cohort9 Final Exam

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Parenteral Nutrition: what is the goal when using PN feeding?

A method to provide nutrients to the body by an IV route A complex mixture containing proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals, and sterile water is administered in a single container. The goals of parenteral nutrition are to improve nutritional status and to attain a positive nitrogen status.

Maintaining Nutrition Balance and Tube Function

Administer feeding at prescribed rate and method and according to patient tolerance. Measure residual prior to intermittent feedings and every 4-8 hours during continuous feedings. Administer water before and after each medication and each feeding, before and after checking residual, every 4 to 6 hours, and whenever the tube feeding is discontinued or interrupted. Do not mix medications with feedings. Use a 30-mL or larger syringe. Maintain delivery system as required. To avoid bacterial contamination, do not hang more than 4 hours of feeding in an open system.

Care of the Patient Receiving Parenteral Nutrition: Assessment

Assist in identifying patients who are candidates for PN Nutrition status Hydration status Electrolytes Signs and symptoms of hypoglycemia/hyperglycemia ◦ Monitor blood glucose levels. Assess for potential complications ◦ VS including temperature every 4 hours or by protocol

Reduce Risk for Aspiration

Elevate HOB at least 30-45 degrees during and for at least 1 hour after feedings. Monitor residual volumes.

Care of the Patient Receiving an Enteral Feeding: Diagnosis

Imbalanced nutrition Risk for diarrhea Risk for ineffective airway clearance Risk for deficient fluid Risk for ineffective coping Risk for ineffective therapeutic regimen management Deficient knowledge

what are some diagnosis forf parenternal feeding? what are we at risk for?

Imbalanced nutrition Risk for infection Risk for excess or deficient fluid Risk for immobility Risk of ineffective therapeutic regimen Collaborative Problems and Potential Complications Pneumothorax Clotted or displaced catheter Sepsis Hyperglycemia Rebound hypoglycemia Fluid overload some of the risk may just be the fact that the line needs to be inserted.

Care of the Patient With a Gastrostomy: Diagnosis

Imbalanced nutrition Risk of infection Risk for impaired skin integrity Ineffective coping Disturbed body image Risk for ineffective therapeutic regimen management

Indications for Parenteral Nutrition

Intake is insufficient to maintain anabolic state. Ability to ingest food orally or by tube is impaired. Patient is not interested in ingesting or is unwilling to ingest adequate nutrients. The underlying medical condition precludes oral or tube feeding. Preoperative and postoperative nutritional needs are prolonged.

Other Interventions

Maintain hydration by supplying additional water and assessing for signs of dehydration. Promote coping by support and encouragement; encourage self-care and activities. Patient teaching

Purposes and Advantages of Enteral Feeding

Meets nutritional requirements when oral intake is inadequate or not possible, and the GI tract is functioning Advantages: ◦ Safe and cost-effective ◦ Preserves GI integrity ◦ Preserves the normal sequence of intestinal and hepatic metabolism ◦ Maintains fat metabolism and lipoprotein synthesis ◦ Maintains normal insulin and glucagon ratios

Care of the Patient With a Gastrostomy: Assessment

Patient knowledge and ability to learn Self-care ability and support- nurse cares for skin surrounding the line by cleaning with soap and water and place dressing around the skin. nurse should also promote patient and family to help in maintenance. To facilitate selfcare, the nurse encourages the patient to participate in flushing the tube, administering medications during hospitalization, and establishing as normal a routine as possible. Skin condition Nutrition and fluid status

Nursing Care of the Patient with a Nasogastric or Nasoenteric Tube

Patient teaching and preparation--- let them know it may cause a gag reflex Tube insertion Confirming placement Securing the tube Monitoring the patient Maintaining tube function Oral and nasal care Monitoring, preventing, and managing complications Tube removal

Tube Care and Preventing Infection

Proper use of dressing Skin care around the tube Manipulation of the stabilizing disk to prevent skin breakdown

Maintaining Normal Bowel Elimination

Selection of TF formula: consider fiber, osmolality, and fluid content Prevent contamination of TF: maintain closed system, do not hang more than 4 hours of TF in an open system. Maintain proper nutritional intake. Assess for reason for diarrhea and obtain treatment as needed. Administer TF slowly to prevent dumping syndrome Avoid cold TF.

Angina Pectoris

-A syndrome characterized by episodes of paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow -Physical exertion or emotional stress increases myocardial oxygen demand, and the coronary vessels are unable to supply sufficient blood flow to meet the oxygen demand. -May be described as tightness, choking, or a heavy sensation -It is frequently retrosternal and may radiate to neck, jaw, shoulders, back, or arms (usually left). -Anxiety frequently accompanies the pain. -Other symptoms may occur: dyspnea/shortness of breath, dizziness, nausea, and vomiting. -The pain of typical angina subsides with rest or NTG. -Unstable angina is characterized by increased frequency and severity and is not relieved by rest and NTG. Requires medical intervention! • Stable angina: predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycerin • Unstable angina (also called preinfarction angina or crescendo angina): symptoms increase in frequency and severity; may not be relieved with rest or nitroglycerin • Intractable or refractory angina: severe incapacitating chest pain • Variant angina (also called Prinzmetal's angina): pain at rest with reversible ST-segment elevation; thought to be caused by coronary artery vasospasm • Silent ischemia: objective evidence of ischemia (such as electrocardiographic changes with a stress test), but patient reports no pain

Manifestations of Gastritis and diagnosis

-Acute: rapid onset of symptoms: abdominal discomfort, headache, lassitude, nausea, vomiting, and hiccupping -Chronic: epigastric discomfort, anorexia, heartburn after eating, belching, sour taste in the mouth, nausea, vomiting, and intolerance of some foods; may cause vitamin deficiency due to malabsorption of B12 -Diagnosis is usually by UGI x-ray or endoscopy and biopsy

Benign prostatic hyperplasia (BPH, enlarged prostate)

-Affects half of men over age 50 and 80% of men over age 80 -Manifestations are those of urinary obstruction, urinary retention, and urinary tract infections -Treatment Pharmacologic: alpha-adrenergic blockers, alpha- adrenergic antagonists, and antiandrogen agents Catheterization if unable to void *Prostate surgery* Several forms of minimally invasive therapy may be used to treat BPH. Transurethral microwave heat treatment (TUMT) involves the application of heat to prostatic tissue. High-energy TUMT devices (CoreTherm, Prostatron, Targis) and low-energy devices (TherMatrx) are available (AUA, 2006). A transurethral probe is inserted into the urethra, and microwaves are directed to the prostate tissue. The targeted tissue becomes necrotic and sloughs. To minimize damage to the urethra and decrease the discomfort from the procedure, some systems have a water-cooling apparatus. Other minimally invasive treatment options include (transurethral needle ablation [TUNA]) by radiofrequency energy and the UroLume stent. TUNA uses low-level radiofrequencies delivered by thin needles placed in the prostate gland to produce localized heat that destroys prostate tissue while sparing other tissues Transurethral resection of the prostate (TURP) remains the benchmark for surgical treatment of BPH. It involves the surgical removal of the inner portion of the prostate through an endoscope inserted through the urethra; no external skin incision is made.

Interventions Hysterectomy

-Anxiety Allow patient to express feelings. Explain physical preparations and procedures. Provide emotional support. -Body image Listen and address concerns. Provide appropriate reassurance. Address sexual issues. Approach and evaluate each patient individually. interventions become more psychosocial than they are physical.

*Nephrotic Syndrome* Any condition that seriously damages the __________ ________ and results in increased permeability to ____ _____. -Results in____and _____. -What causes it? -Medical management?

-Any condition that seriously damages the glomerular membrane and results in increased permeability to plasma proteins -Results in hypoalbuminemia and edema -Causes include chronic glomerulonephritis, diabetes mellitus with intercapillary glomerulosclerosis, amyloidosis, lupus erythmatosus, multiple myeloma, and renal vein thrombosis. -Medical management includes drug and dietary therapy -Nursing management is similar to acute glomerulonephritis. Nephrotic syndrome is a type of renal failure characterized by increased glomerular permeability and is manifested by massive proteinuria (Porth & Matfin, 2009). Clinical findings include a marked increase in protein (particularly albumin) in the urine (proteinuria), a decrease in albumin in the blood (*hypoalbuminemia*), diffuse edema, high serum cholesterol, and low-density lipoproteins (*hyperlipidemia*).

Hemorrhagic Stroke

-Caused by bleeding into brain tissue, the ventricles, or subarachnoid space -May be due to spontaneous rupture of small vessels primarily related to hypertension; subarachnoid hemorrhage due to a ruptured aneurysm; or intracerebral hemorrhage related to amyloid angiopathy, arterial venous malformations (AVMs), intracranial aneurysms, or medications such as anticoagulants -Brain metabolism is disrupted by exposure to blood -ICP increases due to blood in the subarachnoid space -Compression or secondary ischemia from reduced perfusion and vasoconstriction injures brain tissue

Chronic Glomerulonephritis

-Causes include repeated episodes of acute glomerular nephritis, hypertensive nephrosclerosis, hyperlipidemia, and other causes of glomerular damage. -Symptoms vary; may be asymptomatic for years, as glomerular damage increases, before signs and symptoms develop of renal insufficiency/failure. Abnormal laboratory tests include urine with fixed specific gravity, casts, and proteinuria; and electrolyte imbalances and hypoalbuminemia. Medical management is determined by symptoms. The condition may be discovered when hypertension or elevated BUN and serum creatinine levels are detected. Most patients report general symptoms, such as loss of weight and strength, increasing irritability, and an increased need to urinate at night (nocturia). Headaches, dizziness, and digestive disturbances are also common. as disease progress patients may seem poorly nourished, yellow to gray skin, edema, signs of heart failure, rise in blood pressure, difference in bp during inspiration and expiration of greater than 10mmhg A number of laboratory abnormalities occur. Urinalysis reveals a fixed specific gravity of about 1.010, variable proteinuria, and urinary casts (proteins secreted by damaged kidney tubules). As renal failure progresses and the GFR falls below 50 mL/min

Promotion of Oral Health

-Effective mouth care, including regular brushing and flossing -Reduce intake of starches and sugars, and maintain good nutrition. -Fluoride application or fluorinated water -Refrain from smoking and alcohol. -Control diabetes- HELPS WITH THE HEALING PROCESS -Regular dental care- DENTAL CARE EVERY SIX MONTHS IS RECOMMENDED

Peptic Ulcer

-Erosion of a mucous membrane forms an excavation in the stomach, pylorus, duodenum, or esophagus -Associated with infection of H. pylori -Risk factors include excessive secretion of stomach acid, dietary factors, chronic use of NSAIDs, alcohol, smoking, and familial tendency, 30-60 age, Male:female 2-3:1, -Manifestations include a dull gnawing pain or burning in the midepigastrium; heartburn and vomiting may occur -Treatment includes medications, lifestyle changes (stress reduction, rest, smoking cessation, and dietary modification) and occasionally surgery: Misoprostol, sucarlfate, view print out. A peptic ulcer may be referred to as a gastric, duodenal, or esophageal ulcer, depending on its location. A peptic ulcer is an excavation (hollowed-out area) that forms in the mucosal wall of the stomach, in the pylorus (the opening between the stomach and duodenum), in the duodenum (the first part of the small intestine), or in the esophagus. Erosion of a circumscribed area of mucous membrane is the cause (Fig. 37-2). This erosion may extend as deeply as the muscle layers or through the muscle to the peritoneum. Currently, the most commonly used therapy for peptic ulcers is a combination of antibiotics, proton pump inhibitors, and bismuth salts that suppress or eradicate H. pylori. Recommended therapy for 10 to 14 days includes triple therapy with two antibiotics (eg, metronidazole [Flagyl] or amoxicillin [Amoxil] and clarithromycin [Biaxin]) plus a proton pump inhibitor (eg, lansoprazole [Prevacid], omeprazole [Prilosec], or rabeprazole [Aciphex]), or quadruple therapy with two antibiotics (metronidazole and tetracycline) plus a proton pump inhibitor and bismuth salts (Pepto-Bismol). Research is being conducted to develop a vaccine against H. pylori (Kabir, 2007). Histamine-2 (H2) receptor antagonists and proton pump inhibitors are used to treat NSAID-induced ulcers and other ulcers not associated with H. pylori infection. Table 37-3 provides information about the medication regimens used for peptic ulcer disease. (Table 37-1 presents details about specific medications.)

Maintaining the Airway: WHAT POSITION SHOULD THEY BE IN?

-Frequent assessment -Place in Fowler's position. -Encourage coughing and deep breathing. -If patient has a tracheostomy, provide tracheostomy care as required: GOOD

Chest Physiotherapy

-Includes postural drainage, chest percussion and vibration, and breathing retraining. Effective coughing is also an important component. -Goals are removal of bronchial secretions, improved ventilation, and increased efficiency of respiratory muscles. -Postural drainage uses specific positions to use gravity to assist in the removal of secretions. -Vibration loosens thick secretions by percussion or vibration. -Breathing exercises and breathing retraining improve ventilation and control of breathing and decrease the work of breathing.See Chart 25-4

Intermittent Positive-Pressure Breathing:indicated for? monitor for which side effects?

-Indicated for patients who need to increase lung expansion -Rarely used -Monitor for side effects, which may include pneumothorax, increased intracranial pressure, hemoptysis, gastric distention, psychological dependency, hyperventilation, excessive oxygen administration, and cardiovascular problems.

Bariatric Surgery

-Morbid obesity: persons more than two times IBW, BMI exceeds 30 kg/m2 or more than 100 pounds greater than IBW; high risk for health complications -Surgery is performed only after nonsurgical methods have failed -Selection factors include body weight, patient history, failure to lose weight using other means, absence of endocrine disorders, and psychological stability. types: Roux-en-Y Gastric Bypass, gastric banding, Banded Gastroplasty, and Duodenal Switch

Medical Management

-Prevention: control of hypertension -Diagnosis: CT scan, cerebral angiography, and lumbar puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhage -Care is primarily supportive -Bed rest with sedation -Oxygen -Treatment of vasospasm, increased ICP, hypertension, potential seizures, and prevention of further bleeding

Renal Failure: results when? what will the lab data show for acute renal failure? what will the results show for chronic renal failure? nonoliguria?oliguria? anuria? what are the 3 main categories of renal failure and what do they mean? what are the 4 phases?

-Results when the kidneys cannot remove wastes or perform regulatory functions -A systemic disorder that results from many different causes -Acute renal failure is a reversible syndrome that results in decreased GFR and oliguria -Chronic renal failure (ESRD) is a progressive, irreversible deterioration of renal function that results in azotemia -Results when the kidneys cannot remove wastes or perform regulatory functions -A systemic disorder that results from many different causes -Acute renal failure is a reversible syndrome that results in decreased GFR and oliguria -Chronic renal failure (ESRD) is a progressive, irreversible deterioration of renal function that results in azotemia Renal failure results when the kidneys cannot remove the body's metabolic wastes or perform their regulatory functions. The substances normally eliminated in the urine accumulate in the body fluids as a result of impaired renal excretion, affecting endocrine and metabolic functions as well as fluid, electrolyte, and acid-base disturbances. Possible changes include oliguria (less than 500 mL/day), nonoliguria (greater than 800 mL/day), or anuria (less than 50 mL/day) Some of the factors may be reversible if identified and treated promptly, before kidney function is impaired. This is true of the following conditions that reduce blood flow to the kidney and impair kidney function: (1) hypovolemia; (2) hypotension; (3) reduced cardiac output and heart failure; (4) obstruction of the kidney or lower urinary tract by tumor, blood clot, or kidney stone; and (5) bilateral obstruction of the renal arteries or veins. If these conditions are treated and corrected before the kidneys are permanently damaged, the increased BUN and creatinine levels, oliguria, and other signs may be reversed. The major categories of ARF are prerenal (hypoperfusion of kidney), intrarenal (actual damage to kidney tissue), and postrenal (obstruction to urine flow). They are related to where the cause originated, for example heart failure would be prerenal; nephrotoxic agents such as ACE inhibtors) would be intrarenal; and urinary tract obstruction would be postrenal. There are four phases of ARF: initiation, oliguria, diuresis, and recovery. Renal failure results when the kidneys cannot remove the body's metabolic wastes or perform their regulatory functions. The substances normally eliminated in the urine accumulate in the body fluids as a result of impaired renal excretion, affecting endocrine and metabolic functions as well as fluid, electrolyte, and acid-base disturbances. Possible changes include oliguria (less than 500 mL/day), nonoliguria (greater than 800 mL/day), or anuria (less than 50 mL/day) Some of the factors may be reversible if identified and treated promptly, before kidney function is impaired. This is true of the following conditions that reduce blood flow to the kidney and impair kidney function: (1) hypovolemia; (2) hypotension; (3) reduced cardiac output and heart failure; (4) obstruction of the kidney or lower urinary tract by tumor, blood clot, or kidney stone; and (5) bilateral obstruction of the renal arteries or veins. If these conditions are treated and corrected before the kidneys are permanently damaged, the increased BUN and creatinine levels, oliguria, and other signs may be reversed. The major categories of ARF are prerenal (hypoperfusion of kidney), intrarenal (actual damage to kidney tissue), and postrenal (obstruction to urine flow). They are related to where the cause originated, for example heart failure would be prerenal; nephrotoxic agents such as ACE inhibtors) would be intrarenal; and urinary tract obstruction would be postrenal. There are four phases of ARF: initiation, oliguria, diuresis, and recovery.

Vulvovaginal Infection: Intervention

-Sitz baths may help relieve discomfort. -Explaining the cause of symptoms and methods to help prevent infections may help reduce anxiety. -Douching is usually avoided; however, therapeutic douching may be prescribed to reduce odors and remove excessive drainage. -Patient education includes handwashing, proper hygiene, preventive strategies, measures to reduce risk, information regarding medications, and information regarding self-examination.

Pulmonary Emboli

-The obstruction of a pulmonary artery or branch by blood clot, air, fat, amniotic fluid, or septic thrombus. Most thrombi are blood clots from the veins of the legs. -The obstructed area has diminished or absent blood flow. Although this area is ventilated, no gas exchange takes place. -Inflammatory process causes regional blood vessels and bronchioles to constrict, which further increases pulmonary vascular resistance, pulmonary arterial pressure, and right ventricular workload. -Ventilation-perfusion imbalance, right ventricular failure, and shock occur.

