoms generally resolve
Common signs and symptoms may include: fever, spontaneously.
cough, shortness of breath, sweating, shaking chills,
headache, muscle pain, fatigue, and chest pain that – Fungal – This is treated with antifungal
fluctuates with breathing (pleurisy). medication.

• Medications and treatments: Treatments http://www.mayoclinic.com/health/pneumonia/

vary depending on the severity of DS00135
symptoms and type of pneumonia.
– Bacterial – Treated with antibiotics,
which have been determined by blood
cultures, or sputum cultures, to be
the most effective against the type of
bacteria identified.

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III. Cardiac
 III. Cardiac

Acute Coronary Syndrome: This is any condition – Beta Blockers: Help relax the heart muscle,
brought on by sudden, reduced blood flow to slow heart rate and decrease blood
the coronary arteries. A description of chest pain pressure, thereby decreasing the oxygen
felt during a heart attack, chest pain felt at rest demand of the heart. These medications
or light physical activity is referred to as unstable can increase blood flow to the coronary
angina. Patients should immediately call 911 if these arteries, thereby decreasing chest pain and
symptoms are felt. Acute coronary syndrome the potential for myocardial damage.
is treatable if diagnosed quickly. Acute coronary – Angiotensin-Converting Enzyme (ACE)
syndrome treatments vary depending on signs, inhibitors and Angiotensin Receptor
symptoms and overall health condition. Symptoms Blockers (ARBs): These medications allow
may include: chest pain that feels like burning, blood to flow from the heart more easily.
pressure, or tightness lasting several minutes or The physician may prescribe ACE inhibitors
longer. Left arm pain or jaw pain, nausea, vomiting, or ARBs on discharge, after having an
shortness of breath, or sudden heavy sweating. episode of acute coronary syndrome or
http://www.mayoclinic.com/health/acute-coronary- myocardial infarction if the heart’s pumping
syndrome/DS01061 capacity is diminished. These drugs also
• Medications and treatments: Treatments vary lower blood pressure and may prevent
depending on symptoms and degree to which subsequent ACS or MI.
arteries are blocked. Medications are given – Calcium Channel Blockers: These
to relieve chest pain and improve blood flow medications relax the heart, allowing
through the coronary arteries. increased blood flow to and from the heart.
– Aspirin (ASA): Decreases blood clotting, Generally given if symptoms persist after
helping to keep blood flowing through nitroglycerin and beta blockers are given.
narrowed coronary arteries. This drug • Procedures
is one of the first things given in the – Angioplasty and Stenting: A physician
emergency room for suspected acute inserts a catheter via the femoral vein
coronary syndrome. If a patient is under fluoroscopy into the blocked or
experiencing chest pain at home, give 325 narrowed part of the coronary artery. A
mg of ASA and chew it, then call 911. wire with a deflated balloon is passed to
– Thrombolytics: Also called “clot busters”, the narrowed area. The balloon is inflated
help prevent a blood clot that is blocking compressing the deposits against the artery
blood flow to the heart from enlarging. The walls. A mesh tube (stent) is usually left in
earlier thrombolytic drugs are given during the artery to help keep the artery open.
a heart attack lessens the damage to the Angioplasty may also be done with laser
heart. “TIME IS MUSCLE.” technology.
– Nitroglycerin: This vasodilator will help
improve blood flow to the coronary blood
vessels thereby alleviating chest pain. Side
effects include: headache and hypotension.

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Hypertension: High blood pressure (hypertension) – Cerebral Damage:

quietly damages the body for years before • Transient Ischemic Attack (TIA): This
symptoms develop. Left uncontrolled it can cause is a brief, temporary disruption of
disability, end-stage renal disease, destruction of blood to the brain; often caused by
cardiac function, which results in poor quality of life, atherosclerosis or a blood clot — both
or a fatal heart attack. With treatment and lifestyle of which can be attributed to high blood
changes, hypertension can be controlled to reduce pressure. A transient ischemic attack
risk of life-threatening complications. is often a warning sign of increased
• Complications risk of a full-blown stroke. Patient may
– Arterial Damage: Healthy arteries are flexible, experience temporary numbness, facial
strong and elastic.Their inner lining is smooth droop or confusion. Patients are often
allowing blood to flow freely, supplying vital not aware that they are at high risk of
organs and tissues with adequate nutrients having a stroke.
and oxygen. With hypertension, the increased • Cerebral Vascular Accident (CVA,
pressure of blood flow through arteries Stroke): This occurs when part of
gradually causes a variety of problems: the brain is deprived of oxygen and
• Narrowing: Hypertension damages the nutrients, causing brain cells to die.
cells of the arterial inner lining, launching Uncontrolled hypertension can lead to
a cascade of events making artery stroke by damaging and weakening the
walls thick and stiff (arteriosclerosis) or brain’s blood vessels, causing them to
hardening of the arteries. Dietary fats narrow, rupture or leak. Atherosclerotic
enter the bloodstream, passing through disease causes blood clots to form
the damaged cells and start the disease in the arteries leading to the brain,
of atherosclerosis. These changes affect blocking blood flow and potentially
arteries throughout the body, restricting causing a stroke.
blood flow to the heart, kidneys, brain, • Dementia: Brain disease resulting
arms and legs. The damage can cause in problems with thinking, speaking,
many problems, including chest pain reasoning, memory, vision and
(angina), heart attack, heart failure, movement. There are a number of
kidney failure, stroke, blocked arteries in causes of dementia. One cause, vascular
legs or arms (peripheral arterial disease), dementia, can result from narrowing
eye damage, and aneurysms. and blockage of the arteries that
• Aneurysm: Constant pressure, over time, supply blood to the area of the brain
of blood moving through a weakened that controls memory, cognition and
artery can cause a section of its wall to emotions. It can also result from strokes
enlarge and form a bulge (aneurysm). caused by an interruption of blood flow
An aneurysm can potentially rupture, to the brain. In either case, high blood
causing life-threatening internal bleeding. pressure may be the culprit. High blood
Aneurysms can form in any artery in pressure that occurs even as early as
the body, most dangerous one is found middle age can increase the risk of
in the aorta, the body’s largest artery. dementia in later years.

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– Renal (Kidney) Damage: Kidneys are – Cardiomyopathy: A disease that weakens

responsible for balancing the body’s fluid and enlarges the heart muscle. There
status, electrolyte balance and removal are three main types of cardiomyopathy
of waste. A process that depends on — dilated, hypertrophic and restrictive
healthy blood vessels in the kidneys. High — all of which affect heart muscle.
blood pressure can injure both the blood Cardiomyopathy makes it harder for the
vessels in and leading to your kidneys, heart to pump blood and deliver it to
causing several types of kidney disease the body. The ventricles have become
called nephropathies. Having diabetes weak and boggy. There are many causes
in addition to high blood pressure can of cardiomyopathy, including coronary
worsen the damage, often resulting in end- artery disease and valvular heart disease.
stage renal disease which requires either Cardiomyopathy can lead to heart failure
transplantation of chronic dialysis. resulting in death.
• Renal Failure: Hypertension is one of Cardiomyopathies can be treated. The
the most common causes of kidney type of treatment depends on the type
failure. It can damage both the large of cardiomyopathy and how serious it
arteries leading to the kidneys and the is. Treatment may include medications,
tiny blood vessels (glomeruli) within surgically implanted devices or, in severe
the kidneys. Damage to either causes cases, a heart transplant.
ineffective renal filtration of fluids, http://www.mayoclinic.com/health/
electrolytes and toxins from the blood. cardiomyopathy/DS00519
As a result, dangerous levels of fluid,
electrolytes and toxins can accumulate, – Dilated Cardiomyopathy: The most
ultimately requiring dialysis or kidney common type of cardiomyopathy. In
transplantation. this disorder, your heart’s main pumping
chamber — the left ventricle —
– Ocular (Eye) Damage: These tiny, delicate becomes enlarged (dilated), its pumping
blood vessels supplying blood to the eyes ability becomes less forceful, and blood
can be damaged by hypertension. does not flow as easily through the
– Retinopathy: Damage of the vessels heart. This causes blood to back up into
supplying blood to the retina. This the lungs as well as in the periphery.
condition can lead to bleeding in the Although this type can affect people of
eye, blurred vision and complete loss of all ages, it occurs most often in middle-
vision. aged people and is more likely to
– Optic Neuropathy: Blocked blood flow affect men. Some people with dilated
damages the optic nerve. It can kill cardiomyopathy have a family history of
nerve cells in the eyes, which may cause the condition.
bleeding within the eye or vision loss.
http://www.mayoclinic.com/health/high-blood-
pressure/DS00100

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• Hypertrophic Cardiomyopathy: This type Regardless the type of cardiomyopathy,

involves abnormal growth or thickening signs and symptoms tend to get worse
of the heart muscle, particularly affecting unless treated. In certain people, this
the left ventricle. As thickening occurs, worsening happens quickly, while in
the heart tends to stiffen and the size others, cardiomyopathy may become
of the left ventricle may shrink, reducing worse slowly through time.
cardiac output and thus interfering with Causes: Most of the time, the cause of
the heart’s ability to deliver blood to the the cardiomyopathy is unknown. Possible
body. Hypertrophic cardiomyopathy can causes of cardiomyopathy include:
develop at any age, but the condition
tends to be more severe if it becomes • Long-term high blood pressure
apparent during childhood. Most • Heart valve problems
affected people have a family history of • Heart tissue damage from a previous
the disease, and some genetic mutations heart attack
have been linked to hypertrophic
• Chronic rapid heart rate
cardiomyopathy.
• Metabolic disorders, such as thyroid
Symptoms: Some people who develop
disease or diabetes
cardiomyopathy have no signs and
symptoms during the early stages of the • Nutritional deficiencies of essential
disease. As the condition advances, signs vitamins or minerals, such as thiamin
and symptoms usually appear. B type (vitamin B-1), selenium, calcium and
Binaturectic Peptide (BNP) is a blood magnesium
test that can identify cardiomyopathy. • Pregnancy
Cardiomyopathy symptoms may include:
• Excessive use of alcohol over many
• Breathlessness with exertion or even years
at rest
• Abuse of cocaine or antidepressant
• Swelling of the legs, ankles and feet medications, such as tricyclic
• Bloating of the abdomen due to fluid antidepressants
buildup • Use of some chemotherapy drugs to
• Fatigue treat cancer
• Irregular heartbeats that feel rapid, • Certain viral infections, which
pounding or fluttering may injure the heart and trigger
cardiomyopathies. (Rheumatic fever
• Dizziness, lightheadedness and
in childhood)
fainting
• Iron buildup in heart muscle
(hemochromatosis)

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 III. Cardiac

– Restrictive Cardiomyopathy: The heart ECG Interpretation

muscle in people with restrictive Cardiac Anatomy
cardiomyopathy becomes rigid and The coronary arteries descend from the ascending
less elastic, meaning the heart cannot aorta. The coronary arteries bring fresh oxygenated
properly expand and fill with blood blood to all areas of the heart. Myocardial oxygen
between heartbeats. While restrictive demand is high for the heart. The heart contains
cardiomyopathy can occur at any age, 3 valves: The tricuspid valve which separates the
it most often tends to affect older right atrium from the right ventricle; the mitral
people. It is the least common type of valve, which separates the left atrium from the left
cardiomyopathy and can occur for no ventricle; and the aortic valve which is located in the
known reason (idiopathic). The condition ascending aorta.
may also be caused by diseases elsewhere
in the body that affect the heart. Coronary Artery Disease (CAD) occurs when
blockage begins to build in the main coronary
Treatment: Depending on type and severity arteries. When the blockage becomes severe
of heart failure a number of options are enough, the person will usually experience chest
available. pain, arm pain, and complain of severe pressure in
Surgery: the sternal area. Treatment for this depends on how
Heart valve repair or replacement: many blockages are present. If the blockage is 50%
Cardiologists may recommend heart or lower, determined in the cath lab, then stents are
valve repair or heart valve replacement placed. If the patient has severe blockage in several
surgery to treat a weaken heart valve by of the main coronary arteries, the person will be
reconstruction or implants (mechanical or taken to surgery for a Coronary Artery Bypass
pig valve). Ineffective valves in the heart will Graft (CABG).
lead to congestive heart failure. Heart valve Valvular problems result in mechanical issues for
surgery may relieve your symptoms and the heart. Tricuspid or mitral regurgitation are the
improve quality of life. names of these problems the valves can have. If the
Heart transplant: Those with severe valves are incompetent (inability to allow complete
congestive heart failure may need a heart atrial filling), then this person will also require heart
transplant. Severe left ventricular failure is surgery. All three valves can be repaired or replaced.
the reason for a transplant. Left ventricular It is important that the mitral and tricuspid valves
devices are used in order to buy time until are competent so the atrium has time to fill before
a heart is found. blood enters the ventricles.
Myectomy: The surgeon removes part
of the overgrown septal muscle in the
heart to increase cardiac output. Cardiac
output is severely reduced if a patient has
hypertrophic cardiomyopathy. Surgeons
may perform myectomy when medication
no longer relieves symptoms.

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 III. Cardiac

Electrical Physiology Area Artery

Understanding the electrical physiology of the heart Inferior Right Coronary Artery
is essential for understanding and learning ECG Anteroseptal Left Anterior Descending
interpretation. The electrical conduction system of Left Anterior Descending
the heart includes the sinoatrial node (SA node), Anteroapical
(distal branch)
the atrioventricular node (AV node), the Bundle Anterolateral Circumflex
of His which then divides into the left and right
Posterior Right Coronary Artery
bundles branches. The Purkinje fibers are located at
the base of the heart. (Reference to diagram C). The Waves and Intervals
electrical system is responsible for the relaxation The electrical tracing of the heart consists of the
and pumping of the heart, which then sends blood P wave, QRS complex, and a T wave. The baseline
to all parts of the body. An impulse is generated for the tracing is called the isoelectric line. Three
from the SA node which then travels to the AV intervals are also reviewed when interpreting a strip:
node. The impulse hesitates allowing the atrium to the PR interval, QRS complex, and the QT interval.
completely empty into the ventricles. The impulse The ST segment will often be the first area of
then continues down the Bundle of His and Purkinje change if a person is having an MI.
fibers which cause the ventricles to contract.
Understanding the electrical and physiological The P wave represents the impulse across
functioning of the heart allows a nurse to read a the atria to the AV node. The P wave reflects
strip and determine what issues the heart may be depolarization of the atria.
having. The PR interval is measured from the beginning of
the P wave to the beginning of the QRS.
Coronary Blood Supply
The QRS complex reflects the rapid depolarization
The coronary arteries are critical to normal heart
of the right and left ventricles.
function as well. If circulation to any area of the
heart is obstructed and blood flow is not re- The ST segment connects the QRS complex and
established, then the patient will suffer a myocardial the T wave. This segment is the period of time
infarction. Let’s discuss coronary arteries and their represented when the ventricles are depolarized. It
locations. The main vessels run down the front of is isoelectric.
the heart. The major vessels include the left anterior Ventricular recovery or repolarization is the T
descending, circumflex, and right coronary artery. wave. The interval from the beginning of the QRS
(See diagram A ). These vessels supply the majority complex to the apex of the T wave is called the
of the cardiac muscle with blood supply. The vessels absolute refractory period.
also have branches that supply the posterior and The QT interval (measured from the beginning of
inferior blood areas of the heart. The anatomic the QRS complex to the end of the T wave) varies
regions of the heart are supplied as follows: with heart rate. A prolonged QT interval is a risk
factor for ventricular tachyarrhythmias and sudden
death.

