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FINAL STUDY GUIDE
Neurological System1. Cranial nerves
I. Olfactory (Smell)II. Optic (Vision)III. Oculomotor (Eye movement, pupillary constriction, upper eyelid elevation)IV. Trochlear (Down and in eye movement)V. Trigeminal (Chewing, corneal reflex, face and scalp sensations)VI. Abducens (Lateral eye movement)VII. Facial (Expression in forehead, eye, and mouth; taste)VIII. Accoustic (Hearing, balance)IX. Glossopharyngeal (Swallowing, salivating, taste)X. Vagus (Swallowing, gag reflex, talking, sensations of the throat, larynx, and
abdominal viscera)XI. Accessory (Shoulder movement/ head rotation)XII. Hypoglossal (Tongue movement)
2. Assessment findings Memory impairment, agnosia (inability to recognize objects), numbness/tingling, muscle
wekness, twitching/spasm, HA, dizziness, fainting, loss of balance/coordination, N&V, ringing in the ears,emotional lability, blurred/double vision, change in bladder/bowel pattern, tremors, stiff neck, seizures, drooping eyelids
3. Glasgow Coma Scale Provides a quick, standardized account of neurological status. Assess opening response, motor response, and verbal response On a scale of 3 to15, a score of 7 or less indicates severe neurological damage
4. Diagnostic Testing and Procedure EEG (Noninvasive test of the brain that reveals a graphic representation of the brain’s
electrical activity)o Nursing intervention before the procedure
1. Explain the procedure to the pt.2. Determine the pt.’s ability to lie still3. Explain to the pt. that they will be subject to stimuli (lights and sounds)4. Withhold medications, stimulants, and depressants for 24-48 hrs before
the procedure
Computerized tomography (CT) scan (Noninvasive test , which contrast may be used to visualize the brain and its structure)
o Nursing intervention before the procedure1. See if the pt. is allergic to iodine, seafood, and radiopaque dye2. Explain the procedure to the pt.
3. Obtain signed consent form 4. Tell the pt. they will have to lie still during the test.5. Possible throat irritation and flushing in the face, if dye is used6. Relieve anxiety and administer sedation, as prescribed
Magnetic Resonance Imaging (MRI) (Noninvasive scan using magnetic and radio waves to visualize the brain and its structure)
o Nursing intervention before the procedure1. Be ware that a pt. w/ a pacemaker, surgical or orthopedic clip, aneurysm
clip, artificial heart valves, bullet fragment, ect. shouldn’t be scanned2. Assess for hx of claustrophobia3. Remove jewelry and metal objects from the pt.4. Determine the pt.’s ability to lie still5. Obtain signed consent form 6. Administer sedation as prescribed.
Cerebral angiography (Invasive procedure using a radiopaque dye to examine the cerebral arteries)
o Nursing intervention before the procedure1. See if the pt. is allergic to iodine, seafood, and radiopaque dye2. Obtain signed consent form 3. Possible throat irritation, flushing in the face, and ,metallic taste in the
moutho Nursing intervention after the procedure
1. Monitor VS2. Check insertion site for bleeding3. Maintain affected extremity in straight alignment for 6hrs, or as order to
prevent a hematoma4. Check pulse in affected extremity5. Provide adequate hydration 6. Relieve anxiety
Lumbar puncture (Invasive procedure that collects CSF from the lumbar subarachnoid space, measure CSF pressure, and injection of radiopaque dye for myelogram)
o Nursing intervention before the procedure1. Obtain signed consent form 2. Determine the pt.’s ability to lie still in a flexed, lateral, recumbent
position3. The presence of increased intracranial pressure is a contraindication of the
procedure because brain herniation may develop when CSF is removedo Nursing intervention after the procedure
1. Keep the pt. flat in the prone position for 2hrs, side-lying position for 2-3 hrs prone or supine position for 6 or more hrs
2. Check puncture site for bleeding3. Monitor for HA4. Encourage fluids to offset CSF leakage
(EMG) Electromyography (Noninvasive test , graphic recording of the electrical activity of a muscle )
o Nursing intervention1. The pt. must flex and relax the muscles during the procedure2. Cooperation is needed during the test3. Pt. will feel some discomfort4. Administer analgesics PRN after the procedure
Skull x-ray (Radiographic picture of the head and neck bones)o Nursing intervention before the procedure
1. Determine the pt.’s ability to lie still
Positron emission tomography (PET) scan (Invasive procedure that involves injection of a radioisotope; provides visualization of oxygen uptake, blood flow, and glucose metabolism)
o Nursing intervention 1. Determine the pt.’s ability to lie still2. Withhold alcohol, tobacco, and caffeine for 24hrs before the test3. Withhold medications before the test4. Check the injection site for bleeding after the procedure
5. Risk Factors Modifiable
o Exposure to chemical or environmental pollutantso Substance abuseo Smokingo Alcohol o Participation in contact sportso Hypertensiono Diabetes
Nonmodifiableo Agingo Family hx of neurologic diseaseo Hx of cardiac diseaseo Hx of head injuryo Exposure to viral or bacterial infection
6. Parkinson’s Disease Progressive degenerative disease of the extrapyramidal system (EPS) associated with
dopamine deficiency
Pathophysiology
o Nerve cells in the basal ganglia are destroyed, resulting in impaired muscular function. Lack of dopamine results in ↓ inhibition of the synaptic transmitter for muscle tone and coordination
Assessment findingso “Pill rolling” tremorso Shuffling gaito Masklike facial expressiono Stiff jointso “Cogwheel” rigidityo Stooped posture
Medical Managemento High-residue, high-calorie, high-protein diet; soft foodso Anticholinergics o Antiparkinsonian agento Antispasmodico Antidepressanto Dopamine receptor agonists
Nursing interventiono Prevent fallso Maintain a patent airwayo Reinforce gait trainingo Reinforce independence in careo Assess neurovascular and respiratory status
Pt. educationo Stop smokingo Regular exerciseo Stress reduction strategies o Avoid alcohol
7. Multiple Sclerosis Progressive immune-mediate demyelinating disease of motor and sensory neurons that
has periods of remissions and exacerbation Pathophysiology
o Scattered demyelination occurs in the brain and spinal cordo Degeneration of myelin shealth results in patches of sclerotic tissue and impaired
conduction of motor nerve impulses. Assessment finding
