Professional Documents
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MedSurgATI1
MedSurgATI1
C = (F -32) x 5/9
Defibrillate
Arterial puncture
...
- alarm indicate low exhaled volume dt disconnection, cuff leak, and tube
- alarm indicate excess secretions, client biting the tubing, kinks and client
Apnea alarm: Ventilator indicate that the ventilator does not detect spontaneous respiration
Asthma Chronic inflammatory disorder of the airways. It is INTERMITTENT and REVERSIBLE airflow
obstruction tat affects the bronchioles
- occurs either by inflammation or airway hyperresponsiveness
Manifestation
- Mucosal edema
- broncoconstriction
- excessive secretion production
Classification: Asthma - Mild intermittent: < 2x/week
- Mild persistent: >2x/week
- Moderate persistent: daily with exacerbations 2x/wk
- Severe persistent: continuous with frequent exacerabation
Triggers: Asthma
- smoke
- strong odors
- allergens
- exercise
- pollutants
- stress or emotions
- medications (NSAIDS, beta blockers, cholinergic)
- chemicals
Dx: Asthma
...
Corticosteroids:
- Flovent/Prednisone
- side effects: hypokalemia, poor wound healing, fluid retention, immunosuppression, hyperglycemia
- Leukotriene antagonists: Singulair
- Mast cell stabilizer: Intal
- Monoclonal antiboies: omalizumab (Xolair)
Status Asthmaticus
- s/s
- extreme wheezing, labored breathing, use of accessory muscles, distended neck veins, and risk for cardiac
and/ or respiratory arrest
- tx
- EPINEPHRINE (potent bronchodilator) then initiate systemic steroid therapy
Older Adults: Asthma
receptors
- dyspnea
- cough
- hypoxemia
- hypercarbia (increased PaCO2)
- Respiratory acidosis
- crackles
- shallow respirations
- use of accessory muscles
- barrel chest
- hyperresonance dt "trapped air"
- pallor and cyanosis
Nx Interventions: COPD - Position at high- Fowler's
- encourage deep breathing and use of incentive spirometer
- meds use: same as asthma meds
- administer heated and humidified O2 therapy
- monitor for skin breakdown
- teach: diaphragmatic or abdominal breathing
- teach pursed lip breathig
- may need only 2-4 L/min per nasal cannula and only 40% per Venturi mask
- include plenty of rest
- smoking cessation
Complications: COPD
Respiratory infection
Nx intervention
- administer positie inotropic and contractility medications (digoxin)
- administer diuretics and IV fluids
Older Adults: COPD
- advance age
Atelectasis
- airway inflammation and edema leads to alveolar collapse and increases the risk of hypoxemia
- diminished or absent breath sounds over affected area
- cxr shows area of density
Acute Respiratory Failure
- persistent hypoxemia
- prepare for intubation
Older Adults: Pneumonia
- have weak cough reflex and decreased muscle strength -> trouble expectorating with can lead to difficulty
in breathing and specimen retrieval
s/s
- CONFUSION from hypoxia
- fever, cough and purulent sputum are often absent
- cxr is important dx tool bc sx are often vague
Tuberculosis
- airborne route
- cxr appears Ghon Tubercle
- contagious only when s/s of infection is present
- TB test will be (+) 2 to 10 weeks of exposure to infection
dx:
Mantoux
- cough
- NIGHT SWEATS
- purulent sputum, blood streaked
Nx Interventions: Tuberculosis - Nurse: wear N95 or HEPA respirator
- place client in NEGATIVE airflow room with airborne precaution
- have client wear mask when transporting
- diet: high in protein, iron and vit C
- follow up care in 1 year
- sputum samples are needed Q2-4 weeks; clients are no longer infectious after 3 negative sputum cultures
Medications: Tuberculosis
S.T.R.I.P.E.
- Isoniazid (INH):
- take in empty stomach
- take with vit B6
- Rifampin
- urine and other secretions will turn ORANGE
- monitor for hepatomegaly
- Ethambutol (EMB)
- obtain baseline visual acuity; determine color discrimination
- Streptomycin
- check for ototoxicity
Complications: Tuberculosis
- Meningitis
- pericarditis
Pack Year History
Superior Venal Cava Syndrome results from pressure placed on the vena cava by tumors. This is a medical
emergency
- early signs
- facial edema
- tight ness of shirt collars
- nosebleeds
- dyspnea
- late signs
- hypotension
- change in metnal status
- cyanosis
- hemorrhage
Tx: Radiation and stent placement provide temp relief
Metastasis (lung cancer)
- to the bones can cause bone pain and increase the risk of pathologic
fractures. Encourage to ambulate carefully
- to the CNS can lead to changes in mentation, lethargy and bowel and bladder malfunction. Reorient the
client as needed
Pulmonary Embolism Occurs when a substance (solid, gaseous, or liquid) enters venous circulation and
terminates in the pulmonary vasculature
- common origin from DVT
Risk Factors: Pulmonary Embolism
- oral contraceptive; estrogen therapy
- smoking
- HYPERCOAGULABILITY
- obesity
- surgery
- ATRIAL FIBRILLATION
- sickle cell disease
- immobility
- Tachycardia
- anxiey
- S3, S4
- decreased SaO2
- CRACKLES
- petechiae, cyanosis
Medications: Pulmonary Embolism
...
Alteplase, Streptokinase
Indications:
- A cerebral angiogram is used to assess the blood flow to and within the brain, identify aneurysms, and
define the vascularity of tumors (useful for surgical planning). It may also be used therapeutically to inject
medications that treat blood clots or to administer chemotherapy.
Nx Intervention: Preprocedure Angiogram
Preprocedure
If the client is pregnant, a determination of the risks to the fetus versus the benefits of the information
obtained by this procedure should be made.
Nursing Actions
NPO for 4 to 8 hours prior to the procedure.
Assess for allergy to shellfish or iodine, which
Ensure that the client is not wearing any jewelry. A mild sedative is usually administered
Nx Intervention: Intraprocedure Angriogram
- A catheter is placed into an artery (usually in the groin or
the neck), dye is injected, and x-ray pictures are taken.
Nx Intervention: Postprocedure Angiogram
Nursing Actions
...
Preprocedure
Client Education
- NO caffeine 6-9 hr prior to procedure
- Instruct the client to wash his hair prior to the procedure and eliminate all oils, gels, and sprays.
- If indicated, instruct the client, to be sleep-deprived, because this provides cranial stress, increasing the
possibility of seizure activity occurring during the procedure.
Intraprocedure
- Flashes of light or pictures may be used during the procedure to assess the client's response to stimuli.
- An EEG provides information about the ability of the brain to function and highlights areas of abnormality.
Postprocedure
Client Education
- Instruct the client that normal activities may be resumed.
Glasgow Coma Scale
Interpretation of Findings
- The best possible GCS score is 15. In general, total scores of the GCS correlate with the degree or level of
coma.
- 9 to 12: Indicate a MODERATE head injury
- Less than 8: Associated with SEVERE head injury and coma
ICP
Normal ICP is 10 to 15 mm Hg. Persistent elevation of ICP extinguishes cerebral circulation, which
will result in brain death if not treated urgently.
Symptoms of increased ICP include:
- severe headache
- deteriorating level of consciousness
- restlessness, irritability
- dilated or pinpoint pupils, slowness to react,
- alteration in breathing pattern (Cheyne Stokes respirations, central neurologic hyperventilation, apnea),
- deterioration in motor function, and abnormal posturing (decerebrate, decorticate, flaccidity).
Lumbar Puncture (Spinal Tap)
Preprocedure:
Indications
- capable of discriminating soft tissue from tumor or bone
Pain Management
...
