Utilize your weekly objectives to help guide your studying. Peri op topics: A. Preoperative Nursing: begins when the decision to proceed with surgical interventions is made and ends with the transfer of the patient onto the OR bed B. Intraoperative Nursing: begins when the patient is transferred onto the OR bed and ends with the admission to the PACU; intraoperative nursing responsibilities: a. Acting as a scrub nurse, circulating nurse, or registered nurse first assistant C. Postoperative Nursing: begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home D. Pain Management E. Discharge Teaching 1. Explain the nurse’s responsibilities preoperatively and during surgery a. One goal of preoperative nursing care is to educate the patient how to promote optimal lung expansion and resulting blood oxygenation after anesthesia. b. The goals of promoting mobility postoperatively are to improve Spring Exam 1 Blueprint circulation, prevent venous stasis, and promote optimal respiratory function. The patient should be taught that early and frequent ambulation postoperatively, as tolerated, will help prevent complications. c. Diaphragmatic breathing refers to a flattening of the dome of the diaphragm during inspiration, with resultant enlargement of the upper abdomen as air rushes in. During expiration, the abdominal muscles contract. d. Preoperative patient education also needs to include the difference between acute and chronic pain so that the patient is prepared to differentiate acute postoperative pain from a chronic condition such as back pain. Preoperative pain assessment and education for the older patient may require additional attention e. The circulating nurse coordinates the care of the patient in the OR. Care provided by the circulating nurse includes planning for and assisting with patient positioning, preparing the patient’s skin for surgery, managing surgical specimens, anticipating the needs of the surgical team, and documenting intraoperative events. f. As patient advocates, intraoperative nurses monitor factors that have the potential to cause injury, such as patient position, equipment malfunction, and environmental hazards, and protect the patient’s dignity and interests while the patient is under anesthesia. Additional responsibilities include maintaining surgical standards of care and identifying and minimizing risks and complications. 2. Identify the purpose and components of preoperative nursing assessment and interpret the significance of data related to the patient’s health status and risk a. The liver is important in the biotransformation of anesthetic compounds. Disorders of the liver may substantially affect how anesthetic agents are metabolized. Acute liver disease is associated with high surgical mortality; preoperative improvement in liver function is a goal. Careful assessment may include various liver function tests b. The kidneys are involved in excreting anesthetic medications and their metabolites; therefore, surgery is contraindicated if a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems c. hyperglycemia. Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin. Hyperglycemia, which can increase the risk of surgical wound infection, may result from the stress of surgery, which can trigger increased levels of catecholamine.Spring Exam 1 Blueprint i. Although the surgical risk in the patient with controlled diabetes is no greater than in the patient without diabetes, strict glycemic control (80 to 110 mg/dL) leads to better outcomes d. Patients who have received corticosteroids are at risk for adrenal insufficiency. e. Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis (with hyperthyroid disorders) or respiratory failure (with hypothyroid disorders). The patient with an associated history of a thyroid disorder is assessed preoperatively f. Aspirin, a common OTC medication that inhibits platelet aggregation, should be prudently discontinued 7 to 10 days before surgery 3. Explain the etiology and nursing assessment with management of post-operative care a. Frequent, skilled assessments of the patient’s airway, respiratory function, cardiovascular function, skin color, level of consciousness, and ability to respond to commands are the cornerstones of nursing care in the PACU b. After the initial assessment, vital signs are monitored and the patient’s general physical status is assessed and documented at least every 15 minutes c. Administration of the patient’s postoperative analgesic requirements is a top priority to provide pain relief before it becomes severe and facilitate early ambulation d. In the clinical unit, the pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours. 4. Choose strategies to prevent postoperative complications a. Assessing breathing and administer supplemental oxygen if prescribed b. Monitor vital signs and note skin warmth, moisture, and color c. Assess the surgical site and wound drainage systems; connect all drainage tubes to gravity or suction as indicated and monitor closed drainage systems d. Assess LOC, orientation, ability to move extremitiesSpring Exam 1 Blueprint e. Assess pain level, pain characteristics, and timing, type and route of administration of last dose of analgesic f. Administer analgesic meds as prescribed and assess their effectiveness in relieving pain g. Place the call light, emesis basin, ice chips, and bedpan/urinal within reach h. Position the patient to enhance comfort, safety, and lung expansion (HOB 30 degrees) i. Assess IV sites for patency and infusions for correct rate and solution j. Assess urine output in closed drainage system or use bladder scanner to detect distention k. Reinforce the need to begin deep breathing and leg exercises l. Provide information to the patient and family 5. Explain pain control in the postoperative patient. a. IV opioids provide immediate pain relief and are short acting, thus minimizing the potential for drug interactions or prolonged respiratory depression while anesthetics are still active in the patient’s system b. Intense pain stimulates the stress response, which adversely affects the cardiac and immune systems. When pain impulses are transmitted, both muscle tension and local vasoconstriction increase, further stimulating pain receptors. This increases myocardial demand and oxygen consumption. The hypothalamic stress response also results in an increase in blood viscosity and platelet aggregation, increasing the risk of thrombosis and PE. 6. Describe general discharge teaching for the postop patient a. To ensure patient safety and recovery, expert patient education and discharge planning are necessary when a patient undergoes same-day or ambulatory surgery b. Patient will be able to:Spring Exam 1 Blueprint i. Describe ongoing postoperative therapeutic regimen, including medications, diet, activities to perform (e.g., walking and breathing exercises) and to avoid (e.g., driving a car, contact sports), adjuvant therapies, dressing changes and wound care, and any other treatments. ii. Describe signs and symptoms of complications. iii. Identify interventions and strategies to use in adapting to any permanent changes in structure or function iv. Describe pertinent health promotion activities (e.g., weight reduction, smoking cessation, stress management). F&E Electrolyte disturbances – know normal values Sodium: natremia Hypo: <135 mEq/L Cause: adrenal insufficiency – deficiency of aldosterone; water intoxication; SIADH or losses by vomiting; diarrhea; sweating; diuretics; anticonvulsants – tegretol, keppra S&S: Dependent on cause, severity, and acuity. Decrease