Final Exam Flashcards
generalized osteoporosis
primary
secondary
- a bit longer and more complex
- multiple structures
- causes: anemic states, drugs (steroids/heparin), dietary deficiency (scurvy, malnutrition, calcium
- both primary and secondary fall under this.Primary occurs in postmenopausal woman and in **70-80 year old men. Secondary results from past medical conditions. Prolonged mobility from spinal cord damage
- ***long term corticosteroid use
regional osteoporosis
- *Also caused localized
- *Affects 1 bone or area
- *Traumatic fracture
- Characterized by arthralgia which migrates between the weight bearing joints of the lower limbs
- Causes: immobilization and disuse, reflex sympathetic dystrophy syndrome, transient regional osteoporosis (transient regional osteoporosis of the hip, regional migratory osteoporosis
- ***Decreased mobility for longer than 8-12 weeks can result from this type
modifiable risk factors for osteoporosis
smoking
-more than 2 - 3 drinks alcohol
little to no exercise
High volume intake of carbonated drinks
nonmodifiable risk factors
gender small framed/thin menopause **Protein deficiency **estrogen **Chronic low calcium or vitamin d
diagnostic test for osteporosis
- Doctor will order bone density scan - measures bone mineral density
- BMD assessment by a DXA (dual energy xray absorptiometry) - measures bone mineral density
- Ct- can measure volume of bone density and strength of vertebral spine
pharmacological management for osteomyeltis
4-6 weeks antimicrobical therapy more than 1 prescribed given at specific intervals to maintain therapeutic serum levels zoysn central line
non pharm management for osteomyelitis and stump
mrsa precautions
stump elevation
line prone for 15 mins four times a day
hypobaric oxygen therapy
E.B. asks you “What do they do with my leg after it is removed?” How do you respond?
It’s your choice on what you wish to happen after it is amputated. Some cultures decide to have the amputation stored for later burial or buried immediately. Other times, it can be donated for scientific research, or sent to biohazardous waste and is cremated.
Culturally component nursing care
interventions for healing a stump
- Promote mobility as tolerated
- Assess for adequate tissue perfusion and hemorrhaging (pinkish color, warm but not hot)
- Vital signs, specifically pulses near the amputation site
- Monitor and treat pain
- Assess psychosocial needs (body image issues)
- Maintaining a healthy diet
- Exercise
phantom limb pain
Phantom limb pain, although the limb is gone the nerve endings at the site of the amputation continue to send pain signals to the brain that make the brain think the limb is still there. Finding a treatment to relieve phantom pain can be difficult. Doctors usually begin with medications such as over-the-counter pain relievers, antidepressants, anticonvulsants, narcotics, NMDA receptor antagonists. Doctors may then add noninvasive medical therapies such as mirror box, acupuncture, repetitive transcranial magnetic stimulation, spinal cord stimulation. Surgery may be an option if other treatments haven’t helped, the only surgical option is brain stimulation.
four major complications of acute fractures
infection
acute compartment syndrome
vte
fat embolism
infections cm fracture
fever, high WBC, chills and sweats, SOB, inflammation, swelling
acute compartment syndrome
pain due to reduced perfusion: pain severe despite being medicated, which causes further ischemia. Sensory perception deficits and paraesthesia. Pale color due to low perfusion and weak pulses. Cyanosis, tingling, and numbing can occur if not treated.
vte cm fracture
SOB, rapid breathing, chest pain upper rib cage, heart rate increases, leg pain or tenderness of the leg or calf, edema to the LE
fat embolism cm fracture
Dyspnea, increased RR, decreased o2 sat, tachycardia, confusion, chest pain
delayed union
Fracture takes longer than usual to heal (longer than 6 months)
nonunion
things to help
Fracture that never heals
- Electric bone stimulation and bone grafting can treat
- Low intensity pulsed ultrasound can promote healing to treat
- Can occur more frequently in older adults due to impaired healing process
- Can cause immobilizing deformity of the bone involved
malunion
Fracture heals incorrectly
Can cause immobilizing deformity of the bone involved
nonpharmacological interventions osteoarthritis
**Rest
**Balanced rest with exercises
Elevation ( only small pillows) slightly bent if not created flexion contractures
Diet
**Loose weight
**Brace (assistive devices)
**Thermal modalities and or ice ( whichever provides more relief)
**Keep extremity in function/ dependent positon
- cyrotherapy
exercise plan osteoarthritis
- Start with short walks (aerobic), then make the walks longer distances or a quicker pace. Pay close attention to how the joint feels and what level of pain they are experiencing.
- National guidelines recommend 150 minutes per week (spaced out) of moderate intensity physical activity, plus 2 strength training sessions/ week. Examples include: brisk walking, slow biking, general gardening, and ballroom dancing
pain meds for osteoarthitis
tylenol, lidocaine, tramadol, glucosamine with chondroitin
rheumatoid factor clinical significance
Rheumatoid factor: measures the presence of unusual antibodies of the immunoglobulins G (IgG) and M (IgM) types that develop in a number of connective tissue diseases: many patients have an RA have a positive titer
antinuclear antibody clinical significance (RA)
- measures the titer of a group of antibodies that destroy the nuclei of cells and cause tissue death in patients with autoimmune disease.