Junctional Tachycardia: What can it be caused by?

3 or more PJCs at a rate of 100 bpm or more Caused by enhanced automaticity. May be caused by myocardial ischemia or infarction, CHF or dig. toxicity (tx: Digoxin immune Fab) Rhythm: Regular Rate: 101 - 180 bpm P waves: Before, during, or after QRS; inverted in leads II, III, aVF PR interval: Less than 0.12 sec QRS: Usually 0.10 sec or less This might be SVT

Ventricular Tachycardia (VT)

3 or more PVCs in succession at a rate of 100 bpm or greater Rhythm: Regular Rate: 101 - 250 bpm P waves: Present or absent; no relationship to QRS PR interval: n/a QRS: Greater than 0.12 sec T waves: Difficult to differentiate Tx: cpr ***Defibillation stops the heart and starts it at a higher voltage basically shacking them out of it. Epi and antirhytimics

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-commonly the tubes are incorrectly inserted into the right main bronchus -x-ray should be used initially to confirm placement • Measurement of tube length. It is necessary to measure the length of the exposed portion of the tube and document the length. Every shift the nurse measures this length and compares it with the original measurement. An increase in the length of exposed tube may indicate dislodgement. • Visual assessment of aspirate color. Gastric aspirate is most frequently cloudy and green, tan, off-white, or brown. Intestinal aspirate is primarily clear and yellow to bile colored. • pH measurement of aspirate. The pH of gastric aspirate is acidic (1 to 5). The pH of intestinal aspirate is typically 6 or higher, and the pH of respiratory aspirate is more alkaline (7 or greater). An enteral tube with a pH sensor that can facilitate distinguishing between gastric and small intestinal placement of the tube is commercially available. • Air auscultation. Studies have found that the traditional method of injecting air through the tube while auscultating the epigastric area with a stethoscope to detect air insufflationis an unreliable indicator of gastric placement.

Atherosclerosis

-is the abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumen. -In coronary atherosclerosis, blockages and narrowing of the coronary vessels reduce blood flow to the myocardium.

Management of Patients With Musculoskeletal Disorders

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1. Use both hands to palpate the testis. The normal testicle is smooth and uniform in consistency. 2. With the index and middle fingers under the testis and the thumb on top, roll the testis gently in a horizontal plane between the thumb and fingers (A). 3. Feel for any evidence of a small lump or abnormality. 4. Follow the same procedure and palpate upward along the testis (B). 5. Locate and palpate the epididymis (C), a cordlike structure on the top and back of the testicle that stores and transports sperm. Also locate and palpate the spermatic cord. 6. Repeat the examination for the other testis, epididymis, and spermatic cord. It is normal to find that one testis is larger than the other. 7. If you find any evidence of a small, pealike lump or if the testis is swollen (possibly from an infection or tumor), consult your physician

Pleural effusion

: a collection of fluid in the pleural space, usually secondary to another disease process -Large effusions impair lung expansion and cause dyspnea.

Psoriasis

A chronic, noninfectious inflammatory disease of the skin in which epidermal cells are produced at an abnormally rapid rate Affects about 2% of the population, primarily those of European ancestry Improves and recurs; a life-long condition May be aggravated by stress, trauma, and seasonal and hormonal changes Treatment: baths to remove scales and medications;see PUVA therapy (Table 56-6 )

Radical Neck Dissection and Selective Radical Neck Dissection

A classic radical neck dissection in which the sternocleidomastoid and smaller muscles are removed. All tissue is removed, from the ramus of the jaw to the clavicle. The jugular vein has also been removed. B, The selective neck dissection is similar but preserves the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve. C, The wound is closed, and portable suction drainage tubes are in place.

Gastritis

A common GI problem that causes inflammation of the stomach Acute: rapid onset of symptoms usually caused by dietary indiscretion. Other causes include medications, alcohol, bile reflux, and radiation therapy. Ingestion of strong acid or alkali may cause serious complications. Chronic: prolonged inflammation due to benign or malignant ulcers of the stomach or Helicobacter pylori. May also be associated with some autoimmune diseases, dietary factors, medications, alcohol, smoking, and chronic reflux of pancreatic secretions or bile. Acute gastritis is often caused by dietary indiscretion—a person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. Other causes of acute gastritis include overuse of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, and radiation therapy. A more severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to become gangrenous or to perforate. Scarring can occur, resulting in pyloric stenosis or obstruction. Acute gastritis also may develop in acute illnesses, especially when the patient has had major traumatic injuries; burns; severe infection; hepatic, renal, or respiratory failure; or major surgery. Gastritis may be the first sign of an acute systemic infection. Chronic gastritis and prolonged inflammation of the stomach may be caused either by benign or malignant ulcers of the stomach or by the bacteria Helicobacter pylori. Chronic gastritis is sometimes associated with autoimmune diseases such as pernicious anemia; dietary factors such as caffeine; the use of medications such as NSAIDs or bisphosphonates (eg, alendronate [Fosamax], risedronate [Actonel], ibandronate [Boniva]); alcohol; smoking; or chronic reflux of pancreatic secretions and bile into the stomach.

Mini-Nebulizer Therapy

A hand-held apparatus that disperses a moisturizing agent or medication such as a bronchodilator into the lungs. The device must make a visible mist. Nursing care: instruct patient in use. -Patient is to breathe with slow, deep breaths through mouth and hold a few seconds at the end of inspiration. -Coughing exercises may be encouraged to mobilize secretions after a treatment. Assess patient before treatment and evaluate patient response after treatment.

Cardiogenic Shock

A life-threatening condition with a high mortality rate Decreased CO leads to inadequate tissue perfusion and initiation of shock syndrome. Clinical manifestations: symptoms of HF, shock state, and hypoxia

Interventions

A major nursing goal is to compensate for the patient's loss of protective reflexes and to assume responsibility for total patient care; protection includes maintaining the patient's dignity and privacy Maintain an airway

Infective Endocarditis

A microbial infection of the endothelial surface of the heart. Vegetative growths occur and may embolize to tissues throughout the body. Usually develops in people with prosthetic heart valves or structural cardiac defects. Also occurs in patients who are IV drug abusers and in those with debilitating diseases, indwelling catheters, or prolonged IV therapy. Types: Acute Subacute

Cast

A rigid, external immobilizing device Uses -Immobilize a reduced fracture -Correct a deformity -Apply uniform pressure to soft tissues -Provide support to stabilize a joint Materials: nonplaster (fiberglass), plaster

Acute Respiratory Distress Syndrome what does hypoxemia not respond to?

A severe form of acute lung injury A syndrome characterized by sudden and progressive pulmonary edema(wet lungs), increasing bilateral lung infiltrates on CXR, hypoxemia refractory to oxygen therapy, and decreased lung compliance Symptoms: -Rapid onset of severe dyspnea -Hypoxemia that does not respond to supplemental oxygen

Explain the Pathophysiology of Atherosclerosis

A, B, Atherosclerosis begins as monocytes and lipids enter the intima of an injured vessel. Smooth muscle cells proliferate within the vessel wall, C, contributing to the development of fatty accumulations and atheroma, D. As the plaque enlarges, the vessel narrows and blood flow decreases, E. The plaque may rupture and a thrombus might form, obstructing blood flow Atherosclerosis is thought to begin as fatty streaks of lipids that are deposited in the intima of the arterial wall. These lesions commonly begin early in life, perhaps even in childhood. Not all fatty streaks later develop into advanced lesions. Genetics and environmental factors are involved in the progression of these lesions. The development of atherosclerosis over many years involves an inflammatory response, which begins with injury to the vascular endothelium (Futterman & Lemberg, 2006). *The injury may be initiated by smoking, hypertension, and other factors.* The presence of inflammation has multiple effects on the arterial wall, including the attraction of inflammatory cells, such as monocytes (macrophages). The macrophages ingest lipids, becoming *"foam cells"* that transport the lipids into the arterial wall. Activated macrophages also release biochemical substances that can further damage the endothelium, attracting platelets and initiating clotting (Carreiro-Lewandowski, 2006).

Sliding Esophageal and Paraesophageal Hernia

A, Sliding esophageal hernia. The upper stomach and gastroesophageal junction have moved upward and slide in and out of the thorax. B, Paraesophageal hernia. All or part of the stomach pushes through the diaphragm next to the gastroesophageal junction.

WHAT IS THE TOP PRIORITY AFTER NECK SURGERY?

AIRWAY CLEARANCE

AN ATRIAL QUIVER IS FOUND IT WHAT WAVE FORM? WANDERING

ATRIAL FIBRILLATION

AN ATRIAL SAWTOOTH IS FOUND WITH WHAT WAVE FORM? SVT

ATRIAL FLUTTER?

Junctional Rhythms

AV node and nonbranching part of bundle of His=AV junction Other term: Nodal rhythms AV node will pace the heart if: SA node fails SA block—blocked after leaving the SA node Rate of discharge is slower than the AV node Impulse from SA node doesn't reach ventricles

Seizures

Abnormal episodes of motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons Classification of seizures Partial seizures: begin in one part of the brain Simple partial: consciousness remains intact Complex partial: impairment of consciousness Generalized seizures: involve the whole brain

Constipation

Abnormal infrequency or irregularity of defecation; any variation from normal habits may be a problem Causes include medications, chronic laxative use, weakness, immobility, fatigue, inability to increase intraabdominal pressure, diet, ignoring urge to defecate, and lack of regular exercise Increased risk in older age Perceived constipation: a subjective problem in which the patient's elimination pattern is not consistent with what he or she believes is normal

Treatment for Achalasia

Achalasia is absent or ineffective peristalsis of the distal esophagus, accompanied by failure of the esophageal sphincter to relax in response to swallowing. Pneumatic Dialition: Achalasia may be treated conservatively by pneumatic dilation to stretch the narrowed area of the esophagus (Fig. 35-6). Pneumatic dilation has a high success rate. Although perforation is a potential complication, its incidence is low. The procedure can be painful; therefore, moderate sedation in the form of an analgesic or tranquilizer, or both, is administered for the treatment. The patient is monitored for perforation. Abdominal tenderness and fever may indicate perforation. The patient is instructed to eat slowly and to drink fluids with meals. As a temporary measure, calcium channel blockers and nitrates have been used to decrease esophageal pressure and improve swallowing. Injection of botulinum toxin (Botox) into quadrants of the esophagus via endoscopy has been helpful because it inhibits the contraction of smooth muscle. Periodic injections are required to maintain remission.

Patient with HF: Diagnosis

Activity intolerance and fatigue Excess fluid volume Anxiety Powerlessness Noncompliance Nursing Diagnoses Based on the assessment data, major nursing diagnoses for the patient with HF may include the following: • Activity intolerance and fatigue related to decreased CO • Excess fluid volume related to the HF syndrome • Anxiety related to breathlessness from inadequate oxygenation • Powerlessness related to chronic illness and hospitalizations • Ineffective therapeutic regimen management related to lack of knowledge Collaborative Problems/Potential Complications Based on the assessment data, potential complications that may develop include the following: • Hypotension, poor perfusion, and cardiogenic shock • Dysrhythmias • Thromboembolism • Pericardial effusion and cardiac tamponade

Medical Management of Gastritis

Acute -Refrain from alcohol and food until symptoms subside -If due to strong acid or alkali treatment to neutralize the agent, avoid emetics and lavage due to danger of perforation and damage to the esophagus -Therapy is supportive and may include nasogastric (NG) intubation, analgesic agents and sedatives, antacids, and IV fluids. Fiberoptic endoscopy may be necessary. In extreme cases, emergency surgery may be required to remove gangrenous or perforated tissue. A gastric resection or a gastrojejunostomy (anastomosis of jejunum to stomach to detour around the pylorus) may be necessary to treat pyloric obstruction, a narrowing of the pyloric orifice, which cannot be relieved by medical management Chronic -Modify diet, promote rest, reduce stress, and avoid alcohol and NSAIDs -Chronic gastritis is managed by modifying the patient's diet, promoting rest, reducing stress, recommending avoidance of alcohol and NSAIDs, and initiating pharmacotherapy. H. pylori may be treated with selected drug combinations (Table 37-1). Antibiotics, antidiarrheal, Histamine-2 receptor antagonists, and Proton pump Inhibitors of gastric acid.

Pulmonary Edema: how would you intervene? what position should the patient be placed in? Drugs given?

Acute event in which the LV cannot handle an overload of blood volume. Pressure increases in the pulmonary vasculature, causing fluid to move out of the pulmonary capillaries and into the interstitial space (3 rd space) of the lungs and alveoli. Results in hypoxemia Clinical manifestations: CHANGING COLOR, FROTHY PINK SPUTUM. restlessness, anxiety, dyspnea, cool and clammy skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations), increased sputum production (sputum may be frothy and blood-tinged), decreased level of consciousness Intervention: Prevention Early recognition: monitor lung sounds and for signs of decreased activity tolerance and increased fluid retention Place patient upright and dangle legs (puts lets resistance on the heart) Minimize exertion and stress. Oxygen Medications Morphine Diuretic (furosemide-- LASIX)

Nursing Process—Diagnosis of the Patient With Osteomyelitis

Acute pain Impaired physical mobility Risk for extension of infection: bone abscess formation Deficient knowledge

Maintain body temperature

Adjust environment and cover patient appropriately If temperature is elevated, use minimum amount of bedding, administer acetaminophen, use hypothermia blanket, give a cooling sponge bath, and allow fan to blow over patient to increase cooling Monitor temperature frequently and use measures to prevent shivering

Relief of Pain

Administration of medications -Patient-controlled analgesia (PCA) -Other medications -Medicate before planned activity and ambulation Use alternative methods of pain relief -Repositioning, distraction, guided imagery, etc. Specific individualized strategies to control pain -Use ice or cold -Elevation -Immobilization

Osteoporosis

Affects approximately 40 million people over the age of 50 in the U.S. Normal homeostatic bone turnover is altered and the rate of bone resorption is greater than the rate of bone formation, resulting in loss of total bone mass Bone becomes porous, brittle, and fragile and breaks easily under stress Frequently results in compression fractures of the spine, fractures of the neck or intertrochanteric region of the femur, and Colles' fractures of the wrist Risk factors: see Chart 68-7

Nursing Process: The Care of the Patient with a Radical Neck Dissection: MONITORING AND Assessment

Airway and breathing Pain Potential bleeding and wound drainage system Other

Altered Level of Consciousness (LOC)

Akinetic mutism: unresponsiveness to the environment, the patient makes no movement or sound but sometimes opens eyes Persistent vegetative state: patient is devoid of cognitive function but has sleep-wake cycles Locked-in syndrome: patient is unable to move or respond except for eye movements due to a lesion affecting the pons

Glomerular Diseases: what is the nature of this disease? what are three types of this disease? what are some manifestations?

An inflammation of the glomerular capillaries Acute nephritic syndrome Chronic glomerulonephritis Nephrotic syndrome The major clinical manifestations of glomerular injury include proteinuria, hematuria, decreased GFR, decreased excretion of sodium, edema, and hypertension

Urinary Incontinence: is it a consequence of aging

An underdiagnosed and underreported problem that can significantly impact the quality of life and decrease independence and may lead to compromise of the upper urinary system Urinary incontinence is not a normal consequence of aging

Medications given for HF

Angiotensin-converting enzyme inhibitors Angiotensin II receptor blockers Beta-blockers Diuretics Digitalis Other medications View print out.

Nursing Process—Diagnosis of the Patient Undergoing Prostatectomy Including interventions

Anxiety Acute pain preoperatively Acute pain postoperatively Deficient knowledge Based on the assessment data, the patient's major nursing diagnoses may include the following. • Anxiety about surgery and its outcome • Acute pain related to bladder distention • Deficient knowledge about factors related to the disorder and the treatment protocol Postoperative Nursing Diagnoses • Acute pain related to the surgical incision, catheter placement, and bladder spasms • Deficient knowledge about postoperative care Collaborative Problems/Potential Complications Based on the assessment data, the potential complications may include the following: • Hemorrhage and shock • Infection • Deep vein thrombosis • Catheter obstruction • Sexual dysfunction

Maintain fluid status

Assess fluid status by examining tissue turgor and mucosa, lab data, and I&O Administer IVs, tube feedings, and fluids via feeding tube as required: monitor ordered rate of IV fluids carefully

`Excess Fluid Volume

Assess for signs and symptoms of fluid volume excess, and keep accurate I&O and daily weights Limit fluid to prescribe amounts Identify sources of fluid Explain to patient and family the rationale for the restriction Assist patient to cope with the fluid restriction Provide or encourage frequent oral hygiene

Promoting Bowel and Bladder Function

Assess for urinary retention and urinary incontinence May require indwelling or intermittent catherization Initiate bladder-training program Assess for abdominal distention, potential constipation, and bowel incontinence Monitor bowel movements Promote elimination with stool softeners, glycerin suppositories, or enemas as indicated Diarrhea may result from infection, medications, or hyperosmolar fluids

Nursing Process—Assessment of the Patient Undergoing Prostatectomy

Assess how the underlying disorder (BPH or prostate cancer) has affected the patient's lifestyle Urinary and sexual function Health history Nutritional status Activity level and abilities

Imbalanced Nutrition

Assess nutritional state preoperatively and intervene early to prevent nutritional problems. Encourage high-density, high-quality intake. Diet may need to be modified to liquid diet, or to soft, puréed, and liquid foods. Consider patient preferences and cultural considerations in food selection. Provide oral care before and after eating. Nasogastric or gastrostomy feedings may be required.

