National Patient Safety Goals Rights of Delegation (five rights) SATA 1. Right task a. One that can be delegated for a specific patient 2. Right circumstances a. Appropriate patient setting, available resources 3. Right person a. Right person is delegating the right task to the right person 4. Right directions and communication a. Clear, concise description of task 5. Right supervision and evaluation a. Appropriate monitoring, evaluation, intervention, and feedback Eye Surgeries (Cataract and Retinal Detachment) ● Cataracts: ○ Decreased vision, abnormal color perception and glare ○ Most common form of cataract surgery is phacoemulsification ● Retinal Detachment ○ See flashes ○ Is an emergency ○ If not corrected, it is a risk for blindness in that eye ○ Caused by trauma or myopia (elongated, stretched, also called nearsightedness) Pain medications-proper uses, complications, contraindications, and nursing considerations/interventions, adjuvant pain meds, ice/heat Pain Medications Tables 8-8, 8-9, & 8-11 Just know these adjuvant medications: ● Lidocaine ● Gabapentin ● Amitriptyline ● Bupropion (wellbutrin) 1 Skull Fractures ● Le Forte ● 3 levels ● Worried about patients airway ● Basilar ● fracture across the base of the skull that usually causes bleeding ● Two classic signs of basilar fracture: ○ “Racoon’s eyes” → Black and blue around the eyes ● ● ○ “Battle sign” → bruising behind the ear Glucose will be + if it is CSF…… If there is blood, still check for CSF Halo test- drop blood on gauze, it will have a yellow halo on the outside of the blood drop. This shows + for CSF ( photo on page 1327) Joint surgeries ● Knee surgery ● Do incentive spirometer at least 10X after surgery ● CPM- continuous passive motion device ● Physical therapist decides or frequent ● The device will be on the bed with the patient HALO Traction- “Halo” traction ● Clean each pin to avoid infection ● No driving when in the halo External fixator- traction on the outside of extremity or head Internal fixation- on the inside ○ ● It is permanent 2 TSLO- TLSO braces are used to put pressure on unnatural curves that an individual may have, it then slows down the growth to eliminate the progress of the curve. These braces are used if you are diagnosed with a spinal disorder, deformity, or a different problem that needs structural support. Autonomic Hyperreflexia ● Injury at T-6 and higher ● The communication between sympathetic and parasympathetic are disrupted ● Two triggers: o Distended bladder o Constipation ● HTN up to 300 (systolic) – can lead to hypertensive crisis Interventions: · Serious emergency · Find the trigger first · sit the head of the bed up (need the blood to go to the feet) · Digitally dis-impact · Take everything off the patient, including clothes Guillain-Barre Syndrome- RF, CM, DX Tx, pt teaching, nursing considerations · · · · · Autoimmune process that occurs following a viral or bacterial infection Starts with your legs and spreads to your upper body Causes paralysis in the end Biggest concern is respiratory being paralyzed Ataxia: looks like being drunk; slurred words, stumbling Inflammation and Wound Healing ● Measured by using the face of a clock ● Wounds are always measured in cm ● Always measure using a cotton-tipped applicator Immunoglobulins and their characteristics ● Immune System- Main organs are Tonsils, Lymph Nodes, Thymus gland, Spleen, Bone Marrow. Innate immunity- present at birth, our first line of defense, non-specific and FAST Acquired Active immunity- acquired through natural contact with antigen through actual infection or artificially through immunization with the antigen in it (vaccine for varicella, mumps, etc.) Acquired Passive immunity- naturally acquired through transplacental and colostrum transfer from mother to child, and artificially through infection of serum with the antibodies from one person to another who doesn't have the antibodies (Hep B immune globulin) ● Immunoglobulins- 5 classes: IgG- located in plasma and interstitial fluids, is the only immunoglobulin that crosses the placenta. Responsible for secondary immune response. IgA- located in body secretions (tears, saliva, breast milk, colostrum). Lines mucus membranes and protects body surfaces. IgM- located in plasma. Is responsible for the primary immune response. Forms antibodies to ABO blood antigens. IgD- located in plasma. Present on lymphocyte surface. Differentiates B lymphocytes. IgE- located in plasma and interstitial fluids. Causes symptoms of allergic reactions. Fixes to Mast cells and basophils. Assists in defense against parasitic infections. 