This study material is compiled from various sources, including a lecture audio transcript and copy-pasted text. It is designed to provide a comprehensive overview of critical medical concepts and nursing principles for university-level students.

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📚 Comprehensive Medical & Nursing Study Guide

💡 Introduction

This study guide aims to consolidate essential medical facts and nursing practices into a clear, organized format. It covers a wide range of topics from endocrine disorders and infection control to critical assessments and pharmacological principles, providing key information and practical tips to guide clinical practice.

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1. 🩺 General Nursing Principles & Critical Thinking

1.1. Prioritization & Assessment

• ✅ DO NOT delegate what you can EAT!
  • E - Evaluate
  • A - Assess
  • T - Teach
• ✅ Assessment First: Always assess the patient before checking monitors or machines. For example, listen to fetal heart tones with a stethoscope before checking the monitor.
• ✅ Emergency Situations: In an emergency, patients with a greater chance to live are treated first.
• ✅ Key Words: Avoid answers with absolutes (e.g., "always," "never," "must").
• ✅ Patient-Focused: Always select a "patient-focused" answer.
• ✅ Actual vs. Potential Problems: Always deal with actual problems or harm before potential problems.
• ✅ "Why" Questions: Never use "why" questions when asking patients.
• ✅ Reassessment: An answer option that states "reassess in 15 minutes" is probably wrong.
• ✅ Delegation: Assessment, teaching, medication administration, and evaluation of unstable patients cannot be delegated to Unlicensed Assistive Personnel (UAP). LVN/LPNs cannot handle blood.

1.2. Communication

• ✅ Do not use "why" or "I understand" statements when dealing with patients.
• ✅ For phobic disorders, use systematic desensitization.
• ✅ When a patient has hallucinations, redirect them. For delusions, distract them.
• ✅ For children, explain time in relation to a known common event (e.g., "Mom will be back after supper") as they cannot interpret time.

1.3. Safety

• ✅ Traction Safety: Never release traction unless there is an MD order. For a halo, have a screwdriver nearby.
• ✅ Compartment Syndrome: This is an emergency. Paresthesias and increased pain are classic symptoms. Neuromuscular damage is irreversible 4-6 hours after onset.
• ✅ Four Side-Rails Up: Can be considered a form of restraint. Keep lower rails down, one side of the bed against the wall, lowest position, wheels locked for fall risk patients.

1.4. Fluid & Electrolyte Balance

• ✅ Weight: The best indicator of dehydration.
• ✅ Water Follows Sugar: Wherever there is glucose, water follows.
• ✅ No Pee, No K: Do not give potassium without adequate urine output.
• ✅ Edema: Is in the interstitial space, not the cardiovascular space.

1.5. Pain Management

• ✅ Acute Pain: Use cold (e.g., sprained ankle).
• ✅ Chronic Pain: Use heat (e.g., rheumatoid arthritis).
• ✅ Guided Imagery: Great for chronic pain.
• ✅ Distress: When a patient is in distress, medication administration is rarely a good first choice.

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2. 🎛️ Endocrine System Disorders

2.1. Adrenal Gland Disorders

• Addison's Disease (Adrenal Insufficiency) 📉
  • Mnemonic: "down, down, down, up, down"
  • Signs & Symptoms: Hyponatremia, hypotension, decreased blood volume, hyperkalemia, hypoglycemia, dark pigmentation, decreased resistance to stress, fractures, alopecia, weight loss, GI distress.
  • Addisonian Crisis: Nausea, vomiting, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP.
  • Management: Administer mineralocorticoids. Managing stress is paramount. Blood pressure is the most important assessment parameter due to severe hypotension.
• Cushing's Syndrome (Adrenal Hyperfunction) 📈
  • Mnemonic: "up, up, up, down, up"
  • Signs & Symptoms: Hypernatremia, hypertension, increased blood volume, hypokalemia, hyperglycemia, prone to infection, muscle wasting, weakness, edema, hirsutism, moon face, buffalo hump.
  • Prednisone Toxicity: Can cause Cushing's syndrome symptoms.
• Pheochromocytoma
  • Description: Hypersecretion of epinephrine/norepinephrine.
  • Signs & Symptoms: Persistent hypertension, increased heart rate, hyperglycemia, diaphoresis, tremor, pounding headache.
  • Management: Avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods. Surgery to remove the tumor.

