Genitourinary: Case Study

Genitourinary- 40 questions

Assessment Findings
*PAIN won’t always be present.
KIDNEY: (dull constant ache) Not always present if pt has renal disease (don’t have w/ proteinuria or hematuria) Have CVA tenderness (hit hand over kidney), lower abdominal pain, intermittent pain(indicates renal stones), flank pain (side) N/V, diaphoresis, s/sx of shock. Cause: Acute obstruction like stone, clot
BLADDER- lower ABD pain (usually seen w/ distention) dull, continuous pain may be intense after voiding S/Sx: Urgency, pain after voiding (from spasms) Causes: Infection, cystitis, over distended bladder

*Patients should urinate 5-6 times daily with a urinary output of 1500-2000 mL/day!
*”How many times do you urinate a day??”
* Pt’s may have increased frequency,
urgency, burning/ hesitancy (indicative of enlarged prostate), nocturia, polyuria(diabetes), or oliguria(100-400mL/day!)

LAB VALUES
*Creatinine (protein)- Normal 0.6-1.2- best indicator of renal function (looks @ effectiveness) It is the end product of skeletal muscle metabolism

*Urea Nitrogen (BUN) Normal 10-20 Index of renal function. Can be affected by muscle/tissue damage, fluid volume (decrease volume increases BUN b/c it is more concentrated), & protein intake
*BUN to Creatinine ratio- 10:1 Evaluates hydration status. Elevated ratio seen in hypovolemia. Normal ration w/ elevated BUN & creatinine is seen w/ intrinsic renal failure
*Specific Gravity- 1.003-1.030- Evaluates ability of kidney to concentrate urine. (If kidney can’t concentrate may not be functioning properly)
*Urine Osmolarity- Normal 300-900. Concentrating ability is lost early in kidney disease. SG & Osmolarity may be used to determine early renal failure
*Renin assists in blood pressure control
*Erythropoetin is needed for production of RBC’s in the bone marrow.

OBTAINING SPECIMENS
*The best time to obtain a specimen is EARLY MORNING!
*Instruct pt to call immediately after specimen is obtained b/c it collects bacteria (if longer than 1 hr no good!)
*Clean catch- wipe front to back, clean 3 times wiping the labia’s first then the urethra. first part of stream goes into the toilet, catch midstream for specimen
*In and out cath
*Indwelling cath- clamp tubing for appx 30 mins, and then obtain from port (never from bag)- Sterile!

DIAGNOSTIC TESTS
*24 hr Creatinine clearance- VERY sensitive test to indicate renal disease/or progression of disease. Lab comes around 6 am & draws blood to compare serum and urine levels. Directions: Discard 1st specimen & then 24 hr measure begins. Men- don’t urinate into container b/c of chemicals (can burn them) Good measure of GRF. Volume of urine x urine creatinine/ (divided by) serum creatinine.

*Blood Tests- Creatinine is MOST SENSITIVE to renal function!

*Urinanalysis- should NEVER see protein, bacteria, or glucose. pH may be affected by ingestion of fruits, vegetables, and protein.

ABNORMAL SUBSTANCES IN URINE:
*Glucose- seen from diabetes when spilling over
*Protein- indicates damage to glomeruli (some benign causes are fever & strenuous exercises)
*Bacteria- infection (UTI)
*Ketones- breakdown of fat (byproduct) Seen with DM type 1 (DKA)

*IVP- intervenous pyelography- Inject radiographic dye to show kidneys, bladder, urethra. Pre op- ASSESS allergies to shellfish, dye, iodine Contrast agents should be used carefully in elderly, pt’s with diabetes, vol depletion, & renal insufficiency b/c can’t excrete. May give laxative to prevent interference of visualization. Encourage pt to increase fluid intake unless on fluid restrictions.

*Renal biopsy- To diagnose cancer. Insert needle through skin. *Because of the risk for bleeding after the biopsy, coagulation studies such as platelet count, Pt and aPTT may be performed prior to surgery. *PreOp- Need consent!! Pt must be NPO 4-6hrs before procedure. *PostOp: Pt must be supine for 4-6 hrs post procedure., 24 hr bedrest, watch for hematuria (if there is blood in urine compare post op to pre op values), watch vitals (hemorrhage (hypovolemic shock), Monitor for flank pain or decrease in urinary output- HEMORRHAGE Avoid ANY strenuous activity for two weeks, if ANY back pain call dr. STAT (indication of bleeding), can have referred pain to shoulder/flank or dysuria (painful urination) *Teach patients not to lift heavy objects for 2-4 weeks post procedure. Driving may also be restricted

*Renal Arteriogram-allows dye to enter the renal blood vessels and generates imagesto determine blood vessel size and abnormalities.

*Cystoscopy- is used to visualize urethra & bladder (and to collect specimen or collect calculi) *Lower- pt conscious. *Upper- Pt. may get sedation meds if upper cystoscopy. *Pre Op-NPO. *PostOP- Assess hematuria (blood-tinged), burning on voiding and urine frequency can be expected. Warm sitz baths or heat to lower ABD are helpful to relieve pain. Urinary retention is not normal (common with obstructions like prostatic hyperplasia)-may need to give sitz bath, meds like flavosate (Uripas) to relax sphincter

URINE COLOR/MEDICATIONS:
*Orange- concentrated Causes: Meds- Pyridium (for UTI), Rifamptin fever, bile, carotene (eat lots of carrots), increase bilirubin
*Blue/Green- dyes, methalyne blue, Meds- (amitriptline), Chemotherapy drugs
*Pale- diuretics, DIABETES INSPIDUS, glucosuria (diabetes causes polyuria), renal disease, diluted
*Yellow to milky white (cloudy) –Infection, pyuria (contains pus)
*Bright yellow- Multivitamins
*Pink to Red-may indicate blood! Foods may be r/t: beets, blackberries, meds (phentoin, ryfampin (rusty)
*Brown to black- old RBC, melanin, extremely concentrated urine from dehydration or Meds- (iron, cascara, quinine, metronidazole)

EXTRAS NOT ON BLUEPRINT:

**Elderly pts have decreased bladder compliance, decreased GFR, and vasopressin which cause nocturia and incontinence. Vasopressin is releases @ night due to decreased fluid intake (retains Na so you don’t urinate( increase BP) Elderly also @ higher risk for hypernatremia b/c of improper thirst mechanism which can cause fluid vol deficit. Urine incontinence is NOT normal in elderly but is COMMON. Older men have trouble starting stream (hesitancy) b/c of enlarged prostate
*Unexplained fatigue (anemia), SOB, & exercise intolerance may indicate early kidney problem
*WEIGHT best indicator of function. 1 lb= 500mL

Chapter 69 12 questions

URINARY TRACT INFECTION-

RISK FACTORS: females more prone, diabetics b/c glucose causes bacterial growth, older males b/c of benign prostatic hyperplasia, sexual activity, spermicides, catheters, poor hygiene, decreased fluid intake, and age. Men- usually get b/c of obstruction & it takes more/longer periods of antibiotics to treat.

SIGNS AND SYMPTOMS: frequency, urgency, dysuria, hesitancy, or difficulty initiating stream, lower back pain, nocturia, incontinence, hematuria, pyuria, and incomplete bladder emptying, cloudy urine

*Pyelonephritis-Upper UTI (kidney)- fever chills, lower back pain (Costalvertebral pain), HA, N/V, malaise, dysuria (painful), flank pain

*Cystitis- Lower UTI (bladder)- pain, frequency, burning, bladder spasms, hematuria, back pain TX with antibiotics & Pyridium (Will see bacteria in urine=infection)

*The only symptom in older adults may be increasing mental confusion or frequent and unexplained falls.

*PREVENTION- cranberry juice, H2O (no caffeine/sodas), teach to wipe front to back, empty bladder after sex, no bubble baths/oils (only showers), loose clothing, take ALL antibiotics, avoid alcohol, drink 2-3L of fluid daily, get adequate sleep, rest and nutrition, and urinate frequently (every 2-3 hrs) to empty bladder. Teach patients to avoid urinary stasis by urinating every 3-4 hours rather than waiting until bladder is fully distended.