in BP, poor skin turgor, dry mucous membranes, headache, nausea, abdominal cramping, AMS, seizures or coma (cerebral swelling). Sudden Na loss will increase cerebral edema and mortality Tx: water restriction, sodium replacement by mouth, IV fluids – Normal saline or lactated ringers. SIADH – hypertonic IV fluids, restrict fluids and Lasix. * 3% or 5% IV fluids is only in very critical cases, not in medsurg bedside Nursing: assess and prevent, dietary sodium and fluid intake, id and monitor at-risk patients, effects of meds (diuretics, lithium). Early detection, anorexia, n/v, abdominal cramping or CNS changes. Encourage diet high in Na – beef cube = 800 mg of Na or tomato juice Hyper: > 145 mEq/L Cause: Excess water loss, excess sodium administration, diabetes insipidus, heat stroke, hypertonic IV solutions S&S: thirst (not always in geri), increased temp, dry swollen tongue, sticky mucosa, restlessness, weakness Tx: Hypotonic – D5W Nursing: assess and prevent, OTC sources, encourage fluids, provide sufficient water with tube feedings Potasium: kalemia Hypo: <3.5 mEq/LSpring Exam 1 Blueprint Cause: GI loss, meds (diuretics), acid-base imbalance, poor dietary intake, hyperaldosterism S&S: fatigue, nausea, vomiting, dysrhythmias, muscle weakness and cramps, paresthesia, glucose intolerance, deep tendon reflexes. Flat T wave and appearance of U wave Tx: dietary increase potassium, IV replacement or tablets Nursing: assess and prevent, monitor ECG and ABGs, dietary potassium, care with IV potassium administration. (never push straight, must ALWAYS be diluted) Hyper: > 5.0 mEq/L Cause: usually treatment related, impaired renal function, hypoaldosteronism, tissue trauma, acidosis S&S: cardiac changes and dhysrhythmias, muscle weakness w/ potential for respiratory impairment, paresthesia, anxiety, GI manifestations. Peaked T wave, wide-flat P wave and wide QRS complex. Tx: ECG monitoring, limit dietary potassium, cation-exchang resin (Kayesalate), iv sodium bicarb, IV calcium gluconate, regular insulin and Hypertonic dextrose iv, dialysis. Beta-2 agnoists Nursing: assess serum potassium levels, mix IVs well, monitor med response, dietary teaching, *blood draw above IV site may result in false lab result, hx of HTN salt substitutes may contain potassium, renal dysfunction, potassium sparing diuretics may cause elevation in potassium. Calcium: calcemia Hypo: < 8.6 mg/dl Cause: hypoparathyroidism, malabsorption, pancreatitis, alkalosis, renal failure S&S: tetany, circumoral numbmness, paresthesias, hyperactive deep tendon reflexes, Trousseau’s sign, Chostek’s sign, seizures, dyspnea and laryngospasm, anxiety Tx: IV calcium gluconate, calcium and vit D supplements, diet Nursing: assess, weight bearing exercise to decrease bone calcium loss, diet teaching, calcium supplement, Hyper: >10.2 mg/dl Cause: malignancy, hyperparathyroidism, bone loss related to immobility S&S: muscle weakness, incoordination, anorexia, constipation, n/v, abdominal and bone pain, polyuria, thirst, dysrhythmias Tx: underlying cause, fluids, Lasix, phosphates, calcitonin, biphosphonates Nursing: asses, hypercalcemic crisis, ambulation, fluids 3-4 L/day, fluids containins sodium unless contraindicated, fiber for constipation, ensure safety Magnesium: magnesemia Hypo: <1.3 mg/dl Cause: alcoholism, laxative abuse, parenteral feeding deficient in magnesium, rapid administration of citrated blood, contributing factors like DKA, sepsis, burns S&S: muscle weakness tremors, neuromuscular irritability, tremors, ECG changes, dysrhythmias, alterations in mood and LOC Tx: diet, oral magnesium, magnesium sulfate IVSpring Exam 1 Blueprint Nursing: assess, ensure safety, diet, medication and alcohol use teaching. Check BP and serum levels for IV mag sulfate treatment, Hyper: >2.3 mg/dl Cause: DKA, renal failure, excessive magnesium administration S&S: flushing, lowered BP, n/v, hypoactive reflexes, drowsiness, muscle weakness, bradypnea, ECG changes, dysrhythmias Tx: IV calcium gluconate, IV fluids – NS or LR, dialysis Nursing: assess, hold meds that contain magnesium like OTC meds, teaching about OTC meds Phosphorus: phosphatemia Hypo: <2.5 mg/dl Cause: alcoholism, refeeding patient after starvation, heat stroke, respiratory alkalosis, hyperventilation, DKA, hyperparathyroidism, diarrhea, vit d deficiency, diuretic or antacid medications S&S: confusion, muscle weakness, tissue hypoxia, muscle and bone pain, increased susceptibility to infection Tx: oral or IV phosphorus replacement Nursing: asses, encourage foods high in phosphorus, gradually introduce calories for malnourish patients receiving parenteral nutrition Hyper: >4.5 mg/dl Cause: renal failure, excess phosphorus, excess vit D, acidosis, hypoparathyroidism, chemo S&S: few symptoms, usually due to associated hypocalcemia Tx: underlying disorder, vit D preperations, calcium binding antacids, phosphate-binding gels or antacids, loop diuretics, IV fluids – NS, dialysis Nursing: assess, diet avoiding high-phosphorus foods, teaching related to food, phosphate-containing substance and signs of hypocalcemia Chloride: chloremia Hypo: < 97 mEq/L Cause: Addison’s disease, reduced chloride intake, GI loss, DKA, excessive sweating, fever, burns , metabolic acidosis, can occur with loss of other electrolytes, potassium & sodium S&S: irritability, agitation, weakness, hyper excitability of muscles, dysrhythmias, seizures, coma Tx: replace chloride, IV fluids – NS or 0.45% NS Nursing: assess, avoid free water, encourage high-chloride foods, patient teaching related to diet Hyper: > 107 mEq/L Cause: excess sodium chloride infusions w/ water loss, head injury, hypernatremia, dehydration, severe diarrhea, respiratory alkalosis, metabolic acidosis S&S: tachypnea, lethargy, weakness, rapid deep respirations, HTN, cognitive changes. Tx: restore electrolyte and fluid balance, LR, sodium bicarb & diuretics Nursing: assess, pt teaching related to diet and hydration Types of IV fluids Replace volume and provided electrolytes, medications and bloodSpring Exam 1 Blueprint Normal or Isotonic NS (0.9% Sodium Chloride) – replace ECF fluid volume deficit, blood products but cautiously with HF patients D5W* (isotonic at first, then disperses as hypotonic 1/3 ECF, 2/3 ICF) not to be used to replace volume rapidly because can develop hyperglycemia LR* can be used to correct dehydration, replace GI losses but NS is most common Hypertonic – used very cautiously, ICU 3% NS D50 Quality and Safety Nursing Alert The nurse must know that solutions with higher concentrations of dextrose, such as 50% dextrose in water, are strongly hypertonic and must be administered into central veins so that they can be diluted by rapid blood flow. Hypotonic – can be compared with plasma; used to replace cellular fluid TX hypernatremia 0.45% NS (half normal saline) D5W Fluid volume deficit – Hypovolemia Loss of ECF exceeds intake Dehydration Diabetes Insipidus S&S: oliguria, ⇑ urine concentration, poor skin turgor, postural hypotension, rapid weak pulse, ⇑ temp, cool clamy, thirst, nausea, muscle weakness and cramps Labs: elevated BUN in relation to serum creatinine, increased hematocrit, serum electrolyte changes Tx: IV fluids: Normal saline, fluid intake, Nursing: I&O, daily weight, vital signs, mental status assess, oral care Fluid Volume Excess Heart Failure Renal Failure Cirrosis or Liver Failure Excessive dietary sodium or sodium containing IV fluids S&S: Edema, distended neck veins, adventitious lung sounds, tachycardia, ⇑ BP, SOB, increased urine output Tx: Diuretics, fluid restrictions and sodium Nursing: I&O, daily weights, assess lung sounds, Semi-fowlers position, positioning and skin care, monitor diuretic responseSpring Exam 1 Blueprint Necessary for life & homeostasis. Need to be able to ID, respond to and prevent imbalances. 