Physiological Integrity Reduction of Risk Physiological Integrity

Physiological Integrity Reduction of Risk Physiological Integrity
Concorde - Garden Grove

Reduction of Risk Potential
Physiological Integrity Reduction of Risk Potential

Changes/Abnormalities in VS
Monitor VS Compare to baseline Reinforce client teaching about normal/abnormals (i.e. hypertension, fever, etc.)

Diagnostic Tests Performing/collecting
EKG blood glucose O2 saturation occult blood Specimen (blood, urine, stool, sputum Reinforce teaching about diagnostic testing

Assist With Invasive Procedures
Call time out Assist with bronchoscopy, needle biopsy, etc.

Lab Values ABGs BUN/creatinine Cholesterol Glucose
Hemoglobin/hematocrit Hemoglobin A1C Platelets Potassium, sodium PT/PTT & APTT INR WBC

Follow Up Maintain central venous catheter
Reinforce teaching on purpose of laboratory tests Monitor diagnostic/laboratory tests Notify provider of results

Basic Alterations Signs and symptoms of infection
Identify/intervene hypo or hyperglycemia Recognize basic abnormalities on EKG Care for wound drain (i.e Jackson Pratt) Care for Central Line Cooling/warming measures to control body temperature Care of tracheostomy Care of ostomy (i.e. colostomy, ileostomy, etc) Care of client on ventilator

Potential Alterations in Body Systems
Identify clients at risk for/exhibit: Insufficient blood circulation Change in LOC Change from baseline Urinary retention Implement ways to prevent

Potential for Complications
Identify client response to dx tests/procedures/treatment Complete incident report when unusual occurrence or variance occurs Monitor continuous/intermittent suction to NG tube Implement measures to decrease risk (i.e. TCDB)

Potential for Complications
Insert, maintain, remove urinary catheter, NG tube, IV per facility policy Maintain strict technique Care of patient with electroconvulsive shock therapy, dialysis, seizures, wounds, burns, a pacemaker, hemorrhage, ostomy Notify provider of change in condition

Post-op Complications
Respiratory: atelectasis and pneumonia Signs and symptoms Cough, dyspnea, shortness of breath Elevated temperature Restlessness/anxiety Adventitious breath sounds Chest expansion Pain with respirations Interventions Turn, cough, deep breathe Mobilize secretion (suction prn) Increase fluids Assessment (breath sounds, VS, etc.)

Pneumonia Atelectasis

Thrombophlebitis Symptoms Red, tender calf Pain Edema Elevated temperature Positive Homan’s sign (do not repeat -> can dislodge clot) Interventions Elevate lower extremities CMS checks Assessment Avoid ambulation TED hose unaffected leg

Wound Infections Symptoms Elevated temperature Tachycardia Pain and tenderness at surgical site Edema, erythema, warmth around sutures Purulent drainage Interventions Dressing/skin dry Sterile technique

Wound separation Dehiscence and evisceration Pre-disposing factors Infection, altered ability to heal, excess pressure on incision Assessment Sensation of “giving way” or pain Interventions Position to decrease stress on site Cover moist, sterile gauze Notify MD immediately Prepare for surgery Provide emotional support

Question The nurse is contributing to the plan of care for a client with heart failure. Which of the following interventions should the nurse recommend including in the client’s plan of care? Select all that apply. Obtaining the client’s weight daily Encouraging the client to increase the daily fluid intake Monitoring the client’s serum potassium level Limiting the client’s intake of fresh fruits and vegetables Checking the client for peripheral edema A c e

Physiological Adaptation
Physiological Integrity Physiological Adaptation

Body Fluids Adults Infants 75-80% Note 2.2lb is 1 L fluid
Women 50-55% body weight in water Men 60-70% body weight in water Older adults 47% body weight in water Infants 75-80% Note 2.2lb is 1 L fluid

Fluids and Electrolytes
Water Intracellular (80%) Extracellular (20%) Intravascular Interstitial Balance Intake (ingestion and oxidation) Output (skin, lungs, saliva, stool, secretions, urine)

