Remediation 2

Type 2 Diabetes

Kaplan Overview Chronic systemic disease characterized by glucose intolerance stemming from impaired tissue sensitivity to insulin and impaired insulin secretion; requires oral hypoglycemics to stimulate insulin production and may also receive insulin; ketosis rare; indications include the classic trio of polyuria, polydipsia, polyphagia, all stemming from hyperglycemia; other diagnositc symptoms include recurrent blurred vision, weakness, fatigue, dizziness; both hypoglycemia can occur with diabetes, each with its own characteristi csymptoms and appropriate treatment, nursing interventions include perform teachngs related to hypoglycemia and hyperglycemia symptoms and appropriate treatments dietary management, teach about oral hypoglycemic agents' function and management (including instruction about insulin in case it is requiredin their condition per physician order), teach self monitoring of blood glucose, teach skin and foot care, exercise b. Essential Nursing Care Type 2 diabetes involves the body's ability to produce some insulin, but cells are resistant to its effects Signs and Symptoms: polyuria (increased urination), polydipsia (excessive thirst), polyphagia (increased appetite), nocturia (increased urination at night), blurred vision or other vision changes, fatigue and weakness, slowly healing skin lesions, numbness of the hands and feet, vaginal infections, irritability, weight loss, dry skin Nursing Care: Design a meal plan that is feasible for the patient, but adequately controls blood glucose levels (less than 120mg/dL before meals; 180mg/dL) to avoid hyperglycemia, hypoglycemia, or keto-acidosis, teach the patient the importance of adhering to a carefully planned diet to meet nutritional needs, control blood glucose levels, and maintain a proper body weight, monitor patient's hemoglobin A1C levels to assess long-term diabetes control, administer oral anti-diabetic agents as prescribed, and monitor patient for adverse reactions, design an aerobic exercise program that suits the patient's lifestyle, incorporating activity at least three times a week for 45 to 60 minutes c. Background Nursing Care Type 2 diabetes involves the body's ability to produce some insulin, but cells are resistant to its effects Diabetes: Metabolic disease; presents as hyperglycemia (high level of blood glucose). Type 2: Patient produce some insulin but cells in the body are resistant to its effects; must take oral hypoglycemic or insulin Causes/ Risk Factors: Family history of diabetes, Obesity, African-American, Hispanic- American, Native- American, Asian, American, Pacific Island heritage, age over 30 years, High blood pressure, reproductive history positive for gestational diabetes, high-density lipoprotein or triglyceride level, hormonal contraceptives and pregnance, increased hepatic glucose production, insulin antagonists Diagnostic Tests: Fasting plasma glucose test; at least two tests indicationg above 126 mg/dL, if fasting glucose is normal, then two blood glucose levels above 200 mg/dL during a 2-hour glucose tolerance test, ophthalmologic examination showing diabetic retinopathy, plasma insulin level dtermination, urinetesting for glucose and ketone bodies, glycosylated hemoglobin (Hb A1C) determination, which reflects blood glucose levels over several months

Allergies

Kaplan Overview Hypersensitivity caused by exposure to an allergen; reaction includes shortness of breath, wheezing, inflamed airways, itching, congestion, erythema; allergic reaction is caused by immense amounts of histamine rapidly dispersed throughout the circulatory system, resulting in extensive vasodilation and severe edema of the bronchial tissue; common Nursing Care: Obtain a detailed history, establishing airway, administering aqueous epinephrine through EpiPen and/or diphenhydramine (Benadryl) and/or aminophylline for severe bronchospasm and/or vasopressors for severe shock, starting IV with large-bore needle Client Education: inhaler and EpiPen, how to avoid allergens, Sexually transmitted disease

Cystic Fibrosis (CF)

Kaplan Overview Hereditary dysfunction of exocrine glands, causing obstructions because of flow of thick mucus; involves dysfunction in sweat glands, respiratory, and GI systems (particularly pancreas voracious appetite early in disease and loss of appetite later, difficulties with eating due to respiratory difficulties; b. Essential Nursing Care Cystic Fibrosis is a chronic, progressive, inherited condition in which the viscosity of the bronchial, pancreatic, and mucous gland secretions is increased. The accumulation of thick, tenacious secretions in the bronchioles and alveoli causes respiratory changes, resulting in frequent respiratory tract infections, including pneumonia. Cystic Fibrosis also affects the intestines, pancreas, and liver. Signs and symptoms 1. barrel chest 2. distended abdomen 3. paroxysmal (sudden severe) cough 4. yellow-green sputum 5. wheezing and crackles 6. dyspnea 7. cyanosis 8. clubbing of the fingers and toes Treatment 9. because there is no cure for this inherited condition, treatment is pallative to help the patient lead as normal a life as possible. Treatment depends on the organ system involved: Nursing Care 10. Teach patient to recognize and manage symptoms in order to prevent complications, including reducing exposure to crowds or ill individuals. 11. Perform chest physiotherapy (i.e. postural drainage, chest percussion, breathing exercises) to encourage the clearance of secretions. Instruct patient and family members how to do this at home several times a day. 12. Auscultate the chest for wheezing and crackles. 13. Observe for signs and symptoms of respiratory infections. 14. Examine sputum for color and consistency. 15. Administer broad spectrum antibiotics (i.e. oral, aerosol, intravenous), bronchodilators, mucolytic agents (e.g. dornase alfa, N-acetylcysteine), anti-inflammatory agents (e.g. corticosteroids), and oxygen therapy as needed. 16. Measure and maintain electrolyte balance. 17. Instruct patient on use of pancreatic enzymes with meals and snacks to prevent problems with digestion and absorption 18. Discuss fluid and dietary intake, making sure it is adequate. 19. Monitor weight gain or loss. 20. Develop an exercise program to maintain functional status. 21. Discuss end-of-life issues with patient experiencing progressive disease. c. Background Nursing Care Cystic Fibrosis is an inherited autosomal recessive disease, manifested primarily by chronic and progressive respiratory symptoms. Background information 1. Because cystic fibrosis is autosomal recessive (a defective recessive gene is carried on an autosome), the affected individual must inherit a mutated cystic fibrosis gene from each of his parents 2. The cystic fibrosis transmembrane conductance regulator (CFTR) gene, which has been implicated in this disease, is located on chromosome 7. 3. It is hypothesized that there are more than 900 CFTR mutations that code for cystic fibrosis. Causes/Risk Factors 4. Individuals at risk include those whose parents are carriers of the defective cystic fibrosis gene. 5. It has been estimated that 1 in 31 people in the United States are carriers of this defective gene.

Mantoux

Kaplan Overview Signs and Symptoms 1. Expiratory wheezing 2. Recurrent nonproductive cough 3. Chest tightness 4. Shortness of breath with activity or at rest 5. Decreased breath sounds 6. Prolonged expiration 7. Tachycardia 8. Tachypnea 9. Accessory muscle use Treatment 10. Removal of precipitating causes 11. Airway maintenance and cough enhancement techniques 12. Oxygen 13. Bronchodilators (beta-adrenergics, cholinergic antagonists, theophylline, 14. Influenza and pneumococcal vaccinations 15. Corticosteroids 16. Leukotriene modifiers 17. Anti-IgE antibody 18. Allergen immunotherapy Nursing Care 19. Educate patient about reduction of risk factors 20. Administration and monitoring of oxygen therapy 21. Increased fluid intake to liquefy secretions 22. Educate patient about cough enhancement techniques 23. Educate patient about use of peak flow meter 24. Education patient about used of metered dose inhalers or dry powder inhalers 25. Anxiety reduction and rest during acute attacks 26. Education about exercise regimen b. Essential Nursing Care Determines whether a person has been infected with the TB bacillus. Tubercle bacillus extraact (tuberculin), purified protein derivative (PPD), is injected into the forearm. General Procedure: Use intermediate-strength PPD in a tuberculin syringe with a half-inch 26 or 27-gauge needle. Insert the needle (bevel facing up) into the intradermal layer of the inner aspect of the forearm; approximately four inches below the elbow. Inject 0.1 mL of the PPD, creating a wheal or bleb. c. Background for Nursing Care Interpretation of Results: A reaction occurs when there is both induration and erythema present. An induration of 0-4mm is considered not significant. An induration of 5 mm or greater may be significant in people who may be at risk, including: (Patient's who are HIV positive, Pts who have risk HIV risk factors and are of unknown HIV status, Pts who are in close contact with someone with active TB, Patients who have chest x-ray results consistent with TB), An induration of 10 mm or greater is usually considered significant in people that have normal or mildly impaired immunity.

