HESI STUDY GUIDE ACUTE CARE NURSING

1 HESI STUDY GUIDE ACUTE CARE NURSING Acute Kidney Injury Acute Pancreatitis - Care 1. Withhold food and fluid during acute period and maintain hydration with IV fluids 2. Administer TPN for severe nutritional depletion 3. Administer supplemental vitamins and minerals to increase caloric intake 4. NG tube to suction for patient with biliary obstruction, vomiting, or paralytic ileus 5. Administer opiates for pain 6. Administer H2-receptor antagonist or proton pump inhibitors as prescribed to decrease hydrochloric acid production and prevent activation of pancreatic enzymes 7. Instruct client to avoid alcohol, caffeine, and fatty and spicy foods 8. Stress the importance of follow-up appointments 9. Instruct client to notify HCP if acute abdominal pain, jaundice, clay-colored stools, or dark colored urine 10. Monitor for neuromuscular manifestations of hypocalcemia (tetany, muscle twitching, grimacing, seizure, altered deep tendon reflexes and spasms) 11. Place patient in semi-Fowler’s position to decrease pressure on the diaphragm (sitting up or leaning forward helps reduce pain) 12. Encourage the client to cough and deep breathe, and/or use incentive spirometry 13. Monitor for dysrhythmias related to electrolyte imbalance Addison’s Disease 1. Autoimmune disorder commonly found in conjunction with other autoimmune endocrine disorder, a primary disorder, hypofunction of the adrenal cortex 2. Sudden withdrawal from corticosteroids may precipitate symptoms of Addison’s disease (patients should be cautioned against stopping steroids suddenly, they must be tapered off slowly) 3. Characterized by lack of cortisol aldosterone, and androgens 4. Definitive diagnosis made using an ACTH stimulation test 5. If ACTH production by the anterior pituitary gland has failed, it is considered secondary disease 6. Requires lifelong replacement of glucocorticoids and possibly mineralocorticoids if significant hyposecretion occurs; the condition is fatal if left untreated 7. Patients taking exogenous corticosteroids must establish a plan with their HCPs for increasing corticosteroids during times of stress Addison’s Crisis 1. A life-threatening disorder caused by acute adrenal insufficiency 2. Precipitated by stress, infection, trauma, surgery, abrupt withdrawal from corticosteroid use, or decreased salt intake 3. Can cause hyponatremia, hyperkalemia, hypoglycemia, and shock 2 4. S/S – severe headache, severe abdominal pain, leg and lower back pain, generalized weakness, irritability and confusion, severe hypotension, shock 5. Treatment - prepare to administer glucocorticoids IV; IV fluids to replace fluids and restore electrolyte imbalance; following resolution of the crisis administer oral glucocorticoid and mineralocorticoid; monitor vitals and urine output; monitor neurological status especially irritability and confusion; monitor lab values especially Na, K, Glucose; protect patient for infection; maintain bedrest and provide a quiet environment AED Use Allergic Rhinitis ALS - priority finding Aneurysm findings – action Angina - exercise 1. Occurs when oxygen supply is insufficient to meet demand 2. Often precipitated by exercise Angiogram- difficulty swallowing Antiviral – shingles 1. Caused by a reactivation of the varicella-zoster virus, can occur during any immunocompromised state in a patient with history of chickenpox 2. Antivirals are often used to treat shingles Assess 1 st - appendicitis 1. Monitor for signs of peritonitis: a. guarding of abdomen b. fever and chills c. pallor d. progressive abdominal distention and pain e. Restlessness f. Tachycardia and tachypnea Asthma acute findings Symptoms of hypoxia a. early – restlessness, anxiety, tachycardia, tachypnea, decreased oxygen saturation b. late – bradycardia, extreme restlessness, severe dyspnea, cyanosis respiratory acidosis Asthma – exercise and steroid inhaler Encourage patient to have inhaler on hand and may need to use prior to exercise Autonomic Dysreflexia 3 1. Generally occurs after a period of spinal shock is resolved and occurs with lesions or injuries above T6 and in cervical lesions 2. Commonly caused by visceral distention from a distended bladder or impacted rectum (constipation) 3. Neurological emergency that must be treated immediately to prevent a hypertensive stroke 4. Signs and Symptoms: a. sudden onset of severe, throbbing headache b. severe hypertension and bradycardia c. flushing above the level of the injury d. pale extremities below the level of the injury e. nasal stuffiness f. nausea g. dilated pupils or blurred vision h. sweating I. piloerection (goose bumps) j. restlessness and apprehension BPH signs and symptoms 1. diminished size and force of urinary stream (early sign) 2. urinary urgency and frequency 3. nocturia 4. inability to start (hesitancy) or continue urine stream 5. feelings of incomplete bladder emptying 6. post-void dribbling from overflow