Chest pain caused by myocardial ischemia, often related to coronary artery disease.
Indications include: Chest pain that radiates to the left shoulder and upper arm and proceeds down arm into fingers, may also radiate to the right shoulder, neck, or jaw. Pain usually lasts less than 5 minutes, pain may be described as squeezing, burning, aching, may be described as a feeling of indigestion or heart burn.
Other symptoms include dyspnea, pallor, palpitations, dizziness, diaphoresis.
Pain may be aggravated by activity and relieved by rest or nitroglycerin
Nitroglycerin - One pill is taken 3 times in 5 minute intervals
If pain isn't relieved by the 3rd pill, go to the ER
Record duration of pain
12 lead EKG
Blood lab values
Cardiac catheterization, coronary artery angiography
Measurement of C-reactive protein
Surgical interventions: percutaneous transluminal coronary angioplasty (PTCA) or CABG
Asthma is a chronic inflammatory airway disease characterized by airway inflammation and hyperresponsiveness. The inflammatory response causes a release of chemical mediators such as histamine and leukotrienes. Inflammation response promotes bronchoconstriction, vascular congestion, edema, and formation of thick mucus.
S/S - Expiratory wheezing, recurrent, nonproductive cough, chest tightness, SOB, decreased breath sounds, prolonged expiration, tachycardia, tachypnea
Treatment: Oxygen, brochodilators (beta-adrenergics, cholinergic antagonists, theophylline)
Educate patient about use of peak flow meter and MDI (metered-dosed inhaler)
Increase fluid intake to liquefy secretions
Peak expiratory flow rate (PEFR)
Bell's Palsy is unilateral face paralysis involving seventh cranial nerve. Usually temporary. Inflammation in the nerve blocks conduction and causes compression. Can be caused by infection, hemorrhage, tumor, etc.
Indications include inability to close eye, decreased corneal reflex, increased lacrimation, drooping mouth, speech difficulty, eating difficulty, Bell's phenomenon (eye rolling up-ward as eye is closed)
Prednisone (oral corticosteriod) - Reduces facial nerve edema and improves conduction and blood flow. After 14th day of prednisone - electrotherapy for atrophy of facial muscles
Nursing interventions include protect head from cold and drafts, apply moist heat to reduce pain, administer analgesics, assist with electrical stimulation, teach isometric excercises for facial muscles and also gentle massage in upward motion for 5-10 mins 3x a day
Group of conditions associated with obstruction of airflow entering or leaving the lungs, including asthma, emphysema, chronic bronchitis, and cystic fibrosis.
Airways become inflamed and influence the thickening of vessel walls.
Chronic bronchitis - narrowing of the bronchus resulting in obstruction of airways
Emphysema - Abnormal distention of airspaces (alveloli)
Indications include change in skin color, weakness, dyspnea, cough, and adventitious breath sounds.
Administering bronchodilators, mucolytics, corticosteroids, anticholinergics. Administering low flow oxygen, encouraging fluids, providing small frequent feedings, listening to breath sounds, teaching about breathing exercises.
Reduced ability to exercise
Dyspnea with minimal exertion
Leukotriene antagonists (montelukast)
These drugs are often give by a MDI (metered dose inhaler)
Spirometry (evaluates airflow obstruction)
Alpha 1 antitrypsin deficiency screening
Prolonged state of unconsciousness. No response to verbal stimuli. No voluntary movement. Possibly varying responses to painful stimuli and possible altered pupil response to light. No blinking, possible altered respiratory pattern.
Absence or motor and verbal responses
Fixed pupils (no response to light)
Nursing interventions: frequent objective assessment, especially of neurological status, enteral feeding to give nutrition and prevent muscle wasting, prevent fluid volume deficit, frequent turning and oscillating bed to prevent pneumonia and bed sores, side rails up and bed in lowest position, eye drops or artifical tears, maintain airway, suction as needed, frequent oral care, passive range of motion to decrease muscle wasting, sequential compression stockings to prevent thromboembolism
The first step is to obtain and maintain a patent airway. Oral or nasal intubation may be used, or a tracheostomy may be performed. A mechanical ventilator is used to maintain adequate oxygenation if necessary
Maintain the airway.
Protect the patient (e.g. padded side rails).
Main fluid balance and manage nutritional status.
Provide mouth care.
Maintain skin and joint integrity.
Preserve corneal integrity.
Prevent urinary retention.
Promote bowel function.
Provide sensory stimulation.
Meet families' needs.
Retina is a nervous tissue membrane of the eye that perceives light images of external objects and transmits impulses to the optic nerve.
Detachment is separation of retina from choroid, resulting from trauma to the eye, aging process, diabetes, or tumors; indications include flashes of light, blurred or "sooty" vision, sensation of particles moving in line of vision, delineated areas of vision blank, feeling of a curtain coming up or down, loss of vision, confusion, apprehension
An increased number of floaters, appearing suddenly
Bright flashes of light
Sudden, painless loss of vision often described as a curtain that eliminates a portion of the visual field
Nursing interventions include maintain bed rest; patch for affected eye or both eyes (as ordered by health care provider)
Client education: prevent bumping head, do not move eyes rapidly, avoid rapidly jerking head, delay hair washing for 1 week, do not perform strenuous activity for 3 months, use of stool softeners to avoid straining at stool, maintain head in position as ordered by health care provider.
-Restriction of eye movements through bed rest and sedation
-Cryotherapy to seal a hole or tear in the peripheral retina
-Laser therapy to seal a hole or tear in the posterior portion of the retina
-Scleral buckling in which pressure is applied to the separated retinal layers by a tiny synthetic band so that an adhesion can form and vitreous fluid is prevented from seeping between the detached layers
-Pneumatic retinopexy in which the hole or tear is sealed with cryotherapy (cold therapy) and gas is injected into the eye, the pressure from which helps the retina to reattach
-Vitrectomy for tractional retinal detachment in which tiny incisions are made in the white of the eye through which instruments are inserted to remove the vitreous and replace it with gas; the gas exerts pressure on the retina, helping it to reattach
-Place patient face down if gas has been injected to maintain pressure on the retina to position the gas bubble correctly.
-After surgery, observe for eye discharge, fever, or sudden sharp eye pain and instruct patient to report these.
-Administer eyedrops to keep the pupil dilated, antibiotics to prevent infection, and a corticosteroids to reduce inflammation.
-Apply ice packs to reduce swelling of the eyelids.
-Institute safety precautions such as raising the side of the bed and helping the patient to walk, because she must wear eye patches for several days.
-Advise the patient to avoid any activity that would raise the intraocular pressure, such as coughing, sneezing, straining at stool, or heavy lifting.
-Administer an antiemetic if the patient is nauseated, because vomiting increases intraocular pressure.
