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Temperature Formulas F = C (9/5) + 32
C = (F -32) x 5/9
Defibrillate - start at lowest joules (200-> 300 -> 360)
- indicated for VF and pulseless ventricular tachycardia
How to obtain ABG sample Arterial puncture
- use heparinize syringe
- perform Allen''s test prior to puncture to verify patent radial and ulnar circulation; compresses the ulnar and radial arteries while the client pumps fists, then releasing the radial artery slowly -> should turn pink quickly. then repeat for the ulnar artery
- place the specimen in basin of ice
post care:
- apply pressure for 5 min and 20 min for those on anticoagulants
Arterial line
- use heparinize syringe
- place on ice for transport to lab
- flush the arterial line with pre-connected flushing system
- assess the arterial wave form upon completion
Oxygen Toxicity s/s
- nonproductive cough, substernal pain, nasal stuffiness and hypoventilation
tx:
- use of CPAP, BiPAP or PEEP
- give the least amount of O2 necessary to maintain SaO2 levels
- use Venturi Mask when client needs precise amount of O2 delivered such as those with COPD
Types of Ventilator alarms ...
Volume alarm: Ventilator - alarm indicate low exhaled volume dt disconnection, cuff leak, and tube displacement
Pressure alarm: Ventilator - alarm indicate excess secretions, client biting the tubing, kinks and client coughing
Apnea alarm: Ventilator indicate that the ventilator does not detect spontaneous respiration
Asthma Chronic inflammatory disorder of the airways. It is INTERMITTENT and REVERSIBLE airflow obstruction tat affects the bronchioles
- occurs either by inflammation or airway hyperresponsiveness
Manifestation
- Mucosal edema
- broncoconstriction
- excessive secretion production
Classification: Asthma - Mild intermittent: < 2x/week
- Mild persistent: >2x/week
- Moderate persistent: daily with exacerbations 2x/wk
- Severe persistent: continuous with frequent exacerabation
Triggers: Asthma - smoke
- strong odors
- allergens
- exercise
- pollutants
- stress or emotions
- medications (NSAIDS, beta blockers, cholinergic)
- chemicals
Dx: Asthma - PFTs are most ACCURATE
- PFR is the fastest airflow rate reached during exhalation
- green: 80-100; no changes in meds needed
- yellow: 50 -79; increase meds
- red: < 50: need to see physician
Medications: Asthma ...
Cholinergic antagonists - ipratropium (Atrovent)
- blocks parasympathetic nervous system
- allows for the sympathetic nervous system effects of increased bronchodilation and decreased pulmonary secretions.
Methylxanthins - theophylline (Theo-Dur)
- therapeutic range: 10 -20 mcg/ml
Anti-inflammatories Corticosteroids:
- Flovent/Prednisone
- side effects: hypokalemia, poor wound healing, fluid retention, immunosuppression, hyperglycemia
- Leukotriene antagonists: Singulair
- Mast cell stabilizer: Intal
- Monoclonal antiboies: omalizumab (Xolair)
Status Asthmaticus - Life threatening episode, often unresponsive to tx
- s/s
- extreme wheezing, labored breathing, use of accessory muscles, distended neck veins, and risk for cardiac and/ or respiratory arrest
- tx
- EPINEPHRINE (potent bronchodilator) then initiate systemic steroid therapy
Older Adults: Asthma - less likely to respond to beta agonists dt decrease sensitivity to beta adrenergic receptors
- more susceptible to infections
COPD Typically affects the middle age and older adults
- Emphysema
- Chronic bronchitis
Normal SaO2: 94% to 98%
Emphysema - characterized by the loss of lung elasticity and hyperinflation of lung tissue. Causes destruction of the alveoli leading to decreased area for gas exchange, carbon dioxide retention and respiratory acidosis
Chronic bronchitis - Is an inflammation of the bronchi and bronchioles dt chronic exposure to irritants
S/S: COPD - dyspnea
- cough
- hypoxemia
- hypercarbia (increased PaCO2)
- Respiratory acidosis
- crackles
- shallow respirations
- use of accessory muscles
- barrel chest
- hyperresonance dt "trapped air"
- pallor and cyanosis
Nx Interventions: COPD - Position at high- Fowler's
- encourage deep breathing and use of incentive spirometer
- meds use: same as asthma meds
- administer heated and humidified O2 therapy
- monitor for skin breakdown
- teach: diaphragmatic or abdominal breathing
- teach pursed lip breathig
- may need only 2-4 L/min per nasal cannula and only 40% per Venturi mask
- include plenty of rest
- smoking cessation
Complications: COPD Respiratory infection
- administer O2 and abx
Right sided Heart Failure
- blood flow through lung tissue is difficult. This increased work load leads to enlargement and thickening of the right atrium and ventricle
s/s
- hypoxia, cyanotic lips, tender liver
Nx intervention
- administer positie inotropic and contractility medications (digoxin)
- administer diuretics and IV fluids
Older Adults: COPD - make sure influenza vaccination is up to date
- provide plenty of rest period
Pneumonia An inflammatory process in the lungs that produces excess fluid. Triggered by infectious organisms or by the aspirations of an irritant, resulting in EDEMA and EXUDATE that fills the alveoli
Risk Factors: Pneumonia - advance age
- recent exposure to viral infections
- tobacco use
- chronic lung disease (asthma)
- aspiration
- mechanical ventilation
- impaired ability to mobilize secretions
- immunocompromised status
s/s:Pneumonia - Fever
- dyspnea, tachypnea
- sputum production
- CRACKLES
- coughing
- DULL CHEST PERCUSSION
- poor O2 sat
Nx: Intervention: - heater and humidified O2 therapy
- high- Fowler's position
- administer abx: PCN and cephalosporins
- administer bronchodilators:
- short acting beta2 agonists and methylaxanthines
- administer corticosteroids: to decreased inflamation
- monitor for: hypokalemia, hyperglycemia, fluid retention, immunosuppresion and poor wound healing
- ensure up dated vaccinations
- influenza vaccines
- pneumococcal vaccine; administered 1 time.
Complications: Pneumonia Atelectasis
- airway inflammation and edema leads to alveolar collapse and increases the risk of hypoxemia
- diminished or absent breath sounds over affected area
- cxr shows area of density
Acute Respiratory Failure
- persistent hypoxemia
- prepare for intubation
Older Adults: Pneumonia - increase susceptibility in infections
- have weak cough reflex and decreased muscle strength -> trouble expectorating with can lead to difficulty in breathing and specimen retrieval
s/s
- CONFUSION from hypoxia
- fever, cough and purulent sputum are often absent
- cxr is important dx tool bc sx are often vague
Tuberculosis caused by Myobacterium tuberculosis
- airborne route
- cxr appears Ghon Tubercle
- contagious only when s/s of infection is present
- TB test will be (+) 2 to 10 weeks of exposure to infection
dx: Mantoux
- 10 mm is positive for non immunocompromised
- 5 mm is positive for immunocompromised
- cxr to detect active lesions
- sputum culture CONFIRMS dx
s/s - cough
- NIGHT SWEATS
- purulent sputum, blood streaked
Nx Interventions: Tuberculosis - Nurse: wear N95 or HEPA respirator
- place client in NEGATIVE airflow room with airborne precaution
- have client wear mask when transporting
- diet: high in protein, iron and vit C
- follow up care in 1 year
- sputum samples are needed Q2-4 weeks; clients are no longer infectious after 3 negative sputum cultures
Medications: Tuberculosis S.T.R.I.P.E.
- Isoniazid (INH):
- take in empty stomach
- take with vit B6
- Rifampin
- urine and other secretions will turn ORANGE
- monitor for hepatomegaly
- Ethambutol (EMB)
- obtain baseline visual acuity; determine color discrimination
- Streptomycin
- check for ototoxicity
Complications: Tuberculosis - Miliary TB: spreads through blood stream
- Meningitis
- pericarditis
Pack Year History # of packs of cigarettes smoked per day (x) # of years smoked
Superior Venal Cava Syndrome results from pressure placed on the vena cava by tumors. This is a medical emergency
- early signs
- facial edema
- tight ness of shirt collars
- nosebleeds
- dyspnea
- late signs
- hypotension
- change in metnal status
- cyanosis
- hemorrhage
Tx: Radiation and stent placement provide temp relief
Metastasis (lung cancer) - to the bones can cause bone pain and increase the risk of pathologic fractures. Encourage to ambulate carefully
- to the CNS can lead to changes in mentation, lethargy and bowel and bladder malfunction. Reorient the client as needed
Pulmonary Embolism Occurs when a substance (solid, gaseous, or liquid) enters venous circulation and terminates in the pulmonary vasculature
- common origin from DVT
Risk Factors: Pulmonary Embolism - immobility
- oral contraceptive; estrogen therapy
- smoking
- HYPERCOAGULABILITY
- obesity
- surgery
- ATRIAL FIBRILLATION
- sickle cell disease
- LONG BONE FRACTURES
s/s: Pulmonary Embolism - Tachycardia
- anxiey
- S3, S4
- decreased SaO2
- CRACKLES
- petechiae, cyanosis
Medications: Pulmonary Embolism ...
Anticoagulants Enoxaparin (Lovenox), heparin, warfarin (Coumadin)
- used to prevent clot from getting larger or other clots from forming
- contraindicated: active bleeding, PUD, hx of stroke and recent trauma.
- Monitor bleeding times
- side effects: thrombocytopenia, anemia, hemorrhage
Fibrinolytic therapy Alteplase, Streptokinase
- used to BREAK UP clots
- side effects is similar to anticoagulants
Client Education: Pulmonary Embolism - Avoid long periods of immobility
- monitor intake of food high in vit K
Nx Interventions: Pulmonary Embolism - avoid IM injections
- avoid rectal temperatures or enemas
- administer fluids and blood products as required
Angiogram Indications:
- A cerebral angiogram is used to assess the blood flow to and within the brain, identify aneurysms, and define the vascularity of tumors (useful for surgical planning). It may also be used therapeutically to inject medications that treat blood clots or to administer chemotherapy.
Nx Intervention: Preprocedure Angiogram Preprocedure
If the client is pregnant, a determination of the risks to the fetus versus the benefits of the information obtained by this procedure should be made.
Nursing Actions
■ NPO for 4 to 8 hours prior to the procedure.
■ Assess for allergy to shellfish or iodine, which
■ Ensure that the client is not wearing any jewelry. ■ A mild sedative is usually administered
Nx Intervention: Intraprocedure Angriogram - A catheter is placed into an artery (usually in the groin or the neck), dye is injected, and x-ray pictures are taken.
Nx Intervention: Postprocedure Angiogram Nursing Actions
■ The area is closely monitored to assure that clotting occurs.
■ Movements are restricted for 8 to 12 hours to prevent rebleeding at the catheter site.
Electroencaphalography EEG ...
Nx Intervention: EEG Preprocedure
Client Education
- NO caffeine 6-9 hr prior to procedure
- Instruct the client to wash his hair prior to the procedure and eliminate all oils, gels, and sprays.
- If indicated, instruct the client, to be sleep-deprived, because this provides cranial stress, increasing the possibility of seizure activity occurring during the procedure.
Intraprocedure
- Flashes of light or pictures may be used during the procedure to assess the client's response to stimuli.
- An EEG provides information about the ability of the brain to function and highlights areas of abnormality.
Postprocedure
Client Education
- Instruct the client that normal activities may be resumed.
Glasgow Coma Scale Interpretation of Findings
- The best possible GCS score is 15. In general, total scores of the GCS correlate with the degree or level of coma.
- 9 to 12: Indicate a MODERATE head injury
- Less than 8: Associated with SEVERE head injury and coma
ICP Normal ICP is 10 to 15 mm Hg. Persistent elevation of ICP extinguishes cerebral circulation, which will result in brain death if not treated urgently.
Symptoms of increased ICP include:
- severe headache
- deteriorating level of consciousness
- restlessness, irritability
- dilated or pinpoint pupils, slowness to react,
- alteration in breathing pattern (Cheyne Stokes respirations, central neurologic hyperventilation, apnea),
- deterioration in motor function, and abnormal posturing (decerebrate, decorticate, flaccidity).
Lumbar Puncture (Spinal Tap) Preprocedure:
- Have the client EMPTY their BLADDER
- Place the client in a "CANON BALL" position or "fetal" position
Postprocedure
- Have client supine for several hours
- once stable, normal activities can be resumed
Complication
- CSF leak: s/s HEADACHE and can result to infection
MRI use magnet; save for pregnant women
Indications
- capable of discriminating soft tissue from tumor or bone
Pain Management ...
Substances that increase pain transmission and cause inflammatory response - Substance P
- Prostaglandins
- bradykinin
- Histamine
Substances that decrease pain transmission and produces analgesia • Serotonin
• endorphins
Nociceptive Pain Nociceptive pain arises from damage to or inflammation of tissue other than that of the peripheral and central nervous systems.
- it is usually throbbing, aching, and localized.
- this pain typically responds to opioids and nonopioid medications.
Types of nociceptive pain
◯ Somatic: in bones, joints, muscles, skin, or connective tissues
◯ visceral: in internal organs such as the stomach or intestines. it can cause referred pain in other body locations not associated with the stimulus
◯ Cutaneous: in the skin or subcutaneous tissue
Neuropathic Pain Neuropathic pain arises from abnormal or damaged pain nerves.
- it includes PHANTOM limb pain, pain below the level of a spinal cord injury, and diabetic neuropathy.
- usually intense, shooting, burning, or described as "PINS and NEEDLES."
- typically responds to adjuvant medications (antidepressants, antispasmodic agents, skeletal muscle relaxants).
Nonpharmacological Pain Management - transcutaneous electrical nerve stimulation (TENS)
- heat, cold, therapeutic touch,
- massage
Meningitis - ensure infants receive Hib vaccines
- pneumococcal vaccines for: adults, older adults and immunocompromise
- MCV4 vaccines for adolescents prior to dormitory living
- use of insect repellant when risk for mosquito bites
Risk for: Meningitis Viral:
- mumps, measles, herpes, and arboviruses (West Nile)
Bacterial
- otitis media, pneumonia, or sinusitis, Neisseria meningitidis, Streptococcus pneumoniae, or Haemophilus influenzae
- Immunosuppression
Invasive procedures, skull fracture,penetrating head wound (direct access to cerebrospinal fluid
- Overcrowded or communal living conditions
s/s: Meningitis - nuchal rigidity
- HEADACHE
- photophobia
- fever and chills
- altered mental status
- positive Kernig's
- positive Brudinzki (flexion of extremeties and neck)
Nx Intervention: Meningitis - ISOLATE the client
- DROPLET precautions which requires a private room or a room with cohorts, wearing of a surgical mask when within 3 feet of the client, appropriate hand hygiene, and the use of designated equipment, such as blood pressure cuff and thermometer. Continue until antibiotics have been administered for 24 hr.
- Implement fever-reduction measures, such as a cooling blanket, if necessary.
