Medical Surgical Nursing- Chapter 4 HESI

Safety

Hint: Safety is a priority with all clients. Ascertain the use of complementary therapies by addressing contraindications and side effects. Safety includes safe handoff, interprofessional communication, fall prevention, assessing, and reporting changes in conditions, as well as responses to treatments and medications

Amputations

Surgical removal of a diseased part or organ *peripheral vascular disease, 80% {75% of these are clients with diabetes] Hint: The residual limb (stump) should be elevated on one pillow. If the residual limb (stump) is elevated too high, the elevation can cause contracture (only for the first 24 hrs) after 48 hrs do not elevate residual stump, keep in extended position and turn to prone position 3 times a day to prevent hip flexion contracture -Be aware the phantom pain is real, it will eventually disappear, and it responds to pain medication

Lung Cancer

- Lung cancer is the leading cause of cancer-related deaths in the United States -exposure to occupational hazards such as asbestos and radioactive dust poses significant risk. -cigarette smoking is responsible for 80%-90% of all lung cancers -it tends to appear years after exposure, most commonly at 50 or 60 yrs - has a poor prognosis Hint: Some tumors are so large that they fill entire lobes of the lung. When removed, large spaces are left. Chest tubes are not usually used with these clients because it is helpful if the cavity, where the lung used to be, fills up with fluid. This fluid helps to prevent the shift of the remaining chest organs to fill the empty space. - position client on operative side or back Hint: Various pathophysiologic conditions can be related to the nursing diagnosis: *Ineffective breathing patterns*: 1. inability of air sacs to fill and empty properly (emphysema, cystic fibrosis) 2. obstruction of the air passages (carcinoma, asthma, chronic bronchitis) 3. accumulation of fluid in the air sacs (pneumonia) 4. respiratory muscle fatigue (COPD, pneumonia)

Benign Prostatic Hyperplasia (BPH)

-BPH tends to occur in men over 40 years of age 3 treatment approaches: -active surveillance (watchful waiting) -drug therapy with 5-alpha reductase inhibitors such as finasterine (Proscar) and alpha-adrenergic receptor blockers (tamsulosin) -surgery (TURP): most common and prostate is removed by endoscopy Hint: Bladder spasms frequently occur after TURP. The catheter may cause a continuous sensation of bladder fullness. The client should not try to void around the catheter because bladder spasms may occur. Client can request medication to reduce or prevent spasms Hint: Instillation of hypertonic or hypotonic solution into a body cavity will cause a shift in cellular fluid. Use only sterile saline for bladder irrigation after TURP because the irrigation must be isotonic to prevent fluid and electrolyte imbalance. Clients with Foley catheters require perineal care and Foley catheter care twice per day *normal drainage after prostate surgery is reddish pink, clearing to light pink within 24 hours after surgery. Some small to medium-sized blood clots may be present. Monitor for bright-red bleeding with large clots and increased viscosity Hint: Inform the client before discharge that some bleeding is expected after TURP. Large amounts of blood or flank bright bleeding should be reported. However, it is normal for the client to pass small amounts of blood, as well as small blood clots, during the healing process. He should rest quietly and continue drinking large amount of fluid (3000ml/day or 12-14 glasses of water/day)

Gastrointestinal System Hiatial Hernia and Gastroesophageal Reflux Disease

-Hiatial hernia is a herniation of the esophagogastric junction and a portion of the stomach into the chest through the esophageal hiatus of the diaphragm. Sliding hernia is the most common -Gastroesophageal reflux disease (GERD) is the result of an incompetent lower esophageal spincher that allows regurgitation of acidic gastric contents into the esophagus. medications: PPI ending in azole -encourage small frequent meals -avoid caffeine, catsup, strawberries, and chocolate -encourage client to sit up while eating and remain in an upright position for at least 1 hr after eating -stop eating 3 hours before bedtime -elevate bed on 6-8 inch blocks Hint: A Fowler or semi-Fowler position is beneficial in reducing the amount of regurgitation, as well as in preventing the encroachment of the stomach tissue upward through the opening in the diaphragm

Spinal Cord Injury

-Permanent impairment cannot be determined until spinal cord edema has subsided, usually by 1 week Hint: Physical assessment should concentrate on respiratory status, especially clients with injury at C3 to C5, because cervical plexus innervates the diaphragm Hint: it is imperative to reverse spinal shock as quickly as possible. Permanent paralysis can occur if a spinal cord is compressed for 12-24 hrs Evaluate for presence of spinal shock ( a complete loss of all reflex, motor, sensory, and autonomic activity below the lesion). This is a medical emergency that occurs immediately after the injury -hypotension, Bradycardia -complete paralysis and lack of sensation below the lesion -bowel and bladder distention Hint: A common cause of death after spinal cord injury is urinary tract infection. Bacteria grow best in alkaline media, so keeping urine dilute and acidic is prophylactic against infection. Also keep the bladder emptied assists in avoiding bacterial growth in urine that has stagnated in the bladder Fluids that promote acidic urine: cranberry juice, prune juice, bullion, tomato juice and water -Maintain client in an extended position with cervical collar on during any transfer Evaluate for autonomic dysreflexia (exaggerated autonomic responses stimuli), which occurs in clients with lesions at or T6.Medical emergency that usually occurs after the period of spinal shock has finished and usually triggered by a noxious stimulus such as bowel or bladder distention. -Elevated BP, pudding headache, sweating, nasal congestion, goosebumps, bradycardia,, bladder and bowel distention *administer high dose c.orticosteroids to decrease edema and reduce cord damage

Cancer of the Cervix

-Some cervical cancer are directly linked to the human papillomavirus (HPV) -Young women between 9-30 years are encouraged to be immunized with the intramuscular HPV injection - All women should be tested for HPV, and women over 21 yrs of age and those who have engaged in sexual intercourse for at least 3 years should continue to have yearly Papanicolaou (PAP) test -The precursor of cancer of the cervix is dysplasia (presence of abnormal type within a tissue) Hint: Laser therapy or cryosurgery is used to treat cervical cancer when the lesion is small and localized. Invasive cancer is treated with radiation, ionization, hysterectomy, or pelvic exenteration [a drastic surgical procedure where the uterus, ovaries, Fallopian tubes, vagina, rectum and bladder are removed in an attempt to stop metastasis]. Chemotherapy is not useful for this type of cancer Hint: Pap smears recommendations: women aged 30-65 years, annual cervical cancer screening should not be performed. Patients should be counseled that annual well-woman visits are recommended even if cervical cancer screening is not performed at each visit. Every three years is the recommended time frame for Pap smears. Women ages 30-65 years should have a Pap smear with an HPV test every 5 years. Women over 65 do not need Pap smear. Pap smears should not be performed for any woman under age 21 regardless of onset of sexual activity *care for the patient with radiation implants pg 179

Spiritual Assessment

A spiritual assessment tool may assist the nurse to integrate a spiritual assessment into the clients plan of care. FICA= Faith and Belief: Importance, Community, and address in Care.

Diabetes Mellitus (DM)

A metabolic disorder characterized by high levels of glucose resulting from defects in insulin secretion, insulin action, or both Four ways to diagnose DM: 1. Fasting plasma glucose greater tan or equal to 126 mg/dL 2. Glycosylated Hgb [HbA1C] grater than or equal to 6.5% 3. Random blood glucose greater than or equal to 200 mg/dL in a client with classic symptoms of hyperglycemia 4. Oral glucose tolerance test greater than 200 *use plasma glucose, not fingesticks to diagnose diabetes **see chart on page 136** Type 1: results from B-cell destruction Type 2: results from progressive secretory insulin deficit and or defect in insulin uptake Gestational diabetes Prediabetes: blood glucose levels when fasting are 100-125 mg/dL or HbA1c of 5.7-6.4 -obesity is a major risk factor in type 2 DM Teach diet regimen: 45-50% carbohydrates 15-20% protein 30% or less fat Hint: Why do clients with diabetes have trouble with wound healing? High blood glucose contributes to damage of the smallest vessels, the capillaries. This damage causes permanent capillary scarring, which inhibits the normal activity of the capillary. This phenomenon causes disruption of capillary elasticity and promotes problems such as diabetic retinopathy, poor healing of breaks in the skin, and cardiovascular abnormalities Hint: Glycosylated Hgb (HbA1c) -indicates glucose control over 90-120 days (life of the red blood cells -is a valuable measurement of diabetes control -informs diagnosis of diabetes or prediabetes Hint: the body's response to illness and stress is to produce glucose. Therefore any illness results in hyperglycemia Hint: if in doubt whether a client is hyperglycemic or hypoglycemic, treat for hypoglycemia Hint: SELF-MONITORING OF BLOOD GLUCOSE (SMBG) -uses techniques that are specific to each meter - frequency of monitoring based on treatment regimen, change in meals, illness and exercise regimen -requires recording results and reporting results to health care provider at time of visit -results of monitoring used to assess the efficacy of therapy and to guide adjustments in medical nutrition therapy, exercise, and medication to achieve the best possible blood glucose control Hint: Insulin is prescribed in basal/bolus and correction factor therapy. The goal of insulin therapy is to mimic the body's normal basal/bolus secretion of insulin. Basal insulin (long-acting and intermediate acting insulin) surpasses glucose production between meals and overnight. Bolus insulin or mealtime limits hyperglycemia after meals, Correction factor is the amount of insulin needed to correct hyperglycemia, usually given before a meal.

