Final Exam

Vitamin B12 Deficiency Anemia - Diagnostic Studies

Laboratory findings - Hgb, Hct - RBCs appear large (macrocytic) & have abnl shapes - Serum cobalamin levels - Endoscopy & biopsy - Schilling test

Etiology: Heart Failure

Primary Causes - CAD/AMI - HTN/HTN crisis - Valvular disorders - Rheumatic Disease - Congenital heart defects - Myocarditis - Pulmonary HTN - Hyperthyroidism Precipitating Causes: related to increased ventricular workload - Anemia Infection - Bacterial endocarditis Thyroid Problems - Thyrotoxicosis - Hypothyroidism - Arrhythmias - Obstructive Sleep Apnea - Pulmonary Embolism - Hypervolemia - Pulmonary Embolism - Nutritional deficits

Benign Prostatic Hyperplasia (BPH)

What is it? Enlargement of the prostate gland - Effects inner part of prostate - Most common urologic problem in male adults - Occurs in 50% of men over 50 & 90% of men over 80 - 25% of men require some form of treatment

Causes: Acute Glomerulonephritis

- 2-3 weeks post-streptococcal infection (tonsillitis, strep throat, impetigo) - Also can occur with lupus, HTN, DM, DIC

Gastrointestinal Regulation: Fluid & Electrolyte Balance

- 2-3L daily from fluids & foods - Up to 8L of digestive fluid is secreted & reabsorbed in the digestive tract each daily - Vomiting & diarrhea can cause significant water & electrolyte loss Prolonged NG Suction - Fluid volume deficit - Loss of Na+, K+, H+, & Cl- (Hyponatremia, hypokalemia, metabolic alkalosis)

Lymph system - lymph fluid & nodes: Hematologic System

- Carries fluid from interstitial spaces to the blood - Primary function: Filtration of pathogens and foreign particles

Non-Invasice Physical Tx: Pain

- Cold/Heat therapies - Massage/Touch - Exercise/Yoga - Positioning - Support/splinting - Immobilization - Vibration - TENS Invasive: Acupuncture

Reasons: Urinary Diversion

- Cystectomy - Bladder cancer - Neurogenic bladder - Congenital anomalies - Strictures - Trauma to bladder - Chronic infections with deterioration of renal function

Interprofessional Care: Asthma

- Identify/avoidance & elimination of known triggers - Desensitization Immunotherapy - prn Drug Therapies: -Long term control meds = to manage disease - Rescue meds = for quick relief of acute sx Pt & Caregiver Teaching: Assess for control - Peak Expiratory Flow: pt. monitoring - Note: condition is not well controlled if s/sx & rescue inhalers used > 2 days per week

Care Plans HTN: Nursing Diagnosis

- Ineffective health management - Anxiety - Risk for sexual dysfunction - Potential medical complications: CVA = cerebral vascular attack, MI = myocardial infarction

pursed lip breathing

- Inhale through the nose with mouth closed - The patient should shape the mouth as through whistling and breath out slowly against the force of the air leaving the lungs.

Continent Urinary Diversions

- Intra-abdominal urinary reservoir - Need to self-catheterize every 4-6 hours - Wear small bandage to catch mucous/small leakage - Reservoir made with portion of bowel - Stoma formed

Nursing Considerations: Addiction

- Is the pt's seeking drugs or pain relief - Drug seeking behaviors are the struggle to maintain or safeguard an adequate quantity of pain meds Pseudo-adduction can be caused by insufficient pain control - Withholding prn's may contribute to a cycle of discomfort & anxiety

Clinical Manifestations: Alzheimer's

- Same as dementia Early warning signs of AD - Memory loss that affects job skills - Difficulty performing familiar tasks - Problems with language - Disorientation to time and place - Poor or decreased judgement - Problems with absent thinking - Misplacing things - Changes in mood or behavior - Loss of initiative

Clinical Manifestations: Chronic Kidney Disease

- As disease progresses, oliguria occurs (<400mL/24 hrs) - Followed by anuria (<100mL/24hrs) As GFR decreases - Increase in BUN and serum creatinine - BUN = N/V, lethargy, fatigue, impaired thought process, headaches - Defective protein synthesis (muscle wasting) Altered carbohydrate metabolism - If diabetic, may require less insulin - Elevated triglycerides (hyperlipidemia) Electrolyte and acid-base imbalances Hyperkalemia - Most serious electrolyte disorder associated with CKD Results in dysrhythmias Hyponatremia - Sodium retained and water follows -> edema, HTN, HF, mental status changes from dilutional hyponatremia - Metabolic acidosis Kussmaul breathing - Anemia (decrease in production of erythropoietin) - Bleeding tendencies (defect in quality of platelet function) - Infection - Hypertension - SOB, pulmonary edema, pleural effusion From fluid overload GI system - Mucosal ulcers - Uremic fetor (urinous odor of the breath) - Anorexia, nausea, vomiting - Diarrhea - GI bleeding CNS depression - Lethargy, fatigue - Inability to concentrate, altered mental ability - Irritability - Seizures - Coma Peripheral neuropathy - Restless legs, "Bugs crawling inside of legs" - Bilateral foot drop - Muscular weakness & atrophy - Loss of reflexes - Nocturnal leg cramps Skeletal changes - Caused by alterations in calcium and phosphate metabolism - Weakened bones, fracture risk - Yellowish-gray discoloration to skin - Pruritus - Infertility & decreased llibido (decrease hormone levels) - Depression

NCP: Acute Pain (Stable Angina)

- Assess chest pain: symptom variables (onset/duration, location, radiation, quantity, quality, and precipitating/aggravating and alleviating factors) rating on a scale of 0 to 10 to accurately evaluate, treat, and prevent further ischemia - Obtain PQRST data - Check changes in patterns - Monitor patient: B/P, HR & cardiac rhythm to assess for B/P increases and decreases and arrhythmias which may lead to hypoperfusion - Provide O2 via nasal cannula: and monitor the effectiveness to increase oxygenation of myocardial tissue and prevent further ischemia - Ensure appropriate diagnostic tests are completes STAT: to rule out Acute Coronary Syndrome (example - Acute MI): 12 lead ECG & cardiac blood tests - Administer NTG (nitroglycerin): to prevent and relieve pain and ischemia prn to decrease anxiety and cardiac workload - Teach patient & family to decrease anxiety, promote compliance, and prepare for discharge

NCP: Ineffective management r/t lack of knowledge (Stable Angina) r/t lack of knowledge of disease process, risk factors, diet and meds

- Assess current knowledge: related to CAD & pt's individual risk factors - Explain the pathophysiology: of the disease & dx tests - Discuss lifestyle changes: with patient and family that may be required to prevent further complications and/or slow disease (i.e diet, no smoking, exercise, blood glucose & HTN control) - Referrals PRN: Registered Dietician, Cardiac Rehab, Diabetic Educator. Refer to local support groups or valid web-based resources - Med instruction: purpose, action, dose, route, and possible side effects (i.e. prn NTG use)

NCP: Activity Intolerance (Stable Angina) r/t chest pain, med SE's

- Assess pt. normal activities: to determine if they have been impacted - Assess BP, HR, and rhythm, chest pain symptoms before, during & after activity: for baseline/evaluation data - Encourage rest periods: to restore and conserve energy Encourage a program of progressive exercise - Do not work with arms above head! - Instruct on NTC prophylactic use - Referral to Cardiac Rehabilitation Center or exercise specialist

Post-Operative Care: Amputations

- Assess: VS & dressings for hemorrhage, check stump skin Positioning: residual limb - Elevate first 24 hours only! For AKA/BKA: To avoid hip flexion contractures - Limit chair sitting (<1 hour) - Avoid use of pillows under stump - Place in prone with hip extended for 30 minutes: TID/QID Pain management: includes phantom limb sensations/surgical pain: Use narcotics PRN & adjunctive tx - EBP: mirror therapy - Fall and pressure ulcer prevention Dressing: Compression bandaging & stump care - Patient Teaching Compression Dressing - Reduces edema - Decreases pain - Supports soft tissue - Body image interventions & emotional support Physical activity - PT: gait, transfers, strengthening & ROM's - OT: ADL assistance & use of related equipment

Knee Injury: Meniscus Injury

- Associated with sports Pain with movement - Acute tears may be present with tenderness, swelling - Reports click, pop lock, and/or instability - Dx: MRI imaging - OPS: Meniscectomy via arthroscopy - PT: for rehabilitation

Prostate Cancer: Signs & Symptoms/Diagnostics

- Asymptomatic in early states Symptoms of BPH - Dysuria, hesitance, dribbling, frequency, urgency, hematuria, nocturia, retention, interruption of urinary stream, inability to urinate - Metastasis: pain in lumbosacral area that radiates to hips/legs Screening - Digital rectal exam (DRE) Prostatic specific antigen (PSA) - Normal 0-4 ng/mL - False positives - not reliable alone U.S Preventive Services Guidelines for prostate cancer screening changes May 2019 - High risk: 45 or older - Average risk: 55 or older - Discuss risk/benefit of annual screening until age 69 Diagnostic Studies Transrectal US (TRUS) with biopsy***

PAD Complications

- Atrophy: skin & underlying muscles - Delayed wound healing - Wound infection - Tissue necrosis: may lead to gangrene Critical limb ischemia! - Rest pain > 2 weeks - Arterial ulcers: dry, dark often found over bony areas of toes, feet, lower legs. - Gangrene - Amputations: r/t gangrene/infection

GERD: Diagnostics

- Based on symptoms Upper GI endoscopy (with biopsy if indicated) - EGD (esophagogastroduodenoscopy) Barium swallow - X-ray with fluoroscopy &amp; contrast medium - NPO, no smoking after Midnight, white stool

Pulmonary Embolus

- Blockage of lung arteries via an embolus caused by a thrombus, fat, tumor, or air (from IV therapy) - Results in obstruction of blood perfusion to alveoli causing disruption in gas exchange - 90% caused by a thrombus in deep veins that dislodges (embolism) & travels to the lungs - Other sites: clots from right side of heart during atrial fibrillation, pelvic veins (childbirth/surgery) Additional Causes: bone marrow, fat emboli, air (IV therapy) and tumors

Components of a hemodialysis system

- Blood removed via needle inserted in fistula/via catheter lumen -> - Propelled to dialyzer by blood pump -> - Dialysate is pumped into the dialyzer and flows in the opposite direction of the blood -> - Dialyzed blood returned to pt thorough 2nd needle/catheter lumen - Heparin is infused as a bolus before dialysis or thorough a heparin pump continuously to prevent clotting - Old dialysate & ultrafiltrate are drained and discarded

Respiratory Alkalosis: Pathophysiology

- CO 2 excretion from hyperventilation - Compensatory response of HCO 3 excretion by kidneys

Respiratory Acidosis: Pathophysiology

- CO 2 retention from hypoventilation - Compensatory response of HCO 3 retention by kidneys

Medical Diagnosis: Pneumonia

- CXR: key dx tool Sputa: collect before starting antibiotics if possible! - Gram stain - C & S - CBC with WBC (often 15,000) N: 4.8-10.8 - Pulse oximetry with ABG's if needed - Blood cultures prn Common Complications - Atelectasis = collapsed airless alveoli - Pleurisy = inflammation pleura - Pleural effusion = fluid in pleural space Bacteremia = bacterial infection in blood - May lead to sepsis and septic shock - Empyema = purulent exudate pleural space - Pneumothorax = collapsed lung due to air - Acute Respiratory Failure

GOUT

- Caused by an increase in uric acid production, decrease in kidney excretion or increase in foods containing purines which are metabolized to uric acid. - Primary gout: hereditary (90% of cases), seen mostly in middle aged men - Secondary gout: is related to other disorders or meds side effects

Wet Desquamation

- Cell sloughing occurs faster than ability of new epidermal cells to replace dead cells Symptoms - Exposure of dermis - Weeping of serous fluid - Pain - Fissures may be present Treatment Wound Care - Non-adherent dressings - Vaseline gauze - Hydrogel dressings

Aplastic Anemia - Clinical Manifestations

- Class anemia symptoms (fatigue, weakness, tachycardia, pallor, SOBOE) - Bone marrow suppression - Neutropenia: infection - Thrombocytopenia: bruising, spontaneous bleeding (petechiae, purpura, epistaxis) - Low Hgb, WBC's, Platelets; other RBC labs are normal - Prolonged bleeding time - Bone Marrow - hypocellular with increased yellow marrow (fat content)

Vitamin B12 Deficiency Anemia - Clinical Manifestations

- Classic symptoms of anemia - Sore, red, beefy shiny tongue, anorexia, N/V, abdominal pain - Weakness - Paresthesias of hands and feet - Ataxia - Muscle weakness - Impaired thought processes

Clinical Manifestations: Hepatitis

- Classified as acute and chronic - Many patients: asymptomatic Symptoms intermittent or ongoing - Malaise - Fatigue - Myalgias/arthalgias - Right upper quadrant tenderness Acute phase - Maximal infectivity; lasts 1-6 months Symptoms during incubation - Anorexia - Lethargy - Weight loss - Fatigue - Nausea/vomiting - RUQ tenderness - Distaste for cigarettes - Decrease sense of smell Acute phase Physical examination findings - Hepatomegaly - Lymphadenopathy - Splenomegaly - Icteric (jaundice) or anicteric If icteric, patient can also have - Dark urine - Light or clay-colored stools - Pruritus Convalescent phase - Begins as jaundice is disappearing - Lasts weeks to months Major complaints - Malaise - Easy fatiguability - Hepatomegaly persists - Splenomegaly subsides

Clinical Manifestations (aka s/sx = signs &amp; symptoms) Hypothyroidism

- Cold intolerance - Skin: dry, thick, cold, pale, edema (generalized and facial) - Hair/nails: dry hair with loss, thick/brittle nails - CV: ↓C/O & HR, anemia, risk for HF & angina - Respiratory: dyspnea - GI: Constipation, wt. gain, ↓ appetite, N/V - Neuro: impaired memory/slower processing, slow slurred speech, ↑ sleep but still fatigued, lethargic, depressed, - Muscle: weakness, aches/pains, slow movements - Others: menstrual changes, ↓ libido, goiter (hoarse voice)

Chronic Pyelonephritis

- Complication of recurring acute pyelonephritis - Kidneys become atrophied, shrunken & lose function - Caused by scarring or fibrosis - Can result in renal failure

Neutropenia Causes

- Consequence of a variety diseases/conditions - Chemotherapy use in treatment of cancer Other drug induced causes: - Anti-inflammatory drugs - Some antimicrobial agents (Bactrim) Hematologic Disorders - Aplastic anemia, leukemia, myelodysplastic syndrome Autoimmune disorders - Lupus, rheumatoid arthritis Infections - Viral (hepatitis, HIV, measles, influenza) Misc - Severe, sepsis: bone marrow infiltration (carcinoma, TB, lymphoma): hypersplenism (portal hypertension); nutritional deficiencies (folic acid, cobalamin); hemodialysis

Interprofessional Care: disk damage: Back Pain

- Conservative Tx: most heal in 6 months Restrict activity: for several days - Limitation of movement (brace, corset, belt) - NOT total bedrest Medications - NSAIDS - Analgesics - Muscle relaxants - Anti-seizure and antidepressants - Hot / Cold Therapies - US or TENS therapy - PT: back strengthening exercises after pain - Epidural Steroid Injections

Metabolic Alkalosis: Nursing Management

- Correction of underlying cause - Administration of NaCl (Cl helps diminish bicarb reabsorption)

Metabolic Acidosis: Nursing Management

- Correction of underlying cause - Administration of sodium bicarbonate - Administration of insulin (SQ or IV drip) for diabetic acidosis - Dialysis for renal failure

Nursing Considerations: Acute Glomerulonephritis

- Daily wt. - I & O - Abdominal girth - Edema assessment - Infection prevention Health promotion - Encourage early diagnosis & treatment of sore throats & skin lesions - If streptococci found in culture - antibiotic Teach the importance of taking full course of antibiotics - Good personal hygiene - Prevent spread of streptococcal infections

Traction

- Definition: pulling force applied to injured or diseased body part or extremity - Often with counter pull = pull in opposite direction (aka counter-traction) Purposes - Prevent or reduce pain & muscle spasms - Reduce/realign dislocation or a fracture - Immobilize joint or body part - Expand joint space during surgery or before reconstruction Skin Traction - Applied directly to skin using foam wraps, boots or splints and secured with tape or Velcro straps Short term (2-3 days) - Often before skeletal/OR 5 to 10 lbs. weights - Heavier cervical/pelvic SKIN: Assessment r/t - Increase risk for breakdown Purposes - Assists reduction - Maintain alignment - ↓ Muscle spasm Examples - Buck's - Pelvic Skeletal Traction - Applied directly to bone via pins/wires - Long term (weeks) - 5 to 45 lbs. - Risk for infection and immobility issues Purpose - Maintain alignment - Immobilization - Joint contractures - Congenital hips Examples - Balanced suspension usually for leg fractures

ά -Glucosidase Inhibitors

- Delays GI absorption CHO ("starch - blockers") - acarbose (Precose) & miglitol (Glyset) - Taken with "first bite" of each meal - Check effectiveness with 2 hour post-prandial BG level - SE r/t GI: abd pain, gas, diarrhea

Esophageal Cancer: Management

- Depends on location in esophagus & if metastasis has occurred Surgery Esophagectomy - removal of part or all of esophagus - Dacron graft to replace resected part - Esophagogastrostomy - resection of esophagus and connect directly to stomach Endoscopic procedures - EMR (endoscopic mucosal resection) - Laser therapy to ablate metaplasia - Esophageal dilatation - Stent placement - Radiation and chemotherapy Post-op Care - Monitor post-op hemorrhage - NG in place with bloody drainage for 8-12hrs -> greenish/yellow - No repositioning or reinsertion of NG - contact MD if issues - Position: Lock the bed at 30degrees -> Aspiration risk Nutritional therapy - May have TPN/IL after surgery to allow gut to rest - Gastrostomy/jejunostomy

Diagnosis: Dementia

- Determine cause - reversible vs. nonreversible factors - Physical assessment to r/o other causes - Screening for cobalamin deficiency & hypothyroidism - Cognitive testing: Mini-Mental State Examination - Made when 2 or more brain functions are significantly impaired

Varicose Veins

- Dilation of superficial veins in LE caused by weak vein walls, increased venous pressure * incompetent valves - Risks: family history, obesity, pregnancy, prolonged standing, oral contraceptives, tobacco use Clinical s/sx: - Pain/ "heavy achy" feeling after prolonged standing, oral contraceptives, tobacco use - edema - visible swollen & distended veins - may develop SVT = superficial venous thrombosis Varicose Veins: Treatments Interventions - Avoid sitting/standing for long periods - Limb elevation - Wearing support hose: ensure proper fit and application - Weight loss prn - Daily walking Invasive Options - Sclerotherapy = injection of a substance to obliterate the vein - Laser or high intensity pulsed light therapies - Endovascular ablation - Surgeries (Ligation)

African Americans - HTN

- Disease occurs at a younger age than in whites - Affects women more than men - HTN is more aggressive resulting in more severe end-organ damage - Higher mortality (death) rates Produce less renin and to not respond well to ACE/ARBS - Ca2+ channel blockers & diuretics may work better

Incontinent Urinary Diversion

- Diversion to the skin requiring an appliance Cutaneous urostomy - Ureters connected or left separate & brought to skin Ileal conduit (ileal loop) urostomy - Most common type - 6-8 inches of ileum removed and converted into a conduit for urinary drainage - Ureters connected to one end of conduit, other end brought to surface of skin forming a stoma

Diverticulosis & Diverticulitis

- Diverticula: saccular dilations/outpouchings of the mucosa that develop in the colon - Diverticulosis - when multiple diverticula are present - Diverticulitis = When they become inflamed perforation into the peritoneum Causes - High luminal pressures in sigmoid colon d/t deficiency of fiber intake - Loss of muscle mass & collagen with aging

Pulmonary Embolus (PE) CLINICAL S/SX

- Dyspnea (85%) - Hypoxia - Tachypnea - Crackles/Wheezing - Cough - Hemoptysis - Chest pain - Tachycardia - Fever Note: Clinical presentation is highly variable dependent on size & extent emboli! Small emboli may go undetected or produce nonspecific symptoms

Assessment key respiratory history

- Dyspnea: orthopnea/proximal nocturnal dyspnea - Cough (note sputa characteristics) - Any dizziness or confusion or anxiety/nervousness - Tobacco use Use of O2 - Check hospital equipment - Ask if used at home (CPAP for sleep apnea) Also inquire about any heart or respiratory disease history: CAD, CHF, COPD, Asthma, Lung/throat cancer

Diagnostic Studies: Epilepsy

- EEG - CT/MRI - rule out structural lesions - CBC, chemistries, liver & kidney function, UA - rule out metabolic disorders - Important to correctly diagnose seizure type as treatment varies accordingly

Identifying High Risk Clients

- Elderly - Multisystem diseases - Chronic/terminal ill - Major surgery - Emotional/mental instability - Financial insecurity - Lack of transportation - Inadequate/unsafe living situations

Management: Acute Kidney Injury

- Eliminate the cause - Manage signs and symptoms - Prevent complications while kidneys recover Diuretics - Lasix (furosemide), - Bumex (bumetanide) Maintenance of fluid volume Fluid volume replacement calculated by adding 600ml to current day's losses. Total is amount replaced next day - Ex; If patient excretes 300mL urine on Tuesday with no other losses, fluid replacement/restriction for Wednesday is 900mL? Hyperkalemia - Kayexalate (sodium polystyrene) Dialysis Indications - Volume overload resulting in compromised cardiac &/or pulmonary status - Significantly elevated K+ - Metabolic acidosis (bicarb <15meq/L) - BUN > 43 mmol/L (nl. 8-20mmol/L) - Significant mental status change - Pericarditis, pericardial effusion, cardiac tamponade Diet - Increased carbohydrates and fat - Potassium & sodium depending on serum levels

Pre-operative Care: Amputations

- Emotional support and referrals prn - Teaching r/t phantom limb sensations (90%) - Type of amputation & prosthesis if planned - Dressings: compression bandage or stump shrinker - Positioning - Pain management Referrals PT: - Strengthening/ROM exercises - Use of assistive ambulation devices & transfers OT: for ADL's assistance and adaptive devices Care Management - Rehabilitation Unit/LTC - Home health

Ostomies: Nursing Management

- Emotional support, body image Assessment - Stoma - rose to brick red = nl; pale = anemia =; dark red, purple = inadequate perfusion - Edema - mild expected after surgery (lasting 2-3wks); severe can cause obstruction/indicate allergic reaction - Bleeding - small amt expected (vascular area); moderate to large requires follow up Teaching - Ostomy Care - Bag may have to be burped if filled with gas - Empty when 1/3 full - Additives to bag to dec odor How to measure and cut wafer, pouch, empty, clean, skin care - Stoma size will decrease as swelling decreases Teaching - Fluids & Foods - Increase fluid 3,000mL/day - Foods that produce odor in stool - Eggs, garlic, onions, fish, asparagus, cabbage, broccoli, ETOH - Gas forming foods - Beans, cabbage, onions, beer, carbonated beverages, cheeses, sprouts Foods causing potential obstruction in ileostomy - Chew very well, limit amt, and drink water when eating - Nuts, raisins, popcorn, seeds, raw vegetables, celery, corn

Self-Blood Glucose Monitoring: SBGM

- Enables decisions regarding diet, exercise, and meds - Accurate record of glucose fluctuations - Helps identify hyper/ hypoglycemia Monitoring times o Before & after meals o Before, during & after exercise o During illness o PRN if signs and symptoms of hypo present

PUD: Diagnosis

- Endoscopy (EGD) Barium contrast study - For pts who cannot undergo endoscopy Labs - CBC - anemia - Guaiac (blood) - Serum amylase - Pancreatic function when posterior duodenal ulcer penetration of the pancreas is suspected

Dipeptidyl Peptidase - 4 (DDP-4) Inhibitors

- Enhance actions of incretin hormones: thus↑ insulin release ;↓ hepatic glucose production - Sitagliptin (Januvia) "gliptins" - SE: pancreatitis, allergic reactions

Peptic Ulcer Disease (PUD)

- Erosion of GI mucosa secondary to the digestive action of HCI acid and pepsin Any portion of GI tract that comes into contact with gastric secretions is at risk - Lower esophagus, stomach, duodenum Types - Acute: superficial erosion, minimal inflammation, short duration - Chronic: long duration, eroding through muscular wall, fibrous tissue formation Causes - Same as gastritis

Hiatal Hernia: Complications

- Esophagitis - Hemorrhage from erosion - Stenosis - Ulcerations of the herniated portion of the stomach - Strangulation of the hernia - Regurgitation with tracheal aspiration

Basic Principles of Pain Tx

- Every patient has the right to accurate pain assessments and adequate treatments - Use holistic approach & interprofessional input - Design treatment based on pt's goals Some may bee help to make realistic Post-op pain wont = 0 -Use drug and non-drug therapies Multimodel approaches have better outcomes - Evaluate effectiveness of all therapies - Prevent and/or manage med SE's (side effects) - Incorporate pt./caregiver teaching throughout care

ANGINA: Precipitating (Aggravating) Factors: 5 E's

- Exertion: most common factor! - Extreme temperatures - Emotion strong - Eating heavy meal Excitement (over-sympathetic) - Tobacco use - Stimulants: cocaine, amphetamines - Sexual activity

Clinical Signs/Symptoms: GOUT

- Extreme tenderness, inflammation and discoloration (dusky) joints usually <4 - Commonly affected: great toe, ankle, knee, and wrist - Onset sudden...often overnight - Overtime may develop tophi (crystals)

Nursing Considerations: Parkinsons

- Fall risk - Assistive devices - Assistance with eating - Dysphagia diet - PT referral - Home modifications

Metabolic Acidosis: Patho

- Gain of fixed acid, inability to excrete acid or loss of base - Compensatory response of CO 2 excretion by lungs

Anesthesia Types

- General - Regional - Local Monitored Anesthesia Care (MAC)/Conscious Sedation - Can be performed in OR, Endo, ER, pt. bedside - Sedatives - Opioids - Priority = respiratory assessment - Written discharge instructions & no driving/decision making after procedure)

Interprofessional Care: Cushing's

- Goal: to normalize hormonal levels - Treatment: dependent on underlying cause SURGERY Pituitary Tumor (Adenoma) - Surgery to remove pituitary gland: Transphenoidal Hypophysectomy - Radiation is also an option Adrenal Tumors or Hyperplasia Gland - Surgery: Adrenalectomy - Might need bilateral removal Ectopic ACTH secreting tumors - Treat or remove underlying cancer (often lung or pancreas) MEDICATIONS Drug Therapies: used to suppress corticosteroids - Used if surgery is contraindicated or if done has not worked If Cushing Syndrome is due to prolonged corticosteroids - Will need to gradually taper off meds

Medical Diagnosis: Osteoarthritis

- H & P X-Rays - Used for dx and staging joint damage - Joint space narrowing & osteophytes - Note: Findings may not correlate with pt's degree of pain - Scans: Bone/CT/MRI detect early joint changes Synovial fluid analysis - Remains clear yellow without signs of inflammation - Labs: none yet identified as specific indicators for OA

Interventions: Acute Decompensated Heart Failure (ADHF)

- High Fowlers position - O2: may need endotracheal intubation (ET) & Ventilator Continuous monitoring - VS/O2 sats - I&O including hourly U/O - Daily weights - Telemetry Hemodynamic monitoring & management for optimal pressures - ABP (arterial blood pressure) - CVP (central venous pressures) - PA (pulmonary artery) - CO (cardiac output) / CI (cardiac index) - Medications NOTE: Critical Care Unit

Diagnosing & TX: DVT

- History & Physical Exam (H&P): risk factors present and + findings (pregnant, hypercoagulability factors, antibiotics causing it, just had major surgery?) - D-dimer (fragment of fiber): increased levels suggest DVT's Non-Invasive Image Studies - Duplex US (ultrasound) (most common dx test) - Can see bloodflow Invasive Studies - CT venography - MRI venography LABS: Baseline & Evaluation of medication and effectiveness Coagulation Studies - ACT = activated clotting time - aPTT = activated partial thromboplastin time - PT = protime - INR = international normalized ratio - Anti-factor Xa (aka Heparin Assay) Blood Counts CBC: - Hgb/Hct - Platelet counts

Federal Requirements for Discharge Planning (The Joint Commission)

- Hospital must provide all pts. Timely DC (discharge) planning - Early id of pts. to prevent adverse problems after DC Plans must be developed by RN, SW, qualified HCP. - Multidisciplinary (interdisciplinary approach) is best! - Pt's capacity for self-care and/or receive care in previous living environment must be assessed - Plan must address need for post-hospital services and availability of those services prior to DC - Plan must be documented in pt's medical records.

HYPERTENSIVE CRISIS

- Hypertensive crisis is a term used to indicate either a hypertensive urgency or emergency. This is determined by the degree of target organ disease and how quickly the BP must be lowered. • Hypertensive urgency develops over days to weeks. The BP is severely elevated but there is no clinical evidence of target organ disease. ♣ Hypertensive urgencies usually do not require IV drugs but can be managed with oral drugs. ♣ If a patient with hypertensive urgency is not hospitalized, outpatient follow-up should be arranged within 24 hours. • Hypertensive emergencies require hospitalization with intensive care monitoring and the IV administration of antihypertensive drugs, including vasodilators, adrenergic inhibitors, ACE inhibitors, and/or calcium channel blockers. Drugs are titrated based on MAP. • Regular, ongoing assessment (e.g., ECG monitoring, vital signs, urinary output, level of consciousness, visual changes) is essential to evaluate the patient with severe hypertension.

Nutritional Therapy: N & V

- IV Fluids (electrolytes &amp; glucose) - NG to suction may be necessary - Clear liquids - Dry toast, crackers for nausea - Small portions - Start slow - Area free of noxious odors - Avoid coffee, spicy foods, highly acidic foods - Alternative Therapies - Ginger, vitamin B6, peppermint oil, deep breathing, acupressure & acupuncture

Fluid Replacement - IVF

- IV solutions contain dextrose or electrolytes mixed in various proportions with water The choice of IV solution is determined based the achievement of the following goals - Provide water, electrolytes & nutrients to meet daily requirements - Replace water & correct electrolyte &/or acid-base imbalances - Provide a medium for IV drug administration - Free water cannot be administered IV because it would rapidly enter RBC's & cause them to burst - Solutions are either isotonic, hypotonic, or hypertonic depending on whether the total osmolality is the sam as, < or > blood osmolality

Nursing Diagnosis & Care Plans: Patient with Heart Failure

- Impaired Gas Exchange - Decreased Cardiac Output - Excess Fluid Volume - Activity Intolerance

Nursing Diagnoses: COPD

- Impaired Gas Exchange - Ineffective Airway Clearance - Ineffective Breathing Pattern

Nursing Care Plan: Pneumonia

- Impaired Gas Exchange - Ineffective Breathing Pattern - Acute Pain

Nursing Management - Teaching: IBD

- Importance of rest and diet management - Perianal care - Action and side effects of drugs - Symptoms of recurrence - When to seek medical care - Light exercise - Body image Ostomy Care - Refer enterostomal therapist prior to surgery/Wound care nurse - HHC referral Teaching - Permanent size occurs within 3-4 months - Assess for signs of irritation, cyanosis - Care of stoma and surrounding skin - Changing and emptying pouch - Where to purchase supplies - Stoma swelling occurs for about 2-3 weeks post-op - Avoid foods that can create odor (fish, eggs, onions etc.) - Fluids > 2000cc/day

Polycythemia - Diagnosis

- Increased RBC's, Hgb - Elevated WBC - Elevated Platelets - Elevated uric acid (increase RBC destruction that accompanies increased RBC destruction that accompanies increased RBC production) - Elevated histamine levels - Bone marrow - hypercellularity

Pneumonia Risk Factors: LOTS!

- Increased age - Chronic diseases - URI (i.e flu) - Smoking - Inhalation/Aspiration - Air pollution - BR / long immobility - Abdominal/chest surgery - Resident ECF - Altered LOC: lots! - Loss of gag reflex - Tracheal Tubes - NG Tube Feedings - Immunosuppressive conditions/treatments

Nursing Diagnosis: PAD

- Ineffective issue perfusion (peripheral) - Activity tolerance - Chronic pain - Ineffective self-health management

Complications of Joint Surgery

- Infection - Thromboembolism - Fat emboli

Hypothyroidism

- Insufficient circulating thyroid hormones - Clinical presentations (aka manifestations or signs/symptoms) vary based on severity, duration of deficiency, &amp; patient's age at onset. Incidence: - 4% of U.S. population have mild hypothyroidism with most common cause being primary gland atrophy. Gender Differences - Thyroid disorders of all types (hypo/hyper, nodules, and cancer) are more common in women than men Hypothyroidism: Classification Primary: caused by - destruction of thyroid tissue - or defective hormone synthesis Secondary: caused by - hypothalamic dysfunction resulting in low TRH - or pituitary disease resulting in low TSH Transient: related to - Thyroiditis - Discontinuing thyroid hormonal medications

Chronic Leukemia

- Involves mature cells and are classified by the predominant cell in the bone marrow CLL (chronic lymphocytic leukemia) - lymphocytes - Lymph node enlargement throughout body CML (chronic myelogenous leukemia) - granulocytes - move into peripheral blood stream in massive numbers - ultimately infiltrate the liver and spleen - Slower onset Early signs and symptoms - Fatigue, Weakness - Pallor - Anorexia, Weight loss - Initially fewer infections than with acute but develop eventually

Arrhythmia Care

- Is the patient hemodynamically stable? - Interpret the rhythm AND evaluate the clinical status of the patient - Determine cause of dysrhythmia - Treat the patient, not the monitor!

Spleen: Hematologic System

- LUQ of abdomen Four functions - Hematopoietic - formation of RBCs during fetal development Filtration - Removal of old and defective RBCs from circulation - Return iron components of hemoglobin to BM for reuse - Filtering circulating bacteria (esp. gram-positive cocci) Immunologic - Rich supply of lymphocytes, monocytes, immunoglobulins Storage of RBCs and platelets - 30% platelets

Assessing for Infection: Kidney Trasplant

- Leukocytes and platelets are watched closely because immunosuppressive therapy can depress their formation Septicemia - Shaking chills - Tachycardia - Tachypnea - Increased or decreased WBC's - Urine cultures usually done routinely

Oral Cancer: Clinical Manifestations

- Leukoplakia (white patches on inside of mouth) - Erythroplakia (red patch in mouth) - Ulcerations - Sores that bleed easily - c/o chronic sore throat/mouth, voice changes - Late: pain, dysphagia, difficulty chewing &amp; speaking, inc. salivation, tooth ache, ear ache - Neck mass

Mrs. Miller is c/o pain and asks for medication What are the nursing considerations? As a student, what should you assess

- Location (inspect site) - Quality & quantity How long since last pain med? - Review EMAR - Drug, dose, time - Was patient satisfied with relief? Any SE's? - What are other options? - What's your plan? it is now 0800 PRN Medications Morphine Sulfate 4-8 mg IM q 3-4 hours for severe pain Last dose: 0600 6 mg Morphine Sulfate 1-4 mg IV q 2 hours for breakthrough pain Hydrocodone with acetaminophen (Norco) 5/325 1-2 tabs PO q 4-6 hours prn for moderate pain Sumatriptin (Imitrex) 50 mg PO prn q 12 hours (this is for headache) We should use Morphine Sulfate if it is severe pain

Hiatal Hernia: Clinical Manifestations

- May be asymptomatic - Symptoms of GERD - Heartburn, especially after a meal or lying supine - Bending over causes severe burning pain, relieved by sitting up - Increased pain after eating large meals, smoking, consuming alcohol - Dysphagia

CHECK for: Orthostatic changes = postural decrease in B/P

- Measure supine after 2-3 minutes of rest - Measure again after 1-2 minutes sitting then after 1-2 min standing - +Orthostatic hypotension is defined as: changes with position changes: SBP lower than >20mmHg or DBP lower than >10mmHg and/or increase > 20 bpm in pulse - Signs and Symptoms: lightheadeness, dizziness, syncope - Caused by: intravascular volume loss, inadequate vasoconstriction related to disease or meds - Normal change: < 10mmHg SBP drop upon standing with slight increases in DBP & pulse - More common in elderly & can lead to falls

Nursing Care: VTE: ***SAFETY ALERTYS***

- Monitor for acute respiratory changes/chest pain - PE's - Watch closely for bleeding (GI tract, GU tract, nose bleeds) - Monitor for neuro/mental status changes - Prevent bleeding/injuries - Avoid IM injections - Fall prevention measures especially in elderly

Recipient Selection (vary depending on transplant center): Kidney Transplant

- Morbid obesity - Continued smoking Contraindications: - Disseminated malignancies, untreated cardiac disease, chronic resp failure, extensive vascular disease, chronic infection, unresolved psychosocial disorders (noncompliance with medical regiments, alcoholism, drug addiction)

Catheter-acquired UTIs (CAUTIs)

- Most common HAIs - Bacteria biofilms develop on inner surface of catheter - Can lead to bacteremia & sepsis Prevention - Aseptic technique for insertion - Foley & perineal care daily and PRN - Secure catheter - Seal intact - No kink/loops in tubing - Keep bag below level of bladder - Keep bag off the floor - Empty bag prior to transport - Assess need for Foley continuation q shift - get them out ASAP! - CAUTI education Indications - Relief of urinary obstruction or retention - Neurogenic bladder - Bladder decompression preoperative & operatively - Surgical repair of urethra & surrounding structures - Accurate measurement of UO in critically ill pt - Contamination of stage III or IV pressure ulcers with urine that has impeded healing - Palliative/comfort care at end of life - Strict bedrest - Prolonged immobilization: unstable spine, pelvic fx, chemical paralysis - Instillation of medications into bladder/CBI Two reasons not to perform catheterization - Routine acquisition of a urine specimen - Convenience of the nursing staff or patient's family Complications of long-term use of indwelling catheters (>30 days) - Bladder spasm - Periurethral abscess - Pain - CAUTIs - Urosepsis - Urethral trauma/erosion - Fistula/structure formation - Stones

Management: Alzheimers

- No cure Goal - Improve or control decline in cognition - Control undesirable behavioral manifestations - Provide support for caregivers

Management: ALS

- No cure or treatment Medication to slow progression (don't need to know specific meds) - Rilukek (riluzole) Assistive devices - Ambulation - Facilitate communication - Eating - Aspiration risk - Pain management - Fall risk - DNR status & Advanced directives - Tube feedings - Oxygen, CPAP, Trach

Management: Huntington's

- No cure or treatment - Care is palliative - Meds to manage symptoms only - Death occurs 10-20 years after onset of symptoms - End states include wt. Loss in spite of caloric intake, respiratory distress, lethargy

Non-Drug Therapies/Treatment: Osteoarthritis

- Nutritional management: Wt. loss Therapeutic Exercise - Low impact aerobic - Water aerobics - Stationary biking - Strengthening with ROM & other exercises (i.e. quadiceps) Joint rest & protection - Modify activities to decrease joint stress - Use assistive devices - Rest with functional immobilization (< 1 week) acute flare ups Heat/Cold Therapy: to decrease pain/stiffness - HEAT: for stiffness: hot packs, W/P, US, wax baths - COLD: for acute flare-ups: ice, frozen veggie/fruit bags Complementary/Alternative Therapies Movement therapies - Yoga/Tia Chi - Acupuncture - Massage Nutritional supplements Anti-inflammatory effects - SAM-e (S-adenosylmethionine) - Ginger - Glucosamine & Chonftoiyin-Effectiveness - Arthroscoipic Surgery < 55 y/o - Reconstructive Joint Surgery

Hyperosmolar Hyperglycemic Syndrome (HHS)

- Occurs in pts who produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular FVD. - Although less common than DKA, may be seen in Type 2 elderly patients - Maybe r/t functional inability to replace fluids - immobile and or altered mental status - Causes: illness, infections &new dx. DM Type 2.

Fat Embolism Syndrome

- Occurs when fat globules from fx are embolized to tissue & organs (lung) 24-48 hours after long bone, ribs, pelvic or joint/spine surgeries & liposuction Limited diagnostics - Infiltrates on CXR "White out effect" - Fat in urine, blood, sputa - PaO2 decreased (as well as ABGs) Clinical S/sx - ARDS - Chest pain - Tachypnea - Cyanosis - Dyspnea - Tachycardia - Hypoxia - Change in LOC Assess for petechiae each shift! Prevention: Immobilization fx and limit movement until reduction & fixation has occurred Acute Treatment: - Respiratory support: Oxygen, intubation, with use of ventilators prn - IV Fluids - Correction of acidosis - Blood Transfusion

Clinical Signs & Symptoms: Osteoarthritis

- Often asymmetrical Joint pain Esp. wt. bearing - Feet, knees & feet Cervical, lumbar spine - Mild to significant Worsens with joint use - Relieved initially with rest - May increase with falling barometric pressures Joint Stiffness - After inactivity - Resolves within 30 minutes - Over activity stiffness with mild effusion - Crepitation (grindy feeling) Deformities Herberden's nodes - Boney DIP growths - Close to nails - Red/tender/swollen Bouchard's nodes - Bony POP growths - Middle joints (i.e knuckles) - Same s/sx Knee/hip - Bow legged - Altered gait - Shortened limb

Anterior Cruciate Ligament (ACL)

- Often occurs when pt. Pivots, lands a jump or slows down when running Reports acute pain and "pop" sensation with swelling Dx: Lachman's test (PE) & MRI - Lachman's test: Flex knee 15-30 Degrees and pull tibia forward - + if tibia moves forward with soft or indistinct endpoint it's positive for ACL Outpatient Surgery (OPS) if severe PT for rehabilitation - Recovery 6-8 months - Risk for OA later

Opiod Addiction

- Opioids affect the brain by stimulating the opioid receptors and flooding dopamine, a chemical that rewards you with happiness, causing a rush of euphoria and pleasant relaxation - Over time, however, a tolerance or resistance to the drug is built - forcing the user to use more or a stronger dosage in order to receive the "high" - The brain and body becomes used to the drug stimulation and begins depending on it for dopamine production. Without the drug, the user would experience physical and mental withdrawal

Ileostomy

- Ostomy of the ileum - Stool is more liquid - Increased fluid requirement

Clinical presentation: Fractures

- Pain / tenderness - Loss of function/wt. bearing - Muscle spasm - Deformity - Edema / swelling - Ecchymosis / Contusion (aka Bruise) = breakage of tiny blood vessels - Crepitation - Possible break in skin - CHECK for: paresthesias & loss of sensation & movement

Emergency Treatment for DKA: Priority Interventions

(Listed in order or priority) 1. Ensure airway patency &amp; give oxygen 2. Start large lumen IV 3. Provide IV FLUIDS: - NaCl: 0.45 /0.9% per IV at 1 / L /hr. until U/O improves t Target: increased urine output to 30-60 ml / hr. & increase B/P until adequate adequate - After BG falls to 250 mg/dl: add 5 % Dextrose solutions to prevent hypoglycemia 4. Continuous Regular Insulin infusion (IV drip) @ 0.1 U/kg/hr to reduce blood glucose slowly - Goal is 36 - 54 mg/dl reduction per hour - Rate of drip is titrated per hourly blood glucose levels 5. Electrolyte monitoring: replace K+ prn: as insulin is given will drive water and K + into the cells. 6. After blood glucose falls to about 200, a long acting insulin will usually be started.

Mucositis

- Painful inflammation & ulceration of mucous membranes in GI track Causes - Chemotherapy - Radiation of head, neck, abdomen, pelvis Etiology - Mucosal cell death Symptoms - Burning pain in mouth/throat - Reddended mucosa - White/yellow ulcers - Difficulty swallowing - Taste blindness - Reduced taste, bitter, metalic Management - Soft bristle tooth brush am, after meals, HS Mouth washes - Non-alcohol based - No citrus - Sodium bicarbonate & salt 1/4 baking soda, 1/4 salt, 1 cup warm water - Topical anesthetics for pain - Viscous lidocaine - Magic mouthwash - Avoid spicy, acidic, hard, hot foods/beverages Oral lubricants for dry mouth - Biotene

Testicular Cancer: Signs and Symptom

- Painless lump in scrotum - Feeling of heaviness, dull ache Late symptoms associated with metastases - Backache - Cough - Dyspnea - Hemoptysis - Dysphagia Alterations in vision or mental status - Seizures

Complications & Diagnosis Diverticulosis & Diverticulitis

- Perforation with peritonitis - Abscess & fistula formation - Obstruction - Bleeding Dx. - CT with oral contrast

Thromnocytopenia - Clinical Manifestations

- Petechiae, purpura, ecchymosis - Easy bruising - Prolonged bleeding after lab draws, injections - Bleeding from gums, GI tract, epitaxis - Internal bleeding (weakness, fainting, dizziness, tachycardia, abdominal pain, hypotension) Complications - Hemorrhage - Cerebral hemorrhage may be fatal - GI bleeding - Prolonged bleeding time - Thromboses (in some of the disorders) as bleeding does clot -> vascular ischemic problems

Planning Nurse Care r/t pain meds

- Plan painful activites to coincide with peak analgesia effect - Evaluate for relief, duration of relief, and monitor for SE's - DO NOT let pain get out of control! Teach about PRN's - Whats ordered, doses when and how to ask, why it's needed, possible SE's and safety precautions

Hemophilia - Nursing Management

- Prevent and treat bleeding - Replacement of blood products during acute bleeds - Replacement of deficient clotting factors Teaching - Observe s/sx bleeding (stool, urine, oral, skin) - Prevention of bleeding DDAVP (demasopressin acetate) - Stimulates increase in factor VII - Results seen in 30 min, last for 12 hrs

Renal Regulation of Fluid & Electrolyte Movement

- Primary organ for regulating fluid & electrolyte balance by adjusting urine volume & concentration of what is reabsorbed & what is excreted Play a major role in maintaining - Normal plasma osmolality - Electrolyte balance (Sodium-Potassium Pump Works here) - Blood volume - Acid-Base balance Impaired renal function results in - Edema, acidosis & electrolyte imbalances (potassium, phosphorus, calcium, magnesium)

Gallbladder cancer

- Primary uncommon - Adenocarcinomas - Relationship with chronic cholecystitis and cholelithiasis - More common in women Early symptoms - Insidious - Similar to those of cholecystitis and cholelithiasis Late symptoms - Usually those of biliary obstruction Diagnosis and staging - EUS - Transabdominal ultrasonography - CT - MRI - MRCP - Usually not detected until advanced - Can be cured if found early - Endoscopic stent placement in biliary tract to reduce jaundice Adjuvant therapies - Radiation therapy - Chemotherapy - Poor prognosis overall

Nursing Management of the Cancer Patient

- Psychosocial support - Education & information - Chemo certification - Chemo/radiation precautions - Management of side effects

Hepatitis E virus (HEV)

- RNA virus - Transmitted via fecal-oral route - Most common mode of transmission: drinking contaminated water - Occurs primarily in developing countries - Few cases in United States hepatitis No Vaccine

External Beam Radiation Planning - Simulation

- Radiation treatment fields are define, filmed (x-ray), and marked out on the skin (tattoo) - Immobilizing device created - Done to ensure the target area is treated while avoiding unnecessary exposure to surrounding tissue

Hepatitis a VIRUS (HAV)

- Ranges from mild to acute liver failure - Not chronic - Incidence decreased with vaccination (rare in US) RNA virus transmitted via fecal-oral route - Found in feces 2 weeks prior to the onset of symptoms and up to 1 week post onset of jaundice - Contaminated food or drinking water - HEP A VACCINATION AND GOOD HAND HYGIENE ARE THE BEST MEASURES TO PREVENT OUTBREAKS

Nursing Care r/t diuretics and interventions to decrease elderly patient fall risks

- Re-evaluation medication regimen o For example: take evening dose of diuretic by 4 PM - Reduction of night time fluids - Activity tolerance considerations - Use additional adaptive aids to ↓ the risk of falls o Night time urinal o Bedside commode o Night lights o Bed alarms - Frequent toileting rounds

PACU: Postoperative Care

- Receive Report PACU Assessment - What are the Immediate Priorities? - resp. rate - airway - circulation - neuro - Aldrete Scoring System

Preventative & Early Detection Strategies: Cancer

- Reduce or avoid exposure to known or suspected carcinogens & cancer-promoting agents (ie. including cigarette smoke & sun exposure) - Eat a balanced diet that includes vegetables & fresh fruit, whole grains & adequate amounts of fiber. Reduced dietary fat & preservatives, including smoked & salt-cured meats containing high nitrate concentrations. - Limit alcohol intake - Participate in regular exercise (30 minutes or more of moderate physical activity five times weekly) - Maintain a healthy weight - Obtain adequate, consistent periods of rest (at least 6 to 8 hours per night) - Eliminate, reduce, or change the perceptions of stressors & enhance the ability to effectively cope with stressors - Have a physical examination on a regular basis that include a health history. Be familiar with your own family history & your risk factors for cancer - Learn & practice the recommended American Cancer Society cancer screening guidelines for breast, colon, cervical, testicular & prostate cancer - Learn & practice self-examination - Know the seven warning signs of cancer - Seek immediate medical care if you notice a change in what is normal for you and if cancer is suspected.

Prehab - Oral Cleansing

- Reduce risk of Hospital Acquired Pneumonia (HAP) - Prehab: Evening before surgery and morning of surgery - Rinse mouth for 1 minute with 1/2 T (7.5mL) solution - Continue with oral care 3-4 times daily

Lifelong Considerations: Kidney Transplant

- Rejection is always concern Fear of complications associated with immunosuppressive therapy a concern - Cushing's syndrome - DM - Capillary fragility - Osteoporosis - Glaucoma - Cataracts - Increased risk of CA - Fungal infection - Life-long follow up care required

Complications Post-TURP

- Retrograde ejaculation Erectile dysfunction - Anxiety Bladder may take up to 2 month to return from normal functioning

ED: Treatment

- Reverse SE of drug therapy - Androgen replacement therapy - Counseling by a qualified therapist Drug therapy: - Sildenafil Tadalafil - S/E: h/a dyspepsia, flushing, nasal congestion - Vision disturbances, sudden hearing loss, erection lasts over 4 hours - Vacuum constriction devices Intraurethral devices - Topical gels - Intracavernosal self-injection - Medication pellet Inserted into the urethra - Penile implants - Highly invasive - Last course of treatment

Respiratory Alkalosis: Nursing Management

- Review ABGs - Treat underlying cause - Reduce amt of mechanical ventilation

Diagnostic studies: pancreatitis

- Serum amylase increased (24-72 hrs) - Serum lipase increased - Urinalry amylase increased - Blood glucose increased - Serum calcium decreased - Serum triglycerides - Abd U/S - Xray - CT with contrast - ERCP - MRCP - CXR (to assess pulmonary changes)

Metabolic Alkalosis: Cause

- Severe vomiting - Excess gastric suctioning - Diuretic therapy - Potassium deficit - Excess NaHCO 3 intake - Excessive mineralocorticoids

Dry Desquamation

- Shedding of outer most layer of skin Symptoms - Erythema -> peeling - Discomfort, pruritus Treatment - Nonirritating lotion (no alcohol, perfumes, additives) - aloe vera - Topical steroid - hydrocortisone

Risk Factors: Dementia

- Smoking - Cardiac dysrhythmias - HTN - Hypercholesterolemia - DM - CAD - Metabolic syndrome

OUTLINE: Interprofessional Care: COPD

- Smoking Cessation Immunizations - Yearly flu shots - Pneumonia Vaccine - Long-term oxygen Pulmonary Interventions - Airway clearance - Pulmonary Toileting - Pursed lip breathing - Tripod positioning - Medications - Nutrition Therapy: used for decreased BMI Adequate Hydration - 3 L/d unless contraindicated Progressive Exercise - Pulmonary Rehab - Patient/Caregiver Teaching

Homeostasis

- State of equilibrium in the internal environment of the body - Requires careful balance of fluid & electrolytes - Multiple systems are involved in the regulation of fluid & electrolyte balance - Many disease states can alter this balance - Many medical/nursing interventions affect this balance - Alterations in the balance have systemic effects

Colostomy

- Stool more formed the further along it is - No increased fluid requirement in sigmoid colostomy, Do need increased fluids with ascending or transverse - Sigmoid colostomy may have control &amp; not need pouch, by may need irrigations every 24-48hrs

Angiotensin Converting Enzyme (ACE's) Inhibitors

- Stop conversion A-I to A-II - Blocking vasoconstriction & aldosterone release - Enalapril (Vasotec) - Lisinopril (zestril) Side Effects (ACE's & ARB's) - Hypotension - Loss of taste - Dry cough (ACE's) - Hyperglycemia (increased K+) - Angioedema - Renal impairment

Erectile Dysfunction (ED)

- The inability to attain or maintain an erect penis that allows satisfactory sexual performance - 10 million men in U.S - Occurs at any age - Incidence increases with age - 50% of all men ages, 40-70 have some degree of ED - ED is increasing in sexually active males of all ages Younger men - Increase attributed to substance abuse - Alcohol and illicit drugs Middle aged men - Increase attributed to disease process - DM, HTN - Treatment of these may also increase ED as well as some antidepressants and other medications

Interprofessional Care: RA

- Therapeutic Nutrition - Therapeutic Exercise: ROM - Joint rest/protection Hot/Cold therapy - Hot: < 20 min - Cold: 10-15min Complementary - Herbal: fish oil, ginger Movement - Drug Therapy - Reconstructive surgery Interdisciplinary Team - Rheumatologist - RD - PT - OT - Exercise Specialist Community Support - Meals on wheels - Support groups - Psychological support - Websites

Interdisciplinary Care Outcomes: Heart Failure

- Treat underlying cause & contributing factors - Maximize cardiac output - Preserve target organ function - Reduce symptoms - Improve quality of - Improve mortality and morbidity

Drug Therapy: N & V

- Use with caution - Blocks neurochemicals in CNS Antiemetic drugs Variety of classifications - Phenothiazine - prochlorperazine (Compazine), chlorpromazine (Thorazine) - Antihistamines - dimenhydrinate (Dramamine), meclizine (Antivert), promethazine (Phenergan) - Prokinetic - metoclopramide (Reglan) - Serotonin antagonist - ondansetron (Zofran) - Anticholinergic - scopolamine transdermal (Transderm Scop) - Others - dexamethasone (Decadron), trimethobenzamide (Tigan)

Pulmonary Function Tests

- Used to evaluate lung function - Spirometer measures air movement as patient performs various maneuvers Prep - Inform/signed consent - Position upright and ask patient to perform desired respiratory moves - Withhold respiratory meds (i.e. bronchodilators) 6 hours prior Pulmonary Exercise Testing - Used determine exercise capacity - Measures ECO2/Sats while on treadmill - Prep: wear tennins shoes/proper clothing to exercise in

Low Back Pain

- 80% of adults will have one episode - 2nd most common pain complaint next to HA - Number one reason for lost work and work disability claims

Gerontology Considerations: Pain

- >50% of community-based elderly and up to 80% of older adults in ECF (extended care facility) have chronic pain Pain is often under-reported & under-treated - dementia and delirium are two common conditions when pain can be difficulty yo assess & treat Poorly treated chronic pain often results in - Depression - Sleep disturbance - Decreased mobility - Increased health care utilization - Physical and social role dysfunction

Causes of Dementia

- AD - Lewy body - Vascular Disease - Other

Hiatal Hernia

- AKA diaphragmatic hernia &amp; esophageal hernia - Portion of the stomach herniates into the esophagus through opening in the diaphragm Risk factors Intra-abdominal pressure - Pregnancy, obesity, ascites, tumors, regular heavy lifting, age Diagnostics - Endoscopy - Barium swallow

Peritoneal Dialysis (PD)

- Access obtained by inserting catheter thorough the abdominal wall 7-14 day waiting period before using catheter -vSite should be clean, dry, and free from redness/tenderness Three phases of PD Called an exchange - Inflow (fill) - Dwell (equilibration) - Drain

Risk Factors: Alzheimers

- Advanced age Genetic factors - Overproduction of Beta-amyloid - cell damage and neuron death - 3 genes associated with early onset dementia Cellular factors - Inflammation (free radicals) Modifiable factors - DM, smoking, depression

Pain Management: Elderly

- Allow more time for assessment and consider depression as a co-diagnosis Sensory, cognitive, and social limitations may hinder assessment, treatment, and evaluations - Consider using Behavioral Pain Scale for altered cognition of Functional Scales for chronic pain Increased possibility of desired and adverse reactions - (due to slower metabolism and elimination of drugs) - Increased possibility of side effects - Increased change of interactions with other meds - Titrate med dosages: "Start low & go slow!" - Compliance may also be affected by many factors - Include family and SO in teaching

Diet Considerations: Diebetes

- American Diabetic Association (ADA) diet! Nutritional Therapy: GOALS - Maintain BG near normal as safely possible - Normal lipid profiles & BP - Wt. loss if needed - Prevent or slow complications - Respect pt. needs/preferences - Maintain pleasurable eating CARB COUNTING - No foods eliminated, but ALL carbs counted. - CHOs include whole grains, fruit, veggies, dairy (milk) - 1 choice = 15 gm CHO (standard serving size)

Medications: PAD

- Anti-diabetic Anti-lipid - Simvastatin (Zocor) AND - Fibric acid derivative - gemfibrozil (Lopid) Antihypertensive - ACE inhibitors - for symptomatic pts Ex: Ramipril (Altace) - B/P Control is important! Anti-platelet - ASA 76-325 (note if aspirin not tolerated) - Clopidogrel (Plavix) - 75 mg/d is used Claudication - Cilostazol (Pletal) - Pentoxifyline (Trental)

Amputations: Underlying Causes

- Arterial Occlusive Disease (aka PAD) Diabetes Mellitus - peripheral neuropathy - Note most common cause in elderly is co-morbidities of PAD & DM - Trauma Uncontrolled/wide-spread infection - Gangrene - Osteomyelitis - Necrotizing fascitis - Thermal Injuries (burns/frostbite) - Bone cancer (Osteosarcoma)

A 44-yr-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After providing instruction, which statement by the patient indicates correct understanding? "If I take this medication, I will not need to follow a special diet." "It is normal to have some swelling in my face while taking this medication." "I will need to eat foods such as bananas and potatoes that are high in potassium." "If I develop a dry cough while taking this medication, I should notify my doctor."

