1. Review Erickson’s stage of development
- Infancy (birth till 18mons) Trust Vs mistrust. Task: Attachment to mother
- Early adulthood (18mons to 3 years): Autonomy vs shame. Task: Gaining basic control
- Late childhood (3-6) : Initiative vs Guilt. Task : Becoming purposeful and directive
- School age (6-12) : Industry vs Inferiority. Task: Developing social, physical skills
- Adolescence (12-20): Identity vs role confusion.
- Early adulthood (20-35): Intimacy vs Isolation. Task: establishing intimate bonds
- Middle adulthood (35-65): Generativity vsd stagnation. Task: Fulfilling life goals
- Later (65+) Integrity vs despair
.
2. Elder abuse and assessments
- Physical: Sprain, dislocation, fractures, bruises, puncture wounds, burns, pressure sores
- Sexual: Discomfort/bleeding in the genital area.
- Emotional: Confusion, fearful and agitated, changes in appetite and weight, withdrawn
- Neglect: Dehydration and malnutrition, disheveled appearance, lacking physical needs, meds overdose, economic exploitation
3. Review age related changes (affecting nutrition, hydration, medications in the elderly)
- Dec skin tugor, elasticity, dry skin, inc resp. rate & decrease oxygen intake,
- Decrease: need for calories-appetite-thirst-lean body weight, stomach emptying time, metabolic rate,
- Decrease capacity of bladder, inc residual urine, incidence of incontinence and infection
- Medication doses are prescribed at one half or 1/3 of adult doses. Common sign of AE is acute changes in mental status
4. Review care of patients with chest tubes (Remove or drain air from int intrapleural space, to expand the lung after surgery, and to restore subatmospheric pressure to the thoracic cavity) Negative pressure
a. Keep all tubing coiled loosely below chest level, with connections tight and taped
b. Keep water seal and suction control chambers at appropriate water levels
c. Monitor the fluid drainage and mark the time of measurements and fluid level
i. 1 to 4 hours intervals using a piece of tape
d. Observe for air bubbling in the water seal chamber and fluctuations (tidaling)
i. If fluctuation cease, check for kinked tubing, accumulation of fluid in the tubing, occlusions, or change in the client's position, b/c expanding lung tissue may be occlusions the tube opening
ii.Know Pneumothorax, intermittent bubbling in the water seal chamber is expected as air is drained from the chest, but cont. bubbling indicates an air leak in the system
Notify the physician if there is a cont. bubbling in the water seal chambers
e. Monitor the client's clinical status
f. Check the position of the chest drainage system
g. Encourage the client to breathe deeply periodically
h. Do not empty collection container. Do not strip or mild chest tubes
i. Chest tubes are not clamped routinely. If the drainage system breaks, place the distal end of the chest tubing connection in a sterile water container at a 2 cm level as an emergency water seal
j. Maintain dry occlusive dressing
Interventions for Chest tubes
Monitor drainage; notify the physician if drainage is more than 100 mL/hr or if drainage becomes BRIGHT RED or INCREASED suddenly
Assess respiratory status and ausculate lung sounds
Monitor for sings of extended pneumothorax or hemothorax
When removed ask the client to deep breath and hold it, and the tube is removed; a dry sterile dressing, petroleum gauze dressing, or Telfa dressing is taped in place after removal of the chest tube
◦ Valsalva's maneuver
5. Use of anti-inflammatories for treatment of pain (Nonnarcotics)
Acts by means of peripheral mechanism at level of damaged tissue by inhibiting prostaglandin and other chemical mediator syntheses involved in pain
NSAIDs relive inflammation and pain to treat rheumatoid arthritis, bursitis, tendinitis, osteoarthritis, and acute gout
Slow antipyretic activity through action on the hypothalamic heat-regulating center to reduce fever (Bayer, nonsalicylates, acetaminophen (Tylenol), ibuprofen (Motrin)
◦ Analgesic and can be sued with other agents
Teach s/s BLEEDING, avoid ETOH, observe for TINNITUS, admin corticosteroids for server rheumatoid arthritis, NSAIDs reduce the effects of ACE inhibitors in hypertensive clients
◦ Pt taken anticoagulant should not take aspirin or NSAIDS
◦ ASPIRIN and NSAIDS should not be taken together b/c ASPRIN DECREASE the blood level and the effectiveness of NSAIDS and can INCREASE the risk of bleeding
High risk of TOXICITY exists if ibuprofen is taken concurrently with CALICUM BLOCKERS
Hypoglycemia can result if ibuprofen (Motrin) is taken with INSULIN or ORAL HYPOGLYCEMIC MEDIATION
Encourage routine appt to check liver/renal labs and CBC
Adverse reactions
GI irritation, bleeding, N/V/Constipation, Elevated liver enzymes, Prolonged coagulation time, tinnitus, thrombocytopenia, fluid retention, nephrotoxicity and blood decrease (plasma cells)
6. Endocrine
a. Hypothyroid S/S( Thyroid gland disorder) Hashimoto disease and Myxedema
Insufficiency of thyroid hormones T3 and T4
Decreased rate of body metabolism
Treated with hormone replacement
Endemic goiters occur in individuals living in areas where there is a DEFICIT of IODINE
◦ Iodized salt has helped to prevent this problem
b. Assessments
Fatigue, lethargy
Weakness, muscle aches, paresthesias
Intolerance to COLD
Thin, dry hair, dry skin
Thick, brittle nails
Constipation
Bradycardia, hypotension
Goiter
Periorbital edema, facial puffiness (myxedema)
Weight gain
Dull emotions and mental processes
Forgetfulness, loss of memory
Menstrual disturbances
Cardiac enlargement, tendency to develop CHF
c. Nursing interventions and pt teaching
MONITOR VITALS SIGNS, HR and RHYTHM
MAINTAIN PATENT AIRWAY through SUCTION and ventilatory support
Daily dose of prescribed hormone
Check BP and pulse regularly
WEIGHT DAILY
AVOID IODINE
◦ Levothyroxine sodium (Synthroid)
◦ Increase metabolic rates. Synthetic T3
▪ Anxiety, Insomnia, tremors, tachycardia, palpitations, angina, dysrhythmias
Ongoing follow-up to determine serum hormone level
Thyroid replacement therapy and about the clinical manifestations of both HYPOTHROIDISM and HYPERTHROID r/t UNDERREPLACEMENT OR OVERRREPLACEMENT of the hormones
Prevent constipation
Fluid intake to be 3L/day
High-fiber, including fresh fruits and vegetables
Increase activity
Little or no use of enemas or laxatives
