NUR 308 Exam 3 Study Guide
NUR 308 Exam 3 Study Guide NUR 308
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NUR308 Exam 111 Study Guide Spring 2014 Please note this study guide is not meant to replace the required reading practice questions or review of lecture content in preparation for the exam It is intended to supplement your preparation Hepatitis Hepatitis in ammation of the liver Can be Viral or toxic 1 3 phases a Preicteric phase fatigue NV anorexia abdominal pain elevated LFTs AST and ALT not 100 of the time occurs before patient becomes jaundiced b Icteric phase jaundice dark urine clay colored stools pruritis due to inability to excrete biosalts RUQ pain increased bilirubin coagulopathies check HH c Posticteric phase symptoms subside may occur as patients begin to improve Lab values normalize 2 Hepatitis A a Most common type of Viral hepatitis 13 of americans have had it and become immune b Risk factors children day care centers close contact with someone with Hep A sexual partners oralanal or analanal c Mode of transmission fecaloral contaminated food water shellfish oralanal sex contaminated workers poor sanitation d 88 fatigue nausea vomiting anorexia abdominal pain i Lab Values 1 AntiHAV antibodies with the onset of symptoms active infection 2 IgM Means it is an acute infection active infection 3 IgG Means immunity has been established not sure what caused the immunity e Prevention Vaccine 12 months and older are high risk populations gamma globulin someone who has not had the vaccine but has been exposed only lasts 6 months hygiene 3 Hepatitis B a More probable to become chronic in children than adults b Becomes chronic if the antigen is still positive in blood stream after 6 months c Risk factors gay men IV drug users babies dialysis patients prisoners 1 Mode of transmission parental sexual perinatal blood saliva semen vaginal secretions e SS Anorexia NV fever fatigue RUQ pain dark urine light stool joint pain jaundice usually occur Within 25180 days of exposure i Lab Values 1 HB SAG hep B surface antigen active infection presence of virus The patient is infected as long as this is present in the blood 2 HB sABAntiHBs indicative of immunity f Management incubation period can be up to 90 days Many adults who get Hep B recover clear virus and develop immunity i ii iii iv V decrease multiples of virus commonly use these meds for HIV patients side effects are headachemalaise Nucleoside analogs antiviral drugs 1 Lamivudine Epivir taken for 1 year 2 Adefovir Hepsera When active viral replication exists inhibit viral DNA synthesis Pegylated Interferon Pegasys Reduces replication of Hep B and increases immunity May cause ulike symptoms depression hair thinning and insomnia Is renal toxic Usually a combination of antiviral nucleoside analogs and interferon g Prevention Vaccineseries of 3 injections over 6 months HBIG given to exposure Screen blood donors Safe sex don t share razors with infected 4 Hepatitis C a 1 reason patients need liver transplants b Most common blood borne infection in US more common than HIV c Mode of transmission parental sexual perinatal most common via drug exposure IV drugs tattoos transfusions d 88 Most people are asymptomatic i Lab Values 1 AntiHCV means that the patient has been exposed Doesn t distinguish between active and previous infection Positive for longer than 5 months lead to chronicity 2 Elisa test is the initial testing 3 HCV PCR RNA to identify actual values Only test that can confirm an active infection 4 Genotyping most patients have genotype 1 e Management Classic treatment of chronic hep C is a combination of interferon and ribavirin Given as injection once a week for 2448 weeks i Peginterferon alfa 2a Pegasys and Ribavirin Classic treatment for chronic Hep C combination of ribavirin and interferon Given as an injection once a week Treatment lasts 2448 weeks May cause anemia anorexia cough rash pruritus dyspnea insomnia teratogenicy ii Antiviral Bocepriver Telaprevir Sometimes treatment doesn t work for everyone You can have resolution and get infected again iii Liver transplant When treatment doesn t work May still redevelop hepatitis f Prevention No vaccine minimize risk behaviors needle precautions 5 Hepatitis D a Risk Factors IV drug abusers sexual partners b Mode of transmission coinfection With HBV blood semen saliva vaginal secretions c SS i Lab Values 1 HDag Hep D antigen increase can be seen Within a few days of infection 1 Prevention Screen blood donors Safe sex don t share razors With infected 6 Nursing Interventions for Viral Hepatitis 3 Promote adequate hydration If nauseous give IV uids Promote 34 Lday b Promote adequate nutrition treat the symptoms May require antiemetic Small frequent meals Increased protein for healing High carb high calorie moderate fat and protein after NV subsides Encourage patients to eat foods that are appealing High calorie snacks and multivitamins may be needed Monitor prealbumin levels for nutritional status Avoid all alcoholdrugs that are hepatotoxic acetaminophen c Manage pruritus cool environment antihistamines 1 Provide rest to reduce the liver s metabolic demands and increase it s blood supply Rengl Content 1 Assessment Blood Tests a Serum Creatinine 1012 i Most indicative of renal problems b Blood Urea Nitrogen 1020 i Elevated BUN but creatinine is normal 9 dehydration 1 Look for other signs and symptoms of d e hyd ratio n 2 Can lead to renal problems if not treated ii Elevated BUN amp elevated creatinine 9 renal problems developing renal failure iii BUN is affected by hydration c Blood Urea Nitrogen to Serum Creatinine Ratio 201 i BUN 1020 creatinine 1012 d Blood Osmolarity i Don t want to be high and dry 2 Urinalysis a Color odor and turbidity i Normal clear to straw colored odorless except food turbidity should be clear ii Concerned if it s cloudy infection red blood dark or tea colored liver problems b Speci c gravity i The higher the gravity the more concentrated ii The lower the gravity the more dilute c pH i Normal acidic lt70 9 bacteria are less likely to multiply in acidic urine 1 Cranberry juice Vitamin C help make the urine more acidic d Glucose should NOT have glucose in the urine i May indicated DKA e Ketone bodies none to minimal is normal i If dieting you might have minimal ketones in urine from breakdown of fat and protein ii Diabetes might be DKA f Protein i May indicate infection or more serious renal problems g Leukoesterase nitrites i Byproducts of bacteria may signify an infection h Cells casts crystals and bacteria i Byproducts of bacteria may signify an infection ii A little bit of bacteria is not considered a UTl the amount is more important 3 Other Urine Tests a Urine for culture and sensitivity i Determines what bacteria and what it is sensitive to in terms of antibiotics ii Typically give broad spectrum antibiotic before sensitivity level returns then a more speci c antibiotic is prescribed b Composite urine collections i Save and collect urine over a period of time usually 24 hours 1 Discard the rst void ii Midstream catch is the cleanest iii Urinate into hat and then put in brown container put itonice iv If one gets messed up have to start over remind patients put a sign up C d e Creatinine clearance best indication of overall kidney function i Best indicator of glomerular infection rate 1 Measures how well the kidneys clear creatinine ii Average 125 mlmin iii Can be done through blood serum or through 24 hour clearance iv The lower the number the worse the situation renal insuf ciency a perfusion problem prerenal failure v We re not as concerned about high as we are with low Urine electrolytes i Not going through speci cally Urine osmolarity i Not going through speci cally 4 Urinary Tract Infection a b c d Lower UTI cystitis prostatitis urethritis Upper UTI more signi cant pyelonephritis Females are more prone to UTI because of shorter urethra wipe front to back Risk factors foley cather gt24 hours vesiscoureteral re ux back ow or urine during voiding into the ureters Neurogenic Bladder i Flaccid bladder over ow incontinence bladder gets too distended decreased sensation don39t feel the urge to void are exive 1 Associated with lower neuron injuries ii Spasdic bladder empties on re ex patient presents as incontinent spinal cord injury stroke 1 Upper motor neuron problems Diagnostic Tests i Urinalysis culture and sensitivity 1 Important to be midstream or clean catch 2 Females wipe back to front use towelette rst Clinical Manifestations frequency dysuria pain burning cloudiness odor possible fever i Vesicoureter re ux back ow of urine during voiding from urethra into ureters Management i Medications antibiotics 1 Bactrim sun sensitivity no alcohol 2 Cipro uroquinolone used for more complicated UTls 3 Macrodanten bacteriocidal antiseptic not a true antibiotic but preventative ii Pain reduction measures 1 Pyrideum analgesic helps with the pain associated with UTI a Decreases the burning sensation b Turns the urine orange c NOT an antibiotic have to take the abx also iii Fluids push a lot of uids 1 34 L a day iv Dietary measures 1 Supplementary cranberry juice 2 Increasing vitamin C 3 Avoid bladder irritants coffee caffeine alcohol v Patient teaching 1 Continue taking all medications even if pain goes away 5 Pyelonephritis a Etiology may result from an ascending UTI i Risk diabetics pregnant women immunosuppressed patients ii Untreated can result in bacteremia and urosepsis b Acute versus chronic i Acute temporary affects renal function ii Chronic permanent destruction to the kidneys because of scarring can lead to ESRD 1 Decreased urine output 2 Hyperkalemia Hypermagnesemia hyperphosphatemia 3 BUN and Creatinine increased and don39t go normal a Ex BUN50 Cr8 always will be up even with dialysis more concerned about K c Clinical manifestations UTI signs and symptoms fever CVA tenderness i Frequency urgency dysuria indirect ank percussion pain d Diagnosis i Urinalysis culture and sensitivity BUN creatinine e Management i Want a follow up to reevaluate urine with a culture and sensitivity ii Antibiotics iii Early detection follow up to reevaluate urine and culture and sensitive f Acute Glomerulonephritis i Disease the affects the glomerular capillaries ii Etiological factors 1 Associated with immunological problems 2 Possible complication of recent or untreated strep infection iii Pathophysiology 1 Damage to glomeruli GFR decreases iv Clinical manifestations 1 Proteinuria hematuria leaking protein 2 Azotemia elevated BUN creatinine 3 Elevated sed rate in ammation infection Positive anti strep titer means it39s related to strep infection Decreased urine output lt400 mL24 hours concentrated urine a Anuria lt30 mL24 hours 6 Crackles edema possible HTN v Diagnostic exams UA BUN creatinine urine creatinine clearance serum albumin vi Management 1 Antibiotics a Prophylactic PCN 2 Immunosuppressantssteroids a Prednisone used for antiin ammatory processes b May be used after infection is resolved c Avoid sick people 3 Plasmapheresis a Removing antibodies from the plasma to prevent antigen antibody response 4 Dietary measures a Look at lab values to determine how much protein in diet i High labs 9 low protein 5 Bed rest a Avoid fatigue 6 Nephrotic Syndrome a Damages the glomeruli severe proteinuria hallmark sign Protein being spilled into the urine Results in low blood volume Edema secondary to loss of protein that is spilling into the urine with hyperlipidemia 9 hallmark b Etiology Allergic reaction Infections NSAle Systemic diseases lupus iv Cancer c