-Indirect ophthalmoscopic examination to search the retina for holes and tears
-Goldman three-mirror examination to identify all retinal tears, degenerative changes, and fibrous bands
-Ocular ultrasonography if the lens is opaque or the vitreous humor is cloudy
-Ophthalmoscopic examination through a well-dilated pupil to confirm the diagnosis
Nursing care includes providing support if necessary for the head, having the client upright, feeding the client slowly in small amounts, placing food on unaffected side of mouth, allowing client to sit in upright position with head flexed slightly, instructing client to use tongue actively, administering liquids slowly, avoiding milk-based products, providing semisolid foods (easiest to swallow), instructing to swallow while eating, maintaining upright position for 30 to 45 min after eating. Obtain baseline weight and weigh pt on a daily basis.
-Abnormal sensation of food sticking back of throat/upper chest on act of swallowing
May be indicated by choking or coughing
-Acute pain on swallowing (also referred to as odynophagia)
Records electrical activity of brain.
Nursing care in preparation for test includes explain procedure, tranquilizer, cigarettes, and stimulant (caffeine, cola, tea) withheld according to institution policy, client may be asked to hyperventilate 3 to 4 minutes and watch bright flashing light, eat regularly scheduled meals.
Post-test care includes help client remove paste from hair, administered prescribed medication withheld before EEG, observe for seizure activity in clients who are seizure-prone.
Electroencephalograms (EEGs) can help identify seizure disorders, head injuries, intracranial lesions (such as abscesses and tumors), TIAs, stroke, or brain death.
Instruct patient not to sleep the night before the EEG, if recommended.
Instruct patient not to take antiseizure medications (except in patients with seizures), tranquilizers, stimulants, and depressants for 24 to 48 hours before test.
Tell patient that during the EEG, he'll be positioned comfortably in a reclining chair or on a bed.
Explain that a technician will apply paste and attach electrodes to areas of skin on the patient's head and neck after these areas have been lightly abraded to ensure good contact.
Discuss any specific activity that the patient will be asked to perform, such as hyperventilating for 3 minutes or sleeping, depending on the purpose of the EEG.
Use acetone to remove any remaining paste from the patient's skin.
Encourage patient to resume normal activities, as ordered.
Epilepsy is a condition characterized by recurrent seizures, which are paroxysmal events associated with abnormal electrical discharges in the brain.
Signs and Symptoms
-Simple partial seizures:
Sensory (flashing lights, smells, auditory hallucinations)
Autonomic (sweating, flushing, pupil dilation)
Psychic (dream states, anger, fear)
-Complex partial seizures:
-Absence seizures (brief changes in LOC):
Blinking or rolling of the eyes; a blank stare
Slight mouth movements
Brief involuntary muscular jerks of the body or extremities
-Generalized tonic-clonic seizures:
Typically beginning with a loud cry
Change in LOC
Body stiffening, alternating between muscle spasm and relaxation
Tongue biting, incontinence, labored breathing, apnea, cyanosis
On wakening, possible confusion and difficulty talking
-The most commonly prescribed drugs for generalized tonic-clonic and complex seizures are phenytoin, carbamazepine, phenobarbital, and primidone.
-The most commonly prescribed drugs for absence seizures are valproic acid, clonazepam, and ethosuximide.
If drug therapy fails, surgery may be necessary.
-Emergency treatment for status epilepticus usually consists of diazepam, lorazepam, fosphenytoin, or phenobarbital; 50% dextrose I.V.; and thiamine I.V.
Biochemical, hematologic, and serologic studies
MRI and EEG
Leading cause of blindness - occupational injuries, sports, assault, motor vehicular accident, explosions; medical treatment: removal of foreign object, antibiotic systemically or eye ointment, surgery as indicated (vitrectomy or enucleation or repair of detached retina or ocular surface grafting); nursing considerations: chemical - if chemical in eye, flood immediately with saline or running tap water, foreign object in eye: do not remove or jar to prevent further injury and apply no tight covering - use eye shield or stiff small inverted paper cup, administer tetanus immunization; client education: activity restriction, take medication as directed, keep eye patched, use eye lubricant as directed, return for follow-up appointments as directed; community education: prevent trauma by providing safe toys, use eye protectors when working with chemicals or tools and when playing sports, protect eyes from ultraviolet light. Malignant neoplasm of the stomach; predisposing factors include infection with Helicobacter pylori, history of pernicious anemia, ingestion of pickled foods, salted fish, salted meat, nitrates in smoked foods; indications include indigestion, abdominal discomfort and/or pain, nausea, vomiting, obstructive symptoms, weight loss, feeling full after a small meal, anemia; treatment is surgical resection combined with chemotherapy or radiation therapy; nursing care includes monitor for postoperative complications (pneumonia, hemorrhage, bowel obstruction, dumping syndrome), administer enteral feedings, observe, teach about how to prevent dumping syndrome.
Signs and Symptoms:
Early stages: may be absent
Nausea and vomiting
Cure is possible if tumor removal can be accomplished while the tumor is still localized to the stomach.
Cure is impossible if the tumor has spread beyond the area that can be removed. Palliative surgery to prevent discomfort may be possible.
If surgery is not curative, chemotherapy or radiation treatment may be used.
Reduce patient anxiety and provide psychosocial support. Encourage the patient and family to express fears and concerns about the diagnosis, prognosis, and upcoming procedures.
Promote optimal nutrition.
Relieve pain. Administer analgesics as prescribed.
Teach patients self-care, which depends on specific method of treatment.
Help promote continuing care in the home, as necessary.
Quick, practical, and standardized system for assessing level of consciousness; scores assigned of 1-4 points for eye opening response, 1-5 points for best verbal response, and 1-6 for best motor response; scores range from 3-15; score less than 8 indicates coma, score of 3-8 indicated severe head injury, score of 8-12 moderate head injury, score of 13-14 minor head injury, score of 15 indicates client is alert and oriented.
The Glasgow Coma Scale tests a patient's level of consciousness after a head injury or trauma, including neurologic trauma.
Grades responses to verbal, motor, and sensory stimulation.
Describes baseline mental status
Helps detect and interpret changes from baseline findings
-Determine the extent of the head injury by questioning the patient (if awake), the family, witnesses, or rescue personnel.
-Determine if possible what caused the head injury as well as the direction and force of the blow.
-Establish whether or not the patient lost consciousness and for how long after the initial injury.
-Administer the Glasgow Coma Scale to assess the patient's mental status during the acute phase of the injury, noting that this does not replace a full neurologic assessment.
-Maintain a patent airway and administer oxygen, fluid, electrolytes, and nutrition until the status of the patient is known.
-Monitor vital signs continuously, looking for signs of increased intracranial pressure, such as a slow heart rate, low blood pressure, a slow pulse, and rapid respirations.
-Use the Glasgow Coma Scale at regular intervals to assess level of consciousness so that any deterioration can be treated emergently.
