Endocrine - Diabetes o Type 1 § Diabetic diet treatment** • Diabetic exchange list: each food item on the list has the same amount of carbs, protein, fat, and calories as the other food items on the list o Type 2 o Blood sugar § Normal levels • 70-99 § Low • 40 o Management § Insulin • Regular – short acting o 6 to 10 hour • Long acting o Glargine 24 hours • Intermediate acting o Isophane 16 hours • Rapid acting o Lispro 3 to 5 hours § Oral hypoglycemic agents • Stimulate beta cells in the pancreas to release endogenous insulin o hyperglycemia § s/s • blurred vision, fatigue, constant thirst, high blood sugar o diabetes insipidus § s/s • thirst, frequent urination, low specific gravity § treatment • desmopressin o patient should maintain normal specific gravity if medication is working properly § nursing management • monitoring urine specific gravity, daily weights o DKA § Cause • Inadequate amounts of insulin § s/s • blurred vision, fatigue, constant thirst, high blood sugar, and fruity breath • hot, dry, flushed skin, excessive thirst, rapid pulse • KETONURIA • Hyperglycemia, dehydration, electrolyte loss, acidosis Treatment • Normal saline, NaCl, ½ NS, regular insulin and potassium • Monitor blood glucose levels hourly • Administer insulin at 45 degree angle § Safety • Intubation set at bedside o hyperosmolar hyperglycemic state (HHS) § s/s • blurred vision, fatigue, constant thirst o uncontrolled diabetes can lead to § damage to lining of blood vessels, PVD § chronic kidney disease § glaucoma, cataracts, diabetic retinopathy § erectile dysfunction, peripheral neuropathy, autonomic neuropathy o teaching § if blood sugar glucose is below 60 mg drink 4 ounces of juice or cola § 15 minutes after patient eats/drinks something to correct hypoglycemia, recheck blood sugar § Always keep hard candies on you § It is important to eat as soon as you have injected regular insulin dose o Key terms § Glycosuria • Abnormal amount of glucose in the urine § Somogyi effect/dawn phenomenon • Taking insulin before bed and wakes up with high blood glucose levels • Treat with bedtime snack or increased insulin administration at night Thyroid o Grave’s § s/s • anxiety and nervousness o treat with beta-adrenergic blocking agents • increased perspiration, ruddy and oily skin • irritability, apprehension, increased pulse rate, palpations • increased sensitivity to heat § Treatment • Subtotal thyroidectomy • Methimazole § Management • Avoid seafood due to iodine levels • Vitamin D and calcium may be necessary due to risk for osteoporosis • Avoid caffeine and cigarettes § - • Avoid salted foods Levels • Low TSH and high T4 o Underactive (hypothyroid/Hashimoto’s) § s/s • dry, pale, and scaly skin (moisturizer) • bradycardia, intolerance to cold • dull and dry hair, alopecia, and obesity • low energy or fatigue • constipation § levels • high TSH and low T4 • high cholesterol and triglycerides • low BMR § treatment • levothyroxine o teaching § administer at same time every day without food o adverse effects § weight loss, arrhythmias, tachycardia, insomnia, irritability, nervousness, heat intolerance, and menstrual irregularities § diet • avoid calcium supplements – will interfere with absorption of medication • well-balanced diet of 1,200 calories a day § danger s/s • myxedema o what is it: worsening of hypothyroid symptoms in clients who have had hypothyroidism for a long time o s/s: weakness, confusion, chills, & swelling in the face/tongue/lower legs o tx: medication asap o X: coma and death o subtotal thyroidectomy § dangers • damage to parathyroid gland – numbness in the fingers • Respiratory distress § Due to swelling or tetany*** § Keep patient in semi-fowler’s position with ice bag at the incision site • KEEP TRACHESTOMY KIT AT BEDSIDE § Prep • Iodine solution before procedure to prevent postoperative hemorrhage for 10-14 days § • Reduces the vascularity and size of the thyroid Nursing interventions • Bedside table o Calcium gluconate – damage to parathyroid gland can occur, causing low calcium § injection o Oxygen with humidified air o Suction o Tracheostomy kit – edema in the trachea o Hypoparathyroidism § s/s • tingling sensations in hands and feet § levels • low calcium § treatment • calcitriol Adrenal glands o Hormones § Glucocorticoids • Cortisol or steroids o Provide rapid energy from the conversion of proteins and fats into glucose • Anti-inflammatory effect o Addison’s § What is it • Lack of cortisol and aldosterone § s/s • abnormally dark and pigmented skin o especially seen with knuckles, knees, and elbows • fatigue, weakness, dehydration, decreased resistance to stress, alopecia • dysrhythmias § treatment • life-long glucorticoid hormone replacement therapy § diet • avoid potassium*** o s/s of hyperkalemia: dysrhythmias, muscle weakness, paralysis, N/D • increase sodium o s/s of hyponatremia: N, muscle cramps, ICP, confusion, twitching, and