Pathophysiology Normal function 2 Glomerular capillaries are impermeable to serum proteins Plasma proteins create colloid osmotic pressure to retain intravascular uid Glomerular capillaries become permeable to serum proteins resulting in proteinuria and decreased serum osmotic pressure GFR decreases d Clinical Manifestations Severe generalized edema Pronounced proteinuria iii Hypoalbuminia iv Hyperlipidemia triglycerides LDLs total cholesterol all elevated v BUN and Creatinine high 1 Creatinine clearance normal 125 Diagnostic exams UA elevated lipids cholesterol and triglycerides low serum albumin Nursing Actions i Medication management 1 Prednisone autoimmune related 2 lmmunosuppressants cyclosporine 3 ACEInhibitors DECREASE PROTEIN IN THE URINE a Associated HTN b Prevent angiotensin cascade from being initiated 4 Mild diuretics use cautiously a Might help with edema but might have some intravascular volume problems ii Maximizing nutrition 1 Assess lab values a If BUNCr are high moderate protein intake b BUNCr are low more protein 2 Limit fats hyperlipidemia low cholesterol diet 3 Support renal function 4 Give P0 or might need albumin iii Implementing infection control procedures 1 Patients with this syndrome are more likely to get an infection taking immunosuppressing drugs iv Preventing complications v Patientfamily teaching 1 Effects of nephrotic syndrome on the kidneys and possible need for dialysis or renal transplant in the future 2 Medication regimen name dose actions side effects and the need to nish any antibiotic prescription if appropriate 3 Information about the nutritional needs and restrictions a The need for increased calories and adequate protein to meet nutritional need b Limit the intake of dietary sodium 4 How to selfassess uid status including sign of hypo and hypervolemia a Wight every day 5 Signs andsymptoms requiring medical attention increased edema dyspnea fatigue headache or infection 6 Importance of health habits to prevent infection including exercise adequate rest and sleep avoiding sources of infection 7 Need for followup care to monitor renal function 7 Nephrosclerosis a an Major causative factor HTN i Renal stenosis causes hypertension Pathophysiology renal arteries thicken and narrow i Perfusion is decreased Clinical manifestations proteinuria casts nocturia Diagnostics UA possible biopsy i Before biopsy evaluate medications for anticoagulants PTINRP39IT ii Postop Monitor for signs of bleeding Management HTN treatment chronic renal failure i Good HTN management 1 Chronic renal failure can be treated with dialysis ii If oliguric will RESTRICT not push uids Teaching i Need for follow up care ii Selfmonitoring to determine adequacy of BP control 1 Assessing VS measuring lO recording daily weights iii Lifestyle modi cations to prevent HTN dietary changes exercises iv Medication actions dosages schedules and potential side effects v Explain the possible need for dialysis or transplant in the future if endstage renal disease develops 8 Renal Artery Stenosis a Pathophysiology i Renal artery is narrowed by atherosclerosis 9 decreased perfusion b Clinical manifestations C Hypertension usually abrupt onset ii Abdominal bruits turbulence iii Disparity in kidney size one kidney is not getting perfused iv Unexplained azotemia elevated BUNCr Diagnostic arteriography Doppler MRI i Contrast medium is used assess for allergies give uids check BUNCr before giving 1 See if patient is on Metformin Glucophage need to stop before to prevent lactic acidosis ii After care pressure make sure patient doesn39t bleed depending on what artery was used arm keep it lifted and prevent from bending groin bedrest keep eg straight 1 CMS check in whatever extremity was used pulse warmth cap re ll movement sensation d Management i HTN management ii Aspirin want to decrease risk of clot formation iii Smoking cessation iv Percutaneous angioplasty advance a catheter into a renal artery that39s sterosed and place a stent to keep it open v Bypass e Patient Teaching i Importance of followup care for regular blood pressure checks and measurement of renal function 1 How to monitor the patient39s BP at home and the need to apprise the HCP of patient s status 2 How to recognize the signs of decreasing renal function and the need to report these symptoms promptly ii Need for periodic noninvasive studies such as ultrasound to screen for restenosis iii Behaviors that lower cholesterol maintaining a diet low in animal fat increasing aerobic exercise 9 Renal Calculi Types 1 Urolithiasis stones in the ureter 2 Nephrolithiasis stones in the kidney Etiology 1 Risk factors dehydration hypercalciuria elevated protein and sodium intake purine 2 Form when the urine is saturated in stone forming salts a 75 of renal calculi are calcium oxylate or calcium phosphate b Struvite phosphite uric acid i Treatment nutritional therapy is different for each one c If you have one your risk of getting one again is increased Clinical manifestations 1 Renal colic lower abdominal pain ank pain it can radiate to the groin region as the stone moves 2 Hematuria blood in the urine 3 Nauseavomiting pressure inside abdomen region 4 Fever Diagnostic exams KUB XR CT lVP intravenous pyelogram electrolytes urine pH 24 hour urine 1 WP injected with contrast media and then serial Xrays are taken to see obstruction 2 Bowel prep may be indicated before exams so they can see the kidneys 3 Urine pH helps determine what type of stone it is 4 24 hour urine strain to try and catch the stone and determine what it s made of Management 1 Pain relief a Toradol a nonnarcotic analgesic that39s an NSAID b If pain is severe the may require narcotics such as morphine 2 Fluid a Very important to push lots of uids to help pass the stone b Hyperparathyroidism is associated with renal calculi 3 Medications Thiazides Cellose a Thiazides not really for acute attack but might be used long term to decrease calcium in the urine i If someone has a known obstruction we don39t want to give them diuretics ii Used on a long term basis b Cellose Phosphate inhibits the absorption of calcium in the intestines 4 Interventions a ExtraCorporeal Shock Wave Lithotripsy i Lay on table uid lled cushion shockwave generator 1 Shockwave breaks the stone up to pass easier ii Preprocedure EKG dc anticoagulants pacemaker 1 Want to know if on anticoagulants discontinue to prevent bleeding 2 Therapy may disprogram pacemakers iii Postprocedure pain management pink tinged urine is normal but not bloody urine 1 Afterwards we want to push uids and strain urine they may have an endoscopic procedure to move the pieces 2 Procedure itself can cause bleeding iv May have conscious sedation Versed Propofol b Stent c Percutaneous Ureteroscopy d Nephrolithotomy goes into the kidney to break the stone up 5 Strain all urine and catch the stone to send to the lab vi Nursing Care Managing pain Promoting uid intake Monitoring uid balance Preventing infection Dietary most helpful if we know what it is composed of a General considerations i Calcium origin low sodium LJ39gtLJlJll I ii Oxylate peanuts spinach rhubarb iii Calcium phosphate limit intake of animal protein 1 Get protein from a nonanimal source iv Strovite high phosphate foods dairy products organ meats goose v Uric acid stones high purine alcohol things avoid in gout yeast beer organ meats b Acid ash check summary c Alkaline ash 6 Patientfamily teaching a Fluids b Dietary measures 10 Cystoscopy a Scope through urinary meatus into the bladder to look around or biopsy b Nursing Considerations i More diagnostic whereas TURP is a procedure ii Monitor UO postop and presence of frank bleeding a little is ok but not a lot 11 NP c Nursing considerations i Preop need to see if they are taking diabetes drug something with meth and stop any interacting drugs before 1 Bowel prep may be indicated ii Postop 24 hour urine strain 12 Urinary Diversions d Urinary diversions bladder has been removed have to make a urinary diversion i lleal conduit most common 1 Take a small piece of the small intestine is removed and is placed attached to the kidney ureters and stoma is brought through the abdomen to the skin 2 Bag is attached ii Colon conduit section of colon that is used as a passage way iii Continent urostomy iv Koch continent ileal reservoir 1 A piece of the small intestine is formed into a pouch a valve ls created and acts as a sphincter the ureters are attached a stoma is created 2 Patient does NOT need a bag 3 Catheterize the patient to remove urine 4 Stoma can be covered with a nonadhesive type of dressing 5 Catherize every 23 hours initially v lliocecal pouch AKA lndiana Pouch 1 Uses a portion of the large intestine to make a reservoir 2 Patient needs catheterizing 3 Larger holds more urine doesn39t require as much catheterization vi Nursing management 1 Preoperative a Bowel prep b Antibiotics neomycin to try and clean out system 2 Post operative a Catheters b Intakeoutput assess urine c Following removal void 020 minutes i Only applies to partial cystectomy patient ii Initially might need to void quiet frequently d Fluids e NGT suction helps decompress the abdomen f Drainage tubes Pain management vii Care of the Diversion 1 Assessment stoma a Needs to be not painful b Apply a bag or appliance if necessary c Should look red and beefy may initially be bloody i Should NOT be dark or purple 2 Skin care a Mild soap and water make sure it is dry after b Fungal infections are most likely to occur prevent these infection 3 Changing of pouch a Vinegar water dilution to help the smell b Cut 18 size initially and then a little larger we expect edema i Check this c May be mucus want to make sure it s patent may need irrigation 4 Patient teaching return demonstration a If there is mucus we want to irrigate 5 Address body image issues a Group resources 6 Resources 13 Kidney Trauma o Kidney more commonly involved Ss hematuria pain in ank low back Hematuria is very common in any type of kidney trauma Diagnosis CT or MRI Patient Teaching for Blunt Kidney Trauma Causes MVA contact sports faIIs Wear a seat belt in an automobile Follow safety rules when riding a bike or walking Wearing protective equipment when participating in contact sports Want to make sure the patient does not go into shock viii Hypotension LOC change tachycardia 14 Urinary Retention e Causes i Mechanical urethral stricture urinary tract malformation spinal cord malformation ii Acquired renal caIcuIi UTI trauma tumor pregnancy iii Functional causes neurogenic bladder dysfuntion ureterovesical re ux decreased peristaltic activity of the ureter detrusor muscle atrophy atrophy fear of pain after surgery medications anticholinergics anesthetics opioids sedatives antihistamine f Clinical manifestations inability to void distended bladder discomfort retention with over ow i Retention with over ow lower motor neuron injury might not feel stimulus to void gets so full they leak g Patient Measures i Post void residuals ii Medications cholinergic drugs Urecholine 1 Trying to promote urination 2 Don39t use unless there is an obstruction make sure you relieve obstruction rst iii Reestablishing urine ow 1 Noninvasive warm water over perineum proper positioning hand under water 2 Invasive catheterizing Cystostomy opening into the bladder ex Superpubic catheter iv Implementing infection control measures prevent UTI v Surgical nephrostomy or pyeIostomy tube vi Patientfamily teaching 1 IMPORTANT avoid anticholinergics 2 Urinary Continence a Stress associated with activity straining coughing sneezing i Treatment