*TREATMENT-antibiotic therapy may be prescribed for bacterial UTI’s

CATHETRIZATION: *Don’t do unless you have to (infection) *Prevent infection w/ cath care (@ least 2 x a day and PRN after bowel movements)- clean perineal *If pt. on indwelling cath @ home teach clean technique instead of sterile techinique *Empty bag when 1/3 full (or every 8 hrs) *Subpubic cath- in through skin. CAN’T D/C *Urinary catheters MUST be changed after 30 days. *Keep catheter below bed level, and do NOT inject more than 10mL into the balloon.

INCONTINENCE: *Stress Incontinence- is a decrease in the pelvic floor and ligament support. May be caused by cough, sneeze, change positions Commonly seen in females after pregnancy and males after BPH (embarrassing & effects quality of life), elderly, and males with prostatectomy. Teach Keagal exercises. This helps in strengthening the muscles of the pelvic floor. Have patients initiate urine stream, stop and hold for 10 seconds and then finish urinating. Estrogen may be used to treat post menopausal women. *Urge Incontinence- also known as overactive bladder. Pt’s have a strong urge to urinate- must go right then (elderly) Teach patients to avoid alcohol, caffeine, or artificial sweeteners(bladder irritants). Check for bladder distention. *Overflow Incontinence: From over distention of bladder aka “Reflux Incontinence” (cause is neurological or obstruction) *Functional Incontinence: UTI, pt that has severe cognitive dysfunction, or paraplegic

TREATMENT: Behavioral therapy, management of fluids (don’t drink @ night before bed & drink 1,500-1,600 mL in small increments), timed voiding (when you wake up, before meals, before bed, and once @ night if need to..about every 2-3 hrs), Keagal exercises (stress), and also may tx with meds (Dextrol LA), no lasix after 4 pm, no caffeine, ETOH, or aspartame (NutraSweet), stop smoking (smokers cough and cause stress incontinence), make sure you don’t get constipated

*If can’t go to bathroom run H2O

UROLITHASIS: Renal calculi (kidney stones) in the urinary tract. *Risk Factors: dehydration, alkaline urine, infection, urinary stasis, increased uric acid, hypercalcemia (immobility),damage to the lining of the urinary tract and is more common in men ages 30-50 *Signs and Symptoms- varies depending on location of blockage. SEVERE pain is MOST COMMON, N/V, flank pain, cholic wave-like pain that radiates through perineum, pt. thinks they have to void but can’t b/c of blockage, diaphoresis, and hematuria -Flank pain indicates the stone may be in the kidney or ureter -Pain that radiates to the abdomen suggests the stone is in the bladder or ureter. Diagnosis: -KUB (xray) & IVP (inject dye- see earlier notes) to diagnose stones. *Dr. will give a strainer to save stone and run test to see what kind it is- diet has a lot to do with type of stone *Give morphine for pain (PAIN MANAGEMENT & TEACH PREVENTION)

Prevention- DIET (see below), low protein < 60 g/day, increase fluids (3000-4000 mL)- want urine output > 2L a day, drink 2 glasses H2O @ bedtime & 1 glass @ each awakening in night, avoid sudden increase in temperatures that cause excessive sweating & dehydration, call dr. @ first sign of UTI, avoid swimming, and dehydration, report changes in pain (stone main be moving)

NUTRITION: *Calcium oxylate: Avoid spinach, black tea, and rhubarb, strawberries, chocolate, peanuts, wheat bran, and decrease sodium intake. * Calcium Phosphate: Limit intake of foods high in animal protein and decrease sodium intake. *Uric acid stones: Low purine diet (shellfish, anchovies, asparagus, mushrooms, and organ meats, and other proteins limited. MEDS: Allopurinol (Zyloprim)

*Cystine stones: low protein diet ( 1 cm then needs to be removed *ESWL Lithotripsy (Shock wave therapy that perverizes stone)-noninvasive *Surgery only if stone doesn’t respond to other tx’s -Monitor cardiac rhythm -Strain Urine -Patient may have bruising over flank area. -Encourage patient to walk to help pass stone -Increase fluid intake -Teach breathing and relaxation techniques

BLADDER CANCER- *Risk Factors: TOBACCO LEADING CAUSE, reoccurring bladder infections/UTI, high urine pH, exposure to dyes, rubber, leather, ink, paint, hypercholesteremia, bladder stones, * More common in Caucasians age 50-70, females from lower gynecologic tract & in males from prostate, colon & rectum *Painless visible hematuria most common symptom of cancer; infection of urinary tract common complication. Pelvic or back pain may occur w/ metastasis *Treatment: Transurethral resection (or cauterization) for benign epithelial tumors- after surgery administer BCG (live TB strain); simple/radical cystectomy for sever cancer

ILEAL CONDUIT:
*Oldest & most common urinary diversion- (from ureter to surface)
*Stents often left in place (taken out in 10-21 days( risk for infection)
*Watch for wound dehiscence, obstruction, urinary leakage, gangrene stoma, obstruction
Delayed complications- kidney stones, stenosis, pyleonephritis (upper UTI-kidney infection)
*Monitor weight/I &O < 30 mL U.O may indicate obstruction, leakage, dehydration or backflow
*Moisture in bed linens, odor around urine should alert nurse of leakage, poor hygiene, or infection
*Urine pH needs to be kept below 6.5 by giving PO asorbic acid
*Encourage fluids, reduce anxiety, improve body image (RN needs to explain why wearing gloves so pt doesn’t think it is aversion to stoma site)
*Teach patient about avoiding foods that produce gas (cheese, eggs, esparagus)
*Encourage patient to empty pouch when it’s 1/3 full and cleaning techniques
*Change bad every 3-7 days
*Infection prevention
*Skin Care/Stoma Care- needs to be BEEFY RED! pale:anemia purple: lack of O2
*Peritonitis can occur- Watch for ABD pain & distention, paralytic illeus, fever, leukocytosis, N/V
Chapter 70 3 Questions:

Renal Cell Cancer:
-very metastatic cancer and occurs more frequently in males!

*SMOKING IS A BIG RISK FACTOR, and those who are exposed to lead, phosphate and cadmium.

Signs and Symptoms: painless hematuria in LATER STAGES, dull/aching flank pain, palpable mass in abdomen, bruit on auscultation

*Diagnosed by BIOPSY!

TREATMENT: NEPHRECTOMY!

*COMPLICATIONS: Hemorrhaging AEB: Decreased BP, LOC, and U.O and Increased HR and RR
*Check patients bed linens under the patient for bleeding and inspect abdomen for distention.
*Assess urine output hourly for the first 24 hours after surgery and monitor vital signs
*Teach patients to avoid contact sports post op, turning, coughing and deep breathing exercises.

Chapter 71 13 Questions:
Acute Renal Failure: (loss of kidney function from a few hours to a few days (Decrease in GRF)
*Experience oliguria (Most common sign) < 400 mL in a day (which is the minimum needed to dispose of metabolic waste)

Categories of Acute Renal Failure:

1. Pre-Renal- Impaired perfusion causes decrease in GRF (Decreased U.O & Na < 20, BUN 20:1, Increased Creatinine, SG, Osmolarity (500 mOsm) & hypoperfusion) CAUSES: ~ Volume depletion (ex:hemorrhage, shock, hypovolemia, diabetes insipidus (diuresis), diuretics,diabetes, ~Vasodialation: ex: SEPSIS (very common cause of renal damage), anaphylaxis, antihypertensive meds that cause vasodialation ~Impaired cardiac function: MI, HF, dysrythmias, cardiogenic shock

2. Intra Renal- Functional damage (parenchymal) to glomeruli or kidney from blockage to tubules (Increased BUN, creatinine, Na > 40, U.O. varies but usually low, SG low normal, urine osmolarity about 350 similar to serum) CAUSES: ~trauma, crush injury, NSAIDS, ACE inhibitors, infection

3. Postrenal- obstruction distal to kidney (Increased BUN & creatinine, UO varies but may have sudden anuresis, NA often decreased 20, cool & clammy, decrease U.O., CONFUSED/COMBATIVE, resp. alkalosis (hyperventilation)

PROGRESSIVE-
BP- Systolic 150, RR rapid, shallow w/ crackles, mottled/petechiae skin, LETHARGIC, metabolic acidosis

IRREVERSIBLE (REFRACTORY)-
Asystole, intubation, jaundice, anuric, unconscious, ESRD