Abnormal increase in intraocular pressure leading to visual disability and blindness; cause: obstruction of outflow of aqueous humor; indications include cloudy or blurry vision or loss of vision, artificial lights appear to have rainbows or halos around them, decreased peripheral vision, pain, headache, nausea, vomiting; nursing considerations include instruct about correct usage of prescribed medication (miotics), avoid tight collars, instruct about the danger signs of glaucoma — brow arching, halos around lights, blurry vision, diminished peripheral vision, headache, or eye pain.
Glaucoma refers to a group of disorders characterized by abnormally high intraocular pressure (IOP), resulting in optic nerve damage.
Signs and Symptoms
-Chronic open-angle glaucoma (symptoms do not appear until late):
Mild aching in the eyes
Gradual loss of peripheral vision
Seeing halos around lights
Reduced visual acuity, especially at night, that cannot be corrected with glasses
-Acute narrow-angle (angle-closure) glaucoma (rapid in onset):
Unilateral inflammation and pain
Pressure over the eye
Moderate pupil dilation that is nonreactive to light
Cloudy cornea and blurring and decreased visual acuity
Photophobia and seeing halos around lights
Nausea and vomiting
Drugs used to decrease IOP include beta-adrenergic blockers (such as timolol or betaxolol), epinephrine, or a carbonic anhydrase inhibitor (such as acetazolamide).
Miotic eyedrops such as pilocarpine may also be useful.
Patients who are unresponsive to drug therapy may be candidates for argon laser trabeculoplasty, iridectomy, or trabeculectomy.
Administered medications as ordered.
Prepare patient psychologically for surgery.
After laser surgery:
Apply eye packs as needed to help decrease pain.
Watch for hyphema (hemorrhaging into the anterior chamber of the eye).
Administer a topical corticosteroid to decrease inflammation and medication to dilate the pupil.
Administer a stool softener to prevent constipation and straining during bowel movements.
Evaluate the patient.
-Myelin is a complex substance that covers nerves.
Damage to the myelin sheath interferes with transmission of nerve impulses.
-The cause of GBS is a cell-mediated immune attack of myelin proteins on peripheral nerves.
-The cell that produces myelin in the peripheral nervous system, the Schwann cell, is spared in GBS, allowing for remyelination in the recovery phase of the disease.
-Apparently, an infectious organism contains an amino acid that mimics the myelin protein. The human immune system cannot distinguish between the two and attacks the myelin.
Progressive inflammatory autoimmune response occurring in peripheral nervous system, results in compression of nerve roots and peripheral nerves; indications include paresthesia, pain often occurring in glove-and-stocking distribution, hypotension, tachycardia, vasomotor flushing, paralytic ileus, profuse sweating; motor losses symmetrical, usually beginning in lower extremities, then extend upward to include trunk, upper extremities, cranial nerves, and vasomotor function; nursing considerations include administer steroids in acute phase, aggressive respiratory care, prevent hazards of immobility, maintain adequate nutrition, pain-reducing measures, eye care, psychological support to deal with fear, anxiety, and altered body image.
Signs and Symptoms
-Symmetrical muscle weakness, usually appearing in the legs first (ascending type) and then extending to the arms and facial nerves within 24 to 72 hours
-Facial diplegia, possibly with ophthalmoplegia
-Hospitalization is necessary
-Monitoring of respiratory function several times daily is essential. Mechanical ventilation may be required
-Plasmapheresis may be necessary
-High-dose immune globulins and steroids are also used
-Watch for ascending motor loss.
-Monitor the patient's vital signs and LOC.
-Assess respiratory function. Watch for signs of increasing partial pressure of arterial carbon dioxide (PaCO2).
-Provide meticulous skin care to prevent skin breakdown.
-Perform passive ROM exercises within the patient's pain limits.
-Evaluate the patient's gag reflex.
-Be alert for hypotension.
-Inspect the legs regularly for signs of thrombophlebitis.
-Provide eye and mouth care every 4 hours if the patient has facial paralysis.
-Watch for urine retention.
Heart failure is the inability of the myocardium to pump blood effectively enough to meet the body's metabolic needs.
There are two types of heart failure:
-Diastolic heart failure: an alteration in ventricular filling, which occurs as the result of continued increased workload on the heart
-Systolic heart failure: an alteration in ventricular contraction, which means that less blood is ejected from the ventricle
To view a graph detailing the pathophysiology of heart failure regarding a decrease in cardiac output
Signs and Symptoms
-Left-sided heart failure:
Dyspnea, initially on exertion
Paroxysmal nocturnal dyspnea
Fatigue and muscle weakness
Edema and weight gain
Irritability, restlessness, and shortened attention span
Ventricular gallop (heard over the apex)
-Right-sided heart failure:
Edema, initially dependent
Jugular vein distention
-Diuretics, which reduce preload by decreasing total blood volume and circulatory congestion
-ACE inhibitors, which dilate blood vessels and decrease systemic vascular resistance, thus reducing the workload of the heart. Vasodilators may be given to the patient who cannot tolerate ACE inhibitors
-Digoxin, which may help strengthen myocardial contractility
-Beta-adrenergic blockers, which may prevent cardiac remodeling (left ventricular dilation and hypertrophy)
It is necessary to alternate periods of rest with periods of activity.
A sodium-restricted diet is essential.
Patients with severe heart failure may benefit from a mechanical ventricular assist device or cardiac transplantation.
Administer prescribed medications.
Frequently monitor BUN, serum creatinine, potassium, sodium, chloride, and magnesium levels.
Reinforce the importance of adhering to the prescribed diet.
Weigh the patient daily to assess for fluid overload.
To prevent deep vein thrombosis, assist the patient with ROM exercises. Apply antiembolism stockings.
Evaluate the patient.
A heart murmur is longer than a heart sound and is characterized by a vibrating, blowing, or rumbling noise caused by turbulent blood flow through normal or abnormal valves.
Signs and Symptoms:
Location: Determine where the murmur is loudest on the chest wall.
Timing: Determine when the murmur occurs during the cardiac cycle (e.g., in systole or diastole).
Pitch: Determine whether the pitch is low, medium or high.
Quality: Determine the character of the murmur (e.g., rumbling, blowing, whistling, harsh, musical).
Intensity: Determine the intensity of the murmur.
Grade I, barely audible
Grade II, audible but soft and quiet
Grade III, moderately loud without a thrust (palpable or visible movement of the chest wall) or thrill (a vibration of the chest wall)
Grade IV, loud with a thrill
Grade V, very loud with a thrust or a thrill
Grade VI, loud enough to be heard with a stethoscope off the chest
Radiation: determine where the murmur radiates from its loudest point (e.g., to the axilla, the carotid arteries in the neck, the left shoulder, the back).
