NCLEX Adult Med-Surg

Endocrine system functions and disorders Pancreas Disorders of pancreas Diabetes mellitus Meds/ education/ guidelines

(see pharmacology) Insulin pump: -External device that provides basal dose of rapid-acting or regular insulin with a bolus dose for meals, which is calculated by the client using a predetermined insulin-to-carb ratio; doesn't read blood glucose -->Needles are inserted into subq abdominal tissue (change q 3 days) -->Complications are 2ndary to continuous administration of insulin or from disruption of insulin infusion -->Allows for flexibility of diet Education: -Nutritional therapy as prescribed (exchange carb counting, calories, healthy food choices) -Consistent exercise; self glucose monitoring/ interpret -Med administration: med importance and schedule, med route (PO, subq, pump), rotation of injection -Manifestations and management of hypo/hyperglycemia -Wear medic alert bracelet -Foot care: cleanse feet daily in warm, soapy water; rinse and dry carefully; trim nails straight across; wear supportive, protective shoes; inspect feet daily Guidelines (sick day rules): -Take usual doses of insulin or antidiabetic agents -Test blood glucose and urine for ketones q 3-4 hr -Report elevated blood glucose or urine ketones -Consume 4 oz of sugar free, non-caffeinated fluids q 30 min to prevent dehydration -Eat small, freq meals of soft foods or liquids to meet carb needs

Cardiovasular system disorders Diagnostic procedures Lab tests

-Serum electrolytes -Erythrocyte sedimentation rate (ESR) -C reactive protein -Blood coagulation tests -->PTT: most significant if on heparin -->PT: most significant if on warfarin -->INR BUN and creatinine: -Reflect renal function and perfusion; levels may increase in MI, CHF, and cardiomyopathy Total serum cholesterol desirable: -Low density lipids (LDLs) -High density lipids (HDLs) -Triglycerides B-type natriuretic peptide (BNP): -Indication for diagnosing heart failure --> <100 (none), 100-300 (possible), >300 (mild), >600 (moderate), >900 (severe) Enzymes (test indicates death of myocardial muscles; heart attack): -Creatinine phosphokinase MB (CK-MB): isoenzyme increases within 4-6hr following an MI and remains elevated from 24-72 hr -Troponin: protein that's considered gold standard in diagnosing MI; remains elevated for 2-3 weeks following an event; normal level is <0.2 ng/dL

Neurosensory disorders Disorders Seizure disorder

Abnormal, sudden, uncontrolled, excessive drainage of electrical activity within the brain Contributing factors: -Drug/ alcohol withdrawal; trauma; brain tumors -Toxicity or infection; fever Classifications: -Generalized seizures -->Tonic clonic (grand mal); Absence (petit mal) -->Muoclonic; Atonic or akinetic (drop attacks) -Partial seizures -->Complex (impairment of consciousness) -->Simple (w/o alteration of consciousness) Interventions: -Maintain patent airway (side-lying) -Monitor respiratory status and loosen clothing -Protect from injury; don't restrain/ put anything in mouth -Turn head to side to prevent aspiration -Document observations, before, during, after seizure -Observe for prodromal signs of an aura: sensory warning that a seizure is about to occur -Document how long client is unconscious -Determine if any incontinence; precipitating factors -Monitor/ document behavior postictal phase (following) -Initiate precautions: bed rest w/ padded rails, ensure immediate access is available for O2 administration/ suction Meds: -Phenytoin (dilantin); carbamezepine (tegretol) -Calproic acid (depakote); phenobarbital (luminal) -Levetiracetam (keppra); topiramate (topamax) Education: -Take meds consistently- don't stop abruptly -Teach manifestations of toxicity; avoid alcohol -Get adequate rest (fatigue); med alert bracelet -Follow state laws regarding operating vehicles -Keep follow up appointments; Identify seizure triggers

Genitourinary system disorders Kidney and urinary system Specific disorders Acute renal failure

Abrupt decrease in renal function; result of trauma, allergic reactions, drug overdose, kidney stones, shock Contributing factors: -Prerenal: disrupted blood flow to kidneys; hypovolemic shock, dehydration, HF, burn, anaphylaxis -Renal: renal tissue damage; trauma, hypokalemia, acute glomerulonephritis, hemolytic uremic syndrome (e.coli), substance abuse -Postrenal: urine flow from kidney is compromised; kidney stones, prostate hyperplasia, tumors, strictures Manifestations: -Onset: beings w/ onset of event and lasts hours-days -Oliguric (1-3 wks): sudden onset, <400 mL in 24 hr, edema, elevated BUN, creatinine and K; increased specific gravity; acidosis; HF; dysrhythmias -Diuretic: urine output increases followed by diuresis of up to 4,000-5,000 mL/day, indicating recovery of damaged nephrons; decreased specific gravity; hypotension and F&E imbalances are a concern -Recovery: make take up to 1 yr until renal function returns to normal (baseline); older adults are at increased risk for residual impairment Interventions: -Eliminate or prevent cause -Correct metabolic acidosis, hyperkalemia, hyperphosphatemia, hypocalcemia -->Kayexalate: ion exchange resin given orally or by enema to treat hyperkalemia -->IV glucose and insulin: causes K to enter cells -->Calcium IV or sodium bicarbonate to stabilize cell membrane Diet: -Oliguric phase: low protein, high-carb, and restricted K -Diuresis: low protein, high calorie and restricted fluids -->Encourage bed rest in oliguric phase -->Monitor: daily weights, I & O -->Implement dialysis (as ordered) until function returns -->Assess for pericarditis (friction rubs) Meds: -Phosphate binders to lower phosphorous while replacing calcium -Epogen (procrit) to treat anemia

Genitourinary system disorders Kidney and urinary system Specific disorders Acute glomerulonephritis

Acute renal disease involving renal glomeruli of both kidneys; antigen-antibody reaction that damages glomeruli; may be 2ndary response to infection in other areas of body that occurs in kids Contributing factors: -Beta-hemolytic streptococcal -Can follow tonsilitis or pharyngitis Manifestations: -Hematuria (cold or tea colored urine) w/ proteinuria -Edema (facial and periorbital; ascites) -Oliguria or anuria; HTN w/ headache -Azotemia; flank/ abdominal pain; anemia Interventions: -Bed rest to protect kidney; restrict fluids -Increase calories and reduce protein and sodium -Monitor daily weight Meds: -Penicillin for streptococcal infection -Corticosteroids for inflammatory disease -Antihypertensives for increased BP

Neurosensory disorders Disorders Guillain-Barre syndrome

Acute, autoimmune attack on peripheral nerve and cranial nerve myelin Manifestations: -Preceded by an infection (respiratory or GI) -Presents w/ascending weakness, which may progress to paralysis, leading to acute respiratory failure -Hyporeflexia; recovery takes months-2 yrs -Paresthesia and pain Interventions: -Assess respiratory status and provide respiratory support -Monitor VS and ECG -Provide nutrition and prevent aspiration, may need parenteral supplementation -Manage bladder/bowel problems -Collaborate w/ PT to maintain strength, flexibility, contracture -Prevent complications of immobility: pneumonia, DVT, UTI, atelectasis, skin breakdown -Decrease anxiety by providing info and support Therapeutic: -Respiratory support (mechanical ventilation) -Plasmapheresis; IVIG Education/ referral: -OT/PT/ speech and respiratory therapy -Teach strategies to prevent complications of immobility -Inform recovery may take up to 2 years

Endocrine system functions and disorders Pancreas Disorders of pancreas Diabetes mellitus Diabetic ketoacidosis

Acute, life-threatening complication of DM due to insufficient insulin; main clinical manifestations are hyperglycemia (300-800 mg/dL), acidosis, dehydration, and fluid loss; most common in type 1 DM Contributing factors: -Decreased/missed dose of insulin; illness or infection -Undiagnosed or untreated diabetes Manifestations: -Exacerbated polyuria, polydipsia, polyphagia -Anorexia, N/V, abdominal pain -Metabolic acidosis w/ ketonuria; kussmaul's resp -Acetone breath (fruity); Altered mental status -Blurred vision, headache, weak/rapid pulse -Orthostatic hypotension Interventions: -Monitor: blood glucose, LOC, VS, strict I & O -Administer IV fluids to promote perfusion: -->NS infusion, follow with 45% saline, add fluids containing dextrose when blood glucose ~ 250 mg/dL -Administer insulin -->Insulin infusion at 0.1mg/kg/hr (REGULAR) -->Usually blood glucose checks hourly while on infusion -->Resume subq when possible -Monitor: K levels and replace; acid-base balance -Teach strategies to prevent DKA and hyperglycemic hyperosmolar state HHS

Endocrine system functions and disorders Pancreas Disorders of pancreas Diabetes mellitus Hyperglycemic hyperosmolar state (HHS)

Acute, life-threatening complication of diabetes (T2); elevated blood glucose levels >600 mg/dL, hyperosmolar state--> fluid and electrolyte loss Contributing factors: -Acute illness (surgery, infection, CVA) -Meds that exacerbate hyperglycemia (thiazides) -Tx (dialysis) Manifestations: -Signs of dehydration: hypotension, tachycardia, elevated BUN -Generally not seen with ketosis -Altered mental status Interventions: -Replace fluids as prescribed (monitor fluid overload) -Administer insulin and electrolytes as prescribed -Monitor: blood glucose, LOC, VS, electrolyte levels, acid-base balance -Teach strategies to prevent HHS

Disorders of musculoskeletal system Osteomyelitis

Acute/ chronic bone infection Contributing factors: -Diabetes; hemodialysis; injection drug use -Poor blood supply; recent trauma Manifestations: -Bone pain; fever; general discomfort (malaise) -Local swelling, redness and warmth -Chills, excessive sweating, low back pain, swelling of ankles/feet/ legs Diagnostic: -Bone biopsy (then cultured), scan, x-ray -CBC, CRP, ESR, MRI -Needle aspiration of area around affected bones Interventions: -IV antibiotic therapy ASAP; contact precautions (drainage) -Teach: full course of antibiotics must be completed -Implement wound irrigation -Wound care nurse PRN Meds: -Antibiotics & analgesics Therapeutic measures: -Surgical excision of dead and infected bone -Bone grafting in large impacted areas

GI, hepatic, pancreatic disorders Pancreatic disorders Acute and chronic pancreatitis

Acute: Inflammation of pancreas caused by autodigestion by exocrine enzymes (life-threatening) Chronic: Progressive disease of pancreas characterized by remissions and exacerbations resulting in diminished function Contributing factors: -Alcohol use; gallstones; illegal drug use; infection -Blunt abdominal trauma; operative manipulation Manifestations: -Severe midepigastric or LUQ pain -Pain intensifies after meals and when lying down -N&V; abdominal tenderness; elevated amylase/ lipase -Steatorrhea; turner's sign; cullen's sign Diagnostic: -Lab profiles: liver enzymes, bilirubin, pancreatic enzymes -CT scan w/ contrast Interventions: -Dietary management -->NPO initially; after 24-48 hr, begin jejunal feedings -->When food is tolerated, advance to small, freq, moderate-high carb, high-protein, low fat meals -NG tube for severely ill, w/ intractable vomiting or biliary obstruction -Pain management; position for comfort (fetal, sitting up) -Monitor: bowel sounds; I&O; indications of hypocalcemia and hypomagnesemia; respirations -Reassure clients and explain procedures to reduce anxiety Meds: -Antibiotics; anticholinergics; pancreatic enzymes -Opioid analgesics: morphine or dilaudid (demerol contraindicated) -H2 blockers or PPIs Therapeutic measures: -TPN; ERCP to create opening in sphincter of oddi -Cholecystectomy -Pancreaticojejunostomy (roux-en-y) to reroute pancreatic secretions to jejunum Education for chronic pancreatitis: -Take enzymes before meals; follow up with lab testing -Nutrition: high calorie needs; abstain from alcohol -Limit fat intake Referral/ follow up: -Alcohol recovery program -Home health for clients requiring long term TPN -Refer to dietitian

Respiratory system alterations Respiratory emergencies Chest tube complications

Air leak (continuous rapid bubbling in water seal chamber) -Start at chest and move down tubing to locate leak; tighten connection or replace drainage system; keep connection taped securely No tidaling in water seal chamber -Assess for kinks in tubing; assess breath sounds (lungs re-expanded) No bubbling in suction control chamber -Verify tubing is attached and water is filled to prescribed level; assess wall suction regulator Chest tube is disconnected from system -Insert open end of chest tube into sterile water until system can be replaced Chest tube accidentally pulled from client -Cover insertion site w/ sterile dressing, taped on 3 sides; contact provider; prepare for reinsertion

Need to know lab values Liver function

Albumin: 3.5-5 g/dL Ammonia: 15-45 mcg/dL Total bilirubin: 0.1-1.0 mg/dL Total protein: 6-8 g/dL

GI, hepatic, pancreatic disorders Diagnostic procedures Endoscopy

Allows direct visualization of tissues, cavities, and organs using flexible fiber-optic tube Colonoscopy: exam of entire large intestine -Bowel prep to clear fecal contents (1-3 day prep) -Clear liquid diet 12-24 hr before procedure -NPO except water 6-8 hr before procedure -IV sedation -Monitor postprocedure for excessive bleeding or severe pain Virtual colonoscopy: -Bowel prep for traditional colonoscopy -Performed using MRI or CT; images viewed on screen Sigmoidoscopy: exam of rectum and sigmoid colon -Clear liquid diet 24 hr before procedure; laxative evening before procedure; enema morning of procedure -Sedation not required; tissue biopsy may be performed -Report excessive bleeding Small bowel capsule endoscopy: small bowel & distal ileum -Only water allowed 8-10 hr before test; NPO 2 hr before -Abdomen marked for location of placement sensors -Wears abdominal belt with data recorder -Administer video capsule w/ full glass of water -Resume normal diet 4 hr after swallowing pill -Return to facility w/ capsule equipment for data -Procedure takes ~8 hr -Capsule will be excreted via stool (no action needed) EGD: esophagus, stomach, duodenum -NPO 6-8 hr before procedure -Avoid: anticoags, aspirin or NSAIDs for several days b/f -IV sedation; atropine to dry secretions -Local anesthetic sprayed to inactivate gag reflex -Prevent aspiration -Monitor: perforation, pain, bleeding, fever -Comfort measures for hoarseness or sore throat (days ERCP: liver, gallbladder, bile ducts, pancreas -NPO 6-8 hr before procedure -Avoid: anticoags, aspirin or NSAIDs for several days b/f -Assess allergies to x-ray dye; IV sedation -Colicky abdominal discomfort -Monitor for severe pain, fever, nausea, vomiting (perforation)

Genitourinary system disorders Kidney and urinary system Specific disorders Peritoneal dialysis

Alternative method using peritoneum to remove fluids, electrolytes and waste products form blood; accomplished via catheter surgically placed into peritoneal cavity Interventions: -Assist in voiding prior to procedure; weigh daily -Monitor VS and baseline electrolytes; maintain asepsis -Sterile dressing changes per facility policy -Keep accurate record of fluid balance Procedure: -Warm dialysate (1-2 L of 1.5%, 2.5% or 4.25% glucose) -Allow to flow in by gravity -5-10 min inflow time; close clamp immediately -30 min equilibrium (dwell time) -10-30 min drainage (clear and pale yellow) -Monitor for complications: peritonitis, bleeding, respiratory difficulty, abdominal pain, bowel or bladder perforation

Hematologic disorders Anemia Types Anemia 2ndary to renal disease Iron deficiency anemia

Anemia 2ndary to renal disease: lack of erythropoietin Meds: -Erythropoietin (Procrit, Epogen) Iron deficiency anemia: resulting form low iron levels; iron stores are depleted 1st, followed by hemoglobin stores Contributing factors: -Chronic blood loss (bleeding ulcer) -Nutritional deficiency -Common in infants, older adults, young adult women Manifestations: -Microcytic RBCs, weakness, pallor, low serum ferritin Interventions: -Monitor: symptoms of bleeding; labs Meds: -Administer iron preps Therapeutic: -Follow provider prescriptions for ulcer tx

Neurosensory disorders Disorders Head injury

Any trauma that leads to injury of skull, scalp, or brain ranging from concussion to skill fracture; classified as either closed or open Closed head injury: -Head sustains blunt force trauma; concussion -Contusion (brain damaged; loss of consciousness and confusion) -Diffuse axonal injury (shearing and rotational forces produce brain damage) Basilar skull fracture -Bleeding from nose/ears; raccoon eyes (edema/ bruise) -Otorrhea, rhinorrhea: CSF from ears or nose; differentiate b/w CSF and mucus by assessing glucose in drainage -Battle's sign: postauricular ecchymosis; mastoid bone Hematoma: -Epidural: bleeding into space b/w skull and dura -->Middle meningeal artery -->Client sustains injury-brief loss of consciousness-lucid interval-rapid deterioration -->Emergency management: burr holes & placement of drain to relieve increasing ICP -Subdural hematoma: bleeding below the dura -->Acute: symptoms develop over 24-48 hr; change in LOC, pupillary changes, hemiparesis -->Subacute: develop 48 hr-2 weeks after surgery -->Chronic: freq in elderly; may mimic CVA -->Management: surgical evacuation of hematoma and/or burr holes & drain placement Interventions: -Assess freq for signs of increased ICP -Prevent/ minimize increased ICP

Neurosensory disorders Neuro assessment History, mental status, cranial nerves

Assessment 1) History of present illness 2) Mental status -LOC (alert, lethargic, obtunded, stuporous, comatose) -Orientation (person, place, time) -Affect; mood -Speech (clarity, consistency, word finding ability) -Cognition (judgement and abstraction ability Cranial nerves (I-XII) CNI: olfactory (sensory, smell) CNII: optic (sensory, vision) CNIII: ocuomotor (motor, eye) CNIV: trochlear (motor, eye) CNV: trigeminal (sensory, face, motor, chewing) CNVI: abducens (motor, eye) CNVII: facial (sensory, face, hands) CNVIII: acoustic (sensory, hearing, balance) CNIX: glossopharyngeal (sensory, posterior taste) CNX: vagus (sensory, throat, motor, swallow, speech, cardiac innervation) CNXI: accessory (motor, throat, neck muscles, upper back CNXII: hypoglossal (motor, tongue)

Neurosensory disorders Sensory assessment Ocular assessment

Assessment of visual acuity with use of snellen chart; client stands 20 ft from chart and asked to read smallest line; corrective lenses for distance should be worn Manifestations: -Myopia (nearsightedness): distant objects appear blurry -Hyperopia (farsightedness): close objected appear blurry -Presbyopia (Farsightedness associated w/ aging): progressive, lens of eyes lose ability to focus -Macular degeneration: progressive disorder of retina, loss of central vision -Legal blindness: vision in better eye doesn't exceed 20/200 or whose widest visual field is 20 degrees or less -External eye exam -Direct/ indirect ophthalmoscopy -Tonometry: measures intraocular pressure Treatment -Abnormal refractory finding typically treated w/ corrective lenses -Laser eye surgery: changes shape of cornea w/ goal of restoring 20/20 vision

Neurosensory disorders Sensory assessment Auditory assessment

Assessment: -Inspection of external ear; otoscopic examination -Evaluation of gross auditory acuity; audiometry Disorders: -Meniere's disease: abnormal inner ear fluid balance, may lead to disabling symptoms -->Manifestations: vertigo, tinnitus, pressure in ear Interventions: -Provide small, freq meals low in sodium -Initiate/ teach fall precautions -Maintain quiet environment Meds: -Antihistamines: meclizine -Tranquilizers: control acute vertigo (diazepam) -Antiemetics: control N/V and vertigo (promethazine) -Diuretics: reduce pressure from fluid Education: -Encourage: low sodium diet; drink plenty of fluids but avoid caffeine and alcohol -Avoid monosodium flutamate (MSG), Aspirin, and aspirin containing meds (may increase symptoms)

Genitourinary system disorders Kidney and urinary system Diagnostic tests Renal function

BUN -Increase may indicate: -->Hepatic/ renal disease -->Dehydration/ decreased kidney perfusion -->High protein diet; infection; stress -->Steroid use; GI bleeding Creatinine -Best measure of renal function -24 hr creatinine clearance: 75-120 mL/min -->Have client void/ discard first specimen -->Obtain serum creatinine -->Collect all urine for next 24 hr (refrigerate) -->At completion of 24 hr, test is stopped Uric acid (serum) Prostate-specific antigen -Greater than 10 indicates risk of prostate cancer

GI, hepatic, pancreatic disorders Diagnostic procedures Radiographic studies

Barium series: x-ray visualization form mouth to duodenojejunal junction; may include small bowel -NPO 8 hr before procedure -Avoid: opioid analgesics and anticholinergic meds for 24 hr before the test -Drink 16oz of barium liquid -Assume multiple positions during x-ray exam -Include additional fiber and fluids to promote barium elimination -Visualize stool for barium contents next 24-72 hrs (chalky white) -Brown stool should return when barium is evacuated -Mild laxative or stool softener as needed to promote bowel elimination

Perioperative care Postoperative phase

Begins when client enters postanesthesia recovery area and continues until discharge from health care facility Interventions (immediate recovery period): Ongoing assessment -Pulmonary: verify airway and check gag reflex, assess for bilateral breath sounds, encourage coughing and deep breathing -Circulatory: compare VS to baseline, assess tissue perfusion -Neuro: eval LOC, assess reflexes and movement -GU: monitor I&O, asses urinary output (color, clarity, amount) -GI: assess for bowel sounds and abdominal distention -Skin: assess color, wound, drainage insertion sites Nursing actions -Verify IV fluid type, rate and site -Check dressings for type and amount of drainage -Identify drainage including color and amount -If NG tube,determine type and amount of suction ordered -Position in semi-fowler's (maximum oxygenation) -Monitor O2 saturations -Ensure thermoregulation; Provide pain management -Maintain NPO until alert and gag reflex returns -Prevent complications; transfer or discharge

Perioperative care Intraoperative phase

Begins when client enters surgical suite and ends with transfer to postanesthesia recovery area; nursing focus on safety, client advocacy, and health team collaboration Universal protocol (safety initiative): -Conduct preprocedure verification process -Mark procedure site -Perform "time out" before starting procedure Collaborative care: Perioperative nursing staff -Holding, circulator, scrub, specialty Interventions: -Implement role according to established standards -Maintain safe environment; ensure asepsis -Apply grounding devices -Ensure correct sponge, needle, and instrument count -Position client; remain alert to complications -Communicate with surgical team Therapeutic measures: -Blood transfusion, radiology, biopsy, lab profiles

Endocrine system functions and disorders Adrenal Gland Disorders of adrenal medulla Pheochromocytoma

Benign tumor of adrenal medulla that causes hypersecretion of epinephrine and norepinephrine Manifestations: -5 Hs: HTN, headache, hyperhidrosis (sweating), hypermetabolism, hyperglycemia Diagnostic: -Plasma levels of catecholamines and metanephrine -24 hr urine level of catecholamines and metabolites -CT, MRI, PET scan; adrenal biopsy -Clonidine suppression test (catecholamines are not suppressed) Interventions: -Assess VS; provide high-calorie, nutritious diet -Avoid caffeine, encourage freq rest periods -Provide quiet environment -Prevent stroke 2ndary to HTN crisis -Don't palpate/ assess for CVA tenderness- can cause rupture of tumor Meds: -Alpha (phentolamine) and beta blocker (propranolol) to diminish effect of norepi prior to surgery -Sodium nutriprusside; calcium channel blockers Therapeutic: -Surgical removal of tumor

Hematologic disorders Anemia Types Aplastic anemia

Bone marrow suppression for new stem cell production--> deficiency of circulating WBCs, platelets, RBCs; can be due to meds, viruses, toxins, radiation exposure Manifestations: -Hypoxia, fatigue, pallor (anemia) -Increased susceptibility to infection (leukopenia) -Hemorrhage, ecchymosis/petechiae (thrombocytopenia) -Pancytopenia (decrease in RBCs, WBCs, platelets) Interventions: -Monitor: labs; manifestations of infection -Provide: protective isolation; emotional/ psychological support -Implement protective barrier precautions Meds: -Immunosuppressive therapy: prednisone, cyclosporine -Chemo meds: cytoxan, procytox Therapeutic: -Hematopoietic stem cell transplantation -Splenectomy; cautious use of blood transfusions

GI, hepatic, pancreatic disorders Gastric surgical procedures Colostomy

Brings end of colon thru abdominal wall, creating an opening for evacuation of fecal material (temporary or permanent) Indications: -Cancer/ tumors; obstructive bowel disease; trauma -Colectomy; severe diverticulitis or crohn's disease Interventions: -Monitor: ostomy site; output from stoma (higher an ostomy is placed in small intestine-more liquid and acidic) -Empty ostomy baf when 1/4 to 1/2 full -Fit appliance to prevent leakage -Monitor for complications: fluid and electrolyte imbalances, ischemia of ostomy, bleeding, infection, peristomal skin inrriation -Offer emotional support/ refer to support group Education: -Teach how to fit, care for, change appliance -Refer to ostomy nurse for additional teaching -Breath mint may be placed in bag to reduce odor -Dietary management: -->Avoid hard to digest foods- nuts, popcorn, celery, seeds, coconut -->Maintain adequate fluid intake -->Reintroduce foods one at a time -->Foods that contribute to odor and gas: cruciferous veggies, asparagus

