Adult Health I Final

Fracture Healing

-1 fracture hematoma (when a fracture occurs, bleeding creates a hematoma, which surrounds the end of the fragments, the hematoma is extravasated blood that changes from a liquid to a semisolid clot, this occurs in the first 72 hours after injury) -2 granulation tissue (active phagocytosis absorbs the products of local necrosis, the hematoma converts to granulation tissue, granulation tissue (consists of new blood vessels, fibroblasts, and osteoblasts) produces the basis for new bone substances called osteoid during days 3-14 postinjury) -3 callus formation (as minerals (calcium, phosphorus, and magnesium) and new bone matrix are deposited in the osteoid, an unorganized network of bone is formed that is woven about the fracture parts, callus is primarily composed of cartilage, osteoblasts, calcium, and phosphorus, it usually appears by the end of the second week after injury, evidence of callus formation can be verified by x-ray) -4 ossification (ossification of the callus occurs from 3 weeks to 6 months after the fracture and continues until the fracture has healed, callus ossification is sufficient to prevent movement at the fracture site when the bones are gently stressed, however the fracture is still evident on x-ray, during this stage of clinical union the pt may be allowed limited mobility or the cast may be removed) -5 consolidation (as callus continues to develop the distance between bone fragments diminishes and eventually closes, during this stage ossification continues, it can be equated with radiologic union which occurs when there is x-ray evidence of complete bony union, this phase can occur up to 1 year after injury) -6 remodeling (excess bone tissue is resorbed in the final stage of bone healing, and union is complete, gradual return of the injured bone to its preinjury structural strength and shape occurs, bone remodels in response to physical loading stress or Wolf's law, initially stress is provided through exercise, weight bearing is gradually introduced, new bone is deposited in sites subjected to stress and resorbed at areas where this is little stress -many factors influence time needed for complete fracture healing, including displacement and site of the fracture, blood supply in the area, immobilization, and internal fixation devices (screws, pins), the ossification process may be arrested by inadequate reduction and immobilization, excessive movement of fracture fragments, infection, poor nutrition, and systemic disease, healing time for fractures increases with age

Table 1-8 Five Rights of Nursing Delegation

-3 things to never delegate: assessment, teaching, evaluation

Types of Fractures

-Colles' fracture: fracture of the distal radius, one of the most common fractures in adults, usually occurs when pts attempt to break a fall with an outstretched arm or hand, clinical manifestations include pain in the immediate area of injury, pronounced swelling, and dorsal displacement of the distal fragment, a major complication is vascular insufficiency secondary to edema, carpal tunnel syndrome can be a later complication, usually managed by closed manipulation of the fracture and immobilization by either a splint or a cast or, if displaced, by internal or external fixation -fracture of the humerus: common among young and middle-aged adults, manifestations are obvious displacement of the humerus shaft, shortened extremity, abnormal mobility, and pain, complications are radial nerve injury and vascular injury to the brachial artery as a result of laceration, transection, or muscle spasm, treatment depends on the location and displacement of the fracture, and may include a hanging arm cast, shoulder immobilizer, skin or skeletal traction, and surgical repairs -fracture of the pelvis: range from benign to life-threatening, manifestations include local swelling, tenderness, deformity, unusual pelvic movement, and acchymosis, treatment depends on the severity of the injury, and may include pelvic sling traction, skeletal traction, external fixation, open reduction, or a combination, bed rest is maintained from a few days to 6 weeks, early mobilization is encourage when applicable, turn the pt only when ordered by the HCP -hip fracture: common in older adults, most commonly from a fall, refers to a fracture of the proximal (upper) third of the femur, manifestations include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness around the fracture site, initially the affected extremity may be immobilized by Buck's traction until the pt's physical condition is stabilized and surgery can be performed, surgical treatment of hip fractures permits early mobilization and decreases the risk of major complications, the type of surgery depends on the location and severity of the fracture and the person's age, but include repair with internal fixation, replacement of part of the femur with a prosthesis (partial hip replacement), and total hip replacement (involves both the femur and acetabulum) -femoral shaft fracture: occurs with a severe direct force because the femur can bend slightly before an actual fracture occurs, young adults have a higher incidence for this type of fracture, the force exerted to cause the fracture such as from a motor vehicle collision or gunshot wound frequently damages the adjacent soft tissue structures displacement of the fracture fragments often results in open fracture and increased soft tissue damage, leading to considerable blood loss, most common types of femoral shaft fracture include transverse, spiral, comminuted, oblique, and open, clinical manifestations include marked deformity and angulation, shortening of the extremity, inability to move either the hip or knee, and pain, common complications include fat embolism, nerve and vascular injury, and problems associated with bone union, open fracture, and soft tissue damage, initial management is directed towards stabilization of the pt and immobilization of the fracture, traction may be used temporarily before surgical treatment or if the pt cannot undergo surgery, the method of treatment usually used for femoral shaft fractures is intermedullary nailing (a metal rod is placed into the marrow canal of the femur, the rod passes across the fracture to keep it in position) -fracture of the tibia: strong force is required to produce a fractured tibia, as a result, soft tissue damage, devascularization, and open fracture are frequent, one of the more common sites for a stress fracture, complications are compartment syndrome, fat embolism, problems associated with bony union, and possible infection associated with open fracture, management is usually closed reduction with a long leg cast -stable vertebral fracture: usually caused by motor vehicle collisions, falls, diving, or athletic injuries, the fracture or fragment is not likely to cause spinal cord damage, usually in the lumbar region, most pts experience only brief periods of disability, the most serious complication is fracture displacement, which can cause damage to the spinal cord, the pt usually complains of pain or tenderness in the affected region of the spine, sudden loss of function below the level of fracture indicates spinal cord impingement and parapalegia, also kyphotic deformity, the goal of management is to keep the spine in good alignment until union as been accomplished, the pt is discharged after regaining ambulation skills, learning care of the cast or orthotic device, and learning how to cope with the safety and security issues imposed by the injury and the treatment -facial fracture: any bone of the face can be fractured as a result of trauma, the primary concern is to establish and maintain pt airway and to provide adequate ventilation, foreign blood and material need to be removed, suctioning may be necessary, a tracheostomy may be needed, treatment depends on the site and extent of the facial fracture and the associated soft tissue injury, be sensitive about the alterations in appearance that may occur after a facial fracture, mandibular fractures may result from trauma to the face or the jaws, may be simple with no bone displacement or it may involve the loss of tissue and bone, may require immediate and sometimes long-term treatment to ensure survival and restore satisfactory appearance and function, may also be therapeutically performed to correct an underlying malocclusion problem that cannot be corrected by orthodontic procedures alone, the mandible is resected during surgery and manipulated forward or backward depending on the occlusion problem, surgery consists of immobilization with intermaxillary fixation, internal fixation may be done with screws and plates, usually only necessary for 4-6 weeks because the fractures often heal rapidly

Inflammatory Bowel Disease (IBD)

-a chronic imflammation of the GI tract -characterized by periods of remission interspersed with periods of exacerbation -exact cause is unknown -no cure -classified as Crohn's disease (involves any of the GI tract) or ulcerative colitis (limited to the colon) based on clinical manifestations, both commonly occur during the teenage years and early adulthood, head a second peak in the sixth decade, and many people with IBD have a family member with the disorder -autoimmune disease involving immune reaction to a person's own intestinal tract, resulting in widespread tissue destruction -caused by a combination of factors, including environmental factors (diet, hygeine, stress, smoking, NSAIDS, influence the environment of the microbial flora and the immune system, high dietary intake of total fats, polyunsaturated fatty acids, omega-6 fatty acids, and meat is associated with an increased risk, high fiber and fruit intake is associated with decreased risk of Crohn's and vegetable intake is associated with decreased risk of ulcerative colitis), genetic predisposition (more frequent in whites, and family members, especially monozygotic twins, NOD2 gene mutations is associated with Crohn's, IBD is a group of diseases that produce similar types of destruction of the mucosa), and alterations in the function of the immune system (in Crohn's it involves all layers of the bowel wall, can occur anywhere in the GI tract from the mouth to the anus, most commonly in the terminal ileum and colon, segments of normal bowel can occur between diseased portions (skip lesions), typicaly ulcerations are deep and logitudinal and penetrate between islands of inflamed edematous mucosa, causing the classic cobblestone appearance, strictures at the areas of inflammation may cause bowel obstruction, microscopic leaks can allow bowel contents to enter the peritoneal cavity and form abcesses or produce peritonitis, fistulas can develop between adjacent areas of bowel, between the bowel and the bladder, and betweel the bowel and the vagina,can also form a tract through the skin to the outside of the body; ulcerative colitis usually starts in the rectum and moves in a continual fashion toward the cecum, the inflammation and ulcerations occur in the mucosal layer, the innermost later of the bowel wall, fistulas and abcesses are rare, diarrhea with large fluid and electrolyte losses is a characteristic feature of damages, areas of inflammed mucosa for psuedopolyps (tongue-like projectios into the bowel lumen)) -clinical mafiestations: dirrhea, bloody stoool, weight loss, abdominal pain, fever, and fatigue for both, in crohn's diarrhea and crampy abdominal pain are more common, if the small intestine is involved weight loss occurs from malabsorption, rectal bleeding sometimes occurs; in ulcerative colitis the primary manifestations are bloody diarrhea and abdominal pain, pain may vary from mild lower abdominal cramping associated with diarrhea to severe, constant pain associated with acute perforations -complications" GI complications include hemorrhage (can lead to anemia, strictures, perforation (and possible peritonitis), fistulas, colonic dilation (toxic megacolon), nutrition problems are common with Crohn's (fat malaborption and anemia), IBD pts have an increased risk for cholorectal cancer, those with Crohn's are at increased risk for small intestinal cancer, some people with IBD suffer from systemic complications, including joint, eye, mouth, kiney, bone, vascular, and skin problems, circulating factors such as cytokines trigger inflammation in these areas, sclerosing cholangitis, a complication of IBD, can lead to liver failure -diagnostic studies: ruling out other diseases with similar symptoms and then determining whether the pt has Crohn's or ulcerative colitis, CBC, fluid electrolytes, albumin, erythrocyte sedimentation rate, C-reactive protein, stool cultures, examined for blood, pus, and mucus, double-contrast barium enema, small bowel series, transabdominal ultrasound, CT, MRI, colonsocopy, biopsy specimens -treamtment: goals are to rest the bowel, control the inflammation, combat infection, correct malnutrition, alleviate stress, provide symptomatic relief, and improve quality of life, drugs used are aminosalicylates, antimicrobials, corticosteroids, immunosuppresants, and biologic and targeted therapy, treated with either a "step-up" approach (uses less toxic therapies first, more toxic medications are started when initial therapies do not work) or the "step-down" approach (biologic and targeted therapy first), Sulfasalazine (Azulfidine) suppresses inflammatory mediators,Methotrexate can be used for Crohn's, 5 major biologic and targeted medications, 4 are antitumor necrosis factor (TNF) agents (infliximab (Remicade), adalimumab (Humira), certolizumab pegol (Cimzia) and golimumab (Simponi), the 5th, natalizumab (Tysabri), inhibits leukocyte adhesion; surgical therapy for ulcerative colitis is a total proctocolectomy, which is curative, including either the ileal pouch/anal anastamosis (IPAA, most common, a diverting ileostomy is performed, and an ileal pouch is created and anastamosed directly to the anus, the two procedures performed 8-12 weeks apart, the initial involving a colectomy, rectal mucosectomy, ileal pouch construction, ileoanal anastamosis, and temporary ileostomy, the second involving closure of the ileostomy to direct stool toward the new pouch, adaptation of the pouch occurs over the next 3-6 months, usually resulting in a decreased number of BMs, the pt is able to control defecation at the anal sphincter, the major complication of this procedure is acute or chronic pouchitis) or with permanent ileostomy (one-stage operation involving the removal of the colon, rectum, and anus with closure of the anal opening, the end of the terminal ileum is brough out through the abdominal wall and forms a stoma, usually in the RLQ below the beltline, continence is not possible); surgery for Crohn's disease is usually performed for complications such as strictures, obstructions, bleeding, and fistulas, most pts with Crohn's eventually require surgery, conservative surgery is advocated instead of resective surgery in pts with Crohn's; diet is an important component in the treatment of IBD, goals of diet management are to provide adequate nutrition without exacerbating symptoms, correct and prevent malnutrition, replace fluid and electrolyte losses, and prevent weight loss, nutritional deficiencies are due to decreased oral intake, blood loss, and depending on the location of the inflammation, malabsorption of nutrients, overall, it is essential that people with IBD eat a balanced, healthy diet with sufficient calories, protein, and nutrients, during an acute exacerbation pts may not be able to tolerate a regular diet, liquid enteral feedings are preferred over parenteral nutrition because atrophy of the guy and bacterial overgrowth occur when the GI tract is not used, there are no universal triggers for IBD but individuals may find that certain foods cause diarrhea, a food diary helps to identify problem foods to avoid, because many patients with IBD are lactose intolerant, symptoms improve when milk and milk products are avoided, they can use yogurt as a substitute, high-fat foods tend to trigger diarrhea, cold foods and high-fiber foods (bran cereal, nuts, raw fruits with peels) tend to promote diarrhea, smoking stimulates the GI tract and should be avoided -nursing implementation: during the acute phase, focus your attention on hemodynamic stability, pain control, fluid and electrolyte balance, and nutritional support, maintain accurate I&O, and monitor the number and appearance of stools, establish a rapport and encourage pts to talk about self-care strategies, explain all procedures and treatment helps to build trust and decrease apprehension, teach the pt about stress management techniques, talk with smokers about quitting, psychotherapy to decrease stress and depression about it being a chronic illness, help the pt stay clean, dry, and free of odor when diarrhea is present, teaching includes the importance of rest and diet management, perineal care, drug action and side effects symptoms of recurrence of disease, when to seek medical care, and use of diversional activities to reduce stress

Cirrhosis

-a chronic progressive disease of the liver characterized by extensive degeneration and destruction of the liver cells -an insidious, prolonged course of development, usually after decades of chronic liver disease -twice as common in men as in women, 8th leading cause of death in the US -any chronic liver disease can cause cirrhosis, the specific cause may not be determined in all pts, the most common cause is hepatitis C infection and alcohol-induced liver disease, malnutrition, malabsorption, obesity, genetic predisposition and environmental factors can also lead to cirrhosis -clinical manifestations: early symptoms include fatigue, later symptoms may be severe and result from liver failure and portal HTN, jaundice, peripheral edema, and ascites develop gradually, skin lesions, hematologic disorders, endocrine disturbances, and peripheral neuropathies are other symptoms -complications: portal HTN (structural changes in the liver result in compression and destruction of the protal and hepatic veins and sinusoids, causing obstruction to the normal flow of blood through the protal system, characterized by increased venous pressure in the portal circulation, splenomegaly, large collateral veins, ascites, and gastric and esophageal varices, varicosities may develop in areas where the collateral and systemic circulations communicate, resulting in esophageal and gastric varicies and hemmorrhoids, causing them to be more likely to bleed because they contain little elastic tissue and are fregile, which is the most life-threatening complication of cirrhosis, as this would cause massive hemmorhage), peripheral edema and ascities (edema results fromdecreased colloidal oncotic pressure fromimpaired liver sunthesis of albumin and increased portacaval pressure from protan HTN, ascites is the accumulation of serous fluid in the abdominal cavity, due to increased osmotic pressure in the lymphatic system, causing excess proteins and water to leak through the liver capsule into the peritoneal cavity, the pt has signs of dehydration and a decrease in urine output, hypokalemia is common, and because of alterations in immune function associated with cirrhosis, pts with ascites are at risk for spontaneous bacterial peritonitis (SBP), a bacterial infection), hepatic encephalopathy (a neuropsychiatric manifestation of liver disease, includes the neurotoxic effects of ammonia, abnormal neurotransmission, aastrocyte swelling, and inflammatory cytokines, can occur after placement of transjugular intrahepatic portosystemic shunt (TIPS) which is used to treat portan HTN, characteristic manifestation is asteruxus (flapping tremors), to manage the goal is the reduction of ammonia formation with lactulose, a drug that traps ammonia in the gut, and treatment of precipitating causes), and hepatorenal syndrome, (a type of renal failure with advancing azotemia, oliguria, and intractable ascites, the kidneys have no structural abnormalities, and the etiology is complex but the final pathway is likely to be portal HTN along with liver decompensation resulting from splanchnic and systemic vasodilation and decreased arterial blood volume, causing renal failure), pts without complications have compensated cirrhosis -diagnostic studies: liver function tests, total protein, albumin, serum bilirubin, globulin levels, cholesterol levels, PT, liver ultrasound, liver biopsy -treatment: goals is to slow the progression of cirrhosis and prevent and treat any complications, sodium restriction, fluid removal, assess and monitor fluid and electrolyte imbalances, diuretic therapy, paracentesis, TIPS (nonsurgical procedure in which a shunt between the systemic and portal venous systems in created to redirect portal blood flow, a catheter is placed in the jugular vein and then threaded through the superior and inferior vena cava, to the hepatic vein, the wall of the hepatic vein is punctured, and the catheter is directed to the portal vein, stents are positioned along the passageway, overlapping in the liver tissue and extending into both veins, reducing both protal venous pressure and decompresses the varicies, thus controlling bleeding), avoid alcohol, aspirin, and NSAIDs, EGD, IV therapy, supportive measures, administer fresh plasma and blood, vitamin K, and PPIs, no specific drug therapy, the diet for the pt who has cirrhosis without complications is high in calories with high carbohydrate content and moderate to low levels of fat -nursing interventions: identify, reduce, and eliminate risk factors, urge pts to avoid alcohol ingestion, adequate nutrition, conserve pt's strength while maintaining muscle strength and tone, modify the activity and rest schedule according to signs of clinical improvement, provide food preferences whenever possible, explain reasoning for any diet restrictions to pt and caregiver, assess pt's physiologic response to the cirrhosis, note the color of urine and stools, accurate calculations and recording of I&O, daily weights, and measurements of extremities and abdominal girth help in the ongoing assessments of the location and extent of edema or ascites, meticulous skin care is essential because the edematous tissues are subject to breakdown, monitor electrolytes and renal function, observe for fluid and electrolyte imbalances, observe and provide care for hematologic problems, assess pt response to body image, observe for any sings of bleeding from varicies, maintain airway in times of hematemesis, maintain a safe environment, sustain life, and assist with measures to reduce ammonia formation, assess the pt's level of responsiveness, sensory and motor abnormalities, acid-base imbalances, and the effect of treatment measures, understand the importance of continual health care and medical supervision, provide information regarding community support programs, teach the pt and caregiver about manifestations of complications and when to seek medical attention, explain both verbally and in written form about fluid or possible dietary changes, include instructions about adequate rest periods, how to detect early signs of complications, skin care, drug therapy precautions, observation for bleeding, and protection from infection, referral to home care may be needed