Dehydration: fluid volume deficit
Loss of skin turgor Dry mucous membranes ↑HR & R Hyperthermia Cap refill > 3 sec Weakness Fatigue Labs: ↑Hct,/urine spec gravity/osmolarity Late signs: oliguria, decreased central venous pressure, flattened neck veins

Fluid Overload Cough, dyspnea, crackles ↑BP, P, R Headache Weight gain
Hemodiluttion electrolytes/Hct Late: JVD, tachycardia, pitting edema, increased CVP

Electrolytes Na+ 135-145 mEq/L Ca+ 8.5-10 mg/dL Cl- 85-115 mEq/L
HCO mEq/L K mEq/L Mg mEq/L

Electrolyte Function Maintain homeostasis
Promote neuromuscular excitability Maintain fluid balance Distribute water balance between fluid compartments Maintain cardiac stability Regulate acid-base balance

Hypokalemia From: GI loss, ↓intake, diuretics, aminoglycosides
Signs and symptoms Muscle weakness, fatigue N/V Dysrhythmias Flat T waves Interventions Administer K EKG monitoring Teach diet sources Never give bolus

Hyperkalemia From: tissue injury, K+ sparing diuretics, renal failure, adrenal insufficiency, ↑intake Signs and symptoms Muscle cramps, weakness, paralysis Bradycardia Dysrhythmias Tall T waves Interventions Monitor EKG Kayexelate 50% glucose with insulin Calcium gluconate Loop diuretics Dialysis

Hyponatremia From: GI loss, SIADH, diuretics, adrenal insufficiency, diuretics, water intoxication, ↓intake Signs and symptoms Weakness Lethargy Confusion Seizures Coma Interventions Daily weight, I&O CNS changes, seizure precautions Restrict fluid prn Teach fluid sources

Hypernatremia From: water deprivation, GI loss, diabetes insipidus, ↑loss Signs and symptoms Thirst Mucous membranes sticky Restlessness/Weakness Orthostatic hypotension Muscle irritability, seizures coma Often overlooked in elderly Interventions Daily weight, I&O Seizure precautions Teach dietary sources (esp. medications)

Magnesium mEq/L Affected by kidney function and metabolic disturbances Elevation can slow cardiac conduction and muscle function = bradycardia, coma, death Decreases can lead to muscular irritability, paresthesias, tetany, agitation Check Chvostek’s & Trousseau’s sign

Hypercalcemia From: hyperparathyroidism, malignant dx, prolonged immobility, Vit D excess, thiazide diuretics, lithium Signs and symptoms Cardiac dysrhythmias Confusion Muscle weakness Hypercalciuria/renal stones Lethargy/coma Interventions Increase mobility Calcitonin IV Lasix Glucocorticoids Biophosphonates Increased risk of fractures

Acid-Base Balance pH 7.35-7.45 CO2 35-45 HCO3 22-28 Respiratory
Opposite CO2 and pH opposite directions Metabolic Equal HCO3 and pH go same way

Questions? A client has the following laboratory values: a pH of 7.55 and a HCO3 level of -22 mm Hg, and a PCO2 of 30 mm Hg. What should the nurse do? 1. Perform the Allen’s test 2.Prepare the client for dialysis 3. Administer insulin as prescribed 4. Encourage the client to slow down breathing Encourage the client to slow down the breathing. Respiratory alkalosis

A client is scheduled for blood to be drawn from the radial artery for an ABG. A nurse assists with performing Allen’s test before drawing the blood to determine the adequacy of: 1. Ulnar circulation 2.Carotid circulation 3.Femoral circulation 4.Brachial circulation 1.Ulnar circulation

Respiratory Diagnostic Tests
Chest X-ray Pulse oximetry Pulmonary function tests Sputum culture ABG’s Bronchoscopy Mantoux Test (PPD) QuantiFERON-TB Gold In Tube Test (QFT-GIT) and T-SPOT TB – test for immune response to TB bacteria in whole blood Thoracentesis

