med-surg HESI review

leukemia

- Abnormal overproduction of immature forms of any of the leukocytes. - Anemia: dec RBC - Immunosuppression: large # immature WBCs; profound neutropenia. - Hemorrhage: thrombocytopenia. - Dx: biopsy, BMA, LP, frequent blood counts. - Tx: Antineoplastic chemotherapy. Most oncologic drugs cause immunosuppression. Prevention of secondary infections is vital! - Acute myelogenous leukemia (AML): inability of leukocytes to mature; those that do are abnormal. Insidious w/ poor prognosis. Cause of death- overwhelming infection. - Chronic myelogenous leukemia (CML): abnormal production of granulocytic cells. Prognosis is poor. Tx is conservative, involving oral antineoplastic agents (Hydroxyurea (Hydrea, an inhibitor of DNA synthesis); Interferon (mechanism of action not known); Imatinib mesylate (Gleevec) targeted therapy if cells are Philadelphia chromosome positive) - Acute lymphocytic leukemia (ALL): Abnormal leukocytes in blood-forming tissue. most common childhood CA w/ favorable prognosis. - Chronic lymphocytic leukemia (CLL) 1. Inc production of leukocytes and lymphocytes and proliferation of cells w/in BM, spleen, liver. Most clients are asymptomatic and are not tx A. Tendency to bleed 1. Petechiae 2. Nosebleeds 3. Bleeding gums 4. Ecchymoses 5. Nonhealing skin abrasions B. Anemia 1. Fatigue 2. Pallor 3. HA 4. Bone and joint pain 5. Hepatosplenomegaly C. Infection 1. Fever 2. Tachycardia 3. Lymphadenopathy (swollen lymph nodes) 4. Night sweats 5. Skin infection, poor healing D. GI distress 1. Anorexia 2. Wt loss 3. Sore throat 4. Abd pain 5. Diarrhea 6. Oral lesions (thrush) A. Monitor WBC; assess oral cavity and genital area for signs of yeast infection. B. Monitor VS frequently. Usually report temp elevations of 38.05˚C +. C. Abx: Trough- blood sample shortly before admin. Peak- blood sample 30 min - 1 hr after admin D. Infection ctrl: hand washing, avoid sick people & crowds, avoid undercooked & raw food; Neutropenic and reverse isolation precautions PRN. E. Oral hygiene regimen F. C/DB to prevent stasis of secretions in lungs. G. Protect from bleeding/injury. Avoid rectal thermometers and suppositories to prevent bleeding. H. Monitor fluid status and balance; febrile clients dehydrate rapidly: I&O; fluid intake of at least 3 L/day. I. Mobility to decrease pulm stasis. J. Care for invasive catheters and lines K. high-protein & cal diet

UC

- Affects the superficial mucosa of large intestines and rectum, causing the bowel to eventually narrow, shorten, and thicken due to muscular hypertrophy. - Sigmoidoscopy and colonoscopy allow direct examination of the large intestinal mucosa and are used for dx A. Diarrhea, Abd pain and cramping B. Intermittent tenesmus (anal ctxs), rectal bleeding C. Liquid stools containing blood, mucus, pus (10-20/ day) E. Weakness and fatigue; An Dx: Risk for deficient fluid vol; Acute pain; Imbalanced nutrition: less than body requirements A. Determine bowel elimination pattern, ctrl diarrhea w/ diet and meds. B. Nutritious, well-balanced, low-residue & fat, high-protein & calorie, no dairy or spicy foods C. Vit supp & Fe D. E. Avoid smoking, caffeinated beverages, pepper, alcohol. F. Complete bowel rest w/ IV hyperalimentation G. Meds: corticosteroids, antidiarrheals, sulfasalazine (Azulfidine), mesalamine (various brands), infliximab (Remicade) or other biologic tx, if there is no response to previous meds. H. I&O, serum electrolytes. I. Weigh at least 2x/wk. J. Teach stoma care - Opiate drugs depress gastric motility. However, they should be given w/ caution. Assess for abd distention, pain, s/s of shock (inc HR, dec BP) indicating possible perforation/GI bleed

osteoporosis

- Bone demineralization results in dec density and subsequent fractures - Postmenopausal women @ highest risk. A. Classic dowager's hump, or kyphosis of the dorsal spine B. Loss of ht, often 2-3 in C. Back pain, often radiating around trunk D. Pathologic fractures E. Compression fracture of spine: assess ability to void, defecate. Dx: Risk for injury; Impaired physical mobility; Deficient knowledge A. Hazard-free environment. Safety B. Bed in low position. C. Shoes or nonskid slippers out of bed. D. Assistance w/ ambulation. E. Regular exercise: ROM, ambulation several x/day; Proper body mechanics; Wt-bearing F. High protein, Ca Vit D; discourage alcohol, caffeine. H. Preventive measures for females. HRT (may cause breast, uterine CA); vit D, Ca, wt-bearing exercise J. Bisphosphonates: inhibit osteoclast-mediated bone resorption (1) Alendronate (Fosamax) (2) Etidronate (Didronel) (3) Ibandronate (Boniva) (4) Pamidronate (Aredia) (5) Risedronate (Actonel) (6) Tiludronate (Skelid) - SE: anorexia, wt loss, gastritis - Take w/ full glass water, 30 min before food/meds, remain upright 30 min after. I. SERM: mimic effect of E on bone by reducing bone resorption w/out stimulating tissues of breast or uterus. (1) Raloxifene (Evista) (2) Teriparatide (Forteo) - SE: leg cramps, hot flashes. J. DEXA, measures bone density as a baseline after menopause - Tums are an excellent source of Ca, but they are also high in Na, so hypertensive or edematous individuals should seek another source

hyperthyroidism (graves, goiter)

- Can result from a primary disease state; use of replacement therapy; excess TSH by anterior pituitary tumor. - Graves disease: autoimmune process - Dx: serum hormone levels - Tx: 1. Thyroid ablation by meds 2. Radioactive I 3. Thyroidectomy 4. Adenectomy of portion of anterior pituitary where TSH-producing tumor is located - Make the client hypothyroid, requiring TH replacement. A. Enlarged thyroid gland B. Acceleration of body processes: Wt loss; Inc appetite; Diarrhea; Heat intolerance; Tachycardia, palpitations, Inc SBP; Diaphoresis, wet or moist skin; Nervousness, insomnia C. Exophthalmos D. T3 > 220 ng/dL; T4 > 12 mcg/dL; Dec TSH w/ primary disease (elevated T4 suppresses TRH, which suppresses TSH). If source is anterior pituitary, both will be elevated. E. Radioactive iodine uptake (indicates presence of goiter) F. Thyroid scan (indicating presence of goiter) Dx: Activity intolerance; Deficient knowledge; Imbalanced nutrition: less than body requirements; Risk for injury A. Calm, restful atmosphere. B. Observe for signs of thyroid storm C. Teach: after surgery- require daily TH replacement (s/s of OD- hyperthyroidism; s/s underdosage- hypothyroidism) D. High-cal & protein, low caffeine & fiber (if diarrhea is present). E. Eye care for exophthalmos: Artificial tears; Sunglasses when in bright light; Annual eye exams TX: 1. Thyroid ablation: Propylthiouracil (PTU) & methimazole (Tapazole) block conversion of T4 to T3 2. Radiation: radioactive I given to destroy thyroid cells; very irritating to the GI tract (vomiting common); radiation precautions 3. Thyroidectomy: Check frequently for bleeding, irregular breathing, neck swelling, frequent swallowing, sensations of fullness; Support neck when moving (do not hyperextend); Check for laryngeal edema, laryngeal nerve damage leads to vocal cord paralysis; Monitor Trousseau and Chvostek signs, because removal of the parathyroid(s) may lead to tetany. e. Keep drainage devices, like Jackson-Pratt (JP) drains, compressed and empty. 4. Hypophysectomy (pituitary adenectomy) if d/t inc pituitary secretion of ACTH; TSH-secreting pituitary tumors (transsphenoidal hypophysectomy). Postop assess drainage for glucose - T-storm causes: Graves disease, CHF, DKA, infection, PE, emotional distress, trauma, surgery. S/s: fever, tachycardia, agitation, anxiety, HTN. Maintaining airway, adequate aeration. PTU & methimazole (Tapazole); Propranolol to dec excess SNS stimulation. - After a thyroidectomy- risk for laryngeal edema. Tracheostomy set, O2, suction machine at bedside - Ca gluconate if PTH glands accidently removed. Normal 9.0-10.5 mEq/L. - If 2 + glands have been removed, chance of tetany inc. Check for tingling of toes, fingers, around mouth; Chvostek & Trousseau sign; Serum Ca

angina

- Chest discomfort or pain that occurs when myocardial O2 demands exceed supply - Causes: Atherosclerotic heart disease; HTN; Coronary artery spasm; Hypertrophic cardiomyopathy; Activity that inc heart's O2 demand A. Pain: Mild to severe intensity; heavy, squeezing, pressing, burning, choking, aching, feeling of apprehension; Substernal, radiating to L arm/ shoulder, jaw, R shoulder; Transient or prolonged, w/ gradual or sudden onset; Short duration; Relieved by rest/ nitro B. Dyspnea, tachycardia, palpitations, n/v, fatigue, diaphoresis, pallor, weakness, syncope, dysrhythmias C. ECG generally at client baseline unless during anginal attack (ST-segment depression & T-wave inversion) D. Exercise stress test: ST-segment depression and hypotension E. Stress Echo: Looks for changes in wall motion (indicated in women) F. Coronary angiogram: Detects coronary artery spasms G. Cardiac cath: Detects arterial blockage H. Risk factors: Heredity; Male > female until menopause, then equal risk; Afr Am; Age (NONMODIFIABLE). Hyperlipidemia; Cholesterol > 300 mg/dL; LDL > 100 mg/dL; HDL <60 mg/dL; HTN; Cigarette smoking; Obesity; Physical inactivity; Metabolic syndrome; Stress; Elevated homocysteine; Substance abuse (NONMODIFIABLE) Dx: Dec CO; Acute pain; Anxiety A. Monitor meds B. Determine factors precipitating pain C. Teach risk factors D. During an attack: immediate rest; VS; ECG; no > 3 nitro q5min; Emergency tx if no relief E. Physical activity: Avoidance of isometric activity; Exercise program; Sexual activity resumed after exercise tolerated (able to climb 2 flights of stairs w/out exertion) prophylactic nitro F. Nutritional info about modifying fats (saturated) and Na. Antilipemic meds to lower cholesterol G. PTCA/PCI: balloon catheter is repeatedly inflated to split or fracture plaque, and the arterial wall is stretched, enlarging the diameter of the vessel. A rotoblade is used to pulverize plaque. H. Arthrectomy: catheter w/ a collection chamber is used to remove plaque from a coronary artery by shaving, cutting, grinding. I. CABG, Coronary laser therapy, Coronary artery stent or drug-eluding stents

cholecystitis & cholelithiasis

- Cholecystitis: acute inflam of gallbladder; - Cholelithiasis: formation or presence of stones in gallbladder - greater in females who are multiparous and overwt . B. Treatment for cholecystitis consists of IV hydration, administration of antibiotics, and pain control with morphine or NSAIDs; anticholinergics are administered to decrease smooth muscle spasms. C. Treatment for cholelithiasis consists of nonsurgical removal of stones. 1. Dissolution therapy (administration of bile salts; used rarely) 2. Endoscopic retrograde cholangiopancreatography (ERCP) 3. Lithotripsy (not covered by many insurance carriers, thereby limiting its use) D. Cholecystectomy is performed if stones are not removed nonsurgically and inflammation is absent. It may be done through laparoscope. Assessment A. Pain, anorexia, vomiting, or flatulence precipitated by ingestion of fried, spicy, or fatty foods B. Fever, elevated WBCs, and other signs of infection (cholecystitis) C. Abdominal tenderness D. Jaundice and clay-colored stools (blockage) E. Elevated liver enzymes, bilirubin, and WBCs Analysis (Nursing Diagnoses) A. Acute pain related to ... B. Deficient knowledge (specify) related to ... C. Deficient fluid volume related to... Nursing Plans and Interventions A. Administer analgesic for pain as needed. B. Maintain NPO status. C. Maintain NG tube to suction if indicated. D. Administer IV antibiotics for cholecystitis, and administer antibiotics prophylactically for cholelithiasis. E. Monitor I&O. F. Monitor electrolyte status regularly. G. Teach client to avoid fried, spicy, and fatty foods and to reduce caloric intake if indicated. H. Provide preoperative and postoperative care if surgery is indicated I. Monitor T-tube drainage. - After an ERCP, the client may feel sick. The scope is placed in the gallbladder, and the stones are crushed and left to pass on their own. These clients may be prone to pancreatitis. Nonsurgical management of a client with cholecystitis includes: • Low-fat diet • Decompression of the stomach via NG tube • Medications for pain and clotting if required

chronic airflow limitation

- Chronic lung disease includes chronic bronchitis, pulmonary emphysema, asthma - Emphysema (air trapping) & chronic bronchitis (chronic cough & sputum), termed COPD: characterized by bronchospasm and dyspnea. Damage to lung is irreversible & inc in severity. - Asthma (airway narrowing), unlike COPD: intermittent disease w/ reversible airflow obstruction and wheezing. A. Changes in breathing pattern (inc in rate w/ dec in depth) B. Overinflation causes rib cage to remain partially expanded (barrel chest) C. Generalized cyanosis of lips, MM, face, nail beds ("blue bloater") D. Cough (dry or productive) E. High CO2; Low O2 F. Dec breath sounds G. Coarse crackles- tend to disappear after coughing, wheezing H. Dyspnea, orthopnea I. Poor nutrition, wt loss J. Activity intolerance K. Anxiety concerning breathing Dx: Ineffective airway clearance; Ineffective breathing pattern; Impaired gas exchange; Anxiety related activity intolerance A. Sit upright and bend slightly forward to promote breathing. (tripod). B. Diaphragmatic and PLB. Teach prolonged expiratory phase to prevent bronchiolar collapse and prevent air trapping. C. Admin O2 @ 1-2 L per NC D. Pace activities to conserve energy. E. Maintain adequate dietary intake: Small, frequent easily eaten meals w/ inc calories and protein, but do not overfeed; Dietary supp- For people continuing to smoke, vit C; Mg & Ca bc of their role in muscle ctx and relaxation for people w/ COPD. F. Adequate fluid intake (min 3 L/day)- should be taken b/t meals to prevent excess stomach distention and to dec pressure on the diaphragm. G. Relaxation techniques (teach when not in distress). H. Prevention of secondary infections. I. Medication regimen: 1. Adrenergics & sympathomimetics (epi, albuterol, terbutaline, salmeterol; bronchodilator; may inc HR, anxiety, n/v, retention) 2. Methylxanthine (aminophylline IV, theophylline PO; bronchodilator; may cause inc HR, hyperactivity, sleepinessm GI distress, dysrhythmias) 3. Corticosteroids (anti-inflam) 4. Anticholinergics (ipratropium, tiotropium; bronchodilator/ ctrl rhinorrhea; may cause dry mouth, blurred vision; cough) K. Smoking cessation L. Health-promoting activities. - Exposure to tobacco smoke = primary cause of COPD - Productive cough and comfort can be facilitated by semi-Fowler or high-Fowler position, which lessens pressure on the diaphragm by abd organs. Gastric distention becomes a problem in these clients bc it elevates diaphragm and inhibits full lung expansion. - Overinflation of lungs causes the rib cage to remain partially expanded, giving the characteristic appearance of a barrel chest --> works harder to breathe, but the amt of O2 taken in is not adequate. Insufficient oxygenation occurs w/ chronic bronchitis --> generalized cyanosis, R HF(cor pulmonale). - Inadequate arterial oxygenation manifested by cyanosis and slow CRT. A chronic sign is clubbing of the fingernails, late sign is clubbing of the fingers. - As COPD worsens, dec O2 (hypoxemia) & inc CO2 (hypercapnia) --> resp acidosis. Kidneys retain bicarb as compensation. - Prevent secondary infections - Report any change in sputum. - Dec caffeine- diuretic effect. - Obtain vac (flu and pneumonia).