Fluid & Electrolytes- 6 questions
*Hypovolemia-
~Causes: Decreased intake, diabetes insipidus, 3rd spacing (can’t be measured)
~S/sx:decrease BP, increase HR, weak thready pulses, decreased U.O., look @ mucous membranes (dry), decreased skin turgor (forehead & sternum best for adults), measure weight
~TX- Lower HOB, Lactated ringers, NS

*Hypervolemia-
~Causes: Renal failure, high intake Na, cirrohsis, over administer fluids
~ S/Sx Weight gain (best indicator), JVD, crackles, wheezes, SOB, peripheral edema, bounding pulses, increase BP
~TX- elevate HOB, restrict Na & fluids, diuretics, hemodialysis, bedrest

K 3.5-5.0 (K and pH are inverses- decrease K increases pH)
*Hypokalemia-
~Causes- Diarrhea, vomiting, diuretics, corticosteriods
~S/Sx- muscle weakness & leg cramps, flat T & ST depressed can cause dig toxicity (normal level 0.5-2.0) will see halos, N/V, can cause dysrythmias
*Treat w/ diet & meds (oral K)
*Hyperkalemia- caused by salt substitutes, tissue trauma, metabolic acidosis (diabetes), renal failure
~S/sx- See tall peaked T-waves (if on monitor), if not you will hear dysrythmias when ascultating heart, slow HR, paralysis, flaccid muscles
~Tx- Kexalate, diuretics (lasix), D50 & Insulin (pushes K back into cell)
When on Lasix if lab value is 5- ok to give if 3.2 hold

Na 135-145
*Hyponatremia:
~S/sx- CONFUSION, muscle cramps/twitching, N/V, seizures
~TX- restricts fluids as long as neurologically intact. If not then give 3 % NaCl (or 5%)
*Hypernatremia: (causes- sweating, not enough H20 in take, Alka-seltzer)
~S/Sx: THIRST, dry/swollen tongue, increased temp, hallucinations
~Tx- Offer fluids @ regular intervals (if not a choice on test then D5W)

**Never IV push electrolyte

ABG pH 7.35-7.45, PaCo2 34-35, HCO3- 22-26

*Resp Acidosis (not blowing off enough CO2)-:
~Causes: COPD, HF, hypoventilation
~S/sx- Confusion, palpitations, muscle twitch
~Tx- Administer O2, Fowlers position, hydration (thin secretions), pulmonary hygiene (suctioning)

*Resp Alkalosis (blowing off too much CO2)
~Causes: Anxiety/stress, panic attacks, ASTHMA (initially but progresses to acidosis), fever, Increase depth & rate of breathing, early Aspirin intoxication,
~S/sx- Hyperventilation syndrome, tinnitus (with ASA intoxication), palpitations, sweating, dry mouth, N/V
~Tx- Breath slow (into paper bag), tx underlying cause (sedative)

*Metabolic Acidosis: (think about simulation)
~Causes: Renal failure, DKA
~S/Sx- Confused, decreased LOC, HA, N/V, cold, clammy, shaky, increase resp rate
~Tx- Correct underlying problem, Eliminate Cl, Nicarb may be given

*Metabolic Alkalosis-
~Causes: NG Suctioning, vomit, Lasix (K losing diuretics)
~S/sx: Tingling fingers/toes, dizzy, < RR, hypokalemia
~Tx- Reverse underlying cause, give fluids w/ NaCl

IV THERAPY
*Monitor site-
Infiltration-cool, edema (take out) (If infiltrated elevate site to reduce edema)
Infection- red, warm
If pain @ site but no S/sx infection or infiltration still take out
*When you take out make sure cannula is intact and check for bleeding (apply pressure to site. If D/C central or PICC need pressure for @ least 5 min)
* TKO- to keep vein open (run @ 30 mL/hr)

DIET
Na- processed meats (salami, bologna), canned soup, tomatoes/juice, milk, chz, eggs (Avoid w/ renal failure, CHF, HTN, edema)
K- legumes, whole grains, dried fruits (raisins, apricots, prunes), green leafy veggies, broccoli, potatoes, tomatoes, SOME fruits (oranges, melon, bananas)

ONCOLOGY- 7 questions

Carcinogens- (PREVENTION- use common sense)
*Chemical- chemo drugs, SMOKING, ETOH, pesticides (farmer)
*Physical- sunlight & radiation, chronic inflammation or irritation (football player, tennis elbow)
*Viruses/Bacteria- HPV, Herpes, Hepatitis B (liver), Epstein Barr (Burkett’s Lymphoma)
*Genetic- BR1 or 2 (breast cancer), FAP (GI tract)-familia adrenial poyopsis (screened in teenage yrs if have it then take out entire colon
*Dietary- fat (colon & breast), smoked meats/cured, ETOH (HELP PREVENT: Deep green veggies, yellow veg (squash), Vit C, Vit E & Selenium)
*Hormonal agents- Estrogen (BC, & ovarian), DES (drug for migraines) linked to vaginal cancer

Immunoseppresion Precautions-
~Thrombocytopenia: (DECREASED PLATLET: normal 150-500,000)- < 50,000 bleeding, < 20,000 spontaneous bleeding)
*Falls precautions
*Soft tooth brush, avoid constipation (increase fluids, laxative), avoid valsalveur maneuver, electric razor, be careful blowing nose

~Neutropenia: Very low Neutrophils (Natir 10-14) Increase risk for infection- Hand hygiene most important (teach hygiene), don’t be in crowds, take temperature
*If neutopenic pt has temp of 100.4 call dr. b/c a low fever may be the only sign of infection

~Anemia: < 25-30 (need transfusion)
Mild diet w/ iron and may need erythropoietin injections

Chemotherapy: (some cycle specific and some not)
*Vesicant drugs can cause necrosis of tissues- check blood return before, during, and after therapy (can’t hang vesicant drug in peripheral line)

*Chemo precautions: Double glove (or special gloves), flush toilet 2 x, wash laundry once by itself and then again with other stuff, never touch any bag w/o gloves, goes in yellow bag

*Can be exposed to chemo in 3 ways 1. Inhaled 2. Absorbed (through skin- chemo drugs are in ALL body fluids) 3.Ingested (get on hands & touch mouth eyes etc)
***Chemo drugs stay in a person’s system for 48 hours

Radiation Precautions:
*Time (30 min contact in 8 hrs), Distance stay as faraway as possible), Shielding
**For patient external radiation can burn skin- tell them no perfumes, limit sun exposure, wear loose clothing, no washcloth only use hands,
*To tx fatigue manage with periods of activity and rest, treat N/V, pain management imperative

Treatments:
1. Primary- main tx (ex surgery)
2. Adjuvant- tx to kill cancer cells that can’t be detected after primary tx is done (ex radiation/chemo after surgery)
3. Salvage- extensive tx when other has failed (ex: radical mastectomy b/c lumpectomy wasn’t enough)
4. Palliative- Just to relieve pain and provide comfort (ex: metastasis to spine( radiate spine to relieve pressure
5. Combination- 2 primary tx’s simultaneously
6. Neo-Adjuvant- aimed @ site of high risk- comes BEFORE surgery (x: lung cancer on rt side will eventually go to left so go ahead and radiate lt side to hopefully prevent it)
7. Profelactic- tx aimed at area of high risk.. ex: know breast cancer runs in family so have mastectomy, or have stomach taken out to prevent FAP

TEACH & TREATING SIDE/EFFECTS- • No smoking, good mouth care (NO COMMERCIAL MOUTH WASHES b/c of ETOH in them) • Drink plenty of fluids to flush out chemo drugs • Mucocitis & stomotatis- good oral hygiene, offer SOFT BLAND foods (mashed potatoes • Men may become sterile from drugs- may want to look into sperm bank

