NUR 313: Adult Health - Study Guide
NUR 313: Adult Health - Study Guide NUR 313
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This 35 page Study Guide was uploaded by Courtney Erika on Tuesday October 21, 2014. The Study Guide belongs to NUR 313 at Arizona State University taught by Flogel in Fall. Since its upload, it has received 81 views. For similar materials see Adult Health in Health Sciences at Arizona State University.
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Date Created: 10/21/14
Diabetes Mellitus Diabetes Mellitus A chronic multisystem disease related to abnormal insulin production impaired insulin utilization or both Affects 258 million people Seventh leading cause of death Diabetes Mellitus Leading cause of 0 Adult blindness C End stage kidney disease 0 Nontraumatic lower limb amputations Maj or contributing factor 0 Heart disease 0 Stroke 0 Hypertension Etiology and Pathophysiology Two most common types 0 Type 1 C Type 2 C Other types 0 Gestational C Prediabetes 0 Secondary diabetes 0 Pancreatitis hormone disturbances corticosteroids Etiology and Pathophysiology Insulin C Promotes glucose transport from bloodstream across cell membrane to cytoplasm of cell 0 Decreases glucose in the bloodstream C Enhances fat deposition 0 1 protein synthesis Type 1 Diabetes Mellitus Progressive destruction of pancreatic b cells by body s own T cells C Autoantibodies cause a reduction of 80 to 90 in normal b cell function before manifestations occur Requires exogenous insulin to sustain life 5 of diabetes population Type 2 Diabetes Mellitus Most prevalent type of diabetes 95 of patients with diabetes Prevalence increases with age 80 to 90 of patients are overweight Genetic basis 0 Highest in Native Americans and Alaskan Natives also African Americans Hispanic Americans Type 2 Diabetes Mellitus Pancreas continues to produce some endogenous insulin Insulin produced is insufficient or is poorly utilized by tissues C 3 cells fatigued from compensating C Insulin receptors are either unresponsive or insufficient in number 0 Secondary Diabetes Treatment of a medical condition that causes abnormal blood glucose level 0 Corticosteroids Prednisone C Thiazides C Phenytoin Dilantin C Atypical antipsychotics clozapine Usually resolves when underlying condition treated Clinical Manifestations Type 1 Diabetes Mellitus Classic symptoms usually acute C Polyuria C Polydipsia C Polyphagia Weight loss Weakness Fatigue Clinical Manifestations Type 2 Diabetes Mellitus Nonspecific symptoms 0 May have classic symptoms of type 1 Fatigue Recurrent infection Prolonged wound healing Visual changes Diabetes Mellitus Diagnostic Studies Methods of diagnosis 0 AIC 2 65 0 Recommended to be used as a diagnostic test 0 Useful in determining glycemic levels over time 0 re ects glucose levels over past 2 to 3 months 0 Shows the amount of glucose attached to hemoglobin molecules over RBC life span 0 Fasting plasma glucose level gt126 mgdL 0 Random or casual plasma glucose measurement 2200 mgdL plus symptoms Symptom Comparison Collaborative Care Goals of diabetes management 0 Decrease symptoms 0 Promote well being C Prevent acute complications 0 Delay onset and progression of longterm complications Need to maintain blood glucose levels as near to normal as possible Collaborative Care Patient teaching 0 Nutritional therapy 0 Drug therapy 0 Exercise 0 Selfmonitoring of blood glucose Diet exercise and weight loss may be sufficient for patients with type 2 diabetes All patients with type 1 require insulin Medication Therapy Insulin Exogenous insulin 0 Insulin from an outside source 0 Required for type 1 diabetes 0 Prescribed for patient with type 2 diabetes who cannot control blood glucose by other means 0 Insulin Human insulin 0 Genetically engineered in laboratories Categorized according to onset peak action and duration 0 Rapid acting C Shortacting C Intermediateacting C Longacting Commercially Available Insulin Medication Therapy Insulin Insulin pump 0 Continuous subcutaneous infusion C Batteryoperated device 0 Connected via plastic tubing to a catheter inserted into subcutaneous tissue in abdominal wall 0 Potential for tight glucose control Insulin Pump Drug Therapy Oral Agents Work to improve mechanisms by which insulin and glucose are produced and used by the body 0 Insulin resistance 0 Decreased insulin production 0 Increased hepatic glucose production Medication administration morningevening Biguanides C Metformin Glucophage 0 Reduce glucose production by liver Enhance insulin sensitivity Improve glucose transport May cause weight loss Used in prevention of type 2 diabetes Withhold if contrast medium is used Sulfonylureas O 1 Insulin production from pancreas C Major side effect hypoglycemia 0 Examples 0 Glipizide Glucotrol C Glyburide Micronase DiaBeta Glynase Glimepiride Amaryl C Thiazolidinediones 0 Most effective in those with insulin resistance 0 Improve insulin sensitivity transport and utilization at target tissues 0 Examples 0 Pioglitazone Actos C Rosiglitazone Avandia C Rarely used because of adverse effects Nutritional Therapy 0 Cornerstone of care for person with diabetes but the most challenging 0 American Diabetes Association ADA 0 Exercise Guidelines indicate that within context of an overall healthy eating plan person with diabetes can eat same foods as person who does not have diabetes Type I Meal plan is based on individual s usual food intake and is balanced with insulin and exercise patterns More exibility with rapidacting insulin multiple daily injections and insulin Pump Type II Emphasis on achieving glucose lipid and blood pressure goals Weight loss 0 Essential part of diabetes management 1 insulin receptor sites Lowers blood glucose levels Contributes to weight loss Best done after meals Minimum 150 minutesweek aerobic 0 Resistance training three timesweek Exercise 0 Several small carbohydrate snacks can be taken every 30 minutes during exercise to prevent