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 III. Cardiac

Six Critical Questions 2. Rate: Most strips are 6 second strips so you
Developing habits/techniques when analyzing ECG strips multiply the number of QRS complexs by 10.
will allow you review all important issues with ECG 3. P Waves: Is there a P wave for every QRS
strips and allow you to come up with an interpretation, complex? Are they upright or are they
without much trouble. Some rhythms will need you inverted?
to remember the rules/issues that identify them.You 4. PR Interval: should be .20 or less. If the
will need to memorize the characteristic of 1st degree distance is greater than .20, begin to think of
block. 2nd degree block- Mobitz type I and 2nd degree some type of block.
block- Mobitz type II. Each of these rhythms has unique
5. QRS wave: The distance should be .12 or less.
identifiers that will help you distinguish one from the
other. Junctional rhythms are another arrhythmia that 6. Interpretation: After you have answered each
often is missed. Memorizing a few rules in regards to of these questions, you should have enough
the above rhythms and always answering the 6 critical information for you to be able to determine
questions will bring you to the correct interpretation what the rhythm is.
each and every time. The next section of this study guide is designed to help
1. Regularity: Is the rhythm regular or is it not? answer these six critical questions.
Measure from R-R interval and measure P-P http://library.med.utah.edu/kw/ecg/index.html
interval.
http://www.12leadecg.com/arrhythmias/

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 III. Cardiac

Basic Rules for ECG Interpretation

Rhythm Regularity Rate P Wave PRI QRS
Between .12-.20 &
Normal Sinus Regular, constant R-R A/V rate = between 60-100 Ps uniform. One P for every QRS QRS < or = .12
constant
Between .12-.20 &
Sinus Bradycardia Regular A/V rate = < 60 bpm Ps uniform. One P for every QRS QRS < or = .12
constant
A/V rate = > 100 bpm, usually Between .12-.20 &
Sinus Tachycardia Regular Ps uniform. One P for every QRS QRS < or = .12
between 100-160 bpm constant
Irregular, R-R interval A/V rate = usually between 60- Between .12-.20 &
Sinus Arrhythmia Ps uniform. One P for every QRS QRS < or = .12
varies with respiration 100 bpm but can be slower constant
Usually Regular,
Ventricular rate will Atrial 250-350 bpm.Ventricular
Seen as “Flutter” waves, have sawtooth
Atrial Flutter be regular if AV node will vary based on impulses Cannot be measured QRS < .12
appearance
conducts in consistent conducted
pattern
If ventricular rate < 100 bpm
No discernable P waves, fibrillatory
rhythm said to be “controlled”,
Atrial Fibrillation Grossly Irregular waves or grossly chaotic undulations of Cannot be measured QRS < .12
if > 100 bpm considered rapid
baseline
ventricular response
Between .12-.20 but
P wave of premature beat will have
can be prolonged;
Premature Atrial Usually regular except different morphology of others. Usually
Depends on underlying rhythm PRI of ectopic will be QRS < .12
Contraction ectopic beat notched or flat. May be lost within T
different from PRI of
wave of preceding complex
other complexes
If precedes QRS then
Ectopic interrupts the
Premature P waves may be before, after or hidden < .12. If behind or
underlying rhythm’s
Junctional Depends on underlying rhythm by QRS complex, if visible will be during QRS no PRI QRS < .12
regularity, R-R will be
Contraction inverted measurement can be
irregular
given.
If precedes QRS then
< .12. If behind or
Junctional Escape A/V rates = Rate =inherent P waves may be before, after or lost in
Regular, R-R constant. during QRS no PRI QRS < .12
Rhythm junction rate 40- 60 bpm QRS complex, if visible will be inverted
measurement can be
given.
If precedes QRS then
Accelerated A/V rates = Usually between < .12. If behind or
P waves may be before, after or lost in
Junctional Regular, R-R constant. 60-100. Not a true tachycardia during QRS no PRI QRS <. 12
QRS complex, if visible will be inverted
Rhythm because not > 100 bpm measurement can be
given.
If precedes QRS then
P waves may be before, after or hidden < .12. If falls behind or
Junctional A/V rates = Usually between
Regular, R-R constant. by QRS complex, if visible may be during QRS no PRI QRS < .12
Tachycardia 100-180 bpm.
inverted measurement can be
given.
At least .12.
configuration
different from
Premature Ectopic beat interrupts Ectopic not preceded by P wave. May
Depends on rate of underlying underlying QRS
Ventricular the regularity of see coincidental P near PVC but is No PRI
rhythm complexes.T wave
Contraction underlying rhythm dissociated
frequently opposite
direction from QRS
complex

24 RNnetwork Study Guide

 III. Cardiac

Rhythm Regularity Rate P Wave PRI QRS

1st degree block
Not a true
PRI will always be
block because Based on underlying Depends on rate of underlying P waves upright & Uniform with every P
constant across strip QRS < .12
each impulse rhythm rhythm wave followed by QRS complex
& > .20
conducted
through vent.
PRI gets progressively
2nd degree block R-R irregular Cyclic Atrial rate usually normal. longer, until one P wave
P waves upright & uniform and always
Type I, Mobitz I pattern of grouped Ventricular rate may be not followed by QRS. QRS < .12
more P waves than QRS complexes.
or Wenckebach beats bradycardia range. After blocked beat
cycle repeats.
If conduction
consistent, R-R will be Atrial rate usually normal. PRI on conducted
2nd degree block P waves upright & uniform and always
regular. If conduction Ventricular rate may be beats constant & may QRS < .12
Type II, Mobitz II more P waves than QRS complexes.
varies, R-R will be bradycardia range. be longer than .20
irregular
QRS < .12 if focus
Totally inconsistent. No
3rd degree or P-P regular & R- R Atrial usually normal range. P waves upright & uniform and always junctional, QRS
relationship between P
CHB regular but not related Ventricular will be slower more P waves than QRS complexes .12 or > if focus
waves & QRS
ventricular
P wave in front of every QRS, the Between .12-.20 &
configuration may be flattened or constant. Difficult to
Atrial Tachycardia Regular, R-R constant Usually 150-250 bpm QRS < .12
notched. P waves can be lost in the T measure if P obscured
waves by T wave
Often difficult to
Atrial cannot be determined,
differentiate the
Ventricular Usually Regular, but may Ventricular range 150-250 bpm
None seen No PRI QRS from the T
Tachycardia be slightly irregular considered slow VT. > 250 bpm
wave. Measures @
called Ventricular flutter
least .12 or >
Cannot determine Cannot be determined with
Ventricular No discernible QRS
regularity. Baseline no discernible complexes to No discernible P waves No PRI
Fibrillation complex
chaotic measure
QRS is wide
Usually regular, slows as Ventricular rate usually 20-40
Idioventricular No P waves No PRI measuring @ least
heart dies but may drop below 20 bpm
.12 or >
Straight line no QRS
Asystole Cannot determine No rate No P waves No PRI
complexes

RNnetwork Study Guide 25

 III. Cardiac

 
Practice Strips
1.

 
1.1. Regularity
Regularity__________________  
_______________________________
2.2. RateRate_______________________  
___________________________________
                                                                                                                                                                                                1
3.3. P Waves ________________________________
P  Waves____________________  
4.4. PRIPRI________________________  
____________________________________
5.5. QRS QRS_______________________  
___________________________________
6.6. Interpretation
Interpretation_______________  
____________________________
2.

 
1.1. Regularity
Regularity________________  
_______________________________
2.2. RateRate_____________________  
___________________________________ 2
                                                                                                                                                                                                     
3.3. P Waves ________________________________
P  Waves__________________  
4.4. PRIPRI______________________  
____________________________________
5.5. QRS QRS_____________________  
___________________________________
6.6. Interpretation
Interpretation____________  
____________________________

26 RNnetwork Study Guide

CHG  Healthcare  Services,  Inc.       1  |  P a g e  
 
 III. Cardiac

RNNetwork  Study  Guide  …continued  

RNNetwork  Study  Guide  …continued  

3.

 
 
1. 1. Regularity_______________  
Regularity _______________________________
1. Regularity_______________  
2. 2. Rate ___________________________________
Rate____________________   3
                                                                                                                                                                                                                       
2.
3. 3.
Rate____________________  
P Waves ________________________________
P  Waves_________________  
3
                                                                                                                                                                                                                       
4.3.4. PRI P  ____________________________________
Waves_________________  
PRI_____________________  
5.4.5. PRI_____________________  
QRS____________________  
QRS ___________________________________
6.5. QRS____________________  
Interpretation____________  
6. Interpretation ____________________________
6. Interpretation____________  
4.

 
1. Regularity _______________________________  
1. Regularity__________________  
2.1. Rate ___________________________________
Regularity__________________  
2. Rate_______________________  
3. P Waves ________________________________                                                                                                                                                                                                        4  
2. Rate_______________________                                                                                                                                                                                                          4  
3.
4. PRIP  W aves____________________  
____________________________________
3. P   W aves____________________  
4. PRI________________________  
5. QRS ___________________________________
5.4. QRS_______________________  
PRI________________________  
6. Interpretation ____________________________
6.5. Interpretation______________  
QRS_______________________        
6. Interpretation______________        

CHG  Healthcare  Services,  Inc.       2  |  P a g e  

  CHG  Healthcare  Services,  Inc.       2  |  P a g e  
  RNnetwork Study Guide 27
 RNNetwork  Study  Guide  …continued  
III. Cardiac
RNNetwork  Study  Guide  …continued  

5.

1. 5
Regularity_______________                                                                                                                                                                                                                            

1. Regularity _______________________________
Regularity_______________                                                                                                                                                                                                                        5  
2. Rate____________________  
1.
2.
3. Rate
P  W___________________________________
aves_________________  
2. Rate____________________  
4. PRI______________________  
3.3. PP  Waves ________________________________
Waves_________________  
5. QRS_____________________  
4.
4.6. PRI ____________________________________
PRI______________________  
Interpretation____________  
5.5. QRS ___________________________________
QRS_____________________  
6.6. Interpretation____________  
Interpretation ____________________________
6.

 
1. Regularity _______________________________
1. Regularity_________________      
2. Rate ___________________________________
6      

2.3. PRate______________________  
Waves ________________________________
1. Regularity_________________       6    
3. P  Waves___________________  
2. 4. Rate______________________  
PRI ____________________________________
4. PRI_______________________  
3. 5. P  QRS ___________________________________
Waves___________________  
5. QRS______________________  
4.6.6. PRI_______________________  
Interpretation ____________________________
Interpretation_____________              
5. QRS______________________  
CHG  Healthcare  Services,  Inc.       3  |  P a g e  
6. Interpretation_____________              
 
CHG  Healthcare  Services,  Inc.       3  |  P a g e  
 

28 RNnetwork Study Guide

 RNNetwork  Study  Guide  …continued  

III. Cardiac

RNNetwork  Study  Guide  …continued  

7.

1. Regularity________________         7  
2.1. Rate_____________________  
Regularity _______________________________
3. P  Waves__________________    
2. Rate ___________________________________
4. PRI______________________  
1.3.
5.
P Waves ________________________________
Regularity________________  
QRS_____________________  
      7  
6.4.
2. PRI ____________________________________
Rate_____________________  
Interpretation_____________  
3.5. QRS
P   ___________________________________
Waves__________________  
4.6. PRI______________________  
Interpretation ____________________________
5. QRS_____________________  
8.
6. Interpretation_____________  

 
1. Regularity
1. _______________________________
Regularity_________________                  
2. Rate ___________________________________
2. Rate______________________                 8  
3. P Waves ________________________________  
3. P  Waves___________________  
4. PRIPRI_______________________  
4. ____________________________________
1. Regularity_________________                  
5. QRS
5. ___________________________________
QRS______________________  
2. Rate______________________  
6. Interpretation
 
____________________________
Interpretation_____________  
            8  
3. P  Waves___________________  
CHG  Healthcare  Services,  Inc.       4  |  P a g e  
  4. PRI_______________________  
5. QRS______________________  
6. Interpretation_____________  
CHG  Healthcare  Services,  Inc.     RNnetwork
  Study Guide 4  |  P a g e   29
 
 III. Cardiac RNNetwork  Study  Guide  …continued  
RNNetwork  Study  Guide  …continued  

9.

 
 
1.1. Regularity _______________________________
Regularity_______________                   9  
2.2. Rate
1. ___________________________________
Regularity_______________  
Rate____________________                   9  
3.3. PRate____________________  
2. P  Waves ________________________________
waves_________________  
4.4. PRI
3. PRI_____________________  
P   w____________________________________
aves_________________  
5. PRI_____________________  
4. QRS____________________  
5. QRS ___________________________________
6. QRS____________________  
5. Interpretation___________  
6. Interpretation ____________________________
6. Interpretation___________  
10.

1. Regularity _______________________________  
2. Rate ___________________________________  
1. Regularity___________________    
3. P Waves ________________________________
            10  
1.
2. PRIRegularity___________________  
4. Rate________________________  
____________________________________
              10  
3.
2. P  Waves____________________  
Rate________________________  
5. QRS ___________________________________
4.
3. PRI________________________  
P   Waves____________________  
6.
5.
Interpretation ____________________________
QRS_______________________  
4. PRI________________________  
6.
5. Interpretation______________  
QRS_______________________  
6.Healthcare  
CHG   Interpretation______________  
Services,  Inc.       5  |  P a g e  
 
CHG  Healthcare  Services,  Inc.       5  |  P a g e  
 
30 RNnetwork Study Guide
 RNNetwork  Study  Guide  …continued  
III. Cardiac
RNNetwork  Study  Guide  …continued  

11.

 
 
1. Regularity__________________                 11  
1. Regularity _______________________________
2.
1. Rate_______________________  
Regularity__________________                 11  
3.2. Rate
P  W___________________________________
ave____________________  
2. Rate_______________________  
4.3. P PRI________________________  
Waves ________________________________
3. P  Wave____________________  
4.4. PRI ____________________________________
5. QRS_______________________  
PRI________________________  
6. Interpretation______________  
5.5. QRS ___________________________________
QRS_______________________  
6.6. Interpretation ____________________________
Interpretation______________  
12.

 
1. Regularity _______________________________
 
1.2. Rate ___________________________________
Regularity___________________                 12  
2.3. P Waves
1. ________________________________
Rate________________________  
Regularity___________________                 12  
2.4. PRIRate________________________  
3. P  ____________________________________
Waves_____________________  
4. PRI_________________________  
3.5. QRSP  W___________________________________
aves_____________________  
5. QRS________________________  
4.6. Interpretation ____________________________
PRI_________________________  
6. Interpretation_______________  
5. QRS________________________  
6. Healthcare  
CHG   Interpretation_______________  
Services,  Inc.       6  |  P a g e  
 
CHG  Healthcare  Services,  Inc.       6  |  P a g e  
 
RNnetwork Study Guide 31
 III. Cardiac
RNNetwork  Study  Guide  …continued  
RNNetwork  Study  Guide  …continued  

13.

 
 
1.1. Regularity__________________  
Regularity _______________________________               13  
1.
2.2. Regularity__________________  
Rate ___________________________________
Rate_______________________                 13  
3.3.
2. P  Waves
Waves____________________  
PRate_______________________  
________________________________
4.
3. PRI________________________  
P  W____________________________________
aves____________________  
4. PRI
5.
4. QRS_______________________  
PRI________________________  
5. QRS ___________________________________
6.
5. Interpretation______________              
QRS_______________________  
6. Interpretation ____________________________
6. Interpretation______________              
14.

 
1. Regularity _______________________________  
1.
2.
Regularity____________________    
Rate ___________________________________
            14  
1.
2.3. PRegularity____________________  
Rate_________________________  
Waves ________________________________               14  
3.
2. P  Waves______________________  
Rate_________________________  
4. PRI ____________________________________
4.
3. PRI__________________________  
P   Waves______________________  
5.
5.
QRS ___________________________________
QRS_________________________  
4. PRI__________________________  
6.6.
5.
Interpretation ____________________________
Interpretation________________  
QRS_________________________          
6. Interpretation________________          

CHG  Healthcare  Services,  Inc.       7  |  P a g e  

 
CHG  Healthcare  Services,  Inc.       7  |  P a g e  
 32 RNnetwork Study Guide
 III. Cardiac
RNNetwork  Study  Guide  …continued  
RNNetwork  Study  Guide  …continued  

15.

 
 
1.1. Regularity _______________________________
Regularity____________________                 15  
2.2. Rate
1. ___________________________________
Regularity____________________  
Rate_________________________                 15  
3.3. PRate_________________________  
2. P  Waves ________________________________
Waves_____________________  
4.4. PRI
3. P   W____________________________________
PRI__________________________  
aves_____________________  
5. QRS_________________________  
4.5. QRS
PRI__________________________  
___________________________________
6. Interpretation________________  
5.6. Interpretation
QRS_________________________  
____________________________
6. Interpretation________________  
16.

