exams 1-4 Flashcards
personality traits
behaviors and patterns of perceiving or relating to others; and of thinking about self and others in environment
personality traits may be
adaptive or maladaptive
maladaptive traits are
inflexible;significant functional impairment and subjective distress
persistent maladaptive traits =
personality disorder
personality disorders are
long standing, believed to rise from very beginnings of personality developent
what to look for in personality disorders
connections to Erickson’s developmental task completion, trust issues, autonomy issues are very common themes
enduring personality disorders
a “cure” is unlikely
personality disorders are
not responsive to short-term psychotherapy or drug therapy
which axis are personality disorders identified
axis 2
increased stress in patients with personality disorders
causes exacerbation of symptoms
Cluster A
(secretive, suspicious)Cognitive = unable to trust, indecisive, poverty of thoughtAffective = Quick anger, social anxiety, blunted affectBehavioral = eccentric, craves solitude, argumentative, odd speechSociocultural = impaired or nonexistent relationships, occupational difficulties
Cluster B
(flamboyant, dramatic, attention-seeking)Cognitive = considers self special, unique, egocentric, no long range plans, often identity disturbancesaffective = intense, labile, no sense of guilt, anxious, depressedbehavioral= dramatic, craves excitement, wants immediate gratification, self mutilationsociocultural = manipulates and exploits others, stormy relationships, no amount of attention is enough
Custer C
(fearful, indecisive)Cognitive = moralistic, low self esteem, low self confidenceAffective = anxious, fearful, depressedBehavioral = Tense, rigid routines, submissive, inflexible, passive-aggressiveSociocultural = Dependent on others, avoids overt conflict, seeks constant unconditional love
Cluster A disorders
( Eccentric, isolative with major lack of trust)Paranoid personality disorderschizoid personality disorderschizotypal personality disorder
paranoid personality disorder
increased risk in malessubstance abuse commonincreased risk if family history suspiciousdifficulty adjusting to changesensitive, argumentativefeels irreversible injury by others - often without evidence unwilling to forgive even minor eventsanxiety, difficulty relaxingshort temperdifficulty problem solvinglack of tender feelings toward othersjealous of significant other - often without evidence
schizoid personality disorder
lack of desire to socialize ; likes solitudelacks strong emotionsdetached, self absorbedlacks trustmay have brief psychotic episodes when stresseddifficulty expressing anger passive reaction to crisis
schizotypal personality disorder
often seek help for anxiety or depression30-50% also have major depressionincorrectly interprets external events - believes all events refer to selfsuperstitious, preoccupied with paranormal phenomenabelieves in magical control of othersconstricted or inappropriate affectanxious in social situationsgenerally seeks therapy for depression, anxiety, dissociative D/O
Communication strategies for Cluster A
reinforce reality limit discussion to concrete familiar topicsclear, simple messages to avoid misinterpretation of words/phrasesresist using logic to counteract clients inappropriate statements- client may engage in power struggle to defend selfdon’t use humoracknowledge pain, fearoffer gentle reassurance when perceptions are frighteningdon’t touch the client - may be misinterpreted
Cluster A pharmacological therapy
usually treated for axis 1 problemantidepressants, anxiolytics, low dose antipsychotics
Cluster B Disorders
(dramatic, self centered)antisocial personality disorderborderline personality disorderHistrionic personality disorderNarcissistic personality disorder
antisocial personality disorder
Usually diagnosed by age 18 H/O conduct D/O High % in prison or h/o legal trouble High % with substance abuseincreased incidence in malesIrresponsible –Fail to honor financial obligations including child careLack guiltDifficulty learning from mistakesInitial charm becomes coldness, manipulation, blaming othersLacks empathyIrritable affect
borderline personality disorder
75% female H/O physical, sexual abuse, neglect, hostile conflicts Often early parental loss/separationIntense, stormy relationshipsDichotomous thinking – all good or all badImpulsive – often engages in reckless behavior - e.g. binging, spending money, reckless driving, unsafe sexual activitySelf-mutilatesDifficulty identifying selfNegative/angry affectFeels empty, boredDifficulty being alone, feelings of abandonment
dichotomous thinking
all good or all bad
characteristics of borderline personality disorder
Usually above average intelligenceOften initially very charming, ingratiatingTend to be very demanding - demand others meet their needsNo sense of boundaries - others’ assertion of boundaries feels like rejection or punishmentNot all traits may be present Don’t focus on analysis of condition but on behavior and your response to itBPD overlaps with many other disorders especially PTSDPeople with BPD suffer a lot of emotional pain and they don’t know what to do to feel betterMost of behaviors come from unconscious motivations - little insight into “why” they feel and act as they doThe best thing we can do for ourselves and people with BPD is set boundaries
boundaries for borderline personality disorder
Communicate honestly, fairly and consistentlyDon’t argue or bargainFollow through - message must be consistent in words and actionsRemain calm - refrain from responding emotionally to provocation or manipulation Avoid power struggles by enforcing rules and limits consistently and refusing to respond to manipulative behavior (remember manipulation could be quite charming or ingratiating)Give positive feedback when appropriate - help person identify strengthsStay focused on topic of discussion - don’t get side-tracked to other issues, what other people did, etc.Be compassionately objective - clear - consistentRespect your own boundaries and model that behavior - we teach others what our boundaries are by how we let others treat us
Histrionic personality disorder
More common in womenRapid fluctuation in emotionsAttention-seeking, self-centeredSexually seductive, flamboyantVery attentive to own appearanceDramatic style of speechVague logic-lacks conviction in arguments, often switches sidesShallow emotional expressionCraves immediate satisfactionMany c/o physical illnessSuicide gestures
narcissistic personality Disorder
50-70% are malesGrandiose view of selfLack of empathyNeeds to admiredPreoccupied with fantasies of success, brilliance, beauty, ideal love
communication strategies for Cluster B
Don’t argue, rationalize or bargainStay calm!Communicate expectations clearlyAvoid power strugglesHelp client focus on thoughts/feelings behind self-destructive actionsBe consistent!Confront inappropriate behavior – try to assess if behavior stems from fear or attention-seekingBe compassionately objectiveGive positive feedback when appropriateHelp client stay focused on topic of discussionHelp client assume responsibility for feelings
Cognitive therapies for Cluster B
DBT, CBTWork with client to see consequences of inappropriate behaviorsBuild trusting relationshipHelp client develop strategies for self-destructive behaviorsHelp client develop skills for social adaptation
pharmacological therapy for cluster B
Aimed at Axis 1 diagnosisAnti-depressants, axiolytics
Cluster C disorders
(Fearful, anxious)avoidant personality disorderdependent personality disorderobsessive compulsive personality disorder
avoidant personality disorder
Fearful of criticism, disapproval, rejectionAvoids social interactionsWithholds thoughts, feelingsNegative sense of self, low self-esteem
dependent personality disorder
Submissive, clingingUnable to make decisions by themselvesCannot express negative emotionsDifficulty following through on tasks
obsessive-compulsive personality disorder
Preoccupied with perfection, organization, structure, controlProcrastinatesAbandons projects due to dissatisfactionExcessive devotion to workDifficulty relaxingRule-consciousSelf-criticism, unable to forgive own errorsReluctant to delegateUnable to discard anythingInsist others conform to own methods, ideas
Communication strategies for Cluster C
Help client explore misinterpretation of others’ actions/remarksas criticismDiscuss and model assertive communication & behaviorsHelp client learn to express feelingsHelp client learn to have fun/develop leisure activities
cognitive therapy for cluster C
Learn new ways to cope with anxiety,anger,other emotionsHelp client recognize/eliminate unrealistic expectations of self/othersFormulate ways to increase client’s social interactionsPlan activities to enhance client’s self-esteem, decision-making
pharmacological therapy for cluster C
Aimed at Axis 1 dxAnti-depressants, axiolytics
interventions for cluster C
Promote safetyAssess for suicidal ideationContract for safetyAssess for escalation of anger -> rage; impulsive violent actionContract for no violent actsTeach alternate means to manage angerGroup therapy to practice problem-solving/explore alternativesAssess for self-mutilationContract to talk c staff if urge to self-mutilatePut pt. on close observation until pt identifies need for self-harm has passed Identify other means of emotional release – i.e. wrap in sheet movement therapy If wounds occur treat in non-judgmental way – with little discussionEncourage journalingPhysical restraint if necessary
what are interventions aimed at
aimed at modifying life-long disruptive/dysfunctional behaviors/thoughts
major thing to remember about antisocial personality disorder
there is no sense of guilt. Nothing is their fault
what to remember about borderline personality disorder
neglect, a lot of sexual abuse , emotional separation of a parent, or physical separation
borderline personality disorder (important)
attempt suicide with no clear expectation of death , death is not the goal
anti social is very
id oriented. They only think about themselves
important for narcissitic disorder
help client assume responsibility for feelings
Delegation
A process that transfers to a competent individual the authority to perform a selected task in a specific situation.
accountability
Being answerable for the actions or omissions of self or others in the context of delegation
assistive personnel are accountable for
Decision to accept delegationPerformance
Nurse’s are accountable for
Decision to delegateDelegated taskClient outcomes
assistive personnel is accountability is to
Self Delegating nurseEmployer
Nurse’s accountability is to
SelfClientsEmployerLicensing boardProfession
Delegation process
evaluationmonitoring delegation assessment
5 rights of assessment delegation
RIGHT taskRIGHT circumstanceRIGHT personRIGHT direction/communicationRIGHT supervision
assessment red flags
Complex nursing activityUnidentified client needsRequisite knowledge and skills missingInsufficient opportunity to trainInsufficient opportunity to monitor/supervise
steps for delegation
Communication of task to be delegatedMutual agreementTransfer of authority
process of how to delegate
WHO will doWHAT byWHEN andHOW, WHERE, andWHY it will be done
directions for delegation
Priority of activityExpected timelinesGuidelines for consulting mid-activityReportable conditionsGuidelines for reporting task completionRole as delegator and supervisor
red flags of delegation
Refusal to accept delegationIncomplete directionsFailure to confirm expectationsFailure to communicate
supervision
Provision of guidance or direction, evaluation and follow-up by the licensed nurse for a process and the outcomes of a delegated task
degree of supervision required depends on
Client needsStability of the clientCompetency of the assistantNature of the taskAvailable supervision
red flags for monitoring
Change in other client’s condition with impact on workloadFailure of assistant to report unexpected events or client outcomesWork completed incorrectlyWork not completedInadequate communication from assistantInadequate direction from delegatorInadequate or lack of monitoring from delegator
desired delegation outcomes
Protection of client safetyAchievement of desired client outcomesReduction of health care costsAccess to appropriate levels of health careDecreased nursing liability
inappropriate delegation may result from
Inadequate resourcesConflict of employee policies and lawInappropriate employer directionLack of knowledge about delegationFailure to accept accountability for nursing care provided
corrective action for delegation
Educate and trainRestate expectationsReturn skill demonstrationIdentify specific checkpointsIncrease frequency of check-insEvaluate directions
evaluation red flags
Failure to evaluate delegation effectivenessFailure to evaluate the delegator/assistant relationshipFailure to learn from work experience
keys to delegating affectively
Communicate continuouslyValue all team member contributionsDevelop trust between co-workersLearn from experience
what does a leader do
influence other people to obtain a goal
role of a nurse
meeting patients needs in an effective and timely manner
one of the biggest parts of communication is
listening
types of leaders
authoritarian/autocraticdemocratic/ benevolentlaissez-faire
authoritarian/autocratic
they will do whatever it takes to obtain the goal. the goal is the only thing that is important. My way or the highway type leader.(very efficient, get things done, but long term, their team falls apart)very stiffling relationshipwork by intimidation
what are some certain situations where a leader needs to take on an authoritarian role.
in an emergency
democratic/ benevolent
this does not mean that youre not a leader and you don’t direct people, or you aren’t in charge but you have good communication skills and value what other people have to say. Take a team approach. Really involved in your team. You make sure your team is involved in the decisions that are made.
democratic/ benevolent
not as efficient as authoritarian but still as effective and you have a team that sticks around
laissez-faire
a hands-off approach that allows followers to set rules and make decisions.try to give the least possible guidance tosubordinates, and try toachievecontrolthrough less obviousmeans. They believe that people excel when they are left alone to respond to theirresponsibilitiesandobligationsin their own ways.
if someone accepts a delegation
they are then accountable for completing it. they are accountable for accepting it and completing it.
what can’t a nurse delegate to unlicensed individuals
assessmentplanningteachingand evaluation
indirect delegation
a list of a CNA’s responsibilites (job profile). Things they are responsible for.You need to be aware of what they are and what they are comfortable doing.
RN skills that you can’t give up
assessmentplanningteachingcounselingevaluation
RN/ LPN IV meds
giving IV meds (some LPN’s have taking courses to give certain IV meds)IV push meds (RN only)Hanging blood (RN only)
LPN skills
vitalsmeds (not iv’s)some IV medsnot iv pushphysical carecontribute to data of assessment (but RN is responsible)
CNA skills
personal carehelp with feeding (on stable individual)
right task
are they abledo they have the experiencedoes it require alot of judgementdoes it require a lot of nursing knowledge
right circumstance
are these tasks free from independant nursing judgement
right direction/communication
clearly state what you want done
ectopic rhythm
irregular heart rhythm due to a premature heartbeat. Ectopic rhythm is also known as premature atrial contraction, premature ventricular contraction, and extrasystole.
Coronary artery
only place in the body perfused during Diastole
organs that take a lot of oxygen and will get damaged quick
brainkidneysandheart
left coronary artery
branches out into two significant branchesanterior descending branch (contracting of left ventricle, supplies all bundle branches)circumflex branch
when the anterior descending branch is blocked
anterior wall MImost serious MIresults in death
right coronary artery
supplies right side of heartsupplies the SA node and AV nodeMI on this side messes up the conduction of the heart. could result in a pacemaker .
SA node is
is the pacemaker of the heartthe cells in here generate an electrical impuleThis impulse spreadsThis causes the atria to contract / depolarization
SA node
has an intrisic ratethe rate that it fires at in normal situations (60-100 bpm)
depolarization
another term for contraction
AV node
gatekeeper. Receives impulses from SA.lets the impulses through to the ventricles. usually lets it through unless its over 180. Too many beats can cause a block.
AV nodes intrinsic rate
40-60 bpmthis is what it creates on its own. (if your SA node gives out) Normally SA node intrinsic ratewins out
junctional rhythm
unstable rhythm
impulse travels
impulse goes through the bundle of his, to pukinje fibers, to ventricles
idioventricular rhythm
20-40 bpm
ventricles intrinsic rate
less than 40 bpm
sympathetic
norepinephrine increases heart rate and bp
parasympathetic
slows heart rate and BP via acetocholine
vagal nerve
controlled by parasympathetic nervous system causing your heart rate to slow way way down. ventricle can’t fill with enough blood to contract
interupted rhythms
when you interupt the rhythm the SA node will pick back up again
12 lead ecg
4 limb leads6 B- leads (on chest)gives you 12 different views. need twelve views to see whats wrong
ischemia causes
st depression
atropine
speeds up heart . stimulates sympathetic heart
potassium
needs to be right at 3.5 -5.5low potassium irratates the heart causing ectopic rhythmshigh potassium depresses the heart causing blocks or a cardiac arrest.
calcium
too little ventricular arrythmiastoo much can cause an MI
magnesium
needed for calcium to be used by the heart
infection can result in
increases heart rate.
PR interval
impulse to get from the SA node through the AV node, just before depolarization.
qrs complex
depolarization
ST segment
time between ventricular depolarization and ventricular repolarization
T wave
ventricular repolarization
repolarization
getting back to stage 0 again
sodium
sodium make the cells more positive to make the heart contractthen the sodium must get into the blood and push potassium back into the cell .
during repolarization you have
refractory periodrelative or vulnerable refractory period
one minute is how many boxes
300 boxes
one box =
0.04 seconds
5 boxes
.20 secs
what are we interested in with a cardiac strip
ventricular response
pr interval has to be
.12-.20 seconds3-5 little boxes
qrs complex
.04-.10 secs1-2 1/2 boxes
.12 secs and above on a qrs
most likely a bundle branch block
st segment
should be flatdepressed is ischemiaelevated is cardiac injury
st segment is
end of ventricular depolarization and begining of repolarization .
T wave is
repolarization
tented T wave
hyperkalemia
flat plateau T wave
hypokalemia
qt interval
time betweeen the onset ventricular depolarization and the end of ventricular repolarizationaverage is .34 to .43 is average
qt interval should be
less than half the distance between 2 consecutive heart beats.
causes of bradycardia
digbeta blockerscalcium channel blockersheart diseaseMIhypothyroidismhypothermiaincreased intercranial pressure
bradycardia symptoms
dizzyconfusionSOBanginaBP lowdon’t feel good
what do you do for bradycardia
give atropine (first)
what if you can’t fix the bradycardia
they end up with a pacemaker . you can’t continue to give atropine continuously
sinus tachycardia
below 150 bpm
atrial tach
above 150 bpm
sinus tach symptoms/causes
dizzypounding sensationdiaphoreticSOBcaused by stimulantscoffeenicotinechocolate
sinus tach is treated with
beta blockerscalcium channel blocker
sinus arrhythmia
slightly irregular rhythmeverything else looks normalusually changes upon breathing. there might be slight differences between the qrs complexes
sinus arrhythmia
childrenelderlyathletesthey don’t treat it because you are still getting good cardiac output
sinus arrest orblock
sinus node falls asleep for a minute
premature atrial contraction
shorter distance between the qrs’s randomly. Still has a P wave, looks normal. But randomly beats are closermost premature beats are follow by a pause.non compensatory beat
Non- compensatory
take 3 beatsmove it over and see if the beat is coming in on time . if it does not come in on time it’s NON compensatoryif it comes in on time, its compensatory
causes of PAC’s
overtiredstresssmokingcaffeinedrugs (perscribed)hyperthyroidismalcohol
when is there a problem with PAC’s
if there is more than 6 or more a minutetrigenimy’sif they are happening on the T wavedon’t normally treat unless there is a potential for harm
most begnign of the premature beats
PAC’s
which do you treat first PAC’s or PVC’s
PVC’s are more dangerous
atrial tachycardia
over 151 bpm to 250 bpm
difference between Atrial Tach and SuperVentricular Tach
you can see a P wave in an atrial tach
what do you give for atrial tachycardia
calcium channel blocker (IV)adenosine (IV) only drug given fast
Synchronizedcardioversion
machine synchronizes with patients rhythm so theshock is NOTdelivered on T wave
atrial flutter
no P waves, flutter waves250-350 bpmyou can’t hear it with apical pulse because it does not effect ventricular ratesawtooth pattern
treatment for atrial flutter
meds (calcium channel blockers, beta blockers, potassium blockers,…)cardioversion first. Then drugs
atrial Fibrillation
350-500 bpm (atrial rate)No P waves., wavy baseline.second biggest cause of strokesif ventricular rate is60-100 -controlled A. Fib101-150 rapid ventricular responseover 150 - uncontrolled A. Fib
A Fib
cardioversionanticoagulant for ones you can’t fix (living with)they throw clots. (strokes)
psychosis
A state in which a person’s mental capacity to recognize reality; communicate; and relate to others is impaired Person moves in and out of reality Reality for the person is the world as that person perceives it- not necessarily as it exists
most common psychosis diagnosis
schizophrenia
two types of psychosis
functional and organicCurrent research emphasizes both biological and psychosocial factors
functional psychosis
results from interpersonal conflict, stress->psychogenic origin
organic psychosis
results from physiological damage/dysfunction
psychotic behavior
Person attempts to adapt, attempts to explain experiences and/or attempts to structure a “crazy” worldEx. Schizophrenic person may cut himself for reassurance that he is “real” because he bleeds and feels pain
cognitive factors of psychopathology
what a person knows/believes about self, others, principles, places, objects, actions, etc.
Cognitive disruptions of psychopathology
Thinking DistortionsCommunicating DistortionsDelusionsHallucinations
Thinking distortions of psychopathology
Selective Abstraction Overgeneralization Magnification Superstitious thinking Dichotomous thinking
selective abstraction
“I’m still too fat – look how big my hands and feet are.”
overgeneralization
“You don’t see fat people on TV. So you have to be thin to be successful at anything in life.”
magnification
“If I gain 2 pounds, I know everyone will notice it.”
superstitious thinking
“If I wear all black I’ll lose weight”
dichotomous thinking
“If I’m not thin I’m fat” (black and white thinking)
communications distortions
loose associationsflight of ideasword salad
loose associations
“Don’t you think my stomach is getting bigger? Fall is when lots of food is harvested like corn and pumpkins.”
flight of ideas
“The weather looks like it’s changing. These pants make me look thin Lunch was really bad. I don’t think I should be taking all those pills.”(speech is rapid and there is a continuous flow of words)
word salad
“animals, cars, bedtime, dark, prayers closets…”
Delusions
Fixed, firm beliefs contrary to reality
examples of delusions
grandiositypersecutioncontrolreligioussin/guiltsomaticideas of referencethought broadcastingthought withdrawal thought insertion
grandiosity
I’ve been a member of the President’s Cabinet since the Reagan years. No president can do without my advice.”
persecution
See those people in the hall? They’re not really visitors, they’re from the CIA. They’re here to spy on me.”
control
“I have a wire in my head. My family had it implanted so they can control me. They control everything I say. I can’t do anything on my own.”
religious
“I can’t stop to talk with you I have to keep reading this Bible out loud so God will hear me and make sure nobody can hurt me.”
sin/guilt
“I am being punished now because when I was growing up I was a bad kid. That’s why I when I get a job and start doing good I have to quit to make up for my bad behavior. I shouldn’t be happy, not after as bad as I was”
somatic
“My esophagus is being torn apart because there’s a rat in my stomach and sometimes he comes up to my throat. He eats away at my esophagus. Look in my throat you can probably see him.”
ideas of reference
That doctor and nurse at the desk are talking about me. You say they aren’t but I know they are. You people talk about me all the time.”
thought broadcasting
“I’m afraid to think anything because I know you can read my mind and know exactly what I’m thinking.”
thought withdrawal
“I can’t tell you what I’m thinking. Somebody just stole my thoughts.”
thought insertion
“You think what I’m telling you is what I’m thinking but it isn’t. My father keeps putting all these thoughts in my head. There’s no room for my thoughts. These aren’t mine.”
Hallucinations
Perceptual experiences occurring in the absence of any appropriate sensory stimuliDo not confuse with illusions which result frommisinterpretation of sensory experience-magiciansMost frequent types of hallucination = visual andauditory- but can arise from any of five sensesOften hallucinations have religious contentAssessed at different levels of intensity
hallucinations levels of intensity
comfortingcondemningcontrolling conquering
comforting hallucinations characteristics
Pt has intense emotions like anxiety, loneliness, guilt, fear-tries to focus on comforting thoughts to anxiety; knows thoughts & sensory experiences are controllable if anxiety is managed
comforting hallucinations behaviors
Grinning, laughter that seems inappropriate; moving lips without making sound; rapid eye movement; slowed verbal responses as if preoccupied
condemning hallucinations characteristics
Sensory experience repulsive & frightening; pt begins to feel loss of control; may attempt to distance self from perceived source; may feel embarrassed by experience and withdraw from others
condemning hallucinations behaviors
autonomic nervous system signs of anxiety; attention span narrows; preoccupation with sensory experience; loss of ability to differentiate hallucination from reality
comforting hallucinations
Moderate level of anxietyHallucination generally pleasant in nature
condemning hallucinations
Severe level of anxietyHallucination generally repulsive
controlling hallucinations
Severe level of anxietyHallucination becomes omnipotent
hallucinations can be
auditoryvisual(are most frequent)but they can be tactile
controlling hallucination characteristics
Pt gives up trying to combat experience & gives in to it; content of hallucination may become appealing; pt may experience sadness/loneliness if hallucination ends
controlling hallucination behaviors
Directions given by hallucinations will be followed rather than objected to; difficulty relating to others; attention down to only a few minutes at best, may be only seconds; unable to follow directions; sx of intense fight or flight response
conquering
Panic level of anxietyHallucination becomes elaborate & interwoven with delusions
conquering hallucination characteristics
Sensory experiences may become threatening if pt doesn’t follow commands; without therapeutic intervention hallucinations may last for hours or days
hallucinations, what to ask patient
are you hearing/seeing something.i can’t hear it, what do you hear what are you hearing, what do you seedescribe what are you are seeing/hearingare they soft, or loud
conquering hallucination behaviors
Terror-stricken behavior such as panic; strong potential for suicide/homicide; physical activity reflects content of hallucination i.e. violence, agitation, withdrawal, catatonia; unable to respond to most directions; unable to respond to more than one person
schizophrenia
18-22 is normally when a schizophrenics first psychotic break happensthey start hearing voices in their teens maybe even earlier
affect
How a person feels - Mood Assessment data/conclusions about patient’s affect come, in part, from cognitive and behavioral assessment
descriptors of affects
AppropriateInappropriateStableLabileElevatedDepressedOverreactiveBluntedFlat
appropriate affect characteristics
Mood in agreement with immediate situation
inappropriate affect characteristics
Mood not related to immediate situation
stable affect characteristics
Mood resistant to sudden change when there is no provocation in milieu
Labile affect characteristics
Mood shifts suddenly in a way that cannot be understood in the context of the situation
Elevated affect characteristics
Mood is euphoric not necessarily related to immediate situation
depressed affect characteristics
Mood is despondent no necessarily related to immediate situation
overreactive affect characteristics
Mood is appropriate to the situation but out of proportion
blunted affect characteristics
Mood is dulled response to the immediate situation
flat affect characteristics
No visible clues to the person’s mood
Behavior
How a person acts, what a person doesFreud: all behavior has meaningBehavioral assessment may give valuable information about cognitive clarity and/or affectExamples of Behavioral Assessment Factors Insomnia/hypersomnia – marked sleep disturbances Inappropriate social contacts – behaviors may range from hyperactivity, excessive talking, (laughing, joking) -> complete withdrawal from voluntary contactsMarked impairment in personal hygiene – noticeable changeImpaired role functioning – noticeable difference in performance of role (s) i.e. spouse, employee
Congruency/Consonance
Cognitive, affective and behavioral aspects all operating together = congruency/consonanceBeliefs, feelings and behavior toward a given ”thing” are all positive/negativeIf one aspect is out of “sync” the person will attempt to change that aspect to achieve congruencyEx.: A paranoid person believes (delusionally) that all store clerks want to destroy him. He feels afraid and may act out against a store clerk (behavior) to make all aspects congruent.
an accurate assessment drives the rest of the steps of the nursing process. The nursein charge understands that the management function that drives effective management is
planning
which action is an example of a nurse working independently
assigning another nurse to administer medications(delegating tasks is an independant task)
which is most basic for a nurse new to a management position
strong interpersonal comunication skills
a unit manager mentors a new unit manager as part of orientation to the position. which type of power is being used by the unit manager mentor
expert (expert power is the respect one receives based on one’s ability, skills, knowlege and expierience)
a nurse identifies that a post op patient is hemorrhaging. The nurse direct another nurse to call the surgical resident and sends the nurses aid to grab equipment from utility room and then proceeds to try to stop the bleeding.Which style of leadership did the nurse use in this situation
autocratic
which intervention should an RN perform rather than delegate to an unliscensed nursing assistant
assess the skin on a newly admitted patient
A nurse arrives on the unit for the last 5 minutes of a 20 minute change of shift report for a second time within a week. How should the charge nurse handle this situation
discuss the lateness with the nurse in private, immediately after the report
which specimen collection should a registered nurse delegate to LPN rather than a unlicensed nursing assistant.
wound drainage for culture and sensitivity
a nurse manager considers that there are “Five rights of delegation” - right task, right person, right communication, right time, and right…..
supervision
what should the manager do first to overcome resistance to change
ensure that the planned change is within the current beliefs and values of the group
what activities does a nurse manager engage in who values the importance of positive role modeling
following the policies of the agency (positive role modeling, follow the rules and your employees will too)
when condisering leadership styles an “autocratic” leader is to “authoritarian” as a “democratic” leader is to
consultative
what nursing care delivery model is based on case management
primary nursing
which statement is most significant in relation to the concept of change theory in the health-care environment
weigh the risks and benefits
several nurses complain to the nurse manager that one of the patient care aides constantly takes extensive lunch breaks. What should the nurse manager do
talk with the patient care aide to explore the reasons for the behavior and review expectations
what should the nurse do to ensure efficiency when managing a daily assignment
organize care around legally required activities
a supervisor communicates expectations about a task to be completed and then delegates the task. Which management function is being implemented by the supervisor
directing
a student nurse in the clinical area is given an appropriate patient assignment by the instructor. What should the student nurse do
assume accountability for the tasks that are assigned by the instructor
which statement is most significant in relation to the concept of change theory in the health care environment
change generates anxiety by moving away from the comfortable
a patient is to be discharged from the hospital. which discharge task can be delegated to a nursing assistant
obtaining the patient’s temperature, pulse, and respiratory rate
what is the major focus of nursing management
accomplishing an objective
A staff nurse must solve a complex problem. Which is the nurse’s most effective resource
unit’s nurse manager
when delegating a specific procedure to a patient care aide, the aide refuses to perform the procedure. What should the nurse do first
explore why the patient care aide refused to perform the procedure
what is the first thing the nurse hould do when planning to apply for a new position within an agency
review the job description
The most important reason why a nurse aide must fully understand how to implement a delegated procedure is because the nurse aide must be able to
complete the procedure safely
The nursing team leader delegates a wound irrigation to a licensed practical nurse. It has been a long time since the LPN performed this procedure. To ensure patient safety the nursing team leader should
Have the LPN demonstrate how to perform the procedure
a nurse manager is informed that a large number of patients will be admitted in response to a terrorist attack. Which type of leadership style is most appropriate in this situation
authoritarian
a nurse manager is experiencing staff resistance when implementing change. What is the most important action by the nurse manager to overcome resistance to change
identify the reason for the resistance
what is the major focus of leadership
inspiring people
The primary difference between effective leaders and managers is that managers have
Responsibility
which situation is most reflective of the saying “a stitch in time saves nine?”
collecting equipment for a procedure before entering the room
A RN delegates a procedure to an LPN. what is the primary purpose of delegation
improve productivity
a nurse manager plans to provide feedback to a subordinate who needs a change in behavior. What is the best intervention by the nurse manager
identify the unacceptable behavior
what is the main reason the nurse manager achieves a consensus when making a decision within a group
facilitate cooperative effort toward goal achievement
The nurse manager evaluates the performance of a subordinate. Which mangement function is being implemented by the nurse manager
controlling
which is most related to systems theory
cyclical process
The nurse and a nursing assistant (unlicensed assistive personnel) are working together on a surgical unit. which nursing activity should the nurse assign to the nursing assistant
emptying a urine collection bag that is attached to continuous bladder irrigation
which tasks should be delegated to a RN (select all that apply)obtaining vitalsproviding dishcarge teachingevaluating a patients repsonse to morphineadministering a cleansing enema to a patienttransporting a patient to the OR for surgery
providing discharge teachingevaluating a patients response to morphine
Lewin’s planned change theory progresses through phases. Order these statements by the nurse manager as change moves through the process1. “let’s implement a pilot project next week”2. “this is a new venture that should be exciting”3. “I know it may be difficult but you are doing a great job”
2.”this is a new venture that should be exciting”1.”let’s implement a pilot project next week”3.”I know it may be difficult but you are doing a great job”
which predisposing factor would be implicated in the etiology of paranoid personality disorder
the individual may have been subjected to parental antagonism and harassment
The nurse is assessing a client diagnosed with the borderline personality disorder. According to Mahler’s theory of object relations, which describes the client’s unmet develppmental need
the need for awareness of separateness of self
Using interpersonal theory which statement is true regarding development of paranoid personality disorder
clients diagnosed with paranoid personality disorder frequently have been family scapegoats and subjected to parental antagonism and harassment
when confronted a client diagnosed with narcissistic personality disorder states “contrary to what everyone believes, I do not think that the whole world owes me a living”. This client is using what defense mechanism
denial
a client diagnosed with borderline personality disorder coyly requests diazepam. When the physician refuses, the client becomes angry and demands to see another physician. What defense mechanism is the client using
splitting
A diabetic client admitted to a medical floor for medication stabilization has a history of antisocial personality disorder. Which documented behaviors would support that Axis II diagnosis
“Began cursing when confronted with drug-seeking behaviors.”