Irritable Bowel Syndrome (IBS)

-a common, chronic functional disorder -symptoms: intermittent and may occur for years, include abdominal pain, discomfort, alterations in bowel patterns (diarrhea or constipation), abdominal distention, excessive flatuence, bloating, urgency, and sensation of incomplete evacuation, fatigue, sleep disturbances, history of GI infections and food intolerances, FODMAPs (fructans, glalctans, lactose, fructose, sorbitol, xylitol) -psychologic stressors (depression, anxiety, sexual abuse, PTSD) are associated with development and exacerbations of IBS -more frequent in women than men -diagnosis: H&P, determine how it interferes with normal life, tests rule out other GI issues (colorectal cancer, IBD, endometriosis, malabsorption disorders) -treatment: directed at psychologic and dietary factors and drugs to regulate stool output, pts may benefit from keeping a diary of symptoms, diet, and stress to help identify factors that seem to trigger the IBS, have pt have a dietary fiber intake of at least 20g/day if tolerated, avoid common gas-producing foods (broccoli, cabbage), Alosetron (Lotronex) is a serotonergic antagonist used for IBS pts with severe symptoms of pain and diarrhea, but it has serious side effects, Lubiprostone (Amitiza) and Linaclotide (Linzess) are approved for treatment of IBS with constipation, psychologic therapies include cognitive-behavioral therapy, stress management, acupuncture, hypnosis, no single therapy seems to be effects for all pts with IBS

Chronic pancreatitis

-a continuous, prolonged, inflammatory, and fibrosing process of the pancreas -the pancreas being destroyed as it is replaced by fibrotic tissue, strictures and calcifications may also occur in the pancreas -can be due to alcohol abuse, obstruction caused by cholelithiasis (gallstones), tumor, pseudocysts, or trauma, and systematic diseases (systemic lupus erythematosus), autoimmune pancreatitis, and cystic fibrosis, some pts may not have identifiable risk factors, chronic pancreatitis may follow acute pancreatitis, but it may also occur in the absence of any history of an acute condition, most common cause of obstructive pancreatitis is inflammation of the sphincter of Oddi associated with cholelithiasis, cancer of the ampulla of Vater, duodenum, or pancreas can also cause this type, in nonobstructive pancreatitis there is inflammation and sclerosis, mainly in the head of the pancreas and around the pancreatic duct, the most common form, found almost exclusively in alcohol abusers, a genetic factor may predispose a drinker to the direct toxic effects of alcohol on the pancreas -clinical manifestations: a major manifestation is abdominal pain, pt may have exacerbations of acute pain but it usually is chronic and the attacks become more and more frequent until they are almost constant or they may diminish as pancreatic fibrosis develops, the pain is located in the same areas as in acute pancreatitis but it is usually a heavy, gnawing feeling or sometimes burning and cramplike, the pain is not relieved with food or antacids, other clinical manifestations include symptoms of pancreatic insufficiency, including malabsorption with weight loss, constipation, mild jaundice with dark urine, steatorrhea, and DM, urine and stool my be frothy, some abdominal tenderness may be present, complications associated with chronic pancreatitis include pseudocyst formation, bile duct or duodenal obstruction, pancreatic ascites or pleural effusion, splenic vein thrombosis, pseudoaneurysms, and pancreatic cancer -diagnostic studies: based on pt's S&S, laboratory studies, and imagining, serum amylase and lipase, serum bilirubin and alkaline phosphatase, leukocytosis, sedementation rate, CT, MRI, MRCP, abdominal ultrasound, EUS, stool samples, vitamins and coalbumin, glucose intolerance, diabetes, secretin simulation test -treatment: identical to acute pancreatitis, also prevent future attacks, relief of pain, and control of pancreatic exocrine and endocrine insufficiency, diet, pancreatic enzyme replacement, and control of diabetes are ways to control the pancreatic insufficiency, small, bland, frequent meals that are low in fat content are recommended, alcohol, smoking, and caffeine cessation, pancreatic enzyme products (PEPs) are used to replace enzyme deficiencies in the pancreas, sometimes requires endoscopictherapy or surgery, surgical procedures can divert bile flow or relieve ductal obstruction -nursing interventions: chronic care and health promotion, instruct the pt on measures to take to prevent a future attack, dietary control, consistency of treatment measures, observe the pt's stool for steatorrhea, instruct the pt and caregiver to observe the stools, instruct the pt regarding testing of glucose levels and drug therapy if diabetes develops, the pt must avoid alcohol and may need assistance or referral to a support program

Malnutrition

-a deficit, excess, or imbalance of essential nutrients -may occur with our without inflammation -affects body composition and functional status -imbalances with macronutrients (carbohydrates, proteins, fat) or micronutrients (electrolytes, minerals, vitamins) occur with malnutrition -undernutrition: a state of poor nourishment as a result of inadequate diet or diseases that interfere with normal appetite and assimilation of ingested food -overnutrition: the ingestion of more food than is required for body needs, as in obesity -70% of hospitalized adults are considered malnourished or at nutritional risk -etiology: starvation-related malnutrition (occurs when nutritional needs are not met, chronic starvation without inflammation), chronic disease-related malnutrition (associated with conditions that impose sustained inflammation of a mild to moderate degree, occurs when tissue needs are not met even thought the dietary intake would be satisfactory under normal conditions (arthritis, obesity, metabolic syndrome)), acute disease- or injury-related malnutrition (associated with acute disease or injury states with marked inflammatory response (major infection, burns, trauma, closed head injury)) -contributing factors: socioeconomic factors (food security), physical illnesses (malabsorption syndrome), incomplete diets (vitamin deficiencies), food-drug interactions (incompatibilities, altered drug effectiveness, impaired nutritional status) -pathophysiology of starvation: the body selectively uses carbohydrates rather than fat and protein to meet metabolic needs, totally depleted within 18 hours, once carbohydrates are depleted, skeletal protein is converted to glucose for energy, within 5-9 days body fat is fully mobilized to supply much of the needed energy, in prolonged starvation up to 97% of calories are provided by fat, and protein is conserved, fat stores are generally used up in 4-6 weeks, once fat stores are used, body or visceral proteins, including those in internal organs and plasma, can no longer be spared and rapidly decreased because they are the only remaining body source of energy available, as the protein depletion continues, liver function becomes impaired, and synthesis of proteins decreases, body fluids shift from the vascular space into the interstitial space along with the fluid , edema becomes clinically observable, as the total blood volume is reduced, the skin appears dry and wrinkled, the sodium-potassium pump fails, and the cell will expand because of the sodium trapped in, the liver loses mass and gradually becomes infiltrated with fats, death will rapidly ensue, during this process there is a decreased BMR, sparing of skeletal muscle, and decreased protein breakdown -clinical manifestations: most obvious signs are apparent in the skin (dry and scaly skin, brittle nails, rashes, hair loss), muscles (decreased mass and weakness), and CNS (mental changes such as confusion, irritability), the speed at which malnutrition develops depends on the quantity and quality of the protein intake, caloric value, illness, and the person's age, muscles become weak and flabby, delayed wound healing, more susceptible to infections, anemia -diagnostic studies: H&P, serum albumin, prealbumin, serum transferrin, electrolyte levels, ABGs, vitamins, gross measure of muscle and fat content, waist circumference and hip-to-waist ratio, muscle strength, handgrip strength -assessment: nutritional screening, body weight and height, BMI, diet history -nursing implementations: teach and reinforce healthy eating habits, identify nutritional risk factors, between-meal supplements for the undernourished, appetite stimulants (megastrol acetate (Megace) and dronabinol (Marinol)) and feedings to improve nutritional intake, teach about the causes of nutritional imbalances and ways to avoid this problem in future, assess ability to comply, determine need for nutritious meals and snacks after discharge, provide nutritional information if dietitian is not available, teach about diet diary to help reinforce healthful eating patterns, encourage self-assessment of progress by having pt weight themselves once or twice a week and keep a weight record

Fractures

-a disruption or break in the continuity of the structure of bone -although traumatic injuries account for the majority of fractures, some fractures are secondary to disease process (cancer or osteoporosis) -can be classified as open (compound, the skin is broken, exposing bone and causing soft tissue injury) or closed (simple, the skin has not been ruptured and remains intact, also classified as complete (the break is completely through the bone) or incomplete (the fracture occurs partially across a bone shaft but the bone is still in one piece, often the result of bending or crushing forces applied to a bone), also described and classified according to the direction of the fracture line (linear, oblique, transverse, longitudinal, and spiral fractures), also classified as displaced (comminuted, more than two fragments, or oblique) or nondisplaced (the periosteum is intact across the fracture and the bone is still in alignment, usually transverse, spiral, or greenstick) -clinical manifestations: immediate localized pain, decreased function, and inability to bear weight on or use the affected part, the pt guards and protects the extremity against movement, obvious bone deformity may not be present, if a fracture is suspected the extremity is immobilized in the position in which it is found, unnecessary movement increases soft tissue damage and may convert a closed fracture to an open fracture or create further injury to adjacent neurovascular structures -treatment: goals are amatomic realignment of bone fragments (reduction), immobilization to maintain realignment, and restoration of normal or near-normal function of the injured part -fracture reduction: closed reduction (nonsurgical, manual realignment of bone fragments to their previous anatomic position, traction and counteraction and manually applied to the bone fragments to restore position, length, and alignment, usually performed while the pt is under local or general anesthesia, after reduction, traction, casting, external fixation, splints, or orthoses (braces) immobilize the injured part to maintain alignment until healing occurs), open reduction (the correction of bone alignment through a surgical incision, usually includes internal fixation of the fracture with wires, screws, pins, plates, intramedullary rods, or nails, the type and location of the fracture, pt age, and concurrent disease may influence the decision to use open fracture, main disadvantage are the possibility of infection, complications associated with anesthesia, and effect of preexisting medical conditions, if open reduction with internal fixation (ORIF) is used of intraarticular fractures, early initiation of ROM of the joint is indicated, machines that provide continuous passive motion (CPM) to various joints are used to prevent extraarticular and intraarticular adhesions, the use of CPM results in faster reconstruction of the subchondral (beneath cartilage) bone plate, more rapid healing of the articular cartilage, and decreased incidence of posttraumatic arthritis, ORIF facilitates early ambulation, thus decreasing the risk of complications related to prolonged immobility), traction (the application of pulling force to an injured or diseased part of the body or an extremity, countertraction pulls in the opposite direction, traction is used to prevent or reduce pain and muscle spasm associated with low back pain or cervical sprain, immobilize a joint or part of the body, reduce a fracture or dislocation, provide immobilization to prevent soft tissue damage, promote active and passive exercise, expand a joint space during arthroscopic procedures, expand a joint space before major joint reconstruction, and treat a pathologic joint condition (tumor, infection), traction devices apply a pulling force on a fractured extremity to attain realignment while counteraction pulls in the opposite direction, the two most common types of traction are skin traction (used for short-term treatment (48-72 hours) until skeletal traction or surgery is possible, tape, boots, or splints are applied directly to the skin to maintain alignment, assist in reduction, and help diminish muscle spasms in the injured extremity, the traction weights are usually limited to 5-10 lbs) and skeletal traction (in place for longer periods than skin traction, used to align injured bones and joints or to treat joint contractures and congenital hip dysplasia, it provides a long-term pull that keeps the injured bones and joints aligned, to apply skeletal traction the physician inserts a pin or wire into the bone, either partially or completely, to align and immobilize the injured body part, weight for skeletal traction ranges from 5-45 lbs, the use of too much weight can result in delayed union or nonunion, the major complications are infection in the area of the bone where the skeletal pin is inserted and the consequences of prolonged immobility), when traction is used to treat fractures the forces are usually exerted on the distal fragment to align it with the proximal fragment, several types of traction are used for this purpose, fracture alignment depends on the correct positioning and alignment of the pt while the traction forces remain constant, for extremity traction to be effective, forces must be pulling in the opposite direction (countertraction), countertraction is commonly supplied by the pt's body weight or by weights pulling in the opposite direction and it may be augmented by elevating the end of the bed, it is imperative to maintain traction continuously and to keep the weighs off the floor and moving freely through the pulleys) -fracture immobilization: casts (temporary circumferential immobilization device, common treatment following closed reduction, allows the pt to perform many normal ADLs while providing sufficient immobilization to ensure stability, cast materials are natural (plaster of paris), synthetic, acrylic, fiberglass-free, latex-free polymer, or a hybrid of materials, generally incorporates the joints above and below a fracture to restrict tendon and ligament movement, thereby assisting with joint stabilization while the fracture heals, a fresh cast should never be covered because air cannot circulate, heat builds up in the cast that may cause a burn, and drying is delayed, avoid direct pressure on the cast during the drying, handle the cast gently with an open palm to avoid denting the cast, the edges may need to be petaled (putting several strips of tape on the rough edges to ensure a smooth cast edge) -upper extremity injuries: accomplished using a sugar-tong splint (used for acute wrist injuries or injuries that may result in significant swelling), posterior splint, short arm cast (used for the treatment of stable wrist or metacarpal fractures, providing wrist immobilization and permits unrestricted elbow movement), or long arm cast (used for stable forearm or elbow fractures and unstable wrist fractures, similar to short arm but extends to the proximal humerus, restricting motion at the wrist and elbow), direct care at supporting the extremity and reducing the effects of edema by elevating the extremity with a sling -vertebral injuries: body jacket brace (used for immobilization and support for stable spine injuries of the thoracic or lumbar spine) -lower extremity injuries: often use a long leg cast (unstable ankle fracture, soft tissue injuries, fractured tibia, and knee injuries), short leg cast (primarily for stable ankle and foot injuries), a cylinder cast (knee injuries or fractures), a Robert Jones dressing, or a prefabricated splint or immobilizer, after application elevate the extremity on pillows for the first 24 hrs observe for signs of compartment syndrome and increased pressure -external fixation: metallic device composed of metal pins that are inserted into the bone and attached to external rods to stabilize the fracture while it heals, can be used to apply to traction or to compress fracture fragments and to immobilize reduced fragments when the use of a cast or other traction is not appropriate, attached directly to the bones by percutaneous transfixing pins or wires, indicated in simple fractures, complex fractures with extensive soft tissue damage, correction of bony defects (congenital), nonunion or malunion, and limb lengthening, often used in attempt to salvage extremities that otherwise might require amputation, ongoing assessment for pin loosening and infection is critical, instruct pt and caregiver about meticulous pin care -internal fixation: pins, plates, intramedullary rods, and metal and bioabsorbable screws are surgically inserted to realign and maintain bony fragments, biologically inert and made from stainless steel, vitallium, or titanium, proper alignment is evaluated by x-ray studies at regular intervals -electrical bone stimulation:used to facilitate the healing process for certain types of fractures especially those with nonunion or delayed healing, may include increasing the calcium uptake of bone, activating intracellular calcium stores,and increasing the production of bone growth factors -drug therapy: experience varying degrees of pain associated with muscle spasms, central and peripheral muscle relaxants (carisoprodol (Soma), cyclobenzaprine (Flexeril), or methocarbamol (Robaxin)) may be prescribed for relief of pain, in an open fracture the threat of tetanus can be reduced with tetanus and diptheria toxoid or tetanus immunoglobin for the pt who has not been previously immunized -nutrition therapy: proper nutrition is an essential component of the healing process in injured tissues, an adequate energy source is needed to promote muscle strength and tone, build endurance, and provide energy for ambulation and gait-training skills, dietary requirements must include adequate protein, vitamins, calcium, phosphorus, and magnesium to ensure optimal soft tissue and bone healing,three well-balanced meals a day usually provide the necessary nutrients, as well as supplementing them with 2000-3000 mL of fluid/day to promote optimal bladder and bowel function -assessment: a brief history of the traumatic episode, the mechanism of injury, and the position in which the pt was found, document findings before fracture treatment to avoid doubt about whether a problem discovered later was missed during the original examination or was caused by the treatment, neurovascular assessment (color, temperature, capillary refill, peripheral pulses, edema, sensation, motor function, and pain) -nursing implementations: teach pt to take appropriate safety precautions to prevent injuries while at home, at work, driving, or when participating in sports, be an advocate for personal actions known to reduce injuries (seat belt, speed limits, helmets), encourage individuals to participate in moderate exercise to help maintain muscle strength and balance, take fall precautions, stress the importance of adequate vitamin D and calcium, prevent complications associated with immobility, inspect exposed skin areas regularly when slings are used with traction, observe skeletal pains for infection signs -cast care: perform neurovascular assessments frequently, teach the pt S&S of cast complications so that they can be reported promptly, rest, elevate, ice, instruct pt to exercise the joints above and below the cast, discourage pulling out cast padding and scratching or placing foreign objects inside the cast, for itching the pt can use a hair dryer on a cool setting, reassure the pt that the damage to the skin during cast removal is unlikely, teach about possible alterations in the appearance of the extremity (muscle atrophy and dry, wrinkled skin) that has been beneath the cast, help the pt adjust to any problems caused by the injury, offer support and encouragement while actively listening to the pt's and caregiver's concerns -ambulation: discuss with the pt their lifestyle and determine which assistive device would be appropriate for ambulation, use a gait-belt to provide stability while the pt is learning to use an assistive device, when the pt begins to ambulate know the pt's weight-bearing status and the correct technique if the pt is using an assistive device

