Acute HF: Nursing collaborative mgmt
Primary goal to improve LV function
- increase intravascular volume
- decrease preload
- decrease afterload
- improving gas exchange & oxygenation
- improving cardiac function
- reducing anxiety
Acute HF: collaborative care for decreasing preload
- reduce amount of volume returned to LV
- diruetics
- nutritional therapy: decrease Na
- high fowler’s
Acute HF collaborative care: decreasing afterload
- decrease pulmonary congestion (alveolar level)
- ACE & ARBs: decrease constriction, alter aldosterone (not as effective in AA pop)
- Nesiritide (Natrecor)- afterload & preload reducer
Acute HF collaborative care: gas exchange
- decrease pulmonary congestion
- IV morphine- acute phase. low dose to vasodilate
- administer oxygen
- possible intubation- severe cases
Acute HF collaborative care: cardiac function
- Digoxin (watch for toxicity)
- newer inotropics: PDE III inhibitor: Milrinone (Primacor)
- B blockers: help reduce SNS response
- hemodynamic monitoring
Chronic HF: Nursing & Collaborative Mgmt
- treat underlying cause
- maximize (optimize) cardiac output
- alleviate symptoms
- rest
- biventricular pacing
- oxygenation treatment
- mechanical hearts
- heart transplantation
Chronic HF drug therapy
- ACE
- ARBs
- Inotropic drugs: Digoxin, PDE inhibitor
- vasodilators
- beta blockers
- diuretics
- anticoagulants (Warfarin)
- antidysrhythmic drugs
HF discharge training
MAWDS M- medications (lasix, ACE, Bbs_ A- activity (coupled w/rest) W- weight: best indicator of fluid status D- diet: limit fat, sodium S- symptoms
follow-up appointment: better outcomes
call HCP if weight changes >2 lbs overnight or >5lbs in one week
Heart Failure
- abnormal condition- impaired pumping
- a syndrome, not a disease
- associated w/long-standing HTN & CAD
- results from the heart’s inability to pump amount of oxygenatied blood needed to meet metabolic requirements
HF Risk Factors
- CAD & its risk factors
- Age
- Hypertension: to compensate for increase bp, heart thickens. over time force of contraction weakens, preventing normal filling
- increase cholesterol
- AA descent: higher incidence & mortality
Types of HF
Left sided:
- most common
- blood backs up thru left atrium and into pulmonary veins
Right sided:
- backflow to right atrium and venous circulation
- results from diseased right ventricle
- COPD complications
- one sided can lead to biventricular failure
left sided HF clinical manifestations
- PND
- increase pulmonary capillary wedge pressure
- cough
- crackles
- wheezes
- blood tinged sputum
- restlessness
- confusion
- orthopnea
- tachycardia
- exertional dyspnea
- cyanosis
right sided HF clinical manifestations
- fatigue
- increased peripheral venous pressure
- ascites
- enlarged liver & spleen
- JVD
- anorexia & complaints of GI distress
- swelling in hands & fingers
- dependent edema
Acute HF general clinical manifestations
pulmonary edema - agitation - pale or cyanotic - cold, clammy skin - severe dyspnea, crackles, cough (hacking, productive, dry), "frothy" secretions - tachypnea - tachycardia s/s decreased CO - head to toe, abnormal heart sounds (s3 s4)
HF: diagnostic studies
Primary goal to determine underlying cause
- history and physical
- ABGs, serum chemistries
- chest xray
- 12 lead ECG
- hemodynamic assessment/monitoring
- Echocardiogram (gold standard)- LVEF
- stress testing
- nuclear imaging studies
- cardiac cath (underlying problem)
- labs
UTI
- most common health care acquired infection
- most common cause of sepsis in hospitalized patients
- -“urosepsis”
- most common organisms are from GI tract (E. coli)
- common source of hospital-acquired UTI (CAUTI)
UTI classification
- upper tract: renal parenchyma, pelvis, ureters: s/s fever, chills, flank pain
- lower tract: lower urinary tract: no usual systemic manifestations (localized symptoms)
