Final Pn2 Flashcards
Number one cause of spine injuries in adults
Falls
Autodysreflexia prevention key?
Prevention
- Bowel obstruction
- Types-
Complications:
How it occurs?
S/s?
- Nonsurgical Management
- Nasogastric tubes
- IV Fluid replacement/NPO
- Increased activity
- Pain management
- Bowel assessment & VS
- Surgical Management
- Exploratory laparotomy
Mechanical
• Nonmechanical
Fluid & electrolyte disturbances • Altered absorption • Perforation • Bacterial peritonitis • Bowel strangulation
Intussusception-mechanical- telescoping-tunneling in
• Volvulus-mechanical- 180 degree twisting
Assessment: Noticing
• Physical Assessment
• BM, N/V, pain, hiccups
• Abdominal distension
• Peristaltic waves
• Bobborygmi- a rumbling or gurgling noise made by the movement of fluid and gas in the intestines.
•
• Diagnostic Assessment
• abd xray, US, CT or MRI
Hyperactive bowel sounds are often found before a blockage.
It is quite common to find one quadrant with hyperactive bowel sounds and one with none or hypoactive ones.
This is because the intestine is attempting to clear the blockage with increased peristalsis.
You may also hear high-pitched sounds and rushing noises
Ulcers Duodenal most common • -gastritis often causes d/t • H. pylori • Long-term NSAID use • Local irritation from radiation therapy • Accidental or intentional ingestion of corrosive materials • Lifestyle choices
o Signs/symptoms
• Epigastric alterations in comfort
• Nausea, vomiting, upper abdominal or epigastric pain
Hemmorrage-most serious:
• Coffee-ground emesis or hematemesis (upper GI bleed)
• Black, tarry stools/melena (usually duodenal or gastric)
• Frank blood in stool (lower GI bleed or fast transit)
Perforation-serious:
• Ulcer becomes full thickness
• Sudden sharp, diffuse abd. pain, rigid board-like abd, guarding, fetal position
Physical Assessment
• Epigatric tenderness, dyspepsia
• Rigid, boardlike abdomen w/rebound tenderness & pain = perforation into peritoneal cavity
• Gastric versus duodenal ulcer pain
• Assess for fluid volume deficit/dehydration
• Orthostatics
Diagnostic assess
• Testing for H. pylori
• Chest, abdomen x-ray series (if perforation is suspected)
• EGD
• Gold standard
• Immediate diagnosis & intervention
o Management
• Managing pain
o Drug therapy
o Nutrition therapy
▪ Avoid irritating foods
▪ Sit up 30-1hr after eating
• Managing Upper GI bleeding
o Nonsurgical management
o Surgical management
- Balanced diet
- Regular exercise
- Stress-reduction techniques
- Limit foods and spices that cause gastric distress.
- Avoid tobacco, alcohol
- Avoid excessive use of aspirin, NSAIDs.
G
GERD • Occurs as a result of backward flow of stomach contents into esophagus • UES & LES-normally contracted • LES relaxes & allows reflux • Gastric contents irritate mucosa
Barrett’s epithelium
• -pre-malignant tissue that is mor resistant to acid (result of chronic acid exposure)
Esophageal stricture
• -narrowing of esophagus due to fibrosis & scarring
• -can lead to impaired swallowing
Risk Factors
• -large meals, obesity, smoking, caffeine, peppermints, chocolate
o Management **
Patients may be initially asymptomatic.
Healthy eating habits
Limitation of fried, fatty, spicy foods, and caffeine
Sit upright for one hour after eating; don’t eat before bed
• Manifestations • Dyspepsia “indigestion” • Coughing, hoarseness, wheezing at night • Dysphagia • Epigastric pain • Pyrosis “heartburn” • Odynophagia (painful swallowing) • Nausea Globus (feeling of something in back of throat)
- History of heartburn, chest pain, asthma, hoarseness, pneumonia, dyspepsia
- Can mimic cardiac pain with radiation to neck, jaw, back, nausea
- GERD will be relieved with antacids, water, sitting upright
- Risk for Aspirate gastric acid while lying down- keep head elevated in low fowlers
- Diagnostic assessment
- Barium swallow
- EGD
- Visualizes esophagus
- Lifestyle/dietary changes
- Endoscopic therapies
- Drug therapy
- -antacids (calcium carbonate, TUMS-short term!)