incontinence (late sign) 7. urinary retention and bladder distention 8. hematuria 9. urinary stasis and UTIs 10. dysuria and bladder pain Bariatric surgery – abdominal pain Post-op abdominal pain, nausea, and vomiting may indicate a gastric leak Bariatric surgery- postop diet Bone pain management Breast cancer detection Breast engorgement relief Bucks Traction Nurses must be vigilant in assessing for subtle neurovascular changes in these patients (Turney, Noble, & Kim, 2013). The “6 Ps” indicative of symptoms of neurovascular compromise 4 eliminated. are pain, poikilothermia (i.e., takes on the ambient temperature), pallor, pulselessness, paresthesia, and paralysis (Pechar & Lyons, 2016). Early recognition of diminished circulation and nerve function is essential to prevent loss of function. When caring for the patient in traction, the nurse should follow these additional principles: • Traction must be continuous to be effective in reducing and immobilizing fractures. • Skeletal traction is never interrupted. • Weights are not removed unless intermittent traction is prescribed. • Any factor that might reduce the effective pull or alter its resultant line of pull must be • The patient must be in good body alignment in the center of the bed when traction is applied. • Ropes must be unobstructed. • Weights must hang freely and not rest on the bed or floor. • Knots in the rope or the footplate must not touch the pulley or the foot of the bed. Circulatory assessment consists of: Peripheral pulses, color, capillary refill, and temperature of the fingers or toes. Manifestations of deep vein thrombosis (DVT), which include unilateral calf tenderness, warmth, redness, and swelling. The nurse also encourages the patient to perform active foot exercises every hour when awake. Burns - fluid resuscitation 1. There are many methods used to calculate the amount of fluid needed during the resuscitation period of burn wounds. The Parkland (Baxter) formula is most commonly used and is as follows: 4ml/kg/% of Total body surface area of burn (TBSA) – This formula uses only crystalloids (Lactated Ringer’s). 2. The Parkland formula calculates the total fluid volume to be given within the first 24 hours and recommends administering the fluids as follows: (p. 439 in your text book) a. ½ of total volume in the first 8 hours b. ½ of total volume in the second 8 hours c. ¼ of total volume in the third 8 hours 2. The goal is to prevent shock by maintaining adequate circulating blood volume and maintaining vital organ perfusion 3. IV fluid replacement may be titrated on the basis of urine output and electrolyte levels to meet the perfusion needs of the patient 4. Urine output is the most reliable and most sensitive noninvasive assessment parameter for cardiac output and tissue perfusion 5. The amount of fluid administered depends on how much IV fluid per hour is needed to maintain urinary output of 30-100 ml/hr. 6. Successful fluid resuscitation is evaluated by stable vital signs, and adequate urine output, palpable peripheral pulses, and intact LOC and though processes. 7. Massive volumes of IV fluids are given and it is not uncommon to give over 1000 ml/hr during various phases of burn care. 5 Burns – nursing intervention 1. Fluid management/resuscitation 2. Prevention of infection 3. Pain management 4. Wound care 5. Monitor urine output, BUN, Creatnine 6. Airway, breathing, circulation, deformity, exposure CAD - prevention 1. Manage and control cholesterol and triglycerides 2. Increase HDL and decrease LDL 3. Increase physical activity 4. Medications 5. Tobacco cessation 6. Manage hypertension 7. Control diabetes Calcium oxalate calculi – foods Cancer pain Patients benefit from a combination of short acting meds and long acting medications given on a fixed schedule Carpal spasm - assessment – indicates hypocalcemia Trousseau sign can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal tunnel syndrome (an adducted thumb, flexed wrist and metacarpophalangeal joints, extended interphalangeal joints with fingers together) will occur as ischemia of the ulnar nerve develops Cataract extraction- discharge teaching - Wear glasses or eye shield following surgery as instructed. - Always wash hands before touching or cleaning the postoperative eye. - Clean postoperative with a clean tissue; wipe the closed eye with a single gesture from the inner canthus outward. - When bathing or showering, shampoo hair cautiously or seek assistance. - Avoid lying on the affected side the night of surgery. - bathing or showering, shampoo hair cautiously or seek assistance. - Keep activity light (e.g., walking, reading, watching television). Resume the following activities only as directed by the ophthalmologist; driving, sexual activity, unusually strenuous activity. - Avoid lifting, pushing, or pulling objects heavier than 15 pounds. - Avoid bending or stooping for an extended period. 