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Comprehensive Final Review
Aging
Ethno-geriatrics: Is used to describe the specialty area of providing culturally competent care to ethnic elders
• Nurse should attend to primary needs first, ensuring that the pt is pain free and does not need to urinate
• All assistive devices should be in place
Older Adult Women
• Are alone (spouse has often already died) therefore they are at more risks b/c they are home alone
• They have a limited source of income so they may have high out of pocket costs
Cognitively Impaired Older
• Use memory aids for medication and appointment purposes, orientation, use of judgment, emotional
Adults
state
Rural Older Adults
• Limited access to healthcare, transportation
• RN must clearly define the lifestyle values and practices of rural life
Homeless Older Adults
• Have low income, reduced cognitive capacity and often live alone
Frail Older Adults
• Quite often have disability, multiple chronic illnesses, and the presence of geriatric syndromes
• Assess important nutritional indicators: SCALES
• S: Sadness or mood change
• C: Cholesterol, high
• A: Albumin, Low
• L: Loss or gain of weight
• E: Eating problems
• S: Shopping and food preparation problems
Chronically Ill Older Adults
• Have complications with ADLs and IADLs
End Of Life Physical Manifestations
Sensory Changes
Circulatory and Respiratory
Changes
Loss of Muscle Tone
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Blurred vision
Decreased pain and touch perception.
Blink reflex is eventually lost
Sense of touch decreases in the lower extremities first then upper.
Hearing is the last sense to remain intact.
Decreased oxygenation and circulation causes HR to weaken and slow; reducing BP progressively
The Death Rattle occurs because of mouth breathing and mucus in throat
Cheyne-Stokes occurs: alternating periods of apnea and deep, rapid breathing
Sluggish functional abilities
Facial muscles lose tone, causing the jaw to sag
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Brain Death
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Difficulty speaking
Gag reflex is lost
Constipation, distention and nausea
Cerebral cortex stops functioning or is irreversibly destroyed
Types of Grief
Definition: Grief is the emotional and behavioral response to loss. It is an emotional reaction that is necessary to maintain quality in both
emotional and physical well-being
Pathologic
• Can manifest as chronic grief when the intensity doesn’t wane after the first year.
• “Bogged Down”
Conflicted
• Bereaved person has not resolved ambivalent feelings toward the deceased
Absent
• Bereaved person appears to be coping and carrying on a s if nothing has happened
Maladaptive or Dysfunctional
• Prolonged, unresolved, or disruptive
• May be related to a real loss or a perceived loss
• Feelings and behaviors may become exaggerated and disruptive
Adaptive
• Helpful or that assists the person in accepting the reality of death
• Healthy response
Preoperative Care Teaching
• Pt has the right to know what to expect and how to participate effectively during the surgical experience
• Have balance between telling so little that the pt is unprepared, and explaining so much that the patient is overwhelmed
• Explain to patient what they will see, hear, smell and feel during the surgery: cold, bright lights, lots of unfamiliar sounds
• Explain pt will go to the OR and wake up in the PACU
General Surgery Information
• Teach Deep breathing, coughing and moving postop
• Make sure to teach rationale for above activities
• Explain if the pt will have tubes, drains, monitoring devices, or special equipment and explain what
they are for
Ambulatory Surgery
• Teaching normally done in the DR’s office prior to admission
Information
• Include time to arrive (1-2hrs before scheduled)
• Include day of information: pt registration, parking, what to wear, what to bring, and the need to
have a responsible person for transportation after surgery
• NPO and explain rationale: to decrease risk for aspiration and to decrease the risk of post op N/V
Day of Surgery Preparation
Nursing Role
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Preoperative Medications
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Transportation to the OR
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Final pre op teaching, assessment and communication of pertinent findings, and ensuring that all pre
op preparation orders have been completed and that records and reports are present and complete to
accompany the pt to the OR
Verify presence of signed operative consent, laboratory data, H&P, record of any consultations,
baseline vital signs, and RN notes complete to that point
Pt is wearing hospital gown with no underclothes (depends on surgery)
No cosmetics b/c observation of skin colour will be important
Remove nail polish: can interfere with pulse ox
ID band is present on wrist as well as allergy band if any
Can tape wedding ring to the finger
Remove all glasses and hearing aids
Be sure pt has used the rest room
Benzodiazepines and Barbiturates: used for sedative and amnestic properties
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Midazolam (Versed): Reduce anxiety
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Diazepam (Valium): Induce Sedation
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Lorazepam (Ativan): Induce amnesia
Anticholinergics: Reduce secretions
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Atropine: Decrease oral and respiratory secretions
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Glycopyrrolate: Prevent Bradycardia
Narcotics: decrease intraoperative anesthetic requirements and to decrease pain
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Morphine: Relieve discomfort
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Meperidine (Demerol): Relieve pain
Antiemetics: Given to decrease N/V
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Metoclopramide (Reglan): Increase gastric emptying
Eyedrops: pt will require multiple sets of Eyedrops administered at 5 minute intervals
Most pt’s will be advised to take routine cardiac, antihypertensive and asthma medications on the
day of surgery
PO meds should be given 60-90 minutes before the pt goes to the OR
IM and SC injections should be given 30-60 minutes before arrival at the OR
If I/P: transferred to OR in bed
If O/P: taken to OR by cart or wheelchair
RN needs to ensure safety during transportation
Instructed family where to wait
Postoperative Care Nursing Assessment
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Record time of pt’s return to unit
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Note last dose and type of apin control
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Take baseline vital signs
Assess airway and breath sounds
Assess neurologic status including LOC and movement of
extremities
Assess wound, dressing, drainage tubes
Note type and amt of drainage
Assess colour and appearance of skin
Assess urinary status
Note time of voiding
Note presence of catheter and total output
Check for bladder distention or urge to void
Note catheter patency
Assess pain and discomfort
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Postanesthesia Discharge Criteria
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Pt awake (or baseline)
VS stable
No excess bleeding or drainage
No respiratory depression
Oxygen saturation >90%
Report given
Note current pain intensity
Position for airway maintenance, comfort, safety (bed in low
position, side rails up)
Check IV infusion
Note type of solution
Note amt of fluid remaining
Note flow rate
Check integrity of insertion site and size of catheter
Attach call light within reach and orient pt to use of call light
Ensure that emesis basin and tissues are available
Determine emotional condition and support
Check for presence of family member or significant other
Orient pt and family to immediate environment
Check and carry out post op orders
Ambulatory Surgery Discharge Criteria
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All PACU discharge criteria met
NO IV narcotics for last 30 minutes
Minimal N/V
Voided (if appropriate to surgical procedure/orders)
Able to ambulate if age appropriate and not contraindicated
Responsible adult present to accompany pt
D/C instructions given and understood
Cancer
• Group of more than 200 diseases characterized by uncontrolled and unregulated growth of cells.
• Occurs in persons of all ages and ethnicities
• Cancer incidence and death rate higher in African Americans than in whites
Prevention and Detection
• Reduce or avoid exposure to known or suspected carcinogens and cancer-promoting agents,
including cigarette smoke and sun exposure
• Eat a balanced diet that includes vegetables (green, yellow, and orange), fresh fruits, whole grains,
and adequate amts of fiber, and reduce the amt of fat and preservatives, including smoked and saltcured meats
• Participate in a regular exercise regimen
• Obtain adequate, consistent periods of rest (at least 6-8 hrs per night)
• Have a health examination on a regular basis that includes a health history, physical, and specific
diagnostic rests for common cancers in accordance with American Cancer Society
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Surgery
Radiation
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Eliminate, reduce, or change the perceptions of stressors and enhance the ability to effectively cope
with stressors
Enjoy consistent periods of relaxation and leisure
Know the seven warnings signs of cancer: CAUTION
• C: Change in bowel or bladder habits
• A: A sore that doesn’t heal
• U: Unusual bleeding or discharge from any body orifice
• T: Thickening or a lump in the breast or elsewhere
• I: Indigestion or difficulty in swallowing
• O: Obvious change in a wart of mole
• N: Nagging cough or hoarseness
Learn and practice self-examinations
Seek immediate medical care if you notice a change in what is normal for you and if cancer is
suspected. Early detection of cancer has a positive impact on prognosis
Cure and Control
Oldest form of treatment
Try to remove all cancerous tissue
Can be used as supportive measures: Insertion of feeding tubes and Colostomy
Palliative: Debulking of tumor to relieve pain or pressure, Colostomy for relief of a bowel
obstruction, Laminectomy for relief of a spinal cord compression
Rehabilitative: Breast reconstruction after mastectomy
Is the emission and distribution of energy through space or a material medium
Energy produced by radiation, when absorbed into tissue, produces ionization and excitation
Local energy is sufficient to break chemical bonds in DNA, which leads to a biologic effect
Brachytherapy: Consists of implantation or insertion of radioactive materials directly into the
tumor or in close proximity to the tumor. Commonly used for tumors of the head and neck and
GYN tumors. The pt is radioactive during the time the source is in place. Maintain distance, time
and shielding are used when caring for the person with an implant. Must wear a film badge
Fatigue is common side effect: normally begins in the 3rd or 4th week of treatment
Maintain nutritional status
Keep pt active: walking programs
Bone marrow suppression
Decrease in salivary flow: lose taste
Soft, nonirritating high-protein and high-caloric foods should be offered frequently throughout the
day
Encourage nutritional supplements
Weigh pt at least twice each week
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Chemotherapy
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Administer prophylactic antiemetics 1hr before treatment
Eating a light meal before treatment may help reduce post nausea feeling
Permanent cessation of menses occurs in 95% of women less than 40 yrs of age
Offer advice on harvesting of sperm or ova
Nitrogen Mustard: Chemical warfare agent used to treat Acute Leukemia
Alkylating Agents: Damage DNA by causing breaks in the double strand helix, Nitrogen Mustard,
Cytoxan
Antimetabolites: Interfere with synthesis of DNA by mimicking certain essential cellular
metabolites that cell incorporates into synthesis of DNA; cells die immediately, MTX, 5-FU
Antitumor Antibiotics
Plant Alkaloids
Nitrosoureas
Corticosteroids
Hormone Therapy
Leukemia
General term used to describe a group of malignant disorders affecting the blood and blood forming tissues of the bone marrow, lymph
system, and spleen
Etiology and Pathophysiology
• NO single causative agent
• Result from genetic and environment influences
• Increased incidence of leukemia in radiologists, person living near nuclear bomb test sites or clear
reactor accidents, survivors of the bombing of Nagasaki and Hiroshima, and persons previously
treated with radiation or Chemo.
Classifications
• Can be done based on acute versus chronic and on the type of WBC involved
• Acute: characterized by the clonal proliferation of immature hematopoietic cells. Develops from
malignant transformation of a single type of immature hematopoietic cell, followed by cellular
replication and expansion of that malignant clone
• Chronic: involve more mature forms of WBC, and the disease onset is more gradual
• AML:
• ¼ of all leukemia’s, but about 85% of acute leukemia’s
• Onset abrupt and dramatic
• Serious infections and abnormal bleeding from the onset of the disease
• Uncontrolled proliferation of myeloblasts
• Hyperplasia of the bone marrow and spleen
• ALL:
• Most common type of leukemia in children
• 15% of acute leukemia’s in adults
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Clinical Manifestations
Diagnostic Studies
Collaborative Care
Nursing Management
Immature lymphocytes proliferate in the bone marrow
Fever at the time of diagnoses
S&S’s may appear abruptly with bleeding or fever, or may be insidious with progressive
weakness, fatigue, and bleeding tendencies
CNS manifestations
Leukemic meningitis
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• CML:
• Caused by excessive development of mature neoplastic granulocytes in the bone marrow
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Granulocytes move into the peripheral blood in massive numbers and ultimately infiltrate
the liver and spleen
• Philadelphia Chromosome
• Chronic stable phase followed by a more acute aggressive phase
• CLL:
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Production and accumulation of functionally inactive but long lived, mature appearing
lymphocytes
• B cell is involved
• The lymphocytes infiltrate the bone marrow, spleen and liver
• Lymph node enlargement
• Infection
• Hairy Cell Leukemia:
• 2% of all adult leukemias
• Seen in male pt’s over 40
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Chronic disease of lymphoproliferation predominantly involving B lymphocytes that
infiltrate the bone marrow and spleen
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Cells have a hairy appearance
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Splenomegaly common finding
• Problems are caused by bone marrow failure and the formation of leukemic infiltrates
• As the dx progresses, fewer normal blood cells are produced
• Leukemic cells infiltrate the pt’s organs, leading to problems such as splenomegaly, hepatomegaly,
lymphadenopathy, bone pain, meningeal irritation, and oral lesions
• Peripheral blood evaluation
• Bone marrow examination
• Goal of remission
• Chemo
• Bone marrow and stem cell transplantation
• Explain and teach pt about treatments, drugs and side effects.