- If this test result is positive (a value higher than 1:40), various subtypes of this antibody are identified and measured.
invasive diagnostic of ra
arthrocentesis
- invasive diagnostic procedure that may be used for patients with joint swelling caused by excess synovial fluid (effusion). Done as a diagnostic procedure. Can be done as a treatment modality
- The provider inserts a large-gauge needle into the joint (usually the knee) to aspirate a sample of synovial fluid and to relieve pressure caused by excess fluid. The fluid is analyzed for inflammatory cells and immune complexes, including RF. Fluid from patients with RA typically reveals increased WBCs, cloudiness, and volume.
- Patient nursing considerations are to teach the patient to use ice and rest the affected joint for 24 hours after arthrocentesis. Often the primary health care provider will recommend acetaminophen as needed for discomfort.
bucks traction
Buck’s traction is meant to keep the leg in an extended position by means of a longitudinal skin traction applied in one direction with a single pulley. This system is meant to help with fractures, realigns bones, helps correct contractures or deformities and is meant to immobilize the knee
bucks traction nursing considerations
- ensure that the weight bag is hanging freely, to not have the bag rest on the floor, if the rope becomes frayed, it must be replaced, the nurse should ensure that the rope is on the pulley track, and the nurse should make sure the bandages are free from wrinkles.
- Pulling force, pulls bones apart, decrease inflammation and destruction because bones are not being rubbed against
- (Buck) traction may be applied before surgery to help decrease pain associated with muscle spasm.
- Don’t remove weights until surgery or physician order
early s/s of ra
Joint inflammation Systemic low-grade fever Fatigue Weakness Anorexia paresthesias
complications of infusion therapy
- local
- systemic
- cvc dwell
local complications (infusion therapy)
- occur near catheter site
systemic complications infusion therapy
- involve entire vascular system
- may affect multiple systems
cvc dwell complications infusion therapy
complications specifc to central line insertion or dwelling
examples of local complications iv infusion
- infiltration
- extravasation
- thrombosis
- site infection
- phelbitis
infiltration
complication: leakage of nonvesicant solution
causes
- inflammation
- puncture of opposite vessel wall
clinical manifestations
- skin- cool, tight, tender
- fluid leaking from the puncture site
interventions
- stop infusion, remove site
- elevate extremity
- cold compress
prevention
- stabilize catheter
- avoid pressure
- assess frequently
extravasation
complication
- leakage of vesicant solution
causes
- same as infiltration
clinical manifestations
- in attrition to those associated with infiltration
- blistering/ tissue sloughing
intervention
- stop infusion
- surgical intervention may necessary
prevention
- see infiltration
phlebitis
complication
- inflammation
causes
- mechanical- insertion technique
- chemical- fluid or medications
pathogenic-break in aseptic technique
clinical manifestations
- pain at site
- skin- red, inflammed, potentially hard
interventions
- remove site if possible
- head and elevate extremity
prevention
- choose smallest guage necessary
- avoid flexion sites
thrombosis
blood clot within vein
causes
- damage to endothelial linning
- traumatic or multiple venipunctrues
- too large a catheter for size vein
clinical manifestations
- swollen extremitiy
- tenderness/redness
slowed stopped infusion
interventions
- stop infusion, apply cold compress
- elevate extremity
- potential need for surgical intervention
prevention
- use ebp ventipuncture techniques
site infection infusion therapy
infection at insetion point, port pocket or sub c tunnel
causes
- break in aspetic technique
- lack of hand hygiene
clinical manifestations
- site- red swollen warm
- potential purelent or ordor
interventions
- clean exit site, remove catheter, send for culture, cover with dry sterile dressing
prevention
- aseptic technique
- hand hygiene
circulatory overload
s/s
excess fluid in circulatory system
- infusion rate greater than pt. system can accommodate
- SOB, cough, increased bp
speed shock
- systemic reaction to rapid infusion of unfamiliar substances
- drugs reach toxic levels
- change in loc, irregular pulse, chest tightness
catheter embolism
- piece of catheter breaks off into circulation
- anything the damages catheter
- potentially life threatening
cvc migration
- Movement of catheter tip to another vein
- Changes in intrathoracic pressure
- Coughing, sneezing, heaving lifting
-STOP Infusion, Notify HCP
cvc dislodegemnt
- Movement of catheter from insertion site
- Inadequate catheter securement
- Changes external catheter length
- STOP Infusion, NEVER Readvance, Notify HCP
occlusion
- Lumen is partially or totally blocked
- Precipitate from medications, blood clots, inadequate flushing
- Increased resistance, difficulty administering fluids/drawing blood, infusion pump stops/alarms
- Administer appropriate medications to dissolve precipitate or blood clot
PREVENTION!!! - FLUSH, FLUSH, FLUSH
Before, between and after
catheter related bloodstream infection
Occurs when pathogenic organism invades patients’ circulatory system
Clinical Manifestations
- Fever, HA, Chills, malaise
Tachycardia, hypotension, decreased U/O
Treatment
- Determine Cause
- Infusate – change entire infusion system, send to lab
- Catheter – remove, send catheter tip to lab
PREVENTION
H.A.N.D.S
vascular access devices (VAD)
- peripheral IV therapy (PIV)
- short infusion catheter
- midline catheters
- central IV therapy (CVC)
- peripherally inserted central catheter (PICC)