Kegel Estrogen helps strengthen pelvic oor muscles Surgery pessiaries b Urge overactive bladder re exive inability to stress the sudden urge to void UTI neuroIogicaI i Treatment oxybutynin Ditropan or any type of anticholinergic bladder training sit on the toilet at certain times and hours avoid drinking at night c Over ow SCI neurological lower motor neuron dribbling accid bladder i Treatment doxazosin Cardura Tamsulosin Flomax Catheterization d Functional lack of awareness i Elderly neurological impairment comatose patients ii Bladder training change diaper or pads frequently e Interventions I Skin care ii Initiating bladder retraining program iii Dietary considerations iv Medication management v Surgical management vi Providing support and encouragement 3 Patient after Urologic Surgery a Promote ventilation encourage breathing exercises frequent selfturning in bed ambulation b Monitor patency and output of urinary catheters c Prevent compications i Change wet dressings to protect skin ii Restrict food and oral uids is bowel sounds are absent iii Encourage uids to 3 Lday when permitted iv Monitor for bright red blood on dressings or in urine 15 Administer analgesics to control pain Hematologv Content 1 Lab values discussed in class a Mama Laauamo r39 HALUES m AMEMIIA MEMIH l39 Emma Imrl 39Hl tamilni a Fnlnt iiiseam a n lanw a alasrmy Macmillan1 Thalaasraml n Mean mrpusecular lficmuglubln Normal D39L crmscd Increased Normal Dcmcasc lr rn Nnarnml Slightly decreased Elevated Elevated Elevated llTami imnshimling ipacir Slighrlgr decreased Elevated Norm 1 Normal Nnrmal llli l i rul m Nnrmml Manual lillE FFHIEfcl Elevated Elm3 Merl Vimmill Etna Nurnmll Normal Decreased Nurmal Normal Fullaw Sligl n 1y clearmm Nominal Nonrial Dentused Slightly decreased b Anemia Severity i Mild Hgb 1014 gdl 1 May exist without symptoms 2 Possible symptoms palpitations dyspnea diaphoresis ii Moderate Hgb 610 gdl 1 Increased cardiopulmonary symptoms 2 Experienced at rest or during activity iii Severe Hgb lt6 gdl 1 Involve multiple body systems iv Transfusions 1 Give blood around 7 2 Transfusions have citrate preservative monitor for hypocalcemia Chvostek s Troussaeus tetany numbness tingling 3 First 1015 minutes might have a reaction if suspected STOP infusion c 2 Bone Marrow Aspiration a Patient care increased risk of bleeding 3 Microcytic Anemia a Small cells 4 Macrocytic anemia a Large cells 5 Iron de ciency a Loss of iron secondary to chronic blood loss poor nutrition i At risk women elderly poverty malnutrition immigrants b Gradual process fatigue i Labs HH will be low MCV low c Clinical Manifestations i Mild fatigue and exertional dyspnea 1 Oxygenation problems are related to a more severe case 2 Measure exertional dyspnea by how many ights of stairs they can walk before getting fatigued ii Severe brittle spoonshaped nails with longitudinal ridges smooth shiny tongues cheilosis low serum iron levels increased iron binding capacity d Management identify cause and treat iron supplement ferrous sulfate nutrition counseling i Ferrous sulfate iron supplement give it either an hour before or two hours after a meal 1 Do not take with dairy products it affects absorption better to take it with OJ but avoid grapefruit juice 2 Tell patient black tarry stool is normal and constipation may increase promote uids and ben 3 If taking in liquid form avoid staining teeth by taking with a straw e Nutrition liver nuts seed beans whole grains meat in general tofu i Encourage darkyleafy greens forti ed cereals red meat dried fruit nuts seeds 6 Folic Acid De ciency a Folic Acid De ciency dietary de ciency chronic ETOH pregnancy i Diagnosis low folate levels macrocytic anemia 1 RBCs are low HH low MCV are high ii Management oral folic acid replacement ETOH cessation nutritional counseling 1 Alcoholics RALLY packs have thiamine folic acid etc a Not going to be on test just for general knowledge 2 Offer alcohol cessation programs 3 Nutrition forti ed cereals organ meats broccoli eggs soy pasta but avoid fast food 7 312 De ciency a Vitamin 312 Cobalamin De ciency inadequate intake or absorption i Most common cause of macrocytic anemia ii Need to check for pernicious anemia also iii 312 is found in animal products meats milks cheeses b Pernicious Anemia lack of intrinsic factor small bowel surgery i Parietal cells in the stomach secrete intrinsic factor which helps 312 be absorbed in the small intestine 1 Ulcerative colitis Chron s disease gastric bypass any gastric or intestinal resection stomach cancer could cause this ii Diagnosis low 812 level macrocytic anemia typical ss neurological abnormalities peripheral neuropathy Shilling test 1 Peripheral neuropathy is common symptom and altered LOC a Check to double check this is for pernicious anemia 2 Schilling test tests absorption speci cally for pernicious anemia iii Management 812 administration patient teaching 1 812 IM injections for life using the Ztrack method on a monthly basis 2 Don39t give in deltoid muscle 8 Aplastic Anemia a Impaired erythrocyte production 9 all of the cells end up being low called pancytopenia WBC RBC platelets all low i Petechiae and prupura b Etiology autoimmune no known cause i Lymphocytes destroy stem cells autoimmune ii Drugs cancer antineoplastic drugs 9 aplastic anemia c Clinical Manifestations i Leukopenia thrombocytopenia decreased RBC ii Pallor skin mucous membranes conjunctiva capillary re ll iii Fatigue iv Palpitations decreased circulating RBCs tachycardia v Exertional dyspnea vi Infections leukopenia vii Bleeding thrombocytopenia d Diagnosis i Bone marrow aspiration most commonly used place is iiac crest 1 Need consent monitor for bleeding avoid aspirin 2 Results will show a quotdry tapquot 3 Pt might be on bed rest for short period e Nursing Concerns i Infections bleeding anemia 1 Hand washing limit visitors put in isolationprotective area no live owers avoid raw fruits veggies and sushi 2 Note WBC shouldn39t be used as an indicator for infection instead look at direct sources a Ex Sputum blood cultures f Treatment i Remove causative agent ii Bone marrow transplant usually for severe cases and younger patients iii lmmunosuppressive agents steroids risk for infection 1 Monitor glucose levels weight gain and don39t stop abruptly iv Possible transfusions depending on how severe might need platelets v Prevent infection private room protective isolation 1 Stay away from sick people good handwashing neutropenic precautions avoid fresh owers raw food fresh fruits fresh veggies vi Prevent bleeding heparin Coumadin soft bristle tooth brush no straining uids stool softener electric razor no rectal temps or suppositories vii Oxygen therapy nasal cannula viii See 912 Patient family teaching box 9 Hemolytic Anemia a De nition RBCs are produced correctly but are DESTROYED inappropriately i Might see jaundice from excessive destruction of RBC39s b Autoimmune 1 Premature destruction of erythrocytes usually in the spleen a Might see fatigue 2 Warm reacting most common cold reacting drug induced forms a Warm reacting more common in women and associated with lupus i Warm reacting it occurs in warmer conditions cold reacting occurs in cold Treatment is to avoid the weather or trigger 3 Cold reacting associated with Raynaud39s phenomenon a Drug induced PCN some sort of genetic predisposition i Antibodies form and destroy the RBCs 4 Leads to RBC destruction clumping from antibody formation 5 Diagnosis positive Coomb s test decreased HCT increased reticulocytes increased bili a Decreased Hct Hgb RBCs b Coomb s test looks at clumping of RBC39s i If lysing it is 39positive39 c Increased reticulocytes immature RBCs says the bone marrow is working and is trying to produce RBCs but can39t keep up the destruction d Increased biirubin possibly from RBC breakdown Assess palate number 1 sclera skin 6 Management corticosteroids danazol spleenectomy prevent infections a If druginduced remove the drug b Spleenectomy if pt doesn39t respond to more conservative therapy spleen is site where the RBC39s are destroyed i Patients are at increased risk of infection after spleenectomy important to offer pneumovax c Danazol gonadotropin inhibitor hormone is thought to suppress immune response d Corticosteroids to suppress the immune response autoimmune disorder i Increased risk for infection hyperglycemia Cushing39s symptoms take PPIH2I to prevent ulcers taper pt off when discontinued to prevent adrenal insuf ciency c Hereditary spherocytosis i Erythrocytes are thick spherical in appearance with hemolysis in spleen 1 Destroyed secondary to their shape spherical altered shape increases destruction and they are broken down more rapidly rupture prematurely ii Diagnosis peripheral blood smear increased reticulocyte count and biirubin 1 Peripheral blood smear look at RBC in microscope and see altered shape iii Typical signs and symptoms 1 Fatigue maybe jaundice decreased HHRBC iv Management splenectomy give pneumoccal and H Flu vaccines 1 If you remove the spleen more at risk for infections give vaccines v Genetic counseling d Enzyme de cient i Premature RBC destruction results from lack of enzymes G6PD 1 G6PD is an enzyme that helps prevent premature destruction of RBC especially when RBCs come into contact with certain types of agents ii Triggered by infections or medications 1 Certain quotoxidizing agentsquot cause destruction ex Thiazide diuretics sulfa antibiotics 2 Could be medications or infections iii Symptoms back pain jaundice hemoglobinuria 1 Back pain and hemoglobinuria is similar reaction to ABO blood incompatibility iv Management remove causative agent hydration possible blood transfusions 1 Remove agent push uids to prevent renal failure 10 Polycythemia Vera a Myeloproliferative disorder leads to erythrocytosis leukocytosis thrombocytosis i Increased RBC production where RBCs aren39t maturing properly fast enough and increased WBCs and platelets ii High hematocrit levels 9 more viscous blood more likely to form clots iii Platelets tend to be immature and not function properly bleeding risk iv Major causes of death thrombus and hemorrhage b Hypervolemia develops headache vertigo splenomegaly clot formation i Early stage no symptoms ii Moderate stage headache vertigo tinnitus blurred vision iii Late stages thrombosis embolization nose bleeds ecchymoses GI bleeding c Management phlebotomy smoking cessation hydration i Hydration keep viscous blood well hydration to try and decrease clots ii Phlebotomy remove blood from the patient done over a series of treatments v Mild cases have a better prognosis severe cases have shorter life expectancy 4 Sickle Cell Disease a Etiology sickle bers form together and sickles RBCs that obstructs blood ow that cause pain i Long term concern thrombosis PE CVA splenomegaly pulmonary HTN ii Increased risk of infection because the spleen is over lled from sequestered sickled red blood cells and the spleen is not acting appropriately in terms of mounting an immune response b Treatment i High protein high calorie diet ii 02 for hypoxia 1 Decreased 02 saturation is an indicator 2 ABG for more in depth values to see if there is an acidbase imbalance 3 SOB use of accessory muscles any altered LOC earliest indicator are signs 4 Use nasal cannula maybe face mask iii Pain management 1 Crisis triggers stress infection smoking dehydration temperature change 2 Medications morphine IV via PCA or dilaudid a Have Narcan and antihistamines available to reverse effects b Hydroxyurea Hydrea used during sickle cell crisis i Can cause renal dysfunction 