HESI Final

Surgical/Pain

-Surgery performed under aseptic conditions Pre-op care/teaching Care provided from time the client and family make decision to have surgery until the client is taken to the operative suite -Teaching IS and deep breathing -Having pain plan, full history, witnessing consent -Teach early way before event how to recover and what they can expect -You can't obtain consent, only witness it -PROVIDER must answer their questions -Anything of value like rings, earrings, etc. send home with family -Go over proper labs, CBC BMP type of blood -Allergies to medications -Drug/alcohol history Key components of teaching plans -Regulations concerning valuables, jewelry, dentures, and hearing aids -Food and fluid restrictions such as NPO after midnight; clear liquids may be given up to 6 hours before surgery for the no-risk client -Invasive procedures such as urinary catheters, IVs, nasogastric tubes, enemas, douches -Pre-op medications -OR, transportation, skin prep, postanesthesia -Postoperative procedures: respiratory care, activity, pain control, dietary restrictions, ICU orientation Checklist information -Informed consent, surgical consent, signed by the surgeon and client, witnessed by nurse -Site marked by person performing surgery. Before incision is initiated, all team members confirm identity, procedure, site of surgery, and consents. -History and physical exam noted in chart -Chest radiograph, ECG, urinalysis have been performed when prescribed -Hemoglobin, hematocrit,electrolytes, glucose, and type/crossmatch for blood have been determined -ID band on client and allergies noted -Client ID info is clear -Contact lenses, glasses, dentures, partial plates, wigs, jewelry, artificial eyes, makeup, nail polish have been removed -Client has voided -Hospital gown -Vital signs -Premeds have been given -Skin prep has been performed -Signature of nurse certifies completion Intraoperative care (priorities) From the time client is received in operative suite until admission to the PACU, an OR nurse is in charge of care -Skin break down -Patient safety -Positioning of patient -TIME OUT -Body alignment -Apsesis -Temperature (can have hyperthermia to general anesthesia) -Respiratory depression with general anesthesia; vomiting/nausea, hypothermia, malignant hyperthermia, getting organs to wake back up, bowel movement after -Bronchoscopy is looking at upper respiratory tract = ASPIRATION, BLEEDING. -Gag reflex before they can eat again Maintain safety -Conduct client ID: right client, right procedure, right anatomic site -Ensure sponge, needle, instrument counts are accurate. Counts are done and verified and documented by two personnel before, during, and closing incisions and end of surgery -Position client during procedure to prevent injury -Strictly adhere to asepsis -Ensure adequate functioning suction setups are in place -Take responsibility for correct labeling, handling, and deposition for any and all specimens Monitor physical status -If excessive blood loss occurs, calculate effect on client -Report changes in pulse, temp, respirations and BP to surgeon -Position client Provide psychological support -Emotional support to client and family immediately -Arrange with physician to provide info to family -Communicate emotional state of client to other health care team members Post-op care (priorities) From admission to PACU, until client has recovered -ABCs -Can they protect own airway? breathing right? -Circulation, are we bleeding? -Pain; give narcotics -LOC -Has bowel woken up? -DVT prevention -IS, deep breathing, mobility -PCA -Assess for respiratory rate, HR, BP, pain level -ABCs switch to BAC (breathing, airway, circulation). Because we are paralyzing their diapgrahm, we need to make sure breathing pattern is regular, then we want to make sure they are clearing secretions or having any airway issues and then circulatory issues. -On arrival to PACU, client assessed for vital signs, LOC, skin color, dressing location and condition, IV fluids, drainage tubes, position, and O2 saturation levels -When client is stabilized, then client is transferred to ICU Immediate post-op nursing care -Monitor for signs of shock and hemorrhage: hypotension, narrow pulse pressure, rapid weak pulse, cold moist skin, increased capillary filling time, and decreased urine output -Positioning client on side to prevent aspiration and to allow client to cough out airway; side rails up at all times -Provide warmth with blanket -Manage N/V with antiemetic and NG suctioning -Manage pain with IV analgesics

Diabetes

A metabolic disorder characterized by high levels of glucose resulting from defects in insulin secretion, insulin action, or both. Affects metabolism of protein, carbohydrate, and fat 3 P's: Polyuria (urinate more than usual), Polydipsia (very thirsty), Polyphagia (very hungry) Hyperglycemia HOT AND DRY, SUGAR IS HIGH Signs and symptoms -Blurred vision -Weakness -Weight loss -Syncope Nursing action -Encourage water intake -Check blood glucose frequently -Assess for ketoacidosis (urine ketones, urine glucose, administer insulin as directed) Hypoglycemia COLD AND CLAMMY, NEED SOME CANDY Signs and symptoms -Headache -Nausea -Sweating -Tremors -Lethargy -Hunger -Confusion -Slurred speech -Tingling around mouth -Anxiety, nightmares Nursing action -Usually occurs rapidly and is potentially life threatening; treat immediately with complex carbohydrates (fast-acting carbs such as one tube glucose gel, 120-180 mL fruit juice or cola 10-16 jelly beans, 10 gum drops, 3 pieces of hard candy, 5-7 pieces life savers) -Check blood glucose (may seize if less than 40) Insulin therapy Rapid-acting -Lispro & Aspart -Glulisine -Onset: 15-30 min -Peak: 30-90 min -Duration: 3-5 hr -Give within 15 min of a meal (with meal) -Often used with long-acting insulin Short-acting -Regular insulin -Onset: 30-60 min -Peak: 30-90 min -Duration: 5-7 hr -Regular insulin may be given IV Intermediate-acting -Isophane insulin (NPH INSULIN) -Onset: 1-2 hr -Peak: 4-6 hr -Duration: 14-24 -Not given IV -mixtures combine rapid-acting regular insulin with intermediate-acting NPH insulin Long-acting -Glargine (Lantus) -Detemir -Onset: 1 hour -Peak: 14-20 hr -Duration: 24 hour -Not given IV -Give once daily (SUBQ at bedtime) -Do not shake solution, do not mix other insulins with Glargine Teaching -Vision screenings -No infections of respiratory tract -Low cholesterol, low fat diet -Fiber intake (make sure they are not constipated; at risk for bowel obstruction) -Skincare -Feet; worry about ulcers from diabetes from lack of blood flow getting to feet. -Worry about infections -Frequent UTIs (secondary to having high blood sugar) -Always have closed toed shoes on, don't wear tight socks -Remove hazards in home LOW FAT, LOW CHOLESTEROL, HIGH FIBER DIET