- -Histamine receptor antagonists (Pepcid, Zantac)
- -Proton pump inhibitors (Protonix, Nexium, Prilosec)
H
Ulcerative colitis
• Inflammation & edema of rectum & rectosigmoid colon that can extend the entire colon when extensive
• When severe, bleeding, erosions & ulcers occur
• Ulcered areas can lead to abcesses & necrosis
• Continued edema leads to narrowed colon & possible partial bowel obstruction
• Periodic remission & exacerbations; cause unknown
• Stool typically contains blood & mucus
• Patients have an unpleasant & urgent sensation to defecate
• Older adults at high risk of fluid & electrolytes imbalances due to diarrhea
• Associated with increased risk of colon cancer
• Hx
o Bowel pattern/habits, timing of symptoms with meals
o Dietary habits-spicy, fried or hot foods
o Stress/emotional distress & activity
o Recent travel
o Recent antibiotic use or NSAIDS
• S/S
o Malaise, anorexia, anemia, dehydration, fever, & weight loss are common
• Labs
o May have low hemoglobin
o Increased WBC or inflammatory markers (CRP, ESR)
• GI bleeding-considered an emergency
• Monitoring UC stools is important because:
o Periodic bleeding is not uncommon
o Even slow bleeding can lead to anemia
o Active GI bleeding can quickly lead to hypovolemia & shock
o Prudent to have 2 large-bore working IV’s at all times
• Control diarrhea-establish regular stooling pattern
o Drugs: Aminosalicylates (sulfasalazine, mesalamine)
o Glucocorticoids (during exacerbations), antidiarrheals, immunomodulators (Humira, Remicaid)
• Skin care
• Nutrition therapy (sometimes TPN if severe)
• Rest/stress reduction
• surgery to remove portion of colon, rectum and/or anus; sometimes results in ostomy
mental?
• Anxiety due to urge to defecate & diarrhea
• Depression due to social anxiety & change in eating patterns/habits
• Social service consult
• Assistance with arranging home care services
• Affording medications and/or ostomy supplies
• Management of ostomy
• HHC?
J
Gastric ulcers-complications of
Gastric-deep & penetrating
-Usually caused by H. Pylori
I
• GI bleed-signs/symptoms; treatment
s/s- black tarry stools, blood in vomit-coffee ground-like
hypovolemic shock- increased pulse, decreased BP
may be caused by esophageal bleeding, GERD, NSAIDS, alcohol, cigs, cirrhosis. Cancer, gastritis, peptic ulcer, H pylori
peptic ulcer disease is most common cause
tx- oxygen, iv fluids (isotonic-lactated ringers/NS) transfusion, VS, labs
J
Infuenza-Acute viral respiratory infection
Complications are pneumonia & death, Older adults & immunocompromised are at greatest risk, Contagious 24 hrs before symptoms & 5 days after they start
• RAPID ONSET
• *Headache, muscle aches
• *Fever, chills
• *Fatigue
• *Prolonged weakness
• *Sore throat, cough, watery nasal discharge
Tx- supportive- • Rest • Push fluids • Antihistamines • Saline gargles & throat spray Antiviral-Tamiflu, Relenza, Rapivab • Only given if 24-48 hrs after symptom onset • Shorten duration & severity of influenza
Nursing care- Diagnosis based on symptoms or nasal swab
Flu vaccine-
• 3-4 most common strains from previous year used
• Recommended as IM injection (no more intranasal)
• Adults over 50, those in communal living, chronic illnesses, immunocomprised, healthcare workers, young children should receive a vaccine EVERY YEAR
• 2 weeks before antibodies are made
Cover cough/cough into arm (NOT FIST!)
