Hesi Study Materials

Hesi Study Materials Delegation If giving to LVN/LPN or other nurse that is floating or not critical care- give nurse the most STABLE client. Center of Gravity- Older individuals center of gravity is the upper torso. Adults- hips ABC’s ▪ Airway, Breathing, Circulation ▪ (CAB)- compression, airway, breathing ▪ Provide if unwitnessed cardiac arrest occurs. ▪ If unconscious- begin with circulation, airway, breathing; begin CPR. ▪ 30:2 with partner ▪ 15:2 alone ▪ Place hands at lower half of sternum; above xiphoid process ▪ Reposition head to validate proper position to open airway if chest is not moving ▪ When carotid pulse is felt, there is return of cardiac function, with return of breathing • Signs of effective tissue perfusion should be noticed Preoperative- • Nurses role is to educate/advocate, reduce anxiety, Ensure consent has been signed within past 24 hours (valid for 45 days) • Teaching/Learning- outcome is best when demonstrated and not only verbalized; returned demonstration is best method. • KNOW ALLERGIES, OTC, herbal meds • Know any issues with previous surgical experiences • Know about person’s culture • Often no blood transfusions for Jehovah’s Witness • Often NPO after midnight; clear liquids sometimes allowed up to 6 hrs before surgery o If client does not follow, surgery will be rescheduled • Ensure client is both emotionally and physically prepared for surgery Surgical Risk Factors- • Age-young and old • Nutrition- obese and malnutrition • Fluid/Electrolyte-dehydration/hypovolemia • Infection • Cardiac conditions • Blood coagulation disorders • URI/COPD- exacerbated by general anesthesia • Renal disease- impairs F/E balance • Uncontrolled DM- infection & delayed healing • Liver disease- inability to detoxify meds Meds that increase risk: • Anticoagulants- increases bleeding • Tranquilizers- hypotension • Heroin- decreased CNS response • Antibiotics- may be incompatible with anesthesia • Diuretics- may cause electrolyte imbalance • Steroids • OTC herbal meds- o THINK THREE G’s: ginseng, garlic, gingko- increase bleeding o Fish oil, dong quai, feverfew- increase bleeding o Prolong anesthesia- kava, Valerian, St. John’s (also interacts with EVERYTHING) Postoperative- Immediate Care: ▪ VS- BP, pulse, respirations o Especially if client has slurred speech- may indicate neuro deficits o If SOB, may need to intubate ▪ LOC, skin color & condition ▪ Dressing location and condition ▪ IV fluids ▪ Urine output o Notify HCP if dark and less than 30mL/hr ▪ Drainage tubes & position ▪ O2 saturation Monitor for S&S: ▪ Shock/hemorrhage o Compensatory mechanism is activation of SNS that will increase RR & pulse to restore BP; constricts arterioles and causes oliguria o Client will show elevated BP as compensatory mechanism ▪ Narrow pulse pressure ▪ Rapid weak pulse ▪ Cold, moist skin ▪ Increased cap refill Position client on side to prevent aspiration and to allow client to cough out airway; side rails should be up. N/V- suction ▪ When getting out of bed for first time, if client had HOB down, allow client to sit with bed in high fowlers position. ▪ Help client sit and dangle legs on side of bed. ▪ Place chair at a right angle to bedside. ▪ Encourage deep breathing prior to standing. Most common complications: ▪ Urinary retention- monitor hydration status and I&O; offer bedpan/commode ▪ Pulmonary problems- assist to turn, cough, deep breath Q1-2 hrs., Keep hydrated, early ambulation, incentive spirometry. ▪ Wound-healing- teach splinting when patient coughs, monitor for S&S of infection, malnutrition, dehydration HIGH PROTEIN DIET ▪ UTI- increase fluids, empty bladder Q4-6 hrs, monitor I&O, avoid catheterization if possible, remove ASAP ▪ Thrombophlebitis- leg exercises, early ambulation, SCD’s, avoid pressure that may obstruct venous flow; TO NOT PLACE PILLOWS BENEATH KNEES; avoid crossing legs at knees; LMWH- lovenox ▪ Decreased GI peristalsis/constipation/Paralytic ileus- NG tubing to decompress GI tract; client to limit use of narcotics (possibly use stool softeners); encourage ambulation Wound dehiscence ▪ Patient may feel as if something “gave way” ▪ Observe for serosanguinous drainage ▪ Bowel evisceration- Apply sterile dressing Gastrointestinal TPN/Insulin- ONLY Regular insulin may be given IV. If any other type of insulin is added to a mixture, it must be returned to the pharmacy and should NEVER be used. ▪ The most important lab value to monitor when administering TPN is glucose. ▪ They contain high levels of glucose and sugar should be monitored as often as Q6H. ▪ Monitor fluid and electrolytes Diabetes Mellitus ▪ Insulin- Assess willingness of client to learn injection sites when newly diagnosed ▪ Monitor clients for issues related to osmotic diuresis from elevated glucose levels Medications ▪ Rapid – “LOG” fast acting; onset 15 mins; peak 1-2 hours ▪ Regular- Humulin/novolin- onset in 30-60 minutes; peak 2-4 hours ▪ NPH- “LIN”- onset 2-4 hours; peak 4-8 hrs Long acting- “Lantus”; onset 1-2 no peak. ▪ Metformin- biguanide; do not administer within 48 hours of IV contrast- hard on kidneys ▪ Sulfonylureas- allergic to sulfa’s ▪ Patient will often have Hx of obesity. ▪ Patient should be counseled on nutrition and weight loss. ▪ Diabetic neuropathy- loss of feeling in lower extremities; if serum glucose is decreased with a new diabetic numbness may improve. ▪ Increased risk for stroke. ▪ Pedal pulses can be weak or absent with decreased blood supply. ▪ Patient may experience vascular scarring r/t atherosclerotic changes in vessels causing decreased perfusion, delaying wound healing ▪ Microalbuminuria is earliest sign of diabetic nephropathy ▪ Very important to know if patient is allergic to any sulfa drugs as they are some of the anti-hyperglycemic agents (sulfonylurea- we generally see glyburide, glipizide, glimepiride) o Prescribed for type 2 diabetics o Can cause hypersensitivity reaction- trouble breathing, swelling of lips, tongue, face, throat- contact HCP o May cause Low blood glucose (S&S: sweating, dizzy, confusion, tachycardia, trembling) ▪ Cold and clammy give