CATHY
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PARKES
LevelUpRN.COM © 2018
Medical Surgical
Nursing Study Cards
Volume 2
RENAL SYSTEM 125 • 142
REPRODUCTIVE SYSTEM 143 • 150
MUSCULOSKELETAL SYSTEM 151- 167
ENDOCRINE SYS fEM 177 • 205
IMMUNE SYSTEM 206 · 229
PERIOPERA TIVE NURSING CARE 230 · 234
RENAL SYSTEM
RENAL SYSTEM
Expected values: Creatinine, BUN, Urinalysis
Nursing care during Cystography/Urography
Creatinine, BUN, Urinalysis, Cystography/Urography
Creatm111e: 0.6-1.2 mgldl. Elevated levels indicate kidney
a1sease (more definiUve than BUN).
BUN Blood urea nilro en : 10-.20 mg,/dl. Elevated levels may
In 1ca e
ney isease or e ydration.
Ur1nalys1s: Specific gravity should be between 1.01-1.025. No
glucose, protein. ketones, leukocyte esterase, or nitr,ites should t>e
found in urine.
Cyslography/Uroqraph'(:
• Check for allergies to iodine. shellfish.
• NPO after midnight, bowel preparation night before pmced1,1re., 0
• Encourage increased fluid intake after procedure. Pink tinged z
urine expected.
• Monitor for signs of infection: cloudy or foul smelling urine,
"·
urinary urgency, urinalysis positive for leukoesterase, nitrites.
125
RENAL SYSTEM
Hemodlalysis
RENAL SYSTEM
Hemodialysis
Purpose/Indications
Nursing care before, during. after procedure
Hemodialysis: Eliminates excess fluid, electrolytes, and
waste products from the body. Used in patients with acute or
chronic kidney disease. Usually done 3 times a week.
preprocedure· Ensure patent vascular access (check for
bruit. thrill. distal pulses). Assess vital signs, lab values,
weight.
lntraproccdurc: Monitor for hypotension, cramping, n/v,
bleeding. Administer anticoagulants lo prevent clots as
ordered (administer protamine sulfate to reverse heparin if
M
Postprocedure; Decreased BP and lab values expected.
Compare weight to before procedure lo estimate fluid
removed (1L fluid " 1kg).
126
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RENAL SYSTEM
RENAL SYSTEM
Hemodialysis
Patient teaching
Complications and nursing actions
Hemodialysis
Patient teaching:
• Increase protein intake after dialysis, as protein is lost
with each exchange.
,. Avoid carrying items with arm with access site.
,. Don't sleep on arm with acoess site.
,. Perform hand exercises to mature fistula.
Complications:
127
• Disequilibrium syndrome (symptoms: rilv, decreased
LDC, seizures) due to increased ICP. Slow dialysis
exchange rate]
,. Hypotension, Aqminister IV fluids or colloids as ordered.
Slow exchange rate. Lower HOB.
RENAL SYSTEM
RENAL SYSTEM
Peritoneal Dialysis
Peritoneal Dialysis: Installation and dwelling of hypertonic
dialysate solution in lhe peritoneal cavity to remove waste
products. Alternative to l1emodialysis for: older adults,
intolerance to anticoagulants, vascular access difficulties.
Preprocedure: Assess weight. Warm dialysate solution. Use
sterile technique when, accessing catheter insertion site.
Peritonear Dialysis
What is It?
Indications?
Nursln care before and during proi;;edure
lntraprocedure:
128
L_
• Compare inflow vs. outflow of dialysate.
• Keep outflow lower than paHent's abdomen.
• Monitor color of outflow- should be clear, light yellow.
s_1_o_o_d_y,_c_1_o_ud_y_o_u_1f_lo_w_in_d_i_c_at_e_s_p_o_s_s_ib_l_e_i_n_fe_c_ti_o_n_I_,
RENAL SYSTEM
RENAL SYSTEM
..·­-
Peritoneal Dialysis
Complli;;ations
129
RENAL SYSTEM
Kidney Transplant
Nursing care before and alter procedure
Patient teaching
I
Peritoneal Dialysis
Complications:
• Peritonitis (sx: fever, purulent drninage, eryttiema,
swelling, discolored dialysate)
• Protein loss (increase protein in diet)
• Hyperglycemia (administer insulin as needed)
• Poor in'flow/oufflow (check for kinks in tubing,
address cornstipation, reposition patient, milk
tubing to break up clots).
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RENAL SYSTEM
Kidney Transplant
Preprocedure; Provide immunosuppressant therapy as ordered,
Pos1procedure:
• Monitor ,urine output- Repon urine 01.1tput < 30 ml/hr!
• Perfonn bladder irrigation as ordered,
• Monitor for infection (symptoms: fever, erythema, lncisional
drainage).
• Monitor for organ rejection (symptoms: fever, hypertension,
pain at site). Types:
,- Hyperacute (within 48 hours of SUJrgery)
:.-- Acute (within 1 week - 2 years)
,-- Chronic (occurs gradually)
Teaching: Low-fat, high-fiber, high protein, low sodium diet.
130
contact sports.
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RENAL SYSTEM
Glomerulonephrltis
RENAL SYSTEM
Glomerulonephritis
What 1s 117
Risk factors
Signs/Symptoms
Labs
Glomerulonephritis: Immune complex disease resulting in
lnfiammatian of glomerular capillaries.
Risk factors: Strepococcal infection, lupus, hypertension,
diabetes.
S&S: Decreased urine output, fiuid volume excess (edema,
weight gain, dyspnea, hyperte11sion).
Labs:
---;---'j"hroat culture positive for strep.
• Positi:Ve ASO (Anlistreptolysin liter)
• Demeased GFR (obtained through 24 hour urine collection to
determine creatimne clearance).
•
Urlnalys,ls: Increased urine specific gravity, protelnurla,
hematuria (coffee-colored).
• Elevated WBC, ESR
131
RENAL SYSTEM
RENAL SYSTEM
Glomerulonephritis
Nursing care
Therapeutic procedure
'-
Glomerulonephritis
Nursing care:
• Monitor weight (report weight gain of 2 lbs En 24 hr,
or 5 lbs in 1 week).
• Monltor l&Os, labs. Restrict fluids, sodium,
protein.
• Administer antibiotics for strep infection
• Administer diuretics, corticosteroids
Procedure: Plasmapheresis (to filter
antibody complexes out of blood).
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RENAL SYSTEM
RENAL SYSTEM
Acute Kidney Injury
AKI Types:
..
•
Acute Kidney Injury
3 types of AKI
•
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•
Prerenal AKI:Due to decreased blood flow to
kidneys (shock, sepsis, hypavolennia, renal
vascular obstruction).
lntrarenal AKI: Direct damage lo kidneys (physical
trauma, hypoxic injury, chemical injury due la
toxins or medications).
Postrenal AKI: Due lo obstruction leaving the
kidneys (stone, tumor, BPH)
133
RENAL SYSTEM
Acute Kidney Injury
RENAL SYSTEM
AKI Phases:
Acute Kidney Injury
Four phases
•
•
Recommended diet
•
•
Onset: Onset to development of oliguria (hours­
days)
Oliguria: Urine output is 100--400mll24 hours (1-3
weeks).
Diuresis: Slart of kidney recovery, large amou:nt of
urine excreted (2-6 weeks}.
;
Recovery: Continues until complete recovery (up to ;;
1
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Diet: Restrict potassium, phosphate,
magnesium intake. Increase protein intake.
134
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RENAL SYSTEM
RENAL SYSTEM
Chronic Kidney Injury (CKD)
What IS 1!?
Risk factors
CKD stages
Chronic Kidney Injury (CKD)
CKD: Gradual, irreversible loss of kidney function.
Risk factors: Aging, dehydration, AKI, Diabetes.
Hypertension, Chronic glomerulonephritis, medications
(gentamicin, NSAIDs), autoimmune diseases.
Stages:
• Stage 1: GFR > 90 ml/min
• Stage 2: GFR 60-89 ml/min
• Stage 3: GFR 30-59 ml/min
• Stage 4: GFR 15-29 ml/min
• Stage 5: GFR < 15 ml/min
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135
RENAL SYSTEM
RENAL SYSTEM
Chronic Kidney Injury (CKD)
Symptoms
Labs
Chronic Kidney Injury (CKD)
Symptoms (mostly result of fluid volume overload):
jugular distention, hypertension, clyspnea, tachypnea,
crackles, peripheral edema, lethargy. tremors, n/v,
pruritis, uremic frost.
Labs:
• Elevated creatinine, BUN
• Decreased sodium, calcium
• Increased potassium, phosphorus, magnes:ium
• Decreased Hgb and Hct
• Urinalysis: hematuria, proteinuria
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RENAL SYSTEM
t
RENAL SYSTEM
Chronic Kidney Injury (CKD)
Chronic Kidney Injury (CKD}
Nursing care
Meds
137
Nursing care·
• Weigh patien,t daily (1kg weight gain= 1L fiuid retained!).
• Diet High carbs, moderate fat. Restrict sodium,
potassium, pho,sphorus, magnesium.
• Protect skin from breakdown.
• Prepare patient for hemodialysis.
• Promote frequent rest periods.
Meds: Digoxin, sodium polysiyrene (to reduce ser'l.lm
potassium), erythr:opoietin (to increase RBC production),
furosemide. Avoid NSAIDs, contrast dye, and magnesium­
containing antaci ds.
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RENAL SYSTEM
RENAL SYSTEM
Urinary Tract Infection (UTI)
What is 1t?
R,sk factors. Signs/Symptoms
Urinalysis results
1.38
Urinary Tract Infection (UTI)
UTI: Infection in lower urinary tract, usually caused by E coli.
Risk factors: F&male gender (short urethra, close proximity
to rectum), menopause. sexual Intercourse, pregnancy,
synthetic underwear, wet bathing suits, frequent baths,
urinary cathelers, stool incontinence, Diabetes. Incomplete
bladder emptying
Abdominal pain, dysuria {urinary frequency/urgency),
fever, n/v, hematuria, pyurla, cloudy/foul-smelling urine,
confusion (in older adultsl).
Urinalysis: Presence of bacteria, WBC, positive leukocyte
esterase and nitrites.
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RENAL SYSTEM
RENAL SYSTEM
Urinary Tract Infections (UTls
Urinary Tract Infections (UTls)
Med,cabons
Complications
Prevention
Meds : Antibiotics (fiuoroqulnolones, nitrofurantoin, trimethoprim,
sulfonamides), Phenazopyridine (bladder analgesic.- warn patient it
will tum their urine orange).
Complicalio11s: Urosepsis (Symptoms: hypotension, lachyca,dia,
tachypnea, fever).
Prevention:
•
•
•
•
•
•
139
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Drm >= 3L orfluid dally
Maintain good body hygiene
Empty bladder regularly (every 3-4hrs)
Urinate before and after intercourse
Drink cranberry juice.
Women: Wipe front to back, avoid llubble baths and
perfume-contain1ng feminine hygiene products, avoid sitting
in_w_et _ba_l_h_in_g_s_u_ils_,_a_v_oi_d-'-p_a_n-'-ty_h_os_e_o_r_t-=ig'-h_t _cl_ot_h_in-=g'---------------- '
RENAL SYSTEM
RENAL SYSTEM
Pyelonephritis
PvrlonPplJrilis · Kidney Infection, usually caused byE coli. Starts In lower
Pyeloneph ritis
What is it, Risk factors,
Signs/Symptoms. Labs.
Meds. Complicabom,
urinary tract and moves up to kidney.
B!likf:lctcrs· BPH, kidney stones, pregnancy, increased unne pH,
Incomplete bladder emptying, chronic disease.
Co,e;tovertebral tenclemess. fever, fla11k!bacl< pain, nlv,
tachycardia, !ach)1Jnea, hypertension, chills.
Li!l!i:
• Urinalysis positive for leukocyte eslerase. n rrtes. WBCs, bacteria.
•
!clevaled creatfnlne, BUN
•
Eleva ESR, C-reaciive protein
Antibioiics. opioid analgesics
c,;mm11< ttgn5·Septic shock (symptoms: hypotension. tachycar-dia. fever),
CKD, hypertension.
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RENAL SYSTEM
RENAL SYSTEM
Urolithiasis
What is ,t?
Risk factors, Signs/symptoms,
Nursing cara. Medications
Urolithiasis
1Jrn1t1h1as1s ; Presence or stones (calculi) in urinary tract, composed
of calcium phosphate. calcium oxalate, or unc acid.
Risk factors: Male gender, damage to urinary tract lining, high
ar;idity or alkalinity of urine, urinary retention. deh)'(lration.
Severe pain (flank pain. possibly radiating to abdomen),
dysurla, fever, diaphoresis, n/v, pallor, tachycardia, tachypnea,
ollguria, hematuria.
Nurmng care: Monitor l&Os, strain all urine (and save stone for
tab analysis), increase fiuids to 3 Uday, encourage amllulation.
Meds: Opioid analgesics or NSAIDs. anti-spasmodic drugs
_(_o_xy_b_u_iy_n_in_)_.
141
RENAL SYSTEM
RENAL SYSTEM
Urollthiasls
Procedures :
Urolithiasis
Procedures
Patient education regarding nutrition
142
• Ulhotripsy (uses laser or shock-wave energy to break up
stones. done under moderate sedation). Strain urir;e following
procedure. Hematuria, bruising at lilhotrlpsy site is expected.
• $tenting
• Ureterolithotomy (extract stone)
Education:
• Increase fluid intake (2-3 Uday)
• For calcium phosphates.tones, limit Intake of animal protein
anq sodium.
• For oxalate stones, IImil foods higtl in oxalates: spinach.
,rhubarb, strawberries, beets, ci10001ate, nuts, tea.
• For uric acid stones, limit foods high in purines (meat, whole
--g_ra_in_s_,_1e_g_u_m_e _s_).
REPRODUCTIVE SYSTEM
REPRODUCTIVE SYSTEM
Female diagnostic procedures, menstrual disorders
Female diagnostic procedures
Female Diagnostic procedures:
• Pap smear: tests for cancerous cells in the cervix.
Recommended every 3 years starting at age 21.
• Mammogram: tests for breast cancer. Recommended
an11ually starting at age 40. Avoid use of deodorar,t, lolion,
powders in axillary region prior to exam.
Menstrual disorders:
• Menorrhaqia: Excess menstrual bleeding (amour,1/duration).
Amenorrhea: Absence of mer,ses. Car, be due to low body
rat percentage or anorexia.
• PMS: Hormonal imbalarice before period. Symptoms:
lii'ilii5illty, d,iprsssion, breast tenderness. bloating, headache.
• Endomet1riosis: Overgrowll1 of enclometrlal tissue outside the
uterus: common cause of infertility.
P,ap smear, Mammogram
Menstrual disorders
Menorrhagia, Amenorrhea
Premenstrual syndrome (PMS), Endometriosis
143
REPRODUCTIVE SYSTEM
REPRODUCTIVE SYSTEM
!Menopause
Menopause
Menopause: Cessalion of menses (no periods in 12 monU1s).
Symptoms: Hot flashes, decreased vag·inal secretions, mood
swir,gs, decre.is,e(I bone density.
Medications: Hormone Therapy (HT) - oral, tranS<lermal, or
intravagtnal. Prevents hol flashes, reduces vaginal tissue atrophy,
and decreases risk of bor,e fractures. Taking HT increases risk of
embollc events (DVT, Ml, stoke) and breast cancer. Teaching:
• Quit smoking Immediately.
• Avoid knee-high stockiFJgs, and other restrictive socks/clolhlng.
• Avoid sitting for r,rolonged periods of time, Move and stretch
legs regularly.
• Monitor for DVT (symptoms: unilateral leg pain, edema.
warmth, eryl11ema) or Ml.
What is ii? Symptoms,
Medications and complications
Patl,ent teaching
144
REPRODUCTIVE SYSTEM
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REPRODUCTIVE SYSTEM
Cystocele/Rectocele
What are they?
Risk factors,
Treatment
Cystocele/Rectocele
Cystocele/Rectocele: Cystocele is protrusion of
bladder through anterior vaginal wall. Rectocele is
protrusion of rectum through posterior vaginal wall.
Risk factors: Obesity, older age, chronic constipation,
family history, forceps delivery.
Tr,eatment:
• Vaginal pessary (device used lo provide support and
b!ock protrusion of other organs)
•
•
Kegel exercises (contraction of vaginal and rectal
muscles)
Surgical repair
145
REPRODUCTIVE SYSTEM
Fibrocystic Breast Condition
What is it?
Signs/Symptoms
Diagnosis
REPRODUCTIVE SYSTEM
Fibrocystic Breast Condition
Flbrocystic Breasts: Nloncancerous condition
causing development of fibmtic connective tissue
and cysts in the breasts.
S&S: Breast pain. Rubber-like lumps, particularly
in upper/outer quadrant of breasts.
Diagnosis: Breast ultrasound
146
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REPRODUCTIVE SYSTEM
Male diagnostic procedures
REPRODUCTIVE SYSTEM
PSA: Measures the amount of a protein produced by the
prostate gland in the bloodstream. Increased amount of PSA
can indicate presence of prostate cancer or benign prostatic
hyperplasia (BPH).
• Do NOT do DRE prior to drawing blood for a PSA!
Male diagnostic procedures
Prostate Specific Antigen (PSA)
Digital Rectal Exam (DRE)
• Recommended anm,ally for men> 50. African American men
and men with a family history should start screening ea ier.
• PSA > 4ng/ml requires further evaluation.
DRE: Palpation of the prostate gland through the rectal
wall. Provider i,nserts finger into the an.us.
• AbnoJmal findings: Enlarged or hard prostate, irregular shapes
or lumps.
147
REPRODUCTIVE SYSTEM
Benign Prostatlc Hyperplasia (BPH)
REPRODUCTIVE SYSTEM
Benlgn IProstatic Hyperplasia (BPH)
What is it?
Signs/Symptoms, Labs
Medications. Procedures/Surgery
BPH: Enlargement of the prostate gland lhal impalrs urine
oumow lrom bladcler, resulting In urinary retention. This results in
increased risk of infection and reflux into the kklneys.
S8.5: Urinary frequency, mgency, retention, hesitancy,
incontinence. Post-void dribbling, reduced urinary stream force.
HematuriEI, nocturia. Frequent urinary tract Infections.
Labs: Eleveted PSA. Increased WBC w/UTI. Increased
creat'inlne/BUN with kidney involvement.
Meds: Androgen Inhibitor (flnasteride), Peripherally acting
antiadrenergic (tamsulosin).
•
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§
Procedures:
• Prostatic stent Keeps urethra patenl
L..._•_Tr_a_ns_u_re_lh_ra!_re_s_ec_ll_oo_- o_f_th_e.:.p_ro_s_la_te-'(T_U_R_P_:_)_s_urg.:.•_ry.;._.
148
REPRODUCTIVE SYSTEM
REPRODUCTIVE SYSTEM
TURP surgery
Nursing care·
TURP surgery
•
•
Post-op nursing care
•
•
Patient will have indwelling 3•way catheter.
Perform continuous bladder irrigation (CBI) with NS or
prescribed solution. Goal is keep irrigation outflow light
pink.
Increase CBI rate if irrigation outflow is bright red,
ketchup.appearing, or contains clots.
If catheter becomes obstructed (symptoms: bladder
spasms, reduced outtlow): Turn off CBI, irrigate w/SOml
using large piston syringe.
• Expected: patient will h,a11e
Post-op medications
Patient teaching
continuous
need to
REPRODUCTIVE SYSTEM
REPRODUCTIVE SYSTEM
TURP surgery
a
urinate I
149
TURP surgery
Meds:
• Analgesics
• Antispasmodics (to prevent bladder spasms)
•
•
Antibiotics (prophylactic)
Stool softeners (to prevent straining).
Patient teaching:
•
•
•
150
Drink 12 (or more) 8oz glasses of water per day.
Avoid caffeine or alcohol (bladder stimulants)
If urine is b'.loody, stop activity, rest, and increase
fluid intake.
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MUSCULOSKELETALSYSTEM
MUSCULOSKELETALSYSTEM
Diagnostic Procedures
Arthroscopy, Nuclear scan,
Dual X-ray absorptiomelry (DXA), Electromyography
151
Diagnostic Procedures
Arthroscopy: Allows visualization of-the internal structure of
a joint. Contraindicated it patient has infection or cannot bend
at least 40 degrees.
Nuclear Scan: Radioacli\Je material injected hours before
scari. Repeat scans at 24, 48, 72 hours. Bone scan detects
tumors, fractures, bone disease. Galllum scan are more
sensitive than bone scan.
DXA: Used to determine bone mass and presence of
osteoporosis.
Electromyography: Needles placed into muscle, and
electrical activity recorded during muscle cMlraction. Used
to_
diagnose cause o f _
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MUSCULOSKELETALSYSTEM
MUSCULOSKELETALSYSTEM
Arthroplasty
What Is 117
Patient symptoms
Contraindications
Pre-op care
Arthroplasty
Arthroplasty: Replacement of a diseased joint with a
prosthetic joint. Used for patients with osteoarthritis,
rheumatoid arthritis, trauma, or congenital defects.
Patient symptoms: Joint pain, crepitus, swelling
Contraindications: Current/recent inf,ection, arterial
insufficiency to affected extremity.
Pre-op: Adminlster epoetin alfa to increase Hgb,
autologous blood donation. Advise patient to scrub w/
antiseptic soap the night before and morning of surgery.
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152
MUSCULOSKELETALSYSTEM
MUSCULOSKELETAL SYSTEM
Arthroplasty
...
Knee artnroplasty post-op care
Knee Arthroplasty Post-op Care
•
Initiate continuous passive motion (CPM) machine
immediately after surgery (if ordered).
•
DO NOT place pillow under knee (or use knee
gatch), in order to prevent flexion contractures.
•
•
Administer analgesics, antibiotics, anticoagulants,
ice therapy.
Perform neurovascular checks every 2-4 hours
•
Patient should NOT kneel or do deep-knee bends.
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MUSCULOSKELETALSYSTEM
Arthroplasty
Hip arlhroplasty post-op care
154
MUSCULOSKELETALSYSTEM
Hip Arthroplasty Post-op Care
• Monitor for S&S of DVT (unilateral pain, swelling,
erythema) or PE (dyspnea, chest pain, tachycardia).
• Apply SCDs or antiembolic stockings
• Encourage early ambulation, fool exercises.
• Place abduction device between legs. No crossing of
legsl
• Do not allow fiexion-of hipgreater than 90 degrees!
• Externally rotate patient's toes (do not allow Internal
rotation).
• Monitor for joint dislocation: onset of severe pain,
hearing a "pop", shortened affected extremity, internal
rotation of affected extremity.
• _U_s_e_e_le_v_a_te_d_t_o_ile_t_s_ea_t_, A_vo_id_low_c_h_a_ir_s .
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MUSCULOSKELETALSYSTEM
MUSCULOSKELETAL SYSTEM
Amputations
Indications
Nursing
care
after amputation
Amputations
lnd1ca1,ons:
• Trauma (wrap severed extremity in dry sterile gauze, place in
sealed plastic bag, suomerge in ice water)
• Infection
• Peripheral vascular tlisease (symptoms: reduced pulses, cooler
tempBratura, gangr n,;;, cyanosls, decreased sensation).
Nursing Care:
• Treat pt.antam limb pain (ocmmon and real) with lleta bl:ockers,
antiepllepdcs, antispasmodics, antidepressants.
• Posilion stump in c!ependent position.
• Perfonm ROM exercises.
• To shrink residual limb (in preparation for prosthesis): wrap stump
in figure-eight wrap.
• Avoid elevatihg stum·r for 24 hours. Have patient lie ptone- for
20-30 minutes seve-ra times a day.
.;
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MUSCULOSKELETALSYSTEM
MUSCULOSKELETALSYSTEM
Osteoporosis
Ostcoporos,s·
Rate of bone resorption exceeds rate of bone
formation, resulting In low bone density and fragile bones. Osleopenia
is a precursor to osteoporosis.
Risk factors: Female gender, thin/lean body, menopause. Insufficient
calcrum or \oitamin D intake, smoking, .;lcchol abuse, excess caffeioe
intake, lack of phys;cal activity, hyperparathyroidism, long-term steroid
use, long-lerm antlcmwulsant medlcaUon use.
§A!!,; Baok pain, fractures, kyphosis, reduced height.
Diagnosis: Dual x•ray absorptiometry (DXA),
Muds: Calcitor1in, estrogen (increased risk or breast cancer and
DVT), raloxifene, alendronate (remain upright for 30 min after taking).
Teaching: Get sufficient calcium and vitamin D, moderate sun
exposure using s1.mscreen, weight bearing exercises, home safety
measures lo prevent fails.
Osteoporosis
What is it?
Rlsk factors, Signs/Symptoms. D1agnosrs
Medications. Patient teaching
...,.,
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MUSCULOSKELETALSYSTEM
MUSCULOSKELETALSYSTEM
Fractures
Closed (simple) fracture; Does not. break skin surface.
Open {compound) fracture: Breaks skin surface,
increased risk of infection.
Complete fracture: Goes through entire bone.
Incomplete fracture: Goes part way through bone.
Comminuted fracture: Bone split in multiple pieces.
Compression fracture: One or more bones in spine
weaken and collapse (due to loading force},
Oblique fracture: Fracture occurs at an oblique angle.
Spiral fracture: Fracture from twisting motion (sign of
abuse!)
Fractures
Closed (simple), Open (compound) fracture.
Complele vs. Incomplete fracture,
Comminutod fr.ac:ture, Oblique fracture, Spiral fracture
•
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MUSCULOSKELETALSYSTEM
Fractures
Risk factors. Signs/Symptoms. Nursing care,
Medications. Surgeries
158
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MUSCULOSKELETALSYSTEM
Fractures
Risk factors: Os.leoporosis, long-term steroid use, falls,
trauma, bone cancer, substance abuse.
§.!§..; Pain, crepitus, deformity in eldremity, muscle spasms,
edema. ecchymo,sis.
Nursing care: Stabilize affected area, elevale affected limb,
apply ice, perform neurovasclllar assessments every hour.
Meds: Antibiotics (prophylactic), analgesics, muscle
relaxants.
Surgeries:
• External fixation: pins attached to external frame.
• Open reduction and internal fixation (ORIF): pins, plates,
--s_c_r_ew_s_r,_o_d_s_u_s_e_d_i_n_te_m_a_l lY_-
S
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MUSCULOSKELETALSYSTEM
MUSCULOSKELETALSYSTEM
Fractures
Components of 11eurovascular assessment
Fractures: neurovascular assessment
•
Pairi level
•
Sensation (numbness, finglin[j, lack of sensation)
•
Skin temperature
•
Capillary refill (should be <= 2 seconds)
•
Pulses
•
Movemenl
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MUSCULOSKELETALSYSTEM
MUSCULOSKELETALSYSTEM
Immobilization devices:
Casts: Nursing care and patient teaching
Casts
• Handle plaster casts with your palms (not
fingertips!) and wearing gloves until cast is dry.