RESPIRATORY
Assessment:
*Dyspnea- Othopnea (COPD)
*Cough- Dry & irritative=Upper resp infection (Viral) or ACE; Brassy= tracheal lesions; high pitched= laryngthracheitis; Cough @ night= LSHF or asthma; Cough worsens when supine= postnasal drip, Cough w/ food= aspiration, Cough in am w/ sputnum= bronchitis; Recent onset=acute; > 8 wks=chronic (Give warm liquids/meds)
*Sputnum- Color- green/yellow, rust colored & thick= bacterial infection, thin=viral, pink froth= CHF or pulmonary emboli, lung tumor
*Chest pain- usually found on side where condition is (ex pneumonia, pulm embolism) Pain is dull and consistent w/ cancer
*Wheezing- musical high pitched. From bronchispasms (asthma) Give bronchodilators
*Clubbing of fingers- COPD; Long Hx (chronic, >180 degrees, wide base
*Hemoptysis- determine source: From nose=usually with sniffle, from lung=pink frothy usually with chest pain, from stomach= vomited (usually looks like coffee grounds)
*Cyanosis- LATE SIGN (central cyanosis- lips& tongue; peripheral seen in nail beds & ear lobes.but can be from the cold) Circomortal cyanosis- dusky around mouth (COPD)

Auscultate-one side to next. Usually fluid accumulates @ base so you can hear better posterior (If you hear crackles your next question should be: Do you have SOB?)
*Elderly have decreased muscle strength and expansion; have diminished breath sounds (NORMAL) Usually their chief complaint is SOB

Diagnostic Tests:
*Pulmonary function test- look at volumes common in COPD pts. and to evaluate lung function and breathing problems most commonly dyspnea. These tests will help determine whether dyspnea is caused by lung or cardiac dysfunction. o During diagnostic test, provide information to the patient and determine whether the patient has any sensitivity to the contrast material. o Ask whether he or she has a known allergy to iodine or shellfish o Before PFTs, advise patient not to smoke for 6 to 8 hours before testing. Help reduce anxiety by describing what will happen during and after the testing o Bronchoscopy’s are useful in diagnosing and managing pulmonary diseases. o PRE OP:, the patient should be on NPO status for 4-8 hours before this procedure to reduce the risk for aspiration. If blood is a characteristic chocolate-brown in color, notify the Rapid Response Team. After the procedure, monitor the patient until the effects of the sedation have resolved and a gag reflex has returned. The pt may be given atropine during to help dry up secretions. o POST OP, it is important to assess for cough and a gag reflex return. Assess breath sounds every 15 mins for the first 2 hours. o Thoracentesis: is the aspiration of pleural fluid or air from the pleural space and is performed to help relieve blood vessel or lung compression and resp distress. o PRE OP: Tell pt they may experience a “stinging” sensation. STRESS the importance of NOT moving. The pt must be in UPRIGHT position and LEANING FORWARD! o POST OP: CXR is don’t to rule out pneumothorax. Check puncture site and dressing for bleeding. Assess BP, HR, and RR. Urge pt to breath deeply to promote expansion.

Pneumothorax: partial or complete collapse of the lung o Rapid HR o Rapid, shallow respirations o Feeling of air hunger o Uneven respirations o Paleness
*ABG- BEST INDICATOR for where your pt is right now
* Pulse ox- noninvasive way to measure O2 sat. Not always accurate. Finger must be warm.. if not you can put on earlobe. Nail polish, cat scans (dyes), cold extremity can all alter
*CXR- identifies fluid/masses, CT identifies mass (compromise O2)
*Sputum Specimens- Rinse mouth, early morning, from deep down, call when collected
*Biopsy- diagnose cancer- Risk factors: Smoking, environmental chemicals (coal miners & dry cleaners)- NPO , consent, 48 hr patho report

O2 Therapy
*Normal sat 80-98 % w/ chronic respiratory problem 60-95 % is normal
*Don’t smoke when on O2, certain materials are more flammable (flannel & nylon..pantyhose), Vaseline (only give chap stick non petroleum based in hospital)
*O2 toxicity- Decrease LOC, SOB even though getting O2, ABG most accurate way to check. COPD pt’s can have toxicity quickly that is why they are only on nasal cannula (low flow) Prevention: Vit E,C, betacarotene prevent free radicals
*Two types BNC (low flow) and Venturi Mask (high flow). The Venturi mask is more accurate b/c amount adjusted on mask not wall and can deliver high or low amounts

**Suctioning- down to resistance, suction up intermittent in circles, no longer than 10 sec. Pressure is not to exceed 120 mmHg

TB-
Risk factors- poverty, 3rd world countries, travelers, chronic illness, ETOH, elderly, steroid use, HIV, cancer- Transmitted by air
*S/Sx- low grade fever, persistent cough, anorexia, fatigue, night sweats
*Tx of antibiotics for 6 months- take all medication (people considered to be non infectious after 2-3 weeks. Anti-Tuberculosis Meds (1st and 2nd line meds) Antiemetics for nausea caused by TB Drug therapy may last 9 months or longer Proper nutrition is important because anorexia is a symptom

*MEDS: Don’t drink ETOH with INH; Rifampin will turn urine rust color
*Patient Teaching: Teach patient for absolute drug therapy adherence and infection control.
Teach to take TB drugs at bedtime to avoid nausea

COPD-
S/Sx Chronic cough & sputum (classis sign), metabolic acidosis, DOE, SOB, BARREL CHEST, fatigue, cyanosis, clubbing of nails
*Avoid temp extremes, mod exercise, Inhaler (tilt head back inhaler 1-2 in away from mouh, press down, inhale(3-5 sec), hole breath for 8-10 sec, repeat allowing 1-2 min in between, increase fluids, deep cough/breathing,
*Immunizations VERY important b/c progressive disease, stop smoking
*Teach pursed lip breathing (expiration twice as long as inspiration)
*Meds corticosteroids (increase b.g. and decrease immune system), NSAIDS, beta-adrenergic blockers, bronchiodilators, chest PT, TX given before meals
~(Risk factors): Smoking, 2nd hand smoke, occupation exposure (inhaled), genetic
*As COPD worsens, the amount of oxygen in the blood decreases and causes hypoxemia and the amount of carbon dioxide in the blood increases which causes RESPIRATORY ACIDOSIS, which then results in METABOLIC ALKALOSIS when the kidneys retain bicarbonate as a compensation
mechanism.
*Pt is in a chronic hypoxic state.

PULMONARY EMBOLUS: Do leg exercises, ROM, & ambulate to prevent
S/sx (depend on size) SENSE OF IMPENDING DOOM, dyspnea (most common symptom, tachypnea (most common sign), sudden chest pain, fever, tachycardia, cough, diaphoresis, hemoptysis, SHOCK
Obstruction of pulmonary artery or branches by a thrombus from venous system or Rt side of heart
*Risk factors-
~Venous stasis: prolonged immobilization, prolonged sitting/traveling, varicose veins, spinal cord injury
~Hypercoagulability:
Thrombus formation after injury, tumor, increase platelet count
~Venous endothelial disease
Injury, tumor, increased platelet count
~Disease states
HF, postop, COPD, DM, trauma (hip, pelvis, vertebra)
~Predisposing conditions
Adv age, obesity, pregnancy, oral contraceptives, hx of thrombophleitis, constrictive clothing
*Dense CXR- blk, emergency situation pt can dies within one hour
*Tx with O2, establish IV line, EKG monitoring, clot busters (tTP), anticoagulation therapy, dobutamnie or dopamine for hypotension

Pulmonary embolus-
S- Sense of impending doom
U- Untreated results in death
D- Dense on Xray
D- Dyspnea
E- Emergency or will die
N- New onset of symptom

CHEST TUBES: • Water seal- fluctuation ok but should NOT bubble (seal broke). Assess for leak by asking pt to cough & looking for bubbles, if they have then (check tube for leak first, then check site. May need to change/reinforce site) Also assess for crepitus (air in subQ) that usually subsides. If crack in H2O seal put it in any cup of water (ex: if transporting pt) • Suction control- amount of water in chamber determines the amount of suction. If you have bubbling in the suction control you won’t get an accurate water level reading. Disconnect from wall & check • DO NOT CLAMP TUBE (Increase in chest pressure can cause mediastinal shift (organs all move to one side( b/c negative pressure inside chest) • Measure in I & O (and assess color) (if put tube in after lobectomy and > 1000mL call dr b/c hemorrhage)

Cancer of the Larynx/Head/Neck o Signs/Symptoms-hoarseness may be first symptom. It interferes with vocal cords and speech. Later symptoms include: dysphagia, dyspnea, foul breath, weight loss, and enlarged lymph nodes.