Irresponsible guiltless behavior is to a client diagnosed with Cluster B personality disorder as avoidant dependent behavior is to a client diagnosed with a
cluster C personality disorder
A client tells the nurse, when I was a waiter I use to spit in the dinners of annoying customers. This statement would be associated with which personality trait
passive-aggressive personality trait
a client diagnosed with a personality disorder insists that a gradmother through reincarnation has come back to life as a pet kitten. The thought process described as reflectie of which personality disorder
schizotypal personality disorder
a client diagnosed with a personality disorder states you are the very best nurse on the unit and not at all like that mean nurse who never lets us stay up later than 9 pm. This statement would be associated with which personality disorder
borderline personality disorder
a male client diagnosed with a personality disorder boasts to the nurse that he has to fight off female attention and is the highest paid in his company. These statements are reflective of which personality disorder.
narcissistic personality disorder
A nurse encourages an angry client to attend group therapy. Knowing that the client has been diagnosed with a cluster B personality disorder, which client response might the nurse expect.
sarcastically states that group is only for crazy people with problems
a client has been diagnosed with a cluster A personality disorder. Which client statement would reflext cluster A characteristics
my dinner has been poisoned
personlaity disorders are grouped in clusters according to their behavioral characteristics. In which cluster are the disorders correctly matched with their behavioral characteristics
Cluster C; avoidant, dependent, obsessive-complusive disorders, anxious or fearful characteristic behaviors
which behavior would the nurse expect to observe if a client is diagnosed with paranoid personality disorder
the client sits alone at lunch and states, everyone wants to hurt me
according to the DSM-IV-TR, which diagnostic criterion describes a characteristic of schizotypal personality disorder
exhibits behavior or appearance that is odd, eccentric or peculiar
according to the DSM-IV-TR which of the following diagnostic criteria describes the characteristics of borderline personality disorder? (select all that apply) Arrogant, haughty behaviors or attitudes frantic efforts to avoid real or imagined abandonment recurrent suicidal and self-mutilating behaviors unrealistic preoccupatioin with fears of being left to take care of self. chronic feelings of emptiness
frantic efforts to avoid real or imagined abandonment recurrent suicidal and self-mutilating behaviors chronic feelings of emptiness
According to the DSM-IV-TR which of the following diagnostic criteria describes the characteristics of avoidant personality disorder ( select all that apply) fearing shame and/or ridicule, does not form intimate relationships has difficulty making everyday decisions without reassurance from others is unwilling to be involved with people unless certain of being liked shows perfectionism that interferes with task completion views self as socially inept, unappealing and inferior
fearing shame and/or ridicule, does not form intimate relationships is unwilling to be involved with people unless certain of being liked views self as socially inept, unappealing and inferior
when assessing a client diagnosed with histrionic personality disorder, the nurse might identify which characteristic behavior
attention-seeking flamboyance
when assessing a client exhibiting passive-aggressive personality traits, which characteristic behavior might the nurse identify
The client seeks subtle retribution when feeling others have wronged him or her
although there are differences among the three personality disorder clusters, there also are some traits common to all individuals diagnosed with personality disorders.. which of the following are common traits. (select all that apply) failure to accept the consequences of their own behavior self-injurious behaviors reluctance in taking personal risks cope by altering environment instead of self lack of insight
failure to accept the consequences of their own behavior cope by altering environment instead of self lack of insight
a client diagnosed with antisocial personality disorder states “my kids are so busy at home and school, they don’t miss me or even know im gone” which nursing diagnosis applies to this client
ineffective denial
a client diagnosed with borderline personality disorder superficially cut both wrists is disruptive ingroup, and is splittingstaff. Which nursing diagnosis would take priority
risk for self-mutilation R/T need for attention
a client diagnosed with schizoid personality disorder chooses solitary activities, lacks close friends and appears indifferent to criticism. Which nursing diagnosis would be appropriate for this clients problem
social isolation R/T discomfort with human interaction AEB avoiding others
a client exhibiting passive aggressive personality traits continuously complains to the marriage counselor about a nagging husband who criticizes her indecisiveness. which nursing diagnosis reflects this client’s problems
impaired social interaction R/T inability to express feelings openly.
a nurse is discharging a client diagnosed with narcissistic personality disorder. which employment opportunity is most likely to be recommended by the treatment team
prison warden
which client situation requires the nurse to prioritize the implementation of limit setting
a client verbally provoking another patient who is paranoid
a client newly admitted to an in-patient psychiatric unit is diagnosed with schizotypal personality disorder. The client states “I envision my future death by fire.” Which is the most appropriate nursing response
I can see your thoughts are bothersome. how can I help
A suicidal client is diagnosed with borderline personality disorder. Which short-term outcome is most benficial for the client
the client with express feelings without inflicting self-injury by discharge.
a client diagnosed with an avoidant personalit disorder has the nursing diagnosis of social isolation R/T severe malformation of the spine. AEB “I can’t be around people looking like this. Which short term outcome is appropriate for this clients problem
the client will be able to participate in one therapy group by end of shift
a client diagnosed with an obsessive compulsive personality disorder has a nursing diagnosis of anxiety R/T interference with hand washing AEB “ill go crazy if you don’t let me do that. Which short term outcome is appropriate for this client
within 72 hours of admission, the client will notify staff when signs and symptoms of anxiety escalate
A client diagnosed with antisocial personality disorder demands at midnight to speak to the ethics committee about the involuntary commitment process. which nursing statement is appropriate
I realize youre upset; however this is not the appropriate time to explore your concerns
a client diagnosed with antisocial personalty disorder is observed smoking in a nonsmoking area. which initial nursing intervention is appropriate
confront the client about the behavior
after being treated in the ED for self inflicted lacerations to wrists and arms, a client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. Which nursing intervention takes priority
observe client frequently
a 15 year old client living in a residential facility has a nursing diagnosis of ineffective coping R/T abuse AEB defiant responses to adult rules. Which of the following interventions would address this nursing diagnosis appropriately? (Select all that apply) set limits on manipulative behavior refuse to engage in controversial and argumentative encounters obtain an order for tranquilizing medication encourage the discussion of angry feelings remove all dangerous objects from the clients environment
- set limits on manipulative behavior
- refuse to engage in controversial and argumentative encounters
- encourage the discussion of angry feelings
A client diagnosed with a borderline personality disorder is given a nursing diagnosis of disturbed personal identity R/T unmet dependency needs AEB the inability to be alone. Which nursing intervention would be appropriate
help the client identify values and beliefs
a client diagnosed with a dependent personality disorder has a nursing diagnosis of social isolation R/T parental abandonment AEB fear of involvement with individuals not in the immediate family. Which nursing interventions would be appropriate.
role-model positive relationships
a client diagnosed with paranoid personality disorder needs information regarding medications. Which nursing intervention would best assist this client in understanding prescribed medications
provide one on one teaching in the clients room
a nursing student is studying the historical aspects of personality disorder. which entry on the examination indicates that learning has occurred
hippocrates in the 4th century B.C., identified four fundamental personality styles
a nursing student is learning about narcissistic personality disorder. Which student statement indicates that learning has occured
these clients express a grandiose sense of self-importance
a nursing instructor is teaching about personality disorder characteristics. which student statement indicates that learning has occurred
personality disorders cannot be cured or controlled successfully with medication
a client is diagnosed with intermittent explosive disorder. The clinic nurse should anticipate potentially teaching about which of the following medications? (select all that apply) Sertraline paliperidone buspirone phenelzine valproate sodium
paliperidone (invega)valproate sodium
nail biting, scratching, and hair pulling for extended periods of time in a private setting are symptoms associated with the diagnosis of
trichotillomania
a client diagnosed with dependent personality disorder has a nursing diagnosis of altered sleep pattern R/T impending divorce. The client is prescribed oxazepam prn. Which is an appropriate outcome for this nursing diagnosis.
the client sleeps 4-6 hours a night by day 3
a client diagnosed with paranoid personality disorder is prescribed risperidone. The client is noted to have restlessness and weakness in lower extremities and is drooling. Which nursing intervention would be most important.
give the ordered prn dose of trihexyphenidyl
a client diagnosed with obsessive-compulsive personality disorder is admitted to a psychiatric unit in a highly agitated state. The physician prescribes a benzodiazepine. Which medication should the nurse expect to administer
clonazepam
what must a doctor do before putting a patient onquinadine
they need to digitilize the person first because the dig takes care of the heart rate.
quinidine
exacabates CHFcauses thrombocyteapeniaextends refractory period
Norpace side effects
dry mouthexacabates CHFurinary retentionthrombocytopenia
Lidocaine for the heart
has to be preservative free (No epinephrine)makes it harder for a patient to go into a v fibtreats pvc’sprevents patient from going into v tachanestasizes the heart0.5-1 mg/kg depending on your person
lidocaine IV can cause
causes seizurespush over 1-2 minutes (preferably 2 minutes)can cause confusion (especially in elderly)can get a psychosiscardiovascular hypotensionbradycardiapossible blocks and arrestsother arrthymiasdouble vision
important about lidocaine
make sure you pick the right lidocainemake sure you put it in its own line. Do not mix with other drugs in IV line
class 1 C drugs.
This class of drugs are used when other things don’t work. Used for PAF, Life threatening ventricular arrhythmias. 150 to 300 mg po q. 8hrs.Monitor for increase in arrhythmias, CNS effects ( dizziness, anxiety, ataxia, confusion, and seizures.Used for life threatening ventricular arrhythmias. Can cause new or worse arrhythmias. CHF because of negative inotropic effect. Use for AF, PSVT.100mg po BID. Maximum dose of 400 mg.Monitor for increase & severity of arrhythmia. Monitor for CHF, tremors,dizziness and visual disturbances.
class 1 c drugs
Agents: . Flecainide (Tambacor) . Propafenone hydrochloride ( Rythmol )Action: . Most potent Class I agents. Slows conduction through atria , purkingee system and ventricals. Decreases repolarization rate. Decreases contractility. . Causes decrease in PVCS and VT
class 2 Beta blockers
Action: . Only group of antiarrhythmics shown to prolong life . Beta 1 receptors in heart attach to calcium channels. Blockage decreases Ca++ influx. Depresses phase 4 of depolarization. Decreases automaticity, heart rate, and BP. Decreases AV conduction.Agents: . Propranolol ( Inderal )—non selective . Metoprolol ( Lopressor )—selective . Atenolol ( Tenormin ) . Sotalol ( Betapace )Adverse effects: . CV: Bradycardia, hypotension, edema, CHF, Pulmonary Edema , . Resp: Bronchospasm . CNS: Fatigue, weakness, dizziness, mental changes, insomnia, confusion . GI: Constipation, diarrhea, nausea, vomiting . GU: Impotenceendocrine: blood sugar variations
negative inotropic effect causes
heart failure
dromotropic effect causes
(1) Refers to a change in the speed of conduction through the AV junction(2) A positive dromotropic effect results in an increase in AV conduction velocity(3) A negative dromotropic effect results in a decrease in AV conduction velocity
inotropic effect
(1) Refers to a change in myocardial contractility(2) A positive inotropic effect results in an increase in myocardial contractility(3) A negative inotropic effect results in a decrease in myocardial contratility
chronotropic effect
(1) Refers to a change in heart rate(2) A positive chronotropic effect refers to an increase in heart rate(3) A negative chronotropic effect refers to a decrease in heart rate
interactions with Beta Blockers
. Caution with other antiarrhythmics. Can cause additive effects. . NSAIDS may decrease antihypertensive effect. . Cimetidine can increase the effect of inderal. . In diabetics can mask signs of hypoglycemia.
nursing considerations for Beta Blockers
. Monitor vital signs frequently during period of adjustment. Notify MD if pulse falls below 50 to 60 beats / minute and / or SBP falls below 90 to 100. . If meds given IV must be on a monitor during administration and for several hours later. Monitor hepatic, renal and CBC function. . Monitor I&O, daily weight, and check for CHF. . Give with meals or immediately after eatting. Extended release tablets should be swallowed whole. Do not crush.
potassium channel blockers
Action: Block potassium channels, prolong repolarization and refractory periods. They effect fast tissue and commonly are used to manage difficult to treat arrhythmias.Agent: Amiodarone ( Cordarone) Ibutilide fumarate ( Corvert )
potassium channel blockers
ex. AMIODARONEUse: . Treatment of life threatening recurrent V-Fib and hemdynamically unstable V-Tach and SPVT, AF, PAF.Dose: PO—800 to1600 mg/ day for 1 to 3 wk and reduce to 600 to 800 mg/ day for 5 wks: usual maintenance dose, 400 mg/ day. IV: Give through central line if possible.
contraindications of potassium channel blockers
. Severe sinus bradycardia since drug slows heart rate by interfering with SA nodal firing. AV nodal blockage since drug slows conduction through AV node. May cause complete heart block resistant to atropine.
precautions for potassium channel blockers
CHF may be worsened. Hypokalemia may block amiodarone action.Side Effects / Adverse reactions: . CNS—ataxia, tremors . CV—–SA & AV blockage, bradycardia, myocardial depression, IV-hypotension . EYE—small corneal deposits that can impair vision may develop with long term use. When drug is discontinued deposits may slowly disappear. . GI——anorexia, nausea, constipation, abdominal pain . PULMONARY—pulmonary fibrosis, pneumonitis . SKIN—light sensitivity caused by crystals deposited in the skin producing a bluish color
nursing considerations for potassium channel blockers
. Assess EKG , BP and pulse . Assess lung sounds. Rales, decreased lung sounds or friction rub may indicate pulmonary toxicity. Check weight, I&O and signs of CHF . Check skin for bluish coloration. Check gait and check for tremors . Eye exam should be done before and at regular intervals during therapy. Avoid sunbathing, tanning salons because of photosensitivity. Limit outdoor activity between 10 am and 2 pm. . Increase dietary intake of fruit, fiber , fluids and exercise to combat constipation. . Missed dose: Omit. Do not double up on missed dose. Notify MD if two or more doses are missed.
covert
potassium channel blockerUsed for AF, Atrial Flutter. 1mg IV over 10 min. for patients > 60kg. 0.01mg/kg for patients
class 1 sodium channel blockers
. Decrease rate of conduction. Prolongs action potential duration. Reduces speed of impulse conduction. For atrial and ventricular dysrhythmiasCLASS IaAGENTS. Procainamide ( Pronestyl ). Disopyramide ( Norpace ). Quinidine ( Quinidex )
indications of sodium channel blockers
ex:PROCAINAMIDE (PRONESTYL )Indications: Ventricular arrhythmias . Stable ventricular tachycardia . Premature ventricular contractions . Ventricular fibrillation Supraventricular tachyarrhythmias . PSVT, PAT, Junctional tachs. , . Atrial flutter and fibrillation
actions of sodium channel blockers
. Slows conduction. Is a negative inotrope with a ischemic myocardium . Decreases myocardial excitability . Is often used as drug of choice if resistance to lidocaineContraindicated in patient with myasthenia gravis.Caution with patients with MI, CHF, Digoxin intoxication.
adverse effects of sodium channel blockers
Adverse effects: . Myocardial depression. Prolongs duration of QRS, QT interval, AV conduction. . Hypersensitivity. Confusion, seizures, dizziness. . Hypotension if given too fast IV. Blood dyscrasias like thrombocytopenia. . Gastric: anorexia, diarrhea, nausea, vomiting.Nursing: . PO: Give with meals or snack to lessen GI distress. . Monitor EKG, BP, and pulse continously throughout IV administration. . Keep patient supine during IV admininstration. Assess QRS and QT intervals. . When IV, discontinue if QT increases by 50% or PR more than .20 second or if BP drops 15mm Hg.
QUINIDINE (QUINIDEX)
action: . Slows conduction through cardiac tissue. Refractory period is lengthened especially in atria. Used for atrial flutter or fibrillation to maintain sinus rhythm. . Has anticholinergic effect by inhibiting vagal action on SA and AV nodes. Sinus node may accelerate causing a dangerous sinus tachycardia. If Quinidine is given to people with A. Flutter or A. Fibrillation, they should be digitalized first to slow the SA and AV nodes.Dosage: . Quinidine Sulfate—200 to 400 mg every 4 to 6 hours. . Sustained release ( Quindex Extentabs—300 to 600 mg every 8 to 12 hours. . Quinidine Gluconate—324mg every 6 to 8 hours. . Quinaglute 324mg every 6 to 8 hours IM or IVAdverse Effects: . Most common effect is diarrhea. May have nausea and vomiting. . Can cause thrombocytopenia. . Hypotension, tinnitus, vertigo, visual disturbances, confusion, psychosis. . Arrhythmias like SA and AV blocks, sinus arrest. . Asthma like symptoms. Systemic Lupus like symptoms.Interactions: . Will increase digoxin levels. Nifedipine will decrease Quinidine levels.Nursing: . Prior to giving drug need baseline QT interval since drug can prolong it. . Give with meals to decrease GI upset. Do not crush sustained release. . Monitor vital signs, EKG and intake and output. Monitor platelets. . Monitor for CHF.
DISOPYRAMIDE ( NORPACE )
Action: . Prolongs refractory period. Decreases myocardial contractility. Has anticholinergic effect so patients with A. Flutter and A. Fibrillation should be digitalized first. Adverse effects: . Neuro: Blurred vision, dizziness, headache, agitation, depression. . Cardio: Conduction disturbances, hypotension, chest pain, CHF, fatigue, edema, weight gain. . GI: Dry mouth, constipation, nausea, pain, bloating, anorexia, diarrhea. . Resp: SOB . Thrompocytopenia . Renal: Urinary retention, hesitancy,and frequency . Endocrine: Hypoglycemia . RashNursing: . Monitor vital signs, EKG, QRS and QT intervals, I and O, weight. . Monitor for CHF. Check platelets. . Sugarless gum for dry mouth . Take on empty stomach . Eat high fiber diet. Bulk laxatives to treat constipation. . Monitor potassium levels. Ineffectve in hypokalemia. Toxic with hyperkalemia.
class 1 b drugs
Agents: . Lidocaine (Xylocaine) . Tocainide ( Tonocard) . Mexiletine ( Mexitil)
LIDOCAINE ( XYLOCAINE )
Action: . Elevates ventricular fibrillation threshold . Treats symptomatic PVCS. Suppresses ventricular tachycardia.Dosage: . Adult: 1mg/kg to 1.5 mg/kg bolus IV followed by 0.5 mg to 0.75/kg in 10 minutes. About 50 to 100mg. Reduce bolus dose by 5% in patients with CHF. . Infusion rate is 1 to 4 mg/minute. Can give endotracheal if IV not available. . Onset of action is 30 to 60 seconds IV . Therapeutic level is 1.5 to 6 ug/mlAdverse effects: . CNS: Paresthesias, numbness, agitation, confusion, seizures. . CV: Hypotension, bradycardia, cardiac arrest, arrhythmias . GI: vomiting . Integ: PhlebitisNursing; . Monitor vital signs, EKG, QRS and QT levels (3) . Monitor serum levels. Signs of toxicity include confusion, excitation, blurred or double vision, nausea, vomiting, tinnitus, tremors, convulsions, difficulty breathing. . Use only 1% or 2% solutions without epinephrine or preservative. . Administer over 1 to 2 minutes . If given too fast, increase risk of seizures. . Use infusion pump. Do not mix with other drugs.
calcium channel blockers (class IV)
Action: These drugs work by inhibiting the slow channel pathways or the calcium Dependent channels. By doing this they depress phase 4 depolarization. Therefore these drugs: . Prolong AV node effective refractory period . decrease AV node conduction and reduce rapid ventricular conduction due to A. Flutter, AF. Used for SVT Agents: . Ditiazem ( Cardizem ) . Verapamil ( Calan )
DILTIAZEM ( CARDIZEM )
Use: . Temporary control of rapid ventricular response in a patient with A. FIB or A. Flutter. Supraventricular arrhythmias . Vasospastic angina. Essential Hypertension . Unlabled use—prevention of reinfarction in non Q wave MIContraindications: . Hypersensitivity, sick sinus syndrome, 2nd or 3rd Heart , severe hypotension ( less than 90/60 ). Patients undergoing cranial surgery, bleeding aneurysmsCaution: . CHF especially if on beta blocker. Conduction abnormalities. Renal or hepatic impairmentDose: . IV—bolus dose 0.25mg/kg over 2 minutes; second dose 0.35mg/kg over 2 minutes after 15 minutes prn; then 5-10 mg/hr or higher by continuous infusion . PO—usual dose 180 to 360 mg/day in divided doses or 60 to 120 mg sustained releaseAdverse / Side effects: . CNS—headache, fatique, dizziness, drowsiness, nervousness, insomnia, confusion, tremor, gait abnormality . CV—edema, arrhythmias, angina, 2nd and 3rd degree heart block, bradycardia, CHF, hypotension, palpitations, syncope, flushing . GI –nausea, constipation, anorexia, vomiting, diarrhea, impaired taste, increased weight. .Skin rashDrug Interactions: . Increases digoxin levels. Additive effects on AV conduction with beta blocker. . Cimetidine can increase cardizem levelsNursing: . Withhold drug if SBP is blocks. Position changes slowly. Avoid driving until reaction to drug is known. Keep follow up appointments. . PO—AC and HS. IV—may be given direct as bolus over 2 minutes. May be continuous IV infusion. Recommended rate-5 to 15 mg/hr. Can add to D5W, NS and combos.
VERAPAMIL ( CALAN )
Dose: . PO—start with 80mg 3 to 4 times daily; daily range 240 to 480 mg.. . IV—5 to 10 mg bolus over 2 minutes; repeat dose of 30 minutesInteractions: . Beta blockers increase risk of CHF, bradycardia,heart block . Increases digoxin levels. . Lithium and cyclospore may be increased to toxic levels.Nursing: . PO—with food to decrease GI ditress. Capsules can be opened & sprinkled on food. Do not dissolve or chew capsule. . Transient asymptomatic hypotension may accompany IV bolus. Have patient remain in recumberant position for at least 1 hour after dose. (7) . Same as with cardizem
ADENOSINE ( ADENOCARD )
Action: . Slows impulse formation in SA node. Slows conduction time through AV node. Depresses left ventricular function and restores NSR. . General cardiac depressantUses: . Paroxysmal supraventricular tachycardiaPrecautions: . Sick sinus syndrome may be worsened by drug and produce sinus arrestDosage: . IV—6 mg by rapid push with saline flush over 1 to 2 seconds. If not effective, 12 mg by rapid push may be given 2 minutes later; repeat once if necessarySide Effects: . Arrhythmias , flushing, heart block, chest pain, SOB, cough, dizziness , numbness, tingling in arms.Nursing: . Continuous EKG. Monitor BP and pulse, lung sounds, respiratory
ATROPINE SULFATE
Used for bradycardia and heart block. 0.5 to 1mg IV bolus may be repeated every 3 to 5 min up to 0.04mg/kg. Monitor heart rate and rhythm. Assess for chest pain, urinary retention.
inotropic
force of contractionpositive inotropic increases the forcenegative inotropic decreases the force
dromotropic
conduction patternnegative dromotropic slows conductionpositive dromotropic speeds up contractionconduction goes from arrythmia to heart block
Chronotropic
heart rate (can go both ways)positive chronotropic speeds up heart ratenegative chronotropic slows down heart rate
negative inotropic
if contraction not forceful enough blood backs up causing heart failure
when starting a drip
know baseline QT interval
if there is 50% or more distance between 2 complexes
may be a block
cardioversion
used for every rhythm that has a T wave
defribilization
only for v fib (only only only)before you shock someone yell all clear and make sure you are not touching the patient
sodium channel blockers
stabilize membranesdecreases irritationdecreases etopic beats from starting
beta 2
lungs
beta 1
heart
lopresser IV
5mg (3 bolus’) then PO
if adenosine doesnt work
cardiovert
anatomy and physiology of an MI
. Sudden blockage of one of the branches of the coronary arteries. When blood flow acutely decreases by 80% to 90% ischemia develops. b. If blood flow is not restored myocardial tissue necrosis can happen over a period of hours.
what rhythm are patients usually in with an M.I.
V. Fib
M.I. anatomy and physiology
Can result in sudden death or gradual scarring over necrotic area. d. Most MIs are secondary to thrombus formation. Other factors are coronary artery spasm, platelet aggregation, and emboli. e. Cardiac cells can withstand ischemia about 20 minutes before injury occurs.
during an M.I.
Within 4 to 6 hours the entire thickness of the heart will become necrotic.
Around the area of infarction there are two zones:
. Zone of Injury Zone of ischemia
necrotic tissue is
electrically inert
zone of ischemia
really electrically unstablethats why the first 72 hours after an M.I. is so important because that ischemic tissue is so unstable and arrthymic
acute coronary syndrome
•When ischemia prolonged and not immediately reversible, ACS develops.•Encompasses a spectrum of unstable angina, non-ST segment elevation Myocardial Infarction ( NSTEMI ) and ST segment elevation Myocardial In farction.•Reflects the relationship among these disorders.
pathology of an MI
•Ischemia causes a decrease in cardiac functioning.•Can produce a permanent loss of contractile function in the injured area.•Cardiogenic shock can develop from decreased cardiac output and decreased contractility and pumping capacity.•Actual extent of MI depends on collateral circulation, anaerobic metabolism and workload demands on the myocardium.
promestyl
iv bolusgive Over 5 minutesif too fast causes seizures, blocks, hypotension
anterior wall MI
absolute worst MI. Obstruction of left anterior descending artery. 25% of all MIs. Highest mortality. b. Most likely to cause left ventricular heart failure and ventricular dysrhythmias. c. People with anterior MI more likely to die in the first year after the MI than those with other MIs. d. EKG shows ST elevations, abnormal Q waves.
inferior wall MI
right sidedResults from occlusion of right coronary artery. Is 17% of all MIs. 10% mortality rate. b. About 1/3 have right ventricular MI and right ventricular failure. c. EKG can show ST and T wave changes and Q waves.(T wave inverts, thats NOT NORmal)
posterior and lateral wall MI’s
least complications•Result from obstruction of the circumflex artery.•Posterior MI is 2% all MIs. Is uncommon.•Lateral wall MIs have the least complications.
gender differences in acute coronary syndrome(Men)
Men are developing CAD at a younger age than women and their death rates are declining. b. Initial cardiac event is more often MI than angina. c. Have higher rate of left ventricular hypertrophy. d. Have greater collateral circulation.
gender differences in acute coronary syndrome(Women)
CAD causes more deaths in women than men. Usually older and sicker with first MI. b. Initial cardiac event more often angina. c. After menopause risk of MI quadruples. Prior to menopause have higher HDL levels than men. After, LDL levels increase.Fewer women than men present with classic symptoms of MI. Fatigue often 1st sign of ACS. C/o palpitations more than men. e. More likely to experience fatal cardiac event within 1st year after an MI. f. Delay longer before seeking medical help.•Have higher mortality rate and complications after CABG surgery. h. Those on oral contraceptives and who smoke at greater risk for MI.
gerontologic considerations with an MI
•May have decreased responses to neurotransmitters so often pain is atypical. May have jaw pain of faint.•Have had time to develop collateral circulation so may not have lethal complications.
cultural and ethnic consideration for MI’s
•White, middle-aged men have highest incidence of CAD.•African Americans have early age onset od CAD.•African American women have higher incidence and death rate r/t CAD than white women.•African Americans have more severe CAD than whites.•Native Americans under 35 yrs have twice heart disease mortality as other Americans r/t obesity and diabetes.•Hispanics have lower death rates from heart disease than non Hispanic whites.