Acute Kidney Injury

A potentially reversible disorder, it is a rapid loss of kidney function accompanied by a rise in serum creatinine and/or a reduction in urine output. Hint: Normally, kidneys excrete approximately 1 mL of urine per Kg of body weight per hour. For adults, total daily urine output ranges between 1500 and 2000 mL depending on the amount and type of fluid intake, amount of perspiration, environmental or ambient temperature, and the presence of vomiting or diarrhea. Hint: Electrolytes are profoundly affected by kidney problems (a favorite NCLEX-RN topic). There must be a balance between extracellular fluid and intracellular fluid to maintain homeostasis. A change in the number of ions or in the amount of fluid will cause a shift in one direction or the other. Sodium and chloride are primarily extracellular ions. Potassium and phosphate are the primary intracellular ions. Hint: In some cases, persons in AKI may not experience the oliguric phase but may progress directly to the diuretic phase, during which the urine output may be as much as 10L per day -three phases of AKI: 1. Oliguric phase 2. Diuretic phase 3. Recovery phase Hint: Clients at risk for developing AKI in the acute care setting are those with chronic kidney disease (CKD), older age, massive trauma, major surgical procedures, extensive burns, cardiac failure, sepsis, or obstetric complications Hint: Watch for signs of hyperkalemia: dizziness, weakness, cardiac irregularities, muscle cramps, diarrhea, and nausea *Potassium restriction and measures to lower potassium (if elevated). Sodium polystyrene (Kayexalate) may be prescribed if K+ is too elevated Hint: Potassium has a critical safe range (3.5 to 5.0 mEq/L) because it affects the heart, and any imbalance must be corrected by medications or dietary modifications. Limit high-potassium foods (bananas, orange juice, cantaloupe, strawberries, avocados, spinach, fish) and salt substitutes, which are high in potassium. Hint: Clients with renal failure retain sodium. With water retention, the sodium becomes diluted and serum levels may appear near normal. With excessive water retention, the sodium levels appear decreased (dilution). Limit fluid and sodium intake in AKI clients Hint: Body weight is a good indicator of fluid retention and renal status. Obtain accurate weights of all clients with renal failure; obtain weight on the same scale at the same time everyday. Hint: FLUID VOLUME ALTERATIONS- *Excess fluid: Dyspnea, weight gain, tachycardia, jugular vein distention, peripheral edema, elevated BP, signs and symptoms of pulmonary edema, weight gain *Fluid-Deficient: decreased urine output, reduction in body weight, decreased skin turgor, dry mucus membranes, hypotension, tachycardia, weight loss Hint: during the oliguric phase, minimize protein breakdown and prevent rise in BUN by limiting protein intake. When the BUN and creatinine return to normal, acute renal failure (ARF) is determined to be resolved. adequate protein intake (0.6- 2 g/kg/day) depending on the degree of catabolism

Parkinson Disease

Affects motor activity characterized by tremor at rest, increased muscle tone (rigidity), slowness in the initiation and execution of movements (bradykinesia) and postural instability(difficulties with gait and balance Hint: NCLEX- RN questions often focus on the features of Parkinson disease: tremors (a coarse tremor of fingers and thumb on one hand that disappears during sleep and purposeful activity; also called "pill rolling", rigidity, hypertonicity, and stooped posture. Focus: SAFETY Hint: an important aspect of treatment for Parkinson disease is drug therapy. The pathophysiology involves an imbalance between acetylcholine and dopamine, so symptoms can be controlled by administering a dopamine precursor (levodopa)

Fracture

Any break in the continuity of the bone Hint: What type of fracture is more difficult to heal: an extracapsular fracture (below the neck of the femur) or an intracapsular fracture (in the neck of the femur)? The blood supply enters the femur below the neck of the femur. therefore an intracapsular fracture heals with greater difficulty, and there is a greater likelihood that necrosis will occur because the fracture is cut off from the blood supply *chart with types of fractures p146 Hint: NCLEX-RN questions focus on safety precautions. Improper use of assistive devices can be very risky. When using a non wheeled walker, the client should lift and move the walker forward and then take a step into it. The client should avoid scooting the walker or shuffling forward into it; these movements take more energy and provide less stability than does a single movement -crutches: a three point gait is most common. The client advances both crutches and the impaired leg at the same time. The client then swings the uninvolved leg ahead to the crutches -cane: it is placed on the unaffected side. The top of the cane should be at the level of the greater trochanter Hint: The risk for development of a fat embolism, a syndrome in which fat globules migrate into the bloodstream and combine with platelets to form emboli, is greatest in the first 36 hrs after a fracture. It is more common in clients with multiple fractures, fractures of long bones, and fractures of the pelvis. The initial sign of fat embolism is confusion due to hypoxemia (check blood gases for PO2). Assess for respiratory distress,restlessness, irritability, fever, and petechiae. If a embolus is suspected, notify the physician stat, draw blood gases, administer O2, and assist with endotracheal intubation Hint: In client with hip fractures, thromboembolism is the most common complication. Prevention includes passive ROM exercises, use of elastic stockings, elevation of the foot of the bed 25 degrees to increase venous return, and low dose heparin therapy Hint: Clients with fractures, edema, or casts on the extremities need frequent neurovascular assessment distal to the injury. Skin color, temperature, sensation, capillary refill, mobility, pain, and pulses should be assessed Hint: Assess the 5 P's of neurovascular functioning: pain, paresthesia, pulse, pallor, and paralysis

Head Injury

Any traumatic damage to the head Hint: The forces of impact influence the type of traumatic brain injury (TBI). The include acceleration injury, which is caused by the head being in motion, and deceleration injury, which occurs when the head stops suddenly. Helmets are a great preventive measure for motorcyclists and bicyclists Hint: Even subtle behavior changes, such as restlessness, irritability, or confusion, may indicate increased ICP *Change in the level of responsiveness is the most important indicator of increases ICP* Hint: cerebrospinal fluid (CSF) leakage carries the risk for meningitis and indicates a deteriorating condition. Because of CSF leakage, the usual signs of increased ICP may not occur. Avoid activities that increase ICP such as: 1. Change in bed position for caregiving and extreme him flexion 2. Endotracheal suctioning 3. compression of jugular veins (keep head straight and not to one side) 4. coughing, vomiting, or straining of any type (no Valsalva: increased intrathoracic pressure increases ICP) * elevation of ICP over 20 mm Hg should be reported STAT Hint: try not to use restrains; they only increase restlessness. Avoid narcotics because they mask the level of responsiveness Medications to reduce ICP: 1. Hyperosmotic agents and diuretics to dehydrate brain and reduce cerebral edema: a.Mannitol pg158 b.Urea 2. Steroids a.Dexamethasone b. methylprednisolone sodium succinate, to reduce edema 3. Barbiturates a. to reduce brain metabolism and systemic BP

Benign Tumors of the Uterus

Arising from the muscle tissue of the uterus -more common in women who have never been pregnant -Most common symptom is abnormal uterine bleeding (menorrhagia) Hint: Menorrhagia (profuse or prolonged menstrual bleeding) is the most important factor relating to benign uterine tumors. Assess for signs of anemia

Hearing Loss

CONDUCTIVE HEARING LOSS -sound does not travel well to the sound organs of the inner ear. The volume of sound is less, but the sound remains clear. If volume is raised, hearing is normal - it usually results from cerumen (wax) impaction or middle ear disorders such as otitis media Hint: The ear consists of three parts: the external ear, the middle ear, and the inner ear. Inner ear disorders, or disorders of the sensory fibers going to the central nervous system (CNS), often are neurogenic in nature and may not be helped with a hearing aid. External and middle ear problems (conductive) may result from infection, trauma or wax buildup. These types of disorders are treated more successfully with hearing aids SENSORY NEURAL HEARING LOSS -form of hearing loss in which sound passes properly through the outer ear and middle ear but is distorted by a defect in the inner ear or damage to cranial nerve VIII or both -detected easily by the use of a tuning fork -causes: infections, ototoxic drugs, trauma, neuromas, noise, aging process Hint: NCLEX-RN questions often focus on communicating with older adults who are hearing impaired: -speak in a low-pitched voice, slowly and distinctly -stand in front of the person, with the light source behind the patient -use visual aids is available

Ovarian Cancer

Can occur at all ages, including infancy and childhood Hint: The major emphasis in nursing management of cancers of the reproductive tract is early detection

Cataracts

Characterized by opacity of the lens -leading cause of blindness -aging accounts for 95% of cataracts -Surgical removal is done when vision impairment interferes with daily activities. Intraocular lens implants may be used Hint: The lens of the eye is responsible for projecting light onto the retina so that images can be discerned. Without the lens, which becomes opaque with cataracts, light cannot be filtered and vision is blurred Early signs: Blurred vision, decreased color perception, photophobia Late signs: diplopia, reduced visual acuity- progressing to blindness, clouded pupil- progressing to a milky-white appearance Hint: When the cataract is removed, the lens is gone, making prevention of falls important. When the lens is replaced with an implant, vision is better *post operative teaching pg 153*

Cholecystitis/Cholelithiasis

Cholecystitis: acute inflammation of the gall bladder Cholelithiasis: formation or presence of stones in the gall bladder -incidence of these diseases is greater in females who are multiparous and overweight -treatment for cholelithiasis consists of IV hydration, and administration of antibiotics, and pain control with morphine or NSAIDS; anticholinergics are administered to decrease smooth muscle spasms Hint: After an Endoscopic retrograde cholangiopancreatography (ERCP), the client may feel sick. The scope is placed in the gallbladder, the stones are crushed and left to pass on their own. These patients maybe prone to pancreatitis Hint: Nonsurgical management of a client with cholecystitis include: -low-fat diet -decompression of stomach via NG tube -medications for pain and clotting if required

Rheumatoid Arthritis

Chronic, systematic, progressive deterioration of the connective tissue (synovium) of the joints; characterized by inflammation *Joint involvement is bilateral and symmetrical* Hint: A client comes to the clinic complaining of morning stiffness, weight-loss, and swellings of both hands and wrists. Which method of assessment might the nurse use, and which methods would the nurse not use? Use inspection, palpation, and strength testing. Do not assess range of motion [ROM]; this activity promotes pain because ROM is limited Hint: In the joint , the normal cartilage becomes soft, fissures and pitting occur, and the cartilage thins. Spurs form and inflammations sets in. The result is deformity marked by immobility, pain, and muscle spasms. The prescribed treatment regimen is corticosteroids for the inflammation; splinting, immobilization, and rest for the joint deformity; and NSAIDs for pain Hint: Synovial tissues line the bones of the joint. Inflammation of this lining causes destruction of tissue and bone. Early detection of rheumatoid arthritis can decrease the amount of bone and joint destruction. Often the disease goes into remission. Decreasing the amount of bone and joint destruction reduces the amount of disability Hint: What activity recommendations should the nurse provide a client with rheumatoid arthritis? -do not exercise painful, swollen joint -do not exercise any joint to the point of pain -perform exercises slowly and smoothly; avoid jerky movements

Peripheral Vascular Disease

Circulatory problems that can be due to arterial or venous pathology Arterial: intermittent claudication is the classic presenting symptom and is relieved by rest. Rest pain, occurs when extremities are horizontal, may be relieved by dependent position Venous: Persistent, aching, full feeling, dull sensation. Relieved when horizontal. Nocturnal cramps Anticoagulans: -heparin sodium= assess PTT, Hgb, Hct, platelets. Assess stools for occult blood. antagonist: PROTAMINE SULFATE -warfarin sodium= given orally, assess PT, avoid sudden change in intake of foods high in vitamin K. antagonist: VITAMIN K Hint: decreased blood flow results in diminished sensation in the lower extremities. Any heat source can cause severe burns before the client realizes damage is being done.