Avoid SEDATING client, may lead to RESPICRATORY DIFFICULTIES
S/S myxedema coma
Hypotension, hypoglycemia, respiratory failure, bradycardia, hyponatremia, generalized edema, coma
Maintain patent airway
Admin CORTICOSTEROIDS as prescribed
Assess temp hourly
KEEP CLIENT WARM
MONITOR ELECTORLYTE AND GLUCOSE LEVELS
Admin glucose intravenously as prescribed
d. Hyperthyroid (Graves Disease, Goiter) S/S
Excessive activity of thyroid gland and ELEVATED LEVELS of CIRCULATION TYHROID HORMONES
Result from use of REPLACMENT HORMONE THERAPY or EXCESS THYROID-STIMULATING HORMONE (TSH) T3, T4
GRAVES autoimmune process
e. Assessments
Enlarged thyroid gland
Acceleration of body process
1. Weight loss
2. Increased appetite
3. Diarrhea
4. Heat Intolerance
5. Tachycardia, palpitations, increased BP, a-fib
6. Diaphoresis, wet or most skin
7. Nervousness, insomnia, fine tremors of hands
8. Smooth soft skin and hair
9. Personality change such as irritability, agitation and mood swings
10. Exophthalmos (protruding eyeballs)
f. Nursing interventions
Provide ADEQUATE REST
Admin Sedatives as prescribed
Provide cool, and quite environment
Observe for sings of THYROID STORM
◦ Sudden oversecretion of thyroid hormones or uncontrolled is life threatening d/t Graves disease
▪ S/S FEVER, TACHY, AIGITATION, ANXIETY, and HYPTERTENSION
▪ Primary nursing interventions MAINTAIN AIRWAY and ADEQUATE AERATION (AIR CIRCULATED THROUGH)
Obtain daily weight
Provide high-calorie diet
Admin ANTITHYROID meds, (Propylthioracil, PTU) block thyroid synthesis as prescribed
Admin IODINE preparations that inhibits the release thyroid hormone as prescribed
Admin propranolol (INDERAL) for tachycardia and to decrease excessive sympathetic stimulation
Radiation iodine therapy to destroy thyroid cells
◦ Radiation precautions (Time, distances and shielding as means of protection against radiation)
g. Patient teaching
After treatments, resulting HYPOTHYROIDISM will require daily hormone replacement
Wear MediAlert jewelry in case of emergency
Signs of hormone-replacement OVERDOSAGE are the signs for HYPERTHYROIDISM and UNDERDOSAGE HYPOTHROIDISM
Diet: HIGH-CALORIE, HIGH-PROTEIN, LOW-CAFFEINE, LOW-FIBER DIET if DIARRHEA
PTU and Methimazole should take medication exactly as prescribed so that desired affect can be achieved
Perform eye care for exophthalmos
Artificial tears to maintain moisture
Sunglasses when in bright light
Annual eye exams
h. Diabetes S/S METABLOIC DISORDER in which there is an absence of an insufficient production in insulin
DM affects metabolism of protein, carbohydrate and fat
Diagnostic parameter is a fasting glucose level, SERUM or CAPILLARY of greater than 126 mg/dl
TYPE 1: Insulin-dependent DM
◦ Polydipsia, polyphagia, polyuria, weight loss and weakness
◦ THIN and Ketosis
◦ INSULIN required by ALL
◦ Go into KETOACIDOSIS
CLINICAL CHARACTERISTICS
◦ serum glucose of 350 OR above
◦ Ketonuria in large amounts
◦ Venous pH of 6.8 to 7.2, Serum bicarbonate below 15mEg/dl
TREATMENT
◦ Treat with ISOTONIC IV FLUIDS
◦ SLOW IV infusion by IV pump of REGULAR INSULIN with IM or SC bolus
◦ Carefully replacement of POTASSIUM
TYPE 2: Non insulin-dependent DM
◦ Often unnoticed, same as type 1 and BLURRED VISION
◦ OBESE rare KETOACIDOSIS
◦ ORAL hypoglycemics or insulin
◦ develop NONKETOTIC HYPEROSMOLAR HYPERGLYCEMIA with extreme HYPERGLYCEMIA
CLINICAL CHARACTERISTICS
◦ HYPERGLYCEMIA
◦ PLASMA HYPEROSMOLALITY
◦ DEHYDRATION
◦ CHANGED MENTAL STATUS
TREATMENTS
ISOTONIC IV fluids replacements and carefully monitoring of POTASSIUM and GLUCOSE LEVELS
◦ INTRAVENOUS INSULIN (Not always necessary)
i. Assessments
Breaks in skin, infections on skin
DIABETIC DERMOPATHY (skin spots)
Unhealed injection sites
Oral cavity
Carries, Periodontal disease, Candidiasis (raised, white patchy areas on mucous membranes)
Eyes
Cataracts, retinal problems
Cardiopulmonary system
Angina, Dyspena
Periphery
Hair loss on extremities, indicating poor perfusion
Coolness, skin shininess and thinness
Weak or absent of peripheral pulses
Ulcerations of extremities
Pallor
Thick nails with ridges
Kidneys
Edema of face, hands and feet
symptoms of UTI: FATIGUE, PALLOR AND WEAKNESS
URINARY RENTATION
Neuromusculature
Atrophy of hands and feet
Neuropathies and symptoms of numbness tingling, pain burning
GI disturbances
Nighttime diarrhea
Emesis falling into patterns (vomits every night 1 hour after dinner
Gastroparesis (faulty absorption)
Reproduction
Male impotence
vagin*l dryness, frequent vagin*l infections
Menstrual irregularities
GLYCOSYLATED HEMOGLOBIN A1C (presence confirms existence of hyperglycemia in previous 4 mouths)
Glucose control over 120 days (lift of RBC)
Valuable measurement of diabetes control
j. Nursing interventions
Determine baseline labs
◦ Serum glucose, electrolytes, creatinine, BUN and ABGs
k. Patient teaching
Lift skin use 90 degree angle
Rotate injection site (abdomen for type 1)
Draw regular insulin into syringe first when mixing insulin
Carb count and use of exchange list when dinning out
Meals should be timed according to medication peak times
55%-60% carbohydrates
12-12% protein
30% fat or less
Foods high in complex carbs, high in fiber and low in fat
ETOH beverages: acceptable if proper exchange are made
ILLNESS RISE INSULIN
◦ BODY response to illness and stress is to produce glucose (HYPERGLYCEMIA)
Snack may be needed before or during exercise
◦ Monitor blood glucose before, during and after exercise when beginning a new regimen
WEATHER a CLIENT is HYPERGLYCEMIC or HYPERGLYCEMIC treat HYPERGLYCEMIA
Hyperglycemia
POLYDIPSIA, POLYURIA, POLYPHAGIA, BURRED VISION, WEAKNESS, WEIGHT LOSS AND SYNCOPE
◦ Encourage water intake and check BS frequently
Asses for Ketoacidosis
◦ Urine KETONES and GLUCOSE
◦ ADMIN insulin as directed
Hypoglycemia
HA, NAUSEA, SWEATING, TREMORS, LETHARGY, HUNGER, CONFUSION, SLURRED SPEECH, TINGLING AROUND MOUTH, ANXIETY, NIGHMARES
Nursing Action
Occurs rapidly and is potentially life-threatening treat with COMPLEX CHO
◦ graham crackers and peanut butter twice, and if no response seek medical attention
◦ Check blood glucose is < 40
Teach feet care
Feet should be check daily for changes; signs of injury and breaks in skin should be reported to HCP
Feet should be washed daily with mild soap and warm water; soaking is to be AVOIDED, feet should be DRIED well, especially BETWEEN TOES
FEET may be moisturized with a lanolin product, but not BTW TOES