"If I develop a dry cough while taking this medication, I should notify my doctor." Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced-sodium diet.

Post-Vasectomy Care

- Wear close-fitting underwear for 2-3 days to hold the bandages in place - Place an icepack on your scrotum to minimize swelling during the first 24 hours (30 minutes on/30 minutes off) - Take pain medication as needed - You may take showers beginning of the day after the procedure, but avoid soaking the scrotum in baths, swimming pools or hot tubs until the sutures completely dissolved - You can expect some bruising and redness at the site of the incision The sutures in your incision will dissolve and fall out within 5-10 days - There may be some yellow or white discharge from the incision as the sutures dissolve, this is normal - You may notice a small open gap at the site of the incision after the sutures fall out, this is normal and will close up over time - You may notice some firmness in and around the incision site, it will soften, flatten and return to normal within a few weeks - Limit activity for the first 48 hours following procedure, avoid any heavy lifting, pushing or straining

Risk Factors: Testicular Cancer

- White male - History of undescended testicle - History or orchitis - HIV - Maternal exposure to - DES

Key Points: D/C Instructions: Discharge

- Write instructions in layman's terms - Read/review with patient/SO/family Be clear on any new medications or med changes - Previous home meds against hospital & d/c orders - This process is called "medication reconciliation" - Provide prescriptions: meds, equipment, labs - Form required patient or caregiver's signatures - Patient given paper copies of all forms EMR (electronic medical record) documentation - Identify any referrals - Record teaching - Note: Time, location, mode & name of person accompanying pt.

Gastropexy

- attachment of the stomach to the underside of the diaphragm to prevent reherniation - Anti-reflux procedures (Nissen & Toupet)

Nursing interventions: hepatitis

Acute and chronic Adequate nutrition - Well balanced diet - Vitamin supplements Rest (degree and strictness varies) - Avoid alcohol intake and drugs detoxified by liver - Notification of possible contacts - Acute HAV infection: no specific - Acute HBV infection: only if severe Acute HCV infection - Pegylated interferon or DAAs Supportive drug therapy - Antihistamines - Antiemetics

adalimumab (Humira)

Biologic Response Modifiers: inhibit inflammation and slow disease Tumor Necrosis Factor Inhibitors RA Used for mod/severe RA pts who did not respond to DMARDS. May be used with DMARD's Drug Alerts - Monitor for signs of infection - Give PPD test/CXR before starting - Avoid live vaccinations

The nurse admits a 73-yr-old male patient with dementia for treatment of uncontrolled hypertension. The nurse will closely monitor for hypokalemia if the patient receives which medication? Clonidine (Catapres) Bumetanide (Bumex) Amiloride (Midamor) Spironolactone (Aldactone)

Bumetanide (Bumex)

Hypervolemia Labs

Labs - Decreased urine specific gravity (nl. 1.010-1.025) - Decreasd Na - Decreased BUN - Decreased Hct (hemodilution) - Respiratory Acidosis (decreased pH, increased CO2)

Nursing Diagnosis: Hypervolemia

Nursing Diagnosis - Excess fluid volume r/t increased water &/or sodium retention (risk for or actual) - Impaired gas exchange r/t water retention leading to pulmonary edema - Risk for impaired skin integrity r/t edema - Potential complication: pulmonary edema, ascites

Acute Coronary Syndrome (ACS)

Partial occlusion - Unstable angina - NSTEMI = non ST segment elevation myocardial infarction Complete occlusion - STEMI = ST segment elevation myocardial infarction Note: New onset chest pain, occurring at rest or worsening from a stable pattern - Associated with a deterioration of a previously stable plaque - Requires immediate hospitalization

Incentive Spirometry (IS)

Patient Teaching - Exhale completely - Seal mouth tightly around mouthpiece and inhale slowly and deeply - Remove mouthpiece and hold 3-5 seconds - Exhale! - Repeat a few times then cough! Examples of Post-op IS Orders IS 10x hour WA (while awake) Enc C & D WA "Suggest that patient's use IS during TV commercials" @UPHS: Record highest IS level in EMR under measurement tab

Crackles heard on auscultation throughout lungs that do not clear with incentive spirometer (IS) use indicate which of the following A) Cyanosis B) Bronchospasm C) Airway narrowing D) Fluid-filled alveoli

Fluid-filled alveoli Crackles (rales) are caused by the "popping open" of small airways & alveoli collapsed by fluid, exudate, or lack of air. Crackles maybe heard over fluid-filled (heart failure) or collapsed alveoli (atelectasis) during end-inspiration

Hypotonic Fluids

Fluids with less solute concentration than the cells they surround; fluid shifts from intravascular space to intracellular & interstitial space, hydrating cells D5W (5% Dextrose in Water) - Used to supply water, no electrolytes - 50g glucose/L; 170 cal/L - Used to correct an increased serum osmolarity (hypernatremia) - Frequently used as a solute for medication mixtures (IVPB meds) - Don't use with infants or head injury pts - can caused cerebral edema 1/2 NS (0.45% Sodium Chloride) - Used to replace hypotonic fluid loss

Nursing Care Plan: RA

Impaired physical mobility r/t joint pain, stiffness, and deformity Chronic pain r/t joint inflammation/pain, overuse, ineffective tx Disturbed body image r/t disease, deformities, stiffness, ADL limitations, and long-term treatment Ineffective health management r/t complex chronic disease, powerlessness & pain

Symptoms: Hypercalcemia

Result of dec. excitability of muscles & nerves: - lethargy, weakness, coma - depressed reflexes *(hyporeflexia) - decreased memory, confusion, personality changes, psychosis - anorexia, N/V - bone pain - fractures (if cause results in calcium being pulled from bones) - polyuria, dehydration ECG Changes: - Shortened ST segment - Shortended QT interval - Ventricular dysrhythmias - Increased digitalis effect

Bone Marrow Suppression: Cancer

Review hematology notes: - Anemia - Neutropenia - Thrombocytopenia - Chemo affects bone marrow throughout entire body vs radiation - only affects targeted area - Onset of symptoms related to life span of the type of blood cell - WBC's: 1-2 weeks - Platelets 2-3 weeks - RBC's > 3 weeks

Prozac

SSRI Depression Alzheimers

Zoloft

SSRI Depression Alzheimers

Complications: Epilepsy

Status epilepticus - State of continuous seizure activity - Neurologic emergency Can occur d/t any type of seizure - Brain uses more energy than can be supplied - Permanent brain damage may result Tonic-Clonic status epilepticus - Most dangerous - Can cause ventilatory insufficiency, hypoxemia, dysrhythmias, hyperthermia & acidosis -> can be fatal Injury or death from trauma during seizure - Mortality rate 2-3X - SUDEP

glipizide (Glucotrol)

Sulfonylureas Diabetic Med SE: ***hypoglycemia, wt. gains

Postural Drainage with percussion and/or vibration

- loosening mucous in the airway so that it may be coughed out - Done 1hour ac or 3 hours pc - Assess patient's tolerance for dependent positions

Nursing Management: Hyperkalemia

- place pt on telemetry - monitor ECG - eliminate PO & IV intake of potassium - increase elimination of potassium (diuretics, Dialysis in pts with renal failure/sig. elevation, ion exchane resins - ie. Kayexalate) - force potassium from ECF to ICF (admin IV insulin, along glucose; IV sodium bicarb to correct acidosis) - if severe, reverse membrane potential effects by administering calcium gluconate IV

Nursing Management: Hypercalcemia

- promote excretion of Ca in urine - administer loop diuretic - hydration with NS & inc. PO fluids (3-4L/day) to promote renal excretion & prevent kidney stone formation - administer synthetic calcitonin - low Ca diet - encourage wt-bearing activity to enhance bone mineralization (move Ca from blood to bones)

Diagnostics: Acute Kidney Injury

- ↑ Serum creatinine (n=0.6-1.2mg/dL) UA - To differentiate cause of kidney injury - Kidney US* - Renal scan - CT - Avoid contrast dye*

Diagnostic Studies: Addison's

- ↓ Serum and urinary cortisol ACTH levels - ↑ In primary adrenal insufficiency - ↓ In secondary adrenal insufficiency Labs: - ↑ Potassium - ↓ Chloride, sodium, glucose Hormone Testing ACTH stimulation test - Distinguishes between primary & secondary - Likely primary if cortisol level does not increase after ACTH given - Suggests secondary if cortisol does rise (hypo/pituitary issue) - Corticotropin releasing hormone (CRH) stimulation test - Imaging: MRI or CT Medication Therapies Medications Hydrocortisone - 2/3 dose in am - 1/3 dose late afternoon - Has both glucocorticoid and mineralocorticoid properties Fludrocortisone acetate (Florinef) Mineralocorticoids - Given in AM - Women need androgen replacement Increased Dietary Sodium: - More during excess heat/humidity

Hypoglycemia: Treatment: "Rule of 15"

- √ STAT bedside BG If < 70 and/or + s/sx are present: give 15 g simple CHO orally - Example: 4-6 oz. fruit juice or regular soft drink - √ Repeat BG in 15 min - Repeat treatment if BG still < 70 mg/dl - If no improvement after 2-3 doses CHO, seek medical help. If patient is unable to eat: options include - 1 mg glucagon SQ/IM - 20-50 ml of 50% Dextrose IV push If next meal is > 1 hour away: give additional food and longer action CHO with protein or fat - Ex. Crackers with cheese or peanut butter

Drug Therapies: Pulmonary Embolism

1. Anticoagulation Immediate: Lovenox (SQ) Long term warfarin (Coumadin) - PO rivaroxaban (Xareltol) apixaban (Eliquis) - PO 2. Fibrinolytics: Might be used for unstable pts if not contraindicated - Tissue plasminogen activator (tPA) - Alteplase (Activase) (cannot use in trauma patients/women who just had a child) Surgical Intervention Pulmonary embolectomy - For massive PE/unstable pts. who can't receive fibronolytics Inferior vena cava (IVC) filter: used for prevention reoccurrence in high risk pts. - Traps clots from legs thus preventing migration into pulmonary system - Example: Greenfield filter

Indications for Electrical Treatment (Tx): Arrhythmias

1) Emergency Situations - To terminate life-threatening arrhythmias - To support patient during transports/treatment 2) Prophylactic during/after surgery/procedures 3) Known specific arrhythmias - Near Cardiac Death survivors (Arrest) - High risk persons (with poor ejection fractions EF's <30%)

Types of Pneumonia

1. Community-Acquired Pneumonia (CAP) - Seen in pts NOT previously hospitalized or in a LTC over the past 14 days - Decision to treat inpatient vs outpatient is determined by health care provider GOAL: start empiric antibodies ASAP - Which means start antibiotic based on best guess of causative agent 2. Hospital Associate (HAP) - Nosocomial infection - > 48 hours after admission Ventilator Associated (VAP) - A types of HAP - > 48 hrs. after endotracheal intubation - At greater risk for developing a multi-drug resistance (MDR) pneumonia 3. Aspiration - Results from abnormal entry of secretions/flora (food, fluids, vomit, saliva) into lower airways Risk Factors - decreased LOC - Difficulty swallowing - Nasal gastric tubes with or without feedings 4. Opportunistic Immunosuppressed: such as - HIV/AIDS - Chemo/Radiation Cancer (CA) - Long-Term corticosteroids - Organ recipients - Malnourished (alcoholics, cancer patients, anorexia/bulimic, living in extreme poverty)

Interprofessional Care: COPD

1. Smoking Cessation/Avoidance of Respiratory Irritants a. Stopping smoking is most significant factor in halting disease progression b. Avoid known respiratory irritants (aerosol sprays, smoke, pollutants) 2. Prevention of upper respiratory infections: Helps to prevent COPD & minimize exacerbations to slow progression a. Vaccines - Pneumonococcal Vaccines - Influenza Virus Vaccine - (aka flu shot) reformulated each year from inactivated viruses - given each fall/early winter b. Early recognition and outpatient treatment of respiratory infections 3. Oxygen Therapy a. Indicated when O2 sats are <88% (PaO2 < 60) b. Used to treat cor pulmonale c. Evidence Based Practice (EBP): long term continuous use increase survival rates when corpulmonale is present d. RT referrals & consultations e. Be careful using with COPD! - Brain stem normally responds to increased CO2 by increased respiratory rates - But COPD pts. especially later in disease process have chronic increased PCO2 (hypercapnia) so their brains no longer respond to the high CO2 levels - COPD patients respond to hypoxemia (low PaO2) - Thus, too much oxygen may decrease their respiratory drive (rate) - Use low flow delivery systems: Venti masks often used to more precisely control O2 amounts f. Positioning - Maintain High - Fowler's to help with breathing - Tripod positioning 4. Activity Intolerance a. Pace & Space b. Progressive Exercise Program: walking and upper body strengthening with education on disease management topics c. Referral: Pulmonary Rehabilitation Program d. EBP: COPD pts benefit from exercise programs including improved exercise tolerance and quality of life, decreased hospitalizations, and less depression 5. Breathing Exercises: Pursed lip breathing a. Promotes slower rates & prolonged exhalations b. Prevents airway collapse/reduces air trapping c. Have pt. inhale slowly, deeply through nose, then exhale slowly through purse lips (whistle) d. Repeat 8-10x TID/QID e. EBP: Current evidence seems to support the use of this technique 6. Promote Effective Airway Clearance: Huff Coughing (to clear secretions) a. Instruct on proper technique 7. Promote Hydration (to keep secretions thin and less sticky) a. Encourage/Provide fluid intake up to 3 Liters per day unless contraindicated b. Fluids are best ingested between meals to prevent stomach distension and bloating which will put pressure on diaphragm 8. Promote Adequate Nutrition: Eating becomes an effort in later stage a. Rest 30 minutes before meals b. Avoid exercise and treatments 1 hour before meals c. If O2 is needed, use NC during meals c. Try more frequent meals and snacks e. Provide high calorie/high protein meals and snacks f. Eat high calorie foods first g. Avoid foods that require a lot of chewing and/or gas forming foods h. Promote easily prepared or packaged foods but watch sodium content if cor pulmonale is present i. Monitor weight j. Dietician Referral

Candesartan (Atacand)

ARB's Angiotensin Inhibitor

Hemodialysis (HD)

Access devices: Internal arteriovenous fistula (AVF) or graft (AVG) - Autograft or synthetic - Thrill should be palpable, bruit should be auscultated - Accessed with 14-16G needles - 1 to pull blood from circulation to HD machine, 1 to return dialyzed blood to pt NEVER perform BP, insertion of IV, venipuncture in extremity with vascular access - Prevent infection & clotting Potential complications (both require surgical intervention) - Distal ischemia & pain (steal syndrome) - Aneurysms -> can rupture Temporary vascular access Quinton/Permcath (permacath) - Used when immediate vascular access is required Double lumen catheter insertion at the internal jugular or femoral vein -> tip in right atrium - Used 1-3wks Tunneled catheter (exists chest wall - tunneled SQ to IJ or EJ vein) - Can be left in place longer while waiting for fistula placement & development or when other methods have failed

Drug Therapies: Osteoarthritis

Acetaminophen (Tylenol) Do not exceed 3g/day - newer guidelines - Topical creams (Capsaicin or salicylates) NSAIDS - Ibuprofen (Motrin) - Naproxen (Aleve) - Corticosteroids: Intra-articular (IA) injections

Calcium Channel Blockers

Actions: Block Ca2+ from moving into the cells causing vasodilation (decreased SVR/BP). Some slow HR & AV conduction Non-Dihydropyridines - Diltiazem (Cardizem) - Verapamil (Calan) Dihydropyridines - Relaxes vascular smooth muscle (decrease SVR/BP) - Amlodipine (Norvasc) - Nifedipine (Procardia) SE:hypotension, worsening heart failure, bradycardia, AV conduction blocks Note: No grapefruit juice

Nursing Care: Hyperthyroidism

Activity Intolerance - Assess tolerance of activity - Monitor VS Watch for cardiac arrhythmias/chest pain - √ for dyspnea, pallor & diaphoresis - Schedule freq. rest periods /sleep - Assist with ADL's prn Imbalanced Nutrition < BR - Dietician referral to determine type of nutrients and # of calories needed - Provide high calories 4,000 - 5,000 kcal/d - Six well balanced meals plus snacks - High protein (1-2 g/kg) & ↑ CHO's - High vitamins & minerals - Avoid high fiber & highly seasoned foods (they already have diarrhea) - Enc. fluids (juice) / but avoid caffeine drinks - Evaluate: calorie/nutrition records & weights

Differences: Acute vs Chronic Pain

Acute - onset sudden - < 3 months - often id precipitating event - mild to severe - decreases over time clinical s/sx: r/t increase SNS - Goals: control pain to participate in recovery, manage SE & stop pain meds! Chronic - onset gradual or sudden - > 3 months - may start as acute - precipitating event may not be known - mild to severe - pain does not go away may wax & wan - Clinical S/sx: flat affect, fatigue, decreased activities, withdraw, depressed - Goals: control pain/enhance function & quality of life - often need meds

Pneumonia

Acute inflammation of the lung parenchyma - i.e. functional tissue not connecting parts Leading cause of infectious disease death in U.S - Community-Acquired Pneumonia (CAP) along with the flu are the 8th leading cause of death in U.S Pneumonia: Etiology More likely to occur when defense mechanisms are weakened or overwhelmed by infectious agents Decreased Cough/epiglottal reflexes: increased aspiration risk! - Unconscious patients and anyone with impaired swallowing Impaired mucocilliary mechanism - Pollution, cig smoking, upper respiratory infection, ET tubes, aging Chronic Disease - Suppress the immune system weakening ability to fight infection

Scope of the Problem: Pain

Acute pain is the main reason pts seek health care - 25 million annually experience acute pain related to injury and or surgery - Originates in tissue injury that resolves with healing but may become chronic Chronic pain: over 100 million Americans suffer with it - Back pain - Arthritis - Migraines - Neuropathies Cancer: 60 pts experience pain with treatment EBP: Multiple studies across all pt. populations indicate inadequate pain management

Process of Cancer Development

2 Stages Initiation Mutation of cell's genetic structure - 5-10% inherited - Remaining are acquired Promotion - Cell proliferation occurs (think lifestyle habits) Progression - Evidence of clinical disease

Oral Cancer

2 types - Oral cavity cancer - Lower lip, lateral border &amp; undersurface of tongue, buccal mucosa - Oropharyngeal cancer Risk Factors - African Americans - 2x more common in men than women - Tobacco Use, excessive alcoholism, pipe smoker, poor dental care, tanning booths, prolonged exposure to sunlight and HPV

Normal HgAqc Level

4-6% Treatment target: < 6.5%

SQ administration

45-90 degree angle, if you can grab 2 inches of skin do 90 if you can only grab 1 inch do 45. Hold needle in place for 10 seconds after injecting medication Sites: upper arm, lower abdomen, anterior thighs When giving exoparin (Lovenox) don't expel air bubble just flick, chases med into SQ tissue so dose doesn't leak out Don't massage puncture site, could cause bruising

Secondary HTN

5-10% Has a specific cause; treatment aimed at cause Examples Cirrhosis Aorta conditions Renal disease Endocrine disorders Neurological disorders Sleep apnea Drug induced: estrogen replacement therapy (ERT), oral contraceptives, steroids, stimulants (cocaine)

Incidence of HTN

50% adults in U.S will now have high blood pressure under new guidelines Biggest increase in adults < age 45 under new guidelines Incidence in males is tripling Females are doubling Heart disease often directly r/t HTN causes 24% of all deaths/year in U.S

High Fowler's Position

A semi-sitting position; the head of the bed is raised 60 to 90 degrees

Your patient with a history of asthma has developed chest tightness, wheezing, and is tachypnic. Which of the following is a priority intervention A) Administer two puffs of an albuterol (Ventolin) MDI B) Administer one montelkast (Singulair) C) Administer an IV dose of hydrocortisone (Solu-Cortef) D) Administer 5mg oral Prednisone

A) Administer two puffs of an albuterol (Ventolin) MDI

How do nurses evaluate the effectiveness of teaching strategies? Select all that apply. A. Ask the client to do a return demonstration of the skill being discussed. B. Have the client take a post-test of the teaching content. C. Ask pertinent questions relative to the teaching content. D. Summarize the teaching content they presented. E. Clarify misinformation after each teaching session.

A, B, C Summarizing the teaching content or clarifying misinformation does not evaluate the effectiveness of the teaching strategies. It does provide information on retention of information, which can play a role in how effective the strategies have been. However, you do want to evaluate the type of strategy utilized in teaching. Basically, what they are doing in (D) and (E) is reiterating information. You cannot evaluate whether they are able to utilize the information that was covered in the teaching.

Medical Diagnosis: HTN

A. Nurse must be able to obtain accurate measurements - No caffeine, exercise, or smoking 30 minutes prior - Patient should rest quietly 5 minutes before measurement Seated with arms bare - Arm supposed at heart level - Legs on floor not crossed - Cuff should fit properly. Follow manufacturer's instructions - For auscultatory readings inflate cuff 20-30 mm above where radial pulse disappears and deflate 2-3mmHg/sec if using mercury (manual equipment) Check both arms initially - Confirm increased readings in opposite arm (sometimes you can't..examples - removed lymph nodes, dialysis, PICC lines, obvious trauma) - Record both but use highest arm in future - Note should be < 5 mmHg difference between arms - If not take additional readings - Use the average of two readings in highest arm taken approximately 1-2 minutes apart Related Nursing Care - Provide patient with results verbally and in writing, explain target numbers and F/U plan. - Report high readings prn - Wash/Disinfect cuff between patients B. History & Physical - Focus on id risk factors Check for secondary causes and any target organ damage - Example: Ophthalmic Exam to check eyes damage (retinopathy) C. Lead ECG with Echocardiogram if needed - To detect LVH D. Routine Urine Analysis (U&A) E. LABS: to identify primary HTN or rule out 2nd causes of HTN, target organs, determine cardiac risk, and establish baselines before initiating therapy. Provider decision. - U/A - Creatinine Clearance Basic metabolic panel (BMP) - Lytes (Na, K, Ca, Cl) - BUN/Cr - Glucose - fasting - CBC (BP may be high because of high CBC) - Thyroid Stimulating Hormone (TSH) - Lipid Profiles - Uric Acid (can cause GOUT) Baseline may increase with diuretic treatment

Vitamin B12 Deficiency Anemia

A.K.A Cobalamin Deficiency - IF (intrinsic factor) secreted by parietal cells of gastric mucosa, which is a protein required for Vitamin B12 absorption in the ileum of the SI Causes: - Pernicious anemia: gastric mucosa does not secrete IF because of antibodies being directed against the gastric parietal cells of IF itself; prevents dietary sources of Vitamin B12 from being absorbed in distal ileum- Gastrectomy, gastric bypass, resection involving ileum - Chronic gastritis, Cohn's ileitis, celiac disease - Nutritional deficient, strict vegetarians - Alcoholism - Hereditary enzymatic defects of B12 utilization Clinical Manifestations - Classic symptoms of anemia - Sore, red, beefy shiny tongue, anorexia, N/V, abdominal pain - Weakness - Paresthesias of hands and feet - Ataxia (impaired balance) - Muscle weakness - Impaired thought processes Diagnostic Studies Laboratory findings - Hgb, Hct- RBCs appear large (macrocytic) & have abnl shapes - Serum cobalamin levels - Endoscopy & biopsy - Schilling test Treatment If unable to absorb B12 via gut IM Cyanocobalamin- 1000mg IM daily x 2wks, then weekly until Hct is nl, then monthly for lifeIf GI absorption intact - PO supplements Nutritional Therapy - red meats, eggs, salmon, tuna, yogurt, enriched grains

Neurologic Regulation: Fluid & Electrolyte Imbalance

ADH: Antidiuretic Hormone - Released by the brain to regulate vascular fluid levels - causes water reabsorption - Can cause significant fluid & electrolyte imbalances in patients with head injuries, brain tumors, or following brain surgery - If ADH is increased that can cause hyponatremia - increase in water, decrease in sodium Cortisol - Helps regulate both fluid (water reabsorption) & electrolytes (sodium reabsorption & potassium excretion) Aldosterone - Helps regulate sodium (retention) & potassium (excretion)

Peritoneal Dialysis Systems

Automated peritoneal dialysis (APD) - Cycler delivers the dialysate - Times and controls fill, dwell and drain Continuous ambulatory peritoneal dialysis - Manual exchange Involves continuous contact of dialysate with the peritoneal membrane - Approximately 2L of dialysate are maintained intraperitoneally and exchanged by the patient thorough a permanent peritoneal catheter 4-5x/day - Patient can lead a fairly normal lifestyle Advantages of Peritoneal Dialysis (PD) - Provides a steady state of blood chemistries - Machinery not needed - Process easily taught - Few dietary restrictions - More control over daily life - Useful for hemodynamically unstable patients Nursing Care - Maintain strict aseptic technique - VS q4hr - Strict I&O - Assess for signs/symptoms of infection - Assess for edema - During cycle record type of dialysate, amount infused, amount recovered, amount of time left in place, characteristics of recovered dialysate Most Common Complications of Peritoneal Dialysis (PD) - Hypotension - Hypovolemia - Inadequate drainage of fluid from peritoneal space - Pain - Atelectasis - Respiratory complications/distress - Peritonitis

The nurse is caring for a patient admitted with a history of hypertension. The patient's medication history includes hydrochlorothiazide daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy? Weight loss of 2 lb BP 128/86 mm Hg Absence of ankle edema Output of 600 mL per 8 hours

BP 128/86 mm Hg Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Because the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure.

Intestinal Obstruction

Background - Can occur in SI or colon - Can be partial or complete Causes Mechanical: - Surgical adhesions (scar tissue that forms around an area), hernias, tumors, volvulus , diverticular disease Non-mechanical: - Neuromuscular or vascular disorder - Paralytic ileus - lack of intestinal peristalsis - Pseudo-obstruction - neurologic & endocrine disorders - Vascular obstruction - interference with blood supply to portion of the intestines, often caused by thrombosis/emboli of mesenteric arteries Clinical Manifestations N/V - SI (small intestine) obstruction = bile, green - LI (large intestine) obstruction = orange, brown, may have fecal odor Poorly localized abdominal pain - Mechanical obstruction - pain comes and goes as peristalsis attempts to move bowel contents past the obstructed area - Non-mechanical obstruction - pain is constant (no peristalsis), severe, rapid onset - Abdominal distention (worse with LI obstruction) - High pitched bowel sounds above obstruction, absent below obstruction, eventually absent altogether Constipation vs Obstipation - Inability to pass flatus Dx. - Abdominal X-ray - CT - Colonoscopy - CBC - increased WBC indicates strangulation or perforation - Blood gasses - metabolic alkalosis can result from vomiting/NG suction - Monitor electrolytes, Hgb, Hct Management - NPO NG to suction - Oral care - IVF (SN or LR with K) - Analgesics Surgery - Resect obstructed segment of bowel - Partial or total colectomy, colostomy, ileostomy - for extensive obstruction/necrosis

Insulin Treatment Regimen

Basal-bolus Regimen (aka intensive therapy) - Most closely mimics endogenous insulin production - Rapid- or short-acting (bolus) insulin used before meals - Intermediate- or long-acting (basal) background insulin used once or twice a day - Requires frequent SBGM

Interprofessional Care: Osteoarthritis

Because there is no cure, care goals focus on 1. Managing pain and inflammation 2. Preventing disability 3. Maintain and improve joint function - Treatment/Therapies: non-drug is the foundation of treatment - Drug therapy serves as an adjunct to other treatments

Nursing Considerations: Dialysis

Before treatment, the nurse should Complete assessment of - Fluid status (wt, BP, peripheral edema, lung & heart sounds) - Condition of vascular access - Temperature - Skin condition During treatment nurse should - Be alert to changes in condition - Perform vital signs every 30 to 60 minutes

Abilify

Behavioral Problems Antipsychotics Alzheimers

Seoquel

Behavioral Problems Antipsychotics Alzheimers

Benefits vs Disadvantages Kidney Transplants

Benefits Extremely successful 1-year graft survival rate - 90% for cadaver transplants - 95% for live donor transplants - Reverses many of pathophysiologic changes associated with renal failure - Less expensive than dialysis after 1 year - No further need to dialysis Disadvantages - Long waiting lists - Financial considerations - Risks associated with surgery - Risk of rejection

Tumor Classification - Benign or Malignant

Benign Neoplasm - Well differentiated - Cells fairly normal, similar to parent cells - Encapsulated - Rare recurrence Malignant Neoplasm - Poorly differentiated - Cells abnormal, not like parent cells - Metastasis - Highly vascular

Propranolol (Inderal)

Beta Blocker 2 Adrenergic Inhibitor

Drug Therapy: Oral Anti-diabetic Meds

Biguanides ↓ liver glucose production & ↑ tissue (muscle) uptake - Metformin (Glucophage) *** - Take with food 1st line drug for many pts & is used to treat pre-diabetes • *CLINICAL ALERT: Must be held 24-48 hours before & 48 hours after IV contrast media! Resume when serum creatinine levels are normal. Do not give to ETOH abusers, kidney disease, liver disease or heart failure patients. • SE: wt. loss, diarrhea, lactic acidosis Sulfonylureas - Increases insulin production in pancreas • glipizide (Glucotrol) • glyburide (DiaBeta) - SE: hypoglycemia, wt. gains Meglitnides - Increases insulin production in pancreas - repaglinide (Prandin) & nateglinide (Starlix) - Rapid onset: so take 30 minutes or just before meals - SE: hypoglycemia, wt. gains ά -Glucosidase Inhibitors - Delays GI absorption CHO ("starch - blockers") - acarbose (Precose) & miglitol (Glyset) - Taken with "first bite" of each meal - Check effectiveness with 2 hour post-prandial BG level - SE r/t GI: abd pain, gas, diarrhea Dipeptidyl Peptidase - 4 (DDP-4) Inhibitors - Enhance actions of incretin hormones: thus↑ insulin release ;↓ hepatic glucose production - Sitagliptin (Januvia) "gliptins" - SE: pancreatitis, allergic reactions NEWEST: Sodium-glucose co-transporter 2 (SGLT2) inhibitors • Blocks renal reabsorption of glucose, thus increasing glucose excretion • Canagliflozin (Invokana) • SE: genital yeast infections, UTI's and thirst

etancercept (Enbrel)

Biologic Response Modifiers: inhibit inflammation and slow disease Tumor Necrosis Factor Inhibitors RA *- Watch for heart failure (Enbrel) Used for mod/severe RA pts who did not respond to DMARDS. May be used with DMARD's Drug Alerts - Monitor for signs of infection - Give PPD test/CXR before starting - Avoid live vaccinations

Infliximab (Remicade)

Biologic Response Modifiers: inhibit inflammation and slow disease Tumor Necrosis Factor Inhibitors RA Used for mod/severe RA pts who did not respond to DMARDS. May be used with DMARD's Drug Alerts - Monitor for signs of infection - Give PPD test/CXR before starting - Avoid live vaccinations

Cardiovascular: VTE (venous thromboembolism)/ PE (Pulmonary Embolism)

Blood clot formation (usually in the deep veins of the posterior lower leg) that may become mobile & travel to lungs; caused by increase platelet production as a result of the stress response from surgery, anesthesia which causes vasodilation (damages vascular lining), venous stasis. If clot becomes dislodged, leads to PE S/Sx: - VTE/DVT (deep vein thrombosis) - pain swelling, redness, increased pain with dorsiflexion in the calf - PE - tachypnea, dyspnea, chest pain, tachycardia, anxiety, diaphoresis, eventually decreased orientation, decreased BP, crackles, wheezing, blood sputum Risk Factors: surgery (especially orthopedic surgeries), decreased mobility, elderly, obese, history of clots, history of vascular or CV problems, pregnancy, and BCP's with estrogen. Diagnosis: US-most common, veinopraphy, MRI/CT, & symptoms Prevention-Nursing Strategies: pneumatic compression devices/SCDs, medications - LMWH (low molecular weight heparin = enoxaparin (Lovenox), early ambulation, hydration, leg exercises. Compression stockings (TED hose) alone are NOT effective at reducing VTE (EBP) Treatment-Nursing Management: anticoagulation (heparin, warfarin), thrombolytics (clot dissolvers - TPA - tissue plasminogen activator [Alteplase]), clot removal, oxygen; DVT - bedrest until dissolved to prevent dislodge - do not massage calf!

Fracture Complications: Direct

Bone Union Problems - Delayed union: slow to heal - Nonunion: fails to heal - Malunion: heals unsatisfactory causing deformity/dysfunction - Avascular Necrosis: especially seen with displaced femoral neck fractures - Bone infections: Osteomyelitis: high risk with open fractures Indirect - Compartment Syndrome - Deep Vein Thrombosis - Fat Emboli Syndrome

Common Side Effects: Chemo

Bone marrow suppression - Anemia -> fatigue, SOB - Thrombocytopenia -> bleeding - Neutropenia -> infection Integumentary - Alopecia - Skin redness, dryness, itching, peeling - Peripheral neuropathy Gastrointestinal - N/V -> wt. loss, fluid/electrolyte imbalances - Constipation (pain meds) - Diarrhea -> wt. loss, fluid/electrolyte imbalances - Anorexia -> wt loss - Mucositis

Quick Relief Meds: (aka Rescue): Asthma

Bronchodilators 1. Short acting beta2 agonists (SABA) - albuterol (Proventil, Ventolin): given via nebulizer/MDI SE: anxiety, increase HR & B/P & palpitations (arrhythmias), tremors, N/V 2. Anticholinergics - ipratropium (Atrovent) SE: dry mouth, bad taste Note: both meds are commonly used in nebulizer therapy - Patients need to carry these with them at all times - May take second puff after 1 minute. Repeat dose Q 20 minutes up to 3 times Anti-inflammatory: used during severe acute attacks to decrease inflammation Corticosteroids: given IV push or oral burst-dosing method - Prednisone PO - Note: can also be used to control ! - Hydrocortisone (Solu-Cortef) IV - Methylprednisolone (Solu-Medrol) IV SE: Seen more commonly with prolonged use oral use.

Long Term Meds: aka Control: Asthma

Bronchodilators: 1. Long acting B2 adrenergic agonists (LABA) - Salmeterol (Serevent) - Inhaled SE: Shakiness, increased HR, HA NOTE: Used with inhaled corticosteroids for better control 2. Methylxanthine - Theophylline (Theo-24) - Oral, SR tablets, elixir - Aminophylline - IV continuous infusion (aka drip) SE: N/V, increased HR & arrhythmias, seizures, insomnia, avoid caffeine Anti-inflammatory: Corticosteroids: various routes Inhaled corticosteroids (ICS) fluticasone (Flovent Diskus) - Use spacer & rinse mouth after - SE: oral pharyngeal candidiasis, hoarseness and dry cough Oral: prednisone Combo products: control meds: ICS & LABA - Fluticasone/salmeterol (Advair Diskus) - Budesonide/formoterol (Symbicort) Leukotriene Modifiers Receptor Blockers - Montelukast (Singular) Synthesis Inhibitors - Zileuton (Zyflo CR) Note: leukotrienes are inflammatory mediators that cause bronchoconstriction, edema, and inflammation Anti-IgE - Omalizumab (Xolair) - Given SQ q 2-4 weeks - In doctor's office due to risk anaphylaxis - Used for mod/severe pts. Not responsive to inhaled corticosteroids Note: med is a monoclonal antibody to IgE which will decrease IgE levels preventing mast cell attachment and release of chemical mediators.

The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD), angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the patient carefully. Which adverse effect is this patient at risk for given the patient's health history? Hypocapnia Tachycardia Bronchospasm Nausea and vomiting

Bronchospasm Atenolol is a cardioselective β1-adrenergic blocker that reduces blood pressure and could affect the β2-receptors in the lungs with larger doses or with drug accumulation. Although the risk of bronchospasm is less with cardioselective β-blockers than nonselective β-blockers, atenolol should be used cautiously in patients with COPD.

Nurse instructs a client newly diagnosed with Type 2 diabetes about self-care. The priority for preventing the related complications is to A. learn to administer insulin properly and know the signs of hypo/hyperglycemia B. follow diabetic diet closely C. Keep the blood glucose controlled at or near normal levels D. Report to the physician immediately any kidney, or vascular changes

C. Keep the blood glucose controlled at or near normal levels

Diagnostic Tests: Heart Failure

Lab Studies B-type natriuretic peptide (BNP): Heart hormone - Correlates positively with degree of left ventricular dysfunction - Used to differentiate possible causes for dyspnea - increased BNP is associated with cardiac problems vs respiratory causes - N-terminal prohormone of BNP (NT-proBNP) - Newer more precise test - CBC (complete blood counts) - Thyroid function tests - Cardiac Biomarkers: Troponin, CPK-mb, myoglobin - Liver function tests - Lipid Profiles - Lytes: baseline & to monitor drug SE's - Renal studies - ABG's More Diagnostic Heart Studies - Chest X-ray (CXR): check heart size & baseline lung status - 12 Lead Electrocardiogram (EKG/ECG): r/o acute myocardial infarction (AMI) & assess rhythms Echocardiogram (Echo): uses ultrasound to measure ventricular and valve functioning, chamber sizes & EF - Transesophageal Echocardiogram (TEE) - Nuclear Imaging Studies: uses radioactive isotopes to image heart & measure EF (ejection fraction) - Cardiac Catheterization/Coronary artery angiography: detects location & degree of narrowing in coronary arteries caused by CAD, structural problems (valve issues & chamber wall motion), EF's, chamber pressures

American Diabetic Association (ADA) Diet: Nutrition Therapy

CHO - 45-65% of daily calories - Minimum 130g/d - Monitor glycemic index • Term used describe rise in BG levels after CHO food is consumed. - CHO gram counting &amp; meal coverage Examples: - 15 G = 1 unit of insulin coverage for Type 1 - 10 G = 1 unit insulin for Type 2 Fats - Limit sat fat ≤ 7% daily calories - Limit cholesterol &lt;200 mg/d - Limit trans-fat intake Protein - 15-20% daily calories - Watch if renal impaired - Limit alcohol to moderate intake - Fiber: 25-30 g/d - Artificial sweeteners use in moderation STUDY NOTE: You do not need to memorize the daily calorie intake percentages.

B/P

CO x SVR the force exerted by the blood against blood vessel walls. Must be adequate for tissue and organ perfusion during rest and activity. SVR: the force opposing the movement of blood in the vessels Determined mostly by the diameters of arterioles, smooth muscle tone

Biventricular Pacing: Cardiac Re-synchronization Therapy

CRT is used to increase C/O in HF patients who have conduction delays and asynchronous ventricular pumping

Hypocalcemia Cause

Ca < 7.6mg/dL Cause Decreased Total Calcium - CKD - elvated phosphorus - hypoparathyroidism/removal or damage to parathyroid (such as during a thyroidectomy) - Vit D or magnesium deficiency - acute pancreatitis - loop diuretics -chronic alcoholism - diarrhea Decreased Ionized Calcium - Alkalosis

Hypercalcemia: Cause

Ca >10.2 mg/dL Increased Total Calcium - hyperparathyroidism - malignancies (breast cancer, lung cancer, multiple myeloma) & metastasis - prolonged immobilization - Vit D overdose - Thiazide diuretics Increased Ionized Calcium - Acidosis

Calcium

Ca2+ (Cation) 8.6-10.2

Treatment: CAD

Cardiac Catherization with Percutaneous Coronary Intervention (PCI) 1. Coronary Arteriography (Diagnostic) - uses IV contrast medium and - visualize blockages (diagnostic) 2. Percutaneous Coronary Intervention (PCI) Open blockages (interventional) - Using Balloon tip catheter: Percutaneous Transluminal Coronary Angioplasty (PTCA) - During this procedure, a catheter with an inflatable balloon tip is inserted into the coronary artery. - When the blockage is located, the catheter is passed through it, the balloon is inflated, and the atherosclerotic plaque is compressed, resulting in vessel dilation Stent Placement - Intracoronary stents are often inserted in conjunction with balloon angioplasty - Stents are used to prevent restenosis following balloon angioplasty or abrupt closure after thrombolytic med

Heart Disease

Cardiovascular diseases are the leading cause of death in US. - 1/2 of American adults have at least one type of CVS - Every 25 seconds, an American will have a coronary event and about one person every minute will die - Coronary heart disease (aka coronary artery disease = CAD) is the most common form of heart disease Patients with CAD - can be asymptomatic - may develop chronic stable angina May have acute coronary syndrome - unstable angina - myocardial infarction NSTEMI = non ST segment elevation myocardial infarction STEMI = ST segment elevation myocardial infarction

Cardiovesion vs Defibrilation

Cardioversion - elevtive procedure - client awake & frequently sedated - synchronized with "QRS" 50-200 Joules - Consent form - EKF Monitor Defib - Emergency = V-fib/V-tach - No cardiac output - Begin with 200 Joules up to 360 - Client unconscious - EKG monitor

Fluid Volume Deficit (FVD) Hypovolemia: Cause

Cause Excessive Fluid Loss - GI losses: diarrhea, vomiting, fistulas, NG suction - Renal losses: diuretics, polyuria, DI - Skin losses: burns, wound drainage - Hemorrhage Inadequate fluid intake* Insensible water loss - perspiration - fever, heatstroke Third space fluid shifts - burns, intestinal obstruction

Clinical Manifestations: Urinary Tract Calculi

Caused by obstructed urinary flow - Abdominal or flank pain, With N/V - Hematuria Movement & passage of stone - Colicky pain - Mild shock Cool, moist skin - Testicular pain in men - Labial pain in woman

Nausea & Vomiting: Cancer

Causes Chemo/radiation - Triggers chemoreceptor trigger zone in brain - GI lining destroyed by chemo radiation - Release of intracellular breakdown products stimulated CTZ - Cancer of the brain/bowel - Constipation - Anxiety Types - Acute N/V develops within a few hours of chemotherapy - Delayed N/V can start more than 24 hours after treatment - Breaththrough N/V occurs when you vomit despite being on antinausea drug - Anticipatory N/V happens before treatment, and is a learned response to previous treatments Management - Eat small meals - Avoid foods that have odors (cold foods are best), avoid fried, fatty, sweet foods - Drink fluids - water, tear, ginger ale/lemon-lime soda that has lost carbonation - Sit up when eating & for hour afterwards - Avoid strong smells, perfumes - Deep breathing, guided imagery - Acupuncture - Acupressure Medications - give prophylactically - give ATC Medication Classes Anticholinergics - Transderm-Scop (scopolamine) - Tigan (trimethobezamide) - Dramamine (dimenhydrinate) - Antivert (meclizine) 5HT3 receptor antagonists - Zofran (ondansetron) Antihistamine - Vistaril (hydroxyzine) - Phenergan (promethazine) GI Stimulants/Misc - Reglan (metoclopramide) - Compazine (prochlorperazine)

Chronic Venous Insufficiency: CVI

Causes: vein incompetence, DVT's Clinical s/sx - Edema - Brownish skin: discoloration caused by RBC's releasing derosiderin - Eczema (stasis dermatitis) - Pruritus (itching) Venous leg ulcers (formerly called venous stasis ulcers) - partial thickness with irregular borders - wet and painful - Usually above medial malleolus Treatment: CVI A) Proper foot & leg care - Compression Therapies - Use of skin moisturizers - Daily inspection B) Would Care for Venous Leg Ulcers - Moist environment dressing Adequate nutrition for healing - Protein: Albumin (N: 3.4-5.0) - Vitamins A and C along with zinc - Wt. reduction PRN - Control of blood glucose if diabetic - Treat infection with antibiotics if indicated by symptoms/signs after culture is obtained

Interprofessional Care: DI

Central DI IV or oral fluids replacements - hypotonic saline or D 5 W - IV fluids titrated to replace U/O ADH replacement therapy - desmopressin acetate (DDAVP) - vasopressin (Pitressin) Other drugs: chlorpropamide (Diabenese) and carbamazepine (Tegretol) used for thirst control Nephrogenic DI - Thiazide diuretics: help kidneys to reabsorb more H20 - Low sodium Diet (≤ 3 g/d) Indomethacin (Indocin): helps↑ renal response to ADH - Used if above therapies not effective

CAUTION: 7 Early Warning Signs of Cancer

Change in bowel habits or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or a lump in the breasts, testicles, or elsewhere Indigestion or difficulty in swallowing Obvious change in size, color, shape, or thickness of a wart, mole, or mouth sore Nagging cough or hoarseness

A college student who has type 1 diabetes normally walks each evening as part of an exercise regimen. The student now plans to take a swimming class every day at 1:PM

Check BG before, during, and after swimming This new exercise will affect BG, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. (Check DBGM before, during and after)

Development of Cancer: Initiation - Carcinogens

Chemical - Many chemicals have been identified as carcinogens - Long latency period makes identification of carcinogens difficult - Certain medications have been identified as carcinogens Radiation - Damage to DNA - Leukemia, lymphoma, thyroid cancer -> increase after atomic bomb @ Hiroshima - Bone cancer -> radiologists - Ultraviolet radiation is associated with melanoma, squamous cell & basal cell carcinoma Viral - Certain viruses are oncogenic - after DNA - Eptein-Barr Virus -> Burkitt's lymphoma; HIV -> Kaposi sarcoma: Hep B -> Hepatocellular (liver) carcinoma; HPV -> cervical & anal cancer

Radiology Imaging Tests: Respiratory

Chest X-rays (CXR) - Used to screen, diagnose, and evaluate changes & treatments - Views: Posterior, Anterior, & Lateral (ordered PAL) - Can be done portable at bedside - Prep: undress to waist, put on gown, and remove any metal/jewelry Order Examples: STAT portable CXR! CXR: PAL Computed tomography (CT) - Prep same as CXR If contrast (dye) used - Assess for allergies (iodide/seafood) & check renal function (BUN/Cr) - Encourage fluids before/after Magnetic Resonance Imaging (MRI) Screening checklist: - Check implanted metal & remove ALL metal (body piercings) - Check history of claustrophobia - May use non-iodine based contrast - Prep: same as for CXR/CT Position emission tomography (PET) - Uses IV radioisotope to distinguish between malignant or benign nodules. Encourage fluids Pulmonary Angiogram - Used to visualize pulmonary circulation & locate obstructions Contrast dye injected via arterial catheter - Assess contract & iodine allergies - Refer to pre/post PAD arteriography notes for nursing care! Nuclear Lung Scans Ventilation & Perfusion (VQ) Scan - Used to id areas receiving good airflow (ventilation) with poor blood flow (perfusion) = mismatches - Uses IV injection of radioisotope & inhalation of radioactive gas - Prep: same as CXR - No precautions needed afterward due to short half-life

You are monitoring a 53 year-old patient during a treadmill stress test. Which finding will require the most immediate action? a. Blood pressure of 152/88 mmHg b. Chest pain rated as a "2" on a 0-10 scale c. Sinus tachycardia at 134 beats/minute d. Oxygen saturation of 91%

Chest pain rated as a "2" on a 0-10 scale

Gallbladder disease

Cholelithiasis - Most common disorder of biliary system - Stones in gallbladder Cholecystitis - Inflammation of gallbladder - Usually associated with cholelithiasis Risk factors - Female - Multiparity (having 2 or more children) - Age older than 40 years - Estrogen therapy - Sedentary lifestyle - Genetics/ethnicity - Obesity

Cholelithiasis vs. cholecytitis

Cholelithiasis - Develops when balance that keeps cholesterol, bile salts, and calcium in solution is altered, leading to precipitation - Bile secreted by liver supersaturated with cholesterol (lithogenic) - Stasis of bile → supersaturation and changes in composition of bile (biliary sludge) -Immobility, pregnancy, and inflammatory or obstructive lesions of biliary system ↓ bile flow Cholecystitis - Stones may remain in gallbladder or may migrate to cystic or common bile duct Cause pain as they pass through ducts - May lodge in ducts and produce an obstruction - Most commonly associated with obstruction from stones or sludge Acalculous cholecystitis - Older adults and critically ill - Prolonged immobility, fasting, prolonged parenteral nutrition, diabetes - Bacteria or chemical irritants - Adhesions, neoplasms, anesthesia, opioids

Clinical Manifestations: Huntington's

Chorea - abnormal & excessive involuntary movements - Twisting, squirming of face, body and limbs - Affects speech, chewing & swallowing - Gait deteriorates - eventual loss of ambulation - Loss of muscle control - Impairment of bowel & bladder Cognitive deterioration - Decrease perception, memory, attention & learning - Depression common, irritability, anxiety, agitation, obsessiveness, social withdrawal

Rheumatoid Arthritis (RA)

Chronic systemic autoimmune disease - Involves connective tissue of the synovial joints - Exacerbations/ remissions - Extra-articular manifestations common Incidence increases with age - Age of onset: young to middle age (age 30-50) - 1.5 million Americans - 3X greater incidence in females No known specific cause(s) Autoimmune etiology - Combo of genetic & environmental triggers - Antigens trigger an abnormal IgG - Antibodies develop against IgG - Known as Rheumatoid Factor

Multiple Sclerosis

Chronic, progressive, degenerative disorder of CNS - Chronic inflammation, demyelination & scarring of nerve fibers in brain and spinal cord = slowing of nerve impulses Incidence - Onset 20-50y/o - Woman > men (2-3x) - Temperate climates (45-65degrees) - Northern US, Canada, Europe - Family history Cause unknown - Infectious (viral), immunologic and genetic factors - Precipitating factors: infection, physical injury, emotional stress, excessive fatigue, pregnancy, poorer health state

Categories of Seizures

Classes Generalized Involve both sides of the brain Usually loss of consciousness Partial Involve one area of the brain Can potentially spread to other side of brain Phases Prodromal phase: signs or activity that proceeds a seizure Aural phase: sensory warning proceeding a seizure Ictal phase: full seizure Postictal phase: recovery after the seizure

Neutropenia - Clinical Manifestations

Classic signs of infection are impaired - Redness, heat, and swelling may not occur - Pus formation (skin lesion or infiltrates on CXR may be absent) Presence of low-grade fever in neutropenic patients usually indicated significant infection - Fever of > 100.4 with ANC of < 500 is a medical emergency - Sore throat, ulcerative lesions of pharyngeal & buccal mucosa, diarrhea, rectal tenderness, vaginal itching or discharge, SOB, nonproductive cough

Valvular Heart Disease

Classification Development: - Congenital: genetic - Acquired: rheumatic, degenerative, infection (endocarditis) Location (i.e. valve): Aortic, Pulmonic, Mitral, Tricuspid Type of Problem Stenosis - Constriction or narrowing Regurgitation (aka Insufficient or Incompetent) - Incomplete closure of valve results backflow Mitral Prolapse: Valve leaflets buckle back LA during systole. - Most common valvular condition in the US.

