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Rle (NCM 116) Cases
Rle (NCM 116) Cases
Rle (NCM 116) Cases
ZERNA
NCM 116 CASES
RHEUMATOID ARTHRITIS
ASSESSMENT DIAGNOSIS MEDICAL-SURGICAL MGT NURSING INTERVENTION
Presence of Rheumatoid nodules The tests typically ordered for Early RA: The most common issues for the
Joint inflammation during diagnosis may include: Salicylates or NSAIDs. COX-2 patient with RA include pain, fatigue,
palpation Rheumatoid factor (positive) medications block the enzyme limited mobility, and many more. To
Classical symptoms may include: Erythrocyte sedimentation rate involved in inflammation address these issues, some
Joint pain, swelling, warmth, (increased) Analgesics. Additional analgesia interventions may include:
erythema, and lack of function in CBC (moderate anemia; inc. may be prescribed for periods of
affected areas WBC) extreme pain. Provide a variety of comfort
Other symptoms may include: C-reactive protein Methotrexate. Methotrexate is measures
Sunrise stiffness (most severe X-ray of involved joints (soft- currently the standard treatment Administer anti-inflammatory,
pain), soft feeling in joints, and tissue swelling, erosion of joints, of RA because of its success in analgesic, and slow-acting
that it is bilateral or symmetrical etc.) preventing both joint destruction antirheumatic medications as
and long-term disability. prescribed.
Moderate, erosive RA: Encourage verbalization of
Formal program of occupational feelings about pain
and physical therapy; an Assess for subjective changes in
immunosuppressant such as pain
cyclosporine may be added. Explain how to use energy
Persistent, erosive RA: conservation techniques
Reconstructive surgery and Facilitate development of
corticosteroids. appropriate activity/rest
Advanced unremitting RA: schedule
Immunosuppressants. Encourage adequate nutrition
Immunosuppressive agents are Assist patient and teach them
prescribed because of their about the use of assistive devices
ability to affect the production of for mobility.
antibodies at the cellular level.
Antidepressants. For most
patients with RA, depression and
sleep deprivation may require
the short-term use of low-dose
antidepressants such as
amitriptyline, paroxetine, or
sertraline, to reestablish an
adequate sleep pattern and to
manage chronic pain.
CEREBROVASCULAR ACCIDENT
ASSESSMENT DIAGNOSIS MEDICAL-SURGICAL MGT NURSING INTERVENTION
Stroke can have a variety of Tests ordered to diagnose CVA Recombinant tissue plasminogen Nursing care has a significant impact
symptoms depending on many includes: activator would be prescribed on the patient’s recovery. In
factors. But general signs and Non-contrast CT scan unless contraindicated, and there summary, here are some nursing
symtoms include: PET scan should be monitoring for interventions for patients with
Numbness or weakness of the MRI bleeding. stroke:
face. 12-lead ECG and carotid Increased ICP. Management of Position to prevent contractures,
Change in mental status. ultrasound increased ICP includes osmotic relieve pressure, attain good
Trouble speaking or CT angiography or MRI and diuretics, maintenance of PaCO2 body alignment, and prevent
understanding speech. angiography at 30-35 mmHg, and positioning compressive neuropathies.
Visual disturbances. Lumbar puncture to avoid hypoxia through Prevent flexion. Apply splint at
Homonymous hemianopsia. Transcranial Doppler flow studies elevation of the head of the bed. night to prevent flexion of the
Loss of peripheral vision. Transthoracic or transesophageal Possible hemicraniectomy. For affected extremity.
Hemiparesis. echocardiography increased ICP from brain edema Prevent adduction. Prevent
Hemiplegia. Xenon-enhanced CT scan in a very large stroke. adduction of the affected
Ataxia. Single photon emission CT Carotid endarterectomy. This is shoulder with a pillow placed in
Dysarthria. (SPECT) scan the removal of atherosclerotic the axilla.
Dysphagia. Other Lab studies to rule out: plaque or thrombus from the Prevent edema. Elevate affected
Paresthesia. CBC, platelet and clotting studies, carotid artery to prevent stroke arm to prevent edema and
Expressive aphasia. VDRL/RPR, erythrocyte in patients with occlusive disease fibrosis.