60% of adult is fluid (water & electrolytes). Varies with age, body size or fat composition, gender. Normal tonicity of blood 0.9% NaCl. Intracellular fluid (2/3) – fluid within the cells Extracellular fluid (1/3) – fluid outside of cells o Intravascualr – fluid within the blood vessels o Interstitial – fluid that surrounds the cells (i.e. lymph fluid) o Transcellular – smallest amount of ECF found in cerebrospinal fluid (CSF), pericardial, synovial, pleural fluids, intraocular, sweat & digestive secretions Third Spacing – ECF fluid shift into space that is not useful. S&S: decrease in urine output, ⇑HR, ⇓BP, edema, ⇑ weight, Sodium – impacts regulation of fluid volume; in extracellular Potassium – in intracellular Magnesium Calcium Hydrogen Chloride Bicarb Phosphate Movement of fluid: Hydrostatic pressure – exerted on walls of blood vessels Osmotic Pressure – exerted by protein in plasma Filtration – passive, water and solutes moves form high hydrostatic pressure to low hydrostatic pressure Active transport – pressure is moved by expended energy (i.e. sodium-potassium pump maintains higher concentration of extracellular sodium and intracellular potassium) Gains: Food and drinks & IV fluids Losses: Kidneys – average 1.5 L of urine a day Skin – lots of variables, 0-1000 mL or more per hour; fever will increase loss Lungs – 300 mL/day via water vapor; tachypnea increases loss GI – 100-200 mL/day bulk reabsorbed in the intestines Kidneys Regulate ECF and osmolality by selective retention and excretion of body fluids Regulate normal electrolyte levels in ECF Regulate pH in ECF by retention of hydrogen ions Excretes waste and toxic substances Renal perfusion dependent on heart pumping and blood circulation Pituitary – hypothalamus produces ADH; ADH controls the retention or excretion of water by kidneys and regulating blood volumeSpring Exam 1 Blueprint Gerontologic Considerations – reduced homeostatic mechanisms, i.e. cardiac, renal and respiratory function; decreased body fluid percentage, med use and present concomitant conditions IV site selection: ∙ Dominant arm, bruising on arm, multiple needle sticks What will be infusing? ∙ 20-22 gauge are commonly used ∙ 14-18 trauma or blood ∙ 22-24 smaller for older adults Assess the site! At least Q1H Complications: ∙ Infection ∙ Infiltration – edema at site, fluid leakage, discomfort and coolness at site, sloughing of tissue if solution is irritating. D/C IV! ∙ Extravasation – similar to infiltration but with irritant solution or medication. Vasopressors, potassium, calcium and chemo drugs. Necrosis, blistering, inflammation. Stop infusion, antidote may be prescribed ∙ Phlebitis – inflammation of the vein. D/C IV apply warm compress ∙ Thrombophlebitis – discomfort, redness, warmth, swelling, immobility of extremity. ∙ Fluid volume overload; S&S: JVD, palpitations, dyspnea, wheezing, cyanosis, ∙ Air embolism; S&S: JVD, palpitations, dyspnea, wheezing, cyanosis, TX: turn patient on left side in Trendelenburg, cap line that has leaked. A. Fluid Regulation B. Fluid Volume Deficit C. IV Fluids D. Fluid Volume Excess E. Some specific electrolyte disturbances 1. Identify patients at risk for F&E imbalance 2. Describe the etiology, laboratory, diagnostic findings and nursing as well as collaborative management of persons with fluid and electrolyte imbalancesSpring Exam 1 Blueprint DM Insulin types DKA HHNK Patient teaching Hyperglycemia vs hypoglycemia a. Hypoglycemia: low blood sugar, numbers fall to less than 70 mg/dL; severe hypoglycemia is when glucose levels are less than 40 mg/dL i. can occur when there is too much insulin or oral hypoglycemic agents, too little food, or excessive physical activity. ii. In mild hypoglycemia, as the blood glucose level falls, the sympathetic nervous system is stimulated, resulting in a surge of epinephrine and norepinephrine. This causes symptoms such as sweating, tremor, tachycardia, palpitation, nervousness, and hunger. iii. In severe hypoglycemia, CNS function is so impaired that the patient needs the assistance of another person for treatment of hypoglycemia. Symptoms may include disoriented behavior, seizures, difficulty arousing from sleep, or loss of consciousness. iv. In emergency situations, for adults who are unconscious and cannot swallow, an injection of glucagon 1 mg can be administered either subcutaneously or intramuscularly b. Hyperglycemia: Without insulin, the amount of glucose entering the cells is reduced, and production and release of glucose by the liver (gluconeogenesis) is increased, leading to hyperglycemia Exercise effects on blood sugar c. Exercise lowers blood glucose levels by increasing the uptake of glucose by body muscles and by improving insulin utilization d. It also improves circulation and muscle tone; resistance (strength) training, such as weight lifting, can increase lean muscle mass, thereby increasing the resting metabolic rate. e. alters blood lipid concentrations, increasing levels of high-density lipoproteins and decreasing total cholesterol and triglyceride levels. This is especially important for people with diabetes because of their increased risk of cardiovascular disease. Sick care? f. Most important concept in this is to never eliminate insulin doses when nausea and vomiting occur; patient should take the usual insulin dose (or previously prescribed special sick day doses); attempt to consume frequent small portions of carbohydrates (including foods usually avoided, such as juices, regular sodas, Spring Exam 1 Blueprint and gelatin) g. Drinking fluids every hour is important to prevent dehydration; blood glucose and urine ketones must be assessed every 3 to 4 hours. What does the diabetic patient need to know to survive? Chart 51-5 a. Pathophysiology of diabetes i. Definition, normal blood glucose ranges and targets ii. Effect of insulin and exercise (decrease glucose) iii. Effect of food and stress b. Treatment modalities: i. Administration of insulin and oral antidiabetes meds ii. Meal planning iii. Monitoring of blood glucose and urine ketones c. Recognition, tx, and prevention of acute complications i. Hypoglycemia ii. Hyperglycemia d. Pragmatic information: i. Where to buy and store insulin, syringes, glucose monitoring supplies 1. Whether insulin is the short- or the long-acting preparation, vials not in use, including spare vials or pens, should be refrigerated. 2. The insulin vial in use should be kept at room temperature to reduce local irritation at the injection site, which may occur if cold insulin is injected. ii. When and how to contact the PCP B. Type I and II Diabetes a. Type 1: (5-10% of all diabetes): onset any age, but usually young (<30 y); usually thin at diagnosis; recent weight loss; etiology includes genetic, immunologic, and virus; little or no endogenous insulin; need exogenous insulin to preserve life; ketosis prone when insulin absent i. Characterized by destruction of the pancreatic beta cells; the destruction of the beta cells results in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia; ii. If the concentration of glucose in the blood exceeds the renal threshold for glucose, usually 180 to 200 mg/dL (9.9 to 11.1 mmol/L), the kidneys may not reabsorb all of the filtered glucose; the glucose then appears in the urine (glycosuria). When excess glucose is excreted in the urine, it is accompanied by excessive loss of fluids and Spring Exam 1 Blueprint electrolytes. This is called osmotic diuresis. iii. DKA is commonly preceded by a day or more of polyuria, polydipsia, nausea, vomiting, and fatigue with eventual stupor and coma if not treated. The breath has a characteristic fruity odor due to the presence of ketoacids 1. Management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. 