Final Nursing Exam 1430

COMFORT:

Exemplar: OSTEOARTHRITIS: CHRONIC PAIN

Caused by  cartilage breakdown →bone-on-bone friction


RISK FACTORS:

Age, obesity, females, joint injury, occupation (repetitive stress), smoking


Signs and symptoms : Joint pain (more with activity, relief with rest), stiffness(morning), swelling, crepitus(cracking sound), bone spurs, ↓ & flexibility


Management: Pain control with medications, weight loss, PT/OT, Assistive devices, Low impact exercise, joint replacement surgery


COMPLICATIONS:

Chronic disability, limited mobility, sleep disturbance, ↓ quality of life, depression, anxiety, & social isolation.


Exemplar: DDD (degenerative Disk Disease): Neuropathic Pain


disk degeneration → loss of cushioning→ nerve root compression→ neuropathic pain


RISK FACTORS:

Aging, heavy lifting, obesity, smoking, genetics


Signs and symptoms 

Burning/shooting leg pain, numbness/tingling, weakness, limited mobility, Chronic low back pain 


MANAGEMENT:

NSAIDs, muscle relaxants, neuropathic meds (gabapentin/Pregabalin), steroid injections, PT/OT, Discectomy, Spinal fusion.


Exemplar: Total Joint Arthroplasty (TJA): Acute Procedural Pain


OBJECTIVE

KEY POINTS

NURSING PROCESS

ASSESSMENT: Pain scale, incision, perfusion. Planning: Pain <3/10. Interventions: Administer analgesics on schedule, PCA management, ice, elevation, & early ambulation.

PCA CARE PUMP

Two-nurse verification, monitor resp. rate, pulse ox, PATIENT-CONTROLLED ONLY, document  vs. deliveries 

INDEPENDENT 

Distraction, positioning, deep breathing, topical numbing agents,&  emotional support.

COLLABORATIVE

Premedicate, sedation if ordered, local anesthesia 

COMFORT PHARMACOLOGY 

MEDICATION

USE

SE & AE

NURSING CONSIDERATION & PATIENT TEACHING 

NSAIDs (non-opioid analgesics)

Inflammation, mild/moderate pain 

GI upset, n/v

GI bleed, renal damage

PT: Take with food, report black stools (GI bleed), no alcohol & other NSAIDs. Don't take in the 3rd trimester. NC: Monitor renal labs (BUN/Cr), no anticoagulants. Low dose & GI bleed assess.

Opioids (opioid analgesics)

Moderate/severe pain 

Constipation, sedation

Resp depression

PT: Avoid drinking/driving, ↑ stool softeners. NC: Hold if RR<12.Fall precautions, Naloxone (half-life)

Naloxone (opioid antagonist)

Reverse opioid OD

Agitation, N/V, ↑ BP

Arrhythmias, acute withdrawal

PT: EMERGENCY ONLY, may need repeat dosing. NC: Monitor VS q15 min; reassess LOC & pain after use 

Gabapentin/Pregabalin (adjuvant 

Neuropathic pain 

Drowsy, dizzy, edema

Suicidal thoughts, angioedema

PT: Don't stop abruptly. NC:  Assess mood changes; taper gradually; monitor edema/weight; fall risks 


MOBILITY:

Exemplar: HIP FRACTURE & TOTAL HIP ARTHROPLASTY

Often due to falls + osteoporosis

Complications: Hemorrhage, DVT/PE, fat embolism, infection, & Avascular necrosis. Prophylaxis: Early mobilization, anticoagulants (enoxaparin/Warfarin), antibiotics

THA Complications & Prevention

Complications: bleeding, infection, dislocation, VTE (DVT/PE), & Prosthesis loosening. Prevention: Hip precautions( correct positioning), DVT prophylaxis (anticoagulants, SCDs), early PT day 1

THA positioning 

Hip precautions: NO crossing legs/ankles. No Hip flexion> 90 degrees(avoiding bending at the waist. Maintain abduction (legs apart)

jjjjj

  • Exemplar: Osteoporosis

  • Risk factors: Non-modifiable: postmenopause ( ↓estrogen), aging, female, white/asian. Modifiable: low Ca/ Vit D, smoking, alcohol, chronic steroid use 

  • ASYMPTOMATIC until fracture, height loss, kyphosis

Management: 

  • Prevention/teaching: Weight-bearing exercises, ↑ Ca/Vit D, fall prevention

  • Pharm: Alendronate


  • Exemplar: Osteoarthritis 

  • Risk Factors: Non-modifiable: Age > 50, genetics, female Modifiable: Obesity, Smoking, repetitive stress, joint injury.