convulsions § dangers • can cause increased potassium retention • GI problems – anorexia, nausea, vomiting, diarrhea § Addison’s crisis § - • • o Cushing’s § s/s § § - - s/s o Low narrow BP, high HR, anorexia, weakness, N/V, bronzing of the skin Tx o Cortisol and adrenocorticotropic hormone level drawn o 12-lead EKG (hyperkalemia) o IV of normal saline and dextrose (reverse hypotension) • thin legs and arms with truncal obesity • edema, purple skin striations, and decreased resistance to infection comorbidities • hyperglycemia and increased sodium • hypertension treatment • adrenal surgery to remove a tumor o corticosteroid replacement therapy o adjust dosage based on stress levels Pituitary gland o Tumors § Treatment • Transsphenoidal hypophysectomy: removal of tumor o Teaching § Bend at the knees, avoid sneezing/blowing nose/coughing § High fiber diet and increase fluids for bowel movements § DO NOT brush teeth for 1-2 weeks to allow healing - only warm saline mouth rinses every 4 hours § Use room humidifier SIADH o What is it § Producing too much or releasing too much ADH § Water intoxication o s/s § eating ice chips due to water intake has been restricted § dilutional hyponatremia § high urine specific gravity § anorexia, nausea, vomiting, abdominal cramping, tachycardia, and decreased urine output*** § decreased consciousness, increased confusion, and increased lethargy*** o treatment § fluid restriction § diet with added sodium o levels § high specific gravity § low sodium o nursing interventions § initiate seizure precautions – hyponatremia Hematology-Immune - Hematocrit o what is it § ratio of RBC to fluid volume o males § 42%-52% o Females § 35%-47% - Hemoglobin o What is it § Oxygen-carrying capacity of the blood o Males § 13-18 o Females § 12-16 - Hemophilia A o what is it § sex-linked recessive trait from females to males § deficiency of factor 8 o s/s § bleeding internally at the joints § painful swelling o treatment § RICE § Replacement therapy of clotting factors o nursing management § avoid intramuscular injections due to high risk of bleeding into the tissue § avoid aspirin, NSAIDs, or alcohol o teaching § avoiding contact sports and other potential injurious activities - iron-deficiency anemia o what is it § decrease in the number of erythrocytes or reduction in hemoglobin o causes § blood loss, increased metabolic energy demands, GI malabsorption, and diet o s/s § dyspnea, fatigue, paleness, severe palpations, sensitivity to cold, and profound weakness o tx § diet and supplements • liver and onions, spinach, and rice pudding with raisins o red meat, pork, seafood, beans, dark leafy veggies, and dried fruits - - - - o teaching § avoid aspirin and NSAIDs that may cause bleedings § do not take calcium or antacids due to inadequate absorption • take them 2 hours before or after pernicious anemia o what is it § inability of gastric mucosa to absorb B12 due to lack of intrinsic factor o s/s o tx § lifelong injections of B12 o dx § schilling test • fast for 12 hours, small dose of radioactive B12 orally, and nonradioactive dose IM • 24-hour urine collection immune system o organs involved § spleen and thymus • the spleen cleanses the blood of microorganisms • the thymus produces T-lymphocytes o autoimmune diseases § multiple sclerosis • deterioration of the myelin sheath of the CNS • s/s: ataxia, weakness, spasticity, nystagmus, paresthesia, incontinence, and emotional instability • tx: comfort measures, exercises, ambulation training o incubation period § the time between when a person gets infected and when symptoms appear sickle cell anemia o what is it § defective hemoglobin causing low oxygen § red blood cells clump together due to shape and cause an obstruction of the blood flow o s/s § pain and jaundice o dangers § vaso-occulsive crisis • upper respiratory infections*** • monitor neurological status for changes in LOC, headache, or dizziness § visitors with URI must wear a mask and all must maintain ahdn hygiene HIV o s/s § fatigue, weight loss, and night sweats § - weakened immune system making them susceptible to opportunistic infections o Teaching § Avoid unprotected sexual contact § Do not share needles § Can be passed through the placenta, through maternal blood or bodily fluids during birth, and through breast milk § Candidiasis is common fungal infection • White patches in mouth, loss of taste, and dysphagia • Mouth pain o Labs § CD4 • Low results indicate progression of HIV to AIDS o AIDS § s/s • fatigue and shortness of breath • diarrhea § teaching • sit while preparing meals o preserve energy as much as possible • if diarrhea occurs o avoid foods that stimulate intestinal mobility § veggies, fruits, fatty, spicy, sweet foods, alcohol, and caffine § Dementia complex • s/s o memory loss, slowed thinking, loss of concentration, and confusion • management o use uncomplicated and short sentences § simple directions