Chronic Final Exam

Chemotherapy administration and side effects (nsg interventions) and effects on lab values and nursing interventions related to abnormal lab values

Administration: *Do not administer chemo if WBC <2,000 and/or platelet <50,000* Side Effects: myelosuppression (infection, bleeding, anemia), leukopenia, infection, anorexia, mucositis (including stomatitis, esophagitis), N/V/D, alopecia, reproductive system dysfunction (NSG INTERVENTIONS see table pg. 251-252) *Tumor lysis Syndrome: high K, high phos, high uric acid, low calcium* Nsg interventions r/t abnormal lab values: For Bone Marrow Suppression (BMS): Take every possible measure to prevent infection (Handwashing - ns, fam, pt), monitor temperature routinely, (emergency in the case of neutropenia). If thrombocytopenia, concern is spontaneous bleeding or major hemorrhage so avoid invasive procedures and advise pt to avoid activities that put them at r/f bleeding (straining). Platelet transfusions may be necessary if count falls below 20,000. If pt has low hemoglobin level, RBC growth factors may be given (darbopoetin/aranesp, or epoetin/procrit. In severe cases (symptomatic anemia), RBC transfusion could be indication but should be avoided in most cases.

Peritoneal dialysis: advantages and disadvantages

Adv: live longer, more mobility and flexibility, shorter training, easier to travel, no machine required, no needles required, takes less time overall, fewer diet restrictions, good for patient with difficult vascular access, better for diabetic patient because better BP and glucose control, less hemodynamic stability, preserves for kidney transplant and future hemodialysis Disadv: Done everyday; no days off, Catheter may affect body image, Swimming/bathing may be limited, Potential for weight gain due to glucose (sugar) in dialysis fluid, Blood glucose can be more difficult to control in diabetes, Storage space is required at home for supplies and fluid, Potential for infection in the catheter. Peritoneal dialysis is a home-based treatment that can be done anywhere (at home, work, or when sleeping). It must be done daily.

CVA: aspiration precautions

Airway obstruction can occur due to problems with swallowing & chewing, food pocketing, and the tongue falling back All pts should be screened for their ability to swallow and kept NPO until dysphagia is ruled out Thorough mouth care to check for food pocketing Easy to swallow foods *Place food on unaffected side of mouth* Always follow feeding with meticulous oral care

Cirrhosis: RF for developing

Alcoholic (Laennec's) → fat in liver cells and scar formation Post necrotic (Most common globally) → follows acute viral hepatitis and leads to scar tissue in liver r/t toxins/industrial chemicals Biliary: obstruction or infection r/t UC Cardiac: R sided HF, cor pulmonale

Allopurinol vs. Colchicine

Allopurinol: - drug of choice to promote uric acid excretion or reduce production - Use: prevention of an attack, *not to relieve acute attack* Drug of choice to *promote uric acid excretion or reduce production* Educate: regular eye exams, avoid vitamin C supplements Colchicine: - if good response, indicates gout - *acute flare-up, decreases inflammation, cannot be given to anyone with impaired renal function* - acute relief and prevent acute attacks by decreasing swelling and uric acid levels SE: GI upset, r/f neutropenia Toxicity: tingling, numbness in fingers/toes, gray lips NO GRAPEFRUIT JUICE (increases r/f toxicity)

Interventions to manage pain and avoid touch sensitivity in gouty arthritis

Assess joint and history of gout Educate on avoiding high purine foods, medications (ASA), alcohol, high fructose corn syrup, dehydration Elevate covers above the affected area - something to keep them warm but not touching Local heat/cold application, joint immobilization, 2-3 L of water per day, bedrest with extremity in cradle or footboard, weight loss

CRF: Usual assessment, labs (creatinine clearance, urinalysis), usual medications (& contraindicated meds), complications.

Assessment: BUN & creatinine, I&O, daily wt, Ca & Phos, H&H, Na+, K+, bicarb Creatinine clearance: decreased in CKD (*retain creatinine, decr. sp. gravity due to inability to concentrate urine*) Urinalysis: increased protein, glucose, RBCs, WBCs; decreased or fixed specific gravity, BUN directly r/t dietary protein intake Meds: Kayexalate to decrease K+ levels, calcium channel blockers (renoprotective), phosphate intake restricted, Ca-based phosphate binders to bind and excrete phosphate (tums), active vit D form, epogen, supplement folic acid Contraindicated meds: avoid ACE inhibitors, capoten and vasotec that decrease GFR and increase K+, aluminum and magnesium containing antacids should not be used Aminoglycosides: gentamicin, kanamycin, tobramycin potentially nephrotoxic Demerol: never give, can cx seizures; be careful with antibiotics and opioid pain meds Diabetic agents: metformin, glyburide Complications: most drugs are excreted by the kidneys so dosage must be adjusted Digitalis: low K+ potentiates digoxin -> dig toxicity

Renal insufficiency

Beginning stage of ESRD GFR drops to 25% of normal and BUN and creatinine increase Fatigue and weakness develop -> HA, nausea, itching Nocturia and polyuria develop (kidneys lose ability to concentrate urine) Min UO 30ml/hr, @ 4 hours should be 120 ml, 24 hr 720 ml < 100 ml/day anuria, 100-400/day ml oliguria

Metformin (Glucophage)

Biguanide Antidiabetic, decreases hepatic glucose production, decreased intestinal glucose absorption, increases sensitivity to insulin (for maintenance of blood glucose) Abdominal bloating, N/V/D, unpleasant metallic taste Hold 48 hours before and after contrast dye

Osteoporosis (OP): tx

Bisphosphonates: inhibit osteoclast mediated bone resorption alendronate (Fosamax) Teriparatide (forteo): stimulates new bone formation Exercise: wt. Bearing, walking, stair climbing, dancing NO SMOKING; decrease ETOH - calcium, vit D, calcitonin, selective estrogen receptor modulators (Evista)

Interstitial cystitis nursing care and education

Bladder training irrigation/foley/replace fluids Assess for pain, clots, urine Teach diet

Cirrhosis: labs to monitor

CBC (thrombocytopenia, leukopenia, anemia), H&H enzymes: alkaline phosphatase, AST, ALT, ect. All elevated due to damaged tissue Protein: decr. total protein and albumin and incr. globulin Prothrombin time is prolonged (PT) total bilirubin, conjugated and unconjugated bilirubin are all increased

CHF Labs & interpretations

CBC: WBC: 5-10,000 RBC: 4-6 Platelet: 150-450,000 Hgb: 45-60 Hct: 12-16 BMP: - Altered serum electrolytes (especially Na+ and K+), incr. BUN, creatinine, or liver function tests BNP: *helps to distinguish whether dyspnea is caused by respiratory or cardiovascular origin, Lab taken through blood draw, HF >135

Nsg care of CVA

CVAs happen suddenly... need to act FAST to save brain cells Call rapid response or 911 Note the *time* Maintain optimal functioning, prevent joint contractures or muscular atrophy ROM, trochanter roll at hip or hand cones, arm supports *RESPIRATORY*, r/f aspiration, careful w feeding, NPO until swallow study done, oral care Monitor v/s, cardiac, I & O, care for family caregiver - *Teach family signs of TIA and using FAST*, meds, etc. FAST: face (droop or uneven smile), arms (numbness or weakness), speech difficulty (slurred speech), time (act fast)

Non-Hodgkin's Lymphoma

Cancer of the white blood cells, it is not localized, it spreads early, involves painless node enlargement - Primary clinical manifestation: Painless lymph node enlargement, blood smear it is usually normal, maybe widely disseminated at diagnosis, involves lymphocytes arrested in various stages of development, prognosis is not as good as Hodgkins and complete remission uncommon (*painless lymph large, hepatomegaly, renal failure*) - Dx: lymph node biopsy

Peritoneal dialysis: assessment

Catheter site for signs of infection (redness at site, tenderness, and drainage) and peritonitis (abd pain or discomfort) Times of inflow, dwell, and drain Cloudiness or particulates in dialysate solution

Septic arthritis

Causes: - MED EMERGENCY - an infectious or bacterial infection cx by staph aureus pneumonia, strep hemolyticus, neisseria gonorrhea, diplococcus - usually bacteremia - RF: prior joint trauma, arthritic dz, decrease immunity, DM signs and symptoms: - Inflammation of joint cavity with severe pain, erythema and swelling of one or several joints, may have fever and shaking chills - Dx: culture of synovial fluid or bld culture - Septic arthritis is a medical emergency: IV antibiotics 2-8 wks, immobilize joint, may require repeated arthrocentesis (pull of synovial fluid, go home with PICC line for continuous antibx therapy)

CHF essential interventions

Daily weights Strict I/O Administer medications: Beta-blockers, diuretics, antihypertensives, vasodilators Teaching about low sodium diet, fluids restriction, s/s of exacerbation

Nursing diagnosis and communication problems following CVA

Decreased intracranial adaptive capacity r/t decreased cerebral perfusion pressure and sustained increase in ICP secondary to thrombus, embolus, or hemorrhage RF aspiration r/t decreased LOC and decreased or absent gag reflex and swallowing reflexes Impaired physical mobility r/t neuromuscular and cognitive impairment and decreased muscle strength and control Impaired verbal communication r/t aphasia Unilateral neglect r/t visual field cut and loss on one side of the body and brain injury Impaired swallowing r/t weakness or paralysis of affected muscles Situational low self-esteem r/t actual or perceived loss of function and altered body image

COPD oxygen safety at home

Decreasing r/f infection: Brush teeth or use mouthwash several times per day Wash nasal cannula (prongs) with a liquid soap and thoroughly wash once or twice a week Replace cannula every 2-4 weeks If you have a cold, replace the cannula after symptoms pass Always remove secretions that are coughed out If you use an O2 concentrator, everyday unplug the unit and wipe down the cabinet with a damp cloth and dry it Ask the company providing the equipment how often to change the filter Safety issues: Post "no smoking" warning signs outside the home O2 will not "blow up", but it will increase the rate of burning since it is a fuel for the fire Do not allow smoking in the home, and do not smoke yourself while wearing O2. NCs and masks can catch fire and cause serious burns to the face and airways Do not use flammable liquids such as paint thinners, cleaning fluids, gasoline, kerosines, oil-based paints, or aerosol sprays while using O2 Do not use blankets or fabrics that carry a static charge, such as wools or synthetics Inform the staff at your electric company if you are using a concentrator. In case of a power failure, they will know the medical urgency of restoring your power

Migraines: Dx

Diagnosis Usually diagnosed from patient history. Neurologic examination is usually negative and head CTs & MRIs are not recommended). Inspect for local infection, palpate head for tenderness and bony swellings, auscultate for bruits over major arteries - especially over the neck.