Clostridium difficile

Kaplan Overview - Gram-positive bacterium that causes antibiotic-associated colitis; antibiotics depress natural intestinal flora

Anorexia nervosa

Kaplan Overview - Eating disorder more common in females 8 to 18 years; indications Include dramatic weight loss, distorted body image, fear of obesity, anemia, amenorrhea, endocrine dysfunction, hypothermia, electrolyte imbalance, gastric complications, denial/fear of sexuality, repression, and regression, strained family relationships, feelings of powerlessness, over-achievement, depression; b. Essential Nursing Care - Anorexia nervosa is a self-starvation syndrome in which a person becomes preoccupied with food and body image. Signs and symptoms: Physical Findings: Weight loss (body weight is less than 85% of ideal), Emaciation: skeletal muscle atrophy, loss of fatty tissue, breast tissue atrophy, Lanugo (covering of soft, fine hair) on the face and body, Dryness or loss of scalp hair, Hypotension, Bradycardia, Loss of libido, amenorrhea Nursing Care: During hospitalization, monitor the patient's vital signs, nutritional status, and fluid intake and output. Be aware that nutritionally complete liquids are more acceptable during an acute anorexic episode, because they do not require the patient to select foods. Help the patient establish a target weight. Negotiate an adequate food intake with the patient, allowing her to maintain control over the types and amounts of food she eats. Weight the patient daily on the same scale and at the same time each day. Anticipate a weight gain of about 1 lb per week. c. Background Nursing Care Pathophysiology: Anorexia nervosa may be classified into two types: restricting type (no regular binging or purging) and binge eating and purging type (with self-induced vomiting or misuse of laxatives, diuretics, or enemas). Onset may be slow; significant dieting may be present long before the emaciation that results from starvation is apparent. Anorexia nervosa exists on a continuum. Individuals with "partial syndrome" disease, characterized by binge eating and serious dieting, may develop into "full-syndrome" disease, with an increase in binging, purging, and starvation. A variety of body systems are negatively affected in individuals with full-syndrome disease.

Acyclovir (Zovirax)

Kaplan Overview Antiviral to treat recurrent genital herpes, localized cutaneous herpes zoster, and varicella; side effects include headaches, dizziness, seizures, diarrhea; administered PO, IV, topically to slow progression of symptoms, encourage fluids, check liver and renal function tests

Digoxin (Lanoxin)

Kaplan Overview Cardiac glycoside that decreases heart rate and increases force of contraction; side effects include bradycardia, anorexia, nausea, and vomiting, fatigue, dysrhythmias, and diaphoresis. Nursing Responsibilities including knowing baseline VS, checking for signs of toxicity(anorexia, nausea, vomiting, diarrhea, confusion, and visual disturbances), taking apical pulse for 1 full minute noting rate, rhythm, or quality, withholding the medication and notifying physician if rate below 60, observe K levels.

Infective Endocarditis

Infective Endocarditis a. Kaplan Overview Infection of heart lining and valves; signs and symptoms: fever, malaise, back and joint pain, splinter hemorrhages under fingernails and toenails, petechiae in conjunctiva and mucous membranes, heart murmur; nursing care: IV antibiotics for 4-6 weeks, may need surgery for heart valve replacement. b. Essential Nursing Care Infective endocarditis is an infection of the endocardium, heart valves, or cardiac prosthesis, resulting from bacterial or fungal invasion. Signs and symptoms: 1. Weakness 2. Fatigue 3. Weight loss 4. Anorexia 5. Arthralgia 6. Night sweats 7. Intermittent fever (may occur for weeks) 8. Loud, regurgitant murmur, which is typical of the underlying rheumatic or congenital heart disease 9. Murmur that changes or appears suddenly, accompanied by fever 10. Petechiae on the skin (especially common on the upper anterior trunk); the buccal, pharyngeal, or conjunctival mucosa; and the nails (splinter hemorrhages) 11. Osler's nodes 12. Roth's spots Treatment 1. Eradicate the infecting organism with I.V. antibiotics for 4 to 6 weeks followed by oral antibiotics 2. Bed rest 3. Antipyretics for fever and aches 4. Sufficient fluid intake iv. Nursing Care 1. Obtain a patient history of allergies. 2. Administer antibiotics on time to maintain consistent blood levels. Check dilutions for compatibility with other patient medications, and use a compatible solution. 3. Evaluate the patient. 4. Teach patient about anti-infective medication. 5. Tell patient to watch for and report signs of embolization and to watch for signs of relapse. 6. Instruct patient to complete full course of antibiotics v. Expected Outcomes 1. Patient maintains normal temperature, clear lungs, stable vital signs, and adequate tissue perfusion. 2. Patient is able to tolerate activity for a reasonable period and to maintain normal weight. c. Background Nursing Care Infective endocarditis is an infection of the endocardium, heart valves, or cardiac prosthesis, resulting from bacterial or fungal invasion. Causes/ Risk factors 1. Cardiac structural defects 2. Advanced age 3. IV/injection drug use 4. Prosthetic cardiac valves 5. History of endocarditis 6. Shunts or conduits that were surgically constructed 7. Mitral valve prolapse 8. Hypertrophic cardiomyopathy 9. Rheumatic heart disease

Varicella Zoster (chickenpox)

Kaplan Overview Acute, highly contagious, viral disease; Prodromal s/s: slight fever, malaise, anorexia, prurtic rash (begins as macules, then papule, then vesicles), lymphadeonpathy, and elevated temperature. Direct & droplet precautions, spread by contaminated objects also. Incubation 13-17 days. Nursing consideration: isolation until vesicles crusted, communicable from 2 days before appearance of rash, avoid use of aspirin b/c association of Reye's syndrome, use tylenol, topical application of calamine lotion or baking soda baths

Congenital Heart Defect

Kaplan Overview Acyanotic defects include ventricular septal defect (VSD), atrial septal defect (ASD), patent ductarteriosussis )PDA), coarctation of the aorta, pulmonic stenosis, aortic stenosis; cyanotic defects include tetralogy of Fallot, transposition of the great vessels, truncus arteriosus total anomalous venous return; indications in cyanotic conditions include cyanosis, tachycardia, polycythemia, unusual posturing; indications in general include poor weight gain, poor feeding habits, exercise intolerance, small stature, failure to thrive, murmur, dyspnea, frequent respiratory infections b. Essential Nursing Care Congenital heart defects are defects of the heart that have been present since birth 1. Signs and Symptoms may include: cyanosis, respiratory difficulty, fatigability, feeding difficulty, failure to thrive, murmur, and clubbing. 2. Nursing Care: monitor vital signs, monitor heart and lung sounds, administer medications as ordered, and explain the infant's or child's condition to the family members; provide reassurance. c. Background Nursing Care Background Information: The fetal circulation differs anatomically and physiologically from the postnatal circulation, and blood flow through the lungs before birth is less than at any other time in life. At birth, the infant begins to breathe air and switches from placental to pulmonary oxygenation of the blood. a. Patent ductus arteriosus: a fetal blood vessel (the ductus arteriosus) fails to close after birth resulting in increased recirculation of blood through the lungs. b. Atrial septal defect: an opening between the left and right atria results in miscommunication; blood shifts from the left to the right atrium causing increased volume in the right side. c. Ventricular septal defect: an opening in the septum between the ventricles; blood shunts from the left to the right across the septum and back into pulmonary circulation. d. Atrioventricular canal defect (Endocardial cushion defect): results from incomplete fusion of the endocardial cushion, which is the septum of the heart at the junction of the atria and the ventricles. 2. Obstruction to blood flow leaving the heart a. Coarctation of the aorta: a narrowing of the aorta, joining the pulmonary artery to the aorta increasing blood pressure in the heart and upper portions of the body. b. Aortic stenosis: a narrowing or fusion of the aortic valve interferes with left ventricular outflow to the aorta causing increased pressure and hypertrophy of the left ventricle. c. Pulmonary stenosis: a narrowing or fusing of pulmonic valve leaflets resulting in inability of right ventricle to evacuate blood by way of pulmonary artery. 3. Mixed blood flow: a. Hypoplastic left heart syndrome: an underdevelopment of the left side of the heart causes the right ventricle to hypertrophy. b. Transposition of the great arteries: two non-communicating circulatory systems occur when the aorta rises from the right ventricle and the pulmonary artery rises from the left ventricle, a process that affects the heart's entire circulatory system. 4. Decreased pulmonary blood flow a. Tetralogy of Fallot: un-oxygenated blood mixes with oxygenated blood resulting in decreased pulmonary blood flow and cyanosis. b. Tricuspid atresia: the tricuspid valve fails to develop preventing blood from entering the right atrium, disrupting oxygenation; can result in extreme cyanosis, tachycardia, and dyspnea.

Cirrhosis

Kaplan Overview Chronic Progressive liver disease, most often due to alcoholism; may also be from viral infections or toxins, or bile stasis or obstruction; indications include indigestion, flatulence, constipation, diarrhea, anorexia, weight loss, nausea, vomiting, esophageal varices, hemostasis, hemorrhage, ascites, increased bleeding tendencies, anemia, edema in extremities, spider angiomas, jaundice, pruritis, dark urine, clay- colored stools. Obvious monitoring of vitals and intake and output are essential. It is also important to assess fluid retention by weighing the patient daily. b. Essential Nursing Care Cirrhosis disrupts the structure and function of the liver. Signs and symptoms: GI, Respiratory, CNS: progressive signs and symptoms, hematologic, endocrine, skin, and hepatic. Nursing Care: Check gums, stool, vomitus for blood, apply pressure to injection sites, observe closely for behavioral changes, avoid fluid retention, avoid using soap when bathing to avoid skin breakdown. c. Background Nursing Care Cirrhosis of the liver is a chronic disease that causes cell destruction and fibrosis (scarring) of hepatic tissues. Fibrosis alters normal liver structure and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein.

