Term
| AAA- Abdominal Aortic Aneurysm |
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Definition
MAIN PROBLEM: local distention of the artery wall, usually in the thoracic or abdominal area.
INITIAL MANIFESTATION: Initially asymptomatic, PULSATING ABDOMINAL MASS is a common sign, backache and ausculatation of bruit are common manifestations.
LABS: ELEVATED BUN and Creatinine levels.
MRi, CatScan, Xray; UTZ- confirms AAA
NSG DX: Altered tissue perfusion
INTERVENTIONS: AVOID: abdominal palpation |
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Term
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Definition
MAIN PROBLEM: Expulsion of the fetus before 20weeks
INITIAL MANIFESTATION: Vaginal bleeding
LABS: UTZ
NSG DX: Knowledge deficit
INTERVENTIONS: Save all pads and any tissues passed.
Assess for shock, DIC,infectiom, thrombophlebitis |
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Term
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Definition
MAIN PROBLEM: pREMATURE PARTIAL OR COMPLETE SEPARATION OF THE PLACENTA
INITIAL MANIFESTATION: PAINFUL, dark red vaginal bleeding
LABS: UTZ- retroplacental bleeding
NSG DX: Risk for Volume deficit
INTERVENTIONS: Bedrest, Fluids, Support |
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Term
| Acoustic Neuroma (Cranial nerve 8) |
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Definition
MAIN PROBLEM: Tumor of cranial nerve #8
INITIAL MANIFESTATION: Tinnitus
LABS: Caloric stimulation: NO NYSTAGMUS
NSG DX: Sensory- perceptual alteration: AUDITORY
INTERVENTIONS: Safety, Supine pos'n if VERTIGO occurs |
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Term
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Definition
MAIN PROBLEM: Oversecretion of Growth Hormone
INITIAL MANIFESTATION: Coarsening of facial features, INCREASED SHOE SIZE
LABS: Elevated serum HGH, Blood sugar levels
NSG DX: Body Image Disturbance
INTERVENTIONS: Support, Surgery, S/Sx of Diabetes |
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Term
| AGE- ACUTE GASTROENTERITIS/ DIARRHEA |
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Definition
| MAIN PROBLEM: Increase in fluid, frequency and volume of stool usually associated by ROTAVIRUS, Clostridium Defficile, Salmonella INITIAL MANIFESTATION: Frequent watery stool LABS: Decrease in Na and K (+) blood cultures for Salmonella, Rotavirus, Clostridium Defficile NSG DX: F&E Imbalance INTERVENTIONS: Fluid replacement, Fluid status. Weight |
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Term
| AGN- ACUTE GLOMERULONEPHRITIS |
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Definition
MAIN PROBLEM:Damage ito the glomerular membrane due to antibodies or immun omplexes usually trigered by a SORE THROAT
INITIAL MANIFESTATION: Periorbital edema
LABS: Elevated BUN, ASO titer
NSG DX: F&E imbalance
INTERVENTIONS: Bedrest(Acute Phase), I&O, WEigh daily
Low sodium, Low protein DIET
MEDS: ANTIhypertensives, diuretics, antibiotics
Indication of Improvement: Rising total serum complemet activity (c3,C4) |
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Term
| ALL- ACUTE LYMPHOCYTIC LEUKEMIA |
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Definition
MAIN PROBLEM: pROLIFERATION OF IMMATURE WBC
INITIAL MANIFESTATION: s/sx r/t ANEMIA like easy fatigability
LABS: INCREASED WBC (Hyperleukocytosis)
NSG DX: risk for infection
INTERVENTIONS: Avoid crowded places, avoid venipunctures.
Watch for signs of bleeding and infection
MEDS: Allppurinol with child undergoing CHEMO to decrease uric acid production. |
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Term
| AIDS- ACQUIRED IMMUNE DEFICIENCY SYNDROME |
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Definition
MAIN PROBLEM: Slow degeneration of the immune system with the development of oppurtunistic infections, malignancies and frequently impairment of the CNS
INITIAL MANIFESTATION: Flu- like symptoms occur 2-4weeks after infection
LABS: HIV (+) on ELISA confirmed by WESTERN BLIOT
HIV antibodies are detectable by routine tests, 3-6 mos after infection so instruct to have an initial test 3-6mos after exposure.