Classification of Cancer

Classification systems provide a standardized way to - Communicate with health care team - Prepare and evaluate treatment plan - Determine prognosis - Compare groups statistically Tumors can be classified by - Anatomic site - Histology (grading severity) - Extent of disease (staging) Grading Severity: Four Grades of Abnormal Cells Grade 1 - Cells differ slightly from normal cells & well differentiated Grade II - Cells are more abnormal & moderately differentiated Grade III - Cells are very abnormal & poorly differentiated Grade IV - cells are immature, primitive, & undifferentiated - cell of origin is difficult to determine Staging extent (& spread) or disease - 0: Carcinoma (cancer) in situ (group of abnormal cells, sometimes known as pre-cancer. "In-situ" latin for 'in it's place) 1: Tumor limited to tissue of origin; localized tumor growth 2: Limited local spread 3: Extensive local and regional spread 4: Metastasis TNM System Anatomic extent of disease is based on 3 parameters: - Tumor size and invasiveness (T) - Spread to lymph nodes (N) - Metastasis (M)

Gastritis: Clinical Manifestations & Diagnosis

Clinical Manifestation - Anorexia - N/V - Epigastric tenderness - Feeling of fullness - Hemorrhage (more common w/ ETOH abuse) In chronic gastritis, loss of intrinsic factor in gastric wall: - Intrinsic factor necessary for: absorbing vitamin B - Results in: vitamin B deficiency Diagnosis - Patient hx of drug/alcohol use - Endoscopy

Lung Cancer: S/Sx

Clinical Manifestations - Will depend on type of cancer, location and metastatic spread Often silent, nonspecific, or appear late in disease: Persistent productive cough -> most common sign! - Hemoptysis (coughing up blood) - Dyspnea with wheezes - Chest pain Persistent respiratory infections: despite treatment! - Pneumonia - Acute bronchitis Late signs: A/N/V, wt. loss, fatigue, hoarseness, dysphagia

Types of Amputations

Closed - Creates a wt. Bearing stump (i.e. residual limb) - Muscle - skin flap used to cover bone - Suture line posterior not over wt. Bearing area Open - To allow for infected drainage Wound is closed later Disarticulation - Performed thorough joint

O2 Safety & 4 Complications

Combustion Risk! - No smoking! - No open flames Avoid use of - Flammable liquids: gas, kerosene & aerosol sprays Infection Risk - increase with humidification - change equipment prn watch skin intactness - check ears/nose & pad prn - provide oral care prn CO2 Narcosis - COPD pts brain lose their sensitivity to increased CO2 - Hypoxia (low O2) triggers their respirations Use lowest amounts O2 - NOTE: End-stage COPD may need high amounts O2! VENTI masks preferred O2 Toxicity - Results form prolonged use of high dose O2 - Watch is greater or equal to 50% x 24 hours - May lead to ARDS r/t inactive surfactant

Diagnostic Studies of the Hematologic System - Labs

Complete Blood Count* Red blood cells 4.2-5.4/4.6-6.2x10^6/uL (F/M) - Hgb 12-16/14-18g/dL (F/M) - transfuse is <8 - Hct 37-47%/42-52% (F/M) White blood cells 4,000-11,000/uL (4.8-10.8) - Differential Platelet count 150,000-400,000/uL - Blood typing and Rh factor Serum Iron (42-135mcg/dL) - Measures protein-bound iron in blood stream Reticulocyte count 0.5%-1.5% of RBC count - Immature RBCs; reflection of bone marrow activity in producing RBCs Peripheral blood smear - Morphology - looks at shape & size of blood cells to help make diagnosis Erythrocyte sedimentation rate (ESR) <30mm/hr - Indicates inflammatory response if elevated

Complications & Diagnostics: Esophageal Cancer

Complications - Hemorrhage - if tumor erodes esophagus and into aorta - Esophageal perforation with fistula formation into lung or trachea - Esophageal obstruction - Metastasis to liver and lung through lymph system Diagnostics - Endoscopy biopsy - Barium swallow - CT, MRI

Anemia - Causes

Consequence of other diseases/disorders of other systems - Etiologic - underlying cause - Considered a conduction, not a disease process Primary hematologic problem - Morphologic - RBC characteristic changes Decreased RBC Production Dec. Hgb Synthesis - Iron deficiency - Thalassemia Defective DNA Synthesis - Cobalamin (Bit B12 deficiency) - Folic acid deficiency Dec. #RBC precursors - Aplastic anemia - Anemia of myeloproliferative diseases (leukemia) % myelodysplasia - Medications (chemo) Blood Loss Acute - Trauma, blood vessel rupture Chronic - Gastritis, menstrual flow, hemorrhoids Inc. RBC Destruction (Hemolytic) Intrinsic - Abnl Hgb (Sickle cell anemia) Extrinsic - Physical trauma (prosthetic heart valves): Antibodies (autoimmune): infectious agents/toxins

Hiatal Hernia: Management

Conservative - Same as with GERD (Wt. control, No alcohol, no tobacco, elevate HOB, PPIs, H 2 receptor blockers, antacids); avoid heavy lifting and straining Surgery - Herniotomy - excision of the hernia sac Herniorrhaphy - closure of the hernia defect - Pushing herniated stomach back into the abdomen, then tighten hiatus - Gastropexy - attachment of the stomach to the underside of the diaphragm to prevent reherniation - Anti-reflux procedures (Nissen & Toupet)

PUD: Management

Conservative therapy - Adequate rest, cessation of smoking, avoid ETOH/spicy foods/black pepper/acidic foods, PPIs, H2 receptor blockers, antibiotics for H. pylori, antacids, cytoprotective drug therapy (Carafate), stress management, discontinue NSAIDS &amp; ASA if possible, use enteric coated aspirin if needed When acute exacerbations occur - NPO, NG suction, IVF replacement When complications occur - Above + blood transfusions prn, cool saline gastric lavage, LR/albumin if needed, broad spectrum antibiotics - Perf: surgical repair w/ omentum graft - Outlet obstruction: endo balloon dilation, scar tissue removal - Hemorrhage: cauterization

Review of Systems: Preoperative Care

Consider risk for complications during or after surgery based on other medical problems - Cardiovascular (what meds are they on?) - Respiratory (COPD? Sleep apnea? Pneumonia?) - Neurological (can stay in a confused state from anesthesia/pain meds) - Renal (pt. have a hard time urinating, anesthesia can effect that) - Hepatic (decreased hepatic function causes body to hold onto meds longer) - Endocrine (diabetes impairs would healing) - Integumentary (if they have history of pressure ulcers think of positioning) - Musculoskeletal (do they have any barriers for positioning) - Immunological (are they at a higher risk for infection) - Fluid & Electrolyte Status - Nutritional Status

prednisolone

Corticosteroid for IBD helps achieve remission

Cancer Treatment: Goals

Cure - For cancers that are fully treatable - Goal is to cure Control - for cancers that cannot be fully eradicated - treated like a chronic disease - goal is to manage Palliation - for cancers that have not responded to treatment - goal is control of symptoms & qualiy of life

5. You have been assigned to develop a teaching plan for a client being discharged after a laparoscopic procedure for gallbladder removal. What is your priority intervention? A. Assess the home environment for specialized equipment needs. B. Determine when the client plans to return to work. C. Determine who will be at home with the client after discharge. D. Assess the client's usual lifestyle and daily activities.

D Knowing the lifestyle and usual daily activity can assist with determining the impact of changes on this activity and the emphasis on the teaching plan. (A) This procedure is not considered a major surgical intervention. Most of the listed procedures are done on an outpatient basis; therefore, the home environment would not be evaluated. There is no need for specialized equipment. (B) All clients having outpatient or short-stay surgery must have someone take them home because of the anesthesia. It is not important to determine who will be staying at home with the client or when they return to work (C). The physician will give the client directions on the return-to-work date.

Data for which one of the personal characteristics below are least necessary to obtain when planning for client teaching? A. Educational level B. Family composition and living situations C. Ethnic group D. Employment/occupation

D The first three distractors are essential to determine an appropriate educational plan. (A) The educational level determines the level and scope of information that can be presented. (B) Family members should be included in the educational plan. (C) Ethnic and cultural issues need to be taken into account, especially when discussing items such as dietary alterations. The actual employment or occupation in most cases is not necessary in developing the teaching plan.

6. You are developing the strategy for an initial teaching plan for a 24-year-old client admitted with newly diagnosed acute leukemia. Which factor is least important as you develop the initial teaching plan? A. Attention span and retention ability B. Reading level C. Input from client on how he or she learns best D. Support for client at home

D The initial teaching plan will support the client in respect to the diagnosis, treatment, medications, and expected outcomes. Teaching is a major part of this initial plan. Of course, determining the support system at home will become more essential as the teaching continues and discharge planning is discussed. (A), (B), and (C) are essential components for the teaching plan and will be integrated within the plan.

A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80-42 mmHg, and is complaining of feeling faint. Which actions should the nurse take next A) Recheck the heart rhythm and BP in 15 minutes B) Have the patient perform the Valsalva maneuver C) Attach the automatic external defibrillator (AED) D) Apply the transcutaneous pacemaker (TCP) pads

D) Apply the transcutaneous pacemaker (TCP) pads

Iron Deficiency Anemia - Diagnostic Studies

Laboratory findings - Hgb, Hct, TIBC - Serum iron - Stool guaiac test - Endoscopy - Colonoscopy - Bone marrow biopsy

Labs: Hypovolemia

Labs - Increased urine specific gravity (nm. 1.010-1.025) - Increased Na - Increased BUN - Increased Hct (hemoconcentration) - Respiratory Alkalosis (increased pH, decreased CO2)

Post Op care:

Laparoscopic cholecystectomy - Monitor for complications Patient comfort - Referred pain to shoulder pain from CO2 - Sims' position - Deep breathing, ambulation, analgesia - Clear liquids - Discharged same day - Liquids first day, light meals for several days Incisional cholecystectomy - Maintain adequate ventilation - Prevent respiratory complications - General postoperative nursing care - Maintain drainage tubes (T-tube, Penrose tube, or Jackson-Pratt tube), if present - Replace fluids and electrolytes - Liquids to regular diet after return of bowel sounds - May need to restrict fats for 4-6 weeks

Lung Cancer

Leading cause cancer death in U.S (28%) - More deaths than breast, colon, and prostate CA combined! - Estimated 221,000 new cases/158,000 deaths per year Causes Cigarette smoking: 80-90% cases 60 carcinogens in cigarettes! Side-stream smoke exposure: - Nonsmokers exposed to passive smoke increase risk 35% Environmental Exposure - Radon - Asbestos - Industrial/Occupational: ex: radiation, coal dust - Pollution

Neutropenia

Leukopenia - Decrease in total WBC count - (granulocytes, monocytes, lymphocytes) Granulocytopenia - Decrease in granulocytes - (neutrophils, eosinophils, basophils) Neutropenia - Decrease in neutrophils Absolute neutrophil count (ANC) - Total WBC x percentage of neutrophils = ANC - Normal is > 1,500 cells/ul - 1,000 - 1,500 = mild neutropenia, 500-1000 = moderate; < 500 = severe

Complication: Addisonian Crisis

Life threatening emergency caused by insufficient amts. or a sudden, sharp ↓ in adrenal hormones Triggers - Surgery/Injury: adrenal or pituitary gland - Stress (surgery, trauma, infection, emotional) - Sudden stopping meds: corticosteroid meds S/sx Severe Addison's Symptoms/Signs - Severe N/V/D, Abd pain, dehydration, confusion, fever, hypotension - decreased Na & BG, ↑ K - Hypotensive Shock Treatment: high dose hydrocortisone &amp; IV fluids

GERD: Management

Lifestyle modification Foods to avoid - Alcohol, Chocolate, fatty foods, coffee, tea, tomatoes, peppermint - Small frequent meals - Fluids between meals, not with meals - Avoid late night eating - Do not lay down for 2-3 hrs. after eating - HOB slightly elevated - Avoid carbonated beverages & straws - Gum & hard candies increase saliva production decrease symptoms - Stress reduction - Smoking cessation - Heartburn can be relieved with calcium, antacids, water

The nurse is teaching a women's group about prevention of hypertension. What information should be included in the teaching for all the women (select all that apply.)? Lose weight. Limit nuts and seeds. Limit sodium and fat intake. Increase fruits and vegetables. Exercise 30 minutes most days.

Limit sodium and fat intake, Increase fruits and vegetables, Exercise 30 minutes most days. Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in BP. Along with exercise for 30 minutes on most days, the DASH eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. Nuts and seeds and dried beans are used for protein intake. Weight loss may or may not be necessary for the individual.

Toujeo

Long Acting Insulin Onset: 0.8-4 hours - **Peak: less defined or NO peak - Administered once or twice a day. Do not mix with other insulin products - Duration: 24+ hours

degludec (Tresiba)

Long Acting Insulin - Onset: 0.8-4 hours - **Peak: less defined or NO peak - Administered once or twice a day. Do not mix with other insulin products - Duration: 24+ hours

Clinical Manifestations: Pyelonephritis

Lower UTI symptoms - Dysuria, urgency, frequency - Mild fatigue - Chills ** - Fever (>102)** - Vomiting - Malaise - Flank pain (affected side) ** - Costovertebral tenderness on affected side ** - *Risk for urosepsis

Donepezil (Aricept)

Decreased Memory & Cognition Cholinesterase inhibitors Alzheimers

Medication Therapy: Alzheimers

Decreased Memory & Cognition Cholinesterase inhibitors - Donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne) N-menthyl-D-aspirate (NMDA) receptor antagonist - Memantine (Namenda) Depression - SSRIs (Zoloft, Celexa, Prozac) - Tricyclic antidepressants (Elavil, Pamelor) Behavioral Problems Antipsychotics - Haldol, Risperdal, Zyprexa, Seoquel, Abilify Benzodiazepines - Ativan, Restoril Sleep Disturbances - Zolpidem (Ambien)

DI Patho Map

Decreased anti-diuretic hormone -> decreased water reabsorption in renal tubules -> decreased intravascular fluid volume -> increased serum osmolality (hypernatremia) & excessive urine output

Nursing Diagnoses for Upper GI Problems

Deficient fluid volume r/t - Prolonged vomiting - Insufficient intake secondary to anorexia - Fluid loss from NG suction - Acute loss of blood &amp; gastric secretions Imbalanced nutrition: less than body requirements r/t - N/V - Prolonged NPO status secondary to gastric surgery, PUD - Oral pain, difficulty chewing &amp; swallowing - Surgical removal of stomach - Inability to ingest, digest or absorb nutrients More Nursing Diagnoses Nausea r/t - Delayed gastric emptying - Side effect of chemo Ineffective coping r/t - Body image change - Situational crisis & personal vulnerability Ineffective health maintenance r/t - Lack of knowledge of disease process - Lack of knowledge of therapeutic regimen &amp; unavailability of support system Risk for aspiration r/t - Impaired esophageal function - N/V

Electrical Tx: 3: Pacemakers

Definition - a pulse generator used to pace the heart when the normal conduction pathway is damaged Indications: - Symptomatic bradycardia & 3rd degree heart block - Prophylactic: before, during & after heart surgery & procedures Types of Pacemakers Temporary: requires external generator - Transcutaneous: used as bridge to permanent - Epicardial: used during/after heart surgeries Permanent (aka implanted): uses internal (implanted) generator and lead wires

Asthma

Definition: Chromic inflammatory lung disorder that results in variable airflow obstruction due to bronchoconstriction, hyperactivity, and edema. It's usually reversible Affects 18.8 million Americans - Women 62% more likely than men More recent increases in cases has started to decline - However, 3,300 people still die each year Risk Factors 1. Genetic - Inherited IgE mediated allergic response to common allergies 2. Environmental (risk factors and triggers Allergens - Animal dander - Dust mites - Pollens/Mold/Fungi Air pollutants - I.e. Cigarette/wood smoke, vehicle exhaust - OXONE ALERT! = susceptible persons should minimize outdoor activities - Exercise induced (esp. cold, dry air) - Occupational exposures: hospital workers, agriculture, plastics, beauticians - Respiratory infections: viral - Nose & sinus problems - Food additives: MSG, sulfites Drugs: salicylates, NSAIDS, some b-blockers - GERD - Emotional stress

Electrical Tx: 2: Cardioversion

Definition: using a synchronized mode in the defibrillator, a shock is delivered during a specific part of the cardiac cycle (on R wave) Emergent or non-emergent Indications Used for certain unstable rhythms - Supraventricular Tachycardia (SVT) with a pulse - Used for new onset Atrial Fibrillation or Atrial Flutter

The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of 58-yr-old obese female patient admitted with heart failure. Which action by the UAP will require the nurse to intervene? Waiting 2 minutes after position changes to take orthostatic pressures Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg per second Taking the blood pressure with the patient's arm at the level of the heart Taking a forearm blood pressure because the largest cuff will not fit the patient's upper arm

Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg per second The cuff should be deflated at a rate of 2 to 3 mm Hg per second. The arm should be supported at the level of the heart for accurate blood pressure measurements. Using a cuff that is too small causes a falsely high reading and too large causes a falsely low reading. If the maximum size blood pressure cuff does not fit the upper arm, the forearm may be used. Orthostatic blood pressures should be taken within 1 to 2 minutes of repositioning the patient.

Evaluation of O2 Therapy

Desired goals/outcomes - Pulse oximeter O2 sats > 90% on RA Normal ABG's - PO2 within normal limits (WNL) on room air (RA) - Subjective reports of improved breathing - Ability to complete ADLs

Nursing Considerations: Epilepsy

Detailed assessment of observed seizures - When did it occur? - How long each phase (aural, ictal, postictal) - What occurred? - Which body part affected first and how? - Symptoms: loss of consciousness, tongue biting, stiffening, jerking, lack of muscle tone? Autonomic symptoms? (dilated pupils, salivation, altered breathing, cyanosis, diaphoresis, incontinence)? - Postictal assessment: memory loss, VS, position of eyes, muscle soreness, speech changes, weakness or paralysis, sleep period Safety Precautions ** - Maintain patent airway - East pt to floor if standing or sitting - Protect head from injury, but do not hold - Do NOT place objects in pt mouth ** - Seizure pads and full side rails - After seizure: turn to side, oxygen, suctioning prn, low stimuli environment - Teaching needs

BPH: Diagnostics

Diagnostic studies - H&P - symptoms - DRE - UA with C&S - PSA - Serum creatinine - Transrectal ultrasound (TRUS)** - Uroflowmetry

Oral Cancer: Dx. & Management

Diagnostics - Cytology - scraping the suspicious lesion -> microscopic examination - CT, MRI, &amp; PET - useful for staging Management Surgery - Partial mandibulectomy (removal of the mandible) - Hemiglossectomy (removal of half of the tongue) - Glossectomy (removal of the tongue) - Resection of the buccal mucosa & floor of the mouth - Radical neck dissection, often with tracheostomy - Radiation - Chemo - Palliative care

Patient/Caregiver Teaching: HF

Diet Therapy : ↓Na & Fluids o Registered Dietician (RD) Referral o Increase awareness of sodium in prepared foods o Watch OTC meds - many contain sodium Daily wts.: every morning using same scale Health Promotion - Yearly Flu shots - Pneumonia vaccine - Individual focused risk factor plan Medications o Radial pulse/BP checks prn o Desired effects & medication side effects (SE's) to report o Orthostatic hypotension precautions S/sx to Report to medical providers - Worsening heart failure (signs and symptoms) Use of FACES: acronym - Fatigue - Activity limitations - Cough/congestion - Edema - Shortness of breath Sudden wt. gains - 3 lbs. /2 days - 3 - 5 lbs. /week - Pulmonary Edema - Drug SE's

Forces that Influence Fluid & Electrolyte (Between ICF & ECF)

Diffusion - Passive movement of molecules from an area of high concentration to one of low concentration Facilitated Diffusion - Passive movement of molecules from to one of low concentration that is facilitated by bonding with a carrier molecule Active Transport Molecules move against the concentration gradient - Requires Energy (i.e ATP) - Example: Sodium-Potassium Pump (found in kidneys) Osmosis - Movement of water across a semipermeable membrane from an area of low solute concentration to an area of high solute concentration

Nitroglycerin (Tridil)

Direct Vasodilator

Discharge Planning

Discharge planning is defined as the systematic process of planning for client care after discharge from the hospital. GOAL: To meet client needs thorough continuity of care from acute setting to discharge facility

Drug Therapies: RA

Disease modifying antirheumatic drugs (DMARDS) - Methotrexate (Rheumatrex) - most commonly used - Sulfasalazine (Azulfidine) - Leflunomide (Arava) Monitor for bone marrow suppression and hepatotoxicity (CBC & liver enzymes checks) Teratogenic (Arava) so prevent contraception Janus Kinase Inhibitor: Decrease cellular inflammation response - Tofacitinib (Xeljanz) Monitor for opportunistic infections Biologic Response Modifiers: inhibit inflammation and slow disease Tumor Necrosis Factor Inhibitors - etancercept (Enbrel) - adalimumab (Humira) - Infliximab (Remicade) Used for mod/severe RA pts who did not respond to DMARDS. May be used with DMARD's Drug Alerts - Monitor for signs of infection - Watch for heart failure (Enbrel) - Give PPD test/CXR before starting - Avoid live vaccinations NSAIDS - Ibuprofen (Motrin) - COX-2 inhibitors (Celebrex) - NOTE: Increased risk SE in elderly especially GI bleeds & renal toxicity as well as drug interactions - Watch for GI bleeding Corticosteroids - PO or IA for short-term use

Sulfasalazine (Azulfidine)

Disease modifying antirheumatic drugs (DMARDS) Monitor for bone marrow suppression and hepatotoxicity (CBC & liver enzymes checks) RA

Leflunomide (Arava)

Disease modifying antirheumatic drugs (DMARDS) Monitor for bone marrow suppression and hepatotoxicity (CBC & liver enzymes checks) Teratogenic (Arava) so prevent contraception RA

Cognitive Behavioral Tx

Distraction Breathing Exercises - Lamaze Audio/Visual - TV/Video/Computer Relaxation - Rhythmic breathing - Progressive muscle relaxation - Guided imagery - Meditation - Art Therapy - Music Therapy - Pet/Animal Therapy

Classification of Arrhythmias

Disturbances in impulse formation SA (sinoatrial) node fails to function normally or falls completely - Other "alternate" pacemakers take over - Other ectopic sites may develop in atria or ventricles or both Disturbances of Conduction - Occurs when the impulse is either delayed or blocked at any point in the conduction system MONITORING CARDIAC RHYTHMS - 12 Lead electrocardiogram - ECG Continuous heart Monitoring: Telemetry - Used for ongoing monitoring, early detection, evaluation of tx, & EMR documentation - Alarms alert provider when disorders in rate/rhythm occur!

Nursing Diagnoses: Amputations

Disturbed Body Image - Especially for trauma victims - PTSD - Be aware of anticipatory/actual grieving - Impaired Skin Integrity - Impaired Physical Mobility - Risk for Chronic Pain r/t phantom limb pain/sensation or residual limb pain

Bumetanide (Bumex)

Diuretic (Loop)

A patient with a history of chronic hypertension is being evaluated in the emergency department for a blood pressure of 200/140 mm Hg. Which patient assessment question is the priority? Is the patient pregnant? Does the patient need to urinate? Does the patient have a headache or confusion? Is the patient taking antiseizure medications as prescribed?

Does the patient have a headache or confusion? The nurse's priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy from increased cerebral capillary permeability leading to cerebral edema. In addition, headache or confusion could represent signs and symptoms of a hemorrhagic stroke. Pregnancy can lead to secondary hypertension. Needing to urinate and taking antiseizure medication do not support a hypertensive emergency.

Discharge needs for patient with hip fracture

Don't drive while on opioids, wear support stocking for 24 hours a day for 3-4 weeks, move carefully, if she received an artificial hip joint they need to tell their dentist, wash hands often to prevent infection of incision, check daily for soreness, drainage, don't soak wound, use chairs with arms, don't cross legs, keep feet flat on floor, remove electrical cords, throw rugs, any fall risks, non-slip bath mats, health insurance, family support, cellphone/lifealert, elevated toilet needs, walker Assessment - Physical - Social - Financial - Home environment - Referrals: OT/PT

PUD: Surgical Management

Done only when complications occur and are unresponsive to medical management/concern of stomach cancer Partial gastrectomy - removal of portion of stomach Gastroduodenostomy/Billroth I - Removal of distal 2/3 of stomach and reconnection of remaining stomach with duodenum Gastrojejunostomy/Billroth II - As above, reconnection with jejunum Vasotomy - Severing of vagus nerve to decrease gastric acid secretion Pyloroplasty - Surgical enlargement of pyloric sphincter to facilitate passage of contents from stomach

Management: Epilepsy

Drug therapy - Antiseizure medications are primary treatment - Stabilize nerve cell membranes to prevent spread of epileptic discharge - Therapeutic drug ranges Examples: (don't need to know specific drug names) - phenytoin (Dilantin), carbamazepine (Tegretol) **No grapefruit juice, phenobarbital, divalproex (Depakote), clonazepam (Klonopin), gabapentin (Neurontin), lamotrigine (Lamictal), topiramate (Topamax), levitiracetam (Keppra) - Lyrica (pregabalin) - "add on" when seizures not controlled with another med alone - Status epilepticus - IV administration of lorazepam (Ativan) and diazepam (Valium) - No grapefruit with Tegretol ** - All antiseizure meds must be weaned slowly; abruptly stopping can result in seizures Side effects - Reason for noncompliance - Diplopia (double vision) - Drowsiness - Ataxia/decreased coordination and balance - Mental slowing - Rashes, hyperplasia of gingiva, issues with bone marrow, kidneys, liver Surgical Therapy - Remove epileptic focus in brain - Used when medications are not effective Vagal Nerve Stimulation -Adjunct to meds when surgery not feasible - Electrode implanted in neck -> delivery electrical impulses to the vagus nerve to prevent seizures by stopping excessive discharge of neurons - Magnet to activate Ketogenic diet - Children with epilepsy - 4:1 diet of fat:carbs

Drug Therapy: Hypertension

Drugs currently available for treating hypertension work by (1) decreasing the volume of circulating blood and/or (2) reducing SVR. ♣ Diuretics promote sodium and water excretion, reduce plasma volume, and reduce the vascular response to catecholamines. ♣ Adrenergic-inhibiting agents act by diminishing the SNS effects that increase BP. Adrenergic inhibitors include drugs that act centrally on the vasomotor center and peripherally to inhibit norepinephrine release or to block the adrenergic receptors on blood vessels. ♣ Direct vasodilators decrease the BP by relaxing vascular smooth muscle and reducing SVR. ♣ Calcium channel blockers increase sodium excretion and cause arteriolar vasodilation by preventing the movement of extracellular calcium into cells. ♣ Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II and reduce angiotensin II (A-II)-mediated vasoconstriction and sodium and water retention. ♣ A-II receptor blockers (ARBs) prevent angiotensin II from binding to its receptors in the walls of the blood vessels. • Most patients who are hypertensive will require two or more antihypertensive drugs to achieve their BP goals. • Side effects and adverse effects of antihypertensive drugs may be so severe or undesirable that the patient does not comply with therapy. Patient and caregiver teaching related to drug therapy is needed to identify and minimize side effects and to cope with therapeutic effects. • Resistant hypertension is the failure to reach goal BP in patients who are adhering to full doses of an appropriate three-drug therapy regimen that includes a diuretic.

PUD: Post-op Complications

Dumping Syndrome - Normally gastric chyme enters SI in small amts - Following removal of portion of stomach, large boluses of hyperosmolar chyme enter SI, drawing fluid into the bowel lumen - Dec. plasma volume, distention of the intestine and rapid movement of food through intestine results Symptoms: - Within 15-30 min after eating... - Weakness, sweating, palpitations, tachycardia, dizziness (d/t plasma volume) - Abdominal cramps, audible bowel sounds, urge to defecate - Last 1 hr, then resolve Dumping Syndrome causes Postprandial Hypoglycemia - Bolus of fluid high in carbs dumps into SI -> hyperglycemia -> excessive insulin released -> hypoglycemia results - Sweating, weakness, mental confusion, palpitations, tachycardia, anxiety - Occurs 2 hrs after eating Management (of Dumping Syndrome and PP Hypoglycemia) - Fluids between meals, not with meals - Small meals (reduced size of stomach) multiple times a day (6) - Dry foods, low carbs, moderate protein and fat - Eat partially reclined, legs up if possible - Rest after each meal - Symptoms generally resolve after several months -1yr following surgery Post-Op Care - NG to suction - Irrigations - Assess for distention - Splinting during C/DB - Monitor electrolytes, K &amp; replace prn - IVF - Pernicious anemia

Patient Teaching: Chemotherapy

During & for 48 hours after chemo: - Men & women sit to use bathroom (decrease splashing) - Close toilet lid first, then double flush - Wash hands well after BR use - If emesis occurs in toilet - flush twice; in bucket - dump in toilet, flush twice, wash bucket well - CG to wear gloves when handeling anything with body fluids - Do not kiss, share cups/utensils/food for 48 hours - Wash dishes, cups, utensils twice - Any clothing/bedding with body fluids - wash twice, hot, seperate from other clothes - Depends - double bag; skin protectant - Use condom for all intercourse for 2 weeks (chemo in semen & vaginal secretions)

Stomach Cancer: Diagnosis & Management

Dx. Endoscopy - upper GI with biopsy - Stomach can be distended with air so that mucosal folds are stretched out - CT, PET, endo ultrasound for staging - CBC to dx anemia, liver enzymes &amp; amylase to check for liver & pancreatic involvement - Stool for occult blood Management - Surgical procedures and complications same as PUD - Total gastrectomy - esophagus directly to jejunum - Radiation, Chemo

Prevention for DVT/VTE

Early aggressive mobilization - Walking: start early postop: 4-6x per day - Avoidance of crossing legs and prolonged sitting - Up in chair for meals - Leg exercises:Q 2-4 hours, exercise increases venous blood flow Sequential Compression Devices (SCD's) - Need to also be fitted properly & worn! Device turned on - They compress, starting at the bottom then moving upwards. Pushes down on the muscles/tissues to help manually move blood through the legs to the heart. Prevents venous stasis. Use of anti-embolitic stockings (TEDS)- - might see some continued use despite new evidence - Evidence is suggesting not effective - Provide proper hydration - Smoking cessation - Medications - Provide patient/caregiver education

PAD: Risk Factor Modification

Education and referrals tailored to patient's needs - Tobacco cessation Exercise Therapy - Walking for 30-45 min at least 3 days/week - Walk until painful, rest, walk some more Nutrition - DASH - decrease in sat fat & Na+ - Diabetic considerations Protective foot care - Leather shoes - No open toes/heels - Don't go barefoot - Daily inspections - Avoid restrictive circulation - Nail care - Podiatrist referrals PRN

Nursing Role Responsibility: Preoperative Care

Establish baseline data & risk factors for complications - Physical assessment - PMH & ROS - Medication review & allergies - Review labs & diagnostic tests - ID cultural & ethnic factors Determine pt. has received adequate info (patient teaching) - Informed consent - Discharge teaching starts during first patient encounter (On admission or sooner if surgery is planned in advance) Patient Teaching - Anticipatory Guidance - CDB (cough deep breathing) - Early ambulation - IS (incentive spirometer) - Compression Stockings/SCDs - Drains, central lines, monitors - PCA/Plan for pain management - Dressings - Preop shower - Bowel prep - NPO

Evaluation: Pain Tx

Evaluate at regular intervals & after each intervention - Assess at least Q 4 hours - Use both quantitative & qualitative measures MEDS: Document Effectiveness! - At appropriate times - Chart using Numeric Pain Scale/Nonverbal scales - Monitor SE's - Preventative measures: Constipation - Revise care plans prn - Patient/Caregiver Teachinf

Adrenocortical: Hyperfunction: Cushing Syndrome

Excess corticosteroids - Especially glucocorticoids 4 Causes Prolonged use high dose exogenous corticosteroids - Example: Prednisone - Most common cause exogenous Cushing's Syndrome ** Adrenocorticotropic hormone (ACTH) secreting pituitary tumor - aka Cushing Disease - Causes 85% of cases endogenous Cushing Syndrome - Ectopic ACTH from tumors outside the pit. gland (often lung or pancreas) - Adrenal tumors: cortisol secreting tumors inside the adrenal cortex

Nursing Care: Addison's

Fluid Volume Deficit - Monitor mental/neuro's Assess for hypovolemia - Monitor BP/HR's! - Daily wt. - I&O - N/V/D - Administer IV fluids Monitor labs - replace electrolytes prn Knowledge Deficit - Also see teaching guide pg. 1179 - Med teaching SO/family Recognize need for ↑ glucocorticoids dosages during stressful situations • ex. ↑ 2-3x dose Cortisol - During illness, injury, surgery, excessive exercise, emotional crisis Emergency Kit: with hydrocortisone injection supplies - Teach IM injection technique - S/sx of over and under dosing of meds & crisis - Need for lifelong medication, medical care & medic alert ID

Isotonic Fluids

Fluids with the same osmolality as the cell interior/intravascular space; fluid stays in the intravascular space & expands the intravascular compartment (normal water balance, no change in cells) Ns/Normal Saline/0.9% NaCl (Sodium Chloride)*** - Used to treat extracellular (ECF) volume deficits & expand intravascular volume - Used to dilute medications - Only IVF that can be given with blood - Compatible with everything! - Contains Na & Cl LR (Lactated Ringer's) - Contains potassium, calcium, & NaCl (Similar to plasma, but no Mg)

Foot Care: Diabetes

Focus on self-care inspections & teaching Pt. Self-Care: Assessment & protection of skin integrity - Practice performing foot exam and providing related patient teaching • EBP: (evidence-based practice) Approximately 15% of persons with diabetes will develop a diabetic foot ulcer - Of these persons, 84% will develop minor or major lower extremity amputations - > 60% of non-traumatic amputations occur in persons with diabetes - Estimated 50% of amps could be prevented with better care &amp; education! Increased Costs associated with foot ulcers - 5.4 x higher in first year (2.8 x in second year) than for pt. without ulcer

metronidazole (Flagyl) or Vancomycin

For C-Diff

dexamethasone (Decadron) & trimethobenzamide (Tigan)

For nausea

Interprofessional Care: Outline: Diabetes

Four Cornerstones of Treatment 1. Nutritional Therapy 2. Exercise Therapy 3. Self-blood glucose monitoring (SBGM) 4. Drug Therapy - Oral agents - Insulin injections - Non-insulin injections Other meds; - Enteric-coated aspirin (ASA) daily - ACE's or ARB's for endothelial protection - Anti-hyperlipidimic agents Yearly Exams: Dilated eye & foot with treatment prn

Cancer Treatment: Chemotherapy

Goal: Eliminate or reduce # of malignant cells present in the primary tumor & metastatic tumor site(s) - Can offer cure, control, or palliative care Effects on Cells - Cell cycle phase-specific: Kills cells that are dividing cells -> cancer cells escape death by staying in G phase (resting phase) - Cell cycle phase nonspecific: kills cells in all phases of cell cycle - Problems: Presence of drug-resistant, non-cycling cells & mutation of cancer cells can result in resistance to chemotherapy - Multiple drugs that work in different places in the cell cycle can more effectively kill cancer cells Chemo Routes Systemic - IV (most common) Risk for infection, access issues, extravasation Implantable port, CVL, PICC - decrease risk of extravasation, PIV - Oral - IM Regional - directly to site of tumor - Higher concentrations with less systemic SEs - Intracavitary - ie. Intraperitoneal, intravesical - Intrathecal - into CNS via spinal fluid (lumbar puncture -> subarachnoid space) Chemo Precautions Chemo can be absorbed through skin & inhaled - Preparation considerations in pharmacy - under hood - Chemo excreted in body fluids of pt. (blood, urine, saliva, sweat) up to 48 hours after chemo is administered - Can cause changes in DNA, cause tissue death, after development of fetus - birth defects, cause other types of cancer Safe Handling - Chemo gloves, gown, pad, and facemask when hanging and disconnecting chemo - Chemotainer for disposal - Chemo linen bag

Medical Diagnoses: RA

H&P - Morning stiffness >1H - Symmetrical swelling - Swelling >3 joints - Hand swelling - Rheumatoid nodules X-Rays - Erosions - Effusions - Decalcifications - Often seen in hands Synovial Fluid Analysis - Straw colored with fibrin flecks - Increased WBCs (>20,000 with mostly neutrophils) Labs + Rheumatoid Factor (RF) - Found in 80% of pts - Rises with active (acute) inflammation - High assoc. with nodules Increased Erythrocyte Sedimentation rate (ESR) & C-reactive protein (CRP) - Indicate active inflammation - + Antinuclear antibody (ANA): increased in some RA patients - + Anti-cyclic citrullinated peptide (anti-CCP): early marker/+ in many pts

Diagnosing COPD

H&P - smoker history - Pulmonary Function Tests (spirometry) CXR - Flat diaphragm - Hyperinflation - DNA testing: a-antitrypsin levels Sputa Studies: prn to r/o infections - Gram stains - Culture & Sensitivity studies Exercise Testing - 6 minute walk: test to check for desaturation of oxygen - If <88% on RA qualifies for home oxygen O2 sats/ABG's Early Stages - Normal or slight decrease PaO2 & Normal PaCO2 Later Stages - decrease or low normal pH - low sats/PaO2 - increased PaCO2 - increase HCO3 Cardiac: test for HF (right sided seem with cor pulmonale) - 12 lead ECH - Echocardiogram/MUCA Scans

Nursing Considerations: Multiple Sclerosis

Help pt. Identify triggers & develop ways to minimize exposure - Infections (especially URI & UTI), trauma, stress, change in climate, delivery after pregnancy - Fall risk - Immobility during acute phases Bladder control - Incontinence management - Self catheterization for urinary retention - Management of constipation - National Multiple Sclerosis Society

Blood Studies: Respiratory

Hemoglobin (Hgb) - Measures amount of HGB available to combine with oxygen - Indirect measurement of RBC's (when RBCs go down, Hgb goes down - vise versa) - Increase with chronic hypoxemia Normal: Need to know! Male 14-18 Female 12-16 Hematocrit (Hct) - Ratio of RBC's to plasma Normal: Male: 42-52% Female: 37-47% NOTE: Venous blood used Arterial Blood Gases (ABG's) - Arterial sample put into a heparinized tube placed on ice - Apply 5 min pressure & watch for bleeding (monitor site of pts. receiving anticoagulants closely) (Note: Arterial blood used!) NORMAL VALUES: Need to Know! pH 7.35-7.45 P02 90-100mmHg PCO2 35-45 mmHg HCO3 22-26 mEq/L SaO2 > 95%

A patient's hemoglobin is 6.3 and her O2 sat on RA is 90%, but she is very dyspneic (difficult to breath/SOB). Does this patient need oxygen therapy

Hemoglobin is very low Yes! - the patient is not receiving enough O2 because her hemoglobin is 6.3 (female 12-16) - Sats are going to be normal with low hgb, because they do not measures the RBC's but rather the percentage saturated with oxygen - So, if there are not enough RBC's to carry the O2, she may get some help from increasing her supplemental O2 - Increasing her sats to near 100% might help some - She also needs 2 units of packed RBC's

Hyperglycemia

Hot & Dry sugar high Diabetic Ketoacidosis - (DKA) - occurs in Type 1 Hyperosmolar Hyperglycemic Syndrome - (HHS) - occurs in Type 2

Clinical Manifestations: DKA

Hyperglycemia BG ≥ 250 mg/dl - Polyuria - Polydipsia - Polyphagia - Urine: + Glycosuria &+ Ketonuria Dehydration - Poor turgor - Dry membranes / thirst - Tachycardia (weak) - Hypotension often orthostatic drops - Weakness / lethargy - Dry , flushed skin Metabolic Acidosis LABS: Arterial Blood • pH < 7.3 • Bicarb < 16 • + mod to high ketones blood Kussmaul's Respirations - deep & rapid - Dyspnea - Acetone Breath: Sweet/fruity - Abdominal Pain: A/N/V - Restlessness / confusion

The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism? Hypertension promotes atherosclerosis and damage to the walls of the arteries. Hypertension causes direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems. Hypertension increases blood viscosity, which contributes to intravascular coagulation and tissue necrosis distal to occlusions.

Hypertension promotes atherosclerosis and damage to the walls of the arteries. Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, when atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues.

IBD: Clinical Manifestations, Complications, and Diagnosis

IBD: Clinical Manifestations Crohn's - Diarrhea - Bloody stools - less common - fatigue - Abdominal cramping/pain - Fever - Wt loss - severe - Malabsorption & nutritional deficiencies UC - Diarrhea - Bloody stools/rectal bleeding - more common - fatigue - Abdominal cramping/pain - Fever (during acute attacks) - Wt. loss - minimal - Rectal bleeding - Feeling of constant need to pass stool Complications Local (GI tract) - Hemorrhage, perforations, strictures, fistulas, colonic dilation (toxic megacolon), perineal abscess &amp; fistulas Systemic - d/t anemia - Significant fatigue - SOB - Low Hgb & Hct d/t circulating products of inflammation (cytokines) - Arthritis (joint pain) - Finger clubbing - Skin lesions - Kidney stones, thromboembolism - fluid deficits (chronic diarrhea) - Gallstones - Liver sclerosing Dx. - CBC - iron deficient anemia, possibly B12 deficiency anemia, & blood loss - WBC - increase with megacolon & perforation - Electrolytes - Na, K, Cl, HCO3, Mg - Hypoalbuminemia - ESR - increase d/t chronic inflammation - Sigmoidoscopy & Colonoscopy w/ biopsy - Double-contrast barium enema

Clinical Manifestations: Acute Kidney Injury

If causes of AKI is not corrected, kidney damage occurs (4 phases) Initiating phase (1) - Begins @ time of insult & continues until s/sx become apparent Oliguric phase (2) - Caused by reduction in GFR - Occurs 1-7 days after causative event Can last from 10 days to several months - Increased duration = decreased prognosis for recovery Oliguria: UO < 400mL in 24hrs - Occurs in 50% of cases - Fluid volume excess (kidneys can't get rid of fluid) Metabolic acidosis (kidneys can't get rid of acid Hydrogen) - Kussmaul respirations to blow off CO2 Decreased Na (dilutional) - Neuro/mental status changes Increased K (kidneys can't eliminate) - Weakness, ECG changes - Hyperphosphatemia = low Ca (as phosphate minds to Ca) - Elevated BUN & creatinine - Fixed urine spec grav. 1.010 Neurologic changes - build up waste products & low Na - Fatigue, difficulty concentrating -> seizures, stupor, coma Diuretic Phase (3) - Gradual increase in daily urine output to 1 - 3 L/day or more Nephrons not fully functional - Kidneys recover ability to excrete waste, but not concentrate the urine - Hypovolemia and hypotension can occur from fluid losses Uremia may still be severe Near end of diuretic phase - F&Es, acid-base balance, & waste product (BUN, creatinine) values begin to Recovery Phase (4) Begins when GFR increases BUN & serum creatinine levels plateau, then decrease - Major improvement occur in first 1 - 2 weeks - May take up to 12 months to stabilize - Those who do not recover progress to chronic kidney disease (CKD)

Diagnostics: Urinary Tract Calculi

Imaging studies - if obstruction suspected Intravenous Pyelogram (IVP) Visualizing or urinary tract with contrast dye & x-ray - Iodine allergy = contraindication - Localize site and degree of obstruction - See stones that are translucent (don't show up on x-ray) CT scans - Differentiate stone from tumor - US - KUB - kidney/ureter/bladder x-ray UA with C&S - pH to determine stone type - Identify infection - Cystoscopy Labs - Blood: Serum calcium, phosphorus, sodium, potassium, bicarbonate, uric acid, BUN & creatinine - Urine: 24 hrs. Urinary measure of calcium, phosphorus, magnesium, sodium, oxalate, citrate, sulfate, potassium, uric acid, total volume

6-mercaptopurine

Immunosuppressants to maintain remission: IBD

azathioprine (Imuran)

Immunosuppressants to maintain remission: IBD

A 77-year old patient with pneumonia has a fever of 101.2 F is coughing up moderate amounts of green sputa,and has an O2 sat of 88% with RR of 28. The patient is weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is a. Hyperthermia related to infectious illness b. Ineffective airway clearance related to poor cough and thick secretions c. Ineffective breathing pattern related to tachypnea d. Impaired gas exchange related to respiratory congestion

Impaired gas exchange related to respiratory congestion

Pre-diabetes

Impaired glucose tolerance: IGT) or /and impaired fasting glucose (IFG) - High BG but not ↑ enough to be dx with DM increased risk for developing type 2 DM - Most will develop DM within 10 years - Unless preventive measures are taken! - i.e. healthy diet, weight loss, regular exercise - Long-term damage to blood vessels/organs may be happening EBP: Onset of Type 2 can be delayed or prevented! - Dietary, physical exercise, and behavioral interventions can ↓ DM risk

Electrical Tx: 4: ICD's

Implanted cardioverter defibrillators (note these devices will also have pacing capabilities) For patients who have survived or are at risk for sudden cardiac death indications: Cardiac Arrest Survivors: - Require EPS studies to validate need - Patients with recurrent sustained VT/VF - Prophylactic for high risk patient's (EF <30%) NOTE: Some patients may need to wear a LIFE VEST: with an external monitor/defibrillator in order to qualify for an implanted device

Treatment of SVT

In Upper Extremity - Removal of IV catheter - Elevation of extremity - Application of warm moist heat Medications - Anti-inflammatory agents: (NSAIDS) In Lower Extremity Diagnostics: Duplex US Treatment: Elastic Compression stockings - Example: TED hose (used but evidence is weak) - Walking Anticoagulants For clots > 5cm - LMWH/Heparin - Fondaparinux (Arixtra) For clots < 5 cm: usually only NSAIDS

Urinary Retention

Inability to completely empty bladder. Should void by 6-8 hrs post op. palpate bladder, urge to void, bladder scan S/Sx: no void, bladder distension, feel need to void but unable Risk Factors: Anesthesia depresses nervous system, including micturition reflex; decreased ability to initiate void or empty bladder completely; common after lower abdominal or pelvic surgery, can be caused by spasms, immobility, supine position; BPH Diagnosis: no void, bladder distension, bladder scan to confirm Treatment-Nursing Management: straight cath as ordered, may need RX if continues to occur; get pt. into natural position (standing for males, sitting up for females): At least 0.5 ml/kg/hr (no less than 30 mL/hr) for adult pt.

Surgical Site/Wound

Incision infection/Surgical site infection (SSI) - S/Sx: redness, warmth, purulent drainage, swelling at site; fever; leukocytosis (elevated WBC); tachycardia - Temp post op: up to 12 hrs hypothermia to 95F (35C) common (effects of anesthesia, body heat loss during procedure, cool fluids); 48hrs - POD 2 mild elevation up to 100.4F (38C) = normal inflammatory response to surgery, over 100.4F may indicate lung congestion, atelectasis, dehydration; after 48hrs (day 3 and later) elevation over 100F (37.7C) indicative of infection (think surgical wound, urinary, respiratory) Risk Factors: Contamination of the wound-Exogenous flora (staph), oral flora, intestinal flora, accumulation of fluid in the wound, Dehiscence, size of incision & location, health status/immune status, elevated BG, hospital staff not using aseptic techniques when caring for patient Diagnosis: presentation, wound culture -> blood culture Prevention-Nursing Strategies: Prehab: Oral Cleansing (Perox-A-Mint Hydrogen Peroxide Solution), Skin Antisepsis (Chlorhexidine Gluconate (CHG) Cloths), Nasal Antisepsis (Providone-Iodine Solution) Treatment: antibiotics, may need to return to OR

Cardiac Regulation: Fluid & Electrolyte Imbalances

Increased arterial pressure & elevated serum sodium levels stimulate release of natriuretic peptides (ANP & BNP) - Stimulates renal excretion of water and sodium - Suppresses the secretion of ADH, aldosterone, & renin - Increases urine output - A serum BNP is sometimes ordered to assess fluid overload (nl. 100pg/nL)

Nursing Care: HTN Teaching

Ineffective self-management r/t lack of knowledge - Discuss B/P numbers, goal, self-monitoring & when to notify HCP - Explain potential complications if not controlled - Educate id risk factors - Referrals PRN: dietary, exercise/PT - Provide med info including: name, action, dose, side effects and cautions for OTC's - Emphasize need for F/U at monthly intervals or more frequently prn untl target goal is met then q 3-6 month checks - Sexual concerns - Safety Considerations: orthostatic precautions, hot environments, exercise, alcohol intake, NOT to abruptly stop meds

Gastritis

Inflammation of gastric mucosa - Breakdown of mucosal barrier (which normally protects stomach tissue from corrosive action of HCl acid and pepsin) - Results in edema, disruption of capillary walls with plasma loss into stomach and possible hemorrhage - May be acute or chronic, diffuse or localized Causes: - Drugs (ASA, corticosteroids, NSAIDS) - Diet (ETOH, spicy/irritating foods) - Microorganisms (Helicobactor -pylori, salmonella, staphylococcus organisms) - Burns, large hiatal hernia, stress, reflux of bile & pancreatic secretions, renal failure (uremia), sepsis, shock - NG tube, endoscopic procedures

Hepatitis

Inflammation of the liver - Causes - Viral (most common) - Alcohol - Medications - Chemicals - Autoimmune diseases - Metabolic abnormalities Acute infection - Large numbers of hepatocytes are destroyed - Liver cells can regenerate in normal form after resolution of infection - Chronic infection can cause fibrosis and progress to cirrhosis - Antigen-antibody complexes activate complement system Systemic manifestations - Rash - Angioedema - Arthritis - Fever - Malaise - Cryoglobulinemia (proteins in blood) - Glomerulonephritis - Vasculitis

When teaching how lisinopril (Zestril) will help lower the patient's blood pressure, which mechanism of action should the nurse explain? Blocks β-adrenergic effects Relaxes arterial and venous smooth muscle Inhibits conversion of angiotensin I to angiotensin II Reduces sympathetic outflow from central nervous system

Inhibits conversion of angiotensin I to angiotensin II Lisinopril is an angiotensin-converting enzyme inhibitor that inhibits the conversion of angiotensin I to angiotensin II, which reduces angiotensin II-mediated vasoconstriction and sodium and water retention. β blockers result in vasodilation and decreased heart rate. Direct vasodilators relax arterial and venous smooth muscle. Central acting α-adrenergic antagonists reduce sympathetic outflow from the central nervous system to produce vasodilation and decreased systemic vascular resistance and blood pressure.

Brachytherapy: Cancer

Internal Radiation - Implantation or insertion of radioactive materials into or close to tumor - Minimal exposure to healthy tissue - Commonly used in combination with external radiation High dose brachytherapy - Inserted through applicator & left in place for a few minutes at a time only Low dose brachytherapy - Left in place for several hours to days - Pt stays in hospital Pellet/seed brachytherapy - Permanent Brachytherapy Precautions For Temporary internal radiation - pt is radioactive - nurse/caregivers to limit exposure to pt/cluster cares - stay away or shielded - film badge dosimeter - measure exposure to radiation - NO contract with children or pregnant women during this time - Visitors keep 6 feet away and limit time to 30 min/24 For seed/pellet implant - Internal permanent radiation - Very low levels traveling very short distances - Precautions only for 24 hours

Interventions and Teaching. Impaired Gas Exchange

Interventions - raise HOB (head of bed): FOWLER's positions: ____ Administer O2 - Check ats & titrate prn - Provide humidification - Encourage ambulation - Encourage C & DB (coughing and deep breathing) Use incentive spirometer (IS) devices such as Voldyne - RT referral prn Drug Therapies - Bronchodilators - Antibiotics prn Teaching Explain interventions - Medication teaching - Home oxygen use & safety concerns - Instruct C/DB & IS use - Demonstrate splinting

Pain Assessment

Interview - Onset/pattern - Location any radiating/referred? - Intensity/Quantity 0-10 numeric scale wong-baker faces neuropathic pain scale (must be appropriate for population) - Quality = sensations - Associated Symptoms nausea/vomiting increased/decreased heart rates Ask Self-Management - Alleviating strategies - Aggravating factors Understand Pt.'s Goals - Impact on QOL esp. for chronic pain Sociocultural Factors - For chronic pain risk increase - childhood abuse/trauma - maladaptive coping skills - lack of social support - obesity/past surgeries

Locations of Fluid in the Body

Intracellular (ICF): fluid within the cell Extracellular (ECF): fluid outside the cell (in interstitial & intravascular space) Interstitial: fluid between cells/interspaces of tissues in the body Intravascular: fluid within the blood vessels

Acute Leukemia

Involves immature cells and are classified by the predominant cell in the bone marrow - ALL (Acute lymphocytic leukemia) - lymphoblasts - AML (acute myelogenous leukemia) - myeloblasts Rapid onset Signs and symptoms: - Infections - Bleeding - Fever - Lymphadenopathy - Pallor - Fatigue - Ecchymosis - Hepatosplenomegaly

Potassium iodine (SSKI)

Iodine - Inhibits hormone synthesis and blocks their release - Decreases vascularity of gland making surgery safer - Used to treat thyrotoxicosis and to get pt's euthryroid before surgery - Effects seen in 1-2 weeks

NATIONAL PRACTICE STANDARDS: HF

Joint Commission Standards of Care: CORE MEASURES FOR HEART FAILURE MEDICAL CARE: must include the following: - LV(left ventricular) function assessed &amp; documented - ACE/ARB's for LV dysfunctions (EF < 40%) - Smoking cessation counseling/instruction - CHF teaching NURSING CARE Discharge written instructions & teaching must include the following: - Diet - Activity level / restrictions - Meds S/sx monitoring o Including daily wt. - Smoking cessation - F/U (follow-up) plan

Hyperkalemia Cause

K > 5mEq/L Cause Excessive Potassium Intake - PO: potassium chloride supplements (Klor-Con) - excessive or rapid IV administration/overcorrecting hypokalemia - potassium containing salt substitute Failure to eliminate potassium (impaired renal excretion) - Renal disease - Potassium sparing diuretics - adrenal insufficiency (hypoaldosteronism) - ACE inhibitors Shift of potassium out of cells - Acidosis - Injury to muscles/cells - rhabdomyolysis (falls, infection, surgery, crush injuries, prolonged seizures, GI bleeding) - tumor lysis syndrome

Hypoglycemia: Why and when might this happen?