Teach hand hygiene and healthy lifestyle habits
Pneumonia-
▪ Inflammation of the interstitial spaces, alveoli, & bronchioles
▪ Bacteria penetrate the airway mucosa & multiply in the alveoli
▪ WBC’s migrate to this area causing capillary leak, edema, & exudate
▪ Fluid collects in & around alveoli, they collapse, leading to hypoxemia
▪ Capillary leak allows spread of the infection to other areas of the lung
▪ RBC & fibrin move into the area, stiffen the lungs, reducing compliance
▪ Leads to septicemia & possible empyema
Tx-
• Monitor WBC, neutrophil counts
• Chest x-ray- May not show up for 2 or more days after symptoms present
Sputum culture
Complications:
• Dyspnea; tachypnea
-Monitor oximetry closely
-Encourage incentive spirometer
• Flushedappearance
Skin care; linen changes
• Chest pain or discomfort
• Myalgia; Headache
-analgestics
• Fever; Chills- monitor temp; treat with Tylenol; obtain blood cultures
• Cough with sputum production; hemoptysis
• Expectorants prn; push fluids
• Tachycardia
Treatment
• IV fluids/hydration; monitor I & O’s
• Oxygen PRN; ABG analysis when warranted
Antibiotics
Pulmonary hygiene
Bronchodilators
2 antibiotics:
• Pneumococcal polysaccharide vaccine (Pneumovax)
• Pneumococcal conjugate vaccine (Prevnar 13)
• CDC recommends
• Those >65 yrs get both
• Those 19-64 yrs who have chronic illnesses
B
Asthma
Rx for Asthma:
short-acting (Albuterol, Proventil), long-acting (Serevent), corticosteroid (Serevent, Advair) [Tx is effective if sx decrease]
chronic inflammatory disorder- worse at night when s/s are present
Tx for Asthma:
Bronchodilator are rescue meds because they relax and open airway (Albuterol), calm atmosphere, High-Fowler’s, IV corticosteroids if having a severe attack
⬤ Intermittent; reversible ⬤ Affects only airways, not alveoli ⬤ Occurs in two ways ➢ Inflammation obstructing lumens ➢ Airway hyperresponsiveness leading to bronchoconstriction
Complications:
⬤ Assessment: Noticing
➢ History
• Symptoms-onset, exposure, prior allergens
• Smoking
• family history-tendency is inherited but not to specific allergen (ex: anaphylaxis to shellfish)
➢ Physical assessment/clinical manifestations
• Audible wheeze, increased respiratory rate
• Increased cough
• Use of accessory muscles
• “Barrel chest” from air trapping
• Long breathing cycle
• Cyanosis
N
Status Asthmaticus
⬤ Severe, life-threatening, acute episode of airway obstruction
⬤ Symptoms
➢ Labored breathing, wheezing, stridor, use of accessory muscles, distended neck veins
➢ Can progress to pneumothorax & cardiac/respiratory arrest; intubation
⬤ Treatment
➢ IV fluids, potent systemic bronchodilator, steroids, epinephrine, oxygen
⬤ Wheezes stop
➢ prepare for emergent trach!
Nursing care- labs- ABG’s ⬤ Improve air flow & GAS EXCHANGE ⬤ Self-management education ➢ Personal asthma action plan ⬤ Drug therapy ➢ Control therapy drugs (used daily; long acting) ➢ Reliever drugs (used to stop an attack; short acting) ➢ Bronchodilators ➢ Anti-inflammatory agents
J
Nursing care/tx:
COPD/bronchitis/emphysema
⬤ Copd- Includes
➢ Emphysema
➢ Chronic bronchitis
⬤ Characterized by bronchospasm & dyspnea
⬤ Tissue damage not reversible; increases in severity, eventually leads to respiratory failure
G
Emphysemia- Loss of lung elasticity due to breakdown of elastin
➢ Hyperinflation of lung
➢ Small airway narrowing & collapse
➢ Air trapping due to loss of elastic recoil in alveolar walls (bullae)
➢ Some alveoli are destroyed & others become large & flabby with less area for gas exchange
⬤ Hyper-inflated lung flattens diaphragm, weakening it
➢ Results in “air hunger”; not getting air; deep rapid, labored breathing
J
⬤ Bronchitis- Inflammation of bronchi & bronchioles caused by chronic exposure to irritants
➢ Inflammation, vasodilation, congestion, mucosal edema, congestion, bronchospasm
⬤ Affects only airways, not alveoli
⬤ Production of large amounts of thick mucus
➢ Bronchial walls thicken & impair airflow
➢ Chronic infections due to increased mucus
Risk factors-
⬤ Cigarette smoking is the greatest risk factor
⬤ Alpha1-antitrypsin deficiency (protein that protects the lungs); rare cause
⬤ Incidence & prevalence
➢ COPD is the fourth leading cause of morbidity & mortality in the U.S.