Oncology Cancers/ tumors / manifestations

Cancers/tumors: -Classified according to type of tissue from which they evolve -Carcinomas: epithelial tissue (skin, GI tract lining, lung, breast, uterus) -Sarcomas: nonepithelial tissue (bone, muscle, fat, lymph) -Adenocarcinomas: glandular organs -Leukemias: blood forming cells -Lymphomas: lymph tissues -Multiple myeloma: plasma cells and affects bone Manifestations: 7 warning signs: -C: change in bowel or bladder habits -A: a sore that doesn't heal -U: unusual bleeding or discharge -T: thickening or lumps in breast or elsewhere -I: Indigestion or difficulty swallowing -O: obvious change in wart or mole -N: nagging cough or hoarseness -Others: -->Weight loss, fatigue/ weakness, pain, N/V, anorexia

GI, hepatic, pancreatic disorders Pancreatic disorders Pancreatic cancer

Carcinoma has vague symptoms and usually diagnosed in late stages after liver or gallbladder involvement Contributing factors: -Older age, tobacco use, chronic pancreatitis, DM -Cirrhosis, high intake of red/ processed meat -Obesity, small # have inherited risk Manifestations: -Fatigue, anorexia, flatulence, pruritus -Weight loss, palpable abdominal mass, abdominal pain that may radiate to back -Hepatomegaly, jaundice (late sign) -Ascites; clay coloured stools; dark urine -Glucose intolerance Diagnostic: -Carcinoembryonic antigen (CEA) levels -->Expected findings: <2.5 nonsmoker; <5 smoker -->Critical findings: >6 ng/ml -Elevated: serum amylase, lipase, alkaline phosphatase, and bilirubin -ERCP; Ultrasound; CT scan Interventions: -Palliative care measures; pain management -Monitor blood glucose levels -Provide nutritional support (enteral supplements & TPN) Meds: -Opioid analgesics: morphine or dilaudid Therapeutic measures: -Chemo: shrink tumor size, monitor myelosuppression and pancytopenia -Radiation therapy; partial pancreatectomy (small tumor) -Whipple procedure: -->Pancreatoduodenectomy most common to resect cancer; done when located in head of pancreas; removes head of pancreas, duodenum, parts of jejunum and stomach, gallbladder, and spleen; pancreatic duct reconnected to common bile duct and stomach is connect to jejunum -->Interventions: provide routine postop care; monitor NG output (observe bloody or bile tinged drainage); semi-fowler's position; facilitate coughing, deep breathing, incentive spirometer; monitor blood glucose & administer insulin PRN; analgesia Education: -Encourage client to seek palliative care at home, cancer support group, and community resources -Support measures for pain, anorexia and weight loss

Genitourinary system disorders Kidney and urinary system Specific disorders Urine retension

Caused by physical obstruction of urethra from acute/ chronic causes (edema, BPH, tumor, inflammation, or inability of bladder to work; postanesthesia, stroke); risk for hydronephrosis Interventions: -Stimulate relaxation of urethral sphincter by providing privacy, placing client's hands in warm water (turning on water); encouraging guided imagery -Administer bethanechol chloride; position upright -Ensure adequate fluid intake Meds: -Urge incontinence: anticholinergics (tolterodine, oxybutynin) -Stress incontinence: tricycle antidepressant: imipramine

Burns Rule of nines Burn descriptions

Child: -Head (front and back): 18% -Back: 18%, chest: 18% (36%) -Right arm: 9%, left arm: 9% (18%) -Perineum: 1% -Right leg: 13.5%, left leg: 13.5% (27%) Adult -Head (front and back): 9% -Back: 18%, chest: 18% (36%) -Right arm: 9%, left arm: 9% (18%) -Perineum: 1% -Right leg: 18%, left leg: 18% (36%) Descriptions: -Superficial (1st degree): -->Epidermis -->Pink-red, tender, no blisters, mild edema, no eschar -->Sunburns, flash burns; pain -Superficial partial thickness (2nd degree): -->Epidermis and parts of dermis -->Red-white w/ blisters, mild-moderate edema, no eschar -->Flame or burn scalds; pain -Deep partial thickness (3rd degree): -->Epidermis and deep into dermis -->Red-white w/ moderate edema, no blister, soft/dry eschar -->Flame and burn scalds; grease, tar, or chemical burns; exposure to hot objects for prolonged time; pain -Full thickness (3rd degree): -->Same as partial- may extend into subq; nerve damage -->Red-tan, black, brown, white; no blisters; severe edema; hardinelastic eschar -->Burn scalds; grease, tar, chemical, electrical burns; exposure to hot objects for prolonged time; may be pain -Deep full thickness (4th degree) -->All layers plus muscles, tendons, bones -->Black w/ no edema -->Chemical; no pain

Disorders of musculoskeletal system Osteoporosis

Chronic disease in which bone loss causes decreased density and possible fracture; osteopenia is precursor Contributing factors: Primary -Women age 65+, men 75+ -Asian and caucasian; family history -Estrogen or androgen deficiency; protein deficiency -Sedentary lifestyle; smoking and alcohol intake Secondary -Bone cancer; cushing's syndrome; DM -Meds: corticosteroids, phenytoin, cytotoxic agents, immunosuppressants, loop diuretics -Paget's disease; prolonged immobilization -Rheumatoid arthritis Manifestations: -Shortened height; history of fractures -Thoracic kyphosis; decreased bone mass Interventions: -Encourage safe weight-bearing exercises -Teach strengthening exercises; encourage walking -Instruct to increase foods rich in calcium and vit D -Refer to smoking cessation program; fall precautions Meds: -Biophosphonates, calcium and vit D supplements, estrogen agonists/ antagonists, calcitonin -Parathyroid hormone (Forteo): teach to administer subq Education: -Instruct: continue health screenings & diagnostic evaluations; avoid activities w/ increased risk of falls; take meds as prescribed

GI, hepatic, pancreatic disorders GI disorders Irritable bowel syndrome (IBS)

Chronic disorder with recurrent diarrhea, constipation, and/or abdominal pain and bloating (most common) Contributing factors: -Smoking; caffeine; NSAIDs; stress -Mental or behavioral illness; high fat diet -Female; family history; dairy products Manifestations: -Weight loss; fatigue and maliase -Erratic bowel patterns; abdominal distension -Abdominal pain relieved by defecation -Mucus with passage of stool; colicky abdomen with diffuse tenderness Interventions: -Encourage a diet high in fibre and regular exercise -Teach: stress reduction techniques, eat at regular times, eat slowly and chew thoroughly, and the importance of adequate fluid intake but discourage fluids with meals -Encourage food diary, to identify triggers Meds: -Bulk agents: psyllium (metamucil); antidiarrheals -Anticholinergics; antispasmodics; probiotics -Complementary agents: peppermint oil, artichoke leaf extract, caraway oil Diagnostic: -Endoscopy, chest and abdominal x-ray, h.pylori test Education: -Keeping diary identify triggers; avoid causative agents -Symptom management; med and nutrition therapy -Stress reduction

Immunological disorders Systemic lupus erythematosus (SLE)

Chronic inflammatory disease that occurs when body's immune system attacks the tissues and organs; inflammation caused by lupus can affect joints, skin, kidneys, blood cells, heart and lungs Contributing factors: -Female; 15-40 y/o; African America, Latino, Asian -Exposure to light; long term use of certain meds -->Chlorpromazine, hydralazine, isoniazid, pronestyl -Exposure to mercury and/or silica Manifestations: -Insidious onset; remissions and exacerbations -Erythematosus "butterfly rash" on cheeks and across nose -Polyarthralgia; fever, malaise, weight loss -Alopecia; anemia, lymphadenopathy; depression -+ antinuclear antibodies; coin like lesions -Pleural effusion, pneumonia; pericarditis -Raynaud's; abdominal pain; edema; nephritis -Neuro: psychosis, paresis, seizures, migraines Interventions: -Monitor: VS (esp cardio); urinary function; infection -Provide comfort; instruct to use sunscreen -Cover skin/ head when exposed to sunlight -Encourage rest periods; promote restful sleep -Cleanse skin w/ mild soap and pat to dry; lotion Meds: -NSAIDs: reduce inflammation (contraindicated for renal compromise) -Corticosteroids: immunosuppression and reduce inflammation -Immunosuppressant agents: methotrexate, azathioprine -Antimalarial (hydroxychloroquine): suppression of synovitis, fever, fatigue Education/ referral: -Use sunscreen/ wear protective clothing -Encourage small, freq meals is anorexia is present -Limit salt intake for fluid retention 2ndary to steroid therapy and renal involvement -Refer to support group

Respiratory system alterations Disorders Airflow problems Asthma

Chronic inflammatory disorder of airways resulting in intermittent an reversible airflow obstruction of bronchioles Contributing factors: -Extrinsic: antigen-antibody reaction triggered by food, meds, inhaled substances -Intrinsic: pathophys abnormalities within respiratory tract -Older clients: beta receptors are less responsive to agonist and trigger bronchospasms Manifestations: -Sudden, severe dyspnea w/ use of accessory muscles -Sitting up, leaning forward -Diaphoresis and anxiety -Wheezing, gasping, coughing, cyanosis, barrel chest Interventions: -Remain w/ client during attack; position in high-fowlers -Assess lung sounds and pulse ox -Administer oxygen therapy -Maintain IV access Meds: Bronchodilators -Short acting inhaled: albuterol for rapid relief -Methylxanthines:theophylline(monitor therapeutic range) Anti-inflammatory -Corticosteroids: fluticason (flovent) and prednisone (deltasone) -Leukotriene antagonists: montelukast (singulair) Combination -Ipatropium and albuterol (combivent) -Fluticasone and salmeterol (advair) Therapeutic measures/ education -Respiratory treatments, O2 administration -Avoid allergens/ triggers -Proper use of inhaler and peak flow monitoring

Disorders of musculoskeletal system Arthritis Rheumatoid arthritis

Chronic, progressive autoimmune connective tissue disorder primarily affecting synovial joints Contributing factors: -Physical and emotional stress; female gender -Young to middle age; family history Manifestations: -Morning stiffness and pain -Bilateral joint inflammation w/ decreased ROM -Joint deformity in late stage -Warmth, redness, edema of affected areas -Dry eyes and mouth (Sjogren's syndrome) -Numbness, tinging, burning in hands/ feet Diagnostic: -X-ray; MRI; + rheumatoid factor; synovial fluid analysis -Antinuclear antibody test; ESR; CRP Interventions: -Instruct to use ice or heat; encourage physical activity -Monitor: indications of fatigue; complications related to therapy (secondary osteoporosis, vasculitis) -Complementary therapies: ->Hypnosis, imagery, acupuncture, music, omega 3, tai chi Meds: -NSAIDs; corticosteroids -Disease modifying antirheumatic drugs (DMARDs) -->Methotrexate, leulunomide, hydroxychloroquine -Biologic response modifiers (parenterally) -->Etanercept, adalimumab (humira) Therapeutic measures: -Plasmapheresis for severe, life-threatening exacerbation -Synovectomy -Total joint arthroplasty is unresponsive to meds Education: -Mobility devices and safety; rehab; support group Referral/ follow up: -Occupational/ physical therapy -Rehab; arthritis support group

Neurosensory disorders Disorders Multiple sclerosis

Chronic, progressive immune mediated disease of CNS; demyelination in brain/ spinal cord in which symptoms occur in relapse and remission pattern Contributing factors: -Young adults 20-40; women; genetic predisposition Manifestations: -MRI shows sclerotic patches thru brain and spinal cord -Fatigue; visual disturbances (nystagmus, blurred vision) -Slurred speech; emotional lability, depression -Spasticity/ weakness of extremities, paresthesia, numbness, pain -Intention tremors; spastic bladder Management: -No cure; tx aimed at relieving symptoms and decreasing freq and severity of relapses -During exacerbation, administer corticosteroids -Stress management techniques may help Interventions: -Promote independence/ maintain active, normal lifestyle -Teach self-catheterization; daily exercise w/fall precautions -Avoid stressors that exacerbate condition (infections) -Teach self-injection; prevent injury Meds: -Immunosuppressants: Avonex IM weekly, Betaseron subq, Copaxone subq daiy -Spasticity/ tremors: baclofen, gabapentin, clonazepam -Urinary/constipation: oxybutynin, tolterodine, propantheline, psyllium (metamucil) -Depression: amitripyline, sertaline (zoloft), Prozac -Sexual: sildenafil (viagra) -Fatigue: amantadine, modafinil Education/ referrals: -Referrals to OT, PT, speech -Proper med administration (self-injection) -Prevent relapse; self- catheterization

Neurosensory disorders Disorders Parkinson's disease

Chronic, progressive neuro disorder caused by loss of pigmented cells of substantia nigra and depletion of dopamine Manifestations: -Bradykinesia w/rigidity; resting tremor -Postural/ gait disturbances; depression -Expressionless, fixed gaze; masklike -Drooling and slurred speech Interventions: -Teach fall precautions; encourage high fibre diet -Encourage clothing that fosters independence Meds: -Antparkinsonian agent: levodopa -Dopamine agonist: bromocriptine mesylate -Anticholinergic: benztropine -Antiviral: amantadine hydrochloride -Antihistamine: diphenhydramine (benadryl) Therapeutic: -Thalamotomy, pallidotomy; neural transplantation -Deep brain stimulation Education and referral: -Injury prevention; medication regimen -Promotion of adequate nutrition (supplementation) -Strategies to improve bowel/ bladder function -Assistive devices; referral to OT/ PT/ speech

Oncology Cancer management Chemotherapy

Classification (all cause bone marrow depression): -Alkylating agents: uracil mustard, cytoxan, cisplatin -Antimetabolite: 5-FU, methotrexate -Antibiotics: doxorubicin hydrochloride, bleomycin -Antimitotics: incristine, vinblastine -Hormones: estrogen, progesterone, Tamofen, Taxol -Biological modifiers: Procrit, neupogen Common side effects and interventions: -Bone marrow suppression: neutropenia & leukopenia (WBC < 1,000) -->Interventions: balanced diet, rest, handwashing; limit ill visitors, avoid fresh fruits, veggies, plants -->Monitor temperature: any elevation in neutropenia is a sign of infection and report to provider -Anemia (Hbg <10g/dL) -->Administer O2; provide iron rich foods -->Monitor CBCs and blood transfusions PRN -->Administer Epogen and Procrit to increase RBCs -Thombocytopenia -->Administer platelet transfusions; Neumega -->Implement bleeding precautions; avoid aspirin -Alopecia -->Apply ice to client's scalp during chemo to slow hair loss; use gentle shampoos, hats, scarves, sunscreen -->Refer to american cancer society (wigs, support) -Anorexia, N/V, GI issues: -->Administer antiemetic prior to therapy (Zofran) -->Administer loperamide to manage diarrhea -->Drink cool beverages and eat small, favorite meals high in potassium with high-calorie supplements -->Provide soft, bland, high protein foods at room temp for stomatitis and straw for fluids; rinse mouth with topical anesthetic; topical steroids and zinc supplements -Elevated uric acid, crystal, urate stone formation: -->Administer allopurinol; increase fluid intake -Mucositis (GI and mouth): -->Frequent mouth assessment and oral hygiene, including teeth cleaning and mouth rinsing -->Avoid traumatizing oral mucosa due to risk of bleeding; use soft-bristled toothbrush or swabs -->Use plain water or saline for oral rinses -Specific meds have specific toxic effects: -->Doxorubicin hydrochloride: irreversible cardiomyopathy -->Anzemet, methotrexate: renal toxicity -->Cincristine sulfate: peripheral neuropathy

Nutrition: therapeutic diets Therapeutic/ modified diets Clear liquid/ full liquid

Clear liquid Indications: -Rest GI tract; maintain fluid balance -Immediate postoperative period -N/V, diarrhea; prep for diagnostic testing -Short term basis only; nutritionally inadequate Consists of products at room temp: -Primarily water; tea and coffee (limit caffeine) -Broth; carbonated beverages; clear juice; gelatin Full liquid Indications: -Advanced to this if tolerates clear liquids -Intolerance to solid foods; febrile illness; acute gastritis Consists of: -Clear liquids -Milk products: milk, custard, pudding, creamed soups, ice cream/sherbert -Strained fruits, veggies, cereal

Respiratory system alterations Airway management Tracheostomy care

Collaborative care: -Explain procedure; position in semi or high fowler's -Keep 2 extra trach tubes (1 the clients size and 1 smaller) -Suction only as indicated (never on routine); surgical asepsis for suctioning -Assess for respiratory distress -Provide trach care every 8 hr and as needed -Change trach tubes as prescribed Education/referral: -Trach care; prevention of respiratory infections -Nutrition; home health care agency -Community support group

Cardiovasular system disorders Cardiovascular disorders Venous thromboembolism (VTE)

Collective condition of DVT and pulmonary embolism (PE) Contributing factors: -Immobility, surgery, trauma, surgery, obesity, >65 y/o -Spinal cord injury, disorders of coagulation, pregnancy, oral contraceptives Manifestations of DVT: -Edema of affected limb; local swelling, bumpy, knotty -Red, tender, local induration -Venous ulcers around the ankle; reddened and bluish; edema often present Diagnostic: -MRI, CT, ultrasound Interventions: -Heparin: monitor PTT -Warfarin: monitor INR -Thrombolytic therapy: alteplase (activase) -Assess for bleeding and thrombocytopenia -Elevate affected extremity and apply warm, moist compresses -Monitor for manifestations of PE: dyspnea, chest pain, tachycardia, anxiety Prevention of VTE: early mobilization, leg exercises, compression stockings or intermittent pneumatic compression devices, prophylactic subq heparin

GI, hepatic, pancreatic disorders GI therapeutic procedures Gastroesophageal reflux disease (GERD)

Condition in which lower sphincter doesn't close properly, allowing stomach contents to back up into esophagus Contributing factors: -Obesity, smoking, heavy alcohol use, ingestion of very large meals, obstructive sleep apnea Manifestations: -Dyspepsia, regurgitation, eructation, flatulence -Coughing, hoarseness, wheezing, water brash -Dysphagia, odynophagia Interventions: -Teach client dietary management -Limit/eliminate foods that decrease LES pressure: chocolate, caffeine, fried/fatty foods, alcohol, carbonated beverages, spicy and acidic foods -4-6 small meals per day; eat slow; chew thoroughly -Eating nothing for at least 3 hr before going to bed -Teach: elevate HOB 6-12 inches, sleep on R side -Refer to smoking, alcohol cessation programs PRN -Encourage maintenance of proper weight -Wear loose clothing; endoscopic procedures Meds: -Histamine blockers: Pepcid, rantitidine (zantac), cimetidine -Antacids -PPIs: omeprazole (prilosec), esomeprazole (nexium), pantoprazole (protonix) thru IV short term

Nutrition: therapeutic diets Overview

Contributing factors: -Chronic disease, trauma, recent surgery of GI tract -Drug/ alcohol abuse, altered cognitive and functional processes that may affect nutritional status Assess for: -Decreased appetite; weight loss -History of recent illness -Poor fitting dentures, poor dental health -Poor eyesight; dry mouth or mucus membranes -Cognitive/ functional decline; chronic physical illness -Acute/ chronic pain; history of substance abuse -Altered mental health conditions, economic and/or environmental factors -Weight gain/ subjective complaints of lack of satiety Older adults: -Older adults in any health care/ community setting are at increased risk for altered nutrition due to physiologic changes of aging, cognitive and functional decline, environmental factors and social isolation

End of life care

Contributing factors: -Chronic terminal illness, hospice care, palliative care Manifestations: -Anorexia; decreased peripheral circulation (mottled) -Disorientation, somnolence; cheyne-stokes respirations -Increased respiratory secretions; incontinence -Decreased metabolic function; restlessness -Weakness/ fatigue Interventions: -Assess: end of life care plan, advanced directives, support -Don't force to eat/drink; talk (even if no response) -Keep perineal area clean/dry; position for comfort -Elevate HOB; administer meds (pain, restless, secretions) -Avoid noxious stimuli Symptom management: -Clients fear pain the most -->Long acting opioid narcotics, massage, music therapy, aromatherapy -Dyspnea and gurgling are most distressing -->Morphine elixir, scopolamine, O2 via cannula, avoid deep suctioning -Restlessness and agitation -->Lorazepam (ativan), haloperidol (haldol) -Nausea and vomiting -->Prochlorperazine -Incontinence -->Keep perineal area clean/dry; disposable underpads -->Urinary catheter Referral/follow up: -Hospice, chaplain, social services Postmortem care: -Notify provider, chaplain, mortuary defined by end of life care plan -If no autopsy planned, remove tubes/ lines -Clean/ prepare client for immediate viewing as desired by family or significant other -Provide family/ sig other opportunity to participate in care as desired -Verify completion of death certificate and required facility documents -Prepare client for transport to morgue, funeral home, or mortuary per facility protocol (ensure client ID tags present)

Genitourinary system disorders Kidney and urinary system Specific disorders Prostate cancer

Contributing factors: -Men 50+; African American; family history -Elevated testosterone levels, high fat diet Manifestations: -Asymptomatic in early stages; hematuria -PSA >10; rectal exam (hard pea size nodule) -Frequent UTIs Treatments: -Radical prostatectomy; external radiation therapy -Internal radioactive seeds; hormone therapy

Cardiovasular system disorders Cardiovascular disorders Varicose veins

Contributing factors: -Prolonged standing; pregnancy; obesity; heredity Manifestations: -Enlarged, tortuous veins in lower extremities -Pain, edema (after upright) Interventions: -Avoid: prolonged sitting/ standing, crossing legs -Wear supportive antiembolism stockings -Daily exercise; maintain ideal body weight -Elevate lower extremities to reduce edema and promote venous return -Promote circulation w thigh-high antiembolism stockings, ambulation, elevation Medical management: -Sclerotherapy: chemical injection -Ligation and stripping: surgery -Thermal ablation: nonsurgical use of energy or lasers

Respiratory system alterations Disorders Airflow problems COPD Complications

Cor pulmonale: R-sided HF caused by pulmonary disease Manifestations: -Hypoxia and hypoxemia, extreme dyspnea, cyanotic lips, JVD, dependent edema, hepatomegaly, pulmonary HTN Interventions: -Monitor: respiratory status, cardiac status and assess for indications of R-sided HF -Administer O2 and meds as prescribed -Ensure adequate rest periods; encourage low Na diet -Maintain fluid balance; possible fluid restriction Meds: -Diuretics, digoxin Therapeutic measures: -Mechanical ventilation

Hematologic disorders Anemia Contributing factors/ manifestations/ interventions

Deficiency of RBCs characterized by a decreased RBC count, Hbg/Hct or both; clinical sign that results in decreased O2 delivery to the cells Contributing factors: -Acute/ chronic blood loss (GI bleeding) -Greater than normal destruction of RBCs (spleen disease) -Abnormal bone marrow function (chemo) -Decreased erythropoietin (renal failure) -Inadequate maturation of RBCs (cancer) -Nutritional deficiencies (iron, B12, folic acid, intrinsic factor) Manifestations: -Fatigue, weakness, dizziness, headaches -Pallor: 1st seen in conjunctival area (caucasian) and oral (dark skinned) as well as nail beds, palmar creases, around the mouth -Tachycardia, murmurs and gallops, orthostatic hypotension -Decreased activity tolerance -Decreased Hgb, Hct, RBC levels -SOB, dyspnea, decreased O2 sat levels Interventions: -Monitor labs: RBC, Hbg, Hct -Encourage activity as tolerated w/ freq rest periods -Monitor skin integrity and implement measures to prevent breakdown -Provide O2 therapy to client as needed -Administer blood products and meds as prescribed -Encourage foods high in iron (meat, poultry, fish)

Endocrine system functions and disorders Pituitary gland Disorders of posterior pituitary gland Diabetes insipidus (DI)

Deficiency of antidiuretic hormone (ADH or vasopressin) due to a disorder of the posterior pituitary gland that results in the inability of the kidneys to conserve water appropriately; caused by head trauma, tumor, surgery, radiation, CNS infections, malignant tumors, failure of renal tubules Manifestations: -Urine chemistry (dilute): decreased urine specific gravity and osmolality -Serum chemistry (concentrated): hypernatremia, increased serum osmolality, hypokalemia -Polyuria and polydipsia: increased urinary output; may crave ice water in excessive amounts -Dehydration, weight loss, dry skin, hemoconcentration Diagnostic: -Water (fluid) deprivation test: monitor body weight, hourly urine output; assess serum & urine osmolality -Vasopressin test: only if ^ is inconclusive; IV vasopressin is administered and urine/ serum chemistries will improve -MRI of hypothalamus and pituitary; 24 hr urine Interventions: -Weigh daily; monitor urine output/ specific gravity -Assess BP and HR; maintain fluid and electrolyte balance Meds: -Desmopressin acetate (DDAVP) -Vasopressin -If DI is nephrogenic, thiazide diuretics prescribed Education/referral: -Lifetime vasopressin replacement therapy -Report weight gain or loss, polyuria, polydipsia -Monitor fluid intake and urine output -Avoid foods with diuretic action

GI, hepatic, pancreatic disorders GI therapeutic procedures Enteral feeding tubes