- Report infections to the public health department.
Decrease environmental stimuli.
■ Provide a quiet environment.
■ Minimize exposure to bright light
- Maintain bed rest with the HOB elevated to 30°.
- Maintain client safety, such as seizure precautions.
◯ Older adult clients are at an increased risk for secondary complications, such as pneumonia.
Medications: MeningitisCeftriaxone (Rocephin) or cefotaxime (Claforan)
■ Antibiotics given until culture and sensitivity results are available. Effective for bacterial infections.
Phenytoin (Dilantin)
■ Anticonvulsants given if ICP increases or client experiences a seizure.
Acetaminophen (Tylenol), ibuprofen (Motrin)
■ Analgesics for headache and/or fever - nonopioid to avoid masking changes in the level of consciousness.
Cipro and Rifampin
- prophylactic abx
Complications: Meningitis Increased ICP
- decreased level of consciousness
- WIDENED PULSE PRESSURE
- administer MANNITOL
Syndrome of Inappropriate Antidiuretic Hormone
- administer Declomycin and restriction of fluid
Septic Emboli
Seizures Triggering Factors
- Increased physical activity
- Excessive stress
- Overwhelming fatigue
- Acute alcohol ingestion
- Excessive caffeine intake
- Exposure to flashing lights
- Specific chemicals, such as cocaine, aerosols and inhaling glue products
Generalized seizures Referred to as "tonic clonic or grand mal" seizures
- it may begin with an aura
- begins with 15 to 20 sec tonic (stiffining of muscles) episode then loss of consciousness
- 1 to 2 min of clonic episode (rhythmic jerking of extremities) then follows by tonic
- incontinence may occur
- Postical phase: confusion and sleepiness follows the seizure
Tonic seizures - The seizure usually lasts only a few seconds.
- A loss of consciousness does not occur.
- This type of seizure is much less common than a tonic-clonic seizure.
Clonic seizures - Fatigue does not usually follow the seizure.
- This type of seizure is much less common than a tonic-clonic seizure.
Absence seizures Absence seizures are most COMMON in CHILDREN.
- loss of consciousness lasting a few seconds.
- associated with blank staring.
- Baseline neurological function is resumed after seizures, with no apparent sequela.
Myoclonic seizures - consist of brief jerking or stiffening of the extremities, which may be symmetrical or asymmetrical.
- This type of seizure lasts for seconds.
Atonic or Akinetic seizures - characterized by a few seconds in which
muscle tone is lost.
- followed by a period of confusion.
- The loss of muscle tone frequently results in falling.
Partial or focal/local seizures Complex partial seizure
- associated automatisms (behaviors that the client is unaware of: lip smacking or picking at clothes).
- loss of consciousness for several minutes.
- Amnesia may occur immediately prior to and after the seizure.
Simple partial seizures
- Consciousness is maintained throughout simple partial seizures.
- Seizure activity may consist of unusual sensations, a sense of déjà vu, autonomic abnormalities, such as changes in heart rate and abnormal flushing, unilateral abnormal extremity movements, pain or offensive smell.
Seizure precaution During a seizure:
■Protect the client from injury (move furniture away, hold head in lap if on the floor).
■Be prepared to suction oral secretions.
■Turn to the side
■Loosen restrictive clothing.
■DO NOT attempt to restrain the client.
■DO NOT attempt to open jaw or insert airway during seizure activity (may damage teeth, lips, and tongue). Do not use padded tongue blades.
■Document onset and duration of seizure and client findings/observations prior to, during, and following the seizure (level of consciousness, apnea, cyanosis, motor activity, incontinence).
Post seizure:
■Maintain the client in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions.
Check vital signs.
■Allow the client to rest if necessary.
■Reorient and calm the client (may be agitated or confused).
■Institute seizure precautions including placing the bed in the lowest position and padding the side rails to prevent future injury.
■Determine if client experienced an aura, which can possibly indicate the origin of seizure in the brain.
■Try to determine possible trigger (fatigue).
Medications: Seizures Administer prescribed antiepileptic drugs (AED), such as phenytoin (Dilantin): therapeutic range: 1-2 mcg/dL
Nursing Considerations
- Initial goal is to control seizure activity using only one medication. If the chosen medication is not effective either the dose is increased, or another medication is added or substituted.
- Medications should be taken at the same time every day to enhance effectiveness.
- Some antiepileptic medications cause oral gum overgrowth. Routine oral hygiene and dental visits can minimize this side effect.
- When using phenytoin, specific instructions should include:
- avoidance of oral contraceptives, as this medication decreases their effectiveness.
- Warfarin (Coumadin) should also not be given with this medication.
Surgical Intervention: seizures placement of vagal nerve stimulator
- electrode placed on the left vagal nerve
- the client may hold a magnet over the site to stimulate the device at the onset of seizures
excision of the portion of the brain
Status Epilepticus Prolonged seizure activity occurring over a 30 min time frame
complications
- decreased O2 levels
- inability of the brain to return to normal functioning
- continued assault on neuronal tissue
Nursing Actions
- administer loading dose of diazepam (Valium) or lorazepam (Ativan) followed by continuous infusion of the phenytoin (Dilantin)
Parkinson's Disease (PD) is a PROGRESSIVELY debilitating disease that grossly affects motor function.
characterized by:
- tremor
- muscle rigidity
- bradykinesia (slow movement)
- postural instability
sx occur dt overstimulation of the basal ganglia by ACETYLCHOLINE
- tx focuses on increasing the amount of DOPAMINE or decreasing the amount of acetylcholine
5 Stages: Parkinson's Disease (PD) - Stage 1
- Unilateral shaking or tremor of one limb.
- Stage 2
- Bilateral limb involvement occurs making walking and balance difficult.
- Stage 3
- Physical movements slow down significantly, affecting walking more.
- Stage 4
- Tremors may decrease but akinesia and rigidity make day-to-day tasks difficult.
- Stage 5
- Client unable to stand or walk, is dependent for all care, and may exhibit dementia.
Assessment: Parkinson's Disease (PD) - stooped posture
- slow, SHUFFLING, and propulsive gait
- MASK-like EXPRESSION
- drooling
- progressive difficulty with ADLs
Medications - Dopaminergics
- Dopamine agonists
- Anticholinergics
- Catechol O methyltransferase (COMT) inhibitors
- Antivirals
Dopaminergics Levodopa (Dopar)
- converted to Dopamine in the brain, increasing the levels in the basal ganglia
- may be combined with carbidopa (Sinemet)
- Monitor for the "wearing off," which indicate the need to adjust the dosage or time of administration o the need for the medication
Dopamine agonists bromocriptine (Parlodel) and pramipexole (Mirapex)
- activate release of dopamine
- may be used in conjunction with dopaminergic for better results
Nx Management
- monitor for orthostatic hypotension, dyskinesias, and hallucinations
Anticholinergicsbenztropine (Cogentin) and trihexyphenidyl (Artane)
- help control tremors and rigidity
Nx Management
- monitor for anticholinergic effects (dry mouth, constipation, urinary retention)
Catechol O-methyltransferase (COMT) inhibitors entacapone (Comtan
- decrease the breakdown of levodopa, making more available to the brain as dopamine
- can be used in conjunction with dopamine agonist or dopaminergic
Nx Management
- monitor for dyskinesia/hyperkinesia
- dark urine is NORMAL finding
Antivirals amantadine (Symmetrel)
- stimulate the release of dopamine and prevent its reuptake
Nx Management
- monitor for swollen ancles and discoloration of the skin
- may experience atropine like effects
Tx: Parkinson's Disease Stereotactic pallidotomy
- the destruction of a small portion of the brain within the globus pallidus through the use of brain
- the client is assessed for decreased in tremors and muscle rigidity
Deep brain stimulation
- electrode is implanted in the thalamus, goal is to interfere with the electrical conduction with tremor cells, decreasing tremors
Nx Management
- the client will need to be instructed how to use a magnet to adjust the current
- the battery to the magnet will beed to be replaced every few years
Alzheimer's Disease (AD) A nonreversible type of dementia that progressively develops through seven stages over many years.
characterized by:
- memory loss, problems with judgment and changes in personality
Risk Factors: Alzheimer's Disease - Advanced age
- Genetic predisposition
- Environmental agents (herpes virus, metal, or toxic waste)
- Previous head injury
- Apolipoprotein E
7 Stages: Alzheimer's Disease - Stage 1: NO IMPAIRMENT
- Stage 2: Forgetfulness especially of everyday objects (eyeglasses or wallet)
- Stage 3: Mild cognitive deficits, including losing or misplacing important objects; Decreased ability to plan; SHORT-term MEMORY LOSS noticeable to close relatives; Difficulty remembering words or names; Difficulty in social or work situations.
- Stage 4: OBVIOUS MEMORY LOSS; Limited knowledge and memory of recent occasions, current events, or personal history; Difficulty performing tasks that require planning and organizing (paying bills or managing money)
7 Stages: Alzheimer's Disease - Stage 5: INABILITY TO RECALL IMPORTANT DETAILS such as address, telephone number, or schools attended, but memory of information about self and family remains intact; Disorientation and confusion as to time and place
- Stage 6: LOSS OF AWARENESS; Significant personality changes are evident (delusions, hallucinations, and compulsive behaviors); WANDERING behavior; Increased episodes of urinary and fecal incontinence
- Stage 7: Ability to respond to environment, speak, and control movement is LOST; unrecognizable speech; general urinary incontinence; inability to eat without assistance and impaired swallowing; gradual loss of all ability to move extremities (ataxia)
Dx: Alzheimer's Disease - Genetic testing presence for apolipoprotein E can determine if late onset dementia is dt AD
- There is NO definitive dx procedure
Nx Management: Alzheimer's Disease - keep client on a sleeping schedule
- use CALENDAR to assist with orientation
- be consistent and repetitive
- use therapeutic touch
- reminisce with the client about the past
- use memory techniques such as making lists and rehearsing
- stimulate the client's memory by repeating the client's last statement
- avoid over stimulation
- reality orientation (early stages)
validation therapy: acknowledge the client's feeling , don't argue; reinforce and use repetitive actions
- provide routine toileting
Medications: Alzheimer's Disease pharmacotherapeutics is based on the theory that AD is a result of depleted levels of enzyme acetyltransferase, which is necessary to produce the neurotransmitter acetylcholine
- Donepezil hydrochloride (Aricept)
- prevents the breakdown of acetylcholine (ACh), which increases the amount of ACh available.
** cholinersterase inhibitors help slow this process down
Nx Management:
- observe for frequent stools and or upset stomach
- monitor for dizziness and or headache
- caution when given to COPD
Multiple Sclerosis A chronic and progressive disease with no known cure and sx progress in severity over time
- autoimmune disease
triggers:
- viruses and infectious agents
- living in a cold climate
- emotional/ physical stress
- pregnancy
- fatigue
- overexertion
- how shower/bath
s/s: MS - pain or paresthesia
- diplopia: deceased in visual acuity
- Uhthoff's sign (temporary worsening of vision and other neurological functions commonly seen in clients with MS, or clients predisposed to MS, just after exertion or in situations where they are exposed to heat
- tinnitus, vetigo
- dysphagia
- dysarthria
- muscle spasticity
- nystagmus
- memory loss, impaired judgment
Nx Management: MS - monitor: visual acuity, speech patterns, swallowing, activity tolerance and skin integrity
- encourage fluid intake to decrease risk of UTI.
- Crede: placing manual pressure on abdomen over the bladder to expel urine
- place eye patches to tx diplopia
- exercise and stretch
Medications: MS Azathioprine (Imuran) and cyclosporine (Sandimmune)
- immunosuppressive agents are used to reduce the frequency of relapses
- Nx Management: check for sx of infections, HTN and kidney dysfunciton
Prednisone (Deltasone)
- used to reduce inflammation in acute exacerbations
- Nx Management: monitor for infection, hypervolemia, hypernatremia, hypokalemia, hyperglycemia, GI bleeding and personality changes
Antispasmodics: used for muscle spasticity
Dantrolene (Dantrium), tizanidine (Zanaflex), baclofen (LIoresal)- intrathecal used for severe MS, and diazepam (Valium)
- Nx Management: observe for increased weakness, liver damage (dantrium/baclofen); tell client to report to MD if jaundice occurs, do not stop baclofen abruptly
Amyotrophic Lateral Sclerosis (ALS) " Lou Gehrig's disease"
A degenerative neurological disorder of the upper and lower motor neurons that result in deterioration and death of the motor neurons. This results in a progressive paralysis and muscle wasting that eventually causes respiratory paralysis and death. Cognitive function is NOT usually affected
s/s: Amyotrophic Lateral Sclerosis (ALS) - twitching and cramping of muscles
- muscle weakness -> usually begins in one part of the body
- muscle atrophy
- dysphagia
- dysarthria
Dx: Amyotrophic Lateral Sclerosis (ALS) - increased creatnine kinase (CK-BB) level
- muscle biopsy:
- reduction in number of motor units of peripheral nerves and atrophic muscle fuber
Nx Management: Amyotrophic Lateral Sclerosis (ALS) - maintain patent airway and suction and/or intubate
- Keep HOB 45 deg; turn, cough, and deep breathe Q2hr; conduct incentive spirometry, CPT
- facilitate communication
- asses swallow reflex; thicken fluids PRN
- diet: high calories, high fiber and increase fluids
- utilize energy conservation
Medications: Amyotrophic Lateral Sclerosis (ALS) Riluzole (Rilutek)
- glutamate antagonists: that can slow the deterioration of motor neurons by decreasing the release of glutamic acid. Will add approximately 2 to 3 months of life to the client's overall lifespan
Nx Management: hepatotoxic risk; dizziness, vertigo and somnolence. Educate client: DO NOT drink alcohol, take meds at evenly spaced regular intervals; store meds away from bright light
- Baclofen, Dantrium, Valium (antispasmodics)
Complications: Amyotrophic Lateral Sclerosis (ALS) Pneumonia
- can be caused by respiratory muscle weakness and paralysis contributing to ineffective airway exchange
Respiratory failure dt mechanical ventilation
Guillain- Barre Syndrome (GBS) Develops in relation to acute destruction of the myelin sheath of peripheral nerves dt an autoimmune disorder that results in varying decrees of muscle weakness and paralysis
Chronic Inflammatory demyelinating polyneuropathy (CIDP) A different type of GBS that progresses over a very long period, and recovery is rare
- initial period: 1 to 4 weeks; onset of sx until neurological deterioration stops
- plateau period: several days to 2 weeks; no deterioration, and no improvement occurs
- recovery period: 4 to 6 months and up to 2 years; remylination and return of muscle strength
Etiology: UNKNOWN; a hx of recent viral event is reported by many clients
Risk Factors: Guillain- Barre Syndrome (GBS) - Epstein-Barr virus
- Cytomegalovirus
- upper respiratory infection
- Vaccination (Swine Flu vaccination)
s/s: Guillain- Barre Syndrome (GBS) - Ascending muscle weakness and paralysis
- Recovery is in descending order
- muscle flaccidity w/o muscle atrophy
- paresthesias: creeping/crawling sensations
- decreased/absent DTRs
dx: Guillain- Barre Syndrome (GBS) Electromyography (EMG)and nerve conduction velocity (NCV)
- shows evidence of denervation after 4 weeks
WBC
- leukocytosis
Lumbar Puncture
- Shows the distinguishing characteristic GBS finding of an increase in protein w/in the CSF
Nx Management: Guillain- Barre Syndrome (GBS) - Provide alphabet board if client has difficulty talking
- assess difficulty swallowing and chocking
Medications: Guillain- Barre Syndrome (GBS) Morphine
- for pain; check respiratory depression
IV IG
- given to suppress attack on immune system
- side effects: chills, fever, myalgia, renal failure
Neurontin (Gabapentin)
- neuropathic pain
- assess confusion, depression, drowsiness and ataxia
Plasmaphoresis: Guillain- Barre Syndrome (GBS) A tx where blood is removed from the body, ran through a separator, and the circulating antibodies are removed from the plasma. This decreases the attack against the myelin sheath
- assess for dizziness and hypotension
- maintain patency of the shunts
- apply pressure to the dressing
- monitor for infection
Assess lab values
- hypovolemia
- hypocalcemia
- hypokalemia
procedure can last 2-5 hrs
Myasthenia Gravis (MG) A progressive autoimmune disease that produces severe muscular weakness. Characterized by periods of exacerbation and remission. Muscle weakness improves with rest.