Risk Factors for CAD
•Non Modifiable: Age Gender (men > women until 60 yr) Ethnicity (whites > African Americans) Genetic predisposition and family history of heart disease)•Modifiable Risk Factors: Elevated serum lipids Hypertension: 140/90 or greater Smoking Physical inactivity Obesity: waist circumference greater than 39.8 in men & 34.3 in women.•Contributing factors: Diabetes Mellitus Fasting blood sugar > 110 mg/di Psychologic states Homocysteine levels-if elevated can contribute to atherosclerosis
stages of MI healing
•Onset until 3rd day Acute tissue degeneration. Infarct area soft, mushy & necrotic. Dead tissue electrically inert. Peri-infarct area ischemic and electrically unstable. Critical time period-majority of deaths from dysrhythmias.
stages of MI healing
•4th to 7th day: Softening of infarct area. Danger of aneurysm formation.•8th to 10th day: Newly formed capillaries develop around infarct but it is 2 to 3 weeks before any significant circulation.
stages of MI healing
•11th day on: Collagen forms about 12th day. Rupture of ventricle possible from onset 14th day. Takes 3 to 4 weeks before scar is firm. Takes 2 to 3 months before scar is at maximum strength.
clinical manifestations of an MI
•Severe continuous chest pain not relieved by nitroglycerine or rest.•Shortness of breath, pallor, cold clammy diaphoresis, dizziness, nausea, vomiting, BP changes, dysrhythmias, cyanosis, restlessness, and intense anxiety.•Women may experience heaviness, squeezing type of chest pain. May have sharp, fleeting pain that returns. May have pain in jaw, neck, back & shoulder. Often have palpitations, may faint, nausea & vomiting
Deviations in the manifestations of an MI
•Patients with diabetes may have dull pain r/t neuropathies.•African Americans may have dyspnea as major symptom.•Elderly may have mild or absent pain. May have associative symptoms like SOB. Patients over 80 may display confusion or disorientation with decreased cardiac output.
diagnostic evaluation
•Electrocardiogram-serial readings to monitor evolution of MI.•Troponin Levels-establishes diagnosis of MI.•Cardiac Enzymes-CK (Creatine Kinase).•Isoenzymes: CK-MB-Heart•Myoglobulin•White blood cell count, sedimentation rate•Coronary Angiography- patient with NSTEMI may have this to evaluate extent of MI.•Stress Test & Echocardiograms-may need to do dobutamine (Dobutex) stress echocardiogram if patient unable to exercise.
with an MI the
st segment elevatesT wave inversion
with ischemia of the heart
st segment depressionT wave inversion
what meds do they hold for Heart tests
usually beta blockers
goals for med management of MI
•Minimize myocardial damage, relieve pain & provide rest•Prevent complications
emergency management of an MI
•Ensure patent airway. Oxygen at 2 to 4 L via nasal cannula.•Insert 2 IV catheters.•Obtain ECG. Place on monitor.•Assess for pain (PQRST)•Nitro. sl and aspirin if not already done by EMTs. Morphine for pain.•Baseline blood work (cardiac markers) & chest xray•Assess for antiplatelet, anticoagulant, and thrombolytic therapy.•Give beta blocker and antidysrhythmic drugs as needed.
ongoing monitoring of an MI
•Monitor vital signs, level of consciousness, cardiac rhythm, and O2 sat•Monitor response to medications. Remedicate or titrate medications as indicated.•Provide emotional support and reassurance to patient and family.•Explain all procedures/interventions to patient in simple terms.•Anticipate need for intubation if respiratory distress is evident.•Prepare for CPR, defibrillation, cardioversion and transcutaneous pacing as indicated.
thrombolytic therapy
•Used to dissolve the thrombi in coronary arteries and to restore blood flow.•Most effective if done within 4 to 6 hours after start of chest pain where there is evidence of hyperacute or acute ECG changes in 2 or more leads.•Works directly or indirectly to convert plasminogen to plasmin, an enzyme that acts to digest the fibrin matrix of clots.
Thrombolytic side effects/adverse reactions
•Hemorrhage and anemia•Hypotension, fever•Bronchospasm, anaphylaxis•Periorbital swelling, itching, urticaria, headache•Reperfusion dsyrhythmias
contraindications for thrombolytic therapy
•Absolute: Active internal bleeding History of cerebral aneurysm, brain tumor, previous cerebral hemorrhage Ischemic stroke within 3 months. Significant closed head or facial trauma within 3 months Aortic dissection•Relative Contraindications: Active peptic ulcer disease Current use of anticoagulants Pregnancy Ischemic stroke over 3 months ago, dementia, intracranial pathology Recent internal bleeding within 2 to 4 weeks. Serious systemic disease.Uncontrolled hypertension over 180/110 Prolonged CPR Patients who weigh less than 65 kg have to dose adjusted because of increased likelihood of bleeding.
nursing implications of thrombolytic therapy
•Prior to treatment: Assess vs, neuro, and cardiac rhythm. Patient needs two IV lines Draw required labs. Avoid non essential punctures. Don’t shake the drug. It will foam.•During treatment: Assess vs, neuro, cardiac rhythm q 15 min. Check for signs of bleeding Monitor lab values•After treatment: Assess vs, neuro, cardiac rhythm q 15 min. then q 2 hours for 24 hours Monitor for signs of bleeding for 72 hours.
signs of reperfusion (thrombolytic therapy)
•Abrupt cessation of chest pain•Resolution of ST elevation/depression•Rapid rise of CK-MB•Reperfusion dysrhythmias—generally self limiting
complications of thrombolytic therapy
•Reocclusion of the artery. May start heparin therapy to prevent this.•Bleeding
nitroglycerine drug therapy
•May be used short term to reduce the infarct size, decrease heart workload and increase blood supply.•Hypotension, reflex tachycardia are side effects so BP and heart rate are monitored closely and drug is carefully titrated,•Want to keep BP above 90 systolic and heart rate below 110.
morphine sulfate
•Given for chest pain unrelieved by nitroglycerine. Is a vasodilator so decreases cardiac workload by lowering myocardial oxygen consumption.•Reduces contractility, BP and heart rate•Reduces fear and anxiety•In rare cases can depress respirations.
good thing about TPA
specific. Goes right for the clot
Drug therapy
•Beta blockers•Angiotensin-Converting Enzyme Inhibitors•Angiotensin II Receptor Antagonists•Aspirin•Anticoagulants•Antidysrhythmic drugs•Stool Softners•Lipid lowering drugs
nursing care for drug therapy
•Continue to monitor vs, cardiac rhythm, response to drug therapy.•Space activities with rest•After 48 hrs encourage gradual increase in self care activities. Monitor response to activity ie. Vs, O2 sat, changes in cardiac rhythm, chest pain.•Decrease meal time fatigue Small, frequent meals, no very hot or cold foods. Sufficient time for meals•Begin rehab teaching early•Encourage and supervise increased activity level. Start with lying & sitting exercises Increase length of ambulation Encourage exercise for 20 minutes twice a day.•Teach patient to monitor pulse during exercises and to stop if pulse doesn’t increase or if it rises to 20 over resting pulse.•Reinforce plans for home activity program
sodium channel blockers
neg chronotropicneg dromotropic
procainamide (pronestyle)
1a(ventricular arrhythmias)stable ventricular tachypremature ventricular contractionsventricular fibrillation(Supraventricular Tachy)PSVTPATJunctional tachs*atrial flutter and fibrillation
action of procainamide (pronestyle)
slows conductionnegative inotropedecreases myocardial excitability
adverse effects of procainamide (pronestyle)
myocardial depressionprolongs duration of QRS, QT interval, AV conductionHypotension if given too fast IV
labs for procainamide (pronestyle)
platelets
administration of procainamide (pronestyle)
bolus 50-100 mg IV SLOW over 5 minutes
Quinidine Norpase
positive anticholinergicpositive chronotropic
digitilize
give 3 doses of dig for therapeutic blood levels
Quinidine Norpase action
slows conduction through cardiac tissueused for atrial flutter or fibrillation to maintain sinus rhythm
what should you do before administering Quinidine Norpase
digitilize first
adverse effects of Quinidine Norpase
diarrheathrombocytopeniawill increase digoxin levels
nursing considerations for Quinidine Norpase
baseline QT interval monitor platelets
Lidocaine/xylocaine
anesthetizes myocardiumnegative inotropicnegative dromotropic
Lidocaine/xylocaine administration
IV push 1-2 minutes0.5 - 1 mg/kg bolus IV (NO PIGGYBACK)MAKE SURE PLAIN/NO ADDITIVESuse infusion pump, do not mix with other drugs
Lidocaine/xylocaine
PVC’s -Ventricular tachycardia
Lidocaine/xylocaine therapeutic level
1.5 to 6 ug/ml
Lidocaine/xylocaine adverse effects
paresthesiasconfusioncrosses blood/ brain barrier
Class 1c drugs
most potent class I agentsPVCS VTnegative dromotropic
Flecanamide/Rythmol
POTENTused if all other meds failventricular arrythmias rhythmsa fiba fluttersever svt
side effects of flecanamide/rythmol
Chf because of negative inotropic effectCHF, arrythmias
Beta Blockers
neg. chronotropicneg. inotropicneg. dromotropic
beta blockers used for
MI’sHTNcan be used for arrythmiasprolong life
administration of Beta Blockers
IV or PO
Block Beta 1
Heart
Block Beta 2
Lungs (caution in asthma)
monitor in Beta Blockers
BPHR notify doctor if pulse falls below 50-60 bpmor SBP falls below 90-100
potassium channel blockers
Potenttreatment of V-FibV-TachSPVT,A FibPAF
Amiodarone
potassium channel blockerincrease dose then taper to maintenancecan cause arrythmias and severe bradycardia
amiodarone nursing considerations
QT intervalvitalsrhythmcan worsen CHF
amiodarone side effects
blue skincorneal deposits in eyes (vision)may cause complete heart block resistant to atropine
amiodarone administration
Give through central line if possible
Calcium channel blockers
negative inotropicnegative dromotropic
Diltiazem (cardizem)
calcium channel blockerused for A. FibA.FlutterSVT arrhythmiasdecreases BPspasmodic angina
administration of diltiazem (cardizem)
IV- 2 minutes MINIMUM
diltiazem (cardizem) side effects
HAgait abnormality
diltiazem (cardizem) nursing considerations
can cause sick sinus syndromecaution use in CHF withhold drug if SBP is less than 90 or diastolic is less than 60
Verapamil (Calan)
bolus over 2 minutes
verapamil (calan) interactions
beta blockers increase risk of CHF, bradycardia, heart block increases digoxin levelslithium and cyclospore may be increased to toxic levels
Adenosine (adenocard)
given for SVTgive fast 6mg (rapid push over 1-2 secs)
Inotropic
increase or decrease contractilitydigoxin: positive inotropic (stronger)most meds : negative inotropic (depress contractilitywatch for CHF because not pumping blood out
Dromotropic
conduction system (impulses)positive : increased conductionmost meds : interfere with conductiontreat tachy arrythmiasdrugs have potential for blocks
chronotropic
rate @ SA nodestimulate SA node
women
have weird angina
diagnostic evaluation procedure
ECGtroponincardiac enzymesisoenzymesmyoglobulinWBCSed rate
CK
creatinine kinasegoes up fast then decreasesbest for determining early MI
Isoenzymes
CKMB (MB means heart)
WBC
increases because of inflammatory response to attack on heart
sed rate
stays increased for awhile
ECG changes
Q - does not go back to normalST elecatedT wave inversion
emergency management of MI
O22 IV’sECGnitro/asprin/morphinebloodwork/x-rays (enlarged heart)assess antiplatelet/anticoagulation?thrombolyticsbeta blockers/ antidysrhythmics
thrombolytics
TPA4-6 hours after start of chest pain (asap pre-damage)TPA goes to where its neededside effects: hemorrhage/anemiahypotension/feverbronchospasm/anaphyaxisperiorbital swelling/itching/uticaria/headachedysrhythmiascan cause another clot when a large clot is broken up
Heart failure
right side -fluid backupleft side - pulmonary
systolic ventricular dysfunction
not enough blood ejectionfoward failuredecrease cardiac output -fluid backs up
diastolic ventricular dysfunction
left ventricule cant relax enough to accumulate blood to pump out
right vs. left side heart failure
arteries Leftveins rightrt. failure can be caused by left failurert ventricular MI
high output failure
cardiac ouput can be okincrease metabolic demands on hearthyperthyroidseptecemia
what diagnoses Heart Failure
BNPfrom fluid in ventricleschest xrayechocardiogram
diltiazem (cardizem)
calcium channel blocker
metoprolol (lopressor)
beta blcoker
atenolol (tenormin)
beta blocker
Nifedipine (procardia)
calcium channel blocker
timolol (betimol)
beta blocker
amlodipine (norvasc)
calcium channel blocker
the condition of having a reduced clood supply to myocardial cells is call
myocardial ischemia
by causing venodilation, nitrates reduce the amount of blood returning to the heart thus decreaseing
cardiac output
which of the following is true regarding the effect of atenolol (tenormin) on the heart
it selectively blocks beta receptors
the primary mechanism of calcium channel blockers
reducing cardiac workload
what agent has the ability to inhibit the transport of calcium ions into myocardial cells and relaxes both coronary and peripheral blood vessels
diltiazem (cardizem)
what are the goals for pharmacotherapy of acute MI
restore blood supply to the damaged myocardium as quickly as possibleprevent associated dysrhythmias with antidysrhythmicsreduce post- MI mortality with aspirin and ACE inhibitors
in treating MI the function of thrombolytic therapy is to
restore blood supply to the damaged myocardium
the primary risk during thrombolytic therapy is
excessive bleeding
following an acute MI , metoprolol (lopressor) is infused slowly until
a target heart rate of 60-90 beats perminute is reached
opiods such as morphine sulfate are sometimes administered to patients with MI to
reduce acute pain associated with MI
the nurse should administer aspirin as soon as possible following an suspected MI in order to
reduce post MI mortality
patients at high risk for stroke are often treated with
antihypertensives
a drug that blocks impulses from the parasympathetic nervous system is known as
cholinergic blocker
which cardiac enzyme would the nurse expect to elevate first ina client diagnosed with an MI
Troponin
along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing an MI
diaphoresis and cool clammy skin
The client diagnosed with rule out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first
have the client sit down immediately.
The nurse caring for a patient diagnosed with MI who is experiencing chest pain. what interventions should the nurse implement
administer aspirinapply O2
The patient who had an MI is admitted to the telemetry unit from ICU. which referel is most appropriate for the patient
cardiac rehab
patient is day one post-op coronary artery bypass sugery. the client complains of chest pain. which intervention should the nurse implement first
assess the clients chest dressings and vital signs
patient diagnosed with MI is 6 hours post right femoral percutaneous transluminal coronary angioplasty, which assessment data would require immediate attention by the nurse
complains of numbness in right foot
the ICU nurse is assessing the client who is 12 hours post MI. The nurse assesses an S3 heart sound. Which intervention should the nurse implement
notify the health care provider immediately
The nurse is administering a calcium channel blocker to the client diagnosed with a MI. Which assessment data would cause the nurse to question administering this medication
the clients bood pressure is 90/62
The client diagnosed with MI is on bedrest. The CNA is encouraging the client to move the legs. Which action should the nurse implement
praise the CNA for encouraging the client to move his legs
The client diagnosed with a MI asks the nurse “why do I have to rest and take it easy? My chest doesn’t hurt anymore” Which statement would be the nurse’s best response
your heart is damaged and needs abou four to six weeks to heal
The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse
the client refuses to keep the leg straight.
Heart Failure/CHF
Cardiovascular condition in which the heart is unable to pump an adequate amount of blood to meet the metabolic needs of the body
heart failure is a complication of
an MI
common causes of HF
•MI, arrhythmias, CAD, RHD, cardiomyopathy, anemia, endocarditis, pulmonary emboli, hypertensive crisis, congenital defects, Diabetes, smoking, substance abuse, family history.
types of HF
Left sidedright sidedhigh output
left sided heart failure
can be acute or chronicSubtypes: Systolic ventricular dysfunction and Diastolic heart failure.
systolic ventricular dysfunction
•Results when heart cannot contract forcefully enough during systole to eject adequate amounts of blood into the circulation.•Ejection fraction drops to below 40 % with ventricular dilation. Tissue perfusion decreases and fluid accumulates in the pulmonary vessels.•Called forward failure. Cardiac output is decreased and fluid backs up into pulmonary system.
what is another name for systolic ventricular dysfunction
foward failure
diastolic Heart Failure
•Left ventricle cannot relax adequately during diastole. Prevents ventricle from filling with sufficient blood to maintain adequate cardiac output.•Ventricle becomes less compliant over time because more pressure is needed to move the same amount of blood as compared to a healthy heart.
diastolic heart failure backs up in
lungs
right sided heart failure
•May be caused by left ventricular failure, right ventricular MI, pulmonary hypertensionThe right ventricle cannot empty completely so increased volume and pressure develop in the venous system. Peripheral edema results
right sided failure you get more
peripheral edema
high output heart failure
•Cardiac output can remain normal or above normal•Caused by increased metabolic demands or hyperkinetic conditions like septicemia and hyperthyroidism•Not as common
long term use of NSAIDS
cause fluid and sodium retentionwhich can cause HF
pioglitazone (actos)
used for diabetics causes fluid and sodium retention leading to HF
left sided HF symptoms
RESPIRATORY SYMPTOMS•Fatique, weakness, oliguria during the day, nocturia at night, angina, confusion, restlessness, dizziness, tachycardia, palpitations, pallor, weak peripheral pulses, cool extremities,•Decreased PaO2, Hacking cough worse at night, dyspnea, breathlessness, crackles or wheezes in the lungs, frothy pink tinged sputum, tachypnea, murmurs
Right sided HF symptoms
THINK VEINS•Jugular neck vein distention•Enlarged liver and spleen•Dependent edema in legs and sacrum•Distended abdomen, anorexia & nausea•Swollen hands & fingers•Polyuria at night•Weight gain•Increased BP (excess volume) or decreased BP from failure.
diagnostic assessments for HF
BNP (Best TEST)•B-Type natriuretic peptide ( BNP ) is used for diagnosing Heart Failure•Electrolyte imbalances may result from HF•BUN & creatinine to check effect of HF on kidneys•Urinalysis shows proteinuria•Hgb & Hct to identify HF caused by anemia•Microalbuminuria is an early indicator of decreased compliance of heart
B-Type natriuretic peptide (BNP)
secretedfrom the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens.trying to compensate for failure. tries toregulates BP and fluid balance.
more diagnostic tests for HF
•Arterial blood gases often show hypoxia. Respiratory alkalosis may occur because of hyperventilation. Respiratory acidosis may occur because of carbon dioxide retention•Chest Xrays help diagnose LVF•Echocardiogram considered best tool for diagnosing HF. Also determines ejection fraction.•Radionuclide imaging helps dx HF•Electrocardiogram can show ventricular hypertrophy, arrhythmias, and any degree of myocardial ischemia or injury•Pulmonary artery catheters allow assessment of cardiac function and volume in acutely ill patients.
medical treatment for HF
•Medications•Continuous positive airway pressure (CPAP)- improves sleep apnea in HF and improves cardiac output•Cardiac resynchronization therapy (CRT)- is biventricular pacing that stimulates more synchronized contraction and improves ejection fraction. Can be used with ICD.
more medical treatment for HF
•Heart transplant for end stage HF•Ventricular assist devices (VADs)- mechanical pump is implanted to work with patient’s own heart. Can be used short term while waiting for transplant or long term to increase quality of life.•Heart reduction surgery (partial left ventriculectomy PLV )-removes a section of the weakened heart in left lateral ventricle to reduce size and wall tension.
more heart failure treatments
•Endoventricular circular patch cardioplasty-portions of the septum and left ventricular wall are removed and a synthetic circular patch is grafted into opening, Makes more normal shape for left ventricle and improves ejection fraction.•Acorn cardiac support device- polyester mesh jacket placed over ventricles to prevent them from overstretching. Reduces hypertrophy and improves ejection fraction.
and yet more heart failure treatments
•Myosplint- recently approved. Electrical stimulation of several tension pads on the outside of the ventricle changes it to more normal shape and improves function.•Gene Therapy-Investigative. For those not candidates for heart transplant. Replaces damaged genes with normal ones by injecting growth factor into the ventricle. Improves exercise tolerance and regrowth of cardiac cells.
commonly used drugs for systolic HF
•Angiotensin-converting enzyme (ACE) inhibitors or angiotensin- receptor blockers (ARBs)•Diuretics- loops, thiazides, and potassium sparing•Human B-type natriuretic peptides•Nitrates•Inotropics•Beta-adrenergic blockers
loop diurectics
powerful. very powerful.if someone is on one, they usually have a catheter in. If no catheter then strict monitor I & O
positive inotropic drug
increases contraction
beta blockers have
a negative inotropic effecttherefor it can make CHF worse
Nursing assessment for HF
•Assess for mental status changes, pulmonary congestion, breathlessness, oliguria, renal function, edema•Monitor vital signs, O2 sat, cardiac rhythm,•Assess proportional pulse pressure as follows: Systolic BP – Diastolic BP Systolic BPPressure less than 25% indicates severely compromised cardiac output•Assess for extra heart sounds (S3, S4)•Auscultate for crackles and wheezes of the lungs. Note state of breathlessness•Inspect for JVD, hepatomegaly, ascites, dependent edema•Psychological assessment of patient and family for anxiety and depression.•Assess activity level•Assess laboratory data
Nursing diagnosis for heart failure
•Impaired gas exchange•Decreased cardiac output•Activity Intolerance•Excess fluid volume•Acute confusion related to delirium•Anxiety•Ineffective cerebral tissue perfusion
Nursing interventions for HF
•Monitor vital signs, Os sat, heart sounds•Give prescribed meds as ordered•Monitor for adventitious breath sounds•Monitor weight every day. Report increase of 2lbs/day and 5lbs/week. Monitor I&O•Monitor for JVD and edema•Provide oxygen as ordered•Place in fowler’s or semi-fowler’s position•Explore patient feelings about effects of HF on life style•Elevate legs when sitting. Encourage position changes. Keep skin soft and supple to prevent breakdown.•Plan for rest periods. Gradually increase activity. Assist with ADL’s as needed•Give sodium restricted diet as prescribed. Maintain fluid restriction if ordered•Provide small frequent feedings. Prevent constipation•Teach patient and family about nature of HF and reason for various treatments, self monitoring for worsening of HF, how to remain active yet avoid fatigue, management of medications and diet restrictions, and need for follow-up care
infective endocarditis
Is an infection of the innermost layer of the heart where the valves are.Prognosis of IE has improved with use of antibiotics. Untreated will cause death.15,000 cases are diagnosed per year.
acute endocarditis
¨Affects those with healthy valves and is rapidly progressive.
sub acute endocarditis
¨Typically affects those with pre- existing valve disease. Clinical course may extend over months. Usually responds well to treatment.
classified by cause of site (endocarditis)
Intravenous drug abuse infective endocarditis (IE IVDA) b. Fungal endocarditis c. Prosthetic valve endocarditis (PVE)
organisms that cause endocarditis
¨Bartonella quintana, Chlamydia¨Coag. negative staphlococcus, enterococcus¨MRSA, streptococcus, trophenyma whipple,¨Rickettsiae, staph aureus, HACEK group¨Viruses—coxsackie B virus¨Fungi—Candida¨¨Most common cause is staph aureus and steptococcus viradans. Bartonella & trophenyma are new organisms that are difficult to cultivate. MRSA is hard to treat.
predisposing cardiac conditions for endocarditis
¨Prior endocarditis, prosthetic valves¨Acquired valve disease, cardiomyopathy¨Pacemakers, Marfan’s syndrome¨Asymmetrical septal hypertrophy¨Rheumatic Heart Disease
if you receive any procedure with endocarditis
any dental procedures or anything. Like murmursneed to be on an antibiotcs
non cardiac conditions that predispose you to endocarditis
¨IV drug abuse¨Nosocomial infections
procedures that predispose you to endocarditis
¨Intravascular devices, cardiac catherization¨Oropharyngeal procedures¨Bronchoscopy, esophageal dilation, endoscopy¨Surgical procedures
pathophysiology of endocarditis
¨Turbulent blood flow from damaged cardiac valves allows bacteria to settle on low pressure side of valve or defect.¨Hallmark of IE is platelet-fibrin-bacteria mass on valve called vegetation. Organisms surround valve matrix, scarring and perforating leaflets.¨Emboli can occur if vegetative growths break free and enter blood. 22% to 50% will experience systemic embolization with left sided vegetation. Right sided embolization goes to lungs.¨Infection can spread from valve to supporting structures causing arrhythmias, valvular incompetence and possible heart failure.
endocarditis in the mitral valve
affects organscauses emboli to be pushed out into the system
endocarditis in the tricuspid valve
causes emboli to go into the lungs
symptoms of endocarditis
¨In acute type the onset is swift with septicemia and a fever over 38 degrees. The sub-acute is more insidious with vague complaints of malaise & aches & pains with low grade fever.¨Chills, weakness, malaise, anorexia, fatigue.¨Back pain, arthralgias, abdominal discomfort, headache, night sweats, and weight loss. May see clubbing of fingers in sub-acute.
acute symptoms of endocarditis
come on strong. worst
sub acute endocarditis symptoms
take longers to come on. not as stong. low grade fever
vascular symptoms of endocarditis
¨Splinter hemorrhages on nail beds¨Petechiae¨Osler’s nodes-painful, tender, red or purple, pea size lesions on fingertips and toes¨Janeway’s lesions-flat, painless, small red spots on palms and soles of feet.¨Roth’s spots-hemorrhagic retinal lesions.¨Onset of new or changing murmur is noted in most patients with aortic and mitral valve problems.
embolization that comes of the left side (endocarditis)
¨Spleen—sharp LUQ pain and increased size of spleen¨Kidneys—flank pain, hematuria, azotemia¨Brain—neurological damage like ataxia, hemiplegia, aphasia, visual changes, changes in levels of consciousness.¨Peripheral vessels to extremities–gangrene
diagnostic studies for endocarditis
¨History of procedures in last 6months, IVDA(IV drug abuse), heart disease, intravascular devices, renal dialysis, infections.¨Blood cultures¨Elevated WBC, ESR, & C-reactive protein¨Vegetative growth on echocardiogram¨ECG¨Chest Xray to check for cardiomegaly¨Cardiac cath to evaluate valve.
treatment for endocarditis
¨Long term antibiotic therapy¨Valve replacement¨Initially hospitalized for IV antibiotics . Then can get IV antibiotics on outpatient basis.¨Will need prophylactic antibiotic therapy for any invasive procedures in the future.
nursing care for endocarditis
¨Assess for history and subjective/objective symptoms of endocarditis.¨Possible nursing diagnoses: a. Decreased cardiac output b. Hyperthermia c. Activity intolerance d. Knowledge deficit
nursing interventions for endocarditis
¨Monitor vital signs, cardiovascular status, respiratory status and for complications¨Administer medications as ordered¨Give oxygen as needed, I&O, daily weight, keep HOB elevated.¨Monitor labs/diagnostic procedures¨Evaluate activity tolerance. Encourage balance between rest and activity to decrease cardiac workload.
teaching a patient with endocarditis
¨Review patient’s knowledge about this condition¨Review signs & symptoms of the disease and when to notify doctor.¨Patient should avoid contact with people who have infections.¨Patient should take prophylactic antibiotics prior to any invasive procedure.¨Action of medications¨Need for medical follow-up.¨Avoid excessive fatigue.
pericarditis
¨Is an inflammatory process of the visceral or parietal layer of the pericardium (membranous sac that encloses the heart)¨Can be acute or chronic.¨Acute pericarditis is commonly associated with:¡Infective organisms ( bacteria, viruses, fungi)¡Malignant neoplasms¡Post MI syndrome ( Dressler’s Syndrome )¡Post-pericardiotomy syndrome after cardiac surgery¡Systemic connective tissue disease like Lupus¡Renal disease with uremia
acute pericarditis
¡Infective organisms ( bacteria, viruses, fungi)¡Malignant neoplasms¡Post MI syndrome ( Dressler’s Syndrome )¡Post-pericardiotomy syndrome after cardiac surgery¡Systemic connective tissue disease like Lupus¡Renal disease with uremia
pathology of pericarditis
¨Membranes around heart become inflamed and rub against each other causing a friction rub that persists through systole and diastole.
symptoms of pericarditis
¨Patient complains of severe precordial chest pain that resembles MI pain. Pain intensifies in supine position and when the patient breathes deeply. May radiate to the trapezius muscle.¨Pain is often relieved by sitting up and leaning forward.hurts more on inspiration than expiration¨Patient’s with acute pericarditis may also have a fever with an elevated WBC and SED rate.¨May have malaise, myalgias, tachycardias.¨If bacterial get high fevers, chills , shaking, and night sweats.¨Patients with chronic constrictive pericarditis have signs of right sided heart failure, elevated venous pressure with jugular vein distention, hepatic engorgement, and dependent edema.¨Exertional fatigue and dyspnea are common complications.
diagnostics for pericarditis
¨ECG usually shows ST-T spiking with onst of Atrial Fibrillation. May also show pr depression.¨CT, MRI, and Echocardiogram help to diagnosis this. May see thickening and calcification of the pericardium.
pericardial effusion
¨Acute inflammation causes an accumulation of fluid within the pericardial sac. Can be serous. Purulent or hemorrhagic.¨Puts patient at risk for cardiac tamponade. This restricts diastolic ventricular filling and cardiac output drops. Leads to cardiac failure, shock and death.
symptoms of cardiac tamponade
Jugular vein distention Hypotension muffled heart sounds Pulsus paradoxus ( SBP 10 mm Hg or more on expiration than on inspiration. Narrowed pulse pressure
collaborative care for pericarditis
¨Need to make sure it’s pericarditis and not an MI.¨If effusion is small, treatment may be supportive. May use NSAIDS and sometimes corticosteroids. With larger effusions a pericardiocentesis is performed.¨If cardiac tamponade is suspected it is an emergency. Have to manage low cardiac output and remove excessive fluid accumulation with pericardiocentesis. May need pericardial drain placement.¨A portion of the pericardium may have to be removed if tamponade reoccurs.
care of a patient with pericarditis
¨Assess the nature of the patient’s pain. Usually substernal and worse on inspiration and when the patient is supine.¨Auscultate for a friction rub. Assist patient into position of comfort.¨Provide anti-inflammatory agents as prescribed. Avoid use of ASA and anticoagulants since they may increase the risk of tamponade.¨Assess for signs of tamponade and notify physician if it is suspected.
calculation of pulsus paradoxus
¨Auscultate BP carefully to detect paradoxical blood pressure.¨Palpate the blood pressure and inflate the cuff above SBP.¨Deflate the cuff slowly and note when the sounds are first audible on expiration.¨Identify when sounds are audible on inspiration.¨Subtract the inspiratory pressure from the expiratory pressure. Greater than 10 mm hg is an indication of tamponade.
treatment of chronic adhesive pericarditis
¨May need to remove pericardium (pericardiectomy) to restore cardiac function.¨Will need to be monitored closely in ICU following surgery.
aneurysms
. Abnormal dilation in a portion of the arterial wall. Caused by weakness in medial ( muscle ) layer of vessel. Intima & adventitia then stretch. b. Creates high arterial wall tension in area of aneurysm. Can burst, causing hemorrhage.
saccular aneurysm
•bubble in portion of arterial wall
fusiform aneurysms
•dilation entirely encircles a portion of the arterial wall
dissecting aneurysm
•blood separates layers of arterial wall. Blood is lost & blood flow to organs is diminished.more common in thoracic area than abdominal area
false aneurysm
•rupture of an artery but blood collects next to vessel. Occur as result of vessel injury or trauma.
worst aneurysm is
dissecting
aortic aneurysm
•May involve aortic arch, thoracic aorta and abdominal aorta.
abdominal aortic aneurysms
•arise between renal and iliac arteries.
thoracic aortic aneurysms
•arise between subclavian and renal arteries.