Asthma Chronic intermittent and reversible airflow obstruction of bronchioles Extrinsic and/or intrinsic Manifestations: Sudden severe dyspnea with use accessory muscles Tripod sitting Diaphoresis/anxiety Wheezing/gasping/coughing Barrel chest

Asthma Dx: ABG’s, PFT’’s, sputum Nursing interventions:
Remain with patient during attack High Fowler’s Monitor lung sounds Administer O2 Maintain IV access Adminsiter meds= bronchodilators, corticosteroids, leukotriene antagonists, combination drugs/inhalers Proper use HHN/inhaler

Status Asthmaticus Life-threatening episode unresponsive to treatment
Manifestations: extreme symptoms Nursing: High Fowler’s Prepare for emergency intubation Administer oxygen, epinephrine, systemic steroids Provide emotional support

COPD General term for anything that affects expiratory air flow.
Emphysema- distention of alveolar sacs which rupture with destruction of capillary beds Productive cough Pursed lip breathing Wheezing, crackles, shallow/rapid respirations Anorexia/weight loss Weakness Chronic bronchitis- inflammation of bronchi/bronchioles due to irritants S/S: Thick, tenacious secretions Hypoxemia Respiratory acidosis

COPD: Nursing Interventions
Monitor respiratory effort Monitor cardiac status for signs of right sided failure Position upright leaning forward Schedule activities to allow rest periods Administer low flow O2 Use incentive spirometer Encourage fluids to 3L High calorie diet Admin meds: bronchodilators, methylxanthines, anti-inflammatories, mucolytics Chest physiotherapy Reinforce teaching Methylxanthine-theophylline Anti-inflammatory agents-Steroids orcromolyn Mucolytics-acetylcysteine

Cor Pulmonale Right sided heart failure caused by pulmonary disease
Manifestations Hypoxia Dyspnea Cyanotic lips Dependent edema Pulmonary hypertension Interventions Monitor oxygen status Ensure adequate rest Admin diuretics and digoxin Encourage low sodium diet May require mechanical ventilation

Tuberculosis Chronic, progressive infection due to tubercle bacillus
Manifestations: Cough, hemoptysis Positive sputum for AFB Fever with night sweats Anorexia, weight loss Malaise, fatigue Dx tests: Mantoux, sputum culture, smear,, serum analysis, QFT-G, chest x-ray Medications (INH-isoniazid, rifampin, pyrazidamide, ethambutol, streptomycin, etc.) Administer on empty stomach at same time each day Taken for 6-12 months Monitor for hepatotoxicity/nephrotoxicity Reinforce client teaching to decrease transmission Report to health department Transmission (N-95 mask, low air flow room, etc.)

Cancer of the Lung Manifestations
Chronic cough, dyspnea Hemoptysis Hoarseness Unilateral wheezing Fatigue, weight loss, anorexia Clubbing of fingers Chest wall pain Dx: Chest x-ray and CT scan, bronchoscopy with biopsy, TNM for staging

Cancer of the Lung: Nursing
Maintain patent airway Suction prn Monitor VS, pulse ox, nutrition, stomatitis High fowler’s Provide emotional support Protect for immunocompromised client Pain management Palliative care Tx: surgery, chemo, radiation May do pneumonectomy, lobectomy, wedge resection Use ancillary services

Pulmonary Embolism Sudden pain in chest particularly after surgery, trauma- suspect PE Emboli can occur anywhere and the symptoms will be correlated to where the embolism has occurred (brain- CVA) Provide O2, High Fowler’s, maintain IV access, emotional support, anticoagulants, emergency care

Pneumothorax/Hemothorax
Collection or air/blood in pleural space Contributing factors: blunt chest trauma, COPD, occluded chest tube, older adults Manifestations: respiratory distress, tracheal deviation, reduced/absent breath sounds, asymmetrical chest movement, subcutaneous emphysema Dx: chest x-ray, thoracentesis Interventions: administer O2, high fowler’s, monitor chest tube, emotional support, Tx: Chest tube insertion