• Elevate cast above level of heart for first 24-48
hours.
• Tell patient not to place objects under cast
• Itching can be relieved by blowing cold air from a
hair dryer unde-r cast.
• Report to provider: Hot spots, areas with increased
drainage, malodorous areas
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MUSCULOSKELETALSYSTEM
MUSCULOSKELETALSYSTEM
Types of traction
Skin: Weights attached to patient's skin to decrease
Immobilization devices:
Traction: Types of traction
muscle spasms and Immobilize the extremity before
surgery. Examples:
•
•
161
Bryant traction (for hip dysplasia in children)
Buck's traction (for hip fractures in adult patients).
Skeletal: Screws are inserted into the bone. Used for long
bone fractures.
Halo: Used 1or cervical bone fractures. Make sure
wrench to release rods is attached to the vest, so CPR
_c_a_n_b_e_p_e_rf_o_rm ed_!
MUSCULOSKELETALSYSTEM
MUSCULOSKELETALSYSTEM
Immobilization devices
Nursing care
Nursing Care of Immobilization devices
•
•
•
•
•
162
Assess neurovascular status every hour for first 24
h.rs, then every 4 hours afterwards.
Do not lift m remove weights.
Do not let weights rest on floor (make sure they are
hanging freely).
Muscle spasms are expected and should be
treated w/meds, repositioning, heat, or massage.
Report unrelieved muscle spasms to provider.
For halo traction, move patient as a unit and do not
apply pressure to rods.
.-
i
}
MUSCULOSKELETAL SYSTEM
MUSCULOSKELETALSYSTEM
Immobilization devices
Pin site care
Fracture complications
Compartment syndrome: what is it, symptoms, treatment
Pin site care, compartment syndrome
Pin site care:
• Monitor for signs of infection: increased drainage,
erythema, loosening of pins, skin tenting at pin site.
• Clean pins LJSing a NEW cotton tip swab for each pin.
• Do not remove crusting al pin site!
Compartment syndrome: Increased pressYre within
muscle compartment of an e:xtremity that impairs circulation.
• Symptoms: Intense pain w/passiv<;>movement,
parasthesia (early sign!), paralysis {late signI), pallor,
pulselessness (late sign!), hard/swollen muscles.
• Treatment: Fasciotomy
!r
"
i
163
MUSCULOSKELETALSYSTEM
MUSCULOSKELETALSYSTEM
Fracture Com lications
Fat embolism: Fat globule from bone marrow travels to
Fracture Complications
Fat smbolism: wl1at is it, symptoms
Osteomyelitis: what Is it, symptoms, treatment
lungs, impairing respirations Long bone and hip
fractures are most common.
• Symptoms; Dyspnea, confusion (early sign),
tachypnea, tachycardia, pelechiae on upper body
(late signl)
Osteomyelitis: Bone nfeclion
• Symptoms: bone pain, erythema, edema, fever,
elevated WBC.
• Treatment: Long-t erm antibiotic therapy, surgical
debridement of bo ne, hyperbaric oxygen therapy.
.
164
MUSCULOSKELETALSYSTEM
MUSCULOSKELETALSYSTEM
Osteoarthritis
What is ii?
Risk factors, Symptoms
Patient care/teaching
Osteoarthritis
Osteoarthrjtjs: Progressive degeneration of articular
cartilage in joints.
Risk factors: Older age, women, obesity, smoking, repeUlive
stress on joints.
Symptoms: Joint pain/stiffness, crepitus, enlarged joints,
Herberden's nodes (distal interphalangeal joints), Bouchard's
nodes (proximal lnterphalangeal joints)_
Patient care/teachjng;
• Apply ice (acute inflammation) or heat
• Splinting and/or use of assistive devices.
• Physical therapy
-•-T_E_N_S_(_tr_a_ns_c_u_ta_n_e_o_us_el_e_ct_ri_ca_l_n_e_rv_e_s_ti_m_u_la_ti_on )
165
MUSCULOSKELETALSYSTEM
MUSCULOSKELETALSYSTEM
Osteoarthritis
Meds:
Osteoarthritis
Medications
Surgery
•
•
•
•
Oral analgesics (acetaminophen, NSAIDs)
Topical analgesics (aapsaicin): Wear gloves when
applying, do not apply on areas with broken skin,
burning sensation is normal.
Glucosamine: Increases synovial fluid production
and helps rebuild cartilage.
Injections: glucocorticoids, hyaluronic acid.
Surgery: Total joint arthroplasty
166
_,
MUSCULOSKELETALSYSTEM
MUSCULOSKELETALSYSTEM
Osteoarthritis vs. Rheumatoid Arthritis
Osteoarthritis:
•
•
•
•
•
Osteoarthritis vs. Rheumatoid Arthritis
Key differences
Degenerative disease process
Pain with activity, gets better with rest
Affects specific joints, NOT symmetrical
Heberden's and Bouchard's nodes
Negative rheumatoid factor
Rheumatoid arthritis:
•
•
•
•
•
Inflammatory disease process
Pain after rest/immobility, gets better with movement.
Affects ALL joints, symmetrical.
Swan neck and boutonniere deformities.
Positive rheu matoid fac tor.
167
-
INTEGUMENTARY SYSTEM -
INTEGUMENTARY SYSTEM
Used to identify and treat
bacterial skin lesions. Get culture prior to starting
antibiotics! Final results in 72 hours.
• Culture identifies the pathogen.
• Sensitivity determines which antibiotic can be used
to kill the pathogen.
Used to diagnose viral skin lesion.
Used to diagnose fungal skin lesion.
168
INTEG M NTARY SYSTEM
Bathe w/antibacterial soap.
Remove dried exudate before applying topical
antibacterial ointments.
Apply Burrow's solution to promote
crusting of lesions. Avoid restrictive clothing. Topical
antiviral ointments (ex: acyclovir) can be used.
Apply antifungal cream or
powder (ex: clotrimazole) BID for 1-2 weeks after
lesions are no longer visible.
INTEGUMENTAR
SY
Autoimmune disorder that results In overproouclion
of keratin and formation of dry/scaly patches on the skin.
Characterized by periods of exacerbations and remissions.
Scaly patches, pitting/crumbling nails.
..
•
•
Topical steroids (ex: triamcinolone). Do not apply to face, skin folds,
or broken skin.
Tar preparations (01<: coal tar). Use on conjunction with uttrav,alet B
hght lherapy (remove cream before therapy). Cream may stain skin
•
170
and clothes. Can increase risk of skin cancer.
lmmunosuppressants (ex: metholrexate-, cydosporin)
Ultraviolet light therapy. Administer psoralen 2 hours
before treatment (enhances photosensitivity). Provide eye
pmtection to patient
I
--
-
.,_
-
INTEGUMENTARY--=-"'"'-'
SY.STEM
,:
.
-
..
..3.. .
:....:.._
YSTEM
- - --- •
lnfiammation in areas that oontain
a high level of sebaceous glands (ex: scalp, forehead, nose,
groin, axilla). Characterized 'by periods of exacerbations and
remissions. Most common type: dandruff.
Waxy or flaky plaques or scales in oily parts of
lhe body.
..
•
•
Topical corticosteroids
Antiseborrheic shampoos (i.e. shampoos containing
selenium). Use several times a week, leave in hair for
2-3 minutes.
171
'
L
'ARY SYSTEM
INTEGUMENTARY S:Y:StE A
------
r•
_'-
'•-'.I:
_i...._
•
t
�
.......: ,..•-•
,�
_
--
•
..
Calculates % of body bl.!med:
Head = 9%, each arm = 9%, each leg = 18%, anterior torso =
18%, posterior torso= 18%, perinea! area= 1%.
• Superficial: Dam,ige to epidermis. Red/pink color, no blisters.
Ex: sunburn.
• Superficial partial thickness: Damage to epidermis, and part
of !he demnis. Red/pink color with blisters. No eschar.
• Deep partial thick.ness: Damage to epidermis am! deep Into
dermis. Rea/wh1te color. NO blisters. Soft/dry eschar.
• Full thickness: Damage to epidermis, dermis, and part of
sub taneoL1s tissue. Color varies. Pain may not be presem.
No blisters. Hard esci'lar.
• Deep full thickness: Damage to all skin layers. Black color.
·­-
172
UM
.
Y SYSTEM
INTEGUMENTARY SYSTEM
First 24-48 hours from injury.
Initial fluid shift: Fluid shifts to interstitial space, resulting in
hypovolemla.
• Lal:>s: Elevated Hcl. Hgb. Hyponatremla, hyperkalemla.
Starts when fluid resuscitation is complete, and
ends when wounds are healed.
• Fluid moblll2ation {Diuretic stage}: 4!}-72 hours after injury.
Fluid shifts back Into vascular system.
• Latls: Decreased Hci, Hgb. Hyponatremla, hypokalemia.
Decreased protein, albumin.
Begins when wounds are healed, and ends
when reconstructive procedures are complete.
•
Burns
173
.
INTEGUMENTARY SYSTEM
-
INTEGUMENTARY SYSTEM
•
Burns
1 I
•
•
•
•
174
Monitor for S&S of shock: Urine output< 30 ml/hr,
confusion, fever, decrease bowel sounds, increased
capillary refill time.
Administer IV opioid analgesics. Avoid IM or
subcuianeous injections.
Prevent infection: no fresh plants/flowers, no fresh
fnuits/veggies, limit visitors.
Provide nutritional support Increase calorie and protein
intake. Provide TPN as ordered.
Preserve patient mobility: Active and passive ROM
exercises to prevent contractures. Apply pressure
dressings as ordered.
•
•
•
Stop burning process. Flush chemical burns with
large volumes of water. Do not apply greasy lotions
or butler to burns.
Administer tetanus vaccine (if applicable).
Maintain airway. Singed eyebrows, nasal hair,
and sooty sputum are indications of inhalation
damage.
•
•
•
175
_ •
INTEGU!-"ENTARY_SYSJl;ty1
-
,
Bur
Administer humidified oxygen as ordered.
Insert large-bore needle for fluid resuscitation
(0.9%NaCI or Lactated Ringers).
Administer colloids or plasma expanders as
ordered.
-
INTEGUMENTARY SYSTEM
_
•
•
•
Amount or fluid needed In first 24 hours= 4ml lactated Ringer's x
patients weigh! (in kg) x % body surface area (BSA) burned.
Administer ½of that amount in first 8 hours.
Administer¼ of that amount in second 8 ho\Jrs.
Administer¼ of that amount in third 8 hours.
•
Silver sulfad1azme (Sflvadene): Anhmictoblal, does not penetr:ate
•
eschar. May cause transient neutropenia.
• Marenideacetate(Sulfamylon):Ant,microblal. does penetrate
esehar. can cause metabolic acidosis.
Immobilize graft site, elevate extremtty, monitor for signs of
infection.
• Allogrart: from humar, cadavers
• Xenograft from animals
• Autografl: from anolher part of patient's body.
176
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Diagnostlc tests
Water deprfyatjon test: Tests to see if the kidneys are able
to concentrate urine when blood osmolality increases. If
kidneys are unable to cortcentrate urine, this is indicative of
nephrogenic Diabetes lnsipidus.
• Procedure: Obtain weight and send blood, urine
samples to lab hour1y.
Yasopressin test;Tests to see if administration of
subcutaneous vasopressin increases urine specific gravity. If
vasopressin causes increase in urine specific gravity, this is
indicative of neurogenic Diabetes lnsipidus (i.e. issue with
pituitary gland).
Diagnostic tests
Water deprivation test
Vasopressin test
177
•
!,;,
t,·,
'
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Diagnostic Tests
Oexamethasone suppression test: Tests to see if
Diagnostic tests
administration of dexamethasone (steroid similar to
naturally occurring cortisol) results in decreased levels
on ACTH and cortisol. If there is NO decrease, this is
indicative of Cushing's. disease.
ACTH Stimulation test: Tests to see if administration of
ACTH increases levels of cortisol in body. If there is NO
increase, this is indicative on Addison's disease.
• Procedure: Collect two 24-hour urine samples (one
Dexamethasone suppression test
ACTH Stimulation test
.
178
b_e_fo_r_e_a_n_d_o_n_e_a_ft_e ard_m_in_is_tr_a_u_o no_fA_C_T_H_).
l
i
!
_,
ENDOCRINE SYSTEM
Diagnostic Tests
Fasting blood glucose: No foods or fiuids for 8 hours before
test.
Fasting blood glucose
Oral glucose tolerance test
• Normal levels< 110 mg/dL
Oral glucose tolerance test; Fast for 10-12 hours before
test. Take fasting blood glucose. Patient consumes specific
amount of glucose. Blood samples taken every 30 minutes
for 2 hours. Normal levels < 140 mgldl.
HgbA1C; BEST indicator of average blood glucose levels
HgbA1c
over the past 3-4 months.
• <= 5.7% indicates no diabetes
• Between 5.7 - 6.4% indicates pre-diabetes
. • >= 6.5% indicated diabetes
179
_,-
ENDOCRINE SYSTEM
Pheochromocytoma
ENDOCRINE SYSTEM
Pheochromocytoma: Benign tumor on adrenal:gland
causes hypersecretion of calecholamin,es, resulting in
increased sympathetic response in the body.
Symptoms: Tachycardia, hypertension, diaphoresis,
headache, shortness of breath.
Diagnosis: Plasma-tree metanephrine test, clonidine
suppression test.
Meds: Anti-hypertensive medications until surgery.
Surgery: Remove tumor from adrenal gland.
Pheochromocytoma
VVhi:1t151l?
Symptoms, D1ugnos15,
Moo1<:at1anEi, Surgery
180
'
'
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Diabetes lnspidus
What is it?
Signs and symptoms
Labs
Diabetes lnspidus
Diabetes lns101dus: Deficiency or ADH, resulting In kidneys
being unable to concentrate urine.
S&s: Large amounts of dllLJted urine, polydlpsia, dehydration
liacfiycardia, hypotens,on, sunken eyes, dry mucus membranes,
weakness, fatigue),
Labs:
----;---l.Jrine: DECREASED specific gravity(< 1.005), decreased
osmolality•( < 200 mOsm/L), decreased sodium.
• Blood: INCREASED semm osmolality ,( > 300 mOsm/L),
increased sodium.
D1agn0s1s: Water dep.rlvation tes.t, Vasopressin lest
Meds: ADH replacements (desmopressin or vasopressin).
For intranasal administration, clear nasal passageway before
181
ENDOCRINE SYSTEM
S:tndrome of Inappropriate ADH (SIADH)
What is it?
Causes
Signs/Symptoms
182
._i_nh_a_la_t,_on_.
,E
ENDOCRINE SYSTEM
Syndrome of Inappropriate ADH (SIADH)
SIADH: Excessive release of ADH from the posterior
pituitary gland, resulting in increased reabsorption of
water (not sodium) by the kidneys.
Causes: Brain tumor, head injury, meningitis,
medications.
S&S: Small amounts of concentrated urine. Fluid
volume excess (tachycardia, hypertension, crackles,
distended neck veins, weight gain), headache,
weakness, muscle cramping, confusion, seizures, coma
-- --------------------------------------------------------------------------- --
·1
·
ENDOCRINE SYSTEM
Syndrome of Inappropriate ADH (SIADH)
ENDOCRINE SYSTEM
Labs :
•
Urine: INCREASED specific gravity(> 1.030),
osmolarity, sodium.
• Blood: DECREASED serum osmol!arity {< 270 m Eq/L),
sodium.
Nursing care:
• Fluid restnction.
Syndrome of Inappropriate ADH (SIADH)
Labs
Nursing Care (1nclud1ng medications)
1
•
•
•
•
i
l
Monitor l&Os (watch for hyponatremia!)
Weigh patient daily.
Provide hypertonic IV fluids (ex: 3% NaCl).
Administer furosemide (diuretic) as ordered.
!!
183
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Synthesis Pathways
Thyroid svnthosls pathway :
•
•
Synthesis Pathways
Tliyroid hormones
•
Cortisol
Hypotl,alamus produces TR/-1(1hyrold releasing hormom,).
TRH causes the anterior pituitary gland to produce TSH
(thyroid sllmulallng horrnolle).
TSH causss the thyroid gland to produce T3/T4 (thyroid
hormones that oontrolmelabolism in the body).
Cortisol SYOthesjg
Pathwav·
•
Hypolllalamus pr,oduces CRH (Cortisol releasing
•
CRH c:auses the anterior pituitary gtancl to procluce ACTH
(adrenocorllcotropic l1om10.ne).
• ; = , =:
; tr : !t tfsx i
hormone).
io
0
.[: ;oid
li
5'
§
body's response to stress).
184
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Hyperthyroidism
Hyperthyroidism : Excess thyroid hormones (T3 and T4)
Hyperthyroidism
What is it?
Causes
released from thyroid gland, resulting in hypermetabolic state.
Causes:
• Primary (issue wlthyroid gland): G.aves disease {most
common cause, autoimmune issue) or thywid nodule
causes hypersecretion of T3/T4.
• Secondary (issue with pituitary gland): Anterior pituitary
gland produces too much TSH (due to tumor).
• Tertiary (issue with hypothalamus): Hypothalamus
produces too,much TRH.
185
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Hyperthyroidism
Sigm;JSyrnptoms
Labs
Nursing care
Hyperthyroidism
S&S: Tachycardia, hypertension, heat intolerance,
exophthalmos, weight loss, insomnia, diarrhea, warm/
sweaty skin.
Labs: Increased T3/T4, decreased TSH (in primary
hyperthyroidism),
Nursing care:
• Nutrition: Increase patient's calories, protein
intake. Monitor l&Os, weight.
• Exophlhalmos: Tape eyelids closed, provide eye
186
._
lu_b_ri_c_a_nt _.
I
!
i
.
-
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Hyperthyroidism
Meds
Complications
Surgery
Hyperthyroidism
Meds :
----;propyllhiouracil (PTU)
• Beta-blockers (ex: propranolol)
• Iodine solutions (mix w/juice to mask taste)
Radioactive iodine: Stay away from children for 2-4 days,
fiush toilet 3 times, do not share tooU7brush, use disposable
plates/ule nsiIs.
Complrcallons: Thyroicl storm - excessively high levels of
thyroid hormones. with hig,h mortality rate.
• C,;1uses: Infection, stress, DKA.
• Symptoms,: hypertension. dhest pain. dysrhythmias,
dyspnea. delirium.
Surgery: Thyroideclomy (removal of thyroid gland). Patient will
._ne_e_d_t_h..._y_ro_id_re.:..p_ta_c_e_rn_e_n_t _th_e_ra ,p..:y_t..:.o:....rt..:.h..:.e..:.r..:.es;:..t:....o:..cf...:th..:.e:..cir:....J:....if..:.e:..... _
_J
167
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Thyroidectomy
Post -mo,;;eduru N11rsmg care:
Place patient In high-Fowler's position.
Prevent (and monitor for) hemorrhaging. Check dress,ng and
back of neck for bleeding. Supf>Or1 patient's head and neck
with pillows/sandbags. Teach patient to avoid neck flexion or
extension.
Monitor for signs of parathyroid gland damage (i.e. S&S of
Have tracheostomy supplies available at bedside.
Thyroidectomy
Post-procedure Nursing care
188
hypocalcemia): numbness/tingling around mouth or toes,
muscle twitching, positive Chvostek's or Trousseu's signs.
Administer calcium gluconate for treatment of hypocatcemia.
Administer steroids (ex: prednisone) lo decrease post-op
•
- -
!
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Hypothyroidism
Hypothyroidism : lriadequate productlon of thyroid
Hypothyroidism
What is it?
Causes, Signs/
Symptoms. Labs
Nursing care
hormones (T3Er4) by the thyroid gland.
Causes:
rihary (issue w/thyroid gland): Most common type. Ex:
as,moto's disease (autoimmune disorder), cretinism
(severe hypothyroidism in infants).
• Seconctaar (Issue with pituitary gland): Antenor pituitary
gland pro uces insufficient TSH (due to tumor).
• Tert ary !issue with hypolhalamus): Hypoltlalamus produces
msu IcIent TRH.
S&S: Hypotension, bradycardia, let11argy, cold,Intolerance,
const1pation, weight gain, thin hair, brittle fingernails, depression.
Lobs: Decreased T3 (< 70ng/dL), decreased T4 (< 4mcg/dl),
mcreased TSH (with primary hypothyroidism), anemia.
189
ENDOCR1NE SYSTEM
Hypothyroidism
ENDOCRINE SYSTEM
Nursing care:
Hypothyroidism
Nursing care
Meds
1190
•
•
i
Encourage frequent rest periods.
Encourage low-calorie, high-fiber d:iet and increased
activity to promote weight loss and prevent
constipation. No fiber laxatives (interferes with
levothyroxine absorption).
• Provide extra blankets, increase room temperature.
No electric bl,ankets..
Meds: Levothyroxine - Start with low dose, gradually
increase. Take 1 hour before breakfast w/full giass of
water.
I
;
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Hypothyroidism
ComPlications:
Hypothyroidism
•
•
Hyperthyroidism (due to too much levo hyroxine)_
Myxedema coma - Severe lnypothyroidism
Complicatlons
,- Causes: Untreated hypothyroidism, infection/
illness, abrupt discontinuation of levothyroxine.
,... Symptoms: Hypoxia, decreased cardiac output,
decreased LOC, bradycardia, hypotension,
hypothermia.
:-- Nursing care: Maintain patent airway, monrtor
!=:CG, warm pat,ent, administer large doses of
----le_v_o_t_hy_ro_x_in_e___________________________________
2
191
ENDOCRINE SYSTEM
Cushing's Syndrome
ENDOCRINE SYSTEM
CU$hmo1s Svndrnmc· Overproduction of cortlsol byha adnenal cortex.
Cushing's Syndrome
Whal is It?
Causes
Signs/
.
S_y•m PID= ,•
Causes:
• Primary (Adrenal dysfunction): Oversecrelion of cortisol by the adrenal
cor1Bx (r/t adrenal hyperplasia, lumor).
• Secondary (Pituitary dysfunction}, Oversecrellort ol ACTH by the
anterior pituitary gland (r/1tumor)_
• Long-term use or steroids for chrol)]c coOOitions.
S&S: Increased Infections. thin/fragile skin. edema, weight gain (moon
face, buffalo hump, increased abdominal girth), hypertension, t.achyoardia.
bone pain/fractures, hyperglyeemia, gastrtc ulcers, hirsudsm, acne_
Lab,;:
•
•
•
Elevated cortlsol levels in sallw
Increased glucose·, sodium levels
Decrea$ed pot.,sslum, calcium levels
F
e
z
1
li
- ---------------------------------------- '
192
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Cushing's Syndrome
Diagnosis
Nursing care
Medications
Therapeutic procedures/surgeries
'-
Cushing's Syndrome
DiaoTiosls: Dexamelhasone suppression test
Nu ino earn:
•
Diet decrease sodlunn lntako, lncraase Intake of potassium1
calcium, and protein.
• Maintain ere environment due lo increased risk of lraetums.
•
Prevent Infeclion
• Protect paUent's skin from breakdown.
Meds: keloconazole (adr.,nal oortlcosteroid Inhibitor),
spironolactone (postasslum sparing dill retie)_
Procoduros/Surgorlcs:-
Cytotoxlc agents for lumors causing condilion.
, Hypophysectomy (removal of pituitary gland).
Adrenaloctomy (removal of adrenal gland): Hormone replacement
lh•rai>Yneeded, monllor for adrenal crisis r/t drop In cortisol levels_
,
193
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Hypophysectomy
•
Monitor for signs of CSF leak:
►
Hypophysectomy
on edges).
:,. Sweet-tasting drainage
Post-procedure Nursing care
,
•
•
•
194
Halo sign in drainage (clear in center, yellow
Clear drainage from the nose
;.- Headache
Teach patient lo AVOID activities that increase ICP:
5"
coughing, sneezing, blowing nose, bending at waist,
r,
straining during bowel movements (increase fiber intake). !:!
Decreased sense of smell expected for 3-4 months.
Do not brush teeth for 2 weeks (flossing and rinsing
mouth OK).
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Addison's Disease
Whal is it?
Causes
Signs/Symptoms
Labs
,t,;
Addison's Disease
Addison's Disease: Inadequate secretion of hormones by
adrena.l cortex (alclosterone, cortisol, sex hormones).
Causes:
•
Primary (adrenocortical insufficiency): damage or
dysfunction of adrenal cortex (rlt autoimmune
dysfunction, tumors).
• Secondary (pituitary dysfunction): pituitary tumor or
hypophysectomy.
S&S: Weight loss, hyperpigmentation (bronze skin),
lethargy, nlv, hypotension, dehydratiom.
Labs: Increased potassium and calcium. Decreased
195
sodium, glucos,e, cortisol.
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Add.son's Disease
Diagnosis
Nursing care
Complications
Addison's Disease
o,agnosis; ACTH stimulation lest. Administer ACTH, measure
cortisol response after 30 min, 1 hour,
• Primary Addison's - cortisol levels do not rise.
• Secondary Addison's - cortisol levels DO rise.
Nunolna care:
•
•
Adminisler steroids (hydrocortisone, prednlsone).
Administer fiuids, electrolytes as ordered.
• Treat hyperkalemia: sodium polystyrene sulfonate, insulcn
!
{with glucose), caJcium, bicarbonate.
• Treat hypoglycemia: food, supplemental glucose,
"
Comp11cauons· Addisonian crisis- rapid onset, medical emergency. l
Due to infection/trauma or abrupt discontinuation of steroids
l
196
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Diabetes Mellitus
Diabetes Mellitus
What IS ii?
3 types
197
Diabetes Mellitus: Chronic hyperglycemia due lo
insuffiicient insulin production by the pancreas and/or insulin
resistance of cells in the body.
3 Types of Diabetes:
• Type 1 DM: Destruction of beta cells 1n pancreas due to
autoimmune dysfunction. Patients are insulindependent. Usually starts at younger age.
• Type 2 DM: Progressive insulin resistance and
decreased insulin proquction rlt obesity, inacUvity, and
heredity, Usually starts later in life.
• Gestational DM: Higtl blood glucose during pregnancy
-
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Diabetes Mellitus
Risk factors
Signs/Symptoms
Diabetes Mellltus
Risk factors: Obesity, hypertension, hyperlipidemia,
smoking, genetics, race (African American, American
Indian, Hispanic populations), inactivity.