hypoglycemia 0 Exercise plans should be started After medical clearance Slowly with gradual progression Should be individualized Monitor blood glucose levels before during and after exercise 0 Monitoring Blood Glucose C Self monitoring of blood glucose SMBG Enables patient to make self management decisions regarding diet exercise and medication Important for detecting episodic hyperglycemia and hypoglycemia Patient training is crucial Nursing Management Nursing Assessment 0 Past health history 0 Subjective Data Objective Data Nursing Management Nursing Diagnoses Ineffective self health management Risk for injury Risk for infection Powerlessness Imbalanced nutrition More than body requirements Nursing Management Planning Overall goals 0 Active patient participation 0 Few or no episodes of acute hyperglycemic emergencies or hypoglycemia 0 Maintain normal blood glucose levels 0 Minimize long term complications Nursing Management Nursing Implementation Health promotion 0 Identify those at risk 0 Provide routine screening for overweight adults over age 45 0 Promotion of healthy lifestyle Chronic Complications Chronic Complications Angiopathy C Macrovascular C Diseases of large and medium sized blood vessels 0 Occur with greater frequency and with an earlier onset in diabetics C Development promoted by altered lipid metabolism common to diabetes 0 Puts patient at risk for Chronic Complications Angiopathy C Microvascular 0 Result from thickening of vessel membranes in capillaries and arterioles C In response to chronic hyperglycemia C Is specific to diabetes unlike macrovascular Chronic Complications C Microvascular 0 Areas most noticeably affected 0 Eyes retinopathy C Kidneys nephropathy 0 Skin dermopathy C Nerves neuropathy 0 Clinical manifestations usually appear after 10 to 20 years of diabetes Chronic Complications Diabetic retinopathy C Microvascular damage to retina 0 Result of chronic hyperglycemia 0 Most common cause of new cases of blindness in people 20 to 74 years 0 Must have annual dilated eye examinations for type 1 diabetes 0 Chronic Complications 0 Diabetic nephropathy 0 Associated with damage to small blood vessels that supply the glomeruli of the kidney 0 Leading cause of endstage renal disease 0 60 to 70 of patients with diabetes have some degree of neuropathy 0 Critical factors for preventiondelay 0 Tight glucose control 0 Blood pressure management 0 Yearly screening 0 Laboratory testing for renal status 0 Chronic Complications 0 Diabetic neuropathy C Sensory neuropathy C Affects hands andor feet bilaterally 0 Characteristics include 0 Loss of sensation abnormal sensations pain and paresthesias 0 Chronic Complications 0 Diabetic neuropathy cont d C Autonomic 0 Can affect nearly all body systems 0 Complications C Gastroparesis C Delayed gastric emptying 0 Cardiovascular abnormalities 0 Sexual function 0 Neurogenic bladder 0 Chronic Complications C Complications of foot and lower extremity 0 Foot complications 0 Most common cause of hospitalization in diabetes 0 Result from combination of microvascular and macrovascular diseases 0 Necrotic Toe Before and After Amputation 0 Chronic Complications 0 Infection 0 Diabetic individuals more susceptible to infection 0 Defect in mobilization of in ammatory cells C Impairment of phagocytosis by neutrophils and monocytes 0 Nursing Management Evaluation 0 Knowledge 0 Balance of nutrition 0 Immune status 0 Health benefits 0 No injuries 0 Nursing Management Acute Complications Nursing Implementation 0 Acute intervention Diabetic ketoacidosis Hyperosmolar hyperglycemic nonketotic syndrome Hypoglycemia Acute Complications 0 Diabetic ketoacidosis DKA C Caused by profound deficiency of insulin 0 Characterized by Hyperglycemia Ketosis Acidosis Dehydration 0 Most often occurs in type 1 0 Acute Complications C DKA cont d C Precipitating factors 0 DKA cont d C When supply of insulin insufficient Illness Infection Inadequate insulin dosage Undiagnosed type 1 Poor selfmanagement Neglect Acute Complications Glucose cannot be properly used for energy Body breaks down fat stores 0 Ketones are by products of fat metabolism 0 Alter pH balance causing metabolic acidosis C Ketone bodies excreted in urine 0 Electrolytes become depleted 0 Acute Complications C DKA cont d 0 Signs and symptoms Lethargyweakness 0 Early symptoms Dehydration 0 Poor skin turgor 0 Dry mucous membranes 0 Tachycardia C Orthostatic hypotension 0 Acute Complications C DKA cont d 0 Signs and symptoms cont d C Abdominal pain 0 Anorexia vomiting 0 Kussmaul respirations 0 Rapid deep breathing C Attempt to reverse metabolic acidosis 0 Sweet fruity odor 0 Acute Complications C DKA cont d 0 Correct uidelectrolyte imbalance C IV infusion 045 or 09 NaCl 0 Restore urine output 0 Raise blood pressure 0 When blood glucose levels approach 250 mgdL C 5 dextrose added to regimen C Prevent hypoglycemia 0 Potassium replacement 0 Sodium bicarbonate 0 Acute Complications C Hyperosmolar hyperglycemic syndrome HHS C Life threatening syndrome Less common than DKA Often occurs in patients older than 60 years with type 2 Patient has enough circulating insulin that ketoacidosis does not occur Produces fewer symptoms in earlier stages Neurologic manifestations occur because of 1 serum osmolality 0 Acute Complications C HHS cont d 0 Usually history of C Inadequate uid intake 0 Increasing mental depression 0 Polyuria 0 Laboratory values 0 Blood glucose gt400 mgdL 0 Increase in serum osmolality 0 Acute Complications 0 Nursing management DKAHHS 0 Patient closely monitored 0 Administration 0 IV uids C Insulin therapy 0 Electrolytes 0 Assessment 0 Renal status 0 Cardiopulmonary status 0 Level of consciousness 0 Acute Complications C Hypoglycemia 0 Low blood glucose 0 Occurs when 0 Too much insulin in proportion to glucose in the blood 0 Blood glucose level less than 70 mgdL 0 Acute Complications C Hypoglycemia cont d 0 Common manifestations C Confusion Irritability Diaphoresis Tremors