Cirrhosis: ascites management

Diuretics Paracentesis - sterile procedure in which a catheter is used to withdraw fluid from the abd cavity Monitor I&O Rest: reduces metabolic needs, incr. diuresis Ascites: low Na diet (250-500 mg/day); careful I&O and monitor electrolytes

Review the role of erythropoietin and factors associated with its release:

EPO: hormone produced primarily by the kidneys. It plays a key role in the production of red blood cells (RBCs), which carry oxygen from the lungs to the rest of the body. Erythropoietin is produced and released into the blood by the kidneys in response to low blood oxygen levels (hypoxemia). EPO is carried to the bone marrow, where it stimulates production of red blood cells. The hormone is active for a short period of time and then eliminated from the body in the urine. However, if a person's kidneys are damaged and do not produce sufficient erythropoietin, then too few RBCs are produced and the person typically becomes anemic. Similarly, if a person's bone marrow is unable to respond to the stimulation from EPO, then the person may become anemic. This can occur with some bone marrow disorders or with chronic diseases, such as rheumatoid arthritis. Individuals who have conditions that affect the amount of oxygen they breathe in, such as lung diseases, may produce more EPO to try to compensate for the low oxygen level. People who live at high altitudes may also have higher levels of EPO and so do chronic tobacco smokers.

collaborative care of pt with COPD

Evaluate patient's exposure to environmental or occupational irritants and determine ways to control or avoid them Smoking cessation & Drug therapy with respiratory therapist

CA General assessment, nursing diagnosis, evaluating

Fatigue: usually universal in CA patients, assess for reversible signs of fatigue (anemia, hypothyroidism, depression, anxiety, insomnia, dehydration, infection) Nausea & Vomiting: common following chemotherapy Diarrhea: recommend a diet low in fiber and residue before chemo tx; lukewarm sitz bath Mucositis: common complication in radiation Anorexia: common in pts with CA Radiation skin changes: local, only in the tx field; prevent infection; do not use heating packs, ice pack, or hot water; avoid constricting garments Chemotherapy skin changes: erythrodysesthesia syndrome - redness and tingling of the palms and sole of the feet

MCC diet teaching males vs. females

Females: 3-4 servings of carbs per meal, 1-2 servings for snacks q day Males: 4-5 servings of carbs per meal, 2-3 servings for snacks q day Each serving 15 g

Digoxin (Lanoxin)

For: HF, A Fib, Class: antiarrhythmics, inotropic, S/E: bradycardia, arrhythmias, N/V Nsg Implications: Monitor pulse 1 minute before administering and withhold if <60 bpm

Carvedilol (Coreg)

For: HTN, Class: Beta blockers, S/E: dizziness, ED, diarrhea, bradycardia Nsg Implications: Check BP, orthostasis, dizziness

CRF: lab results

GFR < 60ml/min for longer than 3 months Elevated BUN (norm: 8-25) and creatinine (norm: 0.5-1.5) Electrolyte (elevated Na, K, Urea, phos, mag; decreased Ca) acid-base imbalance (elevated HCO3- and ammonia levels) Acidic pH on urinalysis, blood or protein in urine Decreased EPO, decr. Iron and folic acid

Hemodialysis: principles of dialysis

Hemodialysis is a treatment that removes wastes and extra fluid from your blood. It can be done at home ("home hemodialysis") or in a dialysis center. During hemodialysis, your blood is pumped through soft tubes to a dialysis machine where it goes through a special filter called a dialyzer (also called an artificial kidney). As your blood is filtered, it is returned to your bloodstream. Only a small amount of blood is out of your body at any time Diffusion: movement of solutes from an area of greater concentration to one of lesser (substances *except blood and protein* move from blood to dialysate) Osmosis: movement of fluid from an area of lesser concentration to an one of greater concentration (glucose is added to create osmotic gradient) Ultrafiltration: pressure gradient is created across the membrane by increased pressure in blood compartment or decreased pressure in dialysate compartment

Renal and bladder cancer: nsg care

History and physical Cancer pt. Care-watch labs, encourage rest, encourage adequate nutrition, manage pain, prevent/monitor for infection, skin care, psychosocial care, preventing/managing nausea/vomiting Teaching preventative measures: quit smoking, lose weight, control BO, reduce/avoid toxins Teach of early manifestations (hematuria, hypertension) and encouragement early treatment Postop care: instruct pt to drink a large volume of fluid for first week, teach pt to monitor color and consistency of urine, administer opioid analgesics and stool softeners Help family cope with fears about cancer, surgery, and sexuality Encourage regular follow-up care

S/S of hypo/hyperglycemia and treatments

Hypo: cold, clammy, shaky, nervousness, irritability, confusion, increased HR, lightheadedness, hunger, pallor, Rule of 15: have 15 grams of carbs and check glucose after 15 min. If below 70, have another serving If unconscious: give glucagon IM Hyper: polyuria, polydipsia, blurred vision, fatigue, dyspnea, dry mouth, weakness, abd pain Tx: insulin

CHF nsg dx (prioritized)

Impaired gas exchange r/t increased preload and alveolar-capillary membrane changes Decreased CO r/t altered contractility, altered preload, and/or altered stroke volume Excess fluid volume r/t increased venous pressure and decreased renal perfusion 2° heart failure Activity intolerance r/t imbalance between O2 supply and demand 2° cardiac insufficiency and pulmonary congestion

Cirrhosis: assessments

Liver damage -> increase in ammonia Ammonia (LOC changes) crosses blood-brain barrier and produces neurologic toxic manifestations S/S: (early) depression, apathy, irritable, memory loss, confusion, agitation, positive babinski S/S: (late) impending coma = disorientation, flapping tremor (asterixis, hold out hands and they flap down), fetor hepaticus (bad smelling breath), hyperventilation

Braden Scale

Looks at: sensory perception, friction/shear, nutrition, mobility, activity, moisture. RF skin breakdown High alert < 9 Low alert > 15

CA screening

Lung: none Colon: colonoscopy, guaiac stool test Prostate: PSA, digital rectal exam Cervical: Pap smear Skin: mole changes Breast: self exams, mammogram

Migraines: Tx and pt teaching regarding meds/treatment

NSAIDS, ASA, caffeine Ergotamine: causes vasoconstriction Imitrex: affects serotonin receptors and decreases inflammation Prevention: tricyclic antidepressants, topamax, neurontin, Prozac Botox q 3 months Beta blockers, antidepressants, Ca channel blockers can be used Do not overuse meds or could cause more HA, HA diary, diet EVALUATION is key: satisfaction with pain management, appropriate use of meds and non pharmacological measures, preventing GI upset if NSAIDs are used

Cirrhosis: encephalopathy and tx

Neuropsychiatric manifestation of liver dz; includes the neurotoxic effects of ammonia, abnormal neurotransmission, astrocyte swelling, and inflammatory cytokines Damaged liver doesn't remove ammonia from blood → increased ammonia in brain Ammonia crosses blood brain barrier → neurologic toxic s/s S/S: change in neurologic and mental responses, impaired consciousness, inappropriate behaviors, sleep disturbance, trouble concentrating, flapping tremors (asterixis), impairments in writing Tx: Lactulose - inhibits bacteria and traps ammonia and expels it through stool

Med safety with liver dz

No acetaminophen, all meds should be evaluated due to sick liver and inability to metabolize

Pain management with cancer - scheduled meds, prn's, routes

Opioids normally given for moderate to severe cancer pain. Analgesic medications (Morphine, Fentanyl) should be given on a regular schedule (around the clock) with additional doses PRN to manage breakthrough pain. Generally, PO medication is preferred, but transdermal and transmucosal are also available. Pay attention to common SE of pain medications (constipation) NSAIDs (ibuprofen) are often used for adjuvant therapy to opioids for bone pain Antidepressants and antiseizure drugs can be used for neuropathic pain which is often resistant to opioids Radiopharmaceuticals (samarium-153) can be used with diffuse bone pain Nerve blocks or epidural or intrathecal anesthesia may also be used to treat patients with unrelieved pain or to minimize opioid requirements. Remember: with opioids (morphine) the appropriate dose is whatever is necessary to control pain with the fewest SE. Fear of addiction is not warranted but need to explain rationale to patient and screen for risk factors for abuse/misuse.

Hemodialysis: pre and post treatment

Pre: auscultate bruit, palpate thrill During hemodialysis, two needles are inserted into your arm through the access site and taped in place to remain secure. Each needle is attached to a flexible plastic tube that connects to a dialyzer. Through one tube, the dialyzer filters your blood a few ounces at a time, allowing wastes and extra fluids to pass from your blood into a cleansing fluid called dialysate. The filtered blood returns to your body through the second tube. Post: When hemodialysis is completed, the needles are removed from your access site and a pressure dressing is applied to prevent bleeding. Your weight may be recorded again. Then you're free to go about your usual activities until your next session.

Osteoporosis (OP): prevention

Proper nutrition, calcium supplements, vitamin D, exercise - Increased calcium prevents future loss but will not form new bone Foods hi in Ca: milk, yogurt, turnip greens, spinach, cottage cheese, ice cream, sardines *prevent fracture* - drug therapy through biophosphonates, prevention and tx depend on adequate calcium, increased calcium prevents future loss but will not form new bone, vertebroplasty, kyphoplasty - good calcium sources = milk, yogurt, cheese, turnip greens, spincah, cottage cheese, ice cream, sardines - bad Ca sources: eggs, beef, cream cheese, poultry, pork, apples/bananas, potatoes and carrots - encourage exercise to build up and maintain bone mass: wt bearing, walking, stair climbing, dancing - vit D supplements, smoking cessation, cut down on ETOH intake

Peritoneal dialysis: preventing peritonitis

Proper technique during connection exchanges Washing hands before handling dialysis equipment Monitoring for diarrhea, nausea, vomiting, or cloudy peritoneal effluent Daily catheter site care Potential prophylactic antibiotics

CA tx

Radiation, chemo, surgical removal Goals could be: cure, control, or palliation

CHF S/S

Right-sided RV heaves, murmurs, JVD, edema, weight gain, increased HR, ascites, hepatomegaly, fatigue, anxiety, depression, RUQ pain, anorexia and GI bloating, nausea Left-sided LV heaves, pulsus alternans, increased HR, PMI displaced inferiorly and left of midclavicular line, decreased PaO2, slight increase in PaCO2, crackles, S3 and S4, pleural effusion, changes in mental status, restlessness, confusion, weakness, fatigue, anxiety, depression, dyspnea, shallow respirations, paroxysmal nocturnal dyspnea, orthopnea, dry, hacking cough, nocturia, frothy, pink-tinged sputum