candy, shakiness- provide orange juice or simple sugar ▪ Rule of 15g (3x)- peanut butter cracker, oj, candy ▪ Cannot be used if pregnant/breastfeeding ▪ Renal insufficiency- Nocturia is S&S ▪ Polyphagia, Polyuria, polydipsia • Polyphagia- consequence of cellular malnourishment o No insulin; cannot get glucose into cells • Polyuria- o Increased glucose concentration- osmotic diuresis ▪ Glucose so high that it is excreted in urine and water follows • Polydipsia- o Increased glucose concentration dehydration o Often occurs with DKA ▪ Nutrition- fresh fruits, lean meats and fish, vegetables and low grain ▪ Avoid high fat. Use low fat dairy and avoid white bread, essential nutrients are removed. ▪ Teach a patient newly diagnosed with DM 2 to have vision exam Diabetic Tests ▪ A1C- past three months; - check if noncompliant ▪ Fasting glucose- 70-110 ▪ OGTT- drink glucose; after 2 hours if below 140 mg/dL o 140-199: impaired glucose tolerance, or prediabetes o 200 or higher: diabetes Monitor clients with DM If hypoglycemic- check LOC before performing any actions Check blood glucose level again to ensure – assess Hypoglycemic Shock Teach patients and family S&S of shock Gastric lavage Unconscious- • Check BS and begin feeding with peristalsis returns • High fowlers with towel over chest • Check tube placement • Connect tube to funnel or large syringe • Check residual and return residual. • Poor feeding into tilted funnel, unclamp tubing to allow feeding to flow by gravity • Regulate flow by raising/lowering container o TOO QUICK- diarrhea, distention, pain o TOO SLOW- possible obstruction of flow • After feeding, irrigate with tepid water and clamp. • Keep HOB elevated 30 degrees or more during feeding and for one hour after. o Preventing aspiration • May be used when patient has swallowed corrosive substance o If damaging to mucosa- do not induce vomiting ▪ Gastric decompression and charcoal Small bowel obstruction ▪ If fever presents, peritonitis is possible possible rupture of bowel and infection o Monitor VS and S&S of infection ▪ Abdominal cramping is expected ▪ Characterized by severe fluid and electrolyte imbalances ▪ NPO- irrigate NG tube with air only Erythromycin and neomycin S&S of perforation and peritonitis: tx with IV fluids, abx, pain, NG suction ▪ Guarding ▪ Increased temp and chills ▪ Pallor ▪ Progressive abdominal distention and abdominal pain ▪ Restlessness ▪ Tachycardia and tachypnea Assess gag reflex 1st. If not, patient could aspirate. NG tube for obstruction Insert and place on intermittent low suction with HOB elevated to 60-90 degrees Bowel Management- ▪ Can evacuate after last tube feeding of day ▪ Stimulate with insertion of glycerin suppository 15-30 mins before scheduled evac. ▪ Ensure fiber in tube feedings- and fluid 2-4L/day Diverticulitis Diverticulosis- outpouching; often goes unnoticed Diverticulitis- inflammation; peritonitis ▪ Most important- Place client on NPO. ▪ They are at risk for peritonitis and intestinal obstruction and should be made NPO to reduce intestinal rupture. ▪ Assess client’s temperature- often has low-grade fever; if high could indicate peritonitis ▪ Patient will most likely have LLQ pain and low-grade fever ▪ Diverticulitis often occurs in sigmoid colon ▪ Obtain stool specimen. – check for occult blood ▪ Administer IV fluids; increase fluid to 3L ▪ Hard, rigid abdomen and elevated WBC immediate attention; peritonitis is a medical emergency!! Report to HCP ▪ Teach client that they should consume a high fiber diet w/fluids when they have diverticulosis and it is not inflamed o Do not consume when inflammation is occurring o Stool softeners- No laxatives; enemas Acute- NPO, graduate to liquids Recovery- no fiber or irritating Maintenance- high fiber, bran; avoid nuts, seeds, popcorn Ulcerative Colitis ▪ Velvety red, begins in colon and continues ▪ Pain in LLQ ▪ Abdominal pain and intermittent tenesmus (cramping rectal pain and feeling that bowel still needs to be emptied) ▪ Exacerbations of severe diarrhea o May contain occult blood ▪ Ulcerative colitis is 4-5 times more common with Jewish ▪ Weak and fatigue- anemia ▪ UC peaks between ages 15-25 ▪ Second peak is between 55-65 years of age ▪ Low residue, high fat, high protein, high calorie ▪ No dairy ▪ Vitamins and supplements ▪ Avoid smoking, caffeine, pepper, alcohol ▪ Bowel rest- IV ▪ Mesalamine, sulfasalazine ▪ Monitor I&O and F/E ▪ Weight 2x week Give pain meds (narcotics) with caution Appendicitis ▪ Severe pain at McBurney’s Point and nausea- radiates to right side ▪ McBurney’s point is located at the right iliac area of RLQ ▪ Pain that suddenly stops ▪ Avoid application of heat ▪ Coughing, sneezing, deep inhalation can worsen pain ▪ Keep NPO ▪ Keep right side position or low fowlers position Cholestyramine ▪ Used for hyperlipidemia- lowers cholesterol; bile acid sequestrant ▪ This binds bile in GI to prevent reabsorption ▪ Evaluate for vitamin K deficiency ▪ Monitor for increase in PT and INR ▪ Drug absorbs fat soluble vitamins- ADEK ▪ Can be used to treat liver failure ▪ Can be used to treat pruritus ▪ Can be used to treat cholestasis ▪ Binds with oxalate in GI- reduces urine oxalate and calcium oxalate stone formation ▪ Can be used with C. diff to absorb toxins A&B ▪ Max dose 24g/d Pancreatitis ▪ Digested by own enzymes o Alcohol, biliary tract disease o Stop alcohol consumption • Elevated amylase, lipase, glucose levels • Lipase and amylase are lab values • Mid-epigastric pain radiating to back- alcohol or fatty meal • Abdominal guarding; rigid, boardlike abdomen, and abdominal pain • Elevated temp, tachy, decreased BP • Weight loss • Bluish discoloration of flanks (grey turners) • Periumbiical area- cullen’s sign Chronic- ▪ Continuous burning or gnawing pain ▪ Ascites ▪ Steatorrhea, diarrhea ▪ Weight loss ▪ Jaundice, dark urine o Inflammation and obstruction of bile duct ▪ Signs and symptoms of diabetes mellitus o Because they have no insulin ▪ NPO, maintain NG tube to suction, TPN is given. ▪ Hydromorphone and fentanyl ▪ Antacids, H2, anticholinergic, PPIs ▪ Position on side to with legs drawn up to