Complications of cpod
⬤ Hypoxemia/tissue anoxia (no O2)
⬤ Impaired alveoli results in decreased gas exchange
⬤ Acidosis (PaCO2 increases)
⬤ Respiratory infections
⬤ Cardiac failure, namely cor pulmonale
⬤ Cardiac dysrhythmias (due to hypoxia)
s/s
⬤ Assessment: Noticing
➢ History
➢ Activity tolerance
➢ General appearance
➢ Respiratory changes
⬤ Limited chest movement with emphysema due to flattened diaphragm
⬤ Wheezes inspiration & expiration
⬤ clubbing
➢ Cardiac changes
⬤ Signs of RHF
Tx/nursing care:
⬤ Improve gas exchange & reduce carbon dioxide retention
➢ Goal sats 88-90%
➢ Up in chair (esp. for meals)
➢ Bipap, intubation for CO2 retention/resp. failure
⬤ Prevent weight loss
➢ Effective coughing before meals
➢ Small meals frequently, avoid gas producing foods or lots of liquids
➢ Take bronchodilator 30 mins before eating
➢ Nutrition supplements
⬤ Minimize anxiety
⬤ Sit up leaning forward and feet on ground
➢ Pursed lip breathing; tripod position
⬤ Oxygen, bipap therapy
⬤ Drug therapy
➢ Long acting beta adrenergic agents, cholinergic antagonists, corticosteroids, nebs, oxygen
⬤ Exercise conditioning
➢ Pace activities, plan rest periods
⬤ Percussion therapy to loosen secretions
⬤ Hydration
MEDS
⬤ Beta-adrenergic agents (ex: albuterol)
⬤ Methylxanthines (ex: theophylline)
⬤ Corticosteroids (ex: prednisone)
⬤ NSAIDs
⬤ Mucolytics (ex: tessalon pearles, guaifenesin)
Home care management
⬤ Long-term use of oxygen; ed. on proper use
⬤ Pulmonary rehabilitation program
⬤ Self-management education
⬤ Drug therapy
⬤ Manifestations of infection
⬤ Breathing techniques; energy conservation
⬤ Relaxation therapy
⬤ Health care resources
⬤ Food delivery services
⬤ Transportation
⬤ cleaning
M
pulmonary artery hypertension ⬤ Occurs in absence of other lung disorders; sometimes idiopathic ⬤ Blood vessel constriction with increasing vascular resistance in the lung ⬤ Heart fails (cor pulmonale) ⬤ Without treatment, death within 2 years Complications: R sided HF Blood clots Arrhythmias Bleeding- coughing up blood Cyanosis Tachycardia Edema Dizziness Fatigue sob Nursing care/tx: ⬤ Drugs to reduce pulmonary artery pressures by dilating vessels & preventing clot formation ⬤ Endothelin-receptor agonists (promote vessel relaxation) ➢ Sildenafil (Viagra) ➢ Revatio ➢ When cor pulmonale is present: • Diuretics (↓ workload of heart), digoxin ↑ contractility), oxygen Educate healthy lifestyle
G
TB • Most common bacterial infection worldwide- airborne infection affecting lungs Complications: ▪ Assess past exposure ▪ Foreign travel ▪ BCG vaccine ▪ Persistent cough ▪ Anorexia; unintended weight loss ▪ Night sweats; fever/chills ▪ Hemoptysis; blood-streaked sputum ▪ SOB lethargy nursing care/tx: push fluids Pulmonary hygiene Monitor gas exchange Supplemental oxygen PRN Optimize nutrition Drug therapy: • Isoniazid, Rifampin, Pyrazinamide; Ethambutol • Initial phase is 8 weeks • Continuation phase another 18 weeks • Can cause liver impairment; Decrease effectiveness of BC • Repeat sputum every 2-4 weeks; need 3 consecutive negatives • Assessment for TB: • 2+ weeks of cough, fever, weight loss, night sweats, weakness, chills, hemoptysis • • Tx for TB: • Isoniazide and Rifampin
H
Hypoxemia Low levels of oxygen in the blood** • BEST PRACTICES • Verify order • Humidification over 4L/min • Regular skin assessment • Ensure no smoking • Assess & document response to therapy • Ensure adequate oxygen during transport • Prevention of oxygen toxicity
N
Otitis media
inflammatory diseases of the middle ear.
Management:
• Heating pad
• Antibiotics (ear drops best)
• Analgesics (Tylenol, ibuprofen, aspirin)
Surgical-
• Myringotomy
• Tubes placed in ear drum to allow continuous drainage
J
• Allergies
• Allergy testing:
• IgE is produced - IgG is tested for food allergies
• Pt education: Allergy testing
• discontinue allergy meds at least 5 days prior to testing, skin prick test is often done [positive if have wheal and flare]
• Safety: Allergy testing
• anaphylaxis can occur or asthma sx can be triggered
• Benadryl: Diphenhydramine
• -Antihistamine
-Use: rhinitis, allergic response
Side effects: drowsiness, urinary retention, dizziness, disturbed coordination, drying and thickening of oral and other respiratory secretions, and stomach distress
I
o Angioedema
is a swelling of the area beneath the skin, similar to urticaria, or hives. However, urticaria affects only the upper dermis, or top layer of skin. Angioedema affects the deeper layers, including the dermis, subcutaneous tissue, the mucosa, and submucosal tissues.