 
1. Regularity _______________________________  
1.2. Rate
Regularity__________________    
___________________________________             16  
1.
2.3. PRegularity__________________    
Waves ________________________________
Rate_______________________               16  
3.4. PRI
2. P  W ave____________________  
____________________________________
Rate_______________________  
4. P  
3. PRI________________________  
Wave____________________  
5. QRS ___________________________________
5. QRS_______________________  
4. PRI________________________  
6. Interpretation ____________________________
6. QRS_______________________  
5. Interpretation______________  
6. Interpretation______________  

CHG  Healthcare  Services,  Inc.       8  |  P a g e  

 
CHG  Healthcare  Services,  Inc.     RNnetwork
  Study Guide 8  |  P a g e   33
 
 III. Cardiac

Answer Key 6. Regular

1. Regular 5.
40 Upright, one for every QRS
Inverted before the QRS .16
.12 .10
.08 Sinus Bradycardia
Sinus bradycardia 7. Irregular
2. Regular 60
250 Fibrillatory
None Non
None .08
.24 Atrial Fibrillation, controlled
Ventricular Tachycardia 8. Regular
3. Regular 100
120 Upright, 1 for every QRS
Upright, before every QRS .28
.16 .08
.08 Sinus Rhythm with 1st degree block
Sinus Tachycardia 9. Regular except ectopic beats
4. Regular except for ectopic beats 100
100 Upright, 1 for each QRS complex
Upright, one for each QRS .20
.20 .12
.12 NSR with 2 PVCs
Bigeminy ( NSR with PVCs) 10. Irregular
5. Regular 70
80 Upright, 1 for every QRS
Sawtooth atrial rate 320, ventricular rate 80 .16
None .06
.10 Sinus Arrhythmia
Atrial Flutter, 4:1 conduction

34 RNnetwork Study Guide

 III. Cardiac

11. None 15. Regular

None 30
None None
None None
None 14-.16
Ventricular Fibrillation Idioventricular

12. Regular 16. Regular

190 90
None Upright, more than 1 p wave for every QRS
None Varies
Supraventricular Tachycardia .08
Second Degree Heart Block type II
13. Regular
30
More than 1 P for each QRS
No consistent PRI
Complete Heart Block (3rd degree)

14. Regular
40
Two P waves for each QRS
.28 and constant
12
Second Degree Heart Block Type II

RNnetwork Study Guide 35

 III. Cardiac

36 RNnetwork Study Guide

IV. Gastrointestinal
 IV. Gastrointestinal

This body system and its different illnesses comprise • Constipation: Medically defined as fewer than
over 50% of hospital admissions. A variety of factors 3 bowel movements per week. Constipation
can cause issues with the liver, pancreas, GI tract means different things to different people.
as well as bleeding. The following are the most For some it may mean infrequently stools.
commonly seen issues in the ER as well as admitted Many people, especially older Americans are
patients in the hospital. under the impression that if you do not have
• Hemorrhoids: Are painful swollen veins a bowel movement every day, it necessitates
in the lower part of the rectum or anus. using a laxative. Less than 50% of people have
Hemorrhoids may be internal or external. bowel movements every day. For some people,
A patient could have both types. The cause constipation means hard stools, difficulty
of hemorrhoids is often due to too much passing stools, or the feeling of incomplete
pressure on the veins in the pelvic and rectal emptying after a bowel movement. Treating
area. If you strain to have a bowel movement, this problem should be tailored to the patient’s
it increases the pressure and causes the specific complaint. Causes of constipation
veins in the tissues to swell. Pregnancy may can be related to inadequate water intake,
bring about hemorrhoids as well. The most inadequate fiber in the diet, traveling, inactivity,
common symptoms are bleeding during bowel stress, or resisting a bowel movement due to
movements, itching or rectal pain. With internal pain (hemorrhoids).
hemorrhoids you may see streak of bright red • Medications and treatments: Eat a well-
blood on the toilet paper. You may see bright balanced meal. Drink plenty of water. Avoid
red blood in the toilet after you have a normal caffeinated fluids as they have a tendency
bowel movement. External hemorrhoids may to dehydrate. Exercise regularly. If needed,
bleed but usually blood is not visually seen. The a mild stool softener or laxative such as
bleed forms a painful harden lump. Colace or Milk of Magnesia will help with
• Medications and treatments: Stool constipation.
softeners such as Phillips stool softener, – Milk of Magnesia: This medication
Dulcolax, Colace. Patients are counseled contains magnesium hydroxide. This
to increase the fiber in their diet. If issues medication has a chalky taste which for
with itching, there are over the counter some people makes the medication
medications such as Lanacaine which undesirable. Mixing the medication with
provides temporary anesthesia and relieves some type of flavored drink (Gatorade)
itching. Corticosteroids may be used to will greatly improve the taste.
help with inflammation and itching, however, – Docusate: Brand name Colace or
they can only be used for short periods of Surfak. This is a lubricating laxative. It
time. Chronic use may cause skin damage. may also be combined with a stimulant
If problems persist, then non-surgical and (combination) medication called Peri
surgical intervention options are presented. Colace in order to help the stool pass
http://www.webmd.com/a-to-z-guides/ easier and provide additional peristalsis.
hemorrhoids-topic-overview – Senekot: This is a stimulant laxative. This
http://www.medicinenet.com/hemorrhoids/ medication increases peristalsis
article.htm

38 RNnetwork Study Guide

 IV. Gastrointestinal

– Bisacodyl: This is a stimulant laxative – Increased by bending, stooping, lying down

manufactured under the names of or eating.
Correctol and Dulcolax. – Nausea after eating
– Miralax: An osmotic laxative that http://www.medicinenet.com/gastroesophageal_
contains polyethylene glycol and is reflux_disease_gerd/article.htm
usually used for two weeks or less
at a time. This medication is also • Medications and treatments: Do not lie
used in large doses as the prep for a down with a full stomach. Avoid eating 2-3
colonoscopy. hours before bedtime. Do not smoke. Eat
smaller meals. Lose weight. Sleep with your
Overuse of laxatives which can cause the head raised about 6 inches. Medications
bowel muscles to weaken. include proton pump inhibitors, H2
Warning: If a person has blood in the stool, antagonists, antacids, and promotility agents.
losing weight even though you are not dieting, The only surgical procedure is called a Nissen
severe pain with bowel movements, or the Fundoplication. Surgery is used only after
constipation has lasted longer than two weeks, all other non-surgical methods have been
the patient should seek medical attention by exhausted. Life styles changes and medications
calling their physician. often provide the patient with adequate relief.
http://www.medicinenet.com/constipation/ • Class: Proton Pump Inhibitors: These
article.htm medications are designed to reduce acid
http://www.webmd.com/digestive-disorders/ production. By reducing the acid production,
digestive-diseases-constipation the esophagus and other tissue will have the
chance to heal if any damage has occurred.
• GERD (Gastro Esophageal Reflux Disease): These medications are prescribed for people
Food is passed from the mouth through the who suffer from heartburn, ulcers of the
esophagus to the stomach. The stomach has a stomach or intestine, or excess stomach
sphincter that closes to prevent food, liquids, etc, acid. The following is a list of proton pump
from re-entering the esophagus. If this sphincter inhibitors that are commonly prescribed.
is incompetent, food or liquids may reflux back
into the esophagus causing a burning feeling in – Aciphex: Decreases the amount of acid
the stomach or esophagus called “heartburn”. production in the stomach. Used to treat
A hiatal hernia can also cause symptoms of GERD and other excessive acid producing
GERD. This is a condition where a part of the problems.
stomach moves above the diaphragm. Pregnancy – Nexium: Decreases the amount of acid
will often aggravate this condition as well as production in the stomach. It is also used
some drugs, cigarettes, alcohol and obesity. If to treat GERD, erosive esophagitis, and
you suspect a medication is causing this, let your other excessive acid producing problems.
physician know. The most common symptoms – Prevacid: Decreases the amount of acid
patients complain of are: production in the stomach. Used to treat
– Burning pain in the chest (under the and prevent stomach and intestinal ulcers,
breastbone) erosive esophagitis and other conditions
– More likely to be worse at night. involving excess stomach acid.

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 IV. Gastrointestinal

– Prilosec: Decreases the amount of acid http://www.nlm.nih.gov/medlineplus/

production in the stomach. Used for GERD irritablebowelsyndrome.html
and other conditions involving excess How is IBS diagnosed? Your physician will take a
stomach acid production. complete medical history including the patient
– Protonix: Decreases the amount of acid providing a careful description of symptoms
production in the stomach. Used to treat and a physical exam. There is no specific
damage to the esophagus due to acid reflux. test for IBS, although diagnostic tests may be
– Over the Counter: Prevacid, Prilosec, performed to rule out other disease process.
Zantac, and Tagamet. • Medications and treatments: The most
The testing used to determine whether a patient common treatment is increasing fiber in the
has the problem includes: an EGD, barium swallow, diet, which reduces the chance of spasm. Fiber
and continuous esophageal Ph monitoring. Certain also promotes regular bowel movements,
foods can aggravate the symptoms. Some of these helping to reduce bloating. Increasing exercise
include: alcohol, caffeine, carbonated beverages, and quitting smoking will reduce the “flares”.
fruits, fruit juices, and tomato sauces. Patients Identifying food intolerances will also help
should try to identify these foods. Keeping a food decrease symptoms associated with irritable
diary may reveal the offending foods. bowel syndrome. Medications used to treat
IBS such as antispasmodics slow the action of
Warning: If the patient experiences bleeding, the digestive tract and reduce the chance of
choking, shortness of breath, vomiting, or spasm. Examples of antispasmodics are Bentyl,
trouble swallowing, this patient should be Levsin, and Levbid are used in the treatment
seen by a physician as soon as possible. If the of IBS.
patient is at home, they should be taken to an
emergency room. • Antidiarrheal medication such as Imodium
may be used as well. Antidepressants may be
• Irritable Bowel Syndrome: This syndrome is prescribed in small doses which have been
characterized by cramping, abdominal pain, found to help alleviate bowel symptoms. If
bloating constipation, and diarrhea. Despite these treatments are not effective and do
the very uncomfortable and often distressing not provide consistent relief for the patient,
symptoms, the intestines are not permanently the physician may prescribe Zelnorm or
harmed, and do not lead to other serious Lotronex. These medications are used for
diseases as cancer. Symptoms can be controlled women and are approved for short term
with diet, stress management, and medications. use only. This medication is taken twice daily,
For some people, however, this disease can 30 minutes before morning and evening
be disabling. They are unable to work, attend meals. The length of treatment is 4-6 weeks.
social events or even travel short distances. If the patient does respond to this therapy
Symptoms can vary from person to person. an additional 4-6 weeks may be prescribed.
http://www.webmd.com/ibs/guide/irritable- This medication has not been sufficiently
bowel-syndrome-ibs-topic-overview studied in men; therefore the FDA has not
http://www.medicinenet.com/irritable_bowel_ approved it for IBS in men.
syndrome/article.htm http://www.ncbi.nlm.nih.gov/pubmedhealth/
http://www.umm.edu/ency/article/000249.htm PMH0001292/

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 IV. Gastrointestinal

• GI Bleed: Blood loss in the gastrointestinal There is no single cause of colon cancer. Nearly
tract, from the pharynx to the rectum. Its all colon cancers begin as non-cancerous
causes are diverse. A medical history and (benign) polyps which slowly develop into
physician exam, generally distinguishes between cancer.
the main forms. The degree of bleeding can Risk factors:
range from nearly undetectable to acute,
massive, and life-threatening. Management of • Older than 60
this problem is also determined by whether it • African American of Easter European
is an upper GI bleed or lower GI bleed. descent
• Initial treatment is focused on resuscitation • Diet high in red meats
of blood volume with intravenous fluids • Cancer somewhere else in the body
and blood transfusion. Medications used
• Colorectal polyps
to treat are proton pump inhibitors and
occasionally with vasopressin. Vasopressin • IBS
causes constriction of the arteries, thereby • Family history
reducing blood loss. Upper endoscopy
• History of breast cancer
and colonoscopy are generally considered
appropriate to identify the source of • Genetics
bleeding and determine the therapeutic • Tests to screen for colorectal cancer:
interventions. Gastrointestinal bleeding can Colonoscopy, Sigmoidoscopy, Complete Blood
range from microscopic bleeding, where Count, and Liver Function Tests. There are 4
the amount of blood is so small that is can stages of cancer. As the stage number increases,
only be detected by laboratory testing, the severity of the cancer is increased.
to massive bleeding where frank blood
• Treatment: Surgery, Chemotherapy, or
is passed and hypovolemic shock may
Radiation therapy.
develop.
http://digestive.niddk.nih.gov/ddiseases/pubs/
bleeding/
• Colon Cancer: Colon or colorectal cancer is
found in the large intestine or the rectum. The
term colon cancer refers to colon carcinoma
only. Colon cancer in one of the leading causes
of cancer-related deaths in the United States.
Early diagnosis often leads to complete cure.
Colon cancer is, in many cases, a treatable
disease. How well you do depends on many
things, including the stage of the cancer. When
treated in the early stages, patients often
survive about 5 years after the diagnosis. If
it does not return in 5 years, the patient is
considered cured.

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 IV. Gastrointestinal

42 RNnetwork Study Guide

V. Genitourinary
 V. Genitourinary

The genitourinary system consists of the kidneys, stents can also be placed with this procedure
ureters, bladder and urethra. The kidneys are to help increase the flow of urine from the
located in the back below the ribs. The kidneys kidneys to the bladder.
are responsible for water and electrolyte balance, • Enlarged Prostate: The first signs and symptoms
and removing wastes. The kidneys also produce a are frequent trips to the bathroom at night to
hormone called erythropoietin which stimulates void. Difficulty starting urination and leaking are
the bone marrow to produce red blood cells. The other initial symptoms.The prostate enlarges
ureters are narrow long cylindrical tubes which are over time as a man gets older. By the age of 60,
responsible for the flow of urine from the kidney to over 50% of men have BPH (Benign Prostate
the bladder. The bladder stores the urine and when Hypertrophy).The enlarging prostate begins to
a certain level/pressure is met, the patient feels the put pressure on the urethra.This causes narrowing
need to urinate. When urination occurs the bladder of the urethra.This blockage does not allow the
empties through the urethra. The bladder contracts bladder to empty completely. Other symptoms
and flattens. The amount of urine produced and include straining to urinate, continued dribbling
voided by a patient depends on the amount of fluid of urine, and a feeling of incomplete bladder
intake, and intake of high water content foods. The emptying. Due to the bladder not completely
amount of urine produced in an adult is 1.5 quarts emptying, men are more susceptible to bladder
of urine each day. infections. BPH Impact Index is a monitoring
• Cystitis: Signs and symptoms of cystitis include scale which allows doctors to determine when
feelings of urgency, burning, voiding small a patient made need treatment. A score of less
amounts of urine, hematuria and pressure in than 8, is considered mild BPH and the physician
the lower abdomen. Sometimes the patient will monitor this patient periodically to see if the
will also have a fever. These symptoms are score is elevating. When the patient symptoms
caused due to a bacterial infection. Cystitis is start affecting quality of life the physician may start
more common is women than in men. Women medications, or use a minimally invasive procedure
have a much shorter urethra thus it is easier that can be done in the office. If these treatments
for bacteria to enter the bladder. Urinalysis fail to provide relief, surgery is the solution.There
and urine cultures are used to determine are several medications that can be taken to help
if a patient has cystitis. There is a variety of relieve symptoms.
antibiotics that can be used to treat cystitis. The http://www.ncbi.nlm.nih.gov/pubmedhealth/
patient usually takes a course of antibiotics for PMH0001419/
one week. If the infection has advanced to the
kidneys, the treatment takes longer. If a patient http://kidney.niddk.nih.gov/kudiseases/pubs/
continues to have frequent chronic infections, a prostateenlargement/
cystoscopy (a scope procedure that allows the – Medications and treatments: Alpha Blockers:
physician to look inside the bladder) is done. These drugs work by relaxing the muscles
Often times the urethra needs dilation due around the prostate and bladder neck,
to the chronic inflammation associated with however they do not reduce the size of the
frequent urinary tract infections. During the prostate. Relaxation of the muscles around the
cystoscopy, the physician can look for bladder prostate and bladder neck allow urine to flow
stones, causes of blood in the urine, enlarged more easily.The names of some of these drugs
prostate, kidney stones or tumors. Ureteral are Flomax, Uroxatral, Hytrin and Cardura.

44 RNnetwork Study Guide

 V. Genitourinary

– Alpha Reductase Inhibitors: These drugs • Renal Calculi (Kidney Stones): The stones are
work by reducing the levels of a male made up of tiny crystals that create a solid mass
hormone (dihydrotestosterone) DHT and can be found in the kidney or in the bladder.
which can partially shrink the prostate. Kidney stones will block the flow of urine out
These drugs may take up to three months of the kidneys causing the kidneys to swell.The
to work, but urine flow is improved. These pain associated with this problem is severe.
drugs can also reduce the need for surgery. These patients present in the emergency room
Names of these drugs are Proscar and doubled over with pain and often are nauseated.
Avodart. A person who gets kidney stones will often get
– Invasive treatments: These treatments them again in the future.There are different types
are aimed at removing tissue pressing on of kidney stones, which can be made of different
the urethra, destruction of select tissue, types of substances depending on the cause.
or placement of a urethral stent. These Stones made of calcium are the most common.
procedures can be done in the office. Calcium often binds with other substances such
as oxalate. Cystine stones are formed in patients
– Surgery: Transurethral resection of the who have cystinuria, which is caused by too much
prostate (TURP) is the most common amino acid production by the body. It is a genetic
surgical procedure for BPH. This procedure defect known as an autosomal recessive disorder.
cuts tissue and seals blood vessels. One You must inherit the gene from both parents in
side effect of this surgery is retrograde order to have symptoms. Symptoms of kidney
ejaculation. A man will ejaculate backwards stones also includes: abnormal urine color, blood
into the bladder. This is not painful and in the urine, fever, nausea, and vomiting.There are
should not be issue unless fertility is a several tests that can be done to determine if a
concern. Erection problems occur in patient has kidney stones: An abdominal CT/MRI,
5-35% of men. This is often temporary and intravenous pyleogram (IVP) and ultrasound.
normal functioning returns after several
months. Transurethral incision of the http://www.ncbi.nlm.nih.gov/pubmedhealth/
prostate (TUIP) is a surgical procedure that PMH0001493/
places cuts in the prostate, but does not • Medications and treatments: Treatment
remove prostate tissue. The cuts reduce will vary depending on the type of stone
the pressure on the urethra, thus making it and the severity of symptoms. If symptoms
easier to urinate. Open Prostate Surgery are severe, the patient may be hospitalized.
requires the surgeon to make an incision If the physician feels that the stone will pass,
in the abdomen. This surgery is done when the patient will often be given intravenous
the prostate severely enlarged. Surgery fluids and need to increase the amount of
may be required if there is bladder damage, oral fluid intake and strain the urine each
bladder stones or the urethra is narrowed. time he/she urinates in order to collect any
Recovery takes several weeks to months. kidney stones that pass in order for them
Patients go home with a Foley catheter and to be analyzed by the lab. Pain relievers
is removed when the surgeon feels that the are prescribed if pain is severe. For less
patient is able to urinate on their own. severe symptoms NSAIDs are often
recommended. Medications can also be

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 V. Genitourinary

prescribed depending on the type of stone.