Thoracic aortic aneurysm
•Not as common as AAA. Most frequently in men between 40-70 years old.•Most common site for dissection. Often misdiagnosed. 1/3 die from rupture.•Most caused by atherosclerosis & hypertension.•Other causes are trauma, coarctation of aorta, and Marfan’s Syndrome.
dissecting thoracic aortic aneurysm
•Considered life-threatening emergency caused by tear in intima of aorta with hemorrhage into media. Splits vessel wall forming blood filled channel between its layers.hypertension is major predisposing risk factor
Type A dissecting thoracic aorta aneurysm
•called proximal dissection. Affects ascending aorta.
Type B dissecting thoracic aortic aneurysm
•Distal dissection limited to descending aorta.
symptoms of dissecting aortic aneurysm
•Severe anterior chest pain or intrascapular pain radiating down spine into abdomen and legs. May be in neck, jaw, and teeth.•Pain is described as tearing or ripping and boring.•If in the aortic arch, may see changes in levels of consciousness, dizziness, and weakened or absent carotid and temporal pulses.•Superficial veins in chest, neck, arms may be dilated and edema and cyanosis may be seen.•Diaphoresis, nausea, and vomiting, fainting, and apprehension are also common.•Blood pressure changes, decrease or absent peripheral pulses may be seen.•Complications: rupture and hemorrhage
abdominal aortic aneurysm
•Most common cause is atherosclerosis.•Affects men 4xs more than women. Prevalent in the elderly.•2/3 people are symptomatic.•Most occur below renal arteries, usually at branch of iliac arteries.•Associated with hypertension, increased age, and smoking. Most people over 70 years.
symptoms of abdominal aortic aneurysm
•May see pulsatile mass in periumbilical area, slightly left of midline.•Bruits may be heard.•Feeling like there is a heart beat in the abdomen.•When pain is present, may be constant or intermittent. Usually is mid abdominal area or lower back. Severe pain usually indicates impending rupture.•Can cause “blue toe syndrome” with patchy mottling of feet and toes in the presence of pedal pulses.•Sluggish blood flow to small vessels can cause thrombi and embolization.•Complication: rupture and hemorrhage. Up to 50% patients die from rupture before hospitalization. Only 10 to20% survive.
rupture of abdominal aortic aneurysm
•If posterior rupture into retroperitoneal space, bleeding may be tamponaded by surrounding structure, preventing exsanquination.•Have severe back pain and may or may not have back and flank ecchymosis ( Turner’s sign ).•If rupture is anterior into abdominal cavity, death from exsanquination is likely.•If the person survives can have ischemia or infarct to myocardium, kidneys and bowels. Paraplegia is rare.
assessment/ diagnostic of thoracic aneurysm
If large veins in chest compressed, superficial veins in chest, neck, arms may be dilated and edematous. Cyanosis may be seen. b. Pressure against cervical sympathetic chain can cause unequal pupils. c. Diagnosis by chest Xray, MRI, CT, transesophageal echocardiogram (TEE)
assessment/diagnostic of abdominal aneurysm
a. Pulsatile mass, systolic bruit b. Diagnosis by ultrasound, CT. If it is too small for surgery, have ultrasounds every six months to monitor status. c. Aortagraphy via femoral artery can be used to anatomically map the system with contrast dye. Can be nephrotoxic.
management of an aneurysm
very important to keep systolic BP low•Control SB/P to 100 to 120 with antihypertensives. Correct risk factors like smoking.
surgery for aneurysm
Symptomatic & expanding anerysm b. Thoracic more than 6cm. Abdominal more than 5cm. c. Dissecting: 1. Type A- ASAP 2. Type B- depends on involvement & possibility of rupture. d. Can be open surgery or endovascular surgery.
benefits of endocascular repair
•Decreased anesthesia and operative time.•Smaller blood loss.•Decreased morbidity & mortality.•Small bilateral groin incisions.•More rapid resumption of physical activity.•Shortened hospital time. Reduced costs.•Quicker recovery.•Higher patient satisfaction.
potential complications of an endocascular repair
•Has higher reintervention risk.•Aneurysm growth & rupture.•Perigraft leaks. Most common problem•Aortic dissection•Bleeding, graft dislocation, embolization, renal artery occlusion due to graft migration, graft thrombosis, incisional hematoma & infection.
nursing pre-op care for endovascular approach
•Patient may be hydrated. Electrolyte, coagulation, hgb & hct abnormalities corrected.•VS, cardiopulmonary, vascular and neurovascular baseline assessment.•Assess patient’s level of understanding of surgery•Pre-op teaching•Assess other risk factors with surgery•Orientation to ICU if open surgery•NPO, pre-op antibiotics
post op care for endocascular approach
•Monitor VS, LOC, cardiopulmonary status, skin temperature & color, peripheral pulses•Check dressing, IV site, s&s of shock. Monitor blood work ( cbc, coagulation, chemistry )•Evaluate pain. Pain control.•Strict aseptic technique. Deep breathe, incentive spirometer•Monitor I&O, EKG, Chest tube if applicable.•Report manifestations of graft leakage
manifestations of graft leakage
•Ecchymosis of perineum, scrotum, penis, or new expanding hematoma•Increasing abdominal girth•Weak, absent peripheral pulses.•Decreased motor function/ sensation to extremities•Fall in Hgb & Hct, decreased urine output, decreased CVP, BP & increased HR•Increased abdominal, pelvic, back, & groin pain.
home care instructions for after endovascular repair surgery
•Measures to control HTN. Stop smoking•Complications to report•Wound care. Review prescribed antihypertensives & anticoagulant meds•Need for adequate rest and nutrition•Measures to prevent constipation and straining•Avoid prolonged sitting, heavy lifting, strenuous activities and having sex for 6 to 12 weeks.
you deplete your peripheral vascular system of oxygen and blood and you will have
pain
Chronic PVD
•Is a progressive narrowing and degeneration of arteries of the neck, abdomen, & extremities.
what is responsible for most peripheral vascular disease
atherosclerosis
usually what age is PAD
65 and older but earlier with diabetes
what ethnicity has a great risk for pAD
african americans
gender differences with PAD
in 60’s men are 2Xs more likely to have PAD than womenabdominal aortic aneurysms more common in men
Buerger’s ( Thromboangitis Obliterans)
•predominantly seen in men less than 40 yrs.
Women and PAD
•As women age, incidence of PAD is similar or greater than men. Have more decreased functioning, more bodily pain, & greater mood disturbances than men with PAD.•Women have smaller arteries so endovascular repair in AAA may not be an option.•Raynaud’s phenomena is primarily seen in women 15-40 yrs.
who is at risk of DVT’s
•greater in women over 35 yrs who smoke, use oral contraceptives or HRT, are pregnant or post-partal or have a family history of DVTs.
risk for varicose veins is greater
•women who use oral contraceptives or Hormone Replacement Therapy or are pregnant.
4 most significant risk fctors for PAD
•Cigarette smoking•Hyperlipidemia•Hypertension•DiabetesAlso obesity and familial predisposition play a part
Chronic PAD of the extremeties
•Can affect aortoiliac, femoral, popliteal, tibial and peroneal arteries or any combination.•Femoral-popliteal area most commonly affected in non-diabetics. Diabetics develop disease in arteries below the knees.•In advance stages, multiple levels of occlusions can be found.
stages of chronic PAD
asymptomaticclaudicationrest painnecrosis/gangrene
asymptomatic PAD
- No claudication present - Bruit or aneurysm may be present - Pedal pulses are decreased or absent
claudication PAD
Muscle pain, cramping, or burning with exercise and relieved with rest. Symptoms are reproducible with exercise.
rest pain PAD
Pain while resting commonly awakens the patient at night. Is described as numbness, burning, toothache-like pain. - Usually occurs in distal portion of extremity ( toes, arch, forefoot, or heel ), rarely in the calf or the ankle. Relieved by dependent position.
necrosis/gangrene
Ulcers and blackened tissue occur on toes, the forefoot, and the heel. - Distinctive gangrene odor is present
inflow obstructions (PVD)
•involve distal end of the aorta and the common, internal and external iliac arteries. They are located above the inguinal ligament.
outflow obstructions (PVD)
•involve the femoral, popliteal, and tibial arteries. They are located below the superficial femoral artery.
symptoms of PVD
•Classic symptom is intermittent claudication which is ischemic muscle pain that is precipitated by a consistent level of exercise. It resolves within 10 minutes of rest or less and is reproducible. a. Caused by end products of anerobic metabolism. b. Once stop exercise, metabolites clear and pain stops.. Disease of femoral or popliteal arteries causes claudication in calf, ankle, & toes. Below popliteal, claudication in instep or foot. OUTFLOW d. Disease of aortoiliac causes claudication of lower back, buttocks, & thighs. INFLOW
outflow symptoms (PVD)
Disease of femoral or popliteal arteries causes claudication in calf, ankle, & toes. Below popliteal, claudication in instep or foot.
inflow symptoms (PVD)
Disease of aortoiliac causes claudication of lower back, buttocks, & thighs. INFLOW
paresthesia (PVD)
•toes & feet may result from nerve tissue ischemia. Common in Diabetes. Neuropathy can also cause excruciating pain. Diminishing perfusion to neurons produces loss of both pressure and deep pain sensation. Injuries can go unnoticed.
appearance of limb (PVD)
-Skin thin, shiny, & taut. Loss of hair on lower legs. Decreased or absent pulses.- Dry, scaly, dusky, pale or mottled skin. Pallor may occur when extremity is elevated. Reactive hyperemia ( Rubor ) may occur when extremity is in dependent position.•Capillary refill greater than 3 seconds•Ankle-Brachial index less than 0.70•Edema absent unless limb constantly dependent.
complications (PAD)
•Progresses slowly. Prolonged ischemia leads to atrophy of skin and muscles. Will develop pain at rest. Without revascularization may develop ulcers and gangrene.•Decreased blood flow causes delayed healing, wound infection and tissue necrosis. Non healing ulcers can get gangrene
diagnostic studies (PAD)
•Health history and physical•Doppler ultrasound•Segmental blood pressures•Ankle-Brachial Index•Arteriography
ankle-brachial index (PVD)
normal 0.91-1mild- 0.71-0.90moderate -0.41-0.70severe - below 0.40
risk factor modification (PVD)
Stop smoking - Aggressive treatment of hyperlipidemia - Treat hypertension - Control Diabetes - Weight reduction
medications (PVD)
- Antiplatelets: ASA, Plavix ( clopidogrel ) - Trental ( Pentoxifylline )- (helps rbc be more flexible so it can go through blood vessels better ) - Antihypertensives: Ace inhibitors etc.
herbal preps (PVD)
Gingko Biloba- effective in increasing walking distance in claudication. - Carnitine- natural occurring derivative of amino acid lysine. Improves muscle metabolism and improves exercise performance of ischemic muscles.
walking/positioning (PVD)
•Structured walking & exercise program to increase blood flow and to build up collateral circulation.•Positioning to promote circulation - If patient has edema can elevate legs but not above heart level. - In severe cases patient may need to keep legs dependent position
care of an ischemic limb (PVD)
Protect from injury. Keep warm to decrease vasospasm. - Prevent and control infection. - Maximize arterial perfusion - Careful inspection, cleansing & lubrication of skin. - Footware: Soft, roomy and protective - Avoid chemicals, heat and cold. - Keep heels free from pressure. - Drink adequate amount of fluids. - Avoid caffeine, emotional stress.
surgical management (PVD)
•Percutaneous transluminal angioplasty (PTA)•Laser-assisted Angioplasty•Atherectomy•Arterial Revascularization•Amputation
post op management (PVD)
•Monitor for patency of graft per hospital protocol. Check pulses, changes in skin color, temperature of skin’•Observe for reports of throbbing pain. May be sign of occlusion. Monitor for compartment syndrome.•Vital signs, coughing and deep breathing, incentive spirometer. Check dressings for bleeding, signs of infection.
home care management (PVD)
•Assess tissue perfusion•Assess adherence to therapeutic regimen•Assess ability to manage wound care and prevent injury•Assess coping ability of patient and family•Assess home environment for safety
patient teaching (PVD)
•Keep feet clean. Wash with mild soap & room temperature water. Keep feet dry especially ankles and between toes.•Wear comfortable, well-fitting shoes•Keep toenails clean and filed . Cut straight across.•Prevent dry, cracked skin with lubrication.•Prevent exposure to extreme heat or cold.•Avoid constricting garments. Avoid pressure on feet and ankles•Report any problems immediately
acute PVD
sudden occlusioncaused by embolism,thrombuswithout warningsevere painemboli tend to lodge at the branching of arteriesthey also occluding at the narrowingsischemia/tissue deathS &S : pale modeled limb, pulses severly diminished or not there at all, parastethia, burning, tingling , numbness, poikilothermia (limb becomes really cold to the touch),eventually if there is no o2 to tissue in limbs they will become paralyzed. immobility is a sign of ischemic death.could have heparin drip, TPA, directly go in for surgery and remove the clot
Bipolar disorder was formerly called
manic depressive illness
what are the two opposite poles that characterizes Bipolar disorder
–Euphoria–Depression
bipolar disorder is
•Chronic, recurring, life-threatening illness–Individuals experience interpersonal, occupational difficulties even during remission–Associated with highest lifetime suicide rate among psychiatric disorders
Bipolar I
–At least one episode of mania alternating with major depression–Psychosis may accompany manic episodecould see psychosis, or hallucinations
Bipolar II
–Hypomanic episode(s) alternating with major depression–Not accompanied by psychosiswhen they drop down to major depression they may have delusions.
cyclothymia
–Hypomanic episodes alternating with minor depressive episodes
•Specifier from DSM-IV-TR
–Rapid cycling (four or more episodes in 12-month period)
prevelance of bipolar disorder
–Lifetime prevalence in U.S. estimated at 3.9%–First episode commonly occurs between ages 18 and 30
comorbidity bipolar disorder
–Substance use disorders, personality disorders, anxiety disorders, attention deficit hyperactivity disorder–Medical conditions: cardiovascular, cerebrovascular, metabolic disorders
Bipolar Genetics
–Twin, family, and adoptive studies support strong genetic component–Specific genes identified on chromosome 13 associated with bipolar disorder
cycling
moving up and down between moods. The faster someone moves between mania and depression, the more acutley ill the person is.
neurobiological factors bipolar
–Hypothalamic-pituitary-thyroid-adrenal axis dysfunction implicated
neuroanatomical factors bipolar
–Dysregulation in prefrontal cortex and medial temporal lobe implicated
psychological influences
–Stressful life events–Families characterized by high expressed emotion most associated with relapse
cultural considerations
–More prevalent in higher socioeconomic classes–Higher rates noted among creative writers, artists, highly educated men and women
bipolar periods
•Periods of abnormal and persistently elevated mood for at leas:–4 days for hypomania–1 week for mania
hypomania
–Episode associated with decreased function–Hospitalization not required
mania
–Episode associated with marked impairment in function–Hospitalization necessary
common symptoms of mania
–Unstable euphoric mood, intense feeling of well-being, mood may change to irritation and anger when thwarted
behavioral symptoms of mania
– Excessive hyperactivity, involved in pleasurable activities with painful consequences, sexual indiscretion, excessive spending of money, mode of dress/makeup may be outlandish, bizarre
physical symptoms of mania
– Nonstop activity, minimal food intake, little or no sleep–Can lead to exhaustion and even death
cognitive suymptoms of mania
–Poor concentration, problems with verbal memory, sustained attention and executive functioning (may persist even in remission)–Flight of ideas: continuous flow of accelerated speech with abrupt changes from topic to topic usually based on understandable associations–Disorganized and incoherent speech with content often sexually explicit and grossly inappropriate–Clang associations: stringing together of words because of rhyming sounds–Grandiose persecutory delusions
assessment for bipolar disorder
•Determine if patient dangerous to self or others–Presence of physical exhaustion–Poor impulse control–Uncontrolled spending of money•Determine medical symptoms–Dehydration, infections•Determine presence of other medical/psychiatric conditions•Determine if hospitalization is necessary•Determine patient’s and family’s understanding of disorder, treatment, medications, support groups•
common nursing diagnosis for bipolar
–Risk for injury, Risk for self- or other-directed violence, Risk for suicide, Ineffective coping, Disturbed thought processes, Interrupted family processes, Impaired verbal communication, Imbalanced nutrition: less than body requirements
outcomes of bipolar disorder
–Acute phase: goal is prevention of physical injury and decrease in symptoms manifested–Continuation of treatment phase: goal is relapse prevention–Maintenance phase: goal is relapse prevention and limiting severity of future episodes
planning bipolar
Geared toward particular phase of mania as well as other co-occurring issues (e.g., risk of suicide, risk of violence, family/legal crisis, substance abuse, risk-taking behaviors, medical compliance
implementation bipolar
–Directed toward establishing therapeutic alliance–Acute phase implementations related to safety in hospital environment, establishment of controls and medical stabilization
clang associations (billy madison)
rhyming wordscrunch you, munch you , punch you
communication guidlines bipolar
•Use firm, calm approach•Use short, concise statements•Remain neutral; avoid power struggles•Be consistent–Important with firm limit setting•Hear and act on legitimate complaints•Firmly redirect energy into appropriate channels
milieu treatment bipolar
•Seclusion and restraints may be used if patient becomes dangerously out of control and other least restrictive measures failed–Purposes: reduces overwhelming stimuli, protects patient and others from injury, prevents destruction of property•Use of seclusion/restraint associated with complex legal, ethical, and therapeutic issues–Follow well-established institutional protocols for use of these measures
mood stabilizer treatment bipolar
•Used for lifetime maintenance therapy•Lithium carbonate: first-line treatment for mania–Therapeutic blood level must be reached for drug to be effective (usually takes 7-14 days)•Maintenance/therapeutic blood levels between 0.4 and 1.3 mEq/L–Used in combination with antipsychotics or antianxiety medications in initial acute mania
lithium carbonate
first-line treatment for mania–Therapeutic blood level must be reached for drug to be effective (usually takes 7-14 days)•Maintenance/therapeutic blood levels between 0.4 and 1.3 mEq/L–Used in combination with antipsychotics or antianxiety medications in initial acute mania•Adverse reactions–Related to lithium toxicity—fine line between therapeutic and toxic levels–Lithium toxicity ranges from mild to moderate and severe symptoms depending on blood level•Severe symptoms include ataxia, ECG changes, clonic movements, seizures, coma, and death•–Major long-term risks include hypothyroidism and kidney impairment•Necessity for periodic thyroid and renal function tests•Patient and family teaching important–Continue drug therapy to prevent relapse–Maintenance of normal diet with normal salt and fluid intake (1500-3000 mL/day)•Lithium decreases sodium absorption and low sodium levels/dehydration cause lithium toxicity–Stop taking lithium and call physician if symptoms of dehydration develop from sweating and/or nausea, vomiting, diarrhea
antiepileptic medications bipolar
•Adjunct to lithium as well as treatment for patients not responsive to lithium•Commonly used drugs–Carbamazepine (Tegretol), divalproex (Depakote), lamotrigine (Lamictal)•Adverse effects of individual antiepileptic drugs vary but include such problems as sedation, agranulocytosis, hepatitis, life-threatening rash
ECT
•Can be used to subdue severe manic behavior in patients who are treatment resistant to usual medications•May also be used in patients who are suicidal
pyschotherapy bipolar
•Cognitive-behavioral therapy–Cognitive restructuring effective in decreasing affective symptoms, increasing social functioning, and reducing relapse•Interpersonal and social rhythm therapy (IPSRT)–Focuses on resolution of interpersonal problems and prevention of further disputes•Family-focused therapy–Treatment approach focusing on communication within family, communication skills, and education to prevent relapse
evaluation bipolar
•Short-term and intermediate evaluation focused on goal attainment such as:–Are patient’s vital signs stable?–Is patient well hydrated ?–Is patient able to control behavior or respond to external controls?–Does patient sleep at least 5 hours per night?–Does family have understanding of illness and treatment?•Long-term evaluation focused on goal attainment such as compliance with medication regimen, resumption of functioning in community, and family
therapeutic range of lithium
Therapeutic blood level must be reached for drug to be effective (usually takes 7-14 days)•Maintenance/therapeutic blood levels between 0.4 and 1.3 mEq/L
lithium toxicity
•Severe symptoms include ataxia, ECG changes, clonic movements, seizures, coma, and death
major side effects of Lamictal
steven johnson’s syndrome
major depression characteristics
Loss of ambition, motivation, ability to perform ADLs = AvolitionLoss of interest in usual activities (including sexual activity) & ability to experience pleasure = AnhedoniaLoss of energy = AnergiaFeelings of sadness, fear, boredom
major depression etiology
Physiological – neurotransmitter dysfunction, especially serotonin & norepinephrinePsychological – dysfunctional coping with actual or perceived lossNew research seems to implicate the dysfunction stems from a genetic-defect which may be triggered by psychological stressorsDepression is a lethal disease with a high risk for suicide
3 levels of depression
mildmajorsevere
mild depression
•usually triggered by loss -> deep sadness of limited durationAKA grief response – can -> deeper depression if unresolvedCognitive ∆’s = ↓alertness, ↓ability to concentrate, verbalizations of sadnessAffective ∆’s = sadness, downcast appearance, tearfulBehavioral ∆’s = social withdrawal, irritability, sleep disturbancesMay use substances to “anesthetize” or diminish feelings
moderate depression
• depressive symptoms that persist over time-generally > 6 moCognitive ∆’s = slowed thoughts, difficulty concentrating, indecisiveness, ruminative thoughts, narrowed interest (almost obsessive in nature), self-blame, self-doubt, pessimism All lead to hopelessness & thoughts of suicideAffective ∆’s = despondence, ↓self-esteem, helplessness, powerlessness, ineffectiveness, covert anger/rage, anxiety, anhedoniaCognitive ∆’s = slowed thoughts, difficulty concentrating, indecisiveness, ruminative thoughts, narrowed interest (almost obsessive in nature),self-blame, self-doubt, pessimismAll lead to hopelessness & thoughts of suicideAffective ∆’s = despondence, ↓self-esteem, helplessness, powerlessness, ineffectiveness, covert anger/rage, anxiety, anhedoniaBehavioral ∆’s = social withdrawal, tears, irritability, ∆’s in oersonal hygiene, psychomotor retardation (slowing movement/speech)Physiological ∆’s = may include HA, chest/back pain, indigestion/nausea, appetite ∆’s , ↓sexual desire, insomnia/hypersomnia/fatiguePt may seek Rx for physiological sx not connecting them with mood ∆’s
severe depression
•intense/pervasive/persistant manifestations of depression – life comes to a standstillCognitive ∆’s = confusion, inability to concentrate/make decisions – self-blame, self-depricationSuicide is believed to be the only solution BUT pt rarely has the energy or thought clarity to organize & act on suicidal thoughtsSUICIDE RISK IS EXTREMELY HIGH WHEN ENERGY INCREASES AS DEPRESSION BEGINS TO LIFTAffective ∆’s = despair, hopelessness, flat/blunted affect, feelings of worthlessness, guilt, isolation, loneliness – overwhelmed by any task“bottomless emptiness”Cognitive + Affective ∆’s = delusions of condemnation – worthlessnes, guilt, powerless to “fix” what is wrong or to atone for some “sin”May experience auditory hallucinations = harsh soundsBehavioral ∆’s = psychomotor activity comes to near standstill, robot-like appearance, may exhibit aimless, frantic activity i.e. pacing, pulling hair, rubbing skin – poverty of speech w/frequent pauses, low, monotonous tone of voice – pronounced inattention to personal hygiene – social withdrawal from even family & close friendsPhysiological ∆’s = insomnia, sluggish digestion, constipation, anorexia, amenorrhea
avolition
inability to perform adl’sloss of ambition, motivation
anhedonia
Loss of interest in usual activities (including sexual activity) & ability to experience pleasure
anergia
loss of energy
ruminative thoughts
same thought over and over.broken record thoughts
make sure family knows
when patient starts to gain energy, this is when suicide risk is at the highest
possible nursing diagnosis of major depression
•Powerlessness•Ineffective Coping•Anticipatory or Dysfunctional Grieving•Hopelessness•Sleep Pattern Disturbance•Potential for Violence – Self Directed•Potential for Injury•Self Care Deficit•Anxiety•Constipation•Altered Nutrition••HIGHEST PRIORITY IS ALWAYS POTENTIAL FOR VIOLENCE - SUICIDE
planning for major depression
•Establish realistic goals with pt – unrealistic goals are often unmet -> further ↓ self-esteem which then serves to rienforce worthlessness, hopelessness
interventions for major depression
•Safety–Institute suicide precautions–Help pt develop safety plan (both in-pt & after d/c)•Health promotion/disease prevention–Teach early warning signs of depression–Help pt develop coping skills – i.e. journaling, relaxation, guided imagery, exercise•Rest & Sleep–Promote night-time sleeping–Teach/promote sleep hygiene i.e. ↓caffeine, quiet/comfortable milieu–Teach relaxation techniques–Use hypnotics with caution•Nutrition–↑ fiber, ↑fluids - promote elimination–↑ fluids – counters anti-cholinergic SE of meds–Promote intake – favorite foods, provide safe social interaction•Self-Care–Assist with ADLs as necessary
antidepressant medications
•Advantage–Can help alter withdrawal, vegetative symptoms, activity level; improve self-concept•Drawback–Can take 1-3+ weeks to note improvement•Safety considerations–Concerns about relationship between use of antidepressant drugs and suicide; however, no conclusive evidence to support this
tricyclic antidepressants
•Action: inhibit reuptake of norepinephrine and serotonin by presynaptic neurons•Dose: start low and gradually increase•Common adverse reactions–Dry mouth, blurred vision, constipation, and urinary retention–Sedation•Potential dysrhythmias, hypotension, myocardial infarction
SSRI’s for major depression
•Action: selectively block neuronal uptake of serotonin•Common adverse reactions–Agitation, anxiety, sleep disturbance, tremor, sexual dysfunction, headache, weight changes, nausea, diarrhea, dry mouth•Potential toxic effect–Serotonin syndrome (SS): potentially fatal reaction when more than one antidepressant used
seretonin syndrome symptoms
–Hyperactivity, severe muscle spasms, tachycardia leading to cardiovascular shock, hyperpyrexia, hypertension, delirium, seizures, coma, death
treatment of seretonin syndrome
–Stop offending agents–Provide respiratory, circulatory support in intensive care environment–Use medications to reverse excess serotonin: cyproheptadine, methysergide, propranolol
atypical agents for depression
•Action: affect variety of NTs including those affecting serotonin and norepinephrine•Advantage–Can target unique populations of depressed individuals–Can be used to treat other conditions
MAOI’s inhibitors
•Action: enhance NTs at synapse by preventing the enzyme monoamine oxidase from breaking them down•Common adverse reactions–Hypotension, sedation, insomnia, changes in cardiac rhythm, muscle cramps, sexual impotence, anticholinergic effects, weight gain•Potential toxic reaction–Hypertensive crisis
Hypertensive Crisis and MAOIs
•Can occur when monoamine oxidase inhibition prevents the breakdown of tyramine, which is used by the body to make norepinephrine•Preventing hypertensive crisis involves maintaining a special diet (low tyramine) and avoiding medications that contain ephedrine/other psychoactive substances
ECT
•Electroconvulsive therapy (ECT)–Course of treatment: 2 or 3 treatments/week for total of 6 to 12 treatments–For patients not responding to antidepressants or for depression with psychosis–Potential adverse reactions•Initial confusion and disorientation on awakening from treatment•Memory deficits
evaluation depression
•Evaluate short-term indicators and outcome criteria–Reduction in suicidal thoughts–Able to state alternatives to suicide–Decrease in severity of emotional, cognitive and vegetative/physical symptoms of depression
3 major items for problemsof Leukemia
RBC (decreased anemia)WBC (increased infection)platelets (bleeding )
acute leukemia
immature WBCluymphocyte or myelocyte.called bands
leukemia definition
–Cancer of the blood forming tissues, bone marrow, spleen and/or lymphatic system._ Leukemias are malignant neoplasms of the WBC precursors within the bone marrow that disseminate into the general circulation and organs._ Is not a solid cancer and symptoms are caused by an infiltration and replacement of any tissue with nonfunctional leukemic cells. Highly vascular organs like the spleen and liver are most severely affected.
classification of leukemia
•Predominant type of abnormal cell i.e.. lymphocyte or myelocyte.•Maturity of leukemic cells i.e.. Acute or chronic
causes of leukemia
Unknown but genetic and environmental factors are important.