Pressure Ulcers

-a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction -most common site is the sacrum, heels being the second -influencing factors: the amount of pressure (intensity), the length of time the pressure is exerted on the skin (duration), the ability of the pt's tissue to tolerate the externally applied pressure, pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement (shearing force), two surfaces moving together (friction), and excessive moisture -risk factors: advanced age, anemia, contractures, DM, elevated body temperature, immobility, impaired circulation, incontinence, low diastolic BP (<60), mental deterioration, neurologic disorders, obesity, pain, prolonged surgery, and vascular disease -clinical manifestations: depend on the extent of tissue involved, graded or staged according to their deepest level of tissue damage (on future slide), the pressure ulcer may increase in size, odor, and drainage, have necrotic tissue, and be indurated, warm, and painful, untreated ulcers may lead to cellulitis, chronic infection, sepsis, and possibly death -complications: recurrence, therefore it is important to mote the location of previously healed pressure ulcers on a pt's initial admission assessment, if it becomes infected the pt may display signs of infection -assessment: assess for risk initially on admission and at periodic intervals based on pt condition with Braden Scale, conduct a thorough head-to-toe assessment to identify and document a pressure ulcer, conducting periodic reassessment of the skin and wounds, identification of changes may be difficult with pts with dark skin -nursing implementations: identify pts at risk and implement prevention strategies, local care of the wound and support measures of the whole person (adequate nutrition, pain management, control of other medical conditions, pressure relief), initiate interventions based on ulcer characteristics and the pt's general status, carefully document the size of the ulcer, including depth, debridement, wound cleaning, application of a dressing, relief of pressure, keep the pt off the pressure ulcer, encourage pts to reposition themselves by lifting rather than sliding and to use the trapeze if indicated as this can reduce friction and shear, remove necrotic tissue or eschar and provide an appropriate wound environment that supports moist wound healing and prevents disruption of the newly formed granulation tissue,clean pressure ulcers with noncytotoxic solutions that do not kill or damage cells, cover it with an appropriate dressing after cleaning, keeping it slightly moist to enhance epithelialization, stages II to IV are considered contaminated or colonized with bacteria, maintenance of adequate nutrition is an important responsibility for the pt with a pressure ulcer, because often the pt is debilitated and has a poor appetite secondary to inactivity, oral feedings must be adequate in calories, protein, fluids, vitamins, and minerals to meet the pt's nutritional requirements, enteral feedings can be used to supplement the oral feedings, teach prevention techniques to both the pt and the caregiver to prevent recurrence

Pheochromocytoma

-a rare condition caused by a tumor in the adrenal medulla affecting the chromaffin cells, resulting in an excess production of catecholamines (epinephrine, norepinephrine) -most dangerous immediate effect is severe HTN, if left untreated it may lead to hypertensive encephalopathy, DM, cardiomyopathy, and death -most common in young to middle-aged adults -may be inherited in persons with multiple endocrine neoplasia -clinical manifestations: severe, episodic HTN, severe, pounding headache, tachycardia with palpitations, profuse sweating, unexplained abdominal or chest pain, attacks may be provoked by many medications (antihypertensives, opioids, radiologic contrast media, tricyclic antidepressants) and may last from a few minutes to several hours -diagnosis is often missed because it is an uncommon cause of HTN diagnostic studies: urinary fractionated metanephrines (catecholamine metabolites) and fractionated catecholamines and creatinine, usually done as a 34-hr urine collection, CT, MRI, avoid palpating the abdomen as it may cause the sudden release of catecholamines and severe HTN -treatment: surgical removal of the tumor (laparoscopic approach, usally cures HTN), metyrosine (Demser) is used to decrease catecholamine production by the tumor if surgery is not an option nursing implimentations: assess for the triad of symptoms (severe pounding headache, tachycardia, and profuse sweating), monitor the BP immediately if the pt is experiencing an attack, attempt to make the pt as comfortable as possible, monitor glucose levels to assess for DM, pts need rest, nourishing food, and emotional support, emphasize the importance of follow-up and routine BP monitoring, if metyrosine is beig used, instruct the pt to rise slowly and hold onto a secure object since it can cause orthostatic hypotension

Jaundice

-a yellowish discoloration of body tissue, resulting from an alteration in normal bilirubin metabolism or flow of bile into the hepatic or biliary duct system, a functional derangement of liver cells and compression of bile ducts by connective tissue overgrowth -the urine may darken because of excess bilirubin being excreted by the kidneys, if conjugated bilirubin cannot flow out of the liver because of obstruction or inflammation of the bile ducts the stools will be light or clay colored, puritis (intense itching) sometimes accompanies jaundice, occurring as a result of the accumulation of bile salts beneath the skin

Acute Pancreatitis

-an acute inflammation of the pancreas -most common in middle-aged men and women -many factors can cause injury to the pancreas, the most common cause being gallbladder disease (gallstones), which is more common in women, the second most being chronic alcohol intake, which is more common in men, smoking is an independent risk factor, may occur after surgical procedures on the pancreas, stomach, duodenum, or biliary tract, most common pathogenic mechanism is autodigestion of the pancreas, the etiologic factors injure pancreatic cells or activate pancreatic enzymes in the pancreas rather than the intestine, it is thought that alcohol increases the production of the digestive enzymes in the pancreas, there may be a genetic or environmental component that may contribute, as well, the pathophysiologic involvement of acute pancreatitis is classified as either mild pancreatitis (edematous or interstitial pancreatitis) or severe pancreatitis (necrotizing pancreatitis) -clinical manifestations: abdominal pain due to distention of the pancreas, peritoneal irritation, and obstruction of the biliary tract, usually located in the LUQ but it may be in the midepigastrium, commonly radiating to the back because of the location of the pancreas, has a sudden onset and described as severe, deep, piercing, and continuous or steady, aggravated by eating and frequently has its onset when the pt is recumbent, not relieved by vomiting, may be accompanied by flushing, cyanosis, and dyspnea, other manifestations including nausea and comiting, low-grade fever, leukocytosis, hypotension, tachycardia, and jaundice, abdominal tenderness with muscle guarding is common, bowel sounds may be decreased or absent, lungs are frequently involved with crackles present -complications: some pts recover completely, others have recurring attacks, and others develop chronic pancreatitis, two significant local complications are psuedocyst (accumulation of fluid, pancreatic enzyme, tissue debris, and inflammatory exudates surrounded by a wall, manifestations are abdominal pain, palpable gastric mass, nausea, vomiting, and anorexia, the cysts usually resolve spontaneously within a few weeks but may perforate, causing peritonitis, or rupture into the stomach or the duodenum, treatment includes surgical drainage, percutaneous catheter placement and drainage, and endoscopic drainage) and abscess (a collection of pus, resulting from extensive necrosis in the pancreas, may become infected or perforate into adjacent organs, manifestations include upper abdominal pain, abdominal mass, high fever, and leukocytosis, require prompt surgical drainage to prevent sepsis), and two systemic complications of acute pancreatitis, which are pulmonary (pleural effusion, atelectasis, penumonia, and ARDS) and cardiovascular (hypotension) complications and tetany caused by hypocalcemia, pts are at risk for abdominal compartment syndrome as a result of intraabdominal HTN and edema -diagnostic studies: serum amylase and lipase, liver enzymes, triglycerides glucose, bilirubin, calcium, abdominal ultrasound, x-ray, contrast-enhanced CT -treatment: goals are to relieve pain, prevent or alleviate shock, reduce pancreatic secretions, correct fluid and electrolyte imbalances, prevent or treat infections, and remove the precipitating cause, if possible, treatment focuses on supportive care, including aggressive hydration, pain management, management of metabolic complications, and minimizing pancreatic stimulation, when it is r/t gallstones a sphincterotomy may be done or when the diagnosis is uncertain and for pts who do not respond to conservative therapy, currently there are no drugs to cure pancreatitis but there are many drugs to treat problems associated with it, initially the pt is on NPO status to reduce pancreatic secretions, when food is allowed small, frequent feedsings are given, the diet usually high in carbohydrates because that is the least stimulating to the exocrine portion of the pancreas, the pt needs to abstain from alcohol -nursing implementation: assessment of the pt for predisposing and etiologic factors, encouragement of early treatment of these factors to prevent acute pancreatitis, monitor VS and fluid and electrolyte balances during the acute phase, assess respiratory function, observe for symptoms of tetany, assess the pt for a positive Chvostek's sign or Trousseau's sign, pain relief, observe for manifestations of infection, possible home care follow-up, dietary teaching should emphasize the reduction of fats because they stimulate the secretion of cholecystokinin, when then stimulates the pancreas, instruct the pt and caregiver to recognize the symptoms of infection, DM, or steatorrhea (foul smelling, frothy stools)

Gastritis

-an inflammation of the gastric mucosa -one of the most common problems affecting the stomach -may be acute or chronic, diffuse or localized -occurs as a result of a breakdown in the normal gastric mucosal barrier, which normally protects the stomach tissue from the corrosive action of HCl acid and pepsin, when the barrier is broken, HCL acid and pepsin can diffuse back into the mucosa, resulting in tissue edema, disruption of capillary walls with loss of plasma into the gastric lumen, and possible hemorrhage -risk factors: drugs (NSAIDs inhibit the synthesis of prostaglandins that are protective to the gastric mucosa, risks for this are being female, being over age 60, having a history of ulcer disease, taking anticoagulants, other NSAIDs or ulcerogenic drugs, and having a chronic debilitating disorder), diet (prolonged damage due to alcohol abuse, eating large quantities of spicy, irritating foods and metabolic conditions), helicobacter pylori (highest in uderdeveloped countries and in people of low socioeconomic status, infection likely occurs during childhood with transmission from family members to the child, possibly through a fecal-oral or oral-oral route), bacterial, viral, and fungal infections, reflux of bile salts from the duodenum into the stomach as a result of anatomic changes following surgical procedures, prolonged vomiting, intense emotional responses and CNS lesions may also produce inflammation of the mucosal lining -autoimmune gastritis: autoimmune metaplastic atrophic gastritis, inherited condition in which there is an immune response directed against parietal cells, the loss of parietal cells leads to low chloride levels, inadequate production of intrinsic factor, cobalamin (vitamin B12) malabsorption, and pernicious anemia, pts often have other autoimmune disorders, associated with an increased risk for stomach cancer -clinical manifestations: acute (anorexia, nausea and vomiting, epigastric tenderness, and a feeling of fullness, self-limiting, lasting from a few hours to a few days, with complete healing of the mucosa expected), chronic (similar to acute, some pts are asymptomatic, pernicious anemia and neurologic complications due to the deficiency of cobalbumin -diagnostic studies: based on pt's history of drug and alcohol use, endoscopy with biopsy, breath, urine, serum, stool, and gastric tissue biopsy tests for H. pylori infection determination, CBC -treatment and nursing implementations for acute: eliminating the cause and preventing or avoiding it in future are generally all that is needed to treat it, if vomiting accompanies, rest, NPO status, and IV fluids are prescribed, antiemetics are given for nausea and vomiting, in severe cases, an NG tube may be used to monitor for bleeding, lavage the precipitating agent from the stomach or keep the stomach empty and free of noxious stimuli, frequent VS and testing the vomitus for blood if hemorrhage is considered likely, drug therapy focuses on reducing irritation of the gastric mucosa and providing symptomatic relief (H2 receptor blockers or PPIs) -treatment and nursing implementations for chronic: focuses on evaluating and eliminating the specific cause, antibiotics are used to eradicate H. pylori, cobalamin therapy, lifestyle change sand adhering to a drug regimen, smoking is contraindicated, nonirritating diet of 6 small meals a day, provide consistent information and support

Palliative Care

-any form of care or treatment that focuses on reducing the severity of disease symptoms, rather than trying to delay or reverse the progression of the disease itself or provide a cure -the overall goal is to prevent and relieve suffering and improve quality of life for pts with serous, life-limiting illnesses\-focuses on maintaining and improving the quality of life for all pts and their families during any stage of a life-limiting illness, whether acute, chronic, or terminal -aims to prevent and relieve suffering by early identification, assessment, and treatment of pain and other types of physical, psychologic, emotional, and spiritual distress

Grave's disease (Hyperthyroidism)