Receptive aphasia. sedimentation rate (ESR), of the extracranial cerebral Full range of motion
Global aphasia. chemistries (glucose, sodium, arteries. Prevent venous stasis by letting
etc.) Endotracheal Tube. There is a patient exercise
possibility of intubation to Teach patient to maintain
establish patent airway if balance in a sitting position, then
necessary. to balance while standing and
Hemodynamic monitoring. begin walking as soon as standing
Continuous hemodynamic balance is achieved.
monitoring should be Encourage personal hygiene
implemented to avoid an activities as soon as the patient
increase in blood pressure. can sit up.
Neurologic assessment to Manage sensory difficulties.
determine if the stroke is Visit a speech therapist
evolving and if other acute Voiding pattern
complications are developing Be consistent in patient’s
activities. Be consistent in the
schedule, routines, and
repetitions; a written schedule,
checklists, and audiotapes may
help with memory and
concentration, and a
communication board may be
used.
Assess skin. Frequently assess
skin for signs of breakdown, with
emphasis on bony areas and
dependent body parts.
MENINGITIS
ASSESSMENT DIAGNOSIS MEDICAL-SURGICAL MGT NURSING INTERVENTION
Meningitis is usually presented by a The diagnostic tests in patients with Medical Management of the patient Nursing interventions include:
triad of signs and symptoms: Fever, clinical findings of meningitis are as includes: Assessing neurologic status and
Headache, and Neck Stiffness. But follows: Crystalloid infusion when patient v/s constantly.
other data may be assessed such as: Lumbar puncture. In general, experiences shock Insert cuffed endotracheal tube
Fever. The patient presents with whenever the diagnosis of Seizure precautions (or tracheostomy), and position
fever at first, which ultimately meningitis is strongly considered, IVT and O2 administration patient on mechanical ventilation
grow worse. a lumbar puncture should be Begin empiric antibiotic coverage as prescribed.
Seizures. As bacterial meningitis promptly performed; according to age and presence of Rapid IV fluid replacement may
progresses, patients of any age examination of the cerebrospinal overriding physical conditions. be prescribed, but take care not
may have seizures. fluid (CSF) is the cornerstone of Administer other drugs such as: to overhydrate patient
Neurologic symptoms. Patients the diagnosis. Corticosteroids. Reduce high fever to decrease
with subacute bacterial CT scan. A screening computed Diuretics (osmotic and loop). load on heart and brain from
meningitis and most patients tomography (CT) scan of the Osmotic diuretics may reduce oxygen demands
with viral meningitis present with head may be performed before subarachnoid-space pressure Protect the patient from injury
neurologic symptoms developing LP to determine the risk of while loop diuretics increases the Monitor daily body weight
over 1-7 days. herniation. excretion of water. Prevent complications associated
Photalgia (photophobia). Blood studies. CBC may have Anticonvulsants. Anticonvulsants with immobility, such as pressure
Discomfort when the patient leukocytosis as a result. are used to help aggressively and pneumonia.
looks into bright lights. Cultures and bacterial antigen control seizures (if present). Institute infection control
You can also verify that the testing. The utility of cultures is precautions until 24 hours after
patient has stiff neck by testing most evident when LP is delayed initiation of antibiotic therapy
for positive Kernig’s sign and a until head imaging can rule out
positive Brudzinski’s sign. the risk of brain herniation.
CHOLECYSTITIS
ASSESSMENT DIAGNOSIS MEDICAL-SURGICAL MGT NURSING INTERVENTION
Nausea/Vomiting Diagnostic tests include: Management may involve controlling Treatment of cholecystitis depends
Pain in abdomen (epigastric) that Biliary ultrasonography (i.e. the signs and symptoms and the on the severity of the condition and
tends to radiate to the right cholecystosonography) can inflammation of the gallbladder. the presence or absence of
shoulder pain, especially after detect gallstones in most cases. NPO. The patient may not be complications.
consuming a greasy meal White blood cell count reveals allowed to drink or eat at first in Pain assessment. Observe and
Positive Murphy’s Sign: Lay leukocytosis order to take the stress off the document location, severity (0-10
patient in supine position and Serum alkaline phosphatase is inflamed gallbladder. Patient may scale), and character of pain.
palpate under the ribs on the elevated recieve nutrients via TPN/IV. Activity. Promote bedrest,
right side at the midclavicular Ultrasonography detects Daily stimulation of gallbladder allowing the patient to assume a
line. Then have the patient gallstone contraction with IV position of comfort.
