Med Surg II Final Exam Liu

Chemotherapy: Thrombocytopenia

*DECREASED PLATELET LEVELS. 1. Gentle handling; use a lift sheet when moving or positioning patient. Do not drag the patient. 2. Avoid IM injections. Use the smallest gauge needle when injections are necessary. Apply firm pressure for at least 5 minutes at injection site. 3. Avoid medications that interfere with clotting (Warfarin). 4. Observe IV site every 4 hrs for bleeding; test urine and stool for occult blood. 5. Avoid trauma to rectal tissues. No rectal temperatures, examinations, enemas or suppositories. Use stool softeners or increase bulk in diet. 6. Measure abdominal girth daily to assess for blood pooling in peritoneum. 7. Use electric razor and soft-bristled toothbrush. Keep lips moisturized, avoid commercial mouthwashes. 8. Use emery board for nail care. Wear shoes w/ firm soles when ambulating. 9. Avoid contact sports. Avoid forcefully blowing nose or inserting things up the nose. 10. Avoid IDC, use smallest catheter if necessary. 11. *Keep pathways/walkways clear and uncluttered.

Traumatic Amputation: Emergency Nursing Interventions

1. ABC's 2. Control bleeding by applying pressure using layers of gauze. 3. Keep affected extremity elevated above the heart level. 4. Wrap amputated body part with dry sterile gauze; place it in watertight sealed bag. Place the bag in ice water. AVOID direct contact with ice.

Fractures: Emergency Management

1. Assess ABC's first. 2. Apply pressure to control bleeding. 3. Immobilize extremity before moving the patient. 4. NO attempt should be made to reduce the fracture. 5. Check neurovascular status before applying immobilization. 6. Remove clothing and jewelry, keep the patient warm in the E.D.

Care of Vascular Access

1. Assess for adequate circulation in the fistula or graft. 2. Check distal pulses and capillary refill. 3. Check for audible bruit or palpable thrill over access site. 4. Avoid taking BP or drawing blood in the arm with access site. 5. Avoid tight dressing, restraint or jewelry over access site. 6. DO NOT use fistula or graft to deliver IV fluids. 7. Avoid using access site for any purpose other than dialysis unless emergency. 8. Monitor for infection. 9. Teach patient not to carry heavy objects using affected arm.

Activities that Increase Intraocular Pressure (IOP)

1. Bending from the waist 2. Lifting, pushing or pulling objects weighing more than 15 Ib. 3. Sneezing, coughing, vomiting, blowing the nose 4. Straining to have a bowel movement 5. Having sexual intercourse 6. Wearing tight shirt collars 7. Keeping the head in a dependent position

Acute Kidney Injury Drug Therapy

1. Cardiac glycosides (Digoxin): improves ventricular contraction, stroke volume and cardiac output. *Monitor for toxicity e.g. N/V, change in vision. 2. Vitamins/minerals: replacement is essential when patient is on dialysis. Daily stool softener to prevent constipation. 3. Synthetic erythropoietin: prevents anemia. *Report chest pain, difficulty breathing, weight gain, seizures, rash or swelling or feet or ankles. 4. Phosphate binders: prevent hypocalcemia. TAKE WITH MEALS. Separate w/ Digoxin and daily stool softener. 5. Sodium Polystyrene Sulfonate: orally or by enema. IV D50W, insulin and calcium replacement if patient is unstable.

Prevention of Ear Infection or Trauma

1. Do not use small objects (e.g. matches, hairpins) to learn external ear canal. 2. Wash external ear and canal daily in the shower or while washing hair. 3. Blow nose gently. Do not occlude any one of nostrils while blowing nose. Sneeze with mouth open. 4. Wear sound protection around loud or continuous noises. 5. Avoid activities with high risk for head or ear trauma (e.g. wrestling, boxing, motorcycle riding). 6. Keep the volume on head receivers at the lowest setting. 7. Frequently clean objects that come into contact with ear (e.g.headphones, telephone receivers). 8. Avoid environmental conditions with rapid changes in air pressure.

Sickle Cell Crisis Prevention

1. Drink 3-4L fluids daily. 2. Avoid alcohol or tobacco. 3. Avoid temperature extremes (has effects on constriction or dilation of vessels); wear socks/gloves on cold days. 4. Avoid planes w/ unpressurized cabins, avoid travel at high altitudes. 5. Mild exercise 3x weekly when not in crisis. AVOID strenuous activity.

Breast Cancer Etiology & Genetic Risk

1. Female gender 2. Increasing age 3. Family history or personal history of breast or ovarian cancer. 4. Genetic mutation 5. Hormonal factors 6. Null-parity or first child after age 30 7. Early menarche < 12 yo or late menopause > 55 yo 8. Excessive ingestion of animal fat 9. Hormone replacement therapy 10. Alcohol consumption, obesity, high-fat diet. 11. Exposure to ionizing radiation during adolescence and early adulthood. 12. Hx of benign proliferative breast disease.

Breast Cancer Manifestations & Surgery

1. Firm, non-tender, fixed mass or lump with irregular borders. 2. Asymmetry of the breast tissue 3. Changes to breast skin 4. Redness and warmth 5. Nipple retraction, discharge or ulceration 6. Burning or itchy nipple 7. Dimpling, peau d'orange May need lumpectomy or mastectomy. Preoperatively: psychological preparation and preoperative teaching. Postoperatively: relieve pain and discomfort, promote healing, observe complications (e.g. lymphedema, hematoma or seroma formation,1 infection), facilitate rehabilitation, health teaching (teach BSE). Hand and Arm Care After Axillary Lymph Node Dissection: AVOID INJURY AND INFECTION. 1. Avoid BP, infections, venipuncture in affected side extremity. 2. Use sunscreen for extended exposure to sun. 3. Apply insect repellent to avoid insect bites. 4. Apply gloves for gardening. 5. Use cooking mitt for removing objects from oven. 6. Avoid cutting cuticles; push them back during manicures. 7. Use electric razor for shaving armpit. 8. Avoid lifting objects heavier than 5-10 pounds. 9. If skin breaks, wash the area with soap and water, and apply OTC antibacterial ointment.

Depth of Burn

1. First degree/Superficial-thickness burn: only involves epidermis. 2. Second degree/Partial-thickness burn: involves entire epidermis & varying portions of the dermis. a) Superficial partial-thickness: Injury to the upper third of the dermis. b) Deep partial-thickness: Injury extends into the deeper layers of dermis. 3. Third degree/Full-thickness burn: involves entire epidermis & dermis, in some cases underlying tissue. 4. Fourth degree/Deep full-thickness burn: extends beyond the skin into underlying fascia and tissue deep into muscle, bone and tendons.

Instillation of Ear Drops

1. Hand wash & wear gloves 2. Place ear drop bottle in warm water for 5 mins. 3. Tilt the pt's head in the opposite direction of the affected ear & place the drops in ear. 4. With head tilted, gently move the head back and forth five times. 5. Insert a cotton ball into the opening of the ear canal to pack.

Amputation: Complications

1. Hemorrhage 2. Infection 3. Skin breakdown 4. Phantom limb pain: painful sensation in amputated part after surgery. Usually occurs after above the knee amputations. Recognize the pain as real; treat aggressively w/ calcitonin, opioids, beta-blockers, etc. 5. Neuroma: tumor consisting of damaged nerve cells. 6. Joint flexion contractures: preventable through proper positioning. Avoid abduction, rotation and flexion of the lower limb. Avoid placing residual limb on a pillow. Avoid sitting for long periods of time. Encourage patient to turn from side to side and to a prone position if possible. Keep legs together; ROM exercises only.

Total Knee Replacement (Total Knee Arthroplasty): Postoperative

1. IV opioids given PCA 2. Continuous femoral nerve block (CFNB): monitor for metallic taste, tinnitus, nervousness, slurred speech, bradycardia, hypotension, decreased RR or seizures caused by injection. REPORT IMMEDIATELY! 3. Ice or cold packs 4. Neurovascular checks every 2-4 hrs. Encourage active flexion of the foot every hour. Limit flexion position. Avoid knee catch (bend of bed) and pillows behind the knee.