2. Initially, 0.9% sodium chloride (normal saline [NS]) solution is administered at a rapid rate, usually 0.5 to 1 L per hour for 2 to 3 hours. 3. The major electrolyte of concern during treatment of DKA is potassium. b. Type 2: (90-95% of all diabetes: obese-80% of type 2): onset any age; usually >30y; usually obese at diagnosis; causes include obesity, heredity, environmental factors; decrease in endogenous insulin, or increased with insulin resistance; most patients can control blood glucose through weight loss if obese; may need insulin on a short or long term basis to prevent hyperglycemia; ketosis uncommon except in stress or infection i. Insulin resistance refers to a decreased tissue sensitivity to insulin. Normally, insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. In type 2 diabetes, these intracellular reactions are diminished, making insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver ii. Insulin resistance may also lead to metabolic syndrome, which is a constellation of symptoms including hypertension, hypercholesterolemia, abdominal obesity, and other abnormities iii. However, uncontrolled type 2 diabetes may lead to another acute problem—hyperglycemic hyperosmolar syndrome (HHS) iv. If the patient experiences symptoms, they are frequently mild and may include fatigue, irritability, polyuria, polydipsia, poorly healing skin wounds, vaginal infections, or blurred vision v. Prevention: Appropriate lifestyle changes; BMI less than 24; physical activity of moderate intensity vi. Clinical manifestations: “three Ps”- polyuria (increased Spring Exam 1 Blueprint urination), polydipsia increased thirst), polyphagia (increased appetite); fatigue, sudden vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, recurrent infections C. Clinical Manifestations a. Retinopathy (small blood vessels that nourish the retina in the eye are damaged), Nephropathy (the kidney cells are damaged), and Neuropathy (nerve cells are damaged) b. Classic clinical manifestations of diabetes include the “three Ps”: polyuria, polydipsia, and polyphagia. Polyuria (increased urination) and polydipsia (increased thirst) occur as a result of the excess loss of fluid associated with osmotic diuresis. Patients also experience polyphagia (increased appetite) that results from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats c. Other symptoms include fatigue and weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, and recurrent infections. D. Nutrition a. The meal plan must consider the patient’s food preferences, lifestyle, usual eating times, and ethnic and cultural background. For patients who require insulin to help control blood glucose levels, maintaining as much consistency as possible in the amount of calories and carbohydrates ingested at each meal is essential. b. Calorie-controlled diets are planned by first calculating a person’s energy needs and caloric requirements based on age, gender, height, and weight. c. The caloric distribution currently recommended is higher in carbohydrates than in fat and protein. d. ADA recommend that for all levels of caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein e. Increased fiber in the diet may improve blood glucose levels, decrease the need for exogenous insulin, and lower total cholesterol and low-density lipoprotein levels in the blood f. Alcohol is absorbed before other nutrients and does not require insulin for absorption. Large amounts can be converted to fats, increasing the risk for DKA.Spring Exam 1 Blueprint E. Acute and chronic complications 1. Describe the pathophysiology, clinical manifestations, and collaborative care of persons with diabetes a. Insulin is a hormone secreted by beta cells, which are one of four types of cells in the islets of Langerhans in the pancreas i. Insulin is an anabolic, or storage, hormone; when a person eats a meal, insulin secretion increases and moves glucose from the blood into muscle, liver, and fat cells. In those cells, insulin has the following actions: 1. Transports and metabolizes glucose for energy 2. Stimulates storage of glucose in the liver and muscle (in the form of glycogen) 3. Signals the liver to stop the release of glucose 4. Enhances storage of dietary fat in adipose tissue 5. Accelerates transport of amino acids (derived from dietary protein) into cells 6. Insulin also inhibits the breakdown of stored glucose, protein, and fat b. Type 1: onset any age, but usually young (<30 y); usually thin at diagnosis; recent weight loss; etiology includes genetic, immunologic, and virus; little or no endogenous insulin; need exogenous insulin to preserve life; ketosis prone when insulin absent i. Acute manifestation of hyperglycemia: DKA 1. metabolic derangement that occurs most commonly in persons with type 1 diabetes and results from a deficiency of insulin; highly acidic ketone bodies are formed, and metabolic acidosis occursSpring Exam 1 Blueprint 2. DKA is commonly preceded by a day or more of polyuria, polydipsia, nausea, vomiting, and fatigue with eventual stupor and coma if not treated; the breath has a characteristic fruity odor due to the presence of ketoacids. a. Type 2: onset any age; usually >30y; usually obese at diagnosis; causes include obesity, heredity, environmental factors; decrease in endogenous insulin, or increased with insulin resistance; most patients can control blood glucose through weight loss if obese; may need insulin on a short or long term basis to prevent hyperglycemia; ketosis uncommon except in stress or infection ii. Acute manifestation: hyperglycemic hyperosmolar syndrome iii. Insulin resistance may also lead to metabolic syndrome, which is a constellation of symptoms including hypertension, hypercholesterolemia, abdominal obesity, and other abnormities iv. If the patient experiences symptoms, they are frequently mild and may include fatigue, irritability, polyuria, polydipsia, poorly healing skin wounds, vaginal infections, or blurred vision 2. Explain the relationship between diabetes and other disease processes a. Clinical characteristics: i. Accompanied by conditions known or suspected to cause the disease: pancreatic diseases, hormonal abnormalities, medications such as corticosteroids and estrogen containing preparations ii. Depending on the ability of the pancreas to produce insulin, the patient may require treatment with oral antidiabetic agents or insulin 3. Explain the psychological and sociological effects of diabetes in the individual and family. a. Participation in support groups is encouraged for patients who have had diabetes for many years as well as for those who are Spring Exam 1 Blueprint newly diagnosed. Such participation may help the patient and family cope with changes in lifestyle that occur with the onset of diabetes and its complications. b. Support groups provide an opportunity for discussion of strategies to deal with diabetes and its management and to clarify and verify information with nurses or other health care professionals. Participation in support groups may also promote healthy activities. 