chest; hurts when supine ▪ Avoid alcohol, caffeine, fatty foods, spicy foods ▪ Monitor blood sugar, regular insulin ▪ Monitor for hypocalcemia o Body is not making enzymes to digest calcium o Tetany, chovtesk’s, trousseau, numbness around mouth ▪ Pancreatic enzyme replacement ▪ Bland, low fat- diet Crohn’s Disease ▪ Mouth to anus; cobblestone, skipped lesions • May need to use elimination diet to find trigger foods • Teach client about remission and exacerbation • Fatty diarrhea stools- steatorrhea • Diarrhea • Low residue, low fat, no dairy, avoid spicy foods • No smoking, caffeine, pepper, alcohol • High protein, high calorie • Administer vitamins and iron • TPN if necessary • Monitor I&O, F/E • Weight 2x weekly • Provide emotional support • Encourage to talk with enterostomal therapist before surgery Celiac Disease Autoimmune, decreases absorption of fat, carbs, protein Iron deficiency anemia is common GERD Melena COFFEE GROUND VOMIT- obtain vital signs; symptom of bleeding Test for occult blood. Duodenal- relived by eating- DO EAT Gastric- pain with food- NO GO ▪ Antacids- “AFTER MEALS” ▪ PPI- take before meals; omeprazole; pantoprazole ▪ Mucosal healing agents- before meals ▪ Upright position one hour after meals. ▪ Elevate head of bed 6-8 hours. ▪ Small, frequent meals. ▪ Avoid bedtime snacks. ▪ No NSAIDS, alcohol, smoking Billroth II surgery Pulmonary embolism and pneumothorax are risks associated Monitor client VS- administer O2 with any signs of decreased O2 level Esophageal Varices Portal hypertension- causes varices which is dilation of vessel Caused by scar tissue or blockage of liver; RESPIRATORY Tracheostomy- • Inflate cuff prior to the tube feeding if cuffed tracheostomy is in place. • Keep inflated to prevent aspiration of food into respiratory system. • The cuff blocks the trachea and prevents food from entering. • Keep old ties in place until a new one is secured Teach glottal stop technique to remove secretions, deep breath, momentarily occlude trach tube, cough, and simultaneously remove finger from tube). Observe patient with laryngectomy tube for any S&S of bleeding or occlusion, greatest immediate post-operative risk. ▪ Insert catheter until resistance or coughing occurs. ▪ Turn suction to 80-120 mmHg. ▪ Catheter should be withdrawn 1-2 cm at a time with continuous rotation and intermittent suctioning. ▪ Keep extra tracheostomy at bedside- one size smaller ▪ Medicalert bracelet- neck breathers ▪ If dislodged- try to reinsert COPD- ▪ Smoking is one of the biggest risk factors; modifiable. ▪ Client taking steroids for extended period of time are at risk for infection- assess S&S. ▪ Steroids- cause immunosuppression and increase glucose- monitor for S&S of infection!!! ▪ Small, frequent meals ▪ Fluids should be taken between meals not with meals ▪ Blue Bloaters- cyanosis, increase calories and protein; bronchitis; can lead to LHF- cor pulmonale ▪ Pink puffers- barrel chest- puffed out; elasticity of alveoli is gone; accessory muscles ▪ When teaching diaphragmatic breathing- place small book or magazine on abdomen and make it rise while inhaling deeply. ▪ Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the respiratory rate. The client should protrude the abdomen on inhalation and contract it with exhalation. ▪ Purse lips when exhaling not inhaling (inhale through nose, exhale through mouth) ▪ Use O2 1-2 L ▪ Bronchodilator 1st ; steroid 2nd ▪ Copd- Hyperresonance Flail Chest- ▪ Treatment- prevent atelectasis and related complications of compromised ventilation- encourage cough and deep breathing. ▪ Condition is generally diagnosed with clients who have 3+ fractured ribs; paradoxic movement of segment of chest wall. Suctioning may be necessary. Tuberculosis ▪ Place patient on airborne infection precautions; negative pressure room ▪ Nurses wear N95 ▪ If exposed- obtain skin test 4-6 weeks after exposure. ▪ Night sweats, anorexia, fever, frothy pink tinged sputum ▪ Antibiotics for 6-9 months; three medications o Rifampin-body secretions can be red ▪ Monitor alt/ast ▪ BCG – may make you test positive; x-ray will be needed Ventilator Patient: 74 years old; respiratory failure secondary to pneumonia. Vt is 750mL, IMV 10 breaths/min Client: pH 7.48 (alk) , PaCO2 30mmHg (alk) , PaO2 64 mmHg (decreased), HCO3 25 mEq/L (normal) Fio2: 0.80…… This patient has Respiratory Alkalosis; blowing off too much acid (hyperventilation) . ADD PEEP helps improve oxygenation Normal: pH 7.35-7.45; PaCO2 35-45; PaO2 80-100 mmHg; HCO3 22-26 Laryngectomy Teach client to be safe and carry medic alert card/bracelet stating that he is a total neck breather in case CPR is required. – THINK SAFETY!!! Mouth to neck breathing will need to be done; mouth to mouth will NOT help! Hyperresonance- copd/ Saying “99” and the lungs sounding clear Increased clarity of spoken words is indicative of consolidation- pneumonia Increase in vibrations- fluid If clear sounds it’s consolidation. Lung parenchyma can be fluid or tissue. Pneumonia- dull Absent/Diminished Lung Sounds ▪ Lungs may be filled with more air than normal ▪ Pneumothorax/Emphysema Acute Respiratory Distress Disorder ▪ Widespread inflammation of the lung ▪ Respiratory failure- diffuse lung injury ▪ “Wet lung” ▪ prone position is best, but dangerous ▪ Critically ill ▪ Mortality rate is high ▪ Elevate HOB to 30 degrees ▪ Assist with daily awakening or sedation vacation ▪ Comprehensive hygiene and mobilization Emphysema ▪ Pink Puffers- Normal skin coloring ▪ Increased AP diameter (barrel chest- “puffer”) ▪ Nail bed clubbing ▪ Fatigue ▪ Promote energy management with paced activities and rest periods ▪ May need to help clients increase fluid intake ▪ Alveoli become overstretched and retain gases Chronic Bronchitis ▪ Productive cough with grayish-white sputum that usually occurs in morning; often ignored by smokers ▪ Generally occurs for 3 months out of 1 year for 2 years for dx. ▪ Blue Bloaters- cyanosis, increase calories and protein; bronchitis; can lead to LHF- cor pulmonale Pneumonia ▪ Gram Positive ▪ Gram Negative- more resistant to ABX therapy; makes recovery