Colorectal Cancer Etiology & Genetic Risk

1. Increasing age, male gender 2. Personal or family history of colorectal cancer or polyps. 3. Hx of GI diseases (e.g. IBD, polyps, Hx of gastrectomy) that propose to cancer development and Type II DM. 4. Long-term cigarette smoking, increased body fat, physical inactivity, heavy alcohol consumption. 5. High fat diet, particular animal fat from red meats, high protein, low fiber diet, obesity. 6. Hx of genital cancer or breast cancer. 7. Previous colon cancer or adenomatous polyps 8. Race: African American or Ashkenazi Jewish.

Fractures: Nursing Care

1. Manage acute pain with drugs - AVOID Meperidine (Demerol) in older adults. 2. Monitor for neurovascular compromise. 3. Prevent infection: older adults may NOT have an elevated temperature even w/ severe infection. 4. Improve physical mobility - crutches, cane or walker. 5. Encourage foods high in protein, calcium and iron.

Nephrectomy

1. Monitor for signs of bleeding e.g. distended abdomen, low BP, decreased urine output and altered LOC. 2. Monitor for pain and infection. 3. Avoid high-risk activity. 4. Monitor for adrenal-insufficiency postoperatively e.g. assess urine output and report immediately! 5. Healthy diet and adequate fluids.

Wound Management

1. Occlusive dressings 2. Wet dressings (rarely used) 3. Moisture-rententive dressings a) Hydrogels: maintain moist environment; ideal for autolytic debridement, painful wounds, superficial wounds with high serous drainage; require a secondary dressing b) Hydrocolliods: adherent, nonpermeable to water and oxygen; ideal for exudative and acute wounds; do not require a secondary dressing c) Foam dressings: hydrophilic (absorbent, used for wounds with excessive drainage) and hydrophobic (nonabsorbent, waterproof; used for wounds relatively free of drainage); require a secondary dressing d) Calcium alginates: derived from seaweed; used for irritated or macerated wounds, cavity wounds, sinus tract, necrotic wounds; require a secondary dressing 4. Wound healing diet - high in protein, fat, carbohydrates, vitamins (especially A, C, E), minerals (including zinc) 5. Electrical stimulation 6. Vacuum-assisted wound closure (VAC) - priority is to close monitor for bleeding complications; contraindicated in pts on anticoagulant therapy, some degree of reduced tissue health near the wound (e.g.radiation therapy or poor nutrition), any exposed blood vessels, nerves or organs in the wound area) 7. Hyperbaric oxygenation (HBO) 8. Topical growth factors 9. Skin substitutes: a) Monitor the graft for adequate perfusion - Nursing Priority b) Immobilization with bulky cotton pressure dressings for 3-5 days. c) Elevation and complete rest of the grafted area. Donor sites: pressure dressing to promote hemostasis for 1-2 days.

Sickle Cell Crisis Interventions

1. Oral or IV hydration; monitor for fluid overload. 2. High concentration O2 via non-rebreather. PRIORITY. 3. Manage fatigue 4. Keep room warm, remove restrictive clothing. DO NOT use cold therapy, will constrict vessels. 5. Keep extremities extended to promote venous return, elevate HOB; DO NOT elevate knee position. 6. Avoid taking BP via cuff; use central line. 7. Strict aseptic technique; frequent hand washing.

Total Hip Replacement (Total Hip Arthroplasty): Preoperative

1. Patient education 2. Dental procedures should be done BEFORE surgery. 3. Monitor clotting time. 4. Prevent DVT: certain hormones and NSAIDs may be discontinued. Prophylactic low-molecular-weight Heparin may be prescribed. 5. Pain management 6. Autologous transfusion, epoetin alfa or iron supplements may be prescribed. *IV broad-spectrum antibiotic (Cephalosporin) given 60 minutes prior to skin incision and discontinued within 24hrs post-op.

Psoriasis Nursing Interventions

1. Patient education regarding the disease (not contagious), skin care, and treatment regimen. 2. Avoid factors (irritation, injury to skin, current illness, emotional stress, unfavorable environment, nonprescription drugs) that may aggravate the disease. 3. Measures to prevent skin injury: avoid picking or scratching. 4. Measures to prevent skin dryness: use of emollients, avoid excessive washing, and use warm (not hot) water, pat dry. 5. Use of the therapeutic relationship for support and to aid coping.

Ear Irrigation Procedure

1. Place Cerumenex or mineral oil drops into the ear 2-3 days before irrigation. 2. Fill a syringe with warm water to body temp. 3. Place the client in a sit up position or lie with head tilted down slightly toward the affected ear. 4. Place the tip of syringe at an angle so that the fluid pushes on one side of and not directly on the impaction. 5. Apply gentle continuous pressure, allowing the water to flow against the top of the ear canal. Use lowest effective pressure to prevent injury. 6. Do not use blasts or bursts of sudden pressure. 7. If pain occurs, decrease the pressure. If pain persists, stop the irrigation. If becomes nauseated, stop the procedure. 8. Use no more than 5-10 ml of fluid at a time. 9. If the cerumen does not drain out, wait 10 mins and repeat the irrigation procedure, 10. Continue to irrigate the ear with approx. 70 ml of fluid. 11. Position the client with the affected side down after the irrigation

Osteoporosis Etiology/Genetic Risk

1. Postmenopausal women and older men. 2. Small-framed Asian and Caucasian women, particularly those who don't exercise. 3. Diet lacking calcium, vitamin D and protein. 4. Excessive caffeine and large amounts of carbonated drinks. 5. Excessive alcohol and tobacco use. 6. Young adults who practice excessive exercise or weight-loss dieting. 7. Patients post-bariatric surgery. 8. Patients with GI disease causing absorption. 9. Family history of OP. Risk factors for Osteoporosis: ACCESS Alcohol use Corticosteroid use Calcium low Estrogen low Smoking Sedentary lifestyle & long-term use of anticonvulsants e.g. phenytoin.

Fractures: Cast Complications

1. Pressure ulcers: "hot spot" and tightness under the cast. 2. Circulation impairment (should be able to insert a finger between cast and skin). 3. Peripheral nerve damage (numbness, tingling, coldness in extremity) - NOTIFY HCP. 4. Compartment syndrome (most serious complication) - notify HCP; loosen or remove the splint/bivalve the cast. 5. Cast syndrome (rare but serious) s/s include - anxiety, increased RR/HR/BP, diaphoresis, dilated pupils, abdominal distention, N/V after meals, poor oral intake and weight loss.

AIDS Nursing Care: Infection

1. Private room as indicated by WBC count; hand hygiene. 2. Monitor vitals, mouth, skin, mucuous membranes and IV sites. 3. Change gauze and wound dressings daily. 4. Obtain cultures for suspicious areas; notify HCP. 5. Do not use supplies from common areas; keep box of disposable gloves in patient's room. Keep frequently used equipment in patient's room. 6. Limit the number of HCP entering the patient's room. Limit visitors to healthy adults. 7. STRICT ASPECTIC TECHNIQUE. STANDARD PRECAUTION!

Osteomyelitis: Nonsurgical Interventions

1. Start antimicrobial therapy as soon as possible. 2. IV therapy for 3-6 weeks, followed by oral therapy for weeks or months. 3. Care for the long-term vascular catheters and monitor drug side effects at home. 4. Teach the patient and family to finish the full course of antimicrobials to ensure infection is resolved. 5. Analgesics for pain. 6. Avoidance of stress on the affected bone. 7. Hyperbaric O2 therapy 8. Wound irrigation - *Contact Precaution in the presence of purulent discharge to prevent transmission of infection.

Neurovascular Assessment

6 P's - compare with other extremities. Pain: should be localized, stabbing or throbbing pain. Poikilothermia: should be no temperature difference in affected and unaffected extremities. Pallor: should be no change in pigmentation compared with other parts of the body. Pulse: should be strong and no difference in the affected and unaffected extremities. Paresthesia: should be no numbness or tingling, no difference in sensation in affected and unaffected extremities. Paralysis: should be able to move without discomfort. No difference in comfort comparing passive motion and active movement. Capillary refill is the LEAST reliable.

Ear Neoplasm

A benign lesion arising from jugular vein. Surgical removal of tumors is necessary because continued growth can affect other structures & damage the facial or trigeminal nerves.