COPD: S/S, Dx, Tx

S/S: Presentation generally develops slowly Chronic cough or sputum production, dyspnea, hx of smoking, complaints of not being able to take in a full deep breath, heaviness in the chest, gasping for air, increased effort to breathe, air hunger, prolonged expiratory phase, decreased breath sounds, barrel chest, tripod positioning to breathe, pursed-lip breathing Later in the dz: dyspnea at rest, chest breathing, wheezing, fatigue, wt loss, anorexia Diagnosis: Spirometry, chest x-ray, serum α₁-antitrypsin levels, ABGs, six-minute walk test Treatment: Meds, respiratory therapy, surgery

Seizures: Assessment and interventions

SAFETY *ID when last one was, s/s, and precipitating events to avoid* Maintain patent airway Position patient on side Observe and record details of seizure May need suctioning or oxygen afterwards Very scary: stay with patient and family Assess breathing, LOC, injury, psych functioning Allow patient to rest and recover Assess risk factors: seizure precautions (O2 and suction, IV access, padded bed rails, pillow, no restrictive clothing, bed in lowest position) Assess seizure history: prodromal?, aura signs/symptoms, typical duration of seizure, type of seizure, precipitating events to avoid, last med dose, when last seizure was During seizure: position patient on side with pillow under head, do not restrain the patient, do not insert anything in the mouth, remove restrictive items or glasses, time the seizure, note characteristics/details of the event After seizure: stay with patient and family (can be scary), assess breathing, assess LOC, assess injury, perform neuro assessment, allow patient to rest and recover, drawing blood or medications HCP may order an EEG: painless, no caffeine prior to test, hold seizure meds, can eat before, wash and dry hair

GU diagnostic tests

Serum creatinine, GFR, BUN, Urine protein, microalbuminuria, urine creatinine, serum albumin, H&H, electrolytes

CA detection

Seven warning signs of cancer: CAUTION C: Change in bowel or bladder habits A: A sore that does not heal U: Unusual bleeding or discharge from any body orifice T: Thickening or a lump in the breast or elsewhere I: Indigestion or difficulty swallowing O: Obvious change in a wart or a mole N: Nagging cough or hoarseness

COPD Teaching inhaler use

Shake, deep breath in, press down to activate inhaler one time, breathe in slowly and deeply, hold breath for 10 sec, wait 15-30 seconds between puffs and 3-5 min between meds Rinse the cap and mouthpiece with warm water (take metal canister out) and let dry overnight Divide number of puffs by how many puffs per day to determine how many days it will last before needing to get a new one, DO NOT put in water to check if it is empty

Teaching regarding sick days

Sickness can result in hyperglycemia If patients are able to eat normally, they can continue with their regular meal plan while increasing the intake of non-caloric fluids such as water, sugar-free gelatin, and other decaffeinated beverages, and continue taking OAs, noninsulin injectable agents, and insulin as prescribed When illness causes patients to eat less than normal, they can continue to take OAs, noninsulin injectable agents, and/or insulin as prescribed while supplementing food intake with carbohydrate-containing fluids like low-sodium soups, juices, and regular, sweetened decaffeinated soft drinks It is important for the patient to tell the HCP if they cannot keep down food or fluids *Keep taking prescribed meds as ordered, may need additional insulin, check blood glucose, notify HCP of abnormals*

Glucagon

Stimulates hepatic production of glucose from glycogen stores; relaxes the musculature of the GI tract temporarily inhibiting movement; increases blood glucose

CHF assessment memorized for competency

Subjective Data: Important Health Information: Past health history: long-term exposure to chemical pollutants, respiratory irritants, occupational fumes, dust; recurrent respiratory tract infections; previous hospitalizations Meds: Use of O2 and duration of O2 use, bronchodilators, corticosteroids, antibiotics, anticholinergics, OTC drugs, herbs, medications purchased outside US Functional Health Patterns: Health perception-health management: smoking (pack-years, including passive smoking, willingness to stop smoking, and previous attempts); family hx of respiratory dz (especially alpha1-antitrypsin deficiency) Nutritional-metabolic: anorexia, wt loss or gain Activity-exercise: increasing dyspnea and/or increase in sputum volume or purulence (to detect exacerbation); fatigue, ability to perform ADLs; swelling of feet; progressive dyspnea, especially on exertion; ability to walk up on flight of stairs without stopping; wheezing; recurrent cough; sputum production (especially in the morning); orthopnea Elimination: constipation, gas, bloating Sleep-rest: insomnia; sitting up position for sleeping; paroxysmal nocturnal dyspnea *Cognitive-perceptual: HA, chest or abd soreness Coping-stress tolerance: anxiety, depression Objective data: General: Debilitation, restlessness, assumption of upright position Integumentary: Cyanosis (bronchitis), pallor or ruddy color, poor skin turgor, thin skin, digital clubbing, easy bruising; peripheral edema (cor pulmonale) Respiratory: Rapid, shallow breathing; inability to speak; prolonged expiratory phase; pursed-lip breathing; wheezing; crackles, diminished or bronchial breath sounds; decr. Chest excursion and diaphragm movement; use of accessory muscles; hyperresonant or dull chest sounds on percussion Cardiovascular: Tachycardia, dysrhythmias, JVD, distant heart tones, right-sided S3 (cor pulmonale), edema (especially in feet) GI: Ascites, hepatomegaly (cor pulmonale) MS: Muscle atrophy, incr. Anteroposterior diameter (barrel chest) Possible diagnostic findings: Abnormal ABGs (compensated respiratory acidosis, decr. PaO2 or SaO2, incr. PaCO2); polycythemia, pulmonary function tests showing expiratory airflow obstruction (e.g., low FEV1, low FEV1/FVC, large RV), chest x-ray showing flattened diaphragm and hyperinflation or infiltrates; bronchoscopy, sputum C&S

Glipizide (Glucotrol)

Sulfonylurea - primary action is to increase insulin production; hypoglycemia is a major side effect; can also cx wt gain - stimulate release of insulin from pancreatic islets, decrease glycogenolysis and gluconeogenesis, enhance cellular sensitivity to insulin; SE: weight gain, hypoglycemia

Rehab for stroke victims

The process of maximizing the patient's capabilities and resources to promote optimal functioning r/t physical, mental, and social well-being Goal is to prevent deformities and maintain & improve functioning Requires a team approach Physical therapy focuses on mobility, progressive ambulation, transfer techniques, and equipment needed for mobility Occupational therapy focuses retraining for ADLs, cognitive and perceptual evaluation and training Speech therapy focuses on speech, communication, cognition, and eating abilities THE REHAB NURSE: assess the pt, caregiver, & family with attention to the pts rehab potential, physical status of all body systems, complication cx'd by CVA or other chronic conditions, family resources & support, expectations of the pt and caregiver r/t rehab program

Fosamax (Alendronic Acid)

Treats or prevents bone diseases; helps to slow the process of bone loss by inhibiting osteoclast activity

Migraines: types and RF

Types Migraine without aura (formerly called common migraine) Migraine with aura (formerly called classic migraine) - only 10% of cases risk factors Most common age of onset 20-30 yrs, more in women (3:1) Family history, low level of education, low socioeconomic status, high workload, and frequent tension-type headaches

Seizures: types

Types Primary Generalized 1. Tonic-clonic (grand-mal): loss of consciousness, stiffening and jerking of extremities, cyanosis, salivation, incontinent, and can bite tongue during seizure - typically have aura stage, tonic = body stiff, clonic = recurrent jerking of extremities 2. Typical or atypical absence seizure (Petit mal): brief staring, eye blinking, lip jerking, lasts about 30 secs, *day-dreaming* - most common in children, post ictus: immediate, won't remember event 3. Myoclonic seizure: brief jerking or stiffening of extremities, few seconds, cluster 4. Atonic: drop attacks or falling spells, sudden total loss of muscle tone and very brief loss of consciousness. May need a helmet *RF falls/injury* Focal or partial (affecting a portion of the brain) 1. Complex (patient is unaware + motor symptoms): lose consciousness for 1-3 min, lip smacking, patting, picking at clothes 2. Simple (pt is aware): psycho-sensory; no LOC, reports aura/pain/offensive smell - Psychogenic 1. Hx of emotional or psychological abuse or specific traumatic event - Status Epilepticus State of continuous seizure activity or a condition in which seizures recur in rapid succession without return of consciousness between seizures Defined as any seizure lasting longer than 5 minutes NEUROLOGICAL EMERGENCY

Leukemia

Uncontrolled proliferation of leukocytes resulting in overcrowding of bone marrow and decreased production and function of normal hematopoietic blood cells. - Blast cells replace bone marrow resulting in bone marrow failure, which causes a decrease in RBC, WBC, and platelet count. Anemia and pallor occur due to reduction in RBC count. The decrease in WBC count leads to immunosuppression resulting in infection - ALL: most common in children, CNS involvement and meningitis - CLL: most common in adults, frequently no symptoms - AML: hypercellular bone marrow with myeloblasts - CML: insidious onset, often no s/s, hepatosplenomegaly, Dx = philadelphia chromosome - Dx: bone marrow biopsy, smear

S/S CVA

Vary - depending on part of brain affected Motor deficits - mobility, respiratory, swallowing, speech, gag reflex, self care abilities Communication - aphasia *Receptive* - unable to comprehend speech (Wernicke's area) *Expressive* - comprehends speech but can't respond back with speech (Broca's area) Affect - emotional, personality Intellectual function - memory and judgment *L CVA cautious in making judgments, R CVA impulsive and move quickly* Spatial perception deficits common with R CVA Elimination - urinary and bowel, most temporary *Act FAST*

metabolic disturbance associated with CRF and implications for patient care (i.e. pt with DM, HTN, CHF)

Waste product accumulation: BUN and Creatinine increase Altered carb metabolism: cellular insensitivity to insulin leads to impaired use of glucose, diabetic may need less insulin Elevated triglycerides: Increased insulin leads to hepatic production of trigs, increases hyperlipidemia in diabetes. **These levels don't go down with dialysis

COPD discharge planning

What is COPD, breathing and airway clearance exercises, energy conservation strategies (daily activities, PT, OT), meds (types/schedules), correct use of spacers inhalers and nebulizers (demonstrate and return demonstrate using placebo); home oxygen (explanation of rationale for use, guide for home); psychosocial and emotional issues; COPD management plan; healthy nutrition (weight gain/loss, dietician)

Cirrhosis: meds

diuretics: spironolactone, Lasix; paracentesis may be performed to remove fluid esophageal varices: goal avoid bleeding, treat URI promptly; avoid alcohol, ASA and irritating foods; beta blockers, octreotide, vasopressin (stop anything that would increase bleeding)

CHF diet and teaching

low fat, low sodium, limited to no caffeine, sometimes fluid restriction Tips: teach pt to look for sodium hidden in foods by reading labels teach pt to look for sodium in OTC medications like laxatives, cough meds, and antacids teach patient to not add additional salt when cooking or sitting down for meals