- it is caused by antibodies that INTERFERE with the transmission of ACETYLCHOLINE at the neuromuscular junction
Risk Factors: Myasthenia Gravis - systemic lupus
- infection
- stress
- pregnancy
dx: Myasthenia Gravis Tensilon testing:
- EDROPHONIUM CHLORIDE: is administered
- it inhibits the breakdown of acetylcholine, making it available for use at the neuromuscular junction. Positive results in marked improvement in muscle strength that lasts approx. 5 min
- Nx Management:
- observe for fasciculations around the eyes and face and cardiac arrhythmias
- have ATROPINE (antidote)
- Client Education
- discourage the client from demonstrating improvement by increasing effort, which could skew the test results
Management: Myasthenia Gravis - Provide small, frequent high-calorie meals and schedule at times when medications is peaking
- use thickener in liquids as necessary
- apply eye drop during the day and ointment at night, and may need to patch or tape eyes shut at night to prevent damage to the cornea
Medications: Myasthenia Gravis- Cholinesterase inhibitors are first line in therapy
Nx Management
- if periods of weakness is observed, might need to change prescription
- caution with clients who have hx of asthma or cardiac
Education:
- Take with FOOD
- eat within 45 min of taking th emeds to stregthen chewing and reduce the risk for aspiration
Pyridostigmine (Mestinon) and neostigmine (Prostigmin) Used to increase muscle strength in the symptomatic tx of MG. It inhibits the breakdown of acetylcholine and prolongs its effects
- Nx Management:
- assess for hx of seizures
Tx: Plasmapheresis
- monitor for hypovolemia, hypokalemia, and hypocalcemia
Thymectomy
- REMOVAL of the THYMUS gland to better control or complete remission
** highest risk for injury is dt respiratory compromise and failure
Complications: Myasthenic crisis Occurs when the client is experiencing a stressor that causes an EXACERBATION of MG, such as infection, or is taking inadequate amounts of cholinesterase inhibitors
s/s
- respiratory muscle weakness -> mechanical ventilation
- weakness, fatigue, incontinence (MG sx)
- HTN
- Temporary improvement of sx with administration of Tensilon
Complications: Cholinergic crisisOccurs when the client has taken too much cholinesterase inhibitors
- Muscle twitching to the point of respiratory muscle weakness -> mechanical ventilation
- Cholinergic sx: hypersecretions (nausea, diarrhea, respiratory secretions) and hypermotility (abdominal cramps)
- HYPOTENSION
- Tensilon has NO positive effect
- sx improve with the administraTion of anticholinergic medications such as ATROPINE
Eye exams Tonometry
Used to measure the intraocular pressure.
Normal: 10 to 21 mmHg
Snellen Chart
- given in 20 ft
Rosenbaum
- given in 14 in
** medications typically given: Antichoinergics: Isopto ATROPINE opthalmic solution
- provide mydriasis (dilation of the eyes) and cycloplegia (ciliary paralysis)
- adverse effects: blurred vision, photophobia, decreased secretions, tachycardia.
Nx Management: limit alcohol intake, keep BP and cholesterol under control, eat rich in antioxidants, annual exam for adults >40 yrs old
Hemodynamic Readings** the intravascular volume in older adult clients is often reduced; therefore, the nurse should anticipate lower hemodynamic readings, particularly if dehydration is a complication
- ELEVATED results are indicative of HF and pulmonary problems
Central Venous Pressure (CVP) 1-8 mmHg
Pulmonary Artery Systolic (PAS) 15-26 mmHg
Pulmonary Artery Diastolic (PAD) 5 - 15 mmHg
Pulmonary ARtery Wedge Pressure (PAWP) 4-12 mmHg
Cardiac Output (CO) 4-6L/min
Mixed Venous Oxygen Saturation (SvO2) 60% - 80%
Arterial/Pulmonary Artery Line Insertion - Pace the client in supine or trendelenburge position
- level transducer with phlebostatic axis (4th intercostal space, mid-axillary line)
- zero system with atmospheric pressure
- hemodynamic pressure lines must be calibrated to read atmospheric pressure as zero, and the transducer should be positioned at the right atrium
** HOB when obtaining readings should be 15-30 deg
Angiography Indications
- unstable angina
- ECG (T wave inversion, ST elevation/ depression)
- to confirm location and extent of heart disease
Procedure: Angiography Pre:
- NPO for at least 8 hrs
- assess iodine and shellfish allergy (dye feels warm and flushed)
- administer methylpredinisone and benadryl
Post
- Assess VS Q15min x4, Q30 min x2, Qh x4, and then Q4h
- assess the groin site
- maintain bedrest in supine position with extremity straight (older adult 4-6 hrs, and may be painful due to arthritis)
Client Education: Angiography - Avoid strenuous exercise
- restrict lifting (<10 lbs0
Cardiac Tamponade Can result from fluid accumulation in the pericardial sac
s/s
- hypotension
- jugular venous distention
- paradoxical pulse (variance of 10 mmHg or more in systolic BP between expiration and inspiration)
Nx Actions
- prepare the client for pericardiocentesis
** restinosis: clot reformation in the coronary artery can occur immediately or several weeks after procdure
Retroperitoneal Bleeding bleeding into retroperitoneal space
Nx Actions:
- assess for flank pain and hypotension
PICC line care - Assess Q8h
- change the tube and positive pressure Q3 days
- Use 10 mL or larger syringe to flush the line
- Cleaning the insertion port with alcohol for 3 sec and allowing it to dry completely prior to accessing it
- Obtaining blood samples: withdrawing 10 mL of blood then DISCARD; take second syringe and withdraw 10 mL of blood for sample; take third syring and flush with 10 mL N.S.;
- change transparent dressing Q7days
Phlebitis Can be chemical, bacterial or mechanical irritation
s/s:
- Erythma (early sign)
- Pain or burning at the site and the lenght of the vein
- WARMTH over the site
- vein indurated (hard), red streak, and/or cord like
Prevention
- observe site Q2h
tx
- dc infusion
- apply WARM COMPRESS
- restart with new tubing/infusate
Infiltration Is fluid leaking into surrounding subQ tissue and extravasation is unintentional infiltration
s/s
- swelling
- Edema
- COOLNESS in skin
Prevention
- DO NOT use arm with MLC or PICC
- DO NOT use hand veins in older adult clients
- DO NOT use hand veins for vesicant medications
tx:
- Remove catheter
- apply COOL COMPRESS
- DO NOT start IV at same extremity
Cardioversion Is the delivery of a synchronized, direct countershock to the heart
Defibrillation Is the delivery of an unsynchronized, direct coutnershock to the heart. It stops all electrical activity of the heart, allowing the SA node to take over and re-establish a perfusing rhythm
Procedure: Cardioversion - clients who have atrial fibrillation must receive adequate anticoagualtion prior to tx
Intra:
- must synchronize and charge the machine; failure to synchronize can lead to lethal dysrhythmia, such as vfib (defib is indicated for vfib)
Types of Pacemakers ...
External (transcutaneous) - requires large amounts of electricity
- it is used in emergency resuscitation of a client who does not have pacing wires inserted
Epicardial Pacemaker - leads are attached directly to the heart during open heart surgery
- used during and immediately following open heart surgery
Endocardial (transvenous) - pacing wires are threaded through a large central vein and lodged into the wall of the right ventricle
Permanent pacemakers - fixed rate (asynchronous): fires a constant rate
- demand mode (synchronous): detect the ehart's electrical impulses and fires at a preset rate only if the heart's intrinsic rate is below a certain level
- antidysrhythmic function: can overpace a tachydysrhythmia or deliver an electrical shock
Discharge teaching: Permanent pacemakers - batteries last 10 years
- wear sling when out of bed
- DO NOT raise the arm above the shoulder 1-2 wks
- Notify MD if the HR is < 5 beats below the pacer rate
- for clients with pace-defib: anyone touching the client when the device deliver a shock will feel a slight electrical impulse but that impulse will not harm the person
- NO contact sports 2 months
- can resume sexual activity as desired, avoid positions that put stress on the incision site.
- Household appliances should not affect the pacemaker unless held directly over generator: garage door openers, burglar alarms, microwave ovens and antitheft devices
- Will set off airport security detectors
- Inform other MDs and DMDs
- MRI and diathermy (heat therapy) is contraindicated
Angina Warning sign of an impending acute MI
- described as: TIGHT, SQUEEZING, heavy pressure, or constricting feeling in the chest. the pain can radiate to the jaw, neck, or arm.
Types of Angina- stable angina (exertional): occurs with exercise or emotional stress and is relieved by rest or nitroglycerin (Nitrostat)
- unstable angina (preinfarction angina): occurs with exercise or emotional stress, but it increases in occurrence, severity, and duration over time
- variant angina (Prinzmetal's angina): dt a coronary artery spasm, often occurring during periods of rest.
** Pain unrelieved by rest or nitroglycerin and lasting more than 15 in differentiates an MI from angina
Angina vs MI Angina
- precipated by exertion or stress
- relieved by rest or nitroglycerin
- sx last <15 min
- not associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis
MI
- con occur w/o cause, often in the morning after the rest
- relived only by opioids (MORPHINE)
- sx last > 30 min
- associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis
Lab tests - myoglobin: levels no longer evident after 24 hrs
- Creatnine kinase MB: levels n longer evident after 3 days
- Troponin I: levels NO longer evident after 7 days
- Troponin T: levels no longer evident after 14-21 days
Heart Failure/ Cardiogenic shock - injury to LEFT ventricle can lead to decreased CO and HF
- progressive HF leads to cardiogenic shock
s/s
- hypotension
- tachycardia
- altered level of consciousness
- respiratory distress (crackles/ tachypnea)
- decreased peripheral pulses
- chest pain
Heart Failure (HF) classification scale indicate how little, or how much activity it takes to make the client symptomatic
Class I: Client exhibits no sx with acivity
Class II: Client has sx with ordinary exertion
Class III: Client has sx with minimal exertion
Class IV: Client has sx at rest
s/s: Left sided heart failure - S3 gallop
- orthopnea
- oliguria
- frothy sputum
- displaced apical pulse
s/s: right sided heart failure - jugular vein distension
- ascending dependent edema
- polyuria at rest
- abdominal distension (ascites
- weight gain
- hepatomegaly and tenderness
s/s: cardiomyopathy - fatigue
- HF
- S3 gallop
- cardiomegaly
Lab tests: HF - Human B-type natriuretic peptides (hBNP): Elevated in HF; used to differentiate dyspnea rt HF vs respiratory problem
- <100 pg/mL = no HF
- 100 to 300 pg/mL = HF is present
- > 300 pg/mL = mild HF
- >600 pg/mL = moderate HF
- >900 pg/mL - severe HF
Diuretics - Loop: Lasix and Bumex
- administer Lasix no faster than 20 mg/min
- Thiazide: hydrochlorothiazide
- Potassium sparing diuretics: spironolactone (aldactone)
Afterload reducing agents - ACE inhibitors: "prils"
- Angiotensin receptor II blockers: losartan (Cozaar)
- contraindicated for clients who have renal deficiency
- monitor for HYPOTENSION
Client Education
- notify MD if sense of taste decrease
- notify MD if swelling of the face or extremities occurs
- take BP 2 hrs after initial does to detect hypotension
Inotropic agents - digoxin, duutamine, primacor
Increase the contractility and thereby improve CO
Nx considerations
- digoxin: take apical pulse for 1 min; < 60/min hold the med and notify MD
- monitor urine output
client education
- if pulse is irregular; hold meds and notify MD
- take digoxin dose same time each day
- DO NOT take digoxin with antacids; separate by 2 hrs apart
- toxicity signs: fatigue, muscle weakness, confusion, loss of appetite.
Therapeutic range: digoxin 0.8 to 2 ng/mL
Toxicity:
- decreased potassium level
- decreased apical rate < 60
- blurred vision
- dysrhythmia
- leg cramps
- anorexia
- altered metnal status
Vasodilators Nitroglycerine (Nitrostat) and isosorbide mononitrate (Imdur): prevent coronary artery vasospasms and reduce preload and afterload, decreasing myocardial O2 demand.
Nx Considerations
- caution with other antihypertensive medications
- can cause ORTHOSTATIC HYPOTENSION
Client Education
- HEADACHE is common side effects
- Encourage the client to site and lie down slowly
hBNPs nesiritide (Natrecor): used to treat acute HF by casing natriuresis (loss of sodium and vasodilation)
Nx Considerations
- can cause HYPOTENSION
- BNP levels will increased while on this med
Client Education
- client can be asymptomatic with low BP
Pulmonary Edema Nx Actions
- restrict fluid intake
- administer rapid acting diuretics (lasix/bumex), vasodilators (nitroglycerin), inotropic agents (digoxin), antihypertensive ("pril" and "olol")
Client education
- notify md if gain of more than 2lb in a day or 5 lb in a week
- diet: low sodium and fluid restriction
- report: SOB, swelling of feet or ankles, or angina
Complications ...
Acute Pulmonary edema s/s
- tachycardia
- ascending fluid level within the lungs (CRACKLES, productive cough, blood tinged sputum)
Emergency response
- position in high-Fowler's
- Administer O2, positive airway pressure, and/or intubation and mechanical ventilation
- IV morphine
- IV Lasix
** effectiveness = diuresis, reduction in respiratory distress, improved lung sounds, and adequate O2
Hypertension ...