- nontunneled central venous catheters
- tunneled central venous catheters
- implanted ports
peripheral IV therapy
components
position
size
duration
catheter components
- stylet (needle)-insertion
- cannula- continous access
position
- within peripheral vessels
size (gauge)
- 26 gauge (smallest) to 14 gauge (largest)
duration of uses
- rotate sites based on clinical indication
best practice considerations for peripheral IV therapy
- avoid areas of joint flexion
- choose mosy distal site possible
- avoid dominant side if possible
- do not use side of mastectomy, av fistula,, lympth node dissection or paralysis
- limit unsuccessful attempts to 2 per clinician
midline catheters
catheter components
- single or doible lumen
position
- inserted into median antecubital, basilic or cephalic vein
- tip resides no further than axillary vein
size
- 3-8 inches long
- 3-5 french
duration of use
- 6-14 days
best practice considerations for midline catheters
- do not infuse parenteral nutrition
- do not use to draw blood
- do not admin incompatible drugs if double lumen
central venous catheters
- VAD placed in central circulation
placement confirmation
- CXR
- magnet tip locator electrocardiogram
peripherally inserted central catheters (PICCC
component
position
size
duration
catheter components
- single dual or triple lumen
position
- basilic preferred, cephalic okay
- tip resides in SVC
size
- 18-29 inches
- 2-6 fr
duration
- months
best practice considerations for peripherally inserted central catheters (PICCC)
- contrats injection- power PICCC only
- 10ml barrel syringes only
non tunneled
- inserted percutaneously
- cath exits skin near cannulation site
- subclavian or internal jugular
- resides in SVC or IVC
- short term use
- up to 5 lumens
tunneled
portion of catheter under subcu tissue
- seperates where catheter enters vein and exits skin
- reduces risk of infection
- long term use
- single dual or triple lumen
implanted ports
- long term use: 1 year +, chemo
catheter components:
- portal body, dense septum over a reservoir and catheter
- subq pocket house the port body
access
- no part of catheter is visible
- need non-coring needle
hypervolemia
results from too much fluid in body or dilution of electrolytes and rbcs
hypovolemia
not enough fluid in body, especially in the intravascular area
fluid deficit signs and symptoms
- thirst
- rapid weak pulse
- low bp
- dry skin and mucous membranes
- skin tenting
- increased temp
- decreased urine output: increase concentration/ specific gravity
- increase BUN
- increase HCT
fluid deficit interventions
MONITOR DAILY WEIGHT 1L=2.2LBS
- monitor intake and output
- treat underlying cause
- increase fluid intake: PO IV
- use caution with elderly pt
isotonic
what it does?
type of solutions
same concentration no fluid shift
- equal pressure inside and outside cell
- “stay where I put it”
- expands volume
- dilute meds
- fluid resuscitation
- .9 nacl
- lactated ringers
hypotonic
lower concentration- fluid shift out of vessel into cell
- less salt or more water than normal body fluids
- water leaves blood and into cells
- “goes out of vessel”
1/2 normal saline
D5W dextrose 5% water
could lead to vascular fluid depletion and cardiovascular collapse
hypertonic
- higher concentration- fluid shifts into vessel from cell s
- either more salt or less water than our own fluids
- water is removed pulled from cells and pulled into vascular
- can result in vascular overload and dehydration
- enters the vessel
used for na replacement
- volume replacement
D 1/2 NS
D5LR
fluid excess s/s
- bounding pulse
- elevated blood pressure
- respiratory changes
- weight gain
- edema
- increased urine output
- diluted/ decrease specific gravity
- decrease BUN decease NA
fluid excess interventions
- monitor dailey weight
- place in fowleys positon
- admin oxygen
- admin diuretics
- monitor I&O
- restrict fluid and sodium
hypernatremia interventions
diuretic
fluid
145 and up
- monitor VS
- daily weights
- monitor LOC
- I&O
- encourage fluids
medical
- loop diuretics: lasix
- NA free IVFs: D5W
hypokalemia interventions
- cardiac monitor
- D/C loop osmotic diuretics
- frequent iv assessment
- monitor renal function
- decrease dietary intake
medical
- PO admin
- IV admin: always dilute, never IVP, monitor for phlebiti
hyperkalemia interventions
- cardiac monitor
- d/c k+
- increased fluid intake
- dietary restriction
medical:
- admin loop/ osmotic diuretics
- kayexalate
- dialysis
- insulin: moves k + out of blood into cells
- calcium gluconate: counteracts myocardial effect of increase k+ levels
hypocalcemia interventions
- encourage PO intake
- monitor for neuromuscular changes
- trousseaus sign
- chvostek sign
- fall prevention
medical
- oral Ca with it D
- calcium gluconate
PaCO2 level
35-45 mm hg
HCO3 level
21-28 mEq/l
metabolic acidosis levels
ph <7.35
hco3 <21
metabolic acidosis causes
- shock, poor circulation
- diabetic ketoacidosis
- renal failure
- diarrhea
metabolic acidosis s/s
- weakness
- lethargy
- confusion
- headache
- stupor/unconsciousness
- coma
metabolic acidosis treatment
- identify and treat underlying cause
- insulin
- dialysis
- iv bicarb and lactate
respiratory acidosis causes
- slow shallow respirations
- respiratory congestion/ obstruction
respiratory alkalosis causes
- hyperventilation
- anxiety
- high fever
- overdose of asa
lungs- 2nd line
acidic: lungs blow off additional co2, rapid deep breaths
alkaline: conserve co2 via shallow breaths
Peripheral Arterial Disease (PAD)
affects arteries: blood vessels that carry blood away from the heart
peripheral venous disease
- affects veins: blood vessels that carry blood towards the heart
peripheral arterial disease
- Atherosclerosis – chronic, progressive arterial narrowing