Anaphylaxis o Tx § Administer epinephrine ASAP subcutaneously Polycythemia vera o What is it § Increased blood volume and viscosity o s/s § ruddy (reddish) complexion, angina, claudication, dyspnea, thrombophlebitis, and elevated blood pressure § headache, dizziness, tinnitus, fatigue, paresthesia, and blurred vision Neurology - cranial nerves o trigeminal nerve 5 § jaw movement and sensation of the face and neck § tic doulourex: sudden, unilateral, severe, stabbing, and recurrent episodes of facial pain - depression o always assess family support system - trigeminal neuralgia o what is it § chronic pain condition of the trigeminal nerve o management § avoid hot and cold foods as they can trigger pain - autonomic dysreflexia o what is it § life-threatening hypertensive crisis o causes § gastrointestinal, urologic, gynecologic, or vascular stimulation o s/s § headache, nasal congestion, sweating, piloerection (goosebumps) o tx § removal of the stimulation § place patient in high fowler’s - stroke o s/s § slurred speech, difficult to understand § inability to move an extremity § blurry vision § irregular heart sounds o risk factors § high BP and irregular pulse § African American dissent § Cigarettes, alcohol, drug use § Stress § Weight & age o management § avoid over stimulation § pureed diet § upright position with head and neck positioned slightly forward and flexed o nursing intervention § monitor BP & LOC § place on 2L of oxygen, assess pupil size and reaction § EKG, lab work, and CT of the brain § fibrinolytic therapy if indicated - seizure o postictal phase - - - - § after o aura § before o types § typical absence seizures • s/s o patient may appear to be daydreaming o unaware of seizure o no motor activity • management o monitor client for brief interruptions of consciousness § focal seizure • s/s o unilateral movement of an extremity o unusual sensations o change in HR, skin flushing, and epigastric pain EEG o What is it § Detects electrical activity in the brain o Preparation § Avoid caffeinated beverages 12-24 hours § Tell patient it is painless, but they must remain still o Procedure § Lasts about 40-60 minutes Myasthenia gravis o What is it § Acetylcholine deficiency – chronic autoimmune system o s/s § tiredness with slight exertion § weakness in the skeletal progression o management § maintain respiratory function • due to weakness of the respiratory muscles bell palsy o s/s § mild weakness or total paralysis of one side of the face § drooling o warning signs § pain behind the ear or on the face may occurs hours to days prior to paralysis o tx § analgesic to relieve pain – MILD § place an eye shield over the affected eye while sleeping • they may be unable to close the eye & can cause irritation Parkinson disease o What is it § o s/s - - - Decreased dopamine § tremors at rest o warning § patient is at high risk for choking o Management § Avoid liquid foods – semi-solid diet with thickened liquids § Sit upright while eating § Range of motion exercises § Divert attention to an activity to decrease tremors o Tx § Anticholinergic and dopaminergic medications GCS o What is it § Measures motor responses, verbal responses, and eye opening o 15 § Good LOC o 7 or less § Severe traumatic brain injury with coma o Eye care § Keep corneas moist with artificial tears to prevent corneal irritation § May need a protective shield Meningitis o s/s § fever, headache, photophobia, LOC changes § Nuchal rigidity § Kernig sign • Hip is flexed to 90 degrees and patient cannot extend the knee due to restriction and pain § Brudzinski sign • Head to knees & pain – tension in the spinal cord o Treatment § Antibiotics o Management § Reduce risk for seizures – reduce stimulation Multiple sclerosis o What is it § Demyelination of the spinal cord o s/s § paralysis and weakness § urinary retention § memory loss, impaired judgement, decreased ability to problem solve § hyperreflexia of the extremities • intention tremors, spasticity, and paresthesia § constipation § impaired coordination – ataxia - Meniere disease o What is it § Inner ear disorder; typically only one ear § Attacks may last hours to days o s/s § vertigo, hearing loss, tinnitus § N/V, sweating, and pallor o Tx § Diuretics, antihistamines, antiemetics, and tranquilizers o Nursing intervention § During an acute attack • Lay patient down in bed with pillow to prevent movement and further vertigo Oncology - Chemotherapy o Adverse effects § Bone marrow suppression** • Decreased leukocytes, erythrocytes, and platelets • High risk for bleeding and infection § Alopecia § Nausea and vomiting o Nursing management § Keep patient’s personal equipment in the room • Stethoscopes and BP cuffs § Avoid fresh fruits, vegetables, and flowers • May contain bacteria • If patient does consume, advise them to wash prior to consuming § Avoid gardening § Wash toothbrush daily in dishwasher § Administer antiemetics 30 