6 - Be careful when climbing or descending stairs. Chemotherapy – N/V Chest pain – ACS algorithm Chest tube disconnect If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent pneumothorax if the chest tube is inadvertently disconnected from the drainage system, a temporary water seal can be established by immersing the chest tube’s open end in a bottle of sterile water. Chest tube water seal bubbling Intermittent bubbling in the water seal chamber is normal, but continuous bubbling can indicate an air leak. Bubbling and tidaling do not occur when the tube is placed in the mediastinal space; however, fluid may pulsate with the patient’s heartbeat. Chronic Kidney Disease – labs 1. Elevated potassium 2. Decreased GFR 3. Anemia 4. Elevated phosphorous 5. Metabolic acidosis 6. Decreased calcium 7. Client education - wound care Colon Trauma Compartment syndrome – pain Do not ignore patient complains of pain Constipation – plan Continuous bladder irrigation Contrast dye reactions – interventions 1. Assess allergies 7 2. Prepare for epinephrine administration COPD - edema diet Low sodium COPD sputum change Cranberry juice – diabetic CVA - unilateral neglect and visual perception 1. Educate patient to turn head to the affected visual filed to compensate for visual loss 2. The nurse should make eye contact with the patient and draw their attention to the affected side by encouraging the patient to move the head. 3. The nurse may also want to stand at a position that encourages the patient to move or turn to visualize who is in the room. 4. The patient with homonymous hemianopsia turns away from the affected side of the body and tends to neglect that side and the space on that side; this is known as amorphosynthesis. In such instances, the patient cannot see food on half of the tray, and only half of the room is visible. It is important for the nurse to constantly remind the patient of the other side of the body; to maintain alignment of the extremities; and, if possible, to place the extremities where the patient can see them. Cystoscopy DKA- infection DM- long term complications DNR family notification DVT heparin treatment Dehydration treatment Delusions Diabetes A1C Assessment Diabetes Insipidus - signs and symptoms 1. Enormous daily urine output greater than 250 ml/hr 2. Dilute urine with a specific gravity of 1.001 to 1.005 3. Intense thirst, patient may drinki 2 to 20 L of fluid daily and craves cold water 4. Loss of urine continues without fluid replacement 8 5. Attempt to restrict fluid intake cause the patient to experience insatiable thirst and to develop hypernatremia and severe dehydration Diabetes acute confusion Monitor for hypoglycemia Diarrhea assessment Emphysema – patient education 1. The patient should be taught diaphragmatic breathing, which reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and helps the patient control the rate and depth of respiration. It also promotes relaxation, enabling the patient to gain control of dyspnea and reduce feelings of panic. 2. The patient may need additional time to complete activities and may need help in pacing activities, especially those that that require the arms to be positioned over the head. Fluid overload Gastritis – symptoms Gastroplexy GERD- patient education 1. Management begins with educating the patient to avoid situations that decrease lower esophageal sphincter pressure or cause esophageal irritation. 2. The patient is instructed to eat a low-fat diet 3. Avoid caffeine, tobacco, beer, milk, foods containing peppermint or spearmint, and carbonated beverages 4. Avoid eating or drinking 2 hours before bedtime; maintain normal body weight; avoid tight- fitting clothes 5. Elevate the head of the bed by at least 30 degrees. Grave’s Disease Guiac – positive result – correlating lab results 1. Decreased platelets 2. Anemia Guillain Barre nursing priority 9 1. GBS typically begins with muscle weakness and diminished reflexes of the lower extremities. Monitor ABCs 2. The nurse assesses the blood pressure and heart rate frequently to identify autonomic dysfunction so that interventions can be initiated quickly if needed. Medications are given or a temporary pacemaker placed for clinically significant bradycardia. 3. Nursing interventions to enhance physical mobility and prevent the complications of immobility are key to the function and survival of patients. 4. Thorough assessment of respiratory function at regular and frequent intervals is essential, because respiratory insufficiency and subsequent failure due to weakness or paralysis of the intercostal muscles and diaphragm may develop quickly. Respiratory failure is the major cause of mortality. 5. Paralytic ileus may result from insufficient parasympathetic activity. In this event, the nurse administers IV fluids and parenteral nutrition as a supplement and monitors for the return of bowel sounds. If the patient cannot swallow because of bulbar paralysis (immobility of muscles), a gastrostomy tube may be placed to administer nutrients. The nurse carefully assesses the return of the gag reflex and bowel sounds before resuming oral nutrition. 