9 push uids 3 Want to decrease the pain to keep it at a manageable level iv Fluids 1 Want to prevent dehydration and promote increased uid intake 2 Dehydration leads to crisisacute exacerbations c Acute chest syndrome i Very abrupt onset term used to encompass a lot of things ii Causes regular infection onset speci c infection pneumonia clots iii Signs respiratory problems like SOB pulmonary in ltrates CXR abrupt onset of fever tachycardia iv Treatment antibiotics 02 based on severity of symptoms uid therapy 11 Thrombocytopenia o Pathophysiology Decreased production anyone with bone marrow suppression like chemo or sulfa drugs Decreased survival Increased destruction Idiopathic Thrombocytopenia Prupura ITP an autoimmune disorder Sequestration of blood in spleen 12 13 14 Increased consumption disseminated intravascular coagulation DIC seen in septic patients Loss from hemorrhage Drug induced heparin chemo sulfa herbal ginger ginko ginseng methotrexate Acute v chronic Antibodies bind to platelets and destroy them More common in women Acute related to medication results when medication is stopped Chronic patients with leukemia Drug induced heparin chemo drugs sulfa drugs methotrexate Ginger ginko ginseng are associated with low platelets Clinical manifestations Bleeding urine stool emesis petechiae bruising prupura altered LOC Low BP tachycardia if patient is actively bleeding Diagnostic ndings platelet count blood smear bleeding time bone marrow aspiration Platelets will be low HH might be if they are bleeding Bone marrow aspiration increases megakaracytes precursor to platelets Concerned after aspiration is bleeding Management corticosteroids immunoglobulin therapy splenectomy platelet transfusion IG therapy type of antibodyantigen response Spleenectomy where the platelets are destroyed increases risk of infection Platelet transfusion depends on underlying cause of problem Patient teaching bleeding precautions Soft bristle toothbrushes no razors no IM injections apply prolonged pressure avoid straining or anything rectal promote uids ber stool softeners Leukopenia Patient Care Pancytopenia Anemia Everything is low Patient Care Anemia from Chronic Diseases Normochromic normocytic hypoproliferative i Most common chronic disease that leads to anemia is renal failure Associated with other diseases Possible failure or erythropoietin Diagnosis low serum iron low total iron binding capacity increased ferritin Ss fatigue weakness dyspnea plus underlying disease f Management supportive erythropoiten therapy i Epogen monitor for effectiveness by assessing hematocrit normals should go back to normal 1 Adverse effects seizures HTN ii Neupogen treats low WBC s monitor neutrophil counts to see effectiveness watch for pain 1 Given to treat iii Neumega treats low platelets monitor platelet counts for effectiveness 1 Given to treat thrombocytopenia 15ChemotherapyRadiation a Patient Care b Interventions for i Stomatitis in ammation of the mucosal lining of the mouth and GI tract very painful 1 Nutrition concerns 2 Oral care use soft nonirritating nonalcoholic foods and mouthwash a No brushing b Normal saline rinses every 12 hours to keep clean i Remember this food choices c Magic mouth wash also used to swish and spit ii Skin radiation therapy causes burns 1 Markings on skin to direct therapy should not be washed off 2 Use mild soap and water to clean it and dry it very well by patting 3 Dry skin should be lubricated with nonirritating lotion that contains no metal alcohol perfume or additives 4 Wet reaction must be kept clean and protected from further damage iii Nutrition 1 Small frequent meals to prevent nausea avoid strong odor foods 2 Administer antiemetic therapy right before chemo and on a regularly scheduled basis 3 High calorie high protein iv Alopecia 1 Chemotherapy can cause patients to lose their hair 2 It will grow back but not necessarily the same texture as before 3 They can use hats wigs scarves etc 4 Body image issues let patient communicate their feeHngs 16Leukemia a Acute Lymphoblastic Leukemia ALL i Unknown etiology more prevalent in children boys around 4 years of age 1 High cure rate ii Pathophysiology 1 Overproduction of immature WBCs 9 risk of infection 2 Decreased in platelets and RBCs 9 risk for bleeding and anemias iii Diagnosis bone marrow biopsy iv Clinical manifestations anemia bleeding lymphadenopathy v Management chemotherapy vincristine prednisone methotrexate 1 Chemotherapy treatment four stages a Induction patient is getting initial dose of chemo i Eradicate neoplastic cells and healthy cells including bone marrow ii High dose of chemo most likely to have toxic side effects 1 Bone marrow suppression 2 Nadir when the come drug has it39s maximum side effect a Most signi cant with rst dose but continues whenever the drug is given b Watch for infection bleeding and anemia b Intensi cation sometimes this stage isn39t referred too c Consolidation post remission therapy i Lower doses of chemo given to kill off any residual ces d Maintenance come in after an extended period of time i Low dose chemo 2 Combination chemotherapy a Vincristine plant alkaloid i Adverse reaction bone marrow suppression 1 Pancytopenia low everything risk for infection bleeding and fatigue secondary to anemia 2 Stomatitis in amed mucosa lining in the mouth and GI very painful causes nutrition problems b Methotrexate i Adverse reactions nausea vomiting bone marrow suppression renal toxicity monitor BUNCrUO push uids ii Rescue drug eucovorin essentially folic acid will help combat the bone marrow suppression 1 Need folic acid to help stimulate bone marrow to help maturation ofRBCs 3 Nursing Management a Patients have high risk of infection no sick people no owers no raw veggies or fruits b Nurses have to be chemo certi ed have to wear chemo gloves impervious gown mask special spill precautions b Acute Myelogenous Leukemia AML i Unknown etiology most common lymphocytic anemia 1 Poorer prognosis than ALL 2 Die because of overwhelming infection 3 Common in 205305 and then 605705 4 Palliative care and hospice might be appropriate for these individuals ii Pathophysiology myeloid stem cell that is overproduced 1 Proliferation of immature WBCs that affect myeloid stem cells iii Clinical manifestation see ALL 1 Anemia bleeding lymphadenoapthy iv Diagnosis bone marrow aspiration 1 Major concern is bleeding check P39IT and platelets v Management cytarabine doxorubicin 1 Cytarabine bone marrow suppression nausea vomiting renal toxicity 2 Doxorubicin antitumor antibody a Adverse reaction bone marrow suppression anorexia nausea vomiting alopecia i Cardiac toxicity monitor for signs and symptoms of heart failure b Vesicant drug monitor the IV site vi Bone marrow transplant 1 Typically allogenic getting stem cell from another source 2 Patient will get chemo and radiation before transplant c Chronic Lymphoblastic Leukemia CLL i Unknown etiology most common chronic leukemia 1 Common in the elderly decent survival rate ii Pathophysiology proliferation of B lymphocytes iii Clinical manifestations weakness fatigue lymphadenopathy anemia thrombocytopenia enlarged spleen 1 Often asymptomatic 2 Lymphadenopathy tender is better nontender is associated with cancer iv Diagnosis bone marrow biopsy v Management alkylating agents chlorambucil glucocorticoids 1 Chlorambucil not going into that much d Chronic Myelogenous Leukemia CML i Etiology has a chronic phase an accelerated blastic phase 1 Chronic phase typically asymptomatic can last for years 2 Blastic phase symptomatic abnormal proliferation of WBC platelets and RBC drop a Risk of infection bleeding anemia b Prognosis is much poorer more common in young adultsmiddle age ii Pathophysiology abnormal stem cell proliferation of granulocytic cell iii Diagnosis genetic marker Philadelphia chromosome iv Clinical manifestations fatigue weakness anorexia weight loss splenomegaly v Management lmatinib hydroxyurea interferon 1 lmatinib gleevac used in other types of cancers biologic response modi er a Typically given in the chronic phase in order to be effective 2 Hydroxyurea miscellaneous antineoplastic can cause renal dysfunction a Promote a lot of uids 3 Interferon biologic response modi er stimulates body response to infection and disease a Adverse reactions seizures ulike symptoms myalgia increases photosensitivity HTN seizures vi Bone marrow transplant vii Teaching should include 1 How to prevent infection and bleeding 2 Symptoms requiring immediate medical attention feverbleeding 3 Importance of good nutrition and adequate uid intake 4 How to do meticulous oral care to prevent stomatitis 5 Regimen of chemotherapy administration and periodic blood counts 17Lymphoma a Hodgkin s Disease vi vii Malignant disorder of the lymph nodes but can spread to spleen liver bone marrow 1 Proliferation of abnormal giant multinucleated cells a ReedSternberg cells important to remember i If they don39t nd these it is considered nonHodgkin39s b Located in the lymph nodes Insidious onset 1 Rarer than nonhodgkin39s but has a better prognosis tends to be limited more to the lymph nodes 2 Starts in the lymph nodes and causes lymphadenopathy Enlargement of cervical axillary or inguinal lymph nodes 1 Nodes remain movable and nontender 2 Painless unless nodes exert pressure on adjacent nerves Clinical manifestations weight loss weakness fever tachycardia night sweets 1 Additional signs and symptoms based on lymph node involvement Diagnosis peripheral blood analysis 1 Excisional lymph node biopsy bone marrow examination radiologic evaluation 2 Biopsy is looking for ReedSternberg cells Staging 1 Don t need to memorize Management goal is a cure 1 Radiotherapy can be used alone or in combination with chemo a Can cause burning of the skin and problems internally thyroid b Wash skin with mild soap and water avoid alcohol based products c Avoid constrictive clothing and no heatcold compresses 2 Combination chemotherapy MOPP a Mechlorethamine vincristine prednisone procarbazine b NonHodgkins Lymphoma Broad classi cation of malignant lymphoid diseases poor prognosis because it spreads Etiology 1 Neoplastic growth of the lymphoid tissue 2 Increased incidence in men in SOs605 possibly related to chemical exposure 3 Not as good of a prognosis because it in ltrates into other areas of the body iii Classi ed according to 1 Different cellular characteristics NO reed sternberg cells 2 Lymph node characteristics iv Clinical manifestations can originate outside lymph node 1 Spread can be unpredictable v Diagnosis lymph node biopsy vi Staging 1 Determined by spread of cancer vii Management radiotherapy combination chemotherapy 1 Radiation could be alone or in combination with chemotherapy 2 Combination prednisone vincristine doxyrubicin cardiac toxicity Cytoxan a Cytoxan adverse effect is in ammation of the bladder give a lot of uids viii Issues of fertilitysterility 1 Issue of radiation therapy and where it is located c Multiple Myeloma i Overgrowth of BIymphocytesplasma cell 1 Plasma cells are mature but there s a proliferation of them a Decrease in WBCs platelet RBCs 2 Plasma cells are overproducing in the bone 9 bone pain bone breakdown osteoporosis ii Incidence median age 65 years iii Unknown cause risk factors previous radiation therapy infection certain chemicals iv Assessment 1 Patient tends to complain of bone pain fatigue anemia excessive bleeding infection 2 Might have bone fractures 3 Presence of BenceJones proteins in the urines 9 indicates renal problems v Intervention chemotherapy based on if