Pulmonary Tuberculosis

Communicable lung disease caused by an infection by Myobacterium tuberculosis bacteria. Transmission airborne droplet. After initial exposure, the bacteria encapsulate (form a Ghon Lesion). Bacteria remain dormant until later time, when clinical symptoms appear. Hint: TUBERCULOSIS TEST-- Tuberculosis Skin Test (Mantoux); A positive TB skin test in a healthy client is exhibited by an induration 10 mm or greater in diameter 48 to 72 hrs after the skin test. Anyone who has received a bacillus Calmette-Guerin (BCG) vaccine will have a positive skin test and must be evaluated with an initial chest radiograph. A health history with signs and symptoms form may be filled out annually until signs and symptoms arrive, then another radiograph is required. Chest x-rays are required on new employment; employer may require an x-ray every 5 years depending on the exposure risk. CDC guidelines indicate that the QuantiFeron-TB Gold test, a new blot test, is more reliable for TB skin test. Nucleic acid amplification (NAA) testing may be recommended when the client has signs and symptoms of TB. *PATIENT MAY RETURN TO WORK AFTER AFTER 3 NEGATIVE SPUTUM CULTURES* Hint: Teaching is very important with the client with TB. Drug therapy is usually long term (6 months or longer). It is essential that the client take the medications as prescribed for the entire time. Skipping doses or prematurely terminating the drug therapy can result in a public health hazard. Hint: TEACHING POINTS- -Rifampin: reduces effectiveness of oral contraceptives; client should use other birth control methods during treatment; gives body fluids orange tinge; stains soft contact lenses -Isoniazid (INH): increased phenytoin levels -Ethambutol: Vision check before starting therapy and monthly there after; may have to take for 1-2 yrs -Teach rationale for combination drug therapy to increase compliance Resistance develops more slowly if several anti-TB drugs given, instead of just one drug at a time.

Glaucoma

Condition characterized by increased intraocular pressure (IOP) that involves gradual painless vision loss that can lead to blindness if untreated -second leading cause of blindness -aqueous fluid is inadequately drained from eye -generally asymptomatic, cannot be cured but can be treated (meds or surgery) Hint: Glaucoma is often painless and symptom free. It is usually detected as part of a regular eye examination Early signs: increased IOP >22 mmHg, decreased accommodation Late signs: loss of peripheral vision, seeing halos around lights, decreased visual acuity not corrected by glasses, headache and eye pain Hint: Eye drops are used to cause pupil constriction because movement of the muscles to constrict the pupil also allows aqueous humor to flow out, thereby decreasing the pressure in the eye. Pilocarpine is commonly used. Caution the client that vision may be blurred for 1-2 hrs after administration of pilocarpine and that adaptation to dark environments is difficult because of pupillary constriction (desired effect of the drug) -Avoid activities that might increase IOP: emotional upsets, exertion: pushing, heavy lifting, shoveling, coughing severely or excessive sneezing, wearing constrictive clothing (tight collar or tie, tight belt, or girdle), strain at stool or constipation Hint: there is an increased incidence of glaucoma in older adult populations. Older clients are prone to problems associated with constipation. Therefore the nurse should assess these clients for constipation and postoperative complications associated with constipation and should implement a plan of care directed at prevention of, and, if necessary, treatment for constipation *medication chart on pg 152*

Inflammatory Bowel Disease

Consists of Crohn's disease and ulcerative colitis -chronic inflammation extending throughout all layers of intestinal mucosa *CHRONS: cobblestone appearance of the GI mucosa, with period of remission interspersed with period of exacerbation -theres no cure, treatment relies on medications to treat the acute inflammation and maintain remissions -S&S: abdominal pain (unrelieved by defecation) right lower quadrant. Diarrhea, steatorrhea (fatty stool), and weight loss. *Provide a nutritious, well-balanced, low-residue, low-fat, high-protein, high-calorie diet, with no dairy products. Avoid spicy foods. Advise the patient to avoid smoking, caffeinated beverages, pepper and alcohol. Weight at least twice a week. Hint: The GI tract usually accounts for only 100 to 200 mL of fluid loss per day, although it filters up to 8L per day. Large fluid losses can occur if vomiting or diarrhea exists *ULCERATIVE COLITIS: disease that affects the superficial mucosa of the large intestines and rectum, causing the bowel to eventually narrow, shorten, and thicken due to muscular hypertrophy. -colonoscopy and sigmoidoscopy diagnose it -S&S: intermittent tenesmus (anal contractions) and rectal bleeding. Liquid stools containing blood, mucus and pus (may pass 10 to 20 liquid stool per day) Hint: Opiate drugs tend to depress gastric motility. However, they should be given with caution. The nurse should assess for abdominal distention, abdominal pain, abdominal rigidity, signs and symptoms of shock- increased heart rate, and decreased BP, indicating possible perforation/GI bleed

Anemia

Deficiency of erythrocytes (RBCs) reflected as decreased Hct, Hgb, and RBCs Hint: Physical symptoms occur as a compensatory mechanism when the body is trying to make up for a deficit somewhere in the system. For instance, cardiac output increases when Hgb levels drop below 7 q/dL S&S: pallor, especially of the ears and nail beds; palmar crease; conjuctiva. Fatigue, excessive intolerance, othrostatic hypotension, tachycardia, irritability, difficulty concentrating Teach about diet= 1. Iron: red meats, organ meats, whole wheat products, spinach, carrots, legumes 2. Folic acid: green vegetables, liver, citrus fruits 3. Vitamin B12: glandular meats, yeast, green leafy vegetables, milk, and cheese *Vitamin supplements: take iron on an empty stomach to enhance absorption, 1 hour before meals or 2 hours after meal Teach that sickle cell crisis is precipitated by hypoxia 1. provide pain relief 2. provide adequate hydration 3. teach client to avoid activities that cause hypoxia -teach client that oral iron may turn stools black. Give liquid iron through a straw, with oral care afterward, to prevent discoloring teeth Hint: Use only normal saline to flush IV tubing or to run with blood. Never add medications to blood products. Two registered nurses should simultaneously check the physicians prescription, the clients identity, and the blood bag label

Cirrhosis

Degeneration of liver tissue, causing enlargement, fibrosis, and scarring -initially, hepatomegaly occurs; later, the liver becomes hard and nodular Hint: CLINICAL MANIFESTATIONS OF JAUNDICE -yellow skin, sclera, or mucous membranes (bilirubin in skin) -dark colored urine (bilirubin in urine) -chalky or clay-colored stools (absence of bilirubin in stools) Hint: Fetor hepaticus is a distinctive breath odor of chronic liver disease. It is characterized by a fruity or musty odor that results from the damaged liver's inability to metabolized and detoxify mercaptan, which is produced by the bacterial degradation of methionine, a sulfurous amino acid Hint: for treatment of ascites, paracentesis and peritoneovenous shunts(LeVeen and Denver shunts) may be indicated Hint: Esophageal varices may rupture and cause hemorrhage. Immediate management includes insertion of an esophagogastric ballon tamponade (a Blakemore-Sengstaken or Minnesota tube). Other therapies include vasopressors, vitamin K, coagulation factors, and blood transfusions Hint: Ammonia is not broken down as usual in the damaged liver; therefore serum ammonia level rises. The metabolism of drugs is slowed down so they remain in the system longer -Diet: low sodium, low potassium, low fat, high carbohydrate -if encephalopathy is present, lactulose is used to decrease ammonia levels

Multiple Sclerosis

Demyelinating disease resulting in the destruction of CSN myelin and consequent disruption of the transmission of nerve impulses -Increased white matter density seen on CT scan -Presence of plaques seen on MRI Hint: Symptoms involving motor function usually begin in the upper extremities with weakness progressing to spastic paralysis. Bowel and bladder dysfunction occurs in 90% of cases. MS is more common in women. Progression is not orderly Hint: Drug therapy for MS clients- Adrenocorticotropic hormone (ACTH), cortisone, cyclophosphamide (Cytoxan), and other immonosupressive drugs. Nursing implications for administration of these drugs should focus on the prevention of infection Symptoms: Optic neuritis (loss of vision or blind spots visual, swallowing difficulties gait disturbances, intention tremors unusual fatigue, weakness, and clumsiness

Chronic Airflow Limitation (CAL)