Hunger Weakness C Visual disturbances C Untreated can progress to loss of consciousness seizures coma and death 0 Acute Complications C Hypoglycemia cont d C At the first sign 0 Check blood glucose 0 If lt70 mgdL begin treatment 0 If gt70 mgdL investigate further for cause of signssymptoms C If monitoring equipment not available treatment should be initiated 0 Acute Complications C Hypoglycemia cont d 0 Treatment 0 If alert enough to swallow C 15 to 20 g of a simple carbohydrate C 4 to 6 oz fruit juice 0 Regular soft drink 0 Recheck blood sugar 15 minutes after treatment 0 Repeat until blood sugar gt70 mgdL 0 Patient should eat regularly scheduled mealsnack to prevent rebound hypoglycemia 0 Check blood sugar again 45 minutes after treatment 0 Acute Complications C Hypoglycemia cont d 0 Treatment Patient not alert enough to swallow C Administer 1 mg of glucagon IM or subcutaneously C In acute care settings C 20 to 50 mL of 50 dextrose IV push C Gerontologic Considerations Prevalence increases with age Presence of delayed psychomotor function could interfere with treating hypoglycemia Elderly blood sugar levels may not be as tightly controlled Gerontologic Considerations Must consider patient s own desire for treatment and coexisting medical problems Recognize limitations in physical activity manual dexterity and visual acuity 0 Education based on individual s needs using slower pace The nurse plans a class for patients who have newly diagnosed type 2 diabetes mellitus Which action goal is most appropriate a Make all patients responsible for the management of their disease b Ensure the patient understands and adheres to their medication regimen C Enable the patients to become active participants in the management of their disease d Provide the patients with as much information as soon as possible to prevent complications The nurse is caring for a patient with type 1 diabetes mellitus who is admitted for diabetic ketoacidosis The nurse would expect which laboratory test result a Hypokalemia b Fluid overload C Hypoglycemia d Hyperphosphatemia Cerebrovascular Accident 0 Stroke Brain Attack Leading cause of serious long term disability 3 leading cause of death in the US Stroke occurs when ischemia or hemorrhage into the brain results in death of brain cells Approximately 35 of individuals who have an initial stroke die within 1 year Pathophysiology The brain s blood supply 0 Internal carotid arteries 0 Vertebral arteries 0 If Blood Flow Totally Interrupted C Metabolism altered in 30 seconds Metabolism stopped in 2 minutes Cell death in 5 minutes 0 Severity of function loss depends on location and extent of brain involved 0 Risk Factors 0 Nonmodifiable 0 Age 0 Gender 0 EthnicityRace C Family HistoryHeredity C Modifiable 0 Hypertension Heart Disease Diabetes High Cholesterol Smoking 0 Alcohol 0 Physical Inactivity 0 Transient Ischemic Attack Transient 0 short duration 0 not permanent Usually symptoms last less than one hour Most resolve Warning Sign O Precursor to CVA 0 Get Medical help Types Types of Stroke Thrombotic Stroke 60 of strokes HTN and DM leading causes Symptoms MAY be slow and progressive Prognosis depends on amount of brain tissue deprived of blood supply 0 Collateral circulation Embolic Stroke 24 of strokes Embolus lodges in and occludes arteryinfarction Source 0 Heart majority 0 Air and fat from bone fractures Rapid onset of severe symptoms Prognosis depends on amount of brain tissue deprived of blood supply 0 Collateral circulation Hemorrhagic Stroke 10 of strokes poor prognosis Vessel rupturebleeding inside brain HTN is most important cause 0 Also vascular malformations coagulation disorders anticoagulant drugs trauma tumors aneurysms Sudden onset with progression over minutes to hours 0 Extent dependent on amount and duration of bleeding 0 Headache NV decreased LOC Health Promotion Clinical Manifestations Motor Function 0 Contralateral Mobility Respiratory Function SwallowingSpeech Gag Re ex C Self Care C Hypore eXiaHyperre eXia C Akinesia Communication 0 Aphasia C Dysphasia C Dysarthria Affect C Emotions C Frustration 0 Depression Intellectual function 0 Memory 0 Judgment Spatial Perceptual Alterations Elimination Clinical Manifestations Motor Function Most notable along with speech An initial period of accidity 0 May last from days to several weeks 0 Related to nerve damage Spasticity of the muscles follows the accid stage C Related to interruptions in upper motor neuron in uence Contralteral Communication AphasiaDysphasia C Impaired ability to communicate C Non uent minimal speechslow speechobvious effort 0 Fluent speech present but not meaningful 0 Don t confuse with Dysphagia Dysarthria C Muscular control mechanics 0 Pronunciation articulation phonation Might have a combination 0 Spatial Perceptual Homonymous hemianopsia DiagnosisDiagnostic Tests Non contrast CT 0 Ischemic vs Hemorrhagic C Size and location 0 Serial effectiveness of tx and evaluate recovery CT Angiography or MRA blood vessels MRI Extent of injury Cardiac studies if embolic Blood Tests Lumbar Puncture Acute Care Ischemic Stroke Stroke Team Time of onset ABCs BP Drugs if SBP gt220 mmHg Monitor 0 Increased ICP from cerebral edema C Elevate HOB neck midline diuretics C Hyperthermia Seizures Pain tPA Reestablish Blood flow Time limited CT scan first Place any invasive lines before administering NSG VS Neuro status BP Control 0 Safety 0 MERCI Retriever Acute Care Hemorrhagic Stroke HTN Management 0 GOAL SBP lt160 Seizure Prophylaxis Surgery 0 Aneurysm ICP Monitoring Nursing Assessment supporting CVA diagnosis Glasgow Coma Scale 15pts 0 Measures response in 3 areas 0 Best Motor 0 Response Best Eye Opening 0 Best Verbal Response 0 FAST O FACE ARMS SPEECHTIME NIH Stroke Scale 0 TRAINED Observer C 15 items 0 LOC C Language C Neglect C Visual Field Loss Extraocular Movement Motor Strength Ataxia Dysarthria C Sensory Loss 0 Lower Score is Better 0 Nursing Diagnoses Decreased Intracranial