- Results in reduced blood flow, ischemia develops
- Typically affects lower extremities
PAD risk factors
HTN Hyperlipidemia Diabetes Smoking Obesity Sedentary Lifestyle Family Hx Female Sex > 65 Years Old
subjective PAD
Intermittent Claudication
- Burning, cramping pain in legs during exercise
Numbness/burning sensation in feet when in bed
- Pain relief when in dependent position
objective PAD
- Decreased capillary refill
- Decreased/Non-palpable pulses
- Loss of hair on lower calf, ankle, foot
- Dry, scaly, mottled skin= robar
- Thick toenails
- Cold and cyanotic extremity
- Pallor of extremity with elevation
- Rubor (redness) of extremity
Ulcers
- End of Toes or Between Toes
- Pale w/ little granulation
- bad wound flow
6 p’s of arterial disease
Pain Pallor Pulselessness Paresthesia Paralysis- numbness or tingling Poikilothermia (coolness)
interventions of PAD
Promote Vasodilation
- Maintain warm environment, wear socks and avoid cold when possible
- Avoid caffeine and nicotine – cause vasoconstriction
Encourage Appropriate Positioning
- Do NOT cross legs
- Refrain from wearing restrictive garments: no ted stockings
- Cautiously elevate extremities
- Reduces swelling but above heart can cause significant slowing of arterial flow to feet
Medication Therapy
perioheral venous disease patho
Problems with the veins that interfere with adequate return of blood flow from the extremities which results in blood stasis
3 major disorders with pvd
Venous thromboembolism (VTE)
- Clot Formation
- Can break off (Emboli)
Venous Insufficiency
- Skeleton muscle doesn’t contract to help pump blood in veins
Varicose Veins
- Defective (Incompetent) Valves
subjective cues for PVD
Painful/fullness/heaviness in legs after standing
objective clues for pvd
- Calf or groin pain/tenderness
- Warmth, edema, changes in calf circumference
- Brown discoloration
- Distended visible veins
- Cramping Muscle Aches
- Ulcers @ Ankle
drug therapy changes for htn
- Individualized based on patient
- Often need two or more drugs for adequate control
- diuertics
- betablockers
- calcium channel blockers
- ace inhibitors
- ARBS
duiuretics htn
First drug of choice for managing HTN
Decrease BP by reducing blood volume
diurtetics: potassium-sparing: Spironolcatone
diuretics: loop- furosemide
diuretics: thiazide: hydrochlorothiazide
diurtetics: potassium-sparing: Spironolcatone:
- Prevent reabsorption of Na in exchange for K
- Risk for hyperkalemia
diuretics: loop- furosemide & diuretics: thiazide: hydrochlorothiazide
- Prevent/decrease Na reabsorption and increase water and K excretion
- Use Cautiously in Older Adults: ↑ Risk for dehydration, orthostatic hypotension, falls
beta blockers htn
- Drug of Choice for patients with Heart Disease
- Decrease BP AND Slow HR by blocking sympathetic nervous system
Common Examples
- Atenolol
- Metoprolol
Beta Blockers: Atenolol & Metoprolol
- Use Caution: Diabetics – May affect glucose production
- Do NOT Administer
HR < 50 bpm
Systolic BP < 90 mm Hg
Calcium Channel Blockers
- In combo with thiazide diuretics first-line therapy for African American patients
- Decrease BP and HR by interfering with movement of calcium through cell membrane
- *Results in vasodilation and blocks sinoatrial (SA) and atrioventricular (AV)node conduction
Common Examples
- Amlodipine
- Diltiazem
Calcium Channel Blockers: Amlodipine& Diltiazem
- Monitor BP/Pulse before Administration
- Use Cautiously: HF Patients
- Avoid Grapefruit juice
ACE inhibitors
- Angiotensin-Converting Enzymes
- Used as single or combination agents
- Decrease BP by preventing conversion of Angiotensin I to Angiotensin II
Preventing Vasoconstriction
Common Examples
- Lisinopril
- Enalapril
ace inhibitors: Lisinopril & Enalapril
- Monitor for S/S of HF
Edema - Report dry cough
Most common side effect
ARBS
- Angiotensin II Receptor Antagonists
- Decreased BP by blocking the vasoconstrictor Angiotensin II at various receptor sites
Common Examples
- Valsartan
- Losartan
ARBS: Valsartan & Losartan
- Use Cautiously: Impaired renal function
- Monitor for Signs of Angioedema
Dyspnea, facial swelling
PVD meds
anticoagulation
antiplatelet
thrombolytic
pvd meds: anticoagulation
- Prevent or delay coagulation → Preventing clot formation
- Also known as blood thinners
Examples
- Heparin – Monitor PTT
- Lovenox
- Coumadin – Monitor INR
- Eliquis
- Xarelto
pvd meds: antiplatelet
Decrease platelet aggregation → Prevent agglutination →Prevent clot formation
Example
- ASA- asprin
- Plavix
pvd meds thrombolytic
Dissolve or break up existing clots → Open vessel and help prevent future clot formation
Examples
- Heparin
- Lovenox
what is diabetes Mellitus
- common, chronic, complex disorder
- results from inability to produce insulin and the bodys resistance to insulin
- results in hyperglycemia
3 initial symtoms of dm
- polyuria
- polydipisa- thirst
- polyphagia
Diabetic Ketoacidosis (DKA)
- More Common in Type 1 Diabetics
- Insulin deficiency → Cellular Starvation → Breakdown of Fats → Ketones → Acidotic State
Diabetic Ketoacidosis (DKA) Signs/Symptoms
- Nausea/Vomiting
- Excessive Thirst
- Kussmaul’s Respirations
- Fruity Breath
- Changes in LOC
- Metabolic Acidosis
- BG > 300 mg/dL
Hyperglycemic Hyperosmolar Syndrome (HHS)
- More Common in Type 2 Diabetics
- Insulin deficiency combined with profound dehydration → Blood Glucose Elevation
Hyperglycemic Hyperosmolar Syndrome (HHS) s/s
- Blurred Vision
- Headache
- Changes in Mental - Status
- Seizures
- BG > 600 mg/dL
diagnostic testing for dm
Glycosylated hemoglobin (A1C)
- Identifies average blood glucose over time
- Previous 120 days
- Reference Range 4 – 6%
- Diabetics: 6.5 – 8%
- Preference 7% or less
Fasting Blood Glucose (FBG)
- Two separate results >126 mg/dL
