NURS426: Final Exam Review
1. Cancer (20 Questions)
Pathology
1. Characterized by uncontrolled and unregulated growth of cells
2. Cancer Cells:
a. Defects in Proliferation
i. Proliferation is indiscriminate and continuous.
ii. Producing more cells than normal.
iii. No contact inhibition
b. Defects in Differentiation
i. Mutation
ii. Proteins that change the cellular structure.
iii. Lack of proper transfer of genetic information.
3. Natural history of cancer is an orderly process comprising several stages and occurring over a period of time.
4. Benign Neoplasm
a. Well differentiated
b. Usually encapsulated
c. Expansive mode of growth
d. Characteristics similar to parent cell
e. Metastasis is absent.
f. Rarely recur
5. Malignant Neoplasm
a. May range from well differentiated to undifferentiated
b. Able to metastasize
c. Infiltrative and expansive growth
d. Frequent recurrence
e. Moderate to marked vascularity
f. Rarely encapsulated
g. Becomes less like parent cell
6. Classifications = anatomical site, histology, extent of disease
a. Histological Classification
i. Grade (I-IV) of Abnormal Cells - the more differentiated the cell, the harder it is to determine the cell’s origin
ii. Staging (0-4) - location of the cancer (how far as it spread)
iii. TNM - anatomical extent of disease (tumor size/lymph nodes, metastasis)
1. *note: the higher the number, the worse the cancer
Assessment
N/A
Clinical Manifestations
1. CAUTION:
a. Change in bowel or bladder habits
b. A sore that does not heal
c. Unusual bleeding or discharge from any body orifice
d. Thickening or a lump in the breast or elsewhere
e. Indigestion or difficulty in swallowing
f. Obvious change in a wart or mole
g. Nagging cough or hoarseness
Diagnostics
1. Diagnostic plan includes
a.
b.
c.
d.
Nursing Diagnosis
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Goals
Health history
Identification of risk factors
Physical examination
Specific diagnostic studies
Anticipatory Grieving
Situational Low Self-Esteem
Acute Pain
Altered Nutrition: Less Than Body Requirements
Risk for Fluid Volume Deficit
Fatigue
Risk for Infection
Risk for Altered Oral Mucous Membranes
Risk for Impaired Skin Integrity
Risk for Constipation/Diarrhea
Risk for Altered Sexuality Patterns
Risk for Altered Family Process
Fear/Anxiety
1. Collaborative effort:
a. Nursing/Medical
b. Spiritual
c. Case management
d. Social services
e. Nutrition
f. Physical therapy
Interventions
Chemotherapy
1. Response of cancer cells depend on:
a. Mitotic rate
b. Size of tumor
c. Age of tumor
Radiation
1. Primary therapy
2. Adjuvant
3. Prophylaxis/Disease control
4. Palliative
a. External
b. Internal
Evaluations
1.
2.
3.
Always make sure the IV is patent and flushing properly.
Patient teaching for N/V
a. Avoid eating 1-2 hours before chemo
b. Take anti-emetics before treatment
c. Eat small frequent meals
d. Avoid anything that will increase GI upset like hot, spicy or fatty foods.
Mucositis: Painful ulcerations of the mouth.
a. Treated with magic mouthwash. Avoid any ETOH base mouthwashes
4.
5.
6.
7.
8.
9.
Teaching
Alopecia:
a. Might or might not happen. Wig programs.
b. Lubricate area with non-irritating lotion or cream
Bone marrow suppression
a. HCT may need blood products
b. Know values
Neutropenia
a. different levels (Might need revered precautions) Def need good hand washing
b. Watch your WBC and the ANC Absolute neutrophil count know values
Thrombocytopenia
a. Plt know values (Bleed precautions, such as using electric razor, soft bristle toothbrush, and Bowel regimen if
constipation is a factor)
Fatigue
a. Keep up with ADLs and be as activity as they can.
Pain
a. Pt with cancer are going to need standing pain medications along with PRN pain meds for breakthrough pain.
Prevention and Detection
a. Lifestyle habits to reduce risks:
i.
Avoid or reduce exposure to known or suspected carcinogens.
b. Cigarette smoke, excessive sun exposure
i.
Eat a balanced diet.
ii.
Exercise regularly.
iii.
Obtain adequate rest.
c. Habits to reduce risks
i.
Have a regular health examination.
ii.
Change perceptions of stressors.
iii.
Know seven warning signs of cancer.
iv.
Practice recommended cancer screenings.
v.
Practice self-examination.
vi.
Seek medical care if cancer is suspected.
2. Renal - Acute/Chronic kidney failure, UTI, Pyelonephritis (15 Questions)
Patho
UTI
Chronic Kidney Disease
1. Escherichia coli most common
pathogen
2. Fungal and parasitic infections can
cause UTIs
3. Upper tract
a. Renal parenchyma, pelvis, and
ureters
b. Typically causes fever, chills,
flank pain
c. Pyelonephritis(kidney
infection): inflammation of
1. Involves progressive,
irreversible loss of kidney
function
2. Defined as presence of
a. Kidney damage
3. Pathologic abnormalities
4. Markers of damage
a. Blood, urine, imaging tests
b. Glomerular filtration rate
(GFR)
5. <60 mL/min for 3 months or
longer
Acute Kidney Failure
1. Pre-renal
a. Relate to cardiac output:
Hemorrhage, vomiting,
diarrhea, CHF, MI, renal
artery thrombosis
2. Intra-renal
a. Drugs, x-ray dye, lupus,
toxemia of pregnancy
b. ATN-acute tubular necrosis
3. Post-renal
a. Bladder, prostate cancer
b. Spinal cord disease
Pyelonephritis
1. Inflammation of renal parenchyma
and collecting system
2. Caused most commonly by
bacteria
3. Fungi, protozoa, or viruses
infecting kidneys can be the cause.
