1509 Lecture Notes

Normal pH- 7.35-7.45

• Nursing process- ADPIE

  • Assessment

  • Diagnosis

  • Planning

  • Implementation

  • Evaluation

• Subjective- said by the subject or patient

• Objective- comes from your observation, you can see it

• What’s up?

  • W- Where is it?

  • H- How does it feel?

  • A- Aggravating and alleviating factors

  • T- Timing

  • S- Severity (pain scale)

  • U- Useful other data

  • P- Patient perception of the problem

• Planning Care- What is most threatening to my patient?

• Outcome Statements-

  • Measurable

  • Realistic

  • Appropriate time frame

  • Say “No” to vague words

• Evaluate and Reevaluate every time you walk in the room and have an interaction with a patient

• Chapter 14: Causes of Infection

  • Understand infection, causes, and protection

  • Pathogens (causes a disease)

    • Microorganism- (only seen with microscope)

    • Bacteria (give antibiotic)- (take probiotic to help with antibiotic 30 minutes after taking the antibiotic)

    • Viruses (anti- virtual)

    • Fungi

• Primary- caused by one pathogen

• Secondary- caused by a different second pathogen

• Localized- found in one area of the body

• Systemic- spreads to other organs through the bloodstream

• Health-care associated infection (HAI)- an infection acquired while the patient is receiving care in a healthcare setting

• Defenses-

  • Primary: block or trap invading pathogens,

    • Skin, mucous membranes, GI system

  • Secondary: cellular level in reaction to toxins secreted by pathogens

    • Inflammatory process, elevated temperature complement cascade

  • Tertiary: specialized white blood cells lymphocytes fight infection

    • B cells or T cells

• Contact Precautions- (gloves and gown)

• Droplet Precautions- (gloves, gown, mask, shield)

• Airborne Precautions- (N95 mask, negative pressure room)

• Chapter 17- Vitals

  • BP

  • Temp

  • Pulse

  • Respirations

  • Pain

  • Oxygen Saturation

• Blood pressure

  • Cardiac Output- the amount of output of blood from the heart in one pump

  • Systolic (top) and Diastolic (bottom- relax of blood coming back)

  • Pulse Pressure (<30 or >50 Adbornaml)

  • Korotkoff’s sounds- thumbing

  • DO NOT use if amputation, mastectomy, dialysis shunt, dressing/cast/brace, vascular surgery, or trauma, IV

• Hypertension

  • >140 on 2 consecutive reading

  • Primary- results from an unknown cause

  • Secondary- results from, another problem, fix the problem, fixes the BP

  • Risk Fix- family history, smoking, stress, alcohol use, obesity

  • Permanent Damage- CVA, MI, congestive heart failure, kidney failure retinal damage

• Hypotension

  • 20-30 mmHG of a “normal”

  • Orthostatic hypotension/postural (standing up to fast)- Hypotension- position changes result in a systolic drop 15-25 mmHg or diastolic 10 mmHg

  • Transition to Trendelenburg

• Temperature- the amount of heat produced by the body

  • Core temperature- temperature of deeper structures and tissues

  • The liver produces 15-20% of body heat

  • Factors affecting body temperature

    • Environment

    • Time of day

    • Gender

    • Stress

    • Illness

    • Stress

    • Medication

    • Oral 98.6

    • Tympanic 98.6

    • Rectal 99.6

    • Axillary 97.6

  • Hyperthermia- elevations over 105

  • Hypothermia- below 95 degrees

• Pulse- a wave of blood through arteries

  • Point of maximal impulse (PMI)- Midclavicular line down 4 or 5 ribs- need a full minute

  • Pulse deficit- the difference between heart pulse and radial pulse

  • Pulse Beat- 60-100

    • Rate, rhythm, strength

    • bradycardia, tachycardia

    • +1- weak

    • +2- strong

    • +3- bounding

• Respiration

  • Ventilation- air in and out of the lugs

  • Inhalation or inspiration/exhalation or expiration

  • Rate/minure

  • Depth

  • Rhythm

  • Pattern

  • Respiratory effort

• Tachypnea- >20 bpm

• Bradypnea- <12bpm

• Eupnea- normal breathing 12-20

• Dyspnea- labored/ difficult breathing

• Orthopnea- difficulty breathing unless upright

• Tidal Volume- the amount of air inhaled in one breath 300-500

• Adventitious Sounds- abnormal sounds

• Stertorous- noisy, snoring, labored respirations audible without a stethoscope

• Stridor- high-pitched crowing sound, partial obstruction, MED EMERGENCY

• Rhonchi- continuous, low-pitched rattling, partial obstruction of larger airways d/t secretions

• Rales/crackles- air moving over secretion in the lungs, short, choppy

• Acute- sudden onset, serve symptoms, shorter course- opioids

• Chronic- longer duration, ongoing, little change- ancients, therapy

Assessment Components:

• Comprehensive health assessment: in-depth, whole person (i.e admission)

• Inspection: Visual inspection

  • Penlight: Perrla (Pupils equal, round reactive to light, accommodating)

  • Otoscope- Inspect the lining of the nose, tympanic membrane, ear canals,

  • Ophthalmoscope- internal structure of eyes

• Palpation: application of hands= touching patient

  • Abnormalities on the skin or tissue below

  • Skin turgor, growths, edema, size & location of body parts

  • Distention of bladder & strength of pulses, temp, texture, moisture, pain

  • Dorsal- more sensitive assessment of temperature

  • Classified according to depth of compression

    • Light 1-2 cm

    • Moderate 2-3cm

    • 4-5 cm

• Percussion: striking body parts with tips of fingers

  • Blunt percussion use fist rather than fingertips to tap

  • Elicit sounds to help locate/determine size of structure below the surface

    • Solid? Hollow? Fluid?

• Auscultation: listening to sounds produced by the body

  • Belching (eructation) Flatus (rectal gas)

  • Bell side for lower-pitched sounds

    • Heart Valves, murmur

  • Diaphragm side for higher-pitched sounds

    • Heart sounds, breath sounds, bowel sounds

• Olfaction- detect odor characteristics of health problems

  • Halitosis (bad breath)- poor hygiene, sinus infection, strep throat, gastric upset

    • Stress- sour smelling breath

  • Kidney failure & uremia- ammonia or urine smell on the breath

  • Liver disease- musty or sweet breath

  • Diabetic (non-compliant)- acetone or fruity aronma

  • Infectious drainage- foul odor

  • GI Bleed- rusty/iron stool or vomit

• Head to Toe shift Assessment

  • Neurological- Vital signs, LOC & Orientation (AOX4), Facial symmetry, Pupillary size & reaction (Perrla), Speech, Hand grip, Feet Flexion

  • Cardiovascular- Blood pressure & pulse, skin color, temp, moisture, mucous membranes, Jugular vein distinction (JVD), Heart sounds, peripheral pulses, capillary refill, edema, extremities (color, temp, clubbing), activity tolerance

• End of the Unit

• Chapter 8- Infection

• Body Defense Mechanisms- Skin & Mucous Membrane, Cilia, Gastric Acid (pH 1-5), Immunoglobulins, Leukocytes & Macrophages, Lysozymes, Interferon, Inflammatory Response

• Inflammatory Response

  • Vascular Response- Increase blood flow to the area

  • Inflammatory Exudate- inflammation, warm feeling, red looking

  • Phagocytosis (the forming of scabs) and purulent exudate- kick out whatever is trying to enter the body, plasma left over (drainage)

• Risk Factors for Infection- aging, environment, chronic disease, immunocompromised, dysphagia, immobility, incontinence, instrumentation

• Dysh- dysfunction

• A- absent of it

  • Dysphagia- difficulty swallowing

  • Aphagia- absent of swallowing

  • Dysphasia- difficulty speaking

  • Aphasia- absent of speak

• Localized Infection- microbes in one area, pain, redness, swelling, site warmth

• Laboratory Assessment- Culture, Sensitivity, Serum Antibody, CBC with diff, Erythrocyte Sedimentation Rate

• Asepsis- Free from organisms

  • Medical- “clean technique”- reduce pathogen/prevent, PPE

  • Surgical- “sterile technique”- an item or area that is free of all microorganisms and spores

• Respiratory tract infections-

  • High mortality rates

  • Highest-risk= endotracheal, nasotracheal, and tracheostomy tubes

  • Bypass normal defense of URT

• Genitourinary tract infections-

  • Most common

  • Urinary tract= sterile

  • Catheter insertion allows organisms to enter

  • Cauti (catheter-associated urinary tract infection)

  • Secure device, avoid back flow, closed systems

  • Remove as soon as possible

  • Bacteremia= bacteria in the blood- can turn sepsis respone

  • Excellent sterile technique is required

• Surgical Wound Infection-

  • Original dressing applied in OR= sterile

  • Monitor for change instructions

  • Dressing observation

  • Wound assessment

• Methicillin-resistant Staphylococcus Aureus (MRSA)-

  • Difficult to treat

  • Spread easily

  • High mortality rate

  • Can become a superbug

  • Contact isolation required

  • Vancomycin HCL IV antibiotic used to treat

• Vancomycin-resistant Enterococci (VRE)-

  • Enterococci are normal flora in GI/Urinary tract

  • Transmitted direct or indirect contact

  • Indwelling catheters, central venous catheters, immunocompromised, critically ill, multiple antibiotic use, surgical patients, extended hospital stays,

  • Requires isolation

  • Extremely contagious

  • Requires combination therapy to treat

• Clostridium Difficile (C. Diff)-

  • Gram + bacterium

  • Over grow & release toxins= cause diarrhea

  • 20+ stools/day, fever, bloating, abdominal pain

  • Fecal-oral transmission

  • HAND-WASHING

  • Antibiotics stopped

  • Metronidazole (Flagyll) Vancomycin given

  • High recurrence

• Therapeutic Measures-

  • Antibiotics treat bacterial infections

  • Antiviral medications treat viral infections (aimed at symptom
    control not cure)

  • Antifungal drugs for fungal infections but long-term use required

  • Bactericidal=kill bacteria

  • Bacteriostatic=inhibit growth, immune system required for final
    destruction. Not for immunocompromised patients

  • Antibiotics metabolized by the liver, excreted by kidneys.
    Disorders of organs may delay metabolism and require dose
    adjustments

• Nursing Considerations-

  • Probiotics=restore normal GI flora (30 Minutes)

  • Specimen for culture BEFORE antibiotic therapy

  • Monitor anaphylactic reactions (antibiotic reaction)

  • Blood work monitoring (peak & trough)

  • Superinfection= oral thrush, yeast

Chapter 9- Shock

• Hypovolemic Shock- circulatory collapse resulting in organ damage and death without immediate treatment

• Tissue Perfusion- adequate blood volume, effective cardiac pump, effective blood vessels

• Compensation- change in one or both of nonfailing tissue perfusion mechanisms

• Shock- failure in compensation

• Metabolic and Hemodynamic Changes in Shock

  • Sympathetic Nervous System

    • Tachycardia

    • Tachypnea

    • Oliguria

    • Cool, clammy skin with pallor

    • Urination drops

• Decreased blood pressure

• Effect on Organ and Organ Systems

  • Tissue ischemia (lack of blood flow- oxygen to an area) and organ injury

  • Brain death if anoxic over 4 minutes

• Hypovolemic Shock- low volume, blood loss

  • Apply pressure if bleeding

  • Initial symptom: Tachycardia

  • Administer isotonic fluid therapy as ordered

  • (Diaphoresis- excess sweating)

• Anaphylactic Shock- (allergic reaction to something)

  • Extreme hypersensitivity reaction to antigen

  • Teach allergy avoidance methods

  • Most Common: food allergies

  • Carry epinephrine autoinjector

  • Carry medical alert information

• Therapeutic Measures for Shock

  • Maintain airway/respiratory support

  • Provide cardiovascular support

  • Maintain circulatory volume

  • Control bleeding

  • Treat cause/ identify source of infection

• Nursing Care

  • Maintain airway, oxygenation

  • Monitor vital signs

  • Monitor intake and output

  • Provide fluids as ordered

  • Provide warmth- more blood can flow through body

  • Relieve pain

  • Monitor for pressure injury (vasopressor use)

• Urticaria- hives

• Laryngeal Edema- swelling of the airway

• O-: Can give blood to anyone

Chapter 10- Nursing Care of Patients in Pain

• Acute-

  • Lasts less than 3 months

  • Prompts an inflammatory response

  • Signs and symptoms are short-term, objective, and physical (for example, increased heart rate)

• Chronic-

  • Last more than 3 months

  • Signs and symptoms persistent

• Risks of Uncontrolled Pain

• Body produces a stress response that causes harmful substances to be released from injured tissue

• Reactions

  • Breakdown of tissue

  • Increased metabolic rate

  • Impaired immune function

  • Negative emotions

• Prevents patient from participating in self-care activities

• Opioid Addiction

  • Tolerance

  • Physical dependence

  • Addiction/psychological dependence

  • Pseudo addiction

• Pain Treatment

• Analgesics

  • Opioid

  • Nonopioid

  • Adjuvant- originally prescribed for one thing but found it can help with something else

  • Opioid Antagonists

  • Other treatments

• Analgesic Routes

  • Oral

  • Rectal

  • Inhalation

  • Transdermal

  • Intramuscular

  • Subcutaneous

  • Intraspinal

  • IV

    • Patient-controlled analgesia (PCA)- they can control the pain med themselves

• Endorphins: the body's natural reaction to pain

• Chapter 11: Nursing Care of Patients With Cancer

• Cancer Concepts-

  • Neoplasm- any new growth or including abnormal cell growth of tissue

  • Benign- abnormal cells present, not cancer yet but may be growing, can do treatment

  • Malignant- cancerous

• Cancer Pathophysiology

  • Mutation of cellular genes

  • Abnormal cell growth

  • No cell division limit

• Risk Factors For Cancer

  • Viruses- biggest viruses HPV

  • Radiation

  • Chemicals

  • Irritants

  • Genetics

  • Diet

  • Hormones

  • Immune factors

• Cancer Types

  • Carcinoma- tissue of the skin, gland, and digestive, urinary, and respiratory tract linings

    • Sarcoma- connective tissue, including bone and muscle

    • Leukemia- blood, plasma cells, and bone marrow

    • Lymphoma- lymph tissue

    • Melanoma- skin cells

• Metastasis- (most common, lung, brain, bones)

  • Invade blood or lymph vessels

    • Lodge and grow in a new location

• Most Common Cancers

  • Men- prostate, lung, colon

    • Women- breast, lung, colon

• Therapeutic Interventions

  • Surgery

    • Radiation Therapy- radiation kills bad cancer cells but also kills the good cells

    • Chemotherapy- chemicals to kill cancer

• Side Effects of Radiation

  • Fatigue

  • Nausea, vomiting, anorexia

  • Mucositis

  • Xerostomia- dry mouth

  • Skin reactions

  • Bone marrow depression

• Chemotherapy

  • Action

  • Routes of administration- usually IV

  • Combination chemotherapy

• Side effects of chemotherapy

• Bone marrow depression at nadir

  • Leukopenia- low white blood cells

  • Thrombocytopenia- low platelet count

• Anemia- low red blood cells

  • Nadir- the lowest count

• Nausea, vomiting, diarrhea

• Stomatitis

• Alopecia- hair loss

• Neurotoxicity

• Hospice Care

  • Less than 6 months prognosis

  • Inpatient

  • Outpatient

  • Interdisciplinary team

  • Family/caregivers

Chapter 19 Med/Surg- Patients with immune disorders

• Allergic Rhinitis

  • Common allergy

  • Seasonally= hay fever

  • Throughout the year= perennial

  • Environmental & airborne

  • Responses with- Sneezing, nasal itching, runny nose, itchy red eyes

  • Dark eye circles= allergic shiners (venous congestions in maxillary sinuses)

  • TX: Antihistamines, nasal decongestants, corticosteroids, saline nasal spray

• Atopic Dermatitis (Eczema)- Chronic inflammatory skin response

  • Familial

  • Itching, edema, dry skin, eruptions of blisters

  • Decreased sweating, skin thickening

  • Symptom management

  • No diagnostic tests

• Anaphylaxis- severe reaction

  • Can fall into- respiratory (happens first) & cardiac arrest

  • Immediate treatment required

  • Smooth muscle spasms (bronchial narrowing, wheezing, dyspnea, edema)

  • Cramping, diarrhea, nausea, vomiting, tachycardia, hypotension

  • Neurological changes

  • IV epinephrine, vasopressor drugs, F&E support, respiratory support

• Urticaria (Hives)

  • Red, raised, itchy patches

  • Typically trunk & proximal extremities

  • Treatment depends on the severity

  • Corticosteroids, topical steroid creams, antihistamines, histamine blockers

• Contact Dermatitis- (looks rash)

  • Skin becomes red, itchy, fragile vesicles

  • Poison ivy, poison oak most common, latex

  • Symptom control-antihistamines (drug that blocks the histamine), topical agents

Chapter 20 Med/Surg- HIV & AIDS

• HIV- Human immunodeficiency virus- (Causes destruction of immune cells)

  • T lymphocytes malfunction

  • B lymphocytes dysfunctional

  • Initial infection🡪 symptomatic stage= 8-12 yrs

  • Person-to-person transmission

  • Infected blood, vaginal secretions, semen, breast milk, body fluids containing blood

  • Casual contact does not spread the virus (hugging, shaking hands, sharing eating utensils, closed-mouth kissing, sharing towels, bathroom fixtures)

• AIDS- Acquired immunodeficiency syndrome

  • Late phase caused by HIV

  • Not all cases develop AIDS

  • T lymphocytes drop below 200!