Aneurysm 3 types
- abdominal
- aortic
- thoracic
Abdominal aneurysm s/s
- constant gnawing feeling in abdomen; flank or back pain
- pulsating abdomen
- bruit
Aortic dissections (marfan's syndrome) - sudden onset "tearing," "ripping," and "stabbing" abdominal back pain
- hypovolemic shock
Toracic aortic aneurysm- coolness and/or cyanosis or extremities
- hoarseness, SOB, and difficulty swallowing
- decreased urinary outpur
Blood transfusions - usually 20 g needle
Nx Actions
- Hgb <8 g/dL, prescribed use only with NS
- Remain with the client for the first 15-30 min of the infusion
- complete the transfusion within 2-4 hr time frame to avoid bacterial growth
- Hgb should rise by 1g/dL with each unit transfused
Indications: Blood transfusions - Hgb 6 to 10 g/dL -> whole blood cells
- with anemia, Hgb 6 to 10 g/dL -> packed RBCs
Nx Action: Blood transfusion reaction - STOP infusion
- Initiate NS infusion
- save the blood bag with the remaining blood and the blood tubing for testing at the lab
Anemia Nursing Care:
- increase folic acid, iron and B12
- teach energy conservation
Medications
- Iron supplements (administer IM Ztrack)
- hgb will be checked 4-6 weeks
- take with vit C
- take between meals
- Erythropoietin (Epoitin alfa: Epogen, Procrit)
- monitor for sudden increase of hgb >1 gm/dL in 2 weeks
- vit 12 (cyanocobalamin) necessary to convert folic acid to its active form
- do not mix with other meds
Folic acid supplements
- can cause urine dark
Absolute neutrophil count - < 2,000/mm3 increases risk of infection
- < 500/mm3 severe risk for infection
Idiopathic thrombocytopenic purpura (ITP) A coagulopathy that is an AUTOIMMUNE disorder in which the lifesapn of platelets is decreased by antiplatelet antibodies -> hemorrhage following a cesarean birth or lacerations
Nx Actions
- administer corticosteroids and immunosuppresants
- splenectomy may be performed
Risk Factors: Hypernatremia - excessive Na intake
- renal failure
- Cushing syndrome
- aldosteronism
- antidiuretic hormone
Complication: Acute hypernatremia - seizures, convulsions, death
Hypokalemia Risk Factors:
- Abnormal GI loses (vomiting)
- renal losses: excessive use of diurectics (loop/thiazides)
- prolonged admin of non electrolyte containing IV solutions (D5W)
- intracellular shift: metabolic alkalosis; during periods of TISSUE repair (burns, truama, starvation), TPN
s/s: hypokalemia - WEAK, IRREGULAR pulse
- hypotension
- respiratory distress
- hypoactive DTRs
- paresthesias, MUSCLE CRAMPING
- mental CONFUSION
- inverted T waves, ST depression
- GI: decreased motility, ileus
- polyuria
- METABOLIC ALKALOSIS
Nursing Management: hypokalemia - diet: avocados, broccoli, dairy products, dried fruit, cantaloupe, bananas
- NEVER IV BOLUS (max rate: 5 to 10 mEq/hr)
- assess for phlebitis
- Provide assistance with ADLs
Complications
- Respiratory Failure
- Cardiac Arrest
Hyperkalemia Risk Factors:
- salt substitute
- IV administration
- extracellular shift: decreased insulin (DKA), tissue catabolism
- potassium sparing diuretics
- ACE inhibitors
s/s: Hyperkalemia - SLOW, irregular pulse
- peaked T waves
- INCREASED MOTILITY (GI)
- irritability
Nursing Management: Hyperkalemia - CALCIUM GLUCONATE or CALCIUM CHLORIDE (antidote)
steps to take
- dc infusion
- hold PO potassium
- restrict diet high in potassium
- administer dextrose and regular insulin
- administer SODIUM BICARBONATE to reverse acidosis
- meds increase potasium: loop and thiazides diuretics
- KAYEXALATE, works as laxative and excretes excess potassium
Calcium- 8.5 mg/dL to 10.3 mg/dL
- 4.5 mEq/dL to 5.3 mEq/dL
Risk Factors: Hypocalcemia - Malabsorption syndromes (Corhn's)
- hypoalbuminemia
- ESKD
- hypoparathyroidism
s/s: Hypocalcemia - MUSCLE TWITCHES/ TETANY
- Chvostek's sign
- Trouseau's sign
Magnesium - 1.3 to 2.2 mg/dL
Risk factors
- malnutrion
- alcohol ingestion (magnesium excretion)
Nursing Management: Hypomagnesemia - Administer MAGNESIUM SULFATE
- can cause diarrhea
GI Lab Values ...
Aspartate (AST) - normal: 5 to 40 unit/L
** elevation occurs with HEPATITIS and CIRRHOSIS
Alanine (ALT) - normal: 8 to 20 unit/L
- normal: 3 to 35 IU/L
** elevation occurs with HEPATITIS and CIRRHOSIS
Amylase - normal: 59 to 90 IU/L
** elevation occurs with PANCREATITIS
Lipase - normal: 0 to 110 units/L
** elevation occurs with PANCREATITIS
Albumin - normal: 3.5 to 5 g/dL
** decrease may indicate HEPATIC DISEASE
Alpha-fetoprotein - normal: <40 mcg/L
** elevated LIVER CANCER
Ammonia - normal: 15 to 110 mg/dL
** elevated LIVER DISEASE
Bariatric Surgery Post procedure:
- provide 6 small meals
- observe for "dumping syndrome" s/s: tachycardia, diarrhea, dizziness, cramps and fatigue.
- first feeding may only consists of 30 mL of fluids
Client Education
- limited to puree foods for first 6 weeks
- meal size should not exceed 1 cup
- should walk daily for at least 30 min
Complication: Malabsorption
- eat 2 servings of protein
- Avoid colas and fruit juices
Nasogastric Decompression a procedure done for client's who have an intestinal obstruction. Decompression is occomplished by insertion of an NG tube with suction applied until obstruction is relieved
Indications
- paralytic ileus
- cockily abdominal pain and distension
- hiccups
Complication: strangulated obstruction/ intestinal infarction
- occurs when a portion of the intestine is twisted or the blood supply is compromised
- monitor: increase pain, abdominal rigidity, fever, hypotension, tachycardia
Ostomies - ileostomy: at the ileum
- colostomy: large intestine
Postprocedure
- apply skin barriers and creams, such as stoma adhesive paste; let it dry before applying appliance
- empty the bag when it is 1/4 to 1/2 full
Client Education
- Food causes odor: fish, eggs, asparagus, garlic, beans and dark green leafy vegetables
- food causes gas: dark green leafy vegetables, dairy products, corn. YOGURT can decrease gas
- diet: high fiber foods first 2 mos after surgery, chew food well, drink plenty of fluids and evaluate for any evidence of blockage
Complications: Ostomies - normal ostomy appearance: PINK, RED, and MOIST
- signs of stomal ischemia: pale pink, or bluish purple in color and dry in appearance
Intestinal Obstruction
- s/s: abdominal pain, hypoactive or absent bowel sounds, distention, n/v
TPN - hypertonic IV bolus solution; purpose is to prevent or correct nutritional deficiencies and minimize the adverse effects of malnourishment
- contains: 20% to 50% dextrose, lipids, protein, electrolytes, vitamins, and trace elements
When to initiate TPN
- A weight loss of 7% body weight and NPO for 5 days or more
- hypermetabolic state
TPN Guidelines of Care - NEVER abruptly STOP. Speeding up/slowing down the rate is contraindicated
- monitor VS Q4-8h
- change tubing and bag Q24h
- A filter is used on the IV bolus line
- DO NOT use the line for other IV bolus solutions
- DO NOT add anything to the solution
- check capillary glucose Q4-6h at least first 24 hrs
- Need supplemental Regular insulin
- Keep 10% dextrose at bedside, this will minimize the risk for hypoglycemia
- Older clients have increased incidence of glucose intolerance
Complications: TPN metabolic
- hyperglycemia, hypoglycemia, and vit deficiencies
Air Embolism
- a pressure during tubing changes can lead to an air embolism
- s/s: onset of dyspnea, ches, pain and hypoxia
- tx: clamp the catheter and place the client in a TRENDELENBURG position and on the LEFT SIDE to trap air. Administer O2, notify MD
Infection
- glucose is a medium for bacteria
- check sterile dressing Q72h
- DO NOT use TPN line for other IV bolus fluids and medications
Esophagogastric Balloon Tamponade An esophagogastric tube with esophageal and gastric balloons is used to compress blood vessels in the esophagus and stomach. For clients who have esophageal varices
- check balloons for leaks prior to insertion
- traction is applied after balloons are inflated to desired pressure
- when bleeding is stopped, traction is released and the pressure in the balloons is reduced gradually
- done for clients who have unsuccessful transjugular intrahepatic portal system shunts (TIPS )
Nx Actions
- irrigate tube, color: CLEAR
-
Esophageal Cancer dx:
- Barium swallow, Esophageal ultrasound
- Esophagogastrodueodenoscopy (EGD); CT
tx
- chemo often with radiation
- photodynamic therapy (PDT)
- treat chest pain; treat n/v
- AVOID exposure to sunlight
- consume liquid diet unti pain is gone
Surgical Intervention: Esophageal Cancer - Esophagectomy/ esophagogastrostomy
- increase risk of pulmonary complications
- maintain NG tube patency; DO NOT replace NG tube if it comes out
- DO NOT manipulate or irrigate NG tube unless prescribed by the provider
- NPO until anastomosis is confirmed via barium swallow
- monitor for anastamosis leak: fever, saliva, seeping through skin
Client Education: Esophageal Cancer - diet: progress diet beginning with thick liquids and moving to semisolid and well-chewed solid foods
- monitor for abnormal drainage (saliva)
Complications: Esophageal Cancer Vagotomy Syndrome
- causes: dt interruption of the vagal nerve, similar to "dumping syndrome." Related to the quick passage of food into the duodenum, which creates an osmotic gradient with large amounts of fluid entering the bowel and manifesting itself as WATERY DIARRHEA. Occurs 15 to 60 min after a meal.
Nx Action
- observe for: diaphoresis, diarrhea, abdominal pain
- diet: 6 meals/day LACTOSE FREE
Peptic Ulcer Disease (PUD) An erosion of the mucosal lining of the stomach or duodenum. The eroded epithelium is exposed to gastric acid and pepsin and can precipitate bleeding and perforation.
Risk Factors
- H. PYLORI
- NSAIDs and corticosteroid use
- Type O blood
- Excess alcohol ingestion
- Zollinger-Ellison syndrome (combination of peptic ulcers, HTN of gastric acid, and gastrin secreting tumors)
s/s: Peptic Ulcer Disease (PUD) - dyspepsia (heartburn, n/v, bloating)
- epigastric pain upon palpation
- bloody emesis (hematemesis or stools (melena)
- weight loss
sign for perforation:
- RIGID abdomen, rebound tenderness
- tachycardia, pain in RIGHT SHOULDER
Gastric ulcer
- 30 to 60 min after a meal
- rarely occurs at night
- pain exacerbated by ingestion of food
Duodenal ulcer
- 1.5 to 3 hours after meal
- often occurs at NIGHT
- pain may be relieved by ingestion of food or antacid
H. pylori testing - EGD is difinitive dx
- collected via endoscopy
- C 13 urea breath testing: client exhales in the collection container (baseline), drinks carbon enriched urea solution, and is asked to exhaled into a collection container. NPO prior to test. If H. pylori is present, CARBON DIOXIDE will be release. 2 collections are compared to confirm
- stool samples
Nx Management: PUD Medications
- Flagyl, amoxicillin, bismuth, clarithromycin, tetracyline
Client Education
- Histamine receptor antagonists: Zantac, Pepcid
- use with antibiotics
- used to prevent stress to individuals who are NPO after major surgery, have large burns, septic and ICP
- proton pump inhibitors: Protoniz, Nexium, Prilosec
- inhibits the enzyme that produces gastric acid
- DO NOT crush, chew or break sustained-release
- Take Prilosec 1x/day prior to eating in am
Antacids: Aluminum carbonate, magnesium hydroxide (milk of magnesia)
- given 1-3 hours after meals
- give 1 hr apart after other meds
Mucosal protectant
Pernicious Anemia - dt loss of intrinsic factor; decreased in RBC that occurs when the body cannot absorb vit 12in the GI tract. vit 12 is necessary for RBC development
s/s:
- pallor, glossitis, fatigue, and paresthesias
Client Education
- routine life long B12 injections will be necessary
Dumping Syndrome In response to the sudden influx of hypertonic fluid, the small intestine pulls fluid form the extracellular space to convert the hypertonic fluid to an isotonic fluid.
Early sx:
- w/in 30 min after eating
- n/v, dizziness
- tachycardia, palpitation
Later sx
- 90 min to 3 hr after eating
- hunger and sweating
- shakiness and feelings of anxiety
- confusion
tx: administration of PECTIN: slows the absorption of carbohydrates. OCTREOTIDE: blocks gastric and pancreatic hormones
Client Education: Dumping Syndrome - Lay down after a meal
- Limite amount of fluid ingested at one time
- Eliminate liquids with meals for 1 hr prior to an following a meal
- Diet: high-protein, high-fat, low-fiber, and low to moderate carbohydrate diet
- VOID milk, sweets, or sugars
- small frequent meals
GI Medications ...
Histamine antagonist - nizatidine (Axid)
- famotidine (Pepcid)
- ranitidine (Zantac)
Nx Intervention
- monitor for neutropenia and hypotension
- administer SLOWY, or it will cause bradycardia and hypotension
Client Education
- DO NOT smoke or drink alcohol
- take with FOOD
Antacids - Aluminum hydroxide (Amphojel)
- Magnesium hydroxide (Mallox, Mylanta)
- MIlk of Magnesia
Nx Intervetion
- DO NOT give to those with RENAL FAILURE
- monitor for aluminum toxicity, and constipation. Magnesium antacids for diarrhea or hypermagnesemia
Client Education
- Take in EMPTY STOMACH
- have to WAIT 1-2 hrs to take other meds
Proton pump inhibitors - Omeprazole (Prilosec)
- Lonsaprazone (Prevacid )
- Rebeprazole (Aciphex)
- Protanprazole (Protonix)
- Ensomepraxone (Nixium)
Nx Intervention
- can cause n/v, and abdominal pain
Client Education
- Allow 30 min before eating
- it takes 4 days to see effects
- TAKE on an EMPTY stomach
Prostaglandins - Misoprostol (Cytotec)
Nx Intervention
- Can be taken with NSAIDs
- may cause abdominal pain and diarrhea
Client Education
- use contraceptives
- DO NOT take if PREGNANT
- TAKE with FOOD
Ulcerative Colitis s/s
- pain left-lower quadrant
- anorexia and weight loss
- fever
- diarrhea 15-20 liquid stools/day
- high pitched bowel sounds
- abdominal distension, tenderness, firmness upon palpitation
Crohn's disease s/s:
- pain right-lower quadrant
- fever
- diarrhea (5 stools/day with mucous or pus)
- Steatorrhea
- high pitched bowel sounds
Labs
- elevated ESR and WBC (inflammation); decreased Hct (blood loss), decreased folic acid and albumin (malabsorption)
Diverticulitis s/s:
- pain left-lower quadrant
- n/v
- fever
- chills
- tachycardia
dx: Inflammatory bowel diseases - xray, CT
- Barium enema: used to diagnose Ulcerative Colitis. Contraindicated for Diverticulitis
Nx Management: UC and Crohn's - diet: high protein and calories and LOW in FIBER
- AVOID caffeine and alcohol
- take multivitamins with IRON
- need vit 12 injections
- identify trigger foods
Nx Management: Diverticulitis - diet: limited to clear liquids initially -> high fiber -> low fat diet
Toxic Megacolon Occurs dt inactivity of the colon. Massive dilation of the colon occurs and the client is at risk for perforation
Irritable Bowel Syndrome (IBS) Differs from UC and Crohn's bc it DOES NOT cause structural damage to the GI tract and does not involve an inflammatory process. It DOES NOT predisposes the client to CANCER.
