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Flashcards in Final Exam Study Guide Deck (427):
1

What do you monitor for while using Digoxin/Lanoxin

Monitor for digoxin toxicity. Monitor HR. Avoid taking medication with antacids.

2

What do you monitor for while using Furosemide/Lasix

Monitor for hypokalemia, dehydration and confusion. Asses for orthostatic hypotension

3

What do you monitor for while using ACEIs/ARBs
Enalapril/Vasotec Captopril/Capoten Losartan/Cozaar

Cause a rapid drop in blood pressure. Assess for orthostatic hypotension. Monitor for hyperkalemia

4

What are
Lovastatin/Mevacor
Simvastatin/Zocor

Statins

5

What is Digoxin/Lanoxin

Positive Inotropic drug

6

What is Furosemide/Lasix

Loop Diuretic

7

Name the ACEIs/ARBs

Enalapril/Vasotec Captopril/Capoten Losartan/Cozaar

8

What do you monitor for while using Statins Lovastatin/Mevacor Simvastatin/Zocor

Take at bedtime. Monitor liver enzymes and for myopathies

9

INR

0.7 - 1.8

10

WBC

5000 - 10,000

11

RBC Count Females

4.2 - 5.4

12

RBC Count Males

4.7 - 6.1

13

Platelet

150,000 - 400,000

14

Sodium

135-145

15

HCT Females

37% - 47%

16

HCT Males

40% to 54%

17

Calcium

9 - 10.5

18

Normal BUN

10-20

19

Creatinine

0.5 - 1.2

20

BUN/Creat Ratio

Just know- It increases related to dehydration.

If you do not have an increase in the ratio, but you do have an increase in both BUN and Creatinine, you start to be concerned about renal impairment.

21

What is the normal level of protein in the urine?

Protein >0.8mg/dL

22

Normal Urine pH

4.5 to 8

23

Urine Specific Gravity

1.005 to 1.030

24

Normal Potassium

3.5 - 5

25

Albumin

3.5 - 5

26

What are the important triggers to remember for a migraine?

Triggers: caffeine, red wine, stress, MSG.

27

Dilantin,

nursing interventions monitor for gastric distress, gingival hyperplasia, anemia, ataxia, and nystagmus.

Check CBC and calcium levels, monitor for therapeutic drug levels which are 10 to 20 mcg/mL and toxic levels which are greater than 30 mcg/mL.

Four IV Dilantin, flush catheter was saline before and after administration. For fosphenytoin, use phenytoin equivalent for dosing.

28

***Ativan

nursing interventions, monitor airway, breathing, circulation, ABCs. Ativan IM takes 30 minutes to start working, if needed immediately give through the IV.

Check respirations and blood pressure before giving Ativan.

29

A seizure is an

abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain that may result in a change in level of consciousness, motor or sensory ability, and or behavior,

30

What is the etiology of a seizure?

A single seizure may occur for no known reason.

Some seizues are caused by pathologic condition of the brain such as a tumor. It may be caused by an abnormality in the electrical Neuronal activity, and imbalance of neurotransmitters, especially Gama amniobutyric acid or gabba, or combination of both. Can also because by scar tissues within the brain.

Etiology:
Primary: not related to brain lesion or other cause.
Secondary: related to brain lesion caused by brain tumor and trauma. Also related to metabolic disorders, high fever, substance abuse. Cancer can cause seizures as well ,

31

Epilepsy is defined as

two or more seizures experienced by person. It is a chronic disorder in which repeated unprovoked seizures occur.

The seizures have to be on provoked. So drunk seizures and febrile seizures in children are not epilepsy.

32

What are the types of seizures?

Generalized seizures,
partial seizures,
unclassified idiopathic seizures.

33

Generalized seizures

involve both cerebral hemispheres and are referred to as tonic clonic seizures.

The tonic clonic seizure lasting 2 to 5 minutes begins with a tonic phase that causes stiffening or rigidity of the muscles, particularly of the arms and the legs, and immediately immediate loss of consciousness.

Clonic or rhythmic jerking of all extremities follows. The patient may bite his or her tongue and may become incontinent of urine or theses.

Fatigue, acute confusion, and lethargy may last up to an hour after the seizure.

34

Partial seizures begin in

one part of the cerebral hemisphere and are referred to as focal focal seizures.

They are further subdivided into two main classes: complex partial seizures and simple partial seizures.

In addition, some partial seizures can become generalized tonic clonic, tonic, or clonic seizures.

Partial seizures are most often seen in adults and generally are less responsive to medical treatment when compared with other types.

35

Unclassified idiopathic seizures

occur for unknown reasons.

36

Automatisms-

are seen with absence seizures, this is involuntary behaviors such as lipsmacking and picking at clothes. He or she is not aware of the behaviors.

The patient returns to baseline immediately after the seizure. Left undiagnosed or untreated the seizure may occur frequently throughout the day, interfering with school or other daily activity.

37

Preictal-

before the seizure

38

Postictal-

after the seizure

39

Syncope-

loss of consciousness

40

Amnesia-

loss of memory

41

Aura-

unusual sensation

42

Tonic-

stiffening or rigidity of muscles with an immediate loss of consciousness.

43

Clonic-

rhythmic jerking of all extremities.

44

Seizure and epilepsy nursing interventions.

1. Antiepileptic drugs: Dilantin, Klonopin, Depakote, Keppra, Ativan.

2. Prevention, do not stop taking medication, balanced diet and sleep, stress reduction.

45

Seizure precautions

siderails and padding of siderails depends on the hospital,
no padded tongue blades,
bed in the lowest position,
patient education,
nurses watch closely,
IV access,
hook up to the monitor,
suction and oxygen ready.

seizure management: protect airway, Ativan through the IV, oxygen, monitor Vital signs, suction.

46

Nursing safety priority action alert

Seizure precautions include ensuring that oxygen and suctioning equipment with an airway are readily available.

If the patient does not have an IV access, insert a saline lock, especially if he or she is at significant risk for generalized tonic clonic seizures.

The saline lock provides ready access for iv drug therapy that must be given to stop the seizure.

47

Chart 44 –5 best practice for patient safety and quality care. Care of the patient during a tonic clonic or complete partial seizure.

Protect the patient from injury.

Do not force anything into the patient's mouth.

Turn the patient to the side to keep the airway clear.

Loosen any restrictive clothing the patient is wearing.

Maintain the patients airway and suction as needed.

Do not restrain or try to stop the patient's movement, guide movements as necessary.

Record the time the seizure began and ended.

At the completion of the seizure, take the patient's vital signs, preform neurologic checks, keep the patient on his or her side, allow the patient to rest, document the seizure.

48

Health teaching for the patient with epilepsy.

Drug therapy information: name, dosage, time of administration. Actions to take if the side effects occur. Importance of taking drug as prescribed and not missing a dose. What to do if the dose is missed or cannot be taken. Importance of having blood drawn for therapeutic or toxic levels as requested by the healthcare provider.

Do not take any medication, including over-the-counter drugs, without asking your healthcare provider.

Where a medical alert bracelet or necklace, or carry an ID card indicating epilepsy.

Follow up with neurologist, physician, or other healthcare provider.

Be sure a family member or significant other knows how to help you in the event of a seizure and knows when your healthcare provider or emergency medical services should be called.

Investigate and follow state laws concerning driving and operating machinery.

Avoid alcohol and excessive fatigue.

Look for resources and support groups.

49

Status epilepticus

A seizure lasting more than five minutes or a seizure repeating over the course of 30 minutes.

Seizures lasting more than 10 minutes can cause death.

Etiology, sudden withdrawal of antiepileptic drugs, infection, EtOH withdraw (alcohol), head trauma, cerebral edema, metabolic disturbance, infection, severely wasted, throwing up, falls like off a roof.

Nursing interventions for status elipepticus, give Ativan IV push until the seizure stops then hang Dilantin trip. Monitor respirations and blood pressure. And follow all seizure precautions.

50

Meningitis,

inflammation of the meninges that surround the brain and spinal cord.

Etiology, bacterial or viral.

Risk factors, otitis media, pneumonia, acute or chronic sinusitis, sickle cell anemia, brain or spinal surgery.

51

Bacterial meningitis

life-threatening causes loss of limbs and loss of mental functioning. With bacterial meningitis people usually die.

Meningococcal meningitis is the most common bacterial meningitis.

Emergency with high mortality rate, causes the most severe presentation.

It affects the meninges, subarachnoid space, and brain tissue.

It is highly contagious.

It occurs in outbreaks in areas of high population and density areas. Such as in college dorms, day cares, and very crowded places. People get very very sick.

52

Meningitis clinical manifestations,

fever, headache, altered mental status, photophobia, nuchal rigidity.

53

Meningitis nursing interventions,

laboratory, draw blood

Diagnostic, CT

Medications

Nursing assessment including neuro checks

Standard precautions with dropplet precautions for bacterial. If the patient has this, they have to have a mask when being transported outside of the room.

Lumbar puncture: analysis of cerebrospinal fluid if – cerebrospinal fluid is clear, this means no infection. If the cerebrospinal fluid is white or cloudy that's usually a sign of meningitis.

Cloudy= increased WBC,Protein, Pressure increased….Glucose decreased

54

Parkinson's disease, progressive neurodegenerative disease.

***Characterized by four signs and symptoms tremor, rigidity, bradykinesia or akinesia, and posterior instability.

55

Parkinson's disease etiology

environmental, genetic factors.

Risk factors include exposure to pesticides, greater than 40 years old, reduced estrogen levels, men have a greater chance of getting it than women.

56

Parkinson's disease
neurotransmitters:

-dopamine produced in the gray matter of the brain, produce nerve cells transmitted to the brain when needed.

-Acetylcholine produced by neurons, make things excitable. Gets things moving.

When dopamine is released it lets your body have more control over the acetylcholine.

57

Sympathetic nervous system decreases with Parkinson's disease.

Slows the heart rate and the blood pressure. Orthostatic hypotension puts elderly patients at fall risks.

Fall risks are greater at night in the elderly. Educate them to sit on the corner of their bed for a couple of minutes before standing.

58

Clinical manifestations of Parkinson's disease,

dopamine decreases in the brain, person loses refined motor skills.

59

Stages of Parkinson's table 44-3

Stage 1 : initial stage, unilateral limit involvement, minimal weakness, hand and arm trembling.

Stage 2: mild stage, bilateral limb involvement, mask like face, slow shuffling gait.

Stage 3: moderate disease, postural instability, increased gait disturbances.

Stage 4: severe disability, alkinesia, rigidity.

Stage 5: complete ADL dependence .

60

Key features of Parkinson's disease:

Posture: stooped posture, flexed trunk, fingers abducted and flexed, wrist slightly dorsiflexed.

Gait: slow and shuffling, short hesitant steps, propulsive gait, difficulty stopping quickly.

Motor: bradykinesia slow movement, muscular rigidity, alkinesia, tremors, Pill rolling movement, masked like face, difficulty chewing and swallowing, uncontrolled drooling, fatigue, difficulty getting in and out of bed, reduced arm swinging on one side of the body when walking, micrographia (change in handwriting or handwriting gets smaller.)

Speech: soft low pitch voice, slurred speech, echolalia, hypophonia (soft voice),

Autonomic dysfunction: orthostatic hypotension, excessive perspiration, oily skin, seborrhea , Flushing, changes in skin texture, eyelid spasms,

Psychosocial assessment: emotional labile, depressed, paranoid, easily upset, rapid mood swings, cognitive impairments such as dementia, delayed reaction time, sleep disturbances.

61

Nursing interventions for Parkinson's disease

Drug therapy- requip dopamine agonists last about 5 years.
Airway
ADL
Psychosocial support
Surgery

Parkinson's patients do not sleep well, it is important that for them to exercise.

62

Nursing safety priority drug alert

Dopamine agonist are associated with adverse effects such as orthostatic hypotension, hallucinations, sleepiness, and drowsiness.

Remind patients to avoid operating having machinery or driving if they have any of these symptoms.

Teach them to change from a lying or sitting position to a standing by moving slowly.

The healthcare provider should not prescribe drugs in this class to older adults because of their severe adverse drug effects.

63

When drug tolerance is reached, the drugs affect do not last as long as previously.

The treatment of Parkinson's disease drug toxicity or tolerance includes: a reduction in the drug dose, a change of drug or in the frequency of administration, or a drug holiday particularly with levodopa therapy.

During a drug holiday, which typically lasts for up to 10 days, the patient receives no drug therapy for Parkinson's disease.