KEY POINT: Caused by a too much insulin/medication in proportion to available glucose. Possible Causes - Too much diabetic medication (insulin/oral) - Too little food: delayed, omitted, inadequate amounts - Too much exercise without compensation - High glucose level falls too rapidly Timing of occurrence - Peak insulin times - Before meals (delayed meals - disruption in pt. normal routine) - During & after exercise RN's role: - Explore reason why hypoglycemia occurred. - Follow up health care provider r/t med dose or other possible causes - Re-assess pt's ability to recognize and self-treat

Beta Blockers

Adrenergic Inhibitor - Cardiac Selective (B1) & nonselective (B1 & B2) - Block beta 1: decrease CO, HR & renin Block beta 2: cause vasoconstriction - Metoprolol (lopressor) - Propranolol (Inderal) Side Effects of Beta Blockers - Hypotension - Bronchospasm (nonselective agents): - Depression - Impotence - Worsening of CHF - AVOID sudden stopping: which may cause increased BP, HR's, and cardiac ischemia they decrease sympathetic nervous system activity

Alpha (A1) Blockers

Adrenergic Inhibitor Block alpha 1 effects producing peripheral vasodilation; thus decreasing SVR/BP - Prazosin (Minipress) Side Effects - Orthostatic drops - Hypotension - Tachycardia

Prostate Cancer: Risk Factors

Age - >50 Ethnicity - African American Family history - 1st degree relatives High fat diet - Red meat, high-fat dairy, low vegetables & fruits - Occupational exposure to chemicals - History of BPH is NOT a risk for prostate cancer - Proscar (finasteride) reduces chance of prostate cancer by up to 25%

Hemophilia - Clinical Manifestations

All can lead to a life threatening hemorrhage - Slow persistent, prolonged bleeding - Delayed bleeding after minor injuries - Uncontrollable oral bleeding - Epistaxis - Ecchymosis & subcutaneous hematomas - GI bleeding - Hematuria - Pain, anesthesia & paralysis - Hemathrosis Life Expectancy: Age 72

Prazosin (Minipress)

Alpha (A1) Blocker Adrenergic Inhibitor

Carvedilol (Coreg)

Alpha/Beta Adrenergic Inhibitor

Labetalol (Normodyne)

Alpha/Beta Adrenergic Inhibitor

Respiratory Alkalosis: Cause

Always due to hyperventilation: - Hypoxia - Pulmonary embolism - Anxiety/fear - Pain - Exercise - Fever - Stimulated respiratory center caused by septicemia, encephalitis, brain injury, salicylate poisoning - Mechanical hyperventilation

Respiratory Acidosis: Cause ****

Always due to hypoventilation: - COPD - Barbituate or sedative OD - Chest wall abnormality (severe obesity, trauma) - Severe pneumonia/atelectasis - Resp muscle weakness (Guillain-Barre syndrome) - Mechanical hypoventilation

ADRENAL GLAND

Anatomy & Physiology Adrenal Cortex - Function controlled by Anterior Pit: ACTH = Adrenocorticotropic Hormone Adrenal Medulla: Epi, NE & Dopamine Catecholamine's - Bind to adrenergic receptors - Enhance & prolong effects of SNS - Secreted in response to body's stressors Adrenal Cortex: Hormones Glucocorticoids: Cortisol Regulates metabolism - ↑ blood glucose via gluconeogenesis Response to stress - Anti-inflammatory Mineralocorticoids: Aldosterone - Regulates Na + &amp; K + levels Maintains extracellular fluid - Effect kidneys: Androgens: - : Converts to estrogen ♀ and testosterone ♂ in peripheral tissues - Affects growth and development NOTE: Term corticosteroids refers to hormones secreted by the adrenal cortex.

Clinical S/sx of CAD: Angina

Angina (chest pain) is the clinical symptoms of myocardial ischemia - Results from increased demand for oxygen or a decreased supply of oxygen - Occurs when arteries are blocked (stenosed) > 70% - Cardiac cells are viable for 20 minutes Intermittent chest pain: or discomfort occurring with the same pattern of onset, duration, and intensity - Onset: often sudden and associated with physical activity, stress or emotional upset - *Duration: few minutes (5-15 minutes) & subsides when precipitating factors is removed (i.e. stop activity/rest) Note: Is also relieved with nitroglycerine! Intensity/quantity: discomfort may be mild (1-2) to severe (8-10) per numeric scale reporting - Quality: described as a pressure, heaviness, or discomfort - may hear complaints of indigestion or burning but rarely sharp or stabbing Location: usually substernal but may originate from other locations - Radiation is common: to neck, shoulders, down arms

Medications: GERD

Antacids --- 1 hr pc (after meals) and hs (nighttime) - Neutralize acid - Maalox, Tums, MOM (calcium carbonate, aluminum hydroxide, magnesium hydroxide) H 2 -receptor blockers - Antisecretory - cimetidine (Tagamet), famotidine (Pepcid), ranitidine (Zantac) Proton pump inhibitors (PPI) - Antisecretory - esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix) - Use of omeprazole prophylactically in hospitalized patients Prokinetic (promotility) - Reglan Cytoprotective/acid protective - sucrafate (Carafate)

Disorders associated with ADH

Anti-diuretic Hormone (ADH) - Formed in hypothalamus - Stored in post pituitary - Controlled by osmoreceptors &amp; baroreceptors Effects: - cause kidneys to reabsorb water - potent vasoconstrictor Disorders - Syndrome of inappropriate antidiuretic hormone (SIADH) - Diabetes Insipidus (DI)

SAM-e (S-adenosylmethionine)

Anti-inflammatory supplement Osteoarthritis

Drug Treatment: Hyperthyroid

Anti-thyroid - inhibit thyroid hormone synthesis - Used on younger and pregnant pts, & prior to surgery or radiation tx - Also used to treat thyrotoxicosis - Improvement 1-2 weeks. Good results 4 to 8 weeks. Tx. 6-15 months to allow for possible remission in some patients Examples: - propylthiouracil (PTU) - Methimazole (Tapazole) Iodine - Inhibits hormone synthesis and blocks their release - Decreases vascularity of gland making surgery safer - Used to treat thyrotoxicosis and to get pt's euthryroid before surgery - Effects seen in 1-2 weeks Examples: - Potassium iodine (SSKI) - Lugal's solution Beta adrenergic blockers - Used to relieve cardiovascular effects of excess T3/T4 &amp; treat thyrotoxicosis - ↓ HR, nervousness, irritability, tremors • Propranolol (Inderal) or Atenolol (Tenormin) Radioactive Iodine (RAI) - Damages/destroys thyroid tissue thus ↓ hormone secretion - Preferred treatment for non-pregnant adults Effects may take up to 3 months - Thus pt. will continue anti-thyroid meds and beta blockers before and after RAI Causes post treatment hypothyroidism - 80% incidence - Will need Synthroid Nursing Care - Pregnancy test - May cause thyroiditis/parotiditis - Treat with baking soda & salt gargle (1 tsp each in 2 cups warm water) - Radiation precautions @ home 7 days (double flush toilet, avoid body fluid exchange)

Cimzia

Anti-tumor necrosis factor agent for IBD pts can develop antibodies against them = infusion reaction & delayed hypersensitivity reaction

Hymira

Anti-tumor necrosis factor agent for IBD pts can develop antibodies against them = infusion reaction & delayed hypersensitivity reaction

Remicade

Anti-tumor necrosis factor agent for IBD pts can develop antibodies against them = infusion reaction & delayed hypersensitivity reaction

Bactrim (sulfamethoxazole & trimethoprim)

Antibiotic UTI

Management: Pyelonephritis

Antibiotics - 3-5 days IV (preferred to rapidly establish high level of drug) - 2-3 weeks PO as outpatient Relapses treated with 6-week course of antibiotic NSAIDs or antipyretic drugs - Fever - Discomfort - Follow-up urine culture ** - Follow general management for UTI Acid-Ash Diet Produces an acid urine - Cranberries - Blueberries - Prunes and plums - Meat - Whole grains - Eggs - Cheese

Nursing Focus*** Fluid & Electrolyte Imbalance

Anticipate - What are the potential alterations associated with the patient condition & therapies/interventions provided Recognize - What are the signs and symptoms associated with fluid & electrolyte imbalance Intervene - What are the appropriate actions to take to prevent or treat these imbalances

Clopidogrel (Plavix)

Antiplatelet Used for PAD

clopidogrel (Plavix)

Antiplatelet/anticoagnulant

heparin

Antiplatelet/anticoagnulant

warfarin (Coumadin)

Antiplatelet/anticoagnulant

Pyridium (phenazopyridine HCl)*

Antispasmodic UTI

Ditropan

Antispasmotic For Suprapubic catheterization

propylthiouracil (PTU)

Antithyroid - inhibit thyroid hormone synthesis - Used on younger and pregnant pts, & prior to surgery or radiation tx - Also used to treat thyrotoxicosis - Improvement 1-2 weeks. Good results 4 to 8 weeks. Tx. 6-15 months to allow for possible remission in some patients

Methimazole (Tapazole)

Antithyroid - inhibit thyroid hormone synthesis - Used on younger and pregnant pts, & prior to surgery or radiation tx - Also used to treat thyrotoxicosis - Improvement 1-2 weeks. Good results 4 to 8 weeks. Tx. 6-15 months to allow for possible remission in some patients

Arrhythmia

Any rhythm other than normal sinus Some Common Causes 1. Heart related a. CAD/ACS b. CHF = congestive heart failure aka chronic heart failure c. Poor Ejection Fractions < 30% 2. Electrolyte & Acid Base Imbalances (low potassium, low magnesium) 3. Medications 4. Hypoxic conditions

NCP: HF: Decreased Cardiac Output

Assess Cardiovascular Status o √ Responsiveness/LOCO = level of consciousness &amp; orientation o Check: VS &amp; SCM's in extremities o Hemodynamic monitoring PRN for ADHF o Ask/monitor for s/sx decreased cardiac output (chest pain/SOB/dizziness) Monitor ♥ rhythm continuously via telemetry for arrhythmias Examples: - Premature vent complexes (PCV's) aka premature ventricular contractions - Atrial Fibrillation (Afib or AF)

Despite a high dosage, a male patient who is taking nifedipine (Procardia XL) for antihypertensive therapy continues to have blood pressures over 140/90 mm Hg. What should the nurse do next? Assess his adherence to therapy. Ask him to make an exercise plan. Instruct him to use the DASH diet. Request a prescription for a thiazide diuretic.

Assess his adherence to therapy. A long-acting calcium-channel blocker such as nifedipine causes vascular smooth muscle relaxation, resulting in decreased systemic vascular resistance and arterial blood pressure and related side effects. The patient data the nurse has about this patient is very limited, so the nurse needs to begin by assessing adherence to therapy.

♥ NCP: HF: Fluid Volume Excess

Assess: Cardiac/Respiratory Systems - √ Edema: peripheral &amp; dependent - Watch for pulmonary edema Daily weights - Using same scale to ensure accuracy - Same amount clothing - Before breakfast - After morning void Doc & monitor weight trends Teaching - Instruct pt. to report gains: (Important to know; i.e. it's on the test!) - 3 lbs. over 2 days or - 3 - 5 lbs. in a week - Strict I & O - TED Hose Administer/evaluate meds - Desired effects - Monitor for SE's - Check K+ levels Fluid Restrictions: For mod/severe HF - Oral care - Offer dry mouth suggestions - Ice, gum, hard candy,

Discharge Planning: Overview of the Process

Assessment By qualified HCP (health care provider) - RN plays a major role - To identify actual needs and anticipate needs Areas to assess - Physical: age, health conditions, cognitive functioning & ADL/IADL abilities - Emotional: cognitive abilities, coping skills, self-efficacy beliefs - Psychosocial: health beliefs, religious/spiritual beliefs, - Home environment: type of dwelling, is dwelling safe? Are basic services available? (such as phone, electricity, heat, water), any physical barriers present? - Family/Community resources: proximity of family: ability/willingness to help? Any dependents? Community resources Discussions with pt. SO or care provider - To determine understanding, wishes & abilities to provide care Planning - Home/Transfer to another facility - Teaching r/t knowledge and skills needed for self-care - RN's role - Referrals: appropriate & timely ex. Home Health - Arrangements: Follow-up (FU)/transports

Orthopedic Surgery: Post-op Care

Assessments - VS - Dressing & incisions - SCM's - Labs: H & H, electrolytes Pain management: medications & ice Infection prevention - Antibiotics prophylactic - C&CB/IS - CAUTI prevention measures DVT prevention - Early out of bed (OOB), ambulation & leg exercises - SCD's (pneumatic) - TEDS Meds: - Aspirin - Enoxaparin (Lovenox) - Warfarin (Coumadin) - Rivaoxaban (Xarelto) - Apixaban (Eliquis) - ASSESSMENT: Monitor unilateral leg pain, swelling, redness & PE s/sx - Bowel Management Program - D/C plan & teachingOrthopedic Surgery: Post-op Care

Post-Op Nursing Care: Back Surgery

Assessments Neurological - SCM of extremities - Compare to pre-op Monitor for CSF leaks - Clear to yellow drainage - Check fluid to see if it is + for glucose - suggest spinal fluid - Monitor for headache Check bladder and bowel functioning - Report incontinence Incisions and donor bone graft sites Activity Restrictions - Know orders!!! - Proper positioning - Avoid spine twisting - May need log rolling - Help to ambulate - Use of braces - Be aware of medical orders which can vary by providers Meds - Pain management - Muscle relaxants - Anti-anxiety

Complications: DM

Atherosclerosis - CAD = coronary artery disease PAD = peripheral arterial disease - aka PVOD = peripheral vascular occlusive disease - aka PVD = peripheral vascular disease - CVA = cerebral vascular accident r/t carotid disease (aka stroke) • Neuropathy (peripheral, erectile dysfunction, gastroparesis) • Nephropathy (renal insufficiency, ESRD= end stage renal disease) • Retinopathy (cataracts, glaucoma & blindness) • Infections: (UTI = urinary track infections, cellulitis, osteomyelitis) • Amputations • ***Acute Medical Emergencies: r/t extreme ↓ & ↑ blood glucose

4 Types Aerosol Treatments

MDI: metered dose inhaler PDI: powder dose inhaler SVN: small volume nebulizers Nursing Considerations - When to call for help & treatments - When to give prn treatments - Monitor for drug SE Patient teaching - Drug action & SE's - Inhaler/nebulizer: KNOW correct patient use - Spacer use - Mouth rinses - Dose counting

Nursing Care for Fx: Traction

Maintain proper alignment - Maintain counter traction by using patient's own body wt., proper bed positioning, and/or counter-pull wts. Maintain constant traction - Check wts./pulleys/ropes hang freely - Weights must be suspended and not resting Skin Care - Assess q 2 hours - Monitor pin sites (skeletal) - Provide sterile pin site care - Use pressure ulcer prevention devices Assess SCM's frequently - Aka neurovascular checks External & Internal Fixation Care - Uses metals pins/screws, rods to maintain alignment and provide immobilization Key points - Assessment Pin care - Sterile technique - Separate swabs per each pin - Teaching

Lymphoma

Malignant neoplasm originating in bone marrow and lymphatic structures - Results in proliferation of lymphocytes Two major types: Hodgkin's lymphoma (11% of all lymphomas) Non-Hodgkin's lymphoma (NHL) - More aggressive - More responsive to therapy and more likely to be cured

Management: Urinary Tract Calculi

Manage symptoms of acute attack - Pain relief - Antibiotics - Stent placement Temporary nephrostomy Determine cause of stone development - Prevention of further stone development - Hydration - Strain urine - Diet - restrictions of purine, calcium or oxalate depending on type of calculi Break up/remove stones - Cystoscopic lithotripsy - Ureteroscopic lithotripsy - Percutaneous nephrolithotomy - ESWL - extracorporeal shock wave lithotripsy (non-invasive) Surgical therapies (obese pts. & complicated cases) - Nephrolithotomy - incision into kidney - Pyelolithotomy - incision into renal pelvis - Ureterolithotomy - incision into ureter Post Lithotripsy Care - Urine: initially bright red -> rusty -> clear - Strain urine because fragments may pass for several days Observe for signs of obstruction - Decreased urine output - Increased weight - Flank pain Bladder distension - Antibiotics - Pain meds - Fluids - Stent in place for 2 wks.

Acute pancreatitis

Many factors cause injury to pancreas - Gallbladder disease - Chronic alcohol intake - smoking - Biliary Sludge - Hypertriglyceridemia - Trauma - Viral infections - Surgical procedures

Why are s/sx of hypothyroidism missed in elderly females?

Many symptoms are already associated with aging

A patient is admitted to the hospital in hypertensive emergency (BP 244/142 mmHg) Sodium nitroprusside is started to treat the elevated BP. Which management strategies would be most appropriate for this patient?

Measure urine output hourly to assess renal perfusion. Patients treated with IV sodium nitroprusside should have continuous intraarterial BP monitoring. Hypertensive crisis can cause encephalopathy, intracranial or subarachnoid hemorrhage, acute left ventricular failure, myocardial infarction, renal failure, dissecting aortic aneurysm, and retinopathy. The initial treatment goal is to decrease the mean atrial pressure (MAP) by no more than 25% within minutes to 1 hour. Patients receiving IV antihypertensive drugs may be restricted to bed rest. Getting up (e.g., to use the toilet/commode) may cause severe cerebral ischemia and fainting

Collaborative Care: Amputations

Medical Diagnosis - H&P: check neurovascular status (i.e. check SCM assessments & for loss of protective sensation using a monofilament) - CBC with diff Vascular testing - Arteriography - Doppler Studies Treat underlying cause - Stabilization of trauma Management of underlying cause(s) - Control diabetes - Treat infections - Stop smoking Selection of surgery Examples: - AKA: above knee amputation - BKA = below knee amputation Residual limb care Prosthesis fitting - Immediate - Delayed Rehabilitation Referrals - PT - OT - Prosthetist - Care management

INTERPROFESSIONAL CARE: Valvular Heart Disease

Medical diagnosis History & Physical - √ History of Rheumatic fever/ rheumatic heart disease or endocarditis - Ask/Listen murmur - Assess: s/sx heart failure 17 Diagnostic Testing - CXR - 12 Lead ECG Echocardiogram: Ultrasound testing for diagnosis and follow-up monitoring o Doppler o Trans-Esophageal Echocardiogram (TEE) - diagnostic reasons & on-going monitoring - Cardiac (Heart) Catheterization: prior to valve surgery/procedures Management Prophylactic Antibiotics o For pts with history of rheumatic heart disease (RHD), infective endocarditis (IE) and those with prosthetic (artificial, mechanical) valve replacements Prior to ANY invasive procedures such as 1. Dental & Endoscopy 2. Out/Inpatient surgeries o Used to prevent endocarditis & o Reoccurrence rheumatic heart disease - Dietary Na Restrictions - Medications to treat the following: o Heart failure o Arrhythmias o Anticoagulants a. Used for artificial mechanical valves b. Warfarin (Coumadin) • INR: N: 0.75-1.25 • TARGET therapeutic range/goal: 2.5-3.5 Note: Xarelto/Eliquid not yet approved for valve pts.

Management: Parkinsons

Medication Therapy Levodopa with carbidopa (Sinemet) first drug of choice ** Thalamic Stimulation Therapy (DBS) When meds not effective Diet: Dysphagia diet (if difficulty swallowing) Fluids, roughage & fruit to decrease constipation

Management: Myasthenia Gravis

Medication Therapy (don't need to know specific meds) - Anticholinesterase agents - Corticosteroids - Immunosuppressive agents - Medication contraindications/use with caution with MG: anesthetics, antidysrhythmics, antibiotics, antipsychotics, barbiturates, diuretics, opioids, muscle relaxants, thyroid meds & tranquilizers Surgery - Thymectomy (removal of thymus gland) Plasmapheresis - Crisis - Prep for surgery

*****BE AWARE: Increased risk for falls****** Older Adults: Cardiac Disease

Meds may promote orthostatic changes - √ For orthostatic changes o Assess for nocturia - Use of diuretics 1. May potentiate incontinence 2. Assess gait &amp; balance 3. Consider distance to bathroom 19 4. √ related Co-morbidities - Visual impairment - Osteoarthritis

repaglinide (Prandin)

Meglitnides Diabetic medication SE: ***hypoglycemia, wt. gains

BMP

Metabolic Panel Lab for electrolytes (Sodium, potassium, chloride, calcium) - CO2, Glucose, BUN, Creatinine

Inhaler Patient Teaching: Compare the Differences ***

Metered Dose Inhalers (MDI) - Shake well - Spacer required for inhaled corticosteroids & rinse mouth - Exhale completely - Seal lips tightly over mouthpiece Breath in slowly/deeply & press inhaler 1x - If using a spacer press first then within 5 seconds to start to breath in - HOLD breath 10 secs if possible - Wait 1 minute if using rescue meds between doses/medications Dry Powder Inhaler (DPI) - Don't shake!/Note dose count - No spacer - Exhale completely - Seal lips tightly over mouthpiece - Breath in quickly & deep - Breath in deeply - HOLD breath > 10 secs - Check dose counter (should be one less) - Store in a dry place to prevent clumps

Clinical Manifestations** Dementia

Mild (early) - Forgetfulness - Short-term memory impairment - Difficulty recognizing what #s mean - Loss of initiative & interests - Dec. judgement - Geographic disorientation Moderate (middle) - Impaired ability to recognize family/close friends - Agitation - Wandering, getting lost - Loss of remote memory - Confusion - Impaired comprehension - Forget how to do simple tasks - Receptive & expressive aphasia - Insomnia - Delusions - Hallucinations - Behavioral problems Severe (late) - Little memory - Cannot understand words - Difficulty eating, swallowing - Repetitious words or sounds - Inability to perform self-care - Immobility - Incontinence - Dementia

Interprofessional Care SIADH: FVO & Hyponatremia

Mild hyponatremia (Na > 125) - Limit fluids: 800-1000 ml/d After Na ≥ 125 loop diuretics may be used (Lasix) - Supplemental K + , Ca 2+ and Mg + PRN Severe hyponatremia (Na < 120) Hypertonic saline (3%)(NS is 0.9%) - Given slowly using IV pump! - Goal: no more than 8-12 mEq/L increase 24 hours - Limit fluids: 500 ml/d Study Hint: know/memorize normal Na levels 135-145 mEq/L & specific gravity N: 1.010 - 1.025 Chronic SIADH Limit fluids: 800-1000 ml/d - Ice chips & sugar-free gum to ease thirst - Daily weights Medications - Diuretics Demeclocycline (Declomycin) - Blocks ADH effect on kidneys resulting in a more dilute urine - Supplemental lytes with meals (K + &amp; Na + ) especially if loop diuretics used

NCP: HF: Impaired Gas Exchange

Monitor Respirations - Rate, rhythm, depth, effort - Check breath sounds - Monitor s/sx hypoxia - Watch/Monitor/Assess for pulmonary edema! Oxygen Therapy - Administer O2 prn via device needed to be effective Evaluate O2 sats - Keep > 90% - use nasal cannula (NC) during meals Position Semi-to high Fowlers

NCP: Impaired Physical Mobility: RA

Morning stiffness - Warm shower/heat such as hot packs Rest inflamed joints - Rest splints - Assistive devices - Proper footwear - Refer to OT for ADL adaptations & devices - Collaborate with PT for ROM & exercise plan Teach joint protection measures - Modify activities to avoid overexertion & joint stress - Maintain neutral alignment - Use strongest joint for task - Avoid repetitious movements - Avoid heavy lifting & grasping objects for long periods - Change positions freq. - Modify chores to avoid joint stress - Sit on stool for meal prep - Encourage Rest Periods - Rest when possible - Firm mattress - Assist with obtaining help when needed Use of assistive devices - OT Referrals Encourage sleep/rest - Firm mattress/board - No pillows under knees - Small flat pillow under head

Treatment: cholelithiasis & cholecystitis

Most common Analgesics - Morphine Anticholinergics - Atropine - Fat-soluble vitamins (A, D, E, K) - Bile salts Cholestyramine may be given for pruritus - Given in powdered form, mixed with milk or juice - Monitor for side effects (nausea/vomiting, diarrhea, or constipation, skin reactions) - Check drug-drug interactions Nutritional therapy: cholelithiasis & cholecystitis - Small, frequent meals with some fat - Diet low in saturated fat - High in fiber and calcium - Reduced-calorie diet if patient is obese - Avoidance of rapid weight loss After laparoscopic cholecystectomy - Liquids first day - Light meals for several days After incisional cholecystectomy

Complication of Hypothyroidism

Myxedema Coma: Medical Emergency! - Sudden or gradual onset - Often precipitated by infection, trauma, cold exposure or drugs (opiates, barbiturates, tranquilizers) - S/sx: subnormal ↓ body temps, hypotension, hypoventilation Treatment Support vital functions: - Often hospitalized in ICU - may need endotracheal intubation along with mechanical ventilation/cardiac or core body temp monitoring - IV thyroid hormonal replacement

Hypertension

NOTE: Ideally, a medical diagnosis of HTN is determined using the average of 2 or more properly measured, seated readings on >2 office visits Defined as persistent SBP > 130mmHg DBP > 80mmHg Or current use of antihypertensive meds - this means that someone could have 'normal' numbers but if the are taking medications to control their blood pressure, they still have HTN but it's well-managed ****NOTE: NEW DIAGNOSTIC GUIDELINES - released late 2017 - decreased by 10 pts both SPB and DBP. Previously number was >140/90*****

Naproxen (Aleve)

NSAID Osteoarthritis NOTE: Increased risk SE in elderly especially GI bleeds & renal toxicity as well as drug interactions - Watch for GI bleeding

Hyponatremia Cause

Na <135 mEq/L Cause Inadequate Sodium Intake - fasting diets Excessive Water Intake (Dilutional Hyponatremia) - excessiv hypotonic IVF, polydipsia Excessive Sodium Loss - GI losses: diarrhea, vomiting, fistulas, NG suction - Renal losses: diuretics, adrenal insufficiency, Na wasting renal disease - Skin losses: burns, wound drainage Disease States: SIADH, heart failure, primary hypoaldosternoism

Screening - Nasal Swab

Nasal Complete Assay for MRSA/Staph Aureus Polymerase Chain Reaction (PCR) - Ordered by provider to be completed during pre-op testing Nursing Responsibilities - Check chart for MRSA/Staph Aureus Nasal Screening results (Good for 90 days pre-op) - If test not done, complete STAT - Obtain nasal swab from Clean Utility (directions for use on package) - Remove cap at perforation and throw away - Holding red end in hand, insert double swabs into nare and collect specimen; repeat using same double swabs in opposite nare - Insert double swabs into tube; red end functions as cap - Label specimen and deliver to lab STAT Screening Results NEGATIVE result - Document in EMR (Clinical CareStation PREOP Tab) - No nasal treatment needed - Proceed with CHG cloths and Perox-A-Mint POSITIVE result - Document in EMR (Clinical CareStation PREOP tab) - Verify if patient has iodine allergy -> nasal application of mupirocin (Bactroban) x 5 days - Proceed with Prehab including nasal treatment - If also MRSA positive: IV antibiotics prophylaxis Vancomycin & Kefzol No result by hour before surgery - Proceed with nasal treatment Nasal Treatment: 3M Nasal Antiseptic - Reducing S. aureus in the nares will help reduce risk surgical infections Reduces 99.5% of S. Aureus - Effective in 1 hour - Lasts 12 hours (If surgery is delayed more than 8 hours, reapply antiseptic) - Active ingredient (iodine) = antiseptic, doesn't lead to resistance

Metabolic Acidosis: Symptoms

Neurologic: - drowsiness, confusion, headache, coma CV: - ↓ BP, dysrhythmias (r/t hyperkalemia from compensation), warm flushed skin (peripheral vasodilation) GI: - N/V, diarrhea, abdominal pain Respiratory: - Deep rapid respirations (compensatory action by lungs)

Respiratory Acidosis: Symptoms

Neurologic: - drowsiness, disorientation, dizziness, headache, coma CV: - ↓ BP, V fib (r/t hyperkalemia from compensation), warm flushed skin (peripheral vasodilation) Neuromuscular: - seizures Respiratory: - hypoventilation with hypoxia (lungs not able to compensate when there is a problem)

Neutropenia - Nursing Management

Neutropenic precautions* - Strict handwashing and patient hygeiene - Neutropenic diet* Identify site of infection - Blood culture x 2 sites - Antibiotics - Hematopoietic growth factor (neupogen) - Single patient room - Community isolation - Temp q4 hrs Additional Teaching: - avoid crows, mask in public if have to be in crowds, temperature at least daily, bathe/shower daily & use moisturizer, no gardening, no cleaning up after pets, wash hands after petting animals

Treatment of HTN

Newer treatment guidelines For persons > age 60 start treatment at > 150/90 For persons < age 60 start treatment > 140/90 Goal: Control BP and lower risk factors to protect target organs TARGET #: < 130/80 For Some Populations: <120 Known DM (diabetes mellitus) and/or CAD (coronary artery disease) High risk for CAD patients (i.e. tobacco smokers) EBP: Recent study indicated <120/SBP (rather than 140) decreased significantly major cardiovascular risks and deaths

Management: Multiple Sclerosis

No cure - therapy aimed at managing symptoms Drug Therapy (don't need to know specific meds for MS) - Treatment for acute exacerbations - manage inflammation - Adrenocorticotropic hormone (ACTH), methylprednisolone, prednisone Immunomodulator drugs - delay progression & prevent relapses - Interferon Beta-1b (Betaseron) - SQ every other day, interferon Beta 1a (Avonex) - IM; Rebif (interferon Beta-1b) SQ 3x weekly Immunosuppressive drugs - Methotrexate, Cytoxan Medications to manage symptoms of depression, fatigue, pain, bowel problems, bladder problems, cognitive changes, spasticity, etc. (always be cognizant of secondary medications that address symptoms associated with an underlying condition) Therapy ** PT: stretching, ROM, muscle building, ambulation, water therapy OT: ADL assist & modifications/adaptive devices ST: speech, swallowing Bladder training Nutritional Therapy Megavitamin therapy - Cobalamin & Vit C Low-fat, high-protein, gluten-free food & raw vegetables

Review of A&P Pain

Nociception = the physiologic process of how tissue damage is relayed via the CNS 4 Steps - Transduction 1. Noxious stimuli causes cell damage with the release of sensitizing chemicals - Prostaglandins - Bradykinin - Serotonin - Substance P - Histamine (NSAIDS work to decreases the release of these chemicals) 2. These substances activate nociceptors and lead to generation of action potential - Transmission Action potential continues from - site of injury to spinal cord - spinal cord to brainstem and thalamus - thalamus to cortex for processing (Local anesthetics, anti-seizure, opioids, GABA receptor blockers) - Perception Conscious experience of pain (Behavior methods: distraction & relaxation) - Modulation Neurons originating in the brainstem descend to the spinal cord and release substances that inhibit nociceptive impulses (Anti-depressants) Injury Types Include: mechanical, thermal, chemical

Comparing Types of Pain

Nociceptive - Normal processing of sensory input - Usually responsive to non-opioids & opioids A. Somatic - Superficial: from skin, mucous membranes, SQ Well-localized Sunburn, bruises - Deep: arises muscles connective tissue, joints, bones Localized or diffuse & radiating Arthritic, fractures B. Visceral: arises in organs - poorly localized - often referred to other areas - appendicitis, IBS Neuropathic - Abnormal processing of sensory input by PNS/CNS - Caused by damaged nerves, brain lesions, of CNS structures - Usually also need adjuvant analgesics - Report "sharp, burning, electric shock" feelings of pain Examples: Central: Post-stroke pain/MS Peripheral Neuropathies: Diabetic & herpes Deafferentation: Phantom limb & mastectomy

CAD Risk Factors

Non-modifiable Age - Incidence in men > women until age 75 - Increases with aging Gender - Male often present with classic MI signs & symptoms - Female often present with angina, if having an MI likely to have less classic signs and symptoms (s/sx) - Female under diagnosed, often harder to treat, may have poor outcomes Ethnicity - White middle aged men highest incidence - Increase CAD & death African women than white women Family hx/genetics: Genetic contribution estimated to be as high as 40-60% Modifiable (Major) - Tobacco use - Hyperlipidemia - Hypertension (>140/90) - Diabetes mellitus - Physical inactivity - Obesity Modifiable (Contributing) - Elevated homocysteine - Fasting blood glucose (FBG) > 100mg/dl - Psychosocial factors (stress, anger, depression, hostility)

Acetaminophen (Tylenol)

Nonopiod Analgesics Nonsalicylate

Drug Interventions: Pain

Nonopiod Analgesics Nonsalicylate - Acetaminophen (Tylenol) Salicylates - Aspirin (aka ASA) NSAIDS - ibuprofen (Motril, Advil) - naproxen (aleve) - ketorolac (Toradol) Opioid Analgesics - tramadol (Ultram) - morphine (MS, MS Contin) - hydromorphone (Dilaudid) - hydrocodone (Zohydro ER) - oxycodone (Roxicodone, OxyContin) - fentanyl (Sublimaxe - IV, Duargesic - TD) Combo-Meds -hydrocodone/acetaminophen (Norco, Vicodin) -oxycodone/acetaminophen (Percocet, Tylox) - codeine/acetaminophen (Tylenol #3) Note: often multi-model approach maybe used = using different types of pain medications such as morphine and Torosal not necessary combo products

Aspirin (aka ASA)

Nonopiod Analgesics Salicylate

Clinical Presentation: Rheumatoid Arthritis

Nonspecific c/o: fatigue, anorexia with wt. Loss, stiffness - May report precipitating stressful event: infection, childbirth Joints: Symmetrical involvement! - Stiffness: after inactivity, lasting > 1hr - Pain: often affects small joints (hands) first Inflammation - Redness - Swelling - Tenderness - Increased Warmth Deformities: common in hands & feet - Disability and ambulation issues - CTS (carpal tunnel syndrome)

Normal Sinus Rhythm (NSR)

Normal Waveforms P wave: Atrial conduction QRS: Ventricle conduction T-wave: Vent recovery Rhythm: Regular (how to figure this out? listen or palpate, when you palpate you are feeling left ventricular pressure) Adult rates = 60-100

Nursing Diagnosis: Hypernatremia

Nursing Diagnosis - Risk for injury r/t altered sensorium, LOC, & seizures secondary to hyper/hyponatremia - Potential complication: Seizures & coma - Risk for electrolyte imbalance (hypernatremia) r/t excessive intake of sodium &/or loss of water

Nursing Diagnosis: Hyponatremia

Nursing Diagnosis - Risk for injury r/t altered sensorium, LOC, & seizures secondary to hyper/hyponatremia - Potential complication: Seizures & coma - Risk for electrolyte imbalance (hyponatremia) r/t excessive loss of sodium &/or excessive loss of sodium &/or excessive intake or retention of water

Nursing Management: Hypovolemia

Nursing Management - replace fluid & electrolytes if needed - LR or NS IVF - Fall precautions & bed alarm if neuro symptoms/hypotension present - Head down, feet up if BP is low - strict I&O daily wt. best method for tracking fluid gain/loss*** - quick wt. .changes = fluid; nutritional causes of weight change occurs over longer periods of time - same time each day, zero scale 1L of water/IVF = 1kg (2.2 lbs) - assess for symptoms & lab changes (as indicated above) - frequent skin care & position changes - monitor for mental status changes (Na), fall precautions

Nursing Management: Hyponatremia

Nursing Management Treat underlying cause * if cause is water excess, restrict fluids * PO Slow Sodium tablets, IVF - 0.9% NS, if severe, hypertonic saline (3% NaCl) - Monitor levels, increase gradually to prevent too rapid shift of water from cells to interstitial space -> neuro symptoms - drugs that block ADH/vasopressin will get rid of fluid without getting rid of electrolytes (used in dilutional hyponatremia) - Strict I&O

Nursing Management: Hypernatremia

Nursing Management Treat underlying cause *If primary water deficit (prevent loss & replace water via PO or IVF - D5W or 0.45% NS - monitor levels, reduce gradually to prevent too rapid shift of water back into cells -> cerebral edema - restruct dietary sodium - strict I&O

Blood Typing & Rh Factor

O = Universal donor (everyone can receive O blood) AB = Universal recipient (people with this blood type can receive any blood type) - Rh positive people can get Rh positive or Rh negative blood - Rh negative people can only get Rh negative blood otherwise they may treat the blood as a foreign substance = hemolytic transfusion reaction

Why is DM increasing?

Obesity - 65-70% of US adults overweight - 20% of these persons obese - Sedentary lifestyle Dietary Choices - More processed food - Increased fast food choices - Excessive sugar/CARBS - Lack of fresh fruits & veggies Demographic shifts - Prevalence Type 2 DM increased age Improved detection/dx - 2003: ADA lowered dx criteria for FBG from 140 to 126 - 2010: HgA1C's used to dx

Nursing Assessment: PAD

Obtain PAIN history - Identify risk factors Monitor SCM's closely - Baseline in both limbs - Frequent post-op NV check (Use of Dopple prn) - check incisions/dressings Watch for and Report 6 P's immediately: Could be signs of acute arterial ischemia! - Pain - Pallor - Pulselessness - Parathesia - Polar (cold) - Paralysis

Clinical Manifestations: Hypertension

Often called the "silent killer" because it is frequently asymptomatic until it becomes severe and target organ disease occurs. • Target organ diseases occur in the heart (hypertensive heart disease), brain (cerebrovascular disease), peripheral vessels (peripheral vascular disease), kidney (nephrosclerosis), and eyes (retinopathy). ♣ It is one of the leading causes of end-stage renal disease, especially in African Americans. ♣ Damage to retinal vessels provides an indication of concurrent vessel damage in the heart, brain, and kidney. Manifestations of severe retinal damage include blurring of vision, retinal hemorrhage, and loss of vision. • There is a direct relationship between hypertension and cardiovascular disease (CVD). Hypertension is a major risk factor for coronary artery disease (CAD), stroke, and cerebral atherosclerosis. • Sustained high BP increases the cardiac workload and produces left ventricular hypertrophy (LVH). Progressive LVH, especially in association with CAD, is associated with the development of heart failure.

Diagnosing: DM

One of the following four methods is used! Study Hint: * means memorize normal values and what abnormal values mean for patient care. HgA1C levels - Positive if ≥ 6.5% - Pre-diabetes: 5.7-6.4% **Normal: 4-6% Fasting Plasma Glucose (FPG) Normal ≤126 mg/dL - Positive if &gt;126 - 100 to ≤ 125 = pre-diabetes - Note: NPO ≥ 8 hrs. 2 hr. Oral Glucose Tolerance Test (OGTT) - Drink 75 G glucose solution 2 hrs. after ingestion, blood drawn to √ BG: - Diabetes confirmed if ≥ 200 mg/dL - + Pre-diabetes (IGT) if 140 - 199 mg/dL 4 - Normal < 140 mg/dl Random plasma glucose ≥ 200 mg/dL confirms DM when classic symptoms are present (three poly's, and wt. loss) ***Normal BG: 70 - 110 mg/dL

Ongoing Monitoring: DKA

Ongoing Monitoring - Assess VS, LOC (level of consciousness), O2 sats, telemetry, I&O - Monitor lungs: risk for fluid excess due to high rate IV's - Monitor blood glucose every hour and potassium frequently - Administer Na bicarbonate prn if pH < 7.0 Determine diabetes hx and self-management skills. Try to determine....what the heck happened? How did the patient's glucose get so high? - New diagnosis - Noncompliance? - Knowledge deficit? - Malfunction of pump?

Morphine SQ

Onset 20 min Peak 1-1.5 hrs Duration 4-5 hours

Morphine IV

Onset: rapid 2-5 min Peak: 15-20 min Duration: 1-2 hours

fentanyl (Sublimaxe - IV, Duargesic - TD)

Opioid Analgesics

Interprofessional Care: CAD

Overall Goal: 1. Health promotion to prevent CAD 2. Identification high risk persons 3. Management of high-risk persons a. Encourage lifestyle changes tailored to the individual b. Design/teach specific strategies to reduce modifiable risk factors Examples of Strategies to Decrease Modifiable Risk Factors HTN - Regular B/P checks (home) - Take meds as prescribed - Reduce wt. PRN & salt intake High Lipids - decreased body weight - decrease saturated fat/Cholesterol - increase complex CHO (carbohydrates)/ Fiber - increase Omega-3 fatty acids - lipid reduction meds Exercise Regularly - 30 minutes most days - Plus wt. training 2/week Tobacco Use - Adopt cessation program - Ask for caregiver support Diabetes - Follow recommended diet - Reduce or control wt. - Take meds - SBGM = self-blood glucose monitoring Psych States - Increase awareness & coping/management strategies - Seek help prn if depressed or anxious or angry

Adrenergic Inhibitors

Overall action: decrease SNS effects on BP Central acting - Reduce CNS functioning - Vasodilation - Decrease SVR & B/P - Clonidine (catapres) Side effects - Sedation - Hypotension - Dry mouth - Do NOT stop suddenly as may cause rebound syndrome!

NCP: Diagnoses & Interventions: Hypothyroidism

Overweight/obese - DIET: low calorie to promote weight loss or minimize gains. - Assess height/weight to determine BMI (body mass index) - Develop mutual weight and exercise goals - Instruct on diet (calories), activity and medication effects - Referral to registered dietician prn Constipation - Assess BM patterns: freq., consistency, color, shape, volume - Encourage increased fluid intake - Teach about high fiber foods - Encourage physical activity - Use laxatives / stool softeners PRN Impaired memory - Assess for orientation, cognitive & behavioral changes - Re-orientate prn - Modulate human and environmental sensory stimuli (e.g., visiting sessions, sights, sounds, lighting, smells, and tactile stimulation) based on patient's needs Speak slowly & repeat prn - Involve SO/family - Explain cause of s/sx - Use printed handouts Fatigue - Assess to determine baseline physical status &amp; sleep patterns - Pace & space activities Monitor VS changes r/t activity - Pulse rate - Cardiac rhythm - Blood pressure - Respiration rate - Ask about symptoms: chest pain, DOE, palpitations, dizziness - Assist with ADL's

Methods of Oxygen Administration

Oxygen dosing measures by FIO2 - FiO2 = fraction inspired oxygen - Room air (RA) is approximately 21% FiO2 (don't need to memorize numbers) Low Flow: - Nasal cannula: 1-6 LPM delivers 24-44% FiO2 Moderate Flow - Simple mask: usually 6-12 LPM delivers 35-50% FiO2 - Partial & non-rebreather mask: 10 to 15L 60-90% High Flow - High flow nasal cannula: 6-15 LPM can deliver 21-100% with humidification and oxygen/compressed air - Venti: delivers fixed precise FiO2 (24-50%) for COPD patients - 100% rebreather mask - delivers up to 100% Ventilators - mechanical inhalation of oxygen: assisted for 100% Types: - CIAP = continuous positive airway pressure - CIPAP = bi-level positive airway pressure - Endotracheal intubation - Tracheal intubation Ambu Bag-mask device: delivers up to 100% - used for ineffective resp. or no respirations

Clinical S/sx: 6P's

PAIN: early sign - Distal to injury - Unrelieved despite use of pain meds/ out of proportion - With passive movement - PRESSURE - PALLOR / POLAR - PARESTHESIAS: early sign - PULSELESSNESS (late sign) First will feel decreased - PARALYSIS (late sign) Note: if available to measure ↑ intra-compartment pressure readings: + if > 30 mm HG

How do you assess for pain in patients with altered conciousness or mental impairments? example; advanced dementia

PAINAD/Non-verbal pt scale

Phosphate

PO34- 2.4-4.4

Interventions: Severe CHF

Pacemakers - Newer: Biventricular pacing aka Cardiac Resynchronization Therapy (CRT)

Gallbladder Cancer: Nursing Management

Palliative care - Nutrition - Hydration - Skin care - Pain relief

Aplastic Anemia

Pancytopenia - Decrease of all blood call types RBC's - Anemia WBC's - Leukopenia (increases risk for infection & septic shock) Platelets - Thrombocytopenia - Hypocellular bone marrow

Levodopa with carbidopa (Sinemet)

Parkinsons

Nursing assessment: hepatitis Subjective Data

Past health history - Hemophilia (blood cannot properly clot) - Exposure to infected persons - Ingestion of contaminated food or water - Ingestion of toxins - Past blood transfusion ( before 1992) Other risk factors Medications - Acetaminophen, OTC, or herbal medications Subjective Data: Functional Health Patterns - IV drug and alcohol abuse - Distaste for cigarettes (in smokers) - High-risk sexual behaviors - Weight loss, anorexia, nausea/vomiting - RUQ abdominal discomfort - Urine and stool color - Fatigue/arthralgias/myalgia - Exposure to high-risk groups

Oral Agent Teaching: DM meds

Patient / Family teaching - Medication: action, dose, time of day and SE Risk for hypoglycemia & its treatment - Elderly may experience hypoglycemic unawareness - Importance of diet (wt. loss) and exercise plans - SBGM with records to help evaluate drug therapies &amp; other treatments - Sick day care & possible need for prn insulin during severe illness or injuries (ex. postop)

Interdisciplinary Care: Hypothyroidism

Patient will: - Return to a euthyroid state safely and rapidly which will provide relief of symptoms. - Comply with drug therapy (usually lifelong). Drug Therapy Levothyroxine - Synthyroid - May take several weeks to work Side Effects: (opposite of hypothyroidism) • Chest pain • Tachycardia • Arrhythmias • Dyspnea • Nervousness • Tremors • Insomnia • Wt. loss

OR Team Members

Perioperative nurse/Circulating Nurse - Pt. advocate throughout the intraoperative experience - Monitors pt. condition, documents, assists with counting - Meets pt. in holding area (verifies pr. identity), remains with pt. in OR, transfers pt. to PACU - Not scrubbed in/not in sterile field Scrub Nurse or Surgical Technologist - Assists with sterile procedures - Surgeon - Surgeon Assistant (may be a nurse) - Anesthesia Care Provider (ACP) (Anesthesiologist or nurse anesthetist (CRNA)

Nursing Considerations: Urinary Diversion

Peristomal skin care - Risk for yeast infection - Alkaline encrustations with dermatitis - Excoriation/skin shearing from appliance Application of appliance & drainage bag - Cut circle ⅛ inch larger than stoma diameter - 4x4/tissue over stoma while changing - Skin prep - For pts normally in bed - bag hanging to side - For pts who ambulate - bag hanging down - Wash appliances with soap & water, soak in vinegar, rinse & air dry - Hydration

DI: Clinical Signs/Symptoms & Diagnostics

Polyuria - 2 to 20 L/d - Nocturia common Urine Tests - Very low specific gravity (< 1.005) - N: 1.010 - 1.025 - decreased urine osmolality - increased serum osmolality: r/t hypernatremia (↑NA+) - Polydipsia - Fatigue / weakness Fluid Volume Deficit (FVD): if unable to drink large amounts: look for - Wt. loss - Poor turgor - ↓ B/P - ↑ AP (arterial pressure) - CNS: irritability or dullness, may progress to coma - Hypovolemic shock Water Deprivation Test - Baseline assessment: weight, urine osmolality, specific gravity & amounts - No water 8-12 hours - Given desmopressin acetate (DDAVP) (this is the hormonal replacement for ADH) - Should see decrease in U/O and increase in osmolality - Used to dx Central DI

Nursing Care: Arteriography: For PAD

Pre-Procedure - history of contrast allergies and/or food allergies r/t iodine (shellfish) - Prep if allergic to contrast - Check labs: especially lytes and renal function Obtain VS & PV PE - Need baseline for comparison - Mark foot/arm pulses - Keep NPO/Clear liquids - Clip insertion area/skin prep - Start IV - Patient teaching - Signed consent form - Administer sedatives Post-Procedure - Freq. VS with arterial puncture site checks - Common sites (Femoral/brachial/radial arteries) - RISK bleeding @ site! - Freq. neurovascular assessments (S-sensation C-circulation M's) of affected limb Activity restrictions: limb straight for several hours - May see use of devices to prevent bleeding (Femstop or TR band) - Push oral fluids/IV prn - Monitor I/O: U/O

Causes: Acute Kidney Injury

Prerenal (problem BEFORE the kidney) Factors external to the kidneys that reduce systemic blood flow - Decreased renal blood flow - Decreased glomerular perfusion and filtration - Causes: hypovolemia &/or hemorrhage (dehydration, GI losses, burns) CHF, shock (& septic shock), embolism, renal artery/vein thrombosis - Reversible if cause is corrected Intrarenal (problem IN the kidney) - Conditions that cause direct damage to renal tissue - Impaired nephron function Causes: Acute tubular necrosis (ATN) - caused by ischemia or nephrotoxins (antibiotics - gentamicin, amphotericin B; contrast dye), hemolytic blood transfusion reaction, severe crush injury, chemical exposure (ethylene glycol, lead, arsenic) Other causes: HGB released from hemolyzed RBCs, myoglobin released from necrotic muscle, acute pyelonephritis, acute glomerulonephritis, systemic lupus erythematosus, allergies (antibiotics, NSAIDS, ACE inhibitors) Postrenal (problem AFTER the kidney) - Mechanical obstruction of urinary outflow - ureters, bladder, urethra - Urine refluxes into the renal pelvis - Impaires kidney function - Causes: BPH, prostate cancer, bladder cancer, calculi, trauma (back, pelvis, perineum), strictures

Medications/Allergies: Preoperative Care

Prescription medications (risk for bleeding, over sedation, or unstable blood glucose) - Antiplatelet/anticoagnulant meds: ie. clopidogrel (Plavix), heparin, warfarin (Coumadin) - Anticonvultants, tranquilizers - Antihypertensive medications (many anesthesias cause hypertension) - Diabetic medications OTC (risk for bleeding) - NSAIDS (ibuprofen, Motril, Advil, Midol, naproxen) ASA (Ecotrin, baby Aspirin, Excedrin) Herbal Supplements (risk for bleeding) - Ginkgo biloba, St. John's wort, vitamin E

Aplastic Anemia: Nursing Management

Preventing complications from infection and hemorrhage - How? - See neutropenia & thrombocytopenia Untreated prognosis is poor - 70% fatal Treatment options - Bone marrow transplantation - Immunosuppressive therapy

Angiotensin II Receptor Blockers (ARB's)

Prevents action of A-II & increase Na & H2O excretion - Losartan (Cozaar) - Candesartan (Atacand) Side Effects (ACE's & ARB's) - Hypotension - Loss of taste - Dry cough (ACE's) - Hyperglycemia (increased K+) - Angioedema - Renal impairment

Health Promotion: Prevention of Pneumonia

Prevnar & Pneumovax - Prevents streptococcus pneumoniae - All adults > 65 years old - Persons 2-64: chronic health problems, immunosuppression, smokers, asthmatics, nursing home/LTC residents Flu shot: Given yearly - fall/early winter Prevention: High Risk Pts. - Assess gag & swallowing evaluations PRN Feeding Considerations - Raise HOB 30degrees & sit up for all meals - Be careful with thin liquids - NG feedings: check residuals and hold prn - Early mobilization: up chair and ambulation - Pulmonary Toileting: freq. C & DB, IS use Oral hygiene - Ventilator patients: chlorhexidine BID (post-op) - Other high risk patients: mouth rinses (swish and spit) - Position pts. with altered LOC upright or side-lying - Reposition/turn bedridden patients every 2 hours - Frequent Hand hygiene: Staff and visitors!

Adrenocortical: Hypofunction Aka Adrenal Insufficiency

Primary - Called Addison's Disease - ACTH excess but adrenal gland is not responding Cause is inside adrenal gland - Autoimmune (most common, 80% of cases) - Infections: TB,HIV - Cancer - Adrenal hemorrhage - Lack of all 3 corticosteroid hormones Secondary - ACTH deficit Cause is outside adrenal gland - Hypothalamic problem - Pituitary disease - Suppression by endogenous corticosteroids (prednisone) - Results ↓ glucocorticoids and androgens but NOT mineralocorticoids

INSULIN PUMPS & Continuous BG monitors

Pt. can program basal and bolus doses per CHO counts and BG! • Pump (A) delivers insulin via a SQ catheter (B) Continuous BG monitoring (C) with updates 1 to 5 min. - Newer: not yet widely used due to cost Alerts/alarms for highs/lows BG - Most devices now sync with cell phones - Will send text alert to one/more phones Promotes tighter BG control - About 30% Type 1 pts use pumps - Barriers: costs, knowledge deficits - Newest: insulin delivery device PODs

Insulin: Meal Time Dosing (aka Bolus Dosing)

Rapid Acting Insulin - Novolog or Humolog **Onset: within 10-30 min - Inject 15 minutes ac (before meals) **Peak: 30-3 hrs. min - Used for ↑ BG per SBGM - Used to cover meal intake often with carb counting! - Used in pumps Short Acting - Novolin R or Humulin R - **Onset: 30-60 min • Inject 30-45 minutes ac - **Peak: 2-5 hours Used for ↑ BG per SBGM • Used for NPO patients • Used for TPN patients • Used for immediate post-op CABG patients or other open heart pts (valve) - Used in IV infusions: examples insulin drips or may be added to TPN infusions

NCP: Respiratory: Impaired Gas Exchange

Related to Respiratory infections - Inflammation and/or mucus or fluid in airways - Example: pneumonia - Decreased lung expansion post op or after chest/abdominal trauma - Bronchospasms or alveolar damage AEB: = as evidence by - Abnormal O2 sats/ABG's! - Clinical s/sx: hypoxia/hypercapnia Desired Outcomes - Normal O2 sats room air (RA) - Full expansion via chest x-ray (CXR) - Or return to baseline respiratory function Assessments ALL respiratory equipment: Is it working properly, are settings OK, and is equipment being worn correctly? - monitor for skin breakdown Respiratory physical exam (PE) check effectiveness O2 therapy with: - pulse oximetry - Normal > 90% (normal:___) - ABG's prn (know normal values) Mental Status - Anxiety/restlessness - Lethargy - Somnolence

Collaborative Pain: Pancreatitis

Relieve pain - IV morphine commonly used - May be combined with antispasmodic agent - *No meds to decrease gastric motility Prevention or alleviation of shock - Aggressive hydration - Blood products may be used - O2 - keep sats > 95% Reduction of pancreatic secretions - Allow it to rest, PPI, H2 receptor agonists - NPO Correction of fluid and electrolyte imbalances - LR common Preventions of treatment of infections - Necrotic pancreas- good medium for bacterial growth - Infection leading cause of mortality and morbidity - Enteral feeding reduces this risk (NG tube) Removal of precipitating cause - ERCP plus endoscopic sphincterotomy - Surgical removal of pancreas if conservative measures fail

Aliskiren (Tekturna)

Renin Inhibitor Angiotensin Inhibitor

When teaching a patient about dietary management of stage 1 hypertension, which instruction is most appropriate? Increase water intake. Restrict sodium intake. Increase protein intake. Use calcium supplements.