• Transmission

  • Sexual contact (oral & anal higher rates)

  • Females at higher risk

  • Needles

  • Mother 🡪 infant

• Signs & Symptoms FOR BOTH HIV/AIDS

  • Extreme fatigue

  • Headache

  • Fever

  • Lymphadenopathy- swelling of lymph nodes

  • Diarrhea

  • Sore throat

  • SOB

  • Weight loss

  • Night Sweats

  • Shingles- Chickenpox

  • Peripheral Neuropathies- numbness of the nerves

• Treatment

  • Pre-exposure with ARV

  • Daily pill

  • Transmission precautions

• Complications

  • AIDS Wasting Syndrome- loss of more than 10% of body weight for more than 30 days, diarrhea, weakness, fever

  • HIV-Associated Neurocognitive Disorder- targets neurological system, memory loss, loss of motivation, irritability

  • Cancer- immunocompromised, abnormal cells are not being destroyed

  • Opportunistic Infections- infections that occur more often with weakened immune systems

    • Candida Albicans, cytomegalovirus, mycobacterium avium complex, pneumocystis pneumonia, tuberculosis

• Diagnosis

  • HIV Antibody tests

  • CBC/Lymphocyte count

  • T-Lymphocyte count

  • Viral load testing

  • General tests

    • Hepatitis A, B, C, liver panels, syphilis screen

• Therapeutic Measures

  • Goal= prevent or delay development of opportunistic diseases

  • ARV

    • Reduce viral loads

    • 6 drug classes available

    • Affects viruses at different stages

    • 3 medications in 2 different classes used in combination

    • Adherence is important!!

• Nursing Considerations

  • Ineffective protection

  • Pain

  • Fatigue

  • Imbalanced nutrition

  • Diarrhea

  • Impaired skin integrity

  • Risk for low self-esteem

  • Resources

  • Counseling

END OF UNIT

Chapter 53- Integumentary Function, Assessment, and Therapeutic Measures

• Subjective Assessment

  • History of Skin Disorders

  • Risk Factors

  • Hair

  • Nails

  • Medications

  • Exposures

  • WHAT’S UP?

• Physical Assessment

  • Inspection and Palpation

    • Color- Pallor (pale), Erythema (redness)

    • Lesions

    • Moisture

    • Edema- usually legs from the feet always hanging down

    • Vascular Markings- bruising, aging spots, dots on skin

    • Integrity

    • Cleanliness

    • Turgor

• Hair Distribution- (Alopecia)

  • Color

  • Quantity

  • Thickness

  • Texture

• Nails

  • Color

  • Shape

  • Texture

  • Thickness

  • Abnormalities

• Diagnostic Tests

  • Culture

  • Biopsy- aspiration

  • Wood’s Light Examination- turn the lights off, blue light to show different fungus

  • Skin Testing- check for bacterial, fungus, wound cultures

    • Allergy testing can cause anaphylactic shock because they don’t know what they are allergic to

• Therapeutic Measures

  • Open Wet Dressings- (advantage)= promote healing from the inside

  • Balneotherapy

  • Topical Medications- (Ointment)= specific to an area

  • Dressings

    • Tegaderm- transparent dressing -see-through it

Chapter 26- Wound Care

• Terminology Related to Wound Healing

  • Dehiscence: Partial or complete separation of outer wound layers

  • Evisceration: The rupturing of a wound

  • Eschar: Hard, dry, leathery dead tissue (not helpful tissue, don’t want it)

  • Granulation tissue: New tissue that grows and fills in a wound (you need to have)

  • Sinus tract: Tunnel that develops between two cavities or between an infected cavity and the skin’s surface (underground tunnel, can’t see it)

• Wound Conditions

  • Edema- Swelling

  • Erythema- Redness

  • Necrotic- Dead tissue

  • Ischemia- Reduced blood flow

  • Purulent- Containing pus

• Classification of Wounds

  • Contusions- bruise, everything stays intact

  • Abrasions- a superficial wound, that rough up the top layer

  • Puncture wounds- punctured the skin

  • Penetrating wounds- puncture wound with something still in the wound

  • Lacerations- usually accidentally wound, wound won’t come together

• Categories of Wound Contamination

  • Clean: Not infected- (usually the most common)

  • Clean-contaminated: Has direct contact with normal flora and potential for infection

  • Contaminated: Grossly contaminated by breaking asepsis

  • Infected: Infectious process established

  • Colonized: High number of microorganisms present without signs of infection (ex. MRSA)

• Risk Factors for Pressure Ulcer Development

  • Being elderly

  • Being emaciated or malnourished

  • Being incontinent of bowel or bladder

  • Being immobile

  • Having impaired circulation or chronic metabolic conditions (ex. Diabetes, obesity, heart disease)

• Assessment Parameters: Pressure Ulcers

  • Pallor: Related to impaired circulation (pale)

  • Erythema: Increased capillary blood flow due to inflammation (redness, feel very warm)

  • Jaundice: High serum level of bilirubin; skin is more susceptible to loss of integrity (yellow)

  • Bruising: Note any discolored areas that are found to determine if new breakdown occurs

• Three Phases of Wound Healing

  • Inflammatory

    • Occurs when the wound is fresh; includes both hemostasis and (phagocytosis= eating all the pus) -(open fresh wound)

  • Reconstruction (proliferation)

    • Occurs when the wound begins to heal, about 21 days after injury (rebuild tissue, healthy tissue, most vulnerable time for the wound to heal)

  • Maturation (remodeling)

    • Occurs when the wound contracts and the scar strengthens (give the scar strength)

• Types of Wound Closures for Healing

  • First intention

    • Wound is clean with little tissue loss, edges are approximated, and wound is sutured closed (closes on its own)

  • Second intention

    • There is greater tissue loss, wound edges are irregular, and wound is left open (leave the wound open, maybe close tissue underneath)

  • Third intention

    • Wound is left open for some time to form granulation tissue and then sutured closed (just leave the wound open)

• Signs of Wound Infection

  • Redness or increased warmth

  • Swelling

  • Wound drainage

  • Unpleasant smell

  • Pain around wound

  • Fever above 100°F

• Wound Drainage

  • Sanguineous- bloody drainage

  • Serous- yellowish (not infection)- looks like oil- serum

  • Purulent- containing pus, thick yellow green

  • Bilious- green (not infection green)

  • Serosanguineous- both blood and liquid

  • Seropurulent- mixture of serum and pus

• Protein and Wound Healing

  • Protein intake is required for wounds to heal.

  • Patients who are tube fed may not get enough protein and calories which slows wound healing.

• Wound Documentation

  • Amount and color of drainage on old dressing

  • Length, width, diameter, and depth of wound

  • Sinus tracts and their length

  • Color of wound

  • Appearance of surrounding skin

  • Type of dressing applied

Chapter 54- Nursing Care of Patients with Skin Disorders

• Pressure Ulcers

  • Pathophysiology

    • Pressure Against Skin

    • Tissue Anoxia

  • Etiology

• Risk Factors for Pressure Ulcers

  • Immobility

  • Impaired Circulation

  • Impaired Sensory Perception

  • Elderly

  • Very Thin or Obese

• Prevention for Pressure Ulcers

  • Assess Daily

  • Cleanse and Dry Daily and PRN

  • Lubricate Daily

  • Clean Incontinence Promptly

  • Use Moisture Barrier PRN

  • Do Not Massage Reddened Areas

  • Shift every Weight every 15 min

  • Turn/Reposition at Least every 2 hr

  • Keep Heels Off Bed

  • Pad/Protect Bony Prominences

  • Use Pressure-Reducing Mattress

  • Use Lift Sheet to Move

  • Provide Nutrition and Hydration

• Braden Scale

  • Sensory Perception

  • Moisture

  • Activity

  • Mobility

  • Nutrition

  • Friction and Shear

• Signs/Symptoms Pressure Ulcers

  • Pain

  • Redness

  • Blanching?

  • Open Ulcerated Area

  • Color Tip

    • Black

      • Necroses

    • Yellow

      • Infection or Slough

    • Red

      • Healing

• Therapeutic Interventions for Pressure Ulcers

• Remove All Pressure

• Debride- removal of the dead skin or tissue (removal of something)

  • Mechanical- scissors and forceps can be used to remove nonviable tissue

  • Enzymatic- involves application of topical enzyme debriding agent

  • Autolytic- debridement of synthetic dressing or moisture retentive dressing over the injury

  • Surgical- involves removal of devitalized tissue, slough (lose yellow tissue), with a sharp instrumental tool

• Cleanse

• Hyperbaric oxygen therapy

• Maggots

• Leeches

• Dressings Pressure Ulcers

• Types

  • Hydrogel

  • Polyurethane Film

  • Hydrocolloid Wafer

  • Biological

  • Alginate

  • Gauze

  • Moist Environment

  • Caution with Tape

• Stages Pressure Ulcers

• Deep Tissue Injury (pg. 1115)

• Stage I

  • Skin Intact, Red, Does Not Blanch

• Stage II- blister

  • Partial Thickness Skin Loss

• Stage III

  • Full Thickness Skin Loss, May Have Eschar

• Stage IV

  • Damage to Muscle, Bone, or Support Structures

• Unstageable

• Dermatitis

• Pathophysiology

  • Inflammation of the Skin

• Etiology

  • Allergens

  • Irritants

  • Heredity

  • Stress

• Types of Dermatitis

• Contact

  • Irritant

  • Allergic

• Atopic

• Seborrheic

• Dermatitis Signs/Symptoms

• Rash, Itching

• Lesions

  • Scales

  • Crusts

  • Fissures

  • Macules

  • Papules

  • Pustules

• Complications Dermatitis

  • Infection

  • Sepsis

• Therapeutic Interventions Dermatitis

  • Antihistamines

  • Analgesics

  • Antipruritics

  • Steroids

  • Colloidal Oatmeal Baths

  • Wet Dressings

• Psoriasis

  • Pathophysiology

    • Inflammatory Disorder

    • Proliferation of Epidermal Cells

    • Scaling

  • Aggravating Factors

    • Stress

    • Strep Pharyngitis

    • Hormone Changes

    • Cold Weather

    • Skin Trauma

    • Some Drugs

• Signs/Symptoms Psoriasis

  • Papules, Plaques

  • Silvery Scales

  • Itching

• Complications Psoriasis

  • Infection, Fever, Chills

  • Arthritis

  • Nail Changes

  • Lymphadenopathy

• Psoriasis Therapeutic Interventions

  • Therapeutic Interventions

  • Tub Baths

  • Corticosteroids

  • Salicylic Acid

  • Keratolytics

  • Vitamin D Creams

  • Retinoids

  • Coal Tar, Anthralin

  • UV Light

  • Chemotherapy

  • Occlusive Dressings

  • Fish Oil Supplements

• Herpes Simplex

• Pathophysiology

  • Viral Infection

    • HSV1 – Above Waist

    • HSV2 – Below Waist

  • Primary Infection

    • Direct Contact

    • Respiratory Droplet

    • Fluid Exposure

  • Lies Dormant

  • Recurs with Stress

• Herpes Simplex Signs/Symptoms

  • Prodromal Phase

    • Burning, Tingling

  • Vesicles and Pustules

    • Burning, Itching, Pain

• Contagious Until Scabs Form

• Therapeutic Interventions Herpes

  • Antiviral Agents (Acyclovir/Zovirax)

    • Topical

    • Oral

• Antibiotics for Secondary Infection

• Avoid Triggers of Recurrence

• Herpes Zoster (Shingles)

• Pathophysiology

  • Acute Inflammation/ Infection

  • Painful Vesicules

  • Follows Nerve Distribution

  • Usually One-sided

• Etiology Shingles

  • Reactivation of Varicella Zoster Virus (Chickenpox Virus)

  • Occurs with Reduced Immune Function

  • Elderly

  • AIDS

  • Immunosuppressed

• Signs and Symptoms Shingles

  • Vesicles, Plaques

  • Irritation

  • Itching

  • Fever

  • Malaise

  • Pain

• Prevention Shingles

  • Avoidance of Infected Persons

  • Varicella Vaccine (Varivax)

  • Zostavax

• Complications Shingles

  • Postherpetic Neuralgia

  • Persistent Dermatomal Pain

  • Hyperesthesia

  • Ophthalmic Herpes Zoster

  • Sepsis

• Therapeutic Interventions Shingles

  • Acyclovir

    • IV, Oral, Topical

  • Analgesics

  • Anticonvulsants/Antidepressants

  • Antihistamines- for itching

  • Corticosteroids

  • Antibiotics for Secondary Bacterial Infection

• Fungal Infections

  • Pathophysiology/Etiology

    • Direct Contact with Fungus

    • Overgrowth with Antibiotic Therapy

    • Grows in Warm Moist Environment

  • Types

    • Tinea Pedis- athletes feet

    • Tinea Capitas- Ring worm of Scalp

    • Tinea Corporis- Ringworm of Body

    • Tinia Cruris- Ringworm of Groin- jock itch

    • Candidiasis- oral trush

• Cellulitis

  • Pathophysiology

    • Inflammation of Skin/Connective Tissue

    • Infection

      • Staphylococcus/MRSA

      • Streptococcus

  • Etiology

    • Open Wound/Trauma

    • May be Unknown

• Cellulitis Signs/Symptoms

  • Warmth

  • Redness

  • Edema

  • Pain, Tenderness

  • Fever

  • Lymphadenopathy

• Therapeutic Interventions

  • Antibiotics

  • Topical

  • Systemic

  • Debridement

• Pediculosis (Parasitic Disorders)