Carefully monitor the patients for symptoms of Parkinson's disease during this time, and document any assessment findings.

64

What are the types of spinal cord injuries?

Complete- Total fracture of the spinal cord and everything is torn

Incomplete- Not damaged all of the way through.

This is why some people have more movement and sensation than other people.

65

What is the difference between primary and secondary mechanisms of injury involving the spinal cord?

Primary:
Hyperflexion- Can be caused by head on collision

Hyperextension- Can be caused by getting rear-ended.

Axial Loading-(vertical compression) can be caused by fall injuries (roof, ladders) or diving injuries (pool, lake)

Tumors and clots

Secondary:
Something that is caused by the primary injury such as bleeding or ischemia

66

What is the etiology of a spinal cord injury?

Trauma, Falls, Violence

67

What level of injury results in Quadriplegia?

C4 Injury Cervical Neck
C6 Injury

basically anything T5 and up

68

What level of injury results in Paraplegia?

T6 Injury down

69

If a patient comes in with a vertebre fracture, regardless of where it is located, what is your number 1 nursing priority?

Place them on a back-board with a C collar. You do this to stabilize them because you can make it worse.

So number 1 priority is keeping the spine aligned.

Then give Medications

The ABC's

70

What is the first drug that we give for a spinal injury?

Methylprednisone-

This decreases the inflammation to give it a chance to heal. The more pressure that is in there can result in an incomplete spinal injury becoming complete.

71

Thoracic Injury- What is your number 1 Priority after Stabilization and meds?

Worry more about breathing than airway. They can typically maintain their airway because they are not parylized.

So post op with these patients. Really Focus on Incentive Spirometer and Cough and deep breath excercises to prevent breathing complications.

Monitor for fever

And skin Breakdown (people hide their bedsores)

72

Spinal Cord Injury Assessment

**Autonomic Nervous System now is damaged and is not working right

Cardio-
- Bradycardia,
- Hypotension- HR less than 90 causes us to not
perfuse the spinal area. CONCERN
- Hypothermia- these patients are usually cold
because they take on the temperature of the
environment. GIve Blankets.

Stress Ulcers- from steriods

Urinary Retention- right off the bat, then will have
spells throughout their lives.

Muscle Wasting/Skin Breakdown/Psychosocial-
usually we always send them to rehab, helps with skin issues and prevents patient from getting worse than they are. Helps psychologically

Moving/Transferring- Log rolling, done by 3 to 4 people to keep everything aligned.

Rehabilitation- PT and OT

73

Assessing Motor Function in the patient with a spinal cord injury

- to assess C4-5, apply downward pressure while the patient shrugs shoulders upward

- to assess C5-6, apply resistance while patient pulls up his or her arms

- to assess C7, apply resistance while patient straightens their flexed arms

- to assess C8, make sure a patient is able to grasp an object and form a fist

-to assess L2-4, apply resistance while the patient lifts their legs from the bed

- to assess L5, apply resistance while the patient dorsiflexes their feet

- to assess S1, apply resistance while the patient plantar flexes their feet

74

****Nursing Safety Priority Critical Rescue

Observe the patient with an upper SCI (Above the level of T6) for signs of autonomic dysreflexia (hyperreflexia).

Although it does not occur frequently, autonomic dysreflexia is an excessive, uncontrolled sympathetic output.

It is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing.

The cause of this syndrome is a noxious stimulus- usually a distended bladder or constipation. This is a neurologic emergency and must be promptly treated to prevent hypertesive stroke!

75

What is Multiple Sclerosis

An autoimmune disease that affects the myelin sheath and conduction pathway of the CNS

Hard to diagnose because it mimicks other neurological disorders.

Patients often have periods of remission and exacerbation.

Nystagmus is typically first symptom

Over time symptoms become perm

76

What is the etiology of MS

Viral,
Immunologic,
Environmental,

***Genetic- predisposition that causes the body to dysfuntion and attack itself.

77

What are the nursing interventions for a person with MS

Drug therapy

Methylprednisone- steroid that decreases inflammation

Gilenya- oral immunomodulator

Both medications cause the patient to be at risk for infection. Teach to avoid crowds and sick grandchildren.

Teach to monitor pulse because can cause bradycardia

78

Clinical Manifestations of MS

Muscle Weakness
Fatigue
Intention Tremors
Numbness
Increased sensitivity to pain
Inability to direct or limit movement
dysphasia
slurred speech
ataxia
bowel bladder dysfunction
Tinnitus
Diplopia
nystagmus
cognitive changes

79

What is Amyotrophic Lateral Sclerosis (ALS)

adult onset upper and lower neuron disease

no cause, no cure, No specific treatment

With ALS upper and lower motor neurons are destroyed. Patients become weaker and eventually are paralyzed. Brain is 100% intact.

People are usually young when diagnosed 40-60.

Men get it more than women.

Drug therapy Riluzole (Rilutek)- halt respiratory symptoms for 3-6 months

80

Guillain-barre syndrome,

mobility and sensation problem. Acute inflammatory demyelinating polyneuropathy that affects the peripheral nervous system causing motor weakness and sensory abnormalities.

Ascending paralysis might start out not being able to walk and travels to be complete paralysis.

81

Key features of Guillain-barre syndrome,

Motor manifestations:
ascending symmetric muscle weakness, flaccid paralysis without muscle atrophy.

Decreased or absent deep tendon reflexes.

Respiratory compromise, dyspnea, diminished breath sounds, decreased tidal volume and vital capacity and respiratory failure.

Loss of bladder and bowel control (less common)

Ataxia.

Sensory manifestations, paresthesia, pain, cramping

Cranial nerve manifestations, facial weakness, dysphasia, diplopia, difficulty speaking.

Autonomic manifestations, labile blood pressure, cardiac dysrhythmias, tachycardia.

82

Factors associated with development of Guillain-barre syndrome,

Acute illness,
gastrointestinal illness,
bacteria,
HIV infection,
mycoplasma pneumonia,
surgery,
upper respiratory infection,
virus,
vaccinations,
drugs,
Hodgkin's disease.

83

Nursing interventions for Guillain-barre syndrome,

CSF, lumbar function, protein increased but not white count.

Plasmapheresis, like dialysis but it removes antibodies that they feel are attacking the Mylein sheath, hypertension and tachycardia are the main concerns during and after plasmapheresis

Monitor ABC's,

Recovery is very slow

84

Myasthenia gravis,

acquired autoimmune disease characterized by fatigue and weakness primarily in the muscles.

Auto antibody attack on the acetylcholine receptors, nerve impulses are not making it to the muscle. Worried about breathing. Think it is related to enlarge thymus.

Correlation between hyperplasia and the thymus gland

85

Myasthenia gravis diagnostic assessment,

lab for acetylcholine antibodies 90% will have elevated levels.

Tensilon testing, try to check the body into working. Doctors give med through the IV that prevents acetylcholine from breaking down. They can move for a few minutes, then it wears off. They can go into VFIB because of the medicine, have to give atropine to counteract the tensile to fix the problem. Need to be hooked to a heart monitor during the test.

86

Drug therapy, real important,

give immunosuppressive's to calm the body from attacking The acytlcholine receptors.

Give and teach to avoid crowds.

Give meds one hour before eating to prevent aspiration.

87

Myasthenic crisis,

not enough of the medication in their system.

Getting sick can throw them into this crisis.

Causes muscle issues and not being able to breathe.

Interventions are based on the patient's reactions.

Need more meds, and may need to be intubated.

88

Cholinergic crisis,

too much medication on board, give atropine which is the antidote.

89

Trigeminal neuralgia,

affects the trigeminal or fifth cranial nerve

90

Etiology of Trigeminal neuralgia,

impaired inhibitory mechanisms in the brain stem. This causes brainstem issues, signals get messed up, chronic pain, typically starts in 50 or older.

This is a chronic pain syndrome of the face. Teach the patient to use eyedrops at night, do not sleep on that side, eat on the good side.

91

Drug therapy for Trigeminal neuralgia,

Tegretol, and neurontin, so cannot drink alcohol will make too drowsy.

92

Percutaneous stereotactic rhizotomy,

destroys nerve fibers that are causing the pain. The entire nervous not destroyed just the irritated park.

93

Surgical management microvascular decompression

more serious surgery, craniotomy, reroutes the artery from the nerves. ICU Postoperative.

94

Bell's palsy,

disease of the cranial nerve number 7, causes acute paralysis unilateral.

95

Eitiology of Bells Palsy

implement inflammatory process triggered by herpes of the mouth.

96

Nursing interventions for Bells Palsy

- drug therapy, Valtrex and pain medication.

- Manage neurologic deficits, make sure that the eye is protected. Sleep with something over it..

- Diet, small meals, chew on unaffected side, educate the patient to eat soft foods.

Recovery in a few weeks. Most or recover and have no residual side effects. Some may have residual side effects but most do not.

97

What is the Sympathetic NS Responsible for?

Sympathetic, fight or flight.
Dilates pupils
Dries spit
Increases heart rate
Bronchodilation
Slows digestion and secretion
Stimulates glucose release in liver
Stimulates release of Epi and Norepi in kidneys
Relaxes bladder

98

What is cranial nerve number one?

Olfactory

Origin- olfactory bulb.

Type- sensory.

Function, smell.

99

What is cranial Nerve number two?

Optic

Origin- midbrain.

Type- sensory.

Function, central and peripheral vision.

100

What is cranial nerve number three?

Oculomotor

Origin- midbrain.

Type- motor to Eye muscle.

Function- Eye movement via medial and lateral rectus and inferior oblique and superior rectus muscles; lid elevation via Levator muscle and pupil constriction (parasympathetic); Ciliary muscles.

101

What is cranial nerve number four?

Trochlear

Origin- lower midbrain.

Type- motor.

Function- eye movement via superior oblique muscles.

102

What is cranial nerve number five?

Trigeminal

Origin- Pons .

Type- sensory. And motor.

Function-
(sensory) sensation from skin of face and scalp and mucous membranes of the mouth and nose.

(motor) Muscles of mastication or chewing.

103

What is cranial nerve number six?

Abducens

Origin- inferior pons.

Type- motor.

Function- Eye movement via lateral rectus muscles.

104

What is cranial nerve number seven?

Facial

Origin- inferior pons.

Type- sensory, motor, parasympathetic motor.

Function-
(sensory) pain and temperature from ear area. Deep sensation from the face. Taste from anterior two thirds of the tongue.

(motor) Muscles of the face and scalp.

(parasympathetic) Lacrimal , submandibular, and sublingual salivary glands.

105

What is cranial nerve number eight?

Vestibulocochlear

Origin- pons medulla junction.

Type- sensory.

Function- hearing and equilibrium.

106

What is cranial nerve number nine?

Glossopharengeal

Origin- medulla.

Type- sensory, motor, parasympathetic motor.

Function-
(sensory) pain and temperature from the ear. Taste and sensation from posterior one third of tongue and pharynx.

(motor) Skeletal muscles of the throat.

(parasympathetic) Parotid glands.

107

What is cranial nerve number 10?

Vagus

Origin- medulla.

Type- sensory, motor, parasympathetic motor.

Function-
(sensory) pain and temperature from the ear. Sensation from the pharynx, Larynx, thoracic and abdominal viscera.

(motor) Muscles of the soft palate, pharynx and Larynx.

(parasympathetic) Thoracic and abdominal viscera. Cells of the Secretory glands. Cardiac and smooth muscle innervation to the level of the splenic flexure.

108

What is cranial nerve number 11?

Accessory

Origin- medulla anterior grey horn of the cervical
Type- motor.

Function- skeletal muscles of the pharynx and Larynx and sternocleidomastoid and trapezius muscles.

109

What is cranial nerve number 12?

Hypoglossal

Origin- medulla.

Type- motor.

Function- skeletal muscles of the tongue.

110

Anatomy and physiology review of neurologic changes associated with aging.

Mobility

Sensation

Older people have slower movement and slower response time.

Pupils decrease in size a older people do not get as much light as they are used to, so they are at risk for falls.

Make sure to keep the room clean, no clutter, no rugs, no slip socks, bed alarms ect..

111

Chart 43-1
Physiologic changes in the nervous system related to aging.

1. Slower processing time

2. Recent memory loss.

3. ***Decreased touch sensation.

4. Change in perception of pain.

5. Changes in sleep patterns.

6. Altered balance and or decreased coordination.

7. Increased risk for infection.

112

1. Slower processing time

nursing implications provide sufficient time for the affected older adult to respond to questions and or direction.