  • Pain (worse↑activity, better ↑ rest), Stiffness(worse in AM), Crepitus,↓ ROM

  • Pain Management: Weight loss, low-impact exercises, PT/OT, NSAIDs, APAP



MOBILITY PHARMACOLOGY 

MEDICATION

USE

SE & AE

NURSING CONSIDERATION & PATIENT TEACHING 

Heparin

(anticoagulant)

prevention/treatment of thromboembolic disorders 

Bruising at injection site, Bleeding, HIIT

PT: Report bleeding/bruising; avoid NSAIDs. NC: Monitor aPTT, platelet count. Antidote: Protamine sulfate. ↑ Bleeding in elderly 

Warafarin PO(anticoagulant)

DVT prevention LMWH

GI Upset/ Bleeding

PT: Report bleeding, no rubbing site. NC: Monitor INR. Avoid high Vit k foods. Dose adjustment in elderly Antidote= Vit k 

Enoxaparin (anticoagulant)

DVT prevention/treatment

Injection site reaction, Bleeding, Thrombocytopenia 

PT: Don't rub after injection; report bleeding. NC: DO not expel air bubble. Monitor CBC. Adjust dose in renal impairment 

Apixaban 

(anticoagulant)

DVT, PE prevention in post-arthoplasty 

Bleeding, Bruising

PT: Take as prescribed, dont stop abruptly. NC: No routine lad monitor. Educate on bleeding risk. Use caution in elderly

Alendronate

(Bisphosphonate)

Osteoporosis treatment & prevention

GI upset, Esophageal irritation, osteonecrosis of the jaw (Rare)

PT: Take with a full glass of water. Sit upright for 30 minutes after dose. Used in postmenopausal women 

ELIMINATION: 

Exemplar: BENIGN PROSTATE HYPERPLASIA (BPH)

PATHO Enlarged prostate obstructs urethra → urinary changes 

RISK FACTORS : Aging (older adults), men

Signs and symptoms ↑ Frequency (q1-2h), urgency, weak stream, hesitancy, straining, incomplete emptying, retention (emergency obstruction)

Medications: Tamulosin, Finasteride

Interventions: Bladder training, encourage sitting to void, Post-op TURP: Catheter care. Hematuria/spasms up to 1-3 weeks post-surgery are normal. Call provider for clots, inability to void, fever, flank pain.

COMPLICATIONS: UTI, Pyelonephritis, acute/chronic kidney injury 

MEDICATIONS: Tamulosin: Relaxes smooth muscles; fast relief. Finasteride: Shrinks prostate; +6 months 


Exemplar: DIARRHEA/BOWEL INCONTINENCE 

RISK FACTORS

Infections, medications (antibiotics), tube feeding, IBD, IBS

S/S

>3 loose stools/day, urgency, incontinence, cramps, borborygmi (growling), tenesmus (painful sensation)

MANAGEMENT: Medical: Address underlying cause, rehydrate, & antidiarrheal meds. Nursing: Rest, hydration, electrolyte replacement, skin care. Avoid caffeine, carbonated, very hot/cold foods

COMPLICATIONS: Dehydration, electrolyte imbalance (dysrhythmias), Dermatitis (skin breakdown)

MEDICATIONS: Psyllium(Bulk-forming): Safe for long-term use. Diphenoxylate/atropine(opioid agonist): Slows peristalsis. Loperamide: Slows intestinal motility. Aluminum hydroxide(antacid): csn cause constipation


Exemplar: URINARY INCONTINENCE 


PATHO: Weakness of sphinters/Pelvic floor, retention, neurogenic causes

RISK FACTORS: Age-related changes (muscle weakness/sphincter ↓). Gender (Women ↑ risk).Pregnancy & childbirth (pelvic floor changes).Neurological impairment, dementia.

Signs and symptoms: Incontinence. Signs of retention, dysuria, urgency, frequency, nocturia, oliguria, anuria, polyuria

NURSING PROCESS: Interventions: Bladder training/Scheduled toileting. Pelvic floor exercises. Reduce fluids/diuretics in the PM. Habit Training (Scheduled toileting, timed voiding.)

COMPLICATIONS: Skin breakdown, infection, ↓ self-esteem


Exemplar: COLISTIDIUM DIFFICILE (C. DIFF)

PREVENTION: STRICT H&WASHING (soap & water, no alcohol gels). Hygiene, hydration, nutrition 

PATHO: Overgrowth after antibiotic use→ toxin release→ colitis

RISK FACTORS: Recent antibiotic use 

Sign and symptoms: Watery diarrhea, resistant to usual treatment, Positive stool culture

MANAGEMENT: Oral vancomycin, Metronidazole (Flagyl), fecal transplant 

NURSING PROCESS: Monitor renal function, assess stool. Teaching: Complete full course of Vanco/Metro. Metronidazole: AVOID ALCOHOL during & 48 hrs later

COMPLICATIONS: Dehydration, colitis, sepsis


Exemplar: CONSTIPATION/IMPACTION

PATHO: Slowed transit, dehydration, low fiber, inactivity, medications (opioids, anticholinergics) 

RISK FACTORS (AGE-RELATED): ↑ Risk in older adults due to ↓ peristalsis, weakened muscles, & polypharmacy effects

Signs and symptoms: < 3 BMs/week, distention, bloating, straining, hard/dry stool 

MANAGEMENT

NONPARM: ↑ Fluids, fiber, activity. Fruits/vegetables.