- Substance P
- Prostaglandins
- bradykinin
- Histamine
Substances that decrease pain transmission and produces analgesia
endorphins
Serotonin
Nociceptive Pain
Nociceptive pain arises from damage to or inflammation of tissue other than that of
the peripheral and central nervous systems.
- it is usually throbbing, aching, and localized.
- this pain typically responds to opioids and nonopioid medications.
Types of nociceptive pain
Somatic: in bones, joints, muscles, skin, or connective tissues
visceral: in internal organs such as the stomach or intestines. it can cause referred pain in other body
locations not associated with the stimulus
Cutaneous: in the skin or subcutaneous tissue
Neuropathic Pain
- it includes PHANTOM limb pain, pain below the level of a spinal cord injury, and diabetic neuropathy.
- usually intense, shooting, burning, or described as "PINS and NEEDLES."
- typically responds to adjuvant medications (antidepressants, antispasmodic agents, skeletal muscle
relaxants).
Nonpharmacological Pain Management - transcutaneous electrical nerve stimulation (TENS)
- heat, cold, therapeutic touch,
- massage
Meningitis
Viral:
- DROPLET precautions which requires a private room or a room with cohorts, wearing of a surgical mask
when within 3 feet of the client, appropriate hand hygiene, and the use of designated equipment, such as
blood pressure cuff and thermometer. Continue until antibiotics have been administered for 24 hr.
- Implement fever-reduction measures, such as a cooling blanket, if necessary.
- Report infections to the public health department.
Decrease environmental stimuli.
Provide a quiet environment.
Minimize exposure to bright light
- Maintain bed rest with the HOB elevated to 30.
- Maintain client safety, such as seizure precautions.
Older adult clients are at an increased risk for secondary complications, such as pneumonia.
Medications: MeningitisCeftriaxone (Rocephin) or cefotaxime (Claforan)
Antibiotics given until culture and sensitivity results are available. Effective for bacterial infections.
Phenytoin (Dilantin)
Anticonvulsants given if ICP increases or client experiences a seizure.
Acetaminophen (Tylenol), ibuprofen (Motrin)
Analgesics for headache and/or fever - nonopioid to avoid masking changes in the level of consciousness.
Cipro and Rifampin
- prophylactic abx
Complications: Meningitis
Increased ICP
Triggering Factors
Absence seizures
- associated automatisms (behaviors that the client is unaware of: lip smacking or picking at clothes).
- loss of consciousness for several minutes.
- Amnesia may occur immediately prior to and after the seizure.
Simple partial seizures
- Consciousness is maintained throughout simple partial seizures.
- Seizure activity may consist of unusual sensations, a sense of dj vu, autonomic abnormalities, such as
changes in heart rate and abnormal flushing, unilateral abnormal extremity movements, pain or offensive
smell.
Seizure precaution
During a seizure:
Protect the client from injury (move furniture away, hold head in lap if on the floor).
Be prepared to suction oral secretions.
Turn to the side
Loosen restrictive clothing.
DO NOT attempt to restrain the client.
DO NOT attempt to open jaw or insert airway during seizure activity (may damage teeth, lips, and tongue).
Do not use padded tongue blades.
Document onset and duration of seizure and client findings/observations prior to, during, and following
the seizure (level of consciousness, apnea, cyanosis, motor activity, incontinence).
Post seizure:
Maintain the client in a side-lying position to prevent aspiration and to facilitate drainage of oral
secretions.
Check vital signs.
Allow the client to rest if necessary.
Reorient and calm the client (may be agitated or confused).
Institute seizure precautions including placing the bed in the lowest position and padding the side rails to
prevent future injury.
Determine if client experienced an aura, which can possibly indicate the origin of seizure in the brain.
Try to determine possible trigger (fatigue).
Medications: Seizures Administer prescribed antiepileptic drugs (AED), such as phenytoin (Dilantin):
therapeutic range: 1-2 mcg/dL
Nursing Considerations
- Initial goal is to control seizure activity using only one medication. If the chosen medication is not effective
either the dose is increased, or another medication is added or substituted.
- Medications should be taken at the same time every day to enhance effectiveness.
- Some antiepileptic medications cause oral gum overgrowth. Routine oral hygiene and dental visits can
minimize this side effect.
- When using phenytoin, specific instructions should include:
- avoidance of oral contraceptives, as this medication decreases their effectiveness.
- Warfarin (Coumadin) should also not be given with this medication.
Surgical Intervention: seizures placement of vagal nerve stimulator
- electrode placed on the left vagal nerve
- the client may hold a magnet over the site to stimulate the device at the onset of seizures
excision of the portion of the brain
Status Epilepticus
complications
- decreased O2 levels
- inability of the brain to return to normal functioning
- continued assault on neuronal tissue
Nursing Actions
- administer loading dose of diazepam (Valium) or lorazepam (Ativan) followed by continuous infusion of
the phenytoin (Dilantin)
Parkinson's Disease (PD)
characterized by:
- tremor
- muscle rigidity
- bradykinesia (slow movement)
- postural instability
sx occur dt overstimulation of the basal ganglia by ACETYLCHOLINE
- tx focuses on increasing the amount of DOPAMINE or decreasing the amount of acetylcholine
5 Stages: Parkinson's Disease (PD)
- Stage 1
- stooped posture
- drooling
- progressive difficulty with ADLs
Medications
- Dopaminergics
- Dopamine agonists
- Anticholinergics
- Catechol O methyltransferase (COMT) inhibitors
- Antivirals
Dopaminergics Levodopa (Dopar)
- converted to Dopamine in the brain, increasing the levels in the basal ganglia
- may be combined with carbidopa (Sinemet)
- Monitor for the "wearing off," which indicate the need to adjust the dosage or time of administration o the
need for the medication
Dopamine agonists
entacapone (Comtan
- decrease the breakdown of levodopa, making more available to the brain as dopamine
- can be used in conjunction with dopamine agonist or dopaminergic
Nx Management
- monitor for dyskinesia/hyperkinesia
- dark urine is NORMAL finding
Antivirals
amantadine (Symmetrel)
- Advanced age
- Genetic predisposition
- Environmental agents (herpes virus, metal, or toxic waste)
- Previous head injury
- Apolipoprotein E
7 Stages: Alzheimer's Disease
- Stage 1: NO IMPAIRMENT
- Stage 4: OBVIOUS MEMORY LOSS; Limited knowledge and memory of recent occasions, current events, or
personal history; Difficulty performing tasks that require planning and organizing (paying bills or managing
money)
7 Stages: Alzheimer's Disease - Stage 5: INABILITY TO RECALL IMPORTANT DETAILS such as address,
telephone number, or schools attended, but memory of information about self and family remains intact;
Disorientation and confusion as to time and place
- Stage 6: LOSS OF AWARENESS; Significant personality changes are evident (delusions, hallucinations, and
compulsive behaviors); WANDERING behavior; Increased episodes of urinary and fecal incontinence
- Stage 7: Ability to respond to environment, speak, and control movement is LOST; unrecognizable speech;
general urinary incontinence; inability to eat without assistance and impaired swallowing; gradual loss of all
ability to move extremities (ataxia)
Dx: Alzheimer's Disease - Genetic testing presence for apolipoprotein E can determine if late onset
dementia is dt AD
- There is NO definitive dx procedure
Nx Management: Alzheimer's Disease
Nx Management:
- observe for frequent stools and or upset stomach
- monitor for dizziness and or headache
- caution when given to COPD
Multiple Sclerosis
over time
A chronic and progressive disease with no known cure and sx progress in severity
- autoimmune disease
triggers:
- viruses and infectious agents
- living in a cold climate
- emotional/ physical stress
- pregnancy
- fatigue
- overexertion
- how shower/bath
s/s: MS - pain or paresthesia
- diplopia: deceased in visual acuity