insulin
routes
sites
timing
- given for hyperglycemia
Administration Routes
- SQ
- IV
Sites
- Rotate frequently to prevent tissue damage
- Abdominal tissue provides fastest absorption
- Do NOT inject within 2-inches of umbilicus
Timing
- Onset – Time from administration to lowering of BG
- Peak – When insulin is working the hardest
- BG is at its lowest
- Duration – Length of time before all the insulin is used up
elective sugery
- planned for correction on a non acute problem
- time Is not an issue
ex) cataract removal, hernia repair
urgent surgery
- requires prompt intervnetion
- potentially life threatening if delayed more than 24 hr to 48 hour
ex) intestinal obstruction, bone fracture
emergent surgery
- requires immediate intervention
- life threatening consequences
ex) gunshot/stab wounds, severe bleeding, appendectomy
risk factors for surgical complications
- pregnancy
- respiratory disease
- cardiovascular disease
- diabetes
- liver disease
- kidney disease
- coagulation disorders
- medications
post op phase recognizing cues… at risk for
at risk for
- pneumonia
- shock
- cardiac arrest
- vte
- gi bleeding
- early recognition of assessment findings
- decrease potential for serious surgical complications
wound complications
- dehiscence- partial or complete separtion of the wound edges
- evisceration- protrusion of intestinal organs
informed consent
- ensure INFORMED conset is obtained
Surgeon: - detailed description of the procedure
- obtains consent
nurse:
- verifies and clarifies facts
- confirms consent is signed, dates, and times
- may serve as witness
acute kidney injury
- rapid reduction in kidney function
- failure to maintain waste elimination, fluid and electrolyte balance and acid base balanc e
- occurs few hours or days
acute kidney injury serium creatinine
increase serum creatinine by .3 mg/dl
- increase in serum creatinine to 1.5 times or more occurring in 7 days
acute kidney injury causes
- reduced perfusion to kidneys damage to kidney tissue, and obstruction or urine outflow
- RISK FACTORS INCLUDE: SHOCK, CARDIAC SURGERY, HYPOTENSION, PROLONGED MECHANICAL VENTILATION, SEPSIS
- OLDER ADULTS WITH DIABETES, HYPERTENSION, PERIPHERAL VASCULAR DISEASE, LIVER DISEASE, CKD
acute kidney injury physical assessment
- hourly urine output
- assess for fluid overload
- evaluate vital signs for hypoperfusion and hypoxemia
- build up of nitrogenous waste and decreased urine output
acute kidney injury lab assessment
- creatinine, BUN
- gfr lower than 60
- blood electrolyte values
- urine tests
- high sodium
- high potassium
- high phosphate
- high calcium
acute kidney injury intervention/ management
- avoid hypotension, maintain normal fluid fluid balance
- reduce exposure to nephrotoxic agents and drugs
- frequently monitor lab values
- closely watch I/o
- drug therapy
- nutrition
- kidney replacement therapy
chronic kidney disease lab assessment
- creatinine BUN
- sodium, potassium , calcium, phosphorus, bicarb
- hemoglobin and hematocrit
- GFR
- urinalysis
chronic kidney disease intervention
- managing fluid volume
- improving cardiac function
- enhancing nutrition
- preventing injury
- minimising psychosocial compromise
hemodialysis procedure
dialysis works by passive transfer of toxins by diffusion
- be aware of blood clotting
hemodialysis precuations
- check pedal pulses and cap refil in arm with fistula or graft
- check for bruit or thrill by auscultating or palpating access site
hemodialysis access complications
- thrombosis
- stenosis
- infection
- aneurysm
- ischemia
hf
peritoneal dialysis procedure
- soft plastic tube is placed in pt. abdominal cavity
- sterile cleansing fluid put into catheter
- after filtering process is finsihed fluid leaves pt. body through catheter
types of peritoneal dialysis
- continuous ambulatory peritoneal
- intermittent peritoneal
- intermittent perutoneal
peritoneal dialysis complications
peritonitis
pain
do not microwave fluid
peritoneal dialysis nursing care
- assess vitals
- weigh pt. using same scale
- monitor pt. dry weight
- baseline lab test doen before and during
- check dressings
- measure and record overflow
stress incontinence
urine leaks out at times when your bladder is under pressure
ex) coughing or laughing1
stress incontinence symptoms
post-void residual
pelvic exam
- loss of small amount of urine during physical activity or intraabdominal pressure (coughing, sneezing jumping, lifting, exercises)
- normal voiding habits
- postvoid residual usually less than or equal to 50ml
- pelvic exam= hypermobility or urethra or bladder neck with Valsalva maneuvers`
stress incontinence causes
- weakening of the bladder neck supports; associated with childbirth
- intrinsic sphincter deficiency
- acquired anatomic damage to the urethral sphincter
- vaginal prolapse from vaginal birth or aging
urge incontinence
when urine leaks as you feel a sudden urge to pee, or soon afterwards
urge incontinence causes
- idiopathic
- neurological disorders
- benign prostatic hypertrophy
- bladder irritants (artiical sweetners, caffeine, alcohol, citric, drugs, nicotine)
- bladder cancer
- medications that cause increased bladder contractibility
urge incontinence symptoms
- loss of urine preceded by a sudden and severe desire to pass urine
- nocturia
- may have loss of large amounts of urine with occurrence
overflow incontinence (reflex incontinence)
when your unable to fully empty your bladder which causes frequent leaking
overflow incontinence (reflex incontinence)causes
- urethral obstruction
- diabetic neuropahy
- some neurologic disorders
- medications side effects
overflow incontinence (reflex incontinence) symptoms
- bladder distension, constant dribbling of urine
- sense of incomplete emptying of the bladder
- pelvic discomfort