 Medical: Enemas (tap water, saline, mineral oil), disimpaction, laxatives

NURSING PROCESS

Teaching: Respond promptly to urge. Encourage ↑ fluids/fiber/exercise. Avoid chronic laxative use 

COMPLICATIONS: Impaction, hemorrhoids, fissures, rectal prolapse. 


ELIMINATION PHARMACOLOGY 

MEDICATION

USE

SE & AE

NURSING CONSIDERATION & PATIENT TEACHING 

Diphenoxylate & Atropine (antidiarrheal) 

Treats diarrhea 

Drowsiness, dry mouth, toxic megacolon, resp. Depression in high doses

Avoid in infectious diarrhea. Monitor hydration. Do not exceed 20mg/day

Bisacodyl, Sennosides (simulant laxative)

Treats constipation 

Cramping, diarrhea, electrolyte imbalance, & dependence 

Use short-term only. Avoid milk/antacids (Bisacodyl), add fiber to diet

Docusate Sodium (stool softener)

Prevents straining during defecation

Mild GI cramping, diarrhea (rare)

Best for prevention, not severe constipation. ↑ fluid intake 

Polyethylene Glycol 3350 (osmotic laxative)

Constipation, bowel prep

Diarrhea, bloating, nausea, electrolyte imbalance

Ensure adequate hydration. It may take 2-4 days for the effect. Safe for long-term use 

Psyllium (bulk-forming laxative)

Constipation promotes regularity

Bloating gas, GI obstruction (if not enough water)

Take with a full glass of water (8oz). ↑ Fluids/fiber. Safe long-term

Aluminum Hydroxide  (antacid)

Neutralizes stomach acid

Constipation, Hypophospatemia 

Monitor phosphate & Ca levels. Separate from other meds by 2 hrs.

Tamulosin (Alpha-Adrenergic Antagonist)

BPH, urinary retention

Relaxes smooth muscle

Dizziness, headaches, & nasal congestion.Hypotension syncope

Monitor BP. Teach the patient to rise slowly

Finasteride (alpha inhibitor) 

BPH, male baldness

 Shrinks prostate

↓ libido, gynecomastia (man boobs), Sexual dysfunction

Pregnant women should not handle crushed tablets. Takes 6+ months for effect 

Oxybutynin (antispasmodic)

Overactive bladder, urge incontinence 

Dry mouth, constipation, blurred vision, Urinary retention, heat stroke 

Encourage fluids. Monitor urine output. Caution with the elderly (↑ confusion)

Metronidazole (antibiotic, CDIFF)

Treats c diff. Anaerobic infections

Metallic taste, dark urine, GI upset, seizures, neuropathy

Avoid alcohol (during + 48 hrs after). Monitor neurological status 

Vancomycin PO 

(C diff) 

Treats c diff. & MRSA

Hypotension, rash, nephrotoxicity, ototoxicity, red man syndrome 

Monitor trough levels (IV/systemic use). PO used for c.diff, Report ↓ urination.



FUNCTIONAL ABILITY: 

Exemplar: ALZHEIMER’S DISEASE (AD) 

Progressive, neurodegenerative disorder.

RISK FACTORS : Age, family history, genetics (APOE-e4), head trauma, cardiovascular disease.

S/S

Anomia (inability to recall names), Apraxia (inability to perform purposeful movements), Agnosia (inability to recognize objects), Aphasia (language impairment), Amnesia 

STAGES &  SIGNS

 Stage 1: Memory lapses, aphasia, sundowning (confusion, agitation in evening hours). Stage 2: Cannot perform IADLs. Stage 3: Cannot perform basic ADLs, personality changes, dysphagia 

NURSING PROCESS

Safety interventions (critical): address FALL RISK. Remove rugs/clutter, use grab bars, & secure outside exits to prevent wandering. Communication: Use clear, short sentences. Use yes or no questions. DO NOT present reality when hallucinating/delusional. Redirect when agitated.




Exemplar: DOWN SYNDROME 

PATHO: Trisomy 21 (extra chromosome). Leads to developmental delays & systemic complications. 

Signs and symptoms: Intellectual disability, Hypotonia (decreased muscle tone), flat social profile, upward slant eyes, single palmar crease alopecia. Cardiac murmur 

MANAGEMENT : Early interventions: PT/OT/ speech therapy. Regular screenings for cardiac, vision, hearing, thyroid, & sleep apnea.