Patients who are initially HIV negative should have a retest 12weeks or less since a possible exposure.
CD4 lymphocytes <200/cu. mm
NSG DX: Risk for infection
INTERVENTIONS: Practice safe sex, avoid needle sharing
Use 10% household bleaching solution to cleanse areas with blood stains from a (+) HIV.
Assess s/sx of dementia like incoordination |
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Term
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Definition
MAIN PROBLEM: Adrenal hypofunction usually due to autoimmune dse
INITIAL MANIFESTATION: hypotension, broze skin,pigmentation is a common sign
LABS: Hyponatremia, Hyperkalemia, Hypoglycemia
NSG DX: Fluid volume deficit
INTERVENTIONS: Monitor F&E imbalance, Lifelong meds,
High sodium, Low potassium diet |
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Term
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Definition
MAIN PROBLEM: Degeneration and atrophy of the brain cortex leading to impaired brain functioning
INITIAL MANIFESTATION: Progressive memory loss, Retograde amnesia followed by Anterograde
LABS:
NSG DX: Altered thought process
INTERVENTIONS: 5C's
use of Calendar, Clock, Colors to promote orientation, and consistency of caregiver Meds; Cognex (Tacrine) to increase mental ability |
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Term
| Amniotic Fluid embolism (Anaphylacic Syndrome of Pregnancy) |
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Definition
MAIN PROBLEM: Amniotic fluid escapes into maternal circulation through the placental site into the pulmonary arterioles
INITIAL MANIFESTATION: Dyspnea
LABS:
NSG DX: Impaired breathing pattern
INTERVENTIONS: oxygen and Monitor fluids |
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Term
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Definition
MAIN PROBLEM: Bone marrow hypoplasia or aplasia resulting in pancytopenia (Decreased WBC, RBC and platelets)
INITIAL MANIFESTATION: Abnormal bleeding
LABS:Decreased RBC, WBC, Platelet count
NSG DX: Risk for Infection/ Injury
INTERVENTIONS: Bone marrow transplant. S/Sx of bleeding |
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Term
| ANEMIA, Folic Acid Deficiency |
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Definition
MAIN PROBLEM: Depletion of folate, which results to progressive anemia
INITIAL MANIFESTATION: fatigue
LABS: Decreased folate level
NSG DX: Activity intolerance
INTERVENTIONS: Increase source of folic acid like green veges (Asparagus, broccoli and Spinach), yeast, liver, organ meats, fresh fruits
Avoid overcooking of veges |
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Term
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Definition
MAIN PROBLEM: DECREASED O2 carrying capacity of the blood. The condition is usually ssociated with nutritional deficiency of iron.
INITIAL MANIFESTATION: easy fatigability; poor sucking (Infants), chubby buy pale babies (Milk babies)
LABS: Decreased Hgb and hct; Microcytic, hypochromic RBC's
NSG DX: Activity intolerance
INTERVENTIONS: Frequent rest periods.
Increase iron in the diet like Organ met, Egg yolk) |
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Term
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Definition
MAIN PROBLEM: reduced VitB12 absorption due to the absence of the intrinsic factor, usually r/t gastrectomy and atrophy of the gastric mucosa
INITIAL MANIFESTATION: Fatigue, beefy red tongue or glossitis
LABS: Schilling's test reveals more than 40% urinary excreation of ingested vitB12
NSG DX: Activity intolerance
INTERVENTIONS: Monthly IM VitB12 replacement therapy is lifelong.
COMPLICATION: Tingling sensation in the lower extremities indicates complication (Peripheral neuropathy) REPORT! |
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Term
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Definition
MAIN PROBLEM: Insufficient coronory blood flow results to inadequate O2 supply causing intermittent chest pain
INITIAL MANIFESTATION: Squeezing, burning, pressing, choking, aching or bursting left sternal chest pain lasting NOT more than 20 minutes. The patient often says, "It feels like gas or heartburn or indigestion"
LABS: ECG reveals ST segment depression
NSG DX: pain
INTERVENTIONS: Nitoglycerine subligual.