difficult; can affect all lobes of the lung o E. coli, Klebsiella, Pseudomonas and Proteus ▪ Pneumococcal Pneumonia- generally strikes debilitated persons- alcoholics, diabetics, those with chronic lung diseases; mean age is 50 years old ▪ Older clients- often are not febrile; may show confusion, tachycardia ▪ Vaccine- offered once to older adults or persons with hx of chronic illness Asthma ▪ Administer bronchodilators- opens airway and relaxes smooth muscle ▪ Adrenaline or epi can cause dilation- relaxes muscles ▪ Stress, environment, exercise ▪ NO beta blockers “LOL” o Metoprolol, atenolol, propranolol, labetolol LIVER Hepatitis B ▪ Ensure all employees have Hep B series o prevention ▪ Staff could contract Hep B if exposed to blood or body fluids ▪ Wear gloves and gown when coming into contact with body fluids ▪ Blood borne ▪ Can only get Hep D if already have Hep B ▪ No treatment Hepatitis C ▪ Medications such as interferon-alfa-2a and ribavirin can cause depression; review medication side effects. ▪ Blood borne Viral Hepatitis- A&E ▪ Patient may have fatigue and diarrhea ▪ Wash hands!!!! Cirrhosis- End Stage Liver Disease- ▪ Extensive degeneration and destruction ▪ Liver tissue is replaced by fibrosis ▪ Alcohol and NAFLD ▪ Hep C Early S&S: Fatigue and enlarged liver S&S: NV, fatigue, muscle and joint weakness, jaundice, dark urine, clay colored stool, fever, abdominal tenderness RUQ, elevation of ALT/AST and bilirubin (this is why there is clay colored stool) Late signs: liver failure, portal hypertension, jaundice, peripheral edema, ascites, skin lesions (spider angiomas, palmar erythema r/t increased circulation of estrogen) hematologic disorders, endocrine disturbances Men gynecomastia, loss of hair (axillary/pubic), testicular atrophy, impotence Younger women amenorrhea Older women vaginal bleeding Hematologic: thrombocytopenia, leukopenia, anemia, coagulation disorders Leukopenia, anemia, thrombocytopenia backing up into spleen; causes splenomegaly Peripheral neuropathythiamine, folic acid, cobalamin (B12) ▪ Plan rest periods, high calorie, high carb, low sodium diet with moderate fats and protein. ▪ Serve small, frequent meals with vitamin supplements. ▪ Remove any strong odors, administer antiemetics, and have client sit up. ▪ Prevent infection to others!! ▪ Avoid any hepatotoxic drugs- alcohol, aspirin, acetaminophen, sedatives, anti-seizure meds or any medication that is contraindicated with liver damage ▪ Vitamin K may be prescribed due to normal clotting mechanism being damaged ▪ Fluids may be restricted due to ascites that accompanies cirrhosis ▪ Hepatic encephalopathy o Fector hepaticus- musty, sweet odor of breath o Alters LOC – buildup of ammonia ▪ Lethargy, somnolence, lack of coordination, decreased memory ▪ Tx: Lactulose o Asterixis- liver flap ▪ Hand is extended upward at wrist ▪ Resembles bird flapping wings o Changes in mood, personality, movement ▪ can cause difficulty with handwriting ▪ cerebral edema ▪ death Cirrhosis of liver Hct and Hgb decrease Decreased serum ammonia - If blood or protein is removed; intestines no longer breakdown as much protein which forms ammonia. - Lower protein diet or restriction may be necessary - High carb/calorie diet - Low sodium diet 2g KIDNEY GFR 125ml/min Chronic Renal Disease- Labs: ▪ Azotemia ▪ Increased Cr & BUN ▪ Decreased Ca- no vit D absorption ▪ Elevated Phos and Mag- (use phosphate binders, no mag-based antacids/Maalox) ▪ Elevated potassium; metabolic acidosis; low calcium ▪ Anemia (administer antianemic drug) o Erythropoietin- use in caution with older adults; may increase risk for thrombosis o Do not give with high HCT** ▪ Monitor Digoxin levels o Level can increase with kidney disease- S&S of toxicity: N/V/A, headache, visual disturbances, dysrhythmias, pulse 60 BPM Digoxin MONITOR K level. If patient has hypokalemia it can cause digitalis toxicity- N/V/A, headache, eye complications (seeing halos) Therapeutic range for DIG is 0.8-2ng/mL Withhold if apical pulse is LESS THAN 60 BPM. Patient with chronic renal failure often have: HTN, edema, pulmonary edema- pain, discomfort Protein must be restricted with CRF GFR is used as indicator of level of protein consumption. ▪ Monitor electrolytes ▪ Weigh daily ▪ Monitor I&O ▪ Check for JVD and other signs of fluid overload; edema/pulmonary edema o Monitor for wet sounds o Demonstrate method for splinting incision when coughing and deep breathing if patient has had transplant ▪ Provide low-protein, low-sodium, low-potassium, low-phosphate. ▪ High calorie diet. Protein is restricted until blood shows ability to handle protein catabolites; give hard candy, jelly beans, flavored carb powders. ▪ Protein- eggs, milk, meat. ▪ Fluid allowance- 500-600 mL greater than previous day’s 24 hour output. ▪ Periods of rest and activity. ▪ Strict adherence to med therapy. ▪ If hyperkalemia- Kayexalate (sodium polystyrene) ▪ Hyperkalemia with ESRD If transplant occurs, inform patient to ensure immunosuppressants are taken daily Hemodialysis ▪ If blood pressure drops- lower head of chair and elevate feet ▪ Monitor for bruit or thrill to ensure patency of graft or shunt/artertiovenous fistula ▪ Avoid taking blood pressure in arm with graft/shunt/artertiovenous fistula ▪ Decrease sodium intake Polycystic Kidney Disease ▪ UTI- requires prompt attention; bacteria will be in urine o Can cause scarring and further damage ▪ Hematuria is expected finding ▪ Early S&S- steady, dull flank pain ▪ Kidney pain may also be abrupt, episodic, colicky with bleeding into cysts Primary Aldosteronism ▪ Increase in fluid retention and sodium hypertension is most prominent sign ▪ Hypokalemia- wastes Potassium ▪ Sodium is normal or elevated depending on water reabsorption Acute Renal Failure • Nephrotoxic drugs can cause nephron obstruction which can cause patients to require dialysis until ATN subsides. • Best indicator of GFR is creatinine. Needs to be 60; creatinine is 70-135 mL/min o Elevated creatinine level indicates nephron loss, reducing filtration. o Creatinine- product of muscle metabolism Phases of ARF Oliguric- 600 ml plus