6. Patient’s may also need lubricant and eye shields for their eyes to prevent dryness. Heart Failure Exacerbation – interventions to reduce cardiac workload 1. Alternate activity with rest periods and avoid having two significant energyconsuming activities occur on the same day or in immediate succession. 2. Because some patients may be severely debilitated, they may need to limit physical activities to only 3p to 5 minutes at a time, one to four times per day. 3. Talk with your primary provider for specific exercise program recommendations. 4. Begin with low-impact activities such as walking. 5. Start with warm-up activity followed by sessions that gradually build up to about 30 minutes. 6. Follow your exercise period with cool-down activities. 7. Avoid performing physical activities outside in extreme hot, cold, or humid weather. 8. Wait 2 hours after eating a meal before performing the physical activity. 9. Ensure that you are able to talk during the physical activity; if you cannot do so, decrease the intensity of activity. 10. Stop the activity if severe shortness of breath, pain, or dizziness develops. 11. Use bedside commode. 12. Space nursing interventions 13. Assist patient to ambulate HIV health promotion and CD4 count HTN poor control patho Hepatitis A - preicteric phase 10 Herpes Zoster (shingles) In the pre-eruptive phase - The patient will typically complain of pain, or sometimes pruritus or paresthesias, over the sensory region that follows that dermatome. This phase lasts from 1 to 10 days, with 48 hours being typical. Acute Eruptive phase – is heralded by the appearance of unilateral patchy erythematous areas in the dermatomal area that is affected. Vesicles develop that appear initially clear, then become cloudy, and eventually rupture and crust. The pain that accompanies this stage is typically described as severe and unrelenting. This phase typically lasts between 10 and 15 days. Postherpetic neuralgia (PHN) phase - is variable in terms of both duration and manifestations. The pain is typically localized to the dermatomal area that was affected. Approximately 50% of adults older than 60 years with herpes zoster experience PHN pain for longer than 60 days Treatment - infection can be arrested if oral antiviral agents such as acyclovir (Zovirax), valcyclovir (Valtrex), or famciclovir (Famvir) are given within 24 hours of the initial eruption. IV acyclovir may be indicated in patients who are immunocompromised. The goals of management are to relieve the pain and to reduce or avoid complications, which include infection, scarring, and PHN and eye complications. Pain is controlled with analgesic agents because adequate pain control during the acute phase helps prevent persistent pain patterns. Systemic corticosteroids may be prescribed to reduce the incidence and duration of PHN. Healing usually occurs more quickly in those who have been treated with corticosteroids. Triamcinolone (Aristocort, Kenalog) injected subcutaneously under painful areas is effective as an anti-inflammatory agent. Nursing Management - The patient and family members are instructed about the importance of taking antiviral agents as prescribed and in keeping follow-up appointments with the primary provider. The nurse assesses the patient’s discomfort and response to medication and collaborates with the primary provider to make necessary adjustments to the treatment regimen. The patient is educated about how to apply dressings or medication to the lesions and to follow proper hand hygiene techniques to avoid spreading the virus. Diversionary activities and relaxation techniques are encouraged to ensure restful sleep and to alleviate discomfort. A caregiver may be required to assist with dressings, particularly if the patient is an older adult and unable to apply them. Food preparation for patients who cannot care for themselves or prepare nourishing meals must be arranged. High fiber diet and hypercholesterolemia Hypoglycemia Treatment 1. The usual recommendation is for 15 g of a fast-acting concentrated source of carbohydrate. 2. It is not necessary to add sugar to juice, even if it is labeled as unsweetened juice, because the fruit sugar in juice contains enough carbohydrate to raise the blood glucose level. 3. Adding table sugar to juice may cause a sharp increase in the blood glucose level, and patients may experience hyperglycemia for hours after treatment. 4. In emergency situations, for adults who are unconscious and cannot swallow, an injection of glucagon 1 mg can be given either subcutaneously or intramuscularly. Glucagon is a hormone produced by the alpha cells of the pancreas that stimulates the liver to breakdown glycogen, the 11 stored glucose. Injectable glucagon is packaged as a powder in 1-mg vials and must be mixed with a diluent immediately before being injected. After injection of glucagon, the patient may take as long as 20 minutes to regain consciousness. 