GU/Renal

BPH Enlargement or hypertrophy of the prostate -Tends to occur in men over 40 years of age Intervention required when symptoms of obstruction occur 3 treatment approaches: -Active surveillance (WATCHFUL WAITING) -Drug therapy with 5-alpha reductase inhibitors such as finasteride and alpha-adrenergic receptor blockers (tamsulosin) -Surgery (TURP) Prostate is removed by endoscopy (no surgical incision is made) allowing for shorter hospital stay Nursing assessment -Increased frequency of voiding, with a decrease in amount of each voiding -Nocturia -Hesitancy -Terminal dribbling -Decrease in size and force of stream -Acute urinary retention -Bladder distention -Recurrent UTIs Nursing plans and interventions -Info concerning pain from bladder spasms that occurs post-operatively -Maintain patent urinary drainage system (large 3 way indwelling catheter with a 30 mL balloon) to decrease the spasms -Provide pain relief= analgesics, narcotics, and antispasmodics -Check urinary drainage system for clots -Observe color and content of urinary output (normal drainage is reddish pink, clearing to light pink within 24 hours after surgery. Some small to medium-sized clots may be present -Monitor for bright-red bleeding with large clots and increased viscosity -Monitor vital signs frequently for indication of hemorrhage or hypovolemic shock -Monitor hemoglobin and hematocrit for pattern of decreasing values that indicates bleeding -Inform client that burning on urination and urinary frequency are usually experienced during first postop week -Sterility may occur after surgery -AMBULATE first postop day, if possible. Discharge instructions: -Continue to drink 12 to 14 glasses of water a day -Avoid constipation, straining -Avoid strenuous activity, lifting, intercourse, and engaging in sports during first 3 to 4 weeks after surgery Urinary stasis --> leads to reflux up into kidneys --> get UTI --> kidney stones, infection NOCTURIA (not falling, getting up at night) CBI USED TO IRRIGATE BLADDER FOR BPH -Keep foley. bladder spasms frequently occur after TURP -Use only sterile saline for bladder irrigation (MUST BE ISOTONIC) -FOR BLOOD CLOT, MANUALLY TRY TO IRRIGATE IT AKI (Acute Kidney Injury) A potentially reversible disorder; rapid loss of kidney function accompanied by rise in serum creatinine and/or reduction in urine output For adults, total daily urine output ranges between 1500-2000 mL depending on amount and type of fluid intake occurs when metabolites accumulate in the body and urinary output changes 3 phases 1. oliguric phase: less than 400 mL -Increased BUN and creatinine -Increased potassium -Decreased sodium -Decreased pH -Fluid overload -High urine specific gravity (Greater than 1.02) -LIMIT PROTEIN INTAKE 2. Diuretic phase: daily urine output above 400 mL -Decreased fluid volume -Decreased potassium -Further decrease in sodium -low urine specific gravity (less than 1.02) -Output may be as much as 10 L per day 3. Recovery phase: Return of GFR 70 to 80% of normal values -Diagnostics return to normal Nursing Assessment -History of nephrotoxic drugs [NSAIDs, ACE inhibitors, ARBs] -Alterations in urinary output -Edema, weight gain -Change in mental status -Hematuria -Dry mucous membranes -Drowsiness, headache, muscle twitching, seizures Nursing plans and interventions -Monitor I&O; fluid restriction during oliguric phase -Weigh daily; in oliguric phase, client may gain up to 1 lb/day -Document and report any change in fluid volume status -Nutritional therapy -Adequate protein intake (0.6 to 2 g/day) -Monitor lab values of serum and urine to assess electrolyte ESPECIALLY HYPERKALEMIA and ECG changes -Potassium restriction and measures to lower potassium --- use Kayexalate -Restrict sodium -Assess LOC for subtle changes -Prevent cross infection - CKD -Build up in different electrolyte toxins, phosphorus (NEED TO TAKE PHOSPHORUS BINDERS) UTI Infection or inflammation at any site in urinary tract Nursing Assessment -Signs of infection, including fever and chills -Urinary frequency, urgency, or dysuria -Hematuria -Pain at the costovertebral angle -Elevated serum WBCs (greater than 10,000) -Disorientation or confusion in older adults Nursing plans and interventions -Administer antibiotics -Complete full medication regimen -encourage fluid intake of 3000 mL of fluid/day -Maintain I&O -Administer mild analgesics -Encourage client to void every 2 to 3 hours to prevent residual urine from stagnating in bladder -Avoid unnecessary catheterization -Remove indwelling catheters within 24 to 48 hours of insertion during hospitalizations -Routine perineal hygiene especially with use of bedpan or if fecal incontinence is present