2.2. Thyroid Gland Disorders

• Myxedema / Hypothyroidism 🥶
  • Signs & Symptoms: Slowed physical and mental function, sensitivity to cold, dry skin and hair. Myxedema coma is associated with hypothermia.
  • Medication: Synthroid (levothyroxine) - may take several weeks to take effect, notify doctor of chest pain, take in the AM on an empty stomach, can cause hyperthyroidism. Insomnia is a side effect.
• Graves' Disease / Hyperthyroidism 🔥
  • Mnemonic: Think of Michael Jackson in Thriller (skinny, nervous, bulging eyes, up all night, heart beating fast).
  • Signs & Symptoms: Accelerated physical and mental function, sensitivity to heat, fine/soft hair, exophthalmos.
• Thyroid Storm 🌪️
  • Signs & Symptoms: Increased temperature, pulse, and hypertension. It is "HOT" (hyperthermia).
  • Medications: PTU (propylthiouracil) and Tapazole (methimazole) prevent thyroid storm.
• Post-Thyroidectomy Care
  • Positioning: Semi-Fowler's.
  • Precautions: Prevent neck flexion/hyperextension. Keep a tracheostomy tray at the bedside.

2.3. Parathyroid Gland Disorders

• Hypoparathyroidism (Decreased Calcium)
  • Mnemonic: CATS – Convulsions, Arrhythmias, Tetany, Spasms, Stridor.
  • Diet: High calcium, low phosphorus.
• Hyperparathyroidism (Increased Calcium)
  • Signs & Symptoms: Fatigue, muscle weakness, renal calculi, back and joint pain.
  • Diet: Low calcium, high phosphorus.
• Note: The parathyroid gland relies on the presence of Vitamin D to work.

2.4. Pancreatic Disorders

• Diabetes Mellitus
  • Classic Signs (3 Ps): Polyuria, Polydipsia, Polyphagia.
  • Blood Sugar Mnemonics:
    • Hot and Dry: Sugar high (hyperglycemia).
    • Cold and Clammy: Need some candy (hypoglycemia).
  • Insulin Administration:
    • Drawing up Regular & NPH: "RN" (Regular before NPH).
    • Mnemonic: "Nicole Richie RN" - Air into NPH, then air into regular, draw up regular, then draw up NPH.
  • HbA1c: Test to assess blood sugar control over the past 90-120 days. 4-6% corresponds to 70-110 mg/dL; 7% is ideal for a diabetic (corresponds to 130 mg/dL).
  • Prednisone: May require extra insulin as steroids cause increased glucose.
• Diabetic Ketoacidosis (DKA) 🩸
  • Description: Body breaks down fat instead of sugar for energy, producing ketones (acids) that decrease pH.
  • Signs & Symptoms: Kussmaul's breathing (deep, rapid respirations). Serum acetone and serum ketones rise.
  • Management: Fluids are the most important intervention. Expect potassium to drop rapidly, so be ready with replacement.
  • Note: Rare in Type II DM because there is enough insulin to prevent fat breakdown.
• Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)
  • Description: No ketosis, no acidosis.
  • Management: Fluids are the most important intervention. Potassium is low due to diuresis.
• Pancreatitis 💥
  • Pain: Often relieved by the fetal position.
  • Medication: Demerol (meperidine) for pain, NOT morphine sulfate (causes spasm of the Sphincter of Oddi).
  • Nursing Care: NPO, gut rest. Prepare antecubital site for PICC line (likely TPN/lipids). After pain relief, cough and deep breathe are important due to fluid pushing up the diaphragm.
  • Chronic Pancreatitis: Pancreatic enzymes are given with each meal.
  • Signs: Cullen's sign (ecchymosis of umbilicus), Grey Turner's spots (flank grayish blue).

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3. ⚡ Electrolyte Imbalances

3.1. Sodium (Na+)

• Hyponatremia (Low Sodium)
  • Signs & Symptoms: Nausea, muscle cramps, increased ICP, muscular twitching, convulsions.
  • Management: Osmotic diuretics, fluids.
• Hypernatremia (High Sodium)
  • Mnemonic: "SALT" - Skin flushed, Agitation, Low-grade fever, Thirst.
  • Signs & Symptoms: Increased temperature, weakness, disorientation/delusions, hypotension, tachycardia.
  • Management: Hypotonic solution.