patient is a candidate for autologous stem cell transplant 1 Get characterized into stem cell transplant recipients or nonstem cell transplant recipients 2 Also address bone pain and bone breakdown biphosphenates vi Nursing management important to know and feel comfortable with 1 Assessment common side effects of chemo and radiation a Bone marrow suppression look for fatigue risk for infection risk for bleeding secondary to thrombocytopenia i Anemia bleeding can occur anywhere bruising petechiae GI ii Infection don t only assess WBCs also check fever culture source of infection assess lungs and urine iii Interventions that protects clients best with thrombocytopenia 1 Never take rectal temp use electric razor avoid hard toothbrush no ossing no IM injections b Fatigue related to anemia c GI disturbances nausea vomiting anorexia d lntegumentary and mucosal reactions radiation causes burns i Stomatitis mucosal in ammation of the GI and mouth 1 Very painful patient won t want to eat 2 Can affect entire GI tract e Pulmonary effects prone to pleural effusions uid build up f Reproductive effects possibility of sterility from chemo and radiation g Cardiac effects doxyrubicin can cause cardio toxicity CHF h Renal effects a lot of them cause renal problems push uids and monitor i Cytoxan causes cystitis push uids 2 Complications tumor lysis SVC syndrome a Superior Vena Cava Syndrome compressed or obstructed by tumor growth usually in the head neck or chest region i Condition can lead to a painful life threatening emergency ii Signs edema of face edema of arms and hands erythema epistaxis 1 Upper body edema related to blood not draining back 3 into the right side of the heart iii Intervention highdose radiation therapy metal stent in vena cava 1 2 3 4 First option is high dose steroids to decrease the masstumor Radiation decrease tumor size Surgical intervention to remove the tumor Stent opens up the lumen of the vessel b Tumor Lysis Syndrome large numbers of tumor cells are destroyed rapidly resulting in intracellular contents being released into the bloodstream faster than the body can eliminate them 9 emergency due to high potassium levels i Monitor potassium purines convert to uric acid 9 kidneys gout 1 Alopurinol for high uric acid levels ii Collaborative management prevention hydration drug therapy Interventions 1 2 Keep well hydrated to prevent Drug therapy allopurinol for uric acid a Kayexalate for non emergent hyperkalemia b Emergent treatment for hyperkalemia D50 with regular insulin a Prevent infection bleeding anemias pharmacologic agent i Anemias promote rest periods with activity decreased 02 demands if anemia is severe enough to affect oxygenation ii Drugs neupogen epogen and neumega go over these iii Hand washing to prevent infection no sick visitors avoid crows iv Avoid raw and fresh fruits and veggies v Pharmacologic Agents 1 Epogen erythropoietin for anemia look at Hct to evaluate effectiveness 2 Neupogen for infection look at neutrophil count to evaluate effectiveness b Pain management i Use a schedule that provides continuous pain medication and then PRN for breakthrough pain ii Antiemetics for nauseavomiting c Rest i Prevent fatigue d Nutritional concerns i Small frequent meals to prevent nausea avoid strong odored foods ii Administer antiemetic therapy right before chemo and on a regularly scheduled basis e Stomatitis in ammation of the mucous membranes i Very painful concerned that the patient is not going to eat because it hurts also prone to thrush immunocompromised ii Want to give soft nonirritating nonalcohol foods iii Mouth care no alcohol mouthwash no brushing 1 EBP normal saline rinses every 1 to 2 hours to keep clean a Remember this food choices 2 Magic mouth wash also used but not evidence based a May order to swish and swallow to coat GI tract 18lnfectious Mononucleosis a EpsteinBarr virus i VIRAL infection no antibiotics b Mode of transmission saliva kissing utensil sharing drink shanng i Very common in adolescence teenagers young adults c Clinical manifestations fatigue fever lymphadenopathy head amp neck sore throat headaches hepatospleenomegaly particularly the spleen being larged i Acute phase generally lasts weeks ii If spleen is enlarged teach no contact sports for at least a month or maybe longer concerned the spleen is going to rupture d Diagnosis monospot blood test WBC i Never cured the virus still stays dormant ii Often test for strep at the same time e Management symptomatic prevent spread avoid contact sports heavy lifting strenuous activity i Keep well hydrated rest acetaminophen for fever aspirin contraindication in peds population ii Prevent spread teach that it is spread through saliva iii Will get antibiotics if they are coinfected with strep at the same time iv Recommended not to donate blood for 6 months after having mono Ortho Content Non pharm management Carpal Tunnel Syndrome cause SS assessment and management 1 Fractures a Assessment I I r l e p itream 11F ample tipcam ai communal Twainlawn r n gaiigj HFE I iJ u racismat airslum iratzlure Ernstallure b Treatment i Cast care 1 Make sure it39s not too tight bivalve to open it up 2 Don39t get either cast wet brace or plastic covering use palms while drying 3 Note any drainage odors color and report it 4 Perform CMS checks 5 Skin care pedaling the edges it itchy apply ice 6 Nobility weightbearing v non weightbearing is per physician s orders 7 Skin breakdown infection NVA compromise disuse syndrome possible complications Skeletal traction pin is inserted directly into bone usually distal to fracture attached to a weight a pulley system 1 Want the weight to be hanging freely and not touching the oor 2 Want to make sure the rope between the patient and the wheel the weight hangs from should be taunt and not have slack or loose but they might slide down bed check this Skin traction adhesives on the skin with a hard device underneath Buck39s or Russel39s 1 Initial treatment of a hip fracture to realign and decrease muscle spasms 2 The amount of weight that is applied is much LESS than skeletal 3 Board at the bottom of the foot is to prevent foot drop 4 Multipodus splint a thing to prevent the heel from touching the bed 5 Complications skin breakdown heel NVA injury nerve damage 6 Contraindications vascular disease diabetes skin lesions c Common complications Fat embolism onset 2448 hours after injury most common multiple traumas and intramedullary canal reaminglong bone 1 Fat enters blood stream releases bone marrow and travel to lungs 2 55 petechiae hypoxemia chest pain altered mental status a Petechiae most common in head neck chest area Compartment Syndrome increased pressure within a limited anatomical space the pressure compresses circulation viability and function 1 Most common in tibial shaft fractures damage can lead to loss of limb 2 Causes swelling restrictive dressing cast brace 3 55 unrelenting pain changes CMS stretching of digits increases pain diminished pulse paresthesia pain paralysis pallor Delayed healing failure to heal in the expected time frame does eventually heal but longer than usual 1 If it hasn39t healed in about 2 month it39s considered delayed Infection 2 Hip Fractures a Risk Factors elderly steroid use smokers osteoporosis b Signs and Symptoms c Management i Positioning maintain abduction to prevent adduction of the hip 1 Can use abduction pillow 2 Prevent exion of the hip to no more than 60 degrees ii Bucks traction may be done initially but not a de nitive treatment 1 Used to alignreduce and relieve muscle spasms to help alleviate pain iii Pain management PCA pump skeletal muscle relaxants iv Prevent hazards of immobility v 1 risk factor DVT 3 Orthopedic Surgery a Hip i Ball and socket joint may be cemented or noncemented ii Common complication DVT infection nerve damage fat embolism iii Nursing Care 1 Positioning maintain HIP ABUDCTION 6090 degree hip exion a Trying to prevent dislocation and adduction b Avoid high fowler39s put it at 3045 degrees c Don t want them sitting straight up in bed d Keep legs in position that prevents internalexternal rotation 9 proper alignment 2 Wound care drains JacksonPratt Hemovac 3 Activity 003 as quickly as possible a Limit exion of hip to 60 degrees for rst few weeks then don39t want it to be greater than 90 degrees 4 Medications analgesics DVT prophylaxis even post hospitalization iv Discharge Teaching No driving for 68 weeks after surgery Teach about anticoagulants Prophylactic antibiotics prior to dental procedures If you hear a popping sound postop notify HCP immediately DO sit in higher chair to prevent exion of hips use extended toilet commode 6 DON t adduct legs cross legs bend of straight to pick something up PWF P1 b Knee i Nursing Care 1 Positioning initially avoid hyper exion a Start with exion of 2030 degrees 2 Wound care drains check to see they are patent and draining 3 Activity continuous passive motion CPM that moves and exes leg 4 Medications analgesics DVT prophylaxis 5 Discharge teaching a Antibiotics prior to dental procedures b Long term low impact exercise c Spine i Nursing Care 4 SprainsStrain a Strain injury to a muscle tendon unit i Cause overuse overstretching stress ii Tendon bone to bone iii Back quad calf area most common iv Graded 1st degree 3rCI degree 1st is least serious 3rCI means tendon is torn b Sprain injury to ligaments and muscles that support a joint i Ligaments bone to joint ii Ankle most common iii Same grading system c Clinical manifestations pain edema loss of function tender joint d Management RICE i Rest ice compression elevate 9 rst 2448 hours after switch to MOIST heat ii Elevate iii Splints or braces iv Healing can take weeks to months v NSAle narcotics 5 Osteoarthritis a Risk Factors b Signs and Symptoms i Knee pain worsens with exercise and is relieved by rest ii joint stiffness is worse in the morning and improves when moving around iii joint stiffness in the morning lt1 hour crepitus iv Heberden39s nodes distal nodes v Bouchard s nodes proximal nodes vi Varus bowlegged vii Most commonly involved joints hips knees hands c Management i Pharmacological 1 NSAle cause GI problems ulcers bleeding PUD a Acetaminophen is rst line of treatment teach about liver problems b Glucosamine and chondroitin sulfate 2 Steroids a Glucocorticoids reduce in ammation get twice a year injection 3 COX2 Inhibitors Celebrex celecoxib a Fewer GI problems than NSAIDS but increased incidence of MI 4 Topical a Methylsalicylate wintergreen smell like iceyhot b Capsaicin Zortix made from pepper plant topical lotion used herpes NonPharmacological 1 Management 6 Rheumatoid Arthritis a Risk factors women lt45 years autoimmune b Signs and Symptoms more symmetrical than 0A iv v Malaise fatigue Stiffness that lasts more than an hour and at least 6 1 0A stiff in morning but moving helps Soft tissue swelling of 3 or more joints erythema warmth over affected modules Rheumatoid nodules Positive serum factor test c Management Pharmacological 1 NSAIDs 2 DMARDs disease modifying antirheumatic drugs a Methotrexate give with concomitant folic acid i Causes bone marrow suppression monitor CBC ii Rescue drug leukovorin folic acid iii Given folic acid at the same time to increase RBC maturity iv Women should be on BC v Can be hepatotoxic monitor LFTs b Corticosteroids i P0 or local injections Sulasalazine antiin ammatory properties a Important to assess for allergies Gold compounds can be given P0 or IM have antiin ammatory properties a Monitor CBC looking for decreased RBC and anemia lmuran azathioprine and Cytoxan