Med Surg 1, 2 & Comprehensive Rationales ,100% CORRECT

Med Surg 1, 2 & Comprehensive Rationales Med Surg 1A Topics 1. Cushing’s Syndrome (2 questions) → hypersecretion of ACTH (hormone that allows body to react to stress) ○ ● Signs & Symptoms → fatigue, muscle weakness, weight gain, thinning extremities, thin & fragile skin, moon face & ruddy complexion, hirsutism, truncal obesity, broad purple striae, bruising, impaired wound healing, increased blood pressure & sodium, hypokalemia, hyperglycemia, buffalo hump, DM ● Treatment → restore hormone balance by radiation, drug therapy or adrenalectomy (removal of one or both adrenal glands) ● Nursing Considerations → Frequently monitor VS (especially BP), monitor labs for electrolyte changes, monitor daily weight, check for signs of infection, perform passive range of motion for those that have osteoporosis or are bedridden ○ Post-surgery nursing considerations → encourage coughing & deep breathing, monitor for shock & HTN, administer cortisone as ordered ○ Diet → High in protein & potassium, but low in carbs & sodium, high calcium + vit. D 2. Hepatitis (3 questions) → inflammation of the liver that causes liver cell damage ○ ○ Chronic hepatitis ( 6 months) can lead to cirrhosis of the liver ● Causes → bacteria, toxins or viruses , 6 viral types → A, B, C, D, E, G ● Hepatitis A & E → fecal to oral (shellfish from contaminated waters is a major source) ● Hep. A stages ○ Pre-icteric: malaise, N/V, anorexia ○ Icteric: jaundice, clay colored stool, tea colored urine ○ Convalescent: SX resolves ● Hepatitis B,C, D & G → parenteral drug abuse, sex, blood & body fluids, ● Signs & Symptoms → jaundice, anorexia, RUQ pain (due to hepatomegaly), clay-colored stools, tea-colored urine (due to bilirubin leakage), apendicitispruritus, elevated LFT’s (AST & ALT) & prolonged PT ● Treatment → symptomatic → vitamin K, anti-histamines, corticosteroids, anti-emetics & apply calamine lotion ● Nursing Interventions → improve sanitation, vaccination, no ETOH, instruct pt to balance rest and activity, patient cannot donate blood! HAND WASHING #1! ● Diet: low in fat, high in carbs and protein 3. Cytoscopy → direct visualization of the urethra, bladder, ureteral orifices, and prostatic urethra ○ ○ ○ Helps assess ureters and the pelvis of each kidney ○ Can obtain a urine specimen from each kidney to evaluate its function ○ Assist in performing a biopsy ○ Assist in removing calculi from the urethra, bladder and ureter ○ Performed in both lower and upper tract ● Lower tract cystoscopy ○ Pt. is usually awake; discomfort is equal to that of catheterization ○ Viscous lidocaine can be injected prior to the study to minimize post-test discomfort ○ General anesthesia is usually administered ● Upper Tract cystoscopy ○ Pt. usually kept NPO for several hours before test ○ A sedative may be administered ○ Pt. can expect some burning on voiding, blood in urine, urinary frequency ○ Heat applications are helpful in relieving pain and relaxing muscles ● Nursing Care → monitor pt. with prostatic hyperplasia (enlarged prostate that can cause urine difficulty) for urine retention, suggest warm sitz baths and antispasmodic meds, monitor for s/s of UTI 4. Diabetes Mellitus (4 questions) → know setting priorities → Condition is characterized by a high level of glucose in the body ○ Signs & Symptoms → THE POLY’s (polyuria,polydipsia, polyphagia), weakness, dizziness, fatigue i. In Children → those above + enuresis (bed-wetting), unusual fatigue & irritability ○ Type 1 → beta cells in pancreas are destroyed and produce no insulin i. Treatment → insulin injections, continuous infusion via pump & diet control ○ Type 2 → beta cells in pancreas secrete insulin, but the body is resistant to its effects i. Treatment → insulin, oral hypoglycemic injections & diet control ○ Diet Management → monitor total calories, carbs & timing of food ○ Diet Intake → meals with complex carbs, ↓ fat, ↑ fiber, some protein i. Time meals with peak effect of insulin ii. Provide extra snacks for unplanned physical activity iii. Substitute soft foods 6-8 times per day if you cannot stick with the usual meal plan iv. If vomiting, diarrhea or fever persist take in some liquids like ½ cup coke, juice, broth or 1 cup of gatorade to maintain caloric intake every ½ hour or hour v. Report nausea, vomiting & diarrhea to HCp → extreme fluid loss = dangerous vi. Unable to retain fluids = hospitalization to prevent DKA ○ Patient Teachings → lose weight if obese, oral hypoglycemic agents, maintain healthy weight, s/s of hypoglycemia & hyperglycemia, self-monitoring of glucose, skin/foot care, importance of exercise ○ “Sick Day” Rules → guidelines for managing diabetes when ill → aimed at preventing DKA i. Take insulin or hypoglycemic agents as usual ii. Test blood glucose & urine ketones every 3-4 hrs → report elevated levels to MD iii. If you take insulin, you may need supplemental doses every 3-4 hours ○ Dawn Phenomena → early morning glucose levels are elevated caused by nocturnal release of growth hormone ○ Somogyi Effect → fall in blood glucose during the night with ↑ morning glucose levels → caused by 5. Thermal Injury (4 questions) ● First degree (Superficial partial-thickness)→ epidermis affected (destroyed or injured); painful, red, dry, min. or no edema ● Second degree (Deep partial-thickness) → epidermis and part of dermis affected; painful, red, exudes fluid, edema, blistered ● Third degree → Total destruction of epidermis, entire dermis, and in some cases subcutaneous tissue, muscle or bone; painless, varied color (white, red, black, brown or charred), dry, leathery, edema, symptoms of shock, probable hematuria (RBC in urine) and hemolysis (break down of RBC’s) ● First responder interventions: ensure safety of yourself, extinguish flames, cool burn by briefly applying cool water to burn and clothing covering burn, remove other clothing, cover wound to prevent contamination, irrigate chemical burns, asses ABC’s ● Treatment: grafts → use of skin or other materials to cover burned areas ● Nursing Care: IV Lactated Ringers, plasma; F/C to monitor I/O (should be 30ml/hr), check for s/s of fluid overload vs. dehydration, monitor BP, v/s, weight, electrolytes, wound care at least once a day (administer pain meds 30min before wound care), sterile technique, tetanus prophylaxis; high caloric, high-carb, high-protein diet, may require parenteral nutrition; estimate TBSA (total body surface area) with the Rule off 6. Herpes Zoster (Shingles) → Acute infectious viral disease that is reactive of chickenpox virus, presents as unilateral, painful rash, group of vesicles on an erythematous base along a dermatome ○ Treatment → calamine lotion to soothe itching & pain, Acyclovir, corticosteroids to reduce inflammation, vaccination to prevent or modify the disease course ● Nursing considerations: minimize pain & prevent complications, analgesics, apply compresses (wet dressings to skin lesions & cold compresses to ruptured vesicles), administer systemic corticosteroids to diminish severity, prevent spread- contagious to anyone who has not had chickenpox or is immunocompromised 7. Hernia (2 questions → know Umbilical Hernia) → protrusion of intestines through a weakness in the umbilical ring, muscle & fascia Types of Hernias ● ● Umbilical → Hernia occurring at the naval ; more common in women who are obese or multiparous ○ S/S → bulging protrusion at the umbilicus → pain, discomfort at site ○ Treatment → Size of fascial ring less than 2 cm = none; larger = surgery → laparascope ○ Nursing Care → do not use a belly band or tape a silver dollar to the area, keep pressure dressing in place until sutures are healed, sponge-bath child until the dressing is removed & keep diapers folded below the dressing ● Hiatal → opening in diaphragm through which esophagus passes ○ S/S: heartburn, full after meals, GI bleed and N/V (severe) ● Inguinal → Protrusion of the hernia sac