3.2. Potassium (K+)

• Hypokalemia (Low Potassium)
  • Signs & Symptoms: Muscle weakness, dysrhythmias.
  • Diet: Increase K+ (raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery).
  • Note: Alkalosis causes low K+.
• Hyperkalemia (High Potassium)
  • Mnemonic: "MURDER" - Muscle weakness, Urine (oliguria/anuria), Respiratory depression, Decreased cardiac contractility, ECG changes, Reflexes (decreased).
  • Note: Acidosis causes high K+. The vital sign to check first with high potassium is pulse (due to dysrhythmias).
  • Medication: Kayexalate (sodium polystyrene sulfonate) - worry about dehydration (K+ has an inverse relationship with Na+). Do not use if patient has hypoactive bowel sounds.
  • Caution: Never give K+ in IV push.
  • Salt Substitutes: May contain potassium; avoid when taking digoxin and K+ supplements.

3.3. Calcium (Ca2+)

• Hypocalcemia (Low Calcium)
  • Mnemonic: "CATS" - Convulsions, Arrhythmias, Tetany, Spasms, Stridor.
  • Signs: Trousseau's sign (carpopedal spasm), Chvostek's sign (facial spasm).
• Hypercalcemia (High Calcium)
  • Signs & Symptoms: Muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, sedative effect on CNS. Polyuria is common.

3.4. Magnesium (Mg2+)

• Hypomagnesemia (Low Magnesium)
  • Signs & Symptoms: Tremors, tetany, seizures, dysrhythmias, depression, confusion, dysphagia. Can potentiate digoxin toxicity.
• Hypermagnesemia (High Magnesium)
  • Signs & Symptoms: Depresses the CNS, hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. This is an emergency.
  • Antidote: Calcium Gluconate (Ca Glu) is the antidote for MgSO4 toxicity.

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4. 🦠 Infection Control & Precautions

4.1. Transmission-Based Precautions

• Airborne Precautions 🌬️
  • Mnemonic: "MTV" or "My Chicken Hez TB"
    • M - Measles
    • T - TB (Tuberculosis)
    • V - Varicella (Chicken Pox) / Herpes Zoster (Shingles)
  • Requirements: Private room, negative pressure with 6-12 air exchanges/hour. N95 mask for TB.
  • Note: Disseminated Herpes Zoster requires Airborne Precautions. Localized Herpes Zoster requires Contact Precautions; a nurse with localized herpes zoster can care for patients as long as they are not immunosuppressed and lesions are covered. SARS (Severe Acute Respiratory Syndrome) also requires Airborne + Contact.
• Droplet Precautions 💧
  • Mnemonic: "SPIDERMAN!"
    • S - Sepsis, Scarlet Fever, Streptococcal Pharyngitis
    • P - Parvovirus B19, Pneumonia, Pertussis
    • I - Influenza
    • D - Diphtheria (pharyngeal)
    • E - Epiglottitis
    • R - Rubella
    • M - Mumps, Meningitis, Mycoplasma or Meningeal Pneumonia
    • An - Adenovirus
  • Requirements: Private room or cohort. Mask. Maintain 3 ft distance.
• Contact Precautions 🧤
  • Mnemonic: "MRS. WEE"
    • M - Multidrug Resistant Organism (MDRO)
    • R - Respiratory Infection (e.g., RSV)
    • S - Skin Infections (VCHIPS)
    • W - Wound Infection
    • E - Enteric Infection (e.g., Clostridium difficile)
    • E - Eye Infection (e.g., Conjunctivitis)
  • Skin Infections Mnemonic: "VCHIPS"
    • V - Varicella Zoster (localized)
    • C - Cutaneous Diphtheria
    • H - Herpes Simplex
    • I - Impetigo
    • P - Pediculosis
    • S - Scabies
  • Requirements: Gloves and gown.
  • Note: Hepatitis A requires Contact Precautions. Tetanus, Hepatitis B, and HIV require Standard Precautions.

4.2. Neutropenic Precautions

• ✅ No live vaccines, no fresh fruits, no flowers.
• ✅ No milk (as well as fresh fruit or veggies).
• ✅ Yogurt with live cultures should not be given to immunosuppressed patients.