Imbalanced Nutrition

Assess nutritional status; weight changes and lab data Assess patient nutritional patterns and history; note food preferences Provide food preferences within restrictions Encourage high-quality nutritional foods while maintaining nutritional restrictions Assess and modify intake related to factors that contribute to altered nutritional intake, eg, stomatitis or anorexia Adjust medication times related to meals

Risk for Situational Low Self Esteem

Assess patient and family responses to illness and treatment Assess relationships and coping patterns Encourage open discussion about changes and concerns Explore alternate ways of sexual expression Discuss role of giving and receiving love, warmth, and affection

Assessment of the Patient With Low Back Pain

Assess posture, position changes, and gait Physical exam: assess spinal curvature, back and limb symmetry, movement ability, DTRs, sensation, and muscle strength If patient is obese, complete a nutritional assessment

Maintaining Tissue Integrity

Assess skin frequently, especially areas with high potential for breakdown Turn patient frequently; use turning schedule Carefully position patient in correct body alignment Perform passive range of motion Use splints, foam boots, trochanter rolls, and specialty beds as needed Clean eyes with cotton balls moistened with saline Use artificial tears as prescribed Implement measures to protect eyes; use eye patches cautiously as the cornea may contact patch Provide frequent, scrupulous oral care

Nursing Process: The Care of the Patient with Pneumonia: Assessment

Assessment Changes in temperature and pulse Secretions Cough Tachypnea and shortness of breath Changes in physical assessment, especially inspection and auscultation of the chest Changes in CXR Changes in mental status, fatigue, dehydration, and concomitant heart failure, especially in elderly patients Diagnosis Ineffective airway clearance Activity intolerance Risk for fluid volume deficiency Imbalanced nutrition Deficient knowledge collaborative problems Continuing symptoms after initiation of therapy Shock Respiratory failure Atelectasis Pleural effusion Confusion Superinfection Improved airway clearance Maintenance of proper fluid volume Maintenance of adequate nutrition Patient understanding of treatment and prevention Absence of complications

Other Interventions

Assessment and treatment of pain/discomfort, anticholinergic medications prior to meals, analgesics, positioning, diversional activities, and prevention of fatigue Assess fluid deficit, I&O, daily weight, symptoms of dehydration/fluid loss; encourage oral intake; and initiate measures to decrease diarrhea Provide optimal nutrition; elemental feedings that are high in protein and low residue or PN may be needed Reduce anxiety, exhibit a calm manner, allow patient to express feelings, listen, and provide patient teaching

Interventions: Fluid Volume Excess

Assessment for symptoms of fluid overload Daily weight I&O Diuretic therapy; timing of meds in the morning. Fluid intake; fluid restriction Concentrate fluid drip medication to lower the amount of fluid intake. Maintenance of sodium restriction: low sodium diet.

Nursing Process: The Care of Patients who are Mechanically Ventilated:

Assessment of the patient assessment Systematic assessment; include all body systems In-depth respiratory assessment, including all indicators of oxygenation status Comfort Coping, emotional needs Communication Assessment of equipment Diagnosis Impaired gas exchange Ineffective airway clearance Risk for trauma Impaired physical mobility Impaired verbal communication Defensive coping Powerlessness collaborative problems Alterations in cardiac function Barotrauma Pulmonary infection Sepsis Planning Goals include optimal gas exchange, maintenance of patent airway, optimal mobility, absence of trauma or infection, adjustment to nonverbal methods of communication, acquisition of successful coping measures, and absence of complications.

Atrial Flutter (3:1)

Av node is the gatekeeper It prevents the flutter depolarization from getting to the ventricles. 3 atrial beats for every ventricular beats. Ectopic atrial rhythm, irritable site depolarizes regularly Rhythm: Atrial regular, Ventricular regular or irregular Rate: Atrial 250-450 bpm, ventricular varies depending on AV block P waves: No P waves, but Flutter waves present (saw-toothed) PR interval: n/a QRS: Usually less than 0.10 sec

Infectious Diseases of the Skin

Bacterial infections Impetigo Folliculitis, furuncles, and carbuncles Viral infections Herpes zoster Herpes simplex: orolabial and genital Fungal infections: tinea pedis, tinea corporis, tinea capitis, tinea cruris, tinea unguium; see Table 56-5

Assessing Patients Receiving Tube Feedings

Be alert for the following assessment findings: • Tube placement, patient's position (head of bed elevated 30 to 45 degrees), and formula flow rate • Patient's ability to tolerate the formula; observe for fullness, bloating, distention, nausea, vomiting, and stool pattern • Clinical responses, as noted in laboratory findings (blood urea nitrogen, serum protein, prealbumin, electrolytes, renal function, hemoglobin, hematocrit) • Signs of dehydration (dry mucous membranes, thirst, decreased urine output) • Amount of formula actually taken in by the patient • Elevated blood glucose level, decreased urinary output, sudden weight gain, and periorbital or dependent edema • Infection control practices: replace any formula administered by an open system every 4 hours with fresh formula; change tube feeding container and tubing every 24 to 72 hours • Residual volume before each feeding or, in the case of continuous feedings, every 4 hours; return the aspirate to the stomach • Intake and output • Weekly weights • Recommendations made on dietitian consult

Interventions: Activity Intolerance

Bed rest for acute exacerbations Encourage regular physical activity with a 5 minute warm up period; 30-45 minutes daily AFTER BEING CLEARED. A typical program would include walking activity that is increased in duration over 6 weeks. Exercise training Some patients may need to limit activity to 3-5 mins, one to for times a day. Pacing of activities Wait 2 hours after eating before doing physical activity. Avoid activities in extremely hot, cold, or humid weather. Modify activities to conserve energy. Positioning; elevation of HOB to facilitate breathing and rest, support of arms If the patient is hospitalized, vital signs and oxygen saturation level are monitored before, during, and immediately after an activity to identify whether they are within the desired range. HR should return to baseline within 3 minutes following the activity.

Tube Insertion

Before inserting one of these tubes, the nurse determines the length that will be needed to reach the stomach or the small intestine. A mark is made on the tube to indicate the desired length. This length is traditionally determined by (1) measuring the distance from the tip of the nose to the earlobe and from the earlobe to the xiphoid process, and (2) adding 6 inches for NG placement or 8 to 10 inches for intestinal placement, although studies do not necessarily confirm that this is a reliable technique (Cirgen Ellett, Beckstrand, Flueckiger, et al., 2005) (Chart 36-1; Fig. 36-2). While the tube is being inserted, the patient usually sits upright with a towel or other protective barrier spread bibfashion over the chest. The nostril may be swabbed or the oropharynx sprayed with tetracaine or benzocaine to numb the nasal passage and suppress the gag reflex. To make the tube easier to insert, it should be lubricated with a watersoluble lubricant unless it has a dry coating (hydromer), which, when moistened, provides its own lubrication. Gloves should be worn during the procedure. The nostrils are inspected for any obstruction and the more patent nostril is selected for use. The tip of the patient's nose is tilted, and the tube is aligned to enter the nostril. When the tube reaches the nasopharynx, the patient is instructed to lower the head slightly and to begin to swallow as the tube is advanced. The patient may also be encouraged to sip water through a straw to facilitate advancement of the tube if this action is not contraindicated. The oropharynx is inspected to ensure that the tube has not coiled in the pharynx or mouth.

removing tube

Before removing a decompression tube, the nurse may intermittently clamp it for a trial period of several hours to ensure that the patient does not experience nausea, vomiting, or distention. Before any tube is removed, it is flushed with 10 mL of water or normal saline to ensure that it is free of debris and away from the gastric lining. Gloves are worn when removing the tube. The tube is withdrawn gently and slowly for 15 to 20 cm (6 to 8 in) until the tip reaches the esophagus; the remainder is withdrawn rapidly from the nostril. If the tube does not come out easily, force should not be used, and the problem should be reported to the physician. As the tube is withdrawn, it is concealed in a towel to prevent secretions from soiling the patient or nurse. After the tube is removed, the nurse provides oral hygiene.

Pharmacologic Therapy

Biphosphonates -Alendronate: Fosamax -Risendronate: Actonel -Ibandronate: Boniva Selective estrogen receptor modulators (SERMs): Evista Calcitonin Teriparatide: Forteo Need adequate amounts of calcium and vitamin D

Tracheostomy

Bypasses the upper airway to bypass an obstruction, allow removal of secretions, permit long-term mechanical ventilation, prevent aspirations of secretions, or replace an endotracheal tube Complications include bleeding, pneumothorax, aspiration, subcutaneous or mediastinal emphysema, laryngeal nerve damage, posterior tracheal wall penetration. Long-term complications include airway obstruction, infection, rupture of the innominate artery, dysphagia, fistula formation, tracheal dilatation, and tracheal ischemia and necrosis.

The differences between myocardial infarct and myocardial ischemia

CAD produces symptoms and complications according to the location and degree of narrowing of the arterial lumen, thrombus formation, and obstruction of blood flow to the myocardium. This impediment to blood flow is usually progressive, causing an inadequate blood supply that deprives the cardiac muscle cells of oxygen needed for their survival. The condition is known as ischemia. Angina pectoris refers to chest pain that is brought about by myocardial ischemia. Angina pectoris usually is caused by significant coronary atherosclerosis. If the decrease in blood supply is great enough, of long enough duration, or both, irreversible damage and death of myocardial cells may result. Over time, irreversibly damaged myocardium undergoes degeneration and is replaced by scar tissue, causing various degrees of myocardial dysfunction. Significant myocardial damage may result in persistently low cardiac output and heart failure where the heart cannot support the body's needs for blood. A decrease in blood supply from CAD may even cause the heart to abruptly stop beating (sudden cardiac death). myocardial infarction (MI): death of heart tissue caused by lack of oxygenated blood flow. During the end progression of Coronary Atherosclerosis a ruptured plaque is a focus for thrombus formation. The thrombus may then obstruct blood flow, leading to acute coronary syndrome (ACS), which may result in an acute myocardial infarction (MI) if quick, decisive action is not taken. When an MI occurs, a portion of the heart muscle becomes necrotic.

what is the primary issue when a person has renal failure?

CARDIAC ISSUES ARE PRIMARILY A ISSUE WHEN A PERSON HAS RENAL DISEASE

Vaginal Infections: what type of bacteria

Candidiasis Gardnerella Trichomonas vaginalis Bartholinitis Cervicitis Atrophic vaginitis

Cardiomyopathy

Cardiomyopathy is a series of progressive events that culminates in impaired cardiac output and can lead to heart failure, sudden death, or dysrhythmias.

manifestations of an MI (book)

Cardiovascular • Chest pain or discomfort not relieved by rest or nitroglycerin palpitations. Heart sounds may include S3, S4, and new onset of a murmur. • Increased jugular venous distention may be seen if the MI has caused heart failure. • Blood pressure may be elevated because of sympathetic stimulation or decreased because of decreased contractility, impending cardiogenic shock, or medications. • Irregular pulse may indicate atrial fibrillation. • In addition to ST-segment and T-wave changes, ECG may show tachycardia, bradycardia, or other dysrhythmias. Respiratory Shortness of breath, dyspnea, tachypnea, and crackles if MI has caused pulmonary congestion. Pulmonary edema may be present. Gastrointestinal Nausea and vomiting. Genitourinary Decreased urinary output may indicate cardiogenic shock. Skin Cool, clammy, diaphoretic, and pale appearance due to sympathetic stimulation may indicate cardiogenic shock. Neurologic Anxiety, restlessness, and lightheadedness may indicate increased sympathetic stimulation or a decrease in contractility and cerebral oxygenation. The same symptoms may also herald cardiogenic shock. Psychological Fear with feeling of impending doom, or denial that anything is wrong.

Atrial fibrillation BECAUSE SITE OF DEPOLARIZATION COMES FROM MANY DIFFERENT SITES UNLIKE ATRIAL FLUTTER. IT'S GROSSLY IRREGULAR WAVE FORM (IRREGULARLY IRREGULAR) HOW IS IT TREATED?

Caused by multiple reentry circuits in the atria. Atria "quiver," resulting in ineffective contraction. WHY? Rhythm: Irregularly Irregular Rate: Atrial 400-600 bpm, Ventricular rate varies P waves: None. Fibrillation waves present PR interval: n/a QRS: Usually less than 0.10 sec Tx: Cardio-version is timed to shock when it is needed.

Specific Causes of Seizures

Cerebrovascular disease Hypoxemia Fever (childhood) Head injury Hypertension Central nervous system infections Metabolic and toxic conditions Brain tumor Drug and alcohol withdrawal Allergies

Manifestations of Increased ICP—Early

Changes in level of consciousness Any change in condition --Restlessness, confusion, increasing drowsiness, increased respiratory effort, and purposeless movements Pupillary changes and impaired ocular movements Weakness in one extremity or one side Headache: constant, increasing in intensity, or aggravated by movement or straining

Vulvovaginal Infections: Pathophysiology

Common problem The vagina is normally protected by acid pH, which is maintained in part by Lactobacillus acidophilus. The vaginal epithelium is responsive to estrogen, which induces glycogen formation, which breaks down into lactic acid; therefore, decreased estrogen decreases acid production. With perimenopause and menopause, decreased estrogen is related to vaginal and labial atrophy, and tissue is more susceptible to infection.

Nursing Diagnoses: Patients with Endotracheal Intubation or Tracheostomy

Communication Anxiety Knowledge deficit Ineffective airway clearancePotential for infection

Diagnosis of the Patient With Diverticulitis

Constipation Acute pain Collaborative Problems/Potential Complications Perforation Peritonitis Abscess formation Bleeding Planning the Care of the Patient With Diverticulitis Major goals include attainment and maintenance of normal elimination patterns, pain, relief, and absence of complications Maintaining Normal Elimination Pattern Encourage fluid intake of at least 2 L/d East soft foods with increased fiber, such as cooked vegetables Participate in an individualized exercise program Use bulk laxatives (psyllium) and stool softeners

Coronary Artery Bypass Grafts

Coronary artery bypass grafts. One or more procedures may be performed using various veins and arteries. A, Left internal mammary artery, used frequently because of its functional longevity. B, Saphenous vein, also used as bypass graft. The major indications for CABG are: • Alleviation of angina that cannot be controlled with medication or PCI • Treatment of left main coronary artery stenosis or multivessel CAD • Prevention and treatment of MI, dysrhythmias, or heart failure • Treatment for complications from an unsuccessful PCI CABG is performed less frequently in women. For a patient to be considered for CABG, the coronary arteries to be bypassed must have approximately a 70% occlusion (60% if in the left main coronary artery)

Interventions: Cardiogenic Shock

Correct underlying problem Medications -Diuretics -Positive inotropic agents and vasopressors Circulatory assist devices -Intra-aortic balloon pump (IABP)

Thromboembolism

Decreased mobility and decreased circulation increase the risk for thromboembolism in patients with cardiac disorders, including those with HF. Pulmonary embolism: blood clot from the legs moves to obstruct the pulmonary vessels The most common thromboembolic problem with HF Prevention Treatment Anticoagulant therapy

Nursing Process—Diagnosis of the Patient with Psoriasis

Deficient knowledge Impaired skin integrity Disturbed body image Collaborative Problems/Potential Complications Infection Psoriatic arthritis

Urolithiasis and Nephrolithiasis

Depend upon location and presence of obstruction or infection Pain and hematuria (vaguely know symptoms for each location) Signs and symptoms of stones in the urinary system depend on the presence of obstruction, infection, and edema. When stones block the flow of urine, obstruction develops, producing an increase in hydrostatic pressure and distending the renal pelvis and proximal ureter. Infection (pyelonephritis and UTI with chills, fever, and frequency) can be a contributing factor with struvite stones Stones in the renal pelvis may be associated with an intense, deep ache in the costovertebral region. Hematuria is often present; pyuria may also be noted. Pain originating in the renal area radiates anteriorly and downward toward the bladder in the female and toward the testis in the male. If the pain suddenly becomes acute, with tenderness over the costovertebral area, and nausea and vomiting appear, the patient is having an episode of renal colic. acute, excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia. Often, the patient has a desire to void, but little urine is passed, and it usually contains blood because of the abrasive action of the stone Stones lodged in the bladder usually produce symptoms of irritation and may be associated with UTI and hematuria.

Assessment of the Patient With Low Back Pain

Detailed description of the pain including severity, duration, characteristics, radiation, associated symptoms such as leg weakness, description of how the pain occurred, and how the pain has been managed by the patient Work and recreational activities Effect of pain and/or movement limitation on lifestyle and ADLs

Diagnosis of the Patient With Inflammatory Bowel Disease

Diarrhea Acute pain Deficient fluid Imbalanced nutrition Activity intolerance Anxiety Ineffective coping Risk for impaired skin integrity Risk for ineffective therapeutic regimen management Collaborative Problems/Potential Complications Electrolyte imbalance Cardiac dysrhythmias GI bleeding with fluid loss Perforation of the bowel

Physical Assessment

Digital rectal exam- The DRE is used to screen for prostate cancer and is recommended annually for every man older than 50 years of age (45 years of age for men at high risk [African American men and men with a strong family history of prostate cancer]) annually (American Cancer Society [ACS], 2009). The DRE enables the skilled examiner, using a lubricated, gloved finger placed in the rectum, to assess the size, symmetry, shape, and consistency of the posterior surface of the prostate gland (Fig. 49- 2). The clinician assesses for tenderness of the prostate gland on palpation and for the presence and consistency of any nodules. The DRE may be performed with the patient leaning over an examination table or positioning the man in a side-lying position with legs flexed toward the abdomen or supine with legs resting in stirrups. To minimize discomfort and relax the anal sphincter during the rectal examination, the patient is instructed to take a deep breath and exhale slowly as the practitioner inserts a finger. If possible, he should turn his feet inward so his toes are touching. Although this examination may be uncomfortable and embarrassing for the patient, it is an important screening tool Testicular exam-The male genitalia are inspected for abnormalities and palpated for masses. The scrotum is palpated carefully for nodules, masses, or inflammation. Examination of the scrotum can reveal such disorders as hydrocele, inguinal hernia, testicular torsion, orchitis, epididymitis, or a tumor of the testis. The penis is inspected and palpated for ulcerations, nodules, inflammation, discharge, and curvature. If the patient is uncircumcised, the foreskin should be retracted for visualization of the glans penis. The testicular examination provides an excellent opportunity to instruct the patient on how to perform a testicular self-examination (TSE) and its importance in early detection of testicular cancer. TSE should begin during adolescence.