Adaptive Capacity Ineffective Airway Clearance Impaired Physical Mobility Impaired Verbal Communication Unilateral Neglect Impaired Swallowing PlanningGoals Nursing Implementation Respiratory and Cardiovascular Respiratory C Airway C Aspiration Pneumonia C Impaired Consciousness C Dysphagia Oxygen Suction Positioning Cardiovascular 0 Watch for orthostatic hypotension Nursing Implementation Integumentary Skin breakdown due to loss of sensation decreased circulation and immobility Frequent Position Changes Skin Hygiene Emollients Early Mobility Nursing Implementation Nutrition Caution with first oral feeding Check gag re ex Speech Therapyswallowing study High Fowler s Easy to swallow foods Avoid thin liquids Place food on unaffected side of mouth Inability to feed oneself can be frustrating Assistive Devices PEG Nursing Implementation Communication Ability to speak and understand Gestures Picture Board Decrease environmental stimuli One idea at a time Simple yes or no questions Give the person time to think and speak Normal volume and tone Schedule Don t push if tired or upset Don t pretend to understand 0 Organize schedule for day Nursing Implementation SensoryPerceptual Arrange environment within patient s perceptual field Protect from injury due to neglect syndrome Difficulty judging position distance and rate of movement Break down tasks into simple steps Environmental control clutter obstacles lighting Nonslip socks C Assistive devices Nursing Implementation Coping Affects whole family Support communication Lifestyle Changes Listen and plan Clear instructions and explanations Affect C Emotional responses inappropriate for situation 0 Distract patient 0 Explain that they may occur 0 Calm environment 0 Don t shame or scold Stroke Rehabilitation Goal to reduce disability Maintaining mobility gains Prevent deformity Secondary stroke prevention Prevention of stroke recurrence Prevention of complications related to stroke Re integration into the community 0 Question A patient with a stroke has dysphagia Before allowing the patient to eat which of the following actions should the nurse take first 1 Request a soft diet with no liquids 2 Check the patient s gag re ex 3 Place the patient in highFowler s position 4 Test the patient s ability to swallow with a small amount of water Perioperative Nursing Care 0 Perioperative Experience 3 Phases Perioperative Experience Surgery Art and science of treating diseases injuries and deformities by operation and instrumentation 0 Interaction Patient Surgeon Anesthesia Care Provider ACP Nurse Purposes of Surgery 0 Diagnosis Cure 0 Palliation 0 Prevention 0 Exploration 0 Cosmetic Improvement 0 Preoperative Nursing Care 0 Past Health History 0 Previous medical problems surgeries hospitalizations 0 Reason for surgery 0 Family history cardiac or endocrine diseases reaction to anesthesia malignant hyperthermia Medications 0 Prescription Be alert tranquilizers antihypertensives insulin blood thinners Over the counter 0 Herbal supplements 0 Recreational drug use 0 Alcohol 0 Compliance and Last Dose 0 Bring meds with to surgery center 0 Allergies 0 Drug Intolerance Uncomfortable or unpleasant Drug Allergy Hives Anaphylaxis Latex 0 Document 0 Allergy band 0 Psychosocial Assessment 0 Anxiety Unknown Lack of knowledge Religionculture 0 Fear Death Pain Altered body image Anesthesia Life functioning Review of Systems CV Respiratory Neurologic Genitourinary Hepatic Integumentary Musculoskeletal Endocrine Immune FluidElectrolytes Nutritional Status Physical Exam HP on the chart LabsDiagnostic Testing Preoperative Teaching Balance Telling so little Unprepared Explaining so much Overwhelmed Nursing teaching What to do before surgery what to expect after surgery Reinforce surgeonanesthetist teaching Legal Preparation All forms are correct signed on chart Patientcaregiver clearly understand Informed consent Active shared decision making process between HCP and patient 0 Adequate Disclosure Clear Understanding and Comprehension Voluntary Physician obtains RN witness signature 0 Patient advocate Minor unconscious mentally incompetent Medical Emergency 0 Day of Surgery Utilize a Checklist Hospital gown with no underclothes Nail polishartificial nails Identificationallergy band Valuables with caregiver Jewelry prosthesis Hearing aidsglasses Dentures Empty Bladder NPO Status Standard is NPO after MN Prevent regurgitationaspiration Evidence Based Practice suggests Individualize Evaluate risk 0 Patients not at risk for aspiration can have clear uids up to 2 hours before surgery Less preoperative discomfort No increase in vomiting Intraoperative Nursing Care 0 Layout 0 Surgical Suite Minimize spread of organisms Smooth ow 0 Holding Area Operating Room Unrestricted Area Holding arealocker roomsnurses station Street clothes allowed Semirestricted Area Surgical attire required Cover head and facial hair 0 Restricted Area Same as semirestricted plus masks Universal Protocol National Patient Safety Goal 0 Prevents wrong site wrong procedure and wrong surgery Surgical Timeout Identify the patient Compare hospital ID number with patient s wristband Positioning 0 Types of Anesthesia General 0 Neuromuscular blocking agents Spinal Epidural Regional 0 Local Monitored Anesthesia Care 0 Postoperative Nursing Care Care in the PACU 0 Initial assessment Airway patency Oxygenation 0 Pulse oximetry EKG monitoring Neurologic assessment 0 Level of consciousness Orientation Sensory and motor status Assess surgical site and condition of dressing Discharge from PACU 0 Protocol Certain assessment finding must be present prior to discharge to clinical unit 0 Provide verbal report to receiving nurse 0 Receiving unit nurse obtains vital signs and completes assessment and compares with PACU report Post Op Complications Respiratory Nursing Management of Respiratory Problems 0 Respiratory Assessment and Monitoring 0 Patient Positioning Unconscious Lateral recovery position Conscious