Description: chronic lung disease includes chronic bronchitis, pulmonary emphysema, and asthma Hint: Exposure to tobacco smoke is the primary cause of COPD in the United States- COPD is emphysema and chronic bronchitis Hint: 1- Compensation occurs over time in clients with chronic lung disease, and ABGs are altered 2- As COPD worsens, the amount of O2 in the blood decreases (hypoxemia) and the amount of carbon dioxide (CO2) in the blood increases (hypercapnia), causing chronic respiratory acidosis , which results in kidneys retaining bicarbonate as compensation 3- Not all clients with COPD are CO2 retainers, even hypoxemia is present , because CO2 diffuses more easily across lung membranes than O2 4- In advanced emphysema, due to the alveoli being affected, hypercarbia is a problem, rather than in bronchitis , where the airways are affected. 5-It is imperative that baseline data be obtained for the client Hint: Productive cough and comfort can be facilitated by semi-Fowler or high-Fowler position, which lessens the pressure on the diaphragm by abdominal organs. Gastric distention becomes a problem in these clients because it elevates the diaphragm and inhibits full lung expansion *see chart on pg 82* Hint: Overinflation of the lungs causes the rib cage to remain partially expanded, giving the characteristic appearance of barrel chest. The person works harder to breathe, but the amount of O2 taken in is not adequate to oxygenate the tissues. Insufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often to right-sided heart failure (cor-pulmonale) Hint: Cells in the body depend of O2 to carry out their functions. Inadequate arterial oxygenation is manifested by cyanosis and slow capillary refill (<3 seconds). A chronic sign is clubbing of the fingernails, and late sign is clubbing of the fingers . Hint: HEALTH PROMOTION- eating consumes energy needed for breathing. Offer mechanically soft diets, which do not require as much chewing and digestion. Assist with feeding if needed. -Prevent secondary infections, avoid crowds, contact with persons who have infectious diseases, and respiratory irritants (tobacco smoke) -teach client to report any change in characteristics of sputum -encourage client to hydrate well (3L/day) and decrease caffeine due to diuretic effect. -obtain immunizations when needed (flu and pneumonia) Hint: When asked to prioritize nursing actions, use the ABC rule: Airway first, Breathing, Circulation -In cardiopulmonary resuscitation (CPR) circumstances, follow the CAB guidelines: Chest Compressions-Airway-Breathing Hint: Look and listen! If breath sounds are clear but the client is cyanotic and lethargic, adequate oxygenation is not occurring Hint: The key to respiratory status is assessment of breath sounds, as well as visualization of the client. Breath sounds are better described, not named; for example, sounds should be described as crackles, wheezes, or high-pitched whistling sounds Hint: Watch for NCLEX-RN questions that deal with O2 delivery. In adults, O2 must be bubble through some type of water solution so it can be humidified if given at >4 L/min or delivered directly to the trachea. If given at 1 to 4 L/min or by mask or nasal prongs, the oropharynx and nasal pharynx provide adequate humidification. * see charts on pg 84 & 85*

Abdominal Aortic Aneurysm (AAA)

Dilation of the abdominal aorta caused by an alteration in the integrity of it wall -the most common cause of AA is atherosclerosis. It is a late manifestation of syphilis -the most common symptom is abdominal pain or low back pain, with the complaint that the client can fell his/her heart beating Hint: A client is admitted with severe chest pain and states that he feels a terrible tearing sensation in his chest. He is diagnosed with a dissecting aortic aneurysm. What assessments should the nurse obtain in the first few hours? *vital signs every hour *neurologic vital signs *respiratory status *urinary output *peripheral pulses -Bruit (swooshing sound heard over a constricted artery when auscultated) heard over the abdominal aorta, pulsation in upper abdomen Hint: During aortic aneurysm repair, the large arteries are clamped for a certain period, and kidney damage can result. Monitor daily BUN and creatinine levels. Normal BUN is 10-20 mg/dL, and normal creatinine is 0.6-1.2 mg/dL. The ratio of BUN to creatinine is 20:1. When this ratio increases or decreases, suspect renal problems

Sexually Transmitted Diseases (STDs)

Diseases that can be transmitted during sexual contact -Most cases of STDs occur in adolescents and young adults Hint: STDs in infants and children usually indicate sexual abuse and should be reported. The nurse is legally responsible to report suspected cases of child abuse Hint: Chlamydia is the most commonly reported communicable disease in the United States -use a nonjudgemental approach, be straight forward when taking a history Teaching: Reminder that sexual contact should be avoided with anyone while infected Hint: Pelvic inflammatory disease (PID) involves one or more of the pelvic structures. The infection can cause adhesions and eventually result in sterility. Manage the pain associated with PID with analgesics. Bed rest in a semi-fowlers position may increase comfort and promote drainage. Antibiotic treatment is necessary to reduce inflammation and pain and should be effective for N. Gonnorrhea and C. trachomatis Hint: A client comes into the clinic with a chancre on his penis. What is the usual treatment? IM dose of penicillin (such as benzathine penicillin G, 2.4 million units). Obtain a sexual history, including the names of his sex partners, so that they can receive treatment (syphilis) *STD chart on page 183

Complementary and Alternative Interventions

Hint: Reasons why clients use herbal medications: -cultural influence -perception that supplements are safer and "healthier" than conventional drugs -sense of control over ones care -emotional comfort from taking action -limited access to professional care -lack of health insurance -convenience -medica hype and aggressive marketing -recommendation from family and friends *see chart of herbal medications pg 75

Myasthenia Gravis

Disorder affecting the neuromuscular transmission of impulses in the voluntary muscles of the body -considered autoimmune characterized by the presence of acetylcholine receptor antibodies, which interfere with neuronal transmission S&S: diplopia (double vision), ptosis (eyelid drooping), mask like affect, dysphagia, choking, food aspiration, difficulty speaking Advances cases: respiratory failure, bladder/bowel incontinence Hint: in clients with myasthenia gravis, be alert for changes in respiratory status; the most severe involvement may result in respiratory failure Hint: Bed rest often relieves symptoms. Bladder and respiratory infections are often recurring problems. There is a needs for health promotion teachings Hint: myasthenic crisis (undermedication) is associated with a positive endrophonium (tensilon test), whereas cholinergic crisis (overmedication) is associated with a negative test Medication: pyridostigmine bromide

Myocardial Infarction

Disruption in or deficiency of coronary artery blood supply, resulting in necrosis of myocardial tissue Causes: thrombus or clotting, shock or hemorrhage *Women more commonly experience dyspnea, unusual fatigues and sleep disturbances as S&S Hint: -Angina is caused by myocardial ischemia. which cardiac medications would be appropriate for acute angina? Digoxin: NOT APPROPRIATE; increases the strength and contractility of the heart muscle; the problem in angina that the muscles not receiving enough O2. Digoxin will not help Nitroglycerin: APPROPRIATE, causes dilation of the coronary arteries, allowing more O2 to get to the heart muscle Atropine: NOT APPROPRIATE, increases heart rate by blocking saga stimulation, which surpasses the heart rate; does not address the lack of O2 to the heart muscle Propranolol (Inderal): NOT APPROPRIATE for acute angina attack; however is APPROPRIATE for long-term management of stable angina because it acts as a beta blocker to control vasoconstriction Hint: Remember MONA when administering medications and treatments in the patient with myocardial infarction. MONA: morphine, oxygen, nitroglycerin, aspirin. only give thrombolitic agents within 1-4 hrs of MI, but no more than 12 hrs of MI *Best cardiac enzime: troponin, onset as early as 1 hr post injury, peak 10-24 hr, return to normal 5-14 days

Dysrhythmias

Disturbance in hear rate or heart rhythm caused by a disturbance in the electrical conduction of the heart, not by abnormal heat structure *Atrial fibrillation: -no true P waves visible -Irregular ventricular rhythm -treatment: anticoagulant therapy due to risk of stroke *Atrial flutter -saw-tooth wave form -ventricular rhythm stays regular *Ventricular tachycardia -wide, bizarre QRS -Impaired cardiac output -synchronized cardio version if pulse present (if not treat as ventricular fibrillation) *ventricular fibrillation -cardiac emergency -irregular undulations of varying amplitudes, from coarse to fine -no cardiac output (no pulse or BP) -CPR, defibrillation as quick as possible. Hint: A Holter monitor offers continuous observation of the clients heart rate. To make assessment of the rhythm strips most meaningful, teach the client to keep a record of: -medication times and doses -chest pain episodes: type and duration -valsalva maneuver (straining at stool, sneezing, coughing) -sexual activity -exercise and other activities Hint: Cardioversion is the delivery of synchronized electrical shocks to the myocardium Hint: DIFFERENCE IN SYNCHRONOUS AND ASYNCHRONOUS PACEMAKERS: -Synchronous or demand: Pacemaker fires only when the clients heart rate falls below a rate set on the generator -Asynchronous or fixed: Pacepaker fires ar a constant rate -Implantable cardioverter defibrillator (IDC): devise defribillates to detect life-threatening ventricular arrhythmias. May have dual function as a pacemaker

Cushing Disease

Excess adrenocorticoid activity -cause is usually chronic administration of corticosteroids -S&S: moon face, truncal obesity, buffalo hump, abdominal striae, muscle atrophy, thinning of the skin, hirsutism in females, amenorrhea, poor wound healing, susceptible to infections, osteoporosis, HYPERGLYCEMIA, HYPERNATREMIA, HYPOKALEMIA Hint: Teach clients to take steroids with meals to prevent gastric irritation. They should never skip doses. If they have nausea or vomiting for more than 12-24 hours, they should contact the physician

Hyperthyroidism (Graves Disease, Goiter)

Excessive activity of the thyroid gland, resulting in an elevated level of circulating thyroid hormones -Graves disease is thought to be an autoimmune process and accounts for most cases -treatment: thyroid ablation by medication, radioactive iodine therapy, thyroidectomy *all treatments make the client hypothyroid, requiring hormone replacement -S&S: (acceleration of body processes) Weight loss, increased appetite, diarrhea, heat intolerance, tachycardia, palpitations, increased BP, diaphoresis, nervousness, exophthalmos Hint: Thyroid storm is a life threatening event that occurs with uncontrolled hyperthyroidism due to Graves disease. Other causes include childbirth, congestive heart failure (CHF), diabetic ketoacidosis, infection, pulmonary embolism, emotional distress, trauma, and surgery. Symptoms include fever, tachycardia, agitation, anxiety and HTN. Primary nursing interventions include maintaining an airway and adequate aeration. Propylthiouracil (PTU) and methimazole (Tapazole) are antithyroid drugs used to threat thyroid storm. Propranolol (Inderal) may be given to decrease excessive sympathetic stimulation Hint: After a thyroidectomy, be prepared for the possibility of laryngeal edema. Put a tracheostomy set at the bedside along with O2 and a suction machine; calcium glucanoate should be easily accessible if parathyroid glands have been accidentally removed Hint: Normal serum calcium is 9.0-10.5 mEq/L. The best indicator of parathyroid problems is a decrease in the clients calcium compared with the preoperative value Hint: If two or more parathyroid glands have been removed, the chance of tetany increases dramatically: -monitor serum calcium levels (0.9-10.5 mg/dL is normal range) -check for tingling of toes and fingers and around the mouth -Check Chvostek sign (twitching of lip after a tap over the facial nerve at the angle of the jaw means is positive) -Check Trousseau sign (carpopedal spasm after BP cuff is inflated above systolic pressure and helps for 3 minutes means is positive)