Nursing Process: Care of the Patient With a Vulvovaginal Infection: Diagnosis

Discomfort (number 1) Anxiety Risk for infection or spread of infection Deficient knowledge

Ischemic Stroke

Disruption of the blood supply due to an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue Types Large artery thrombosis Small penetrating artery thrombosis Cardiogenic embolism Cryptogenic Other Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction (deprivation of blood supply Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation. Embolic strokes can also be associated with valvular heart disease and thrombi in the left ventricle. Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery, resulting in a stroke. Embolic strokes may be prevented by the use of anticoagulation therapy in patients with atrial fibrillation. The last two classifications of ischemic strokes are cryptogenic strokes, which have no known cause, and strokes from other causes, such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries.

Diverticular Disease

Diverticulum: sac-like herniations of the lining of the bowel that extend through a defect in the muscle layer May occur anywhere in the intestine, but are most common in the sigmoid colon Diverticulosis: multiple diverticula without inflammation Diverticulitis: infection and inflammation of diverticula Diverticular disease increases with age and is associated with a low-fiber diet Diagnosis is usually by colonoscopy

Dumping syndrome

Due to rapid passage of food into the jejunum and drawing of fluid into the jejunum due to hypertonic intestinal contents Causes vasomotor and GI symptoms with reactive hypoglycemia Avoid fluid with meals Avoid high carbohydrate/sugar intake Steatorrhea Reduce fat intake and administer loperamide very common in bearatric post op patients

commissure.

Each valve has leaflets; the site where the leaflets meet is called

Premature Atrial Contractions (PACs). WHERE DO THE BEATS ORIGINATE? WHAT DOES THE P WAVE LOOK LIKE? WHAT DOES RHYTHM LOOK LIKE.

Early beats that originate in the atria, but not at the SA node (EP Rhythm: Irregular because of the PACs Rate: Depends on underlying rhythm P waves: Premature, upright (lead II), AND differs in normal shape IT'S PEAKED A LITTLE PR interval: Normal or prolonged QRS: less than 0.10 sec

Accelerated Junctional Rhythm

Ectopic rhythm from the AV node caused by enhanced automaticity of the AV node Rhythm: Regular Rate: 61 - 100 bpm P waves: Before, during, or after QRS; inverted in leads II, III, aVF PR interval: Less than 0.12 sec QRS: Usually 0.10 sec or less

Compartment Syndrome

Edema is a natural response of the tissue to trauma. The patient may complain that the cast, brace, or splint is too tight. Vascular insufficiency and nerve compression due to unrelieved swelling can result in compartment syndrome (Fig. 67-2). Compartment syndrome occurs when there is increased tissue pressure within a limited space (eg, cast, muscle compartment) that compromises the circulation and the function of the tissue within the confined area. To relieve the pressure, the *cast must be bivalved (cut in half longitudinally)* while maintaining alignment, and the extremity must be elevated no higher than heart level to ensure arterial perfusion (Chart 67-2). If pressure is not relieved and circulation is not restored, a fasciotomy may be necessary to relieve the pressure within the muscle compartment. The nurse closely monitors the patient's response to conservative and surgical management of compartment syndrome The nurse records neurovascular responses and promptly reports changes to the physician. (See Chapter 69 for further discussion of compartment syndrome.)

ECG differences: myocardial Ischemia vs MI

Effects of ischemia, injury, and infarction on an electrocardiogram (ECG) recording. Ischemia causes inversion of the T wave because of altered repolarization. Cardiac muscle injury causes elevation of the ST segment. Later, Q waves develop because of the absence of depolarization current from the necrotic tissue and opposing currents from other parts of the heart. Q waves develop within 1 to 3 days because there is no depolarization current conducted from necrotic tissue. Using the electrocardiogram (ECG) to diagnose acute myocardial infarction (MI). (ST-segment elevation is measured 0.06 to 0.08 seconds after the J point. An elevation of more than 1 mm in contiguous leads is indicative of acute MI.)

BLOOD FLOW EKG measures mechanical or electrical?

Electrical

Disorders of Male Sexual Function

Erectile dysfunction Psychogenic and organic causes Organic causes include vascular, endocrine, hematological, and neurologic disorders, trauma, alcohol, medications, and drug abuse Medications may be associated with erectile dysfunction In the United States, 30 million men experience erectile dysfunction; more than half of men 40 to 70 years of age are unable to attain or maintain an erection sufficient for satisfactory sexual performance (Tanagho & McAninch, 2008). The physiology of erection and ejaculation is complex and involves parasympathetic and sympathetic components

Evaluation: T waves: tall? negative?

Examine the ST Segments Is it isoelectric, elevated or depressed? Examine the T waves Are they upright and normal height? Tall T waves commonly seen in hyperkalemia Negative T waves suggest Myocardial ischemia

Manifestations

Fewer than 3 bowel movements per week Abdominal distention Decreased appetite Headache Fatigue Indigestion A sensation of incomplete evacuation Straining at stool Elimination of small-volume, hard, dry stools Complications: Hypertension Fecal impaction Hemorrhoids Fissures Megacolon

Prevention

Follow a balanced diet high in calcium and vitamin D throughout life Use calcium supplements to ensure adequate calcium intake: take in divided doses with vitamin D Regular weight bearing exercises: walking Weight training stimulates bone mineral density (BMD)

Interventions

Frequent monitoring of respiratory status and lung sounds and measure to maintain a patent airway Position with the head in neutral position and HOB elevation of 0° to 60° to promote venous drainage Avoid hip flexion, Valsalva maneuver, abdominal distention, or other stimuli that may increase ICP Maintain a calm, quiet atmosphere and protect patient from stress Monitor fluid status carefully; during acute phase, monitor I&O every hour Use strict aseptic technique for management of ICP monitoring system

Maintain an airway

Frequent monitoring of respiratory status including auscultation of lung sounds Position the patient to promote accumulation of secretions and prevent obstruction of upper airway: HOB elevated 30°, lateral or semiprone position Provide suctioning, oral hygiene, and CPT

Prevention of Atelectasis

Frequent turning and early mobilization Strategies to improve ventilation: deep-breathing exercises at least every 2 hours, incentive spirometer Strategies to remove secretions: coughing exercises, suctioning, aerosol therapy, and chest physiotherapy

Skin Cancer

Frequently related to sun exposure; prevention involves use of sunscreen and avoidance of sun exposure Incidence is increasing Prevention of all types of skin cancer involves protection from excessive sun exposure Basal cell carcinoma Most common type and most successfully treated because tumors remain localized Squamous cell carcinoma Prognosis depends upon presence of metastasis Treatment involves eradication of the tumor

Cerebrovascular Disorders

Functional abnormality of the CNS that occurs when the blood supply is disrupted Stroke is the primary cerebrovascular disorder and the third leading cause of death in the U.S. Stroke is the leading cause of serious long-term disability in the U.S. Direct and indirect costs of stroke are $53.6 billion

Gastrostomy Tubes

Gastrostomy Tubes Types of tubes: ◦ Stamm ◦ Janeway ◦ PEG ◦ Low-profile gastrostomy device (LPGD) Insertion of the PEG tube

Breathing exercises

General Instructions • Breathe slowly and rhythmically to exhale completely and empty the lungs completely. • Inhale through the nose to filter, humidify, and warm the air before it enters the lungs. • If you feel out of breath, breathe more slowly by prolonging the exhalation time. • Keep the air moist with a humidifier. Diaphragmatic Breathing Goal: To use and strengthen the diaphragm during breathing • Place one hand on the abdomen (just below the ribs) and the other hand on the middle of the chest to increase the awareness of the position of the diaphragm and its function in breathing. • Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. • Breathe out through pursed lips while tightening (contracting) the abdominal muscles. • Press firmly inward and upward on the abdomen while breathing out. • Repeat for 1 minute; follow with a rest period of 2 minutes. • Gradually increase duration up to 5 minutes, several times a day (before meals and at bedtime). Pursed-Lip Breathing Goal: To prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and the amount of airway resistance. • Inhale through the nose while slowly counting to 3—the amount of time needed to say "Smell a rose." • Exhale slowly and evenly against pursed lips while tightening the abdominal muscles. (Pursing the lips increases intratracheal pressure; exhaling through the mouth offers less resistance to expired air.) • Count to 7 slowly while prolonging expiration through pursed lips—the length of time to say "Blow out the candle." • While sitting in a chair: Fold arms over the abdomen. Inhale through the nose while counting to 3 slowly. Bend forward and exhale slowly through pursed lips while counting to 7 slowly. • While walking: Inhale while walking two steps. Exhale through pursed lips while walking four or five steps

Nursing Process: Planning

Goals include the relief of pain or ischemic signs and symptoms, prevention of further myocardial damage, absence of respiratory dysfunction, maintenance of or attainment of adequate tissue perfusion, reduced anxiety, adherence to the self-care program, absence or early recognition of complications.

Wandering Atrial Pacemaker (WAP) or Multiformed Atrial Rhythm: PACEMAKER STARTS WHERE? THE P- WAVE LOOKS LIKE WHAT, WHAT DEFINES THE P-WAVE IN THIS DISORDER?

Gradual shifting of dominant pacemaker from SA node, atria, and AV node sites Rhythm: Irregular as the pacemaker site shifts Rate: Usually 60 - 100 bpm P waves: Size, shape, and direction may change from beat to beat ( THEY ARE ALWAYS CHANGING) PR interval: Varies depending on site of pacemaker QRS: Usually less than 0.10 sec You get a regular sinus rhythm but then it begins to wander around the atria. This creates normal smooth upright and round p-waves but then it begins to become abnormal as pacemaker fire wanders.

Patient Teaching—Pediculosis Capitis

Head lice may infest anyone and are not a sign of uncleanliness Provide instruction in use of shampoo (lindane: Kwell; pyrethrin: RID) and combing of hair with fine-tooth comb dipped in vinegar to remove all nits Note lindane may have toxic effects and must be used only as directed All articles of clothing and bedding must be disinfected, washed in hot water, or dry cleaned; furniture and floors should be frequently vacuumed Do not share combs, hats, etc. All family members and close contacts must be treated

Assessment of the Patient With Cancer of the Colon or Rectum

Health history Fatigue and weakness Abdominal or rectal pain Nutritional status and dietary habits Elimination patterns Abdominal assessment Characteristics of stool

Preventive Treatment and Secondary Prevention

Health maintenance measures including a healthy diet, exercise, and the prevention and treatment of periodontal disease Carotid endarterectomy Anticoagulant therapy Antiplatelet therapy: aspirin, dipyridamole (Persantine), clopidogrel (Plavix), and ticlopidine (Ticlid) Statins Antihypertensive medications

rt vs lft hrt failure

Heart failure is a gradual progressive condition. It starts and proceeds as follows: *left-sided heart failure* ineffective left ventricular contractile function increased workload and end-diastolic volume enlarge the left ventricle pumping ability of the left ventricle fails, cardiac output falls right ventricle becomes stressed because it's pumping against greater pulmonary vascular resistance and left ventricle pressure blood backs up into left atrium and then into lungs diminished function allows blood to pool in the ventricle and atrium and back up into the pulmonary veins and capillaries rising capillary pressure pushes sodium and water into interstitial spaces fluid in the extremities moves into the systemic circulation Signs and symptoms dyspnea orthopnea paroxysmal nocturnal dyspnea reduced sympathetic stimulation while sleeping pulmonary congestion tachycardia S3 S4 Cool, pale skin restlessness right-sided heart failure ineffective right ventricular contractile function stressed right ventricle enlarges with the formation of stretched tissue blood backs up into right atrium and peripheral circulation blood pools in the right ventricle and right atrium backed-up blood also distends the visceral veins patient gains weight and develops peripheral edema rising capillary pressure forces excess fluid from the capillaries into the interstitial space Signs and symptoms jugular vein distention positive hepatojugular reflux hepatomegaly systolic dysfunction left ventricle can't pump enough blood out to systemic circulation blood backs up into pulmonary circulation and pressure increases in pulmonary venous system cardiac output falls; weakness and fatigue occur diastolic dysfunction ability of left ventricle to relax and fill during diastole is reduced and stroke volume falls high volumes needed in ventricles to maintain cardiac output *From Lecture* Right-sided failure RV cannot eject sufficient amounts of blood, and blood backs up in the venous system. This resuts in perpheral edema, hepatomegaly, ascites, anorexia, nausea, weakness, and weight gain.Increased venous pressure leads to JVD and increased capillary hydrostatic pressure throughout the venous system. The systemic clinical manifestations include edema of the lower extremities (dependent edema), hepatomegaly (enlargement of the liver), ascites (accumulation of fluid in the peritoneal cavity), anorexia and nausea, and weakness and weight gain due to retention of fluid. Left-sided failure LV cannot pump blood effectively to the systemic circulation. Pulmonary venous pressures increase, resulting in pulmonary congestion with dyspnea, cough, crackles, and impaired oxygen exchange.A reduction in CO decreases blood flow to the kidneys, reducing urine output (oliguria).Decreased brain perfusion causes dizziness, lightheadedness, confusion, restlessness, and anxiety due to decreased oxygenation and blood flow. As anxiety increases, so does dyspnea, increasing anxiety and creating a vicious cycle.Fatigue also results from the increased energy expended in breathing and the insomnia that results from respiratory distress, coughing, and nocturia.

emodialysis system.

Hemodialysis system. A, Blood from an artery is pumped into (B) a dialyzer where it flows through the cellophane tubes, which act as the semipermeable membrane (inset). The dialysate, which has the same chemical composition as the blood except for urea and waste products, flows in around the tubules. The waste products in the blood diffuse through the semipermeable membrane into the dialysate.

Collaborative Problems/Potential Complications

Hemorrhage Nerve injury

Collaborative Problems/Potential Complications

Hemorrhage and shock Infection DVT Catheter obstruction Sexual dysfunction

Patient Teaching—Viral Infections

Herpes zoster: provide instruction regarding prescribed antiviral medications, lesion care, dressings, and hand hygiene Herpes simplex: provide instruction regarding prescribed use of antiviral and prophylactic medications, information about the spread of herpes, and measures to reduce contagion of partner or of neonates born to mothers with genital herpes

How many seconds does a small box represent? how many seconds does a large box represent?

Horizontal axis = time (sec) Vertical axis = amplitude or voltage (mV) Small boxes are 1mm x 1mm = 0.04 seconds Larger boxes 0.20 seconds (contains 5 small boxes) Voltage has amplitude AND direction→(+) and (-) deflections Default paper speed at 25mm/sec

Most common STD infection among young people is _____. how often should a women get a pap smear? what does Hpv increase the risk for?

Human papillomavirus (HPV) Most common STD among sexually active young people Vaccine Treatment of genital warts Associated with cervical dysplasia and cervical cancer. Need annual Pap smears! Herpes type 2 infection (herpes genitalis) A recurrent life-long viral infection An STD that also may be transmitted by contact; it may be transmitted when the carrier is symptomatic Causes painful itching and burning herpetic lesions

Maintaining Normal Elimination Pattern

Identify relationship between diarrhea and food, activities, or emotional stressors Provide ready access to bathroom/commode Encourage bed rest to reduce peristalsis Administer medications as prescribed Record frequency, consistency, character, and amounts of stools

Interventions

Impaired Gas Exchange: Monitor ABGs and other indicators of hypoxia. Note trends. Auscultate lung sounds frequently. Judicious use of analgesics Monitor fluid balance. A complex diagnosis that requires a collaborative approach Impaired Airway Clearance Assess lung sounds at least every 2-4 hours. Measures to clear airway: suctioning, CPT, position changes, promote mobility Humidification Medications Risk for Trauma and Infection Infection control measures Tube care Cuff management Oral care Elevation of HOB Other Interventions ROM and mobility; get out of bed Communication methods Stress reduction techniques Interventions to promote coping Include in care: family teaching, and the emotional and coping support of the family. Home ventilator care

Patient Teaching—Bacterial Infections

Impetigo is contagious and may spread to other parts of a patient's body or to other persons Patient teaching regarding antibiotics, hygiene, and skin and lesion care Do not share towels, combs, etc. Bathe daily with antibacterial soap Furuncles, boils, or pimples should never be squeezed

Interventions

Implement muscle setting and ankle- and calf-pumping exercises Take measures to ensure adequate nutrition and hydration Large amounts of milk should not be given to orthopedic patients on bed rest Provide skin care measures including frequent turning and positioning Follow physical therapy and rehabilitation programs Encourage the patient to set realistic goals and perform self-care care within limits of the therapeutic regimen Prevent atelectasis and pneumonia Encourage coughing and deep breathing exercises Use incentive spirometry Constipation Monitor bowel function Provide hydration Encourage early mobilization Use stool softeners

Interventions

Improve mobility Instruct on weight-bearing restrictions as prescribed Use assistive devices (crutches or walker) Implement measures to ensure patient safety Implement measures to prevent infection Provide wound or pin care Keep dressing clean and dry Assess for signs and symptoms of infections

Interventions

Improving Airway Clearance Encourage hydration; 2-3 L a day, unless contraindicated Humidification may be used to loosen secretions; by face mask or with oxygen Coughing techniques Chest physiotherapy Position changes Oxygen therapy administered to patient needs Promoting rest Encourage rest and avoidance of overexertion. Positioning to promote rest and breathing (semi-Fowler's) Promoting fluid intake Encourage fluid intake to at least 2 L a day. Maintaining nutrition Provide nutritionally enriched foods and fluids. Patient teaching

peritoneal dialysis

In peritoneal dialysis and in acute intermittent peritoneal dialysis, dialysate is infused into the peritoneal cavity by gravity, after which the clamp on the infusion line is closed. After a dwell time (when the dialysate is in the peritoneal cavity), the drainage tube is unclamped and the fluid drains from the peritoneal cavity, again by gravity. A new container of dialysate is infused as soon as drainage is complete. The duration of the dwell time depends on the type of peritoneal dialysis

what are the two types of incentive spirometers?

Incentive spirometers are available in two types: volume or flow. In the volume type, the tidal volume is set using the manufacturer's instructions. The patient takes a deep breath through the mouthpiece, pauses at peak lung inflation, and then relaxes and exhales. Taking several normal breaths before attempting another with the incentive spirometer helps avoid fatigue. The volume is periodically increased as tolerated. In the flow type, the volume is not preset. The spirometer contains a number of movable balls that are pushed up by the force of the breath and held suspended in the air while the patient inhales. The amount of air inhaled and the flow of the air are estimated by how long and how high the balls are suspended.