Medications used are Allopurinol (for
uric acid stones), Antibiotics (for struvite
stones), or diuretics. Surgical intervention
is done if the stone is too large to pass, is
increasing in size or is blocking the flow of
urine from the kidneys to the bladder. The
most common, non-invasive procedure, is
Lithotripsy. Lithotripsy uses ultrasonic waves
to break the kidney stones into smaller
pieces. Reducing the size of the stones by
this method often will allow the stones
to pass. Ureteroscopy may be used for
stones located in the lower urinary tract.
Nephrolithotomy is the standard open
surgical procedure that may be needed if
other methods fail or for some reason are
not possible.
http://www.mayoclinic.com/health/urinary-
tract-infection/DS00286
http://kidney.niddk.nih.gov/kudiseases/pubs/
stonesadults/
http://www.medicinenet.com/interstitial_
cystitis/article.htm
Warning: If the patient has a sudden and complete
inability to urinate, this is a medical emergency.
Patients should see their doctor right away or go
to the emergency room. A Foley catheter will be
placed temporarily to allow the bladder to empty.

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VI. Wounds
 VI. wounds

Phases of Wound Healing - The entire wound Staging Pressure Ulcers

healing process is a complex series of events The following information was copied verbatim
beginning the moment of injury and can continue from the AHCPR Guidelines, which is consistent
for months to years. The following overview is with the recommendations of the National
designed to help identify the stages of wound Pressure Ulcer Advisory Panel (NPUAP) Consensus
healing. Development Conference:
• Inflammatory Phase • Stage 1
• Immediate - to 2-5 days Nonblanchable erythema (redness) of intact
• Hemostasis – Vasoconstriction, platelet skin, the heralding lesion of skin ulceration. In
aggregation, thromboplastin forms a clot individuals with darker skin, discoloration of the
skin, warmth, edema, induration, or hardness
• Inflammation – Vasodilation, phagocytosis
may also be indicators.This pressure ulcer is
• Proliferative Phase an observable ulcer related to alteration of
• 2 days to 3 weeks intact skin whose indicators, as compared to
the adjacent or opposite area on the body, may
• Granulation – Fibroblasts lay a bed of
include changes in one or more of the following:
collagen, fills the defect and produces new
Skin temperature (warmth or coolness)tissue
capillaries needed to begin wound healing.
consistency (firm or boggy feel) and/or sensation
• Contraction – Wound edges pull together (pain, itching).The ulcer appears as a defined area
to reduce the defect. Often seen as the of persistent redness or lightened pigmented
formation of a scab. skin. Whereas in darker skin tones, the ulcer may
• Epithelialization – Crosses moist surface appear with persistent red, blue, or purple hues.
and cells travel about 3 cm from point of • Stage 2
origin in all directions Partial thickness skin loss involving epidermis,
• Remodeling Phase dermis, or both. The ulcer is superficial and
• 3 weeks to 2 years presents clinically as an abrasion, blister, or
shallow crater.
• New collagen forms which increases tensile
strength to wounds • Stage 3
Full thickness skin loss involving damage to
• Scar tissue is only 80 percent as strong as or necrosis of subcutaneous tissue that may
original tissue extend down to, but not through, underlying
fascia (muscle). The ulcer presents clinically as
a deep crater with or without undermining of
adjacent tissue.
• Stage 4
Full thickness skin loss with extensive destruction,
tissue necrosis, or damage to muscle, bone, or
supporting structures (e.g., tendon, joint capsule).
Undermining and sinus tracts also may be
associated with Stage 4 pressure ulcers.

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 VI. wounds

Ulcer Care • If there is an urgent need for debridement,

Initial care of the pressure ulcer involves as with advancing cellulitis or sepsis, sharp
debridement, wound cleansing, the application of debridement should be used. Surgical
dressings, and possibly adjunctive therapy. In some debridement is often the choice for this
cases, operative repair will be required. In all cases, urgent issue.
specific wound care strategies should be consistent • Those performing sharp debridement
with overall patient goals. should have demonstrated the necessary
• Debridement: clinical skills and meet licensing
requirements.
• Moist, devitalized tissue supports the
growth of pathological organisms. • Although small wounds can be debrided at
Therefore, the removal of such tissue the bedside, extensive wounds are usually
favorably alters the healing environment debrided in the operating room or in a
of a wound. Although debridement is special procedures room. When debriding
a time- honored modality for treating extensive Stage IV ulcers in the operating
pressure ulcers, it has not been studied in a room, the surgeon should consider a bone
randomized trial. biopsy to detect osteomyelitis.

• Removal of devitalized tissue: Remove • Mechanical debridement techniques

devitalized tissue in pressure ulcers when include wet-to-dry dressings, hydrotherapy,
appropriate for the patient’s condition. This wound irrigation, and dextranomers.
reduces chances of infection and allows growth • Enzymatic debridement is accomplished
of healthy tissue to take place. by applying topical debridement agents
• Selection of a method: Select the method of (creams, enzyme ointments) to devitalized
debridement most appropriate to the patient’s tissue on the wound surface.
condition and goals. • Autolytic debridement involves the use of
• Sharp, mechanical, enzymatic, and/or synthetic dressings to cover a wound and
autolytic debridement techniques may be allow devitalized tissue to self-digest from
used when there is no urgent clinical need enzymes normally present in wound fluids.
for drainage or removal of devitalized tissue. This technique should not be used if the
wound is infected.
• Sharp debridement involves the use of a
scalpel, scissor, or other sharp instrument • Dressings during and after debridement:
to remove devitalized tissue. This method Use clean, dry dressings for 8 to 24 hours
is the most rapid form of debridement and after sharp debridement associated with
may be the most appropriate technique bleeding; then reinstitute moist dressings. Clean
for removing areas of thick, adherent dressings may also be used in conjunction
eschar (usually caused from a burn) and with mechanical or enzymatic debridement
devitalized tissue in extensive ulcers. techniques.

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 VI. wounds

• Stable heel ulcers, an exception: Heeling ulcers • Appropriate irrigation pressures: Use enough
with dry eschar need not be debrided if they irrigation pressure to enhance wound cleansing
do not have edema, erythema, fluctuance, or without causing trauma to the wound bed.
drainage. Assess these wounds daily to monitor Safe and effective ulcer irrigation pressures
for pressure ulcer complications that would range from 4 to 15 pounds per square inch
require debridement (e.g., edema, erythema, (psi). Irrigation pressures below 4 psi may not
fluctuance, drainage). cleanse the wound adequately, and pressures
• Pain: Prevent or manage pain associated with greater than 15 psi may cause trauma and
debridement as needed. drive bacteria into the wound tissue. Irrigation
devices that deliver 8 psi of pressure are
Wound Cleansing - Wound healing is optimized significantly more effective in removing bacteria
and the potential for infection is decreased when all and preventing infection than is a bulb syringe.
necrotic tissue, exudate, and metabolic wastes are
removed from the wound. The process of cleansing • Whirlpool: Consider whirlpool treatment for
a wound involves selecting both a wound-cleansing cleansing pressure ulcers that contain thick
solution and a mechanical means of delivering that exudate, slough, or necrotic tissue. Note that
solution to the wound. The benefits of obtaining trauma can result if the wound is positioned
a clean wound must be weighed against the too close to the high-pressure water jets.
potential trauma to the wound bed as a result of Discontinue whirlpool when the ulcer is clean.
such cleansing. Routine wound cleansing should Dressings - Pressure ulcers require dressings to
be accomplished with a minimum of chemical and maintain their physiologic integrity. An ideal dressing
mechanical trauma. should protect the wound, be biocompatible, and
• Cleanse wounds initially and at each dressing provide ideal hydration. The condition of the ulcer
change bed and the desired dressing function determine the
type of dressing needed. The cardinal rule is to keep
• Nontraumatic technique: Use minimal the ulcer tissue moist and the surrounding intact
mechanical force and less coarse materials skin dry.
when cleansing the ulcer with gauze, cloth,
or sponges. • Selection of a dressing: Use a dressing that
will keep the ulcer bed continuously moist.
• Avoidance of antiseptics: Do not clean (Wet-to-dry dressings should be used only
ulcer wounds with skin cleansers or for debridement and are not the same as
antiseptic agents (e.g., povidone, iodine, continuously moist saline dressings, which
iodophor, sodium hypochlorite solution keep the ulcer bed moist.) The following
[Dakin’s solution], hydrogen peroxide or criteria should be considered when selecting a
acetic acid), because they are cytotoxic. dressing:
Table 2 delineates a toxicity index by listing
the dilutions required for various skin and • Moist ulcer bed: Use clinical judgment
wound cleansers to maintain the viability to select a type of moist wound dressing
and phagocytic function of white blood suitable for the ulcer. Studies of different
cells exposed to these agents. types of moist wound dressings showed
no differences in pressure ulcer healing
• Normal saline: Use normal saline for outcomes.
cleansing most pressure ulcers.

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 VI. wounds

• Dry surrounding skin: Choose a dressing

that keeps the surrounding skin intact
(periulcer) dry while keeping the ulcer bed
moist.
• Exudate control: Choose a dressing that
controls exudate but does not desiccate
the ulcer bed. Excessive exudate may delay
wound healing and macerate surrounding
tissue.
• Caregiver time: Consider caregiver
time when selecting a dressing. Film and
hydrocolloid dressings require less caregiver
time than do continuously moist saline
gauze dressings.
• Clinicians should also consider the following:
• Prevent abscess formation: Eliminate
wound dead space by loosely filling all
cavities with dressing material. Avoid over
packing the wound. Over packing may
increase pressure and cause additional
tissue damage.
• Keep dressings intact: Monitor dressings
applied near the anus, because they are
difficult to keep intact. Taping the edges of
dressings (“picture-framing”) may reduce
this problem.
http://www.medicaledu.com/default.htm

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 VI. wounds

52 RNnetwork Study Guide

VII. Diabetes mellitus (DM)
 VIi. Diabetes mellitus (DM)

Diabetes Mellitus is a multisystem disease with both The cause of type 1 diabetes is different from the
biochemical and anatomical/structural consequences. cause of the more familiar type 2 diabetes. In type
It is a chronic disease of carbohydrate, fat, and 2 diabetes, the islet cells are still functioning, but the
protein metabolism caused by the lack of insulin, body becomes resistant to insulin or the pancreas
which results from the marked and progressive does not produce enough insulin or both.
inability of the pancreas to secrete insulin because Symptoms
of autoimmune destruction of the beta cells. Signs and symptoms can come on quickly and may
Type I DM include:
Causes • Increased thirst and frequent urination. As
The exact cause of type 1 diabetes is unknown. We excess sugar builds up in your bloodstream,
do know that in most people with type 1 diabetes, fluid is pulled from the tissues causing thirst. As
their body’s own immune system — which normally a result, you may drink — and urinate — more
fights harmful bacteria and viruses — mistakenly than usual.
destroys the insulin-producing (islet) cells in the • Extreme hunger. Without enough insulin to
pancreas. Genetics may play a role in this process, and move sugar into cells, muscles and organs are
exposure to certain viruses may trigger the disease. depleted of energy, triggering intense hunger
Whatever the cause, once the islet cells are that may persist even after eating. Without
destroyed, we produce little or no insulin. Normally, insulin, the sugar in food never reaches energy-
the hormone insulin helps glucose enter our cells starved tissues.
providing energy to our muscles and tissues. Insulin • Weight loss. Despite eating more than usual
comes from the pancreas, a gland located just behind to relieve hunger, weight loss may occur —
the stomach. When everything is working properly, sometimes rapidly. Without the energy sugar
after eating, the pancreas secretes insulin into the supplies, muscle tissue and fat stores may
bloodstream. As insulin circulates, it acts like a key simply shrink.
unlocking microscopic doors allowing sugar to enter
• Fatigue. If cells are deprived of sugar, you may
the body’s cells. Insulin lowers the amount of sugar in
become tired and irritable.
the bloodstream, and as the blood sugar level drops,
so does the secretion of insulin from the pancreas. • Blurred vision. If blood sugar level is too high,
fluid may be pulled from tissues — including
The liver stores and manufactures glucose. When
the lenses of the eyes, affecting the ability to
insulin levels are low — not having eaten in a while,
focus clearly.
for example — the liver converts stored glycogen
back to glucose to keep our blood glucose level
within a normal range.
In type 1 diabetes, none of this occurs because
there is no insulin to let glucose into the cells. So
instead of being transported into our cells, sugar
builds up in our bloodstream, where it can cause
life-threatening complications.

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 VIi. Diabetes mellitus (DM)

Complications: • Kidney damage (nephropathy). The kidneys

Type 1 diabetes affects many of the major organs, contain millions of tiny blood vessel clusters
including the heart, blood vessels, nerves, eyes and that filter waste from our blood. Diabetes
kidneys. Keeping our blood sugar level close to can damage this delicate filtering system.
normal most of the time can dramatically reduce Severe damage can lead to kidney failure or
the risk of many complications. irreversible end-stage kidney disease, requiring
Long-term complications of type 1 diabetes dialysis or a kidney transplant.
develop gradually, over years. The earlier diabetes • Eye damage. Diabetes can damage the blood
is developed combined with poor control of blood vessels of the retina (diabetic retinopathy),
sugar — the higher the risk of complications. potentially leading to blindness. Diabetes
Eventually, diabetes complications may be disabling also increases the risk of other serious vision
or even life-threatening. conditions, such as cataracts and glaucoma.
• Heart and blood vessel disease. Diabetes • Foot damage. Nerve damage in the feet or
dramatically increases the risk of various poor blood flow to the feet increases the risk
cardiovascular problems, including coronary of various foot complications. Left untreated,
artery disease with chest pain (angina), heart cuts and blisters can become serious infections.
attack, stroke, narrowing of the arteries Severe damage might require toe, foot or even
(atherosclerosis) and high blood pressure. In leg amputation.
fact, about 65 percent of people who have • Skin and mouth conditions. Diabetes increases
type 1 or type 2 diabetes die of some type of our susceptibility to skin problems, including
heart or blood vessel disease, according to the bacterial and fungal infections. Gum infections
American Heart Association. also may be a concern, especially with a history
• Nerve damage (neuropathy). Excess sugar of poor dental hygiene.
can injure the walls of the tiny blood vessels • Osteoporosis. Diabetes may lead to lower
(capillaries) that nourish nerves, especially than normal bone mineral density, increasing
in the legs. This can cause tingling, numbness, the risk of osteoporosis.
burning or pain typically beginning at the tips
of the toes or fingers gradually spreading • Pregnancy complications. High blood sugar
upward. Poorly controlled blood sugar could levels can be dangerous for both the mother
lead to the loss of all sense of feeling in the and the baby. The risk of miscarriage, stillbirth
affected limbs. Nerve damage that affects the and birth defects are increased when diabetes
gastrointestinal tract can lead to problems with is not well controlled. For the mother, diabetes
nausea, vomiting, diarrhea or constipation. For increases the risk of diabetic ketoacidosis,
men, erectile dysfunction may be an issue. diabetic eye problems (retinopathy),
pregnancy-induced high blood pressure and
preeclampsia.
• Hearing problems. Hearing impairments occur
more often in people with diabetes.