o Weaknesso Nystagmuso Diplopia
o Impaired sensationo Optic neuritiso Blurred visiono Fatigueo Pain
Causeso Autoimmune diseaseo Viruso Genetic dispositiono Environment exposure
Medical managemento Muscle relaxanto Immunosuppressanto Skeletal muscle relaxanto Glucocorticoidso Plasmapheresiso Physical therapyo Speech therapy
Nursing interventionso Maintain active and passive ROMo Establish a bowel and bladder patterno Maintain activity w/ adequate rest periodso Prevent injuryo Maintain a stress free environmento Encourage fluidso Avoid exposure to others w/ infectiono Avoid temperature extreme
8. Myasthenia Gravis Neuromuscular disorder that results in weakness of voluntary muscles Pathophysiology
o Disturbance occurs in transmission of nerve impulses at the myoneural junctiono Transmission defect results from deficiency in release of acetylcholine or
deficient number of receptor siteso Thymus gland may remain active, triggering autoimmune reaction
Assessment findingso Muscle weakness that ↑ with activity and ↓ with resto Dysphagiao Diplopiao Dysarthriao Dysphoniao Respiratory distresso Masklike expressiono Drooling
o Impaired speech Medical management
o High calorie dieto Activity as toleratedo Glucocorticoidso Anticholinesteraseso Immunosuppressantso Plasmopherisiso Antacids (Maalox)
Nursing interventionso Assess swallow gag reflexso Watch the pt. for choking while eatingo Encourage small, frequent mealso Administer medications, before meals (maximize muscles for swallowing)o Provide oral hygieneo Avoid hot foods
9. Guillain-Barré Syndrome Peripheral polyneuritis characterized by ascending paralysis Pathophysiology
o Preceding infection synthesizes lymphocytes, which attack the myelin sheath, causing demyelination
o Demyelination is followed by inflammation around nerve roots, veins, and capillaries
o Inflammatory process compresses nerve roots Assessment findings
o Generalized weaknesso Paralysis that starts in the legs (ascending)o Respiratory paralysiso Tachycardiao HTNo ↑ tempo Facial weaknesso Dysphagiao Dysarthriao Ptosis
Causeso Autoimmune diseaseo Infectiono Viruso Pregnancyo Vaccination
Medical managemento Diet: High calorie, high protein
o Activity: bed rest, active and passive ROM, isometric exerciseo Nutritional support: enteral feedingo Physical therapyo Glucocorticoidso Intubation and mechanical ventilation
Nursing interventionso Semi-fowler’s positiono Assess muscle strength, gag and swallow reflexeso Maintain the position and patency of NG and ET tubeso Provide suction and turningo Encourage TCDB and use of incentive spirometry o Turn pt. q2hrso Apply antiembolism stockingso Assess for Homans’ sign
10. Seizure Involuntary muscle contractions caused by abnormal discharge of electrical impulses
from nerve cells Classification
o Generalized (involvement of both hemispheres) Absence (petit mal)- sudden onset , last 5-10sec, loss of responsiveness,
lip smacking Myoclonic – (movement disorder, not a seizure) sudden, brief, shock-like
involuntary contraction of one muscle group Clonic-opposing muscle contract & relax alternately in rhythmic pattern;
mucus production Tonic- muscles are maintained in continuous contracted state (rigid
posture); variable loss of consciousness, pupils dilate, eyes roll up, may foam @ mouth
Grand mal (tonic-clonic)- violent total body seizure; aura, tonic 1st (20-30sec), clonic 2nd (postictal symptoms)
Atonic- drop & fall attack; loss of posture tone Akinetic- sudden brief loss of muscle tone or posture; temporary loss of
consciousnesso Partial (focal seizures) involvement of one hemisphere
Simple (symptoms confined to one hemisphere) no loss of consciousness, hallucinations, tachycardia, flushing
Complex (begins in once focal area but spreads to both) loss of consciousness , aura of visual disturbance
o Status epilepticus – Prolonged or frequent repetition of seizures w/out interruption; consciousness not regained between seizures, last more than 30 minutes
Assessment findingso Aurao Loss of consciousness
o Muscle twitches & spasmso Dyspneao Fixed & dilated pupils
Medical management o Seizure precautionso Anticonvulsantso Diet: ketogenico Bed resto Labs: potassium, glucose
Nursing interventionso Maintain a patent airwayo Protect the pt. from injuryo Observe and record seizure activityo Avoid alcohol
11. Increased Intracranial Pressure ICP elevated beyond the normal pressure exerted by blood, brain, and CSF within the
skull Pathophysiology
o Results in compromised cerebral circulation and anoxia, which can lead to brain injury
Assessment findingso Restlessnesso HTNo Bradycardiao Pupillary changes (sluggich reaction, dilation)o Altered LOCo Abnormal posturing (decortication/decerebration)o HAo Papilledema
Causeso Brain tumoro Edemao Hemorrhageo Hydrocephalus
Medical management o O2 therapy o Semi-Fowler’s positiono Labs: postassium, glucose, sodium, osmolality, BUN, creatinineo Diureticso Anticonvulanto Glucocortcoido Bed rest, passive ROM
Nursing interventions
o Maintain fluid restriction o Maintain neutral alignment of the neck with his bodyo Maintain quite and dimly lit roomo Administer O2o Reposition q2hro Enforce bed rest
12. Stroke Disruption of cerebral circulation due to ischemia or hemorrhage that result in motor and
sensory deficit Pathophysiology
o Disruption of cerebral blood flow Assessment findings
o Sudden numbness or weakness on one side of the bodyo Sudden confusion or trouble speakingo Sudden visual disturbanceo Sudden difficulty walkingo Sudden severe headache
Causeso Thrombosiso Embolismo Hemorrhage
Risk factorso Smokingo HTNo Atrial fibrillation o Family hxo After age 55o African Americanso Meno DMo Obesityo Migraineso Sickle cell disease
Medical management o Maintain ABCo O2 therapyo Antihypertensiveso Physical, Speech, & Occupational therapyo Reperfusion agents: tissue plasminogen activator (Activase), if symptoms are
recognized within 3hrs of onseto Semi-fowler’s positiono Active and passive ROM and isometric exercises
Nursing interventions
o O2 therapyo Monitor swallowing ability o Maintain aspiration precautionso Apply antiembolism stockingso Assess for receptive and expressive aphasia
13. (ALS) Amyotrophic Lateral Sclerosis (Lou Gehrig Disease) Progressive degenerative neurologic disease resulting in decreased motor function in the
upper and lower motor neuron system Pathophysiology
o Myelin sheaths are destroyed and replaced with scar tissue, resulting in distorted or blocked nerve impulses