  • Pathophysiology/Etiology

    • Infestation by Lice

    • Transmission by Direct Contact

  • Types

    • Pediculosis Capitis

    • Pediculosis Corporis

    • Pediculosis Pubis

• Pediculosis

  • Signs and Symptoms

    • Itching

    • Papular Rash

    • Presence of Lice, Nits, and Excreta

  • Therapeutic Interventions

    • Pediculosides

      • Permethrin, Pyrethrin, Lindane

    • Mechanical Removal

    • Antipruritics

    • Topical Corticosteroids

  • Patient Education

    • Self Medication

    • Removal of Nits

    • Cleaning of Clothing and Objects

    • Inspection of Family and Friends

• Scabies

  • Pathophysiology

    • Sarcoptes Scabiei Mites

      • Burrow into Skin

  • Etiology

    • Contact with Infected Clothing or Animals

• Scabies

  • Signs and Symptoms

    • Itching

    • Rash

    • Burrows

  • Diagnosis

    • Shaving of Lesion

    • Microscopic Evaluation

• Scabies

  • Therapeutic Interventions

    • Topical Scabicides

      • Permethrin

      • Crotamiton

    • Antipruritics

  • Patient Education

    • Self Medication

    • Treat Family Members

    • Wash Clothing and Linens

    • Itching May Continue 2 Weeks Following Treatment

• Malignant Skin Lesions

• Cancer Arising From

  • Basal Cell Layer

    • Basal Cell Carcinoma

  • Epidermis

    • Squamous Cell Carcinoma

  • Menalocytes

    • Malignant Melanoma

• Malignant Skin Lesions

  • Risk Factors

    • Ultraviolet Rays

    • Fair Skin

    • Genetic Tendency

    • X-Ray Therapy

    • Chemicals

    • Immunosuppressive Therapy

  • Prevention

    • Limit Exposure to UV Rays

      • Use Sunscreen

    • Wear Protective Clothing

    • Report Changes in Moles

• Malignant Skin Lesions- Therapeutic Interventions

  • Surgical Excision

  • Chemotherapy

  • Radiation Therapy

  • Dermatological Surgery

    • Rhinoplasty

    • Blepharoplasty

    • Rhytidoplasty

    • Otoplasty

• Cyst

  • Saclike growth

    • Liquid, semifluid, solid material

    • Epidermoid cyst most common

  • Treatment

    • Intralesional steroid

    • Antibiotic

    • Excision

END OF UNIT

Chapter 32- Gastrointestinal, Hepatic, and Pancreatic Systems Function, Assessment, and Therapeutic Measures

• GI Anatomy and Physiology

  • Oral Cavity and Pharynx

  • Esophagus

  • Stomach

  • Small Intestine

  • Large Intestine

• Liver, Gallbladder, Pancreas

  • Accessory Organs of Digestion

  • Produce or Store Digestive Secretions

• Liver

  •  Hepatic Portal Circulation

  • Bile

• Liver Functions

  • Carbohydrate Metabolism

  • Amino Acid Metabolism

  • Lipid Metabolism

  • Synthesis of Plasma Proteins

  • Formation of Bilirubin

  • Storage

  • Detoxification

  • Activation of Vitamin D

• Gallbladder- Stores Bile

• Pancreas

  • Amylase

    • Starch to Maltose

  • Lipase

    • Emulsified Fats to Fatty Acids/Monoglycerides

  • Trypsin

    • Polypeptides to Peptides

• Bicarbonate Juice

• Aging and the GI System

  • Fat Absorption Slower

  • Atrophy of Large/Small Intestine

  • Decreased Mucous Secretions

  • Decreased Elasticity of Rectal Wall

  • Weakness of Intestinal Wall

  • Faulty Absorption of Vitamins B1 and B12, Calcium, Iron

• Assessment

  • Health History

    • Travel

    • Elimination

    • Medications

      • Clostridium Difficile

  • Nutritional Assessment

  • Family History

  • Cultural Influences

• Physical Assessment

  • Inspection

    • Jaundice

  • Auscultation

  • Percussion

  • Palpation

    • Abdominal Girth

  • Height and Weight

  • Body Mass Index

  • Oral Cavity

  • Abdomen

• Diagnostic Tests

  • Laboratory Tests

    • CBC

    • Electrolytes

    • Bilirubin

    • Liver Enzymes

    • Stool Tests

  • Radiographic Tests

    • Flat Plate of the Abdomen

    • Upper GI Series (Barium Swallow)

    • Lower GI Series (Barium Enema)

    • Computed Tomography (CT) Scan

  • Endoscopy

    • Esophagogastroduodenoscopy (EGD)

    • Endoscopic Retrograde Cholangiopancreatography (ERCP)

    • Lower Gastrointestinal Endoscopy

      • Proctosigmoidoscopy

      • Colonoscopy

• Enteral Nutrition

  • When oral intake not possible

  • Gravity

  • Pump

  • Intermittent

  • Continuous

• Feeding Tube Nursing Care

  • Placement Check

  • Residual

  • Complications

    • Irritation

    • Obstruction

    • Aspiration/regurgitation

    • Displacement

    • Cramping/bloating

• Therapeutic Measures

  • Gastrointestinal Intubation

  • Decompression

  • Diagnosis

  • Treat/relieve obstructions

  • Gavage feedings

  • Medications

  • Promote healing

  • Lavage

Chapter 33- Nursing Care of Patients with Upper Gastrointestinal Disorders

• Nausea- urge to vomit

• Vomiting- Expelling stomach contents through esophagus and mouth

• Therapeutic Interventions N/V

  • Protect Airway

  • Medications

  • IV Fluids

  • Nasogastric Tube

  • Dietary modifications

• Obesity

  • Weight 20% or greater than ideal body weight

  • BMI (height-to-weight ratio)

  • Caloric intake exceeds energy expenditure

  • Comorbidities- diseases caused by obesity

    • Diseases Associated with Obesity

      • Heart disease, diabetes, atherosclerosis, gallbladder disease, hypertension, depression, sleep apnea

  • Morbid Obesity

    • BMI >40

• Supportive Nursing Care- Obesity

  • PATIENT EDUCATION!!

  • Support groups

  • Surgery

  • Behavior modification

  • Medication

• Bariatric Surgery- Weight Loss surgery

  • Limits stomach size

  • Steatorrhea means there's too much fat in your stool (poop). It's a symptom of fat malabsorption. That means your digestive system is having trouble breaking down and absorbing fats.

  • Complications

    • Vomiting

    • Protein deficiency

    • Vitamin deficiency

    • Mineral deficiency

    • Dumping syndrome

    • Acute gastric distention

    • Steatorrhea

    • Intestinal leakage

    • Infection

    • Erosion

• Postoperative Care for Bariatric Surgery

  • Clear liquid diet

  • Pureed foods

  • Solids at 6 weeks post-op

  • Post-op assessment

• Oral Health- Inflammatory Disorder

  • Important to Overall Health

  • Stomatitis

  • Aphthous Stomatitis- (canker sores)

  • HSV1

  • Halitosis

  • Oral Hygiene

    • Prevents Pneumonia

    • Reduces Ventilator-Associated Pneumonia

  • Prophylactic Antibiotics

  • Xerostomia (Dry Mouth)

    • Artificial Saliva Substitute

• GERD

  • Gastric secretions reflux into esophagus

  • Damage esophagus

  • The inability of sphincter to close

• GERD Signs/Symptoms

  • Heartburn

  • Regurgitation

  • Dysphagia

  • Bleeding

• GERD Complications

  • Aspiration

    • Bronchospasm

    • Pneumonia

    • Asthma

  • Scar Tissue

• GERD Diagnosis

  • Barium Swallow

  • Esophagoscopy

• GERD Therapeutic Interventions

  • Lifestyle Changes

  • Medications

    • Antacids

    • H2 Receptor Antagonists

    • Proton Pump Inhibitors

    • Prokinetic Agents

• GERD Nursing Care

  • Education

  • Lose Weight

  • Low-fat, High-protein Diet

  • Avoid Caffeine, Milk Products, Spicy Foods

• Gastritis- Inflammation of the stomach mucosa

  • Remove Irritating Substance

  • Bland Diet of Liquids/Soft Foods

  • Inflammation of Stomach Mucosa

  • Acute

  • Chronic

• hemat/o (blood) hem/o (blood) 

• Therapeutic Interventions Gastritis

  • Treat Cause

  • Bland Diet

  • Antacids

  • Anti-emetics

• Ulcers (Peptic Ulcer Disease)

  • Stomach

  • Pylorus

  • Duodenum

  • Named by location

    • esophageal, gastric- worse with food, duodenal- improves with food until digestion takes place then gets worse

  • Complications

• Supportive Care- Ulcers

  • Control bleeding

  • Reduce pain

  • Replace fluids

  • Education

  • Medications

Chapter 34- Nursing Care of Patients with Lower GI Disorder

• Lower GI System

  • Small Intestines

  • Large Intestines

  • Rectum

  • Anus

• Constipation- Feces held in the rectal cavity

  • Water absorbed

  • Hard, dry, painful defecation

  • Many causes

  • Obstipation

  • Complication

    • Fecal impaction

    • Ulcers

    • Oozing

    • Megacolon

    • Abdominal distension

    • Bowel loops

• Supportive Care- Constipation

  • Increase fiber

  • Exercise

  • Behavior modification

  • Increase fluid intake

  • Medications

  • Education!

• Diarrhea- rapid passing of fecal matter

  • Decreased water absorption

  • Bacterial or viral

• Supportive Care- Diarrhea

  • Identify Cause

  • Replace Fluids/Electrolytes!

  • Increase Fiber/Bulk

  • Medications

  • Lactinex Restores Normal Flora

  • Antimicrobial Agents

• Abdominal Hernias- Protrusion through abdominal wall

  • Etiology

  • Weakness in Abdominal Wall with Increased Intra-abdominal Pressure

• Abdominal Hernias Signs/ Symptoms

  • None

  • Bulging

• Complications Abdominal hernias

  • Strangulated Incarcerated Hernia

• Supportive Care Abdominal Hernias

  • None

  • Observation

  • Support Devices

  • Surgery

  • Decrease intra-abdominal pressure

  • Signs of strangulation/incarceration

  • Support brief

  • Skin integrity

• Anorectal Problems

  • Hemorrhoids- enlarged veins within the anal tissue caused by increased pressure in veins

    • Internal- above the internal sphincter- usually not painful unless they prolapse

    • External- below the external sphincter- cause itching snd pain when inflamed and filled with blood

  • Fissures- cracks or ulcers in lining of the anal

• Supportive Care Anorectal Problems

  • Postoperative

  • Pain Control

  • Prevention

  • Comfort Measures

  • Dressing Changes

  • Stool Softeners

  • Sitz baths

• Lower GI Bleeding

  • Hematochezia- bleeding from the colon or rectum usually bright red active bleeding

  • Melena- black and tarry stools- bleeding above or in small bowel- older blood

• Signs & Symptoms Lower GI Bleeding

  • Hypotension

  • Lightheadedness

  • Nausea

  • Diaphoresis- sweating

  • Pallor

  • Clammy skin

  • Tachycardia

• Ostomy- Surgically created

  • Stoma- portion of bowl that is sutured onto the abdomen

  • 3 types

    • Ileostomy- end stoma formed by bringing the terminal ileum out to the abdominal wall

    • Colostomy- where in the bowel it is formed

    • Urostomy- opening in belly made during surgery- more for urine and liquid

• Supportive Nursing Care- Ostomy

  • Pain

  • Anxiety & fear

  • Home care

  • EDUCATION!!!

  • WOCN- Wound, ostomy, continence nurse

Chapter 35- Liver, Pancreatic, Gallbladder Disorder

• Hepatitis- inflammation of the liver from viral or bacterial infection

  • No symptoms 🡪 life-threatening

    • A (fecal-oral, vac)-B (blood and bodily fluids, vac)-C(needle shares, unprotected sex, no vac)-D (blood and bodily fluids)- E (contaminated water, uncooked meat)

• Hepatitis Complications

  • Chronic liver failure

  • Acute liver failure

  • Chronic infections

• Hepatitis Therapeutic Measurs

  • Monitor liver status

  • Symptoms relief

  • Supportive Care

  • Promote healing

  • Nutritional support

  • Antivirals

• Laboratory Tests

  • Alanine aminotransferase (ALT)- liver pictures

  • Aspartate aminotransferase (AST)- liver pictures

  • Alkaline phosphatase (ALP)

  • Bilirubin

  • Prothrombin Time (PT)- look at first

• Cirrhosis- progressive replacement of healthy liver tissue with scar tissue

  • Drinking is #1 cause of Cirrhosis

  • Chronic liver disease

  • Signs & Symptoms

  • Anorexia

  • Nausea

  • Vomiting

  • Weight loss

  • Fatigue

  • Jaundice- yellow

  • Pruritus- itching

• Cirrhosis/Chronic Liver Disease Complications (CHEAP)

  • Clotting defects

  • Hepatorenal syndrome- acute kidney injury with advanced liver disease

  • Encephalopathy- bleeding and abdominal distension

  • Ascites- serous fluid in the abdominal cavity from hypertension

  • Portal Hypertension- persistent elevated blood pressure in portal vein

  • Wernicke–Korsakoff syndrome- brain disorder caused by thiamine (B) deficiency, behavior thing

• Cholecystitis

  • Cholecystitis- inflammation of the gallbladder

  • Cholelithiasis- formation of gallstones in the gallbladder

• Signs & Symptoms

  • Epigastric pain

  • RUQ tenderness

  • Right shoulder pain

  • Murphy’s sign- inability to take a deep breath when an examiner's fingers are pressed below the liver margin

  • Gas/belching

  • Nausea/Vomiting

• Supportive Nursing Care Cholecystitis

  • Pain control

  • Infection prevention

  • Fluid & electrolyte support

  • Post-surgical care

END OF UNIT

Chapter 45 Musculoskeletal Function and Assessment

• Anatomy & Physiology

• Muscles- soft tissue that functions to produce force in motion. When muscles contract, it changes the length and shape of that muscle.

• Joints- between bones and allow for movement on either end of the bone

• Bones

• Tendons- connect bone to muscle

• Ligaments- connect bone to bone

• Fasciae- membranous tissue enclosing muscles

• Skeleton

  • Skeleton plays several roles-it’s biggest is in movement. It also protects organs and tissues. For example, it protects the brain within the skull and the lungs within the thoracic cage.

    • Bones within the skeleton contain and produce bone marrow, they also store excess calcium which is necessary for blood clotting and proper functioning of nerves and muscles.

    • Skeleton is stabilized by the muscular system, which contributes to heat production to maintain normal body temperature

    • Muscular system aids in the return of blood from the legs by compression on veins.

    • Calcium and phosphate are being removed and replaced (remodeled) all the time to maintain normal blood levels.

    • Parathyroid hormone increases the removal of calcium and phosphate from the bones.

    • Calcitonin (hormone from thyroid) promotes retention of calcium.

    • 206 bones make up the skeleton

  • -Axial: flat, irregular bones

  • -Appendicular: limbs consist of long bones. Same structure: diaphysis (shaft) and two ends epiphyses

• Structure of the Skeleton

• Skull

  • -8 cranial bones

  • -14 facial bones

  • -3 small auditory bones in the middle ear

  • -Immovable joints, sutures (synarthrosis)

  • -When babies are born, the skull is not fused, which allows for passage through the birth canal.