minutes prior to chemo - Levels o Low platelets ( < 150,000-400,000) § What does this mean • Patient will have difficulty clotting and is at high risk of bleeding § Management • Use soft-bristled toothbrush, avoid flossing & hard foods • Check IV site ever 2 hours • No IM injections – if necessary, use smallest gage needle and pressure for 10 minutes o Low WBC ( < 4,500-11,000) § What does this mean • Patient is at high risk for infection § Management • Limit visitors • Demonstrate meticulous hand washing • Encourage rest and place patient in a private room - - - - - o Bone marrow suppression § What does this mean • patient will have a deficiency of blood cells causing high risk of bleeding § management • patient should avoid medications that contain aspirin o patient is at high risk for bleeding • use electric razor on the skin • blow nose gently to avoid bleedings • add fiber to the diet Teletherapy o Management § Cleanse area with soap and water § Avoid sun exposure § Use patting motion to dry the area § No creams, powders, or ointments on the area*** Breast cancer o Risk factors § Women over 40 & 70 § First-degree female relative • Mother, sister, or daughter § Women who have never given birth Laryngeal cancer o s/s § hoarseness, difficulty swallowing, color changes in mouth or tongue, and oral lesions that do not health skin cancer o risk factors § light complexion § over 60 § overexposure to sunlight § family history, skin that burns easily § blue/green eyes with blonde or red hair o s/s § numerous moles o prevention § sunscreen § limit sun exposure Colorectal cancer o Risk factors § Sedentary lifestyle, diet, alcohol, and tobacco § Obesity o s/s § blood in stools § unintentional weight loss § increasing fatigue o orders § § § § o Tx § - - - - colonoscopy CBC & CMP Low dose CT scan Smoking cessation and diet education Hemicolectomy • Removal of the part of the colon with cancer in it Brain cancer o s/s § drooling lung cancer o s/s § increasing fatigue § unintentional weight loss § hemoptysis o metastasis § sites • brain, lungs, bones, adrenal glands, and liver § s/s • severe headaches, N/V, drooling Acute Myelogenous Leukemia (take from notes) o What is it § § Immunocompromised and at risk for infection o s/s § thrombocytopenia o danger s/s § fever • patient is at risk for infections – call HCP immediately § excessive bleeding o management § antipyretics for fevers § weight pads and tampons before and after use pancreatic cancer o s/s § jaundice o Tx § Whipple • Be aware of colorless, bile-tinged drainage from the NG tube postop*** Fluid should be serosanguineous. • Use low pressure suction • Semi-fowler position • Assess for abdominal distention Gastric cancer o s/s - early § ingestion, loss of appetite, bloating, weight loss, and difficulty swallowing o s/s – advanced § blood in the stool, vomiting (blood), iron deficiency anemia Renal-Urology - urinary calculi o s/s § severe acute pain, N/V, fever, chills, hematuria o tx § relieving pain o management § strain urine o prevention § drinking 3,000 mL of fluid a day § limit animal protein to 5-7 servings a week - acute kidney injury o causes § prolonged hypotension due to severe dehydration § bleeding, excessive V/D o s/s § hyperkalemia - cystitis o prevention § cranberry juice - UTI o s/s § confusion, burning sensation when urinating, fever, nocturia, dysuria o treatment § sulfamethoxazole o nursing intervention § obtain a midstream urine specimen - prostate o benign prostatic hypertrophy § what is it • enlargement of the prostate gland § s/s • urinary frequency, urinary urgency, lower back pain • hesitancy, dysuria, nocturia, retention o transurethral resection of the prostate (TURP) § what is it • treatment of BPH § post-op • blood urine is expected within the first 24 hours o may need to increase rate of irrigation • 3-way catheter - Bladder cancer o s/s - - - - - - § hematuria*** Collections o Sterile urine specimen § Procedure • Clamp the drainage tube below the port, wait 15-30 minutes, scrub the port using alcohol, attach sterile needless access device, and aspirate a specimen o Midstream § Procedure • Clean urethra prior to voiding o Post § Must be refrigerated if sample will be out for longer than one hour Peritoneal dialysis o Procedure § Pre • Warm the dialysate to body temperature • Weigh client • Infuse into peritoneal cavity § Post • Weigh client after • Drain the abdomen AV fistula o Use § Dialysis o Management § Ensure thrill is palpable and bruit is heard over fistula o Warning s/s § Warm to touch may insist infection, which can cause a blockage Cystoscopy o What is it § Direct visualization of the bladder o Post-op § Urine may be pink tinged § Pelvic pain indicates trauma*** Cystectomy o Post-op § Monitor urine output every 1-2 hours • Should be about 60 mL/hr § Stoma should be red • If grayish-blue or pale in color, contact HCP • Should not be edematous § Serosanguineous drainage is expected Dialysis o During procedure § Patient may begin to breathe more rapidly or have shortness of breath • This is normal and due to the pressure on the diaphragm § - • Elevate HOB*** Monitor vital signs every 15 minutes Urine o Per hour § 30 mL is the minimum o 24 hours § Minimum 800 for 24 hours § 800-2000 mL or about 2 liters Pharmacology - Cholesterol o Lovastatin § Teaching • With food • Avoid grapefruit juice • Peak is 4-6 weeks § Adverse • Upset stomach, constipation, diarrhea, gas, and heartburn • Allergic reaction - Aspirin o Usage § Reduction in pain o Adverse § Bleeding and bruising § Jaundice – hepatotoxicity - Heart o Angina § Nitroglycerin • Teaching o Oral with water o Keep dry and in room temperature areas o Never stop abruptly o Beta-blockers § Carvedilol • Usage o Heart failure • Adverse o Hypotension, exacerbation of heart failure symptoms, fatigue o Third degree heart block § Will need continuous monitoring with transcutaneous pacing pads in place - Antibiotics o Ciprofloxacin § Teaching • Must be given at equal intervals of 12 hours around the clock • Take 1 hours before or 2 hours after meals § - - - - - - - Adverse • Headache, N/D, decreased WBC, decreased hematocrit, and rash Diabetes o Regular insulin/short-acting § Onset • 30-60 minutes § Peak • 1-5 hours o Rapid-acting insulin § When to use • 15 minutes before meals § Onset • 30-60 minutes § Peak • 1 to 2.5 hours § Longevity • 3 to 5 hours Hormones o Finasteride § Decreased male testosterone levels, decrease size of the prostate, and urinary symptoms § Can cause decreased libido and impotence Antiemetics o Promethazine § Adverse • Over sedation, uncontrolled eye movements, tinnitus, confusion, disorientation, and sedation Seizures o Phenytoin Parkinson disease o Anticholinergic medications*** § Levodopa § Trihexyphenidyl o Adverse § Trihexyphenidyl • Dry mouth, blurred vision, constipation, urinary hesitancy, and decreased mental activity Dementia o Donepezil § Adverse • Headache, diarrhea, nausea Vertigo/motion sickness o Meclizine § Adverse • Drowsiness, dry mouth, blurred vision, excitation, and restlessness Rhinitis/allergies - - - - - - o Fexofenadine § Adverse • Drowsiness, fatigue, and dyspepsia Peptic ulcer disease o Cimetidine § Teaching • Take once a day at bedtime*** o or • take 2 to 4 times a day before meals and at bedtime • take 30 minutes prior to meals to prevent symptoms o pantoprazole (PPI) § usage • blocks production of acid in the stomach trichomoniasis o metronidazole § teaching • take with food • use a condom or avoid sexual intercourse until treatment is finished § adverse • can cause metallic taste weight loss o phentermine § usage • decreases appetite § adverse • CNS stimulation, hypertension, and palpations Birth control o Medroxyprogesterone § Teaching • Monitor blood pressure daily § Adverse • Cerebral hemorrhage, thrombosis, hypertension, and embolism • N/V, cramping, edema, breast tenderness, breakthrough bleeding, weight changes, and dysmenorrhea Anticoagulants o Heparin § Usage • To prevent or treat thromboembolic disorders Pain o Acetaminophen § Adverse • Liver damage § Antidote • Acetylcysteine o Every 4 hours for 18 doses - - - - - - - o Prednisone § Usage • Severe inflammation and rheumatoid arthritis § Teaching • Dosages will be adjusted frequently • Take with food § Adverse • N/D, abdominal distention Diuretics o Furosemide (loop) § Teaching • Get out of bed slowly Neuralgia o Gabapentin § Usage • Pain and anticonvulsant § Teaching • Take two hours before or after antacids Thyroid o Hyperthyroid § Methimazole • Adverse o Fever, rash, sore throat, jaundice, leukopenia UTI o Phenazopyridine § Adverse • Urine will turn bright orange • HA, vertigo § Teaching • Increase fluids to flush • Take full course of antibiotics Glaucoma o Dorzolamide § Teaching • It is a sulfa – be aware of allergies Smoking cessation o Bupropion § Adverse • HA, dry mouth, N/V § Teaching • Take for one week before smoking cessation Bipolar o Lithium § Teaching - • • • Avoid caffeine Monitor sodium levels – eat more salt*** 2,500-3,000 mL of fluid daily Iron deficiency o Carbonyl iron § Usage • Pregnancy anemia § Adverse • Turn stool black or dark Greek • Constipation • GI upset § Teaching • Increase fluids and fiber intake • Take without food Fluid & Electrolytes - Magnesium sulfate o What is it for § Treatment of preeclampsia o Dangers § Bradycardia, hypotension, weak muscle contractility, lethargy, and diminished or absent deep tendon reflexes § Keep reflex hammer at beside*** § IV calcium gluconate*** - Central venous pressure o How to measure § Place the manometer at the level of the right atrium § Have patient lie flat and breathe normally o Hypovolemia § Less than 2 mmHg o Normal § 2-8 mmHg o Volume overload § 15 mmHg or above - Hypocalcemia o s/s § tetany – intermittent spasms of voluntary muscle • treated with IV calcium