- palpable bladder
cystitis
inflammatory conditon of the bladder
- usually refers to inflammation from infection of bladder
cystitis nonsurgical managment
- drug therapy
- fluid intake
- comfort measures such as pain relief
cystitis surgical managemnt
- treat conditions that increase risk for utis
- removal of obstructions
- removal of vesicoureteral reflux
- removal of calculi
cystitis health promotion and maintenance
- sterile technique when inserting catheters
- clean technique when using intermittent catheters at home
- single-use catheter recommended for home settings
- national pt. safety goal- CAUTI prevention: removal of catheter as soon as possible
- liberal intake of water
urolithiasis
presence of calculi in the urinary tract
urolithiasis managing pain (nonsurgical)
- drug therapy
- lithotripsy
urolithiasis managing pain (surgical management)
minimally invasive surgical procedures
- open procedures
urolithiasis preventing infection
- drug therapy- antibiotics
- lab test (urine sample, C&S test, urine cultures)
urolithiasis preventing obstruction
- high fluid intake (3l/day or more)
- accurate measurements of intake and output
- drug therapy
- nutrition therapy/ diet modification
urinary incontinence planning and integrating (maintaining tissue integrity)
- reduce the risk for skin breakdown
- reduce the risk of pt. developing incontinece- associate dermatits
- educate the pt. on the possibility of using an external device
- discuss the possibility of absorbent pads and breifs with the pt.
- options for functional incontinence include intermittent or long dwelling catheter
Hospital incident commander-
Physician or administrator who assumes overall leadership for implementing the emergency plan
Medical command physician-
Physician who decides the number, acuity, or resource needs of patients
Triage officer-
Physician or nurse who rapidly evaluates each patient to determine priorities for treatment
Community relations or public information officer-
Person who serves as a liaison between the health care facility and the media
Role of Nursing in Health Care FacilityEmergency Preparedness and Response: Before
- Contribute to developing internal and external emergency response plans
- Consider security needs, communication methods, training, alternative treatment areas, staffing for high demand/surge situation, and requirements for resources, equipment, and supplies
- Participate in disaster drills and evaluate the outcomes, also assist with revising the plan of action if needed
who determines when to deactivate emergency response
incident commander
Psychosocial Response of Survivors
- Disaster experience can produce immediate and long-lasting effects
- Lifestyle, roles, routines drastically altered
- Coping ability are severely stressed
- Nurses help survivors adapt
- Monitor for signs of ASD or PTSD
- Impact of Event Scale- Revised (IES-R) questionnaire- can be used by nurses as an assessment tool when caring for survivors with symptoms of ASD and PTSD
Emergency Preparedness Plan
- Mandated by The Joint Commission (TJC)
- Accredited health care organizations take “all-hazards approach” to disaster planning
- Disaster drills take place for training
+ Planned based on risk assessment or vulnerability analysis
evacuation plan
part of a fire prevention and preparedness plans for health care facilities
Red
emmergent needing immediate attention (class 1)
yellow
can wait short time for care (class 2)
green
non urgent or walking wounded (class 3)
Black
expected (and allowed) to die or are dead) (class 4)
hospice
- Model for quality, compassionate care for people facing life-limiting illness or injury
- Often provided to those with terminal cancer, dementia, end-stage COPD, cardiac disease, neurologic disease
- not expected to recover
- less than 6 month to live
Palliative Care
- Philosophy of care for people with life-threatening disease
Goal is to improve quality of life for patient and family - managing pain and illness
\
Durable power of attorney for healthcare (DPOAHC
aka healthcare proxy, healthcare agent, or surrogate decision-maker, makes health care decisions once the health care provider states that the person is unable to make his or her own health decisions
pneumonia (PNA)
- an infection that inflames the air sacs in one or both lungs
- airsacs may fill with fluid or pus
- causing cough with phlegm pus fever chills and difficulty breathing
pneumonia assessment recognize cues: risk factors
risk factors:
- AGE
- no vaccination
- chronic health problems
- use of respiratory equipment
- vaccination status
pneumonia assessment recognize cues: physical assessment and s/s: general appearance
- FLUSHED CHEEKS
- anxious look
- chest pain
- MYALGIA- pain in muscles
- headache
- chills
- fever
- cough
- tachycardia
- dyspna
- hemoptysis (blood sputum)
- SPUTUM- may have blood. color:yellow, green, brown, rusty, thick
pneumonia assessment recognize cues: physical assessment and s/s: respiraotry assessment
- breathing pattern
- use of accessory muscles
- positioning
- cough
- sputum assessment
- lung sounds (crackles)
pneumonia assessment recognize cues: physical assessment and s/s: vital signs
- increased respiration rate
- hypotension
- tachycardia
- dysrhythmias
asthma drug therapy
- control therapy drugs
- reliever drugs
- bronchodilators
- anti-inflammatory agents
control therapy drugs (used daily)
used to reduce airway sensitivity (responsiveness) to prevent asthma attacks from occurring and maintain gas exchange
- inhaled cortical steroid- reduce inflammation
reliever drugs
used to stop an attack
- short acting bronchodilator
bronchodilators
induce rapid bronchodilation through relaxing the smooth muscle
what do anti-inflammatory agents do?