- Uhthoff's sign (temporary worsening of vision and other neurological functions commonly seen in clients
with MS, or clients predisposed to MS, just after exertion or in situations where they are exposed to heat
- tinnitus, vetigo
- dysphagia
- dysarthria
- muscle spasticity
- nystagmus
- memory loss, impaired judgment
Nx Management: MS
integrity
- monitor: visual acuity, speech patterns, swallowing, activity tolerance and skin
- Crede: placing manual pressure on abdomen over the bladder to expel urine
- place eye patches to tx diplopia
- exercise and stretch
Medications: MS
A degenerative neurological disorder of the upper and lower motor neurons that result in deterioration and
death of the motor neurons. This results in a progressive paralysis and muscle wasting that eventually
causes respiratory paralysis and death. Cognitive function is NOT usually affected
s/s: Amyotrophic Lateral Sclerosis (ALS) - twitching and cramping of muscles
- muscle weakness -> usually begins in one part of the body
- muscle atrophy
- dysphagia
- dysarthria
Dx: Amyotrophic Lateral Sclerosis (ALS) - increased creatnine kinase (CK-BB) level
- muscle biopsy:
- reduction in number of motor units of peripheral nerves and atrophic muscle fuber
Nx Management: Amyotrophic Lateral Sclerosis (ALS)
intubate
- Keep HOB 45 deg; turn, cough, and deep breathe Q2hr; conduct incentive spirometry, CPT
- facilitate communication
- asses swallow reflex; thicken fluids PRN
- diet: high calories, high fiber and increase fluids
- utilize energy conservation
Medications: Amyotrophic Lateral Sclerosis (ALS)
Riluzole (Rilutek)
- glutamate antagonists: that can slow the deterioration of motor neurons by decreasing the release of
glutamic acid. Will add approximately 2 to 3 months of life to the client's overall lifespan
Nx Management: hepatotoxic risk; dizziness, vertigo and somnolence. Educate client: DO NOT drink alcohol,
take meds at evenly spaced regular intervals; store meds away from bright light
- Baclofen, Dantrium, Valium (antispasmodics)
Complications: Amyotrophic Lateral Sclerosis (ALS)
Pneumonia
- can be caused by respiratory muscle weakness and paralysis contributing to ineffective airway exchange
Respiratory failure dt mechanical ventilation
Guillain- Barre Syndrome (GBS) Develops in relation to acute destruction of the myelin sheath of peripheral
nerves dt an autoimmune disorder that results in varying decrees of muscle weakness and paralysis
Chronic Inflammatory demyelinating polyneuropathy (CIDP)
over a very long period, and recovery is rare
- Epstein-Barr virus
- Cytomegalovirus
- upper respiratory infection
- Vaccination (Swine Flu vaccination)
s/s: Guillain- Barre Syndrome (GBS)
- Recovery is in descending order
Morphine
- hypovolemia
- hypocalcemia
- hypokalemia
procedure can last 2-5 hrs
Myasthenia Gravis (MG)
A progressive autoimmune disease that produces severe muscular
weakness. Characterized by periods of exacerbation and remission. Muscle weakness improves with rest.
- it is caused by antibodies that INTERFERE with the transmission of ACETYLCHOLINE at the neuromuscular
junction
Risk Factors: Myasthenia Gravis - systemic lupus
- infection
- stress
- pregnancy
dx: Myasthenia Gravis Tensilon testing:
- EDROPHONIUM CHLORIDE: is administered
- it inhibits the breakdown of acetylcholine, making it available for use at the neuromuscular junction.
Positive results in marked improvement in muscle strength that lasts approx. 5 min
- Nx Management:
- observe for fasciculations around the eyes and face and cardiac arrhythmias
- have ATROPINE (antidote)
- Client Education
- discourage the client from demonstrating improvement by increasing effort, which could skew the test
results
Management: Myasthenia Gravis
when medications is peaking
Plasmapheresis
Eye exams
Tonometry
5 - 15 mmHg
4-12 mmHg
4-6L/min
60% - 80%
- level transducer with phlebostatic axis (4th intercostal space, mid-axillary line)
- zero system with atmospheric pressure
- hemodynamic pressure lines must be calibrated to read atmospheric pressure as zero, and the transducer
should be positioned at the right atrium
** HOB when obtaining readings should be 15-30 deg
Angiography
Indications
- unstable angina
- ECG (T wave inversion, ST elevation/ depression)
- to confirm location and extent of heart disease
Procedure: Angiography
Pre:
s/s
- hypotension
- jugular venous distention
- paradoxical pulse (variance of 10 mmHg or more in systolic BP between expiration and inspiration)
Nx Actions
- prepare the client for pericardiocentesis
** restinosis: clot reformation in the coronary artery can occur immediately or several weeks after procdure
Retroperitoneal Bleeding
Nx Actions:
- assess for flank pain and hypotension
PICC line care
- Assess Q8h
s/s:
- Erythma (early sign)
- Pain or burning at the site and the lenght of the vein
- WARMTH over the site
- vein indurated (hard), red streak, and/or cord like
Prevention
- observe site Q2h
tx
- dc infusion
- apply WARM COMPRESS
- restart with new tubing/infusate
Infiltration
Is fluid leaking into surrounding subQ tissue and extravasation is unintentional infiltration
s/s
- swelling
- Edema
- COOLNESS in skin
Prevention
- DO NOT use arm with MLC or PICC
- DO NOT use hand veins in older adult clients
- DO NOT use hand veins for vesicant medications
tx:
- Remove catheter
- apply COOL COMPRESS
- DO NOT start IV at same extremity
Cardioversion Is the delivery of a synchronized, direct countershock to the heart
Defibrillation Is the delivery of an unsynchronized, direct coutnershock to the heart. It stops all electrical
activity of the heart, allowing the SA node to take over and re-establish a perfusing rhythm
Procedure: Cardioversion
prior to tx
Intra:
- must synchronize and charge the machine; failure to synchronize can lead to lethal dysrhythmia, such as
vfib (defib is indicated for vfib)
Types of Pacemakers
...
External (transcutaneous)
- it is used in emergency resuscitation of a client who does not have pacing wires inserted
Epicardial Pacemaker
- leads are attached directly to the heart during open heart surgery
- pacing wires are threaded through a large central vein and lodged into the
- can resume sexual activity as desired, avoid positions that put stress on the incision site.
- Household appliances should not affect the pacemaker unless held directly over generator: garage door
openers, burglar alarms, microwave ovens and antitheft devices
- Will set off airport security detectors
- Inform other MDs and DMDs
- MRI and diathermy (heat therapy) is contraindicated
Angina Warning sign of an impending acute MI
- described as: TIGHT, SQUEEZING, heavy pressure, or constricting feeling in the chest. the pain can radiate
to the jaw, neck, or arm.
Types of Angina - stable angina (exertional): occurs with exercise or emotional stress and is relieved by rest
or nitroglycerin (Nitrostat)
- unstable angina (preinfarction angina): occurs with exercise or emotional stress, but it increases in
occurrence, severity, and duration over time
- variant angina (Prinzmetal's angina): dt a coronary artery spasm, often occurring during periods of rest.
** Pain unrelieved by rest or nitroglycerin and lasting more than 15 in differentiates an MI from angina
Angina vs MI
Angina
classification scale indicate how little, or how much activity it takes to make the
- S3 gallop
- orthopnea
- oliguria
- frothy sputum
- displaced apical pulse
s/s: right sided heart failure
- ascending dependent edema
- polyuria at rest
- abdominal distension (ascites
- weight gain
- hepatomegaly and tenderness
s/s: cardiomyopathy
- fatigue
- HF
- S3 gallop
- cardiomegaly
Lab tests: HF - Human B-type natriuretic peptides (hBNP): Elevated in HF; used to differentiate dyspnea rt
HF vs respiratory problem
- <100 pg/mL = no HF
- 100 to 300 pg/mL = HF is present
- > 300 pg/mL = mild HF
- >600 pg/mL = moderate HF
- >900 pg/mL - severe HF
Diuretics
- digoxin: take apical pulse for 1 min; < 60/min hold the med and notify MD
- monitor urine output
client education
- if pulse is irregular; hold meds and notify MD
- take digoxin dose same time each day
- DO NOT take digoxin with antacids; separate by 2 hrs apart
- toxicity signs: fatigue, muscle weakness, confusion, loss of appetite.