renal parenchyma and
collecting system
4. Lower tract
a. Lower urinary tract
b. Usually no systemic
manifestations
c. Bladder infection (UTI)
d. Cystitis: inflammation of
bladder wall
6. Leading causes of ESRD
a. Glomerulonephritis
b. Diabetes
c. Hypertension
c. Neuromuscular disorders
4. Oliguric phase: < 400 ml/ 24 hrs
5. Diuretic Phase: 1-3 litres/day /
abnormal labs
6. Recovery Phase: GFR
increases, BUN/Cr decrease
7. Elders: more severe disease,
prognosis
Assessment
Subjective Assessment
1. Previous UTIs, calculi, stasis,
retention, pregnancy, STDs,
bladder cancer
2. Antibiotics, anticholinergics,
antispasmodics
3. Urologic instrumentation
4. Urinary hygiene
5. N/V, anorexia, chills, nocturia,
frequency, urgency
6. Suprapubic/lower back pain,
bladder spasms, dysuria, burning
on urination
Objective Assessment
1. Fever
2. Hematuria, foul-smelling urine,
tender, enlarged kidney
3. Leukocytosis, positive findings for
bacteria, WBCs, RBCs, pyuria,
ultrasound, CT scan, IVP
1. History and physical
examination
N/A
Subjective Assessment
1. Previous UTIs, calculi, stasis,
retention, pregnancy, STDs,
bladder cancer
2. Antibiotics, anticholinergics,
antispasmodics
3. Urologic instrumentation
4. Urinary hygiene
5. Nausea, vomiting, anorexia, chills,
nocturia, frequency, urgency
6. Suprapubic or lower back pain,
bladder spasms, dysuria, burning
on urination
Objective Assessment
1. Fever
2. Hematuria, foul-smelling urine,
tender, enlarged kidney
3. Leukocytosis, positive findings for
bacteria, WBCs, RBCs, pyuria,
ultrasound, CT scan, IVP
Clinical
Manifestations
Bladder storage or bladder emptying
1. Urinary frequency: abnormally
frequent (> every 2 hours)
2. Urgency: sudden strong desire to
void immediately
3. Incontinence: loss or leakage of
urine
1. Polyuria
a. Results from inability of
kidneys to concentrate
urine
b. Occurs most often at night
c. Specific gravity fixed
around 1.010
2. Oliguria
a. Occurs as CKD worsens
3. Anuria
a. Urine output <40 mL per
24 hours
Hematologic System
1. Anemia
1. Renal: Oliguria, proteinuria
2. Cardiac: Volume overload
>CHF, Arrythmias
3. Resp: PE, Kussmaul
respirations
4. GI: N,V,D,C
5. Heme: platelet defects
(bleeding), anemia, WBCs
increase
6. Neuro: Lethargy, seizures,
asterixis
7. Metabolic: BUN/Creat, Lytes,
Ca, PO4, bicarb
1.
2.
3.
4.
5.
6.
7.
4. Nocturia: waking up ≥2 times at
night to void
5. Nocturnal enuresis: complaint of
loss of urine during sleep
*geriatrics. = atypical manifestations*
a. Due to ↓ production of
erythropoietin
Mild fatigue
Chills
Fever
Vomiting
Malaise
Flank pain
Lower urinary tract symptoms
characteristic of cystitis
8. Costovertebral tenderness usually
present on affected side
9. Manifestations usually subside in a
few days, even without therapy.
10.Bacteriuria and pyuria still persist.
2. From ↓ in functioning renal
tubular cells
3. Bleeding tendencies
a. Defect in platelet function
4. Infection
a. Changes in leukocyte
function
b. Altered immune response
and function
c. Diminished inflammatory
response
Cardiovascular System
1. Hypertension
2. Heart failure
3. Left ventricular hypertrophy
4. Peripheral edema
5. Dysrhythmias
6. Uremic pericarditis
Neurologic System
1. Expected as renal failure
progresses
a. Attributed to
2. ↑ nitrogenous waste products
3. Electrolyte imbalance
4. Metabolic acidosis
5. Axonal atrophy
6. Demyelination of nerve fibers
7. Restless leg syndrome
8. Muscle twitching
9. Irritability
10.Decreased ability to
concentrate
11.Peripheral neuropathy
Diagnostics
1. History and physical examination
2. Dipstick urinalysis
a. Identify presence of nitrates,
WBCs, and leukocyte
esterase.
3. Urine for culture and sensitivity
4. Clean-catch sample preferred
a. Specimen by catheterization or
suprapubic needle aspiration
more accurate
b. Determine susceptibility of
bacteria to antibiotics
1. History and physical
examination
2. Dipstick evaluation
3. Albumin-creatinine ratio (first
morning void)
4. GFR
5. Serum Levels
6. Renal ultrasound
7. Renal scan
8. CT scan
9. Renal biopsy
N/A
1. History
2. Physical examination
a. Palpation for CVA pain
3. Laboratory tests
a. Urinalysis
b. Urine for culture and sensitivity
c. CBC with differential
d. Blood culture (if bacteremia is
suspected)
4. Ultrasound
5. IVP
6. CT scan
Nursing
Diagnosis
1.
2.
3.
4.
Goals
Educate & Hygiene
Interventions
Acute Pain
Impaired Urinary Elimination
Hyperthermia
Deficient Knowledge
1. Adequate fluid intake
a. Patient may think will worsen
condition because of
discomfort.
b. Dilutes urine, making bladder
less irritable
c. Flushes out bacteria before
they can colonize
2. Avoid caffeine, alcohol, citrus
juices, chocolate, and highly
spiced foods.
a. Potential bladder irritants
3. Application of local heat to
suprapubic or lower back may
relieve discomfort.
4. Instruct patient about drug therapy
and side effects.
5. Instruct patient to watch urine for
changes in color and consistency
and decrease in cessation of
symptoms.
6. Counsel on persistence of lower
tract symptoms beyond treatment;
onset of flank pain or fever should
be reported immediately.
7. Emphasize compliance with drug
regimen.
a. Take as ordered.
8. Maintain adequate fluids.
9. Regular voiding (every 3 to 4
hours)
10. Void after intercourse.
1. Excess fluid volume
2. Risk for injury
3. Imbalanced nutrition: Less
than body requirements
4. Grieving
5. Risk for infection
N/A
5.
6.
7.
8.
N/A
N/A
Educate & Hygiene
1. Sodium restriction
a. Diets vary from 2 to 4 g,
depending on degree of
edema and hypertension.
b. Sodium and salt should
not be equated.
c. Salt substitutes should not
be used because they
contain potassium
chloride.
2. Potassium restriction
a. 2-3 g
b. High-potassium foods
should be avoided.
3. Acute intervention
a. Daily weight
b. Daily BPs
c. Identify signs and
symptoms of fluid
overload.
d. Identify signs and
symptoms of
hyperkalemia.
e. Strict dietary adherence
f. Medication education
g. Motivate patients in
management of their
disease.
4. Drug Treatment
1. Pre-renal
a. Treat dehydration, bleeding
2. Intra-renal
a. Remove the drug
3. Post –renal
a. Treat obstruction, BPH,
tumor etc
4. Monitor
a. Intake/ output (oliguric,
diuretic phases)
b. Cardiac function (electrolyte
imbalances)
c. Risk for infection (immune
suppression)
d. Safety (neuro changes)
e. Labs
f. Drug effects
g. Pre-existing conditions
1. Hospitalization for patients with
severe infections and
complications
a. Such as nausea and vomiting
with dehydration
2. Signs/symptoms typically improve
within 48 to 72 hours after therapy
is started.