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 VIi. Diabetes mellitus (DM)

Tests and Diagnosis: higher suggests diabetes, especially when

In June 2009, an international committee of experts coupled with any of the signs and symptoms
from the American Diabetes Association, the of diabetes, such as frequent urination and
European Association for the Study of Diabetes extreme thirst. A level between 140 mg/dL
and the International Diabetes Federation (7.8 mmol/L) and 199 mg/dL (11.0 mmol/L) is
recommended that type 1 diabetes testing include considered prediabetes, which is a greater risk
the following: of developing diabetes.
• Glycated hemoglobin (A1C) test. This blood • Fasting blood sugar test. A blood sample is
test indicates the average blood sugar level taken after an overnight fast. A fasting blood
for the past two to three months. It measures sugar level less than 100 mg/dL (5.6 mmol/L) is
the percentage of blood sugar attached to normal. A fasting blood sugar level from 100 to
hemoglobin, the oxygen-carrying protein in 125 mg/dL (5.6 to 6.9 mmol/L) is considered
red blood cells. The higher the blood sugar prediabetes. Diabetes is diagnosed If it is 126
levels, the more hemoglobin there is with mg/dL (7 mmol/L) or higher on two separate
sugar attached. An A1C level of 6.5 percent or tests. A level from 100 mg/dL (5.6 mmol/L)
higher on two separate tests indicates diabetes. to 125 mg/dL (6.9 mmol/L) is considered
A result between 5.7 and 6.4 percent is prediabetes.
considered prediabetes, which indicates a high Treatment
risk of developing diabetes. Type 1 diabetes mellitus (DM) requires a
If the A1C test is not available, or certain multidisciplinary approach by the physician, nurse,
conditions making the A1C test inaccurate — and dietitian. In patients with new-onset type 1
such as pregnancy or an uncommon form of diabetes, lifelong insulin therapy must be started.
hemoglobin (known as a hemoglobin variant) Many patients present with diabetic ketoacidosis
— the following tests to diagnose diabetes may (DKA). On occasion, the patient with new-
be used: onset type 1 diabetes who presents with mild
• Random blood sugar test. A blood sample is manifestations and who is judged to be compliant
taken at a random time. Blood sugar values can begin insulin therapy as an outpatient. However,
are expressed in milligrams per deciliter (mg/ this approach requires close follow-up and
dL) or millimoles per liter (mmol/L). Regardless the ability to provide immediate and thorough
of when the last meal was, a random blood education about the use of insulin; the signs,
sugar level of 200 mg/dL (11.1 mmol/L) or symptoms, and treatment of hypoglycemia; and the
need to self-monitor blood glucose levels.
Types of Insulin
Type Onset (hr) Peak (hr) Duration (hr)
Aspart™ (Novolog ), Glulisine™ (Apidra ),
® ®
0.2-0.5 0.5-2 3-4
Lispro™ (Humalog®)
Regular (Humulin® R, Novolin®, Novolin® R) 0.5-1 2-3 6-8
NPH™ (Humulin N , Novolin N , Novolin NPH )
® ® ®
1.5 4-10 16-24
Lente™ 1.5-3 7-15 16-24
Ultralente™ (Humulin U )®
3-4 9-15 22-28
Glargine™ (Lantus®) ? No peak 24-36

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 VIi. Diabetes mellitus (DM)

Type II DM • Family history

Type II DM is characterized by the combination of – The risk of type 2 diabetes increases if your
peripheral insulin resistance and inadequate insulin parent or sibling has type 2 diabetes.
secretion by pancreatic beta cells. Insulin resistance, • Race
which has been attributed to elevated levels of free – Although it is unclear why, people of
fatty acids in plasma, leads to decreased glucose certain races — including blacks, Hispanics,
transport into muscle cells, elevated hepatic glucose American Indians and Asian-Americans —
production, and increased breakdown of fat. are more likely to develop type 2 diabetes
For type 2 diabetes mellitus to occur, both defects than whites are.
must exist. For example, all overweight individuals • Age
have insulin resistance, but diabetes develops only – The risk of type 2 diabetes increases
in those who cannot increase insulin secretion as you get older, especially after age 45.
sufficiently to compensate for their insulin resistance. That is probably because people tend to
Their insulin concentrations may be high, yet exercise less, lose muscle mass and gain
inappropriately low for the level of glycemia. weight as they age. But type 2 diabetes is
In the progression from normal glucose tolerance also increasing dramatically among children,
to abnormal glucose tolerance, postprandial blood adolescents and younger adults.
glucose levels increase first; eventually, fasting • Prediabetes
hyperglycemia develops as suppression of hepatic – Prediabetes is a condition in which your
gluconeogenesis fails. blood sugar level is higher than normal, but
Type 2 diabetes major risk factors not high enough to be classified as type 2
Researchers do not fully understand why some diabetes. Left untreated, prediabetes often
people develop type 2 diabetes and others do progresses to type 2 diabetes.
not. It is clear that certain factors increase the risk, • Gestational diabetes
however, including: – If you developed gestational diabetes when
• Weight you were pregnant, your risk of developing
– Being overweight is a primary risk factor for type 2 diabetes later increases. If you give
type 2 diabetes.The more fatty tissue you have, birth to a baby weighing more than 9
the more resistant cells become to insulin. pounds (4.1 kilograms), you are also at risk
• Fat distribution of type 2 diabetes.
– If your body stores fat primarily in your
abdomen, your risk of type 2 diabetes
is greater than if your body stores fat
elsewhere, such as your hips and thighs.
• Inactivity
– The less active you are, the greater your
risk of type 2 diabetes. Physical activity
helps you control your weight, uses up
glucose as energy and makes your cells
more sensitive to insulin.

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 VIi. Diabetes mellitus (DM)

Symptoms Tests and diagnosis

Type 2 diabetes symptoms may develop very slowly. In June 2009, an international committee composed of
In fact, you can have type 2 diabetes for years and experts from the American Diabetes Association, the
not even know it. Look for: European Association for the Study of Diabetes and
• Increased thirst and frequent urination the International Diabetes Federation recommended
– As excess sugar builds up in your that type 2 diabetes testing include the:
bloodstream, fluid is pulled from the tissues. • Glycated hemoglobin (A1C) test. This blood
This may leave you thirsty. As a result, you test indicates average blood sugar level for
may drink — and urinate — more than the past two to three months. It measures
usual. the percentage of blood sugar attached to
• Increased hunger hemoglobin, the oxygen-carrying protein in red
– Without enough insulin to move sugar blood cells. The higher the blood sugar levels,
into your cells, your muscles and organs the more hemoglobin will have sugar attached.
become depleted of energy. This triggers An A1C level of 6.5 percent or higher on
intense hunger. two separate tests indicates diabetes. A result
between 5.7 and 6.4 percent is considered
• Weight loss prediabetes, which indicates a high risk of
– Despite eating more than usual to relieve developing diabetes. Normal levels are below
hunger, you may lose weight. Without the 5.7 percent.
ability to metabolize glucose, the body
uses alternative fuels stored in muscle and If the A1C test is not available, or if there are
fat. Calories are lost as excess glucose is certain conditions that can make the A1C
released in the urine. test inaccurate — such pregnancy or an
uncommon form of hemoglobin (known as a
• Fatigue hemoglobin variant) — the following tests to
– If your cells are deprived of sugar, you may diagnose diabetes may be used:
become tired and irritable.
• Random blood sugar test. A blood sample will
• Blurred vision be taken at a random time. Blood sugar values
– If your blood sugar is too high, fluid may be are expressed in milligrams per deciliter (mg/
pulled from the lenses of your eyes. This dL) or millimoles per liter (mmol/L). Regardless
may affect your ability to focus clearly. of when you last ate, a random blood sugar
• Slow-healing sores or frequent infections level of 200 mg/dL (11.1 mmol/L) or higher
– Type 2 diabetes affects your ability to heal suggests diabetes, especially when coupled with
and resist infections. any of the signs and symptoms of diabetes,
• Areas of darkened skin such as frequent urination and extreme thirst.
– Some people with type 2 diabetes have A level between 140 mg/dL (7.8 mmol/L)
patches of dark, velvety skin in the folds and 199 mg/dL (11.0 mmol/L) is considered
and creases of their bodies — usually in prediabetes, which puts you at greater risk of
the armpits. This condition, called acanthosis developing diabetes. A blood sugar level less
nigricans, may be a sign of insulin resistance. than 140 mg/dL (7.8 mmol/L) is normal.

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• Fasting blood sugar test. A blood sample will be If you are diagnosed with diabetes, the doctor may
taken after an overnight fast. A fasting blood sugar do other tests to distinguish between type 1 and
level less than 100 mg/dL (5.6 mmol/L) is normal. type 2 diabetes — which often require different
A fasting blood sugar level from 100 to 125 mg/ treatment strategies because in type 1 diabetes, the
dL (5.6 to 6.9 mmol/L) is considered prediabetes. pancreas no longer makes insulin.
If it is 126 mg/dL (7 mmol/L) or higher on two After the diagnosis
separate tests, you have diabetes mellitus. From A1C levels need to be checked between two and
100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9 four times a year. The target A1C goal may vary
mmol/L) is considered prediabetes, which puts depending on age and various other factors. However,
you at greater risk of developing diabetes. for most people, the American Diabetes Association
• Oral glucose tolerance test. For this test, you recommends an A1C level below 7 percent.
fast overnight, and the fasting blood sugar level * The American Diabetes Association has a formula
is measured. Then you drink a sugary liquid, that translates the A1C into what is known as an
and blood sugar levels are tested periodically estimated average glucose (eAG). The eAG more
for the next several hours. A blood sugar closely correlates with daily blood sugar readings.
level less than 140 mg/dL (7.8 mmol/L) is An A1C of 7 percent translates to an eAG of 154
normal. A reading of more than 200 mg/ mg/dL (8.5 mmol/L).
dL (11.1 mmol/L) after two hours indicates
diabetes. A reading between 140 and 199 mg/ Compared with repeated daily blood sugar tests,
dL (7.8 mmol/L and 11.0 mmol/L) indicates A1C testing better indicates how well your diabetes
prediabetes. treatment plan is working. An elevated A1C level
may signal the need for a change in your medication
The American Diabetes Association recommends or meal plan.
routine screening for type 2 diabetes beginning
at age 45, especially if you are overweight. If the
results are normal, repeat the test every three years.
Screening is also recommended for people who
are under 45 and overweight if there are other
heart disease or diabetes risk factors present, such
as a sedentary lifestyle, a family history of type 2
diabetes, a personal history of gestational diabetes
or blood pressure above 135/80 millimeters of
mercury (mm Hg).

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 VIi. Diabetes mellitus (DM)

Treatment
Medications for type 2 diabetes
Healthy lifestyle choices — including diet, exercise and weight control — are an important part of diabetes
treatment. Sometimes medication to control blood sugar is needed, too. Sometimes a single medication is
effective. In other cases, a combination of medications works better.
Medications for type 2 diabetes come in various classes — alpha-glucosidase inhibitors, amylin agonists,
dipeptidyl-peptidase 4 (DPP-4) inhibitors, meglitinides, sulfonylureas and thiazolidinediones. Each class
contains one or more specific drugs. Some of these drugs are taken orally, while others must be injected.
Various diabetes drugs work in different ways to lower blood sugar. A drug may work by:
• Stimulating the pancreas to produce and release more insulin
• Inhibiting the production and release of glucose from the liver, which means you need less insulin to
transport sugar into your cells
• Blocking the action of stomach enzymes that break down carbohydrates or make tissues more sensitive
to insulin.
Medication that increase insulin producton
Medications (examples) Route Advantages Disadvantages
Dipeptidyl-peptidase 4 (DPP-4)
May cause upper respiratory tract infection, sore
inhibitors
By mouth Do not cause weight gain throat and headache; Sitagliptin has been associated
• Saxagliptin (Onglyza)
with severe inflammation of the pancreas
• Sitagliptin (Januvia)

Glucagon-like peptide 1 (GLP-1) May cause nausea, headache and dizziness; rarely, may
agonists By injection May promote weight loss cause kidney problems including kidney failure; taken
• Exenatide (Byetta) twice a day

Meglitinides
May cause low blood sugar and weight gain; taken
• Repaglinide (Prandin) By mouth Work quickly
three times a day
• Nateglinide (Starlix)

Sulfonylureas
• Glipizide (Glucotrol) Can be used alone or with other
By mouth May cause low blood sugar, nausea and weight gain
• Glimepiride (Amaryl) diabetes medications; work quickly
• Glyburide (DiaBeta, Glynase)

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Medications that improve the effectiveness of insulin

Medications (examples) Route Advantages Disadvantages
Do not cause weight gain; may
Metformin (Fortamet, May cause nausea and diarrhea; rarely, may cause a
By mouth decrease LDL (“bad”) cholesterol
Glucophage, others) harmful buildup of lactic acid (lactic acidosis)
and triglycerides

May cause swelling and weight gain that leads to

Thiazolidinediones or worsens heart failure; may increase LDL (“bad”)
May slightly increase HDL
• Rosiglitazone (Avandia) By mouth cholesterol; may increase risk of heart attack,
(“good”) cholesterol
• Pioglitazone (Actos)) although this may not apply to Actos; rarely, may
cause liver problems

Medications that affect food absorption

Medications (examples) Route Advantages Disadvantages
Alpha-glucosidase inhibitors
May cause nausea and diarrhea; taken three times
• Acarbose (Precose) By mouth Do not cause weight gain
a day
• Miglitol (Glyset)

http://www.mayoclinic.com/health/diabetes/DS01121
http://www.mayoclinic.com/health/diabetes-treatment/DA00089
http://www.mayoclinic.com/health/type-1-diabetes/DS00329
http://emedicine.medscape.com/article/117853-overview

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VIII. Burns
 VIiI. Burns

Definition • Third-degree burn. Burns that involve the

Burns are injuries to tissue that can be caused by epidermis and the dermis and reach the tissue
fire, the sun, chemicals, heated objects or fluids, underneath them (subcutaneous tissue) are
electricity, or other means. Burns can be minor called third-degree burns. The skin may appear
medical problems or life-threatening emergencies. stiff, waxy white, leathery or tan. Third-degree
burns can destroy nerves, causing numbness.
Burn treatment depends on the severity and size of the
burn.You can treat most minor burns at home using Complications
first-aid measures, such as cooling the skin and applying Deep or widespread burns can lead to many
an anesthetic cream or aloe gel to the burn. Deep or complications, including:
widespread burns need immediate medical attention. • Local infection. Burns can leave skin vulnerable
to bacterial infection, particularly staphylococcus
Symptoms infection, and increase risk of sepsis.
Signs and symptoms of burns include:
• Widespread infection (sepsis). Sepsis occurs
• Red, swollen skin when bacteria from an infection enter the
• Pain, which may be severe bloodstream and spread throughout the body.
Sepsis is a rapidly progressing, life-threatening
• Wet or moist-looking skin
condition that can cause shock and organ
• Blisters failure.
• Waxy white, leathery or tan skin • Low blood volume (hypovolemia). Burns
• Blackened or charred skin, in severe cases can damage blood vessels causing fluid loss,
resulting in hypovolemia. Severe blood and
Burns do not affect the skin uniformly, so a single
fluid loss prevents the heart from pumping
injury can reach varying depths. Distinguishing a minor
enough blood to the body.
burn from a more serious burn involves determining
the degree of damage to the tissues of the body. The • Dangerously low body temperature
following are four classifications of burns: (hypothermia). The skin helps control the
body’s temperature, so when a large portion
• First-degree burn. This minor burn affects only
of the skin is injured, body heat is lost. This
the outer layer of the skin (epidermis). It causes
increases the risk of hypothermia — the body
redness and pain and usually resolves with first-
loses heat faster than it can produce it.
aid measures within several days to a week.
• Respiratory problems. Breathing hot air or
• Second-degree burn. These burns affect both
smoke can burn airways causing respiratory
the epidermis and the second layer of skin
distress. Smoke inhalation damages the lungs
(dermis), causing redness, pain and swelling. A
and can lead to respiratory failure.
second-degree burn often looks wet or moist.
Blisters may develop and pain can be severe. • Scarring. Burns can cause scars and keloids (ridged
Deep second-degree burns can cause scarring. areas caused by an overgrowth of scar tissue).

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• Bone and joint problems. Deep burns can Treatment

limit skeletal range of motion. Scar tissue can • Assessment of the burn and any related
form causing contractures - when skin, muscles conditions, such as inhalation injuries. If
or tendons shorten and tighten, permanently not already done, clothing and jewelry are
pulling joints out of position. removed from the burned area.
• Malnutrition/Starvation. Hypermetabolism • Intravenous (IV) fluids to prevent dehydration.
or metabolic stress is the direct response to
a severe burn injury. The amount of stress • Medications. Oral or IV pain medications and
increases proportionally to the extent of antibiotics are given to reduce pain and to
the injury and strongly influences a patient’s prevent infection. Topical medications may also
nutritional requirements. This response can be applied to the burned area to reduce pain
magnify the normal metabolic rate by 200%. and speed healing.
Malnutrition, starvation, and delayed wound • Wound care. The burn is cleaned and
healing will result if calories are not provided embedded pieces of clothing or other debris
consistently to meet nutritional requirements. are removed.
Diagnosis • Protective dressings. Depending on the size
and location of the burn, the area may be
Rule of nines
wrapped with dressings or bandages to protect
The rule of nines is one way to calculate the
the skin, reduce pain, and prevent the loss of
percentage of body surface involved in a burn.
heat and moisture through the wound.
Specific areas are assigned percentage values as
follows: head and neck, 9 percent; front part of the • Skin grafting. For burns that cover a large area
torso, 18 percent; back part of the torso, 18 percent; of skin, skin grafting may be required to help
arms, 9 percent each; legs, 18 percent each; and skin tissue regenerate, prevent scarring and aid
pubic area, 1 percent. the healing process.
The rule of nines is usually modified for children • Surgery. In severe cases, surgery may be
because they have relatively smaller limbs and larger necessary to close the wound, remove the
head sizes. dead tissue or treat related complications.
Pulmonary Evaluation
Depending on the type of burn injury, a thorough
pulmonary exam may be done to evaluate if hot air
or gases have caused an inhalation injury. These tests
might include:
• Chest X-ray
• Endoscopy — a procedure using a tiny camera
on the end of a long flexible tube to view the
trachea and upper airway.