S&S: 3 Ps (polyuria, polydipsia, polyphagia),
hyperglycemia, weight loss, dehydration (decreased
skin turgor, weak pulse, hypolension, dry mucus
membranes), fruity breath odor, Kussmaul respirations
(Increased rate and depth of respirations), nlv,
headache, decreased LOC.
lj
198
-
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Diabetes Mellitus
Dlanno•ls: Two or more of the following,011 separate days:
• Casual bloc>d gluoose > 200 mg/di
• FasHng blood glucose> 126 mg/di
• Glucose > 200 mg/di wilh oral glucose toleranc,, test.
• l--lgbA1C > 6.5%
HghA1C le t; Best indicator of lrealment compliance. Cloa I for patient$
wilh 1Diabele$ is HgbA1C < 7%,
Diabetes Mellitus
Diagnosis
Best indicator of treatment compliance
Medications
1
Medo;
-.-Insulin
o Rapid-acting= lispro
•
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o Short-acllng = regular
o lnlermediale-acling = NPH
o Long-acting= glarglne
Oral hypoglycemic agents (Type II DM only): metlorm,ln, gllplc>lde,
repagi nide, ploglitazone, acarbose.
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Diabetes Mellitus: patient teaching
Diabetes Mellitus
Patient teaching
•
Rotate subcutaneous injection sites to prevent
lipohypertrophy.
•
Mixing insulins: Draw up clear {shorter-acting
insulin) before cloudy (longer-acting insulin).
•
Never mix long-acting insulin (i.e. insulin glargine)
with other insulins.
•
Monitor for signs of hypoglycemia (confusion,
diapnoresis, headache, shakiness, blurred vision,
decreased coordinat.ion).
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ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Hypoglycemia
What blood glucose levels indicate hypoglycemia?
Management of hypoglycemia in conscious and
unconsc:ious patients
201
Hypoglycemia
Hypoglycemia: blood glucose <= 7 • 0 mgldl
Conscious patients:
• Consume 15-20g quickly absorbed carbohydrate (ex:
4-602 juice or soft drink).
• Recheck blood glucose in 15 min. If still<= 70 mg/di.,
repeat above step and check again in 15 min.
• Once blood glucose is > 70 mgldl, consume a snack
containing a protein and carbohydrate.
S"
Unconscious patients:
• Administer IM or subcutaneous glucagon.
• Repeat in 10 minutes if patient is still not conscious.
• Once patient is conscious (and can swallow safely), have
patient consume a carbohydrate snack.
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ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Foot care for Diabetics
Key patient teaching
Foot care for Diabetics
•
•
Inspect feet daily
Test waler temperature with hands, use lukewarm waler.
• Dry feet thoroughly after bathing.
• Apply moisl\irizer to feel, but not between toes.
• Wear cotton socks (no synthetic fabrics).
• Wear leather shoes (or slippers wlsoles). Do not go
bar!lfoot or wear open toe/heel shoes.
•
•
•
•
Use foot powder wlcomstarch on sweaty reel
Cut nails straight across, ideally after bath/shower.
Check shoes lor objects that can cause injury.
Do not use OTC products, such as products lor corns/
callouses.
... •_D_o_n_o_at _P_P_IY_h_e_a_ti_ng_p_a_d_s_to_re e_t.
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ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
..
Diabetes Mellltis compllcations
• Cardiovascular disease: Ml, hypertension
• Cerebrovascular disease: Stroke
• Diabetic re!lnopathy: Impaired vision
• Diabetic neuropathy: Nerve damage, leading to neuropathic
pain, numbness, ischemia, infection.
• Diabetic nephropathy: Kidney damage
• Diabetic keloacidosis (OKA): Life-threatening condition with
bloocl glucose >300 mg/di and ketones in blood ;ind urine.
Rapid onset. More common with Type I OM.
Diabetes Mellitis
Complications
•
203
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Hyperglycamic-hyperosmolar state (HHS): Life-threatening
condition with blood glucose> 600 mgfdl, no ketosis, severe
--d_e_h_y_dr_a_ti_o_n_. _G_ra_d_u_a_l o_n_s_e_L_M_o_r_e_c_o_m_m_o_n_w_i_lh_T_Y_P_e_l_l D_M_.
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ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Diabetic complications
OKA :
-.,-R isk factors: lnfectlon, stres.sliUness, untreated or undl:agnosed
..
type I OM, missed Insulin do5'l.
• Sym'plom•: Polyulia, Polydipsia, Poll1)hagia, weight loss, fruity
breath odor, Kussmaul respirations, GI upset, del,ydratic,11(resulting
in hypotension, headache, weakness).
., Labs: Blood glucose> 300 rngldl, kelones In blood and urine,
metabolic acidosis.
Diabetic complications
OKA: Rrnk factors, symptoms, labs
HHS: Risk factors. symptoms, labs
HHS:
-.-Risk factors: Older adults.Inadequate fluid Intake, decreased
···­­-
kfdney function, infection, stress.
• Symptoms: Polyuria, polydlpsla, polypha9la, dehydration (resulting
Jn hy.potension, headache, weakness1.
., Labs: Blood glucose> 600mgldl, NO ketones in blood or urine.
No metilbolic acidosis.
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ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
DKAand HHS
Nursing Care
Patient teaching
OKA and HHS
Nursinq care:
Treat underlying cat:.Jse (e:ic: infectron)
Administer IV nuids and IV insulin
• Check blood glurose hou y (goal < 200 mg/di)
Monitor potassium levels, Insulin causes K to move back lnlo cells
•
,1 ,
•
o ol
(risk of hypokalemia),
Administer Bicarb for metabolic acidosis.
Pat:J nt t(!ach1nq:
tg b!1 i ';;ii";.:::riX.entlywhensick (every 1-4hours).
01
Wear a medicat alert bracelet
Drink 2-J L of wafer per day.
Notify doctor if illness Iasis for more than 1 day, or for temperatu,e >
38.6 degrees C.
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IMMUNE SYSTEM
White Blood Cells
Expected r.anges
Lellokopenia, Leukocylosis, Neutropenia, "Left Shift"
206
5'
g
1
ctor lorblood glueose > 250 Fl11)/dl, or forurine positive for
IMMUNE SYSTEM
White Blood Cells
NonnaI WBC .range = WBC between 5,000-10,000/mm'.
Leukopenia WBC < 4,000/mm'. Can indicate presence
of autoimmune disease, bone marrow suppression, drug,
toxicity.
Leukocytosis = WBC > 10,000/mm'. Can indicate
presence of Infection or Inflammation.
Neutropenia"' Neutrophil count< 2,000/mm'.
Indicates compromised immunity.
"Left shift" (banded neutrophils) "' Indicates release of
Immature neutrophils when body is fighting infection.
!t,
IMMUNE SYSTEM
Types of WBCs
IMMUNE SYSTEM
•
Neutrophils (55-75%): Increased during acute
bacterial infections.
• Lymphocytes (20-40%): Increased during chronic
bacterial or viral infection.
• Monocytes (2·8%): Increased during protozoaI and
viral infections, tuberculosis, chronic inflammation.
• Eosinophils (1-4%): Increased during allergic
reactions or parasite infections.
• Basophils (0.5-1%): Increased due to leukemia.
Types of WBCs
207
IMMUNE SYSTEM
IMMUNE SYSTEM
Types of immunity
Active natural
Active
artificial
Passive natural
Passive artificial
Types of Immunity
Active natura'I immunity: Body produces antibodies
in response to exposure to live pathogen.
Active artificial immunity: Body produces antibodies
in response to vaccine.
Passive natural immunity: Antibodies are passed
from the mom to her baby through the placenta or
breastmilk.
Passive artificial immunity: lmmunoglobulins are
administered to an individual after they have l,een
,._exposed to a patl1ogen.
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Key adult immunizations
..
Key points about vaccines
Expected side effects,Nursing care, Documentation
Key adult immunizations
Key adult lmmunjtt,t;ops·
Pneumococcal vaccine: Rerommendod for adults who are
immunocompromised, have a chroaic disease, smoke. or live in a
long-term care facility.
• Meni•ng:oeoec:.al vacclne: Recommended·fol!"individuals livtng in
crowded living environmenl.s (ex: stuclents In college dormsI)
Herpes,ZC?ster cine: Recommended for adults over 60 years old.
Key points about vaccines:
• Expected side offec!s: Low-grade lever, peln al the injectlon sita.
and irritability
• Nursing care: Administer aotipyretics and cool compresses.
Encourage patienl to mobilize effected extremity.
Document: Type o'f vaccinepdate, mute, s.lte, manufacturer-,
209
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IMMUNE SYSTEM
Vaccines
IMMUNE SYSTEM
..
Vaccines
Contraindications (general and specific)
Vaccines are NOT contraindicated for common colds or minor
illnesses!
General conlraindicat:ions:
• Previous anaphylaclic reaction to a vaccine.
• Allergy to a component of a vaccine.
•
Seizure within 3 days of vaccination.
• Pregnancy (for many vaccines).
• Severe immunodeficiency (ex: IHIV, chemo, long-term steroid
use).
Specific contraindications,
•
MMR, Varicella: Allergy to gelatin/neomycin
• Hepatitis B: Allergy to baker's yeast
• Influenza: Allergy to egg protein
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IMMUNE SYSTEM
IMMUNE SYSTEM
Pneumococcal, Meningococcal, Herpes zoster
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1IMMUNE SYSTEM
HIV/AIDS
IMMUNE SYSTEM
HIV: Retrovirus that targets CD4+ lymphocytes (T-cells),
resulting in clecreased immune function and susceplibilily to
infections. AIDS= Stage 3 (end-stage) HIV infection.
Risk factors: Unprotected sex, multiple sex partners,
perinatal exposure (all pregnant women should be tested!),
IV drug use, health care workers.
Symptoms: Flu-like symptoms, weakness, night sweats,
headache, weight loss, rash.
Stage 3 (AIDS):
HIV/AIDS
What is HIV?
Risk factors, Symptoms
AIDS: CD4+ count, symptoms
,
• CD4+ count< 200 cells/mm•
symptoms: Kaposi's sarcoma. TB, pneumonia, wasling
syndrome, candidiasis of the airways, herpes, other infections.
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IMMUNE SYSTEM
IMMUNE SYSTEM
HIV/AIDS
Diagnosis: Positive ELISA test, confirmed with Western
blot test.
Meds: 3-4 Antiretroviral medications (many end in -vir).
HIV/AIDS
Diagnosis
Medications
Patient teaching
Patient teaching:
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• Practice good hand hygiene, bathe daily with
antimicrobial soap.
• Avoid raw foods
• Don't clean cat litter boxes
• Avoid sick people
• Practice safe sex
•_
Ongoing monitoring _
o f CD4+ c o_
u n_
ts.
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IMMUNE SYSTEM
IMMUNE SYSTEM
Lupus
Wllat is it?
2 main types of Lupus
Risk factors, Signs/Symptoms
Lupus
Lupus: Autoimmune disorder that causes chronic
inflammation in the body. There is no cure. Disease is
characterized by periods of e)(acerbations and remissions.
• Discoid: Affects skin (butterfly rash).
• Systemic: Affects the co11nective tissues in multiple
organs.
Risk factors: Females, ages 20-40, race (Afric8171
American, Asian, Native American).
S&S: Faligue, joint pain, fever, butterfly rash on face,
Raynaud's phenomenon, anemia, pericardilis,
L _ l y_
m_
p h a_
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hy.
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IMMUNE SYSTEM
Lupus
Labs
Medications
Patient teaching
Complic,;tions
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IMMUNE SYSTEM
Lupus
Labs: Positive ANA titer, decreased serum
complement (C3/C4), Decreased RBC, WBC, p!atelets.
Increased BUN, creatinine with kidney involvement.
Meds: NSAIDs, immunosuppressant agents
(prednisone, methotrexate), antimalarial drugs
(hydroxychloroquine), topical steroid creams for rash.
Patient teaching: Avoid'UV/sun exposure, avoid sick
people (due to risk of infection w/immunosuppressants).
Complications: Renal failure
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IMMUNE SYSTEM
IMMUNE SYSTEM
What is it?
Risk factors
Signs/Symptoms
Medications
215
Gout
Inflammatory artl1ritis, resulting In formation of uric
acid crystals in joints and body tissues.
Risk factors: Obesity, alcohol consumptfon, high purine
diet (meat), cardiovascular disease, starvation dieting.
S&S: Severe joint pain (most common in
metatarsophalangeal joint in great toe). Erythema,
swelling, warmth in affected joint. Tophi wlchronic goul
Meds:
• Acute gout: colchicine, NSAIDs, corticosteriods.
• Chronic gout allopurinol, probenecid.
IMMUNE SYSTEM
IMMUNE SYSTEM
Rheumatoid Arthritis (RA)
..
What is it?
Risk factors
SignsfSymptoms
Labs
216
Rheumatoid Arthritis (RA)
RA: Chronic, progressive autoimmune disease that
causes inflammation, thickening, and deformation of the
joints. Joints are affected bilaterally and symmetrically.
Characterized by periods of exacerbations and remissions.
Risk factors: Female gender, ages 20-50, genetics
S&S: Joint pain, morning stiffness, fatigue, Joint swelling
wlerythema and warmth, swan neck and boutonniere
deformities in fingers, subcutaneous nodules, fever, red
sclera,,lymphadenopathy.
Labs: Positive Rheumatoid Factor (RF] antibody,
positive ANA titer. Elevated WBCs, ESR and CRP.
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IMMUNE SYSTEM
IMMUNE SYSTEM
Rheumatoid Arthritis (RA)
Diagnosis, Medications,
Procedures, Patient education,
Complications
Rheumatoid Arthritis (RA)
Dja ,qoosjs: Arthrocentesis (aspiration of synovial fiuid from
joint) to test for WBCs, RF.
Meds; NSAIDs, immunosuppressants (prednisone,
methotrexate), antimalarial ag,ents (hydroxychloroquine).
Procedures: Plasmapheresis (to remove antibodies from
blood), total joint arthroplasty.
Patient education: Take hot shower to relieve morning
stiffness, physical activity to p eserve ROM, use of assistive
devices.
Compljcations: Sjogren's syndrome (dry eyes, dry mouth,
dry vagina).
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IMMUNE SYSTEM
Cancer
IMMUNE SYSTEM
Cancer
Risk factors
Staging (TNM)
Diagnosis
Risk factors: Older age, genetics, smoking, sun
exposme. Diet high in fat and/or red meat, low in fiber.
Staging (TNM):
• T = Tumor {T1 - T4): size and extent of tumor
• N = Node (NO- N3)'. number of regional lymph
notes involved.
M = Metastasis (MO, M1): presence of metastasis
(MO = no metastasis, M1 = metastasis present).
Diagnosis: biopsy (definitive), imaging (MRI, CT, PET
scan, ultrasound).
•
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IMMUNE SYSTEM
IMMUNE SYSTEM
Cancer
Treatment optiorns: Tumor excision, chemotherapy
Cancer
(destroys rapidly dividing cells, administered through
implanted port or central IV catheter), radiation therapy,
hormonal therapy, immun.otherapy.
Treatment options
Complications associated with cancer treatment
Complicatjons:
•
•
•
•
•
Ma.lnutrition (due to increased metabolism, inabllily to
digest and/or absorb nutrients, nlv due to chemo}.
lnfecllon (due to immunosuppression)
Alopecia
Mucositis {inflammation of gums/mouth).
Anemia, thrombocytopenia (dve to immunosuppression).
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IMMUNE SYSTEM
IMMUNE SYSTEM
Chemotherapy: Preventing Infection
•
Chemotherapy: Preventing Infection
Nursing care
Initiate neutropenic precautions for WBC < 1,000/
ul.
•
Monitor temperature; report temp> 37.8 degrees C.
•
Restrict visitors who are ill, ensure visitors perform
frequent hand hygiene.
•
Avoid invasive procedures.
• No fresh ·flowers, plants.
•
Keep dedicated equipment in patient's room.
•
Administer filgrastim to increase WBC count.
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IMMUNE SYSTEM
IMMUNE SYSTEM
Chemotherapy: Preventing Infection
Patient teaching
Chemotherapy: Preventing Infection
• Take temperaiure daily, report temperature greater than
37.8 degrees C.
• Avoid crowds.
• Avoid fresh fruits and veggies.
• Avoid yard work, gardening.
• Do not change cat litter box.
• Do not consume fiuids that have been sitting at room
temperature> 1 hour.
• Wash dishes in hot waler or in dishwasher.
• Wash tooihbrush in dishwasher daily (or rinse in bleach
--s_o_1u_ti_o_n_)._D_o_n_o_1_s_h_a_re_to_il_e1r_ie_s_w_i1_h_o_th_e_r_s_!---------------------------
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IMMUNE SYSTEM
IMMUNE SYSTEM
Chemotherapy complications
..
Nursing care and Patient teaching for:
Malnutrition
Mvcosftis
Chemotherapy complications
Malnutrition:
• Nursing care: Administer antiemetlc meds (ex: ondensetron),
meds lo increase appetite (ex: megestrol)
• Patient teaching: Avoid drinking liquids with meals, eat cold or
room-lemperature food$, :,nd consume a high-calorie, high­
protein, mrtrient-dense diet. Use supplements as needed.
Mucositis:
• Nursing care: Provide oral care before and after meals.
Patient teeiching: Avoid glycerin or alcohol containing
mouthwash. Ril'lse mouth with saline solution twice a day.
Use sofl toottitmish. Eat soft/bland foods (avoid spicy, salty,
acidic foods) - scrambled eggs are a good chOice.
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IMMUNE SYSTEM
IMMUNE SYSTEM
Chemotherapy compIications
Chemotherapy complicatio11s
Anem1arthrombocytopen1a:
•
Nursing care and Patient teaching for:
Anemia, thrombocytopenia
•
Nursing care: Administer epoetin alfa (increases
RBC) and ferrous sulfate as prescribed. Monitor
for blood in stool, urine, and vomit. Avoid IVs and
injections when possible. Apply prolonged
pressure after blood draws or injections.
Patient teaching: Use electric razor, soft
toothbrush. Avoid blowing nose vigorously. Avoid
NSAIDs. Prevent injury due to risk of bleeding.
223
IMMUNE SYSTEM
IMMUNE SYSTEM
Radiation therapy
External Radiation:
• Skin over target area will be marked, do nol wash off
these marks.
• Wash skin over affected area with mild soap and water,
gentlyfat dry.
• Do no apply lotions, powders, ointments to
Radiation therapy
Palient care and teaching
Irradiated skin.
• Wear loose, soft clothing.
• Avoid sun or heat exposure to affected area.
Internal Radiation TheraDlf
• Keep door closed, wrt warning on door.
• Limit visitors to 30 min. visits, maintain distance of>" 6 ft.
• Wear lead apron and dosimeter film badge.
224
IMMUNE SYSTEM
IMMUNE SYSTEM
Skin ca11cer
•
..
Skin cancer
Three majn types
•
•
Squamous cell: Rough/scaly lesions; affects
epidermis.
Basal celil: Small/waxy nodules; affects epidennis
and possibly dermis. Most common type of skin
cancer.
Melanom,1; New mole or change in mole. Most
deadly form of skin cancer. Use ABC DE
assessment.
225
IMMUNE SYSTEM
IMMUNE SYSTEM
Skin cancer
ABCDE assessment of skin lesions
Treatment options
Skin cancer
ABCDE assessment:
• · A= Asymmetry
., B = Border (irregular)
• C = Color (pigment varies across mole)
• D = Diameter (width> 6mm, the size of pencif eraser)
• E = Evolving (change in appearance, or new
bleeding).
Treatment: Excision, cryosurgery, topical
chemotherapy (5-fluorouracil cream), Mohs surgery.
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IMMUNE SYSTEM
IMMUNE SYSTEM
Leukemia/lymphoma
Leukemia: Cancer affecting WBCs; causes destruction
Leu'kemia/lymphoma
of bone marrow. Overgrowth of cancerous WBCs
prevents growth of RBCs, plalelets, and normal WBCs.
Lymphoma: Cancer affecting lymphocytes and lymph
nodes. Two types: Hodgkin's and Non-Hodgkin's
lymphoma.
Priorities: Prevent infection (due to neutropenia).
Prevent injury (due to thrombocytopenia).
Treatment: Chemotherapy, radiation, bone marrow
What is leukemia? What is lymphoma?
Nursi11g care priorities, treatment options
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227
IMMUNE SYSTEM
IMMUNE SYSTEM
Breast cancer
Risk factors, Signs/Symptoms, Treatment options
Nursing care and patient teaching of mastectomy
Breast cancer
Risk factors: Genetics (i.e. family history), early menarche. late
menopause, long-tenmuse of oral contraceptives, smoking,
hormone replacemenl therapy, obesity.
S&S: Firm, I1on-tender, non-mobile lump. Dimpling or peau d­
orange appearance. Nipple discharge, ulceration, or retraction.
Treatment: Hormone therapy (leup!'ollde, tamoxifen),
chemotherapy, radiation, surgery (lumpectomy, masteciomy).
Nursing care of mastectomy:
Teach patient lo wear sling when ambulating
Teach patient lo wear loose (non~reslrictive) clolhlng.
Do not administer injections, obtain blood, or take blood pressure in
affected arm.
• Encourage arm/hand exercises to prevent edema and Increase ROM.
,
228
IMMUNE SYSTEM
IMMUNE SYSTEM
Prostate Cancer
Risk factors: Older age, high fat diet, race
Prostate Cancer
(African Americans at higher risk), family history.
S&S: Urinary retention, hesitancy, frequency.
Frequent bladder infections, hematuria (late sign).
Risk factors, Signs/Symptoms,
Labs, Treatment options
Labs: Elevated PSA (> 4 ng/ml). Take PSA
before digital rectal exam.
Treatment: Hormone therapy (leuprolide),
chemotherapy, radial.ion, prostatectomy.
229
PERtOPERATIVE NURSING CARE
PERIOPERATIVE NURSING CARE
Surgery
Phases of Anesthesia (3)
Medications provided during surgery
Surgery
Phases of Anesthesia:
• Induction: IV line inserted, pre-op meds given, airway
secured.
• Maintenance: Surgery performed, maintenance of
airway,
• Emergence: Completion of surgery, airway removed.
Surgery Meds:
•
Anesthetics (ex: benzodiazepines, propofol)
• Opioid analgesics (ex: fentanyl)
• Antiemetics (ex: ondansetron, metoclopramide)
• Neuromuscular blocking agents (ex: succinylcl1oline)
Anticholnergics (ex: atropine)
230
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PER!OPERATIVE NURSING CARE
Informed Consent
PERIOPERATIVE NURSING CARE
Provider responsibilities:
•
Communicate purpose of procedure, and complete
description of procedure in the patient's primary language
(use medical interpreter if neede<J).
• Explain rtsks vs. benefrts
• Describe other options to treat the condllion.
RN responsibilities:
• Make sure provider gave the patient lhe above information.
• Ensure patient is competent to give Informed aonsent (i.e.
patient is an adult or emancipated minor, not impaired)
• Have paUent sign consent document
• Notify provider If patient has more questions or doesn't
Informed Consent
Provider responsibilities
RN responsibilities
,
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-u_n_d_erst_a_nd_a_11_y_in_1o_nn_a_t_io_n _Pr_o_vl_de_d_. ------ ·'
231
PERIOPERATIVE NURSING CARE
Malignant Hyperthermia
..
What is it?
Syrnploms
Treatment
PERIOPERATIVE NURSING CARE
Malignant Hyp,erthermia
Malignant hyperthermia: Hypermetabolic condition
induced by anesthetic agents in surgery.
Symptoms: FEVER, tachycardia, hypotension,
tachypnea, dysrhythmias, muscle rigidity, mottled
skin, cyanosis.
Treatment:
• Discontinue surgery.
•
•
•
232
Administer dant:rolene (muscle relaxant) as ordered.
Administer 100%01<ygen, obtain ABGs
Administer iced NaCl IV flui,ds, apply cooling blanket.
,_
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PERIOPERATIVE NURSING CARE
PERiOPERATIVE NURSING CARE
Post-op Nursing Care: PACU assessment
•
Post-op Nursing Care
PACU assessment
j
2
•
•
•
•
•
Assess airway. Check SpO2 (should be> 95% or at
pre-op level), respirations, lung sounds. Suction
secretions if needed.
Assess Circulation. Assess for signs of
hemorrhaging (hypoterision, tachycardia), skin
color/temp, peripheral pulses, ECG readings.
Assess vital signs (stable for die from PACU).
Monitor l&Os. Ensure urine output>= 30 ml/hr.
Assess surgical wounds, incisions, dressings
Ensure return of gag and swallow reflexes.
233
PERIOPERATIVE NURSING CARE
PERIOPERATIVE NURSING CARE
Post-op Nursing Care
Nursing care after die from PACU
Post-op Nursing Care: Nursing care after PACU
• Encourage early ambulation.
• Prevent DVTs: apply SCDs, reposition frequently,
administer anticoagulants.
• Treat pain, nausea.
• Monitor for S&S of infection at surgical site
(redness, extreme tenderness, purulent drainage)
;.. Expected findings: pink wound edges,
!
slight edema, slight crusting at incision line.
• Teach patient to splint w/coughing and deep
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breathing.
234
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NERVOUS SYSTEM
NERVOUS SYSTEM
Cerebral Angiogram
Electroencephalography (EEG)
Cerebral Angiogram: Allows for visualization of cerebral
blood vessels. A catheter is placed into an artery (usually in
the groin) and threaded up to the blood vessels in the brain,
dye is injected, x-rays are taken.
EEG: Analyzes electrical activity in the brain. It is used to
identify seizure activity, sleep disorders, behavioral changes.
Small electrodes are placed on the scalp. Takes
approximately one hour.
• Pre-procedure: NPO 4-6 l1rs prior to procedure. Assess
•
for allergy to iodine or shellfish. Assess kidney function
(BUN, creatinine) to determine if kidneys can excrete
the dye.
Post-procedure: Check insertion site for bleeding,
check extremity distal to puncture site (pulses, capillary
refill, temperature, color)
NERVOUS SYSTEM
Glasgow Coma Scale (GCS)
Score between 3 and 15. Between 3-8 = severe head injury
and/or coma. Between 9-12 = moderate head injury. Add up
subscores:
Eye opening: (4) spontaneously, (3) in response to voice,
(2) in response to pain, (1) no eye opening.
Verbal response: (5) coherent/oriented, (4) incoherent/
disoriented, (3) inappropriate words, (2) sounds, no words,
(1) no vocalization.
Motor response: (6) follows commands, (5) local reaction
to pain, (4) general withdrawal to pain, (3) decorticate
posture, (2) decerebrate posture, (1) no motor response.