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Laryngectomy
Removing structures above the true cords-false vocal cords and epiglottis
High risk of aspiration
Requires temporary tracheostomy
Voice is preserved unless they have a total laryngectomy
Teach Supraglottic Swallow
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Take deep breath to aerate lungs
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Perform Valsalva maneuver to approximate cords
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Place food in mouth and swallow. Some food will enter airway and remain on top of closed vocal cords
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Cough to remove food form top of vocal cords
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Swallow so food is moved from top of vocal cords
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Breathe after cough swallow sequence to prevent aspiration of food collected on top of vocal cords
Requires frequent suctioning after surgery
Cataracts
• An opacity within the crystalline lens
• May be in one or both eyes
• Third leading cause of preventable blindness
• Cataract removal is the most common surgical procedure
Etiology and Pathophysiology
• May be caused by blunt or penetrating trauma, congenital factors such as maternal rubella, radiation
or UV light exposure, corticosteroids and ocular inflammation
• Diabetes
• Altered metabolic processes within the lens cause an accumulation of water and alterations in the
lens fiber structure
Clinical Manifestations
• Decrease in vision, abnormal colour perception and glare
• Visual decline is gradual
Diagnostic Studies
• Visual acuity measurement
• Ophthalmoscopy (direct and indirect)
• Slit lamp microscopy
• Glare testing
• Keratometry and A-scan ultrasound
• Visual field perimetry
Collaborative Care
Nonsurgical
• Change prescription of glasses
• Strong reading glasses or magnifiers
• Increased lighting
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Nursing Management
• Lifestyle adjustment
• Reassurance
Acute Care: Surgical Therapy
• Preoperative
• Mydriatic, cycloplegic agents
• Nonsteroidal anti-inflammatory drugs
• Topical antibiotics
• Antianxiety medications
• Surgery
• Removal of lens
• Phacoemulsification
• Extracapsular extraction
• Correction of surgical aphakia
• Intraocular lens implantation (most frequent type of correction)
• Contact lens
• Postoperative
• Topical antibiotics
• Topical corticosteroids or other anti-inflammatory agents
• Mild analgesia
• Eye shield and activity as preferred by patient’s surgeon
• Wear sunglasses,
• Avoid extraneous or unnecessary radiation
• Maintain appropriate intake of antioxidant vitamins-C and E
• Good nutrition
• When giving topical medications for pupil dilation before surgery pt’s with dark irides may need a
larger dose
• Photophobia is common
• Use dark glasses
• When administering mydriatics use punctual occlusion
• Teach there may be scratchiness in the operative eye
• If there is intense pain call MD-may be a sign of hemorrhage, infection or increased IOP
• Surgery is only few hrs long
• Eye remains patched for 24hrs and many pt’s have good vision in their unoperated eye
After Eye Surgery Teaching
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Teach pt and family proper hygiene and eye care techniques to ensure that medications, dressings, and surgical wound are not
contaminated during necessary eye care
Teach pt and family about signs and symptoms of infection and when and how to report those to allow early recognition and tx of possible
infection
Instruct pt to comply with postop restrictions on head positioning, bending, coughing, and Valsalva maneuver to optimize visual
outcomes and prevent IOP
Instruct pt to instill eye medications using aseptic techniques and to comply with prescribed eye medication routine to prevent infection
Instruct pt to monitor pain and take prescribed medication for pain as directed and to report pain not relieved by prescribed medications
Instruct pt of the importance of continued follow up as recommended to maximize potential visual outcomes
Glaucoma
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Is a group of disorders
Characterized by:
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Increased IOP and the consequences of elevated pressure
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Optic nerve atrophy
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Peripheral visual field loss
• Directly related to the balance or imbalance of fluid
• Second leading cause of permanent blindness in the US
• Leading cause of blindness among AA
Etiology and Pathophysiology
• Improper balance between the rate of aqueous production and aqueous reabsorption
• Primary: the outflow of aqueous humor is decreased in the trabecular meshwork. The drainage
channels become clogged
• Secondary: inflammatory reasons that block the meshwork-trauma, intraocular or periorbital
neoplasms, iris neovascularization
Clinical Manifestations
• POAG: develops slowly without symptoms-no pain or pressure, don’t notice the visual loss until
peripheral vision has been severely compromised
• Eventually the pt gets tunnel vision
• Acute angle closure: sudden, excruciating pain in or around the eye, N/V
• See halos around lights
• Blurred vision
• Ocular redness
• Corneal edema-gives the cornea a frosted appearance
Diagnostic Studies
• Visual acuity measurement
• Tonometry
• Ophthalmoscopy
• Slit lamp microscopy
• Gonioscopy
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Collaborative Care
Nursing Management
• Visual field perimetry
• Fundus photography
Ambulatory/Home Care for Open-Angle
• Drug therapy
• B adrenergic blockers
• Alpha adrenergic agonists
• Cholinergic agents
• Carbonic andhydrase inhibitors
• Surgical Therapy
• Argon laser trabeculoplasty
• Cyclocryotherapy destruction of ciliary body
Acute Care Angle-Closure Glaucoma
• Topical cholinergic agent
• Hyperosmotic agent
• Laser peripheral iridotomy
• Surgical iridectomy
• Teach risk factors
• Have eye test every 2-4 yrs fo persons between 40-64 and every 1-2 yrs for 65 and older
• AA in every age category should have examinations more often
Acute Interventions
• Darkening the environment
• Applying cool compresses to the pt’s forehead
• Providing quiet and private space
Ambulatory and Home Care
• Encouragement of following medication regimen
• Provide information about the purpose, frequency and technique for administration of prescribed
agents
• Provide written copy
Gerontologic Considerations
• Older pt’s may experience an additive effect if a systemic b adrenergic blocking drug is also being
taken
• Alpha adrenergic agonists can cause tachycardia or HTN
Meniere’s Disease
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Characterized by symptoms caused by inner ear disease, including episodic vertigo, tinnitus, fluctuating sensorineural hearing loss, and
aural fullness
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Duration of attacks may be hours or days, and may occur several times a year
Autonomic symptoms include pallor, sweating, nausea, and vomiting
Diagnostic Studies
• Audiometic studies, including speech discrimination, tone decay
• Vestibular tests, including caloric test, postional test
• Electronystagmography
• Neurologic Examination
• Glycerol test
Collaborative Care
Acute Care
• Sedative (Diazepam)
• Anticholinergic (Atropine)
• Vasodilators
• Antihistamine (Benadryl)
Surgical Therapy
• Endolymphatic Shunt
• Vestibular Nerve section
• Labyrinthotomy
• Labyrinthectomy
Ambulatory/Home Care
• Diuretics
• Antihistamines
• Vasodilators
• Antiseizure drugs
• Vitamins
• Diazepam
• Low salt diet
• Restriction of caffeine, nicotine, and alcohol
Nursing Management
• During acute attack keep pt in quiet, darkened room in a comfortable position
• Teach to avoid sudden head movement or position changes
• Fluorescent or flickering lights or watching television may exacerbate symptoms and should be
avoided
• Provide emesis basin
• Keep side rails up and bed in low position to minimize falling
• Monitor I&O’s
GERD
Etiology and Pathophysiology
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Syndrome
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Clinical Manifestations
Complications
Diagnostic Studies
Collaborative Care
No one single cause
Defenses of the lower esophagus are overwhelmed by the reflux of stomach acidic contents into the
esophagus
• Predisposing conditions -hiatal hernia, incompetent LES, decreased esophageal clearance resulting
from impaired esophageal motility and decreased gastric emptying
• Heartburn-relieved with milk, alkaline substances or water
• Wheezing, coughing, and dyspnea
• Hoarseness, sore throat and sense of a lump in the throat and coking
• Hot, bitter, or sour liquid taste
• Esophagitis
• Barrett’s esophagus
• Precancerous lesion
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Replacement of the normal squamous epithelium of the esophagus with columnar epithelium
• Bronchospasm
• Laryngospasm
• Cricopharyngeal spasm
• Pneumonia RT aspiration
• Barium swallow-see if there protrusion of the upper part of the stomach
• Endoscopy-see competence of the LES and extent of inflammation, scarring and strictures
• Esophageal manometric studies-measure pressure in the esophagus and LES
• Radionuclide tests-detect reflux of gastric contents and the rate of esophageal clearance
• High dose proton pump inhibitor treatment used as a first step in the diagnosis of GERD
Lifestyle Modifications:
• Diet and drugs
• Stop smoking
Nutritional Therapy:
• Avoid fatty foods, chocolate, peppermint, coffee, and tea
• Avoid milk at night b/c milk increases gastric acid secretion
• Eat small frequent meals
• Don’t eat late
• Fluids should be taken between meals to reduce gastric distention
• Avoid tomatoes and orange juice-acidic
Drug Therapy:
• Antacids
• Antisecretory agents
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H2 receptor blockers
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Proton pump inhibitors
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Nursing Management
Gerontologic Considerations
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• Prokinetic drug therapy
• Cholinergic drugs
Surgical Therapy:
• Nissen fundoplication
• Toupet fundoplication
• Hill gastropexy
• Belsey fundoplication
Endoscopic Therapy:
• Stretta device
• Teach to avoid factors that cause reflux
• HOB is elevated
• Don’t lay down 2-3 hrs after eating
• Eat high protein, low fat diet
• Eat small frequent meals
• Loss weight
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Peptic Ulcer Disease
Condition characterized by erosion of the GI mucosa resulting from the digestive action of HCL acid and pepsin
Types: acute, chronic
Acute: associated with superficial erosion and minimal inflammation; short duration and resolves quickly when the cause is identified and
removed
Chronic: one of long duration, eroding through the muscular wall with the formation of fibrous tissue, present continuously for many
months or intermittently throughout the person’s lifetime; at least four times as common as acute erosion
Gastric and duodenal ulcers also defined as peptic ulcers
Gastric Ulcers
Lesion
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Location of lesion
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Gastric secretion
Incidence
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Superficial; smooth margins; round, oval or cone
shaped
Predominantly atrium, also in body and fundus of
stomach
Normal to decreased
Greater in women
Peak age 50-60 yr
More common in persons of lower socioeconomic
status and in unskilled laborers
Increased with smoking, drug, and alcohol use
Duodenal Ulcers
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Penetrating (associated with deformity of
duodenal bulb form healing of recurrent ulcers)
First 1-2 cm of duodenum
Increased
Greater in men, but increasing in women,
especially postmenopausal
Peak age 35 to 45 yr
Associated with psychologic stress
Increased with smoking, drug, and alcohol use
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Clinical
Manifestations
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Increase with incompetent pyloric sphincter and bile
reflux
Increased with stress ulcers after severe burns, head
trauma, and major surgery
Burning or gaseous pressure in high left epigastrium
and back and upper abdomen
Pain 1-2 hr after meals; if penetrating ulcer,
aggravation of discomfort with food
Occasional n/v, weight loss
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Recurrence rate
Complications
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High
Hemorrhage, perforation, outlet obstruction,
intractability
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Associated with other diseases (COPD,
pancreatic disease, hyperparathyroidism,
Zollinger-Ellison syndrome, chronic renal
failure)
Burning, cramping, pressure like pain across
midepigastrium and upper abdomen; back pain
with posterior ulcers
Pain 2-4 hours after meals and midmorning,
midafternoon, middle of night, periodic and
episodic
Pain relief with antacids and food; occasional
nausea and vomiting
High
Hemorrhage, perforation, obstruction
Gastric Surgery Complications
Dumping syndrome
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Postprandial hypoglycemia
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Dumping syndrome is the direct result of surgical removal of a large portion of the stomach and the
pyloric sphincter
Reduce the reservoir capacity of the stomach
Dumping syndrome more commonly experienced after a Billroth II procedure, can occur after any
gastric reconstruction and vagotomy
Associated with meals having a hyperosmolar composition
Stomach no longer has control over the amount of gastric chime entering the small intestine
Onset of sx occurs at the end of a meal or within 15 to 30 minutes after eating
Feelings of weakness, sweating, palpitations, and dizziness; sx r/t sudden decrease in plasma volume
Pt c/o abdominal cramps, borborygmi, and urge to defecate
Manifestations lasts for no longer than an hour pc
Variant of dumping syndrome
Result of uncontrolled gastric emptying of a bolus of fluid high in carbs into the small intestine
Bolus of concentrated carbs results in hyperglycemia and release of excessive amounts of insulin into the
circulation
Secondary hypoglycemia occurs
Sx occurs about 2 hours after meals
Symptoms: sweating, weakness, mental confusion, palpitations, tachycardia, and anxiety
Bile reflux gastritis
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Gastric surgery that involves the pylorus, either reconstruction or removal can result in reflux alkaline
gastritis
Prolonged contact of bile, especially bile salts causes damage to gastric mucosa
Peptic ulcer may recur after surgical tx
Sx associated with reflux alkaline gastritis are continuous epigastric distress that increases after meals
Vomiting relieves it temporarily
Administration of cholestyramine (Questran) ac or pc
Aluminum hydroxide antacids also tx
Billroth I
Gastroduodenostomy
Partial gastrectomy with removal of the distal two thirds
of the stomach and anastomosis of the gastric stump to
the duodenum
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Billroth II
Gastrojejunostomy
Partial gastrectomy with removal of the distal two thirds of the
stomach and anastomosis of the gastric stump to the jejunum
• Preferred because the duodenum is bypassed
• Prevent recurrence of duodenal ulcers
• Dumping syndrome experienced more commonly
In both procedures the antrum and pylorus are removed
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Ostomies
• Surgical procedure in which an opening is made to allow the passage of intestinal contents from the bowel to an incision or stoma
• Fecal matter is diverted through the stoma to the outside of the abdominal wall
Ileostomy
• Opening from the ileum through the abdominal wall
• Conventional or Brooke Ileostomy
• Commonly used for ulcerative colitits, Crohn’s dx and familial polyposis
Cecostomy
• Opening between the cecum and the abdominal wall
• Both cecostomies and ascending colostomies are uncommon
• Usually temporary and most often used for fecal diversion before surgery or for palliation
Colostomy
• Opening between the colon and the abdominal wall
• Proximal end of the colon is sutured to the skin
• Temporary colostomy is usually performed to protect and end to end anastomosis after a bowel
resection or is an emergency measure following bowel obstruction, abdominal trauma, or a perforated
diverticulum
• Temporary colostomies are usually located in the transverse colon
• Loop colostomy and double barrel colostomy are most commonly performed as temporary colostomies,
but they may be permanent
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Ascending Colostomy
Transverse Colostomy
Stool Consistency
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Semiliquid
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Fluid Requirement
Bowel Regulation
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Increased
No
Pouch and skin
barriers
Irrigation
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Indications for surgery
Ileostomy
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Formed
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Semiliquid to
Semiformed
Possibly increased
Uncommon
•
•
•
•
Yes
•
Yes
•
•
Yes
•
No
•
No
•
•
No
•
Perforating
diverticulitis in
lower colon
Trauma
Inoperable tumors of
colon, rectum, or
pelvis
Rectovaginal fistula
•
Same as for
ascending
Birth Defect
•
No change
Yes (if there is a
history of a regular
bowel pattern
Dependent on
regulation
Possible Q24-48hr
(If patient meets
criteria)
Cancer of the rectum
or rectosigmoidal
area
Perfoating
diverticulum
Trauma
Liquid to
Semiliquid
Increased
No
•
•
•
Ulcerative colitis
Crohn’s disease
Diseased or
injured colon
Birth defect
Familial polyposis
Trauma
Cancer
•
•
•
•
Sigmoid Colostomy
•
•
•
•
•
•
•
Parkinson’s Disease
Disease of the basal ganglia characterized by a slowing down in the initiation and execution of movement (bradykinesia), increased
muscle tone (rigidity), tremor at rest, and impaired postural reflexes.