- sites of infection: pylonephritis, cystitis
ascending tract can move quickly to systemic
predisposing factors to UTI
- factors increasing urinary stasis: intrinsic obstruction, extrinsic obstruction, urinary retention (tumor, stones)
- foreign bodies: urinary calculi, urologic instrumentation (CAUTI)
- anatomical factors: congenitial defects leading to obstruction or urinary stasis, fistula exposing urinary stream to skin, vagina, or fecal stream, shorter urethra
- sexual intercourse
- immunosuppression
- functional disorders (constipation, voiding dysfunction, fecal compaction)
UTI clinical manifestations
symptoms:
- dysuria, frequent urination (>q2h), urgency, suprapublic discomfort or pressure
- hematuria, or sediment, cloudy uring
- flank pain, chills, fever indicate pyelonephritis
- bacteriruia may have no symptoms or nonspecific symptoms like fatigue or anorexia
UTI clinical manifestations in older adults
- could be asymptomatic
- non-localized abdominal discomfort rather than dysuria
- may have cognitive impairment
- less likely to have fever
- frequently we see falls from the cognitive impairment
UTI diagnostic studies
- urinalysis: clean catch is preferred, or cath or suprapubic needle aspiration
- urine culture and sensitivity
- imaging studies in some cases: IVP or abdominal CT when obstruction suspected.
Collaborative Care: Some UTI drug therapy
- Trimthoprim-sulfamethoxaole or nitrofurantoin: used to treat uncomplicated
- Pyridium: OTC, provides soothing effect on ut mucosa. stains urine reddish orange, anesthetic, doesn’t treat the infection
- Prophylactic or suppressive antibiotics: pts w/repeated UTIs, prevent recurrence or a single dose prior to events likely to cause UTI
UTI Nursing Management: Health Promotion
- avoid unnecessary catheterization & early removal of indwelling catheters
- aseptic technique must be followed during instrumentation procedures
- handwashing
- wear gloves for care of urinary systems
- routine & thorough perineal care for all hospitalized patients
- avoid incontinent episodes by answering call light & offering bedpan at frequent intervals
UTI Nursing Management: Acute Care Intervention
- instruct patient about drug therapy & side effects
- emphasize taking full course despite disappearance of symptoms
- second or reduced drug may be ordered after initial course in susceptible patients
- instruct patient to watch urine for changes in color & consistency and decrease or cessation of symptoms
- counsel on persistence of lower tract symptoms beyond treatment or onset of flank pain or fever should be reported immediately
UTI Nursing Management: Ambulatory and Home Care
- emphasize compliance with drug regimen
- maintain adequate fluid intake
- regular voiding
- void after intercourse
- temporary discontinue use of diaphragm
- instruct on follow-up care with urine culture
- recurrent symptoms typically occur 1-2 weeks after therapy
UTI Nursing Management: Evaluation
- use of nonanalgesic relief measures
- appropriate use of analgesics
- pass urine without urgency
- urine free of blood
- adequate intake of fluids
Glomerulonephritis
- immunologic processes involving the urinary tract predominantly affect the renal glomerulus
- inflammation of the renal glomeruli (functional unit of the kidney)
- Accumulation of antigen, antibody and complement in the glomeruli, results to tissue injury (type III hypersensitivity)
Acute glomerulonephritis
- patient assessment: connection with sore throat? (strep infection), proteinuria
- physical assessment
- clinical manifestations: hallmark facial swelling, frothy urine
- laboratory assessment: protein or hematuria
- other diagnostic tests: electrolyte imbalance
- may develop an acute kidney injury
- tx: find underlying cause and treat. some resolves on its own.