Health Promotion
- AVOID food that contains DAIRY, EGGS, and WHEAT products
- AVOID alcoholic and caffeinated beverages
- Encourage 2-3 L/fluid per day
- Increase the amount of daily fiber
Risk Factors
- FEMALE
- stress
- eating large meals containing a large amount of fat
- Caffeine
- Alcohol
s/s" IBS - cramping pain in abdomen
- nausea with meals or passing stools
- abdominal bloating
- BLETCHING
- diarrhea
- constipation
Medications: IBS Alosetron (Lotronex): blocks 5-HT4 receptors that innervate the viscera and result in increased firmness in stools, and decrease the urgency and frequency of defecation
Nx Considerations
- sx should resolve w/in 1-4 weeks but will return 1 week after medications
Lubiproston (Amitiza) is an IBS specific medication that increases fluid secretion in the intestine to promote intestinal motility.
Nx Consideration
- contraindiated with hx of bowel obstruction, Crohn's disease, UC or diverticulitis
- take with FOOD
Cholecystitis s/s
- sharp pain in the RIGHT UPPER quadrant of the abdomen
- pain with deep inspiration during right subcostal palapation (Murphy's sign)
- rebound tenderness
- dyspepsia
- fever
- steatorrhea
- dark urine
- pruritus (accumulation of bile salts in the skin)
Labs
- WBC elevated
- Amylase and lipase (pancreatic involvement)
- elevated AST and ALT (liver involvement)
- >200 mg/dL serum cholesterol
T tube placement indicated for open cholecystectomy
Care
- clamp 1 to 2 hr before and after meals
- avoid heavy lifting and strenuous activity 4-6 weeks post-op
- empty drainage bag Q8h
- take shower rather than baths
- left on for 1-2 weeks post-op
- color of stool should return to brown after a week
gas forming foods - broccoli
- cabbage
- beans
- cauliflower
Pancreatitis Location: knife-like pain (left upper quadrant, mid epigastric radiating to the back)
Risk Factors
- alcoholism
- bilary tract disease
- ERCP
Triggers
- fat and alcohol consumption
s/s
- not relieved by vomiting
- pain is worse when lying down or while eating
- Ecchymoses on the flanks (Turner's sign)
- bluish periumbilical discoloration (Cullen's sign)
** most at risk for:
- generalized jaundice, paralytic ileus, hyperglycema
- tetany: trousseau's sing, Chvostek's sign dt hypocalcemia (greatest risk = cardiac dysrythmias)
- peritonitis: abdominal pain radiating to the shoulder and the abdomen is rigid
Lab tests: - elevated amylase (normal: 59 -90 ui/L) for 2 wks
- elevated lipase (normal: 0-110 ui/L)
** the enzyme rise must be significant 2-3x, but does not directly correlate the severity
- elevated WBC (5,000 -10,000) dt infection
- serum glucose increased (60-110) dt decreased production of insulin from the pancreas
Hepatitis s/s:
- low grade fever
- jaundice
- dark urine
- upper right quadrant pain
labs
- ELISA: confirms the presence of antibodies to hep C
- elevated AST (normal: 8 to 20 u/L or 3 to 35 ui/L)
- elevated ALT (normal: 5-40 u/L)
- elevated ALPL (normal: 42 to 128 u/L; 30-85 ui/L)
- total bilirubin: elevated (normal: 0.1 to 1 mg/dL)
Nx Management: Hepatitis - gloves and gown is worn
- universal precaution
- limit activity
- diet: high carbohydrate, high calorie, low to moderate fat, low to moderate protein, ad small frequent meals to promote nutrition and healing
- Administer interferon for HBV and HCV
Complication: Hepatitis Portal systemic encaphalopathy (PSE)
- the liver is unable to convert ammonia and other waste products to a less toxic form. These products are carried to the brain and cause neurological sx.
Nx Action
- Administer LACTULOSE: reduces the ammonia levels in the body via intestinal excretion
- report asterixis (flapping of the hands) and fetor hepaticus (liver breath)
- diet: protein restricted or ONLY vegetable diet
Procedure: Hemodialysis Shunts the client's blood from the body through a dialyzer and back into circulation.
Preprocedure
- assess site patency (presence of bruit, thrill, distal pulses and circulation)
- meds that lower blood pressure are usually held until after dialysis
- instruct client to notify nurse if muscle cramps, h/s, nausea, dizziness that occur during the procedure
Intraprocedure
- administer anticoagulants as prescribed; have PROTAMINE SULFATE antidote for heparin
Postoperative
- ass for bleeding and/or infection
- Teach the client to AVOID: lifting heavy object with the access site arm, carrying objects that compress the extremity, sleeping on top of the extremity with the access device, perform hand exercises that promote fistula maturation.
- notify MD if bleeding persists 30 min
Complications: Hemodialysis Clotting/infection of access site
Disequilibrium syndrom
- caused by too rapid decrease of BUN and circulating fluid volume -> cerebral edema and ICP
s/s: loss of consciousness, seizures, agitation
Anemia
- blood loss and removal of folate during dialysis
- increase food in folate
Infectious diseases
- increase risk for HIV and HBV and HCV
Procedure: Peritoneal Dialysis Involves instillation of fluid into the peritoneal cavity. The peritoneum serves as the filtration membrane
Preprocedure:
- The client feel fullness when the dialysate is dwelling
Intraprocedure:
- monitor the color (clear, light yellow is expected) and amount (expected to equal or exceed amount of dialysate inflow) of outflow
- monitor for serum glucose level
- warm the dialysate prior to instilling; DO NOT use microwaves
- maintain surgical asepsis
- keep outflow bag lower than the client's abdomen
- reposition the client if inflow or outflow is inadequate
- milk peritoneal dialysis if fibrin clot has formed
Complications: Peritoneal Dialysis Peritonitis
Infection at access site
Protein Loss
- may remove needed protein from the blood as well as excess fluid, wastes, and electrolytes
- increase protein intake
- monitor serum albumin level
Hyperglycemia
- can result dt hyperosmolarity of the dialysate; glucose may be absorbed from the dialysate into the blood, hyperlipidemia may also occur
- administer insulin
Poor dialysate inflow or out flow
- rotate catheter
- reposition the client
- milk the tubing to break up fibrin clot
- tell the client to avoid constipation by using stool softeners and consuming diet high in fiber
Nephrotic Syndrome characterized by:
- proteinuria
- hypoalbuminemia
- edema
Acute Renal Failure (ARF) - Onset: begins with the onset of the event and lasts for hours to days
- Oliguria: begins with the renal insult and lasts for 1 to 3 weeks
- Diuresis: begins with the kidneys start to recover and can last for 2 to 6 weeks
- Recovery: continues until renal function is fully restored and can take up to 12 months
Chronic Renal Failure (CRF) is progressive, irreversible kidney disease
- Stage 1: minimal damage with normal GFR
- Stage 2: mild kidney damage with mildly decreased GFR
- Stage 3: moderate kidney damage with moderate decreased in GFR
- Stage 4: severe kidney damage with sever decrease in GFR
- Stage 5: Kidney failure; ESRD
Nx Management: CRF and ARF - abnormal findings
- weight gain 1kg daily = 1 L of fluids
- diet: high carbohydrates and moderate in fate
- prepare for hemodialysis, pertitoneal dialysis and hemofiltration
- provide skin care
for ARF
- find out the underlying cause
- used diuretics
for CRF
- restrict eletrolytes Na, K (Sodium Kayexalate for elimination of K), P, Mg
UTI Nx Management:
- increase fluid to 3L daily
- Encourage to urinate 3-4x
Medications
- if sulfonamides (bactrim or septra); make sure client is not allergic to sulfa
- advise to urinate before/after intercourse
- avoid bubble baths, bathroom products or toilet paper containing perfume
- avoid wearing pantyhose with slacks or tight clothing
Pyelonephritis - cause: E coli
Risk Factors
- 65 years or greater (women)
- older men with prostate cancer
- spinal cord injury
- bladder tumors
- DM, HTN, chronic cystitis
- pregnancy
s/s:
- cockily abdominal pain
- burning, urgency, and frequency in urination
- fever, flank and back pain
- nucturia
lab test
- Dark, cloudy appearance with foul odor
- positive leukocyte esterase
- positive nitrate
Medications: Pyelonephritis -opioid analgesics
- NSAIDs
- antibiotics: nitrofurantoin (Macrodantin)
- notify MD if persistent cough start
- may turn urine BROWN
Renal Calculi - "urolithias" is the presence of calculi (stones) in the urinary tract.
Risk Factors
- more in MALES
- dehydration
- increased uric production
s/s
- severe pain: intensifies as stone moves through the ureter, FLANK pain suggest stones are located in the kidney
- fever
- oliguria
- hematuria
- diaphoresis, pallor, n/v, tachycardia/pnea
Medications Spasmolytic drugs: Oxybtrynin chloride (Ditropan)
- ask if there is a hx of glaucoma
- monitor for urinary retention/ dizziness and dry mouth common
** Thiazides tx for Calcium phospahte calculi
** Captopril tx for Crytine
** Allopurinol tx for Calcium oxalate and uric acid
** Vit B6 (pyridoxine) tx for Calcium oxate
Tx: Renal Calculi Extracorpeoreal shock wave lithotripsy (ESWL)
- uses sound, laser, or shock wave energies to break the stone into fragments
Nx Action
- Asess gross hematuria
- strain urine following the procedure
- inform the client that bruising is normal at the site where waves are applied and hematuria may be present post-procedure
Client Education: Renal Calculi Educate the client regarding the role of diet and medications in tx ad prevention of urinary stones
- Diet: LIMIT intake of food high in ANIMAL PROTEIN, SODIUM, CALCIUM.
- Thiazide diuretics: are used to increase calcium reabsorption
- Orthophosphates: used to decreased during saturation of calcium oxalate
- Calcium Oxalate food: AVOID Spinach, black tea, rhubarb, cocoa, beets, pecans, peanuts, okra, chocolate, wheat germ, lime peel, and swiss chard
Uric Acid (urate): decrease intake of purine sources:
- AVOID: organ meats, poultry, fish, gravites, red wine, sardines
- Struvite (magnesium ammonium phosphate): AVOID dairy products, red and organ meats, whole grains
- Sodium cellulose phosphate: is used to reduce intestinal absorption of calcium
- Crystine: LIMIT ANIMAL PROTEIN intake
- Captropril (Capoten) is used to lower urine cystine
Types of Voiding Disorders - Stress: the loss of small amounts of urine when laughing, sneezing, or lifting. it is primarily related to WEAK pelvic muscles, urethra, or surrounding tissues
- urge: The inability to stop urine flow long enough to reach the bathroom. related to OVERACTIVE detrusor muscle with increased bladder pressure
- overflow: urinary retention associated with bladder OVERDISTENTION and frequent loss of small amounts of urine. Related to OBSTRUCTION of urinary outlet or an impaired detrusor muscle
- Relfex: the involuntary loss of moderate amount of urine usually w/o warning. related to HYPERREFLEXIA of the detrusor muscle, usually form SPINAL CORD activity
- Functional: the inability to make it to the bathroom to urinate. Related to PHYSICAL, COGNITIVE and SOCIAL impairment
- Total incontinence: The unpredictable, involuntary loss of urine that does not generally respond to tx
Nx Management: Voiding Disorder - Establish a toileting schedule
- remove or control barriers to toileting
- apply and monitor electrical stimulation of the pelvic floor muscles
- apply external or condom catheter to males
- avoid indwelling catheter
Teach Clients
- to keep an incontinence diary
- Kegel exercises (tighten in 10 and slowly release)
- avoid caffeine and alcohol consumption
- vaginal cone therapy to strengthen pelvic muscles
Medications: Voiding Disorder Antispasmodics
- Oxybutyinin (Ditropan)
- assess for intraocular pressure
- Phenaxopyridine (Pyridium)
- used for UTI
- urine will turn ORANGE
- monitor for decreased hct and hgl
- take with food
- notify MD if SKIN turns YELLOW
Client Teaching: Voiding Disorder - drink at least 2-3 L/ day
- instruct the client to try and hold urine, and stay in schedule with bladder training
- Drink CRANBERRY JUICE
Complications: Voiding Disorder- skin breakdown rt chronic exposure to urine
- social isolation rt chronic wetting
Syphillis Testing - Venereal disease research laboratory (VDSL)
- Rapid plasma regain (RPR)
** if both test confirms (reactive) syphillis, additional tests is required
- Flourescent treponemal antibody absorbed (FTA-ABS)
- Treponema pallidum partical agglutination assay (TPPA)
Mammography - should be done 1-2 years beginning at age 40; if family hx indicates risk should be done at an earlier age
** if suspicious lesion is identified it is followed up by a fine needle aspiration or open biopsy
Preprocedure
- AVOID the use of deodorant or powers in the axillary region or on the breast prior to the exam
- CONTRAINDICATED for PREGNANT women
Hormone Replacement Therapy FSH level is indicated to check dx menopause
contraindication
- smoking, hx of cancer, hx of thrombosis
Nx Actions
- DO NOT smoke
- prevent thrombosis
- avoid wearing knee high stockings
- avoid sitting for long periods of time
- take short works
- report sx of unilateral pain, edema, warmth
- TAKE with FOOD to prevent nausea
Alternative therapy
- Dong quai and black cohosh
- phytoestrogen: dandelion greens, alfafa sprouts, black beans and soy beans
- vit E to help decreased hot flashes
Beneficial in prevention of
- osteoporosis
- atrophic vaginitis
Cystocele Is a protrusion of the posterior ladder through the posterior vaginal wall. It is caused by weakened pelvic muscles and/or structures
s/s
- frequent UTI
Rectocele Is a protrusion of the anterior rectal wall through the posterior vaginal wall. It is caused by a defect of the pelvic structures a difficult delivery, or forceps delivery.
s/s
- pushing feces out of the vagina
- bleeding during urination
- pain during sexual intercourse
Breast Cancer Risk Factors
- age > 40
- genetics
- excessive alcohol intake
- smoking
- HRT
s/s
- breast pain or soreness
- skin change (peau d' orange)
- dimpling
- nipple retraction or ulceration
- enlarged lymph nodes
labs
- BRCA1 and BRAC2 gene test -> cannot be done within 3 months of blood transfusion
- HER2 gence cell -> bx determines gene
- biopsy is DEFINITIVE
Total Mastectomy Post-op care
- Avoid placing her arm in a dependent arm position, this will interfere in healing
- Encourage arm and hand exercises to prevent lymphadema and regain full ROM
- DO NOT wear constrictive clothing
Cervical Cancer Risk Factors
- early sexual activity (< 18 years old)
- multiple partners
- family hx of cervical cancer
- AFRICAN AMERICAN
- HPV
- HIV
- cigarette smoking
- intrauterine exposure to diethylstilbestrol during pregnancy
s/s
- painless vaginal bleeding between periods
-water, blood tinged vaginal discharge
- weight loss
- pelvic pain
dx
- Cervical bx is DEFINITIVE
Testicular Cancer - ages 15 to 35
- testicular self examination should begin at age 15
Risk Factors
- cryptorchidism (undescended testes)
- lumps or swelling of the testes
Labs
- elevated alpha-fetoprotein and hCG
Transurethral resection of the prostrate (TURP) indications: Benign prostate hypertrophy (BPH)
- It is performed using a resctoscope that is inserted through the urethra and trims away excess prostate tissue, enlarging the passageway of the urethra through the prostate gland
Post-op care
- placement of a 3way indwelling catheter
- this allows for instillation of a continuous bladder irrigation (CBI) of NS to keep catheter free of obstruction; the rate is adjusted to keep the irrigation return pink or lighter. ** if catheter is obstructed: turn off the CBI and irrigate with 50 mL of solution using a large piston syringe, if obstruction is not alleviated contact MD.