Cardiac

CAD (Coronary artery disease) Angina is main symptom. -Angina at rest (UNSTABLE ANGINA); can't predict, doesn't match patterns, happens even when sitting. -If not relieved by nitroglycerin, patient might have heart attack. -Tell patient to call 911, sit down, and wait for EMS. -3 nitroglycerin pills separated by 5 minutes, then call 911. Medications -Beta blocker -Aspirin to reduce risk of MI -Statins AT NIGHT -Ace inhibitors -If RAAS system not functioning, may put on Arbs or CCB... African Americans can't take ace or arbs for hypertension. When go into ER for chest pain, first thing to do is EKG. Medical interventions = PTCA (A ballon catheter is repeatedly inflated to split or fracture plaque, and the arterial wall is stretched, enlarging the diameter of the vessel.) CHF (Congestive heart failure) Inability of the heart to pump enough blood to meet the tissue's oxygen demands key assessment findings: Edema, fluid overload (JVD, crackles) LEFT-SIDED heart failure = LUNGS. ONLY PULMONARY. RIGHT-SIDED heart failure = REST OF BODY. Ascites, JVD, Peripheral edema. -Venous system getting congested Medications -Digoxin (for contracility) -Diuretics to get rid of fluid -Aces, arbs, diuretics, nitrates, aspirin, statins. -If giving Lasix, MONITOR POTASSIUM!! Too much potassium can make heart stop. Nursing Assessment: Left sided HF: -Pulmonary edema -Dyspnea -Orthopnea -Crackles -Cough -Fatigue -Tachycardia -Anxiety -Restlessness -Confusion -Paroxysmal nocturnal dyspnea Right sided HF: -Peripheral edema -Inability of right ventricle to pump blood out to lungs -Peripheral edema -Weight gain -Distended neck veins -Anorexia, nausea -Nocturia -Weakness -Hepatomegaly -Ascites Enlargement of ventricles indicated by chest radiograph Brain natriuretic peptide (BPN) test measures levels of protein in heart and blood vessels. High BPN levels occur with HF. Nursing plans and interventions -Monitor vital signs at least every 4 hours for changes -Monitor apical HR with vital signs to detect dysrhythmias or abnormal heart sounds such as S3 or S4 Assess for hypoxia -Restlessness -Tachycardia -Angina Auscultate lungs for indication of pulmonary edema (wet sounds or crackles) -Administer oxygen as needed -Elevate head of bed to assist with breathing -Observe for signs of edema -Limit sodium intake -Elevate lower extremitiees while sitting -Check apical HR before administration of digitalis; withold medicaiton and call doctor if rate is less tshan 60 -administer diuretics in morning if possible -provide periods of rest after periods of activity Hypertension Persistent seated BP levels equal to or greater than 140/90 mm Hg Kills the kidneys and makes heart work too hard. Reason for heart failure and renal failure. Work on widening the pipes (CCB and nitrates) Work on dropping the volume (loop diuretics and thiazide diuretics) Work on changing way pump works (increasing contractility or giving beta blocker) Nursing assessment BP equal to or greater than 140/90 mm Hg on two separate occasions -Obtain BP while client is lying down, sitting, and standing. -Assess for headache, edema, nocturia, nosebleeds, and vision changes -Assess level of stress and source of stress -Assess personality type Nursing plans and interventions DIET= LOW-SALT, LOW-FAT, LOW CHOLESTEROL