or calcium gluconate - hypomagnesemia o s/s § tetany • treated with IV magnesium replacement - hypernatremia o s/s § excessive urine output, severe or chronic dehydration, excessive thirst, and weakness o causes § - - - - - - hypertonic tube feedings without water supplements, diarrhea, hyperventilation, DI, OTC aspirin o what do we see this with § diabetes insipidus o nursing intervention § I/O, urine specific gravity, condition of skin, vital signs o Treatment § Desmopressin Hyponatremia o s/s § nausea, muscle cramps, increased ICP, confusion o causes § vomiting, diuretics, excessive administration of IV dextrose and water o nursing intervention § offer sodium-rich foods, restrict fluids, I/O’s hyperkalemia o s/s § dysrhythmias, cardiac arrest, muscle weakness, paralysis, N/D o treatment § sodium polystyrene o causes § acute kidney injury or chronic kidney disease, burns hypokalemia o s/s § muscle weakness, paresthesia, fatigue, nausea, vomiting, dysrhythmias, and increased sensitivity to digitalis o treatment § IV potassium o Cause § Nasogastric drainage, vomiting, diarrhea, and the use of diuretics BUN o Normal § 10-20 o Increased § See it with renal function, diabetic ketoacidosis, and burns Fluid volume excess o s/s § edema, crackles, tachycardia, bounding pulse, elevated BP, and dyspnea o I/O’s § Should be within 200 to 300 mL of each other • If more, patient is retaining fluid Fluid volume deficit o s/s § SG greater than 1.030, potassium greater than 5.3, BUN greater than 20 § Increased temperature, rapid and weak pulse, poor skin turgor, hypotension, dry membranes - - - blood transfusions o ABO incompatibility § s/s • N/V, hypotension, increase pulse rate, decrease urinary output, hematuria o Allergic reactions § S/s • Urticaria, pruritus, and flushing o Hemolytic reactions § s/s • hematuria, cyanosis, back pain, and hypotension o Procedure § Run at 2-5 mL/min for the first 15 minutes o nursing intervention § be aware of signs of fluid overload and allergic reactions § check vitals burns o deep partial thickness § s/s • damage to the dermis, red in color, painful, with blisters o superficial partial thickness § s/s • pink to red in color, with mild edema and pain o full thickness § s/s • invade subcutaneous structures • white or black/brown with decreased sensation • severe edema – maybe, with no blisters • decreased urine output – fluid shift during emergent phase o medication administration § route • intravenously § time • before painful procedures low albumin o dangers § non-healing wounds low protein o dangers § non-healing wounds malnutrition o s/s § pale, thin, frail § slow healing wounds § low WBC count o dangers § early mortality o treatment § increase protein and caloric intake Gastrointestinal - low-residue diet o low fat meats, fish, and poultry o dairy products, juices without pulp o canned fruit and ripe bananas o white or refine bread - cirrhosis o diet § high in protein and low in sodium - cholecystitis o s/s § pain, rapid weight loss, fever, tender abdomen - gastroenteritis o s/s § pain, fever, tender abdomen - cholelithiasis o s/s § gallbladder dilation, pain, elevated WBC o teaching § avoid fatty fish (tuna), dairy products, fried foods, food/meats high in fat, and high cholesterol § increase fresh fruits and vegetables & fiber o nursing intervention § admit to ED!!! § NPO, peripheral IV, vancomycin 1g IV every 12 hours o Dangers § Sepsis - Ulcerative colitis o s/s § frequent stools, intermittent cramping pain in lower abdomen prior to bowel movements o lab values § elevated WBC § decreased hemoglobin o tx § for irritation – clean the perineal area with soap and water after each bowel movement & petroleum jelly § low residue diet • avoid whole wheat grains, nuts, and fresh fruits and vegetables - Cholecystectomy o Post-op § diet • Low in fat & high in carbohydrates § - - - - • Reintroduce fats in six weeks Teaching • Increase activity and limit immobility • Take deep breaths periodically to avoid respiratory issues • Monitor stool color and any changes • Avoid lifting anything more than 5 pounds for first week Colostomy o Post § Scant amount of bright bloody drainage § Stoma should appear beefy-red and moist § If no bag, cover stoma with petroleum gauze with a dry, sterile dressing Duodenal ulcer o What is it § Erosion of the mucosal wall of the duodenum o s/s § abdominal pain and tenderness, melena, epigastric pain 2-3 hours after eating o teaching § eating relieves the pain gastric ulcer o s/s § hematemesis, pain immediately after eating, tarry stools o teaching § pain is relieved by vomiting liver o Laennec cirrhosis § s/s • dark colored urine (when the liver cannot break down bilirubin into bile, it is excreted into the urine) • stools may be clay-colored • N/V, anorexia, weight loss, fatigue, headache, ascites, jaundice, and spider angiomas § cause • chronic hepatitis C infection & alcohol-induced § labs • ALT elevated o hepatic encephalopathy § teaching • low animal protein & high plant protein diet o biopsy § pre • nurse must determine prothrombin time, aPTT, and platelet count § post • instruct patient to lay on their right side to increase pressure on liver to prevent hemorrhaging • avoid coughing or straining - • penrose drain o use § hepatitis o A § § o B § § § o C § § § o D - - - § check vitals q 10-15 minutes for the first hour removes accumulated bile and blood from the surgical site Poor hygiene, food and fecal matter transmission s/s – fatigue, anorexia RUQ pain, pruritus, and jaundice First injection – gives artificial active acquired immunity Spread by contact with infected blood and/or bodily fluids – sexual contact HBIg – temporarily increases the client’s resistance to hepatitis Transmission • Blood and sexual contact s/s • N/V, fatigue, low hemoglobin/hematocrit/platelets, elevated liver enzymes, dark urine, elevated WBC, yellow skin/sclera Treatment • Antiviral medications Spread by contact with infected blood and/or bodily fluids Folate o Organ meats, broccoli, legumes, asparagus, milk, and orange juice Sigmoidoscopy o Prep § Enema the morning of the test Sengstaken-blakemore tube o Use § Treat bleeding of esophageal varices o Nursing intervention § If s/s of respiratory distress – CUT THE BALLOON*** Pancreas o Interstitial pancreatitis § What is it • Swelling of the pancreas and the escape of digestive enzymes into the surrounding pancreatic tissue and peritoneal cavity, causing necrosis § Treatment • Acetazolamide o Carbonic anhydrase inhibitor § Inactivates the enzymes to help minimize the damage caused to normal tissue Gastroscopy o Usage § Aspiration of gastric contents for analysis to assess acid secretion and bacterial activity in the stomach o Hemicolectomy § Post-op • Clear liquid diet to full liquid diet to soft to regular - Paracentesis o What is it § Needle or catheter is inserted into peritoneal cavity to obtain ascites fluid for diagnosis o Procedure § Pre • Have patient empty bladder - Gastrostomy tube o Teaching § Intermittent feeding of 4-6 times a day, with gravity over 30-60 minutes § Refrigerate unused formula § Hang new bag and tubing every 24 hours o Medications § Talk to HCP about what medications can be given through the tube - Parenteral nutrition o Teaching § Taper off PN infusion to avoid hypoglycemia - Diverticulitis o What is it § Infection and inflammation of diverticulum o s/s § irregular bowel function, diarrhea, cramping in lower left quadrant, and low-grade fever o Patient teaching § Clear liquid diet - Medication o Cephalexin § Antibiotic • Any antibiotic can alter natural flora of the GI tract and cause diarhhea Respiratory - Tuberculosis o What is it § A bacterial infection of mycobacterium tuberculosis o How is it transmitted § Aerosol route o Risk factors § Contact with an infected person § Immunocompromised § Substance abuse, crowded living situation, poor sanitation o Treatment § - - - - First line therapy of isoniazid • Be alert for development of hepatitis, peripheral neuritis, rash, and fever • Avoid alcohol intake • Obtain regular liver function tests o Nursing interventions § Provide vitamin B6 (pyridoxine) • Prevents neuritis o Inflammation of a nerve Tracheostomy o What is it § A surgical incision into the trachea to establish an airway o Ventilation § Permits use of positive pressure ventilation o Positives of use § Prevents aspiration of secretions in the unconscious or paralyzed § Promotes removal of tracheobronchial secretions • Decreases chance of infection o Nursing interventions § If accidental removal – ventilate client using a manual resuscitation bag Chest tube o Closed-chest tube § Bedside equipment • Sterile connector, sterile petrolatum gauze pad, and padded clamp o Incase drainage system disconnects from the drainage equipment o Water seal chamber § Intermittent bubbling – lung has not yet re-expanded § Constant bubbling – air leak/pneumothorax o Transportation § Monitor fluctuation in the tube & ensure all connections are taped securely Incentive spirometer o Why is it used § To prevent pneumonia and atelectasis o How to use § Close lips tightly around it and exhale completely & then inhale slowly and deeply to make piston rise Pulmonary oxygen toxicity o What is it § Mild irritation in the trachea made worse with deep inspiration o s/s § frequent nonproductive cough § nasal congestion, subternal discomfort or pain, GI upset, and dyspnea o dangers § can cause atelectasis or structural damage to the lungs § pulmonary edema and hemorrhage - - - - - - § ARDS Bronchitis o Management § Instruct patient to sit with feet on the floor, lean forward, take several deep breaths through the nose & on last breath cough 3 times Rhinoplasty o Post-op § Assess patient for bloody drainage • If excessive, inspect throat for signs of hemorrhage § Assess patient for frequent