Allowing adequate time for processing helps to differentiate normal findings from neurological deterioration.

113

2. Recent memory loss.

Nursing implications, reinforce teaching by repetition and written teaching aids.

Greatest loss of brain weight is in the white matter of the frontal lobe. Intellect is not impaired, but the learning process is slowed.

Repetition helps the patient learn new information and recall it when needed.

114

3. ***Decreased touch sensation.

Nursing implications, remind the patient to look where his or her feet are placed when walking.

 Instruct the patient to wear shoes that provide good support when walking.

If the patient is unable, change his or her position frequently, such as every hour if he or she is in the bed or the chair.

Decreased sensation may cause the patient to fall.

115

4. Change in perception of pain.

Nursing implications, Ask the patient to describe the nature and specific characteristics of pain.

Monitor additional assessment variables to detect possible health problems.

Accurate and complete nursing assessment ensures that the interventions will be appropriate for older adults.

116

5. Changes in sleep patterns.

Nursing implications, ascertain sleep patterns and preferences.

Ask if sleep pattern interferes with daily living.
Adjust the patient's daily schedule to his or her sleep pattern and preferences as much as possible e.g. evening versus morning bath.

Most older adults require less sleep then do younger adults. However, frequent rest periods are needed.

117

6. Altered balance and or decreased coordination.

Nursing implications, instruct the patient to move slowly when changing positions.

If needed, advise the patient to hold on to the hand rails when ambulating.

Assess the need for an ambulatory aid, such as a cane. The patient may fall if moving too quickly.

Assistive and adaptive aids provide support and prevent falls.

118

7. Increased risk for infection.

Nursing implications, monitor carefully for infection.

Older adults often have structural deterioration of microglia the cells responsible for cell mediated immune response in the central nervous system.

119

What color does blood appear on a CT?

Blood appears white on a CT, which is hemorrhagic in nature.

This is stopped by surgery.

120

What color does a clot appear on a CT?

Clots appears dark on a CT which is ischemic in nature. Give TPA. Monitor for bleeding.

121

What cranial nerve does PEERLA assess?

Cranial nerve number 3, 4, 6
oculomotor, Trochlear and Abducens

If a patient presents and they are having a hard time seeing or has cataracts or glaucoma, pupils might be a little bit irregular. Do not be alarmed by this, we are more interested in how they respond to light and accommodation.

122

What is the main functions of the frontal lobe?

The primary motor area also known as the "motor strip, or cortex"

broca's speech center on the dominant side.

voluntary eye movement.

access to current century data.

access to past information or experience.

affective response to a situation.

regulates behavior based upon judgment and foresight.

judgment.

ability to develop long-term goals, reasoning,

concentration, abstraction.

123

What are the main functions of the temporal lobe?

Auditory Center for sound interpretation.

Complicated memory patterns.

Wernecke's area for speech.

124

What is something that you could see if someone had an accident and damaged their frontal lobe?

If someone's frontal lobe is damaged, this could cause judgment issues and blurting out inappropriate things.

125

What is something that you could see if someone's temporal lobe is damaged?

If someone's temporal lobe is damage, that could result in hearing loss on that side, so we would need to speak to the person on the other side. .

126

What is Acute Pancreatitis,

Inflammatory process of the Pancreas.

Excessive pancreatic Enzymes that destroy ductal tissue and pancreatic cells.

127

What is the etiology of Acute Pancreatitis,

Etiology: Trauma, Biliary tract disease w/ gallstones

128

What are the S&S of Acute Pancreatitis,

S&S: Abdominal Pain, Nausea and Vomiting.

129

*****What are the complications of Acute Pancreatitis,

Complications: Turner’s Sign- Bruising of the flanks. That can indicate that the pancreatic enzymes are leaking into the peritoneal area which causes bruising.


Diagnosed: S&S, Labs, CT

130

***What are the non surgical interventions for acute pancreatitis?

Non-Surgical: *****NPO, (will trump everything, even pain meds, we do not want to stimulate the pancreas to produce more enzymes) IV Fluids, Medications, Nutrition

131

What surgeries are done for acute pancreatitis?

Surgical: Endoscopic Retrograde Cholangiopancreatography (ERCP), Cholecystectomy

132

What is chronic pancreatitis?

Destructive disease of pancreas that has remission and exacerbations.

133

*****What is the etiology of chronic pancreatitis?

Etiology: Alcoholism

S&S: same as acute.

134

******What are the Chronic Pancreatitis Interventions

Non-Surgical: NPO, IV Fluids, Medications, Pancreatic-Enzyme Replacement Therapy (PERT) must take with food and can sprinkle on food but must rinse off lips, mouth, skin, fingers ect because it will break down what it is sitting on, Nutrition

Discharge Teaching- Alcohol help, diet needs to be low in fat, smoking is also an issue. The most important one to fix is the alcohol.


Surgical: Palliative

135

Where is the Gallbladder located?

Located underneath the liver.

136

What does the gallbladder do?

Drained by Cystic Duct, which joins the hepatic duct from liver to form the Common Bile Duct.. Stores bile that comes from the liver. You can live without your gallbladder.

Collects, concentrates and stores bile that come from liver

Releases bile into duodenum via Common Bile Duct

137

What is Cholecystitis

Inflammation of the Gallbladder

138

What are the Two types of acute cholecystitis:

1. Calculous-
2. Acalculous

139

What is Calculous-

A type of acute cholecystitis that is characterized by a blockage of the flow of bile due to stones.

140

What is Acalculous

A type of acute cholecystitis that is characterized by inflammation without gallstones. May be from twisting or stasis of the duct.

141

What is Cholelithiasis

the gallstones in the gallbladder

142

Chronic Cholecystitis has periods of remission and exacerbation. Where is the etiology and the risk factors?

Familial or Genetic Tendency, Nutrition Habits

Risk Factors Four Fs: Female, Forty, Fat, Fertile typically

143

What are the Cholecystitis S&S

mainly pain, very severe and wont stop,


Diagnosed X-Ray and Ultrasound and CT

144

What are the non surgical interventions for Cholecystitis

Non-Surgical: Avoid fatty foods, Medications, for pain and nausea, and Fluids

145

What are the surgical interventions for Cholecystitis

Surgical: Cholecystectomy- removal of the gallbladder.

***Teach watch what they eat. Typically fatty foods aggravate it. They inject Carbon Dioxide into the abdomen which can cause referred shoulder/back pain. To prevent this, the patient must ambulate early which helps reabsorb the carbon dioxide. Also give pain meds.

146

What is obstructive jaundice?

Obstructive Jaundice- normal flow of bile is obstructed. Bile salts can accumulate in the skin which causes you to itch. Seen with Gallbladder and Liver Patients.

147

What quadrant is the liver in?

Located RUQ

Forms and continually secretes Bile that is used to digest fats. Aids in the destruction of old RBC’s. It get gets rid of them through your stool. That is what gives it the color that it has.

148

What do hepatic ducts do?

Hepatic Ducts transport bile from liver.

149

Where does the liver receive blood from?

Receives blood supply from hepatic artery and portal vein. About 1500mL of blood flows through liver every minute. So it is very vascular. This is why liver trauma is such as big deal.

150

What are the 3 main functions of the liver?

Function: Storage, Protection, Metabolism

151

What does the liver store?

Stores: Minerals and Vitamins such as iron, magnesium and fat-soluble vitamins A, D, E, K. Since it stores Vitamin K, if it is not working properly, liver patient will have a lot of clotting issues.

152

What is the protective mechanism of the liver?

Protective: Phagocytic Kupffer cells, detoxifies and metabolizes a lot of medications.

153

What does the liver metabolize?

Metabolism: Amino acid breakdown, transports your lipids and hormones, Synthesizes plasma protein, fatty acids and triglycerides, produces bile.

154

What is Jaundice-

build up of billirubin. This is a classic liver issue.

155

What is Liver-Cirrhosis?

Extensive irreversible scarring of the liver usually caused by chronic reaction to hepatic inflammation and necrosis. Once a person has liver cirrhosis, their life expectancy decreases as well as their quality of life. Some can be put on the liver transplant list and some can not. It depends if they are going to stop using the drugs or alcohol.

156

Does Liver-Cirrhosis develop fast or slow?

Develops slowly, is irreversible. Widespread fibrotic (scarred) bands of connective tissue that changes the liver’s normal makeup, this causes it to not work properly.

Hepatocytes are destroyed

As cirrhosis develops the tissue becomes nodular

Nodules can block bile ducts and normal blood flow

157

True or False

Early on, the liver is enlarged (hepatomegaly), firm and hard and may be palpated within the RUQ.

True


Later, as it progresses, the liver shrinks and liver function decreases

158

What are the S&S of Liver Cirrhosis?

S&S may not develop until serious complications occur- GI symptoms. Will usually be found on a CT.

159

What is the etiology of liver cirrhosis?

Etiology - Hepatitis, Alcoholism and Biliary Obstruction. Hepatitis C leading cause of cirrhosis in America. Transmitted via blood. Alcohol has a direct toxic effect on the hepatocytes. Affects men more than women.

160

What are the more common types of liver cirrhosis?

Common types of liver cirrhosis: Laennec’s Cirrhosis (alcohol,
most common in the US),

Billiary, Cirrhosis and Post Necrotic Cirrhosis are the three main groups.

161

What are the risk factors for liver cirrhosis?

Risk Factors- Alcohol intake, IV illicit drug use, Tattoos, Profession (RN, drawing blood)

162

WHat are the clinical manifestations of liver cirrhosis?

Clinical Manifestations - Non-specific early, not a lot of signs and symptoms. The liver tries to fix it, and does a good job. But over time, it just cannot do it anymore.

163

****WHat are the labs that you do for liver cirrhosis?

Lab work: Transaminase Enzymes --- PT/INR usually changes first (increases will cause patient to bleed easily). PTT will change second, AST, ALT will be elevated (this indicates liver injury).

164

What are the complications of liver cirrhosis?

1. Portal HTN-

2. Ascites and Esophageal Varices-

3. Coagulation Defects-
4. Jaundice

5. Portal-Systemic Encephalopathy with Hepatic Coma

6. Hepatorenal Syndrome-

7. Spontaneous Bacterial Peritonitis-

8. Hepatopulmonary Syndrome-

165

What are the 3 most common liver complications for patients with Cirrosis?

1. Ascites
2. Esophageal Varices
3. Hepatic Encephalopathy

166

What is Portal HTN-

elevated pressure in the portal vein system. The damage in the liver puts extra pressure on the portal Vein.

167

What are Coagulation Defects-

PT, PTT, INR will be elevated. Will be worried about bleeding issues with liver patients.

168

What is Hepatorenal Syndrome-

decrease in kidney function. Increase in portal vein system causes the renal arteries to constrict thus reducing blood flow to the kidney’s.

169

What is Hepatopulmonary Syndrome-

prone to SOB and Hypoxia. Get alot of vasodilation in the lungs related to the portal vein system. They have extra fluid in the lungs so you will hear crackles. They cannot tolerate lying flat very well.

170

What is Ascites

A collection of fluid within the peritoneal cavity. This is related to portal vein HTN. The liver makes Albumin, when it is not working, it does not produce enough albumin to keep the fluid in the vascular space. (sort of like a magnet) So the fluid just hangs out in the peritoneal cavity. This can cause hypovolemia and pitting edema all at the same time.

171

**What are the Nursing Interventions for Ascities,-

Nutrition: Low Na, Vitamins

**Drug Therapy: Diuretic, (Lasix), Albumin (in a glass bottle, just hang it like a drip) Normal albumin level is 3.5 - 5. It will become low when the liver is not working correctly.

Monitor for Spontaneous Bacterial Peritonitis (SBP) and for Fluid and Electrolyte Imbalances the patients are at risk for these.

**Paracentesis - drawing off the fluid in the peritoneal cavity. A sample is sent to the lab to make sure that there is not an infection (peritonitis). Usually done in radiology. When they come back from the procedure, what you need to monitor is Blood Pressure and Urine Output. May cause hypotension. They should be able to breathe easier. Cultures take about 3 days to come back.

**Respiratory Support- because all of that fluid in the abdomen can make it hard to breathe. Make sure they are sitting up, Do not lay them back even to cath them. Put them on Oxygen.

172

What are Esophageal Varices-

these patients are prone to having a GI Bleed. What happens is portal HTN causes increased pressure so causes blood to back up from the liver into the esophageal gastric vein system. These veins are very fragile and can break easily.