WELL fitted leather shoes should be worn; going BAREFOOT and wearing SCANDLES are to be avoided
CLEAN SHOCKS should be worn daily
Garters and tight elastic-topped socks SHOLD NOT BE WORN
Corns and calluses should be removed by professional
Nails should be cut or filled straight across
WARM socks should be worn if feet are COLD
l. Addison’s Autoimmune conjunction with other ENDOCRINE DISEASE of AUTOIMMUTE NATURE
Sudden withdrawal from CORTICOSTEROIDS and lack of CORTISOL, ALDOSTERONE, and
ANDROGENS
Disease interventions
Monitor VITAL SIGNS Q15 min if in crisis, BP, WEIGHT and I&O
Instruct client to RISE SLOWLY b/c of the possibility of postural hypotension
BLOOD GLUCOSE and POTASSIUM LEVELS
Admin GLUCOCORTICOID and MINERALOCORTICOID medication
Observe for ADDISONIAN CRISIS caused by STRESS, INFECTION, TRAUMA or SURGERY
▪ Admin IV glucose with parenteral glucocorticoids. (LARGE FLUID VOLUME REPLACEMENT)
Patient teaching
Avoid individuals with INFECTIONS
Diet: HIGH-PROTEIN, and HIGH CARBOHYDRATION
LIFELONG GLUCOCORTICOID therapy
Avoid OTC Medications
Wear Medic-Alert bracelet
s/s R/T UNDERREPLACMENT and OVERREPLACEMENT of HORMONES
m. Care of the patient s/p thyroidectomy
Check for Laryngeal edema by watching for HOARSENESS or INABILITY to SPEAK CLEAR
Put tracheostomy set at the beside with O2 and suction machine, Calcium glucose should be easily accessible
Check frequently for BLEEDING
Support the NECK when MOVING CLIENT (do not hyperextend)
Determine # of PARATHYROID GLANDS that have been removed
◦ Parathyroid problems is decreased in the client's Calcium compared to the preoperative value
◦ Chances of TETANY INCREASED
◦ Check for TINGLING OF TOES and FINGERS and AROUND the MOUTH
◦ CHVOSTEK SIGN (twitching of lip after a tap over the parotid gland mean it is positive)
◦ TROUSSEAU SIGN (carpopedal spasm after BP cuff is inflated above systolic pressure means positive)
Keep DRAINAGE DEVICES COMPRESSED and EMPTY
7. Electrolytes
a. Calcium: Hypocalcemia- <8.6
Inadequate oral intake of CA and vit D
Lactose intolerance
Malabsorption syndromes such as celiac sprue or Crohn's disease
END STAGE RENAL DISASE
Increased Ca excretion
Renal failure, polyric phase
Diarrhea, Steatorrhea
Wound drainage, especially GI
Conditions that decrease the ionized fraction of Ca
Hyperproteinemia
ALKALOSIS
MEDICATIONS such as Ca chelators or binders
Acute pancreatitis
HYPERPOSPATEMIA
IMMOBILITY
REMOVED or DESTRUCTION OF PARATHYROID GLANDS
ASSESSMENT
Cardiovascular
◦ DECREASED HR
◦ HYPOTENSION
◦ DIMINISHED PERIPHERAL PULSES
◦ PROLONGED ST and QT interval
Respiratory
◦ Respiratory failure or arrest can result from DECRASED respiratory movement b/c muscle tetany or seizures
Neuromuscular
◦ Irritable skeletal muscles: TWITCHES, CRAMPS, TETANY, SEIZURES
◦ PAINFUL MUSCLE SPASMS in the calf or foot during periods of inactivity
◦ Paresthesias followed by NUMBNESS that may affect LIPS, NOSE, and EARS in addition to limbs
◦ Positive Trousseau's and Chvostek's sign
◦ HYPERACTIVE DEEP TENDON REFLEXES
◦ Anxiety, irritability
GI
◦ INCREASED GASTRIC MOTILITY, HYPERACTIVE BOWEL SOUNDS
◦ abd cramping, diarrhea
Hypercalcemia: Serum Ca >10mg
Increased Ca absorption
◦ Excessive oral intake of Ca and Vit D
Decreased Ca excretion
◦ Renal failure
◦ Use of thiazide diuretics
Increased bone resorption of Ca
◦ HYPERPARATHROIDISM
◦ HYPERTHROIDISM
◦ Malignancy (bone destruction from metastatic tumors)
◦ Immobility
◦ Use of glucocorticoids
Hemoconcentration
◦ dehydration, use of lithium
◦ ADRENAL INSUFFICIENCY
Assessments
Cardiovascular
◦ Increase in HR in early phase, bradycardia that can lead to cardiac arrest in late stage
◦ Increase in BP
◦ Bounding, full peripheral pulses
Respiratory
Ineffective respiratory movements as a result of profound skeletal muscle weakness
Neuromuscular
Profound muscle weakness
Diminished or absent deep tendon reflexes
Disorientation, lethargy, coma
Renal
Increased urinary output leading to dehydration
Formation of renal calcui
GI
DECREASED MOTILITY and HYPACTIVE BOWEL SOUNDS
ANOREXIA, NAUSEA, ABDOMINAL DISTENION, CONSTIPATION
b. Hypokalemia: POTASSIUM <3.5
LIFE-THREATHING b/c VERY BODY SYSTEM IS AFFECTED
ACTUAL TOTAL BODY POTASSIUM LOSS
◦ Excessive use of medications such as diuretics or corticosteroids
◦ Increased secretion of aldosterone, such as in CUSHING SYNDROME
◦ Vomiting, diarrhea
◦ Wound drainage, particularly GI
◦ Prolonged NG suction
◦ Excessive diaphoresis
◦ Renal disease impairing reabsorption of K
◦ Inadequate K intake: NPO
◦ Movement of K from extracellular fluid to the intracellular fluid
▪ Alkalosis
▪ Hyperinsulinisum
◦ Dilution of serum K
▪ Water intoxication
▪ IV therapy with K-poor solutions
Assessment
Cardio
◦ Thready, weak, irregular pulse
◦ Peripheral pulse weak
◦ Orthostatic hypotension
Respiratory
◦ Shallow, ineffective, respirations that result from profound weakness of the skeletal muscles of respirations
◦ Diminished breath sounds
Neuromuscular
◦ Anxiety, lethargy, confusion, coma
◦ SKELETAL MUSCLES WEAKNESS, EVENTUAL FLACCID PARALYSIS
◦ Loss of tactile discrimination
◦ Deep tendon hyporeflexia
GI
◦ Decreased mortility, hypoactive to absent bowel sounds
Renal
◦ N/V
◦ Constipation, abd distention
◦ Parlaytic ileus
Hyperkalemia K>5
Overingestion of K containing foods or medications such as POTASSIUM CHLORIDE or SALT SUBSTITUES
Rapid infusion of K-containing IV solution
Decrease K excretion
◦ POTASSIUM-SPARING DIURETICS
◦ RENAL FAILURE
◦ ADRENAL INSUFFICIENCY such as ADDISION'S DISEASE
◦ Movement of K from intracellular fluid to extracellular fluid
▪ Tissue damage
▪ Acidosis
▪ Hyperuricemia
▪ HYPERCATABOLISM
Assessment
Cardio
◦ SLOW, WEAK, IRREGULAR HR
◦ Decreased BP
Respiratory
Profound weakness of the skeletal muscle leading to respiratory failure
Neuromuscular
Early: Muscle twitches, cramps, paresthesias (tingling and burning followed by numbness in hands and feet and around mouth)
Late: Profound weakness, ascending flaccid paralysis in the arm and legs (drunk, head and respiratory muscles become affected when the serum K levels reaches a lethal level)
GI
Increased motility, hyperactive bowel sounds
Diarrhea
c. Hyponatremia Sodium <135
Imbalances usually ass with fluid volume imbalances
Increased Na excretion
Excessive diaphoresis
Diuretics
Vomiting/Diarrhea
Wound drainage, GI
Renal disease