Cataracts

A lens opacity or cloudiness that distorts the image projected onto the retina. Risk factors include associated ocular conditions, trauma, exposure to toxic agents, UV light, nutritional and physical factors, systemic diseases and syndromes. Both eyes may have cataracts, but the rate of progression in each eye is different. Early manifestations - painless, blurry vision, light scattering, reduced color perception, reduced contrast sensitivity, reduced sensitivity to glare, reduced visual acuity, astigmatism, diplopia. No pain or redness is associated with age-related cataract. Visual acuity is not a perfect measure of visual impairment. The degree of lens opacity does not always correlate with the pt's functional status. Prevention: Safety is the priority concern because of reduced vision. Optimal medical management is prevention. 1. Smoking cessation 2. Weight reduction 3. Optimal blood sugar control for patients with diabetes 4. Wear sunglasses outdoors Surgery is the only cure.

External Otitis (Swimmer's Ear)

A painful condition resulted from either an allergic response or inflammation of the external ear - known as "swimmer's ear". Common in hot, humid environment, especially in summer. Clinical Manifestations: 1. Affected skin red, swollen, tender to touch especially with manipulation of the auricle. 2. Aural tenderness 3. Greenish or yellow, foul smelling discharge from the ear. 4. Temporary conductive hearing loss. 5. Occasionally fever, cellulitis, and lymphadenopathy Comfort Management - heat application; minimize head movement; analgesics. Instill topical antibiotic and steroid eardrops; Oral or IV antibiotics are used in severe cases. Keep the ear clean and dry - DO NOT use cotton-tipped applicators; use earplugs when engaging in water sports to avoid getting the canal wet. If external otitis is diagnosed, refrain from any water sport activity for approx. 7-10 days.

Osteomyelitis: Acute/Chronic

Acute Osteomyelitis: 1. Constant, localized bone pain. Pulsating worsens with movement. 2. Fever, temperature above 101ºF 3. Swelling around the affected area. 4. Erythema of the affected area. 5. Tenderness of affected area. 6. s/s of sepsis when infection is blood borne. Chronic Osteomyelitis: 1. Constant, localized bone pain. Pulsating worsens with movement. 2. Ulceration of the skin. 3. Sinus tract formation (tunneling wound beneath skin). 4. Drainage from affected area. Prevention: 1. Elective orthopedic surgery should be postponed if the patient has a current infection. 2. Prophylactic antibiotics 3. Remove catheter and drains as soon as possible. 4. ASEPTIC wound care postoperatively. 5. Meticulous foot care for patients with diabetes.

Systemic Lupus Erythematosus (Lupus)

Affect women more than men. Manifestations: 1. Butterfly-shaped erythematous rash across bridge of the nose and cheeks. 2. Alopecia 3. Lupus Nephritis - leading cause of death. 4. Pancytopenia 5. Pleural effusion 6. Pericarditis 7. Raynaud's Phenomenon 8. Abdominal pain 9. Neurological manifestations Management: 1. Skin protection a. AVOID prolonged exposure to sunlight. b. AVOID powder and other drying agents. c. AVOID harsh hair treatment. 2. Pace activities 3. Smoking cessation 4. Monitor s/s - REPORT FEVER! 5. Monitor bone mineral density when taking corticosteroids.

Fractures: Skeletal Traction

Aids in bone realignment. Allows the use of longer traction time and heavier weights (25-40 pounds). Pin site care is PRIORITY! Inspect the site every 8hrs. Chlorhexidine solution is the most effective; if contraindicated, Normal Saline solution should be used. Isometric exercises 10 times each hour when awake (plank, wall sit). Nursing Care for Traction: T: temperature (extremity infection) R: ropes hang freely A: alignment C: circulation check (5 P's) T: type/location of fracture I: increase fluid intake O: overhead trapeze N: no weights on bed or floor Use trapeze to shift weight for repositioning. May ONLY remove weights if life-threatening emergency. Ropes must be unobstructed; knots in rope tied securely

Hemodialysis Nursing Care

Anticoagulation (Heparin) is needed during treatments. 1. Monitor for bleeding. 2. Avoid invasive procedures 4-6 hrs after dialysis. 3. Protamine Sulfate should be available. Vascular Access: 1. AV fistula or graft for long-term access. 2. Hemodialysis for temporary access. 3. Protection of access site is HIGH PRIORITY. Pre-Dialysis: 1. Weigh patient prior to dialysis. 2. Discuss w/ HCP to withhold vasoactive drugs after dialysis treatment. Post-Dialysis: 1. Weigh patient after dialysis. 2. Assess for orthostatic hypotension. 3. Monitor for fever or bleeding. Restrict dietary protein, potassium, phosphorus and fluid (24hr output plus 500ml). *Report neurological symptoms e.g. headache, N/V, restlessness, decreased LOC, seizures, coma or death.

Nephrotic Syndrome

Assessment: 1. Proteinuria >3.5 g/day; HALLMARK! 2. Hypoalbuminemia 3. Facial or periorbital edema 4. Lipiduria (lipid in urine), hyperlipidemia and increased coagulation leads to renal vein thrombosis. Interventions: 1. Corticosteroids, immunosuppressing agents. 2. ACE-Inhibitors to reduce proteinuria. 3. Mild diuretic for edema. 4. Lipid-lowering agents for hyperlipidemia. 5. Daily weights and measure abdominal girth. 6. I/O; sodium and fluid restriction. 7. Bed-rest if severe edema. 8. Increase protein intake if GFR is normal.

Peritoneal Dialysis Nursing Care

Before dialysis: evaluate baseline vital signs, weight, lab tests and empty bowel/bladder. During Dialysis: 1. Monitor patient for respiratory distress, pain and discomfort. 2. Monitor prescribed time and initiate outflow. 3. Observe outflow amount and pattern of fluid. 4. Weigh the patient daily to monitor fluid status. Complications: 1. Peritonitis: most common and serious complication. Maintain strict aseptic technique. *Cloudy or opaque effluent is the earliest sign. Must assess for infection, send specimen of dialysate outflow. Treatment is intraperitoneal and IV antibiotics. 2. Pain: warm dialysate with heating pad or using warm chamber on machine. DO NOT put the bag in the microwave or soak in warm water. 3. Poor dialysate flow: related to constipation, kinked tubing, repositioning, clot formation or catheter displacement. NEVER push the catheter further into the peritoneal cavity. Facilitate draining by turning the patient from side to side or raising HOB. 4. Dialysate leakage: may occur immediately after catheter insertion. Occur more often in patients with obesity, diabetes, older adults or adults on long-term steroids. Avoid leakage by using small volumes of dialysate and increasing gradually.

Orbital & Ocular Trauma: Contusion

Blunt injury (accompanied with an increased incidence of retinal detachment, intraocular tissue avulsion, herniation) Ice application in the early phase. Hematomas causing increased orbital pressure may be surgically evaluated.

Osteomyelitis

Bone infection caused by bacteria, viruses or fungi. Osteomyelitis with vascular insufficiency commonly affect feet. Risk factors: 1. More often in men than women. 2. Advanced age 3. Chronic illness e.g. diabetes or RA. 4. Long-term use of corticosteroids, immunosuppressive drugs or chemo/radiation. 5. Malnutrition or obesity 6. Alcoholism or IV drug users. Nursing Care: 1. *FREQUENT neurovascular assessments is important.* 2. Elevate the affected limb.

Osteomalacia

Bone loss related to vitamin D deficiency. Causes: 1. Lack of sunlight exposure or dietary intake. 2. Malabsorption of vitamin D and calcium. 3. Liver, renal or pancreatic disorders. 4. Bone tumors or hyperparathyroidism. 5. Drugs: anticonvulsants, barbiturates and fluoride. Assessment: 1. Muscle weakness 2. Bone pain 3. Skeletal deformities (kyphosis or bowed legs) Labs: 1. Low serum calcium 2. Low serum phosphorus 3. Elevated ALP (alkaline phosphatase) 4. Low urine excretion of calcium and creatinine. X-rays shows demineralization of bone. May show compression fracture. Interventions: 1. Adequate daily sunlight 2. Increase vitamin D through dietary intake - dairy products, eggs, swordfish, chicken, liver, cereals and bread. 3. Treatment with Ergocalciferol (Vitamin D in active form).