containing the intestine of the inguinal opening 8. Incentive Spirometer → Breathing device used to maximize lung expansion by opening closed alveoli and mobilize secretions → facilitates tissue oxygenation!, prevents atelectasis ● Nursing considerations: instruct client to breath in and exhale normally, seal lips around mouthpiece, inhale slowly and deeply, holding breath for at least 3 seconds while keeping ball or cylinder elevate, exhale, take several normal breaths and repeat 4-5 to,es; client should cough after procedure to facilitate secretion removal 9. NG Tube Insertion → Tube from nose into stomach inserted to instill medication ,food, fluids, to remove stomach contents, to obtain specimen for laboratory analysis ● Insertion: ○ Measure distance from tip of nose to earlobe plus the distance from the earlobe to the bottom of the xiphoid process, mark the distance on the tube with tape ○ Lube end of tube with water-soluble lubricant, insert tube through the nose to the stomach; offer sips of water and advance gently; bend head forward to close epiglottis, closing trachea ○ Observe for respiratory distress→ an indication of misplacement in the lungs ○ If in correctly, secure tube w/ hypoallergenic tape and verify placement by evaluating gastric aspirate; aspirate should have pH of =4 ■ If in lungs = resp. distress ○ Different types of tubes: ■ Lebin tube: used for decompression and tube feeding ■ Salem tube: decompression and suction ■ Seng-staken Blakemore tube: bleeding and esophageal varices 10. Diabetic Ketoacidosis → Life-threatening condition in type 1 DM; caused by lack of insulin; body drawing on fat & protein stores for energy; ketone of Na+, Cl-, K+, water, increased RR & urine output, & leads to dehydration & hypoxia ● When acidosis is severe, Pt can lose consciousness (diabetic coma) ○ Indications of impending coma include HA, drowsiness, weakness, confusion, hypotension, tachycardia, warm dry flushed skin, dry mucous membranes, N/V, elevated temperature, polyuria, polydipsia, rapid & deep respirations (Kussmaul’s respirations), fruity odor to breath (from ketone bodies) ● Nursing intervention: administer insulin; IV fluids; electrolytes as ordered; monitor electrolytes status, I&O’s, blood glucose levels; insert & maintain NG tube & urinary catheter as needed ● Teach measures to prevent recurrence such as daily monitoring of blood glucose & monitoring ketones if blood glucose is over 250-300mg/dL, adherence to diabetes management program (including insulin administration), exercise, keeping appointments, recognizing symptoms of infection (a major cause of DKA), & phoning for assistance if symptoms noted 11. Thyroid Disorders (5 questions → know Grave’s disease & Hypothyroid) → ○ Hyperthyroidism → hypersecretion of thyroid gland (Graves Disease) i. S/S → hyperthermia, HTN, tachycardia, heat intolerance, diaphoresis, increased appetite, irritability, muscle fatigue, hyperactivity, sleep deprivation, hyperreflexia ii. Treatment → radioactive ablation, complete or partial removal, anti-thyroid meds 1. Radioactive precautions: flush toilet twice, use gloves, put clothes in radioactive sealed bag, don’t hand wash clothes (machine wash only x 2 on hot) iii. Nursing Care → monitor for thyroid storm, heart failure, cardiac dysrhythmias, quiet environment with little stimulus iv. Patient Education → high protein, carb, vitamin & mineral diet, cool clothes, balance rest & activity, may need hormone replacement therapy ○ Thyroid Storm → hyperpyrexia (fever), cardiac dysrhythmias & altered mental status → hypothermic blanket, O2 & meds to suppress thyroid ○ Hypothyroidism → low secretion or cellular resistance to thyroid hormone i. S/S → weakness, fatigue, unexplained weight gain, constipation, edema, slow pulse rate, decreased libido, infertility ii. Treatment → gradual thyroid replacement with levothyroxine iii. Nursing Care → high-bulk(protein), low-calorie diet & encourage activity ○ Myxedema → patients w/ hypothyroidism i. non-pitting edema in periorbital area & hands/feet caused by severe or long standing hypothyroidism → patient must continue meds for hypothyroidism to prevent this! 12. Immobility Hazards → know hazardous things if patient is immobile ● Includes pressure ulcers, osteoporosis, hypercalcemia, negative nitrogen balance, increased cardiac workload, orthostatic hypotension, stasis of respiratory secretions, boredom, depression ● Nursing considerations: turn frequently, provide good skin care, give high-protein diet with small-frequent feedings, rise from bed slowly, turn, cough,and deep breathe. ROM exercises at least 3x each or as much as pt. can tolerate, high protein diet, vitamin A and C ● Tx: enoxaparin → prevents DVT 13. Diabetes Insipidus → results from a deficiency in circulating ADH (vasopressin) → results from dysfunction of the pituitary gland ○ Signs & Symptoms → extreme polyuria, polydipsia (especially cold, iced drinks), nocturia, ↑ plasma osmolality, urine specific gravity 1.001-1.005, fatigue, dehydration → weight loss, poor skin turgor, dry mucous membranes, constipation, muscle weakness, tachycardia & hypotension ○ Medical Causes → brain tumor, head injury, brain surgery & lithium therapy ○ Treatment → identify cause of diabetes insipidus & treat it! Until cause is identified, give vasopressin or vasopressin stimulate to control fluid balance & prevent dehydration. You may also give thiazide diuretics to ↓ fluid volume by creating mild salt depletion ○ Nursing Considerations → monitor I&O, urine specific gravity, skin condition, check weight daily weight, s/s of hypovolemic shock (BP, HR & respirations) & monitor labs for hypernatremia ○ Complications → hypernatremia, severe dehydration & vasoconstriction 14. Hyperglycemia → elevated blood glucose level, usually associated with diabetes ○ Signs & Symptoms → THE POLY’s (polyuria, polydipsia, polyphagia), vision changes, fatigue/weakness, dry skin, slow healing wounds, recurrent infections, numbness/tingling in hands or feet ○ Treatment → varies depending on which type of diabetes i. Type 1 → insulin injections ii. Type 2 → Diet, exercise, oral hypoglycemic agents ○ Nursing Care → work with patients on management of the disorder & how to prevent acute & long-term complications 15. Hypoglycemia → abnormally low level of glucose in the blood, usually occurs suddenly as a complication of diabetes ○ Signs & Symptoms → sweating, tremors, tachycardia/palpitations, nervousness, hunger, confusion, headache ○ Treatment → give either 15 grams of carbs in the form of candy, juice or sugar, 1 mg subq or IM glucagon, 25-50 mL IV 50% dextrose in water to unconscious patients i. After symptoms resolve, give a snack of protein or starch 16. Liver: Cirrhosis (2 questions) → chronic, progressive liver disease caused usually by alcoholism, but can also be caused by viral infections, toxins, bile stasis or obstruction ○ Signs & Symptoms → indigestion, gas, constipation, N/V, esophageal varices, hematemesis, hemorrhage, ascites, anemia, edema in extremities, JAUNDICE, pruritus, DARK URINE, CLAY-COLORED STOOLS, palma erythemia ○ Treatment → must treat what is causing the cirrhosis! i. Lactalose → for ammonia ii. If ascites → paracentesis iii. Shunts to relieve portal hypertension iv. Liver transplant v. Diet: high carb, high protein ○ Nursing Care → HIGH PROTEIN DIET (high carb in early stages, but in late stages restrict fiber, protein, fat & sodium) & give supplemental vitamins i. Check skin, gums, stool & emesis regularly for bleeding ii. Apply pressure to injection sites iii. Assess fluid retention → daily weight iv. Avoid using soap when bathing patient to prevent skin breakdown v. LABS: low H & H 17. Allergy → hypersensitivity caused by exposure to an allergen, a true allergy will cause production of IgE antibodies ○ Allergic reaction is caused by large amounts of histamine being dispersed throughout the circulatory system → causes vasodilation & edema of the tissues ○ Signs & Symptoms → SOB, wheezing, inflamed airways, itching, congestion, erythema ○ Common allergens → PCN, radiopaque dyes, aspirin, blood components, Toxins (snake, bee, wasp, hornet), food (berries, milk, chocolate, eggs, shellfish, seafood, wheat, nuts) & latex i. High risk populations for latex allergy → spina bifida kids, urogenital abnormalities, spinal cord injuries, multiple surgeries, health-care workers ii. Why spina bifida kids? ○ Nursing Care → obtain detailed history, establish airway, administer epinephrine or diphenhydramine in the event of a reaction i. Latex allergy → avoid condoms, balloons, gloves, catheters, brown ace bandages, elastic pressure stockings ii. Do not give d5 LR → causes a reaction ○ Client Education → use of inhaler & epi pen, paint walls, toys should be wood, plastic or metal, remove rugs, move bed away from forced air vent ○ Allergic Rhinitis → allergic rxn that results in watery rhinorrhea, nasal obstruction, sneezing, nasal pruritus i. Nursing Care → Anti-histamines & topical anti-inflammatory drugs ○ Allergen Desensitization → used to treat the allergy when the patient is unable to avoid the allergy. Patient is exposed to larger and larger amounts of allergen in an attempt to change the immune system's response. i. Useful for environmental allergies, mostly ii. Serial injections given → start with small doses and gradually increased iii. Safety → Observe for anaphylaxis, have epi on hand, always keep client in office for 30 minutes ○ Eczema → itchy, red skin rash commonly seen in young children, may ooze and form a crust → can also form as a result of an allergen i. Common causes: milk, wheat, eggs ii. Treatment → avoid allergen, apply astringent solution, corticosteroid cream & antihistamines, keep patient from scratching 18. Dialysis (know AV fistula) → 2 types = Peritoneal & Hemodialysis ○ ○ Peritoneal → removal of excessive fluids & wastes through the peritoneal cavity by surgically inserted catheter i. Before procedure → obtain baseline vitals, breath sounds, weight, glucose & electrolyte levels ii. During procedure → infuse 1-2 L of fluid into cavity by gravity using sterile technique, leave fluid in for 20 minutes & then remove it by gravity iii. After procedure → take vital signs, check for respiratory distress, pain or discomfort, assess dressing around catheter for wetness iv. Complications → peritonitis (fever, abd pain & cloudy dialysis drainage, swelling, tenderness, redness or purulent secretions at site), abdominal pain, insufficient return of fluid v. Nursing Care → instruct patient to consume high protein & fiber diet ○ Hemodialysis → removal of excess fluids & wastes by circulating patient’s blood through a semi-permeable membrane that acts as an artificial kidney i. Done through a mature AV shunt, fistula or graft (4-6 weeks old) → created by surgical anastomosis of an artery & a vein (usually radial artery & cephalic vein) 1. Complications→ air embolism, blood leaks, blockage/clotting, contamination & exsanguination ii. Nursing Considerations → check thrill & bruit every 8 hours, do not use that site for BP or blood specimens, assess site for infection, instruct patient to not lift anything heavy on that side or sleep on top of it, monitor closely for hypotension, N/V, malaise, HA, dizziness & muscle cramps 19. Cholecystectomy (2 questions) → surgical removal of the gallbladder to restore biliary flow, can be done either laparoscopic or traditional (T-tube) ○ Before surgery → keep on clear liquids/NPO 24 hours before, assess respiratory status ○ After laparoscopic surgery → monitor wounds & dressings, anesthesia related nausea/vomiting, keep in Semi-Fowlers position, encourage early ambulation, apply heat to right shoulder to alleviate any pain caused by phrenic irritation ○ ○ After traditional surgery → Low Fowler’s position, splint the affected side, assess drainage from T tube & position (make sure it is level with abdomen) watch for signs of post cholecystectomy syndrome (fever, abd pain, jaundice) ○ ○ Patient Education → Encourage client to walk, instruct them that they will need assistance for the first 24-48 hrs after surgery, report any elevated temperatures, apply heat pad, sit-up in bed & that they should return to normal activities within one week ○ Diet: avoids spicey foods and fatty foods 20. Kidney Transplant → Transplantation of a donor kidney from a live donor or a cadaver, attractive alternative to dialysis or ESRD ○ Symptoms of Rejection → oliguria (little urine), edema, fever, hypertension, weight gain, tenderness over kidney ○ Nursing Interventions → monitor I & O’s, monitor K+ labs, and observe for signs of bleeding, report output of less than 100 mL/hr to MD ○ Patient Teaching → Record I&O’s to monitor kidney function, weigh yourself twice a week and report any rapid gain, avoid crowds or contact with people with known/suspected infections for 3 months after surgery, continue immunosuppressant therapy throughout the entire time to prevent rejection 21. Fracture → break in continuity of the bone ○ Open vs. closed fracture i. Open/compound fracture: fractured bone that breaks through the skin ii. Closed/simple fracture: does not penetrate through the skin (skin is intact) ○ Complications of fracture: fat emboli, hemorrhage, sepsis, compartment syndrome ○ Emergency Care → immobilize joint above & below fracture, cover any wound with sterile dressings, check temperature, color, sensation & cap refill, elevate above heart level to reduce swelling i. Extreme caution with spinal fractures → C-spine & log-roll patient ○ Hip Fracture (common in the elderly) → one leg may be shortened, externally rotated or adducted, be very painful, possess a hematoma, muscle spasms i. Treatment → immobilize using Buck’s traction, open or closed reduction with internal fixation, hemiarthroplasty (femoral head prosthesis) ii. Bucks traction: iii. Nursing Care → apply hip protector pads in patients at risk for falls, monitor for hypovolemic shock post surgery, use compression stockings/ICD’s or anti-coagulants to prevent DVT’s, encourage patient to keep moving by using trapeze, administer pain meds, monitor hydration/nutrition/urine output, access the 6 P’s (pain, paresthesia, pallor, paralysis, pulse, poikilothermia (unable to regulate temp.) ○ Skull Fracture → results from direct impact, signs & symptoms may not be evident immediately i. Signs & Symptoms → ecchymosis behind ears, over mastoid process (Battle’s sign) or around eyes (raccoon eyes), CSF leakage from nose or ears, cranial nerve injury manifestations 1. Complications → brain abscess, meningitis, increased ICP 22. Lyme Disease → Inflammatory disorder caused by a spirochete (Borrelia burgdorferi) → spread to humans by deer tick bites ○ Symptoms → flat, flu-like sx, slightly raised red lesions (bulls-eye pattern); fever; fatigue, chills; muscle pain; progresses to joint pain, persistent fatigue, headache, and stiff neck ○ Diagnostic Tests → blood tests to identify the bacteria → anti-body titers, ELISA, Western Blot i. Lumbar puncture to test CSF for the bacteria ii. RBC → anemia, WBC, ↑ sedimentation rate ○ Treatment → antibiotic therapy(3-4 weeks) → Doxycycline, Ceftriaxone, Azithromyocin, Amoxicillin; Analgesics & Anti-pyretics → reduce inflammation & fever, NSAIDs → treat arthritic symptoms ○ Patient Teaching → medication may be required up to 1 month → stress importance of maintaining consistent schedule of NSAIDs; provide education on transmission and prevention (wear long sleeves & pants outside in summer & early fall), use insect repellent, 23. Osteomyelitis → Infection of the bone from a soft tissue infection, bone surgery, trauma or blood-borne infection caused by Staphylococcus aureus ○ Carried by blood from primary site of infection (upper respiratory infections (URIs), otitis media, and tonsillitis). ○ Often a chronic problem → can get sepsis ○ Symptoms → fever, chills, malaise, septicemia, throbbing and deep pain & swelling over the infected area ○ Diagnostic Tests → X-rays, bone scans, blood studies (↑ WBC), wound & blood cultures to identify bacteria ○ Treatment → IV antibiotics around the clock for 3-6 weeks followed by 3 months oral antibiotic therapy i. Immobilization of the affected limb ii. Warm soaks to increase circulation iii. Surgery to expose & remove the abscess (debridement), irrigate with saline solution & apply antibiotic beads to the wound iv. Amputation to relieve pain & avoid therapy resistant osteomyelitis ○ Patient Teaching/Nursing Considerations → support affected extremity with pillows & splints to maintain proper body alignment i. Sterile technique when changing wounds ii. IV fluids, prevent dehydration, diet high in protein and vitamin C 24. Urinary Tract Infection → infection that begins in the urethra, bladder, ureters or bladder usually caused by Gram negative bacteria, more common in females than males ○ Cystitis → bladder inflammation ○ Pyelonephritis → inflammation of the kidney ○ Signs & Symptoms → frequent urination, urges, pain/burning when urinating, nocturia, pain/tenderness over bladder, cloudy or foul smelling urine, fever, retroperitoneal pain & N/V, confusion in the elderly ○ Diagnostic Tests → Clean-catch mid-stream UA, culture & sensitivity ○ Treatment → antibiotics, pyridium, vaginal estrogen therapy, ↑ fluid intake to 3000 mL/day, vitamin C & cranberry juice ○ Nursing Care → preventative education, empty bladder after sex, avoid douche/powders, wipe from front to back 25. Therapeutic Communication (2 questions) → listening to & understanding the client while promoting clarification & insight → occurs in stages during nurse interaction ○ Purpose → develops trust & promotes open communication ○ Goal → understand the client’s message, facilitate client’s verbalization of feelings, communicate nurses understanding & acceptance ○ Techniques → silence, general leads or broad openings, clarification & reflection Nurse-Patient Relationship Stages ● Pre-Interaction → review patient data ● Orientation → introduction to patient - use verbal & non-verbal skills ● Working → team building phase between you, patient & health care team ● Termination → discharge planning, nurse is no longer needed 26. Ileostomy (2 questions → know how to care for one) → surgical passage through abdominal wall (R lower quadrant) into the ileum → drains GI contents when rest of GI system cannot function properly ○ Drainage → liquid stool containing proteolytic enzymes & bile salts ○ Nursing Care → empty the bag when ⅓-½ full, change the bag every 3-7 days during inactive time (before meals or at bedtime), check skin for irritation ○ Patient Education → be cautious of high fiber & high cellulose foods (popcorn, peanuts, coconut, chinese veggies, shrimp, rice, bran, corn, peas) → may cause diarrhea i. No enteric coated meds, laxatives or enemas ii. Always report an increase or decrease in drainage to HCP 27. Anaphylaxis (2 questions) → serious, immediate multiple system response (vasogenic shock) to an antigen-antibody reaction upon exposure (rarely the first time) ○ Signs & Symptoms → feelings of impending doom/fright, weakness, sweating, sneezing, pruritus, urticaria (hives), angioedema, cardiovascular changes, respiratory discomforts & dyspnea ○ Treatment → immediate injection of epinephrine ( you may repeat every 5-20 minutes) ○ Nursing Care → maintain a patent airway is the most important thing i. Start CPR if patient goes into arrest ii. Monitor for hypotension & shock (maintain volume with volume expanders) iii. Monitor I&O, O2 & suction 28. Addison Disease (3 questions - know Addisonian Crisis) → deficiency in adrenocortical hormones ○ Addisonian Crisis → acute adrenocortical insufficiency caused by stress, surgery, trauma or infections i. Signs & Symptoms → classic shock symptoms (hypotension & cyanosis), profound weakness & fatigue, severe N/V, dehydration, H/A, confusion, abdominal pain ○ Signs & Symptoms → weakness/fatigue, anorexia/weight loss, N/V, constipation/diarrhea, BRONZE skin discoloration, increased pigmentation of the mucous membranes, poor coordination, fasting hypoglycemia, craving salty food, amenorrhea ○ Treatment → corticosteroid replacement therapy → cortisone or hydrocortisone i. Fludrocortisone to prevent dehydration & hypotension ii. In crisis → give dexamethasone, hydrocortisone or both ○ Nursing Care → monitor vitals & for s/s of shock, hyperkalemia before treatment & hypokalemia after therapy i. Glucose levels checked if patient also has diabetes ii. Diet → sodium & potassium balance iii. Record weight & monitor fluid/electrolyte intake 29. Impaired: Integument → disruption of skin surface or skin layers ○ Great indicator of overall health status & can provide info that could indicate underlying disease ○ Nursing Assessment → nails (shape, angle, texture, color), skin (vascularity, bleeding, bruising)), hair & scalp (lesions, infestations) Types of Wounds Abrasion → denuded skin Avulsion → tissue torn away from supporting structures Cut → longer than deeper, edges well defined Ecchymosis/Contusion → blood trapped under the skin Hematoma → tumorlike mass of blood trapped under the skin Laceration → irregular edges & vein bridging at site of skin tear Patterned → wound caused by object which leaves imprint Stab → deeper thain longer, well-defined edges Assess wounds for S/S of infection → purulent drainage, pain, redness, swelling, ↑ temperature & WBC ● Signs of Infection? → wound culture to determine bacteria type Types of lesions…. Pressure Ulcers → assess for redness, warmth, induration or hardness, swelling & signs of infection ● Stage 1 → area of skin with observable pressure related changes ● Stage 2 → superficial partial thickness wound that involves the epidermis & dermis ● Stage 3 → full-thickness wound with tissue damage or necrosis of subcutaneous tissue ● Stage 4 → full-thickness skin loss with extensive damage, destruction or necrosis to muscle, bone or supporting structures ○ Treatment → debridement of necrotic tissue, provide a moist wound-healing environment & good nutrition (protein, vitamin C & vitamin A) ● Pruritus → severe, intense itching, tingling & burning ○ Causes → rubbing, scratching, allergies, hyperbilirubinemia ○ Treatment → remove causative agent, corticosteroid, anti-histamines ○ Nursing Care → soothing tepid baths, short nails & mittens ● Psoriasis → chronic, noninfectious inflammatory disease of the skin ○ Signs & Symptoms → thick, itchy, silvery-white scales with symmetrical distribution → common areas are scalp, knees, sacrum, elbows & behind ears ○ Nursing Considerations → oil or coal tar bath, topical steroids, soft brush, anti-metabolites, UV light 30. SIADH → Syndrome of Inappropriate Antidiuretic Hormone → excessive amounts of antidiuretic hormone that results in water imbalance causing water intoxication caused by fluid retention ○ Signs & Symptoms → decreased LOC (cerebral edema, ↑ ICP, HA, irritability, delirium), seizures, coma, sodium less than 120 ○ Treatment → treat the underlying cause! i. Fluid restriction (500-600 mL/24 hours) ii. Sodium replacement iii. Diuretics ○ Nursing Care → daily weight, neuro checks, I&O, check electrolytes,BUN & creatinine, position flat in bed 31. Osteoarthritis (degenerative bone disease) (2 questions) → chronic degenerative disorder that causes deterioration of the joint cartilage; most common form of arthritis ○ S/S → joint pain/atrophy in the hips, knees, hands & cervical/lumbar spine & stiffness in the morning or after exercise (relieved by rest), decreased ROM, crepitus, Heberden’s & Bouchard’s nodes (bony, cartilaginous enlargements in the joints of the hands) ○ Treatment → PALLIATIVE to reduce pain, NOT CURATIVE i. Aspirin, phenylbutazone, indomethacin, ketolorac ii. Intra-articular injections of corticosteroids iii. Glucosamine & Chondroitin → improve tissue function & retard breakdown of cartilage iv. Massage, Acupuncture, moist heat, rest v. Gentle exercise, weight reduction vi. Surgical → arthroplasty, osteotomy, osteoplasty ○ Nursing Care → moderate activities, get plenty of rest, stress importance of maintaining muscle tone, recommend palliative measures (massage, acupuncture, hot soaks) 32. Rheumatoid Arthritis (3 questions) → chronic, systemic inflammatory disease that primarily attacks peripheral joints and surrounding muscles, tendons, ligaments & blood vessels ○ S/S → joints that are painful, red, warm, stiff (especially in the morning), fatigue, weight loss, anorexia ○ Treatment → immunosuppressives (methotrexate), salicylates, NSAID’s, analgesics, corticosteroids, antidepressants (sleep,depression, pain mgmt) & reconstructive surgery ○ Nursing Care → assess all joints carefully - check for deformities, contractures, immobility & inability to perform ADL’s i. Monitor vitals & note weight changes ii. Meticulous skin care & monitor duration of morning sickness iii. Tell pt to take hot showers before bedtime & eat a balanced diet iv. Apply splints carefully & observe for pressure ulcers v. Make sure pt understands the chronic nature of RA & that it will require lifestyle changes 33. Amputation (2 questions) → Surgical removal of a part of the body ○ Complications: phantom limb pain, infection, & hip contracture ○ Nursing Considerations: ROM to prevent contracture of hip, place Pt prone for 20-30 min q3-4hrs; do not elevate residual limb on a pillow after the immediate postoperative period; after the pressure dressing & drains are removed, inspect the wound for inflammation; dressing changed daily until sutures are removed; residual limb wrapped with an elastic bandage to shape the residual limb and keep the dressing in place; observe for symptoms of inadequate tissue perfusion. 34. Kidney: Nephrectomy → Removal of kidney because of tumor, infection, anomalies, advanced kidney cancer that is refractory to chemo. ○ Nursing Considerations → position client in lateral recumbent position, patient will have drains and indwelling catheter, check urine output closely (color, consistency, output → blood in urine is not normal, report to doctor), administer analgesics as prescribed, encouraged to cough and deep breathe, use incentive spirometer, splint incision to help with coughing and encourage early ambulation. i. Four Types of nephrectomy that are performed: 1. Partial Nephrectomy: portion of kidney is removed 2. Simple Nephrectomy: entire kidney is removed 3. Radical Nephrectomy: entire kidney, adrenal gland, and surrounding fat tissue are removed. Patients are placed in a side-lying position during surgery. A 7-inch flank incision just below the diaphragm is needed to perform an open radical nephrectomy. This involves removal of the 12th rib. 4. Nephroureterectomy: entire kidney, surrounding fat tissue, and entire ureter are removed. 35. Colonoscopy: direct visualization of the colon with a fiberoptic colonoscope ○ Purpose: Aids the diagnosis of inflammatory and ulcerative bowel disease, pinpoints lower GI bleeding, detects lower GI abnormalities including, polyps, hemorrhoids, and abscesses. ○ Pre-test: clear liquid diet 24 to72 hours before exam (nothing with red dye), cathartic in evening for 1-2 days before exam, enema the morning of the exam, take enema morning of exam ○ Post-test: allowing client to rest, observing for passage of blood, abdominal pain, signs of perforated bowel (fever, chills, N/V, severe abdominal pain), hemorrhage, and respiratory distress, monitor for resp. distress 36. Irritable Bowel Syndrome: Functional disorder of bowel motility ○ Cause: certain foods, food allergies ○ S/S: Constipation, diarrhea, combination of constipation and diarrhea, pain, bloating, abdominal distension. ○ Nursing considerations: diet goal of providing adequate nutrition tailored to specific GI pattern of IBS, food allergies and intolerance common. ○ Client Education: eat at regular times and slowly, chew food slowly, do not drink fluids with meals, drink fluids between meals, increase fiber along with fluids to normalize GI function while monitoring GI function closely for adverse effects, decrease anxiety and stress, avoid alcohol, large meals, simple sugars, caffeine, excess fats, and cigarettes 37. Laminectomy: Surgical removal of a section of the lamina, a portion of the vertebral body between the spinous process and facet pedicle. Excision allows health care provider the chance to inspect the spinal canal, locate and remove herniated nucleus pulposus that is impinging on spinal cord and nerves relieving and pain. ○ Cervical → lamina located in the cervical spine i. Nursing consideration: sore throat-responds to throat lozenges, humidification, and not talking. Dysphagia-pureed or soft diet easier to swallow than regular. Assess neurovascular function of upper and lower extremities and neurological function using the Glasgow coma scale. Monitor respiratory function. Hematoma formation and edema can occlude the airway. Have tracheostomy tray by room door and suction in room ready to use. Assess dressing for serosanguineous drainage indicating spinal fluid leak, also noted with the client reporting headache. Hoarseness and inability to cough effectively might represent damage to the recurrent laryngeal nerve, inability to cough could lead to atelectasis and pneumonia ii. Client Education: wear collar as directed, avoid twisting or bending or flexing or extending or rotating neck, avoid sitting or standing for over 30 minutes. ○ Lumbar → removal of one or more vertebral laminae plus osteocytes and herniated nucleus pulposus through an incision. i. Postoperative nursing care: checking for fever and hypotension, checking dressing, performing neurovascular (circulation, movement, and sensation) assessment, client should wear antiembolic stockings, log roll every 2 hours by two people, when out of bed, back should be kept straight 38. Cast Care: ○ Immediate cast care: avoid covering cast until dry, handle with palms, not fingertips (plaster cast). Avoid resting cast on hard surfaces or sharp edges. Keep affected limb elevated above heart on soft surface until dry. Observe for blueness or paleness, pain, numbness on affected area. ○ Intermediate care: encourage client to perform prescribed exercises, report any break in cast or foul odor, inform client to not scratch skin underneath cast and avoid putting anything underneath cast. ○ Types of Casts: i. Non-plaster or fiberglass cast: 1. Consist of open-weave, nonabsorbent fabric impregnated with cool water-activated hardeners. Used for nondisplaced fracture and long-term wear. ii. Plaster cast: 1. Rolls of plaster are wet with cool water and smoothed onto body; a crystallizing reaction occurs and heat is given off. ○ Complications: Pressure ulcers, Disuse syndrome, Compartment syndrome and delayed union or nonunion of fractures 39. Urinary Calculi→ (urolithiasis [kidney stone disease]) calcifications in urinary system, commonly called stones; formed in any part of the urinary tract, usually kidney (nephrolithiasis), and can migrate within tract; may be composed of one type of crystal or a combination, calcium being most common; others oxalate, struvite, uric acid, cystine, xanthine. Important to collect stones to determine composition and appropriate treatment. ○ Indications S/S: sharp, severe, sudden pain depending on location of stone, diaphoresis, N/V, fever, chills, hematuria, pallor, anxiety, increased BP and pulse. ○ Interventions: surgery, extracorporeal shock wave lithotripsy ○ Nursing Interventions: administer analgesics as prescribed, monitor I/O, force fluids (urine output should be 3-4 L/day and urine should appear colorless), strain urine and save any stone material, monitor temp., daily weights, teach diet for prevention of stones (dependent upon composition of stones). ○ Patient