• Vertebral Column

  • Spinal column-named by location and number

  • -33 bones vertebrae

  • -Atlas- 1^st seven cervical vertebrae. Articulates with occipital bone of skull to form a pivot joint with axis, 2^nd vertebrae.

  • -12 thoracic vertebrae articulate with posterior ends of the ribs.

  • -5 lumbar largest & strongest

  • -Sacrum- 5 fused vertebrae, articulates with the os coxae at the sacroiliac joints

  • -Coccyx- 4 fused vertebrae serves as an attachment point for muscles of the perineum

  • Thoracic Cage

  • -12 pairs of ribs and sternum

  • -Protects heart & lungs, upper abdominal organs from injury

  • -Flexible, expands upward and outward during breathing

• Synovial Joints- moveable joints (diarthroses)

  • Bursae- small sacs of fluid between the joint and structures that cross over the joint. Lessen wear in areas of friction

  • Joints

    • Symphysis- between vertebrae, pubic bone

    • Ball & socket- movement in all planes, shoulder, hip

    • Hinge- movement in one plane, elbow, knee, between fingers and toes

    • Combined hinge- temporal bone, mandible

    • Pivot- rotation, neck, radius, and ulna (distal to elbow)

    • Gliding- side to side, wrist

    • Saddle- movement in several planes, thumbs

• Muscle Structure

  • Fibers

    • Fibers are specialized for contraction

    • With contraction, muscles shortens and exerts force on a bone

    • Each fiber has its own motor nerve ending

  • Anchored by tendons

    • Muscles are anchored by tendons (connective tissue)

  • 2 tendons per muscle

    • At least 2 tendons, each to a different bone

    • Stationary muscle attachment is origin, movable muscle attachment is the insertion

    • With contraction, muscle moves the bone in a certain direction

  • 700

    • 700 skeletal muscles (figure 45.4 page 889)

    • Without synergism, we would be unable to maintain balance or have fine motor control (walking, talking)

• Role of Nervous System

  • Voluntary movement

    • -Skeletal muscles are voluntary: conscious control initiates nerve impulses to cause contraction

  • Involuntary regulation

    • -Involuntary regulation (CNS) keeps slight contraction on muscles-which keeps our posture

  • Posture

  • Coordination

• Aging and the Musculoskeletal System

  • Figure 45.6 (page 890)

  • One function of estrogen (females) and testosterone (men) is strong bone maintenance.

  • After menopause, bone loses more calcium than is replaced.

    • Can offset bone loss with weight-bearing exercise, which will increase bone density

  • Damage to weight-bearing joints-leading to pain and stiffness

  • Muscle strength declines: leading to more falls accidents

• Assessment of the Musculoskeletal System

  • Subjective Data

    • History- age, gender, allergies, pre-existing conditions, risk factors (smoking, sedentary lifestyle)

      • Injury- pain scale, when did it occur, tx Family: some conditions can be hereditary

      • Occupation

      • Family History

      • Diet History- calcium, vit D intake can affect musculoskeletal disorders

  • Physical Assessment

    • Inspection, Palpation, Range of Motion

      • Inspect- asymmetry, swelling, ecchymosis, color Palpate- pulses below involved area, warmth, weakness ROM- contracture, deformities, altered gait The nurse should expect muscle spasms following a hip fracture.

  • Psychosocial Assessment

    • Deformities Affect Body Image

      • changes in body image, lifestyle alterations to consider, coping with this and the stress

• Diagnostic Tests

  • Laboratory Tests

  • Calcium 8.5-10.5 mg/dL

  • Phosphorus 2.6-4.5 mg/dL

    • Calcium & Phosphorus: when calcium increases, phosphorus decreases and vice versa. Bone disorders cause an imbalance

  • Alkaline Phosphatase m: 45-115/f: 30-100 units/L

    • increases when bone is damaged. Increases reflect osteoblast activity (bone forming cell)

  • Myoglobin 50-120 mcg/mL

    • Protein in striated muscle. Causes red color. Myoglobin rises in the blood with damage.

  • Muscle Enzymes

    • When muscle tissue is damaged, enzymes are released into the blood.

  • Uric Acid m: 4.4-7.6 f: 2.3-6.6 mg/dL

    • indicated gout (painful inflammatory arthritis- next chapter). Usually found in the urine.

• Rhabdomyolysis- muscle destruction relating to an injury- serious and potentially fatal- crush syndrome- Creatinine Kinase 5x greater than normal. Dark urine, muscle weakness, myalgia. Tx goal- restore fluid/ electrolyte balance

  • Xray

    • look at bone and soft tissue damage (alterations in bone alignment and spacing

  • CT

    • joints or spine

  • Myelogram

    • can’t have a CT or MRI. Head down so contrast flows up to the neck

  • MRI

    • diagnosing soft-tissue injuries. More accurate for the vertebral column. Can use contrast. NO METAL! Noisy tube- make sure pt know what to expect

  • Arthroscopy

    • scope, saline injected into the joint, joint visualized from different angles. Local or light general anesthesia. They can do the repair then as well.

  • GT scan/ Thallium Scan

    • Visualization of entire skeleton. G/T radioactive isotopes. Gallium concentrates in areas of tumors, inflammation and infections. Thallium identifies bone cancer. “Hot spots” increased circulation in abnormal bone areas that concentrates the radioactive substance. Indicates bone disease

  • Biopsy

    • Microscopic exam to confirm cancer, infection, inflammation.

  • Ultrasonography

    • sound waves detect osteomyelitis, soft tissue disorders, traumatic injuries

  • EMG

    • nerve conduction study. Measures muscle’s electrical impulses. Diagnoses muscle disease or nerve damage

Chapter 46 Nursing Care of Patients with Musculoskeletal and Connective Tissue Disorders

• Musculoskeletal Medications

  • Treat muscular disorders

    • Dystonia- movement disorder (muscle relaxants help)

    • Antispasmodics- anti spasm medication

  • Treat bone disorders

  • CNS involvement

• Bone and Soft Tissue Disorder

  • Strain- stretched, muscle or tendon

  • Sprain- stretched and then rotated, ligament

  • Dislocation- joints are moved out of their normal position

  • Bursitis- overuse, causes inflammation

  • Rotator Cuff Injury- shoulder, part of nerve gets pinched under your shoulder

• Carpal Tunnel Syndrome- compression of the median nerve

  • Tunnel swelling

  • Numbness

  • Relieve Inflammation

    • Splint

    • Anti-inflammatory

    • Surgery

  • Teach Prevention- for ex. Typing on a keybord

• Fractures- break in the bone

  • Cause

    • Trauma

    • Pathological (From Disease )

  • Open- broke through the skin (watch for infection)

  • Closed- stays under the skin

  • Complete- bone has totally snapped

  • Incomplete- the bone has not totally snapped

  • Displaced- bones are out of alignment

• Fractures S/S

  • Pain

  • Decreased ROM

  • Limb Rotation

  • Deformity, Shortening of Limb

  • Swelling

  • Bruising

• Fractures Diagnostic Tests

  • X-Ray- show if there is a break, hard structure

  • CT scan- further testing to see tissue

• Emergency Treatment

  • Splint It As It Lies!

  • Seek Medical Treatment

• Treatment

  • Manual Realignment /closed reduction

  • Bandages/Splints

  • Casts

  • Open reduction internal fixation

  • External fixation

• Complications of Fractures

  • Nonunion- delaying or no healing

  • Neurovascular compromise- to detect abnormalities

  • Hemorrhage- bone is highly vascular

  • Infection

  • Thromboembolic Complications

  • Acute Compartment Syndrome

  • Fat Embolism Syndrome- fat blood clot going out to system

• Pain

• Paresthesia- painful tingling or burning

• Pallor

• Paralysis- late symptom

• Pulselessness- a late and ominous sign

• Poikilothermia- extremity is cool to the touch

• Supportive Nursing-Care Fractures

  • Cast Care

  • Traction Care

  • Pain Control

  • Neurovascular Checks

  • Skin Care

  • Nutrition

  • Self Care Deficits

  • Psychosocial

• Osteomyelitis- infection of Bone

  • Prevention is Key!

  • Long-term Antibiotic Therapy

  • Incision and Drainage

  • Amputation

• Supportive Nursing-Care Osteomyelitis

  • Iv antibiotics

  • Education

• Osteoporosis- (Porous Bone)- Low Bone Mass

  • Take Calcium and Vitamin D together to help

  • Deterioration

  • Fragile bones

  • Prone to Fractures

  • Imbalanced Remodeling Process

• Osteoporosis S/S

  • Dowager’s Hump

  • Height Decreases

  • Back Pain

  • Fracture

• Osteoporosis Diagnostic Tests

  • Dual-energy X-Ray Absorptiometry (DEXA)- screening tool to measure bone density

  • Serum Calcium- levels are low

  • Vitamin D- levels are low

  • Serum Phosphorus- levels are high

  • Serum Alkaline Phosphatase- levels are high

• Supportive Nursing Care- Osteoporosis

  • No cure

  • Treat symptoms

  • Education

• Gout- build-up of uric acid

  • Systemic connective tissue disorder

  • Urate deposits- tophi

  • Men > Women

  • Attacks: intra-articular

  • S/S: edema, erythema, tophi, tight skin

• Supportive Nursing Care- Gout

  • Medication

    • NSAIDS

    • Allopurinol- drink plenty of water

  • Diet

    • Alcohol in moderation

    • Avoid high-purine foods

    • Increase water intake: 3 quarts

• Osteoarthritis- Degenerative Joint Disease (DJD)

  • Most common

  • Wear & Tear

  • Normal aging

  • Idiopathic

• Supportive Nursing Care- Osteoarthritis

  • No cure-supportive treatments

  • Pain control

  • Medications

  • Exercise

  • Diet

  • Surgery

• Rheumatoid Arthritis

  • Chronic

  • Progressive

  • Systemic

  • Body systems

• Supportive Nursing Care- RA

  • Medications- DMARDS- mexitrexstae

  • Heat/Cold

  • Surgery

Chapter 29: Oxygenation and the Respiratory System

• Respiratory System

  • Upper Tract

    • Thoracic Cavity

  • Lower Tract

    • Thoracic Cavity

  • Alveoli = gas exchange

    • Where gas is exchanged from air to blood of pulmonary circulation. Resp system supplies oxygen to the body and expels carbon dioxide.

• 

  • Hair in nose blocks particles.

  • Nasal mucosa warms and moistens the air.

  • Cilia moves particles toward pharynx to be coughed out or swallowed.

  • Irritant receptors – triggers sneeze/cough.

  • Pharynx – posterior to nasal and oral cavities. Soft palate and uvula rise to block nasopharynx during swallowing.

  • Oropharynx – soft palate to base of tongue – tonsils here.

  • Laryngopharynx – dorsal to pharynx and connects to esophagus.

• 

  • Trachea: larynx to primary bronchi.

  • Mucosa traps dust and microorganisms in the cilia and sweep it up to pharynx where it can be swallowed.

  • In bronchial tree, cartilage is replaced with smooth muscle.

    • Bronchioles – all smooth muscle to maintain patency.

  • Gas exchanges occurs in alveoli (air sacs).

  • Ventilation is the movement of air into and out of the alveoli.

  • Primary resp muscles, and secondary. Resp center in brain. N 12-20 breaths/minute. Impulses come from brain down nerves to contract resp muscles to make your muscle move, diaphragm contract and flatten in inhale. Ease of thoracic and lung expansion is called compliance.

  • Exhalation is passive – lungs compress as lung tissue recoils and compresses alveoli. At rest- no energy used. Forced exhalation is active- contracting thoracic muscles.

• 

  • R lung – shorter, broader, larger. 3 lobes, 55% of gas exchange. 2 fissures.

  • L – 2 lobes (heart in the way).

• Blood Gases

  • In simple form:

    • PAO2 (75-100 MM HG)

      • Arterial blood – bright red. Heparinized needle to prevent clotting.

      • Veinous blood – dark red.

    • PACO2 (35-45 MM HG)

    • PH (7.35-7.45)

    • HCO3 (22-26 MEQ/L)

    • O2 saturation (95-100%)

      • Oxygen is carried in the blood to hemoglobin.

  • Blood carries oxygen, carbon dioxide, and hydrogen ions. CO2 is converted in the rbc into hydrogen and bicarbonate. The bicarbonate leaves the rbc to go to the plasma. The hydrogen in the rbc turns into Hgb. 98% of oxygen is carried in the blood bound to iron of hemoglobin in rbc. Oxygen carried in the blood bound to rbc attached to hemoglobin.

  • Breath in gases, they travel down resp track to alveoli. Pulmonary artery travel to alveoli carrying deoxygenated blood. Pulmonary vein carries oxygenated blood to the heart and then the body. Gas will travel from area of higher concentration to lower concentration. The partial pressure of CO2 is higher in the pulmonary artery than in the alveoli, so it goes into the alveoli. Partial pressure of oxygen is higher in the alveoli, so it goes into the pulmonary vein.

  • Higher pressure of oxygen in blood than carbon dioxide. Tissues have lower partial pressure of oxygen, so oxygen will move from blood to the tissue. CO2 formed as by produce and will go into the blood.

  • Take blood from artery to check arterial blood gas- your acid base balance. That’s your pH. Decrease in RR, excess carbon dioxide in the blood- lowers the pH- resp acidosis. Increased RR- exhaling more CO2, less in the blood- higher pH- resp alkalosis. Hyperventilation, anxiety, high altitude.

  • Resp system compensates from metabolic pH changes. Metabolic acidosis: kidney dz, uncontrolled diabetes, severe diarrhea. Acidosis- too much CO2- RR increase. Metabolic alkalosis: too many antacids, vomiting. Body wants more CO2 in blood, so it will decrease RR. Resp compensation happens quickly.

  • Drawing blood gas-take from radial artery- painful- hold pressure for 3-5 minutes or until bleeding stops.

• 

  • Weak, atrophied muscles- decreased cough.

    • Pneumonia

  • Reduced recoil of tissue- reduced cough and air trapping.

  • Cilia deteriorate, decreased cough reflex, reduced alveolar macrophage effectiveness—increased risk of resp infections and aspiration.

  • Reduced number of alveoli—decreased gas exchange.

• Respiratory Assessment

  • Inspection – nose, rr, accessory muscle usage, retraction, cyanosis, periods of apnea, chest shape (barrel chest- COPD).

  • Palpation – resp excursion- rough measurement of chest expansion on inspiration; Crepitus (rice krispies) air leak with pneumothorax or leaky chest tube.

  • Percussion – tap and compare sounds- N same bilaterally except over heart.

  • Auscultation – abnormal sound- adventitious. N RR 12-20.

    • If someone is hypoxic, what will you see? Cyanosis! Central- blue lips, oral mucosa, nails.

      • Cyanosis is a late sign of o2 depravation.

        • Notice it in: Nose, ears, mucous membrane

    • What if your pt has edema, thickened hands/ toes, nail polish, hypothermia and you can't get nO2 sat? O2 probe on ear and toes.

    • Rhonchi: low pitched wheezes continuous on inspiration and expiration, snoring, gurgling or rattle like quality, occurs in bronchi, pneumonia, CF- cough can temporarily clear the sound.

      • Deeper in the lungs.

    • Wheezes: narrowed airway- fine high-pitched violin sound on expiration- asthma, chronic bronchitis, COPD, smoking, pneumonia.