Cirrhosis: dietary restrictions

low fat, low sodium, small frequent meals, need B complex & Vitamin K high calorie, high CHO, low fat; low protein (0-40 g/day) and low Na+ vitamin supplement usually given What are foods high in sodium: canned soups and veggies, salted snacks, smoked meats and fish, olives/pickles/ketchup and beer - rest: reduces metabolic needs, incr. diuresis Ascites: low Na diet (250-500 mg/day); careful I&O and monitor electrolytes

Amyotropic Lateral Sclerosis (ALS) Lou Gehrig's Disease

progressive neurological disorder with loss of motor neurons. Sensory and autonomic systems are not affected Degenerative disease → muscle weakness → disability → disease - signs & symptoms Weakness of upper extremities, dysarthria, dysphagia, muscle wasting, *death due to resp compromise* - Assessment ROM, muscle tone, swallowing, respirations - Diagnosis: Progressive muscle weakness, electromyogram, nerve conduction study, MRI - treatment and nursing care No treatment: Riluzole slows the progress *Patient totally "with it", body is just wasting away* Facilitate communication *Reduce risk for aspiration* *Decrease pain, risk for injury, boredom*

multiple sclerosis

progressive, *autoimmune*, degenerative disease that affects *myelin sheath of neurons and conduction pathways in the CNS* → inflammation and scarring of neuron → decrease in nerve signal transmission → *motor/sensory disabilities* Signs & symptoms *Emotion/cognitive*: weak, tired, depressed, speech issues, trouble thinking or solving problems, mood swings, decreased concentration, anger, apathy *Sensation*: tremors, spasms, clumsy, numbness, tingling, dizzy, vertigo, coordination issues (+ Romberg's sign), tinnitus, decreased sensation *Vision*: nystagmus, optic neuritis (double vision, blurry vision, dull/gray vision, painful with moving eyes, dark spots in vision *Elimination*: spastic bladder, nocturia, urinary retention, constipation/diarrhea (incontinence) *Motor*: hyperactive reflexes, clonus, positive Babinski, paralysis, Sexual dysfunction, memory loss - Assessment Motor, sensory, LOC, neuro, mental, cognitive - Diagnosis: *No definitive dx test for MS* Hx, clinical manifestations, and results of certain dx tests *MRI* - may show plaques, inflammation, atrophy, & tissue breakdown *CSF analysis* - may show an increase in IgG and oligoclonal banding Evoked potential responses are often delayed To be dx with MS the pt must have: *Evidence of at least 2 inflammatory demyelinating lesions in at least 2 different locations within the CNS* *Damage or an attack occurring at different times* *All other possible dx ruled out* - treatment and nursing care *Preventing the increase of S/S*: avoid heat, calming environment, avoiding infection, avoiding overexertion Educate on importance of exercise - increases energy, decreases depression (DO NOT OVERDO IT) Collaborate with speech-language pathologist (speech and swallowing) and PT (exercise devices) Assist with *bowel and bladder control* - easy access to bathroom, self-cath, 1-2 L of water per day, skin care, increase fiber intake, stool softeners Avoid triggers (heat, cold, fatigue) Maximize independence Health promotion Assistive device help Management Teaching on meds, diet, rest, activity

lactulose (Cephulac)

reduce blood ammonia by excretion of ammonia by stools - Category: Laxative, ammonia detoxicant, Use: Chronic constipation, portal-system encephalopathy, Precautions: nausea, vomiting, and cramps, Can give enema - used to lower serum ammonia levels due to liver's inability to convert ammonia to urea to be excreted 2 -3 soft stools per day - decr. pH inhibits bacteria and traps ammonia and expels it (the whole purpose is to lower ammonia levels, even if pooping make sure it is given so those levels are lowering, ammonia come down and resolve neuro toxicity); meticulous skin care, liquid barrier, not lying in it if incontinent b/c ammonia in stool

Chronic Renal Failure: RF

risk factors for disease Family History, diabetes, age > 60 years, CVD, smoking, obesity, african american,Native American, nephrotoxic drug hx, DM and HTN

CRF: signs & symptoms and reasons for s&s

s/s: polyuria, oliguria, anuria, pyuria, hematuria, protein and casts in urine Signs and symptoms are a result of retained urea, creatinine, hormones, electrolytes, water Anemia, bleeding, infection: all because of dec production of erythropoietin, decreased in iron and folic acid, inc hemolysis, altered immune response HTN, CHF, arrhythmias: because of Na retention, imbalance in angiotensin system, increased K, dec Ca, dec perfusion Sputum, cough, dyspnea because of CHF Diarrhea, constipation, n/v, anorexia, weight loss, GI ulcers because of inc urea and inflammation of gut Lethargy, depression, apathy, encephalopathy, restless leg Infertility, dec libido, dec in hormones Renal osteodystrophy, osteomalacia, osteitis fibrosa because of Ca and Phosphorus Yellow color, pale, itching, dry and brittle hair and nails, petechiae and ecchymosis, uremic frost *uremia = itching due to uremic frost on skin*

Gout

type of arthritis due to the accumulation of uric acid in the blood that causes needle-like crystals to form in the joints Patient has increased uric acid levels by either producing too much or not excreting it Causes: high intake of purines (high fructose corn syrup, alcohol, seafood, liver, red meats, tuna, beer), kidney disease, medications (ASA, cyclosporine, diuretics), dehydration, overweight, physical stress Dx: - urate crystals in synovial fluid of inflamed joint - incr. uric acid levels (8mg/dl) signs and symptoms: - systemic dz, urate crystals deposit in joints and other body tissues -> inflam, associated with incr. levels of serum uric acid - Primary: most common, error in purine metabolism, end product is uric acid, inherited as x-linked trait, males are affected - secondary: hyperuricemia caused by another dz, renal insuff, diuretics and certain chemo -> decreased excretion of uric acid, multiple myeloma and certain carcinomas (treatment with chemo causes )-> incr. production of uric acid S/S: - acute attack: Happens randomly and lasts 1-2 weeks No long term joint damage Tends to start out in the big toe Sudden swelling and redness in one or more joints (awake at night with pain) excruciating pain and infl in one or more sm joints (usually great toe), often cx by stress, trauma, surgery, systemic infection or alcohol ingestion - Chronic gout: multiple joints involved, with "tophi" (urate crystal deposits), severity is highly variable; Happens due to chronic elevated uric acid levels which leads to repeated acute attacks Joints damaged Urate crystals form large masses called *"tophi"* Tophi - white, yellowish nodules found under the skin (helix of ear, fingers, elbow, toes) as well as in the joints or bones Itching, skin peeling Uric acid kidney stones - elevated uric acid alone is not gout, chronic infl may result in joint deformity, observe skin for tophi (ears, hands, arms), excessive uric acid -> kidney stones - *can be caused by chemo and tumor lysis syndrome* Treatment: - *colchicine*, NSAIDs to control infl, corticosteroids reserved when others fail (prolonged can incr. uric acid), *Allopurinol to decrease production* - avoid ASA -> urate retention - adequate hydration is essential to prevent precipitation of uric acid in renal tubules dietary restrictions: - avoidance of foods and fluids with high purine content (anchovies, liver, wine, beer) - low purine diet: avoid organ meat, shellfish, and sardines - limiting proteins, fad "starvation: diet and incr. alcohol -> attack - need urine with high pH (citrus fruits and juices, milk and certain dairy products) *careful with CKD* interventions to manage pain and avoid touch sensitivity: - elevate covers above the affected area, something to keep them warm but not touching; local heat/cold application, joint immobilization

Sjogren's syndrome

what it is: - inflammation and dysfunctino of exocrine glands: especially salivary and lacrimal - mostly women, 1/2 have RA or other connective tissue dz signs & symptoms: - dry mouth -> dysphagia, fissures, carries, altered taste, increased mouth infection - decr. tears -> gritty eyes with burning, blurred vision, photosensitivity - dry skin and rashes, joint and muscle pain, and thyroid problems - vaginal dryness and painful intercourse (dyspareunia) lab findings: - lymphocyte infiltration of salivary and lacrimal glands (histologic study) Diagnosis & treatment: - ophthalmologic exam, measures of salivary gland function, and lower lip biopsy of minor salivary glands aid in diagnosis - Tx: artificial tears, antiinfective drops, surgical punctual occlusion, incr. fluids with meals, dental hygiene nursing care: - use artificial tears, incr. fluids with meals, good dental care - vaginal lubrication and increased humidity in the home to decrease drying of MM - SAFETY: moisten foods, thin foods, food processor, soft/creamy foods, high calorie cold liquids, avoid salty/acidic/spicy foods

TIA

(better in 24 hours) Transient dysfunction, no acute infarct Symptoms last less than an hour Warning sign of progressive CVA Seek tx and evaluation

Rheumatoid arthritis (RA)