COMPLICATIONS: Atlantoaxial instability (C1 & C2 joint risk). Congenital heart defects. ↑ risk for Alzheimer’s 

HEALTH PROMOTION: Genetic counseling. Adherence to screening & early intervention programs

Exemplar: PARKINSON’S DISEASE (PD)

PATHO: Progressive loss of dopamine in the substantial nigra. Creates LOW DOPAMINE, HIGH ACETYLCHOLINE imbalance

MANAGEMENT: Medication: Carbidopa-levodopa (dopamine replacement. Surgical: Thalamotomy ( ↓ Tremor), Pallidotomy (↓rigidity/dyskinesias), Deep brain stimulation (DBS)

NURSING PROCESS: Safety: Suction drool at bedside (airways risk), ↑ fluids/fiber for constipation risk, Dysphagia: Puree diet, thickening agents, monitor swallowing. Encourage stretching & ROM exercises.

COMPLICATIONS: Falls, aspiration pneumonia (due to dysphagia/drooling), severe depression/dementia 

SAFETY:Address orthostatic hypotension. Use proper shoes & assistive devices.


Exemplar: CARDIOVASCULAR ACCIDENT (CVA)


OBJECTIVES 

Ischemic Stroke

Hemorrhagic Stroke

PATHO

Clot (thrombosis/embolism) blocks blood flow →Ischemia 

Blood vessel rupture → bleeding into brain→↑ ICP

RISK FACTORS 

Hypertension, diabetes, atherosclerosis, smoking, high LDLs

Hypertension, auerysm, anticoagulant therapy.

S/S

F.A.S.T(face, arm, speech, time). Gradual or sudden onset 

Severe headache, early & sudden ↓ LOC, vomiting, bleeding 

ACUTE MANAGEMENT

Thrombolytics (“-ase”) within 4.5 hours. Endovascular therapy (clot retrieval in cath lab)

NO anticoagulants, NO blood thinners, NO clot busters. Elevate HOB to 30 degrees. Surgical evacuation

KEY TERMS

Agnosia (inability to recognize objects), Apraxia (inability to perform purposeful movements 

Dysarthria(slurred speech).Hemiparesis (weakness) / Hemiplegia (paralysis).Hemianopsia (loss of ½ vision)

L VS. R BRAIN 

Left brain (language & logic): Dysphasia, reading/writing problems, RIGHT hemiparesis, aware of defects (→ anxiety, depression)

Right brain (“reckless”): lack of impulse control, behavioral changes, LEFT hemiparesis, poor space perception.

COMPLICATIONS

↑ ICP, Dysphagia.↓LOC, seizures (requires seizure precautions), depression. Rehab goal: Restore mobility. Use a transfer belt (strongest aide first)

Increased ICP , Seizures , Hydrocephalus , Hyponatremia , & Rebleeding.


FUNCTIONAL ABILITY  PHARMACOLOGY 

MEDICATION

USE

SE & AE

NURSING CONSIDERATION & PATIENT TEACHING 

Carbidopa-levodopa (Dopamine replacement)

First line for parkinson’s motor symptoms 

n/v, OT, Dyskinesias (toxicity), Hallucinations 

NO HIGH PROTEIN MEALS, report uncontrolled movements, do stop suddenly

Selegiline (antiparkinsonian)

Adjunct to levodopa in Parkinson’s 

Insomnia, dry mouth, nausea, Hypertensive crisis with tyramine foods

Avoid tyramine-rich foods (such as aged cheese & wine). Monitor for serotonin syndrome 

Benztropine (antiparkinsonian)

Parkinson’s tremor/rigidity

Dry mouth, blurred vision, urinary retention, confusion, & hallucinations in elderly 

Monitor bowel/bladder function. ↑ Fluids/fiber. Avoid overheating.

Aspirin (antiplatelet)

Prevention/treatment of ischemic stroke, TIA

GI upset, heartburn, nausea, GI bleeding, hemorrhagic stroke, tinnitus (toxicity)

Take with food. Report unusual bleeding. Avoid in children/adolescents 

Clopidogrel (antiplatelet)

Prevention of stroke, MI

Rash, diarrhea, abdominal pain, GI bleed, hemorrhage, thrombocytopenia 

Stop 5-7 days before surgery. Monitor CBC/platelets. Report bleeding 

Alteplase tPA (thrombolytic)

Acute ischemic stroke, MI, massive PE

Mild bleeding at IV site, fever, hypotension, IC hemorrhage, systemic bleeding 

Given 3-4.5 hours of stroke onset. NO IM injections. Frequent neuro checks 

Donepezil (Anti-Alzheimer’s)

Slows progression of mild to severe Alzheimer’s (Not curative)

Nausea, diarrhea, insomnia, fatigue, Bradycardia, syncope, GI bleed

Take at bedtime. Monitor HR. Contraindicated in COPD/Asthma 

SENSORY PERCEPTION: 

Exemplar: CATARACTS 

PATHO

Clouding of the lens due to clumping of lens proteins

RISK FACTORS & PREVENTION: Risk factors: aging, DM, chronic steroid use, sun exposure, smoking. Prevention: wear UV-preventive sunglasses, manage DM, and avoid smoking 

Signs and symptoms:Blurred or dim vision. Glare and halos around lights. Poor night vision, faded color perception.