can cause cystitis Plaquenal anti malarial drug that is helpful for autoimmune disorders helps with in ammation Bioligcal Agents suppress the immune system response fatigue and anemia are common side effects immunomodulators a Enbrel Entanercept b Remicade In iximab c Humira 8 Oral COX2 Inhibitors Cerebrex similar to NSAIDs but not as much GI upset ii NonPharmacological OTPT Exercise joint protection Splints orthoses Use of assistive devices Heatcold applications preference of the person Dietary high calcium and vitamin D use of omega oils 7 Surgical management 7 Carpal Tunnel Syndrome a Causes hyper exion of the wrist causing pressure on the median nerve b Signs and Symptoms pain paresthesia numbness worst at night interrupts seep i Tinel39s sign tapping the medial nerve positive for CPS will have pain ii Phalen39s sign hands back to back facing down positive for CPS will have pain c Assessment EMG nerve conduction studies Tinel s sign Phalen s sign positive d Management i Conservative steroids splinting NSAIDs 1 Steroids for one time treatment maybe PO 2 Splints prevent hyperextension keep in proper position 3 Ergonomics use of wrist pads and splints to protect hands from environment ii Surgical decompression open procedure iii Postop care assessment pain management elevate ice splint PT P P PP NE Degenerative Disorders a Gout i Risk Factors men obesity hyperlipidemia ii Signs and Symptoms extreme pain swelling erythema can affect any joint in the body 1 Increase of purine metabolism byproduct is uric acid that accumulates in joints iii Lab Values serum uric acid levels are typically elevated iv Nursing Management 2 Medications a NSAIDS Indomethaci help with acute pain and in ammation i During ACUTE outbreak b Colchicine uric acid inhibitor given a short period of time during attack C d i SE diarrhea bone marrow aspiration Allopurinol used for PREVENTION drink 23 L of water to ush uric acid Nonpharm ice rest joint foot cradle 3 Dietary measures a b Lyme Disease Risk Factors living in a wooded area going out around dusk and down caused by a tick bite Signs and Symptoms 4 Stage 1 early stage after being bitten c SLE iv a Limit ETO decrease purines increase uids i Avoid red meat organ meat shell sh yeast beer Erythema migrans not everyone has it skin lesion that looks like a bullet mark that may appear 330 days after bite b Also fatigue headache lymphadenopathy 5 Stage 2 occurs 412 weeks after the bite a Cardiac and neuro problems possibly heart failure 6 Stage 3 arthritis neurological impairment may have entered CSF Lab Values blood work will not show positive for several weeks after bite ELISAWB Nursing Management 7 Medications antibiotics doxycycline a tetracycline or amoxicillin a Stage 2 or 3 stronger antibiotics like rociphen IV 8 Dietary measures 9 Prevention teaching a b c d e Wear light colors because you39re more likely to see tick Wear insect repallant Use a tweezer to remove the entire head of the tick Avoid dense undergrowth when in a wooded area Don t have bird feeder or things that will attack deer and ticks Risk Factors 10Discoid form nonsystemic and only involves the skin 11Drug induced procanimine thorazine lNH remove drug and it goes away 12SLE systemic monitor kidneys affects childbearing women Signs and Symptoms multisystem involvement 13Skin red butter y rash on the cheekbones alopecia 14Cardio pericarditis 9 monitor for cardiac tamponade 15Kidney monitor for proteinuria a Glomerulonephritis 9 possible renal failure most common cause of SLE death 16Arthritis stiffness 17Arthralgia joint pain 18Weakness fatigue depression osteoporosis 19Presence of fever in someone with known lupus is indicative of an exacerbation Lab Values Nursing Management 20Medications 21Dietary measures 22Triggers a Reduce stress b High risk pregnancy refer to OB c Support groups 23Body Image Issues d Fibromyalgia Risk Factors women Signs and Symptoms generalized pain syndrome associated with RA SLE 24Generalized chronic pain 25Poor sleep sleep disorders 26Fatigue morning stiffness depression 27Functiona loss without radiographic changes Lab Values rule out everything else must have pain in 1116 joints Management 28Medications antidepressant therapy amitriptyline or SSRIs 29Dietary Measures exercise diet relaxation techniques coping skills a Restore sleep avoid acoho e Osteoporosis Risk Factors postmenopausal women caucasian caffeine coffee deplete bone of calcium family history nulliparious smoking sedentary lifestyle Signs and Symptoms 30Loss of height back pain fracture a Colle39s fracture wrist from falling b Femurfracture 310ften asymptomatic until fracture Lab Values BMD studies peaks at 2530 screening 32DEXA screen spine or hip scored with a Tscore gold standard Management 33Medications a Calcium supplements for prevention recommended dose 600 mg twice a day i Osteroporosis 1500 mg daily b Vitamin D Calcitrol sun supplements c Hormone replacement therapy occurs because of loss of estrogen i Negatives cancer cardiac problems stroke must stop smoking d Selective Estrogen Receptor Modulators SERM Evista i Similar to estrogen but not as many side effects doesn39t affect all tissue ii Still risk of stroke no smoking iii Helps decrease bone resorption e Biphosphonates inhibit osteoclast activity i Didronel etidronate Fosamax alendronate Boniva ibandronate ii Patient should remain upright 30 minutes after taking medication iii Take in the morning or an empty stomach f Calcitonin P0 or SW for the thyroid inhibits osteoclast activit 34Dietary Measures Increase calcium take meds on empty stomach Exercise with weight loss Limit alcohol and caffeine Smoking cessation apem f Spinal Surgery a b c Patient care Degenerative Disc Disease Herniated lnterverebral Disc disk degeneration a Herniates through ring and compresses nerves b Common place C5C6 C6C7 L4L5 L5Sl Spinal Stenosis narrowing of spinal canal Spondylolisthesis one vertebral body slips down onto c Another anterior or posterior Spondylosis defect in the lamina Clinical Manifestations d Cervical pain tenderness in arm neck hand e Possible motor or sensory impairment f May lose 2point discrimination e Lumbar motor or sensory impairment in leg 35Sciatica pain from lower back to the foot 36Possible bowelbladder involvement a Any change is EMERGENCY 37Pain with straight leg 38Calda equine syndrome change in bowelbladder report immediately h Management f Conservative limited bedrest not extended a Pain management heatcold b NSAle muscle relaxants c Back exercises good for prevention PT complementary therapies Massage TENS acupuncture Proper body mechanics Epidural or steroid injection not a cure palliative g Surgical h Approaches anterior thransthoracic posterior i Anterior cervical discectomy and fusion ACDF approach through the front of the throat and remove the disk and fuse it with a bone from the iliac crest i Going to have a chest tube after surery j Instrumentation bone grafting k Minimally invasive procedures Decompression discectomy fusions m Complications n Infection meningitis test Kernig39s and Brudzinki s nuchal rigidity fever CSF leak neuro impairment assess change in NV status CMS checks DVT PE Neuro impairment Bleeding Management Post Op Assessment Pain management Respiratory care possible chest tube Wound care drains Urinary retention Positioning braces concerned about skin breakdown wear shirt underneath i TLSO wear when sitting upright and 003 g Activity h Patient teaching 0 39Nursin rhmech 500 Reproductive disordersSTIS 1 Menstrual Problems i Dysmenorrhea painful menstruation 1 Primary not associated with underlying pathophysiology maybe high prostaglandins a Occurs after ovulation begins usually after 6 months or more after menarche b Painful uterine cramping with spasmodic lower abdominal pain begins with the onset of menstrual ow and lasts 1272 hours i Pain often travels to lower back and thighs 2 General treatment a NSAIDS decrease prostaglandins to help relieve menstrual pain i Ibuprofen or naproxen take with meals ii Avoid in renal problem patients b Acetaminophen mild dysmenorrhea i Ex Tylenol take with meals c Oral contraceptives decreases prostaglandin production blocks ovulation d Vitamin E mild prostaglandin inhibitor i Provides mild relaxation to uterus e Heating paid uids ii Premenstrual Syndrome PMS 1 PMS group of physical and behavioral symptoms that occurs in the second half of the menstrual cycle luteal phase after ovulation a Low levels of serotonin GABA and beta endorphins 2 PDD symptoms are so severe they impact ADLs 3 Symptoms a Irritability crying moodiness hunger craving sweets or chocolate bloating b Psych depression angry outbursts anxiety irritability social withdrawal c Body breast tenderness edema headache bloating cravings insomnia fatigue d Short term memory problems dif culty concentrating unclear thinking iii Management 1 Diary of symptoms a Keep a chart for at least 2 consecutive menstrual cycles showing the length of each cycle the duration of bleeding and the occurrence of symptoms b True PMS symptoms during the luteal phase are followed by relief with menses and a symptom free phase of at least 7 days 2 Avoid stress alcohol a Exercise a minimum or 30 minutes 3 times a week to boost low endorphin levels 3 Adequate rest diet exercise a Diet avoid salt and processed food restrict sodium intake decrease re ned sugars b Avoid alcohol and caffeine to reduce irritability 4 Medications a Midol NSAle b PDD antidepressants Zoloft Paxil and other SSRls i Monitor for side effects suicidal thoughts GI sexual dysfunction c Hormonal therapy oral contraceptives 5 Complementaryalternative a Yoga massage acupuncture iv Dysfunctional Uterine Bleeding 1 Anovuatory bleeding excessive menstrual bleeding not associated with ovulating a Increased amount of flow and blood loss gt80 ml per cycle prolonged period of time gt21 days b Caused by a hormonal imbalance c Common causes endocrine disturbances diabetes polycystic ovary disease stress obesity Underweight Longterm drug use BC tamoxifen 2 Diagnostic HP biopsy US endocrine studies CBC may be anemic a Might do cancer markers CA125 b CBC check HH 3 Treatment treat underlying cause a Pharmacological treat underlying anemia iron if severe blood products i Estrogen therapy is indicated when bleeding is heavy and acute ii For nonemergent bleeding BC provides the progesterone needed to stabilize the endometrial lining b Surgical i Dilation and curettage DC can be used but is no longer the gold standard ii Endometrial ablation removal of the built up uterine lining with a laser roller ball or balloon is a safer treatment to those who do not respond to medical management 2 Toxic Shock Syndrome a b C Etiology caused by STAPH or STREP organisms that produce a toxin that leads to septicemia Risk factors tampon use wout applicators diaphragm use gt24h cervical caps Signs and symptoms i Abrupt onset of high fever gt102 with headache ii Flulike symptoms iii Severe hypotension iv Rash that looks like a sunburn Management vancomycin clindamycin uids remove tampon i Vanco renal toxic check BUNCrUO ototoxic hearing test peak after 3rCI dose and trough get 30 min before dose is ordered Patient teaching i Role of tampons don39t leave in for more than 23 hours wear pads at night never use tampons again after being diagnosed with TSS 3 Uterine Prolapse a uterus is moving downward out of normal position b Causes neuromuscular damage of childbirth pregnancy obesity physical exertion weakening of pelvic support due to decreased estrogen c Risk Factors multiple pregnancies menopause