3. Drug therapy
a. Antibiotics
4. Parenteral in hospital to rapidly
establish high drug levels
a. NSAIDs or antipyretic drugs
5. Fever
6. Discomfort
a. Urinary analgesics
Acute Pain
Impaired Urinary Elimination
Hyperthermia
Deficient Knowledge
Evaluations
N/A
N/A
N/A
N/A
Teaching
1. Recognize individuals at risk.
a. Debilitated persons
b. Older adults
c. Underlying diseases (HIV,
diabetes)
N/A
N/A
1. Early treatment for cystitis to
prevent ascending infection
2. Patient with structural
abnormalities is at high risk
2.
3.
4.
5.
d. Taking immunosuppressive
drug or corticosteroids
Emptying bladder regularly and
completely
Evacuating bowel regularly
Wiping perineal area front to back
Drinking adequate fluids (15 mL/lb)
a. 20% fluid comes from food.
3. Stress the need for regular medical
care.
a. Need to continue drugs as
prescribed
b. Need for follow-up urine
culture
c. Identification of risk for
recurrence or relapse
d. Encourage adequate fluids
a. Patho
i.
General Kidney Pathology
1. Kidney Function
i.
Regulates volume and composition of extracellular fluid
ii.
Produces and secretes Renin for blood pressure control
iii.
Erythropoietin: hormone in kidney; stimulates RBC production
iv.
Kidney activate Vitamin D/Calcium (bone health, muscle/heart contraction)
2. Renal Failure
i.
Electrolyte imbalances, fluid imbalances
ii.
Renin regulates BP (Too much fluid = BP↑; Too little fluid = BP↓)
iii.
↓Erythropoietin = anemia
iv.
Altered Calcium vs. Phosphate balance
3. Aging System (“Start low, and go Slow”)
i.
↓Kidney size, blood flow, nephron function, GFR, estrogen, muscle support
ii.
↑Prostate size
b. Assessment
i.
History
1. Urinary patterns
2. Weight changes / edema
3. Urinary changes
a. Dysuria: pain with urination
b. Polyuria: large amount of urine in a given time
c. Nocturia: frequent urination at night
d. Oliguria: diminished amounts of urine at a given time
e. Anuria: no urine (24hr Os <100mL)
4. Incontinence
5. Itchy skin
6. Fatigue
7. Anorexia
8. N/V
9. Pain
ii.
iii.
iv.
v.
Physical
1. Hypertension r/t ?
2. Skin changes / pallor r/t ?
3. Edema r/t ?
4. Anemia r/t ?
5. Bone health r/t ?
6. Change in urine: dark, bloody,
concentrated, odorous
*Low Calcium = High Phosphorus*
Blood pressure (most cases, INCREASE in BP – kidneys loss their ability to process the fluid)
Skin changes (ashy, gray)
Anemia (peripheral, lung, generalized/anasarca)
Bone health (muscle pain, bone pain, loss of Vitamin D)
c. Clinical manifestations
d. Diagnostics
i.
1. Urinalysis (UA)
a. Dipstick
2. Urine culture
3. Creatinine clearance
a. Normal 80-135 ml/ min
b. ESRD 15 ml/min
4. Glomerular filtration rate
a. GFR
5. Blood tests
a. Blood Urea Nitrogen(BUN)
b. Creatinine(Creat)
c. Electrolytes
i.
Potassium
ii.
Sodium
iii.
Chloride
d. CBC
e. Calcium, Phosphorous
ii.
1.
2.
3.
4.
5.
6.
KUB (x-ray; indirect image)
Ultrasound
CT scan (image of kidney tissue)
Dye contrast studies (last resort)
Biopsy (GOLD STANDARD; dangerous)
Nuclear studies
Urinalysis (UA)
1. Color: Hematuria, Excessive Bilirubin, Medications (Pyridium) and clarity (Cloudy urine can be a sign of an infection)
2. Odor: UTI
3. Protein: Acute or chronic renal disease (Involving the glomeruli). Check medications
4. Glucose: DM Pituitary disorder
5. Ketones: Altered Carb fat metabolism in DM, starvation, dehydration, vomiting, severe diarrhea
6. Bilirubin: Liver disorder
7. SG: low: too dilute, High dehydration
8. OSMO: Tubular dysfunction-kidney lost ability to concentrate or dilute urine
9. pH: UTI
10. RBC: Trauma, UTI, Cancer, glomerulonephritis, tuberculosis,
11. WBC: UTI or inflammation
12. Bacteria: Depending on concentration either infection or contamination of specimen
1. Asthma (5 Questions)
a. Patho
i.
Chronic inflammatory disorder of airways
ii.
Causes airway hyperresponsiveness leading to wheezing, breathlessness, chest tightness, and cough
iii.
Triggers:
1. Allergen - seasonal, year round, exacerbated after exercise
2. Air Pollutants - heavily industrialized or densely populated areas, climatic conditions often lead to concentrated pollution in the atmosphere,
especially with thermal inversions and stagnant air masses.
b. Assessment
i.
Severe acute attack
1. Respiratory rate >30/min
2. Pulse >120/min
3. PEFR is 40% at best.
c.
4. Usually seen in ED or hospitalized
ii.
Life-threatening asthma
iii.
Too dyspneic to speak
iv.
Perspiring profusely
v.
Drowsy/confused
vi.
Require hospital care and often admitted to ICU
Clinical manifestations
i.
Unpredictable and variable
1. Decrease breath sounds
2. Recurrent episodes of wheezing, breathlessness, cough, and tight chest
3. May be abrupt or gradual
4. Lasts minutes to hours
ii.
Expiration may be prolonged.
1. Inspiration-expiration ratio of 1:2 to 1:3 or 1:4
2. Bronchospasm, edema, and mucus in bronchioles narrow the airways.
3. Air takes longer to move out.
iii.
An acute attack usually reveals signs of hypoxemia.
1. Restlessness
iv.
2. ↑ anxiety
3. Inappropriate behavior
More signs of hypoxemia
1. ↑ pulse and blood pressure
2. Pulsus paradoxus (drop in systolic BP during inspiratory cycle >10 mm Hg)
d. Diagnostics
i.
Classification for Initial Diagnosis
1. Mild intermittent
2. Mild persistent
3. Moderate persistent
4. Severe persistent
ii.
Tidal volume (VT) = amount of air inhaled or exhaled during normal breathing.
iii.
Minute volume (MV) = total amount of air exhaled per minute.
iv.
Vital capacity (VC) = total volume of air that can be exhaled after inhaling as much as you can.
v.