Genetic factors of Leukemia
•Identical twins have a higher incidence for leukemia•Families with an incidence of leukemia have a greater risk.•Acute leukemias have a higher incidence in persons with genetic diseases like Down Syndrome
environmental factors
•Ionizing radiation increases the risk for myelocytic leukemias.•Chemicals ( aromatic hydrocarbons, alkylating agents ) increases the risk of acute myelocytic leukemia.•Epstein Barr Virus is associated with a type of acute lymphocytic leukemia.
acute lymphocytic leukemia
Stem cell or blast cell leukemia -Results in proliferation of immature lymphocyte precursors ( B cell or T cell ) -Affects children less than 15 years old. - 75 to 80 % of childhood leukemias.
acute myelocytic leukemia
Proliferation of immature myelocytic cells’ -Age group—15 to 40 years. 20% of all leukemias.
adult leukemias
•Chronic Lymphocytic Leukemia – affects adults•Chronic Myelocytic Leukemia – affects adults
pathophysiology of all leukemias
•Proliferation of WBCs that are immature in the blood. Replace tissue with nonfunctional leukemic cells. Compete with healthy cells for metabolic elements.•In acute form can have low leukocyte count•Proliferating leukemic cells production of formed elements in the bone marrow.•Presenting symptoms : anemia, infection, thrombocytopenia
other possible symptoms of leukemia
•Weakening of bone so pain and possible fractures•Enlargement of spleen, liver & lymph nodes•Possible involvement of CNS•Hypermetabolism from cell deprivation of nutrients•Hyperuricemia•Invasion into testes, ovaries, GI tract and lungs
diagnostic evaluation of leukemia
History Pancytopenia Peripheral blood smear shows immature forms of leukocytes•Bone marrow aspiration ( positive if hypercellular with blast cells. Use iliac crest.•Lumbar puncture to see if CNS is involved
shift to the left
very indicative sign of leukemia
4 phases of chemotherapy for leukemia
inductionconsolidationmaintenancereinduction
induction therapy (leukemia)
- Induction therapy done to induce remission. Goal is less than 5% blasts. Takes 6-8 weeks.
consolidation phase (leukemia)
- Consolidation phase, also called intensification, treats areas induction may have missed. Primary area for relapse. Radiation for high risk children.
maintenance phase (leukemia)
takes 1-2 years. Use combined drug regimes
reinduction phase (leukemia)
following a relapse
bone marrow transplant
Bone marrow transplant for high risk children, AML. BMT for second relapse in ALL. Prep for BMT is: 1. High dose chemotherapy 2. Family is HLA typed for match 3. Central line is insertedCure after BMT ranges 30 to 60%. Relapse after BMT is dismal prognosis.
all cancer meds (across the board)
7-14 days bone marrow supressionalopeciastomatitis (mouth gets red, raw, bleeding, sore)
Corticosteroids (leukemia)
IV or POmoon facefluid retentionmood changesGI irritationdecreases response to infectiondelays healinghyperglycemiaLONG TERM USE:muscle wastinginterferes with growth (kids)buffalo humpNURSING CONSIDERATIONSmonitor weightlook for signs of infectionmonitor electrolytes
vincristine (oncovin)
IVbone marrow suppressionalopecianeuro toxicitypatients c/o”sataxicdecreased reflexesparasthesiafoot dropdynamic ileus (monitor bowel sounds,stool softener)
L-asparaginase (Elspar)
IVnew start of drug keep code cart near bycan cause anaphalaxisliver failurepancreatitisrenalfailure
doxorubicin (daunorubicin)
IVaccumalitive toxicity (manifests as > cardiac)cardiac abnormalitiesbone marrow suppressionalopeciamonitor HR, Rhthym, watch for CHFturns urine RED
Methotrexate
usually needs rescue drug, leucovorinIV or PO or interthecallysevere N/V diarrheareally ulcerates mouthFOLIC ACID ANTAGONISTso in high doses it can kill you so keep rescue drug nearbythe rescue drug protects the other cells from the cytotoxic action of the methotrexate (if they are on high dose methotrexate they are always on leucovorin)
cytocine (cytosar)
IVbone marrow suppressionhepatitis
late effects chemotherapy/radiation
•Secondary Malignancy•Cardiomyopathy•Neuropsychological deficits if cranial radiation.
prognosis of leukemia
if WBC’s are high, its associated with poor prognosisalso depends on Type of cell (non B, non T has better prognosis)best age for best result is 2-9sex of child (girls do better than boys)karyotype analysis (if genetically abnormal prognosis is poor.
Calla positive
Children with normal or low WBCs and who have non-T, non –B
epogen (leukemia)
•Is contraindicated for use in children with leukemia since besides stimulating RBC production, it could also stimulate the production of malignant WBCs
immunizations (leukemia)
•Because viral infections are particularly dangerous, the child with leukemia is not immunized against measles, rubella, mumps and polio until the immune system is capable of responding to the vaccine. The child can receive the inactivated vaccine for polio (Salk)•Children with cancer should not routinely receive the varicella vaccine.
calculating the absolute neutrophil count (ANC)
ANC=•Total WBC x (% neutophils + % bands ) 100ORtake your Neutrophils and bands % and add themturn them into a decimal and then multiply by 1000. = ANC•Children can return to school when ANC is greater than 500/mm3
Nursing Care Leukemia
•Prepare child and family for diagnostic and therapeutic procedures•Relieve pain-narcotic titrated to child’s needs round the clock.•Prevention of infection•Prevention of hemorrhage•Prevention of anemia•Maintain precautions with chemotherapy
how to prevent infection (leukemia)
report elevated temps (even slight elevation)wash your handsassess potential sites of infection ( inside mouth, IV’s,change tubing everyday,….)monitor labs (watch ANC)looking for any potential signs of infection (breakdown, uti’s, URI, moving bowels, diarrhea, use sterile technique)
prevention of anemia (leukemia )
watch H & Hmake sure good balance with rest and activitymay or may or not due transfusionwatch for any bleeding, (nosebleeds)no invasive procedureskeep pressure on site after injectionswatch for bruising,hematuria, LOC
family teaching
emotional support (be there for your families)assist child to maintain positive body image
neutropenic precuations (ideal)
•Private room if ANC is less than 1000 and restriction of visitors. Germ free environment if complete myelosuppression•Low microbial diet. No fresh salads or unpeeled fresh fruits or vegetables. No fresh flowers.•Change water container every shift. Room cleaned every day.•Care for neutropenic patients first
IV therapy precautions (leukemia)
•No plastic cannulas if ANC is below 500•Central line catheter is preferred•Check IV site at least every shift•Give meticulous IV site care•Cleanse skin with antimicrobial solution prior to venipuncture•Change IV tubing per hospital protocol•Give antibiotics on time
complications of chemotherapy
•Massive leukemic cell destruction form chemotherapy results in release of electrolytes and fluids within the cells into the systemic circulation. Causes: 1. Increased uric acid levels, potassium and phosphate. Called tumor lysis syndrome. 2. Increased uric acid and phosphate make patient vulnerable to renal stones,•Hyperkalemia and hypocalcemia can lead to cardiac arrhythmias, hypotension, neuromuscular problems ( muscle cramps, weakness, spasms, tetany, confusion, and seizures )•Patients require high fluid intake, alkalization of urine and prophylaxis with allopurinol to prevent crystallization of uric acid and stone formation.•Anorexia, nausea, vomiting, diarrhea, and severe mucositis are common side effects•Profound myelosuppression effects of chemotherapy can cause significant neutropenia, thrombocytopenia and anemia. Patient is at risk for infection and bleeding•Hemorrhagic cystitis can result from irritation of bladder by chemotherapy. Can treat with Mesna and liberal fluid intake
mesna
•Drug is activated in kidney tissue to a form that binds with toxic metabolites of the anticancer drugs. Thus, it helps to prevent hemorrhagic cystitis and bladder damage.•Drug can be diluted with D5W, NS, and LR.•Side effects/Adverse reactions: allergic reactions, GI symptoms, unpleasant taste.
assessment for infection
•Skin: tenderness, edema, breaks in skin integrity. Moisture, drainage, lesions under breasts, axilla, groin.•Oral mucosa: lesions, color, moisture•Respiratory: cough, sore throat, lung sounds•GI: abdominal discomfort, distention, nausea, change in bowel pattern, bowel sounds•GU: dysuria, urgency, frequency, color, clarity, odor•Neuro: LOC, headache, stiff neck, visual disturbances, orientation, behavior•Temp: check at least q 4 hrs. Notify MD if greater than 38 degrees ( 101 degrees F. ) and if fever unresponsive to tylenol.
treatment of mouth ulcers and sores
do not give a pediatric patient a med to anesthisize mouth. It supresses the gag reflex (viscous lidocaine)
nursing for anemia / altered nutrition
•Monitor CBC, total protein, albumin, BUN, weight for height•Blood transfusions as ordered•Soft toothbrush, frequent oral hygeine•Increase fluids with meals. Soft meals if stomatitis.•Small more frequent meals. Ensure prn. Avoid milk products for increased mucus•Rescue med, Zofran, for nausea
Interventions (Leukemia)
•Thorough hand washing and appropriate precautions. No one with cold or sore throat in the room.•Avoid suppositories, enemas, rectal temps.•Encourage deep breathing ( spirometer) q4hrs. Ambulate (HEPA filter mask if severe neutropenia.•Prevent skin dryness-water soluble lubricant•Oral hygiene after meals and prn. Warm saline mouth wash. Avoid lemon & glycerine.•Avoid use of commercial mouthwash•Viscous lidocaine is not recommended for young children. If applied to pharynx may depress gag reflex and increase the risk of aspiration. Seizures have been rarely associated with use of oral viscous lidocaine
nursing to prevent hemorhhage
•Assess all body systems for s &s bleeding.•Monitor platelets and vital signs.•Avoid invasive procedures•Meticulous mouth care-gingival bleeding and mucositis are frequent problems•Give good perineal care•Avoid activities that may cause injury•Epistaxis & gingival bleeding are common•Transfuse with platelets as ordered
nursing precations for chemotherapy
•Many drugs cause a lot of damage if they infiltrate. Drugs are given through a free flowing line.•Infusion is stopped if any sign of infiltration ( pain, stinging, swelling, redness )•Anaphylaxis is possible when giving chemotherapy. Observe for 20 minutes after infusion starts. Observe for cyanosis, hypotension, wheezing, urticaria.•Have emergency equipment there.•DC if there’s a problem. Flush IV line with NS•Manage problems with drug toxicity•Control nausea & vomiting. Use Zofran before chemo begins.•Manage neuropathies by bedrest, good alignment, safety during ambulation.
what do you need B12 for
•DNA synthesis depends on adequate amounts of folic acid. Adequate DNA synthesis is needed for RBC production.•Vitamin B12 activates the enzymes needed to move folic acid into the cell for synthesis to occur.
what does vitamin b12 deficiency result in
•Anemia results if vitamin B12 deficiency because folic acid cannot be transported and DNA synthesis is inhibited.
what is a vitamin b 12 deficiency also called
•Is considered a megaloblastic (macrocytic) anemia because the RBCs become larger but are easily destroyed because of a fragile membrane.
how do you get a vitamin B 12 deficiency
•Can result from a poor intake of Vitamin B12 as in vegetarian diets and diets lacking dairy products. This tends to be rare.Can also result from a failure to absorb B12 as in the case of Pernicious anemia
what deficiency goes along with vitamin b 12 deficiency
folic acid deficiency
pernicious anemia
•Develops form a lack in intrinsic factor which is secreted by the cells in the stomach.•Intrinsic factor binds to the B12 and travels with it to the ileum where the vitamin is absorbed.•Can result from atrophic gastric mucosa, gastric and small intestinal surgeries, Crohn’s disease.
pernicious anemia has to do with B 12
absorption
how can you create a B12 deficiency
chron’s diseasegastric bypassdecrease by surgery intrinsic factor
how long does it take to get pernicious anemia
a long time because we store B12
who gets pernicious anemia
•Primarily is a disorder of the elderly. May have a familial tendency.•Without intrinsic factor the body cannot absorb B12. The gastric mucosa atrophies.•Patient’s with pernicious anemia have a higher risk for gastric cancer and should have endoscopic screenings every 2 years.•The body normally has stores of vitamin B12 so it may be years before symptoms occur.
manifestations of B12 deficiency
•May be mild or severe anemia that usually develops slowly. May have pallor, jaundice, weakness, diarrhea, and listlessness.•May have a smooth, beefy red tongue (glossitis) and may lose weight.•Vitamin B12 is important for neurological function. May see paresthesias, problems with proprioception & balance and confusion. CNS symptoms of short duration may be reversable.
diagnostic evaluation for pernicious anemia
•do the Schilling Test to differentiate between a problem with dietary intake of vitamin B12 versus pernicious anemia.•This test measures the presence of B12 in the urine after being given an oral dose of radioactive vitamin B12.•If the patient does not absorb the radioactive B12 it cannot get into the urine.
schilling test
blood draw24 hour urine
how do they find out if you have a deficiency
if there is no B12 in the urine. They will give them vitamin B12 to see if they absorb it. If they do it comes out in the urine. If they don’t absorb it, then it does NOT come out in the urine.
treatment for B12 deficiency
•If the cause of the deficiency is dietary, patients are encouraged to eat foods high in B12 like animal proteins, eggs, nuts, dairy products, dried beans, citrus fruit, and green leafy vegetables. Vegetarians can take oral supplements or fortified soy milk. Vitamin supplements are prescribed when the anemia is severe.
pernicious anemia treatment
•Vitamin B12 injections are given weekly mat first and then monthly for the rest of the patient’s life.•A new drug, cyanocobalamin (CaloMist), has been approved to maintain vitamin levels after the patient’s deficiency has been treated by the traditional injection method.
folic acid deficiency
•Folic acid is required for DNA synthesis and the normal maturation of RBCs.•Folic acid deficiency is characterized by fragile megaloblastic cells.•Folic acid is found in green leafy vegetables, fruits, cereals, and meats. It is absorbed in the small intestine.Has similar symptoms as vitamin B 12 deficiency except it does not have neurological symptoms. It usually develops slowly
common causes of folic acid deficiency
•Poor nutrition—diets lacking in green leafy vegetables, liver, yeast, citrus fruits, dried beans, and nuts.•Malabsorption—Crohn’s disease, Celiac sprue, and chronic alcohol abuse.•Drugs– Anticonvulsants, oral contraceptives and some chemotherapy can slow or prevent absorption of folic acid.
treatment of folic acid deficiency
•Diet high in folic acid•Folic acid replacement therapy
lymphomas definitions
. Lymphomas are malignancies of the lymphoid tissue. They are closely related to lymphocytic leukemias and some believe they are different forms or stages of the same disease process. b. Commonly identified as Hodgkin’s disease and Non-Hodgkin’slymphoma.
statistics/pathophysiology for hodgkin’s
}Occurs most often in people between the ages of 15-35 yrs and over age 50.}More common in men than women.}Exact cause is unknown but Epstein-Barr virus (EBV) infection and genetic factors appear to play a role.}Is one of the most curable cancers. 60% to 90% of people with localized disease achieve cure with a normal life span.}There may be a risk of a secondary cancer later in life.
hodgkin’s disease cancer
if you catch it early. Its one of the most curable cancers
where does hodgkin’s disease develop
}Usually develops in a single lymph node or chain of lymph nodes. Can spread to adjoining nodes.}The malignant cell is the Reed-Sternberg cell, a gigantic atypical tumor cell. Is essential criterion for Hodgkin’s disease.}Malignant cells secrete inflammatory mediator substances, attracting inflammatory cells to the tumor site.}Cells can invade almost any tissue in the body as the disease progresses.}Usually is classified into sub-groups.
what is one indicator of hodgkin’s disease
the tumors do not hurt. kind of rubbery. Do not hurt
what is the malignant cell for hodgkins disease called
Reed-Sternberg cell
Hodgkin’s manifestations
}Can begin above the diaphragm and remain confined to the lymph nodes for a variable amount of time or if it originates below the diaphragm it frequently spreads to extralymphoid tissue such as the liver.}Often begins as a painless, rubbery lymph node enlargement in the cervical or subclavicular area. Can spread to other side of neck and to mediastinal lymph nodes.
what happens if you don’t treat the lymph nodes in hodgkins disease
Pressure on trachea-breathing difficulties 2. Pressure on esophagus-swallowing difficulties
what happens if you let hodgkins disease go without treatment
}If the disease spreads to the chest can have edema to the face and neck. May have chest pain, cough and stridoe.}In some patients, the first nodes to enlarge are those under one arm or in the groin.}Later disease can spread to other areas like the spleen, liver and GI tract.}Systemic symptoms include persistent fever, night sweats, fatigue, & weight loss.}Malaise, pruritus, and anemia are late symptoms.
non-Hodgkin’s statistics pathophysiology
}Is a diverse group of lymphoid tissue cancers that don’t contain the Reed-Sternberg cells.}Tend to arise in peripheral lymph nodes and spread early to tissues throughout the body.}More common than Hodgkin’s. Older adults are more often affected. Is more frequent in men than women.}Cause unknown. Viral infections like EBV, HTLV-1 and HTLV-2 and HIV may play a role. Genetic & environmental factors may also play a role.Begins as a single transformed cell that can arise from the T or B cells or tissue macrophages (histocytes)
where does non hodgkins lymphoma spread
}It tends to arise in a single lymph node but can also arise in lymphoid tissue. It usually spreads early & unpredictably to other lymphoid tissue and organs.}May involve spread to nasopharynx, GI tract, bone, CNS, thyroid, testes, and soft tissue.}Prognosis ranges from excellent to poor depending on the cell type and grade. Low grade tend to be less aggressive and more curable. Higher are more disseminated and have poorer prognosis.}7th leading cause of cancer death. Incidence has doubled since 1970 but is starting to stablilize.
non-hodgkin’s manifestations
}Painless lymphadenopathy localized or widespread.}Organ system involvement may cause symptoms like abdominal pain, nausea, & vomiting. Headaches, peripheral or cranial nerve symptoms, altered mental status, or seizures can occur with CNS involvement.}Systemic symptoms may be present but less common then Hodgkin’s.
diagnosis for lymphomas
}Biopsy of node will differentiate between Hodgkin’s and Non-Hodgkin’s.}CBC may show mild anemia and elevated sed rate in Hodgkin’s. May be normal in Non-Hodgkin’s until pancytopenia develops.}Chemistry studies will look at organ involvement.}Chest Xray to ID enlarged mediastinal lymph nodes & pulmonary involvement.CT scans chest, abdomin and pelvis. PET or gallium scans to diagnose disease
staging of lymphomas
}Used to determine extent of disease and appropriate treatment. Ann Arbor Staging system is used for lymphomas.}Stage 1: involvement of single lymph node region or lymphoid structure.}Stage 2: involvement of 2 or more lymph node regions or structures.}Stage 3: involvement of lymph node regions or structures on both sides of diaphragm}Stage 4: involvement of an extranodal site such as liver, lung or pleura, bone or bone marrow, or skin.
treatments for lymphomas
}Chemotherapy}Radiation}Immunotherapy}Stem cell Transplant
early stages of hodgkins
you can get away with just radiation
secondary cancers and problems that result from chemo for hodgkins
acute mylocitic leukemiacardiac and pulmonary disfunction
what should a male do before radiation treatment below diaphram
store sperm in sperm bank so they can have children later in life
what should women do if they are having radiation below diagphram
store eggs. Be on birth control for at least two years after treatment. The radiation can effect the fetus up to two years. Don’t get pregnant until after radiation is out of system
radiation
}May be primary treatment for early Hodgkins but early chemotherapy is becoming more common.}In later stages of Hodgkin’s and in Non-Hodgkin’s is usually combined with chemotherapy. The involved lymph node region is treated and proper shielding is done to protect unaffected areas.}In advanced disease, total nodal irradiation is done
chemotherapy for hodgkin’s
}Combination chemotherapy is done to treat both. Usually followed by radiation therapy.}Combination regimens include: CHOP ( cyclophosphamide, doxorubicin, vincristine & prednisone) ABVD ( doxorubicin, bleomycin, vinblastine & dacarbazine ) MOPP ( nitrogen mustard, vincristine, procarbazine & prednisone ) ChlVPP ( chlorambucil, vinblastine, procarbazine & prednisone )More than 75% Hodgkin’s patients who do not have systemic symptoms achieve complete remission.
immunotherapy for hodgkins
}Rituximad (Rituxan) is a monoclonal antibody used to destroy the CD20 antigen in B lymphocytes. Results incellular death of the lymphoma cell.}Can be used alone or with chemotherapy like CVP ( cyclophosphamide, vincristine,& prednisone ).}Need to closely monitor patient for tumor lysis syndrome. Caution with patients with known cardiac disease.}Recommend premedicating with diphenhydramine and acetaminophen.
stem cell transplant for hodgkins
}Autologous peripheral stem cell transplant (PBSCT) is treatment option for patients who experience remission of malignant lymphoma.}Uses patient’s own stem cells to restore bone marrow following chemotherapy or radiation.}Obtained following treatment and frozen & stored.}If relapse occurs, patient given high dioses of chemotherapy & radiation to destroy immune system. Patient then given stem cell transplant.}Patient is critically ill. In private room for 6 to 8 weeks until infused stem cells become part of bone marrow.
complications of treatment for hodgkins
}Permanent sterility is common}Bone marrow depression can lead to immunosuppression, anemia and bleeding.}Secondary cancers and cardiac injury are the most serious late adverse effects of treatment.}Risk of leukemia is possible with MOPP chemotherapy.}Cancers such as breast or lung cancer may develop 10 or more years later after thoracic radiation. Also increases risk for CAD and hypothyroidism.
nursing interventions for hodgkins disease and treatment
}Fatigue: Ask about feelings of fatigue and malaise. Encourage verbalization of feelings about the impact of the disease. Encourage enjoyable but quiet activities. Encourage balance between rest & activity. Encourage delegation of responsibilities. Identify energy- saving techniques and equipment. Encourage high carbohydrate diet and liberal fluid intake.
nursing interventions for hodgkins disease and treatment
}Nausea: Assess precipitating factors. Teach measures to prevent or relieve nausea and vomiting like soda crackers, sucking on hard candy, bland foods, avoiding noxious odors. Eat prior to chemo not after. Provide small, frequent feedings of high calorie, high protein content. Antiemetics prior to chemotherapy.
nursing interventions for hodgkins disease and treatment
}Sexual Dysfunction: Encourage discussion of patients concerns. Provide information to clear up misconceptions. Refer to counseling.}Disturbed body image: Assess patient’s perception of body image. What is current understanding of health and limitations imposed by illness
nursing interventions for hodgkins disease and treatment
}Skin Integrity: Frequently assess skin undergoing radiation. Provide and teach measures to provide comfort and relieve itching like cool water & mild soap to bathe. Blot rather than rub when drying self. Apply plain corn starch. Use light weight clothing and blankets. Wash clothes in mild detergent.