Burning sensation under the tongue after Nitroglycerine administration indicates that the drug is POTENT. May alsco cause facial flushing and headache.
PTCA (Percutaneous Transluminal Coronary Angioplasty)- inform pt. that a balloon- tipped catheter will be introduced through a guide wire into a coronary vessel. |
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Term
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Definition
MAIN PROBLEM: Fear of gaining weight
INITIAL MANIFESTATION: Amenorrhea(No mense for 3consecutive mos)
A-menorrhea
N-o other organic factor accounts for the wt loss
O-bviously thin but feels fat
R-efusal to maintain ideal body wt
E-pigastric discomforts
X-symptoms like: hiding foods, collecting recipes
I-ntense fear of gaining weight
A-lways thinking about food
LABS: Decrease K levels due to vomiting, Hypoglycemia
NSG DX: Body image disturbance
INTERVENTIONS: Monitor weight |
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Term
| ANTISOCIAL PERSONALITY DSO |
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Definition
MAIN PROBLEM: Maladaptive behavior taht does not recognize the rights of others
INITIAL MANIFESTATION: Lacks of sense of guilt, habitually breaks the law,
S/sx
A- ggresive
N- o guilt feelings
T- otal lack of learning from past experiences
I- rritable
S- ocially unacceptable behavior (theft, truancy)
O- thers are manipulated for own personal gain
C- annot maintain enduring attachment to sexual partner
I- nability to sustain consistent work
A- bsence of ability to plan ahead
L- acks respect or loyalty
NSG DX: Self esteem disturbance
INTERVENTIONS: be consistent and firm in dealing with the patient |
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Term
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Definition
MAIN PROBLEM: Feeling dread or impending doom accompanied by somatic signs indicative of a hyperactive autonomic nervous system.
INITIAL MANIFESTATION: Restlessness
NSG DX: Anxiety
INTERVENTIONS::
C- alm
A- administer anxiolytics
L- isten to the patient's concern
M- inimize environmental stimuli |
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Term
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Definition
MAIN PROBLEM: Pathologic apnea in infants of more than 37 weeks gestation.
INITIAL MANIFESTATION: Apnea
LABS: Cardiopneumogram, Pneumocardiogram,Polysomnography and end- tidal carbon dioxide measurements.
NSG DX: IMpaired breathing pattern
INTERVENTIONS: NEVER shake the child.
Monitor cardiopulmunary status |
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Term
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Definition
MAIN PROBLEM: Inflammation of the appendix due to obstruction of the intestinal lumen.
INITIAL MANIFESTATION: RLQ abdominal pain with REBOUND TENDERNESS. Lessening of the pain indicates rupture of the appendix.
LABS: Elevated WBC
NSG DX: Pain
INTERVENTIONS: Position of comfort (if the appendix has not yet ruptured)
High fowlers (Ruptured) to prevent the upward spread of infection
Avoid applying HOT compress on the RLQ
MEDS: Antibiotics as ordered
Surgery |
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Term
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Definition
MAIN PROBLEM: Metabolic dso of URIC ACID formation and excretion
INITIAL MANIFESTATION: Initially asymptomatic.
A common sogn is dusky red- hot swollen joints, usually of the great big toe.
LABS: Elevate urate crystals in synovial fluids.
NSG DX: Pain
INTERVENTIONS:
Diet: Purine- restricted diet (AVOID organ meats, alcohol, beans, sardines)
AVOID: Aspirins and diuretics- interfere with uric acid excretion.
Use bed cradle to prevent linen from coming in contact with the inflamed joint, which aggravates the pain.
Complication: Kidney stone formation |
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Term
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Definition
MAIN PROBLEM: Degeneration of the articular cartilage in the joints
INITIAL MANIFESTATION: Pain and swelling in a weight bearing joint, usually aggravated by the activity.