Respiratory

COPD Chronic lung disease that includes emphysema and chronic bronchitis, characterized by bronchospasm and dyspnea (shortness of breath). Damage to lung is not reversible and increases in severity. Exposure to tobacco smoke is primary cause in US. Amount of oxygen in blood decreases (hypoxia) and CO2 in blood increases (hypercapnia) = chronic respiratory acidosis. Nursing assessment -Changes in breathing pattern (increase in rate with decrease in depth) -Overinflation of lungs causes rib cage to remain partially expanded (BARREL CHEST) -Generalized cyanosis of lips, mucous membranes, face, nail beds ("blue bloater") -Cough (dry or productive) -Higher CO2 than average -Low oxygen less than 90-92% -Decreased breath sounds -Coarse crackles in lung fields that tend to disappear after coughing, wheezing -Dyspnea, orthopnea -Poor nutrition, weight loss -Activity intolernace -Anxiety concerning breathing; manifested by anger, fear of being alone, fear of not being able to catch breath Nursing plans and interventions -Teach client to sit up and bend slightly forward to promote breathing: TRIPOD position (arms resting on overbed table or knees) -Teach diaphragmatic and pursed lip breathing -Administer oxygen at 1 to 2 L per nasal cannula -Pace activities to conserve energy -Maintain adequate dietary intake (small, frequent meals. Increase calories and protein, but do not overfeed) -Dietary supplements: Vitamin C for people who continue to smoke tobacco. Magnesium and calcium to help with muscle contraction and relaxation. Routine monitoring of magnesium and phosphorus levels because bone mineral density (osteoporosis). -Provide adequate fluid intake -Fluids should be taken between meals (rather than with them) to prevent excess stomach distention and to decrease pressure on diaphragm. -Relaxation techniques -Prevention of secondary infections -Smoking cessation ABC RULE: Airway, breathing, circulation. Change in mental status will happen as CO2 increases, they will get more sleepy. DO NOT DO INCENTIVE SPIROMETRY!! Inhaled steroids = Swish their mouth our or else they will get thrush. Pneumonia Inflammation of the lower respiratory tract Caused by: infectious agents High risk groups -Accumulated lung secretions (asthma, COPD, sickle cell anemia) -Cigarette smokers -Immobile -Immunosuppressed -Experiencing a depressed gag and/or cough reflex -Sedated -Experiencing neuromuscular disorders -Nasogastric/orogastric intubation -Hospitalized client Nursing assessment -Tachypnea: shallow respirators, often with use of accessory muscles -Abrupt onset of fever with shaking and chills -Productive cough with pleuritic pain -Rapid, bounding pulse Symptoms: -confusion -lethargy/malaise -anorexia -rapid respiratory rate -tachycardia -Pain and dullness to percussion over affected lung area Bronchial breath sounds, crackles (heard over areas of density or consolidation)!! -"E" to "A" changes in lungs -Tactile fremitus: can feel chest vibrations when client says "99" -Chest radiograph indication of infiltrates with consolidation or pleural effusion -Elevated WBC count -ABG indication of hypoxemia -On pulse oximetry, a decrease in oxygen Nursing plans and interventions -Assess sputum for volume, consistency, color, clarity, and distinct odors like Pseudomonas -Assist client to cough productively by: deep breathing every 2 hours (incentive spirometer), humidity to loosen secretions, suctioning the airway, chest physiotherapy -Provide fluids up to 3 L/day -Assess lung sounds before and after coughing -Assess rate, depth, and pattern of respirations regularly -Monitor ABG's: PO2 greater than 80, PCO2 less than 45 -Monitor oxygen saturation with pulse oximetry -Assess skin color -Assess mental status, restlessness, irritability (early signs of hypoxia) -Administer humidifed oxygen -Monitor temp regularly -Provide rest periods throughout day -Administer antibiotics as prescribed -Encourage to get pneumonia and annual flu vaccinations ABGs "ROME" Respiratory = Opposite Metabolic = Equal Diagnostics -Chest X-Ray -Sputum culture, sensitivity (When sputum changes from clear or white to yellow, green, brown = INFECTION) -ABGs -CBCs

Sensory

Cataract surgery INTRACRANIAL PRESSURE!! -Do not rub eye -Glasses should be worn during waking hours -Eye shield should be worn during sleeping hours -Avoid lifting objects over 5 lbs or anything that would increase IOP -Avoid straining ---- use stool softener! -Don't lie on operative side -Avoid getting water into the eye when showering -Monitor for infection

Musculoskeletal

Fracture Complete: break across entire cross section of bone Incomplete: break across only part of the bone Closed: no break in skin Open: broken bone protrudes through skin or mucous membranes (INFECTION) Greenstick: one side of bone is broken; other side is bent Transverse: break occurs straight across bone shaft Oblique: break occurs at an angle across the bone Spiral: break twists around the bone Comminuted: break has more than 3 fragments Nursing assessment S/S -pain, swelling, tenderness -Deformity, loss of functional ability -Discoloration, bleeding at the site through an open wound -Crepitus: crackling sound between two broken bones RISK FOR DEVELOPMENT OF A FAT EMBOLISM (fat globules migrate into bloodstream and combine with platelets to form emobli) IS GREATEST IN FIRST 36 HOURS OF FRACTURE -more common in long bones and pelvis -First symptom is confusion due to hypoxemia Hip fractures = thromboembolism is most common complication -Prevention - passive ROM exercises, use of elastic stockings, elevation of feet to increase venous return, low dose heparin therapy Observe client's use of assistive devices -Crutches: should be 2 to 3 finger widths between the axilla and top of the crutch; 3 point gait is most common. Advance both crutches and impaired leg at same time. Swings uninvolved leg ahead to crutches -Cane: placed on unaffected side. Top of cane level of greater trochanter. -Walker: Strength of upper extremity and unaffected leg is assessed and improved with exercises, if necessary. Client lifts and advances walker and steps forward Joint replacement Infection is concern post-operatively Nursing Assessment Pain not relieved by medication Poor ROM in affected joint Nursing plans and interventions Monitor incision site (assess for bleeding and drainage, assess suture line for erythema and edema, assess suction drainage apparatus for proper functioning, assess for signs of infection) Monitor functioning of extremity -Check circulation, sensation, and movement of extremity distal to replacement -Provide proper alignment of affected extremity -Provide abductor appliance or continuous passive motion device -Monitor I&O every shift, including suction drainage -Encourage fluid intake -Perform self-care activities Coordinate rehabilitation to increase client's mobility gradually -Get client out of bed as soon as possible -Keep client out of bed as much as possible -Keep abductor pillow in place while client is in bed (hip replacement) -Use elevated toilet seat and chairs with high seats for those who have had hip or knee replacements -Do not flex hip more than 9- degrees -Provide discharge planning that includes rehabilitation on an outclient basis as prescribed