Etiology and Pathophysiology
• Increases with age. Peak onset in the 60’s
• Onset before 50 is likely related to a genetic defect
• Encephalitis lethargica, or type A encephalitis, has been associated with the onset of parkinsonism
• Parkinson like symptoms has occurred after intoxication with carbon monoxide and manganese.
• Degeneration of the dopamine-producing neurons in the substantia nigra of the midbrain which in turn
disrupts the normal balance between dopamine and Ach in the basal ganglia.
Clinical Manifestations
• Gradual and insidious
• May involve only one side of the body
• Early signs: tremor, slight limp, or a decreased arm swing
• Late signs: shuffling, propulsive gait with arms flexed and loss of postural reflexes
• Slight change in speech
Tremor:
• 1st, only patient notices it
18
Complications
Diagnostic Studies
Collaborative Care
• Can affect handwriting
• More prominent at rest
• Aggravated by emotional stress or increased concentration
• “Pill rolling”
• Can involve the diaphragm, tongue, lips, and jaw.
Rigidity:
• 2nd sign
• Jerky
• “Cogwheel Rigidity”
• Caused by sustained muscle contraction and consequently elicits a complaitn of muscle soreness; feeling
tired and achy; or pain in the head, upper body, spine, or legs.
• Slowness of movement b/c it inhibits the alternating of contraction and relaxation in opposing muscle
groups
Bradykinesia:
• Loss of automatic movements
• Blinking of the eyelids, swinging of the facial and hand movements, and minor movement of postural
adjustment
• Swallowing may become difficult
• Malnutrition or aspiration
• Pneumonia, UTI’s, skin breakdown
• Gait slows and turning is difficult
• Constipation, ankle edema, contractures due to decreased mobility
• Orthostatic hypotension-falls
• Seborrhea (increased oily secretion of the sebaceous glands of the skin)
• Dandruff
• Excessive sweating
• Conjunctivitis
• Difficulty reading
• Insomnia
• Incontinence
• depression
• Based solely on history and the clinical features
• Diagnoses is based on 2 out of 3 clinical signs (tremor, rigidity, bradykinesia)
• Aimed at reliving symptoms
Drug therapy:
• Correcting imbalance of neurotransmitters with in the CNS
• Levodopa
19
•
•
Nursing Management
Sinemet
Anticholinergic drugs-act by decreasing the activity of Ach, providing balance between cholinergic and
dopaminergic actions.
• Antihistamines-used to manage tremors
• Amantadine-promotes the release of DA from neurons
• Selegiline-monoamine oxidase inhibitor used in combination with Sinemet
Surgical therapy:
• Aimed at relieving symptoms and usually used in patients who are unresponsive to drug therapy or who
have developed severe motor complications
• 3 categories:
1. Ablation (Destruction):
• Involves stereotactic ablation of areas in the thalamus, globus palidus, and subthalamic
nucleus
2. Deep Brain Stimulation:
• Involves placing an electrode in either the thalamus, globus pallidus, or subthalamic
nucleus and connecting it to a generator placed in the upper chest
• Device is programmed to deliver a specific current to the targeted brain location
• Can be adjusted to control symptoms better and is reversible
3. Transplantation:
• Fetal neural tissue into the basal ganglia is designed to provide DA-producing cells in the
brains
• Still in the experimental stages
Nutritional Therapy:
• Easily chewed and soft foods
• Adequate roughage and fruit to avoid constipation
• Cut food into bite sized portions
• Serve warm
• Eat 6 small meals/day
• Provide ample time for eating
• Some patient’s advised to limit protein intake in the evening b/c absorption of levodopa can be impaired
by protein ingestion
• Promotion of physical exercise
• Well balanced diet
• Teach maintenance of good health, encouragement of independence, and avoidance of complications such
as contractures
• Teach think about stepping over imaginary lines on the floor, drop rice kernels and step over them, rock
from side to side, lift the toes when stepping, take one step backward and two steps forward
20
•
•
•
•
Assess for Levodopa overdose
Use slip-on shoes and Velcro hook-and-loop fasteners or zippers on clothing, instead of buttons and
hooks
Use elevated toilet seat
Multiple Sclerosis
Chronic, progressive, degenerative disorder of the CNS characterized by disseminated demyelination of nerve fibers of the brain and
spinal cord
• Disease of young-middle age adults
• Onset normally between 15-50
• Women more affected then men
Etiology and Pathophysiology
• Cause is unknown
• Research suggests viral infections, immunologic, and genetic factors and is perpetuated as a result of
intrinsic factors
• Characterized by chronic inflammation, demyelination, and gliosis in the CNS
Clinical Manifestations
• Insidious and gradual, with vague symptoms that occur intermittently over months or years
• May not be diagnosed until long after the onset of the first symptom
• Motor, sensory, cerebellar, and emotional problems
• Weakness or paralysis of the limbs, trunk, head
• Scanning speech
• Spasticity of the muscles
• Numbness and tingling
• Patchy blindness, blurred vision, vertigo, tinnitus, decreased hearing, and chronic neuropathic pain
• Lhermitte’s Phenomenon
• Transient sensory symptom
• Electric shock radiating down the spine or into the limbs with flexion of the neck
• Nystagmus
• Ataxia
• Dysarthria
• Dysphagia
• Constipation
• Spastic bladder-lesion aboce the second sacral nerve, which cuts off suprasegmental inhibiting influences
on bladder contractility
• Sexual dysfunction-decreased libido, painful intercourse, decreased vaginal lubrication
Diagnostic Studies
• Based on history, clinical manifestations, and the presence of multiple lesions over time
• CSF-show an increase in oligoclonal immunoglobulin G, increased lymphocytes and monocytes
21
Collaborative Care
Nursing Management
Drug Therapy:
• Corticosteroids• Immunomodulators-Betaseron, Interferon
• Immunosuppressants- Axathioprine, methotrexate, Cytoxan
• Cholinergics
• Anticholinergics
• Muscle relaxants
Surgical Therapy:
• Thalamotomy (unmanageable tremor)
• Neurectomy (unmanageable Spasticity)
• Rhizotomy (unmanageable Spasticity)
• Cordotomy (unmanageable Spasticity)
Nutritional Therapy:
• Megavitamin therapy (Vit B & C)
• Diet consisting of low fat and gluten free food and raw vegetables
• High protein diet with supplementary vitamins
• Increase roughage to relieve constipation
• Exacerbations are triggered by infection, trauma, immunization, delivery after pregnancy, stress, and
change in climate
• Prevent major complications of immobility such as UTIs, pressure ulcers and respiratory infections
• Teach avoid fatigue, extreme heat and cold and exposure to infection
• Teach to achieve a good balance of exercise and rest
• Eat nutritious and well balanced meals
• Increase fiber to decrease constipation
Myasthenia Gravis
• Autoimmune disease of the neuromuscular junction characterized by the fluctuating weakness of certain skeletal muscle groups
• Can occur at any age but most commonly between 10-65
• Peak age in women 20-30
• 3 times more common in women, but at older ages both sexes are equally affected
Etiology and Pathophysiology
• Caused by autoimmune process in which antibodies attack Ach receptors, resulting in a
decreased number of Ach receptor sites at the neuromuscular junction. This prevents Ach
molecules from attaching and stimulating muscle contraction.
Clinical manifestations and Complications
• Fluctuating weakness of skeletal muscle
• Strength usually restored after a period of rest
• Muscles most often involved are the muscles that move the eyes and eyelids, chewing,
swallowing, speaking and breathing
22
•
•
•
•
Facial mobility and expression can be impaired
Voice fades after a long conversation
No sensory loss, reflexes are normal, and muscle atrophy is rare
Exacerbations can be precipitated by emotional stress, pregnancy, menses, secondary illness,
trauma, temperature extremes, and hypokalemia
• Myasthenic Crisis-acute exacerbation of muscle weakness triggered by infection, surgery,
emotional distress, or overdose of or inadequate drugs
• History and Physical examination
• EMG- may show a decrementing response to repeated stimulation of the hand muscles,
indicative of muscle fatigue
• Tensilon Test-reveals improved muscle contractility after intravenous injection of the
anticholinesterase agent edrophonium chloride
• ACh receptor antibodies
Drug Therapy:
• Anticholinesterase agents
• Corticosteroids
• Immunosuppressive agents
Surgery:
• Thymectomy
Plasmapheresis:
• Indicated for patients in crisis or in preparation for surgery when corticosteroids must be
avoided
• Maintaining adequate ventilation
• Continuing drug therapy
• Watching for side effects of therapy
• Balanced diet with food that can be chewed and swallowed easily
• Semisolid foods
• Teaching to focus on the importance of following the medical regimen, potential adverse
reactions to specific drugs, planning activities of daily living to avoid fatigue, the availability
of community resources, and the complications of the disease and therapy and what to do
about them.