Kidney Transplantation Criteria & Postoperative

Candidate must be free of medical problems e.g. recent malignancy, active or chronic infection, severe extrarenal disease, morbid obesity, current substance abuse or history of non adherence to treatment regimens. Candidates may be up to 70 years old. Postoperative: 1. Assess for s/s of rejection e.g. oliguria, edema, fever, increased BP, weight gain and swelling or tenderness over transplanted kidney/graft. 2. PRIORITIZE urine output assessment. Assess every hour during the first 48 hrs. Kidneys from living donor may produce large quantities of urine immediately after surgery. 3. Catheter care. REMOVE the catheter as soon as possible.

Acute Kidney Injury (AKI)

Categories: 1) Pre-renal: caused by poor blood flow to the kidney e.g. hypovolemic shock, heart failure, anaphylaxis or sepsis. a. Hypotension b. Tachycardia; decreased cardiac output. c. Lethargy d. Decreased urine output* e. Increased urine specific gravity* 2) Intra-renal: caused by damage to the kidney from infection, drugs, contrast agents, tumors, inflammation of glomeruli or obstruction to kidney blood flow. 3) Post-renal: caused by obstruction of urine outflow e.g. bladder, ureter or urethral cancer. Labs: 1. Rising BUN/Creatinine 2. Low urine specific gravity 3. Metabolic acidosis 4. Hyperkalemia (life-threatening) 5. Increased phosphate 6. Decreased calcium Interventions: 1. Nutrition: TPN may be needed. Parenteral fluids, oral intake and medications are screened to ensure potassium is not given in excess amounts. 2. Dialysis: (a) Hemodialysis; (b) Peritoneal dialysis. 3. Continuous renal replacement therapy for critically ill patients. 4. Monitor fluid/electrolytes, daily weights, bed rest. *Limit fluid intake after discharge.

Herpes Zoster (Shingles)

Caused by reactivation of the dormant varicella-zoster virus in patients who have previously had chickenpox. Clinical manifestations occur in 3 phases: 1. Pre-eruptive phase (lasts 1-10 days): pain, sometimes pruritus or paresthesias. 2. Acute eruptive phase (lasts 10-15 days): unilateral patchy erythematous areas, vesicles initially clear, then become cloudy, eventually rupture and crust, severe & unrelenting pain. 3. Post-herpetic neuralgia (PHN): variable in duration and manifestations. Antiviral drugs (can arrest the disease if administered within 24 hrs of the initial eruption), analgesics, systemic corticosteroids for PHN. Contagious to people who have not had chickenpox and have not been vaccinated against the disease. Contact Precaution. Do not share non-critical equipment between pts.

Tympanic Membrane Perforation

Caused by trauma or infection. Most perforations heal within weeks without treatment. Persistent hearing impairment should be evaluated. Tympanoplasty may be indicated. In the case of a head injury, monitor for otorrhea or rhinorrhea (clear, watery drainage from the ear or nose) & REPORT immediately. Education focus on trauma prevention.

Colorectal Cancer Manifestations

Change in bowel habits: most common presenting symptom. Passage of blood in or on the stools: second most common symptom. 1. Unexplained anemia due to bloody stools. 2. Right-sided lesions - dull abdominal pain, melena. 3. Left-sided lesions - intestinal obstruction symptoms (pain, distention, vomiting, narrowing stools, constipation, fecal oozing), bright red blood in the stool. 4. Rectal lesions - tenesmus (ineffective, painful straining at stool with urge), rectal pain, feeling of incomplete evacuation after bowel movement, alternating constipation and diarrhea, bloody stool. 5. Chill, fever, weight loss, fatigue. Surgery for colostomy bag is typical treatment. Preoperative Care: Providing preoperative education and referral to an enterstomal therapist. 1. Maintaining optimal nutrition & fluid volume balance 2. Preventing infection: bowel prep and prophylactic antibiotics 3. Providing emotional support Postoperative Colostomy Care: 1. Assess the color and integrity of stoma 2. Skin care is a major concern 3. Monitoring potential complications: bowel obstruction, intra-abdominal infection and ischemia, hemorrhage. 4. Demonstration of self care 5. Nutrition changes 6. Psychosocial support

Osteoporosis (OP)

Chronic metabolic disease in which bone loss causes decreased density and possible fracture. Generalized Osteoporosis: a. Primary Osteoporosis: age related; occur in women after menopause and men later in life. b. Secondary Osteoporosis: resulted from other medical conditions e.g. hyperthyroidism, hyperparathyroidism and medications e.g. anticonvulsants, heparin or thyroid hormone. Regional Osteoporosis: results from immobilization. Assessment: 1. Classic "Dowager's hump" 2. Back pain 3. Osteoporotic fracture of the thoracic and lumbar spin. 4. Hip fractures 5. Colles fractures of the wrist (FIRST sign) History: assess risk factors for osteoporosis and falls. Labs: no definitive tests. May require 24-hr urine collection. Imaging: Dual-energy x-ray absorptiometry (DEXA) provides definitive diagnosis (T-score <2.5).

Psoriasis

Chronic non-communicable inflammatory multi-system disorder of the skin. Has genetic predisposition; more prevalent among women and Caucasians. A lifelong condition; may be triggered by emotional stress, anxiety, trauma, infections, seasonal and hormonal changes. Clinical Manifestations: 1. Red, raised patches of skin covered with silvery scales. 2. Pitting, discoloration, crumbling beneath the nails; separation of the nail plate Complications: 1. Asymmetric rheumatoid factor-negative arthritis: priority is to assess joints for pain and decreased ROM. 2. Generalized exfoliative dermatitis (erythroderma).

Rheumatoid Arthritis (RA)

Chronic, progressive, systemic, inflammatory autoimmune connective tissue disease that affects synovial joints. Combination of environmental (cigarette smoking, pollution), genetic factors, reproductive hormones and illness. Positive rheumatoid factor, increased ESR and sensitivity to CRP. Early Manifestations: 1. Symmetric joints - erythema, stiffness (especially in the morning), swelling, pain, warmth and lack of function. 2. Systemic - weakness, fatigue, anorexia and low-grade fever. Late Manifestations: 1. Joints - progressively inflamed and painful deformities, cervical disease can be life threatening. 2. Systemic: weight loss, fever, extreme fatigue, anemia, vasculitis, subQ nodules. R.A. Syndromes: 1. Sjogren's Syndrome a) Dry eyes b) Dry mouth 2. Felty's Syndrome a) Hepatosplenomegaly b) Leukopenia 3. Caplan's Syndrome a) Rheumatoid nodules in the lungs b) Pneumoconiosis

Meneire's Disease

Chronic, recurrent disorder of the inner ear. An excess of endolymphatic fluid that distorts the entire inner-canal system. Clinical Manifestations: a. Three specific features - tinnitus, fluctuating sensorineural hearing loss, episodic vertigo. b. Other common features - pressure or fullness in the ear, nausea, vomiting, nystagmus and severe headaches. Nonsurgical Management: 1. Provide safety; restrict head movement. 2. Nutrition therapy 3. Drink adequate fluids daily & stay hydrated 4. Limit salty foods or fluids (low sodium diet 1,000 to 1500 mg/day or less), limit canned, frozen, or processed foods with high sodium content 5. Limit foods high in sugar, avoid caffeine, smoke and limit alcohol, tea, soft drinks 6. Avoid foods containing MSG 7. Avoid aspirin and aspirin-containing medications. 8. Pay attention to the intake of potassium containing foods if taking a diuretic that causes potassium loss. 9. Drug therapy - mild diuretics (e.g. hydrochlorothiazide, triamterene, spironolactone), nicotinic acid, antihistamines (e.g. meclizine), antiemetics (e.g. promethazine), tranquilizers (e.g. diazepam) Surgical Management (last resort): hearing loss, tinnitus and aural fullness may continue.

Xerosis Nursing Care

Common among elderly. Scratching and rubbing the skin may result in secondary skin lesions, excoriations, lichenification (thickening) and infection. Worsened with dry climates, higher altitudes, central heating, air-conditioning, wind, cold, sunlight, and frequent bathing with harsh soap and hot water. NURSING CARE: Rehydrate skin with creams or lotions after bathing when the skin is slightly damp.