Female cancer/Reproductive

Hysterectomy Hysterectomy is the surgical removal of the uterus CONCERN: BLEEDING. -Number of pads they have used; if going through more than 1 pad an hour, we are going to get concerned. THERE SHOULD BE LESS THAN.1 SATURATED PAD FOR 4 HOURS. -Capture blood and document or record how much there is. -Drainage, HR, BP, CBC -Skin color might change, pale Go into menopause because they do not have glands or organ that can secrete hormone Ovarian Cancer Cancer of ovaries can occur at all ages Malignant germ cell tumors are most common Nursing assessment -Asymptomatic in early stages -Laparotomy is primary tool for diagnosis and staging of the disease; ovarian cancer is surgically staged rather than clinically staged -Pelvic discomfort -Low back pain and leg pain -Weight change -Abdominal pain -Increased abdominal girth -Nausea and vomiting -Constipation -Urinary frequency Nursing plans and interventions -Provide care required for any major abdomainl surgery after lapartomy -Provide care required for chemotherapy -Support Breast cancer Cancer originating in breast Early detection is important to successful treatment Nursing assessment -Hard lump (not freely movable and not painful) -Dimpling of skin -Retraction of nipple -Alterations in contour of breast -Change in skin color -Change in skin texture -Discharge from nipple -Pain and ulcerations -Diagnostic tests include (mammogram and biopsy) Nursing plans and interventions -Assess lesion -Preoperative Post operative

Hepatic/Pancreatic/Biliary

Liver diagnostics If we concerned there is cancer or cirrhosis, we do liver biopsys-- worried about bleeding. Ability to clot. If person has liver issues and liver is what makes clotting factors, then bleeding issue. -MONITOR FOR BLEEDING after someone has liver biopsy. Cirrhosis/End stage liver When cirrhosis occurs, blood flow through the liver is blocked. This blockage causes an increase in the pressure in the main vein (the portal vein) that delivers blood from the digestive organs to the liver (which is why ascites happens) Jaundice, ammonia regulation, ability to clot. Ascites, PARACENTESIS. -Do paracentesis to alleviate or get rid of the ascites To bring ammonia levels down, we use Lactulose (patient has to poop!!) Liver itch- bilirubin build up causes the itch and jaundice. PARACENTESIS -done when a person has a swollen abdomen, pain or problems breathing because there is too much fluid in the abdomen (ascites). Normally, there is little or no fluid in the abdomen. Removing the fluid helps relieve these symptoms. The fluid may be examined to help find out what is causing the ascites. -Puncture, so we are worried about infection and bleeding!! Nursing assessment -History of alcohol, prescriptive and street drug use -Work history of exposure to toxic chemicals -Medication history of long-term use of hepatotoxic drugs -Family health history of liver abnormalities Physical findings: -weakness, malaise -Anorexia, weight loss -Palpable liver (early) -abdominal girth increases as liver enlarges -Jaundice -Fetor hepaticus (fruity or musty breath) -ASTERIXIS (hand flapping tremor that often accompanies metabolic disorders) -Mental and behavioral changes -Bruising, erythema -Dry skin, spider angiomas -Gynecomastia (breast development), testicular atrophy -Ascites, peripheral neuropathy -Hematemseis -Palmar erythema (redness in palms of hands) Clotting factors noted in lab fndings: -elevated bilirubin -aspartate aminotransferase (AST) -alanine aminotransferase (ALT) -Alkaline phosphatase -PT -ammonia -Decreased Hgb, Hct, electrolytes, potassium, sodium, and albumin Nursing plans and interventions -Eliminate causative agent -administer vitamin supplements (A, B, C, K) -Observe mental status frequently Avoid initiating bleeding and observe for bleeding tendencies -Avoid injections whenever possible -Use small-bore needles for IV insertion -Maintain pressure to venipuncture sites for at least 5 minutes -Use electric razor -Provide soft-bristle toothbrush and encourage careful mouth care -Check stools and emesis for frank or occult blood Prevent straining at stool -Administer stool softeners -Provide high fiber diet Provide special skin care -Avoid soap, rubbing alcohol, perfumed products -Apply moisturizing lotion or baby oil frequently -Observe skin for any lesions, including scratch marks -Turn frequently and provide lotion to exposed skin Monitor fluid and electrolyte status daily -Measure abdominal girth DIET = LOW SODIUM, LOW POTASSIUM, LOW FAT, HIGH CARBOHYDRATES If esophageal varices are present, esophagogastric balloon tamponade Pancreatitis Nonbacterial inflammation of the pancreas -Digestion of pancreas by it's own enzymes (trypsin) Nursing assessment -Continuous burning or gnawing abdominal pain -Recurring attacks of severe upper abdominal and back pain -Ascites -Steatorrhea, diarrhea -Weight loss -Jaundice, dark urine -S/S of Diabetes Nursing plans and interventions -Administer analgesics such as hydromorphone, fentanyl, annd mmorphine -administer pancreatic enzymes with meals or snacks. -Monitor stools for number and consistency to determine effectiveness of enzyme replacement -Teach client about consuming a bland, low-fat diet and to avoid rich foods, alcohol and caffeine -Monitor for S/S of diabetes