    • Stridor- airway obstruction-loud crowing noise- heard w/out stethoscope- obstruction foreign body/ tumor, kids with croup.

      • Louder in the throat. Something blocking the trachea.

      • Medical emergency!!

• 

  • Inspection starts at sinuses.

• Respiratory Patterns

  • 

    • Eupnea – normal

  • 

    • Hyperpnea – increased rate and depth – fear/anxiety.

  • 

    • Tachypnea – rapid shallow breathing.

  • 

    • Bradypnea – slow, apnea (absence).

  • 

    • Apnea – 20 sec or more with no breath.

      • Less than 20 secs with symptoms.

  • 

    • Kussmaul’s – fast and deep no pauses – emergency response to acidosis, fast, deep, labored, hyperventilation. Seen with diabetic ketoacidosis.

    • Breathe may smell fruity

  • 

    • Cheyne-stokes – fast and deep, then slow with periods of apnea – will see near death.

  • 

    • Shallow – minimal using accessory muscles.

  • 

    • Agonal – irregular, periods of apnea. After cardiac arrest breathing.

• Oxygen Therapy

  • O2 saturation >90% on room air.

  • Low-flow nasal cannula – flexible catheter with 2 short nasal prongs.

    • Most effective. More comfortable. Delivers lowest concentration (24-45%). Low flow, 2-3 L.

    • COPD 2-3 L max.

  • Simple face mask – 5-10 L/min 40-60% concentrations.

    • If need for higher concentration.

    • Claustrophobic

  • Partial rebreather – reservoir. Allows mixing of room air and O2.

    • 50% and greater concentrations

    • Reservoir. Mask with open ports.

  • Nonrebreather – closed ports, limits mixing of room air & o2. The reservoir holds o2 but not exhaled air.

    • Closed ports, limits mixing. For 70-100% oxygen concentration—highest concentration.

    • Can breathe out air but can’t breathe back in their own air

  • Venturi mask – precise % of o2.

    • For precise percentages of oxygen needed

    • For chronic lung disease with CO2 retention.

• Respiratory Medication

  • Nebulized Mist Treatment

    • Directly into lungs

    • Reduces systemic side effects.

    • Use of supplemental O2

      • Mixed with oxygen and saline.

      • Inhaler uses propellants to deliver the medication.

      • Spacer helps, dry powder inhaler doesn’t use propellant. Make sure you know how to use different kinds.

    • Bronchodilators, steroids- GIVE FIRST 1

      • Relax bronchial muscles. Used with asthma & COPD. Help you breath better. Give these first to open up the airways!

      • Short acting: albuterol last 2-4 hours

      • Long acting: 2x daily, help keep the airways open. Usually paired with inhaled steroid- Advair, Dulera, Symbicort

      • s/e: increased HR, nervous/ shaky, but should increase O2 sats.

    • Mucolytics: thins secretions, use after bronchodilators. 2

      • Carbocisteine, pulmozyme, mucomyst, acetylcysteine.

      • Can be given nebulized to trach.

      • Use with excessive mucous, productive cough.

  • Metered dose inhalers

    • Directly into lungs

    • Bronchodilators, steroids

  • Expectorants: stimulate cough & promote drainage 3

    • Mucinex, guafenesin.

    • Promotes drainage & lubricates the respiratory tract- stimulates cough.

    • Symptomatic relief of dry, non-productive cough

    • Increase fluids with this medication!

• Nursing Treatments

  • Incentive spirometry – if having trouble, start slow and increase volume. Slow, deep breathing between. INHALED EVENT, AT LEAST 2-3 EVERY HOUR

    • Encourages deep breathing.

    • Reduces risk of atelectasis (collapsed lung)

    • Post-operative

  • Chest physiotherapy (CPT) – weak or ineffective cough and at risk for secretions. Use percussion to produce sound waves into the chest to loosen secretions. May use cup, hand, or vest.

    • Moves secretions.

    • Weak or ineffective cough

    • COPD, CF, bronchiectasis

    • BEFORE A MEALTIME

    • LISTEN TO THEIR LUNG SOUNDS

  • Let’s go back to CPR basics with choking pt. conscious – Heimlich, unconscious – start CPR.

• Alternative Airway

  • Tracheotomy

    • Surgical opening into the trachea, temporary or permanent

  • Tracheostomy

    • Tube to maintain patency- insert piece into the placement

      • Cancer, trauma, tumor, prolonged ventilation, excessive secretions

        • Outer cannula, inner cannula, obturator

  • Obturator is guide that is used during insertion- keep one at bedside for emergency. If tube gets removed.

  • Outer cannula is always in place secured by ties or velcro strap (ex: behind the neck)

  • Inner cannula- removed every 8 hours and as needed to clean. Some may have balloon cuff.

  • Communication is hard- air comes out tube and not past vocal cords. The fenestrated tube has holes that if they plug trach, they can talk. Some have valve to allow them to speak. If cuffed- cuff needs to be deflated in order to talk.

• Alternative Airway

  • Intubation- nasal or oral

    • Tube into trachea to maintain oxygenation

    • Short-term, going to be less than 7 days

    • Used with mechanical ventilation.

      • Control (they can set it) or assist (always you to breath in between) ventilation

  • Intubation can damage vocal cords and surrounding tissues, so usually short term. Long term– trach

  • If intubated: lung sounds bilaterally, tube placement, protect skin, move tube. They will have cuff inflated.

  • Need to suction-

    • sterile- visible secretions, crackles/wheezes, drop in O2.

  • Anxious if alert, oral cares. VAP (ventilator associated pneumonia- good hand hygiene, oral cares, elevated HOB 30-45%.

  • Unable to speak. Monitor ABG, Oxygen saturation. When removed tube—high fowlers, watch for resp distress, laryngeal edema

  • Positive pressure ventilation (ppv)

    • Independent breathing-cannot maintain blood gases.

      • Severe respiratory distress, sleep apnea, als

        • Cpap

        • bipap

  • PPV

    • Unable to breath on their own. Pushes air into lungs at preset intervals. Can control or assist with breathing.

  • Non-invasive positive pressure ventilation

    • able to breath on own but unable to maintain normal ABGs. Severe resp distress, sleep apnea, ALS (weakens resp muscles)

  • Mask fits over nose or mouth and nose. Good if alert, cooperative, not a lot of secretions, able to breath on own for periods of time.

  • CPAP

    • continuous pressure- same amt of positive pressure maintained throughout inspiration and expiration to prevent airway collapse.

  • BiPAP

    • higher positive pressure for inspiration, lower level of expiration.

  • Monitor for skin irritation, semi-fowlers to prevent gastric distension, humidifier on machine can reduce dryness to nose/ mouth,

  • Air leak- irritating can blow to eyes- reposition.

Chapter 30: Upper Respiratory Tract Disorders

• Epistaxis

  • Nosebleed

  • Anterior or posterior

  • Etiology:

    • Dry, cracked mucous membranes.

    • Trauma

    • Nose picking, blowing.

    • Disease process

• Supportive Nursing Care – Epistaxis

  • Lean forward.

  • Pressure (without trauma)

  • Ice packs

  • Vasoconstriction

  • Packing

  • Airway obstruction

  • Avoid bending over.

• Sinusitis

  • Inflammation of sinus mucosa

    • If you don’t take care of it, can turn into sinus infection.

    • Acute or chronic

    • Bacterial infection

    • Viral illness

      • 3-5 days

    • Allergies

    • Nasotracheal intubation/ng tube

  • Signs & Symptoms

    • Local pain

    • Purulent nasal drainage

    • Fever

    • Foul breath

  • Complications

    • Osteomyelitis – infection of bone

    • Orbital cellulitis

    • Abscess

    • Meningitis

• Supportive Nursing Care – Sinusitis

  • Relieve pain.

  • Nasal irrigation (chronic)

  • Medication

  • Increase fluid.

  • Warm, moist packs

    • Corticosteroids

    • NO antihistamines!!

• Pharyngitis

  • Sore throat

    • Inflammation of pharynx

    • Bacterial or viral

    • Strep throat #1 (streptococci)

  • Signs & Symptoms

    • Sore throat

    • Dysphagia

    • Exudate

    • Fever

    • Headache

    • Stomachache/vomiting (children)

• Supportive Care – Pharyngitis

  • Throat culture

  • Medications

  • Increase fluids.

  • Rest

• Laryngitis

  • Inflammation of larynx lining

    • Irritation

    • Viral, environmental, bacterial, fungal

  • Signs & Symptoms

    • Hoarse

    • Cough

    • Dysphagia

    • Fever

• Supportive Care – Laryngitis

  • Rest (including vocal rest)

  • Increase fluids.

  • Humidified Air

  • Medications

• Tonsillitis

  • Strep throat

    • Infection of tonsil tissue

    • Viral (most common) or bacterial

  • Signs & Symptoms

    • Sore throat

    • Fever

    • Chills

    • Dysphagia

    • Pain

    • Myalgia

    • Red, swollen.

    • Exudate

• Supportive Care – Tonsillitis

  • Throat culture

  • Medications

  • Increase fluids.

  • Rest

  • Saline gargles

  • Tonsillectomy

• Influenza

  • Viral infection of respiratory tract

    • New strains yearly

    • Droplet transmission

    • Contact transmission

    • Yearly flu shot (> 6 months)

      • Look for egg allergies

    • HAND HYGIENE!!!

  • Signs & Symptoms

    • Abrupt onset

    • Fever

    • Chills

    • Myalgia

    • Sore throat

    • Cough

    • Malaise

    • Headache

    • 2-5 days intense symptoms

• Supportive Care – Influenza

  • Nasal swab

  • Symptom treatment

  • No curative treatment

  • Medication

  • Increase fluids.

  • Rest

  • Respiratory Assessment

Respiratory X-rays

• Bronchitis- inflammation of the bronchial tree.

  • Excessive mucous, congested airway

• Bronchiectasis- dilation of bronchial airways, become flabby and scarred. Secretions pool and are difficult to cough up. BROCHODIALTOR- SIDE EFFECT- SHAKE, TEMURS

  • Infection is common

  • Occurs secondary to chronic respiratory disorder

  • Vitamin D deficiency may play role

  • Can produce as much as 200mL of thick sputum

  • Wheezes/Crackles

  • CT scan provides view of dilated airway

• Pneumonia- acute inflammation from infectious agents entering the lungs. Categorized by how it’s acquired.

  • Fever, chills, chest pain, dyspnea, fatigue, productive cough. Crackles & wheezes, blood-tinged sputum.

  • Different types: Bacterial, Fungal (most common), Viral (AIDS), Aspiration (GERD), Ventilator-Associated, Chemical (inhalation of chemical toxins)

  • Can be confined to one lobe or throughout the lungs

  • X-Ray

  • Hear less airflow on the spot of pneumonia

  • RAISE THE HEAD OF THE BED FIRST

• Tuberculosis- Mycobacterium tuberculosis. Chronic productive cough, blood-tinged sputum, chest pain, fatigue, poor appetite, weight loss, low-grade fever

  • Affects the lungs, but kidney, liver, brain, and bone may be affected

  • Meds can turn urine orange

  • 3-month testing while on medication- tough on liver, hypertoxicity

  • N95 MASK

• Pleural effusion- excess fluid in the pleural space. *SYMPTOM*

  • SOB, cough, tachypnea, decreased lung sounds, often pain

• Chronic Obstructive Pulmonary Disease (COPD)- Group of pulmonary disorders (umbrella). Difficulty exhaling d/t narrowing airway, blocked with inflammation,

  • exacerbations- (symptoms get out of control)

  • (Obstructive- air moving out)

  • Cough, chronic sputum production, dyspnea, crackles, wheezes, barrel-chested, accessory muscles.

  • Deliver oxygen Nasal Cannula 2 L

  • Per lip breathing- increase the duration of the excoriation, get more air out

  • INCREASE PROTEIN

• Atelectasis- collapse of lung

• Asthma- chronic inflammation and edema of mucosal lining. Narrowed airways and air trapping.

  • Chest tightness, dyspnea, coughing, difficulty moving air out.

  • Wheezing on expiration- hear them up high

• Cystic Fibrosis- exocrine glands disorder that affects the lungs, GI tract, sweat glands. Thick, tenacious secretions, cause airway obstruction.

  • Coughing, purulent sputum, finger clubbing, hemoptysis. Foul-smelling stools, bowel obstruction, cirrhosis, cholelithiasis.

  • Sweat test for Diagnostic testing

• Pneumothorax- air in the chest

• Hemothorax- blood in the pleural space

• Empyema- a collection of pus in the pleural space

• Retraction- pulls in while breathing

• Pulmonary embolism- traveling blood clot, blockage in pulmonary arteries, ADMINISTER OXYGEN, First sign could be stabbing chest pain

• Hypoxemia- not getting enough oxygen, Hunger for air

• USE OF INHALER:

  • SHAKE

  • PLACE ON LIPS

  • INHALATION

  • HOLD

  • EXHAUL

Chapter 47- Neurologic System

• Neurologic System

  • Two Divisions

  • Central Nervous System (CNS)

    • Brain

    • Spinal cord

  • Peripheral Nervous System (PNS)

    • Includes nerves of Autonomic Nervous System (ANS)

  • Electrical Impulses

• Neurons

  • Afferent
    A=Affect or sense

  • Efferent
    E= Effect or action

• Synapses

  • Circuit

  • Synapse: small gap between neurons

    • Impulse becomes chemical

  • One way

  • Medication work here

• Spinal Cord

  • Transmit impulses 🡪🡨 brain

  • Nerves attach by roots

  • Meninges

    • Offer protection

  • Circulating CSF

    • Offer protection

• Spinal Nerves

  • 8 cervical pairs

  • 12 thoracic pairs

  • 5 lumbar pairs

  • 5 sacral pairs

  • 1 coccygeal pair

  • Referred by letter & number

• Reflexes

  • Fast, involuntary response to stimulus

  • Stretch

  • Flexor

• Brain

  • 4 areas

    • Cerebrum

      • Frontal, Parietal, Occipital, Temporal

    • Diencephalon

      • Thalamus & Hypothalamus

    • Brainstem

      • midbrain, pons, medulla oblongata

  • Cerebellum

• Cranial Nerves

  • Carry out motor impulses to muscles

  • 12 pairs

• Autonomic Nervous System

  • 2 divisions

    • Sympathetic

    • Parasympathetic

  • Integrated by hypothalamus

• Sympathetic

  • Dominant in stressful situations

    • Fear, anger, anxiety, excitement

  • “S” is for STRESS

• Parasympathetic

  • Dominates during relaxation

  • “P” is for PEACEFUL

• Nerulogical Assessment

• Assessment:

  • Establish present function

  • Detect changes/alternations

  • Diagnosis determines frequency

  • Rapid detection & intervention!!

    • Paresis- weakness or partial paralysis.

    • Dysphagia- difficulty swallowing.

  • Health history

  • Physical Examination

  • Glascow Coma Scale

  • Level of Consciousness

  • Abnormal posture

  • Mental Status

  • Aphasia- unable to speak

  • Examination of the eyes

  • Examination of muscle function

    • Upper/Lower

    • Left/Right

    • Hand grasp, arm drift, plantar strength

      • Anisocoria- unequal pupils

      • Nystagmus- involuntary movement of the eyes

• Diagnostic Testing

  • Lumbar Puncture

  • X-ray

  • Computed Tomography (CT)

  • Magnetic Resonance Imagine

  • Angiogram

  • Myelogram

  • Electroencephalogram (EEG)

• Supportive Nursing Care

  • Assistance with position change & ambulation

  • Monitor for sensory loss

  • PT referral

  • Proper body alignment

  • Splints, footboards, foot support

    • Paresthesia- abnormal sensation (burning or tingling).