o Nerve cells die and muscle fibers have atrophic changes Assessment findings
o Fatigueo Dysphagiao Muscle weakness of hands and armso Awkwardness of fine finger movements
Causeso Genetic predispositiono virus
Medical management o Focus on symptomatic reliefo Antispasmodicso Mechanical ventilator: negative pressure
Nursing interventionso Assess swallow and gag reflexes o Monitor for choking when eatingo Maintain tucked chin position while eating or drinking o Encourage active ROM and assist w/ passive ROM exercise
14. Meningitis Inflammation of the brain and spinal cord meninges Pathophysiology
o Infecting organisms gain entry through basilar skull fractures w/ dural tears, chronic otitis media or sinusitis, neurosurgical contamination, penetrating head wounds, or septicemia
o Exudate formation causes meningeal irritation & ↑ ICP Assessment findings
o Fevero Chillso Severe throbbing HAo Tachycardiao Petechial rash
o Photophobiao Nuchal rigidityo ↓ LOCo Seizures
Causeso Bacterial infectiono Viral infectiono Fungal infection
Medical management o IV therapy: electrolyte replacemento O2 therapyo Antibioticso Anticonvulsantso Diureticso Diet: w/hold food & fluids as ordered; enteral or parenteral feeding as indicatedo Isolation
Nursing interventionso Maintain a quite, dimly lit environmento Maintain seizure precautionso O2 therapyo Bed rest in semi-fowler’s positiono Reposition q2hrs; provide ROMo Use a cooling blanket or tepid bath to control temperature
15. Bell’s Palsy Disease of the 7th cranial nerve that produces unilateral facial weakness or paralysis Pathophysiology
o The conduction block is due to an inflammatory reaction around the nerve Assessment findings
o Inability to close the eye completely on the affected sideo Pain around the jaw or earo Unilateral facial weaknesso Ringing in the ears o Speech difficulties o Taste distortion on the affected anterior portion of the tongue
Causeso Infectiono Hemorrhageo Tumoro Meningitis o Stresso Pregnancy (3rd trimester)
Medical management o Corticosteroid
o Moist heato Physical therapyo Diet: soft o Semi-fowler’s position
Nursing interventionso Arrange for privacy at mealtimeso Protect eye w/ patch, as indicatedo Apply moist heat to the face to reduce paino Apply facial sling to improve lip alignmento Provide frequent oral careo Encourage active facial exerciseo Teach pt. to chew on unaffected side of the mouth
Sensory Disorders1. Diagnostic Tests & Procedures
Extraocular eye muscle testingo Tests parallel alignment of the eyeso Test integrity of the nervous control of eye muscles (CN 3,4,6)o The pt. follows a pencil or finger as it moves in the shape of the letter “H”
Risk Factorso Modifiable
Eyes- work environment exposure , exposure to sun, sport activities Ears- work environment exposure, exposure to loud noise, use of
earphoneso Nonmodifiable
Eyes- aging, diabetes, trauma, glaucoma, HTN, cataracts, family hx, eye surgery or trauma
Ears- diabetes, aging, ear trauma, congenital or genetic abnormalities2. Glaucoma
Visual field loss because of damage to the optic nerve caused by ↑ IOP Pathophysiology
o Open-angle: ↑ IOP is caused by ↑ resistance to aqueous humor drainage, resulting in neuronal & optic nerve degeneration
o Acute-angle closure: ↑ resistance to aqueous humor flow caused by blockage of trabecular meshwork by the peripheral iris
Causeso DMo Family hxo Previous eye trauma or surgeryo Plateau iriso Obesityo Smokingo Agingo African Americanso HTN
Assessment findingso Open-angle (begins in 1 eye & progresses to the other eye, ↓ peripheral vision, ↑
IOP, mild HA, halos around lights)o Acute-angle (unilateral, acute eye or facial pain, halo vision, ↑ IOP, N&V,
dilated pupils, redness in the eye, blurred vision) Medical management
o Dietary restriction: sodium and fluidso Avoid drugs such as, atropine, anticholinergics, or others w/ pupil dilating effectso Topical beta-adrenergic agonist blocker & adrenergic agonisto Carbonic anhydrase inhibitorso Miotic agento Surgery
Nursing Interventionso Teach the pt. to avoid rubbing the eyeso Teach the pt. to wear protective glasses or goggles while participating in sports or
swimmingo Monitor for redness, discharge, watering, blurred or cloudy vision, halos, flashes
of lights, and floaters
3. Retinal Detachment Separation of the sensory layers of the retina from the underlying retinal pigment
epithelium. Vitreous humor leaks behind the retina Pathophysiology
o Retinal separation occurs when vitreous body traction causes retinal tears or holes; fluids leak through holes or tears behind the retina
Causeso Agingo Diabetic neovascularization o Trauma o Intraocular surgeryo Hemorrhage o Myopia
Assessment findingso Floating spotso Recurrent flashes of lighto Painless vision loss (maybe described as veil, curtain, or cobweb that eliminates
part of the visual field Medical management
o Complete bed rest with the retinal hole or tear at the lowest point of the eyeo Eye patcho Restrict eye movement until surgical attachmento Surgical repair
Nursing Interventionso Wash the face w/ no tear shampooo Administer cycloplegic-mydriatic eye drops as ordered
Post-opo Tell the pt. to avoid activities that ↑ IOP (coughing, sneezing, vomiting, lifting,
straining, bending from the waist, & rapid head movement)o Protect the eye with a shield or glasseso Apply cold compression as orderedo Teach the pt. to report fever, yellow or green eye discharge, ↑ redness or
puffiness, reduced visiono Teach pt. to wear a eye shield @ night
4. Ménière’s Disease Inner ear disorder characterized by vertigo, tinnitus, a sensation of pressure in the ears, &
neurosensory hearing loss Pathophysiology
o Distention & ↑ fluid in the ear occur because of the ↑ volume of endolymph Causes
o Autoimmune disordero Allergic responseo Abnormal hormonal influence on blood flow to the labyrintho Injury
Assessment findingso Vertigo w/ N&Vo Tinnituso Pressure or fullness in the earo Fluctuating unilateral neurosensory hearing hearing loss of low tones
Medical managemento Low salt, sugar dieto Avoid alcohol, coffee, chocolate o Stop smokingo Benzodiazepineo Anticholinergico Antihistamineo Diuretic
Nursing Interventionso Assess hearing statuso Safety
GI system1. Diagnostic Test
Endoscopy o NI before: W/hold food/fluids for 6-12hrs; obtain signed consent formo NI after: W/hold food/fluids until gag and cough reflex return
Liver biopsyo NI before: W/hold food/fluids for 6-12hrs; obtain signed consent form; instruct