4. Compare and contrast the pharmacological management and nursing implications associated with persons with diabetes a. Rapid-acting insulins produce a more rapid effect that is of shorter duration than regular insulin; patient is instructed to eat nor more than 5 to 15 minuets after injection i. Lispro (Humalog): onset 10-15 min; peak 1hour; duration 2- 4 hr ii. Aspart (NovoLog): onset 5-15 min; peak 40-50 min; duration 2-4 hr iii. Glulisine (apidra): onset 5-15 min; peak 30-60 min; duration 2 hr b. Short-acting: also called regular insulin (marked R on the bottle); clear solution, administered 20 to 30 minutes before a meal, either alone or in combination with a longer-acting insulin; Regular insulin is the only insulin approved for IV use i. Regular (Humalor R, Novolin R, Ileting II Regular): onset 1.5-1h; peak 2-3 hr; duration 4-6 hour c. Intermediate-acting insulins: also called NPH insulin, white and cloudy, not crucial for it to be taken 30 minutes before the meal if taken alone i. NPH (Neutral protamine Hagedorn): onset 2-4 hr; peak 4-12 hr; duration 16-20 hr ii. Humulin N, Iletin II Lente, Ileting II NPH, Novolin N (NPH): onset 3-4hr; peak 4-12 hr; duration16-20 hr d. Peakless basal or very long acting insulins are approved by the FDA as a basal insuin- absorbed very slowly over 24 hours and given once a day; suspension with a pH of 4, cannot be mixed with other insulins; given at the same time every day; i. Glargine (Lantus): onset 1 hr, no peak; duration 24 hr ii. Detemir (Levemir): onset 1 hr, no peak, duration 24 hr e. One injection per day- Before breakfast: NPH or NPH with rapid acting f. Two injections per day-mixed- Before breakfast and dinner: NPH or NPH with rapid-acting or Premixed (rapid-acting insulin) i. Simplest regimen that attempts to mimic normal pancreas g. Three or four injections per day- Rapid acting insulin before each Spring Exam 1 Blueprint meal with: NPH at dinner or NPH at bedtime or Glargine 1 or 2 times/day h. Insulin Pump- Uses ONLY Rapid-acting insulin at continuous, low rate called basal rate (commonly 0.5-1.5 units/hr) and premeal bolus doses activated by pump wearer 5. Apply the concepts of nutrition to the care of persons with diabetes a. The meal plan must consider the patient’s food preferences, lifestyle, usual eating times, and ethnic and cultural background. For patients who require insulin to help control blood glucose levels, maintaining as much consistency as possible in the amount of calories and carbohydrates ingested at each meal is essential. b. Calorie-controlled diets are planned by first calculating a person’s energy needs and caloric requirements based on age, gender, height, and weight. c. The caloric distribution currently recommended is higher in carbohydrates than in fat and protein. d. ADA recommend that for all levels of caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein e. Increased fiber in the diet may improve blood glucose levels, decrease the need for exogenous insulin, and lower total cholesterol and low-density lipoprotein levels in the blood f. Soluble fiber—in foods such as legumes, oats, and some fruits— plays more of a role in lowering blood glucose and lipid levels than does insoluble fiber, although the clinical significance of this effect is probably small. At least 25 g of fiber should be ingested daily. i. One risk involved in suddenly increasing fiber intake is that it may require adjusting the dosage of insulin or oral agents to prevent hypoglycemia. g. Alcohol is absorbed before other nutrients and does not require insulin for absorption. Large amounts can be converted to fats, increasing the risk for DKA. i. Alcohol may decrease the normal physiologic reactions in the body that produce glucose (gluconeogenesis). ii. Therefore, if a patient with diabetes consumes alcohol on an empty stomach, there is an increased likelihood of hypoglycemia iii. To reduce the risk of hypoglycemia, the patient should be cautioned to consume food along with the alcohol; however, carbohydrate consumed with alcohol may raise blood glucose.Spring Exam 1 Blueprint h. Nutritive sweeteners include fructose (fruit sugar), sorbitol, and xylitol, all of which provide calories in amounts similar to those in sucrose (table sugar). i. Cause less elevation in blood sugar levels than sucrose does and are often used in sugar-free foods; sweeteners containing sorbitol may have a laxative effect. i. Nonnutritive sweeteners have minimal or no calories; used in food products and are also available for table use i. Produce minimal or no elevation in blood glucose levels and have been approved by the U.S. Food and Drug Administration (FDA) as safe for people with diabetes. ii. Nonnutritive sweeteners include saccharin, aspartame (NutraSweet), acesulfame-K (Sunett), and sucralose (Splenda). 6. Appraise the learning needs and develop teaching plans for the person with diabetes a. Exercise 3 times each week with no more than 2 consecutive days without exercise. b. Perform resistance training twice a week (for people with type 2 diabetes). c. Exercise at the same time of day (preferably when blood glucose levels are at their peak) and for the same duration each session. d. Use proper footwear and, if appropriate, other protective equipment (i.e., helmets for cycling). e. Avoid trauma to the lower extremities, especially in patients with numbness due to peripheral neuropathy. f. Inspect feet daily after exercise. g. Avoid exercise in extreme heat or cold. h. Avoid exercise during periods of poor metabolic control. 7. Identify the nursing responsibility in the short and long-term management (including discharge instructions) of the person with diabetes a. the nurse should remind the patient to participate in recommended health promotion activities (e.g., immunizations) and age appropriate health screenings (e.g., pelvic examinations, mammograms). b. Support groups provide an opportunity for discussion of strategies to deal with diabetes and its management and to clarify and verify information with nurses or other health care professionals.Spring Exam 1 Blueprint Vascular Arterial vs. venous disease – know the differences Treatment – what does the nurse need to monitor What does the nurse have to assess? a. Inspection of the skin: Adequate blood flow warms the extremities and gives them a rosy coloring. Inadequate blood flow results in cool and pale extremities. i. Rubor, a reddish-blue discoloration of the extremities, may be observed within 20 seconds to 2 minutes after the extremity is placed in the dependent position. Rubor suggests severe peripheral arterial damage in which vessels that cannot constrict remain dilated. Even with rubor, the extremity begins to turn pale with elevation. ii. Cyanosis, a bluish tint of the skin, is manifested when the amount of oxygenated hemoglobin contained in the blood is reduced. iii. Gangrenous changes appear after prolonged, severe ischemia and represent tissue necrosis. b. Palpation of pulses: Palpation of pulses is subjective, and the examiner may mistake his or her own pulse for that of the patient. To prevent this, the examiner should use light touch and avoid using only the index finger for palpation, because this finger has the strongest arterial pulsation of all the fingers. i. Absence of a pulse may indicate that the site of stenosis (narrowing or constriction) is proximal to that location. ii. Pulses should be palpated bilaterally and simultaneously, comparing both sides for symmetry in rate, rhythm, and quality. c. Doppler Ultrasound: To evaluate the lower extremities, the patient is placed in the supine position with the head of the bed elevated 20 to 30 degrees; the legs are externally rotated, if possible, to permit adequate access to the medial malleolus. Acoustic