Raynauds effects/definitions
fingertips and toesarterioles vasocontrictnot sure what causes itcould be linked to autoimmune disease
raynauds
usually seen in women 16-40rheumatoid arthritisa lot of typing and hammering causes itpeople have gotten frostbitepeople that have gotten electrical shockcarpal tunnelbeta blockers
raynauds can be triggered by
emotional stresscoldoccurs more in cold climates (winter)
ischemic phase of raynauds
fingertips get cold and turn whiteun oxygenate blood pools in fingertips and turns bluecauses parasthias
hyperemic phase II of Raynauds
vasodialation occursblood and oxygen coming back into fingersgets red purple colorhurts
raynauds can cause
gangrene on fingertipscan cause decubitus on fingertips
diagnostics for raynauds
cold stimulation testput fingertips in ice water with probes on fingers
treatment of raynauds
possiblity of vasoconstrictor meds*(most common) put on calcium channel blockers (long acting cardizem or procardia)abnergic blockers-minipress (can give bad hypotension. given in hospital. watched for first couple doses)transdermal nitroglycerins, long acting (decreases time for hands to go back or reperfuse)start swinging your arms if you feel an attack coming on
what can you also do for raynauds
low in dietary fatlose weightno smokingexercise
Bunengers / thromboangitis obliterans
inflammatory process recurring inflammation of your small arteries and veins of the lower and upper extremitiesthrombocyte forms, can cause an occlusiononly happens in men who smokecauses microabsessesdon’t know what causes it
symptoms of bunengers
if you occlude an artery it causes paincramps in the instep of your feetintermittent claudication after exerciseburning paincan be aggravated by emotional stresscold causes vasoconstrictionget symptoms like PAD
managment of Buengers
stop smokingcauses amputations if you don’t quitvasodialators don’t work because artery is already damagedgood skin care
definitions of schizophrenia
Ødecreases a person’s ability to interpret realityØdisrupts communicationØimpairs ability to perform simple tasks/follow simple instructions• or perform basic self-careØmakes it difficult/impossible to develop relationshipsØaffects perception, thoughts, language, emotions, volition & social behaviorØIs considered to be primarily biological in etiology•It is not:Ø“split personality”Øa result of poor nurturing
the MATRICS
group determined seven seperable cognitive dimensions that are affected in schizophrenia
MATRICS
measurement and treatment research to improve cognition in schizophrenia
Neuropsychological deficits in schizophrenia
verbal fluencyreasoning/problem solvingworking memorysocial learningverbal learning/memoryvisual learning/memoryattention/vigilance
3 phases of schizophrenia
Phase I-APhase I-BPhase IIPhase III
Phase I-A (schizophrenia)
slow, insidious course characterized by:seen in children ages 6-7 (can be confused with ADHD) increased anxiety evidence of thought disorder -> poor concentration, intrusive thoughts, symbolical meaning placed on ordinary events, frequent misinterpretation of others’ words/actionsIncreasing acuity near end of this phase evidenced by: emotional/physical withdrawal occasional hallucinations/delusions odd mannerisms & neologisms (words that mean something only to them) preoccupation with emotional-laden topics i. e. religion, homosexualityBelieved to be occurring throughout later childhood and adolescence
Phase I-B(schizophrenia)
acute psychotic phase characterized by: multiple psychotic symptoms highly disorganized thinking extremely poor reality testing1st psychotic “break” from reality -> hospitalizationGenerally occurs late teens or early 20’s
Phase II(schizophrenia)
A - Psychosis always present but symptom intensity varies B – Episodes of psychosis followed by nearly complete recovery from any evidence of illness – exacerbation & remission
phase III(schizophrenia)
Long term/chronic state Intensity of symptoms may decrease w/age
Pier Program (schizophrenia)
(portland identification and early referral )intervene early and try to help the child and family learn about whats going on and how to cope and adjust. Has very good sucess.
when do you see the first psychotic break with schizophrenia
late teens early 20’s. great diagnostic for schizophrenia
neurochemical schizo
Excess dopamine -> psychotic symptoms “Discovered” when Thorazine was found to be an effective treatment for schizophrenia BUT Thorazine caused sx of Parkinson’s (deficit in dopamine) – by extension it was hypothesized that schizophrenia must result from excess dopamine
geneticf schizophrenia
Increased incidence when blood relations have schizophrenia
viral schizophrenia
Birth dates of people w/schizophrenia peak in late winter/early spring the same time viral activity peaks Little credence given to this theory at present
genetic predisposition + environmental, social, and psychological factors = (schizophrenia)
neurodevelopmental abnormalities and target featuresleads tobrain dysfunction, improper balance of chemicalsleads to schizophrenia
diagnosis of schizophrenia
•No definitive test for schizophrenia exists••Diagnosis is based on a comprehensive assessment of:•clinical history, symptoms, and signs•information from ancillary sources (family, friends, and teachers)-> establishing chronology of illness onset••DSM definition:•two or more characteristic symptoms (delusions, hallucinations, disorganized speech, disorganized behavior, negative symptoms) X 1-mo period are required for the diagnosis•prodromal signs of illness (social, occupational, or self-care impairments) must be evident for a 6-mo period that includes 1 mo of active symptoms.
what you must rule out for schizophrenia
•psychotic disorders due to physical disorders or A/W substance abuse•primary mood disorders with psychotic features•underlying medical, neurologic, and endocrine disorders that can present as psychosis (eg, vitamin deficiencies, uremia, thyrotoxicosis, electrolyte imbalance).••Structural brain abnormalities seen on MRI or CT scans are consistently found in patients with schizophrenia as a group but are insufficiently specific to have diagnostic value for individual patients•medial and superior temporal lobe abnormalities A/W positive symptoms•frontal cortical and ventricular system abnormalities A/W negative symptoms
paranoid schizophrenia
•preoccupation with delusions or auditory hallucinations• organized speech/appropriate affect•tend to be less severely disabled and more responsive to available treatments
disorganized schizophrenia
•disorganized speech• disorganized behavior• flat or inappropriate affect
catatonic schizophrenia
• immobility or excessive motor activity• assumption of bizarre postures, predominate
undifferentiated schizophrenia
symptoms are mixed
4 fundamental signs of schizophrenia
Affect – flat, blunted, inappropriate- may include depression, elation, or suicidal ideation Associative looseness – jumbled, illogical, disorganized thinking – communication disruptions Autism – thinking not bound to reality i.e. delusions Ambivalence – simultaneously having opposing emotions/ideas/wishes
communication distortions schizophrenia
Loose associations - “Don’t you think my stomach is getting bigger? Fall is when lots of food is harvested like corn and pumpkins.”Flight of Ideas - “The weather looks like it’s changing. These pants make me look thin Lunch was really bad. I don’t think I should be taking all those pills.” (speech is rapid and there is a continuous flow of words)Word Salad - “animals, cars, bedtime, dark, prayers closets…”
disorganized thinking and delusions schizophrenia
Grandiosity – “I earned the Congressional Medal of Honor but they can’t give it to me yet or they’d blow my cover.”Persecution – “See those people in the hall? They’re from the CIA here to watch me.”Control – “A wire has been implanted in my head so the spooks can control everything I say and do.”Thought broadcasting - “I’m afraid to think anything because I know you can read my mind & know exactly what I’m thinking.”Thought withdrawal - “I can’t tell you what I’m thinking. Somebody just stole my thoughts.”Thought insertion - “You think what I’m telling you is what I’m thinking but it isn’t. My father keeps putting all these thoughts in my head. There’s no room for my thoughts. These aren’t mine.”Religiosity – “God will be mad if I tell you everything he said to me.”
hallucinations schizophrenia
Perceptual experiences occurring in the absence of any appropriate sensory stimuliDo not confuse with illusions which result frommisinterpretation of sensory experience-magiciansMost frequent types of hallucination = visual andauditory- but can arise from any of five sensesOften hallucinations have religious contentAssessed at different levels of intensity
hallucination levels
comfortingcondemingcontrollingconquering
comforting hallucinations
moderate level of anxietyhallucination generally pleasant in natureCharacteristics :Pt has intense emotions like anxiety, loneliness, guilt, fear- tries to focus on comforting thoughts to â anxiety; knows thoughts & sensory experiences are controllable if anxiety is managedBehaviors:Grinning, laughter that seems inappropriate; moving lips without making sound; rapid eye movement; slowed verbal responses as if preoccupied
condeming hallucinations
Severe level of anxiety Hallucination generally repulsivecharacteristics :Sensory experience repulsive & frightening; pt begins to feel loss of control; may attempt to distance self from perceived source; may feel embarrassed by experience and withdraw from othersBehaviors:á autonomic nervous system signs of anxiety; attention span narrows; preoccupation with sensory experience; loss of ability to differentiate hallucination from reality
Controlling hallucinations
Severe level of anxiety Hallucination becomes omnipotentcharacteristics:Pt gives up trying to combat experience & gives in to it; content of hallucination may become appealing; pt may experience sadness/loneliness if hallucination endsBehaviors :Directions given by hallucinations will be followed rather than objected to; difficulty relating to others; attention down to only a few minutes at best, may be only seconds; unable to follow directions; sx of intense fight or flight response
conquering hallucinations
Panic level of anxiety Hallucination becomes elaborate & interwoven with delusionscharacteristics:Sensory experiences may become threatening if pt doesn’t follow commands; without therapeutic intervention hallucinations may last for hours or daysbehaviors :Terror-stricken behavior such as panic; strong potential for suicide/homicide; physical activity reflects content of hallucination i.e. violence, agitation, withdrawal, catatonia; unable to respond to most directions; unable to respond to more than one person
positive symptoms of schizophrenia
are floridly psychotic but respond well to all types of antipsychotic medicationsCognitive symptoms Delusions &/or hallucinations Poor memory Attention deficit Executive dysfunction Associative looseness in speech/ideas Concrete thinking – inability to think abstractly Neologisms – new words – meaning known only to pt Echolalia – repetition of others’ words/sounds Clang association – apparently meaningless rhyming Word salad – apparently meaningless mix of words Depersonalization – loss of identity/loss of body part Derealization – belief that environment has changedAffective symptoms Bizarre, inappropriate Fearful – due to inability to determine reality Depression, elation, suicidal ideationBehavioral symptoms Bizarre rituals – frequently associated with religion Eccentric dress/grooming Extreme motor agitation – pacing, tapping Waxy flexibility – some consider this a negative symptom Automatic obedience Impulsivity
negative symptoms of schizophrenia
are a lack of “normal” behaviors/thoughts/affectCognitive symptomsPoverty of content of thought/speechThought blocking – thoughts “taken away”Affective symptomsAnhedoniaFlat/blunted/inappropriate affectBehavioral symptomsAnergiaAvolition – inability to do anything on one’s ownWaxy flexibility – assuming bizarre postures for long periods of timeNegative symptoms respond poorly to many antipsychotic medications especially “typical” antipsychotics
common co morbid symptoms of schizophrenia
Depression/suicidal ideation Substance abuse Violence – in response to fear of harm
sample nursing diagnosis of schizophrenia
Altered Thought Process Sensory/Perceptual Alteration Impaired Verbal Communication Risk for Violence Anxiety Ineffective Individual Coping Self Care Deficit Alteration in Nutrition
planning goals for schizophrenia
State voices are no longer threatening or do not interfere with his life by (date)Take medications as prescribed by (date)Describe purpose, schedule & side effects of prescribed medications by (date)Identify personal strategies to decrease anxiety/fear/hallucinations by (date)Demonstrate willingness to socialize with others by (date)Participate in simple activity w/nurse & one other person by (date)Participate in ADL’s with minimal direction by (date)Contract to inform staff when feeling unsafe by (date)
interventions for schizophrenia
Sample interventions R/T problem of “Impaired Communication”: Decode whenever possible Mirror pt thoughts Don’t pretend to understand – tell pt you’re having difficulty understanding & place cause with yourself Ex: “I’m having difficulty understanding” vs “You’re not making any sense.” Listen for & mention recurring themes Tell pt when you do understand – reinforces trust & clearer communication Be especially aware of non-verbal communication & mention if appropriate Ex: “I noticed you looked worried about something – is there something bothering you?” Be as clear as possible in your own communication Ex.: “Are you hearing (seeing) something?” to a pt who appears to be hallucinating
interventions geared to phases of schizophrenia
Phase I Crisis stabilization, safety measures, limit setting, developing therapeutic relationship, evaluation of initial treatments Phases II and III As psychosis clears promote healthy functioning, emphasize strengths, reinforce appropriate self-care, engage in problem-solving for ADL’s Pt & family (support persons) teaching, i.e. illness, medications including purposes, side effects, schedules, signs of relapse/impending crisis Establish out-pt services & follow-up care including social & work needs
concrete thinking
inability to think abstractlywhen you say its raining cats and dogs they take that seriously. It’s not raining cats and dogs.Take everything seriously.usually a result of a lot of meds on board
thorazine
•1st drug developed to treat psychosis introduced in 1950’s – prior to that there were no pharmacological treatments for psychotic D/O•Thorazine, mellaril, stellazine, haldol are all 1st generation or typical anti-psychotics- primarily effective for positive symptoms- high incidence of extra -pyramidal symptoms - believed to decrease dopamine levels - little/no effect on other neurotransmitters- little positive effect on negative symptomsOften called “non-surgical lobotomies” the side effects often exacerbated negative signs of schizophrenia
clozaril
•introduced in the early 1990’s, was the first 2nd generation or atypical anti-psychotic–found to have few of the extrapyramidal side effects of 1st generation drugs–more effective in treating negative symptoms–believed to effect other neurotransmitters in addition to dopamine–newer 2nd generation drugs may have some extrapyramidal effects but not to degree as older 1st generation drugs–2nd generation antipsychotics have other side effects–2nd generation drugs of choice when initially treating psychosis– Thorazine making a come back especially in treatment resistant psychotic D/O–atypical antipsychotics being used now (off-label) for other D/O such as profound depression, mania and severe anxiety D/O
side effects of first generation antipsychotic medications
•Extra-pyramidal symptoms (EPS)–Particularly effect motor & fine motor coordinationDystonia - involuntary, irregular clonic contortions of muscles of trunk and extremities - initially patients c/o “thick tongue” and inability to hold neck up straight - cog-wheeling – twisting contortions of body when moving – evidenced initially by jerking arm movement when trying to flex against pressure - difficulties speaking/swallowing - A/W higher potency - treated w/Benedryl, Cogentin, ArtaneNsg considerations - sx typically occur in first hours/days of treatment/inc.dose - assess chewing/swallowing - support/teach pt
side effects of first generation antipsychotic medications
pseudo parkinsonism•muscular rigidity w/ cog-wheeling, immobile face, involuntary of head, tremors & “pill-rolling”•- occurs in first week of treatment – usually ceases 2-3 mo later•- if severe may be treated w/anti-Parkinson drugsNsg considerations - teach pt/family about sx - assess for safety/esteem/communication difficulties
side effects of first generation antipsychotic medications
Akathesia - extreme inability to sit still - constant body movement – if ns. stops movement in trunk, feet/pelvis will move - described by pts as “jumping out of their skin” or “heebie-jeebies” or “all over, inside, pins and needles” - often mislabeled as agitation/severe anxiety - most frequent reason given for non-complianceNsg considerations - assess for restlessness, inability to sit, insomnia, fright, anger, terror, rage - teach pt about sx – usually go away 1-3 months after onset
1st generation side effects of antipsychotic medications
Tardive Dyskinesia•- usually occurs later in anti-psychotic drug treatment•- A/W higher potency drugs i.e. Thorazine, Mellaril, Stelazine•- repetitive involuntary movements of mouth, lips, tongue, trunk &• extremities•- usually preceded by psuedo-parkinsonism but anti-parkinson drugs• worsen condition•- becomes permanent if drug is continued•Nsg considerations - can be reversed if assessed early & drug dc’d - earliest signs = excessive blinking, fine vermiform (worm-like) movements on surface of tongue - pts on long-term drug Rx must be assessed q 3 months w/ AIMS test
atypical 2nd generation antipsychotic meds
Aripiprazole (Abilify)Introduced in US in 2003Usual dose is 15-30 mg/dayLow incidence of motor side effects (extrapyramidal symptoms)Less likely to cause weight gain than other atypical antipschoticsMay contribute to diabetes and elevated blood sugar
atypical 2nd generation antipsychotic meds
Risperidone (Risperdal)Introduced in US in 1994Less sedative than other atypical antipsychoticsAvailable in a long-acting formulation – depot injectionMore likely than other atypical psychotics to cause motor side effects (extrapyramidal symptoms)Risk of weight gain and diabetes, but less than clozapine or olanzapine
atypical 2nd generation antipsychotic meds
Olanzapine (Zyprexa)Introduced in the US in 1996Typical dose is 10-20 mg/dayLow risk of motor side effects (extrapyramidal symptoms)May improve negative symptomsSignificant potential for weight gain and risk of diabetes
atypical 2nd generation antipsychotic meds
•Quetiapine (Seroquel)Introduced in US in 1997Usual dose is 400-800 mg/day, higher for treatment-resistant illnessLow incidence of motor side effects (extrapyramidal symptoms)Risk of weight gain and diabetes, but less than clozapine or olanzapine
atypical 2nd generation antipsychotic meds
•Ziprasidone (Geodon)Introduced in US in 2001Usual dose is 80-160 mg/day; intramuscular formulation availableLow incidence of motor side effects (extrapyramidal symptoms)Less likely to cause weight gain than other atypical antipsychoticsMay contribute to cardiac arrhythmia, and must not be combined with other drugs having this effect
atypical 2nd generation antipsychotic meds
Clozapine (Clozaril)Introduced in the US in 1990Typical dose is 300-700 mg/dayDemonstrated effective against treatment-resistant schizophreniaMay reduce suicidal behaviorsCan cause agranulocytosis so patients must have regular blood tests.Significant potential for weight gain and risk of diabetes
first sign of Dystonia
sore neckpainful or disturbed motion
Although symptoms of schizophrenia occur at various times in the lifespan, what client would be at higher risk for this diagnosis?A 10-year-old girlA 20-year-old manA 50-year-old woman A 65-year-old man
A 20 year old man
A nursing instructor is teaching about the etiology of schizophrenia. What statement by the nursing student indicates an understanding of the content presented? Schizophrenia is a disorder of the brain that can be cured with the correct treatmentA person inherits schizophrenia from a parent Problems in the structure of the brain cause schizophreniaThere are many potential causes for this disease and its etiology is controversial
There are many potential causes for this disease and it’s etiology is controversial
What is required for effective treatment of schizophrenia?Concentration on pharmacotherapy alone to alter and balances inaffected neurotransmittersMultidisciplinary, comprehensive efforts, which include Pharmacotherapy and psychosocial careEmphasis on social and living skills training to help the client fit into societyGroup in family therapy to increase socialization skills
Multidisciplinary, comprehensive efforts, which include pharmacotherapy and psychosocial care
When one fraternal twin has been diagnosed with schizophrenia, the other twin has approximately a _______% chance of developing the disease
15
When one identical twin has been diagnosed with schizophrenia, the other twin has approximately a _______% chance of developing the disease
50
From a biochemical influence perspective, which accurately describes the etiology of schizophrenia?Adopted children with non-schizophrenic parents, raised by parents diagnosed with schizophrenia have a higher incidence of this diseaseAn excess of dopamine dependent Neuronal activity in the brainA higher incidence of schizophrenia occurs after there is prenatal exposure of the mother to influenzaPoor parent child interaction and dysfunctional family systems
An excess of dopamine dependent neuronal activity in the brain
A nurse is working with a client diagnosed with schizoid personality disorder. What symptom of this diagnosis should the nurse expect to assess, and what risk is this client for acquiring schizophrenia?Delusions and hallucinations - high riskLimited range of emotional experience and expression- high riskIndifferent to social relationships- low riskLoaner who appears cold and aloof- low risk
Limited range of emotional experience and expression- high risk
The nurse is assessing a client with a long history of being a loner and having few social relationships. This clients father has been diagnosed with schizophrenia. The nurse would suspect that this client is in what phase of the development of schizophrenia?Phase I - schizoid personalityPhase II- prod tonal phase Phase III - schizophreniaPhase IV - residual phase
Phase I - schizoid personality
The client diagnosed with schizophrenia is experiencing social withdrawal, flat affect, and impaired role functioning. To distinguish whether this client is in the prodromal or residual phase of schizophrenia, what question would the nurse ask the family?Have the symptoms followed an active period of schizophrenic behaviors?How long have the symptoms been occurring? Has a client had a change in mood?Has the client been diagnosed within any developmental disorders?
Have the symptoms followed an active period of schizophrenic behaviors?
The nurse is assessing a client diagnosed with disorganized schizophrenia. Which symptoms should the nurse expect to exhibit?Markedly progressive, primitive behavior, and extremely poor contact with reality. Affect is flat or grossly inappropriate. Personal appearance is neglected, and social impairment is extreme.Marked abnormalities in motor behavior manifested in extreme psychomotor retardation with pronounced decreases in spontaneous movement and activity. Waxy flexibility is exhibitedThe client is exhibiting delusions of persecution or grandeur. Auditory hallucinations related to a persecutory theme are present. The client is tense, suspicious, and guarded and may be argumentative, hostile, and aggressive.Client has a history of psychotic symptoms, such as delusions or auditory and visual hallucinations, but these prominent psychotic symptoms are not exhibited currently.
Markedly progressive, primitive behavior, and extremely poor contact with reality. Affect is flat or grossly inappropriate. Personal appearance is neglected, and social impairment is extreme.
On an inpatient unit, the nurse is caring for a client who is assuming bizarre positions for long periods of time. To which diagnostic category of schizophrenia would this client mostlikely be assigned?Disorganized schizophrenia Catatonic schizophrenia Paranoid schizophrenia Undifferentiated schizophrenia
Catatonic schizophrenia
The student nurse is assessing a 20-year-old client who is experiencing auditory hallucinations. The student states “I believe the client has schizophrenia. “Which of the following instructor responses is the most appropriate? Select all that apply.How long is the client experience these symptomsHas the client taken any drugs or medication that could cause these symptomsIt is not within your scope of practice to assess for a medical diagnosisDoes the client have any mood problemsWhat kind of relationships has the client established
How long is the client experience these symptomsHas the client taken any drugs or medication that could cause these symptomsDoes the client have any mood problemsWhat kind of relationships has the client established
A 21-year-old client, being treated for asthma with a steroid medication, has been experiencing delusions of persecution and disorganized thinking for the past six months. Which factor may rule out any diagnosis of schizophrenia?The client has experienced signs and symptoms for only six monthsThe client must hear voices to be diagnosed schizophreniaThe clients age is not typical for this diagnosisThe client is receiving medication that could lead to thought disturbances
The client is receiving medication that could lead to thought disturbances
A client is brought to the emergency department after being found wandering the streets talking to unseen others. Which situation is further evidence of a diagnosis of schizophrenia for this client? The client exhibits a developmental disorder, such as autismThe client has a medical condition that could contribute to the symptomsThe client experiences manic or depressive signs and symptomsThe client signs and symptoms last for six months
The client signs and symptoms last for six months
The client on an inpatient psychiatric unit refuses to take medications because “the pill has a special code written on it that will make it poisonous”. What kind of delusion is this client experiencing?An erotomanic delusionA grandiose delusions.A persecutory delusions.A somatic delusion
A persecutory delusions
The nurse is performing in mission assessment on a client diagnosed with paranoid schizophrenia. To receive the most accurate assessment information, which of the nurse consider?This client will be able to make a significant contribution to history data collection.Data will need to be gained by reviewing old records and talking with family.This client assessment will be easy because of the consistent nature of the symptoms.The nurse can primarily rely on the clients global assessment of functioning.
Data will need to be gained by reviewing old records and talking with family.
The Nurse is interviewing a client who states “the dentist put a filling in my tooth. I now received transmissions that control what I think and do”. The nurse accurately documents this symptom with which charting entry?Client is experiencing a delusion of persecutionClient is experiencing a delusion of grandeur Client is experiencing a somatic delusionClient is experiencing a delusion of influence
Client is experiencing a delusion of influence
The children’s saying “step on a crack and break your mothers back” is an example of which type of thinking?Concrete thinkingThinking using neologismsMagical thinking Thinking using clang associations
Magical thinking
The nurse is assessing a client diagnosed with schizophrenia. The client states, we wanted to take the bus, but the airport took all the traffic. Which charting entry accurately document this symptom?The client is experiencing associative loosenessThe client is attempting to communicate by the use of word saladThe client is experiencing delusional thinkingThe client is experiencing an illusion involving planes
The client is experiencing associative looseness
The nurse reports that the client diagnosed with a thought disorder is experiencing religiosity. Which client statements would confirm this finding?I see Jesus in my bathroomI read the Bible every hour so that I would know what to do nextI have no heart. I’m dead and in heaven todayI can’t read my Bible because the CIA has poison the pages
I read the Bible every hour so that I would know what to do next
The nurse states “it’s time for lunch”. A Client diagnosed with schizophrenia responds “it’s time for lunch, lunch, lunch.” Which type of communication process is the client using, and what is the underlying reason for its use?Echopraxia, which is an attempt to identify with the person speakingEchoLalia which is an attempt to acquire a sense of self and identityUnconscious identification to reinforce week ego boundariesDepersonalization to stabilize self identity
EchoLalia which is an attempt to acquire a sense of self and identity
Clients diagnosed with schizophrenia may have difficulty knowing where their ego boundaries end and others begin. Which client behavior reflects this deficit?The client eats only prepackaged foodThe client believes that family members are adding poison to foodThe client looks for actual animals when others state “it’s raining cats and dogs”The client imitates other people’s physical movements
The client imitates other people’s physical movements
The nurse documents that a client diagnosed with schizophrenia is expressing a flat affect. What is an example of this symptom?The client laughs when told of the death of his or her motherThe clients sits alone and does not interact with othersThe client exhibits no emotional expressionThe client experiences no emotional feelings
The client exhibits no emotional expression
Which client is most likely to benefit from group therapy?The client diagnosed with schizophrenia being followed up in an outpatient clinicA client diagnosed with schizophrenia newly admitted to an inpatient unit for stabilizationThe client experiencing an exacerbation of the signs and symptoms of schizophreniaA client Diagnosed with schizophrenia who is not compliant with antipsychotic medications
The client diagnosed with schizophrenia being followed up in an outpatient clinic
In the United States which diagnosis has the lowest percentage of occurrence?Major depressive disorder Generalized anxiety disorder Obsessive compulsive disorderSchizophrenia
Schizophrenia
The client who is hearing and seeing things others do not is brought to the emergency department. Lab values indicate a sodium level of 160 mEq/L. Which diagnosis would take priority? Altered thought processes R/T low blood sodium levels Altered communication processes R/T altered thought processes Risk for impaired tissue integrity R/T dry oral mucous membranes Imbalanced fluid volume R/T increased serum sodium levels
Imbalanced fluid volume R/T increased serum sodium levels
A client diagnosed with schizophrenia is experiencing am hedonic. Which nursing diagnosis addresses the clients problem that this symptom may generate?Disturbed thought processDisturbed sensory perceptionRisk for suicideImpaired verbal communication
Risk for suicide
A client diagnosed with a thought disorder is experiencing clang associations. Which nursing diagnosis reflects this clients problems?Impaired verbal communicationRisk for violenceIneffective health maintenance Disturbed sensory perception
Impaired verbal communication
A disheveled client diagnosed with thought disorder has body odor and halitosis. Which nursing diagnosis reflects this clients current problems.Social isolationImpaired home maintenance Interrupted family processesSelf care deficit
Self care deficit
A clients family is having a difficult time accepting the clients diagnosis of schizophrenia, and this has led to family conflict. Which nursing diagnosis reflects this problem?Impaired home maintenance Interrupted family processes Social isolationDisturbed thought processes
Interrupted family processes
a client diagnosed with paranoid schizophrenia tells the nurse about three previous suicide attempts. which nursing diagnosis would take priority and reflect this client’s problem?disturbed thought processesrisk for suicideviolence: directed toward othersrisk for altered sensory perception
risk for suicide
a client has the nursing diagnosis of impaired home maintenance R/T regression. Which behavior confirms this diagnosis?the client fails to take antipsychotic medicationsthe client states I haven’t bathed in a weekthe client lives in an unsafe and unclean environmentthe client states you can’t draw my blood without crayons
the client lives in an unsafe and unclean environment
which outcome should the nurse expect from a client with a nursing diagnosis of social isolation?the client will recognize distortions of reality by day 4the client will use appropriate verbal communication when interacting by day 3the client will actively participate in unit activities by dischargethe client will rate anxiety as 5/10 by discharge
the client will actively participate in unit activities by discharge
which outcome should the nurse expect from a client diagnosed with schizophrenia who is hearing and seeing things others do not hear and see?The client will recognize distortions of reality by dischargethe client will demonstrate the ability to trust by day 2the client will recognize delusional thinking by day 3the client will experience no auditory hallucinations by discharge
The client will recognize distortions of reality by discharge
a client admitted to an in patient setting has not been adherent with antipsychotic medications prescribed for schizophrenia. Which outcome related to this clients problem should the nurse expect the client to achieve?the client will maintain anxiety at a reasonable level by day 2the client will take antipsychotic medications by dischargethe client will communicate to staff any paranoid thoughts by day 3the client will take responsibility for self care by day 4
the client will take antipsychotic medications by discharge
a client taking olanzapine (zyprexa) has a nursing diagnosis of altered mental sensory perception r/t command hallucinations. Which outcome would be appropriate for this clients problem?the client will verbalize feelings related to depression and suicidal ideationsthe client will limit caloric intake because of the side effect of weight gainthe client will notify staff members of bothersome hallucinationsthe client will tell staff members if experiencing thoughts of self harm
the client will notify staff members of bothersome hallucinations
a homeless client, diagnosed with schizophrenia, is seen in the mental health clinic complaining of insects infesting arms and legs. which intervention should the nurse implement first?check the client for body licepresent reality regarding somatic delusionsexplain the origin of persecutory delusionsrefer for in patient hospitalization because of substance induced psychosis
check the client for body lice
a client states to the nurse “I see headless people walking down the hall at night”. Which nursing response is appropriate?what makes you think there are headless people herenow let’s think about this. a headless person would not be able to walk down the hallit must be frightening. I realize this is real to you but I see no headless peopleI don’t see those people you are talking about
it must be frightening. I realize this is real to you but I see no headless people
a client with a nursing diagnosis of disturbed thought processes has an expected outcome of recognizing delusional thinking. Which intervention would the nurse first implement to address this problem?reinforce and focus on realityappreciate that the client has experienced disturbing delusional thinkingindicate that the nurse does not share the beliefpresent logical information to refute the delusional thinking
appreciate that the client has experienced disturbing delusional thinking
a client is in the active phase of paranoid schizophrenia . which nursing intervention would aid in facilitating other interventions?assign consistent staff membersconvey acceptance of the delusional beliefhelp the client understand that anxiety causes hallucinationsencourage participation in group activities
assign consistent staff members
a client newly admitted to an in patient psychiatric unit is scanning the environment continuously. which nursing intervention is most appropriate to address the clients behavior?offer self to build a therapeutic relationship with the clientassist the client in formulating a plan of action for dischargeinvolve the family in discussion about dealing with the client’s behaviorsreinforce the need for medication adherence on discharge
offer self to build a therapeutic relationship with the client
which interaction is most reflective of an appropriate psychotherapeutic approach when interacting with a client diagnosed with schizophrenia ?the nurse should exhibit exaggerated warmth to counteract client lonelinessthe nurse should profess friendship to decrease social isolationthe nurse should attempt closeness with the client to decrease suspiciousnessthe nurse should establish a relationship by respective the clients dignity
the nurse should establish a relationship by respective the clients dignity
The nurse is educating the family members of a client diagnosed with schizophrenia about the effects of psychotherapy. Which statement should be included in the teaching plan?psychotherapy is a short term intervention that is usually successfulmuch patience is required during psychotherapy because clients often relapsemajor changes in client symptoms can be attributed to immediate psychotherapyindependent functioning can be gained by immediate psychotherapy
much patience is required during psychotherapy because clients often relapse
a client diagnosed with schizoid personality disorder asks the nurse in the mental health clinic, does this mean I will get schizophrenia. what nursing response would be most appropriate?does that possibility upset younot all clients diagnosed with schizoid personality disorders progress to schizophreniafew clients with a diagnosis of schizophrenia show evidence of early personality changeswhat do you know about schizophrenia
not all clients diagnosed with schizoid personality disorders progress to schizophrenia
which intervention used for clients diagnosed with thought disorders is a behavioral therapy approach?offer opportunities for learning about psychotropic medicationsattach consequences to adaptive and maladaptive behaviorsestablish trust with a relationshipencourage discussions of feelings related to delusions
attach consequences to adaptive and maladaptive behaviors
which intervention used for clients diagnosed with thought disorders is a milieu therapy approach?assist family members in dealing with life stressors caused by interactions with the clientone on one interactions to discuss family dynamicsrole play to enhance motor and interpersonal skillsemphasize the rules and expectations of social interactions mediated by peer pressure
emphasize the rules and expectations of social interactions mediated by peer pressure
which of the following clients has the best chance of a positive prognosis after being diagnosed with schizophrenia? select all that applya client diagnosed at age 35a male client experiencing a gradual onset of signs and symptomsa female client whose signs and symptoms began after rapea client who has a family history of schizophreniaa client who has a family history of a mood disorder diagnosis
a client diagnosed at age 35a female client whose signs and symptoms began after rapea client who has a family history of a mood disorder diagnosis
The nurse is teaching a client diagnosed with schizophreniform disorder about what may affect a good prognosis. which of the following features should the nurse include? select all that apply confusion and perplexity at the height of the psychotic episodegood premorbid social and occupational functioningabsence of blunted or flat affectpredominance of negative symptomsonset of psychotic symptoms within 4 weeks of noticeable behavioral change
confusion and perplexity at the height of the psychotic episodegood premorbid social and occupational functioningabsence of blunted or flat affectonset of psychotic symptoms within 4 weeks of noticeable behavioral change
which symptom experienced by a client diagnosed with schizophrenia would predict a less positive prognosishearing hostile voicesthinking the TV is controlling his or her behaviorcontinuously repeating what has been saidhaving little or no interest in work or social activities
having little or no interest in work or social activities
The nurse is education the family of a client diagnosed with schizophrenia about the importance of medication adherence. which statement indicates that learning has occurred?after stabilization the relapse rate is high, even if antipsychotic medications are taken regularlymy brother will have only about a 30% chance of relapse if he takes his medications consistentlybecause the disease is multifaceted taking antipsychotic medications has little effect on relapse ratesbecause schizophrenia is a chronic disease taking antipsychotic medications has little effect on relapse rates
my brother will have only about a 30% chance of relapse if he takes his medications consistently
the nurse documents that a client diagnosed with thought disorder is experiencing anticholinergic side effects from long term use of thioridazine (Mellaril). Which symptoms has the nurse noted?akinesia, dystonia, and pseudoparkinsonismmuscle rigidity, hperpyrexia, and tachycardiahyperglycemia and diabetesdry mouth, constipation, and urinary retention
dry mouth, constipation, and urinary retention
a client has a history of schizophrenia, controlled by haloperidol (Haldol). During an assessment, the nurse notes continuous restlessness. Which medication would the nurse expect the physician to prescribe for this client?haloperidol (Haldol)fluphenazine decanoate (prolixin decanoate)clozapine (clozaril)benztropine mesylate (Cogentin)
benztropine mesylate (Cogentin)
a client diagnosed with schizophrenia takes clozapine (clozaril) 25 mg gd. lab results reveal: rbc 4.7, wbc 2000, and TSH 1.3. which would the nurse expect the physician to order?levothyroxine sodium (synthroid) 150ferrous sulfate (feosol) 100discontinue clozapinediscontinue clozapine and start levothyroxine sodium (synthroid) 150
discontinue clozapine
The nurse is discussing the side effects experienced by a female client taking antipsychotic medications. The client states I haven’t had a period in 4 months. which client teaching should the nurse include in the plan of care?antipsychotic medications can cause a decreased libidoantipsychotic medications can interfere with the effectiveness of birth controlantipsychotic medications can cause amenorrhea, but ovulation still occursantipsychotic medications can decrease red blood cells, leading to amenorrhea.