Restrict sodium intake. The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Protein intake does not affect hypertension. Calcium supplements are not recommended to lower blood pressure.

Sedation Scale

S = Sleep, easy to arouns Acceptable no action necessary, may increase dose if opioid needed 1 =Awake and alert Acceptable no action necessary, may increase dose if opioid needed 2 = Slightly drowsy, easily aroused Acceptable no action necessary, may increase dose if opioid needed 3 = Frequently drowsy, arousable, drifts off to sleep during conversation. Unacceptable; monitor respiratory status and sedation level closely until sedation level is stable at <3 and respiratory status is satisfactory; decrease opioid dose 25%-50% or notify primary or anesthesia provider for orders; consider administering a non sedating opioid-sparing nonopiod such as acetaminophen or a non steroidal anti-inflammatory drug, if not contraindicated, ask patient to take deep breaths every 15-30 minutes 4 = Somnolent, minimal or no response to verbal and physical stimulation Unacceptable; stop opioid; consider administering naloxone; call Rapid Response Team (code blue) stay with patient, stimulate, and support respiration as indicated by patient status; notify primary or anesthesia provider, monitor respiratory status and sedation level closely until sedation level is stable at <3 and respiratory status is satisfactory

Factors Affecting HR

SNS: Stimulates beta receptors causing increased HR and increased force on contractions PNS: Baroreceptor stimulation causes decreased HR & vasodilation Chemoreceptors: stimulated by hypoxia or acidosis increase cardiac functioning

Celexa

SSRI Depression Alzheimers

Med Interventions: Administration: Pain

Scheduling - PRN versus ATC - Anticipatory (pre-procedure, before tx & activity) - Break-through (ability to give med before it's due) - End-of-dose failure (they can make it to 3:40 so maybe it needs to be shorten every 3 hours) Dosing Use of ranges - Example: MS 6 to 12 mg IM q 3 hours PRN Equianalgesic Dosing - Compares a specific med & dose to other choices/doses that would likely be equally effective - Charts used to prescribe equivalent doses when switching meds or route due to unwanted SE's or poor effectiveness Titration - Dose adjustment based on effectiveness vs. SE's using smallest amount possible for effective control

Diagnostic (Dx) Studies: PAD

Segmental blood pressures - Uses Doppler US and sphygmomanometer to determine differences between thigh, below knee and ankle pressures - decrease >30 mmHg suggests PAD Ankle-brachial Index (ABI) - Ankle SBP + Branchial SBP - Obtained with hand-held Doppler US and B/P cuff Doppler US with Duplex imaging - Maps blood flow - Angiography & MRI angiography: to detect exact location & extent lesion(s) - Injection of radiopaque contrast medium into artery with serial x-rays to visualize any plaque

Diagnostics: Hyperthyroidism

Serum Lab Studies - TSH (↓) Free T 4 (↑) - Total T 3 & T 4 not as useful because most are bound to proteins and not biologically active! Radioactive iodine uptake scan (RAIU) - Differentiates Graves from other forms of thyroiditis - + slow diffuse uptake - Assess for iodine allergy - Pt swallows a liquid capsule containing iodine, a probe is placed over the thyroid gland along the outside of the neck Image Studies: might be done if mass/lesion suspected - US - Thyroid scans Other associated tests - Ophthalmologic Exam - 12 Lead ECG/EKG Interprofessional Care: Goals - Block adverse effects of thyroid hormones Suppress hormones over-secretion - Restore euthyroid - Prevent Complications

In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? Serum uric acid of 3.8 mg/dL Serum creatinine of 2.6 mg/dL Serum potassium of 3.5 mEq/L Blood urea nitrogen of 15 mg/dL

Serum creatinine of 2.6 mg/dL The normal serum creatinine level is 0.6 to 1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other laboratory results are within normal limits.

Complications Post-Vasectomy

Short term - Discoloration of the scrotum - Bleeding or hematoma - Surgical site infection - Surgical failure Long term - Begin to produce anti-sperm antibodies - Post-vasectomy pain - Delayed surgical failure - Epididymis - Sperm granuloma

Clinical Manifestations: By Seizure Type - Partial Seizures

Simple Partial Seizures - No loss of consciousness - <1min - May involve motor, sensory, and/or autonomic symptoms Complex Partial Seizure - Alteration in consciousness - > 1 min with postictal confusion, amnesia of the event Behavioral, emotional, affective & cognitive symptoms - Lip smacking, repetitive movements (automatisms), picking at clothing, fumbling with objects (real or imaginary) - Visual or auditory distortions, vertigo - Alterations in memory or thought process

Zolpidem (Ambien)

Sleep Disturbances Alzheimers

Canagliflozin (Invokana)

Sodium-glucose co-transporter 2 (SGLT2) inhibitors Diabetic Medication SE: genital yeast infections, UTI's and thirst

Complications: Urinary Tract Calculi

Stones can lead to - Infection - Complete obstruction - Hydronephrosis - Loss of kidney function

Male Reproductive System

Structures and Function Three primary roles - Produce & transport sperm - Deposit sperm in female reproductive tract - Secrete hormones Reproductive system consists of primary (or essential) organs and secondary (or accessory organs) - Primary reproductive organs are gonads - Testes - Contain seminiferous tubules - Form sperm - Contain interstitial cells - Form testosterone (male sex hormone) Secondary reproductive organs - (Ducts, Sex glands, External genitalia) Ducts: Transport sperm from testes to outside of body Epididymis -> sits on top of testes, transports sperm as they mature Ductus deferens (vas deferens) -> Ejaculatory duct -> Urethra Extends from the bladder, through the prostate, and ends at meatus Glands: Produce & secrete seminal fluid (semen) that surrounds the sperm to form ejaculate Seminal vesicles Prostate gland Located beneath the bladder (urethra passes thorough it) Cowper's glands External genitalia - Penis - Scrotum

Nursing Care: Thyroid Surgery

Study Hint: Know how to recognize possible/actual complications and the related treatments. Recognize equipment needed for room. Be able to teach a person about the post-op care. *** Pre-op Interventions - Teach neck support and limit flexion/extension's Discuss talking limitations - Expect hoarseness & pain 3 - 4 days - Report worsening hoarseness &amp; dysphagia Set up Room - O2 - Suction equipment - Emergency tracheotomy trays /kit Emergency meds: IV Calcium Post-op Interventions: MONITOR FOR POTENTIAL COMPLICATIONS Maintain patent airway! - Semi-Fowler's with neck support - √ for Tracheal compression - Inspect neck/dressing: Anterior/posterior - Monitor resp. effort & rates, √ trachea position - Assess for feelings of choking or neck fullness - Check swallowing ability and frequency - √ for Laryngeal nerve damage Assess speech for hoarseness - Vocal cord paralysis - May lead to spastic airway obstruction Monitor laryngeal stridor - Caused by hemorrhage, edema or tetany Assess/Monitor for Bleeding - VS - Monitor drain amounts - Dressing: Drainage - √ anterior &amp; posterior Tightness /swelling - Monitor for frequent swallowing - Ask about choking sensations - Assess & Medicate for Pain Body image: Disturbance - assess for - Neck incision is visible - Reassure about healing/scar Teaching: s/sx of hypothyroidism, meds & FU care Risk for ↓ Ca 2+ (hypocalcemia) Bedside assessment: √ chvostek's & trousseau's signs - Tingling in toes, fingers or @ mouth - Apprehension - Muscle twitches - Difficulty speaking - Stridor from spasm - Monitor labs N: 8.5-10.5 mg/dl Treatment: IV calcium ASAP!

Surgical Nursing Care: Adrenalectomy

Study Hint: Know the pro/postop care for adrenalectomy including patient teaching. Pre-op Interventions Promote physical health - Control of ↑ B/P & glucose levels - Correction of low K - High protein diet to treat protein depletion Teaching - Specific to planned procedure & related equipment Emotional support - Pt. may feel unattractive or unwanted - Reassure pt. physical changes and emotional lability will resolve when hormone levels return to normal Post-op Interventions Increased Risk for hemorrhage due to vascular adrenal gland(s) - Monitor VS & dressings closely Risk for release of adrenal hormones causing - Unstable B/P's, fluid balance and electrolyte levels. - Strict I & O & daily lab monitoring Assess for infections which may be masked (Ø fever/redness) due to ↓ immune response: √ pain/ purulent drainage/loss of function - Adhere to sterile techniques to prevent infections Corticosteroid Therapy - Hydrocortisone (i.e. SoluCortef) high doses needed several days! - Monitor for related hyperglycemia Monitor for acute adrenal insufficiency: See Addisonian Crisis notes Discharge Teaching: Ambulatory & Home Care - Home nurse referral especially if elderly Medication: lifetime replacement therapies - Will need adjustments - Need for Medic Alert ID & jewelry TEACH: S/sx adrenal insufficiency r/t ↓ corticosteroids - N/V, weakness, fainting, fever, dehydration, - Can be caused by stress, temp extremes, infections, and emotional upsets. Instruct how to avoid if possible. How to adjust their corticosteroid therapy prn r/t increased stress - When to contact providers

Clinical Presentations: COPD

Subjective = History (hx) data Cough - Intermittent - Productive or not Dyspnea - Progressive DOE - At rest - Wheezing - Chest pain: tightness - Anorexia/Weight loss - Fatigue History + RF - Obtain smoking hx - Desire to stop/attempt hx Objective = PE - Tripod positioning - Use of accessory muscles - Increased A/P diameter = barrel shaped Auscultation - Increased Expiratory phase - Wheezing - Adventitious sounds - Decreased breath sounds - Hypoxia with hypercapnia Bluish-red skin color from: - polycythemia (increased RBC's/hemoglobin) - cyanosis - Clubbing - Ankle Edema

PAD: Clinical Symptoms & Signs

Subjective: c/o "PAIN!" Intermittent Claudication - approx. 1/3 pts - Ischemic muscle pain caused by exercise, resolved in approx. 10 min with rest, and is reproducible. Results from buildup of lactic acid Locations: blockage or narrowing causes decrease in size of artery lumen - pain is felt below where the narrowing is - Aortoiliac blockage -> pain felt in buttocks/thigh - Femoral blockage(s) -> pain is felt in calf - Popliteal blockage -> pain in lower calf and foot - Internal iliac -> may lead to may erectile dysfunction - Atypical leg pain: pain (burning, tightness) odd places (ankle, knee) - Rest pain: often @ night in distal feet & occurs with increased limb elevation - Paresthesia's = numbness or tingling from nerve tissue ischemia - Neuropathy = severe, sharp, shooting or burning pain NOTE: Loss of ability to feel pressure and deep pain sensations which increase risk injury OBJECTIVE - Skin: thin, shiny, taunt, hair loss - Decrease or absent pulses (i.e. pedal, popliteal, femoral) - Cool/cold skin Color changes - Elevation pallor - Reactive hyperemia: redness of foot when limb is dependent (aka dependent rubor)

Seizures

Sudden, excessive, uncontrolled electrical discharge of neurons in the brain that interrupts normal function Often symptom of underlying illness Metabolic disturbances Electrolyte/Acid-Base imbalances, hypoglycemia, hypoxia, ETOH & barbiturate withdrawal, significant dehydration Extracranial disorders - Heart, lung, liver, kidney disease - Systemic lupus, erythematosus, DM, HTN, septicemia

GERD: Management

Surgery Anti-reflux surgery - Severe cases that are not managed with meds; stricture; esophagitis; Barrett's - Laparoscopic Nissen fundoplication - Laparoscopic Toupet fundoplication Endoscopic Therapy Stretta Procedure - Radio frequency energy to LES to tighten it - Clear liquid diet, then soft diet for 2 wks - No NSAIDS x 10 days - Mucosal resection and procedures to kill cells through heating when dysplasia exists Post-Op Care - Meds for pain, N/V Assess peristalsis, once returns -> - Start with fluids, slowly - Add solids gradually - Follow all other management suggestions - Dysphagia may be present up to a month d/t edema

Collaborative Care for Lung Cancer

Surgery: - VATS (video assisted thorascopic surgery): near the outside of lung - Wedge of segmental Resection (removed piece) Lobectomy - Removal of one or more lobes - Radiation: Curative, adjunctive, or palliative - Chemotherapy: Curative or Adjunctive

Compartment Syndrome (CS): Fractures

Swelling and increased pressure in a confined space - Causes compression of blood vessels & nerves in myofascial compartments - Forearm (distal humerus) & lower leg (proximal tibia) are most common sites Causes - ↓ Compartment size r/t restrictive dressings, splints, casts or excessive traction - ↑ Compartment contents r/t bleeding, inflammation, edema or IV infiltration Onset: 4-8 hours but may be delayed for several days - May also occur in crush injuries or in compression situations (heavy object or person's own body). Can start within 4-8 hours but may be delayed for several days.

Symptoms: Hypocalemia

Symptoms Result of inc. excitability of muscles & nerves - fatigue - depression, anxiety, confusion - numbness & tingling in extremities & around mouth - osteoporosis, fractures (if chronic) - hyperreflexia * muscle cramps - Chvostek's sign - Trousseau's sign - Tetany, seizures ECG Changes - Elongation of ST segment - Prolonged QT interval - V tach

Symptoms: Left Sided Heart Failure

Symptoms (Hx) - Fatigue/weakness - Dry, hacking cough Dyspnea (know these terms) 1. Orthopnea 2. Paroxysmal nocturnal dyspnea (PND) 3. Dyspnea on exertion (DOE) - Nocturia - Anxiety - Depression Physical Exam = Objective Signs Respiratory - increased RR = tachypnea - decreased O2 sats - Crackles (aka rales) - Pulmonary Edema: Report frothy, pink sputa! - Pleural effusion = fluid shifts into pleural space - diagnosed chest x-ray (CXR) Cardiac - Increased HR (check apical pulse for a full minute) - Displaced PMI (point of maximum impulse) - S3 & S4 heart sounds (may hear a "gallop rhythm" (S4 + S1 + S2 + S3) - Pulses alternans: alternating strong and weak peripheral pulses upon palpation Neuro Changes: mental status changes such as restless/confusion

When caring for elderly patients with hypertension, which information should the nurse consider when planning care (select all that apply.)? Systolic blood pressure increases with aging. Blood pressures should be maintained near 120/80 mm Hg. White coat syndrome is prevalent in elderly patients. Volume depletion contributes to orthostatic hypotension. Blood pressure drops 1 hour postprandially in many older patients. Older patients will require higher doses of antihypertensive medications.

Systolic blood pressure increases with aging, White coat syndrome is prevalent in elderly patients, Volume depletion contributes to orthostatic hypotension, Blood pressure drops 1 hour postprandially in many older patients Systolic blood pressure increases with age and patients older than age 60 years should be maintained below 150/90 mm Hg. Older patients have significantly higher blood pressure readings when taken by health care providers (white coat syndrome). Older patients experience orthostatic hypotension related to dehydration, reduced compensatory mechanisms, and medications. One hour after eating, many older patients experience a drop in blood pressure. Lower doses of medications may be needed to control blood pressures in older adults related to decreased absorption rates and excretion ability.

The UAP is taking orthostatic vital signs. In the supine position, the blood pressure (BP) is 130/80 mm Hg, and the heart rate (HR) is 80 beats/min. In the sitting position, the BP is 140/80, and the HR is 90 beats/min. Which action should the nurse instruct the UAP to take next? Repeat BP and HR in this position. Record the BP and HR measurements. Take BP and HR with patient standing. Return the patient to the supine position

Take BP and HR with patient standing. The vital signs taken do not reflect orthostatic changes, so the UAP will continue with the measurements while the patient is standing. There is no need to repeat or delay the readings. The patient does not need to return to the supine position. When assessing for orthostatic changes, the UAP will take the BP and pulse in the supine position, then place the patient in a sitting position for 1 to 2 minutes and repeat the readings, and then reposition to the standing position for 1 to 2 minutes and repeat the readings. Results consistent with orthostatic changes would have a decrease of 20 mm Hg or more in systolic BP, a decrease of 10 mm Hg or more in diastolic BP, and/or an increase in HR of greater than or equal to 20 beats/min with position changes.

Testicular Cancer: Management

Teaching about TSE (testicular self exam) - Monthly - When warm (during/following shower - What is normal/abnormal - Orchiectomy (surgical removal of testes) - Chemotherapy/Radiation Meticulous follow-up evaluations - 95% obtain complete remission if detected in early stages Emotional support - Men may feel disease is threat to masculinity & self-worth Infertility from treatment is likely - Sperm banking is possible prior to treatment

A patient with newly discovered high BP has an average reading of 158/98 mmHg after 3 months of exercise and diet modification. Which management strategy will be a priority for this patient?

The patient has hypertension, stage 1. Lifestyle modifications will continue, but drug initiation of therapy is a priority. Reduction of BP can help to prevent serious complications related to hypertension.

GERONTOLOGIC CONSIDERATIONS: HYPERTENSION

The prevalence of hypertension increases with age. The lifetime risk of developing hypertension is approximately 90% for middle-aged (age 55 to 65) and older (age older than 65) normotensive men and women. • In some older people, there is a wide gap between the first Korotkoff sound and subsequent beats (auscultatory gap). Failure to inflate the cuff high enough may result in underestimating the SBP. • Orthostatic hypotension often occurs in older adults because of impaired baroreceptor reflex mechanisms, volume depletion, and chronic disease states, such as decreased renal and hepatic function or electrolyte imbalance.

You are the night shift RN on a Cardiac Unit. The telemetry monitor alarms: displaying a slow heart rate 42 bpm on a patient. - Is the patient tolerating this arrhythmia? - What do you need to assess?

The pumping ability of the heart has now changed, the heart pumps oxygenated blood out to the body. We now have decreased tissue perfusion Objective (physical exam) data: Check Responsiveness & CABs Is she alert? C = color (pale, blue, cold, diaphoretic), check pulse (carotid), blood pressure A = is her airway open B = is she breathing - dyspnea - effort - rate - O2 sat No? Call code 5555 Subjective (interview) data: Altered LOC - Dizziness - Fainting (synscope) - Anxious/restless - Confusion - SOB/Dyspnea - Chest pain - Palpitations - N/V - Feeling of impending doom!

Surgical Treatments: Hyperthyroidism

Thyroidectomy - Unresponsive to anti-thyroid therapies - Large goiters causing tracheal compression - Thyroid Cancer Types of Thyroidectomy Surgery - Subtotal - Total Approaches - Open - Endoscopic - Robotic

Clinical Manifestations By Seizure Type - Generalized Seizures

Tonic-Clonic Seizures* - Loss of consciousness & falling to ground - Stiffening of body (tonic phase) - Jerking of extremities (clonic phase) - Cyanosis, excessive salivation, tongue/cheek biting, incontinence, hyperventilation - Postictal phase - muscle soreness, fatigue, sleep for hours, no memory of seizure Atypical Absence Seizure* - Staring spell - Peculiar behavior during the seizure - Confusion after seizure common - Not aware of seizure activity - Can be missed/interpreted as inattention Other Types Myoclonic - Sudden, excessive jerk of body or extremities - May be forceful enough to hurl person to ground - Brief, may occur in clusters Atonic - Drop attack - Tonic episode or loss of muscle tone resulting in falling to ground - Protective helmets Tonic - Sudden onset of maintained increased tone - Falls common Clonic - Sudden loss of consciousness & loss of muscle tone - Limb jerking may or may not be present

Type 1 vs Type 2 Diabetes

Type 1 characteristics Age: More common in children but can occur at any age Onset: s/sx usually start abruptly Prevalence: 5-10 % Insulin: little to no endogenous - Requires insulin Genetics: + genes found Environmental: virus, toxins Nutrition: thin, normal, obese Type 2 characteristics Age: Usually ≥ 35 Onset: often insidious (slow) Prevalence: 90-95% Insulin: endogenous present but insufficient / poorly used - ↑ initially r/t resistance/later ↓ - Some pts may require insulin Genetics: +Family history = risk factor Race: ↑ Africa, Native, Hispanic, Hawaiians Americans Environmental: Obesity, lack exercise Nutrition: freq. overwt/obese

SPUTUM STUDIES: Respiratory

Types of Tests Gram Stain - Permits identification of +/- types to guide therapy until C/S available Culture & Sensitivity (C&S) - Used to diagnoses, select antibiotic & evaluate effectiveness of treatment - Takes 48-72 hours for results AF Smear & Culture - Series of three early morning specimens used for identify active TB (Mycobacterium tuberculosis) Cytology - Container has fixative & is used to identify normal cells Collect ASAP and before starting antibiotics!

Diagnostics: UTI

UA - Nitrates (bacteriuria) WBC's (infection) - Leukocyte esterase (pyuria) - Bacteria - RBCs Urine C&S - Determines type of bacteria & susceptibility to antibiotics

Risk Factors: Urinary Tract Calculi

UTIs Associated with urea-splitting bacteria (i.e.: Proteus, Klebsiella, Pseudomonas) - Creates alkaline urine - Promotes stone formation - Metabolic abnormalities that cause increase urine levels of calcium, uric acid, critic acid - Warm climates (dehydration) Diet - Large intake of protein - increases uric acid excretion - Excessive amt tea & juices - elevate urinary oxalate level - Large intake of calcium - Low fluid intake ** - Genetics - Sedentary lifestyle, immobility

Thoracentesis

Used for dx, remove fluid, or instill meds Pt. Prep - Informed consent form signed & witnessed - Position upright, upright, leaning on over bed table, feet supported & must be still during procedure Procedure - Large bore needle inserted via chest wall after topical anesthetic - Specimens labeled & sent Post-Procedure Care - Lie affected side up to allow for lung expansion - Check dressing with VS assessments - Frequent VS & monitor respiratory status closely - STAT post CXR: r/o pneumothorax After specimens are sent, tube can be connected to drainage bag

LMWH

Used for prevention and smaller DVT - *exoparin (Lovenox): SQ - Does not require frequent lab monitoring or dose changes - *Antidote for LMWH is protamine sulfate

HEPARIN

Used for prevention in high risk pts & treatment large VTE's For VTE treatment - Usually IVP loading dose then continuous IV infusion - Dosing is wt. based & titrated per lab results Therapeutic effectiveness: = **aPTT: N: 25-35 seconds (GOAL: 46-70 sec) - **Anti-factor Xa: N: 0 U/ml (Goal 0.3-0.7): Most common test! For VTE prevention: heparin may be prescribed SQ QD or Q 12 hours Nursing Notes: VTE pts on heparin are often started on Coumadin with daily INR's/PT (overlap therapy for about 5 days) - Coumadin given for several days (4-5) until INR > 2.0 x 24 hrs - Report daily labs to medical providers - Expect dose changes in either Heparin or Coumadin **Antidote for Heparin = Protamine Sulfate

Back Surgery

Used if conservative tx fails, constant pain, progressive radiculopathy, or loss bowel/bladder function Types of Surgery Disk Procedures - Intradiscal electrothermoplasty (IDET) - Radiofrequency discal nucleoplasty - Discectomy - percutaneous = minimally invasive - Laminectomy: note mat include a spinal fusion Spinal Stenosis - Interspinous process decompression (X-stop) Spinal fusion: requires bone grafting or artificial fillers - Such as bone morphogenic protein (BMP): genetically engineered protein used to stimulate bone growth at the graft site

Electric Bone Stimulation: Fractures

Used to facilitate healing process especially for nonunion or delayed union. - Increases calcium uptake. - Activates intracellular calcium stores. - Increases bone growth factor production Example: bone morphogenic protein - Types: skin electrode, or invasive into bone

STAT: Naloxone (Narcan)

Used: for narcotic overdose and to reverse resp depression Post-op resp dep dose: 0.4 to 2 mg IV Mr q 2-3 min up to 10 mg titrated per response Opioid OD: 2 mg IN MR q 2-3 min prn Desired Outcomes: return of adequate RR & O2 sats, alert, without significant pain Monitor: LOC, VS closely - May see re-occurrence of resp dep. - Have oral suction equip. available SE: B/P changes, increased HR & arrhythmias, N/V, sweating

Harmful Effects: Unrelieved Pain

VS: changes-acute pain - increase HR -> heart issues (CP) - increase B/P - increase RR -> hypoxia/atelectasis/ decrease resp. breath -> cough/retain sputa Neurologic - Impaired cognition - confusion/decisions MSK - Impaired function/spasm - Immobility/weakness Endocrine/Metabolic - increased stress hormones - increase E/NE -> VS changes - increase ACTH -> increase cortisol - increase ADH -> fluid retention - increase Renin & Aldosterone - decrease insulin -> increase BG Immunologic - decreased immune response GI - decreased motility -> paralytic ileus, constipation, anorexia

Etiology of VT: "Virchow's Triad"

Venous Stasis - Dysfunctional valves Inactive muscles/prolonged immobility - Prolonged BR/sitting - traveling - Altered mobility states: Leg/Hip fractures., CVA/SCI/Paralysis - Surgery especially hip/knee surgeries - Obesity - Advanced age Endothelial Damage - Direct: IV catheters, trauma, Abdominal/pelvic surgeries & burns - Indirect: Chemo/caustic IV drugs, diabetes, sepsis Hypercoagulability - Hematologic disorders: polycythemia, severe anemia, some cancers & abnormal clotting conditions - High altitudes (develop more RBC because they need the oxygen carrying capability) - Sepsis & septic shock - releases endotoxins - Dehydration & malnutrition - Hormones: oral contraceptives and hormone replacement therapy (HRT) - Cigarette smoking - Pregnancy and post-partum

DVT: Invasive Treatment

Venous Thrombectomy (rarely done) - Surgical removal - Vena cava interruption devices used to prevent PE's in patient's with chronic problems Ex: Greenfield filter EBP: Decrease in insertion rates past 5 years due to adverse reactions. FDA recommends removal after VTE risk declines

Impact on Nursing & Healthcare: Opioid Epidemic

We will see many more people with opioid adduction(s) - ED's will be often be point of entry - Risk to nurses for blood borne pathogens (HIV, Hepatitis), and accidental needle sticks - Risk for more workplace violence - More interaction with law enforcement - Lack of inpatient/outpatient treatment centers will cause delays or no care - Frustrated patients/families - Health care costs related to addiction care will increase Way we treat persons with acute & chronic pain will change - 2016 first national guidelines for opioid use for chronic pain; try other meds/limit # narcotic given in a single prescription - RISK of undertreating/poorly managing patients who truly need narcotics

Inflammatory Bowel Disease (IBD)

What is it? Chronic inflammation of GI tract - Autoimmune condition = systemic symptoms - Periods of exacerbation & remission 2 classifications: - Crohn's Disease & Ulcerative Colitis Causes - unknown & no cure, genetic component

Colorectal Cancer (CRC)

What is it? - 3rd most common cancer, 2nd leading cause of cancer death 85% develop from adenomatous polyps - Can be detected and removed with routine colonoscopy Risk Factors - Men > women - Age, family hx, colorectal polyps & IBD - Obesity, smoking, large intake processed meat, red meat Complications - Obstruction, bleeding, perforation, peritonitis, fistula formation Clinical Manifestations - Symptoms don't appear until disease is advanced - Vary depending on area effected - Left side: bleeding, alternating constipation with diarrhea, change in stool caliber (narrow, ribbon like) & sensation of incomplete emptying, obstruction symptoms appear earlier - Right side: asymptomatic until very late, vague and discomfort or cramping - Fatigue & weakness from anemia Dx. - Colonoscopy w/ biopsy- gold standard - Barium enemas - CT/MRI --- check for further metastasis FOB - Patient needs to avoid NSAIDS, Vit. C, citrus juices and red meats 3 days before tests Staging - I - no invasion beyond submucosa - II - extension into muscularis - III - extension into or through serosa - IV - involvement of lymph nodes - V - distant metastases Management Surgery - only cure - Polyp vs. larger resection - Lymph node removal - Before surgery - prep with polyethylene glycol (MiraLax, GoLYTELY) to cleanse bowel, ATB May have colostomy; location depends on extent of colon removal - Chemotherapy - Radiation therapy - Pain relief - Nutritional support - Emotional support

Appendicitis

What is it? - Inflammation of the appendix Causes - Obstruction - stool, tumor (cecum or appendix) -> distention & accumulation of mucus/bacteria -> gangrene & perforation Clinical Manifestations - Periumbilical pain, anorexia, N/V - Pain is persistent & continuous, eventually shifting to RLQ & localizing at McBurney's point - Localized & rebound tenderness & guarding - Pain increased when R leg is straightened - Rovsing's sign: when left lower quadrant is palpated it causes pain on right, rebound tenderness Complications - Infection - Perforation - Peritonitis Dx. - WBC - elevated - CT (preferred) or - US Management - NPO - ATB (antibiotics) & IVF: 6-8hrs before surgery - Prior to surgery - ice to RLQ ok, avoid heat - Appendectomy

Chronic Glomerulonephritis

What is it? - Irreversible and progressive glomerular fibrosis Characterized by - Proteinuria ** - Hematuria - Slow development of uremia ** Progresses to renal failure over long period Chronic Kidney Disease (CKD -> ESRD)

Peritonitis

What is it? - Localized or generalized inflammation of the peritoneum Primary - directly in peritoneal cavity Secondary - infection develops somewhere else and enters the peritoneal cavity Secondary Causes - Appendicitis with rupture - Blunt/penetrating trauma to abdominal organs - Diverticulitis with rupture - Ischemic bowel disorders - Pancreatitis - Perforated intestine - Perforated peptic ulcer - Postoperative (breakage of anastomosis) - Blood-born organisms - Genital tract organisms - Cirrhosis w/ ascites Clinical Manifestations - Abdominal pain - Rebound tenderness (not as tender when pushing down, but when you raise your palm it's painful), muscle rigidity & muscle spasm - Abdominal distention/ascites, fever, tachycardia, tachypnea, N/V, altered bowel elimination may be present, BS Complications - Hypovolemic shock, sepsis, abscess, paralytic ileus, ARDS (stomach is in pain, can't take as deep breaths, don't want to cough, more chance of developing atelectasis -> develops into acute respiratory distress syndrome) - Can be fatal if not treated promptly DX CBC - increased WBC - Hemoconcentration from fluid shift into peritoneum (less volume..so blood is more vicious) - X-Ray - US & CT - Peritoneal aspiration (blood, bile, pus, bacteria, fungus & amylase content) Management - NPO - NG to suction - ATB, IVF - Oxygen PRN - Surgery to locate cause of inflammation, drain purulent fluid & repair - Drains

Prostate Cancer

What is it? - Malignant tumor of the prostate gland (outer portion) - Average age 65 - ⅕ men will develop prostate cancer - Most common cancer in men, excluding skin cancer 2nd leading cause of cancer death in men - Lung cancer is leading cause of cancer death in men

Testicular Cancer

What is it? - Most common cancer in males between 15-34 years of age

Dialysis

What is it? - Movement of substances (solutes) & water from blood through semipermeable membrane & into a dialysis solution (dialysate) or from dialysate back to blood according to concentration gradients - Used to correct fluid/electrolyte imbalances & remove waste products in renal failure - Treat drug overdoses - Begun when patient's uremia can no longer be adequately managed conservatively - Initiated when GFR (or creatinine clearance) < 15mL/min

Renal Failure

What is it? - Partial or complete impairment of kidney function - Inability to excrete metabolic waste products & water (FVE) -> functional disturbances in all body systems 2 Type - Acute kidney injury (AKI) (reversible) - Chronic kidney disease (CKD)

Acute Kidney Injury (AKI)

What is it? - Previously called acute kidney failure - Reversible loss of kidney function Syndrome characterized by - Rapid loss of renal function - Progressive azotemia (high levels of nitrogen containing compounds) Eventual development of uremia (abnormally high levels of waste products in blood): - Condition in which renal function declines to the point that the symptoms develop in multiple body systems - Often associated with oliguria (< 400ml urine in 24 hours)

Chronic Kidney Disease (CKD)

What is it? - Progressive, irreversible loss of kidney function Defined as presence of either Kidney damage - Pathological abnormalities - Markers of damage Blood (BUN, creatinine) Urine (protein) - Glomerular filtration rate (GFR) < 60 mL/min for 3 months or longer (nl. > 90mL/min) Decreases with age, higher in AA

Diarrhea

What is it? - Stool frequency, volume, & looseness - 3 or more loose or liquid stools/day Causes - Alterations in GI motility, increased secretions, & decreased absorption Ingestion of infectious organisms - Salmonella - undercooked eggs & chicken - E. coli - undercooked meat & chicken - Giardia - contaminated drinking water, lakes, pools - Clostridium difficile (C. Diff) - antibiotics kill off nl. flora - Fecal oral spread - Dumping syndrome: large amts undigested carbs in bowel -> osmotic diarrhea - Laxatives GI Conditions: - Gastroenteritis, Crohn's, Colitis, IBS, Celiac disease, Short gut syndrome Management - Dx.: stool sample to check for blood, mucus, WBCs, parasites; culture; toxins for C. Diff - Focus on underlying cause - Fluid & electrolyte replacement - Antidiarrheal agents contraindicated if infectious diarrhea - Fiber (psyllium) to thicken stool C. Diff Meds - metronidazole (Flagyl) (IV) or Vancomycin (PO) Precautions - Spores survive 70 days on surfaces - Cleaning agent: Bleach - Isolation type: Contact Isolation - Hand hygiene: Hand washing with soap and water, NOT hand sanitizer

Care of the Patient With Cancer

What is it? - Group of more than 200 diseases - Characterized by uncontrolled and unregulated growth of cells Who does it effect? - 77% of cases are diagnosed in those over age 55 - Men > women Incidence & Mortality - decrease in breast, colorectal, lung & oropharyngeal cancer - increase in kidney, thyroid, pancreases, liver, uterus, skin melanoma, multiple myelmona & non-Hodgkin's lymphoma - decreased mortality rates but... 2nd most common cause of death in US - Leading cause of death in people 40-79 years of age Overall Role of the Nurse - Assist in risk reduction & early detection - Help patients comply with management regimens - Provide patient support to pt. & family Biology of Cancer 2 major dysfunctions in the process of cancer development - Defective cell differentiation - Defective cell proliferation (growth) 2 genes that can be effected by mutation - Protooncogenes promote normal cell growth -> Oncogene: promote abnormal cell growth (tumor) growth - Tumor supressor genes: suppress abnormal cell growth -> don't suppress normal growth BRCA1 & BRCA2 -> breast cancer

Naloxone (Narcan)

What is it? Naloxone is a medication that can reverse an overdose that is caused by an opioid drug such as prescription pain medication or heroin How does it work? When administered during an overdose, naloxone blocks the effects of opioids on the brain and restores breathing within two to eight minutes to prevent death

endoscopy

a nonsurgical procedure used to examine a person's digestive tract. Using an endoscope, a flexible tube with a light and camera attached to it, your doctor can view pictures of your digestive tract on a color TV monitor

Partial gastrectomy

a surgical procedure when a part of the stomach is removed.

Patient and Caregiver Education: COPD

a. Avoid persons with respiratory infections b. Avoid respiratory/environmental irritants c. Medication instruction & proper use of delivery devices d. Breathing exercises & proper huff coughing e. Home O2 therapy and precautions f. Vaccines: pneumonia and yearly flu shots g. Smoking cessation instruction and support h. Nutrition considerations i. Psychosocial, sexual, and end of life concerns j. Referrals: Dietician, Discharge planner/Case Manager, Home Nursing, RT: home oxygen, Pulmonary Rehab, & local or on-line support groups, hospice care k. Advanced Directives: Planning for end of life care needs especially for the possibility of needing endotracheal intubation and ventilators l. Early recognition & treatment of respiratory infections to help prevent acute exacerbations/acute respiratory failure requiring hospitalization m. Signs and Symptoms to report: - Increased dyspnea - Increased coughing with significant increases/changes in sputa - Fever - Hypercapnia (confusion, headache, irritability, flushing, diaphoresis, sleepiness) - R-sided heart failure: swelling, weight gains, GI upset

A patient is receiving morphine sulfate intravenously (IV) for right flank pain associated with a kidney stone in the right ureter. The patient also complains of right inner thigh pain and asks the nurse whether something is wrong with h right leg. In responding to the question, the nurse understands that this patient a. is experiencing referred pain from the kidney stone b. has neuropathic pain from nerve damage caused by the acute inflammation c. has acute pain that may be progressing into chronic pain d. is experiencing pain perception that has been affected by the morphine received earlier

a. is experiencing referred pain from the kidney stone - the spread of pain to uninjured tissue is termed referred pain - neuropathic pain refers to pain cased by nerve damage rather than by tissue injury or damage - when pain has lasted less than 3 months and is associated with an acute event (such as kidney stone), it is acute pain - Morphine administration will decrease the perception of pain intensity, but it will not change the location of pain

Rhonchi

are continuous course, rattling sounds often caused by secretions heard during in/expiration

Which of the following is the most important rationale for qualifying a patient for a PCA? a. determine if this pain method will relieve the patient's pain b. evaluate if the patient is mentally alert and able to comply with instructions c. assess the level of pain and use if the patient reports pain at a "6" or higher d. use the PCA only for acute and breakthrough pain

b. evaluate if the patient is mentally alert and able to comply with instructions - the decision to use the PCA is initially determined by the HCP. The patient needs to understand and be physically able to use the devise. Family should not be delivering doses - Evaluation of effectiveness needs to be done after implementation - Once implemented, the patient decides when to use the PCA. A rating of "6" or higher is not required - PCA's can be used for chronic or intractable pain

Teach pt with IBD about dietary modifications the nurse determines that teaching is effective when they choose

baked cod, sweet potato, canned pears

A 68-year old patient with a stroke is unconscious and unresponsive to stimuli. After learning the patient had a history of GERD the nurse will plan to perform frequent assessments of the patient's

breath sounds

An elderly patient with acute pain after outpatient surgery is instructed on his prescribed hydrocodone/acetaminophen (Norco) prescription. Which of the following statements indicate that the client has correctly understood the nurse's discharge instructions? a. "I will take the pain medication faithfully every four hours" b. "The best time to take my medication is after I shower and dress to prevent a fall" c. "The medication worst best when I take it soon after the pain begins" d. "I will take the pain medication whenever the pain reaches a "7" on the pain scale of "10"

c. "The medication worst best when I take it soon after the pain begins" Acute surgical pain is usually managed with PRN oral medication in the home setting. This patient may not need the medication every 4 hours. Pain medication should be taken before the pain becomes severe for optimal effectiveness and might be needed before physical activities such as walking or showering. Fall risks are always a concern but should not result in withholding of analgesics.

Which of the following comments made by the patient indicates that additional instruction about how the care of a new ileostomy is needed - change daily to prevent odors - when i change the appliance i should check the skin for irritation - i should clean the stoma with mild soap and water and pat dry - need to alter appliance opening when the stoma becomes smaller

change daily to prevent odors no, gonna cause further skin irritation

A pt. with advanced cirrhosis who has ascites is short of breath and has an increased respiratory rate. Nurse should a. Initiate oxygen therapy at 2L to increase gas exchange b. Notify the health care provider so that a paracentesis can be performed c. Ask the patient to cough and breath deeply to clear respiratory secretions d. Place the patient in Fowler's to position to relieve pressure on the diaphragm

d. Place the patient in Fowler's to position to relieve pressure on the diaphragm

A postoperative patient who has undergone extensive bowel surgery moves as little as possible and does not use the incentive spirometer unless specifically reminded. The patient rates the pain severity as an "8" on a 10-point scale but tells the nurse, "I can tough it out". To encourage the patient to use pain medication, the best explanation by the nurse is that a. very few patients become addicted to opioids when using them for acute pain control b. there is little need to worry about side effects because these problems decrease over time c. these are many pain medications and if one drug is ineffective, other drugs may be tried d. unrelieved pain can be harmful due to the effect on respiratory function and activity level

d. unrelieved pain can be harmful due to the effect on respiratory function and activity level - the patients low activity level, lack of spirometer use, and statement to the nurse indicate a lack of understanding about the purpose of postoperative pain management - The patient did not express a concern about becoming addicted , a desire for alternate medications, or anxiety related to analgesic side effects

Cardiac Catheterization/Coronary artery angiography

detects location & degree of narrowing in coronary arteries caused by CAD, structural problems (valve issues & chamber wall motion), EF's, chamber pressures

osteoarthritis

inflammation of the bone and joint

On auscultation of this patient's lungs, the nurse hears continuous high-pitched sounds in the right and left lower lobes on inspiration and expiration. The nurse records the findings as a. bilateral stridor b. inspiratory/expiratory wheezes in both lungs c. fine crackles in the right and left lower lobes d. bilateral pleural friction rub

inspiratory/expiratory wheezes in both lungs stridor is an upper lung sounds crackles are usually only heard on inspiration Wheezes are continuous, high pitched musical sounds Stridor is a loud musical sound of constant pitch usually on inspiration heard in the larynx or trachea caused by partial/full obstruction Crackles are discontinuous low-pitched (fine) or "bubbling" (course) sounds heard during end of inspiration Pleural friction rubs are grating/rubbing sounds that are heard during both inspiration and expiration.

Sims position

lying on left side with right knee drawn up and with left arm drawn behind, parallel to the back helps with post-op Laparoscopic cholecystectomy

Prokinetics

metoclopramide (Reglan) For nausea AND GERD - increase peristalsis

Tolerance

need for increased amounts of meds to achieve same effects

The patient's blood pressure has not responded to the prescribed drugs for hypertension? Which should the nurse assess first?

patient's adherence to drug therapy, first ask, are they even taking the meds? side effects of HTN may be so undesirable they dont take it

Total proctocolectomy with permanent ileostomy

removal of colon, rectum &amp; anus, with closure of anus and new ileostomy

Anticholinergics

scopolamine transdermal (Transderm Scop) For nausea

AEROSOL

solid or liquid particles suspended in a gas Example: suspension of a drug dispensed in a cloud or mist Aerosol Therapy: Overview The major purpose of this is the delivery of medications or humidity or both to the mucosa of the respiratory tract and pulmonary alveoli. Agents delivered by aerosol therapy may act in a number of ways: 1) relive spam of the bronchial muscles 2) reduced edema of the mucous membranes 3) make secretions more liquid for easier removal 4) humidify the respiratory tract 5) administer meds locally by depositing them in the respiratory tract

miglitol (Glyset)

ά -Glucosidase Inhibitors Diabetic Medication

Blood Pressure Measurement

• Accurate BP measurements are critical. An important role of the nurse is to provide patient and caregiver teaching regarding measuring BP at home. • Orthostatic hypotension is defined as a decrease of 20 mm Hg or more in SBP, a decrease of 10 mm Hg or more in DBP, and/or an increase of 20 beats per min or more in pulse from supine to standing. • Orthostatic (or postural) changes in BP and pulse should be measured in older adults, in patients taking antihypertensive drugs, and in patients who report symptoms consistent with reduced BP upon standing (e.g., light-headedness, dizziness, syncope).

Interprofessional Care: Hypertension

• Lifestyle modifications are indicated for all patients with prehypertension and hypertension. These include (1) reducing weight (if appropriate), (2) using the DASH eating plan, (3) restricting dietary sodium and alcohol intake, (4) avoiding tobacco products, (5) participating in physical activity, and (6) reducing psychosocial risk factors that contribute to the risk of developing CVD.

Etiology Hypertension

• Primary (essential or idiopathic) hypertension is elevated BP without an identified cause. It accounts for 90% to 95% of all cases of hypertension. • Secondary hypertension is elevated BP with a specific cause. It accounts for 5% to 10% of hypertension in adults.

Pathophysiology of Primary Hypertension.

• The hemodynamic hallmark of hypertension is persistently increased systemic vascular resistance (SVR). • This persistent elevation in SVR may occur in various ways. Defects in any of the mechanisms involved in the maintenance of normal BP, including sodium intake, the renin-angiotensin-aldosterone mechanism, and sympathetic nervous system (SNS) stimulation, can result in the development of hypertension. • Defects in glucose, insulin, and lipoprotein metabolism are common in primary hypertension. • Contributing factors to the development of hypertension include cardiovascular risk factors combined with socioeconomic conditions and gender and ethnic differences. • Endothelial dysfunction is recognized as a marker for CVD including primary hypertension

NURSING MANAGEMENT: PRIMARY HYPERTENSION

• The primary nursing responsibilities for long-term management of hypertension are to assist the patient in reducing BP and complying with the treatment plan. • Nursing actions include evaluating therapeutic effectiveness, detecting and reporting any adverse treatment effects, assessing and enhancing compliance, and patient and caregiver teaching. • Patient and caregiver teaching includes the following: (1) nutritional therapy, (2) drug therapy, (3) lifestyle modification, and (4) home monitoring of BP (if appropriate).

Metabolic Alkalosis

↑ pH > 7.45 / ↑ HCO 3 > 26 / nl. PaCO 2 = uncompensated ↑ PaCO 2 = compensated Cause: - Severe vomiting - Excess gastric suctioning* - Diuretic therapy - Potassium deficit - Excess NaHCO 3 intake - Excessive mineralocorticoids Patho: - Loss of strong acid or gain of base- Compensatory response of CO 2 retention by lungs Symptoms: Neurologic: - dizziness, irritability, nervousness, confusion CV: - tachycardia, dysrhythmias (r/t hypokalemia from compensation) GI: - N/V, anorexia Neuromuscular: - tetany, tremors, tingling of fingers & toes,muscle cramps, hypertonic muscles, seizures Respiratory: - hypoventilation (compensatory action by the lungs) Nursing Management: - Correction of underlying cause - Administration of NaCl (Cl helps diminish bicarb reabsorption)

Addison's disease: s/sx: often slow onset

↓ Glucocorticoids - Fatigue / weakness - Anorexia/N&V - Wt. loss - Diarrhea Skin: hyper pigmented bronzed coloring - Addison's only r/t ↑ ACTH - Weakened immune system - Hypoglycemia ↓ Mineralocorticoids Fluid & electrolyte - Hypovolemia - Hyponatremia: c/o "Salt cravings" - Hyperkalemia Cardiovascular - Decreased C/O - Orthostatic ↓ B/P

Biguanides

↓ liver glucose production & ↑ tissue (muscle) uptake - Metformin (Glucophage) - Take with food 1st line drug for many pts & is used to treat pre-diabetes • *CLINICAL ALERT: Must be held 24-48 hours before & 48 hours after IV contrast media! Resume when serum creatinine levels are normal. Do not give to ETOH abusers, kidney disease, liver disease or heart failure patients. • SE: wt. loss, diarrhea, lactic acidosis

Respiratory Acidosis: Lab Values

↓ pH< 7.35 ↑ PaCO2 > 45 nl. HCO 3 = uncompensated ↑ HCO 3 = compensated

Obtain history of injury: Fractures

- Ask about mechanism Ask about circumstances - Setting - Drugs and/or alcohol involved - Vehicles damaged - Police involved - Ask if protective equipment was worn - Inquire other possible injuries besides obvious Ask about other persons - Loved ones injured or killed - Family nearby

How is osteoporosis diagnosed?

- Bone Mineral Density (BMD) Test - Height assessment: loss of height & stooped posture

Nephrostomy: Catheter

- Temporary to preserve renal function when there is complete obstruction of ureter - Inserted directly into the renal pelvis - Assess for output, kinking, never irrigate with more than 5mL sterile sol.

Respiratory Acidosis: Nursing Management

- review ABGs - Improve ventilation - Reverse underlying cause

Cilostazol (Pletal)

Antiplatelet Used for PAD

Types of Pain Management

Drug Interventions - Nonopiods & opiods - Adjuvants - Administration consideration s Non-pharm Interventions Interventional Therapy - Nerve blocks

Potassium

K+ (Cation) 3.5-5.0

Treatment: Lower Back Pain

Medications - Analgesics: NSAIDS - Muscle relaxants - Massage /manipulation Brief rest period - Supine - Side lying with knee flexion - 1-2 days Thermotherapy - Hot/cold treatment

Pulse oximeter

O2 saturation measures the percentage of hemoglobin binding sites occupied by oxygen

Nurse is teaching diabetic pt. how to differentiate hypoglycemia from hyperglycemia. If its high which of the following will develop

Polyuria, fruity breath, thirst, nausea/vomiting

Antidote for Coumadin

Vitamin K & Kcentra

promethazine (Phenergan)

anthistamine nausea med

Sulfasalazine (Azulfidine)

used for IBD

Heart Failure

- Condition related to impaired pumping and/or filling - Results in insufficient blood flow & oxygenation to tissues - Acute (develops suddenly and often reversible) or Chronic Heart Failure Stats (don't memorize) - 650,000 estimated new cases per year - increased rates due to aging population and better heart attack survival rates - African americans higher incidence and mortality Most common dx hospital admits > 65 yrs Risk Factors Coronary Artery Disease - HTN - High cholesterol - DM - Tobacco use - Obesity - Sedentary Lifestyle - Hypertension (HTN) Etiology - CAD/AMI - HTN/HTN crisis - Valvular disorders - Rheumatic Disease - Congenital heart defects - Myocarditis - Pulmonary HTN - Hyperthyroidism Precipitating Causes: related to increased ventricular workload - Anemia Infection - Bacterial endocarditis Thyroid Problems - Thyrotoxicosis - Hypothyroidism - Arrhythmias - Obstructive Sleep Apnea - Pulmonary Embolism - Hypervolemia - Pulmonary Embolism - Nutritional deficits Left HF - systolic failure: Left ventricle has decreased ability to effectively eject blood through aorta (reduced ejection fraction - EF) results in... - Blood backing up into atrium & pulmonary veins, which leads to... - Increased pulmonary intravascular pressure causing fluid shifts out of vessels leading to pulmonary congestion and may cause pulmonary edema Left HF - diastolic failure: ventricles cannot fill resulting in decreased stroke volume & cardiac output - Mixed systolic & diastolic (many patient's have both) Symptoms (Hx) - Fatigue/weakness - Dry, hacking cough Dyspnea (know these terms) 1. Orthopnea 2. Paroxysmal nocturnal dyspnea (PND) 3. Dyspnea on exertion (DOE) - Nocturia - Anxiety - Depression Physical Exam = Objective Signs Respiratory - increased RR = tachypnea - decreased O2 sats - Crackles (aka rales) - Pulmonary Edema: Report frothy, pink sputa! - Pleural effusion = fluid shifts into pleural space - diagnosed chest x-ray (CXR) Cardiac - Increased HR (check apical pulse for a full minute) - Displaced PMI (point of maximum impulse) - S3 & S4 heart sounds (may hear a "gallop rhythm" (S4 + S1 + S2 + S3) - Pulses alternans: alternating strong and weak peripheral pulses upon palpation Neuro Changes: mental status changes such as restless/confusion Right Sided Main cause is primary L-sided failure Right HF: right ventricle fails to pump blood effectively - Blood backs up into right atrium and superior & inferior vena cava - increased pressure superior vena cava = jugular vein distension (JVD) increased pressures inferior vena cava: leads to - sudden wt. gains Edema - Peripheral - Abdominal ascites - GI Concerns Symptoms (Subjective) - Fatigue - Dependent bilateral edema - RUQ Pain GI Complaints - GI Bloating - Anorexia/nausea - Anxiety - Depression Signs (Objective - PE) - JVD - Weight gain Edema: Note location and amount chart using numeric scale - Pitting dependent: Limbs - especially feet/ankles If bedridden: check sacrum/scrotum - Anasarca (massive generalized body edema) GI - Ascites: fluid in abdomen - Hepatomegaly: liver enlargement - Tachycardia Complications: HF Pleural effusion - Shifting of fluid from capillaries into pleural spaces - S/sx: dyspnea, cough, and chest pain Pulmonary Edema = Medical emergency! - Fluid/blood in alveoli/interstitial spaces - S/sx: dyspnea, orthopnea, tachypnea, accessory muscle use, productive cough with frothy (pink) sputa, crackles/wheezes, skin: cool, clammy, cyanotic Dysrhythmias Atrial Fibrillation most common - Risk for atrial emboli leading to CVA Risk for Ventricular Fibrillation (VF)/Vent Tachycardia (VT) - if Ejection Fraction (EF) < 30% Normal EF 55-60% - Note: EF = % diastolic blood volume ejected during systole - basically how much blood gets pumped per each beat from left ventricle - Left ventricular thrombus: stroke s/sx - Hepatomegaly: congestion leads to impaired function - Renal failure: decreased perfusion may lead to insufficiency and end-stage renal disease (ESRD) Diagnostic Tests: Heart Failure Lab Studies B-type natriuretic peptide (BNP): Heart hormone - Correlates positively with degree of left ventricular dysfunction - Used to differentiate possible causes for dyspnea - increased BNP is associated with cardiac problems vs respiratory causes - N-terminal prohormone of BNP (NT-proBNP) - Newer more precise test - CBC (complete blood counts) - Thyroid function tests - Cardiac Biomarkers: Troponin, CPK-mb, myoglobin - Liver function tests - Lipid Profiles - Lytes: baseline & to monitor drug SE's - Renal studies - ABG's More Diagnostic Heart Studies - Chest X-ray (CXR): check heart size & baseline lung status - 12 Lead Electrocardiogram (EKG/ECG): r/o acute myocardial infarction (AMI) & assess rhythms Echocardiogram (Echo): uses ultrasound to measure ventricular and valve functioning, chamber sizes & EF - Transesophageal Echocardiogram (TEE) - Nuclear Imaging Studies: uses radioactive isotopes to image heart & measure EF (ejection fraction) - Cardiac Catheterization/Coronary artery angiography: detects location & degree of narrowing in coronary arteries caused by CAD, structural problems (valve issues & chamber wall motion), EF's, chamber pressures Interventions: Chronic Heart Failure (CHF) - Semi-Fowler's - Oxygen via nasal cannula (NC) prn - Rest-activity periods - Medications- Diet/Fluid Restrictions - Daily weightsImplanted devices - Biventricular Pacers (newer device)ICD's (implanted cardioverter-defibrillator) used if poor ejection fractions (<30%) - Device will cardiovert, defibrillate, and pace as needed by sensing pts - Home Health - Cardiac Rehabilitation Nursing Care Impaired Gas Exchange Monitor Respirations - Rate, rhythm, depth, effort - Check breath sounds - Monitor s/sx hypoxia - Watch/Monitor/Assess for pulmonary edema! Oxygen Therapy - Administer O2 prn via device needed to be effective Evaluate O2 sats - Keep > 90% - use nasal cannula (NC) during meals Position Semi-to high Fowlers Activity Intolerance Pace and space! (Alternate rest and activity periods) Monitor response to activity o √ VS changes: before, during, after o ♥ Rhythm &amp; watch for arrhythmias o Assess signs &amp; symptoms of intolerance - Instruct regarding activities - Referrals: PT, OT, RT, Exercise specialist & Cardiac Rehab • PT = physical therapy; OT = occupational therapy; RT = respiratory therapy

Diagnostics: GOUT

- Elevated serum uric acid levels - Elevated 24 hour urine for uric acid levels

PaCO2

35-45mmHg low = resp alkalosis high = resp acidosis

Normal BG range

70-110 mg/dL

PaO2

80-100mmHg

Losartan (Cozaar)

ARB's Angiotensin Inhibitor

Veins

Carry deoxygenated blood towards heart

budesonide (Entocort)

Corticosteroid for IBD helps achieve remission

vasopressin (Pitressin)

Diabetes insipidus ADH replacement therapy

Amlodipine (Norvasc)

Dihydropyridines Calcium Channel Blocker

Nifedipine (Procardia)

Dihydropyridines Calcium Channel Blocker

Sitagliptin (Januvia)

Dipeptidyl Peptidase - 4 (DDP-4) Inhibitors Diabetic Medication

Spironolactone (Aldactone)

Diuretic (Aldosterone Receptor Blocking)

Clinical Manifestations: Diverticulosis & Diverticulitis

Diverticulosis - Usually no symptoms - Abd pain, bloating, flatulence &/or changes in bowel habits - 25% progress to diverticulitis Diverticulitis - Localized pain over involved area of colon, usually LLQ - Fever, leukocytosis, bloating, palpable abdominal mass

Acetaminophen (Tylenol)

Do not exceed 3g/day - newer guidelines Osteoarthritis

Management

Medications - Suppress inflammatory cytokines & other mediators - Medications may be delivered PR or systemically - Sulfasalazine (Azulfidine)-Principal drug used During acute attacks: - Metronidazole (Flagyl)/ciprofloxacin (Cipro) - Corticosteroids such as prednisolone & budesonide (Entocort) - help achieve remission Immunosuppressants to maintain remission - 6-mercaptopurine, azathioprine (Imuran) - Methotrexate for Crohn's (SE: flu-like symptoms, bone marrow depression, liver dysfunction) Anti-tumor necrosis factor agents (Remicade, Humira, Cimzia) - Patients can develop antibodies against them = infusion reaction & delayed hypersensitivity reaction Adjunct medications* - Cobalamin, cholestyramine, PRBCs, iron Diet - During Flares Low Residue Foods - Bananas, applesauce, no added sugars, rice, baked chicken, baked salmon, yogurt - Fluids (between meals) - Small meals Surgery - 75% Crohn's eventually require surgery - Reserved for emergency situations (hemorrhage, obstruction, perforation, peritonitis), fistulas, or when medications have failed - Strictureplasty - widen areas of narrowed bowel - Resection of diseased bowel Total Colectomy with ileoanal reservoir - removal of colon , use part of ileum to form a new "rectum" (ileoanal reservoir) - Temporary ileostomy - Total proctocolectomy with permanent ileostomy - removal of colon, rectum & anus, with closure of anus and new ileostomy Postoperative Care - Stoma care & teaching re new ostomy - Ileostomy - 1500-2400mL output in 1 st 24hrs - Assess for hemorrhage risk, SBO, dehydration - NG to suction until bowel function returns Fetal incontinence with new ileoanal reservoir - Perianal care, barrier cream, kegals - Risk for infection to surgical incision Nutritional Therapy: - High-calorie - High-protein - Low-residue diet (lower fiber) Avoid foods that make diarrhea worse (different for everyone) - Food diary - ETOH, coffee, soda, spicy foods, beans, fatty foods, high-fiber foods, nuts/seeds, raw fruit with skins &amp; uncooked vegetables, red meat & dairy. - Follow BRAT diet Elemental diets (for significant losses or malabsorption) - Liquid - high in calories &amp; nutrients, lactose free &amp; absorbed in proximal SI (allows distal bowel to rest) - TPN - in very severe cases, allow bowel to rest & promote positive nitrogen balance Supplements & Meds After Surgery & Beyond - Cobalamin (when terminal ileum involved) - Cholestyramine (binds to bile salts, which are normally reabsorbed in ileum, & contribute to diarrhea when not reabsorbed) - Folic acid (1mg folate) for pts taking sulfasalazine - Calcium for pts taking corticosteroids - Iron

Celebrex

NSAID COX-2 inhibitors RA

Potassium

Normal Range 3.5-5mEq/L Function - Maintain resting membrane potential of nerve & muscle cells - cellular & metabolic functions - regulated intracellular osmolality & promotes cellular growth - role in acid-base balance Absorption Excretion Regulation - diet - urine, feces, sweat - kidneysL inverse relationship between Na & K reabsorption in the kidneys

Sprains & Strains

RICE treatment often prescribed along with NSAIDS R = rest I = ice C = compression (often ACE wrap) E = elevation

Gastroduodenostomy/Billroth I

Removal of distal 2/3 of stomach and reconnection of remaining stomach with duodenum

-ide

diuretics

Methotrexate

for Crohn's SE: flu-like symptoms, bone marrow depression, liver dysfunctions

Serotonin antagonists

ondansetron (Zofran) For nausea

Bradypnea

< 12 breaths/min

Allopurinol (Zyloprim)

Chronic Gout

Febuxostat (Uloric)

Chronic Gout

Chloride

Cl- (Anion) 98-108

PUD: Clinical Manifestations

Gastric ulcers - Burning & gaseous pain upper epigastric area 1-2 hrs. after eating Duodenal ulcer - Burning or cramp-like pain mid-epigastric area, below xiphoid process 2-5 hrs. after a meal - Back pain may be present - Caused by gastric acid aggravating the ulcer

Bicarbonate

HCO3- (Anion) 22-26

CO

HR x SV

Emergency: HTN Crisis

HTN Urgency - Develops over days to weeks BP >180/110

Novolin N / Humulin N

Intermediate Acting Insulin - Onset: 1.5 - 4 hours **Peak: 4-12 hours - Cloudy; must be agitated before removal vial

Goiter

Most common cause is iodine insufficiency Note: a goiter may result in hyper/hypo functioning

Cyclobenzaprine (Flexeril)

Muscle Relaxant: Fractures

Methocarbamol (Robaxin)

Muscle Relaxant: Fractures

BP Categories for Adults

Normal: <120 SPB and <80DBP Hypertension(HTN): Stage 1: SBP 130-139 or DBP 80-89 Stage 2: SPB >140 or DBP >90 Normal Range for Adults is 100/60 to 129/89 is normal range

Nursing Diagnosis: Hypokalemia

Nursing Diagnoses - Risk for electrolyte imbalance r/t excessive loss of potassium secondary to - Risk for injury r/t muscle weakness & hyporeflexia - Potential complication: dysrhythmias

Tramadol (Ultram)

Opioid Analgesics

An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. What explanation for this drug should the nurse give?