GI

PUD (Peptic Ulcer Disease) Ulceration that penetrates the mucosal wall of the GI tract H. Pylori treatment -Antibiotics -Proton pump inhibitors for acid suppression -Initial treatment is 7-14 days of triple-drug therapy with omeprazole, amoxicillin, and clarithromycin Lifestyle modifications -Avoid spicy foods, acidic foods & black pepper -Avoid substances that may stimulate acid secretion & delay healing (NSAIDs [aspirin, ibuprofen], alcohol, caffeine, chocolate, tobacco) -Reduce stress & rest, smoking cessation!!!! Could also happen due to acute medical crisis, familial tendency, or Blood Type O Complications Call HCP if: Gastrointestinal bleeding -Orthostatic hypotension -Tachycardia -Black stools -Coffe-ground emesis -Bright-red rectal bleeding -Fatigue -Pallor -Severe abdominal pain (report immediately, could be perforation) Perforation (always requires surgery) -Increased epigastric pain radiating to the back (relieved with antacids) -Nausea -Vomiting -Fever Peptic ulcer pain is relieved with food. Obstruction Nursing plans and interventions -Monitor color, quantity, consistency of stools and emesis; test for occult blood -Administer medications usually 1 to 2 hours after meals and at bedtime -Administer mucosal healing agents at least 1 hour before meals -Encourage small, frequent meals; no bedtime snacks; avoidance of beverages containing coffee Dumping syndrome may occur postoperatively (if uncontrolled bleeding, obstruction, or perforation occurs) -Occurs 5 to 30 min after eating -Vertigo, syncope, sweating, pallor, tachycardia, and hypotension -Minimized by small, frequent meals: high-protein, high fat, low-carb diet -Exacerbated by consuming liquids with meals; helped by lying down after eating Gallbladder If they have gallbladder disease, Stones = worried about acute pancreatitis -Stones may get into common bile duct --> occluding common bile duct --> liver failure or travel down and block pancreatic duct --> pancreatitis. S/S -Jaundice -High blood sugar and S/S of diabetes (but it's not, it's just pancreas can't do job because its blocked) if patient has stones, REMOVE gallbladder. -ERCP (look at all ducts to see if nothing is remaining Driven by fat and ability to digest fats well. The pancreas produces enzymes to help break down proteins, fats and carbohydrates. The gall bladder stores the bile that is produced by the liver. When needed, bile passes into the small intestine, where it breaks down fat Ostomies Strangulation of ostomy = not right color and doesn't look like it's getting blood to it = medical emergency. -should be moist and red/pink colored Ileostomy -small intestine -liquid Colostomy -large intestine -semi-solid form Crohn's From mouth to anus ("C"omplete.) Complete GI tract inflammation in GI tract Malabsorption issues, weight issues, nutritional deficit because of inflammation No cure, so treatment relies on medications to treat acute inflammation and maintain remission. -Surgery for clients who are unresponsive to medications or develop life-threatening complications (Total proctocolectomy where permanent ileostomy is formed) Nursing assessment -Abdominal pain (unrelieved by defecation), right lower quadrant -Diarrhea, steatorrhea (excretion of abnormal quantities of fat with the feces owing to reduced absorption of fat by the intestine), and weight loss, with client becoming emaciated -Constant fluid loss -Low grade fever -Perforation of the intestine occurring due to severe inflammation; constitutes a medical emergency -Anorexia related to pain after eating -Weight loss, anemia, malnutrition Nursing plans and interventions -Determine bowel elimination pattern and control diarrhea with diet and medication as indicated -Provide a nutritious, well-balanced, low-residue, low-fat, high-protein, high-calorie diet, with no dairy products -Administer vitamin supplements and iron -Advise client to avoid foods that are known to cause diarrhea, such as milk products and spicy foods -Advise client to avoid smoking, caffeinated beverages, pepper, and alcohol -Provide complete bowel rest with IV TPN if necessary -Monitor I&O and serum electrolytes -Weigh at least twice a week -Provide emotional support UC Colon and rectum where patient has ulcerations. -Use steroids to reduce inflammation, IV Methylprednisone -Pain medication and antibiotic to treat actual infection if they have it May lose enough blood; blood transfusions Disease that affects mucosa of large intestines and rectum, causing bowel to eventually narrow, shorten, and thicken due to muscular hypertrophy. Nursing assessment -Diarrhea -Abdominal pain and cramping -Intermittent tenesmus (anal contractions) and rectal bleeding -Liquid stools containing blood, mucus, and pus (may pass 10 to 20 liquid stools per day) -Weakness and fatigue -Anemia Nursing plans and interventions -Determine bowel elimination pattern and control diarrhea with diet and medication -Provide nutritious, well-balanced, low-residue, low-fat, high-protein, high-calorie diet, with no dairy products -Administer vitamin supplements and iron -Advise client to avoid foods that are known to cause diarrhea such as milk products and spicy foods -Advise client to avoid smoking, caffeinated beverages, pepper, and alcohol -Provide complete bowel rest with IV hyperalimentation if necesssary -Monitor I&O and electrolytes -Weigh at least 2x a week -Emotional support IBD (just consists of Crohn disease and UC)