Male Reproductive System

Includes conditions that affect reproduction, sexuality, and urinary elimination Patient may experience anxiety and embarrassment Be sensitive to cultural and emotional issues related to sexuality and the genitals to accomplish effective assessment and communication Provide for privacy and education

Manifestations

Increased frequency and fluid content of stools Abdominal cramps Distention Borborygmus Painful spasmodic contractions of the anus Tenesmus Complications Fluid and electrolyte imbalances Dehydration Cardiac dysrhythmias Acute diarrhea is most often associated with infection and is usually self-limiting, lasting up to 7 to 14 days; chronic diarrhea persists for more than 2 to 3 weeks and may return sporadically.

Diarrhea

Increased frequency of bowel movements (more than 3 per day), increased amount of stool (more than 200 g per day), and altered consistency (ie, looseness) of stool Usually associated with urgency, perianal discomfort, incontinence, or a combination of these factors May be acute or chronic Causes include infections, medications, tube feeding formulas, metabolic and endocrine disorders, and various disease processes

considerations for patients with indwelling caths

Indwelling catheters should be avoided if possible and removed at the earliest opportunity. However, if an indwelling catheter is necessary, the following specific nursing interventions are initiated to prevent infection and urosepsis: • Using strict aseptic technique during insertion of the smallest catheter possible • Securing the catheter with tape to prevent movement • Frequently inspecting urine color, odor, and consistency • Performing meticulous daily perineal care with soap and water • Maintaining a closed system • Following the manufacturer's instructions when using the catheter port to obtain urine specimens

The Care of the Patient with a Radical Neck Dissection: Diagnosis

Ineffective airway Knowledge deficiency Acute pain Impaired tissue integrity Imbalanced nutrition Impaired physical mobility secondary to nerve

Nursing Process—Diagnosis of the Patient With Increased Intracranial Pressure

Ineffective airway clearance Ineffective breathing pattern Ineffective cerebral perfusion Deficient fluid volume related to fluid restriction Risk for infection related to ICP monitoring

Nursing Process—Diagnosis of the Patient With Altered Level of Consciousness

Ineffective airway clearance Risk of injury *Deficient fluid volume* Impaired oral mucosa *Risk for impaired skin integrity and impaired tissue* integrity (cornea) Ineffective thermoregulation Impaired urinary elimination and bowel incontinence Disturbed sensory perception Interrupted family processes Collaborative Problems/Potential Complications Respiratory distress or failure Pneumonia Aspiration Pressure ulcer Deep vein thrombosis (DVT) Contractures

The Care of the Patient with ACS: Diagnosis

Ineffective cardiac tissue perfusion Risk for fluid imbalance Risk for ineffective peripheral tissue perfusion Death anxiety Deficient knowledge

Osteomyelitis

Infection of the bone occurs due to: -Extension of soft-tissue infection -Direct bone contamination -Bloodborne spread from another site of infection -----This typically occurs in an area of bone that has been traumatized or has lowered resistance Causative organisms -Staphylococcus aureus (70% to 80%) -Other: Proteus, Pseudomonas, and E. coli Prevention of osteomyelitis is the goal Early detection and prompt treatment of osteomyelitis are required to reduce potential for chronic infection and disability

Patient Teaching—Fungal Infections

Instruction regarding medications, use of oral and topical agents, and shampoos Instructions regarding hygiene; use clean towels and washcloths every day Do not share towels, combs, etc. Keep skin folds and feet dry Wear clean, dry, cotton clothing including underwear and socks; avoid synthetic underwear, tight-fitting garments, wet bathing suits, and plastic shoes Avoid excessive heat and humidity Hair loss associated with tinea capitus is temporary

Interventions for upper airway disorders

Interventions to maintain a patent airway Promote comfort -Analgesics -Gargles for sore throat-- -Use of hot packs for sinus congestion or ice collar to reduce swelling, and also bleeding post tonsillectomy and adenoidectomy Rest Refrain from speaking, use alternative communication Encourage liquids; 2-3 L a day and appropriate foods \ Maintaining a Patent Airway An accumulation of secretions can block the airway in patients with an upper airway infection. As a result, changes in the respiratory pattern occur, and the work of breathing increases to compensate for the blockage. The nurse can implement several measures to loosen thick secretions or to keep the secretions moist so that they can be easily expectorated. Increasing fluid intake helps thin the mucus. Use of room vaporizers or steam inhalation also loosens secretions and reduces inflammation of the mucous membranes. To enhance drainage from the sinuses, the nurse instructs the patient about positioning; this depends on the location of the infection or inflammation. For example, drainage for sinusitis or rhinitis is achieved in the upright position. In some conditions, topical or systemic medications, when prescribed, help relieve nasal or throat congestion.

...

Intracranial pressure waves. Composite diagram of A (plateau) waves, which indicate cerebral ischemia; B waves, which indicate intracranial hypertension and variations in the respiratory cycle; and C waves, which relate to variations in systemic arterial pressure and respirations.

Management of ARDS

Intubation and mechanical ventilation with PEEP (positive end-expiratory pressure) to treat progressive hypoxemia Positioning: frequent position changes Nutritional support General supportive care

Premature Ventricular Complexes (PVCs) what normally follows a PVC

Irritable focus in either ventricle. Enhanced automaticity or reentry Rhythm: Regular with premature complexes Rate: Depends on underlying rhythm P waves: Usually absent, but with retrograde conduction, may appear after QRS PR interval: n/a QRS: Greater than 0.12 sec, wide and bizarre T wave: Usually in opposite direction of QRS Typically a full compensatory pause follows a PVC (SA node usually not affected by the PVC) Full compensatory pause does not reliably differentiate a ventricular ectopy

Evaluating P waves

Is the P wave present? Is it positive, negative, notched...? Does it occur regularly before each QRS complex? Normally: One P wave precedes each QRS complex. P waves occur regularly and appear similar in size, shape and position.

PR Interval QRS Duration

PR Interval Begin: Point P wave leaves baseline End: Beginning of QRS Complex QRS Duration Begin: Point where first wave deviates from baseline End: Point where last wave levels out

Properties of Cardiac Cells

It's a piece of Cake...CACE Conductivity: ability to receive an impulse and pass it on Automaticity: ability to spontaneously initiate impulse independent of other sources of stimulation Contractility: ability of cells to shorten in response to an impulse Excitability: respond to external stimulus

Pyloroplasty

Longitudinal incision is made into the pylorus and transversely sutured closed to enlarge the outlet and relax the muscle Usually accompanies truncal and selective vagotomies, which produce delayed gastric emptying due to decreased innervation.

ICP and CPP Formula for CPP? what is normal CPP? What CPP causes permanent neuralgic damage?

MAP (mean arterial pressure) CPP(cerebral perfusion pressure) ICP (intra-cranial pressure) CPP= MAP-ICP Normal CPP is 70 to 100 A CPP of less than 50 results in permanent neuralgic damage Relate 70 to education, below 70 is a fail. Also, 50 is an F means permanent damage.

Planning the Care of the Patient With Inflammatory Bowel Disease

Major goals include attainment of normal bowel elimination patterns, relief of abdominal pain and cramping, prevention of fluid deficit, maintenance of optimal nutrition and weight, avoidance of fatigue, reduction of anxiety, promotion of effective coping, absence of skin breakdown, increased knowledge of disease process and therapeutic regimen, and avoidance of complications

The Care of the Patient with a Radical Neck Dissection- Planning

Major goals include patient participation in the treatment plan, maintenance of respiratory status, attainment of comfort, absence of infection, viability of graft, maintenance of adequate nutrition and fluid intake, effective coping strategies, effective communication, maintenance of neck and shoulder motion, and absence of complications.

Nursing Process—Planning the Care of the Patient With Osteomyelitis

Major goals include relief of pain, improved physical mobility within therapeutic limitations, control and eradication of infection, and knowledge of therapeutic regimen

Nursing Process—Planning the Care of the Patient With Psoriasis

Major goals may include: Increased understanding of psoriasis and the treatment regimen Achievement of smoother skin with control of lesions Development of self-acceptance Absence of complications

Nursing Process—Planning the Care of the Patient Undergoing Prostatectomy

Major goals preoperatively include adequate preparation and reduction of anxiety and pain Major goals postoperatively include maintenance of fluid volume balance, relief of pain and discomfort, ability to perform self-care activities, and absence of complications

ED flow chart

Pharmacologic therapy Oral medications: sildenafil (Viagra) -Side effects include headache, flushing, dyspepsia -Caution with retinopathy -Contraindicated with nitrate use Injected vasoactive agents -Complications include priapism (persistent abnormal erection) Urethral suppositories Penile implants Negative pressure devices

Monitoring and Managing Potential Complications

Many potential problems associated with HF therapy relate to the use of diuretics: • Excessive and repeated diuresis can lead to hypokalemia (ie, potassium depletion). Signs include ventricular dysrhythmias, hypotension, muscle weakness, and generalized weakness. Hypokalemia poses problems for the patient with HF because it markedly weakens cardiac contractions. In patients receiving digoxin, hypokalemia can lead to digitalis toxicity. Digitalis toxicity and hypokalemia increase the likelihood of dangerous dysrhythmias (see Chart 30-3). Patients with HF may also develop low levels of magnesium, which can add to the risk of dysrhythmias. • Hyperkalemia may occur, especially with the use of ACE inhibitors, ARBs, or spironolactone. • Prolonged diuretic therapy may produce hyponatremia (deficiency of sodium in the blood), which results in disorientation, apprehension, weakness, fatigue, malaise, and muscle cramps. • Volume depletion from excessive fluid loss may lead to dehydration and hypotension. ACE inhibitors and beta-blockers may contribute to the hypotension. • Other problems associated with diuretics include increased serum creatinine and hyperuricemia (excessive uric acid in the blood), which leads to gout.

Treatment

Measures to improve respiratory and CV status Anticoagulation and thrombolytic therapy

Antibiotic Prophylaxis

Mechanical valve replacements including annuloplasty or other prosthetic material Valvular defects including mitral click and murmur or mitral regurgitation, mitral stenosis, aortic stenosis, and aortic regurgitation A history of rheumatic heart disease, endocarditis, or myocarditis Antibiotic prophylaxis is required for dental procedures and surgical interventions, including GU and GI procedures, to prevent endocarditis.

Patient Teaching—Scabies

Mites frequently involve fingers and hands; contact may spread infection; health care personnel should wear gloves when providing care until infection is ruled out Instruct patient to take a warm, soapy bath; allow skin to cool; apply the prescription scabicide lindane, crotamiton, or 5% permethrin to entire body, not including the face or scalp; leave on for 12 to 24 hours Wash clothing and bedding in hot water and dry in a hot dryer Treat all contacts at the same time Pruritus may continue for several weeks and does not mean retreatment is required

where are the mitral, tricuspid and aortic valve. What valvular disorders can each have?

Mitral valve prolapse Mitral regurgitation Mitral stenosis Aortic regurgitation Aortic stenosis

PLISSIT

Model of sexual assessment and intervention -Permission -Limited Information -Specific Suggestions -Intensive Therapy begins by asking the patient's permission (P) to discuss sexual functioning. Limited information (LI) about sexual function may then be provided to the patient. As the discussion progresses, the nurse may offer specific suggestions (SS) for interventions. A professional who specializes in sex therapy may provide more intensive therapy (IT) as needed. The BETTER (bringing up the topic, explaining, telling, timing, educate about treatment-related sexual side effects, recording) model was developed more recently to assist health care professionals to include sexuality in the assessment of patients with cancer

Relief of Pain

Monitor urinary drainage and keep catheter patent Assessment of pain -Bladder spasms cause feelings of pressure and fullness, urgency to void, and bleeding from the urethra around the catheter Medication and warm compresses or sitz baths relieve spasms Administer analgesics and antispasmodics as needed Encourage patient to walk but to avoid sitting for prolonged periods Prevent constipation Irrigate catheter as prescribed

Increased Intracranial Pressure (ICP)

Monro-Kellie hypothesis: because of limited space in the skull, an increase in any one skull component—brain tissue, blood, or CSF—will cause a change in the volume of the others Compensation to maintain a normal ICP of *10 to 20 mm Hg* is normally accomplished by shifting or displacing CSF With disease or injury, ICP may increase Increased ICP decreases cerebral perfusion, causes ischemia, cell death, and (further) edema Brain tissues may shift through the dura and result in herniation Autoregulation: refers to the brain's ability to change the diameter of blood vessels to maintain cerebral blood flow CO2 plays a role; decreased CO2 results in vasoconstriction, and increased CO2 results in vasodilatation Three things that can change the pressure in the brain: brain tissue, blood, or csf Usually, this is accompanied by a slow bounding pulse and respiratory irregularities. These changes in blood pressure, pulse, and respiration are important clinically because they suggest increased ICP.

Testicular Cancer

Most common cancer in men age 15 to 40 Highly treatable and curable Risk factors: undescended testicles, positive family history, cancer of one testicle, Caucasian American race Manifestations: painless lump or mass in the testes Early diagnosis: monthly testicular self-exam (TSE) and annual testicular exam Treatment: orchidectomy, retroperitoneal lymph node dissection (open or laparoscopic), radiation therapy, and chemotherapy

what is the treament for HSV2

No cure Antiviral agents acyclovir (Zovirax), valacyclovir (Valtrex), and famiciclovir (Famvir) can suppress symptoms. Recurrences may be associated with stress, sunburn, dental work, inadequate rest, and inadequate nutrition. Infants delivered vaginally are at risk for becoming infected; therefore, cesarean delivery may be performed.

Prevention and risk

Nonmodifiable risk factors -Age (over 55), male gender, African American race Modifiable risk factors -Hypertension: the primary risk factor -Cardiovascular disease -Elevated cholesterol or elevated hematocrit -Obesity -Diabetes -Oral contraceptive use -Smoking and drug and alcohol abuse

Sinus Arrhythmia (SA)

Normal conduction pathway Rhythm: Irregular Rate: 60 - 100 bpm P waves: Present and uniform (upright in lead II) PR interval: 0.12 - 0.20 sec QRS: 0.10 sec or less if the amount of blood is enough to profuse completely.

Sinoatrial-exit block

Normal conduction pathway, but SA block is present ****Rhythm: Irregular because of the SA block A QRS WILL NOT FIRE ON THE STRIP AT SOMETIMES BUT WILL COME BACK IN WITH THE CORRECT RHYTHM. THERE WILL BE A PAUSE IN THE BEATS. Rate: 60 - 100 bpm P waves: Present and uniform (upright in lead II) may be hidden in fast rates PR interval: 0.12 - 0.20 sec QRS: 0.10 sec or less/

sinus arrest

Normal conduction pathway, but SA node may fail to ***Rhythm: Irregular Rate: 60 - 100 bpm P waves: Present and uniform (upright in lead II) may be hidden in fast rates PR interval: 0.12 - 0.20 sec QRS: 0.10 sec or less

Sinus Rhythm (NSR) Sinus Bradycardia (SB) SinusTachycardia (ST)

Normal electrical conduction activity Rhythm: Regularly Regular Rate: 60-100 bpm PR interval: 0.12 - 0.20 sec P waves present and uniform (upright in lead II) QRS: 0.10 sec or less SB: less than 60 ST: rate between 101-180 p-wave is almost on top of t-wave

Causes of PVCs

Normal variant Hypoxia Stress Digitalis Toxicity Acid-Base Imbalance Myocardial Ischemia Electrolyte Imbalance CHF Acute MI Stimulants Other medications

Patient Education

Prevention of upper airway infectionsSee Chart 22-3 Emphasize frequent handwashing When to contact health care provider Need to complete antibiotic treatment regimen Annual influenza vaccine for those at risk

Patient Learning Needs

Normal variations of bowel patterns Establishment of normal pattern Dietary fiber and fluid intake Responding to the urge to defecate Exercise and activity Laxative use See Chart 38-1 exercise and activity level, occupation, food and fluid intake, and stress level Patient education and health promotion are important functions of the nurse (Chart 38-1). After the health history is obtained, the nurse sets specific goals for teaching. Goals for the patient include restoring or maintaining a regular pattern of elimination by responding to the urge to defecate, ensuring adequate intake of fluids and high-fiber foods, learning about methods to avoid constipation, relieving anxiety about bowel elimination patterns, and avoiding complications.

Interventions/prevention UTI

Number one preventive measure is hand washing Prevention: avoid indwelling catheters; exercise proper care of catheters ALWAYS -WASH CATH FROM PROXIMAL TO DISTAL Exercise correct personal hygiene Take medications as prescribed: antibiotics, analgesics, and antispasmodics Apply heat to the perineum to relieve pan and spasm Increase fluid intake Avoid urinary tract irritants such as coffee, tea, citrus, spices, cola, and alcohol Frequent voiding Patient education

Interpretation

ORIGIN OF THE RHYTHM MECHANISM VENTRICULAR RATE EX: SINUS TACHYCARDIA AT 140bpm

Plan of Care for a Patient Experiencing a Seizure

Observation and documentation of patient signs and symptoms before, during, and after seizure Nursing actions during seizure for patient safety and protection After seizure care, prevent complications

treatment for Acute MI

Obtain diagnostic tests including ECG within 10 minutes of admission to the ED. Oxygen Aspirin, nitroglycerin, morphine, beta-blockers Angiotensin-converting enzyme inhibitor within 24 hours Evaluate for percutaneous coronary intervention or thrombolytic therapy. As indicated; IV heparin or LMWH, clopidogrel or ticlopidine, glycoprotein IIb/IIIa inhibitor Bed rest

Rheumatic Endocarditis

Occurs most often in school-age children, after group A beta-hemolytic streptococcal pharyngitis Injury to heart tissue is caused by inflammatory or sensitivity reaction to the streptococci. Myocardial and pericardial tissue is also affected, but endocarditis results in permanent changes in the valves. Need to promptly recognize and treat "strep" throat to prevent rheumatic fever.