The medicine is given to help your body respond to stress after the removal of the adrenal glands

Wheezing

is caused by airway narrowing and bronchospasms (c/o chest pain)

digitalis

strengthens the contraction of the heart muscle, slows the heart rate, and helps eliminate fluid from body tissues may cause N/V used: CHF, atrial arrhythmias

acarbose (Precose)

ά -Glucosidase Inhibitors Diabetic Medication

Respiratory Alkalosis

↑ pH>7.45 ↓ PaCO2 < 35 nl. HCO 3 = uncompensated ↓ HCO 3 = compensated

Corticosteroid Tx: Self-review

**KEY POINTS: r/t long-term use - Always know the reason why your patient is taking this med! NEVER stop corticosteroids abruptly if taken for > 1 week! - Use > 1 week may suppress ACTH causing decreased endogenous cortisol levels - Abrupt stop may lead to Addisonian Crisis - Doses must be tapered/decreased slowly! - During hospitalization/illness/stress, doses often need to be increased then gradually decreased to baseline.

Significance & Causes: Chronic Kidney Disease

- 26 million Americans have CKD 1 out of every 9 - More common thank AKI - Leading causes Diabetes Hypertension

HEPATITIS B VIRUS (HBV)

- Acute or chronic disease - Incidence decreased with vaccination DNA virus transmitted - Perinatally (from mother to child) (can still breastfeed children) - Percutaneously - Via small cuts on mucosal surfaces and exposure to infectious blood, blood products, or other body fluids At-risk populations - Men who have sex with men - Household contact of chronically infected - Patients undergoing hemodialysis - Health care and public safety workers - Transplant recipients *Vaccine Available*

Nursing Diagnoses for Fractures:

- Acute pain - Impaired physical mobility - Risk for peripheral neurovascular dysfunction -Readiness for enhanced self-health management Outcomes: Match with above nursing diagnoses - Reports satisfactory pain management - Experiences no immobility problems & demonstrates correct use of assist devices - Normal NV function - Verbalizes rationales for treatment & performs activities as prescribed

Stomach Cancer

- Adenocarcinoma of the stomach wall Risk Factors - Mucosal injury - causes changes in cells - H. pylori infection - Repeated exposure to irritants - bile, anti-inflammatory agents, tobacco use - Diets high in smoked meats, salted fish & pickled vegetables - Obesity - Hx. gastritis, pernicious anemia, gastrectomy for PUD Clinical Manifestations Late Symptoms: - Unexplained wt. loss - Lack of appetite - Indigestion - Abdominal discomfort/pain Anemia - Pale, weak, fatigue, dizziness, possible SOB - Chronic blood loss as the lesion erodes through mucosa or destroys areas of intrinsic factor - Mass in epigastrium may be felt

Risk Factors for Primary HTN

- Age: SBP increases with age - Gender: older males young and early middle age females >64 - Ethnicity: 2x increase for african americans - Family history - Increased alcohol use - Smoking tobacco - Diabetes - Obesity - esp. central - Sedentary lifestyle - Increased serum lipids - Increased sodium diets: 1 in 3 persons who eat high NA diets develop HTN Socioeconomic status - More prevalent in lower income levels and less educated person's - Stress

HEPATITIS D VIRUS (HDV)

- Also called delta virus - Defective single-stranded RNA virus - Cannot survive on its own - Requires HBV to replicate - Transmitted percutaneously - No vaccine

Diagnotic Studies: Myasthenia Gravis

- H & P - EMG - Tensilon test

Medical Diagnosis: Lung Cancer

- H&P - CXR: detects mass, infiltrates, mediastinal involvement and lymph nodes Imaging - Check lungs & r/o mets - CT scan: most common Spiral lung (also done for screening) Total body & bone - Others: MRI, PET Invasive Testing Biopsy - CT Needle Aspiration - Bronchoscopy - Mediastinoscopy - Video assisted thorascopic surgery (VATS) Useful for dx type of CA, staging (TNM) & evaluation of treatment

Diagnosis of Cancer

- Health history, HPI - Identification of risk factors - Physical examination Diagnostic studies - Cytology Biopsy - Punch, fine needle aspiration, large-core, excisional, endoscopic, surgical Imagine - X-ray, mammography, CT, MRI, US, PET Blood Tests - CBC, chemistry profile - Liver function studies Endoscopic examinations - Colonoscopy, upper GI - Tumor markers

Polycythemia - Nursing Management

- Hydration to reduce viscosity - Phlebotomy to reduce hematocrit - Low dose ASA - Medications as prescribed - Allopurinol to reduce gouty attacks

Hyperthyroidism

- Hyperactivity of gland resulting in sustained increase in synthesis and release of thyroid hormones (T3 & T4) Affects women more than men - Most common in 20-40 years old - May be precipitated by exposure to iodine based contrast media (CT scans/angiography studies) Grave's Disease - Causes 75% hyperthyroidism - Autoimmune condition of unknown origin: ↑ size gland resulting in excess hormones (T3/T4) Other Causes of Hyperthyroidism - Toxic nodular goiter -Thyroid cancer - Thyroiditis - Excess iodine intake - Pituitary tumors (excess TSH)

Diagnostics: Acute Glomerulonephritis

- Increased blood urea nitrogen (BUN) - Increased serum creatinine UA - Protein 1-3+ - Casts - Blood - WBCs - ASO titer to ID & treat strep infection

Renin Inhibitors

- Inhibits renin, thus reducing conversion of angiotensin to angiotensin - Aliskiren (Tekturna) Renin inhibitors - risk for angioedema! Note: ASA & NSAIDS may decreased effectiveness

Metabolic Alkalosis: Patho

- Loss of strong acid or gain of base - Compensatory response of CO 2 retention by lungs

Leukemia - Treatment: Bone Marrow Transplant

- Major impact on AML - Goal: eliminate leukemic cells from the body Prior to transplant chemo and total body irradiation - Destroy malignant cells - Inactive immune system - Decrease risk of rejection - Empty marrow cavities to provide space - About 40-50% develop rejection scs

Recovery: hepatitis

- Most patients recover completely with no complications - Most cases of acute hepatitis A resolve - Some HBV and majority of HCV result in chronic hepatitis

N & V: Clinical Manifestations

- Nausea: increased salivation, increased GI motility, anorexia - Dehydration Loss of water/electrolyte imbalance - Decreased Na, K, H, Cl - Decreased extracellular fluid/plasma volume - Metabolic alkalosis (loss of gastric hydrochloric acid) - Wt. loss Aspiration - Elderly, unconscious, loss of gag reflex (CVA) - Semi-Fowlers or side-lying position

Diagnostics: Multiple Sclerosis

- No definitive test MRIs over time show multiple lesions - White-matter lesions in brain and spinal cord - Sclerotic plaques CSF - In some cases, increased immunoglobulin G, lymphocytes & monocytes

Clinical Manifestations: Esophageal Cancer

- None until extensive tumor growth - Progressive dysphagia (first with meat, then soft foods, then liquids) - Feeling of food not passing - Substernal, epigastric pain; increases with swallowing - Pain may radiate to neck, jaw, ears & shoulders - wt. loss - Regurgitation of blood-tinged esophageal contents

PE: Medical dx

- O2 sats/ABG's: assessments - D-dimer: increased levels with clot degradation Spiral (helical) CT scan: becoming most frequently used dx test - Aka CT angiography (CTA) - Requires IV contrast Perfusion/Ventilation (VQ) Nuclear Scan - Often used if + contrast allergy - Pulmonary arteriography: requires the insertion of an arterial catheter, advancement of catheter into the pulmonary artery, and injection of contrast. Being replaced by CTA

Interprofessional Care: Pneumonia

- O2 therapy prn Drug Therapies Antibiotics: - CAP & HAP tailored per patient's risk factors - Especially if multi-drug resistance (MDR) organism suspected - Antipyretics (for fever) - Analgesics - Others: bronchodilators, corticosteroids, mucolytic, cough suppressants - Increased hydration: fluid intake (3 L/day) - Activity: Limited and encourage rest - Positioning: increase HOB - Encourage C & DB with splinting for pleuritic/pleurisy pain

Adimssion to Clinical Unit: Postoperative Care

- Obtain report (phone call) - Set up room (prior to pt. arrival) Assess Patient - What is unique to general anesthesia assessments vs. spinal/epidural? - Review orders Pt. Teaching - PIC - CDB, IS, Early Ambulation Pt comfort - 4 P's - hourly rounds: position, pain, potty, possessions - Antiemetics - Rest

Deep Vein Thrombophlebitis (DVT)

- Often asymptomatic! Unilateral (90-95% LE) - Pain: c/o sense of fullness, with wt. bearing & tenderness per palpation - Edema - Paresthesia "pins & needles" sensation - Increased warmth - Redness (erythema) - Dilated superficial veins - Fever ( >100.4)

Iron Deficiency Anemia

- One of the most common chronic hematologic disorders - Risk: young, women in reproductive years, poor diet Causes: - Inadequate dietary intake - Malabsorption - Blood loss - Pregnancy

Administration Routes: Pain

- Oral - Sublingual/buccal - Rectal Parenteral - SQ - IM - IV: IVP, continuous infusions (drips), PCA Intraspinal - Epidural - Intrathecal

Testicular Cancer: Diagnostic Studies

- Palpation of scrotal contents - Cancerous mass is firm and does not transilluminate - US* -> if positive for suspicion of cancer, orchiectomy - CXR & CT abdomen and pelvis (to detect metastasis)

Morphine Sulfate (MS)

- Reduced preload & afterload - Dilates pulmonary & systemic vessels relieving dyspnea - decreased anxiety 1st line drug for Pulmonary Edema/followed by diuretic (IV Lasix) - IV STAT (push) 2nd drug given: Diuretic (Furosemide IVP)

Thrombocytopenia - Definition

- Reduction in platelets below 150,000 ul

Nursing Diagnoses: Hyperkalemia

- Risk for electrolyte imbalance (hyperkalemia) r/t excessive retention or cellular release of potassium secondary to.. (list risk factors) - Risk for injury r/t LE muscle weakness - Potential complications: dysrhythmias

Key Points: Pain Meds

- Routes will affect analgesic response times which impacts planning nursing care - Doses are usually NOT interchangeable between routes Resp. depression is often preceded by sedation - Watch patients closely who are difficult to arouse - RR < 10 need to reassess & have Narcan available - Check O2 sats - Consider continuous monitoring

Sildenafil/Tadalafil

- S/E: h/a dyspepsia, flushing, nasal congestion - Vision disturbances, sudden hearing loss, erection lasts over 4 hours Used for erectile dysfunction

EBP: Reduction of SSIs & HAIs in Surgical Patients

- SSI: Surgical Site Infection - HAI: Hospital Acquired Infection Staphlyococcus aureus - Leading cause of SSI - In nares of nearly 30% of the population - 95% of nasal carriers have MRSA at other body sites - 80% of S. aureus infections caused by pt's nasal flora

Nursing Considerations: Chronic Kidney Failure

- See AKI - Ice chips, lemon, hard candies to reduce thirst Careful assessment for - Increased wt. BP, SOB, edema, fatigue/weakness, confusion or lethargy - Teaching - Avoid OTC NSAIDs, magnesium based laxatives & antacids - Daily weights (report >4lb in 24hrs) Daily B/Ps - Identify S&S of fluid overload - Identify S&S of hyperkalemia - Strict dietary adherence - Medication education

Patient Education topics related to Insulin

- Self-injection Procedure - Drug info - SBGM - Safe storage and disposal used syringes (needles &amp; lancets) - Timing with diet &amp; exercise SE: hypoglycemia (know these!) - Recognition - Treatment - Prevention

Interventions: Chronic Heart Failure (CHF)

- Semi-Fowler's - Oxygen via nasal cannula (NC) prn - Rest-activity periods - Medications - Diet/Fluid Restrictions - Daily weights Implanted devices - Biventricular Pacers (newer device) ICD's (implanted cardioverter-defibrillator) used if poor ejection fractions (<30%) - Device will cardiovert, defibrillate, and pace as needed by sensing pts. - Home Health - Cardiac Rehabilitation

Clinical Manifestations: HYperosmolar Hyperglycemic Syndrome (HHS)

- Severe dehydration - High Blood Glucose (>600) - Marked ↑ serum osmolality - KEY POINT:: Absent ketones Neurological changes • Somnolence • Seizures • Hemiparesis • Aphasia • Coma NOTE: What condition is similar?

Lymphoma - Treatment

- Stage I and II - radiation - Stage III - radiation and chemo - Stage IV - combination chemo/radiatio; Stem cell transplant

Nursing Considerations: Acute Kidney Failure

- Strict I&O - Daily weights - Assessment of edema, heart sounds - S3 gallop/murmurs, neck vein distention, BP, lung sounds, oral mucosa, ECG changes - Avoid contrast dye if renal function is impaired - Avoid NSAIDs - Monitor for infection - impaired immune response

Safety Considerations: Intraoperative Care

- Surgical Time Out - Positioning Maintaining Asepsis - Health care provider prep - OR suite & instrument prep - Surgical site prep Preventing hypothermia - Closely monitor temperature - Apply warming blankets - Warm IV fluids

Sexual Functioning: Vasectomy

- Surgical resection of the vas deferens for purpose of sterilization - 15-30 minutes under local anesthesia - Alternate form of contraception until semen exam reveals no sperm - 10 ejaculations or 6wks. No change in - Erection - Ejaculation volume/consistency - Hormone level

Suprapubic: Catheter

- Surgically placed through the abdominal wall into the bladder Indications Temporary - After bladder, prostate, urethral surgery Long term - Male quadriplegia patients who form penoscrotal fistula/other complications of long term catheter use - Neurogenic bladder - Urethral damage - Severe BPH - People with long term catheters who wish to remain sexually active Considerations - Prone to obstruction Bladder spasms & urine leakage around catheter can occur - Protect skin Treatment of bladder spasms - Ditropan - Belladonna and opium (B&O) suppositories

Thyroid hormones - A review

- T4 Thyroxine accounts for 90% of thyroid hormones but T3 is much more potent. - However, only 20% of T3 is secreted by gland and the rest is converted peripherally from T4. - 99% of the thyroid hormones are bound to plasma proteins so only the free hormones are biologically active. - Thus, free T4 is often used along with TSH rather than T3 for diagnosing thyroid problems

REVIEW: Thyroid Gland: Function

- The thyroid gland controls the body's metabolism and controls how sensitive the body is to other hormones via the thyroid hormones called triiodothyronine (T 3 ) and thyroxine (T 4 ). The thyroid also produces calcitonin, which plays a role in calcium homeostasis (i.e. reducing blood calcium levels). - The thyroid is regulated by thyroid-stimulating hormone (TSH) produced by the anterior pituitary, which itself is regulated by thyrotropin-releasing hormone (TRH) produced by the hypothalamus.

Hypoglycemia: Medical Emergency

- Untreated hypoglycemia can progress to loss of consciousness, seizures, coma, and death - May mimic alcohol intoxication! Hypoglycemic unawareness: note seen in some patients especially elderly/beta blockers - No warning s/sx until glucose level critically low - R/t autonomic neuropathy and lack of counter-regulatory hormones - At risk: persons with frequent low BG episodes, elderly, and on beta blockers - Pts at risk should keep BG levels somewhat higher

Diagnostics: Chronic Kidney Disease

- Urine dipstick for protein - Urine test for albumin to creatinine ratio - Kidney US - Renal Scan - CT - BUN, serum creatinine clearance (urine test) - GFR < 60 for 3 months*

Signs and symptoms: cholelithaiasis

- Vary from severe to none at all Pain more severe when stones moving or obstructing - Steady, excruciating - Tachycardia, diaphoresis, prostration (feeling extremely weak) - May be referred to shoulder/scapula - Residual tenderness in RUQ - Occur 3-6 hours after high-fat meal or when patient lies down When total obstruction occurs: - Dark amber urine - Clay-colored stools - Pruritus (itchiness) - Intolerance to fatty foods - Bleeding tendencies - Steatorrhea (fatty feces)

Risk Factors for Osteoporosis

- Woman - Older - Asian - Low Calcium - Low vitamin D - Small stature - Caucasian - + Family history - Smoking cigarettes - Excessive ETOH > 2 drinks/day - Sedentary lifestyle - Decreased Estrogen/Testosterone Post-menopausal

pt admitted w/ acute exacerbation of ulcerative colitis, passing 15 bloody stools a day - give reglan (no increases peristalsis) - decrease food intake (NPO) - administer vitamin B12 injections - teach patient about colectomy surgery

- decrease food intake (NPO)

Nursing Diagnosis: Hypocalcemia

- risk for injury r/t tetany & seizures - risk for electrolyte imbalance (hypocalcemia) r/t decreased production of PTH

Tachypnea

> 20 breaths/min

SaO2

> 95% % of hemoglobin saturated with oxygen

A client becomes very agitated and hostile when you approach him to begin client teaching for discharge. Which one of the actions would not be an appropriate action by the nurse? A. Begin the teaching and explain you are required to complete the teaching. B. Attempt to determine the reason for the agitation and hostility. C. Do not begin the teaching program but explain that you will return later. D. Ask another nurse to assist you in assessing the reason why the client is refusing the teaching.

A The client will become more agitated with you if you attempt to continue with the teaching. The other responses are all appropriate for this situation. It is best to come back at a different time (C). At that time, you may be able to determine why the client is agitated and hostile (B). Frequently, another nurse is able to establish rapport with a client, and it would be best to ask that nurse for assistance with the client (D).

Gastritis: Management

Acute: - Remove causative factor - Manage symptoms - NPO, fluid replacement if vomiting exists - Antiemetics, antacids, H 2 blockers, PPIs - NG if symptoms are severe (allow gut to rest and heal) - Diet: clear liquids, advance slow Chronic: - Remove/treat causative agent - Small frequent feedings - Antacids - Smoking/alcohol cessation - contraindicated - Lifelong cobalamin may be needed - Regular follow up - risk of gastric cancer

desmopressin acetate (DDAVP)

ADH replacement therapy Diabetes Insipidus

Coronary Artery Disease: Etiology and Pathophysiology

Atherosclerosis is the major cause of CAD - characterized by lipid deposits within intima of artery - endothelial injury and inflammation play a major role in development

Which client with high risk-factors at discharge usually requires specific instructions? A. Client living alone B. Client with multisystem issues C. Small child D. Client with a job requiring immediate return to work

B Clients with multisystem issues usually require education regarding diagnosis, multiple treatments, and medications. (A) Living alone does not necessarily place a client at high risk for discharge. If the client is young, self-sufficient, and has a good support system, the client is not at high risk. Answers (C) and (D), in and of themselves do not place clients in a high-risk category.

HEPATITIS C VIRUS (HCV)

- Acute: asymptomatic - Chronic: liver damage, lead to cirrhosis. Most common reason for liver transplant RNA virus transmitted percutaneously - into skin • IV drug use (most common) • High-risk sexual behaviors • Occupational exposure • Dialysis • Perinatal exposure • Blood transfusions before 1992 No vaccine

Nursing Diagnoses: Valvular Heart Disease

- Decreased Cardiac Output r/t valvular incompetence - Excess Fluid Volume r/t fluid retention secondary to valvular HF - Activity Intolerance r/t insufficient O 2 secondary to ↓cardiac output and pulmonary congestion

Clinical Manifestations: Acute Glomerulonephritis

- Hematuria, smoky or rust colored - Foamy urine (proteinuria) - Oliguria or anuria - Facial edema (early) ** - Anasarca (Generalized edema) - late ** - HTN - Mild fever - Flank pain

Diagnosis: Parkinson's

- Made with ⅔ characteristic signs in the triad - Confirmed with improvement upon starting Parkinson's meds

Nursing Care: VTE: Activity Orders

- May include limb elevation - Evidence Based Practice: early ambulation compared to bed rest does not seem to increase PE risks and may help decrease edema After edema gone or when ordered - Measure and apply compression stockings or sleeves

BPH: Risk Factors

- Obesity - Decreased physical activity - ETOH - Smoking - Diabetes - Family history

Lymphedema: Cancer

- Occurs after lymph nodes are removed - Can impact upper or lower extremities - Usually impacts only one side (left or right) - Discomfort, skin thickening, infections can occur Nursing Considerations - Limb precautions - no BP, IVs/lab draws - Exercise, compression, massage

Drug Therapy: Fractures

- Pain Management Muscle Relaxants - Cyclobenzaprine (Flexeril) - Methocarbamol (Robaxin) Open Fractures - Irrigation & Debridement - Tetanus/Diphtheria Immunization Prophylactic Antibiotics - Bone penetrating - Ex; Cephalosporins

Thrombocytopenia - Diagnosis Studies

- Platelets < 150,000/uL - Increased PT (nl: 10-13 seconds) - Increased PTT (nl: 21-30 seconds) - Bone marrow biopsy - CBC

Skin Antisepsis

- Reduce risk of surgical site infection (SSI) - CHG cloths reduce bacteria on the skin by raipd bactericidal action - Prehab: Evening before surgery and morning of surgery CHG is a neurotoxin - Do not apply to face, eyes, ears, nose mouth, genitalia, open wounds, or lumbar puncture sites - Do not microwave package of CHG wipes

Nursing Diagnosis: Hypercalcemia

- Risk for injury r/t neuromuscular & sensorium changes secondary to hypercalcemia - Risk for electrolyte imbalance (hypercalcemia) r/t excessive bone demineralization secondary to prolonged immobility

3 Primary Treatments for Hyperthyroid

1. Anti-Thyroid medications 2. Radioactive iodine therapy (RAI) (aka RAI ablation) 3. Surgery - Treatment choice(s) is determined by HCP and is influenced by pt's age, severity, complications, preferences, and if pregnant. - KEY POINT: If surgery is desired, euthyroid state must be met prior to going to the OR.

Overveiw: Med Goals: Heart Failure

1. Identify & trat underlying cause(s) 2. Maximize CO: decrease workload/O2 needs decreased preload - decreased intravascular volume & venous return decreased afterload - reduction of pressure LV must pump against increased cardiac contractility These 3 make it easier for heart to pump blood

HCO3

22-26mEq/L low = acidosis high = alkalosis

Extra - Articular S/sx's of RA

3 Most Common Rheumatoid Nodules (50% of pts) - Firm non-tender mass over joint - Can progress to ulcers and infections Sjogren's Syndrome - Decreased lacrimal glands & salivary secretions - Photosensitivity - Also found in SLE patients (systemic lupus erythematosus) Felty Syndrome - Splenomegaly - Leukopenia

Bolus dose

A large, initial dose given to bring the blood level of a drug up to a therapeutic level

A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? A. Assist with active range of motion. B. Observe for agitation and paranoia. C. Give muscle relaxants as needed to reduce spasms. D. Use simple words and phrases to explain procedures.

A. Assist with active range of motion.

Urinary Tract Calculi

A.K.A Nephrolithiasis (kidney stone disease)

-pril

ACE Inhibitor

Enalapril (Vasotec)

ACE Inhibitor Angiotensin Inhibitor

ciprofloxacin (Cipro)

Acute attacks of IBD

PRBCs

Adjunct medication IBD

iron

Adjunct medication IBD

cholestyramine

Adjunct medication IBD binds to bile salts, which are normally reabsorbed in ileum, & contribute to diarrhea when not reabsorbed

Anti-dysrhythmia meds

Amiodarone (Cardarone) - Used Atrial Fibrillation (AF) - Used for ventricular tachycardia (VT)/ventricular fibrillation (VF)

Glucosamine & Chonftoiyin-Effectiveness

Anti-inflammatory supplement Osteoarthritis

Haldol

Behavioral Problems Antipsychotics Alzheimers

-olol

Beta blocker

-ine

Calcium channel blocker

Probenecid (Benemid)

Chronic Gout

The telemetry monitor alarms indicating an arrhythmia. Which assessment indicates a sudden decrease in cardiac output? Select ALL that apply a. Confusion b. Hypertension c. Abdominal distension d. Bounding radial pulse e. Dizziness f. Shortness of breath

Confusion Dizziness Shortness of breath

PCA: Patient controlled analgesia Dosing

Criteria for pt. selection - Caution: SO & family should not be giving Loading Dose - Given upon starting PCA Dose - Administered by patient PRN using pre-set amts & times - Ex. 1 mg MS q 10 minutes Basal dose - Continuous infusion - Low dose given over an hour Ex. 4 mg MS q hour Break-through dose - Used if basal and/or PCA dose is not effective Example 1 mg up to 2x

What is expected when acute heart failure is successfully treated A. weight fluctuates by less than2kg/day B. Uses only two pillows to sleep during night C. Follows her prescribed 2 hm Na restricted diet D. Able to dress herself and walk around unit without dyspnea

D. Able to dress herself and walk around unit without dyspnea

Management: Diverticulosis & Diverticulitis

Diet: low fiber diet during acute exacerbation, then... - High fiber diet, fresh fruits & vegetables, low fat, low red meat - NPO, bed rest, IVF, antibiotics -> clears, ADAT Surgery - For complications (abscess or obstruction) - Resect - Temporary colostomy - Teaching re: recurrent acute attacks - Stool softeners - prevent constipation - Wt. loss if indicated

Nitroprusside (Nipride)

Direct Vasodilator

Diabetes Mellitus (DM)

Disorder of glucose metabolism related absent or insufficient insulin supply and/or poor utilization of available insulin.

Triamterene (Dyrenium)

Diuretic (K+ sparing)

gemfibrozil (Lopid)

Fibric Acid Derivitive Anti-lipid Used for PAD

Pts with substance abuse hx: Pain

Focus on opioid abuse - Most commonly abused are prescription pain meds! Nurse are often quick to label pts - "Drug seeking does not equal Addiction"

What signs/symptoms suggest hip fracture?

Inability to move after fall, severe pain in hip/groin, inability to put weight on the leg, stiffness/bruising in hip area, leg shorter on side of injured him, turning leg outward on side of injured hip

Erythropoietin (Epogen, Procrit)

Iron Replacement For Chronic Kidney Disease

Tofacitinib (Xeljanz)

Janus Kinase Inhibitor: Decrease cellular inflammation response Monitor for opportunistic infections RA

Hypokalemia Cause

K < 3.5mEq/L Cause Lack of potassium intake - starvation - diet low in potassium - failure to include potassium in parenteral fluids if NPO Excessive potassium loss - GI losses; diarrhea, vomiting, fistulars, BG suction - Renal losses: diuretics, hyperaldosteronism, magnesium depletion - Skin losses: diaphoresis - Dialysis Shift of potassium into cells - Alkalosis - increased insulin - tissue repair (healing after surgery) - increased epinephrine (stress)

Classification: UTI

Lower urinary tract infection - Urethra, bladder - No systemic symptoms - Urethritis (inflamed urethra) - Cystitis (inflamed bladder) Upper urinary tract infection - Ureters & kidneys - Symptoms of lower + systemic symptoms: fever, chills, flank pain - Pyelonephritis Urosepsis

nateglinide (Starlix)

Meglitnides Diabetic medication SE: ***hypoglycemia, wt. gains

MI

Myocardial Infarction (Heart Attack) - Can cause N/V NSTEMI: Partial Occlusion = non ST segment elevation myocardial infarction STEMI: Complete Occlusion = ST segment elevation myocardial infarction New onset chest pain, occurring at rest or worsening from a stable pattern - Associated with a deterioration of a previously stable plaque - Requires immediate hospitalization Clinical Manifestations Chest pain - **Severe not relieved by rest, positioning or nitrates - Often described as "crushing, pressure, or heaviness" with radiation common - Located substernal or epigastric areas - Onset during activity, resting or sleep often early AM - **Lasting > 20 minutes Diagnosis: 12 lead ECG (aka EKG) - Assess Note: One of the key steps in differentiating chest pain is health history intake using the seven variables. 12 Lead ECG/EKG is often useful noninvasive diagnostic tool after obtaining the patient's chief complaint history - Chest x-ray (CXR): to confirm other conditions Labs 1. Cardiac enzymes (aka heart markers) Used for ruling out or diagnosing acute myocardial infarction (aka Acute Coronary Syndrome - ACS) - Cardiac Troponin - rise within 3-4 hours injury N: < 0.04 nl/ml troponin T values > 0.01 ng/mL that are rising make the diagnosis of cardiac injury. Will rise within 3-4 hours of injury and are most specific of ALL markers to the heart - CK-MB - Myoglobin Others: used to dx heart risk factors - Lipid Profile & Homocysteine levels - Hgb-A1C & Basic metabolic Profile (lytes, BUN/CR) - used to provide baselines Exercise stress test - Pt. exercises to reach an age predicted target HR while being monitored for any s/sx of cardiac ischemia Assessment: check B/P, HR, rhythm, waveforms (ST segment depression, T wave inversion). Ask about CHEST PAIN! Nuclear imaging test often with pharmacology (meds given) - stimulate exercise chemically - Echocardiogram - can be used alone or with exercise and nuclear imaging Cardiac angiography (in Cath lab) - Patient care for heart cath with angiography is similar to PAD arteriography - Review PAD notes & pre/post cardiac cath

Sodium

Na+ (Cation) 135-145

Metabolic Alkalosis: Symptoms

Neurologic: - dizziness, irritability, nervousness, confusion CV: - tachycardia, dysrhythmias (r/t hypokalemia from compensation) GI: - N/V, anorexia Neuromuscular: - tetany, tremors, tingling of fingers &amp; toes, muscle cramps, hypertonic muscles, seizures Respiratory: - hypoventilation (compensatory action by the lungs)

Nitrobid

Nitrate used PRN - May cause hypotension - Take up to 3, 5 minutes apart

NitroDur

Nitrate, used for chronic stable angina - May cause hypotension

Diltiazem (Cardizem)

Non-Dihydropyridines Calcium Channel Blocker

Treatment: HHS

Note this condition is very similar to DKA and so is the treatment! Fluid Resuscitation - Infusion of 0.45 or 0.9% NaCl IV fluids - More fluid replacement is often needed - Add dextrose when BG & 250 o May require hemodynamic monitoring for safety Regular Insulin Infusion Monitor serum potassium and replace as needed • Correct underlying precipitating cause

Morphine IM

Onset 10-30 minutes Peak 1/2-1 hour Duration 3-7 hours

Factors Affecting SV

Preload: volume returning to R side of the heart (RV) Afterload: Amount of pressure LV must overcome to eject blood (arterial B/P) Contractility - Strength of contraction - Affected by pH, oxygen & electrolytes & SNS (E/NE)

Cancer Treatment: Surgery

Purposes of Cancer-Related Surgeries - Prevention - Diagnosis - Cute/Control - Rehabilitation/Reconstructive - Supportive - Palliation

Assessing for Rejection: Kidney Transplant

Rejection can occur as early as 24-73 hours post-op - May require removal of kidney - Oliguria - Edema - Weight gain - HTN - Fever - Swelling or tenderness over graft

glyburide (DiaBeta)

Sulfonylureas Diabetic Med SE: ***hypoglycemia, wt. gains

Dementia - What is it?

Syndrome characterized by dysfunction or loss of - Memory - Orientation - Attention - Language - Judgement - Reasoning Personality changes and behavioral problems can also occur (in approx. 90% of patients) - Agitation ("Sundowning) - Delusions - Hallucinations

Nurse is caring for a female patient who just retured to the surgical unit following a thriodectomy. The nurse is most concerned if which is observed? a. The patient complains of increased thirst b. The patient reports a sore throat when swallowing c. The patient makes harsh. vibratory sounds when breathing

The patient makes harsh. vibratory sounds when breathing

Demeclocycline (Declomycin)

Used in SIADH - Blocks ADH effect on kidneys resulting in a more dilute urine

cholecalciferol, calcitriol

Vitamin D supplementation chronic kidney disease

Irritable Bowel Syndrome (IBS)

What is it? - Chronic condition - Effects large intestine - Does not cause changes to bowel tissue or increase risk of colorectal cancer (difference between IBD) S/Sx - Cramping, bloating, abdominal pain, alternating diarrhea & constipation Management Diet - Triggers vary: chocolate, spices, fats, fruits, beans, cabbage, cauliflower, broccoli, milk, carbonated beverages and alcohol - Stress reduction - Medications - for constipation and diarrhea

Fowler's position

a semi-sitting position; the head of the bed is raised between 45 and 60 degrees

Metabolic Acidosis

↓ pH&lt;7.35 ↓ HCO 3 &lt; 22 nl. PaCO 2 = uncompensated ↓ PaCO 2 = compensated

Epilepsy

- Condition of spontaneous recurring seizures Problem originates in the brain - Results from long lasting changes in the brain

Diagnostics: Alzheimer's

- Diagnosis is one of exclusion - No single clinical test - Diagnosis is made once all other possible conditions causing cognitive impairment are ruled out Brain imaging tests - CT - MRI - SPECT - PET Diagnosis - Confirmed at autopsy Brain examined for presence of - Neurofibrillary tangles - Neuritic plaques

Lymphoma - Signs & Symptoms

- Lymph node enlargement (firm, non-tender, painless) - Hyper-metabolism-fever, weight loss, night sweats, pruritus, fatigue and malaise (part of staging) - Hepatomegaly/splenomegaly: jaundice With progression: - Mediastinal involvement (non-productive cough, dyspnea, dysphagia) - Ureteral obstruction - Spinal cord compression

Nutritional Therapy: Fractures

- Protein (1 g/kg) Calcium - 1000 mg/d (premenopausal) & men < 70 - 1200 mg/d postmenopausal & men > 70 - Phosphorous - Magnesium - Vitamins (D, B, C) - High fiber - ↑ Fluids: 2000 to 3000 mL / day - Bowel management program

Lisinopril (zestril)

ACE Inhibitor Angiotensin Inhibitor

Ramipril (Altace)

ACE Inhibitor Used for PAD

Collaborative Treatments: PAD

Administer medications: - Antiplatelet - Antihtpertensives - Anticholesterol - Pain meds - Prophylactic Antibiotics - Post op wound care Encourage walking - Loss of sensation & pain increase fall risks

Clonidine (catapres)

Adrenergic Inhibitor

Simvastatin (Zocor)

Anti-Lipid used for PAD

Arteries

Carry oxygenated blood away from heart

Electrical Tx: 1. Defibrillation

Definition: emergency tx that delivers a direct current shock without regard to the cardiac cycle - Intent is to depolarize all cardiac cells so the SA node will resume normal functioning - Most effective is done within first 2 minutes Indications - Ventricular Fibrillation (VF) - Ventricular Tachycardia (VT) without a pulse

Patho of SIADH

Increased antidiuretic hormone -> increased water reabsorption in renal tubules -> increased intravascular fluid volume -> dilutional hyponatremia and decreased serum osmolality

Morphine PO/rectal

Peak 1 hr Duration 4-5 hours (slow release 8-12 hours)

Vasotomy

Severing of vagus nerve to decrease gastric acid secretion

Thrombocytopenia

low platelet count

Development of Cancer: Progression

- Cancer is detectable Increased growth rate of tumor - Angiogenesis - Invasiveness Metastasis - Sentinel lymph node - Main sites of metastasis

Neutropenia - Diagnosis

- Total WBC < 4000/ul (leukopenia) - ANC < 1,000/ul (neutropenia) - Bone marrow biopsy - Cultures of nose, throat, sputum, urine, stool, lesions, blood (as indicated) - Chest x-ray

Drug Therapy HTN

2 main actions Decrease volume of circulating blood Reduce systemic vascular resistance (SVR) - Diuretics Adrenergic Inhibitors - Central acting antagonists - Alpha blockers - Beta blockers - Mixed alpha/beta - Direct Vasodilators Angiotensin Inhibitors - ACE inhibitors - Angiotensin II Receptor Blockers - Renin Inhibitors - Calcium Channel Blockers

When performing B/P screening at a health fair which person does the nurse identify at highest risk for developing hypertension?

56 y.o african american who's father died from a stoke - age, ethnicity, family history, HTN is risk factor for stroke and MI

Pentoxifyline (Trental)

ANTIPLATELET Action: Prevent plateles from aggragating (clumping together) by inhibiting enzymes and factors that normally promote clotting Used for PAD

Antidote for Xarelto & Eliquis (Factor Xa Inhibitors)

Andexxa

Ginger

Anti-inflammatory supplement Osteoarthritis

Nursing Care: S↑ADH

Assessments - Frequent VS - Monitor: heart and lung sounds &amp; neuro status (LOC) - I & O /daily wts. - √ urine SG: N: 1.010 - 1.025 - Monitor serum sodium and osmolality which should gradually ↑ - Watch for s/sx hyponatremia Position HOB flat or < 10° - Helps ↑ venous return & LA filling pressures which ↓ ADH release - Teach about fluid restrictions & oral care Protect from injury - Seizure Precautions - Fall Precautions

Urinary Tract Infection: Cause

Bacterial invasion of urinary tract (usually sterile above urethra) - E. Coli - Asymptomatic bacteriuria

Risperdal

Behavioral Problems Antipsychotics Alzheimers

Pneumonia: Clinical Picture

CC/HPI - Fever & chills - Dyspnea Cough - If productive: ask patient to describe sputa - Pleuritic chest pain Nonspecific - Fatigue, diaphoresis, myalgias, anorexia - Note Elderly may present atypical: confusion, stupor, hypothermia Physical Exam - Mental status changes - anxiety/restlessness, confusion - Hypoxia: decreased arterial oxygenation - Purulent sputa: check color, amount, consistency - Tachypnea Percussion: - Dullness - Increased Fremitus Auscultation - Crackles over affected area - Bronchial if consolidation occurred

Forces the Influence Capillary Fluid Movement

Capillary Fluid Movement: Movement of fluid between the capillaries & interstitial space Interstitial space: space around capillaries Hydrostatic Pressure - The major force that pushes fluid out of the vasculature - Caused by BP & is higher in arterial end & lower in venous end Oncotic Pressure - Force that pulls water into the vasculature (caused by proteins - we give albumin) - Cause by the concentration of the intravascular fluid (mainly controlled by proteins) which is consistent in the entire capillary bed

Furosemide (Lasix)

Diuretic (Loop)

Bumex (bumetanide)

Diuretics Acute Kidney Injury

Lasix (furosemide)

Diuretics Acute Kidney Injury

GERD: Complications

Esophagitis - Esophageal irritation & inflammation - Esophageal ulcers Esophageal stricture - Scar tissue formation & decreased flexibility - Dysphagia Barrett's esophagus - Esophageal metaplasia - Precancerous lesion Respiratory - Cough, bronchospasms, laryngospasms- Asthma, chronic bronchitis & pneumonia - Dental erosion

Hypertonic Solutions

Fluids with more solute concentration than the cells they surround; draws fluid into the intravascular space from the cells & interstitial space D5 1/2 NS, D5NS - Used to treat hyponatremia - also replaces volume - 170 cal/L - Caution: go slow & monitor BP, pulse, lung sounds, serum Na & UO

Hypernatremia Cause

Na > 145mEq/L Cause Excessive Sodium Intake - Diet, IV fluids, hypertonic tube feedings Inadequate water intake - unconscious/cognitively impaired/elderly or very young (normally thirst mechanism prevents hypernatremia) Excessive Water Loss - osmotic diuretics (mannitol) - fever - diarrhea - hyperglycemia (loss of dilute urine) - prolonged hyperventilation Disease States: Diabetes insipidus, Cushing's, Adrenal tumor (hyperaldosteronism), uncontrolled DM

ibuprofen (Motril, Advil)

Nonopiod Analgesics NSAIDS

hydrocodone (Zohydro ER)

Opioid Analgesics

Complications: pancreatitis

Psuedocyst - Abd pain - Palpable epigastric mass - N/V/A - Serum amylase elevation Can be diagnosed with: - CT - MRI - EUS Abcess - Upper abd pain - Abd mass - High fever - Leukocytosis - Requires prompt surgical drainage to prevent sepsis Can lead to: - Pleural effusion, atelectasis, pneumonia, ARDS, hypocalcemia- could lead to tetany

Diagnostics: Pyelonephritis

UA** - Pyuria - Nitrates (bacteriuria) - RBCs (hematuria) - WBC casts in urine = involvement of renal tissue* Proteinuria (chronic) C&S CBC w/ differential - Leukocytosis with increase in immature neutrophils (bands) Imaging Studies - Renal ultrasound

Crackles

associated with atelectasis will clear with C/DB and usually are located in the bases. Crackles associated with fluid don't clear wirh C/DB and can often be heard above bases

Postop. a pt w/ an incisional cholecystectomy had a nursing diagnosis of ineffective breathing pattern related to splinted respirations to a high abdominal incision. Which action should the nurse take first? a. Assess heart and lung sounds b. Administer the prescribed analgesic c. Position the pt. on the operative side d. Instruct the patient to cough and deep breath

b. Administer the prescribed analgesic

pruritus

itching

Phenothiazines

prochlorperazine (Compazine), chlorpromazine (Thorazine) For nausea

Nursing Diagnoses: Back Pain

- Acute Pain - Impaired Physical - Mobility - Chronic Pain - Ineffective Coping - Ineffective Health - Management

Post-Op Prostatectomy Care

- Catheter & Bladder irrigation - Hemorrhage - Bladder spasms oxybutynin/Ditropan, B&O - Urinary incontinence - UTI - Scrotal edema

All Cells are Affected: Chemo

- Chemo cannot distinguish between cancer cells & normal cells - All dividing cells can be effected - Chemo Side effects - result of destruction of normal cells Cells most impacted are those that proliferate rapidly - - -

Complications: cholecystitis

- Gangrenous cholecystitis - Subphrenic abscess (accumulation of infected fluid between diaphragm, liver, and spleen) - Pancreatitis - Cholangitis (inflammation of bile duct system) - Biliary cirrhosis - Fistulas - Gallbladder rupture → peritonitis - Choledocholithiasis (stones in the bile duct)

Venous Thrombosis

- Most common disorder of the veins Involves the formation of a blood clot (thrombus) and inflammation of the vein (phlebitis) = thrombophlebitis - Classified as 2 types: superficial or deep - May cause pulmonary embolus (PE)! Venous thromboembolism (VTE) - Term covers the DVT to PE spectrum

BPH: Complications

- Recurrent UTIs - Significant urinary retention requiring catheterization and/or surgery 25-30% of all men with BPH

Cushing's NCP

- Risk for Infection r/t lowered resistance to stress and immune suppression - Overweight/Obesity - Situational Low Self-Esteem r/t altered body image - Risk for Impaired Skin Integrity

ED: Diagnostics

- Thorough sexual, health, and psychosocial history - International Index of Erectile Function(IIEF) - Questionnaire Physical Exam - DRE, BP, palpation and auscultation of femoral arteries - Labs: glucose, lipid profile, hormone levels, BMP, CBC - Nocturnal penile tumescence of rigidity testing - Penile arteriography - Duplex Doppler u/s

Post-Operative Considerations: Kidney Transplant

- Vascular access/fistula or shunt maintained because hemodialysis may be necessary - Live donor kidneys usually function immediately and may produce large amounts of urine - Cadaver kidneys may take up to 2-3 weeks to function - Maintenance of F&E status important

Fatigue: Cancer

Causes - Anemia - Accumulation of toxic sybstances after cell death from cancer treatment - Body's need for extra energy to repair tissue damaged by treatment - Lack of sleep - Psychological distress - Pain/pain medication SE - Lack of nutritional intake secondary to N/V, anorexia - Cachexia Management Encourage conservation strategies - Rest before activity - Get assistance with activity Maintain nutritional and hydration status - Water, protein, fruits and vegetables - Assess for reversible causes of fatigue - Short naps (30 min) Exercise - PT referral - Low impact, such as walking - Support group

Cobalamin

Adjunct medication IBD when terminal ileum involved

Orthopedic Surgery: Pre-op Care

Assessments - Functional status (determine baseline prior to surgery or injury) - SO/Social support - Autologous transfusions Discharge needs - Assistive equipment Interdisciplinary Referrals Case manager for discharge planning - Might need home health, rehabilitation unit or nursing home - PT - OT Patient & Family teaching - Self-efficacy & recovery expectations - Post op care; include positioning ambulation expectations & equipment: - Foley, IV, PCA, HS, oxygen - Pain management - Self-care instructions: i.e. Lovenox injections

Kussmal Respirations

Deep labored breathing pattern; increased rate, large volumes often seen in Diabetic Ketoacidosis

Metoprolol (lopressor)

Beta Blocker 2 Adrenergic Inhibitor

Acid Base Imbalances

Body normally maintains a steady balance between - acids produced during metabolism & - bases that neutralize & promote excretion of acids Acidity (acid) or alkalinity (base) depends on hydrogen (H+) concentration - Expressed as pH - Normal pH of blood is 7.35-7.45 - Increased H+ leads to acidity (decrease pH, pH <7.35) - Decreased H+ leads to alkalinity (increased pH, pH >7.45) - pH < 7 is acidic - pH > 7 id alkalotic - Respiratory disturbances affect carbonic acid (CO2) levels - Metabolic disturbances affect base bicarbonate (HCO3)

Combined Alpha/Beta

Carvedilol (Coreg) Labetalol (Normodyne)

A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs & symptoms 1. Fever 2. Diarrhea 3. Lethargy 4. Tremors 5. Bradycardia 6. Hypotension

Fever, diarrhea, tremors

Hydrocortisone

For Addison's 2/3 dose in am - 1/3 dose late afternoon - Has both glucocorticoid and mineralocorticoid properties

Huntington's

Hereditary progressive disease of nervous system - Autosomal dominant - Offspring have 50% risk of inheriting - Deficiency of neurotransmitters ACh and GABA resulting in excess of DA - Onset 30-50y/o - Cause is unknown

Health care-associated infections (HAIs)

Hospital-acquired UTI accounts for 31% of all nosocomial infections

Respiratory: Pneumonia

Inflammation in the lungs caused by infection -> atelectasis can progress to pneumonia if not treated - S/Sx: crackles, fever, tachypnea, productive cough, elevated WBC, decreased SaO2 - Risk factors: abdominal/thoracic surgery, smokers, elderly & those with respiratory history, atelectasis, aspiration - Diagnosis: symptoms & CXR - Prevention-Nursing Strategies: TCDB, IS, early ambulation, hydration & prevent aspiration - Treatment-Nursing Management: antibiotics, may need oxygen & continue with preventative strategies

Lugal's solution

Iodine - Inhibits hormone synthesis and blocks their release - Decreases vascularity of gland making surgery safer - Used to treat thyrotoxicosis and to get pt's euthryroid before surgery - Effects seen in 1-2 weeks

Lantus

Long Acting Insulin - Onset: 0.8-4 hours - **Peak: less defined or NO peak - Administered once or twice a day. Do not mix with other insulin products - Duration: 24+ hours

Positive Inotropics

Main actions: increase force of contraction & decrease heart rates Digoxin (Lanoxin) - Dig toxicity: associated with too high drug blood levels; aggravated by lyte imbalances: hypo/hyperkalemia, hypermagnesemia - Monitor lytes closely and replace PRN - Side effects: A/N/V/D, visual changes, HA, fatigue, palpitations

ketorolac (Toradol)

Nonopiod Analgesics NSAIDS

Nursing Diagnosis: Hypovolemia

Nursing Diagnoses - Deficient fluid volume r/t excessive ECF losses or decreased fluid intake (risk for or actual) - Decreased cardiac output r/t excessive ECF losses or decreased fluid intake - Potential complication: hypovolemic shock - Risk for altered tissue perfusion - Knowledge deficit r/t fluid intake, especially with diuretics - Risk for constipation r/t decreased oral fluid intake

12 Lead EKG aka ECG (Electrocardiogram)

Used to Diagnose Angina & Acute Coronary Syndrome What does this provide the health care provider? 1. Myocardial Problems Lack of blood flow - Ischemia - Injury - Infarction - Location in heart Hypertrophy - Example: Heart failure 2. Arrhythmias - Rates/patters Electrolyte Imbalances Example K+ - Hypo: PVC's (premature ventricular complexes) & U waves - Hyper: peaked T waves