PD

- Chronic, progressive, debilitating disease of the basal ganglia and substantia nigra, affecting motor ability and - Tremor at rest, inc muscle tone (rigidity), slowness in the initiation and execution of movement (bradykinesia), postural instability (difficulties w/ gait and balance) - Inc Ach & dec DA- controlled by administering dopamine precursor (levodopa) A. Rigidity of extremities B. Masklike facial expressions; difficulty in chewing, swallowing, speaking C. Drooling D. Stooped posture and slow, shuffling gait E. Tremors at rest, "pill-rolling" movement F. Emotional lability G. Inc tremors w/ stress or anxiety A. Activities later in the day to allow sufficient time for client to perform self-care w/out rushing. B. Activities and exercise. C. Eliminate environmental noise; Speak slowly and clearly, pausing at intervals. D. Soft diet E. Antiparkinsonian drugs: anticholinergics (atropine, benztropine); dopamine replacements (levodopa); monoamine oxidase type B inhibitor (selegiline, rasagiline); catechol-O-methyl transferase (COMT) inhibitor (entacapone, tolcapone) F. SAFETY!

RA

- Chronic, systematic, progressive deterioration of the connective tissue (synovium) of joints; characterized by inflammation - Bilateral and symmetrical. A. Fatigue B. Generalized weakness C. Wt loss D. Anorexia E. Morning stiffness F. Bilateral inflam w/: 1. Decreased ROM 2. Joint pain 3. Warmth 4. Edema 5. Erythema G. Joint deformity B. Dx: 1. Elevated ESR 2. (+) RF 3. Presence of ANA 4. Joint-space narrowing indicated by arthroscopic exam (provides joint visualization) 5. Abnormal synovial fluid by arthrocentesis 6. CRP by active inflammation - Dx: Chronic pain; Impaired physical mobility; Self-care deficit; Ineffective coping A. Pain relief: 1. Moist heat: Warm, moist compresses, Whirlpool baths, Hot shower in morning 2. Use diversionary activities. 3. Admin meds: NSAIDs, corticosteroids B. Rest after periods of activity: Perform activities when client feels most energetic & allow time. Do not: exercise painful, swollen joints; to point of pain. Perform exercises slowly & smoothly; avoid jerky movements. C. Avoid overexertion; maintain proper posture & joint position. D. Assistive devices - Use inspection, palpation, strength testing. Do not assess ROM- promotes pain - Cartilage becomes soft, fissures and pitting occur, cartilage thins. Spurs form and inflam sets in --> deformity, immobility, pain, muscle spasm. Tx: corticosteroids; splinting, immobilization, rest for joint deformity; NSAIDs.

lung CA

- Cigarette smoking is responsible for 80% to 90% of all lung cancers. - Exposure to occupational hazards: asbestos and radioactive dust A. Persistent dry, hacking cough early, w/ cough turning productive as disease progresses B. Hoarseness C. Dyspnea D. Hemoptysis; rust-colored or purulent sputum E. Pain in chest area F. Diminished breath sounds, occasional wheezing G. Abnormal CXR H. (+) sputum for cytology and for pleural fluid Dx: Chronic pain; Ineffective breathing pattern; Impaired gas exchange; Imbalanced nutrition: less than body requirements; Anxiety A. Similar interventions as COPD. B. Semi-Fowler C. PLB to improve gas exchange. D. Relaxation techniques E. Admin O2 F. Allay anxiety. G. Dec pain- admin analgesics (w/in safety range for resp difficulty). H. Surgery 1. Thoracotomy for clients who have a resectable tumor. 2. Pneumonectomy (removal of entire lung): Position on operative side or back; Chest tubes not usually used. 3. Lobectomy and segmental resection: Position on back; Chest tubes usually inserted; Check to ensure tubing is not kinked or obstructed. 4. Chest tubes a. Keep tubing coiled loosely below chest level, w/ connections tight and taped. b. Keep water seal and suction ctrl chamber at the appropriate water levels. c. Monitor fluid drainage, mark the time of measurement and the fluid level. d. Observe for air bubbling in the water seal chamber and fluctuations (tidaling). e. Monitor clinical status. f. Check position of the chest drainage system. g. Encourage the client to breathe deeply periodically. h. Do not empty collection container. Replace unit when full. i. Do not strip or milk tubes. j. Not routinely clamped. If the drainage system breaks, place the distal end of the chest tubing connection in a sterile water container at a 2-cm level as an emergency water seal. k. Maintain dry occlusive dressing. I. Chemotherapy (give antiemetics), Radiation therapy (skin care, don't wash off lines; wear soft cotton garments only; avoid use of powders and creams - If the chest tube is accidentally dislodged from pt, the cover w/ a dry sterile dressing taped on 3 sides. notify HCP - Fluctuations (tidaling) in the fluid occur if there is no external suction- good indicator system is intact. should move upward w/ inspiration and downward w/ expiration. - If fluctuations cease, check for kinked tubing, accumulation of fluid in tubing, occlusions, or change in the pt's position, bc expanding lung tissue may be occluding the tube opening. - When a chest tube is connected to suction, continuous bubbling is an indication of an air leak.

peripheral vascular disease (PVD)

- Circulatory problems that can be due to arterial or venous pathology A. Predisposing factors: 1. Arterial: Arteriosclerosis; Advanced age 2. Venous: DVT hx; Valvular incompetence B. Associated diseases 1. Arterial:. Raynaud disease (nonatherosclerotic, triggered by extreme heat or cold, spasms of the arteries); Buerger disease (occlusive inflammatory disease, strongly associated w/ smoking); DM; Acute occlusion (emboli/thrombi) 2. Venous: Varicose veins; Thrombophlebitis; Venous stasis ulcers C. CHARACTERISTICS 1. Arterial: - Thin, Dry, Smooth, Shiny, Loss of hair, Thickened nails - Pallor on elevation; Dependent Rubor - Cool; Dec or absent pulses - Sharp pain that inc w/ walking & elevation; Intermittent Claudication; Rest pain occurs when extremities horizontal; Relieve by dependent position; Often appears when collateral circulation fails to develop - Painful ulcers; on lateral lower legs, toes, heels; Demarcated edges; Small, but deep; Circular; Necrotic; Not edematous 2. Venous: - Brown pigment around ankles - Cyanotic when dependent - Warm; Normal pulses - Persistent, aching, full feeling, dull sensation; Relieved when horizontal (elevate and use compression stockings (ONLY VENOUS)); Nocturnal cramps - Slightly painful ulcers (dull ache or heaviness) on medial legs, ankles; Uneven edges; Superficial, but large; Marked edema; Highly exudative Dx: Ineffective tissue perfusion (peripheral); Activity intolerance; Impaired skin integrity; Risk for infection; Acute pain 1. Noninvasive Arterial: Elimination of smoking; Topical abx; Saline dressing; Bed rest, immobilization; Fibrinolytic agents if clots are the problem (not for Raynaud or Buerger) 2. Noninvasive Venous: Systemic abx; Compression dressing (snug) or alginate dressing if ulcerated; Limb elevation; Thrombosis: fibrinolytic agents& anticoagulants 1. Surgery Arterial: Embolectomy- removal of clot; Endarterectomy- removal of clot and stripping of plaque; Arterial bypass- Teflon or Dacron graft or autograft; Percutaneous transluminal angioplasty (PTA): compression of plaque; Amputation: removal of extremity 2. Surgery Venous: Vein ligation; Thrombectomy; Débridement A. Monitor extremities at designated intervals: color, temp, sensation, pulse B. Activities w/in client's tolerance level. C. Rest at 1st sign of pain. D. Keep extremities elevated (venous) when sitting, change position often. E. Avoid crossing legs and to wear nonrestrictive clothing. F. Keep the extremities warm by wearing extra clothing & don't use external heat sources. Dec blood flow --> diminished sensation. Any heat source can cause burns. G. Change position frequently; Nonrestrictive clothing; Avoid crossing legs or keeping legs in a dependent position; Support hose or antiembolism stockings; Shoes when ambulating; Proper foot and nail care. H. Discourage cigarette smoking (causes vasoconstriction and spasm of arteries). I. Preop: Affected extremity in a level position (venous) or in a slightly dependent position (arterial; 15 degrees), at room temp, protect from trauma. J. Postoperative: Assess surgical site frequently for hemorrhage, check distal peripheral pulses. Anticoagulants may be continued.

hearing loss

- Conductive Hearing Loss: sound does not travel well to the sound organs of the inner ear. Vol is less, but clear. If vol is raised, hearing is normal. May result from infection, trauma, wax buildup. tx more successfully w/ hearing aids. - Sensorineural Hearing Loss: sound passes properly through outer and middle ear but is distorted by a defect in the inner ear or damage to CN VIII, or both. involves perceptual loss, usually progressive and bilateral. Inner ear disorders often are neurogenic in nature and may not be helped w/ a hearing aid. A. Reduce distraction; Do not switch topics abruptly; Face directly; Speak slowly and distinctly in a low-pitched voice; Helpful aids; Hearing Aids

anemia

- Deficiency of erythrocytes (RBCs) reflected as dec Hct, Hgb, and RBCs A. Pallor, esp ears and nail beds; palmar crease; conjunctiva B. Fatigue, exercise intolerance, lethargy, ortho hypo C. Tachycardia, heart murmurs, HF D. Signs of bleeding (hematuria, melena, menorrhagia) E. Dyspnea F. Irritability, difficulty concentrating G. Cool skin, cold intolerance H. Risk factors: 1. Diet lacking in Fe, folate, B12 2. FH of genetic diseases 3. Med hx of anemia-producing drugs (salicylates, thiazides, diuretics) 4. Exposure to toxic agents (lead or insecticides) I. Hgb <10 g/dL; Hct <36%; RBCs <4 × 10 12; Bone marrow aspiration J. Blood loss K. Medical HO kidney disorders A. Blood products- Use only NS to flush IV tubing or to run w/ blood. Never add meds to blood products. 2 RNs should simultaneously check the physician's prescription, the client's identity, and the blood bag label. Stay for 1st 15 min B. Alt periods of activity w/ rest. C. Diet. Fe (red meats, organ meats, whole wheat products, spinach, carrots); Folic acid (green veg, liver, citrus fruits); Vitamin B12 (glandular meats, yeast, green leafy vegetables, milk, cheese) D. Take iron on an empty stomach, 1 h before meals or 2 h after meals. Vit C to enhance absorption. Z-track if IM. Straw w/ liquid. E. B12 and folic acid orally except to clients w/ pernicious anemia who should receive B12 parenterally (lack intrinsic factor to absorb) F. Sickle cell crisis precipitated by hypoxia: pain relief; adequate hydration

cirrhosis

- Degeneration of liver tissue, causing enlargement, fibrosis, scarring - CAUSES: 1. Chronic alcohol ingestion (Laënnec cirrhosis) 2. Viral hepatitis 3. Exposure to hepatotoxins (including meds) 4. Infections 5. Congenital abnormalities 6. Chronic biliary tree obstruction 7. Chronic severe R HF 8. Idiopathy - Initially, hepatomegaly occurs; later, the liver becomes hard and nodular. A. HO alcohol, prescriptive & street drug B. Work hx: exposure to toxic chemicals (pesticides, fumes) C. Med hx of LT use of hepatotoxic drugs D. FH of liver abnormalities E. Weakness, malaise; Anorexia, wt loss; Palpable liver (early), abd girth incr as liver enlarges; Jaundice; Fetor hepaticus (fruity or musty breath); Asterixis; Mental and behavioral changes; Bruising, erythema; Dry skin, spider angiomas; Gynecomastia, testicular atrophy; Ascites, peripheral neuropathy; Hematemesis; Palmar erythema F. Clotting defects: Inc bilirubin, AST, ALT, alkaline phosphatase, PT, ammonia; Dec H&H, electrolytes, K, Na, albumin G. Complications: 1. Ascites, edema 2. Portal HTN 3. Esophageal varices 4. Encephalopathy 5. Resp distress 6. Coagulation defects Dx: Excess fluid vol; Risk for bleeding; Pain; Ineffective breathing pattern; Imbalanced nutrition: less than body requirements; Risk for infection; Impaired skin integrity A. Eliminate causative agent (alcohol, hepatotoxin). B. Vit Supp (A, B complex, C, K) C. Observe mental status frequently (at least q2h) D. Avoid initiating bldg, and observe for bldg tendencies. E. Provide special skin care: Avoid soap, rubbing alcohol, perfumed products (drying); Moisturizing lotion; Observe for lesions; Turn frequently F. Monitor F&E status daily: I&O (accurate output measurement may require Foley); Edema, pulm edema; Measure abd girth (ascites); Daily wt; Restrict fluids to 1500 mL/day G. Monitor dietary intake, esp protein intake. Restrict protein w/ hepatic coma; otherwise, encourage foods w/ high biologic protein. H. Low Na, K, fat; High carb I. If encephalopathy is present, lactulose to dec ammonia levels J. If esophageal varices are present, esophagogastric balloon tamponade (Blakemore tube), sclerotherapy, and/or portal systemic shunts - Tx ascites: paracentesis and peritoneovenous shunts (LeVeen and Denver shunts) - Esophageal varices may rupture and cause hemorrhage. Insertion of esophagogastric balloon tamponade (a Blakemore-Sengstaken or Minnesota tube), vasopressors, vit K, coagulation factors, blood transfusions. - Ammonia not broken down as usual, so levels rise. The metabolism of drugs is slowed down, so they remain in the system longer.