Therapeutic range: digoxin
0.8 to 2 ng/mL
Toxicity:
- decreased potassium level
- decreased apical rate < 60
- blurred vision
- dysrhythmia
- leg cramps
- anorexia
- altered metnal status
Vasodilators
Nitroglycerine (Nitrostat) and isosorbide mononitrate (Imdur): prevent coronary artery
vasospasms and reduce preload and afterload, decreasing myocardial O2 demand.
Nx Considerations
- caution with other antihypertensive medications
- can cause ORTHOSTATIC HYPOTENSION
Client Education
- HEADACHE is common side effects
- Encourage the client to site and lie down slowly
hBNPs nesiritide (Natrecor): used to treat acute HF by casing natriuresis (loss of sodium and vasodilation)
Nx Considerations
Nx Actions
s/s
- tachycardia
- ascending fluid level within the lungs (CRACKLES, productive cough, blood tinged sputum)
Emergency response
- position in high-Fowler's
- Administer O2, positive airway pressure, and/or intubation and mechanical ventilation
- IV morphine
- IV Lasix
** effectiveness = diuresis, reduction in respiratory distress, improved lung sounds, and adequate O2
Hypertension
...
Aneurysm
3 types
- abdominal
- aortic
- thoracic
Abdominal aneurysm
s/s
- usually 20 g needle
Nx Actions
- Hgb <8 g/dL, prescribed use only with NS
- Remain with the client for the first 15-30 min of the infusion
- complete the transfusion within 2-4 hr time frame to avoid bacterial growth
- Hgb should rise by 1g/dL with each unit transfused
Indications: Blood transfusions - Hgb 6 to 10 g/dL -> whole blood cells
- with anemia, Hgb 6 to 10 g/dL -> packed RBCs
Nx Action: Blood transfusion reaction
- STOP infusion
- Initiate NS infusion
- save the blood bag with the remaining blood and the blood tubing for testing at the lab
Anemia Nursing Care:
- increase folic acid, iron and B12
- teach energy conservation
Medications
- Iron supplements (administer IM Ztrack)
- hgb will be checked 4-6 weeks
- excessive Na intake
- renal failure
- Cushing syndrome
- aldosteronism
- antidiuretic hormone
Complication: Acute hypernatremia
Hypokalemia
Risk Factors:
s/s: hypokalemia
- hypotension
- respiratory distress
- hypoactive DTRs
- paresthesias, MUSCLE CRAMPING
- mental CONFUSION
- inverted T waves, ST depression
- GI: decreased motility, ileus
- polyuria
- METABOLIC ALKALOSIS
Nursing Management: hypokalemia
bananas
- peaked T waves
- INCREASED MOTILITY (GI)
- irritability
Nursing Management: Hyperkalemia
steps to take
- dc infusion
- hold PO potassium
- restrict diet high in potassium
- administer dextrose and regular insulin
- administer SODIUM BICARBONATE to reverse acidosis
- meds increase potasium: loop and thiazides diuretics
- KAYEXALATE, works as laxative and excretes excess potassium
Calcium - 8.5 mg/dL to 10.3 mg/dL
- 4.5 mEq/dL to 5.3 mEq/dL
Risk Factors: Hypocalcemia
- hypoalbuminemia
- ESKD
- hypoparathyroidism
s/s: Hypocalcemia
- Chvostek's sign
- Trouseau's sign
Magnesium
Risk factors
- malnutrion
- alcohol ingestion (magnesium excretion)
Nursing Management: Hypomagnesemia
- can cause diarrhea
GI Lab Values
...
- normal: 8 to 20 unit/L
- normal: 3 to 35 IU/L
** elevation occurs with HEPATITIS and CIRRHOSIS
Amylase
- normal: 59 to 90 IU/L
Post procedure:
Indications
- paralytic ileus
- cockily abdominal pain and distension
- hiccups
Complication: strangulated obstruction/ intestinal infarction
- occurs when a portion of the intestine is twisted or the blood supply is compromised
- monitor: increase pain, abdominal rigidity, fever, hypotension, tachycardia
Ostomies
- signs of stomal ischemia: pale pink, or bluish purple in color and dry in appearance
Intestinal Obstruction
- s/s: abdominal pain, hypoactive or absent bowel sounds, distention, n/v
TPN
- hypertonic IV bolus solution; purpose is to prevent or correct nutritional deficiencies and minimize
the adverse effects of malnourishment
- contains: 20% to 50% dextrose, lipids, protein, electrolytes, vitamins, and trace elements
When to initiate TPN
- A weight loss of 7% body weight and NPO for 5 days or more
- hypermetabolic state
TPN Guidelines of Care - NEVER abruptly STOP. Speeding up/slowing down the rate is contraindicated
- monitor VS Q4-8h
- change tubing and bag Q24h
- A filter is used on the IV bolus line
- DO NOT use the line for other IV bolus solutions
- DO NOT add anything to the solution
- check capillary glucose Q4-6h at least first 24 hrs
- Need supplemental Regular insulin
- Keep 10% dextrose at bedside, this will minimize the risk for hypoglycemia
- Older clients have increased incidence of glucose intolerance
Complications: TPN
metabolic
Nx Actions
- irrigate tube, color: CLEAR
Esophageal Cancer
dx:
- Esophagectomy/ esophagogastrostomy
Vagotomy Syndrome
- causes: dt interruption of the vagal nerve, similar to "dumping syndrome." Related to the quick passage of
food into the duodenum, which creates an osmotic gradient with large amounts of fluid entering the bowel
and manifesting itself as WATERY DIARRHEA. Occurs 15 to 60 min after a meal.
Nx Action
- observe for: diaphoresis, diarrhea, abdominal pain
- diet: 6 meals/day LACTOSE FREE
- stool samples
Nx Management: PUD Medications
- Flagyl, amoxicillin, bismuth, clarithromycin, tetracyline
Client Education
- Histamine receptor antagonists: Zantac, Pepcid
- use with antibiotics
- used to prevent stress to individuals who are NPO after major surgery, have large burns, septic and ICP
- proton pump inhibitors: Protoniz, Nexium, Prilosec
- inhibits the enzyme that produces gastric acid
- DO NOT crush, chew or break sustained-release
- Take Prilosec 1x/day prior to eating in am
Antacids: Aluminum carbonate, magnesium hydroxide (milk of magnesia)
- given 1-3 hours after meals
- give 1 hr apart after other meds
Mucosal protectant
Pernicious Anemia
- dt loss of intrinsic factor; decreased in RBC that occurs when the body cannot
absorb vit 12in the GI tract. vit 12 is necessary for RBC development
s/s:
- pallor, glossitis, fatigue, and paresthesias
Client Education
- routine life long B12 injections will be necessary
Dumping Syndrome
In response to the sudden influx of hypertonic fluid, the small intestine pulls fluid
form the extracellular space to convert the hypertonic fluid to an isotonic fluid.