- The color of urine should progress toward amber 2-3 days.
- expected output is 150-200 mL every 3-4 hrs. Contact MD if unable to void
Client Teaching
- AVOID strenuous work and intercourse 2-6 weeks
- drink 12 or more 8 oz glasses of water each day
- AVOID caffeine and alcohol
- if urine become bloody: stop activity, rest and increase fluids
Testicular Self Examination - Examine testicles after a shower
- Roll testes between thumb and fingers, in front of mirror
- report any changes in size, shape, or consistency
Amputations - Disarticulation: describes an amputaion performed through a joint
Post-op care
- palpate redisual limb for warmth. heat may indicate infection
- differentiate between phantom limb (tx beta blockers: propranolol and antiepileptics: neurontin) and incisional limb pain
Client's perception and feelings about amputation
- allow the client/family to grieve for the loss
- feelings: depression, anger, withdrawal and grief
- rehab should include adaptation to new body image and integration of prosthetic and adaptive devices into self image
Residual limb prep and prosthetic fittingResidual limb must be shaped and shrunk in preparation for prosthetic training
Shrinkage interventions:
- Wrapping the stump, using ace bandages (figure 8) to prevent restriction of blood flow
- utilizing stump shrinker sock
- using an air splint (plastic inflatable devise) inflated to 20-22 mm Hg for 22-24 hr/day
Phantom Limb Pain Is a sensation of pain in the location of the extremity following the amputation. This is related to servered nerve pathways and is frequent complications in clients who experience chronic limb pain before the amputation. It occurs less frequently following traumatic amputation. Tends to lessen with time but some client experience pain or sensation indefinitely.
Nx consideration
- recognize the pain is real and manage accordingly
- described as deep and buring, cramping, shooting or aching.
Flexion contractures Can occur in the hip or knee joint following amputation dt improper positioning
Nx Actions
- Prevention: ROM exercises and proper positioning
- AVOID elevating the stump on a pillow after the first 24 hrs
- Have the client lie prone several times a day
- DO NOT sit for a long time
Osteoporosis Occurs when the rate of bone resorption (osteoclast cells) exceeds the rate of bone formation (osteoblast cells) resulting in fragile bone tissue and subsequent fractures.
health promotion and disease prevention
- increase calcium and vit D
- expose skin to sun 5-30 min 2x a week
- discuss pros and cons of HRT postmenopause
- engage in weight bearing exercise
Risk Factors
- Female, age > 60; and male, age > 75
- secondary result from: hyperparathyroidism, long term corticosteroid use (asthma and lupus)
- thin frame
s/s: osteoporosis - reduced height
- acute pain after lifting and bending
- kyphosis
- pain upon palpation over affected area
- restriction in movement
dx: osteoporosis - radiographs reveal LOW density
- DEXA; used to screen early changes in bone density
- Quantitative ultrasound (QUS) usually of the heel, is inexpensive, portable and low risk method to determine osteoporosis and assessing for risk of fracture.
Nx Management: osteoporosis - calcium supplement (take with FOOD)
- increase calcium, protein, magnesium, and vit K needed for bone formation
- need for vit D
- weight bearing exercise
- asses environment for safety
reinforce use of safety equipment and assistive devices
- AVOID inclement weather (ice, slippery surfaces)
- clearly mark thresholds doorways and steps
Medications: - HRT: replaces estrogen lost dt menopause
- increase risk for DVT and breast cancer
- Calcium supplement
- give with food and with water
- may cause GI upset
- monitor for kidney stones
Vit D supplement
- toxicity can occur: nausea, constipation, kidney stones
Thyroid hormone: calcitonin (Miacalcin)
- can be given IM/subQ or nasally; use alternate nostrils
Types of fractures - simple: has one fracture line
- complete: goes through the entire bone, dividing it into 2 parts.
- incomplete: goes through part of the bone
- commuted: bone is fragmented
- impacted: bone is wedged inside the opposite fractured fragment
- greenstick: fracture that occurs on one side (cortex), but does not extend completely through he bone. Occurs most often in CHILDREN
displace: has bone fragment that are not in alignment
s/s: Fractures - crepitus
- deformity
- muscle spasms
- edema
- ecchymosis
Nx Management: Fractures - Place the client in supine position
- stabilize injured area
- provide RICE: raise, ice, compress, elevate
- remove clothing and jewelry near injury
Types of Casts Spica cast: used on children with congenital hip dysplasia; referred to a portion of the trunk and 1 or 2 extremities.
body cast: encircle the trunk of the body
** cast materials:
- Plaster of Paris: it is HEAVY, NOT water resistance, dry time 24-48 hrs
- Synthetic fiberglass casts: LIGHT, WATERPROOF, dry time 30 min
Cast Care: Mole skin: is used over any rough area of the cast that may rub against the client's skin
Nx Actions
- web roll is applied prior to cast application
- use gloves to touch the cast until its completely dry
- elevate cast above the level of the heart 1st 24 hours
- if any drainage is seen on the cast, it should be outlined, dated, and timed
Client Education
- DO NOT place any foreign objects under the casts
- itching can be relieved by blowing COOL air from a hair dryer
- Plastic covering over the cast can be used to avoid soiling form urine or feces
- use plastic to cover while showers and baths
Types Traction - skin tractions: the pulling force is applied by weights that are attached by rope to the client with tape, straps, boots, or cuffs
- Ching halter straps,
- Bryant's traction (congenital hip dislocation in children),
- Buck's traction (used for hip fractures)
- manual: a pulling force is applied by the hands of the provider for temporary immobilization, usually with sedation or anesthesia
- skeletal: the pulling force is applied directly to the bone. weights up to 25 lbs can be applied
- Halo and Gardner-Wells: cervical injuries
- halo screws: are placed through a halo type bar that encircles the head. Assure that the wrench to release the rods is attached to the vest in case of need for CPR
Nx Management: Traction - Avoid lifting or removing weights
- assure weights hang freely
- If weights are displaced, replace the weights, notify if not resolved
- assure that pulley ropes are free of knots
- Notify MD if client has severe pain.
- move client as a unit, when in a halo traction w/o applying pressure to the rod -> prevention of loosening pins
Fat Embolism Usually occurs 48 hrs following LONG bone fractures.
manifestation
- decreased mental acuity
- respiratory distress
- tachycardia/pnea
- fever
- cutaneous petechia
Nx Action
- PREVENTION: immobilization of fractures of the long bones and minimal manipulation during turning
- tx: O2, corticosteroids for cerebral edema, vasopressors, and fluid replacement for shock
DVT Nx Actions
- administer anticoagulants
- encourage fluid intake
- rotate feet and ankles and perform other lower extremity exercises
Osteomylitis An inflammation within the bone secondary to penetration by infectious organisms
s/s:
- bone pain that is worse with movement
- erythma and edema at the site of infection
- fever
- leukocytosis, elevated ESR
dx: biopsy is DEFINITIVE
tx: 3 months of abx, hyperbaric oxygen tx (100% O2 with increase in atmospheric pressure)
Osteoarthritis Characterized by progressive deterioration of the articular cartilage. It is a NONINFLAMMATORY (unless localized), non systemic.
Risk Factors:
- Obesity
- FEMALE
- Age: >55 years old
- hx or repetitive stress on joints
s/s
- joint pain and stiffness RESOLVES with REST or INACTIVITY
- Crepitus in one or more of the affected joints
- Heberden's nodes enlarged (at DIP joints)
- Bouchard's nodes enlarged (PIP joints)
Labs: Osteoarthritis - elevated ESR (but not an indicator) and C-reactive protein
- radiographs and CT scan shows decreased joint space and bone spurs
Nx Management: Osteoarthritis - balance rest with activity
- encourage the use of CAM, tai chi, hypnosis magnets, music therapy and acupuncture.
- splint joints
- use assistive devices to promote safety and independence
Medications: Osteoarthritis Topical Analgesics:
- Trolamine salicylate (Aspercreme)
- contains salicylate
- Capsaicin (Axsain, Capsin)
- made from alkaloid that is derived from hot peppers.
- wear gloves during applications
- burning sensation on skin after application is normal and should subside
- apply 4x/day
Cartilage rebuilding
- Glucosamine: naturally occuring chemical involved in the make up of cartilage.
tx:Osteoarthritis - transcutaneous electrical nerve stimulation (TENS)
- conservative therapy: balances rests and activity
- total joint arthrosplasty
Psoriasis Risk Factors:
- genetics
- stress
- seasons
- hormones
s/s:
- SCALY patches
- bleeding stimulated by removal of scales
- skin lesions primarily on the scalp, elbows, knees and genetitals
Medications: Psoriasis topical glucocosteroids: Kenalog
- apply avoid use on the face or in skin folds, and take periodic medication vacations
Tar preparations: Coal Tar
- repress cell divisions and decreases inflmmation and itching, may stain skin and hair
- dt odor and staining, should apply at NIGHT and cover areas of body with old pajamas, gloves and socks
Topical epidermopoiesis suppressive medications: Calcipoteriene and tazarotene
- NOT recommended for OLDER ADULTS
- side effects; hypercalcemia: muscle weakness, fatigue and anorexia
- DO not put on face or skin folds
- burning and stinging can occur when applied
- use sunscreen
Cytotoxic: Methotrexate
- monitor for bone marrow suppression
- avoid alcohol
tx: Psoriasis Psoralen (photosensitizing medications) and ultraviolet light (PUVA)
- Psoralen is given 2 hours before light tx ** to enhance photosentitivity
- given 2-3x/wk, avoid consecutive days
- wear eye protection, notify MD of extreme
redness, swelling and discomfort
Oil or coal tar baths
- done on regular basis
- ad oil/tar to water and remove scales using soft brush after soaking followed by acid base emollient
Seborrheic Dermatitis health promotion/ disease prevention
- Keep SKIN DRY, avoid OVERHEATING and PERSPIRING
- DO NOT scratch pruritic lesions
Risk Factors:
- genetics
- stress
- hormones
- Older adults = seborrheic keratoses -> more plaque like in appearance
s/s
- pruritic lesions
- WAXY or FLAKY appearance
- lesions scalp, forehead, nose, axilla, groin
- seborrheic keratoses lesions may be pigmented tan, brown, or black
Medications: Seborrheic Dermatitis Topica corticosteroids
- avoid getting meds in the eyes
- apply an occlusive dressing after application
- wear gloves after application for lesions on hands
- avoid using the medication in the skin fold
antiseborrheic shampoos
- selenium sulfide, sulfur, or salicylic alcid
- used 3x/week
- leave in 3-5 min
Stages of Pressure Ulcer- Stage 1: skin is intact, NONBLANCHABLE redness, may feel war or cool to touch.
- Stage 2: Partial-thickness skin loss involving the EPIDERMIS and the DERMIS. The ulcer may appear an abrasion, blister, shallow cavity.
- Stage 3: Full-thickness tissue loss with damage to or necrosis of subQ tissue -> may reach but not extend thorough the fascia below. appears as a DEEP CRATER with or without undermining adjacent tissue. Drainage and infection is common
- Stage 4: Full thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, or ESCHAR.
- unstageable: Ulcers whose stages cannot be determined bc eschar or slough obscures the wound.
Health Promotion and Disease Prevention: Pressure Ulcers - maintain the skin CLEAN, DRY and provide wrinkle free linens
- Clean and dry the skin immediately following urine or stool incontinence
- apply moisture barrier creams to the skin of clients who are incontinent
- use TEPID water, use minimal scrubbing, and pat the skin dry
- diet: high protein and vegetables
Nx Management: Pressure Ulcers - increase fluid intake 2,00 to 3,000 L/day
- Note if serum albumin is < 3.5
Wound Cleansing
- cleanse in a direction form the least contaminated toward the most contaminated
- use gentle friction
- use isotonic solutions
- NEVER use the same gauze to cleanse across an incision or wound more than once
- Irrigation w/solution filled syringe health 2.5 cm (1in) above the wound
Medications: Pressure Ulcers - Antimicrobial therapy
- antipyretics
- analgesics therapy
Nx Management for Dehiscence- Call for help
- stay with the client
- cover the wound and any protruding organs with sterile towels or dressing that have been soaked in a NS soluion.
- DO NOT attempt to reinsert the organs
- Position the client supine with hips and knees bent
- Maintain calm
Burn Care: 3 Phases 1) Emergent (Resuscitative phase)
- first 24-48 hrs
2) Acute
- begins when fluid resuscitation is finished
- ends when the wound is covered by tissue
3) rehabilitative
- begins when most of the burn area is healed
- ends when reconstructive and corrective procedures are complete
Types of Burns - Superficial: damage to the EPIDERMIS; pink to red, NO blisters; heals 5-10 days; NO scarring; ei: sunburn
- Superficial partial thickness: damage to EPIDERMIS and some of DERMIS; BLISTERS, NO ESCHAR, heals in 14 days, flame or burn scalds
- Deep partial thickness: RED to WHITE; NO blisters; heals 14-36 days, SCARRING likely, graft may be needed; ie: grease, tar or chemical burns.