173

What are the S&S of Esophageal Varices-

S/S of Esophageal Varices- Patients will present with vomiting blood.

174

Nursing Interventions for Esophageal Varices-

Medications: Prevention-Beta-Blocker (keeps the pressure low to prevent the patient from bleeding), Bleeding-Vasoactive (if actively bleeding, PT will be placed on a Vasoactive drug until they can go for a Ligation or Sclerotherapy.)

Esophageal Varices- Patients will be NPO, if they do not have a balloon they will have an NG tube to decompress the stomach, may give Blood, get Labs, Vital Signs, keep their nausea under control.


***Endoscopic Therapies: This is for THE FIRST TIME BLEEDERS ONLY. Ligations (They get an O Ring and place it at the base of the bleeding vessel and block it off. This works well for patients) and Sclerotherapy (Inject the vein with saline, the vein will collapse and the body will reabsorb it in theory.

175

****What are the nursing interventions for a person who has Esophageal Varices and underwent endoscopic therapy but is now RE-BLEEDING?

Rescue Therapies for Re-Bleeding: This is more aggressive therapy.


***Balloon- Blakemoore tube, has a lot of complications attached with it. It is kind of like an NG Tube. It inflates and places pressure against the esophageal wall until it stops. If your patient has it monitor their breathing. They can aspirate easily. If ballooned to tight it can rupture the esophagus. Airway and breathing is priority. High Fowlers position. Mostly done in ICU. Remember that you can deflate and remove it if in distress.

Stents- are similar to cardiac stents. Fairly new therapy. Teach that the patient needs to eat soft foods after these are placed.

TIPS. Trans-Juggular Intra-Hepatic Portal Systemic Shunt- opens the portal vein up so that all of the pressure is not so high.

176

What is Hepatic Encephalopathy-

This is very common in liver patients. What you liver normally detoxifies and gets rid of, it isn’t able to do any more, so it gets put back into the GI tract which causes an elevated ammonia bi-product. This ammonia level builds up in the circulation and the first place that gets affected is your brain. It can causes LOC changes that range from confusion to coma. The liver cannot get rid of the ammonia. This is why we have them on a low protein diet because the more protein that you eat, the more ammonia that you have.

177

******What are the Nursing Interventions for Hepatic Encephalopathy-

**Nutrition: Low-to-Moderate Protein ( VERY LITTLE)

**Drug Therapy: Lactulose (binds with the ammonia and they get rid of it that way. It takes it a hour or so to work and then the patients LOC will start to get Better) , Some medications are restricted

**Neuro, Safety- Patient is confused so will be more prone to falling and will not be able to turn themselves in bed ect.

Ammonia levels are drawn and put on ice when sent to lab (so is lactic acid) (NOT ON TEST)

178

****What is the etiology and recovery of Hepatitis C?

***Etiology: Blood, IV Drug use

Incubation: 7 weeks

S&S: Some none, others RUQ pain, malaise, fever, jaundice or when they begin to have liver problems

****Recovery: Typically develop Liver Cirrhosis 9 times if not 10 time out of 10. Be careful when drawing blood.

179

When is hepatitis considered chronic?

Considered to be chronic when liver inflammation last longer than 6 months

180

Which 2 types of hepatitis can be chronic?

Chronic Hepatitis usually occurs as a result of Hepatitis B (HBV) and Hepatitis C (HCV)

181

Which type of hepatitis is the most common?

Hep C most common

182

**Paracentesis -

drawing off the fluid in the peritoneal cavity. A sample is sent to the lab to make sure that there is not an infection (peritonitis). Usually done in radiology. When they come back from the procedure, what you need to monitor is Blood Pressure and Urine Output. May cause hypotension. They should be able to breathe easier. Cultures take about 3 days to come back.

183

Pre-Malignant Lesions

What are the 2 types of Oral Tumors (Pre-Malignant Lesions) That we went over?

1. Leukoplakia-
2. Erythroplakia-


Oral Tumors affects swallowing, chewing and speaking. We have a lot of airways issues in this group;.

184

Leukoplakia-

the location will determine whether it is pre cancerous or not. They can be related to poor mouth care, poor fitting dentures that rub, bacteria can invade, but the main cause of these are due to chewing tobacco as well as cigs.

185

Leukoplakia S&S:

thick white patches,

186

Erythroplakia-

This type generally turns to cancer more than not.

187

Erythroplakia S&S:

red velvety mucosal lesion

188

*** Prevention of Pre-Malignant Lesions-

We need to educate patients on how to prevent these cancers because once they have it, it takes them down a whole new road of interventions.

1. Teach them to avoid too much Sun or Tanning Bed Exposure.

2. Tobacco- chewing and cigs.

3. Alcohol- in excess.

189

What are the two types of cancerous lesions of the mouth that we went over?

1. Squamous Cell Carcinoma of the mouth

2. Basal Cell Carcinoma of the mouth

190

Squamous Cell Carcinoma of the mouth

1. 90% of oral cancers are squamous cell carcinoma

******2. Etiology: Increase age, tobacco, alcohol. This one metastasizes.

191

Basal Cell Carcinoma of the mouth

1. Primary on lips or under the tongue, a raised scab

******2. Etiology: Excessive sunlight exposure, tobacco, usually does not metastasize

192

Treatments of Squamous Cell Carcinoma and Basal Cell Carcinoma of the mouth-


Non-Surgical-

Radiation/Chemotherapy or Multimodal therapy.

Mouth Care: Rinse mouth with sodium bicarbonate solution or warm saline.

Do not use mouthwash with alcohol and no lemon-glycerine swabs

193

Treatments of Squamous Cell Carcinoma and Basal Cell Carcinoma of the mouth-

** Surgical Management-

Types of surgeries:

These are pretty dramatic. Glossectomy-tongue removal or Hemiglossectomy- partial- they use skin from your wrist or from somewhere else to replace what they removed.

Mandibulectomy-jaw removal or mandibular resection.

Neck Dissection- where they remove lymph nodes ect.

**Airway is a big issue.

194

Treatments of Squamous Cell Carcinoma and Basal Cell Carcinoma of the mouth-

** Surgical Management-

Pre-op:

Post-op:

Pre-op: accepting diagnosis- social and emotional aspects to deal with.

Post-op (ICU): Depends on the Size, location, invasion into bone and presence or absence of metastasis influence the extent of surgery. They will be intubated and Trached, with NG Tubes.

**Airway is a big issue.

195

Treatments of Squamous Cell Carcinoma and Basal Cell Carcinoma of the mouth-

** Surgical Management-

What would you do to promote airway management?

Airway Management--
HOB elevated, especially if patient complains of swelling,

have suction ready. Make sure suction device is ready and hose it attached with a yanker at the bedside.

Patient may have trach after surgery, NPO, Respiratory, NG tube, dysarthria.

More than likely they will get TPN.

Promote early ambulation.

Turn Cough Deep Breathe and IS.

Increase fluids.

Help them communicate with a board.

196

Treatments of Squamous Cell Carcinoma and Basal Cell Carcinoma of the mouth-

** Surgical Management-

What is the discharge teaching for the patient and family?

Leaving Hospital after surgery- Need to teach them 2 things.

1- mouthcare and

2 Monitor for metastasis of cancer.

Teach them where it would travel next such as the neck and lymph-nodes.

Cancerous lumps feel hard. Avoid Xerostomia because risk for cavities.

197

The nurse is teaching a group of teenage boys who are on a college baseball team about the risks of chewing tobacco. Which of the following should the nurse instruct the teenagers to report to their parents and physicians? Select all that apply.


a) Dysphagia
b) Sensitive teeth
c) Unexplained mouth pain
d) Lump in the neck
e) Decreased saliva
f) White patch on the mucosa

a) Dysphagia

c) Unexplained mouth pain
d) Lump in the neck

f) White patch on the mucosa

198

A nurse is caring for a client who has just returned from surgery to treat a fractured mandible. Which of the following items should always be available at this client’s bedside? Select all that apply.

a) Nasogastric tube
b) Wire cutters
c) Oxygen cannula
d) Suction equipment
e) Code cart

b) Wire cutters
d) Suction equipment

199

The nurse is preparing a community presentation on oral cancer. Which of the following is a primary risk factor for oral cancer that the nurse should include in the presentation?

a) Use of alcohol
b) Frequent use of mouthwash
c) Lack of vitamin B12
d) Lack of regular teeth cleaning by a dentist

a) Use of alcohol

(or tobacco)

200

A client has entered a smoking cessation program to quit a two-pack-a-day cigarette habit. He tells the nurse that he has not smoked a cigarette for 3 weeks but is afraid he is going to slip up and smoke because of current job pressures. What would be the most appropriate reply for the nurse to make in response to the client’s comments?

a) “Don’t worry about it. Everybody has difficulty quitting smoking and you should expect to as well.”

b) “If you increase your self-control, I am sure you will be able to avoid smoking.”

c) “Try taking a couple of days of vacation to relieve the stress of your job.”

d) “It is good that you can talk about your concerns. Try calling a friend when you want to smoke.”

d) “It is good that you can talk about your concerns. Try calling a friend when you want to smoke.”

201

**** What is cranial nerve number 5

Trigeminal Nerve #5 (sensation, biting, chewing, those types of things).

202

**** What is cranial nerve number 7

Cranial Nerve #7 Facial - controls muscle and facial

203

***Salivary Gland Tumors-

It is slow growing, painless and rare. It involves the facial nerves depending on how large the tumor has grown, and it will be on that side of the face. They can have facial paralysis or weakness on that side and also have issues with their tongue.

204

Who is at risk for Salivary Gland Tumors-

At risk those who have head radiation to head and neck areas

205

****What do you need to assess when a patient has Salivary Gland Tumors-

Assessment of facial nerve, monitor for asymmetry-

Need to ask them to smile or frown. Raise your eyebrows, puff your cheeks out. This is how you assess the patients Trigeminal Nerve #5.

206

What is the treatment for Salivary Gland Tumors-

Treatment: Same for benign and malignant tumors- Radiation and Surgical Excision

Parotidectomy (removal of parotid gland)- This depends upon which of the glands that it is.

Submandibular Gland Surgery

207

*** What is the post-op care for Salivary Gland Tumors-

Post-op- They have gone to surgery and had a gland removed.

During the surgery, they have probably damaged their Trigeminal Nerve #5 (sensation, biting, chewing, those types of things).

So you will notice weakness, or complete loss of that cranial nerve on that side.

Cranial Nerve #7 Facial - controls muscle and facial expression. If a nerve was effected, they will be forever.

Facial weakness on operative side r/t facial nerve irritated during surgery

208

Gastroesophageal Reflux Disease (GERD)

Result of reflux (backward flow) of GI contents into the esophagus.

209

****What is the normal pH of the stomach?

pH of stomach 1.5-2.0

210

**** What is the normal pH of the distal esophagus?

pH of distal esophagus is 6.0-7.0-

211

Which is more acidic, the stomach or the distal esophagus?

the stomach is naturally more acidic than the esophagus,

212

What is the etiology of Gastroesophageal Reflux Disease (GERD)

Etiology- Obesity increases abdominal pressure. NG Tube keeps the sphincter open all of the time so it makes them more prone to for GERD.

213

Regurgitation while lying flat at risk for which complication?

Aspiration.

214

If your patient experiences reflux with regurgitation what assessment is a priority?

So priority would be HOB elevated. If you think the patient has aspirated, perform a respiratory assessment. See if they have crackles. They will have an Acid taste in the mouth.

215

What are the nursing interventions for GERD?

eat small meals daily is the most important. (East 4-6 small meals daily)

Do not eat right before bed,
Give yourself 2-3 hours.

Weight loss,
limit alcohol,
caffeine,
and tobacco intake.


Medications: Zantac, Prilosec

216

Which medication is for mild GERD?

Zantac

217

What would you teach your patient about zantac

Zantac can be taken with or without food.

They prefer that you take it at bedtime.

Take it on a daily basis not just with pain.

218

Which medication is for severe GERD?

Prilosec

219

A client is taking Zantac at home to treat GERD. The client understands proper administration of Zantac when she says that she will take the drug at which of the following times?

a) Before meals
b) With meals
c) At bedtime
d) When pain occurs

c) At bedtime

220

A client who has been diagnosed with GERD complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet?

a) Lean beef
b)Air-popped popcorn
c) Hot Chocolate
d) Raw vegetables

c) Hot Chocolate

221

Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing GERD?

a) Limit caffeine intake to no more than 6 cups of coffee per day.

b) Do not lie down for 2 hours after eating.

c) Follow a low protein diet.

d) Take medications with milk to decrease irritation.

b) Do not lie down for 2 hours after eating.