previous 24 hour fluid loss; not diuresing; daily weight May gain 1 Ib/day Diuretic- monitor for S&S of hypovolemia; monitor electrolytes; begins to excessively diurese Na K Gero Considerations & Renal Function ▪ Protein rises r/t kidney changes or UTI ▪ Glucose increases slightly due to changes in kidney ▪ Specific gravity declines slightly ▪ Yellow is the easiest color for individuals with failing vision to see Pheochromocytoma • Triad of symptoms- headache, diaphoresis, palpitations • Tumor of adrenal medulla- epinephrine and norepinephrine is secreted Acute Glomerulonephritis Dietary guidelines- restrict sodium intake Restrict protein consumption Lithotripsy- used to break up calculi ▪ Monitor stream for decrease in output ▪ Strain all urine for stones ▪ Increase fluid intake ▪ Monitor for changes in urine- foul smelling; cloudy o May indicate infection TURP- transurethral prostectomy ▪ Limit driving until after first postoperative visit with HCP ▪ Small blood clots are normal; large clots are not normal ▪ Monitor for decrease in urinary stream ▪ May irrigate if there are blood clots Bladder cancer- more white men Uric acid stones- more Jewish NEUROLOGY AND BONE Neurologic system- MVE (6, 5, 4) Max on glasgow is 15; minimum is 3 Motor- 1-6; 6-verbal command, 5- localized pain, 4- flexes and withdraws 3- decorticate (internal rotation), 2- decerebrate- external rotation, 1- none Verbal- 5- oriented and converses, 4-disoriented, converses, 3- uses inappropriate words (word salad), 2- incomprehensible sound, 1- none Eyes- 1-4; four opening spontaneously, 3 verbal command, 2 to pain, 1- none 7 or less- coma 3-4 poor prognosis and high mortality 8 good prognosis for recovery Neuro VS: • Any change in LOC should be identified- Generally first indication of deterioration • Pupil size- any change in size or reactivity is indication of IICP o Hypoxia produces progression in decreased LOC may develop as confusion, lethargy, disorientation • Limb movement with scale • VS- BP, temp, pulse, respirations Monitor skin integrity and corneal integrity apply drops if necessary Check bladder for fullness, auscultate lungs, monitor cardiac If altered state of consciousness- fed via enteral route due to risk of aspiration; presence of 100 mL of residual in adult indicates poor gastric emptying; withhold feeding. Parkinson’s • Masklike expression with infrequent blinking are common features. • May have difficulty starting, maintaining, or performing motor activities. • May feel “frozen” in one spot. •  lack of dopamine (THINK…NO DOPE IN THE PARK!!) S&S of toxicity with tx: dyskinesia, hallucinations, psychosis, shuffling gait, masklike facial expression, tremors of head are common, pill rolling Carbidopa/levodopa- Sinimet Chorea • Abnormal involuntary movement disorder. • One of a group of neuro disorders- dyskinesias. • Loss of short-term memory, facial tics, grimaces, constant writhing movements; Dance like movements Myasthenia Gravis ▪ Neuromuscular disorder- communication between nerve and muscle is lost; antibodies block, alter, or destroy neurotransmitter receptors on muscle tissue. ▪ Extreme muscular weakness, easy to fatigue, ptosis, trouble talking, facial paralysis, difficulty breathing, difficulty swallowing ▪ Sporadic, progressive weakness or abnormal fatigability of striated muscles eventually cause loss of function ▪ May cause decreased tidal volume and vital capacity breathing and clearing airway can become more difficult Multiple Sclerosis ▪ Think “MS- MYELIN SHEATH” ▪ Numbness of extremities, loss of balance, and visual disturbances ▪ Patients may need to schedule extra rest periods if exacerbations occur- result of fatigue and stress. o Develop plans to avoid or minimize the effects of triggers that may cause an exacerbation of symptoms ▪ Patient’s may need to be taught how to self-catheterize ▪ Monitor patient’s for any falls and assess neuro if any occur Meningitis ▪ S&S: nuchal rigidity, photophobia, severe headache ▪ Isolated ▪ Place patient in ISOLATION ▪ Monitor for positive brudzinski- knees and legs flex when the neck is flexed ▪ Kernig sign- thigh is flexed at hip and knee at 90 degrees and subsequent extension in knee is painful ▪ Lumbar puncture- put pressure on site Basilar Skull Fracture ▪ Halo sign + CSF ▪ Can also test clear drainage for glucose, if +  CSF o Rhinorrhea; otorrhea ▪ Battle sign; ▪ High risk for infection- meningitis ▪ Monitor for S&S of infection!!! HIGH TEMP ▪ With head injuries- Look for LOC. Spontaneous eye opening is a simple measure of alertness. USE GLASGOW and neuro assessments. ▪ Impaired speech and hearing- temporal lobe; wernicke’s ▪ Impaired decision making and speaking, memory, personality changes, but can understand words; Broca’s; frontal ▪ Occipital- vision Head Injury ▪ Monitor LOC ▪ Confusion and drowsiness may indicate decreased perfusion ▪ Monitor pupils may indicate hemorrhage Osteomalacia Highest priority- risk for injury Osteoporosis ▪ Most common cause of fractured hip is osteoporosis resulting from reduced calcium in bones r/t hormonal changes in perimenopausal years ▪ Calcium loss can be slowed by increasing calcium intake and exercise o Encourage foods higher in calcium- yogurt, milk, cheese, broccoli ▪ Eliminate hazards in home- at risk for fractures from falls ▪ Bone density test- DEXA ▪ Weight bearing activity o Biking o Weights Osteoarthritis ▪ Healthy weight can help protect client’s joints ▪ Patients have decreased mobility and joint pain ▪ Prevent falls and injury ▪ Swimming is good exercise Rheumatoid Arthritis ▪ Splint can be used to prevent deformities Trigeminal Neuralgia (tic douloureux) ▪ Disorder of nerve at side of head ▪ Sudden stabbing, severe pain over lip, chin, eyes, nose, scalp, forehead, jaw ▪ Paroxysms of pain similar to electric shock ▪ Mild stimulation can cause intense pain ▪ Trigeminal Nerve-5th nerve Can be caused by: MS or similar disorder that damages myelin sheath that protects certain nerves Treatment: Typically anti-seizure meds (oxcarbazepine, lamotigrine, phenytoin, carbemazepine) SE: dizzy, confused, drowsy, nausea MONITOR LEVELS!!