Early sx:
- w/in 30 min after eating
- n/v, dizziness
- tachycardia, palpitation
Later sx
- 90 min to 3 hr after eating
- hunger and sweating
- shakiness and feelings of anxiety
- confusion
tx: administration of PECTIN: slows the absorption of carbohydrates. OCTREOTIDE: blocks gastric and
pancreatic hormones
Client Education: Dumping Syndrome
- nizatidine (Axid)
- famotidine (Pepcid)
- ranitidine (Zantac)
Nx Intervention
- monitor for neutropenia and hypotension
- administer SLOWY, or it will cause bradycardia and hypotension
Client Education
- DO NOT smoke or drink alcohol
- take with FOOD
Antacids
s/s
- fever
- diarrhea 15-20 liquid stools/day
- high pitched bowel sounds
- abdominal distension, tenderness, firmness upon palpitation
Crohn's disease s/s:
- pain right-lower quadrant
- fever
- diarrhea (5 stools/day with mucous or pus)
- Steatorrhea
- high pitched bowel sounds
Labs
- elevated ESR and WBC (inflammation); decreased Hct (blood loss), decreased folic acid and albumin
(malabsorption)
Diverticulitis
s/s:
- xray, CT
Toxic Megacolon
Occurs dt inactivity of the colon. Massive dilation of the colon occurs and the client
is at risk for perforation
Irritable Bowel Syndrome (IBS) Differs from UC and Crohn's bc it DOES NOT cause structural damage to the
GI tract and does not involve an inflammatory process. It DOES NOT predisposes the client to CANCER.
Health Promotion
- AVOID food that contains DAIRY, EGGS, and WHEAT products
- AVOID alcoholic and caffeinated beverages
- Encourage 2-3 L/fluid per day
- Increase the amount of daily fiber
Risk Factors
- FEMALE
- stress
- eating large meals containing a large amount of fat
- Caffeine
- Alcohol
s/s" IBS - cramping pain in abdomen
- nausea with meals or passing stools
- abdominal bloating
- BLETCHING
- diarrhea
- constipation
Medications: IBS
Alosetron (Lotronex): blocks 5-HT4 receptors that innervate the viscera and result in
increased firmness in stools, and decrease the urgency and frequency of defecation
Nx Considerations
- sx should resolve w/in 1-4 weeks but will return 1 week after medications
Lubiproston (Amitiza) is an IBS specific medication that increases fluid secretion in the intestine to promote
intestinal motility.
Nx Consideration
s/s
Care
- clamp 1 to 2 hr before and after meals
- avoid heavy lifting and strenuous activity 4-6 weeks post-op
- empty drainage bag Q8h
- take shower rather than baths
- left on for 1-2 weeks post-op
- color of stool should return to brown after a week
gas forming foods
- cabbage
- beans
- broccoli
- cauliflower
Pancreatitis
Location: knife-like pain (left upper quadrant, mid epigastric radiating to the back)
Risk Factors
- alcoholism
- bilary tract disease
- ERCP
Triggers
- fat and alcohol consumption
s/s
- not relieved by vomiting
- pain is worse when lying down or while eating
- Ecchymoses on the flanks (Turner's sign)
- bluish periumbilical discoloration (Cullen's sign)
** most at risk for:
- generalized jaundice, paralytic ileus, hyperglycema
- tetany: trousseau's sing, Chvostek's sign dt hypocalcemia (greatest risk = cardiac dysrythmias)
- peritonitis: abdominal pain radiating to the shoulder and the abdomen is rigid
Lab tests:
s/s:
labs
- ELISA: confirms the presence of antibodies to hep C
- elevated AST (normal: 8 to 20 u/L or 3 to 35 ui/L)
- elevated ALT (normal: 5-40 u/L)
- elevated ALPL (normal: 42 to 128 u/L; 30-85 ui/L)
- total bilirubin: elevated (normal: 0.1 to 1 mg/dL)
Nx Management: Hepatitis
- universal precaution
- limit activity
- diet: high carbohydrate, high calorie, low to moderate fat, low to moderate protein, ad small frequent
meals to promote nutrition and healing
- Administer interferon for HBV and HCV
Complication: Hepatitis Portal systemic encaphalopathy (PSE)
- the liver is unable to convert ammonia and other waste products to a less toxic form. These products are
carried to the brain and cause neurological sx.
Nx Action
- Administer LACTULOSE: reduces the ammonia levels in the body via intestinal excretion
- report asterixis (flapping of the hands) and fetor hepaticus (liver breath)
- diet: protein restricted or ONLY vegetable diet
Procedure: Hemodialysis
circulation.
Shunts the client's blood from the body through a dialyzer and back into
Preprocedure
- assess site patency (presence of bruit, thrill, distal pulses and circulation)
- meds that lower blood pressure are usually held until after dialysis
- instruct client to notify nurse if muscle cramps, h/s, nausea, dizziness that occur during the procedure
Intraprocedure
- administer anticoagulants as prescribed; have PROTAMINE SULFATE antidote for heparin
Postoperative
Disequilibrium syndrom
- caused by too rapid decrease of BUN and circulating fluid volume -> cerebral edema and ICP
s/s: loss of consciousness, seizures, agitation
Anemia
- blood loss and removal of folate during dialysis
- increase food in folate
Infectious diseases
- increase risk for HIV and HBV and HCV
Procedure: Peritoneal Dialysis Involves instillation of fluid into the peritoneal cavity. The peritoneum
serves as the filtration membrane
Preprocedure:
- The client feel fullness when the dialysate is dwelling
Intraprocedure:
- monitor the color (clear, light yellow is expected) and amount (expected to equal or exceed amount of
dialysate inflow) of outflow
- monitor for serum glucose level
- warm the dialysate prior to instilling; DO NOT use microwaves
- maintain surgical asepsis
- keep outflow bag lower than the client's abdomen
- reposition the client if inflow or outflow is inadequate
- milk peritoneal dialysis if fibrin clot has formed
Complications: Peritoneal Dialysis
Peritonitis
characterized by:
- proteinuria
- hypoalbuminemia
- edema
Acute Renal Failure (ARF)
- Onset: begins with the onset of the event and lasts for hours to days
- Oliguria: begins with the renal insult and lasts for 1 to 3 weeks
- Diuresis: begins with the kidneys start to recover and can last for 2 to 6 weeks
- Recovery: continues until renal function is fully restored and can take up to 12 months
Chronic Renal Failure (CRF)
Nx Management:
s/s:
- cockily abdominal pain
- burning, urgency, and frequency in urination
- fever, flank and back pain
- nucturia
lab test
- Dark, cloudy appearance with foul odor
- positive leukocyte esterase
- positive nitrate
Medications: Pyelonephritis
-opioid analgesics
- NSAIDs
- antibiotics: nitrofurantoin (Macrodantin)
- notify MD if persistent cough start
- may turn urine BROWN
Renal Calculi
Risk Factors
- more in MALES
- dehydration
- increased uric production
s/s
- severe pain: intensifies as stone moves through the ureter, FLANK pain suggest stones are located in the
kidney
- fever
- oliguria
- hematuria
- diaphoresis, pallor, n/v, tachycardia/pnea
Medications
- uses sound, laser, or shock wave energies to break the stone into fragments
Nx Action
- Asess gross hematuria
- strain urine following the procedure
- inform the client that bruising is normal at the site where waves are applied and hematuria may be
present post-procedure
Client Education: Renal Calculi Educate the client regarding the role of diet and medications in tx ad
prevention of urinary stones
- Diet: LIMIT intake of food high in ANIMAL PROTEIN, SODIUM, CALCIUM.