Teaching: teach recognition of urinary tract infections and need to contact health care provider promptly 40. Urinary Tract Disorders→ Infection of one or more structures in urinary tract (cystitis, pyelonephritis, urethritis.) Usually caused by gram-negative bacteria. ○ More common in females than males. i. Indications S/S: urinary frequency, urgency, burning, pain with voiding, nocturia, pain or tenderness over bladder, cloudy or foul smelling urine, fever with or without chills, retroperitoneal pain, nausea vomiting, possibly visible blood or pus in urine. ii. Nursing Interventions: obtain clean catch midstream urine specimen for urinalysis, culture sensitivity and possibly gram stain. Force fluids to 3000 mL/day, encourage cranberry juice or other urinary acidifiers iii. Treatment: Antibiotic therapy, Pyridium, Vaginal estrogen therapy, increased fluids, and increased vitamin C and cranberry juice intake. iv. Pt. teaching: females void following intercourse, avoidance of douche or powders, bladder cath care, clean properly after defecation (wipe front to back). ○ Children: i. Indications S/S: Hematuria, enuresis, fever, foul-smelling urine, poor appetite, painful urination ii. Parent instructions: administration of prescribed antibiotics, encourage child to drink clear liquids, instruct parents of good perineal hygiene, avoid tight clothing or diapers, encourage child to void frequently. ○ Cystitis → Bladder inflammation i. S/S: burning or pain on urination, urinary frequency, urinary urgency, bladder spasms. ii. Treatment: Symptomatic, organism-specific antibiotic iii. Nursing considerations: Monitor urination for frequency and amount, assess urine for cloudiness and hematuria, obtain specimen for analysis and culture and sensitivity, iv. Client Education: increase fluid intake to dilute urine, use heating pad on lower abdomen for bladder spasms, take meds as directed. ○ Pyelonephritis: Inflammation of the kidney caused by bacterial infection, UTI, pregnancy, tumors, or urinary obstruction. i. S/S: chills, fever, malaise, flank pain, costovertebral angle tenderness ii. Nursing care: bed rest during acute phase, administer and teach about antibiotics, encourage fluids. 41. HIV/AIDS (3 questions) ○ HIV (Human Immunodeficiency Virus) i. Virus that causes immunodeficiency that can lead to AIDS 1. Transmitted: via blood and body fluids 2. S/S: early stage: asymptomatic, later as immune system deteriorates...opportunistic infections. 3. Medical Treatment: antiretroviral medications, organism-specific medications, chemotherapy, antidepressants, nutritional support, symptomatic. 4. Nursing Considerations: user personal protective equipment to prevent infection, supportive care depending on presence of opportunistic infections. 5. Client and Public Education: Practice safe sex. ○ AIDS: i. Syndrome distinguished by serious deficits in cellular immune function; causes opportunistic such as Pneumocystis jiroveci pneumonia, Candida albicans stomatitis and esophagitis, cytomegalovirus, Kaposi sarcoma. 1. Pneumocystis jiroveci Pneumonia is the most common opportunistic infection of AIDS a. Indications: Gradually worsening chest tightness, SOB, persistent, dry, nonproductive cough, dyspnea, tachypnea, fever, progressive hypoxemia, cyanosis. b. Nursing Care: offering high-protein, high-caloric diet, monitoring vitals signs, chest sounds, suction and maintaining oxygen as ordered, monitoring for indications of secondary infection, provide restful environment, assisting with personal care, implementing infection control precautions, handwashing when entering and leaving room, monitoring for oral infections, assessing breath sounds, monitoring weight, encouraging nutritional supplements, assessing hydration, encouraging client to express feelings. ○ AIDS Dementia Complex: Dementia resulting from effects of HIV ○ Children with AIDS: 91% of children with AIDS were infected through perinatal transmission. i. Indications: lymphadenopathy, hepatosplenomegaly, Candida albicans stomatitis, chronic or recurrent diarrhea, failure to thrive, developmental delays; Pneumocystis jiroverci pneumonia most common opportunistic infection in children. ii. Treatment → antiretroviral drugs iii. Nursing considerations: scrupulous handwashing, instructing child and family about importance of handwashing, children from being around persons who are infectious, restricting infected children who bite or do not have control of bodily functions, providing high-calorie, high-protein meals and snacks, monitoring child’s weight and height, encouraging child to participate in activities with other children, providing anticipatory guidance to the family because child has potentially fatal disease. 42. Chronic Kidney Disease (2 questions) → know a lot of nursing judgment and concepts ○ Irreversible, progressive reduction of functional kidney tissue resulting in inability of kidneys to excrete wastes, concentrate urine, and conserve electrolytes. i. Indications S/S: anemia, acidosis, azotemia, fluid retention, hypertension, hypocalcemia, anorexia, N/V, constipation, impaired insulin action. ii. Interventions: to slow progression, control blood pressure and make fluid and dietary adjustments. Dialysis or transplantation may be done when these measures are no longer effective. iii. Nursing interventions: Monitor fluid status, encourage nutrition by decreasing nausea, vomiting and stomatitis, and other GI symptoms, teach appropriate diet (low protein, low potassium, low sodium), manage constipation, teach to balance rest and activity, encourage good skin care with emphasis on moisturizing, teach coping skills to client and fam, teach dialysis-related procedures, explain transplantation process and subsequent potential issues and care. Important to increase non-protein calories, such as fruit ice. iv. Diagnostic tests: 1. Urine specimen (reveals low specific gravity, hematuria, proteinuria) 2. Blood studies (reveal elevated BUN, creatinine, potassium) 3. Creatinine clearance test (measures glomerular filtration rate) 4. Ultrasonography of kidneys, renal scan, CT scan 43. Peptic Ulcer Disease (3 questions) ○ Excavation formed in mucosal wall of stomach, pylorus, duodenum. Caused by infections with Helicobacter pylori (H. Pylori), a gram-negative bacterium. i. Indication: normal-hypersecretion of HCl, weight loss may occur, pain occurs 0.5-1 hour after a meal, vomiting, hemorrhage more likely occurs with duodenal ulcer. ii. Predisposing factors: ages 40-60, familial tendencies, chronic use of NSAIDs, alcohol ingestion, excessive smoking. iii. Diagnostic tests: noninvasive; include immunological tests of antibodies to H. pylori and urea breath tests. Invasive; endoscopy, gastric biopsy, and biopsy with bacterial culture for H. pylori. iv. Nursing considerations: small, frequent feedings if not taking antacids or histamine blocker, avoid coffee, alcohol, seasonings if use causes discomfort, reduce stress. Instruct patient to take medication 1 hour before meals. v. Treatment therapy: 1. Antacids a. Proton pump inhibitors or H2 receptor antagonists 2. Anticholinergics a. Inhibit the vagus nerve effect on parietal cells and reduce gastrin production. 