help to improve bronchiolar airflow and increase gas exchange
COPD planning and implementation
- improve gas exchange and reduction of carbon dioxide retention
- ensure consistent use of drug therapy, airway maintenance, monitoring, breathing techniques, positioning, effective coughing, oxyen therapy, exercise conditioning, suctioning, and hydration
- surgical intervention
- preventing weight loss
- minimizing anxiety
- improving endurance
- preventing respiratory infection
surgical intervention for copd
lung transplantation
- lung volume reduction surgery
preventing weight loss for copd
dyspnea management
food selection
improving endurance for copd
- energy conservation
COPD evaluating outcomes
- attain and maintain gas exchange at a level within his or her chronic baseline values
- achieve an effective breathing pattern that decrease the work of breathing
- maintain a patent airway
- achieve and maintain a body weight within 10% of his or her ideal weight
- have decreased anxiety
- increase activity to a level of acceptance to him or her
- avoid serious respiratory infections
PE analysis & prioritze
- hypoxemia due to mismatch of lung perfusion and alveolar gas exchange with oxygenation
- hypotension due to inadequate circulation to the left ventricle
- potential for excessive bleeding due to anticoagulation or fibrinolytic therapy causing inadequate clotting
- anxiety due to hypoxemia and life-threatening illness
lifestyle changes with pe
- smoking cessation
- reducing weight
- physically active
- herarin or indirect thrombin inhibitor
- IVC filter
if traveling with a pe
- drink plently of water
- change positions often
- avoid crossing legs
- get up from sitting for 5 mins each hour
managing hypoxemia in pe
- sudden onset of dyspnea: activate rapid response team
- apply oxygen, elevate the HOB and reassure the pt
- oxygen therapy
- monitor pt
- admin anticoagulation or fibronolytic therapy
managing hypotension in pe
- iv therapy (crystalloid substance) to restore plasma volume and prevent shock
- drug therapy with vasopressors (norepinephrine, epinephrine, dopamine) used if iv therapy doesn’t work
controlling bleeding in pe
- assess for s/s of bleeding
- ensure correct dosage and timing of medication
- monitor, lab values (INR)
conditions favoring gastric ulcers
favoring the development of duodenal ulcers, which are normal diffusion of acid back into stomach tissues with increased secretions of gastric acid and increased stomach emptying.
- pain worse with food
complications of ulcers: Hemorrhage
- Occurs more often in patients with gastric ulcers and in older adults
- Patients have a second episode of bleeding if underlying infection with H. pylori remains untreated or if therapy does not include H2 antagonist
- Massive bleeding = vomiting bright red or coffee- ground blood (hematemesis)
- Minimal bleeding from ulcers = minimal occult bleeding in a dark, ”tarry” stool (melena), melena may occur with gastric ulcers, more common with duodenal ulcers
complications of ulcers: perforation
- Occurs when the ulcer becomes so deep that the entire thickness of the stomach or duodenum is worn away
- The stomach or duodenal contents can then leak into the peritoneal cavity
- Patients can experience sudden, and sharp pain, peritonitis infection, severe illness within hours, bacterial septicemia and hypovolemic shock, paralytic ileus
what kind of emergency is peptic perforation
surgical emergency and can be life threatening
ulcers of complications: pyloric (gastric outlet) obstruction (blockage)
where does it occur
symptoms
what occurs due to vomiting
- Occurs in small percentage of patients and manifests with vomiting caused by stasis and gastric dilation
- Obstruction occurs as the pylorus (the gastric outlet) and is cased by scarring, edema, inflammation, or a combination of these factors
- Symptoms of obstruction include abdominal bloating, nausea, and vomiting
- With persistent vomiting, metabolic alkalosis may occur due to loss of large quantities of acid gastric juice in the vomitus
- Hypokalemia may also occur from the vomiting or metabolic alkalosis
complications of ulcers: intractable disease
May develop from complications of ulcers, excessive stressors in the patient’s life, or an inability to adhere to long-term therapy
acute gastritis
- rapid onset of epigastric pain and dyspepsia
- epigastric burning sensation referred to as heart burn
acute gastritis accompanied by
- gastric bleeding
- Hematemesis- vomiting blood or melena (dark, “tarry” sticky stool
chronic gastritis assessment
may have few symptoms unless ulceration occurs
- nausea, vomiting, upper abdominal discomfort, periodic epigastric pain may occur after a meal, some patients have anorexia
acute gastritis treating
- treated symptomatically and with supportive care because the healing process is spontaneous and occurs within a few days
- Eliminate causative factor, which usually results in pain and discomfort being reduced
- A blood transfusion and fluid replacement may be given if bleeding occurs
- Drugs that block and buffer gastric acid secretions