Mitral valve stenosis: anticoagulation therapy, correction of valve function (e.g., percutaneous mitral balloon valvuloplasty), and mitral valve repair or replacement
Mitral valve prolapse: relief of symptoms with beta-blockers and avoidance of stimulants (caffeine, alcohol, tobacco)
Mitral valve regurgitation: valve replacement
Aortic valve stenosis: percutaneous balloon valvuloplasty and aortic valve replacement
Aortic regurgitation: medical management of heart failure and valve replacement
All but the most minor murmurs may indicate a need for antibiotic prophylaxis to prevent endocarditis before dental work, surgery, and some invasive procedures.
To auscultate the heart, place patient in a supine position in a quiet room, using a stethoscope with a diaphragm and a bell.
If a murmur is detected, identify the loudest location and pinpoint the time that it occurs during the cardiac cycle.
Describe the pitch, quality, intensity, and radiation of all murmurs and then alert the physician as to your findings.
Hypertension refers to an intermittent or sustained elevation in systolic (> 140 mm Hg) or diastolic (> 90 mm Hg) blood pressure.
Signs and Symptoms:
Retinal changes (e.g., hemorrhages, fluid accumulation)
Shortness of breath
Alterations in vision or balance
-Diuretics to decrease vascular volume and cardiac output
-Beta-adrenergic receptor blockers to decrease heart rate, cardiac output, and renin release by the kidney
-Angiotensin-converting enzyme inhibitors to inhibit the conversion of angiotensin I to angiotensin II, thus lowering peripheral vascular resistance; angtiotensin II receptor blockers to achieve the same goal by a different mechanism of action
-Calcium channel blockers to decrease peripheral vascular resistance by inhibiting calcium in smooth muscle cells
-Central alpha2- adrenergic agonists to decrease sympathetic outflow
-Alpha1-adrenergic receptor blockers to cause vasodilation, thereby reducing peripheral vascular resistance
-Vasodilators to decrease peripheral vascular resistance by relaxing vascular smooth muscle
-Monitor blood pressure at frequent intervals to determine the effectiveness of any medications.
-Instruct patient on the importance of compliance with the medical regimen.
-Educate patient about the importance of making lifestyle changes, including regular exercise, weight loss, and smoking cessation, to help control blood pressure and lower cardiovascular risk. Recommend support groups for stress reduction, weight control, and quitting smoking.
-Recommend that the patient consult with a dietician or nutritionist to develop a weight-loss program and a heart-healthy diet (e.g., low-salt Mediterranean diet).
-Advise patient to limit alcohol intake.
-Educate patient and family about hypertension and how to manage it.
-Counsel patient that antihypertensive medications can cause hypotension and that positional changes should be made slowly to avoid a rapid change in blood pressure.
Hypoxia occurs when an insufficient amount of oxygen is available to cells.
Insufficient cellular tissue oxygenation; indications include apprehension, restlessness, dizziness, confusion, fatigue, tachycardia, hyperpnea, dyspnea; client may use multiple pillows when lying down to avoid being flat and ease breathing; interventions include medications, oxygen, physical reconditioning, relaxation techniques.
-Assess patient's skin temperature and color, including the color of the nail beds for blue or dusky tints.
-Check capillary refill for reduced blood flow.
-Assess for signs of hypoxia, including:
Decreased level of consciousness, tachycardia, arrhythmias, diaphoresis, restlessness, altered blood pressure or respiratory rate, clammy skin, and cyanosis
If symptoms of hypoxia are present:
Check pulse oximetry reading
Check oxygen delivery equipment for malfunction
Acquired hemorrhagic disorder; excessive destruction of platelets because of autoimmune response; indications: easy bruising, heavy menses, petechiae; nursing considerations: assessing activities that increase risk for bleeding, instruct client to avoid aspirin and NSAIDs, avoid constipation and using dental floss, use soft-bristled toothbrush; instruct children about no contact sports, bike riding, skateboarding, climbing, or running; encourage quiet activities; instruct to contact health care provider if there is head or abdominal trauma; increased platelet count (100,000 to 400,000/mm3) indicates improvement. Cranium is a closed cavity; increase in pressure causes shifting of brain; causes of increased intracranial pressure include bleeding, tumors, edema; indications include change in level of consciousness, restlessness, confusion, pupil changes, motor changes, cardiac rate changes, headache, nausea and vomiting, diplopia (double vision); treatment includes osmotic diuretics, steroids, antihypertensives, anticonvulsants, hyperventilation, surgery for decompression or shunt; nursing care includes maintaining airway by suctioning, elevating head of bed 30 degrees, keeping head in midline position, administering fluids as ordered.
Increased intracranial pressure (ICP) is a syndrome in which pathological conditions alter the relationship between intracranial volume and pressure, resulting in the body's inability to maintain the pressure equilibrium.
Signs and Symptoms:
Changes in level of consciousness (LOC)
Slow, bounding pulse
Slowing of speech
Delay in response
Administration of osmotic diuretics and corticosteroids
Restriction of fluids
Draining of CSF
Regulation of fever
Maintenance of systemic blood pressure and oxygenation
Reduction of cellular metabolic demands
Maintain airway, suctioning as needed.
Maintain proper positioning of patient, with the head in a midline position and the head of the bed raised 30 degrees.
Administer fluids as necessary.
Reduce increased risk of infection.
Monitor patient for complications.
Infection of heart lining and valves; signs and symptoms: fever, malaise, back and joint pain, splinter hemorrhages under fingernails and toenails, petechiae in conjunctive and mucous membranes, heart murmur; nursing care: IV antibiotics for 4-6 weeks, may need surgery for heart valve replacement.
Signs and Symptoms:
Intermittent fever (may occur for weeks)
Loud, regurgitant murmur, which is typical of the underlying rheumatic or congenital heart disease
Murmur that changes or appears suddenly, accompanied by fever
Petechiae on the skin (especially common on the upper anterior trunk); the buccal, pharyngeal, or conjunctival mucosa; and the nails (splinter hemorrhages)
Janeway lesions (rare)
Eradicate the infecting organism with I.V. antibiotics for 4 to 6 weeks followed by oral antibiotics
Antipyretics for fever and aches
Sufficient fluid intake
Obtain a patient history of allergies.
Administer antibiotics on time to maintain consistent blood levels. Check dilutions for compatibility with other patient medications, and use a compatible solution.
Evaluate the patient.
Teach patient about anti-infective medication.
Tell patient to watch for and report signs of embolization and to watch for signs of relapse.
Instruct patient to complete full course of antibiotics.
Usually develops as metastasis from esophagus, stomach, colon, rectum, breasts, lungs; can also be the primary site; indications include epigastric or right upper quadrant abdominal pain, fatigue, anorexia, weight loss; later indications include jaundice, ascites, bleeding.