Pre-procedure patient instructions:
•
•
•
•
Wash hair prior to procedure.
Arrive sleep-deprived (as this increases chance of seizures).
No NPO is needed. Avoid stimulants, sedative medications
12-24 hours before procedure.
Inform patient that flashing lights may be used during
procedure, or patient may be instructed to hyperventilate (to
increase electrical activity).
NERVOUS SYSTEM
lntracranial Pressure (ICP) monitoring
ICP monitoring: Device inserted into cranial cavity in
the OR to measure pressure. Huge risk of infection.
Indications: Patient with a GCS score of 8 or less (or
in a coma).
Symptoms of increased ICP: Irritability (early
sign!), restlessness, headache, decreased LOC, pupil
abnormalities, abnormal breathing (ex: Cheyne
Stokes), abnormal posturing.
Normal ICP range: 10-1SmmHg.
NERVOUS SYSTEM
Lumbar Puncture
NERVOUS SYSTEM
Magnetic Resonance Imaging (MRI)
Lumbar Puncture: Cerebral Spinal Fluid (CSF) sample is taken
from the spin I canal for analy is.
Indications: Used to di gn se multiple sclerosis, syphilis,
meningitis, infection in CSF.
• Pre-procedure: Have patient void. Position patient in
cannonball po ltlon on th Ir sid , or have patient stretch over
table while sitting.
• Post-procedure: Pati nt should lay flat for several hours. If
the dura puncture site does not heal, CSF may leak, resulting
in headache (administer pain meds and encourage increased
fluid intake). Epidural blood patch can be used to seal off the
hole.
NERVOUS SYSTEM
Nociceptive vs. Neuropathic Pain
Nociceptive pain: Damage/inflammation of tissues (not
part of CNS). Pain described as: throbbing, aching, and is
usually localized. 3 types:
• Somatic: bones/joints, muscle, connective tissue
• Visceral: internal organs
• Cutaneous: skin, subcutaneous tissue
Neuropathic pain: Result of damaged nerves. Pain
described as: shooting, burning, "pins and needles".
Adjunct meds often used: antidepressants, muscle relaxants
•
Assess for allergy to shellfish/iodine if contrast will
be used.
•
Assess for history of claustrophobia.
•
Have patient remove all jewelry.
•
Make sure patient does not have any metal
implants (pacemaker, orthopedic joints, artificial
heart valves, IUDs, aneurysm clips).
•
Earplugs can be provided, as MRls are loud.
NERVOUS SYSTEM
Components of Pain Assessment
•
Location of pain
•
Quality of pain (how it feels to patient, ex:
"burning", "aching")
•
Intensity of pain (rate on scale from 0-10)
•
Timing (onset, duration, frequency)
•
Setting (how it affects patient's ADLs)
•
Associated symptoms (ex nausea, fatigue)
•
Aggravating/relieving factors
NERVOUS SYSTEM
NERVOUS SYSTEM
Non-opioid vs. opioid analgesics
Meningitis
•
•
•
Meningitis: Inflammation of meninges (membranes around
brain and spinal cord). Viral meningitis is most common
(resolves w/o treatment). Bacterial meningitis is contagious,
with a high mortality rate.
Prevention: Immunizations help prevent bacterial
meningitis. Hib vaccine is given to infants. MCV4 vaccine
• Naloxone is antidote.
is given to students living in dorms.
Symptoms: Headache, nuchal (neck) rigidity,
photophobia, nausea, vomiting, positive Kernig's and
Brudzinski's signs, fever, altered LOC, tachycardia,
•
seizures.
Non-opioid: Use for mild to moderate pain.
•
Key concerns: acetaminophen intake should not
exceed 4g/day.
Monitor for salicylism w/aspirin (sx: tinnitus, vertigo).
Administer w/food to prevent GI upset.
Long-term NSAID use carries risk of bleeding.
Opioid: Use for moderate to severe pain.
• Key side effects include: constipation, hypotension,
urinary retention, n/v, sedation, respiratory depression.
Administer around the clock (vs. PRN).
NERVOUS SYSTEM
NERVOUS SYSTEM
Meningitis
Seizures
Diagnosis: CSF analysis. Bacterial will have cloudy CSF,
decreased glucose content. Viral will have clear CSF.
Seizures: Uncontrolled electrical discharge of neurons
in brain.
Elevated WBC and elevated protein for both types of
meningitis.
• Epilepsy= chronic seizures (2 or more)
Risk factors: Fever, cerebral edema, infection,
toxin exposure, brain tumor, hypoxia, alcohol/drug
withdrawal, fluid or electrolyte imbalances.
Triggering factors: Stress, fatigue, caffeine, flashing
lights.
Nursing care:
•
Droplet precautions until antibiotics are administered
for 24 hours.
• Quiet room, low light, HOB to 30 degrees, monitor for
increased ICP, instruct patient to avoid coughing/
sneezing, implement seizure precautions.
Meds: Antibiotics, anticonvulsants (ex: phenytoin).
NERVOUS SYSTEM
NERVOUS SYSTEM
Types of Seizures
Seizures
Tonic Clonic: May be preceded by aura. 3 phases:
•
•
•
Tonic episode: stiff ning of m 1scl s, loss of consciousness.
Clonic episode: 1-2 min of rhythmic jerking of extremities.
Postictal phase: confusion, sle piness
Absence: Loss of consciousness for a few seconds. Key
features: blank staring, eye fluttering, lip smacking,
picking at clothes.
Myoclonic: brief stiffening of extremities.
Atonic: loss of muscle tone, results in falling.
Status epilepticus: Repeated seizure activity within 30
min, or a single seizure lasting more than 5 min.
NERVOUS SYSTEM
Parkinson's Disease
Cause: Degeneration of substantia nigra, resulting in too
little dopamine and too much acetylcholine.
Symptoms: Tremor, muscle rigidity, slow/shuffling gait,
bradykinesia (slow movement), masklike expression,
drooling, difficulty swallowing.
Nursing care: Monitor swallowing/food intake, thicken food,
sit patient upright to eat, have suction equipment available.
Encourage ROM and exercise, assist w/ADLs.
Meds: Levodopa/carbidopa (increases dopamine levels),
benztropine (decreases acetylcholine levels)
Diagnosis: EEG to identify origin of seizure.
Nursing care:
• During s izure: Turn patient to the side, loosen restrictive
clothing, do not insert airway or restrain patient, document
onset/duration of seizure.
• Post seizure: check vital signs, neurological checks, reorient
patient, seizureprecautions, determine possible trigger.
Meds: Anti-seizure drugs such as phenytoin.
Surgeries: Vagal nerve stimulator, craniotomy to remove
brain tissue causing seizures.
NERVOUS SYSTEM
Alzheimer's Disease
Alzheimer's: Non-reversible dementia, resulting in memory
loss, problems with judgment, and changes in personality.
Stages:
• Stage 1:No impairment.
• Stage 2: Forgetfulness, no memory problems.
• Stage 3: Mild cognitive deficits, short-term memory loss
noticeable to family members.
• Stage 4: Personality changes, obvious memory loss.
• Stage 5: Assistance w/ADLs necessary.
• Stage 6: Incontinence (fecal, urinary), wandering.
• Stage 7: Impaired swallowing, ataxia, no ability to speak.
NERVOUS SYSTEM
NERVOUS SYSTEM
Alzheimer's Disease
Multiple Sclerosis
Nursing care: Maintain structured environment. Provide
short directions, repetition. Avoid overstimulation. Use
single-day calendar. Provide frequent reorientation. Maintain
routine toileting schedule.
Home safety: Remove scatter rugs. Install door locks,
good lighting (particularly on stairs). Mark step edges w/
colored tape, remove clutter.
Meds: Donepezil (prevents breakdown of ACh, improves
ability to do ADLs), other meds to manage symptoms (anti­
psychotics, antidepressants, anti-anxiety meds).
Multiple Sclerosis: Autoimmune disorder where plaque develops
in white matter of the CNS. Ag of onset is typically 20-40 years of
age, mor common in worn n. Characterized by periods of
relapsing and remitting.
Triggers: Temp ratur
xtrom s, stress/injury, pregnancy, fatigue
Symptoms: Eye problems (Diplopia/nyslagmus), muscle spasticity
and weakness, bow I/bladder dysfunction, cognitive changes, ear
problems (tinnitus/hearing issues), dysph gia, fatigue.
Meds: lmmunosuppressive agents (cyclosporine), prednisone
(anti-inflammatory), muscle relaxants (danlrolene, baclofen).
NERVOUS SYSTEM
NERVOUS SYSTEM
Amytrophic Lateral Sclerosis (ALS)
Myasthenia Gravis (MG)
ALS: Degenerative neurological disorder of upper and
lower motor neurons, resulting in progressive paralysis.
Eventually causes respiratory paralysis within 3-5
years. Cognitive function not impacted. No cure.
Symptoms: Muscle weakness, atrophy
Nursing care: Maintain patent airway, suction/
intubate as needed. Monitor for pneumonia, respiratory
failure.
Meds: Riluzole - slows deterioration of motor neurons,
extends patient's life 2-3 months.
MG: Autoimmune disorder that causes severe muscle
weakness. Caused by antibodies that interfere with Ach at
neuromuscular junction (NMJ). Characterized by periods of
exacerbation and remission. Associated with thymus
hyperplasia.
Symptoms: Muscle weakness (worse w/activity), diplopia,
dysphagia, impaired respiration, drooping eyelids,
incontinence.
Diagnosis: Administer edrophonium, which increases Ach
at NMJ. If symptoms improve, it is MG. If not, it is a
cholinergic crisis (Atropine is antidote).
NERVOUS SYSTEM
Myasthenia Gravis (MG)
Nursing care:
Maintain p tent airw y (oxyg n, suction and intubation
equipment t bedside)
• Encourag periods of r st.
• Provide sm 11/frequ nt/hi h-calorie meals, have patient sit
upright while eating, thi ken Ii 1uids
• Administer lubric ting ye drops, tape eyes shut at night (to
prev nt damage to corne ).
Medications: Anticholin terase agents (pyridostigmine
or neostigmine), immunosuppressants.
Procedures/surgeries:
• Plasmapheresis - removes antibodies from plasma.
• Thymectomy - removal of thymus.
•
NERVOUS SYSTEM
Cluster headaches
Macular Degeneration and Cataracts
Severe, unilateral, non-throbbing pain that radiates to
forehead, temple, cheek.
Lasts 30 min - 2 hours. Usually occurs daily at the
same time for 4-12 weeks.
More frequent in spring and fall. More common in men
between 20-50 years old.
• Facial sweating
• Nasal congestion
Medications: sumatriptan, ergotamine (same as migraine
headaches)
anxiety, menstrual cycles, certain foods (MSG, tyramine,
nitrites).
Symptoms: Photophobia, nausea/vomiting, unilateral
pain (usually behind one eye or ear). Can happen with or
without aura (visual disturbances, numbness/tingling). Pain
persists for 4-72 hours.
Nursing care: Provide cool/dark/quiet environment. Teach
patient to avoid triggering foods, reduce stress levels.
Meds: NSAIDs (mild migraine), antiemetics (for n/v),
sumatriptan or ergotamine for more severe migraines.
NERVOUS SYSTEM
Symptoms:
•
Migraine headaches
Risk factors/triggers: Allergies, bright lights, fatigue, stress,
•
•
NERVOUS SYSTEM
Macular Degeneration: Central loss of vision. Number one cause of
vision loss over age 60. No cure.
• Symptoms: Blurred vision, loss of central vision, blindness.
Cataracts: Opacity in lens of an eye, impairing vision.
• Symptoms: Decreased visual acuity, progressive/painless loss
of vision, diplopia, halo around lights, photosensitivity, absent
red reflex
• Post-surgery teacl1ing: Wear sunglasses, avoid increasing
IOP (don't bend over at waist, avoid sneezing/coughing/
straining, avoid hyperflexion of head and restrictive clothing,
avoid tilting head back to wash hair, limit housework and rapid/
jerky movements). Best vision occurs 4-6 weeks after surgery.
NERVOUS SYSTEM
NERVOUS SYSTEM
Glaucoma
Glaucoma
Glaucoma: Increase in IOP due to issue with optic
nerve. Glaucoma is a leading cause of blindness.
• Open-angle: Most common. Aqueous humor outflow
decreased, resulting in gradual increase in IOP.
Symptoms: mild eye pain, loss of peripheral vision.
• Closed-angle: Less common. Angle between iris and
sclera closes completely, resulting in sudden increase
of IOP. Symptoms: severe pain, nausea.
IOP: Normal range is 10-21 mmHg. Measure using
tonometry. Measure drainage angle w/gonioscopy.
NERVOUS SYSTEM
Meniere's disease
Meniere's disease: Inner ear disorder, resulting in the
following symptoms: tinnitus, unilateral sensorineural
hearing loss, vertigo, vomiting, balance issues.
Risk factors: Viral/bacterial infections, ototoxic
medications.
Otoscopic examination: Pull auricle back and up for
adults and children > 3 years, back and down for
children < 3 years. Tympanic membrane should be
pearly gray and intact. Light reflex should be at 5
o'clock for right ear, 7 o'clock for left ear.
Medications:
• Pilocarpine (constricts the pupil)
• Beta blockers - timolol (reduces aqueous humor
production)
• Mannitol - osmotic diuretic for closed angle glaucoma;
quickly reduces IOP.
Patient teaching for eye drops: Administer 1 drop in each
eye twice a day. Wait 5-10 min between eye drops. Do not
touch tip of applicator to eye. Place pressure at lacrimal
duct (puncta) after installation.
Post-surgery teaching: Same as cataract surgery (i.e.
avoid activities that increase IOP)
NERVOUS SYSTEM
Meniere's disease
Medications: Antihistamines, anticholinergics,
antiemetics (examples: meclizine, droperidol,
diphenhydramine, scopolamine). Watch for signs of
urinary retention, sedation.
Patient teaching: Avoid caffeine and alcohol. Rest in
quiet/dark place when experiencing severe vertigo.
Space intake of fluids throughout day, decrease intake
of salt.
Surgeries: Stapedectomy, cochlear implant,
labryintectomy.
NERVOUS SYSTEM
NERVOUS SYSTEM
Head Injury
First priority: Stabilize cervical spine.
Signs of increased ICP: Irritability (early sign!),
headache, decreased LOC, pupil abnormalities, abnormal
breathing (ex: Cheyne Stokes), abnormal posturing,
Cushing's triad (severe hypertension, widening pulse
pressure, bradycardia)
Interventions to decrease ICP: Reduce hypercarbia
(hyperventilate patients), avoid suctioning, maintain HOB
more than 30 degrees. Teach patient to avoid: coughing,
blowing nose, extreme neck flexion/extension,
restrictive clothing.
NERVOUS SYSTEM
Stroke/Cerebrovascular accident (CVA)
3 type of Stroke:
•
Hemorrhagic: Ruptured artery/aneurysm
• Thrombotic: Blood clot in cerebral artery
• Embolic: Blood clot from other part of body that
travels to cerebral artery.
Key risk factors: Smoking, hypertension, diabetes,
AFIB, hyperlipidemia
Overall Symptoms: Visual disturbances, dizziness,
slurred speech, weak extremity
Head Injury
Medications:
•
•
•
•
Mannitol: Osmotic diuretic to treat cerebral edema.
Pentobarbital: Induces coma, decreases metabolic demands
Phenytoin: Prevents/treats seizures.
Morphine: Treats pain
Surgical interventions: Craniotomy to remove nonviable
brain tissue. Many risks (infection, death).
Complications:
•
•
•
Brain herniation (downward shift of brain tissue r/t
cerebral edema). Symptoms: fixed dilated pupils,
decreased LOC, abnormal respirations and posturing.
Hematoma, intracranial hemorrhage
SIADH
NERVOUS SYSTEM
Stroke: Left and Right Cerebral Hemisphere
LEFT hemisphere: Language skills, math skills,
analytical thinking.
Symptoms: Expressive aphasia (inability to speak and
understand language), reading and writing difficulty, right­
sided hemiparesis (weakness) or hemiplegia
(paralysis).
RIGHT hemisphere: Visual and spatial awareness
Symptoms: Overestimation of abilities, poor judgment
and impulse control, one-sided neglect syndrome
(ignore left side of body), left-sided hemiparesis or
hemiplegia.
NERVOUS SYSTEM
Stroke
NERVOUS SYSTEM
Spinal Cord Injury (SCI)
Monitor patient's BP. SBP>180 or DBP>110 can indicate an
ischemic stroke.
• Assess swallowing and gag reflex before allowing patient to
eat. Thicken liquids if needed. Teach patient to swallow w/head
and neck flexed forward.
• Reposition patient frequently to protect from pressure injuries.
• Teach patient to use scanning technique (turn head from
direction of unaffected side to affected side) for homonomous
hemianopsia.
Meds: Anticoagulants, antiplatelets, thrombolytic meds (give within
4.5 hours of initial symptoms).
Surgery: Carotid artery angioplasty w/stenting
lower extremities.
Quadriplegia: Injuries in cervical region, resulting in paralysis/
paresis of all 4 extremities.
Neurogenic Shock: Occurs after SCI for several days
to weeks. Symptoms: hypotension, dependent edema,
temperature regulation issues.
Nursing care:
Paraplegia; Injuries below T1, resulting in paralysis/paresis of
•
Upper motor neuron injyrjes (above L1/L2): spastic muscle
tone, spastic neurogenic bladder.
Lower motor neuron injuries (below L 1/L2): flaccid muscle
tone, flaccid neurogenic bladder.
NERVOUS SYSTEM
Spinal Cord Injury (SCI)
Meds: Glucocorticoids (reduces spinal cord edema), vasopressors
(treats hypotension during neurogenic shock), muscle relaxers
(baclofen, dantrolene), stool softeners (in addition to a bowel/
bladder schedule).
Autonomic dysreflexia: For injuries above T6: stimulation of
sympathetic nervous system with inadequate response from
parasympathetic nervous system.
• Symptoms: extreme hypertension, severe headache,
blurred vision, diaphoresis.
• Nursing actions: Sit patient up, notify provider, determine
Arterial Blood Gas (ABG)
•
•
•
•
•
pH: 7.35-7.45
PaO2: 80-100 mmHg
PaCO2: 35-45 mmHg
HCO3: 21-28 mEqll
SaO2: 95-100%
ABG prncedur k
•
•
cause (distended bladder, fecal impaction, tight clothing,
undiagnosed injury), treat cause (catheterize patient,
•
remove impaction, remove tight clothing), administer
antihypertensives.
•
,0111
Usually performed by respiratory therapist
Perform Allen's test prior to puncture (compress ulnar and
radial arteries simultaneously)
Hold direct pressure over site for at least 5 min (20 min if
patient on anticoagulants) afterwards.
If air embolism suspected, place patient on left side in
Trendelenburg position.
Bronchosco · Allows for visualization of airway
(larynx, trachea, bronchi), biopsies, aspiration of deep
sputum, or excision of lesions.
Pre proc.edure Patient NPO 4-8 hours, administer
prescribed meds (atropine, antianxiety meds, viscous
lidocaine).
Post-proc durc.: Ensure patient's LOC and presence
of gag reflex before allowing patient to eat/drink.
Sore throat, dry throat, and small amount of blood-tinged
sputum is expected.
home ente'>1 Surgical perforation of chest wall and pleural space
with a large-bore needle to obtainspecimens, inject medication, or
remove fluid/air.
nptorn, ofpl ur I eflu 1011 Chest pain, shortness of breath,
cough.
Nur 111q c.u Have patient sit upright, with arms supported on
pillows or overbed table. Patient should remain totally still. Amount
of fluid removed should not exc ed 1L (to prevent cardiovascular
collapse). After procedure, closely monitor respiratory status.
Comphcallon Mediastinal shift, bleeding, infection,
pneumothorax (symptoms: deviated trachea, pain on affected side,
unequal movement of chest during inhalation/exhalation, air hunger,
tachycardia, shallow respirations).
Chest Tubes
Chest Tubel'. Drains fluid, air, or blood from pleural space.
Chest tube tip positioned UP for pneumothorax, and DOWN
for hemothorax or pleural effusion.
Dr maae c.ollect1on ch.Jmbu Chart amount and color of
drainage. Report drainage> 70 ml/hr to provider.
WJter se I ch mbet. Add sterile fluid up to 2cm line, check
every 2 hr. Chamber must be kept upright and below chest
tube insertion site. Tidaling expected. Lack of tidaling = lung
re-expansion or obstruction. Continuous bubbling indicates
air leak.
Suction control chamber -20 cm H2O common.
Continuous bubbling expected.
Chest Tubes
Nursjng c,1r
t r
tu e
• Assess chest tube insertion site for erythema, pain,
crepitus.
• Position patient in semi/high Fowler's position.
• Obtain chest x-ray to verify tube placement!
• Keep 2 hemostats, sterile water, occlusive dressing at
bedside.
• Only clamp when ordered; do not strip/milk tubing.
Chest tube removal: Tell patient to take a deep breath,
exhale, and bear down (or take a deep breath and hold it)
during removal. Apply sterile petroleum jelly gauze dressing
over chest tube site.
Oxygen Delivery
. plications
------Chest Tube Com
_
.,
•
If drainage system becomes compromised, place
end of tube into sterile water (to maintain water
seal).
• If chest tube is accidentally removed, apply dry
sterile gauze over area_ taped only on THREE
sides.
•
Tem,1on neumothorax: can result fromkink in
tubing or obstruction. Symptoms: tracheal
deviation, absent breath sounds on affected side,
respiratory distress, asymmetry of chest.
Oxygen delivery
s
•
•
:t..mw
Early: Restlessness/irritability, tachypnea, tachycardia,
pale skin, hypertension, nasal flaring, use of accessory
muscles, adventitious lung sounds.
Late: Confusion, cyanosis, bradypnea, bradycardia,
hypotension, dysrhythmias.
S&SofoxygentoxiLity
•
Non-productive cough, substernal pain, nasal
congestion, n/v, fatigue, headache, sore throat.
Avoidin combustion Post "no smoking" signs, avoid
synthetic or wool fabrics, do not use flammable materials
(alcohol, acetone).
•
Nasal c mnula 1-6 L/min. Use humidification for
flow rate 4L/min
1.mplc r ce m k 5-8 Umin
Pa t1al robtoatho ma k: 6-11 L/min. Adjust
oxygen flow to keep reservoir bag from deflating.
• Nonr br t1 hum sk 10-15 Umin. Keep reservoir
bag 213full. Assessvalve, flaphourly.
• Venturi ma k: 4-10 L/min. Most precise oxygen
delivery.
• Aerosol mask/face tent: Good for patients with
facial trauma or burns; provides high humidification.
•
•
Mechanical Ventilation
Low r sur
1splacement.
Hs
ur IJrm Excess secretions, patient biting tube,
Kinks in tu 111g, coug 1ng, pulmonary edema, bronchospasm,
pneumothorax.
Nursin care
• Suction oral and tracheal secretions.
• Reposition ET tube every 24 hrs; monitor for skin breakdown.
Provide frequent oral care.
• Have manual resuscitation bag and reintubation equipment at
bedside.
• After extubation: encourage coughing, deep breathing, use of
incentive spirometer, frequent position changes (to mobilize
secretions).
Pneumonia
Asthma
S&S. fever, shortness of breath, chest pain, cough, dyspnea,
confusion (very common in older patients), crackles/
wheezes.
Lab te ts Obtain sputum sample BEFORE starting
antibiotic therapy. Elevated WBC, decreased Pa02 levels.
Dia no • Chest x-ray (shows consolidation).
Nursm c,ue Position patient in high-Fowler's, administer
02 as prescribed. Encourage coughing, deep breathing, use
of an incentive spirometer, increased fluid intake.
Meds antibiotics, bronchodilators (albuterol), anti­
inflammatories (glucocorticosteroids).
A thma Chronic inflammatory disorder of the airway;
intermittent and reversible.
S&S Wheezing, coughing, prolonged exhalation, low Sa02,
barrel chest, use of accessory muscles.
D1agnoc;1 Pulmonary function tests (FVC, FEV1).
Meds Bronchodilators (short-acting: albuterol, long-acting:
salmeterol), anticholinergic meds (ipratropium), anti­
inflammatory meds (corticosteroids).
Statu asthmaticus Airway obstruction unresponsive
to typical treatment. Administer 02, bronchodilators,
epinephrine. Prepare for emergency intubation.
---Chronic Obstructive Pulmona r-y =Di-se-a-se-----------Nur
COPD Emphysema (loss of lung elasticity and
hyperinflation of lung tissue) and chronic
bronchitis (inflammation of bronchi). Irreversible.
Smoking is primary risk factor.
Sb.S: Dyspnea upon exertion, crackles/wheezes,
barrel chest, use of accessory muscles, clubbing,
hyperresonance (due to trapped air), decreased
SaO2 levels, rapid and shallow respirations.
Labs: Increased Hct (due to low 02 levels); PaO2 <
80mmHg, PaCO2 > 45mmHg, respiratory acidosis.
COPD
1
• Position patient in high Fowlers.
Encourage coughing, deep breathing, use of incentive spirometer.
Ensure proper nutrition (increased calories and protein). Teach
breathing techniques:
• Abdominal breathing: take breaths from diaphragm, lie on
back w/knees bent.
• Pursed lip breathing: breathe in through nose and out through
mouth.
Meds: Bronchodilators, anti-inflammatories, mucolytic agents
(acetylcysteine, guaifenesi n).
Com hc.ations: Right-sided heart failure. Symptoms: dependent
edema, distended neck veins, enlarged liver
Tuberculosis (TB)
TB: Infectious disease in lungs caused by Mycobacterium
tuberculosis.
S& Cough lasting> 3 weeks, night sweats, purulenU
bloody sputum, lethargy, weight loss.
DIJ nos1
• Quantiferon Gold (blood test)
• Mantoux test (skin test): Read within 48-72 hrs. lnduration
10mm = positive result (5mm for immunocompromised
patients). Those who had the BCG vaccine may get a false
positive result.
• Chest x-ray: to visualize active lesions in lungs.
• Acid-fast bacilli culture: use 3 early morning sputum samples.
Tuberculosis (TB)
Nur::,ma Care
•
•
•
Place patient on airborne precautions, in a negative air
flow room. Wear N95 mask in patient's room; have patient
wear surgical mask if they need to leave room.
Screen family members for TB.
Teach patient that sputum samples will be needed every
2-4 weeks. Patients are not infectious after 3 negative sputum
cultures.
Meds.
•
Up to 4 antibiotics are required for 6-12 months of
treatment, including: isoniazid, rifampin, pyrazinamide,
ethambutol.