- 10-20mg/L for phenytoin Some can cause liver issues! Monitor ALT/AST Clonazepam Gabapentin- “NEURONTIN” often used for nerve pain (I THINK NEURO.. Nerves) Botox injections Meniere’s Tinnitus, vertigo, hearing difficulties Meclizine Bell’s Palsy Unilateral facial weakness and paralysis Disorder of hypoglossal nerve- 12th Difficulty in chewing, talking, swallowing Scleroderma Abnormal blood flow in response to cold is precipitated with scleroderma. Keep room warm. CVA Biggest risk factors: Hypertension and DM REMEMBER “MONA”- morphine, oxygen, nitro, ASA Do not use ASA in acute period; discern between ischemic or hemorrhagic stroke Ischemic stroke- TPA; more likely to survive, poor prognosis Hemorrhagic- craniotomy; most deadly but best prognosis Expressive Aphasia Broca’s- frontal lobe Client understands what is being said but client is unable to verbally communicate Encourage communication- with pictures; whiteboard Understanding Wernicke’s Client is unable to understand but can speak Client’s responses do not make sense Gout Encourage intake of 3L daily to help decrease amount of uric acid Allopurinol- uric acid CANCER AND HEMATOLOGY Cancer- ▪ Patient should eat meal low in fat; avoid high fat dairy products ▪ Avoid uncooked foods. ▪ Avoid water standing in cups. ▪ Encourage 3L of fluid intake. ▪ Wash hands, avoid crowds, or infected people. ▪ Neutropenic and reverse isolation as needed. ▪ Use soft-bristle tooth brush and salt and soda mouth rinse. ▪ Avoid lemon glycerin swabs and rectal thermometers. ▪ If patient has thrombocytopenia- handle gently with avoiding needle sticks if possible. Use smallest gauge. Apply pressure for 10 mins after needle stick. ▪ Use electric razor only and avoid blowing/picking nose and ASA ▪ Biopsy offers definitive confirmation ▪ Provide PAIN relief!!!! ▪ If patient is undergoing radiation therapy- do not allow visitors during treatment ▪ CT scans- uses narrow bean x-ray to provide cross-sectional view of organs ▪ MRI- magnetic fields and radiofrequency ▪ Help client become aware of their expectations if they are diagnosed; assess client for any doubts ▪ Try to lessen fears and anxiety- ensure client has a good understanding and that Chemotherapy ▪ Affects cells of body that grow rapidly- these are both normal and malignant cells o Hair may fall out ▪ Causes rapid cell catabolism- tumor lysis syndrome; rapid destruction of large number of tumor cells; intracellular contents are released, including potassium and purines into blood; Purines- converted to uric acid and may cause hyperuricemia; this can cause blockage in the kidney tubules and may lead to ARF - Patient will have low neutrophil count after chemotherapy o No raw fruits, veggies, flowers o Avoid large crowds, infected individuals Patient should not have large amounts of hematuria Contact HCP Tumor Lysis Syndrome ▪ Metabolic abnormality- complication during treatment of cancer when large amounts of tumors are killed off and lysed releasing contents into bloodstream. ▪ S&S- hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia, high BUN and azotemia. ▪ Hyperkalemia- cardiac conduction abnormalities; severe muscle weakness or paralysis ▪ Hyperphosphatemia- AKF, deposits calcium phosphate crystals in kidney parenchyma ▪ Hypocalcemia- tetany, sudden mental incapacity, parkinsonian movement disorders, trousseau’s and chvostek’s Multiple Myeloma ▪ Malignancy of plasma cells- infiltrates bone causing demineralization and hypercalcemia ▪ Maintain urine output of 1.5-2L per day to promote excretion of calcium ▪ Encourage fluid intake of 3-4 L per day ▪ May have risk of pathological fracture due to osteoporosis ▪ Encourage mobilization and weight bearing to promote bone reabsorption of calcium ▪ Include pain management in plan of care Anemia- ▪ Encourage foods with Iron- red meats, organ meats, whole wheat products, spinach, carrots ▪ Folic acid- green vegetables, liver, citrus ▪ Vitamin B12- meat, yeast, green veggies, milk/cheese (low-fat) ▪ Iron supplements- take on empty stomach 1 hr before meals, 2 hour after meals and with vitamin C for enhanced absorption. ▪ If patient has pernicious anemia- administer B12 parentally; they no longer have IF to absorb B12. ▪ If parenteral iron is required, Z track method. ▪ If oral iron is required- may turn stools black. Give liquid through stray with oral care after to prevent staining teeth. Thrombophlebitis ▪ Pain in calf upon exertion which is relieved by rest and elevation ▪ Typically occurs with exercise at site of thrombus- aggravated by placing extremity in dependent position. ▪ Risk increases in women taking contraceptives- Notify HCP if pain in calves occur. ▪ Use SCD’s to prevent thrombophlebitis ▪ Do not assess for Homan’s sign if client has thrombophlebitis. DVT ▪ Goal is to prevent- leg exercises; ROM ▪ If patient has reddened area on calf with pain- assess circumference and compare to second leg. Most important- auscultate breath sounds r/t pulmonary embolus secondary to DVT. ▪ Patients should remain in bed with affected leg elevated; Initial care is bedrest and elevation. ▪ If suspected DVT, infuse NS S&S: aching pain, redness, warmth DIC ▪ Septic emboli- can lodge in small arterioles- causes decrease in circulation and may lead to gangrene ▪ Fibrogen levels are decreased ▪ Developed from septicemia ▪ Abnormal clotting cascade; patient will need FFP HIV ▪ Diagnosing AIDS- when T count is below 500 with infection ▪ Infections typical are: PCP, candidacies, crytpococcus, cryptosporidiosis, Kaposi’s sarcoma, CNS lymphomas, Pneumonia jivorec ▪ Wear gloves when coming into contact with blood or bodily fluids ▪ Positive antibodies show up with ELISA in 6-12 weeks Sarcoidosis ▪ Inflammatory condition- formation of widespread granulomatous lesions involving pulmonary site ▪ Chet radiography can identify sarcoidosis ▪ Biopsy is necessary for definitive confirmation HEART Alcoholism and Heart complications- BP 90/54; HR 160/min- give MAGNESIUM Hypomagnesemia is recommended for torsades de pointes (type of polymorphic ventricular tachycardia); usually associated