the pt. to exhale & hold their breath during insertion of the needleo NI after: Check insertion site for bleeding; observe for signs of shock &
pneumothroax; position on the right lateral side for hemostasis
2. Risk factors Modifiable
o Diet o Smokingo Stresso Alcoholo inactivity
Nonmodifiableo Family hxo Hx of GI dysfunction
3. Cholecystectomy (surgical removal of the gallbladder) Pre-op NI
o Demonstrate TCDB, splinting, and ROM exercise for post-opo Obtain consent form
Post-op NIo Check respiratory status & fluid balanceo Wound care & dressing changeo Reinforce TCDB & splinting incisiono Semi-fowler’s positiono Teach pt. to avoid lifting for 6 wkso Adhere to a low fat diet for 6 wks
4. Gastric surgery
Pre-op NIo Demonstrate TCDB, splinting, and ROM exercise for post-opo Obtain consent formo Administer bowel preparation
Post-op NIo Reinforce TCDB & splinting incision, incentive spirometryo Wound care & dressing changeo Semi-fowler’s positiono Apply sequential compression deviceso Daily weighto ↑food intake gradually as tolerated; eat 6 small meals a dayo Limit fluids with meals
5. Hiatal Hernia Protrusion of the stomach through the diaphragm into the thoracic cavity Pathophysiology
o The opening in the diaphragm where the esophagus enters the stomach becomes enlarged and weakened
Cause
o Congenital weakness o Traumao ↑abdominal pressure
Contributing factorso Obesityo Pregnancyo Asciteso Aging
Assessment findingso Dysphagiao Regurgitationo Sternal pain 1-4 hrs after eating (heartburn)o Vomitingo Pyrosiso Tachycardia
Medical managemento Small frequent mealso Avoidance of spicy or irritating foodso Semi-fowler’s positiono Proton pump inhibitorso H2 receptors antagonistso Avoid activities that ↑ intra-abdominal pressure
Nursing interventionso Keep in Semi-fowler’s position during and after mealo Avoid flexion @ the waist o Remain upright for 2hrs after eatingo Avoid constrictive clothingo Avoid lifting, bending, straining, and coughingo Don’t smokeo Loss weight
6. Peptic ulcer disease Erosion of the mucosal or duodenal lining of the stomach Pathophysiology
o ↑ emptying time of gastric acid from the gastric lumen into the small intestine causes inflammatory reaction w/ tissue breakdown
o Combination of hydrochloric acid & pepsin gastric mucosa Cause
o Drug inducedo Gastritiso Infection: H. pylorio Smoking & alcohol abuseo Severe physiologic stress
Assessment findings
o Epigastric pain 1-2 hrs after eatingo Hematemesiso Relief from pain after administration of antacidso Heartburno Dyspepsia
Medical managemento Stop smokingo NPO if active bleeding, NG tube insertiono Semi-fowler’s positiono Triple therapy for infection: Amoxicillin, Clarithromycin (Biaxin), Priloseco Tx: saline lavage by NG tube, if hemorrhageo Transfusion if needed
Nursing interventionso Assess respiratory, GI and cardiovascular statuso Small frequent meals as toleratedo Minimize environmental stress & maintain a quite environmento Monitor consistency, color, amount, & frequency of stools or emesis
7. Gastric cancer Malignant stomach tumor usually develops in the distal 3rd of the stomach Pathophysiology
o Unregulated cell growth and uncontrolled cell division result in the development of a neoplasm
o Most common neuoplasm is adencarinoma Risk factors
o Family hxo Smokingo High alcohol intakeo Type A blood o High intake of salty and smoked foods
Assessment findingso Weakness & fatigueo N&Vo Wt. losso Epigastric fullness and paino Melenao Anorexiao Dysphagia
Medical managemento High protein and calorie dieto Radiation therapyo Gastric surgeryo Analgesicso Vitamin supplements: folic acid & B12
Nursing interventionso Keep pt. in semi-fowler’s positiono Administer TPN & lipids until diet is resumedo Provide prophylactic skin & oral careo Teach pt. to avoid people w/ infectons
8. Ulcerative colitis Episodic inflammatory chronic disorder that causes ulceration of the mucosa of the colon Pathophysiology
o Inflammatory edema of the mucous membrane of the colon and rectum leads to bleeding & shallow ulcerations
o Mucosal ulceration begin in the distal end of the colon and ascend the large intestine
Risk factorso Emotional stresso Allergieso Genetics
Assessment findingso Bloody, purulent mucoid, watery stools (10-20 per day)o Abdominal tenderness and pain, crampingo Hyperactive bowel soundso Abdominal distentiono Jaundiceo Wt. loss
Medical managemento Immunosuppressive agentso Diet: high protein & calorie, low residue, bland foods in small frequent feedings
w/ restricted intake of milk and gas forming foods; NPO if severeo Semi-fowler’s positiono Corticosteroid
Nursing interventionso Monitor #, amount, and character of stoolso Assess perineal excoriation, and provide perianal care and sitz bathso Teach pt. to avoid highly seasoned foods, raw fruits and vegetables and milk
productso Reduce stress
9. Crohn’s disease Pathophysiology
o Ulcerations of intestinal mucosa are accompanied by congestion, thickening of the small bowel, and fissure formations
o Enlarged regional mesenteric lymph nodes accompany fibrosis and narrowing of the intestinal wall
o Cobblestone appearance Risk factors
o Allergieso Immune disordero Genetics
Assessment findingso Fatigue and weaknesso Crampy, colicky pain in the RLQo Chronic diarrhea o Elevated temp
Medical managemento Diet: small, freq. feedings; avoid dietary irritants (raw vegetables and fruit, milk
and gas forming foodso Antidiarrhealo Anti-inflammatoryo Immunosuppressantso Corticosteroidso Anticholinergics
Nursing interventionso Minimize stresso Monitor #. Amount, and character of stoolso Teach pt. to avoid laxatives and ASA
10. Diverticular disease Pathophysiology
o Muscle tone is weakened in the intestinal wall, resulting in a saclike out pouching (diverticula)
o Inflammation is caused by bacteria and fecal material trapped in the diverticulao Intestinal wall thickens and narrowso Typical sites: sigmoid colon
Risk factorso Age o Low intake of roughage and fiber
Assessment findingso LLQ paino Severe abdominal crampso Change in bowel patterno Bloody stoolo Low grade fevero Constipation and diarrhea
Medical managemento Diet: high fiber, low fat; avoid foods with seeds, kernels or indigestible roughage o Antibioticso Analgesico Stool softener
Nursing interventions
o Assess bowel sounds and abdominal distentiono Monitor stools for occult bloodo Semi-fowler’s position
11. Intestinal Obstruction Pathophysiology