Pre-op Review history Identify risk factors Check informed consent
Perform baseline assessment Assess allergies, esp. Latex Verify NPO status Coordinate lab, EKG and x-rays Reinforce client teaching Exercises, TCDB Equipment NPO Medication, pain mgmnt Identify anxieties Early ambulation Unit routines

Intraoperative Phase Implement role according to standards
Maintain safety Ensure asepsis Apply grounding devices Ensure correct sponge, needle, instrument count Position patient Remain alert for complications Communicate with surgical team Coordinate blood transfusions, radiology, biopsy, lab profiles as needed

Post-op Airway, Oxygen, Gag reflex
Breath sounds, encourage deep breathing Level of consciousness, monitor reflexes Vital signs, compare to baseline Monitor I&O and urine output Monitor bowel sounds, abd distension Monitor skin color, wound, drains Verify equipment Check dressings Ensure thermoregulation Pain management Maintain NPO until gag reflex returns IV patency Prevent complications

Atelectasis Hypostatic Pneumonia Respiratory Depression Hypoxia Nausea Shock Urinary Retention/Hesitancy Decreased Peristalsis Wound Hemorrhage Thrombophlebitis Delayed Wound Healing Wound Infection Wound Dehiscence/Evisceration Urinary Tract Infection

GI Disease Contributing Factors
Alcohol Autoimmune Diet History Genetics NSAIDs Older Adult Obesity Smoking Sedentary Lifestyle Stress

GI Lab Tests Albumin Ammonia Bilirubin
Direct Indirect Cholesterol/Trigglycerides/HDL/LDL SGOT/SGPT Amylase/lipase Protime Stool sample (C&S, O&P, occult blood)

GI Diagnostic Tests Endoscopy Barium series Barium enema Liver biopsy
Colonoscopy Sigmoidoscopy Small bowel capsule endoscopy Esopagogastroduodenoscopy (EGD) Endoscopic restrograde cholangiopancreatography (ERCP) Barium series Barium enema Liver biopsy Paracetesis

GI Therapeutic Procedures
Gastrointestinal Tubes Levin Salem Sump Miller-Abbott Sengstaken-Blakemore Enteral feeding tubes Small bore nasogastric feeding tubes Small bore nasointestinal/jajunostomy tube Percutaneous endoscopic gastrostomy (PEG)

Hiatal hernia Nursing Interventions: S/S Regurgitation Heartburn
Protrusion of stomach through diaphragm into thoracic cavity Nursing Interventions: S/S Regurgitation Heartburn Dysphagia Flatulence Belching Epigastric pain Hoarseness in AM Dry cough Hypersalivation Review diet history and necessary changes Small frequent meals Avoidd eating 3 hrs before bed Sit up 1-2 hr after eating Sleep right side Encourage weight decrease to BMI < 25 Monitor for complications Admin meds-antacids, H2 antagonists, prokinetic agents, PPI’s, prepare fundoplication prn

Peptic Ulcer Disease (PUD)
Stomach or duodenum Predisposing factors Stress Salicylates & NSAIDS Smoking H. pylori bacteria corticosteroids S/S Dyspepsia, upper epigastric pain 1-2 hours after meals,symptoms worse on empty stomach/better with antacids, belching, bloating Treatment Monitor stools for bleeding, sm frequent meals, no HS snacks, Admin meds (antacids, PPI’s, prokinetics, H2 antagonists), monitor labs/dx tests, reinforce teaching/stress mgmnt

Ulcerative colitis S/S Treatment Rectal bleeding
Abd. Cramping/distention Unpredictable bowel movements Weight loss Treatment Drugs: antiinflammatories, antibiotrics, steroids, antidiarrheals Diet: decrease residue, increase protein, calories, vitamins Stress control Surgery

Diverticulosis/Diverticulitis
Diverticulum- oupouching of intestinal lining in weak area of muscle Diverticulosis- multiple diverticulae without symptoms unless Diverticulitis- inflammation and infection of diverticula S/S- cramps, diarrhea, constipations, dyspepsia, gas, abdominal distention.