3 Allergy disorders-RF, CM, DX Tx, pt teaching, nursing considerations Allergic Reactions Anaphylaxis: MEDICAL EMERGENCY! - Type 1 reaction - Instant and highly sensitive - Rapid onset - Swelling causing airway obstruction - Evaluate pt history- medications, diagnoses, hx with allergies - Prevention (of loss of O2 circulation) is the priority - Maintain adequate ventilation - High fowlers - O2, trach, etc - Albuterol, corticosteroids, epi - Restore adequate circulation -IV fluids - Treatment - Mild to Severe reaction: - Antihistamines and/or Epi (0.3-0.5mg) SQ or IM - Severe: - Epi 0.5mL IV (1:10,000) - According to Table 13-11: ○ - Initial Interventions - Ensure patent airway, intubate if obstruction - Remove insect stinger if present - Establish IV access - Epi (1mg/mL) give 0.3-0.5mg IM preferably in mid-outer thigh, repeat every 5-15 min as needed. - High flow O2 (8-10L/min) - Nebulized albuterol for bronchospasm resistant to epi - Benadryl for urticaria and itching - Corticosteroids IV - Hypotension: - Place recumbent and elevate legs - IV normal saline bolus rapid 1-2L - Maintain BP with fluids, volume expanders, vasopressors - Ongoing Monitoring: - Monitor vitals, level of consciousness, cardiac rhythm, urine output - Anticipate intubation with severe respiratory distress - Anticipate cric or trach with severe laryngeal edema Systemic Lupus Erythematosus- multisystem inflammatory autoimmune disorder affecting multiple organs. Antibodies attack and cause damage to the body's organs and tissues. - RF- women in child bearing years, more likely AA, Hispanic, NA than Caucasian, sunlight exposure, stress, meds, infection and virus exposure. - Characteristics/Causes- Periods of exacerbation and remission, tissue is injured, inflammatory response is activated, skin, muscle, lining of lungs, heart, nervous tissue, kidneys- most common tissues affected. Most common complaints- fever, weight loss, joint pain, excessive fatigue (later sign) - Sx- increased susceptibility to infection, butterfly rach on face, alopecia, ulcerations, arthritis, swelling, nephritis, HTN, seizures, anemia, thrombocytopenia, dyspnea, ulcers of oral mucosa, depression, anxiety 4 - MALAR RASH- RED, DISCOID RASH- BLACK DX- no one specific test- genetic tests TX- NSAIDS for mild, steroid sparing drugs, antimalarials, corticosteroids, immunosuppressive drugs Interventions- nursing assessment, monitor I/O, observe for bleeding, provide emotional Support Patient Teaching- energy reducing, relaxation, prevention of SLE is not possible, severity can progress quickly, avoid triggers. Types of Hypersensitivity reactions and nursing interventions Hypersensitivity Reactions Type 1- Mediated Reaction- IgE - Anaphylaxis (most severe) - Latex (can be immediate) - Atopic- most common! - Allergic rhinitis - Urticaria/ hives - Bronchial asthma Type 2- Cytotoxic- IgG and IgM - Blood incompatibility such as hemolytic shock - Reaction to blood transfusion Type 3- Autoimmune- RIGHT AWAY (inflammation)! Can be systemic or organ specific! - SLE - RA Type 4- Cell Mediated- DELAYED hypersensitivity - Tb skin test - Poison ivy- contact - Transplant reaction/rejection - Latex- over time Psoriasis● Psoriasis- autoimmune disorder - RF- all races and genders, develops between 15-35 years old. A third of affected have a relative with the disease. Those with DM, heart disease, depression are more likely to develop as well. - DX- Based on appearance, lesions are red, scaling papules. Silver scales that bleed easily. - TX- Dermatologist specialty, UV