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5. 🛏️ Patient Positioning

• 1️⃣ Air/Pulmonary Embolism: Turn patient to left side and lower the head of the bed.
• 2️⃣ Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia): Turn on left side (and give O2, stop Pitocin, increase IV fluids).
• 3️⃣ Tube Feeding w/ Decreased LOC: Position patient on right side (promotes emptying of the stomach) with the HOB elevated (to prevent aspiration).
• 4️⃣ During Epidural Puncture: Side-lying.
• 5️⃣ After Lumbar Puncture (and oil-based Myelogram): Patient lies in flat supine (to prevent headache and leaking of CSF). For 4-12 hours.
• 6️⃣ Patient w/ Heat Stroke: Lie flat with legs elevated.
• 7️⃣ During Continuous Bladder Irrigation (CBI): Catheter is taped to thigh so leg should be kept straight. No other positioning restrictions.
• 8️⃣ After Myringotomy: Position on side of affected ear after surgery (allows drainage of secretions).
• 9️⃣ After Cataract Surgery: Patient will sleep on unaffected side with a night shield for 1-4 weeks.
• 🔟 After Thyroidectomy: Low or semi-Fowler's, support head, neck, and shoulders.
• 1️⃣1️⃣ Infant w/ Spina Bifida: Position prone (on abdomen) so that sac does not rupture.
• 1️⃣2️⃣ Buck's Traction (skin traction): Elevate foot of bed for counter-traction.
• 1️⃣3️⃣ After Total Hip Replacement: Don't sleep on operated side, don't flex hip more than 45-60 degrees, don't elevate HOB more than 45 degrees. Maintain hip abduction by separating thighs with pillows.
• 1️⃣4️⃣ Prolapsed Cord: Knee-chest position or Trendelenburg.
• 1️⃣5️⃣ Infant w/ Cleft Lip: Position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position.
• 1️⃣6️⃣ To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries): Eat in reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low CHO and fiber diet, small frequent meals). Low-Fowler's recommended during meals.
• 1️⃣7️⃣ Above Knee Amputation: Elevate for first 24 hours on pillow, position prone daily to provide for hip extension.
• 1️⃣8️⃣ Below Knee Amputation: Foot of bed elevated for first 24 hours, position prone daily to provide for hip extension.
• 1️⃣9️⃣ Detached Retina: Area of detachment should be in the dependent position.
• 2️⃣0️⃣ Administration of Enema: Position patient in left side-lying (Sim's) with knee flexed.
• 2️⃣1️⃣ After Supratentorial Surgery (incision behind hairline): Elevate HOB 30-45 degrees.
• 2️⃣2️⃣ After Infratentorial Surgery (incision at nape of neck): Position patient flat and lateral on either side.
• 2️⃣3️⃣ During Internal Radiation: On bedrest while implant in place.
• 2️⃣4️⃣ Autonomic Dysreflexia/Hyperreflexia: Place client in sitting position (elevate HOB) first before any other implementation.
• 2️⃣5️⃣ Shock: Bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg).
• 2️⃣6️⃣ Head Injury: Elevate HOB 30 degrees to decrease intracranial pressure.
• 2️⃣7️⃣ Peritoneal Dialysis when Outflow is Inadequate: Turn patient from side to side BEFORE checking for kinks in tubing.
• 2️⃣8️⃣ Infant w/ Cleft Lip: Position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position.
• 2️⃣9️⃣ Above Knee Amputation: Elevate for first 24 hours on pillow, position prone daily to provide for hip extension.
• 3️⃣0️⃣ Below Knee Amputation: Foot of bed elevated for first 24 hours, position prone daily to provide for hip extension.
• 3️⃣1️⃣ Detached Retina: Area of detachment should be in the dependent position.
• 3️⃣2️⃣ Administration of Enema: Position patient in left side-lying (Sim's) with knee flexed.
• 3️⃣3️⃣ After Supratentorial Surgery (incision behind hairline): Elevate HOB 30-45 degrees.
• 3️⃣4️⃣ After Infratentorial Surgery (incision at nape of neck): Position patient flat and lateral on either side.
• 3️⃣5️⃣ During Internal Radiation: On bedrest while implant in place.
• 3️⃣6️⃣ Autonomic Dysreflexia/Hyperreflexia: Place client in sitting position (elevate HOB) first before any other implementation.
• 3️⃣7️⃣ Shock: Bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg).
• 3️⃣8️⃣ Head Injury: Elevate HOB 30 degrees to decrease intracranial pressure.
• 3️⃣9️⃣ Peritoneal Dialysis when Outflow is Inadequate: Turn patient from side to side BEFORE checking for kinks in tubing.
• 4️⃣0️⃣ After Appendectomy: Position on right side with legs flexed.
• 4️⃣1️⃣ After Ventriculoperitoneal Shunt Placement: Flat position initially. If signs of increased ICP, raise HOB 15-30 degrees.
• 4️⃣2️⃣ With GERD: Position prone with HOB elevated.
• 4️⃣3️⃣ William's Position: Semi-Fowler's with knees flexed (increased knee gatch) to relieve lower back pain.
• 4️⃣4️⃣ Pneumonia: Lay on the affected side to splint and reduce pain. If trying to reduce congestion, the sick lung goes up.
• 4️⃣5️⃣ Wheelchair: Place parallel to the bed on the side of weakness.
• 4️⃣6️⃣ Crutches (Going Up Stairs): "Step up" - good leg goes up first, followed by crutches and bad leg.
• 4️⃣7️⃣ Crutches (Going Down Stairs): Crutches go first, followed by the good leg.
• 4️⃣8️⃣ GERD: Lay on left side with HOB elevated 30 degrees.