Decreased secretion of aldosterone
Inadequate Na intake
NPO
low salt diet
Dilution of serum Na
Excessive ingestion of hypotonic fluids or irrigation with hypotonic fluids
Renal failure
Fresh water drowning
Syndrome of inapp. Antidiuretic hormones secretions
Hyperglycemia
CHF
Assessment
Cardio
Symptoms vary with change in vascular volume
Normovolemic: Rapid pulse, rate normal bp
Hypovolemic: Thready, weak, rapid pulse rate, hypotension, flat neck veins, normal or low CVP
Hypoervolemic: Rapid, bounding pulse, bp normal or elevated, normal or elevated CVP
Respiratory
Shallow, ineffective respiratory movements as a late manifestation R/T skeletal muscle weakness
Neuromuscular
Generalized skeletal muscle weakness that is worse in the extremities
Diminished deep tendon reflexes
Cerebral function
HA, PERSONALITY CHANGES, CONFUSION, SEIZURES COMA
GI
Increased motility and hyperactive bowel sounds
Nausea
Abd cramping and diarrhea
Renal
Decreased urinary specific gravity
Increased urinary outputs
Hypernatremia Sodium>145
Decreased Na secretions
◦ Corticorosteroids
◦ Cushing's syndrome
◦ Renal failure
◦ Hyperaldosteronim
Increase Na intake
Excessive oral Na injection or excessive admin of Na containing IV fluids
Decrease water intake: NPO
Increased water loss: Increased rate of metabolism, fever, hyperventilation, infection, excessive diaphoresis, watery diarrhea, diabetes inspidus
Assessment
Cardio
HR and BP that respond to vascular volume status
Respiratory: Pulmonary edema if hypervolemia presentation
Neuromuscular
◦ Early: Spontaneous muscle twitches, irregular muscle contractions
◦ Late: Skeletal muscles weakness, deep tendon reflex diminished or absent
Central nervous system
◦ Altered cerebral function is the most common manifestation of hypernatuermia
◦ Normovolemia or hypovolemia: Agitation, confusion, seizures
◦ Hypervolemia: Lethargy, stupor, coma
Renal
◦ Increased urinary specify gravity
◦ Decreased urinary output
Integumentary
◦ Dry skin
◦ Presence or absence of edema, depending on fluid volume change
Cardiac
Hypertension patient teaching and evaluation
Information about the disease process
Risk factors, causes, long-term complications, lifestyle modification
Relationship of treatment to prevention of complications
Information about treatment plan
◦ Reason for each medication
◦ How to take own BP
◦ How and when to take each medication
◦ Necessity of consistency in medications regiment
◦ Need to outgoing assessment while taking antihypertensive
HESI HINT
The number ONE cause of a STROKE in HTN clients is noncompliance with medication regimen
HTN is often symptomless and antihypertensive medications are expensive and have side effects
d. Heart Failure inability of the heart to PUMP enough blood to meet the TISSUE demands
Cause
Ischemic heart disease, MI, Cardiomyopathy, Valvular heart disease and HTN
e. Left-sided HF
PULOMANARY EDEMA (LF ventricular failure)
Pulmonary congestion d/t the inability of the Lf ventricle to pump blood to the periphery
S/S
DYSPNEA
ORTHOPNEA
“WET” LUNG SOUNDS
COUGH, FATIGUE
TACHYCARDIA
ANXIETY, RESTLESSNESS
CONFUSION
f. Right-Sided HF
Peripheral congestion d/t inability of the RIGHT VENTRICLE to pump blood out of the lungs; often results from left-sided failure or pulmonary disease
S/S
PERIPHERAL EDEMA
WEIGHT GAIN
DISTENDED NECK VEINS
ANOREXIA, NAUSEA, WEAKNESS
NOCTURIA
Planning and Interventions
Monitor vitals q4 hours for changes
Monitor apical heart rate with vital signs to detect dysrhythmias, S3 or S4
Asses for Hypoxia
RESTLESSNESS
TACHYCARDIA, ANGINA
Auscultate lungs for indications of pulmonary edema
WET SOUNDS and CRACKLES
Admin O2 as needed
Elevate HOB to assist with breathing
Observe for signs of edema
◦ Weigh daily
◦ Monitor I&O
◦ Measure abd girth observed ankles and fingers
Limit Na intake
ELEVATE LOWER EXTERMITIES while SITTING
Check apical HR prior to admin of digitalis
◦ WITHOLD medication and call physician if rate is <60 bmp
Admin diuretics in the AM
Provide periods of REST after periods of activities
g. Angina
Chest discomfort or pain that occurs when myocardial O2 demands exceed supply
Cause
Atherosclerotic heart disease
HTN
Coronary artery spasm
Hypertrophic cardiomyopathy
h. Assessments
Mild to severe intensity, described as HEAVY, SQUEEZING, PRESSING, BURNING, CHOCKING, ACHING, and feeling of APPREHENSION
SUBSTERNAL, RADIATING to Lf arm and or shoulder, jaw, right shoulder
Transient or prolonged, with gradual or sudden onset; typically of short duration
Often PRECIPITATED by EXERCISE, EXPOSURE to COLD, a HEAVY MEAL, MENTAL TENSION, SEXUAL INTERCOURSE
RELIEVED by REST and or NITROGLYCERIN
Dyspnea, tachycardia, palpitations
N/V, Fatigue, Diaphoresis, pallor, weakness
Syncope
Dyshrythmias
◦ ST-segment depressed and T-wave inversion
i. Interventions/ Pt teaching
Monitor medication and instruct client with proper administration
Determine factors precipitation pain, and assist client and family in adjusting lifestyle to decrease these factors
Teach risk factors, and identify clients own risk factors during attack
Provide IMMEDIATE REST
Take vital signs
Record an ECG
Admin no more than 3 NITROGLYCERIN tables for 5 MINS apart
Seek emergency treatments if no relief has occurred after taking nitroglycerin
Physical activity
Teach avoidance of ISOMETRIC ACTIVITES
Implement an EXERCISE PROGRAM
Sexual activity may be resumed after exercise is tolerated, usually when able to climb 2 FLIGHTS OF STAIRS without EXERTION
◦ NITROGLYCERIN can be taken prophylactically before intercourse
Provide nutritional information about modifying FAT (saturated) and SODIUM
◦ ANTILIPEMIC medications may be prescribed to lower cholesterol levels
j. CVA-sudden loss of brain function resulting from a disruption in the blood supply to a part of the brain. THROMBOTIC or HEMMORHAGICA
Stroke assessments
◦ CHANGE in LOC
◦ Paresthesia, paralysis
◦ Aphasia, agraphia
◦ Memory loss
◦ Vision impairment
◦ Bladder and bowel dysfunction
◦ behavioral changes
◦ Ability to swallow, eat and drink without aspiration
Assessment of client's functional abilities
MOBILITY, ADL'S, ELIMINATION, COMMUNICATON
k. interventions/patient teaching
Control HTN to help prevent future strokes
Maintain proper body alignment while client is in bed
◦ Use splints or other assistive devices ( bed rolls and pillows)
Position client to minimized edema, prevent contraction and maintain skin integrity