with prolonged QT interval that occurs with hypomagnesemia Heart Medications Amiodarone- increases QT interval Procainamide- increases QT interval Lidocaine- antiarrhythmic of choice; drug-induced monomorphic VT Heart Rhythm- Monitor client for safety. Clint may be at risk for injury due to decreased cardiac output. Client may have syncope and may fall. V Fib- life-threatening dysrhythmia ▪ Cardiac EMERGENCY ▪ Irregular undulations of varying amplitudes from coarse to fine ▪ NO cardiac output ▪ 1.CPR ▪ 2.Defibrillation ▪ Anti-dysrhythmic drugs A Fib- chaotic activity with AV Node; no true P waves, irregular ventricular rhythm ▪ Anticoagulant therapy due to risk of stroke ▪ Should be given before rhythm control therapies- prevents cardioembolic event ▪ Cardioversion to treat atrial dysrhythmias ▪ May be given digoxin ▪ Slows rate of conduction by prolonging refractory period of AV node; decreases rate and CO. ▪ Used for uncontrolled A. Fib- results in decreased CO A flutter- saw-toothed; fluttering in chest, ventricular rhythm stays regular ▪ Cardioversion ▪ Anti-dysrhythmic drugs ▪ Radiofrequency cath ablation V tach- wide, bizarre QRS ▪ Assess pulse, impaired cardiac output ▪ Racing pulse with exertion ▪ Synchronized cardioversion if pulse is present ▪ IF NO PULSE treat as V FIB ▪ CPR and defib ▪ Anti-dysrhythmic drugs Cardioversion is delivery of synchronized electrical shocks; Defibrillation- Lidocaine- treats V dysrhythmia Atropine- treats symptomatic sinus bradycardia Myocardial Infarction ▪ First line of treatment- ACE inhibitor ▪ Ventricular ectopy (multiple PVC’s) is caused by myocardial ischemia exacerbated by hypokalemia ▪ Elevated CK-MB o Most sensitive and reliable indicator of damage of cardiac enzymes o Peaks in 12-20 hours after infacrction ▪ Elevated LDH o Peaks around 48 hours ▪ Women may complain of pain in substernal region; may take antacids- if no relief place client on cardiac monitor PVC’s- Tx: increase O2- this provides increased oxygen flow rate and provides more oxygen to client’s myocardium and may decrease irritability; premature ventricular contractions of QRS complex ▪ May appear inverted, near T wave; often no P wave before. Ventricles are attempting to contract without the atrium contracting first. ▪ Can be multifocal PVC ▪ Couplet/Bigeminy (every 2nd) ▪ Ventricular trigemini 2 normal QRS, 3rd is abnormal, no pwave, widened QRS with depressed S wave Angina Pectoris Help patient to sitting position. Stop all activity immediately to reduce oxygen requirement. Cardiac Tamponade- Pericarditis ▪ Fluid collection in pericardial sac- decreases CO o Decreases ventricular filling ▪ Muffled heart sounds ▪ May cause CVP to become increased due to compressed ventricle during diastole with decrease in CO; causes right atrial and venous congetsion ▪ JVD- (if noticed when supine, raise client to 30- 45 degrees; assess in semi-fowler’s) o If noticed with fluids, slow fluid down; volume overload ▪ Tx: Pericardial Tap ▪ Pericardial frictuion rub may be present with pericarditis o Sitting up and leaning forward relieves pain Left Sided Heart Failure S3 is present with Left sided heart failure Right Sided Heart Failure Pacemakers Feelings of dizziness can occur as a result of decreased HR ECG ▪ ABC’s are always priority- so if ECG tracing is available it needs to be reviewed ▪ Electrolytes, hypothermia, etc. can cause dysrhythmias! ▪ If client does not have ECG done and has heart complications this is a priority and needs to be completed ASAP! Evaluation should be done 24 hours to 2 weeks prior to surgery if patient is over 40 years old and has hx of CVD. ▪ Any client admitted with heart failure needs to have continuous cardiac monitoring- especially if there have been any dysrhythmias or electrolyte imbalances that can alter rhythm. Reading ECG’s ▪ Depolarization from the AV node throughout the ventricles on the ECG is the QRS. ▪ P wave- depolarization of atria o (repolarization of atria is lost when depolarization of ventricles occur, so it is not recorded) ▪ T wave- repolarization of ventricles ▪ Interval between PR-QRS: length of time it takes for impulse to travel from atria to ventricles MCL I Telemetry monitoring ▪ Negative polarity LEFT shoulder ▪ Positive RIGHT chest nipple line ▪ Ground left chest nipple line Buerger’s Disease- “Thromboangitis obliterans” SMOKING cessation is most important Intermittent Claudication If patient has leg pain, encourage progressive leg exercise. Abdominal Aortic Aneurysm Monitor client for S&S of shock after surgery ENDOCRINE Cushings ▪ Encourage patient to take glucose levels daily r/t hypersecretion of glucocorticoids in adrenal cortex; may develop DM. ▪ Patient has generalized edema ▪ Potassium is generally obtained by diet ▪ Excessive glucocorticoids ▪ Hyperglycemia Addison’s – adrenal crisis ▪ Cyanosis, fever, classic signs of shock ▪ Hypoglycemia, hypovolemia, hypotension ▪ Hyperkalemia SIADH Encourage client to use hard candies when thirsty Hyperparathyroidism Nausea, vomiting, muscular weakness Hypoparathyroidism- causes DECREASED CALCIUM May be c aused by: parathyroidectomy Inability of parathyroid glands to produce PTH Inability of kidneys and bones to respond to PTH Low levels of mag Excessive radiation Autoimmune S&S: Dry hair, brittle nails, heavier periods, weakened tooth enamel Numbness, tingling, cramps in extremities (tetany, Chvostek sign, Trousseau sign, parasthesias, Prolonged QT) Treatment: Restore Ca and mineral balance in body Take vitamins with calcium and vitamin D - Calcium intake should be 1500 mg daily Hypothyroidism Monitor LOC if patient presents with lethargy and confusion Diabetes Insipidus May occur after head injury; large amount of urine output; multiple liters per day MEDICATIONS Vecuronium Bromide Causes muscle paralysis Used when patient is mechanically ventilated (on respirator) Helps increase tolerance of endotracheal intubation Patient will be unable to move/talk- they cannot communicate needs Beta Blockers “LOL” Can cause bradycardia- blocks SNS so it slows down the HR and decreases contractility Dobutamine