-occurs due to dander, pollen, etc.
I
Anaphylaxis
is a serious, life-threatening allergic reaction. The most common anaphylactic reactions are to foods, insect stings, medications and latex. If you are allergic to a substance, your immune system overreacts to this allergen by releasing chemicals that cause allergy symptoms.
s/s- wheezing, low bp, high pulse
o Treatment
• Treatment consists of vasoconstrictors
• If not treated right away, usually with epinephrine, it can result in unconsciousness or death.
• Medications
• Vasoconstrictor, Bronchodilator, Antihistamine, and Steroid
• Tracheal intubation, Cardiopulmonary resuscitation (CPR), and IV fluids
Immediate injection of epinephrine 1:1,000 aqueous solution, 0.3 to 0.5 mL intramuscularly (preferred) or subcutaneously every 5 to 15 minutes for up to three doses or 2 to 10 micrograms per minute of a 1:10,000 solution by slow I.V. infusion; endotracheal or intraosseous administration if I.V. administration isn’t possible
Bed rest until stable
Treatment-General
Airway maintenance, possibly including endotracheal intubation with assisted ventilation; tracheostomy
Cardiopulmonary resuscitation, if cardiac arrest occurs
Treatment-Diet
Nothing by mouth until stable
I.V. fluids (typically normal saline and lactated Ringer’s solution)
Avoidance of suspected food trigger(s)
o Patient education
type of allergy or allergen responsible, if possible
risk of delaying treatment for symptoms, emphasizing the importance of reporting them immediately
use of epinephrine as first and best treatment for anaphylaxis; that antihistamines and albuterol inhalation, although somewhat helpful, do not prevent or relieve the airway obstruction and are not life-saving
need for possible skin testing to determine the allergen
avoidance of exposure to known allergens, including measures to reduce exposure risk
importance of carrying and becoming familiar with an anaphylaxis kit and learning to use it before the need arises, including use of EpiPen; development of an anaphylaxis emergency action plan that lists the most common signs and symptoms of anaphylaxis and instructions for treatment
need for medical identification jewelry to identify allergy.
need to renew prescription for epinephrine auto-injector each year
need to manage other conditions and illnesses, such as asthma
importance of adhering to follow-up schedule for immunotherapy, if appropriate.
K
Glaucoma Tunnel vision -Increased ocular pressure s/s: • Headache or brow pain • Nausea and vomiting • Colored halos around lights • Sudden blurred vision with decreased light perception
Types:
• Primary open-angle glaucoma
• Angle-closure glaucoma
Drug therapy
• Prostaglandin agonists (ex: Lumigan, Xalatan)
• Cause eye color to darken & lashes to elongate
• Cholinergic Agonsists (ex: Isopto, Pilocarpine)
• Can cause HA, flushing, increased saliva, sweating
• Beta-adrenergic blockers (ex: timpoptic, Timolol)
• Can induce hypoglycemia & potentiate BB’s (lower HR)
• Adrenergic Agonists (ex: Alphagan)
• Increase blood pressure, do not take with MAOI’s
J
Cataracts
• Lens loses water & increases in density, which decreases transparency
• Opacity makes it difficult to see retina
• No pain or eye redness
• Early signs
o Slightly blurred vision (smudged lens)
o Progresses to blurred & double vision
o Decreased color perception
o Progresses to blindness without surgical intervention
Post surgical Nursing care–
• Antibiotics given subconjunctivally
• Eye is unpatched, discharge usually occurs within 1 hour
• Dark glasses required
• Post op antibiotic & steroid eye drops
• Nursing Care:
• Mild itching normal
• Pain: early pain may indicate increased IOP or hemorrhage, esp. if n/v present
• Prevent infection
•
Bluury, dim, dull, yellow, distorted vision
Need surgery-sound waves break up lens
H
Meniere’s
• Usually occurs in men between 20 and 50 years old
• 3 features: tinnitus, one-sided sensorineural auditory loss & vertigo
o May also include headache, fullness of ear, n/v, nystagmus, “whirling” sensation
• Teach to move head slowly, reduce sodium, stop smoking, comply with drug therapy
• Pressure pulse treatment; labyrinthectomy
J
o Mentation- mental activity/status ▪ Assessment • Level of consciousness/GCS o Alert-can be alert but not necessarily oriented o Lethargic-drowsy, awakes easily o Stuporous-drowsy, difficult to wake o Comatose-unconscious, cannot wake
J
o Dementia ▪ Patient care ▪ Education ▪ Medications o Trigeminal neuralgia ▪ Nursing considerations ▪ Nursing care
H