Perform FULL ROM exercises 4 times a day
Encourage client to participate in or manage own personal care
Set realistic goals, add new tasks daily
l. Care of patients with hemiplegia
m. Care of patients with hemianopsia
Appropriate self-care activities for pt
◦ Bathing, brushing teeth, shaving and electric razor
◦ Eating, combing hair
◦ Encourage client with assist with dressing activities and modify them as necessary(wear street clothes during waking hours)
Analyze bladder or elimination
Offer bedpan or urinal according to client's particular pattern of elimination
Reassure client that bladder control tends to be regained quickly
Follow-up speech programs initiated by speech and language therapist
Ensure consistency with program
Reassure the client that regaining speech is VERY SLOW PROCESS
Give ONE set of INSTRUCTIONS at a time
Encourage total family involvement in rehab
Encourage client and family to join support group
Encourage family members to allow the client to perform self-care activities as outlined by rehab team
Teach swallowing modifications may include soft diet (pureed foods, thickened liquids) and head positions
HESI HINT
Steroids are administered after a stroke to decrease cerebral edema and retard permanent disability
H2 inhibitors are admin to prevent peptic ulcers
8. Respiratory
a. ABG interpretation- Measurement of the dissolved oxygen and carbon dioxide in the arterial blood helps indicate the acid-base state and how well OXYGEN is being carried to the body
Prepro
Perform ALLEN'S TEST before drawing radial artery specimens
Assist with the specimen draw by preparing a heparinized syringe
Have pt rest for 30 MIN before specimen collection to ensure accurate measurement of body oxygenation
Avoid SUCTIONING before drawing the ABG sample. Do not turn off oxygen unless the ABG sample is ordered to drawn with the clients breathing room
Postprocedure
Place specimen on ice
Note clients temp on the lab form
Note the oxygen and type of ventilation that the client is receiving on the lab form
Apply pressure on the puncture site for 5 to 10 min or longer if the client is taking anticoagulant therapy or has a bleeding disorder
Transport specimen to the laboratory within 15 min
NORMAL ARTERIAL BLOOD GAS VALUES
pH: 7.35-7.45
Pco2- 35 to 45 mm Hg
Hco3- 22-27
PO2- 96-100%
Asthma: Chronic inflammatory disorders of the airways that causes VARYING DEGREE OF OBSTRUCTION in the airways. AIRWAY INFLAMMATION and HYPERRESPONSIVENESS to stimuli or triggers
b. Risk factors (triggers)
Infections
Allergies
Exercise
Irritants
IgE-mast cell medicated response
◦ Obstruction of large and small airways
◦ Air trapping
◦ RESPIRATORY ACIDOSIS
◦ HYPOXEMIA
Asthma causes recurrent episodes of WHEEZING, BREATHLESSNESS, CHEST TIGHTNESS, and COUGHING associated with AIRFLOW OBSTRUCTION that may be resolved spontaneously, often reversible with treatment
Status asthmaticus is severe life-threatening ASTHMA episode that is refractory to treatment and may result in PNEUMOTHORAX, acute cor pulmonale or respiratory arrest
c. Assessments
RESTLESSNESS ( early signs of cerebral hypoxia, brain is not receiving enough 02)
WHEEZING OR CRACKLES
ABSENT OR DEMINISHED LUNG SOUNDS
HYPERRESOANCES
USE OF ACCESSORY MUSCLES FOR BREATHING
TACHYPNEA (rapid breathing) with HYPERVENTILATION
PRONLONGED EXHALATION
TACHYCARDIA, PULSE PARADOXUS (Systemic arterial pressure normally falls by less than 10 mmHg during inspiration, but this decline is not palpable at the peripheral pulse)
DIAPHORESIS, CYANOSIS, DECREASED OXYGEN SAT
f. Treatments
ADMINIST BRONCHODILATORS, FLUIDS and HUMIDIFICATION
◦ Hydration enables liquefactions of mucus trapped in the bronchioles and alveoli, facilitating expectoration
◦ Essential for clients experiencing fevers
◦ 300-400ml of fluid is lost daily by the lungs through evaporation
Nursing Interventions
PROMOTE AIRWAY CLERANCE (fluids, antibiotics)
Monitor vital signs, pulse ox, peak flow
Position pt in HIGHT FOWLER’S POSTION or SITTING to aid in breathing
Admin oxygen as prescribed
Admin bronchodilator as prescribed
◦ Dilate the airways of the respiratory tree, making air exchange and respiration easier for the client, and relax the smooth muscle of the bronchi
◦ QUICK RELIEF MEDICATION
◦ If taken THEOPHYLLINE monitor therapeutic level 10 to 20 mcg
Record color, amount and consistency of sputum if any
Admin corticosteroids as prescribed (Metered-dose inhaler) MDI
◦ Anti-inflammatory agent and reduce edema of the airways
◦ LONG TERM control
Ausculate lung sounds before, during and after treatment
Minimizing anxiety
Nursing care, calm approach. Keep pt and family informed about procedures
Pt. Education
INTERMITTENT NATURE OF SYMPTOMS and NEED for LONG-TERM management
Instruct client to identify possible triggers and measures to prevent episodes
management of medication and proper administration
Correct use of peak flow meter
Asthma action plan with primary care provider and teach the client what to do if asthma episodes occur
INHALER
◦ HAVE CLIENT EXHALE COMPLETELY
◦ GRIP MOUTHPIECE (IN MOUTH) ONLY IF THERE IS A SPACER, otherwise, KEEP THE MOUTH OPEN TO BRING IN VOLUME OF AIR WITH MISTED MEDICATION. WHILE INHALING SLOWLY, PUSH DOWN FIRMLY ON THE INHALTER TO REALASE MEDICATION
◦ USE BRONCHODILATOR INHALOR BEFORE STEROID INHALER
◦ WAIT AT LEAST 1 MIN BEFORE PUFFS (INHALED DOSES)
d. COPD- CHRONIC OBSTRUCTIVE LUNG DISEASE and CHRONIC AIRFLOW LIMITATINS. CHRONIC COUGH, SPUTUM PRODUCTION, and INCREASED WORK of BREATHING as well as DOE
e. Diagnostic tests
Pulmonary function Test
◦ EVALUATE LUNG MECHANICS, GAS EXCHANGE, and ACID-BASE DISTRUBANCES through SPIROMETRIC MEASRMENTS, LUNG VOLUMES and ABG LEVELS
◦ Determine whether an analgesic that may depress the respiratory function is being administered
▪ Hold BRONCHODILATOR before test (consult with physician)
▪ Void before the procedure and wear loose clothing
▪ Instruct client to refrain from smoking or eating heavy foods 4 to 6 hours before the test
Postprocedure:
Client may resume normal diet and any bronchodilators and respiratory treatments that were held before the procedure
HESI HINT
COPD worsens, the amount of O2 in the blood decreases (HYPOXEMIA) and amount of carbon dioxide (CO2) in blood increases (HYPERCARBIA)
▪ cause CHRONIC RESPIRATORY ACIDOSIS (INCREASED ARTERIAL CARBON DIOXIDE) PaCO2