Glomerulonephritis collaborative care
- management of infection
- prevention of complications
- dialysis
- plasmapheresis (like dialysis. filters foreign bodies off plasma)
- patient education
chronic glomerulonephritis
- develops over period of 20-30 years or longer (progressive. had an acute version and was in remission)
UT Caliculi
Nephrolithiasis- kidney stone disease
- majority of cases caused by calcium stones (oxalate, phosphate)
- caucasian, 20-55 year old men
UT Caliculi risk factors
- metabolic: increase Ca, uric acid. hyperparathyroidism, bone disease
- climate: higher temperatures
- urinary stasis
- urinary retention: anticholinergics
- immobilization
- dehydration
- genetic
- lifestyle
UT Caliculi: Clinical Manifestations
Manifestations result from obstruction of urinary flow
- ureterovesical junction (UVJ) common site of complete obstruction (haven’t passed urine in a while- medical emergency)
Symptoms:
- abdominal or flank pain (usually severe), hematuria, renal colic
- n/v
- pain may be absent if stone unobstructing: pain is where stone is struggling to pass. generally start in kidney. usually asymptomatic until it begins to mobilize
- stone near UVJ: lateral flank, labia, or groin
- UTI s/s, fever, vomiting, nausea and chills
UT Caliculi: collaborative care. diagnostic tests, hx & physical
Diagnostic studies
- urinalysis, urine culture, IVP, retrograde pyelogram, ultrasound, cytoscopy, CT scan
- serum BUN, creatinine (will be elevated)
- hx & physical: use of OTC medications and dietary supplements, previous history, family history
Indications for endourologic, lithothripsy or open surgical stone removal
- stones are too large for spontaneous passage
- stones associated with bacteriuria or symptomatic infection
- stones causing impaired renal function
- stones causing persistent pain, nausea, or ileus (bowel blockage)
- inability of patient to be treated medically
- patient with one kidney
UT caliculi nursing management: implementation
- fluid intake should be advised according to persons’s activity, underlying illness, etc
- normal Ca diet, low animal protein, salt or both
- pain mgmt & comfort measures
- teach pt to report spontaneous passage of stone (give a straining device)
- encourage mobility
- safety measures, for patients experiencing acute colic, particularly if using opioid analgesics
- ice packs for bruising with lithotripsy
Bladder cancer
- most frequent malignant tumor: transitional cell carcinoma
- most common in men 60-70
bladder cancer risk factors
- cigarette smoking
- exposure to dyes used in rubber and cable industries
- chronic abuse of certain analgesics (phenacetin)
- women treated with radiation for cervical cancer
- cylophosphamide (cytoxan): unknown mechanism
- chronic recurrent bladder stones and chronic lower UTIs
- chronic indwelling catheters (long periods)
bladder cancer clinical manifestations
- gross painless hematuria (common finding)
- bladder irritability with dysuria, frequency, urgency
bladder cancer diagnostic studies
- urine for cytology: detects exfoliated cells from the bladder
- IVP, ultrasound, CT or MRI
- cystoscopy- biopsy confirms diagnosis
- TNM staging (tumor, node, metastases)
- low stage, low grade bladder cancers are most responsive to treatments and more easily cured
surgical therapy: bladder cancer
- transurethral resection
- laser photocoagulation
- open loop resection
- cystectomy: segmental, partial, radical
indications for urinary diversion
- cancer of the bladder
- neurogenic bladder
- congenital anomalies
- strictures
- trauma to the bladder
- chronic infections with deterioration of renal function
bladder cancer postop management
- meticulous skin care around stoma: keep urine acidic to prevent alkaline encrustations, stoma is expected to shrink within first few weeks
- change appliance as needed
- psychosocial support: altered body image
- discharge planning/teaching: proper fitting of appliance, information where to purchase supplies, emergency telephone numbers, location of ostomy clubs, follow-up visits. measures to prevent complications and renal function deterioration.