obesity d Clinical Manifestations i First degree cervix is still within the vagina 1 Might be asymptomatic or complain of fullness ii Second degree cervix is coming through the vagina 1 Pain painful intercourse vaginal discharge a little bleeding iii Third degree complete uterine prolapse the uterus is through the vagina 1 Risk factors multiple deliveries decrease of pelvic oor muscle Caucasians obesity iv Feeling quotsomething is falling outquot painful intercourse backache heaviness or pressure in the pelvis e Complications i Cystocele herniation or outpouching of the bladder into the vagina 1 Fullness urinary stress incontinence difficulty emptying bladder frequencyurgency ii Rectocele bulging of rectum into the vagina 1 Constipation possibly hemorrhoids fecal impaction feelings of rectal fullness iii Both are still intact f Diagnostic Pelvic exam i A large bulge of the anterior vaginal wall when the woman is asked to bear down g Management i Estrogen minor a cream to help tighten the pelvic oor muscles 1 For 1st and 2nCI degree prolapse ii Exercise kegels about 1015 times a day 1 Tell them to start peeing and then stop 2 510 seconds and repeat 1015x a day iii Pessaries holds the uterus in place 1 Inserted in a physician s office 2 Can stay in for a prolonged period of time weeksmonths 3 In some cases the women can reinsert it or they may have to go for a follow up appointment 4 May be used for a MINOR uterine prolapse iv Surgeries both are done through the vagina 1 Anterior Colporrhaphy for cystocele vaginal approach tightens pelvic muscles for better bladder support a Also bladder training and attention to complete emptying b 2 Posterior Colporrhaphy for rectocele a Bowel movements are often painful give pain medications before BM b Promotion of bowel elimination high ber diet stool softeners laxatives 3 Hysterectomy vaginal abdominal a Used if women does not want children 4 Epididymitis a In ammation of the epididymis and scrotal sac i Population 1535 in younger ages more commonly caused by gonorrhea or chlamydia 1 Older population more commonly caused by ascending UTI b Symptoms tenderness pain swelling i Prehn39s sign elevating the scrotum RELIEVES pain positive sign 1 Does not subside with testicular torsion c Diagnosis urinalysis culture blood ow testing ultrasound i Blood ow testing is to rule out testicular torsion d Treatment antibiotics pain management bed rest ice scrotal support i Warmth or ice depending on the patient preference ii Antibiotics if caused by bacterial origin chlamydia or gonorrhea 1 Doxycycline or Arithomax iii Recommend that the patient remains on bedrest or well rested until the pain subsides 1 Promotes elevation of the scrotum 4x4 gauze placed under scrotal sac iv Want them to avoid straining and the Valsalva maneuver 1 Stool softeners ber uids e Patient teaching safe sex practices i May have to treat partner for STD 5 Orchitis a In ammation of infection of the testicle i Bacterial origin gonorrhea chlamydia ii Viral origin MUMPS an Symptoms mimic those of epididymitis plus systemic manifestations nausea vomiting fever Diagnosis history examination Treatment gamma globulin antibiotics pain management I Gamma globulin only indicated if a postpubescent male is exposed to mumps and they ve never had mumps or never had the vaccine Antibiotics if from bacterial origin Pain management elevate the scrotum bed rest acetaminophen 6 Prostatitis a 7 BPH In ammation of the prostate gland i Bacterial E coli is common 1 Acute 2 Chronic ii Nonbacterial source is not always known idiopathic Clinical Manifestations swollen painful change in voiding patterns i Hesitancy urgency frequency decreased stream nocturia dysuria Diagnostic urinalysis culture usually E Coli i Trying to nd out if it is a urinary problem or a prostate problem ii Manual prostate exam Patient teaching i Comfort measures prevent straining possibly use of heat encourage uids 1 Sitz bath may be helpful i Pharmacotherapy 1 Antibiotics bacterial origin Bactrim is commonly used for E Coli assess for allergies increase uids avoid sunlight Sexual activity refrain from sexual activity for the rst 2 weeks 1 If it is a chronic issue recommended to increase sexual activity after the rst 2 weeks because ejaculation helps clean the system out Effects of alcohol and drugs 1 Alcohol is considered a bladder irritant can increase discomfort 2 Avoid anticholinergics leads to anticholinergic a Atropine Cogentin 3 Antihistamines also cause urinary retention Nursing Management 1 Avoid catheterizing them it increases the risk of an ascending infection 2 Can translocate bacteria Prevalence older men gt60 1 Enlargement of the prostate gland that causes an obstruction a Concerned about increased risk of UTI and obstruction ii Clinical manifestations depends on the extent of the enlargement DWFQP PWF Straining to urine Hesitancy in starting urine ow Decreased force of urine stream Postvoid dribbling Nocturia Dysuna Hematuria Urgency frequency Incomplete emptying of bladder Poten ial Complications 1 Hydronephrosis back up of urine into the renal pelvis and kidney itself causing distention a Can lead to renal failure if not treated rule out cancer as well iv Diagnostic testing renal function PSA cystoscopy PVR 1 PWquot gt International prostate symptom score tool to determine severity of obstruction a Know that it is a diagnostic tool Baseline urinary function test BUN and Creatinine Urinalysis culture and sensitivity to rule out UTI Digital rectum exam DRE recommended in all men gt50 years sooner in African Americans PSA prostate speci c antigen to rule out prostate cancer should be less than 4 a Recommended every year after 50 except for highrisk individuals rst degree relative African Americans may be done earlier Cystoscopy scope into bladder to visualize Post void residual PVR going to tell you if they are completely emptying the bladder a Right after the patient urinates we are going to catheterize them and see how much residual they have i Normal residual lt100 ml b The higher your PVR the more increased risk of infection v Management 1 Medications a Alpha reductase inhibitor Proscar Avodart i Decrease DHT and helps to shrink the prostate ii Know it39s working by seeing a decrease in symptoms rt urination iii Contraindicated in pregnancy b Alpha receptors blockers Flomax Cardura Helps to constrict the prostate Cardura is also used for HTN great drug to use for both HTN and BPH 1 Give it at night to decrease orthostatic hypotension 2 Routine monitoring a Continue to monitor them after they are started on medications 3 Laser surgery Foley catheter 4 TURP Transurethral Prostatectomy a Removing or resecting the enlarged prostate Ussue Important that there is continuous irrigation at the same time b Post operative considerations VI Urine output patency of catheter 1 Normal to initially have pinktinged urine not clots though a If clots increase irrigation ow or ush catheter 2 3way urinary catheter a Purpose is to keep urinary system patent and keep clots from forming b Retention balloon holds 30 mLs the patient is going to feel like they have to urine risk for water intoxication i Teach patient not to urinate around the catheter it will cause bladder spasming and pain c Once catheter is removed encourage them to urinate frequently Bladder irrigation during the surgery and postop 1 At least for the rst day to clean out blood 2 Keeping it patent Pain management suppositories 1 Belladonna suppository antispasmodic Stool softeners prevent straining also give uids and ber Antibiotics prophylaxis Avoid heavy lifting stairs sexual activity 1 Avoid sexual activity for 46 weeks vii Kegel exercises help strengthen the pelvic oor 1 Start urinating and stop the stream 2 Do 1015 times a day 8 Vaginitis a Bacterial Gardinella i SS pruritus vaginal discharge thin shy odor pH lt45 ii Treatment 1 Flagyl for up to 7 days a Turns urine orangered no ETOH don39t take on empty stomach 2 Clindamycin can have vaginal suppositories best time at night or PO a Abstain from sex until treatment is completed partners NOT treated b Fungal C albicans i 55 thick white cottage cheese like discharge pruritus ii Treatment Di ucan PO x 1 but is more expensive 1 Other options Monitstat suppositories antifungal suppository a Best prior to bed time partner not usually treated is if recurrent c Protozoan Trichmonoas i SS copious amounts of foul smelling discharge may be yellowgreenish 1 Treatment Flagyl NO ETOH urine color change a Avoid sex for duration of treatment at least 7 days b Partner is treated d Management i Safe sex practices ii If on antibiotics women should use a backup contraceptive e Patient teaching i Encourage women to urinate following sexual intercourse ii Encourage intake of vitamin C 9 increases acidity iii Can use sitz bathes can use cotton underwear avoid tightconstrictive clothing 9 Treatment of Partners a Protozoan Trich treats partners b Bacterial and fungal don39t treat partner unless it39s recurrent 10Prevention Safe sex practices a Condoms 11 Gonorrhea a Incidence 24 and younger b Often concurrent STDs 9 chlamydia i Often treat for both cncuba on i If they are asymptomatic and don39t get treated it can develop into PID d Clinical manifestations i Women vaginal discharge dysuria bleeding with intercourse 1 Often asymptomatic 2 Not going to have all of these if they have any ii Men urethritis dysuria purulent discharge pain 1 May or may not have discharge from the penis e Diagnostic testing i Culture the organism f Treatment i Ceftriaxone Rocephin a cephalosporin 1 Given IM x 1 ii Concurrent treatment for chlamydia 1 Zirthomax macrolide one dose more expensive 2 Doxycycline tetracycline cheap but take for 7 days a Encourage a lot of uids during treatment iii Treat partners expedited partner therapy 1 HCP can write a prescription for partner even if they don39t see them 2 Important to get partner treated to prevent re infection iv Safe sex practices 1 Refrain from sexual activity with a partner until therapy is treated a Can be transmitted orally vaginally semen anaIIy 2 One time dose they should still refrain for 7 days 12 Chlamydia a Incidence most common STD reported to the CDC i Concern about developing into PID b Transmission i Conjunctiva vaginal rectal throat urethra ii Concerned during delivery of baby c Clinical manifestations often asymptomatic i Women vaginal discharge dysuria bleeding ii Men discharge from urethra dysuria d Diagnostic testing culture testing nonculture testing i Direct DNA testing e Treatment Azithromycin or doxycycline i Doxycycline increase uids avoid direct sunlight ii Recommended that all sexually active women under the age of 24 get an annual Pap with chlamydia testing f Management safe sex treat partners i Use of condoms does not prevent STD transmission it decreases the risk 13 HPV a Incidence i Can present externally warts or internally cervix 9 cancer ii 50 of sexually active individuals will have HPV sometime in their life 1 90 of cases resolve spontaneously iii Can also be transmitted vaginally rectally orally b High risk strains i 6 and 11 most likely to cause genital warts ii 16 an 18 most likely to lead to cervical cancer Often asymptomatic i Genital warts condylomata acuminate soft moist esh colored bumps may appear weeks or months after infection ii Cervical asymptomatic will be picked up on a PAP smear d Diagnostic PAP colposcopy i If positive on a PAP wait and watch with routine pap smears ii Colposcopy identi es lesion on the cervix 1 Persistent scope vaginally to look at the