antipsychotic medications can cause amenorrhea, but ovulation still occurs
For the past year, a client has received haloperidol (Haldol). The nurse administering the client’s next dose notes a twitch on the right side of the clients face and tongue movements. Which nursing intervention takes priority?give haloperidol (Haldol) and benztropine (Cogentin) 1 mg per orderassess for other signs of hyperglycemia resulting from the use of the haloperidolcheck the clients temperature and assess mental statushold the haloperidol, and call the physician
hold the haloperidol, and call the physician
a client has been prescribed ziprasidone (Geodon) 40 mg. Which of the following interventions are important related to this medication ? select all that applyobtain a baseline EKG initially and periodically throughout treatmentteach the client to take the medication with mealsmonitor the clients pulse because of the possibility of palpitationsinstitute seizure precautions and monitor closelywatch for signs and symptoms of a manic episode
obtain a baseline EKG initially and periodically throughout treatmentteach the client to take the medication with mealsmonitor the clients pulse because of the possibility of palpitations
a client prescribed quetiapine (Seroquel) 50 mg bid has a nursing diagnosis of risk for injury R/T sedation. Which nursing intervention appropriately addresses this clients problem?assess for homicidal and suicidal ideationsremove clutter from the environment to prevent injurymonitor orthostatic changes in pulse or blood pressureevaluate for auditory and visual hallucinations
remove clutter from the environment to prevent injury
a client is newly prescribed hydroxyzine (atarax) 50 and clozapine 25. which is an appropriate nursing diagnosis for this client?risk for injury R/T serotonin syndromerisk for injury R/T possible seizurerisk for injury R/T clozapine toxicityrisk for injury R/T depressed mood
risk for injury R/T possible seizure
which atypical antipsychotic medication has the highest potential for a client to experience serious side effects?haloperidol (Haldol)chlorpromazine (thorazine)risperidone (Risperdal)clozapine (clozaril)
clozapine (clozaril)
a woman is prescribed risperidone (risperidal) 1 mg. At her 3- month follow up the client states, I knew it was a possible side effect but I can’t believe I am not getting my period anymore. which is a priority teaching need?sometimes amenorrhea is a temporary side effect of medications and should resolve itselfI am sure this was very scary for you . How long has it been since your last menstrual cyclealthough your menstrual cycles have stopped there is still a potential for you to become pregnantmaybe the amenorrhea is not due to your medication. Have your menstrual cycles been regular in the past
although your menstrual cycles have stopped there is still a potential for you to become pregnant
a client is exhibiting sedation, auditory hallucinations, dystonia and grandiosity. Then client is prescribed haloperidol (Haldol) and trihexyphenidyl (artane). Which statement about these medications is accurate.artane would assist the client with sedationartane would assist the client with auditory hallucinationsHaldol would assist the client in decreasing grandiosityHaldol would assist the client with dystonia
Haldol would assist the client in decreasing grandiosity
a client is prescribed aripoprazole (abilify). The client complains of sedation and dizziness. Vital signs reveal b/p 100/60, pulse 80 respiration rate 20 and temperature 97.4 which nursing diagnosis takes priorityrisk for noncompliance R/T irritating side effects knowledge deficit r/t new medication prescribedrisk for injury r/t orthostatic hypotensionactivity intolerance r/t dizziness and drowsiness
risk for injury r/t orthostatic hypotension
a client recently prescribed fluphenazine (prolixin) complains tot he nurse of severe muscle spasms. On examination heart rate is 110, blood pressure is 160/92, and temp is 101.5 which nursing intervention takes priority check the cart for a prn order of benztropine mesylate (Cogentin) because of increased extrapyramidal symptomshold the next dose of prolixin and call the physician immediately to report the findingsschedule an examination with the clients physician to evaluate cardiovascular functionask the client about any recreational drug use, and ask the physician to order a drug screen
hold the next dose of prolixin and call the physician immediately to report the findings
lithium carbonate (lithium) is to mania as clozapine (clozaril) is toanxietydepressionpsychosisakathisia
psychosis
neuroleptic malignant syndrome
caused by atypical antipsychotic drugsseen usually 10 day s after starting medicationcauses fever, sweating, unstable bp, muscular rigidity, and autonomic dysfunctionpt complains of being really cold. fever is up to 104-105stop medications immediatly.
Pituitary (aka “master gland”)
Secretes hormones which in turn cause hormone secretion by other endocrine glandsDivided into anterior (adenohypophysis) and posterior (neurohypophysis)Control behind the “master” = hypothalamusAnt. pit. hormones secreted in response to releasing factors from hypothalamusPost. pit. hormones synthesized in hypothalamus then stored and released from posterior pituitary
thyroid
Hormones regulate metabolism in body by:regulating cellular O2 consumptionaltering responsiveness of tissues to other hormones
hypothalamus
control behind the “master” pituitary
hyperthyroid effects
insulin
parathyroids
regulate calcium and phosphorus metabolism
adrenals
• 2 sections:•core/middle = medulla•outer portion/”coat” = cortex•• medulla - catecholamines - fight or flight response••cortex - steroids -•conversion of glucose from amino acids,•mobilization of fat for energy,•resistance to stress,•regulation of sodium and potassium in kidney tubules (reabsorption of sodium and water in exchange for potassium and hydrogen),•sml. amt gender hormones
the only thing that comes out of the core of the adrenal glands
epinephrine and norepinephrine
pancrease
islets of langerhansregulation of glucose metabolism
which glands are part of the endocrine system
thyroidparathyroidadrenalpituitary
what is the name of the substance secreted by the endocrine glands
hormones
which mechanism is used to transport hormones produced bu the endocrine glands to their target tissues
bloodstream
what hormones are excreted by the anterior pituitary
growth hormonethyroid stimulating hormone (tsh)adrenocorticotropic hormone (acth)
which hormones are excreted bu the posterior pituitary
antidiuretic hormone (ADH)oxytocin
which hormones are secreted by the adrenal cortex
CortisolAldosterone
which hormones are secreted by the adrenal medulla
epinephrine and norepinephrine
which hormones are secreted by thyroid gland
thyrocalcitonin (calcitonin)triiodothyronine (T3)Thyroxin (T4)
which hormones are secreted by Alpha cells (islets of langerhans)
glucagon
which hormones are secreted by beta cells - islets of langerhans
insulin
which hormones are secreted by delta cells (islets of langerhans)
somatostatin
which hormones are secreted by parathyroid
parathyroid hormone (PTH)
which hormones are secreted by ovaries
estrogen
which hormones are secreted by testes
testosterone
which hormones are secreted by hypothalmus
Corticotropin-releasing hormone (CRH)
the target tissue for ADH is which organ
kidney
the binding of a hormone to a specific receptor site is an example of which endocrine process
lock and key manner
what are tropic hormones
hormones produced b the anterior pituitary gland that stimulates other endocrine glands
which hormone is directly suppressed when circulating levels of cortisol are above normal
CRH
the maintenance of internal body temperature at approximatley 98.6 is an example of which endocrine process
neuroendocrine regulation
the anterior pituitary gland secretes tropic hormones in response to which hormones from the hypothalamus
releasing hormones
which happenswithpituitary hormones is
follicle stimulating hormone stimulates sperm production in men
what is true about gonads
external genitalia maturation is stimulated by gonadotropins during puberty
whiat is the major function of the hormones produced by the adrenal cortex
control of glucose, sodium, and water
which hormone responds to a low serum calcium blood level by increasing bone resorption
PTH
which hormone responds to elevated serum calcium blood level by decreasing bone resorption
calcitonin
which are the target organs of PTH in the regulation of calcium and phorphorus
kidneynoneintestinal tract
what should we know about the pancreas
somatostatin inhibits pancreatic secretion of glucagon and insulin
what should you know about glucagon secretion
it acts to increase blood glucose levels
in addition to the pancreas that secretes insulin which gland secretes hormones that affect protein carbohydrate and fat metabolism
thyroid
the bloodstream delivers glucose to the cells for energy production. Which hormone controls the cells use of glucose
insulin
which disease involves a disorder of the islets of langerhans
diabetes mellitus
which endocrine tissues are most commonly found to have reduced function as a result of aging
ovariestestespancreasthyroid gland
what should we know about age related changes in older adults and the endocrine system
thyroid hormone levels decrease
what happens to the body when the thyroid isaging and decreasing infunction
decreased metabolic rate
what happens to the body when the pancreasisaging and decreasing infunction
decreased sensitivity of peripheral tissues to the effects of insulin
what happens to the body when the ovary isaging and decreasing infunction
osteoporosis, decreased production of estrogen
what happens to the body when the posterior pituitary glandisaging and decreasing infunction
decreased concentrating ability of the kidneys
an older adult reports a lack of energy and not being able to do the usual daily activities without several naps during the day. Which problem may these symptoms indicate that is often seen in the older adult
hypothyroidism
the nurse is performing an assessment of a patient’s endocrine system. Which gland can be palpated
thyroid
which statement about performing a physical assessment of the thyroid gland is correct
the patient is instructed to swallow to aid palpation
what is the correct nursing action before beginning a 24 hour urine collection for endocrine studies
check whether any preservatives are needed in the collection container
a patient is suspected of having a pituitary tumor. which radiographic test aids in determining this diagnosis
CT/MRI
after an ultrasound of the thyroid gland which diagnostic tests determine the need for surgical intervention
needle biopsy
a patient is at risk for falling related to the effect of pathologic fractures as a result of bone demineralization. which endocrine problem is this pertinent to
overproduction of PTH
what should we know about hormones and the endocrine system
specific normal blood levels of each hormonehormones exert their effects on specific target tissuesmore than one hormone can be stimulated before the target tissue is affected
what should we know about the pituitary glands
the main role of the anterior pituitary is to secrete tropic hormonesthe posterior pituitary gland stores hormones produced by the hypothalamusthe anterior pituitary gland secretes gonadotropins
what should we know about the adrenal glands
the cortex secretes androgens in men and womenthe cortex secretes aldosterone that maintains extracellular fluid volume
what should we know about cortisol being secreted by the adrenal cortex
cortisol has an effect on the body’s immune functionstress causes an increase in the production of cortisolcortisol affects carbohydrate, protein and fat metabolism
what does the nurse monitor in response to catecholamines released by the adrenal medulla
increased HR related to vasoconstrictionincreased BP related to vasoconstrictionincreased perspirationincreased blood glucose in response to glycogenolysis
what should we know about the thyroid gland and hormones
the gland has two lobes joined by a thin tissue called the isthmusthyroxine (T4) and triiodothyronine (T3) are two thyroid hormonesthyroid hormones increase red blood cell production
what should we know about T3 and T4 hormones
the basal metabolic rate is affectedhypothalamus is stimulated by cold and stress to secrete thyrotropin releasing hormone (TRH)these hormones need intake of protein and iodine for productionT3 and T4 increase oxygen use in tissues
what should we know about insulin secretion
insulin levels increase following the ingestion of a mealbasal levels are secreted continuouslycarbohydrate intake is the main trigger for insulin secretion
what diagnostic methods are used to measure patient hormone levels
stimulation testingsuppression testing24 hour urine testingchromatograhic assay
what should you teach a patient about urine collection for endocrine studies
empty the bladder completely then start timingtime the test for exactly the instructed # of hoursnotify the lab of all meds you are takingempty the bladder at the end of the time period and keep that specimen
what are types of radiographic tests that may be used for an endocrine assessment
ultrasonographyskull x-rayMRICT
function of ADH
water conservation
what is ADH released in response to
dehyrdration, decrease blood volume,increased serum osmolarity, stress/ anxiety
why is ADH inhibited or not realeased
increased blood volume, overhydration, decreased serum osmolarity
what is the action of ADH
increase water absorption in distal tubules,decreased urine output
diabetes insipidus Etiology
•deficiency in ADH secretion• Primary DI is rare- usually results from tumor/trauma to pituitary/hypothalamus
clinical symptoms of Diabetes Insipidus
• Polyuria, polydipsia, decreased urine specific gravity, anorexia, wgt loss• Without Rx -> severe dehydration, sodium depletion, vascular collapse
diagnostic test for diabetes indipidus
water deprivation•Water deprivation•Withhold all fluids X 8-12h (3-5% body wgt)•Check plasma & urine osmolarity @ start & end•+ result if pt continues to excrete lrg amts of dilute urine
nursing care during water deprivation test
•Nsg care during test•Watch for: sx of hypovolemic shock : tachycardia hypotension•Do hourly wgts for loss up to 5%•Provide emotional support esp. r/t thirst
vasopression stimulation test for Diabetes Insipidus
•Done after water deprivation•Done to determine if problem is with conc. by renal tubules OR DI•Urine osmolarity checked before and 1 hr after administration of SQ vasopressin•+ for DI if urine osmolarity rises > 5% after vasopressin
Treatment for Diabetes Insipidus
•Treatment for DI•Synthetic ADH (vasopressin) usually desmopressin•Nursing Considerations•Teach pt on long-term Rx: Daily wgt – report >3% increase to MD• Notify MD if polyuria/polydipsia• Sx of fluid excess
SIADH etiology
•Most common cause = oat cell carcinoma of lungs•Other causes = severe stress, trauma, CNS damage, lrg. doses chemo, radiation Rx•Pathophysiology•Secretion not controlled by usual mechanism-> excess ADH -> increased reabsorption H2O•in renal tubules -> increased ECF volume, hemodilution, dilutional hyponatremia
Treatment of SIADH
•Treatment•Treatment for underlying cause•Fluid restriction•Diuretics, albumin
Nursing considerations for SIADH
•Nursing Considerations•Assess for: decreased urine output, increased urine specific gravity, weight gain, decreased LOC
Thyroid (PPT. slide)
•Produces three hormones: T4 (thyroxine), T3 (triiodothyronine) and calcitonin••T4 and T3•Regulated by ant. pituitary via negative feedback•↓ T4/T3 -> release of TSH -> ↑ secretion of T4/T3 until normal levels are attained•Function = regulation of overall body metabolism, energy production, F&E balance, tissue use of fats, proteins, carbohydrates•Diagnostic: must look at TSH in addition to thyroid hormones• Determines if problem is pituitary or thyroid in nature••Calcitonin• Inhibits mobilization of calcium from bones -> ↓ serum calcium
hyperthyroidism Characteristics
•Excess circulating thyroid hormone -> hypermetabolic state•Graves’ Disease = @ 85% of hyperthyroidism•Characteristics = enlarged thyroid, exophthalmos, ↑ pulse, weight loss, fatigue, heat intolerance, diarrhea/frequent defecation, restlessness, tremor, insomnia ( see pg. 685 Lemone)
Thyroid crisis (Thyroid storm)
• Thyroid Crisis (thyroid storm)•Acute exacerbation of hyperthyroidism•Hyperthermia, tachycardia, CNS irritability, systolic HTN•May -> coma•Medical emergency - -> death in @ 20% patients who develop it•Precipitating factors = infection, trauma, severe emotional distress, or manipulation of thyroid during subtotal thyroidectomy
treatment for hyperthyroidism
•RX for Hyperthyroidism• Pharmacological = medication to reduce thyroid hormone production•Propylthiouracil (PTU), methimazole (Tapazole)• Radioactive iodine•Thyroid absorbs all iodine – radioactive destroys thyroid tissue -> hypothyroidism• Surgical = removal all/part of thyroid
if your patient has hyperthyroidism DO NOT
palpate their thyroid
hypothyroidism
•Inadequate amt. circulating thyroid hormone -> ↓ metabolic rate in all systems•Primary hypothyroidism = pathologic change in thyroid•>90% cases hypothyroidism•Etiology = dietary iodine deficiency, thyroiditis, radiation Rx to•neck, surgical removal of thyroid, drug Rx used to ↓ thyroid activity•Secondary hypothyroidism + dysfunction of ant. pituitary -> ↓ TSH••Characteristics = possible goiter (enlarged thyroid), bradycardia, ↓ cardiac output, hypothermia, fatigue, weight gain, anorexia, lethargy, cold intolerance, obesity, dry, cool & coarse skin, thin, coarse & brittle hair, depression, constipation, hyporeflexia, ↑ serum cholesterol & triglycerides (see pg. 695 Lemone)
hypothyroid crisis (myedema coma)
•Acute/exaggerated hypothyroidism•Hypoventilation, hypothermia, hypotension, shock•May -> seizures, coma
hypothyroidism medical emergency
•- -> > 50% mortality rate•Precipitating factors = trauma, infection, noncompliance with thyroid replacement Rx, exposure to cold, use of CNS depressants
treatment hypothyroidism
•Pharmacological -> thyroid hormone replacement•Surgical -> may have sub-total thyroidectomy if goiter -> resp. distress, severe dysphagia
if they remove the whole thyroid, what happens
hypothyroidism
what should you not use with patients with hypothyroidism
CNS depressants (morphine, etc.) it will push them into hypothyroid crisis.
Parathyroids
maintain calcium phosphate balance
parathormone
•Works directly to ↑ reabsorption of Ca+ through kidneys and to ↑ breakdown of bone → increase serum calcium•Works indirectly by activating Vit D in GI tract → ↑ absorption Ca+ from diet
hyperparathyroidism
•Etiology: tumor/ over reaction to hypocalcemia from other diseases/ hypocalcemia 2⁰ Vit D deficiency/ kidney disease•Symptoms: cardiac arrhythmias/ bone demineralization → brittle bones & fractures/ ↑serum calcium → kidney stones/ generalized weakness & fatigue/ bone pain•Treatment: dietary modifications/ surgical removal of some or all parathyroids•Nursing Considerations:–Pre-parathyroidectomy ?–Post-parathyroidectomy – see hypoparathyroidism
nursing considerations for hyperparathyroidism
Pre nsg care = watch for cardiac, enforce low Ca+ diet, STRAIN urine for stones, enc cranberry juice to decrease urine pH, FALL precautions
hypoparathyroidism
•Etiology: most common cause = surgical removal•Symptoms: decreased serum Ca+ → cardiac arrhythmias/ tetany →laryngeal spasm, convulsions/ bone or ocular calcifications•Treatment: parathormone, Ca+ , teach about high Ca+ low phosphate diet•Post-parathyroidectomy or thyroidectomyProvide calm, quiet environmentMonitor cardiac rhythm Assess for sx tetany
tetany
Can occur as soon as immediate post-op period & as late as 4to 5 days post-opGive calcium gluconateSupport airway – tracheostomy may be necessary for severe laryngeal spasmSupport cardiac function
symtpoms of tetany
invol jerky spasms – circumoral tingling + numbness – muscle cramps – hyperreflexia: Chvostek’s sign (tap the face angle)Depending on severity of sx Ca+ may be given po -> IV –Eggs, milk, cheese all have HIGH PHOSPHATE
adrenal Cortex
corticosteroids - (i.e.)mineralocorticoidsglucocorticoidsadrogens and estrogens
mineralocorticoids
–primarily aldosterone•Maintains extracellular fluid volume – renin-angiotensin-aldosterone system•↓ fluid volume → release of aldosterone →kidneys reabsorb Na+ and H2O, excrete KAldosterone secretion may be stimulated by ↑ K+ or ACTH stimulation
glucocorticoids
–primarily glucocorticoid•Metabolism of protein, fat & carbohydrates/ affects stress response/ emotional stability/immune function–↑gluconeogenesis, lipolysis, protein catabolism (breaks down collagen & connective tissue)•Released in response to adrenocorticotropic hormone -> ACTH (ant.pituitary) & corticotropin-releasing hypothalamus -> CRH (hypothalamus)PROTEIN CATABOLISM DEGRADES COLLAGEN & CONNECTIVE TISSUE
androgens and estrogens
–small amounts•Primary source of testosterone in women
adrenal medulla
•catacholamines–Epinephrine & Norepinephrine•Fight or flight response -> glycogenolysis, gluconeogenesis, glucagon & insulin release
adrenal cortical insufficiency (Addison’s disease)
•Loss or severe deficit of corticosteroidsEtiology:–Primary: TB, autoimmune D/O, metastatic CA, hemorrhage, infections–Secondary: sudden cessation of long-term, high-dose glucocorticoid therapy, hypopituitarism, surgical removal of the pituitary
symptoms of addison’s disease(adrenal cotical insufficiency)
develop more quickly with stress–Loss of glucocorticoids: inability to regulate blood glucose levels →hypoglycemia as stores are used up – weakness, sx low blood glucose ↑urea nitrogen retention by kidneys → ↑BUN ↓gastric acid production → anorexia, weight loss–Loss of aldosterone: ↑Na+ and H2O excretion→ hyponatremia & hypovolemia ↑K+ retention → hyperkalemia fascilitating ↑reabsorption of hydrogen→acidosis–Initial symptomsanorexia, n & v, diarrhea/ fatigue/weight loss/ muscle weakness/ hypotension/ pain in abdomen, back & legs due to F & E imbalance, volume depletion, sx dehydration, hyperpigmentation of the skin (bronze skin color)Severity of symptoms R/T degree of deficiency – severe deficiency = Acute Adrenal Insufficiency or Addison’s Disease
diagnostics for Addison’s disease
–↓ serum cortisol, ↓ blood glucose, ↓sodium/ ↑potassium, ↑ BUN–In primary insufficiency ↑ ACTH–Most conclusive test = ACTH stimulation test•IV ACTH administered•Serum cortisol levels measured before test, 30 minutes after ACTH & 60 minutes later•Positive for primary adrenal insufficiency if cortisol levels remain the same•Positive for secondary adrenal insufficiency if cortisol levels are elevated → further examination of pituitary/hypothalmic functioning–↓ serum cortisol, ↓ blood glucose, ↓sodium/ ↑potassium, ↑ BUN–In primary insufficiency ↑ ACTH–Most conclusive test = ACTH stimulation test•IV ACTH administered•Serum cortisol levels measured before test, 30 minutes after ACTH & 60 minutes later•Positive for primary adrenal insufficiency if cortisol levels remain the same•Positive for secondary adrenal insufficiency if cortisol levels are elevated → further examination of pituitary/hypothalmic functioning
treatment for addison’s disease
•Hormone replacement therapy•Re-establish F&E balance•Teach re hormone replacement, diligence in avoiding/treating infection, sx of hyperadrenalism
acute adrenal crisis (addisonian crisis)
–Life-threatening situation – shock, hypotension, kidnet shutdown, tachycardia, tachypnea–Often without warning stimulated by stressful event i.e. trauma, surgery, infection–Potential for cardio-vascular collapse–Requires immediate treatment to maintain life–“5 S’s” treatment•Salt replacement•Sugar replacement•Steroid replacement•Support of physiologic functions•Search for and treat any identified cause
Adrenal Cortical Excess (cushing’s disease)
Oversecretion of one/more corticosteroids → hypercortisolism, hyperaldosteronism, and/or elevated androgen production•Etiology: pituitary or hypothalamic disease, long-term or excessive use of corticosteroids/predisposing factors=stress, obesity
symptoms of Cushing’s disease (adrenal cortical excess)
•Symptoms: Exaggerated effects of corticosteroids–Excess serum glucose – polyuria, polydipsia–Excess serum lipids → fatty deposits in trunk/ breakdown protein → loss of muscle mass → apple-shaped body with thin extremities– Breakdown of collagen & connective tissue → thin skin with striae, easy bruising, petechiae, osteoporosis, moon face, buffalo hump–Corticosteroids kill lymphocytes & organs containing them → liver, spleen & lymph nodes shrink → ↓ antibody response → risk of infection–Corticosteroids play a role in mood stabilization – excess may → depression, ↓ libido–↑ androgens → acne, hirsutism, scant/infrequent menses – may be reason for woman to seek medical treatment–Excess Na+ & H2O retention→ extracellular fluid volume– Excess potassium excretion may → loss of H → metabolic alkalosis–Excess catacholemines (from medullary pheochromocytoma) → elevated signs of fight or flight
diagnostics and treatment for adrenal cortical excess (Cushing Disease)
•Diagnostics:–Dexamethazone suppression test = administration dexamethazone @ midnight/ cortisol levels drawn at 0800•Suppression of cortisol = normally functioning pituitary & adrenals•Elevated cortisol levels → need for further etiological testing•Treatment:– Surgical removal, irradiation, pharmacological treatment of symptoms
the nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (addison’s) which clinical manifestations should the nurse expect to assess?
bronze pigmentation hypotension and anorexia
The nurse is developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (aids) who has developed an infection in the adrenal gland. Which client problem is highest priority ?altered body imageactivity intoleranceimpaired copingfluid volume deficit
fluid volume deficit
the nurse is planning the care of a client diagnosed with Addison’s . which intervention should be included ?
administer steroid medications
The client is admitted to rule out cushing’s syndrome. Which laboratory tests should the nurse anticipate being ordered?
plasma levels of ACTH and cortisol
The client has developed iatrogenic cushing’s disease. Which statement is the scientific rationale for the development of this diagnosis.the client has an autoimmune problem causing the destruction of the adrenal cortexthe client has been taking steroid medications for an extended period for another disease processthe client has a pituitary gland tumor causing the adrenal glands to produce to much cortisolthe client has developed an adrenal gland problem for which the healthy care provider does not have an explanation
The client has been taking steroid medications for an extended period for another disease process
The nurse is performing discharge teaching for a client diagnosed with cushing’s disease. which statement by the client demonstrates an understanding of the instructionsI will be sure to notify my health care provider if i start to run a feverbefore I stop taking the prednisone, I will be taught how to taper it offIf i get weak and shaky, I need to eat some hard candy or drink some juiceIt is fine if I continue to participate in weekend games of tackle football
I will be sure to notify my health care provider if i start to run a fever
The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse ?The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedationThe client diagnosed with lung cancer and iatrogenic cushing’s disease with ABGs of PH 7.35 PaO2 88, Paco2 44, and HCo322The client diagnosed with Addison’s disease who is lethargic and has a BP of 80/45, P 124 and R28The client diagnosed with hyperthyroidism who has undergone a thyroidectomy two days ago and has a negative trousseau’s sign
The client diagnosed with Addison’s disease who is lethargic and has a BP of 80/45, P 124 and R28
The nurse writes a problem of “altered body image” for a 34 year old client diagnosed with Cushing’s disease. Which intervention should be implemented
Use therapeutic communication to allow the client to discuss feelings
The client diagnosed with Addison’s disease is admitted to the ER after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement.
Start an IV with an 18 gauge needle and infuse NS rapidly
The nurse manager of a medical surgical unit is asked to determine if the unit should adopt a new care delivery system. Which behavior is an example of an autocratic style of leadership?call a meeting and educate the staff on the new delivery system being used. organize a committee to investigate the various types of delivery systemswait until another unit has implemented the new system and see if it works outdiscuss with the nursing staff if a new delivery system should be adopted
call a meeting and educate the staff on the new delivery system being used.