-autoimmune disease characterized by diffuse thyroid enlargement and excessive thyroid hormone secretion -accounts for 80% of the cases of hypothyroidism -women are 5x more likely to develop than men -precipitating factors: insufficient iodine supply, infection, stressful life events may interact with genetic factors, cigarette smoking increases the risk and development of eye problems related to the disease -the pt develops antibodies to the TSH receptor, these antibodies attach to the receptors and stimulate the thyroid gland to release T3, T4, or both -clinical manifestations: related to the effect of excess circulating thyroid hormone, directly increasing metabolism and tissue sensitivity to stimulation by the sympathetic nervous system; goiter, bruits, opthalmopathy (abnormal eye appearance or function), exophthalmos (protrusion of the eyeballs from the orbits that is usually bilateral, results from fat deposits and edema in the orbital tissues and ocular muscles, the increased pressure forcing the eyeballs outward), the upper lids usually are retracted and elevated, with the sclera visible above the iris, exposing the corneal surfaces and causing dryness and irritation, diplopia due to the muscle weakness, weight loss, increased nervousness, acropachy (clubbing of the digits) -complications: thyrotoxicosis (tyrotoxic crisis or thyroid storm, acute, severe, and rare condition that occurs when excess amounts of thyroid hormones are released into the circulation, life-threatening emergency, results from stressors in a pt with preexisting hyperthyroidism, either diagnosed or undiagnosed, thyroidectomy pts are prone to this, all symptoms are prominent and severe (severe tachycardia, heart failure, shock, hyperthermia, restlessness, irritability, seizures, abdominal pain, vomiting, diarrhea, delirium, and coma), treatment is aimed at reducing circulating thyroid hormone levels and drug therapy) -diagnostic studies: TSH, free T4 levels, RAIU test to differentiate Graves' disease from other forms -treatment: goal is to block the adverse effects of excess thyroid hormone, suppress oversecretion of thyroid hormone, and prevent complications, options include antithyroid medications (antithyroid drugs (pylthiouracil (PTU) and methimazole (Tapazole) which inhibit the synthesis of thyroid hormone, improvement begins 1-2 weeks after the start of therapy, emphasize the importance of adherence to the drug regimen), iodine (prepare the pt for thyroidectomy or for treatment of thyrotoxicosis rapidly inhibits synthesis of T3 and T4 and blocks the release of these hormones into circulation, also decreases the vascularity decreases the vascularity of the thyroid gland to make surgery easier and safer, maximal effect s seen within 1-2 weeks, not effective as a long-term treatment), B-adrenergic blockers (used for symptomatic relief of thyrotoxicosis, block the effects of sympathetic nervous stimulation, thereby decreasing tachycardia, nervousness, irritability, and tremors)), radioactive iodine therapy (treatment of choice for most nonpregnant adults, damages or destroys thyroid tissue, thus limiting thyroid hormone secretion, maximum effect may not be apparent for up to 3 months so the pt is usually treated with drugs until the effects are apparent, usually effective but has a high incidence of posttreatment hypothyroidism, resulting in the need for lifetime thyroid hormone therapy, teach pt and family about the symptoms and to seek medical help if these symptoms do occur, usually administered on an outpt basis, pregnancy test is done before initiation on all women who experience menstrual cycles, may cause dryness and irritation of the mouth and throat, instruct on the importance of home precautions to limit exposure of radiation to others (use private toilet facilities and flush 2-3 times after each use, separately laundering towels, linens, and clothes, not preparing food for others that requires prolonged handling with bare hands, and avoid being close to pregnant women or children for 7 days after therapy), surgical interventions (thyroidectomy is indicated for individuals who have a large goiter causing tracheal compression, been unresponsive to antithyroid therapy, or thyroid cancer, surgery may be done also when the pt is not a candidate for RAI, a subtotal thyroidectomy is usually preferred and involves removing a significant portion (90%) of the thyroid, an endoscopic thyroidectomy is minimally invasive procedure, small incisions are made and a scope is inserted to remove thyroid tissue or nodules, there is less scarring and pain and a faster return to normal activity), and nutritional therapy (high-calories diet (4000-5000/day, 6 full meals a day and snacks high in protein, carbohydrates, minerals, and vitamins, avoid highly seasoned and high-fiber foods because these foods can further stimulate the already hyperactive GI tract, and avoid caffeine-containing liquids to decrease the restlessness and sleep disturbances) to satisfy hunger, prevent tissue breakdown, and decrease weight loss, the choice of treatment is influenced by age, preference, coexistence of other diseases, and pregnancy status -implementation: administer medications that block thyroid hormone production and the sympathetic nervous system, provide supportive therapy (heart rhythm monitoring, adequate oxygenation, IV fluids), ensure adequate rest, provide appropriate environment to promote rest, encourage exercise involving large muscle groups to allow the release of nervous tension and restlessness, relieve eye discomfort and apply artificial tears to soothe and moisten conjunctival membranes, salt restriction, elevated pt's head to promote fluid drainage, good grooming to reduce the loss of self-esteem from an altered body image, prepare pt for post-op complications of thyroidectomy, assess for iodine toxicity, teach pt about comfort and safety measures, the importance of performing leg exercises, practice neck ROM exercises, explain that talking my be difficult for a short time after surgery, respiration may also become difficult because of excess swelling of the neck tissues, hemorrhage, and hematoma formation, laryngeal stridor may occur during inspiration and expiration as a result of edema of the laryngeal nerve, assess for hemorrhage or tracheal compression, place pt in semi-Folwer's position and support the pt's head with [pillows, avoid flexion of the neck and tension on the suture lines, monitor VS and calcium levels, control post-op pain with medications, reassure the pt that the scar will fade in color and eventually look like a normal neck wrinkle, regular follow-up care is necessary (biweekly for a month, and then at least semi-annually) to assess thyroid function and teach pt the S&S of progressive thyroid failure and to seek medical care if these develop

Wound Classification

-cause (surgical or nonsurgical, acute or chronic) -depth of tissue affected (superficial, partial thickness, or full thickness) -color (red, yellow, black)

Diabetes Insipidus (DI)

-caused by a deficiency of production or secretion of ADH or a decreased renal response to ADH -the decrease in ADH results in fluid and electrolyte imbalances caused by increased urine output and increased plasma osmolality -several types, central DI is the most common -clinical manifestations: polydipsia, polyuria, excretion of large quantities of urine with a very low specific gravity and low urine osmolality, hyponatremia, fatigue from nocturia and generalized weakness, acute onset, accompanied by excessive fluid loss, severe hydration if oral intake cannot keep up with urinary losses (manifested by poor skin turgor, hypotension, tachycardia, hypovolemic shock) -diagnostic studies: water deprivation test, weight, urine osmolality, volume, and specific gravity, ADH levels -management: early detection, maintenance of adequate hydration, pt leaching for long-term management, goal is to maintain fluid and electrolyte balance, fluid and hormone therapy, vasopressins (Pitressin, Diapid) can be used to replace ADH, dietary measures (low-sodium) and thiazide diuretics, indomethacin (Indocin)

Carpal Tunnel Syndrome (CTS)

-condition caused by compression of the median nerve, which enters the hand through the narrow confines of the carpal tunnel -the carpal tunnel is formed by ligaments and bones -most common compression neuropathy in the upper extremity -associated with hobbies or occupations that require continuous wrist movement (musicians, carpenters, computer operators) -often caused by pressure from trauma or edema caused by imflammation of a tendon (tenosynovitis), meoplasm, RA, or soft tissue masses such as ganglia, hormones may be involved, since initial manifestations of CTS often occur during the premenstrual period, pregnancy, and menopaause, persons with DM, peripheral vascular disease, and RA have a higher incidence of CTS because of swelling that changes blood flow to the nerve and narrows the carpal tunnel, women are more likely than men to develop, possibly because of smaller carpal tunnel -clinical manifestations: weakness, pain , numbness, or impaired sensation in the distribution of the median nerve, numbness and tingling may awaken the pt at night, shaking the hand often relieves these symptoms, clumsiness in performing fine hand movements is also common. positive Tine's sign (elicited by tapping over the median nerve as it passes through the carpal tunnel in the wrist, a positive response is a sensation of tinging in the distribution of the median nerve over the hand) and Phalen's sign (elicited by allowing the wrist to all freely into maximum flexion and maintain the position for longer than 60 sec, a positive response is a sensation of tinging in the distribution of the median nerve over then hand, in late stages there is atrophy of the thenar muscles around the base of the thumb, resulting in recurrent pain and eventual dysfunction of the hand -to prevent CTS teach employees and employers to identify risk factors, adaptive devices such as wrist splints may be worn to hold the wrist in a slight extension and relieve pressure on the median nerve, special keyboard pads and mouses that help prevent repetitive pressure on the median nerve are available for computer users, workstation modifications, changes in body positions, and frequent breaks from work-related activities can also help, splints worn at night can help keep the wrist in a neutral position and may reduce night pain and numbness, carpal tunnel release is generally recommended if symptoms last for more than 6 months, surgery involves severing the band of tissue around the wrist to reduce pressure on the median nerve, done it the outpt setting under localized anesthesia, open release surgery (an incision is made in the wrist and then the carpal ligament is cut to enlarge the carpal tunnel) or endoscopic carpal tunnel release (performed through one or more small incisions in the wrist and palm, a camera is attached to a tube, and the carpal ligament is cut, allows for faster recovery and less post-op discomfort), symptoms may be relieved immediately after surgery and full recovery may take months, after surgery assess for neurovascular status, instruct the pt about wound care and the appropriate assessments to perform at home

Cushing Syndrome

-condition that results from chronic exposure to excess corticosteroids, particularly glucocorticoids -several causes, the most common being iatrogenic administration of exogenous corticosteroids (prednisone), ACTH-secreting pituitary adenoma (Cushing disease) causes 85% of the cases of endogenous Cushing syndrome -Cushing disease is more common in women in the 20-40s, Ectopic ACTH more common in men -clinical manifestations: on future slide -diagnostic studies: 24-hr urine collection for free cortisol, low-dose dexamethasone suppression test, CT, MRI, plasma ACTH levels -treamtment: goal is to normalize hormone secretion, the specific treatment depends on the underlying cause, surgical removal of the pituitary tumor, radiation therapy, adrenalectomy (occasional bilateral), locating and removing ACTH-secreting tumors, drug therapy if the pt is a poor candidate for surgery or prior surgery has failed, the goal of drug therapy is to suppress the synthesis and secretion of cortisol from the adrenal gland (medical adrenalectomy, include ketoconazole (Nizoral), amiglutethimide (Cytaden), and mitotane (Lysodren), used cautiously because they are often toxic at the dosages needed to reduce cortisol secretion), if Cushing syndrome has developed during the course of prolonged corticosteroid administration, gradual discontinuance of corticosteroid therapy, reduction of the corticosteroid dose, and conversion to an alternate-day regimen can be tried -nursing implementations: pt teaching r/t medication use and monitoring side effects, S&S of hormone and drug toxicity and complicating conditions (CVD, DM, infection), assess and monitor VS, daily weight, glucose, and possible infection, assess for pain, loss of function, and purulent drainage, monitor for S&S of abnormal thromboembolic events such as PE, provide emotional support as the pt may feel unattractive, repulsive, or unwanted because of the change in appearance, be open and sensitive to the pt's feelings and offer respect and acceptance, reassure that the physical changes will resolve when the hormone levels return to normal, pre-op and post-op care if surgery is required, instruct the pt to wear a medic alert bracelet and to carry medical identification and instructions in wallet at all times, avoid exposure to extreme temperatures, infections, and emotional disturbances, teach pts to adjust their corticosteroid replacement therapy in accordance to their stress level or to go to their HCP to do so

Hypothyroidism

-deficiency of thyroid hormone that causes a general slowing of the metabolic rate -more common in women than men -can be classified as primary (caused by destruction of thyroid tissue or defective hormone synthesis) or secondary (caused by pituitary disease with decreased TSH secretion or hypothalamic dysfunction with decreased thyrotropin releasing hormone (TRH) section, may also be transient and related to thyroiditis or discontinuance of thyroid hormone therapy -iodine deficiency is the most common cause of hypothyroidism, most common cause of primary is atrophy of the pituitary gland (end result of Hashimoto's thyroiditis or Graves' disease, which are autoimmune disease that destroy the thyroid), may develop because of treatment for hyperthyroidism, specifically surgical removal or RAI -hypothyroidism that develops in infancy (cretinism) is caused by thyroid hormone deficiency during fetal and early neonatal life -clinical manifestations: depend on the severity and the duration of the thyroid deficiency, as well as the pt age and onset, onset of symptoms may occur over months to years, pt is often fatigued and lethargic and experiences personality and mental changes, including impaired memory, slowed speech, decreased initiative, and somnolence, depressed, weight gain, low exercise tolerance and shortness of breath (decreased contractility and cardiac output), anemia, increased serum cholesterol and triglyceride levels can result in coronary atherosclerosis, myxedema (alters the physical appearance of the skin and subcutaneous tissues with puffiness, facial and periorbital edema, and a masklike affect) -complications: myxedema coma (mental sluggishness, drowsiness, and lethargy may progress to a notable impairment of consciousness or coma, medical emergency, characterized by subnormal temperature, hypotension, hypoventilation) -diagnostic studies: TSH, free T4, H&P, thyroid antibodies -treatment: goal is restoration of a euthyroid state as safely and rapidly as possible with hormone therapy, low-calorie diet to promote weight loss or prevent weight gain, Levothyroxine (Synthroid) is the drug of choice, initial doses are low to avoid increases in rest HR and BP -assessment: note any previous history of hyperthyroidism and treatment with antithyroid medications, RAI, or surgery, ask pt about iodine-containing medications, changes in appetite, weight, activity level, speech, memory, and skin, such as increased dryness or thickening, assess for cold intolerance, constipation, and signs of depression -implementation: high-risk individuals should be screened (those with family history of thyroid disease neck radiation, women over 50, and postpartum women), most are treated on an outpt basis, administer medications , monitor VS, especially temperature, weight, I&O, and visible edema, note changes in alertness and energy level, provide written instructions, repeat information often, and assess comprehension level, stress the need for receiving long-term drug therapy and avoiding abrupt discontinuation, instruct on side effects of medications, include S&S of hypothyroidism or hyperthyroidism that indicate hormone imbalance, teach pt to immediately contact a HCP if manifestations of overdose occur (orthopnea, rapid pulse, palpitations, chest pain, nervousness, insomnia), the pt with DM should test glucose at least daily, instruct about toxic S&S of thyroid drugs -with treatment, most adults return to a normal state, cardiovascular conditions and psychosis may persist despite corrections of the hormonal imbalance, relapses occur if treatment is interrupted

Nursing Management of Ostomy Surgery

-emotional support as the pt copes when a radical change in body image and pt and caregiver teaching about stoma care and the ostomy -people with ostomies lose control over flatus and feces and worry about odor and leakage of feces from around the bag, with time people learn to manage the stoma and make adjustments in work, social interactions, and sexual activities, people with new ostomies may be reluctant to return to normal activities like work and avoid being around other people, initially pts may feel unattractive to their partners and unwilling to engage in sexual activities, with emotional support and teaching pts can learn to manage the ostomy and return to their previous lifestyle -pre-op: psychologic preparation for the ostomy, selection of a flat site on the abdomen that allows secure attachment of the collection bag, and selection of a stoma site that will be clearly visible to the pt who will be taking care of it and is appropriate for clothing habits and activities, provide opportunities for verbalization of questions and concerns to enhance the pt's feelings of control and ability to cope, consult a WOC nurse to determine pt's ability for self-care, identify support systems, and determine any modifications that could facilitate learning during rehabilitation, the pt and caregiver should understand the extent of the surgery, the type of stoma, and related care, ask the pt if he or she would like to meet a pt that has adjusted to an ostomy to give the pt and caregiver an opportunity to question a person who has experienced some of the same feelings and concerns -post-op: assessment of the stoma and provision of appropriate pouching system that protects the skin and contains drainage and odor, the stoma should be dark pink to red, assess and document the stoma every 4 hours and ensure that there is no excessive bleeding, teach the pt that the stoma is mildly to moderately swollen the first 2-3 weeks after surgery, a smaller pouch opening will be needed to accommodate the stoma's changing size, determine the size of the stoma with a measuring card, ostomy bags should be emptied after one-third full because the weight of the drainage can cause the adhesive wafer to pull away from the skin, record the volume, color, and consistency of the drainage, each time the pouch is changed observe the condition of the skin for irritation, teach the pt to perform a pouch change, provide appropriate skin care, control odor, care of the stoma, and identify S&S of complications, instruct the pt about the importance of fluids and healthy diet, home care and follow-up by a WOC nurse are highly recommended, pts should be discharged with information about their particular ostomy, instructions for pouch changes, a list of supplies and where to purchase them, outpt follow-up appointments with the surgeon and WOC nurse, and phone numbers of the surgeon and nurse teaching is often complicated by the emotional responses to the stoma, emotional support, interventions for skillful WOC nurses, and visits from people who have successfully learned to manage their ostomies will help pts learn to cope with and manage the new stoma -colonostomy care: instruct the pt to use a drainable pouch if it is in the ascending or transverse colon, as this has semiliquid stools, a colonostomy in the sogmoid or descending colon has semiformed or formed stools and can sometimes be regulated by the irrigation method, for these pts a drainage pouch may or may not be needed, a well-balanced diet and adequate fluid intake are important, and most pts with colonostomies can eat anything they choose, dietary modifications are helpful for decreasing gas production and odor, colonostomy irrigations may be used to stimulate emptying of the colon, when this is done regularly no stool is eliminated between irrigation sessions, irrigation requires manual dexterity and adequate vision, if bowel control is achieved little or no spillage should occur between irrigations and the pt may need ot wear only a pad or small pouch over the stoma, regularity is possible only when the stoma is in the distal colon, irrigation is not used for more proximal ostomies, people who irrigate regularly should still have ostomy bags readily available in case they develop diarrhea from foods or illnesses ileostomy care: drainage is frequent and extremely irritating to the skin, since regularity cannot be established with an ileostomy a pouch must be worn at all times, an open-ended, drainable pouch is preferable so drainage can be easily emptied, the pouch is usually worn 4-7 days before being changed, unless leakage occurs, in that care the pouch should be promptly removed, the skin cleansed, and a new pouch applied, a solid skin barrier should always be used, a transparent pouch should be used initially to be able to assess stoma visibility and pouch application by the pt, but pts might prefer opaque pouches later on, observe for S&S of fluid and electrolyte imbalance, particularly potassium, sodium, and fluid deficits, in the first 24-48 hours after surgery the amount of drainage from the stoma may be negligible, pts must learn these S&S so that they can take appropriate action, a low-fiber diet is ordered initially, and fiber-containing foods are reintroduced gradually, the ileostomy pt is susceptible to obstruction because the lumen is less than 1 iinch in diameter and may narrow further at the point where the bowel passes through the fascia/muscle layer of the abdomen, foods such as popcorn, coconut, mushrooms, olives, stringy vegetables, foods with skins, dried fruits, and meats with casing must be chewed extremely well before swallowing, the goal is for the pt to return to a normal diet, the stoma bleeds easily when it is touched because it has a high vascular supply, tell the pt that minimal oozing of blood is normal -adaptation to an ostomy: pts experience grief from the loss of a body part and an alteration in body image, the may fee like there are no longer normal and may experience shame and social isolation, people commonly feel anxiety and fear about stool leaking and the smells and sounds of flatus and stool entering the pouch, the are concerned about how the stoma will affect their lifestyle, including work, eating, sports, sex, and sleeping, they may be angry, depressed, or resentful, discuss the psychologic impact of the stoma and how it affects the pt's bod image and self-esteem, assist the pt in identifying ways of coping with depression and anxiety resulting from illness, surgery, or post-op problems, support from the caregiver, family, and friends is vitally important and reassures the pt that he or she is cherished and valued despite having the ostomy, encourage pts to share and ask questions, provide information in a manner that is easily understood, recommend support services and groups, and help pts develop confidence and competence in managing the stoma, the pt can resume ADLs within 6-8 weeks but should avoid heavy lifting, the pt's physical condition determines when sports may be resumed, some HCP recommend avoiding participation in sports where direct trauma to the stoma is likely, bathing and swimming can be done with or without the pouch in place, pts want to know how to manage gas and body odors and how to choose clothing that will hide the stoma -sexual function after ostomy surgery: the pt may feel rejection by a partner or that others will not find them desirable, incorporate a discussion of sexuality and sexual function in the plan of care, help the pt understand that it may be affected but it doesn't have to be altered, help the pt realized that it takes time to adjust to the pouch and to body changes before feeling secure in his or her sexual functioning, also a woman with an ostomy can still become pregnant