Tx for diverticulitis Clear liquids until inflammation reduced, then high-fiber, low-fat diet Teach stress management Medications- antibiotics and analgesics

Hemorrhoids Usually presented as a complication related to pregnancy, chronic constipation, or prolonged sitting or standing Treatment Reduce pain and swelling, control bleeding Teaching Increase bulk and fluids

Cholelithiasis/Cholecystitis
Definition: Cholecystitis- inflammation of the gallbladder Cholelithiasis- presence of stones in the gallbladder S/S Pain in the upper-right quadrant Occurs after a fatty meal Sudden onset of NV Increased pulse and respiration

Cholelithiasis/Cholecystitis
Treatment Mild attack-low or no fat diet Surgical intervention Laser surgery- outpatient basis Incisional surgery with T-tube placement

Hepatitis Type A Transmitted by fecal- oral route Symptoms
Poor sanitation High incidence among children and young adults Symptoms Act like mild flu Sudden onset of symptoms Fever, chills, severe headache, GI Liver symptoms Jaundice, hepatomegaly, RUQ tenderness

Hepatitis B Transmitted by blood, blood products, contaminated needles, body fluids Symptoms Acts like liver disease Sudden onset of jaundice, hepatomegaly, RUQ tenderness

Supportive care Prevent transmission
Diet- adequate with some protein restriction Rest Skin care with pruritis from jaundice

Cirrhosis Not just alcohol-related
May follow hepatitis and/or be a complication of other disorders

Problems from Cirrhosis
Fluid retention from abnormal F&E balance- ascites Bleeding from abnormal clotting factors and capillary fragility Malnutrition from abnormal metabolism Toxic effects from medications due to abnormal detoxification Fever and dehydration from poor nutrition, inadequate fluid intake Delirium tremens from abnormal metabolism of alcohol Hypoglycemia and hypoproteinemia

Problems from Cirrhosis
Hypotension Abnormal neuro symptoms- Confusion Memory loss Perceptual problems Reflexes altered Fatigue and weight loss Esophageal varices from portal hypertension

Treatment Diet- high in vitamins and minerals; protein restricted, low sodium and fat Monitor for bleeding Supportive care Frequent mouth and skin care Ascites- fluid restriction and diuretics Sengstaken-Blakemore tube for esophageal varices Daily weight I&O: lactulose to reduce serum ammonia Semi-Fowler’s position Psychological/spiritual support

Appendicitis S/S Treatment- surgery
Pain in the right lower quadrant, McBurney’s point, radiating down towards pelvis Elevated WBC count Treatment- surgery Appendectomy

Arthritis Osteoarthritis Rheumatoid Systemic Local Destroys
Hands and/or feet Autoimmune Crippling Diagnosis: blood and x-ray Local Degenerates Weight-bearing joints Aging process Functional changes Diagnosis: x-ray

Arthritis Treatment Encourage weight loss if BMI > 25
Anti-inflammatory medications Heat-paraffin treatments Physical therapy Adequate rest/sleep Encourage independence Get equipment

Osteomyelitis Infection and inflammation of bone/bone marrow
Seen after compound fractures Signs and symptoms same as infection Key: prevention

Osteoporosis Decrease in bone mass (density) Predisposing factors:
Post-menopausal women Prolonged immobility Insufficient calcium Endocrine disorders Teaching: Ca + Vit D, weight-bearing activity, body mechanics

Fractures Break in continuity of bone Signs and symptoms Types Pain
Deformity Edema Bruising Crepitus Types Open/compound Closed Incomplete Comminuted Pathologic/spontaneous