MS

- Demyelinating disease resulting in the destruction of CNS myelin and consequent disruption in the transmission of nerve impulses - Onset insidious - Dx: 1. Presenting s/s 2. Inc white matter density on CT 3. Presence of plaques on MRI 4. CSF electrophoresis w/ oligoclonal (IgG) bands. A. Hx: 1. S/s 2. Progression of illness 3. Tx received and responses 4. Additional health problems 5. Current meds B. Physical assessment: 1. Optic neuritis (loss of vision or blind spots) 2. Visual or swallowing difficulties 3. Gait disturbances; intention tremors - S/s involving motor function usually begin in the upper extremities w/ weakness progressing to spastic paralysis. 4. Unusual fatigue, weakness, clumsiness 5. Numbness, particularly on 1 side of face 6. Impaired bladder and bowel cntrl 7. Speech disturbances 8. Scotomas (white spots in visual field, diplopia) A. Orient client to environment, maximize vision; self-care B. Frequent rest; exercise up to the point just short of fatigue, stretch-hold-relax exercises, stationary bike, swimming helpful for muscle spasticity, as are riding a C. Voiding schedule, self-cath, straight cath D. Fluid intake, high-fiber foods, bowel regimen for constipation E. Steroid therapy and chemotherapeutic drugs in acute exacerbations to shorten length of attack. ACTH, cortisone, cyclophosphamide (Cytoxan), immunosuppressive drugs. Prevent infection. N. BMRs (interferon-beta products 322(Betaseron, Rebif, Avonex)) have shown recent success for MS relapse

Abdominal Aortic Aneurysm

- Dilatation of the abd aorta caused by an alteration in the integrity of its wall - Most common cause: atherosclerosis. - Late manifestation of syphilis - Asymptomatic. Most common s/s is abd pain or low back pain, w/ the complaint that the client can feel his or her heart beating. - Those taking antihypertensive drugs are at risk A. Bruit over abd aorta, pulsation in upper abd B. Abd or lower back pain C. May feel heartbeat in abd, or feel an abd mass D. Abdominal radiograph (aortogram, angiogram, abdominal ultrasound) to confirm dx if aneurysm is calcified E. S/s of rupture: hypovolemic or cardiogenic shock w/ sudden, severe abd pain Dx: Activity intolerance; Risk for vascular trauma; Anxiety; Acute pain A. Assess per pulses and VS regularly. B. Observe for signs of occlusion after graft: Change in pulses; Severe pain; Cool to cold extremities below graft; White or blue extremities C. Observe renal functioning for signs of kidney damage (artery clamped during surgery may result in kidney damage): Output > 30 mL/hr; Amber urine; Inc BUN/Cr D. Observe for postop ileus: NGT to low continuous suction f1-2 d postop (may help to prevent ileus); Bowel sounds q shift Initial Assessments • VS q h; Neuro VS; Resp status; Urinary output; Per pulses - During repair, large arteries are clamped for a certain period, and kidney damage can result. Monitor daily BUN (10-20) and Cr (0.6-1.2) levels.

MG

- Disorder affecting NM transmission of impulses in voluntary muscles of body (dec ACh) - Autoimmune disease characterized by presence of acetylcholine receptor (AChR) antibodies, which interfere w/ neuronal transmission. A. Diplopia (double vision), ptosis (eyelid drooping) B. Masklike affect: sleepy appearance d/t facial muscle involvement C. Weakness of laryngeal and pharyngeal muscles: dysphagia, choking, food aspiration, difficulty speaking D. Muscle weakness improved by rest, worsened by activity E. Advanced cases: resp failure, bladder and bowel incontinence. Most severe involvement may result in resp failure. F. Myasthenic crisis w/ undermedication. Inc in MG s/s (more difficulty swallowing, diplopia, ptosis, dyspnea). (+) edrophonium (Tensilon) test G. Cholinergic crisis (anticholinesterase OD): diaphoresis, diarrhea, fasciculations, cramps. (-) test A. Have tracheostomy kit available for possible myasthenic crisis. B. Cholinergic drugs: pyridostigmine (antidote- atropine; cholinergic crisis w/ OD) C. Schedule nursing activities to conserve energy; allow rest periods. Plan activities during high-energy times, often in early morning. Bed rest often relieves s/s D. Avoid situations that produce fatigue or physical or emotional stress E. C/DB q4-6h (Muscle weakness limits ability to cough up secretions, promotes URI.) F. Bladder and resp infections often recurring problems.

MI

- Disruption in or deficiency of coronary artery blood supply, resulting in necrosis of myocardial tissue - Causes: Thrombus or clotting; Shock or hemorrhage A. Sudden onset of pain in lower sternal region (substernal). Heavy and viselike pain radiates to shoulders, down arms/ to neck, jaw, back. Substernal, retrosternal, epigastric. Women: SOB, fatigue, sleep disturbance, n/v, anxiety, feeling of impending doom/death. May not have pain (silent MI- diabetic neuropathy) B. Rapid, irregular, thready pulse C. Decreased LOC w/ dec cerebral perfusion D. L heart shift sometimes occurring after MI E. Dysrhythmias F. Cardiogenic shock or fluid retention G. Cardiac-specific troponin: myocardial muscle protein released into circulation after MI or injury w/ greater sensitivity and specificity for myocardial injury than CK-MB. onset as early as 1 hr/ 3-12 h, peak 10-24 h; normal 5-14 d H. CK: intracellular enzymes released into circulation after MI, also elevated after intracoronary procedures. onset 3-12 h; peak 24 hrs; normal 2-3 d I. CK-MB: specific to myocardial cells; help quantify myocardial damage. onset 4-8 h; peak 12-24 h; normal 48-72 h J. Narrowed pulse pressure K. Bowel sounds are absent or high pitched, indicating possibility of mesenteric artery thrombosis, which acts as an intestinal obstruction. L. HF: crackles in the lungs sounds M. ECG changes as early as 2 h after or as late as 72 h after MI N. Cool, pale, diaphoretic skin O. Dizziness, fatigue, syncope Dx: Risk for decr cardiac tissue perfusion; Dec CO; Activity intolerance; Acute pain r A. For pain and to inc O2 perfusion, IV morphine sulfate (peripheral vasodilator, dec venous return); Nitrates, ACEIs, BBS, CCBs (when BBs contraindicated), Aspirin, Antiplatelet B. VS, ECG C. O2 @ 2-6 L per NC. D. Obtain cardiac enzymes E. Quiet, restful environment. F. Assess breath sounds for rales (pulm edema). G. Patent IV line for admin of emergency meds. H. Monitor fluid balance. I. Semi-Fowler position to assist w/ breathing- bed rest for 12 hr. J. Resume activity gradually. K. Thrombolytic agents, w/in 1-4 hours of MI, but not > 12 hrs of MI L. IABP to improve myocardial perfusion M. Surgical reperfusion w/ CABG N. PCI w/ stenting - Myoglobin: onset 1-4 h; peak 12 h; normal 24 h - MONA: morphine, oxygen, nitroglycerin, aspirin.

dysrhythmias

- Disturbance in HR or rhythm - Often asymptomatic until CO altered. CAUSES 1. Drugs (e.g., digoxin, quinidine, caffeine, nicotine, alcohol), illicit drugs 2. A/B and electrolyte imbalances (K, Ca, MG) 3. Marked thermal change; Disease and trauma; Stress A. Change in pulse rate or rhythm B. ECG changes C. C/O Palpitations; Syncope; Pain; Dyspnea; Diaphoresis; Hypotension; Electrolyte imbalances Dx: Risk for dec tissue perfusion; Activity intolerance; Dec CO 1. Afib: Chaotic activity in AV node. No true P waves visible. Irregular ventricular rhythm a. Anticoagulant therapy- risk for stroke b. Diltiazem, metoprolol, digoxin, amiodarone c. Sync Cardioversion if < 48 h d. Cardiac catheter ablation 2. Aflutter: Saw-toothed waveform. Fluttering in chest. Ventricular rhythm regular a. same tx as Afib 3. Vtach: Wide, bizarre QRS, Impaired CO a. Synch cardioversion if unstable & pulse present (if no pulse, tx as vfib) b. Antidysrhythmic drugs if stable- amiodarone 4. Vfib: Cardiac emergency. Irregular undulations of varying amplitudes, from coarse to fine. No cardiac output (no pulse or BP) a. CPR b. Defibrillation as quickly as possible c. Epi, Antidysrhythmic drugs (amiodarone) A. Determine meds currently taking, serum drug levels, electrolyte levels (esp K & Mg) B. Be prepared for emergency measures, such as cardioversion or defibrillation. C. Be prepared for pacemaker insertion. 1. Temporary: temporarily in emergency situations. A pacing wire is threaded into the RV via SVC, or an epicardial wire is put in place (through the client's chest incision) during cardiac surgery. 2. Permanent internal pacemaker w/ pulse generator implanted in abd or shoulder: may be single or dual chambered. Programmable pacemakers can be reprogrammed by placing a magnetic device over the generator. 3. Instruct the client to: Report pulse rate < set rate of pacemaker; Avoid leaning over an automobile w/ the engine running; Stand 4-5 ft away from high-output generators and electromagnetic sources; Avoid MRIs; notify TSA of the presence of a pacemaker. K. Recognize and treat symptomatic PVCs - Holter monitor offers continuous observation of HR. Keep a record of: Med times and doses; Chest pain episodes; Valsalva maneuver; Sexual activity; Exercise and other activities • Synchronous, or demand: Pacemaker fires only when the client's HR falls below a rate set on the generator. • Asynchronous, or fixed: Pacemaker fires at a constant rate. • Implantable cardioverter defibrillator (ICD); device defibrillates to detect life-threatening ventricular arrhythmias. May have dual function as a pacemaker.

infective & inflammatory heart disease

- Endocarditis: inflam disease of the inner surface of the heart, including valves. Organisms travel through the blood to the heart, where vegetations adhere to the valve surface or endocardium and can break off and become emboli. Causes: Rheumatic heart disease, CHD, IV drug abuse, Cardiac surgery, Immunosuppression, Invasive procedures - Pericarditis inflam of outer lining of heart. Causes: MI, Trauma, Neoplasm, Connective-tissue disease, Heart surgery, Idiopathic, Infections A. Endocarditis: 1. Fever 2. Chills, malaise, night sweats, fatigue 3. Murmurs 4. s/s HF 5. Atrial embolization B. Pericarditis: 1. Pain: sudden, sharp, severe; Substernal, radiating to back or arm; Aggravated by coughing, inhalation, DB; Relieved by leaning forward. 2. Pericardial friction rub @ left lower sternal border. 3. Fever; 4. ST-segment elevation, T-wave inversion Dx: Dec CO; Risk for injury: emboli A. Endocarditis 1. Monitor hemodynamic status (VS, LOC, urinary output). 2. IV Abx 4-6 wks & before dental or GU procedures in high-risk pts. 3. Teach clients about anticoagulant therapy if prescribed. 4. Maintain good hygiene. 5. Inform dentist and other HCPs of hx B. Pericarditis 1. Provide rest and maintain position of comfort. 2. Analgesics & antiinflammatory drugs. - Valvular stenosis or regurgitation (insufficiency), most commonly of the mitral valve, can occur, depending on the type of damage inflicted by the lesions, and can lead to s/s of L or R HF - Acute endo: often affects individuals w/ previously normal hearts and healthy valves and carries a high mortality rate - Subacute endo: affects individuals w/ preexisting conditions (rheumatic heart disease, mitral valve prolapse, immunosuppression) - IV drug users: valves on R side (tricuspid, pulmonic) affected bc of introduction of common pathogens that colonize skin into venous system

BPH

- Enlargement or hypertrophy of the prostate - Men over 40 - Tx: 1. active surveillance (watchful waiting), 2. drug therapy w/ 5-alpha-reductase (finasteride (Proscar)) and alpha-adrenergic receptor blockers (tamsulosin), 3. surgery. - TURP: prostate is removed by endoscopy (no surgical incision is made), allowing for a shorter hospital stay. A. Inc frequency of voiding, w/ a dec in amt; Nocturia; Hesitancy; Terminal dribbling; Dec in size and force of stream B. Acute urinary retention; Bladder distention; Recurrent UTIs Dx: Acute or chronic pain; Risk for injury: hemorrhage/ infection; Risk for urinary retention r A. Preop teaching: Pain from bladder spasms postop. B. Patent urinary drainage system (large 3-way indwelling catheter with a 30-mL balloon) to dec spasms. C. Pain relief D. Minimize cath manipulation; Maintain gentle traction on cath. E. Check urinary drainage system for clots & Irrigate bladder- If continuous, keep Foley bag emptied to avoid retrograde pressure. F. Observe color and content of urinary output: Normal drainage is reddish pink, clearing to light pink w/in 24 hrs. Small to medium blood clots may be present. Monitor for bright-red bleeding w/ large clots and inc viscosity. G. Monitor VS for indication of hemorrhagic or hypovolemic shock; H&H H. After cath removed: Monitor amt and # of times client voids; Encourage fluids; Use urine cups for specimen w/ each voiding; Observe for hematuria (urine should be clear yellow color by 4th day); Burning on urination and frequency during 1st postop wk; Sterility may occur; Monitor urethral stricture: straining, dysuria, weak urinary stream; Antispasmodics; Ambulate 1st postop day I. Increase fluid intake to 3000 mL/day. J. Teach: Drink 12-14 glasses/day; Avoid constipation, straining, strenuous activity, lifting, intercourse, sports during the 1st 3-4 wks - Cath may cause a continuous sensation of bladder fullness. Try to void around the catheter bc bladder spasms may occur. - Hypertonic or hypotonic solution into a body cavity will cause a shift in cellular fluid. Use only sterile saline (isotonic) for bladder irrigation after TURP to prevent F&E imbalance.