Functional residual capacity (FRC) = amount of air left in lungs after exhaling normally.
vi.
Residual volume = amount of air left in the lungs after exhaling as much as you can.
vii.
Total lung capacity = total volume of the lungs when filled with as much air as possible.
viii.
Forced vital capacity (FVC) = amount of air exhaled forcefully and quickly after inhaling as much as you can.
ix.
Forced expiratory volume (FEV) = amount of air expired during the first, second, and third seconds of the FVC test.
x.
Forced expiratory flow (FEF) = average rate of flow during the middle half of the FVC test.
xi.
Peak expiratory flow rate (PEFR) = fastest rate that you can force air out of your lungs.
e. Nursing Diagnoses
i.
Ineffective Breathing Pattern
ii.
Ineffective Airway Clearance
iii.
Deficient Knowledge
iv.
Anxiety
v.
Activity Intolerance
vi.
Health-Seeking Behaviors: Prevention of Asthma Attack
vii.
Interrupted Family Processes
viii.
Fatigue
f. Goals
i.
ii.
iii.
iv.
v.
Acute intervention
1. Monitor respiratory and cardiovascular systems:
Lung sounds
Respiratory rate
Pulse
BP
An important goal of nursing is to ↓ the patient’s sense of panic.
1. Stay with patient.
2. Encourage slow breathing using pursed lips for prolonged expiration.
3. Position comfortably.
g. Interventions
i.
Bronchodilators (Short-acting)
1. Albuterol inhaler (SABA)
2. Atrovent inhaler (ipratropium) (HFA)
ii.
Corticosteroid (Quick-acting)
1. IV steroids
iii.
Bronchodilators (Long-acting)
1. Advair (Fluticasone propionate and Salmeterol)
2. Flovent (ICS)
3. Oral Prednisone
4. Singulair (monelukast) (LTRA)
h. Evals
i.
Also monitor ABGs, pulse oximetry, and peak flow.
ii.
The nurse should note that louder wheezing may actually occur in the airways that are responding to the therapy as airflow in the airways increases.
i. Teaching
i.
Avoid triggers
ii.
Seek medical attention for bronchospasm or when severe side effects occur.
iii.
Maintain good nutrition.
iv.
Exercise within limits of tolerance.
v.
Use inhaler before exercising.
vi.
Medication compliance.
vii.
Measure peak flow at least daily.
viii.
Compliance with Asthma Action Plan
ix.
Asthmatic individuals frequently do not perceive changes in their breathing.
vi.
3. Musculoskeletal - OP, OA, RA, MS Assessment (10 Questions)
a.
Osteoporosis (OP)
Patho
1. Usually bone deposition and
bone reabsorption are equal so
bone mass stays constant.
2. Characterized by low bone
mass and structural
deterioration of bone tissue
leading to increased bone
fragility
Osteoarthritis (OA)
1. DJD
2. Degeneration of articular
cartilage
3. Slow , progressive
4. Affects weight bearing joints
5. Before age 50, affects men >
women
6. After age 50, affects women >
men
Rheumatoid Arthritis (RA)
1. Chronic, systemic
2. Inflammation of connective
tissue in the synovial joints.
3. Affects all ethnic groups
4. Occurs at any time during the
life span.
5. Cause – unknown
6. Etiology – thought to be autoimmune.
Musculoskeletal (MS)
1.
2.
3.
4.
5.
6.
Function
Support
Protection of internal organs
Voluntary movement
Blood cell production
Mineral storage
3. Occurs more frequently in
women but men do suffer from
it.
4. Women over age 60 should be
screened for it
5. Most often occurs in spine,
hips and wrists
6. “silent disease” – lack of
symptoms
7. First signs are back pain or
spontaneous fractures
7. May be idiopathic or secondary
8. No one single cause
9. Degeneration / wearing away of
cartilage
10. Body’s repairing can’t keep up
with destruction
7. RF combines with IgG to form
immune complexes that affect
joints. Activates inflammatory
response
8. See joint changes from the
inflammation.
9. Genetic factors
10. May be higher incidence (have
seen higher incidence with
identical vs. fraternal twins)
Assessment
Subjective
1. Important health information
2. PMHx, MS impairment, recent
trauma, pain, weakness,
deformities, limitation in
movement, stiffness, joint
crepitation.
3. Medications
4. Anti-seizure meds,
phenothiazines,
corticosteroids, K depleting
diuretics.
5. Surgery and other treatment
6. FHP
7. Health perceptions, Nutrition,
Elimination, Activity, Sleep
rest, Cognitive-perceptual,
Role-relationships.
Objective
1. Inspection
2. Head to toe, body build,
swelling, deformity, nodules.
3. Palpation
4. Skin temp, local tenderness,
swelling.
5. Motion
6. Passive and active range of
motion.
7. Synovial Joint Movement
Review Table 61-3
8. Muscle-strength testing
9. 0-5
Subjective
1. Important health information
2. PMHx, MS impairment, recent
trauma, pain, weakness,
deformities, limitation in
movement, stiffness, joint
crepitation.
3. Medications
4. Anti-seizure meds,
phenothiazines, corticosteroids,
K depleting diuretics.
5. Surgery and other treatment
6. FHP
7. Health perceptions, Nutrition,
Elimination, Activity, Sleep rest,
Cognitive-perceptual, Rolerelationships.
Objective
1. Inspection
2. Head to toe, body build,
swelling, deformity, nodules.
3. Palpation
4. Skin temp, local tenderness,
swelling.
5. Motion
6. Passive and active range of
motion.
7. Synovial Joint Movement
Review Table 61-3
8. Muscle-strength testing
9. 0-5
Subjective
1. Important health information
2. PMHx, MS impairment, recent
trauma, pain, weakness,
deformities, limitation in
movement, stiffness, joint
crepitation.
3. Medications
4. Anti-seizure meds,
phenothiazines,
corticosteroids, K depleting
diuretics.
5. Surgery and other treatment
6. FHP
7. Health perceptions, Nutrition,
Elimination, Activity, Sleep
rest, Cognitive-perceptual,
Role-relationships.
Objective
1. Inspection
2. Head to toe, body build,
swelling, deformity, nodules.
3. Palpation
4. Skin temp, local tenderness,
swelling.
5. Motion
6. Passive and active range of
motion.
7. Synovial Joint Movement
Review Table 61-3
8. Muscle-strength testing
9. 0-5
Subjective
1. Important health information
2. PMHx, MS impairment, recent
trauma, pain, weakness,
deformities, limitation in
movement, stiffness, joint
crepitation.
3. Medications
4. Anti-seizure meds,
phenothiazines, corticosteroids, K
depleting diuretics.