▪ METABOLIC ALKALOSIS (increase arterial bicarbonate)
▪ Not all COPD pt are CO2 retainers, even when hypoxemia is present, b/c CO2 diffuse more easily across lung membranes than O2
f. Assessment
◦ Blue bloater (cyanosis)
◦ Right sided heart failure, distended neck veins
◦ COUGH
◦ DOE
◦ CRACKLES
◦ Expiratory WHEEZES
◦ SPUTUM PRODUCTION
◦ WEIGHT LOSS
◦ PROLONGED EXPIRATION
◦ ORTHOPNEA
◦ CARDIAC DYSRHYTHMIAS
◦ HYPERINFLATION OF LUNGS and FLAT DIAPHRAGM
◦ ABG levels that indicate RESPIRATORY ACIDOSOS and HYPOXEMIA
g. Planning
◦ IMPROVE GAS EXCHANGE, ACHIEVMENT OF AIRWAY CLERANCE
◦ SMOKING CESSATION
◦ IMPROVED BREATHING PATTERN
◦ MAXIMAL SELF-MANAGMENT
◦ IMPROVED ACTIVITY TOLERANCE
◦ IMPROVED COPING ABILITY
◦ IMPROVED HEALTH-RELATED QUALITY OF LIFE
h. Nursing Interventions
◦ IMPROVING GAS EXCHANGE
▪ Monitor for dyspnea and hypoxia
▪ Admin medications and be alter for potential side affects
▪ Assess relief of bronchospasm through pt report of less dyspnea
▪ Monitor prescribed oxygen effectiveness with pulse oximetry or ABG's
▪ B/C HYPOXEMIA IS A STIMULUS FOR RESPIRATION IN THE PT with COPD, AVOID DEPRESSING the RESPIRATORY DRIVE with ADMINSTERING OXYGEN to CORRECT HYPOXEMIA
Interventions
Monitor vital signs
Admin low concentration of O2 (1 to 2/Lmin) stimulus to breathe is a low arterial PO2 instead of an increased PCO2
MONITOR PULSE OXIMETRY
In DIAPHRAMATIC OR ABDOMINAL TECHNIQUES and PURSED-LIP BREATHING
RECORD COLOR, AMOUNT, and CONSISTENCY OF SPUTUM
SUCTION FLUIDS from the CLIENT'S LUNGS, if ness. To CLEAR the AIRWAYS and PREVENT INFECTION
MONITOR WEIGHT and ENCOURAGE SMALL FREQUENT MEALS to MAINTAIN NUTURTION and PREVENT DYSPNEA
◦ HIGH-CALORIE, HIGH-PROTIEN DIET
▪ Magnesium and Calcium b/c of their role in MUSCLE CONTRACTION and RELAXATION
▪ Monitor Mg and Phosphorus levels b/c role to bone mineral density (osteoprosis)
ENCOURAGE FLUID INTAKE UP TO 3000 ml/day to keep SECRETIONS THIN, unless contraindicated
◦ MONITOR for S/S of fluid overload
HESI HINT
If breath sounds are clear, but client is cyanotic and lethargic, adequate OXYGENATION is not OCCURING
Key to Respiratory Status is assessment of BREATH SOUNDS as well as VISUALIZATION of the client
◦ Crackles, wheezing, or high-pitched whistling sounds rather than RALES or RHONCHI
◦ O2 must bubble through some type of water solution so it can be humidified if given at >4L/min or delivered directly to trachea
i. Patient teaching
Relaxation techniques when not in distress
PLACE CLIENT IN HIGH FOWLER's POSITION and LEAN FORWARD to aid in BREATHING
TEACH CLIENT to SIT UPRIGHT and BEND SLIGHTLY FORWARDS to PREVENT BREATHING
PURSED-LIP and DIAPHRAGMATIC BREATHING
◦ PRONLONGED EXPIRATORY PHASE to CLEAN TRAPPED AIR
j. health promotion
MECHANICALLY soft DIET, which do not require as much chewing and digestion
Prevent secondary infections: AVOID CROWDS, CONTACT with PEOPLE who have INFECTIOUS DISEASE and RESPICRATORY IRRANTS (tobacco smoking)
Client report any changes in characteristics of SPUTUM
HYDRATE 3/Lday and decrease caffeine due to diuretic effects
IMMUNIZATIONS when needed (flu and pneumonia)
◦ Older adult 65 year older with hx chronic illness once a lifetime
▪ Immuniosuppression clients or clients with hx of pneumonia revaccination is sometimes required
Inform smoking with nor near oxygen is extremely dangerous
k. Pneumonia diagnostic testing
Chest x-ray show lobar or segmental consolidation pulmonary infiltrates, or pleural effusions
Blood and sputum cultures identify organism
gram stain
WBC count and Erythrocytes sedimentation rates are elevated
l. Assessments
Respiratory alkaloids
Cyanosis and cold and clammy skin
Encourage cough deep breathing, and use of IS q 2hours
Semi-fowler's pt to facilitate breathing and lung expansion
Change positions frequently and ambulates as tolerated to mobilize secretions
Perform nasotracheal suctioning if client is unable to clear secretions
Pulse Oximetry
high-calorie, high-protein diet with small frequent meals
3 L/day to thin secretions unless contraindicated
Abrupt onset of ELEVATED FEVER with shaking and CHILLS
TACHYPNEA: Shallow respirations use of accessory muscles
RHONCHI and WHEEZES, use of ACCESSORRY MUSCLES for breathing, MENTAL STATUS CHANGES
SPUTUM PRODUCTION
Reproductive cough with pleuritic pain
Rapid, bounding pulse
Older adults
◦ CONFUSION, LETHARGY, ANOREXIA, RAPID RESPIRATORY RATE
PAIN and Dullness to percussion over the affected lung field
m. characteristics of lungs sounds
Bronchial breath sounds are heard over areas of density or consolidation, crackles
n. bronchial secretions
Amount, color and color of secretions (Green, Rusty and Red)
o. medication administration
Antipyretics, bronchodilators, cough suppressants, mycolytic agents, and expectorants
p. patient teaching
Instruct the importance’s of rest, proper nutrition and adequate fluid intake
Avoid chilling and exposure to individuals with respiratory infections or virus
Notify the MD if chills, fever, dyspnea, hemoptysis, or increased fatigue occurs
q. health promotion
Older adults: Flu and pneumonia immunizations
Immunosuppressed and debilitated persons: infection avoidance, sensible nutrition, adequate intake, balance and rest and activity
avoid sources of infection and indoor pollutants (dust, smock, and aerosis) NO SMOKING
COMATOSE and IMMOBILE PERSONS: elevation of HOB to feed and for 2 hours after feedings. Frequent turning
2. Musculo skeletal
a. Assessment and care of patients with fractures
Maintaining and Restoring function
3. Reduction and immobilization are maintained as prescribed to promote bone and soft tissue healing
4. Edema is controlled by elevating the injured extremity and applying ice as prescribed
5. Neurovascular status (Circulating, Movement, Sensation) is monitored and the orthopedic surgeon is notified immediately if sings of neurovascular compromise are identified
6. Restlessness, anxiety and discomfort are controlled with a variety of approaches, such as reassurance, position change and pain relief strategies, including use of analgesics
7. Participation in ADL’s is encouraged to promote independent functioning and self-esteem
8. Internal fixation the surgeon determines the amount of movement and weight-bearing stress the extremity can withstand and prescribes the level of activity
Nursing Management (Patients with closed fractures)