Fracture Complications: Acute Compartment Syndrome

Condition where increased pressure within one or more compartments reduces circulation. Common in lower leg and forearm. Assessment: 1. Pain occurs/intensifies with passive ROM; pain is severe and unrelieved by drugs (EARLIEST sign). 2. Paresthesia, numbness, tingling - occurs before changes in vascular or motor signs. 3. Poikilothermia - the affected limb feels cooler than the unaffected limb. 4. Pulse is weak or absent - pulselessness is a LATE sign. 5. Pallor, cyanosis or necrosis 6. Paresis or paralysis Infection may require amputation!

Impetigo

Contagious superficial skin infection caused by staphylococci, streptococci, or multiple bacteria. Commonly seen on face or extremities. Begins with small, red macules, which quickly become discrete, thin-walled vesicles that rupture and become coved with a honey-yellow crust. Topical antibacterial therapy; systemic antibiotics if infections are widespread. **Contact precautions. Educate pt and family members to bathe at least once daily with bactericidal soap. Good hygiene to prevent infection transmission. Avoid contact with other people until lesions heal.

Orbital & Ocular Trauma: Lacerations

Corneal lacerations are an ocular emergency. DO NOT remove penetrating object. IV antibiotics and surgery.

Fracture Complications

Crush Syndrome: external crush injury that compresses one or more compartments in the leg, arm or pelvis. May cause hypovolemia, hyperkalemia, muscle weakness/pain, dark brown urine. Hypovolemic shock: common with pelvic fractures or open femoral fractures. VTE: common complication of lower extremity trauma or surgery. DIC: triggered by massive trauma.

Rheumatoid Arthritis Nursing Interventions/Pharmacology

DMARD 1. Methotrexate: increased risk for infection, liver toxicity and birth defects. 2. Leflunomide: increased liver enzymes and birth defects. 3. Azathioprine: bone marrow suppression, increased risk for infection. 4. Hydroxycholoroquine: retinal damage. NSAIDs (Ibuprofen/Naproxen) 1. GI bleeding 2. Sodium retention Glucocorticoids: take calcium and vitamin D daily to prevent osteoporosis. Biological DMARD 1. Avoid if patient has serious infection. 2. Report site reactions. Nursing Interventions: 1. Adequate rest 2. Proper positioning 3. Ice and heat application 4. Promote self-management but limit joint stress. 5. Manage fatigue 6. Enhance body image

Macular Degeneration

Deterioration of the macular (the area of central vision). Central vision decline is common. Peripheral vision remains. Aged-related macular degeneration (AMD) - dry or wet. Risk factors include smoking, HTN, female, short stature, family history, diet poor in carotene and vitamin E. Management: 1. Dry AMD - no cure, slowing the progression by increasing intake of antioxidants, vitamin B12, Zeaxanthin (Carotenoids). 2. Wet AMD - laser therapy, vascular endothelia growth factor inhibitors (Ranibizumab, Bevacizumab).

Electromyography (EMG)

Evaluates muscle weakness. DISCONTINUE muscle relaxants before the procedure. Contraindicated in patients on anticoagulant therapy or with extensive skin infections. Do not use lotions or creams on the day of the test. Ice application to hematoma after the procedure. Warm compresses may relieve residual discomfort after the procedure.

Fracture Complications: Fat Embolism Syndrome (FES)

Fat globules are released from the bone marrow into the blood stream. Patients with fractured hips have the highest risk. Manifestations: TRIAD 1. Hypoxemia: dyspnea, tachypnea & substernal chest pain (FIRST signs) 2. Altered LOC - IMMEDIATE ABG. 3. Late petechiae (CLASSIC sign) Prevention: 1. Immediate immobilization of fractures. 2. Minimal fracture manipulation. 3. Adequate support of fractured bones during turning or positioning. 4. Maintenance of fluid/electrolyte balance. Management: 1. Respiratory support w/ mechanical ventilation. 2. IV corticosteroids 3. Vasopressor medications 4. Accurate I/O records.

Anaphylaxis Manifestations/Interventions

First feelings of uneasiness, apprehension, weakness and impending doom. Next signs are erythema and angioedema of the eyes, lips or tongue. Manifestations: 1. Respiratory distress 2. Hypotension/Tachycardia 3. Loss of consciousness 4. Incontinence 5. Hypotonia (flaccid muscles) 6. Absent DTRs Interventions: 1. Assess respiratory status (RR/pattern, O2 saturation, lung sounds). STAY WITH THE PATIENT. 2. Call rapid response team! 3. High flow O2 90-100% 4. Elevate HOB 45º unless hypotension is present; raise feet and legs. 5. IV Normal Saline is CRITICAL. Drugs: Epinephrine SubQ, antihistamine, corticosteroids and inhaled beta-adrenergic agonists.

Osteomyelitis: Surgical Intervention

For chronic osteomyelitis. 1. Sequestrectomy (removal of dead bone/tissue that has separated from healthy tissue). 2. Bone grafts from fibula and iliac crest. 3. Muscle flaps for large defect. 4. Internal fixation or external supportive devices may be needed. 5. Amputation of affected limb.

AIDS/Transmission

HIV attacks the immune system by removing CD4+ T-cells from circulation. AIDS diagnosis is confirmed with a positive HIV test and CD4+ T-cells count is less than 200 and/or the patient becomes ill with an opportunistic infection. Transmission Routes: 1. Sexual transmission 2. Parenteral transmission - injection drug users, blood products. 3. Perinatal transmission - pregnancy, exposure to blood and vaginal secretions during birth; exposure through breast milk. 4. Healthcare workers - needle stick or sharp injury. BEST prevention for HCPs is the consistent use of standard precautions for all patients. HIV is NOT transmitted by casual contact. Sharing household items e.g. towels, linens, utensils or toilets do NOT transmit HIV.

Oncological Emergency: SIADH (Syndrome of Inappropriate Antidiuretic Hormone)

HYPONATREMIA Symptoms similar to Heart Failure, FLUID EXCESS. Manifestations: 1. Weakness/fatigue 2. Muscle cramps 3. Loss of appetite 4. If Na+ drops below 110; seizure, coma or death may occur. 5. Crackles (assess lung sounds) 6. JVD 7. Bounding pulse Interventions: 1. *Priority is patient safety 2. Monitor for fluid overload every 2 hrs 3. Fluid restriction 4. Diuretics 5. Drug therapy - Demeclocycline (Declomycin) is a broad spectrum antibiotic given to reduce kidney bond to ADH. 6. Immediate radiation or chemotherapy

Fractures of the Pelvis

Hemorrhage and shock are most serious consequences. Assess for internal abdominal trauma; monitor BP, blood in urine/stool, ecchymosis, severe back pain or abdominal rigidity. Handle patient gently. 1. Stable pelvic fracture: bed rest 2. Unstable pelvic fracture: surgical intervention; risk for hemorrhage and shock.

Orbital & Ocular Trauma: Hyphema

Hemorrhage in the anterior chamber. 1. Semi-Fowler's position 2. Restrict eye movement 3. Avoid reading or TV 4. Cycloplegic (paralyzing) eyedrops; topical corticosteroids & anti-fibrinolytic agent. 5. Apply eye shield. *Aspirin is contraindicated.

Scleroderma

Higher mortality rate than Lupus. Women are affected more than men. 1. Raynaud's phenomenon and edema in hand/forearm (FIRST sign). 2. Skin is dry. Extremities stiffen and loses mobility. Face appears mask-like, immobile. Avoid extreme temperatures and use lotion to minimize skin dryness - prevents effects of Raynaud's phenomenon. 3. Cardiovascular involvement is the leading cause of death. Spider veins. 4. Lung involvement - fibrosis of alveoli and interstitial tissue. 5. Hardening/sclerosing of esophagus - GERD, peristalsis, diarrhea. *NO medication is effective. Interventions: 1. Small, frequent meals. 2. Minimize intake of foods/fluids that stimulate gastric secretions (spicy foods, caffeine or alcohol). 3. Keep HOB elevated 1-2 hrs after meals.