types of AKI
- prerenal: shock, decreased volume, dehydration
- intrarenal: polycystic, nephritis, dugs (NSAIDS, antibiotics)
- Postrenal: stones, BPH
benign breast disorders
- fibroadenoma
- solid, slowly enlarging, benign mass; round, firm, easily moveable, nontender, and clearly delineated from surrounding tissue
- usually located in upper outer quadrant of breast
fibrocycstic breast changes
- fibrocystic changes of breast (may involve lobules, ducts, stromal tissues)
- common in premenopausal women between 20-50 years of age
- possibly caused by imbalance in normal estrogen-to-progesterone ratio
- rubbery, ill-defined
- painful/tender (opposite of malignant lumps)
- increased tenderness & size prior to menstruation
- symptoms increase in the premenstrual phase
filbrocystic breast changes: collaborative care
- diagnostic studies: aspiration or needle biopsy, mammography or ultrasound
- surgical removal
- supportive undergarments
- OTC pain relievers
- caffeine
- vitamins
- low Na diet or diuretics
- hormones
types of breast cancer
intra-ductal
non ductal
complications of breast cancer
- invasion of lymph channels causing skin edema
- metastasis to lymph nodes
- bone, lungs, brain, liver- sites of metastatic disease from breast cancer
- ulceration of overlying skin
clinical manifestations of breast cancer
- single lump, mass, or mammographic abnormality
- painless, hard, irregular edges= more likely to be cancerous
- can also be tender, soft, or rounded
- orange peel appearance
- swelling of all or part of a breast
- skin irritation or dimpling
- breast or nipple pain
- nipple retraction
- redness, scaliness, or thickening of nipple or breast skin
- a discharge other than breast milk, e.g. clear or bloody
breast cancer in men
- of all breast cancers, 1% occur in men
- usually presents as hard, painless, subareolar mass
- often widely spread disease because it is usually detected at a later stage in women
breast cancer collaborative care
Diagnostic studies Surgical Therapy Radiation therapy chemotherapy prophylactic oophorectomy hormonal therapy
axillary lymph node vs. sentinel node dissection
exam of nodes more powerful prognostic indicator. increased nodal involvement > 4, increased risk of reoccurrence < risk of lymphedema with SLND
Surgical therapy for breast cancer
Lumpectomy: if clear margins, no further treatment needed
- conserves the breast, nipple
- removal of tumor with small amts of normal tissue
- radiation post removal
- ALND vs SLND
Modified radical mastectomy
- removal of breast & axillary nodes but conserves the pectoralis muscle
radiation therapy: breast cancer
- primary treatment (5-6 weeks)
- shrink a large tumor size to operable size
- palliative treatment for pain
- brachytherapy
chemotherapy for b.c.
cytotoxic drugs to destroy cancer cells administered pre & post op
- pre-op (neoadjuvant): shrink tumor, <extensive surgery
- suppresses tumor growth & prolongs survival
diagnostic studies for b.c.
- same as fibrocystic breast changes: aspiration or needle biopsy, mammography or ultrasound
- ploidy status: tumor differentiation (abnormality), correlates with tumore aggressiveness
- axillary lymph node vs. sentinel lymph node dissection
- tumor size: larger the tumor, poorer prognosis
- stages: TMN classification
hormonal therapy: b.c.
tamoxifen citrate (Novaldex)- blocks estrogen
- post menopausal women w/o lymph node involvement, BRCA 2 mutation, or increased risk breast cancer
- prevention in individuals in high risk category
- side effects: hot flashes, nausea, vomiting, blood clots, & endometrial cancer
breast cancer: post op nursing management
- LOC, v/s
- bleeding (dsg, drains)
- infection
- avoid bp, injections, phlebotomy affected arm
- ambulation & diet
- postmastectomy exercises
- breast reconstruction- dep on patient
- adjuvant therapy
adjuvant therapy
- radiation
- chemo
- targeted therapy (e.g. monoclinal antibodies for HER2/neu gene positive cancers)
- hormonal therapy
- stem cell transplantation
benign prostatic hyperplasia
- glandular units in the prostate that undergo an increase in number of cells, resulting in enlargement or prostate gland.