    • Contractures- Permanent muscle contractions occurring from lack of use.

  • ADL assessment & assistance

  • Communication assessment

  • Nutrition assessment

  • Family assessment

    • Dysarthria- difficulty speaking.

    • Expressive aphasia-difficulty or inability to verbally communicate with others.

    • Receptive aphasia-inability to understand spoken language.

Chapter 48- Care of Patients with CNS Disorder

• Dementia- not a diagnosis

  • Progressive loss of mental functioning

  • Can progress to Alzheimer’s

  • Reduced blood flow

  • Short-term memory affected first

  • Disorientated to time

  • Aphasia- absent of speech

  • Behavioral problems

  • Delirium- mental disturbance that is temporary. MEDICAL EMERGENCY. Treatable

    • Disorganized thinking

    • Safety #1 priority

• Supportive Nursing Care- Dementia

  • Medications-

    • Slow progression

    • Reduce symptoms

    • Improve cognition

    • Donepezil (Aricept)

    • Memantine (Namenda)

  • LTC facility placement

• Parkinson’s Disease- decrease of dopamine

  • Chronic, degenerative movement disorder

  • Destruction of cells 🡪 decreased dopamine production🡪 impairment of semiautomatic movements

  • Tremors, changes in posture & gait, rigidity, slowness of movements

  • Akinesia- loss of muscle movement

  • Acetylcholine- excitatory neurotransmitters

• Parkinson’s Disease S/S

  • Gradual onset

  • Muscular rigidity

  • Bradykinesia- slow movement

  • Akinesia

  • Postural changes

  • Tremors- ipsilateral (same side) then contralateral (opposite side)

  • Alterations in mobility, ADL function

  • Increased symptoms with fatigue

• Supportive Nursing Care- Parkinson’s

  • Fall risk!

  • Support impaired swallowing

  • Symptom control (no cure)

  • Medications

    • Entacapone (Comtan)- prolongs levodopa action

    • Levodopa/Carbidopa (Sinemet)- convert into dopamine in the brain

      • Not with food or after (food after medication)

      • Discolors urine

      • 15 minute range, every 4 hours

  • “Drug Holiday”- off medication and restarted on lower doses

  • PT/OT- maintain the function that they have for awhile

  • ROM/PROM

  • Dietary support (thickened liquids)

  • Bed/chair alarm (facility dependent)

• Alzheimer’s Disease

  • Women > Men

  • Most common dementia type

  • Deficiency of acetylcholine

• Alzheimer’s Disease 5 A’s

• Stage 1

  • 2-4 years

  • Increasing forgetfulness

  • Stage 2

    • Longest in duration

    • 2-12 years

    • Progressive cognitive deterioration

    • Irritability

    • Depression

    • Aphasia

    • Disrupted sleep

    • Hallucinations

    • Seizures

  • Stage 3

    • Progression to complete dependency

    • Inability to converse

    • Incontinence of B & B

    • Loss of emotional control

    • Inability to move independently

    • Inability to swallow

    • Tube feedings

    • Duration depends on health status

• Supportive Nursing Care- Alzheimer’s

  • No cure

  • Focus on minimizing effects & maintaining independence

  • Medications

    • Acetylcholinesterase (AChE) inhibitors (donepezil (Aricept) ) Inhibit acetylcholine breakdown

    • NMDA antagonists (memantine (Namenda) ) prevents overexcitation

    • Antidepressants

    • Antipsychotics

    • Antianxiety

  • Safety assessment

  • ADL assistance

Chapter 49- Nursing Care of Patients with Cerebrovascular Disorder

• Transient Ischemic Attack (TIA)

  • Temporary impairment blood to the brain

  • Deprives brain of glucose and oxygen

  • Symptoms resolve

  • 15% of all Strokes are preceded by TIA

• Cerebrovascular Accident (Stroke) CVA

  • Inadequate Blood Flow to Brain

  • Infarction of Brain Tissue

  • Permanent Damage if Not Reversed

  • Neurological Deficits

• Etiology

  • Ischemic- deficient blood supply

    • Thrombotic- stroke occurs when occlusion builds up in an artery

      • Embolic- caused by a blood clot

  • Hemorrhagic- rupture of a cerebral blood vessel that allows blood to escape the blood vessel

    • Subarachnoid- surface of the brain

    • Intracerebral- occurs in the deeper tissue of the brain, caused by uncontrolled hypertension

• Risk Factors Modifiable

  • Hypertension

  • Smoking

  • Diabetes Mellitus

  • Cardiovascular Disease

  • Atrial Fibrillation

  • Carotid Stenosis

  • TIA

  • Sickle Cell Anemia

  • Dyslipidemia

  • Obesity

  • Excessive ETOH intake

  • Poor Diet

  • Physical Inactivity

  • Oral Contraceptives

• Non-Modifiable Risk Factors

  • Age

  • Gender

  • Heredity

  • Prior Stroke or Heart Attack

• Warning Signs

  • Sudden Numbness or Weakness- typically one-sided

  • Sudden Confusion

  • Sudden Change in Vision

  • Sudden Trouble Walking/Dizziness

  • Sudden Severe Headache

  • CALL 911!

• S/S

  • Depend on Area of Brain Affected

  • One-Sided Weakness/Paralysis

  • Dysphagia

  • Sensory Loss

  • Mental Status Changes

  • Visual Disturbance

  • Speech Disturbance

• Diagnostic Testing

  • CT Scan- give TPA

  • EKG

  • CBC, Electrolytes, Glucose

  • Metabolic Panel

  • PT, INR

  • NIH Stroke Scale

  • Carotid Doppler

  • Carotid Angiography

• Supportive Nursing Care- Stroke

  • Thrombolytic Therapy

  • Airway Management

  • Control

    • Hypertension- the bottom number is the more important one

    • Fever- less than 99.6

    • Glucose

• Thrombolytic Therapy

  • TPA Dissolves Clot- don’t give TPA if you do not see the clot

  • 4.5 Hour Time Window

  • May Reverse Symptoms

    • Or prevent progression

  • TIME LOST IS BRAIN LOST!

• Prophylactic Management

  • Treat Cause of Stroke

  • Physical, Occupational, Speech Therapy

  • Antiplatelet Agent- aspirin, Plavix

  • Anticoagulant Agent- Warfin, Heparin

  • Antihyperlipidemic Agent

  • Antidysrhythmic Agent

  • Maintain Patent Airway

  • Surgery

    • Carotid endarterectomy- is surgery to treat carotid artery disease. The carotid arteries are the main blood vessels that carry oxygen and blood to the brain. In carotid artery disease, these arteries become narrowed. This reduces blood flow to the brain and could cause a stroke.

• Prevention

  • Control

    • Weight

    • Hypertension

    • Cholesterol

  • Smoking Cessation

  • Aspirin or Warfarin

  • Early Recognition and Treatment

• Long-Term Affects

  • Impaired Motor Function

  • Impaired Sensation

  • Dysphagia/Aphagia

  • Dysphasia/Aphasia

  • Emotional Lability

  • Impaired Judgment

  • Unilateral Neglect

• Nursing Process: Assessment

  • LOC

  • Restlessness

  • Dizziness

  • Vision Changes

  • Pupil Changes

  • Vital Signs

  • Pain

  • SpO₂

  • Paresthesias

  • Weakness

  • Paralysis

  • Seizures

  • Respiratory Status

  • Swallowing

Chapter 51- Vision and Hearing

• Eyeball Structures

  • Sclera- outer, white

  • Cornea- clear part

  • Retina- light sensitive

  • Optic nerve- back part that sends signals

  • Iris- color of the eye

  • Lens

• Aging Sensory System

  • EYES:

    • Color vision fades

    • Glare adaption difficulties- more so at night

    • Peripheral vision decreases

    • Depth perception decreases

    • Farsightedness

    • Lens opacity

  • EARS:

    • Unable to filter background noises

    • Impaired verbal communication

    • Inner ear cell damage

    • High pitch loss

• Assessment

  • Patient history

  • Nutrition history

  • Family history and genetic risk

  • Current health problems

  • Visual acuity

  • Visual field

  • Extraocular muscle function

  • Pupillary reflexes

  • Color vision

  • Inspect & palpate

• Supportive Nursing Care- Eyes

  • Regular eye examinations

  • Eye hygiene

  • Nutrition

  • Eye safety & injury prevention

  • Eye irrigation

  • Medication administration

• Ear

  • 3 areas

    • Outer ear

      • Auricle

      • Auditory canal

    • Middle ear

      • Air-filled

      • Vibrations transmitted through auditory bones

    • Inner ear- bony labyrinth- HEARING

      • Hearing

      • Equilibrium

• Assessment

  • Health History

  • Physical Examination

    • Inspection & palpation

    • Auditory acuity testing

      • Whisper test- hearing function in each ear

      • Rinne test- conductive and sensorineural hearing loss

      • Weber test- third test to determine hearing acuity

    • Balance testing- ROMBERG TEST

• Diagnostic Testing

  • Audiometric testing- screening tool to determine type and degree of hearing loss

  • Tympanometry- tympanic membrane and evaluate middle ear function

  • Caloric test- function of 8^th cranial never and asses vestibular reflexes of inner ear that control balance

  • Electronystagmogram- unilateral hearing loss of unknown origin, vertigo, or ringing in the ears

  • CT/MRI

  • Laboratory tests

    • Ear cultures- drainage from ear canal

    • Pathology examination- tissue obtained during surgery ruled out

• Supportive Nursing Care

  • Medications

  • Maintenance

  • Assistive Hearing Devices

Chapter 52- Sensory Disorders- Vision & Hearing

• Eye Infections & Inflammation

  • Types of Conjunctivitis- inflammation of the conjunctiva caused by either virus or bacterial- PINK EYE

    • Allergic Conjunctivitis- itching and redness of the eye, swelling of the conjunctiva and the eyelid

    • Viral Conjunctivitis- redness of the eyes and periodic itching, increased lacrimation

    • Bacterial Conjunctivitis- redness, dryness of eye and skin around them mucopurulent discharge

• Diabetic Retinopathy- retinal blood vessels affected

  • Diabetic complication- more so from uncontrolled

  • Total blindness can result

• Retinal Detachment S/S

  • Sudden vision change

  • Flashing lights

  • Floaters

  • “Looking through a veil”

  • Curtain

  • No pain

• Retinal Detachment Therapeutic Interventions

  • Laser Reattachment

  • Cryosurgery

  • Scleral Buckling

• Glaucoma- Group of Diseases that damage optic nerve- pressure within the eye

  • Elevated pressure

  • Silent, progressive, irreversible

  • Lifelong treatment

• Glaucoma Acute Angle-Closure- Pain- No Benadryol

  • Narrow angle blocks aqueous fluid

  • MEDICAL EMERGENCY

  • Signs & Symptoms

    • Severe eye pain

    • Blurred vision

    • Rainbows around lights

    • Redness

    • Photophobia

    • Tearing

    • Steamy-appearing cornea

• Glaucoma Primary Open-Angle- NO PAIN

  • Degeneration of drainage system

  • Gradual

  • Painless

  • Signs & Symptoms

    • Headache

    • Halos around lights

    • Visual changes

• Glaucoma Treatments

  • Medications- decreased the pressure in eye and try to drain the fuild

    • Miotics

      • Carbachol (Isopto Carbachol)

      • Pilocarpine (Pilocar)

    • Agents to decrease production of aqueous fluid

      • Dipivefrin (Propine)

      • Timolol (Timoptic)

    • Mydriatics: DO NOT GIVE TO AACG

      • Atropine, diphenhydramine, hydroxyzine

• Cataracts

  • Opacity in lens

  • Signs & Symptoms

    • Loss of visual acuity

    • Halos

    • Difficulty reading

    • Glare sensitivity

    • Double vision

    • Decreased color vision

• Macular Degeneration

  • Slow, progressive loss of central/near vision

  • Daily screening

    • Amsler Grid- the only time you use it is with Macular Degeneration

• Eye Medications

  • Diagnostic- stain the eye (yellow), wear gloves, tissues

  • Anesthetics- topical

  • Antiangiogenic- growth factor, inhibits the growth

  • Allergy relief

  • Antibiotics

  • Antivirals

  • Antifungals

  • Anti-inflammatories- bring down inflammation

  • Lubricants- artificial tears

  • Miotics- cause the pupil to constrict

  • Osmotic- decreases pressure

  • Beta-Adrenergic Blockers

• Hearing Loss

  • Congenital or Acquired- Congenital- disorder that present at birth, Acquired- aquired during the lifetime

  • Effects communication, social life, work

  • Conductive- stops sounds from getting through the outer or middle ear (Hearing Aids)

  • Sensorineural- caused by lesion/disease of the inner ear, Ex: Lyme Disease, Viral/Bacterial Infection or tramua

  • Therapeutic Measures

• Optic Medications

  • Diagnostic

  • Cerumenolytics- liquid solutions that help thin, softer, etc ear wax

  • Anti-inflammatory

  • Analgesics

  • Antibiotics

• Presbycusis- gradual hearing loss in both ear

Chapter 21- Cardiovascular System Function, Assessment, and Therapeutic Measueres

• The Heart

  • In mediastinum

  • Pericardial sac: Three layers- tissue that surrounds the heart

    • Fibrous pericardium- outer most layer

    • Parietal pericardium- middle layer

    • Visceral pericardium (epicardium)- inner most layer

    • Serous fluid between inner layers

• Cardiac Structure and Vessels

  • Four chambers

    • Right/left atrium, right/left ventricle

  • Cardiac layers

    • Epicardium, myocardium, endocardium

  • Coronary arteries

  • Valves

    • Tricuspid, pulmonic, mitral, aortic

• Blood Flow

  • Vena cava » right atrium » tricuspid valve »

  • right ventricle » pulmonic valve » pulmonary

  • artery » lungs » pulmonary veins » left

  • atrium » mitral valve » left ventricle (thicker wall, pumps out with 5x the force)» aortic

  • valve » aorta

• Cardiac Conduction

  • Sinoatrial (S A) node- pacemaker, beat of heart

  • Atrioventricular (A V) node

  • Bundle of HIS

  • Right and left bundle branches

  • Purkinje fibers

• Cardiac Output (CO)

  • Amount of blood ejected from the left ventricle in 1 minute

  • Stroke volume multiplied by heart rate = C O

• Hormones and The Heart

  • Epinephrine increases

  • Aldosteraone

• Blood Vessels

  • Arteries- carry blood away from the heart, thicker, more muscle

  • Veins- carry blood towards the heart

  • Capillaries- tiny, take waste out to the tissue

• Blood Pressure

  • Blood force against blood vessel walls

• When blood flow to the kidneys is decreased, Renin-Angiotensin-Aldosterone Mechanism, protects the organs

• Aging

  • Atherosclerosis- deposition of lipids in the arterial walls

  • At risk for developing orthostatic hypotension🡪 falls.

• Cardiovascular Disease

  • Number 1 cause of death

  • Healthy lifestyle

    • Smoking cessation

    • Exercise

    • Dietary fat reduction

    • Normal B P, glucose, cholesterol levels

    • Normal weight

• Cardiovascular Assessment

  • Health history

  • Physical assessment

    • General appearance

    • Vital signs

      • Orthostatic BP

    • Height/weight

  • Diagnostic studies

• Physical Examination

  • Inspection

    • Oxygenation, skin color

    • Extremities: Hair, skin, nails, edema, color

    • Jugular vein distention- right sided heart failure from liver

    • Capillary refill

    • Clubbing

      • Put index fingers at the nailbeds/first joint together.