gel is applied to the patient’s skin to permit uniform transmission of the ultrasound wave. The tip of the Doppler transducer is positioned at a 45- to 60-degree angle over the expected location of the artery and angled slowly to identify arterial blood flow. Excessive pressure is avoided because severely diseased arteries can collapse with even minimal pressure. A. Peripheral arterial disordersSpring Exam 1 Blueprint ∙ Arterial occlusion ∙ Arterial insufficiency B. Peripheral venous disease a. Varicose veins: are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves i. Most commonly, this condition occurs in the lower extremities, the saphenous veins, or the lower trunk, but it can occur elsewhere in the body, such as the esophagus ii. Symptoms, if present, may include dull aches, muscle cramps, increased muscle fatigue in the lower legs, ankle edema, and a feeling of heaviness of the legs. Nocturnal cramps are common. iii. The patient should avoid activities that cause venous stasis, such as wearing socks that are too tight at the top or that leave marks on the skin, crossing the legs at the thighs, and sitting or standing for long periods. ∙ Thrombophlebitis C. Complications ∙ Pulmonary embolism ∙ Amputation 1. Compare & contrast signs & symptoms of arterial vs. venous disorders. a. 2. Discuss the role of common risk factors associated with the of atherosclerosis. 3. Discuss medical, surgical, and nursing management of venous & arterial disorders. 4. Develop a teaching plan for a patient with arterial/venous occlusive diseases. 5. Describe complications of peripheral vascular disorders and measures to prevent their occurrence. 6. Identify & describe nursing intervention priorities for patients with vascular problems including cellulitis.Spring Exam 1 Blueprint HTN Patient teaching needed Primary vs secondary Diet Therapy Plan of care A. Classifications B. Stages C. Etiology D. Risk Factors E. Effect on organs 1. Review the regulation of normal blood pressure. a. BP >140/90 b. Normal: SBP <120; DBP <80 c. Prehypertension: SBP 120-139; or DBP 80-89 d. Stage 1 Hypertension: SBP 140-159; or DBP 90-99 e. Stage 2 Hypertension: SBP >160; or DBP >100 2. Identify risk factors associated with primary hypertension. a. Usually no symptoms other than elevated BP (That’s why it’s called the Silent Killer) b. Symptoms seen related to organ damage: i. Retinal and other eye changes ii. Renal Damage iii. Myocardial infarction iv. Cardiac Hypertrophy- Left ventricular hypertrophy occurs in response to the increased workload placed on the ventricle as it contracts against higher systemic pressure; when heart damage is extensive, heart failure follows. v. Stroke c. Genetics plays a huge risk in HTN d. Modifiable factors: overweight/obesity, high sodiumSpring Exam 1 Blueprint 3. Explain the medical and nursing management of the person with hypertension. a. Weight reduction (BMI- 18.5-24.9) b. DASH diet, decreased NA c. Physical activity (30 minutes moderate activity, most days of the week) d. Moderate alcohol consumption e. Medications: i. Diuretics, beta-blockers, alpha-blockers, combined alpha and beta, vasodilators, ACE inhibitors, Ca channel blockers, dihydropyridines, direct renin inhibitors ii. For patients with uncomplicated HTN and no specific indications for another medication, what is the initial medication given? 1. Thiazide diuretic: if the BP does not fall less than 140/90, the dose is increased gradually and additional medications are included as necessary to achieve control iii. JNC 7 specifies a lower goal pressure of 130/80 mm Hg for people with diabetes or chronic kidney disease, which is defined as either a reduced glomerular filtration rate (GFR) (flow rate of filtered fluid through the kidney, an indicator of renal function) resulting in a serum creatinine of greater than 1.3 mg/dL in women or greater than 1.5 mg/dL in men, or albuminuria of greater than 300 mg/day f. History and physical examination, risk factors g. Lab tests: kidney function (UA), EKG, cholesterol levels h. Assess for potential symptoms: i. Angina, shortness of breath, altered speech, vision changes, nosebleeds, headaches, dizziness, balance problems, nocturia ii. Cardiovascular assessment: apical and peripheral pulses i. Planning and Goals i. Understanding dz process and tx ii. Participation in self-care program iii. Absence of complications j. Interventions: i. Patient education ii. Support adherence to the tx regimen iii. Consultation and collaboration iv. Follow-up care v. Emphasize control rather than cure vi. Reinforce and support lifestyle changes vii. Lifelong process k. Evaluation:Spring Exam 1 Blueprint i. Reports knowledge of disease management sufficient to maintain adequate tissue perfusion 1. Maintains BP less than 140/90 with no symptoms of complications; stable BUN and serum creatinine, palpable peripheral pulses ii. Adherence to the self-care program 1. Reduce calorie, Na, and fat intake, exercise, takes meds as prescribed, measures BP, abstains from tobacco and excessive alcohol intake iii. Reports no additional complications 4. Identify the impact of uncontrolled hypertension on other body systems. - Collaborative problems and potential complications: a. Left ventricular hypertrophy b. Myocardial infarction c. Heart failure d. TIA e. CVA f. Renal insufficiency g. Retinal hemorrhage - The remaining small percentage, probably about 5% to 10%, have secondary hypertension, which occurs when a cause for the high blood pressure can be identified. These causes include: a. renal parenchymal disease, narrowing of the renal arteries, hyperaldosteronism (mineralocorticoid hypertension), pheochromocytoma, certain medications (e.g., prednisone, epoetin alfa [Epogen]), and coarctation of the aorta - JNC 7 introduced the category of prehypertension to emphasize that people whose blood pressure begins to rise above 120/80 mm Hg are more likely to become hypertensive, and that even small increases in pressure are associated with an adverse risk factor profile as well as increased risk of stroke, heart attack, heart failure, and cardiovascular death o The prevalence of uncontrolled hypertension varies by ethnicity, with Hispanics and African Americans having the highest prevalence at approximately 63% and 57%, respectively 5. Identify which evaluation(s) would indicate a therapeutic response to the medical and nursing interventions. a. Evaluation: i. Reports knowledge of disease management sufficient to Spring Exam 1 Blueprint maintain adequate tissue perfusion 1. Maintains BP less than 140/90 with no symptoms of complications; stable BUN and serum creatinine, palpable peripheral pulses ii. Adherence to the self-care program 1. Reduce calorie, Na, and fat intake, exercise, takes meds as prescribed, measures BP, abstains from tobacco and excessive alcohol intake iii. Reports no additional complications 6. Identify and discuss what is/are the priority teaching(s) to patients with hypertension i. Patient education ii. Support adherence to the tx regimen iii. Consultation and collaboration iv. Follow-up care v. Emphasize control rather than cure vi. Reinforce and support lifestyle changes vii. Lifelong process 7. Describe hypertensive crisis and their treatment. a. Hypertensive emergency: BP 180/120; must be lowered immediately to prevent damage to target organs i. Reduce BP 25% in the first hour ii. Reduce to 160/100 over 6 hours iii. Gradual reduction to normal over a period of days iv. Exceptions are ischemic stroke and aortic dissection v. Medications: IV vasodilators: sodium nitroprusside, nicardipine, fenoldopam