Delivery of nutritionally complete feeding directly into stomach, duodenum or jejunum *Initial placement confirmed by x-ray, subsequent confirmed by aspirating stomach or intestinal contents and measuring pH (gastric:1.5-4, intestinal:6, respiratory: 7+) Small bore nasogastric feeding tubes -Obtain xray for placement; assess gastric pH before each feeding; q 4 hr for continuous feeding -Maintain semi-fowler's while infusing -Assess residual in stomach and refeed residual, unless it exceeds maximum (100 mL) -Provide nose and mouth care; Replace tube every 4 weeks Small bore nasointestinal/jejunostomy tubes -Inserted thru skin and occasionally sutured in place for long-term feeding -Obtain x-ray; assess length of exposed tubing -Assess placement before feeding using intestinal pH -Maintain semi-fowler's -Assess residual (greater volume=upward migration) Monitor for complications: -Refeeding syndrome can be life-threatening; bleeding -Infection -Tube misplacement/ dislodgement, aspiration: immediately remove any tube suspected of being dislodged -Abdominal distention, N&V, diarrhea, constipation -Fluid imbalance: hyperosmolar preparation>dehydration -Electrolyte imbalance: most common hypoNa and hyperK Percutaneous endoscopic gastrostomy (PEG): -Assess skin integrity; assess residual volume -Allow feeding to infuse slowly (raise/ lower syringe) -Flush with 30 mL warm water before and after feeding -Maintain semi-fowler's position with 1-2 hr after feeding

Burns Diagnostic / interventions

Diagnostic: -CBC, serum electrolytes, BUN, ABGs. fasting blood glucose, liver studies, urinalysis, clotting studies, chest x-ray; creatinine and myoglobin for deep burns -->Initial fluid shift (1st 24 hr): ----->Hct/Hbg shifts into interstitial spacing/ fluid loss ----->Sodium decreased secondary to 3rd spacing ----->K increased (disruption of Na-K pump, tissue destruction, RBC hemolysis) -->Fluid mobilization (48-72 hrs): ----->Hct/ Hbg decrease (fluid shift form interstitial back into vascular fluid) ----->Na decreased; K increases (renal loss and movement back into cells) -WBC count: initial increase then decrease w/ shift to left (increase in % of neutrophils having only 1 or a few lobes) -->Blood glucose: elevated due to stress response -->ABGs: slight hypoxemia and metabolic acidosis -->Total protein & albumin: low due to fluid loss Interventions: -Maintain airway/ ventilation; humidified O2 -Monitor VS; maintain CO and IV fluid replacement -Maintain urine output of 30-50 mL/hr for burn client -Manifestations of shock; pain management -Assess for and prevent infection; nutritional support -->Large burn will be in a hypermetabolic state and need 5,000 calories/ day -->Increase protein to prevent tissue breakdown -->Enteral or TPN often necessary -Premote restoration of mobility; prevent psych support

Nutrition: therapeutic diets Therapeutic/ modified diets Alteration in amino acid metabolism/ low cholesterol

Diet for alteration in amino acid metabolism -Use for phenylketonuria (PKU), glactosemia & lactose intolerance -Dietary restrictions aimed at reducing/eliminating offending enzyme -Avoid milk/ milk products for all 3 diets (include soy based products) -PKU: avoid high protein (meats, dairy, eggs), and aspartame -Galactosemia: simple sugar in lactose must be avoided; educate to read labels carefully -Supplement calcium and vit D in those w/ lactose-restricted or eliminated diets Low cholesterol Indications: -Cardiovascular disease, DM, hyperlipidemia Limit animal products high in low density lipoproteins, saturated fats, and trans fats -Egg yolks, organ meats, fatty meats (bacon), whole milk, better Encourage high density lipoproteins, omega 3 fatty acids, and unsaturated fats -Sardines & salmon, olive & flaxseed oils, shellfish -Walnuts, fruits/veggies, lean meats, skinless fowl

Need to know lab values Therapeutic medication monitoring

Digoxin level: 0.8-2.0 ng/mL Lithium level: 0.4-1.4 mEq/L Phenobarbital: 10-4- mcg/mL Theophylline: 10-20 mcg/mL Dilantin: 10-20 mcg/mL

Genitourinary system disorders Kidney and urinary system Specific disorders Nephrosis

Disorder associated with protein wasting; 2ndary to diffuse glomerular damage Contributing factors: -Autoimmune; glomerular membrane more permeable Manifestations: -Insidious onset of pitting edema (generalized edema anasarca) -Proteinuria; anemia; hypoalbuminemia -Anorexia, malaise, and nausea -Oliguria; ascites Interventions: -Maintain bed rest (severe edema only) -Low-Na, low-K, moderate protein, high-calorie diet -Protect from infection; monitor I & O -Weigh client and measure abdominal girth daily Meds: -Loop diuretics: furosemide (lasix) -Steroids: prednisone -Immunosuppressive agents: cyclophosphamide

Cardiovasular system disorders Cardiovascular disorders Myocardial infarction (MI) Interventions

Early -Administer O2 and meds -->Aspirin -->Antidysrhythmics: amiodorone , lidocaine -->Analgesics: morphine sulfate -->Anticoagulants: heparin IV -->Thrombolytics within 6 hr of cardiac event: streptokinase, alteplase recombiant -->Vasodilator: nitroglycerine -->Beta blockers: metoprolol (lopressor) -->Calcium channel blockers: verapamil, nifedipine (procardia) -Freq monitor VS, O2 sats, and ECG -Provide emotional support to client Later -Administer stool softeners (prevent straining) -Provide soft, low fat, low cholesterol, low sodium diet -Bedside commode- less energy than bedpan -Promote self care, stop on onset of pain -Plan for cardiac rehab; exercise program -Teach/ encourage use of stress management techniques -Teach to modify any risk factors: obesity, stress, diet, HTN, tobacco use, physical inactivity -Recognize risk non-modifiable risk factors: heredity, race, age, gender -Bleeding precautions: anticoagulant and antiplatelets -Initiate long term medication therapy: -->Anticoagulants/ antiplatelets: heparin, aspirin, warfarin, enoxaparin (lovenox), clopidogrel (plavix) -->Antihypertensives: ----->Beta blockers: metoproplol (lopressor) ----->Calcium channel blockers: diltiazem (cardizem) -->Vasodilators: nitroglycerin -->Antilipidemics: simvastatin, atorvastatin (lipitor)

Neurosensory disorders Disorders Hyperthermia

Elevated temperature may be caused by infection or damage to hypothalamic temp regulating center; this increases O2 demand Contributing factors: -Infection; cerebral edema; environmental heat Manifestations: -Temperature elevation, shivering, hypoxia Interventions: -Asses neuro status & VS; use hyperthermia blanket or cool sponge bath -Monitor: ECG for tachycardia and dysrhythmias; dehydration (I & O and weigh daily) -Initiate seizure precautions (benzos to suppress seizure) -Prevent shivering, may occur if temp is reduced to quickly, to decrease risk of increased ICP/ O2 consumption (Chlorpromazine, diazepam)

Respiratory system alterations Disorders Airflow problems COPD Pulmonary emphysema

Encompasses pulmonary emphysema and chronic bronchitis (not reversible) Pulmonary emphysema: destruction of alveoli, narrowing of bronchioles, and trapping of air resulting in loss of lung elasticity Contributing factors: -Cigarette smoking (main causative factor); passive smoke inhalation -Advanced age, exposure to air pollution, alpha-antitrypsin deficiency (inability to break down pollutants), occupational dust and chemical exposure Manifestations: -Dyspnea w/ productive cough, difficult w/ exhalation (pursed lip breathing), wheezing, crackles, barrel chest, shallow/ rapid respirations, respiratory acidosis w/ hypoxia, weight loss, clubbed fingernails, fatigue

Genitourinary system disorders Kidney and urinary system Specific disorders Transurethral resection of prostate (TURP)

Enlarged portion of prostate is removed thru endoscopic instrument Interventions: Preoperative -Insert indwelling urinary catheter -Administer antibiotics as prescribed Postoperative: -Monitor: shock & hemorrhage; continuous bladder irrigation (expect blood drainage; monitor I&O) -Avoid heavy lifting, prolonged sitting, constipation or straining (rebleed) -Encourage fluid intake (3,000 mL/day) -Assses for TURP syndrome: cluster of manifestations resulting from absorption of irrigating fluids thru prostate tissue (hyponatremia, confusion, bradycardia, hypo/hypertension, n/v, visual changes) -Medicate for pain control: meds and narcotics to decrease bladder spasm -Keep catheter taped to leg (hemostasis at surgical site by catheter balloon) -Teach client kegel exercises

Genitourinary system disorders Kidney and urinary system Specific disorders Benign prostatic hyperplasia

Enlargement of prostate that may accompany aging process in males; exact cause unknown Manifestations: -Difficulty starting stream/ dribbling -Decrease force of urinary stream -Frequent urinary tract infections -Nocturia, hematuria Diagnosis: -Digital rectal exam or cystoscopy -PSA for diagnosis Treatments: -Urinary antibiotics -Alpha-blockers meds to promote urinary flow: terazosin, tamsulosin, alfuxosin, sildosin, doxazosin -Enzyme inhibitors to decrease size of prostate gland: dutasteride and finasteride

GI, hepatic, pancreatic disorders Oral and esophageal disorders Dental caries

Erosive process of tooth that occurs when acid is formed by the action of bacteria on fermentable carbohydrates Contributing factors: -Dental plaque; poor oral hygiene; lack of fluoridated h2o -High intake of refined carbs; decrease in saliva Manifestations: -Halitosis, tooth pain, tooth erosion, discoloring Interventions: Teach to regularly use preventive measures: -Brush teeth after eating; floss -Increase intake of fresh fruits and veggies, nuts, cheese, plain yogurt -If h20 isn't fluoridated, obtain from other source -Dental sealants -2x yearly dental cleaning and screening

Endocrine system functions and disorders Pituitary gland Disorders of posterior pituitary gland Syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

Excessive release of ADH resulting in inability to excrete an appropriate amount of urine this developing fluid retension and dilutional hyponatremia; caused by neoplastic tumors, head injury, meningitis, respiratory disorders, some meds (vincristine, phenothiazines, tricyclic antidepressants, thiazide diuretics) and nicotine Manifestations: -Urine chemistry (concentrated): increased urine specific gravity and osmalality -Serum chemistry (dilute): hyponatremia, decreased serum osmolality, hyperkalemia -Mental confusion, irritability, lethargy, seizures (hypona) -Weakness, anorexia, N&V (hypona) -Increased ADH (vasopressin) levels -Weight gain Interventions: -Restrict oral fluids to 500-1,000mL/day -Monitor I&O; weight client daily -Monitor mental status freq; initial seizure precautions Meds: -Hypertonic saline infusion (3%-5% NaCl) -Loop diuretics (hypervolemic hyponatremia) -Declomycin; vasopressin receptor antagonists (vaprisol) Therapeutic measures: -Treat underlying cause w/ surgery, chemo, radiation

Endocrine system functions and disorders Thyroid gland Disorders of thyroid gland Hyperthyroidism

Excessive secretion of thyroid hormones (Grave's is most common and causes overstimulation of thyroid by circulating immounoglobulins) Manifestations: -Anxiety, irritability, insomnia, fatigue, tachycardia -Tremors, diaphoresis, intolerance of heat; weight loss -Exophthalmos, diarrhea, light/ absent menstrual cycle Diagnostic: -Elevated T4 & T3; decreased TSH Thyroid storm: -Life-threatening seen in untreated/ uncontrolled hyperthyroidism; hyperpyrexia, tachycardia, HTN, other exaggerated symptoms of hyperthyroidism Interventions: -Assess VS; promote comfort; weigh daily -Encourage adequate rest in cool, quiet environment -Provide high-caloric diet w/o extra stimulation -Provide emotional support; elevate HOB -Eye protection (exophthamos): ophthalmic meds, taping eyes at night, decreasing sodium and water Meds: -Beta-blockers: tachycardia, anxiety, tremors -Propylthiouracil: blocks thyroid hormone production -Methimazole: short term use to block production of thyroxine; used no more than 8 wks; monitor CBC (agranulocytosis) -Iodides: decreases vascualrity & inhibit release of thyroid hormones; give thru straw to prevent staining -->Lugol's solution; saturated solution of K iodide (SSKI) -Radioactive iodine tx shrinks thyroid gland- alone or prior to surgery (radiation precautions) Therapeutic: -Thyroidectomy: removal of all/part of thyroid gland; requires lifelong intake of levothyroxine (synthroid) and calcium supplementation --Preop goal:decrease thyroid function toward normal range (euthyroid) using SSKI and antithyroid meds --Postop interventions: -->Semi-fowler's; assess dressing (back of neck) -->Observe resp distress (trach tray, O2, suction bedside) -->Assess s/s hemorrhage; note hoarseness (nerve injury) -->Limit talking; observe s/s tetany (damage or accidental removal of parathyroid glands>hypocalcemia) -->Calcium gluconate IV at bedside -->Observe for thyroid strom caused by increased release of thyroid hormone due to manipulation of thyroid gland -->Gradually increase ROM to neck and support client when sitting up

Neurosensory disorders Disorders Amyotrophic lateral sclerosis (ALS)

Fatal neuro disease that attacks nerve cells that control voluntary muscles Manifestations: -Fasciculations (twitching), cramping, muscle weakness -Fatigue -Slurred or nasal speech w/ difficulty forming words -Difficulty chewing/ swallowing (dysphagia) -Overactive deep tendon reflex; fatigue -Some experience cognitive impairment -Respiratory compromise; death occurs from respiratory failure, infection or aspiration Interventions: -Provide: education, information, support -Implement aspiration precautions/ alternate methods of communication if needed -Support respiratory function: mechanical vent or noninvasive positive pressure ventilation) -Administer meds: relief from excessive salivation, pain, muscle cramps, constipation, depression -Supportive services (anticipatory grieving) Meds: -Glutamate antagonist: riluzole -Spasticity: baclofen, dantrolene sodium, diazepam Education/ referral: -Disease progression, prognosis; advance directive -Interventions to max respiratory function/ prevent infection -Strategies to prevent aspiration -Alternate communication methods -Referral to OT/ PT/ speech, home care, hospice

Fluids and electrolytes Fluid imbalance Deficit

Fluid volume deficit (FVD)(ex: isotonic dehydration most common) Contributing factors: -Excess GI loss, diaphiresis, fever, excess renal loss, hemorrhage, insufficient intake, burns, diuretic therapy, aging (less body water and decreased thirst sensation) Manifestations: -Weight loss, dry mucus membranes, increased HR and respirations, thready pulse, cap refill <3 sec, weakness, fatigue, orthostatic hypotension, poor skin turgor -Late signs: oliguria, decreased CVP, flattened neck veins Diagnostic: -Serum electrolytes, BUN, creatinine, Hct (high due to hemoconcentration) -Urine: specific gravity and osmolarity Collaborative care/ interventions: -Monitor: VS, skin turgor, daily weight, lab data -Maintain strict I&O (output at least 0.5 mL/kg/hr) -Fluid replacement: increase oral fluid intake- initiate oral rehydration solution; IV fluids for severe dehydration/maintain as ordered -Initiate fall precaution Meds: -Electrolyte replacement and IV fluids

Fluids and electrolytes Fluid imbalance Excess

Fluid volume excess (FVE) Contributing factors: -Kidney failure, heart failure, cirrhosis, interstitial to plasma fluid shifts (hypertonic, burns), excessive water intake Manifestations: -Cough, dyspnea, crackles, increased BP, tachypena and tachycardia, bounding pulse, weight gain (1L h20= 1 kg of weight), increased urine output, increased CVP, edema Diagnostic (decreased due to hemodilution): -Serum: electrolytes, BUN ,creatinine, Hct -Urine: specific gravity and osmolarity -Chest xray: if respiratory complications present Collaborative/ interventions: -Monitor: respiratory rate/ symmetry/ effort, breath sounds, edema (pitting on a scale of +1- +4; monitor dependent edema by measuring circumference of extremities), ascites and abdominal girth, vitals -Weight daily, maintain strict I&O -Administer diuretics (osmotic, loop) -Limit fluid intake, provide frequent skin care, use semi-fowler's, reposition every 2 hr, restrict sodium intake

Genitourinary system disorders Assessment of kidney and urinary system

Functions of kidney -Regulates: acid-base balance; F&E balance -Excretes metabolic wastes (creatinine, urea) -Regulates BP: renin stimulates production of angiotensin I, which is converrted to angiotensin II in the lungs; angiotensin II is a strong vasoconstrictor and stimulates aldosterone secretion; vasoconstriction and Na reabsorption result in increase blood volume & BP -Secretes erythropoietin -Converts vit D to active form for absorption of calcium -Excretes water-soluble meds/ med metabolites -Minimum urine output 0.5 ml/kg/hr Contributing factors: -History of: GU disorder; HTN; diabetes -Family history of renal disease (PKD) -Incontinence, BPH, cancer, kidney stones -Nephrotoxic medications Manifestations: -Flank pain radiating to upper thigh, testis, labium -Changes in voiding: hematuria, proteinuria, dysuria, frequency, urgency, burning, nocturia, incontinence, polyuria, oliguria, anuria -Thirst, fatigue, generalized edema

GI, hepatic, pancreatic disorders Diagnostic procedures Lab profiles

Gastric aspirate Hydrochloric acid and pepsin (zollinger-ellison syndrome) -NPO 12 hr -Avoid: alcohol, tobacco, meds that change gastric pH for 24 hr -Insert NG tube; aspirate gastric contents; obtain pH Hepatic/pancreatic disease -Albumin -Ammonia: liver's ability to break down protein by-products -Bilirubin: measured in blood Cholesterol:total, LDL (bad), HDL (good), triglycerides Liver enzymes: ALT/SGPT, AST/SGOT, ALP Pancreatic enzymes: amylase, lipase, prothrombin time GI parasites, bacteria, bleeding Stool sample -Inspect: color, consistency -Tests: ova and parasites, c.diff, urobilinogen, fecal fat, fecal nitrogen, food residues, cytotoxic assay Fecal screening tests (at home and mailed in) -Fecal occult blood test >Recommended annually to detect colon cancer >Avoid: red meat, aspirin, turnips and horseradish 72 hrs prior (false positive) -Fecal immunochemical test >Hemosure, hematest II, SENSA, hemoquant -Stool DNA

Hematologic disorders Anemia Types Hemolytic anemia Sickle cell

Genetic defect found in African Americans or Mediterraneans; Hgb molecule assumes sickle shape and delivers less O2 to tissues; the sickle cells become lodged in the blood vessels, esp the brain and kidneys Contributing factors (precipitate crisis by enhancing sickling): -Stress, dehydration, hypoxia, high altitudes, infections Manifestations: -Severe pain and swelling; fever; jaundice -Susceptibility to infection -Hypoxia damage: spleen, liver, heart, kidney, brain Diagnostic: -Percentage of hemoglobin S (Hb S) seen on electrophoresis; sickle cell trait has <40% Hb S and sickle cell disease may have 80-100% Hb S Interventions: -Maintain adequate hydration; O2 therapy -Encourage to rest, avoid high altitudes, alcohol, temp extremes -Teach to identify triggers, get immunizations in timely manner, refer for genetic counseling Meds: -Morphine sulfate or hydromorphone (dilaudid) [pain] -Hydroxyurea: reduce amount of sickling/ amount of painful episodes

Neurosensory disorders Neuro assessment Glasglow coma scale, pupils, vital signs

Glasglow coma scale: Neuro assessment tool; rating 3-15 (least to most) -Eye opening response -->1: none, 2: to pain, 3: to voice, 4: spontaneous -Verbal response -->1: none, 2: no words, sounds, 3: words, not coherent, 4: disoriented conversation, 5: normal conversation -Motor response -->1: none, 2: decerebrate, 3: decorticate, 4: withdraws to pain, 5: localizes to pain, 6: normal Pupil check (PERRLA) -Pupils Equal in size, Round in shape, Reactive to light and Accommodation Vital signs -BP or pulse changes may indicate increased intracranial pressure

Need to know lab values Blood glucose levels

Glucose (fasting): 70-105 mg/dL HbA1c: 4-6% within expected reference range (>8% indicates poor DM control )

Endocrine system functions and disorders Pancreas Disorders of pancreas Diabetes mellitus Glycemia control/ manifestations/ long term complications

Glycemic control: -Glucose control is monitored on day-to-day basis by capillary blood glucose levels -->Normal fasting blood glucose: 70-105 mg/dL -->Normal postprandial blood glucose: <180 mg/dL -Glucose control is monitored on long-term basis by HbA1C Manifestations: -3 poly's -->Polyuria, polydipsia, polyphagia (hunger) -Fatigue, weakness, sudden vision changes -Recurrent infections, slow wound healing -Type 1: sudden weight loss, N/V, abdominal pain Long-term complications: -Neuropathy, nephropathy, retinopathy -Cardiovascular disease, infection and slow wound healing

Genitourinary system disorders Kidney and urinary system Specific disorders Dialysis

Goals: -Remove end products of metabolism (urea and creatinine) from client's blood -Maintain safe concentration of serum electrolytes -Correct acidosis; remove excess fluid from blood

Hematologic disorders Anemia Types Hemolytic anemia

Group of anemias that occur when bone marrow is unable to increase production to makeup for premature destruction of RBCs; sickle cell and thalassemia Contributing factors: -Trauma; crushing injuries; lead poisoning -TB; infections; transfusion reactions; toxic agents Manifestations: -Chills, dark urine, enlarged spleen, pallor -Rapid HR, SOB, jaundice Interventions: -Treat underlying cause; hydrate; blood transfusion Meds: -Severe immune-related: steroid therapy necessary

Endocrine system functions and disorders Pancreas Disorders of pancreas Diabetes mellitus Types

Group of metabolic disorders characterized by hyperglycemia caused by altered insulin production action or combo Type 1: -Acute onset before 30 y/o; pancreatic beta cells are destroyed by genetic predisposition (not inherited), immunologic, environmental or combination of factors Type 2: -Occurs after 30 y/o and is comprised of inadequate insulin production and insulin resistance Contributing factors: -Family history, obesity, race/ethnicity (African Americans, Hispanic Americans, Native Americans, Asian Americans, Pacific Islanders), HTN, history gestational diabetes, sedentary lifestyle Metabolic syndrome: -Insulin resistance-->increase insulin production in attempt to maintain glucose at normal level -HTN, hypercholesterolemia, abdominal obesity -If beta cells can't produce enough insulin to meet demands, type 2 diabetes will develop Diagnostic: -Symptoms of diabetes + casual plasma glucose of 200mg/ dL or greater -Fasting glucose 126 mg/dL or greater -2 hr postload glucose of 200 mg/dL or greater during oral glucose tolerance test

Neurosensory disorders Sensory assessment Common optical problems Glaucoma

Group of ocular conditions characterized by optic nerve damage, which may be caused by increased IOP Manifestations: -Acute (closed angle) -->Results from obstruction to outflow of aqueous humor resulting in increased IOP -->Rapidly progressive visual impairment -->Severe pain in/around eye;reduced central visual acuity -->Blurred vision w/ dilated pupils; N/V -Open angle -->Insidious onset w/ slowly decreasing visual acuity -->Bilateral, but one may be more affected -->Halos around lights; fluctuating IOPs -->May have no symptoms Interventions: -Administer meds consistently on time -Avoid anticholinergics Meds (promote pupils to contract): -Cholinergics: miotics (pilocarpine) -Adrenergic agonists: epinephrine -Beta blockers: betaxolol -Carbonic anhydrase inhibitors: acetazolamide -Prostaglandin analogues: lantanoprost -Alpha adrenergic agonists: apraclonidine Therapeutic: -Laser trabeculoplasty; iridotomy; drainage implants/ shunts Education: -Teach appropriate administration of medications -Discuss importance of avoiding activities that may increase IOP -Inform importance of follow up appointments

Immunologic disorders AIDS Stages/ contributing factors/ manifestations/diagnostic

HIV stages: 1) Acute infection: "worst flu ever", retroviral syndrome occurs 2-4 wks after infection is aquired 2)Latency: sometimes called asymptomatic or chronic HIV infection; HIV reproduces at low levels (still active); CD4 counts can remain at healthy levels; can last 8yrs + 3) AIDS: CD4 counts drop <200 cells/mm3; body becomes susceptible to opportunistic infections; survival 1-3 yrs 4)HIV infection: no info available on CD4+T lymphocyte count or % and no info on AIDS defining conditions Contributing factors: -Unprotected sexual contact; IV drugs/ contaminated needles; multiple sexual partners -Pregnant/ breastfeeding: transmission from mother to baby -Blood transfusion (0.02%) Manifestations: 1) Fever, lymph adenopathy, pharyngitis, rash, arhralgia, myalgia, HIV viral load high (may/may not test + for antibodies), CD4 >500 cells/mm3, virus transmissible 2) Lymphadenopathy (may be asymptomatic), will test + for HIV antibodies, CD4 count 200-499 cells/mm3 3) Opportunistic infections occur; wasting syndrome, AIDS dementia; weakness/ malaise; CD4 <200 cells/mm3 -Respiratory: pneumocystis carinii pneumonia, TB, kaposi's sarcoma -GI: cryptosporidiosis, candida, CMV, isosporiasis, kaposi's sarcoma -Neuro: CMV, toxoplasmosis, cryptococcosis, non-hodgkin's lymphoma, shingles, herpes simplex -Skin: shingles, hersps, kaposi's sarcoma -Psychosocial: anxiety, depression, poor self image Diagnostic procedures -ELISA (antibody assay): + within 3 wks- 3mnths following infection; most common, least expensive -PLASMA HIV 1 RNA viral load > 1,500 copies -CD4+ cell count: decreased <750 cells/mm3; <200 cells/mm3 have 85% change of progressing to AIDS in 3 yr -CBC and platelets decreased; brain/lung/CT abnormal