Primary liver cancer is rare and most often associated with chronic liver disease. However, metastatic cancer to the liver from another site is relatively common, occurring in 50% of all advanced cancers.
Signs and Symptoms:
Loss of appetite
While a very small number of primary liver tumors are resectable, most patients are so sick with liver disease that the risk of surgery is often too great. Radiation and chemotherapy have been used with mixed results but always to alleviate symptoms not to cure the cancer.
-For a patient undergoing surgery, monitor for cardiopulmonary complications and liver dysfunction.
-Monitor intravenous blood and fluids, including 10% glucose, postoperatively.
-Monitor the biliary drainage system and instruct patient on its use and care after she is discharged, including keeping it clean by irrigating with sterile saline.
-Instruct the patient receiving chemotherapy and radiation to recognize complications and side effects and to report these to the physician.
-Instruct patient on how to care for the chemotherapy infusion site.
-Help patient and her family to cope with the poor prognosis.
-Be sure patient has adequate pain medications, good nutritional support, and adequate treatment of any complications.
Malignancy in epithelium of respiratory tract; cigarette smoking is the primary risk factor; no effective screening test, limited treatment options, usually poor prognosis; indications include change in respiratory patterns, persistent cough, bloody or purulent sputum, unexplained dyspnea, unexplained weight loss, recurring pulmonary system problems, pain in arm or shoulder or chest or back; interventions include surgery, chemotherapy, radiation; nursing interventions related to surgery include usual preoperative and postoperative teaching (especially related to respiration), maintenance of chest tube drainage system; nursing interventions related to chemotherapy and radiation include gentle and careful skin care, administration of antiemetics and analgesics, provide mouth care, appealing small frequent meals high in calories and protein, hair care, including coping with alopecia, balance rest with activity.
Signs and Symptoms:
Cough (or a change in an existing cough)
Hemoptysis (expectoration of blood)
Unexplained weight loss
Pain in the arm, shoulder, chest, or back
Treatment depends on the stage of the disease, the cancer cell type, and the health status of the patient. It is often palliative rather than curative because the diagnosis is usually made when the lung cancer is advanced. In most cases, the prognosis is poor.
To reduce tumor bulk, sometimes in preparation for surgical resection
To prevent or shrink brain metastasis in small cell lung cancer
To control cancer-related symptoms (e.g., pain from bony metastasis) and prolong function
Surgery (the only curative therapy):
Partial removal of a lung (wedge resection, lobectomy)
Total removal of a lung (pneumonectomy) (do not need chest tube)
Fluorouracil, vincristine, and mitomycin induce remission in 40% of patients with adenocarcinoma.
Cyclophosphamide, doxorubicin, and vincristine
Carboplatin, paclitaxel, and etoposide
Vincristine, ifosfamide, cisplatin, carboplatin, and etoposide
Provide comprehensive and supportive care to promote recovery from surgery, radiation, and chemotherapy, including:
Maintain chest tube drainage system after surgery.
Maintain careful skin care.
Administer antiemetics and analgesics as ordered.
Provide frequent small meals high in calories and protein.
Help patient to cope with the nausea, vomiting, fatigue, and alopecia that result from chemotherapy.
Maintain airway patency by removing secretions, using chest physiotherapy, deep-breathing exercises, suctioning, and oxygen.
Teach patient and family to recognize signs and symptoms of respiratory tract infection and to report these immediately.
Teach patient how to use home oxygen therapy.
Refer patient who wants to quit smoking to the local branch of the American Cancer Society, the American Lung Association, or a hospital-sponsored program.
Inform patient that the process of quitting smoking may involve nicotine replacement and an antidepressant, sometimes in combination with participation in a support group.
Lung cancer results from epithelial cell changes in the airways that result after a carcinogen damages DNA, leading to abnormal cell growth and eventually malignancy. Tumor growth may cause partial or complete airway blockage, resulting in atelectasis (collapse of the lung lobes). There are two broad categories of lung cancer: small cell and non-small cell types
Non-small cell cancers include:
Squamous cell carcinoma, commonly found in the bronchi
Adenocarcinoma, commonly found as a peripheral mass (most common lung cancer for both men and women)
Large cell carcinoma (undifferentiated carcinoma), commonly found as a peripheral mass
Bronchioalveolar cell carcinoma, commonly found in the terminal bronchus and alveoli
Small cell cancers are found anywhere in the tracheobronchial tree.
Ménière's disease is a disease of the inner ear characterized by too much endolymph fluid in the membranous labyrinth. It can lead to severe hearing loss and debilitating episodes of vertigo. The disease occurs with equal frequency in men and women and may affect either ear or both ears.
Signs and Symptoms:
Intense vertigo (dizziness), with associated pallor, nausea, vomiting, and sweating, lasting minutes to hours
Feelings of imbalance
Episodic, progressive hearing loss
Pressure in the ear
Tinnitus (ringing in the ear)
The goal of therapy is to reduce the distention in the endolymphatic space medically or surgically:
-Antihistamines (meclizine [Antivert]) to suppress the activity of the vestibular system, thereby helping to control vertigo
-Antiemetics (promethazine [Phenergan]), to control the nausea and vomiting and to some extent the vertigo
-Tranquilizers, such as diazepam (Valium), to relieve vertigo
-Diuretics (hydrochlorothiazide), to decrease the amount of endolymphatic fluid, relieving pressure in the endolymphatic system
-A diet low in sodium, to reestablish fluid balance in the inner ear, and high
in potassium, to replace potassium lost with diuretic therapy
-Corticosteroids (e.g., prednisone), to help maintain hearing and prevent vertigo
-Psychological evaluation, to improve a patient's acceptance to this disorder
Endolymphatic sac surgery in which a shunt is installed to drain excess endolymph and to relieve pressure
Ototoxic medicine (e.g., gentamicin) infusion into the inner ear, to diminish vestibular function and reduce vertigo
Vestibular nerve section, to relieve vertigo by severing the nerve's communication pathway to the brain
If hospitalized, monitor patient's vital signs, fluid intake and output, and laboratory findings.
Determine patient's history of vertigo, establishing whether vertigo has been associated with other ear symptoms.
Advise patient how to administer medications, being sure to cover all possible side effects.
Instruct patient to sit or lie down when experiencing vertigo.
Instruct patient to restrict movement to prevent injury or aggravation of dizziness.
Help patient identify triggers of a vertigo attacks in order to prepare for it.
Meningitis is an infection (viral or bacterial) that causes inflammation of the brain and spinal meninges; it can involve all three meningeal membranes: dura mater, arachnoid, and pia mater. Meningitis is most like to develop due to the spread of microorganisms through the bloodstream as a result of another infection.
However, it may also occur after a traumatic injury, such as a fractured skull or after an invasive procedure, especially to the head and neck.