Traction Skin Skeletal Applied outside skin with straps, tape, etc.
Buck’s Maintain extension for knee/hip fracture, reduce spasms Russells’ – sling to knee Bryant’s Children under 25 lb femur fracture(s) Hips = counter weight Pins to or through bone Halo Crutchfield tongs

Treatment of Fractures
Cast/Surgical repair Pins Plates Wires Halo Risk for infection Open fracture increases risk Antibiotics as ordered Aseptic technique Assistive devices Walkers Canes Crutches

Hip Fracture Affected leg shorter External rotation Treatment: surgery
Hip precautions: No adduction No crossing legs Maintain 90 degree angle No “pigeon toed”

Knee Replacement CPM (continuous passive motion) post-op
May begin weight bearing same day Physical therapy for stair climbing Prophylactic antibiotics for dental procedures

Amputation Extremity Disturbed body image Impaired mobility
Therapeutic communication Impaired mobility Traumatic versus non-traumatic Phantom pain Need for prone positioning

Arteriosclerosis vs. Atherosclerosis
A decrease in the elasticity of blood vessels Atherosclerosis: The accumulation of plaque on the inside of blood vessels. Underlies most CV disorders S/S depend on location- do not just consider the cardiac symptoms (myocardial, cerebral, peripheral)

Nursing care/teaching
Prevention of atherosclerosis Dietary and cholesterol reduction Risk potentials Change in lifestyle in cases of altered perfusion, circulation Safety Needs vary with part of body involved Surgical treatment Percutaneous transluminal coronary angioplasty (PTCA) Coronary artery bypass graft (CABG)

Hypertension Primary hypertension is due to a problem within the cardiovascular system. Secondary hypertension occurs as a result of another disease process of because of problems with another body system. Teaching: Safety (dizziness) Rest periods HA control Obesity- prevention Salt intake Cholesterol control Stress

Phlebitis/thrombophlebitis
Usually seen as a complication of another disease process Discussed as a complication of surgery Anticoagulants with need for observation (monitor PT and PTT)

Myocardial Infarction (MI)
Cause- disruption of circulation in myocardium due to obstruction of coronary artery Emergency treatment- focus on preservation of life S/S- severe crushing chest pain, substernal, often radiates down left arm or into jaw. Treatment Rehabilitation Preventing valsalva maneuver

Treatment CPR if needed
Provide support and keep patient as quiet as possible Increase oxygen concentration Reduce pain Monitor cardiac status Medications

Rehabilitation Begins once stabilized and after emergency portion of treatment Needs teaching and emotional support Prevent Valsalva Maneuver- increases intrathoracic pressure

Heart Failure/Congestive HF
Heart is no longer able to pump enough blood to meet the demands of the body. Left-sided causes pulmonary congestion S/S: Fatigue Angina Anxiety Oliguria Dyspnea Cough Frothy tinged sputum

Heart Failure Right–sided causes systemic venous congestion:
Blood returning from body is halted Right-sided usually a complication of left S/S: Edema of feet and ankles Hepatomegaly Ascites Distended jugular veins

Treatment Digitalis to help make pump more efficient
Diuretics to eliminate excess fluid Oxygen to increase concentration and make respirations less difficult Monitor fluid and electrolyte balance Monitor VS Reduce anxiety to conserve energy

Anemia Signs are generic: Diet- increase Fe B12 – increase
Fatigue Pallor Increased pulse Lower B/P Dyspnea Diet- increase Fe B12 – increase Safety due to bleeding problems Correct underlying cause

Leukemia Alteration in WBCs: may be reduction or proliferation of immature cells Treatment Chemotherapy Infection prevention Safe, gentle care Pain control and support

Increased Intracranial Pressure
Signs ALOC VS- elevated B/P, reduced pulse, slow respirations Limb movement- restlessness Dilation of one or both pupils Interventions- Surgery last option Monitor signs carefully Elevate HOB- no straining Maintain calm, soothing environment