o Risk Factors: -Tobacco and alcohol use especially in combination! -Voice Abuse (singers, public speakers) -chronic laryngitis -exposure to industrial chemicals -poor oral hygiene

o Nursing Diagnosis: -Risk for Aspiration -Anxiety -Disturbed Body Image o Post OP care: -Monitor airway patency, vital signs, hemodynamic status, and comfort level -Check for hemorrhage and other general complications of surgery -Take vital signs hourly for the first 24 hrs and then every 2 hours according to policy - Airway maintenance and ventilation are the 1st priorities

o Bilateral closed vocal cord paralysis causes airway obstruction and is a medical emergency if the symptoms are severe and the patient cannot compensate. Stridor is the major manifestations. Immediately notify the Rapid Response Team if dyspnea w/ stridor occurs o Apply oxygen to any patient who develops stridor o Teach patient to hold the breath during swallowing due to risk for aspiration o While patient is an inpatient, place a sign on his door, over the bed, and on the intercom system to help implement voice rest o Hemorrhage is uncommon with laryngectomy o If a carotid artery leak is suspected, call the Rapid Response Tea and do not touch the area because additional pressure could cause an immediate rupture. If a carotid artery ruptures because of drying or infection, immediately place constant pressure over the site and secure the airway. Do not leave the patient. Carotid artery rupture has a high risk of stroke and death. Nursing response can save the patient’s life o Morphine often is given IV by a PCA pump for the 1st 1-2 days after surgery

Pneumonia ➢ is related to excess fluid in the lungs resulting from an inflammatory process, which reduces gas exchange and leads to hypoxemia interfering with oxygenation and tissue perfusion.
Risk Factors: o Has never received the pneumococcal vaccination or received it more than 6 years ago o Did not receive the influenza vaccine in the previous year o Uses tobacco or alcohol o Has chronic lung disease o Has altered LOC o Is currently receiving mechanical ventilation o Has poor nutrition
Signs and Symptoms: -SOB, chills, shaking, 101-105 temp., stabbing chest pain (aggravated with breathing), cough, tachypnea, purulent sputum, and orthopnea.

Diagnostics: -Chest Xray, Bronchoscopy, Sputum specimen.
Patient education is important in the prevention of pneumonia, especially encouraging everyone older than 65 years and those who have a chronic health problem to receive the PPV23 o Strict handwashing to avoid the spread of organisms and avoiding large gatherings of people during cold and flu season o Encourage oral fluids o Oral care at least every 12 hours to reduce the risk because many of the most common organisms causing VAP are translocated from the patient’s mouth into the respiratory tract o Avoid smoking o Encourage pneumonia vaccine o The most common manifestation of pneumonia in the older adult patient is acute confusion from hypoxia rather than fever or cough o Warn the patient of the danger of MI if smoking is continued while using the patches o To prevent infection, teach patient to use deep breathing o OUTCOMES: attains or maintains adequate gas exchange, maintains patent airway, if free of invading organism, returns to his pre-pneumonia health status
Treatment: Broad Spectrum Antibiotics, Rest, and Supplemental Oxygen

DIABETES- 7 questions
Lab Values:
*Casual B.G. (anytime)- want < 200
*Fasting B.G. (preferred method- no caloric intake for 8 hr)- < 126
*2 Hr post prandial- (stop diuretics, coticosteriods, estrogen, dilantin) & drink 75 g glucose > or = 200 means diabetic
* Glycosylated Hemoglobin (3 month check of Hemoglobin A1C)- want < 6.5 (or 7)
*BG should go back to normal 2 hrs after eating- want < 165
*Glucouria-

*K is number one electrolyte lost in urine (because polyuria

DM TYPE 1
Onset < 30 y.o
(Brittle diabetes)- very thing and fragile
Little or no insulin (insulin dependent)
DKA (hyperglycemia)
Develop ketones- breakdown of fats

TYPE 2- • > 30 y.o, OBESITY #1 cause (tx: weight control, diet (control caloric intake. Carbs 50-60%, protein 30-30%, fats 10-20%)- TEACH moderation, portion control, family compliance & eating out- Minimal ETOH b/c decreases BG • *HHNS- age 50-70, right before illness, gradual onset of symptoms, dehydration, deadly- BG VERY high- usually> 600

Complications (usually seen more with Type 2 b/c goes a long time without being diagnosed & it has already done damage:
MICROVASCULAR complications- Kidney failure (nephropathy), vision problems/blurred vision (retinopathy), neuropathy (numbness in feet)
MACROVASCULAR- CAD, Stroke, MI, HTN, infection, PVD (extremities cold)
TEACH- wear lose socks, cut nails straight across, lotion (but not in-between toes, good shoes, check water before getting in bathtub, if traveling know time zone changes (for meds) & have letter from dr. for syringes, check feet daily, keep supplies with you at all times, med alert bracelet, NO heating pads

Hyper/hypoglycemia:

Cold and clammy( eat hard candy
Hot and dry( glucose is high

Hypoglycemic: (If BG falls < 35 lose brain cells that you can’t get back)
D-diaphoresis
I- increase pulse
R- restless
E- extra hungry
*Sweaty, clammy, palpitations, CRANKY, weak, N/V
*Protein & Vit C
*Give 2-3 tsp sugar, 6-8 oz fruit juice, 6 hard cadies, regular soda

Hyperglycemic:
*3 P’s, dry, itchy skin, tingling/numbness in hands & feet (neuropathy), recurrent infections (b/c body doesn’t heal), ABD pain, N/V
DKA (administer NS for hyperglycemia)

EXERCISE:
*Have full physical first, if high b.g. don’t exercise b/c will increase bg, Guidelines- 3 glucose tabs, eat 15g of carbs, med alert bracelet, monitor BG before, during and after exercise

INSULIN- expect hypoglycemic reaction @ PEAK time of insulin
*Rapid acting- must have trays out before giving Onset 10-15 min, Peak 1 hr, Last 3-4
*Regular (only type you can mix/give IV) Onset- 30 min, Peak 2-5 hrs, Lasts 6-10 hrs
*NPH- Onset- 2-4 hrs, Peak- 4-12 hrs, Lasts 6-20
*Lantus- can’t be mixed/ no peak

Oral Antidiabetic agent-
*Metformin (Biguanidies) – only preventative oral med (stop before surgery or cath procedures ADR w/ dyes)- blocks glucogenisis and uptake of CHO (was a answer to last test ?)
*Precose (Alpha Glucosides)- pt must have glucose tabs, good for pt with irregular eating habits
* Glyburide (Sulonomides)- safe for elderly- watch for hypoglycemia stimulate release of insulin (Type 2 DM) ADR: ETOH, NSAIDS, Zantac
*Thiazolidendiones- improve insulin resistance (UASE CAUTIOUSLY IN HF PTS)
Sick days- take insulin, check bg & ketones Q3H and call dr if > 300

Diabetes Insipidus- (head trauma, brain tumor, surgery, radiation, meds
S/sx- want to constantly drink. NOT disease of pancreas- Deficient ADH (vasopressin) produced, large volumes of dilute H2O, hypernatremia
**Fluid restriction doesn’t help
*Tx underlying cause (pituitary tumor), replace ADH

***CORTICOSTERIODS FOR LONG PERIODS CAN BURN OUT PANCREAS AND MAKE YOU DIABETIC

***Somogyis phenomenon: Rebound morning hyperglycemia after nighttime hypoglycemia- caused by too much insulin or lask of adequate bed time snack

**Self test bg- Type 1 ac & hs (2-4x a day) Type 2 1-3 x a day. Increase w/ stress, illness, change in meds

CARDIAC- 20 questions
Ch 35
ASSESSMENT:
*The parasympathetic (vagus nerve) system slows the HR, the sympathetic stimulation increases the HR
*Elderly pt’s HR < 60 be worried. *Women do not have typical s/sx of chest pain (complain of shoulder/upper back pain, SOB, and fatigue) *Elderly do not describe pain the same way (tired)
*Nocturia is a key sign of a heart problem
*You may have an underlying comorbitity (ex: diabetes)
*Stable angina- can predict when it is coming (take Nitroglycerin before you do that activity) Unstable- take sublingual Nitroglycerin @ first sign of pain. Can take up to three 5 min. apart( call 911 if pain persists
*Modifiable Risk factors of heart disease: Hyperlipidemia, Obesity, tobacco, ETOH, elevated blood sugar, Type A personality, use of oral contraceptives, HTN, inactivity
Nonmodifiable risk factors: Family Hx, Men, Postmenopausal, Black, increased age
*S/sx heart disease: Chest pain, SOB, dyspnea, edema, weight gain, syncope, palpitations, fatigue, dizziness
*Patient should be asked whether they have recently used Cocaine or any IV “street” drugs. These can lead to endocarditis or chest pain.
*Ask women about oral contraceptive usage or estrogen replacement. The incidence of MI and stroke in women older than 35 years who take oral contraceptives is increased but only if they smoke, have diabetes, or have hypertension.
*The severity of orthopnea is measured by the number of pillows or the amount of head elevation needed to provide restful sleep.
*A sudden weight increase of 2.2 lbs (1 kg) can result from excess fluid (1 L) in the interstitial spaces. Weight gain is the best indicator of fluid retention. Ask whether the patient has noticed a tightness of shoes, indentations from socks, or tightness of rings.
*Decreased perfusion is manifested as cool, pale, and moist skin. Pallor is characteristic of anemia and can be seen in areas such as the nail beds, palms, and conjunctival mucous membranes in any patient. Dark-skinned patients may experience cyanosis as a graying of the same tissues.