LABS: X-ray
NSG DX: Pain
INTERVENTIONS:
Priority: minimize discomfort
W- eight control
H- ot compress or icepacks
A- spirin use
T- runk assistive devices (cane) |
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Term
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Definition
MAIN PROBLEM: Recurrent inflammation of the synovial lining of the joints usually of the upper extremeties. It is more common in WOMEN.
INITIAL MANIFESTATION: Morning stiffness relieved by warm bath or soaks
LABS: Elevated ESR
NSG DX: Pain r/t joint inflammation
INTERVENTIONS: Aspirin regularly ven if the absence of symptoms. TINNITUS is a side effect.
Apply moist heat for 15-30 minutes to reduce muscle spasm. Ice packs during acute phase to decrease the pain. |
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Term
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Definition
MAIN PROBLEM: bLOOD SALICYLATE LEVEL OF 50-100MG/ML
INITIAL MANIFESTATION: tINNITUS
LABS: Elevate serum aspirin level
NSG DX: Ineffective breathing pattern (results to Resp. Alkalosis)
INTERVENTIONS: Induce vomiting and using syrup of ipecac.
Assess bleeding tendencies.
Keep Vit. K at the bedside |
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Term
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Definition
MAIN PROBLEM: Abnormal bronchial hyperactivity to certain susbtances
INITIAL MANIFESTATION: Dyspnea
LABS: Elevated IMMUNOGLOBULIN e, abg reveals RESP. Acidosis
NSG DX: Ineffective breathing pattern r/t bronchospasm
INTERVENTIONS:
# E's Exercise in cold weather
Environmental factors (dust, pollen
Emotional factors
Postion: Sit upright and lean forward on a table
Encourage purse lip breathing |
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Term
| ADHD- ATTENTION DEFICIT HYPERACTIVITY DSO |
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Definition
MAIN PROBLEM: Decreased attention span
INITIAL MANIFESTATION: Impulsitivity, hyperactivity, Inattention
S/SX:
D- ifficulty in reamaining seated
E- asily distracted by extraneous stimuli
F- idgets with hands or feet or squirms in seat
I- nterrupts or intrudes on others
C- hild exhibits hyperactivity
I- ndulges in physically dangerous activities withour considering possible consequences
T- alks excessively
LABS:--
NSG DX: Risk for injury
INTERVENTIONS: Foods than can be "eaten on the run"
MEds: Ritalin (Methylphenidate)
Safety, Limit caffeine |
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Term
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Definition
MAIN PROBLEM: Faulty socail skills
INITIAL MANIFESTATION: LAcks eye contact, Loves to spin objects,
LABS:--
NSG DX: Impaired social interaction
INTERVENTIONS: Observe consistency in providing care to the child.
If the child throws himself into headbanging and tantrums, provide helmet |
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Term
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Definition
MAIN PROBLEM: EXAGGERATED AUTONOMIC RESPONSED TO LOCAL STIMULI BELOW THE LEVEL OF SPINAL CORD INJURY
INITIAL MANIFESTATION: Pounding HA or severe HTN
NSG DX: Urinary retention r/t effects of spinal injury
INTERVENTIONS: Catheterize the pt
Sitting position to help lower the BP
Antihypertensives |
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Term
| BELLS' PALSY (Facial Paralysis) |
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Definition
MAIN PROBLEM: Inflammation of the 7th (FACIAL) cranial nerve,one side of the face.
AGES: 20-50 y/o lasts 2-8 weeks
INITIAL MANIFESTATION: Facial pain, impaired chewing and swallowing ability, diminished blink reflex
LABS: Physical assessment
NSG DX: Pain
INTERVENTIONS: Prevent corneal irritation by using artificial tears, Keep WARM, Small frequent meals, PREDNISONE |
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Term
| BENIGN PROSTATIC HYPERTROPHY |
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Definition
MAIN PROBLEM:Enlargement of the prostate gland resulting to narrowing of the urethal opening
INITIAL MANIFESTATION: Decreased urinary system
LABS: Elevated ph of prostatic fluid
NSG DX: Altered bladder elimination r/t enlarged prostate
INTERVENTIONS: TURP- no incision |
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Term
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Definition
MAIN PROBLEM: Hyperactivity alternating with periods of depression
INITIAL MANIFESTATION: Hyperactivity, rapid speech is a ommon sign
LABS: Increased levels of orepinephrine and serotonin in Mania and decreased levels in depresion.