swallowing Acute asthma attack o What is it § Chronic inflammatory disease of the airways that causes reversible airflow obstruction, airway inflammation, and airway hyper-responsiveness o s/s § cough, chest tightness, wheezing, and dyspnea § high-pitched musical-like squeaky sounds o treatment § epinephrine subq (non-selective adrenergic – bronchodilation) § albuterol & fluticasone/salmeterol diskus o tests § check patient ABGs and chest x-ray • look at oxygen and CO2 levels & check for infiltration, inflammation, or infection diaphragmatic breathing o what is it § chest remains still while the abdominal muscles do the work of breathing ABGs o What does it do § Measures tissue oxygenation, carbon dioxide removal, and acid-base balance o Tests for § Hypoxia*** Aspiration o Prevention § For patients that have had a stroke, have them flex their head slightly forward and sit upright while eating – closes the epiglottis Ventilator o SIMV § Primary mechanism • Ventilator breaths are correlated with client breathing and the client can breathe naturally in between § Settings • Preset tidal volume & rate o Controlled mechanical ventilation § Primary mechanism • Used when a client cannot initiate a breath Settings • Set tidal volume at a set rate o Assist-control § Settings • Set tidal volume and rate § Watch for • Hyperventilation*** - Oxygen delivery o Venturi mask § Function • Provides oxygen at specific percentages – FiO2 § Who uses this • Clients with COPD or emphysema - Lung sounds o High-pitched music § Indicate asthma o High-pitched harsh § Indicate bronchial breath sounds – normal § Over trachea and larynx o Low-pitched rubbing § Indicate pleural friction rub § Inspiration and expiration - Pneumonia o Risk factors § NG tube due to risk of aspiration into the lungs - Thoracentesis o What is it § Aspiration of pleural fluid or air from the pleural space o Prep § Place patient sitting upright on the edge of the bed with feet supported - COPD o Oxygen flow § Keep patient on lowest concentration to reduce hypoxia and maintain levels between 88% and 92% § High-flow may interfere with breathing Cardiovascular - Myocardial infarction o Lab values § Elevated creatine kinase, troponin, and myoglobulin o Medication § Lidocaine drip IV • Decreases the myocardial irritability - EKG o Patient prep for resting § Educate patient that sitting still will promote better results § - - - - - - Stress test o What is it § Determines the amount of stress that your heart can tolerate o Procedure § Client runs on a motorized treadmill while heart rate and blood pressure are monitored o Why is it done § Determine if cardiac ischemia is occurring Angiography o What is it § Arterial test to determine the adequacy of your peripheral circulation Angina o Treatment § Nitroglycerin • Decreases preload & dilates the peripheral vessels – decreases blood pressure • Can cause a headache o Teaching § Client should report change in character, pattern, frequency, or intensity of the pain § Report dizziness, faintness, or SOB with activity § Small, frequent meals to avoid blood shunting to stomach Thrombophlebitis o What is it § Clot and blockage in a vein (usually in the lower extremities) o Prevention § Administer low molecular weight heparin § Encourage the client to drink fluids while on bedrest § Instruct client to flex and point the toes every 2 hours Cardiac catheterization o Procedure § Using the femoral artery o Post-op § Check extremities for pulses, swelling, and firmness § Monitor for bleeding from femoral artery Heart failure o Management § Digoxin – positive inotropic medication • Increases the force of the heart’s contractions by slowing the heart rate and conduction through the AV node Hypertension o Management § Sodium restriction, low fats, high fiber, and whole grains § Limit alcohol consumption § Weight loss if indicated o Elevated - - - - § 120 – 129 / less than 80 o Stage 1 § 130-139 / 80-89 o Stage 2 § 140 or higher / 90 or higher o Crisis § 180 or higher / 120 or higher CPR o Pulse check § 1-8 & adults • Use carotid artery § Infants • Branchial artery Medications o Warfarin (anticoagulant) § Management • Monitor blood work – prothrombin time o Hydrochlorothiazide (diuretic) § Adverse • Hypokalemia o Methyldopa § Usage • Those with moderate to severe hypertension § Adverse • Loss of libido, drowsiness, sedation, orthostatic hypotension, bradycardia, weight gain, nightmares Peripheral artery disease o s/s § pain in lower extremities, cold, mottled leg, numbness or burning heart failure o s/s § edema, weight gain, fatigue, SOB, tachycardia o nursing intervention § auscultate for crackles, wheezing, tachypnea, and frothy sputum anatomy o body’s pacemaker § SA node*** o AV node § Receives impulses from SA node, generate impulses if SA node fails § 40-60 BPM o Purkinje fibers & bundle of His § Enable electrical impulses responsible for myocardial contraction