Altered State of Consciousness

Glasgow Coma Scale objectively documents the clients level of consciousness -Maximum total is 15, minimum is 3 -a score of 7 or less indicates coma Hint: Use of the Glasgow Coma Scale eliminates ambiguous terms to describe neurologic status, such as lethargic, stuporous, or obtunded Hint: Almost every diagnosis in the NANDA format is applicable because severely neurologically impaired persons require total care Hint: A client with an altered state of consciousness is fed via enteral routes because the likelihood of aspiration is high with oral feedings. Residual feeding is the amount of previous feeding still in the stomach. The presence of 100 mL of residual in an adult usually indicates poor gastric emptying, and the feeding should be withheld; however, the residual should be returned because it is partially digested Hint: Paralytic ileus is common in comatose clients. A gastric tube aids in gastric decompression Hint: Any client on bed rest or immobilized must have ROM exercises often and very frequent position changes. Do not leave the client in any one position for longer than 2 hours. Any position that decreases venous return, such as sitting with dependent extremities for long periods, is dangerous -position client for maximal ventilation: three quarters prone position or semi prone position to prevent tongue from obstructing airway and slightly to one side with arms away from chest wall -keep client NPO until responsive, and provide mouth care every 4 hrs -record clients weight daily ** see chart on page 156** Hint: if temperature elevates, take quick measures to decrease it, because fever increases cerebral metabolism and can increase cerebral edema (acetaminophen, aspirin, cooling blankets) Hint: Safety features for immobilized clients: -prevent skin breakdown by frequent turning -maintain adequate nutrition -prevent aspiration with slow, small feedings or NG feedings or enteral feedings -monitor neurologic signs to detect the first signs that ICP may be increasing -Provide ROM exercises to prevent deformities -prevent respiratory complications; frequent turning and positioning provide optimal drainage Hint: Restlessness may indicate a return to consciousness but can also indicate anoxia (absence of oxygen), distended bladder, covert bleeding, or increasing cerebral anoxia. Do not overstate, and report any symptoms of restlessness *avoid overstating because sedatives and narcotics depress responsiveness and affect pupillary reaction (an important assessment in neurologic vital signs

Valvular Heart Disease

Heart valves that are unable to open fully (stenosis) or close fully (insufficiency or regurgitation) *most commonly occurs on the left side of the heart; the mitral valve is most commonly involved followed by the aortic valve Hint: In mitral valve stenosis, blood is regurgitated back into the left atrium from the left ventricle. In the early period, there may be no symptoms, but as the disease progresses, the client will exhibit excessive fatigue, dyspnea on exertion, orthopnea, dry cough, hemoptysis, or pulmonary edema. There will be a rumbling apical diastolic murmur, and atrial fribillation is common

Prostate Cancer

High risk groups include those with a history of multiple sexual partners, sexually transmitted diseases, certain viral infections, and family history S&S: symptoms of urinary obstruction Elevated prostate-specific antigen (PSA) test should be conducted before a digital rectal examination (DRE) so that manipulation the prostate does not give false positive readings . Serial blood screening should be done to observe trends -PSA levels can rise with inflammation, benign hypertrophy, or irritation, as well as in response to cancer -DRE revealing palpable nodule, definitive diagnosis by biopsy

Brain Tumor

Hint: Benign tumors continue to grow and take up space in the confined area of the cranium, causing neural and vascular compromise in the brain, increased ICP, and necrosis of brain tissue. Even benign tumors must be treated because they may have malignant effects Hint: Craniotomy preoperative medications: -Corticosteroids to reduce swelling -agents and osmotic diuretics to reduce secretions (atropine, glycopyrrolate) -Agents to reduce seizures (penytoin) -propylactic antibiotics

Health Promotion and Disease Prevention

Hint: Changing unhealthy behaviors can modify or even prevent some chronic illnesses. Nurses play a major role in helping clients manage their chronic illnesses and disabilities through behavioral changes. Health teaching and counseling often are the role of the nurse in helping the client focus on improving health habits. Areas of behavioral change include: -Physical activity -Nutrition -Stress -Use of tobacco or marijuana -Use of alcohol -Spiritual perspective -Coping skills -Support systems Hint: According to the American Lung Association smoke is harmful to lung health. Burning wood, tobacco, or marijuana releases toxins and carcinogens

Chest Tubes

Hint: If the chest tube becomes disconnected, do not clamp!!! Immediately place the end of the tube in a container sterile saline water or water until a new drainage system can be connected. If the chest tube is accidentally dislodged from the client, the nurse should cover with a dry sterile dressing taped on three sides. If an air leak is noted, tape the dressing on three sides only; this allows air to escape and prevents the formation of a tension pneumothorax. Notify the health provider Hint: NCLEX-RN Content on Chest Tubes- fluctuations (tidaling) in the fluid will occur if there is no external suction. These fluctuating movements are a good indicator that the system is intact; they should move upwards with each inspiration and downward with each expiration. If fluctuation cease, check for kinked tubing, accumulation of fluid in the tubbing, occlusions, or change in the clients position, because expanding lung tissue may be occluding the tube opening. When a chest tube is connected to suction, continuous bubbling is an indication of an air leak.

Cultural Diversity

Hint: Obtain a cultural and spiritual assessment and include cultural and spiritual preferences in the plan of care when appropriate and feasible. Nurse are expected to provide care for all clients. It is important to note that clients are culturally diverse, regardless of their ethnicity, race, or socioeconomic status and to note that in every culture subgroups may form. However, culturally diverse clients may be distinguished from mainstream culture by ethnicity, social class, and/or language. Since the 2000 census there has been a notable change in the cultural, ethnic, and racial alignment of the US. Culture influences how clients seek medical attention or treat themselves

Joint replacement

Hint: Orthopedic wounds have the tendency to ooze more than other wounds. A suction drainage devise usually accompanies the client the postoperative floor. Check drainage often Hint: NCLEX-RN questions about joint replacement focus on complications. A big problem after joint replacement is infection Hint: Fractures of bone predispose the client to anemia, especially if long bones are involved. Check hematocrit every 3-4 days to monitor erythropoiesis Hint: after a hip replacement, instruct the client not to lift the leg upward from a lying position or to elevate the knee when siting. This upward motion can pop the prothesis out of the socket Hint: Immobile clients are prone to complications: skin integrity problems, formation of urinary calculi (clients milk intake may be limited), and venous thrombosis (client may be on prophylactic anticoagulants

Pneumonia

Hint: Pneumonia affects people of all ages, especially those 65 or older or infants under age 2 (because their immune system is still developing) Hint: Increased temperature also increases metabolism and the demand for O2. Fever can also cause dehydration because of excessive fluid loss due to diaphoresis -Assessment: listen for bronchial breath sounds "E" to "A" changes (ego phony), client says letter while nurse listens. Assess for tactile fremitus: nurse can feel chest vibrations when client says 99 Hint: Clients are risk for pneumonia: -altered level of consciousness -brain injury -depressed of absent gag and cough reflexes -susceptible to aspiring oropharyngeal secretions, including alcoholics, anesthetized individuals -drug overdose -stroke victims -immunocompromised *review antibiotics pg 78 Hint: Bronchial breath sounds are heard over areas of density or consolidation. Sound waves are easily transmitted over consolidated tissue Hint: HYDRATION- thins out the mucus trapped in the bronchioles and alveoli, facilitating expectoration. Is essential for clients experiencing fever. It is important because 300-400 ml of fluid is lost daily by the lungs through evaporation Hint: Irritability and restlessness are early signs of cerebral hypoxia; the clients brain is not receiving enough O2 Hint: PNEUMONIA PREVENTIVES: -older adults: annual flu vaccinations, pneumococcal vaccination at age 65 or older and younger clients who are at high risk, avoiding sources of infection and indoor pollutants (dust, smoke, and aerosols), no smoking -immunosuppressed and debilitated persons: annual flu vaccinations, pneumonia vaccinations, avoid infections, sensible nutrition, adequate fluid intake, appropriate balance of rest and activity -comatose and immobile persons: elevation of head of bed at least 30 degrees for feeding and for 1 hour after feeding; turn frequently -patient with functional or anatomical asplenia:: flu and pneumonia vaccine. *Asplenia refers to the absence of normal spleen function and is associated with some serious infection risks.*

Communication

Hint: Therapeutic communication is necessary to elicit important information from clients and their families in all nursing interventions and settings. It is important in crisis interventions to ascertain cultural awareness/cultural influences on health; to note and address religious and spiritual influences on health; to assess family dynamics; and to detect sensory alterations, such as hearing loss or speech deficits Hint: The SBAR format is used in many institutions during communication processes with other nurses, physicians, PAs, PT, SC, pharmacist, laboratory technicians, etc,. SBAR stands for Situation, Background, Assessment, and recommendations Hint: Nonverbal communication maybe more important than verbal communication. Body language, use of personal space, and verbal/oral messages should be congruent. Tone of voice and facial expression are part of body language. An example of positive body language is leaning in toward a client while talking. Recognition of cultural differences regarding personal space is an important component of communication. Most Americans maintain half a meter (1.7. of 1 1/2 feet) distance between people when talking. Body language and verbal/oral communication should be congruent; state messages in a positive manner even when providing negative feedback Hint: Clear verbal communication and accurate written records are critical during care transitions. Care transitions include such times as change of shift, when the client moves from unit to unit, or when the client moves to a new care setting Hint: Therapeutic communication is necessary in eliciting important information from clients and their families in all nursing interventions and settings, including crisis intervention, cultural awareness/cultural influences on health, religious and spiritual influences on health, family dynamics, and sensory alterations

Teaching/Learning

Hint: To develop a collaborative learning environment between the nurse and the client, nurses must be acutely aware of their own beliefs and values about the teaching-learning process, including client empowerment

Cardiovascular System

Hint: What is the relationship of the kidneys to the cardiovascular system? -The kidneys filter about 1L of blood per minute -If cardiac output is decreased, the amount of blood going through the kidneys is decreased; urinary output is decreased. Therefore a decreased urinary output may be a sign of cardiac problems -When kidneys produce and excrete 0.5 mL of urine/kg of body weight or average of 30 mL/hr output, the blood supply is considered to be minimally adequate to perfuse body organs