Goiter

-enlarged thyroid gland -due to an overactive thyroid (hyperthyroidism) or an underactive thyroid (hypothyroidism) -most common cause worldwide is a lack of iodine in the diet -a nontoxic goiter is a diffuse enlargement of the thyroid gland that does not result from a malignancy or inflammatory process, associated with normal levels of thyroid hormone -nodular goiters are thyroid hormone-secreting nodules that function independent of TSH stimulation, may be multiple nodules or a single, usually benign follicular adenomas, toxic if associated with hyperthyroidism (common with Graves' disease, occur in men and women, frequent in people over 40) -measure TSH and T4 levels are measured to determine whether the goiter is associated with normal thyroid function, hyperthyroidism, or hypothyroidism, thyroid antibodies are measured to assess for thyroiditis -treatment with the thyroid hormone may prevent further thyroid enlargement, surgery is used to remove large goiters

Peptic Ulcer Disease (PUD)

-erosion of the GI mucosa resulting from the digestive action of HCl acid and pepsin -any portion of the GI tract that comes in contact with gastric secretion is susceptible to ulcer development, including the lower esophagus, stomach, duodenum, and margin of a gastrojejunal anastamosis after surgical procedures -acute or chronic, acute is associated with superficial erosion and minimal inflammation, short duration and resolves quickly when the cause is identified and removed, chronic is of long duration, eroding through the muscular wall with the formation of fibrous tissue, present continuously for many months or intermittently throughout the person's lifetime, more common -develop only in an acid environment, H. pylori (the bacteria can survive a long time in the stomach by colonizing the gastric epithelial cells within the mucosal layer, alters gastric secretion and produces tissue damage), medication-induced injury (ulcerogenic drugs (aspiring, NSAIDs) inhibit synthesis of prostaglandins, increase gastric acid secretion, and reduce the integrity of the mucosal barrier, responsible for the majority of the non-H. pylori peptic ulcers), lifestyle factors (high alcohol intake is associated with acute mucosal lesions and stimulates acid secretion, coffee is a strong stimulant of gastric acid secretion, psychologic distress can negatively influence the healing of ulcers once they have developed, smoking also delays healing), gastric ulcers, duodenal ulcers (account for about 80% of all peptic ulcers, often associated with a high HCl acid secretion, alcohol ingestion, and smoking), stress-related mucosal disease (SRMD) -clinical manifestations: discomfort located high in the epigastrium and occurs about 1-2 hours after meals, burning or gaseous pain, symptoms of duodenal ulcers occur 2-5 hours after meals and pain is burning or cramplike, most often located in the midepigastric region beneath the xiphoid process, can also produce back pain, antacids alone or in combination with an H2 receptor blocker, as well as food, neutralize the acid to provide relief, silent peptic ulcers are more likely to occur in older adults and those taking NSAIDs -complications: hemorrhage (most common complication of PUD, duodenal ulcers account for a greater percentage of upper GI bleeds than gastric ulcers), perforation (the most lethal complication, commonly seen in large penetrating duodenal ulcers, mortality rates associated with perforation of gastric ulcers are higher, the ulcer penetrates the serosal surface with spillage of either gastric or duodenal contents into the peritoneal cavity, small perforations heal themselves, large perforations require immediate surgical closure, sudden and dramatic onset, during the initial phase (0-2 hours after perforation) the pt experiences sudden, severe, upper abdominal pain that quickly spreads throughout the abdomen, the pain radiates to the back and is not relieved by food or antacids, the abdomen appears rigid and board-like as the muscles attempt to protect from further injury, respirations become shallow and rapid, tachycardia, weak pulse, absent bowel sounds, nausea and vomiting, contents entering the peritoneal cavity from the stomach may contain air, saliva, food particles, HCl acid, pepsin, bacteria, bile, and pancreatic fluid and enzymes, bacterial peritonitis can occur if the condition is untreated within 6-12 hours), gastric outlet obstruction (the result of edema, inflammation, or pylorospasm and fibrous scar tissue formation, pt reports discomfort and pain that is worse toward the end of the day as the stomach fills and dilates, relief may be obtained with belching or by self-induced vomiting, vomiting is common and often projectile, containing food particles that were ingested hours or days before the vomiting episode, constipation occurs because of dehydration and decreased diet intake secondary to anorexia) -diagnostic studies: used to determine the presence and location of an ulcer, endoscopy, biopsy of antral mucosa and testing or urease, stool or breath testing, barium contrast study for those who cannot undergo endoscopy, CBC, liver enzyme studies, serum amylase determination, stool examination -treatment: adequate rest, drug therapy, elimination of smoking, dietary modifications, and long-term follow-up care, aim of treatment is to decrease gastric acidity and enhance mucosal defense mechanisms, pts are generally treated in ambulatory care clinics, pain disappears after 3-6 days, but ulcer healing is much slower, complete healing may take 3-9 weeks, endoscopic examination is the most accurate method to monitor for ulcer healing, the usual follow-up examination is 3-6 months after diagnosis and treatment, aspirin and NSAIDs are d/c for 4-6 weeks, interruption or discontinuation of drug therapy can have harmful results, encourage pt to adhere to therapy and continue with follow-up care as prescribed, pts are taught to eat and drink foods and fluids that do not cause any distressing symptoms (hot, spicy foods, pepper, carbonated beverages, and broth) -nursing implementation: identify pt risk for PUD, early detection and effective treatment are important to reduce morbidity risks associated with PUD, teach pts to report symptoms related to gastric irritation, including epigastric pain, to their HCP, NPO, NG tube, and IV fluids during acute exacerbation, regular mouth care alleviates dry mouth analyze the gastric content with pH testing, assessing for blood, bile, or other substances, monitor VS, pain relief, maintain patency of the NG tube if present, maintain accurate I&O, especially of the gastric aspirate, teach pt about the disease process itself, drugs, possible lifestyle changes, and regular follow-up care, provide information about the negative effects of smoking and alcohol, encourage pt to seek immediate intervention if symptoms return, emphasize adherence to the treatment regimen completely, including lifestyle modifications, even if there is no discomfort -surgery may be performed for pts that are unresponsive to medical management or concerns about stomach cancer, include partial gastrectomy, vagotomy, and pyloroplasty, complications post-op include dumping syndrome, postprandial hypoglycemia, and bile reflux gastritis

Peritonitis

-generalized or localized inflammation of the peritoneum -primary peritonitis occurs when blood-borne organisms enter the peritoneal cavity, secondary peritonitis occurs when abdominal organs perforate or rupture and release their contents (bile, enzymes, and bacteria) into the peritoneal cavity, common causes include ruptured appendix, perforated gastric or duodenal ulcer, severely inflamed gallbladder, and trauma from a gunshot or knife wounds -intestinal contents and bacteria irritate the normally sterile peritoneum and produce an initial chemical peritonitis, which is followed a few hours later by a bacterial peritonitis. the resulting inflammatory response leads to massive fluid shifts (peritoneal edema) and adhesions as the body attempts to wall off the infection -clinical manifestations: abdominal pain is the most common symptoms, a universal sign is tenderness over the involved area, rebound tenderness, muscular rigidity, spasms, pts may lie still and take only shallow breaths because movement causes pain, abdominal distention, fever, tachycardia, tachypnea, nausea, vomiting, altered bowel habits -complications: hypovolemic shock, sepsis, intraabdominal abscess formation, paralytic ileus, acute respiratory distress syndrome, if treatment is delayed peritonitis can be fatal -diagnostic studies: CBC, peritoneal aspiration and analyze the fluid for blood, pus, bile, bacteria, fungus, and amylase content, x-ray, ultrasound, CT, peritoneoscopy for direct examination and biopsy -assessment: pain, bowel sounds, increasing abdominal distention, abdominal guarding, nausea, fever, hypovolemic shock manifestations -nursing implementations: supportive care, IV fluids, antibiotic therapy, monitor the pt for pain and response to analgesics, accurate monitoring of I&O, VS, antiemetics, place pt on NPO status and possible NG tube to decrease gastric distention and further leakage of bowel contents into the peritoneum, low-flow oxygen therapy may be needed, drains are inserted if the pt has an open surgical procedure to remove purulent drainage and excess fluid

Clostridium difficile infection (C. diff)

-health care-associated infection -most serious antibiotic-associated diarrhea (antibiotics kill off the normal flora, making the individual more susceptible to pathogenic organisms -its spores can survive for up to 70 days on objects -can be transmitted from pt to pt by health care workers who do not adhere to infection control precautions -symptoms include watery diarrhea, fever, anorexia, nausea, abdominal pain -impair absorption by destroying cells, cause inflammation of the colon, and produce toxins that also cause damage -usually treated by stopping antibiotics and starting the pt on either metronidazole (Flagyl) or vancomycin (Vancocin), metronidazole is the first line of treatment in mild disease because of concerns about vancomycin-resistant enterococcus (VRE), recovery rates are substantially better with vancomycin so it is preserved for serious infections, both drugs are given orally, but metronidazole can also be given IV, Fidaxomicin (Dificid) is generally reserved for pts who are at risk for relapse orr have recurrent infections -recurrent C. diff occurs in about 20% of pts and the probability of recurrence rises with each subsequent infection, feces transplantation is under investigation as a potential therapeutic option for pts with recurrent and resistant C. diff infections (a healthy person's feces is inserted into the GI tract using an enema or NG tube, or during colonoscopy

Soft tissue Injuries

-include sprains, strains, dislocations, and subluxations -usually caused by trauma -sprains and strains are common injuries from abnormal stretching or twisting forces that may occur during vigorous activities, tend to occur around joints and in the spinal musculature -sprain: an injury to the ligamentous structures surrounding a joint, usually caused by wrenching or twisting motion, most occur in the ankle, wrist, and knee joints, classified according to the degree of ligament damage, first-degree (mild, involves tears only in a few fibers, mild tenderness and swelling), second-degree (moderate, partial disruption of the involved tissue with more swelling and tenderness), third-degree (severe, complete tearing of the ligament in association with moderate to severe swelling, a gap in the muscle may be apparent or palpated through the skin if the muscle is torn, the injury can be extremely painful) -strain: excessive stretching of muscle, its fascial sheath, or a tendon, most occur in the large muscle groups, including the lower back, calf, and hamstrings, may also be classified as first degree (milk or slightly pulled muscle), second degree (moderate or moderately torn muscle), and third degree (severely torn or ruptured muscle) -clinical manifestations of sprains and strains iunclude pain, edema, decreased function, contusion, pain aggravated by continued use is common edema develops because of local inflammatroy response; mild srains and strains are self-limiting, with full function returning within 3-6 weeks, x-rays may be taken to rule out fracture, severe strains may require surgical repair of the muscle, tendon, or surrounding fascia; warming up muscles before exercising and vigorous activity, followed by stretching, may significantly reduce the risk of sprains and strains, strength, balance, and endurance exercises are also important, if an injury occurs the immediate care focuses on stopping the activity and limiting movement, RICE, providing analgesics as necessary, after the acute phase (usually 24-48 hours) warm, moist heat may e applied to reduce swelling and provide comfort, heat and cold application should not exceed 20-30 minutes, movement of the joints maintains nutrition to the cartilage and muscle contraction improves circulation and resolution of the contusion and swelling, so encourage the pt to use the limb as much as possible, most sprains and strains are treated in an outpt setting, encourage RICE and pain management, emphasize the importance of strengthening and conditioning exercises to prevent reinjury -dislocation: severe injury of the ligamentous structures that surround a joint, results in the complete displacement or separation of the articular surfaces of the joint, characteristically result from forces transmitted to the join that dirupt soft tissue support structures surrounding it, most frequently occurs in the thumb, elbow, shoulder, hip, and patella, most obvious clinical manifestation is deformity, additional include local pain, tenderness, loss of function of the injured part, and swelling of the soft tissues in the joint region, major complications are open joint injuries, intraarticular fractures, avascular necrosis (bone cell death as a result of inadequate blood supply), and damage to adjacent neurovascular tissue, x-ray studies are performed to determine the extent of displacement of the involved structures, the joint may also be aspirated to assess for hemarthritis or fat cells -subluxation: a partial or incomplete displacement of the joint surface, clinical manifestations are similar to dislocation but less severe -nursing interventions: dislocation requires prompt attention and is often considered an orthopedic emergency, may be associated with severe vascular injury, the longer the joint remains unreduced the greater the possibility of avascular mecrosis, compartment syndrome may also occur, neurovascular assessment is critical, the first goal is to realign the dislocated part of the joint in its original anatomical position, accomplished by a closed reduction, which may be performed under local or generalized anesthesia or IV conscious sedation, often necessary to relax muscles so that the bones can be manipulated, after reduction the extremity is usually immoblizied by bracing, splinting, taping, or using a sling to allow the torn ligaments and capsular tissue time to heal, relieve pain and support and protection of the injured joint, gentle ROM exercises may be recommended if the joint is stable and well supported, pt should gradually resume normal activities

Complications of Fractures

-infection: devitalized and contaminated tissue is an ideal medium for many common pathogens, including gas-forming (anaerobic) bacilli, treatment of infection is costly in terms of extended nursing and medical care, time for treatment, and loss of pt income, osteomyelitis can become chronic, require surgical debridement (the wound is initally cleansed b sulsating saline lavage in the OR, gross contaminants are irrigated and mechanically removed, contused, contaminated, and devitalized tissue are surgically excised (debridement),the extent of soft tissue damage determines whether the wound is closed up after surgery or if it needs repeat debridement, closed suction drainage, and skin grafting,antibiotics, in conjunction with aggressive surgical management, have greatly reduced the occurrence of infection -compartment syndrome: a condition in which swelling and increased pressure within a limited space press on and compromise the function of blood vessels, nerves, and/or tendons that run through the compartment, causes capillary perfusion to be reduced below a necessary level for tissue viability, usually involves the leg, but can also occur in the arm, shoulder, and buttocks, the two basic causes of compartment syndrome are decreased compartment size resulting from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia, and increased compartment contents related to bleeding, inflammation, edema, or IV infiltration, delays in diagnosis and treatment can cause irreversible muscle and nerve ischemia, resulting in a functionally useless or severely impaired extremity, usually associated with trauma, fractures, extensive soft tissue damage, and crush injury, characteristics include the 6 P's (PAIN distal to the injury that is not relieved by opioid analgesics and on passive stretch of muscle traveling through the compartment, increasing PRESSURE in the compartment, PARASTHESIA (numbness and tingling), PALLOR, coolness, and loss of normal color of the extremity, PARALYSIS or loss of function, and PULSELESSNESS or diminished or absent peripheral pulses, surgical decompression of the compartment may be necessary and the fasciotomy site is left open for several days to ensure accurate soft tissue decompression, which can lead to an increased risk for infection, amputation may be required in severe cases -venous thrombosis: lower extremity and pelvic veins are highly susceptible after a fracture, anticoagulant drugs may be ordered, wearing compression stockings and using sequential compression devices, as well as moving the fingers or toes of the affected extremity against resistant and perform ROM exercises on the unaffected lower extremities -fat embolism syndrome: systemic fat globules from fractures are distributed into tissues and organs after a traumatic skeletal injury, early recognition is crucial, most pts manifest symptoms 24-48 hrs after injury, including S&S of ARDS, changes in mental status, and skin color changes, treatment is directed at prevention, including fluid resuscitation to prevent hypovolemic shock, correction of acidosis, and replacement of blood loss, encourage coughing and deep breathing exercises