DIAGNOSTIC & LAB TESTS
*CK & CK-MB (used together)- 1st thing to increase, good indicator of MI, must know when chest pain started b/c narrow window (24 hrs)
*Troponin (do in a series of 3)- good to use if pt doesn’t go to hospital right away (can be elevated for 1-3 wks)
*Myoglobin- (never look @ Myoglobin or CK-MB alone)- usually elevated within 2 hrs of MI and declines after 7 hrs. Elevations in 1-4 wks but can be altered by renal or musculoskeletal disease. (May not be indicator that they have had MI but if NEGATIVE then it helps rule out an MI)
*Normals= Total Cholesterol ( 3= bad); Homocysteine (normal 5-15)- can be altered by diet low in B12, folic acid, and genetic factors
*EPS (invasive)- used to determine atrial from Vtach – ASSESS for pleural friction rubs, bedrest 24 hrs, HOB 30 deg.
~(Have pt hold breath to determine if cardiac or pleural friction rub. If holding breath & still there then cardiac)

STRESS TEST-
*Preop- can have light meals 2 hrs prior. Meds w/ SIPS of water (depending on med- no andergeneric cardiac meds), no caffeine, smoking, stimulants, wear something comfortable
*During- notify physician if complaining of chest pain, dizziness, N/V, tachycardia or flushing; may code so be ready
*Avoid hot shower 1-2hrs after because this test can cause HTN

CARDIAC CATH: (look @ amount of blockage or rule out CAD)( done before bypass
*Preop: Assess vitals (especially pulses) for baseline, Assess allergies to dyes, shellfish, NPO, iodine, IV line, sedation, cath into groin & thread up to coronary artery (teach pt that)
*Tell the patient about the sensations he or she may experience during the procedure, such as palpitations (as the catheter is passed up to the left ventricle), a feeling of heat and a hot flash (as the medium is injected into either side of the heart), and a desire to cough (as the medium is injected into the right side of the heart).
**Anytime giving dye Metformin must be stopped 24 hr before & after
*Postop- Assess site for S/Sx of infection or hemorrhage (assess vitals (shock) q15 min for 1 hour, q30 min for 2 hrs or until VS are stable and then q 4 hrs or according to hospital policy, check peripheral pulses DISTAL to site & dopple if you can’t find it (dorsalis pedis & post tibial), bed rest for 4-6 hrs unless a vascular closure device is used, pressure bandage must stay on for 24 hrs
*Because the contrast medium acts as an osmotic diuretic, monitor UO and ensure that the patient receives sufficient oral and IV fluids for adequate excretion of the medium.

ECHOCARDOIGRAPHY-
*Inform the patient that the test is painless and takes 30-60 minutes to complete. Instruct the patient to lie quietly during the test on his or her left side with the head elevated 15-20 degrees.

MRI –
*Ensure that the patient has removed all metallic objects, including watches, jewelry, clothing w/ metal fasteners, and hair clips. Depending on the type of MRI, patients w/ pacemakers or implanted defibrillators should not undergo an MRI because the magnetic fields can deactivate them.

CH 36 Rhythms
*Inverted T wave= ischemia
*Elevated ST = acute MI

Sinus Arrhythmia HR increases slightly during inspiration and decreases slightly during exhalation.

Sinus bradycardia (HR < 60) –vomiting, VAGAL stimulation (valsalveur maneuver)
Don’t tx if ASYMPTOMATIC; if symptoms- give Atropine to convert back to NS rhythm
The patient may be asymptomatic except for the decreased pulse rate. Assess for syncope, dizziness, weakness, confusion, hypotension, diaphoresis, SOB, anginal pain, and ventricular ectopy. If patient has any of these symptoms and the underlying cause cannot be determined, the treatment of choice is atropine to increase HR to about 60 bpm. If the patient remains hypotensive, initiate intravascular volume replacement rather than administering another dose of atropine. If a medication is suspected to be the cause, withhold the drug and notify the physician.

Sinus tachycardia (> 100 , PVCs in a row @ Rate > 100 bpm
(Usually associated w/ CAD) • Causes similar to PVC • Emergency if pt is unresponsive & pulseless (Cardioevert on QRS- synchronize), Other tx’s anti-arrhythmic (Amniodorne), lidocaine bolus 50 mg

Vfib (same causes as Vtach
VENTRICULAR RATE > 300, extremely irregular w/ no pattern, no atrial activity
*Absence of pulse, immediate CPR & defibrillation (shock, 5 x CPR, check vitals)
*This rhythm is rapidly fatal if not successfully ended within 3-5 minutes. Death results w/o prompt intervention.
*Shock- yell clear 3 x , don’t charge until ready, 20-25 pounds pressure
*Call dr anytime there is a change in ANY rhythm

Ventricular Asystole – FLATLINE
The patient is in full cardiac arrest
Begin CPR immediately (unless there is a DNR order) and call for assistance.

PACEMAKER- if there is no beat then provides one. Tell pt to avoid magnetic fields (MRI, metal detectors—microwaves are ok), wear med alert bracelet, avoid heavy lifting, battery change every 5 yrs
*Teach all patients and their family members how to take a pulse. Take your pulse for 1 full minute at the same time each day, and record the rate in your pacemaker diary. Take your pulse any time you feel symptoms of a possible pacemaker failure, and report your HR and symptoms to your physician.
*Patients who have a permanent pacemaker or ICD are given written and verbal information about the type and settings of their pacemaker.
*Instruct patients with pacemakers and ICD: ~Keep handheld cellular phones at least 6 inches away from the generator, with the handset on the ear opposite the side of the generator. ~Avoid sources of strong electromagnetic fields, such as magnets, large electrical generators transmitters, and telecommunications (radio or television) transmitters (Radio, television, other home appliances, and antennas do not pose a hazard). These may cause interference and could change the pacemaker settings, causing a malfunction. MRI is usually contraindicated, depending on the machine’s technology. ~Remind patients to carry a pacemaker identification card and to wear a medical alert bracelet. ~Do not apply pressure over the generator. Avoid tight clothing or belts. ~You may take baths or shower w/o concern for your pacemaker. ~Inform airport personnel of your pacemaker before passing through a metal detector, and show them your pacemaker identification card. The metal in your pacemaker will trigger the alarm in the metal detector device. ~Be aware that it is safe to operate a microwave oven unless it does not have proper shielding. ~If you feel symptoms when near any device, move 5-10 feet away from it and then check your pulse. Your pulse should return to normal. ~Follow instructions on restrictions on physical activity, such as no sudden jerky movements for 8 weeks to allow the pacemaker to settle in place, no swimming, driving motor vehicles, or operating dangerous equipment. ~Avoid activities that involve rough contact.
*If patients experience an internal defibrillator shock, they must sit or lie down immediately and notify the physician.
*Recommend resources for the family to learn how to perform CPR. Family members should know that if they are touching you when the device discharges, they may feel a slight shock but that is not harmful to them.