o Gas, fluid, and digested substances accumulate proximal to the obstructiono H2O and electrolytes are secreted into the blocked bowelo Dehydration from fluid loss
Causeo Fecal impactiono Tumorso Strangulated hernias o Paralytic ileuso Toxicity
Assessment findingso Abdominal crampingo Vomiting green colored bileo Abdominal distentiono Absent bowel sounds below the obstructiono Wt. loss
Medical managemento NPO until the obstruction is relieved, then high fiber dieto GI decompression: NG tubeo Semi-fowler’s positiono Bed rest
Nursing interventionso Measure and record abdominal girtho Monitor color, frequency, amount of stoolso Teach pt. to avoid constipation foods
12. Peritonitis Pathophysiology
o Peritoneal irritants cause inflammatory edema, vascular congestion, and hypermotility of bowel sounds
o Movement of extracellular fluids into the peritoneal cavity leads to hypovolemia and ↓ urine output
Causeo Bacterial infectiono Pancreatitiso Chemical inflammationo Inflammation of kidneys or colono Intestinal perforation
Assessment findings
o Constant, diffuse, and intense abdominal paino Rebound tendernesso Elevated tempo Abdominal rigidity and distentiono Weak, rapid pulseo ↓ or absent bowel soundsao Shallow respiration
Medical managemento NPOo Semi-fowler’s positiono Antibiotics o LMWH
Nursing interventionso Assess bowel soundso TCDB and incentive spirometryo Turn q2hrs and encourage ambulation as soon as able
13.Cholecystitis & Cholelithiasis Pathophysiology
o Inflamed gallbladder can contact in response to fatty foods entering the duodenum because of obstruction by calculi or edema
o Accumulated bile is absorbed in the blood Cause
o Infection of the gallbladdero Reduced blood supply to the gallbladdero Estrogen therapyo Prolonged immobilityo Chronic dietingo Opioid abuse o Cholesterol
Assessment findingso Jaundice o Episodic colicky pain in the epigastric area, radiates to the right shoulder and
backo N&V, chillso Murphy sign’s (tenderness over the RUQ that ↑ on inspiration)o Belchingo Clay colored stoolso Low grade fevero Severe UQ paino Indigestion or CP after eating fatty or fried foods
Medical managemento Low fat diet, small freq. mealso Semi-fowler’s position
o Tx: tepid baths w/out soap, incentive spirometry Nursing interventions
o TCDB
14. Pancreatitis Pathophysiology
o Acute: pancreatic enzymes are activated in the pancreas rather than the duodenum, resulting in tissue damage & autodigestion of the pancreas
o Chronic: chronic inflammation results in fibrosis and calcification of the pancreas, obstruction of the ducts, and destruction of the secreting acinar cells
Causeo Biliary tract diseaseo Alcoholismo Metabolic and endocrine disorderso Bacterial or viral infection
Risk factorso Heredityo Renal failure and kidney transplantationo Medication induced: steroids, thiazide diuretics, hormonal contraceptives
Assessment findingso N&Vo Aching, burning, stabbing, pressing paino Tachycardiao Intense epigastric pain centered close to the umbilicus, radiating to the back
between the 10th thoracic and 6th lumbar vertebraeo Abdominal tenderness and distentiono Hypotensiono Wt. loss o Dehydrationo ↓ or absent bowel soundso Position chest-knee, fetal, or lean forward to relieve paino Cullen’s sign (irregular, bluish hemorrhagic patches on skin around umbilicus)o Turner’s sign (bruiselike discoloration of the skin)
Medical managemento Respiratory supporto Diet: gradual increase of low fat and protein dieto Semi-fowler’s positiono Stop alcohol and caffeine intakeo Antidiabetic
Nursing interventionso Encourage incentive spirometry, TCDBo Turn q2hrso Monitor urine ad stool color, character and amounto Teach pt. to avoid large meals and alcohol consumption
15. Cirrhosis Pathophysiology
o Inflammation causes liver parenchymal cell destruction, w/ subsequent fibrosiso Fibrotic changes cause obstruction of hepatic blood flow and normal liver
function; obstruction causes portal hypotensiono ↓ liver function leads to ↑ secretion of aldosterone, prolonged clot time,
ineffective detoxification of protein waste Assessment findings
o N&Vo Anorexiao Jaundiceo Pain RUQo Weakness and fatigueo Indigestiono Hepatomegalyo Melena
Medical managemento Diureticso Ammonia detoxicant: lactulose (Cephulac)o Diet: high calorie, low sodium; small freq. feedings, restricted alcohol and fluid
intakeo Semi-fowler’s positiono Regular exercise unless active bleedingo Stool softenero Vitamins: zinc
Nursing interventionso Assess neurologic, GI, and fluid balance statuso Low sodium dieto TCDB, incentive spirometryo Monitor for S/S of infectiono Bed rest and quite environmento Teach pt. to avoid use of OTC meds, alcohol, people w/ infections, and straining
while defecating, blowing the nose, coughing, and hard tooth brush
16. Hepatitis Pathophysiology
o Inflammation of the liver tissue leads to diffuse injury and necrosis of hepatocytes Cause
o Hep A: contaminated food, milk, H2O, feceso Hep B: parenteral , sexual, oral, transmitted through contact w/ any body fluidso Hep C: blood or stream transmitted through contact with any infected body fluids
Assessment findingso Fatigue
o Anorexiao Clay colored stoolso Dark urineo Jaundiceo Hepatomegalyo Wt. losso Elevated tempo HA, photophobia
Medical managemento High calorie, moderate protein diet; avoid alcoholo Frequent rest periods during activityo Antiviralso Alpha interferons
Nursing interventionso Provide skin careo Teach pt. to avoid people w/ infections, alcohol useo Increase fluid intake to 3L/dayo Safe sex practices
17. GERD Pathophysiology
o Reflux occurs when lower esophageal sphincter (LES) pressure is deficient or when pressure within the stomach exceeds LES pressure
Causeo Impaired LES functioningo ↑ intra-abdominal pressure (obesity, pregnancy, constrictive waistline, bending
over) Risk factors
o Alcohol ingestion o Hiatal herniao Smokingo Ingestion of peppermint or spearminto Gastric distention (large meals or ascites)
Assessment findingso Dyspepsia o Pain worsens with lying down or bending overo Regurgitation of warm, sour, or bitter fluido Laryngitiso Chronic cougho Chronic pain radiating to the neck, jaws, and arms that may mimic angina pectoris
Medical managemento Position upright after meals; sleep w/ the HOB elevatedo Small, freq. meals w/ ↑ fluid intake; avoid meals b4 bedo Stop smoking
18. Appendicitis Pathophysiology
o Lumen of the appendix becomes obstructed and inflamed o Mucosa continues to secrete fluids and pressure in the lumen continues to increaseo Blood flow is restricted and infection occurs