Appendicitis

-inflammation of the appendix, a narrow blind tube that extends from the inferior part of the cecum -most common cause of abdominal pain -common cause is obstruction of the lumen by a fecalith (accumulated feces), which leads to distention, venous engorgement, and the accumulation of mucus and bacteria, which can lead to gangrene, perforation, and peritonitis -clinical manifestations: diagnosis can difficult because many pts do not have classic symptoms, typically begins with periumbilical pain, followed by anorexia, nausea, and vomiting, the pain is persistent and continuous, eventually shifting to the RLQ and localizing at McBurney's point (halfway between the umbilicus and the right iliac crest), localized tenderness, rebound tenderness, muscle guarding, coughing, sneezing, and deep inhalation magnify the pain, pt usually prefers to lie still, often with the right leg flexed, low-grade fever may or may not be present -diagnostic studies: H&P, differential WBC, urinalysis, CT, ultrasound -if diagnosis and treatment are delayed, the appendix can rupture, and the resulting peritonitis can be fatal -treatment: immediate surgery (appendectomy) if the inflammation is localized, usually performed laproscopically, done soon as the diagnosis is made, antibiotics and fluid resuscitation is administers pre-op, parenteral fluids and antibiotics are given for 6-8 hours before the appendectomy if there is evidence of peritonitis or an abscess, to prevent dehydration and sepsis -nursing interventions: encourage the pt to see a HCP and avoid self-treatment if they experience abdominal pain, laxatives and enemas are especially dangerous because peristalsis can cause perforations of the appendix, keep pts on NPO diet until they can been seen by a HCP just in case surgery is needed

Hepatitis

-inflammation of the liver -hepatitis is most commonly caused by viruses but can also be caused by drugs (alcohol), chemicals, autoimmune disease, and metabolic abnormalities -types of viral hepatitis are A, B, C, D, and E, the differ in their modes of transmission and clinical manifestations, can be responsible for acute and chronic liver disease, other less common viruses can cuase liver disease like cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpesvirus, coxsackievirus, and rubella virus -hepatitis A: viral infection, can cause mild flu-like illness or acute hepatitis with jaundice, can also cause acute liver failure, does not result in chronic infection, a riboneucleic acid (RNA) virus that is transmitted primarily through the fecal-oral route, frequently occurs in small outbreaks caused by fecal contamination of food or drinking water, poor hygiene, improper handling of food, crowded situations, and poor sanitary conditions are contributing factors, transmission occurs between family members, institutionalized individuals, and children in day care centers, the virus is present in feces during the incubation period, so it can be carried and transmitted by persons who have undetectable, subclinical infections, the greatest risk of transmission occurs before clinical symptoms are apparent found in feces 2 or more weeks before the onset of symptoms and up to 1 week after the onset of jaundice, present only briefly in blood, vaccinations and thorough hand washing are the best measures to prevent outbreaks -hepatitis b: can cause either acute or chronic disease, transmission occurs when the virus (from infected blood or bodily fluids) enters the body of an uninfected person who has not received the HBV vaccine, in the majority of adults with acute hepatitis b the infection completely resolves, a deoxyribonucleic acid (DNA) virus, can be transmitted perinatally by mothers infected with HBV, percutaneously (IV drug use, accidental needle-stick punctures), or by mucosal exposure to infectious blood, blood products, or other bodily fluids, organ and tissue transplantation is another potential source of infection, sexual transmission is a common mode of transmission, men who have sex with men are at risk for infection, especially when unprotected, although the risk of transmission is much lower kissing and sharing food items may spread the virus via saliva, HBV can live on a dry surface for at least 7 days and it is much more infectious that HIV -hepatitis C: can result in both acute and chronic illness, acute is usually asymptomatic, the most common cause of acute are injection drug use and outbreaks among HIV-positive men who have sex with men, the majority of pts that acquire HCV usually develop chronic infection and most are unaware of their infection, chronic results in potentially progressive liver failure, with 20-30% of these pts developing cirrhosis, most common cause of chronic liver disease and the most common indication for liver transplantation in the US, RNA virus that is primarily transmitted percutaneously, most common mode of transmission is the sharing of contaminated needles and equipment among IV drug users, the risk of perinatal HCV transmission is higher in women who are co-infected with both HIV and HCV, persons at risk for HCV infection are also at risk for HBV and HIV infections, co-infection with HIV and HCV places the pt at greater risk for progression to cirrhosis -heptatits D: also called delta virus, a defective single-stranded RNA virus that cannot survive on its own, it requires HBV to replicate it, it can be acquired at the same time as HBV, or a person with HBV can be infected with HDV at a later time, transmitted percutaneously, it can cause a spectrum of illnesses ranging from an asymptomatic chronic carrer state to acute liver failure, there is no vaccine for HDV but vaccination against HBV reduces the risk of HDV co-infection -heptatitis E: an RNA virus transmitted be the fecal-oral route, the usual mode of transmission is drinking contaminated water -pathophysiology: during an acute viral hepatitis infection, liver damage is mediated by cytotoxic cytokines and matural killer cells that cause lysis of infected hepatocytes, inflammation can interrupt bile flow (cholestatis), after resolution of an acute infection, liver cells can regenerate and, if no complications occur, resume their normal appearance and function, a chronic viral hepatitis infection causes chronic inflammation and can cause fibrosis that can progress to cirrhosis; the antigen-antibody complexes between the virus and its corresponding antibody may form circulating immune complexes in the early phases of hepatitis, which activate the complement system, clinical manifestations of this are rash, fever, angioedema, arthritis, and malaise -clinical manifestations: a large number of pts with acute hepatitis have no symptoms,others may have intermittent or ongoing malaise, fatigue, myalgias, arthralgias, and hepatomegaly, the acute phase lasts for 1-4 months, during the incubation period symptoms may include malaise, anorexia, and weight loss, fatigue, nausea, occasional vomiting, and RLQ discomfort, the pt may find food repugnant and smokers find cigarettes distasteful, there is also a decrease in the sense of smell, other symptoms may include headache, low-grade fever, arthralgias, and skin rashes, physical exam may reveal hepatomegaly, lymphadenopathy, adn splenomegaly, the acute phase is the period of maximal infectivity, the acute phase may be icteric (jaundice) or anicteric; the convalescent phase following the acute phase begins as jaundice fades and lasts for weeks to months, with an average of 2-4 months, during this period, the pt's major complaint is malaise and easy fatigability, hepatomegaly remains for several weeks but splenomegaly subsides during this period, prior infection with HAV or HBV can provide immunity to that virus (homologous immunity), however, the pt can still be infected with another type of hepatitis virus -complications: most pts with acute hepatitis recover completely, the mortality rate is higher for older adults and those with underlying debilitating illnesses, complications that occur include acute liver failure, chronic hepatitis, cirrhosis of the liver, and hepatocellular carcinoma, almost all cases of HAV resolve, but a small number have a viral relapse in the first 2-3 months after the infection,some HBV and HCV result in chronic viral infection, chronic HBV is more likely to develop in infants born to infected mothers and in those who acquire the virus after age 5, HCV is more likely than HBV to become chronic, risk factors for progression to cirrhosis include male gender, alcohol consumption, and excess iron deposition in the liver, elevated cholesterol or triglycerides, obesity, and DM are also risk factors for progression to cirrhosis -diagnostic studies: testing the pt's blood for specific antigens or antibodies, liver function tests, RNA testing, viral genotype testing, physical assessment may reveal hepatic tenderness, hepatomegly, and splenomegaly, the liver is palpable, a liver biopsy may be done for chronic hepatitis -treatment: no specific treatment for acute viral hepatitis, most pts can be managed at home, emphasizing rest ot the body and assisting the liver in regenerating, the degree of rest ordered depends on the severity of symptoms, counseling should include the importance of avoiding alcohol and notification of possible contacts for testing and prophylaxis, there are no drug therapies for HAV, treatment for HBV is indicated only in pts with severe hepatitis and liver failure, treatment for HCV is pegylated interferon for the first 12-24 weeks of infection to decrease the development of chronic HCV, supportive drug therapy may include antiemetics for nausea; for chronic HBV drug therapy is focused on decreasing the viral load and liver enzymes and slowing the rate of progression, preventing cirrhosis, liver failure, and hepatocellular cancer, current drug therapies do not eradicate the virus but work well to suppress viral replication and prevent complications of HBV, interferon (PEG, pegylation) serves to only to delay elimination of the drug, pts receiving interferon should have blood counts and liver function tests performed every 4-6 weeks, neucleosides and nucleotide analogs do not prevent all viral reproduction but they can substantially lower the amount of virus in the body, having beneficial effects in therms of reducing viral load, decreasing liver damage, and decreasing liver enzymes, most pts with HBV require long-term treatment with these medications, for chronic HCV drug therapy is directed at eradicating the virus and preventing HCV-related complications, including pegylated interferon given with ribavirin (Rebetol, Copegus), treatment is individualized and based on the genotype, the severity of the liver disease, potential side effects, presence of co-morbid conditions, pt's readiness for treatment, and presence of other health problems,pts who have advanced fibrosis or cirrhosis can be treated with drug therapy as long as liver decompensation is not present, depression or mood changes are common in pts receiving treatment for HCV, so pts need to be screened for mood disorders at the beginning and periodically throughout therapy; no special diet is required in the treatment of viral hepatitis, emphasis is placed on a well-balanced diet that the pt can tolerate, adequate calories are important because the pt usually loses weight, vitamin supplements are frequently used, fluid and electrolytes must be maintained - nursing implementation: prevent and control hepatitis, including personal and environmental hygiene and health education to promote good sanitation, educate about vaccinations for prevention, if applicable, all children at 1 year of age should receive the HAV vaccine, the best way to prevent HBV is to identify those at risk, screen them for HBV, and vaccinate those who are not infected, teach about safe sex practices, the HBV vaccine should be given at birth, no vaccine is currently available for HCV, so to prevent one must screen blood, organ, and tissue donors, use infection control precautions, and modify high-risk behavior, in pts with acute hepatitis assess for the presence and degree of jaundice, comfort measures to relieve pruritis, headache, and arthralgias are helpful, assess the pt's tolerance of special foods and eating pattern, stimulate the appetite, if necessary, with mouth care, antiemetics, and attractively swerved meals in pleasant surroundings, adequate fluid intake is important, assess pt response to rest and activity plan, modifying when necessary, assess pt knowledge since most care is done at home, caution the pt about overexertion and the need to follow the HCP's advice about when to return to work and other normal activities, teach how to prevent transmission to other family members,and teach what symptoms need to be reported to the HCP, instruct the pt to have regular follow-up appointments for at least 1 year after the diagnosis of hepatitis,teach about alcohol avoidance, educate on any necessary medications, especially interferon

Cholelithiasis (Gall Stones)

-most common disorder of the biliary system -the stones maybe lodged in the neck of the gallbladder or in the cystic duct -usually occurs along with cholecystitis (inflammation of the gallbladder) -higher incidence in women and persons over 40 years old, oral contraceptives affect cholesterol production and increase the likelihood of gallbladder cholesterol saturation, other factors that increased risk are obesity, sedentary lifestyle, and a familial tendency -the cause of gallstones is unknown, develops when the balance that keeps cholesterol, bile salts, and calcium in solution is altered so that these substances precipitate, conditions that upset this balance include infection and disturbances in the metabolism of cholesterol, in pts with cholelithiasis the bile secreted by the liver is supersaturated with cholesterol (lithogenic bile), the bile in the gallbladder also becomes supersaturated with cholesterol, causing precipitation of cholesterol, changes in the composition of bile are probably significant in the formation of gallstones, stasis of bile leads to progression of the supersaturation and changes in the chemical composition of the bile (biliary sludge), immobility, pregnancy, and inflammatory or obstructive lesions of the biliary system decrease bile flow, hormonal factors during pregnancy may cause delayed emptying of the gallbladder, causing stasis of bile, the stones may remain in the gallbladder or migrate to the cystic duct or the common bile duct, the cause pain as they pass through the ducts, and they may lodge in the ducts and produce an obstruction, small stones are more likely to move into a duct and cause obstruction, if the blockage occurs in the cystic duct, the bile can continue to flow into the duodenum directly from the liver, and when the bile in the gallbladder cannot escape, this stasis of bile may lead to cholecystitis -clinical manifestations: many pts have "silent cholelithiasis," the severity of symptoms depends on whether the stones are stationary or mobile and whether obstruction is present, when a stone is lodged in the ducts or when stones are moving through the ducts, spasm may result in response to the stone, sometimes producing severe pain, termed biliary colic, this pain can be excruciating and accompanied by tachycardia, diaphoresis, and prostration, the severe pain may last up to an hour and when it subsides there is a residual tenderness in the RUQ, the attack frequently occurs 3-6 hours after a high-fat meal or when the pt lies down -complications: gangrenous cholecystitis, subphrenic abscess, pancreatitis, cholangitis (inflammation of the biliary ducts), biliary cirrhosis, fistulas, and rupture of the gallbladder, which can produce bile peritonitis -diagnostic studies: ultrasonography, ERCP, bile culture, percutaneous transhepatic cholangiography (the insertion of a needle directly into the gallbladder duct followed by injection of contrast materials to indicate a bile duct blockage), laboratory tests (CBC, bilirubin levles, alkaline phosphatase, ALT, AST, serum amylase) -treatment: depends on the stage of the disease, bile acids (cholesterol solvents, such as ursodeoxycholic acid (ursodiol) and chenodeoxycholic acid (chenodiol)) are used to dissolve stones, however gallstones may recur, ot usually treated with drugs because of the high use and success of laparascopic cholecystectomy (treatment of choice for symptomatic cholelithiasis, the gallbladder is removed through one of four small punctures in the abdomen, a laparoscope, which has a camera attached, as grasping forceps are inserted into the abdomen through the punctures, using closed-circuit monitors to view the abdominal cavity, the surgeon retracts and dissects the gallbladder and removes it with grasping forceps, a safe proceudre with minimal morbidity, the main complication of the surgery is injury to the common bile duct, pts normally have minimal post-op pain and can resume normal activities within 1 week), ERCP with endoscopic sphincterotomy may be used for stone removal (allows visualization of the biliary system, dilation, and placement of stents and sphincterotomy if warranted, (the endoscope is passed to the duodenum, with an electrodiathermy knife attached to the endoscope, the stone is commonly left in the duodenum to pass naturally in the stool), most common drugs used to treat gallbladder disease are analgesics, anticholinergics, fat-soluble vitamins, and bile salts, fat-soluble vitamins (A, D, E, and K) may need to be used for chronic gallbladder disease or any biliary tract obstruction, people have fewer problems if they eat smaller, more frequent meals with some fat at each meal to promote gallbladder emptying, diet should be low in saturated fats (butter, shortening, lard) and high in fiber and calcium, rapid weight loss should be avoided because it can promote gallstone formation -nursing implementation: be aware of predisposing factors for gallbladder disease, treat pain, relieve nausea and vomiting, provide comfort and emotional support, maintain fluid and electrolyte balance and nutrition, make accurate assessments to ensure effective treatment, and observe for complications, assess for progression of symptoms or development of complications, assess for infections, monitor VS, dietary teaching