Neuro

Parkinsons Change in affect (MASK expression) Very flat or blunted. Shuffling gait. Pill rolling at rest. Increased muscle rigidity Tremor at rest Slowness in movement Nursing assessment -Rigidity of extremities -Masklike facial expressions with associated difficulty in chewing, swallowing, and speaking -Drooling -Stooped posture and slow, shuffling gait -Tremors at rest, "pill-rolling" movement -Emotional lability -Increased tremors with stress or anxiety Nursing plans and interventions -Schedule activities later in day to allow sufficient time for client to perform self-care activities without rushing -Encourage activities and exercise. a cane or walker may be needed -Eliminate environmental noise, encourage client to speak slowly and clearly, pausing at intervals -Serve a SOFT DIET, which is easy to swallow. -Administer antiparkinsonian drugs (LEVODOPA) CVA (stroke) Sudden loss of brain function resulting from disruption in blood supply to a part of the brain Nursing assessment -Change in LOC -Paresthesia, paralysis -Aphasia, agraphia -Memory loss -vision impairment -Bladder and bowel dysfunction -Behavioral changes -Ability to swallow, eat, and drink without aspiration Nursing plans and interventions -Control hypertension to help prevent future stroke -Maintain proper body alignment while client is in bed. -Position client to minimize edema, prevent contractures, and maintain skin integrity -Perform full ROM exercises four times a day Swallowing modifications may include a SOFT DIET (pureed foods, thickened liquids) and head positioning. MS (multiple sclerosis) Demyelinating disease resulting in the destruction of CNS myelin and consequent disruption in the transmission of nerve impulses Can be triggered by heat, cold, stress, infections Nursing assessment Symptoms involving motor function usually begin in upper extremities with weakness progressing to spastic paralysis. -Optic neuritis (loss of vision or blind spots) -Visual or swallowing difficulties -Gait disturbances; intention tremors -Unusual fatigue, weakness, and clumsiness -Numbness, particularly on one side of face -Impaired bladder and bowel control -Speech disturbances -Scotomas (white spots in visual field, diplopia) Nursing plans and interventions -Keep own routine -Orient client to environment and teach strategies to maximize vision -Encourage self-care and frequent rest periods -Encourage client to work up to the point just short of fatigue -For muscle spasticity, stretch-hold-relax exercises are helpful, as are riding stationary bicycle and swimming -Voiding schedule -May need to learn self-catheterization or condom catheter -Adequate fluid intake, high fiber foods, and bowel regimen for constipation -Steroid therapy and chemotherapeutic drugs in acute exacerbations to shortern length of attack -ACTH, cortisone, and other immunosuppressive drugs Interferon-beta products such as Betaseron, Rebif, Avonex have shown recent success for MS relapses Coma scale (altered mental status) -Maximum total is 15, MINIMUM IS 3 -Score of 7 or less indicates coma -Clients with low scores have high mortality rates and poor prognosis (3 to 4) -Clients with scores greater than 8 have good prognosis for recovery Guillan Barre Triggered by infections, vaccinations REVERSE PRIORITY of BAC (breathing, air, circulation) Constant monitoring of these clients is required to prevent life-threatening problem of acute respiratory failure Full recovery usually occurs within several months to a year Nursing assessment -Paresthesia (tingling and numbness) -Muscle weakness of legs progressing to upper extremities, trunk, and face -Paralysis of the ocular, facial, and oropharyngeal muscles, causing marked difficulty in talking, chewing, and swallowing Assess for: -Breathlessness while talking -Shallow and irregular breathing -Use of accessory muscles while breathing -Any change in respiratory pattern -Paradoxical inward movement of the upper abdominal wall while in a supine position, indicating weakness and impending paralysis of the diapgrahm -Increasing pulse rate and disturbances in rhythm -Transient HTN, orthostatic hypotension -Possible pain in the back and in calves of legs Nursing plans and interventions -Monitor for respiratory distress and initiate mechanical ventilation if necessary Myasthenia Gravis Disorder affecting the neuromuscular transmission of impulses in the voluntary muscles of the body Neurotransmitter we are worried about = Ach Nursing assessment -Diplopia (double vision), ptosis (eyelid drooping) -Masklike affect -Weakness of muscles: dysphagia, choking, food aspiration, difficulty speaking -MUscle weakness iMPROVED BY REST, worsened by activity -MYASTHENIC CRISIS SYMTPOMS: associated with undermedication. More difficulty swallowing, diplopia, ptosis, dyspnea -Chloinergic crisis: associated with ACH Overdose. Diaphoresis, Diarrhea, fasciculations, cramps, marked worsening of symptoms resulting from overmedication. Nursing plans and interventions -Have tracheostomy kit available for possible myasthenic crisis -Wear MedicAlert bracelet -Administer cholinergic drugs -Schedule nursing activites to conserve energy -Allow rest periods -High energy activities first in morning -Avoid situations that produce fatigue or physical or emotional stress -Encourage coughing and deep breathing every 4 to 6 hours