NSG DX: Risk for injury
INTERVENTIONS: Safety, FOODS: can be eaten "on the run" or "finger foods" like meat sandwich
MEDS: Lithium carbonate |
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Term
| BLEEDING ESOPHAGEAL VARICES |
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Definition
MAIN PROBLEM: Bleeding of dilated veins in the lower esophagus
INITIAL MANIFESTATION: Hematemesis
LABS:
NSG DX: Fluid volume deficit
INTERVENTIONS: Airway, Sengstaken- blakemore tube insertion (KEEP A PAIR OF SCISSORS AT THE BEDSIDE, THIS IS USED TO CUT THE PORT OF THE TUBE LEADING THE BALLOON, TO DEFLATE IT, IN CASE ASPIRATION OCCURS) |
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Term
| BORDERLINE PERSONALITY DSO |
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Definition
MAIN PROBLEM: Instability of mood, interpersonal relationships and self image
INITIAL MANIFESTATION: Impulsitivity
P- ersistent identity dso
E- fforts to avoid real or imagined abandonement
C- hronic feelings of emptiness of boredom
U- nstable and intense interpersonal relationship
L- ack of ontrol of anger
I- mpulsiveness in atleast two areas that is potentially self- damaging
A- ffective instability
R- ecurring suicidal threats
NSG DX: Impaired social functioning
INTERVENTIONS: be CONSISTENT and FIRM
provide structured and quiet env't, set limits on the pt's maladaptive behavior |
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Term
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Definition
MAIN PROBLEM: Inflammatin of the bronchioles with accumulation of excessive mucus exudates causing lung hyperinflation, cyanosis and dyspnea
INITIAL MANIFESTATION: Proxysmal hacking cough
LABS: ABG reveals RESPIRATORY ACIDOSIS
NSG DX: Impaired gas exchange
INTERVENTIONS: Provide cool mist tent
Change clothing frequently, as acumulated mist soaks the pt's clothing. Institute postural drainage |
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Term
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Definition
MAIN PROBLEM: Vasculitis of the small and medium- size veins and arteries usually in the lower extremeties. Common in men
INITIAL MANIFESTATION: PAIN- outstanding symptom
INTERMITTENT CLAUDICATION- common problem
LABS: LEg arteriography revels inflammatory lesions
NSG DX: Altered peripheral tisue perfusion
MEDS: calcium channel blockers |
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Term
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Definition
MAIN PROBLEM: Binge eating and purging
INITIAL MANIFESTATION: Wt loss,
B- inge eating
U- nder strict dieting or vigorous exercise
L- ak of control over eating binges
I- nduced vomiting
M- inimum of two binge eating episode in a week for a period of 3 mos
I- ncreased or persistent concern over body size or shape
A- buse of laxatives or diuretics
LABS: Hypokalemia, hypoglycemia
NSG DX: Body image disturbance, F&E imbalance
INTERVENTIONS: Pt's Weight, Stay with the pt for at least 30mis to 1hr after meals, to prevent self- induced vomiting. Frequent oral hygiene |
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Term
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Definition
MAIN PROBLEM: Traumatic injury caused by thermal, electrical, chemical or radioactive agents
INITIAL MANIFESTATION: First degree: pinkish skin
Second degree: Pinkish skin with blisters
Third degree: Eschar
LABS: Hyperglycemia and Anemia
NSG DX: Decreased Cardiac output r/t fluid shifts
INTERVENTIONS: Fluids, High calorie, high protein, I&o |
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Term
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Definition
MAIN PROBLEM: Malignant cells in the bladder
INITIAL MANIFESTATION: Painless hematuria
LABS: Elevated acid phosphates
NSG DX: Altered urinary elimination
INTERVENTIONS: Surgery and chemo |
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Term
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Definition
MAIN PROBLEM: mALIGNANT CELLS IN THE CERVIX associated with multiple partners and hx of STD
INITIAL MANIFESTATION: Initially asymptomatic, postcoital bleeding
LABS: Paps smear reveals presene of malignant cells
NSG DX: Knowledge deficit
INTERVENTIONS: before PAPS smear- avoid doucthing and sexual intercourse.