      • If there is a diamond shape in the space at the nailbeds, this is normal.

• Physical Examination

  • Palpation

    • Point of maximum impulse- apical pulse (by the heart pulse)

    • Extremity temperature

      • Poikilothermy- when your body temp is same as environment time

    • Edema

    • Thrill- vibration caused by blood flowing through the fistula (feel it)

    • Bruit- listen to the incision cite- whooshing sound, (hear)

• Physical Examination

  • Auscultation

    • Heart sounds

    • Murmurs

    • Pericardial friction rub

• Cardiovascular Testing

  • X-ray: size, position, contour, structures (enlargement, fluid, calcification, heart failure)

  • Computed Tomography (CT): evaluates heart structures (plaque w/ atherosclerosis)

  • Angiography: view blood vessels and coronary arteries * check kidney function* because they use *iodine*, allergic to shellfish

  • Magnetic Resonance Imaging: identifies ischemia and abnormalities

  • Electrocardiogram: records electrical activity, enlarged chamber size, electrolyte imbalances, dysrhythmias

  • Echocardiogram: ultrasound, heart enlargement, CAD, pericardia effusion

  • Transesophageal echocardiogram (TEE): transducer into esophagus

  • Stress test: dysrhythmias and ischemia, effects of exercise on the heart

  • Cardiac Catheterization: catheter into heart, detects chamber pressures, cardiac disease- risk for: bleeding first, check everything distal from the point of entry

• Blood Studies

  • Cardiac biomarkers

    • Creatine kinase, troponin (sign of heart attack, chest pain), myoglobin

  • C-reactive protein

  • Homocysteine

  • Lipids- deals with cholesterol, fats

    • Triglycerides, cholesterol, phospholipids

  • Magnesium

  • Potassium- can become toxic fast in pt. (3.5-5 number range)

• Therapeutic Interventions

  • Exercise

  • Smoking cessation

  • Diet

  • Oxygen

  • Medication-vasodilators, antihypertensives, antidysrhythmias, antianginals, anticoagulants, thrombolytics

  • Anti-embolism devices-TEDS, SCDs

  • Cardiac surgery

Chapter 22 Hypertension

• Hypertension

  • High blood pressure

  • Average of at least 2 or more BP readings on 2 different occasions

  • Change in vessels, increase in blood thickness, increased fluid volume contribute to elevated BP

• Hypertension Primary (Essential)

  • Chronic elevation from unknown cause

• Hypertension Primary (Secondary)

  • Known cause

  • Sign of another problem

    • Kidney abnormality

    • Adrenal glad tumor

    • Congenital defects

  • Once treated, bp returns to norm.

• S/S Hypertension

  • Often no signs or symptoms

    • Headache, bloody nose, severe anxiety, SOB

  • “Silent Killer”- don’t know they have it

  • Often found when seeking care for unrelated issues

• Risk Factors Modifiable

  • Lifestyle modifications

  • Diet

  • Exercise

  • Antihypertensive drugs

  • Cholesterol

• Risk Factors Non-Modifiable

  • Family HX

  • Age

  • Race & ethnicity

  • Diabetes mellitus- Type 1

• Hypertension Meds

  • Combined Alpha & Beta blockers

  • Alpha2 Agonists

  • Angiotensin-Converting Enzyme (ACE) inhibitor

  • Angiotensin II receptor antagonists (ARB)

  • Calcium channel blockers

  • Direct vasodilators

  • Diuretics- start with, get rids of the fluid

    • Thiazide diuretics

      • Loop diuretics

      • Potassium-Sparing diuretics

    • (Sympatholytics) Beta Blockers

• Diuretics

  • Take with food to avoid GI upset

  • Assess edema

  • Assess BP for hypotension

  • Electrolyte imbalances- Potassium

  • Nocturia- excessive urination at night

• Diuretics Meds- monitor potassium levels

  • Potassium-Sparring- high potassium can be caused

    • spironolactone (Aldactone)

  • Loop- low potassium can be caused

    • bumetanide (Bumex)

    • furosemide (Lasix)

  • Thiazide (& like)- low potassium can be caused

    • hydrochlorothiazide (HCTZ)

    • metolazone (Zaroxolyn)

• Beta Blockers (OLOL)- monitor bradycardia, check pulse first, can’t stop abruptly

  • atenolol (Tenormin)

  • metoprolol (Lopressor)

  • metoprolol XR (Toprol XL)

  • propranolol (Inderal)

• Combined Alpha & Beta Blockers- cause vasodilation, BP could drop

  • carvedilol (Coreg)

  • labetalol (Normodyne)

• Alpha2 Agonists

  • clonidine (Catapres)

  • guanfacine HCL (Tenex)

• ACE Inhibitors (PRIL)- reduce BP, LISTEN TO LUNG SOUNDS AND NEW ONSET COUGH

  • fosinopril (Monopril)

  • lisinopril (Zestril, Prinvil)

  • quinapril (Accupril)

  • enalapril (Vasotec)

  • captopril (Capoten)

  • benzepril (Lotensin)

• ARB (TAN)

  • losartan (Cozaar)

  • olmesartan (Benicar)

  • valsartan (Diovan)

• Calcium Channel Blockers- prevent movement, extra calcium

  • amlodipine (Norvasc)

  • diltiazem (Cardizem)

  • nifedipine (Procardia)- change vessel lining of the heart, smooths muscle contractions

  • verapamil

• Direct Vasodilators

  • hydralazine (Apresoline)

  • minoxidil (Loniten)

• Hypertension Complications

  • Coronary Artery Disease (CAD)

  • Atherosclerosis

  • Myocardial Infarction (MI)

  • Heart failure

  • Cerebral-vascular accident (CVA/Stroke)

  • Pulmonary edema

  • Kidney disease

  • Renal damage

  • Eye damage- so much pressure and tiny vesssels

  • Hypertrophy- increased size caused from hypertension and overwork muscle

• Hypertensive Emergency

  • Severe hypertension

  • Systolic > 180

  • Diastolic > 120

  • Target-organ dysfunction (MI, HF, dissecting aortic aneurysm)

  • CVA

  • Gradual reduction is desired to prevent decreased blood flow to kidneys, heart, brain

• Patient Education

  • Lifelong BP control

    • Self-care lifestyle measures

    • Prescribed medical regimen

  • Dizziness may increase the risk of falling.

  • Rise slowly to prevent orthostatic hypotension.

Chapter 23- Valve, Inflammatory, Venous Disorders

• Cardiovascular Meds

  • Nitrates

  • Anticoagulants

  • Antiplatelet agents

  • Thrombolytics

  • Potassium channel blockers

  • Vasopressors

  • Inotropic agents

  • ACE inhibitors

  • Beta-adrenergic blockers

  • Diuretics

  • Calcium channel blockers

  • Cardiac glycosides

  • Angiotensin receptor blockers

  • Vasodilators

• Cardiac Valve Disorders

  • Mitral, tricuspid, pulmonic, aortic

  • Forward blood flow compromised with stenosis

  • Blood back up = regurgitation (hear murmurs)

    • Stagement blood is clotting blood

    • Increases workload of heart

    • Increases pressures in chambers

• Cardiomyopathy

  • Enlargement of heart muscle

  • Complications: heart failure, myocardial ischemia, myocardial infarction (MI)

  • No cure

  • Types:

    • Dilated

    • Hypertrophic

    • Restrictive

  • Heart failure s & s: dyspnea, fatigue, orthopnea, atypical chest pain, syncope, crackles

  • Cardiomegaly on x-ray

  • Anticoagulants

  • Heart failure treatment as needed

  • Palliative care

Left ventricle goes to lungs, so back up will spill over into the lungs, s/s everything pulmonary, wet lung sounds, pulmonary edema/hemorrhage

Right sided heart failure = rest of the body, backs up to liver, JVD, perfilary edema, spleen swelling

• Thrombophlebitis

  • Clot 🡪inflammation within a vein

  • Most common vein disorder

  • Legs most common

  • Deep venous thrombosis (DVT) most serious d/t PE risk

  • Platelets attach to vein wall

  • Cells and fibrin collect

  • Stasis of blood flow, damage to wall lining, increased coagulation=Virchow’s triangle

• Thrombophlebitis S/S

  • None

  • Superficial veins

    • Redness, warmth, swelling, tenderness

    • Palpation reveals vein feels like a cord (induration)

  • DVT- most several form, most worried about PE (large clot into a smaller vessel), O2

    • Located in leg usually

    • Swelling, edema, venous distension, pain in deep calf (usually), warmth, tenderness

    • DEHYRDRATION

    • TED STOCKING

    • AMBULTIATION IS IMPORTANT

• Thrombophlebitis Complications

  • Pulmonary embolism

    • Life-threatening emergency

  • Chronic venous insufficiency

  • Varicose veins

  • Recurrent DVT

• Thrombophlebitis Prevention

  • ID risk factors

  • Prevent dehydration

  • Antiembolism devices (teds/scds/IPCDs)

  • Mobility

  • Medication

    • Heparin

    • Coumadin

      • International normalized ratio (INR)-measures effectiveness

Chapter 24- Occlusive Cardiovascular Disorders

• Cardiovascular Disease

  • Leading cause of death in US

  • Education important!

  • Every 25 secs a coronary event happens

  • Every minute someone dies from coronary event

  • 1 in 3 women affected

  • Decreases with higher education

    • <high school education higher incidence than college degree

• Arteriosclerosis- normal part of aging

  • Thickening

  • Loss of elasticity

  • Calcification of arterial walls

• Atherosclerosis- plaque inside arteries, not normal part of aging

  • A Type of arteriosclerosis

  • Can start in childhood

  • Causes coronary artery disease (CAD)

  • Partial or total occlusion of the artery=reduced blood flow

  • Distal ischemia

• Atherosclerosis

  • Pathophysiology

    • Injury, inflammation

    • Smooth muscle cells grow

    • Collagen and fibrous proteins are secreted.

    • Lipids, platelets, clotting factors accumulate.

    • Scar tissue replacement

    • Fatty streak

    • Plaque build-up—reduced blood flow

    • Reduced blood flow from narrowing artery

    • Calcium fibrous cap—rupture/ tear

    • Blood clot forms.

• Atherosclerosis Non-Modifiable Risk Factors

  • Age

  • Gender

  • Ethnicity

  • Genetic predisposition for hyperlipidemia

• Atherosclerosis Modifiable Risk Factors

  • Alcohol

  • Obesity

  • Sedentary lifestyle

  • Stress

  • Tobacco

  • Diabetes

  • Hypertension

  • Elevated Cholesterol

  • Elevated LDL apolipoprotein B

  • Elevated homocysteine

• Atherosclerosis Diagnostic Tests

  • Low-Density Lipoproteins (LDL)- under 200

  • High-Density Lipoproteins (HDL)- lose some weight, quit smoking

  • Radiological studies

• Atherosclerosis Therapeutic Measures

  • Diet

  • Smoking

  • Exercise

  • Medications

• Angina Pectoris- chest pain from ischemia

  • Narrowed vessels can’t dilate

  • Less oxygen/blood to heart

• Angina Pectoris Types

  • STABLE ANGINA

    • Exertion, familiar pattern

    • Pain is predictable.

    • More so during a physical activity

  • UNSTABLE ANGINA

    • Pain is unpredictable.

    • Rest/ sleep occurance

    • Meds don’t help

    • MI risk

    • DO NOT need to be doing anything

  • VARIANT ANGINA (PRINZMETAL)

    • Coronary artery spasm

    • Cyclic pain

    • Longer duration

    • IF NOT FOUND: can be serious and lead to other things, not as painful as other two

• Angina Pectoris S/S

  • Men- more common S/S

    • Heaviness, tightness, viselike, crushing pain in chest center

    • Radiate to arms, shoulder, neck, jaw, or back

    • Pale, diaphoretic, dyspneic

  • Women

    • Chest or jaw pain

    • Heartburn

    • Atypical

    • N/V

• Angina Pectoris: Medication

  • Vasodilators #1- improve blood flow going to the heart, nitro (under the touge)

  • Calcium channel blockers

  • Beta Blockers- watch for bradycardia

  • ACE Inhibitors- pril

  • Statins- high cholesterol, watch liver function studies (AST, ALT)

  • Antiplatelets- aspirin, Plavics (anticoagulant)

• Acute Coronary Syndrome- MI

  • Encompass CAD continuum

  • Silent ischemia

    • Sudden cardiac death

  • Myocardial infarction (MI)

  • Non-ST-segment elevation MI (NSTEMI) ST-segment elevation MI (STEMI)

  • TIME IS MUSCLE

• MI S/S

  • Crushing, viselike pain

    • Radiates: Arm/shoulder/neck/jaw

  • Diaphoresis (sweating)

  • Dizziness, fainting

  • Dyspnea

  • Nausea

  • Restlessness

  • EMERGENCY!

• Women and MI

  • Leading cause of death

  • African American women at higher risk

  • Higher mortality rate

  • Prodromal (not common) symptoms the month before

    • More tired

    • SOB

    • S/S don’t show to having a heart attack

  • Atypical symptoms

• Older Adults and MI

  • Report to health care provider

    • Shortness of breath

    • Fatigue

    • Fast/slow heartbeats

    • Chest discomfort

  • May have silent MI

  • Collateral circulation may offer protection

• MI Diagnosis

  • Consider patient history

  • Diagnostic tests

    • Serial E C G

    • Serum cardiac troponin I or T (not going to show elevation right away, check again 4-6 hours)

    • Myoglobin

    • Creatine kinase (C K)-M B

    • C R P

    • Magnesium

    • Potassium (3.5-5)

• MI Therapeutic Interventions- MONA (Morphine, oxygen, nitro, aspirin)

  • Antiarrhythmics

  • Weight loss

  • Smoking cessation

  • Statins

  • ACE inhibitors

  • Oxygen

  • Aspirin

  • Morphine sulfate

  • Thrombolytics

  • Vasodilators

  • Beta blockers

• Arterial Thrombosis (hanging out) & Embolism (gets away and goes on adventure)

  • Occlusions most common in lower extremities

  • Thrombus

  • Embolism

  • “6 Ps”

• Arterial Thrombosis/Embolism- Therapeutic interventions

  • Anticoagulants

  • Thrombolytics

  • Thrombectomy

  • Embolectomy

• Peripheral Arterial Disease (PAD)

  • Chronic narrowing of arterial vessels

  • Lower extremities

  • Atherosclerosis (plaque) leading cause

  • Organic disease

  • Functional disease

  • Intermittent claudication- pain in calf during exercise, blood supply to muscle decreases

  • DO NOT use heating pads

  • SHOULD NOT have TEDS on

• Raynaud’s Disease

  • Vasoconstrictive response

  • Fingers, ears, lips, toes, nose

  • Primary or secondary

  • Skin turns white, then blue

  • Re-warm slowly- prevent injury to area

  • Wear gloves

  • Avoid vasoconstrictors

• Varicose Veins

  • Primary:

    • Structural defect in vessel wall

    • Incompetent valves

    • Blood pooling

    • Superficial veins

  • Secondary:

    • Deep veins

    • Blood stasis/ increased pressure

    • Dilation of collateral and superficial veins

• Varicose Veins- S/S

  • Telangiectasias (spider veins)

  • Dull pain

  • Cramping

  • Edema

  • Heavy feeling in lower extremities

  • Ulceration (from blood just sitting there)

  • Disfigurement of lower extremity

  • Goals: improve circulation. Relieve pain

    • Compression socks

    • Laser ablation procedures

Chapter 25- Cardiac Dysrhythmias

• Cardiac Conduction System

  • Sinoatrial (SA) node: 60 to 100 beats per minute, your pacemaker (SINUS)- working as it should

  • Atrioventricular (AV) node: 40 to 60 beats per minute

  • Bundle of His

  • Right and left bundle branches

  • Purkinje fibers

• Cardiac Cycle

  • One heartbeat

  • Electrical representation of contraction and relaxation of atria/ventricles

• Electrocardiogram (ECG)

  • Shows cardiac electrical activity

  • 12-lead ECG = 12 different cardiac views

  • Waveforms change appearance in different leads

  • Waveforms upright in lead Two

  • Continuous monitoring often in lead Two

• Electrocardiogram (EKG/ECG)

  • Shows electrical activity of the heart

  • Dysrhythmias- abnormal rhythm

• Process for Arrhythmia Interpretation

  • Is it regular?