- Full thickness: damage to ENTIRE EPIDERMIS, DERMIS and extends to SUBQ; NERVE damage also occurs; Pain may or may not be present; Hard and inelastic; Red to tan, black brown or white; heals within weeks to months.
- Deep full thickness: damage to ALL layers of skin, extends to bone, tendons and muscles; BLACK, NO edema; ie: chemical burns.
Labs: Burns Initial fluid shift
- elevated hct and hgl: dt loss of fluid shift into interstitial space
- decreased Na dt third spacing
- increase K dt cell destruction
Fluid mobilization (48-72 hours)
- decreased hgb and hct dg fluid shift from interstitial back into vascular fluid
- decreased Na dt renal and wound loss
- decreased K dt renal loss and movement back into cells
- elevated blood glucose dt stress response
Nx Management: Minor burns - stop the burning process
- remove clothing or jewelry that might conduct heat
- apply cool water soaks or run cool water over injury; DO NOT use ICE
- flush chemical burns with large amounts of water
- cover burn with clean cloth to prevent contamination and hypothermia
- cleans with mild soap and tepid water
- AVOID using greasy lotions or butter on burn
Nx Management: Moderate and Major Burns - maintain airway and ventilation
- provide humidified supplemental O2
- initiate IV access
- Fluid replacement within first 24 hrs
- LR or NS are used for fluid replacement at Emergent phase
- Colloids such as plasma expanders (Hespan), may be used after the first 24 hrs
Infection Prevention: Burns - restrict plants and flowers
- restrict consumption of fresh fruits and vegies
- Limit visitors
- use reverse isolation
- administer tetanus toxoid
- increased caloric intake up to 5,000/day
- increase protein
Restoration of Mobility: Burns - maintain correct body alignment, splint extremities, and facilitate position changes to prevent contractures
- maintain active and passive ROM
- apply pressure dressings to prevent contractures and scarring
Medications: Burns - Silver nitrate 0.5%:
- painful on applications
- discolors wound, DOES NOT penetrate ESCHAR
- Silver sulfadiazine 1%
- maintains joint mobility
- effective against gram pos bacteria/ yeast
- may cause neutropenia
- Mafenide acetate
- penetrates ESCHAR, effective on ELECTRICAL wounds
- may cause metabolic acidosis or hyperpnea
- Bacitracin
- maintains joint mobility; PAINLESS, easy to apply
- limited effectiveness on gram-neg organisms
tx: burns Mechanical debridement:
- use scissors and forceps to cut away the dead tissue during hydrotherapy tx
hydrotherapy tx
- use mild soap or detergent to gently wash burns and then rinse with room temp water
- encourage joint exercise during tx
- use enzymatic topicals to breakdown and remove dead tissue
Nx Actions: following a graft for burn tx - maintain immobilization of graft site
- ELEVATE extremety
- provide wound care to the donor site
Water deprivation Measures the kidneys' ability to concentrate urine in light of an increased plasma osmolality and low plasma vasopressin level
Indications:
- DM insipidus (Na has to be normal range and osmolality is <300 mOsm/kg H2O
Procedure: Water deprivation - client at recumbent position for 30 min
- obtain 7-10 of heparinized blood in an ice tube and sent to lab
- ask the client to empty the bladder, record the amount and sent the specimen to lab
- weight the client
- initiate fluid resuscitation
- repeat 3 steps hourly; record sx if any
- continue steps until serum Na concentration or osmolality rises
Complication
- dehydration
Fasting Glucose Normal: less than 110 mg/dL
- client NPO for 8 hrs
- antidiabetic meds should be postponed
Oral glucose tolerance test Normal: less than 140 mg/dL
- instruct to consume a balanced diet for 3 days prior to the test, and NPO 10-12hrs prior to test
- A fasting glucose is drawn at start of the test -> glucose is given to the client -> blood glucose is drawn Q30min for 2hrs.
- Monitor for hypoglycemia
HbA1c - 5% or less indicates NO DM
- 6.4% indicates preDM
- 6.5% or higher indicates DM
** it is an indicator of blood glucose for the past 120 days
DM Insipidus - deficiency of ADH; from the POSTERIOR PITUITARY gland
Types
- neurogenic: damage from hypothalamus or pituitary
- Nephrogenic: inherited; DO NOT react to ADH
- drug induced: lithium or democlocycline
Risk Factors: DM Insipidus - head injury
- meningitis
- infection
- surgery around the pituitary gland
- taking lithium or democlocycline
- older adult clients
s/s: DM insipidus - polyuria
- polydipsea
- nocturia
- fatigue
- dehydration
Vassopressin test A subQ test injection, produces a urine output with an increased specific gravity
Nx Management: DM Insipidus - weight the client daily
- restrict diuretic foods
- promote safety: bed rails up, assistance when walking, provide bathroom bedpan, answer call light promply
- add bulk foods and fruit juices
- use soft toothbrush
Medications: DM Insipidus ADH replacements: Desmopressin acetate (DDVAP) or Pitressin
- for intranasal dose: clear nasal passage and sit upright prior to nasal inhalation
- notify MD of weight gain 2lb in 24hrs
ADH stimulants: Carbamazepine
- take with food
- monitor for dizziness and drowsiness, thrombocytopenia
- use caution when operating heavy machinery
- notify MD of sore throat, fever or bleeding
SIADH s/s
- headache, weakness, WEIGHT gain w/o edema, not sodium retained
- Na decreases -> sluggish DTRs, n/v, hostile personality -> seizures, coma
- cheyne stokes
- confusion
Nx Managment: SIADH - restrict oral fluid 500 to 1,000 L/day
- weigh daily: weight gain of 2lbs indicates 1L of fliud
Medications: SIADH Demeclocycline:
- tetracycline derived
- it may take 1 weeks to see result
- advise for yeast infection
- rinse toothbrush with diluted (10%) bleach and increase yogurt consumption
Lithium
- s/s of toxicity: nausea, diarrhea, tremors, ataxia
- effectiveness in 1-3 weeks
- take with FOOD
Furosemide
- can worsen hyponatremia
- advise to position slowly -> orthostatic hypotension
- AVOID alcohol consumption
Complications: SIADH Water intoxication, cerebral edema and severe hyponatremia
- institue seizure precautions
- early signs of water intoxication: CRACKLES; distended neck vein, twitching and disorientation
Hyperthyroidism Hyperthyroidsm is a clinical syndrom caused by excessive circulating thyroid hormones.
Overview: the thyroid gland produces 3 hormones: thyroxine (T4), triiodothyronine (T3) and thyrocalcitonin (calcitonin). T3 and T4 is regulated by the ANTERIOR pituitary gland; when T3 and T4 levels decreases -> TSH is released by the anterior pituitary gland, stimulating the thyroid to secrete more hormones.
Risk Factors
- Grave's disease: autoimmune mimics TSH -> hypersecretion of thyroid hormones
s/s: Hyperthyroidism - tremor
- HEAT intolerance
- PALPITATIONS
- hyperactivty
- BRUIT over the thyroid gland
- elevated systolic pressure with widened pulse pressure
- WEIGHT LOSS
- EXOPTHALMUS
- older adult often present with HF and atrial fibrillation
Nx Management: Hyperthyroidism - minimize energy expenditure
- promote calm environment
- provide eye protection for client with exophthalmos
- prepare for total thyroidectomy
medications: Hyperthyroidism Antihyperthyroid medications: act by blocking thyroid hormone synthesis and reducing thyroid level
- Propylthiouracil (PTU) or methimazole (Tapozole)
- monitor for hypothyroidism: cold, edema, bradycardia, increase in weight and depression
- monitor for leukopenia or thrombocytopenia
Client Education
- take with FOOD
- report to MD fever, sore throat, bruising, jaundice
Propranolol (Inderal)
- take apical pulse before each dose
Saturated solution of potassium iodide (SSKI): inhibit the release of stored thyroid hormone and retard hormone synthesis
- short term use only
- give 1 hr after an antithyroid med
- contraindicated on pregnant women
Radioactive therapy Radioactive iodine is taken up by the thyroid and destroys some of the hormone producing cells
- contraindicated: Pregnant women
- monitor for hypothyroidism: edema, cold, bradycardia, increase weight and depression
Client Education
- effects not evident until 6-8 weeks
- stay away from infants or small children 2-4 days and avoid getting pregnant for 6 months after therapy
Total or subtotal thyroidectomy Pre-op
- usually prescribed propylthiouracil (PTU) or methimazole 4-6wks prior to surgery
- receives 10-14 days before surgery
Post-op
- Keep at high-Fowler's position
- ask the client to speak to check laryngeal damage
Thyroid Storm "thyrotoxic crisis"
- results form a sudden surge of large amounts of thyroid hormones in the blood stream, causing an even greater increase in body metabolism.
Precipitating factors
- emotional stress following a thyroidectomy
s/s
- hyperthermia
- hypertension
- delirium
- vomiting
- abdominal pain
- hyperglycemia
- tachydysrhthias
Nx Management: Thyroid Stormqm - administer acetaminophen
- administer PTU to prevent further synthesis and release of thyroid hormones
- administer sodium iodide, 1 hr before PTU
- administer small doses of insulin
Client Education
Hypocalcemia and Tetany s/s
- tingling of fingers and toes
- carpopedal spasms
- convulsions
dx
- test for chvostek's and trousea signs
- administer IV calcium gluconate
- provide SEIZURE precaution
HypothyroidsimInadequate amount of circulating thyroid hormones in the body
Risk Factors
- WOMEN, incidence rising in age 40-50
- inadequate intake of iodine
- use of lithium, amiodarone
s/s
- fatigue
- COLD intolerance
- WEIGHT GAIN
- thin, brittle fingernails
- thinning hair
- joint and/or muscle pain
Late findings
- Slow through process and speech
- thickening of the skin
- dry, flaky skin
- decreased libido
Labs: Hypothyroidsim - decreased T3 (normal 70-205)
- TSH (normal 0.4-6.15)
- elevated serum cholesterol
- CBC -> anemia
Nx Management: Hypothyroidsim - apply antiembolism stockings and elevate the client's legs to assist venour return
- diet: low calorie, high bulk -> encourage activity to prevent constipation
- provide extra clothing and blankets for client with decreased cold tolerance
Medications: Hypothyroidsim Levothyroxine (Synthroid)
- increases the effects of warfarin (Coumadin) and can increase the need for insulin and digoxin (Lanoxin)
Client education
- tx begin slowly, dosage is increased Q2-3 wks
- tx is lifelong
Complications: Hypothyroidsim Myxedema Coma
- life threatening condition that occurs when hypothyroidism is untreated or when a stressor, such as infection, affects an individual who has hypothyroidism.
Risk Factors
- sudden abrupt stop of synthroid
s/s
- hypoxia, hypercapnia
- decrease CO
- stupor
- hypotension
- hypoglycemia
- hyponatremia
Nx Management: Myxedema Coma - administer synthroid IV; monitor vital signs bc rapid correction can cause adverse cardiac effects
- administer corticosteroids
- check for infection
Cushing's Syndrome Caused by over secretion of the ADRENAL CORTEX (mineralocorticoids: aldosterone; Glucocorticoids: cortisol; sex hormones: androgens and estrogens). The adrenal cortex over secretes GLUCOCORTICOIDS, resulting in increased cortisol and increased androgens
Risk Factors
- adrenal hyperplasia, adrenocortical carcimona
- organ transplant
- chemotherapy
- asthma, allergies, chronic inflammatory disease
s/s
- weakness, fatigue back and joint pain
- thin fragile skin
- bruising and petechiae
- HTN (sodium and water retention)
- weight gain, dependent edema
Health Promotions and Disease prevention: Cushing's Syndrome - diet: high in calcium and vit D; decreased Na, AVOID alcohol and caffeine
- AVOID infections
labs: Cushing's Syndrome - elevated plasma cortisol
- elevated ACTH
- decreased serum K and Ca
- increased Na
- increased glucose
Nx Management: Cushing's Syndrome Aminoglutethimide
- decreases adrenal hormone synthesis to provide short term symptom relief for clients with Cushing's syndrome
ketoconazole (Nizoral)
- adrenal corticosteroid inhibitor; is an antifungal agent that when taken in high dosages inhibits adrenal corticosteroids synthesis
Addison's The production of of mineralocorticoids and glucocorticoids is diminished, resulting in decreased aldosterne and cortisol
- Adrenal crisis also known as acute adrenal insufficiency, has a rapid onset.
Risk Factors
- TB
- idiopathic autoimmune
- Cancer
- STEROID WITHDRAWAL
- pituitary neoplasm
s/s
- hyperpigmentation
- weakness and fatigue
- dehydration
- hypoNa, Ca, hypoglycemia, hyper K
Medications: Addison's Fludrocortisone (Florinef)
- a mineralocorticoid used as a replacement in adrenal insufficciency
- monitor HTN
Client education
- warn the client to expect mild peripheral edema
Client After Care Discharge: Addison's - Avoid using alcohol and caffeine
- monitor for signs of gastric bleeding
- monitor for hypoglycemia
Addisonian Crisis occurs when there is an acute drop of adrenocorticoids dt sudden dc of flucocorticoid medications or when iduced by severe trauma, infection, or stress
Diabetes Mellitus characterized by chronic hyperglycemia dt inadequate insulin secretion and/or the effectiveness of endogenous insulin
Risk Factors
- genetics
- obesity
- sedentary lifestyle
- pancreatitis, Cushing's syndrome
s/s; hyyperglycemia
- thirst
- hunger
- frequent urination
- skin is war, dry and flushed with poor turgor
- rapid deep respirations (Kussmaul respirations)
labs: DM - glucose concentration > 200 mg/dL
- fasting glucose > 126mg/dL
- 2 hour glucose > 200 mg/dL with oral glucose tolerance test
Nx Management: DM - assess visual alteration
- sensory alteration
- exercise patterns
Teach the client proper foot care
- inspect feet daily, wash with mild soap and warm water
- pat feet dry gently, esp between the toes
- use mild foot powder on sweaty feet
- best time to perform nail care is after a bath/shower
- separate overlapping toes with cotton or lamb's wool
- AVOID open toe, open heel shoes; leather shoes are preferred than plastic ones; wear shoes that fit correctly, wear slippers with soles, DO NOT go barefoot, shake out shoes before putting them on
- socks made of wool or cotton
- DO NOT use hot water bottles or heating pads to warm feet, wear socks for warmth
- AVOID prolonged sitting, standing and crossing legs
Nutrition: DM - eat at regular intervals, DO NOT skip meals
- recognize that 15 g of carbohydrates are equal to 1 carbohydrate exchange
- include fiber in diet
- use artificial sweeteners
- keep fat content below 30% of the total caloric intake
Instruction when Sick: DM - take blood glucose Q3-4h
- consume 4oz of sugar free, on caffeinated liquid Q30min to prevent dehydration
Call MD if
- blood glucose is >240 mg/dL
- fever is >102F and does not respond to acetaminophen
- feeling disoriented or confused
- rapid breathing
- diarrhea occurs more than 5x or for longer than 24 hrs
- unable to tolerate liquids
- illness last longer than 2 days
- eat at regular intervals, AVOID alcohol intake and adjust insulin to exercise and diet to avoid hypoglycemia
Nx Management: Hypoglycemia - treat with 15-20 g carbohydrates
- 4 oz orange juice, 2 oz of grape juice, 8 oz of milk, glucose tables equal to 15 g
- recheck blood glucose in 15 min
- if still low, give 15-20 g more carbohydrates
- recheck blood glucose in 15 min
- if blood glucose is within normal limits, take 7 g protein
-ie: 1 0z cheese (1 string cheese), 2 tblspoons of peanut butter, or 8 oz of milk
If client is unconscious, or unable to swallow
- administer glucagon SubQ or IM, repeat in 10 min if still unconscious and notify MD
Types of insulin ...