Diagnostic Studies
Collaborative Care
Nursing Management
Guillian-Barre Syndrome
Etiology and Pathophysiology
•
•
•
•
Acute
Rapidly progressing
Potentially fatal form of polyneuritis
Affects the PNS and results in loss of myelin and edema and inflammation of the affected nerves, causing
23
Clinical Manifestations
Diagnostic Studies
Collaborative Care
Nursing Management
a loss of neurotransmission to the periphery
• Affects both genders
• Etiology is unknown, but is believed to be a cell mediated immunologic reaction directed at the peripheral
nerves
• Often preceded by immune system stimulation from a viral infection, trauma, surgery, viral
immunizations, HIV, or lymphoproliferative neoplasm’s
• Campylobacter jejuni
• Heterogeneous
• Symptoms usually develop 1-3 weeks after an upper respiratory or GI infection
• Weakness of the lower extremities occurs over hrs to days to weeks, usually peaking about the 14th day
• Distal muscles are more severely affected
• Numbness and tingling in the extremities
• Reduced muscle tone and lack of reflexes are common and persistent symptoms
• Pain, worse are night
• Respiratory or UTIs may occur
• immobility
• diagnosis based on patients history and clinical signs
• CSF is normal or has a low protein but after 7-10 days shows and elevated protein level to 700mg/dl
• EMG and nerve conduction studies-show sever abnormalities
• Supportive care
• Ventilatory support during the acute phase
• Plasma exchange used in the first two weeks IB of high dose Sandoglobulin-need to be well hydrated and
have adequate renal function
• After 3 weeks of disease onset, plasma exchange and immunoglobulin therapies have little value
Nutritional Therapy:
• Difficulty swallowing b/c of cranial nerve involvement-place patient in upright position and flexing the
head forward during feedings
• TPN
• Monitor body weight, albumin, and calorie counts regularly
• Support body symptoms until the patient recovers
• Monitor ABGs
• Suctioning
• Urinary retention is common for a few days
• Intermittent catheterization preferred to avoid UTIs
• PT
• Passive ROM
• Artificial tears frequently during the day
24
•
•
•
•
•
•
Inspect eyes for presence of eyelashes
Check for gag reflex
Note drooling and other secretions which may be indicative of an inadequate gag reflex
B/C of delayed gastric emptying, residual volumes of the feedings should be assessed at regular intervals
or before feedings
Monitor fluid and electrolyte balances
Begin bowel program b/c constipation is a common problem
Amyotrophic Lateral Sclerosis
•
•
•
•
•
•
•
•
•
•
•
Rare progressive neurologic disorder
Loss of motor neurons
Usually leads to death within 2-6 yrs after diagnosis
Onset between 40-70 yrs old
More common in men
For unknown reasons motor neurons in the brainstem and spinal cord gradually degenerate
Symptoms-weakness in the legs
Death is from respiratory infection secondary to compromised respiratory function
No cure
Riluzole slows the progression
• It decreases the amount of glutamate in the brain
Support the patients cognitive and emotional functions by facilitating communication, reducing risk of aspiration, decreasing pain secondary
to muscle weakness, decreasing risk of injury related to falls, providing divisional activities such as reading and human companionship, and
helping the person and family with advance are planning and anticipatory grieving related to loss of motor function and death
Seizure Disorders and Epilepsy
Seizures
• Paroxysmal, uncontrolled electrical discharge of neurons in the brain that interrupts normal function
• Often symptoms of underlying diseases
• May occur spontaneously without any apparent cause
Epilepsy
• Person has spontaneously recurring seizures caused by a chronic underlying condition
• Higher in underdeveloped countries
• Rates are higher during the first year of life, decline during childhood and adolescence, plateau in middle age, and rise sharply again
among the elderly
Etiology and Pathophysiology
• Most common cause during first 6 months of life are severe birth injury, congenital defects
involving the CNS, infections, and inborn errors of metabolism
25
•
Clinical Manifestations
Generalized Seizures
Partial Seizures
Pt’s between 2-20yrs old the primary causative factors are birth injury, infection, trauma, and
genetic factors
• Between 20-30yrs old usually occurs as the result of structural lesions, such as trauma, brian
tumors, or vascular disease
• After 50 the cause are cerebrovascular lesions and metastatic brain tumors
• ¾ of all seizure disorder cases can’t be attributed to a specific cause and are considered idiopathic
• Preferred method of classifying recurring seizures is the International Classification System
• Seizures are divided into Generalized and Partial Seizures
• Phases:
•
Prodromal-with signs or activity which precede a seizure
•
Aural-Sensory warning
•
Ictal-full seizure
•
Postictal-period of recovery after the seizure
• Characterized by bilateral synchronous epileptic discharges in the brain from the onset of the
seizure
• No warning or aura
• Pt loses consciousness for a few seconds to several minutes
Tonic Clonic Seizures
• Most common generalized seizure
• Loss of consciousness and falling to the ground
• Followed by stiffening of the body for 10-20 seconds and subsequent jerking of the extremitites for
another 30-40 seconds
• Cyanosis, excessive salivation, tongue or cheek biting and incontinence may accompany the seizure
• In postictal phase the pt usually has muscle soreness, is very tired, and may sleep for several hrs
• Pt has no memory of the seizure
Typical Absence Seizures
• Usually occurs only in kids
• May cease as kid grows older
• Brief staring spell that lasts only a few seconds
• Often unnoticed
• When untreated, may occur up to 100 times a day
• Can often be precipitated by hyperventilation and flashing lights
Atypical Absence Seizures
• Staring spell accompanied by other signs and symptoms, including brief warnings, peculiar
behaviour during the seizure, or confusion after the seizre
• Being in specific region of the cortex
• May be confined to one side of the brain and may spread to other parts of the brain
26
•
•
Complications
Diagnostic Studies
Collaborative Care
Nursing Management
Todd’s paralysis (focal weakness)
Involves lip smacking and automatisms (repetitive movements that may not be appropriate)-picking
at clothing, fumbling with objects, or walking away
Physical
• Status Epilepticus
•
State of continuous seizure activity or a condition in which seizures recur in rapid
succession without return to consciousness between seizures
•
Most serious complication of epilepsy and is a neurologic emergency
•
Neurons become exhausted and cease to function
•
Permanent brain damage may result
• Death from head injury
• Drowning in the bathtub
Psychosocial
• Associated with supernatural powers
• Possession by the devil
• Insanity
• May experience employment discrimination
• Driving laws
• Birth and development history
• Significant illnesses and injuries
• Family History
• Febrile seizures
• Comprehensive neurologic assessment
• Precipiating factors
• Antecendent events
• Seizure description
• CBC, UA, LYTES, CREA, fasting blood glucose
• Lumbar puncture
• CT, MRI, MRA, MRS, PET scans
• EEG
• Antiseizure drugs
• Surgery
• Vagal nerve stimulation
• Psychosocial counseling
• Wear helmets
• Maintain proper diet
• Adequate rest
27
•
•
•
•
•
Exercise
When seizure occurs observe and record all details of the event-onset, course and nature of the
seizure (LOC, tongue bitting, automatisms, stiffening, jerking, total lack of muscle tone), body parts
involved, presence of autonomic signs, such as dilated pupils, excessive salivation, altered
breathing, cyanosis, flushing, diaphoresis, incontinence
During the seizure maintain airway-supporting the head, turning the pt to the side, loosening
constrictive clothing, easing the pt to the floor
Don’t restrain the pt
DON”T PLACE THINGS IN THE MOUTH
Mastectomy
• Removal of breast and auxiliary lymph nodes,
• Preserves the pectorals major muscle.
• Selected if the tumor is too large to excise with good margins and attain a reasonable cosmetic result.
• Reconstructive surgery can be performed immediately following the mastectomy or delayed until post op recovery (6 months)
• The most common site of recurrence of breast cancer is at the surgical site
Follow Up Care
• The woman must be followed up for the rest of her life at regular intervals.
• Examinations every 6months for 2 years then annually thereafter.
• Most continue BSE monthly on both breast or remaining breast and mastectomy site.
• Most common site of recurrence is surgical site.
Post Mastectomy Pain Syndrome
• S/S- chest and upper arm pain, tingling down the arm, numbness, shooting/pricking pain, and
unbearable itching that persist beyond the normal 3 month healing time.
• Rx- NSAIDS, antidepressants, topical lidocaine patches, guided imagery training, physical therapy
to prevent “frozen shoulder” syndrome R/t dec. movement, and psychologic counseling.
Prostate Cancer
Pathophysiology
•
•
•
•
•
•
•
•
Androgen-dependent adenocarcinoma
The majority of tumors occur in the outer aspect of the prostate gland
Usually slow growing
Spreads by three routes: direct extension, lymph system, bloodstream
Spread by direct extension involves the seminal vesicles, urethral mucosa, bladder wall, and
external sphincter
The cancer later spreads through the lymphatic system to the regional lymph nodes
The veins from the prostate seem to be the mode of spread to the pelvic bones, head of the femur,
lower lumbar spine, and lungs
Age, ethnicity, and family history are 3 nonmodifiable risk factors
28
Clinical Manifestations
Collaborative Care
Health Promotion
•
•
•
•
•
•
•
The incidence of prostate cancer rises markedly after age 50
AA have the highest incidence of prostate cancer of any ethnic group
A high-fat diet is thought to be associated with an increased risk of prostate cancer
Occupational exposure to chemicals may be associated with higher prostate cancer risk
A history of BPH is not a risk factor
Usually asymptomatic in the early stages
Eventually, the patient may experience dysuria, hesitancy, dribbling, frequency, urgency,
hematuria, nocturia, retention, interruption of urinary system, and inability to urinate
• Pain in the lumbosacral area that radiates down to the hips or legs, when coupled with urinary
symptoms, may indicate metastasis
• The tumor can spread to pelvic lymph nodes, bones, bladder, lungs, and liver.
• Once the tumor has spread to distant sites, the major problem becomes the management of pain
• As the cancer spreads to the bones, pain becomes severe, especially in the back and legs because of
compression of the spinal cord and destruction of bone
• Early-stage prostate cancer is a curable disease in the majority of men
• Collaborative care depends on the stage of cancer and overall health of patient
Stage A (clinically unrecognized)
• Watchful waiting with annual PSA and DRE
• Radical prostatectomy
• Radiation therapy (external beam, brachytherapy)
Stage B (clinically intracapsular)
• Radical prostatectomy
• Radiation therapy
Stage C (clinically extracapsular, localized to periprostatic area)
• Radical prostatectomy
• Radiation therapy
• Hormone therapy
• Orchiectomy
Stage D (metastatic disease)
• Hormone therapy
• Orchiectomy
• Chemotherapy
• Radiation therapy to metastatic bone areas
Prognosis is very unfavorable
• Encourage patients to have annual prostate screening (PSA and DRE) starting at age 50 or younger
if risk factors are present
•
Acute Intervention
Ambulatory/Home Care
•
•
•
•
•
•
•
29
AA men and other men with family history of prostate cancer should have annual PSA and DRE
beginning at age 45
Provide sensitive, caring support for patient and family to help cope with diagnosis of cancer
Preoperative and postoperative phases of radical prostatectomy are similar to procedures for BPH
If patient is discharged with an indwelling catheter in place, the patient must be taught appropriate
catheter care
Instruct patient to clean urethral meatus with soap and water once a day, maintain high fluid intake,
keep collecting bag lower than bladder at all times, keep catheter securely anchored to inner thigh
or abdomen, and report any signs of bladder infections such as bladder spasms, fever, or hematuria
If urinary incontinence is a problem, patients should be encourage to practice pelvic floor muscle
exercises (Kegel exercises) at every urination and throughout day
Continuous practice during the 4 to 6 week healing process improves success rate
Management of pain is one of the most important aspects of nursing care for patients with stage D
prostate cancer
BPH
• BPH is an enlargement of the prostate gland resulting from an increase in the number of epithelia cells and stromal tissue.
• It is the most common problem of the adult male reproductive system.
• Prostate hyperplasia does not predispose to the development of prostate cancer.
• BPH develops in the inner part of the prostate.
• This enlargement gradually compresses the urethra, eventually leading to partial or complete obstruction.
• It is the compression of the urethra that ultimately leads to the development of clinical symptoms.
• There is no direct relationship between the size of the prostate and degree of obstruction.
• It is the location of the enlargement that is most significant in the development of obstructive symptoms.
Risk factors
• Family history
• Environment
• Diet
• Higher risk for BPH has been found in association with a diet high in zinc, butter, and margarine.