light, meds, radiation, lasers, antihistamines, corticosteroids. Proper wound measurement Wounds are always measured in CM. Always measure a wound using the face of a clock. Measure depth with the wooden part of the cotton swab. Tube feeding, proper flushing, syringe use ● Use 60 cc syringe to flush (piston syringe) ● Use regular water to hang with feeding (not sterile, just want you would drink at home) ● Aspirate stomach contents - residual check Chest tubes and proper care 5 ● ● ● ● ● ● Bubbles are a bad sign ( means there is an air leak somewhere) If it comes out put an occlusive dressing over opening (taped on 3 sides, one side open) No milking the tube Keep drain below the chest Mark drainage Never clamp tube with hemostats Glasgow coma scale- (insert scale) ● Tests eyes, speech, and motor ● Max score = 15 ● Let dr know if score drops by 3, ( change in status) ● 8= intubate Early and late signs of neuro decline ● Frequent neuro checks for the first 48 hours ● Elevate head of the bed ● First noticeable sign in a decline- eyes, level of consciousness ● ICP- last signs PET scan process Positron Emission Tomography Uses radioactive tracer Evaluates organs and tissues at the cellular level Patients are awake Instructions for patient: 1. 24 hours before test: low-carb,no-sugar diet; no strenuous exercise. 2. 6 hours before test: NO eating 3. Day of: blood sample taken to check glucose level 4. IV delivers radioactive tracer 5. Wait 60 minutes fo tracer to circulate through body 6. Lie on scanning bed inside PET chamber. Scans last 20-45 minutes Headaches and characteristics ● Headaches ○ A common symptom of various underlying pathologic conditions in which pain- sensitive nerve fibers respond to unacceptable levels of stress and tension, muscular contraction, in upper body, pressure from a tumor, or increased ICP ○ Three primary classifications of headaches include Tension, Migraine, and Cluster ■ Tension ● Muscle contraction headache ● Most common of all headaches ● Feeling of tightness like a band around the head ● Onset is gradual ● May be accompanied by dizziness, tinnitus, or lacrimation ● Associated with stress and premenstrual syndrome ● Treatment: NSAIDS, Relaxation, Yoga, Stress Management ■ Migraine 6 ● ● ● ● ● ● ● ● Cluster ● Rare headache that is more common in men ● Occurs in numerous episodes or cluster ● No aura ● Unilateral pain often arising in nostril and spreading to forehead and eye • Often occurs at same time of day ● Treatment: High flow oxygen Nursing Interventions ○ Prevention ○ Recognize triggers, decrease stress, adjust medications during menstrual cycle ○ Watch for signs of ominous headache ○ New onset unilateral headache in person older than 35 yrs ○ Vomiting not accompanied by nausea ○ Pain awakens patient ■ ● Constriction of intracranial vessels leading to an intense throbbing pain when vessels return to normal Prodromal or aura Crescendo quality Unilateral pain Often beginning in eye area Nausea, vomiting, photophobia Migraines are seriously debilitating and may require lifestyle and occupational changes Treatment: Sumatriptan; Dihydroergotamine mesylate ○ Encourage patients to keep a “headache diary” for best management and treatment. ICP management ● What do you do for intracranial pressure?- Pt will be in the ICU ● Call dr. most likely won't act on it, but needs to be informed of change ● Dr wont do anything unless pressure goes up to 20 ● Tested by a probe in the head Precautions with neuro surgery Multiple Sclerosis- Decreased impulse conduction, destruction of nerve axon, and blockage of impulse Conduction. - RF- any age, onset typically between 20-50 years old. Women are 2-3 times more than men, more prevalent in climates where temp reaches 45-65 degrees, such as northern states, Canada, Europe, etc. - Characterized by multiple areas of demyelination from inflammatory scarring of the neurons in the brain and spinal cord (CNS) - Destruction of the myelin - Destruction of the nerve- blockage of impulse conduction - Possible reasons include autoimmunity and exposure to a virus - Delay in Diagnosis - Slow onset and vague symptoms (blurry or double vision (early sign), Lhermitte sign- an electric shock sensation with certain neck movements, paresthesia or numbness/tingling (early sign), and bowel or bladder dysfunction (early sign). - Symptoms occur months to years before dx - Symptoms can be better and then bad again -Types of MS - RELAPSING- REMITTING MS: Most common!