5. Surgery and other treatment
6. FHP
7. Health perceptions, Nutrition,
Elimination, Activity, Sleep rest,
Cognitive-perceptual, Rolerelationships.
Objective
1. Inspection
2. Head to toe, body build, swelling,
deformity, nodules.
3. Palpation
4. Skin temp, local tenderness,
swelling.
5. Motion
6. Passive and active range of
motion.
7. Synovial Joint Movement Review
Table 61-3
8. Muscle-strength testing
9. 0-5
Clinical
manifestations
1. no clinical manifestations until
there is a fracture.
1. Systemic – No symptoms
2. Joints – predominant symptom
is joint pain
1. Onset insidious
2. Fatigue, anorexia, weight loss,
generalized stiffness.
1. Edema
2. Pain / tenderness
3. Muscle spasm
2. Many vertebral fractures are
asymptomatic.
3. They may be diagnosed as an
incidental finding on chest or
abdominal radiographs.
4. The clinical manifestations of
symptomatic vertebral
fractures include pain and
height loss.
3. Hips and knees (most
common)
4. hands, vertebrae
5. May have crepitus, deformity
3. Articular involvement – heat,
swelling, tenderness,
decreased joint motion.
4. Joint symptoms – symmetrical.
5. Fingers, toes, wrists, elbows,
shoulders, hips knees, ankles
4.
5.
6.
7.
Diagnostics
1. Xray is not helpful
2. BMD – bone mineral density
1.
2.
3.
4.
5.
Xray
CT
MRI
Bone Scan / Imaging
No lab markers for OA
Labs
1. + RF; ESR, C reactive protein,
ANA
a. ANA (antinuclear
antibody test) may be
positive in clients with
autoimmune disorders
such as RA.
2. Synovial fluid analysis
3. Bone Scan / imaging
Image
1. Xray
2. CT scan
3. MRI
4. Bone scan
5. Arthroscopy
Laboratory Testing
1. Calcium
2. Phosphorus
3. Rheumatoid factor
4. Assess Autoantibodies.
Assessment for connective tissue
dz.
5. Erythrocyte sedimentation rate
6. Non-specific measure of
inflammation
7. Uric acid
8. Levels usually increased in gout.
9. C-reactive protein
10. Used to dx inflammation,
infection, malignancy
Nursing
Diagnoses
1. Impaired Physical Mobility
2. Imbalanced Nutrition: Less
1.
2.
3.
4.
Acute Pain/Chronic Pain
Impaired Physical Mobility
Activity Intolerance
Risk For Injury
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Pain control
Rest / joint protection
Heat / cold therapy
Nutritional therapy / exercise
Alternative therapies
Drug Therapy
Salicylates
Tylenol
NSAIDS
Pain control
1. Maintain joint motion
2. Active exercise to prevent
deformities
3. Nutrition therapy
Drug Therapy Management
1. Salicylates
2. NSAIDS
a. Cox II inhibitors
Than Body Requirements
3. Risk for Poisoning
4. Deficient Knowledge
Interventions
1. Proper nutrition (eating high
calcium foods)
2. Calcium supplements (1000 –
1500 mg/day)
3. Vitamin D supplements (post
menopausal)
4. Exercise
5. Prevention of fractures
Acute Pain
Impaired Physical Mobility
Disturbed Body Image
Self-Care Deficit
Risk for Impaired Home
Maintenance
6. Deficient Knowledge
Deformity
Ecchymosis
Loss of function
Crepitation
6. Medications ( Biphosphonates
- fosamax, boniva)
7. take with a full glass of water,
remain upright for 30 minutes
after taking and take on an
empty stomach
8. Fosamax – once per week
oral dose
9. Boniva – once per month oral
dose
10. Calcimar – nasal spray daily
11. Forteo – stimulates new bone
growth – SQ daily
12. Prolia – given SQ every 6
months
a. Cox II inhibitors
10. Corticosteroids
4. Hypertension (5 Questions)
a. Patho
i.
Primary Hypertension (Essential/Idiopathic)
1. Unknown cause
2. Water & Sodium Retention (obesity/age/African
Americans)
ii.
Secondary Hypertension
1. Specific cause (drug/endocrine
b. Assessment
i.
Subjective Data
1. Past health history
2. Current medications
3. Functional health pattern/management
ii.
Objective Data
1. Elimination (kidney function)
2. Activity-Exercise, cognitive perceptual, coping = stress
3. BP, HR, Heart sounds, Lung sounds, Peripheral pulses,
Peripheral edema, Carotids
4. Neurologic/Eye exam
c. Clinical manifestations
i.
“Silent Killer”
ii.
Often no symptoms
iii.
Symptoms are often secondary to target organ disease
iv.
Complications
1. Target organ diseases (ex. Heart, brain, kidney, eyes)
2. CAD, LVH, HF, PVD, Nephrosclerosis, Retinal damage
3. CVD (stroke, TIAs)
d. Diagnostics
i.
BP measurement in both arms (x2 measurements)
1. Use arm with higher reading for subsequent measurements
2. BP highest in early morning
3. Lowest at night
3. Non opioid analgesics
a. Tylenol, Ultram
4. Opioid analgesics
5. Corticosteroids
a. Prednisone
6. Methotrexate
7. Gold
8. Antimalarials
9. Immunosuppressants
10. Biologic therapy
11. Antibiotics
a. Minocin
“White coat” phenomenon
1. Repeat the BP at the end of the visit.
2. Anxiety can increase BP.
iii.
Echo/ECG
e. Nursing Diagnoses
i.
Risk for decreased cardiac tissue perfusion
ii.
Risk for decreased cerebral tissue perfusion
iii.
Risk for ineffective renal perfusion
iv.
Ineffective self health management
v.
Knowledge deficit
vi.
Anxiety
vii.
Potential complication: Stroke
viii.
Potential complication: MI
ix.
Potential complication: Adverse effects from antihypertensive therapy
x.
Potential complication: Hypertensive crisis
f. Intervention
i.
Lifestyle Modifications (weight, dietary sodium)
ii.
Moderations of alcohol consumption
iii.
Physical activity
iv.
Avoidance of tobacco products
v.
Stress management
vi.
Drug Therapy (reduce SVR, reduce volume of circulating blood)
1. Diuretics
i.
lasix, hydrochlorothiazide - deplete potassium, cause orthostatic hypertension
ii.
Spironolactone - increase in potassium
2. Direct vasodilators
i.
Hydralazine
3. Adrenergic inhibitors (beta-blockers)
ii.
i.
atenolol, metoprolol - resp condition /c meds can worsen bronchospasms, ↓HR
4. Angiotensin inhibitors (ACE inhibitors)
i.
Lisinopril *COUGH*
ii.