cushing syndrome

- Excess adrenocorticoid activity - Cause: chronic admin of corticosteroids; adrenal, pituitary, hypothalamus tumors. A. Physical: 1. Moon face 2. Truncal obesity 3. Buffalo hump 4. Abd striae 5. Muscle atrophy 6. Thinning of skin 7. Hirsutism in females 8. Hyperpigmentation 9. Amenorrhea 10. Edema, poor wound healing 11. Impotence 12. Bruises easily B. HTN, Osteoporosis, infection susceptibility, PUD formation, C. Labs: 1. Hyperglycemia 2. Hypernatremia 3. Hypokalemia 4. Dec eosinophils and lymphocytes 5. Inc plasma cortisol 6. Inc urinary hydroxycorticoids Dx: Excess fluid vol; Risk for infection; Disturbed body img; Imbalanced nutrition: more than body requirements; Impaired skin integrity A. Protect from exposure to infection. B. Good handwashing technique. C. Monitor s/s of infection: 1. Fever 2. Oral infection 3. Vaginal yeast 4. Adventitious lungs sounds 5. Skin lesions 6. Elevated WBCs D. Teach Safety: 1. Position bed close to floor, call light w/in easy reach. 2. SR use 3. Walkways unobstructed. 4. Wear shoes when ambulating. E. Low-Na diet; Consume Vit D & Ca. F. Good skin and perineal care. G. Discuss possibility of weaning from steroids after surgery. (If too quickly, s/s Addison disease) H. I&O & daily wt. J. Ulcer prophylaxis. K. Take steroids w/ meals to prevent gastric irritation. Never skip doses. n/v > 12-24 h, contact HCP

altered LOC

- GSC: 1. Max 15; min 3 or less indicates coma. - Assess pupil size, limb movement, VS (BP, temp, pulse, respirations); skin & corneal integrity; bladder for fullness, auscultate lungs, monitor cardiac status. - Maintain adequate resp, airway, oxygenation. - Position in 3/4 prone or semiprone position to prevent tongue from obstructing airway and slightly to 1 side w/ arms away from chest wall. - Insert airway if tongue is obstructing or if pt paralyzed; ETT; suctioning - Arterial PO2 and PCO2 - CPT; nutritional and F&E support. NPO until responsive, mouth care q 4 h; Feedings as prescribed; Monitor I&O; Wt - Prevent complications of immobility: Skin breakdown (turn q2h, skin care), DVT (SCDs, anticoag), Urinary calculi (fluids); Contractures & joint immobility(ROM q4h) - Monitor and evaluate VS changes: 1. HR <60 or >100 bpm w/inc ICP. >100 bpm w/ indicate infection, thrombus formation, dehydration. 2. BP: rising BP or widening PP w/ ICP. 3. Temp: elevation can indicate worsening condition, damage to temp-regulating area of brain, infection. 4. LOC 5. Pupillary changes - Prevent injury and promote safety. Avoid oversedating - Maintain hygiene and cleanliness - Rapid infusion of tube feedings may cause diarrhea; lack of fiber and inadequate fluids may cause constipation. - Fed via enteral routes bc the likelihood of aspiration is high w/ oral feedings. 100 mL of residual in an adult usually indicates poor gastric emptying, and the feeding should be w/held; however, the residual should be returned because it is partially digested. - Paralytic ileus is common- gastric tube aids in gastric decompression. - If temp elevates, take quick measures to dec it- fever inc cerebral metabolism and can inc cerebral edema. - Restlessness may indicate a return to consciousness but can also indicate anoxia, distended bladder, covert bleeding, inc cerebral anoxia.

glaucoma

- Gradual painless vision loss that can lead to blindness if untreated. - Aqueous fluid inadequately drained from the eye. A. Inc IOP > 22 B. Dec accommodation or ability to focus C. Late signs: 1. Loss of peripheral vision 2. Halos around lights 3. Dec visual acuity not correctable w/ glasses 4. HA or eye pain D. Dx: 1. Tonometer measures IOP E. @ Rsik: FH, DM, ocular problems; antihistamine/anticholinergic use A. Eye drops: - Parasympathomimetics (pilocarpine; pupil constriction; caution w/ pregnancy, asthma, HTN) - Beta-adrenergic receptor-blocking agents (-lol; inhibits aqueous humor production; caution w/ asthma, 2nd/3rd block, taking antiHTN meds) - Carbonic anyhydrase inhibitors (-zolamide; dec aqueous humor production; contra: sulf allergy) - Alpha agonist (-idine; lowers IOP by dec fluid production) - Prostaglandin antagonists (-prost; lowers IOP by inc outflow) B. Orient to surroundings; Saftety, Announce self/what is happening; Avoid nonverbals C. Teach eye drop admin: Instill drop into lower lid, w/out touching lid w/ the tip of the dropper. Close eye 3-5 min. Apply gentle pressure on inner canthus to dec systemic absorption. D. Safety measures to prevent injuries; Avoid activities that may inc IOP - Eye drops used to cause pupil constriction bc movement of muscles to constrict the pupil also allows aqueous humor to flow out, thereby dec pressure in eye (Pilocarpine- vision may be blurred 1-2 h after & adaptation to dark environments).

valvular heart disease

- Heart valves that are unable to open fully (stenosis) or close fully (insufficiency or regurgitation) - Causes: Rheumatic fever, CHD, Syphilis, Endocarditis; HTN A. Pericardial effusion w/ possible tamponade that requires pericardiocentesis B. Fatigue; Dyspnea, orthopnea C. Hemoptysis, pulm edema D. Murmurs; Irregular cardiac rhythm; Angina Dx: Dec CO, Impaired gas exchange; Excess fluid vol r/t fluid retention secondary to valvular-induced HF; Activity intolerance r A. HF management B. Monitor for afib w/ thrombus formation. C. Prophylactic abx before any invasive procedure D. Prepare the client for surgical repair or replacement of heart valves. E. Mechanical valve replacement- need lifelong anticoagulant therapy to prevent thrombus formation. Tissue (biologic) valves and autografts do not require this. - In mitral valve stenosis, blood is regurgitated back into the LA from LV. In the early period, there may be no symptoms, but as the disease progresses, the client will exhibit excessive fatigue, dyspnea on exertion, orthopnea, dry cough, hemoptysis, pulm edema, rumbling apical diastolic murmur, afib

hiatal hernia & GERD

- Hiatal hernia: herniation of the esophagogastric junction and a portion of the stomach into chest through esophageal hiatus of diaphragm. - GERD: incompetent LES that allows regurgitation of acidic gastric contents into esophagus. A. Heartburn after eating that radiates to arms and shoulders B. Feeling of fullness and discomfort after eating C. + dx determined by fluoroscopy, barium swallow, gastroscopy Dx: Acute pain; Deficient knowledge; Anxiety; Imbalanced nutrition: less than body requirements A. Eating pattern that alleviates symptoms: small, frequent meals; eliminate caffeine, ketchup, strawberries, chocolate; sit up while eating and remain in upright for 1 hr after; don't eat 3 h before bed; Elevate HOB on 6- to 8-inch blocks (fowler, semi-fowler); H2 antagonists, PPIs antacids B. Differentiate b/t s/s of hiatal hernia and MI. C. Be alert to possibility of aspiration.

colorectal CA

- Highest incidence > 50 - Diet of high-fiber, low-fat, cruciferous vegetables (broccoli, cauliflower, Brussels sprouts, cabbage, kale), less animal fat may be a factor in prevention - Tx: surgical removal of the tumor, w/ adjuvant radiation or antineoplastic chemo - Dx made by DRE (should be done q yr after 40), flexible fiberoptic sigmoidoscopy w/ biopsy, colonoscopy, barium enema. A. Rectal bleeding (early s/s); Change in bowel habits; Sense of incomplete evacuation, tenesmus; Abd pain, n/v; Wt loss, cachexia; Abd distention or ascites B. FH, HO polyps Dx: Deficient knowledge; Ineffective coping; Disturbed body image A. Prepare for surgery & bowel preparation, which may include laxatives and gut lavage w/ polyethylene glycol (GoLYTELY). B. If colostomy has been performed, teach stoma care ( C. Provide high-cal & protein diet. D. Prevention of constipation w/ high-fiber Stoma Care 1. The more distal the stoma is, the > chance for continence- sigmoid colon on L side of abd 2. An ileostomy drains liquid material; peristomal skin is prone to breakdown by enzymes. 3. The lower the stoma's location is in the GI tract, the more solid Pouch care 1. The adhesive-backed opening, designed to cover the stoma, should provide about ⅛-in clearance from the stoma. 2. Rubber band or clip is used to secure the bottom of the pouch and prevent leakage. 3. A simple squirt bottle is used to remove effluence from sides of bag. Pouch system is changed q3-7d 4. Should be emptied when 1/3-1/2 full. 5. Those w/ descending-colon colostomies can irrigate to provide ctrl over effluence- @ the same time daily; use warm water; wash around stoma w/ lukewarm water and mild soap; skin barriers; odor ctrl 6. Ilesotomy- chew food thoroughly. Eliminate high-fiber foods (popcorn, peanuts, unpeeled vegetables)- can cause severe diarrhea 7. Colostomy- resume regular diet gradually. - stool blood test q yr after 50 & those w/ inc risk factors - colonoscopy or sigmoidoscopy q 10 yr after 50 in avg-risk clients

detached retina

- Hole or tear in, or separation of the sensory retina from, pigmented epithelium - Result of: inc age, severe myopia, eye trauma, retinopathy (diabetic), cataract or glaucoma surgery, FH or personal hx. - Surgery: 1. Cryotherapy (freezing) 2. Photocoagulation (laser) 3. Diathermy (heat) 4. Scleral buckling A. Bed rest; eye patch; pain ctrl B. Meds to inhibit accommodation and constriction; cycloplegics (mydriatics and homatropine) to dilate pupil before surgery. C. If gas bubble is used (inserted in vitreous), position client so bubble can rise against area to be reattached. D. Do not do any heavy lifting or straining w/ BM, no vigorous activity for several wks.

addison disease (primary adrenocortical deficiency)

- Hypofunction of the adrenal cortex - Sudden w/drawal from corticosteroids - Lack of cortisol, aldosterone, androgens. - Definitive dx: ACTH stimulation test. - If ACTH production by the ant. pituitary has failed, it is secondary A. Fatigue, weakness; Wt loss, a/n/v; Postural hypotension; Hypoglycemia; Hyponatremia; Hyperkalemia; Hyperpigmentation of MM and skin (primary); Signs of shock when in Addison crises; Loss of body hair; Hypovolemia; Hypotension; Tachycardia; Fever Dx: Deficient fluid vol; Deficient knowledge; Risk for electrolyte imbalance A. Frequent VS- q15min in crisis B. I&O & daily wt. C. Rrise slowly- postural hypo. D. During crises, IV glucose w/ parenteral hydrocortisone (mineralo & glucocorticoid properties); Large fluid vol replacement. E. Monitor electrolyte F. Low-stress environment (cannot physiologically cope w/ stress). G. Teach: lifelong replacement; s/s OD & underdosage; high Na, low K, high carb, 3 L fluids/day; ulcer prophylaxis. - Caution against stopping steroids abruptly- taper off - Addison crisis: sudden w/drawal of steroids, stressful event (trauma, severe infection), exposure to cold, overexertion, dec Na intake. • Vascular collapse: Hypotension, tachycardia; IV fluids at a rapid rate • Hypoglycemia: IV glucose. • Essential to reversing: Parenteral hydrocortisone. • Aldosterone replacement: fludrocortisone acetate (Florinef) PO w/ salt (NaCl) if pt has Na deficit.

HF

- Inability of the heart to pump enough blood to meet the tissue's O2 demands - Underlying conditions: Ischemic heart disease; MI; Cardiomyopathy; Valvular heart disease; HTN 1. L HF: pulm edema (1) Dyspnea (2) Orthopnea (3) Crackles (4) Cough (5) Fatigue (6) Tachycardia (7) Anxiety (8) Restlessness (9) Confusion (10) Paroxysmal nocturnal dyspnea (PND) 2. R HF: (1) Peripheral edema; often results from L HF or pulmonary disease (2) Wt gain (3) JVD (4) a/n (5) Nocturia (6) Weakness (7) Hepatomegaly (8) Ascites - Brain natriuretic peptide test measures levels of protein in heart and blood vessels. High BPN levels occur w. HF Dx: Dec CO; Impaired urinary elimination; Activity intolerance; Anxiety; Ineffective tissue perfusion A. Monitor VS q4h; AHR B. Assess for hypoxia: Restlessness; Tachycardia; Angina C. Auscultate lungs for pulm edema (wet sounds or crackles). D. O2 as needed. E. Elevate HOB to assist w/ breathing. F. Observe for signs of edema. Daily wt; I&O; abd girth; observe ankles and fingers. G. Limit Na intake. Restricting Na reduces salt and H2O retention, thereby reducing vascular vol & preload. H. Elevate lower extremities while sitting. I. W/hold digoxin if HR <60 bpm J. Administer diuretics in morning if possible

joint replacement

- Infection concern posto - Monitor incision site. Assess for bldg and drainage; erythema and edema. - Assess suction drainage apparatus for proper functioning. - Check circulation, sensation, movement of extremity - Proper alignment of affected extremity- abductor appliance (hip replacement) or CPM device if indicated. - Do not flex hip more than 90 degrees; Do not lift leg upward from a lying position or elevate knee when sitting (hip replacement). - I&O; Encourage fluid intake of 3 L/day, encourgae self-care - Rehab - Immobile clients prone: skin integrity problems, formation of urinary calculi