The client diagnosed with cushing’s disease has undergone a unilateral adrenalectomy. Which discharge instructions should the nurse discuss with the client?Call a meeting and educate the staff on the new delivery system being usedorganize a committee to investigate the various types of delivery systemswait until another unit has implemented the new system and see if it works outdiscuss with the nursing staff if a new delivery system should be adopted.
wait until another unit has implemented the new system and see if it works out
The client diagnosed with a pituitary timor developed syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should the nurse implement?
assess for N/V and weigh daily
The nurse is admitting a client to the neurological intensive care unit who is postoperative transsphenoidal hypophysectomy. which data warrant immediate intervention?The client is alert to name but is unable to tell the nurse the locationthe client has an output of 2500 ml since surgery and an intake of 1,000 mlthe clients vital signs are 97.6,88,20,130/80The client has a 3 cm amount of dark red drainage on the turban dressing
the client has an output of 2500 ml since surgery and an intake of 1,000 ml
which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus
serum sodium
the nurse i discharging a client diagnosed with diabetes insipid us. which statement made by the client warrants further interventioni will keep a list of my medications in my wallet and wear a medic alert braceleti should take my medication in the morning and leave it refrigerated at homei should weigh myself every morning and record any weight gainIf I develop a tightness in my chest, I will call my health care provider
i should take my medication in the morning and leave it refrigerated at home
the client is admitted to the medical unit with a diagnosis of rule out diabetes insipidus. Which instructions should the nurse teach regarding a fluid deprivation test?
The client will be NPO and vital signs and weights will be done hourly until the end of the test
The nurse is caring for clients on a medical floor . Which client should be assessed first.the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who has a weight gain of 1.5 pounds since yesterdaythe client diagnosed with a pituitary timor who has developed diabetes insipid us and has an intake of 1500 and an output of 1600 in the last 8 hrs.The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitchingthe client diagnosed with diabetes insipid us who is complaining of feeling tired after having to get up at night
The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching
The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that applyRestrict fluids per health care provider orderassess level of consciousness every 2 hoursprovide an atmosphere of stimulationmonitor urine and serum osmolalityweigh the client every 3 days
Restrict fluids per health care provider orderassess level of consciousness every 2 hoursmonitor urine and serum osmolality
The nurse is caring for a client diagnosed with Diabetes insipid us. Which intervention should be implemented
assess tissue turgor every four hours
The UAP complains to the nurse she has filled the water pitcher four times during the shift for a client diagnosed with a closed head injury and the client has asked for the pitcher to be filled again. Which intervention should the nurse implement first
assess the client for polyuria and polydipsia
The nurse is admitting a client diagnosed with syndrome of inappropriate antidiurectic hormone (SIADH). Which clinical manifestations should be reported to the health care provider Serum sodium of 112 and a headacheserum potassium of 5.0 and a heightened awarenessserum calcium of 10 and tented tissue turgorserum magnesium of 1.2 and large urinary output
Serum sodium of 112 and a headache
The male client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to cancer of the lung tells the nurse he wants to discontinue the fluid restriction and does not care if he dies. Which action by the nurse is an example of the ethical principle of autonomy
notify the health care provider of the clients wishes and give the client fluids as desired
The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit?
complaints of extreme fatigue and hair loss
The nurse identifies the client problem risk for imbalanced body temperature for the client diagnosed with hypothyroidism. Which intervention should be included in the plan of care
discourage the use of an electric blanket
the client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (synthroid) which assessment data indicate the medication has been effective
the clients temperature is WNL
Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism
provide 6 small well balanced meals a day
The client is admitted to the ICU diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse serum glucose of 74pulse ox reading of 90%telemetry reading showing sinus bradycardiathe client is lethargic and sleeps all the time
pulse ox reading of 90%
Which medication order should the nurse question in the client diagnosed with untreated hypothyroidism
sedatives
which statement made by the client makes the nurse suspect the client is experiencing hyperthyroidismi just don’t seem to have any appetite anymorei have a bowel movement about every 3-4 daysmy skin is really becoming dry and coursei have noticed all my collars are getting tighter
i have noticed all my collars are getting tighter
The 68 year old client diagnosed with hyperthyroidism is being treated with radioactive iodine therapy. Which interventions should the nurse discuss with the client
explain it will take up to a month for symptoms of hyperthyroidism to subside
The nurse is teaching the client diagnosed with hyperthyroidism. Which information should be taught to the client? Select all that applyNotify the HCP if a 3 lb weight loss occurs in 2 daysdiscuss ways to cope with the emotional labilitynotify the HCP if taking over the counter medscarry a medical identification card or braceletteach how to take thyroid medications correctly
Notify the HCP if a 3 lb weight loss occurs in 2 daysdiscuss ways to cope with the emotional labilitynotify the HCP if taking over the counter medscarry a medical identification card or bracelet
The nurse is providing an in service on thyroid disorders. Once of the attendees asks the nurse why don’t the people in the united states get goiters as often? Which statement by the nurse is the best responseit is because of the screening techniques used in the USit is a genetic predisposition rare in the North AmericansThe medications available in the US decrease goitersIodized salt helps prevent the development of goiters in the US
Iodized salt helps prevent the development of goiters in the US
The nurse is preparing to administer the following medications. Which med should the nurse question administering
the loop diuretic to the client with a potassium level of 3.3
Which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm
hyperpyrexia and extreme tachycardia
Problems in the hypothalamus that change the function of the anterior pituitary land result in which condition
secondary pituitary dysfunction
Which are hormones produced and secreted by the anterior pituitary gland (select all that apply)Growth Hormone ProlactinThyrotropin (TSH)serotoninGonadotropins (FSH and LH)epinephrine
Growth Hormone ProlactinThyrotropin (TSH)Gonadotropins (FSH and LH)
a malfunctioning posterior pituitary gland can result in which disorders (select all that apply)hypothyroidismaltered sexual functionDiabetes insipidusgrowth retardationsyndrome of inappropriate antidiuretic hormone (SIADH)
Diabetes insipidussyndrome of inappropriate antidiuretic hormone (SIADH)
a malfunctioning anterior pituitary gland can result in which disorders (select all that apply)pituitary hypo functionpituitary hyper functiondiabetes insipidushypothyroidismosteoporosis
pituitary hypo functionpituitary hyper functionhypothyroidismosteoporosis
The assessment findings of a male patient with anterior pituitary tumor include reports of changes in secondary sex characteristics such as episodes of impotence and decreased libido. The nurse explains to the patient that these findings are a result of overproduction of which hormone
PRL inhibiting secretion of gonadotropins
a patient with PRL secreting tumor is likely to be treated with which medication
dopamine agonists
a patient is prescribed bromocriptine mesylate (parlodel). which information does the nurse teach the patient (select all that apply) get up slowly from a lying positiontake medication on an empty stomachtake daily for purposes of raising GH levels to reduce symptom of acromegalybegin therapy with a maintenance level dosereport watery nasal discharge to the health care provider immediately
get up slowly from a lying positionreport watery nasal discharge to the health care provider immediately
Patients diagnosed with an anterior pituitary tumor can have symptoms of acromegaly or gigantism. These symptoms are a result of overproduction of which hormone
GH
The nurse is performing an assessment of an adult patient with new onset acromegaly. What does the nurse expect to find
thickened lips
When analyzing laboratory values, the nurse expects to find which value as a direct result of overproduction of GH
hyperglycemia
In caring for a patient with hyperpituitarism, which symptoms does the nurse expect the patient to report (select all that apply) joint painvisual disturbanceschanges in menstruationdecreased libidoheadache
joint painvisual disturbanceschanges in menstruationdecreased libidoheadache
a deficiency of which anterior pituitary hormones is considered life threatening (select all that apply)GHmelanocyte stimulating hormone (MSH)PRLTSHACTH
TSHACTH
Which statements about the etiology of hypopituitarism are correct? (select all that apply)dysfunction can result from radiation treatment to the head or braindysfunction can result from infection or a brain tumorinfarction following systemic shock can result in hypopituitarismsevere malnutrition and body fat depletion can depress pituitary gland functionThere is always an underlying cause of hypopituitarism
dysfunction can result from radiation treatment to the head or braindysfunction can result from infection or a brain tumorinfarction following systemic shock can result in hypopituitarismsevere malnutrition and body fat depletion can depress pituitary gland function
which statement about hormone replacement therapy for hypopituitarism is correct.
testosterone replacement therapy is contraindicated in men with prostate cancer
a femal patient has been prescribed hormone replacement therapy. What does the nurse instruct the patient to do regarding this therapy
take measures to reduce risk for hypertension and thrombosis
A patient requires 100 g. of oral glucose for suppression testing and GH levels are measured serially for 120 minutes. The results of the suppression testing are abnormal. The nurse assesses for the signs and symptoms of which endocrine disorder
hyperpituitarism
a patioent is recovering from a transsphenoidal hypophysectomy. What postoperative nursing interventions apply to this patient (select all that apply)vigorous coughing and deep breathing exercisesinstruction on the use of a soft bristled toothbrush for brushing the teethstrict monitoring of fluid balancehourly neurologic checks for first 24 hoursinstructing the patient to alert the nurse regarding postnasal drip
strict monitoring of fluid balancehourly neurologic checks for first 24 hoursinstructing the patient to alert the nurse regarding postnasal drip
Following a hupophysectomy the patient requires instruction on hormone replacement for which hormones (select all that apply)cortisolthyroidgonadalvasopressinPRL
cortisolthyroidgonadalvasopressin
After a hypophysectomy, home care monitoring by the nurse includes assessing which factors (select all that apply)hypoglycemiabowel habitspossible leakage of csf24 hour intake of fluids and urine output24 hour diet recallactivity level
bowel habitspossible leakage of csf24 hour intake of fluids and urine output24 hour diet recallactivity level
Postoperative care for a patient who has had a transsphenoidal hypophysectomy includes which intervention
testing nasal drainage for glucose to determine whether it contains CSF
While caring for a post op patient following a transphenoidal hypophysectomy, the nurse observes nasal drainage that is clear with yellow color at the edge. This halo sign is indicative of which condition
drainage of CSF from the patients nose
A patient with hpophysectomy can post op experience transient diabetes insipidus Which manifestation alerts the nurse to this problem
output much greater than intake
The action of ADH influences normal kidney function by stimulating which mechanism
distal nephron tubules ad collecting ducts to reabsorb water
What is the disorder that results from a deficiency of vasopressin (ADH) from the posterior pituitary gland called
diabetes insipidus
Which statements about diabetes insipid us are accurate (select all that apply)it is caused by ADH deficiencyIt is characterized by a decrease in urinationUrine output of greater that 4 L/24 hours is the first diagnostic indication the water loss increases plasma osmolaritynephrogenic DI can be caused by lithium (eskalith)
It is caused by ADH deficiencyUrine output of greater that 4 L/24 hours is the first diagnostic indication the water loss increases plasma osmolarity
What does the nurse instruct patients with permanent DI to do (select all that apply)continue vasopressin therapy until symptoms disappearmonitor for recurrence of polydipsia and polyuriamonitor and record weight dailycheck urine specific gravity three times a weekwear a medical alert bracelet
monitor for recurrence of polydipsia and polyuriamonitor and record weight dailywear a medical alert bracelet
A patient uses desmopressin acetate metered dose spray as a replacement hormone for ADH. Which is an indication for another dose ( select all that apply) excessive urinationspecific gravity of 1.003dark concentrated urineedema in the legsdecreased urination
excessive urinationspecific gravity of 1.003
The nurse is caring for a patient with DI. What is the priority goal of collaborative care
correct the water metabolism problem
Which medications are used to treat DI (select all that apply)chlorpropamide (diabinese)desmopressin acetate (DDAVP) lithium (Eskalith)Vasopressin (Pitressin)Demeclocycline (declomycin)
chlorpropamide (diabinese)desmopressin acetate (DDAVP) Vasopressin (Pitressin)
Which patients history puts him or her at risk for developing SIADH?
58 year old with metastatic lung or breast cancer
which statement about the pathophysiology of SIADH is correct
water retention results in dilution hyponatremia and expanded extracellular fluid (ECF) volume
Which statement about the etiology and incidence of SIADH is correct
demeclocycline may be used to treat SIADH
The effect of increased ADH in the blood results in which effect on the kidney
tubular reabsorption of water increases
In SIADH as a result of water retention from excess ADH which laboratory value does the nurse expect to find (select all that apply)increased urine osmolality (increased sodium in urine)elevated serum sodium levelincreased specific gravity ( concentrated urine)decreased serum osmolaritydecreased urine specific gravity
increased urine osmolality (increased sodium in urine)increased specific gravity ( concentrated urine)decreased serum osmolarity
Which nursing intervention is the priority for a patient with SIADH
restrict fluid intake
Which type of IV fluid does the nurse use to treat a patient with SIADH when the serum sodium level is very low
3% normal saline
In addition to IV fluids a patient with SIADH is on a fluid restriction as low as 500 to 600 /24 hours. Indicate the serum and urine results that demonstrate effectiveness of this treatment by writing increases or decreases for each item belowurine specific gravity resultsserum sodium resultsurine output
urine specific gravity results (dec)serum sodium results (inc.)urine output (inc.)
which medications are used in SIADH to promote water excretion without causing sodium loss (select all that apply)Tolvaptan (samsca)demeclocycline (declomycin)furosemide (lasix)conivaptan (vaprisol)spironolactone (aldactone)
Tolvaptan (samsca)conivaptan (vaprisol)
Which statement about pheochromocytoma is correct
it is a catecholamine producing tumor
A patient in the emergency department is diagnosed with possible pheochromocytoma. What is the priority nursing intervention for this patient
monitor blood pressure for severe hypertension
the nurse expects to perform which diagnostic test for pheochromocytoma
24 hour urine collection for vanillylmandelic acid (VMA)
Which intervention applies to a patine with pheochromocytoma
instruct not to smoke or drink coffee
which intervention is contraindicated for a patient with pheochromocytoma
palpating the abdomen
which diuretic is ordered by the health care provider to treat hyperaldosteronism
spironolactone ( aldactone)
which statement about hyperaldosteronism is correct
hypokalemia and hypertension are the main issues
when diagnosed with cushing syndrome the manifestations are most likely related to an excess production of which hormone
cortisol from the adrenal cortex
what is the most common cause of endogenous hypercortisolism or cushing syndrome
hyperplasia of the adrenal cortex
Which are the physical findings of cushing’s syndrome? (select all that apply)moon faced appearancedecreased amount of body hairbarrel chesttruncal obesitycoarse facial featuresthin easily damaged skinexcessive sweatingextremity muscle wasting
moon faced appearancetruncal obesitythin easily damaged skinextremity muscle wasting
When assessing a patient with cushing’s syndrome, what does the nurse expect to find
hypertension
which lab findings does the nurse expect to find with cushing’s syndrome (select all that apply)decreased serum sodiumincreased serum glucoseincreased serum sodiumincreased serum potassiumdecreased serum potassium
increased serum glucoseincreased serum sodiumdecreased serum potassium
the nurse determines a priority patient problem of altered self concept in a female patient with cushion’s syndrome who expresses concern about the changes in her general appearance. What is the expected outcome for this patient
to verbalize an understanding that treatment will reverse many of the problems
Mitotane (lysodren)
adrenal vytotoxic agent used for inoperable adrenal tumors
aminoglutethimide (cytadren)
adrenal enzyme inhibitor that decreases cortisol production
cyproheptadine (periactin)
interferes with ACTH production
a patient is scheduled for bilateral adrenalectomy. Before surgery, steroids are to be given. Which is the reasoning behind the administration of this drug
to compensate for sudden lack of adrenal hormones following surgery
The nurse is teaching a patient being discharged after bilateral adrenalectomy. What medication information does the nurse emphasize in the teaching plan
the patient should learn how to give himself an intramuscular injection of hydrocortisone
which statement about a patient with hyperaldosteronism after a successful unilateral adrenalectomy is correct
glucocorticoid replacement therapy is temporary
which are causes for decreased production of adrenocortical steroids (select all that apply) inadequate secretion of ACTHDysfunction of hypothalamic pituitary control mechanismadrenal gland dysfuctioncancerAIDS
inadequate secretion of ACTHDysfunction of hypothalamic pituitary control mechanismadrenal gland dysfuctioncancerAIDS
which patient is at risk for developing secondary adrenal insufficiency
patient who suddenly stops taking high dose steroid therapy
An ACTH stimulation test is the most definitive test for which disorder
adrenal insufficiency
which interventions are necessary for a patient with acute adrenal insufficiency ( addisonian crisis) (select all that apply)IV infusion of normal salineIV infusion of 3% salinehourly glucose monitoringinsulin administrationIV potassium therapy
IV infusion of normal salinehourly glucose monitoringinsulin administration
a patient in the ER who reports lethargy, muscle weakness, nausea, vomiting , and weight loss over the past weeks is diagnosed with addisonian crisis (acute adrenal insufficiency) which drugs does the nurse expect to administer to this patient
solu-coref IV along with IM injections of hydrocortisone
The nurse determines that the administration of hydrocortisone for Addisonian crisis is effective when which assessment is made
lethargy improving; patient alert and oriented
which nursing intervention is a preventive measure for adrenocortical insufficiency
reducing high dose glucocorticoid doses gradually
The nurse should instruct a patient who is taking hydrocortisone to report which symptoms to the health care provider for possible dose adjustment (select all that apply)rapid weight gainround facefluid retentionGI irritationUrinary incontinence
rapid weight gainround facefluid retention
The nurse determines that the patient in acute adrenal insufficiency is responding favorably to treatment when
the patient appears alert and oriented
when assessing a patient who is returned to the surgical unit following a thyroidectomy. the nurse would be most concerned if the patient
makes harsh, vibratory sounds when she breathes
an IV hydrocortisone treatment is started for a patient being taken to surgery for a bilateral adrenalectomy. The nurse explains to the patient that this is done to
provide substances to respond to stress after removal of the adrenal glands
a priority nursing intervention for a patient with primary adrenal cortex dysfunction would be to
monitor vital signs and the patients physiologic response to stress
signs and symptoms of hyperthyroidism
weight loss with increased appetiteincreased HR, palpitationsphotophobiamanic behaviordyspnea with or without exertioninsomniaincreased stoolscorneal ulcersirritabilityfine, soft, silky, body hairincreased libidoheat intolerance, warm skindiaphoresistremors
signs and symptoms of hypothyroidism
constipationdecreased libidocold intolerancefatigue, increased sleepingimpaired memoryfacial puffinessweight gaindry, coarse, brittle hair
which assessment finding should trigger a more detailed assessment of the patients endocrine system
changes in hair texture and distribution
which is a possible outcome for a patient experiencing an age related decrease in antidiurectic hormone
diluted urine and dehydration
a patient diagnosed with small cell lung cancer might present with endocrine symptoms consistent with
syndrome of inappropriate antidiurectic hormone (SIADH)
what is a priority question to ask a patient with a hypopituitary tumor
have you noticed a change in your libidohave you experienced a change in growth with your facial hair have you had an unexpected weight loss
which patient with cushing’s disease is at greatest risk for developing heart failure
42 year old with a serum creatinine level of 3.7 mg/dl
which factor is a hallmark assessment finding that signifies hyperthyroidism
heat intolerance
which factor is a main assessment finding that signifies hypothyroidism
cold intolerance
which sign/symptom is one of the first indicators of hyperthyroidism that is often noticed by the patient
vision changes or tiring of the eyes
which laboratory result is consistent with a diagnosis of hyperthyroidism
increased serum T3 and T4
the lab results for a 53 year old patient indicate a low T3 level and elevated TSH. What do these results indicate
hypothyroidism
the clinical manifestations of hyperthyroidism are known as which condition
thyrotoxiocosis
what is the most common cause of hyperthyroidism
grave’s disease
the nurse assessing a patient palpates enlargement of the thyroid gland, along with noticeable swelling of the neck. How does the nurse interpret the finding
Goiter
The nurse is assessing a patient diagnosed with hyperthyroidism and observes dry, waxy swelling of the front surfaces of the lower legs. How does the nurse interpret this finding
pretibial myxedema
which statement best describes globe lag in a patient with hyperthyroidism
upper eyelid pulls back faster than the eyeball when the patient gazes upward
the nurse is assessing a patient with graves disease and observes an abnormal protrusion of both eyeballs. how does the nurse document this assessment finding
exophthalmos
which statements about hyperthyroidism are accurate (select all that apply)it is most commonly caused by Grave’s diseaseit can be caused by overuse of thyroid replacement medicationit occurs more often in men between the ages of 20-40weight gain is a common manifestationserum T3 and T4 results will be elevated
it is most commonly caused by Grave’s diseaseit can be caused by overuse of thyroid replacement medicationserum T3 and T4 results will be elevated
the nurse is providing instructions to a patient taking levothyroixine (synthroid). When does the nurse tell the patient to take this medication
on an empty stomach
the nurse is providing instructions to a patient who is taking the antithyroid med propylthiouracil (PTU). The nurse instructs the patient to notify the health care provider immediately if which s/s occurs
dark colored urine
a patent who has been diagnosed with Graves disease is going to receive radioactive iodine (RAI) in the oral for of 131I. What does the nurse teach the patient about how this drug works
it destroys the tissue that produces thyroid hormones
A patient who has been diagnosed with Graves disease is to receive radioactive iodine (RAI) in the oral form of 131 I as treatment. What instructions does the nurse include in the teaching plan about preventing radiation exposure to others (select all that apply)do not share a toilet with others for 2 week after treatmentflush the toilet threw times after each usewash clothing separately from others in the householdlimit contact with pregnant women infants and childrendo not use a laxative within 2 weeks of having the treatment
do not share a toilet with others for 2 week after treatmentflush the toilet threw times after each usewash clothing separately from others in the householdlimit contact with pregnant women infants and children
which statements about hyperthyroidism are accurate (select all that apply)it occurs more often in womenit can be caused by iodine deficiencyweight loss is a common manifestationit can be caused by autoimmune thyroid destructionmyxedema coma is a rare but serious complication
it occurs more often in womenit can be caused by iodine deficiencyit can be caused by autoimmune thyroid destructionmyxedema coma is a rare but serious complication
the nurse is assessing a patient with a diagnosis of hashimoto’s disease. what are the primary manifestations of this disease (select all that apply)dysphagiapainless enlargement of the thyroid glandpainful enlargement of the thyroid glandweight lossintolerance to heat
dysphagiapainless enlargement of the thyroid gland
lab findings of elevated T3 and T4 decrease TSH and high thyrotropin receptor antibody titer indicate which condition
graves disease
uncommon; usually occurs with large follicular carcinomas
thyroid carcinoma
T3 and T4 secretion increased before destruction of gland. hyperthyroid state usually transient
thyroiditis (radiation induced)
autoimmune disease antibodies bind to TSH receptors and rep them activated increasing the size of the gland and increasing the production of thyroid hormones
graves disease
multiple thyroid nodules resulting in thryoid hyperfunction
toxic multinodular goiter
pituitary adenoma resulting in excessive TSH secretion
pituitary hyperthyroidism
after a visit to the heath care providers office a patient is diagnosed with general thyroid enlargement and elevated thyroid hormone level. This is an indication of which condition
hyperthyroidism and goiter
which condition is a life threatening emergency and serious complication of untreated or poorly treated hypothyroidism
myxedema com
a patient with exophthalmose from hyperthyroidism reports dry eyes especially in the morning. The nurse teaches the patient to perform which intervention to help correct this problem
tape the eyes closed with nonallergenic tape
which factors are considered to be triggers for thyroid storm (select all that apply)infectioncold tempsvigorous palpation of a goiterpregnancyextremely warm temps
infectionvigorous palpation of a goiterpregnancy
a patient has the following assessment findings; elevated TSH level , low T3 and T4 level difficulty with memory, lethargy, and muscle stiffness. These are clinical manifestations of which disorder
hypothyroidism
a patient has been prescribed thyroid hormone for treatment of hypothyroidism . Within what time frame does the patient expect improvement in mental awareness with this treatment
2 weeks
which signs and symptoms are assessment findings indicative of thyroid storm (select all that apply)abdominal pain and nauseahypothermiafevertachycardiaelevated systolic blood pressure bradycardia
abdominal pain and nauseafevertachycardiaelevated systolic blood pressure
management of the patient with hyperthyroidism focuses on which goals (select all that apply)blocking the effects of excessive thyroid secretiontreating the s/s the patient experiencesestablishing euthyroid functionpreventing spread of the diseasemaintaining an environment of reduced stimulation
blocking the effects of excessive thyroid secretiontreating the s/s the patient experiencesestablishing euthyroid functionmaintaining an environment of reduced stimulation
which are preoperative instructions for a patient having thyroid surgery (select all that apply)teach postop restrictions such as no coughing and deep breathing exercises to prevent strain on the suture lineteach the moving and turning technique of manually supporting the head and avoiding neck extension to minimize strain on the suture lineinform the patient that hoarseness for a few days after surgery is usually the result of a breathing tube used during surgeryhumidification of air may be helpful to promote expectoration of secretions. suctioning may also be usedclarify any questions regarding placement of incision complications and post op carea supine position and lying flat will be maintained post op to avoid strain on the suture lineteach the patient to report immediately any respiratory difficulty tingling around the lips or fingers, or muscular twitchinga drain may be present in the incision. all drainage and dressings will be monitored closely for 24 hours
teach the moving and turning technique of manually supporting the head and avoiding neck extension to minimize strain on the suture lineinform the patient that hoarseness for a few days after surgery is usually the result of a breathing tube used during surgeryhumidification of air may be helpful to promote expectoration of secretions. suctioning may also be usedclarify any questions regarding placement of incision complications and post op careteach the patient to report immediately any respiratory difficulty tingling around the lips or fingers, or muscular twitchinga drain may be present in the incision. all drainage and dressings will be monitored closely for 24 hours
the nurse is preparing for a patient to return from thyroid surgery. What priority equipment does the nurse ensure immediately available? (select all that apply)tracheostomy equipmentcalcium gluconate or calcium chloride for IV administrationhumidified oxygensuction equipmentsandbags
tracheostomy equipmentcalcium gluconate or calcium chloride for IV administrationhumidified oxygensuction equipmentsandbags
after a thyroidectomy, a patient reports tingling around the mouth and muscle twitching. Which complication do these assessment findings indicate to the nurse
hypocalcemia
the nurse assesses a patient post thyroidectomy for laryngeal nerve damage. which findings indicate this complication (select all that apply)dyspneasore throathoarsenessweak voicedry cough
hoarsenessweak voice
after hospitalization for myxedema a patient is prescribed thyroid replacement medication. which statement by the patient demonstrates a caret understanding of this therapy?
Ill be taking thyroid medication for the rest of my life
which statements about thyroiditis are accurate (select all that apply)it is an inflammation of the thyroid glandHashimoto’s disease is the most common typeit always resolves with antibiotic therapythere are three types: acute, subacute, and chronicthe patient must take thyroid hormones
it is an inflammation of the thyroid glandHashimoto’s disease is the most common typethere are three types: acute, subacute, and chronicthe patient must take thyroid hormones
which statements about acute thyroiditis are accurate (select all that apply)it is caused by a bacterial infection of the thyroid glandit is treated with antibiotic therapyit results from a viral infection of the thyroid glandsubtotal thyroidectomy is a form of treatment manifestations include neck tenderness fever and dysphagia
it is caused by a bacterial infection of the thyroid glandit is treated with antibiotic therapymanifestations include neck tenderness fever and dysphagia
serum calcium levels are maintained by which hormone
parathryroid hormone (PTH)
PTH production
raises calcium levels
calcitonin production
lowers calcium levels
Bone changes in the older adult are often seen with endocrine dysfunction and increased secretion of which substance
PTH
In addition to regulation of calcium levels PTH and calcitonin regulate the circulating blood levels of which substance
phosphate
a patient has a positive Trousseau’s or Chvosteks sign resulting from Hypoparathyroidism. What condition does this assessment finding indicate
hypophosphatemia
which food does the nurse instruct a patient with hypoparathyroidism to avoid
fresh fruit
a patient with continuous spasms of the muscles is diagnosed with hypoparathyroidism . The muscle spasms are a clinical manifestation of which condition
tetany
causes of hypoparathyroidism
removal of the thyroid gland parathyroidectomy
causes of hyperparathyroidism
chronic kidney diseasevitamin D deficiencyneck traumacarcinoma of the lung kidney or GI tract producing PTH like substance
a patient has hyperparathyroidism and high levels of serum calcium. Which initial treatment does the nurse prepare to administer to the patient
force fluids (intravenous or oral) and administer lasix
which are assessment findings of hypocalcemia (select all that apply)numbness and tingling around the mouthmuscle crampingmental status changes including irritability fever tachycardia
numbness and tingling around the mouthmuscle crampingmental status changes including irritability
which medication therapies does the nurse expect patient with hypoparathyroidism to receive (select all that apply)calcium chloridecalcium gluconatecalcitrolmagnesium sulfateergocalciferol
calcium chloridecalcium gluconatecalcitrolmagnesium sulfateergocalciferol
discharge planning for a patient with chronic hypoparathyroidism include which instructions (select all that apply)prescribed medications must be taken for the patient’s entire lifeeat foods low in vitamin D and high inphophoruseat foods high in calcium but low in phosphorusafter several weeks, medications can be discontinuedkidney stones are no longer a risk to the patient
prescribed medications must be taken for the patient’s entire lifeeat foods high in calcium but low in phosphorus
in older adults assessment findings of fatigue altered thought processes, dry skin and constipation are often mistaken for signs of aging rather than assessment findings for which endocrine disorder
hypothyroidism
which conditions may precipitate myexedema coma (select all that apply)rapid withdrawal of thyroid medicationvitamin D deficiencyuntreated hypothyroidismsurgeryexcessive exosure to iodine
rapid withdrawal of thyroid medicationuntreated hypothyroidismsurgery