Lifelong follow up. Surgery, radiation therapy, Chemo |
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Term
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Definition
MAIN PROBLEM: Malignant tumor in esophagus r/t alcoholism and smoking
INITIAL MANIFESTATION: Difficulty in swallowing(dysphagia) is the usual presenting symptom
LABS: Barium swallow with fluroscopy revelas large masses. CT SCAN
NSG DX: Altered nutrition
INTERVENTIONS: Surgery, radiation therapy, Chemo |
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Term
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Definition
MAIN PROBLEM: Malignant cells in the larynx associated with smoking and alcoholism
INITIAL MANIFESTATION: Hoarseness or voie chang, tikling sensation in the throat
LABS: Laryngoscopy and bipsy reveals malignant cells
NSG DX: Knowledge deficit
INTERVENTIONS: Prepare for: Radiation, Chemo and surgery
Teach to avoid cold air
Post Laryngectomy: swimming is not recommended |
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Term
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Definition
MAIN PROBLEM: Gynecologic cancer associated with high fat diet and nulliparity
INITIAL MANIFESTATION: Initially asymptomatic, vaguo abdominal discomfort like indigestion, is a common symptom
LABS: Laparoscopy and UTZ- presence of mass
NSG DX: Pain
INTERVENTIONS: Prepare for: Chemo and surgery
Change in body image |
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Term
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Definition
MAIN PROBLEM: Malignant tumor in the prostate
INITIAL MANIFESTATION: Decreased in size and force of urinary stream
LABS: Elevated prostate specific antigen (PSA) Elevated acid phosphatase
NSG DX: Pain
INTERVENTIONS: Prepare for: Radiation, Chemo and surgery (radical prostatectomy) removal of the entire prostate gland, may cause impotence |
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Term
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Definition
MAIN PROBLEM: Malignant tumors in Upper outer quadrant of the left breast, associated nulliparity( first child at 35y/o)
NSG DX: Knowledge deficit
INTERVENTIONS: Chemo, radiation, surgery
Perform self breast exam monthly, a week after period since the breasts are less tender at this time. Best position is lying down with pillow under the shoulder.
Mammography- placing the breast b/n two xray plates.
POST OP mastectomy- elevate the affected arm to prevent lymphedema |
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Term
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Definition
MAIN PROBLEM: mALIGNANCY IN THE TESTES ASSOCiated with cryptorchidism
INITIAL MANIFESTATION: Painless swelling or enlargement of the testes, acompanied by sensation of heaviness in the scrotum
LABS: Elevated HCG and alpha feto protein
NSG DX: Knowledge deficit
INTERVENTIONS: Prepare the patient for surgery and chemo
Testicular Exam: Once a month, warm bath while standing in front of the mirror.
Suspect cancer of the testes when the normally smooth testicles become spongy on palpation |
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Term
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Definition
MAIN PROBLEM:
INITIAL MANIFESTATION:
LABS:
NSG DX:
INTERVENTIONS: |
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Definition
MAIN PROBLEM:
INITIAL MANIFESTATION:
LABS:
NSG DX:
INTERVENTIONS: |
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Definition
MAIN PROBLEM:
INITIAL MANIFESTATION:
LABS:
NSG DX:
INTERVENTIONS: |
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Definition
MAIN PROBLEM:
INITIAL MANIFESTATION:
LABS:
NSG DX:
INTERVENTIONS: |
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Definition
MAIN PROBLEM:
INITIAL MANIFESTATION:
LABS:
NSG DX:
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Definition
MAIN PROBLEM:
INITIAL MANIFESTATION:
LABS:
NSG DX:
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