RESPIRATORY SYSTEM
Pulmonary Embolism (PE)
Pulmonary Em bolism (PE)
PF· Life-threatening blockage in pulmonary vasculature, most
Sur ical Int rvu ntlon Embolectom y (removal of clot), vena cava
filter (prevents new emboli from entering pulmonary vasculature).
Nursmg care Place patient in high Fowlers position. Administer
02.
Patient le, chmg for ant1co;19ulants·
• Frequent blood draws required to monitor PT/INR levels
(therapeutic level = 2-3).
• Maintain consistent intake of vitamin K while on
warfarin.
• Encourage smoking cessation, increased mobility,
compression stockings.
• Reduce risk of bleeding (no aspirin, use electric shavers,
soft toothbrushes, avoid blowing nose).
commonly caused by a DVT.
Risk f c!Qrs: Immobility, oral contraceptives, smoking,
obesity, surgery, AFIB, long-bone fractures (fat emboli).
S&S Anxiety (feeling of impending doom), pain on inspiration,
dyspnea, pleural friction rub, tachycardia, hypotension,
tachypnea, petechiae, diaphoresis.
Dia nosis· CT scan. Labs: elevated D-dimer indicates
presence of clot.
Meds: Anticoagulants (heparin/enoxaparin, warfarin),
thrombolytic therapy (alteplase, streptokinase).
---
------
CARDIOVASCULAR SYSTEM
Cardiac Enzymes
Respiratory Emergencies
Pneumolho,a
Lung collapse due to air in the pleural space. Key
symptom: Hyperresonance w/percussion.
Ten 10n 111 umo hor
Air nters pleural space during inspiration,
but cannot exit during expiration. Key symptom: Tracheal
deviation.
Hemothor x Blood accumulates in pleural space. Key symptom:
Dull percussion.
Flail che t Chest w II expansion limited due to multiple fractured
ribs. Key symptom: Paradoxical chest wall movement.
Common 5&$ of AL I Respiratory distress, reduced/absent breath
sounds on affected side.
Treatment. 02, meds (benzodiazepines for anxiety, opioids for
pain), chest tube (for pneumothorax and hemothorax).
Cardiac Enzymes: Released in bloodstream in response
to ischemia in heart muscle. Troponin is most specific!
•
•
•
•
CK-MB: More specific to heart than CK. Should be 0%.
Elevated for 2-3 days.
Troponin T: Should be less than 0.1 ng/L. Elevated for
10-14 days.
Troponin I: Should be less than 0.03 ng/L. Elevated for
7-10 days.
Myoglobin: Can be elevated due to heart damage OR
skeletal muscle damage. Should be < 90 mcg/L.
Elevated for 24 hours.
CARDIOVASCULAR SYSTEM
CARDIOVASCULAR SYSTEM
Cholesterol levels, Hemodynamic monitoring
Coronary Angiogram
Cholesterol Levels:
• Total Cholesterol: < 200 mg/dl
• HDL (H ="Happy"):> 55 mg/dl (women),>45mg/dl(men)
• LDL (L = "Lousy"): < 130 mg/dl
• Trigylcerides: Between 35-135 mg/dl (women), between
40-160 mg/dl (men)
Hemodynamic Monitoring:
• CVP (Central Venous Pressure): 2-6 mmHg
• PAWP (Pulmonary Artery Wedge Pressure): 6-15 mmHg
• CO (Cardiac Output): 3-6 Umin
Nursing care during Arterial line insertion: Level transducer
with phlebostatic axis (4th intercostal space, midaxillary line),
zero system, confirm placement w/x-ray
Coronary Angiogram (i.e. cardiac cath): Invasive procedure
used to determine if patient has coronary artery blockages or
narrowing. Catheter inserted into femoral artery and threaded up to
heart.
• Pre-procedure: NPO 8 l1rs prior to procedure. Assess for
allergy to iodine or shellfish. Assess kidney function (BUN,
creatinine) to determine if kidneys can excrete the dye.
• Post-procedure: Check insertion site for bleeding, check
extremity distal to puncture site (pulses, capillary refill,
temperature, color). Take VS every 15min x 4, every 30 min x
2, every hour x 4. Patient lies flat in bed for 4-6 hours after
procedure.
CARDIOVASCULAR SYSTEM
Cardiac Tamponade
Cardiac tamponade: Accumulation of fluid in pericardiaI
sac.
S&S: Hypotension, muffled heart sounds, distended
jugular veins, paradoxical pulse (variance of 10 mmHg
or more in SBP between inspiration and expiration).
Diagnosis: Chest x-ray, echocardiogram
Treatment: Pericardiocentesis (removal of fluid from
pericardia! sac).
CARDIOVASCULAR SYSTEM
---
IV complications
Phlebitis:
•
S&S: erythema, pain, warmth, edema, indurated or
•
cordlike veins, red streak.
Care: Discontinue IV, warm compress
Infiltration:
•
S&S: edema, coolness, taut skin
•
Care: Discontinue IV, cool compress, elevation
Air embolism:
•
•
S&S: shortness of breath
Care: place in Trendelenburg position on left side, give
oxygen, notify provider.
CARDIOVASCULAR SYSTEM
PICC line, Implanted port
PICC: Used for long-term administration of IV antibiotics, TPN,
chemotherapy. Tip positioned in lower 1/3 of superior vena cava.
Can stay in place for up to 12 months.
Nursing care of PICC:
• Assess site every 8 hr.
• Use 10ml (or larger) syringe to flush line.
• Flush w/10ml of 0.9% NaCl before, between, and after
medications.
• Blood draws: withdrawal 10ml blood and discard, withdrawal
10ml blood for sample; flush w/20ml NaCl (or per facility
policy).
• No BP on arm with PICC line.
lmwanted port: For long-term (>= 1 yr) vascular access; common
w,t chemotherapy. Access with non-coring (Huber) needle.
CARDIOVASCULAR SYSTEM
Dysrhythmias
Bradycardia (HR< 60 bpm): If symptomatic, administer atropine.
Electrical intervention: pacemaker.
AFIB, SVT, Ventricular tach cardia with ulse: Administer anti­
arrhythmic medication (ex: amiodarone, adenosine, verapamil).
Electrical intervention: cardioversion. Nursing care for cardioversion:
• Patient must be on anticoagulation for 4-6 weeks before
cardioversion.
• Staff needs to stand clear of patient when shock is delivered.
• After procedure: assess airway, monitor VS, obtain EKG.
Monitor for S&S of dislodged clot (PE, stroke, Ml).
Ventricular tachycardia without pulse, Ventricular fibrillation:
Administer anti-arrhythmic medication (ex: amiodarone, lidocaine,
ephinephrine). Electrical intervention: Defibrillation.
CARDIOVASCULAR SYSTEM
CARDIOVASCULAR SYSTEM
Pacemakers
Pacemakers: Nursing care and patient teaching
Pacemaker: Provides electrical stimulation of heart
when natural pacemaker in heart doesn't maintain
proper rhythm. Programmed to pace atrial (A),
ventricular (V), or both chambers (AV).
Modes:
• Asynchronous: fires at constant rate regardless of
heart's electrical activity.
• Synchronous: Fires only when heart's intrinsic rate
falls below a certain rate.
Indications: Symptomatic bradycardia, heart block, sick sinus
syndrome.
Provide sling and instruct patient to minimize
shoulder movement.
Assess for hiccups, which may indicate
pacemaker is pacing the diaphragm.
Instruct patient to: carry pacemaker ID card, take
pulse daily, avoid contact sports and heavy lifting for
2 months.
Pacemaker will set off airport security detectors.
MRls are contraindicated.
OK to use garage door openers and microwave.
•
•
•
•
•
CARDIOVASCULAR SYSTEM
CARDIOVASCULAR SYSTEM
Percutaneous Coronary Intervention (PCI)
Coronary Artery Bypass Graft (CABG)
PCI: Procedure to open coronary arteries. Periormed within 3 hours
of onset of Ml symptoms. Three types:
• Artherectomy (removal of plaque in vessel)
• Placement of stents
• PTCA (inflating a balloon to widen the arterial lumen).
Nursing care: S me as coronary angiogram.
Com ications:
•
•
•
•
•
•
rlery dissection (monitor for hypotension and tachycardia)
Cardiac tamponade
Bleeding/hematoma at insertion site
Embolism
Retroperitoneal bleeding (monitor for flank pain and
hypotension)
• Restenosis of vessel (monitor for chest pain, assess EKG).
CABG: Surgery to bypass one or more coronary arteries, due to
blockages and/or persistent ischemia. Saphenous vein often
used. Patient's core temperature low red to decrease metabolic
(and oxygen) demand during proc dure.
Key nursing care:
•
•
Monitor BP: Hypertension can cause bleeding from grafts.
Hypotension can cause coll pse of graft.
Monitor chest tube: Over 150 ml/hr can indicate
hemorrhage - notify provider.
Patient teaching: Treat angina with sublingual nitroglycerin, quit
smoking, consume heart healthy diet, participate in cardiac rehab
program.
CARDIOVASCULAR SYSTEM
CARDIOVASCULAR SYSTEM
Peripheral Bypass Graft
Angina
Peri heral B ass Graft: Surgery to restore blood flow to
extremity due to periph ral artery disease (PAD).
Nursing care:
• Obtain consent, pati nt NPO for 8 hours before procedure.
• Closely monitor periph ral pulses, capillary refill, skin color,
skin temperature.
• Patient should maintain b drest for 18-24 hours after surgery,
with legs straight.
• Patient should avoid sitting for long periods of time or crossing
legs.
• Apply antiembolic stockings.
• Monitor for S&S of compartment syndrome (worsening pain,
swelling, taut skin) - fasciotomy used to relieve compartment
syndrome.
Stable angina: Occurs with exercise, relieved by rest (or
nitroglycerin).
Unstable an ina: Occurs with exercise or at rest. Increases
in duration, occurrence, or severity over time.
Variant angina: Related to coronary artery spasm, occurs
during rest.
Angina vs. Ml: Pain unrelieved by rest or nitroglycerin and
lasts more than 30 minutes is indicative of an Ml (vs.
angina). Mis (unlike angina) often have other symptoms,
such as: nausea, epigastric discomfort, diaphoresis,
dyspnea.
CARDIOVASCULAR SYSTEM
CARDIOVASCULAR SYSTEM
Myocardial Infarction (Ml)
Heart Failure
Ml risk factors: Male gender, post-menopausal women,
hypertension, smoking, hyperlipidemia, diabetes, stress, inactivity.
S&S: Anxiety, chest pain, nausea, diaphoresis, cold/clammy skin,
pallor, tachycardia.
Labs: Elevated carcliac enzymes (CK-MB, Tropinin I, Troponin T,
myoglobin).
EKG changes: ST depression or elevation, T wave inversion,
abnormal Q wave.
Medications: Nitroglycerin, analgesics, beta blockers, thrombolytic
meds, antiplatelet meds, anticoagulants.
Complications: Heart failure, cardiogenic shock (symptoms:
tachycardia, hypotension, decreased urinary output, altered LOC,
respiratory, decreased peripheral pulses, chest pain).
Heart Failure: Heart muscle does not pump effectively, resulting
in decreased cardiac output.
• Left-sided HF: Results in pulmonary congestion (pulmonary
edema). Key symptoms: dyspnea, crackles, orthopnea,
fatigue, pink/frothy sputum.
• Right-sided HF: Results in systemic congestion. Key symptoms
jugular vein distention, peripheral edema, ascites,
hepatomegaly.
Labs: hBNP elevated (>100 pg/ml)
ffiagnosis:
• Hemodynamic monitoring: Increased CVP, PAWP; decreased CO
• Echocardiogram: Reduced ejection fraction (Normal: Left
55-70%, Right 45-60%)
CARDIOVASCULAR SYSTEM
CARDIOVASCULAR SYSTEM
Heart Failure
Valvular Heart Disease
2 Types of Valvular Heart Disease:
Nursing care for HF:
• Monitor daily weight, l&Os
• Position patient in high-Fowlers
• Administer 02
• Restricted fluid and sodium intake
Medications for HF:
• Diuretics
• Afterload-reducing meds (ACE inhibitors, angiotensin II
receptor blockers, calcium channel blockers)
• lnotropic agents (Digoxin)
• Beta Blocker·s
• Vasodilators (Nitroglycerin)
• Human 8-type natriuretic peptides (hBNP)
• Anticoagulants
CARDIOVASCULAR SYSTEM
Valvular Heart Disease
Meds for Valvular Heart Disease:
• Diuretics
• Afterload-reducing meds (ACE inhibitors, angiotensin II
receptor blockers, beta blockers, calcium channel blockers)
• lnotropic agents (Digoxin)
• Anticoagulants
Surgical Interventions:
• Percutaneous ballon valvuloplasty - opens valves that have
stenosis
• Valve repair or replace w/prosthetic valve
Patient teaching: Prophylactic antibiotics need to be taken
before dental work, surgery, or other invasive procedures.
•
•
Stenosis: narrowed opening
Insufficiency: regurgitation of blood
Key risk factors:
•
•
•
•
Hypertension
Rheumatic fever/disease r/t streptococcal infections
Infective endocarditis r/t streptococcal infections
Older age (causes fibrotic thickening)
Symptoms: Murmurs, extra heart sounds, arrhythmias,
dyspnea w/mitral stenosis or insufficiency.
Diagnosis: Chest x-ray, EKG, echocardiogram
I
CARDIOVASCULAR SYSTEM
Inflammatory Heart Disorders
Pericarditis: Inflammation of pericardium.
• Key symptoms: chest pain (relieved by sitting up and leaning
forward), friction rub, shortn ss of breath.
Rheumatic endocarditis: Infection of endocardium due to upper
respiratory infection from group A beta-hemolytic streptococcal
bacteria. Causes lesions to form on heart.
• Key symptoms: murmur, fever, chest pain, joint pain, rash,
shortness of breath, friction rub, tachycardia.
Infective endocarditis: Infection of endocardium due to
streptococcal bacteria. Common w/lV drug users.
• Key symptoms: fever, flulike symptoms, murmur, petechiae,
red streaks under nailbeds (splinter hemorrhages)
CARDIOVASCULAR SYSTEM
Inflammatory Heart Diseases
Lab tests:
• Increased WBC
• Positive blood culture
• Elevated ESR and CRP (due to inflammation)
• Throat culture positive for streptococcal
infection.
Meds: Antibotics (for infection), NSAIDs (for fever,
inflammation), prednisone (for inflammation)
Complications: Cardiac tamponade
CARDIOVASCULAR SYSTEM
Peripheral Arterial Disease (PAD)
Patient teaching with PAD:
•
•
•
•
Walk until point of pain, stop and rest, then walk a little more.
Avoid crossing legs and restrictive garments
Maintain warm environment, wear insulated socks
Avoid cold, stress, caffeine, nicotine - which can lead to
vasoconstriction.
Meds: Antiplatelet medications (aspirin, clopidogrel) to reduce blood
viscosity, statins.
Surgeries: Angioplasty (balloon, stent), peripheral bypass graft.
Complications: Graft occlusion (sx: reduced pedal pulses,
increased pain, pallor, cold), compartment syndrome (sx: numbness,
pain w/passive movement, edema).
CARDIOVASCULAR SYSTEM
Peripheral Arterial Disease (PAD)
PAD: Inadequate blood flow to lower extremities due to
artherosclerosis.
Risk factors: hypertension, diabetes, smoking, obesity,
hyperlipidemia.
Symptoms:
• Pain in legs during exercise (relieved by placing legs in
dependent position - i.e. dangling them)
• Decreased capillary refill of toes
• Decreased pedal pulses
• Lack of hair on calves
• Thick toenails
• Pallor w/elevation, dependent rubor
• Ulcers/gangrene on toes
CARDIOVASCULAR SYSTEM
Peripheral Venous Disorder
Peripheral Venous Disorder: Issue with adequate
blood return from the extremities. 3 kinds:
(1) Venous thromboembolism (VTE): Blood clot.
(2) Venous insufficiency: Caused by incompetent
valves in the deeper veins. This can lead to swelling,
venous ulcers, and cellulitis.
(3) Varicose veins: Enlarged superficial veins.
CARDIOVASCULAR SYSTEM
CARDIOVASCULAR SYSTEM
Venous thromboembolism
Venous insufficiency
Risk factors: Virchow's triad (impaired blood flow,
hypercoagulability, endothelial injury), hip and knee
replacement surgery, heart failure, immobility, pregnancy, oral
contraceptives
Symptoms: Calf/groin pain, edema in extremity, warmth/
hardness over blood vessel, shortness of breath (PE).
Diagnosis: Positive d-dimer, venous duplex ultrasonography.
Nursing care: Elevation of extremity (no pillow or knee gatch
under knees), warm/moist compresses, NO massaging limb,
compression stockings, watch for S&S of pulmonary
embolism (PE)
Meds: anticoagulants, thrombolytics
Risk factors: Sitting/standing in one place for a long
time, obesity, pregnancy
Symptoms: Aching pain and feeling of heaviness in
legs, brown discoloration of legs (stasis dermatitis),
BLE edema, venous stasis ulcers (usually around
ankles).
Nursing care: Elevate legs, avoid crossing legs or
restrictive clothing, compression stockings (apply in
morning when swelling is reduced).
CARDIOVASCULAR SYSTEM
CARDIOVASCULAR SYSTEM
Varicose veins
Hypertension
Varicose vein risk factors: Female, jobs that
require prolonged standing, pregnancy, obesity,
family history
Symptoms: Distended/tortuous veins just below
the skin surface, aching, pruritis.
Therapeutic procedures: Sclerotherapy (chemical
solution is injected into varicose vein to close off
the vein), vein-stripping, laser treatment, radio
frequency.
Primary hypertension: No known cause.
Secondary hypertension: Caused by disease or
medications.
Risk factors:
• Primary: family history, excess sodium intake,
inactivity, obesity, smoking, stress, hyperlipidemia,
race (African American).
• Secondary: Kidney disease, Cushing's syndrome,
pheochromocytoma
Symptoms: Headache, dizziness, visual issues;
OR patients may not have ANY symptoms
CARDIOVASCULAR SYSTEM
Hypertension
BP levels·
• Prehypertension: SBP 120-139; DBP 80-89
• Stage I: SBP 140-159; DBP 90-99
• Stage II: SBP >=160; DBP >= 100
• Hypertensive crisis: SBP >240; DBP >120
·Meds: Diuretics, calcium channel blockers, ACE inhibitors,
angiotensin II receptor antagonists, aldosterone receptor
antagonists, beta blockers.
Patient teaching: Take BP regularly, limit alcohol intake, DASH diet
(HIGH in fruits, veggies, low-fat dairy; LOW in salt and fat), reduce
weight, reduce stress, stop smoking.
Complications: Hypertensive crisis (symptoms: severe headache,
blurred vision).
CARDIOVASCULAR SYSTEM
Hemodynamic shock
Symptoms: Hypoxia, tachypnea, hypotension, tachycardia,
weak pulses, decreased urine output; wheezing, angioedema,
rash with anaphylactic shock.
Labs: Increased serum lactic acid, abnormal ABGs,
increased cardiac enzymes w/cardiogenic shock, decreased
Hct/Hgb w/hypovolemic shock, positive blood cultures with
septic shock.
Nursing care: Administer 02, prepare for intubation, place
patient flat w/legs elevated for hypotension.
Meds: Dobutamine, vasopressin, epinephrine, colloids for
hypovolemic shock (replace volume first), antibiotics for
septic shock.
Complications: MODS, DIC
CARDIOVASCULAR SYSTEM
Types of Hemodynamic shock
Cardiogenic: Cardiac pump failure due to heart failure,
Ml, dysrhythmias.
Hypovolemic: Blood loss due to trauma, surgery, burns or
fluid loss due to GI losses, diuresis.
Obstructive: Blockage of great vessels (ex: PE, tension
pneumothorax, cardiac tamponade)
Distributive: Extreme vasodilation. Three kinds:
• Septic: Endotoxins in bloodstream from infection (most
commonly gram negative bacteria)
• Neurogenic: Loss of sympathetic tone due to trauma or
spinal shock.
• Anaphylactic: Antigen-antibody reaction due to
exposure to allergens.
CARDIOVASCULAR SYSTEM
Aneurysms
Aneurysm: Widening or ballooning in the wall of a blood
vessel.
AAA: Flank/back pain, pulsating abdominal mass
Aortic dissection: Feeling of "ripping" or "stabbing" in
abdomen or back. Symptoms of hypovolemic shock
(hypotension, tachycardia, decreased pulses, n/v,
diaphoresis).
Thoracic aortic aneurysm: Severe back pain, shortness
of breath, difficulty swallowing, cough.
Nursing care: Reduce SBP to 100-120 mmHg, administer
antihypertensives. Monitor VS, cardiac rhythm, ABGs, urine
output (report output less than 30ml/hr).
•••
HEMATOLOGIC SYSTEM
i b o------------od
--·
4-6 million/ul (approximately)
5,000 - 10,000 /mm3
150,000 - 400,000 mm3
12-18 g/dl (approximately)
37-52% (approximately 3 times the Hgb)
11-12.5 seconds
30-40 seconds (therapeutic range is 1.5-2.5
times this amount while on heparin).
0.8 - 1.1 (therapeutic range is 2-3 while on
warfarin)
a•
Stop transfusion, infuse 0.9% NaCl through
separate line. Send blood bag to lab.
t
,
1
Low back pain, fever/chills, tachycardia,
hypotension, tachypnea.
f
r
Fever/chills, hypotension, tachycardia.
• Administer antipyretics
Mile I
Itching, flushing, hives (urticaria).
• Administer diphenhydramine.
An >n c K Wheezing, dyspnea, cyanosis, hypotension.
( in ul ,
c v I J d Dyspnea, tachycardia, tachypnea, crackles,
hypertension, jugular vein distension
• Slow infusion rate, administer diuretics.
ions
Can receive type A and 0
Can receive type B and 0
ilE.£
Can receive type A, B, AB, and 0
l Can receive type 0
n1 1 1b llt If a Rh-negative person receives Rhpositive blood, it will cause hemolysis.
I , J r n
1
• Use 20 gauge or bigger IV catheter.
• Confirm patient ID, blood compatibility, expiration
time with another RN.
• Prime administration set w/0.9% NaCl ONLY.
HEMATOLOGIC SYSTEM
HEMATOLOGIC SYSTEM
lion
nr
t
1
'l
mi
•
•
•
•
•
•
Blood loss: Trauma, GI bleed, menorrhagia.
Sickle cell anemia: Defective Hgb, malformed RBCs.
Iron deficient anemia: Most common type of anemia in
children and pregnant women. Provide iron
supplements: ferrous sulfate, iron dextran.
Pernicious anemia: Lack of intrinsic factor in gastric
mucosa, which prevents absorption of 812. Administer
cyanocobalamin (812) parenterally or intranasally.
Felic acid deficiency: Provide folic acid orally or
parenterally. Note: large doses of folic acid can mask
812 deficiency.
Bone marrow suppression
HEMATOLOGIC SYSTEM
Co
ul tion D"
rd r
III
Autoimmune disorder, where lifespan of platelets is
decreased, increasing risk of hemorrhage.
r Clotting factors are depleted through formation of thousands
of micro-clots in the body. These clots cause ischemia, and lack of
clotting factors cause increased risk of bleeding.
,
Bleeding from gums/nose, oozing/trickling of blood
from incisions, pet chiae, tachycardia, hypotension
Administer blood, platelets, clotting factors.
Administer 02, fluid volume replacement. Implement bleeding
precautions, injury prevention
M.e!. . z.;.
•
•
ITP: corticosteroids, immunosuppressants
DIC: anticoagulants (heparin)
GI losses, diuretics, hemorrhage, diaphoresis, diabetes
insipidus, kidney disease, hyperventilation
Tachycardia, tachypnea, hypotension, weak pulse,
fatigue, weakness, thirst, dry mucus membranes, GI upset, oliguria,
decreased skin turgor, decreased capillary refill, diaphoresis,
flattened neck veins.
Increased Hct, serum osmolarity, urine specific gravity,
BUN, serum sodium.
Fluid replacement, monitor weight and l&Os, notify
provider for urine output< 30ml/hr., implement fall precautions.
Hypovolemic shock. Administer02, colloids,
crystalloids, vasoconstrictors.
F"LUIO ELECTROLYTE AC101BASE IMBALANCES
Heart failure, steroid use, kidney dysfunction,
cirrhosis, burns, excess sodium intake.
Tachycardia, tachypnea, hypertension, bounding
pulses, weight gain, edema, ascites, dyspnea, crackles,
distended neck veins.
Decreased Hct and Hgb, serum osmolarity, urine
osmolarity, urine specific gravity, BUN.
Place patient in semi or high Fowler's position,
monitor weight daily, monitor l&Os, limit fluid and sodium
intake, administer diuretics and oxygen as ordered.
Pulmonary edema.
Maintains fluid balance in body, nerve and muscle function.
• Causes: GI losses, diuretics, kidney disease, skin losses, SIADH,
hyperglycemia, heart failure.
• Symptoms: Tachycardia, hypotension, confusion (common in elderly!),
fatigue, n/v, headache.
• Care: Administer isotonic (0.9% NaCl), increase sodium intake. For
acule hyponatremia, administer hyperlonic (3% NaCl) IV fluids slowly.
• Causes: Water deprivation, excess sodium intake, kidney failure,
Cushing's syndrome, Diabetes insipidus, burns, excess sweating.
• Symptoms: Tachycardia, muscle twitching/weakness, GI upset.
• Care: Administer isotonic (0.9% NaCl) or hypotonic IV (0.45% NaCl) IV
fluids, decrease sodium intake, increase water intake.
FL\JtO ELECTROLYTE ACID"BASE IMBALANCES
FLUID. ELECTROLYTE ACIDiBASE IMBALANCES
Maintains ICF (intracellular fluid balance),
nerve function, regulates muscle and heart contractions.
•
•
Causes: GI losses, diuretics, skin losses, metabolic alkalosis.
Symptoms: Dysrhythmias, muscle weakness and cramps,
constipation/ileus, hypotension, weak pulse.
• Care: Increase foods high in potassium, administer supplements (PO,
IV), cardiac monitoring.
•
Causes: Uncontrolled diabetes (OKA), metabolic acidosis, salt
substitutes, kidney failure, potassium-sparing diuretics (spirinolactone).
• Symptoms: Dysrhythmias, muscle weakness, numbness/tingling,
diarrhea.
• Care: Limit foods high in potassium. Administer loop diuretics, sodium
polystyrene sulfonate (Kayexalate), insulin (with dextrose).
•
Bone/teeth formation, nerve and muscle function, clotting.
•
•
•
•
•
Causes: Vitamin D deficiency, hypoparathyroidism,
hyperphosphatemia, pancreatitis.