SupineHOB elevated reposition Q 12 hours 0 Oxygen Deep breathing Coughing Analgesics to help with ventilation and ambulation Complications Cardiovascular Nursing Management of Cardiovascular Problems Cardiovascular Assessment Causes of hyperhypotension Fluid volume blood loss medications Frequent vital signs Look at trends compare to preop SBP lt90 or gt160 HR lt60 or gt 120 Change in cardiac rhythm Nursing Management of Cardiovascular Problems Accurate I amp O Labs 0 Early ambulation Stimulates circulation Maintains respiratory function Increases muscle tone Improves GI and urinary tract function Complications Emergence Delirium Waking Up Wild Restless Agitated Disoriented Thrashing Shouting Suspect hypoxia 0 Other causes Anesthesia Bladder distention Pain ETT 0 Alcohol Withdrawal Neuro Assessment Maintain normal physiological function FE Balance Nutrition Sleep Pain mgmt Bowel and Bladder function Mobility Keep Orientated Nausea and Vomiting 0 Assess Related to anesthesia or surgery Quantitycolorcharacteristics Abdomen 0 Treatment Medications Prevent aspiration if vomiting NPOAdvance diet slowly IVF when NPO Ambulation Low Urine Output and Urine Retention Low Urine Output Surgery Stress Increased aldosterone and ADH Fluid restriction Fluid loss and drainage during surgery Urine Retention Anesthesia depresses nervous system including micturition re ex Medications anticholinergic and opioids Interventions Normal positioning Privacy Drink waterrunnning water Bladder scancatheterize Surgical Incisions Assessment Wound and any drains Small amount of serous drainage is common If drain in place larger amount expected Sanguinous serosanguinous serous Amount should decrease over time Complications Wound infection purulent drainage Wound dehiscence Interventions Note amount color consistency and odor Open to air once drainage ceases Initial operative dressing surgeon removes Drains Numbertypelocation Pain and Discomfort Assessment Self report Restlessness VS changes Diaphoresis Nursing Diagnoses Acute Pain Anxiety Management Analgesics Slow and titrate 0 Time around activity NSAIDS PCA Therapy Positioning Management of Postoperative Pain 0 Result of Trauma from surgery Re ex muscle spasms Anxietyfear Positioning Internal devices Deep breathing coughing ambulating Pain Mechanism 0 Nociceptive Pain Damage to somatic or visceral tissue 0 Surgical incision broken bone or arthritis Usually responsive to opioids and nonopioid medications Neuropathic Pain Damage to peripheral nerve or CNS 0 Numbing hot burning shooting stabbing or electrical in nature 0 Sudden intense shortlived or lingering Nursing Assessment 0 Self report is best indicator 0 If not possible look for other indications of pain 0 Identify location 0 Baseline assessment of painpain response essential Acute pain complaints vs chronic pain Nursing Implementation 0 IV opiods Epidural catheters PCA or regional anesthetic blockade NSAIDS Non pharmacologic measures 0 Appropriate pain medication administration according to patient complaintassessment 0 Nurses often undermedicate for pain Patient teaching about availability of pain medication 0 Remember principles of pain as they relate to wound healing 0 Potential Complication Venous Thromboembolism Venous Thrombosis Clinical Manifestations Unilateral leg edema pain possible erythema Complications 0 Life threatening Thromboembolism to heart lungs brain Obstruction of blood ow from extremity Diagnostic Studies 0 Ultrasound angiography laboratory Venous Thrombosis Collaborative Care 0 Nonpharmacologic prevention and prophylaxis Activity nutrition circulation aids 0 Drug therapy Anticoagulation therapy for VTE prophylaxis Anticoagulation therapy for VTE treatment gtgt Heparin Warfarin 0 Nursing Management Venous Thromboembolism Assessment Nursing Implementation Acute intervention Ambulatory and home care Evaluation 0 PostOperative Education When does it start In Preop 0 Care of incision and dressings Medications actions and side effects Activity Diet Symptoms to report Follow up Emergency Contact number Parkinson s Disease and Seizures 0 Disease of basal ganglia 0 Degeneration of the dopamine producing neurons 0 Disruption of dopamine and acetylcholine balance 0 Dopamine is a neurotransmitter essential for posture support and voluntary motion Etiology and Pathophysiology Mix of environment and genetics Diagnosis increases with age with peak onset in the seventh decade More common in men ratio of 32 Clinical Manifestations Onset is gradual and insidious Classic triad of PD 0 Tremor often first sign 0 Rigidity increased resistance to passive motion 0 Bradykinesia loss of automatic movements slow movement 0 Appearance of Patient With PD 0 Complications 0 As disease progresses complications increase 0 Motor symptoms 0 Weakness 0 Akinesia 0 Neurologic problems 0 Neuropsychiatric problems 0 Dementia occurs in 40 of patients Diagnostic Tests 0 No specific tests 0 Diagnosis based solely on history and clinical features 0 At least two of three characteristics of the classic triad are present 0 Nursing Management Nursing Assessment 0 Health history 0 Related to in ammation toxicity injury 0 Objective data 0 Blank faces infrequent blinking 0 Seborrhea 0 Dandruff 0 Ankle edema 0 Postural hypotension Nursing Management Nursing Assessment 0 Objective data cont d 0 Tremor at rest 0 Poor coordination 0 Subtle dementia 0 Nursing Management Nursing Diagnoses C Impaired physical mobility C Imbalanced nutrition less than body requirements 0 Impaired verbal communication Nursing Management Planning 0 Maximize neurologic function 0 Maintain independence in activities of daily living ADLs for as long as possible 0 Optimize psychosocial well being 0 Nursing Management Nursing Implementation 0 Promote physical exercise and a well balanced diet 0 Limit the consequences from decreased mobility 0 Specific exercises to strengthen muscles involved with speaking and swallowing 0 Teach maintenance