Signs and Symptoms:
High fever, chills, and malaise (usually the presenting symptoms)
Headache and vomiting
Signs of meningeal irritation
Stiff neck (nuchal rigidity)
Positive Brudzinski's sign (flexion of the neck produces flexion of the knees and hips; also when the lower limb on one side of the body is flexed, the opposite side of the body also flexes)
Positive Kernig's sign (when the patient lies with the hip flexed, the leg cannot be completely extended without pain)
Exaggerated deep tendon reflexes
Photophobia (excessive sensitivity to light)
Skin lesions, ranging from a rash to ecchymosis
Disorientation, confusion, delirium, deep stupor, and coma
Seizures and increased intracranial pressure
Brain stem herniation and eventual death
Lumbar puncture to obtain cerebrospinal fluid (CSF) for testing:
Usually shows offending organism unless it is a virus.
May show increased CSF pressure
May show increased CSF protein
May show low glucose levels
Positive Brudzinksi's sign
Positive Kernig's sign
-Immediate treatment with antibiotics to stop the multiplication of bacteria is necessary. This is given intravenously for 2 weeks and orally thereafter. Choices include penicillins (e.g., ampicillin, piperacillin), cephalosporins (e.g., ceftriaxone, cefotaxime), and vancomycin with rifampin (for resistant strains)
-Dexamethasone as adjunctive therapy with bacterial meningitis
-Supportive care, if a viral etiology
-Digoxin to control arrhythmias
-Mannitol to decrease cerebral edema
-An anticonvulsant phenytoin (Dilantin) to treat seizures or sedatives to reduce restlessness
-Acetaminophen to relieve headache and fever
-Vaccination as prophylaxis for high-risk groups (e.g. college freshman, military recruits, travelers to endemic areas)
-For contacts of meningitis patients: antimicrobials, including rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone (Rocephin)
-Assess patient's neurologic status often, watching for deterioration, including an increase in temperature over 102F (38.9), seizures, altered consciousness, and altered respirations.
-Monitor carefully the patient's fluid balance, making sure he receives enough fluids to prevent dehydration, but avoid fluid overload to decrease the risk of cerebral edema.
-Turn patient often to prevent joint stiffness and neck pain.
-Maintain adequate nutrition and elimination, measuring intake and output accurately.
-Maintain a quiet, comfortable, dark environment (to reduce the pain of photophobia).
-Give a nonnarcotic analgesic, such as acetaminophen, to relieve headaches. (Avoid narcotics, which interfere with neurologic assessments.)
-Use strict aseptic techniques when treating a patient with a head wounds or skull fracture.
-Teach patient and his family how to prevent meningitis, for example, by seeking proper treatment for chronic infections (e.g., sinusitis).
Ensure that family members and other contacts of patient with bacterial meningitis are evaluated promptly for post-exposure antibiotic prophylaxis.
Recurring vascular headache; lasts 4 to 72 hours; indications include severe pain, throbbing in nature, unilateral, associated with nausea, vomiting, diarrhea; sometimes prodromal aura present (lights, lines, tastes, odors, tingling, vertigo, tinnitus), blurred vision, photophobia, focal neurological symptoms (vertigo, dysarthria, ataxia, diplopia), scalp tenderness, mood alterations; interventions include prevention with various medications and modifying trigger factors, treatment of attacks with ergotamine, NSAIDs, antiemetics, sumatriptan, and a quiet dark room and lying down can be helpful.
Migraine headache classically manifests as a unilateral pulsating pain that becomes more generalized over time.
Signs and Symptoms:
Premonitory symptoms are called auras; they are often visual, including flashing lights (scotomas).
Hemianopia (defective vision in part of one or both eyes)
Unilateral paresthesia (numbness, tingling, or other abnormal sensation on one side of the body)
Anorexia, nausea, and vomiting
Photophobia (excessive sensitivity to light)
To Treat Migraines:
Ergotamine tartrate alone or with caffeine (Cafergot), which causes constriction of the cranial blood vessels
Sumatriptan (Imitrex), naratriptan (Amerge), rizatriptan (Maxalt), and zolmitriptan (Zomig), which bind with serontonin receptors, causing vasoconstriction, reducing inflammation, and reducing pain
Metoclopromide or promethazine, antiemetics that should be taken early for best results
Analgesics ranging from aspirin, naproxen, and other nonsteroidals, to narcotics, including codeine and meperidine
Tranquilizers, such as diazepam (Valium), for acute attacks
To Prevent Migraines:
Beta-blockers (e.g., propranolol [Inderal], metoprolol [Lopressor]), to control dilation of blood vessels
Amitriptyline (Elavil), an antidepressant
Antiseizure medication (e.g., divalproex [Valproate])
Calcium channel blockers (e.g., verapamil, diltiazem), for a patient with bradycardia, diabetes mellitus, or asthma, for whom beta-blocker therapy may not be appropriate
A migraine headache patient is not typically hospitalized unless the nausea and vomiting are severe enough to cause dehydration or shock.
Evaluate patient to determine the effectiveness of the prescribed medications.
Instruct patient to lie down in a dark, quiet room during a migraine attack with ice packs on the forehead until the medicine takes effect.
Take a detailed history to determine the headache triggers (e.g., lack of sleep, certain foods like chocolate) and then instruct the patient how to avoid these triggers.
Instruct patient to take migraine medicine at the onset of the migraine and prevent dehydration by drinking plenty of fluids when the nausea and vomiting subside.
Myasthenia gravis is an autoimmune disease that affects the muscles, resulting in sporadic but progressive weakness and abnormal fatigue. It is characterized by exacerbations and remissions.
Systemic disturbance of nerve impulse transmission because of deficiency of acetylcholine at myoneural junction
Signs and Symptoms:
Diplopia (double vision)
Ptosis (drooping eyelids)
Weakness of the muscles of the face, causing a mask-like facies
Dysphonia (voice impairment)
Difficult chewing or swallowing if throat muscles are involved
Bobbing motion of the head
Symptoms of respiratory failure, if respiratory muscles are involved
Anticholinesterase drugs (e.g., neostigmine [Prostigmin], pyridostigmine [Mestinon]), to increase levels of acetylcholine (Ach) at receptors and to relieve muscle weakness and fatigue
Corticosteroids, to suppress the immune system, thereby decreasing antibody production
Immunosuppressants, such as azathioprine (Imuran), cyclophosphamide (Cytoxan), and cyclosporine, to reduce circulating antibodies, in patients for whom other medications produce no response
Plasmapheresis, whereby normal plasma and antibody-containing plasma are removed and separated; only the normal plasma is reinfused in the body. This is used for exacerbations.
Thymectomy, to remove the thymus gland if there is a tumor
Tracheotomy, positive-pressure ventilation, and vigorous suctioning, to treat severe respiratory failure
Educate patient and her family on self-care, medication management, and prevention of complications.