TEACHING POINTS : AVOID bending, lifting, or straining (prevents ↑IOP). Report severe pain, vision loss, or flashes of light. Use eye drops correctly (punctual occlusion)

COMPLICATIONS: Infection, retinal detachment (floaters, cobweb vision, flashes of light), ↑ IOP, falls 


Exemplar: GLAUCOMA  

PATHO: ↑Intraocular pressure (IOP) from impaired aqueous humor drainage → optic nerve damage → Irreversible vision loss 

RISK FACTORS : Aging, heredity, African American race, DM, Infection, and steroid use.

Signs and symptoms: Open-angle (most common): Gradual peripheral vision loss (→ tunnel vision), ↑IOP. Closed-angle(emergency): Sudden, severe pain, blurred vision, headaches, N/V, ↑ IOP 


NURSING PROCESS

Post-op/Interventions: Avoid anything that ↑ IOP(coughing, sneezing, straining/valsava). No bending at the waist, no heavy lifting. NO anticholinergics (atropine, Benadryl)

COMPLICATIONS

Progressive, irreversible blindness. Optic nerve atrophy.

MEDiCATIONS 

Beta-blockers (Timolol): ↓ aqueous humor. Prostaglandin analogs (laranoprost): ↑ Outflow. Carbonic anhydrase inhibitors (Dorzolamide): ↓ Production (avoid in sulfa allergy). Cholinergics (pilocarpine): ↑ outflow via pupil constriction.

TEACHING POINTS 

Use punctual occlusion. Wait 5 minutes between different drops. Dont stop abruptly 

Exemplar: PERIPHERAL NEUROPATHY 

OBJECTIVES 

DESCRIPTION 

PATHO

Damage to peripheral nerves (sensory/motor/autonomic) → disrupts normal transmission. Results in loss of sensation, pain, or weakness in “Stocking-glove” pattern. Common cause: Chronic hyperglycemia (diabetes).

RISK FACTORS

Chronic diseases (DM, kidney disease). Alcohol use, poor nutrition ( B defiency). Chemotherapy 

S/S

Numbness or tingling (“pins and needles”). Burning or sharp pain. Loss of sensation, unsteady gait. Autonomic: Orthostatic Hypotension, ↓ sweating.

MANAGEMENT

Primary: Control underlying cause (especially blood glucose in DM). Meds: Anticonvulsants (Gapapentin), Antidepressents, topical agents (capsaicin, lidocaine path)

COMPLICATION

Foot ulcers, infections, aputations. Burns or injuries due to lack of sensation. Falls

INTERVENTIONS 

Non-pharm: Teach daily foot care and proper footwear. Inspect bathwater temperature. Remove tripping hazards 

SENSORY PERCEPTION  PHARMACOLOGY 

MEDICATION

USE

SE & AE

NURSING CONSIDERATION & PATIENT TEACHING 

TImolol (beta blocker)

Open-angle glaucoma 

Stinging, blurred vision, Bradycardia, hypotension, bronchospasm 

Use Punctual occlusion. Monitor HR and BP. Report SOB

Dorzolamide (Carbonic anhydrase inhibitor)

Open-angle glaucoma 

Burning, stinging, bitter taste, Allergic conjunctivitis 

Avoid in sulf allergy. Use punctual occlusion 

Pilocarpine (Cholinergic)

Open-angle/ close-angle glaucoma 

Blurred vision, brow pain, retinal detachment (rare)

Expect temporary blurred vision. Avoid driving at night 

Brolucizumab (VEGF inhibitor) 

Wet (exudative) MD

Eye pain, floaters, redness, retinal detachment, endophthalmitis 

Report pain, vision changes immediately. Administered intravitreal  

Capsaicin (Topical analgesic)

Peripheral neuropathy, osteoarthritis 

Burning, stinging, erythema, severe irritation (rare)

Apply consistently for full effect. Use gloves. Burning is common.

Lidocaine Patch (Topical anesthetic)

Peripheral neuropathy, localized pain relief 

Local redness, irritation, systemic toxicity 

12 hrs on, 12 hrs off. Avoid heat over patch. Apple only to intact skin.

*NUTRITION 

Diagnostics: ↓Albumin (long-term protein status), ↓ Prealbumin (short term protein status), Hgb/Hct, BUN/Creatinine, UA (hydration/protein loss). 

Micro vs. macronutrients: Macro: Protein, carbs, lipids, water, fiber. Purpose: energy, gorwith, tissue building. Micro: vitamins and minerals. Purpose: metabolism, hormones, nervous system function.