Captopril
5. Calcium channel blockers
i.
Diltiazem
ii.
Verapamil
iii.
Norvasc
g. Teaching
i.
Control blood pressure
ii.
Reduce CVD risk factors
iii.
Start with lifestyle modification
iv.
Identify, report, and minimize side effects:
1. Orthostatic hypotension
2. Sexual dysfunction
3. Dry mouth
4. Frequent urination
5. Diabetes Mellitus (10 Questions)
a. Patho
i.
Normal insulin metabolism (produced by the B-cells)
ii.
iii.
iv.
v.
vi.
Released after food, consistently released into the bloodstream
A chronic multisystem disease related to
1. Abnormal insulin production
2. Impaired insulin utilization
3. Or both
Leading cause of
1. End-stage renal disease
2. Adult blindness
3. Nontraumatic lower limb amputations
Major contributing factor
1. Heart disease
2. Stroke
Classifications
1. Pre-diabetes
2. Type I
3. Type II
4. Gestational
5. Secondary diabetes
b.
Pre-diabetes
Patho
1. Long-term damage
already occurring
2. Heart, blood vessels
3. Usually present with
no symptoms
Type I
Type II
Gestational
Secondary Diabetes
1. Most often occurs in
people younger than 40
years of age
2. Occurs more frequently
in younger children
3. End result of longstanding process
4. Progressive destruction
of pancreatic b cells by
body’s own T cells
5. Manifestations develop
when pancreas can no
longer produce insulin.
a. Rapid onset of
symptoms
b. Present at ED with
ketoacidosis
6. Will require exogenous
insulin to sustain life
7. Diabetic ketoacidosis
(DKA)
a. Occurs in absence
of exogenous
insulin
b. Life-threatening
condition
c. Results in
metabolic acidosis
1. Usually occurs in
people over 35 years of
age
2. 80% to 90% of patients
are overweight.
3. Prevalence increases
with age.
4. Genetic basis
5. Pathophysiology
a. Increase demand
on pancreas
b. Insulin Resistance
c. Liver
d. Metabolic
syndrome
1. Develops during
pregnancy
2. Detected at 24 to 28
weeks of gestation
3. Usually normal glucose
levels at
4. 6 weeks postpartum
5. Increased risk for
cesarean delivery,
perinatal death, and
neonatal complications
6. Increased risk for
developing type 2 in 5 to
10 years
7. Therapy: First
nutritional, second
insulin
8. Metformin
1. Results from another
medical condition
a. Cushing syndrome
b. Hyperthyroidism
c. Pancreatitis
d. Parenteral nutrition
e. Cystic fibrosis
f. Hemochromatosis
Assessment
1. Past health history
a. Viral infections
b. Medications
c. Recent surgery
2. Positive health history
3. Obesity
4. Weight loss
5. Thirst
6. Hunger
7. Poor healing
8. Kussmaul respirations
1. Past health history
a. Viral infections
b. Medications
c. Recent surgery
2. Positive health history
3. Obesity
4. Weight loss
5. Thirst
6. Hunger
7. Poor healing
8. Kussmaul respirations
1. Past health history
a. Viral infections
b. Medications
c. Recent surgery
2. Positive health history
3. Obesity
4. Weight loss
5. Thirst
6. Hunger
7. Poor healing
8. Kussmaul respirations
Clinical
Manifestations
1. Must watch for
diabetes symptoms
2. Polyuria
3. Polyphagia
4. Polydipsia
1. Classic symptoms
a. Polyuria (frequent
urination)
b. Polydipsia
(excessive thirst)
c. Polyphagia
(excessive hunger)
2. Weight loss
3. Weakness
4. Fatigue
1. Nonspecific symptoms
2. Polyuria, polydipsia,
polyphagia
3. Fatigue
4. Recurrent infection
5. Recurrent vaginal yeast
or monilia infection
6. Prolonged wound
healing
7. Visual changes
Diagnostics
1. Exogenous Insulin
a. Insulin from
outside source
b. Required for Type
I DM
1. Hemoglobin A1C Test:
useful in determining
glycemic levels over time
a. Shows the amount
of glucose
attached to
hemoglobin
molecules over
RBC lifespan
b. Reduces risk of
retinopathy
1. Exogenous Insulin
2. SOMETIMES used for
Type II
a. Rapid Acting
(Lispro)
b. Short Acting
(Regular)
c. Intermediate
Acting (NPH)
d. Long Acting
(Lantus)
Nursing Diagnosis 1. Risk for Unstable Blood
Glucose
2. Deficient Knowledge
3. Risk for Infection
4. Risk for Disturbed
Sensory Perception
5. Powerlessness
6. Risk for Ineffective
Therapeutic Regimen
Management
7. Risk for Injury
1. Risk for Unstable Blood
1. Risk for Unstable Blood
1. Risk for Unstable
2.
3.
4.
5.
6.
7.
Glucose
Deficient Knowledge
Risk for Infection
Risk for Disturbed
Sensory Perception
Powerlessness
Risk for Ineffective
Therapeutic Regimen
Management
Risk for Injury
2.
3.
4.
5.
6.
7.
Glucose
Deficient Knowledge
Risk for Infection
Risk for Disturbed
Sensory Perception
Powerlessness
Risk for Ineffective
Therapeutic Regimen
Management
Risk for Injury
1. Past health history
a. Viral infections
b. Medications
c. Recent surgery
2. Positive health history
3. Obesity
4. Weight loss
5. Thirst
6. Hunger
7. Poor healing
8. Kussmaul respirations
2.
3.
4.
5.
6.
7.
Blood Glucose
Deficient Knowledge
Risk for Infection
Risk for Disturbed
Sensory Perception
Powerlessness
Risk for Ineffective
Therapeutic Regimen
Management
Risk for Injury
1. Past health history
a. Viral infections
b. Medications
c. Recent surgery
2. Positive health history
3. Obesity
4. Weight loss
5. Thirst
6. Hunger
7. Poor healing
8. Kussmaul respirations
1. Risk for Unstable
Blood Glucose
2. Deficient Knowledge
3. Risk for Infection
4. Risk for Disturbed
Sensory Perception
5. Powerlessness
6. Risk for Ineffective
Therapeutic Regimen
Management
7. Risk for Injury
8. Imbalanced Nutrition:
8. Imbalanced Nutrition:
8. Imbalanced Nutrition:
8. Imbalanced Nutrition:
8. Imbalanced Nutrition:
Less Than Body
Requirements
9. Risk for Deficient Fluid
Volume
10. Fatigue
11. Risk for Impaired Skin
Integrity
Less Than Body
Requirements
9. Risk for Deficient Fluid
Volume
10. Fatigue
11. Risk for Impaired Skin
Integrity
Less Than Body
Requirements
9. Risk for Deficient Fluid
Volume
10. Fatigue
11. Risk for Impaired Skin
Integrity
Less Than Body
Requirements
9. Risk for Deficient Fluid
Volume
10. Fatigue
11. Risk for Impaired Skin
Integrity
Less Than Body
Requirements
9. Risk for Deficient Fluid
Volume
10. Fatigue
11. Risk for Impaired Skin
Integrity
Goals
1. Active patient
participation
2. Few or no episodes of
acute hyperglycemic
emergencies or
hypoglycemia
3. Maintain normal blood
glucose levels.