of good health independence and avoidance of complications Nursing Management Nursing Implementation 0 Problems secondary to bradykinesia can be alleviated by 0 Consciously thinking about stepping over a line on the floor 0 Lifting toes when stepping 0 Purposeful movement Nursing Management Nursing Implementation 0 Get out of a chair by using arms and placing the back legs on small blocks Remove rugs and excess furniture Simplify clothing from buttons and hooks Use elevated toilet seats Assist patients as they make adjustments to their lifestyle to accommodate symptoms Drug Therapy Correct neurotransmitter imbalance 0 Enhance release or supply of dopamine or 0 Antagonize or block acetacholine C LevodopaCarbidopa Sinemet 0 Levodopa is a dopamine precursor C Dopamine Receptor Agonists 0 May be used first and add Sinemet as symptoms progress 0 Stimulate dopamine receptors 0 Evaluation 0 Quality of life Slow progression of disease Seizures C Seizure Electrical discharge on neurons in the brain 0 Interrupts normal function 0 Paroxysmal 0 Uncontrolled 0 Often symptom of underlying illness 0 Epilepsy Condition in which a person has spontaneously recurring seizures caused by underlying chronic condition 0 In United States 3 million people with epilepsy 0 Higher incidence in those gt60 years of age Clinical Manifestations C Determined by site of electrical disturbance Divided into two major classes generalized and partial Algorithm for Classification of Seizures Clinical Manifestations May progress through several phases 0 Prodromal phase 0 Aural phase 0 Ictal phase 0 Postictal phase Clinical Manifestations Generalized Seizures C Affecting large areaboth sides of brain 0 No warning or aura as entire brain is affected 0 Loss of consciousness from seconds to n1inutes 0 Clinical Manifestations Generalized Seizures C Tonicclonic seizures 0 Characterized by loss of consciousness and falling 0 Body stiffens tonic with subsequent jerking of extremities clonic 0 Cyanosis excessive salivation possible tonguelip biting 0 No memory of seizure 0 Post ictal general soreness weak extremely fatigued Clinical Manifestations Generalized Seizures 0 Typical absence seizures 0 Occurs only in children and rarely into adolescence 0 May cease or develop into another type 0 Typical symptom is staring spell for only a few seconds and usually goes unnoticed 0 Brief loss of consciousness 0 May occur up to 100 timesday if untreated Clinical Manifestations Partial Seizures 0 Partial seizures are referred to as partial focal seizures Caused by focal irritations Begin in specific region of cortex May spread and involve entire brain accumulating in tonicclonic Clinical Manifestations Partial Seizures Divided into simple and complex partial seizures 0 Simple simple motor or sensory phenomena with elementary symptoms with no loss of consciousness and lasting less than 1 minute 0 Complex involve behavioral emotional affective and cognitive function I Alteration in consciousness I Automatisms and lip smacking I Followed by period of postictal confusion 0 Complications 0 Status epilepticus is state of constant seizure or condition when seizures recur in rapid succession without return to consciousness between seizures 0 Neurologic emergency 0 Can involve any type of seizure 0 Status epilepticus causes the brain to use more energy than is supplied 0 Neurons become exhausted and cease to function 0 Permanent brain damage can result 0 Complications C Tonic clonic status epilepticus most dangerous as it can cause ventilatory insufficiency hypoxemia cardiac arrhythmias hyperthermia and systemic acidosis 0 Trauma during seizures can cause severe injury and death 0 Complications 0 Social stigma 0 Interferes with values of self control conformity and independence 0 Discrimination in employment and education 0 Driving sanctions 0 Diagnostic Studies 0 Accurate comprehensive description of seizures with patient s health history 0 EEG 0 Only small percentage of patients with seizure disorders have abnormal findings with first test 0 Continuous monitoring may be needed 0 Collaborative Care 0 Drug therapy aimed at prevention 0 Stabilize nerve cell membranes and prevent spread of epileptic discharge 0 70 of patients controlled with medication 0 Serum levels of medication should be monitored 0 Antiseizure drugs should not be discontinued abruptly as this can precipitate seizures 0 Collaborative Care 0 Primary drugs for treatment of generalized tonic clonic and partial seizures 0 Older I phenytoin Dilantin I carbamazepine Tegretol I phenobarbital I divalproex Depakote 0 Collaborative Care 0 Primary drugs for generalized tonic clonic and partial seizures 0 Newer I gabapentin Neurontin lamotrigine Lamictal topiramate Topamax tiagabine Gabitril levetiracetam Keppra lllll zonisamide Zonegran 0 Nursing Assessment History C Risks Birth defects or injuries at birth Anoxic episodes CNS trauma Tumors Metabolic disorders Alcoholism Exposure to metals or carbon monoxide Hepatic or renal failure 0 Compliance with antiseizure medications C Headaches aura mood or behavioral changes before seizure 0 Anxiety depression loss of selfesteem social isolation Nursing Assessment Acute seizure episode Physical C Abnormal respiratory rate Apnea during the seizure Absent or abnormal breath sounds Airway occlusion Bitten tongue soft tissue damage cyanosis Safety Nursing Assessment Physical Hypertension tachybradycardia Bowelurinary incontinence excessive salivation Weakness paralysis after a seizure Abnormal CT MRI EEG Nursing Diagnoses Ineffective breathing pattern Risk for injury Ineffective coping Ineffective self health management Planning Overall goals are that patient will 0 Be free from injury during seizure 0 Have optimal mental and physical functioning while taking antiseizure medications 0 Have satisfactory psychosocial functioning Nursing Implementation Prevention 0 Wear helmet if risk for head injury General health habits diet