- 85% Sporadic attach with exacerbating and 7 - - - remitting last days or months - PRIMARY PROGRESSIVE: 10% After years of the above, patient experiences slow, steady, worsening of their sx without improvement between exacerbations. Plateaus occur but the baseline function worsens. Symptoms vary with each patient, ranging from mild to severe. DX- No definitive diagnostic test! H & P, CSF analysis, CT, MRI - Criteria to be diagnosed- Pt must have evidence of at least 2 inflammatory demyelinating lesions in at least 2 different locations within CNS. If pt only has one, they will be monitored frequently for second. TX- No cure~ Treatment begins with immunomodulator drugs to modify disease progression and prevent relapse - Teach self injection, rotate sites, and report side effects (suicidal thoughts, depression) wear sunscreen. - Flu like symptoms are common, so NSAIDS or acetaminophen are ok. - Monitor liver function and avoid pregnancy... also spingosine- reduces MS activity by preventing it from reaching the CNS, used for relapsing. - And antiinflammatory and ACH to help with stress Teaching- avoid triggers (high temps and infections etc), get rest, eat healthy, fiber Myasthenia Gravis- autoimmune. Characterized by fluctuating weakness of certain skeletal muscle groups. Neuromuscular disease with decrease in ACTH at receptor sites in the neuromuscular junction “Grave Muscle Weakness”. Exacerbated by Stress and drugs like aminoglycosides can aggravate. - RF- any gender, women 3:2 men, average onset for women 28 yo, men 42 yp. 20 in 100,000 have it. - SX- variable but progressive, skeletal muscle fatigue, Ptosis and Diplopia are the early and most common 1st symptom seen, facial mobility impairment, speech impairment, no sensory deficit, loss of reflexes or muscular atrophy, poor bowels and bladders. - DX- Confirmation made by EMG- would note decreased response to repeated stimulation of had muscles which indicated muscle fatigue. Tensilon test- MG will be improved muscle contractility after this injection is positive for MG. CT used to evaluate Thymus. - TX- Drug therapy, anticholesterine drugs, surgical therapy (removal of thymus), plasmapheresis, IV immuno - Serious Diseases! MYASTHENIC CRISIS- risk of aspiration, dysphagia, respiratory function, increased BP, treated with thymus removal..., and CHOLINERGIC CRISIS- due to overuse of medication (anticholingeric drugs) n/v/d, weakness with swallowing, treated with atropine Tensilon test- done in patients with Myasthenia Gravis, reveals improved muscle contractility. This test verifies the diagnosis of MG. Bells Palsy- RF, CM, DX Tx, pt teaching, nursing considerations ● ● ● ● ● ● ● ● ● ● Weakness or paralysis of the muscles of the face Damage to the 7 cranial nerve (facial nerve) Some sort of infection triggers it Idiopathic ○ not a stroke, tumor, etc. absence of nasolabial fold drooping of mouth or eyelid Hypersensitivity to loud noises Most recover within 6 months, others develop permanent damage Treated with corticosteroids Can do surgery to release the nerve 8 TIA- RF, CM, DX Tx, pt teaching, nursing considerations- Same as stroke, for most part? ● CM ○ Visual defects: blurred vision, diplopia, blindness of one eye, tunnel vision ○ Transient hemiparesis, gait problems ○ Slurred speech, confusion ○ Transient numbness or an extremity Stroke- RF, CM, DX Tx, pt teaching, nursing considerations ● Risk Factors ○ Prevention is the most effective way to decrease the risk of stroke ○ Nonmodifiable risk factors ■ Age, gender, race, heredity ○ Modifiable risk factors ■ Hypertension is the most important modifiable risk factor, others are hyperlipidemia, smoking, excessive alcohol