symptoms of BPH
- hyperirritable bladder
- urgency & frequency
- hypertrophied bladder wall muscles
- cellules and diverticula
- hydroureter
- hydronephrosis
- overflow urinary incontinence
diagnostic studies for BPH
- digital rectal exam
- urine analysis & culture
- serum creatinine and BUN
- PSA (prostate specific antigen): very controversial
- urodynamic flow studies
- cystourethroscopy
neurologic manifestations of CKD
- confusion,
- altered mental status
- lethargy
- depression
- grieving
cardiovascular manifestations of CKD
- hypertension
- heart failure (LV change)
- dysrhythmias (anemia leading to hypoxic state, electrolyte imbalances)
respiratory manifestations of CKD
- acidosis
- kussmaul respirations (increase rate and depth- compensating for acid state of kidneys)
- pulmonary edema
hematologic manifestations of CKD
- primary is anemia
- alteration in platelets
GI manifestations of CKD
- anorexia
- weight loss
- n/v
- uremic levels go through GI, can lead to halitosis
- diarrhea/constipation
skeletal manifestations of CKD
- altered calcium= fractures
- increased parathyroid hormone
urinary manifestations of CKD
- oliguric
- anuric (stasis)
- increased risk for UTI
skin manifestations of CKD
- pruritis/uremic toxin building up.
- uremic frost- hard crystals on skin
- greying/dulling of skin
general clinical manifestations of HF
Fatigue- earliest symptoms, after activities which are not normally tiring r/t decreased CO (chronic hypoxic state)
Dyspnea (PND) or SOB
- caused by alveolar edema
- PND: reabsorption from dependent areas when pt is sleeping. c/o suffocation feelings
Tachycardia
- compensatory mechanism from SNS
Heart murmur: S3, S4 from altered pumping/filling
Heaves/Lifts
- 3rd to 5th ic spaces using ball of hand
Edema/Anasarca
- legs, liver, abdomen
Nocturia r/t recumbent position, increases blood flow
Chest pain r/t decreased coronary perfusion. can be anginal.
weight changes
skin changes: dusky
sleep apnea
behavioral changes
HF complications
- pleural effusion: fluid around viscera of lung
- arrhythmias: PVCs, A fib
- left ventricular thrombus: stasis
- hepatomegaly: increased size of liver
- pulmonary hypertension
CHF classification according to functional status
I: no symptom limitation with ordinary physical activity
II: ordinary physical activity somewhat limited by dyspnea
III: exercise limited by dyspnea at mild work loads (long distance walking, 2 flights of stairs)
IV: dyspnea at rest of with very little exertion (short distance walking, one flight of stairs)
Chronic HF: nursing management planning
Overall goals:
- decrease peripheral edema
- decrease SOB
- increase exercise tolerance
- compliance with medications, diet, clinic appointments
- no complications
Chronic HF: nursing management implementation
- establishment of quality of life goals
- symptom management
- conservation of physical/emotional energy
- support system
Chronic HF: nursing management evaluation
- tissue perfusion
- respiratory status
- sleep
- fluid balance
- activity intolerance
- anxiety control
- knowledge: disease process
- support system
ejection fraction values
should be between 50-70%
impaired: below 40%
classifications of glomerulonephritis
- Extent of damage: diffuse or focal
- initial cause of disorder: SLE, scleroderma, strep infection
- extent of changes: minimal or widespread
clinical manifestations of acute glomerulonephritis
- facial swelling
- alteration in urine: rust colored, cloudy, frothy
- hypertension
- HF
- SOB
- fatigue
- n/v
causes of AKI
- hypovolemic shock
- heart failure: hypoperfused, overloaded
prerenal azotemia
- acute AKI
- buildup of nitrogenous waste
phases of AKI
- onset: insult occurs. could be from increased amounts of nephrotoxic drugs
- oliguric: small urine output. increased fluid retention. holding onto sodium.
- diuretic: aimed at reperfusion
- recovery
terms used with kidney dysfunction
- azotemia: buildup of nitrogenous waste
- uremia
- uremic syndrome
Stages of CKD
- reduced renal reserve: decrease in GFR. no symptoms unless pt gets an infection, is fluid overloaded, or is pregnant.