222

Hiatal Hernias are Also called diaphragmatic hernias.

What are the two main types?

1. Sliding Hernias
2. Rolling Hernias

223

What are Sliding Hernias

Most common, these patients can develop reflux, volvulus rare (Witch is twisting). This one is not as severe. It has more GERD S&S/

224

What are the S&S of sliding hernias?

S&S: Reflux, Dysphagia, Belching--Worse after meals and in supine position


Identify as Sliding Hernia with barium swallow study with fluoroscopy (not on test)

225

What are people with sliding hernias at risk for?

At risk for? Aspiration

226

What are rolling hernias?

These patients do not usually develop reflux but volvulus is more common. Iron deficiency anemia common. (twisting) More complicated

to identify as hiatal hernia barium swallowing study with fluoroscopy

227

****What are the important things to monitor with rolling hernias>

Monitor for S&S of Obstructions. The S&S will manifest itself as? The abdomen will be distended and firm.

228

What are the nursing interventions for rolling hernias?

Nursing Interventions for Rolling Hernias: (The same as sliding hernia) Nutrition, Medications, Lifestyle changes

229

Surgical Management for Rolling Hernias.
What are the 2 types of surgeries?

1. Laparsocopic Nissen Fundoplication

2. Open Fundoplication

230

What is a Laparsocopic Nissen Fundoplication ?

Minimally invasive surgery, little 1/2 inch incisions on the abdomen and they go in to restore the sphincter so it will not be so open and wide.

repairs rolling hernias

231

****What is the post op care for a person that had a Laparsocopic Nissen Fundoplication?

Post-op- Not as invasive since it is Laparsocopic so post op os a little different. What we are going to monitor for post op is bleeding and infection. To monitor for bleeding, check H&H, Vital Signs (HR will increase first), B/P decreases. Abdomen distention. Monitor incision sites. Monitor temperature for infection.

Education- Education will still be the same. Nutrition, Meds, Lifestyle Changes. If they have already lost the weight, educate them to keep it off. They are not in the hospital long.

232

****What is the post op care for a person that had a Open Fundoplication?

Post-op: chest tubes, NG tube, NPO then advance to clear liquids


Post-op care: Monitor for respiratory complications. NG Tube drainage- frank red blood is never good. Should be brown after surgery and as the day progresses will turn to yellow/green. Pain control is huge with this group because if they are in a lot of pain, they are not going to want to take deep breaths or get up and ambulate. We also do not want them vomiting. Give them nausea medication first, and then their pain medication to avoid this.

Post-op education- teach them to monitor for infection at home. monitor temperature, come back or call the doctor if there is puss draining from the infection site, redness that is growing larger around the incision sites. Little red and tender ok.

233

Which of the following factors would most likely contribute to the development of a client’s hiatal hernia?

a) Having a sedentary desk job
b) Being 5ft 3ins tall and weighing 190lbs
c) Using laxatives frequently
d) Being 40 years old

b) Being 5ft 3ins tall and weighing 190lbs

234

The client asks the nurse whether he will need surgery to correct his hiatal hernia. Which reply by the nurse would be most accurate?

a) “Surgery is usually required, although medical treatment is attempted first.”

b) “Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications and lifestyle changes.

c) “Surgery is not performed for this type of hernia.”

d) “A minor surgical procedure to reduce the size of the diaphragmatic opening will probably be planned.”

b) “Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications and lifestyle changes.

235

Esophageal Tumors, Some benign, most cancerous. They Grow quickly & Spread quickly, more than 1/2 of them metastasize.

What are the risk factors?

Risk Factors: Tobacco and Alcohol

236

What is the assessment for esophageal tumors?

Assessment: Dysphagia is the main complaint/Odynophagia (painful swallowing) can be apart from dysphagia. Just because you have one does not mean that you always have the other.

237

****What is the diet and nursing interventions for someone who has esophageal tumors?

Diet: Semisoft foods, thickened liquids, nothing hard like a streak

Priority Nursing Interventions for Esophageal Tumors: Protection of the patients airway and preventing aspiration. Make sure that they are sitting up, and eating the proper diet, family is not sneaking them stuff, suction at the bedside.

238

What is the Early Stages of dysphagia

can eat a steak but can eat other items.

239

What is the Late stage of dysphagia

can no longer swallow liquids.

240

***** What is the Surgical Treatment for Esophageal Cancer?

Esophagogastrostomy,- they can remove part of the esophagus, it just depends on where the tumor is located and other factors such as the patients age and history ect. once that is removed, they will probably go to ICU first.

****Priority is Airway and Breathing. HOB elevated, suction ready.

241

***What are the Post op nursing interventions for Esophagogastrostomy

****Priority is Airway and Breathing. HOB elevated, suction ready.


Pain control- is very important and will help them their respirations. We want to keep this under control so that they want to cough and deep breath, ambulate early ect..

NG Tube- So as a whole, when it comes to irrigating NG tubes, there may be some that you irrigate and some that you do not. People that have this surgery, we DO NOT irrigate the NG tube. EVER. Initially the drainage will be blood tinged but not bright red blood, then will change to brown, then to green/and yellow by the end of the post-op day. If you see frank red blood, get the vitals and let the doctor know.

Post-op- can develop fistulas, they can also develop abscesses (pockets of puss), worry about respirations, pain control, NG tube drainage, and complications.

242

****TWO MAIN PRIORITIES FOR Esophagogastrostomy

DO NOT irrigate the NG tube. EVER

AIRWAY MOST IMPORTANT

243

****What is the discharge teaching for post Esophagogastrostomy

Discharge Instructions- teach about diet, keep their pain under control. Educate that if they get a cough or a temp to call the doctor. Do not go in large crowds due to risks for infection, Monitor their site for infection.

244

What is your priority nursing intervention with a esophageal cancer patient?

a) Maintaining nutritional intake
b) Preventing aspiration
c) Managing the patients pain
d) Allow ventilating of feelings

b) Preventing aspiration

ABC

245

Stomatitis-

Inflammation or Erosion of protective lining of the mouth/oral cavity.

246

What are the 2 classifications of Stomatitis?

Primary and secondary

247

Primary Stomatitis (most common)-

Aphtlous, Herpes Simplex (HSV-1), Trauma, canker sores.

248

**** Secondary Stomatitis-

Thrush, Related to bacteria, fungi, yeast. Usually is something that has to be treated with medication such as antibiotics. HIV patients or patients with decreased immune function are prone to get thrush

249

*** Nursing Interventions for Secondary Stomatitis (Thrush)

Nutrition: Teach patients to avoid the following foods- Alcohol, Tobacco, Coffee, Fruits and Nuts, Spicy, Foods, Acidic Foods,

Medications: Anti-Fungals such as nystatin (Mycostatin)-swish and swallow, 4x daily for 7-10 days. They usually need to swallow so that it can get on the fungus in the throat as well.

Mouthcare: Soft-bristled toothbrush, Rinse every 2-3 hrs with Na Bicarbonate solution or Warm Saline solution, do not use mouthwash with alcohol.

250

Urethritis-

Inflammation of the Urethra that causes symptoms similar to UTI.

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Urethritis Etiology-

For men, related to STD.

Intervention is education and antibiotics.

Women- r/t decreased estrogen levels.

Interventions- estrogen cream.

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Urothelial Cancer

Malignant tumors of the urothelium.

R/T smoking, chemical exposures, diet

Diagnosing- CT- Biopsy

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Urothelial Cancer Non-Surgical Interventions

Intravesical Chemo, Radium Implant into the bladder that is peed out.

So Interventions include teach to use a separate bathroom at home.

They need to be in a private room in the hospital.

***Cannot be used if cancer has metastisized.

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Urothelial Cancer Surgical Interventions

Cystectomy- Bladder removal.

Post-op - pt will have illoconduit. Monitor stoma. Pink beefy red, not blue or crusty.

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What is the Pathophysiology of Acute Glomerulonephritis?

Glomerulus is damaged, typically they have an infection

Symptoms 10 days from time of infection

Recovery is usually quick and complete

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What is the Etiology of Acute Glomerulonephritis?

Infection, e.g Streptococcus or cold sores in the mouth. They get an infection and don’t get it treated fast enough and it causes kidney issues

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****What are the Clinical Manifestations of Acute Glomerulonephritis?

GFR low (normal is 125) when they get to 50 or less, you will start to see fluid overload issues.

Fluid Retention & Na Retention causes high BP and pulmonary edema.

Weight Gain

SOB/Crackles

Heart- will hear S3 Gallop from extra fluid in the ventricles. Will have JVD.

Fatigue

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*** What are the Nursing Interventions for Acute Glomerulonephritis?

Manage Infection with antibiotics and figure out the cause

**Prevent Complications- give diuretics, reduce sodium intake. restrict fluid intake (fluid that they can have in a day is equal to their 24 hour urine output plus 500-600ml) , strict I&O’s, weight loss or gain is equal to fluid loss or gain, weight loss indicates that the interventions are working.

***Weight gain/loss- weigh every day (we want them to lose about a pound a day)

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What is the Pathophysiology of Chronic Glomerulonephritis?

Develops over 20-30 years or longer

260

What is the Etiology of Chronic Glomerulonephritis?

Etiology unknown, but possible related to HTN (causes poor blood flow to the kidneys), infections, inflammation, poor blood flow to kidneys


Always leads to ESRD- kidney tissue will atrophy, nephrons will decrease in number, protein will increase in the urine and GFR will decrease (the sicker they are, the more their GFR will decrease)

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***What are the Clinical Manifestations of Chronic Glomerulonephritis?

Systemic Overload- crackles in the lungs, respirations increased, S3 gallop, weight increases, pulmonary edema.

Uremic Symptoms- kidneys remove waste so when not working properly, waste will build up.

This causes them to have uremic symptoms such as ataxia (uncontrolled movements), slurred speech, skin will change (texture, dryness, scratching, bruise easily)

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***What are the Nursing Interventions for Chronic Glomerulonephritis?

BP- Give Medications

Nutrition- Low sodium, appropriate fluid intake,

Dialysis- most people end up here sooner than expected. Need to get rid of waste. Urine output is decreased.

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The patient has been diagnosed with chronic glomerulonephritis. The nurse should teach the patient that the disease may progress to:

a) thromboemboli
b) systemic lupus erythematosus
c) diabetes mellitus
d) end stage renal disease

d) end stage renal disease

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**** What level is the gold standard for evaluating kidney functioning?

Creatinine. Normal range 0.5 - 1.2

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The nurse caring for a patient who is experiencing renal cancer would include which priority nursing intervention after a radical nephrectomy?

a) Assess for signs of infection.
b) Assess for signs of pain.
c) Assess for respiratory complications.
d) Assess for coping strategies.

c) Assess for respiratory complications.

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What is the Pathophysiology of Kidney Trauma?

what matters is where the trauma took place in the kidney. could be stabbed, fell off the roof, car wrecks ect


Minor- parenchyna and caylx are considered minor

Major- cortex, veins, arteries are considered more serious.

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What is the Etiology of Kidney Trauma?

Trauma

Duh lol

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What are the S&S of Kidney Trauma?

Ecchymosis to abdomen or flank

Pain, CVA Tenderness

UA, hematuria

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****What are the Nursing Interventions for Kidney Trauma?

Drug Therapy- bleeding- you hang blood, BP down- you hang fluid

Fluid Therapy (bolus)

**Urinary Catheter- if there is any kind of bleeding, you do not stick a catheter in. Always let the doctor know.

Surgery- remove the kidney, partially or total. depends on injury. (Bench surgery, take the kidney out, set it on the abdomen, fix the arteries, put it back in)

**Prevention- teach avoid contact sports, don’t get on the roof, wear seatbelt. Dont drive fast.

**Post-op Care- once it has been partially removed, removed or bench surgery. Post op care is, Monitor I &O, infection, bleeding, pain management, social and emotional things. Football players that have kidney removed can no longer play football.

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***What is the first thing that you need to know about a colostomy?

the first thing that you have to know is that it can be placed at different locations. You must know the different locations in order to provide great nursing care. To find out where it is located, you can either look at the abdomen, ask the patient, or check the chart. Just figure it out.

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**Why is it important to know where a colostomy is located on a patient?

Because the stool looks different in different parts of the colon. You must know what is normal so that you know what to look for that may be abnormal.

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**What does stool in the ascending colon look like?

Stool in the ascending colon would look like water. It is more liquid.