cervix under a microscope 2 Put an acid on the cervix to identify lesions on the cervix n e Vaccine i Gardisil helps prevent against all 4 ii Age 926 for boys and girls iii If they are diagnosed with HPV they SHOULD GET THE VACCINE iv 3 shots 1 month 3 month 6 month f Treatment may just watch it with PAP smears because it may resolve on it39s own i Topical application 2 podo lox imiquimod 1 Patient application that they put on the external lesions 2 Cytotoxic killing that tissue 3 Special precautions used over an extended period of time with speci c instructions ii Cryotherapy 1 Use of liquid nitrogen to freeze off warts 2 Might need more than one treatment 3 HCP done iii TCA application trichloroacetic acid 1 Topical application done by the HCP iv lntralesional interferon v Laser surgery vi Leep procedure 1 Go in and remove part of the cervix with the lesions 2 Not a great option if someone wants to have children 9 may cause incompetent cervix vii Patient teaching frequent follow up 1 Can be 39cured39 of genital warts they don39t come back like Herpes 2 Reinfection can occur through another exposure or they didn39t completely eradicate it the rst time 14 Genital Herpes a Acute recurring incurable viral disease i Once you have it you have it for life goal is to prevent exacerbations ii If you do not have lesions you are still contagious and can pass the infection 1 quotviral sheddingquot is still going on even if there are no lesions b Assessment patient history physical examination and viral culture i Type 1 oral lesions ii Type 2 genital lesions iii There can be cross contamination iv Vesicle lesion as the vesicle matures it ruptures and forms a crust v A padromal syndrome recognize something occurring before the outbreak that is like a signal that lets them know they will have an outbreak important for treatment purpose vi Triggers stress cold weather illness c Treatment symptomatic with goals to decrease discomfort promote healing without secondary infection decrease viral shedding and prevent infection transmission d Drug therapy i Antiviral drugs do not cure the infection but do decrease the severity promote healing and decrease the frequency of recurrent outbreaks while the are being used 1 Acyclovir famicyclovir valaclovir may be prescribed 2 If patient has an initial outbreak they will be treated for that 3 If they have frequent outbreaks they can be given suppression therapy a When they get the sensation before an outbreak they can take the medication to help prevent or reduce outbreak e Nursing Management i Patient counseling and education about the infection the potential for recurrent episodes the correct use and possible side effects and antiviral therapy viral shedding even when the patient is symptom free and sexual transmission 1 Use of condoms will greatly decrease risk of transmission 2 Oral dam can be used for oral sex 3 Teach that it is chronic and potential partners have to be informed ii Assessment of the patient s psychological responses to the diagnosis of genital herpes 1 Don t minimize the psychological parts of the diagnosis 15 PID a Risk factors early sexual activity multiple partners smoking history of STDs i Often goes unrecognized and untreated and can persist for many years causing scar tissue infertility ii Much higher risk of ectopic pregnancy with PID b Pathophysiology common causes include gonorrhoeae chlaymdia haemophilus streptococci c Clinical manifestations i Severe abdominal pain intermenstrual bleeding dyspareunia fever and chills nausea and vomiting chandelier sign ii When a young sexually active women comes in with abdominal pain 9 think PID iii Chandelier sign cervical motion tenderness CMT on palpation it hurts so they jump up towards the chandelier d Management i Diagnostics WBC elevated ESR elevated might get a laproscopic exam culture secretions ii Antibiotic therapy 1 Outpatient doxycycline azithromycin 2 Inpatient IV antibiotics initially gentamycin a Nephrotoxicity peak and trough and ototoxicity iii Bed rest generally elevated about 3045 degrees to promote drainage iv Comfort measures DO NOT use sitz bath v Managing fever vi Patient teaching Care of the Patient with Infectious Diseases HIVAIDS i Transmission a Direct transmission by sexual contact b Direct inoculation with contaminated blood products needles or syringes c Infected mother to her fetus or newborn ii Testing signi cance of each a ELISA b WB c Viral Load d CD4 Count e HIV v AIDS iii Opportunistic Infections a Occur when CD4 count lt200 cellsmm3 i AIDS can experience one or more at the same time ii Infections might return when abx are discontinued HAART is the most effective means of preventing the development of infections b Mycobacteria Avium Complex MAC iv Atypical nonTB mycobacteria found in water soil unpasteurized dairy products aerosol droplets 9 most common bacterial infection in AIDS Occurs when CD4 lt50 cells profound immune suppression Can be asymptomatic or present with TBlike pulmonary process disseminated disease is common with accompanying physical lab ndings 1 Very similar to TB can only differentiate by culture Combination therapy includes antimycobacterial agents and antibiotics prophylactic therapy may be initiated c Prophylaxis Against Opportunistic Infections vi vii CD4 lt 200 cells 9 PCP prophylaxis with Bactrim 1 PCP causes respiratory distress 2 Bactrim is a sulfa monitor for allergies CD4 lt 100 cells 9 toxoplasmosis prophylaxis with Bactrim i Toxoplasmosis is a neurological condition 40CD4 lt 50 cells 9 MAC prophylaxis with Zithromax every week MTB 1 HIVpositive individuals should be tested annually 2 Asymptomatic with positive tuberculin skin test TST gt5mm patient should undergo diagnostic evaluation begin prophylactic single or dual therapy 3 Symptomatic with negative TST patient should undergo diagnostic evaluation suspect TB 4 Combination therapy for active disease Candidiasis 1 Might be early sign of HIV infection rst opportunistic infection 2 Found in mouth most common throat esophagus stomach bowel vagina skin 3 Characteristic glistening white patches on tongue or oral mucosal surfaces creamy white vaginal discharge 4 Prophylactic therapy is not recommended requires longterm suppressive therapy Cryptococcosis 1 Fungal infection acquired by inhalation a Only infectious if the receiving person is immunosuppressed 2 Found in pigeon droppings remains viable for up to 2 years 3 Primarily affects CNS usually manifests as meningitis can present with skin lesions a Safety is concern 4 Amphotericin B for initial infection longterm suppressive therapy required to prevent recurrence viii Histoplasmosis 1 Usually benign fungal infection that occurs primarily in the lungs very rare SW 2 Can manifest as pulmonary infection more often occurs as disseminated disease 3 High percentage of cases present with normal radiograph establish diagnosis with bone marrow biopsy pulmonary tissue secretions blood cultures 4 Drugs of choice amphotericin B uconazole long term suppressive therapy required a Amphoterrible causes rigors cannot stop shivering related to histamine release can cause hypotension and an acute anaphyactic reaction i Premedicate with Benadryl and Tylenol ix Cryptosporidium 1 Protozoal infection parasite present in numerous animal species a Diarrhea associated with eating something contaminated 2 Pathogenic animal to human person to person waterborne transmission 3 Commonly occurs in small intestine can affect entire GI tract profound dehydration or eectroyte imbalances can occur a Priority is managing uid and electrolytes rapid uid resuscitation 4 Selflimiting in immunocompetent individuals 5 No effective anticryptosporidial therapy control pain decrease peristalsis a Fluid and rehydration x Penumocystis jiroveci Pneumonia formerly called p carinii 1 Protozoal infection Pneumocystisjiroveci pneumonia formerly P carinii pneumonia PCP very common severe opportunistic infection among persons with AIDS found in air water on food airborne transmission Generally con ned to ungs Biopsy in patients with pneumonia presumptive diagnosis often made based on CDC guidelines a Dyspnea or cough diffuse biatera in ltrates blood gas analysis and no evidence of bacterial pneumonia 4 Sulfa is therapy of choice prophylactic treatment in certain circumstances 5 Occurs when CD4 less than 200 cells UJN xi Toxoplasmosis 1 Protozoal infection transmission in humans primarily through meats and vegetables generally benign in healthy hosts 2 Local infection presents similarly to mononucleosis disseminated infection a major cause of encephaHUs a Presents like they have had a stroke priority is safety b May be very disoriented have personality changes speech changes 3 Combination therapy for those with AIDS prophylactic drug therapy initiated for HIVpositive individuals diagnosed with toxoplasmosis 4 Occurs when CD4 less than 100 cells xii CMV Cytomegalovirus 1 Widespread in general population found in secretions breast milk blood a Seen a lot in newborns b Untreated can lead to blindness 2 Asymptomatic in immunocompetent host latent or chronic a Reactivated in the presence of HIV b Disseminated infection in immunocompromsied individuals produces in ammatory reactions in lungs CNS liver eyes 3 Diagnosed by presence of antibodies in serum 4 Ganciclovir among drugs of choice prophylaxis might be considered in certain circumstances xiii HSV Herpes Simplex Virus 1 Type 1 transmitted via oral and respiratory secretions type 2 transmitted via sexual contact 2 Produces painful vesicular lesions disseminated infections affect brain liver lungs a Remains dormant in tissues and reactivated in the presence of HIV infection 3 Diagnosed by presence of serum antibodies 4 Acyclovir effective for acute episodes can be used as daily suppressive therapy for chronic lesions a Acyclovir can crystallize in the kidneys important to drink a lot of water xiv Kaposi s Sarcoma 1 Most common neoplasm in AIDS 2 Exact cause unknown lesions on the skin mucous membranes can affect internal organs 3 Diagnosed by skin biopsy high index of suspicion with lesions in immunocompromised individuals 4 Treatment excise local lesions treat systemic lesions with radiation or chemotherapy a Drug Therapy xv All go through rstpass mechanism which activates cytochrome P450 and causes drug intx 1 xvi 4 5 b Prevention xvii xviii Work at different part of the infection cycle so have to take all for best result Classes of HIV drugs 1 NucleosideNucleotide Reverse Transcriptase Inhibitors NRTIs a Side effects i AZT ANEMIA ii D drugs PERIPHERAL NEUROPATHY iii Headache nausea vomiting rash NonNucleosideNucleotide Reverse Transcriptase Inhibitors NNRTI39s a Side effects i Sustiva hallucinations CNS side effects false THC Protease Inhibitors PI a Side effects i Increased cholesterol and triglycerides ii Insulin resistancediabetes iii Lipodystrophy fat redistribution Fusion Inhibitors Integrase Inhibitors Patient Teaching c Nursing Care Psychosocial Issues 1 Diagnosis may revert to denial unsure of how they are going to tell their families think they will be alone for the rest of their life Mental health HIV is very stressful any illness is concerning and think they might die from it a Intimate partner relationships have to tell them before you have sex Substance abuse a lot of HIV is associated with substance abuse a Alcohol IV drug use b Substance abusers don39t adhere to medication regimen Violence intimate partner violence has a high incidence with HIV infection
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