breathe out and then take a deep Endoscopic retrograde cholecystokinin may help prevent Diversion. Encourage use of
breath in. While the patient is cholangiopancreatography may the formation of gallbladder relaxation techniques, and
breathing in, palpate on this area reveal inflamed common bile sludge in patients receiving TPN. provide diversional activities.
under the ribs. If the patient ducts, gallbladder, and Medications: Communication. Make time to
stops breathing in during gallstones. Antibiotic therapy such as listen and to maintain frequent
palpation it is considered a Percutaneous transheptic Levofloxacin and Metronidazole. contact with the patient.
positive Murphy’s Sign. cholangiography can identify Promethazine or Calories. Calculate caloric intake
Fever gallstones within the bile ducts. Prochlorperazine to identify nutritional deficiencies
Bloating Hepatobiliary (HIDA, PIPIDA) Oxycodone or Acetaminophen or needs.
Steatorrhea, jaundice, dark scan: May be done to confirm Surgery: Food planning. Consult the
brown urine, light colored stools diagnosis of cholecystitis, Cholecystectomy. patient about likes and dislikes,
(chronic cholecystitis) especially when barium studies Cholecystectomy is most foods that cause distress, and
are contraindicated. commonly performed by using a preferred meal schedules.
laparoscope and removing the Promote appetite. Provide a
gallbladder. pleasant atmosphere at mealtime
Endoscopic retrograde and remove noxious stimuli.
cholangiopancreatography Laboratory studies. Monitor
(ERCP). ERCP visualizes the biliary laboratory studies: BUN, pre-
tree by cannulation of the albumin, albumin, total protein,
common bile duct through the transferrin levels.
duodenum.
CROHN’s DISEASE (IBD)
ASSESSMENT DIAGNOSIS MEDICAL-SURGICAL MGT NURSING INTERVENTION
The signs and symptoms of Crohn’s Diagnostic tests include: Medications: Help patient understand that
disease may vary from mild to Blood test to check for anemia Anti-inflammatory drugs, there is no cure for the disease;
severe. If the condition is active, it and infection including corticosteroids and oral that surgery is only done to
can develop symptoms such as: Stool studies to check for blood, 5-aminosalicylates – initially used correct strictures, fistula, etc.
Diarrhea parasites and other organisms to reduce the inflammation Ostomy care if patient has
Fever Colonoscopy – used for Immunosuppressant and biologic ileostomy or colostomy
Fatigue visualization of the drugs – decrease inflammation Encourage the patient to stop
Abdominal pain gastrointestinal tract and its by targeting the immune system smoking if applicable
Abdominal cramps affected areas Antibiotics – used to fight off Administering TPN order
Blood in stool Computerized tomography (CT) harmful bacteria found in the Monitoring weight
Mouth sores Scan intestines and to decrease pus Monitoring I/O
Loss of appetite Magnetic resonance imaging formation and drainage from Monitoring GI system: bowel
Weight loss (MRI) fistula and abscess movements, pain/bloating,
Rectal Bleeding Capsule endoscopy Anti-diarrhea medications frequency of bowel movement
Pain or drainage near or around Balloon-assisted enteroscopy Analgesics Educate patient with what to eat
the anus Vitamins and supplements and what to avoid eating
Nutrition therapy
Severe cases of Crohn's disease may A special diet may be prescribed
develop: to treat malnutrition and reduce
Inflammation of skin, eyes, joints, inflammation by allowing the
liver, or bile ducts bowel to rest. A low fiber and low
Kidney stones residue diet may also be
Iron deficiency (anemia) recommended to reduce
Delayed growth or sexual blockage of the intestines and
development, in children the quantity of stools.
Surgery:
This is usually recommended
when the medication, nutrition
therapy, and lifestyle
modification fail to alleviate or
improve symptoms.
NOTE: SURGERY DOES NOT CURE but
only save unaffected portions of the
intestines.