9. Nurses encourages pt with closed simple fractures to return to their usual activities as rapidly as possible.
10. Nurse teaches pt how to control edema and pain associated with the fracture and with soft tissue trauma and encourages the pt to active within the limits of the fracture immobilization
11. Important to teach exercises to maintain the health of unaffected muscles and to increase the strength of muscles needed for transferring for using assistive devices (crutches, walker, special utensils)
12. Plans are made to help pt modify their home environment as needed and to secure personal assistants if necessary
13. Pt teaching include; self-care, medication information, monitoring for potential complications and the need for continuing health care supervision
14. Fracture healing and restoration of full strength and mobility may take many months
Pt with Open Fractures
15. Risk for osteomyelitis (infection of the bone), tetanus, and gas gangrene
16. Goal is to prevent infection of the wound, soft tissue, and bone and to promote healing of soft tissue and bone
a. Nurse admin.tetanus prophylaxis if indicated
17. Serial irrigation and debridement are used to remove anaerobic organism
a. IV antibiotics are prescribed to prevent or treat infections
b. Wound is cultured and devitalized bone fragments are removed
18. Damaged to blood vessels, soft tissue, muscles, nerves, and tendons is treated
19. Open fracture primary wound closure is usually delayed
20. Heavily contaminated wounds are left unsaturated and dressed with sterile gauze to permit edema and wound drainage
21. After determined that infection is not present, the wound is closed in 5 to 7 days and all dead space is obliterated by grafting of autogenous skin or flap
22. Nurse evaluates the extremity to minimize edema and the importance to asses neurovascular status frequently
23. Measuring temp at regular intervals and monitors the pt for signs of infection
24. Fracture Healing and Complications
25. Weeks to months are required for most fractures to heal
26. Affected bone must have an adequate blood supply
27. Fractures at the ends of long bones, where the bone is more vascular and cancellous, heal more quickly than do fractures in areas where the bone is dense and less vascular (midshaft)
28. If fracture healing is disrupted, bone union may be delayed or stopped completely
a. Factors that can impair fracture healing include inadequate fracture immobilization, inadequate blood supply to the fracture side or adjacent tissue, extensive space btw bone fragments, interposition of soft tissue btw bone ends, infection and metabolic problems
29. Enhance fracture healing
30. Immobilization of fracture fragments
31. Maximum bone fragment contact
32. Sufficient blood supply
33. Proper nutrition
34. Exercise: weight bearing for long bones
35. Hormones: grown hormone, thyroid, calcitonin, vit D anabolic steroids
36. Electric potential across fracture
37. Inhibit Fracture Healing
38. Extensive local trauma
39. Bone loss
40. Inadequate immobilization
41. Space or tissue btw bone fragments
42. Infection
43. Local malignancy
44. Metabolic bone disease (Paget’s disease)
45. Irradiated bone (radiation necrosis)
46. Avascualr necrosis
47. Intra-articular fracture (synovial fluid contains fibrolysis, which lyse the initial clot and retard clot formation)
48. Age (elderly persons heal more slowly)
49. Corticosteroids (inhibit the repair rate)
a. Osteoarthritis risk factors
Degeneration of cartilage, a wear-and tear process
usually affects ONE or TWO joints
ASSYMMETRICALY
OBESITY and OVERSUE are PREDISPOSING factors
Assessments
JOINT pain that INCREASES with ACTIVITY and improves with REST
Morning stiffness
Asymmetry of affected joints
Crepitus (grating sound in the joint)
Limited Movement
visible joint abnormalities indicted on radiographs and joint enlargement and body nodules
RA and OA Nursing Interventions
Weight-Reduction diet
Excessive use of the involved joint aggravates pain and may accelerate degenerations
Implement pain relief measures
◦ Use moist heat
▪ WARM, MOST COMPRESS
WIRLPOOL BATHS
Hot shower in the AM
PERIODS of REST after PERIODS of ACTIVITY
PERFORM ACTIVITES during DAY when client feels most Energetic
Encourage avoid overexertion and to maintain proper posture and joint position
Use of assistive devices
◦ Elevated toilet seat
◦ Shower chair
◦ Cain, walker and wheelchair
◦ Reaches
◦ Adaptive clothing with Velcro closures
◦ Straight-backed chair with elevated seat
Teach client
Correct posture and body mechanics
Sleep with rolled terry cloth towel under cervical spine if neck pain is a problem
Keep joint in functional position
b. Rheumatoid arthritis risk factors
CHORNIC, SYSTEMATIC, PREOGESSIVE DETERIORATION of the CONNECTIVE tissue ( synovium) of the joint
◦ INFLAMMATION
IMMUNE COMPLEX disorder
Joint involvement is bilateral and symmetrical
Morning stiffness
Weight loss
Swelling of both hands and wrists
c. Diagnostic testing
ELEVATED ESR
Positive Rheumatoid factor (RF)
Presence of antinuclear antibody (ANA)
JONT-SPACE Narrowing
Abnormal SYNOVIAL fluid (fluid in joint)
C-reaction protein (CRP) ACTIVE INFLAMMTION
HESI HINT
EARLY detection of RA can decrease the amount of bone and joint destruction
Goes into REMISSION
DECREASING the amount of bone and joint destruction reduces the amount of disability
d. Assessments
FATIGUE
GENERALIZED WEAKNESS
WEIGHT LOSS
ANOREXIA
MORNING STIFFINESS
BILATERAL INFLAMMATION of JOINTS with the following symptoms
◦ Decreased ROM
◦ JOINT PAIN
◦ WARMTH
◦ EDEMA
◦ ERYTHEMA
◦ JOINT DEFORMITY
▪ CORTICOSTEROIDS for INFLAMMATION, SPLINTING, IMMOBILIZATION and REST for joint deformity and NSAIDs for pain
50. Sensory disorders
a. Care of the patients with glaucoma
Chronic open-angle glaucoma know as adult PRIMARY glaucoma is OPEN ANGLE
Increased intraocular pressure
gradual, painless vision loss
Can lead to blindness if untreated
Increased in older adults population
bilaterally in those who have a family hx of glaucoma
AQUEOUS FLUID is INADAQUATELY DRAINED from the eye
ASYMPTOMATIC especially in early stages
dx during routine visual examination
Loss of peripheral vision and see HALOS around LIGHTS
DECREASED VISUAL ACUITY not correctable with glasses
HA or EYE PAIN that may be so severe as to cause N/V (ACUTE OPEN-ANGLE glaucoma)
Interventions
Eye drops are used to cause PUPIL CONSTRICTION b/c movement of muscles to constrict the pupil allows AQUEOUS HUMOR to FLOW OUT. DECREASE PRESSURE IN EYE
◦ PILOCARPIN used. Vision may be blurred for 1 to 2 hours after admin and adaptation to DARK ENVRONMENT is difficult b/c pupillary constriction
ANTIHISTAMINES AND ANTICHOLINERGICS side affects
Orient client to surrounds
Avoid nonverbal communication that requires VISUAL ACUITY(facial expressions)
Develop a teaching plain that includes:
Carefully adherence to eye-drop regimen can prevent blindness
Vision already lost cannot be restored
EYE DROPS are NEEDED for the Rest of LIFE
Proper eye-drop instillation technique. OBTAIN RETURN DEMOSTRATION
◦ Wash hands and external eye
◦ Tilt head back slightly
◦ Instill drop into lower lid, without touching the lid with the tip of the dropper
◦ Release the lid, a sponge excess fluid from lip and check
◦ CLOSE EYE GENTLY and LEAVE CLOSE 3-5 MIN
◦ APPLY GENTLE PRESSURE on INNER CANTUS to DECREASE SYSTEMIC ABSORPTION
REMOVE throw rugs
Adjust lighting to meet needs
Avoid activities that may INCREASE INTRAOCULAR PRESSURE