Causeo Mucosal ulcerationo Fecal mass o Foreign bodyo Stricture
Assessment findingso Abdominal rigidity o Rebound tendernesso Sudden cessation of pain (indicates rupture)o Generalized pain that becomes localized in RLQo N&Vo Anorexia
Medical managemento NPO until after surgeryo Best rest until after surgeryo Antibioticso Analgesic
Endocrine system1. Risk factors
Modifiableo Medicationo Stresso Dieto obesity
Nonmodifiableo Agingo Hx of traumao Family hx
2. Adrenalectomy Removal of one or both adrenal glands Pre-op NI
o Obtain signed consento Administer steroids and vasopressors as prescribed
Post-op NIo Monitor I&O and electrolyte levels (mineralocorticoid & glucocorticoid secretion
alters levels)
o Assess cardiac respiratory, & neurologic statuso Inspect the surgical dressingo TCDB, incentive spirometry, and splinting the incisiono Maintain quite environmento Teach pt. to avoid people w/ infection, and extreme temperatureso Teach pt. to recognize S/S of infection, hypovolemia, and hypoglycemia
3. Thyroidectomy & Parathyroidectomy Pre-op NI
o Obtain signed consent formo Administer iodine preparation and anti-thyroid medications
Post-op NIo Assess respiratory statuso Inspect surgical dressing for bleeding, especially behind the neck; change
dressing as directedo TCDB, incentive spirometry, and splinting incisiono Keep pt. in semi-fowlers position, neutral alignment, support the necko Keep calcium gluconate or calcium chloride and tracheostomy tray availabeo Assess for thyroid stormo Discourage talkingo High calcium diet w/ Vit. D for parathyroidectomy care
4. Hyperthyroidism Pathophysiology
o Thyroid-stimulating antibodies have a slow sustained stimulating effect on thyroid metabolism
o Accelerated metabolism causes ↑ synthesis of thyroid hormones Cause
o Autoimmune and genetic factorso Graves’ diseaseo ↑ TSH secretiono Pituitary tumorso Thyroid adenomaso Stresso Infection o DKAo Excessive iodine intakeo Surgery
Assessment findingso Heat intoleranceo Diaphoresiso Tachycardiao Bruit or thrill over thyroido Mood swings
o Flushed, smooth skino Fine hand tremorso Weakness
Medical managemento Radiation therapyo Bed resto Restrict stimulantso Lab: T3 & T4o Glucocorticoidso Beta-adrenergic blocking agent: Propranolol (Inderal)
Nursing interventionso Rest periods in a quite, cool environmento Stop smokingo Teach s/s of thyroid storm (tachycardia, delirium, agitation, coma, dehydration,
diarrhea, arrhythmias, death)o Avoid exposure to people w/ infection
5. Hypothyroidism Pathophysiology
o Thyroid gland falls to secrete a satisfactory quantity of thyroid hormone o Hyposecretion of thyroid hormone results in overall decrease in metabolism
Causeo Autoimmune disease: Hashimoto’s thyroiditis o Thyroidectomy o Malfunction of the pituitary glando Use of radioactive iodineo Overuse of antithryoid drug
Assessment findingso Fatigue o Wt. gaino Dry, flaky skino Cold intoleranceo Mental sluggishnesso Hypothermiao Thick tongue, swollen lipso ↓ diaphoresis
Medical managemento Thyroid hormone replacement o Caution w/ contact sports or heavy physical laboro Monitor VS, I&O, and labs (T3 &T4)
Nursing interventionso Encourage physical activity and mental stimulation as toleratedo Encourage fluidso S/S of myxedema coma (severe stress, severe hypothyroidism)
o Provide warm environmento Avoid sedationo Exercise regularly
6. Hyperparathyroidism Pathophysiology
o PTH secretion ↑; serum calcium level elevateso Excessive compensatory production of PTH stems from a hypocalcemia-
producing abnormally outside the parathyroid gland that isn’t responsive to PTH Cause
o Chronic renal failureo Bone disease o Malignant tumor of the parathyroid glando Vit. D deficiency
Assessment findingso Recurring nephrolithiasiso Arrhythmias o N&Vo Muscle weakness in legso Personality disturbance o Polydipsiao Polyuriao Cataractso Skin necrosiso Chronic low back pain
Medical managemento ↑ fluid intake to 3000ml/dayo Bisphosphonate: Alendronate (Fosamax)o Calcitonino Antineoplastico Phosphate saltso Dialysis using calcium-free dialysateo Vit. Do Glucocorticoid
Nursing interventionso Assess bone and flank paino Move the pt. carefully to prevent pathologic fractureso Keep a tracheostomy tray @ bedsideo Support the pt. head and neck w/ sandbags
7. Hypoparathyroidism Pathophysiology
o ↓ PTH decreases stimulation to osteoclasts, resulting in decreased release of calcium and phosphorus from bone
o ↓ blood calcium causes a rise in serum phosphates and decreased phosphate exertion by the kidney
Causeo Autoimmune diseaseo Massive thyroid irradiationo Parathyroidectomyo Hypercalcemiao hypomagnesmia
Assessment findingso Tingling in the fingers, around the mouth and occasionally in the feeto ↑ deep tendon reflexeso N&Vo Abdominal paino Brittle nails personality changes dyspnea
Medical managemento High-calcium, low phosphoruso Oral calcium salts
Nursing interventionso Keep a tracheostomy tray and IV calcium gluconate availableo Maintain a calm environment
8. Cushing’s syndrome Pathophysiology
o Hypothalamic stimulation of the pituitary gland causes excessive secretion of corticotrophin
o Excessive secretion of corticotropin causes increased plasma cortisol Cause
o Hyperplasia of the adrenal glands o Hypothalamic stimulation of the pituitary
Assessment findingso Wt. gain o HTNo Moon faceo Truncal obesity w/ thin extremitieso Mood swingso Fragile skino Poor wound healingo Buffalo hump
Medical managemento Radiation therapyo Glucocorticoidso Adrenal suppressantso Hypoglycemico Diet: low sodium, high calorie, potassium, and protein
Nursing interventionso Protect the pt. from infectiono Check for infections of the skin and the respiratory and urinary tractso Keep the HOB elevated at least 30 degreeso Avoid activities that increase intracerebral pressureo Avoid exposure to people w/ infections
9. Addison’s disease Pathophysiology
o Chronic hypoactivity of the adrenal cortex, resulting in insufficient secretion of glucocorticoids (cortisol) and mineralocorticoids (aldosterone)
Causeo Tuberculosiso Idiopathic atrophy of adrenal glandso Surgical removal of adrenal glandso Autoimmune disease o Infectiono Pituitary hypofunction
Assessment findingso Hypoglycemia o Weakness and lethargyo Orthostatic hypotensiono Wt. losso Bronzed skino Craving of salty foods o Chronic diarrhea
Medical managemento Mineralocorticoidso Glucocorticoidso Diet: high-carbohydrate , protein, and sodium, low potassium; in small freq.