mesylate, enalaprilat, nitroglycerin vi. Need very frequent monitoring of BP and CV status b. Hypertensive urgency: BP is very high but no evidence of immediate or progressive target organ damage i. Patient requires close monitoring of BP and CV status ii. Assess for potential evidence of target organ damage iii. Medications: Fast-acting oral agents: beta-adrenergic blocker-labetalol; angiotensin-converting enzyme inhibitor captopril; alpha 2 agonist- clonidine HF- Chap 29 Plan of care Symptoms Teaching Symptoms of complications: h. Pulmonary edema: acute event in which the LV cannot handle an overload of blood volume; pressure increases in the pulmonary Spring Exam 1 Blueprint vasculature, causing fluid movement out of the pulmonary capillaries and into the interstitial space of the lungs and alveoli i. Results in hypoxemia j. Clinical manifestations: Restlessness, anxiety, dyspnea, cool and clammy skin, cyanosis, weak and rapid pulse, cough, lung congestion (moist, noisy respirations), increased sputum production (frothy and blood tinged), decreased LOC k. Management: Prevention i. Early recognition of lung sounds, signs of decreased activity tolerance, and increased fluid retention ii. Place patient upright and dangle legs iii. Minimize exertion and stress iv. Oxygen v. Medications 1. Diuretics (Furosemide), Vasodilators (Nitroglycerin) A. Pathophysiology Review: HF identified by assessment of LV function by echocardiogram a. Systolic HF: characterized be a weakened heart muscle b. Diastolic HF: characterized by a stiff and noncompliant heart muscle, making it difficult for the ventricle to fill c. Normal EF: EF is calculated by subtracting the amount of blood present in the left ventricle at the end of systole from the amount present at the end of diastole and calculating the percentage of blood that is ejected i. 55% to 65% of the ventricular volume ii. EF is normal in diastolic HF but severely reduced in systolic HF d. Significant myocardial dysfunction usually occurs before the patient experiences signs and symptoms of HF such as shortness of breath, edema, or fatigue e. As HF develops, the body activates the neurohormonal compensatory mechanisms B. Interprofessional Management of the client with Heart Failure C. The Nursing Care Plan for the client with Heart FailureSpring Exam 1 Blueprint a. Activity intolerance R/t decreased CO b. Excess fluid volume r/t HF syndrome (Edema) c. Anxiety-related symptoms r/t complexity of the therapeutic regimen; shortness of breath, “elephant feet” d. Powerlessness r/t to chronic illness and hospitalizations e. Ineffective family therapeutic regimen management 1. Discuss the compensatory mechanisms involved in HF a. Systolic HF results in decreased blood ejected from the ventricle. The decreased blood flow is sensed by baroreceptors in the aortic and carotid bodies. The sympathetic nervous system is then stimulated to release epinephrine and norepinephrine; i. The purpose of this initial response is to increase heart rate and contractility and support the failing myocardium, but the continued response has multiple negative effects; ii. Sympathetic stimulation causes vasoconstriction in the skin, gastrointestinal tract, and kidneys; decrease in renal perfusion due to low CO and vasoconstriction causes the release of renin by the kidneys; 1. Renin converts the plasma protein angiotensinogen to angiotensin I, which then circulates to the lungs. Angiotensin-converting enzyme (ACE) in the lumen of pulmonary blood vessels converts angiotensin I to angiotensin II, a potent vasoconstrictor, which increases the blood pressure and afterload. b. Angiotensin II also stimulates the release of aldosterone from the adrenal cortex, resulting in sodium and fluid retention by the renal tubules and an increase in blood volume; i. These mechanisms lead to the fluid volume overload commonly seen in HF. c. Angiotensin, aldosterone, and other neurohormones (e.g., endothelin) lead to an increase in preload and afterload, which increases stress on the ventricular wall, causing an increase in cardiac workload. d. A counter-regulatory mechanism is attempted through the release of natriuretic peptides;Spring Exam 1 Blueprint i. Atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP; brain type) are released from the overdistended cardiac chambers; 1. these substances promote vasodilation and diuresis. However, their effect is usually not strong enough to overcome the negative effects of the other mechanisms. e. As the heart’s workload increases, contractility of the myocardial muscle fibers decrease-> decreased contractility results in an increase in end-diastolic blood volume in the ventricle, stretching the myocardial muscle -> increasing thickness of heart muscle (ventricular hypertrophy) i. Results in abnormal changes in structure and function of myocardial cells -> enlarged myocardial cells become dysfunctional and die early (apoptosis) ii. Cells die and heart muscles become fibrotic, (diastolic HF can develop); iii. Stiff ventricle resists filling and less blood in the ventricles causes a further decrease in CO iv. Known as “vicious cycle of HF”- low CO leads to multiple mechanisms that make the heart work harder, worsening HF 2. Describe the nursing & collaborative management of persons with HF a. Bed rest for acute exacerbations b. Encourage regular physical activity 30-45 min c. Exercise training d. Pacing of activities e. Wait 2 hours after eating for physical activity f. Avoid activities in extreme hot, cold, humid weather g. Modify activities to conserve energy h. Positioning; elevating HOB to facilitate breathing and rest, support the arms (tripod) 3. Highlight the priority of care for the person with HF a. BNP- most critical lab, clinical marker for HF b. Decreased CO- look for signs: diaphoresis, cool pale skin, weak Spring Exam 1 Blueprint peripheral pulses, restlessness c. Record daily weights, I&O, d. High fowler’s position if experiencing shortness of breath e. Fluid restrictions f. Signs of Hypokalemia & hyponatremia due to diuretics i. Hypokalema: signs include ventricular dysrhythmias, hypotension, muscle weakness, and generalized weakness 1. In patients receiving digoxin, hypokalemia can lead to digitalis toxicity, which increases the likelihood of dangerous dysrhythmias. ii. Hyponatremia (prolonged diuretic therapy): result in disorientation, weakness, muscle cramps, anorexia, and abdominal discomfort. iii. Hyperkalemia (due to use of ACE inhibitors, ARBs, Spironolactone): lead to profound bradycardia and other dysrhythmias. g. Breath sounds, heart sounds h. Encourage patient to do simple exercises at bedside; self-care i. Teaching about medications and diet 4. Describe the medical and nursing management of patients with pulmonary edema. a. Assessment for symptoms of fluid overload b. Daily weight c. I&O d. Diuretic therapy; timing of meds e. Fluid intake; fluid restriction f. Maintenance of sodium restriction 5. Describe the medical and nursing management of patients with thromboembolism, pericardial effusion, and cardiac arrest. a. Thromboembolism: decreased mobility and decreased circulation increase the risk for thromboembolism in patient with cardiac disorders, including those with HF b. Pulmonary embolism: blood clot from the legs moves to obstruct the pulmonary vessels i. Most common thromboembolic problem with HF ii. Prevention (SCDs, foot/leg exercises) iii. TX iv. Anticoagulant therapy c. BNP- most critical lab, clinical marker for HF d. Interventions: i. Promoting activity tolerance 1. Reduced physical activity caused by HF symptoms leads to