consumption, obesity, physical inactivity, poor diet, and drug abuse ● CM ○ • Hemiplegia ○ • Aphasia ○ • May be unaware of the affected side; neglect syndrome ○ • Cranial nerve impairment ○ • Possibly incontinent ○ • Agnosia –perceptual defect that causes a disturbance in interpreting sensory information ○ • Cognitive impairment of memory, judgment, awareness of ones body position (proprioception) • Hypotonia (flaccidity) for days to weeks , followed by hypertonia (spasticity) ○ • Visual defects ○ • Apraxia ○ • Increased ICP, drowsiness to coma ○ • Pain in eye, nose, or face ○ • Gait disturbances ○ ● DX ○ • Confirm it is a stroke and not another brain lesion such as a subdural hematoma • Identifies the likely cause of stroke ○ • Can measure the size and location of the lesion and can differentiate between ischemic and hemorrhagic stroke ○ • CT – non contrast ○ • MRI ● Tx ○ • Prophylactic ○ • Aspirin, platelet inhibitors ○ • Antihypertensives, anticoagulants ○ • Immediate Treatment ○ • Medical ○ • Medications to decrease cerebral edema ○ • Anticoagulants for thrombotic stroke (NEVER administer to pt. with hemorrhagic stroke) ○ • Anticonvulsants ○ • Thrombolytic therapy or fibrinolytic therapy such as recombinant tissue plasminogen activator (TPA considered for NON-HEMORRHAGIC patients within 3-4.5 hours of first manifestation of stroke signs. ○ • Antihypertensives and antidysrhythmics ○ • Surgical 9 ● ○ • Carotid endarterectomy, especially for TIA ○ • Craniotomy for evacuation of hematoma ○ • Extracranial-intracranial bypass for mild strokes Nursing Considerations ○ • Prevent Stroke ○ • Maintain Patent Airway and Adequate Cerebral Oxygenation ○ • Assess and decrease ICP ○ • Maintain Nutritional Intake ○ • Preserve Function of the Musculoskeletal System ○ • Maintain Homeostasis ○ • Determine previous bowel patterns and promote normal elimination ○ • Avoid use of urinary catheter ○ • Offer bedpan or urinal every 2 hours – establish a schedule ○ • Prevent constipation ○ • Provide privacy and decrease emotional trauma related to incontinence ○ • Prevent problems of skin breakdown ○ • Assist patient to identify problems of vision ○ • Maintain psychological homeostasis ○ • Patient may be anxious because of lack of understanding of what has happened and his inability to communicate ○ • Speak slowly and clearly and explain what has happened ○ • Assess patient’s communication abilities and identify methods to promote communication Stroke (brain attack) Two Types of Stroke ● Ischemic = blockage ● Hemorrhagic = rupture ● Occurs when there is an interruption in the blood supply that results in the death of brain cells o either from ischemia to part of the brain or hemorrhage ● Atherosclerosis (hardening and thickening of arteries) is major cause of ischemic stroke o Like plaque buildup, the flow is blocked o Can lead to thrombus formation and contribute to emboli Risk Factors ● HTN, hyperlipidemia, smoke, ETOH ● Prevention is the most effective way to decrease the risk of stroke Diagnostics ● CT- with NO CONTRAST Treatment ● Tissue plasminogen activator Transient Ischemic Attack (TIA) “baby stroke”, kind of like a warning sign ● Symptoms but no damage ● Symptoms last less than 24 hours but usually resolve in less than 1 hour Ischemic Stroke (87% of strokes) Two types ● Thrombotic Stroke ● Embolic Stroke o Occlusion of a cerebral artery by an embolus o Common site of origin is the endocardium (inner layer of the heart) 10 Hemorrhagic Stroke ● rupture of a cerebral artery caused by HTN, trauma, or aneurysm ● blood compresses the brain “BEFAST” B- balance; loss of balance, headache, or dizziness E- eyes; blurred vision F- face; one side of the face is drooping A- arms; arm or leg weakness S- speech; speech difficulty T- time; time to call ambulance ASAP ● The affected side will always show symptoms on the opposite side (table 57-4) Assess and decrease ICP ● Increased ICP signs: o Early: change in LOC, restless, irritable, lethargic, slowing speech & delay in response o Intermediate: unequal pupil response, projectile vomiting ▪ Cushing’s Triad: widened pulse pressure, increased systolic BP, decreased HR o Late: decreased LOC, decreased reflexes, hypoventilation, dilated pupils, posturing ● Factors that increase ICP: o Valsalva maneuver, Coughing, sneezing, suctioning, hypoxemia, arousal from sleep TPA- (only for ischemic stroke)Thrombolytic therapy or fibrinolytic therapy such as recombinant tissue plasminogen activator (TPA considered for NON-HEMORRHAGIC stroke patients within 3-4.5 hours of first manifestation of stroke signs.) Cranial Nerves 1. Olfactory a. Sniff test 2. Optic a. Visual acuity 3. Oculomotor a. 6 cardinal gazes, pupillary constriction, opening & closing of the eyes 4. Trochanter a. 6 cardinal gazes, downward and inward movement of the eyes 5. Trigeminal a. Facial sensation - maxillary, mandibular, masseter strength and temporalis muscle strength 6. Abducens a. 6 cardinal gazes, lateral movement of eyes 7. Facial a. Puffing out cheeks, smile and frown 8. Acoustic a. Whisper test, weber, rhine and rhomber 9. Glossopharyngeal a. Gag reflex, swallow 10. Vagus a. Coughing, gag reflex (motor) 11. Spinal accessory 11 a. Shrugging- trapezius, side to side movement - sternocleidomastoid 12. Hypoglossal a. Tongue movement and strength, “light, tight, dynamite” Cervical spine fracture managementSpinal column ● 7 cervical ● 12 thoracic ● 5 lumbar ● 5 sacral C3- cut off for being a ventilated patient C4- depends of now they heal after the shock of injury Parapalegic● T-1 - 6 ● Affects the lower extremities Quadrapalegic ( tetraplegia)● C1-3 ● Affects both upper and lower extremities Cervical spine FX: ● Immobilization ● ABC’s ● O2 ● intubation Pyelonephritis-RF, CM, DX Tx, pt teaching, nursing considerations 12 Upper UTI RF: ● Infection ● Lower UTI can travel up ● Bacterial infection (most common,) (can be fungi, protozoa, or viral) ● Poor perineal care CM: ● ● ● ● ● ● DX: ● ● ● ● ● ● Flank pain Signs of infection Dysuria Frequency Fatigue Chills, N&V CBC ○ Leukocytosis UA ○ WBC casts (indicates something is going wrong with kidneys), bacteriuria, hematuria Urine culture ○ To see what antibiotic to treat with Ultrasound Blood culture CT ○ May show further complications, such as scarring or abscesses Tx: ● ● ● Mild symptoms ○ Outpatient antibiotics for 14-21 days In hospital tx ○ Parenteral antibiotics are given initially to get antibiotic therapy started quickly ○ Sulfa ○ Cipro Symptoms and signs improve within 48*72 hours typically on antibiotics Complications of pyelonephritis: ● If it gets all the way to kidney, its very bad ● High fever ● Urosepsis: check vital signs → Low BP and high HR= septic shock ● Irreversible damage to kidneys Pt teaching ● Proper hygiene ● Medication teaching AKI (pre, intra and post renal causes) 13 Acute kidney injury (AKI) is a clinical syndrome with sudden loss of kidney function that may occur over several hours or days, characterized by uremia. The most common causes are hypotension, prerenal hypovolemia, or exposure to a nephrotoxic Can happen ● Prerenal- above kidney ○ Causes volume depletion ○ Is reversible ● Intrarenal- at the kidney ○ Kidney is actually damaged ○ ● Post renal- below the kidney ( affecting the ureters and bladder) ○ Obstruction Oliguric phase• Most common EARLY S/S • Reduction of urine <400 mL/day • Occurs within 1-7 days of injury (if ischemia -> occurs within 24 hrs of injury; if nephrotoxic drugs -> takes a week to occur) • Increase of BUN, creatinine, uric acid, potassium, and magnesium levels and presence of metabolic acidosis • Lasts 10-14 days but can last months. • The longer it lasts, the poorer the outcome • 50% of pts. will not be oliguric so dx. will be more difficult Diuretic phase Sudden onset within 2-6 weeks after oliguric phase ● • Daily urine output is 1-3L but can be up to 5L or more • Hypovolemia and hypotension may occur d/t massive fluid loss • BUN level stops increasing. Urinary creatinine clearance stabilizes • May last for 1 – 3 weeks Recovery phase Begins when GFR increases, which allows the BUN and creatinine to decrease. • Major improvements occur during the first 