Constipation

Kaplan Overview Difficulty in passing stools or incomplete or infrequent passing of hard stools; causes may be intestinal obstruction from tumors or other causes, diverticulitis, medications, inadequate fluid or bulk or exercise, slow peristalsis, decreased muscle tone, anal sphincter dysfunction, poor bowel habits; client may experience feeling of fullness and pressure in rectum, straining at stool, abdominal and/or back pain, headache, poor appetite; nursing interventions may include administering enemas or laxatives as ordered to address current issues; promoting normal elimination is major focus and involves teaching client to respond to urge to defecate. b. Essential Nursing Care - Constipation is the infrequent, sometimes painful, passage of hard, dry stool Signs and symptoms: less than 3 bowel movements per week, small dry stools, abdominal distension, abdominal pain or pressure, straining at stool Treatment (aimed at treating the underlying cause) Nursing care: Assess for the presence of signs and symptoms of constipation, Assess diet and fluid intake, Teach about prevention through high-fiber foods (bran, fruits, vegetables, and whole-grain), 8 to 10 glasses of water a day and exercise, Caution patients not to increase fiber intake without increasing water, Encourage patients to pay attention to a defecation stimulus, Remove impacted feces, if necessary c. Background Nursing Care Constipation is the infrequent, sometimes painful, passage of hard, dry stool The colon has three major functions: Mucosal transport (mucosal secretions facilitate passage of contents through colon), Myoelectric activity (mixing of contents and propulsive action), Processes of defecation

Drug Overdose

Kaplan Overview Effects of opiate overdose include possible dilation of pupils, respiratory depression, respiratory arrest, coma, shock, convulsions; overdose by hallucinogenics indicated by psychosis, brain damage, hypertensive crisis, respiratory arrest, seizures; effects of inhalant overdose include damage to the nervous system, death

Enteral Tube Feedings

Kaplan Overview Enteral tube feeding is delivery of liquid food to the stomach, distal duodenum, or proximal jejunum by way of a tube; can be continuous or intermittent; ensure that feeding is at room temperature, elevate the head of the bed at least 30 degrees, verify tube placement, check for gastric residual, return residual to stomach unless greater than 100 mL, flush tubing with 30mL water, initiate feeding, flush tubing with 30mL water. b. Essential Nursing Care The purpose is to allow patients who can't or won't eat to receive nourishment and permits administration of supplemental feedings to patients who have high nutritional requirements. Implementation: Provide privacy, wash hands, inform the patient that nourishment will be received via tube and explain the procedure, cover the chest with a towel or linen-saver pad if the patient has nasal or oral tube, assess patient's abdomen for bowel sounds and distention, elevate bed to semi-fowlers or high fowlers position and check placement of tube. Never give a feeding prior to ensuring tube is properly positioned in the patient's stomach. Use a syringe to aspirate gastric secretions and examine aspirate and place a small amount on the pH test strip; should be pH 5.0 or less. Assess gastric emptying by aspiration and measuring residual gastric contents, hold feedings if residual volume is greater than predetermined amount given by doctor. Connect gavage bag tubing to feeding tube; purge tubing of air and attach to feeding tube. Flush after feedings and if you are administering a continuous feeding flush every four hours. To discontinue gastric feeding, close the clamp on the gavage bag, disconnect the syringe from the feeding tube, or turn off the infusion controller, leave the patient in semi-fowlers or high fowler's position for at least 30 mins. Expected outcomes include: patient successfully receives feeding without experience of nausea and vomiting, free from signs and symptoms of aspiration, and weight increases and nutritional requirements are met. c. Background Nursing Care Patient teaching includes explaining to both the patient and the family that the enteral route is the best alternative to oral feeding, inform the patient and family about the procedure to reduce anxiety and promote cooperation by stating a tube is passed into the GI tract where formula containing total or supplemental nutrients is administered which may be short or long term, instruct patient that a feeding schedule will be set up and if they are continued in a home setting the patient and family need to be provided individualized instructions in written form.

Priorities

Kaplan Overview Establishing priorities enables the nurse to attend to the clients most important needs and helps the nurse organize care; situations that, if left untreated, could cause physical harm to the client having the highest priority; using Maslow's hierarchy of needs enables the nurse to establish priorities b. Essential Nursing Care Purpose 1. Enables nurse to attend to patient's most important needs 2. Helps nurse organize care Implementation 3. Develop a prioritized list of nursing diagnoses 4. Deal with medical problems (or suspected medical problems) first; consider all health needs and determine relationship between problems 5. Then, prioritize needs in terms of Maslow's Hierarchy a. Help patient meet basic physiologic needs (oxygen, food, water, temperature, elimination, sexuality, physical activity, and rest) b. Assist patient with safety and security needs c. Support patient in meeting love and belonging needs d. Help patient meet self esteem needs e. Help patient meet self actualization needs, the highest level of hierarchy f. Consider patient preference g. Anticipate future problems if a patient chooses to ignore a priority c. Background Nursing Care Priorities are guidelines for ranking nursing diagnoses, and are established by way of Maslow's hierarchy of human needs, patient preference, and anticipation of future problems.

Demand Pacemaker

Kaplan Overview Functions when HR falls below a set rate; inserted to treat complete heart block and sick sinus syndrome; nursing considerations include monitor HR and rhythm, instruct pt to carry ID, request hand scanning at airport, avoid electromagnetic fields

Buspirone Hydrochloride (BuSpar)

Kaplan Overview Nonbenzodiazepine antianxiety agent; side effects include dizziness, drowsiness, insomnia, tachycardia, chest pain, nausea, diarrhea, blurred vision. nursing considerations include drug should not exceed 60 mg daily; contraindicated with 14 days MAO medication, drug is not a controlled substance and has not shown to be addictive, effects of drug will not occur for several weeks, alcohol is contraindicated while taking this drug, monitor for CNS changes, not recommended for pts with significant renal or hepatic failure.

Postpartum

Kaplan Overview Nursing care during post-partal period: check lochia (color, volume) every 15 min; lochia (endometrial sloughing); day 1 to 3 rubra (bloody with fleshy odor; may have clots); day 4 to 9 serosa (pink/brown with fleshy odor); day 10+ alba (yellow-white); at no time should there be a foul odor (indicates infection); check vital signs (BP, pulse) every 15 minutes; follow protocol until stable, check fundus every 15 minutes; position - should be at or 1 cm/finger breadth above the umbilicus for the first 12 hours, then descend by one finger breadth each succeeding day; pelvic organ usually by day 10, check urinary output; measure first void; may have urethral edema, urine retention. b. Essential Nursing Care A postpartum assessment consists of history and physical examination in the few days following delivery. Assessment 1. Check medical record for information on a. Problems encountered during pregnancy Time of labor onset and admission to labor and delivery area Types of analgesia and anesthesia used b. Length of labor c. Time of delivery d. Time of placenta expulsion, appearance of placenta e. Sex, weight, and status of infant 2. Ask patient to describe delivery experience 3. Ask patient about home life, family structure, support system, community, socioeconomic level 4. Physical examination a. General i. Vital signs ii. General appearance iii. Skin iv. Eyes, including color of conjunctiva c. Background Nursing Care A postpartum assessment consists of history and physical examination in the few days following delivery. Abnormal Findings 1. General a. Elevated temperature lasting more than 24 hours; may indicate infection b. Increased pulse, high or low blood pressure; may indicate hemorrhage, infection, late-onset preeclampsia c. Absent or decreased bowel sounds, constipation; may indicate paralytic ileus d. Hemorrhoids 2. Breasts a. Unrelieved engorgement 3. Lochia a. Scant or absent (may be scant with cesarean birth) b. Saturates pad in less than 1 hour, indicates excessive flow c. Presence of clots or tissue, should be sent for laboratory examination d. Foul-smelling, indicates infection e. Sudden change in color or sudden increase in amount 4. Uterus a. Uterus fails to contract and heavy bleeding occurs b. Higher position than expected, may indicate retained tissue c. Boggy feeling d. Displaced to one side, indicated uterine atony secondary to distended bladder or retained placental fragment 5. Perineum a. Tearing of tissues b. Signs of infection at episiotomy site: redness, swelling, increasing discomfort, purulent drainage, white line along episiotomy c. Irritation, ecchymosis, tenderness, hematoma, hemorrhoids d. Severe, intractable pain

Delusions

Kaplan Overview Hallucinations are false sensory perceptions in the absence of external stimulus; may be auditory, visual, olfactory, or tactile; delusions are persistent false beliefs; Grandeur- belief that one is special; persecutory- belief that one is victim of a plot b. Essential Nursing Care Delusions are false beliefs that cannot be changed by reasonable arguments. Signs and symptoms 1. Bing suspicious, belief that others are controlling the patient. belief that the patient is famous or related to someone famous. Claim to have accomplished a great deed. Belief that the patient is god. Belief that the patient has a special religious mission. Nursing care 2. Assess the nature of the patient's delusions to become aware of what behaviors to expect. When obtaining information, be careful not to judge the beliefs. Attempt to establish a basis of reality for the patient. Avoid overtly confronting the patient's delusions or arguing about it. c. Background Nursing Care Delusions are false beliefs that cannot be changed by reasonable arguments.