Symptoms Positive Chvostek's and Trousseau's signs, muscle
spasms, numbness/tingling in lips/fingers, GI upset, hypotension,
decreased heart rate.
Care: Increase foods high in calcium, provide supplements.
Causes: Hyperparathyroidism, long-term steroid use, bone cancer.
Symptoms: Constipation, decreased deep tendon reflexes, kidney
stones, lethargy
►LUID
ELECTROLYTE ACIO-'BASE IMBALANCES
A
Nerve and muscle function, bone formation. Critical for
many biochemical reactions in body.
•
•
•
•
•
Causes: GI losses, diuretics, malnutrition, alcohol abuse.
Symptoms: Hyperactive deep tendon reflexes, tetany, seizures,
constipation/ileus.
Care: Increase foods high in magnesium, provide supplements
(oral Mg can cause diarrhea!).
Causes: Kidney disease, laxatives containing magnesium.
Symptoms: Hypotension, muscle weakness, lethargy,
respiratory and cardiac arrest.
First line of defense. Bind or release
hydrogen ions to quickly change pH.
Second line of defense. Chemoreceptors
sense change in CO2, send signal to brain to adjust respirations.
• Increased CO2 results in increased rate and depth of
respirations (reduces the number of hydrogen ions).
• Decreased CO2 results in decreased rate and depth of
respirations (increases the number of hydrogen ions).
Third line of defense. Slower to respond, but has
longest duration.
• Kidneys reabsorb and produce more bicarbonate in response
to high levels of hydrogen ions.
• Kidneys excrete more bicarbonate in response to low levels of
hydrogen ions.
FLUID ELECTROLYTE, ACID18ASE IMBALANCES
A 1d B
lmb Ian
•
Acid B
lmbal nee
Causes: □KA, kidney failure, diarrhea, pancreas/liver failure.
Labs: pH < 7.35, HC03 < 22
Symptoms: Bradycardia, hypotension, weak pulses,
dysrhythmias, Kussmaul respirations (deep, rapid breathing),
warm/flushed skin,
Care: Administer insulin for DKA, sodium bicarbonate.
Causes: respiratory depression, inadequate chest
expansion, airway obstruction, PE, pulmonary edema.
• Labs: pH< 7.35 and PaC02 > 45
• Symptoms: Tachycardia, tachypnea, shallow breathing,
pale/cyanotic skin, confusion
• Care: Administer 02, broncl1odilators
•
•
•
• Causes: hyperventilation (r/t fear, anxiety, salicylate toxicity)
• Labs: pH> 7.45 and PaC02 < 35
• Symptoms: Tachypnea, deep and rapid breathing, anxiety,
chest pain, dysrhythmias.
• Care: Reduce anxiety
• Causes: Antacid overdose, GI losses (vomiting, NG
suctioning)
• Labs: pH> 7.45, HC03 > 26
• Symptoms: Tachycardia, dysrhythmias, muscle weakness.
• Care: Administer antiemetics for vomiting.
GASTROINTESTINAL SYSTEM
Expected ranges in blood
AST: 0 - 35 units/L
ALT: 4 -36 units/L
Amylase: 30 - 220 IU/L
Lipase: < 160 units/L
Bilirubin: < 1.0 mg/dl
Albumin: 3.5 - 5.0 g/dl
Ammonia: 10 - 80 mcg/dl
•
GASTROINTESTINAL SYSTEM
Endoscopy procedures
Colonoscopy: Allows visualization of anus, rectum,
sigmoid, descending, transverse, and ascending colon.
Done under moderate sedation.
• Bowel prep: polyethylene glycol, clear liquid diet, NPO
after midnight.
EGO:Allows visualization of esophagus, stomach, and
duodenum. Done under moderate sedation.
• Prep: NPO 6-8 hours before procedure.
Siqmoidoscopy: Allows visualization of anus, rectum, and
sigmoid colon. No anesthesia required.
• Bowel prep: polyethylene glycol, clear liquid diet, NPO
after midnight.
GASTROINTESTINAL SYSTEM
GASTROINTESTINAL SYSTEM
I
GI Series
GI series: Identifies GI abnormalities (ulcers,
tumors, obstructions). Patient drinks barium, x-rays
taken as barium moves through GI tract.
• Prep: Clear liquid diet, NPO after midnight, no
smoking or chewing gum.
• Patient teaching: Increase fluid intake to flush out
barium. Stools will be white for 24-72 hours after
procedure until barium is cleared.
Total Parenteral Nutrition (TPN)
Indications: Malabsorption, hypermetabolic state,
chronic malnutrition, prolonged NPO.
Administration: Through central line (ex: PICC line)
Nursing care:
• Gradually increase/decrease flow rate
• Change tubing and bag every 24 hours
• Use micron filter on tubing.
• Monitor l&Os, daily weights, electrolyte levels, blood glucose
(every 4-6 hrs for first 24 hrs)
• If the next TPN bag is unavailable, administer 10%
dextrose in water until in arrives.
• Do not use TPN line for other fluids or meds!
• Monitor central line insertion site for S&S of infection
(erythema, pain, exudate).
GASTROINTESTINAL SYSTEM
GASTROINTESTINAL SYSTEM
Bariatric Surgery
Paracentesis
Paracentesjs: Insertion of needle through abdominal wall to
remove fluid from peritoneal cavity.
lndjcatjons; Ascites (usually r/t cirrhosis) with respiratory
distress.
Nursing care;
• Have patient sign consent form, void before procedure.
• Take VS, weight, abdominal girth circumference before
and after procedure.
• Monitor for hypovolemia (peritoneal fluid removed is
high in protein, causing a fluid shift). Administer albumin
as prescribed.
Indications: Morbid obesity
Nursing care:
•
Eat only nutrient dense foods. Avoid milk, sweets, high
sugar foods.
• Eat 6 small meals a day (vs. larger meals).
• Allow for 30-60 minutes to eat. Chew foods thoroughly
and slowly.
• Do not consume liquids with meals. Restrict fluids to
30ml at a time initially.
• Watching for symptoms of dumping syndrome:
abdominal cramping, nausea, diarrhea, diaphoresis,
tachycardia, hypotension
GASTROINTESTINAL SYSTEM
GASTROINTESTINAL SYSTEM
Nasogastric (NG) tubes
NG tube Indications: Intestinal obstruction
(symptoms: vomiting, abnormal bowel sounds,
abdominal pain and distention).
Nursing care:
• Assess bowel sounds, abdominal girth.
• Monitor NG tube for displacement.
• Assess nasal mucosa for breakdown. Provide oral
care.
• Monitor l&Os, electrolytes.
• Encourage ambulation to increase peristalsis.
Ostomies
Ostomies: Performed when part of bowel must be
removed due to disease/injury. lleostomy creates an
opening into the ileum; colostomy creates an opening into
the large intestine.
Nursing care:
• Inspect stoma - should be pink and moist. Pale pink or
blue/purple indicates ischemia.
• Empty ostomy bag when it is 1/4-1/2 full.
• Patient can use breath mint in pouch to decrease odor.
• Teach patient to avoid foods that cause gas and odor.
• Cut opening in skin barrier <= 1/8 inch larger than stoma
(no bigger!).
GASTROINTESTINAL SYSTEM
Gastroesophageal reflux disease (GERO)
GERD: Gastric contents (including enzymes) backflow into
esophagus causing pain and mucosal damage (esophagitis,
Barrett's epithelium).
Risk factors: Obesity, smoking, alcohol use, older age,
pregnancy, ascites, hiatal hernia, supine position, diet high in
fatty/fried/spicy foods, caffeine, citrus fruits.
Symptoms:
• Dyspepsia (indigestion)
• Throat irritation, bitter taste
• Burning pain in esophagus. Pain worsens when laying
down, improves with sitting upright.
• Chronic cough
GASTROINTESTINAL SYSTEM
Gastroesophageal reflux disease (GERD)
Meds:
•
•
•
•
Antacids (take 1-3 hours after eating, 1 hr before/after meds)
H2 receptor antagonists (ex: ranitidine).
Proton Pump Inhibitors (ex: panloprazole)
Prokinetics (ex: metoclopramide: accelerates gastric emptying,
watch for symptoms of EPS).
Surgery: Fundoplication (fundus of stomach is wrapped around
esophagus).
Patient education:
• Avoid fatty/fried/spicy foods
• Eat smaller meals
• Remain upright after meals
• Avoid tight-fitting clothing
• Lose weight
• Elevate HOB 6-8" with blocks
GASTROINTESTINAL SYSTEM
GASTROINTESTINAL SYSTEM
Esophageal Varices
Peptic Ulcer Disease
Esophageal Varices: Swollen/fragile blood vessels in
esophagus that can hemorrhage (life-threatening!).
Risk factors: Portal hypertension (increased BP in veins
from intestines to liver) due to cirrhosis, hepatitis.
Signs/symptoms: Elevated liver enzymes (AST, ALT). With
bleeding: hypotension, tachycardia, decreased Hct/Hgb.
Meds: Nonselective beta blockers (ex: propranolol),
vasci'constrictors (ex: vasopressin).
Procedures: Sclerotherapy, variceal band ligation,
transjugular shunt, esophagogastric balloon tamponade.
(compresses blood vessels in espophagus and stomach),
bypass.
GASTROINTESTINAL SYSTEM
Peptic Ulcer Disease
•
MULTIPLE antibiotics to prevent resistance (metronidazole,
amoxicillin, clarithromycin, tetracycline)
• H2 receptor antagonist (ex: ranitidine)
• PPI (ex: pantoprazole)
• Antacids (take 1-3 hrs after meals, 1 hr apart from other meds)
• Mucosal protectant (ex: sucralfate, given 1 hr before meals
and at bedtime).
patjent teachjng: Avoid acid-producing foods (milk, caffeine, spicy
foods), avoid NSAIDs.
compljcatjons: Perforation (resulting in hemorrhaging):
Symptoms include severe epigastric pain, rigid/board-like
abdomen, rebound tenderness, hypotension, tachycardia.
Peptic Ulcer Disease: Erosion in the stomach,
esophagus or duodenum mucosa.
Risk factors: H. pylori infection, NSAID use, stress.
Signs/symptoms: N/V, heartburn, bloating, bloody
emesis or stools, pain:
•
Gastric ulcer: pain 30-60 min after meal, worse
in DAY, worse w/eating
Duodenal ulcer: pain 1.5-3 hrs after meal, worse
in NIGHT, better w/eating or antacids.
Diagnosis: Esophagogastroduodenoscopy (EGO)
•
GASTROINTESTINAL SYSTEM
Irritable Bowel Syndrome (IBS)
An intestinal disorder causing abdominal pain, gas,
diarrhea, and constipation.
Patjent teachjng;Avoid dairy, eggs, wheat products,
alcohol, caffeine. Increase fiber intake (30-40 g/day) and
fluid intake (2-3 L/day). Keep diary of food intake and
bowel patterns.
Meds:
• Alosetron: For IBS with diarrhea (side effect is
constipation).
• Lubiprostone: For IBS with constipation (side
effect is diarrhea).
GASTROINTESTINAL SYSTEM
GASTROINTESTINAL SYSTEM
Intestinal Obstruction
Inflammatory Bowel Disease
Mechanical obstruction causes: adhesions from surgery (most
common), tumors, d1vert1culit1s, fecal impactions.
Non-mechanical obstruction i.e. aral tic ileus causes:
neurogenic 1sor er, vascu ar 1sor er, e ectro yte 1m a ance,
inflammation.
Symptoms:
•
•
•
Both: abdominal distention, obstipation, abdominal pain, high pitched
bowel sounds above obstruction, hypoactive bowel sounds below
obstruction.
Small bowel only: projectile vomiting w/fecal odor, severe F&E
imbalances, metabolic alkalosis.
Large bowel only: diarrhea or ribbon-like stools around impaction.
Nursing care: NPO, place NG tube, administer IV fluids and
electrolytes
Surgery: colon resection, colostomy, lysis of adhesions.
Ulcerative Colitis: Inflammation of the colon, causing
continuous lesions.
•
Symptoms: LLQ pain, fever, 15-20 liquid stools/day,
abdominal distention and pain, mucus/blood/pus in stools.
Crohn's Disease: Inflammation and ulceration of the
small intestine, causing sporadic lesions. Risk of fistulas.
• Symptoms: RLQ pain, fever, 5 loose stools/day, mucus/pus
in stools, abdominal distention and pain, steatorrhea.
Diverticulitis: Inflammation of diverticula (small pouches in
the colon). Can perforate and cause peritonitis.
• Symptoms: LLQ pain, n/v, fever, chills
GASTROINTESTINAL SYSTEM
GASTROINTESTINAL SYSTEM
Ulcerative Colitis and Crohn's Disease
Diverticulitis
Labs: Decreased Hct/Hbg and albumin. Increased ESR, CRP,
WBC.
Risk factors: Genetics, Caucasians, Jewish descent, stress,
autoimmune disorders.
Meds: 5-aminosalicylic acid (ex: sulfasalazine), corticosteroids
(ex: prednisone), immunosuppressants (ex: cyclosporine),
antidiarrheals (ex: loperamide).
Nursing care:
• Monitor for signs of peritonitis (symptoms: n/v, rigid/boardlike
abdomen, rebound tenderness, fever, tachycardia).
• Monitor l&Os, electrolytes (risk of hypokalemia).
• Diet: NPO during exacerbations. Ongoing, eat foods high in
protein and calories, low in fiber. Avoid caffeine, alcohol. Eat
small frequent meals.
Labs: Decreased Hct/Hbg, Increased WBC
Meds: Antibiotics (ex: Metronidazole), analgesics
Nursing care:
• Diet: NPO or clear liquid diet during exacerbations,
then progress to low-fiber diet. Ongoing, eat high­
fiber diet. Avoid seeds, nuts, popcorn.
• Monitor for signs of peritonitis (symptoms: n/v,
rigid/boardlike abdomen, rebound tenderness,
fever, tachycardia).
GASTROINTESTINAL SYSTEM
GASTROINTESTINAL SYSTEM
Cholecystitis
Cholecystectomy
Cholecystjtjs: Inflammation of gallbladder. It is usually caused by
cholelithiasis (i.e. gallstones). These gallstones block the cystic or
common bile ducts and cause bile to back up into the gallbladder
Risk factors: Female, high-fat diet, obesity, genetics, older age.
Symptoms: RUQ pain (possibl radiation to right shoulder), pain
and n/v with ingestion of high-fat food, jaundice, clay-colored stools,
steatorrhea, dark urine, pruritis, dyspepsia, gas.
Increased WBC, bilirubin (if bile duct blocked), amylase and
lipase (if pancreas is involved), AST and ALP (if common bile duct
blocked),
lnteryentjons: Lithotr•ipsy (to break up gallstones), cholecystectomy
(removal of gallbladder)
Cholecystectomy: Removal of gallbladder. If done via
laparoscopic approach, shoulder pain is expected (encourage
ambulation to reduce free air pain). If done via open approach, T­
tube may be placed in bile duct. Nursing care ofT-tube:
•
Record drainage. > 400ml expected in first 24 hours, then will
gradually decrease. Drainage> 1,000ml/day needs to be reported.
• Empty drainage bag every B hours.
• Clamp tube for 1-2 hours to assess for tolerance to eating prior to
removal.
• After removal, stools should return to brown color in about 1 week.
Patient teaching: Low fat diet, avoid gas-causing foods, lose
weight.
Complications: Pancreatitis, peritonitis r/t rupture of gallbladder.
GASTROINTESTINAL SYSTEM
GASTROINTESTINAL SYSTEM
Pancreatitis
Pancreatitis
Pancreatjtjs: Autodigestion of the pancreas by pancreatic
digestive enzymes that are prematurely activated before
reaching the intestines.
Rjsk factors; Bile tract disease, alcohol abuse, GI surgery,
trauma, medication toxicity.
Sjgns/Symptoms: Severe LUQ or epigastric pain (radiating
to the back or left shoulder), n/v, Turner's sign (ecchymoses
on flanks), Cullen's sign (blue/grey discoloration around
umbilicus), jaundice, ascites, tetany.
Increased amylase, lipase, WBC, bilirubin,
glucose. Decreased calcium, magnesium, platelets.
Nursing care: NPO, NG tube, antiemetics, insulin, IV
fluids and electrolytes, opioid analgesics, pancreatic
enzymes (pancrelipase) with meals/snacks. Progress to
bland/low-fat diet.
Patient teaching: No alcohol consumption, encourage
Alcoholics Anonymous (AA), no smoking, reduce stress.
Complications: Chronic pancreatitis, pancreatic
pseudocyst, type 1 Diabetes.
GASTROINTESTINAL SYSTEM
GASTROINTESTINAL SYSTEM
Hepatitis
Routes of transmission
•
•
•
Hep A: fecal/oral
Hep B: blood/body fluids
Hep C: blood/body fluids
Risk factors: IV drug use, body piercing, tattoos,
unprotected sex, travel to underdeveloped countries,
crowded living environments.
Symptoms: Flu-like symptoms, fever, jaundice,
dark-colored urine, clay-colored stools.
Labs: Increased ALT, AST, bilirubin.
Cirrhosis
Cjrrhosis:Normal liver tissue is replaced with fibrotic scar
tissue.
• Postnecrotic: Due to viral hepatitis, toxins, or medications.
• Laennec's: Due to chronic alcoholism.
• Biliary: Due to chronic biliary obstruction.
S&S: Jaundice, ascities, petechiae, spider angiomas,
palmar erythema, pruritis (itching), confusion, fatigue, GI
bleeding, asterixis, fetor hepaticus (fruity breath), peripheral
edema.
Labs:
---:-Tncreased ALT, AST, bilirubin, ammonia levels.
• Decreased serum protein, albumin, RBC, Hbg, Hct, platelets.
GASTROINTESTINAL SYSTEM
GASTROINTESTINAL SYSTEM
Cirrhosis
Cirrhosis
Diagnosis: Liver biopsy (most definitive!), ultrasound,
CT, MRI
Nursing care:
•
•
•
•
•
•
Strict l&Os, restrict fluids and sodium as ordered.
Elevate HOB to help w/breathing.
Diet: high carb, moderate fat, high protein, low
sodium diet. Vitamin/mineral supplements. Several
small meals vs. fewer big meals.
Measure abdominal girth daily (over largest part)
Wash skin w/cold water and apply lotion to reduce
itching.
Encourage alcohol recovery program'
Meds: Lactulose to remove excess ammonia
through stool (monitor for hypokalemia!),
diuretics
Procedures:
•
•
Paracentesis: Void before procedure! Supine
position w/HOB elevated. Assess extracted fluid
(color, amount).
Liver transplant
Complications: Encephalopathy (reduce
ammonia levels w/lactulose!), esophageal varices.
RENAL SYSTEM
RENAL SYSTEM
Creatinine, BUN, Urinalysis, Cystography/Urography
Hemodialysis
Creatinme: 0.6-1.2 mg/dl. Elevated levels indicate kidney
Isease more definitive than BUN).
BUN (Blood urea nitrogen): 10-20 mg/dL. Elevated levels may
Hemodialysis; Eliminates excess fluid, electrolytes, and
waste products from the body. Used in patients with acute or
chronic kidney disease. Usually done 3 times a week.
r ·o
!.@.. Ensure patent vascular access (check for
iiia1cate kidney disease or dehydration.
bruit, thrill, distal pulses). Assess vital signs, lab values,
Urinalysis: Specific gravity should be between 1.01-1.025. No
glucose, protein, ketones, leukocyte esterase, or nitrites should be
weight.
found in urine.
lntraprocedure, Monitor for hypotension, cramping, n/v,
Cystography/Urography:
bleeding. Administer anticoagulants to prevent clots as
• Check for allergies to iodine, shellfish.
ordered (administer protamine sulfate to reverse heparin if
• NPO after midnight, bowel preparation night before procedure. needed}.
• Encourage increased fluid intake after procedure. Pink tinged P s roc;edute Decreased BP and lab values expected.
urine expected.
Compare weight to before procedure to estimate fluid
• Monitor for signs of infection: cloudy or foul smelling urine,
urinary urgency, urinalysis positive for leukoesterase, nitrites. removed (1L fluid= 1kg).
•
RENAL SYSTEM
ri on
I
•
t n I
Installation and dwelling of hypertonic
dialysate solution in the peritoneal cavity to remove waste
products. Alternative to hemodialysis for: older adults,
intolerance to anticoagulants, vascular access difficulties.
Pr r e; ur Assess weight. Warm dialysate solution. Use
sterile technique when accessing catheter insertion site.
Increase protein intake after di lysis, as protein is lost
with each exchange.
Avoid carrying items with arm with access site.
Don't sleep on arm with access site.
Perform hand exercises to mature fistula.
•
•
•
Cm
1
• Disequilibrium syndrome (symptoms: n/v, decreased
LOC, seizures) due to increased ICP. Slow dialysis
exchange rate!
• Hypotension. Administer IV fluids or colloids as ordered.
Slow exchange rate. Lower HOB
RENAL SYSTEM
· ly i
lntr
•
•
•
pro d1
Compare inflow vs. outflow of dialysate.
Keep outflow lower than patient's abdomen.
Monitor color of outflow - should be clear, light yellow.
Bloody, cloudy outflow indicates possible infection!
RENAL SYSTEM
I
i n y Tr n
101
•
•
•
•
Peritonitis (sx: fever, purulent drainage, erythema,
swelling, discolored dialysate)
Protein loss (increase protein in diet)
Hyperglycemia (administer insulin as needed)
Poor inflow/outflow (check for kinks in tubing,
address constipation, reposition patient, milk
tubing to break up clots).
immunosuppr s nt therapy as ord red.
o I
•
•
•
r
Monitor urine output - Report urine output < 30 ml/hr!
Perform bladd r irrigation
rd r d.
Monitor for infection (symptoms: fev r, rythem , lncisional
drainage).
• Monitor for organ r j ctlon (symptom : f v r, hyp rt nsion,
pain at site). Typ s:
;.. Hyperacute (within 48 hours of urgery)
,.. Acute (within 1 week - 2 years)
;.. Chronic (occurs gradually)
ff Jr.him Low-fat, high-fiber, high protein, low sodium diet.
Avoid contact sports.
RENAL SYSTEM
RENAL SYSTEM
I
nl
C I m , I , 1 11 lmn
r ulting in
inflammation of glom ruin
1
Strepococcal infection, lupus, hyp rtcn ion,
diabetes.
Decreased urine utput. flui I volum
xc s (edem ,
w ight gain, dy pn a, t,yp rt n i 11).
LJL
• Throat cultur positive for strep.
• Positive ASO (Antistreptolysin titer)
• Decreased GFR (obtained through 24 hour urine collection to
determine creatinine clearance).
• Urinalysis: increased urine specific gravity, proteinuria,
hematuria (coffee-colored).
• Elevated WBC, ESR
IRENALSYSTEM
Acut Kidney Injury
•
•
•
Prerenal AK.I: Due to decreased blood flow to
kidneys (shock, sepsis, hypovolemia, renal
vascular obstruction).
lntrarenal AKI: Direct damage to kidneys (physical
trauma, hypoxic injury, chemical injury due to
toxins or medications).
Postrenal AKI: Due to obstruction leaving the
kidneys (stone, tumor, BPH)
Nt r
II
n
Monitor weight (report weight gain of 2 lbs in 24 hr,
or 5 lbs in 1 week).
• Monitor l&Os, labs. Restrict fluids, sodium,
protein.
• Administer antibiotics for strep infection
• Administer diuretics, corticosteroids
P, t du
Plasmapheresis (to filter
antibody complexes out of blood).
•
RENAL SYSTEM
RENAL SYSTEM
I
C"h n
Acut Kidney Injury
n y Ir ,ry (
Gradual, irreversible loss of kidney function.
r Aging, dehydration, AKI, Diabetes,
Hypertension, Chronic glomerulonephritis, medications
(gentamicin, NSAIDs), autoimmune diseases.
CK
A I Pl
• Onset: Onset to development of oliguria (hours­
days)
• Oliguria: Urin output is 100-400ml/24 hours (1-3
weeks).
• Diuresis: Start of kidney recovery, large amount of
urine excreted (2-6 weeks).
• Recovery: Continues until complete recovery (up to
1 year).
D1 t Restrict potassium, phosphate,
magnesium intake. Increase protein intake.
1
•
•
•
•
•
Stage
Stage
Stage
Stage
Stage
1: GFR > 90 ml/min
2: GFR 60-89 ml/min
3: GFR 30-59 ml/min
4: GFR 15-29 ml/min
5: GFR < 15 ml/min
RENAL SYSTEM
hr r i
In'
rv (
O)
vm m (mostly result of fluid volume overload):
jugular distention, hypertension, dyspnea, tachypnea,
crackles, peripheral edema, lethargy, tremors, n/v,
pruritis, uremic frost.
L
• Elevated creatinine, BUN
• Decreased sodium, calcium
• Increased potassium, phosphorus, magnesium
• Decreased Hgb and Hct
• Urinalysis: hematuria, proteinuria
onic Kidn y Injury (CKD)
Chr
------r I
• Weigh patient daily (1kg weight gain= 1L fluid retained).
• Diet: High carbs, moderate fat. Restrict sodium,
potassium, phosphorus, magnesium.
• Protect skin from breakdown.
• Prepare patient for l1emodialysis.
• Promote frequent rest periods.
<J Digoxin, sodium polystyrene (to reduce serum
potassium). erythropoietin (to increase RBC production),
furosemide. Avoid NSAIDs, contrast dye, and magnesium­
containing antacids.
RENAL SYSTEM
r"n ,
T
Jrin y T
UT Infection in lower urinary tract, usually caus d by E coli.
r
Female g nder (short ur thra, close proximity
to rectum), menopause, sexual int recurse, pregnancy,
synthetic underwear, wet b thing suits, frequent baths,
urinary catheters, stool incontinence, Diabetes, incomplete
bladder emptying.
Abdominal pain, dysuria (urinary frequency/urgency),
fever, n/v, hematuria, pyuria, cloudy/foul-smelling urine,
confusion (in older adults!).
Urmc.11 1 Presence of bacteria, WBC, positive leukocyte
esterase and nitrites.
1
RENAL SYSTEM
f(1
cl nd n
od by -. oh. St rls m lower
I
, 11"1
incomplete bladd
Costovcrtcbml t
tachycardia, tnchypn a, h
k/b k p 111, n/v,
•
•
•
I
Llllne
pl I,
Urinalysis positive fo, I ukocyt
I,
e, nitrit , WBC , ba teria.