Laparoscopic cholecystectomy

excision of the gallbladder through a laparoscope

Oral Cancer: Nursing Care

- Analgesic - Mouth washes without alcohol - Non-acidic foods - PEG (percutaneous endoscopic gastrostomy); NG if unable to swallow - Oral suction - Monitor airway Education Re: - Risk factors and lifestyle changes - Oral hygiene and preventative dental care

Immobilization

- Splints - Casts - Traction Fixation Devices - External - Internal

Herniorrhaphy

- closure of the hernia defect - Pushing herniated stomach back into the abdomen, then tighten hiatus

Principles of Dialysis

Diffusion: movement of particles from an area of greater concentration to an area of lesser concentration - Urea, creatinine, uric acid, K+, & phosphate move from blood to dialysate Osmosis: movement of fluid from an area of lesser to an area of greater concentration - Glucose is added to dialysate and creates osmotic gradient, pulling excess fluid from the blood Ultrafiltration: movement of fluid across a semipermeable membrane as a result of artificially created pressure gradient - Excess fluid removal

Nursing Dx: Ineffective Self Health Management - Need Pt/SO/ Family Instruction

Disease Process - Relationship between diet, exercise, stress, and illness effects on BG - Risk for macro/microvascular complications - Risk for acute complications: Too high/low BG and how to treat SBGM Medication Therapy - Oral agents - Insulin - Diet & meal planning - Physical activity: Exercise precautions - Foot Care - Sick Day Care - Need for routine medical care: foot, eye and dental exams - Interdisciplinary Referrals

Gerontologic: Male Reproductive System

Decrease in hormonal activity (Male menopause) - Increase in prostate size - Decrease testosterone level - Decrease sperm production - Decrease muscle tone of scrotum and firmness of testicles - Erectile dysfunction

galantamine (Razadyne)

Decreased Memory & Cognition Cholinesterase inhibitors Alzheimers

Before Surgery (night before/day of) Nursing Responsibilities

Preop Checklist - VS, Ht, Wt, Allergies, Isolation - Chart review (H&P, Consents, Labs & Diagnostics) - Arm bands (ID, Allergy, Fall, Blood) - Procedures: NPO, BG (notify OR if >250), Beta blocker, Preop shower/skin prep, makeup & nail polish removed, preop meds, last void - Valuables - Assessment - Communication of pertinent findings

Basal dose

maintenance dose of medication

Antidote for Heparin

protamine sulfate

Amyotrophic Lateral Sclerosis (ALS)

- A.K.A. Lou Gehrig's disease Degenerative neurologic disease - Loss of motor neurons - Death within 2-6 years from dx. - Onset 40-70y/o - Woman:men 2:1

Management: Acute Glomerulonephritis

- Activity - bed rest until asymptomatic - Fluid restriction - Diet-protein and Na+ restrictions - Diuretics - Antihypertensives - Antibiotics only if streptococcal infection still present

Nursing Diagnoses r/t DVT

- Acute Pain r/t decreased venous return, congestion, and inflammation - Ineffective health maintenance r/t lack of knowledge - Risk for impaired skin integrity Potential Complications: RNs need to be on high alert for - Pulmonary embolism - Bleeding r/t anticoagulants - Chronic venous insufficiency

Complications: hepatitis

- Acute liver failure Chronic hepatitis - Some HBV and majority of HCV infections - Cirrhosis - Portal hypertension - Hepatocellular carcinoma Acute liver failure - Fulminant hepatic failure Manifestations include - Encephalopathy - Gastrointestinal bleeding - Disseminated intravascular coagulation - Liver transplant is usually the cure

Risk Factors: Epilepsy

- Age over 60 - African American - Socially disadvantaged - Males - Hx. Alzheimer's disease - Hx. Stroke - Parent with epilepsy

Esophageal Cancer

- Age over 70 - Not very common, but 5yr survival rate low at 34% - Cause unknown Risk factors: - Barrett's metaplasia, smoking, excessive alcohol use, central obesity, occupational exposure - asbestos & cement dust

Risk/Causative Factors: Osteoarthritis

- Aging - Genetics - Gender: female affected more often than men until about age 70 Obesity - 93 million U.S adults Direct Joint Damage - Trauma Mechanical stress - Sports - Occupation - Joint inflammation Neurological - Diabetic neuropathy - Drugs: corticosteroids, indomethacin, colchicine

Pain: Pt. With addiction hx

- All patients should receive unbiased assessments and management - Involve addiction specialists PRN for patients with substance issues if pain is difficult to manage

The Joint Commission (JC): Pain

- All pts have right to pain assessment & management - Comprehensive and regular assessments - Staff must be competent in pain assess/manage - Safe medication policies & procedures be used - Outcomes measuring effectiveness and the appropriateness of assessments are monitored (Continuous Quality Improvement plans are used) - Discharge planning involves pain management

Respiratory Alkalosis: Symptoms

Neurologic: - lethargy, light-headedness, confusion CV: - tachycardia, dysrhythmias (r/t hypokalemia from compensation) GI: - N/V, epigastric pain Neuromuscular: * Alkalosis causes decreased ionized calcium - tetany, numbness, tingling of extremities, hyperreflexia seizures Respiratory: - hyperventilation (lungs not able to compensate when there is a problem)

Methotrexate (Rheumatrex)

most commonly used Disease modifying antirheumatic drugs (DMARDS) Monitor for bone marrow suppression and hepatotoxicity (CBC & liver enzymes checks) RA

Antidote for LMWH

protamine sulfate

Sodium

135-145mEq/L Function - Major determinant of ECF/intravascular osmolality - Major influence on H2O distribution between ECF & ICF - nerve impulse generation & transmission - role in acid-base balance * Note: serum sodium levels reflec the sodium/water ration, not necessarily the gain or loss of sodium * Changes in sodium can reflect a primary water imbalance, a primary sodium imbalance, or a combination of both Absorption Excretion Regulation - dietary intake (GI),IVF - urine, feces, sweat - kidneys: ADH regulates excretion/retention of water & aldosterone regulates reabsorption of sodium

A patient receives aspart (NovoLog) insulin at 8:00AM which time will it be most important for the nurse to monitor for symptoms of hypoglycemia

8:30AM

Primary (Essential/Idiopathic) HTN

90-96% No single identifiable cause Contributing factors are well known Examples Increase SNS, overweight/obesity, smoking, ETOH, diabetes, increased dietary NA

Ativan

Behavioral Problems Benzodiazepine Alzheimers

Restoril

Behavioral Problems Benzodiazepine Alzheimers

CO

Cardiac Output HR x SV the total blood volume pumped per minute Stroke volume: amount of blood pumped out of left ventricle per beat (Adult avg. 70mL) Heart Rate: # beats per minute

Fluid Volume Excess (FVE) Hypervolemia Cause

Cause Excessive Fluid Intake - Primary polydipsia - Excessvie isotonic or hypertonic IVF Abnormal Retention of Fluids - CHF, renal failure, SIADH, Cushing syndrome Other Causes - long term use of corticosteroids

Complications: Hemodialysis

Hypotension From rapid removal of vascular volume Muscle cramps From rapid removal of sodium and water Blood loss From not being completely rinsed from dialyzer, separation of tubing, dialysis membrane rupture, bleeding after removal of needles Sepsis From infections of vascular access site

Types of Lung Cancer

Non-small cell lung cancer (NSCLC) - 80% - Growth and characteristics vary per kind 3 kinds - Squamous cell carcinoma - Adenocarcinoma - Large cell undifferentiated carcinoma Small cell lung cancer (SCLC) - 20% - Very rapid growth - Most malignant form lung CA - Frequent brain mets

naproxen (aleve)

Nonopiod Analgesics NSAIDS

Novolin R or Humulin R

Short Acting Insulin - **Onset: 30-60 min • Inject 30-45 minutes ac - **Peak: 2-5 hours Used for ↑ BG per SBGM • Used for NPO patients • Used for TPN patients • Used for immediate post-op CABG patients or other open heart pts (valve) - Used in IV infusions: examples insulin drips or may be added to TPN infusions

Tylenol #3

codeine/acetaminophen

Stridor

is an abnormal high-pitched musical breathing sound. It is caused by a blockage or narrowing in the upper airways. It is more often heard during inspiration, frequently without the aid of a stethoscope

ejection fraction

measurement of the volume percentage of left ventricular contents ejected with each contraction normal EF = 55-60% < 30% -> vtach/vfib ICDs should be placed if EF is < 30%

Dependence

normal physiological response to chronic opioid use - Withdrawal s/sx may occur if meds stopped or dose lowered significantly

Acute Lower Back Pain

Lasts < 4 weeks - Most improve 2 weeks - Associated with activity - Symptoms may appear gradually due to spasms - Straight leg raise causes pain in lumber area but no radiation unless herniation is present

Clinical Picture: Left HF

Left HF - systolic failure: Left ventricle has decreased ability to effectively eject blood through aorta (reduced ejection fraction - EF) results in... - Blood backing up into atrium & pulmonary veins, which leads to... - Increased pulmonary intravascular pressure causing fluid shifts out of vessels leading to pulmonary congestion and may cause pulmonary edema Left HF - diastolic failure: ventricles cannot fill resulting in decreased stroke volume & cardiac output - Mixed systolic & diastolic (many patient's have both)

Consent: Preop Nursing Responsibilities

Legal Document 1. name of procedure, purpose, expected outcome, risks 2. pt. must demonstrate clear understanding (at least 18 y.o, own decision maker) 3. Voluntary - Surgeon responsible for obtaining consent - Nurse witnesses pt. signature Nurse ensures all required forms are signed and in chart - Informed consent - Blood transfusions - Advance directives - Power of attorney

Magnesium

Mg2+ (Cation) 1.3-2.1

Osteoarthritis (OA)

Most common form in U.S. affecting 30 million adults - Begins ages 20-30 Symptoms 50-60 - 50% of adults >65 have one affected joint - Slow progressive non-inflammatory joint disorder affecting synovial joints - Previously called degenerative joint disease (DJD); aka 'wear and tear' arthritis - Gradual loss of articular cartilage with body out growths

Ibuprofen (Motrin)

NSAID Osteoarthritis RA NOTE: Increased risk SE in elderly especially GI bleeds & renal toxicity as well as drug interactions - Watch for GI bleeding

A pt is admitted with SIADH - which of these do we expect to see a. urinary output > intake by 1,000mL b. Na 130 c. HR 110 d. Hct is increased e. Decreased skin turgor f. Crackles upon auscultation of lungs g. BP 160/90

Na130, Crackles upon auscultation of lungs, BP 160/90

hydromorphone (Dilaudid)

Opioid Analgesics

morphine (MS, MS Contin)

Opioid Analgesics

oxycodone (Roxicodone, OxyContin)

Opioid Analgesics

Corticosteroids: Intra-articular (IA) injections

Osteoarthritis

♥ NCP: HF: Activity Intolerance

Pace and space! (Alternate rest and activity periods) Monitor response to activity o √ VS changes: before, during, after o ♥ Rhythm &amp; watch for arrhythmias o Assess signs &amp; symptoms of intolerance - Instruct regarding activities - Referrals: PT, OT, RT, Exercise specialist & Cardiac Rehab • PT = physical therapy; OT = occupational therapy; RT = respiratory therapy

LIFESTYLE MODIFICATIONS: HTN

Physical Activity (Exercise) - Moderate intensity aerobic activity > 20 minutes, most days of the week (goal: > 150min/week) - Muscle-strengthening activities at least 2 times a week - Flexibility and balance exercises 2 times a week for older adults especially at risk for falls Avoidance of Tobacco - Smoking, chewing, vaping - Nicotine is a potent vasoconstrictor and increases BP especially in HTN persons - Management of psy-social risk factors: low socioeconomic status, social isolation, lack of support, work and family stress, and negative emotions such as depression and hostility The usual impact of each lifestyle change is a 4-5mmHg decrease in SBP and 2-4mmHg, decrease in DBP; but a diet low in sodium, saturated fat, and total fat and increase in fruits, vegetables, and grains may decrease SBP by approximately 11mmHg

Non-pharmacological Interventions: Pain

Physical Therapies - Non-invasive - Invasive Cognitive Therapies - Distraction - Relaxation

Complications: HF

Pleural effusion - Shifting of fluid from capillaries into pleural spaces - S/sx: dyspnea, cough, and chest pain Pulmonary Edema = Medical emergency! - Fluid/blood in alveoli/interstitial spaces - S/sx: dyspnea, orthopnea, tachypnea, accessory muscle use, productive cough with frothy (pink) sputa, crackles/wheezes, skin: cool, clammy, cyanotic Dysrhythmias Atrial Fibrillation most common - Risk for atrial emboli leading to CVA Risk for Ventricular Fibrillation (VF)/Vent Tachycardia (VT) - if Ejection Fraction (EF) < 30% Normal EF 55-60% - Note: EF = % diastolic blood volume ejected during systole - basically how much blood gets pumped per each beat from left ventricle - Left ventricular thrombus: stroke s/sx - Hepatomegaly: congestion leads to impaired function - Renal failure: decreased perfusion may lead to insufficiency and end-stage renal disease (ESRD)

Interprofessional Care for Fractures

Reduction = realignment A. Closed: manual manipulation often using local or ICVS B. Open: Surgery 1. Debridement 2. Irrigation 3. Antibiotics 4. Tetanus & diphtheria immunization prn C. Traction: May be used for reduction and also to maintain alignment and/or decrease pain and muscle spasms Immobilization A. Splinting/ Casts B. Traction C. Fixation Devices - External - Internal Restoration of function A. PT/ OT B. Rehabilitation Centers

Risk Factors: UTI

Gender Woman > men, increases with age, pregnancy, & sexual activity Structural abnormalities Fistulas (skin, bowel, vagina), Reflux (VUR) Obstructions Tumors, BPH, calculi/stones, strictures Impaired bladder innervation Spinal cord injury, MS, anesthesia/PUR - postoperative urinary retention Chronic disease DM, immunosuppression Instrumentation Catheterization, diagnostic procedures (cystoscopy), ureteral stent, nephrostomy Miscellaneous: poor hygiene, incontinence, habitual delay or urination

N & V: Management

Goal: Assessment - Associated symptoms - Characteristics of the emesis Partially digested food several hrs after eating = gastric outlet obstruction/delayed gastric emptying - Fecal odor & bile = obstruction below level of pylorus - Coffee ground emesis = lower GI bleeding Bright red blood = active bleeding, possibly in esophagus - Mallory-Weiss tear: disruption of mucosal lining near esophageal-gastric junction - Esophageal varices - Gastric or duodenal ulcer - Neoplasm

BPH: Management

Goals - Restore bladder drainage - Relieve symptoms - Prevent/treat complications Watchful waiting Drug therapy - Reduce size of prostate gland - 5 alpha reductase inhibitors (Proscar/finasteride and Avodart/dutasteride) - Alpha adrenergic receptor blockers (Hytrin/terazosin and Flomax/tamsulosin) Surgery - Laser, TURP, open prostatectomy

Clinical Manifestations: Multiple Sclerosis

Gradual onset - Central - Visual - Hearing -Speech - Throat - Musculoskeletal - Sensation - Bowel - Urinary

Vitamin B12 Deficiency Anemia - Treatment

If unable to absorb B12 via gut IM Cyanocobalamin - 1000mg IM daily x 2wks, then weekly until Hct is nl, then monthly for life If GI absorption intact - PO supplements Nutritional Therapy - red meats, eggs, salmon, tuna, yogurt, enriched grains

Leukemia - Treatment: Chemo

Induction - intensive course of chemotherapy designed to induce complete remission Consolidation - given once remission is achieved modified course of intensive course to eradicate the disease Maintenance - small doses of different combos q 3-4 weeks for prolong period - Usually only needed for AML

Diuretics

Thiazides - Hydrochlorothiazide = HCTZ Loop - Furosemide (Lasix) - Bumetanide (Bumex) K+ sparing - Triamterene (Dyrenium) Aldosterone Receptor Blockers - Spironolactone (Aldactone) Actions - Increase Na+ & Cl- excretion - Decrease plasma volume - Decrease vascular response to catecholamines Side Effects - Fluid and electrolyte imbalances - Hypo/hyperkalemia KNOW Normal Values! K+: 3.5-5.0 - May need replacement therapy Orthostatic hypotension - Considerations: May increase fall risks in elderly; concurrent NSAID use may decrease diuretic/HTN effects and cause renal impairment

chlorpropamide (Diabenese)

Thirst control Diabetes Insipidus

carbamazepine (Tegretol)

Thirst control Diabetes Insipidus

Complication: Hyperthyroidism

Thyrotoxicosis (thyroid storm) = a rare but life threatening condition often precipitated by infection, trauma or surgery in a patient with pre-existing hyperthyroidism - Severe tachycardia - Hyperthermia (105°) - Restlessness/irritability - Seizures, delirium, coma - Heart Failure/Shock Treatment for thyroid storm: - ↓ thyroid hormone levels using meds & SNS agents Supportive Therapy: ICU - Respiratory care - Arrhythmia monitoring - Fever reduction - Fluid replacement to maintain circulation - Exophthalmos Eye Care

Capsaicin or salicylates

Topical Cream Osteoarthritis

Iron Deficiency Anemia - Treatment

Treat underlying cause Iron replacement - PO supplements (ferrous sulfate)150-200mg elemental iron - Empty stomach, with OJ/vitamin C for best absorption* - IM/IV - Stool softener; dark stools - Nutritional Therapy

Elavil

Tricyclic antidepressants Alzheimers

Pamelor

Tricyclic antidepressants Alzheimers

Normal Clotting Mechanism (Hemostasis)

Vascular Response - Immediate vasoconstriction when blood vessel is injured Platelet Plug Formation - In response to interstitial collagen from injured blood vessel Plasma clotting factors - Formation of visible fibrin clot on platelet plug concludes clotting process

Miss Elaine Maki is a 79 year-old mentally impaired Finnish American who lives in a rural area of Michigan's Upper Peninsula in an old farmhouse with her older brother. He's been her caregiver and legal guardian for many years. She is being discharged home from a Cardiac Unit after a six-day stay for placement of a new mechanical aortic valve. She has a history of chronic heart failure, CAD, and HTN. You are her RN! Physician's Discharge Orders: Medications - furosemide (Lasix) 40 mg BID oral - potassium chloride (K-Tabs) 10 meq BID oral - carvedilol (Coreg) 6.25 mg BID oral - lisinopril (Prinivil) 10 mg BID po - Aspirin 325 mg po daily - warfarin (Coumadin) 5 mg po daily - nitroglycerin (Nitro-Stat) 0.4 mg sl PRN MR x 2 Diet: 2 gram sodium Activity: Up as tolerated Daily weights CHF teaching by nursing: signs and symptoms to report - Provide teaching packet Follow-up appointment: See Dr. Heart in one month with INR draws every week in the local clinic. Upon a review of her interdisciplinary discharge plan, you discover the following pertinent information based on assessments documented upon admission and throughout her stay: Physical: ADL's/IADL's: Client is mentally impaired with older brother serving as caregiver. She has multiple co-morbidities (new aortic valve, HF,CAD, HTN). Independent in ADL's, but she will need transportation for weekly INR's and help with IADL's such as buying food, meal preparation, and taking her meds. Emotional: Although she has some mental impairment, Elaine is aware of her heart condition and is compliant with caregiver requests. Client's brother believes that he can provide all the ordered care for his sister. Psychosocial: Both admit to drinking a few beers "once in a while" but deny smoking cigarettes. He hunts for venison on their farm property. They take saunas twice a week and attend a local church. She has Medicare insurance and social security. Brother admits to living on a fixed income but denies financial difficulties. Home living: Client lives in an old farmhouse heated with wood. Brother reports they have "lights" but use an outhouse for toileting. Their bedrooms are located on the second level which has a bathtub and sink. A neighbor helps with snow removal and wood is delivered as needed. They do not have cell phones but do have a standard landline. They do not own a computer. Home health nurse needs to assess home further for safety considerations. Family/community support: Client's brother is an 83 years-old with a history of HTN and COPD. A sister and nephew live in Wisconsin. Although, they have not received much help in the past, with encouragement, they are receptive to home health visits.

Why is Miss Maki a high-risk discharge client? Elderly, just had a major surgery, mentally impaired, housing (rural, limited access to medical providers), chronic illnesses (comorbidities) What are the cultural considerations related to discharge planning for Miss Maki? Do you have any related health concerns? sauna (could be dangerous because it causes vasodilation/hypotension - temp limit, sauna buddy, limit amount of time), beers, using wood/oil heat (her caregiver is 82, this could be a concern), outhouse, deer hunting (U.P lifestyle) SISU: strength of will, "have guts", many finish people may not want medications because they're "too strong" Upon reviewing the discharge assessments, do you have any concerns about her returning home? Home: bedroom on second floor (can she use stairs), has to go outside to use outhouse (shes on Lasix, a diuretic - this could be an issue, maybe bring up bedside commode), only have a landline not a cellphone, could be a problem in medical emergency, can they heat the house, limited lighting in house could be a risk of fall. Can she use the tub? Could consult a home health nurse Physical: elderly, mentally impaired. Heath conditions (new valve, HF, CAD) High risk for bleeding because coumadin Emotional: mentally impaired, coping skills seem OK, cooperative, has brother. Psychosocial: sauna, attends church might get help prn After completing medication reconciliation, which discharge med order should you question as her RN? Which medication order for home is missing? Aspirin and coumadin should not be given together, both have risk of bleeding. She should also have something for post-op pain On her discharge forms, what should you include under the section titled "symptoms requiring medical attention?" CHF: Fluid retention, 3lbs in 2 days or 5lbs week is bad, edema in legs, trouble breathing (especially trouble breathing white laying down), productive cough. Surgery (New Aortic Valve): Risk for infection (pus buildup, increasing redness, warmth, increased pain around site, fever), swelling in legs/pain could be DVT should be reported

When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask? a. "Have you lost any weight lately? b. "Do you crave fluids containing sugar?" c. "How long have you felt anorexic" d. "Is your urine unusually dark-colored?"

a. "Have you lost any weight lately? Weight loss occurs because the body is no longer able to absorb glucose and starts to break down fats and protein for energy The patient is thirst but does no necessarily crave sugar-containing fluids

Diagnostic Studies: Hypothyroidism

TSH - High ► primary cause r/t thyroid problem (gland is not responding to high TSH) - Low ► secondary cause r/t hypothalamus (↓TRH) or pituitary problem (↓ TSH) Thyroxine (T4 )= low - Free thyroxine (FT 4 ) • Not bound to protein • Low in hypothyroidism - Total serum: T3 & T4 - Thyroid Antibodies + Suggest ► autoimmune hypothyroidism

Nurse administers corticosteroids to a patient with acute adrenal insufficiency. Nurse determines that the treatment is effective is what is observed? a. Patient is alert and oriented b. The patient's lung sounds are clear c. The patient's urinary output decreases d. The patient's potassium is 5.7 mEq/L

a. Patient is alert and oriented

Pleural Friction Rubs

are grating/rubbing/squeaking sounds that are heard during both inspiration and expiration associated with pleurisy (aka pleural inflammation)

Hypovolemic Shock

state of shock due to loss of fluids/blood S/Sx: Decreased BP, weak pulse, tachycardia, cool & clammy skin, pale, decrease UO, restlessness, decreased LOC Risk Factors: bleeding (internal or external from surgical site) lack of fluid replacement, excessive drainage from NG, surgical site, diuresis Diagnosis: based on symptoms, H & H will confirm blood counts, platelets, coags, imaging for source of bleeding, assess surgical site Prevention-Nursing Strategies: frequent assessment post op for early detection of this complication, Post-op VS frequency (q 15 min x 4, q 30 minutes x 2, q hr x 2, then q 4 hours until 24 hours post-op), fluid replacement Treatment-Nursing Management: Position flat with legs elevated (Note: Trendelenburg [tilting of bed with head lower than feet] is not effective per EBP), open IV, oxygen assess for external bleeding & apply pressure, notify MD, may need to return to OR if internal bleeding

50 y.o man vomiting blood streaked fluids is admitted to thw hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about

use of non steroidal anti-inflammatory drugs

RAAS Inhibitors

used ADHF/CHF decrease pre/afterload ACE's - enalopril (Vasotec) Monitor: ortho B/P's, angioedema, cough, increased K+, renal insufficiency ARB's - used for pts who don't tolerate ACE's - losartan (Cozaar) Monitor: for orthostatic BP decrease & K dietary intake

Vasodilators

used for ADHF & CHF decrease afterload/preload & dilates coronary & kidney arteries Nitrates - Nitroglycerin (NitroDur/Tridil) - Isosorbide dinitrate (Isordil) hydralazine (Apresoline) Monitor: BP closely!

Echocardiogram (Echo)

uses ultrasound to measure ventricular and valve functioning, chamber sizes & EF

Strictureplasty

widen areas of narrowed bowel

Four Types of Diabetes

• Type 1 • Type 2 • Gestational Others: r/t medical conditions or medications • Cushing Syndrome/Disease • Corticosteroids (Prednisone) • phenytoin (Dilantin)(anti-seizure med) • Total Parenteral Nutrition (TPN)

Clinical S/sx: Cushing Syndrome

↑ Glucocorticoid excess **(predominant) Weight gain - Central obesity: trunk - 'Moon' face - Buffalo hump - Thin extremities muscle waste Skin changes: - Thin, fragile skin - Easy bruising/petechiae - Plethora (red checks) - Striae - Delayed wound healing - Hypercalcemia (from bones= osteoporosis): ↑ risk kidney stones - Hyperglycemia - Gastric ulcers - Mood changes: i.e. swings - ↓ Immune response ↑ Mineralocorticoids' - ↑ Na & ↓ K - Increased B/P - Hypervolemia &amp; Edema ↑ Androgens - Acne, hirsutism & ↑ pigmentation - ♀: masculine ▲'s, deeper voice, baldness, menstrual disorders - ♂: ▲'s Gynecomastia. Impotence, testicular atrophy

Metabolic Alkalosis

↑ pH&gt;7.45 ↑ HCO 3 &gt;26 nl. PaCO 2 = uncompensated ↑ PaCO 2 = compensated

Superficial Thrombophlebitis (SVT)

2 Types of Thrombosis 1 is Superficial - Redness - Tenderness - Warmth - "Itchy" - Palpable firm & cordlike vein - Edema - Loss of catheter patency (due to clot) - Often caused by vein trauma (IV's) UE/varicose veins LE - Occurs in 65% of pts with IV's Note: 25% may also have DVT or PE at time of diagnosis or are at risk for developing later. Therefore, SVT's can lead to problems that are more serious.

Chronic Obstructive Pulmonary Disease

- Characterized by persistent airflow limitations that is slowly progressive associated with a chronic inflammatory response - 3rd leading cause of death in U.S - 12.7 million COPD Risk factors COPD - #1 = Cig Smoking COPD is 4x more prevalent in cig smokers affecting about 15% of smokers - Occupation exposure: Chemicals & dust - Environmental: Air pollution/coal fuels - Recurrent RTI: risk factor & exacerbates COPD Heredity: genetic a-antirypsin deficiency - approx 3% causes, causes emphysema

Development of Cancer: Promotion

- Characterized by reversible proliferation of altered cells Activities of promotion are reversible - - - - Latent Period - Between promotion and progression - Mutation has occurred but no disease detectable - Can last for decades

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

- Characterized excessive (↑ ) ADH - Can be a transient or a chronic condition - Seen more frequently in older adults Causes - Malignant tumors - CNS disorders: Head injury/infections/ brain tumors/stroke - Drug therapies - Miscellaneous conditions: lung infections, HIV,

Nursing Care: VTE: Assessments

- Check VS frequently - Monitor for bleeding & Pulmonary Embolism (PE) - Assess effected limb; Measure limb circumference daily - Assess for use of any OTC med/vitamin/herbal therapies Monitor labs closely; CBC, ACT, aPTT - Anti-factor Ca, INR & PT, Platelet counts (decrease may indicate HITS) Consult with Dr. about labs/doses PRN - Titrate (change if needed) doses per labs using protocols or new orders

Myasthenia Gravis

- Chronic progressive autoimmune disease that affects neuromuscular junction - Weakness of voluntary muscles Decreased amount of acetylcholine available at the neuromuscular junction - Anti-Ach receptor antibodies in pts with MG - Occurs mostly between 10-65y/o - Peak age of onset in woman is during childbrearing years

Parkinson's

- Chronic, progressive neurodegenerative disorder - Degeneration of dopamine producing neurons - Eventual loss of coordination & involuntary muscle movement Incidence - Increases with age - peak onset 70s - 15% of cases younger than 50 - Autosomal dominant & recessive gene - linked - Men > woman 3:2 Additional forms: - Parkinson-like symptoms following intoxication with carbon monoxide & manganese (copper miners) - Drug-induced: lithium, haloperidol (Haldol), Thorazine - Illicit Drugs: amphetamine & methamphetamine - Hydrocephalus, hypoxia, infections, stroke, tumor, Huntington's, & trauma

Effectiveness of HD

- Cannot fully replace metabolic and hormonal functions of kidneys - Can ease many of the symptoms of CKD - Can prevent certain complication CKD Does not alter the increased rate of development of CV disease - Majority of CKD deaths are from stroke and MI, followed by infectious complications

Alzheimer's Disease - What is it?

- Chronic, progressive, degenerative disease of the brain - The most common form of dementia 5.3 million Americans have AD - 5% of 65-74y/o - 50% of >85y/o More likely to occur in woman - Women live longer than men Characteristic findings in the brain - Amyloid plaques - Neurofibrillary tangles - Loss of consciousness between cells & cell death

Nursing Considerations r/t med: Synthroid Hypothyroidism

- Careful assessment of elderly with cardiac hx. Monitor labs: expect dose adjustments PRN • Teach patients / family members to: - Check pulse rates/rhythm & HOLD med for pulse ≥100! - Report: chest pain, palpitations, wt. loss, ↑ nervousness, tremors &amp; insomnia - Take in AM on empty stomach (ex. UPHS: @ 7am) - Monitor for improvement: may take several weeks Discuss with pharmacist: - Switching brands of medication: may impact effectiveness - Use with any other prescribed meds &amp; any OTC meds • Example: may ↑ BG & potentiate anti-coagulants & digoxin

BPH Surgery: Postoperative Nursing Care

- Catheter & bladder irrigation Potential complications: - Hemorrhage Bladder spasms - oxybutynin/Ditropan - Urinary incontinence - UTI - Scrotal edema - Erectile dysfunction Teaching - Push po fluids - Avoid sitting for prolonged time - Kegels For 6-8 weeks avoid - Valsalva maneuver (contripation) - Long car rides - Strenuous exercise - Sexual activity - Limit caffeine, ETOH - Avoid cold remedies with pseudoephedrine (Sudafed) Notify MD if - Bleeding - Infection - Obstruction

Acquisition into lungs: 3 ways: Pneumonia

1. Inhalation of microbes in air 2. Aspiration Of normal flora from nasopharynx/oropharynx 3. Hematogenous Spreads via circulation from primary infection outside of lungs. Example: Staphylococcus aureus

A patient who has chest pain is admitted to the emergency department (ED), and all the following are ordered which should the nurse complete first a. chest x-ray b. lipid profile test c. insertion of a peripheral IV d. 12 lead EKG

12 lead EKG

Atenolol (Tenormin)

Beta adrenergic blockers - Used to relieve cardiovascular effects of excess T3/T4 &amp; treat thyrotoxicosis - ↓ HR, nervousness, irritability, tremors

Propranolol (Inderal)

Beta adrenergic blockers - Used to relieve cardiovascular effects of excess T3/T4 &amp; treat thyrotoxicosis - ↓ HR, nervousness, irritability, tremors

Scope of Opioid Epidemic

250,000 deaths since 2000 - 18,893 prescription opioid overdose deaths in 2014 Previously was mostly an urban minority problem - now spread to all areas of US impacting all socioeconomic and racial groups - More adults use prescription painkillers than cigarettes, smokeless tobacco or cigars combined

Nursing Responsibility - Prehab for Surgical Patients (UPHS-MQT Policies & Procedures)

3 Components - Oral Cleansing: Perox-A-Mint Hydrogen Peroxide Solution - Skin Antisepsis: Chlorhexidine Gluconate (CHG) Cloths - Nasal Antisepsis: Povidone-Iodine Solution

pyloric sphincter

Controls passage of food from stomach to small intestine

Risk Factors: Heart Failure

Coronary Artery Disease - HTN - High cholesterol - DM - Tobacco use - Obesity - Sedentary Lifestyle - Hypertension (HTN)

H 2 -receptor blockers

For GERD - Antisecretory cimetidine (Tagamet) famotidine (Pepcid) ranitidine (Zantac)

Antacids

For GERD Neutralize Acid Maalox Tums MOM (calcium carbonate, aluminum hydroxide, magnesium hydroxide)

Cytoprotective/acid protective

For Nausea sucrafate (Carafate)

Proton pump inhibitors (PPI)

For Nausea - Antisecretory esomeprazole (Nexium) lansoprazole (Prevacid) omeprazole (Prilosec) pantoprazole (Protonix) - Use of omeprazole prophylactically in hospitalized patients

Anticoagulants

For atrial fibrillation patients and EF <20% - warfarin (Coumadin) - rivaroxaban (Xarelto) - apixaban (Eliquis)

Macrodantin /Macrobid (nitrofurantoin)

Antibiotic UTI

Aplastic Anemia - Causes

Congenital - Chromosomal alterations Acquired - Results from exposure to radiation, chemical agents, drugs, viral and bacterial infections

Diagnostic Studies: Hypertension

• Basic laboratory studies are performed to (1) identify or rule out causes of secondary hypertension, (2) evaluate target organ disease, (3) determine overall cardiovascular risk, or (4) establish baseline levels before starting therapy. • Routine urinalysis, BUN, serum creatinine, and creatinine clearance levels are used to screen for renal involvement and to provide baseline information about kidney function. • Lipid profile provides information about additional risk factors that predispose to atherosclerosis and cardiovascular disease. • ECG and echocardiography provide information about the heart status. • Ambulatory BP monitoring (ABPM) is used to measure BP at preset intervals over a 24-hour period. It is the best method for diagnosing hypertension

NEWEST: Sodium-glucose co-transporter 2 (SGLT2) inhibitors

• Blocks renal reabsorption of glucose, thus increasing glucose excretion • Canagliflozin (Invokana) • ***SE: genital yeast infections, UTI's and thirst

Normal Regulation of Blood Pressure

• Blood pressure (BP) is the force exerted by the blood against the walls of the blood vessel. It must be adequate to maintain tissue perfusion during activity and rest. • Regulation of BP involves nervous, cardiovascular, endothelial, renal, and endocrine functions.

Review of Metabolic Effects: Impacts the 3 macronutrients

• Glucose utilization decreased: due to absent, insufficient and/or ineffective insulin causing ↑ blood glucose (Type 1 & 2) • Fat metabolism increased: due to unavailable glucose causing hyperlipidemia (Types I & II) and may lead to ↑ ketones /metabolic acidosis (DKA) in Type 1 • Protein utilization increased: breakdown and less protein synthesis (Type 1)

Urinary Tract Infection

Significance - 2nd most common bacterial infection overall - Most common bacterial infection in women

rivastigmine (Exelon)

Decreased Memory & Cognition Cholinesterase inhibitors Alzheimers

Exercise Considerations: Diabetes

"JUST DO IT!" May not be safe for diabetics! Provide exercise prescription: Type/amount • 30 min/ 5 days week aerobic • Resistance training 2-3x/week Discuss benefits/goals - Promotes weight loss - ↓ Insulin resistance &amp; BG - ↓ Triglycerides and LDL - ↑ HDL - Improve BP and circulation KEY POINT: Exercise may lower blood glucose levels - Therefore, patients are taught to: √ their BG before, during & after exercise especially if taking insulin or meds known to cause hypoglycemia - May need to adjust (lower) meds or change diet prn

NCP: Chronic Pain: RA

- Assess pain & evaluate treatment - Reduce/eliminate factors that ↑ pain Teach Non-pharm tx - Hot/cold - Massage -Relaxation/ distraction measures - Teach about Medications

Diabetic Ketoacidosis: DKA

- aka: Diabetic Acidosis / Diabetic Coma - Caused by a profound insulin deficit - Occurs mostly in Type 1 but can be seen in Type 2 during severe illness Precipitating factors - Illness - Infection - Inadequate insulin - Undiagnosed Type 1's - Poor self-management

Fowlers

semi-sitting body position in which a person's head and shoulders are elevated 45 to 60 degrees

ISBAR

I = identification S = situation B = background (past relevant history, recent history) A = assessment findings R = recommendation(s)

A pt. w/ acute hepB is being discharged in 2 days. Discharge teaching plan, the nurse shold include a. avoid alcohol b. use a condom during sexual intercourse c. have a family members get an injection of immunuglobulin d. follow a low-protein, moderate-carbohydrate,moderate-fat diet

b. use a condom during sexual intercourse

-ostomy

create an opening

-otomy

cutting into

A patient who has been treated with morphine by patient-controlled analgesia (PCA) is discharged from the hospital with instructions that all of the following medications may be used for pain. Which medication will the nurse instruct the patient to use first? a. Aspirin b. Ibuprofen (Motrin, Advil) c. Acetaminophen (Tylenol) d. Oxycodone/acetaminophen (Percocet)

d. Oxycodone/acetaminophen (Percocet) - to make the transition from infusion PCA (morphine) to oral dosing, oral oxycodone (an opioid analgesic) should be administered even before the morphine is discontinued. Equianalgesic dosing allows for substitution of analgesics.

Antihistamines

dimenhydrinate (Dramamine) meclizine (Antivert) promethazine(Phenergan) For nausea

Herniotomy

excision of hernia sac

Cholestyramine

given for pruritus - Given in powdered form, mixed with milk or juice - Monitor for side effects (nausea/vomiting, diarrhea, or constipation, skin reactions)

HgA1c

glucose over 90-120 days

Metabolic Syndrome: 5 Components

if 3 of 5 are present. 1/3 of U.S. adults have this! 1. Elevated blood glucose > 100 2. Triglycerides > 150 3. WAIST > 35 women > 40 men 4. BP > 135/80 5. HDL < 40

osteomyelitis

inflammation of bone and bone marrow

The surgical treatment of choice for patient with symptomatic gallbladder disease is a

laprascopic cholecystectomy

At his 1st postoperative checkup appointment following a gastrojejunostomy (billroth II) a patient reports dizziness, weakness and palpitation occurring about 20 minuets after eating each meal. The nurse will teach the patient to a. increase amount of fluids with meals b. eat foods that are higher in carbohydrates c. lie down for about 30 minutes after eating d. drink sugared fluids or eat candy after meals

lie down for about 30 min after eating

-oscopy

looking into

Hypoglycemia

low blood sugar, insulin reaction Cold & Clammy need some candy

lithostripsy

method of removing stones by crushing them into smaller pieces so that they can be expelled

Using Insulin: Basal Dosing

o Used to control glucose between meals and overnight Intermediate - Onset: 1.5 - 4 hours **Peak: 4-12 hours - Cloudy; must be agitated before removal vial - Example: Novolin N / Humulin N Long Acting - Onset: 0.8-4 hours - **Peak: less defined or NO peak - Administered once or twice a day. Do not mix with other insulin products - Duration: 24+ hours - Examples: glargine (Lantus, Toujeo); detemir (Levemir); degludec (Tresiba)

Incisional cholecystectomy

open surgery, removal off gallbladder

Percocet, Tylox

oxycodone/acetaminophen

-ectomy

removal

Semi-Fowler's Position

the head of the bed is raised 30 degrees; or the head of the bed is raised 30 degrees and the knee portion is raised 15 degrees

Back Pain: Chronic

Chronic - Lasts > 3 months - Or is a repeat, incapacitating event Causes Degenerative conditions - Arthritis - Disc disease - Osteoporosis - Spinal stenosis - Chronic strain Clinical s/sx LB herniation!! - LBP - Radiating down to buttock to knee - + straight leg raise - Paresthesia - Muscle weakness Diagnostic Studies - Myelograms: EMG - MRI - X-rays - CT

Heart Failure (HF)L aka CHF (congestive heart failure)

- Condition related to impaired pumping and/or filling - Results in insufficient blood flow & oxygenation to tissues - Acute (develops suddenly and often reversible) or Chronic Heart Failure Stats (don't memorize) - 650,000 estimated new cases per year - increased rates due to aging population and better heart attack survival rates - African americans higher incidence and mortality Most common dx hospital admits > 65 yrs

Evaluating Glucose Control: HgA1C

- If BG levels ↑ over time, will result in ↑ amts. of glucose attaching to Hgb for the life of the RBC (approximately 2-3 months) - Used to screen for, diagnose, and evaluate treatment of diabetes &amp; pre-diabetes (IGT) Expressed as % of total Hg ** N: 4-6% - **Treatment target: < 6.5% - Frail elderly with less than 5 years life expectancy: 8-9%

Endoscopy: Bronchoscopy

- Used for diagnosis, biopsy or to obtain specimen collection and/or directly assess - Can be used to remove foreign objects. Example: Button aspirated by a child Pt. Prep - NPO: 6-12 hours prior to test - Signed informed consent - IV & sedative: Will receive IV conscious sedation (IVCS) Procedure - Flexible fiber optic scope inserted after throat is anesthetized Post-Procedure Care - NPO until gag returns! - Frequent VS - Expect sore throat & possible blood tinged sputa Monitor: Resp/Bleeding complications & recovery from IVCS - Watch for active bleeding (larger amounts of bright blood in sputa)

Preoperative Care: Kidney Transplant

Dialysis Used to obtain as normal of metabolic state as possible Immunosuppressive meds Suppress immunologic defense mechanism Prevent later rejection Must be infection free

Prostate Cancer: Management

Accurate staging - 5-yr survival rate if early diagnosis is 100% Conservative therapy - Watchful waiting Surgical therapy - Radical prostatectomy Retropubic - low abdominal wound Perineal - incision in the perineum Suprapubic - through the bladder - Laprocscopic, robotic assisted (da Vinci) - Cryotherapy - Same post-op considerations & complications as listed above, most significant with radical prostatectomy Radiation therapy - Used for patients who are poor surgical risks - Men > 70 years old - Men wishing to avoid surgery - External radiation vs. brachytherapy (no radiation precautions needed) Drug therapy - doesn't cure - Hormonal therapy - Chemotherapy - Combination of hormonal therapy and chemotherapy

Clinical S/sx S↑ADH &amp; Diagnostics

1. Fluid Volume Excess Increased body wt. - Without edema Low U/O - Concentrated urine - increase urine specific gravity: > 1.025 N: 1.010 - 1.025 Measurement of urine osmolality ↓ serum osmolality - decreased serum Na : < 134mEq/l N: 135-145 Dilutional hyponatremia 2. Hyponatremia - Initial: ↑ Thirst, fatigue &amp; DOE = dyspnea on exertion - Mild: Muscle cramps, irritability, headache Moderate/Severe - NA < 120 mEq - N/V, abd cramps, &amp; muscle twitching Late: Cerebral edema - Lethargy - Confusion - Seizures - Coma

Diagnostics: Angina & ACS

12 lead ECG (aka EKG) - Assess Note: One of the key steps in differentiating chest pain is health history intake using the seven variables. 12 Lead ECG/EKG is often useful noninvasive diagnostic tool after obtaining the patient's chief complaint history - Chest x-ray (CXR): to confirm other conditions Labs 1. Cardiac enzymes (aka heart markers) Used for ruling out or diagnosing acute myocardial infarction (aka Acute Coronary Syndrome - ACS) - Cardiac Troponin - rise within 3-4 hours injury N: < 0.04 nl/ml troponin T values > 0.01 ng/mL that are rising make the diagnosis of cardiac injury. Will rise within 3-4 hours of injury and are most specific of ALL markers to the heart - CK-MB - Myoglobin Others: used to dx heart risk factors - Lipid Profile & Homocysteine levels - Hgb-A1C & Basic metabolic Profile (lytes, BUN/CR) - used to provide baselines Exercise stress test - Pt. exercises to reach an age predicted target HR while being monitored for any s/sx of cardiac ischemia Assessment: check B/P, HR, rhythm, waveforms (ST segment depression, T wave inversion). Ask about CHEST PAIN! Nuclear imaging test often with pharmacology (meds given) - stimulate exercise chemically - Echocardiogram - can be used alone or with exercise and nuclear imaging Cardiac angiography (in Cath lab) - Patient care for heart cath with angiography is similar to PAD arteriography - Review PAD notes & pre/post cardiac cath

Types of Joint Surgery

Arthroscopic - Used to diagnose and repair injured or diseased joints Arthroplasty Reconstruction - Hip resurfacing Replacement - Hemi arthroplasty - Total arthroplasty Arthrodesis - Surgical fusion of a joint

Care of the Surgical Patient

3 Phases of Perioperative Nursing - Preoperative - Intra-operative - Postoperative Types of Surgery - Diagnostic (biopsy) - Curative (take out portion of lung/kidney - to 'cure') - Palliative (to maintain patient comfort, doesn't cure - helps with pain.) - Preventative (BRCA positive, remove breast/ovaries/uterus) - Exploratory (can be used to diagnose aswell, or patient has symptoms - can't say you have endometriosis until they see it) - Cosmetic Classifications - Elective - Emergency (urgent)

osteoporosis

A condition in which the body's bones become weak and break easily.

Anemia - General Definition

A deficiency in the... - Number of erythrocytes (RBCs) - Quantity of hemoglobin (Hgb) - Volume of packed RBCs (hematocrit) Diagnosis - CBC - Reticulocyte count - Peripheral blood smear

Leukemia

A group of malignant disorders affecting the blood and blood-forming tissues of: - Bone marrow - Lymph system - Spleen Cause unknown, associated with: - Chemical agents - Chemotherapy - Viruses - Radiation - Immunologic deficiencies

Pancreatitis: Signs and Symptoms

Abdominal pain - Commonly LUQ, epigastrium, radiates to back - Aggravated by eating and recumbent positioning - Nausea, vomiting (make em NPO) - Low grade fever - Leukocytosis - Hypotension - Tachycardia - Jaundice

Nursinf Care: PCA

Assessment: Q 4/PRN - LOC Respiratory Status - Skin color - RR - ETCO2: N 35-45 mmHg - O2 sats: N > 90% - Sedation Scale - VS - IV site - Monitor SE (nausea, vomiting, urinary retention, constipation, hives, skin rashes ) Evaluate Effectiveness - Numeric pain scale - Sedation scales Patient/family teaching

Complications continued: hepatitis

Chronic hepatitis - Chronic HBV is more likely to develop in infants and those under age 5 - HCV infection is more likely than HBV to become chronic - Manifestations include anemia and coagulation problems, as well as skin manifestations Hepatic encephalopathy - Potentially life-threatening spectrum of neurologic, psychiatric, and motor disturbances - Results from liver's inability to remove toxins Cirrhosis Risk factors include - Male gender - Alcohol consumption - Concomitant fatty liver disease - Excess iron deposition in liver - Patients with metabolic syndrome Ascites - Accumulation of excess fluid in peritoneal cavity - Due to reduced protein levels in blood, which reduces the plasma oncotic pressure

3 Types of Fracture

Complications 1. DVT 2. Compartment Syndrome 3. Fat Emboli Syndrome

More Nursing Considerations related to Insulin

Injection Procedures - know proper techniques SBGM techniques - Use of sliding scales Injection skills - Mixing two kinds of insulin in one syringe - How to use Insulin Pens - Site selection - Storage of insulin - Discarding needles safely

Arterial Disease

Peripheral Arterial Disease (PAD) - aka PVOD Atherosclerosis causes progressive narrowing of arteries - Clinical symptoms occur 60-75% narrowing Severity depends on: site(s), degree of obstruction, and amount of collateral circulation Risk factors for atherosclerosis (NOTE * = important RF's associated with PAD plus chronic renal disease) Unmodifiable - Genetics/family hx - Increased Age - Gender: women Modifiable (Significant) - *Cigarette smoking (single most important risk factor for PAD) - * Hyperlipidemia (cholesterol & triglycerides) - * HTN - *Diabetes Mellitus - Increased C - Reactive Protein (CRP) Modifiable (Additional) - Obesity - Sedentary Lifestyle - Hyperhomocysteinemia - Hyperuricemia - Stress * = important RF r/t PAD - Plus chronic renal disease

Symptoms: Hyperkalemia

Symptoms Result of increased cellular excitability (changes resting membrane potential) - irritability, anxiety, abdominal cramping, diarrhea, paresthesia, rapid irregular pulse - weakness of lower extremities - irregular pulse - cardiac arrest if sudden or severe ECG Changes: - Tall, peaked T wave - prolonged PR interval - ST segment depression - Loss of P wave - Widening QRS - V fib

Symptoms: Hyponatremia

Symptoms Result of water shifting into cells = cellular swelling Decreased Na with Decreased ECF volume: - irritability, confusion, dizziness, personality changes, tremors, seizures, coma - dry mm - orthostatic hypotension, decreased BP, decreased CVP, increased HR, thready pulse - cold, clammy skin Decreased Na with nl or increased ECF Volume: - same neuro symptoms - N/V diarrhea, and cramps - wt gain, increased BP, increased CVP

Metronidazole (Flagyl)

Acute attacks of IBD

Hydrochlorothiazide = HCTZ

Diuretic

Verapamil (Calan)

Non-Dihydropyridines Calcium Channel Blocker

Iron Deficiency Anemia - Clinical Manifestations

- Gradual development - Classic symptoms of Anemia - Pallor* - Glossitis - Chelitis - Headache, paresthesias, burning sensation of tongue (lack of iron to the tissues)

Anemia - Nursing Implementation

- Treatment & Interventions depend on cause of anemia - Blood/blood product transfusion - Drug therapy (erythropoietin, vitamin supplements) - Volume replacement - Oxygen therapy - Dietary & lifestyle changes (depending on type) - Balance rest & activity

The nurse teaches a 28-yr-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which patient statement requires reinforcement of teaching? "I will avoid adding salt to my food during or after cooking." "If I lose weight, I might not need to continue taking medications." "I can lower my blood pressure by switching to smokeless tobacco." "Diet changes can be as effective as taking blood pressure medications."

"I can lower my blood pressure by switching to smokeless tobacco." Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (e.g., the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure-lowering medication.