ULCERATIVE COLITIS (IBD)
ASSESSMENT DIAGNOSIS MEDICAL-SURGICAL MGT NURSING INTERVENTION
Severe diarrhea containing pus, Diagnostic tests include: Medications: Monitor VS, patient’s bowel
blood and mucosa Colonoscopy: small camera used Anti-inflammatory drugs. These movements, keep hydrated,
Abdominal cramping and to examine the whole colon are the first line of treatment for monitor daily weights, focus on
tenderness Barium enema: x-ray used to people with ulcerative colitis. GI assessment (bowel sounds:
Anorexia and weight loss assess the colon. An enema of 5-Aminosalicylates can be given hyperactive, hypoactive, or
Usually occurs in the descending contrast is given through the by mouth or as suppository absent, tenderness).
colon and rectum rectum to help line the colon and depending on the affected part of Signs and symptoms of toxic
Rectal bleeding and or rectal pain rectum for x-ray pictures. Then the colon. megacolon: abdominal
Inability to defecate the anatomy of the colon can be On the other hand, distention, fever, diarrhea,
Fever assessed by the physician. corticosteroids are commonly abdominal pain, dehydration,
Fatigue Stool analysis is positive for prescribed if other treatments tachycardia, hypoactive or absent
Has similar signs and symptoms with blood. Entemoeba histolytica, cause no response. bowel sounds
Crohn’s disease, the main difference which causes dysentery, must be Immune system suppressors. Signs and Symptoms of
being that ulcerative colitis usually ruled out. These drugs work by prohibiting peritonitis: distention or
occurs in the descending colon and inflammatory response through abnormal bloating, increased
rectum while Crohn's disease occurs suppressing the immune system. heart rate, tachypnea, pain
in the ileum and ascending colon. Biologics. Also called monoclonal Educate patient with what to eat
antibodies, these drugs are and what to avoid eating
usually prescribed to people with
ulcerative colitis who cannot
tolerate other treatments.
Surgery:
Proctocolectomy: Complete
removal of the colon and rectum.
Patient will have a permanent
ileostomy
Ileoanal anastomosis (J-pouch):
Colon and rectum removed and a
pouch is created that is attached
to the ileum to allow stool to
pass from the small intestine to
the anus (so no outside ostomy
created)
DIABETES MELLITUS (DM)
ASSESSMENT DIAGNOSIS MEDICAL-SURGICAL MGT NURSING INTERVENTION
Clinical manifestations depend on the Several blood tests are used to There is no known cure for DM. Advice patient about the
level of the patient’s hyperglycemia. measure blood glucose levels, the Management of the disease importance of an individualized
Polyuria or increased urination. primary test for diagnosing diabetes. focuses on control of the serum meal plan in meeting weekly
Polyuria occurs because the Additional tests can determine the glucose level to prevent or delay weight loss goals and assist with
kidneys remove excess sugar from type of diabetes and its severity. the development of compliance.
the blood, resulting in a higher Random blood glucose test — complications. Assess patients for cognitive or
urine production. for a random blood glucose test, When diet, exercise and sensory impairments, which may
Polydipsia or increased thirst. blood can be drawn at any time maintaining a healthy weight interfere with the ability to
Polydipsia is present because the throughout the day, regardless aren’t enough, you may need the accurately administer insulin.
body loses more water as polyuria of when the person last ate. A help of medication. Medications Demonstrate and explain
happens, triggering an increase in random blood glucose level of used to treat diabetes include thoroughly the procedure for
the patient’s thirst. 200 mg/dL (11.1 mmol/L) or insulin. insulin self-injection. Help patient
Polyphagia or increased appetite. higher in persons who have Many people inject themselves to achieve mastery of technique
Although the patient may symptoms of high blood glucose with insulin using a syringe or an by taking step by step approach.
consume a lot of food but glucose suggests a diagnosis of diabetes. insulin pen injector,a device that Review dosage and time of
could not enter the cells because Fasting blood glucose test — looks like a pen, except the injections in relation to meals,
of insulin resistance or lack of fasting blood glucose testing cartridge is filled with insulin. activity, and bedtime based on
insulin production. involves measuring blood A number of drug options exist for patients individualized insulin
Fatigue and weakness. The body glucose after not eating or treating type 2 diabetes, including: regimen.
does not receive enough energy drinking for 8 to 12 hours Sulfonylurea drugs Instruct patient in the
from the food that the patient is (usually overnight). A normal Meglitinides importance of accuracy of insulin
ingesting. fasting blood glucose level is less Biguanides preparation and meal timing to
Sudden vision changes.The body than 100 mg/dL. A fasting blood Alpha-glucosidase inhibitors avoid hypoglycemia.