Bmi parameters: Underweight: <18.5. Normal: 18.5-24.9 Overweight: 25-29.9. Obese: equal or > 30 

Health promotion: Emphasize whole grains, fruits, & vegetables, adequate protein. Limit simple sugars & processed foods. Control portion sizes


Exemplar: OBESITY  

OBJECTIVES 

DESCRIPTION 

PATHO

Hypertrophic (↑ size) vs. hypercellular (↑ number) adipose cells. Adipose tissue is involved in hormonal regulation and inflammation

RISK FACTORS 

Age, Cultural/family diet patterns, food accessibility, genetics 

ACCOMADATIONS

Appropriate bed/wheelchair size. Nonjudgmental care. Screening for eating disorders

MANAGEMENT

Dietican/social referral. Bariatric surgery (last resort). Statins if high cholesterol .

NURSING PROCESS

Reduce calories by 500/day. Increase physical activity.

COMPLICATIONS

High cholesterol and co-existing conditions. Respiratory issues (sleep apnea). Psychological impacts and bias in healthcare

PATIENT TEACHING 

Focus on lifestyle modifications (diet + exercise). Limit simple sugars.

Exemplar: IRON DEFICIENCY ANEMIA 

OBJECTIVES 

DESCRIPTION 

PATHO

Not enough iron for RBC production. Causes : inadequate intake, chronic bleeding, malabsorption 

RISK FACTORS

Low red-meat/beans/greens intake. Lack of iron-fortified foods, 

S/S

Fatigue, pallor, tachycardia, dyspnea, Brittle nails, glottis (tongue inflammation), stomatitis (mouth and lip infammagtion), PICA

DIANOSTICS

↓Hgb/Hct. ↓Ferritin and Transferrin. RBC indices abnormal. Occult blood in stool.

MANAGEMENT

Iron supplement awith vitamin C . DIetician reffereal. O2/blood if needed

DIET RECS

↑ red meats, beans, leafy greens 

COMPLICATIONS 

↑ fatigue, ↓physical performnce, possible developmental delays in children. 

Exemplar: DYSPHAGIA 

OBJECTIVES 

DESCRIPTION 

PATHO

Impaired swallowing. Caused by neurologic dysfunction ( stroke, parkinsons), Aging, cancer, dental issues 

RISK FACTORS

Stroke, Parkinson’s, tumor 

S/S

Coughing after swallowing , slow eating, food residue in mouth (pocketing). Gurgling, hoarse voice.

DIAGNOSTICS

Swallow study (videofluoroscopy) → evaluates aspiration risk. Chest XR →infiltrates (for aspiration pneumonia)

NURSING PROCESS

HOB in High-fowler’s, fully awake to feed. Small bites, allow rest. Use thickened liquids (nectar/honey). NPO until swallow screening 

COMPLICATIONS

Aspiration pneumonia, choking, malnutrition

NUTRITION PHARMACOLOGY 

MEDICATION

USE

SE & AE

NURSING CONSIDERATION & PATIENT TEACHING 

Atorvastin

(Statin)

OBESITY Lowers cholesterol, 

Muscle aches, GI upset, Rhabdomylosis(muscle breakdown), hepatotoxicity 

Monitor LFTs (AST/ALT); assess muscle pain. Avoid grapefruit. Report dark urine 

Pantoprazole 

(Proton pump inhibitor )

Malnutrition, GERD, ulcers

Headache, diarrhea, C. diff, osteoporosis (long-term).

Give 30 minutes before meals. Monitor magnesium. Report black/tarry stools.

Famotidine (H2 antagonist)

Malnutrition, GERD, ulcers

Heacahce, constipation, confusion in elderly 

Take 30 minutes before meals, monitor renal function. Avoid smoking, alcohol, NSAIDs.

Cyanocobalamin (B12)

B 12 deficiency, pernicious anemia 

Headache, GI upset, Hypokalemia (rare)

Monitor b12 levels.

Ferrous SUlfate (iron supplement) 

Iron deficiency anemia 

COnstipation, black stools, iron toxicity.

Balck sttols is normal , administer with Vit C for absorption. ↑  fluids/fiber. Toxic to children.

Ascorbic Acid(Vit C)

Aids iron absorption 

GI upset, kidney stones (high doses)

Encourage dietary sources(citric, berry, fruits) . Take with iron.

Exemplar: IMPETIGO (BACTERIAL)

OBJECTIVES 

DESCRIPTION 

PATHO

Bacterial infection (strep/staph). Enters though break in skin. Highly contagious 

S/S

Honey colored crusts . Itchy blisters, oozing lesions.

NURSING/TEACHING

Interventions: Topical antibiotics, hygiene. Teaching: handwashing, no sharing towels. Can return to school after starting antibiotics for 24 hours. Shorten fingernails

Exemplar: PSORAISIS (AUTOIMMUNE)

OBJECTIVES 

DESCRIPTION 

PATHO AND RISK 

Autoimmune, chronic. Epidermal hyperplasia. Triggered by stress, trauma, infection.