Conjunctivitis (pink eye)

Inflammation of the conjunctiva. Caused by bacteria, viruses, fungus and parasites. Edema, "blood shot" eye appearance, tears & discharge. Foreign body, scratching or burning sensation, itching, photophobia. Topical antibiotics required for bacterial conjunctivitis. Viral conjunctivitis is not responsive to any treatment. Very contagious. Education about frequent hand hygiene is essential.

Otitis Media

Inflammation or infection of the middle ear. Clinical Manifestations: 1. Ear pain with or without movement of the external ear. 2. Purulent inflammatory discharge. 3. Temporary conductive hearing loss. 4. Headaches, malaise, fever, nausea and vomiting. 5. In severe cases, lymph nodes behind the ear increased in size; eardrum (tympanic membrane) perforation. Non-Surgical Management: 1. Quiet environment; limit head movement; heat and cold application. 2. Systemic antibiotics, oral analgesics, antihistamines and decongestants. Surgical Myringotomy: -Preoperative: relieve anxiety; clean the external canal. -Procedure: local anesthetic agent used. -Postoperative: 1. Avoid straining a bowel movement. 2. Avoid drinking through a straw for 2 to 3 weeks. 3. Avoid air travel for 2 to 3 weeks. 4. Avoid excessive coughing; gently blow the nose if need to without occluding either nostril, with mouth open. 5. Avoid washing hair or showering for one week. 6. Keep ear dry for 6 weeks by placing a cotton ball coated with petroleum jelly. 7. Avoid rapidly moving the head, bouncing or bending. 8. Stay away from people with respiratory infections. 9. Change ear dressing q24 hrs or as directed. 10. Report excessive drainage.

Polycystic Kidney Disease (PKD)

Inherited disorder which cause fluid-filled cysts to develop in the nephrons. NO PREVENTION FOR PKD. Genetic counseling is essential for adults that have one or both parents w/ PKD. Etiology/Risks: 1. Common in white people; leading cause of kidney failure. 2. Men and women have equal chances of acquiring. 3. Autosomal Dominant AND Recessive trait Assessment: 1. Hypertension (PRIORITY for treatment). 2. Abdominal or flank pain (FIRST sign). 3. Polyuria, nocturia (EARLY sign). 4. Constipation, increased abdominal girth. 5. Kidney stones or bloody, cloudy urine. 6. Cerebral aneurysm - can rupture and cause bleeding or death. Labs: 1. Proteinuria 2. Hematuria 3. Elevated BUN/Creatinine 4. Small cysts detected by ultrasound, CT or MRI.

Bone Scan (nuclear scan)

Injection of IV radioisotope. Pre-Scan: assess allergies to radioisotope and contraindications (pregnancy, breast feeding); empty the bladder before scanning pelvic bones. May experience hot flashes from isotope during procedure. Post-Scan: encourage fluid intake. NO precautions required in handling excreta (not radioactive).

Renal Cell Carcinoma

Major risk is tobacco use or chemical exposure. Assessment: 1. Dull, aching pain 2. Hematuria (LATE sign) 3. Kidney mass s/s from metastasis e.g. weight loss, weakness or anemia. Interventions: 1. Biological response modifiers, tumor-necrosis factors or targeted therapy agents. 2. Renal-artery embolization in metastatic renal carcinoma. -Postinfarcation Syndrome Management: parenteral analgesics, acetaminophen, antiemetic, IVT and restriction of oral intake. 3. Nephrectomy is the preferred treatment if the tumor can be removed.

Assessment Findings of Benign v.s. Malignant Lesions

Malignant lesions are asymmetrical, have irregular borders, the color varies throughout or is black and if the mole's diameter is larger than a pencil eraser. A.B.C.D.E.

Von Willebrand Disease

Manifestations: bleeding tends to be mucosal, recurrent nosebleeds, easy bruising, heavy menses, prolonged bleeding from cuts, postoperative bleeding. Treatment: 1. Replacement of vWF or factor VIII at the time of spontaneous bleeding or prior to invasive procedures (e.g. lumbar puncture, dental extraction, endoscopy, colonoscopy). 2. Desmopressin (DDAVP) can be used to prevent and/ or manage bleeding associated surgical procedures. 3. Aminocaproic acid in mild forms of mucosal bleeding. 4. Cryoprecipitate (packed Plasma) only in emergent situation.

Anaphylaxis

May be caused by medications (Penicillin or Sulfa antibiotics), foods (peanuts), insect bites/stings or latex. Anaphylaxis deaths are related to a delay in epinephrine administration. Teach patient how to use Epi-Pen; teach patient with history of anaphylaxis to carry at all times. Strict avoidance of potential allergens. EPI PEN ADMINISTRATION: 1. Uncap Epi-Pen device, hold it so the injecting end is upright. 2. Position the device at the middle portion of the thigh. 3. Push device into thigh as far as possible. Epi-Pen device will auto inject a premeasured dose of epinephrine into subcutaneous tissue.

Prevention of Skin Cancer

Minimize Sun Exposure: 1. Avoid sun between 10 AM - 4PM. 2. Wear hat, protective clothing, seek shady areas when outdoors. 3. Use caution around snow and water because of reflective sun rays. Use Sunscreen: 1. Use sunscreen with a SPF 15 or higher; use lip balm with SPF of 15 or higher. 2. Apply sunscreen generously 20 minutes prior to sun exposure. 3. Reapply every 2 hrs, or immediately after swimming. Do not use artificial UV sources (e.g. tanning beds, booths). Check Skin Regularly: 1. Self-examination monthly. Seek medical advise if noticing changes. 2. Schedule an examination if over 50 y.o.

Psoriasis Medical Management

NO CURE. Bath to remove the scales first. Pharmacology: 1. Topical corticosteroids with occlusive dressing (should not remain in place > 8 hrs): only low-potency corticosteroids can be used on the face and intertriginous areas; potential for cataract development when corticosteroid repeatedly used on the face and around the eyes; potential for adrenal suppression when potent corticosteroids applied to large skin areas 2. Topical calcipotriene (Dovonex): avoid face and intertriginous areas; monitor for hypercalcemia. Not recommended for older adults, pregnant or lactating women 3. Topical tazarotene (Tazorac): use effective sunscreen; avoid other photosensitizers. A negative pregnancy test result must be obtained before initiating treatment & effective contraceptive should be continued during treatment Phototherapy in conjunction with photosensitizing oral drug. Systemic Agents: Methotrexate (first line drug for moderate to severe psoriasis): monitor live, bone marrow and renal functioning; avoid alcohol; contraindicated in pregnant women.

Polycystic Kidney Disease Interventions

NO CURE: ONLY SUPPORTIVE TREATMENT. Pain: 1. Cautious use of NSAIDs. AVOID Aspirin-containing compounds. 2. Deep breathing 3. Antibiotics if pain is infection-related. Constipation: 1. HIGH fiber diet, adequate fluid intake when urine output is normal. 2. Stool softeners or bulk agents. Hypertension: 1. Antihypertensive medications & diuretics 2. Measure BP and weight daily. 3. LOW-SODIUM diet 4. LOW-PROTEIN intake as disease progresses.

Osteoporosis Interventions: Nutrition/Lifestyle

Nutrition: 1. Adequate intake of calcium, vitamin D, vitamin K, protein, magnesium and trace minerals. 2. Increase fruits, vegetables, low-fat dairy and fiber products. 3. Avoid smoking, alcohol and caffeine consumption. Lifestyle: 1. Muscle strengthening exercises, swimming. 2. Weight-bearing exercises: walking 30 minutes 3-5 times a week is the most effective. 3. Avoid high-impact activities such as running or bowling. 4. Ensure hazard-free environment: use night-light, stair railings and handrail in the bathroom. Avoid scatter rugs and cluttered room. Drugs: 1. Calcium & Vitamin D (vitamin D alone is not effective) a) Teach women to start supplements in young adulthood. b) Divide calcium a third daily dose at bedtime*, take with meals or vitamin C, push fluids. c) Monitor for hypercalcemia and renal calculi. 2. Biphosphonates: most commonly used for OP. a) Oral: take on empty stomach first thing in the morning with a full glass of water. Sit upright for 30-60 minutes. Avoid taking at the same time as calcium and vitamin D. b) IV: dental exam before starting drug, yearly dental exams recommended follow-up. c) Monitor serum creatinine while receiving Zoledronic Acid. 3. Estrogen agonist/antagonist: contraindicated in women with history of venous thromboembolism and liver disease.