Health Promotion
• The cause of BPH is largely attributed to the aging process; the focus of health promotion is on
early detection and treatment
• A yearly medical history and DRE for men over 50 yrs of age is recommended to provide early
detection of prostate problems
• Ingestion of alcohol and caffeine tends to increase prostatic symptoms because the diuretic effect of
these substances increases bladder distention
• Compounds found in common cough and cold remedies such as pseudoephedrine and
phenylephrine often worsen the symptoms of BPH
Acute Intervention
30
• The patient with obstructive symptoms should be advised to urinate every 2 to 3 hours and when
first feeling the urge to minimize urinary stasis and acute urinary retention
• Fluid intake should be maintained at a normal level to avoid dehydration or fluid overload;
restricting fluid intake increases the chances of infection
• If the patient increases fluid intake too rapidly, bladder distention can develop because of prostatic
obstruction
Preoperative
• Urinary drainage must be restored before surgery; a urethral catheter such as a Coude (curvedtip) catheter may be needed to restore drainage
• Antibiotics are usually administered before any invasive procedure; any infection of the urinary
tract must be treated before surgery
• Restoring urine drainage and encouraging a high fluid intake (2 to 3 L/day) are also helpful in
managing infection
• The patient needs to know how the surgery may affect sexual functioning
• Inform patient that the ejaculate may be decreased in amount or totally absent
• Retrograde ejaculation results in some degree
Postoperative
• The main complications following surgery are hemorrhage, bladder spasms, urinary
incontinence, and infection
• Patient will have standard catheter or a triple lumen catheter
• Bladder irrigation is done to remove clotted blood from bladder and ensure drainage of urine
• If the bladder is manually irrigated, 50 mL of irrigating solution should be instilled and then
withdrawn with a syringe to remove clots that may be in the bladder and catheter
• With continuous bladder irrigation (CBI), irrigating solution is continuously infused and drained
from the bladder; the rate of infusion is based on the color of drainage
• Ideally the urine drainage should be light pink without clots
• The secretions that accumulate around the meatus can be cleansed daily with soap and water
• Blood clots are expected for the first 24 to 36 hrs after surgery
• Postoperative hemorrhage may occur from displacement of the catheter, dislodging a large clot,
or increases in abdominal pressure
• Traction on catheter may be applied to provide counterpressure (tamponade) on bleeding site in
prostate, thereby decreasing bleeding
• Instruct patient not to urinate around catheter because this increases the likelihood of spasm
• If bladder spasms develop, check catheter for clots
• The catheter is often removed 2 to 4 days after surgery
• The patient should urinate within 6 hrs after catheter removal
• Sphincter tone can be strengthened by Kegel exercises 10 to 20 times per hour while awake
Ambulatory/Home Care
31
• Patient should be encouraged to practice starting and stopping the stream several times during
urination to facilitate learning the pelvic floor exercises
• In some instances, control of urine may never be fully regained
• The patient can also be instructed to use a penile clamp, condom catheter, or incontinence pads
or briefs to avoid embarrassment from dribbling
Dietary intervention and stool softeners are important to prevent patient from straining while having bowel
movements
• Instructions include:
1. caring for indwelling catheter if one is left in place
2. managing urinary incontinence
3. maintaining oral fluids between 2 to 3 L/day\
4. observing for S/S of UTI and wound infection
5. preventing constipation
6. avoiding heavy lifting (more than 10 lb)
7. refraining from driving or intercourse after surgery as directed by physician
• Many men experience retrograde ejaculation because of trauma to internal
sphincter; semen is discharged into bladder at orgasm and may produce cloudy
urine when patient urinates after orgasm
• Although some patients experience concerns regarding change in sexual function,
this is not a universal concern; many men are comfortable with such changes and
view them as appropriate for their age
• The bladder may take up to 2 months to return to normal capacity
• Instruct patient to drink at least 2 L of fluid/day and urinate every 2 to 3 hrs to
flush urinary tract
Advise patient to continue to have a yearly DRE if he has had any procedure other than complete removal
of the prostate
TREATMENT
Transurethral resection of the
prostate (TURP)
DESCRIPTION
-
-
Open prostatectomy
-
Use of excision and
cauterization to remove
prostate tissue
cytoscopically
Considered the most
effective treatment of
BPH
Surgery of choice for
men with large prostates
ADVANTAGES
-
-
DISADVANTAGES
Best long-term relief of
prostatic obstruction
Erectile dysfunction
unlikely
-
Bleeding
Retrograde ejaculation
Complete visualization of
prostate and surrounding
tissue
-
ED
Bleeding
Postoperative pain
32
-
Transurethral incision of the
prostate (TUIP)
Transurethral microwave
thermotherapy (TUMT)
Transurethral needle ablation
of the prostate (TUNA)
Involves external incision
with three possible
approaches (retropubic,
perineal, suprapubic)
- Involves making
transurethral slits or
incisions into prostatic
tissue to relieve
obstruction
- Effective for men with
relatively little prostatic
involvement
Use of microwave radiating heat
to produce coagulative necrosis
of the prostate
-
Usually only indicated if
prostate gland is very
large
-
Risk of infection
-
Outpatient procedure
Minimal complications
Good for high risk
patients
No ED or retrograde
ejaculation
-
Considered temporary solution to
obstructive problem
Urinary catheter needed after
procedure
-
Low-wave radiofrequency used
to heat the prostate causing
necrosis
-
Outpatient procedure
Short procedure
ED and retrograde
ejaculation are rare
Short outpatient
procedure
ED and retrograde
ejaculation are rare
Precise delivery of heat
to desired area
Very little pain
experienced by patient
Short procedure
Minimal bleeding
Fast recovery time
Very effective
-
-
-
Laser Prostatectomy
Transurethral
electrovaporization of prostate
(TUVP)
Urethral Stents
-
Procedure uses a laser
beam to cut or destroy
part of the prostate
- Different techniques
available: visual laser
ablation of prostate,
contact laser technique,
interstitial laser
coagulation
Electrosurgical vaporization and
desiccation are used together to
destroy prostatic tissue
Insertion of self-expandable
metallic stent into urethra where
enlarged area of prostate occurs
-
-
Minimal risks
Minimal bleeding and
sloughing
Safe and effective
Low risk
-
-
-
Potential for damage to
surrounding tissue
Urinary catheter needed after
procedure
Urinary retention common
Irritative voiding symptoms
Hematuria
-
Postprocedure catheterization (up
to 7 days) needed because of
edema and urinary retention
Delayed sloughing of tissue
Takes several weeks to reach
optimal effect
Retrograde ejaculation
-
Retrograde ejaculation
Intermittent hematuria
-
Stent may move
Long-term experience is limited
-
33
•
•
PNEUMONIA
Acute inflammation of the lung parenchyma caused by a microbial agent
Leading cause of death from an infectious disease in the U.S
Etiology
• Normal Defense Mechanisms
• Factors Predisposing to Pneumonia
◊ Defense mechanisms become incompetent or are overwhelmed or overwhelmed
by the virulence or quantity of infections agents
◊ Decreased consciousness depresses the cough, which may allow aspiration of
Oropharyngeal contents into the lungs
◊ Tracheal intubation
◊ air pollution, cigarette smoking, viral upper respiratory infections, and normal
Changes of aging
◊ Malnutrition
◊ Bed rest and prolonged immobility
◊ Chronic diseases
• Acquistion of Organisms
1. Aspiration from the nasopharynx or oropharynx
2. Inhalation of microbes present in the air
3. Hematogenous spread from a primary infection elsewhere in the body
Pathophysiology
• Pneumococcal pneumonia is the most common cause of bacterial pneumonia
• 4 characteristic stages of the disease process:
1. Congestion: outpouring of fluid into the alveoli→ organisms multiply in the serous fluid, and
the infection is spread
2. Red hepatization: massive dilation of the capillaries, and alveoli are filled w/organisms,
neutrophils, RBCs and fibrin
3. Gray hepatization: blood flow decreases, and leukocyte and fibrin consolidate in the affected
part of the lung
4. Resolution
Clinical Manifestations
• CAP: fever, chills, cough productive of purulent sputum, and pleuritic chest pain,
• Elderly or debilitated pt: confusion or stupor (possibly related to hypoxia)
• Dullness to precussion, increased fremitus, bronchial breath sounds, and crackles, may be found
• Gradual onset of dry cough, headache, myalgias, sore throat, N&V and diarrhea
Complications
• Pleurisy: inflammation of the pleura
• Pleural effusion
• Atelectasis: collapsed, airless alveoli. Clear w/effective coughing and deep breathing
• Delayed resolution from persistent infection and is seen on x-ray as residual consolidation.
34
•
•
•
Diagnostic Studies
•
•
•
•
•
•
•
Collaborative Care
•
•
•
•
•
•
•
•
•
•
•
Lung abscess
Empyema: accumulation of purulent exudates in the pleural cavity. Requires antibiotic therapy and
drainage of the exudates by a chest tube or open surgical drainage
Pericarditis: from spread of the infecting organism from an infected pleura or via hematogenous route
to the pericardium
Arthritis: from systemic spread of the organism.
Meningitis
Endocarditis: organism attack the endocardium and the valves of the heart
History and physical examination
Chest x-ray: shows a typical pattern characteristic of the infecting organism and is an invaluable
adjunct in the diagnosis of pneumonia.
Gram stain of sputum: provides info on the predominant causative organism.
Sputum culture and sensitivity test: if drug resistant pathogen or organism not covered by empiric
therapy
Pulse Oximetry or ABGs
CBC, differential, and routine blood chemistries
Blood cultures
Prompt Rx w/ the appropriate antibiotic almost always cures bacterial and mycoplasma pneumonia
Oxygen therapy for hypoxemia
Analgesics to relieve chest pain
Antipyretics for significantly elevated temp
During acute febrile phase, pt’s activity should be restricted, and rest should be encouraged and
planned
Influenza vaccine is considered a mainstay of prevention and is recommended annually for use in the
individual considered to be at risk
Pneumococcal Vaccine
1. Has chronic illnesses such as lung and heart disease and DM
2. Recovering from a severe illness
3. In a long term care facility
◊ Revaccination is recommended every 5 years for immunosuppressed individuals
Drug Therapy
◊ Main problem problems are the development of resistant strains of organisms
and the pt’s hypersensitivity or allergic reaction to certain antibiotics
◊ Empiric Rx w/broad spectrum antibiotics
◊ Category 1: either azithromycin (Zinthromax) or clarithromycin (Biaxin)
◊ Doxycycline (Vibramycin) recommended for pt who is allergic to marolides, but
is not reliably active against pneumococcus organisms
35
•
Nursing Management
•
•
Types of Pneumonia
•
•
◊ Clinical response evaluated by factors such as change in fever, sputum purulence,
leukocytosis, oxygenation or x-ray patterns
Nutritional Therapy
◊ fluid intake of at least 3 L per day
◊ At least 1500 cals per day to provide energy for the increased metabolic
processes
◊ Small, frequent meals are better tolerated
Health Promotion
◊ practice good health habits, such as proper diet and hygiene, adequate rest, and
regular exercise
◊ avoid exposure to URI
◊ Pts w/altered consciousness place them in positions (side-lying, upright) that
will prevent or minimize the risk of aspiration
◊ turn and reposition pt q2h
◊ Avoid overmedication w/narcotics or sedatives, which can cause a depressed
cough reflex and accumulation of fluid in lungs
◊ Practice strict medical asepsis and adherence to infection control
Ambulatory and Home Care
◊ reassure that complete recovery is possible
◊ Emphasize the need to take all of the prescribed drug and to return for follow up
◊ Drug-drug and the food-drug interactions should be taught
◊ Deep breathing exercises should be practiced for 6-8wks
Community-Acquired Pneumonia (CAP)
◊ lower respiratory tract infection of the lung parenchyma w/onset in the
community or during the first 2 days of hospitalization
◊ Highest in the winter months
◊ Smoking is an important risk factor
◊ S.pneumoniae
◊ Category 1: outpatients w/no hist of cardiopulmonary disease, no modifying
factors
◊ Category 2: Outpatients w/cardiopulmonary disease and/or modifying factors
◊ Category 3: inpatients, not admitted to ICU
◊ Category 4: ICU admitted pts
◊ Modifying risk factors: age > 65, alcoholism, multiple medical comorbidities,
and immunosuppressive disease
Hospital Acquired Pneumonia
◊ occurring 48 hrs or longer after hospital admission and not incubating at the time
of hospitalization
36
◊ Has the highest morbidity and mortality rates of any nosocomial infection
◊ predisposing factors: immunosuppressive therapy, general debility and
endotracheal intubations
◊ Group 1: pts w/o unusual risk factors who have mild to moderate HAP w/onset at
any time during hospitalization or severe HAP of early onset
◊ Group 2: pts w/specific risk factors who have mild to moderate HAP occurring
any time during hospitalization
◊ Group 3: Pts w/sever HAP either of early onset w/specific risk factors or of late
onset
• Fungal Pneumonia
• Aspiration Pneumonia
◊ sequelae occurring from abnormal entry of secretions or substances into the lower
airway
• Opportunistic Pneumonia
◊ Pneumocystis carinii
◊ Rx trimethoprim-sulfamethoxazole (Bactrim)
◊ Risks: severe protein cal malnutrition, immune defiencies, transplants treated
w/immunosuppressive drugs, chemo, radiation and corticosteroids
•
•
•
•
TUBERCULOSIS
Infectious disease cause by Mycobacterium tuberculosis
Involves lungs, but also larynx, kidneys, bones, adrenal glands, lymph nodes, and meninges
Kills more pple worldwide than any other infectious disease
Seen disproportionately in poor, underserved and minorities
• Homeless pple, residents of inner city neighborhoods, foreign born persons, older adults, institutions, injection drug users,
socioeconomically disadvantaged, and medically underserved of all races are at risk
Etiology and Patho
• Usually spread from person to person via airborne droplets
• Repeated, close, prolonged exposure to infected person
• Can’t be spread by fomites
• When bacilli inhaled→ pass down bronchial system and implant on respiratory bronchioles or
alveoli→ multiply w/no initial resistance from host→ spred through lymphatic channels to regional
lymph node and via thoracic duct to circulating blood while cellular immune response is being
activated
• Lower lungs initial site of bacterial implantation
• Table 27-7
Clinical Manifestations
• Usually free of symptoms in early stages
• Systemic: fatigue, malaise, anorexia, weight loss, low grade fever, night sweats
37
•
Complications
Diagnostic Studies
Collaborative Care
Pulmonary manifestation: cough that becomes frequent and produces mucoid or mucopurulent
sputum, chest pain
• Chills, flulike symptoms, pleuritic pain, and productive cough
• Military TB
◊ blood invasion and spread to all body organs
Pleural Effusion and Empyema
◊ fluid accumulation in pleural area
◊ Pus in the lungs
Tuberculosis Pneumonia
◊ tubercle bacilli discharged from the liquefied necrotic lesion into the
lung or lymph nodes
• Other organ involvement
• Tuberculin Skin testing
◊ positive reaction occurs 2-12 wks after the initial infection,
corresponding to time needed to mount an immune response
◊ PPD used primarily to detect the delayed hypersensitivity
response
◊ positive reaction indicates the presence of tuberculosis
infection, BUT does not show whether the infection is
dormant or active
• Chest x-ray
◊ Important, but it’s not possible to make a diagnosis of TB
solely on the basis of this
◊ This is b/c other diseases can mimic the x-ray appearance of
TB
• Bacteriologic Studies
◊ essential for establishing a dx
◊ usually the 1st bacteriologic evidence of the presence of
tubercle bacilli
◊ 3 consecutive sputum specimens collected on diff days are
obtained and sent for smear and culture
◊ most accurate means of dx is a culture technique
◊ Disadvantage: may take 6-8wks for mycobacterium to grow
◊ Nucleic acid amplification (NAA): rapid diagnostic test.