4. Prevent or delay
chronic complications.
5. Lifestyle adjustments
with minimal stress
1. Active patient
participation
2. Few or no episodes of
acute hyperglycemic
emergencies or
hypoglycemia
3. Maintain normal blood
glucose levels.
4. Prevent or delay chronic
complications.
5. Lifestyle adjustments with
minimal stress
1. Active patient
participation
2. Few or no episodes of
acute hyperglycemic
emergencies or
hypoglycemia
3. Maintain normal blood
glucose levels.
4. Prevent or delay
chronic complications.
5. Lifestyle adjustments
with minimal stress
1. Active patient
participation
2. Few or no episodes of
acute hyperglycemic
emergencies or
hypoglycemia
3. Maintain normal blood
glucose levels.
4. Prevent or delay
chronic complications.
5. Lifestyle adjustments
with minimal stress
1. Active patient
participation
2. Few or no episodes of
acute hyperglycemic
emergencies or
hypoglycemia
3. Maintain normal blood
glucose levels.
4. Prevent or delay
chronic complications.
5. Lifestyle adjustments
with minimal stress
Interventions
- Standing Orders
- Sliding Scale Order
- Insulin Pump
Drug Therapy
1. b-adrenergic blockers
a. Mask symptoms of
hypoglycemia
b. Prolong
hypoglycemic
effects of insulin
2. Thiazide/loop diuretics
a. Can potentiate
hyperglycemia by
inducing
potassium loss
“”
“”
1. Insulin
2. Insulin needle sizes
come in ½-5/16 inches
in length, The gauges
are 28, 29, 30.
3. 45-90 degree angle.
1. Treatment of a medical
condition that causes
abnormal blood
glucose level
a. Corticosteroids
(Prednisone)
b. Thiazides
c. Phenytoin
(Dilantin)
d. Atypical
antipsychotics
(clozapine)
1. Blood sugar and A1C
checks
2. Maintaining health
weight
3. Regular exercise
4. Healthy diet choices
1. Blood sugar and A1C
checks
2. Maintaining health weight
3. Regular exercise
4.
Healthy diet choices
1. Blood sugar and A1C
checks
2. Maintaining health
weight
3. Regular exercise
4.
Healthy diet
choices
1. Blood sugar and A1C
checks
2. Maintaining health
weight
3. Regular exercise
4.
Healthy diet
choices
Evals
Teaching
1. Blood sugar and A1C
checks
2. Maintaining health
weight
3. Regular exercise
4. Healthy diet choices
5. Heart Failure (5 Questions)
a. Patho
i.
Abnormal clinical syndrome that involves inadequate pumping and/pr filling of the
heart
ii.
Systolic Failure
1. Inability of the heart to pump blood
2. Hallmark sign – decrease in LV ejection fraction (EF)
3. Cardiomyopathy
4. Valcular disease
iii.
Diastolic Failure
1. Ventricles not able to relax and fill during diastole
2. Leads to decreased CO
3. Pt has pulmonary congestion, pulmonary HTN, ventricular hypertrophy
but a normal EF
iv.
CHF Classes
1. Class I - no limitation of physical activity
i.
NO: SOB, angina pain, palpitations, fatigue with usual activity
2. Class II - slight limitation. No symptoms at rest;
i.
YES: SOB, angina pain, palpitations, fatigue with usual activity
3. Class III - limitation with physical activity
i.
Comfortable at rest
ii.
YES: SOB, angina pain, palpitations, fatigue with usual activity
4. Class IV - inability to do activity without discomfort/symptoms
i.
Quality of life affected
ii.
YES: SOB, angina pain, palpitations, fatigue with usual activity
b. Assessment
i.
Subjective
1. PMH, Mdx, nutrition, ROS, cardiac, resp, vascular
ii.
Objective
1. Full physical exam
2. Respiratory
3. O2 sat
4. Lung sounds
5. Cardiac
6. Heart rate
7. Blood pressure
8. Vascular
9. Edema
10. Cap refill
c. Clinical manifestations
i.
Left Sided Heart Failure = most common; poor contraction in LV, back up into pulmonary tract
1. Systolic failure - low EF; LV loses pressure to eject blood out
2. Diastolic failure - inability of the ventricles to relax and fill during Diastole
3. Mixed/Both - Dilated Cardiomyopathy
ii.
Right Sided Heart Failure = RV fails to pump effectively
*Left sided HF may lead to right sided failure (right side compensating)*
1. Venous engorgement
d. Diagnostics
i.
Chest xray
ii.
Echocardiogram
1. ejection fraction decreased CO
iii.
12 lead EKG
1. arrhythmias
iv.
BNP (b-Type natriuretic peptide)
v.
Electrolytes (especially K+, Na+)
vi.
ABG’s
vii.
Cardiac enzymes
viii.
LFT’S
ix.
BUN / Creat
e. Nursing Diagnoses
i.
Impaired gas exchange
ii.
Decrease cardiac output
iii.
Excess fluid volume
iv.
Activity intolerance
v.
Risk for alterations in skin integrity
f. Goals
i.
Decrease preload - venous return
1. Diuretics, sit up
ii.
Decrease afterload – work of LV
1. Dilate peripheral vessels
iii.
Improve gas exchange – nasal 02/ mask
iv.
Improve cardiac function – drugs
v.
Reduce anxiety
g. Interventions
i.
Drug Therapy
Positioning – High Fowler’s
Get VS including O2 sat
Continuous cardiac/respiratory monitoring
Listen to lung sounds
Supplemental O2
Diuretic - Remove the fluid
a. Loop - Furosemide (Lasix)
b. Thiazides - Hydrochlorothiazide( HCTZ)
- Metolazone
c. Potassium sparing - Spironolactone( Aldactone)
7. Ace Inhibitors - Improves systolic function
a. Captopril (Capoten)
b. Lisinopril
1.
2.
3.
4.
5.
6.
h. Teaching
i.
Daily weights
ii.
I+O
iii.
Fluid restriction
iv.
Elevation of LE’s
v.
1 – 2 gm Na diet
vi.