- Thiazide diuretics: are used to increase calcium reabsorption
- Orthophosphates: used to decreased during saturation of calcium oxalate
- Calcium Oxalate food: AVOID Spinach, black tea, rhubarb, cocoa, beets, pecans, peanuts, okra, chocolate,
wheat germ, lime peel, and swiss chard
Uric Acid (urate): decrease intake of purine sources:
- AVOID: organ meats, poultry, fish, gravites, red wine, sardines
- Struvite (magnesium ammonium phosphate): AVOID dairy products, red and organ meats, whole grains
- Sodium cellulose phosphate: is used to reduce intestinal absorption of calcium
- Crystine: LIMIT ANIMAL PROTEIN intake
- Captropril (Capoten) is used to lower urine cystine
Types of Voiding Disorders
- Stress: the loss of small amounts of urine when laughing, sneezing, or
lifting. it is primarily related to WEAK pelvic muscles, urethra, or surrounding tissues
- urge: The inability to stop urine flow long enough to reach the bathroom. related to OVERACTIVE detrusor
muscle with increased bladder pressure
- overflow: urinary retention associated with bladder OVERDISTENTION and frequent loss of small amounts
of urine. Related to OBSTRUCTION of urinary outlet or an impaired detrusor muscle
- Relfex: the involuntary loss of moderate amount of urine usually w/o warning. related to HYPERREFLEXIA
of the detrusor muscle, usually form SPINAL CORD activity
- Functional: the inability to make it to the bathroom to urinate. Related to PHYSICAL, COGNITIVE and
SOCIAL impairment
- Total incontinence: The unpredictable, involuntary loss of urine that does not generally respond to tx
Nx Management: Voiding Disorder
- instruct the client to try and hold urine, and stay in schedule with bladder training
- Drink CRANBERRY JUICE
Complications: Voiding Disorder - skin breakdown rt chronic exposure to urine
- social isolation rt chronic wetting
Syphillis Testing - Venereal disease research laboratory (VDSL)
- Rapid plasma regain (RPR)
** if both test confirms (reactive) syphillis, additional tests is required
- Flourescent treponemal antibody absorbed (FTA-ABS)
- Treponema pallidum partical agglutination assay (TPPA)
Mammography - should be done 1-2 years beginning at age 40; if family hx indicates risk should be done at
an earlier age
** if suspicious lesion is identified it is followed up by a fine needle aspiration or open biopsy
Preprocedure
- AVOID the use of deodorant or powers in the axillary region or on the breast prior to the exam
- CONTRAINDICATED for PREGNANT women
Hormone Replacement Therapy FSH level is indicated to check dx menopause
contraindication
- smoking, hx of cancer, hx of thrombosis
Nx Actions
- DO NOT smoke
- prevent thrombosis
- avoid wearing knee high stockings
- avoid sitting for long periods of time
- take short works
- report sx of unilateral pain, edema, warmth
- TAKE with FOOD to prevent nausea
Alternative therapy
- Dong quai and black cohosh
- phytoestrogen: dandelion greens, alfafa sprouts, black beans and soy beans
- vit E to help decreased hot flashes
Beneficial in prevention of
- osteoporosis
- atrophic vaginitis
Cystocele
Is a protrusion of the posterior ladder through the posterior vaginal wall. It is caused by
weakened pelvic muscles and/or structures
s/s
- frequent UTI
Rectocele
Is a protrusion of the anterior rectal wall through the posterior vaginal wall. It is caused by a
defect of the pelvic structures a difficult delivery, or forceps delivery.
s/s
- pushing feces out of the vagina
- bleeding during urination
- pain during sexual intercourse
Breast Cancer Risk Factors
- age > 40
- genetics
- excessive alcohol intake
- smoking
- HRT
s/s
- breast pain or soreness
- skin change (peau d' orange)
- dimpling
Post-op care
- Avoid placing her arm in a dependent arm position, this will interfere in healing
- Encourage arm and hand exercises to prevent lymphadema and regain full ROM
- DO NOT wear constrictive clothing
Cervical Cancer Risk Factors
- early sexual activity (< 18 years old)
- multiple partners
- family hx of cervical cancer
- AFRICAN AMERICAN
- HPV
- HIV
- cigarette smoking
- intrauterine exposure to diethylstilbestrol during pregnancy
s/s
- painless vaginal bleeding between periods
-water, blood tinged vaginal discharge
- weight loss
- pelvic pain
dx
- Cervical bx is DEFINITIVE
Testicular Cancer
- ages 15 to 35
Post-op care
- palpate redisual limb for warmth. heat may indicate infection
- differentiate between phantom limb (tx beta blockers: propranolol and antiepileptics: neurontin) and
incisional limb pain
Client's perception and feelings about amputation
- allow the client/family to grieve for the loss
- feelings: depression, anger, withdrawal and grief
- rehab should include adaptation to new body image and integration of prosthetic and adaptive devices
into self image
Residual limb prep and prosthetic fittingResidual limb must be shaped and shrunk in preparation for
prosthetic training
Shrinkage interventions:
- Wrapping the stump, using ace bandages (figure 8) to prevent restriction of blood flow
- utilizing stump shrinker sock
- using an air splint (plastic inflatable devise) inflated to 20-22 mm Hg for 22-24 hr/day
Phantom Limb Pain
Is a sensation of pain in the location of the extremity following the amputation. This
is related to servered nerve pathways and is frequent complications in clients who experience chronic limb
pain before the amputation. It occurs less frequently following traumatic amputation. Tends to lessen with
time but some client experience pain or sensation indefinitely.
Nx consideration
- recognize the pain is real and manage accordingly
- described as deep and buring, cramping, shooting or aching.
Flexion contractures
Can occur in the hip or knee joint following amputation dt improper positioning
Nx Actions
- Prevention: ROM exercises and proper positioning
- AVOID elevating the stump on a pillow after the first 24 hrs
- Have the client lie prone several times a day
- DO NOT sit for a long time
Osteoporosis Occurs when the rate of bone resorption (osteoclast cells) exceeds the rate of bone
formation (osteoblast cells) resulting in fragile bone tissue and subsequent fractures.
health promotion and disease prevention
- reduced height
- Calcium supplement
- give with food and with water
- may cause GI upset
- monitor for kidney stones
Vit D supplement
- toxicity can occur: nausea, constipation, kidney stones
Thyroid hormone: calcitonin (Miacalcin)
- can be given IM/subQ or nasally; use alternate nostrils
Types of fractures
- crepitus
- deformity
- muscle spasms
- edema
- ecchymosis
Nx Management: Fractures
Mole skin: is used over any rough area of the cast that may rub against the client's skin
Nx Actions
- web roll is applied prior to cast application
- use gloves to touch the cast until its completely dry
- elevate cast above the level of the heart 1st 24 hours
- if any drainage is seen on the cast, it should be outlined, dated, and timed
Client Education
- DO NOT place any foreign objects under the casts
- itching can be relieved by blowing COOL air from a hair dryer
- Plastic covering over the cast can be used to avoid soiling form urine or feces
- use plastic to cover while showers and baths
Types Traction - skin tractions: the pulling force is applied by weights that are attached by rope to the
client with tape, straps, boots, or cuffs
- Ching halter straps,
- Bryant's traction (congenital hip dislocation in children),
- Buck's traction (used for hip fractures)
- manual: a pulling force is applied by the hands of the provider for temporary immobilization, usually with
sedation or anesthesia
- skeletal: the pulling force is applied directly to the bone. weights up to 25 lbs can be applied
- Halo and Gardner-Wells: cervical injuries
- halo screws: are placed through a halo type bar that encircles the head. Assure that the wrench to release
the rods is attached to the vest in case of need for CPR
Nx Management: Traction
- assure weights hang freely
manifestation
- decreased mental acuity
- respiratory distress
- tachycardia/pnea
- fever
- cutaneous petechia
Nx Action
- PREVENTION: immobilization of fractures of the long bones and minimal manipulation during turning
- tx: O2, corticosteroids for cerebral edema, vasopressors, and fluid replacement for shock
DVT
Nx Actions
- administer anticoagulants
- encourage fluid intake
- rotate feet and ankles and perform other lower extremity exercises
Osteomylitis
s/s:
- bone pain that is worse with movement
- erythma and edema at the site of infection
- fever
- leukocytosis, elevated ESR
dx: biopsy is DEFINITIVE
tx: 3 months of abx, hyperbaric oxygen tx (100% O2 with increase in atmospheric pressure)
- radiographs and CT scan shows decreased joint space and bone spurs
Nx Management: Osteoarthritis - balance rest with activity
- encourage the use of CAM, tai chi, hypnosis magnets, music therapy and acupuncture.