pulls away fluid from the eye in an glucose of 126 mg/dL (7.0 Thiazolidinediones Explain the importance of
attempt to compensate the loss of mmol/L) or higher indicates Drug combinations. By combining exercise in maintaining or
fluid in the blood, resulting in diabetes. The test is done by drugs from different classes, you reducing weight.
trouble in focusing the vision. taking a small sample of blood may be able to control your Advise patient to assess blood
Tingling or numbness in hands or from a vein or fingertip. It must blood sugar in several different glucose level before strenuous
feet. Tingling and numbness occur be repeated on another day to ways. activity and to eat carbohydrate
due to a decrease in glucose in the confirm that it remains snack before exercising to avoid
cells. abnormally high . hypoglycemia.
Dry skin. Because of polyuria, the Hemoglobin A1C test (A1C) — Assess feet and legs for skin
skin becomes dehydrated. The A1C blood test measures temperature, sensation, soft
Skin lesions or wounds that are the average blood glucose level tissues injuries, corns, calluses,
slow to heal. Instead of entering during the past two to three dryness, hair distribution, pulses
the cells, glucose crowds inside months. It is used to monitor and deep tendon reflexes.
blood vessels, hindering the blood glucose control in people Maintain skin integrity by
passage of white blood cells which with known diabetes, but is not protecting feet from breakdown.
are needed for wound healing. normally used to diagnose Advice patient who smokes to
Recurrent infections. Due to the diabetes. Normal values for A1C stop smoking or reduce if
high concentration of glucose, are 4 to 6 percent . The test is possible, to reduce
bacteria thrives easily. done by taking a small sample of vasoconstriction and enhance
blood from a vein or fingertip. peripheral flow.
Oral glucose tolerance test —
Oral glucose tolerance testing
(OGTT) is the most sensitive test
for diagnosing diabetes and pre-
diabetes. However, the OGTT is
not routinely recommended
because it is inconvenient
compared to a fasting blood
glucose test.
CASE: APPENDICITIS
Questions:
SUBJECTIVE OBJECTIVE NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOMES
The patient Nausea Acute pain related to Inside the appendix is After hours of nursing Assess pain, noting Useful in After hours of nursing
reports having Vomiting inflammation as mucosal lining, which interventions, the location, monitoring interventions, the
abdominal pain. Anorexia evidenced by reports is continuously patient will be able to: characteristics, effectiveness of patient reports of
She says that her Elevated WBC of abdominal pain secreting mucus and severity (0–10 medication, controlled or relieved
pain under the upon CBC – fluids. There are also Report pain is scale). Investigate progression of pain; she appears to
pain scale is 8/10. 15,000µL Definition: bacteria that normally relieved/controlled. and report healing. Changes be relaxed and is able
CT-scan shows Unpleasant sensory live in the appendix. Appear relaxed, changes in pain as in characteristics to sleep; patient
presence of and emotional The blockage in the able to sleep/rest appropriate. of pain may demonstrates
inflammed experience associated lumen of the appropriately. indicate relaxation skills and
appendix with actual or appendix causes Demonstrate use developing diversional activities.
Positive Psoas sign potential tissue major INCREASE of relaxation skills abscess or
Positive Rovsing’s damage or described PRESSURE inside the and diversional peritonitis,
sign in terms of such appendix as these activities, as requiring prompt
damage; sudden or contents continue to indicates, for medical evaluation
V/S: slow onset of any grow and it can NOT individual situation. and intervention.
Temperature: 38 ̊
C intensity and with a move anywhere due
duration of less than 3 to the blockage. This Keep at rest in To lessen the pain.
months leads to inflammation semi-Fowler’s Gravity localizes
and eventually pain in position inflammatory
Reference: the abdomen. exudate into lower
Doenges, M. E., abdomen or pelvis,
Moorhouse, M., & relieving
Murr, A. C. (2019). abdominal
Nurse's Pocket Guide tension, which is
Diagnoses, Prioritized accentuated by
Interventions, and supine position.
Rationales 15th Ed. In
Decreased Cardiac Provide diversional Refocuses
Output (p. 633). activities attention,
promotes
relaxation, and
may enhance
coping abilities.