Junctional Escape Rhythm (beats)

Originates in the AV junction Rhythm: Regular Rate: 40 - 60 bpm P waves: Before, during, or after QRS; inverted in leads II, III, aVF PR interval: Less than 0.12 sec QRS: Usually 0.10 sec or less

Ventricular fibrillation (Vf) how does it differ from VT?

Originates in the ventricles. No organized depolarization. Rhythm: Rapid and chaotic, no regularity Rate: Cannot be determined V-tach differs from v-fib by it's abnormal organizations of depolarization. P waves: Cannot differentiate PR interval: n/a QRS: Cannot differentiate

What does each waveform represent? p- how many secs long and height?

P-atrial depolarization: First wave of the cardiac cycle Upward slope=impulse from SA to AV node Downslope=stim. of L atrium Therefore depolarization of atria No more than 0.11 sec in duration and 2.5mm in height Q- Represents depolarization of the interventricular septum (L to R)less than 0.04 sec and less than 25% R amplitude RS:Both waves represent simultaneous depolarization of the R and L ventricles Generally, represents activity occurring in the L ventricle (greater muscle mass) QRS: duration .06-.10 ST- Between the QRS complex and the T wave Represents early repolarization of the R and L ventricles Begins at isoelectric line to the beginning of the T wave (gradual curve upward) T Wave: Represents ventricular repolarization Begins when ST segment appears to become steeper Ends when it returns to baseline Normally oriented in same direction as preceeding QRS complex Lead II reveals tallest T wave PR: Measure from the point P wave leaves baseline to the beginning of QRS complex Depolarization of the atria and the spread of the impulse to the AV node, Bundle of His, bundle branches and Purkinje fibers Measures: 0.12 to 0.20, shortens as HR increases

Packing of the nasal cavity or balloon catheter

Packing to control bleeding from the posterior nose. A, Catheter is inserted and packing is attached. B, Packing is drawn into position as the catheter is removed. C, Strip is tied over a bolster to hold the packing in place with an anterior pack installed "accordion pleat" style. D, Alternative method, using a balloon catheter instead of gauze packing. The packing may remain in place for 48 hours or up to 5 or 6 days if necessary to control bleeding. Antibiotics may be prescribed because of the risk of iatrogenic sinusitis and toxic shock syndrome.

Care of the Patient Undergoing Surgery of the Hand or Wrist

Pain control measures: medication, elevation, and intermittent ice or cold Prevention of infection: keep dressing clean and dry, provide wound care, and assess for signs and symptoms of infection Assist with ADLs and measures to promote independence Neurovascular assessment of the exposed fingers every hour for the first 24 hours following surgery is essential for monitoring function of the nerves and perfusion of the hand. If the patient is ambulatory, the arm is elevated in a conventional sling with the hand at heart level. Intermittent use of ice packs to the surgical area during the first 24 to 48 hours may be prescribed to control edema. Unless contraindicated, active extension and flexion of the fingers to promote circulation are encouraged, even though movement is limited by the bulky dressing • Demonstrate how to assess neurovascular status. ✔ ✔ • State abnormal findings (eg, unrelenting pain; paralysis; paresthesia; cool, nonblanching fingers) ✔ ✔ to report to physician promptly. • Demonstrate control of edema by elevating hand above elbow and applying ice intermittently ✔ ✔ if prescribed. • Identify signs and symptoms of infection (eg, elevated temperature, purulent drainage). ✔ ✔ • Demonstrate finger exercises to promote circulation, unless contraindicated. ✔ • Describe methods to prevent wound infection (eg, keeping hand dressing clean and dry ✔ ✔ during activities of daily living). • Describe use of prescribed medications. ✔ ✔ • Demonstrate use of assistive devices, if appropriate.

Types of PVCs

Pair (Couplet) = 2 sequential PVCs Run: 3 or more sequential PVCs Ventricular Bigeminy: Every other beat is PVC --Vent. Trigeminy: Every 3rd beat PVC --Vent. Quadrigeminy: --Every 4th beat PVC

Interventions

Patient teaching regarding the disease, skin care, and treatment regimen; see Chart 56-5 (view print out) Measures to prevent skin injury: avoid picking or scratching Measures to prevent skin dryness: use emollients, avoid excessive washing, use warm (not hot) water, and pat dry Use of the therapeutic relationship for support and to aid coping

Diverticular disease: how to care for these patients.

Patients may have chronic constipation preceding development of diverticulosis, frequently asymptomatic but may include bowel irregularities, nausea, anorexia, bloating, and abdominal distention With diverticulitis, symptoms include mild or severe pain in lower left quadrant, nausea, vomiting, fever, chills, and leukocytosis Determine the onset and duration of pain, and past and present elimination patterns Encourage nutrition that includes fiber intake Inspect stool and monitor for symptoms of potential complications

Patient Teaching—Pediculosis Corporis and Pubis

Pediculosis corporis is a disease related to poor hygiene and occurs in those who live in close quarters Pediculosis pubis is common and spread chiefly by sexual contact Bathe in soap and water; apply prescription scabicide or an OTC permethrin, such as NIX; mechanically remove any nits; if eyelashes are involved, Vaseline may be applied twice a day for 8 days

Percutaneous Coronary Intervention

Percutaneous transluminal coronary angioplasty. A, A balloontipped catheter is passed into the affected coronary artery and placed across the area of the atheroma (plaque). B, The balloon is then rapidly inflated and deflated with controlled pressure. C, A stent is placed to maintain patency of the artery, and the balloon is removed.

what are two potential complications of pericarditis?

Pericardial effusion Cardiac tamponade

Pericardial Effusion and Cardiac Tamponade

Pericardial effusion is the accumulation of fluid in the pericardial sac. Cardiac tamponade is the restriction of heart function due to this fluid, resulting in decreased venous return and decreased CO. -Clinical manifestations: ill-defined chest pain or fullness, pulsus parodoxus, engorged neck veins, labile or low BP, shortness of breath Cardinal signs of cardiac tamponade: falling systolic BP, narrowing pulse pressure, rising venous pressure, distant heart sounds Pulsus parodoxus is defined as an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10mmHg or 10torr. When the drop is more than 10mmHg or 10torr, it is referred to as pulsus paradoxus. Managed: Pericardiocentesis Pericardiotomy- makes a window to release pressure of the heart.

Postoperative Care for intercarnial surgery: What is monitored? What type of lines do these patients have?

Postoperative care is aimed at detecting and reducing cerebral edema, relieving pain, preventing seizures, and monitoring ICP and neurologic status The patient may be intubated and have arterial and central venous lines

Risk Factors for Vulvovaginal Infections

Premenarche/perimenopause/menopause/low estrogen levels Pregnancy/oral contraceptive use Poor hygiene *Tight garments and synthetic clothing* *Frequent douching* Antibiotics Allergies Diabetes mellitus Intercourse with infected partner/oral-genital contact/HIV

Nursing Care of the Patient Undergoing Bariatric Surgery

Preoperative care, evaluation, and counseling Postoperative care resembles that of gastric resection, but the patient is at greater risk for complications due to obesity Postoperative diet: 6 small feedings totaling 600 to 800 calories per day (see Chart 37-4) Patients require psychosocial interventions to modify their eating behaviors Follow-up care Education regarding long-term effects

causes for each type of renal failure

Prerenal Failure • Volume depletion resulting from: Hemorrhage Renal losses (diuretics, osmotic diuresis) Gastrointestinal losses (vomiting, diarrhea, nasogastric suction) • Impaired cardiac efficiency resulting from: Myocardial infarction Heart failure Dysrhythmias Cardiogenic shock • Vasodilation resulting from: Sepsis Anaphylaxis Antihypertensive medications or other medications that cause vasodilation Intrarenal Failure • Prolonged renal ischemia resulting from: Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures) Myoglobinuria (trauma, crush injuries, burns) Hemoglobinuria (transfusion reaction, hemolytic anemia) • Nephrotoxic agents such as: Aminoglycoside antibiotics (gentamicin, tobramycin) Radiopaque contrast agents Heavy metals (lead, mercury) Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic) Nonsteroidal anti-inflammatory drugs (NSAIDs) Angiotensin-converting enzyme inhibitors (ACE inhibitors) • Infectious processes such as: Acute pyelonephritis Acute glomerulonephritis Postrenal Failure • Urinary tract obstruction, including: Calculi (stones) Tumors Benign prostatic hyperplasia Strictures Blood clots

Needs of Patients After Hip or Knee Replacement Surgery (cont.)

Prevention of infection Infection may occur in the immediate postoperative period (within 3 months), as a delayed infection (4 to 24 months), or due to spread from another site (more than 2 years) Prevention of DVT Patient teaching and rehabilitation Mobility and ambulation -Patients usually begin ambulation within a day after surgery using walker or crutches -Weight bearing as prescribed by the physician Drain use postoperatively -Assess for bleeding and fluid accumulation Use of an Abduction Pillow to Prevent Hip Dislocation After Total Hip Replacement

Teaching Needs of the Patient With a Cast

Prior to cast application -Explain condition necessitating the cast -Explain purpose and goals of the cast -Describe expectations during the casting process: eg, the heat from hardening plaster Cast care: keep dry; do not cover with plastic Positioning: elevation of extremity; use of slings Hygiene Activity and mobility Explain exercises Do not scratch or stick anything under the cast Cushion rough edges Report the following signs and symptoms: persistent pain or swelling; changes in sensation, movement, skin color, or temperature; and signs of infection or pressure areas Required follow-up care Cast removal

Weaning

Process of withdrawal of dependence upon the ventilator Successful weaning is a collaborative process. Process of withdrawal of dependence upon the ventilator Successful weaning is a collaborative process. Criteria for weaning Patient preparation Methods of weaning:The PAV mode of partial ventilatory support allows the ventilator to generate pressure in proportion to the patient's efforts. CPAP allows the patient to breathe spontaneously while applying positive pressure throughout the respiratory cycle to keep the alveoli open and promote oxygenation. Weaning from the tube is considered when the patient can breathe spontaneously, maintain an adequate airway by effectively coughing up secretions, swallow, and move the jaw. The patient who has been successfully weaned from the ventilator, cuff, and tube and has adequate respiratory function is then weaned from oxygen. The FiO2 is gradually reduced until the PaO2 is in the range of 70 to 100 mm Hg while the patient is breathing room air. If the PaO2 is less than 70 mm Hg on room air, supplemental oxygen is recommended.

Interventions (cont.)

Promote good nutrition including vitamin C and protein Encourage adequate hydration Administer and monitor antibiotic therapy Patient and family teaching -Long-term antibiotic therapy and management of home IV administration -Mobility limitations -Safety and prevention of injury -Follow-up care Referral for home health care

Medical Management DuringAcute Phase of Stroke

Prompt diagnosis and treatment Assessment of stroke: NIHSS assessment tool Thrombolytic therapy -Criteria for tissue plasminogen activator (tPA): see text -IV dosage and administration -Patient monitoring -Side effects: potential bleeding -Elevate HOB unless contraindicated -Maintain airway and ventilation -Provide continuous hemodynamic monitoring and neurologic assessment -Carotid Endarterectomy--The main surgical procedure for selected patients with TIAs and mild stroke is carotid endarterectomy, which is currently the most frequently performed noncardiac vascular procedure. A carotid endarterectomy is the removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries

Proper and Improper Lifting Techniques

Proper and improper lifting techniques. Left, Correct position for lifting. This person is using the long and strong muscles of the arms and legs and holding the object so that the line of gravity falls within the base of support. Right, Incorrect position for lifting because pull is exerted on the back muscles and leaning causes the line of gravity to fall outside the base. \ Standing. Advise the patient to adhere to the following guidelines: • Avoid prolonged standing and walking. • When standing for any length of time, rest one foot on a small stool or box to relieve lumbar lordosis. • Avoid forward flexion work positions. • Avoid high heels. Sitting. Discuss the following strategies with the patient: • Avoid sitting for prolonged periods. • Sit in a straight-back chair with back well supported and arm rests to support some of the body weight; use a footstool to position knees higher than hips if necessary. • Eradicate the hollow of the back by sitting with the buttocks "tucked under." • Maintain back support; use a soft support at the small of the back. • Avoid knee and hip extension. When driving a car, have the seat pushed forward as far as possible for comfort. • Guard against extension strains—reaching, pushing, sitting with legs straight out. • Alternate periods of sitting with walking. Lying. Encourage the patient to do the following: • Rest at intervals; fatigue contributes to spasm of the back muscles. • Place a firm bed board under the mattress. • Avoid sleeping in a prone position. • When lying on the side, place a pillow under the head and one between the legs, with the legs flexed at the hips and knees. • When supine, use a pillow under the knees to decrease lordosis. Lifting. Emphasize the importance of the following strategies: • When lifting, keep the back straight and hold the load as close to the body as possible. • Lift with the large leg muscles, not the back muscles. • Use trunk muscles to stabilize the spine. • Squat while keeping the back straight when it is necessary to pick something off the floor. • Avoid twisting the trunk of the body, lifting above waist level, and reaching up for any length of time. Exercising. Daily exercise is important in the prevention of back problems. • Walk daily and gradually increase the distance and pace of walking. • Perform prescribed back exercises twice daily, increasing exercise gradually. • Avoid jumping and jarring activities.

Proper and Improper Standing Postures

Proper and improper standing postures. Left, Abdominal muscles contracted, giving a feeling of upward pull, and gluteal muscles contracted, giving a downward pull. Right, Slouch position, showing abdominal muscles relaxed and body out of proper alignment.

Preventive Nursing Care Needs of the Patient in Traction

Properly apply and maintain traction Monitor for complications of skin breakdown, nerve pressure, and circulatory impairment -Inspect the skin at least 3 times a day -Palpate traction tapes to assess for tenderness -Assess sensation and movement -Assess pulses, color capillary refill, and temperature of fingers or toes -Assess for indicators of DVT -Assess for indicators of infection

Nursing Management of the Hospitalized Patient on Dialysis

Protection of vascular access; assess site for patency and signs of potential infection, and do not use for blood pressure or blood draws. Monitor fluid balance indicators and monitor IV therapy carefully; accurate I&O, IV administration pump. Assess for signs and symptoms of uremia and electrolyte imbalance; regularly check lab data. Monitor cardiac and respiratory status carefully. Hypertension: monitor blood pressure, antihypertensive agents must be held on dialysis days to avoid hypotension.

What are the 6 ways of Analyzing the Rhythm Strip?

Rate Rhythm/Regularity P Waves Intervals—PR interval, QRS Duration, QT interval Evaluate Interpret

Urinary Diversion

Reasons: bladder cancer or other pelvic malignancies, birth defects, trauma, strictures, neurogenic bladder, chronic infection or intractable cystitis; used as a last resort for incontinence Types: -Cutaneous urinary diversion: ileal conduit, cutaneous ureterostomy, vesicostomy, and nephrostomy -Continent urinary diversion

Patient Learning Needs

Recognition of need for medical treatment Rest Diet and fluid intake Avoid irritating foods (caffeine, carbonated beverages) and very hot and cold foods Perianal skin care Medications May need to avoid milk, fat, whole grains, fresh fruit, and vegetables Lactose intolerance

Interventions

Reduce anxiety; use calm approach and explain all procedures and treatments Promote optimal nutrition. For acute gastritis, the patient should take no food or fluids by mouth; introduce clear liquids and solid foods as prescribed. Evaluate and report symptoms. Discourage caffeinated beverages, alcohol, and cigarette smoking. Refer patient for alcohol counseling and smoking cessation. Promote fluid balance; monitor I&O for signs of dehydration, electrolyte imbalance, and hemorrhage Measures to relieve pain: diet and medications See Chart 37-1

Interventions

Relieve pain -Immobilization -Elevation -Handle with great care and gentleness -Administer prescribed analgesics Improve physical mobility -Activity is restricted -Perform gentle ROM to joints above and below the affected part -Participate in ADLs within limitations

Interventions Compartment Syndrome

Relieve pain Elevate to reduce edema Apply ice or cold intermittently Implement position changes Administer analgesics Unrelieved pain may indicate compartment syndrome; discomfort due to pressure may require change of cast

Billroth II-Gastrojejunostomy

Removal of lower portion (antrum) of stomach with anastomosis to jejunum. Dotted lines show portion removed (antrectomy). A duodenal stump remains and is oversewn. Dumping syndrome, anemia, malabsorption, weight loss. Recurrence rate of ulcer is 10%-15%.

Billroth I-Gastroduodenostomy

Removal of the lower portion of the antrum of the stomach (which contains the cells that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum May be performed in conjunction with a truncal vagotomy. The patient may have problems with feeling of fullness, dumping syndrome, and diarrhea. Recurrence rate of ulcer is 1%.

Manifestations of Increased ICP—Late What is Cushing's Traid?

Respiratory and vasomotor changes VS: increase in systolic blood pressure, widening of pulse pressure, and slowing of the heart rate; pulse may fluctuate rapidly from tachycardia to bradycardia and temperature increase ---Cushing's triad: bradycardia, hypertension, and bradypnea Projectile vomiting Further deterioration of LOC; stupor to coma Hemiplegia, decortication, decerebration, or flaccidity Respiratory pattern alterations including Cheyne-Stokes breathing and arrest Loss of brain stem reflexes: pupil, gag, corneal, and swallowing

Rhythm and Regularity

Rhythm indicates the site of origin of an electrical impulse Rhythm also indicates regularity or irregularity of the waveforms Regularity is determined by comparing distances between P waves and QRS complexes Same distances=regular; different=irregular

Atrial Rhythms

Rhythms that originate in the atria and not at the SA node. THE EPTOPIC BEAT THE RHYTHM STARTS OUTSIDE WHERE IT'S SUPPOSE TO BE.

Nursing Diagnoses—Postoperative for urinary diversions.

Risk for impaired skin integrity Acute pain Disturbed body image Potential for sexual dysfunction Deficient knowledge

Transient Ischemic Attack (TIA)

Temporary neurologic deficit resulting from a temporary impairment of blood flow "Warning of an impending stroke" Diagnostic work-up is required to treat and prevent irreversible deficits

Prostate Cancer

Second most common cancer and the second most common cause of cancer death in men Risk factors include increasing age, familial predisposition, and African American race Manifestations Early disease has few/no symptoms Symptoms include urinary obstruction, blood in urine or semen, and painful ejaculation Symptoms of metastasis may be the first manifestations Early diagnosis is vital; regular health screening is crucial Treatment may include prostatectomy, radiation therapy, hormonal therapy, and/or chemotherapy TEST: 40 YEARS OF AGE IS THE APPROPRIATE AGE FOR SCREENING.