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6. ❤️ Cardiovascular System

6.1. Cardiac Conditions

• Angina: Low oxygen to heart tissues; no dead heart tissues. Crushing, stabbing pain relieved by nitroglycerin.
• Myocardial Infarction (MI): Dead heart tissue present. Crushing, stabbing pain radiating to left shoulder, neck, arms, unrelieved by nitroglycerin.
  • Blood Tests: Myoglobin, CK (Creatine Kinase), Troponin.
• Congestive Heart Failure (CHF):
  • Signs & Symptoms: Bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, hypertension, urine specific gravity <1.010.
  • Positioning: Semi-Fowler's.
  • S3 Sound: Normal in CHF, not normal in MI.
  • Infant CHF: Don't pick cough over tachycardia as a sign.
• Cor Pulmonale: Right-sided heart failure caused by pulmonary disease (e.g., bronchitis or emphysema). Signs are fluid overload (edema, JVD).
• Coarctation of the Aorta: Causes increased blood flow and bounding pulses in the arms.
• Hypertension: Newly diagnosed patients should have BP assessed in both arms.

6.2. Dysrhythmias & Management

• Cardiac Output: Decreases with dysrhythmias.
• Medications:
  • VTach (Ventricular Tachycardia): Lidocaine.
  • SVT (Supraventricular Tachycardia): Adenosine or Adenocard.
  • Asystole (No Heartbeat): Atropine.
  • Anaphylactic Shock: Epinephrine.
  • Amiodarone: Effective in both ventricular and atrial complications.
  • Flecainide (Tambocor): Limit fluids and sodium intake (sodium increases water retention, leading to heart failure).
  • Digitalis: Increases ventricular irritability; could convert a rhythm to v-fib following cardioversion.
• PVCs (Premature Ventricular Contractions): Dead tissues cannot have PVCs. If left untreated, PVCs can lead to VF (Ventricular Fibrillation).

6.3. Shock

• Signs & Symptoms: Decreased BP, increased pulse, increased respirations.
• Positioning: Bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg).
• Sepsis & Anaphylaxis: Reduce circulating volume by way of increased capillary permeability, leading to reduced preload.

6.4. Blood Transfusions

• Signs of Allergic Reaction (in order): Flank pain, frequent swallowing, rashes, fever, chills.
• Blood Types: "O" is the universal donor. "AB" is the universal recipient.

6.5. Vascular Issues

• PVD (Peripheral Vascular Disease):
  • Mnemonic: "DAVE" (Legs are Dependent for Arterial & for Venous Elevated).
  • Elevate Veins; Dangle Arteries: For better perfusion.
• DVT (Deep Vein Thrombosis): Homan's Sign.
• Air/Pulmonary Embolism:
  • Signs & Symptoms: Chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom.
  • Management: Turn patient to left side and lower the head of the bed.
  • First Sign of PE: Sudden chest pain, followed by dyspnea and tachypnea.
  • O2 Deprivation: Body compensates by hyperventilating (respiratory alkalosis). Patient needs oxygen.