ICD- internally shocks if notices an abnormal rhythm. Teach- No contact sports (football), may shock family members if touching them

Digoxin (Lanoxin)- Normal level (0.5-2.0)
Indications- CHF, afib/flutter, PAC
Cause toxicity- N/V (ADULT TOXICITY), halos around lights, anorexia, muscle weakness, vertigo, confusion (ELDERLY) (Decreased K, Mg, and increase Ca can cause)
**Don’t administer w/ antacids!
*Hold if apical < 60

Heparin Sodium (anticoagulant) • SubQ is prevention- once you have clot give IV (stroke & Afib give IV) • Want PTT (1.5-2.5) normal pt level for therapy • Increase effect w/ ASA, ETOH, antibiotics • Increase bleeding, garlic, ginger, ginko ginseng (THE G’S), chamomile • Check for bleeding gums, hematuria • Antidote Protamine Sulfate • Leaves body fast so on Heparin & Coumadin @ same time when switching

Coumadin or Warafrin • INR more accurate (if hish give tx) (2-3) • Diet low in Vit K (b/c K is antidote)( asparagus, cabbage, turnip greens • Glucosteroids, ETOH, Salysilics increase effectiveness • Rifampin, oral contraceptives, estrogen, Dilantin decrease effectiveness • Avoid suppositories, falls precaution, soft toothbrush, stool softeners etc) • Pain won’t be associated w/ spontaneous bleeding • Takes longer to get out of system (7 days)

READING RYTHMS- nurse must read themselves, can’t go by what tech says

Cardiomyopathy/ MI- (Black, Men, more @ risk)
*HF- give morphine, lasix, dig, etc
*Low Na, no caffeine, fluid restrictions (CHF)
*Surgery- for transplant resting HR should be < 70 (EF < about 20 need transplant)
*Decreased ejection fraction (normal 65%) Hallmark MI sign < 55
*Increase risk embolism so on anticoagulant
*S/Sx SOB, fatigue, murmurs, arrhythmia, peripheral edema, CONFUSION, orthopnea, PND (nocturnal dyspnea)
*Tx- (for heart disease) Wait 2 hrs after eating for activity, bed rest w/ ROM, avoid cold, prevent infection, activity w/ rest
*Pulmonary edema- upright dangling
Meds:
Angina/MI treatment- Nitrates- dilates the veins and in high doses, the arteries; increases coronary blood flow by preventing vasospasm and increasing circulation through collateral vessels; routes are sublingual, spray, topical, and IV; sublingual alleviates pain of ischemia within 3 min; usually don’t give if systolic BP 5.0 and creatinine >3.0. - If the creatinine is greater than 1.8, notify the health care provider before administering supplemental potassium. - Give Natrecor thorough a separate infusion line because it is incompatible with heparin and most other parenteral medications. Expect an increase in serum BNP after drug administration. - Keep in mind that 1 kg of weight gain or loss equals 1 liter of retained or lost fluid. The same scale should be used every morning before breakfast for the most accurate assessment of weight. - Diuretics are the first-line drug of choice in older adults with HF and fluid overload. - Loop diuretics = fluid loss = dehydration - Digoxin (TR=0.5-2.0)(don’t administer if pulse 20 mmHg
Ships to ICU for monitoring
Anoxia of nonvital organs & hypoxia of vital organs
Compensatory mechanisms functions BUT can’t deliver sufficient oxygen
Life-threatening emergency
75-80% O2 sat
Patient can tolerate this situation for only a SHORT TIME/WITHIN 1 HOUR before being damaged permanently - Continuous monitoring and comparison w/ earlier findings is critical at this stage to assess therapy effectiveness
Refractory Stage:
Irreversible stage
Below 70% O2 sat – life-threatening emergency
Too much cell death & tissue damage result from too little oxygen reaching the tissues - Therapy is not effective in saving the patient’s life, even if the cause of shock is corrected and MAP temporarily returns to normal - Rapid loss of consciousness, nonpalpable pulse, cold, mottled, or dusky extremities, slow, shallow respirations, unmeasurable O2 saturation
MODS – the most profound change is damage to the heart muscle

Hypovolemic Shock

What might you notice?
-Rapid and thready pulse, pulse pressure narrowed, rapid and shallow respirations, O2 sat decreased, skin cyanosis, skin cool and clammy, restlessness, anxiety, thirst
-Sustained decrease in MAP that results from decreased circulating blood – MAIN TRIGGER LEADING TO HYPOVOLEMIC SHOCK
-“Shunting” – moving oxygenated blood into selected areas while bypassing others causes the manifestations of shock.
-The effects are temporary and reversible if the cause of shock is corrected within 1 to 2 hours after onset.
-Signs of shock are first evident as changes in CARDIOVASCULAR FUNCTION.
-INCREASE in HR – earliest manifestation of shock
-Changes in systolic BP should not be used as the main indicator of shock presence and progression.
-RNs should assess and obtain vital signs when patients are at risk for hypovolemic shock.
Overall Causes:
Hemorrhage (trauma, GI ulcer, surgery, inadequate clotting)
Dehydration (( Hemoglobin & hematocrit, vomiting, diarrhea, heavy diaphoresis, NG suction, diuretic therapy, diabetes insipidus, hyperglycemia)
Health Promotion and Maintenance: • Teach all people to prevent dehydration by having an adequate fluid intake during exercise and when in hot, dry environments. • Urge people to prevent trauma and hemorrhage by using proper safety equipment and seat belts & being aware of hazards in the home & workplace. • Secondary prevention – Patient in the acute care setting is a risk factor. IDENTIFY patients at risk for dehydration (especially important for those who have reduced cognition/reduced mobility/NPO status) • Insert and maintain a large-bore IV access, IV therapy or fluid resuscitation is a mainstay of management for hypovolemic shock (normal saline-infused w/ nay blood product & Ringer’s lactate – do not infuse due to calcium’s clotting factor) • Increase IV fluid infusion rate • Whole blood – to replace large volumes of blood loss • Packed red cells – moderate blood loss to improve oxygen w/o adding excessive fluid volume • Place patient in supine or elevate no more than 30 degrees, legs elevated position • Do not leave the patient • Vasoconstrictors o Dopamine & Norepinephrine – stimulates venous return, decreased pooling • Inotropic o Dobutamine – improve heart muscle contraction
Assessment:
Age – hypovolemic shock from trauma is more common in young adults and other types of shock are common in older adults o Information about urine output is especially important because it is reduced during the 1st stages of shock, even when fluid intake is normal. Measure urine output at least every hour. o Also check under the patient for blood. o Avoid closed ended questions.
-Central nervous system changes with shock often first manifest as thirst.
-Skeletal muscle changes during shock are muscle weakness and pain in response to tissue hypoxia and anaerobic metabolism.
-Changes in mental status and behavior may be early signs of shock.

Anemia o Reduced function of RBCs to the point that tissue oxygen needs are not completely met. o Single most common symptom of anemia is FATIGUE. o Note whether the patient can complete a 10-word sentence w/o stopping for a breath o Palpate abdomen gently & cautiously because an enlarged spleen may be tender and easily ruptured
Key Features:
Pallor, cool to touch, intolerance to cold temperature, nails club, tachycardia, orthostatic hypotension, DOE, decreased O2 sat levels, increased somnolence and FATIGUE, headache, murmurs and gallops heard on auscultation when anemia is severe

Spleen and liver are important accessory organs for blood production. They help regulate the growth of blood cells and form factors that ensure proper blood clotting.
Splenectomy – reduced immune functions, greater risk for infection and sepsis
Vitamin K – needed to produce blood-clotting factors
Radioactive colloids – patient is given a radioactive isotope IV about 3 hours before procedure.
Bone marrow aspiration or biopsy – iliac crest (prone position or occasionally side-lying position) o Verify that a patient having a bone marrow aspiration or biopsy has signed and informed consent statement o You can help reduce anxiety and allay fears by providing accurate information and emotional support. Some patients like to have their hand held during the procedure. o Check the needle site at least every 2 hours after a bone marrow biopsy or aspiration o Apply ice pack to the needle site o Avoid contact sports that may result in trauma to the site in 48 hours
Older adults o Platelet counts do not appear to change with age. Use another body area, such as the lip, to assess capillary refill. Skin moisture is not usually a reliable indicator of an underlying pathologic condition in the older adult. Pallor in an older adult may not be a reliable indicator of anemia. o Obtain a stool specimen for occult blood testing (GI bleeding – common cause of anemia in adults.
Anticoagulant drugs – prevent new clots from forming, can’t break down existing clots
Fibrinolytic drugs – best clot breakdown w/ less disruption of blood clotting, first-line therapy for MI, limited arterial thrombosis, & thrombotic strokes.
Platelet inhibitors – either prevent platelets from becoming active or prevent activated platelets from clumping together
Diet
Leafy green vegetables (Vit K) – increase the rate of blood clotting
Iron – red meat, organ meat, kidney beans, leafy greens, egg yolks, raisins
Vit B12 – animal protein, eggs, nuts, dairy products, dried beans, citrus fruit, and leafy green vegetables
Sickle Cell Disease o Results from inheritance of the sickle hemoglobin gene and is inherited in people of African American descent mainly.