3. Physical rest to promote healing 4. Gastroscopy to facilitate coagulation of bleeding site 5. Surgery if patient: a. Does not respond to treatment, has perforation, or suspected cancer or other complications 44. Gastrointestinal Tests: Upper GI→allows practitioner to visualize the upper GI organs and sphincters for diagnosis of anatomic or functional abnormalities. Used to diagnose ulcers, varices, tumors, regional enteritis, malabsorption syndromes, gastritis, cancer, hiatal hernia, diverticula, and strictures. ○ Upper GI is ingestion of barium sulfate to determine patency and size of esophagus, size and condition of gastric walls, patency of pyloric valve, and rate of passage to small bowel. i. Preparation: Maintaining NPO after midnight, informing client that stool will be light-colored after procedure. ii. Post-test: encouraging fluids, administering laxatives to prevent constipation, and informing client that stool will be white from barium 45. Esophagogastroduodenoscopy ○ Visualization of esophagus, stomach, and duodenal mucosa through light, flexible fiberoptic tube. Identifies ulcerations, tumors, and obtains tissue biopsy (detect presence of Helicobacter pylori or to rule out gastric carcinoma) or fluid samples. i. Preparation: verify informed consent has been obtained, maintain NPO at least 8 hours before procedure, teach client about numbness of throat due to local anesthetic applied to posterior pharynx. ii. Post Procedure: maintain NPO until gag reflex returns, observe for vomiting of blood, respiratory distress, inform client to expect sore throat for 3-4 days after procedure. ○ Description of Procedure: i. Patient is sedated ii. Lubricated endoscope is passed through the mouth and into the esophagus for visualization of the gastric wall and sphincters. iii. Endoscope is advanced to duodenum iv. Still and video images are taken, or images are shown on a monitor for continuous viewing during the procedure. v. Biopsy forceps are passed through the scope to obtain any necessary tissue samples 46. Inflammatory Bowel Disease: Includes Crohn’s disease and ulcerative colitis ○ Indications: abdominal pain, diarrhea, fluid imbalance, weight loss. Diarrhea in Crohn’s disease is less severe than in ulcerative colitis. ○ Nursing Considerations: include high-protein, high-calorie, low-fat, low-fiber diet, may require TPN to rest the bowel, administer analgesics, anticholinergics, sulfonamides (gentamicin), corticosteroids, antidiarrheals, and anti peristaltics, maintain fluid/electrolyte balance, monitor electrolytes, promote rest, relieve anxiety. i. Crohn’s Disease: Subacute and chronic inflammatory bowel disease involving segments of the terminal ileum and proximal colon; extends through all layers of the bowel wall; restricts absorption of nutrients. 1. Symptoms: colicky lower right quadrant pain not relieved by defecation, diarrhea, weight loss, low-grade fever, nutritional deficit, anemia, dehydrations; fistulas, anorectal fissure or fistula. 2. Treatment: medications→antidiarrheals, antispasmodics, anticholinergics, sulfonamides, steroids. 3. Diet: High calorie, high protein, parenteral nutrition used for bowel rest. NO cocoa, chocolate, citrus juices, cold or carbonated drinks, nuts seeds, popcorn or alcohol. 4. Nursing considerations: High-Protein, high-calorie, low-fat, low-fiber diet, administer medications, maintain fluid and electrolyte balance. ii. Ulcerative colitis: Inflammatory condition of colon characterized by eroded areas of mucous membrane and tissue beneath it. 1. Indications: rectal bleeding, blood, pus, mucus in stool, abdominal pain occurs pre defecation, may have 20 to 30 diarrhea stools daily, nutrition deficit, weight loss, anemia, dehydration. 2. Diet: High-protein, high-calorie, low-fat, low-fiber diet, TPN used for bowel rest, analgesics, anticholinergics, antibiotics, corticosteroids to reduce inflammation, ileostomy. 3. Nursing Considerations: Instruct client about medications and diet, maintain fluid/electrolyte balance, monitor electrolytes, promote rest, relieve anxiety. 47. Lithotripsy: Extracorporeal Shock-wave → noninvasive technique that uses high-energy shock waves to break up obstructive renal calculi & allow their normal passage ○ Preparation → tell the patient that he may receive general or epidural anesthetic, will have an IV line & foley in place after the procedure ○ Morning & Aftercare → encourage ambulation as early as possible after treatment, increase fluid intake to aid passage of calculi, strain urine - educate patient that slight hematuria usually occurs for several days after procedure but tell the doctor if there is frank or persistent bleeding ○ Patient Education → drink 3-4 L of water up to 1 month after treatment, strain all urine for one week, report severe hematuria or inability to void 48. Safety: Older Adult → know safety & intervention 49. Continuous Passive Motion → known devices? ○ Device to supply slow continuous range of motion to joint by an electronically controlled vise. i. Uses: promotes healing after a total joint arthroplasty, increases circulation to the area, prevents joint contracture, encourages early motion of joint; degrees of flexion and extension and amount to be increased over specified time frame determined by healthcare provider and physical therapist. ii. Nursing Considerations: Neurovascular assessment of affected extremity, administer pain meds as ordered, ensure proper alignment of extremity in devise, document degrees of flexion and contraction and time in device, allow client control over time in and out of device as possible. iii. Client Education: rationale for use of machine, expected time in device, degrees of flexion and extension. 50. Pancreatitis→Inflammation of pancreas that can be acute or chronic. ○ Acute: mild inflammation with minimal discomfort to severe disease that is unresponsive to any medication, ending in death. This is caused by the premature activation of enzymes, particularly trypsin, which then self-digest the pancreas. The process of self-digestion is often triggered by the obstruction of the common bile duct by gallstones, causing bile to reflux back into the pancreatic duct, which stimulates the premature activation of the pancreatic enzyme (normally, activation begins later in the duodenum.) i. S/S: Severe, acute abdominal pain, back pain, abd distension, N/V, decreased intestinal motility, fever, jaundice, ALOC, Hypotension, ARF, Tachycardia, Respiratory distress, Hyperglycemia, Hypocalcemia. ii. Treatment: Parenteral nutrition, withhold oral intake so pancreatic enzymes are not stimulated. Nasogastric suction, Biliary drains and stents, surgery, and intravenous fluids after the initial crisis is over to restore electrolytes. 1. Meds: a. Histamine-2 (H2) antagonists. (cimetidine {Tagamet}, ranitidine {Zantac}), to decrease gastric acid production b. Analgesics for pain c. Antiemetics to prevent vomiting. iii. Nursing Care: 1. Record I & O hourly, and monitor electrolyte levels. 2. Patients with NG, good mouth and nose care and assess respiratory patterns regularly. 3. Administer pain meds 4. Watch for complications from parenteral nutrition (hypokalemia, overhydration, metabolic acidosis) and watch for signs of a calcium deficiency (cramps, tetany, seizures). 5. Instruct patient on the need for lifestyle modifications to prevent recurrences and to avoid factors that aggravate the dx. (alcohol). ○ Chronic: Characterized by the progressive destruction of the pancreas after repeated attacks of pancreatitis. Protein plugs and calculi in the pancreas form as a result of the hypersecretion of protein as a result of excessive alcohol consumption over long period of time. Alcohol is also toxic to pancreatic cells. Cells are eventually replaced by fibrous tissue, which obstructs the pancreatic and common bile ducts, blocking drainage to the duodenum. i. S/S: Attacks of severe abd and back pain, N/V, Anorexia, and weight loss, Malabsorption and foul-smelling stools with high-fat content (steatorrhea), and calcification of the pancreas. ii. Treatment: 1. Endoscopy, to remove duct stones and dilate strictures 2. Pain meds and avoidance of pain triggers (alcohol) 3. Diet, insulin, or oral antidiabetic agents, to treat diabetes if present 4. Pancreatic enzyme replacement, to treat malabsorption and steatorrhea 5. Surgery (pancreaticojejunostomy, pancreaticoduodenectomy or the Whipple procedure, to relieve pain, restore proper drainage of pancreas and to reduce the frequency of attacks. 