GI, hepatic, pancreatic disorders Diagnostic procedures Breath tests

Hydrogen breath test -To evaluate carbohydrate absorption -Aids in detection of bacterial overgrowth in intestine Urea breath test -To detect presence of H. Pylori -Instruct to avoid antibiotics and pepto-bismol 1 month before the test, PPIs and sucralfate 1 week before testing and H2 inhibitors for 24 hr before testing

Endocrine system functions and disorders Pituitary gland Disorders of anterior pituitary gland Acromegaly

Hypersecretion of GH that occurs after puberty Manifestations: -Enlargement of skeletal extremities; increase in adult height; change in ring/ shoe size -Protrusion of jaw and orbital ridges -Headache, visual problems, blindness -Muscle weakness; organ enlargement -Decalcification of skeleton; endocrine disturbances Diagnostic: -Serum studies (elevated GH); CT & MRI (tumor) -X rays show abnormal bone growth Interventions: -Provide: emotional support, sympathetic care -Prepare client for surgery or radiation if indicated Meds: -Octreotide: synthetic GH analogue -Bromocriptine mesylate or pergolide: dopamine agonists Therapeutic measures: -Surgical removal of pituitary gland- 1st tx option -Replacement therapy needed following removal/ radiation therapy -->Corticosteroids and thyroid hormones -Radiation therapy Education and referral: -Medication adherence and compliance w/ follow up

Endocrine system functions and disorders Pituitary gland Disorders of anterior pituitary gland Giantism

Hypersecretion of GH that occurs in childhood prior to closure of growth plates Manifestations: -Proportional overrowth in all body tissue Diagnostic: -Serum studies (elevated GH); CT & MRI (tumor) -X rays show abnormal bone growth

Endocrine system functions and disorders Parathyroid gland Disorders of parathyroid gland Hyperparathyroidism

Hypersecretion of PTH (tumor or renal disease)--> loss of calcium from bones into serum--> hypercalcemia & hypophosphatemia Manifestations (may not have symptoms): - Kidney stones (containing Ca); osteoporosis -Hypercalcemia and hypophosphatemia -Abdominal pain, constipation, N/V -Muscle weakness, fatigue, skeletal/joint pain -Polyuria, polydipsia (thirst); HTN; cardiac dysrhythmias Interventions: -Minimum 2,000mL of fluids daily; low-Ca, low vit D diet -Prevent constipation and fecal impaction -Strain all client's urine; safety measures (fractures) -Encourage cranberry juice to lower urinary pH -Monitor hypercalcemic crisis- occurs w/ Ca >15mg/dL -->IV rehydration, phosphate therapy, calcitonin, dialysis Meds: -Calcimimetics: cinacalcet (senipar) mimic Ca in blood and may cause parathyroid to decrease release parathormone -Calcitonin: decreases release of skeletal Ca & increases kidney excretion of Ca; enhanced if given along w/ glucocorticoids -Hydration and diuretics: furosemide (lasix) promotes excretion of excess Ca (avoid thiazides) -Biphosphates Therapeutic -Surgical remal parathyroid gland

Endocrine system functions and disorders Adrenal Gland Disorders of adrenal cortex Hyperaldosteronism (Conn's syndrome)

Hypersecretion of aldosterone from adrenal cortex (tumor) Manifestations: -Hypokalemia, hypernatremia, hypertension -Muscle weakness, numbness, cardiac probs, fatigue -Headache, polyuria, polydipsia, alkalosis Diagnostic: -Abdominal CT, ECG, serum aldosterone/ renin & K, urine aldosterone Interventions: -Provide quiet environment; assess BP and cardiac activity -Monitor K and be prepared to replace K -Closely monitor I & O Meds: -Antihypertensive meds: spironolactone (aldactone) -Eplerenone: blocks action of aldosterone Therapeutic: -Surgical removal of tumor/ adrenal gland

Endocrine system functions and disorders Adrenal Gland Disorders of adrenal cortex Cushing's disease and Cushing's syndrome

Hypersecretion of glucocorticoids caused by hyperplasia of adrenal cortex or pituitary gland tumor; cushing's syndrome is caused by exogenous use of steroid meds Manifestations: -Upper body obesity and thin extremities; moon face, buffalo hump, neck fat; skin fragility w/ purple striae -Osteoporosis, hyperglycemia, hypernatremia, hypokalemia, hypocalemia -Hirsutism, amenorrhea, elevated triglycerides and HTN -Sexual dysfunction, decreased libido, erectile dysfunction -Immunosuppression, peptic ulcer disease -Kids: slower growth rate -Backache, bone pain, tenderness -Increased thirst and urination Diagnostic: -Dexamethosone suppression test: suppression of cortisol indicates hypotalamic-pituitary-adrenal axis is functioning properly -Nighttime salivary cortisol levels Interventions: -Monitor for infection; protect client from accidents/ falls -Monitor and treat hyperglycemia -Assess BP and heart rhythm Meds: -Adrenal enzyme inhibitors (metyrapone, aminoglutethimide, mitotane, and ketoconazole) Therapeutic measures: -Pituitary adenoma: transsphenoidal adenomectomy -Adrenal carcinoma: unilateral/ bilateral adrenalectomy -Monitor: adrenal insufficiency following postsurgery -Slowly taper corticosteroid therapy Education/ referral: -Exogenous steroid therapy: educate concerning long-term self administration of hormone suppression therapy (disease) and tapering steroid doses (syndrome) -Eat foods high in protein & calcium, low in carbs & sodium, w/ potassium supplementation -Teach infection prevention, fall precautions, skin care

Endocrine system functions and disorders Pituitary gland Disorders of anterior pituitary gland Dwarfism

Hyposecretion of GH during fetal development or childhood that results in limited growth congenital or result form damage to pituitary gland Manifestations: -Head/ extremities disproportionate to torso -->Face may appear larger than peers' -Short stature; slow or flat growth rate -Progressive bowed legs and lordosis -Delayed adolescence or puberty Diagnostic: -Comparison height/weight against growth chart; slowed -Serum growth hormone level -MRI of head (assess pituitary gland) Interventions: -Teach child and family: adaptive measures for ADLs, how to administer GH (earlier the better) -Provide positive feedback to child to promote positive self-esteem Meds: -Human growth hormone injections

Endocrine system functions and disorders Adrenal gland Disorders of adrenal cortex Addison's disease

Hyposecretion of adrenal cortex hormones caused by autoimmune disease, TB, histoplasmosis, adrenalextomy, tumors, HIV; can be induced by abrupt cessation of steroid meds *With Addison's, you need to ADD cortisol Manifestations: -Weakness and fatigue, N/V, hyperpigmentation -Hypotension, increased HR, hypoglycemia, hyponatremia -Hyperkalemia, hypercalcemia, craving salty foods -Emotional lability, depression, diminished libido Diagnostic: -Serum adrenocortical hormone levels -ACTH stimulation; electrolyte panels -Abdominal/ renal CT scan Interventions: -Assess BP and heart rhythm -Monitor: F&E balance; hypoglycemia -Monitor for Addisonian crisis: shock (hypotension, tachycardia, tachypnea, pallor); occurs secondary to stressors such as infection, trauma, surgery, pregnancy, or emotional stress [requires IV fluid replacement and IV steroids and may require respiratory support] -Monitor adverse effect of hormone replacement therapy: same manifestations as hypersecretion of adrenal cortex Meds: -Adrenocorticoid replacement -->Hydrocortisone, prednisone, cortisone Education and referral: -Emotional support and instructions on lifelong disease management (meds, prompt tx of infection & illness, stress management) -Educate about lifelong med replacement; potential need for increased steroid therapy during stress/illness -->Teach manifestations of excessive/insufficient hormone replacement -->Instruct to promptly notify provider in cases of infection, injury and stress; doses will be individually adjusted -Teach: indications of Addisonian crisis, avoid caffeine and alcohol, appropriate med identification at all times -Advise to eat high-protein and high-carb diet

Endocrine system functions and disorders Parathyroid gland Disorders of parathyroid gland Hypoparathyroidism

Hyposecretion of parathyroid hormone (PTH)--> hypocalcemia and hyperphosphatemia usually caused by surgical removal of parathyroid gland tissue during parathyroidectomy, thryoidectomy, radial neck dissection Manifestations (hypocalcemia): -Paresthesia, muscle cramps and tetany -Chvostek's sign: tapping the side of cheek causes muscle spasms and twitching around mouth, throat, cheeks -Trousseau's sign: pressure from BP cuff induces muscle spasms in distal extremity -Circumoral paresthesia w/ numbness & tingling of fingers -Severe tetany--> bronchospasm, laryngeal spasm, carpopedal spasm, dysphagia, cardia dysrhythmias, seizures Interventions: -Monitor ECG; assess signs of neuromuscular irritability -Provide high-calcium, low-phosphorous diet -Seizure precautions Meds: -Acute: IV calcium gluconate -Chronic: oral calcium salts, phosphate binders, vit D

GI, hepatic, pancreatic disorders GI therapeutic procedures Parenteral nutrition

IV administration of hypertonic IV solution made up of glucose, insulin, minerals, lipids, electrolytes and other essential nutrients; used when client can't effectively use GI tract for nutrition Partial or peripheral parenteral nutrition (PPN) -Used when client can eat, but can't take in enough nutrients to meet needs -Administered thru large distal arm vein or PICC line Total parenteral nutrition (TPN) -Used when client required intensive nutritional support for an extended time period -Delivered thru central vein Contributing factors: - GI motility disorders, inability to achieve or maintain adequate nutrition for body requirements, short bowel syndrome, chronic pancreatitis, severe burns, malabsorption disorders Intervention: -Confirm placement with x-ray -Monitor: central line insertion site for local infection, signs of systemic infection, glucose, electrolytes, and fluid balance -Maintain strict surgical asepsis for dressing change (every 72 hr) -Change tubing and remaining TPN every 24 hr -Prevent air embolism; use infusion pump -Keep 10% dextrose/water available -For clients receiving fat emulsions, monitor for fat overload syndrome: fever, increased triglycerides, clotting problems and multi-system organ failure, discontinue infusion and notify provider immediately

Cardiovasular system disorders Cardiovascular disorders Adjunctive management

If meds are ineffective in eliminating dysrhythmias, electrical cardioversion and defibrillation may be used for tachydysrhythmias and pacemaker therapy for bradycardias Cardioversion: treats tachydysrhythmias by delivering an electrical current to the heart in an effort to convert the client to a normal rhythm -->Synchronized: timed to coincide w client's own cardiac cycle -->Used when client has a pulse; may be scheduled -->Sedation is commonly used Defibrillation: delivers electrical current to heart but only for life threatening dysrhythmias in an effort to convert client to more stable rhythm -Used for VF or pulseless VT; unsynchronized -Delivery is required immediately (not scheduled) -Not effective treatment for asystole Pacemaker: provides repetitive electrical stimuli to heart (controls HR) -Permanent -->surgically placed in subq tissue of chest -->Avoid raising arm above head until wound heals -->Observe for hiccups (accidental dislodgement) -->Education: avoid large magnets (MRIs); know set rate and check pulse daily; recognize/ report signs of battery failure; wear loose fitting clothing; avoid contact sports -Temporary (transvenous) -->Monitor ECG; check HR; assess hematoma/infection -->Administer analgesics PRN; electrically safe environment Settings: -Ventricular demand: fires preset rate when HR drops below predetermined/ preprogrammed rate -Ventricular fixed: fires constantly at preset rate, regardless of clients HR -Dual chamber: stimulates both atria and ventricles -Atrial demand: fires PRN when atria don't originate a rhythm -Variable rate: senses O2 demands and increases the firing rate to meet the client's needs

Disorders of musculoskeletal system Diagnostic tests for musculoskeletal disorders MRI

Imaging produced thru interaction of magnetic fields, radio waves, and atomic nuclei to diagnose muscle, tissue, and bone disorders -Client must remove all metal objects -Contraindicated for clients with pacemakers, stents, surgical clips -Clients w/ titanium joints may have MRI -Assess client for claustrophobia is closed scanner is used -Assess client for ability to lie still in supine position for 45-60 min

GI, hepatic, pancreatic disorders Contributing factors

Impaired function of GI tract, pancreas, and liver result from structural, mechanical, motility, infection or cancerous conditions -History of autoimmune disorder; alcohol use disorder -Dietary patterns; NSAIDs; age; family history -Previous abdominal surgery; allergies -Musculoskeletal impairment; obesity; smoking -Sedentary lifestyle; stress

Cardiovasular system disorders Cardiovascular disorders Heart failure

Inability of heart to meet the tissue requirements for oxygen; manifestations of fluid overload or inadequate tissue perfusion; called congestive heart failure due to freq occurrence of pulmonary and peripheral congestion Left sided HF (pulmonary congestion): -Dyspnea, cough, crackles, orthopnea, elevated PAWP -Paroxysmal nocturnal dyspnea, low O2 sats Right sided HF (systemic congestion): -Dependent edema, hepatomegaly, ascites, weakness -Anorexia, vomiting, weight gain, jugular vein distension, elevated CVP Hemodynamic monitoring: -Central venous pressure: 1-8 mmHg -->Increased: hyperolemia, R sided HF -->Decreased: hypovolemia -Pulmonary artery wedge pressure: 4-12 mmHg -->Increased: hyperolemia, L sided HF -->Decreased: hypovolemia Interventions: -Respiratory status -->Auscultate lung sounds to detect crackles/ wheezes -->O2 therapy PRN; Fowler's position to help WOB -Fluid volume -->Fluid restriction depending on severity -->Low Na diet 2,000-3,000 mg/ day -->Report 2-3 lb weight increase in 1 day -Pharmaloligcal -->ACE inhibitors; ARBs; hydralazine, nitrates, diuretics -->Beta blockers, calcium channel blockers, digitalis -->IV nesiritide, IV milrinone, IV dobutamine

Cardiovasular system disorders Shock

Inadequate delivery of O2 and nutrients to support vial organs and cellular function--> impaired tissue perfusion Types: -Cardiogenic: failure of heart to pump adequately -Hypovolemic: decreased circulating blood volume -Distributive (circulatory): vasodilation-->blood to pool in peripheral vessels -->Neurogenic: spinal cord injury, certain meds, or hypoglycemia; warm, dry skin and bradycardia -->Anaphylactic: hypersensitivity reaction-->hypotension; life-threatening; respiratory distress, cardiac arrest -->Septic: most common; results from systemic infection; warm, dry skin, bounding pulses, tachypnea Manifestations (decreased tissue perfusion): -Tachycardia w/ hypotension; tachypnea; oliguria -Cold, moist skim (except neuro/ septic); ashen, pallor -Metabolic acidosis; decreased LOC Interventions: -Position in modified trendelenburg -Secure large bore IV line (16-18 gauge) -Administer O2; record VS q 5 min -Promote rest/ decease movement; monitor urine output Treatment: -Hypovolemic: volume replacement - Cardiogenic: increase contractility and reduce afterload (BP) -Septic: IV fluids and vasopressors -Anaphylactic: epinephrine and diphenhydramine -Neurogenic: treat cause (stabilize spinal cord)

GI, hepatic, pancreatic disorders GI disorders Inflammatory bowel disease Diverticular disease

Includes 3 conditions that involve numerous small sacs or pockets in the wall of the colon -Diverticulosis: presence of pouchlike herniations along the wall of the intestines; most common in sigmoid colon -Diverticular bleeding: results from injury of small vessels near diverticula -Diverticulitis: inflammation of 1+ diverticula Contributing factors: -Aging; constipation -Diet risk: low-fibre, high-fat, and red meat -Connective tissue disorders causing weakness in colon wall Manifestations (diverticulitis): -Alternating diarrhea with constipation -Painful cramps or tenderness in lower abdomen (LLQ) -Chills or fever Interventions: -Dietary management -->Diverticulitis: being w/ clear liquids, advance to low-fibre diet -->Diverticulosis: high fibre diet -->Educate about fibre sources; avoid foods with nuts, seeds, or kernels -Increase fluid intake to 3 L/day; nutrition counseling -Manage pain; avoid laxatives -Monitor: bowel elimination patterns, complications (obstruction, hemorrhage, infection) -Surgery: resection Meds: -Bulk laxatives (preventive); metronidazole (flagyl) -Trimethoprim/sulfamethoxazole (bactrim, septra) -Ciprofloxacin (cirpo) -Antispasmodics (daricon); Analgesics (Denerol) *Morhpine contraindicated- increases pressure in colon Therapeutic measures: -Emergency colon resection for peritonitis, bowel obstruction, abscess Teaching: -High-fibre vs low-fibre diet -Collaborative w/ nutritionist -Preventive measures

Respiratory system alterations Disorders Airflow problems Tuberculosis

Infectious disease transmitted through aerosolization Contributing factors: -Older and homeless populations -Lower socioeconomic status; foreign immigrants -Those in freq contact w/ untreated persons -Overcrowded living conditions Manifestations: -Cough, hemoptysis, + sputum culture for AFB, low grade fever w/ night sweats, anorexia, weight loss, malaise, fatigue Diagnostic: -Mantoux, sputum culture and smear for AFB to confirm, serum analysis, QFT-G, CXR Interventions: -Initiate airborne isolation precautions -Obtain sputum sample b/f administering meds -Maintain adequate nutritional status -Teach client to avoid foods containing tyramine when taking INH -Inform client that rifampin can alter metabolism of other meds - Monitor lab findings for liver and kidney function Meds (combination drug therapy): -Administer meds on empty stomach at same time q day -Meds should be taken for 6-12 months as directed -Instruct client to watch for indications of hepatotoxicity, nephrotoxicity, and or visual changes, and to notify provider if any of these are noted Meds to treat: -Isoniazid, rifampin, pyrazinamide, streptomycin, ethambutol Education/ referral: -Encourage client to practice good hand hygiene and always cover nose and mouth when sneezing/coughing -Ensure med compliance and follow up care Cases of diagnosed TB are reported to local or state health department

Respiratory system alterations Disorders Airflow problems COPD Chronic bronchitis

Inflammation and hypersecretion of mucus in bronchi and bronchioles caused by chronic exposure to irritants Contributing factors: -Cigarette smoking (main cause) -Exposure to air pollution and other environmental irritants Manifestations: -Productive cough, thick/tenacious sputum, hypoxemia, respiratory acidosis Diagnostic procedures: -CXR, pulmonary function tests (air trapped in lungs), pulse ox (<90%), ABGs (chronic respiratory acidosis), CT Interventions: -Assess: respiratory status, cardiac status for signs of R-sided failure -Position upright and leaning forward, schedule activities to allow for frequent rest periods, administer O2 therapy as prescribed, incentive spirometry -Encourage: fluids 2-3 L per day, high-calorie diet -Emotional support Meds: -Bronchodilators, methylxanthines, anti-inflammatory agents, mucolytic agents Therapeutic measures: -Chest PT/ pulmonary drainage -Lung reduction surgery Education/ referral: - Breathing techniques, O2 therapy, meds, nutrition, promote smoking cessation, infection prevention measures, encourage immunizations for pneumonia and influenza, pulmonary rehab, activity pacing

GI, hepatic, pancreatic disorders GI disorders Inflammatory bowel disease Crohn's disease

Inflammation of GI tract that extends thru all layers; can occur anywhere in intestinal tract, but most common in distal (terminal) ileum; "cobblestone" appearance of ulcers separated by normal tissue Contributing factors: -Family history; jewish ancestery; bacterial infection -Smoking; adolescents/ young adults (15-40) -Living in an urban area Manifestations: -Abdominal pain (LRQ); doesn't resolve w/ defecation -Pain aggravated with eating; low grade fever -Diarrhea, steotorrhea; weight loss (emaciated) -Formation of fistulas (abnormal tracts b/w bowel and skin/bladder or vagina) -Usually no bleeding; leukocytosis -Maybe accompanied by arthritis, skin lesions, conjunctivitis/ oral ulcers -String sign on x-ray: indicates constriction in segment of terminal ileum -Decreased hematocrit and hemoglobin; elevated ESR Interventions: -Promote adequate rest periods -Record color, volume, frequency, and consistency stools -Monitor and prevent fluid deficit -Nutrition therapy: high-calorie, protein, low-fibre, no dairy -Provide supportive care, support group -Complications: intestinal obstruction, perianal disease, fluid electrolyte imbalances, malnutrition, fistula, abscess -Surgery: bowel resection w/ ileostomy or stricturoplasty Meds: -Steroids; antiinfective- metronidazole (flagyl) -Aminosalicylates; TPN -Immune modulators: infliximab (remicade), humira, cimzia, tysabru Therapeutic measures: -Bowel resection (possible ileostomy) -Stricturoplasty -Lab profiles: Hct, hemoglobin, c-reactive protein, WBC, ESR -Abdominal x-ray Education: -Refer to support group; diet; health promotion/relaxation

Genitourinary system disorders Kidney and urinary system Specific disorders Cystitis

Inflammation of urinary bladder Contributing factors: -Wiping back to front after toileting, 2ndary to ascending infection from e.coli -Prolonged baths w/ excessive soap -Benign prostatic hyperplasia (males) Manifestations: -Freq and urgency, only voiding small amounts of urine -Dysuria w/ hematuria -Suprapubic tenderness; pain in bladder region; flank pain -Fever, malaise, chills; cloudy, foul smelling urine Interventions: -Obtain clean catch urine sample for culture and sensitivity before initiating antibiotic therapy -Maintain acidic urine pH; push fluids (>3,000mL/day) -Encourage cranberry juice; apply heat for comfort Meds: -Antimicrobials: sulfonamides (if allergic, Bactrim and Macrodantin) -Urinary analgesics (phenazopyridine): inform client that med will temporarily turn urine orange -Antispasmodics: hyoscyamine (cystospaz) Education/referral: -Follow appropriate perineal care (front to back) -Wear cotton underwear; avoid bubble baths -Maintain increased fluid intake; avoid sex -Drink cranberry juice daily

Respiratory system alterations Disorders Airflow problems Pneumonia

Inflammatory process in the lungs that produces excess fluid and exudate that fill the alveoli; classified as bacterial, viral, fungal or chemical Contributing factors: -Advanced age, chronic lung disease, immunocompromised, mechanical ventilation, postop, sedation/ opioid use, prolonged immobility, tobacco use, enteral tube feeding Manifestations: -Tachypnea, and tachycardia -Sudden onset: chills, fever, flushing, diaphoresis -Productive cough, dyspnea w/ pleuritic pain, crackles, elevated WBC, decreased O2 sats Diagnostic: -CXR, pulse ox, sputum culture and sensitivity Interventions: -Assess: respiratory status, sputum -Administer O2; Monitor VS -Encourage 3 L of fluid per day & mouth care -Promote nutritionand provide pulmonary hygiene Meds: -Anti-infectives, antipyretics, bronchodilators, anti-inflammatories Education: -Med administration, preventive measures, vaccines

Hematologic disorders Anemia Types Hemolytic amemia Thalassemia

Inherited blood disorder: body makes abnormal form of hgb--> excessive destruction of RBCs-->anemia Contributing factors: -Must inherit defective gene from both parents to develop thalassemia major -Asian, mediterranean, African American -Family history Manifestations: -Develops during 1st yr of life; bone deformities in face -Fatigue; growth failure; SOB; yellow skin (jaundice) Diagnostic: -RBCs appear small and abnormally shaped -CBC reveals anemia -Hgb electrophoresis shows the presence of an abnormal form of hgb -Mutational analysis detects alpha talassemia that can't be seen with hbg electrophoresis Interventions: -Encourage: increase of folate- dark green leafy veggies, dried beans and peas (legumes), citrus fruits and juices -Administer blood transfusions; encourage rest -Provide genetic counseling Therapeutic: -Tx involves regular blood transfusions (don't take iron supplements--> high iron levels in blood) -Chelation therapy: remove excess iron from body -Bone marrow transplant may treat disease in some Meds: -Folic acid

Neurosensory disorders Diagnostic Cerebral arteriography

Injection of dye via femoral artery to allow visualization of cerebral arteries Interventions: Preprocedure -Verify informed consent signed -Check for allergies to iodine, contrast dyes, shellfish -Assess BUN and creatinine -Keep client NPO 4-6 hr before procedure -Mark distal peripheral pulses -Instruct that face may feel warm during procedure Postprocedure -Monitor for altered LOC and sensory or motor deficits -Check for bleeding or hematoma at the insertion site; movement is restricted for 8-12 hr -Check peripheral pulses, colour, and temperature of extremities

Genitourinary system disorders Kidney and urinary system Diagnostic tests Renal biopsy