Prevention

See Chart 23-8 Exercises to avoid venous stasis Early ambulation Anticoagulant therapy Sequential compression devices (SCDs) Venous Stasis (slowing of blood flow in veins) • Prolonged immobilization (especially postoperative) • Prolonged periods of sitting/traveling • Varicose veins • Spinal cord injury Hypercoagulability (due to release of tissue thromboplastin after injury/surgery) • Injury • Tumor (pancreatic, gastrointestinal, genitourinary, breast, lung) • Increased platelet count (polycythemia, splenectomy) Venous Endothelial Disease • Thrombophlebitis • Vascular disease • Foreign bodies (IV/central venous catheters) Certain Disease States (combination of stasis, coagulation alterations, and venous injury) • Heart disease (especially heart failure) • Trauma (especially fracture of hip, pelvis, vertebra, lower extremities) • Postoperative state/postpartum period • Diabetes mellitus • Chronic obstructive pulmonary disease (COPD) Other Predisposing Conditions • Advanced age • Obesity • Pregnancy • Oral contraceptive use • History of previous thrombophlebitis, pulmonary embolism • Constrictive clothing

surgical management for peptic ulcers: vagotomy

Severing of the vagus nerve. Decreases gastric acid by diminishing cholinergic stimulation to the parietal cells, making them less responsive to gastrin. May be performed via open surgical approach, laparoscopy, or thoracoscopy May be performed to reduce gastric acid secretion. A drainage type of procedure (see pyloroplasty) is usually performed to assist with gastric emptying (because there is total denervation of the stomach). Some patients experience problems with feeling of fullness, dumping syndrome, diarrhea, and gastritis.

Manifestations

Similar to ischemic stroke Severe headache Early and sudden changes in LOC Vomiting

BPM: SA, AV, bundle of his, bundle branches, and purkinje network.

Sinoatrial (SA) node: a natural pacemaker (60-100bpm) Atrioventricular (AV) node: A junction or gatekeeper, also a backup pacemaker (40-60bpm) Bundle of His: connection between atria and ventricles Bundle Branches: right and left Purkinje network: fibers that continue toward the apex

Rate Rate - The 6 second method

Six-Second Method - quick Large Box Method - best if rhythm is regular Small Box Method - time consuming but accurate Sequence Method (Ruler Method) - easier to use if you have the ruler Locate the 3 second markers on the ECG paper Count number of QRS complexes in 6 second period Multiply by 10

Treatment of Atelectasis

Strategies to improve ventilation and remove secretions Treatments may include PEEP (positive end-expiratory pressure) and IPPB (intermittent positive-pressure breathing). Bronchoscopy may also be used to remove obstruction.

what is the purpose of the incentive spirometer?

The purpose of an incentive spirometer is to ensure that the volume of air inhaled is increased gradually as the patient takes deeper and deeper breaths. Types: volume and flow Device ensures that a volume of air is inhaled and the patient takes deep breaths. Used to prevent or treat atelectasis Nursing care Positioning of patient, teach and encourage use, set realistic goals for the patient, and record the results.

Incontinence: stress, urge, reflex, overflow, functional

Stress incontinence is the involuntary loss of urine through an intact urethra as a result of sneezing, coughing, or changing position Reflex incontinence is an inability to control the release of urine. Reflex incontinence occurs when a person's bladder contracts without the person being able to stop it, causing leakage of urine. Sometimes people find that they cannot stop their bladders from constantly dribbling, or continuing to dribble for some time after they have passed urine. It is as if their bladders were like a constantly overflowing pan, hence the general name overflow incontinence. Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed. The patient is aware of the need to void but is unable to reach a toilet in time. Functional incontinence refers to those instances in which lower urinary tract function is intact but other factors, such as severe cognitive impairment

Nitroglycerin

Sublingual nitroglycerin is generally placed under the tongue or in the cheek (buccal pouch) and ideally alleviates the pain of ischemia within 3 minutes. Nitroglycerin may be given by several routes: sublingual tablet or spray, oral capsule, topical agent, and intravenous (IV) administration. • Recommend that the patient note how long it takes for the nitroglycerin to relieve the discomfort. Advise the patient that if pain persists after taking three sublingual tablets at 5-minute intervals, emergency medical services should be called. • Inform the patient that the medication should be taken in anticipation of any activity that may produce pain. Because nitroglycerin increases tolerance for exercise and stress when taken prophylactically (ie, before anginaproducing activity, such as exercise, stair-climbing, or sexual intercourse), it is best taken before pain develops. • replace every six months and store out of sun. •It usually is not administered if the systolic blood pressure is 90 mm Hg or less. Generally, after the patient is symptom-free, the nitroglycerin may be switched to an oral or topical preparation within 24 hours. extra: Nitrates are an important treatment for angina pectoris. A vasoactive agent, nitroglycerin is administered to reduce myocardial oxygen consumption, which decreases ischemia and relieves pain. Nitroglycerin dilates primarily the veins and, in higher doses, the arteries. Dilation of the veins causes venous pooling of blood throughout the body. As a result, less blood returns to the heart, and filling pressure (preload) is reduced. If the patient is hypovolemic (does not have adequate circulating blood volume), the decrease in filling pressure can cause a significant decrease in cardiac output and blood pressure. Nitrates in higher doses also relax the systemic arteriolar bed, lowering blood pressure and decreasing afterload. These effects decrease myocardial oxygen requirements and increase oxygen supply, bringing about a more favorable balance between supply and demand.

Impaired Tissue Integrity

Suctioning should be done with great care to protect suture lines. Support the head and neck when moving the patient. Assess wound drainage system and empty as required. Assess dressings, wound, and graft condition.

Medical Treatment of Pneumonia

Supportive treatment includes fluids, oxygen for hypoxia, antipyretics, antitussives, decongestants, and antihistamines. Administration of antibiotic therapy is determined by Gram stain results. If the etiologic agent is not identified, use empiric antibiotic therapy. Antibiotics are not indicated for viral infections but are used for secondary bacterial infection.

Care of the Patient Undergoing Surgery of the Hand or Wrist

Surgery is usually an outpatient procedure Patient teaching is a major nursing need for a patient undergoing outpatient surgery Neurovascular assessment is vital: every hour for the first 24 hours assess motor function only as prescribed; instruct patient about signs and symptoms to assess and report

Hysterectomy

Surgical removal of the uterus to treat cancer, dysfunctional uterine bleeding, endometriosis, nonmalignant growths, persistent pain, pelvic relaxation and prolapse, and previous injury to the uterus. Total hysterectomy - uterus and cervix Radical hysterectomy - uterus, tubes and ovary

Clinical Manifestations

Symptoms are due to myocardial ischemia. Symptoms and complications are related to the location and degree of vessel obstruction. Angina pectoris Myocardial infarction Heart failure Sudden cardiac death The most common symptom of myocardial ischemia is chest pain; however, some individuals may be asymptomatic or have atypical symptoms such as weakness, dyspnea, and nausea. Atypical symptoms are more common in women and in persons who are older or who have a history of heart failure or diabetes.

Manifestations of Ischemic Stroke

Symptoms depend upon the location and size of the affected area Numbness or weakness of face, arm, or leg, especially on one side Confusion or change in mental status Trouble speaking or understanding speech Difficulty in walking, dizziness, or loss of balance or coordination Sudden, severe headache Perceptual disturbances

Supraventricular Tachycardia (SVT) IN SVT: HOW DO WE SLOW DOWN THE HEART? HOW IS ADENOSINE INJECTED?

Tachycardias that originate above the bundle of His Rhythm: Regular Rate: 150 - 250 bpm NARROW AND NOT PACED. P waves: May be hidden, atrial P waves may be present (different from sinus P waves) PR interval: If P waves present, usually 0.12-0.20 sec QRS: less than 0.10 sec and NARROW Give them something to slow there heart rate down- beta-blockers, ccb (USE OF IONS) , and other cardiac drugs. Adenosine- natural substance in the body, when injected it stops cardiac activity. It works really fast and metabolizes really quickly Adenosine rapid iv-push (6mg-12mg) Tell the patient "you might feel your heart skip a few beats" Used many times to temporally stop the heart and find out what the real reason is later. THEY WILL SHOCK THE PATIENT AFTERWARDS.

Sensory Stimulation and Communication

Talk to and touch the patient and encourage the family to talk to and touch the patient Maintain normal day-night pattern of activity Orient the patient frequently A patient aroused from coma may experience a period of agitation; minimize stimulation at this time Initiate programs for sensory stimulation Allow family to ventilate and provide support Reinforce and provide consistent information to family Provide referral to support groups and services for the family

Headaches

Tension headaches Tension headaches, the most common type, feel like a constant ache or pressure around the head, especially at the temples or back of the head and neck. Not as severe as migraines, they don't usually cause nausea or vomiting, and they rarely halt daily activities. Cluster or focal headaches, which affect more men than women, are recurring headaches that occur in groups or cycles. They appear suddenly and are characterized by severe, debilitating pain on one side of the head, and are often accompanied by a watery eye and nasal congestion or a runny nose on the same side of the face. When a sinus becomes inflamed, often due to an infection, it can cause pain. It usually comes with a fever and can be diagnosed by symptoms or the presence of pus viewed through a fiber-optic scope. Migraines can run in families and are diagnosed using certain criteria. • At least five previous episodes of headaches • Lasting between 4-72 hours • At least two out of these four: one-sided pain, throbbing pain, moderate-to-severe pain, and pain that interferes with, is worsened by, or prohibits routine activity • At least one associated feature: nausea and/or vomiting, or, if those are not present, then sensitivity to light and sound A migraine may be foreshadowed by aura, such as visual distortions or hand numbness. (About 15% to 20% of people with migraines experience these.)

Acute Nephritic Syndrome:

The acute nephritic syndrome is the clinical manifestation of glomerular inflammation. Glomerulonephritis is an inflammation of the glomerular capillaries that can occur in acute and chronic forms. -Postinfectious glomerulonephritis, rapidly progressive glomerulonephritis, and membranous glomerulonephritis Postinfectious causes are group A betahemolytic streptococcal infection of the throat that precedes the onset of glomerulonephritis by 2 to 3 weeks (Fig. 44-1). It may also follow impetigo (infection of the skin) and acute viral infections (upper respiratory tract infections, mumps, varicella zoster virus, Epstein-Barr virus, hepatitis B, and human immunodeficiency virus [HIV] infection). In some patients, antigens outside the body (eg, medications, foreign serum) initiate the process, resulting in antigen-antibody complexes being deposited in the glomeruli. In other patients, the kidney tissue itself serves as the inciting antigen. -Manifestations include hematuria, edema, azotemia (an abnormal concentration of nitrogenous wastes in the blood), proteinuria, and hypertension "The primary presenting features of an acute glomerular inflammation are hematuria, edema, azotemia, an abnormal concentration of nitrogenous wastes in the blood, and proteinuria or excess protein in the urine" -May be mild, or may progress to acute renal failure -Medical management includes supportive care and dietary modifications; treat cause if appropriate—antibiotics, corticosteroids, and immunosuppressants

Traction

The application of pulling force to a part of the body Purposes: -Reduce muscle spasms -Reduce, align, and immobilize fractures -Reduce deformity Increase space between opposing forces Used as a short-term intervention until other modalities are possible All traction needs to be applied in two directions. The lines of pull are "vectors of force." The result of the pulling force is between the two lines of the vectors of force. Principles of Effective Traction Whenever traction is applied, a counterforce must be applied; frequently the patient's body weight and positioning in bed supply the counterforce Traction must be continuous to reduce and immobilize fractures Skeletal traction is never interrupted Weights are not removed unless intermittent traction is prescribed Any factor that reduces pull must be eliminated Ropes must be unobstructed and weights must hang freely Knots or the footplate must not touch the foot of the bed

Atelectasis

The collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression. Causes include bronchial obstruction by secretions due to impaired cough mechanism or conditions that restrict normal lung expansion on inspiration. Postoperative patients are at high risk for atelectasis. Symptoms are insidious and include cough, sputum production, and a low-grade fever. Respiratory distress, anxiety, and symptoms of hypoxia occur if large areas of the lung are affected.

Guidelines for Care of the Patient With a Tracheostomy Tube: View print out for more.

The cuff of the tracheostomy tube fits smoothly and snugly in the trachea in a way that promotes circulation but seals off the escape of secretions and air surrounding the tube. B, For a dressing change, a 4- by 4-inch gauze pad may be folded (cutting would promote shredding, placing the patient at risk for aspiration) around the tracheostomy tube and C, stabilized by slipping the neck tape ties through the neck plate slots of the tracheostomy tube. The ties may be fastened to the side of the neck to eliminate the discomfort of lying on the knot.

Renal Failure Tx

The goal of management is to maintain kidney function and homeostasis for as long as possible. All factors that contribute to ESRD and all factors that are reversible (eg, obstruction) are identified and treated. Management is accomplished primarily with medications and diet therapy, although dialysis may also be needed to decrease the level of uremic waste products in the blood and to control electrolyte balance. Pharmacologic therapy: calcium and phsophorus binders, antihypertensive and cardiovascular agents, antiseizure agents, erythropoietin. Diet:careful regulation of protein intake, fluid intake to balance fluid losses, sodium intake to balance sodium losses, and some restriction of potassium. At the same time, adequate caloric intake and vitamin supplementation must be ensured. Protein is restricted because urea, uric acid, and organic acids—the breakdown products of dietary and tissue proteins—accumulate rapidly in the blood when there is impaired renal clearance. The allowed protein must be of high biologic value (dairy products, eggs, meats). High-biologic-value proteins are those that are complete proteins and supply the essential amino acids necessary for growth and cell repair. Usually, the fluid allowance per day is 500 mL to 600 mL more than the previous day's 24-hour urine output. Calories are supplied by carbohydrates and fat to prevent wasting. Vitamin supplementation is necessary because a proteinrestricted diet does not provide the necessary complement of vitamins. Additionally, the patient on dialysis may lose water-soluble vitamins during the dialysis treatment. *Hyperkalemia* is usually prevented by ensuring adequate dialysis treatments with potassium removal and careful monitoring of diet, medications, and fluids for their potassium content.

Heart Failure pg 823

The inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients A syndrome characterized by fluid overload or inadequate tissue perfusion The term HF indicates myocardial disease, in which there is a problem with the contraction of the heart (systolic failure) or filling of the heart (diastolic failure). Some cases are reversible. Most HF is a progressive, lifelong disorder managed with lifestyle changes and medications.

Categories of Acute Renal Failure

The major categories of ARF are prerenal (hypoperfusion of kidney), intrarenal (actual damage to kidney tissue), and postrenal (obstruction to urine flow). Prerenal ARF, which occurs in 60% to 70% of cases, is the result of impaired blood flow that leads to hypoperfusion of the kidney and a decrease in the GFR. Intrarenal ARF is the result of actual parenchymal damage to the glomeruli or kidney tubules. Acute tubular necrosis (ATN) is the most common type of intrinsic ARF. Characteristics of ATN are intratubular obstruction, tubular back leak (abnormal reabsorption of filtrate and decreased urine flow through the tubule), vasoconstriction, and changes in glomerular permeability. These processes result in a decrease of GFR, progressive azotemia, and fluid and electrolyte imbalances. CKD, diabetes, heart failure, hypertension, and cirrhosis can lead to ATN (Bednarski, Castner & Douglas, 2008). Postrenal ARF usually results from obstruction distal to the kidney. Pressure rises in the kidney tubules and eventually, the GFR decreases.

Treatment of Epistaxis

The patient sits upright with the head tilted forward to prevent swallowing and aspiration of blood and is directed to pinch the soft outer portion of the nose against the midline septum for 5 or 10 minutes continuously. Topical vasoconstrictors -Phenylephrine -Adrenaline -Cocaine If these two steps fail than: Packing of the nasal cavity or balloon catheter

Monitoring Intracranial Pressure and Cerebral Oxygenation

The purposes of ICP monitoring are to identify increased pressure early in its course (before cerebral damage occurs), to quantify the degree of elevation, to initiate appropriate treatment, to provide access to CSF for sampling and drainage, and to evaluate the effectiveness of treatment. ICP can be monitored with the use of an intraventricular catheter (ventriculostomy), a subarachnoid bolt, an epidural or subdural catheter, or a fiberoptic transducertipped catheter placed in the subdural space or in the ventricle (Fig. 61-3). Intracranial pressure monitoring. A device may be placed in (A) the ventricle (B) the subarachnoid space (C) the intraparenchymal space or (D) the subdural space.

Valvuloplasty

The repair, rather than replacement, of a cardiac valve.

Urinary Tract Infections (UTIs)

The second most common reason for seeking health care -Urinary tract infections (UTIs) are caused by pathogenic microorganisms in the urinary tract (the normal urinary tract is sterile above the urethra). UTIs are generally classified as infections involving the upper or lower urinary tract and further classified as uncomplicated or complicated, depending on other patient-related conditions -A common site of nosocomial infection Lower UTIs Cystitis Prostatitis Urethritis Upper UTIs Pyelonephritis: acute and chronic Interstitial nephritis Renal abscess and perirenal abscess

Colorectal Cancer

The third most common cause of U.S. cancer deaths Risk factors: see Chart 38-8 Importance of screening procedures Manifestations include change in bowel habits; blood in stool—occult, tarry, bleeding; symptoms of obstruction; pain, either abdominal or rectal; feeling of incomplete evacuation Treatment depends upon the stage of the disease Along with an abdominal and rectal examination, the most important diagnostic procedures for cancer of the colon are fecal occult blood testing, barium enema, proctosigmoidoscopy, and colonoscopy (see Chapter 34). The majority of colorectal cancer cases can be identified by colonoscopy with biopsy or cytology smears. Carcinoembryonic antigen (CEA) studies may also be performed. Although CEA may not be a highly reliable indicator in diagnosing colon cancer because not all lesions secrete CEA, studies show that CEA levels are reliable prognostic predictors. With complete excision of the tumor, the elevated levels of CEA should return to normal within 48 hours. Elevations of CEA at a later date suggest recurrence.

how to prevent stomach emptying from dumping syndrome. what position should the be in after meals? how long should they be in this position.