Hypothyroidism (Hashimoto Disease, Myxedema)

Hypofunction of the thyroid gland, with resulting insufficiency of thyroid gland -treated by hormone replacement Hint: Myxedema coma can be precipitated by acute illness, withdrawal of thyroid medication, anesthesia, use of sedatives, or hypoventilation (with the potential for respiratory acidosis and CO2 narcosis). The airway must be kept patent and ventilator support used as indicated Iodine deficiency is the most common cause of hypothyroidism*** Symptoms: fatigue, dry hair, dry skin, thick brittle nails, bradycardia, hypotension, constipation, goiter, periorbital edema, facial puffiness, cold intolerance, weight gain, dull emotions, depression, husky voice*** (edema of the neck), slow speech T3 < 70; T4 < 5 Treated by daily hormone replacement therapy Levothyroxine (Synthroid): synthetic T4; adverse reactions include anxiety, insomnia, tremors, tachycardia, palpitations; avoid foods and products containing iodine; weigh daily Ongoing follow-up to determine serum hormone levels S&S of myxedema coma: hypotension, hypothermia, hyponatremia, hypoglycemia, respiratory failure Avoid sedating client*** (can lead to respiratory difficulties)

Heart Failure (HF)

Inability of the heart to pump enough blood to meet the tissues O2 demands *Left sided heart failure: pulmonary edema -dyspnea -orthopnea: SOB when lying flat, causing the person to sleep propped up in bed -crackles -cough -fatigue -tachycardia -anxiety -restlessness -confusion -paroxysmal nocturnal dyspnea (PND) Right sided heart failure:peripheral edema -peripheral edema -weight gain -distended neck veins -anorexia, nausea -nocturia -weakness -hepatomegaly -ascites Hint: Restricting sodium reduces salt and water retention, thereby reducing vascular volume and preload Hint: DIGITALIS (Digoxin) -side effects of digitalis are increased when client is hypokalemic -digitalis has a negative chronotropic effect (it slows the heart rate). Hold digitalis if the pulse rate is <60 or >120 bpm (<90in an infant) or has markedly changed rhythm -bradycardia, tachycardia, and dysrhythmias may be signs of digitalis toxicity; these signs include nausea, vomiting, and headache in adults -If withheld, consult with physician

Urinary Tract Infection (UTI's)

Infection or inflammation at any site in the urinary tract (kidney, pyelonephritis; urethra, urethritis; bladder, cystitis; prostate prostatitis) -most common infectious agent is Escherichia Coli Hint: The key to resolving UTIs with most antibiotics is to keep the blood level of the antibiotic constant. It is important to tell the client to take the antibiotics around the clock and not to skip doses so that a consistent blood level can be maintained for optimal effectiveness - consume oral fluids up to 3L a day -avoid urinary tract irritants: alcohol. sodas, citrus juices, spices -void every 2-3 hrs during the day -wear cotton undergarments

Thrombophlebitis

Inflammation of the venous walls with the formation of a clot; also known as venous thrombosis, phlebothrombosis, or DVT Hint: Heparin prevents conversion of fibrinogen to fibrin and prothrombin to thrombin, thereby inhibiting clot formation. Because the clotting mechanism is prolonged, do not cause tissue trauma, which may lead to bleeding when given heparin subcutaneously. Do not massage area or aspirate, give in the abdomen between the pelvic bones, 2 inches from umbilicus; rotate sites Hint: ANTICOAGULANTS *Heparin: -Antagonist: protamine sulfate -laboratory: PTT or aPTT determines efficacy -keep 1.5 to 2.5 times normal control *Warfarin (Coumadin) -antagonist:vitamin K -laboratory: Pt determines efficacy -keep 1.5 to 2.5 times normal control -INR (international normalized ratio): desirable therapeutic level usually 2-3 (reflects how long it takes a blood sample to clot) Hint: clients may ingest foods high in vitamin K to maintain therapeutic blood levels based on their dietary intake

Inflammatory and Infectious Heart Disease

Inflammatory and infectious process involving the endocardium and pericardium Hint: Infective endocarditis damage to heart valves occurs with the growth of vegetative lesions on valve leaflets. These lesions pose a risk for embolization, erosion, or perforation of the valve leaflets or abscesses within adjacent myocardial tissue. Valvular stenosis or regurgitation (insufficiency), most commonly of the mitral valve, can occur, depending on the type of damage inflicted by the lesions, and can lead to symptoms of left or right-sides heart failure Hint: PERICARDITIS- the presence of a friction rub is an indication of pericarditis (inflammation of the lining of the heart). ST-segment elevation and T-wave inversions are also signs of pericarditis Hint: ACUTE AND SUBACUTE INFECTIVE ENDOCARDITIS- there are two types of infective endocarditis: acute, which often affects individuals with previously normal hearts and healthy valves and carriers a high mortality rate, and subacute, which typically affects individuals with preexisting conditions, such as rheumatic heart disease, mitral valve prolapse, or immunosuppression. Intravenous drug abusers are at risk of both acute and subacute bacterial endocarditis. When this population develops subacute infective endocarditis, the valves on the right side of the heart (tricuspid and pulmonic) are typically affected because of the introduction of common pathogens that colonize the skin (Staphylococcus epidermis or Candida spp.) into the venous system.

Eye Trauma

Injury to the eye sustained as the result of sharp or blunt trauma, chemicals or heat. -Every eye injury should be considered an emergency. - Protective eye shields in hazardous work environments and during athletic sports may prevent injuries. NURSING PLANS AND INTERVENTIONS: -Position the client according to the type of injury; a sitting position decreases IOP. -Remove conjunctival foreign bodies unless embedded. -**Never attempt to remove a penetrating or embedded object. Do not apply pressure.** -Apply cold compresses to eye contusion (black eye). -After chemical injuries, irrigate the eye with copious amounts of water. Administer eye meds as prescribed. -Explain that an eye patch may be applied to rest the eye. Reading and watching tv may be restricted for 3-5 days. -Explain that a sudden increase in eye pain should be reported.

Breast Cancer

Leading cancer in women -Early detection is important to successful treatment -of all breast cancers 90-95% are discovered through breast self examination Risk factors= -positive family history -menarche before 12 years of age and menopause after age 50 -nulliparous and those bearing first child after age 30 -history of uterine cancer -daily alcohol intake -highest incidence: those age 40-49 and over 65 Hint: the importance of teaching female clients how to conduct a breast self-examination cannot be overemphasized. Early detection results in positive outcomes *every woman should perform a breast self-examination monthly, preferably as soon as menstrual bleeding ceases or if postmenopausal, the same date every month Mammograms: every 1-2 years for women in their 40s. Annual mammogram for women over 50 yrs. No use of lotions, talc powder, or deodorant under arms before procedure (may mimic calcium deposits on radiograph *tumors less than 4 cm are deemed curable . Definitive diagnosis of cancer is made by biopsy Hint: the presence or absence of hormone receptors is paramount in selecting clients for adjuvant therapy (adjuvant: applied after initial treatment for cancer, especially to suppress secondary tumor formation.) *S&S: hard lump (not freely movable and not painful), dimpling of skin, newly retraction of nipple, alteration in contour of breast, change in skin color, change in skin texture (peak d'orange), discharge from nipple, pain and ulcerations (late signs)* Post operative: -monitor bleeding -position arm on operative side on a pillow, slightly elevated -avoid BP measurements, injections, and venipuncture in arm where surgery occurred - encourage hand activity fo the arm where surgery occurred by squeezing a small rubber ball

Testicular Cancer

Leading cause of death in men 15-35 yrs Hint: Men whose testes have not descended into the scrotum or whose testes descended after age 6 are at greatest risk for developing testicular cancer. The most common symptom is the appearance of a small, hard lump about the size of a pea on the front or side of the testicle. Testicular self-examination (TSE) should be done regularly at the same time every month by all males after age 14. It should be done after the shower by gently palpating the testes and cord to look for a small lump. Swelling may also be a sign of testicular cancer

Hodgkin Disease

Malignancy of the lymphoid system that initiates in a single lymph node -characterized by generalized painless lymphadenopathy -incidence higher in males and young adults -Prognosis is good -Diagnosis is made by excision of node for biopsy; characteristic cell is called REED-STERNBERG *stage on page 175* S&S: enlarged lymph nodes (one or more) usually cervical lymph nodes Hint: Hodgkin disease is one of the most curable of all adult malignancies. Emotional support is vital. Career development is often interrupted for treatment. Chemotherapy renders many male clients sterility. May bank sperm before treatment, if desired

Leukemia

Malignant neoplasm of the blood forming organs -characterized by an abnormal overproduction of immature forms of any of the leukocytes, results in decreased number of RBC's and platelets Causes: -Anemia -Immunisupression: due to the large number of immature RBC's or profound neutropenia -Hemorrhage due to thrombocytopenia Hint: Many health care delivery systems require the nurse to be credentialed in order to administer parenteral chemotherapy. The practical nurse (PN) should recognize complications of chemotherapy related to administration, safety, side effects, and nursing assessment parameters and should report these to to the registered nurse and health care provider *see chart on page 168* TYPES OF LEUKEMIA A. Acute myelogenous leukemia (AML) -inability of leukocytes to mature -occurs anytime during life cycle -poor prognosis -cause of death tends to be overwhelming infection B. Chronic myelogenous leukemia (CML) -abnormal production of granulocytic cells -chronic phase last approx. 3 yrs -acute phase lasts 2-3 months -Prognosis poor C. Acute lymphocytic leukemia (ALL) -abnormal leukocytes are found in blood forming tissue -occurs in children (most common childhood cancer) -prognosis favorable, children live 5 years or longer D. Chornic lymphocytic leukemia -Involves increased production of leukocytes and lymphocytes and proliferation of cells within the bone marrow, spleen and liver -occurs after the age of 35 - good survival rate Hint: A 24 yo is admitted with large areas of ecchymosis on both upper and lower extremities. She is diagnosed with acute myelogenous leukemia. What are the expected laboratory findings for this client, and what is the expected treatment? Laboratory: decreased Hgb, decreased Hct, decreased platelet count, altered WBC (usually quite high) Treatment: Prevention of infection; prevention and control of bleeding, high protein, high calorie diet, assistance with ADLs, drug therapy Hint: Infection in the immunosuppressed person may not be manifested with an elevated temperature. Therefore it is imperative that the nurse perform a total and thorough assessment of the client frequently *obtain through or peak blood levels of antibiotics Through; draw blood sample shortly before administration of antibiotic Peak: draw blood sample 30 min- 1 hr after administration of drug Hint: Most oncologic drugs cause immunosuppression. Prevention of secondary infections is vital! Advise client to stay away from persons with known infections such as colds. In the hospital, place client in a private room, and maintain an environment as sterile and as clean as possible. These persons should not eat raw vegetables or fruits-- only cooked foods-- so as to destroy any bacteria *no medication can be piggy backed with an infusion of chemotherapeutic agents. Central lines and implanted ports can often be used for collecting blood samples, but regular IV sites cannot *central lines chart pg. 175