Interventions Preprocedure -Obtain bleeding, clotting and prothrombin times -Obtain results of prebiopsy x-rays of kidney -Administer IV fluids; maintain NPO for 6-8 hr -Position with a pillow under abdomen and shoulders on bed -Verify informed consent is signed -Instruct to remain still during procedure Postprocedure -Maintain in supine position; remain in bed for 24 hr -Monitor VS q 5-15 min for 4 hr -Maintain pressure to puncture site for 20 min -Observe client for any pain, N/V, and BP changes -Encourage fluid intake -Assess Hct and Hgb 8hr after procedure -Monitor urine output -Avoid strenuous activity sports, heavy lifting for 2 weeks

Neurosensory disorders Diagnostic CT scan

Interventions Preprocedure -Verify informed consent is signed -Check for allergies to iodine, contrast dyes, shellfish -Assess BUN and creatinine -Instruct to sit still and flat Postprocedure -Increase fluids to clear dye form client's system -Assess: dye injection site, allergic reaction to dye

Cardiovasular system disorders Cardiovascular disorders Angina (stable, unstable, varient) Interventions/ education

Interventions: -Assess pain: location (jaw, arm, chest), character, duration (relieved w/ rest or nitroglycerine), precipitating factors (eliminate or minimize to avoid attacks) -Administer O2 PRN; provide quiet environment (rest); avoid activities -Administer meds: -->Aspirin, nitrates, beta blockers, statins, calcium channel blockers, angiotensin-converting enzyme (ACE) Education: -Lifestyle changes: avoid constipation, avoid excessive activity in cold weather, decrease stress, exercise, consume low-sodium/low-fat diet, maintain healthy weight, rest after meals, promote tobacco cessation -Teaching on correct use of nitroglycerin -->Take as need at onset of chest pain/ tightness or in prep of exertional activity -Take as prescribed: at onset of attack, and every 5 min up to 3 doses; if pain not relieved after 1st, call 911 -Store in dark, dry spot, and replace every 6 months -Side effects: headache, hypotension -Types: tablets, ointment, patch, spray -If given for prevention, must be nitroglycerine free daily for 12 hr to prevent tolerance -Patch: apply in AM and remove at bedtime -Instruct to take while sitting down and stopping all activity -Erectile dysfunction med is contraindicated w/ use of nitrates

Endocrine system functions and disorders Pancreas Disorders of pancreas Diabetes mellitus Interventions

Interventions: -Monitor blood glucose; administer meds prescribed -Provide education; monitor VS and I&O -Refer to diabetic educator -Monitor for complications Possible complications: -Hypoglycemia (blood glucose <60 mg/dL) -->Causes: decreased dietary intake, excess insulin, decreased exercise -->Manifestations: tachycardia, diaphoreis, weakness, fatigue, irritability, anxiety, confusion -Transient hyperglycemia: elevated blood glucose treated with sliding scale insulin to return serum blood glucose to normal range -->Prompt treatment to avoid hyperglycemic emergencies -->Treat w/ regular insulin -->Don't hold insulin when blood glucose is normal -->Educate on importance and strategies to maintain blood glucose in the normal range Interventions: -Give client 15 g of fast acting simple carbs --> 3 or4 glucose tabs= 15 g carbs -->4 oz fruit juice or regular soda; 6-10 hard candies --> 2-3 teaspoons of sugar or honey -If unconscious/ unable to swallow: admin glucagon IM or subq; repeat in 10 min if client is still unconscious and notify provider -Follow 15/15/15 rule -->Administer 15 g of simple carbs -->Wait 15 min and recheck blood glucose -->Administer 15 + g of carbs if glucose <70 mg/dL -->Give 7g protein when glucose is normal ------->2 tbsp peanut butter, 1 oz cheese, 8 oz milk

Immunologic disorders AIDS Interventions/ meds/ education

Interventions: 1)Prevention -Teach about transmission routes; emphasize condoms -Risk is reduced by limiting partners -Teach IV drug users to use clean needles (water/ bleach) -Pregnant women who are HIV+ should be on antiviral therapy- infants should NOT be breastfeed -Ensure consistent use of standard precautions by health care workers in clinical settings 2) Stages 1 & 2 -Teach about risk of transmission of HIV to others -Emphasize compliance w/ antiviral therapy -Healthy lifestyle habits; psychological support 3) Stage 3 -Prevent infection; enhance oxygenation; comfort -Monitor: weight, I&O, calorie count; high calorie diet -Frequent oral care; scrupulous skin care -Monitor mental status; reorient PRN; consistent environment -Psychosocial support; include significant others Meds: -Efavirenz, axidothymidine (AZT), lamivudine -->Adverse effects: neutropenia, GI distress, anemia, insomnia -Zidovudine (AZT): protecting unborn fetus of HIV+ pregnant women -Interferon -Pneumocystis pneumonia prophylaxis: pentamidine -Antifungals: metronidazole (flagyl); amphotericin B -Antituberculosis as needed -Acyclovir herpes tx -Protease inhibitors: saquinovir, nitonavir -Antivirals: zalcitabine, didoxycytidine Education: -Transmission, control measures, safe sex practices -Nutritional needs, self-medication of prescriptions, potential side effects -Symptoms that need to be reported ASAP: infection, bleeding -Need for follow up monitoring CD4+ and viral load counts

Genitourinary system disorders Kidney and urinary system Diagnostic tests Cystoscopy

Invasive procedure in which a scope is passed to view the interior of the bladder, urethra, or position of urethral orifices to remove calculi from urethra, bladder and ureter; treat lesions of the bladder, urethra, prostate Interventions: Preoperative -Maintain NPO if client is given general anesthesia -Administer preop cathartics enemas as ordered -Teach client deep breathing exercises to relieve bladder spasms -Monitor for postural hypotension -Inform client that pink-tinged or tea-coloured urine is common following procedure, but bright red urine or clots should be reported -Provide nonpharmacological pain management after Postoperative -Assess: leg cramps due to lithotomy position; back pain or abdominal pain - Offer warm sitz baths for comfort -Push fluids and provide analgesics -Monitor I&O

Cardiovasular system disorders Diagnostic procedures Cardiac catheterization

Involves advancement of catheter (thru femoral artery into coronary arteries); dye may be injected to visualize blockages, which can then be treated w/ percutaneois coronary intervention (PCI); femoral vein can be accessed to perform other assessment of cardiac function Types of PCI: -Coronary angioplasty: balloon-tipped catheter used to press coronary blockage to open to improve blood flow -Coronary stent: during angioplasty, leaves metal mesh in place as structural support to prevent blockage from reoccurring Purpose: -Perform angiography or PCI -Obtain info about cardiac structure, blood flow, samples -Determine cardiac output Interventions: Prior to catheterization: -Verify procedural consent has been obtained -Know approach for shave prep- right (venous) side, or left (arterial) side -NPO for 6 hr prior to procedure -Mark distal (baseline) pulses -Explain: procedure may leave a metallic taste and mayb feel flushed when dye is injected -Verify client doesn't have any history of allergy (dye or shellfish) After catheterization: -Monitor: BP & apical pulse q 15 min for 2-4 hr; bleeding/ hematoma at catheter insertion site; vasospasm, dysrhythmia, or rupture of coronary vessel -Perform neurovascular assessment q 15 min for fist 2 hr, then q 30 min until able to sit up -Apply pressure for minimum of 15 min to prevent bleeding or hematoma formation -Assess chest pain; keep extremity extended for 4-6 hr -Maintain bed rest; no hip flexion/ sitting up in bed -Increase fluid intake to enhance flushing of dye

Nutrition: therapeutic diets Therapeutic/ modified diets Iron alterations/ calcium alternations

Iron alterations -Increased iron is indicated for correction/prevention of iron deficiency anemia (infants, toddlers, adolescents, pregnant women) -Food sources high in iron: fish, meats (organ), green leafy veggies, enriched breads, cereals/ macaroni, whole grain products, dried fruits (raisins, apricots), egg yolks -Vitamin C enhances absorption of iron from GI tract -Oral iron supplementation can cause constipation and GI distress, so adequate iron intake thru foods is ideal Calcium alterations -Increased calcium intake is indicated for: growing children/ adolescents, pregnant/lactating women, and postmenopausal women (prevent osteoporosis/osteopenia) -Food sources high in calcium: milk/milk products (yogurt&cheese), dark green veggies (collard greens, kale, broccoli), dried beans/peas, shellfish & canned salmon, antacids (tums, rolaids, titralac) -No more than 600 mg Ca can be absorbed at 1 time, so supplements should be taken 3 x daily; no more than 2,500 mg of Ca should be consumed per day -Vitamin D required for absorption of Ca from GI tract

Fluids and electrolytes IV fluids

Isotonic -Indication: tx of vascular system fluid deficit -Characteristics: concentration equal to plasma; prevent fluid shift b/w compartments -Solutions: normal saline (0.9%NS), lactated ringer's (LR), 5% dextrose in water (D5W) Hypotonic -Indication: tx of intracellular dehydration -Characteristics: lower osmolality than ECF; Shift fluid from ECF to ICF -Solutions: .45% normal saline (0.45% NS), 2.5% dextrose in 0.45% saline (D2.545% NS) Hypertonic -Indication: used only when osmolality is critically low -Characteristics: osmalality higher than ECF; shift fluid from ICF to ECF -Solutions: D10W, D50W, 5% dextrose in .9% saline (D5NS), D5W in 0.45%NaCl, D5LR

Genitourinary system disorders Kidney and urinary system Specific disorders Renal and urinary tract surgery

Kidney transplant -For clients with ESRD -Requires well matched donor -->Living nor cadaver Preoperative management -Interventions prescribed to correct metabolic status -Administer immunosuppressive therapy -Perform hemodialysis within 24 hr -Provide client with emotional support Interventions (postop) -Monitor labs: CBC, electrolytes, BUN/creatinine -Administer immunosuppressive meds: azathioprine, cyclosporine, steroids -Monitor for rejection: oliguria, edema, fever, tenderness over graft site, F&E balance, HTN, elevated BUN, creatinine, elevated WBCs -Monitor for infection and maintain protective isolation -Provide emotional support and monitor depression

Genitourinary system disorders Kidney and urinary system Diagnostic tests Radiologic tests

Kidneys, ureters, bladder (x-ray): -Shows size, shape, position of kidneys, ureters and bladder; no prep necessary (verify client isn't pregnant) IV pyelography (contrast dye): -Help in visualization of urinary tract Interventions: -Verify informed consent signed and last creatinine level -Remain NPO for 8 hr; fluids permitted -Administer: laxatives; enema or suppository on morning of test (as necessary) -Assess for allergies t iodine or shellfish -Inform of potential sensations during exam: flushing, warmth, nausea, metallic or salty taste, incontinence -Emergency equipment readily available -Encourage fluids to flush dye

Neurosensory disorders Common surgical procedures

Laminectomy: -Remove portion of vertebrae of tx of severe pain and disability resulting from compression of spinal nerves by ruptured disk or bony compression; also an option to relieve persistent pain or to treat progressive neuro problems due to nerve compression Diskectomy: -Remove herniated disk Spinal fusion: -Surgical fusion of vertebral spinous process w/ bone graft (autologous or banked), which provides stabilization of spine and decreased risk of recurrence Interventions: -Monitor VS; assess for neuro deficits -Monitor dressing for spinal fluid, bleeding, or infection -Log roll client; teach to maintain proper alignment and decrease stress on spine -Address sexual concerns; manage pain -Refer to rehab if indicated

Respiratory system alterations Disorders Airflow problems Lung cancer

Leading cause of cancer related deaths for both men and women; primary or metastatic disease Contributing factors: -Smoking (1st and 2nd hand), radiation exposure, chronic exposure to inhaled irritants, older adult Manifestations: -Chronic cough, chronic dyspnea, hemoptysis, hoarseness, fatigue, weight loss, anorexia, clubbing, chest wall pain Diagnostic: -CXR and CT, CT guided needle aspiration, bronchoscopy w/ biopsy -TNM for staging (Tumor, nodes, metastasis) Interventions: -Maintain patent airway; suction as indicated -Monitor: VS, pulse ox, nutritional status -Position in high-fowlers; emotional support -Assess and treat stomatitis -Ensure protection for immunocompromised client Meds: -Chemo agents and opioid narcotics Therapeutic measures: -Palliative care: meds and thoracentesis -Surgical: tumor excision, pneumonectomy, lobectomy, wedge resection -Radiation Education/ referral: -Meds, constipation prevention/ management, mouth and skin care, nutrition -Respiratory services, radiology, rehab, nutrition, hospice

Respiratory system alterations Disorders Airflow problems Status Asthmaticus

Life threatening episode of airway obstruction that is often unresponsive to treatment Manifestations: -Extreme wheezing, labored breathing, use of accessory muscles, distended neck veins, high risk for cardiac/respiratory arrest Interventions: -High fowler's; prepare for emergency intubation -Administer O2, epinephrine, and systemic steroid as prescribed -Provide emotional support

Respiratory system alterations Respiratory emergencies Pulmonary embolism

Life-threatening hypoxic condition caused by a collection of particulate matter that enters venous circulation and lodges in the pulmonary vessels causing pulmonary blood flow obstruction Contributing factors: -Chronic Afib, hypercoagulability, long bone fracture, long term immobility, oral contraceptive or estrogen therapy, obesity, postop, PVD, DVT, sickle cell anemia Manifestations: -Dyspnea, tachypnea, chest pain, tachycardia, anxiety, diaphoresis, decreased SaO2, pleural effusion, crackles, cough (*petechial rash w/ fat embolus) Diagnostic: -ABGs, d-dimer, CXR, V/Q scan, pulmonary angiography Interventions: -Assess respiratory status and VS -Provide: respiratory support an O2 therapy -Position in high-fowler's -Initiate IV access; provide emotional support Meds: -Thrombolytics & anticoagulants Therapeutic measures: -Embolectomy, vena cava filter Education/ referral: -Preventive measures; dietary precaution w/ vitamin K -Follow up for PT or INR -Bleeding precautions

GI, hepatic, pancreatic disorders Hepatic disorders Nonviral hepatitis

Liver injury and inflammation caused by ingestion of drugs and chemicals (industrial toxins, alcohol, drugs) Contributing factors: -Inhalation of hepatotoxic agents; drug toxicity -Alcohol -Secondary infection may occur with epstein-barr, herpes simplex, varicella-zoster, cytomegalovirus Manifestations: -Jaundice, liver enlargement, liver necrosis Collaborative care: -Monitor: sings of liver impairment, RUQ pain, weight -Treatment specific to symptoms/ causative factors

Cardiovasular system disorders Cardiovascular disorders Aortic aneurysm

Local distention of aortic artery wall, usually thoracic or abdominal; monitored until above 5 cm, when rupture increases and surgery is required Contributing factors: -Thoracic: pain, dyspnea, hoarseness, cough, dysphagia -Abdominal: abdominal pain, persistent/ intermittent low back or flank pain, pulsating abdominal mass Diagnostic: -CT, MRI, X-ray, ultrasound Interventions: -Preop: maintian systolic pressure @ 100-120mmHg w/ beta blockers and/or hypertensives (hydralazine); continuous IV nipride may be required; monitor for manifestations of rupture (intense pain, decreasing BP) -Postop: monitoring of peripheral circulation below the level of the aneurysm; monitoring of BP; low BP may indicate hemorrhage; high BP places stress on aterial suture line -Postop complications: arterial occlusion, hemorrhage, infection, renal failure

Nutrition: therapeutic diets Therapeutic/ modified diets Low- protein/ high- protein

Low protein Indications: -Hepatic encephalopathy; hepatic coma -Renal impairment Limit high protein foods: -Meats, eggs, milk/milk products, beans Considerations: -Increase carbs to meet nutritional needs -Limit sodium in presence of edema/ ascites High protein Indications: -Tissue repair/ building; burns -Malabsorption syndromes; pregnancy Encourage high biological value protein: -Egg whites, soy & milk products, fish & fowl, organ & meat sources Encourage oral fluids to decrease damage to renal capillaries as a result of increased protein

Fluids and electrolytes Electrolyte imbalances Ranges and function

Major intracellular electrolytes -Potassium, phosphorus, magnesium Major extracellular electrolytes -Sodium, calcium, chloride, bicarbonate Function: -Maintain homeostasis, promote neuromuscular excitability, maintain fluid volume, distribute water b/w fluid compartments, maintain cardiac stability, regulate acid-base balance

Respiratory system alterations Disorders Airflow problems Laryngeal cancer

Malignant cells occurring in mucosal tissue of larynx; more common in men b/w 55-70 Contributing factors: -Smoking, radiation exposure, chronic laryngitis/ straining of vocal cords Manifestations: -Hoarseness extending longer than 2 weeks, dysphagia, dyspnea, cough, sore throat, hard/ immobile lymph nodes in neck, weight loss, anorexia Diagnostic: -MRI, direct laryngoscopy w/ biopsy, X-ray, CT, bone/ PET scan Interventions: -Maintain patent airway, swallowing precautions -Emotional support, nutrition, pain management -Administer meds as elixir when possible Therapeutic measures -Partial or total laryngectomy -Radiation therapy Education/ referral: -Communication, stoma care, swallowing maneuvers, speech therapy

Cardiovasular system disorders Cardiovascular disorders Angina (stable, unstable, varient) Contributing factors/ manifestations/ diagnostic procedures

Manifestation of myocardial ischemia caused by arterial stenosis or blockage, uncontrolled BP, or cardiomyopathy Stable: triggered by physical exertion; emotional stress, cold temps, heavy meals, smoking can be triggers Unstable: fatty deposits in blood vessel rupture/ blood clot forms- can quickly block or reduce flow thru narrowed artery, suddenly and severely decreasing blood flow to heart muscle; can be caused by severe anemia when narrowed coronary arteries are present; not relieved by rest or meds Varient (prinzmetal's): caused by spasm in coronary artery in which artery temporarily narrows (2% of angina cases) Contributing factors: Coronary artery disease -Family history, advanced age, hyperlipidemia -Tobacco use, HTN, DM, obesity, physical inactivty Manifestations: -Chest pain/ discomfort; pain in arms/neck/jaw/shoulder -Nausea; fatigue; SOB; Anxiety; diaphoresis; dizziness Diagnostic: -ECG; stress test; cardiac cath; echo; enzymes, biomarkers

Cardiovasular system disorders Cardiovascular disorders Peripheral arterial occlusive disease

Manifestations: -Intermittent claudication: pain/cramping when walking; resolves w/ rest -Calf muscle atrophy; shiny skin w/ hair loss; thick nails -Poor neurovascular integrity; necrotic ulcers (punched-out, no edema present) -Tinging/ numb toes; cool extremities w/ poor pulses Interventions: -Exercise therapy: walk to point of pain 3 x week -Encourage tobacco cessation; weight reduction -Dependent position relieves pain Administer meds: -Pentoxifylline and cilostazol Therapeutic: -Surgical tx: -->Femoral popliteal bypass surgery -->Angioplasy or stenting

Respiratory system alterations Airway management Suctioning

Manifestations: -Restlessness, tachypnea, tachycardia, decreased SaO2, adventitious breath sounds, visualization of secretions, absence of spontaneous cough Collaborative care: -Hand hygiene; explain procedure; don PPE -Position to semi or high fowler's position -Obtain baseline breath sounds, VS, and SaO2 -Medical aseptic technique (oral suction) -Surgical aseptic technique all other types -Hyperoxygenate -Suction 10-15 sec (rotating motion); limit to 2/3 attempts -Allow recovery b/w attempts (20-30 sec) -Document amount, color, consistency of secretions as well as client response

Burns Meds/ treatments/ methods/ education

Meds -Antimicrobial creams -->Silver nitrate 0.5% soaks -->Silvadene cream: broad spectrum coverage; water soluble -->Mafenide acetate cream: broad spectrum coverage; penetrates tissue wall; never use dressing; breakdown of med causes heavy acid load, may cause acidosis; painful -->Bacitracin -Pain management -->PCA -->IV opioid analgesics: morphone sulfate, hydromorphone (dilaudid) and fentanyl Treatments -Wound care; biologic skin covering; permanent skin cover Methods of treating burns: -Open exposure -->Allows drainage of exudate; eschar forms hard crust -->Use of topical therapy; asepsis crucial -->Skin easily visualized and assessed; ROM easier -->Disadvantages: increases pain/ heat loss & difficult to manage burns on hands/ feet -Closed -->Gauze wrapped distal to proximal -->Decrease fluid & heat loss -->Limited mobility may result in contractures -->Wound assessment only during dressing changes -Topical antimicrobials -Biologic dressings/ tissue grafts -->Homograft or allograft (human tissue donors) -->Xenograft or heterograft (animal sources) -->Amniotic membrane -->Biosynthetic or synthetic (transparent film) Education: -Wear pressure garment 23.5hr/day to reduce scarring and control swelling -Engage in regular exercise per PT -Elevate affected areas as much as possible -Keep skin moisturized -Control itching w/ bool baths and lose, cotton fabric -Avoid sun; scars fade from red- near natural colour -Encourage to consume extra calories and protein

Hematologic disorders Anemia Types B12 deficiency anemia

Megaloblastic and/or pernucious: due to lack of dietary intake or absorption of vitamin B12 Contributing factors: -Atrophy of gastric mucosa/ hypochlorhydria (underproduction of hydrochloric acid by stomach) -Total gastrectomy (lack of intrinsic factor decreases intestinal B12 absorption) -Malnutrition Manifestations: -Numbness, tingling of extremities (paresthesia) -Hypoxemia; pallor; jaundice; glossitis; poor balance Diagnostic: -Shilling test: measures presence of B12 inurine after given an oral dose of radioactive B12 -CBC: megaloblastic RBCs (macrocytic) Interventions: -Monitor labs -Promote rest and encourage balanced dietary intake Meds: -Cobalamin (vit B12): standard dose 1,000 mcg IM daily for 2 weeks, then weekly until Hct level is therapeutic, then monthly for life; cyanocoabalamin intranasally maintains B12 levels

GI, hepatic, pancreatic disorders Hepatic disorders Type C (HCV)

Mode of transmission: -Blood to blood -Illicit IV drug sharing -Blood products; organ transplant before 1992 Manifestations: -Most asymptomatic -Diagnosis w/ blood testing -Chronic inflammation progresses to cirrhosis Prevention: -Avoid high risk behaviors Treatment: -Antiviral drugs -Administer peginterferon-apha 2B (pegintron) -Monitor kidney function

GI, hepatic, pancreatic disorders Hepatic disorders Type A (HAV)

Mode of transmission: -Fecal oral route -Person to person -Food contamination Manifestations: -Mild course -"Flu like" -Advanced age and chronic disease increase severity Prevention: -Hand washing -Vaccine for ages 2+ -2 doses 6-18 months apart Treatment: -Symptom specific -May have change in medication regimen to rest liver

GI, hepatic, pancreatic disorders Hepatic disorders Type B (HBV)

Mode of transmission: -Unprotected sex -Sharing needles; Needlesticks -Blood products; organ transplant before 1992 Manifestations: -May be asymptomatic -RUQ pain; anorexia, N&V; fatigue -Febrile; dark urine -Light-colored stool; jaundice Prevention: -Vaccine infants and high-risk populations -3 doses over 6 month period Treatment: -Antiviral drugs -Administer peginterferon-alpha 2B (pegintron) -Monitor kidney function

Nutrition: therapeutic diets Therapeutic/ modified diets Modified fat/ potassium modified/ sodium restricted

Modified fat Indications: -Gallbladder disease, hepatic disorders -Cystic fibrosis, malabsorption syndrome Avoid: -Whole milk products, gravies/ creams -Fatty meat & fish, nuts & chocolate, polyunsaturated oils Allowed: -2/3 eggs per week; lean meat, fowl, fish -Fruits/ veggies, bread and cereal Potassium modified High potassium foods: -Bananas, oranges, apples, milk, spinach, apricots/ prunes -Soy, lima, kidney beans; baked potatoes (white/sweet) Low potassium foods: -Breads, cereals, asparagus, cabbage, cherries -Blackberries, blueberries Sodium restricted Indications: -HTN; HF; myocardial infarction; adrenal cortical disease -Kidney disease; lithium carbonate therapy -Cystic fibrosis; liver cirrhosis; preeclampsia High sodium foods: -Salty snack foods (chips); canned soups/ veggies -Baked goods that contain baking powder/ soda -Processed meats (bologna, ham, bacon) -Dairy products (cheese); pickles, olives -Soy sauce, steak sauce; salad dressings Encourage to become "label savvy" for sodium

GI, hepatic, pancreatic disorders Gastric surgical procedures Bariatric surgery for morbid obesity

Morbid obesity: more than 2x ideal body weight; methods include- restrictive (gastric banding-reduces volume of stomach) and malabsorptive (roux-en- y gastric bypass- interferes with food and nutrient absorption) Indications: -BMI > 40; >35 with other diseases -Repeated failure of nonsurgical weight reduction Interventions: -Preop care -->Ensure thorough psychological prep -->Teach what to expect postsurgically: diet of liquids and pureed foods for 1st 6 weeks -->Reinforce healthy lifestyle changes -->ensure support systems available -Postop care -->Priority is airway; ensure abdominal binder in place -->Place in semi-fowler's; assist to ambulate ASAP (day of) -->Measure and compare abdominal girth; bowel sounds -->Collaborate w/ dietitian to introduce 6 small feedings per day; begin w/ 1 oz cups of clear liquids; increase as tolerated -->Monitor for dumping syndrome: tachycardia, nausea, diarrhea, abdominal cramping, diaphoresis, and anastomotic leak (most common and can be life threatening- increasing back, shoulder and abdominal pain, restlessness, tachycardia, oliguria) Meds: -Analgesics, antispasmodics, multi-vitamin Long term management: -Prevent dumping syndrome: eat slow, avoid drinking liquids w/ meals, after beginning solid foods, avoid high-fat foods/ refined carbs/ sugars, lie flat w/ head slightly elevated for 1 hr after eating -Encourage increase in physical activity -Provide ongoing psychological support