UTI

- Infection or inflam at any site in the urinary tract - @ Risk: DM; Pregnant women; Prostatic hypertrophy; Immunosuppressed; Catheterized; Urinary retention; Older women (bladder prolapse) Dx: Clean-catch midstream urine collection; IV pyelogram to determine kidney functioning; Cystogram to determine bladder functioning; Cystoscopy to determine bladder or urethral abnormalities A. Signs of infection- fever and chills B. Urinary frequency, urgency, dysuria; Hematuria C. CVA tenderness D. Elevated WBCs (>10,000) E. Disorientation or confusion in older adults Dx: Acute pain; Impaired urinary elimination; Deficient knowledge; Risk for infection A. Admin abx- take ATC, don't to skip doses so that a consistent blood level can be maintained for optimal effectiveness. B. Fluid intake of 3000 mL/day. C. Maintain I&O. D. Administer mild analgesics (phenazopyridine [Pyridium], acetaminophen, aspirin). E. Void q2-3h F. Avoid unnecessary catheterization &. Remove indwelling catheters w/in 24-48 hr of insertion G. Routine perineal hygiene H. Teach: Take entire prescription; Consume fluids up to 3 L/day (water, juices- no citrus juices); Shower rather than bathe; Front to back; AVOID alcohol, sodas, citrus juices, spices; Cotton undergarments and loose clothing

pneumonia

- Inflam of lower resp tract - Organisms reach lungs by: 1. Aspiration 2. Inhalation 3. Hematogenous spread - May be community-acquired or medical care-associated pneumonia (HAP, VAP) - High-risk groups: 1. Debilitated by accumulated lung secretions (asthma, COPD, sickle cell anemia) 2. Cigarette smokers 3. Immobile 4. Immunosuppressed 5. Depressed gag and/or cough reflex 6. Sedated 7. NM disorders 8. NG/OG intubation 9. Hospitalized client A. Tachypnea: shallow respirations, accessory muscle use B. Abrupt onset of fever w/ shaking and chills (not reliable in older adults) C. Productive cough w/ pleuritic pain D. Rapid, bounding pulse E. Older adults: Confusion; Lethargy/malaise; Anorexia; Rapid RR; Tachycardia F. Pain and dullness to percussion G. Bronchial breath sounds ("E" to "A" changes in lungs (egophony)), crackles H. Tactile fremitus (chest vibrations w/ "99"); Infiltrates w/ consolidation or pleural effusion I. Elevated WBC J. ABG indication of hypoxemia Drop in SpO2 (should be >90%, ideally >95%) Dx: Impaired gas exchange; Ineffective airway clearance; Activity intolerance; Risk for deficient fluid vol; Ineffective breathing pattern; Risk for imbalanced body temp A. Assess sputum vol, color, consistency, clarity, odors B. Assist client to cough productively by: DB q2h (may use IS); Using humidity to loosen secretions (may be oxygenated); Suctioning airway; CPT C. Fluids up to 3 L/day unless contraindicated D. Lung sounds before and after coughing. E. Rate, depth, pattern of resp F. Monitor ABGs (PO2 >80 mm Hg; PCO2 <45 mm Hg). G. Monitor SpO2 (ideally >95%). H. Skin color (nail beds, MM). I. Mental status, restlessness, irritability. J. Humidified O2 K. Monitor temp regularly. L. Adequate rest periods M. Admin abx (begin even if it may be viral) - Inc temp = incr metabolism & O2 demand. can also cause dehydration d/t diaphoresis. - Bronchial breath sounds heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue. - Irritability and restlessness: early signs of cerebral hypoxia Clients at High Risk for Pneumonia • Altered LOC • Brain injury • Depressed/absent gag and cough reflexes • Susceptible to aspirating oropharyngeal secretions (alcoholics, anesthetized) • Drug OD • Stroke victims • Immunocompromised Hydration • Thins out mucus, facilitating expectoration • Essential for client experiencing fever • 300-400 mL fluid lost daily by the lungs through evaporation Preventives • Older adults: Annual flu vac; pneumococcal vac @ 65 + and younger clients @high risk; avoiding sources of infection and indoor pollutants (dust, smoke, and aerosols); no smoking • Immunosuppressed and debilitated persons: Annual flu vac, pneumonia vac, avoid infections, sensible nutrition, adequate fluid intake, appropriate balance of rest and activity • Comatose and immobile persons: HOB 30 for feeding and 1 hr after; turn frequently • Patients w/ functional or anatomic asplenia: Flu and pneumonia vac

thrombophlebitis

- Inflam of venous walls w/ the formation of a clot A. Calf tenderness, redness or pain, calf pain w/ dorsiflexion of foot B. Functional impairment of extremity C. Edema and warmth D. Asymmetry E. Dx: Venogram; Doppler US; Fibrinogen scanning F. Risk factors: Prolonged, strict bed rest; General surgery; Leg trauma; Previous venous insufficiency; Obesity; OCPs; Pregnancy; Malignancy Dx: Acute pain; Ineffective peripheral tissue perfusion A. Anticoagulant therapy: Observe for SE (bldg). B. PTT determines efficacy of heparin. C. PT or INR determines efficacy of Coumadin. D. Use soft toothbrush, waxed floss; avoid alcohol, safety razors, aspirin & NSAIDs. D. Wear antiembolic stockings. elevate extremity, use shock blocks at foot of bed, bed rest, avoid straining. E. Monitor for dec pain, edema F. Monitor for PE (chest pain, SOB). G. Dietary precautions w/ warfarin (Coumadin): avoid high K foods (can maintain intake, but don't inc) - Heparin: Do not massage area or aspirate; give in the abd b/t the pelvic bones, 2 in from umbilicus; rotate sites. - Heparin Antagonist: protamine sulfate; PTT or aPTT determines efficacy- Keep 1.5-2.5x normal - Warfarin (Coumadin) Antagonist: vit K; PT determines efficacy Keep 1.5-2.5x normal; INR desirable therapeutic level usually 2:3

testicular CA

- Leading cause of death from CA in males 15- - If detected and tx early, 90-100% chance of cure. - Men whose testes have not descended into the scrotum or whose testes descended after age 6 are at high risk - Most common s/s: small, hard lump about the size of a pea on the front or side of the testicle. - TSE should be done regularly at the same time q mo after age 14. Done after a shower by gently palpating the testes and cord to look for a small lump. Swelling may also be a sign A. Early signs are subtle and usually go unnoticed. B. Feeling of heaviness or dragging sensation in lower abd and groin. C. Lump or swelling (painless) on testicle. D. Late signs: 1. Low back pain 2. Wt loss 3. Fatigue A. Postop care after orchidectomy: Observe for hemorrhage. Active movement may be contraindicated. B. Care for clients receiving radiation therapy. C. Encourage genetic counseling (sperm banking is often rec). D. Sexual functioning usually not affected bc the remaining testis undergoes hyperplasia, producing sufficient T to maintain sexual functioning.

hodgkin disease

- Malignancy of the lymphoid system that initiates in a single lymph node - Generalized painless lymphadenopathy. 1. Stage I: single lymph node region or a single extralymphatic organ or site. 2. Stage II: 2+ lymph nodes on the same side of the diaphragm or localized involvement of an extralymphatic organ or site. 3. Stage III: lymph node areas on both sides of the diaphragm to localized involvement of 1 extralymphatic organ, the spleen, or both. 4. Stage IV: diffuse involvement of 1+ extralymphatic organs, with or without lymph node involvement. - Tx: 1. Radiotherapy 2. Chemo: ABVD (Adriamycin, Blenoxane, Velban, Dacarbazine) 3. Splenectomy A. Enlarged lymph nodes, usually cx B. Anemia, thrombocytopenia, elevated leukocytes, dec plt C. Fever, inc susceptibility to infections D. Anorexia, wt loss E. Malaise, bone pain F. Night sweats G. Pruritus H. Pain in affected lymph node after consuming alcohol A. Protect from infection; monitor temp carefully. B. Observe for signs of anemia. C. Adequate rest. D. Preop and postop care for laparotomy or splenectomy. E. High-nutrient foods.

SCI

- Most common: C5, C6, C7, T12, L1. - Permanent impairment cannot be determined until spinal cord edema has subsided, usually by 1 wk. A. Assess breathing pattern, auscultate lungs. B. Frequent neuro VS, esp sensory and motor functions. Assess cardiovascular status. C. Assess abd: girth, bowel sounds; assess lower abd for bladder distention. D. Assess temp, hyperthermia occurs commonly. E. Assess psychosocial status. F. Hypotension & bradycardia w/ any injury above T6 bc sympathetic outflow is affected. Acute Phase: 1. Altered LOC intervention. 2. Extended position w/ c-collar 3. Stabilize when transferring 4. Maintain a patent airway (most important). 5. In cx injuries, skeletal traction is maintained by use of skull tongs or a halo ring (Crutchfield tongs or a Gardner-Wells fixation device). 6. High-dose corticosteroids help ctrl edema during the first 8 to 24 hours. 7. Kinetic therapy tx table (RotoRest bed), which provides continuous side-to-side motion. 8. Assess for resp failure, esp in clients w/ high cx injuries. 9. Further loss of sensory or motor function below injury can indicate additional damage to cord d/t edema and should be reported immediately. 10. Evaluate for presence of spinal shock (complete loss of reflex, motor, sensory, autonomic activity below lesion). Emergency immediately after injury. Hypotension, bradycardia; Complete paralysis and lack of sensation below lesion; Bladder and bowel distention 11. Evaluate for autonomic dysreflexia (exaggerated autonomic responses to stimuli), w/ lesions at or above T6. Emergency after the period of spinal shock has finished; triggered by a noxious stimulus (bowel or bladder distention) Elevated BP; Pounding HA, sweating, nasal congestion, goose bumps, bradycardia; Bladder and bowel distention 12. Watch for acute paralytic ileus, lack of gastric activity- bowel sounds; gastric suction to reduce distention, prevent vomiting and aspiration. rectal tube to relieve gaseous distention. 13. Suction w/ caution to prevent vagus nerve stimulation 14. IV high-dose corticosteroids to dec edema & cord damage. B. Rehabilitative phase: - DB; CPT - Kinetic bed to promote blood flow to extremities - SCDs; ROM; Mobilize to chair ASAP - Turn frequently; Clean and dry; Skin care - Intermittent cath q4h; Bladder-emptying techniques; Monitor I&O; Drink fluids that promote acidic urine (cranberry juice, prune juice, bouillon, tomato juice, water) - Rehab - Concentrate on resp status, esp in injury @ C3-C5, bc the cervical plexus innervates diaphragm. - A common cause of death is UTI. Bacteria grow best in alkaline media, so keeping urine dilute and acidic is prophylactic against infection. Keep bladder emptied

pancreatitis

- Nonbacterial inflam of pancreas - ACUTE: digestion of pancreas by its own enzymes, primarily trypsin. Alcohol ingestion and biliary tract disease are major causes. Pain is located retroperitoneally. Any enlargement of the pancreas causes the peritoneum to stretch tightly. Therefore sitting up or leaning forward reduces the pain 1. Severe midepi pain radiating to back; usually r/t excess alcohol ingestion or a fatty meal 2. Abd guarding; rigid, boardlike, pain; n/v 3. Elevated temp, tachycardia, dec BP 4. Bluish discoloration of flanks (Grey Turner sign) or periumbilical area (Cullen sign) 5. Elevated amylase, lipase, triglycerides, glucose 6. Low serum Ca - CHRONIC: progressive, destructive disease that causes permanent dysfunction. LT alcohol use is the major factor 1. Continuous burning or gnawing abd pain 2. Recurring attacks of severe upper abd and back pain 3. Ascites 4. Steatorrhea, diarrhea, wt loss 5. Jaundice, dark urine 6. s/s of DM Dx: Acute pain; Chronic pain; Imbalanced nutrition: less than body requirements; Deficient fluid volume; Risk for electrolyte imbalance Acute 1. Maintain NPO status; NGT to suction; TPN; 2. Hydromorphone (Dilaudid) or fentanyl (Sublimaze) PRN 3. Antacids, histamine H2 receptor-blocking drugs, anticholinergics, PPIs 4. Position on side w/ legs drawn up to chest. 5. Avoid alcohol, caffeine, fatty and spicy foods. BG monitoring & regular insulin 6. NM manifestations of hypocalcemia (tetany, muscle twitching, cramping, grimacing, seizure, altered DTRs, spasm). 7. Semi-Fowler position to dec pressure on diaphragm. 8. C/DB; IS 9. Monitor ECG for dysrhythmias r/t electrolyte imbalances. Chronic 1. Hydromorphone (Dilaudid), fentanyl (Sublimaze), morphine; Pancreatic enzymes (pancreatin (Creon) or pancrelipase (Viokase)) w/ food- Powdered forms should be mixed w/ fruit juice or applesauce (mixing with proteins should be avoided). 2. Monitor stools for # and consistency to determine effectiveness of enzyme replacement. 3. Bland, low-fat diet; Avoid rich foods, alcohol, caffeine. 4. Monitor for s/s DM