Elevated er at1111n , BUN
Elevated ESR, C-rea tiv prot in
M
Antibiotics, opioid analge ics
Cc, , II< >.n Septic shock (symptoms: hypotension, tachycardia, fever),
CKD, hypertension.
t
ti n (UTI
M J Antibiotics (fluoroquinol n , nit,ofur nloin, trimetl10prim,
sulfonamides), Ph nazopyridinc (bl dd r analgesic - warn patient it
will turn their u,ine o,ang ).
om 11 t, n Ur s psis (Symptoms: hypo! nsion, tachycardia,
tachypne , fever).
Pr
•
•
•
•
•
•
V
nt C I
Drink >= 3L of fluid d ily
Maintain good body hygiene
Empty bl cider regularly (every 3-4hrs)
Urinate before and after intercourse
Drink cranberry juice.
Women: Wipe front to back, avoid bubble baths and
perfume-containing feminine hygiene products, avoid sitting
in wet bathing suits, avoid pantyhose or tight clothing.
RENAL SYSTEM
I
RENAL SYSTEM
Uroltthi
r
ry trn t, comp sed , r
• Lit11otrip y (us s I, s r r 11
nergy to break up
1 1Hic H 1d.
st n s, I n 11nrl r mod rd . d;:ition). Strcin urine following
linrny 1rn t li11i11g, high
proc rlure. Hematuria, bruising al lit11ot1ipsy sit xpected.
lion, ,dhydrr Ii n.
• Stenting
dinting to l'lhdom ),
• Ur t rolithotomy ( xtracl tone)
Educ 11 11
r, tnchy ardia, t l,ypne ,
• Iner as fluid intak (2-3 L/day)
• For cal ium pl1osphate stones, limit Intake of animal protein
Monitor l&Os, strain all urine ( nd sav stone for
and sodium.
lab analysis), increase fluids to 3 L/day, encourage mbulation.
• For oxalate stones, limit foods high in oxalates: spinach,
rhubarb, strawberries, beets, chocolate, nuts, tea.
Opioid analgesics or NSAIDs, anti-spasmodic drugs
• For uric acid stones, limit foods high in purines (meat, whole
(oxybutynin).
grains, legumes).
LI
of c,Jcium
I I
acidity or
S
dysuri , ·
oliguria, I
REPRODUCTIVE SYSTEM
REPRODUCTIVE SYSTEM
Female diagnostic procedures, menstrual disorders
Menopause
Female Diagnostic procedure
• Pap smear: t sts for cane r us c lls in th cervix.
R c mmend d v ry 3 y firs s1arting at age 21.
• Mammogram: t st for bre I
annu Uy st I ting l
powd rs in axilI ry r
ncer. Recommended
e 40. Avoid use of deodorant, lotion,
ion prior to exam.
Menstrual disorders:
• Menorrhagia: Excess m nstrual bleeding (amounUduration).
• Amenorrhea: Abs nc of m nses. Can be due to low body
fat percentag or anorexia.
• PMS: Hormonal imbalance befor period. Symptoms:
1rntability, depression, breast tenderness, bloating, headache.
• Endometriosis: Overgrowth of endometrial tissue outside the
uterus: common cause of infertilitv.
Menopause: C ssntion of m ns (no p riod in 12 months).
Symptoms: Hot flash s, d - cre::ised va inal secretions, mood
swings, d ere s d b nc d n ily.
Medications: Harmon Th r c py (HT) - oral, trnnsd rmal, or
intravaginal. Prev nts hot fltl 11 s, r due vaginal tissue trophy,
and decrease ri k of b ne fra tures. Taking HT increases risk of
embolic events (DVT, Ml, stoke) and breast cancer. Teaching:
• Quit smoking imm dial ly.
• Avoid knee-high stockings, and other restrictiv socks/clothing.
• Avoid sitting for prolonged periods of time. Move and stretch
legs regularly.
• Monitor for DVT (symptoms: unilateral leg pain, edema,
warmth, erylhema) or Ml.
REPRODUCTIVE SYSTEM
REPRODUCTIVE SYSTEM
Cystocele/Rectocele
Fibrocystic Breast Condition
C stocele/Rectocele: Cystocele is protrusion of
bladder through anterior vaginal wall. Rectocele is
protrusion of rectum through posterior vaginal wall.
Risk factors: Obesity, older ag , chronic constipation,
family history, forceps delivery.
Treatment:
• Vaginal pessary (device used to provide support and
block protrusion of other organs)
• Kegel exercises (contraction of vaginal and rectal
muscles)
• Surgical repair
Fibrocystic Breasts: Noncancerous condition
causing development of fibrotic connective tissue
and cysts in the breasts.
S&S: Breast pain. Rubber-like lumps, particularly
in upper/outer quadrant of breasts.
Diagnosis: Breast ultrasound
REPRODUCTIVE SYSTEM
REPRODUCTIVE SYSTEM
Male diagnostic procedures
PSA: Measures the amount of a protein produced by the
prostate gland in the bloodstream. Increased amount of PSA
can indicate presence of prostate cancer or benign prostatic
hyperplasia (BPH).
•
Do NOT do DRE prior to drawing blood for a PSAI
• Recommended annually for men> 50. African American men
and men with a family history should start screening earlier.
• PSA > 4ng/ml requires further ev luation.
DRE: Palpation of the prostate gland through the rectal
wall. Provider inserts finger into the anus.
• Abnormal findings: Enlarged or hard prostate, irregular shapes
or lumps.
Benign Prostatic Hyperplasia (BPH)
BPH: Enlargement of the prostate gl nd th t impairs urine
outflow from bladder, resulting in urinary retention. This results in
increased risk of infection and reflux into the kidneys.
Urinary frequency, urgency, retention, hesitancy,
incontinence. Post-void dribbling, reduced urinary stream force.
Hematuria, nocturia. Frequ nt urinary tract infections.
Labs: Elevated PSA. Iner ased WBC w/UTI. Increased
creatinine/BUN with kidney involvement.
Meds: Androgen inhibitor (finasteride), Peripherally acting
antiadrenergic (tamsulosin).
Procedures:
•
•
Prostatic stent: Keeps urethra patent.
Transurethral resection of the prostate (TURP) surgery.
REPRODUCTIVE SYSTEM
-------- TURP
_
Meds:
• Patient will have indw lling 3-way catheter.
• Perform continuous bladder irrigation (CBI) with NS or
prescribed solution. Goal is keep irrigation outflow light
pink
Increase CBI rate if irrigation outflow is bright red,
ketchup-appearing, or contains clots.
• If catheter becomes obstructed (symptoms: bladder
spasms, reduced outflow): Turn off CBI, irrigate w/50ml
using large piston syringe.
•
TURP surgery
surge_,r..y:.
Nursing care:
•
REPRODUCTIVE SYSTEM
Expected: patient will have a continuous need to
urinate!
•
Jn
• Analgesics
• Antispasmodics (to prevent bladder spasms)
• Antibiotics (prophylactic)
• Stool softeners (to prevent straining).
Patient teaching:
• Drink 12 (or more) 8oz glasses of water per day.
• Avoid caffeine or alcohol (bladder stimulants)
• If urine is bloody, stop activity, rest, and increase
fluid intake.
MUSCULOSKELETALSYSTEM
I r
r tr
>
Allows visualization of the internal structure of
a joint. Contraindicated if patient has infection or cannot bend
at least 40 degrees.
h n c n Radioactive material injected hours before
scan. Repeat scans at 24, 48, 72 hours. Bone scan detects
tumors, fractures, bone disease. Gallium scan are more
sensitive than bone scan.
Used to determine bone mass and presence of
osteoporosis.
E:leuromyo Jr phy Needles placed into muscle, and
electrical activity recorded during muscle contraction. Used
to diagnose cause of muscle weakness.
h
Replacement of a diseased joint with a
prosthetic joint Used for p ti nts with osteoarthritis,
rheumatoid arthritis, tr uma, or congenital defects.
,, > 1
P I n
Joint pain, crepitus, swelling
C nt ,m
I
Current/recent infection, arterial
insufficiency to affected extremity.
Pre Administer epoetin alfa to increase Hgb,
autologous blood donation. Advise patient to scrub w/
antiseptic soap the night before and morning of surgery.
•
MUSCULOSKELETALSYSTEM
•
•
•
•
•
Initiate continuous passive motion (CPM) machine
immediately after surgery (if ordered).
DO NOT place pillow under knee (or use knee
gatch), in order to prevent flexion contractures.
Administer analgesics, antibiotics, anticoagulants,
ice therapy.
Perform neurovascular checks every 2-4 hours
Patient should NOT kneel or do deep-knee bends.
• Monitor for S&S of DVT (unilateral pain, swelling,
erythema) or PE (dyspnea, chest pain, tachycardia).
• Apply SCOs or antiembolic stockings
• Encourage early ambulation, foot exercises.
• Place abduction device between legs. No crossing of
legs!
• Do not allow flexion of hip greater than 90 degrees!
• Externally rotate patient's toes (do not allow internal
rotation).
• Monitor for joint dislocation: onset of severe pain,
hearing a "pop", shortened affected extremity, internal
rotation of affected extremity.
• Use elevated toilet seat. Avoid low chairs.
MUSCULOSKELETALSYSTEM
MUSCULOSKELETALSYSTEM
Amputation
!!ch
•
•
•
tr1
Trauma (wrap s vered xtremity in dry sterile gauze, place in
sealed plastic b g, subm rg in ic water)
Infection
Peripheral v scL1lar dis ase (symptoms: reduced pulses, cooler
temperature, gangrene, cyanosis, decreased sensation).
Nur mr
r
• Treat phantom limb pain (common and real) with beta blockers,
antiepileptics, antispasmodics, antidepressants.
• Position stump in depend nt position.
• Perform ROM exercises.
• To shrink residual limb (in preparation for prosthesis): wrap stump
in figure-eight wrap.
• Avoid elevating stump for 24 hours. Have patient lie prone for
20-30 minutes several times a day.
Osteoporo i
Rate of bone resorption exceeds rate of bone
formation, resulting in low bone density and fr gile bones. Osteopenia
is a precursor to osteoporosis.
1 f,
Jr, Female gender, thin/lean body, menopause, insufficient
calcium or vitamin D intake, smoking, alcohol abL1s , excess caffeine
intake, lack of physical activity, hyperparathyroidism, long-term steroid
use, long-term anticonvulsant medication use.
Back pain, fractures, kyphosis, reduced height.
Di, no I Dual x-ray absorptiometry (DXA).
M •< · Calcitonin, estrogen (increased risk of breast cancer and
DVT), raloxifene, alendronate (remain upright for 30 min after taking).
Tc .1ch11q: Get sufficient calcium and vitamin D, moderate sun
exposure using sunscreen, weight bearing exercises, home safety
measures to prevent falls.
1
MUSCULOSKELETALSYSTEM
F
MUSCULOSKELETALSYSTEM
tu
Does not break skin surface. fu_:_ c , Osteoporosis, long-term steroid use, falls,
trauma, bone cancer, substance abuse.
, Breaks skin surface,
Pain, crepitus, deformity in extremity, muscle spasms,
increased risk of infection.
edema, ecchymosis.
Goes
through
entire
bone.
Com
J 1r
r Stabilize affected area, elevate affected limb,
lnco
Goes part way through bone.
apply ice, perform neurovascular assessments every hour.
Commin
re Bone split in multiple pieces.
d!:> Antibiotics (prophylactic), analgesics, muscle
Com
ir
One or more bones in spine
relaxants.
weaken and collapse (due to loading force).
Surgcir
Obllgu f r r . Fracture occurs at an oblique angle.
• External fixation: pins attached to external frame.
S.1>.iral fncturn: Fracture from twisting motion (sign of
• Open reduction and internal fixation (ORIF): pins, plates,
screws, rods used internally.
abuse!)
Fr1 tl r
•
MUSCULOSKELETALSYSTEM
sessment
•
•
Pain level
Sensation (numbness, tingling, lack of sensation)
•
•
Skin temperature
Capillary refill (should be<= 2 seconds)
•
•
Pulses
Movement
• Handle plaster casts with your palms (not
fingertips!) and we ring gloves until cast is dry.
• Elevate cast above level of he rt for first 24-48
hours.
• Tell patient not to place objects under cast.
• Itching can be relieved by blowing cold air from a
hair dryer under cast.
• Report to provider: Hot spots, areas with increased
drainage, malodorous areas
MUSCULOSKELETALSYSTEM
Weights attached to patient's skin to decre se
muscle spasms nd immobili7 th xtremity before
surgery. Examples:
1
•
•
Bryant traction (for hip dysplasia in children)
Buck's traction (for l1ip fractures in adult patients).
_
I Screws are insert d into the bone. Used for long
bone fractures.
H I Used for cervical bone fractures. Make sure
wrench to release rods is attached to the vest, so CPR
can be performed!
MUSCULOSKELETALSYSTEM
£.Ir
MUSCULOSKELETALSYSTEM
·
•
•
•
•
•
Assess neurovascular status every hour for first 24
hrs, then every 4 hours afterwards.
Do not lift or remove weights.
Do not let weights rest on floor (make sure they are
hanging freely).
Muscle spasms are expected and should be
treated w/meds, repositioning, heat, or massage.
Report unrelieved muscle spasms to provider.
For halo traction, move patient as a unit and do not
apply pressure to rods.
•
at globule from bone marrow travels to
• Monitor for signs of infection: increased drainage,
lungs, impairing respirations. Long bone and hip
erythema, loosening of pins, skin tenting at pin site. fractures are most common.
• Clean pins using a NEW cotton tip swab for each pin.
• Symptoms: Dy pn
, confu ion ( arly sign),
• Do not remove crusting at pin site!
tachypnea, tachycardia, petechiae on upper body
on I n
,
Increased pressure within
(late sign!)
muscle compartment of an extremity that impairs circulation. 0
Bone infection
• Symptoms: Intense pain w/passive movement,
• Symptoms: bone pain, erythema, edema, fever,
parasthesia (early sign!), paralysis (late sign!), pallor,
elevated WBC.
pulselessness (late sign!), hard/swollen muscles.
• Treatment: Long-term antibiotic therapy, surgical
• Treatment: Fasciotomy
debridement of bone, hyperbaric oxygen therapy.
MUSCULOSKELETALSYSTEM
rt r 1
t o Ir
Progressive degeneration of articular
cartilage in joints.
1
or Older age, women, obesity, smoking, repetitive
stress on joints.
m
I
Joint pain/stiffness, crepitus, enlarged joints,
Herberden's nodes (distal interphalangeal joints), Bouchard's
nodes (proximal interphalangeal joints).
/
P, t E r
• Apply ice (acute inflammation) or heat.
• Splinting and/or use of assistive devices.
• Physical therapy
• TENS (transcutaneous electrical nerve stimulation)
MUSCULOSKELETALSYSTEM
0 teoarthriti
Md
• Oral analgesics (acetaminophen, NSAIDs)
• Topical analgesics (capsaicin): Wear gloves when
applying, do not apply on areas with broken skin,
burning sensation is normal.
• Glucosamine: Increases synovial fluid production
and helps rebuild cartilage.
• Injections: glucocorticoids, hyaluronic acid.
Surgt;ry: Total joint arthroplasty
MUSCULOSKELETALSYSTEM
toid Arthriti
0
r lrl
• Degenerative disease process
• Pain with activity, gets b tter with rest
• Affects specific joints, NOT symmetrical
• Heberden's and Boucl1ard's nodes
• Negative rheumatoid factor
Rt t.UI
•
•
•
•
•
1 I
Inflammatory disease process
Pain after rest/immobility, gets better with movement.
Affects ALL joints, symmetrical.
Swan neck and boutonniere deformities.
Positive rheumatoid factor.
Used to identify and treat
bacterial skin lesions. Get culture prior to starting
antibiotics! Final results in 72 hours.
•
•
Culture identifies the pathogen.
Sensitivity determines which antibiotic can be used
to kill the pathogen.
Used to diagnose viral skin lesion.
Used to diagnose fungal skin lesion.
INTEGUMENTARY SYSTEM
Bathe w/antibacterial soap.
Remove dried exudate before applying topical
antibacteriaf ointments.
Apply Burrow's solution to promote
crusting of lesions. Avoid restrictive clothing. Topical
antiviral ointments (ex: acyclovir) can be used.
Apply antifungal cream or
powder (ex: clotrimazole) BID for 1-2 weeks after
lesions are no longer visible.
Autoimmune clisord r th8l r suits in overproduction
of keratin and form lion of dry/s aly p-1tch on th kin.
Characterized by period of xac rb lions , nd remissions.
Scaly pRtcl1e , pitting/crumbling n ils.
• Topical steroids (ex: tri mcinolon ). Do not apply to face, skin folds,
or broken skin.
• Tar prepar lions (ex: coal tar). Use In conjunction with ultraviolet B
ligl1t therapy (remov ere m before th rapy). Cream may stain skin
and clothes. Can increase risk of skin cancer.
• lmmunosuppressants (ex: methotrexate, cyclosporin)
Ultraviol t light therapy. Administer psoralen 2 hours
before treatment (enhances photosensitivity). Provide eye
protection to patient.
INTEGUMENTARY SYSTEM
Inflammation in areas that contain
a high level of sebaceous glands (ex: scalp, forehead, nose,
groin, axilla). Characteriz d by p riods of exacerbations and
remissions. Most common type: dandruff.
Waxy or flaky plaques or scales in oily parts of
the body.
•
•
Topical corticosteroids
Antiseborrheic shampoos (i.e. shampoos containing
selenium). Use several times a week, leave in hair for
2-3 minutes.
•
•
Calculates % of body burn d:
Head= 9%, each arm= 9%, each leg= 18%, anterior torso=
18%, posterior torso = 18%, perin c I r = 1%.
Superficial: Dam e to epid rmis. Red/pink color, no blisters.
Ex: sunburn.
• Superficial partial thickness: Damage to epidermis, and part
of the dermis. Red/pink color with blisters. No eschar.
• Deep partial thickness: Damag to epidermis and deep into
dermis. Redlwhrte color, NO blisters. Soft/dry eschar.
• Full thickness: Damage to epidermis, dermis, and part of
subcutaneous tissue. Color varies. Pain may not be present.
No blisters. Hard eschar.
• Deep full thickness: Damage to all skin layers. Black color.
INTEGUMENTARY SYSTEM
First 24-48 hOL1rs from injury.
Initial fluid shift: Fluid hift to inlerstiti I space, resulting in
hypovolemia.
• Labs: Elev led Hct, H b. Hyponat,emia, hyperkalemia.
Starts wh n fluid r suscitation is complete, and
ends when wounds are he I I.
• Fluid mobilization (Diur tic stage): 48-72 hours after injury.
Fluid shifts back into vascular system.
• Labs: Decreased Hct, Hgb. Hyponatremia, hypokalemia.
Decreased protein, albumin.
Begins when wounds are healed, and ends
when reconstructive procedures are complete.
•
INTEGUMENTARY SYSTEM
•
Monitor for S&S of shock: Urine output< 30 ml/hr,
confusion, fever, decrease bowel sounds, increased
capillary refill time.
• Administer IV opioid analgesics. Avoid IM or
subcutaneous injections.
• Prevent infection: no fresh plants/flowers, no fresh
fruits/veggies, limit visitors.
• Provide nutritional support: Increase calorie and protein
intake. Provide TPN as ordered.
• Preserve patient mobility: Active and passive ROM
exercises to prevent contractures. Apply pressure
dressings as ordered.
•
•
•
•
•
•
Stop burning process. Flush chemical burns with
large volumes of water. Do not apply greasy lotions
or butter to burns.
Administer tetanus vaccine (if applicable).
Maintain airway. Singed eyebrows, nasal hair,
and sooty sputum are indications of inhalation
damage.
Administer humidified oxygen as ordered.
Insert large-bore needle for fluid resuscitation
(0.9%NaCI or Lactated Ringers).
Administer colloids or plasma expanders as
ordered.
INTEGUMENTARY SYSTEM
•
•
•
•
Amount of fluid need d In lust 24 hours= 4ml Lactated Ringer's x
patients weight (in kg) x % body surf ce ar (BSA) burned.
Administer½ of that amount in first 8 hoLirs.
Administer ¼ of that amo 1nt In
ond 8 hours.
Administer ¼ of t11at amount In third 8 hours.
•
Silver sulfadiazine (Sllvaden ): Antimicrobial, does not penetrate
escl1ar. May cause transient neutropenia.
• Mafenide acel le (Sulfamylon): Antimicrobial, does penetrate
eschar. Can cause metabolic acidosis.
Immobilize graft site, elevate extremity, monitor for signs of
infection.
• Allograft: from human cadavers
• Xenograft: from animals
• Autograft: from another part of patient's body.
ENDOCRINE SYSTEM
g
Tests to see if the kidneys are able
1 1
to concentrate urine when blood osmolality increases. If
kidneys are unable to concentrate urine, this is indicative of
nephrogenic Diabetes lnsipidus.
• Procedure: Obtain weight and send blood, urine
samples to lab hourly.
V_ o
t t Tests to see if administration of
subcutaneous vasopressin increases urine specific gravity. If
vasopressin causes increase in urine specific gravity, this is
indicative of neurogenic Diabetes lnsipidus (i.e. issue with
pituitary gland).
ENDOCRINE SYSTEM
D
rn 1
n
11n
I
Tests to see if
administration of dexamethasone (steroid similar to
naturally occurring cortisol) results in decreased levels
on ACTH and cortisol. If there is NO decrease, this is
indicative of Cushing's disease.
AC H II ul 10n
Tests to see if administration of
ACTH increases levels of cortisol in body. If there is NO
increase, this is indicative on Addison's disease.
• Procedure: Collect two 24-hour urine samples (one
before and one after administration of ACTH).
.. -
ENDOCRINE SYSTEM
D qno ti
Ufilln. =
hror10cyt m
No foods or fluids for 8 hours before
test.
• Normal levels < 110 mg/dl
r. I lu< o
I ,
Fast for 10-12 hours before
test. Take fasting blood glucose. Patient consumes specific
amount of glucose. Blood samples taken every 30 minutes
for 2 hours. Normal levels< 140 mg/dl.
HqbA)(, BEST indicator of average blood glucose levels
over the past 3-4 months.
• <= 5.7% indicates no diabetes
• Between 5.7 - 6.4% indicates pre-diabetes
•
Ph ocnr m , n Benign tumor on adrenal gland
causes hypersecretion of catecholamines, resulting in
increased sympathetic response in the body.
ymptom Tachycardia, hypertension, diaphoresis,
headache, shortness of breath.
D1dc r1m,i Plasma-free metanephrine test, clonidine
suppression test.
Med Anti-hypertensive medications until surgery.
Surgery: Remove tumor from adrenal gland.
>= 6.5% indicated diabetes
ENDOCRINE SYSTEM
Oiall t
D1abete hl' l1 du
In pid1..1
ENDOCRINE SYSTEM
----
Defici ncy of ADH, resulting in kidneys
being unable to concentrate urine.
»&
Large amounts of diluted urine, polydipsia, dehydration
(fachycardia, hypotension, sunken eyes, dry mucus membranes,
weakness, fatigue).
LJIJ•
• Urine: DECREASED specific gravity(< 1.005), decreased
osmolality ( < 200 mOsm/L), decreased sodium.
• Blood: INCREASED serum osmolality ( > 300 mOsm/L),
increased sodium.
D1agn ls s. Water deprivation test, Vasopressin test.
Meds. ADH replacements (desmopressin or vasopressin).
For intranasal administration, clear nasal passageway before
inhalation.
S
yndromP
of Ina propriate ADH (SIADH)
SIADH. Excessive release of ADH from the posterior
pituitary gland, resulting in increased reabsorption of
water (not sodium) by the kidneys.
Caus · Brain tumor, head injury, meningitis,
medications.
S&S· Small amounts of concentrated urine. Fluid
volume excess (tachycardia, hypertension, crackles,
distended neck veins, weight gain), headache,
weakness, muscle cramping, confusion, seizures, coma
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Synthesis Pathways
Syndrome of In ppropriat ADH (SIADH)
Thyroid
Lab ·
•
• Urine: INCREASED specific gravity (> 1.030),
•
osmolarity, sodium.
• Blood: DECREASED serum osmolarity (< 270 mEq/L), •
sodium.
Cor
NursIn
•
•
•
•
•
Fluid restriction.
Monitor l&Os (watch for hyponatremia!)
Weigh patient daily.
Provide hypertonic IV fluids (ex: 3% NaCl).
Administer furosemide (diuretic) as ordered
111
t
Hypothalamus produces TRH (thyroid releasing hormone).
TRH causes the anterior pituitary gland to produce TSH
(thyroid stimul ti, g hormone).
TSH causes the thyroid gland to produce T3rr4 (thyroid
hormones t11at control metabolism in the body).
,1 vn 11
l hi.\'<
• Hypothalamus produces CRH(Cortisol releasing hormone).
• CRH causes the anteriorpituitary gland to produce ACTH
(adrenocorticotropic hormone).
• ACTH causes the adrenal cortex to produce cortisol (steroid
hormone that controls metabolism, immune function, and
body's response to stress).
.. -
ENDOCRINE SYSTEM
!:!Y rth
yp rthy idi n
S&S: Tachycardia, hypertension, heat intolerance,
(,du
exophthalmos, weight loss, insomnia, diarrhea, warm/
sweaty skin.
Hy
r 1yroidi m
ro I
Excess thyroid hormones (T3 and T4)
released from thyroid gland, resulting in hypermetabolic state.
• Primary (issue w/thyroid gland): Graves disease (most
common cause, autoimmune issue) or thyroid nodule
causes hypersecretion of T3/T4.
• Secondary (issue with pituitary gland): Anterior pituitary
gland produces too much TSH (due to tumor).
• Tertiary (issue with hypothalamus): Hypothalamus
produces too much TRH.
!.J? : Increased T3/T4, decreased TSH (in primary
hyperthyroidism).
Nu m
r ·
•
Nutrition: Increase patient's calories, protein
intake. Monitor l&Os, weight.
•
Exophthalmos: Tape eyelids closed, provide eye
lubricant.
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Hyp rthyroidi m
f
:l
•
•
•
•
Propylttiiouracil (PTU)
Beta-blockers (ex: propranolol)
Iodine solutions (mix w/juice to mask taste)
Radioactive iodine: Slay away from children for 2-4 days,
flush toilet 3 limes, do not share toothbrush, use disposable
plates/utensils.
com
1t101
Thyroid storm - excessively high levels of
thyroid hormones, with high mortality rate.
• causes: infection, stress, OKA.
• Symptoms: hypertension, chest pain, dysrhythmias,
dyspnea, delirium.
l r
Thyroidectomy (removal of thyroid gland). Patient will
need thyroid replacement therapy for the rest of their life.
••
•
•
•
Place patient in high-Fowler's position.