Hypothyroidism

Kaplan Overview Hyposecretion of thyroid hormone, causes slowed physical and mental functions; indications include decreases activity level, sensitivity to cold, potential alterations in skin integrity, decreased perception of stimuli, obesity, weight gain, alopecia; treatment includes thyroid replacement therapy; nursing considerations include pace activities, allow client extra time to think, speak, act, teaching should be done slowly and in simple terms, frequent rest periods between activities, maintain room at 75F (24C), restrict use of soaps and supply lanolin or creams to skin, high-protein, low-calorie diet, increased fluid intake. b. Essential Nursing Care Hypothyroidism is a state of low serum thyroid hormone levels or cellular resistance to thyroid hormone. Signs and Symptoms: 1. Weakness, fatigue, forgetfulness, cold intolerance, unexplained weight gain, constipation, goiter, slow speech, decreasing mental stability, cool/dry/coarse/flaky/inelastic skin, puffy face/hand/and feet, periorbital edema, dry/sparse hair, thick/brittle nails, slow pulse rate, anorexia, abdominal distention, menorrhagia, decreased libido, infertility, ataxia, intention tumor, nystagmus, delayed reflex time. Nursing Care 2. Provide a high-bulk, low-calorie diet and encourage activity. 3. Administer cathartics and stool softeners, as needed. 4. After thyroid replacement therapy begins, watch for signs of hyperthyroidism, such as restlessness, sweating, and excessive weight loss. 5. Advise patient how to obtain medical identification jewelry. 6. Tell the patient to report signs of aggravated cardiovascular disease, such as chest pain and tachycardia. 7. To prevent myxedema coma, tell the patient to continue the course of antithyroid medication even if symptoms subside. 8. Instruct the patient to report infection immediately and to make sure any health care provider who prescribes drugs for the patient knows about the hypothyroidism. 9. Evaluate the patient. c. Background Nursing Care Hypothyroidism is a state of low serum thyroid hormone levels or cellular resistance to thyroid hormone. Background Information 1. The thyroid produces hormones that affect all organ systems in the body 2. The two components of thyroid hormone are thyroxine (T4) and triiodothyronine (T3) a. Influence the replication of cells b. Play an important role in brain development c. Alter the response of other tissues to hormones d. Increase levels of enzymes that affect oxygen consumption e. Regulate growth 3. The other hormone produced by the thyroid is calcitonin a. Secreted when plasma levels of calcium are elevated b. Increases bone deposits of calcium to decrease plasma levels. Causes/Risk Factors 4. Autoimmune thyroiditis (Hashimoto's disease) 5. Hyperthyroidism treated with radioiodine, antithyroid medications, or surgery 6. Atrophy of thyroid gland, associated with aging, most common in older women 7. Older men with a history of head or neck cancer treated with radiation therapy 8. Patients treated with lithium, iodine compounds, and antithyroid medications 9. Thyroid diseases like amyloidosis and scleroderma 10. Deficiency or excess of iodine

Inflammatory Bowel Disease

Kaplan Overview IBD includes Crohn's disease (regional enteritis) and ulcerative colitis. Indications include abdominal pain, diarrhea, fluid imbalance, wt loss. Diarrhea in Crohn's disease is less severe than in ulcerative colitis. Nursing considerations include high protein, high calorie, low fat, low fiber diet, may require TPN to rest the bowel, administer analgesics, anticholinergics, sulfonamides (Gantrisin), corticosteroids, antidiarrheals, and antiperistaltics, maintain fluid/electrolyte balance, monitor electrolytes, promote rest, relieve anxiety.

Shock

Kaplan Overview In any emergency situation, shock should be anticipated e fore it develops; hypovolemia is the most common cause of shock; indications include increased HR, decreased BP, pallor, diaphoresis, moist cold skin, oliguria, hyperpnea, metabolic acidosis, and altered sensorium b. Essential Nursing Care Shock occurs when systemic blood pressure is too low to carry necessary oxygen and nutrients to vital organs and cells. Types of shock include anaphylactic, cardiogenic, hypovolemic, neurogenic, and septic. Signs and symptoms vary with the stage of shock 1. Compensatory Stage a. Normal blood pressure, but increased heart rate and increased respiratory rate b. Mental status changes (confusion, combativeness) 2. Progressive Stage a. Low mean arterial pressure (MAP) b. Rapid and shallow respirations, crackles in lung fields c. Rapid heart rate, chest pain d. Change in mental status; initially agitation and confusion, then loss of consciousness e. Decrease in urinary output (possible acute renal failure) 3. Irreversible Stage a. BP remains low b. Patient unresponsive to treatment and cannot survive Treatment 4. Compensatory stage a. Identify the cause; correct underlying disorder b. Fluid replacement and medication therapy (to maintain BP and adequate tissue perfusion) 5. Progressive Stage a. Depends on the type of shock, its cause, and decompensation in organ systems; common treatments include: i. IV fluids and medications (to restore tissue perfusion and intravascular volume) ii. Early enteral nutritional support (for metabolic requirements) iii. Vasoactive medications (to restore vasomotor tone and improve cardiac function) iv. IV insulin, (for aggressive hyperglycemic control) v. Antacids, histamine-2 blockers (h2) blockers, antipeptic agents (reduce risk of GI ulceration and bleeding) 6. Irreversible Stage a. Usually comparable to treatment for progressive stage, but patient fails to respond to treatment b. Experimental options may include investigational medications (to reduce or reverse severity of shock) Nursing Care 7. Compensatory stage a. Prepare to recognize and understand significant of even slight changes in patient assessment data b. Carefully monitor geriatric patients who are at greater risk if any of the following apply: i. Medications such as beta-blocking agents ii. Increasing trend in body temperature iii. Failure of heart to function in hypoxemic states iv. Sudden change in mentation c. Provide patient support to reduce anxiety d. Monitor patient's level of consciousness, vital signs, and urine output 8. Progressive Stage (often intensive care setting) a. Prepare to recognize and understand significance of even slight changes in patient assessment data b. Become familiar with patients with any possible risk for shock, and report any and all subtle changes in assessment, including: i. Hemodynamic monitoring, electrocardiographic (ECG) monitoring, arterial blood gases, serum electrolyte levels, physical and mental status changes c. Administer medications and fluids frequently, as ordered d. Provide mechanical ventilation, dialysis, and intra-aortic balloon pump, as necessary or as prescribed e. Carefully document treatments, medications and fluids to promote care from other members of health care team i. Record time, dosage or volume, and patient responses c. Background Nursing Care 1. Compensatory stage a. Arterial pressure and tissue perfusion falls b. Compensatory mechanisms activated to maintain cardiac output and perfusion to the heart and brain c. As baroreceptors in carotid sinus and aortic arch sense a drop in blood pressure, epi and norepi are secreted d. Secretion of epi and norepi increases peripheral resistance, blood pressure and myocardial contractility e. Reduced blood flow to kidney activates renin-angiotensin-aldosterone system, causing vasoconstriction and sodium and water retention 2. Progressive Stage a. Compensatory mechanisms can't maintain cardiac output b. Tissues become hypoxic c. Cells switch to anaerobic metabolism and lactic acid accumulates, producing metabolic acidosis d. Tissue hypoxia promotes release of endothelial mediators, leading to venous pooling and increased capillary permeability e. Sluggish blood flow increases the risk of DIC 3. Irreversible Stage a. Inadequate perfusion damages cell membranes b. Lysosomal enzymes are released, and energy stores are depleted, leading to cell death c. Lactic acid continues to accumulate, increasing capillary permeability and the movement of fluid out of the vascular space, further contributing to hypotension d. Perfusion to the coronary arteries is reduced, causing myocardial depression and further reduction in cardiac output

Sexual Transmitted Diseases (STD)

Kaplan Overview Infections acquired through sexual contact; diseases include syphilis, gonorrhea, genital herpes, Chlamydia, genital warts, AIDS; indications may be absent or there may be burning, itching, fever, growths, discharge, difficulty with urination; opportunistic infections with AIDS; diagnosis, treatment, teaching to prevent recurrence of same or other STDs, and notification of contacts are all important. c. Essential Nursing Care Sexually transmitted diseases (STDs) are among the most common infections in the United States. These include Chlamydia, gonorrhea, trichomoniasis, hepatitis B and C (HBV, HCV), genital herpes (HSV-1, HSV-2), HIV (AIDS), human papillomavirus (HPV), syphilis, chancroid, and granuloma inguinale. Signs and Symptoms 1. · Vaginitis, urethritis, epididymitis, prostatitis, or proctitis 2. · Vaginal or penile discharge (often purulent) 3. · Pharyngitis 4. · Lower abdominal pain 5. · Dysuria 6. · Lesion (vesicles) on the skin or mucous membranes 7. · Regional lymphadenopathy d. Background Nursing Care · Explain risk factors and behaviors that put patients at risk or STDs. · Discuss the importance of using condoms to prevent most STDs. However, be sure to explain that condoms do not prevent all STDs as several (e.g. HPV, HSV-2) can be acquired through contact who should be treated as well. · Have patients notify all of their sexual contacts who should be treated as well. · Instruct patients to take all medications as prescribed, usually for 7 - 10 days, but sometimes for up to 4 weeks. · Advise patients to abstain from sexual activity until treatment is completed. · Suggest warm baths and mild analgesics to relieve pain. · Protect the privacy and confidentiality of all patients with STDs but inform them that there is a legal obligation to report many STDs to state and local health authorities. · Encourage patients to discuss their feelings about their STD. · Encourage patients to seek treatment for any recurrences.