5. A concentrated source of carbohydrate followed by a snack should be given to the patient on awakening to prevent recurrence of hypoglycemia 6. In hospitals and emergency departments, for patients who are unconscious or cannot swallow, 25 to 50 mL of dextrose 50% in water (D50W) may be administered IV. The effect is usually seen within minutes. The patient may complain of a headache and of pain at the injection site. Ensuring patency of the IV line used for injection of 50% dextrose is essential because hypertonic solutions such as 50% dextrose are very irritating to veins. Hyperparathyroidism – manifestations 1. Apathy, fatigue, muscle weakness, nausea, vomiting, constipation, hypertension, and cardiac dysrhythmias may occur. 2. Increased serum calcium 3. Psychological effects from irritability and neurosis to psychosis 4. Formation of kidney stones, increase urinary calcium 5. Decrease in nerve and muscle excitation potential 6. Bone demineralization causing skeletal pain 7. Peptic ulcer development 8. Pancreatitis Hypoxia – signs and symptoms 1. Changes in mental status (progressing through impaired judgment, agitation, disorientation, confusion, lethargy, and coma) 2. Dyspnea 3. Increase in blood pressure 4. Changes in heart rate and/or dysrhythmias 5. Central cyanosis (late sign) 6. Diaphoresis 7. Cool extremities. Hypothyroidism- labs In advanced cases, the diagnosis is made on the basis of the symptoms, a decrease in serum TSH, increased free T4, and an increase in radioactive iodine uptake. Patients with myxedema may exhibit low levels of serum sodium. ICU - restlessness Ileal conduit complications 1. Complications that may follow placement of an ileal conduit include wound infection or wound dehiscence, urinary leakage, ureteral obstruction, hyperchloremic acidosis, small bowel obstruction, ileus, and gangrene of the stoma (dark discoloration of the stoma). 2. Delayed complications include ureteral obstruction, contraction or narrowing of the stoma (stenosis), kidney deterioration due to chronic reflux, pyelonephritis, renal calculi, and cancer recurrence 12 Influenza precautions Inguinal hernia repair – teaching The patient should be encouraged to avoid coughing and when necessary provided antitussives/cough suppressants to prevent Intestinal Obstruction = NGT insertion Iron deficiency Knee replacement post op bleeding Autotransfusion Lactulose therapeutic response Diarrhea with decreased potassium level Lantus insulin POC Malignant Hyperthermia – management 1. A rare inherent muscular disorder that is chemically induced by administration of an anesthetic agent such as succinylcholine. 2. Anesthesia and surgery should be postponed. However, if end-tidal CO2 monitoring and dantrolene sodium (Dantrium) are available and the anesthesiologist is experienced in managing malignant hyperthermia, the surgery may continue using a different anesthetic agent. Although malignant hyperthermia usually manifests about 10 to 20 minutes after induction of anesthesia, it can also occur during the first 24 hours after surgery. 3. Ice packs may be used to help reduce patient temperature. 4. Clinical manifestations include, tachycardia (heart rate greater than 150 bpm) may be an early sign. Sympathetic nervous stimulation also leads to ventricular dysrhythmia, hypotension, decreased cardiac output, oliguria, and, later, cardiac arrest. Hypercapnia, an increase in carbon dioxide (CO2), may be an early respiratory sign. With the abnormal transport of calcium, rigidity or tetanus-like movements occur, often in the jaw. Generalized muscle rigidity is one of the earliest signs. The rise in temperature is actually a late sign that develops rapidly; body temperature can increase 1°C to 2°C (2°F to 4°F) every 5 minutes, and core body temperature can exceed 42°C (107°F). Melanoma – teaching 13 Instruct patient to monitor for areas that have the appearance resembling a mole – Assess for the following: A – Asymmetry B – Irregular border C – Variegated color D – Diameter (> 6mm, size of an eraser is suspicious) E – Evolving (appearance changes over time) Meningitis MI symptoms and EKG changes in women 1. Although chest pain or discomfort can occur in both men and women, it is more likely to be experienced by men. On the contrary, women can experience more atypical symptoms including fatigue, nausea, neck pain, right arm pain, jaw pain, dizziness, and syncope. 2. Patient will experience that is unrelieved by rest and medication. 3. Patients may present with a combination of symptoms, including chest pain, shortness of breath, indigestion, nausea, and anxiety 4. They may have cool, pale, and moist skin. Their heart rate and respiratory rate may be faster than normal. 