OA

- Noninflammatory arthritis - Degeneration of cartilage, wear-and-tear process. - Asymmetric. - Obesity and overuse A. Joint pain that inc w/ activity and improves w/ rest B. Morning stiffness C. Asymmetry D. Crepitus E. Limited movement F. Visible joint abnormalities G. Joint enlargement & bony nodules - Dx: Chronic pain; Impaired physical mobility; Deficient self-care; Deficient knowledge A. Manage like RA B. Wt-reduction diet. C. Excessive use aggravates pain D. Teach: 1. Use correct posture and body mechanics 2. Sleep w/ rolled terry cloth towel under c-spine w/ neck pain 3. Relieve pain in fingers and hands by wearing stretch gloves @ night 4. Keep joints in functional position

amputation

- Observe wound color, warmth, approximation of incision. Monitor for infection. - Elevate residual limb (stump) 1st 24 h postop. If elevated too high, can cause a contracture. - Do not elevate after 48 h postop. - Keep in extended position, and turn client to prone position 3x/day to prevent hip flexion contracture. - Phantom limb pain: real & responds meds

cataract

- Opacity of the lens. - Surgical removal when vision impairment interferes w/ daily activities. Intraocular lens implants may be used. Under local anesthesia on an outpt basis. - Lens is responsible for projecting light onto retina so that imgs can be discerned. W/out the lens, which becomes opaque w/ cataracts, light cannot be filtered, vision is blurred A. Early: 1. Blurred vision 2. Dec color perception 3. Photophobia B. Late: 1. Diplopia 2. Reduced visual acuity, progressing to blindness 3. Clouded pupil C. Dx: 1. Ophthalmoscope; Slit-lamp biomicroscope; Keratometry; A-scan ultrasound Analysis A. Preop Teaching: Med instillation; Don't rub or put pressure on eye, Glasses or shaded lens during day; Eye shield while sleeping; Avoid lifting > 5 lb, activity that can inc IOP; Keep water from getting into eye; Report inc IOP and infection

head injury

- Open TBI: fracture of the skull or penetration by an object. - Closed TBI: result of blunt trauma (more serious bc of chance of inc ICP in closed vault). - Inc ICP: main concern in head injury; it is r/t edema, hemorrhage, impaired cerebral autoregulation, hydrocephalus. A. Unconsciousness or disturbances in consciousness B. Vertigo C. Confusion, delirium, disorientation D. S/s inc ICP: 1. Change in level of responsiveness most important 2. Changes in VS- slow/irregular resp, inc/dec pulse, rising BP or widening PP, temp rise 3. HA 4. Vomiting (projectile) 5. Pupillary changes E. Seizures F. Ataxia G. Abnormal posturing (decerebrate- extension; decorticate- flexion) H. CSF leakage through nose (rhinorrhea) or through ear (otorrhea). I. Hematomas. J. CT scan or MRI will show a lesion- epidural or subdural hematoma, requiring surgery. K. EEG determines presence of seizure activity. A. Maintain adequate ventilation and airway. Monitor PO2 and PCO2. Semiprone or lateral recumbent to prevent aspiration. Turn side to side to prevent lung secretion stasis. HOB 30-45 to aid venous return & dec cerebral vol. C. Neuro checks qh; continuous record of observations and GCS ratings. D. Avoid activities that inc ICP: 1. Change in bed position for caregiving and extreme hip flexion 2. Endotracheal suctioning 3. Compression of jugular veins (keep head straight and not to 1 side) 4. Coughing, vomiting, straining E. If temp inc, take immediate measures to reduce (aspirin, acetaminophen, cooling blanket) bc ICP inc; avoid shivering. F. Intracranial monitoring system: 1. Catheter inserted into lateral ventricle, a sensor placed on dura, or a screw into subarachnoid space attached to a pressure transducer. ICP > 20 mm Hg should be reported G. Reduce ICP w/: 1. Hyperosmotic agents & diuretics to dehydrate brain and reduce cerebral edema (Mannitol- Pulls fluid from brain to blood to be excreted vie kidneys. Be careful w/ CHF & renal failure (risk for fluid overload), Urea 2. Steroids (Dexamethasone (Decadron)), Methylprednisolone sodium succinate (Solu-Medrol)) 3. Barbiturates (reduce brain metabolism & systemic BP) I. Foley to prevent restlessness caused by distended bladder and to monitor balance b/t restricted fluid I&O, especially if placed on osmotic diuretics. J. Passive hyperventilation on ventilator to reverse hypercapnia: leads to resp alkalosis --> cerebral vasoconstriction and dec cerebral blood flow --> dec ICP. K. Seizure precautions. L. Prevent complications of immobility - Even subtle behavior changes (restlessness, irritability, confusion) may indicate inc ICP. - CSF leakage carries risk for meningitis and indicates a deteriorating condition. Bc of CSF leakage, usual s.s of inc ICP may not occur - Try not to use restraints; they only increase restlessness. Avoid narcotics- mask level of responsiveness.

urinary tract obstruction

- Partial or complete blockage of the flow of urine at any point in the urinary system - Foreign body (calculi); Tumors; Strictures; Functional (e.g., neurogenic bladder) - Urine is retained above the obstruction. - Hydrostatic pressure builds, causing dilation of organs above the obstruction. Hydronephrosis develops --> renal failure. A. Pain: Renal colic; Radiating down thigh and to genitalia B. Fever, chills, n/v/d, abd distention C. Change in voiding pattern: Dysuria, hematuria; Urgency, frequency, hesitancy, nocturia, dribbling; Difficulty in starting a stream; Incontinence Dx: Acute pain; Impaired urinary elimination; Urinary retention; Risk for infection; Risk for injury A. Narcotics for pain and alpha-adrenergic blockers to relax smooth muscle in the ureter to facilitate stone passage. B. Moist heat to the painful area C. High oral fluid intake to help dislodge the stone. D. IV abx if infection present. E. Strain all urine! Send any stones found to lab. F. Accurately document I&O. G. Endourologic procedures: Cystoscopy; Cystolitholapaxy; Ureteroscopy; Percutaneous nephrolithotomy H. Lithotripsy: Ultrasonic; Electrohydraulic;. Laser; Extracorporeal shockwave I. Surgery: Nephrolithotomy; Pyelolithotomy; Ureterolithotomy; Cystotomy J. Teach: Follow-up care, bc stones tend to recur; High fluid intake of 3-4 L/day; Prescribed diet (based on composition of stone); Avoid long periods of remaining in supine position • Flank pain: stone in kidney or upper ureter • Radiates to the abd or scrotum: stone in ureter or bladder. • Preferable to admin pain meds at regularly scheduled intervals rather than PRN to prevent spasm and optimize comfort. • Percutaneous nephrostomy: Needle or catheter inserted through skin into calyx of kidney. The stone may be dissolved by percutaneous irrigation w/ a liquid that dissolves the stone or by US sound waves (lithotripsy) that can be directed through the needle or catheter to break up the stone, which then can be eliminated through the urinary tract.

HTN

- Persistent > or equal to 140/90 - Essential (primary) HTN: no known cause (idiopathic). - Secondary HTN: in response to an identifiable mechanism or another disease - Genetic risk factors (nonmodifiable): FH, men at younger age than women; Inc age; Afr. Am; Alcohol, tobacco, caffeine; Sedentary lifestyle, obesity High Na and fat intake; OCPs, estrogens, steroids; Stress - Associated problems: Renal failure; Impaired renal function; Resp problems (esp COPD); Cardiac problems (esp valvular disorders); Dyslipidemia; DM E. A. HA, edema, nocturia, nosebleeds, vision changes (may be asymptomatic). B. Level of stress and source C. Personality type Dx: Deficient knowledge; Noncompliance; Ineffective tissue perfusion (peripheral) A. Teach: disease, meds, lifestyle, diet, risk factors, serum electrolytes, BUN, Cr q 90-120 days, BP & pulse monitoring B. Stress reduction; Wt loss; Tobacco cessation; Exercise C. Med SE: Impotence, Insomnia D. Low-salt, fat, cholesterol diet) - #1 cause of a stroke in hypertensive clients- noncompliance w/ med regimen. HTN is often symptomless, and antihypertensive meds are expensive and have SE. - alpha-adrenergic blockers (-zosin; peripheral vasodilator) - alpha/beta blocker (labetalol, carvedilol; dec BP w/out reflex tachy/bradycardia; contra: HF, heart block, COPD, asthma) - BB (-lol; dec HR & BP; contra: Asthma; caution: mask hypoglycemia, bronchospasm) - AIIRBs (-sartan) - ACEIs (-pril; monitor renal function; useful w/ DM) - CCBs (-pine, diltiazem, verapamil; avoid grapefruit) - vasodilators (hydralazine, minoxidil) - cantral-acting inhibitors (clonidine, guanabenz acetate, guanfacine, methyldopa)

CRF: ESRD

- Progressive, irreversible damage to nephrons and glomeruli, resulting in uremia - Dialysis becomes necessary. Transplantation is an alt A. HO high med usage B. FH renal disease C. Inc BP &/ chronic HTN D. DM E. Edema, pulm edema F. Dec urinary function: Hematuria; Proteinuria; Cloudy urine; Oliguric (100-400 mL/d);Anuric (<100 mL/day) H. Dialysis I. Previous kidney transplant J. Labs: Azotemia; Inc Cr & BUN; Dec Ca; Inc P, Mg, K, Na; Anemia Dx: Risk for electrolyte imbalance; Excess fluid vol; Imbalanced nutrition: less than body requirements; D. Dec CO A. Monitor serum electrolyte levels. B. Daily wt, strict I&O C. Check for JVD, other s/s of fluid overload. D. Monitor for per. and pulm edema. E. Low-protein, Na, K, P. F. Admin phosphate binders w/ food bc client is unable to excrete P (no Mg-based antacids). G. Protein intake to be of high biologic value (eggs, milk, meat) bc the client is on a low-protein diet. H. Fluid allowance is 500-600 mL > the previous day's 24-hr output. I. Alt periods of rest w/ periods of activity. J. Strict adherence to medication regimen; ask HCP before taking any OTC meds. K. Sodium polystyrene sulfonate (Kayexalate) for acute hyperkalemia. L. Complications: Anemia; Renal osteodystrophy (abnormal Ca metabolism causes bone pathology); Severe, resistant HTN; Infection; Metabolic acidosis M. Transplant:. Monitor for rejection, infection. Maintain immunosuppressive drug therapy - Uremia: Accumulation of waste products from protein metabolism. Protein must be restricted, but if protein intake is inadequate, a (-) N balance occurs, causing muscle wasting. GFR is most often used as an indicator of level of protein consumption. - Ensure high cal intake so protein is spared for its own work - Frequent monitoring of labs, esp serum albumin, prealbumin (may be a better indicator of recent or current nutritional status than albumin), ferritin for nutritional status.

larynx CA

- Prolonged use of ETOH & tobacco - Earliest sign: hoarseness, change in vocal quality > 2 wks. - - Tx: Radiation often w/ adjuvant chemo or surgical removal of the larynx (laryngectomy). A. MRI B. Direct laryngoscopy C. Hoarseness of > 2 wks D. Color changes in mouth or tongue- white, gray, dark brown, black; may appear patchy. E. Dysphagia, dyspnea, cough, hemoptysis, wt loss, neck pain radiating to ear, enlarged cervical nodes, halitosis (later changes) F. Radiographs of head, neck, chest G. CT of neck and biopsy Dx for laryngectomy: Risk for aspiration; Anxiety; Ineffective airway clearance; Impaired verbal communication; Ineffective breathing pattern; Imbalanced nutrition: less than body requirements A. Preop teaching: tracheostomy tubes, suctioning, communication methods, SLP, rehab B. Postop care: Simplify communications; call bell/light; yes/no ?s C. Promote resp functioning. RR & characteristics q1-2h; Semi-Fowler; humidify laryngeal airway; lung sounds q2-4h; Suction excess secretions; tracheostomy care q2-4h & PRN; tube feedings; ambulation ASAP - Natural humidifying pathway is gone for the client who has had a laryngectomy. If the air is not humidified before entering the lungs, secretions tend to thicken and become crusty. - Laryngectomy tube: larger lumen, shorter than tracheostomy tube. Observe for bleeding or occlusion, - Fear of choking is very real for laryngectomy clients. cannot cough as they could earlier. Teach the glottal stop technique to remove secretions (take a deep breath, momentarily occlude the tracheostomy tube, cough, and simultaneously remove the finger from the tube).

prostate CA

- Rarely occurs before 40 - @ Risk: HO multiple sexual partners, STDs, certain viral infections, FH. A. Asymptomatic if confined to gland B. S/s of urinary obstruction C. W/ metastasis: low back pain, fatigue, aching in legs, hip pain D. Elevated PSA- PSA test should be conducted before DRE so that manipulation of the prostate does not give a false-positive reading. PSA can rise w/ inflam, BPH, irritation, in response to CA. E. Elevated prostatic acid phosphatase (PAP) F. DRE revealing palpable nodule G. Transrectal ultrasound (TRUS) visualizing nonpalpable tumors H. Definitive diagnosis by biopsy A. Importance of early detection. B. Prepare client for radiation therapy 1. External beam "teletherapy" radiation irradiates the prostate and pelvic region. (1) Need for repetitive tx (2) Attend all sessions for successful outcome. SE: (1) Radiation-induced cystitis or proctitis (2) Dysuria- Subsides 4-6 wk (3) Daytime voiding frequency (4) Inc in # of x awakens to void (5) Suprapubic discomfort—may irritate the perineal skin; cleanse perineal skin w/ a mild cleanser & lukewarm water, pay special attn to skin folds, pat dry, loose cotton clothing to relieve skin irritation. (6) Fatigue and loss of appetite: 6 small meal/day, high in protein and carbs; daily multivitamin 2. Proton beam radiotherapy combines conformal imaging and charged protons to target more specifically prostate CA cells while limiting damage to the overlying skin or adjacent structures including the bladder and rectum 3. Brachytherapy: internal implantation of radioactive iodine-125 or palladium-103 seeds directly into the prostate, which emit highly localized radiation energy to kill localized cancer cells without excessive harm to nearby healthy cells. a. Prep: bowel cleansing, prophylactic abxs, clear liquid diet 12-24 h b. Rectal pressure or mild discomfort when US probe placed, but pain is not associated w/ implantation of radioactive seeds. c. Cath left in place that may be removed on the day of the procedure. Complete a voiding trial d. Seed implantation will cause inflam of prostate and may cause daytime voiding frequency, inc nocturia, difficulty initiating a urinary stream. e. Semen may have a brownish color over 1st 1-2 mo; intercourse should be avoided during this period and childbearing is contraindicated. f. Monitor stool for passage of large volumes of bright red blood (rare), and advise client about how to manage radiation cystitis and proctitis. g. Avoid close contact w/ pregnant women and infants, refrain from having children sit in their lap for a prolonged period 1st 2 mo C. reduce intake of foods or beverages likely to irritate the bowel or bladder (caffeine, heavily spiced, fatty foods) D. postop: 1. Monitor for urine leaks, hemorrhage, infection. 2. support dressing or supportive underwear to perineal incision. 3. donut cushion to relieve pressure on incision site while sitting. 4. Avoid rectal manipulation 5. low-residue diet until wound healing advanced. 6. prevent bowel action in the 1st postop wk to prevent contamination of incision.