Tuberculosis

Kaplan Overview Infectious disease of insidious onset that primarily affects the lungs; signs/symptoms include fatigue, lethargy, anorexia, weight loss, low-grade fever, and productive cough of mucopurulent sputum b. Essential Nursing Care Tuberculosis (TB) is an infectious disease primarily affecting the lungs, but may spread to anywhere in the body, especially the kidneys, lymph nodes, meninges, and bones. Signs and Symptoms: low-grade fever, persistent cough, hemoptysis, fatigue, weight loss and anorexia, and altered mental status (in elderly patients) Treatment 1. Prevention a. TB vaccine can be up to 76% effective 2. First-line TB Medications a. Rifampin, Isoniazid (INH), Pyrazinamide, Streptomycin, Ethambutol 3. Drug-resistant TB a. Antibiotic regimen initially consists of at least four drugs. b. Antibiotics should be taken for 6-12 months c. Strict adherence to treatment protocols to avoid resisitance d. Directly observed treatment is used when compliance is suspected. Nursing Care 4. Because TB is spread through airborne transmission, follow airborne precautions. a. Place patient in a private room with monitored negative air pressure. b. Perform 6 to 12 air changes per hour. c. Keep door closed and patient in room. d. Transport patient out of room only when necessary, and with use of a surgical mask. e. Appropriate discharge of air outside, or monitored filtration if air is re-circulated. f. Keep door closed and patient in room. g. Use respiratory protection when entering room. h. Consult the CDC Guidelines. i. Become familiar with the Hospital Infection Control Practices Advisory Committee. j. Assist in helping facilities maintain up-to-date isolation practices. 5. Instruct patient how to keep airways clear (adequate hydration, proper posture) 6. Stress importance of adhering to the drug regimen. 7. Explain the multidrug treatment so that the patient understands how to follow protocol. 8. Teach patient proper hygience, so that opportunities for transmission are minimized. 9. Address nutritional problems (anorexia, malnutrition, weight loss) associated with TB. 10. Watch for side effects of medications. 11. Monitor vital signs for indication of drug resistance or spread of TB to other parts of the body. c. Background Nursing Care Tuberculosis (TB) is an infectious disease primarily affecting the lungs, but may spread to anywhere in the body, especially the kidneys, lymph nodes, meninges, and bones. Background Information 1. TB has reputation as nineteenth-century scourge, but continues to pose formidable threat today. a. Vaccine results in positive skin test (Mantoux test or PPD) i. Correct technique for needle insertion; bevel facing upward. ii. Skin reaction in form of welt. iii. Commercially prepared gauge interpreting extent of reaction. 2. TB is caused by the bacterium, Mycobacterium tuberculosis. 3. A third of the world's population tests positive for M. tuberculosis. 4. Disease affects the lungs first but may be carried by lymph or blood to other areas of the body. 5. TB is leading cause of death in people who are HIV positive. 6. Drug-resistant forms of TB now make the disease more difficut to control than in the early twentieth century. Cause/Risk Factors 7. Causes a. Inhalation of infected sputum 8. Risk Factors a. Living in crowded and poorly ventilated environs (prisons, shelters) b. A compromised immune system (HIV-positive patients) c. Alcoholism and malnutrition d. Intravenous drug use e. Working with a TB patient (health care providers) f. Immigration from a country with a high prevalence of TB (most third-world countries)

Lactulose (Chronulac)

Kaplan Overview Lactulose (Chronulac is a laxative administered for treatment of hepatic encephalopathy, decreases blood ammonia by excreting it in stool; side effects include belching, cramping, distension, flatulence; nursing considerations including mixing with fruit juice, water, milk, or carbonated citrus beverage, administering with full glass of liquid, giving on empty stomach for more rapid results, assessing client's mental status throughout treatment.

Abdominal Aortic Aneurysm

Kaplan Overview Localized enlargement of wall of abdominal aorta; may be asymptomatic or pt may complain abdominal pain, low back pain, pulsating mass in periumbilical area, bruit over the aorta, BP may be lower in legs than arms; nursing considerations include monitor BP frequently, monitor renal function, CBC, instruct to avoid bending, lifting constipation

Enoxaparin (Lovenox)

Kaplan Overview Low-Molecular weight heparin used to prevent DVT and pulmonary emboli; Side effects include hemorrhage, tissue irritation/pain at injection site, anemia, thrombocytopenia, fever; nursing considerations include give deep SQ, never IV or IM, does not require lab test monitoring.

Defense mechanisms

Kaplan Overview Methods, usually unconscious, of managing anxiety by keeping it from awareness; include denial (failure to acknowledge intolerable thoughts, feelings, experience, or reality), displacement (redirection of emotions or feelings to a subject that is more acceptable or less threatening), projections (attributing to other one's feelings, impulses, thoughts, or wishes), undoing (an attempt to erase an act, thought, feeling, or desire), compensation (attempt to overcome a real or imagined shortcoming, Repression (unacceptable thoughts kept from awareness) suppression (consciously putting a disturbing thought or incident out of awareness)

Bipolar Disorder

Kaplan Overview Mood disorder ; manic episodes usually begin suddenly, with rapid escalation; Indications include elevated or expansive mood, agitation, accelerated speech, thought, and movement, distractibility, self-confidence, aggression, sarcasm, inappropriate dress, inattention to personal hygiene, anorexia, weight loss, constipation, insomnia; b. Essential Nursing Care Bipolar disorder, also called manic-depressive disorder, is a mood disorder marked by severe, pathologic mood swings. Signs and symptoms: Manic Phase: Expansive, grandiose, or hyperirritable mood, Increased psychomotor activity, Excessive social extroversion, Short attention span, Rapid speech with frequent topic changes, Decreased need for sleep or food, Impulsivity and impaired judgment. Depressive Phase: Low self-esteem, Overwhelming inertia, Social withdrawal, Feelings of hopelessness, Nursing Care:During a manic episode: Maintain a calm environment and protect the patient from overstimulation, Provide emotional support and set realistic goals for behavior. Set firm limits, Watch for early signs of frustration. Tell the patient firmly that threats and hitting are unacceptable; Alert the health care team promptly when acting-out behavior escalates. During a depressive episode: Provide the patient's physical needs, and help with personal hygiene, if necessary. Encourage him to eat, or feed him if necessary. Keep in mind that a depressed patient needs continual positive reinforcement to improve his self-esteem. Provide a structured routine. To prevent self-injury or suicide, remove harmful objects from the environment. Institute suicide precautions per facility policy. Observe the patient closely, and strictly supervise his medications. c. Background Nursing Care There are three major groups of bipolar disorders: Bipolar I disorder: combination of major depressive, manic, or mixed episodes (symptoms of both manic and depression) Bipolar II disorder: combination of major depression and hypomania Cyclothymic disorder: combination of hypomanic episodes intermixed with depressive episodes that do not fully satisfy the criteria of a major depressive episode Bipolar disorder is a chronic, cycling condition, Bipolar disorder can result in severe functional impairment as manifested by isolation from family, friends, and coworkers; financial difficulties; and job loss. Mania: Elevated, grandiose, or restless mood, Exaggerated self-esteem, Inability to sleep, Pressured speech, Flight of ideas, Easy distractibility, Participation in increased number of activities, with more energy, Use of poor judgment in high-risk activities, sometimes with severe consequences

Chemotherapy

Kaplan Overview Nursing considerations include bone marrow suppression (monitor bleeding, avoid IM injections and rectal temperatures, press venipunctures sites); nausea and vomiting (monitor appetite and nutrition, I and O; prophylactic antiemetics; small, frequent meals); altered immunologic response (prevent infection and report early signs); impaired oral mucous membrane; stomatitis (monitor oral hygiene; avoid hot, spicy foods; administer antifungals and anesthetics as ordered); fatigue (rest, energy conservation teaching). b. Essential Nursing Care Chemotherapy is used as a treatment for cancer, primarily for systemic disease rather than for localized lesions Nursing care: Monitor nutritional, fluid, and electrolyte status; it may be necessary to use creative methods to encourage adequate fluid and nutritional intake, control risks for infection, which are increased because of bone marrow and immune system suppression, monitor and treat patient for stomatitis, help patient prepare for and cope with hair loss, take measures to minimize nausea and vomiting, monitor patient for necrosis at administration site due to extravasation, follow safety precautions to minimize exposure to chemotherapeutic agents. c. Background Nursing Care Antineoplastic agents interfere with cellular function and reproduction, thereby destroying tumor cells. They are administered in a variety of different routes: topical, oral, intravenous, intramuscular, subcutaneous, arterial, intracavitary, and inrathecal. One dosage of chemotherapeutic agent destroys only a portion of tumor cells because it is most effective on cells in active cell division; doses must be repeated over a prolonged period of time to kill cells as they reach the cell division phase of the cell cycle. Treatment rarely eradicates 100% of the tumor; the goalis to kill enough of the tumor so that the remainder can be killed by the body's immune system. Complications: Nausea and vomiting, stomatitis, anorexia, cachexia, malabsorption, myelosuppression, renal damage, hyperkalemia, hyperphosphatemia, hypocalcemia, cardiac toxicity, congestive heart failure, pulmonary fibrosis, altered testicular and ovarian function, possibly including sterlity, peripheral neuropathies, loss of deep tendon reflexes, paralytic ileus, hearing loss, fatigue, infection, alopecia, chronic pain, bleeding problems

Placenta Previa

Kaplan Overview Placenta abnormally implanted near or over the cervical opening; indications include painless bright red vaginal bleeding accompanied by a soft uterus usually in third trimester between 29 to 30 weeks; caused by scarring of uterus from pregnancy, tumor; treatment includes bed rest, ultrasound to locate placenta, no vaginal/rectal exams before fetal viability, amniocentesis for lung maturity, daily Hgb and Hct, 2U cross-matched blood available.