- splint joints
- use assistive devices to promote safety and independence
Medications: Osteoarthritis
Topical Analgesics:
Risk Factors:
- genetics
- stress
- seasons
- hormones
s/s:
- SCALY patches
- bleeding stimulated by removal of scales
- skin lesions primarily on the scalp, elbows, knees and genetitals
Medications: Psoriasis topical glucocosteroids: Kenalog
- apply avoid use on the face or in skin folds, and take periodic medication vacations
Tar preparations: Coal Tar
- repress cell divisions and decreases inflmmation and itching, may stain skin and hair
- dt odor and staining, should apply at NIGHT and cover areas of body with old pajamas, gloves and socks
Topical epidermopoiesis suppressive medications: Calcipoteriene and tazarotene
- NOT recommended for OLDER ADULTS
- side effects; hypercalcemia: muscle weakness, fatigue and anorexia
- DO not put on face or skin folds
- burning and stinging can occur when applied
- use sunscreen
Cytotoxic: Methotrexate
- monitor for bone marrow suppression
- avoid alcohol
tx: Psoriasis
Topica corticosteroids
- Clean and dry the skin immediately following urine or stool incontinence
- apply moisture barrier creams to the skin of clients who are incontinent
- use TEPID water, use minimal scrubbing, and pat the skin dry
- diet: high protein and vegetables
Nx Management: Pressure Ulcers
- Antimicrobial therapy
- elevated hct and hgl: dt loss of fluid shift into interstitial space
- decreased Na dt third spacing
Restoration of Mobility: Burns - maintain correct body alignment, splint extremities, and facilitate position
changes to prevent contractures
- maintain active and passive ROM
- apply pressure dressings to prevent contractures and scarring
Medications: Burns
- painful on applications
- discolors wound, DOES NOT penetrate ESCHAR
- Silver sulfadiazine 1%
- maintains joint mobility
- effective against gram pos bacteria/ yeast
- may cause neutropenia
- Mafenide acetate
- penetrates ESCHAR, effective on ELECTRICAL wounds
- may cause metabolic acidosis or hyperpnea
- Bacitracin
- maintains joint mobility; PAINLESS, easy to apply
- limited effectiveness on gram-neg organisms
tx: burns
Mechanical debridement:
- use scissors and forceps to cut away the dead tissue during hydrotherapy tx
hydrotherapy tx
- use mild soap or detergent to gently wash burns and then rinse with room temp water
- encourage joint exercise during tx
- use enzymatic topicals to breakdown and remove dead tissue
Nx Actions: following a graft for burn tx - maintain immobilization of graft site
- ELEVATE extremety
- provide wound care to the donor site
Water deprivation
Measures the kidneys' ability to concentrate urine in light of an increased plasma
osmolality and low plasma vasopressin level
Indications:
- DM insipidus (Na has to be normal range and osmolality is <300 mOsm/kg H2O
Procedure: Water deprivation - client at recumbent position for 30 min
- obtain 7-10 of heparinized blood in an ice tube and sent to lab
- ask the client to empty the bladder, record the amount and sent the specimen to lab
- weight the client
- initiate fluid resuscitation
- repeat 3 steps hourly; record sx if any
- continue steps until serum Na concentration or osmolality rises
Complication
- dehydration
Fasting Glucose Normal: less than 110 mg/dL
- client NPO for 8 hrs
- antidiabetic meds should be postponed
Oral glucose tolerance test
- instruct to consume a balanced diet for 3 days prior to the test, and NPO 10-12hrs prior to test
- A fasting glucose is drawn at start of the test -> glucose is given to the client -> blood glucose is drawn
Q30min for 2hrs.
- Monitor for hypoglycemia
HbA1c - 5% or less indicates NO DM
- 6.4% indicates preDM
- 6.5% or higher indicates DM
** it is an indicator of blood glucose for the past 120 days
DM Insipidus
Types
- head injury
- meningitis
- infection
- surgery around the pituitary gland
- taking lithium or democlocycline
- older adult clients
s/s: DM insipidus
- polyuria
- polydipsea
- nocturia
- fatigue
- dehydration
Vassopressin test
A subQ test injection, produces a urine output with an increased specific gravity
- for intranasal dose: clear nasal passage and sit upright prior to nasal inhalation
- notify MD of weight gain 2lb in 24hrs
ADH stimulants: Carbamazepine
- take with food
- monitor for dizziness and drowsiness, thrombocytopenia
Demeclocycline:
- tetracycline derived
- it may take 1 weeks to see result
- advise for yeast infection
- rinse toothbrush with diluted (10%) bleach and increase yogurt consumption
Lithium
- s/s of toxicity: nausea, diarrhea, tremors, ataxia
- effectiveness in 1-3 weeks
- take with FOOD
Furosemide
- can worsen hyponatremia
- advise to position slowly -> orthostatic hypotension
- AVOID alcohol consumption
Complications: SIADH
Overview: the thyroid gland produces 3 hormones: thyroxine (T4), triiodothyronine (T3) and thyrocalcitonin
(calcitonin). T3 and T4 is regulated by the ANTERIOR pituitary gland; when T3 and T4 levels decreases -> TSH
is released by the anterior pituitary gland, stimulating the thyroid to secrete more hormones.
Risk Factors
- Grave's disease: autoimmune mimics TSH -> hypersecretion of thyroid hormones
s/s: Hyperthyroidism
- tremor
- HEAT intolerance
- PALPITATIONS
- hyperactivty
- BRUIT over the thyroid gland
- elevated systolic pressure with widened pulse pressure
- WEIGHT LOSS
- EXOPTHALMUS
- older adult often present with HF and atrial fibrillation
Nx Management: Hyperthyroidism
Propranolol (Inderal)
- take apical pulse before each dose
Saturated solution of potassium iodide (SSKI): inhibit the release of stored thyroid hormone and retard
hormone synthesis
- short term use only
- give 1 hr after an antithyroid med
- contraindicated on pregnant women
Radioactive therapy
producing cells
Radioactive iodine is taken up by the thyroid and destroys some of the hormone
- delirium
- vomiting
- abdominal pain
- hyperglycemia
- tachydysrhthias
Nx Management: Thyroid Stormqm
- administer acetaminophen
s/s
- diet: low calorie, high bulk -> encourage activity to prevent constipation
- provide extra clothing and blankets for client with decreased cold tolerance
Medications: Hypothyroidsim
Levothyroxine (Synthroid)
- increases the effects of warfarin (Coumadin) and can increase the need for insulin and digoxin (Lanoxin)
Client education
- tx begin slowly, dosage is increased Q2-3 wks
- tx is lifelong
Complications: Hypothyroidsim Myxedema Coma
- life threatening condition that occurs when hypothyroidism is untreated or when a stressor, such as
infection, affects an individual who has hypothyroidism.