Acute Glomerulonephritis Assessment/Interventions

Occur after skin or upper respiratory infection caused by group A beta-hemolytic Streptococcus. 1. Edema in face, eyelids, hands and other areas. 2. Fluid overload (assess for crackles in lung fields) 3. Circulatory congestion (assess gallop rhythm, JVD; may be misdiagnosed as congestive heart failure). 4. Hypertension 5. Proteinuria, hematuria 6. Decreased GFR 7. Elevated BUN & creatinine levels, azotemia, decreased serum albumin. 8. Increased Antistreptolysin-O titers Kidney biopsy can provide a definitive diagnosis. Corticosteroids, manage hypertension. Preventing and Treating Complications: hypertensive encephalopathy (medical emergency), heart failure, pulmonary edema. 1. Sodium and water restriction (equal to the 24-hr output plus 500-600ml). 2. Potassium and protein restriction 3. Dialysis or plasmapheresis, high-dose corticosteroids & cytotoxic agents. 4. Conserve the patient's energy Preparing for Self-Management: 1. Comply with medication regimens and dietary requirements (protein restriction with renal insufficiency and nitrogen retention). 2. Monitor weight and blood pressure daily.

Oncological Emergency: Tumor Lysis Syndrome (TLS)

Occurs after the first cycle of chemotherapy or radiation. A POSITIVE sign that cancer treatment is effective. Labs: 1. Hyperkalemia 2. Hyperphosphatemia (leading to hypocalcemia) 3. Hyperuricemia

Oncological Emergency: Hypercalcemia

Occurs most often in bone metastasis. Early Manifestations (less serious): 1. N/V/Fatigue 2. Loss of appetite 3. Constipation 4. Increased urine output Serious Manifestations: 1. Muscle weakness 2. Loss of DTR (diminished response to tapping) 3. Paralytic ileus 4. Dehydration 5. EKG changes Interventions: 1. Oral hydration or IV Saline** 2. Drug therapy - oral glucocorticoids, calcitonin, etc. (temporary fix) 3. Dialysis 4. *Patient must consume 2-4L of fluid daily unless contraindicated. 5. Maintain nutritional intake w/o restricting Calcium 6. Antiemetic for N/V 7. Dietary/Drug interventions for constipation 8. Promotion of mobility

Oncological Emergency: Spinal Cord Compression

Occurs when the tumor is compressing the spinal cord. Manifestations: 1. Back pain 2. Sensation of heaviness in the arms or legs 3. Numbness or tingling in the hands or feet 4. Inability to distinguish hot and cold 5. Unsteady gait 6. Bladder/bowel dysfunction (inability to void) Interventions: 1. High dose corticosteroids (reduces swelling) 2. High dose radiation (shrink tumor) or surgery 3. External back or neck brace Perform neurological assessments. Assist w/ ROM exercises. Urinary catheter and bowel training for patients w/ bladder or bowel dysfunction.

Retinal Detachment

Ocular emergency. Surgical scleral buckling and vitrectomy is most commonly used. Nursing priorities are to provide information and reassurance. Restrict activity and head movement. Eye patch to the affected eye. Topical drugs. Surgery is performed under general anesthesia. Postoperative: positioning is critical when a gas bubble is used (prone position with head turned & affected eye facing up); report sudden increase in pain or pain with nausea; avoid activities that increase IOP; avoid reading and writing in the first week after surgery.

Orbital & Ocular Trauma: Foreign Bodies

Ocular irrigation with tap water or normal saline for chemical burn or splash injuries. Cultures obtained and prophylactic antibiotics. No attempt to remove the foreign object. No pressure or patch to the affected eye. Avoid MRI when involving metallic foreign bodies.

Fractures: Surgical Management - ORIF

Open reduction with internal fixation (ORIF) External fixation with closed reduction: a) Advantages include minimal blood loss, early ambulation and exercise while relieving pain, increase patient comfort, immediate fracture stabilization and good alignment. NEVER ADJUST CLAMPS ON EXTERNAL FIXATOR. b) Disadvantage is an increased risk for pin site infections and loosening. Postoperative: 1. IV Ketorlac (Toradol) 2. Aggressive pain management 3. Pin site care is major concern - clear, serous fluid drainage or weeping, mild redness is EXPECTED in the first 48-72hrs. Report and culture drainage from pin site if infection is suspected.

Orbital & Ocular Trauma: Orbital Fractures

Orbital roof fractures are dangerous. Surgery is usually non-emergent within 10-14 days.

Multiple Myeloma

Overgrowth of B-lymphocyte plasma cells in the bone marrow secreting antibodies. Elevation of serum total protein or detection of a protein (Bence-Jones protein) in the blood or urine. Manifestations include bone pain usually in the back or ribs, fatigue, easy bruising at the early stage; bone fractures, hypertension, infection, hypercalcemia and fluid imbalance may occur as the disease progresses. Any old adult with back pain and an elevated total protein level should be evaluated for possible multiple myeloma. Treatment may include stem cell transplant, chemotherapy, corticosteroids, radiation therapy, and biphosphonates. Nursing care focuses on hydration & pain management: analgesics, relaxation techniques, aromatherapy, hypnosis, bisphosphonates.

Fractures: Casts Nursing Care

PRIORITY is neurovascular assessment every 4hrs for the first 24hrs and 1-4hrs thereafter. 1. Elevate extremity higher than heart to reduce swelling and enhance perfusion for the first 24-48hrs. 2. Ice application for the first 24-36hrs. Avoid indentations or wetting the cast. Keep the cast dry and clean. 3. Handle wet cast with the palms of the hands to prevent indentations. 4. Smooth rough edges of the cast to prevent skin irritation.5. AVOID sticking anything under the cast. 6. Blow cool air from hair dryer to relieve itching; antihistamines may be prescribed if itching persists. 7. Exercise each joint that is not immobilized. NEVER IGNORE COMPLAINTS FROM PATIENT IN A CAST.

Orbital & Ocular Trauma: Penetrating Injury

Poor chance to regain vision. Avoid MRI. IV antibiotics, corticosteroids and surgery.

Toxic Epidermal Necrolysis (TEN) & Stevens-Johnson Syndrome

Potentially fatal acute skin disorders. Most commonly triggered by reaction to medications (antibiotics especially sulfonamides, anti-seizure agents, NSAIDs, allopurinol) in adults; precipitated by infections in children. Characterized initially by conjunctival burning or itching, cutaneous tenderness, fever, cough, sore throat, headache, extreme malaise, followed by a rapid onset of widespread erythema and macule formation with blistering, excruciating cutaneous tenderness. Complications: keratoconjunctivitis, sepsis (major cause of death from TEN), MODS. Supportive Care: 1. Discontinue any medications that precipitate TEN or SJS. 2. IV crystalloid fluids; thermoregulation; wound care, pain management; TPN. 3. IV immunoglobulin; immunosuppressive agents. 4. Protecting the skin with topical antibacterial and anesthetic agents.

Cataracts Pre/Postoperative

Preoperative: 1. Stress the requirement of instilling different eyedrops for 2-4 weeks after surgery. 2. Assess medications that affect blood clotting. 3. Assess the use of Alpha-antagonists, tamsulosin (Flomax) which can cause intraoperative floppy iris syndrome. 4. Sedative & instillation of eyedrops before surgery. Postoperative: 1. Antibiotic and steroid eyedrops. An eye patch is worn for the first 24 hrs. 2. An eye shield can be worn at night for the first week. 3. Wear dark glasses outdoors or in brightly lit; refrain from driving. 4. Cool compresses, mild (e.g. acetaminophen) analgesics, avoid aspirin. 5. Avoid activities that increase IOP; cooking, housekeeping are permitted but not vacuuming. Best vision achieved within 6-12 weeks post surgery. Healing Process: NORMAL: mild itchy, bloodshot, ready eye. Discomfort, "scratchy" feeling. Creamy, dry crusty drainage. Dramatic vision improvement. ABNORMAL: increased swelling, redness or bruising. Pain with nausea or vomiting. Yellow or green drainage. Reduction of vision or new floaters, flashing lights. REPORT ABNORMAL FINDINGS IMMEDIATELY.