feedings before steroid therapy; high potassium and low sodium when on steroid therapy
o Bed rest (adrenal crisis) Nursing interventions
o Protect pt. from fallso Encourage fluid intakeo Maintain quite environmento Teach pt. to avoid strenuous exercise especially in hot weather and avoid using
OTC drugso ↑ fluid intake in hot weather
10. Pheochromocytoma Pathophysiology
o Tumor in the adrenal medulla secretes large amounts of catecholamines (epinephrine and norepinephrine)
Causeo May be inherited as an autosomal dominant trait
Risk factorso Anesthesiao Medicationo Radiation contrast dyeo Childbirth
Assessment findingso Labile malignant HTNo Throbbing HAo Diaphoresiso Tachycardiao Tachypneao Vertigoo Tremors
Medical managemento Diet: high proteino Alpha adrenergic blockerso Beta adrenergic blocker
Nursing interventionso Semi-fowler’s positiono Protect the pt. from fallso Rest periods and minimize environmental stresso Assess the wound and dressing for signs o Stop smoking
Reproductive disorders1. Prostate surgery
Transurethral resection of prostate (TURP): insertion of a restopscope into the urethra to excise prostatic tissue
Pre-op NIo Demonstrate TCDB, incentive spirometry, splinting, and leg ROM exerciseo Obtain a signed consent
Post-op NIo Semi-fowler’s positiono Encourage the pt. to express his feelings about the surgery and fear of sexual
dysfunctiono Administer stool softenerso Evaluate urine appearance o Avoid giving enemas and taking rectal tempo Avoid Valsalva’s maneuver, lifting, vigorous exercising, or prolonged sitting in
the car
2. Benign Prostatic Hyperplasia Pathophysiology
o Enlarged prostate gland compresses urethra, resulting in urinary obstruction and retention
Risk factorso Ageo Intact tests
Assessment findingso ↓ force and amount of urine streamo Urinary hesitancy and urgencyo Interrupted urine streamo Nocturia, hematuriao Dribbling, incontinence
Medical managemento Prostatectomyo TURPo Encourage fluids
Nursing interventionso Assess urine output for amount and appearance o Monitor and record: vital signs, I&O
Musculoskeletal system1. External fixation
Fracture immobilization in which transfixing pins are inserted through the bone above and below the fracture and attached to a rigid external metal frame
Pre-op NIo Monitor fracture complicationso Maintain the position of the affected extremity w/ sandbags and pillows, tracts, or
a splint Post-op NI
o Semi-fowler’s positiono Active and passive ROM , isometric exercises (strengthening & ↑ muscle tone by
contracting muscles against resistance )o Provide wound careo Maintain balanced suspension traction
2. Amputation Pre-op NI
o TCDB, incentive spirometry, splinting, ROM exerciseso Prepare pt. for the possibility of phantom limb sensation or paino Provide emotional supporto Obtain signed consent form
Post-op NIo Provide wound care
o Active and passive ROM , isometric exercises (strengthening & ↑ muscle tone by contracting muscles against resistance )
o Elevate the affected extremityo Inspect stump for bleeding, infection, and edemao Maintain a rigid dressing for the stump prosthesiso Provide trapeze
3. Carpal tunnel release Surgical ligation of the transverse carpal ligament to relieve compression of the median
nerve in the carpal canal of the wrist Pre-op NI:
o TCDB, incentive spirometry, splinting, ROM exerciseso Obtain signed consent form
Post-op NIo Elevate hand and apply iceo Apply splinto Encourage movement of the fingers to ↓ swellingo Provide wound care
4. Open reduction internal fixation (ORIF) Surgical reduction and stabilization of a fracture, using orthopedic devices or hardware
(Austin Moore prosthesis, Smith-Peterson nail, Jewett nail, intramedullary nails, and compression screws)
Pre-op NIo Demonstrate TCDB, incentive spirometry, splinting, ROM exerciseso Keep the extremity in position w/ sandbags and pillows or traction
Post-op NI:o Assess cardiac and respiratory statuso Semi-fowler’s position: no higher then 30 degreeso Use abductor pillow and trochanter rollso Apply compression stockingso Administer anticoagulants o Administer stool softeners
5. Rheumatoid Arthritis Pathophysiology
o Inflammation of the synovial membranes is followed by formation of pannus, an inflammatory exudates, and destruction of cartilage, bone, ligaments
o Pannus is replaced by fibrotic tissue and calcification Cause
o Autoimmune diseaseo Genetic transmission
Assessment findingso Painful, swollen jointso Symmetrical joint swellinig
o Morning stiffnesso Crepituso Enlarged lymph nodeso Limited ROM due to deformity
Medical managemento NSAIDs o Disease modifying anti-rheumatic drugs: Arava, Rheumatrex, Remicade, Enbrel,
Plaquenilo Glucocorticoids: Deltasone, Cortefo Heat & cold therapy
Nursing interventionso Keep joint extended; provide ROM exerciseso Check for swelling, pain, redness o Teach pt. to avoid stress, cold, and infectiono Complete skin & foot care daily
6. Osteoarthritis (DJD) Degeneration of articular cartilage affecting the wt. bearing joints (spine, knees, hips) Pathophysiology
o Cartilage softens w/ age narrowing the joint spaceo Cartilage flakes enter the synovial lining which fibroses
Causeo Agingo Obesityo Joint traumao Congenital abnormalities