Disorders of musculoskeletal system Diagnostic tests for musculoskeletal disorders Dual-energy x-ray absorptiometry (DEXA) scan

Most common screening tool for measuring bone mineral density for diagnosis of osteopenia and osteoporosis -Baseline for women in their 40s -Client should wear loose clothing w/o zippers or metal -Client must remove jewelry -Instruct client to stop vitamin D and calcium supplementation 48 hr prior to scan

Neurosensory disorders Neuro assessment Motor function and reflexes

Muscles -Size, symmetry, tone, strength Coordination Movement -Voluntary control/ involuntary movements -Tremors, twitches, balance and gait Posturing -Decorticate: abnormal posturing indicated by rigidity, flexion of arms to chest, clenched fits, extended legs; indicative of damage to corticospinal tract -Decerebrate: abnormal posturing indicated by rigid extension of the arms and legs, downward pointing of toes, and backward arching of head; indicative of deterioration of structures of NS, upper brain stem Reflexes -Deep tendon reflexes -->Biceps, triceps, brachioradial, quadriceps -Superficial reflex -->Plantar, abdominal, Babinski -Reflex activity -->Absent, no response: 0; Weaker than normal: 1+ -->Normal: 2+; stronger/more brisk: 3+ -->Hyperactive: 4+

Cardiovasular system disorders Cardiovascular disorders Myocardial infarction (MI) Contributing factors/ manifestations/ diagnostic

Myocardial tissue is destroyed due to reduced coronary blood flow and lack of O2; actual necrosis of heart muscle occurs Contributing factors: -Atherosclerotic heart disease; coronary artery embolism Manifestations: -Severe chest pain, unrelieved w/ nitroglycerin or rest -Crushing quality, radiated to jawline, left arm, neck, back -Women, older adults,& clients w/DM often report no pain -Diaphoresis, N/V, anxiety, fear -VS changes: tachycardia, hypotension, dyspnea, dysrhythmias Diagnostic: -Lab results: elevated troponin and CK-MB enzymes, elevated LDH -12 lead ECG: obtained ASAP to identify ST changes; may be ST elevation MI (STEMI) or non-ST elevation MI (NSTEMI)

GI, hepatic, pancreatic disorders GI therapeutic procedures GI tubes

Nasogastric -Levin (single lumen): decompress stomach (ileus, gastric atony, or instestinal obstruction) -Salem sump (double lumen): suction aspiration, vent; obtain specimens for analysis (pH of gastric fluid and presence of blood) -Interventions: elevate HOB, verify placement, frequent mouth care, maintain NPO Miller-abbott -Double lumen: aspiration, inflate balloon at tip; small bowel suction -Interventions: reposition every 1 hr, do NOT tape tube to nose, monitor advancement of tube, assess color Sengstaken-blakemore -Triple lumen: esophageal balloon, gastric balloon, suction/ irrigation; tx of esophageal varices, can cause potential trauma and complications for client (rebleeding, pneumonia, respiratory obstruction) -Interventions: monitor for resp distress (ETT), keep scissors at bedside, monitor signs of shock

GI, hepatic, pancreatic disorders Diagnostic procedures Paracentesis

Needle inserted thru abdominal all into peritoneal cavity, withdrawing fluid accumulated due to ascites -Have client void; obtain baseline VS; position upright -Administer mild sedation and prescribed IV fluids or albumin to restore fluid balance (as much as 4 L of fluid slowly drained from abdomen) -Monitor VS; record weight before and after procedure -Measure abdominal girth before and after procedure -Assess lab profile before and after- albumin, amylase, protein, BUN, creatinine

GI, hepatic, pancreatic disorders Diagnostic procedures Liver biopsy

Needle inserted thru abdominal wall to obtain sample for biopsy or tissue examination; performed under fluoroscopy Preparation: -Informed consent -Assess coagulation studies: PT, aPTT, INR, platelet count -NPO 8-10hr before procedure -Position on affected side to promote hemostasis -Monitor for bleeding complications

Neurosensory disorders Diagnostic EEG

Noninvasive assessment of electrical activity of the brain; electrodes detect and record patterns of electrical activity, and also check for abnormalities such as seizure disorders, evaluation of head injuries, tumors, infections, degenerative diseases, metabolic disturbances, or to confirm brain death Interventions: -Verify which meds should be administered before EEG; depressive, stimulant and antiseizure not given -Avoid caffeine 8hr before test -Advise to wash hair before the test b/c it must be free of oils, sprays, conditioners -Verify if test is to be done awake, asleep or sleep deprived

Neurosensory disorders Diagnostic MRI

Noninvasive procedure that uses a magnetic field to construct clear, detailed, cross-sectional images of the body Interventions: -Verify informed consent is signed -Assess client for claustrophobia -Remove all objects (body piercings, jewelry, credit cards, watches) -No special test, diet, or meds required

Respiratory system alterations Diagnostic tests

Noninvasive procedures -Chest x-ray, pulse ox, pulmonary function tests, sputum culture, CT, MRI Invasive procedures Arterial blood gas: allows most accurate method of assessing respiratory function -Allen test if no arterial line -Sample drawn into heparinized syringe -Keep on ice and transport to lab immediately -Document amount and method of o2 delivered -Apply direct pressure to puncture site for 5 min -Monitor for hematoma Bronchoscopy: visual larynx, trachea, bronchi; obtain biopsy; foreign body removal -Obtain informed consent; Maintain NPO 8-12 hr -Provide local anesthetic throat spray; Position upright -Administer meds as presecribed, such as atropine (reduce oral secretions), sedation and/or anti-anxiety -Observe postprocedure: gag reflex, bleeding, resp status, VS, and LOC Mantoux test: + test indicates exposure to TB; must be confirmed with sputum culture for presence of AFB -Administer 0.1mL of purified protein derivation intradermal to upper half inner surface of forearm -Assess for reaction in 48-72 hrs following injection; induration of 10mm or greater is considered +; 5mm significant if imunocompromised QuaniFERON-TB gold test and T-SPOT.TB: identify presence of mycobacterium TB infection by measuring the immune response to TB bacteria in whole blood Thoracentesis: perforation of pleural space to obtain specimen, remove fluid or air or instill medications -Obtain consent; educate client (remain still, position) -Position upright; monitor respiratory status and VS -Label specimens -Document: response, amount, color, viscosity of fluid (max amount of fluid to be removed at one time is 1 L) -Chest tube @ bedside; CXR before and after

Perioperative care Common post-op complications Wound infection

Occurrence: - 3 to 5 days Manifestations: -Signs of delayed healing with purulent/discolored drainage, pain in incisional area Interventions: -Promote: healthy diet, adequate fluid intake, adequate rest and exercise -Wound care -Antibiotics

Perioperative care Common post-op complications Decreased peristalsis/ paralytic ileus

Occurrence: -2 to 4 days Manifestations: -Hypoactive/ absent bowel sounds -No flatus Interventions: -NG to decompress stomach; limit narcotics -Ambulation -Prokinetic agents: metoclopramide (Reglan) as prescribed

Perioperative care Common post-op complications Wound dehiscence/ evisceration

Occurrence: -4 to 15 days Manifestations: -Open wound revealing underlying tissue (dehiscence) or organs (evisceration) Interventions: -Position client to decrease tension at suture line -Apply sterile saline-soaked gauze -Notify surgeon -Instruct client not to cough or strain -Provide emotional support

Perioperative care Common post-op complications Delayed wound healing

Occurrence: -5 to 6 days Manifestations: -Edema, redness, pallor, separation at edges, absence of granulation tissue Interventions: -Splint incision as needed -Use incision support devices (abdominal binder) -Promote high-protein diet

Perioperative care Common post-op complications Urinary tract infection

Occurrence: -5 to 8 days Manifestations: -Frequency, urgency, dysuria, malodorous, cloudy urine Interventions: -Wipe front to back after urination -Limit use of indwelling catheters -Encourage voiding and increase fluids 3L/day -Cranberry juice -Antibiotics and uroanalgesics as prescribed

Perioperative care Common post-op complications Thromboplebitis

Occurrence: -7 to 14 days Manifestations: -Redness, warmth, calf tenderness/pain, edema at site Interventions: -Early ambulation -Apply antiembolic stockings or sequential compression devices as prescribed -Avoid actions that decrease venous flow -Anticoagulant prophylaxis

Perioperative care Common post-op complications Hypostatic pneumonia

Occurrence: -After 48hr Manifestations: -Febrile, tachycardia, tachypnea, crackles, rhonchi Interventions: -Incentive spirometer -T,C, DB q 2 hr -Early ambulation -Hydration -Mucolytics

Perioperative care Common post-op complications Atelectasis

Occurrence: -First 48 hrs Manifestations: -Tachycardia, tachypnea, shallow respirations Interventions: -Incentive spirometer -T,C,DB q 2 hr -Early ambulation -Hydration -Mucolytics

Perioperative care Common post-op complications Urinary retention/ hesitancy

Occurrence: -Immediate to 3 days Manifestations: -Inability to void, bladder distention, restlessness, increased BP Interventions: -Privacy, bladder scan, offer bedpan, I&O

Perioperative care Common post-op complications Respiratory depression

Occurrence: -Immediate to 48 hr Manifestations: -Bradypnea, shallow respirations, decreased LOC Interventions: -Monitor: respiratory rate & rhythm, LOC -Regulate narcotics -O2 therapy -Narcotic antagonis: naloxone (narcan)

Perioperative care Common post-op complications Hypoxia

Occurrence: -Immediate to 48 hr Manifestations: -Confusion, tachypnea, increased BP/pulse Interventions: -Monitor VS -O2 therapy -Resolve underlying problem

Perioperative care Common post-op complications Shock

Occurrence: -Immediate to 48 hr Manifestations: -Decreased BP, pulse, urinary output -Cold, clammy, pale skin -Lethargy, stupor Interventions: -Monitor VS, I&O, LOC -Replace fluids -Position in modified trendelenburg -Administer vasopressors as prescribed

Perioperative care Common post-op complications Nausea

Occurrence: -Immediate to 48hr Manifestations: -Nausea Interventions: -Comfort measures, relaxation -Mouth care -Antiemetic -NG tube to decompress stomach

Perioperative care Common post-op complications Wound hemorrhage

Occurrence: -Immediate to discharge Manifestations: -Bleeding from drainage tubes or surgical site -Signs of shock Interventions: -Assess site; identify early signs -Monitor drainage device, keep patent -Avoid tension at surgical site

Burns Overview/ parkland formula

Overview -Thermal, chemical, electrical, radioactive agents can cause burn resulting in cellular destruction of skin layers and underlying tissue -Can result in loss of temperature regulation, sweat and sebaceous gland function, sensory/ organ function -Assessment/ severity based upon: -->% of total body surface area; depth; location; age -->Causative agent; other injuries; respiratory involvement Maintain cardiac output and provide IV fluid replacement using Parkland formula: -Give 4 mL/kg/ % burn -Give half of total fluids in first 8 hr -Give second half over remaining 16 hr -Deduct any fluid given prehospital from amount to be infused in first 8 hr

Oncology Overview of cancer/ risk factors/ consequences

Overview: -Healthy cells transform into malignant cells upon exposure to etiological agents- virus, chemicals, physical agents -Malignant cells metastasize and extend into adjacent tissue; move thru lymph system; enter blood; diffuse Risk factors: -Age -->Older adult women: colorectal, breast, lung, pancreatic, ovarian -->Older adult men: lung, colorectal, prostate, pancreatic, gastric -Race; genetic disposition -Exposure: chemicals, viruses, tobacco, alcohol, bacteria, sun -Diet high in red meat and fat and low in fibre General disease-related consequences of cancer: Decreased immunity and blood producing function: -Leukemia and lymphoma/ any cancer that invades bone marrow and reduces production of WBCs, RBCs, and platelets >thrombocytopenia -Increased risk for infection -Changes caused by cancer or chemo -May experience weakness, fatigue, bleeding Altered GI structure and function: -Impaired absorption and elimination related to tumor obstruction or compression -Tumors: increases metabolic rate, increasing need for proteins, fats, carbs -Liver tumors: reduce function> malnutrition Motor and sensory deficits: -Occur when cancers invade bone/brain/ compress nerves -Bone metastases cause pain, fractures, spinal cord obstruction, hypercalcemia (decreases mobility) -Sensory changes occur if spinal cord is damaged by tumor pressure/ compression -Sensory, motor, cognitive impaired when tumor's in brain -Pain significant, esp in terminal stages Decreased respiratory function: -Disrupts respiratory function and gas exchange (tumors in airway cause obstruction) -Lung capacity decreased; gas exchange impaired -Tumors can compress blood & lymph vessels in the chest, blocking blood flow thru the chest and lungs, causing pulmonary edema and dyspnea

GI, hepatic, pancreatic disorders GI disorders Inflammatory bowel disease Intestinal obstruction

Partial/ complete blockage of intestinal contents; results from mechanical obstruction (adhesions, tumors, colculus), neurogennic (paralytic ileus), or vascular (mesenteric artery occlusion) Contributing factors: -Crohn's disease; radiation therapy -Fecal impaction; carcinomas -Surgical procedures; narcotics -Hypokalemia; diverticulitis Manifestations: -Inability to pass flatus or stool for grater than 8 hr -Abdominal distention -hyperactive bowel sound above site of obstruction -Hypoactive or active bowel sounds below site of obstruction Small bowel: -Sporadic colicky pain; visible, peristaltic waves -Profuse, projectile vomitus w/ fecal odor (vomiting relieves pain) Large intestine: -Diffuse and constant pain -Significant abdominal distention -Infrequent vomiting, leakage of fecal fluid around impaction Interventions: -NPO; assess bowel sounds; IV fluids -Preoperative care; NG tube for decompression -Prevent fluid and electrolyte deficit Therapeutic: -Abdominal x-rays; endoscopy; CT -Surgical: remove obstruction, resection Teaching: -Preventive measures based on etiology; diet

Neurosensory disorders Disorders Spinal cord injury

Partial/ complete disruption of nerve tracts & neurons; results in paralysis, sensory loss, altered activity, autonomic NS dysfunction Contributing factors: -Male 16-30; motor vehicle crashes; falls; violence; sports Types: -Contusion, laceration, compression of cord, complete transection (paralyzed below level of injury) Manifestations: -Cervical: partial or complete quadriplegia/tetraplegia -->Respiratory dysfunction (ventilator dependent) -->Partial or complete paralysis of all 4 extremities -->Loss of bladder/bowel control, sexual function -Thoracic: partial or complete paraplegia -->Loss of bladder/bowel control, sexual function -->Partial or complete paralysis of lower extremities and major control of body trunk -->Potential complication of autonomic dysreflexia= above T6; respiratory complications -Lumbar -->Partial or complete paralysis of lower extremities -->Loss of bladder/bowel control, sexual function Interventions -Immobilize: spinal board, halo traction, gardner-wells traction or crutchfield tongs, cervical collar -Maintain/monitor respiratory function -Monitor spinal shock: loss of sensation, flaccid paralysis, reflexes below level of injury -Monitor neurogenic shock: decreased BP, HR & CO, venous pooling) -Monitor autonomic dysreflexia: sudden, severe HTN triggered by noxious stimuli below damage of cord; impaction,bladder distension, pressure points, ulcers, pain -->Manifestations: HTN w/ bradycardia, headache, flushing, piloerection, sweating, nasal congestion -->Interventions: place in high-fowler's (decrease BP), remove causative stimuli, teach bowel/ bladder management, administer meds as prescribed -->Therapeutic: surgical management -->Referral: OT & PT

Genitourinary system disorders Kidney and urinary system Specific disorders Continuous ambulatory peritoneal dialysis (CAPD)

Peritoneal dialysis performed by client w/o use of machine Procedure: -Permanent indwelling catheter inserted into peritoneum -Fluid infused by gravity (1.5-3 L) -Dwell time: 4-8hr -Dialysate drains by gravity: 20-40 min -4-5 exchanges daily, 7 days/week (some do night w/ automatic cycling machines; 10-14 hr, 3 times/week); continuous cycling peritoneal dialysis (CCPD) Interventions: -Monitor: complications; peritonitis (rebound tenderness, fever, cloudy outflow); bladder perforation (yellow); hypotension; bowel perforation (brown) Advantages: -Independence; may continue normal activities during -Free dietary intake/ better nutrition -Satisfactory control of uremia; least expensive -Deceased likelihood of future transplant rejection -More closely approximates normal renal function

Cardiovasular system disorders Cardiovascular disorders Hypertension

Persistent BP >140/90 mmHg; "silent killer" Primary HTN: -Most common type; hereditary disease; cause unknown -Common in African Americans -Late manifestations: headaches, fatigue, dyspnea, edema, nocturia, blackouts -No manifestations until end-organ involvement occurs Secondary HTN: -Identifiable cause; pheochromocytoma; renal pathology Interventions: -Weight control; tobacco cessation; regular exercise -Decrease alcohol/ caffeine intake; reduce stress -Sodium restricted diet -DASH diet: increased fruits, veggies, low fat dairy, limited saturated fats Meds: -Loop diuretics: furosemide, bumetanide -Thiazide-hydrocholorthiazide, chlorothiazide -->Interventions: K supplements, dietary sources of K, hypokalemia increases risk of digitalis toxicity -K sparing diuretics: spironolactone, triamterene; monitor increased K level -Beta blockers: propranolol HCl, atenolol, metoprolol -->Interventions: monitor for bradycardia, pulse daily, and manifestations of HF; noncardioselective BB may be contraindicated in clients w/ asthma; monitor for hypoglycemia in clients w/ DM (may be masked) -Central-acting alpha-blockers (sympatholytics): clonidine HCl, guanfacine HCl, methyldopa -Angiotensin converting enzyme (ACE) inhibitors: captopril, enalapril, lisinopril -Calcium-channel blockers: nidedipine, verapamil, diltiazem

Respiratory system alterations Respiratory emergencies Pneumothorax Tension pneumothorax Hemothorax

Pneumothorax: -Collection of air or gas in chest or pleural space that causes part or all of a lung to collapse due to loss of negative pressure Tension pneumothorax: -Occurs when air enters pleural space during inspiration thru 1-way valve an is not able to exit upon expiration; the trapped air causes pressure on heart and lung; as a result, increase in pressure compresses blood vessels and limits venous return, leading to decrease in CO; death can result if not treated immediately Hemothorax: -Accumulation of blood in pleural cavity Contributing factors: -Blunt chest trauma, COPD, closed/ occluded chest tube, advanced age, penetrating chest wounds Manifestations: -Respiratory distress, tracheal deviation to unaffected side (tension) -Reduced or absent breath sound (affected side) -Asymmetrical chest wall movement -Hyperresonance on percussion due to trapped air (pneumo) -Subq emphysema; chest pain Diagnostic: - CXR, thoracentesis (hemo) Interventions: -Monitor respiratory status, chest tube/ dressing -Position in high fowler's; administer O2 -Provide emotional support Therapeutic measures: -Chest tube insertion: inserted to pleural space for draining fluid, blood or air; reestablishes a negative pressure; facilitates lung expansion -->Position in high fowler's> verify informed consent is signed> prepare chest drainage system prior to insertion>administer pain and sedation med as ordered> assist provider as needed> apply dressing to insertion site> maintain chest tube system> monitor respiratory status, pulse ox, VS, client response, complications

GI, hepatic, pancreatic disorders GI therapeutic procedures Hiatal hernia

Portion of stomach protrudes thru esophageal hiatus of diaphragm into the chest Contributing factors: -High-fat diet, caffeinated beverages, tobacco products -Meds: Ca++ channel blockers, anticholinergics, nitrates -Obesity Manifestations: -Regurgitation, persistent heartburn and dysphagia, belching, epigastric pain, dysphagia, breathlessness or feeling of suffocation after eating, chest pain that mimics angina, symptoms worsen after a meal or when supine Interventions: -Prepare for barium swallow with fluoroscopy -Assess diet history; encourage small freq meals -Avoid eating 3 hr prior to bedtime, sit upright 1-2 hr after meals -Elevate HOB; encourage weight reduction BMI >25 -Avoid straining or vigorous exercise -Wear loose clothing around abdomen -Monitor for complications: bleeding, esophageal ulcers, Barrett's esophagus, aggravation of asthma, chronic cough, pulmonary fibrosis Meds: -Antacids; histamine receptor antagonists -Prokinetic agents; PPIs Education: -Dietary med regimen and precautions of aspiration Therapeutic measures: -Hiatal hernia-fundoplication is other measures ineffective

Neurosensory disorders Neuro assessment Diagnostic Lumbar puncture

Procedure that inserts a needle into subarachnoid space to measure pressure, obtain CSF for analysis, and inject contrast, anesthetics and medications Interventions: -Verify informed consent is signed -Client empty bladder and bowel -Position on side with knees pulled toward chest and chin tucked down -Assist with measuring pressure and collecting fluid Post procedure: -Encourage fluid intake -Check puncture sites for redness, swelling, clear drainage -Assessment movement of extremities -Monitor for complications

Perioperative care Preoperative phase

Procedures or teaching completed prior to surgical procedure- reduce potential complications and postop discomfort, relieve anxiety and increase participation in care Interventions: -Take client history -Identify risk factors: infants, elderly, poor health, respiratory conditions, obesity, emergent procedures -Check for informed consent -Perform baseline assessment; assess allergies -Verify NPO status Meds: -Anesthesia: inhalation, IV, regional, topical -Antibiotics, anticholinergics, narcotics, sedatives Diagnostics: -Lab profile, CXR, ECG, pregnancy test for females Education: -Fears and anxiety; invasive procedures -Meds: hold anticoagulants for 7-10 days prior to surgery -Incentive spirometry -Turn, position, and perform early ambulation, including leg exercises -Analgesics and pain control methods -Routine and expected postop care -Pre, intra, postop routines

Genitourinary system disorders Kidney and urinary system Specific disorders Hemodialysis

Process of cleansing blood of accumulated waste product and fluids; used for ESRD or clients who are acutely ill and require short term treatment Interventions: -Weight client before and after procedure -Monitor BP continuously during procedure -Provide care to access site (prevent clotting/infection) -Assess for presence of thrill and bruit -Provide adequate nutrition as prescribed -Post sign that warns of no BP readings/ blood work on side of fistula -Maintain fluid restriction -Withhold regular morning meds prior to dialysis -Notify nurse:muscle cramps, headache, nausea, dizziness -Provide emotional support; offer books, magazines, etc

Disorders of musculoskeletal system Arthritis Osteoarthritis

Progressive deterioration and loss of cartilage in 1+ joints Contributing factors: -Aging; female; metabolic disease; obesity -Repetitive use or abuse of joints; smoking Manifestations: -Chronic joint pain and stiffness -Pain diminished after rest and worsens after activity -Crepitius; limited movement -Heberden nodes (closest to end of fingers/ toes) -Bouchard's nodes (middle joints of fingers/ toes) -Excess joint fluid (esp w/ knee involvement) -Skeletal muscle atrophy from disuse Diagnostic: -X rays, MRI, erythrocyte sedimentation rate (ESR), CRP Interventions: -Assess/ manage pain; instruct to use ice or heat -Encourage to perform ROM and isometric exercises, and adequate rest/ sleep -Involve PT as appropriate -Use assistive devices to increase independence & ADLS Meds: -NSAIDs, corticosteroids, topical analgesics Therapeutic measures: -Total joint arthroplasty or replacement Education: -Mobility devices and safety -Prevent complications -Perform exercises per tx plan Referral/ follow up: -PT; rehab therapy

Genitourinary system disorders Kidney and urinary system Specific disorders Chronic kidney disease

Progressive failure of kidney function that results in death unless hemodialysis or transplant is performed; irreversible Stages: 1) Glomerular filtration rate (GFR) >90 mL/min 2) GFR 60-89 mL/min 3) 30-59 mL/min 4) 15-29 mL/min 5) <15 mL/min (end stage renal disease ESRD) Contributing factors: -DM (leading cause), uncontrolled HTN (2nd), chronic glomerulonephritis, pyeloephritis -Congenital kidney disease, PKD -Ethnicity: African American, Native American Asian Manifestations: -Fatigue 2ndary to anemia; headache and HTN -N/V, diarrhea; irritability; edema -Hypocalcemia, hyperkalemia; pruritus, uremic frost -Pallid, grey-yellow complexion -Metabolic acidosis; elevated BUN and creatinine; decreased GFR -Convulsions, coma Interventions: -Bed rest; monitor/ treat HTN as prescribed -Renal diet: low protein, low K, high carb, vitamins and calcium supplements, low Na, and low phosphate -Strict I&O; fluid replacement: 500-600mL more than prev 24 hr urine output; monitor electrolytes -Don't administer antacids w/ magnesium or enemas w/ phosphorous -Maintain dialysis; administer diuretics in early stages -Meticulous skin care; emotional support -Assess for bleeding tendencies Meds: -Phosphate binders (amphojel), calcium acetate, sevelamer hydrochloride -Epoetin alfa/ erythropoietin (Epogen, Procrit) for anemia to stimulate RBC formation/ transfuse as necessary