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**What does stool in the Transverse colon look like?

Transverse colon would look more pasty.

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***What does stool in the descending colon look like?

The descending colon will be solid in nature.

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*** After a colostomy is placed, what should the stoma look like?

The Stoma- the color should be beefy red and moist.

If not, call the doctor.

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***What is the Post-op after a colostomy is placed?

after a colostomy is placed, the patients stool will be loose for 2-4 days. It will then change depending on where it is located.

Priority nursing interventions include monitoring the stoma for color, make sure it is getting circulation, and monitor the skin around the stoma. It may be monitored by wound care, however it is the nurses job to check it daily and chart it. If it is not looking well, it needs to be reported to the doctor.

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Abdominal Trauma,

Most of these people will go to the ICU. It just depends on the extent of the trauma.

injury to the structures located between the diaphragm and the pelvis.

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What is the etiology of abdominal trauma?

Etiology: Blunt or penetrating forces. MVC, Falls, Aggravated Assaults, Contact Sports, etc.

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Who is at risk for abdominal trauma?

Risk: <40 years of age

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****What are the nursing interventions for abdominal trauma?

ABCs. Once they have had trauma to the abdomen it makes it hard for them to breathe.

IVs, IV fluids, T&C, NPO, Labs, ABG, Detailed Assessment (must do all of the systems. Not just a focused assessment because you may not be able to see what else may be going on (neuro, heart, lungs, especially GI, extremities)),

(Be careful with NGT and Foley Catheter, if they are bleeding, we do not put these in or if the patient has brain trauma, we don’t put an NG Tube)

One of the major things to look for with abdominal trauma is bruising. Ecchymosis across the abdomen may indicate organ injury.

Cullen’s Sign is bruising around the umbilicus area. Can be from pancreatitis, trauma.

Grey Turners Sign is bruising along the flanks.

These people are generally pretty sick. Neuro, they might be confused, Urine output will be low due to their blood loss. This is why they typically go to ICU.

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What is the typical surgery for abdominal trauma?

Surgery: Exploratory Laparotomy- they may not know where the bleeding is coming from so they will go in an look around until they find it.

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Acute Inflammatory
Bowel Disorders

What is Appendicitis?

Acute inflammation of the appendix.

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****What are the S&S of Appendicitis?

S&S: Classic symptoms Fever, High WBC, RLQ pain and is diagnosed by x-ray or CT. Sometimes by surgery after it is visualized. These people go to surgery within hours.

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What is the etiology of Appendicitis?

Etiology: Fecaliths, Infection- starts to expand when inflammation builds up and eventually it will rupture.

285

What is the patho behind Appendicitis?

Patho: Inflammation causes obstruction of lumen of appendix, leading to infection as bacteria invades appendix. Blood flow restricted causing pain.

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What is the treatment for Appendicitis?

Surgery: Appendectomy - incision is made on the abdomen, they will remove it, sew them back up and most people recover without any issues. Usually occurs more in younger people rather than older. This is not 100% of the time but mostly.

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What is the post-op care after an Appendectomy?

Post-op care- fairly minimal, they need early ambulation with normal post op care. Check for infection ect.

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What is Peritonitis?

Acute inflammation of the peritoneum and endothelial lining of the abdominal cavity

if an appendix ruptures the patient is at risk for peritonitis.

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What is the etiology of Peritonitis?

Etiology: Appendicitis, Diverticulitis, Peptic Ulcer Disease, Gunshot/Stab wound, Bowel Obstruction can lead to peritonitis.

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****What are the S&S of Peritonitis?

S&S: most important- nausea and vomiting, fever, swelling, ****RIGID ABDOMEN. Distended, B/P issues, (body tries to wall off infection, ends up 3rd spacing, if that does not fix the problem, body sends more blood to help fight, which increases the 3rd spaced fluid and pulls more out of the vascular system thus decreasing B/P and increasing heart rate.)

***REBOUND TENDERNESS

this needs to be on your assessment and charted.

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Peritonitis, Non-Surgical:

not everyone goes to surgery but some do. They will get IV fluids, antibiotics, they will be NPO, and get NGT to decompress the stomach because they don’t want anything else flowing through there and leaking out into the peritoneal cavity.

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Peritonitis Surgical:

Exploratory Laparotomy- they will go in and fix whatever the issue is, such as a ruptured appendix, diverticulitis, ect.

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Postoperative Care for Peritonitis-

Normal post op care.

294

What is Botulism-

Paralytic disease resulting form ingestion of a toxin in food contaminated with Clostridium botulinum.. This one is a little more serious because it causes respiratory problems.

295

What is the etiology of Botulism-

Occurs in home-canned foods, and meat and fish. Once consumed, it releases a toxin within the body that acts upon the respiratory system.

296

What are the S&S of Botulism-

S&S: Diplopia (blurry vision), dysphagia (trouble swallowing), dysarthria (slurred speech), nausea, vomiting, (neuro issues that the other groups do not have)

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*****What is the Incubation time of Botulism?

Incubation 18-36 hours

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Botulism Nursing Interventions

Trivalent Botulism Antitoxin
Stomach Lavage- like an NG tube that flushes the stomach out with water.

ABCs, respiratory function can decline with this group. Support respiratory functions by raising the head of the bed up, Incentive Spirometer, Oxygen, They might even need to be intubated (just depends on the severity) If they are intubated they do not take anything PO.

IV Fluids

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Anal Disorders

What is an Anorectal Abscess?

Localized area of induration and pus caused by inflammation of the soft tissue near the rectum or anus.

300

What is the etiology of an Anorectal Abscess?

Etiology: Obstruction of ducts of glands in the anorectal region. Feces, foreign bodies or trauma can be the cause of the obstruction.

301

What are the S&S of an Anorectal Abscess?

S&S: Rectal Pain, local swelling, redness and tenderness, bleeding, pruritus

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What are the Anorectal Abscess Nursing Interventions-

I&D- the doctor will make an incision to drain all of that puss out, then pack it with iodoform. Then it will heal by secondary intention (inside to out). Send them home with antibiotics, then they usually follow up with primary doctor in 10 days.

****Perineal Hygiene- after the I&D is done, we have to teach them to keep the area clean. We do not want stool to get in the area that was just drained.

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What is Gastritis?

Inflammation of gastric mucosa (stomach lining)


It can be Scattered or Localized and Erosive or Non-Erosive. and it is classified as either Acute or Chronic Gastritis

304

Gastritis ~ Pathophysiology

Break in protective barrier, mucosal injury occurs resulting in worsening by histamine release and vagus nerve stimulation. Hydrochloric acid can diffuse back into the mucosa and injure small vessels. This diffusion causes edema, hemorrhage and erosion of the stomach lining.

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Acute Gastritis Etiology

Helicobactor Pylori- Gram negative bacteria that is spiral shaped and it digs its way into the stomach. The end result is that it increases the acid in the stomach.

****Long Term NSAID’s are the biggest contributors. They inhibit the prostaglandins, which allows the stomach to loose its protective barrier.

Alcohol, Caffeine, Corticosteroids- increases acid production.

Emotional Stress and Acute Anxiety- increases acids.

Radiation Therapy, Accidental or Intentional Ingestion fo Corrosive Substances

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What is Acute Gastritis-

typically heals within several months as long as muscle is not involved and is not really deep.

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What is Chronic Gastritis

is persistent inflammation and is very deep. The mucosal damaging of the glands can cause cellular changes. This puts the patient at risk for cancer.

308

What are the 3 different types of Chronic Gastritis (Etiology)?

Type A: Non-Erosive-Genetic Component. Your body produces antibodies that damage the parietal cells. This can cause pernicious anemia.

Type B: Most Common r/t H. Pylori Infection

Atrophic: Most often older adults

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Which are pathologic changes associated with acute gastritis? (select all that apply)

A. Vascular congestion

B. Severe mucosal damage and ruptured vessels

C. Edema

D. Acute inflammatory cell infiltration

E. Increased cell production in the superficial epithelium of the stomach lining

A. Vascular congestion

C. Edema

D. Acute inflammatory cell infiltration

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A patient with chronic gastritis is being admitted. Which S&S does the nurse identify as being associated with this patient’s condition?

A. Pernicious anemia
B. Gastric hemorrhage
C. Hematemesis
D. Dyspepsia

A. Pernicious anemia

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Assessing for Gastritis

***What are the main S&S?

Know the difference between acute and chronic signs and symptoms.

Acute is more hemorrhaging, vomiting blood, indigestion.

chronic has fewer signs and symptoms. more vague.

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If gastritis suspected, blood test available. What are they?

(IgG/IgM anti-H. Pylori antibody

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****EGD (Esophagogastroduodenoscopy)- after the procedure- you monitor?

you monitor their vital signs until they return to baseline. (so need to get a baseline before they go). What happens during the procedure is that they numb their throat to keep them from gagging.

Since it has been numbed, swallowing is an issue. This means no eating or drinking until their gag reflex is present. This can take a few hours. They need to remain NPO in the mean time.

Assess their ability to swallow, if they do ok you can start them off with drinking before you progress to a full meal.

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***What are the Gastritis Nursing Interventions?

Remove the Cause, such as NSAID’s, Alcohol. Whatever the etiology is.

If Severe Blood Loss (Meaning H&H is low, BP is low) they will get a Blood Transfusion

If Severe Fluid Loss (B/P is decreased but H&H is ok) will will give them a Fluid Replacement.

Surgery with major bleeding and ulceration.

Medications- focus on handout. Malox, Mylanta. Increases PH of the stomach. Nursing interventions for these medications include take 1-3 hours after meals. Assess the renal function because it is metabolized by the kidneys. No other meds within 1-2 hours of taking antacids.

Sodium bicarb (Baking soda)- treats heartburn. causes fluid retention and edema, so not good for CHF patients.

Pepsid / zantac- Pepsid is stronger, give at bedtime. can be given IV to prevent stress ulcers.

Teach patients to continue taking them even if heartburn stops

Proton pump inhibitors- prilosec, nexium, - keeps acid from being release from parietal cells. rules are no crushing. and give an hour before meals. at risk for pernicious anemia.

cytotec- not good for pregnant. no magnesium antacids. helps to protect if on NSAIDS

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What are the Medications to Avoid when you have gastritis

Teach Patients to avoid drugs and other irritants that are associated with gastritis episodes

Corticosteroids because causes increased acid.

Erythromycin because causes increased acid.

NSAIDs (naproxen, ibuprofen)
NSAIDs in other OTC medications.

Other Items to Avoid

Teach Patients to avoid these irritants that are associated with gastritis episodes

Caffeine

Alcohol

Tobacco

High Acid Content- tomatoes, oranges, juice, no spicy like peppers or onions.

Heavy Seasoning, Spicy

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****What would you teach as Health Promotions
For Gastritis?

Balanced Diet, Regular Exercise (helps movement of your gut) , Stress reduction techniques
Avoid Alcohol and Tobacco
Avoid excessive use of ASA and other NSAIDs

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*** Hemorrhage-

is the most serious. Typically patient who have gastric ulcers. and if you are older with a gastric ulcer it puts you at greater risk.

Perforation

Pyloric Obstructions

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***Hemorrhage Complication

Most serious and tends to occur more often in patients with gastric ulcers and in older adults.

S&S: Vomiting bright red or coffee-ground blood (has time to sit before they throw it up). Hematemesis (Bright red) (usually indicates upper GI bleed) and Melena (more common with duodenal ulcers)

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****GI Bleed
Nursing Interventions

Actively bleeding is an emergency. Priority ABC. set them up in the bed. suction ready.

Large-bore IV access for replacing fluids and blood (16-18G)

Monitor Vital Signs, Hct/Hgb, Oxygen Saturation

Insert NG tube, patient NPO to decompress the stomach.

Lab values- focus on H&H. Continous vitals as well

Gastric Lavage- Flush with room-temperature tap water in volumes of 200-300ml into the NG tube and then pull it back out to clear out the stomach. Patient MUST BE ON THEIR left side. THis limits the flow of the water flowing through the GI tract. Then chart what you put in on the I&O sheet.

320

NG Tube

HOB Elevated 30% or >

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Iron Deficiency Anemia

Definition- iron storage is more depleted than hemoglobin storage

S&S: Fatigue, pallor

Etiology: Inadequate Diet

****Nursing Interventions: Foods rich in iron such as--Red meat, Egg yolks, Organ Meat

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Sickle Cell Disease

Definition- Abnormal Hemoglobins, genetic disorder resulting in chronic anemia, pain, disability, organ damage and increased risk for infection.