AKI

- Rise in Cr and/or reduction in urine output. Occurs when metabolites accumulate in the body and urinary output changes. - Prerenal: interference w/ renal perfusion; hemorrhage, hypovolemia, dec CO, dec renal perfusion - Intrarenal: damage to renal parenchyma; prolonged prerenal, nephrotoxins (iodine, vancomycin, gentamycin), intratubular obstruction, infections (glomerulonephritis), renal injury, vascular lesions, acute pyelonephritis - Postrenal: obstruction of urine d/t tumors, BPH, etc A. HO taking nephrotoxic drugs (salicylates, abx, NSAIDs, ACEIs, ARBs) B. Alt in urinary output C. Edema, wt gain D. Change in mental status E. Hematuria F. Dry MM G. Drowsiness, HA, muscle twitching, seizures H. Diagnostics in oliguric phase: Inc BUN & Cr, K, spec. grav; Dec Na, pH; Fluid overload I. Diagnostics in diuretic phase: hypovolemia; dec K, Na, spec grav Dx: Excess fluid vol; Deficient fluid vol; Anxiety; Risk for electrolyte imbalance A. Monitor I&O accurately: Fluid restriction in oliguric phase (600 mL + previous 24-hr fluid loss) B. Daily wt: in oliguric phase, pt may gain up to 1 lb/day. C. Document and report any change in fluid vol status. D. Nutritional therapy E. Adequate protein intake (0.6 to 2 g/kg/day) depending on degree of catabolism F. Monitor labs to assess electrolyte status, esp. hyperkalemia & ECG changes. G. K restriction; Sodium polystyrene (Kayexalate) H. Na restriction. I. Assess LOC for subtle changes. J. Prevent cross-infection. K. Cardiac rate and rhythm - Normally, kidneys excrete approximately 1 mL/kg/hr. - A change in the number of ions or in the amt of fluid will cause a shift in 1 direction or the other. Na & Cl- primary ec ions. K & P- primary ic ions. - May not experience the oliguric phase but may progress directly to diuretic phase - @ Risk: CKD, older age, massive trauma, major surgical procedures, extensive burns, cardiac failure, sepsis, OB complications. - Body wt- good indicator of fluid retention and renal status. - Hyperkalemia: dizziness, weakness, cardiac irregularities, muscle cramps, diarrhea, nausea. - Limit high-K foods (bananas, orange juice, cantaloupe, strawberries, avocados, spinach, fish) and salt substitutes - Limit fluid and Na intake - During oliguric phase, minimize protein breakdown and prevent rise in BUN by limiting protein intake. When the BUN and Cr return to normal, ARF is determined to be resolved

Crohn's disease

- Subacute, chronic inflam through all layers of intestinal mucosa (most commonly in terminal ileum) - cobblestone appearance, periods of remission & exacerbation. - Teenage yrs and early adulthood, 2nd peak in 60s. - Capsule endoscopy has shown greater sensitivity than radiography when dx - Combination of environmental factors and genetic predisposition - No cure, meds tx acute inflam & maintain a remission. - Surgery: unresponsive to meds or who develop life-threatening complications. - Total proctocolectomy (colon and rectum removed, anus is closed, terminal ileum brought through abd wall for permanent ileostomy A. Abd pain (unrelieved by defecation), RLQ B. Diarrhea, steatorrhea wt loss w/ client becoming emaciated C. Constant fluid loss D. Low-grade fever E. Perforation of the intestine d/t severe inflammation; emergency F. Anorexia r/t pain after eating G. Wt loss, anemia, malnutrition Dx: Risk for bleeding; Risk for deficient fluid vol; Chronic pain; Imbalanced nutrition: less than body requirements A. Determine bowel elimination pattern, ctrl diarrhea w/ diet and meds. B. Nutritious, well-balanced, low-residue & fat, high-protein & calorie, no dairy or spicy foods C. Vit supp & Fe D. E. Avoid smoking, caffeinated beverages, pepper, alcohol. F. Complete bowel rest w/ TPN G. Meds: aminosalicylates, antimicrobials, corticosteroids, immunosuppressants, biologic therapy H. I&O, serum electrolytes. I. Weigh at least 2x/wk. J. Teach stoma care - GI tract usually accounts for only 100-200 mL of fluid loss/day, although it filters up to 8 L/day. Large fluid losses can occur if vomiting or diarrhea exists.

CVA/stroke

- Sudden loss of brain function resulting from a disruption in blood supply to a part of the brain - Risk factors: 1. HTN 2. Previous TIA 3. Cardiac disease: atherosclerosis, valve disease, HO dysrhythmias (aflutter, afib) 4. Advanced age 5. DM 6. OCPs, HRT 7. Smoking 8. Alcohol > 2 drinks/day - Dx: clinical signs; CT scan; MRI; Doppler flow studies; US imaging 1. Motor loss, usually exhibited as hemiparesis or hemiplegia 2. Dysarthria (difficulty articulating), dysphasia (dysfunctional swallowing; impairment of speech and verbal comprehension), aphasia (loss of ability to speak), apraxia (inability to perform purposeful movements in the absence of motor problems), alexia (loss of the ability to read) 3. Perceptual disturbance- visual, spatial, sensory 4. Impaired mental acuity or psychological changes (dec attn span, memory loss, depression, lability, hostility) A. Change in LOC B. Paresthesia, paralysis C. Aphasia, agraphia D. Memory loss E. Vision impairment F. Bladder and bowel dysfunction G. Behavioral changes H. Assess functional abilities: 1. Mobility 2. ADLs 3. Elimination 4. Communication I. Ability to swallow, eat, drink w/out aspiration A. Control HTN to prevent future stroke. B. Proper body alignment- splints or other assistive devices C. Position to minimize edema, prevent contractures, maintain skin integrity. D. ROM exercises 4x/day. E. Encourage pt participation F. Set realistic goals; add new tasks daily. G. Analyze bladder elimination pattern. H. SLP therapy; Teach that swallowing modifications may include a soft diet (pureed foods, thickened liquids) & head positioning. I. tPA if ischemic w/in 3 hrs; anticoags, steroids dec cerebral edema and retard permanent disability, H2 inhibitors prevent peptic ulcers.

SLE

- Systemic inflam connective-tissue disorder - Discoid lupus erythematosus (DLE) affects skin only. - SLE can cause major body organs and systems to fail. - Kidney involvement = leading cause of death - Triggers: 1. Sunlight 2. Stress 3. Pregnancy 4. Drugs A. DLE: 1. Dry, scaly rash on face or upper body (butterfly rash) B. SLE 1. Joint pain, dec mobility 2. Fever 3. Nephritis 4. Pleural effusion 5. Pericarditis 6. Abd pain 7. Photosensitivity 8. HTN Dx: Chronic pain; Disturbed body imd; Activity intolerance; Impaired physical mobility A. *Avoid prolonged exposure to sunlight.* B. Clean the skin w/ mild soap. C. Admin steroids.

TB

- Transmission by airborne droplets. A. often asymptomatic. 1. Fever w/ night sweats 2. Anorexia, wt loss 3. Malaise, fatigue 4. Cough, hemoptysis 5. Dyspnea, pleuritic chest pain w/ inspiration 6. Cavitation or calcification on CXR 7. Positive sputum culture 8. Repeated URIs Dx: Ineffective breathing pattern; Ineffective air clearance; Noncompliance; Ineffective self-health management related to lack of knowledge A. Teaching. 1. Cough into tissues, dispose of immediately into biohazardous bags. 2. Take all meds 9-12 mo- isoniazid (inc phenytoin levels), rifampin (orange secretions, use other BC), ethambutol (vision checks), pyrazinamide, rifapentine 3. Proper handwashing technique. 4. Report s/s of deteriorating condition, esp hemorrhage. B. Collect sputum cultures as needed- return to work after 3 (-) cultures. C. Resp isolation while hospitalized. E. Adequate nutrition. - (+) TB skin test: induration 10 mm or greater in diameter 48-72 hrs after - Anyone who has received a BCG vac will have a (+) skin test & must be evaluated w/ a CXR.

hypothyroidism (hashimoto, myxedema)

- Tx by hormone replacement. - Endemic goiters- living where there is a deficit of I. Iodized salt helps prevent. A. Fatigue; Thin, dry hair; dry skin;Thick, brittle nails; Constipation; Bradycardia, hypotension; Goiter; Periorbital edema, facial puffiness; Cold intolerance; Wt gain; Dull emotions and mental processes; Husky voice; Slow speech B. Dx: Low T3 (< 70), T4 (< 5); Presence of T4 antibody Dx: Imbalanced nutrition: more than body requirements; constipation; Deficient knowledge; Noncompliance; Activity intolerance A. Teach: meds, follow-up care, s/s myxedema coma (hypoventilation, hypotension, hypothermia, hyponatremia, hypoglycemia, lactic acidosis, and respiratory failure) B. Bowel elimination plan to prevent constipation: fluids, fiber, inc activity, little/no enema/lax use C. Avoid sedating - Myxedema coma can be precipitated by acute illness, w/drawal of thyroid meds, anesthesia, sedatives, hypoventilation (potential for resp acidosis & CO2 narcosis). Airway must be kept patent and ventilator support used as indicated.

PUD

- Ulceration that penetrates the mucosal wall of the GI tract A. - Gastric ulcers: in lesser curvature of stomach. - Duodenal ulcers: in duodenum (most common location of PUD). - Esophageal ulcers: in esophagus. - Helicobacter pylori, Drugs (NSAIDs, corticosteroids), Alcohol, Cigarette smoking, Acute medical crisis or trauma, FH, Blood type O 1. Belching 2. Bloating 3. Epigastric pain radiating to the back & relieved by antacids A. Determine how food intake affects pain (gastric 1-2 h after meal- food worsens; duodenal when gastric acid comes in contact w/ the ulcers 2-3 h after meals, dec w/ food) B. Presence of melena (black tarry stools). C. Presence and location of peptic ulcer: 1. Esophagogastroduodenoscopy (EGD) 2. Barium swallow 3. Gastric analysis indicating inc levels of stomach acid D. Complications 1. Hemorrhage 2. Perforation (which always requires surgery) 3. Obstruction Dx: Acute pain; Imbalanced nutrition: less than body requirements; Deficient knowledge; Risk for injury A. Determine s/s onset & how they're relieved B. Color, quantity, consistency of stools and emesis; test for occult blood. C. Meds usually 1-2 h after meals and at bedtime. Mucosal healing agents at least 1 h before meals D. Small, frequent meals; no bedtime snacks; avoidance of beverages containing caffeine. E. Prepare for surgery w/ uncontrolled bldg, obstruction, perforation. 1. Gastric resection 2. Vagotomy 3. Pyloroplasty G. Dumping syndrome postop secondary to rapid entry of hypertonic food into jejunum (pulls water out of bloodstream); 5-30 min after eating; vertigo, syncope, sweating, pallor, tachycardia, hypotension. -- Minimized by small, frequent meals: high-protein & fat, low-carb. -- Exacerbated by consuming liquids w/ meals -- Helped by lying down after eating H. Avoid Salicylates, NSAIDs, Corticosteroids in high doses, Anticoagulants I. s/s of GI bleeding. 1. Dark, tarry stools 2. Coffee-ground emesis 3. Bright-red rectal bleeding 4. Fatigue 5. Pallor, cool extremities (shock) 6. Severe abd pain, mass, bruit 7. Dec BP, Inc HR & RR J. Smoking cessation, stress management.

Guillan-Barre Syndrome

- Usually preceded by a (viral) resp or GI infection 1-4 wks before onset of neuro deficits - Constant monitoring w/ risk of acute respiratory failure. - Full recovery w/in several mo- yr A. Paresthesia (tingling and numbness) B. Muscle weakness of legs progressing to upper extremities, trunk, face (ASCENDING) C. Paralysis of the ocular, facial, oropharyngeal muscles- marked difficulty in talking, chewing, swallowing. Assess for: 1. Breathlessness while talking 2. Shallow and irregular breathing 3. Use of accessory muscles while breathing 4. Any change in resp pattern 5. Paradoxical movement D. Increasing pulse, disturbances in rhythm E. Transient HTN, ortho hypo F. Possible pain in back & calves G. Weakness or paralysis of the intercostal and diaphragm muscles A. Monitor for resp distress, and initiate mechanical ventilation if necessary B. Interventions for altered LOC

hepatitis

- Widespread inflam of liver cells, usually caused by a virus - @ Risk: 1. Homosexual males & unprotected sex 2. IV drug users 3. Tattoos or body piercing that could have been applied using dirty needles. 4. Living in crowded conditions 5. Health care workers w/ improper PPE use A. Fatigue, malaise, weakness; a/n/v; Jaundice, dark urine, clay-colored stools; Myalgia, joint pain; Dull HA, irritability, depression; RUQ Abd tenderness; Fever; Elevations of liver enzymes (ALT, AST, alkaline phosphatase), bilirubin Dx: Risk for impaired liver function; Imbalanced nutrition: less than body requirements; Risk for infection; Activity intolerance A. Assess client's response to activity, and plan periods of rest after periods of activity. Necessary for regeneration B. Assist w/ care prn C. High-cal & carb, moderate fats & proteins. Small, frequent meals. Vit supp. Sit up. Environment conductive to eating D. Meds, interferon, nucleoside and nucleotide analogs, protease inhibitors, antiemetics E. Personal hygiene, using individual drinking and eating utensils, toothbrushes, razors. Prevention of spread emphasized. F. Avoid hepatotoxic substances: alcohol, aspirin, acetaminophen, sedatives. G. Recovery takes many mo, and previously taken meds/ OTC drugs should not be resumed w/out HCP's directions.

fracture

1. Complete fracture: across the entire cross section of bone 2. Incomplete fracture: across only part of bone 3. Closed fracture: No break in skin 4. Open fracture: protrudes through skin or MM (infection risk) - Greenstick; Transverse; Oblique; Spiral; Comminuted: 1. Pain, swelling, tenderness 2. Deformity, loss of functional ability 3. Discoloration, bleeding at site 4. Crepitus - Observe use of assistive devices. 2-3 finger widths b/t axilla and top of crutch. Cane on unaffected side. Lifts and advances walker and steps forward. - Intracapsular fracture (in the neck of the femur): blood supply enters femur below the neck; heals w/ greater difficulty - Fat emboli: risk in 1st 36 hrs. initial s/s is confusion d/t hypoxemia. Assess for resp distress, restlessness, irritability, fever, petechiae. Draw ABGs, admin O2 , assist w/ endotracheal intubation. - Prevent thromboembolism. - Frequent NV assessment distal to injury: color, temp, sensation, CRT, mobility, pain, pulses - 5 Ps of NV functioning: pain (inc pain despite meds or disproportionate to injury- compartment syndrome), paresthesia, pulse, pallor, paralysis.