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IX. Labor and Delivery
 ix. Labor and Delivery

As a woman progresses to the 38th week of and 100% effaced. Most physicians will place a
pregnancy, she will begin to experience a variety fetal monitor on the patient, which monitors
of symptoms that let her know that the baby will the fetus’s heart rate as well as the mother’s
soon be delivered. Braxton Hicks contractions are contractions. As labor progresses, the pain and
sporadic and can be felt starting in the 3rd trimester. intensity of the contractions are very powerful.
They are irregular and are essentially painless. The contractions are very close together and
Towards the end of the pregnancy (last few weeks) there is little time for relaxation. The end of
the child’s head becomes engaged and the women’s stage one is when the cervix is fully dilated (10
pregnancy appears to have moved lower down. centimeters).
When this occurs, the mother is able to breathe B. 2nd Stage – Active Labor: The second stage of
easier. However, she also has to urinate more labor is when the delivery of the baby occurs.
frequently due to the baby and uterus pressing on The cervical opening is 10 centimeters and
the bladder. the cervix is 100% effaced. The patient can
Labor is divided into three stages: 1st Stage – Early choose whatever delivery position that may
Labor, 2nd Stage – Active labor, and 3rd Stage – provide her comfort and allows the delivery to
Transition. progress. Squatting can provide some benefits.
A. 1st Stage – Early Labor: The first stage of This position seems to shorten this stage of
labor is often the longest phase of labor. The labor and lowers the risk of a vaginal tear.
contractions are not very intense yet. Early Crowning occurs when the baby’s head fully
labor contractions may be anywhere from appears. Your doctor will ask you to push in
5 to 20 minutes apart lasting from 30 – 45 order to deliver the rest of the baby. When the
seconds. When the contractions become infant is delivered, the umbilical cord is cut. The
closer together (5 minutes apart for one baby’s nose and throat are suctioned out and
hour) and stronger, the mother should get in the infant is wrapped in warm blankets and
contact with her care provider. Most often, her placed under a warmer.
physician will direct her to go to the hospital. C. 3rd Stage – Transition: The third stage of
She may experience some vaginal discharge. labor is the delivery of the placenta. After
This discharge is often the mucus plug from the placenta has been delivered, the patient
the cervix, which protected the baby from will be taken back to her room, the nurse will
infection during the pregnancy. Usually the continue to monitor the amount of bleeding
patient’s water breaks during this stage of labor. and massage the uterus to help with uterine
When the water has broken, the contractions contraction and bleeding. Nursing the infant
become even stronger. After the patient’s will also cause the uterus to contract.
water has broken, the fetus needs to be http://www.webmd.com/baby/guide/normal-labor-
delivered within 24 hours, which reduces the and-delivery-process
chance of infection. If the patient has labored
more than 18 hours and the water had already
broken, she will be given antibiotics. When she
is admitted to the L&D unit, the patient will
have a vaginal exam checking for dilation and
effacement. The patient should be 3 % dilated

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Pain Management During Labor and Delivery Pundendal blocks are anesthetic blocks used to
During the course of the patient’s pre-natal visits numb the perineal area. This block is given 10-15
and birthing classes, the mother should have a good minutes before delivery. It also provides numbness if
understanding of the options for pain management. the physician need to do an episiotomy.
Today, women have multiple options. Regional Complications during labor and delivery
anesthesia and opioids are some of the options If the mother has been receiving pre-natal care
used in labor and delivery. The various regional throughout her pregnancy, the risk of complications
anesthetic blocks are the most common method of are rare. The following are the most common
pain control chosen by patients. complications that can be seen during labor and
An Epidural Block is by far the most common choice delivery. Complications during labor can be very
of pain control.The medication stays in the epidural minor or life threatening for the mother and baby.
space, providing the mother relief and no medication is http://www.webmd.com/baby/understanding-labor-
circulated to the baby.The patient sits up at the side of delivery-complications-basics
the bed.The anesthesiologist will ask her to lean over
as far as she can (towards her feet).This allows the Preterm Labor: Labor that is considered pre-term
epidural space to stretch helping the anesthesiologist is labor that starts before the 37th week. Some
with placement of the needle.The skin is numbed women start going into labor much earlier. The
and then the epidural needle is placed in the epidural earlier the labor starts, the greater risk for the infant.
space. Local anesthetic is injected into the epidural Even if your baby is born a few weeks early, risk to
space numbing the nerves and thus providing pain the baby is still present. Options in treating pre-term
relief for the mother. A catheter is placed over the labor depends on how early in the pregnancy this
needle and threaded into the epidural space so that is occurring and what is happening with the mother.
the patient may be re-dosed with anesthetics and/or The following are options/treatments used to
narcotics. An epidural will not slow labor and according manage pre-term labor.
to dose, may allow the mother to walk. • Hydration (oral or IV)
Spinal block is a stronger dose of local anesthesia • Bed rest (Home or hospital)
and is placed in the subarachnoid space. This type • Medications to stop labor (magnesium,
of block is often used in patients who need a terbutaline and brethine).
C-section. The patient will not be able to move their
legs until the anesthetic has worn off. It will provide • Medication to prevent infections (membrane
complete pain relief, up to two hours, in the lower rupture or belief that an infection is causing the
body. This anesthetic will not affect the baby as well. labor)

Opioid (narcotics) may be used to relieve labor pain. • Evaluation of your baby (non-stress, stress test,
They may be given IM or IV. The issue with narcotics amniotic fluid evaluation and an ultrasound).
is they might cause sleepiness and nausea as well as • Medications to help the lung development
depressing breathing for the mother and baby. more quickly.

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 ix. Labor and Delivery

Placental Issues: If there are issues with the Fetal Distress

placement of the placenta, it is often known before When a patient is admitted, external fetal monitors
birth via ultrasound. are attached to the mother in order to monitor
Placenta previa is where the placenta is covering the the fetus and monitor for signs and symptoms of
cervical os thus blocking the birth canal. distress. A fetoscope can be used by the health
http://pregnancy.about.com/od/laborcomplications/p/ professional to listen for the baby’s heartbeat. A
problemlabor.htm Doppler can be used as well to search for the baby’s
heartbeat. External electronic fetal monitoring is
Placental abruption: The placenta tears away from
the most common device used to monitor mother
the uterine wall. This is an emergency for mother
and baby’s well-being. The external monitor consists
and baby both. The blood loss due to the abruption
of two belts. One uses ultrasound to measure the
requires an emergency C-Section.
baby’s heart rate, and the other belt measures
Bleeding Issues the mother’s contractions. If the pregnancy is
Vaginal bleeding is normal after delivery and high risk, the healthcare professional may choose
decreases as the uterus contracts. If the bleeding is to use an Internal Fetal Monitor. Internal fetal
excessive, as is often seen in C-sections, your doctor monitoring consists of placing a scalp electrode
has some options to help stop or greatly decrease by screwing a tiny wire into the top layers of the
the bleeding. Uterine massage is often done by baby’s scalp. An intrauterine pressure catheter is
nurses on the L&D floor as ordered by the doctor. placed between the uterine wall and the baby. This
Medications such as Pitocin can help with uterine type of monitoring measures force of contraction
clotting at the placental attachment point during much more accurately than the external device. If
the post-partum period. Excessive bleeding can the fetal monitor shows the fetus is having difficulty
be caused by failure of the placenta to deliver. In maintaining a healthy heart rate during contracts,
these cases, surgical removal of the placenta may be the baby’s heart rate is low, or there is concern
required. If bleeding continues the uterus will need that the baby is not getting sufficient oxygen, the
to be removed. healthcare provider will take the mother and
perform a C-section immediately. Possible causes
of fetal distress leading to emergent C-sections can
include the umbilical cord around the neck of the
fetus or the cord is compressed during contractions.
If the meconium is present before delivery,
meconium aspiration is a danger for the infant. This
risk greatly increases if the mother has gone past
her due date. Meconium is the baby’s first bowel
movement, which normally occurs after birth. Vaginal
deliveries can have the infant born with the cord
around the neck. The obstetrician can remove this
due to the cord being able to stretch thus allowing
the physician to remove it.

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Abnormal presentation
Most infants deliver in the head down position. The
baby faces the mother’s back and the baby’s chin
is tucked in towards the chest. This position allows
the baby to deliver without much difficulty. Different
issues can cause an abnormal presentation. Failure
of the infant to engage into the birth canal is due
to the fact that the fetus is able to move much
easier due to the fetus being small. Excess amniotic
fluid (polyhydramios) or multiple fetuses can also
cause abnormal presentations. Placentia previa
blocks the cervical opening and often requires a
C-section. Other types of abnormal presentations
are breech, occipitoposterior, frank breech and
footling breech. A Breech presentation means that
the baby’s buttocks is presenting instead of the
head. Many times though the baby will turn by the
36 weeks. Occipitoposterior presentation means
the baby is born face up instead of face down. If
the abnormal position is a frank breech, then the
legs are extended with the feet close to the baby’s
face. The baby’s buttock is presenting to the cervical
opening. A footling breech is the presentation of
one or both feet in the birth canal. One of the
more rare presentations is a face presentation
meaning the face is positioned over the cervix.
Abnormal presentations are often discovered during
the antenatal visits by ultrasounds.
http://www.laboranddelivery.com/

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X. Obstetrics
 x. obstetrics

Obstetrics is the care of a woman during her Your physician will discuss any medications you are
pregnancy as well as delivering the fetus. Please on. If a medication you are taking poses a risk to
review the section on labor and delivery for the fetus (especially during the first trimester), the
information regarding this phase of care for the physician may have you stop taking the medication
pregnant woman. This section will focus on pre- depending on your condition. Smoking and
natal care, medical problems that may arise during drinking can pose a risk to your baby as well. Pre-
pregnancy and high risk pregnancy. natal vitamins will be prescribed that contain folic
When a couple decides to become pregnant or acid which is important for proper neural tube
have recently found out they are pregnant, there development and occurs in the first 28 days. The
are a number of issues that your obstetrician/ mother should maintain a healthy diet and continue
nurse midwife should discuss with you. Calculation to participate in healthy activities. Mothers who are
of delivery date is done by counting 38 weeks used to working out or running can continue to do
from the start of the last menstrual period. If the these activities until the last few weeks of pregnancy
healthcare provider feels that your pregnancy is or the activity starts to become uncomfortable. If
high risk, you will be referred to an obstetrician your physician feels that physical activity poses a risk
who specializes in high risk pregnancy. If you or to your pregnancy, they will make you aware of this.
your partner has a significant genetic disorder in http://nursingcrib.com/nursing-notes-reviewer/
your family history, the physician may order genetic maternal-child-health/the-apgar-scoring-system/
testing. If you have any of the following issues you http://kidshealth.org/parent/pregnancy_newborn/
fall under the high risk category: medical_care/medical_care_pregnancy.html
• Chronic condition such as diabetes or heart http://womenshealth.gov/pregnancy/childbirth-
problems beyond/labor-birth.cfm
• Increased risk of pre-term labor (occurred in
previous pregnancies)
• Older than 35
• Pregnant with more than one fetus

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XI. Pediatric Nursing
 xI. Pediatric nursing

Pediatric nursing is a branch of medicine, whose Growth and Development

focus is to provide medical care to infants, children
and adolescents. Physicians who specialize in this
Infant to Toddler (age zero to 3 y.o.)
area of medicine are called Pediatricians. Treatment Physical:
of children became a specialty around the late • Double their height by the age of 3
1800’s to early 1900’s. Children’s hospitals were • Birth weight will have tripled by age of 3
being built in large cities in Europe during this time.
• Development of teeth and able to eat solid
Pediatric nursing encompasses caring for children foods
when they are ill as well as making sure they are
• Learn to crawl and walk
developmentally on course. Nurses also monitor
vaccination time tables. Teaching the parents about • Begin toilet training
the vaccinations will hopefully relieve any anxiety Cognitive:
about vaccinating their child. There has been a • Advances from using single words to complete
lot of media attention throughout the years that sentences
vaccinations may cause autism. Vast clinical trials have
• Imagination develops. May have imaginary
been conducted through the years and there is no
friends.
connection between vaccination and autism.
• Concrete thinking occurs. Child is able to use
The lifelong process of growing up encompasses
the 5 senses to process information.
physical, behavioral, cognitive and emotional growth
and change. Growth and development stages • Understands the difference between male and
identified are babyhood to childhood, childhood female.
to adolescence, and adolescence to adulthood. Emotional:
As a person goes through these phases; attitudes, • Development of trust with those who fulfill
relationships and understanding of the world around their emotional and physical needs.
us make us who we are. Each stage of development • Testing of independence and exploring of limits.
has specific markers. Reaching these markers is
important for becoming an emotional, physical and • Able to demonstrate feelings in a physical
healthy sexual adult. manner. Kissing, hugging to show love. Hitting to
show anger.
Four factors are assessed as we grow and develop -
physical, cognitive, sexual and emotional development. • “ Terrible twos” child is expressing their
The following are the goals of each age group. These individuality by saying “NO”
lists are not comprehensive but do represent the Sexual:
most important goals of each area assessed. • Curious about their own bodies and others.
• Touching of genitals
• Talk openly about their bodies.
• When taught, able to name and understand
body parts(head, nose, penis, etc.)

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Preschoolers ( ages 4-5) Grade-schoolers (6-8 yrs. Old):

Physical: Physical:
• Growth rate slower than during infancy. • Increase in height slows to about 2 ½ inches
Internal organs grow faster than body giving per year and 8 pounds per year.
the appearance of a rounded tummy. • Develop more muscle.
• Reach 50% of adult height and 20% of adult • Increase in strength.
weight by age 5.
• Start losing baby teeth and adult teeth are
• Better coordination. Able to run, skip climb up erupting.
and down stairs with no problems.
• Able to use large and small motor skills in
• 90% of brain development completed by age 5. sports and other physical activities.
• Lose their “baby look” Cognitive:
Cognitive: • Able to understand more complex and
• Separation from family not as traumatic due to abstract ideas.
increased independence. • Begin elementary school
• Understands about being healthy “ need for • Start spending greater amount of time with
brushing teeth, washing hands” peers. Will turn to peers for information.
• Understands what “privacy” means. • Understands past, present and future.
• Understands concepts of good and bad. • Conforming to “proper behavior”. Learned
Emotional: from adults about what proper behavior is.
• Not as emotionally dependent on caregivers. • Improved self-control.
Child does not need or want as much physical
contact. • Understands concept of abnormal vs. normal.
Concerned about being perceived as normal.
• Begins to develop friendships with peers. Curious about what the difference is between
Realize that some people they do like and the two concepts.
some they don’t.
• Have opinions and think for themselves.
Sexual: Information comes through reading and media.
• Curious about where babies come from.
Emotional:
• Curious about bodies. May play games like • Concerned about modesty and wants privacy
doctor
• Expression of love is through talking and
• Sure of their own gender and can identify sharing. May now be embarrassed by physical
female vs male. affection.
• Recognizes gender roles and able to distinguish • Understanding more complex emotions such
role as either male or female. as confusion and excitement.
• Desires more freedom and space from parents.
• Have friends and peer groups they interact with.

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Sexual: • Focus at school is centered on academics

• Socialize with their own gender. Separation instead of play centered activities.
between males and females is fairly rigid.Teased Emotional:
by others if they don’t act according to the • Don’t want to stand out. Want to blend in with
predefined roles of female or male. Group their peers.
understanding and association with this philosophy
is what keeps the child in the peer group. • Increasing focused on outward appearance.
Want to look like everyone else.
• Understand social stigmas and taboos around
sexuality. Understand that intercourse is not • Increase in self-consciousness and self-
just for making a baby. centeredness.

• Rely on peers, media and other sources of • Relationships with peers are more important
information about sex. than family. Concerns are about dating,
relationships and crushes.
• Stronger self confidence in gender and body
image. • Development of sexual feelings for others. A
new dimension to relationships with others.
Preteens (9-12 yrs old): • Understands the concept of a loving caring
Physical: relationship.
• Growth spurt occurs with increase in weight
• Mood swings, especially with family
gain, muscle growth and enter puberty.
relationships.
• May begin to have pimples. Skin becomes more
Sexual:
oily
• Awareness of their sexuality and how they
• Hair growth under arms and pubis. Boys may choose to express it.
begin to grow facial hair and hair on chest.
• Continues to be concern about whether they
• Joint pain due to rapid growth. are normal. Especially in regards to sexual
• Males experience growth of genitals, darkening feelings, masturbation, and wet dreams.
of scrotum, voice deepens and sperm • Anxious about when puberty will occur. When
production starts. will it happen? How to be prepared for it?
• Females experience maturing of genitals, breast • Privacy extremely important.
development, ovulation and start of menstrual
cycle. Teens (13-17):
Cognitive: Physical:
• Continue to move towards more • Puberty is complete and looks are those of an
independence. adult for the most part. Rate of transition can
vary. Some children develop faster than others.
• As they become more independent, their skill
in making decisions continues to improve. • For females, they have reached their adult
height. Males often continue to grow into their
• Start to think about the future. Going to twenties.
college and picking an occupation.
• Understands complex social issues such as
poverty and war.