Plastic Reconstructive and Cosmetic Procedures

Preoperative: 1. Teach the patient what to do before and after surgery to prevent complications - bleeding, infection, failed tissue reattachment. 2. Avoid aspirin and other NSAIDs for several weeks before and after the procedure. 3. Teach the importance of blood pressure control. 4. Avoid smoking or nicotine in any form. Postoperative: 1. Extensive bruising and swelling are expected. 2. Monitor pressure dressings and drainage. 3. Maintain airway and pulmonary function. 4. Relieve pain and achieve comfort: cool compresses or ice packs; oral analgesics. 5. Maintain adequate nutrition: soft or liquid diet high in protein. 6. Enhance communication: use a nonverbal method of communication. 7. Improve self-concept 8. Promote family coping 9. Monitor for wound infection (most common complication) and wound healing. 10. Both the donor site and the grafted area must be protected from exposure to extremes in temperature, external trauma and sunlight. 11. After facial surgery (rhytidectomy, rhinoplasty), monitor for active bleeding (e.g. repeated swallowing followed by belching) & report immediately, semi-Fowler's position, avoid activities that increase pressure in the head and neck.

Typanoplasty & Stapedectomy Pre/Postoperative

Preoperative: prevent infection; ear irrigation to restore normal pH. Operative procedure: local anesthesia normally used. Postoperative: 1. Ear canal packing causes temporary hearing loss. 2. Prevention of ear infection or trauma. 3. Supine position with the operative ear facing up. 4. Assess for facial nerve damage or weakness after Stapedectomy (asymmetric appearance, drooping on the affected side, decreased lateral gaze on the affected side, slurred speech, difficulty swallowing, changes in facial perception). 5. Ensure safety.

Total Hip Replacement (Total Hip Arthroplasty): Postoperative I

Prevent hip dislocation, correct positioning AT ALL TIMES. 1. Supine with head slightly elevated, keep affected leg in neutral position and abduction splint/pillows placed between legs to prevent adduction beyond midline of body. 2. Avoid flexing hips more than 90º. Hips should be higher than knees while sitting. 3. DO NOT sit or stand for prolonged period. DO NOT bend forward when seated in chair. DO NOT cross legs beyond body midline. DO NOT bend at the waist. 4. DO NOT twist body when standing. Avoid stress to new hip joint for the first 8-12 weeks, when the risk of dislocation is the highest. 5. Keep the operative hip in abduction when turning the patient in bed to the unaffected side. Avoid turning the patient to the affected side unless specified by surgeon. 6. Use assistive/adaptive devices e.g. high-seat chairs with arm rests, semi-reclining wheelchairs and raised toilet seats. 7. Prevent DVT: intermittent devices at all times; oral Warfarin or subQ Enoxaparin, early mobilization. 8. Prevent infection: monitor for altered LOC. DO NOT rely on fever as only sign of infection. 9. Prevent pressure ulcer in older adult patient: pressure-relieving mattress and heels off the bed with cradle boot. 10. Monitor wound drainage: assess for bleeding (200-500ml in first 24hrs; <30ml/8hr by 48hrs). 11. Promote ambulation: OOB within a day after surgery (limited flexion maintained); assistive devices (walker, crutches). Can resume routine ADLs by 3 months.

Amputation: Collaborative Care

Psychosocial preparation if possible. Postoperative: 1. Assess tissue perfusion and managing pain are priorities. 2. Promote wound healing: wear closed rigid cast dressing or an elastic residual limb shrinker. 3. If the cast or elastic dressing comes off, wrap the residual limb with an elastic compression bandage IMMEDIATELY. Prevent hemorrhage: place large tourniquet at the bedside. Apply tourniquet to the residual limb immediately if excessive bleeding occurs. Prevent skin breakdown: wash and gently dry residual limb at least twice daily. Promote body image and prepare for prosthesis.

Normal Lab Values (CBC)

RBC count (males: 4.7-6.1; females: 4.2-5.4). Hemoglobin level (males: 14-18 g/dL; females: 12-16 g/dL). Hematocrit (males: 42%-52%; females: 37%-47%) WBC count (4000-11,000 cells/mm3). Platelet count (150,000 - 400,000 cells/mm3). BUN: 8-25 mg/dL Creatinine: 0.6-1.2 mg/dL

Kidney Transplant Complications

Rejection: MOST serious complication. Oliguria, edema, fever, increased BP, weight gain and swelling or tenderness over transplanted kidney/graft. 1. Hyper-acute rejection: removal of transplanted kidney (48hr onset, malaise, high fever & graft tenderness). 2. Acute rejection (most common): increase the dose of immunosuppressive drugs (oliguria/anuria, fever, hypertension, flank tenderness, increased BUN/Cr/K+, fluid retention). 3. Chronic rejection: conservative management until dialysis required (months to years, increased BUN/Cr, proteinuria, fatigue). *IMMUNOSUPPRESSIVE DRUG THERAPY LIFE-LONG. Patient MUST adhere to medications!

Compression Fracture of the Spine

Severe pain, change in the normal curves or in the gap between spinous processes, swelling, paravertebral muscle spams, occasional neurological compromise. Priority care: immobilization and maintenance of spinal alignment is critical to prevent neurologic damage. Stable spinal fractures 1. Bed rest 2. Analgesics, nerve blocks 3. Spinal brace or plastic thoraco-lumbar-sacral orthosis applied during progressive ambulation 4. Physical therapy; restrict strenuous activities for 6 months. Unstable spinal fractures 1. Bed rest 2. Open reduction, decompression, fixation with spinal fusion and instrument stabilization (vertebroplasty, kyphoplasty).

Brachytherapy: Radionuclide IV Isotopes & Sealed Implants

Systemic administration of radionuclide (e.g. IV Isotopes, Radioactive Iodine-131). Excreta IS radioactive and should not be directly touched by others. Take precaution and do NOT share toilet. Radioactive Sealed Implants: Excreta is NOT radioactive, but the person IS. 1. Assign patient private room/bath. Place a caution sign on the door of the patient's room, keep door closed. 2. Wear dosimeter badge when caring for the patient (measures exposure to radiation). 3. Wear lead apron while providing care to provide protection; do not face back towards the patient. 4. Pregnant staff should NOT be allowed to care for the patient. 5. Do NOT allow pregnant visitors or children <16 y.o. Limit visit to 30 minutes per day. 6. Save dressings/linen in the patient's room until the radioactive source is removed. After the radioactive source is removed, dispose of dressings/linen. 7. If the implant is dislodged, use long-handled forceps to retrieve the source and deposit into lead container. NEVER touch the radioactive source w/ bare hands.

Fractures: Skin Traction - Buck's Extension

To decrease painful muscle spasms and promote immobilization. *Weight is limited to 4.5-8 pounds on an extremity or 10-20 pounds on pelvis to prevent skin injury. Body weight and bed position adjustments provide counter-traction. Remain supine, avoid turning side to side. Patient may shift position slightly with overhead trapeze. Complications: 1. Skin breakdown: remove foam boots three times a day w/ second person supporting extremity during skin care; use static mattress. 2. Nerve damage: monitor foot drop (difficulty lifting front of foot). 3. Circulatory impairment: assess circulation of the foot every 15-30 minutes then every 1-2 hrs. Foot exercises every hr when awake.

Oncological Emergency: Superior Vena Cava (SVC) Syndrome Interventions

Treatment: a. High dose radiation to upper chest. b. Metal stent placed in the vena cava to keep open. 1. Avoid upper extremity venipuncture and BP measurement. 2. Instruct patient to avoid tight clothing or jewelry 3. Place the patient in semi-fowlers position; AVOID supine or prone. 4. Monitor fluid status; administer IV fluids cautiously.

Pruritus Nursing Care

Vicious "itch-scratch-itch" cycle. Nursing priority is to increase patient comfort and prevent skin injuries. 1. Use tepid water for baths, shake off the excess water and blot body folds with a towel. 2. Apply emollient immediately after bathing. 3. Avoid situations that cause vasodilation (e.g. exposure to hot environment, ingestion of alcohol or hot foods and liquid, activities resulting in perspiration). 4. Avoid soap and hot water, avoid rubbing vigorously.