Energy conservation
vii.
Exercise
viii.
Edema management
ix.
Understanding symptoms and knowing what to do if they get worse.
1. Vasodilation - Increase cardiac output
i.
Hydralazine
ii.
Nitrates
2. Positive inotrope - Promotes vasodilation
i.
Digoxin
3. Anxiety
i.
Morphine *reduces preload & afterload*
ii.
Ativan
4. Antidysrhythmic
5. Anticoagulants
6. Antibiotics
7. Oxygen/Cardiac meds
x.
xi.
xii.
xiii.
xiv.
Medication compliance
Understanding mediations side effects
Keep all follow up appointments
Diet considerations
Electrolyte balance
6. Parkinson's (5 Questions)
a. Patho
i.
Degeneration of the neurons of basal ganglia
ii.
characterized by
1. Slowing down in the initiation and execution of movement
2. ↑ muscle tone
3. Tremor at rest
4. Gait disturbance
iii.
Pathologic process of PD involves degeneration of dopamine-producing neurons in substantia nigra of the midbrain.
iv.
Disrupts dopamine-acetylcholine balance in basal ganglia
1. DA = neurotransmitter essential for normal functioning of the extrapyramidal motor system
b. Assessment
i.
Observe for parkinsonian gate/shuffle
c. Clinical manifestations
i.
Onset is gradual and insidious.
ii.
Classic triad of PD
1. Tremor
2. Rigidity
3. Bradykinesia: difficulty in starting, continuing or coordinating movement
iii.
Beginning stages may involve only mild tremor, slight limp, or ↓ arm swing.
iv.
Later stages may have shuffling, propulsive gait with arms flexed, and loss of postural reflexes.
d. Diagnostics
i.
No specific tests
ii.
Diagnosis based solely on history and clinical features
1. Firm diagnosis can be made when at least two of three characteristics of the classic triad (tremor, rigidity, and bradykinesia) are present.
iii.
The ultimate confirmation of PD is a positive response to antiparkinsonian drugs.
e. Nursing Diagnoses
i.
Ineffective Airway Clearance
ii.
Disturbed Thought Process
iii.
Impaired Verbal Communication
iv.
Impaired Physical Mobility
v.
Imbalanced Nutrition: Less Than Body Requirements
vi.
Impaired Swallowing
vii.
Risk for Injury
viii.
Ineffective Coping
ix.
Deficient Knowledge
x.
Other Nursing Care Plans
f. Goals
i.
Promote safety
1. Fall precaution
ii.
Promote physical exercise
1. Promote independence
2. Limit the consequences from decreased mobility
3. Specific exercises to strengthen muscles involved with speaking and swallowing
Well-balanced diet.
1. Aspiration precautions
2. Several small meals
3. Vit B6 supplements
g. Interventions
i.
Enhance the release or supply of dopamine and acetylcholine
1. Levodopa
2. Levodopa with Carbidopa (sinemet)
i.
Monitor for dyskinesia
ii.
Positive effect may take several weeks to months to note
ii.
Antihistamine with anticholinergic properties (Benadryl)
1. Manage tremors
iii.
Antivirals
1. Promotes the effects of dopamine
h. Evals (N/A)
i. Teaching
i.
Safety
ii.
Physical exercise
iii.
Well-balanced diet
iii.
7. Seizures (5 Questions)
a. Patho
i.
Seizures: Uncontrolled electrical discharge of neurons in the brain that interrupt normal function.
ii.
Not considered epilepsy when removal of the underlying causes stop the seizures:
1. Acidosis
2. F&E imbalances
3. Hypoglycemia
iii.
1. Birth - 6 months of life
a. Severe birth injury
b. Congenital birth defects involving CNS
c. Infections
d. Inborn errors of metabolism
2. Age 2 - 20 y/o
a. Birth injury
b. Infection
c. Trauma
d. Genetic factors
iv.
Generalized
1. Tonic-Clonic
i.
Tonic-muscle stiffening
ii.
Clonic-rhythmical jerking
2. Absence(petit mal)
i.
Begin on both sides of the brain
ii.
Lapse of awareness
iii.
staring
3. Atonic
i.
Pt loses muscle tone and goes limp
1. Age 20 - 30 y/o
a. Structural lesions
b. Trauma
c. Brain tumor
d. Vascular disease
2. Age 50 y/o +
a. Cerebrovascular lesions
b. Metastatic brain tumors
c. 75% of seizure disorders are considered idiopathic.
v.
b.
c.
d.
e.
f.
g.
h.
i.
Focal
1. Focal Onset Aware (Simple partial) = Awake and aware
2. Focal Onset impaired (Complex partial) = Confused
Assessment
i.
Accurate, comprehensive description of seizures with patient’s health history
ii.
EEG
1. Only a small percentage of patients with seizure disorders have abnormal findings with first test.
2. Continuous monitoring may be needed.
3. CBC, serum chemistries, liver and kidney function, UA to rule out metabolic disorders
Clinical manifestations (N/A)
Diagnostics
i.
Accurate, comprehensive description of seizures with patient’s health history
ii.
EEG
1. Only a small percentage of patients with seizure disorders have abnormal findings with first test.
2. Continuous monitoring may be needed.
3. CBC, serum chemistries, liver and kidney function, UA to rule out metabolic disorders
Nursing Diagnoses
i.
Risk for Trauma or Suffocation
ii.
Risk for Ineffective Airway Clearance
iii.
Situational Low Self-Esteem
iv.
Deficient Knowledge
v.
Noncompliance
Goals
i.
maintaining a patent airway
ii.
maintaining safety during an episode
iii.
imparting knowledge and understanding about the condition
iv.
monitor the patient for signs of toxicity
Interventions
i.
Medication Therapy
1. Narrow-Spectrum AEDs - DILANTIN; used to specific seizures (ie. partial, focal, absence, myoclonic)
2. Broad-Spectrum AEDs - CLONAZEPAM; some effectiveness for a wide variety of seizures (partial/absence)
ii.
Acute Interventions
1. Observation and treatment of seizure
2. Clear the area for safety.
3. Put the patient on their side to maintain the airway, support head, loosen constrictive clothing, ease to floor.
4. Given IV Ativan as ordered
5. May require suctioning or oxygen after seizure
6. Assessment of level of understanding
7. Collaborative Care
8. Planning
Evals (N/A)
Teaching
i.
Medication compliance
ii.
Teach non-drug techniques like relaxation etc.
iii.
Community supports.
iv.
Medical alert bracelet.
v.
Avoid excessive alcohol intake, fatigue, loss of sleep.
vi.
Driving laws for patients with seizures.
vii.
Safety safety safety.
8. Med Calculations (5 Questions)