◦ Emotional upsets
◦ Exertion: pushing, heavy lifting, shoveling
◦ Coughing severely or excessive sneezing (get medical attention before upper respiratory infections worsens)
◦ DO NOT WEAR CONSTRICTIVE CLOTHING
◦ STRAINING at STOOL and CONSIPATION
▪ Older clients prone to constipation
▪ The nurse should ASSESS these clients for constipation and postoperative complications associated with constipation and should implement a plan of care directed at prevention of and treatment
b. Care of the patients with cataracts
Opacity of the lens
Lens of the eye is responsible or projection light onto the Retina so that images can be discerned
◦ without the lends, opaque with cataracts, light cannot be filtered and vision is blurred
Early signs: Blurred vision, DECREASED COLOR PERCEPTION
Late Signs: Diplopia, Reduced visual acuity, progression to blindness
Clouded pupil, progressing to a milky-while appearance
◦ Preoperative: Demonstrate and request a return demonstration of eye medication instillation from clients or family member
◦ Postoperative: Warning not to rub or put pressure on eye
◦ Teaching that gasses or shaded lens should be worn during WAKING HOURS
◦ AVOID LIFTING objects over 15lbs, bending, straining, coughing, or an y other activity that can INCREASE IOP
◦ STOOL SOFTNER to prevent STRAINING at STOOL
◦ Teaching to AVOID LYING on OPERATIVE SIDE
◦ KEEP WATER FROM GETTING INTO EYE while showering or washing hair
◦ Report s/s of increased IOP and INFECTION (pain, changes in vital signs)
◦ When the cataract is removed, the lens is gone, MAKING PREVENTION of FALLS IMPORTANT
▪ When lens is replaced with an implant, vision is BETTER
c. Care of the patients with hearing impairment
Prior to starting conversation, reduce distraction as much as possible
Turn the TV or radio down or OFF, CLOSE the DOOR, or MOVE to a quieter location
Devote full attention to the conversation; do NOT try to do TWO things at once
Look and Listen during the conversation
Do not switch topics abruptly
Lip reader, face him or her directly
SPEAK SLOWELY and DISTINCTLY, determine whether you are being understood
ALLOW ADEQUATE time for the conversation to take place; try to avoid hurried conversations
Use active listening techniques
Be sure to into inform the health care staff of the client's hearing loss
HELP FULL AIDS
◦ AMPLIFIER earphone attachments for the radio and TV, and lights or buzzers that indicate the doorbell is ringing, located in the most commonly used room of the house
HESI HINT
SPEACK in a low-pitched voice, slowly and distinctly
Stand in front of the person, with the light source behind the client
Use visual aids if available
51. Skin Disorders
a. Impetigo
CONTAGIOUS BACTERAL INFECTION of the skin caused by beta-hemolytic streptococci
Occur from POOR HYGIENE
Common around the MOUTH, and then on the HANDS, NECK AND EXTERMITEIS
Lesions begin as VESICLES or PUSTULES SURROUNDED by EDEMA and REDNESS
VESICLES fluid becomes cloudy and vesicles reputes, leaving honey-colored crusted covered ulcerated based
Interventions
Contact isolations
lesions dry by air exposure
Warm saline to lesions two or three times a day followed by soap and water to remove crusted and allow for healing
Apply emollients to prevent skin cracking
Methods to prevent the spread of the infection, especially carefully hand washing
Use separate towel, lines and dishes
Wash clothes with DETERGENT in HOT water
b. Contact dermatitis
INFLAMMATORY response of the skin that produces skin changes after contact with SPECIFIC ANTIGEN
Assessments
Pruritus and burning
EDEMA
ERTHEMA at the POINT of CONTACT
Sign of INFECTIONS
VESICLES AND DRAINAGE
Interventions
ELEVATED and EXTREMITY to REDUCE EDEMA
Apply cool, wet dressings and TEPID baths as prescribed
Maintain a cool environment
Protect the affected area from trauma
Prevent scratching and rubbing of the affected area
Assisted with skin test as prescribed to determine allergens
Instruct the client to avoid contact with the ALLERGEN when determined
Avoid hard soaps
Avoid using heating pads or blankets
Psoriasis
CHRONIC, noninfectious SKIN inflammation involving KERATIN SYNTHESES that result in PSORIATIC PATCHES
Possible cause STRESS, TRAUMA, INFECION and changes in climate
May be EXACERBATED by the use of certain medications
Koebner phenomenon is the development of POSOIATIC LESIONS
Assessments
Pruritus
SHEDDING, SIVERY, WHITE SCALES on a RASIED, REDDENDED, ROUND PLAQU that usually affects the SCALP, KNEES, ELBOWS, EXTRSONS surfaces of ARMS and LEGS
and SACRAL REGIONS
Interventions
Assist with client to remove the scales DURING the SOAK and SOFT WASHCLOTH and GENTLE, CIRCULAR MOTIONS; EMOLLIENT CREAM or SALICYLIC ACID
keep the skin LUBRICATED to minimize ITCHING
WEAR light COTTON clothing over affected areas
c. Herpes Zoster infection
Chickenpox, shingles is caused by the reactivation of the varicellazoster virus; shingles can occur during any immunocompromised state in a client with a hx of chickenpox
Dormant virus in located in the DORSAL NERVE ROOT GANGLION of the Sensory cranial and spinal nerves
Contagious to individuals who have not had chickenpox
Assessments
UNILATERALLY CLUSTERED skin VESICLES long PERIPHERAL SENSORY NERVES on the TRUCK, THROAX, or face
FEAVER
BURNING or NEURALGIA
PRURITIS
PARESTHESIA
Interventions
Isolate the client b/c exudate from the lesions contains the virus (maintain standard and other precaution such as contact precaution
Assess neurovascular status and 7th cranial nerve function
s/s infection and Keep blisters intact if formed
Assist the client with acetic acid compressions, cool, wet compressions and tepid baths
Nerve block using lidocaine (Xyocaine)
Use air mattress and bed cradle on the clients bed and keep the environment cool, warmth and touch aggravate pain
Prevent client from scratching and rubbing the affected arm
Instruct the client to wear lightweight, loose cotton clothing and to avoid wool and synthetic clothing
Neurological
Seizures, care of patients with seizures, assessments, interventions, potential complications
- Seizures are an abnormal discharge of electrical activity within the brain.
- Assessment: Seizure history, type and occurrence of seizure, presence of aura
- Interventions: Note time and duration, place client on floor, head to side and protect head, maintain patent airway, administer O2, don’t restrain. As for meds administer: Valium, Dilantin. Tell client to avoid alcohol, stress, and fatigue.
- Tonic Clonic seizure begins with an aura, followed by stiffness and rigidity of muscles and legs that lasts 10-20sec. Absence seizure lasts seconds and victims appear to be day dreaming. Myoclonic seizures involve generalized jerking.
Bell’s palsy S/S, assessments, patient teaching
- Lesion of the seventh cranial nerve, resulting in paralysis in one side of the face
- Assessment: Flaccid facial muscles, inability to raise eyebrows, frown or smile loss of taste.
- Interventions: Encourage facial exercises, protects eyes from dryness, frequent oral care, instruct client to chew on unaffected side.
◦ Review instruments to assess neurological status (interpretation of results)
Glasgow come scale…..
Hepatic
Cirrhosis, assessments
- History of alcohol and street drugs, exposure to toxic chemicals, hepatotoxic drugs, family history of liver abnormalities.
- Physical findings: weakness, malaise, anorexia, weight loss, jaundice, fetor hepaticus