Assessment findingso Pain relieved by resto Joint stiffnesso Crepitation (grating sensation associated w/ DJD that can be heard and felto Smooth, taut, shiny skin
Medical managemento Heat & cold therapyo ASAo NSAIDso Isometric exercises, strengthening exercise, aerobic exerciseso Wt. reductiono Canes, walkers
Nursing interventionso Provide rest o Maintain calorie counto Provide moist compresses and paraffin bath (heat therapy)o Teach proper body mechanics o Passive ROM
7. Osteomyelitis Bacterial infection of the bone and soft tissue Pathophysiology
o Organisms reach bone through an open wound or via the bloodstream o Infection causes bone destruction o New bone cells form over the necrotic bone fragments during healing, results to
nonunion Cause
o Staphylococcus aureuso Hemolytic streptococcus
Risk factorso Open woundo infection
Assessment findingso Bone paino Localized edema, redness, and warmtho ↑ pain w/ movemento ↑ tempo Tachycardiao Muscle spasmso Nausea
Medical managemento Antibioticso Cast or splinto Wound careo Heat therapyo Diet: high calorie, vitamin C & D, protein, and calcium
Nursing interventionso Encourage fluids up to 3L/dayo Turn q 2hrso Teach pt. to avoid others w/ infection
8. Osteoporosis Metabolic bone dysfunction that results in reduced bone mass and ↑ porosity Pathophysiology
o Rate of bone resorption exceeds the rate of bone formationo ↑ phosphate stimulates parathyroid activity; estrogen ↓ bone resorption
Causeo Calcium, vit. D, & protein deficiencyo Bone marrow disordero Liver diseaseo Cushing’s syndrome hyperthyroidism
Risk factors
o Ageo Femaleo Family hx.o Smokingo Immobilityo Postmenopauseo Corticosteroid use
Assessment findingso Back pain: thoracic and lumbaro Kyphosis (Dowager’s hump)o Loss in heighto Joint pain o weakness
Medical managemento Diet: high calcium, protein, vitamins, minerals, and borono Limit caffeine and alcoholo Weight bearing exercise programo Calcitonino Calcium supplemento Hormone replacement
Nursing interventionso Prevent fallso Assist in planning Weight bearing exercise program
9. Fractures Pathophysiology
o Fractures occur when stress is placed on the bone more than it can withstando Localized tissue injury, results in muscle spasms, edema, hemorrhage,
compressed nerves and ecchymosis Risk factors
o Agingo Immobilityo Malnutrition o Osteoporosiso Contact sportso Bone tumoro Previous fracture
Assessment findingso Pain aggravated by motiono Loss of function or motiono Deformityo Edemao Ecchymosiso Crepitus
Medical managemento Elevate extremity (25 degrees for hip); keep pt. flat w/ leg abducted for fracture
hipo Active and passive ROM; isometric exerciseo Ice packs, abductor pillow (fractured hip)o Skin tractiono Skeletal traction: Crutchfield tongs (neck)o Cast or closed reduction o Cast or pin careo ORIF
Nursing interventionso Elevate and apply iceo Skin care, pin, and cast careo Turn q2hrso Provide trapeze o Maintain traction to ensure proper body alignment and proper healingo TCDB, incentive spirometry
10. Systemic Lupus Erythematosus (SLE) Chronic inflammatory autoimmune disorder that affects connective tissue Pathophysiology
o Defect the body immunologic mechanism produces serum autoantibodies directed against components of the pt. cell nuclei
o Affects connective tissue cells throughout the body (heart, brain, muscles, kidneys, skin, joints, mucous membranes, blood vessels
Risk factorso Stress or emotional upseto Streptococcal or viral infection o Exposure to sunlight or ultraviolet lighto Injuryo Surgeryo Immunizationo Abnormal estrogen metabolismo Exhaustion
Assessment findingso Painful or swollen joints o Butterfly erythema on faceo Malaise and weaknesso Low grade fevero Raynaud’s phenomenono Abdominal pain o Wt. loss
Medical managemento Corticosteroids
o NSAIDso Immunosuppressantso Plasamapheresiso Regular exercise program
Nursing interventionso Provide resto Prevent infectiono Minimize environmental stresso Teach pt. to avoid others w/ infection and sunlight exposure
Immune disorders1. AIDS
Pathophysiologyo HIV is transmitted by contact w/ infected blood or body fluids. Infected
lymphocytes are carried on semen, vaginal secretions, and bloodo Transferred through minute breaks in the skin and mucosa, transfusion, & fetal
circulationo A retrovirus selectively infects human cell containing CD4 antigen on their
surface; majority are T4 lymphocyteso HIV virus reproduces within T4 lymphocytes, destroy them; destruction of T4
diminishes resistance to disease Cause
o Exposure to blood containing HIV: transfusions, contaminated needles, utero Assessment findings
o Anorexia o Wt. losso Recurrent diarrheao Night sweatso Disorientation, confusion, dementiao Palloro Fevero Weaknesso Malnutrition
Medical managemento IV therapy: hydration, electrolyte replacement, and saline locko O2 therapyo Active and passive ROMo TPN if pt. can’t take food by moutho Tx.: chest physiotherapy, postural drainage, incentive spirometryo Transfusion therapy: fresh frozen plasma, platelets, and packed RBCso Antibiotics o Highly active anti-viral therapy
Nursing interventionso Encourage TCDB and use of incentive spirometry
o Monitor VS, I&O, labs, daily wt. and pulse oximetryo Provide skin and mouth careo Teach pt. to refrain from donating blood; use condoms during sexual intercourse;
avoid using alcohol and recreational drugs