Nutrition: therapeutic diets Guidelines

Protein: 10-35% of total kcal/day Fat: 20-35% of total kcal/day Carbs: 40-60% total kcal/day Fluids: 2-3 L/day for women; 3-4 L/day for men Fibre: 25 g/day for women; 38 g/day for men Sodium: 1,500 mg/day or less for 50+, african americans, history of DM, HTN, chronic kidney disease Goods w/ increased levels of fat & water soluble vitamins: Foods rich in fat-soluble vitamins: -Vit A: liver, yolk, whole milk, butter, green/ yellow veggies -Vit D: fish oils, fortified milk & margarine, sunglight -Vit K: yolks, liver, cheese, green leafy veggies Foods rich in water soluble vitamins: -Vit C: citrus fruits, tomatoes, broccoli, cabbage -Thiamine (B1): lean meats (beef, pork, liver), whole grain cereals, legumes -Ribolfavin (B2): milk, organ meats, enriched grains, green leafy veggies -Niacin (B3): meat, beans, peas, peanuts, enriched grains -Pyridoxine (B6): products w/ yeast, wheat, corn, organ meats -Cobalamin (B12): lean meats, liver, kidneys -Folic acid (B9): leafy green veggies, eggs, liver

GI, hepatic, pancreatic disorders GI disorders Inflammatory bowel disease Abdominal hernia

Protrusion of bowel thru muscle wall of abdominal cavity (umbilical, ventral, inguinal/femoral); reducible, irreducible or strangulated Contributing factors: -Aging; male; obesity; heavy lifting/ straining -Abdominal surgery; pregnancy -Congenital' acquired muscle weakness -Ascites, distension Manifestations: -Client reports "lump" felt at involved site -Pain in groin when bending, coughing, or lifting -Absent bowel sounds (strangulated) -Palpation of mass Interventions: -Wear abdominal binder for support of herniated tissue -Encourage increased fluid intake -Monitor for complications: strangulation, perforation -Surgery: minimally invasive inguinal hernia repair or laproscopic repair; bowel resection for strangulation -Postsurgical care: -->Allow to stand to void -->For inguinal repair: elevate scrotum and apply ice -->Teach to avoid coughing and lifting/straining during recovery (4-6 weeks) Meds: -Analgesics, stool softeners Therapeutic: -Herniorrhaphy laproscopic repair Education: -Avoid lifting 4-6 weeks after surgery

Nutrition: therapeutic diets Therapeutic/ modified diets Pureed/ soft diet/ mechanical soft diet

Pureed Indications: -Transition from full liquid to regular diet -Swallowing or chewing difficulties; oral/facial surgery Consists of: -Foods/ liquids that have been pureed to a thick liquid form (scrambled eggs, pureed meats/veggies/fruits) -Consistency varies w/ client needs -Nutritional content caries w/ client needs Soft diet (bland/low fibre) Indications: -Transition from liquid to regular diet -Acute infections; chewing difficulties -Gastric or duodenal ulcers by eliminating irritating foods Consists of: -Low in fibre; lightly seasoned; easily digested -Smooth and creamy -Non gas forming: avoid cereals, beans, fruits, veggies Mechanical soft Indications: -Chewing/ swallowing difficulty; post CVA -Head/ neck/ mouth surgery; intestinal stricture Consists of foods w/ minimal chewing: -Ground/finely diced meat; canned fruits -Softly cooked veggies; cheese; rice; light bread Foods to exclude: -Dried fruits; raw fruits/ veggies; nuts/ seeds

Need to know lab values CBC

RBCs -Males: 4.7-6.1 million/uL -Females: 4.2- 5.4 million/uL Hgb -Males: 14-18 g/dL -Females: 12-16 g/dL Hct -Males: 42-52% -Females: 37-47% WBCs -Male and female: 5,000-10,000 mm3 ESR -Males and female: <20 mm/hr

Oncology Cancer management Radiation

Radiation delivery: -Teletherapy: distance treatment, source is external -Brachytherapy: short or close therapy; radiation comes into direct, continuous contact w/ tumor tissues; provides high dose radiation w/ limited amount to surrounding tissue Interventions: -Must always be in same position for all treatments; ensure client can maintain same position during treatment; fixing devices and markings must be in correct position for each treatment -Assess condition of skin, cleanse area gently each day -Wet reaction: skin becomes dry or develops blisters that may break, causing pain and potential for infection; if dry, keep clean and lubricated; if wet, clean and cover -Don't remove skin marking; avoid powders, lotions -Wear soft, loose clothes and avoid the sun -Manage cancer pain and psychosocial support -Sealed implants: -->Assign to private room; place caution sign on door -->Wear lead apron; don't care for client if pregnant -->Limit visitors to 1/2 hr each day and remain 6 ft away -->Don't touch stone with bare hands -->Save radioactive dressing and linens until source is removed -->Follow guidelines for containment

Disorders of musculoskeletal system Diagnostic tests for musculoskeletal disorders Bone scan

Radioactive medium injected for viewing entire skeleton, primarily to detect tumors, arthritis, osteomyelitis, osteoporosis, vertebral compression fractures and unexplained bone pain -Technician or physician administers isotope 4-6 hr prior to testing -Client must lie still for 30-60 min as imaging is performed -Increase fluids post procedures

Genitourinary system disorders Kidney and urinary system Specific disorders Testicular cancer

Rare cancer affecting one or both testes; self exam should begin in adolescents Contributing factors: -Men 20-54 y/o; high risk in males w/ undescended testis -Family history Manifestations: -Swelling or painless lump in 1 or both testes -Possible heaviness or aching in lower abdomen/ scrotum Treatment: -Offer sperm banking prior to surgery -Orchiectomy to remove affected testicle -Chemotherapy; emotional support

Cardiovasular system disorders Diagnostic procedures Electrocardiogram (ECG)

Recording of electrical activity occurring in heart; 12-lead ECG should be obtained within 10 min of onset of chest pain to identify any areas of myocardial damage -T wave inversion: ischemia -ST segment elevation: injury - Q wave enlargement: infarction Wave elements: -P wave: atrial depolarization (contraction) -QRS complex: ventricular depolarization (contraction)- should be <0.12 sec -T wave: ventricular repolarization (relaxation); T wave depression (inversion) indicates ischemia -PR interval: time b/w SA node and AV node; should be b/w 0.12-0.20 sec -ST segment: elevation, indicates myocardial injury

GI, hepatic, pancreatic disorders GI disorders Inflammatory bowel disease Ulcerative colitis

Recurrent ulcerative and inflammatory disease of the superficial mucosa of the colon; usually begins in the rectum and spreads proximally thru the entire colon; contiguous ulcers Contributing factors: -Family history; Jewish ancestry; isotretinoin (accutane) -Young and middle age adults (15-25 yrs; 55-65 yrs) -Caucasian ethnicity Manifestations: -Liquid, bloody stool (10-20 per day); low grade fever -Abdominal distention along the colon -Rebound tenderness indicates perforation/ peritonitis -Passage of mucous and pus from the bowel -Left, lower quadrant abdominal pain; anorexia -Weight loss; vomiting/ dehydration -Sensation of urgent need to defecate; hypocalcemia -Anemia; associated arthritis, conjunctivitis, skin lesions and/or liver problems *Bleeding common- helps differentiate from crohn's Interventions: -Promote adequate rest periods -Record color, volume, frequency, and consistency stools -Maintain NPO status during acute phase -Monitor: dehydration (maintain fluid balance), electrolytes (IV fluids may be indicated) -Provide dietary management and education: increase oral fluids, & low-residue, high-calorie, high-protein diet -Administer multivitamin and supplemental iron -Refer to support group -Prepare for surgery: proctocolectomy with ileostomy Meds: -Antidiarrheals (megacolon); Aminosalicylates (5-ASAs) -Immune modulators: infliximab, adalimumab (humira), cimzia, tysabri -TPN -Corticosteroids (oral, parenteral, topical) Therapeutic: -Surgical management is indicated for bowel perforation, toxic megacolon, hemorrhage, colon cancer -->Colectomy and ileostomy -->Total proctocolectomy with permanent ileostomy -->Lab profiles: Hct, hemoglobin, C-reactive protein, WBC, ESR -->Abdominal x-ray Education: -Refer to support group, dietary, health promo/relaxation

Cardiovasular system disorders Cardiovascular disorders Buerger's disease (thromboangiitis obliterans)

Recurring inflammation of arteries and veins of lower and upper extremities, resulting in thrombus w/ occlusion (cause unknown) Contributing factors: -Genetic predispostition; cigarette smoking/ chewing -Occurs in men 20-35 Manifestations: -Intermittent pain in legs, feet, arms, hands (eases when activity is stopped- claudication) -Inflammation along a vein below the skin's surface (blood clot in vein) -Cold sensitivity of Raynaud type occurs in hands -Painful open sores on fingers/toes -Ulcerations and gangrene w/ amputation common Interventions: -Promote smoking cessation -Avoid cold/ constricting clothing

Genitourinary system disorders Kidney and urinary system Specific disorders Urinary diversion

Removal of bladder and surroundig structures to reroute urinary flow thru a pouch and abdominal stoma Interventions: -Monitor: VS; complications (hemorrhage, shock); stoma -Provide pain control; manifestations of paralytic ileus -Provide adequate fluid replacement -Weight client daily -Maintain function and patency of drainage tubes: -->Indwelling catheter: dependent position, tape to thigh -->Nephrostomy tube: never clamp; irrigate w/ 10mL of 0.9% NaCl; assess for leakage of urine -->Urethral catheters: each cath drains half of urinary system; blood drainage expected after surgery, should clear within 24-48 hr; never irrigate surgical implant; aseptic technique required

Respiratory system alterations Airway management Mechanical ventilation

Respiratory support thru controlled delivery of ventilation and oxygenation via endotracheal tube, tach tub or noninvasive ventilation via mask thru continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) Indication: -During surgery, acute respiratory distress, respiratory failure Interventions: -Explain procedure to client -Establish means of communication, including asking yes/no questions, providing writing materials, using dry erase board/ picture communication board or lip reading Maintain patent airway -Ensure advanced airway device is secured -Assess position and placement of tube, document cm at client's lips or teeth, & respiratory status every 1-2 hr and as needed -Prevent accidental extubation; wrist restraints may be required -Suction oral and tracheal secretions as indicated by assessment Monitor ventilator settings and alarms -Never turn off vent alarms; if the cause of an alarm cannot be identified and corrected, and the clients respiratory status begins to decline, the nurse should vent the client using a manual resuscitation bag until issue is resolved -Low pressure alarm: indicates low volume and is associated with tube disconnections, cuff leak, or tube dislodgement -High pressure alarm: indicates increased pressure which may be caused by secretions, kinking of tube, pulmonary edema, or client coughing/ biting tube -Apnea alarm: indicates there's been no spontaneous breath within a preset time period -Maintain adequate but not excessive cuff pressure (<20mmHg to reduce risk of tracheal necrosis) -Reposition endotracheal tube every 24 hr or by protocol (monitor for skin breakdown) Administer meds as prescribed -Analgesics, sedation, neuromuscular blocking agents Prevent complications: -Pneumonia: hand hygiene, elevate HOB, oral hygiene -Pneumothorax: caused by high vent pressures, auscultate lung sounds freq, consider if sudden distress, requires immediate action (chest tube)

Cardiovasular system disorders Cardiovascular disorders Valvular disorders

Result in narrowing of valve that prevents/ impedes blood flow (stenosis) or impaired closure that allows backward leakage of blood (regurgitation); may affect mitral, aortic, or tricuspid valve Contributing factors: -History of endocarditis and rheumatic fever Manifestations: -R sided HF: mitral stenosis, mitral regurgitation, tricuspid stenosis -L sided HF: aortic stenosis, aortic regurgitation -Murmurs; decreased cardiac output Interventions: -Management: similar as HF -Valvuloplasty: postprocedure care similar to PCI; watch for signs of systemic emboli (dislodged from valve) -Valve replacement -->Mechanical: will require lifelong anticogulants using warfarin (Coumadin); INR 2.0-3.0 -->Biologic: requires prophylactic anticoags for 3 months -->All require prophylactic antibiotics prior to any future invasive procedures or tests, including dental procedures to prevent infective endocarditis

Neurosensory disorders Disorders Increased ICP

Rise in pressure within the skill that can result form or cause a brain injury Contributing factors: -Head injury w/ subdural/ epidural hematoma -CVA or cerebral edema; brain tumor -Hydrocephalus; meningtitis, encephalitis -Ruptured aneurysm & subarachnoid hemorrhage Manifestations: -Changes in LOC: restlessness, confusion, drowsiness, lethargy, stupor; motor/ sensory changes -Headache, irritability; N/V (projectile) -Pupil changes: dilated, unequal, nonreactive -Diplopia; changes in VS -->Cushing's triad: HTN w/ widening pulse pressure, bradycardia, irregular breathing -->Irregular respirations: cheyne-stokes -->Elevated temperature Interventions: -Monitor VS & neuro function; HOB elevated 30-45 degree -Head in neutral position (enhance drainage) -Avoid: coughing, sneezing, straining, suctioning -Maintain max respiratory exchange -Administer O2; monitor fluid I&O (may restrict) -Administer meds; hypothermia to decrease ICP -Decrease environmental stimuli -Intensive care required (ventriculostomy) Meds: -Avoid opiates & sedatives unless ventilated -Barbiturates: place into therapeutic coma w/ vent support -Acetaminophen: fever -Osmotic diuretics (mannitol) and steroids (dexamethosone): decrease cerebral edema

Fluids and electrolytes Electrolyte imbalance/ interventions Potassium (K+) Hypokalemia

Risk factors: -Adverse effects of meds: corticosteroids, diuretics, digitalis, laxatives (abuse) -Body fluid loss: vomiting, diarrhea, wound drainage, NG suction -Excessive diaphoresis: kidney disease, dietary deficiency, alkalosis Manifestations: -Muscle weakness, cramping, fatigue, N&V, irritability, confusion, decreased bowel motility, paresthesia, dysrhythmias, flat/inverted T waves Interventions: -Monitor: respiratory status, ECG, I&O, arterial HCO3 and pH -Initiate: fall precautions, K replacement (oral, IV) -Provide client education -Dietary sources, medications *Never give K IV bolus; MUST dilute *No P= No K (if client is not urinating, don't administer K)

Fluid and electrolytes Acid-base imbalance Metabolic acidosis

Risk factors: -Diarrhea, fever, hypoxia, starvation, seizure, renal failure, DKA, dehydration -Overdose: salicylates or ethanol Manifestations: -VS: bradycardia, weak pulses, hypotension, tachypnea -Flaccid paralysis, confusion, hyporeflexia, lethargy, confusion, warm/flushed/dry skin, kussmaul's respirations Interventions: -Treat underlying cause; administer fluids, electrolytes

Fluids and electrolytes Electrolyte imbalance/ interventions Sodium (Na+) Hyponatremia

Risk factors: -GI loss, SIADH, adrenal insufficiency, water intoxication, excessive diaphoresis -Meds:: diuretics, anti-coagulants, SSRIs, lithium Manifestations: -Weakness, lethargy, confusion, seizures, headache, anorexia, N&V, muscle cramps, twitching, hypotension, tachycardia, weight gain, edema Interventions: -Sodium replacement (oral, GI tube, IV), restrict oral fluid intake, daily weight, I&O -Meds: conivaptan hydrochloride (Vaprisol) *Risk with hypertonic solutions- cerebral edema

Fluids and electrolytes Electrolyte imbalance/ interventions Magnesium (Mg++) Hypomagnesemia

Risk factors: -GI loss, alcoholism, hypocalcemia, hypokalemia, DKA, hyperparathyroidism, malabsorption, TPN, laxative abuse, acute MI -Meds: gentamicin, cysplatin, cyclosporine Manifestations: -Paresthesias, dysrhythmias, trousseaus sign, chvosteks sign, agitation/confusion, hyperreflexia, HTN, insomnia/ irritability, anorexia, N&V, dysphagia Interventions: -Seizure precautions, monitor swallowing, dietary measure and education, monitor urine output and respirations -Administer meds: IV magnesium sulfate, PO magnesium salts *Monitor for signs of magnesium toxicity with IV replacement and treat with calcium gluconcate

Fluids and electrolytes Electrolyte imbalance/ interventions Calcium (Ca++) Hypercalcemia

Risk factors: -Hyperparathyroidism, malignant disease, prolonged immobilization, vitamin D excess, thiazide diuretics, lithium, digoxin toxicity, overuse of calcium supplements Manifestations: -Muscle weakness, hypercalciuria/kidney stones, dysrhythmias, lethargy/coma, hyporeflexia, pathologic fractures, flank pain, deep bone pain, polyuria, polydipsia, dehydration, HTN, N&V Interventions: -Increase mobility, isotonic IVF, dialysis, cardiac monitor -Meds: Furosemide (calcitonin, glucocorticoids, biphosonates, calcium chelators)

Fluid and electrolytes Acid-base imbalance Respiratory alkalosis

Risk factors: -Hyperventilation, hypoxemia, altitude sickness, asphyxiation, asthma, pneumonia Manifestations: -Tachypnea, anxiety/ tetany, paresthesias, palpitations, chest pain Interventions: -Regulation O2 therapy, reduce anxiety, rebreathing techniques

Fluids and electrolytes Electrolyte imbalance/ interventions Calcium (Ca++) Hypocalcemia

Risk factors: -Hypoparathyroidism, hypomagnesemia, kidney failure, vitamin D deficiency, adequate intake -Disease process: celiac disease, lactose intolerance, crohn's, alcohol use disorder Manifestations: -Tetany/ cramps, paresthesias, dysrhythmias, Trousseau's sign, Chvostek's sign, seizures, hyperreflexia, impaired clotting time Interventions: -Seizure precautions, IV calcium replacement, daily calcium supplements, vitamin D therapy, monitor for orthostatic hypotension, dietary increase and education *IV calcium must be administered slowly and site monitored for extravasation- diluted in D5W, NEVER NS

Fluid and electrolytes Acid-base imbalance Metabolic alkalosis

Risk factors: -Ingestion of antacids, GI suction, hypokalemia, TPN, blood transfusion, prolonged vomiting Manifestations: -Dizziness, paresthesias, hypertonic muscles, decreased respirations Interventions: -Treat underlying cause; administer fluids, electrolytes

Fluids and electrolytes Electrolyte imbalance/ interventions Potassium (K+) Hyperkalemia

Risk factors: -Renal failure, adrenal insufficiency, acidosis, excessive K intake -Meds: K-sparing diuretics, ACE inhibitors Manifestations: -Peaked T waves, ventricular dysrhythmias, muscle twitching and paresthesia (early), ascending muscle weakness (late), increased bowel motility Interventions: -Monitor: ECG, bowel sounds -Initiate dialysis, dietary restriction and teaching -Administer meds: Kayexalate (monitor bowel sounds), 50% glucose w/ insulin, calcium gluconate, barcarbonate, loop diuretics

Fluids and electrolytes Electrolyte imbalance/ interventions Phosphorus Hyperphosphatemia

Risk factors: -Renal failure, chemo, high vitamin D, high phosphorus intake, excessive enema use, acidosis Manifestations: -Tetany/ cramps, paresthesias, dysrhythmias, trousseus sign, chvosteks sign, hyperreflexia, anorexia, N&V, soft tissue calcifications Interventions: -Meds: vitamin D, aluminum hydroxide (amphogel), diuretics -IV NS, dialysis dietary management and education

Fluids and electrolytes Electrolyte imbalance/ interventions Magnesium (Mg++) Hypermagnesemia

Risk factors: -Renal failure, excessive Mg therapy, adrenal insufficiency, laxative overuse, lithium toxicity, extensive soft tissue injury or necrosis Manifestations: -Hypotension, drowsiness, bradycardia, bradypnea, coma, cardiac arrest, hyporeflexia, N&V, facial flushing Interventions: -Mechanical ventilation -IV fluids: lactated ringers or normal saline -Meds: IV calcium gluconate, loop diuretics -Monitor: respirations, BP, deep-tendon reflexes *Magnesium shouldn't be administered to clients in renal failure

Fluid and electrolytes Acid-base imbalance Respiratory acidosis

Risk factors: -Respiratory depression, penumothorax, airway obstruction, inadequate ventilation Manifestations: -Dizziness, palpitations, muscle twitching, convulsions Interventions: -Maintain patent airway, reversal agents for narcotics, regulation ventilation therapy, bronchodilators, mucolytics

Fluids and electrolytes Electrolyte imbalance/ interventions Phosphorus Hypophosphatemia

Risk factors: -Vitamin D deficiency, refeeding after starvation, alcohol withdrawal, DKA, alkalosis, hypomagnesemia, hypokalemia -Excessive loss of body fluids: sweat, diarrhea, vomiting, hyperventilation, burns -TPN, overuse of antacids Manifestations: -Paresthesia, muscle weakness, bone pain and deformities, chest pain, confusion, seizures, nystagmus Interventions: -oral phosphate replacement, careful IV administration of phosphorus (severe cases), gradual introduction of solution for clients on TPN, protect from infection, dietary management and education, seizure precautions *Phosphorus has inverse relationship with calcium

Fluids and electrolytes Electrolyte imbalance/ interventions Sodium (Na+) Hypernatremia

Risk factors: -Water deficit, GI loss, hypertonic tube feedings, diabetes insipidus, burns, heatstroke Manifestations: -Fever, swollen/dry tongue, sticky mucous membranes, hallucinations, lethargy/restlessness/irritability, seizures, tachycardia, HTN, hyperreflexia/ twitching, pulmonary edema Interventions: -Daily weight, I&O, seizure precautions, IV infusion of hypotonic or isotonic fluid, diuretics, dietary sodium restriction and education, increase oral fluid intake

GI, hepatic, pancreatic disorders GI therapeutic procedures Salivary gland, oral mucosa, pharyngeal disorders

Salivary glands consist of parotid, submandibular, sublingual, and buccal glands. Disorders may affect lubrication, protection form harmful bacteria and digestion; disorders include candidiasis (thrush), parotitis, sialoadenitis, salivary calculus, stomatitis, and cancer Contributing factors: -Tobacco use, alcohol use disorder, aging, dehydration, radiation, stress, malnutrition, poor oral hygiene, immunosuppression Manifestations: -Pain, cheesy white plaque (candidiasis) -Inflammation, redness, xerostomia -Persistent, painless oral lesion that doesn't heal (cancer) Interventions: -Monitor: nutritional status, swallowing ability, indications of infection -Implement alternatives to oral communication PRN -Ensure adequate food and fluid intake -Perform and teach regular and thorough oral hygiene -Promote positive self image

Neurosensory disorders Sensory assessment Common optical problems Detached retina

Sensory retina separates from pigment epithelium of retina; vitreous humor fluid flows b/w layers when tear occurs in retina; can be related to age or trauma Manifestations: -Sudden visual disturbances; flashes of light -Blurred vision w/ floaters -Curtain/ shadow over visual field across 1 eye Interventions: Preoperative -Maintain bed rest w/ patch to affected eye -Avoid coughing, sneezing, straining -Surgical: scleral buckling, photocoagulation, cryosurgery, vitrectomy, pneumatic retinopexy Postoperative -Bed rest in prescribed position w/ eye path and shield in place -Avoid jarring, bumping head, straining, coughing -Administers meds: antiemetic, antibiotic, antiinflamm -Teach regular self-administration of eye drops

Neurosensory disorders Disorders Status epilepticus

Series of generalized seizures w/o full recovery of consciousness b/w; may be caused by sudden withdrawal of anticonvulsant medications; can lead to brain death Interventions -Initiate seizure precautions Meds: -Lorazepam (Ativan); Diazepam (valium) -Phenytoin (dilantin): administer IV slowly, no more than 50 mg/min -->Don't mix with glucose- administer in 0.9% NaCl -Fosphenytoin (cerebyx)

Need to know lab values Renal function

Serum creatinine: -Males: 0.6-1.2 mg/dL -Females: 0.5-1.1 mg/dL BUN: 10-20 mg/dL Creatinine clearance test -Males: 90-139 mL/min -Females: 80-125 mL/min -Calculation of glomerular filtration rate (GFR) and is the best indicator of overall renal function

Neurosensory disorders Sensory assessment Common optical problems Cataract

Slow, progressive clouding of the lens Manifestations: -Painless, diplopia, blurred vision -Decreased visual acuity, freq change in eyeglass prescription -May perceive surroundings being dimmer Interventions: Preop (dilate the eye) -Mydriatics, antibiotics, corticosteroids Postop -Keep eye covered; elevate HOB 30-40 degrees -Avoid bending at waist, lifting, sneezing, coughing -Don't tough eye area -Prevent vomiting/straining; report severe pain ASAP Therapeutic: -Surgical: removal of lens under local anesthesia, w/ intraocular lens implant

Need to know lab values Electrolytes

Sodium (Na): 136-145 mEq/L Potassium (K): 3.5-5 mEq/L Calcium total (Ca): 9.0-10.5 mg/dL Magnesium (Mg): 1.3-2.1 mEq/L Phosphorus (PO4): 3.0-4.5 mg/dL Chloride (Cl): 98-106 mEq/L