Insulin Lispro (Humolog) - RAPID acting
- onset < 15 min
- peak .5 to 1 hr
- duration: 3-4 hr
Regular Insulin - SHORT acting
- onset 30 min to 1 hr
- peak: 2-3 hrs
- duration 5-7 hrs
NPH - Intermediate
- onset: 1-2 h
- peak: 4 -12 hrs
- duration: 18-24 hrs
Insulin glargin (Lantus) - LONG acting
- onset: 1h
- peak none
- duration: 10.4 to 24 hrs
Nx Management: Insulin administration - DO NOT mix insulin glargine (Lantus) with other insulins dt incompatibility
- AVOID alcohol with sulfonylurea agents
- inject needle SubQ at 90 deg angler for bigger clients and 45 deg for thinner client
Oral hypoglycemics Metformin
- reduces the production of glucose through suppression of gluconeogenesis
- monitor for GI upset
- monitor for lactic acidosis s/s: myalgia, sluggishness, somnolence, hyperventilation
Client teaching
- take with vit B12 and folic acids
Sulfonylureas
- Tolbutamide (Orinase), chlopropamide (diabinese and glyburide
- stimulates insulin release form the pancreas
- monitor for hypoglycemia; beta blockers mask tachycardia typically seen during hypoglycemia
- AVOID pregnancy
- Avoid alcohol dt disulfiram effect
Complications: DM - Cardiovascular and cerebrovascular disease
- impaired vision
- foot injury
- renal failure
Diabetic Ketoacidosis (DKA) An acute, life threatening condition characterized b hyperglycemia (> 300 mg/dL), resulting in the breakdown of body fat for energy and an accumulation of ketones in the blood ad urine.
Risk Factors
- type 1 DM
s/s
- n/v, abdominal pain
- polyuria, polydipsia, polyphagia
- ketones present in urine
- metabolic acidosis
Hyperglycemic hyperosmolar state (HHS) an acute, life threatening condition characterized by profound hyperglycemia (>600 mg/dL) dehydration and an absence of ketosis. Onset occurs several days and the mortality rate is up to 15%
Risk Factors
- untreated or undiagnosed type 2 DM
- polyuria, polydipsia, polyphagia
- generalized SEIZURES
- NO KETONES in urine
- Absences of acidosis
Risk Factors: DKA ...
Nx Management: DKA / HHS - Provide rapid NS solution, followed by hypotonic fluid (.45% NS)
- when glucose serum reaches 250 mg/dL, add glucose to IV fluids to minimize the risk of cerebral edema associated with drastic changes in serum osmolality
- Administer Regular Insulin 0.1unit/kg, IV bolus dose then follow by continuous IV infusion of Regular insulin 0.1 unit/kg/hr
- monitor glucose and K; K levels will initially be elevated with insulin therapy, but potassium will shift into cells and the client will need to be monitored for hypokalemia.
- Administer sodium bicarbonate by slow IV infusion for severe acidosis (pH <7.0)
HIV/AIDS - HIV is found in feces, urine, tears, saliva, cerebrospinal fluid cervical cells, lymph nodes, corneal tissue, and brain tissue
- ALL women who are pregnant should be screened for HIV
Stages of HIV infection Stage 1: manifestation 2-4 weeks of infection; sx similar to influenza, marked by rapid rise in the HIV viral load, decreased CD4+ cells and increased CD8; lymphadenopathy persists throughout the disease process
Stage 2: asymptomatic for up to 10 years; Ati HIV antibodies are produced HIV positive; over time the virus begins active replication using the host's genetic machinery; CD4+ are destroyed, viral load increases, dramatic loss of immunity begins
Stage 3: AIDS characterized by life threatening opportunistic infections, w/o tx death occurs within 3-5 years.
s/s: HIV/AIDs - chills
- anorexia
- weakness and fatigue
- headache
- night sweats
labs: HIV/AIDS - pancytopenia
- platelet count < 150,000/mm3
** ELISA confirmed by positive result then Western blot test
- p24 antigen test neutralization assay
- PCR test
medications: HIV/AIDS Highly active antiretroviral therapy (HAART): involves using 3-4 medications in combination with other antiretroviral medications to reduce medication resistance
- Enfuvirtide (Fuzeon)
- Necleoside rever transcriptase inhibitors (NRTIs)
- non- nucleoside reverse transcriptase inhibitors (NNRTIs)
- Protease inhibitors
- Antineoplastic medication
Care After discharge: HIV/AIDs - refer to local support groups
client education
- practice good hand hygeine
- AVOID traveling in crowded and por countries
- AVOID raw foods, such as vegetables and meat
- AVOID clean pet litter boxes to reduce the risk of toxoplamosis
Complications: HIV/AIDS Opportunistic infections
- TB, pneumonia
- T(toxoplasmosis) O(other infections) R (rubella) C (cytomegalovirus) H (herpes)
Wasting Syndrome
- maintain nutrition
- provide between meal supplements/snacks
- serve at least 6 small feedings with high protein value
HIV encephalopathy
- SEIZURES
- implement seizures precaution
Systemic Lupus Erythmatosus (SLE) An autoimmune disorder in which an atypical immune response results in chronic inflammation and destruction of healthy tissue
Classification
- Discoid: primarily affects the skin. Characterized by an erythematosus butterfly rash over the nose and cheeks and is generally self limiting
- Systemic: affects the connective tissues of multiple organ systems and can lead to major organ failure
- Medication: induced SLE can cause mdications (procainamide, hydralazine, INH). sx resolve when medication is dc, and does not cause renal or neurological disease
Risk Factors: SLE - FEMALES
- ages between 15-40
- African, Asian, or Native American descent poses a risk
- incidence drops after menopause but steady in men
- older adults: joint pain is limited, at risk for fracture when taking corticoidsteroids
s/s: SLE - fatigue
- malaise
- weight loss/ anorexia
- alopecia
- fever
- joint pain, swelling and tenderness
- lymphadenopathy
- RAYNAUD'S phenomenon (arteriolar vasospasm in response to cold/stress)
- BUTTERFLY RASH on face
labs: SLE - ANA titer: positive in 90% (normal is negative ANA titer in a 1:20 dilution
- Anti-DNA- positive (not specific but positive for most clients)
- Anti-Smith (anti-Sm): Positive (HIGHLY specific)
- Serum Complement (C3 and C4): CONFIRMS dx, depletion secondary to exaggerated inflammatory response
- elevated BUN, +2 urine protein
Nx Management: SLE - provide small frequent meals if anorexia is concern
- limit salt intake
Medications: SLE NSAIDS
- reduce inflammation
Corticosteroids
- Do not stop or decrease dose abruptly
prednisone:
- side effects: weight gain, buffalo hump, moonface, abdominal striae, elevated blood glucose
Methotrexate and Imuran
- suppresses immune response
- monitor for bone marrow suppression
Antimalarial: hydroxochloroquine (plaquenil)
- used for suppression of synovitis, fever and fatigue
- do frequent eye exams
Discharge Care: SLE - Avoid UV and sun exposure
- use mild protein shampoo and avoid harsh tx
- use steroid creams for skin rash
- notify MD: peripheral and periorbital edama
- Avoid crowds, illness can precipitate exacerbation
complications: SLE Lupus nephritis (renal failure/glomerulonephritis)
- major cause of death
- take immunosuppressants and corticosteroids as prescribed
- avoid stress and illness
Pericarditis and myocaditis (report chest pain)
Rheumatoid Arthritis (RA) RA is an autoimmune disease that is precipitated by WBC attacking synovial tissue. WBC cause the synovial tissue to become inflamed and thickened. Can affect any connective tissues: blood vessels, pleura (lungs) and pericardium.
Overview: Progressive inflammatory disease that can affect tissues and organs but principally attacks the joints producing an inflammatory synovitis. It involves joints bilaterally and symmetrically, and typically affects several joints at one time.
Risk Factors: RA - FEMALE
- ages 20-50
- genetics
- EPSTEIN BARR VIRUS
- stress
s/s: RA - fatigue and joint discomfort
- pain at rest and with movement
- pleuritic pain (upon inspiratio)
- paresthesia
- recent illness/ stressor
- joints may become deformed merely by completing ADLs
labs: RA- Anti- CCP antibodies: positive
- ESR: elevated
- 20-40 mm/hr is mild inflammation
- 40-70 mm/hr is moderate inflammation
- 70-15o mm/hr is severe inflammation
- C-reactive protein: positive
- ANA titer: positive
- elevated WBC
Nx Management: RA - apply heat or cold to the affected areas
- morning stiffness (hot shower
- pain in hands/fingers (heated paraffin)
- edema (cold therapy)
- max functional activity
- minimize pain
- conserve energy
- provide safe environment
- use progressive muscle relaxation
- notify MD: fever, infection, pain upon inspiration, pain in the substernal area of the chest
Medications: RA NSAIDS
- take with FOOD or with glass of water or milk.
- observe GI bleeding
- do not take with alcohol
Corticoseroids
- observe for cushingoid changes
- observe for vision, blood glucose and healing impairement
Disease modifying anti-rhematic drugs
- antimalarial: plaquenil
- antibiotic: Minocycline
- Sufonamid: sulfasalazine
- biologic response modifiers: Etanercept, infliximab
- cytotoxic: methotrexate, Imuran
tx: RA - plasmapheresis
- total joint arthroplasty
complications: RA Sjogren's syndrome: triad of sx: dry eyes, dry mouth and dry vagina
- caused by obstruction of secretory ducts and glands
- provide eyedrops and artificial saliva and recommend vaginal lubricants
- increased fluid
Secondary osteoporosis
Immobilization caused by arthritis; promote weight bearing exercise
Vasculitis (organ schema)
Chemotherapy - Monitor TEMPERATURE (report if > 100F) and WBC count
- If WBC is <1,000/mm3
- place in a PRIVATE ROOM and initiate NEUTROPENIC PRECAUTIONS
- have the client remain in the room unless other diagnostic procedure necessitate the client to leave
- Restrict visitors who are ill
- keep designated procedures in the room
- administer colony stimulating factors (Neupogen) to stimulate WBC production
Client Education
- Avoid eating fresh foods, yard work, changing pet's litter box, DO NOT drink fluids sitting in room temp for more than 1 hr
- Wash toothbrush with diluted bleach solution
Stomatitis Nx Action
- Examine mouth several x/day
- Avoid use of glycerin based mouthwashes or mouth swabs
- Administer a topical anesthetic
- discourage selection of salty, acidic, or spicy foods
- offer mouth care before and after meals
Client Education
- rinse mouth with solution of half NS and half peroxide at least 2x/day, and use soft toothbrush
- eat soft foods: mashed potatoes, scrambled eggs, cooked cereal; milk shakes, ice cream, frozen yogurt, bananas, breakfast mixes
Radiation Therapy: Brachytherapy (internal) Involves the use of ionizing radiation to target tissues and destroy cells
Brachytherapy: insertion via body orifice (vagina) or body cavity (abdomen)
- PRIVATE ROOM, warning at door for radiation
- health care should wear dosimeter film badge
- visitors limited to 30 min visits with 6ft distance
- those pregnant and under 16 is NOT ALLOWED
- LEAD CONTAINER should be in the room with TONGS to place radioactive materials in the container
- CONTRAINDICATED: laxative
Client Education
- remain in a position necessary to NOT dislodge radiation implant
Radiation Therapy: Telethreapy (external) - delivered in a course of several weeks
preparation
- client skin is marked with tattoos that guide the positioning of the external source
On going care
- DO NOT eat RED MEAT
- schedule rest periods
Client Education
- inform that fatigue is common
- gently wash the skin over the irradiated area with MILD SOAP and WATER, PAT to DRY
- DO NOT remove "tattoos"
- DO NOT apply POWDERS, OINTMENTS, LOTIONS or PERFUMES to the irradiated skin
- wear soft clothing over the irradiated skin, AVOID tight or constricting clothes
- DO NOT expose skin to the sun or heat source
Hormonal Therapy gonadotropin-releasing hormone agonist (GnRH) like Eligard, Lupron
- monitor for cardiac status, BP and pulmonary edema
- decreased libido, erectile dysfunction, hot flashes, bone loss, gynecomastia
Adrogen antagonist: Flutamide (Eulexin)
- monitor for liver enzymes and CBC
- warn about gynecomastia, erectile dysfunction
Estrogen antagonist
- monitor: clotting times, CBC, Calcium, cholesterol, liver function
- side effects: n/v, hot flashes, weight gain, vaginal bleeding, increased risk for THROMBOSIS
- take calcium and vit D
Immunotherapy Biologic response modifiers
- Interferons, interleukins, cytokines
Cytokines: the primary BMRs-> work to enhance immune system, recognize cancer cells and use the body's natural defenses to destroy them.
Nx Actions (interluekins)
- monitor for INFLUENZA like sx
Nx Actions (Interferons)
- monitor for peripheral neuropathy: vision, hearing, balance and gait
- report: INFLUENZA like sx
- skin rashes are common, use perfume free moisturizer
- AVOID the SUN and SWIMMING if skin sx arise
Regional Nerve Blocks - obtain baseline VS
- monitor for systemic infusion (metallic taste, ringing in ears, perioral numbness, seizures)
Client Education
- notify MD: metallic taste, ringing in ears, perioral numbness and seizures
Epidural or intrathecal catheters - monitor during insertion and 1 hr after: respiratory depression and sedation, hematoma = infection
client Education
- notify MD when signs of infection and systemic infusion is observed
Transcutaneous electrical nerve stimulation (TENS) Low voltage electrical impulses are transmitted throuh electrodes that are attached to the skin near or over the area of pain
Nx Action
- use with conductive gel
- monitor for burns or rash
- Contraindicated: clients who have pacemakers or infusion pumps, pregnant women
Client Education
- inspect the skin under the electrodes
- DO NOT use near the HEAD or over the HEART