S/S 

Silvery plaques (elevated). Itchy, scales, red lesions. Joint pain 

NURSING/TEACHING

Treatments: moisturizers, UV therapy (sun limits skin cell division), immunosuppressants. Teaching: Avoid skin trauma, manage stress, moisturize.

Exemplar: TRUAMATIC AND SURGICAL WOUNDS

OBJECTIVES 

DESCRIPTION 

HEALING INTENTIONS

Primary: Sutured/approximated edges. Secondary: Open, heals by granulation. Tertiary: delayed closure (infection)

DEHISCENCE VS. EVISCERATION

Dehiscence: Surgical wound reopens. Evisceration: Internal organs protrude 

NURSING INTERVENTIONS 

Dehiscence prevention: Splint abdominal wounds (“ support your incision every time you cough or move”) Avoid valsava. Eviceration care: Cover with saline soaked gauze

Exemplar: TINEA PEDIS (FUNGAL)

OBJECTIVES 

DESCRIPTION 

PATHO & RISK FACTORS

Fungal infection(athlete’s foot). Grows in warm moist areas. Contagious 

S/S

Scaling, redness, maceration between toes. Vesicles possible. Pruritus

NURSING/TEACHING

Interventions: Apply antifungals. Teaching: keep feet clean and dry

Exemplar: CANDIDIASIS (FUNGAL)

OBJECTIVES 

DESCRIPTION 

PATHO & RISK FACTORS

Fungal Infection (Candida). Common in moist skin fold and mouth. ↑ in immunocompromised  

S/S

Thrush: White plaques that DO NOT wipe off. Skin: Red rash with defined borders, itching.

NURSING/TEACHING

Interventions: Nystatin (topical or oral). Keep areas dry. Oral care: swish & swallow Nystatin, no eating/drinking for 30 min 

Exemplar: PEDICULOSIS CAPITIS (LICE)

OBJECTIVES 

DESCRIPTION 

PATHO & RISK FACTORS

Lice infestation. Spread via contact (hats, brushes, bedding). 

S/S

Nits on hair shafts. Itching behind ears and neck.

NURSING/TEACHING

Interventions: Permethrin treatment. Remove nits with a comb. Repeat in 7 days if needed. Teaching: wash bedding and clothing in HOT water. Do not share personal items.

TISSUE INTEGRITY PHARMACOLOGY 

MEDICATION

USE

SE & AE

NURSING CONSIDERATION & PATIENT TEACHING 

Ketoconazole 

(topical Antifungal)

Tinea Pedis, cutaneous candidiasis

Burning,stinging,itching, allergic contact dermatitis 

Apply to clean,dry skin. Continue for full duration.

Nystatin (Topical antifungal)

Oral thrush, candidiasis

Mild burning, dryness, severe rash

For oral thrush: Swish & swallow, no eating/drinking 30 mins after. Keep areas clean & dry.

Acyclovir (topical antiviral )

Herpes simplex 1 -cold sores

Burning, stinging, local irritation.

Use gloves for application. Use at first sign of tingling. DOes not prevent future outbreaks.

Permethrin 

Head lice

Itching, burning, Local inflammation.

Leave on for 10 mins, rinse, comb out nits. Repeat in 7 days. Treat entire household

THERMOREGULATION:

Attributes: Stable core temp (36.5-37.5 C OR 97.7-99.5 F)


Exemplar: HYPOTHERMIA/FROSTBITE

OBJECTIVES 

DESCRIPTION 

PATHO & RISK 

Core temp < 35 degrees C. Heat loss> Heat production. Risk factors: Aging (systemic)

S/S

Apathy, confusion drowsiness →coma, ↓HR, ↓BP,→ arrhythmias. Frostbite (local): white, cold, waxy skin, redness

INTERVENTIONS

Independent: Remove wet clothing, warm blankets, ↑ oral fluids. Collaborative: warm IV fluids, forced -air warming blankets. Frostbite: rapid rewarming (warm bath water ) DO NOT RUB.

Exemplar: NEONATAL HYPOTHERMIA

OBJECTIVES 

DESCRIPTION 

DEVELOPMENT & DANGER

Thin skin, large surface area →lose heat quickly. Rely on brown fat and non-shivering thermogenesis. Danger: ↑ oxygen consumption, acidosis, hypoglycemia. 