5. Elevated cardiac enzymes and bi0markers (Troponin, Creatinine Kinase, Myoglobin) 6. EKG Findings STEMI: The patient has ECG evidence of acute MI with characteristic changes in two contiguous leads on a 12-lead ECG. In this type of MI, there is a significant damage to the myocardium. NSTEMI: The patient has elevated cardiac biomarkers (e.g., troponin) but no definite ECG evidence of acute MI. In this type of MI, there may be less damage to the myocardium Mechanical ventilator - aspiration Keep HOB elevated at least 30 degrees Ensure endotracheal cuff inflated Migraine headache – Assessment and Diagnosis 1. Obtain health history for precipitating and provoking factors, description of pain and other medical and surgical history. 2. What is the location? Is it unilateral or bilateral? Does it radiate? 3. What is the quality—dull, aching, steady, boring, burning, intermittent, continuous, or paroxysmal? 4. How many headaches occur during a given period of time? Questions to ask the patient: 1. What are the precipitating factors, if any—environmental (e.g., sunlight, weather change), foods, exertion, other? 14 2. What makes the headache worse (e.g., coughing, straining)? 3. What time (day or night) does it occur? 4. How long does a typical headache last? 5. Are there any associated symptoms, such as facial pain, lacrimation (excessive tearing), or scotomas (blind spots in the field of vision)? 5. What usually relieves the headache (aspirin, nonsteroidal anti-inflammatory drugs, ergot preparation, food, heat, rest, neck massage)? 6. Does nausea, vomiting, weakness, or numbness in the extremities accompany the headache? 7. Does the headache interfere with daily activities? 8. Do you have any allergies? 9. Do you have insomnia, poor appetite, loss of energy? 10. Is there a family history of headache? 11. What is the relationship of the headache to your lifestyle or physical or emotional stress? 12. What medications are you taking? Multiple Sclerosis – urinary retention 1. Provide bedside commode 2. Intermittent urinary catherization 3. Bladder and bowel problems are often difficult for patients, and a variety of medications (anticholinergic agents, alpha-adrenergic blockers, antispasmodic agents) may be prescribed. 4. Nonpharmacologic strategies also assist in establishing effective bowel and bladder elimination Multiple sclerosis vision Visual disturbances due to lesions in the optic nerves or their connections may include blurring of vision, diplopia (double vision), scotoma (patchy blindness), and total blindness. Myxedema coma - meds Nasal Polyps – goals 1. Airway patency 2. Absence of infection Nausea – help Nephrotoxic drug reaction – nursing action 1. To prevent complications from nephrotoxic drugs the patient should be adequately hydrated, so IV fluids are increased. 2. The patient is also monitored for hematuria. 3. Kidney function must be monitored. 4. Limiting the patient’s exposure to contrast agents and nephrotoxic medications will reduce the risk of contrast induced nephrotoxicity (CIN). 15 5. Administration of N-acetylcysteine and sodium bicarbonate before and during procedures, reduces risk, but prehydration with saline is considered the most effective method to prevent CIN. Nephrectomy – postop Nitroglycerin infusion Osteoarthritis –exercise Osteomalcia – nursing priority Osteoporosis – goal Paracentesis for ascites – nursing management 1. The removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions. 2. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. 3. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of hepatic encephalopathy. PAD – outcome 1. Arterial blood supply to a body part can be enhanced by positioning the part below the level of the heart. 2. For the lower extremities, this is accomplished by elevating the head of the patient’s bed or by having the patient use a reclining chair or sit with the feet resting on the floor. 3. Nursing interventions may involve applications of warmth to promote arterial flow and instructions to the patient to avoid exposure to cold temperatures, which causes vasoconstriction. 4. Adequate clothing and warm temperatures protect the patient from chilling. 5. If chilling occurs, a warm bath or drink is helpful. A hot water bottle or heating pad may be applied to the patient’s abdomen, causing vasodilation throughout the lower extremities. 6. Analgesic agents such as hydrocodone plus acetaminophen (Vicodin, Norco, Lortab), oxycodone (Roxicodone), oxycodone plus acetylsalicylic acid (Percodan), or oxycodone plus acetaminophen (Percocet, Roxicet) may be helpful in reducing pain so that the patient can participate in therapies that can increase circulation and ultimately relieve pain more effectively. 6. Good nutrition promotes healing and prevents tissue breakdown and is therefore included in the overall therapeutic program for patients with peripheral vascular disease. 