- reduced GFR:
- ESKD: GFR is less than 15
Cardiac changes in CKD
- HTN
- hyperlipidemia: later stages
- HF: early. volume overload.
- pericarditis: inflammation of outer sac of heart (increase in uremic acid leads to inflam)
Priority nursing care: CKD
- dietary restrictions: protein individualized. increase calcium. decrease phosphorus.
- uremic frost: pruritis. tepid bath. at risk for cellulitis from itching. more end stage.
- muscle strength, energy: will be low.
- family members
- excess fluid volume: renal replacement, diuretics. 500-700mL fluids per day. LOOPS, not K sparing.
- decreased CO
- recombinant human erythropoietin: epogen, iron, folic acid
vascular access
- AV fistula or graft for long-term permanent access
- hemodialysis catheter, dual or triple lumen, or AV shunt for temp access
precautions for vascular access
assess for patency. listen for bruits, light palpation for thrills.
- “save the arm”
- advise patient against tight fitting clothing
complications in vascular access
- thrombosis or stenosis
- infection
- aneurysm formation
- ischemia: bp stopping circulation
- heart failure: vol overload. not a direct complication.
hemodialysis nursing care
- drugs: hold ones that can induce hypotension. antibiotics, antiepileptics, diuretics. customize schedule. insulin is ok
- postdialysis assessment: hypotension, h/a, n/v, malaise, dizziness, cramps. know baseline. bleeding- esp at site from anticoagulation therapy
complications of hemodialysis
- dialysis disequilibrium syndrome
- infectious disease: if machine not cleaned properly
- hep b & c
- HIV
complications of peritoneal dialysis
- peritonitis
- pain
- exit site/tunnel infections
- poor dialysate flow: dep on anatomy
- dialysate leakage
- other complications: cath infection
nursing care for peritoneal dialysis
- before tx: evaluate baseline v/s, weight, labs
- continually monitor pt for respiratory distress, pain, discomfort
- monitor prescribed dwell time, initiate outflow
- observe outflow amount and pattern of fluid
complications of kidney transplant
- rejection
- acute tubular necrosis
- thrombosis
- renal artery stenosis
- other complications
- immunosuppressive drug therapy
- psychosocial preparation
drug therapy for BPH
hormonal manipulation: Proscar. shrink prostate (could take a while).
alpha-adrenergic blockers:
- minipress, Cardura, Hytrin (decrease constriction)
- side effects: orthostatic hypotension, dizziness
conservative therapy for BPH
- stents, prostatic balloon
- foley catheters
treatment goals for BPH
- restore bladder drainage
- relieve symptoms
- treat complications
indications for BPH surgery
- decrease in urine flow sufficient to cause discomfort
- persistent residual in urine
- acute urinary retention
- hydronephrosis
TURP
- invasive therapy
- choice for debilitating patient with moderate prostatic enlargement
- no incision, less likely to cause erectile dysfunction
- noes not completely remove the prostate tissue
- bleeding is common
preoperative nursing interventions for TURP
- urethral catheter- to restore urinary drainage (Coude or filiform)
- treat UTI
- high fluid intake
postoperative nursing interventions for TURP
- CBI: use of 3 way foley catheter; removes clots, urinary drainage
- observe for hemorrhage: 24-36 hours, normal blood clots
- relieve bladder spasms
- promote sphincter tone (Kegels)
- monitor for s/s infection
- dietary interventions, stool softeners
patient teaching: TURP
- catheter care
- managing incontinence
- maintain adequate oral intake
- sexual counseling: erectile dysfunction
types of prostatectomy
- suprapubic
- retropubic
- perineal
biggest complication of prostatectomy procedures
bleeding
interventions for chronic glomerulonephritis
- slowing progression, preventing complications
- diet changes: salt, protein, alcohol
- fluid intake
- drug therapy: ACE improves blood flow to kidneys. Halts renin, improves vasodilation
- dialysis, transplantation
- worried about excessive amounts of electros
- avoid more inflammation and injury