Anterior Cruciate Ligament (ACL) Injury

-most commonly injured knee ligament -usually noncontact injuries that occur when the athlete pivots, lands from a jump, or slows down when running, pts often report coming down on the knee, twisting, and hearing a pop, followed by acute knee pain and swelling, athletes usually cannot continue playing, and the knee may feel unstable -can result in a partial tear, complete tear, or an avulsion (tearing away) from the bone attachments that form the knee -examination of the knee with an ACL tear may produce a positive Lachman's test (performed by flexing the knee 15-30 degrees and pulling the tibia forward while the femur is stabilized, considered positive if there is forward motion of the tibia with the feeling of a soft or indistinct endpoint -MRI is usually used to diagnose coexisting conditions, including a fracture, meniscus tearing, and collateral ligament injuries -nursing interventions: prevention programs, conservative treatments for an intact ACL include rest, ice, NSAIDs, elevation, and ambulatoin as tolerated with crutches, if there is a tight, painful effusion it may be aspirated, a knee immobilizer or hinged knee brace may be helpful in supporting the knee, PT often assists the pt in maintaining knee joint motion and muscle tone -reconstructive surgery is usually recommended in physically active pts who have sustained severe injury to the ligament and the meniscus, in reconstruction the torn ACL tissue is removed and replaced iwth autologous or allograft tissue, ROM is encouraged soon after surgery and the knee is place in a brace or immobilizer, rehabilitation with PT is critical with progressive weight bearing determined by the degree of surgical repair, a safe return to previous activity may take 6-8 months

GI Physical Exam

-mouth: inspection (symmetry, color, size, abnormalities, lesions, bucal mucosa, tooth and gums for caries, loose teeth, abnormal shape and position of teeth, swelling, bleeding, discoloration, or inflammation of the gingivae, note any distinctive odor, inspect the pharynx to observe the tonsils, uvula, soft palate, and anterior and posterior pillars, instruct the pt to say "ahh" to see if the uvula and soft palate rise and are midline), palpation (any suspicious areas, note ulcers, nodules, indurations, tenderness, pay attention to dentures, ability to swallow, the tongue, and lesions, ask pt with dentures to remove them during the exam to allow for good visualization and palpation of the area) -abdomen: good lighting should shine across the abdomen, pt should be supine and relaxed and have an empty bladder, use warm hands to avoid elicit muscle guarding, ask pt to breathe slowly through the mouth, inspection (assess for skin changes (color, texture, scars, striae, dilated veins, rashes, lesions), umbilicus (location and contour), summetry, contour (flat, rounded, concave, protuberant, distended), observable masses (hernias or other masses), and movement (pulsations and preistalsis), normal aortic pulsation may be seen in the epigastric area, look across the abdomen tangentially for peristalsis), auscultation (listen in all 4 quadrants, starting with the RLQ, listen for at least 5 minutes,normal sounds are high pitched and gurgling, a perfectly silent abdomen is uncommon, also listen for bruit near the aorta, which should not normally be present), percussion (estimates the size of the liver and determine the presence of fluid, distention, and masses, air produces distention, fluid or masses produces dullness, lightly percuss all 4 quadrants, percuss the liver), palpation (light palpation to detect tenderness or hypersensitivity, muscular resistance, masses, and swelling, deep palpation to deliniate abdominal organs and masses, observe facial expressions for nonverbal cues of discomfort or pain, palpate the liver and spleen) -rectum and anus: inspect perianal and anal areas for color, texture, masses, rashes scars, erythema, fissures, and external hemmorhoids), palpate any masses or unusual areas with a gloved hand

Foodbourne Illnesses (food poisoning)

-nonspecific term that describes acute GI symptoms such as nausea, vomiting, diarrhea, and cramping abdominal pain caused by the intake of contaminate food or liquids -there are 31 known foodbourne pathogens, bacteria accounting for most of them, raw foods that have become contaminated during growing, harvesting, processing, storing, shipping, or final preparation are the most common source -interventions are focused on prevention of an infection, teaching includes correct food preparation and cleanliness, adequate cooking, and refrigeration, emphasize correction of fluid and electrolyte imbalance from diarrhea and vomiting -Escherichia coli O157:H7 poisoning: causes hemorrhagic colitis and kidney failure, can be life threatening, found primarily in undercooked meats, particularly poultry and hamburger, person-to-person contact is also an important mode of transmission, infection can also occur after drinking raw milk, unpasteurized juice, or contaminated fruit juices after swimmin in or drinking sewage-contaminated water, most strains of E.coli are harmless and live in the intestines of healthy humans and animals but O157:H7 produces a powerful toxin and can cause severe illness, clinical manifestations include diarrhea (often bloody) and abdominal cramping pain for 2- days after swallowing the organism, diagnosed by detecting the bacteria in the stool, treatment involves supportive care to maintain blood volume, no evidence that antibiotics improve course of the disease, pts should avoid antidiarrheal agents

Types of Specialized Nutritional Support

-oral feeding: may be used in the pt whose nutritional intake is deficient, may include milkshakes, puddings, etc. -enteral nutrition (EN): also known as tube feeding, nutrition provided through the GI tract via a tube, catheter, or stoma that delivers nutrients distal to the oral cavity, may be ordered for the pt that has a functional GI tract byt is unable to take any or enough oral nourishment, or when it is unsafe to do so, common delivery options are continuous infusion by pump, intermittent infusion by gravity, intermittent bolus by syringe, and cyclic feedings by infusion pump, nasally and orally placed tubes (orogastric, nasogastric, nasoduodenal, or nasojejunal) are most commonly used for short-term feeding (less than 4 weeks), nasoduodenal and nasojejunal are used when pathophysiologic conditions warant feeding the pt below the pyloric sphincter, orogastric, nasogastric, and nasointestinal tubes are radiopaque (their position is readily identified by x-ray), they are more easily clogged, particularly prone to obstruction when drugs are not thoroughly crushed and dissolved, can be dislodged by vomiting or coughing and can also become knotted or kinked, a gastrostomy tube may be used for a pt who require EN over an extended period of time, the pt must have an intact, unobstructed GI tract, and the esophageal lumen must be wide enough to pass the endoscope for PEG tube (percutaneous endoscopic gastrostomy tube) placement, for the pt with chornic reflux a jejunostomy with continuous feedings may be necessary to reduce the risk of aspiration, enteral feedings can be started 24-48 hours after a surgically placed gastrostomy or jejunostomy tube without waiting for flatus or a BM, PEG tube feeding may be started within 2 hours of insertion -tube feeding and safety: proper pt positioning can reduce the risk of aspiration, elevate HOB to a minimum of 30 degrees, but preferably 45 degrees to prevent aspiration, evaluate aspiration risk by ensuring tube placement before starting tube feedings, checking gastic residual volumes every 4 hrs during the first 48 hours and then every 6-8 hours in non-critically ill pts and every 4 hrs in critically-ill pts, do not rely on auscultation to differentiate between gastric and respiratory placement, use x-ray, capnography, aspirate the syringe to draw up gastric fluids -complications related to tube feedings: skin irritation, dislodgement of the tube, enteral feed misconnection -parenteral nutrition (PN): the administration of nutrients by a route other than the GI tract (the bloodstream), used when the GI tract cannot be used for the ingestion, digestion, and absorption of essential nutrients, usually composed of dextrose and protein in the form of aminno acids, electrolytes, vitamins, and trace elements,calories are supplied primarily by carbohydrates in the form of dextrose and fat in the form of fat emulsion, may be administered as central PN (through a central venous catheter or PICCs, used when long-term support is necessary or when the pt has high protein and caloric requirements), peripheral PN (administered through a peripherally inserted catheter or a vascular access device, used when nutritional support is needed for only a short time, protein and caloric requirements are not high, the risk of a central catherter is too great, or PN is used to supplement inadequate oral intake), central PN and PPN differ in tonicity (central are hypertonic, PPN are hypertonic but less than central) -complications: phlebitis, fluid overload, refeeding syndrome (characterized by fluid retention and electrolyte imbalances)

Acromegaly

-overproduction of growth hormone, which leads to an overgrowth of soft tissue and bones; because the problem develops after epiphyseal closure, the bones of the arms and legs do not grow longer -both genders are affected equally -most often occurs as a result of a benign pituitary tumor (adenoma) -changes occur over a number of years -clinical manifestations: enlargement of hands and feet with joint pain that can range from mild to crippling, carpal tunnel syndrome, thickening and enlargement of the bony and soft tissues of the face, feet, and head, enlargement of the tongue results in speech difficulties, the voice deepens because of hypertrophy of the vocal cords, sleep apnea may occur because of upper airway narrowing and obstruction from increase amounts of pharyngeal soft tissue, the skin becomes thick, leathery, and oily, may experience peripheral neuropathy and proximal muscle weakness, women may develop menstrual disturbances, visual changes may occur due to pressure on the optic nerve from pituitary edema, headaches, glucose intolerance and manifestations of diabetes mellitus may occur due to GH antagonizing the action of insulin (polydipsia and polyuria), increased free fatty acids in blood due to GH mobilizing stored fat for energy, which predisposes pt to atherosclerosis -life expectancy is reduced by 5-10 years, and they are more likely to succumb to cardiac and respiratory diseases, diabetes mellitus, and colorectal cancer -even when it is cured or well-controlled, joint pain and deformities often remain -diagnostic studies: H&P, plasma insulin-like growth factor, OGTT, MRI, CT, ophthalmologic exam, -prognosis depends on the age at onset, age when treatment started, and tumor size -overall goal is to return GH levels to normal treatment: surgery (hypophysectomy, permanent loss of pituitary hormones, essential hormones produced by target organs are given instead, hormone therapy continues throughout life), radiation therapy (used when surgery fails to cure or when pts are poor candidates for surgery, full effects may not be noted for months to years, may lead to hypopituitarism, stereotactic radiosurgery may be used for small, inaccessible tumors), drug therapy (common in pts who have had an inadequate response to surgery and/or in combination with radiation therapy, primary drug is octreotide (Sandostatin), a subcutaneous injection given 2-3 times/week that reduces GH levels, GH levels are measured every 2 weeks to giude dosing and then every 6 months until the desired response is obtained, dopamine agonists (bromocriptine (Parlodel), pergolide (Permax), cabergoline (Dostinex)) reduce the secretion of GH from the tumor, GH antagonists (pegvisomant (Somavert) reduce the effect of GH in the body by blocking the hepatic production of IGF-1), or a combination; with treatment, bone growth can be stopped and tissue hypertrophy reversed, but sleep apnea, diabetes, and cardiac complications may persist -assessment: S&S of abnormal tissue growth, evaluate changes in physical size, question the pt about increases in hat, glove, and shoe sizes, older photographs are helpful to evaluate changes -implementation: post-op care (elevate HOB at 30 degrees at all times to avoid pressure and decrease headaches, monitor pupillary response, speech patterns, and extremity strength to detect neurologic complications, perform mouth care q4h to keep surgical area clean and free of debris, avoid tooth brushing for at least 10 days to protect the suture line, observe for signs of bleeding, instruct the pt to voiding vigorous coughing, sneezing, and straining to prevent CSF leakage), if radiation is used (the pt will be in a stereotactic head frame, carefully monitor VS, neurologic status, and fluid volume status, complications include increased headaches, seizures, nausea, and vomiting, perform pin-site care if necessary), observe pt for transient DI, which may occur because of the loss of ADH (closely assess urine output and serum and urine osmolarity), if a hypophysectomy is performed or the pituitary gland is damaged (hormone therapy is necessary, ADH, cortisol, TH, , maybe FSH and LH, may decrease fertility, teach the pt about lifelong therapy, photographs to show improvements may help), pts are at higher risk for colon polyps and colorectal cancer, so they should have a screening every 3-4 years

Eating Disorders

-primarily psychiatric disorders, occur most often in women, men are also at risk but less likely to seek treatment -anorexia nervosa: a self-imposed weight loss, endocrine dysfunction, and a distorted psychopathologic attitude towards weight and eating. clinically manifested as abnormal weight loss, deliberate self-starvation, intense fear of gaining weight, lanugo (soft, downy hair covering the body except the palms and soles), refusal to eat, continuous dieting, hair loss, sensitivity to cold, compulsive exercise, absent or irregular menstruation, dry and yellowish skin, and constipation, signs of malnutrition are noted during the physical exam, diagnostic studies usually show iron-deficiency anemia, an elevated BUN, potassium deficiency, treatment involves nutritional support and psychiatric care -bulimia nervosa: frequent binge eating and self-induced vomiting associated with loss of control related to eating and a persistent concern with body image, may have a normal weight for height, may also abuse laxatives, diuretics, exercise, or diet drugs, may have signs of frequent vomiting (macerated knuckles, swollen salivary glands, broken blood vessels in the eyes, and dental problems), goes to great lengths to conceal abnormal eating habits, treatment includes psychologic counseling and diet therapy, antidepressants are helpful for some, education and emotional support for the pt and family are vital -binge-eating disorder: less severe than bulimia nervosa and anorexia nervosa, individuals do not have a distorted body image and are often overweight or obese

Addison's Disease

-primary cause of adrenocortical insufficiancy (hypofunction of the adrenal cortex), all 3 categories of adrenal corticosteroids (glucocorticoids, mineralocorticoids, and adrogens) are reduced -most common cause is an autoimmune response, adrenal tissue is destroyed by antibodies against the pt's own adrenal cortex -often other endocrine conditions are present and Addison's is considered a component of autoimmune polyglandular syndrome (rare syndrome caused by a mutation in a gene that helps to regulate the immune system, inherited as an autosomal recessive trait -most common in white females if caused by an autoimmune response -other causes include TB, infarction, fungal infections, AIDS, metastatic cancer -clinical manifestations: on future slide -complications: addisonian crisis (a life-threatening emergenc caused by insufficient adrenocortical hormones or a sudden sharp decrease in these hormones, triggered by stress, the sudden withdrawal of corticosteroids hormone therapy, adrenal surgery, or sudden pituitary gland destruction, manifestations include hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, confusion, nausea, vomiting, diarrhea, and pain in the abdomen, lower back, or legs -diagnostic studies: cortisol, ACTH stimulation test, ECG, CT, MRI -treatment: focused on managing the underlying cause, hormone therapy, saline and dextrose to reverse hypotension adn electrolyte imbalances -nursing implementations: monitor pt fluid and electrolyte balances, assess VS, establish baseline mental status, VS, and weight, H&P, note changes in BP, weight gain, weakness, or other manifestations of Cushing syndrome, protect against exposure to infection and assist with daily hygeine, protect pt from noise, light, temperature extremes, and any other environmental stressors, recognize the need for extra medication and techniques for stress management,help pt maintain hormone balance while managing medication regimen, teach pt about S&S of corticosteroid deficiency and excess (Cushing syndrome) and to report those signs to their HCP so the dose can be adjusted, critical that the pt wear an identification bracelet and carry a wallet card so that appropriate therapy can be initiated in case of emergency, provide verbal instructions and handouts about medications, insruct those using mineralocorticoids how to take their BP, increase salt intake, and report any significant changes to their HCP, pt should carry around an emergency kit at all times (100 mg of IM hydrocortisone, syringes, and instructions for use), instruct pt and significant others how to give an IM injection in case the hormone therapy cannot be taken orally, have the pt verbalize instructions and practice IM injections with saline -pts who take their medications consistently can anticipate a normal life expectancy

Hospice Care

-provides compassion, concern, and support for the dying, persons in the last phase of a terminal disease so that they might live as fully and as comfortable as possible -provide care with an emphasis on symptom management, advanced care planning, spiritual care, and family support -provided once a person decides to forgo curative treatments -emphasize palliative rather than curative care, and quality rather than quantity of life -admission to a hospice program has two criteria: the pt must desire the services and agree in writing that only hospice care (and not curative care) can be used to treat the terminal illness, pts can withdraw from the program at any time and can receive care for other health problems that begin after starting hospice, and the pt must be considered eligible for hospice

Pain Assessment

-regularly screen all pts for pain and, when present, perform a more thorough pain assessment -the goals of nursing pain assessment are to describe the pt's pain experience in order to identify and implement appropriate pain management techniques and identify the pt's goal for therapy and resources for -self management -elements of a pain assessment: recognize other words pts may use for pain (soreness, aching), pain onset (duration, when the pain started, pain pattern, breakthrough pain, end-of-dose failure), location (describe the site(s) of pain, point to a painful area on the body, or mark painful areas on a pain map), intensity (severity, pain scales (numeric, verbal descriptor, thermometer scale, Wong-Baker FACES Pain Rating), quality (nature or characteristics of pain), associated symptoms (anxiety, fatigue, depression, ask about activities and situations that increase or decrease pain), management strategies (what the pt is currently using or used before to treat pain and the outcomes of these methods), impact (influence on the pt's quality of life and functioning, including mood, sleep, enjoyment of life, interaction of others, performing work and household duties, and engaging in social and physical activities), pt's beliefs, expectations, and goals (influence responses to pain and pain treatment) -documentation: initial pain assessment, treatment, and reassessment -reassessment: depends on pain severity, physical and psychosocial condition, type of intervention and risks of adverse effects, and institutional policy