Diverticular Diseases

Manifests in two clinical forms: -diverticulosis- bulging pouches in the GI wall (diverticula), which push the mucosa lining through the surrounding muscle -diverticulitis- inflamed diverticula, which may cause obstruction, infection, and hemorrhage Hint: Diverticulosis is the presence of pouches in the wall of the intestine. There is usually no discomfort, and the problem goes unnoticed unless seen on radiologic examination (usually prompted by some other condition). Diverticulitis is an inflammation of the diverticula (pouches), which can lead to perforation of the bowel -S&S: left lower quadrant pain -barium enema or colonoscopy positive for diverticular disease (barium not used during acute phase) -well-balanced diet, high-fiber diet unless inflammation is present, in which client is NPO, followed by low-residue foods. Hint: a client admitted with complaints of severe lower abdominal pain, cramping, and diarrhea is diagnosed as having diverticulitis. What are the nutritional needs of this client throughout recovery? -Acute phase: NPO, graduating to liquids -Recovery phase: no fiber or foods that irritate the bowel -Maintenance phase: high-fiber diet with bulk forming laxatives (Metamucil) to prevent pooling of foods in the pouches where they can become inflamed; avoidance of small, poorly digested foods such as popcorn, nuts, seeds etc.

Osteoporosis

Metabolic disease in which bone demineralization results in decreased density and subsequent fractures *Postmenopausal women are at highest risk Hint: postmenopausal, thin, white women are at the highest risk for development of osteoporosis. Encourage exercise, a diet high in calcium, and supplemental calcium. Tums are an excellent source of calcium, but they are also high in sodium, so hypertensive or edematous individuals should seek another source of supplemental calcium Hint: The main cause of fractures in older adults, especially in women, is osteoporosis. The main fracture site seems to be hip, vertebral bodies, and Colles fracture of the forearm {A Colles Fracture is a complete fracture of the radius bone of the forearm close to the wrist resulting in an upward (posterior) displacement of the radius and obvious deformity.}

Cancer of the Larynx

Neoplasm occurring in the larynx, most commonly squamous cell in origin -Prolonged use of combined effects of alcohol and tobacco is directly related to development -earliest sign is hoarseness or a change in vocal quality that lasts more than 2 wks -later changes: dysphagia, dyspnea, cough, hemoptysis, weight loss, neck pain radiating to the ear, enlarged cervical nodes, and halitosis Hint: With cancer of the larynx, the tongue and mouth often appear white, gray, dark brown, or black and may appear patchy Hint: Tracheostomy care involves cleaning the inner cannula, suctioning, and applying clean dressings Hint: Air entering the lugs is humidified along the nasobronchial tree. This natural humidifying pathway is gone for the client who has had a laryngectomy . If the air is not humidified before entering the lugs, secretions tend to thicken and become crusty. Hint: A laryngectomy tube has a larger lumen and is shorter than the tracheostomy tube. Observe the client for any signs of bleeding or occlusion, which are the greatest immediate postoperative risks (first 24 hrs) Hint: Always have suction equipment available at the bedside for new and chronic tracheostomy clients Hint: Fear of chocking is very real for laryngectomy clients. They cannot cough as they could earlier because the glottis is gone. Teach the glottal stop technique to remove secretions (take a deep breath, momentarily occlude the tracheostomy tube, cough, and simultaneously remove finger from the tube)

Pancreatitis

Nonbacterial inflammation of the pancreas Acute: occurs when there is digestion of the pancreas by its own enzymes, primarily trypsin. Alcohol ingestion and biliary tract disease are major causes -severe midepigasric pain radiating to the back -abdominal guarding -nausea and vomiting -bluish discoloration of flanks (Grey Turner sign) or periumbilical area (Cullen sign) -elevated amylase, lipase, triglycerides, and glucose levels -low calcium levels (tetany, muscle twitching, cramping, grimacing, seizures, altered DTR's) Chronic: progressive, destructive that causes permanent dysfunction. Cause by long term alcohol use -continuous burning or gnawing abdominal pain -recurring attacks of severe upper abdominal and back pain -jaundice, dark urine -S&S of diabetes Hint: Acute pancreatic pain is located retroperitoneally. Any enlargement of the pancreas causes the peritoneum to stretch tightly. Therefore sitting up or leaning forward reduces the pain

General Oncology Content

Palliative procedure: relieves symptoms without curing the cause Seven warning signs of cancer: 1. Change in usual bowel and bladder function 2. a sore that does not heal 3. Unusual bleeding or discharge, hematuria, tarry stools, ecchymosis, bleeding mole 4. thickening or lump in the breast or elsewhere 5. indigestion or dysphagia 6. obvious changes in wart or mole 7. nagging cough or hoarseness

Intestinal Obstruction

Partial or complete blockage of intestinal flow (fluid, feces, gas) that occurs mostly in the small intestines Hint: BOWEL OBSTRUCTIONS -Mechanical: Due to disorders outside the bowel (hernia, adhesions (most common)) caused by disorders within the bowel (tumors, diverticulitis) or by blockage of the lumen in the intestine (intussusception, gallstone) -Nonmechanical: Due to paralytic ileus, which does not involve any actual physical obstruction but results from inability of the bowel itself to function Hint: A client admitted with complaints of constipation, thready stools, and rectal bleeding over the past few months is diagnosed with a rectal mass. What are the nursing priorities for this client? -NPO -NG tube (possibly an intestinal tube such as a Miller-Abbott) -IV fluids -Surgical preparation of bowel(if obstruction is complete) -foods and fluids are restricted for 8-10 hrs before surgery if possible -if the patient has a bowel obstruction or perforation, bowel cleansing is contraindicated -oral erythromycin and neomycin are given to further decrease the amount of colonic and rectal bacteria -if possible, all clients who require surgery for obstruction undergo NG intubation and suction before surgery. However in cases of complete obstruction, surgery should proceed without delay -Teaching (preoperative nutrition, etc.)

Urinary Tract Obstruction

Partial or complete blockage of the flow of urine at any point in the urinary system Hint: Location of the pain can help to determine the location of the stone. -Flank pain usually means the stone is in the kidney or upper uterer. If the pain radiates to the abdomen or scrotum, the stone is likely to be in the uterer of bladder.- Excrutiating spastic-type pain is called colic.-During kidney stone attacks, it is preferable to administer pain medications at regularly scheduled intervals rather than PRN to prevent spasm and optimize comfort Clients at risk for developing calculi: -Strictures -Prostatic hypertrophy -Neoplasms -congenital malformations -history of calculi -family history of calculi *strain all urine! Hint: Percutaneous nephrostomy: A needle or catheter is inserted through the skin into the calyx of the kidney. The stone may be dissolved by percutaneous irrigation with a liquid that dissolves the stone or by ultrasonic sound waves (lithotripsy) that can be directed through the needle or catheter to break up the stone, which then can be eliminated through the urinary tract

Hypertension

Persistent seated BP levels equal to or greater then 140/90 mm Hg on two separate occasions -Essential (primary) HTN has no known cause (idiopathic) -Secondary HTN develops in response to an identifiable mechanism or another disease Hint: Blood pressure is created by the difference in the pressure of the blood as it leaves the heart and the resistance it meets flowing out to the tissues. Diet and exercise, smoking cessation, weight control, and stress management can control many factors that influence the resistance blood meets as it flows from the heart *Take pharmacologic history bc steroids and estrogens (oral hypertensives) increase BP Hint: Remember the risk factors for HTN: heredity, race (African Americans), age, alcohol abuse, increased salt intake, obesity, and use of oral contraceptives Hint: The number-one cause of a stroke in hypertensive clients is noncompliance with medication regimen. HTN is often symptomless, and antihypertensive medications are expensive and have side effects. Studies have shown that the more clients know about their antihypertensive medications, the more likely they are to take them; teaching is important! *determine medication side effects experienced by clients: importance, insomnia *diet: low salt, low fat, low cholesterol diet

Chronic Renal Failure (CRF): End Stage Renal Disease (ESRD)

Progressive, irreversible damage to the nephrons and glomeruli, resulting in uremia Decreasing urinary function: 1. Hematuria 2. Proteinuria 3. Cloudy urine 4. oliguric (100-400 mL/day_ 5. anuric (<100 mL/day) Hint: Accumulation of waste products from protein metabolism is the primary cause of uremia. Protein must be restricted in CRF clients. However, if protein intake is inadequate, a negative nitrogen balance occurs, causing muscle wasting. The glomerular filtration rate (GFR) is most often used as an indicator of the level of protein consumption Hint: The major difference between dialysate for hemodialysis and peritoneal dialysis is the amount of glucose. Peritoneal dialysis is much higher in glucose. For this reason, if the dialysate is left in the peritoneal cavity too long, hyperglycemia may occur. Hint: Dialysis Covered by Medicare: -All persons in the United States are eligible for Medicare as of their first day of dialysis under special ESRD funding -Medicare card will indicate ESRD -Transplantation is covered by Medicare procedure; coverage terminates 6 months postoperative if dialysis is no longer required Hint: Protein intake is restricted until blood chemistry shows ability to handle the protein catabolites, urea and creatinine. Ensure high caloric intake so protein is spared for its own work; give hard candy, jelly beans, or flavored carbohydrate powders Hint: Frequent monitoring of laboratory parameters, especially serum albumin (3.5-5), prealbumin (may be a better indicator of recent or current nutritional status than albumin) and ferritin are necessary to evaluate nutritional status. All patients with CKD should be referred to a dietitian for nutrition education and guidance. Hint: As kidneys fail, medications must often be adjusted. Of particular importance is digoxin toxicity because digitalis preparations are excreted by the kidneys. Signs of toxicity in adults includes nausea, vomiting, anorexia, visual disturbances, restlessness, headache, cardiac dysrhythmias, and pulse <60bpm *antianemic: Erythropoietin- given due to anemia due to decreased production or erythropoietin in end stage renal disease. Stimulates RBC production, increases hub, reticulocyte count, and Hct