Prevent (and monitor for) hemo11haging. Cl1eck dressing and
back of neck for ble ding. Support pati nt's head and neck
with pillows/sandbags. Teach patient to avoid neck flexion or
extension.
Have tracheostomy supplies available at bedside.
Monitor for signs of parathyroid gland damage (i.e. S&S of
hypocalcemia): numbness/tingling around mouth or toes,
muscle twitching, positive Chvostek's or Trousseu's signs.
Administer calcium gluconate for treatment of hypocalcemia.
Administer steroids (ex: prednisone) to decrease post-op
edema.
ENDOCRINE SYSTEM
1•
H,
I
•
•
t y 'd' n
H
t v
r Inadequate production of thyroid
hormones (T3/T4) by t11e thyroid gland.
11
• Primary (issue w/thyroid gland): Most common type. Ex:
Hashimoto's disease (autoimmune disorder), cretinism
(severe hypothyroidism in infants).
• Seconda&. (issue with pituitary gland): Anterior pituitary
gland pro uces insufficient TSH (due to tumor).
• Tertiary (issue with hypothalamus): Hypothalamus produces
insufficient TRH.
Hypotension, bradycardia, lethargy, cold intolerance,
cons ipation, weight gain, thin hair, brittle fingernails, depression.
L
Decreased T3 (< 70ng/dl), decreased T4 (< 4mcg/dl),
Increased TSH (with primary hypothyroidism), anemia.
Hypothyroidism
N r in
• Encourage frequent rest periods.
• Encourage low-calorie, high-fiber diet and increased
activity to promote weight loss and prevent
constipation. No fiber laxatives (interferes with
levothyroxine absorption).
• Provide extra blankets, increase room temperature.
No electric blankets.
Levothyroxine - Start with low dose, gradually
increase. Take 1 hour before breakfast w/full glass of
water.
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Hypothyroidism
Comph
Cushin
'
t1on
• Hyperthyroidism (due to too much levothyroxine).
• Myxedema coma - Severe hypothyroidism
,- Causes: Untreated hypothyroidism, infection/
illness, abrupt discontinuation of levothyroxine.
,- Symptoms: Hypoxia, decreased cardiac output,
decreased LOC, bradycardia, hypotension,
hypothermia.
,- Nursing care: Maintain patent airway, monitor
ECG, warm patient, administer large doses of
levothyroxine.
ENDOCRINE SYSTEM
C c.:;hing' Syndr m e
- - -------
Dexamethasone suppression test
Nurs1, c re
-•-Diet: decrease sodium intake, increase intake of potassium,
calcium, and protein.
• Maintain safe environment due to increased risk of fractures.
• Prevent infection
• Protect patient's skin from breakdown.
Ml?d-,. ketoconazole (adrenal corticosteroid inhibitor),
spironolactone (postassium sparing diuretic).
Proc aurns/
• Cytotoxic agents for tumors causing condition.
• Hypophysectomy (removal of pituitary gland).
• Adrenalectomy (removal of adrenal gland): Hormone replacement
therapy needed, monitor for adrenal crisis r/t drop in cortisol levels.
rr
yndrome
Overproduction of cortisol by the adrenal cortex.
Call
•
Primary (Adrenal dysflinction): Oversecretion of cortisol by the adrenal
cortex (r/t adrenal hyperplasia, tumor).
• Secondary (Pituitary dysfunction): Oversecretion of ACTH by the
anterior pituitary gland (r/t tumor).
• Long-term use of steroids for chronic conditions.
s Increased infections, thin/fragile skin, edema, weight gain (moon
face, buffalo hump, increased abdominal girth), hypertension, tachycardia,
bone pain/fractures, hyperglycemia, gastric ulcers, hirsutism, acne.
I ab
• Elevated cortisol levels in saliva
• Increased glucose, sodium levels
• Decreased potassium, calcium levels
ENDOCRINE SYSTEM
Hy ophy
c omy
• Monitor for signs of CSF leak:
--=---------
,.. Halo sign in drainage (clear in center, yellow
on edges).
,.. Sweet-tasting drainage
:.- Clear drainage from the nose
:.- Headache
• Teach patient to AVOID activities that increase ICP:
coughing, sneezing, blowing nose, bending at waist,
straining during bowel movements (increase fiber intake).
• Decreased sense of smell expected for 3-4 months.
• Do not brush teeth for 2 weeks (flossing and rinsing
mouth OK).
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Addison s Di ease
Addi on':, 01 ease
Addison l i ea C" Inadequate secretion of hormones by
adrenal cortex (aldosterone, cortisol, sex hormones).
C use
• Primary (adrenocortical insufficiency): damage or
dysfunction of adrenal cortex (r/t autoimmune
dysfunction, tumors).
• Secondary (pituitary dysfunction): pituitary tumor or
hypophysectomy.
S S Weight loss, hyperpigmentation (bronze skin),
lethargy, n/v, hypotension, dehydration.
Labs: Increased potassium and calcium. Decreased
sodium, glucose, cortisol.
ENDOCRINE SYSTEM
t
Ii u
Di
( lh I Chronic hyperglycemia due to
insufficient insulin production by the pancreas and/or insulin
resistance of cells in the body.
J
•
•
•
Type 1 OM: Destruction of beta cells in pancreas due to
autoimmune dysfunction. Patients are insulin­
dependent. Usually starts at younger age
Type 2 OM: Progressive insulin resistance and
decreased insulin production r/t obesity, inactivity, and
heredity. Usually starts later in life.
Gestational OM: High blood glucose during pregnancy
Di,
ACTH stimulation test. Administer ACTH, measure
cortisol response after 30 min, 1 hour.
• Primary Addison's - cortisol levels do not rise.
• Secondary Addison's - cortisol levels DO rise.
Nur!:i nq c:. ir
• Administer steroids (hydrocortisone, prednisone).
• Administer fluids, electrolytes as ordered.
• Treat hyperkalemia: sodium polystyrene sulfonate, insulin
(with glucose), calcium, bicarbonate.
• Treat hypoglycemia: food, supplemental glucose.
Complt, 1t1ons Addisonian crisis - rapid onset, medical emergency.
Due to infection/trauma or abrupt discontinuation of steroids
ENDOCRINE SYSTEM
i1
R,
<. Obesity, hypertension, hyperlipidemia,
smoking, genetics, race (African American, American
Indian, Hispanic populations), inactivity.
3 Ps (polyuria, polydipsia, polyphagia),
hyperglycemia, weight loss, dehydration (decreased
skin turgor, weak pulse, hypotension, dry mucus
membranes), fruity breath odor, Kussmaul respirations
(Increased rate and depth of respirations), n/v,
headache, decreased LOC.
•• Di
01 qr o
Two or more of the following on separate days:
• Casual blood glucose > 200 mg/di
• Fasting blood glucose > 126 mg/di
• Glucose > 200 mg/di with oral glucose tolerance test.
• HgbA1C > 6.5%
!:!g_b
t
Best indicator of treatment compliance. Goal for patients
with Diabetes is HgbA1C < 7%.
Med
• Insulin
o Rapid-acting = lispro
o Short-acting = regular
o Intermediate-acting = NPH
o Long-acting = glargine
• Oral hypoglycemic agents (Type II DM only): metformin, glipizide,
repaglinide, pioglitazone, acarbose.
ENDOCRINE SYSTEM
Hypogly en i'
Hypoglycem1
Consc1ou ,
•
•
•
1e11
Consume 15-209 quickly absorbed carbohydrate (ex:
4-6oz juice or soft drink).
Recheck blood glucose in 15 min. If still <= 70 mg/dl,
repeat above step and check again in 15 min.
Once blood glucose is > 70 mg/dl, consume a snack
containing a protein and carbohydrate.
Uncon:.c.10
•
•
•
blood glucose <= 70 mg/dl
tten
!:>
Administer IM or subcutaneous glucagon.
Repeat in 1O minutes if patient is still not conscious.
Once patient is conscious (and can swallow safely), have
patient consume a carbohydrate snack.
ENDOCRINE SYSTEM
Diabete Mellitu : pati nt earhing
• Rotate subcutaneous injection sites to prevent
Iipohypertrophy.
• Mixing insulins: Draw up clear (shorter-acting
insulin) before cloudy (longer-acting insulin).
• Never mix long-acting insulin (i.e. insulin glargine)
with other insulins.
• Monitor for signs of hypoglycemia (confusion,
diaphoresis, headache, shakiness, blurred vision,
decreased coordination).
ENDOCRINE SYSTEM
Foot care for Diabetics
• Inspect feet daily
• Test water temperature with hands, use lukewarm water.
• Dry feet thoroughly after bathing.
• Apply moisturizer to feet, but not between toes.
• Wear cotton socks (no synthetic fabrics).
• Wear leather shoes (or slippers w/soles). Do not go
barefoot or wear open toe/heel shoes.
• Use foot powder w/cornstarch on sweaty feet.
• Cut nails straight across, ideally after bath/shower.
• Check shoes for objects that can cause injury
• Do not use OTC products, such as products for corns/
callouses.
• Do not apply heating pads to feet.
ENDOCRINE SYSTEM
ENDOCRINE SYSTEM
Di b te M llitic; complicati ons
- ------. O1\A
• Cardiovascular disease: Ml, hypertension
• Cerebrovascular disease: Stroke
• Diabetic retinopathy: Impaired vision
• Diabetic neuropathy: Nerve damage, leading to neuropathic
pain, numbness, ischemia, infection.
• Diabetic nephropathy: Kidney damage
• Diabetic ketoacidosis (OKA): Life-threatening condition with
blood glucose >300 mg/di and ketones in blood and urine.
Rapid onset. More common with Type I OM.
• Hyperglycemic-hyperosmolar state (HHS): Life-threatening
condition with blood glucose> 600 mg/di, no ketosis, severe
dehydration. Gradual onset. More common with Type II OM.
ENDOCRINE SYSTEM
DKA and HHS
c rt
---;---'rreat underlying cause (ex: infection)
• Administer IV fluids and IV insulin
• Check blood glucose hourly (goal < 200 mg/di)
• Monitor potassium levels. Insulin causes K to move back into cells
(risk of hypokalemia).
• Administer Bicarb for metabolic acidosis.
Nursin
P tic nt e chi
-
:
• Monitor blood glucose more frequently when sick (every 1-4 hours).
Do NOT skip insulin when sick.
• Wear a medical alert bracelet.
• Drink 2-3 L of water per day.
• Notify doctor if illness lasts for more than 1 day, or for temperature >=
38.6 degrees C.
• Notify doctor for blood glucose> 250 mg/di, or for urine positive for
ketones.
-
Diabetic complications
•
Risk factors: Infection, stress/illness, untreated or undiagnosed
•
Symptoms: Polyuria, Polydipsia, Polyphagia, weight loss, fruity
type I DM, missed insulin dose.
breath odor, Kussmaul respirations, GI upset, dehydration (resulting
in hypotension, l1eadache, weakness).
•
Labs: Blood glucose> 300 mg/di, ketones in blood and urine,
metabolic acidosis.
tlH
-•-Risk factors: Older adults, inadequate fluid intake, decreased
•
•
kidney function, infection, stress.
Symptoms: Polyuria, polydipsia, polyphagia, dehydration (resulting
in hypotension, headache, weakness).
Labs: Blood glucose> 600 mg/di, NO ketones in blood or urine.
Nometabolic acidosis.
IMMUNE SYSTEM
White Blood Cells
NormaI WBC range= WBC between 5,000-10,000/mm3•
Leukopenia WBC < 4,000/mm3. Can indicate presence
of autoimmune disease, bone marrow suppression, drug
toxicity.
Leukocytosis = WBC > 10,000/mm 3. Can indicate
presence of infection or inflammation.
Neutropenia = Neutrophil count < 2,000/mm3•
Indicates compromised immunity.
"Left shift" (banded neutrophils) = Indicates release of
immature neutrophils when body is fighting infection.
IMMUNE SYSTEM
Types of WBCs
• Neutrophils (55-75%): Increased during acute
bacterial infections.
• Lymphocytes (20-40%): Increased during chronic
bacterial or viral infection.
• Monocytes (2-8%): Increased during protozoa! and
viral infections, tuberculosis, chronic inflammation.
• Eosinophils (1-4%): Increased during allergic
reactions or parasite infections
• Basophils (0.5-1%): Increased due to leukemia.
IMMUNE SYSTEM
Key adult immunizations
Key adult immunizations:
·• Pneumococcal vaccine: Recommended for adults who are
immunocompromised, have a chronic disease, smoke, or live in a
long-term care facility.
• Meningococcal vaccine: Recommended for individuals living in
crowded living environments (ex: students in college dorms!)
• Herpes zoster vaccine: Recommended for adulls over 60 years old.
Key points about vaccines:
• Expected side effects: Low-grade fever, pain at the injection site,
and irritability
• Nursing care: Administer antipyretics and cool compresses.
Encourage patient to mobilize affected extremity.
• Document: Type of vaccine, date, route, site, manufacturer,
lot number, expiration date, patient's name/address/signature
IMMUNE SYSTEM
Types of immunity
----------
Active natural immunity: Body produces antibodies
in response to exposure to live pathogen.
Active artificial immunity: Body produces antibodies
in response to vaccine.
Passive natural immunity: Antibodies are passed
from the mom to her baby through the placenta or
breastmilk.
Passive artificial immunity: lmmunoglobulins are
administered to an individual after they have been
exposed to a pathogen_
IMMUNE SYSTEM
Vaccines
Vaccines are NOT contraindicated for common colds or minor
illnesses!
General contraindications:
• Previous anaphylactic reaction to a vaccine.
• Allergy to a component of a vaccine.
• Seizure within 3 days of vaccination.
• Pregnancy (for many vaccines).
• Severe immunodeficiency (ex: HIV, chemo, long-term steroid
use).
Specific contraindications:
• MMR, Varicella: Allergy to gelatin/neomycin
• Hepatitis B: Allergy to baker's yeast
• Influenza: Allergy to egg protein
IMMUNE SYSTEM
IMMUNE SYSTEM
HIV/AIDS
HIV/AIDS
HIV: Retrovirus that targets CD4+ lymphocytes (T-cells),
Diagnosis: Positive ELISA test, confirmed with Western
resulting in decreased immune function and susceptibility to blot test.
infections. AIDS= Stage 3 (end-stage) HIV infection.
Meds: 3-4 Antiretroviral medications (many end in -vir).
Risk factors: Unprotected sex, multiple sex partners,
Patient teaching:
perinatal exposure (all pregnant women should be tested!),
• Practice good hand hygiene, bathe daily with
IV drug use, health care workers.
antimicrobial soap.
Symptoms: Flu-like symptoms, weakness, night sweats,
• Avoid raw foods
headache, weight loss, rash.
• Don't clean cat litter boxes
Stage 3 (AIDS):
3
• Avoid sick people
• CD4+ count < 200 cells/mm
• Practice safe sex
• Symptoms: Kaposi's sarcoma, TB, pneumonia, wasting
syndrome, candidiasis of the airways, herpes, other infections.
• Ongoing monitoring of CD4+ counts.
IMMUNE SYSTEM
Lupus
Lupus: Autoimmune disorder that causes chronic
inflammation in the body. There is no cure. Disease is
characterized by periods of exacerbations and remissions.
• Discoid: Affects skin (butterfly rash).
• Systemic: Affects the connective tissues in multiple
organs.
Risk factors: Females, ages 20-40, race (African
American, Asian, Native American).
S&S: Fatigue, joint pain, fever, butterfly rash on face,
Raynaud's phenomenon, anemia, pericarditis,
lymphadenopathy.
IMMUNE SYSTEM
Lupus
Labs: Positive ANA titer, decreased serum
complement (C3/C4), Decreased RBC, WBC, platelets.
Increased BUN, creatinine with kidney involvement.
Meds: NSAIDs, immunosuppressant agents
(prednisone, methotrexate), antimalarial drugs
(hydroxychloroquine), topical steroid creams for rash.
Patient teaching: Avoid UV/sun exposure, avoid sick
people (due to risk of infection w/immunosuppressants).
Complications: Renal failure
IMMUNE SYSTEM
IMMUNE SYSTEM
Gout
Gout: Inflammatoryarthritis, resulting information of uric
acid crystals in joints and body tissues.
Risk factors: Obesity, alcohol consumption, high purine
diet (meat), cardiovascular disease, starvation dieting.
S&S: Severe joint pain (most common in
metatarsophalangeal joint in great toe). Erythema,
swelling, warmth in affected joint. Tophi w/chronic gout.
Meds:
• Acute gout: colchicine, NSAIDs, corticosteriods.
• Chronic gout: allopurinol, probenecid.
R_h_e_u_m_a_t_o_id_A_rt_h_r_i_ti_s--'(_R_A ...... )
RA: Chronic, progressive autoimmune disease that
causes inflammation, thickening, and deformation of the
joints. Joints are affected bilaterally and symmetrically.
Characterized by periods of exacerbations and remissions.
Risk factors: Female gender, ages 20-50, genetics
S&S: Joint pain, morning stiffness, fatigue, joint swelling
w/erythema and warmth, swan neck and boutonniere
deformities in fingers, subcutaneous nodules, fever, red
sclera, lymphadenopathy.
Labs: Positive Rheumatoid Factor (RF) antibody,
positive ANA titer. Elevated WBCs, ESR and CRP.
IMMUNE SYSTEM
IMMUNE SYSTEM
Rheumatoid Arthritis (RA)
Cancer
Diaqnosjs: Artl,rocentesis (aspiration of synovial fluid from
joint) to test for WBCs, RF.
Meds: NSAIDs, immunosuppressants (prednisone,
methotrexate), antimalarial agents (hydroxychloroquine).
Procedures: Plasmapheresis (to remove antibodies from
blood), total joint arthroplasty.
Patient education: Take hot shower to relieve morning
stiffness, physical activity to preserve ROM, use of assistive
devices.
Complications: Sjogren's syndrome (dry eyes, dry mouth,
dry vagina).
Risk factors: Older age, genetics, smoking, sun
exposure. Diet high in fat and/or red meat, low in fiber.
Staging (TNM):
•
•
T = Tumor (T1 - T4): size and extent of tumor
N = Node (NO - N3): number of regional lymph
notes involved.
• M = Metastasis (MO, M1): presence of metastasis
(MO= no metastasis, M1 = metastasis present).
Diagnosis: biopsy (definitive), imaging (MRI, CT, PET
scan, ultrasound).
IMMUNE SYSTEM
IMMUNE SYSTEM
-:;::-=-:.:=: -=-= =-=-=--:;::-=C-=-a::-:n::-:c:-::-:e-::-r:-::-:----:-::--::-=-::; ------
:C::::..:_:h:::,:em=oth:..:,:erapy: Preventing Infection
Treatment options: Tumor excision, chemotherapy
(destroys rapidly dividing cells, administered through
•
Initiate neutropenic precautions for WBC<
implanted port or central IV catheter), radiation therapy,
hormonal therapy, immunotherapy.
•
Complications:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Malnutrition (due to increased metabolism, inability to
digest and/or absorb nutrients, n/v due to chemo).
Infection (due to immunosuppression)
Alopecia
Mucositis (inflammation of gums/mouth).
Anemia, thrombocytopenia (due to immunosuppression).
•
•
•
•
ul.
Monitor temperature; report temp> 37.8 degrees C.
Restrict visitors who are ill, ensure visitors perform
frequent hand hygiene.
Avoid invasive procedures.
No fresh flowers, plants.
Keepdedicatedequipment in patient's room.
Administer filgrastim to increase WBC count.
IMMUNE SYSTEM
IMMUNE SYSTEM
Chemotherapy: Preventing Infection
Chemotherapy complications
Take temperature daily, report temperature greater than
37.8 degrees C.
Avoid crowds.
Avoid fresh fruits and veggies.
Avoid yard work, gardening.
Do not change cat litter box.
Do not consume fluids that have been sitting at room
temperature > 1 hour.
Wash dishes in hot water or in dishwasher.
Wash toothbrush in dishwasher daily (or rinse in bleach
solution). Do not share toiletries with others!
1,000/
Malnutrition:
• Nursing care: Administer antiemelic meds (ex: ondensetron),
meds to increase appetite (ex: megestrol)
• Patient teaching: Avoid drinking liquids with meals, eat cold or
room-temperature foods, and consume a high-calorie, high­
protein, nutrient-dense diet. Use supplements as needed.
Mucositis:
• Nursing care: Provide oral care before and after meals.
• Patient teaching: Avoid glycerin or alcohol containing
mouthwash. Rinse mouth with saline solution twice a day.
Use soft toothbrush. Eat soft/bland foods (avoid spicy, salty,
acidic foods) - scrambled eggs are a good choice.
IMMUNE SYSTEM
Chemotherapy complications
Anemia/thrombocvtopenia:
•
•
Nursing care: Administer epoetin alfa (increases
RBC) and ferrous sulfate as prescribed. Monitor
for blood in stool, urine, and vomit. Avoid IVs and
injections when possible. Apply prolonged
pressure after blood draws or injections.
Patient teaching: Use electric razor, soft
toothbrush. Avoid blowing nose vigorously. Avoid
NSAIDs. Prevent injury due to risk of bleeding.
IMMUNE SYSTEM
IMMUNE SYSTEM
Radiation t herapy
-..a...a'
External Radiation:
• Skin over target area will be marked, do not wash off
these marks.
• Wash skin over affected area with mild soap and water,
gently pat dry.
• Do not apply lotions, powders, ointments to
irradiated skin.
• Wear loose, soft clothing.
• Avoid sun or heat exposure to affected area.
Internal Radiation Therapy:
• Keep door closed, with warning on door.
• Limit visitors to 30 min. visits, maintain distance of>= 6 ft.
• Wear lead apron and dosimeter film badge.
Skin cancer
•
•
•
Squamous cell: Rough/scaly lesions; affects
epidermis.
Basal cell: Small/waxy nodules; affects epidermis
and possibly dermis. Most common type of skin
cancer.
Melanoma: New mole or change in mole. Most
deadly form of skin cancer. Use ABCDE
assessment.
IMMUNE SYSTEM
IMMUNE SYSTEM
Skin cancer
Leukemia/lymphoma
ABCDE assessment:
Leukemia: Cancer affecting WBCs; causes destruction
of bone marrow. Overgrowth of cancerous WBCs
• A = Asymmetry
prevents growth of RBCs, platelets, and normal WBCs.
• B = Border (irregular)
• C = Color (pigment varies across mole)
Lymphoma: Cancer affecting lymphocytes and lymph
• D = Diameter (width > 6mm, the size of pencil eraser) nodes. Two types: Hodgkin's and Non-Hodgkin's
• E = Evolving (change in appearance, or new
lymphoma.
bleeding).
Priorities: Prevent infection (due to neutropenia).
Prevent injury (due to thrombocytopenia).
Treatment: Excision, cryosurgery, topical
Treatment: Chemotherapy, radiation, bone marrow
chemotherapy (5-fluorouracil cream), Mohs surgery.
transplant.
IMMUNE SYSTEM
IMMUNE SYSTEM
Breast cancer
Prostate Cancer
Risk factors: Genetics (i.e. family history), early menarche, late
menopause, long-term use of oral contraceptives, smoking,
hormone replacement therapy, obesity.
S&S: Firm, non-tender, non-mobile lump. Dimpling or peau d­
erange appearance. Nipple discharge, ulceration, or retraction.
Treatment: Hormone therapy (leuprolide, tamoxifen),
chemotherapy, radiation, surgery (lumpectomy, mastectomy).
Nursing care of mastectomy:
• Teach patient to wear sling when ambulating.
• Teach patient to wear loose (non-restrictive) clothing.
• Do not administer injections, obtain blood, or take blood pressure in
affected arm.
• Encourage arm/hand exercises to prevent edema and increase ROM.
Risk factors: Older age, high fat diet, race
(African Americans at higher risk), family history.
S&S: Urinary retention, hesitancy, frequency.
Frequent bladder infections, hematuria (late sign).
Labs: Elevated PSA (> 4 ng/ml). Take PSA
before digital rectal exam.
Treatment: Hormone therapy (leuprolide),
chemotherapy, radiation, prostatectomy.
PERIOPERATIVE NURSING CARE
Surgery
Phases of Anesthesia:
• Induction: IV line inserted, pre-op meds given, airway
secured.
• Maintenance: Surgery performed, maintenance of
airway.
• Emergence: Completion of surgery, airway removed.
Surgery Meds:
• Anesthetics (ex: benzodiazepines, propofol)
• Opioid analgesics (ex: fentanyl)
• Antiemetics (ex: ondansetron, metoclopramide)
• Neuromuscular blocking agents (ex: succinylcholine)
• Anticholnergics (ex: atropine)
PERIOPERATIVE NURSING CARE
,
PERIOPERATIVE NURSING CARE
Informed Consent
Provider responsibilities:
• Communicate purpose of procedure, and complete
description of procedure in the patient's primary language
(use medical interpreter if needed).
• Explain risks vs. benefits
• Describe other options to treat the condition.
RN responsibilities:
• Make sure provider gave the patient the above information.
• Ensure patient is competent to give informed consent (i.e.
patient is an adult or emancipated minor, not impaired)
• Have patient sign consent document
• Notify provider if patient has more questions or doesn't
understand any information provided.
Malignant Hyperthermia
Malignant hyperthermia: Hypermetabolic condition
induced by anesthetic agents in surgery.
Symptoms: FEVER, tachycardia, hypotension,
tachypnea, dysrhythmias, muscle rigidity, mottled
skin, cyanosis.
Treatment:
•
•
•
•
Discontinue surgery.
Administer dantrolene (muscle relaxant) as ordered.
Administer 100% oxygen, obtain ABGs
Administer iced NaCl IV fluids, apply cooling blanket.
PERIOPERATIVE NURSING CARE
Post-op Nursing Care: PACU assessment
•
•
•
•
•
•
Assess airway. Check SpO2 (should be> 9?/o or at
pre-op level), respirations, lung sounds. Suction
secretions if needed.
Assess Circulation. Assess for signs of
hemorrhaging (hypotension, tachycardia), skin
color/temp, peripheral pulses, ECG readings.
Assess vital signs (stable for die from PACU)
Monitor l&Os. Ensure urine output >= 30 ml/hr.
Assess surgical wounds, incisions, dressings
Ensure return of gag and swallow reflexes.
PERIOPERATIVE NURSING CA
Post-op Nursing Care: Nursing care after PACU
• Encourage early ambulation.
• Prevent DVTs: apply SCDs, reposition frequently,
administer anticoagulants.
• Treat pain, nausea.
• Monitor for S&S of infection at surgical site
(redness, extreme tenderness, purulent drainage)
,
Expected findings: pink wound edges,
slight edema, slight crusting at incision line.
• Teach patient to splint w/coughing and deep
breathing.
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