exercise Assist to identify events or situations precipitating seizures and avoid if possible Instruct to avoid excessive alcohol fatigue and loss of sleep Nursing Implementation Acute Intervention Observation and treatment of seizure 0 Maintain patent airway support head turn to side loosen constrictive clothing ease to floor 0 May require suctioning or oxygen after seizure 0 TIME Prepare for emergency measures 0 Assessment of level of understanding Nursing Implementation Ambulatory and Home Care 0 Medication adherence Teach family members emergency management Emotional support and identification of coping mechanisms Medical alert bracelets Referrals to agencies and organizations Evaluation Appropriate HRrhythm depth of respirations No injury Verbalization of knowledge of potential injury Arrangement of environment to minimize injury Urinary Elimination Renal Calculi BPH C Dipstick urinalysisfUA O UA CampS O O Nitrates WBCs leukocyte esterase Urine for culture and sensitivity Bacteria WBC RBC IVP for higher urinary issues calculi BPH PSA for BPH Urinary Tract Infection UTI Second most common bacterial disease Most common bacterial infection in women Escherichia coli most common pathogen Classification Complicated versus uncomplicated O O Etiology Uncomplicated l Occurs in otherwise normal urinary tract I Usually involves only the bladder Complicated I Those with coexisting presence of O Obstruction Stones Catheters Existing diabetesneurologic disease Pregnancy induced changes Recurrent infection and Pathophysiology Alteration in defense mechanisms increases risk of contracting UTI Predisposing factors O O Etiology Factors increasing urinary stasis I Examples BPH tumor neurogenic bladder Foreign bodies I Examples Catheters calculi instrumentation and Pathophysiology Predisposing factors cont d O O O O O Anatomic factors I Examples Obesity congenital defects fistula Compromising immune response factors I Examples Age HIV diabetes Functional disorders I Example Constipation Other factors I Examples Pregnancy multiple sex partners women Etiology and Pathophysiology C Hospital acquired UTI accounts for 31 of all nosocomial infections O Causes I Often E coli I Seldom Pseudomonas O Catheteracquired UTIs I Bacterial biofilms develop on inner surface of catheter C UTI Symptoms Urinary frequency Urgency Incontinence Nocturia Nocturnal enuresis Weak stream Hematuria Hesitancy Intermittency Postvoid dribbling Urinary retention Dysuria OOOOOOOOOOOOO Pain on urination 0 Not UTI symptoms 0 Flank pain chills and fever indicate infection of upper tract 0 Pyelonephritis C UTI Symptoms in Elderly 0 Older adults 0 Symptoms are often absent 0 Experience nonlocalized abdominal discomfort rather than dysuria 0 May have cognitive impairment 0 Are less likely to have a fever 0 Collaborative Care 0 Antibiotics 0 Selected on empiric therapy or results of sensitivity testing 0 Uncomplicated I Short term course 1 to 3 days 0 Complicated UTIs I Require longterm treatment 7 to 14 days Nursing Assessment 0 Health history Nursing Diagnoses Impaired urinary elimination Ineffective selfhealth management Pain Patient Outcomes 0 Patient will have 0 Relief from lower urinary tract symptoms 0 Prevention of upper urinary tract involvement 0 Prevention of recurrence 0 Adoption of adequate hygiene measures Nursing Interventions 0 Health promotion 0 Recognize individuals at risk Emptying bladder regularly and completely Evacuating bowel regularly Wiping perineal area front to back OOOO Drinking adequate uids I 20 uid comes from food Regular voiding every 3 to 4 hours Void after intercourse OOO Acute Care Nursing Interventions Health promotion 0 Wash hands 0 Wear gloves for care of urinary system 0 Routine and thorough perineal care for all hospitalized patients 0 Avoid incontinent episodes Acute Care Nursing Interventions Foley catheter care Nursing Interventions Ambulatory and home care 0 Emphasize compliance with drug regimen I Take as ordered 0 Evaluations Pain free Passage of urine without urgency Urine free of blood Adequate intake of uids The nurse identifies the patient with the greatest risk for a urinary tract infection as a 1 37yearold man with four sexual partners 2 26yearold pregnant woman who has a history of urinary tract infection 3 69yearold man who has urinary retention caused by benign prostatic hyperplasia 4 72yearold woman hospitalized with a stroke who has a urinary catheter because of urinary incontinence Benign Prostate Hyperplasia Enlargement of prostate gland resulting from increase in number of epithelial cells and stromal tissue Most common urologic problem in males Benign Prostate Hyperplasia Occurs in 50 of men over 50 and 90 of men over 80 Approximately 25 will require treatment by age 80 Does not predispose to development of prostate cancer Etiology and Pathophysiology Not completely understood Thought to result from endocrine changes from aging process Enlargement gradually compresses urethra 0 Partial or complete obstruction Compression of urethra leads to clinical symptoms BPH Symptoms Symptoms due to urinary retention 0 Decrease in caliber of force of urinary stream 0 Difficulty in initiating urination O Intermittency O Dribbling at end of voiding BPH Symptoms Symptoms associated with in ammation or infection 0 Urinary frequency and urgency O Dysuria O Bladder pain 0 Nocturia O Incontinence Nursing Assessment Medications O Estrogen or testosterone supplementation Surgery or previous treatment for BPH Knowledge of condition Nocturia Nursing Assessment Urinary urgency weak stream Hesitancy in initiating voiding Postvoid dribbling Incontinence Dysuria Sensation of incomplete voiding Anxiety of sexual dysfunction Nursing Diagnoses Nursing Management Acute Kidnev Iniurv and Chronic Kidney Disease Acute pain Risk for infection Alteration in elimination Planning Goals of patient having invasive procedures 0 Restoration of urinary damage Nursing Interventions Focus early