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7. 🫁 Respiratory System

7.1. Conditions

• COPD (Chronic Obstructive Pulmonary Disease): Chronic. Emphysema and bronchitis are both COPD.
  • Stimulus to Breathe: Low PO2, not increased PCO2. Do not "slam" them with oxygen (2LNC or less). PaO2 of 60ish and SaO2 90% is normal for them.
  • Management: Encourage pursed-lip breathing (promotes CO2 elimination), encourage up to 3000mL/day fluids, high-Fowler's and leaning forward.
• Pneumonia: Acute.
  • Signs & Symptoms: Rusty sputum. Fever and chills usually present. Confusion often present in the elderly. Crackles suggest pneumonia, likely accompanied by hypoxia.
  • Positioning: Lay on the affected side to splint and reduce pain. If trying to reduce congestion, the sick lung goes up.
• Asthma: Wheezing on expiration. Coughing without other symptoms is suggestive of asthma. Watch out if your wheezer stops wheezing (could mean worsening). Intercostal retractions are a concern. Swimming is a good exercise.
• ARDS (Acute Respiratory Distress Syndrome): Fluids in alveoli. Always secondary to something else.
  • Cardinal Sign: Hypoxemia (low oxygen level in tissues).
  • First Sign: Increased respirations. Later comes dyspnea, retractions, air hunger, cyanosis.
• TB (Tuberculosis):
  • PPD (Purified Protein Derivative) Test: Positive if induration is >5mm (immunocompromised), >10mm (normal), >15mm (area where TB is rare). A positive PPD confirms infection, not just exposure.
  • Diagnosis: Sputum test confirms active disease.
  • Management: If patient is unable/unwilling to comply with treatment, supervision (direct observation) may be needed (public health risk).
  • Drugs: Liver toxic. An adverse reaction is peripheral neuropathy.
    • INH (Isoniazid): Causes peripheral neuritis (take Vit B6 to prevent). Hepatotoxic. Do not give with Dilantin (can cause phenytoin toxicity). Monitor LFTs. Hypotension will occur initially, then resolve.
    • Rifampin: Dyes bodily fluids orange (tears, urine). Contraceptives may not work as well.
    • Ethambutol: Affects eyes.
• Emphysema: Barrel chest.
• Bronchopulmonary Dysplasia: Abnormality/alteration. Can be caused by mechanical ventilation in premature newborns.

7.2. Ventilation

• Mechanical Ventilator Alarms: "HOLD"
  • High alarm: Obstruction (incr. secretions, kink, patient coughs, gags, or bites).
  • Low pressure alarm: Disconnection or leak in ventilator or patient airway cuff, patient stops spontaneous breathing.
• Tidal Volume: 7-10 mL/kg.
• Complications of Mechanical Ventilation: Pneumothorax, ulcers.
• NG Tube: An antacid should be given to a mechanically ventilated patient with an NG tube if the pH of the aspirate is <5.0. Aspirate should be checked at least every 12 hours.

7.3. Procedures

• Thoracentesis:
  • Prep: Take VS, shave area, position patient with arms on pillow on overbed table or lying on side. No more than 1000cc at one time.
  • Post: Listen for bilateral breath sounds, VS, check leakage, sterile dressing.
• Lung Biopsy:
  • Prep: Position patient lying on side of bed or with arms raised on pillows over bedside table. Patient holds breath in mid-expiration.
  • Post: Chest x-ray immediately afterwards (check for pneumothorax), sterile dressing.

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8. 🧠 Neurological System

8.1. Increased Intracranial Pressure (ICP)

• Signs & Symptoms: Increased BP, decreased pulse, decreased respirations (opposite of shock). Cushing's Triad (hypertension, bradycardia, irregular respirations).
• Management: Elevate HOB 30 degrees.
• Head Injury: Elevate HOB 30 degrees to decrease ICP. No nasotracheal suctioning with head injury or skull fracture.
• Medication: Mannitol (osmotic diuretic) - crystallizes at room temp, so ALWAYS use a filter needle.
• CO2: Causes vasoconstriction (can increase ICP). High potassium is expected with carbon dioxide narcosis (hydrogen floods the cell forcing potassium out), which causes increased ICP.