*Autoimmune* condition that causes inflammation of the joints, specifically the membrane lining the joint ("*synovium*") RA tends to affect fingers and wrists, but also the neck, shoulder, elbows, ankle, knees, feet Doesn't just affect joints, but *systemic* (heart, skin, lungs, anemia, etc) OA affects weight bearing joints, whereas RA affects ALL joints Cause: unknown, *EBV*, autoimmune (against IgG), 2-3x more common with *fam hx* RA can happen at *any age*, whereas OA is in older age Risk factors: RA is the 2nd most common connective tissue dz and the most destructive to joints a chronic, progressive, systemic inflammatory process affecting *synovial joints* RA has remissions and exacerbations *75% are women*, onset during childbearing years (younger women) very disabling disease (adjust lifestyle) Signs and symptoms: *extra articular manifestations*; Rh nodules most common (infl of am blood vessels -> subQ firm, non-tender mass extensor surface forearm, usually associated with severe) Arteritis and scleritis, neuropathy, pericarditis, lymphadenopathy, splenomegaly Vasculitis: inflammation of blood vessels → ischemia to major organs with malfunction (peripheral neuropathy, paresthesia, respiratory pleurisy, interstitial fibrosis, pulm HTN, cardiac pericarditis, myocarditis; ocular iritis and scleritis) *Patient will have soft, tender, warm, stiff, swollen joints* Affects same joints *bilaterally/symmetrical* (different than OA since OA is asymmetric) *Stiffness/pain worse in the mornings for > 30 min (OA is <30 min)* Early: fatigue, gen weakness, stiffness, anorexia, and wt loss with occasional low grade fever, upper ext joints initially involved (hand), joints slightly red, warm, stiff, swollen, and tender Typical pattern is bilateral and symmetric Late: joints become progressively inflamed and painful, pt c/o morning stiffness (30 min several hours), palpation: soft, due to synovitis and effusion fingers "spindle like", muscle atrophy and decreased ROM, most all synovial joints eventually affected (wrists, elbows, shoulders, knees, hips), inflammation and fibrosis of joint capsule → deformity (swann neck deformity, ulnar drift, boutonniere def, hallux valgus joint on big toe extend outward) *"SEVEN S'S"*: sunrise stiffness, soft feeling in joints, swelling in joint (warm), symmetrical, synovium (affected and inflamed), systemic (fever, fatigue, anemia, heart, lungs), stages (synovitis, pannus, ankylosis) Stages: *Synovitis*: joint inflammation at synovium site and excess synovial fluid *Formation of pannus* (inflammation granulation tissue) formed at juncture of synovium and cartilage invades joint capsule *Tough fibrous tissue* replaces pannus occluding joint space *Fibrous tissues calcifies, bony ankylosis* → total joint immobilization (fixed and unable to do everyday activities, ADLs) Diagnosis: No conclusive test- suggestive with H & P Moderate anemia *Increased ESR, + Rheumatoid factor, increased WBC count of synovial fluid* X-ray shows early bone demineralization or later narrow joint space and deformity Treatment: - ASA and NSAIDs for inflammation and pain: common, enteric coated to prevent GI SE, new gen NSAIDs = *celebrex* (cox 2 inhibitors) - Dx modifying agents = *hydroxychloroquine (Plaquenil) one of the safest* SE = n/v, abd discomfort, rash, irreversible retinal degeneration (scheduled eye exams) - Imuran can be used but cause pancytopenia (low all cells) - Humira, cimzia simponi - Surgery - joint replacement - Synovectomy - removal of synovium - Arthrodesis (joint fusion) - joint removed and the bone fused with bone graft - *Prednisone (Rayos)*: intra-articular injection with flare-ups Corticosteroid Anti-inflammatory drug (problem with chronic steroid therapy) - *Methotrexate*: mod-severe, is DOC Disease-modifying antirheumatic drugs (DMARDs) Suppresses immune system and helps slow down destruction of disease SE: bone marrow suppression, hepatotoxicity (monitor liver function test), need frequent lab evaluation Complications: infection, osteoporosis, spinal cord compression (quadriplegic/paralysis) or phrenic nerve involvement Complete nursing care and teaching - Nutrition: no special diet for RA, fatigue and pain interfere with food prep, steroids and immobility = wt gain - Goal: reduce inflammation, relieve pain, preserve joint function and prevent or correct deformity (collab with PT, OT) - Tx: anti-inflammatory meds, rest, joint protection, heat, exercise, and lots of teaching Hospital may be necessary with acute attack; physical, psych, environmental for increased fall risk - Needs scheduled rest periods, avoid total bedrest, px over exertion, good body alignment Joint protection: protect from stress, use energy conserving devices, simplify tasks Daily heat and exercise: ice for acute episodes and heat for chronic stiffness, ROM exercises daily, aquatic is good Psych support: evaluate family support, affect women of childbearing age, pt threatened by limited fxn, fatigue, loss of self-esteem, fear of disability, and deformity; financial planning, community resources

Muscular dystrophy

- progressive symmetrical wasting of skeletal muscle without neurological involvement - S/S: gradual loss of strength, incr. disability and deformity - genetic link - muscle serum enzymes creatinine kinase elevated, EMG, muscle fiber, echo (cardiomyopathy) - Bx: fat and connective tissue deposits, muscle fiber degeneration and necrosis - No way to stop progression, goal preserve mobility and independence; pt, exercise, assist devices - focus support on pt and family, avoid prolonged bedrest or immobility

Osteoporosis (OP): assessment

- sudden strain, fractures spine, hips, wrists, back pain, loss of ht, spinal deformities, one compression vertebral fx increase risk for a second within one year - Porous bones, low bone mass, structural deterioration of bone tissue, increased bone fragility

Assessing pressure ulcers & staging

1. Alteration in skin, slightly red, non blanchable 2. Partially into epidermis or dermis 3. Into subq and fat tissue 4. Tissue necrosis, down to bone and muscle

DKA

Caused by a profound deficiency of insulin & characterized by hyperglycemia, ketosis, acidosis, and dehydration S/S: poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, lethargy, weakness, soft & sunken eyes, abd pain, Kussmaul respirations (rapid, deep breathing associated with dyspnea, sweet & fruity smelling breath Labs: blood glucose > 250 mg/dL, pH < 7.30, serum bicarb < 16 mEq/L, moderate to large ketones in urine or serum Treatment: Administration of IV fluids; IV administration of short-acting insulin; electrolyte replacement; recording of I&O

Complications of CVA

Motor deficits are the most obvious effect of CVA including mobility, respiratory function, swallowing & speech, gag reflex, and self-care abilities; may have the loss of skilled voluntary movement (akinesia), impairment of integration of movements, alterations in muscle tone, and alterations in reflexes (hyporeflexia or hyperreflexia) Communication: may experience aphasia, expressive aphasia, dysphagia, dysarthria Affect: difficulty controlling emotions; exaggerated emotional response; depression & loss of control; frustration Intellectual function: memory & judgement impairment; difficulty making generalizations Spatial-Perceptual Alterations: incorrect perception of self and illness (parietal lobe); neglect of all input from affected side; difficulty with spatial orientation; agnosia; apraxia Elimination: many problems with elimination are temporary; pts with impaired mobility r/t CVA are at risk for constipation; urinary & bowel problems may also be associated with the inability to verbalize the need to eliminate or difficulty with managing clothing

Hemodialysis: Think back over your dialysis observation experience - what did the nurse do if the pt experienced nausea, dizziness, hypotension during dialysis

Nausea: slowing down rate of machine, antiemetic Dizziness: result of low BP Hypotension: slowing down rate of machine, fluid assessment prior to treatment, do not take antihypertensive before tx

Nursing care for the family caregiver of CVA pt

Need help coping with the losses associated with a CVA Supporting communication between the pt and the family Discussing lifestyle changes resulting from the CVA deficits Discussing changing roles and responsibilities within the family Being an active listener to allow expression of fear, frustration, and anxiety Including the family and pt in short-term and long-term goal planning and pt care Supporting family conferences Identifying support groups and referrals needed

Actos (pioglitazone)

Oral antidiabetic, decreased insulin resistance, resulting in glycemic control without hypoglycemia, may be used with metformin CHF, edema, macular edema, liver failure, bladder cancer, anemia

Peritoneal dialysis: complications

Peritonitis, atelectasis, pneumonia, bronchitis (all 2nd displaced diaphragm), protein loss, carb and lipid imbalances, hernias, lower back problems, bleeding, and protein loss

Safety of diabetic patient with diagnostic tests involving contrast

Hold metformin for 48 hours before and after contrast dye Check allergies to shellfish, iodine, and dyes; or any alteration in renal function

Lasix (furosemide)

Loop diuretic, used to treat edema and HTN Dehydration, electrolyte imbalances, SJS, TEN

Type 1 vs. Type 2 DM

Type 1: Immune beta cell destruction → absolute insulin deficiency Juvenile onset S/S: polyuria, polydipsia, polyphagia, weight loss, fatigue, ↑ infection risk, rapid early onset Complications: DKA (lack of insulin and presence of ketones) Electrolyte imbalance, weight loss, muscle wasting Type 2: non-insulin dependent Adult onset usually Risk Factors: sedentary lifestyle, family hx, > 50 y/o, HTN S/S: fatigue, recurrent infections Diagnostics: FBS made with 2 tests with results over 126 A1C: > 6.5% Best indicator of avg glucose over last 90-120 days

TPA

tissue plasminogen activator Intravenous injection of tissue plasminogen activator (tPA) In some instances, tPA can be given up to 4.5 hours after stroke symptoms begin This drug restores blood flow by dissolving the blood clot causing your stroke, and it may help people who have had strokes recover more fully - *For ischemic stroke NOT hemorrhagic* - Nursing interventions: check for bleeding, neuro checks, v/s, labs, monitor glucose, promote bedrest, avoid unnecessary venipunctures or IM injections, most patients will go to ICU

CVA: Safety with eating

- Gag reflex must be tested, assess and plan first feeding carefully - Check for food pocketing that may cause aspiration after feeding is over

Seizure Phases

- Prodromal: signs that precede a seizure S/S: depression, anger, difficulty sleeping, anxiety, GI & urinary issues Can start days before actual seizure - Aural: sensory warning (not all patients experience) Happens at beginning of a seizure...a warning sign! S/S: altered vision or hearing, anxiety, deja vu, sudden weird taste or smell, dizziness, inability to speak - Ictal: seizure (1-3 minutes) Greater than 5 minutes or starts to have seizures back-to-back → status epilepticus - Postictal: recovery from seizure Takes hours to days S/S: very very tired, confusion, headache, injury

S/S associated with cirrhosis and those related to complications

- angiomas on skin - Early manifestations: fatigue, anorexia, flatulence, N/V/D/C, RUQ/epigastric pain, fever, slight weight loss, hepatosplenomegaly Later manifestations: jaundice, skip lesions/spider angioma, palmar erythema (↑ estrogen in the palms) Men: gynecomastia, loss of axillary and pubic hair, testicular atrophy, impotence, decreased libido Women: amenorrhea, vaginal bleeding Complications: Portal HTN, esophageal varices, peripheral edema, ascites

Ankylosing spondylitis

- chronic infl dz affecting vertebral column and causing spinal deformities - cause is known-90% pos HLA B27 - major threat rigid chest wall -> compromised resp function - Dx studies: new bone formation *bamboo spine*, ESR, alk phosphatase and CLK are all elevated - S/S: low back pain, stiffness and limited ROM worse at night and early morning; other features: iritis, develop kyphosis with bent over posture and impaired neck movement - Nsg: goal maintain max skeletal mobility, NSAIDs

Psoriatic arthritis

- progressive inflam dz affecting about 1/3 of those with psoriasis - common benign inflam skin condition manifested as red, irritated, scaly patches - exact cause unknown, combo of environmental, genetic, immune factors - both genetic HLA link, develop psoriasis first then later PsA, can affect distal fingers and toes, pitting and color changes in nails - asymmetric or symmetric: joints similar to RA - Dx tests: xray, Uric acid levels, ESR - Tx: joint protection, splinting, PT, NSAIDs, DMARDs like methotrexate for joint and skin

Prevention of pressure ulcers

-Skin assessment should be done on a daily basis -If patient is restricted in mobility, assess the skin every 8hrs -Assess pressure points every 2hr =It is possible for pressure ulcers to occur in 2 to 3 hours. Turn patient every 2 hours Use pillows, support, donut ring for head, floating ankles to reduce pressure on pressure points Keep patient clean and dry, change incontinence briefs often