7. Eating a diet that contains adequate protein and vitamins is necessary for patients with arterial insufficiency. Pain scale – med selection 16 Parkinson’s bradykinesia One of the most common features of PD is bradykinesia, which refers to the overall slowing of active movement. Patients may also take longer to complete activities and have difficulty initiating movement, such as rising from a sitting position or turning in bed. Peritoneal dialysis – continuous ambulatory peritoneal dialysis 1. continuous, patient is free from a dialysis machine and has control over daily activities Peritonitis Pernicious anemia – confusion Vitamin B 12 replacement for life These patient become confused Pleural effusion – lung sounds Decreased to absent breath sounds; if large patient will be in respiratory distress and may have tracheal deviation away from the affected side Pneumothorax - signs and symptoms Post CPR - magnesium sulfate Given to patients with torsade de pointes, a type of VT Postop – bleeding Postoperative - spinal fluid leak Prednisone – symptoms 1. Mood swings 2. Weight gain 3. Electrolyte imbalances Pre-operative assessment Pre-operative checklist immediate intervention 1. Abnormal potassium level 2. Unsigned consent form 3. Patient has questions or concerns regarding surgery Prostatectomy – postoperative care 1. During the postoperative period, the patient is at risk for imbalanced fluid volume because of the irrigation of the surgical site during and after surgery. With irrigation of the urinary catheter to prevent its obstruction by blood clots, fluid may be absorbed through the open surgical site 17 and retained, increasing the risk of excessive fluid retention, fluid imbalance, and water intoxication. The urine output and the amount of fluid used for irrigation must be closely monitored to determine whether irrigation fluid is being retained and to ensure an adequate urine output. An intake and output record, including the amount of fluid used for irrigation, must be maintained. 2. Patients experiencing bladder spasms may report urgency to void, a feeling of pressure or fullness in the bladder, and bleeding from the urethra around the catheter. Medications that relax the smooth muscles can help ease the spasms, which can be intermittent and severe; these medications include flavoxate (Urispas) and oxybutynin (Ditropan). Warm compresses to the pubis or sitz baths may also relieve the spasms. 3. Nurse should help patients to deal with incontinence, anticipate leakage, and cope with lack of complete control. Preventing incontinence involves increasing voiding frequency, avoiding positions that encourage the urge to void, and decreasing fluid intake prior to activities. Promoting continence involves pelvic floor exercises (see the Educating Patients About SelfCare section that follows), biofeedback, and electrical stimulation. Psoriasis - psychosocial and assessment Pulmonary embolism - priority of care Pyelonephritis – nursing priorities 1. Hydration with oral or parenteral fluids is essential in all patients with UTIs when there is adequate kidney function. Unless contraindicated, 3 to 4 L of fluids per day is encouraged to dilute the urine, decrease burning on urination, and prevent dehydration. 2. The nurse assesses the patient’s temperature every 4 hours and administers antipyretic and antibiotic agents as prescribed. 3. For outpatients, a 2-week course of antibiotic agents is recommended because renal parenchymal disease is more difficult to eradicate than mucosal bladder infections. Commonly prescribed agents include many of the same medications prescribed for the treatment of UTIs. Raynaud’s Phenomenon – patient teaching 1. Stress management classes may be helpful. 2. Exposure to cold must be minimized, and in areas where the fall and winter months are cold, the patient should wear layers of clothing when outdoors. 3. Hats and mittens or gloves should be worn at all times when outside. 4. Fabrics specially designed for cold climates (e.g., Thinsulate) are recommended. 5. Patients should warm up their vehicles before getting in so that they can avoid touching a cold steering wheel or door handle, which could elicit an attack. 6. During summer, a sweater should be available when entering air-conditioned rooms. 7. Space heaters may be used to keep warm. 8. Patients are often concerned about serious complications, such as gangrene and amputation; however, these complications are uncommon unless the patient has another underlying disease causing arterial occlusions. 18 9. Patients should avoid all forms of nicotine; nicotine gum or patches used to help people quit smoking may induce attacks. 10. Patients should be cautioned to handle sharp objects carefully to avoid injuring their fingers. In addition, patients should be informed about the postural hypotension that may result from medications, such as calcium channel blockers, used to treat Raynaud’s phenomenon. Renal calculi- priority nursing interventions 1. The major goals for the patient may include relief of pain and discomfort, prevention of recurrence of kidney stones, and absence of complications. 