Colostomy care

Kaplan Overview Pouch should be measured accurately to fit well; when changing the pouch, the client should assess the color, moistness, presence of edema, tenderness, skin irritation; cleanse around stoma with water and soap; dry well; apply skin barrier and pouch; client education about diet; immediately postoperatively low residue diet for several weeks to allow for healing, then add foods as tolerated, avoid gas forming foods; utilize wound ostomy continence nurse (WOCN) in client care

Paracentesis

Kaplan Overview Removal of fluid from the peritoneal cavity; pre-procedure preparation includes informed consent require, void, take VS, measure abdominal girth, weigh pt; During procedure take VS q15 min; after procedure care includes documenting amount, color, characteristics of drainage obtained; assessing pressure dressing for drainage; positioning in bed until VS stable, 2-3L may be removed

Tonsillectomy

Kaplan Overview Removal of the tonsils that are frequently inflamed; postoperative nursing care: positioning on side, coughing discouraged, ice collar, administering analgesics, suction set at bedside, offering clear liquid diet, checking throat for bleeding; client teaching: after discharge avoid irritating or highly seasoned food, gargling, or vigorous tooth-brushing. c. Essential Nursing Care 1. Nursing Care: a. Evaluate the child preoperatively for infections, in which case surgery must be postponed. b. Evaluate for any speech disorders, for which referral may be necessary. c. Postoperatively, monitor vital signs for 24 hours and watch for signs of hemorrhage (e.g. frequent swallowing, vomiting blood, increased pulse and respirations, throat clearing, anxiety). d. Place Child on stomach with a pillow under the chest to encourage drainage from the mouth and not down the throat. i. If bleeding occurs, elevate the child's head and turn him or her on the side to reduce pressure on the surgical wound. e. Administer liquids, ice chips, and popsicles; avoid ice cream, acidic juices, or red or brown liquids. f. Although child may be released after only 24 hours, danger of bleeding is greatest 7 to 10 days after surgery when the membrane formed at the operative site begins to slough off; therefore, parents must be told to: i. Encourage gentle brushing of teeth; avoid vigorous brushing, gargling, and irritating mouthwashes for several weeks ii. Monitor child for signs of hemorrhage iii. Restrict child's activity for 7 to 10 days after discharge iv. Avoid exposure to people with infectious illnesses (i.e. colds) for at least 2 weeks 2. Expected Outcomes: a. Patient does not experience any bleeding following tonsillectomy. b. Parents keep follow-up appointments and report that chronic infectious have not recurred. d. Background Nursing Care A tonsillectomy, or removal of tonsillar tissue, is performed by ligation or laser surgery. 1. Description: a. Indications for surgery include: i. Obstruction of upper airway by enlarged tonsils (which causes hypoxia or sleep apnea); pertonsillar abscess; chronic tonsillitis; recurrent otitis media. b. Risks Include: i. Postoperative bleeding (because no sutures used); aspiration of blood during and after procedure ii. Septicemia, if surgery is performed while tonsils are infected (bacterial infection spreads to blood)

Schizophrenia

Kaplan Overview Schizophrenia is a chronic illness resulting in psychotic behavior; indications include autism (withdrawal from relationships and the world), inappropriate or no display of feelings; hypochondriasis and depersonalization; hallucinations (false sensory perceptions in the absence of external stimulus), delusions (persistent false beliefs), short attention span, regression, inability to meet basic survival needs; b. Essential Nursing Care Signs and Symptoms 1. Positive symptoms: a. Delusions b. Hallucinations 2. Negative symptoms: a. Apathy b. Lack of motivation c. Blunted affect d. Poverty of speech e. Anhedonia f. Asociality 3. Disorganized symptoms: a. Thought disorders b. Bizarre behavior (agitation, inappropriate behavior) Nursing Care 4. Maintain a safe environment 5. If the patient expresses suicidal thoughts, institute suicidal precautions 6. Establish trust. Do not touch the patient without first informing patient exactly what the nurse is going to do. If necessary, postpone procedures until less suspicious or agitated. 7. Use an accepting, consistent approach, and use clear, unambiguous language. 8. Assess the patient's ability to carry out activities of daily living. Meet needs, but do for patient only what patient cannot do for self. 9. Monitor the patient's nutritional status. 10. Reward positive behavior. 11. Encourage the patient to engage in meaningful interpersonal relationships, and help him learn social skills. 12. Engage the patient in reality-oriented activities. 13. Administer prescribed medications. Monitor for adverse effects and report these promptly. 14. Encourage the patient to comply with the medication regimen to prevent relapse. c. Background Nursing Care Causes/Risk Factors 1. First-degree relatives with schizophrenia 2. Comorbid disorders: 3. Substance abuse and depression a. Diabetes mellitus b. Disordered water balance

Low sodium diet

Kaplan Overview - Purpose of low Na diet is to lower body water and promote excretion; foods not allowed include preserved meats, cheese, fried foods, milk products, canned foods, added salt.

Pancreatic Cancer

Kaplan overview Indications include wt loss, vague upper or mid abdominal discomfort, abnormal glucose tolerance test (hyperglycemia), jaundice, clay colored stools, dark urine; nursing considerations include high calorie, bland, low-fat diet, small frequent feedings, avoid alcohol, administer anti-cholinergics, pain medication, anti-neoplastic chemotherapy, post op care after whipple procedure; survival rate for clients with non-resectable pancreatic cancer is approx 6 months. b. Essential nursing care Signs and symptoms 1. Upper or mid abdominal pain, severe pain in the mid back, jaundice, pruritus, weight loss, ascites, diabetes, clay colored stools, dark urine Treatment 2. Radiation 3. Chemotherapy 4. Nasogastric suction to give the GI tract a rest 5. Parenteral nutrition 6. Curative procedures a. Total pancreatectomy, to resect the entire pancreas b. Pancreaticoduodenectomy (whipples procedure) to resects the head of the pancreas if there is no tumor else where in the body 7. Palliative procedure a. cholecystojejunostomy, to relieve jaundice by diverting bile flow into the jejunum. Nursing care 8. Assess patient for the effectiveness of pain medications, and ensure good nutrition 9. Provide a special mattress for a pt who is so malnourished that pressure sores and discomfort from bony prominences are major considerations 10. Maintain IV and arterial lines 11. Instruct pt on the need for a low fat, high protein diet, pancreatic enzyme replacement and vitamin supplementation 12. Provide counseling for pt and family concerning the poor prognosis and end of life decisions 13. Refer pt to hospice care c. Background Causes/Risk Factors 1. Tobacco use 2. Exposure to industrial chemicals or toxins 3. High fat diet 4. Alcoholism Diagnostic test 5. CT and MRI to detect pancreatic tumors 6. GI X-rays to detect distortions in normal anantomy 7. Endoscopic retrograde cholangiopancreatography to visualize the biliary tree 8. Percutaneous fine needle aspiration biopsy with ultra sound or CT guidance 9. Percutaneous transhepatic cholangiography 10. Angiography, ultrasonography, CT, and laparoscopy

Total Hip Arthroplasty

Kaplan Overview Surgical replacement of the head of the femur and acetabula w/ artificial joint; used for diseased femoral joint or fracture of the head of the femur or femoral neck; nursing responsibilities: positioning leg in abduction using abduction splints or wedge or 2-3 pillow b/w the legs, hip should not be flexed more than 45-60 degrees, HOB should not be elevated more than 45 degrees, turn from back to unaffected side, use a fracture bedpan by having the client flex the unoperative hip while using a trapeze to lift the pelvis or have the pt ambulate to the bedroom or use a bedside commode, use of over bed trapeze to reposition in bed, and incision care b. Essential Nursing Care Nursing Care: 1. Explain to patient why pre-op tests are necessary. Suggest that patient donate own blood to avoid the risks involved in blood transfusions 2. Post-op, keep patient on bed rest as prescribed, assess the level of pain, and provide analgesics as ordered. If using narcotics continuously assess pt to toxicity or over sedation 3. Monitor for complications of hip replacement surgery, particularly hypovolemic shock from blood loss during surgery, fat emboli or venous thromboembolia, all potentially fatal. Report any complications promptly 4. Inspect the incision for signs of infection and change the dressing as needed, using strict sterile technique 5. Prevent pressure ulcers, encourage coughing and deep breathing to prevent atelectasis and pneumonia, and stress the need for adequate fluid intake 6. Instruct pt to keep her hips abducted, not to cross legs, and not to bend at the waist so as not to dislocate the prostheses. Position legs in abduction, using abduction splints. In addition, hips should not be flexed more than 45-60 degrees so the bed should not be elevated more than 45 degrees. A trapeze can be used to lift the pelvis over a special bed pan c. Background Nursing Care Description: 1. In order for the prosthesis to be properly fitted to the joint, the acetabular socket is formed to accept it. After the top of the femur is removed, the center of the femur is drilled so that the metal component of the prosthesis fits inside 2. While hip replacement surgery is performed under general anesthesia w/ an incision to expose the operative field, dislocation of the prosthesis postop can be corrected w/ closed reduction. However, the hip must be stabilized emergently so that nerve damage does not occur. Complications: 3. Surgery should be scheduled before serious debilitation occurs as a result of contracture or atrophied muscles at the joint following surgery, complications may include: Dislocation of the prosthesis, DVT w/ or w/out Pulmonary embolism, Nerve palsy, Infection of the bone (osteomyelitis) or wound site, heterotrophic ossification