SIADH (Syndrome of Inappropriate Antidiuretic Hormone)

-results from abnormally high production or sustained secretion of ADH -ADH is released despite normal or low plasma osmolarity -characterized by fluid retention, serum hypoosmolality, dilutional hyponatremia, hyopchloremia, concentrated urine in the presence of normal or increased intravascular volume, and normal renal function -occurs more commonly in older adults -various causes but the most common cause is malignancy, especially small cell lung cancer -clinical manifestations: muscle cramping, pain, and weakness, thirst, dyspnea on exertion, and fatigue, low urine output, increased body weight, vomiting, abdominal cramps, muscle twitching, seizures, cerebral edema, lethargy, confusion, headache, coma -diagnostic studies: simultaneous measurements of urine and osmolality -assessment: be alert for low urine output with a high specific gravity, sudden weight gain without edema, decreased sodium level, monitor I&O, VS, heart and lung sounds, observe for signs of hyponatremia -treatment: directed at the underlying cause, medications that stimulate the release of ADH should be avoided or d/c, fluid restriction, daily weights, position HOB flat or elevated no more than 10 degrees to enhance venous return to the heart and increase left atrial filling pressure, reducing the release of ADH, frequent turning, repositioning, and ROM exercises are important to maintain skin integrity and joint mobility, protect the pt from injury because of possible alterations in mental status, implement seizure precautions, provide frequent oral care and distractions, vasopressin receptor antagonists (tolvaptan (Samsca) and conivaptan (Vaprisol)) are used to treat euvolemia-hyponatremia in hospitalized pts, demeclocycline (Declomycin) blocks the effect of ADH on the renal tubules, resulting in a more dilute urine, teach pt to supplement the diet with sodium and potassium, especially if also using loop diuretics, teach pt the symptoms of fluid and electrolyte imbalances, especially those involving sodium and potassium

Upper GI Bleeding

-severity depends on whether the origin is venous, capillary, or arterial, a massive bleed is a loss of more than 1500 mL of blood or 25% of intravascular blood volume -the longer the passage of blood throughout the intestines, the darker the stool color because of the breakdown of hemoglobin and the release of iron -esophageal origin: most likely due to chronic esophagitis, Mallory-Weiss tear, or esophageal varices, chronic esophagitis can be caused by GERD, the ingestion of drugs irritating the mucosa, alcohol, and smoking -stomach or duodenal origin: bleeding peptic ulcers account for 40% of upper GI bleeding, drugs are a major cause, stress-related mucosal disease (SRMD), also called physiologic stress ulcers, occur in pts that have had severe burns, trauma, or major surgery, there is either diffuse superficial mucosal injury or discrete deeper ulcers in the fundus and body portions of the stomach -diagnostic studies: endoscopy, angiography, CBC, BUN, serum electrolytes, PT, PTT, liver enzymes, ABGs, and a type and crossmatch for blood transfusions, all vomitus and stool should be tested for gross and occult blood -assessment: history of events leading up to bleeding episode is deferred until after emergency care is initiated,physical exam should focus on early identification of S&S of shock (tachycardia, weak pulse, hypotension, cool extremities, prolonged capillary refill, and apprehension), monitor VS every 15-30 min,thorough abdominal exam, note the presence or absence of bowel sounds, level of consciousness, VS, skin color, capillary refill, abdomen for distention, guarding, and peristalsis, history of previous bleeding, previous blood transfusions received and any reactions to them, any other illnesses or medications that may contribute to bleeding or interfere with treatment, religious preferences that prohibits the use of blood or blood products -treatment: infusion of saline and blood products, supplemental oxygen to increase blood O2 saturation, urine output via an indwelling catheter to assess output hourly, endoscopy and endotherapy, surgical intervention is indicated when bleeding continues regardless of therapy provided and when the site of the bleeding has been identified, empiric PPI therapy with high-dose IV bolus and subsequent infusion is started before the endoscopy during the acute phase of the GI bleed, drugs are used to decrease bleeding, decrease HCl acid secretion, and neutralize the HCl acid that is present, instruct at-risk pt to avoid gastric irritants, emphasize the importance of treating an URI immediately, as coughing or sneezing can increase pressure on the already fragile varicies and may result in major hemorrhage, approach pt in a calm manner to reduce anxiety, teach how to avoid future bleeding episodes, emphasize the importance to adhering to therapy

End-of-Life Care

-the final phase of a pt's illness when death is imminent -services related to death and dying, focusing on the physical and psychosocial needs for the pt and the pt's family -goals for EOL care are to provide comfort and supportive care during the dying process, improve the quality of the pt's remaining life, help ensure a dignified death, and provide emotional support to the family -physical manifestations: as death slowly approaches, metabolism is reduced and the body gradually slows down until all functions end, respiratory changes are common at the end of life(rapid or slow, shallow, and irregular (Cheyne-Stokes respirations, alternating periods of apnea and deep, rapid breathing), wet and noisy breath sounds (death rattle, caused by mouth breathing and accumulation of mucus in the airways) -psychosocial manifestations: overwhelmed, fearful, powerless, and fatigued, the family may have a hard time accepting the terminal diagnosis and the fact that there is no cure, the pt's needs adn wishes must be respected, pts need time to think about and express their feelings) -bereavement and grief: bereavement is the state of loss, the period following death of a loved one during which grief is experienced and mourning occurs, grief is the reaction to the loss -the manner is which a person grieves depends on factors such as the relationship with the person who has died, physical and emotional coping resources, concurrent life stresses, cultural beliefs, personality, physical and mental health, economic resources, religious influences or spiritual beliefs, family relationships, social support, and time spent preparing for the death -spiritual needs: beliefs, values, and practices that relate to the search for existential meaning and purpose and that may or may not include a belief in a higher power, many times at the end of life pts questions their beliefs about a higher power, their journey through life, religion, and an afterlife

Meniscus Injury

-the menisci are crescent-shaped pieces of fibrocartilage in the knee, but they are also found in other joints -injuries are closely associated with ligament sprains common among athletes in sports such as baseball, football, soccer, and hockey, as these activities produce rotational stress when the knee is in varying degrees of flexion and the food is planted or fixed, a blow to the knee can cause the meniscus to be sheared between the femoral condyles and the tibial plateau, resulting in a torn meniscus, people who work in occupations that requires squatting or kneeling and older pts may be at risk for degenerative tears -meniscus injuries alone do not usually cause significant edema because most of the cartilage is avascular, however an acutely torn meniscus may be suspected when localized tenderness, pain, and effusion are noted, pain is elicited by flexion, internal rotation, and the extension of the knee (McMurray's test), the pt may feel that the knee is unstable and often reports that the knee clicks, pops, locks, or gives way, quadriceps atrophy is usually evident if the injury has been present for some time, traumatic arthritis may occur from repeated meniscus injury and chronic inflammation -MRI is beneficial in confirming the diagnosis before arthroscopy, the degree of knee pain and dysfunction, occupation, sport activities, and age may affect the pt's decision to have or postpone surgery -nursing interventions: teach athletes to do warm-up exercises, the knee should be examined within 24 hours after injury, initial care involves application of ice, immobilization, and weight bearing as tolerated with crutches, most injuries are treated in an outpt setting, use of a knee brace or immobilizer during the first few days after the injury protects the knee and offers some pain relief, after acute pain has decreased PT can help the pt regain knee flexion and muscle strength to assist in returning to full function, surgical repair or excision of part of the meniscus (meniscectomy) may be necessary, meniscal surgery is performed by arthroscopy, pain relief may include NSAIDs or other analgesics, rehabilitations occurs soon after surgery, including quadriceps and hamstring strengthening exercises and ROM, when the pt's strength is back to its preinjury level normal activities may be resumed

Amputation

-the removal of a body extremity by trauma or surgery -most are performed due to PVD (peripheral vascular disease), especially in older pts with DM, but also because of trauma and thermal injuries, tumors, osteomyelitis, and congenital limb disorders, pain may be present but it's not usually the primary reason for amputation -diagnostic studies: depend on the underlying problem that makes the amputation necessary, may include CBC, vascular tests, like arteriography, Doppler studies, and venography -if the amputation is elective, carefully assess the pt's general health, chronic illnesses and infection are important considerations before performing an amputation, help the pt and caregiver understand the reasoning for the amputation and assure them that rehabilitation can result in an active, useful life, if it is an emergency amputation the physical and emotional management of the pt is more complicated -the goal is to preserve extremity length and function while removing all infected, pathologic, or ischemic tissue, the type of amputation depends on the reason for the surgery, a closed amputation is performed to create a weight-bearing residual limb (stump), disarticulation is an amputation performed through a joint, a Syme's amputation is a form of disarticulation at the ankle, an open amputation leaves a surface on the residual limb that is not covered with skin to control actual or potential infection, the wound usually closed later by a second procedure or closed by skin traction surrounding the residual limb, called a guillotine amputation -nursing implementations: teach pts with causative illnesses to examine their lower extremities daily for signs of potential problems, instruct the pt and caregiver to report changes in the feet or toes to their HCP, including changes in the skin, color or temperature, decrease or absence of sensation, tingling, burning pain, or lesions, instruct in proper safety precautions for recreational activities and potentially hazardous work, recognize the tremendous psychologic and social implications of an amputation, use therapeutic communication to assist the pt and caregiver through this process to arrive at a realistic attitude about the future, tell the pt that the amputated limb may feel like it is still present after surgery, called phantom limb sensation, prosthetic fitting, preferably delayed, is a good choice for above the knee or below the elbow amputations, older adults, debilitated individuals, and those with infection, but not all pts are candidates for prostheses, before discharge instruct the pt and caregiver in residual limb care, ambulation, prevention of contractures, recognition of complications, exercise, and follow-up care, when healing has occurred satisfactorily and the residual limb is well molded the pt is ready for fitting of the prosthesis, upper limb amputations may be more devastating for lower limb amputations because of the enforced dependency being depressing or frustrating

Rotator Cuff Injury

-the rotator cuff is a complex of 4 muscles in the shoulder: the supraspinatus, infraspinatus, teres minor, and subscapularis muscles, all acting to stabilize the humeral head in the glenoid fossa while assisting with the ROM of the shoulder joint and rotation of the humerus -a tear in the rotator cuff may occur as a gradual, degenerative process resulting from aging, repetitive stress (especially overhead arm motions), or injury to the shoulder while falling, can tear as a result of sudden adduction forces applied to the cuff while the arm is held in abduction, in sports, repetitive overhead motions, such as swimming, weight lifting, and swinging a recquet (tennis, raquetball) often cause injury, other causes include falling onto an outstretched arm and hand, a blow to the upper arm, heavy lifting, or repetitive work motions -clinical manifestations: shoulder weakness and pain and decreased ROM, pts usually experiences severe pain when the arm is abducted between 60 and 120 degrees, the drop arm test (the arm falls suddenly after the pt is asked to slowly lower the arm to the side after it has been abducted 90 degrees) is another sign of rotator cuff injury, an x-ray alone does not usually diagnose, a tear can usually be confirmed by an MRI -treatment: a partial teat can be treated with rest, ice, heat, NSAIDs, corticosteroid injections into the joint, ultrasound, and PT, surgical repair may be necessary if the pt does not respond to conservative therapy, most surgical repairs are performed as outpt procedures through an arthroscope, if the tear is extensive an acromioplasty (surgical removal of part of the acromion to relieve compression of the rotator cuff during movement) is done, a sling or shoulder immobilizer may be used directly after surgery to limit shoulder movement but the shoulder should not be immobilized for too long because "frozen" shoulder or arthrofibrosis may occur, pendulum exercises and PT begin the first post-op day, restrictions for lifting weights are usually given, with full recovery taking up to 6 months

Liver transplantation

-therapeutic option for those with end-stage liver disease or localized cancer -liver disease r/t chronic viral hepatitis is the leading indication for liver transplantation, other indications include congenital biliary abnormalities, inborn errors of metabolism, liver cancer, sclerosing cholangitis, acute liver failure, and chronic end-stage liver disease -not recommended for the pt with widespread malignant disease -candidates must go through rigorous presurgery screening to confirm the diagnosis of end-stage liver disease and to assess for other co-morbid conditions that may affect the pt's surgical outcome, including H&P, lab testing (CBC, liver function tests), cardiac and pulmonary evaluations, endoscopy, CT, and psychologic testing, potential recipients receive education on cigarette smoking and alcohol abstinence -contraindications for transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug or alcohol abuse, and inability to comprehend or comply with the rigorous posttransplant course -performed using both deceased and live donor livers, a donor liver may be divided into two parts and implanted into two recipients -post-op complications include bleeding, infection, and rejection, but the liver is subject to a less aggressive immunologic attach than other organs -immunosuppressive therapy includes a combination of corticosteroids, a calcineurin inhibitor, and an antiproliferative agent -approximately 78% of pts survive more than 5 years after liver transplant, long-term survival depends on the cause of the liver failure, -the first two months are critical for monitoring for infection, infection can be viral, fungal, or bacterial, fever may be the only sign of infection, emotional support and teaching for pt and caregiver are essential

Table 1-1 Healthy People 2020

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Table 2-1 Erikson's Developmental Tasks

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Table 39-13 Liver Function Tests

Ammonia, PT, INR, vitamin K, AST, ALT

Table 62-7 Diagnostic Studies Musculoskeletal System

CT, myelogram with or without contrast, MRI, bone scan, Rheumatoid factor, ESR, ANA, EMG, Doppler

Table 42-10 Drug Therapy for Gastroesophogeal Reflux Disease (GERD) and Peptic Ulcer Disease (PUD)

PPI, H2 receptor blockers, cholinergic

Table 62-6 Assessment Abnormalities (Musculoskeletal System)

ataxic gait, atrophy, contracture, crepitation, dislocation, ganglion cyst, tennis elbow, paresthesia, subluxation, knock-knees, bowlegs

Table 42-3 Infections and Inflammation of the Mouth

gingivitis, oral candidiasis, herpes simplex, stomatitis

Hernias

protrusion of the viscus (internal organ such as the intestine) through the abnormal opening or a weakened area in the wall of the cavity in which it is normally contained -may occur in any part of the body but it usually occurs within the abdominal cavity -hernias that easily return to the abdominal cavity are reducible, the hernia that can be reduced manually or may reduce spontaneously when the person lies down -if the hernia cannot be placed back into the abdominal cavity it is known as irreducible or incarcerated, the intestinal flow may be obstructed in this case, when the hernia is irreducible and the intestinal flow and blood supply are obstructed, the hernia is strangulated, resulting in an acute intestinal obstruction -inguinal hernia: most common type, occurs at the point of weakness in the abdominal wall where the spermatic cord (men) or the round ligament (women) emerges, more common in men -femoral hernia: where there is a protrusion through the femoral ring into the femoral canal, appears as a bulge below the inguinal ligament, easily becomes strangulated, occurs more often in women -umbilical hernia: occurs when the rectus muscle is weak (as with obesity) or the umbilical opening fails to close after birth -ventral or incisional hernia: due to weakness of the abdominal wall at the site of a previous incision, occur most commonly in pts who are obese, have had multiple surgical procedures in the same area, or have had inadequate wound healing because of poor nutrition or infection -clinical manifestations: may be readily visible, especially when the person tenses the abdominal muscles, may be some discomfort as a result of the tension, if the hernia becomes strangulated the pt will have severe pain and symptoms of a bowel obstruction (vomiting, cramping abdominal pain, distention), strangulated hernias or inflamed, painful hernias that cannot be reduced require emergency surgery -diagnosis: based on H&P findings -treatment: laproscopic surgery is treatment of choice, surgical repair of a hernia, a herniorrhaphy, is usually an outpt procedure, reinforcement of the weakened area with wire, fascia, or mesh is known as a hernioplasty, strangulated hernias are treated immediately with resection of the involved area or a temporary colonostomy so that necrosis and gangrene do not occur -nursing interventions: after a repaid the pt may have difficulty voiding, measure I&O and observe from distended bladder, scrotal edema is a painful complication after an inguinal hernia repair, a scrotal support with application of an ice bag may help relieve pain and edema, encourage deep breathing, but not coughing, teach pts to splint the incision and keep their mouths open when coughing or sneezing are unavoidable, the pt may be restricted from heavy lifting for 6-8 weeks

Table 39-12 Gastrointestinal System Diagnostic Studies

upper GI, barium enema, EUS, EGD, colonoscopy, sigmoidoscopy, amylase, lipase, livery biopsy, stool culture