- Consider Nutrition and Drug Therapy
- Nutrition
- Drug therapy
food to avoid in gastritis
- avoid caffeine
- highly acidic foods
- spicy foods
chronic gastritis treatment
- causative agent
- may require b12 for prevention or treatment of pernicious anemia
- H.Pylori infection
ulcerative colitis
Widespread chronic inflammation of the rectum and rectosigmoid colon
Can extend into entire colon
Has periodic remissions and exacerbations
physical assessment & s/s of uc
- May have low-grade fever
- Note any abdominal distention along the colon
- Assess for signs and symptoms associated with extraintestinal complications, such as inflamed joints and lesions inside the mouth
- Usually finding are nonspecific
ulcerative colitis lab assessment
- Hematocrit and hemoglobin
- Increased WBC, C-reactive protein, erythrocyte sedimentation rate (ESR) is consistent with inflammatory disease
- ***Low sodium, potassium, chloride
- ***Hypoalbuminemia
consider nutrional therapy and rest ulcerative colitis
- Patients with severe symptoms who are hospitalized are NPO to allow for bowel rest
- Consider foods that may increase diarrhea, cramping or GI symptoms
- During exacerbations, rest is encouraged
managing skin integrity
Consider ways to reducer skin irritation
- For leakage of stool, the patient can use an absorbent cotton or panty liner and for incontinence, pads can be used at night
diet for chrons
fistual management
- patient requires at least 3000 calories daily to promote healing of fistula
- Total enteral nutrition (TEN) or TPN may be needed
nutrition therapy
- bowl rest
- nutrition suuport with TPN
- Ensure & Sustacal
- advoid gi stimulatns
- relaxation therapies to relax the patient and soothe the GI tract
ulcerative colitis hypothesis
- Diarrhea due to inflammation of the bowel mucosa
- Acute or persistent pain due to inflammation and ulceration of the bowel mucosa and skin irritation inflammation
- Potential for lower GI bleeding and resulting anemia due to Ulcerative colitis
acute pancreatitis lab
**Amylase: elevated
**Lipase: elevated
Serum bilirubin and alkaline phosphatase: elevated
ALT: elevated
WBC: elevated
ESR: elevated
calcium and magnesium: decreased
acute pancreatitis promoting nutrtion
- **NPO status maintained in early stages of pancreatitis
- Antiemetics prescribed for nausea and vomiting
- Patients with severe pancreatitis who are unable to eat for 24-48 hours will need jejunal **tube feeding, patient should be weighed daily
- Once food is tolerated, patient should ***small, frequent, moderate to high carb, high-protein, low-fat meals, food should be bland with little spice, avoid caffeine containing foods and alcohol
- ***Monitor the patient beginning to resume oral food intake for nausea, vomiting, and diarrhea (if any of these symptoms occur, notify the PCP immediately)
- Nutritional supplements may be used to ***boost caloric intake, doctor may prescribe vitamin and mineral supplements
pancreatitis diet
- Main focus of nursing care is aimed at pain control by interventions that decrease GI tract activity, which *decreases pancreatic stimulation
- Fasting and rest, drug therapy, and comfort measures used to **decrease pain
chronic cholecystitis physical exam
afebrile
- may have localized tenderness over a palpable gallbladder
chronic cholecystitis ultrasound
stones in gallbladder
- thickened gallbladder wall
- advanced cases contracted gallbladder
- Chronic cholecystitis symptoms
jaundice, clay-colored stools, and dark urine from biliary obstruction, icterus, steatorrhea (fatty stools)
diet teaching for cholecystitis
Avoid fatty foods, withhold food and fluid if nausea and vomiting occur
- NPO
managing fluid volume cirrhosis
Treat ascites, consider nutrition therapy (decrease sa), drug therapy, paracentesis, and respiratory support (02)
preventing hemmorrhage cirrhosis
- Monitor for esophageal varices by endoscopy
- because massive esophageal bleeding can cause rapid blood loss, emergency interventions are needed
- Prevent bleeding and infection, non-selective beta blocking agent to prevent bleeding, antibiotics used to prevent infection
- Endoscopic therapies include ligation of the bleeding veins or endoscopic sclerotherapy
- Transjugular intrahepatic portal-systemic shunt (TIPS)- procedure used for patient who have not responded to other modalities for hemorrhage or long-term ascites
- NGT, Packed RBCS, fresh frozen plasma, Dextran, albumin, and platelets may be needed
- Monitor vs every hour, PT, PTT, and INR
preventing or managing confusion in cirrhosis
Slow or stop increase of ammonia in the blood, assess and monitor neuro status, nutrition counseling and protein in diet, lactulose used to excrete ammonia in stool, nonabsorbable antibiotics if lactulose does not help
managing pruritus IN CIRRHOSIS
Avoid being too warm, moisture skin, avoid irritants to skin, cool compress and/or corticosteroid creams
lactulose
lactulose used to excrete ammonia in stool, nonabsorbable antibiotics if lactulose does not help
ascites
collection of FREE FLUID within the peritoneal cavity caused by increased hydrostatic pressure from portal hypertension