AIDS

Kaplan Overview Syndrome distinguished by serious deficits in cellular immune function; causes opportunistic infections such as Pneumocystis jiroveci pneumonia, Candida albicans stomatitis and esophagitis, cytomegalovirus (CMV), Kaposi's sarcoma; nursing care includes providing restful environment, assisting w/ personal care, implementing infection control precautions b. Essential Nursing Care Marked by progressive weakening of cell-mediated immunity, AIDS increases susceptibility to opportunistic infections and unusual cancers. 1. Signs and Symptoms: After initial exposure, an infected person may have no signs or symptoms- or may have a flulike illness (seroconversion illness) and then remain asymptomatic for years. As syndrome progresses, potential signs and symptoms may include: Neurologic symptoms caused by HIV encephalopathy, symptoms of an opportunistic infection or disease, weakened immune defense is eventual symptom as a result of repeated opportunistic infections. Other manifestations of HIV and AIDS: respiratory symptoms (shortness of breath, dyspnea, cough, chest pain, fever), gastrointestinal symptoms (loss of appetite, nausea, vomiting, oral and esophageal candidiasis, chronic diarrhea) and depression. 2. Treatment: While no cure exists, signs and symptoms are managed with treatment. Primary therapy for HIv infection includes three different types of antiretroviral drugs: protease inhibitors, nucleoside reverse transcriptase inhibitors, and nonnucleoside reverse transcriptase inhibitors. 3. Nursing Care: Monitor patient for fever, noting patterns, assess for tender, swollen lymph nodes, checking laboratory values regularly, watch for signs and symptoms, encourage daily oral rinsing with normal saline or bicarbonate solution, offer coping support, and evaluate the patient, and educate about the disease. c. Background Nursing Care Background Information: Human immunodeficiency virus (HIV) belongs to a group of viruses known as retroviruses, and is the causative agent of AIDS. The infection integrates intelse into a person's immune system. HIV can be classified as HIV-1 (more predominant) and HIV-2, which is similar in spectrum, but typically characterized as having slower disease progression, requires specific testing, and is most commonly found in western Africa. Diagnostic Tests: A thorough health history indicates the need for HIV screening. Several screening tests are used for diagnosis, while other tests are used to assess disease stage and disease progression. Some screening tests may include: HIv antibody tests including EIA (enzyme immunoassay [can be blood or saliva test]), and Western blot used to confirm EIA, Viral load, measures HIV RNA in the plasma, and CD4/CD8 ratio, assesses markers found on lymphocytes indicating severity of impaired immune system.

Ultrasound

Kaplan Overview Transducer rubbed over the pelvic region and abdomen transmits sound waves that show the fetal image on screen; done as early as 5 weeks to confirm pregnancy and gestational age; client must drink fluid prior to test to have a full bladder to assist in clarity of image. b. Essential Nursing Care Ultrasonography is a noninvasive, nonradiographic monitoring method. Purpose: Confirms pregnancy Verifies due date and correlates it with fetal size Allows visualization of fetus Evaluates condition of fetus through observation of activity, breathing movements, amniotic fluid volume Rules out pregnancy in suspected cases of false-positive pregnancy test Determines cause of spotting or bleeding early in pregnancy Locates intrauterine device (IUD) that was in place at time of conception Locates fetus before amniocentesis and during chorionic villi sampling Diagnoses presence of multiple gestations Determines if abnormally rapid uterine growth is due to excessive amniotic fluid Determines condition of placenta Verifies presentation and fetal or cord position before delivery Nursing Care: Have patient drink 1 quart (1 liter) of fluid 1 hour before test and instruct her not to void; full bladder serves as landmark c. Background Nursing Care Description: Performed with transabdominal or transvaginal handheld transducer Captures real-time moving or still image of fetus within the uterus

Chest Tubes

Kaplan Overview - Chest tubes are placed in the pleural space to drain air and blood so the lung can re-expand; drainage system consists of one or more chest tubes; collection container placed below the chest and a water seal is used to keep air from entering the chest; nursing responsibilities include observing for constant bubbling in the water-seal chamber (indicates a leak in the drainage system); if chest tube becomes dislodged, apply pressure over the insertion site with a dressing that is tented on one side to allow for the escape of air; if the tube becomes disconnected from the drainage system, cut the contaminated tip off the tubing using sterile scissors and immerse the end of the chest tube in 2 cm sterile water until system can be re-established. b. Essential Nursing Care Purpose 1. Inserted into the pleural space, chest tubes allow blood, fluid, pus or air to drain and allow the lung to reinflate. They may be required to help treat pneumothorax, hemothorax, empyema, pleural effusion, or chylothorax. Nursing Care 2. Preparation: a. Obtain baseline vital signs and administer a sedative as ordered. b. Collect necessary equipment, including a thoracotomy tray and an underwater-seal drainage system. c. Set up the underwater-seal drainage system according to the manufacturer's instructions and place it at the bedside. Stabilize the unit to avoid knocking it over. i. Monitoring and aftercare: 1. When the patient's chest tube is stabilized, instruct the patient to take several deep breaths to inflate the lungs fully and help flush pleural air out through the tube. 2. Obtain vital signs immediately after tube insertion and every 15 minutes thereafter, according to facility policy (usually for 1 hour). 3. Routinely assess chest tube function. Describe and record the amount of drainage on the intake and output sheet. 4. After most of the air has been removed, the drainage system should bubble only during forced expiration, unless the patient has a bronchopleural fistula. Constant bubbling may indicate that a connection is loose or that the tube has advanced slightly out of the patient's chest. Promptly correct any loose connections to prevent complications. 5. If the chest tube becomes dislodged, cover the opening immediately with petroleum gauze and apply pressure to prevent negative inspiratory pressure from sucking air into the chest. Call the physician. Reassure the patient and monitor closely for signs of tension pneumothorax. c. Background Nursing Care - There are three types of chest tubes and drainage systems, which all have three compartments: traditional water seal (wet suction) systems, dry suction water seal systems, and dry suction (one-way valve) systems. 1. Water seal systems have a collection chamber for drainage, a water seal chamber, and wet suction control chamber. 2. Two-compartment water seal systems (water seal chamber and collection chamber) are available for patients who need only gravity drainage. a. The water seal chamber, which has a one-way valve or water seal, prevents air from moving back into the chest when the patient inhales. Discontinuous bubbling in the water seal chamber is normal, but continuous bubbling may indicate an air leak b. The suction control chamber controls the amount of negative pressure applied to the chest. After the suction is turned on, bubbling can be seen in the suction chamber. Water is needed for suction. dry suction seal systems have a collection chamber for drainage, a water seal chamber, and a dry suction control chamber.

Asthma

Kaplan Overview - Chronic inflammatory disease of the airways caused by increased responsiveness of tracheobronchial tree to various stimuli; indications include cough, dyspnea, wheezing; assess respiratory status, administer as prescribed, instruct about use of peak flow meter, use of metered-dose inhaler (MDI), asthma triggers avoid. Essential Nursing Care - Status asthmaticus is severe asthma, a chronic inflammatory airway disorder, in which symptoms persist despite large amounts of medication. Signs and Symptoms 1. Sudden dyspnea, wheezing, cough, or chest tightening 2. Severe bronchospasm 3. Increased mucous secretion, resulting in thick, clear or yellow sputum 4. Tachypnea Nursing Care 5. Status asthmaticus that is unrelieved by usual asthma therapy both in and out of the hospital is a medical emergency. 6. Administer humidified oxygen by nasal cannula at 2 L/min, as needed to ease breathing difficulty and increase arterial oxygen saturation 7. Start intravenous fluids and administer medications, as ordered 8. Assist patient and their physicians in developing a written self-management plan c. Background Nursing Care Causes/Risk Factors 1. Genetic predisposition 2. Continuous exposure to allergens, tobacco, or other irritants or sensitizing agents either at home or at work 3. Gastroesophageal reflux disease 4. Chronic sinusitis or other infections (e.g., Mycoplasma, Chlamydia, respiratory syncytial virus) 5. Noncompliant with medications protocol or peak flow monitoring 6. Underestimation of an asthma attack Complications 7. Respiratory failure, requiring mechanical ventilation 8. Death from asphyxia or dysrhythmia d. Essential Nursing Care Signs and Symptoms 1. Expiratory wheezing 2. Recurrent nonproductive cough 3. Chest tightness 4. Shortness of breath with activity or at rest 5. Decreased breath sounds 6. Prolonged expiration 7. Tachycardia 8. Tachypnea 9. Accessory muscle use Nursing Care 10. Educate patient about reduction of risk factors 11. Administration and monitoring of oxygen therapy 12. Increased fluid intake to liquefy secretions 13. Educate patient about cough enhancement techniques 14. Education patient about used of metered dose inhalers or dry powder inhalers 15. Anxiety reduction and rest during acute attacks Background Nursing Care -Pulmonary ventilation takes place across the alveolar-capillary membrane. Oxygen diffuses into the pulmonary capillaries and carbon dioxide diffuses into the alveoli from the capillaries. The alveoli normally have elastic recoil and partially collapse during expiration. The alveoli distend during normal inspiration allowing a greater surface area for gas exchange. Causes/Risk Factors - Genetic, allergen exposure, environmental pollution, and tobacco smoke Complications - Respiratory acidosis, cardiac dysrhythmias, cardiopulmonary arrest, and chronic obstruction to airflow