2. Severe acute pain is often the presenting symptom of a patient with kidney and urinary calculi and requires immediate attention. Opioid analgesic agents (IV or intramuscular) may be prescribed and given to provide rapid relief along with an IV NSAID. 3. All urine is strained because uric acid stones may crumble 4. A priority diagnosis is pain related to renal calculus. Resuscitation – safety When defibrillating the code team member must ensure that no one is too close to the bed to prevent unintentional shock SBAR Spinal cord injury - rehabilitation transfer SIADH – electrolyte imbalance and nursing interventions 1. Patients with SIADH cannot excrete a dilute urine, retain fluids, and develop a sodium deficiency known as dilutional hyponatremia. 2. Diuretic agents such as furosemide (Lasix) may be used along with fluid restriction if severe hyponatremia is present. 3. Close monitoring of fluid intake and output, daily weight, urine and blood chemistries, and neurologic status is indicated for the patient at risk for SIADH. Supportive measures and explanations of procedures and treatments assist the patient in managing this disorder. 4. Sucking on hard candy can help with excessive thirst Sickle cell – temperature These patient are at high risk for disease so must be monitored for s/s of infection Stomatitis post chemotherapy - Advise patient to avoid irritants such as commercial mouthwashes, alcoholic beverages, and tobacco. - Brush with a soft toothbrush using a nonabrasive toothpaste for 90 seconds after meals and at bedtime. - Use oral swabs for severe moderate to severe stomatitis. - Maintain adequate hydration. - Use normal saline mouth rinses every 1-4 hours. 19 - Remove dentures except for meals; be cautious that dentures fit well. - Apply water soluble lubricant. - Avoid foods that are spicy or hard to chew and those with extremes of temperature. - Use oral rinses (may combine in solution saline, anti-Candida agent, such as Mycostatin, and topical anesthetic agent as prescribed, or place patient on side and irrigate mouth; have suction available. - Provide liquid or pureed diet. STEMI – posthrombolysis lidocaine Sputum collection Stomal Care Suprapubic catheter - prostatitis Supraventricular tachycardia (SVT) interventions 1. Adenosine rapid IV push to diagnose rhythm 2. Beta blockers (Lopressor) or calcium channel blockers to slow rhythm (Cardiazem) Testicular cancer Tuberculosis – diagnosis 1. Once a patient presents with a positive skin test, blood test, or sputum culture for acid-fast bacilli (AFB; see later discussion on these), additional assessments must be done. These tests include a complete history, physical examination, tuberculin skin test, chest x-ray, and drug susceptibility testing. 2. A sputum specimen may be used to screen for TB. The presence of AFB on a sputum smear may indicate disease but does not confirm the diagnosis of TB because some AFB are not M. tuberculosis. A culture is done to confirm the diagnosis. For all patients, the initialM. tuberculosis isolate should be tested for drug resistance. Ulcerative Colitis – Exacerbation Symptoms to report 1. GI bleeding – blood in stool especially with volume loss 2. Cardiac dysrhythmias 3. Electrolyte imbalance 4. Bowel perforation Venous leg ulcers – nursing management Cleanse with mild soap and lukewarm water. Elevate lower extremities to promote the exchange of cellular materials and waste products. Avoid injury to affected area, use protective boots. 20 For patients on bed rest relieve heel pressure and use a bed cradle to prevent pressure on toes. Avoid hot water, heating pads, or hot water bottles. Generally activity should be restricted until the infection subsides, then activity should be increased gradually. Analgesics before activity and for complaints of pain. Encourage a diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to promote healing. Particular consideration should be given to iron intake, because many patients are older adults who are at risk for iron deficiency anemia. Ventricular tachycardia interventions 1. If the patient is stable, continuing the assessment, especially obtaining a 12-lead ECG, may be the only action necessary. 2. The patient may need antiarrhythmic medications, anti-tachycardia pacing, or direct cardioversion or defibrillation. Procainamide may be used for monomorphic stable VT in patients who do not have acute MI or severe HF (Link et al., 2015). IV amiodarone is the medication of choice for a patient with impaired cardiac function or acute MI. Sotalol may also be considered for stable monomorphic VT. 3. For long-term management, patients with an ejection fraction less than 35% should be considered for an implantable cardioverter defibrillator (ICD) (see later discussion). Those with an ejection fraction greater than 35% may be managed with amiodarone.