detection and treatment Yearly physical exam for men over 50 Instruct patient with obstructive symptoms to urinate every 2 to 3 hours and when first feeling urge Teach patient need for adequate uid intake Acute need for catheterization Pre and Post operative care if surgical procedure Collaborative CareTreatment Transurethral resection TURP 0 Removal of obstructing prostate tissue using resectoscope inserted through urethra O Bladder irrigated for first 24 hours to prevent mucous and blood clots O Complications include bleeding clot retention dilutional hyponatremia retrograde ejaculation Laser procedures Evaluation No complaints of pain No evidence of UTI or other infection Absence of or satisfactory control of dribbling Acute Kidney Injury Renal Failure Etiology and Pathophysiology I Prerenal I Intrarenal I Postrenal Acute Kidney Injury Clinical Manifestations I Oliguric phase 0 Urinary changes 0 Fluid volume 0 Metabolic acidosis Sodium balance Potassium excess 0 Hematologic disorders 0 Waste product accumulation Neurologic disorders I Diuretic phase 0 Immature uid processing 0 Daily urine output is 1 to 3 L 0 May reach 5 L or more 0 Concern is uidelectrolyte balance I Recovery phase long term return to baseline May take up to 12 months for kidney function to stabilize Nursing Management Acute Kidney Injury Nursing Assessment I Cause of AKI signs and symptoms associated health history Nursing Diagnoses I What is the evidence from your assessment supporting for a dx Nursing Implementation I Health promotion I Acute intervention support elimination of cause and symptom management Acute Kidney Injury Collaborative Care I Fluid therapy 0 Restrictions related to acute nature of kidney injury and ability to function 0 Fluid restriction Acute Kidney Injury Collaborative care I Nutritional therapy 0 Maintain adequate caloric intake 0 Restrict sodium protein 0 Increase dietary fat 0 Enteral nutrition Acute Kidney Injury Collaborative care I Renal replacement therapy RRT Peritoneal dialysis PD 0 Intermittent hemodialysis HD 0 Continuous renal replacement therapy CRRT Chronic Kidney Disease Result of years of kidney injury I Slow progression I Irreversible Chronic Kidney Disease Stages of Chronic Kidney Disease Clinical Manifestations Urinary System Polyuria I Results from inability of kidneys to concentrate urine I Occurs most often at night I Specific gravity fixed around 1010 Clinical Manifestations Urinary System Oliguria I Occurs as CKD worsens Anuria I Urine output lower than 40 mL per 24 hours Clinical Manifestations I Metabolic disturbances Waste product accumulation Urea Nitrogen creatinine hormones 0 Altered carbohydrate metabolism Elevated triglycerides 0 Altered lipid metabolism Clinical Manifestations I Electrolyte and acidbase imbalances 0 Potassium Sodium 0 Calcium and phosphate 0 Magnesium Metabolic acidosis Clinical Manifestations Cardiovascular system Hypertension Heart failure Left ventricular hypertrophy Peripheral edema Dysrhythmias Uremic pericarditis Clinical Manifestations Neurologic System Expected as renal failure progresses I Attributed to 0 1 Nitrogenous waste products Electrolyte imbalances 0 Metabolic acidosis Atrophy Demyelination of nerve fibers Clinical Manifestations I Hematologic system 0 Anemia Bleeding tendencies 0 Infection I Cardiovascular Respiratory Gastrointestinal Musculoskeletal Integumentary Endocrine Psychological Diagnostic Studies UA 24 hr urine serum creatinine BUN GFR CBC HH Metabolic Panel Renal ultrasonography Renal scan CT scan Renal biopsy Chronic Kidney Disease Nursing Management Chronic Kidney Disease Nursing Assessment I Complete history of any existing renal disease family history I Longterm health problems I Dietary habits I Nursing Management Chronic Kidney Disease Nursing Diagnoses I Excess uid volume I Risk for injury I Imbalanced nutrition Less than body requirements I Grieving I Risk for infection Nursing Management Chronic Kidney Disease PlanningGoals I Demonstrate knowledge and ability to comply with therapeutic regimen I Participate in decision making I Demonstrate effective coping strategies I Continue with activities of daily living within physicalpsychologic limitations Chronic Kidney Disease Collaborative Care Conservative Therapy I Drug therapy 0 Hyperkalemia 0 Hypertension CKD mineral and bone disease The nurse teaches a patient with chronic kidney disease about prevention of complications What should the nurse 0 Anemia 0 Dyslipidemia Chronic Kidney Disease Collaborative Care cont Nutritional therapy 0 Protein restriction Water restriction Sodium and potassium restriction Phosphate restriction Nursing Management Nursing Implementation Health promotion Reduce risk factors Acute intervention 0 Daily weight 0 Daily BPs 0 Identify signs and symptoms of uid overload hyperkalemia Strict dietary adherence Fluidelectrolyte balance manage symptoms of waste buildup nutrition Ambulatory and home care include in the teaching plan Monitor for proteinuria daily with a urine dipstick 8 Perform selfcatheterization every 4 hours to measure urine Adjust sodium intake related to amount of daily urine output Check weight daily and report a gain of greater than 4 pounds Dialysis Hospital and home Hemodialysis administered by certified RN Dialysis Peritoneal Dialysis Peritoneal Dialysis Peritoneal Dialysis Complications of Peritoneal Dialysis Exit site infection Peritonitis Hernias Lower back problems Bleeding Pulmonary complications Protein loss Hemodialysis Vascular Access Sites Arteriovenous fistulas and grafts Hemodialysis Temporary venous catheter Nursing Care for Hemodialysis Baseline Labs Nutrition VS During Procedure I VS assessment Post Procedure I VS assessment Medication administration Hemodialysis Complications of Hemodialysis I Hypotension I Muscle cramps I Hepatitis Effectiveness of Hemodialysis I Easing of uid and nutrition restriction I Extend life
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