Results available in few hrs.
• Mainstay is drug therapy
• Drug Therapy
◊Active disease
38
Nursing Management
•
•
•
•
▪ Rx consists of combination of at lest four drugs
▪ 5 primary drugs used are INH, rifampin (rifamate),
pyrazinamide, streptomycin, and ethambutol (myambutol)
▪ Pts on antiretroviral drugs for HIV can’t take rifampin b/c it
can impair the effectiveness of antiretroviral drugs
▪ Table 27-10: Regimen options
▪ Follow up care to ensure adherence to the Rx regimen
▪ Noncompliance is a major factor
▪ Critical to teach pts about the S.E of the drugs and when to
seek prompt medical attention
▪ Major S.E. of INH, rifampin and pyrazinamide is hepatitis
▪ Monitor liver function test
◊ Latent tuberculosis infection
▪ occures when an individual becomes infected
w/M.tuberculosis but doesn’t become acutely ill
▪ INH generally used
▪ qd for 6-9 months
▪ Indications for Rx: Table 27-11
◊ Vaccine
▪ bacilli Calmette-Guerin
▪ efficacy not clear
Assess for productive cough, night sweats, afternoon temp elevation, weight loss, pleuritc chest pain,
and crackles over apices of lungs
Health Promotion
◊ selective screening programs in known risk groups
◊ Chest x-ray for a person w/positive tuberculin skin test to
assess presence of TB
◊ Identify contacts of individual to be assessed for possibility
of infection
Acute Intervention
◊ In hospital: 1. placed on respiratory isolation 2. receive four
drug regimen and 3. receive an immediate medical workup
◊ negative pressure isolation room
◊ Pt should be taught ot cover nose and mouth w/tissue
every time he/she coughs, sneezes or produces sputum
◊ Tissues should be thrown in a paper bag and disposed of
w/trash, burned or flush down the toilet
Ambulatory and Home Care
◊ develop a therapeutic, consistent relationship w/ each pt
39
◊ notify public health department if drug compliance is
questionable
◊ reassure TB can be cured if the prescribe regimen is followed
ASTHMA
• Chronic Inflammatory disorder of the airways in which inflammation causes varying degrees of obstruction in the airways
• Inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness and cough, particularly at night and early morning
• African Americans have a higher hospitalization rate and mortality rate from asthma than whites
Triggers of Asthma Attack
Allergens
◊ Pollen, house dust mite, animal danders, perfumes etc
◊ Attach to IgE receptors on mast cells→ mast cell degranulation at
second exposure
• Exercise
◊ after vigorous exercise
◊ bronchospasm, SOB, cough and wheezing
◊ perform warm up of stretching for 2-3 mins before exercise
◊ Inhale meds 10-20 mins before exercise
• Respiratory Infections
◊ most common participating factor
◊ avoid pple w/colds or flu and get yearly influenza vaccinations
◊ Avoid taking OTC cold remedies unless approved by Dr
• Nose and Sinus Problems
◊ Allergic rhinitis: can be seasonal or perennial
◊ Nasal polyps
• Drugs and Food Additives
◊ NSAIDs
◊ foods, beverages and flavorings containing salicylic acid
◊ β adrenergic blockers: prevent bronchodilation
◊ ACE inhibitors produces cough
◊ Tartarazine (yellow dye #5), vitamins and sodium metabisulfite (food
preservative in fruits, beer and wine)
• GERD
• Emotional Stress
Patho
• Hallmarks are airway inflammation and non-specific hyperirritability or hyperresponsiveness
• Reduction in airway diameter and an increase in airway resistance related to mucosal inflammation,
constriction of bronchial smooth muscle, and excess production of mucus
•
Clinical Manifestations
•
•
•
•
Complications
•
•
•
•
40
Bronchial smooth muscle hypertrophy, basement membrane thickening, mucous glad hypertrophy,
thick and tenacious sputum, hyperinflation, and air trapping in the alveoli leading to increased work
of breathing
Characteristic clinical manifestations are wheezing, cough, dyspnea, and chest tightness after
exposure to precipitating factor or trigger
Wheezing unreliable sign to gauge te severity of an attack
Severely diminished breath sounds “Silent chest” ominous sign indicating severe obstruction and
impending respiratory failure
Restlessness, increased anxiety, inappropriate behavior, increased pulse and BP, and pulsus
paradoxus (drop in systolic during the inspiratory cycle >10 mm hg)
Resp rate increased (>30 bpm) w/use of accessory muscles
Hyperresonance in lungs and inspiratory or expiratory wheezing upon auscultation
Classification of asthma Table 28-2
Status Asthmaticus
◊ severe, life threatening asthma attack that is refractory to usual Rx and places pt at risk for
developing respiratory failure
◊ Causes: viral illness, ingestions of aspirin or other NSAIDs, emotional stress, increase in
environmental pollutants or other allergens exposure, abrupt discontinuation of drug therapy, abuse
of
Diagnostic Studies
Collaborative Care
aerosol med, and ingestion of β adrenergic blockers
◊ CM similar to asthma, but are more severe and prolonged
◊ extreme anxiety, fear of suffocation, severely increased work of breathing and daphoresis are
Common
◊ HTN, sinus tachycardia and ventricular arrhythmias may occur
◊ Complications: pneumothorax, pneumomediastinum, acute cor pulmonale w/ right ventricular failure
and severe respiratory muscle fatigue
◊ Death usually the result of respiratory arrest or cardiac failure
• History and Physical assessment
• Pulmonary function studies including response to bronchodilator therapy
• Peak expiratory flow monitoring
• Chest x-ray
• Measurement of ABGs or oximetry
• Allergy test testing
• Blood level of esinophils and IgE
• Education for an active partnership w/patients remains the cornerstone of asthma management and
should be carried out by health care providers
Mild Intermittent and Persistent Asthma
◊ avoid triggers of acute attacks and premedicate before exercising
41
◊ Mild: use inhaled β adrenergic agonists, cromolyn (Intal) or nedocromil (Tilade) before exercising
or
Drug Therapy
when anticipating exposure to allerges
◊ Moderate: regular or maintainence use of inhaled anti-inflammatory meds. Corticosetriods,
cromolyn
and nedocromil
◊ Persistent: inhaled or oral corticosteroids, β2 adrenergic agonists and theophylline
Acute Asthma Episode
◊ O2 therapy started immediately, monitored by pulse ox
◊ Initial therapy: inhaled β2 adrenergic agonists administered by MDI. Every 20mins to 4 hrs
◊ Corticosteriods if initial response insufficient
Status Asthmaticus
◊ focuses on correcting hypoxemia and improving ventilation
◊ typical MDI use is 2-6 puffs every 5-20mins
◊ Continous monitoring critical
◊ inhaled β2 adrenergic drugs or anticholinergic agents
◊ IV aminophylline and corticosteriods
◊ O2 by mask or nasal prongs
◊ IV fluids
◊ IV magnesium
◊ heliox therapy
Antiinflammatory Drugs
◊ Corticosteroids: most potent and effective anti-inflammatory med currently available.
Suppress inflammatory response
▪ block the late phase response and subsequent bronchial hyperresponsiveness
▪ Onset action approximately 3-6hrs after oral admin
▪ oropharyngeal candidiasis, hoarseness and dry cough are local adverse effects caused by
inhalation of corticosteroids
▪ insomnia, heartburn, mood swings, blurry vision, headache, increased appetite and
weight gain are side effects of oral corticosteroids
◊ Cromolyn and nedocromil: inhibit the immediate response from exercise and allergens and
prevent the late phase response
◊ Leukotrene modifiers: interfere with the synthesis or block the action of leukotrienes
Bronchodilators: 3 classes
◊ β adrenergic agonist: short term relief and choice Rx for acute exacerbations of asthma
▪ Onset w/in mins and effective for 4-8 hrs
▪ If used often may produce tremors, anxiety, tachycardia, palpitations, and nausea
◊ Methylxanthines: bronchodilation, which is useful in the early phase response
◊ Anticholinergic drugs: inhibit only the component of bronchoconstriction related to the
42
Nursing Management
parasympathetic nervous system
▪ used in combination with other bronchodilators
▪ onset is slower than β2 adrenergic agonists, peaking at 1 hr and lasting longer, usually
up to 4-6 hrs.