1-2 weeks of this phase, but kidney function can take up to 12 mo. to stabilize • Some do not recover and go into end stage renal disease DX: ● Nephrotoxic drugs ● Contrast media ● Prostate issues ● UA ● Creatinine and BUN ● Renal ultrasound ● Renal Scan ● CT scan ● MRI ● Renal biopsy TX: Correct cause • Fluid restriction (600 mL plus previous 24 hr fluid loss) • Adequate protein intake (0.6-2 g/kg/day) 14 • Enteral nutrition • Lower potassium if elevated (Table 46-5) • Calcium supplements • Initiation of dialysis if needed • Adequate caloric intake (30-35 kcal/kg) • Energy should be primarily from carbohydrates and fat sources to prevent ketosis from fat breakdown • Dietary fat should be 30-40% of total calories. • Lipids given IV, TPN given if GI not functioning Nursing considerations: ● Fluid and electrolyte imbalance ● Daily weights ● I/O’s ● Assess for hypovolemia ( oliguric, and diuretic phase) ● Protect from infectious disease ● Protect from nephrotoxic drugs ● Perform skin and mouth care Nephrotic syndrome- RF, CM, DX Tx, pt teaching, nursing considerations ● ● ● MAJOR amounts of protein loss NO BLOOD in the urine (compared to glomerulonephritis) RF: ● CM: ● ● ● ● ● ● ● ● ● ● DX: ● Secondary to a systemic disease ( lupus) Not going to be a significant drop in the GFR (opposite of glomerulonephritis) Edema ○ Facial ○ Periorbital ○ Lower extremities ○ Labia ○ Ascites ○ And pleural effusion Proteinuria Hypoalbuminemia Hyperlipidemia Gradual increase in weight Volume of urine is decreased and the urine looks foamy Irritable, fatigues, lethargy Malnourishment Infection can result in significant morbidity or mortality Decreased serum protein levels ○ Hypoalbuminemia ● ○ ○ Increase specific gravity Massive proteinuria ( greater than 31) 15 Complications ● Compromised immune system leading to an increase in infections ○ Pneumonia ○ Bronchitis ○ Peritonitis ● Circulatory insufficiency caused by hypovolemia, with severe edema TX: ● Corticosteroids ● Diuretics ● Prophylactic broad spectrum antimicrobial agents ● Low sodium diet (2-3 g/day) ● Proteins consumed should have high biological value (low to moderate protein diet) ● Fluid is usually not restricted Nursing considerations: ● Reduce edema ● Prevent infection ● Promote nutrition Pt teaching: ● Inform about medical regime ● Reassure pt that prognosis is good ● Teach how to dipstick Acromegaly- RF, CM, DX Tx, pt teaching, nursing considerations RF Both genders CM Thickening and enlargement of bony and soft tissue of the face, hands & feet Muscle & joint pain Carpal tunnel Peripheral neuropathy Tongue enlargement/dental problems Speech issues Enlargement of vocal cords/deep voice Possible sleep apnea Thick oily skin/ Acne outbreaks Visual changes Headaches Glucose intolerance->polydipsia & polyuria (pt is more prone to DM, CVD & colorectal cancer) DX Growth Hormone test to see if GH is responding appropriately MRI CT w/contrast Visual changes TX Reduce GH levels back to normal Surgery Radiation,Drugs, Or a combo Surgery - hypophysectomy (transsphenoidal approach) 16 Octreatide - SQ 3x a week, helpful in reducing the GH levels to normal PT ED/Nursing considerations Psychosocial aspects, ADL’s, support groups Glomerulonephritis- RF, CM, DX Tx, pt teaching, nursing considerations Glomerulonephritis Inflammatory and immune reactions following an infection such as strep can also be from an autoimmune problem. (aftermath of strep) (or an immune response) ← simple terms Table 45-8 RF: ● ● CM: ● ● ● ● ● ● ● ● ● ● ● Recent strep infection Most common in children Decreases the GFR Compare it to nephrotic syndrome* Weight gain from water retention Facial edema lethargic Oliguria- holds on to a lot of fluid Dysuria Proteinuria (protein loss, wouldn’t see a lot of protein) Tea or cola colored urine- caused by hematuria Increase in BP Azotemia- presence of nitrogen DX: 17 ● ● ● Based on H&P Serum BUN & Creatinine Dipstick UA ○ Erythrocyte casts are suggestive of APSG ○ Proteinuria may range from mild to severe Complications ● Chronic kidney disease ● Circulatory overload ( pulmonary