Hydrocephalus

Kaplan Overview - Congenital or acquired condition characterized by an increase in the accumulation of CSF w/in the ventricular system and subsequent increase in ventricular pressure; indications include front-occipital circumference increases at abnormally fast rate, split sutures and widened distended, tense fontanels, prominent forehead, dilated scalp veins, irritability, vomiting, unusual somnolence, convulsions, high-pitched cry; treatment includes shunting; nursing care prior to surgery is to assess for increasing ventricular size, increased ICP, irritability; postoperatively, position on the un-operated side, keep flat to prevent complication due to too rapid reduction of intracranial fluid, assess for increased ICP, S/S of infection

Delegation:

Kaplan Overview - Delegation: Responsibility and authority for performing a task (function, activity, decision) is transferred to another individual who accepts that responsibility and authority. Delegator remains responsible for the task. Delegatee is accountable to delegator for responsibilities assumed. Can only delegate tasks for which the nurse is responsible. Responsibility is transferred. Can only delegate tasks for which you are responsible. Must transfer authority along with the responsibility to act. To Delegate, provide: what, when, where and how the task is to be delegated. State what type of report is required from delegate (written, verbal), Tell them what needs to be brought to delegator's attention (BP critical etc), give reason for the task, describe expected outcome and timeline for completion. Ineffective Delegation: Under delegation is when you do not transfer full authority, take responsibility back, don't equip or direct delegate and question the competence of delegate. Reverse Delegation: Lower person on hierarchy delegates to someone higher. Failure to delegate and supervise properly can result in liability. Nurses have a legal responsibility to make sure persons under their supervision perform consistently with established standards of nursing LPN/LVN: Assist with implementation of defined plan of care, perform procedures according to protocol, differentiate normal from abnormal; reports to RN, care for physiologically stable clients with predictable conditions, has knowledge of asepsis and dressing changes, ability to administer meds varies w/ education background and state nurse practice act. NAP: Assist with direct client care activities (bathing, transferring, ambulating, feeding, toileting, obtaining vital signs, height weight, I & O, housekeeping, transporting, stocking supplies. Includes Nurses aids, assistants, technicians, orderlies, and nurse extenders.

Croup

Kaplan Overview - General term for a respiratory system complex affecting children, names of which are are given according to main anatomic areas affected, LTB is the most common; indications include cough described as barking or seal-like in sound, hoarseness, dyspnea, inspiratory stridor, restlessness, irritability, low-grade fever; may develop hypoxia, cyanosis, respiratory acidosis, eventually respiratory failure; nursing interventions include consistent vigilant observation and accurate assessment of respiratory status, with particular focus on recognizing signs of impending respiratory failure so emergency measures can be taken immediately if needed; a. Essential Nursing Care Croup is an obstructive upper airway disease that affects primarily children younger than 5 years of age Signs and symptoms 1. upper respiratory infection 2. low-grade fever 3. barking cough (croupy cough) at night 4. inspiratory stridor 5. substernal and suprasternal retractions 6. agitation or restlessness Nursing Care 7. carefully monitor hospitalized children for respiratory status and airway obstruction, including color, effort of respirations, and evidence of fatigue 8. assess vital signs for worsening symptoms 9. administer prescribed medications, as ordered 10. provide humidified air by vaporizer or mist tent 11. encourage oral hydration to help loosen secretions, but use intravenous fluids in the child who is at risk for aspiration (i.e. the child with a respiratory rate over 60 breaths/minute) b. Background Nursing Care Background 1. croup usually results from a viral infection (e.g. respiratory syncytial virus), but it may also be caused by a bacterial infection 2. it is typically seen more often in boys than in girls between the ages of 6 months and 5 years 3. usually self-limited 4. involves severe inflammation and obstruction of the larynx, trachea, and major bronchi

Sports Injuries

Kaplan Overview - Injuries include contusions, dislocations, sprains, strains;treatment includes immediate icing (apply for no more than 30 minutes), compressions, elevation, support. a. Essential Nursing Care - School-aged children and adolescents participate in school and recreational sporting events, during which injuries occur. Most injuries occur during recreational sports. Improving playing conditions, demanding compliance with rules, and using protective equipment can decrease the risk of injury. In addition, adults must provide diligent coaching and supervision. Signs and Symptoms: Sprains, strains, bruises, broken noses, head or neck injury, cardiac or respiratory arrest, hemorrhage or shock, dehydration or hyperthermia, hyponatremia due to excessive hydration 3. Nursing care - Educate students about safety equipment and the potential risks of individual sports. Encourage students to use protective equipment (e.g., helmets pads, guards) when playing contact sports. Encourage students to seek help for even minor injuries so that more serious injuries do not result.

Therapeutic communication

Kaplan Overview - Listening to and understanding the client while promoting clarification and insight; goals is to understand the clients message, to facilitate the clients verbalization of feelings, to communicate nurses understanding and acceptance, and to identify problems, goals, and objectives. Includes using silence, using general leads or broad opening, clarification and reflecting. b. Essential Nursing Care - All therapeutic relationships occur in stages during nurse interaction with a patient in a clinical setting. Purpose: developing trust, promotes open communication. Expected Pt outcomes: Pt develops trust In the nurse and healthcare team, communicate effectively and provides accurate information, receives accurate information and correct treatment, experiences a smooth transition into care from other healthcare team members, keeps necessary follow up appointments, and cooperates with correct rehabilitation regimen. c. Background Nursing Patient Teaching - Answer any question patient may have, let patient know when you are entirely familiar with any subject, encourage goal setting and accomplishments of goals, encourage patient to be honest, and encourage friendly conversations. Special Consideration- General: avoid giving false assurance. Pediatric: effective communication among patient and family members. Geriatric: Touch can be reassuring

Intake and Output

Kaplan Overview - Measuring 24 hour I & O evaluates the patient's fluid status. Intake includes all liquids taken by mouth, through NG or jejunostomy feeding tubes, IV fluids, and blood and its components. Also, intake includes beverages, fluids contained in solid foods, foods that are liquid at room temperature (gelatin, custard, and ice cream). Output includes urine, diarrhea, vomitus, gastric suction, and drainage from postsurgical wounds and chest tubes. Essential Nursing Care - Helps evaluate a patient's fluid and electrolyte balance. Nursing Diagnoses: Deficient fluid volume, Excess fluid volume, and Risk for imbalanced fluid volume. Implementation: Document patients feeding according to facility's policy and record amount in mL. Monitor I & O during each shift. Notify the physician if amounts differ significantly over a 24-hour period. Expected outcome: Patient maintains an approximate balance between fluid intake and fluid output. Background Nursing Care - Patient teaching: Tell patient and family that record of all fluid entering and leaving the body ensures proper fluid balance. Give instructions for how the patient can help keep measurements of I & O accurate. Explain to parents the importance of replacing fluid that is lost when children are ill. Special Considerations: Diuretics can affect I & O measurements and any significant change in UO should be reported.

Oxytocin

Kaplan Overview - Oxytocin is used to stimulate an active labor pattern; nursing care includes administering with infusion pump, closely monitoring mother and baby; if contractions occur less than 2 min apart, last longer than 60 to 90s, or if there is significant change in fetal heart rate, stop infusion and turn patient to left side. Essential Nursing Care - Oxytocin is a naturally occurring hormone-released by posterior pituitary; a synthetic form is used to stimulate or augment uterine contractions during labor. Nursing Implications/Care: 1. Administered intravenously with infusion pump, start primary IV line, Insert tubing of administration set through infusion pump, set drip rate to prescribed dosage and infusion rate (Infusion rate: 0.5 to 1.0 mL/minute) (Labor-starting dosage: 10 units Oxytocin in 100ml isotonic solution) (Maximum dosage: 20 to 40mU). 2. Administer Oxytocin by piggyback method in IV line (always given as piggyback, so that if hyper-stimulation occurs, the drug can be stopped immediately and IV fluid can continue; also, if necessary, drug can be restarted easily to achieve goals. 3. Using external electronic fetal monitoring methods, monitor for fetal heart rate deceleration or fetal distress and stop infusion immediately if these occur. 4. Monitor maternal heart rate (if hypertension occurs, stop infusion and notify doctor,) 5. Review infusion rate to prevent uterine hyper-stimulation, (if hyper-stimulation occurs, discontinue Oxytocin and administer oxygen, increase uterine blood flow by changing patient's position and increasing infusion rate of primary IV line, resume Oxytocin infusion, per institution policy, after hyper-stimulation is resolved) 6. Monitor intake and output and watch for signs of water intoxication; limit IV fluids to 150mL/h. Expected Outcomes: Contractions begins and follow pattern of natural labor, patients suffers no adverse effects from drug, fetus suffers no distress, fetus is delivered successfully. Background Nursing Care - Action 1. Increases uterine contraction by increasing circulation of free intracellular calcium. 2. Oxytocin receptors increase during pregnancy, especially in third trimester and in latent phase of labor due to influence of estrogen, progesterone, and prostaglandin 3. Half-life is only 1 to 5 minutes, so stopping infusion results in a rapid decrease in effect. 4. Adverse Effects: Nausea, vomiting, cardiac arrhythmias, uterine hyper-tonicity, titanic contractions, uterine rupture, severe water intoxication, and fetal bradycardia.