8.2. Spinal Cord Injuries

• Most Common Sites: Cervical or lumbar regions.
• Autonomic Dysreflexia/Hyperreflexia: Life-threatening emergency (inhibited sympathetic response to noxious stimulus, T-7 or above).
  • Signs & Symptoms: Pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension.
  • Cause: Usually a full bladder.
  • Management: Place client in sitting position (elevate HOB) first before any other implementation. Loosen constrictive clothing, assess for bladder distention and bowel impaction. Administer antihypertensive meds (may cause stroke, MI, seizure).
• Spinal Shock: Occurs immediately after spinal injury.

8.3. Neurodegenerative Diseases

• Multiple Sclerosis (MS): Myelin sheath destruction, disruption in nerve impulse conduction.
  • Signs & Symptoms: Limb weakness, paralysis, slow speech, numbness, tingling, tinnitus, nystagmus, ataxia, dysphagia, dysarthria. Hyperactive deep tendon reflexes, vision changes, fatigue, spasticity. Charcot's Triad (IAN - Intention tremor, Ataxia, Nystagmus).
• Myasthenia Gravis (MG): Decrease in receptor sites for acetylcholine. Worsens with exercise and improves with rest.
  • Signs & Symptoms: Smallest concentration of ACTH receptors are in cranial nerves, so expect fatigue and weakness in eye, mastication, pharyngeal muscles. Descending muscle weakness.
  • Diagnosis: Tensilon test (positive reaction improves symptoms).
  • Management: Give neostigmine about 45 min before eating to help with chewing and swallowing.
• Guillain-Barre Syndrome: Ascending paralysis. Keep eye on respiratory system.
• Parkinson's Disease:
  • Mnemonic: "RAT" - Rigidity, Akinesia (loss of muscle movement), Tremors (pill-rolling).
  • Medications:
    • Levodopa: Contraindicated in patients with glaucoma. Avoid B6.
    • Sinemet (carbidopa/levodopa): Sweat, saliva, urine may turn reddish brown occasionally. Causes drowsiness. Contraindicated with MAOIs.
    • Artane (trihexyphenidyl): Sedative effect.
    • Cogentin (benztropine): Treats Parkinson's and extrapyramidal effects of other drugs.
• Alzheimer's Disease: Chronic, progressive, degenerative cognitive disorder. Decreased acetylcholine is related to senile dementia.
• Amyotrophic Lateral Sclerosis (ALS): Degeneration of motor neurons in both upper & lower motor neuron systems.
• Huntington's Chorea: 50% genetic, autosomal dominant.
  • Signs & Symptoms: Chorea (writhing, twisting movements of face, limbs, body). Gait deteriorates to no ambulation.
  • Management: No cure, just palliative care.

8.4. Cerebrovascular Events

• TIA (Transient Ischemic Attack): Mini stroke with no dead brain tissue.
• CVA (Cerebrovascular Accident): With dead brain tissue.

8.5. Seizures

• Status Epilepticus:
  • Medication of Choice: Valium (diazepam). Ativan (lorazepam) is also a treatment of choice.
  • Assessment: Level of consciousness is the most important assessment parameter.
• Dilantin (Phenytoin):
  • Therapeutic Level: 10-20 mcg/mL.
  • Side Effects: Rash (stop med), gingival hyperplasia (good hygiene).
  • Toxicity: Poor gait + coordination, slurred speech, nausea, lethargy, diplopia.
  • Pregnancy: Phenobarbital can be taken during pregnancy, but Dilantin is contraindicated.

8.6. Diagnostics

• EEG (Electroencephalogram):
  • Prep: Hold meds for 24-48 hours prior. No caffeine or cigarettes for 24 hours prior. Patient can eat. Patient must stay awake night before exam. May be asked to hyperventilate and watch a bright flashing light.
  • Post: Assess patient for seizures (increased risk).
• Lumbar Puncture:
  • Prep: Fetal position.
  • Post: Neuro assessment q15-30 min until stable, flat for 2-3 hours, encourage fluids, oral analgesics for headache, obse…