Sickle Cell Crisis Etiology: Infection and Dehydration

Nursing Intervention for Sickle Cell Crisis: Pain control, No meds IM, Keep patient hydrated po/IV (please note an IV KVO rate or keep vein open rate is not keeping a patient hydrated. The KVO rate is only used to keep the IV patent.)

Keep patients room warm 80degrees

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Blood Transfusion

Pre-Transfusion Responsibilities-
Patient Identifications prior to infusion, patent 20g, Assess VS, Monitor electrolytes mainly Potassium

Transfusion Reaction S&S:
When to stop the blood transfusion-
Reactions like rash or back pain or chest pain

when to slow down the blood transfusion-
if the pts respirations increase
if they show signs of circulatory overload

324

Stress Test

People who may have angina will be sent for a stress test.. This test is to determine how the patients heart will function under stress when additional workload is added.

First they start out walking and see how they do, then they pick up the pace and see how the heart handles the workload.

325

If you were in charge of a stress test, Why would you need to stop it?

If there were ST elevation or depression on the monitor or if the patient is literally about to pass out.

You do not stop the test just because the patient tells you that they are tired.

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MRI

Very Expensive- around $3-4 thousand.

We like MRI's because that is the best picture that we are going to get, but we don't get MRI first because of how expensive they are.

Radio-waves bounce off of the bodies tissue.

327

What are the rules before an MRI?

No Metal

Consent form

No pace makers

No Hair Clips, Earings, Piercings

They might have to be sedated.

328

Heart Failure
Pathophysiology

CHF is the most common reason for someone 65 or older to be hospitalized.

Inability of the heart to work effectively as a pump. So all of the blood full of oxygen and nutrients is not being delivered to the body adequately.

Decreased cardiac output leads to decreased perfusion.

Results in accumulation of fluid in the lungs and other body tissues.

329

If the left side is not pumping correctly,

fluid backs up into the lungs. Eventually left sided heart failure turns into right sided heart failure. Right sided heart failure causes blood to build up into the tissues in the neck and those types of places.

330

There is a difference between early and late heart failure.

Early on the right side is compensating. Heart rate and respirations increase, but as they are trying to fix the problem, it will eventually fail.

331

Heart Failure
Etiology

Etiology-
HTN,
MI,
Valvular Dysfunction such as
*****Aortic Stenosis

332

Heart Failure S&S (general)

S&S: Problems with activity, fatigue, sleeping, fluid volume, urinary, edema, JVD, wt gain

333

Types of Heart Failure

When a patient comes in to the hospital, it may not be listed as to whether or not they have left sided or right sided heart failure. You can usually tell by their symptoms. It typically starts as left and ends up being right anyway.

334

Left-Sided- Typically r/t aortic stenosis, CAD, HTN, it is an issue with pumping the blood out to the body. S/S specific to left sided heart failure are

SOB, crackles, confusion, dizzy, fatigued, weak, have hard time completing tasks,

Low urine output (oliguria= less than 400ml day)

Orthopnea (Sleeping with extra pillows at night, can’t lay flat),

S3 gallop,

Apical pulse displaced to the left (heart enlarged),

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Right-Sided- typically related to left sided. They can have a right sided MI, so it can originate from that side. If you only had right sided heart failure the signs and symptoms would be-

blood back up so JVD,
pitting edema,
weight gain,
shoes fit tight,

abdominal distention (not wanting to eat from all of the pressure build up)

Increased thirst (all extra fluid is causing hyponatremia so they become thirsty),

waking up at night to pee,

336

Left-Sided Heart Failure

Systolic - forward failure, contraction part. So systolic left sided heart failure = heart cannot contract forcefully enough to eject that amount of blood out. So causes decreased tissue perfusion, blood will back up because it cant get it out

Diastolic- the ventricle cannot relax, if it cannot relax, it cannot fill up correctly. Causes decreased cardiac output because it isn’t filling with enough blood.

337

Ejection Fraction-

Normal is 50-70%. We can tell their ejection fraction from an echocardiogram. The volume of blood pumped out to the body after each heart beat.

338

If a person had an ejection fraction of 40% or less, that would mean

that you would see signs of the body not getting enough nutrients and oxygen such as low urine output from decreased kidney perfusion and confusion. The signs and symptoms that a patient is having will determine your interventions.

*****If it was less than 40%, you would assess for decreased tissue perfusion.

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Right-Sided Heart Failure

Specific to right sided heart failure- fluid is building up because it is trying to get inside the heart but the ventricles are not working right, or it cant go forward because the left side is not working properly. Fluid Builds up and backs up the system causing the right side to work hard to try to compensate for all of the extra fluid.

Blood pressure increases, weight increases, education and intervention for weight gain, weigh daily same time of day, same blankets on bed, or same clothes if standing.

1 liter of fluid = 2.2 pounds.

Pitting edema does not occur until you have about 4-7 liters on board. (10-15lbs)

340

Your patient is diagnosed with right-sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply.

A) Peripheral Edema
B) JVD
C)Diuresis at rest/Increased Thirst
D) S3/S4 Gallop
E) Breathlessness

A) Peripheral Edema
B) JVD
C)Diuresis at rest/Increased Thirst

341

You are taking care of a patient with left-sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply.

A) Confusion
B) Ascites
C)Oliguria
D) S3/S4 Gallop
E) Breathlessness/Crackles in lungs

A) Confusion
C)Oliguria
D) S3/S4 Gallop
E) Breathlessness/Crackles in lungs

342

Whenever the heart cannot meet the demand of the body, it decides to help out.

At first this is helpful because it helps with early signs and symptoms of heart failure, but over time it ends up doing damage and the pump does not work correctly..

343

Things that happen to increase cardiac output.

1. The first thing is the Sympathetic nervous system gets stimulated


2. Your renin system activates

3. Chemical response- BNP increases

4. Myocardial hypertrophy-

344

1. The first thing is the Sympathetic nervous system gets stimulated

and increases HR, Afterload, Vasoconstriction to help fix the problem

345

2. Your renin system activates

Your renin system activates because it senses that the kidneys are not being perfused and it wants to help (vasoconstriction, aldosterone is secreted which holds on to water and sodium. Preload increases and afterload increases.

346

3. Chemical response- BNP increases

Whenever the ventricles become full, it releases this into the bloodstream saying “Hey I have a lot of volume”, it releases it so that someone else will come help fix the problem. (Released from the ventricles when the patient has fluid overload) Normal BNP is less than 100, if it is high, they will get an echo to determine the issue. In order to diagnose CHF you need elevated BNP and Echo.

347

4. Myocardial hypertrophy-

Myocardial tissue gets thicker in order to push the blood out. Bigger and Stronger to increase contractility and cardiac output. Over time ends up with cardiomyopathy because everything is to large. Causes apical pulse to be displaced.

348

Laboratory Values:
for CHF

Hct (F 37%-47% M 40%-54% mL/dL) will be low r/t Hemodilution

Sodium (135-145 mEq/L) will be low r/t Hemodilution

BNP (<100 ng/mL) will be elevated r/t extra fluid on board

UA (30ml/hr minimum) Oliguria/Polyruia, decreased UO. ***High Specific Gravity (1.005-1.030)

Proteinuria & Microalbuminuria will be present indicating decrease in renal filtration. Early warning sign of decreased compliance of the heart

ABG-May reveal hypoxemia r/t oxygen not diffusing well through fluid filled alveoli

349

CHF Interventions

xray (pneumonia, and enlarged heart)

EKG
Catheter
I&O
HOB Elevated
Echo
Oxygen
Lasix

CPAP
Priority is always Respiratory!!

350

Complications of HF

Pulmonary Edema-Abnormal build up of fluid in alveoli


S&S: Confusion/Lethargic, pink-tinged sputum, crackles, dyspnea at rest, tachycardia, decreased urinary output.

351

Diet for Cardiac Patients

Low Sodium

Salt Substitues have Potassium so avoid them

352

Lasix is the

first med to give in CHF

Monitor for hypokalemia, dehydration and confusion. Asses for orthostatic hypotension

353

Digoxin

decreases HR but increased Contractility

Monitor for digoxin toxicity. (Would see on monitor in Rhythm)

Monitor HR.

Avoid taking medication with antacids. (absorbed in GI tract)

354

Risk Factors for Atherosclerosis

Diabetes
Smoking
Obesity

Smoking is the most important, Teach the patient not to smoke and have a nicotine patch together. That is a huge cardiovascular risk factor.

355

Low Cholesterol Diet

lean meats
Fat Free
No Fried foods

356

Lipid Levels

TC= < 200
LDL < 100
HDL > 40
Triglycerides < 150

357

The higher the LDL gets, the greater the risk for Athlerosclerosis

High Lipid levels can be genetic but most is related to diet or sedentary lifestyle.

358

PT=

11 - 12.5

359

aPTT

20 - 35 sec

360

Claudication

Arterial Problem

Hurts for the patient to walk a certain distance

Relieved by rest

If not claudication gets so bad that it hurts to be in bed asleep then patient will need surgery

361

Know the difference between Venous and arterial problems

Arterial = Arteries - pale, cyanotic, usually appears in big toe, ruber color, loss of hair to the area, diminished pulses to that area,

ask how far they can walk

venous- ulcers in ankles, edema (non pitting), brown color in skin due to stasis of blood)

do not treat with betadine, no NSAIDS, treat with compression and elevation.

362

The three main factors for developing atherosclerosis is

diabetes, smoking, and obesity.

Smoking is the most important.

If someone is trying to quit smoking, teach them not to smoke and use nicotine patch. It is a huge cardiovascular risk factor.

363

The higher the patients LDL the greater the patients risk for

atherosclerosis.

364

Nutrition for Cholesterol

no fried foods, fruits, veggies, nuts, whole grain, fat free.

365

Drug therapy for cholesterol issues-

-Lovastatin- Simvastatin-

Teach the patient to take at bedtime because that is the natural rhythm of the body.

Monitor the patients live enzymes and for myopathies. Keep eye on labs.

366

Nursing Interventions for Hepatic Encephalopathy-

Drug Therapy: Lactulose (binds with the ammonia and they get rid of it that way.

It takes it a hour or so to work and then the patients LOC will start to get Better) ,

Some medications are restricted

Neuro, Safety- Patient is confused so will be more prone to falling and will not be able to turn themselves in bed ect.

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Buerger’s Disease-

Arterial Issue- more occlusive disease that occurs in the extremities.

Men have more than women,

smoking is a huge factor,

Intermitant claudication, decreased pulses.
Ruber, decreased cap refill, ulcers.

Teach stop smoking to minimize vasoconstrictions.

Can lose fingers

368

Raynaud’s Disease-

vasospasms,
not occlusions,
(may be connective tissue issue)

more common in women,

Assessment= cool skin, numb feeling, pallor,

Teach- avoid cold, and stress. Wear gloves when outside.

Can lose fingers

369

Claudication-

pain while walking that is relieved by rest.

Arterial problem.

370

Main difference between arterial ulcers and venous issue-

Arterial - circulation= pale cyanotic, typically with arterial ulcers occur on the big toe, it can be ruber color, (first it will have inflammation, develop and ulcer, then become cyanotic) loss of hair, diminished or weak pulses, may need dopler to find pulses.

Ask the patient how far they can walk before they have claudication.

We know that they are getting worse when they are in bed resting and having claudication. THis indicates they are worsening and probably need surgery.

Interventions are exercise to increase collateral blood flow, position = do not sit in chairs all day long, elevate but not above the heart, Promote vasodilation by applying warmth, avoid cold by putting items that prevent you from getting cold.

No smoking, this has an instant effect on the arteries.

371

PVD Ulcers

brown discoloration, no claudication, ulcers are higher so more around the ankles.

372

cytotec-

not good for pregnant. no magnesium antacids. helps to protect if on NSAIDS

373

Imaging (CT/Urography)-

uses dye, it flows through the veins and lights up to show us what we need to see.

It is potentially damaging to the kidneys because it is hard to filter.

Must check the creatinine level to determine how the kidneys are functioning. Must run before scan.

Once the creatinine is elevated above 1.8-2 they will not use.

***The other rule is that when a patient is on Metformin, they are supposed to discontinue it 24 hours before their CT and they cannot start it again for 48 hours.

Educate them to increase PO fluids (water) and at least a liter IV at hospital.

374

Acute Peripheral Arterial Occlusion-

Happens suddenly is dramatic and noticeable. PAD happens over years. Most common cause is from an ambolus r/t atrial fibrulation. Assessing = 6 P’s Pain, Pallor, Pulses, Paralysis, Poikilothermy (coolness), Pressure.