Interstitial cystitis what is it, S/S, Dx, Tx

A chronic painful inflammatory dz of the bladder Can result from allergy, vascular dz, autoimmune dz, lining defects bladder wall, abn substances in urine, unusual infections S/S: Severe bladder and pelvic pain, urinary frequency, urinary urgency, hematuria Dx: Cystoscopy, pelvic exam, UA rule out: UTI, bladder cancer, nerve problem, DM, side effect of drugs or chemicals Tx: No cure. Emliron repairs damaged lining of bladder Low dose antidepressants for pain relief Anti-inflammatories, anti-spasmodics, antihistamines Muscle relaxants Bladder instillations Avoid acidic or spicy foods, caffeine, and alcohol Kegels, hold urine, bladder retraining TENS, sacral nerve stimulation Irrigation with a three way foley cath

Peritoneal dialysis: dialysate solutions 1.5%, 2.5%, & 4.25%

A higher dextrose concentration moves fluid and more wastes into the abdominal cavity, increasing both early and long-dwell exchange efficiency. Eventually, however, the body absorbs dextrose from the solution. As the concentration of dextrose in the body comes closer to that in the solution, dialysis becomes less effective, and fluid is slowly absorbed from the abdominal cavity

Hyperglycemic hyperosmolar nonketotic syndrome (HHNK) also known as HHNS:

A life-threatening syndrome that can occur in the pt with diabetes who is able to produce enough insulin to prevent DKA, but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion S/S: blood glucose > 600 mg/dL; marked increase in serum osmolality; absent or minimal ketones; hypotension; dehydration; oliguria, anuria Treatment: immediate IV administration of insulin and normal saline; usually requires large volumes of fluid replacement; assess v/s; monitor I&O

Activity and DM

ADA recommends that people with diabetes do 150 minutes/week of moderate-intensity aerobic activity and resistance training 3x/week unless contraindicated If using meds that can cause hypoglycemia: Schedule exercise 1 hour after a meal, or have a 10-15g carb snack and the check their blood sugar after 15-30 minutes - delay exercise if glucose ≤100 Carry a fast-acting carbohydrate (glucose tablet, hard candy) Moderate-intensity activity: active housework, light bicycling, bowling, dancing, gardening, golf, roller skating, walking briskly

Hemodialysis: care of access devices AVF, AVG, CVL

AVF & AVG: No BP, no sticks on that arm, asses thrill/bruit, prevent infection CVL: maintain sterile technique, prevent infection, heparin flushes with 10 mL syringe

ASA

Acetylsalicylic Acid (Aspirin) Antipyretic, non-opioid analgesic Rheumatoid arthritis, osteoarthritis, mild to moderate pain, fever, prophylaxis of TIA and MI SE: Bleeding, dyspepsia, epigastric distress, nausea

Review Epogen & Procrit:

Action: Synthetic erythropoietin Uses: Increase RBCs in anemia, used in ESRF, HIV, cancer, also used to decrease blood transfusion reactions Contraindications: uncontrolled HTN or albumin allergy SE: HTN, h/a, n, arthralga, NIC: medicate will not pay for unless Hgb less than 9

Osteoarthritis

deterioration of cartilage, specifically of articular cartilage Involves gradual loss of articular cartilage with formation of *bony outgrowths (osteophytes)* at joint margins; not normal aging but *wear/tear* Start 20-30 yrs and symptomatic 50-60 yrs Risk factors: *Age > 65 y/o* Decreased estrogen after menopause, obesity (knees), trauma/stress, athletes of repetitive motion, lack of exercise, metabolic dz: DM and Paget's Cause: event or condition that damages cartilage or joint instability; secondary due to trauma, function, or infection Primary OA <3 joints; generalized OA >3 joints Patho: smooth white cartilage becomes yellow and opaque, fissures, pitting and ulcerations; cartilage and bone erode -> joint space narrowing and osteophytes form (spurs), inflammation of synovial membrane, subluxation and joint deformity -> immobility, pain, muscle spasms S/S: "OSTEO" *Outgrowths "bony"* from bone spurs that cause redness, swelling, and tenderness Heberden's nodes: develops in the distal interphalangeal joints of fingers and toes; common in women; most common type of malformation Bouchard's nodes: develops in the proximal interphalangeal joints of fingers and toes; less common *Sunrise stiffness less than 30 minutes* *Tenderness* when touching joint site with bone overgrowth (no warmth) *Experience crepitus* → joint pain with activity, but goes away with rest *Only the joints*: weight-bearing joints; not systemic; not symmetrical Hips: may be very disabling, pain on motion or wt bearing (affected by weather) Knees: obesity implicated mechanical stress *S/S increase with humidity/weather/pressure*, crepitation may be heard or felt, affects joints *asymmetrically* Most common joints = hands, hips, knees, lower lumbar and cervical vertebra Teaching: - Therapy aimed at: pain control, prevention of progression and disability, restoration of joint function - no specific tx, usually confined to a few joints and is not crippling - healthy wt, use assistive devices, avoid forceful repetitive movements, avoid awkward positions, use good posture and body mechanics, seek help with needed tasks that cx pain, organize routine tasks and pace self, modify home and work environment to decrease stress protecting joints: - nutrition: wt reduction - health promotion: eliminate strain on joints, body mechanics, message, heat/cold, low impact exercise, complementary and alternative therapies = massage, tai chi, acupuncture - Goal: manage pain, maintain joint mobility, wt reduction, independence in self care Diagnosis: - no specific labs for OA - x-rays shows joint space narrowing - *ESR is usually normal* - *synovial fluid analysis = increase in volume* Treatment Naproxen and other NSAIDS: - 1st line: acetaminophen 1g/day with topical agents, Ibuprofen 400 mg 4x/day (*GI upset and gastritis*) - 2nd line: full dose NSAIDs (watch adverse SE & not with kidney dz, may combo with Pepcid to prevent gastritis) - new gen NSAIDs: celebrex (cox-2-inhib) less GI problems - Intra-articular inj: corticosteroids, used with flare-up of OA (don't use systemic steroids) - Tx: surgery, total hip replacement, arthroscopy, *no cure!*

CRF: Risk factors for fluid/electrolyte imbalance (what & why)

Inability to excrete electrolytes and retain Na so H2O is retained causing fluid imbalance - the more severe, the worse the imbalance

CVA: types

*Ischemic strokes*: 1. Thrombotic strokes: occurs from injury to a blood vessel wall and *formation of a blood clot*. The lumen of the blood vessel narrows and if occluded leads to infarction. *Most common* type of strokes (60%). Seen often in patients with high cholesterol, atherosclerosis, DM, or HTN. More common in men; oldest median age; *often during or after sleep; stepwise progression; s/s develop slowly* 2. Embolic Strokes: Occurs when an *embolus lodges* in an occludes a cerebral artery, resulting in infarction and edema of the area supplied by the involved vessel (clot travels to brain) Embolism is *2nd most common* cause of stroke Most originate in the endocardial layer of the heart, with the plaque breaking off from the endocardium and entering circulation More common in men; *sudden onset likely to occur during activity; s/s develop quickly* *Hemorrhagic Strokes*: 1. Intracerebral hemorrhage: Due to *ruptured vessels associated with HTN* No prodromal TIA but severe HA *Poorest prognosis and higher mortality rate* 30 day mortality rate (40-80%) 50% deaths occur within first 48hrs HTN most common cause, other vascular disorders, coag disorders, anticoagulant, and thrombolytic drugs, trauma, brain tumors, & ruptured aneurysms *Usually occurs during period of activity* *Sudden onset, progressive over minutes* to hours because of ongoing bleeding S&S→ *neuro deficits, HA, N/V, decreased LOC, HTN* 2. Subarachnoid hemorrhage: *Intracranial bleeding* into cerebrospinal fluid filled space between arachnoid & pia mater membranes on brain surface Commonly occur with *ruptured aneurysm* (40% die first episode, 15% from subsequent bleeding) Other causes → trauma & illicit drug abuse (cocaine) May have prodromal HA → *"worse ha ever!"* LOC depends on severity of bleed *Focal neuro deficits N&V, seizures, stiff neck*

Parkinson's disease nsg care and symptoms

*Parkinson's disease: damage or loss of dopamine producing cells in substantia nigra - Dopamine's significance = creates accuracy with movement; inhibitory neurotransmitter - Affects older adults (60+), no cure, cause is unknown nursing care Assess swallowing or get speech path Impaired mobility, nutrition, swallowing, communication Maintain safety Encourage mobility, ADLs, independence - Safety: assistive devices, patient should change position slowly, patient should wear low heel shoes without rubber sole Education for "freeze-ups": change direction of movement, use a cane or walker with laser pointer, don't push through it - Psychosocial: make patient feel independent Education to maintain their independence: special cookware and utensils, shirts without buttons/zippers, support groups, exercise, shoes that don't tie, destress, encourage ADLs and mobility - Digestion/nutrition: assess swallowing (speech path), soft easy-to-chew foods, high fiber diet with 2L of water per day, watch protein rich foods with medications Symptoms and expected assessment findings: Muscle rigidity, bradykinesia, tremors: shuffling gait, pill rolling tremor, cogwheel rigidity, loss of automatic movements like blinking, stooped posture, masked face, drooling, dec BP, sweating, conjunctivitis - Tremors: tremors at rest (especially hands, arms, legs, lips, tongue), pill-rolling tremor, tremors improve with purposeful movement - Muscle rigidity (arms don't swing with gait) - Bradykinesia: movements are slow (drooling, mask-like face, chewing issues, slurred speech) - Shuffling gait, cogwheel rigidity, loss of automatic movements like blinking, stooped posture, dec BP, sweating, conjunctivitis - Non-motor S/S: loss of smell, constipation, depression

Huntington's disease

*hereditary (autosomal dominant) def of Ach and GABA (excitatory transmitters) and excess dopamine* - signs & symptoms Brisk, jerky, purposeless movements that pt can't control, decline in mental and emotions, progressive dementia like mental change, chloroform movements (jerky) - Assessment Assess movements and safety of environment, patient's understanding of disease, cognition deterioration - Diagnosis Review family history and clinical symptoms along with genetic testing - treatment and nursing care Usually palliative care Tetrabenazine (Xenazine) - tx of chorea Increased caloric intake needed - 4,000-5,000 calories/day to maintain body wt Discussion of end-of-life care

Plavix (clopidogrel)

Anti-platelet aggregation, reduction in risk of MI and stroke SE: SJS, TENS, bleeding All HCP and dentists should be informed that the drug is being taken especially before scheduling surgery or major dental procedures, drug may have to be discontinued 10-14 days before surgery if anti-platelet effect is not desired

Heparin

Anticoagulant, prophylaxis and treatment of venous thromboembolism, pulmonary emboli, atrial fibrillation with embolization SE: Bleeding, HIT, anemia Assess PTT, protamine sulfate is antidote

Coumadin (warfarin)

Anticoagulant, prophylaxis and treatment of venous thrombosis, pulmonary embolism, atrial fibrillation with embolization Management of MI: decreases risk of death, subsequent MI, and risk of future of thromboembolic events Dermal necrosis, cramps, nausea, CALCIPHYLAXIS, BLEEDING High alert, assess for bleeding and hemorrhage Assess PTT/INR, vit K is antidote

Imitrex (sumatriptan)

Antimigraine, 5-HT1 agonist SE: serotonin syndrome, commonly cause chest/jaw/neck tightness, pain, or pressure that is usually not serious. However, these side effects are like symptoms of a heart attack, which may include chest/jaw/left arm pain, shortness of breath, or unusual sweating, hypertension, Flushing, feelings or tingling/numbness/prickling/heat, tiredness, weakness, drowsiness, or dizziness may occur.