Teach patient how to conserve energy.
Instruct patient to eat just after taking anticholinesterase medication to benefit from the peak effects, thereby minimizing the risk of aspiration.
Teach patient to avoid stress, infections, strenuous activity, certain medications, and hot environments.
Provide patient with contact information for support groups such as the Myasthenia Gravis Foundation of America.
Myocardial infarction (MI) is an occlusion of a coronary artery that leads to oxygen deprivation, myocardial ischemia, and eventual necrosis.
Signs and Symptoms:
Severe, persistent chest pain
Unrelieved by rest or nitroglycerin
May be described as crushing or squeezing
Usually substernal, pain may radiate to the left arm, jaw, neck, or shoulder blades
Feeling of impending doom; anxiety
Nausea and vomiting
Shortness of breath
Hypotension or hypertension
Palpable precordial pulse
Serum markers of acute MI: creatine kinase and its isoenzymes, myoglobin, troponin*
Should be started within 3 hours of the onset of symptoms, if possible
Involves streptokinase, alteplase, anistreplase, or reteplase
Percutaneous transluminal coronary angioplasty (PTCA)
Nitroglycerin (to relieve chest pain)
Morphine (for analgesia)
Aspirin (to inhibit platelet aggregation)
I.V. heparin (to increases the chances of patency in the affected coronary artery)
-Monitor and record electrocardiogram (ECG) readings, blood pressure, temperature, and heart and breath sounds. -Frequently monitor the ECG to detect heart rate changes or arrhythmias.
-Assess pain and administer analgesics, as orders. Record the severity and duration of pain. Avoid giving I.M. injections because absorption from the muscle is unpredictable.
-Check the patient's blood pressure after giving nitroglycerin, especially the first dose.
-Watch for signs and symptoms of fluid retention (crackles, cough, tachypnea, and edema), which may indicate impending heart failure. Carefully monitor daily weight, intake and output, respirations, and serum enzyme levels.
-Assist with range-of-motion exercises and ambulation, as allowed.
-Promote comfort, rest, and emotional well-being. Involve patient's family to participate in care as much as possible.
Neurogenic bladder refers to any bladder dysfunction caused by a lesion of the central nervous system, causing a failure to store (spastic neurogenic bladder) or empty (flaccid neurogenic bladder) urine.
Signs and Symptoms:
All types are associated with:
Changes in initiation or interruption of voiding
Inability to completely empty the bladder.
Spastic Neurogenic Bladder:
Involuntary, frequent, scant urination without a feeling of bladder fullness
Spontaneous spasms of the arms and legs
Increased anal sphincter tone
Severe hypertension, bradycardia, and headaches with bladder distention
Tactile stimulation of abdomen, thighs, and genitalia results in voiding and spontaneous contractions of the arms and legs.
Flaccid Neurogenic Bladder:
Diminished anal sphincter tone
Greatly distended bladder without the feeling of bladder fullness
Mixed Neurogenic Bladder
Dulled perception of bladder fullness
Diminished ability to empty the bladder
Urgency to void without control of the bladder
Treatment focuses on preventing complications, such as infections (from urinary stasis), overdistention (from overfilling), and kidney damage (from backward flow of retained urine) as well as on minimizing the social and psychological effects of this disorder.
-Anticholinergic drugs (e.g., tolterodine [Detrol], oxybutynin [Ditropan], propantheline [Pro-Banthine]), to decrease bladder hyperactivity
-Cholinergic drugs (e.g., bethanechol chloride [Urecholine]), to increase bladder tone
-Muscle relaxants (e.g., diazepam [Valium] and baclofen [Lioresal]), to decrease external sphincter tone
Desmopressin (DDAVP), a nasal spray, to treat nocturia
-Botulinum-A toxin injection, to paralyze muscles of the external sphincter
-Bladder retraining, including voiding at certain times and assuming body postures that make voiding possible
-Diet low in calcium, to avoid stone formation
Transurethral resection of the bladder neck
Implantation of an artificial urinary sphincter
Monitor patient for signs of infection, such as fever or cloudy, foul-smelling urine.
Encourage patient to drink fluids to prevent renal calculi and infection from urinary stasis.
Measure fluid intake and urine output, especially in a patient who is catheterized, so that renal function can be assessed.
Encourage patient to stay mobile.
Refer patient to an enterostomal therapist if a urinary diversion procedure is planned.
Educate patient about his condition, what to expect from treatment, how to evacuate the bladder, and how to avoid infections.
Discuss the ramifications of incontinence as it relates to sexual issues as patient may be distressed but too embarrassed to bring up this subject.
Used for clients at increased risk for infection, such as immunosuppressed with neutrophil count under 500 mm3; private room scrupulously cleaned; meticulous handwashing and use of personal protective equipment by all; restriction of visitors; no fresh fruit or vegetables; avoid invasive procedures, such as catheterization, unless essential.
Take steps to provide neutropenic precautions, including the following:
-Air in rooms should be under positive pressure (i.e., air flows from the room to the corridor not the reverse).
-All rooms should have own wash basin and toilet, which should be sanitized after each use.
-Door to room should be closed at all times with a sign on corridor side stating how room is being used.
-Any equipment must be for use of the patient only and wiped down with alcohol wipes (or detergent and water) after every use.
-Supply of single-use gloves, gowns, aprons, and masks must be kept in the room.
-Room should be meticulously cleaned before it can be occupied and kept clean on a daily basis with cleaning supplies used for this room only.
-Prohibit fresh flowers due to stagnant water.
-All eating utensils must be decontaminated before use.
-Restrict persons with fever, cough or other symptoms of infection from coming in contact with patient.
-Avoid venipunctures and invasive procedures when possible.
-Obtain physician's permission to take patient out of room; if allowed to ambulate, patient should wear HEPA filter mask if neutropenia is severe.
-Provide low microbial diet; eliminate fresh salads and unpeeled fresh fruits or veggies and any uncooked foods.
-Avoid enemas, suppositories, or rectal temps.
-Care for neutropenic patient before caring for other patients, if possible.
-Observe patient's skin, especially under breasts, axillae, groin, skin folds, bony prominences, and perineum; assess for breaks, moisture, lesions, edema, and other abnormalities.
-Monitor any device insertion sites for signs and symptoms of infection.
-Monitor patient's respiratory tract for coughing and sore throat; auscultate breath sounds.
-Monitor intake and output.
-Assess oral mucosa for lesions and color.
-Auscultate bowel sounds; check for abdominal discomfort, distention, and nausea.
-Assess patient for headache, stiffness in neck, and visual disturbances, as well as level of consciousness, orientation, and behavior.
-Recommend vaccination programs to patients
Cancer of the pancreas can affect the head (75%-80%), body, or the tail of the pancreas.
Tumors in the head of the pancreas commonly result in obstruction of the common bile duct.