PREVENTION STAGES 

Skin-to-skin contact, immediately dry infant. Place under radiant warmer, hat on head 

Exemplar: HYPERTHERMIA/HEAT STROKE, ELDERLY 

OBJECTIVES 

DESCRIPTION 

Heat exhaustion vs. heat stroke 

Exhaustion: sweating, thirst, dizziness. Stroke(emergency): Temp>105 F.(40.55 C)  Hot dry skin, NO SWEATING, Neuro changes  (confusion, seizure)

RIsk factors: elderly 

↓sub fat,↓sweat gland function, ↓BMR

Interventions 

Independent: Cool environment/clothing,hydration encouragement. Collaborative: cool IV fluids, cooling blankets, ice packs 

Prevention 

Adequate hydration, AC, limit sun/heat.

Exemplar: PEDIATRIC FEVER

OBJECTIVES 

DESCRIPTION 

PATHO & S/S

Immune response to infection (hypothalamus rests temp). Higher temps in PM. Signs: ↑HR, tachypnea, shivering, irritability 

INTERVENTIONS

Non-pharm: ↑ fluids =, light clothing, cool bath/cloth. Pharm: acetaminophen or NSAIDs. Call provide if : rash, oliguria , trouble breathing 

Exemplar: MALIGNANT HYPERTHERMIA 

OBJECTIVES 

DESCRIPTION 

PATHO & RISK 

Genetic, life-threatening reaction to anesthesia. Uncontrolled calcium release in muscles → hypermetabolic state. Risk: family history, bulky muscles.

S/S

Early: Hypercapnia (↑CO2 ), tachycardia, muscle rigidity, acidosis. Late: fever, myoglobinuria (muscle protein in urine), organ failure

INTERVENTIONS

Immediately administer Dantrolene IV. Stop trigger agents, Continue supportive cooling and electrolyte correction. Monitor LFTs

THERMOREGULATION PHARMACOLOGY 

MEDICATION

USE

SE & AE

NURSING CONSIDERATION & PATIENT TEACHING 

Dantrolene (Muscle relaxant) 

Malignant hyperthermia (emergency )

Drowsiness, weakness, Hepatotoxicity (major risk). Resp Depression

Ensure immediate IV administration. Monitor liver enzymes (AST/ALT). Avoid CNS depressants.

NSAIDs (non-opioid analgesics)

Fever 

GI upset, n/v

GI bleed, renal damage

PT: Take with food, report black stools (GI bleed), no alcohol & other NSAIDs.. NC: Monitor renal labs (BUN/Cr),

Acetaminophen (antipyretic)

Fever, mild moderate pain

GI upset, Hepatotoxicity 

MAX DOSE 4g/day . Monitor liver enzymes 

SLEEP

OBJECTIVES 

DESCRIPTION 

Types and risks 

Types: REM, NREM, or combined deprivation. Risk factors: long hospitalizations, chronic illness, stress, age.

s/s

Excessive daytime sleepiness, fatigue. ↓attention & concentration, irritability, slowed responses.

interventions

Cluster care to ↓ interruptions. Reduce noise and light. Adjust timing of medications. Promote comfort.

Patient teaching

Exercise regularly. Maintain a consistent sleep schedule. Avoid naps, late meals/drinks, caffeine/alcohol. Optimize bedroom temp/lighting.

complications

Confusion,psychosis, seizures. Postoperative delirium.

Exemplar: INSOMNIA 

OBJECTIVES 

DESCRIPTION 

Types & consequences 

Types: difficulty falling asleep, early morning awakening. Consequences: Daytime sleepiness, poor concentration, ↓accident risk 

Non-pharm interventions 

Sleep hygiene CBT-1 (behavioral therapy). Relaxation techniques. Limit screens before bed. Cool, quiet dark room 

Pharm interventions

Hypnotics (Zolpidem). Antidepressants (trazodone).

Exemplar: SLEEP APNEA

OBJECTIVES 

DESCRIPTION 

Tyoes & definitions 

Obstructive (OSA): Pharynx collapses, blocking airway. Central(CSA): Brain fails to send signal to breathe. Apnea: Period of +10 seconds without breathing 

s/s

Loud snoring. Extreme daytime sleepiness. ↑ CO2 (Hypercapnia → respiratory acidosis.) Headaches on awakening.

Collab interventions 

CPAP/BiPAP. Weight loss. Oral appliances, tonsillectomy/surgery  

Nursing 

Elevate HOB. Avoid sleeping on back. Encourage exercise. Limit alcohol reinforce CPAP use 

complications

Hypertension, dysrhythmias, pulmonary hypertension→ right sides heart failure.MI, Stroke

SLEEP PHARMACOLOGY 

MEDICATION

USE

SE & AE

NURSING CONSIDERATION & PATIENT TEACHING 

Zolpidem (hypnotic)

Insomnia (short term)

Drowsiness,dizzy, sleepwalking/driving 

Must have 6-8 hours available for sleep, take on empty stomach . avoid alcohol.

Trazodone (serotonin modulator)

Insomnia 

Sedation dry mouth, serotonin syndrome, priapism.

GIve at bedtime due to sedation. Monitor for dizziness/ orthostatic hypotension. Report prolonged erection immediately