Sympathomimetic- direct acting cardiac stimulant, increases HR ACE INHIBITORS- “PRIL”- angiotensin converting enzyme inhibitor Blocks conversion of angiotension 1 to 2; decreases aldosterone (H20 and Na) so reduction in fluid retention ▪ Diuretic- take in the morning; if taken later can cause nocturia ▪ Can cause HYPERKALEMIA (ARBS (sartan’s) can cause this too!!) ▪ Causes annoying “cough” ▪ Can cause angioedema- facial/throat swelling and lip swelling (emergency) ▪ Do not instruct patient to stop taking unless emergency- continue until speaking with HCP; can cause rebound hypertension ▪ Generally not well tolerated in African Americans ▪ Often first line use in treating heart disease!! ▪ May also be used to help decrease excessive water intake in patients with schizophrenia Diuretics- ▪ Furosemide ▪ Hypokalemia- LOW AND UNDER “U wave” ▪ Hyperkalemia- TALL AND TOO MUCH “T WAVE”, prolonged QT, Widened QRS ▪ If BNP is elevated r/t HF diuretic may be given ABX- Draw trough 5 mins before next dose and 30 mins-1 hour after dose is given. - Generally done with aminoglycosides!! o Vanc, Gent, Tobramycin ▪ Monitor for tinnitus Nystatin Used to treat candidiasis. SWISH AND SWALLOW. – hold med in mouth a few minutes before swallowing Morphine Should not be used if patient has asthma- histamine-releasing opioid; can cause exacerbation Thiazide Diuretics ▪ Hydrochlorothiazide, chlorothiazide ▪ K wasting-supplement may be given if level is low Vasopressin- Causes constriction of blood vessels- can help reduce any type of bleeding Can be used for esophageal varice rupture May cause vasoconstriction of coronary arteries and lead to angina If any chest tightness occurs- stop med; start NITRO or some type of vasodilator Loop Diuretics ▪ Furosemide (Lasix) ▪ If BNP is elevated r/t HF diuretic may be given ▪ Bumetadine (Bumex) ▪ K wasting- may need supplement ▪ Clients should take early; can cause nocturia and disturb sleep Albumin ▪ Albumin should be infused within four hours because it does not contain any preservatives ▪ Any fluid remaining after four hours should be discarded ▪ This frequency is often used during the first hour of a blood transfusion. ▪ A large gauge catheter allows for fast infusion rate, which may be necessary Hemodilution may decrease hemoglobin and hematocrit ▪ Increased blood volume and blood pressure may cause bleeding ▪ Monitor VS to assess for fluid volume overload (Q1-2 hours) Aluminum Hydroxide Binds to phosphorus to help with elimination TRAUMA Amputation When patients have had amputation- have tourniquet at bedside in case severe bleeding occurs- THINK SAFETY!! What could happen?? What will help? Residual limb- part that remains after amputation; do not raise on pillows- flexion contracture at hip can result Constant direct pressure should be avoided because it can alter wound healing. Allow client to lie in prone position to prevent flexion and contracture of the hip! When wrapping amputation, apply to distal then wrap to proximal to encourage venous return and prevent impaired circulation Penrose Drain ▪ Surgical drain placed in wound to prevent buildup of fluid- often from abscess; best to have client in private room to prevent contamination. ▪ A penrose drain does not require any suction. ▪ Can also be used to drain CSF with hydrocephalus Burns ▪ Full-thickness burns destroy the entire dermal layer- Included in this destruction is the regenerative tissue ▪ Observe for inhalation injury with any facial, neck, upper torso burns o Monitor for hoarseness, stridor, dyspnea ▪ Can cause swelling of upper respiratory tract ▪ Prevent hypovolemic shock- monitor urine output of 30-50mL/hr o Measures tissue perfusion ▪ tissue regeneration does not occur, and skin grafting is necessary ▪ Jewish clients get xenograft from nonhuman sources ▪ Ocular burns- flush lids, conjunctiva and cornea to prevent further damage o Irrigation ▪ Help prevent contractures- place any burned areas in a functional position to help prevent any deformities ▪ After burns occur, fluid generally shifts from the intravascular space to the intracellular space ▪ Use rule of 9’s to estimate TSBA burned Insurance Advantage of PPO- insurance coverage is less expensive to employers WOMENS HEALTH AND STD’s Perimenopause Postmenopausal Notify HCP if there are episodes of vaginal bleeding- may indicate endometrial cancer Estrogen deficiency causes vaginal tissues to become dry and thin Breast Cancer ▪ Staging and typing- tumor’s estrogen receptor guides treatment options o Tumors can be estrogen secreting or progesterone secreting ▪ Poorest prognosis- Inflammatory with peau d’orange ▪ Non-mobile mass with poor margins/edges- possibly cancer ▪ Fibrocystic changes of the breast- perform BSE monthly ▪ Newly retracted nipple may be an indication of breast cancer and needs follow up Intermittent nipple discharge is common in 80% of women ▪ Yearly mammogram should be done after age 40 ▪ BSE should be recommended for all women ▪ Individuals who have BRC2 and BRC2 or family history of cancer should be recommended and followed closely by HCP ▪ Tender lumpiness bilaterally is common for fibrocystic breasts ▪ Most lumps are benign but it is always best to go in for an exam TSS Do not leave diaphragm in place longer than 8 hours Replace old every three months Diaphragm should be in for 6-8 hours after intercourse Mastectomy ▪ Avoid BP measurement and constriction of clothing on affected arm- can cause lymphedema ▪ Lymphedema- prevent by elevating arm above heard to promote venous return Genital Herpes ▪ Teach to have annual physical and pap smear ▪ Take antiviral medications as prescribed ▪ Use condoms to avoid transmission to others ▪ Warm sitz bath can relieve itching Testicular Examinations ▪ Should begin performing before age 20 ▪ Assess in shower ▪ Commonly occurs between ages 20-30 years old ▪ Elevated HCG levels EYES Visual Changes Aging- less elasticity of lens; leads to vision burring Muscles of iris become more stiff and pupils dilate more slowly and less completely Do not give anticholinergics to an individuals with narrow angle glaucoma