Do they have them? How bad is it? If they do have this issue, their leg is not getting circulation and they will lose the leg if we do not do something about it.

Intervention’s include Heparin (anticoags) to thin the blood and keep it from getting bigger, do angioplasty (go in an visualize the clot to determine how bad it is,)

If they need a surgery, they will have an artiotomy and they will go in and remove the clot. Called embolectomy.

**Post op- at risk from compartment syndrome.

**Monitor 6 P’s ever hour after surgery for the first day, monitor for complications, (infection, compartment syndrome)

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Compartment syndrome=

increased pain, swelling, and tenderness. Interventions are loosing dressings, elevate leg to level of heart, notify the doctor.

376

pH =

7.35 - 7.45

377

Gastroenteritis Nursing Interventions:

Most people that come to the ER with this will go home. Some may get admitted if they are extremely dehydrated or Elderly.

The main thing is Fluid Replacement, Labs, Make sure that they do not have an obstruction by getting a CT or and X-ray of the abdomen. Medications for nausea and pain , Keep their Skin Intact from all of the diarrhea (make patient do this themselves unless elderly and can’t, educate them the importance of keeping the area clean)

Things we can do to keep the skin intact is: barrier cream, sitz bath, ointments, wet wipes, medications to stop that from progressing.

Also need to monitor Potassium because this gets off when a person has a lot of diarrhea. Monitor their heart.

Lomotil can cause dizziness so caution with the elderly or with anyone.

Do not let them drive home.

Safety is a big deal with this medication.

378

Hypertrophy=

is just an increase in the size of the cell, doesn’t necessarily mean cancer. It can be normal.

379

Hyperplasia

is more of a cancer issue, it can be benign or malignant. Hyperplasia is just an increase in the number of cells.

380

So if someone has a benign brain tumor, why would we need to remove that?

Because it can still grow bigger which can compress and cause issues. It can cause issues with the cranial nerves and vision problems.

381

Cancer Development-

Initiation Phase,
Primary Tumor,
Metastasis,
Secondary Tumor,
Blood Born Metastasis, Lymphatic Spread.

382

Initiation Phase-

During initiation phase, there is damage to your DNA. Whether you have been in the sun to much or smoking, whatever the etiology may be, there was damage to the DNA that starts the process.

383

Primary Tumor-

It will have a primary tumor site, and the cancer will always be identified by the tissue that it came from. So if it came from breast tissue, lungs, pancreas, sometimes it can stop it if we catch it soon enough. If not, it will metastasize to some place else. So if it moves from breast tissue to the lung, it is still breast cancer.

***Whatever the original origin, that is its name but with mets to the lung.

384

Secondary Tumor-

After metastasis, a secondary tumor will arrive in another location. Then it can get into the blood and into the lymph system and spread from there.

385

Grading Malignant tumors-

Gx=

Grade Cannot be determined,

386

Grading Malignant tumors-


G1=

slow growing

387

Grading Malignant tumors-

G2=

more moderate growing

388

Grading Malignant tumors-

G3 =

worse and so on

389

Grading Malignant tumors-

G4=

The worst, it is poorly differentiated

390

T1, T2, T3, T4 Refers to what when talking about cancer?

The size of the tumor

391

N1,N2, N3 Refers to what when talking about cancer>

How many lymph nodes it has spread to

392

Mx

presence of distant mets cant be assessed

393

M0

no mets

394

M1

mets to someplace distant

395

Staging Of cancers-

Stage 4 is worse than stage 1, we also use this along with the grading.

396

Cancer Etiology-

The three influences for cancer development are Chemical Carcinogenesis, Tobacco use, Oncoviruses.

397

Chemical Carcinogens-

chemicals, drugs, radiation.

398

Tobacco Use-

is the most important preventable carcinogen. People that smoke are at very high risk for cancer.

399

Oncoviruses-

Virus’s that cause cancer. Alters DNA and leads them down the cancer path.

400

What if your patient smokes and drinks and says that they can only quit one. Which one would you educate them to quit?

Smoking.

401

Seven Warning Signs of Cancer= CAUTION

Changes in Bowel Or Bladder Habits

A Sore that does not Heal

Unusual bleeding or discharge

Thickening of the breast or lump

Indigestion or difficulty swallowing

Obvious changes in a wart or mole

Nagging cough or hoarseness

Patients sometimes do not know this, so this would be a good thing to educate them on especially when they start talking to you about what is going on with them. Something like “Ohh what do you mean you have had a cough for 6 months, what do you mean?” This is something that you need to address to help you figure out what is important.

402

Primary Cancer Prevention-

Primary cancer prevention are avoiding things that you know will cause cancer such as: Smoking, Tanning Beds, Too much sun in general, asbestos in the workplace, and getting vaccinations (Gardicil to prevent cervical cancer.) to help avoid cancer. (There are people who get lung cancer who never smoked)

403

Secondary Cancer Prevention-

Secondary cancer prevention are things such as: Yearly mamograms, 40 and older ( will not prevent but you can catch it earlier to cure it faster) colonoscopy once you turn 50,

They also have a gene mutation test- BRCA1 and 2 gene (they draw your blood to see if you have this gene)

***BRCA1 gene increases your risk for breast and ovarian cancer,

**(BRCA-2 gene is just an increased risk for Breast cancer).

404

Decreased platelets-

fall precautions,
limit iv sticks,
bleed easily,
brush teeth with soft brissled tooth brush.

Weak fatigue at risk for falls.

405

Normal WBC

5000, 10,000

406

Nutrition for cancer

Teach High Carb, High Protein, bland diet

407

Bone cancer is very painful, bones easily break. Doesn’t matter if it is primary or mets. Interventions would be-

pain management (DON”T BE LATE),

use the draw sheet to move them in the bed (ALWAYS).

If a person has breast cancer, and they come to the ER complaining of pain in their legs and bones, you will send them to get an x-ray or CT, could mean mets.

408

Radiation Interventions-

Education- What we try to do is deliver a small amount of radiation for a longer period of time. Example - Small amount of radiation on Monday, Then again on Wednesday, and then again on Friday. We do not want them having a large amount of radiation once a month. They have found that that does not kill the cancer as well as the little doses. Patients will ask you this.

Educate- do not go into the sun after radiation therapy. Need to stay out of sun for a whole year. Do not apply sunscreen. No sun at all.

If they have radiation of the throat and the chest- monitor their airway and make sure that they are breathing ok. They will have dysphagia. Intervention- Assess if they can swallow before they can eat.

Xerostomia- dry mouth- teach can give you cavities, dehydration, focus is mouth care. Brush teeth after you eat and before you go to bed.

409

Chemotherapy- One general rule

from a nurses standpoint is that you have to protect yourself when you are around someone’s chemotherapy. You can do this by PPE, Gloves Gowns. Do not handle without gloves. EVER.

Complications- there are several- Accidental Extravasation of the chemotherapy into the extravascular space. This can happen with any IV meds, but when it happens with chemo medication, that is huge. It will damage the healthy tissue.

Nursing Interventions for this is prevention, check patency by flushing with saline first and then monitor it closely. The patient might tell you that it is burning or hurting or you may see a big knot above the IV. If they say this, you STOP whatever is flowing ASAP

410

Chemotherapy Side Effects:

Anemia

Neutropenia

Thrombocytopenia

Chemo induced Nausea and vomiting

Mucostitis-

Alopecia-

Psychosocial- (Anxiety, sleep changes)

Chemo Brain-

Chemotherapy Induced Peipheral Neuropathy CIPN-

Sepsis

DIC

Hypercalcemia

411

Anemia- S/S

SOB, Fatigue, pale. Interventions- depends on the etiology- Fall Risks.

412

Neutropenia-

Means low WBC. Interventions- Protect them from infections, help prevent,

Low bacteria diet (No fresh flowers, fruit or veggies, or bloody meat, no over easy eggs. fish) Check their temp (even a little bit of a temp is a big deal)

Wash hands.

If they say that it hurts when they urinate, it is a big deal. Cough important.

413

Thrombocytopenia-

Bleeding risk- Interventions include - Fall Risk, No Aspirins, No NSAIDS, constipation give stool softener, soft bristled tooth brush, (They can have Tylenol)

414

Chemo induced Nausea and vomiting-

This is a big problem that the drugs will give the. Nursing interventions- Give Zofran and Morphine 30 min prior to chemo to prevent nausea and vomiting.

415

Mucostitis-

sores in mucus membranes that line the GI tract. Can be anywhere. Interventions are: Stomatitis- oral care, soft bristled tooth brush, no listerine, can use saline.

416

Alopecia-

hair loss, generally maybe about a month or so after chemo it will start growing back, but it may be different than their original hair, (texture). Educate to cover the head to protect them from the sun.

417

Chemo Brain-

temporary. May last months to years. More common with breast cancer treatment. They experience changes with their concentration and their memory learning ect.

418

Chemotherapy Induced Peipheral Neuropathy CIPN-

lose sensory and motor because chemo damages it. Usually is permanent. Diabetes people, this effect them more. Nursing interventions are preventing injuries and falls.

419

Sepsis-

Organism enters the blood stream. Can lead to septic shock which is life threatening situation. Want to catch before it gets that bad. Cancer patients are at risk for sepsis because their WBC’s are low. Always get a RAINBOW, and need blood cultures as well. Blood has to be drawn from 2 seperate sites. Two bottles make up 1 blood culture. Label it where you got the blood from. Takes three days to grow. Assessment is the most important- notice when something is wrong and intervine. Might see fever and elevated HR and respirations. As they go from sepsis to septic shock, you start adding more symptoms to the problem such as cool pale skin, blood pressure drops, LOC changes. When they are checking the labs you will see a shift to the left.

420

DIC-

Disseminated Intravascular Coagulation- ICU patient. Cancer patients are at risk for this. They can develop sepsis and then DIC. Blood vessels throughout the body will form clots, circulation is impaired, if it is in the kidneys it will damage them. It can be acute or chronic but cancer patients are prone to more chronic DIC. Chronic is not years but weeks to months. Platelets go to all of the areas and form clots. Eventually fewer platelets are circulating, which leads to serious bleeding. (Nose bleeds, mouth bleeding, IV sites might ooze blood,) Urine output will be decreased;

421

Hypercalcemia

Increased Serum calcium levels. Normal Calcium is 9-10.5. Normally patients with bone cancer, calcium is released from the bone into the bloodstream making the calcium level elevate. Calcium is needed in bones, heart, muscle contractions, hormones, S/S of hypercalcemia- twitching, dehydrated, fatigued, GI Nausea and Vomiting, Constipation, Polyuria, loss of appetite. Interventions- Fall risk, increase their fluids (PO or IV) assist in and out of bed. Moans Stones Groans and Bones.

422

Early Dumping Syndrome

30 min after eating

S/S vertigo and pallor

Interventions- Have patient lie down

423

Late Dumping Syndrome

90 min after eating

S/S hyperglycemia, Dizzy, Diaphoretic, confused,

Nursing interventions: Check blood sugars.

424

Gastric Cancer

Usually begins in the glands of the stomach mucosa (from chronic gastritis that changes the cells)

No symptoms in early stages (this is why hard to cure)

Disease is advanced when detected

***Risk Factors, - chronic gastritis
Chronic Gastritis

****Correlated with H. Pylori, history of untreated GERD, eating pickled foods, nitrates from processed foods (hotdogs and bacon) and salt added to food. (what is used to preserve these foods are what puts you at risk)

425

Treatments for gastric cancer

once diagnosed longevity id decreased

Non-Surgical: Radiation and Chemotherapy
Surgical: Resection by removing the tumor

Surgical: Palliative- removing part of the stomach.

426

****Postoperative Care for gastric cancer surgery

Prevent atelectasis, paralytic ileus, wound infection, monitor for complications

Dumping Syndrome, the result of rapid emptying of food into the intestines. Earyl dumping syndrom happens within 30 min of eating have syncope, get tachy, have to sit down.

Late dumping is 90 min-3 hours after eating. causes hyperglycemia. (dizziness). teach small meals, decrease liquid intake when they eat.

427

To reduce the risk of dumping syndrome, the nurse should teach the client to do which of the following?

a) Sit upright for 30 minutes after meals.
b) Drink liquids with meals, avoiding caffeine.
c) Avoid mild and other dairy products.
d) Decrease the carbohydrate content of meals.

d) Decrease the carbohydrate content of meals.