Nursing interventions with cerebellar dysfunction, brainstem infarct

Cerebellar dysfunction Goal: maintain optimal function by preventing joint contractures and muscular atrophy In acute phase ROM and positioning are important nursing interventions Exercise is important for rehabilitation and recovery Position each joint higher than the joint proximal to it to prevent dependent edema Place a trochanter roll at the hip to prevent external rotation Hand cones (not wash clothes) to prevent hand contractures Arm supports with slings and lap boards to prevent shoulder displacement Avoidance of pulling the pt by arm to avoid shoulder displacement Posterior leg splints, footboards, or high-top tennis shoes to prevent foot drop Hand splints to reduce spasticity Nsg interventions with brainstem infarct Respiratory is priority; particularly vulnerable to respiratory problems, atelectasis, and pneumonia Risk for aspiration pneumonia is high because of altered LOC and dysphagia. Airway obstruction can happen from problems with chewing and swallowing, food pocketing, and tongue falling back some , especially those with brainstem or hemorrhagic stroke, are more at risk for needing endotracheal intubation or mechanical ventilation All pts need to be screened and kept NPO until swallow study is done

Chronic bronchitis and teaching

Chronic Bronchitis is the presence of cough and sputum production for at least 3 mon. in each of 2 consecutive years Teach Huff Coughing Inhale slowly through the mouth while breathing deeply through diaphragm; hold breath for 2-3 seconds; forcefully exhale quickly as if to fog up a mirror creating a huff; repeat the huff 1-2 more times while refraining from regular cough; cough when mucus is felt to be moving through the breathing tubes; rest for 5-10 regular breaths; repeat the huffs until you feel you have cleared the mucus

Avandia (rosiglitazone)

Classification: Antidiabetic. Thiazolidinediones Therapeutic Effects: Decrease insulin resistance Adverse Reactions & side effects: Edema, anemia, wt gain, increased cholesterol Nursing Implications & teaching: Monitor for fluid retention, hypoglycemia. Check PLFTs & CBC High Alert Medication!

Keppra (levetiracetam)

Common: aggression, agitation, anger, anxiety, apathy, depersonalization, depression, dizziness, drowsiness, fatigue, hostility, irritability, personality disorder, psychosis, weakness, HTN Life threatening: suicidal thoughts, SJS, TEN, agranulocytosis, anaphylaxis, DRESS

Depakote (valproic acid)

Common: agitation, dizziness, HA, insomnia, sedation, visual disturbances, abd pain, anorexia, diarrhea, indigestion, N/V, thrombocytopenia, tremor Life threatening: suicidal thoughts, hepatotoxicity, pancreatitis, DRESS, hyperammonemia, hypothermia

Dilantin (phenytoin)

Common: ataxia, diplopia, nystagmus, hypotension, gingival hyperplasia, nausea, rash Life threatening: Suicidal thoughts, acute hepatic failure, SJS, TEN, agranulocytosis, aplastic anemia, DRESS

Lamictal (lamotrigine)

Common: ataxia, dizziness, HA, N/V, photosensitivity, rash Life threatening: aseptic meningitis, suicidal thoughts, hepatic failure, SJS

Tegretol (carbamazepine)

Common: ataxia, drowsiness Life threatening: suicidal thoughts, hepatotoxicity, pancreatitis, DRESS, SJS, TEN, agranulocytosis, aplastic anemia, thrombocytopenia

Topamax (topiramate)

Common: cognitive disorders, dizziness, drowsiness, fatigue, impaired concentration, nervousness, speech problems, sedation, abnormal vision, diplopia, nystagmus, nausea, metabolic acidosis, weight loss, ataxia, paresthesia Life Threatening: seizures, suicidal thoughts, bleeding

Neurontin (gabapentin)

Common: confusion, depression, dizziness, drowsiness, ataxia Life threatening: suicidal thoughts, rhabdomyolysis, anaphylaxis, angioedema

Phenobarbital (Luminal)

Common: hangover, delirium, depression, resp depression, hypotension, N/V/C/D, photosensitivity Life threatening: laryngospasm, angioedema, serum sickness

Review of dx tests for seizures

Comprehensive seizure hx (H&P) EEG- not definitive CBC, BMP, liver and kidney fxn tests CT and MRI (LP to r/o meningitis)

COPD review complications

Cor pulmonale (d/t pulmonary HTN), acute exacerbations (d/t infection), & acute respiratory failure, polycythemia (d/t overstimulation of EPO from hypoxemia)

Hemodialysis: Advantages and disadvantages

In-center treatment time is 3-5 hours, 3 times a week. People who do home hemodialysis have more flexibility about how often it can be done. If done daily, treatment time would be 1½ to 2 hours (Adv): Trained staff perform all aspects of treatment. (You may be able to do some things yourself like insert the needles.) Since other people are dialyzing at the same time, friendship and camaraderie may develop. (Disadv): Treatment day and times are scheduled by the center. You must travel to the center at least three times weekly. Other people are doing dialysis at same time, so you have less privacy Loved ones can't be with you during treatment. There may be rules against eating and drinking while on dialysis. Adv: Studies show that having dialysis at home 5-7 times a week has dramatically better outcomes in every way, including longer life and better survival; You and your dialysis partner learn to do treatments without the in-center staff, Dialysis is done in the comfort of your own home; No need to travel to a dialysis center; More flexibility to choose a convenient time of day to do dialysis; Greater sense of control from being independent and doing treatment yourself. Disadv: A dialysis partner must be present while you are on dialysis; Both you and your dialysis partner must take time off work or regular routine to attend training; Space in the home needs to be dedicated to the machine, water system (if needed) and supplies; Special electricity and plumbing may be needed; There are no medical professionals at home to monitor treatment or answer immediate questions (although you can call the center at any time, and go to the center periodically to be checked).

RF for CVA

Increases with age, doubles each decade after 55 yrs - "STROKES HAPPEN" = Smoking, thinners, rhythm changes (a fib), oral contraceptives, kin (family hx), excessive weight, senior citizens, hypertension, atherosclerosis, physical inactivity, previous TIA, elevated glucose (DM), aneurysm brain More common in men, but more women die from stroke 2x more common in African Americans Family history of stroke, subarachnoid hemorrhage, or aneurysm *HTN (most important)*, heart disease, DM, smoking, obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet, drug and alcohol abuse

COPD nsg dx (prioritized) & interventions

Ineffective breathing pattern r/t alveolar hypoventilation, anxiety, chest wall alterations, and hyperventilation Elevate HOB, teach breathing exercises, monitor ABGs, monitor pulse ox, lung sounds, respiratory status, skin, LOC, O2 Ineffective airway clearance r/t expiratory airflow obstruction, ineffective cough, decreased airway humidity, and tenacious secretions Increase fluids, chest physiotherapy, mucolytics, expectorants, huff cough, TCDB, elevate HOB, O2 Impaired gas exchange r/t alveolar hypoventilation Elevate HOB, teach breathing exercises, monitor ABGs, monitor pulse ox, lung sounds, respiratory status, skin, LOC, O2

Insulins

Inhaled Insulin: (afrezza), Onset: 12-15 min, Peak: 60 min, Duration: 2.5-3 hours Rapid-acting Insulin: (Lispro), Onset: 10-30 min, Peak: 30 min-3 hours, Duration: 3-5 hours Short-acting Insulin: (Humulin R, Novolin R), Onset: 30 min-1 hour, Peak 2-5 hours, Duration: 5-8 hours Intermediate Insulin: (Humulin N, NPH), Onset: 1.5-4 hours, Peak 4-12 hours, Duration: 12-18 hours Long-acting Insulin: (Glargine, Lantus): Onset: 0.8-4 hours, Peak: None, Duration: 16-24 hours

teaching related to diabetes, diet, meds, exercise, glucose monitoring, and long term complications

Insulin Administration: evaluation of his/her abilities to safely manage their therapy; rotating sites for each injection; correct storage of insulin vials; correct disposal of insulin syringes and vials Oral & Non Insulin injectable agents: proper administration of the drugs; assessment of the pts use and and response to the drugs; inform the patients that these meds are used along with diet change and exercise (lifestyle changes); do not take extra pills if you have overeaten; teach about hypoglycemia Personal Hygiene: encourage daily toothbrushing to decrease risk for periodontal dz; regular visits to the dentist; emphasis on foot care; avoid going barefoot; wear supportive & comfortable shoes; monitor wounds for decreased wound healing Medication ID & Travel: carry medical identification at all times indicated that he/she is a diabetic; have a medical care that says the name of your HCP, type of DM, type & dose of insulin, non insulin injectable agents, or OAs; encourage the pt to get up q 2 hours when traveling to decrease r/f DVT; keeps snacks in carry-on luggage Patient and Caregiver Teaching: ADA website, psychosocial support Glucose monitoring: teach correct blood glucose monitoring; include when to check blood glucose levels, how to record them, and how to adjust insulin levels if necessary Exercise: Discuss the effect of regular exercise on the management of blood glucose, improving cardiovascular function, and general health Diet: Stress the importance of a well-balanced diet as part of the diabetes management plan; explain the impact of CHO on the blood glucose Eyes: need a regular eye exam to keep track of ocular changes and prevention of retinopathy, blindness

CA prevention (Review screening table and think about age and gender specific)

Reduce or avoid exposure to known carcinogens (cigarette smoke, tanning beds, sun exposure) Eat a balanced diet that includes vegetables and fresh fruits, whole grains, and adequate fiber. Reduce dietary fat and preservatives including smoked and salt-cured meats containing high nitrite concentrations Limit alcohol intake Participate in regular exercise (30 min or more of mod intensity/5x per week) Maintain a healthy weight Obtain adequate, consistent rest (6-8 hours of sleep/night) Eliminate, reduce, or change perception of stressors Have a regular physical exam that includes a health history. Be familiar with you own family history and your risk factors for cancer. Learn and follow American Cancer Society's recommended cancer screening guidelines for breast, colon, cervical, and prostate cancer. Learn and practice self-examination (breast or testicular) Know the 7 warning signs of cancer and inform the HCP if they are present Seek immediate medical care if you notice a change in what is normal for you and if cancer is suspected. - Cancer-related deaths are higher in men than in women; African Americans have a higher death rate from cancer than whites. Thyroid cancer is more prevalent in women. Prostate cancer is the most common type of cancer in men. The incidence of lung cancer is the same for men and women. - The mortality rate from lung cancer is higher in men than in women. The highest incidence of cancer among men is prostate cancer. Head and neck cancers occur more frequently in men than in women. Therefore the nurse should include these statements in the teaching session. Men, not women, are more likely to develop liver cancer. Men are also more likely than women to die from cancer-related deaths each year.