diverticular disease

1. Diverticulosis: bulging pouches in GI wall (diverticula), which push the mucosa lining through surrounding muscle. usually no discomfort, goes unnoticed unless seen on radiologic exam 2. Diverticulitis: inflamed diverticula, which may cause obstruction, infection, perforation of bowel, hemorrhage A. LLQ pain; Inc flatus; Rectal bleeding B. Intestinal obstruction: 1. Constipation alternating w/ diarrhea 2. Abd distention 3. Anorexia 4. Low-grade fever C. Barium enema or colonoscopy; Obstruction, ileus, perforation confirmed by abd radiograph (barium not used during acute phase of illness) Dx: Risk for bleeding; Ineffective tissue perfusion; Acute pain; Imbalanced nutrition: less than body requirements A. Well-balanced, high-fiber diet unless inflam is present, in which case client is NPO, followed by low-residue bland foods. • Acute phase: NPO, graduating to liquids • Recovery phase: no fiber or foods that irritate the bowel • Maintenance phase: high-fiber diet w/ bulk-forming laxatives (metamucil) to prevent pooling of foods in pouches where they can become inflamed; avoid small, poorly digested foods (popcorn, nuts, seeds). B. Fluid intake 3 L/day. C. I&O and bowel elimination; avoid constipation (stool softener or bulk laxatives). D. Complications. 1. Obstruction 2. Peritonitis/ other infections 3. Hemorrhage (tx for ruptured diverticula is a temporary colostomy maintained for ~ 3 mo to allow the bowel to rest) 4. Infection - Diverticulosis is the). 242Diverticulitis is an

burns

1. First degree: Superficial partial-thickness (sunburn); Injury to the epidermis; pink or red, no blisters; Dry; Painful (relieved by cooling); Slight edema; No scarring, 2. Second degree: Partial Thickness (destruction of epidermis and upper layers of dermis) & Deep partial-thickness (Injury to deeper portions of the dermis); Painful (sensitive to touch and cold air); red or white, weeps fluid, blisters; Hair follicles intact; Edematous; Blanching followed by capillary refill; Heals w/out surgical intervention, usually does not scar 3. Third degree: Full-thickness and deep full-thickness; total destruction of dermis and epidermis; cannot regenerate; skin grafting; underlying tissue (fat, fascia, tendon, bone) may be involved; dry and leathery as eschar develops; painless 1. Rule of nines: head and neck 9%, upper extremities 9% each, lower extremities 18% each, front trunk 18%, back trunk 18%, perineal area 1% 2. Lund and Browder method: Estimates % BSA burned based on age; critical body areas are face, hands, feet, and perineum F. Three stages of burn care 1. Stage I: Resuscitative/emergent phase a. begins at time of injury, concludes w/ restoration of capillary permeability, which typically reverses 48-72 h after t b. fluid shift from intravascular to interstitial and shock; focus of care is to preserve vital organ functioning. c. large volumes of fluid 2. Stage II: Acute phase a. beginning of diuresis (48- 72 h after) to near completion of wound closure. b. fluid shift from interstitial to intravascular. c. infection ctrl, wound care and closure, pain management, nutritional support, PT 3. Stage III: Rehabilitation phase a. major wound closure to return to optimal level of physical and psychosocial adjustment (~ 5 yrs) b. grafting and rehab A. Absence of bowel sounds indicating paralytic ileus B. Radically dec urinary output in the 1st 72 h, inc spec grav C. Radically inc urinary output (diuresis) 72 h - 2 wks D. S/S inadequate hydration: 1. Restlessness 2. Disorientation 3. Dec urinary vol and urinary Na, inc spec grav E. S/s of inhalation burn: 1. Red or burned face 2. Singed facial and nasal hairs 3. Circumoral burns 4. Conjunctivitis 5. Sooty nasal mucus or bloody sputum 6. Hoarseness 7. Asymmetry of chest movements, use of accessory muscles indicative of hypoxia 8. Rales, wheezing, rhonchi denoting smoke inhalation 9. Impaired speech and drooling indicating laryngeal edema A. Emergent phase: stabilization w/ ongoing assessment. 1. Admission care a. Extinguish source of burn (1) Thermal: Remove clothing, cool burns by immersion in tepid water, apply dry sterile dressings. (2) Chemical: Flush w/ water or NS. (3) Electrical: Separate client from electrical source. b. Open airway; intubation if laryngeal edema risk. c. Baseline data: VS, ABGs, Wt. d. Depth and extent of burn. e. Tetanus toxoid. f. Initiate F&E therapy: LR w/ electrolytes and colloids g. NGT to prevent vomiting, abd distention, gastric aspiration. h. IV pain meds 2. Monitor hydration status. a. Urinary output hourly (30-100 mL/hr). b. IV fluids titrated to keep urine output 30-100 mL/hr. c. I&O. d. Daily wt. e. Signs of inadequate hydration: (1) Restlessness (2) Disorientation (3) Hypothermia (4) Dec urine output 3. Monitor resp functioning. a. Provide care for the intubated client. b. Suction ETT or nasotracheal tube, when needed. c. Monitor ABGs. d. Observe for cyanosis, disorientation. e. O2 f. IS, C/DB g. Elevate HOB 30 + for burns of the face and head. 4. Wound care. a. Strict aseptic technique b. Perform débridement and dressing changes c. Change dressings in minimum time (very painful); premedicate; maintain sterile technique. d. Maintain room temp > 90° F, humidified and free of drafts. e. Monitor body temp; have hyperthermia blankets available. 5. Assess for paralytic ileus: Absence of bowel sounds; n/v; Abd distention 6. Manage pain: meds, relaxation, distraction, etc 7. Assess for circulatory compromise in burns that constrict body parts. Prepare for escharotomy. 8. Provide proper nutrition. NPO until bowel sounds heard, then advance to clear liquids; High-protein, carbohydrates, fats, vit B. Acute phase: Characterized by fluid shift from interstitial to intravascular (diuresis begins); occurs 72 hrs - 2 wks after 1. Provide infection ctrl a. Maintain protective isolation b. Cover hair at all times. c. Wear masks during dressing changes. d. Use sterile technique for hydrotherapy, dressing change, débridement. e. IV abx if indicated. f. Remove live plants and flowers 2. Splint and position client to prevent contractures. Avoid use of pillows in cases of neck burns. 3. ROM exercises 3-5x/day; they are painful- admin meds. Mobilize ASAP using splints 4. Provide fluid therapy; colloids to keep fluid in vascular space. a. Monitor serum chemistries b. Keep an IV site available c. Strict I&O. d. Encourage oral intake of fluids. 5. Adequate nutrition: high-cal (up to 5000/day), protein & carb b. Supp via NGT or EN at night if caloric intake is inadequate. c. Accurate cal counts. d. Admin meds w/ milk or juice. e. May require TPN f. Daily wt 6. Provide burn and wound care. (daily or up to 3x/day) in hydrotherapy or shower. b. Silver sulfadiazine (Silvadene) or mafenide acetate (Sulfamylon), silver impregnated dressings can be left for 3-14 days; antimicrobials c. Cover w/ dressing (closed method) or leave open (open method) d. Prepare for grafting when eschar removed. e. Prepare for autografts f. Use heat lamp to donor site after graft to allow the area to reepithelialize. C. Rehabilitation phase: absence of infection risk 1. Ongoing discharge planning occurs. 2. Client may return home when danger of infection eliminated. 3. High-protein fluids w/ vit supp 4. Pressure dressings worn continuously to prevent hypertrophic scarring and contractures.

brain tumor

A. HA more severe on awakening B. Vomiting not associated w/ nausea C. Papilledema w/ visual changes D. Behavioral and personality changes E. Seizures F. Aphasia, hemiplegia, ataxia G. CN dysfunction H. Abnormal CT/MRI/PETA A. Interventions to similar to head injury and inc ICP. B. HOB 30-45 C. Radiation- skin care w/ non-oil-based soap and water. Avoid alcohol, powder, oils; Alopecia temporary; Don't wash off the lines drawn D. Chemo: E. Surgical removal of tumor (craniotomy). 1. Preop (shave head) 2. Postop: frequent neuro VS; HOB elevated for supratentorial lesions and flat for infratentorial lesions; On side opposite operative site; Dressings & drainage (CSF); Resp status to prevent hypoventilation; Avoid activities that cause inc ICP; Monitor for seizures Craniotomy preop meds: • Corticosteroids to reduce swelling • Agents and osmotic diuretics to reduce secretions (atropine, glycopyrrolate) • Agents to reduce seizures (phenytoin) • Prophylactic abxs

DM

Dx 1. FPG > 126 mg/dL 2. HbA1c > 6.5% 3. Random BG > 200 mg/dL w/ s/s hyperglycemia 4. OGTT > 200 - Type 1: B-cell destruction; insulin deficient. DKA risk (>250, ketonuria, pH < 7.3, bicarb < 15, n/v, dehydration, abd pain, kussmaul, acetone breath) - Type 2: progressive secretory insulin deficit and or defect in insulin uptake; insulin resistant. HHNS risk (> 600, plasma hyperosmolality, dehydration, AMS, no ketones) - Other: transplant-related, CF-induced, iatrogenic-induced (stress, hospital), steroid-induced; GDM - Prediabetes: Fasting BG 100-125 mg/dL; HbA1C 5.7-6.4%. - DKA cause: infection & inadequate or undermanagement of glucose. Tx w/ isotonic IV fluids, NS until BP stabilized & urine output 30-60 mL/hr; IV regular insulin (too rapid infusion--> cerebral edema) - HHNS Tx: isotonic IV fluid replacement, monitor K & BG, IV insulin given until BG 250 mg/dL - Complications: skin infections, impaired healing, retinopathy, angina, dyspnea, HTN, hair loss & cool extremities (poor perfusion), shiny/thin skin, weak pulses, edema, UTI, renal failure, neuropathies, gastroparesis (faulty absorption), impotence, vag infection, depression, AN w/ DM 1 Dx: Readiness for enhanced; Risk for injury; Readiness for enhanced coping; Deficit fluid vol; Readiness for enhanced self-health management A. Labs: 1. BG 2. Electrolytes 3. Cr 4. BUN 5. Cholesterol 6. Triglycerides 7. ABGs B. Teach injection technique and/or oral med(s). C. Diet: insulin scheduling w/ food. 45-50% carb; 15-20% protein; 30% or less fat D. Sick days (illness raises BG). E. Exercise after meal; monitor BG - hyper: 3 P's, blurred vision, weakness, wt loss, syncope - hypo: HA, nausea, sweating, tremors, lethargy, hunger, confusion, slurrd speech, tingling, anxiety - If in doubt whether a client is hyperglycemic or hypoglycemic, tx for hypoglycemia. - Rapid-acting (lispro, aspart, glulisine): onset 15-30 min; peak 30-90 min; duration 3-5 h - Short-acting (regular): onset 30-60 min; peak 2-3 h; duration 5-7 h - Intermediate: onset 1-2 h; peak 4-6 h; duration 14-24 h - Long-acting (glargine, detemir): onset 1 h; 14-12 h (detemir peakless); duration 24 h

intestinal obstruction

Partial or complete blockage of intestinal flow (fluids, feces, gas) that occurs mostly in the small intestines A. Mechanical causes of intestinal obstruction 1. Adhesions (most common cause) 2. Hernia (strangulates the gut) 3. Volvulus (twisting of the gut) 4. Intussusception (telescoping of the gut within itself) 5. Tumors; develop slowly; usually a mass of feces becomes lodged against the tumor B. Neurogenic causes of intestinal obstruction 1. Paralytic ileus (usually occurs in postoperative clients) 2. Spinal cord lesion C. Vascular cause of intestinal obstruction 1. Mesenteric artery occlusion (leads to gut infarct)Assessment A. Sudden onset of abdominal pain, tenderness, or guarding B. History of abdominal surgeries C. History of obstruction D. Distention E. Increased peristalsis when obstruction first occurs, then peristalsis becoming absent when paralytic ileus occurs F. Bowel sounds that are high pitched with early mechanical obstruction and diminish to absent with neurogenic or late mechanical obstruction Analysis (Nursing Diagnoses) A. Risk for dysfunctional GI motility related to ... 244B. Deficient volume related to ... C. Acute pain related to ... Nursing Plans and Interventions A. Maintain client NPO, with IV fluids and electrolyte therapy. B. Monitor I&O; a Foley catheter maintains strict output. C. Implement nasogastric (NG) intubation. 1. Attach to low suction (intermittent; 80 mm Hg). 2. Document output every 8 hours. 3. Irrigate with normal saline if policy dictates. D. NG tube (passed through the nose into the stomach; Miller-Abbott tube is used for decompression; it is passed through the nose and the stomach into the small intestines then connected to suction; placement is usually performed by the health care provider. 1. Nasogastric tube a. Measure correct length of tubing to be inserted by measuring from the tip of the client's nose to the client's earlobe to the xiphoid process. 2. Advance decompression tube every 1 to 2 hours. 3. Do not secure to nose until tube reaches specified position. 4. Reposition client every 2 hours to assist with placement of the tube. 5. Connect tube to suction. 6. Irrigate NG tube with normal saline; irrigate Miller-Abbott tube with air only. 7. Note amount, color, consistency, and any unusual odor of drainage. 8. Assess for signs of dehydration (skin turgor, amount and color of urine). 9. Monitor electrolyte values. E. Document pain; medicate as prescribed. F. Assess abdomen regularly for distention, rigidity, change in status of bowel sounds. G. If conservative medical interventions fail, surgery will be required to remove obstruction. • Mechanical: Due to disorders outside the bowel (hernia, adhesions) caused by disorders within the bowel (tumors, diverticulitis) or by blockage of the lumen in the intestine (intussusception, gallstone) • Nonmechanical: Due to paralytic ileus, which does not involve any actual physical obstruction but results from inability of the bowel itself to function HESI Hint A client admitted with complaints of constipation, thready stools, and rectal bleeding over the past few months is diagnosed with a rectal mass. What are the nursing priorities for this client? • NPO • NG tube (possibly an intestinal tube such as a Miller-Abbott) • IV fluids • Surgical preparations of bowel (if obstruction is complete) • Foods and fluids are restricted for 8 to 10 hours before surgery if possible. • If the patient has a bowel obstruction or perforation, bowel cleansing is contraindicated. • Oral erythromycin and neomycin are given to further decrease the amount of colonic and rectal bacteria. • If possible, all clients who require surgery for obstruction undergo NG intubation and suction before surgery. However, in cases of complete obstruction, surgery should proceed without delay • Teaching (preoperative nutrition, etc.) 245