edema) and CHF TX: ● ● ● ● ● ● ● Diuretics Antihypertensives Antibiotics if strep is still present Plasmapheresis for filtering out immune complexes (if immune response) Decrease sodium intake (so they don't keep holding onto water) Protein restriction Fluid restriction may be implemented if urinary output is decreased Nursing interventions ● Goal to protect patients kidneys by preventing secondary infections ○ Antibiotic therapy ○ Monitor I/O’s ● Monitor labs closely ● Sign of getting better- patient starts peeing alot ● Prevent complications ○ CKD ○ CHF ○ UTI- voiding regularly, wiping front to back, urinate after sexuals ● Report signs of N&V, fatigue, decreased urinary output & symptoms of infection Suprapubic catheters ● Right above pubic bone, can drain right into foley or right into toilet (keep it clamped if so) ● Aseptic technique ● Do not pull on catheter, it is sutured in place ● Bag is attached ● Observe urine for color, clarity, smell, and amount ● Sutured in place ○ Watch for signs of infection Urinary diversion devices Urinary diversions Ileal loop/ conduit- surgical Utereters come together and are formed into a conduit on the inside of the body and comes out of a stoma outside the body. Bypass the bladder and urethra ● Drains from a stoma outside the body into a bag Neobladder Make a completely new bladder form the small bowel 18 ○ Won't feel the urge to void ■ Need to void every 2-4 hours Hyperparathyroidism- RF, CM, DX Tx, pt teaching, nursing considerations calcium levels are too high (“stones, bones, groans, and moans”) RF: ● Benign parathyroid adenoma is primary cause ● Women 40-50 years old ● Neck surgery or head or neck radiation ● Hypocalcemia (secondary cause) ● Renal calculi ● Decreased bone density Over secretion of PTH leads to hypercalcemia & hypophosphatemia CM: ● Loss of appetite ● N&V ● Constipation ● Muscle weakness ● Aches and pains in bones and joints ● Fatigue ● Depression ● Confusion ● Kidney stones ● Increased thirst & urination *sometimes a patient can have no symptoms at all DX: ● Bone density test ● High levels of calcium in the urine & blood ● Hypophosphatemia ● Locate the tumor by an MRI, CT, or US TX: ● Parathyroidectomy (removing the parathyroid gland) o Will be on hormone replacement for the rest of their life ● Phosphates if kidney function is normal ● Annual X-Rays and DEXA scan ● Diet: High in fluids & Moderate calcium intake ● Phosphates ● Osteoporosis drugs Pt Ed: ● Don’t have a sedentary life and ambulate often Hypoparathyroidism- RF, CM, DX Tx, pt teaching, nursing considerations calcium level deficiency, parathyroid is underactive RF: ● Neck surgery can damage the parathyroid glands ● Autoimmune destruction ● Absent parathyroid gland 19 CM: ● Going to have signs of hypocalcemia o Acute: ▪ Tingling of the fingers ▪ Chvostek’s, Trousseau’s o Chronic: ▪ Fatigue, weakness ▪ Personality changes ▪ Loss of tooth enamel ▪ Dry scaly skin ▪ Cardiac arrhythmia Low calcium can cause seizures (“CATS” of hypocalcemia) C- Convulsions A- Arrhythmias T- Tetany S- Spasms & Strider *table 49-12 compares hypo and hyper parathyroidism All due to hypocalcemia: ● Tetany, tingling in the lips, stiffness of extremities ● Painful tonic spasms of smooth and skeletal muscles which can dysphagia & laryngospasms ● Lethargy, anxiety, and personality changes may occur DX: ● Decreased Ca and PTH, and increased phosphorus (Ca and phosphorus have inversed relationship) TX: ● Maintaining normal calcium levels & preventing long term complications ● IV Ca must have patient on EKG o high Ca levels can cause dysrhythmias, cardiac arrest, hypotension o IV Ca can irritate vein, so make sure you have good IV before giving ● Breathing into paper bag helps tetany (muscle cramps), allows pt to hold onto CO2 ● Send pt home with Ca, Mg, & vitamin D ● Eat high calcium foods (dark green veggies, just not spinach), soy beans, tofu Acute management ● Preventing seizures ● Addressing tetany & muscle spasms (can be very painful) ● Preventing laryngeal stridor Pt ED: ● Follow up appointments 3-4x/year math 20