Treatment for pressure ulcers

Reduce pressure on the affected area Wet dressing: moisture helps the wound heal Wound care nurse, prescribed antibiotics or anti-infectives Debridement if dead tissue areas Negative pressure therapy/wound vac Good nutrition: additional calories and protein needed

Kayexalate (sodium polystyrene sulfonate)

Reduces serum potassium levels (used to treat hyperkalemia) SE: constipation, fecal impaction, anorexia, gastric irritation, ischemic colitis, N/V, hypocalcemia, hypokalemia, sodium retention, hypomagnesemia

Renal and bladder cancer: Dx

Renal cancer CT scan, ultrasound, angiography, biopsy, and MRI, radionuclide isotope scanning Bladder cancer Urinalysis, urine cytology studies, cystoscopy with biopsy, CT scan, and ultrasound

Renal and bladder cancer: S/S

Renal cancer Early stage kidney cancer usually has no symptoms Hematuria, flank pain, palpable mass in the flank or abdomen, weight loss, fever, HTN, and anemia Bladder cancer *Painless hematuria*, bladder irritability with dysuria, frequency, and urgency, epithelial bladder cells in urine

Renal and bladder cancer: Tx

Renal cancer Surgical therapy (partial or radical nephrectomy), ablation, cryoablation, radiation, chemotherapy, immunotherapy, targeted therapy Bladder cancer Surgical therapy (transurethral resection with fulguration, laser photocoagulation, open loop resection with fulguration, cystectomy-segmental, partial, or radical), radiation, intravesical immunotherapy, intravesical chemotherapy, systemic chemotherapy and immunotherapy

Renal and bladder cancer: RF

Renal cancer: male, smoking, increased age (50-70), first-degree relative of someone has had or has renal cell carcinoma, obesity, hypertension, exposure to asbestos, cadmium, and gasoline, those who have acquired cystic disease of the kidney associated with ESRD Bladder cancer: male, increased age (60-70), cigarette smoking, exposure to dyes used in rubber and other industries, women treated with radiation for cervical cancer, pts who receive cyclophosphamide, patients on pioglitazone (DM drug), pts with chronic recurrent renal calculi and chronic lower UTIs, and indwelling catheters for long periods of time

Compare right sided and left sided stroke & expected problems based on location of stroke

Right -brain damage Paralyzed left side (hemiplegia) Left sided neglect Spatial-perceptual deficits Tends to deny or minimize problems Rapid performance, short attention span Impulsive, safety problems Impaired judgement Impaired time concepts Left-brain damage Paralyzed right side (hemiplegia) Impaired speech/language aphasias Impaired right/left discrimination Slow performance, cautious Aware of deficits: depression, anxiety Impaired comprehension r/t language, math

Peritoneal dialysis: teaching

With peritoneal dialysis, the blood is cleaned *inside your body*, not outside. The lining of your abdomen (the *peritoneum) acts as a natural filter*. During treatment a cleansing solution, called dialysate, flows into your abdomen (your belly) through a soft tube called a PD catheter. Wastes and extra fluid pass from your blood into the cleansing solution. After several hours, you *drain* the used solution from your abdomen and *refill with fresh cleansing solution* to begin the process again. Removing the used solution and adding fresh solutions takes about a half hour and is called an "exchange." *Daily cath care* Check your PD catheter every day for signs of cracking or pulling Do not wear tight clothes and belts around the exit site Wash your hands with soap and water for at least two minutes and dry them with a disposable paper towel before handling your PD catheter, and before and after an exchange is made Tape the PD catheter down to your skin Keep the PD catheter away from scissors or other sharp objects Cleanse the PD catheter thoroughly with a washcloth and soap every day Keep a special dressing over the exit site if your dialysis care team tells you to do so Do not allow tugging or pulling of your PD catheter

Hemodialysis: assessment

Your weight, blood pressure, pulse and temperature are checked. The skin covering your access site is cleansed, heart and lung sounds, edema, condition of vascular access, temp and condition of skin, compare last dialysis wt with present wt (*determines amount to be removed, wt gain should be no more than 1-1.5 kg or 2.2-3.3 lbs*) Monitor for fluid overload Because blood pressure and heart rate can fluctuate as excess fluid is drawn from your body, your blood pressure and heart rate will be checked several times during each treatment.

Nephrotoxic drugs

abuse of aspirin or ibuprofen, antibiotics - gentamicin Amino-glycosides Amphotericin B ACE inhibitors Acyclovir Cisplatin Cyclosporine Loop diuretics NSAIDs Tacrolimus

COPD meds

antibiotics: due to frequent infections, rocephin, zithromax, levaquin (only if complication of pneumonia, get C&S) bronchodilators: used as maintenance beta adrenergic agonists, anticholinergics esp atrovent, combo drugs combivent anti-inflammatories: controversial; corticosteroids: solumedrol, prednisone

Osteoporosis (OP): S/S & RF

chronic, progressive metabolic bone disease - porous bone, low bone mass, structural deterioration of bone tissue, increased bone fragility RF: - women > men due to lower Ca intake, less bone mass because of smaller frame, bone resorption begins earlier and accelerates after menopause, pregnancy and breast feeding deplete women's skeletal reserve of calcium, longevity increases likelihood of osteoporosis, women live longer - "CALCIUM": calcium & vitamin D deficiency, age, lifestyle (smoking, ETOH use, sedentary), Caucasian or Asian women, inherited, underweight (BMI <19, small frame, anorexia), medications (glucocorticoid use > 3 months, anticonvulsants) Early menopause, low testosterone in men - Drugs that interact with bone metabolism: corticosteroids, PPI, anti-seizure, aluminum antacids, CA tx, excess TH - Female gender, increasing age, low body weight, White or Asian ethnicity, family hx, early menopause, ETOH, smoking, sedentary, insufficient Ca, long-term use of corticosteroids, thyroid replacement, anti-seizure drugs, low testosterone in men - Patho: peak bone mass before age 20, determined by heredity, nutrition, exercise, and hormone function - bone loss after midlife is inevitable but rate of loss is variable - *bone resorption exceeds bone deposition* (osteoclasts > osteoblasts), *occurs most commonly in spine, hips and wrists* S/S: - wedging and fractures of vertebrae produce gradual loss of ht and a humped back (Dowager's hump or kyphosis) - the usual *first signs are back pain and spontaneous compression fractures* - *"FRAIL"*: fractures (hips, wrists, spine), rounding of upper back (Dowager's hump or kyphosis), asymptomatic, inches of height lost 2-3 inches, low back/neck/hip pain on palpation or activity that puts pressure - Termed "silent disease" because no symptoms - No signs, usually first sign is back pain or spontaneous fracture *Age > 60 = have ht checked every year* Dx: H&P, bone mineral density scan (BMD), ultrasound, dual energy x-ray absorptiometry, osteoporosis is a BMD less than or equal to 2.5 standard deviations below a young adult BMD, *osteopenia is more than normal bone loss but not yet at the level of osteoporosis*

Scleroderma

what it is: - *disorder of connective tissue* characterized by fibrotic, degeneration, and occasional inflammatory changes - cardinal features: *skin thickening and tightening & whitening of fingers* - may be rapidly progressive with fatal outcome - more benign *"CREST" variants*: calcinosis, esophageal hypo mobility, raynaud's phenomenon, sclerodacytly, white fingers - cx: unknown, collage overproduction, this leads to problems with lungs, kidney, heart, and GI tract signs & symptoms: - tight incontinence and whitening of fingers - Raynaud's phenomenon: vasospasm of digits, decreased blood flow to digits on exposure to cold - skin/joint: symmetric painless swelling or thickening of skin of fingers and hands; skin loses elasticity = taut or shiny (expressionless) - organs: esophagus hypo motility = GERD, lungs pleural thicken, heart dz = pericarditis and arrhythmia, *renal dz = malignant HTN (major cause of death)* lab findings: - mildly elevated ESR and ANA antibodies - x-ray of hands and chest - skin biopsy Diagnosis & treatment: - anti-infl: ASA, NSAIDs- steroids for myositis - Raynaud's = vasodilators (Ca-channel blockers), reserpine increased blood flow to fingers - PT = maintain joint mobility and muscle strength nursing care: - keep warm, wearing gloves on hands - daily assess v/s, wt, I&O, resp. function, ROM (renal issues) - avoid stress, cold, finger sticks (makes vasospasms worse) - protect hands and feet from cold - discourage smoking (more vasoconstriction) - lotion to dry skin - eat 6 sm meals/day and encourage increased fluids (because of hypo motility of esophagus) - psych support

Fibromyalgia

what it is: - more common in women - differs from SEID: chronic pain syndrome of unknown etiology - *no known cause, good prognosis, exercise and relaxation are essential* signs & symptoms: - fatigue, stiffness, myalgia, arthralgia, HA, IBS, sleep disturbance (50% are associated with irritable bowel syndrome) - muscles, ligaments, tendons affected = no joint damage - *pain: deep muscular aching, throbbing, shooting, stabbing, and or burning may occur* - sleep disturbances - *fatigue: mild to incapacitating, "legs are tied to concrete blocks" or "brain fog"* - *irritable bowel syndrome* - TMJ dysfunction syndrome - other common symptoms: premenstrual pain, chest pain, morning stiffness, numbness and tingling, swollen, dry eyes, moth, impaired coordination, sensitivity to sounds, odors etc. lab findings: - *Muscle biopsy may reveal a nonspecific moth-eaten appearance* or fiber atrophy *1. Pain is experienced in 11/18 sites & 2. Widespread pain that occurs on both sides of body for at least 3 months* Diagnosis & treatment: - made by tender points 18 pts, tender in normal pt, will be hypersensitive in FM - hx widespread pain and presence of at least 11 out of 18 tender points - Tx: tylenol, elavil, flexeril, benzos, ambien, massage, heat/cold, stretching, yoga, avoid sugar/caffeine/alcohol, vitamins minerals, biofeedback, counseling nursing care: - NSAIDS for pain, antidepressants (Elavil), muscle relaxants, stress mgt, deep relaxation, good exercise program-best to reduce stress, combine physical fitness, stress reduction and psychologic counseling - lots of complementary therapies