Cerebrovascular Accident
Portion of the cerebrum dies due to loss of blood supply (clot or hemorrhage). Data collection Sx’s depend on which part of brain is affected Mote, cognitive, communication sills may be impaired Monitor VS- brain stem may be involved First 24 hours most critical

CVA Nursing interventions regarding aphasia, feeding Keep HOB elevated
Rehab begins from the moment of injury Maintain highest level of function possible Communication alters with receptive vs expressive aphasia Gag/swallow reflexes may be absent

Specific Care Concepts
Endocrine

Thyroid Hypo vs Hyper Thyroidism Teaching
Hyperthyroidism: Increases body functions and metabolism Causes more pathology Hypothyroidism: slows down body functions including metabolism Controlled by replacement hormone Teaching Balance activity with rest Proper nutrition, caloric needs increased or decreased Monitor heart rate of both clients

Thyroid Post-op positioning for thyroidectomy and assessments
Supine with HOB slightly elevated: support neck and maintain suture line Vascular area- high risk for hemorrhage Maintain airway patency incase of swelling in addition to risk from bleeding Parathyroid gland may be inadvertently removed or damage: calcium regulation is impaired Monitor neurological reflexes: Chvostek’s sign Change in voice can signal laryngeal edema Hormone replacement- Life long

Diabetes Alteration in glucose metabolism Underlying causes
Type 1 vs Type 2 Type 1: no to little insulin production Type 2: insulin resistance

Diabetes Teaching Hyperglycemia- elevated blood glucose: Diabetic coma
Signs and symptoms Polyphagia Polyuria Polydypsia Glucosuria Dehydration HA, flushed skin Weakness

Diabetes Hypoglycemia- low blood sugar: Insulin reaction, Insulin shock Signs and symptoms Fatigue Hunger Tingling Confusion Slurred speech Pale skin Diaphoretic

Diabetes Safety Infections Diet Exercise Alterations in skin integrity
Increased risk due to alteration in skin integrity and hyperglycemia Diet Most important consideration for control Type 2 may be able to manage with diet and oral hypoglycemic medications Type 1 will be insulin dependent for life Exercise Must be balanced with nutritional intake

Medications Insulin-know application! Type Onset Peak Duration

Urinary Calculi Technical names:
Urolithiasis/ureterolithiasis, renal calculus Prevention-adequate fluid intake, certain food intake predisposes Strain urine- capture stone for examination Pain usually in the flank

Renal failure Acute vs. Chronic Signs and symptoms:
Acute may be due to toxic effect of medication, high fever that has destroyed nephrons Chronic more complicated, more gradual onset Signs and symptoms: Acute: Oliguria Elevated BUN and creatinine Lethargy, N/V Reversible Chronic: Lethargy, disorientation, decreased strength Muscle cramps, anorexia Anuria

Renal failure Interventions: Hemodialysis Peritoneal dialysis
Requires access to patient’s circulatory system to route blood through a machine where waste products are removed Peritoneal dialysis Requires a catheter be placed into the peritoneal space through which dialyzing fluid is instilled, then drained after a period of time. Monitor I&O. Weight Other systems will try to excrete wastes that the kidney can’t handle

Benign prostatic hyperplasia (BPH)
Enlargement of the prostate Symptoms- Difficulty voiding, frequency Treatment Medications Surgery Transurethral Resection of Prostate (TURP) Suprapubic Observe for bleeding following surgery Newer treatments: Laser vaporization of tissues Needle ablation with radiofrequencies Microwave thermotherapy

Prostate Cancer PSA screening
First symptoms same as BPH, blood in urine, painful ejaculation Treatment Radical prostatectomy Newer, nerve sparing surgeries Radiation Hormone therapy

Breast Cancer Early detection- breast self-examination (BSE) Surgery
Lumpectomy Simple mastectomy Modified radical mastectomy Radical mastectomy Post-op management Immediate rehab exercises (start with ADLs) Emotional support for altered self-concept and altered body image