Need to know lab values Urinalysis

Specific gravity: 1.005-1.025 Protein: 0.8 mg/dL Glucose: <0.5 g/day Ketones: none pH: 4.6-8 WBC -Males: 0-3 per high power field -Females: 0-5 per high power field

Genitourinary system disorders Kidney and urinary system Diagnostic tests Indwelling catheterization

Sterile procedure to empty contents of bladder, obtain sterile specimen, determine residual urine, initiate irrigation of bladder or bypass obstruction Interventions: -Maintain closed system; measure output every shift -Provide meticulous perineal care -Keep drainage bag below level of bladder -Increase daily fluid intake -Prevent dependent loops in catheter tubing -Discontinue ASAP due to increased risk for UTI

Genitourinary system disorders Kidney and urinary system Specific disorders Urilithiasis (urinary calculi)

Stones in urinary system Contributing factors: -Obstruction and urinary stasis; uric acid stones (purines) -Immobilization -Common in men 20-40 and reoccurs Manifestations (based on location and size): -Pain: severe renal colic (ureter); dull, aching (kidney); radiates to groin -N/V, diarrhea, or constipation -Hematuria; manifestations of a UTI Interventions (eradicate stone & prevent nephron destruction): -Force fluids- at least 3,000 mL/day (IV or mouth) -Strain all urine; provide pain control -Maintain proper urine pH (depends on type of stone) Meds: -Opioids: morphine IV for rapid pain relief; NSAID ketorolac in acute phase -Allopurinol for uric acid stones Therapeutic: -Lithotripsy to crush tone thru sound waves Education: -Avoid foods high in oxalates if calcium oxalate stone (spinach, black tea, rhubarb, chocolate) -Maintain fluid intake to maintain hydration

Neurosensory disorders Disorders Cerebrovascular accident (CVA)

Stroke; sudden loss of brain function resulting from disruption of blood supply to involved part of the brain; causes temporary or permanent neuro deficits Contributing factors: -HTN, obesity; smoking or cocaine use; hyperlipidemia -DM; peripheral vascular disease; aneursym -Cranial hemorrhage Manifestations: -Severity determined by location/ extent of tissue ischemia -Change in mental status; slurred speech, aphasia, dysphagia -Numbness/weakness of face or extremities (one side) -Visual disturbance; cranial nerve disturbance -Loss of balance or coordination; severe headache Interventions: -Maintain: airway; F&E balance -Monitor: neuro function, VS; aspiration due to risk of dysphagia (feed slowly, place food back & unaffected side) -Establish baseline level of function and glasgow coma -Provide psychological support; establish communication -Encourage slow, deliberate speech -ROM: prevent flexion contractures, keep extremities in position of extension or neutrality -Maintain skin integrity; safety issues (hemiparesis/plegia) -Help achieve bowel and bladder control -Hemianopsia: place articles within client's visual range Therapeutic: -Thrombolytic therapy (ischemia CVA) -Surgical management (hemorrhagic CVA) Education/ referral: -Occupational / physical / speech therapy

Respiratory system alterations Disorders Airflow problems Carbon dioxide toxicity

Stuporous secondary to increased CO2 retention Contributing factors: -CO2 retention and excessive O2 delivery Manifestations: -Alteration in LOC, tachypnea, increased BP, tachycardia w/ dysrhythmias Collaborative care: -Monitor pulse ox and ABGs -Avoid excessive concentrations of O2 -Provide pulmonary hygiene -Provide ventilatory support with CPAP, BiPAP, or mechanical ventilation

Endocrine system functions and disorders Thyroid gland Disorders of thyroid gland Hypothyroidism

Suboptimal levels of thyroid hormone resulting in decreased metabolism; freq in older women Manifestations: -Fatigue, weakness, increased sensitivity to cold -Constipation, dry skin, brittle hair/ nails -Weight gain, deepened/ hoarse voice, joint pain -Hyperlipidemia, anemia, depression, menstrual disturb Diagnostic: -Low serum T4 & T3 -Elevated TSH Myxedema coma: -Rare, life-threatening condition seen in untreated/ uncontrolled hypothyroidism; hypothermic w/ changes in mental functioning (depression-unconsciousness); severly decreased metabolism causes resp depression and cardiovascular collapse; management is to provide intensive supportive measures w/ hemodynamic therapy; high mortality rate Interventions: -Warm environment; rest periods for the day -Low-calorie, low-cholesterol, low-fat diet -Increase roughage and fluids; avoid sedatives -Weight daily -Observe for overdose of thyroid preparations: palpitations, insomnia, increased appetite, tremors Meds: -Levothyroxine (synthroid) Education/ referral: -Educate regarding lifelong med therapy -Follow up w/ provider -Take med on empty stomach each AM -Know manifestations of med toxicity -Eat diet high in fibre; monitor need for sleep

Disorders of musculoskeletal system Total joint arthroplasty (replacement)

Surgical procedure to replace a joint w/ a prosthetic system; may be performed for ankle, finger, elbow, should, toe, wrist, knee and hip Contributing factors: -Impaired mobility and uncontrolled pain related to osteoarthritis -Congenital anomalies; trauma; osteonecrosis Interventions: -Position client correctly, maintaining alignment -->Hip: keep abductor pillow in place in bed, don't flex more than 90 degrees -->Knee: maintain cont passive motion machine (mobility) -Assess: pain, rotation, extremity shortening, neurovascular status -Use aseptic technique for wound care and emptying of drains -Monitor for indications of infection -Ambulate the day of surgery, after stabilization -Use toilet seat extender -Exercises to reduce DVT: ankle dorsiflexion, circles with feet, push feet into bed while tightening quads, straight-leg raises Meds: -Anticoagulants, NSAIDS, opioid narcotics (extended release epidural morhphine or PCA) Education: -Instruct: participate in exercise regimen, and use of ambulation devices Referral/ follow up: -PT for ambulation, transfer, joint movement -Occupational therapy to meet goals of independence and self care

Hematologic disorders Anemia Types Folic acid deficiency anemia

Symptoms similar to B12 deficiency, but nervous system functions remain normal Contributing factors: -Poor nutrition; malabsorption (2ndary to crohn's) -Drugs: chronic alcohol abuse, anticonvulsants, oral contraceptives Interventions: -Identify high-risk clients: alcoholics, elderly, debilitated Meds: -Folic acid replacement

Disorders of musculoskeletal system Arthritis Gouty arthritis

Systemic inflammatory disease caused by probel,s with purine metabolism (primary gout) or hyperuricemia (2ndary gout) Contributing factors: -Family history; excessive alcohol intake -High intake of foods w/ purines (organ meats, yeasts, spinach, sardines) -Obesity; comorbid conditions (DM or kidney disease) Manifestations: -Excruciating pain and inflammation in 1+ small joints (great toe most common) -Appearance of tophi (depostis of Na urate crystals) -Progressive joint damage and deformity -Increased incidence of uric acid renal stone Diagnostic: -Serum uric acid >7; ESR; synovial fluid analysis (will show uric acid crystals) Interventions: -Maintain bed rest during acute attacks -Use bed cradle to keep linen elevated above affected joint -Promote fluid intake 3 L/day; limit foods high in purine Meds: -Acute phase: colchicine -Chronic tx: allopurinol -NSAIDs; corticosteroids ( or injection into affected joint) Education: -Foods to avoid (high purine); keep diary of triggers -Avoid alcohol; lose weight slowly

Neurosensory disorders Disorders Transient ischemic attack (TIA)

Temporary episode of neurological dysfunction lasting <1 hr 2ndary to decreased blood flow to brain; may be warning of impending stroke Contributing factors: -Nonmodifiable: advanced age, male, genetics -Modifiable: HTN, hyperlipidemia, DM, smoking, Afib Manifestations: -Sudden change visual function & motor/sensory functions Diagnostic: -Carotid ultrasound; CT or MRI -Arteriography; 12-lead ECG Interventions: -Encourage cessation of smoking/ limit alcohol intake -DASH diet: high in fruits/veggies, moderate low fat dairy, low in animal protein -Stress importance of maintaining ideal body weight Meds: -Antiplatelet: Plavix, Persantine + Aspirin, Ticlid -Anticoagulant: warfarin (Coumadin) -Lipid lowering agents Therapeutic: -Angioplasy -Carotid endarterectomy: removal of plaque from arteries

Need to know lab values Anticoagulant therapy coagulation times

Therapeutic INR -2.0-3.0 PT -11-12.5 seconds -Therapeutic range anticoagulant therapy is 1.5-2x normal or control value aPTT -30-40 seconds -Therapeutic range for anticoagulant therapy is 1.5-2x normal/control value INR -Normal INR is 0.7-1.8 -INR is corrected ratio of a client's prothrombin time to normal -Universal test is not affected by variations in lab norms -If client requires anticoagulation, desired value is increased to 2-3 Platelets -150,000-400,000/ mm3

Need to know lab values Blood lipid levels

Total serum cholesterol -Desirable <200 mg/dL -Risk for cardiac/ stroke event >150mg/dL LDL -Desirable <130 mg/dL HDL -Males: 35-65 mg/dL -Females: 35-80 mg/dL Triglycerides -Desirable <150 mg/dL -Males: 40-160 mg/dL -Females: 35-135 mg/dL

Genitourinary system disorders Kidney and urinary system Specific disorders Incontinence

Types -Urge: can't hold urine when stimulus to void occurs -Functional: can't physically get to bathroom or is not aware of stimulus to avoid -Stress: pressure such as coughing, straining, lifting, bearing down, or laughing causes incontinence Interventions: -Adult incontinency devices; decrease fluids after 6pm -Maintain regular toilet schedule -Perform crede maneuver PRN; monitor signs of cystitis -Teach kegel exercises to strengthen sphincter -Ensure physical environment enhances ability to get to bathroom

Disorders of musculoskeletal system Ambulations

Types: -Above the knee, below the knee, mid foot, toe Contributing factors: -Peripheral vascular disease; malignant tumors -Severe crushing of tissues or significant vessels -Osteomyelitis Interventions: -Assess: neurovascular and psychosocial status, willingness/ motivation to withstand prolonged rehab -Manage phantom limb and residual limb pain -Monitor: signs of wound healing & complications: -->Hemorrhage, infection, phantom pain, flexion contractures -Promote: mobility and ROM, independence -Maintain aseptic technique w/ dressing changes -Wrap stump w/ figure 8 elastic bandage after dressing is removed Meds: -Opioids (residual limb pain) -Calcitonin (phantom pain) -Antispasmotics (muscle spasms) -Beta blockers (constant, dull, burning pain) -Antiepileptics (knifelike or sharp burning pain) Education: -Types of pain and management regiment -Measures to prevent contractures -Use of ambulatory devices or prosthetics Referral/ follow up: -Rehab therapy and support group

GI, hepatic, pancreatic disorders Hepatic disorders Gallbladder disease

Types: -Cholecystitis: inflammation of gallbladder -Cholelithiasis: presence of stones in gallbladder Contributing factors: -Female; over age 40; overweight -High consumption of cholesterol, fat -Sedentary lifestyle; family history; DM -American Indian ethnicity Manifestations: -RUQ, epigastric or shoulder pain -N&V; dietary fat intolerance; Murphy's sign -Jaundice with pruritus; icterus -Flatuence; dyspepsia; dark urine, clay-coloured stool Diagnostic: -Ultrasound, hepatobiliary scan -Endoscopic retrograde cholangiopancreatography (ERCP) -Cholangiography Interventions: -Administer analgesics; prevent F&E imbalances -Maintain low-fat diet; postoperative care -Cholecystectomy client may have T-tube -->Monitor drainage, keep below level of GB -->Empty collection bag q 8hr -->Report drainage amounts >1,000mL/day -->Never irrigate w/o physician order -Observe color of stool -Monitor indications of postcholecystectomy syndrome (manifestations of cholecystitis after surgery) and report to physician Meds: -Analgesics: morphine, hydromorphone (dilaudid), ketoralac (toradol) *Morphine contraindicated for acute biliary pain- breaks down toxic metabolite that can cause seizures -Antiemetics; anticholinergics; antibiotics -Ursodeoxycholic acid (Urso) and chenodiol can be used to non-surgically dissolve stones Therapeutic measures: -Spincterotomy w/ stone removal w/ ERCP -Extracorporeal shock wave lithotripsy (ESWL) to break up stones (small cholesterol stones) -Cholecystectomy Education: -Resume regular low-fat diet -Prevent dumping syndrome -Care of T-tube at home

Disorders of musculoskeletal system Fractures

Types: -Close, comminuted (fragmented), compression, displaced, greenstick, impacted, oblique, open (compound), pathologic (tumors, infection bone disease), spiral, stress (small crack in bone) Collaborative care: -Assess neurovascular status (6 Ps): -->Pain, pressure, paralysis, pallor, pulselessness, paresthesia -Monitor changes in skin temperature -Monitor complications of fat embolism: -->Confusion, anxiety, tachycardia, tachypnea, hemoptysis, petechiae over neck/ upper arms/ chest/ abdomen (late sign) -Monitor complications of compartment syndrome -->Pain unrelieved by positioning or medication, cyanosis, tinging, paralysis -Maintain correct body alignment -Provide nursing care specific to therapeutic measures of fracture reduction Therapeutic measures: Cast -Assess neurovascular status; allow cast to air dry -Elevate affected extremity; monitor for complications -Client may "petal" plaster cast if irritation develops -Reduce infection-->don't place objects down cast Skin traction (pulling force to overcome spasms) -Buck's, Bryant's, cervical halter, pelvic Skeletal traction (directly on bone- reduce fracture) -Pins or wires inserted thru skin and soft tissue into bone -Balanced suspension using splints, slings, weights External fixation device (aligns and immobilize) -Assess pulses/ vascular status; maintain proper alignment -Verify weights are free hanging -Monitor skin for pressure points for breakdown -Promote strengthening exercises for uninjured areas -Consult w/ PT

GI, hepatic, pancreatic disorders GI disorders Peptic ulcer disease

Ulcerations in stomach or duodenum as a result of mucosal tissue destruction; high risk of perforation and bleeding; may be referred to as gastric, duodenal or esophageal ulcer Contributing factors: -NSAIDs, corticosteroids, H. pylori infection, smoking -Uncontrolled stress, caffeine, alcohol, type O blood -Age between 40-60 years Manifestations: -Dyspepsia -Dull, gnawing, burning, mid-epigastric and/or back pain with localized tenderness -Symptoms worsen with empty stomach -Relief noted with antacids; belching; bloating -Vomiting of undigested food that may/may not be proceeded with nausea -Melena; decreased hematocrit and hemoglobin Interventions: -Refer to smoking and or alcohol cessation programs PRN -Encourage stress-relieving techniques such as biofeedback, meditation, relaxation exercises -Dietary modifications: >Avoid very cold and very hot foods >Eat 3 regular meals per day (small, freq not necessary if antacid or histamine blocker taken) >Avoid: caffeine, alcohol, decaffeinated coffee, milk, and cream >If methods are not effective, prepare for surgery (pyloroplasty, anterectomy) Meds: -Triple therapy for 10-14 days: 2 antibiotics (flagyl or amoxicillin and clarithromycin + PPI) -Quadruple therapy: + bismuth -Muscosal healing agents, stool softeners, antacids, histamine receptor antagonists, prokinetic agents, PPIs Diagnostic tests: -EGD, chest and abdominal x-ray, hematocrit and hemoglobin, stool specimen Education: -Symptom management, med and nutrition therapy, stress reduction

Respiratory system alterations Airway management Oxygen therapy

Used in acute and chronic respiratory problems to improve cellular oxygenation and prevent hypoxia or hypoxemia Clinical manifestations of hypoxia and hypoxemia: -Early: tachypnea, tachycardia, restlessness, pale skin and mucous membranes, elevated BP, use of accessory muscles, nasal flaring, adventitious lung sounds -Late: bradypnea, bradycardia, confusion and stupor, cyanotic skin and mucus membranes, hypotension, cardiac dysrhythmias Oxygen delivery devices: -Nasal cannula: 24-44% at 1-6L/min -Simple face mask: 40-60% at 6-8L/min -Partial rebreather mask: 50-75% at 8-11L/min -Non-rebreather mask: 80-100% at 12L/min -Venturi mask: 24-40% at 4-8L/min -Aerosol mask: 30-100% at 8-10%L/min -T-piece: 30-100% at 8-10L/min Education: -Assess for electrical hazards -Post O2 in use sign; wear cotton gown -No smoking

Disorders of musculoskeletal system Diagnostic tests for musculoskeletal disorders Electromyography (EMG) and nerve conduction studies

Used to evaluate muscle weakness by emission of low-frequency electrical stimulation -Client will be asked to perform activities for measurement of muscle activity -Observe needle insertion sites for hematoma -Support client w/ anxiety related to testing

Cardiovasular system disorders Cardiovascular disorders Raynaud's syndrome

Vasospastic or obstructive condition of arteries/ arterioles of upper/ lower extremities resulting from exposure to cold/stress; common in women Contributing factors: -Not clearly understood; blood vessels in hands/ feet overreact to cold or stress Manifestations: -Coldness, pallor, pain in extremities 2ndary to vasospasm -Ulceration in fingertips -Colour changes from white to blue to red (bilateral or symmetrical) Diagnostic: -Cold-stimulation test: placing hands in cool water or exposing to cold air to trigger an episode Interventions: -Avoid cold and keep extremities warm; wear warm but nonconstrictive gloves -Encourage client to stop smoking and limit caffeine intake Meds: -Administer nifedipine (procardia)

Genitourinary system disorders Kidney and urinary system Diagnostic tests Renal angiography

Visualization of renal arterial supply; contrast material injected thru catheter Interventions: Preprocedure -Approach is thru femoral or brachial artery -Locate and mark peripheral pulses -Void before procedure -May create feeling of warmth along the vessel Postprocedure -Maintain bed rest for 6-8 hr -Monitor VS until stable -Observe for swelling and hematoma -Palpate peripheral pulses/ vascular checks -Monitor client' s I&O including urinary status

Endocrine system functions and disorders Adrenal Gland Disorders of adrenal cortex 4 S's of Cushing's and Addison's disease

cuShingS diSeaSe ADDIsONs DIsEAsE Steroid ^ v (need to add) Sugar ^ v Sodium ^ v Skin Thin, fragile, striae Hyperpigmented

Fluids and electrolytes Acid-base balance Imbalances

pH PCO2 HCO3 Normal: 7.35-7.45 35-45 mmHg 21-28 mEq/L Metabolic acidosis v normal v Metabolic alkalosis ^ normal ^ Respiratory acidosis v ^ normal Respiratory alkalosis ^ v normal * v= below ^= above ROME -Respiratory Opposite, Metabolic Equal Tips -If all 3 are normal, ABGs are normal -If 2 are abnormal, ABGs are fully compensated or uncompensated -If 3 are abnormal, ABGs are partially compensated or combined disorder Regulation of acid-base balance regulated by:; -Lungs (carbonic acid thru respiration) -Kidneys (bicarbonate by retention or excretion)

Need to know lab values Arterial blood gases (ABGs)

pH: 7.35-7.45 PaCO2: 35-45 mm Hg PaO2: 80-100 mm Hg HCO3: 21-28 mEq/L

Neurosensory disorders Disorders Myasthenia gravis

Autoimmune; antibodies are produced (thymus gland) which damages ACh receptor sites leading to impaired transmission at myoneural junction; results in voluntary muscle weakness that increases with activity, improves w/ rest, characterized by periods of exacerbation & remission Manifestations: -Muscular weakness that increases w/ activity & improves w/ rest -Early: involve ocular muscles leading to increased risk of aspiration; diplopoa, ptosis, dysphagia, dysphonia -Progressive deterioration (respiratory) & muscle wasting Diagnostic: -Tensilon: ACh inhibitor injected IV; immediate improvement that lasts ~5min is considered +; may be used to differentiate b/w cholinergic and myasthenic crisis; atropine should be available to counteract side effects (bradycardia, sweating, cramping) -Serum ACh receptor antibodies -MRI thymus gland; EMG Types of crisis: -Cholinergic: from over medication; twitching--> respiratory distress, increased GI motility, hypersecretion, hypotension; no improvement/ worsening w/ Tensilon -Myasthenic: exacerbation trigger or inadequate med; varying degrees of resp distress, dysphagia, dysarthria, ptosis, diplopia, HTN, increased muscle weakness; improve during Tensilon Factors leading to exacerbations: -Infections; pregnancy; stress/ emotional distress/ fatigue -Increase in body temp; inconsistent med administration Interventions: -Maintain patent airway: prevent aspiration, keep suction & manual vent @ bedside -Plan activities for client early in day (fatigue) -Provide small, freq, high calorie meals during peak time for meds (45 min of administration) -Administer meds on time -Provide eye care: artificial tears/ taping eye shut Meds: -Anticholinesterase: increase ACh in neuro function -->Pyridostigmine (first line), atropine (antidote) -Immunosuppressants -->Steroids (prednisone), cytotoxic meds (azathioprine) Therapeutic: -Thymectomy; IV immunoglobulin (IVIG); plasmapheresis Education/ referral: -Importance of med administration; energy conservation -Prevent aspiration (timed meals w/ peak action of med, head flexed forward, foods thickened, suction) -Factors that contribute to exacerbations/ actions to take if exacerbation occurs -Referral to speech and myasthenia gravis foundation

GI, hepatic, pancreatic disorders Hepatic disorders Cirrhosis

Characterized by extensive, irreversible scarring of the liver that disrupts structure and function Contributing factors: -Alcohol consumption (Laennec's) -Postnecrotic (hepatitis, chemicals) -Biliary disease; severe R sided HR Manifestations: Early -Enlarged liver, jaundice, GI disturbances, weight loss Late -Liver becomes smaller and nodular; spenomegaly -Ascites, distended abdominal veins; increased pressure in portal system; anemia -Bleeding tendancies; decreased vitamin K & prothrombin -Esophageal varices, internal hemorrhoids, increased pressure in portal area -Dyspnea from ascites and anemia; pruritus from dry skin -Clay-colored stools; no bile in stool -Tea-colored urine; bile in urine End -Prodromal: slurred speech, vacant stare, restlessness, neurological deterioration -Impending: asterixis (flapping tremors), apraxia, lethargy, confusion -Stuporous: marked mental confusion, somnolence -Coma: unarousable, fetor hepticus, seizures, high mortality rate Interventions: -Encourage rest; weigh daily and measure abdom girth -Assess skin integrity freq; monitor I&O -Assess for bleeding and hemorrhoids -Avoid hepatotoxic meds; limit sodium/ fluid intake -Maintain high-calorie, low-protein (20-40g/day), low-fat, low sodium (protein restriction during stages I&II of encephalopathy; no protein stages III&IV) -Monitor liver enzymes, bilirubin, hematologic testing: CBC, WBC, platelets, PT/INR, ammonia levels Meds: -Diuretics: spironolactone, lasix -Neomycin and metronisazole (flagyl): reduces intestinal bacteria -Lactulose: decreases ammonia levels -Supplemental vitamins: B1 and B complex, A, C, K, folic acid, thiamine -Fat-soluble vitamin supplements and folic acid IV -PPIs and H2 receptor antagonist -Albumin IV to decrease ascites Therapeutic measures: -Liver biopsy, EGD, paracentesis -Transjugular intrahepatic portosystemic shunt (TIPS) Education: -Alcohol abstinence, dietary guidelines, bleeding risk Referral/ followup: -Alcohol recovery program, nutrition, social services

Disorders of musculoskeletal system Diagnostic tests for musculoskeletal disorders Laboratory

-Serum calcium and phosphorous -Alkaline phosphatase -Creatine kinase -Lactic dehydrogenase -Aspartate aminotransferase -Aldolase

Genitourinary system disorders Kidney and urinary system Diagnostic tests Urinalysis

-Specific gravity -Colour: yellow, amber, or clear -Negative glucose, protein, nitrites, RBCs, WBCs -pH -First voided morning sample preferred: 15 mL -Sent to lab immediately or refrigerated -If clean catch, get urine for culture prior to starting antibiotics -->Cleanse labia, glans penis -->Obtain midstream sample

Endocrine system functions and disorders Pituitary gland Anterior pituitary gland

APG: secretion of hormones is controlled by hypothalamus -Adrenocorticotripic hormone (ACTH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), gonadotropoc hormones, prolactin, growth hormone, thyroid-stimulating hormone

Cardiovasular system disorders Cardiac surgery Coronary artery bypass graft

Bypass occluded coronary arteries and reestablish perfusion to the heart muscle Preoperative/ general care: -Obtain baseline VS, physical assessment, history -Provide psychological support & administer anxiolytic agents PRN (diazepam, lorazepam) -Inform client/family what to anticipate: intubation, IV lines, urinary catheter, arterial line, chest tubes Postoperative care: -Assess hourly for first 8 hr: >Neurologic: responsiveness, pupils, reflexes >Cardiac: BP, CVP, PAWP, HR, rhythm, cardiac sounds >Respiratory: chest movement, breath sounds, ventilator settings, chest tube drainage, ABGs >Peripheral vascular status: pulses, edema, skin color/ temp >Renal: urinary output, urine specific gravity >F&E: I&O, electrolytes >Pain: type, location, intensity Complications: -Decreased CO; fluid volume/ electrolyte imbalance -Impaired gas exchange and cerebral circulation