physical deconditioning that worsens the patient’s symptoms and exercise tolerance ii. Managing fluid volume: patients with severe HF may Spring Exam 1 Blueprint receive IV diuretic therapy; 1. Oral diuretics should be administered early in the morning so that diuresis does not interfere with the patient’s nighttime rest 2. Patient’s fluid status is monitored closely by auscultating the lungs, monitoring daily body weight and assisting the patient to adhere to a low-sodium diet a. Weight gain in a patient with HF almost always represents fluid retention 3. Patient is positioned or taught how to assume a position that facilitates breathing; number of pillows may be increased, HOB elevated a. Lower arms are supported with pillows to eliminate the fatigue caused by the pull of the patient’s weight on the shoulder muscles iii. Controlling anxiety: patients with HF have difficulty maintaining adequate oxygenation, likely to develop dyspnea -> restlessness and anxiety Notes: - Right-Sided (Venous Congestion) o Viscera and Peripheral congestion o JVD o Dependent edema o Hepatomegaly o Ascites o Weight gain - Left-Sided (Lungs) o Pulmonary congestion, crackles o S3 or ventricular gallop o Dyspnea on exertion o Orthopnea o Dry, nonproductive cough initially; may turn into pink, frothy sputum- signs of pulmonary edema o Oliguria - Hypoxia: first signs- restlessness, agitation, tachycardia - Which classification of medications play a pivotal role in the management of HF caused by systolic dysfunction? o Ace inhibitors Lisinopril, Enalapril: decrease BP and afterload; relieves S&S of HF; prevents progression of HF Considerations: observe for symptomatic hypotension, increased serum K+, cough, worsening renal function - Beta-blockers: have been found to reduce mortality and morbidity in patients with class II or III HF by reducing the adverse effects from the constant stimulation of the SNSSpring Exam 1 Blueprint o Metoprolol: dilates blood vessels and decrease afterload o Carvedilol: decrease S&S of HF, improves exercise capacity o Considerations: observe for decrease HR, symptomatic hypotension, dizziness, fatigue - Diuretics are prescribed to reduce excess extracellular fluid by increasing the rate of urine produced in patients with signs and symptoms of fluid overload o Loop diuretic: furosemide Decrease fluid volume overload and S&S of HF Considerations: observe for electrolyte abnormalities, renal dysfunction, diuretic resistance, decreased BP; carefully monitor I&O and daily weight o Thiazide: Metolazone, HCTZ; improves HF symptoms in advanced HF Considerations: Observe for hyperkalemia, hyponatremia o Aldosterone antagonist: Spironolactone Improves HF symptoms in advanced HF Considerations: observe for hyperkalemia and hyponatremia - Digitalis increases the force of myocardial contraction and slows conduction through the AV node- Digoxin o Improves cardiac contractility; decreases S&S of HF o Considerations: observe for bradycardia and digitalis toxicity Toxicity: anorexia, nausea, vomiting, visual disturbances, confusion, bradycardia - Angiotensin Receptor Blockers: o Valsartan, Losartan Decrease BP and afterload; relieves S&S of HF; prevents progression of HF Considerations: observe for symptomatic hypotension, increased serum K+, and worsening renal function o Hydralazine, Isosorbide: dilates blood vessels, decreasing BP and afterload Considerations: observe for symptomatic hypotension - IV inotropes: Milrinone, Dobutamine o Increase the force of myocardial contraction; indicated for patients with acute decompensated HF o Used for patients who do not respond to routine pharma therapy; reserved for patients with severe ventricular dysfunction o Dobutamine: major action is to increase cardiac contractility and renal perfusion to enhance urine output; also increases the HR and can precipitate ectopic beats and tachydysrhythmias - IV Vasodilators: Nitroprusside, Nitroglycerin, Nesiritide o Used in patients with severe decompensated HF o Patient is admitted to ICU and monitored continuously with Spring Exam 1 Blueprint hemodynamic monitoring Obesity- Chap 47 Plan for patient Nothing specific about bariatric surgery: performed only after nonsurgical attempts at weight control have failed; majority of the patient’s weight loss is 25% to 35% of previous body weight within the first 18-24 months; comorbid conditions such as diabetes, HTN, sleep apnea may resolve; dyslipidemia improves A. Classification: a. Overweight: 25-30 kg/m2; health risk mild b. Class I: 30-35 kg/m2; health risk moderate c. Class II: 35-40 kg/m2; health risk severe d. Class III: >40 kg/m2; health risk very severe B. Associated health risks: a. Asthma, cancer, CVA, Cholecystitis, Choleslithiasis, Chronic back pain, CAD, Diabetes type 2, Heart Failure, Hypercholesterolemia, HTN, Nonalcoholic fatty liver dz, Obstructive sleep apnea, Osteoarthritis, Pulmonary embolism C. Treatment modalities: Lifestyle modifications, pharmacotherapy, bariatric surgery 1. Discuss the epidemiology and etiology of obesity a. Obesity is BMI above 30 b. 66% of all adults are overweight or obese c. Obesity-related mortality rates are 30% greater for every gain of 5kg/m2 of body mass beyond a BMI of 25Spring Exam 1 Blueprint d. Increased risk for dz, disorders, low self-esteem, impaired body image, depression, and diminished quality of life e. Women >35 inches and Men >40 increase risk for dz 2. Explain the health risks/describe metabolic syndrome a. Metabolic syndrome: i. Insulin resistance (fasting glucose more than 100mg/dL or abnormal glucose intolerance test) ii. Central obesity (waist circumference more than 35 inches in females, 40 inches in males) iii. Dyslipidemia: triglycerides more than 150 mg/dL, HDL less than 50 mg/dL in females, less than 40 mg/dL in males iv. Blood pressure persistently greater than 130/85 v. Proinflammatory state (high levels of C-reactive protein [CRP]): known to be an inflammatory marker for CV risk, including acute coronary events and stroke vi. Prothrombotic state (high fibrinogen level) 3. Discuss/describe nursing interventions. a. The nurse counsels the patient anticipating bariatric surgery to ingest nothing but clear liquids for a specified period of time preoperatively (typically about 48 hours). b. The patient’s diet will be quite limited postoperatively; because of this, patients scheduled for bariatric surgery are given guidelines on which foods and liquids they may consume postoperatively prior to surgery so that they may stock up on these items at home before they are admitted to the hospital. i. include sugar-free drinks, gelatins and puddings, flavored electrolyte drinks, fat-free milk, protein drinks, sugar-free applesauce, and low-fat soups. c. The nurse ensures that preoperative screening tests are obtained and scrutinizes the resultsSpring Exam 1 Blueprint i. Typical laboratory tests include: CBC, electrolytes, blood urea nitrogen (BUN), and creatinine. ii. Patients who are obese may have sleep apnea, GERD, heart disease, nonalcoholic fatty liver disease, diabetes (or prediabetes), and vitamin and mineral deficiencies; thus, other screening tests that may be obtained include a sleep study, upper endoscopy, electrocardiogram, lipid panel, liver function tests, glucose, and hemoglobin A1c, as well as iron, vitamin B12, thiamine, folate, vitamin D, and calcium levels. d. Postoperatively, the nurse assesses the patient to ensure that goals for recovery are met and that the patient exhibits absence of complications secondary to the surgical intervention.
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