Clinical Manifestations HTN

"Silent Killer" - Most patients are asymptomatic! Symptoms of severe hypertension r/t effect on organs - Fatigue - Dizziness - Palpitations - Angina - Dyspnea

Lipid Profile (Panel)

**Do not have to memorize these labs** Prep: fast for 12 hours with no alcohol x 24 hours Total Cholesterol - > 200 mg/dl mod risk/>240 high risk CAD (GOAL < 200) - decreased levels: diet, psyllium LDL = low density lipoprotein - > 160 mg/dl recommended (Note: lower if other risk factors present) - decrease statin meds, niacin, psyllium HDL = high density lipoprotein **GOOD CHOLESTEROL*** - < 40 in men and < 50 in women = High Risk for CAD - GOAL > 60 - increased levels: Niacin & exercise, moderate alcohol intake, fibric acid derivatives, statins Triglycerides - > 150 is high risk (GOAL: < 150) - decreased levels: fish oils (omega 3), fibric acid derivatives, limiting alcohol & simple sugar, exercise

NCP: Disturbed Body Image: RA

- Assess personal factors and body image views to develop plan - Help to verbalize feelings - Promote non-physical attributes/accomplishments - Encourage support with other patients

Complications: Target Organ Damage HTN

- Cardiac: CAD = coronary artery disease (Angina/MI) & LVH = left ventricular hypertrophy (CHF = chronic/congestive heart failure) - Cerebrovascular: TIA = transient ischemic attack & CVA = cerebral vascular attack (aka stroke) - Peripheral Vascular: Aortic aneurysms & PAD = Peripheral arterial disease - Renal: Nephrosclerosis & ESRD = end-stage renal disease - Eyes: Retinopathy & hemorrhages

Metabolic Acidosis: Cause

- Diabetic ketoacidosis - Lactic acidosis - Starvation - Severe diarrhea - Renal tubular acidosis - Renal failure - GI fistulas - Shock

Direct Vasodilators

- Direct arterial vasodilation - Reducing SVR & B/P Examples - Nitroprusside (Nipride) - Nitroglycerin (Tridil) - Often used for HTN crisis! Very high blood pressure! - Used in IV drips (continuous infusions) - Critical care units

Medications: HF

- Diuretics - Vasodilators - RAAS Inhibitors - Beta Adrenergic Blockers - Positive Inotropics - Morphine Sulfate (MS) - Anti-dysrhythmia meds - Anticoagulants

PUD: Complications

- Emergency situations, may require surgical intervention Hemorrhage - Duodenal ulcers > gastric ulcers Gastric Outlet Obstruction - Obstruction in distal stomach & duodenum d/t edema, inflammation, pylorospasm, &amp; fibrous scar tissue formation - Pain that increases as day goes on as stomach fills - Relief with belching, vomiting (which can be projectile) - Emesis contains food particles that were ingested hours to days prior - Very foul odor - Constipation (dehydration &amp; decreased intake/anorexia) - Dilation of stomach may be visible & palpable Perforation - Duodenal ulcers perforate more frequently - Gastric ulcer perforations are more lethal - Ulcer penetrates serosal surface with leaking of gastric or duodenal contents into peritoneal cavity - Bacterial peritonitis may occur within 6-12 hrs - Small perfs may seal themselves - Large perfs require immediate surgical closure Symptoms: - Sudden, severe abdominal pain radiating to the back & unrelieved by food or antacids - Rigid and board like abdominal muscles - Shallow resp., tachypnea - Tachycardia, weak pulse - Absent bowel sounds - N/V

Liver: Hematologic System

- Filtration - Production of procoagulants essential to blood coagulation - Storage of iron in excess of tissue needs

Medical Diagnostics & Evaluation: Asthma

- H & P Pulmonary Function Testing (aka spirometry) - Measures lung volumes - Prep: stop bronchodilators 6-12 hours before, no smoking 24 hours - May see bronchodilators used during test! Point of care devices - Peak Flow Meter: measures peak expiratory flow rates (PEFR) - Pulse oximetry: O2 sats Blood tests: - Eosinophils: increase with allergic reactions - IgE: increase with exposure to allergens/can be helpful to id. Triggers - ABG's: low PO2/low or high PCO2 as pt. fatigues - Allergy Skin Testing - CXR: if resp. infection is suspected

Hypoglycemia: Common S/sx Symptoms: Per patient

- Headache - Anxiety/nervousness - Tremors/shakiness - Faintness/dizziness - Sweating - Hunger - Vision changes Signs: PE Findings •** < 70 mg/dl blood glucose • Tachycardia • Pallor • Cold, clammy skin Change in LOC - Confusion - Combative - Slurred speech - Unsteady gait - Seizure - Coma - Death

3 Common Nursing Diagnoses: Respiratory

- Impaired Gas Exchange - Ineffective Airway Clearance - Ineffective Breathing Pattern

Meglitnides

- Increases insulin production in pancreas - repaglinide (Prandin) & nateglinide (Starlix) - Rapid onset: so take 30 minutes or just before meals - SE: ***hypoglycemia, wt. gains

Sulfonylureas

- Increases insulin production in pancreas • glipizide (Glucotrol) • glyburide (DiaBeta) - SE: ***hypoglycemia, wt. gains

Polycythemia - Definition & Causes

- Increases production & presence of RBCs - Hyperviscosity - Hypervolemia 2 Types Polycythemia vera - chronic & recurring - Chromosomal mutilation affecting pluripotent stem cells - Increased RBCs, WBCs & platelets - Hypercoagupathy - Splenomegaly & hepatomegaly Secondary polycythemia - Hypoxia driven - Hypoxia independent

Signs and Symptoms: cholecystitis

- Indigestion - Fever, chills - Jaundice Pain, tenderness RUQ - Referred to right shoulder, scapula - Nausea/vomiting - Restlessness - Diaphoresis Inflammation - Leukocytosis - Fever Physical Examination Findings - RUQ or epigastrium tenderness - Abdominal rigidity Chronic cholecystitis - Fat intolerance - Dyspepsia - Heartburn - Flatulence

Nursing Diagnoses & Care

- Ineffective Airway Clearance - Anxiety Knowledge Deficit - Trigger avoidance - Medication instruction - Peak expiratory flow rate (PEFR) monitoring - Asthma treatment plans

Risk Factors: Lower Back Pain

- Lack of muscle tone - Obesity - Poor posture - Cigarette smoking - Stress - Prolonged sitting - Heavy lifting - Prior back injury/disease - Family history back problems

Desirable Outcomes: Pain

- Patient reports pain controlled to a satisfactory level (< 3), RR wnl, no sedation/little within X min (as determined via route) - Patient is able to demonstrate correct PCA use - Patient experiences no adverse reactions & safety is maintained - Patient is able to participate in post-op activities

type 1 diabetes symptoms

- Polydipsia - Thirst - Polyphagia - Extreme hunger - Polyuria - Frequent urination - N&V - Acetone Breath - Fatigue - Rapid weight loss - Unconsciousness

Management: Chronic Kidney Disease

- Referral to nephrologist - Conservative Therapy - Correction of extracellular fluid imbalances Nutritional Therapy - Dietitian referral - Protein restriction (unless getting dialysis) - Water restriction 600mL plus output (in mLs) from previous day - Sodium and potassium restriction - Phosphate restriction Limit dairy, beer, cola, chocolate, processed foods (phosphate additives) Medications - Antihypertensive - Diuretics - Kayexalate (for hyperkalemia) PhosLo (calcium acetate) & Caltrate (calcium carbonate) & Renvela (sevelamer)- phosphate binders - Give WITH meals: binds to phosphate in diet & exercises in stool - Avoid aluminum & magnesium products (Maalox, Mylanta) - Vitamin D supplementation (cholecalciferol, calcitriol) - Supplemental Calcium Erythropoietin (Epogen, Procrit - IV or SQ) - Iron supplement (take between meals) - Folic acid supplements - Statins - Be aware of meds that are excreted by kidneys - digoxin, metformin, glyburide, vanco, gent, opioids -> NSAIDS can cause further damage

Goals of Surgery: Amputations

- Remove infected, ischemic, or pathologic tissue - Preserve extremity length - Preserve function

Collaborative Care: Pulmonary Embolism

- Report STAT! If PE is massive 10% pts will die in first hour! Oxygen Therapy - Supplemental O2 via device needed for effective oxygenation - Endotracheal intubation (ET) with ventilator assistance PRN - Pulmonary toileting prn - Fluids, diuretics, analgesics as needed Prevent further thrombi/emboli - using anticoagulant medications - Freq. bleeding assessments & lab monitoring

Diagnostics: cholelithiasis

- Ultrasound ERCP - Endoscopic retrograde choleoangio-pancreatography - Percutaneous transhepatic cholangiography Laboratory tests ↑ WBC count ↑ Serum bilirubin level ↑ Urinary bilirubin level ↑ Liver enzyme levels ↑ Serum amylase level

Clinical Manifestations: ALS

- Weakness (starting in UE) - Dysarthria - Dysphagia - Muscle wasting - Drooling - Pain - Impaired sleep - Spasticity - Emotional fluctuations - Depression - Constipation - Esophageal reflux - Cognition remains intact, body wastes away

Nursing Management: Hypocalcemia

- treat underlying cause - PO or IV calcium supplements - vitamin D supplements - Diet high in calcium rich foods - treat pain & anxiety to prevent resp alkalosis caused by hyperventilation - carefully monitor pts who have undergone thryoid or neck surgeries (proximity to parathyroid)

Vitamin B12 Deficiency Anemia

-A.K.A Cobalamin Deficiency - IF (intrinsic factor) secreted by parietal cells of gastric mucosa, which is a protein required for Vitamin B12 absorption in the ileum of the SI Causes: - Pernicious anemia: gastric mucosa does not secrete IF because of antibodies being directed against the gastric parietal cells of IF itself; prevents dietary sources of Vitamin B12 from being absorbed in distal ileum - Gastrectomy, gastric bypass, resection involving ileum - Chronic gastritis, Cohn's ileitis, celiac disease - Nutritional deficient, strict vegetarians - Alcoholism - Hereditary enzymatic defects of B12 utilization

Causes (by age): Epilepsy

0-6 mos: birth injury, congenital defects involving CNS, infections, inborn error of metabolism 2-20yrs: birth injury, infection, trauma, genetic factors 20-30yrs: structural lesions - trauma, brain tumors, vascular disease > 50yrs: cerebrovascular lesions (stroke), metastatic brain tumors Idiopathic: 75% of seizure disorders cannot be attributed to a specific cause

Stages of Chronic Kidney Disease

1 - kidney damage, but no decreased GFR (>/=90) 2 - kidney damage with mild decrease in GFR (60-89) 3 - moderate decrease in GFR (30-59) 4 - severe decrease in GFR (15-29) 5 - kidney failure (<15)

COPD: Complications

1) Cor Pulmonale - Hypertrophy of RV r/t pulmonary HTN - s/sx of R sided HF - Treated with low flow O2 & diuretics 2) COPD Exacerbations - Caused by infections - Will increase with progression - Worsening respiratory s/sx: SOB, cough and/or sputa changes - Treat with meds: Antibiotics, O2, bronchodilators, and oral corticosteroids Prevention - Yearly influenza vaccines - Pneumonia vaccination 3) Acute resp failure Caused by - Delay in seeking help - D/C respiratory meds abruptly - Treated with ET/Vents - Consider Adv. Directives

Edema

1+ - barely detectable, immediate rebound 4+ very deep > 20 seconds to rebound

Order the priority of interventions Starts a regular insulin drip at 50 U/hr Give Lantus 20 units SQ Infuse 1 liter of normal saline 250/hr Continuous Telemetry

1. Continuous Telemetry 2. Infuse 1 liter of normal saline 250/hr 3. Starts a regular insulin drip at 50 U/hr 4. Give Lantus 20 units SQ

Chronic Stable Angina: Management

1. Drug Therapy Nitrates - Short acting: used prn! Example Nitrobid sublingual tablets - Long acting (prevention) : Example Transdermal-control release patches-NitroDur Antiplatelets - ASA (Aspirin) or Plavix - Beta blockers (-olol) - Ca2+ Channel Blockers (-dipine) - ACE's/ARB's (-pril, -sartan) - Anti-lipid agents Risk Factor Management Revascularization Treatments - PCI = percutaneous coronary intervention: balloon angioplasty with stent - CABG = coronary artery bypass surgery

Point of Care: Diagnostic Tools: Asthma

1. O2 pulse oximeter: % oxygen saturation 2. Peak Flow Meter Green Zone - > 80% of personal best - 0 s/sx; can do activities! - Remain on prescribed medications Yellow Zone - 50-79% of personal best - Indicates caution - S/sx present - Use SABA -> Asthma is being triggered - If continues, call HCP Red Zone - < 50% of personal best - Very SOB, s/sx worsening - Indicates serious problem - Take SABA and oral steroid STAT! - Call HCP/report ED Danger: trouble walking or talking due to shortness of breath, blue lips/fingernails - 4-6 puffs rescue/nebs

Resp. Meds

1. Long-term control medications - Achieve and maintain control of persistent asthma 2. Quick-relief medications - Treat symptoms of exacerbations - Rescue meds aka SABA

Management of Older Adults with Cardiac Disease:

1. Need open discussions with family &amp; healthcare team o Interprofessional is best including spiritual/psych members 2. Screen for depression 3. Ensure patient participation in decision making 4. Review all medications with pt./ caregivers o Stress desired effects o Common side effects Caution abruptly stopping can be dangerous o Especially for beta blockers, antiarrhythmic &amp; nitrates - Discuss possible interactions with over-the-counter meds/enc. Pharmacist consulting when buying OTC medications and dietary supplements! o Discuss what to do if meds are accidentally omitted o Assess Insurance coverage o Assess ability to pay co-pays

Invasive Treatments: Valvular Heart Disease

1. Percutaneous Transluminal Balloon Valvoplasty o Opens stenosed valves using balloon catheter 2. Surgery Valve Repair • Commissurotomy (Valvulotomy): opens stenosed valves • Valvuloplasty: repair of torn structures in regurgitate valves • Annuloplasty: repair of the annulus Valve Replacement Surgical Approaches - Open heart using heart-lung bypass machine - Newer Procedure: TAVR = Transcather aortic valve replacement Types of valves - Mechanical: artificial, last longer but require anticoagulation - Biologic: made from animal or human materials, less durable but no anticoagulation required

Overall Patient Goals: COPD

1. Prevention of disease progression & exacerbations 2. Maintaining the ability to perform ADL's & improved exercise tolerance 3. Relief of Symptoms 4. No related complications 5. Enhance self-care knowledge and ability to implement long-term treatment 6. Improved quality of life

DM: Interprofessional Care Goals

1. Reduce symptoms 2. Prevent acute complications - Hypoglycemia Hyperglycemia - DKA: Diabetic Ketoacidosis - HHNS: Hyperosmolar Hyperglycemic Non-ketonic Syndrome 3. Delay the progression of long-term complications "These goals are more likely to be met by near normal blood glucose levels"

Complications: Asthma

A) Severe Exacerbations Dyspneic at rest - Speaks using gasping words no sentences - PEFR is 40% of predicted or personal best - Accessory muscle use - Tachycardia - PEFR is 40% predicted or personal best - Usually seen in ED, ambulatory clinic; often required hospitalization B) Life-Threatening - Too dyspneic to speak - Perspiring profusely - Drowsy/confused - Breath sounds maybe markedly diminished - PEFR < 25% predicted or personal best - Bradycardia - Require immediate care/often admitted to ICU

Fx Classifications (Descriptions)

A) Skin intactness - Closed (simple) - Open (compound) B) Anatomical Location - Identifies body location C) Type of fracture - Direction of fx line D) Displaced/Non-displaced - Displaced = two ends separated - Non-displaced = periosteum intact and/or bones aligned E) Complete/Incomplete - Degree of break F) Direction of fx line

pH

7.35-7.45 (use 7.4 as normal, anything below is acidosis, anything higher is alkalosis)

Which patient is most at risk for developing coronary artery disease a. A hypertensive Caucasian male who smokes cigarettes b. An overweight college student who uses smokeless tobacco c. A First nation male who has diabetes and uses a treadmill d. An African American woman who is sedentary and has elevated homocysteine

A hypertensive Caucasian male who smokes cigarettes Pt. A has 4 risk factors = 2 major modifiable & gender

In documentation for discharge, which of the following would you include? Select all that apply. A. Summary of vital signs during hospitalization, including latest vital signs B. Description of the activity level of the client during hospitalization C. Summary of the teaching plan and client's response to teaching D. Summary of nursing interventions provided during hospitalization E. Intake and output findings during hospitalization

A, B, C C) These data are important information for other healthcare workers to have in order to develop an appropriate plan of care for the client. Nursing interventions (D) and I&O records (E) are not necessary unless there is a specific issue with them. For example, if the client's urine output has been low and he or she is not taking in fluids, it should be included in the discharge summary.

MEDICATIONS: COPD

A. Asthma Medications B. Nebulizer treatments 1. Medication(s) is mixed with water and suspended in a fine water mist 2. Pt. inhaled medication directly into their trachea & bronchials 3. Monitor for med side effects 4. Patient education if ordered for home C. Proper use of Metered Dose Inhalers (MDI) & Dry Powder Inhalers (DPI) 1. Instructions on how to use inhalers and spaces 2. Pt. should be able to demonstrate correct use

Diuretics

ADHF (acute decompensated heart failure) & CHF (chronic heart failure) Reduce preload, fluid volume, edema & pulmonary venous pressures Loop - Furosemide (Lasix) - Bumetanide (Bumex) Thiazides: HCTZ Potassium Sparing: spironolactone (Aldactone) - Aka Aldosterone antagonists Monitor: serum K+ levels & U/O closely Assess: orthostatic B/P decreases, & daily weight

Management: UTI

Antibiotics Sulfa drugs are most common - Bactrim (sulfamethoxazole & trimethoprim) - Macrodantin /Macrobid (nitrofurantoin) - Complicated - above or fluoroquinolones (ciprofloxacin) - Prophylactic antibiotics sometimes administered to patients with repeated UTIs Symptom Management - Pyridium (phenazopyridine HCl)* - Antispasmodic Teaching - Increase fluid intake Avoid bladder irritants: Caffeine, alcohol, citrus juices, chocolate & highly spiced foods - Local heat to suprapubic or low back area for pain relief Prevention - Cranberry - Adequate fluid intake - Wipe front to back - Empty bladder before and after intercourse & DRY area - Regular & complete bladder emptying - Check & change incontinent pts often

Aspirin (ASA)

Antiplatelet, used for chronic stable angina

Plavix (clopidogrel)

Antiplatelet, used for chronic stable angina

It's the night shift and you're a new RN. You answer a patient's call light. Pt. states, "I feel winded. I can't seem to catch my breath!" - What do you need to assess? - What should you do? - What questions should you ask? - Call provider using SBAR

Assess: General appearance: color, position, holding throat? (choking), air hunger. Assess lung sounds - Use oxygen, is it actually in her nose, follow the tube is it connected, raise head of bed Airway - Breathing - Circulation Airway - is it clear/patent. She's talking so theres not an obstruction, listen for gurgling or muffled breath sounds, coughing,, central cyanosis (blueness around lips), check airway (not if they have a neck respiratory) Breathing - depth of resp. RR - N 12-20 breaths/min - Elderly 16-25 - position assumed Patterns: depth/rates - I/E N= 1:2 regular pattern - Identify other patterns Chest expansion - Check accessory muscle use Circulation Mental Status: LOC & orientation (LOCO) - Note: restlessness, anxiety Skin: - color - temperature (to touch) - moisture - diaphoretic? (poor perfusion) - CRT/nal beds - Heart rate/rhythm - B/P QUESTIONS - History of asthma, do you use an inhaler - Has this happened before - Did it wake you up (proximal nocturnal dyspnea) - Do they have COPD - Ask about CPAP for sleep apnea - History of heart disease?

It is imperative the client's family participate in teaching activities. What actions would not be used to determine their ability and willingness to participate? A. Assessment of cognitive ability to understand instructions B. Assessment of how long and how often they visit the client C. Evaluation of the extent of active participation of family during instruction D. Evaluation of interactions between client and family

B The amount of time the family spends at the client's bedside may be dependent on their work schedule, family responsibilities at home, and so on; it does not correlate with willingness and ability to participate in teaching activities. Cognitive ability to understand (A) is important. Once the teaching needs are determined, then it is important to evaluate their active participation (C). The nurse does observe and evaluate interactions between the client and family (D).

The nurse is providing care for a a patient immediately after a thoracentesis. Which statement indicates the patient needs further instruction A. "I will call if I have trouble breathing" B. "I will lie on the affected side for 1 hour" C. "I can expect a chest x-ray soon" D. "This procedure will help my breathing"

B. "I will lie on the affected side for 1 hour"

When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about A. oral corticosteroids. B. Carbidopa-levodopa. C. Magnetic resonance imaging (MRI). D. electroencephalogram (EEG) testing.

B. Carbidopa-levodopa.

Which item should the nurse offer to the patient who is to restart oral intake after being NPO for nausea and vomiting A. Orange juice B. Lemon jello C. Coffee w/milk D. Hot chicken broth

B. Lemon jello

Cancer Treatment: Radiation

Background - Emission of energy from a source -> travels through space/tissue & absorbed into tissue -> breaks chemical bonds in DNA -> cell death - Different types of ionizing radiation are used to treat cancer - Typically delivered daily 5 days a week for 2 to 8 weeks Used to treat a carefully defined area of the body - not a primary treatment for systemic disease May be used by itself, or with chemotherapy or surgery - multimodal approach - To treat primary tumors - For palliation of metastatic lesions 2 Types Teletherapy - external beam radiotherapy Brachytherapy - internal radiation - Temporary & Permanent

Zyprexa

Behavioral Problems Antipsychotics Alzheimers

Kidney Transplantation

Best treatment for pts with ESRD < 4% receive a transplant

Clinical Manifestations: UTI

Bladder storage symptoms - Frequency - Urgency - Incontinence - Nocturia/Nocturnal enuresis Bladder emptying symptoms - Weak stream - Hesitancy - Intermittency - Post void dribbling - Retention - Dysuria Other - Suprapubic discomfort/pressure - Hematuria - Cloudy appearance (sediment) - Four/strong odor - Flank pain, fever, chills - upper urinary tract (pyelonephritis) Symptoms can be absent in older adults - Non-localized abdominal tenderness - May have confusion/cognitive impairment

Beta Adrenergic Blockers

Blocks SNS effects on failing heart - decrease afterload: also lowers blood pressure & HRs - Can also reduce contractility Meoprolol (Lopressor) Monitor: for decrease B/P & heart rates, worsening HF, fatigue, bronchospasm (non-selective). Do not stop abruptly!

Structure and Functions of the Hematologic System

Bone Marrow - Hematopoiesis (Blood cell production) - Iron Storage Blood - Plasma Blood Cells - Erythrocytes - Leukocytes Granulocytes (Neutrophils, Eosinophils, Basophils) Lymphocytes Monocytes - Thrombocytes

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clinic seizure. Which action should the nurse take? A. Insert an oral airway during the seizure to maintain a patent airway. B. Restrain the patient's arms and legs to prevent injury during the seizure. C. Time, observe, and record the details of the seizure and postictal state. D. Avoid touching the patient to prevent further nervous system stimulation.

C. Time, observe, and record the details of the seizure and postictal state.

Interdisciplinary Care for Compartment Syndrome

Check SCM's freq Monitor pressures - Increased-compartment pressure readings: + if > 30mmHg Monitor U/O - Myoglobin released from damaged muscle is trapped in kidneys causing tubular necrosis - Watch for dark reddish brown urine! DO NOT - Elevate extremity - Apply Ice Contact Health Care Provider STAT - May remove or loosen splint or casts - Fasciotomy

ACS: Clinical Manifestations

Chest pain - **Severe not relieved by rest, positioning or nitrates - Often described as "crushing, pressure, or heaviness" with radiation common - Located substernal or epigastric areas - Onset during activity, resting or sleep often early AM - **Lasting > 20 minutes

Some Types of Opioids

Codeine - Commonly known for it's use in Tylenol 3 Hydrocodone - known by the brand names Lortab, Lorcet, Vicoden, and Norco Oxycodone - brand names including Percocet, Percodan, and OxyContin Hydromorphone - known most commonly by the brand name Opana Meperidine - known by the name Demerol Fentanyl - powerful opioid known by the brand names Abstral, Actiq, Fentora, and Onsolis

Actual Discharge Instructions: Topics

Current Condition - VS, physical/psychosocial status r/t admission - Outcomes met or not Medications - Times, doses, SE's - Time of last dose - Meds to stop @ home - Med reconciliation - is complete by the RN - Prescribed Diet Treatments/Procedures - Such as incision care and dressing changes - Use of hot/cold therapies - Home oxygen Equipment - Such as dressings, ostomy supplies, urine straight cath, leg bags, TEDS Activity level: any restrictions/precautions including driving, lifting, return to work, sexual activity. - S/sx requiring medical attention (worsening condition, potential complications, & SE) - F/U (follow-up) appointments - Referrals: provide contact names and numbers

Diagnostic Studies: Cushing Syndrome

Cortisol measurements 24 hr. urine cortisol test - Positive if levels are ↑ Plasma/Salivary Cortisol levels - Elevated - May see loss of diurnal variation - Normally: higher in early am Plasma ACTH: can be low, normal or high per cause - Helps determine if ↑/↓ of cortisol by the adrenal cortex is being caused by gland dysfunction, pituitary problems or exogenous causes. Examples High/normal► Cushing's Disease - Example: Pituitary tumor might be present causing more ACTH or ectopic tumor producing ACTH - Low ACTH = indicates adrenal problem (adrenal tumor) or exogenous medication cause (prednisone) Dexamethasone (ACTH Suppression) Test - Done if 24 hour urine cortisol test is borderline - a low dose of Decadron (dexamethasone) is given at 11 PM to suppress hypothamic CRH (Corticotropic releasing hormone) - Decadron should cause the suppression CRH & thus the anterior pituitary's release of ACTH therefore↓ adrenal cortisol production - Plasma cortisol is drawn at 8 AM - Evaluates the hypothalamus/pituitary functioning and adrenals' response to ACTH SCANS: CT & MRI - to r/o tumors in hypothalamus, pituitary or adrenals glands

C&DB

Cough & Deep breath (often splinting is helpful) Patient Teaching - Position pt. upright with feet on floor if possible or Fowlers with knees flexed - Have pt. inhale slowly and deeply using diaphragm several times - Next, ask patient to take a deep breath, bend slightly forward and huff cough (3-4X during each exhalation) - Use splinting for abdominal or chest wounds/incisions - Provide splint pillow or blanket - Useful for position changes too!

Crohn's vs. Colitis

Crohn's Disease - Involves all layer of bowel - Occurs anywhere in GI tract (mouth to anus) - Most commonly effects terminal ileum & colon - Skip lesions - cobblestone appearance - Strictures @ areas of inflammation can lead to bowel obstruction - Fistulas - between adjacent areas of bowel, bladder, vagina, outside of body Ulcerative Colitis - Involves mucosal layer only - Occurs in colon & rectum - Starts in rectum and moves towards cecum - Fluid & electrolytes cannot be absorbed through inflamed mucosa -> diarrhea - Pseudopolyps - Toxic megacolon colon becomes so inflamed and WBC count goes up, fluid shifts into area, cause quick drop in BP, treated ASAP with antibiotics to decrease chance of septic shock

Which healthcare team member (HCT) usually assumes the leadership role in directing the educational plan for the client and/or family? A. Physician B. Healthcare member whose role represents the greatest teaching need requiring education C. Discharge planner D. Nurse

D (D) Nurses are the principal providers of care; therefore, they usually take the leadership role in directing the educational plan. Other health team members may play a major role in the teaching; however, the nurse usually directs and guides the process. (A) Physicians usually do not play a major role in education while the client is hospitalized. A trained health care member would do the teaching (B). (C) Discharge planners are pivotal in determining placement of clients on discharge and in obtaining equipment for the home.

Monitor shows atrial fib at 130, which intervention should the nurse plan A. check the serum sodium level B. be prepared to defibrillate immediately C. Apply a transcutaneous pacemaker STAT D. Monitor closely for signs of stroke

D. Monitor closely for signs of stroke

Diabetes Insipidus (DI)

DI is characterized - deficit of ADH (production or secretion) or - ↓ renal response to ADH - Condition can be transient or chronic life-long Classifications of DI: r/t cause Central DI (neurogenic) Deficiency of ADH synthesis, release, or transport Caused by - Brain tumor - Head injury / surgery - CNS infections Nephrogenic DI - Inadequate renal response Caused by: - Drug therapy ( most common cause =Lithium) - Renal damage/ hereditary disease

Memantine (Namenda)

Decreased Memory & Cognition N-menthyl-D-aspirate (NMDA) receptor antagonist Alzheimers

Fractures

Definition: disruption or a break in the bone continuity Causes - Trauma - Disease State (pathologic fx) - Osteoporosis - Bone mets

Types of Stomas

End Stoma - Bowel cut and proximal end forms stoma - Temporary: Distal portion of bowel may be sewn shut &amp; left in body - Permanent: Distal portion of bowel &amp; rectum completely removed from body with anus sewn shut Loop stoma - Loop of bowel brought to form stoma - 2 openings (proximal and distal) - Temporary: done to give lower bowel chance to rest and recover - Plastic rod left in place 7-10 days to prevent loop from slipping back into the body Double-Barreled Stoma Bowel resected and both ends brought to surface (2 separate stomas) - Proximal end is functional - Distal end = mucus fistula - Temporary

Adjuvants Meds

Enhance analgesic's effectiveness - Used alone or with nonopiods and opiods - Some have analgesic effects but often developed for other purposes Used to augment acute pain tx; but often needed for chronic & neuropathic pain! Examples: Anti-depressants, corticosteroids, GABA receptor agonist, a2-adrenergic agonist, local anesthetics, cannabinoids (medical marijuana)

Cause: Urinary Tract Calculi

Exact etiology unknown - Common calculi compositions - Calcium phosphate - Calcium oxalate - Uric acid - Cystine - Struvite

FRACTURE HEALING Stages of Fx Healing

Factors influencing healing - Displacement and site of fracture - Blood supply to area - Immobilization - Internal fixation devices - Infection - Poor nutrition - Age (children heal faster than adults) - Smoking - The ossification process may be arrested by inadequate reduction and immobilization, excessive movement of the fracture fragments, infection, poor nutrition, and systemic disease - Healing time for fractures increases with age and smoking

Clinical Manifestations: Myasthenia Gravis

Fluctuating weakness of skeletal muscles Muscles most often effected - Moving the eyes & eye lids, chewing, swallowing, speaking & breathing - Muscle weakness/fatigue progresses as day goes on - Impaired facial mobility/expression - Speech fades after long conversations - Difficulty chewing & swallowing Myasthenic Crisis ** - Acute exacerbation of muscle weakness - can impair swallowing & breathing - When is patient at risk? - Aspiration, respiratory insufficiency & respiratory infection

Fludrocortisone acetate (Florinef)

For Addisons Mineralocorticoids - Given in AM

Type 2: Diabetes: clinical S/sx

Gradual onset: BG may be high for years before detected! - May have milder classic type 1 s/sx Nonspecific s/sx! - Fatigue Recurrent infections - Examples: UTI's/ vaginal yeast/candida - Visual changes - Prolonged wound healing

GERD: Clinical Manifestations

Heartburn (pyrosis) - > 2x per week - Occurs at night & wakes person up - Dyspepsia (pain or discomfort centered in the abdomen) - Hypersalivation - Regurgitation - Hoarseness, sore throat, sense of lump in throat* GERD related chest pain - Burning or squeezing - can radiate to back, neck, jaw or arms - Unlike angina, relived with antacids

Interprofessional Care for Arrhythmias

INITIAL CARE - Check responsiveness & LOC = level of consciousness Ensure ABC's stable - Provide oxygen - Obtain VS & check O2 sats Rhythm - Obtain STAT 12 Lead ECG - Continue Telemetry interpret dysrhythmia - Establish IV access Initiate treatment using protocols - Call medical providers prn Be prepared! - How do you call for help? - Know how to do CPR - Location of Crash Cart - Anti-dysrhythmic Meds Electrical Treatments 1. Defibrillation 2. Cardioversion 3. Pacemakers 4. Implanted pace-cardioverter-defibrillatory (PCD's)

Late Effects of Chemo & Radiation

Inc. risk for leukemia & secondary malignancies - Multiple myeloma - Non-Hodgkin's lymphoma Cancers of the - Bladder, kidney, utterers, osteosarcoma of rib, scapula, clavicle, humerus, sternum, ilium, and pelvis - Secondary malignancies usually resistant to treatment - Significant increase risk in patients who continue to smoke - Alkylating agents and high dose radiation = greatest risk

Polycythemia - Clinical Manifestations

Increased blood viscosity, total blood volume - H/A, dizziness, tinnitus & visual disturbances - Pruritis: histamine release from increased # basophils - Painful burning & redness of hands & feet - Thrombosis -> stroke Hemorrhage - Petechiae, ecchymosis, epistaxis, GI bleeding - Hepatomegaly; Splenomegaly

Nursing Care: HTN

Individual Assessment - Appropriate referrals Periodic follow-up - Recheck B/P q month then every 3-6 months - Labs for drug SE's/target organs damage Assess risk for noncompliance or barriers to compliance Estimated non-compliance rates with meds > 50% - Inadequate teaching - Low health literacy - Side effects - Return to normal BP - $ issues - No insurance

Revascularization Therapies: PAD

Interventional Radiology Percutaneous Transluminal Angioplasty (PTA) - uses balloon tip catheter to compress plague to open lumen & stent is placed Atherectomy - using a cutting disc or laser to remove long obstructing plaque Cytoplasty - PTA plus cold therapy. Liquid nitrous oxide changes into a gas as it enters the balloon. Cold temp limit restenosis. Surgical Options Endarterectomy - Open artery to remove plaque (example: Carotid) Peripheral Artery Bypass Surgery - Native vein - Synthetic graft Amputation

Clinical Manifestations (S/sx): Hyperthyroidism

Intolerance to heat - ↑ body Temp - Neck: goiter = enlarged gland Eyes: Exophthalmos = protrusion of eyeball caused by fluid/fat - eye lid retraction &; lag - corneal ulcers - GI: ↑ appetite &amp; thirst but wt. loss, & diarrhea - Skin: warm, smooth, moist (diaphoretic) skin, - Hair/nails: fine hair with patchy loss, thin/brittle nails, acropachy (clubbing) - MSK: weakness, fatigue, dependent edema - GU: menstrual/sexual ▲'s - Neuro: nervousness, fine tremors, agitation, rapid speech, hyper-reflexia, inability to concentrate, labile moods & insomnia, fatigue, depression - CV: ↑ SBP &amp; cardiac output (CO), bounding, rapid pulse, angina, arrhythmias (palpitations) - Resp: ↑ RR, mild DOE (dyspnea on exertion)

detemir (Levemir)

Long Acting Insulin - Onset: 0.8-4 hours - **Peak: less defined or NO peak - Administered once or twice a day. Do not mix with other insulin products - Duration: 24+ hours

Nursing Interventions: DVT

MEDS used for both prophylactic (prevention) & VTE's Vitamin K Antagonists (VKA) - *warfarin (Coumadin): PO Thrombin Inhibitors - Indirect - * Unfractionated Heparin (UH): Heparin sodium: SQ or IV continuous infusion - Low molecular weight heparin (LMWHs) enoxaparin (Lovenox): SQ Factor Xa Inhibitors - rivaoxaban (Xarelto): PO - apixaban (Eliquid): PO - fondaparinux (Arixtra): given SQ Potential Complication: HIT = heparin induced thrombocytopenia - Caused by immune reaction to heparin - Severe decreased in platelet count and with increase art/vein clots <150,000 or > 50% decreases baseline - Diagnosed: measure heparin antibodies - If occurs, stop heparin and switch to different anticoagulant such as fondaparinux (Arixtra)

Clinical Picture: Right-Sided HF

Main cause is primary L-sided failure - Right HF: right ventricle fails to pump blood effectively - Blood backs up into right atrium and superior & inferior vena cava - increased pressure superior vena cava = jugular vein distension (JVD) increased pressures inferior vena cava: leads to - sudden wt. gains Edema - Peripheral - Abdominal ascites - GI Concerns

Gout Treatment

Medications Acute - Colchicine - NSAIDS - Corticosteroids Chronic (also known as maintenance therapy) - Allopurinol (Zyloprim) - Probenecid (Benemid) - Febuxostat (Uloric) Nutritional - Limit alcohol - Decrease weight if needed - Limit foods high in purines - Sardines, liver, venison, meats

BPH: Signs & Symptoms

Most common complaint is feeling of incomplete bladder emptying Obstructive (from urinary retention) - Decrease in caliber and force of the urinary stream - Difficulty initiating void - Intermittency - Dribbling at end of urination Irritative (associated with inflammation and/or infection) - Frequency - Dysuria - Bladder pain - Nocturia - Incontinence - Hematuria

GERD: Gastroesophageal Reflux Disease

Mucosal damage 2degrees to reflux of gastric contents into lower esophagus Causes/Risk Factors: - Hiatal hernia - Incompetent lower esophageal sphincter - Increased Intra-abdomial pressure - Decreased gastric emptying - Obesity - Pregnancy - Foods: caffeine, chocolate - Habits: smoking - Medications: anticholinergics (antidepressents)

Nausea & Vomiting

Nausea - Feeling of discomfort in epigastrium with a conscious desire to vomit Vomiting (Emesis) - Forceful ejection of gastric contents - GI tract becomes overly irritated, excited or distended. - Protective mechanism Causes: - Variety of GI disorders - Pregnancy - Infection - CNS disorders (meningitis, tumor) - CV problems (MI, heart failure) - Metabolic disorders (diabetes, Addison's, renal failure) Side effects of drugs (chemo, opioids, digitalis) - Empty stomach - Psychologic factors (stress, fear)

Calcium

Normal Range 8.6-10.2mg/dL Function - Transmission of nerve impulses - muscle contractions - myocardial contractions - blood clotting - formation of bone * Ca combines with phosphorus & is stored in skeletal system * can be transferred to or from skeletal system to balance ECF concentrations Absorption Excretion Regulation - diet - renal, generally stored in bones vs. excreted - parathyroid hormone (PTH): low serum Ca triggers PTH to be released which causes mobilization of Ca from bones, increased absorption in GI * reabsorption in renal tubules - calcitonin: stimulated by high Ca levels - opposes PTH, resulting in opposite effects - vitamin D; needed for absorption of Ca from GI tract

A client with a history of asthma presents in the physicians office with complains of difficulty breathing. The nurse is concerned that the client's status has worsened based on which findings

Noticeably diminished breath sounds

Nursing Management: Hypervolemia

Nursing Management - diuretics - fluid restriction, Na restriction (use salt substitues) - oxygen, bronchidilators for respiratory symptoms - strict I&O daily wt. best method for tracking fluid gain/loss*** - quick wt. .changes = fluid; nutritional causes of weight change occurs over longer periods of time - same time each day, zero scale 1L of water/IVF = 1kg (2.2 lbs) - assess for symptoms & lab changes (as indicated above) - frequent skin care & position changes - monitor for mental status changes (Na), fall precautions

Nursing Management: Hypokalemia

Nursing Management - place pt on telemetry - monitor ECG - administer PO/IV potassium chloride (KCl) * IV KCL must always be diluted (normally hung as an IVPB) * never IVP * use CVL if possible * assess PIV frequently (irritating to vein, can cause extravasation) * (max rate = 10mEq/hr for PIV & 20mEq/hr for CVL)

Gerontologic considerations for client education should include which one of the following concepts for older clients? A. Older adults learn best by reading material. B. They remember 30% to 50% of what they read. C. Older adults need extraneous noises decreased while teaching is being presented. D. Older adults learn best in group settings.

Older clients frequently have hearing deficits and extraneous noise impairs their hearing. This can lead to perceiving incorrect information and directions. (B) Older clients remember about 5% of what they read. (A) They remember 50-70% of what they hear and verbalize. (D) Usually, older clients do not learn best in groups, because it can be noisy and disruptive.

PhosLo (calcium acetate)

Phosphate Binder Chronic Kidney Disease Give WITH meals: binds to phosphate in diet & exercises in stool

Renvela (sevelamer)

Phosphate Binder Chronic Kidney Disease Give WITH meals: binds to phosphate in diet & exercises in stool

Clinical Manifestations: Parkinson's

Parkinson's Triad** Bradykinesia - Slowness in initiation & execution of movement - Loss of nl arm swing when walking - Decreased blinking - Dysphagia Rigidity - Increased muscle tone - Increased resistance to passive movement - Jerky, slow movement Tremor at rest - Starts in upper arm/hand - Pill rolling - Can involve head - twitching side to side - Stooped posture - Shuffling gait - Mask-like face (blank expression) - Dysarthria

Thrombocytopenia - Nursing Management

Pressure for 5-10 min after lab draws, injections, avoid IM injections if possible Education re; reducing bleeding risk - No straight edge razors - Soft bristle tooth brushes only - Fall prevention - Assess stool with every BM, prevent constipation/straining - Assess skin & MM - No plucking hair - Don't blow nose - Light activity Platelet transfusion for platelet counts < 10,000/uL

Proscar (finasteride)

Prostate Anti-inflammatory reduces chance of prostate cancer by up to 25%

The nurse is caring for a patient with hypertension who is scheduled to receive a dose of metoprolol (Lopressor). The nurse should withhold the dose and consult the prescribing physician for which vital sign taken just before administration? O2 saturation 93% Pulse 48 beats/min Respirations 24 breaths/min Blood pressure 118/74 mm Hg

Pulse 48 beats/min Because metoprolol is a β1-adrenergic blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the health care provider for parameters regarding pulse rate limits.

Nursing Responsibility: Maintaining NPO Status Preop

Purpose - Usually NPO after midnight - Some surgeries/procedures - clear liquids up to 2 hours before procedure - Necessary AM meds (with small sips of water) are still given (BP, BG)

Clinical Signs/Sx: Asthma

Symptoms Cough: might be only symptoms - Nonproductive - Productive: thick sputa - Chest tightness - Dyspnea Wheezing - Unreliable way to gauge severity PE (physical exam) findings with Asthma: Might be normal if well controlled but during acute attack - Hypoxia - Tachypnea -Prolonged expiration - Accessory muscle use Auscultation - Wheezing - Decreased breath sounds/no wheeze = bad finding! - Allergy signs: runny nose, swollen nasal passages/polyps

NDP: Respiratory: Ineffective Airway Clearance

Related To - Aspiration - Artificial airways: ET (endotracheal tube) - Ineffective cough - Increased, thick sputa AEB: ineffective/absent cough, inability to raise/expectorate sputa adventitious sounds Desired Outcomes Patent Airway! - Effective coughing/expectoration prn - Clear breath sounds Assessments - Ability to cough & expectorate - Check sputa: document characteristics Interventions Keep HOB elevated - Encourage sitting & ambulation Adv. Airway Management - Suction PRN - Tube care prn Chest Physical Therapy - Postural Drainage - Percussion/Vibrations Maintain hydration - PO (2-3L/day) or IV prn Oxygen therapy - Humidified Enc. C&DB with IS - Splint prn Drug Therapies - Bronchodilators - Mucolytics - Expectorants Pt. Teaching - Proper huff coughing - Splinting

Symptoms: Hypokalemia

Symptoms Result of reduced cellular excitability (changes resting membrane potential) - fatigue, muscle weakness, soft/flabby muscles - paralytic ileus, constipation, N/V - paresthesia, decreased reflexes - weak, irregular pulse - polyuria - hyperglycemia ECG Changes - Flattened T wave - presence of U wave - ST segment depression - fatal ventricular dysrhythmias, PVC's - bradycardia - enhanced digitalis (digoxin) effect

Symptoms: Hypervolemia

Symptoms - Rapid weight gain - Edema - generalized, dependent, putting - JVD, Bounding pulse, increased BP, increased CVP - Polyuria (with nl renal function) - Dyspnea, crackles, pulmonary edema Due to dilutional hyponatremia - Headache, confusion, drowsiness/lethargy - Seizures, coma - muscle spasms

Nausea/Vomiting

Risk Factors: anesthesia, decreased motility, eating/drinking too soon before bowel is coordinated, pain meds Prevention-Nursing Strategies: ensure bowel sounds and flatus prior to starting PO, slow advancement of diet (ADAT) Treatment-Nursing Management: Antiemetics, emesis basin, tissue, mouthwash, HOB elevated; record emesis as output in I&O

Symptoms: Hypovolemia

Symptoms - Rapid weight loss - Thirst, dry mucous membranes - Decreased skin turgor, poor cap refill - Postural hypotension, increased HR, decreased CVP, decreased BP - Decreased UO (<30mL/hr) - Concentrated urine - Increased RR - weakness, dizziness Due to relative hypernatremia: - Restlessness, drowsiness/lethargy, confusion - seizures, coma

Patient-Caregiver Teaching: PAD

Risk factor modification: Stop smoking/control B/P & glucose - Nicotine is potent vasoconstrictor - avoid use, decrease stent patency - Referrals PRN: i.e Dietician/Diabetic Educator/Podiatrist - Exercise: Progressive Walking Program - Medication instruction Proper Skin/Foot Care with daily inspections - Instruct on factors that interfere with circulation - Inspect feet daily & report s/sx infection - Wear protective footwear with clean cotton or wool socks - Avoid sitting with crossed legs & prolonged standing Protect from extreme hot/cold exposure - Avoid use of heating ads, hot water bottles - Check bath water with thermometers - File/cut toenails across natural curve, don't cut into edges

When providing dietary instruction to a patient with hypertension, the nurse would advise the patient to restrict intake of which meat? Broiled fish Roasted duck Roasted turkey Baked chicken breast

Roasted duck Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall cardiovascular disease risk. The other meats are lower in fat and are therefore acceptable in the diet.

Skin Reactions to Radiation & Chemo

Radiation - Occur in radiation treatment field - Acute or chronic - Develop 1 to 24 hours after treatment - Generally progressive as treatment dose accumulates Types - Dry Desquamation - Wet Desquamation Chemo - Dry skin, peeling - Dry/brittle nails Radiation recall - Sunburn-type reaction to previously radiated areas when chemo is given General Skin Care Strategies - Gentle cleaners & moisturizers (fragrence-free, alcohol free, hypallergenic) - Warm, not hot water when showering - Avoid baths & hot tubs - Use creams & ointments instead of lotions - Hydration - Avoid heating pads and cold packs - Sunscreen - No artificial nails, avoid manicures if neutropenic - Assess skin daily - Pay special attention to skin folds, pressure areas - Rubber gloves for dishes/cleaning - Gloves for gardening

Insulin

Routes - SQ via injections or pumps - Inhaled - IV: IVP or continuous infusions (drips) Types of insulin - Rapid - Short - Intermediate - Long - Mixtures: ex. 70/30

Diagnostic Studies of the Hematologic System

Radiologic Studies - Computed tomography (CT) - Magnetic resonance imaging (MRI) - Position emission tomography (PET) Biopsies - Bone marrow aspiration & biopsy - Lymph node biopsy - Molecular cytogenetics and gene analysis

Novolog or Humolog

Rapid Acting Insulin **Onset: within 10-30 min - Inject 15 minutes ac (before meals) **Peak: 30-3 hrs. min - Used for ↑ BG per SBGM - Used to cover meal intake often with carb counting! - Used in pumps

NCP: Respiratory: Ineffective Breathing Patterns

Related to - Chest wall alterations & pain: surgical, trauma, infection and disease - Anxiety AEB: dyspnea, nasal flaring/accessory muscle use, barrel chest, pursed lips, tripod Desired outcomes - Effective respiration pattern: normal rate, rhythm, depth, without dyspnea - Return to baseline Assessments - Respiratory physical exam (PE) & check oxygen status Interventions Position to aid respirations & increase comfort - raise HOB - Reposition PRN - Frequent turning in bed (or use automatic rotating beds) - Leaning over bed table or tripod positioning - Encourage/assist with C&DB - Use IS devices Breathing Exercises (know how to teach this) - Pursed lip Drug Therapies - Bronchodilators - Analgesics Teaching - Breathing exercises - C/DB & IS use - Splinting - Meds

Nursing Care: DI

Related to Fluid Volume Deficit - Freq. assessments: B/P, HR, U/O, LOC Measurements: - I&O - Daily wt. - √ urine specific gravity - monitor labs: esp. Na+ - Blood glucose Chronic: Teach about home med use and s/sx to report

Gastrojejunostomy/Billroth II

Removal of distal 2/3 of stomach and reconnection of remaining stomach with jejunum

Paralytic Ileus

S/Sx: Decreased to absent bowel sounds (turn off suction if NG in place while listening); no stool of flatus; N/V, abdominal distention, pain Risk Factors: GGI surgery, physical manipulation of the bowel, feeding too soon before return of coordinated peristalsis, pain meds Prevention-Nursing Strategies: chewing gum (EBP), early ambulation Treatment-Nursing Management: NG, IVF, ambulation, ADAT, stool softness/laxatives

Abdominal Distension

S/Sx: rounded abdomen, firm, may c/o pain Risk Factors: abdominal surgery -> motility to large intestine returns in 2-5 days, small intestines in 24 hours Treatment-Nursing Management: ambulation & frequent position changes to promote motility, NG to decompress abdomen if severe

Isolated Systolic Hypertension

SBP > 130mmHg coupled with DBP < 90mmHg Common in elderly Systolic is higher, diastolic is normal. Vessels get tight.

Factors Influencing Capillary Fluid Movement

Shift of Plasma to interstitial fluid - Elevated venous hydrostatic pressure - Decreased plasma oncotic pressure - Elevated interstitial oncotic pressure - pulls fluid into interstitial space - Results in edema, FVD Shift of interstitial fluid to plasma - Increased tissue hydrostatic pressure - Increase in plasma oncotic pressure - Results in decreased edema, FVE

Pyloroplasty

Surgical enlargement of pyloric sphincter to facilitate passage of contents from stomach

Symptoms: Hypernatremia

Symptoms Result of water shifting out of cells into ECF - dehydration & shrinking of cells Increase Na with Decreased ECF Volume - Restlessness, agitation, tremors, seizures, weakness, lethargy, coma - intense thirst; dry swollen tongue, sticky mm - orthostatic hypotension, decreased BP, decreased CVP, increased HR, thready pulse Increase Na with nl or increased ECF volume - name neuro symptoms & thirst, flushed skin - wt gain, peripheral edema, & pulm edema (crackles, SOB, low SaO2), increased BP, Increased CVP

S.Sx R-Sided HF Symptoms/Signs

Symptoms (Subjective) - Fatigue - Dependent bilateral edema - RUQ Pain GI Complaints - GI Bloating - Anorexia/nausea - Anxiety - Depression Signs (Objective - PE) - JVD - Weight gain Edema: Note location and amount chart using numeric scale - Pitting dependent: Limbs - especially feet/ankles If bedridden: check sacrum/scrotum - Anasarca (massive generalized body edema) GI - Ascites: fluid in abdomen - Hepatomegaly: liver enlargement - Tachycardia

Collecting Sputa: Role of the Nurse

Use Sterile containers/sputa trap devices Patient Instructions - Early morning is best time! - Take several deep breaths - Expectorate after deep cough - Need sputa not saliva! - Avoid food/fluids - May need to increase oral fluids - Consult RT prn - Label & send to lab ASAP following universal precautions

Kayexalate (sodium polystyrene)

To treat Hyperkalemia caused by acute renal failure

Dialysis Types

Two methods of dialysis available - Peritoneal dialysis (PD) - Used in 10% of dialysis patients Hemodialysis (HD)

Prevention of hip fractures

Use of an assistive device such as a walker or cane Exercise: Weight bearing such as walking - Bone mass peaks at age 20 - < 30 promotes - > 30 maintains - Walking 30 min 3x week - Weight training Diet: Calcium & Vitamin D, avoid excessive drinking - 1000 mg/d (premenopausal) woman & men < age 70 - 1200 mg/d > 70 Medications: Watch for medications that make you dizzy or weak Fosomax - Take w/ full glass h2o in AM 30 min before food or other medications - Don't eat/drink 30 minutes or lay down - Calcitonin - Selective Estrogen Receptor Modulators

Pyelonephritis

What is it? - Bacterial infection of kidney tissue - begins in the lower urinary tract & ascends into the kidneys - Can be acute or chronic* Same risk factors as UTI Vesicoureteral reflux (VUR) - Backward movement of urine from lower to upper urinary tract Dysfunction of lower urinary tract - Obstruction from BPH, stricture, stone

Acute Glomerulonephritis

What is it? - Immunologic process causing inflammation in the glomeruli - Affects both kidneys equally** - Third leading cause of renal failure in US

Urinary Diversion

What is it? - Surgical procedure to reroute urine flow

LIFE STYLE MODIFICATIONS: Diet HTN

Wt. Reduction - Small losses (10kg/22lbs) may decrease SP 5-20mmHg DASH eating plan Dietary Approaches to Stop Hypertension - Fish/poultry - Fruits/veggies - Beans, nuts, seeds - Fat free/Low fat dairy - Whole grains Sodium Restrictions - < 2300 mg/d if healthy - HTN: <1500 mg/d Moderate Alcohol Intake - Male 2 drinks/day - Female 1 drink/day 1 Drink = - 12 oz beer (2 cans/beer) - 5 oz wine - 1.5 oz. liquor (shot)

Medical Diagnostic Assessments History & Physical: Fractures

X -rays: determines intactness of bone CT scan: soft tissue, bone abnormalities, & MSK trauma MRI: good for soft tissue injuries, avascular necrosis; Imaging maybe also used prn to evaluate healing

Hemophilia

X-linked recessive genetic disorder caused by defective/deficient coagulation factor Hemophilia A: 1/5,000-10,000 males - Reduction in factor VIII - Classic hemophilia Hemophilia B: 1/30m000-50,000 males - Reduction in factor IX - Christmas disease Labs: - PT, platelets, thrombin time, bleeding time all normal - Factor, deficiencies seen (as above) - PTT - Prolonged due to deficiency in intrinsic clotting factor

Respiratory: Atelectasis

alveolar collapse - caused by retained secretions/mucous plug or decreased respiratory excursion - S/Sx: dyspnea, decrease SaO2, crackles or diminished breath sounds, elevated temperature, if severe: possibly asymmetrical chest expansion, tachycardia, & restlessness - Risk Factors: abdominal.thoracic surgery, smokers, pain, elderly & those with respiratory history - Diagnosis: based on symptoms, confirmed by chest-x-ray (CXR) - Prevention-Nursing Interventions: TCDB (splinting) sustained maximal inspiration, IS, early ambulation, hydration 2-3L/day (unless fluid restriction due to CHF, kidney disease), pain management - Treatment-Nursing Management: same as what is done to prevent, may need oxygen to support (use humidification), hydration, bronchodilators, CPAP/BIPAP/intubation if severe

dimenhydrinate (Dramamine)

antihistamine nausea med

meclizine (Antivert)

antimhistamine nausea med

A client with COPD has a RR of 24, bilateral rhonchi and crackles and is coughing but unable to expectorate sputa. Which nursing diagnosis is priority for the patient a: Risk for decreased cardiac output b. impaired gas exchange c. ineffective breathing patterns d. ineffective airway clearance

ineffective airway clearance

Percutaneous transhepatic cholangiography

contrast medium is injected using a needle placed through the abdominal wall into the liver

Syncope

fainting - often orthostatic/postural hypotension, fluid deficit, decreased CO Risk Factors: most common in older adults or pts with prolonged immobility, patients with fluid losses (N/V/diarrhea/blood), medications (BP, narcotics, anesthesia) Prevention-Nursing Strategies: Get up slowly: first raise HOB, then sit on side of bed with legs dangling, assess pulse/dizziness, stand slowly, get up with assistance only (esp. first few times); Fall precautions, assess for orthostatic symptoms

Norco, Vicodin

hydrocodone/acetaminophen

A client with a diagnosis of Addisonian crisis is admitted to ICU which findings should we look for 1. Hypotension 2. Leukocytosis 3. Hyperkalemia 4. Hypercalcemia 5. Hypernatremia

hypotensive, hyperkalemic NOT hyper- but hyponatremic vascular tone decreased due to low cortisol -> aldosterone is low leading to salt and water losses and potassium being saved. Calcium is not impacted and the white blood cell counts do not increase unless there's an infection

Cheyne-Stokes respiration

pattern of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea

Semi-Fowler's Position

position is the position of a patient who is lying in bed in a supine position with the head of the bed at approximately 30 degrees. place pt in this position if they are experiencing N/V to prevent aspiration - also place for HF

Nursing Care: VTE: Patient & Caregiver Teaching

r/t anticoagulants Medication: action/when/how to take & SE's - preferably late afternoon or evening for Coumadin - Lovenox injection teaching - Need for F/U labs & dose changes - Avoid ASA & NSAID's - Consult with pharmacist for any OTC med/herbal/vitamins/minerals & new meds - Stop smoking! Avoid all tobacco products - Limit alcohol (1 drink per day) - Don't change diet esp. adding food high in Vitamin K (if on Warfarin) - Wear medic alert jewelry/carry wallet drug info - S/sx bleeding & PE's to report

Total Colectomy with ileoanal reservoir

removal of colon , use part of ileum to form a new "rectum" (ileoanal reservoir)

-plasty

repair/construction

jejunum

second part of the small intestine

Factor Xa Inhibitors

used for prevention & treatment of DVT/PE/ for hx of HITS Examples: - fondaparinux (Arixtra): SQ - rivaocaban (Xarelto): po (take with food) - apixaban (Eliquis): po - Can be used as a single drug therapy (i.e. without heparin) - Does not require lab monitoring, dosing adjustments, or diet restrictions! Does require monitoring of complete blood counts (CBC's) and creatinine clearance levels - Therapeutic effectiveness can be checked with anti-factor Xa test *Andexxa: antidote for uncontrolled bleeding with Xarelto and Eliquid

warfarin (Coumadin)

used for prevention and treatment Therapeutic Effectiveness: **INR N: 0.75-1.25 - DVT GOAL: (2-3) ** PT: N 10-13 seconds (goal 1.5-2 x control) Nursing Notes - Takes 3-5 days to reach therapeutic levels Started before other meds (heparin/Lovenox) are stopped - Usually 4-5 days - Given for 3 to 6 months after VTE - Taken orally at the same time each day (evening) - Associated with vit K dietary restrictions **Antidote for Coumadin = Vitamin K & Kcentra

PVC (Premature Ventricular Contraction)

wide, bizarre looking complexes that can be uniform in shape (same ectopic site) or multifocal different shapes (more than one ectopic site) Strip 1 have multifocal PVC's and strip 2 has unifocal PVC's.