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Cognitive: Common childhood illnesses

• Cognitive maturity has occurred. Knowledge of As we grow and mature, so does our immune
options and consequences, they have the ability system. At times it seems your child is always sick.
to make mature decisions. Children are more susceptible to bacterial and
• Peer influence is still important but not as strongly viral illnesses due to the immaturity of the immune
as when they were in the pre-teen phase. system. However, with each exposure, the body
• Now are old enough to drive. This increases creates antibodies against bacterial/viral illnesses.
their independence. Teething also occurs around six months of age.
Runny noses, sore gums and fever are common
• Continue to build skills in order to be self-
symptoms associated with teething. The following
sufficient.
is an introduction to some of the most common
• Relationships with peers and family are more childhood illnesses. We will discuss the symptoms,
mature. treatment, incubation period, and the infectious
Emotional: period. Many common childhood illnesses now have
• Teens have the ability/capacity to develop vaccinations. Measles were a common childhood
long lasting, mutual and healthy relationships. illness 30 yrs ago. In the late 80s, college campuses
The foundation has to be in place for this. The were having outbreaks of measles in their student
foundation was created through relationships population. A vaccination was developed and now,
with family, peers, teachers, and authority in order to get into college, you need proof of
figures. The ability to trust, along with past vaccination against this disease or have already had
positive experiences, allows them to have a the disease as child, which makes you immune to
healthy understanding of love. another episode. The vaccinations cover measles,
mumps and rubella and multiple other childhood
• The personality of a person is now more
illnesses as well. It is important to vaccinate people
important than the looks.
against these illnesses to prevent outbreaks.
Sexual: Infectious processes such as these can be potentially
• See themselves as sexual beings and fatal in more vulnerable populations (elderly,
understand the options and consequences of immuno compromised, under 6 months)
sexual behavior.
Chicken pox: The symptoms of chickenpox are red,
• Expression of sexuality may or may not include itchy spots or blisters spread over the entire body.
sexual intercourse. The child has a moderate fever as well. Treatment
• Educated and have a solid understanding for chickenpox is to control the symptoms. Since it
of pregnancy, HIV/AIDS and other sexually is a virus, antibiotics will not work as a treatment.
transmitted diseases. Able to make decisions Calamine lotion is a liquid medication that is used
about sex based on knowledge. for the treatment of itching and soothing skin
• Understand what their sexual orientation is. irritation. You can buy this at any drug store. Using
a cotton ball, dab the cream onto the affected
• Ability to recognize healthy and unhealthy areas. The medication should be allowed to dry for
relationships. several minutes in order for the application to last.
http://www.advocatesforyouth.org/ The incubation period is between 10-20 days from
parents/152?task=view being exposed and then showing symptoms of

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chickenpox. A child remains contagious until 6 days The child appears to be getting well and then a rash
after the first spots appear. Chickenpox will resolve appears several days later. A bright red rash appears
on its own. The most important issue is controlling on the face with red blotches spreading to the
the symptom of itching and treating the fever. trunk, arms, and legs. The rash does not appear on
Whooping cough: Also called Pertussis is a bacterial the palms of the hand or soles of the feet. When the
infection of the upper respiratory system. Symptoms rash is clearing, the center of the blotches becomes
include severe coughing spells with a “whooping” clear. This often leaves the appearance of a lacy net-
sound when the person breathes in. At first the like appearance. Children under the age of 10 are
symptoms are similar to those of the common cold, most likely to catch Fifth’s disease. The incubation
runny nose, sneezing, mild cough and low grade period is two weeks between the exposure and the
fever. However symptoms continue to persist and appearance of symptoms. Once the rash appears,
after several weeks, the coughing spells become the child is no longer infectious.
severe and can last up to more than a minute. The http://kidshealth.org/parent/infections/skin/fifth.html
child may turn red or purple. Breathing is wheezy. Hand, Foot and Mouth Disease: The symptoms
Sometimes the child will vomit during a severe manifest as a large number of small spots and
coughing spell. The symptoms are usually worse blisters. They occur particularly in the mouth feet
at night. Treatment again is focused on relief of and hands. The child may have a low grade fever for
symptoms. Humidification of the air, plenty of fluids, several days as well. Treatment is mainly focused on
and sedatives may be given. These are prescribed in keeping the temperature down. OTC fever reducers
order to help the child rest. OTC cough mixtures for children are very effective in controlling this
are ineffective and are NOT recommended. If the symptom. The mouth is often very sore due to the
child’s skin has a bluish tint(lack of oxygen),periods ulcerations. The child should be fed things that don’t
of stopped breathing(apnea), seizures or convulsions require a lot of chewing. The incubation period for
and high fever, they should be taken to the hand, foot and mouth disease is 2-3 days between
emergency room right away. At this point, the child exposure and the appearance of rash/ulcerations
is not able to oxygenate well enough on their and fever. The child is contagious as long as the
own and need medical treatment. The incubation spots/blisters are still present.
period begins 7 days after exposure to the virus.
This childhood illness has a vaccination as well. DTaP Scarlet Fever: This illness is caused by the group
is the name of the vaccination given to prevent A strep bacteria. Symptoms include low grade
pertussis. A series of 5 vaccinations is recommended fever, sore throat and a rash which is located in
beginning at 2 months, 4 months, 6 months, 15-18 the armpits and groin. The skin starts peeling and
months and at 4-6 yrs old. It is recommended that the tongue surface becomes coarse and pink. This
adults be vaccinated as well. The adult form of the condition is known as strawberry tongue. The
vaccination can be given up to 65 years old. treatment for scarlet fever is antibiotics and fever/
pain control (OTC acetaminophen or ibuprofen).
http://kidshealth.org/parent/infections/lung/ Dosing is according to age and weight. The
whooping_cough.html incubation period is 3-8 days from exposure to the
Fifth’s Disease: Early symptoms are similar to those infection and showing symptoms. It is imperative
of the flu. This is a viral illness and therefore will not that the child completes the course of antibiotics.
respond to antibiotics. Early symptoms include a low The rash may persist for several weeks.
grade fever, headache, and a stuffy or runny nose.

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Mumps: Mumps is a viral infection that is spread have started out as an AOM. The bacterial infection
by sneezing, coughing and sharing food or drink. has been treated but there still is fluid in the ear. The
Symptoms of the mumps are swelling between the ear Eustachian tube is the part of the ear that becomes
and the jaw at the salivary glands, facial pain, headache, blocked with fluid. The Eustachian tube drains into
and sore throat.The incubation period is between 12- the back of the throat. There is minimal pain with
24 days after exposure.Treatment is focused at keeping this type of Otitis and almost always goes away on
fever reduced, provide cool drinks to help increase its own. Fluid may remain in the middle ear and take
fluid intake and reduce pain.The MMR (measles, month or longer for it to resolve on its own.
mumps, reubella) vaccination is given between the age Otitis Externa (Swimmer’s Ear): This type of
of 12-15 months old or at the age of 4-6 and age 11- infection usually is microbial and occurs suddenly,
12 if the vaccination has done been given. rapidly worsens and then becomes very painful. The
Ear Infections difference between Otitis Externa and other ear
infections is that touching or pulling gently on the
Ear infections are the most common reason for a
ear brings on acute pain. The patient may have ear
trip to the pediatrician. Almost half of all antibiotic
discharge and itchiness. If the swelling and buildup of
prescriptions written for children are for otitis media.
fluid become great enough, the patient may suffer
Upon physical exam the physician looks at the ear drum
temporary conductive hearing losses. An increase in
using an otoscope. A red, bulging ear drum is the classic
pain due to touching or moving the outer ear is the
presentation of otitis media. Common upper respiratory
classic sign of Otitis Externa. The lack of cerumen
infections such as a cold or the flu, most often will cause
is also a sign of Otitis Externa as well. Antibacterial
a middle ear infection as well.These problems cause the
or antifungal solutions are used to acidify the ear
Eustachian to become so swollen that air can no longer
environment, hopefully to prevent bacterial growth.
flow in the middle year and therefore fluid cannot drain
Prescription drops containing anti-inflammatory
out causing the bulging ear drum.
steroids help reduce swelling and itching. After
Acute Otitis Media: There are three different types several days of treatment with solutions and anti-
of ear infections - Acute Otitis Media, Otitis Media inflammatory medications, the otitis resolves.
with effusion and Otitis Externa. Acute otitis media Complete return to hearing with normal cerumen
is the most painful of the three Colds, allergies or production may take some additional time. When
upper respiratory infections with the accumulation the ear is completely healed, the ear canal is self-
of pus and mucous blocking the Eustachian tube, cleaning. External otitis is usually either bacterial or
often results in an earache and swelling. The swollen fungal so only one type of medication is needed.
eardrum is painful and often times the child will pull
http://www.cdc.gov/getsmart/antibiotic-use/URI/ear-
on the affected ear. The infection often starts as viral
infection.html
but bacteria quickly find their way into the warm
moist environment of the middle ear. Treat with http://www.netdoctor.co.uk/diseases/facts/
antibiotics and OTC pain relievers for children. The childrensdiseases.htm
healing process takes from 2-6 weeks. http://en.wikipedia.org/wiki/Otitis_externa
http://en.wikipedia.org/wiki/Otitis_media http://en.wikipedia.org/wiki/Pediatrics
Otitis Media with Effusion: This is an issue where
there is buildup of fluid in the middle ear, without
acute signs or symptoms of infection. The OME may

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XI. Orthopedics
 XI. orthopedics

Most people will experience some type of Sports injuries to the knee include ACL injury
orthopedic problem in their life time. Fractures, (anterior cruciate ligament), MCL (middle cruciate
dislocations, shoulder injuries, low back pain and ligament), PCL (posterior cruciate ligament) and
knee/hip issues are some of the top injuries that are torn cartilage. If you start to have the following
seen in the ER and Orthopedists. Injuries are usually symptoms, you should seek medical advice.
sustained from trauma, falls, sports and aging. • Hearing a popping noise or the knee gives out
Fractures are identified by their severity and the at the time of injury
impact on surrounding tissues. • Severe pain
If the fracture ruptures through the skin then the • Cannot move the knee
fracture is designated as open or compound. If there
is no piercing of the skin, the fracture is designated • Begin limping
as simple. There are also other classifications of • Have swelling at the injury site.
fractures defined by the type fracture sustained. http://www.foxnews.com/story/0,2933,527700,00.
Types of Fractures html
• Transverse fracture: a fracture at right angles to http://forums.studentdoctor.net/showthread.
the long axis of the bone php?t=718902
• Greenstick Fracture: A fracture on one side of http://wrightstatephysicians.org/ortho/injuries.html
the bone, which causes the other side to bend. Osteoarthritis
Seen most often in children.
Osteoarthritis is a condition where the cartilage
• Commuted Fracture: A fracture that results in breaks down and wears away. The knee starts swell
3 or more bone fragments. and is painful and stiff. The ligaments around the joint
• Intra-articular: A fracture that involves the joint. become weaker and stiffer. Osteoarthritis occurs in
The most common orthopedic sports injuries men and women equally until the age of 55. After 55,
include ankle sprains, Achilles Tendinitis, groin strain, women seem to have this problem more than men.
shin splints, lower back pain, tennis or golf elbow, Causes of this disease are heredity (runs in families)
shoulder injury, and runner’s knee. Ankle sprains and being overweight. Fractures that occurred
could be caused by inversion of the foot, strain or earlier in life make an individual more susceptible to
tears of the weaker lateral ligament of the ankle. The OA. Jobs that involve repetitive kneeling, squatting,
RICE protocol is the method of treatment. RICE lifting, climbing stairs, or walking leave these workers
stands for resting the affected ankle or other injury, very susceptible to sustaining osteoarthritis. High
ice, compression and elevation. NSAIDs are used for impact actives such as basketball, football, soccer,
pain control. If the injury is severe, narcotics may be or baseball increase the chances of arthritis.
prescribed as well. Medications used in treating this problem include:
The knee is a vulnerable joint that is often injured • Corticosteroids injected into the knee. Steroids
by playing sports or the patient has chronic reduce inflammation and decrease pain, however
degenerative osteoarthritis causing the loss of this treatment does not work for everyone.
cartilage in the knee. • OTC medications such as glucosamine and
chondroitin sulfate can provide pain relief over
time.

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• Skin Cream (Capsaicin) can help to relieve common medications used to treat this problem.
pain. Exercise and diet can also improve bone density.
• Artificial joint fluid such as Synvisc and Hyalgan Osteoporosis can be prevented by making sure you
injected into the knee can relieve joint pain up have enough calcium and Vitamin D in your diet.
to 3-6 months. Orthopedic Nursing
Physical therapy is an alternate solution to improve Orthopedic Nursing is often centered on the
muscle strength and motion of stiff joints and care of a patient who has had some type of
balance. If these non-invasive treatments no not joint replacement, spine or neck surgery, and
help, your orthopedist may talk to you about arthroscopies. The following is a list and description
surgical options. Many procedures are now done of the most common orthopedic surgeries done.
arthroscopically. Treatment of torn and damaged
Total Knee Replacement: A surgical procedure to
cartilage can be done arthroscopically. Surgical
replace a diseased knee joint with artificial material.
fusion of the bones, usually in the spine area of the
The end of the femur bone is removed and replaced
lower back can provide relief from back pain. Joint
with a metal shell. The tibia is also removed and
replacement (total or partial) is usually done when
replaced with a channeled plastic piece with a metal
the person can no longer tolerate the pain in the
stem. If the kneecap is diseased as well then a plastic
affected joint.
button may also be added under the knee cap
Hip pain and fractures surface. The artificial joint is anchored in place with
Hip pain is also a common problem. Hip pain bone cement or a material which allows the bone
can have many causes. Seeing an Orthopedist is tissue to grow into it. Total knee replacement surgery
important to find out what the underlying cause is considered for patients whose knee joints have
is and to also rule out fractures. Hip fractures are been progressively damaged by arthritis, trauma or
most common in the older population. Osteoporosis other destructive diseases of the joint. Pain, stiffness
is often the cause. Osteoporosis is the thinning of and decreasing daily function lead most patients to
bone tissue and loss of bone density over time. In consider having knee replacement surgery.
the early stages there are no signs or symptoms; http://orthoinfo.aaos.org/topic.
however as the disease progresses, pain and cfm?topic=a00325#Knee
tenderness in the affected hip will occur. Some of Total Hip Replacement: This is a surgical procedure
the causes of osteoporosis are being bedridden, whereby the diseased cartilage and bone of the hip
chronic rheumatoid arthritis, taking long term steroids, joint is surgically replaced. Replacement involves
hyperparathyroidism and Vitamin D deficiency. removal of the diseased ball and socket and
Various medications and treatments are available replacing them with a metal ball and stem inserted
to help strengthen the bones and stop bone loss. into the femur bone and an artificial plastic cup
Bone density tests are used to test for osteoporosis. socket. The metallic artificial ball and stem are called
Treatment is geared towards control of pain, the “prosthesis”. Conditions that lead to total hip
slow/stop bone loss, prevention of fractures with replacement include bony fractures of the hip joint,
medications, and minimize risk of falls. Medications rheumatoid arthritis and death (aseptic necrosis)
are used to strengthen bones. Biophosphates of the hip bone. Replacement is usually done when
(Fosamax, Boniva, and Actonel), Calcitonin, and chronic pain and impaired daily functioning occur.
hormone replacement therapy are the most

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Total shoulder replacement: These patients suffer fracture. This device can be used for wrist, foot/
from joint dysfunction. Causes are osteoarthritis or ankle, and knee fractures. The key to proper healing
rheumatoid arthritis. Patients who have suffered a is to prevent infection. Pin site care is imperative and
shoulder fracture from severe trauma are candidates most often is a nursing function. The pin site care
for this surgery as well. supplies that are used:
In a total shoulder replacement, a metal ball is used • Cleansing solution and Sterile Water
to replace the humeral head while a polyethylene • Disposable Cups to hold the sterile water
cup becomes the replacement of the glenoid socket.
• Sterile gauze 2” x 2” and 4” x 4”
Rotator cuff repair: A tear in the cuff will often limit
the range of motion. The rotator cuff helps anchor • Sterile cotton swabs
the shoulder joint and helps it move as well. If pain • Bag for waste disposal
does not improve with non-invasive treatments such http://en.wikipedia.org/wiki/External_fixation
as physical therapy or medication, surgery may be
Be sure to wash hands before giving pin site care
recommended.
and then wear a pair of gloves. First, massage the
Arthroscopic surgery: this procedure allows the skin around the pin site.This will bring any drainage
surgeon to view and repair a joint by using an to the surface. Next saturate a sterile cotton swab
arthroscope. An arthroscope consists of a tube, with the cleansing solutions which are ordered by the
lens and a light source to visualize the surgical area. physician. Apply the solution directly to pin site. Using
Orthopedic surgeons can use an arthroscope for the cotton swab, swab in a circular motion, always
knees, shoulders and other repairs. moving away from the pin. If any crust has formed be
http://www.harrisonmedical.org/home/common- sure to remove it. After the drainage and any crusting
orthopaedic-procedures have been removed, dry the pin site with a new cotton
swab. Use a new sterile cotton swab for each pin site.
Devices Wrap sterile gauze around the pin site. Gently press
Orthopedic nursing provides most of the care down on the skin around the pin site. After several
for patients with various devices. Some more days, the gauze will not be used. Pin sites will be left
complicated than others. The following is a brief uncovered and exposed to air.The external fixator
overview of some of the most common devices device also needs to be kept clean. Clean the entire
used in orthopedics. device with 4”x4” gauze and cotton swabs. Be sure
External Fixation Device: The purpose of this device that before the patient goes home they have a good
is to set bone fractures which cannot be casted. understanding of pin care. After 10 days, the patient
A cast would not allow proper alignment of the will be allowed to shower.Teach the patient about
fractured bone. External fixation is used for fractures signs and symptoms of infection: Redness or swelling
but also is used to correct deformities. This device is at pin site; thick or colored discharge from the pin
worn outside the body. This device is called a fixator. site; loosening or movement of the pins; pain and/
or soreness at the pin sites. If the patient suspects
A fixator is connected to the bone using bone
infection, they should see their doctor as soon as
screws or more commonly called pins. The pins will
possible. Pin site care should be done twice a day.
go through skin and muscle in order to connect the
external part of the fixator to the bone. This device
will allow for proper healing and alignment of the