Endocrine

Thyroid Hyperthyroidism (Graves Disease, Goiter) Metabolism is very high, worried about temperature, weight loss or gain, fatigued, increased appetite and may be losing weight if hyper. Physically can't keep up; lose fluids; tachycardia; diarrhea; higher respirations; may ahve temp elevation. Radioactive iodine or PTU to treat, or thyroidectomy -Worried about hypothyroidism (may swing too far other way) -All treatments make client hypothyroid, requiring hormone replacement -Radiation precautions = radioactive = avoid sharing body fluids with people until no longer radioactive. Too high = THYROID STORM and Thyrotoxicosis. Nursing assessment -Enlarged thyroid gland Acceleration of body processes -Weight loss -Increased appetite -Diarrhea -Heat intolerance -Tachycardia, palpitations, increased systolic BP -Diaphoresis, wet or moist skin -Nervousness, insomnia -Exophthlamos -T3 elevated above 220 -T4 elevated above 12 -Radioactive iodine uptake (indicates presence of goiter) -Thyroid scan (indicating presence of goiter) Nursing plans and interventions -Provide a calm, restful atmosphere -Observe for signs of THYROID STORM (sudden over-secretion of thyroid hormone) -PTU used to treat & methimazole Teach: -After treatment, resulting hypothyroidism will require daily replacement hormone -Wear MedicAlert jewelry in case of emergency -DIET = High-calorie, high-protein, low-caffeine, low-fiber diet (if diarrhea is present) Perform eye care for exophthalmos -artificial tears to maintain moisture -Sunglasses in bright light -Annual eye exams Thyroidectomy -Check frequently for bleeding, irregular breathing, neck swelling, frequent swallowing, sensations of fullness -Support neck when moving client -Check for horaseness or inability to speak clearly -Clearly monitor Trousseau and Chvostek signs -Keep drainage devices Hypothyroidism (Hashimoto Disease, Myxedema) Everything is slowed down. Taking medication for rest of their life. -Kind of medication matters; if they stay on generic, they have to stay on exact generic. -Taking first thing in morning!! MYXEDEMA COMA can be precipitated by acute illness, with-drawl of thyroid medication. Airway must be kept patent and ventilator support used as indicated. Nursing assessment -Fatigue -Thin, dry hair; dry skin -Thick, brittle nails -Constipation -Bradycardia, hypotension -Goiter -Periorbital edema, facial puffiness -Cold intolerance -Weight gain -Dull emotions and mental processes -Low T3 (below 70) -Low T4 (below 5) -Husky voice -Slow speech Nursing plans and interventions Teach: -Medication regimen: daily dose of prescribed hormone -Medication effects -Ongoing follow-up to determine serum hormone levels -S/S of Myxedema coma (hypoventilation, hypotension, hypothermia, hyponatremia, hypoglycemia, lactic acidosis, and respiratory failure) Develop bowel elimination plan to prevent constipation -Fluid intake to be 3L -High fiber diet, including fresh fruits and veggies -Increased activity -Little or no use of enemas and laxatives -Avoid sedating client; can lead to respiratory difficulties Adrenal Addison's is LOW, I'm going to ADD back what I don't have. Cushing's is HIGH, so they are real CUSHY. SUGAR, SALT, SEX hormones. Sugar (Glucocorticoids) Salt (Mineralcorticoids) Sex (Androgens) Addison Disease (Adrenocortical Deficiency) Adrenal glands not producing at level they need to, everything is low. Glucocorticoids are low = hypoglycemic Mineralocorticoids low = hyponatremic (also drop volume because water goes with salt = hypotensive which means DRY DRY DRY. Need moisture back.) Androgens low If person stops taking steroids (prednisone) after a long time, they will look like Addison's patient. Adrenal glands aren't working because they went on vacation. --Give IV version of prednisone (Methylprednisolone [Solu-Medrol[) Diagnosis made by ACTH stimulation test -If ACTH production by anterior pituitary has failed, it is considered secondary Addison disease Nursing Assessment -Fatigue, weakness -Weight loss, anorexia, nausea, vomiting -Postural hypotension -Hypoglycemia -Hyponatremia -Hyperkalemia (Potassium is opposite sodium) -Hyperpigmentation of mucous membranes and skin (TAN) -Signs of shock when in Addison crises -Loss of body hair -Hypovolemia (hypotension, tachycardia, fever) Nursing plans and Interventions -Take vital signs every 15 min if in Crisis -Monitor I&O and weigh daily -Instruct to rise slowly due to postural hypotension -During Addison crises, administer IV glucose with parenteral hydrocortisone, a steroid. Requires large fluid volume replacement -Monitor electrolyte levels -Maintain low-stress environment (protect client from noise, light, and temperature extremes because client can't cope with stress) -NEED FOR LIFELONG HORMONE REPLACEMENT -Need for Medical Jewelry -DIET = HIGH SODIUM, LOW POTASSIUM, AND HIGH CARBOHYDRATE -Provide ulcer prophylaxis Addison Crisis -Brought on by sudden withdrawal of steroids, a stressful event (trauma or severe infection), exposure to cold, overexertion, or decrease in salt intake -Administer Hydrocortisone -IV fluids Cushing Disease (Excess) Cause is usually chronic administration of corticosteroids Glucocorticoids high = Hyperglycemic. High blood sugar. Mineralocorticoids high = High in salt, so they hang on to fluid and get puffy Androgens high If person is taking steroids (prednisone) over long period of time, start to look like Cushing's. Adrenal glands go on vacation due to steroids. Higher risk for infection (because they are so sweet, bacteria loves it) Risk for osteoporosis. Nursing Assessment -Hypertension -Susceptibility to multiple infections -Osteoporosis -Peptic ulcer formation -Many false positives and negatives in lab testing (hyperglycemia, hyperntremia, hypokalemia, decreased eosinophils and lymphocytes, increased plasma cortisol) Physical Symptoms: -Moon face -Truncal obesity -Buffalo hump -Abdominal striae -Muscle atrophy -Thinning of the skin -Hirsutism in females -Hyperpigmentation -Amenorrhea -Edema, poor wound healing -Impotence -Bruises easily Nursing plans and interventions -Encourage client to protect self from exposure and infection -Wash hands; use good handwashing technique Monitor client for signs of infection -Fever -Oral infection by Candida spp. -Vaginal yeast infections -Adventitious lungs sounds -Skin lesions -Elevated WBCs Safety measures: -Position bed close to floor, with call light within easy reach -Encourage use of side rails -Be sure walkways are unobstructed -Encourage wearing shoes when ambulating Provide low sodium diet; encourage consumption of foods that contain VITAMIN D and CALCIUM Provide good skin and perineal care Discuss possibility of weaning from steroids after surgery (if wean off steroids too quickly, Addison disease will occur) Encourage selection of clothing that minimizes visible aberrations Monitor I&O weight daily Take steroids with meals, never skip doses, if N/V for more than 12-24 hours tell HCP.