Risk Factors
- sudden abrupt stop of synthroid
s/s
- hypoxia, hypercapnia
- decrease CO
- stupor
- hypotension
- hypoglycemia
- hyponatremia
Nx Management: Myxedema Coma
cause adverse cardiac effects
- administer corticosteroids
- check for infection
Cushing's Syndrome
Caused by over secretion of the ADRENAL CORTEX (mineralocorticoids: aldosterone;
Glucocorticoids: cortisol; sex hormones: androgens and estrogens). The adrenal cortex over secretes
GLUCOCORTICOIDS, resulting in increased cortisol and increased androgens
Risk Factors
- adrenal hyperplasia, adrenocortical carcimona
- organ transplant
- chemotherapy
- asthma, allergies, chronic inflammatory disease
s/s
- weakness, fatigue back and joint pain
- thin fragile skin
- bruising and petechiae
- HTN (sodium and water retention)
- weight gain, dependent edema
Health Promotions and Disease prevention: Cushing's Syndrome - diet: high in calcium and vit D; decreased
Na, AVOID alcohol and caffeine
- AVOID infections
labs: Cushing's Syndrome
- elevated ACTH
- decreased serum K and Ca
- increased Na
- increased glucose
Nx Management: Cushing's Syndrome Aminoglutethimide
- decreases adrenal hormone synthesis to provide short term symptom relief for clients with Cushing's
syndrome
ketoconazole (Nizoral)
- adrenal corticosteroid inhibitor; is an antifungal agent that when taken in high dosages inhibits adrenal
corticosteroids synthesis
Addison's
The production of of mineralocorticoids and glucocorticoids is diminished, resulting in
decreased aldosterne and cortisol
- Adrenal crisis also known as acute adrenal insufficiency, has a rapid onset.
Risk Factors
- TB
- idiopathic autoimmune
- Cancer
- STEROID WITHDRAWAL
- pituitary neoplasm
s/s
- hyperpigmentation
- weakness and fatigue
- dehydration
- hypoNa, Ca, hypoglycemia, hyper K
Medications: Addison's Fludrocortisone (Florinef)
- a mineralocorticoid used as a replacement in adrenal insufficciency
- monitor HTN
Client education
- sensory alteration
- exercise patterns
Teach the client proper foot care
- inspect feet daily, wash with mild soap and warm water
- RAPID acting
- Intermediate
- onset: 1-2 h
- peak: 4 -12 hrs
- duration: 18-24 hrs
Insulin glargin (Lantus) - LONG acting
- onset: 1h
- peak none
- duration: 10.4 to 24 hrs
Nx Management: Insulin administration - DO NOT mix insulin glargine (Lantus) with other insulins dt
incompatibility
Metformin
- impaired vision
- foot injury
- renal failure
Diabetic Ketoacidosis (DKA)
An acute, life threatening condition characterized b hyperglycemia (> 300
mg/dL), resulting in the breakdown of body fat for energy and an accumulation of ketones in the blood ad
urine.
Risk Factors
- type 1 DM
s/s
- n/v, abdominal pain
- polyuria, polydipsia, polyphagia
- ketones present in urine
- metabolic acidosis
Hyperglycemic hyperosmolar state (HHS)
an acute, life threatening condition characterized by
profound hyperglycemia (>600 mg/dL) dehydration and an absence of ketosis. Onset occurs several days
and the mortality rate is up to 15%
Risk Factors
- untreated or undiagnosed type 2 DM
- polyuria, polydipsia, polyphagia
- generalized SEIZURES
- NO KETONES in urine
- Absences of acidosis
Risk Factors: DKA
...
- when glucose serum reaches 250 mg/dL, add glucose to IV fluids to minimize the risk of cerebral edema
associated with drastic changes in serum osmolality
- Administer Regular Insulin 0.1unit/kg, IV bolus dose then follow by continuous IV infusion of Regular
insulin 0.1 unit/kg/hr
- monitor glucose and K; K levels will initially be elevated with insulin therapy, but potassium will shift into
cells and the client will need to be monitored for hypokalemia.
- Administer sodium bicarbonate by slow IV infusion for severe acidosis (pH <7.0)
HIV/AIDS
- HIV is found in feces, urine, tears, saliva, cerebrospinal fluid cervical cells, lymph nodes,
corneal tissue, and brain tissue
- ALL women who are pregnant should be screened for HIV
Stages of HIV infection Stage 1: manifestation 2-4 weeks of infection; sx similar to influenza, marked by
rapid rise in the HIV viral load, decreased CD4+ cells and increased CD8; lymphadenopathy persists
throughout the disease process
Stage 2: asymptomatic for up to 10 years; Ati HIV antibodies are produced HIV positive; over time the virus
begins active replication using the host's genetic machinery; CD4+ are destroyed, viral load increases,
dramatic loss of immunity begins
Stage 3: AIDS characterized by life threatening opportunistic infections, w/o tx death occurs within 3-5
years.
s/s: HIV/AIDs
- chills
- anorexia
- weakness and fatigue
- headache
- night sweats
labs: HIV/AIDS - pancytopenia
- platelet count < 150,000/mm3
** ELISA confirmed by positive result then Western blot test
- p24 antigen test neutralization assay
- PCR test
medications: HIV/AIDS Highly active antiretroviral therapy (HAART): involves using 3-4 medications in
combination with other antiretroviral medications to reduce medication resistance
- Enfuvirtide (Fuzeon)
- Necleoside rever transcriptase inhibitors (NRTIs)
- non- nucleoside reverse transcriptase inhibitors (NNRTIs)
- Protease inhibitors
- Antineoplastic medication
Care After discharge: HIV/AIDs - refer to local support groups
client education
- practice good hand hygeine
- AVOID traveling in crowded and por countries
- AVOID raw foods, such as vegetables and meat
- AVOID clean pet litter boxes to reduce the risk of toxoplamosis
Complications: HIV/AIDS
Opportunistic infections
- TB, pneumonia
- T(toxoplasmosis) O(other infections) R (rubella) C (cytomegalovirus) H (herpes)
Wasting Syndrome
- maintain nutrition
- FEMALES
- ANA titer: positive in 90% (normal is negative ANA titer in a 1:20 dilution
NSAIDS
- reduce inflammation
Corticosteroids
- Do not stop or decrease dose abruptly
prednisone:
- side effects: weight gain, buffalo hump, moonface, abdominal striae, elevated blood glucose
Methotrexate and Imuran
- suppresses immune response
- monitor for bone marrow suppression
Antimalarial: hydroxochloroquine (plaquenil)
- used for suppression of synovitis, fever and fatigue
- do frequent eye exams
Discharge Care: SLE
Overview: Progressive inflammatory disease that can affect tissues and organs but principally attacks the
joints producing an inflammatory synovitis. It involves joints bilaterally and symmetrically, and typically
affects several joints at one time.
Risk Factors: RA - FEMALE
- ages 20-50
- genetics
- EPSTEIN BARR VIRUS
- stress
s/s: RA - fatigue and joint discomfort
- pain at rest and with movement
- pleuritic pain (upon inspiratio)
- paresthesia
- recent illness/ stressor
- joints may become deformed merely by completing ADLs
labs: RA- Anti- CCP antibodies: positive
- ESR: elevated
- 20-40 mm/hr is mild inflammation
- 40-70 mm/hr is moderate inflammation
- 70-15o mm/hr is severe inflammation
- C-reactive protein: positive
- ANA titer: positive
- elevated WBC
Nx Management: RA
NSAIDS
Sjogren's syndrome: triad of sx: dry eyes, dry mouth and dry vagina
Nx Action
preparation
- client skin is marked with tattoos that guide the positioning of the external source
On going care
- DO NOT eat RED MEAT
- schedule rest periods
Client Education
- inform that fatigue is common
- gently wash the skin over the irradiated area with MILD SOAP and WATER, PAT to DRY
- DO NOT remove "tattoos"
- DO NOT apply POWDERS, OINTMENTS, LOTIONS or PERFUMES to the irradiated skin
- wear soft clothing over the irradiated skin, AVOID tight or constricting clothes
- DO NOT expose skin to the sun or heat source
Hormonal Therapy
client Education
- notify MD when signs of infection and systemic infusion is observed
Transcutaneous electrical nerve stimulation (TENS)
Low voltage electrical impulses are transmitted
throuh electrodes that are attached to the skin near or over the area of pain
Nx Action
- use with conductive gel