  • What’s the rate?

  • P waves?

  • PR interval?

  • QRS interval?

  • QT interval?

  • Normal sinus rhythm:

    • Rhythm-regular

    • HR: 60-100

    • P waves- rounded, preceed QRS

• Normal Sinus Rhythm- 60
  

• Sinus Brady(slow)cardia- 40

• Sinus Tach(fast)ycardia- 140

• Atrial Flutter- (abnormal), heart contracting fast, AV, shock heart back into normal rhythm

• Atrial Fibrillation- (AV)- no defined P waves- 300-650 bpm

• Ventricular Tachycardia- Ventriculus have taken over, 3 or more contractions in a row, wide bases, S/S: SOB, Sweating, Lightheaded, Pt. is dead, does not have pulse, bp (CPR)

• Ventricular Fibrillation- Ventriculus, can’t determine rate, complete loss of cardiac output, defibulator- vefib, every minute decrease surivial rate

• Asystole- dead, have to have rhythm to shock, CPR

• 

Chapter 26- Heart Failure

• Heart Failure

  • Inability of ventricles

  • Dyspnea

  • Fatigue

  • Fluid volume overload- isn’t pumping effectively

  • Right/Left (thicker wall, pump 5x force, get blood out) sided

  • Causes

    • MI 🡪 cardiac ischemia

    • CAD

    • HTN- Hypertension

• Left-Sided Heart Failure- backups into lungs

  • Afterload

  • Left side🡪 Lungs- everything pulmonary

  • Reduced gas exchange

    • SOB

    • Cyanosis

    • Pulmonary edema

      • Acute HF

      • Pink, frothy sputum

• Left-Sided Heart Failure Causes

  • Aortic Stenosis

  • Cardiomyopathy

  • Coarctation of aorta

  • Hypertension

  • Heart muscle infection

  • Myocardial infarction

  • Mitral regurgitation

• Right-sided heart Failure- backup to rest of the body

  • Preload

  • Increased work of right ventricle

  • Cor pulmonale- right ventricles increases in size

  • Abnormal emptying

  • Right🡪Systemic build-up

• Right-Sided Heart Failure Causes

  • ASD

  • Cor pulmonale- right ventricles increases in size

  • Left-sided HF

  • Pulmonary HTN

  • Pulmonary valve stenosis

• Chronic Heart Failure S/S

  • Fatigue

  • Weakness

  • Dyspnea

  • Cough

  • Crackles & Wheezes

  • Tachycardia

  • Chest pain

  • Edema

  • Anemia

  • Nocturia

  • Cyanosis

  • Altered mental status

  • Malnutrition

• Chronic Heart Failure Complications

  • Hepatomegaly

  • Splenomegaly

  • Pleural effusion- Left sided heart, fluid in pleural space

  • Left ventricular thrombus

  • Cardiogenic shock

• Chronic Heart Failure Diagnostic Testing

  • Laboratory tests

    • BNP

    • BUN

    • Creatinine

    • Liver enzymes

  • X-Ray

  • EKG-Dysrhythmias

  • Echocardiogram

  • Stress testing- consent is required

  • MRI

  • Cardiac catheterization/angiography- inside vessels, inside view of chambers

• Chronic Heart Failure Theraputic Interventions

  • Improve pumping ability & decrease oxygen demands.

    • ID & treat underlying cause.

    • Increase strength of heart’s contraction.

    • H2O/Na balance

    • Decrease workload- diuretic

• Chronic Heart Failure Drug Therapy

  • Oxygen

  • ACE inhibitors, ARBs, ARNis

  • Beta blockers

  • Diuretics

  • Inotropes

  • Vasodilators

  • Anticoagulants

Chapter 36- Urinary System Function & Assessment

• AP

  • Urinary System Consists of:

  • Two Kidneys

  • Two Ureters

  • Urinary Bladder

  • Urethra

• Kidneys: Urine Formation

  • 3 part process:

    • Glomerular Filtration

    • Tubular reabsorption

    • Secretion

  • Glomerular Filtration Rate: measures kidney function

• AP- Kidneys

  • Form urine

  • Regulation of BP

  • Regulation of electrolyte balance

  • Regulation of acid-base balance

  • Erythropoietin production

  • Vitamin D activation

• AP- Ureters

  • Eliminate urine

  • Kidney to bladder

  • Peristalsis

  • Compression to avoid backflow

• AP- Bladder

  • Behind pubic symphysis

  • Temporary urine storage

• AP-Urethra

  • Eliminates urine from bladder

• Urine Characteristics

  • Amount

    • ~1000-2000 mls/24 hrs

  • Color

    • Straw/Amber

    • Diluted=lighter

    • Concentrated=darker

    • Freshly voided=clear

    • Cloudy=infection

  • Specific Gravity

    • Kidneys’ concentrating ability

    • 1.005-1.030

    • Higher= concentrated

    • Lower= diluted

  • pH

    • 4.6-8 (avg 6)

  • Elements of Urine

    • Urine is 95% water

    • Nitrogenous waste: Urea, creatinine, uric acid

• Nursing Assessment

  • Health History

  • Pain/Burning with Voiding

  • New Onset Edema, Shortness of Breath, Weight Gain

  • Fluid Intake

  • Functional Ability

  • Physical Assessment

    • Vital signs

    • Lung sounds

    • Edema

    • Daily weights

    • I & O

• Laboratory Testing

  • Urinalysis (urine analysis)

    • Diagnostic test

    • Assesses urinary system, kidney disease, systemic disease

    • Room temp 1 hours/refrigerate

  • Urine Culture

    • Bacteria in urine

    • Sensitivity to antibiotics

  • Renal Biopsy

    • Identify kidney disease

  • Pyelogram

    • Xray examination

  • Nephropathy

  • U/S, CT, MRI

• Laboratory Testing

  • Renal Function Tests

  • Serum Creatinine (Male: 0.61-1.21mg/dL, Female: 0.51-1.11mg/dL)

    • Waste product from muscle metabolism

    • Very good indicator of kidney function

    • Blood Urea Nitrogen (8-21mg/dL)

    • Waste product of protein metabolism excreted by kidneys

    • Elevated levels=kidney disease, dehydration, high-protein diet, heart failure

  • Serum Uric Acid (male: 4-8mg/dL, female: 2.5-7mg/dL)

    • Purine metabolism end product and breakdown of body proteins

    • Elevated levels=possible renal disease

  • Bun-creatinine ratio (10:1 to 20:1)

    • Evaluates hydration status

• Urinary Incontinence

  • Involuntary leakage of urine

    • Stress incontinence

      • Involuntary loss of <50 ml urine

      • Coughing, sneezing, laughing

    • Urge incontinence

      • Involuntary loss with strong desire to void

    • Functional incontinence

      • Inability to physically get to the toilet

    • Overflow incontinence

      • Involuntary loss due to over-distention

    • Total incontinence

      • Continuous, unpredictable loss of urine

      • Often neurologically impaired

• Urine Retention- Inability to empty the bladder completely

  • Acute Retention

    • Post-surgical

    • Extreme pain

    • Risk for bladder rupture

  • Chronic Retention

    • Enlarged prostate

    • Diabetes

    • Pregnancy

    • Obstruction

  • Palpation

  • Percussion

  • “fullness”

  • Bladder scan

• Urinary Catheters

  • Indwelling catheters

    • Justifiable reasons

      • Medical emergency

      • Urinary tract obstruction

      • Medical procedure

      • High infection rate!

    • Intermittent

      • Unable to void

      • Every 3 hours

      • Taught self-cath for home

    • Suprapubic

      • Through abdomen into bladder

      • Long-term situations

Chapter 37- Nursing Care of Patients W/ Disorders of Urinary System

• Urinary Tract Infections

  • E. Coli

  • Lower: urethritis, prostatitis, cystitis

  • Upper: pyelonephritis, urethritis

  • Women > Men

  • Risk factors

    • Incomplete emptying

    • Contamination

    • Instruments

    • Reflux

    • Anatomical

    • pregnancy

• S/S UTI

  • Dysuria

  • Urgency

  • Frequency

  • Incontinence

  • Nocturia

  • Hematuria

  • Back/Flank pain

  • Foul-smelling urine

  • Cloudy

  • Fever

• UTI

• LIMIT Caffeine

  • Urethritis

    • Chemicals

    • Bacteria

    • Trauma

    • STI (Gonorrhea/Chlamydia)

  • Cystitis

    • 90 % E. Coli

    • Perineal ascend

    • Pelvic pain/ pressure

  • Pyelonephritis

    • Hx of UTI

    • Sexual intercourse

    • Spermicide- vaginal birth control

    • Structural problems

    • Urosepsis- UTI leads to sepsis

• Supportive Nursing Care UTI

  • Education

  • Medication

  • Increase fluids

• Renal Calculi- Kidney Stones

  • Crystal masses

  • Concentrated urine gathers salts

  • <5 mm, passed in urine

• Renal Calculi S/S

  • Extreme flank pain

  • Radiating pain

  • Hematuria- blood in the urine RBC

  • Costovertebral tenderness!

  • Anuria (<50 ml daily)

  • Oliguria (<400 ml daily)

• Renal Calculi Prevention

  • Hydration

  • Diet

  • Exercise

• Renal Calculi Diagnostic Tests

  • Blood tests: Calcium, uric acid, blood urea nitrogen (B U N), creatinine

  • Urinalysis: Hematuria, crystals, urine pH

  • Two 24-hour urine collections

  • Helical computed tomography (CT) scan

  • Renal ultrasound

  • Abdominal x-ray

  • IV pyelogram- X-Ray exam injects contrast material into kidneys

• Supportive Nursing Care

  • Pain management

  • Surgical intervention

  • Urine straining

  • Antibiotics

  • IV fluids

  • Medications

    • Allopurinol

    • Flomax

• Benign Prostatic Hyperplasia- noncancerous enlargement of prostate gland

  • Nonmalignant growth

  • Increased effort

  • Increased time for urination

  • Goal=slow enlargement process

• S/S BPH

  • Obstruction

    • Decrease the size/force of stream

    • Difficulty starting urination

    • Dribbling

    • Retention

    • Fullness

    • Midstream stop

  • Irritation

    • Nocturia

    • Dysuria

    • urgency

• Supportive Nursing Care- BPH

  • Medication

    • Flomax (Tamsulosin)

    • Proscar (Finasteride)

  • Surgical intervention

    • TURP- surgery to remove inside part of prostate gland

  • Incontinence education

Chapter 38- Endocrine System, Function, and Assessment

• Anatomy & Physiology

  • Pituitary Gland

  • Thyroid Gland

  • Parathyroid Glands

  • Adrenal Glands

  • Pancreas

• Nursing Assessment

  • Health history

  • Physical examination

    • Inspection

    • Palpation

• Diagnostic Testing

  • Hormone tests

    • Stimulation- inject a certain substance, to see if you kick out the hormone

    • Suppression- inject substance, to suppress hormone

  • Urine

  • Nuclear scanning

  • Radiographic tests

  • Ultrasound

  • Biopsy

Chapter 40- Endocrine Pancreas

• Diabetes Mellitus- affects pancreas

  • Defects in insulin secretion

  • Result in elevated blood glucose levels

  • Insulin

  • Glucagon- raise blood glucose levels

• Type 1

  • (Juvenile diabetes, insulin-dependent, IDDM)

  • Destruction of beta cells- which produces the insulin

  • No insulin

• Type 2

  • (Adult-onset, non-insulin-dependent, NIDDM)

  • Resistance

  • Inadequate insulin amount

  • May require insulin

  • Heredity

  • Obesity

• S/S

  • Polydipsia- excessive amounts of fluid- thirsty

  • Polyuria- body makes too much urine

  • Polyphagia- extreme hunger

  • Glycosuria- glucose or sugar in your urine

  • Nocturia- wake up in night and need to pee

  • Ketoacidosis- high levels of ketones cause the blood to become more acidic

• Diagnostic Testing

  • Fasting Plasma Glucose

    • <100mg/dL

    • Pre-diabetic 100-126mg/dL

    • Diabetic > 126mg/dL

  • Random Plasma Glucose >200mg/dL

  • Oral Glucose Tolerance Test >200mg/dL

  • Glycohemoglobin, aka hemoglobin A1C

    • Normal 4-6%

  • A1C:

    • 6= (fasting) 126

    • 7= 154

    • 8= 183

    • 9= 212

    • 10= 240

    • 11= 269

    • 12= 298

• Prevention

  • Type 2 prevention

  • Weight-loss

  • Exercise

  • -7% body weight, 150 minutes/week

  • Metformin

• Goals of Treatment

  • Preprandial glucose 80 to 130 milligrams per deciliter

  • Peak postprandial glucose <180 milligrams per deciliter

  • Blood pressure <140/90 millimeters of mercury

  • Glycohemoglobin <7%

• Therapeutic Interventions

  • Nutrition therapy

  • Exercise

  • Medication

  • Monitoring

  • Education

• General Principles

  • Type 1

    • Avoid wide swings in blood glucose.

  • Type 2: Control

    • Blood pressure

    • Weight

    • Lipids

  • Regular eating schedule

• Insulin

  • Daily

  • Subcutaneous

  • Site rotation

  • Pump

  • Onset/Peak/Duration

  • Ex: Lantus, Humalog

  • Sliding scale

  • Mixing

• Oral Medicaiton

  • Type 2

    • NOT insulin pills

    • Pancreas stimulation

  • Metformin (Glucophage)

    • decreases glucose production in liver

  • Glipizide (Glucotrol)

    • stimulates insulin secretion

  • Januvia

    • reduces glucagon secretion/ increases insulin release

    • Works when BG is high

  • Byzetta, Victoza, Trulicity- SQ injection

    • mimics to cause insulin release/ reduce glucagon release

• Self-Monitoring

  • Before meals

  • HS

  • May require more

  • Continuous monitoring

• High Blood Sugar Complications

  • Hyperglycemia- high blood glucose (blood sugar)

  • Diabetic Ketoacidosis- Type 1

  • Hyperosmolar Hyperglycemic State (HHS)- Type 2

• Long-term Complications

  • Circulatory system

  • Eyes

  • Kidneys

  • Nerves

  • Infection

• Supportive Nursing Care-Diabetes

  • EDUCATION!!!!!

  • Nutritional management

  • Lifestyle modifications

  • Blood glucose monitoring

  • Medication