To delay stomach emptying and dumping syndrome, assume low-Fowler's position after meals; lie down for 20 to 30 minutes Take antispasmodics as prescribed Avoid fluid with meals Meals should contain more dry items than liquid items Eat fat as tolerated but keep carbohydrate intake low, and avoid concentrated carbohydrates Eat small frequent meals Take dietary supplements as prescribed: vitamins, medium-chain triglycerides, and B12 injections

Asystole (Cardiac Standstill)

Total absence of ventricular electrical activity. Rhythm: atrial rate may be discernible; may be regular or irregular Rate: no ventricular rate P waves: shape varies depending on origin; may be absent PR interval: n/a QRS: n/a

Esophageal Reconstruction with Free Jejunal Transfer

Tx for throat cancer: Esophageal reconstruction with free jejunal transfer. A portion of the jejunum is grafted between the esophagus and pharynx to replace the abnormal portion of the esophagus. The vascular structures are also anastomosed.

Patient Teaching

Understanding of disease process Nutrition/diet Medications Information sources: National Foundation for Ileitis and Colitis Ileostomy care if applicable: • Demonstrate ostomy care, including wound cleansing, irrigation, and appliance changing. ✔ ✔ • Describe the importance of maintaining peristomal skin integrity. ✔ ✔ • Identify sources for obtaining additional dressing and appliance supplies. ✔ ✔ • Identify dietary restrictions (foods that can cause diarrhea and constipation). ✔ ✔ • Identify measures to be used to promote fluid and electrolyte balance. ✔ ✔ • Describe medication regimen: identify medications by name, use, route, and frequency. ✔ ✔ • Describe potential complications and necessary actions to be taken if complications occur. ✔ ✔ • Identify how to contact wound-ostomy-continence or home health nurse.

Factors Contributing to UTI

Urethrovesical reflux-which is the reflux (backward flow) of urine from the urethra into the bladder Ureterovesical reflux- refers to the backward flow of urine from the bladder into one or both ureters Uropathogenic bacteria Shorter urethra in women Mechanisms of urethrovesical and ureterovesical reflux may cause urinary tract infection. Urethrovesical reflux: With coughing and straining, bladder pressure rises, which may force urine from the bladder into the urethra. A, When bladder pressure returns to normal, the urine flows back to the bladder (B), which introduces bacteria from the urethra to the bladder. Ureterovesical reflux: With failure of the ureterovesical valve, urine moves up the ureters during voiding (C) and flows into the bladder when voiding stops (D). This prevents complete emptying of the bladder. It also leads to urinary stasis and contamination of the ureters with bacteria-laden urine. risk factors in older adults: • High incidence of multiple chronic medical conditions • Frequent use of antimicrobial agents • Presence of infected pressure ulcers • Immunocompromise • Cognitive impairment • Immobility and incomplete emptying of bladder • Use of a bedpan rather than a commode or toilet

Assessment

Urinary function and symptoms Sexual function and manifestations of sexual dysfunction Symptoms related to urinary obstruction-- assessment begins with urinary function -Increased urinary frequency -Decreased force of stream -"Double" or "triple" voiding -Nocturia, dysuria, hematuria, and hematospermia (blood in the sperm) Medications(eg, antihypertensive and anticholesterolemic medications, psychotropic agents), drug, and alcohol use Presence of conditions that may affect sexual function (diabetes, cardiac disease, and multiple sclerosis)

...

Used to treat spontaneous and traumatic pneumothorax Used postop to re-expand the lung & remove excess air, fluid, blood Types of drainage systems -Traditional water seal -Dry suction water seal -Dry suction Management Prevention of cardiopulmonary complications

Nursing Process Ischemic and Hemorrhagic

VIEW PRINT OUT

Tx for incontinence

VIEW PRINT OUT

Ventricular Rhythms: what shape does the QRS take on.

Ventricles generate impulses at a rate of 20-40 bpm Assumes pacing responsibility if SA node fails Impulse blocked as it exits SA node Rate of SA node is < that of ventricles Irritable site in the ventricles Characterized by abnormal QRS complexes that are prolonged (greater than 0.12 sec) Also said qrs is wide. When it is wide the origin of the pacemaker is in the ventricular. The heart will not contract the right way. It's like contracting a muscle with only half the strong and going the wrong way.

Analyzing a Rhythm Strip

What is the rate? Determine ventricular rate (R-R intervals) Determine atrial rate (P-P intervals) A "tachycardia" exists if rate is >100 bpm A "bradycardia" exists if rate is <60 bpm

Tissue (biologic) valves

Xenograft (heterograft): pig or cow valve Homograft (allograft): human valve Autograft: patient's own valve

Empyema

accumulation of thick, purulent fluid in the pleural space -Patient is usually acutely ill. Fluid, fibrin development, and loculation will impair lung expansion. Resolution is a prolonged process.

tracheostomy collars, and face tents

all of which are used with aerosol devices (nebulizers) that can be adjusted for oxygen concentrations from 27% to 100% (0.27 to 1.00).

Pleurisy

an inflammation of both layers of the pleurae -Inflamed surfaces rub together with respirations and cause sharp pain that is intensified with inspiration.

Unclassified cardiomyopathies

are different from or have characteristics of more than one of the previously described types

Non-rebreathing masks

are similar in design to partialrebreathing masks except that they have additional valves. A one-way valve located between the reservoir bag and the base of the mask allows gas from the reservoir bag to enter the mask on inhalation but prevents gas in the mask from flowing back into the reservoir bag during exhalation. One-way valves located at the exhalation ports prevent room air from entering the mask during inhalation. They also allow the patient's exhaled gases to exit the mask on exhalation.

Simple masks. used for?

are used to administer low to moderate concentrations of oxygen. The body of the mask itself gathers and stores oxygen between breaths. The patient exhales directly through openings or ports in the body of the mask. If oxygen flow ceases, the patient can draw air in through these openings around the mask edges. don't put on too tight.

stupor

arousal for short periods from stimuli. requires some painful stimuli to wake- a very annoying, pinching, twist skin, etc.

altered level of consciousness

condition of being less responsive to and aware of environmental stimuli Level of responsiveness and consciousness is the most important indicator of the patient's condition LOC is a continuum from normal alertness and full cognition (consciousness) to coma Altered LOC is not the disorder but the result of a pathology

delirium

confusion with disordered perception and deccreased attention span

The T-piece

connects to the endotracheal tube and is useful in weaning patients from mechanical ventilation.

Interventions: others

controlling anxiety: minimize workload, administer oxygen, along with reassurance the nurse can teach patient ways to manage there anxiety, restraints should be avoided, patient may sit in chair at night if it helps lower anxiety, and look for signs of depression. Minimizing powerlessness: be reassured, take time to listen, encourage them to make food and fluid choices

lethargy

drowsy, falls asleep quickly

Hypospadias and epispadias Phimosis Penile cancer Bowen's disease Priapism Peyronie's disease Urethral stricture Circumcision

epididymitis: infection of the epididymis that usually descends from an infected prostate or urinary tract; also may develop as a complication of gonorrhea phimosis: condition in which the foreskin is constricted so that it cannot be retracted over the glans; can occur congenitally or from inflammation and edema penile cancer: malignancy that can involve the glans, the body of the penis, the urethra, and regional or distant lymph nodes priapism: an uncontrolled, persistent erection of the penis from either neural or vascular causes, including medications, sickle cell thrombosis, leukemic cell infiltration, spinal cord tumors, and tumor invasion of the penis or its vessels Peyronie's disease: buildup of fibrous plaques in the sheath of the corpus cavernosum, causing curvature of the penis when it is erect circumcision: excision of the foreskin, or prepuce, of the glans penis Bowen's disease (BD) (also known as "squamous cell carcinoma in situ"[1]:655) is a neoplastic skin disease, it can be considered as an early stage or intraepidermal form of squamous cell carcinoma. Urethral stricture is an abnormal narrowing of the tube that carries urine out of the body from the bladder (urethra). Symptoms: Blood in the semen; Bloody or dark urine; Decreased urine output; Difficulty urinating;

Leaflet repair

for elongated, ballooning, or other excess tissue leaflets is removal of the extra tissue. The elongated tissue may be folded over onto itself (ie, tucked) and sutured (ie, leaflet plication). A wedge of tissue may be cut from the middle of the leaflet and the gap sutured closed (ie, leaflet resection)

Partial-rebreathing masks

have a reservoir bag that must remain inflated during both inspiration and expiration. The nurse adjusts the oxygen flow to ensure that the bag does not collapse during inhalation. A high concentration of oxygen can be delivered because both the mask and the bag serve as reservoirs for oxygen.

Confusion

inappropriate response to questions

Decerebrate posturing,

involving extension and outward rotation of upper extremities and plantar flexion of the feet.

restrictive cardiomyopathy

is characterized by diastolic dysfunction caused by rigid ventricular walls that impair diastolic filling and ventricular stretch (see Fig. 29-8). Systolic function is usually normal. may be associated with amyloidosis (amyloid, a protein substance, is deposited within cells) and other such infiltrative diseases.

Dilated cardiomyopathy

is distinguished by significant dilation of the ventricles without simultaneous hypertrophy (ie, increased muscle wall thickness) and systolic dysfunction (Fig. 29-8). The ventricles have elevated systolic and diastolic volumes but a decreased ejection fraction.

The Venturi mask. who is it used for? how should it fit? when should it be removed and what should be placed on patient if it is?

is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. It is used primarily for patients with COPD because it can accurately provide appropriate levels of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. -The mask should fit snugly enough to prevent oxygen from flowing into the patient's eyes. The nurse checks the patient's skin for irritation. - It is necessary to remove the mask so that the patient can eat, drink, and take medications, at which time supplemental oxygen is provided through a nasal cannula.

A commissurotomy

is the procedure performed to separate the fused leaflets

Annuloplasty. it's a useful treatment for what valve problem?

is the repair of the valve annulus (ie, junction of the valve leaflets and the muscular heart wall). General anesthesia and cardiopulmonary bypass are required for all annuloplasties. The procedure narrows the diameter of the valve's orifice and is useful for the treatment of valvular regurgitation.

comatose

neither awake nor aware. completely unable to wake up. prolonged state of unconsciousness. unconsciousness, unresponsiveness, and inability to arouse

Arrhythmogenic cardiomyopathy

occurs when the myocardium of the right ventricle is progressively infiltrated and replaced by fibrous scar and adipose tissue. Initially, only localized areas of the right ventricle are affected, but as the disease progresses, the entire heart is affected. Eventually, the right ventricle dilates and develops poor contractility, right ventricular wall abnormalities, and dysrhythmias.

Coronary Vascular Disorder

pg 755 Cardiovascular disease is the leading cause of death in the United States for men and women of all racial and ethnic groups. CAD (coronary artery disease) is the most prevalent cardiovascular disease in adults.

Decorticate Posturing

posturing and flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet.

Pericarditis

refers to an inflammation of the pericardium, the membranous sac enveloping the heart. It may be a primary illness or it may develop during various medical and surgical disorders. For example, pericarditis may occur after pericardectomy (opening of the pericardium) following cardiac surgery

Chordoplasty

repair of the chordae tendineae. The mitral valve is involved with chordoplasty (because it has chordae tendineae); the tricuspid valve seldom requires chordoplasty. Stretched, torn, or shortened chordae tendineae may cause regurgitation. Stretched chordae tendineae can be shortened, transposed to the other leaflet, or replaced with synthetic chordae

Obtunded

requires some tactile stimuli to wake them up- shake there arm with voice.

Hypertrophic cardiomyopathy

the heart muscle asymmetrically increases in size and mass, especially along the septum (see Fig. 29-8). HCM often affects nonadjacent areas of the ventricle. The increased thickness of the heart muscle reduces the size of the ventricular cavities and causes the ventricles to take a longer time to relax after systole.

Valve prolapse

the stretching of an atrioventricular valve leaflet into the atrium during diastole

Regurgitation

the valve does not close properly and blood backflows through the valve

Stenosis

the valve does not open completely and blood flow through the valve is reduced

HEALTH PROMOTION Preventing Constipation

• Emphasize the importance of responding to the urge to defecate. • Teach how to establish a bowel routine, and explain that having a regular time for defecation (eg, best time is after a meal) may aid in initiating the reflex. • Provide dietary information; suggest eating high-residue, high-fiber foods, (eg, fruits, vegetables) adding bran daily (must be introduced gradually), and increasing fluid intake (unless contraindicated). • Explain how an exercise regimen, increased ambulation, and abdominal muscle toning will increase muscle strength and help propel colon contents. • Describe abdominal toning exercises (contracting abdominal muscles 4 times daily and leg-to-chest lifts 10 to 20 times each day). • Explain that the normal position (semisquatting) maximizes use of abdominal muscles and force of gravity. • Avoid overuse or long-term use of stimulant laxatives (eg, bisacodyl) because they can weaken colonic function.

Eligibility Criteria for t-PA Administration

• Age 18 years or older • Clinical diagnosis of ischemic stroke • *Time of onset of stroke known and is 3 hours or less* • Systolic blood pressure 185 mm Hg; diastolic 110 mm Hg • Not a minor stroke or rapidly resolving stroke • No seizure at onset of stroke • Not taking warfarin (Coumadin) • Prothrombin time 15 seconds or INR 1.7 • Not receiving heparin during the past 48 hours with elevated partial thromboplastin time • Platelet count 100,000/mm3 • No prior intracranial hemorrhage, neoplasm, arteriovenous malformation, or aneurysm • No major surgical procedures within 14 days • No stroke, serious head injury, or intracranial surgery within 3 months • No gastrointestinal or urinary bleeding within 21 days

ED medication

• Antiadrenergics and antihypertensives: guanethidine (Ismelin), clonidine (Catapres), hydralazine (Apresoline), metoprolol (Lopressor) • Anticholinergics and phenothiazines: prochlorperazine (Compazine), trihexyphenidyl (Artane) • Antiseizure agents: carbamazepine (Tegretol) • Antifungals: ketoconazole (Nizoral) • Antihormone (prostate cancer treatment): flutamide (Eulexin), leuprolide (Lupron) • Antipsychotics: haloperidol (Haldol), chlorpromazine (Thorazine) • Antispasmodics: oxybutynin (Ditropan) • Anxiolytics, sedative-hypnotics, tranquilizers: lorazepam (Ativan), triazolam (Halcion) • Beta-blockers: nadolol (Corgard) • Calcium channel blockers: nifedipine (Adalat, Procardia) • Carbonic anhydrase inhibitors: acetazolamide (Diamox) • H2 antagonists: nizatidine (Axid) • Nonsteroidal anti-inflammatory drugs: naproxen (Naprosyn) • Diuretics: hydrochlorothiazide (HydroDIURIL), furosemide (Lasix), spironolactone (Aldactone) • Antidepressants: tricyclic antidepressants: amitriptyline (Elavil), desipramine (Norpramin); selective serotonin reuptake inhibitors: fluoxetine (Prozac), sertraline (Zoloft) • Parkinson's disease medications: levodopa (Sinemet) • Antihistamines: diphenhydramine (Benadryl)

kidney stones: patient teaching

• Avoid protein intake; usually protein is restricted to 60 g/day to decrease urinary excretion of calcium and uric acid. • A sodium intake of 3 to 4 g/day is recommended. Table salt and high-sodium foods should be reduced, because sodium competes with calcium for reabsorption in the kidneys. • Low-calcium diets are not generally recommended, except for true absorptive hypercalciuria. Evidence shows that limiting calcium, especially in women, can lead to osteoporosis and does not prevent renal stones. • Avoid intake of oxalate-containing foods (eg, spinach, strawberries, rhubarb, tea, peanuts, wheat bran). • During the day, drink fluids (ideally water) every 1 to 2 hours. • Drink two glasses of water at bedtime and an additional glass at each nighttime awakening to prevent urine from becoming too concentrated during the night. • Avoid activities leading to sudden increases in environmental temperatures that may cause excessive sweating and dehydration. • Contact your primary health care provider at the first sign of a urinary tract infection.

Risk Factors for Colorectal Cancer

• Increasing age • Family history of colon cancer or polyps • Previous colon cancer or adenomatous polyps • High consumption of alcohol • Cigarette smoking • Obesity • History of gastrectomy • History of inflammatory bowel disease • High-fat, high-protein (with high intake of beef), low-fiber diet • Genital cancer (eg, endometrial cancer, ovarian cancer) or breast cancer (in women) Regular screening, beginning at age 50, is the key to preventing colorectal cancer.1 The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer using high-sensitivity fecal occult blood testing, sigmoidoscopy, or colonoscopy beginning at age 50 years and continuing until age 75 years.1

Aspiration

• Seizure activity • Brain injury • Decreased level of consciousness from trauma, drug or alcohol intoxication, excessive sedation, or general anesthesia • Nausea and vomiting in the patient with a decreased level of consciousness • Endotracheal intubation; tube malposition; high residual volumes • Flat body positioning • Stroke • Swallowing disorders • Cardiac arrest • Silent aspiration When a nonfunctioning nasogastric tube allows the gastric contents to accumulate in the stomach, a condition known as silent aspiration may result. Silent aspiration often occurs unobserved and may be more common than suspected. If untreated, massive inhalation of gastric contents develops in a period of several hours. Prevention: Several preventive interventions, including positioning, dietary changes, drugs, oral hygiene, and tube feeding, have been proposed, especially for elderly patients. Compensating for Absent Reflexes Assessing Feeding Tube Placement Identifying Delayed Stomach Emptying Managing Effects of Prolonged Intubation

Purposes of GI Intubation

• To decompress the stomach and remove gas and fluid • To lavage (flush with water or other fluids) the stomach and remove ingested toxins or other harmful materials • To diagnose disorders of GI motility and other disorders • To administer medications and feedings • To compress a bleeding site • To aspirate gastric contents for analysis

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