Type 2 Diabetes Mellitus

Results from either the inadequate production of insulin by the body or lack of sensitivity to the insulin being produced -With extreme hyperglycemia, hyperosmolar hyperglycemia nonketonic syndrome (HHNKS) develops Clinical characteristics of HHNKS: -hyperglycemia >600 -plasma hyperosmolarity -dehydration -changed mental status -absent ketone bodies Treatment: - usually with isotonic IV flit replacement and careful monitoring of potassium and glucose levels -IV insulin given until BS stable at 250

Type 1 Diabetes Mellitus

Results from the progressive autoimmune-based destruction of beta cells -precipitating factors for diabetic ketoacidosis (DKA) include infection and inadequate or undermanagement of glucose Clinical characteristics of DKA: -serum glucose level of 250 and above -Kenoturia in large amounts -Arterial pH of <7.30 and HCO3 <15 -Nausea, vomiting, dehydration, abdominal pain, kussmaul's respirations, acetone odor to breath Treatment: -isotonic IV fluids, 0.9% NaCl solution until BP stabilizes and urine output is 30-60 mL/hr -slow infusion by IV pump of regular insulin

Stroke/Brain Attack: Cerebral Vascular Accident (CVA)

Sudden loss of brain function resulting from a disruption in the blood supply to a part of the brain Hint: CNS involvement related to cause of stroke= -Hemorrhagic: caused by a slow or fast hemorrhage into the brain tissue; often related to HTN -Embolic: caused by a clot that has broken away from a vessel and has lodged in one of the arteries of the brain, blocking the blood supply. Often related to atherosclerosis (so it may occur again) Hint: Atrial flutter and fibrillation produce a high incidence of thrombus formation after dysrhythmia caused by turbulence of blood flow through all valves and heart Hint: A woman has a stroke 2 days earlier has left-sided paralysis. She has begun to regain some movement in her left side. What can the nurse tell the family about the clients recovery period? " The quicker movement is recovered, the better the prognosis is for full or improved recovery. She will need patience and understanding from her family as she tries to cope with the stroke. Mood swings can be expected during the recovery period, and bouts of depression and tearfulness are likely Hint: words that describe losses in a stroke= 1. Apraxia: inability to perform purposeful movements in the absence of motor problems 2. Dysarthia: difficulty articulating 3. Dysphasia: impairment in speech and verbal comprehension 4. Aphasia: loss of the ability to speak 5. Agraphia: loss of the ability to write 6: Alexia: loss of the ability to read 7. Dysphagia: dysfunctional swallowing Hint: Steroids are administered after a stroke to decrease cerebral edema and retardations permanent disability. H2 inhibitors are administered to prevent peptic ulcers(ranitidine, cimetidine, famotidine, nizatidine)

Burns

Tissue injury or necrosis caused by transfer of energy from a heat source to the body First degree a. superficial partial-thickness (sunburn) b. injury to epidermis c. leaves skin pink or red, no blisters d.dry, painful (relieved by cooling) e. no scarring, and skin grafts are not required Second degree a. deep partial thickness destruction of epidermis and upper layers of the dermis b. injury to deeper portions of the dermis c. painful (sensitive to touch and cold air) d. appears red or white, weeps fluid, blisters present e. hair follicles intact, very edematous f. heals without surgical intervention, usually does not scar Third degree a. full thickness and deep full thickness; involves total destruction of dermis and epidermis b. skin cannot regenerate c. requires skin grafting d. underlying tissue (fat, fascia, tendon, bone) may be involved e. wound appears dry and leathery as eschar develops f. painless Severity of burn is determined by extent of surface area burned. *Rule of nines= head and neck 9%, upper extremities 9% each, lower extremities 18% each, front truck 18%, back trunk 18%, perineal area 1% Hint: ABCs of assessment -Airway -Breathing -circulation IV fluid used: LR Hint: Massive volumes of IV fluids are given. It is not uncommon to give over 1000 mL/hr during various phases of burn care. Hemodynamic monitoring must be closely observed to be sure the client is supported with fluids but is not overloaded Hint: Infection is a life threatening risk for those with burns Hint: Dressing changes are very painful!! Medicate client before procedure!! Hint: Preexisting conditions that might influence burn recovery are age, chronic illnesses (diabetic, cardiac problems, etc), physical disabilities, disease, medications used routinely, and drug or alcohol abuse

Colorectal Cancer

Tumors occurring in the colon -Second leading cause of cancer related deaths in the US -highest incidence in persons older than 50 yrs of age Hint: Diet recommendations by the American Cancer Society to prevent bowel cancer: -eat more cruciferous vegetables (those from the cabbage family such as, broccoli, cauliflower, Brussel sprouts, cabbage, and kale) -increase fiber intake -maintain average body weight -eat less animal fat Hint: American Cancer Society recommendations for early detection of colon cancer: - a digital rectal exam (DRE) every year after 40. -a stool blood test every year after 50 -a colonoscopy or sigmoidoscopy examination every 10 years after the age of 50 in average risk clients, or more often based on the advise of a physician Hint: An early sign of colon cancer is rectal bleeding. Encourage patients 50 years of age or older and those with increased risk factors to be screen yearly with fecal occult blood testing. Routine colonoscopy at 50 is also recommended.

Peptic Ulcer Disease

Ulceration that penetrates the mucosal wall of the GI tract -Duodenal ulcers occur in the duodenum, which is the most common location of PUD -significant number of gastric ulcers are caused by a bacterium, Helicobacter pylori -symptoms- belching, bloating, epigastric pain radiating to the back and relieved by antacids (aluminum hydroxide/magnesium hydroxide -complications: hemorrhage, perforation, obstruction Hint: Stress can cause or exacerbate ulcers. Teach stress-reduction methods, and encourage those with a family history of ulcers to obtain medical surveillance for ulcer formation Hint: Clinical manifestations of GI bleeding: -pallor: conjunctival, mucous membranes, nail beds -dark, tarry stools -bright-red or coffee- ground emesis -abdominal mass or bruit -decreased BP, rapid pulse, cool extremities (shock), increased respirations

Uterine Prolapse, Cystocele, and Rectocele

Uterine prolapse is downward displacement of the uterus. Cystocele is the relaxation of the anterior vaginal wall with prolapse of the bladder. Rectocele is the relaxation of the posterior vaginal wall by prolapse of the rectum *Preventive measures= 1. postpartum perineal exercises 2. spaced pregnancies 3. weight control Hint: what is the anatomic significance of a prolapsed uterus? When the uterus is displaced, it impinges on other structures in the lower abdomen. The bladder, rectum, and small intestine can protrude the vaginal wall *Predisposing conditions= -multiparity -pelvic tearing during childbirth -vaginal muscle weakness associated with aging -obesity

Hepatitis

Widespread inflammation of liver cells, usually caused by a virus *chart with types on page 128* Hint: PROVIDE AN ENVIRONMENT CONDUCTIVE TO EARTING for clients that are anorexic or nauseated: -remove strong odors immediately; they can be offensive and increase nausea -encourage client to sit up for meals; this can decrease the propennsitive to vomit -serve small frequent meals -give antiemetic before eating Hint: Liver tissue is destroyed by hepatitis . Rest and adequate nutrition are necessary for regeneration of the liver being destroyed by the disease. Many drugs are metabolized in the liver (alcohol, aspirin, acetaminophen, and sedatives), so drug therapy must be scrutinized carefully. Caution the client that recovery takes many months, and previously taken medications and/or over the counter drugs should not be resumed without the health care providers directions

Lupus Erythematous

a systemic inflammatory CT disorder Two types: 1. Discoid lupus erythematous (DLE) affects skin only 2. Systemic lupus erythematous (SLE) can cause major body organs and systems to fail [more prevalent] -autoimmune disorder. Kidney involvement is the leading cause of death in clients with lupus followed by cardiac involvement Hint: NCLEX-RN questions often focus on the fact that avoiding sunlight is key in the management of lupus erythematous; this is what differentiates it from other connective-tissue diseases Trigger factors: 1. sunlight 2.stress 3.pregnancy 4.drugs

Addison Disease

hypofunctioning of the adrenal cortex -characterized by lack of cortisol, aldosterone, and androgens -sudden withdrawal from corticosteroids may precipitate symptoms of Addisons disease Hint: many people take steroids for a variety of conditions. NCLEX-RN questions often focus on the need to teach clients the importance of following the prescribed regimen precisely. They should be cautioned against stopping the medications suddenly and should be informed that is necessary to taper off the dosage when taking steroids S&S: fatigue, weakness, weight-loss, anorexia, nausea, vomiting, postural hypotension, HYPOGLYCEMIA, HYPONATREMIA, HYPERKALEMIA, hyperpigmentation of mucous membranes and skin, loss of body hair, hypovolemia (hypotension, tachycardia, fever) Hint: ADDISON CRISIS IS A MEDICAL EMERGENCY. It is Brough on by sudden withdrawal of steroids or a stressful event (trauma/severe infection) or exposure to cold, overexertion, or decrease in salt intake. -vascular collapse: hypotension and tachycardia occur; administer IV fluids at a rapid rate until stabilized -hypoglycemia: administer IV glucose -Essential to reversing the crisis; administer parenteral hydrocortisone -aldosterone replacement: Administer flurocortisone acetate PO (available only as oral preparation) with simultaneous administration of salt (sodium chloride) if client has a sodium deficit

Guillain-Barre Syndrome

no hints