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Halo Cervical Traction System CPM machine

Halo crown application and vest: Halo traction is CPM stands for Continuous Passive Motion. This
used to stabilize cervical fractures. The halo acts machine helps blood flow through the knee and
as a cast would for an arm. The brace consists of exercises the knee. Patients who have had major
3 main parts. The vest, which is on your chest, and surgery on the knee joint (total knee replacement,
the halo encircles your head, and the rods which ACL repair, Arthoplasty or microfracture) are just
extend from the ring to the vest. This device must a few of the surgical patients that will be placed in
be worn at all times. The vest is usually worn next this device after surgery. The machine allows for
to the skin. The lining of the vest may be wool or gentle flexion and extension of the joint. The goal is
some acrylic matter. To increase comfort, wearing a to reduce the amount of scar tissue development
tee shirt under the vest can help. The shirt should and so that stiffness of the knee will be minimal. The
be a few sizes larger. Pants, shorts, or skirts should device is easy to apply. The affected joint is placed
be no problem. It is best to wear low-heeled shoes in the CPM machine. Velcro strips help keep the leg
or runner shoes. This allows for better traction and in place. The device can be set to various degrees
decrease the risk of falling of slipping. The skin under of flexion. Through time, the patient should increase
the vest should be checked daily. A flashlight can the degree of flexion in order to get full ROM back.
help with visualization. Be sure to check the bony http://orthopedics.about.com/cs/kneereplacement/i/
prominences carefully. Look for excess perspiration cpm.htm
or pressure sores. These patients are not permitted
to shower due to the fact that the vest liner may
remain wet. Use towels or plastic to help keep the
vest dry and keep it from getting wet. If the patient
has been lying down and wants to get up, there is
a great need for caution. Bending at the waist puts
a lot of stress and strain on the head pins. The best
way to get out of the bed is to roll to one side, drop
your legs over the side of the bed and use your
arms to get in an upright position.
Pin care is essentially the same as care of an
external device. Use a clean Q-tip for each pin site.
Do not use ointments or antiseptics unless your
physician has prescribed this. A metal wrench should
be at the bedside at all times. The wrench should be
used by medical personnel only.

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XII. Drug Calculations
 XII. Drug Calculations

Systems of Measurement Example 1 illustrates that move. To convert from

Three systems of measurement are used in a smaller unit to a larger one, the decimal moves
medication administration: three places in the direction you move from S to L,
or to the left.
• Metric
Example 2 illustrates that move.
• Apothecary
Example 1: Example 2:
• Household
Convert: 300mg to mcg Convert: 300 mg to g
Metric System is based on the decimal system and 300 mg = 300,000mcg 300 mg = 0.3 g
uses the gram as the basic unit of weight. The liter is
the basic unit of volume, and the meter is the basic
unit of length. For correct metric notation, when an Metric Abbreviations Metric Equivalencies
for Volume for Volume
amount is less than one, a zero should be placed in
Liter (L) 1000 ml = 1L
front of the decimal point. For example: 0.5mg. Milliliter (ml) 1cc = 1ml
Accepted abbreviations for metric system measures Cubic Centimeter (cc) (cc’s and ml’s are used
interchangeably)
frequently used in dosage calculations are as follows:
The Apothecary System uses grains, drams and
Metric Abbreviations Metric Equivalencies
for Weight for Weight ounces as units of weight. Lowercase Roman
Kilogram (kg) 1 kilogram = 1000 g
numerals are used when amounts are greater than
Gram (g) 1 gram = 1000 mg one; fractions are used when amounts are less than
Milligram (mg) 1 milligram = 1000 mcg one. The abbreviation precedes the amount, for
Microgram (mcg)
example, grains x or grains 1/150.
When converting within the metric system, simply One-half can be expressed as ss, therefore: iiiss = 3 1/2.
move the decimal point three places to the left Apothecary Abbreviations
or right, depending whether you are changing to a Grain (gr)
larger or smaller unit of measure. Dram (dr)
A useful method to consider is the - Ounce (oz)
LMNOPQRS Equivalencies when converting from apothecary to
metric are:
The letter L represents larger unit, the letter S
represent smaller unit. To convert from large Apothecary & Metric Equivalencies
to small, the decimal moves three places in the 1 ounce (30 cc = 30 mL)
direction you move from L to S, or to the right. 1 dram (4 mL)
1 grain (60 mg)

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Household measures are commonly used to measure medications at home. Abbreviations and
equivalencies follow.
Equivalencies
Household measure Abbreviation Metric measure Apothecary measure
1 cup C 1 C = 240 cc 8 oz
1 tablespoon T (tbs) 1 T = 15 cc or 15 mL
1 teaspoon t (tsp) 1 t = 5 cc
drop gtt depends on size of drop
pound lb 2.2 lb = 1 kg 1 lb. = 16 oz

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Quiz - Systems of Measurement

Problems
1. 0.4 mg = _____________ mcg
2. 600 mg = _____________ _ g
3. 20 mg = _______________ g
4. 6.6 g = _______________ mg
5. 0.06 g = ______________ mg
6. 0.7 L = ________________ cc
7. 650 mL = ______________ L
8. Gr. v = _ ______________ mg
9. Gr. 3 = _______________ mg
10. 90 mg = _____________mcg
11. 1/2 tsp = _ ___________ mL
12. Gr. 1/100 = ___________ mg
13. 15 oz = _ _____________ cc
14. 4 oz = _ ______________ cc
15. 150 cc = ________ ounce (s)
16. 2 T = _ ______________ mL
17. 400 mcg = ___________ mg
18. 0.25 mg = ___________ mcg
19. Gr. ss = ______________ mg
20. Gr. X = ______________ mg
21. drams 3 = _ __________ mL
22. 20 mL = ______________ T.
23. 45 mL = ________ ounce (s)
24. 12 mL = __________ drams
25. 90 mL = ________ ounce (s)

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Problem # Key Drug Calculations

1. 400 mcg Common Conversions:
2. 0.6 g 1 Liter = 1000 Milliliters
3. 0.02 g 1 Gram = 1000 Milligrams
1 Milligram = 1000 Micrograms
4. 6600 mg
1 Kilogram = 2.2 pounds
5. 60 mg
Methods of Calculation
6. 700 cc Any of the following three methods can be used to
7. 0.65 L perform drug calculations. Select the one that works
for you. It is important to practice the method that
8. 300 mg
you prefer to become proficient in calculating drug
9. 180 mg dosages.
10. 90,000 mcg Remember: Before doing the calculation, convert
11. 2.5 mL units of measurement to one system.
12. 0.6 mg I. Basic Formula: Frequently used to calculate
13. 450 cc drug dosages.

14. 120 cc D (Desired dose)

15. 5 oz H (Dose on hand)

16. 30 mL V (Vehicle-tablet or liquid)

17. 0.4 mg D/H x V = Amount to Give

18. 250 mcg
19. 30 mg D = dose ordered or desired dose
20. 600 mg H = dose on container label or dose on hand
21. 12 mL V = form and amount in which drug comes
(tablet, capsule, liquid)
22. 1.3 T
Example:
23. 1.5 oz
Order- XYZdrol 50 mg p.o. TID
24. 3 drams Drug available- XYZdrol 125 mg/5ml
25. 36 oz D=50 mg H=125 mg V=5 ml
50/125 x 5 = 250/125 = 2 ml

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II. Ratio & Proportion:

Known Desired
=
H • V D • X
(Means)
Extremes
(Left side is known quantities) (Right side is desired dose & amount to give)
Multiply the means and the extremes
HX = DV
X = DV/H

Example:
Order- XYZdrol 1 gm p.o. BID
Drug available- XYZdrol 250 mg per capsule
D=1 gm (note: need to convert to milligrams) 1 gm = 1000 mg
H=250 mg
V=1 capsule
250 • 1 = 1000 • X
250X = 1000
X = 1000
250
X = 4 capsules

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III. Fractional Equation

H/V = D/X
Cross multiply and solve for X.
H/V = D/X
HX = DV
X = DV/H
Example:
Order - ABColol 0.25 mg p.o. QD
Drug Available – ABColol 0.125 mg per tablet
D=0.25 mg H=0.125 mg V=1 tablet
0.125/1 = 0.25/X
0.125X = 0.25
X = 0.25/0.125
X = 2 tablets
IV. Intravenous Flow Rate Calculation (two methods)
Two Step Method
Step 1 - Amount of fluid divided by hours to administer ml/hr
Step 2 -
ml/hr x gtts/ml(IV set)
= gtts/min
60 min
Example
Step 1 - 1000/4 = 250
Step 2 - 250 x 15/60 = 62.5 (62 gtts/min)
One Step Method
amount of fluid x drops/milliliter (IV set)
hours to administer x minutes/hour (60)
Example:
1000 ml over 4 hrs
IV set = 15 gtts/ml
1000 x 15/4 hrs x 60 = 15,000/240 = 62.5 (62 gtts/min)

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V. How to Calculate Continuous Infusions

A. mg/min (For example - Lidocaine, Pronestyl)
Solution cc x 60 min/hr x mg/min
= cc/hr
Drug mg

Drug mg x cc/hr
= mg/hr
Solution cc x 60 min/hr

Lidocaine & Pronestyl Rule of Thumb

2 gms/250 cc D5W

1 mg = 7 cc/hr
2 mg = 15 cc/hr
3 mg = 22 cc/hr
4 mg = 30 cc/hr

B. mcg/min (For example - Nitroglycerin)

Solution cc x 60 min/hr x mcg/min
= cc/hr
Drug mg

Drug mcg x cc/hr

= mg/hr
Solution cc x 60 min/hr

Nitroglycerin Rule of Thumb

NTG 100 mg/250 cc

1 cc/hr = 6.6 mcg/min

NTG 50 mg/250 cc
1 cc/hr = 3.3 mcg/min

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C. mcg/kg/min (For example - Dopamine, Dobutamine, Nipride, etc.)

1. To calculate cc/hr (gtts/min)
Solution cc
x 60 min/hr x kg x mcg/kg/min = cc/hr
Drug mg
Example:
Dopamine 400 mg/250 cc D5W to start at 5 mcg/kg/min.
* Patient’s weight is 290 lbs.
250 cc
x 60 min x 131.8 x 5 mcg/kg/min = 24.7 cc/hr
400,000 mcg

2. To calculate mcg/kg/min
Drug mcg/ x cc/hr
= mcg/kg/min
Solution cc x 60 min/hr x kg
Example: Nipride 100 mg/250 cc D5W was ordered to decrease your patient’s blood
pressure. The patient’s weight is 221 lbs, and the IV pump is set at 30 cc/hr.
How many mcg/kg/min of Nipride is the patient receiving?

100,000 mcg x 30 cc/hr 3,000,000

= = 1.99 mcg/kg/min
250 cc x 60 min x 100.4 kg 1,506,000

VI. How to calculate mcg/kg/min if you know the rate of the infusion
Dosage (in mcg/cc/min) x rate on pump
= mcg/kg/min
Patient’s weight in kg
Example:

3200 mcg/cc
800mg of Dopamine in 250 cc D5W = = 53.3 mcg/cc/min
60 min/hr
53.3 is the dosage concentration for Dopamine in mcg/cc/min based on having 800 mg
in 250 cc of IV fluid.You need this to calculate this dosage concentration first for all drug
calculations.
Consider a 100 kg patient

53.3 mcg/cc/min x 10 cc on pump

= 5.33 mcg/kg/min
Patient’s weight in kg (100 kg)

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VII. How to calculate drips in cc per hour when you know the mcg/kg/min that is ordered or desired
mcg/kg/min x patient’s weight in kg
= rate on pump
dosage concentration in mcg/cc/min
Example: 800 mg Dopamine in 250 cc D5W = 53.3 mcg/cc/min

3.5 mcg/kg/min x 100 kg

= 6.6 cc
53.3 mcg/cc/min
ALWAYS WORK THE EQUATION BACKWARDS AGAIN TO DOUBLE CHECK YOUR
MATH!
Example: 6.6 cc x 53.3 mcg/cc/min

100 Kg = 3.5 mcg/kg/min

= 3.5 mcg/kg/min
100 Kg

Dosage (in mcg/cc/min) x rate on pump

= mcg/kg/min
Patient’s weight in kg

Dosage (in mcg/cc/min) x rate on pump

Patient’s weight in kg

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Practice Exercises
A. Conversion:
1. 3.25 liters to milliliters
2. 2.75 grams to milligrams
3. 0.15 milligrams to micrograms
4. 7525 milligrams to grams
5. 75 micrograms to milligrams
6. 800 milliliters to liters
7. 195 pounds to kilograms
8. 85 kilograms to pounds
B. How many milligrams will be given for each dose? (Use the method you have chosen to calculate the
amount to give).
1. Order-Dexamethasone 2 mg
Drug available-Dexamethasone 0.5 mg per tablet
2. Order-Tagamet 0.9 gm
Drug available-Tagamet 300 mg per tablet
3. Order-Phenobarbital 75 mg
Drug available-Phenobarbital 15 mg per tablet
4. Order-Ampicillin 1.5 gm
Drug available-Ampicillin 250 mg per 5 ml
5. Order-Dicloxacillin 62.5 mg
Drug Available-Dicloxacillin 62.5 mg per 5 ml
6. Order-Medrol 100 mg IM
Drug Available-Medrol 125 mg per 2 ml
7. Order-Lidocaine 3 mg per kg
Patient’s weight is 152 pounds
8. Order- 650 mg of a medication in a 24 hour period. The drug is ordered every 6 hours.

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C. Infusion Rate- Calculate gtts/min

1. Order – 1000ml over 8 hrs (IV set 15gtts/ml)
2. Order – 750ml over 6hrs (IV set 10 gtts/ml)
3. Order – 250ml over 30 min. (IV set 15gtts/ml)
D. Practice Problems:
1. Dopamine 400 mg in 250 cc D5W to infuse at 10 mcg/kg/min. The patient’s weight is 175 pounds.
How many cc/hour would this be on an infusion pump?

2. A Dopamine drip (400mg in 250 cc of IV fluid) is infusing on your 90 kg patient at 15 cc/hour. How
many mcg/kg/min are infusing for this patient?

3. A Nitroglycerin drip is ordered for your patient to control his chest pain. The concentration is 100
mg in 250 cc D5W. The order is to begin the infusion at 15 mcg/min. What is the rate you would
begin the infusion on the infusion pump?

4. A Nitroglycerin drip (50mg in 250 cc D5W) is infusing on your patient at 14 cc/hour on the
infusion pump. How many mcg/min is your patient receiving?

5. A procainamide drip is ordered (2gms in 250 cc D5W) to infuse at 3 mg/min. The patient weighs
315 pounds. Calculate the drip rate in cc/hour for which the infusion pump will be set at.

6. A Lidocaine drip is infusion on your 67.5 kg patient at 15 cc/hour. The Lidocaine concentration is 2
grams in 250 cc of D5W. How many mg/min is your patient receiving?

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Answers to Practice Problems

A. Practice Problems
1. 3250 mL
2. 2750 mg
3. 150 mcg
4. 7.525 gm
5. 0.075 mg
6. 0.8 L
7. 88.6 kg
8. 187 lbs
B. Practice Problems
1. 4 tablets
2. 3 tablets
3. 5 tablets
4. 30 mL
5. 5 mL
6. 1.6 mL
7. 69 kg = 207 mg
8. 162.5 mg for 4 doses
C. Practice Problems
1. 31.25 (31)
2. 20.8 (21)
3. 125
D. Practice Problems
1. 29 cc/hr
2. 4.5 mcg/kg/min
3. 2.3 cc/hr
4. 46.2 mcg/min
5. 22 cc/hr
6. 2 mg/min

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