◊ Monoclonal antibody of IgE: Omalizumab (Xolair) decreases circulating free IgE levels
▪ prevents IgE from attaching to mast cells, thus preventing the release of chemical
mediators
▪ Used to treat patients who have been inadequately controlled with inhaled
corticosteroids
Patient Teaching related to drug therapy
◊ Info about med should include the name, dosage, method of admin and schedule
◊ Major factors determining success in asthma management is the correct administration of
drugs
◊ Inhalation is preferred b/c a lower dose is needed and systemic effects are reduced
◊ It is important to explain to the pt the importance and purpose of taking the long term
therapy regularly, emphasizing the maximum improvement may take more than 1 week
Nonprescription combination drugs
◊ Usually combos of a bronchodilator, an expectorant and a sedative
◊ Generally should be avoided
◊ Some dangers of these drugs:
▪ Epinephrine, found in Primatene spray, acts only for short time and may increase the pt’s
HR and BP. Not recommended for use
▪ Teophylline, taken with other xanthines including caffeine, has an additive effect. Side
effects include CNS and cardiovascular effects, vomiting, nausea and anorexia
▪ A combo of ephedrine and theophylline causes synergistic stimulation of CNS and cardio
system. Side effects include nervousness, heart palpitations and arrhythmias, tremors,
insomnia and increases BP
• Health Promotion
◊ Pt should be taught to identify and avoid known personal triggers for asthma and irritants
◊ use dust covers on mattresses can significantly reduce exposure to dust mites
◊ dress properly w/carves or using a mask to reduce the risk if cold air can’t be avoided
◊ aspirin and NSAIDs should be avoided
◊ encouraged to maintain a fluid intake of 2-3 L per day, good nutrition and adequate rest
• Acute intervention
◊ monitor respiratory and cardiovascular systems
◊ administer O2, bronchodilators, chest physiotherapy, and meds and ongoing pt monitoring
◊ encourage slow breathing using pursed lips for prolonged exhalation during acute attack
• Ambulatory and Home Care
◊ good nutrition and physical exercise are important
43
◊ Involve family in the management plan
◊ emphasize the importance of monitoring PEFR daily because asthma tends to worsen
gradually over time
◊ Counseling may be indicated to help pt and family
◊ Relaxation therapy may help pt relax respiratory muscles and decrease the respiratory rate
•
•
•
EMPHSEMA AND CHRONIC BRONCHITIS
COPD is a disease state characterized by the presence of airflow obstruction caused by chronic bronchitis or emphysema
Chronic bronchitis is the presence of chronic productive cough for 3 months in each of 2 successive years in a pt
Emphysema is a abnormal enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls and
w/o obvious fibrosis
Etiology
• Cigarette Smoking
◊ major risk factor
◊ remains the most preventable cause of premature death in U.S
◊ smoke causes hyperplasia of cell, which results in increased mucous production
◊ reduces O2 carrying capacity
• Infection
◊ impair normal defense mechanisms, making the bronchioles and alveoli more susceptible to injury
• Heredity
◊ α1-Antitrypsin (AAT) deficiency is the only known genetic abnormality that leads to COPD
• Aging
◊ results from changes in the lung structure, thoracic cage and respiratory muscles
Patho
• Emphysema
◊ hyperinflation of alveoli
◊ destruction of alveolar walls
◊ destruction of alveolar capillary walls
◊ narrowed, tortuous, small airways
◊ loss of lung elasticity
◊ 2 major types
1. Centrilobular: area of involvement is the central part of the lobule. Respiratory bronchioles
enlarge→ wall are destroyed→ bronchioles become confluent. Often associated w/ chronic
bronchitis
2. Panlobular: distention and destruction of the whole lobule. Usually found in pple w/AAT
deficiency
• Chronic Bronchitis
◊ hyperplasia of mucous-secreting glands in the trachea and bronchi
◊ increase in goblet cells
◊ disappearance of cilia
44
Clinical Manifestations
•
•
Complications
•
•
•
•
Diagnostic Studies
•
•
•
•
•
•
•
•
•
◊ chronic inflammatory changes and narrowing of small airways
◊ altered function of alveolar macrophages, leading to increase bronchial infections
◊ alveolar structure and capillaries are normal
◊ chronic inflammation is the primary pathologic mechanism
Emphysema
◊ dyspnea is an early symptom
◊ barrel chest
◊ Hypoxemia maybe be present (exercise) and hypercapnia develops later in the disease
◊ Underweight
◊ protein calorie malnutrition
Chronic Bronchitis
◊ frequent, productive cough during most winter months is the earliest symptom
◊ Bronchospasms at the end of paroxysms of coughing
◊ normal weight or heavyset, w/ ruddy appeareance
◊ hypoxemia and hypercapnia result from hypoventilation cause by increased airway resistance
◊ bluish-red colored skin from polycythemia and cyanosis
◊ Hgb 20 g/dl or more
Comparison of both Table 28-15
Cor Pulmonale
◊ hypertrophy of the right side of the heart resulting from pulmonary HTN
◊ distended neck veins, hepatomegaly
◊ Management: continuous low-flow O2, dietary salt restriction
Acute Exacerbations of Chronic Bronchitis
◊ CM: worsened cough, hemoptysis, wheezing, increased SOB, and changes in the amount, color,
consistency or viscosity of the sputum
◊ Rx w/antibiotics, corticosteroids, humidification, and postural drainage
Acute Respiratory Failure
◊ Respiratory tract infection or acute bronchitis most common
PUD and GERD
Pneumonia
To determine the major disease component of COPD, severity of the disease and the impact of
disease on the pt’s quality of life
H&P examination
Pulmonary function tests
Chest x-ray
ABGs
ECG
Exercise testing w/oximetry
45
Collaborative Care
•
•
•
•
•
•
•
•
•
•
Nursing Management
•
Echocardiogram or cardiac nuclear scans
Primary goals are to 1) improve ventilation, 2) promote secretion removal, 3) prevent complications,
4) promote pt comfort and participation in care, and 5) improve quality of life as much as possible
Have influenza vaccine yearly and pneumococcal vaccine every 5 yrs
Most common antibiotics are amoxicillin, amoxicillin w/clavulanate, cipro, erythromycin and
trimethoprim-sufamethoxazole (Bactrim)
Smoking Cessation
◊ most significant factor in slowing the progression of the disease
Drug Therapy
◊ Bronchodilator therapy
◊ Cortiosteriods
O2 Therapy
Surgical Therapy for COPD
◊ lung volume reduction surgery: decreases airway obstruction
◊ lung transplantation
Respiratory Therapy
◊ PURSED-LIP BREATHING
Purpose is to prolong exhalation and prevent bronchiolar collapse and air trapping
• Breath in slow through nose
• Purse lips as if drinking through a straw
• Breath out slowly and evenly through pursed-lips
• Inhale through nose 2—3 sec
• Exhale more slowly for 4-6 sec – O2 sats
Nutritional Therapy
◊ Difficult to maintain – especially acute care
◊ Frequent small meals
◊ Vitamins
◊ Monitor electrolytes and albumin levels
◊ H&H, decrease salt intake
◊ Allow extra time for eating
◊ Adequate fluids
Health Promotion
◊ Counseling and treatment should be offered
o Clear and truthful information
o Assistance to attend a program
o Quit date
o Means to get nicotine patches
o Reassurance that quitting is difficult and may require multiple attempts
46
•
Ambulatory and Home Care
◊ SLEEP AND REST
▪Check O2 sat levels - >90%
▪Elevate the HOB
▪Clear secretions prior to sleep
▪May need an increase in O2 during sleep
◊ Pt should be encouraged to walk 15-20 mins a day w/gradual increases
DVT
Clinical Manifestations
Risk factors
Complications
Diagnostic Studies
Collaborative Care
•
May have no symptoms or have unilateral leg edema, extremity pain, warm skin, erythema and a
systemic temp greater than 100.4 F
• Positive Homans’ sign but is unreliable
• Involvement of inferior vena cava: lower extremities may be edematous and cyanotic
• Involvement of superior vena cava: upper extremities, neck, back and face
• Venous Stasis: obesity, CHF, Prolonged immobility, Stroke etc
• Endothelial Damage: abd and pelvic surgery, hst of dvt, IV drug abuse, Indwelling femoral vein
catheter etc.
• Hypercoagulability of Blood: Cigarette smoking, dehydration or malnutrition, sepsis, Antithrombin
III deficiency
• Pulmonary embolism: life threatening
• Chronic venous insufficiency: from valvular destruction, allowing retrograde flow of venous blood
• Phlegmasia cerulean dolens: swollen, blue, painful leg. Rare complication
• Blood Lab Studies: platelet count, bleeding time, INR, APTT, D-dimer
• Noninvasive Venous studies: venous Doppler evaluation, Duplex scanning
• Venogram
• Lung Scan
• Pulmonary Angiogram
• Spiral CT scan
Prevention and prophylaxis:
◊ early mobilization
◊ If on bed rest instruct pt to change position, dorsiflex their feet, and rotate their ankles q2-4h
◊ Elastic compression stocking
◊ Intermittent compression devices (ICDs): for hospitalized pts at moderate, high risk for DVT
and PE
Nonpharmacologic Therapy:
◊ elevation of the affected extremity about the level of heart
◊ Warm compresses
47
Nursing Management
Drug Therapy:
◊ Anticoagulants: heparin, LMWHs, hirudin derivatives, and coumarin compunds
Surgical Therapy
◊ Venous Thrombectomy
◊ Inferior vena cava interruption
• Acute Intervention
◊ closely observe for indication of bleeding when receiving anticoagulants
◊ Assess urine for gross or microscopic hematuria
◊ Review w/pt any meds currently being taken that my interfere w/anticoagulant therapy
◊ Monitor PTT, INR, Hgb, Hct and platelet levels
• Ambulatory and Home Care
◊ evaluate the pt’s psychologic response
◊ discharge teaching should focus on elimination of modifiable risk factors for DVT, importance of
compression stockings, monitoring of lab values, med instruction and guidelines for follow up
◊ Avoid prolonged standing or sitting in the motionless, leg dependent position
◊ Teach pt and family S&S of PE
◊ Well balanced diet is important b/c Ca and Vit E play active roles in the clotting mechanism
◊ Proper hydration
HIV/AIDS
Transmission
–Viral load – number of HIV particles in the blood
–Fragile virus – contact with infected body fluids
• Blood, semen, vaginal secretions, and breast milk
–Transmission occurs through
• Sex, blood exposure & perinatal
–Not transmitted through any casual contact
–High viral load first 2-6 months after infection and then in later stages
–Health care workers at low risk
–Most common mode of transmission is sexual contact with an infected person
–Greatest risk for exposure of HCW is through puncture (needle-sticks) wounds – 0.3%-0.4%
–Higher the patients viral load the greater the risk
–Deep puncture wounds and hollow-bore needles with visible blood
–Children – perinatal transmission
Pathophysiology
–HIV affects human cells with CD4 receptors on their surfaces
•
Lymphocytes, monocytes, macrophages, astrocytes and oligodendrocytes
48
Clinical Manifestations
Chronic HIV Infection
Diagnostic Studies
Drug Therapy
• HIV immune dysfunction caused by damage to and destruction of CD4 T-cells
–Normal CD4 T cells per microliter of blood – 800-1200
–Normal life span of a CD4 T-cell is 100 days - HIV – 2 days
–Immune problems begin to occur when CD4 levels drop below 500
–Seroconversion – Development of HIV-specific antibodies
–Flu-like symptoms – fever, sore throat, swollen glands, headache, malaise, nausea, etc.
–Acute Retroviral Syndrome – 1-3 weeks following initial exposure (includes sx such as fever, swollen
lymph glands, sore throat, nausea, malaise, muscle pain, diarrhea, headache, rash)
–Early – CD4 count is >500, VL is low (can be asymptomatic, but can have fatigtue, low grade fever,
headaches, night sweats and PGL)
–Intermediate – CD4 count drops to 200-500, VL is high
• Common infection – Candida (oral thrush) (leukoplakia)
–Late – diagnosis of AIDS after meeting CDC specific criteria – Table 14-1 on page 268
• CD4 T cells < 200
• Development of OIs (fungal, bacterial, viral, protozoal infections)
–Detection of HIV-specific antibodies
• Best test but 2 month lag time for positives
–Table 14-3 on page 271 (HIV antibody test screening process)
• EIA is done to detect serum antibodies that attach to HIV antigens
• If EIA is positive, the test is repeated
• If continuously positive, then take Western blot test or IFA
• Western Blot uses purifies HIV antigens electrophoresed gels
• IFA is used to identify HIV infected cells w/a fluorescent light
• Blood that is reactive in all 1st 3 tests is reported as HIV+
–Disease progression is followed with CD4+-T cell counts
–EIA, Western Blot (most common, definitive), IFA
–Goals of therapy:
• Dec HIV-RNA levels to 50 copies or less
• Maintain or raise CD4 levels to > 200
• Delay HIV related opportunistic infections
–Education and strict adherence to the protocol is imperative – resistance can happen rapidly
–Nucleoside Reverse Transcriptase Inhibitors (NRTI’s)
• Mechanism of axn: inserts a bit of protein into the developing HIV DNA chain, blocking further
development of the chain and leaving the strand of HIV DNA incomplete
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Nursing Management
Nursing Interventions
• AZT, Retrovir
• SE: N&V, anemia, leucopenia, myopathy, fatigue, headache
–Nonucleoside Reverse Transcriptase Inhibitors (NNRTI’s)
• Mechanism of axn: combines w/reverse transcriptase enzyme to block the process needed to convert
HIV RNA into HIV DNA
• Viramune
• SE: rash, stevens-johnson syndrome, hepatitis, inc transaminase levels
–Nucleotide Reverse Transcriptase Inhibitors
• Mechanism of axn: inhibit action of reverse trancrioptase
• Viread
• SE: N&V, vaginal irritation, renal impairment
–Protease Inhibitors (PI’s)
• Mechanism of axn: prevent the protease enzyme from cutting HIV proteins into the proper lengths
needed to allow viable virons to assemble and bud out from the cell membrane
• Viracept, indinavir
• SE: Diarrhea, Nausea, Flatulence, nephritis, kidney stones
–Fusion Inhibitors
• Mechanism of axn: prevent binding of HIV to cells, thus preventing the entry of HIV into healthy
cells
• Fuzeon
• SE: skin irritation at injection site, fatigue, nausea, neuropathy
–Review pages 272 and 273 including the tables
–Assessment of risk factors
• Four major questions
1. Ever had an blood transfusion? If so before 85?
2. Ever shared needles, syringes or other injecting equipment
3. Ever had a sexual experience?
4. Ever had and STD?
–Nursing Diagnosis – dictated by multiple variables: stage, presence of specific etiologic probs, and social
factors
–Planning – affects entire holistic person (social, economic, emotional, spiritual, and physical)
–Assist with the following:
•
•
•
Adhere to drug therapy
Promote healthy lifestyle
Prevent opportunistic disease
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Implementation
Complications
• Protect others from the disease
• Maintain, develop healthy support systems
• Activity, productivity
• Acceptance of disease , illness, disability, death – spirituality
–Health promotion – prevent disease
–Prevention of HIV infection – preventable
–Safe sex
–Risk related to drug use
–Risk associated with perinatal transmission
–Risk at work – post-exposure prophylaxis shown to significantly reduce risk
–Pneumocystis carinii pneumonia (fungus)
–Cryptococcal meningitis (yeast)
• Stiff nect
• Sensitivity to light
• Ataxia
• Flu symptons
–Mycobacterium avium complex
• Causes GI problems (diarrhea, abd pain)
• Spleen and lymph nodes
• Bone marrow
–Kaposi Sarcoma
• Neoplastic lesions on skin and oral mucosa
–Cytomegalovirus
• Esophagitis
• Colitis
• Pneumonia
• Rentinitis (leads to blindness)
HYPERTENSION
•
•
•
•
•
Sustained elevation of BP
SBP > 140.