Signs and symptoms: ❖ PAIN is the most common symptom of sickle cell crisis

❖ Main problem is the formation of abnormal hemoglobin chains ❖ Jaundice ❖ Decreased Hematocrit ❖ Tachycardia ❖ Cardiac Murmurs/ Cardiomegaly

Teaching/Interventions o Compare peripheral pulses, temperature, & capillary refill in all extremities o Assess for jaundice (often cause itching) in patients with darker skin by inspecting the roof of the outh for a yellow appearance o Drug therapy often starts with at least 48 hours of IV analgesics o Avoid PRNs and IM injections o Check circulation in extremities every hour o Administer oxygen and keep HOB no more that 30 degrees elevated o Hydroxyurea has been successfully used to reduce the number of sickling and pain episodes. It works by stimulating fetal hemoglobin (HbF) production which recudes the sickling od RBCs in patients with sickle cell disease. o Hydrate with hypotonic fluids (normal saline) o Hydration by the oral or IV route helps reduce the duration of pain episodes. Urge the patient to drink water or juices. Hypotonic fluids, such dextrose 5% in water (D5W) or dextrose 5% in 0.45% sodium chloride, are infused at 250 mL/hr for 4 hours. o When administering IM by Z-track method (IM – 22-gauge, 2-3 inches long, discard the needle to draw up the drugs, select the dorsal gluteal site, don’t massage the injection site o Inspect the mouth every 8 hours, listen to the lungs every 8 hours, take vital signs every 4 hours o Frequent, thorough handwashing is the utmost importance o Drink at least 3-4 liters of liquids every day o Be sure to get a FLU SHOT and pneumonia vaccine every year o Avoid high altitudes, planes with unpressureized cabins, and strenuous activities o Promote coping skills o Avoid temperatures of extreme hot or cold

Nursing Diagnosis ❖ Acute Pain related to poor tissue oxygenation ❖ Chronic Pain related to joint destruction ❖ Risk for Sepsis and Multiple Organ Dysfunction

Leukemia o Rib or sternal tenderness is an important sign o Age is important because the risk for adult-onset leukemia increases with age o Infection (gram negative bacteria) is a major cause of death in the patient with leukemia because the WBCs are immature and cannot function and sepsis is a common complication o Induction therapy – rapid, complete remission, Consolidation therapy – intent is to cure, & Maintenance therapy – maintain the remission o Ensure that the patient is in a private room to reduce cross-contamination o Don’t allow standing water in vases, denture cups, or humidifiers in the patient’s room, because they are breeding grounds for organisms o Take vital signs at least every 4 hours to assess for fever. A temperature elevation of even 0.5( above baseline is significant for a patient with LEUKOPENIA and indicates infection until it has been proved otherwise
Key Features:
Ecchymoses, petechiae, open infected lesions, pallor, bleeding gums, anorexia, weight loss, enlarged liver and spleen, reduced bowel sounds, constipated, hematuria, tachycardia, orthostatic hypotension, palpitations, DOE, fatigue, headache, fever, bone pain, joint swelling and pain

Neutropenia

❖ Occurs when there are decreased levels of WBC’s in the blood ❖ Teach pt’s to avoid crowds and other large gatherings of people ❖ Wash genital and armpit area atleast twice daily with antimicrobial soap. ❖ Clean toothbrush daily ❖ Wash hands with antimicrobial soap before eating, drinking or after touch a person or pet. ❖ Eat a low bacteria diet, and avoid salads, raw fruits and vegetables, and undercooked meat. ❖ Take temperature atleast twice daily

Thrombocytopenia o Handle patient gently o Use a lift sheet when moving and positioning in bed. o Avoid IM injections and venipunctures (use the smallest-gauge needle if necessary) o Apply ice to trauma o Teach the patient to wear shoes with firm soles when ambulating o Observe IV sites every 2 hours for bleeding o Apply firm pressure to the needle stick site for 10 minutes o Avoid contact sports

ONCOLOGY- 7 questions

Carcinogens- (PREVENTION- use common sense)
*Chemical- chemo drugs, SMOKING, ETOH, pesticides (farmer)
*Physical- sunlight & radiation, chronic inflammation or irritation (football player, tennis elbow)
*Viruses/Bacteria- HPV, Herpes, Hepatitis B (liver), Epstein Barr (Burkett’s Lymphoma)
*Genetic- BR1 or 2 (breast cancer), FAP (GI tract)-familia adrenial poyopsis (screened in teenage yrs if have it then take out entire colon
*Dietary- fat (colon & breast), smoked meats/cured, ETOH (HELP PREVENT: Deep green veggies, yellow veg (squash), Vit C, Vit E & Selenium)
*Hormonal agents- Estrogen (BC, & ovarian), DES (drug for migraines) linked to vaginal cancer

Immunoseppresion Precautions-
~Thrombocytopenia: (DECREASED PLATLET: normal 150-500,000)- < 50,000 bleeding, < 20,000 spontaneous bleeding)
*Falls precautions
*Soft tooth brush, avoid constipation (increase fluids, laxative), avoid valsalveur maneuver, electric razor, be careful blowing nose

~Neutropenia: Very low Neutrophils (Natir 10-14) Increase risk for infection- Hand hygiene most important (teach hygiene), don’t be in crowds, take temperature
*If neutopenic pt has temp of 100.4 call dr. b/c a low fever may be the only sign of infection

~Anemia: < 25-30 (need transfusion)
Mild diet w/ iron and may need erythropoietin injections

Chemotherapy: (some cycle specific and some not)
*Vesicant drugs can cause necrosis of tissues- check blood return before, during, and after therapy (can’t hang vesicant drug in peripheral line)

*Chemo precautions: Double glove (or special gloves), flush toilet 2 x, wash laundry once by itself and then again with other stuff, never touch any bag w/o gloves, goes in yellow bag

*Can be exposed to chemo in 3 ways 1. Inhaled 2. Absorbed (through skin- chemo drugs are in ALL body fluids) 3.Ingested (get on hands & touch mouth eyes etc)
***Chemo drugs stay in a person’s system for 48 hours

Radiation Precautions:
*Time (30 min contact in 8 hrs), Distance stay as faraway as possible), Shielding
**For patient external radiation can burn skin- tell them no perfumes, limit sun exposure, wear loose clothing, no washcloth only use hands,
*To tx fatigue manage with periods of activity and rest, treat N/V, pain management imperative

TEACH & TREATING SIDE/EFFECTS- • No smoking, good mouth care (NO COMMERCIAL MOUTH WASHES b/c of ETOH in them) • Drink plenty of fluids to flush out chemo drugs • Mucocitis & stomotatis- good oral hygiene, offer SOFT BLAND foods (mashed potatoes • Men may become sterile from drugs- may want to look into sperm bank

TREATMENTS-
*Adjuvant: controls potential metastatic sites. Example is have mastectomy first then chemo to follow up when being diagnosed with breast cancer
*Salvage: treatment to treat cancer after conservative treatment has failed. Example is if a patient with breast cancer had a lumpectomy after finding out about the cancer but one year later the cancer is back so now the patient has a mastectomy
*Palliative: comfort treatment to control symptoms and pain
*Combination: two primary treatments are given at the same times. Example of a combination treatment would be if a patient had head/neck cancer the treatment would be radiation and chemo at the same time
*Neo-adjuvant: same as adjuvant treatment except it is done prior to primary treatment. An example would be if a patient with lung cancer comes in a week before having surgery to have radiation
*Prophylactic: Treatment is aimed at preventing the cancer for those who are at high risk. Example would be if colon cancer ran in your family and you were at high risk, having your colon removed prior to ever developing cancer.