51. Intestinal Obstruction: Partial or complete blockage of lumen of large or small intestines; compression of the bowel lumen leading to blockage of passage through intestines. ○ Causes: May be mechanical (tumor, hernia, adhesions, intussusception, volvulus) or nonmechanical (paralytic ileus, abdominal infections, intestinal ischemia.) Manifestations depend on location of obstruction. ○ S/S: absence of bowel sounds, intermittent and severe abdominal pain and distension, vomiting, tympanitic and tender abdomen, obstipation (absence of stool or gas), obstruction of ileum causes fecal vomiting, nausea, abdominal tenderness, decreased bowel movements. ○ Treatment: NPO, insertion of NG or Intestinal tube for decompression, IV fluid and electrolyte replacement, laxatives or enemas for fecal impaction, disimpaction, pain management, possible surgical intervention of colectomy possibly including temporary or permanent colostomy or ileostomy. ○ Complications: fluid volume deficit, bowel strangulation, necrosis, perforation, infection, nutritional deficiencies. ○ Nursing Considerations: maintenance of nasogastric tube (record amount and color of drainage) , monitoring for complications (metabolic acidosis/alkalosis), IV fluid replacement, postoperative care, monitor fluid and electrolyte levels, assist with ADLs, good oral and skin car, monitor vital signs (observe closely for signs of shock), Fowler's position to facilitate breathing, measure abdominal girth, administer antibiotics, pain and N/V management, auscultate for bowel sounds and watch for signs of returning peristalsis, ○ Client Education: Encourage high Fiber diet and plenty of fluids. ○ Diagnostic tests: i. Laboratory studies (electrolyte studies, complete blood count), which reveal dehydration, loss of plasma volume, and sometimes infection ii. Abdominal x-ray, which show abnormal amounts of gas and/or fluid in the bowel. In large bowel obstruction, they show a distended colon. iii. Barium studies are contraindicated. 52. Hyperglycemic, Hyperosmolar, Nonketotic syndrome → know Hyperosmolar Nephrotic Syndrome is a complication of hyperglycemia, which also involves hyperosmolarity, minimal to absent ketosis, and altered sense of awareness. Occurs in type 2 diabetics over 50 years of age ○ Pathophysiology: i. Uncontrolled hyperglycemia causes the kidneys to excrete the excess glucose with water and electrolytes (osmotic diuresis). ii. Water then shifts from intracellular fluid space to extracellular fluid space, causing hypernatremia and increased osmolarity. 1. Indications: glucose levels greater than 800 mg/dL, hypotension, dry mucous membranes, poor skin turgor, tachycardia, altered awareness, seizures, hemiparesis; ketosis and acidosis do not occur. 2. Nursing Care: Administer normal saline and regular insulin, assess vital signs, blood glucose, central venous pressure, LOC, urine output, and temperature. 53. Acute Kidney Disease/injury → Abrupt acute disruption in kidney function that impairs ability of body to maintain balance of fluid, electrolytes, and acid-base status. ○ Phases of ARF: i. Initiation: Begins with initial insult and ends when oliguria develop ii. Oliguria: Output less than 400 mL/day; increase in BUN, creatinine, uric acid, potassium, magnesium; uremic symptoms occur 1. Indications: N/V, irritability, drowsiness, confusion, coma, restlessness, twitching, seizures, hypertension, pulmonary edema, increased serum potassium, BUN, creatinine, calcium, sodium, and pH. iii. Diuresis: gradual increased urinary output; may still have uremic symptoms. 1. Indications: increased urinary output, decreased serum sodium, potassium, BUN, creatinine, correction of metabolic acidosis, increased mental and physical activity. iv. Recovery period : 1. Indications: returned to normal functioning while healing takes place. ○ Interventions: treat underlying cause, treat fluid and electrolyte imbalance, prevent infection, administer high caloric and low protein diet, possible dialysis ○ Nursing Interventions: maintain strict intake and output and compliance with fluid restriction/intake as ordered, daily weights, monitor vital signs closely, assist client with managing anorexia and eating appropriate foods, provide good skin care, monitor for infection, encourage rest, support dialysis if indicated. ○ Nephrotic syndrome: Minimal-change nephrotic syndrome (MCNS) most common in type of nephrotic syndrome in children; i. Indications: periorbital or ankle edema, larger than expected weight gain, decreased urinary output, pallor, fatigue, hyperalbuminuria, hypoalbuminemia, ascites, hypovolemia. ii. Treatment: restrict salt, corticosteroid therapy, immunosuppressive therapy iii. Nursing considerations: monitor I/O, daily weights, test urine for albumin, measure abdominal girth, protect from upper respiratory infection, instruct parents about S/S to observe for at home, how to administer steroid therapy, and adverse effects. ○ Diagnostic tests: Urine specimen (reveals low specific gravity, hematuria, proteinuria), Blood studies (reveals elevated BUN, creatinine, potassium), Creatinine Clearance test (measures glomerular filtration rate), and Ultrasonography of kidneys, renal scan and CT scan. 54. Thyroidectomy → complete or partial excision of the thyroid gland ○ Purpose → corrects hyperthyroidism, removes breathing obstruction caused by goiter, treats thyroid cancer, treats hyperparathyroidism ○ After surgery → monitor respiratory status, ensure that incision drains properly, monitor pulse & temperature for indications of thyrotoxicosis or thyroid storm ( fever, tachycardia 130, delirium, coma) i. Monitor for tetany → could indicate that parathyroid glands were damaged during surgery which would cause hypocalcemia (Chovsteks & Trousseau’s sign) ii. Keep patient in Semi-Fowlers position, apply ice to reduce the swelling iii. Make sure to have suction, O2, trach set, IV calcium & suture removal kit at bedside iv. Ask patient to speak every 2 hours to check tone & hoarseness v. Emphasize importance of adhering to thyroid replacement therapy after discharge vi. Keep incisions clean & dry 55. Cholecystitis→Inflammation of gallbladder, that may be calculous (obstructed by calculi or gallstones) or acalculous (not obstructed by gallstones.) ○ Indications & S/S: intolerance to fatty foods, indigestion, N/V, severe pain in upper right quadrant of abdomen, elevated temp, Belching that leaves a sour taste in the mouth, Flatulence and possible jaundice and clay-colored stools with common duct obstruction. ○ Risk factors: obesity, sedentary lifestyle, female, ages 50-60 ○ Nursing Considerations: administer antibiotics, analgesics, antispasmodics, NPO until acute symptoms subside, reduce weight if needed, instruct to avoid fatty, fried foods. ○ Treatment: Surgery (usually elective), Vit K for itching, jaundice, and bleeding tendencies caused by Vit K deficiency. Nonsurgical treatment=insertion of flexible catheter, formed around T tube, through the sinus tract into the common bile duct. Guided by fluoroscopy, the doctor directs the catheter toward the stone, A Dormia basket in threaded through the catheter to entrap the calculi. i. Preparing for surgery: 1. Monitor and stabilize nutritional status and fluid balance 2. Clear liquid 24 hour before surgery 3. Give pre op meds, and insert NG tube ii. Aftercare: 1. Monitor site for infection 2. Monitor N/V from anesthesia 3. Apply heat to pt. Shoulder to alleviate right shoulder pain caused by phrenic irritation from carbon dioxide under the diaphragm. 4. Semi-Fowler’s to decrease discomfort 5. Early ambulation ○ Diagnostic tests: Abdominal X-Ray, Ultrasonography, Radionuclide imaging or cholescintigraphy, and ERCP. 56. Paracentesis → removal of fluid from the peritoneal cavity (2-3 liters) ○ Preparation → Informed consent, encourage voiding, take vitals, measure abdominal girth & weigh client ○ During → take vitals Q15min ○ After → document amount, color & characteristics of drainage obtained, assess pressure dressing for drainage, keep patient in bed until vitals are stable