DBP > 90.
Diagnosis requires elevated readings on 3 occasions over several weeks
AAs, Puerto Ricans, Cubans, and Mexican Americans – highest incidence.
51
•
AAs –highest incidence, develop at younger age, AA women particularly high, more aggressive with more end-organ damage, higher
mortality, AAs in SE US higher incidence, AAs produce less renin = ↓ response to ACE inhibitors (stops conversion of Ang I to Ang II)
Mechanisms involved in
• BP= CO x SVR (Systemic Vascular Resistance)
regulating BP
• CO= Stroke volume x HR for 1 minute (Total blood flow through the systemic ciculation per minute)
• SVR= force opposing the movt of blood within the blood vessels.
• Sympathetic nervous system
- Inc SNS activity= Inc HR and Contractility, Vasoconstriction in peripheral
arterioles, releases renin from kidneys.
- Baroreceptors (nerve cells): senses changes in BP, and transmitted to
vasomotor centers in the brainstem.
- Norepinephrine activates receptors located in SA node, myocardium, and vascular smooth muscle
which cause inc contractions (inotropic) and inc HR (chronotropic) and inc speed of conduction.
• Baroreceptors are specialized nerve cells loc in the carotid arteries and when stimulated by an Inc in BP,
sends impulses to the vasomotor center in the brainstem. A fall in BP sensed by baroreceptors causes an
activation of SNS.
• Vascular endothelium is a single layer that lines the blood vessels. Endothelin which is prodeuced by
endothelial cells is a potent vasoconstrictor.
• Renal system. The kidneys contribute to BP regulation by controlling sodium excretion and ECF volume.
Na retention- Water Retention- inc ECF voume - Inc venous return to the heart- Inc SV- Inc BP- Inc CO.
The renin-angiotensin system plays an imp role as well.
•Endocrine system.Stimulation of the SNS results in release of Epinephrine along with the norepinephrine by
adrenal medulla. An inc in blood sodium stimulates the release of ADH. ADH increase the ECF volume,
elevates BP.
Classifications
•Primary hypertension (95% of all cases): cause is uknown but some
contributing factors include: inc SNS ativity, Inc Na retaining hormones, inc sodium intake, DM, and
elevated allcohol intake.
o 50 million people in US.
o Prevalence increases with age.
o Incidence higher in African-Americans.
o Develops at earlier age in African-Americans.
o African-Americans have higher mortality rate at every level of HTN.
o More prevalent in less educated.
o More men than women until age 55.
o 55 to 75 equal (men and women).
o Over 75 more women
o RISK FACTORS.
▪ Heredity.
▪ H20 and Na+ retention. (The more salt, the greater the circulating volume in IVS)
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Complications
▪ Altered Renin-Angiotensin System.
▪ Stress.
▪ Increased SNS. (Fight or Flight response going on all the time)
▪ Insulin resistance and hyperinsulinemia.
▪ Endothelial cell dysfunction.
o MANIFESTATIONS
▪ Usually asymptomatic (silent killer).
▪ Symptoms signify either secondary causes or effects of sustained elevated BP on endorgans.
• CAD. (Major risk factor)
• LVH. High BP increse heart worload leading to LVH can lead to Heart Failure
• Cerebrovascular disease. Atherosclerosis is the most common cause
• Peripheral vascular disease.
• Renal insufficiency.
•Secondary hypertension (<5% adults; > 80% in children; specific cause).
• Causes.
1. Coarctation of the aorta.
2. Renal disease.
3. Endocrine disorders.
4. Neurological disorders.
5. Sleep apnea.
6. Medications.
7. Pregnancy.
• Clinical findings.
1. Unprovoked hypokalemia.
2. Abdominal bruit.
3. Variable pressures with Hx of tachycardia, sweating and tremor.
4. Family history of renal disease.
• Asymptomatic until severe.
• Symptoms secondary to pressure in target organs
• Increased workload of the heart can possibly cause CHF
53
Diagnostic studies
Collaborative Care
•CAD.
•LVH.
•CHF.
•CV disease. (Atherosclerosis is the most common ause of CVD)
•PVD.( a classic sx of PVD: intermittent claudication -muscle pain))
•Nephrosclerosis. HTN is one of the leading causes of end stage renal disease. Renal dysfuncn is the direct
result of ischemia caused by narrowed lumen of BV.
•Retinal damage. Only plac ein body where the vessels can be directly visualized, it proides imp info about
the severity and duration of the HTN.
• H&P.
• UA.
• BUN, serum creatinine.= renal involvement
• Serum electrolytes, esp. K+. checks for hyperaldosteronism (secondary HTN0
• Blood glucose. (DX of DM)
• Serum cholesterol & triglycerides.
• Uric acid.
• EKG. (provides baselines info about cardiac status; heart and lungs are married)
• Echocardiogram. (size and structure of the heart)
• Eye Exam.
• Assess BP several months before initiating TX (must have 3 consistent readings)
• Decide to TX based on overall CV risk.
• Lifestyle modifications foundation for TX.
• TX primary & systolic HTN up to age 85.
• LIFESTYLE MODIFICATIONS (takes at least 3 months)
• Dietary changes: restrict Na, caffeine, reduce cholesterol and saturated fats, maintain dietary intake of
K, Ca, Mg and restrict calories if overweight
• Limitation of alcohol intake.(Excessive alcohol consumption is the most frequent cause of secondary
HTN)
• Regular physical activity. (30 mins or more of physical activity QD)
• Avoidance of tobacco (smoking & chewing).
• Modify ETOH intake.
• Stress management.
• DRUG THERAPY
• GOAL: BP < 135/85, young adults, mild HTN.
• <140/90, older adults with elevated SBP & DBP.
• <140, older adults with ISH.
• 2 main actions of meds-
54
1. Reduction of systemic vascular resistance.
2. Reduction of volume of circulating blood.
• Diuretics: promote water and NA excretion (Lasix)
• Adrenergic (sympathetic) inhibitors: Decrease fight or flight responses; inhibit norepinephrine
release.
• Vasodilators: Decrease BP by relaxing smooth muscle.
• Angiotensen inhibitors: prevents conversion on Ang I to Ang II
• Calcium channel blockers: Inc Na excretion, prevents movt of Ca into cells.
• All patients with stages 2 or 3 not controlled by lifestyle changes.
• Causes for Lack of Response
- Nonadherence to Therapy (cost of med, dementua, inconvenient dosing, lack of
involvement, instructions not clear)
- Drug Related Causes (dosages too low, rapid inactivation, drug interaxns, inapprop
combinations)
- Associated Conditions (inc obesity, alcohol intake more than 1 oz/day)
- Secondary HTN (renal insuff, primary aldosteronism)
- Volume Overload (Inadequate diuretic therapy, excess Na intake, fluid retention
from red BP)
- Preogressive renal damage
- PseudoHTN
•
SIDE EFFECTS
• Hyperuricemia, hyperglycemia, hypokalemia-thiazide & loop diuretics.
• Hyperkalemia-potassium-sparing diuretics and ACE inhibitors.
• Impotence with many diuretics.
• Orthostatic hypotension & sexual dysfunction-adrenergic inhibiting agents.
• Tachycardia & orthostatic hypotension-vasodilators & angiotensen inhibitors.
55
Classification/Drugs to Know
Nursing Management
Gerontologic Considerations
•
•
•
•
•
Thiazide diuretics: Inhibit NaCl reabsorption, Inc excretion Na and Cl, Dec in ECF
Loop diuretics: Inc excretion Na and Cl
Potassium-sparing diuretics: Reduce K and Na exchange, Inhibit the Na retaining and K excreting effects.
Centrally-Acting Adrenergic Antagonists: Reduces sympathetic outflow from CNS.
Peripherally-Acting Adrenergic Antagonists: Prevents peripheral release of norepinephrine, resulting in
vasodilation, lowers CO and SBP more than DBP.
• Alpha Blockers: Block adrenergic effects producinf peripheral vasodilation (Dec SVR and BP)
• Beta Blockers: Reduced BP by antagonizing B-adrenergic effects. Dec CO . Dec renin secretion by
kidneys.
• Combined Alpha/Beta Blockers: Produce peripheral vasodilation, Dec HR, Red CO, SVR and BP
• Ganglionic Blockers: Interrupts adrenergic control of arteries.
• Direct Vasodilators: Reduces SVR and BP by direct arterial vasodilation
• ACE Inhibitors: Inhibit angiotensin converting enzyme, reduce conversion of Ang I to Ang II, prevent
vasoconstriction.
• Angiotensen II Receptor Blockers: Prevent action of angiotensin II and produce vasodilation and Inc salt
and H2O excretion
• Calcium Channel Blockers: Block movt of extracellular calcium into cells causing vasodilation and dec
SVR.
•Achieve and maintain desired BP.
•Understand, accept, and implement therapeutic plan.
•Experience minimal or no unpleasant side effects of therapy.
•Be confident of ability to manage and cope with this condition
•Health Promotion
• Primary Prevention.
• Lifestyle modifications.
• Diet rich in fruits, vegetables, low-fat dairy foods, reduced saturated and total fats, reduced
sodium chloride.
• Screening programs: Cholesterol, BP, Etc..
• Appropriate Technique for Measuring Blood Pressure: Too tight, falsely high/ Too loose, falsely low
• Review Table 32-13 on Page 794- Teaching Guide
• Ambulatory and Home Care
• Assist the patient in reducing BP.
• Assist with complying with TX plan.
• Patient and family education.
• Detection & reporting adverse effects of TX
• Compliance assessment and enhancement.
• Evaluating therapeutic effectiveness
• >50% US pop 65 & older.
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Isolated Systolic Hypertension
Pseudohypertension
Hypertensive Urgency
Hypertensive Emergency
Hypertensive Crisis
• Age-related physical changes.
• Loss of tissue elasticity.
• Increased collagen content-stiff myocardium.
• Increases peripheral vascular resistance.
• Decreased beta/adrenergic receptor sensitivity.
• Blunting of baroreceptor reflexes: in kidneys and crotid arteries
• Decreased renal function.
•Decreased renin response to Na+ & H2O depletion
• Sustained elevation of SBP>160 & DBP<90.
• Borderline -SBP 140-159 & DPB <90.
• More common in elderly.
• More prevalent in women & Blacks.
• Caused by loss of elasticity from atherosclerosis.
• Can occur with sclerosis of the large arteries
• Suspect if
• arteries feel rigid, or
• when few retinal or cardiac signs present.
• Use Osler’s maneuver to differentiate.
• Must use intra-arterial catheter to accurately measure if pseudohypertension is present.
• Develops over days to weeks.
• Severely elevated BP without end-organ damage.
•Ususlly do not require IV meds can be managed with oral alone.
• Develops over hours to days.
• Acute target organ damage, esp. CNS.
• Hypertensive encephalopathy.
• Intracranial or subarachnoid hemorrhage.
• Acute left ventricular failure with pulmonary edema.
• MI.
• Renal failure.
• Dissecting aortic aneurysm.
•NEED IV drugs and oral drugs
• Severe, abrupt elevation.
• DBP of 120 to 130 mm Hg.
• Rate of rise more important than absolute value.
• It is classified by degree of organ damage and the rapidity in which the BP must be lowered.
• It is important to determine cause after crisis is resolved to make sure further crisi dont occur.
57
• Clinical Manifestations
• HA.
• Nausea.
• Vomiting.
• Seizures.
• Confusion.
• Stupor.
• Coma.
• Blurred vision and transient blindness.
• Renal insufficiency.
• Nursing and Collaborative management
• Mean arterial pressure used instead of BP.
• Hospitalization.
• IV medications.
• EKG monitoring.
• Urinary output monitoring.
• Neurological monitoring