Cervical Cancer Diagnosis- PAP smear screening, cervical bx Prevention
Vaccination- Gardisil Use of condoms- prevents spread of HPV viruses Treatment surgery

Cancer of the uterus Type of hysterectomy Hormone replacement therapy
Vaginal, abdominal, or laparoscopic Hormone replacement therapy May be needed if ovaries are removed

Ovarian Cancer Symptoms come late in the disease
Treatment is surgery with chemotherapy and radiation

Sexually Transmitted Infections
Syphilis 4 stages Primary (chancre) Secondary (systemic with rash) Latent (nothing happening) Tertiary (systems damaged) Can be treated at any stage Gonorrhea Reportable to the Health Department Treat all contacts Chlamydia Major STD and highly contagious May be passed from mother to baby during delivery

STD cont. Herpes Trichomonas Not curable
Treat with antiretroviral drugs, both oral and topical Can be spread without symptoms Trichomonas Treat all partners Flagyl (metronidazole)- abstain from alcohol

HIV Disease Process: Assessment: Treatment
Virus infection attacks part of the immune system responsible for mobilizing infection control. Person may be HIV positive for long periods of time before beginning the symptoms of disease (AIDS) Transmitted by direct contact with blood or bodily fluids or by transmission from mother to baby Assessment: Diagnostic tests Opportunistic infections May be first diagnosed with opportunistic pneumonia Kaposi’s sarcoma—skin fragile Treatment Antiviral medications

HIV cont. Nursing care: Reduce risk for infection Medication teaching
Monitor effects and side effects of medications Nutritional status Help maintain best possible nutritional status Supportive therapies Emotional support

Specific Care Concepts
Skin- Burns

Burns Extent Emergency care Superficial (first degree)- like a sunburn
Partial-thickness (second degree)- scalds, flash flame Full-thickness (third degree)-burn of complete skin thickness. Emergency care Cover area to keep clean and transport to care facility as soon as possible

Burns Complications Respiratory- inhaled fire
Often have soot on nose. Mouth and may need ventilator support Infection- d/t impairment of skin integrity Shock- d/t alteration of F&E balance Contractures- physical therapy Stress ulcers Nutrition- need calories and protein for healing Types of grafts- allograft, autograft, artificial graft

Eye Cataracts Glaucoma Detached retina Vision not clear
Most surgery outpatient Protect affected eye at night- avoid valsalva maneuver Glaucoma Causes blindness if not treated Miotics and mydriatics- instillation of eye drops Detached retina Flash of light, sudden loss of vision Laser surgery usually outpatient

Ear Loss of hearing Dealing with the hearing-impaired
Communications altered; speak directly to client, use written messages

Shock Inadequate blood volume to sustain normal functioning
Interventions Treat underlying cause Restore blood volume Monitor LOC

Shock interventions Treat cause immediately
Establish airway, control bleeding and reduce pain Restore blood volume with IV fluids and blood products Keep NPO No narcotics Keep client flat in bed with lower extremities elevated Maintain temperature Monitor consciousness, VN, skin color and urinary output

Anaphylactic shock Severe allergic reaction, potentially fatal
Interventions Epinephrine and vassopressor drugs Monitor VS Oropharyngeal intubation Aminophylline Antihistamines and corticosteroids CPR if cardiac arrest Teach to avoid allergic substances

Medical Emergencies Respond to life-threatening situations
Provide care for emergency wound disruption Notify primary provider of unusual events Recommend change in plan of care based on client response Document client response to emergency situation

Unexpected Response to Therapies
Identify and treat IV infiltration Recognize and report change in condition Intervene and respond to client unexpected negative response to therapy (i.e. unexpected bleeding) Promote recovery from client unexpected negative response

Question The nurse is collecting data from a client who is reporting diarrhea for the past 72 hours. Which of the following findings would indicate the client is experiencing a fluid volume deficit? Select all that apply. Orthostatic hypotension Excessive thirst Dry tongue Bradycardia Increased urine output

Physiological Integrity Reduction of Risk Physiological Integrity

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