Because the flow of bile is impeded, patient will have pain, jaundice, clay-colored stools, and dark urine.
Malabsorption results because bile does not flow into the gastrointestinal tract; thus, catastrophic weight loss is a common presentation.
Signs and Symptoms:
Upper or mid-abdominal pain
Severe pain in the mid-back
Most pancreatic tumors are non-operable because they are most often diagnosed after the disease has progressed and metastasized. Treatment in these advanced cases is palliative, not curative.
-Chemotherapy (e.g., fluorouracil, gemcitabine)
-Nasogastric suction, to give the gastrointestinal tract a rest
-Total pancreatectomy, to resect the entire pancreas
-Pancreaticoduodenectomy (Whipple's procedure), to resect the head of the pancreas if there is no tumor elsewhere in the pancreas
-Cholecystojejunostomy, to relieve jaundice by diverting bile flow into the jejunum
-Assess patient for the effectiveness of pain medications, and ensure good nutrition.
-Be sure opioids are administered generously, as ordered, as pain is often extremely severe.
-Provide a special mattress for a patient who is so malnourished that pressure sores and discomfort from bony prominences are major considerations.
-Maintain intravenous and arterial lines, especially postoperatively.
-Instruct patient on the need for a low-fat, high-protein diet, pancreatic enzyme replacement, and vitamin supplementation.
Parkinson's disease is a chronic disease of the nervous system characterized by fine, slowly spreading tremor, muscular rigidity, and altered gait; nursing care includes encouraging finger exercises (e.g., typing, piano playing, range of motion (ROM) as appropriate), teaching client ambulation modification, referral to physical therapy, goose-stepping walk, walking with wider base, concentrating on swinging arms while walking, turning around slowly using small steps; promoting family understanding of the disease, intellect not impaired, sight and hearing are intact, disease is progressive but slow, does not lead to paralysis, referring for speech therapy, potential stereotactic surgery; administering medication.
Parkinson's disease is a slowly progressive, degenerative disorder that can appear at any age and affects both sexes but most commonly appears in men over age 60. Caused by a dopamine deficiency
Signs and Symptoms:
Tremor (beginning with a pill-roll tremor)
Muscle rigidity (uniform or jerky)
Bradykinesia (abnormally slow movements)
Gait disturbances (difficulty walking)
High-pitched monotone voice
Mask-like facies (poor blink reflex, wide open eyes)
Loss of postural control (body bends forwards when walking)
Dysphonia (slow, monotonous slurred speech)
Dysphagia (difficulty swallowing) and drooling
Micrographia (shrinking, slow handwriting)
Depression, dementia, sleep disturbances, and hallucinations
Treatment is mainly palliative and not curative. The object is to maintain as high a level of function as possible for as long as possible. Unfortunately, response to medication is often transient and symptoms inevitably become progressively medication resistant.
-Levodopa is combined with carbidopa (Sinemet), to reduce side effects of levodopa (e.g., confusion, hallucinations, depression, sleep alterations)
-Dopamine agonists (e.g., pergolide), to postpone use of levodopa and carbidopa
Anticholinergics (e.g., trihexyphenidyl), to control tremor and rigidity
-Monoamine oxidase inhibitors (e.g., selegiline [Eldepryl]), to slow progression of the disease
-Antihistamines (e.g., diphenhydramine), to reduce tremors
-Antiviral agents (e.g., amantadine [Symmetrel]), to reduce rigidity, tremor, and bradykinesia
-Catechol-O-methyltransferase inhibitors (e.g., entacapone [Comtess]), to prolong the effects of levodopa and carbidopa
-Antidepressants, to relieve the depression associated with this disease
-Budipine (not yet available in the United States), a non-dopaminergic antiparkinsonian drug, to reduces dyskinesia, which results from the long-term use of levodopa
Stereotactic neurosurgery (e.g., thalamotomy, pallidotomy), to prevent involuntary movements in patients who have not responded to medical therapy
Neural transplantation, to attempt to replace the dopaminergic brain cells damaged or destroyed in this disease (experimental)
Deep brain stimulation (with electrodes in the thalamus or globus pallidus), to stop uncontrolled movements; an image of a surgically implanted pulse generator for deep brain stimulation can be seen in the following figure. The generator is placed in a pouch beneath the clavicle.
Exercise, to maintain normal muscle tone and function
-Encourage patient to be as independent as possible given their disabilities.
-Remind patient that fatigue can exacerbate symptoms, thereby making patients more dependent on others.
-Establish a schedule for voiding and defecating by encouraging patient to drink 2 L of liquid a day and to eat high-fiber foods.
-Encourage patient to remain as active as possible as this slows the progression of the disease.
-Instruct patient and his family about Parkinson's disease and its treatment.
-Discuss the importance of a good nutritional diet, as food becomes difficult to chew and swallow.
-Monitor patient's vital signs, respiratory status, intake and output, and encourage self-care and other daily activities.
Watch closely for urinary and respiratory tract infections.
Indications include rubor, cool, shiny skin, cyanosis, ulcers, gangrene, impaired sensation, intermittent claudication, decreased peripheral pulses; predisposing factors include smoking, exposure to cold, emotional stress, diabetes mellitus, high-fat diet, hypertension, obesity; treatment includes sympathectomy, grafting, vasodilators, anticoagulants, endarterectomy; nursing considerations include monitor peripheral pulses, good foot care, do not cross legs, regular exercise, stop smoking. Peripheral vascular disease is reduction of blood flow through arteries in peripheral circulation, especially the lower extremities.
May be arterial (arteriosclerosis, Raynaud's disease, Buerger's disease) or venous (varicose veins, thrombophlebitis);
Indications of arterial include rubor, cool, shiny skin, cyanosis, ulcers, gangrene, impaired sensation, intermittent claudication, decreased peripheral pulses.
Indications of venous include cool, brown skin, edema, ulcers, pain, normal or decreased pulses.
Performing dorsiflexion of the foot, Homan's sign, is contraindicated as it might dislodge the clot resulting in pulmonary embolism.
Nursing interventions for arterial include monitor peripheral pulses, lower legs, teach not to cross legs, encourage regular exercise, counsel to stop smoking, administer vasodilators, anticoagulants as ordered.
Nursing interventions for venous include monitor peripheral pulses, elevate legs, carefully measure and apply elastic antithrombotic stockings, establish and monitor intermittent pneumatic compression device as ordered, administer anticoagulants as ordered, maintain bed rest as ordered, apply warm moist packs.
Signs and Symptoms:
Thinning of and decreased hair growth on skin
Lower extremity pallor
Increased pallor with lower limb elevation
Dependent rubor when leg in dependent position
Diminished or absent peripheral pulses
Rest pain with severe disease
Lower extremity numbess and paresthesias
Increase blood flow to the affected extremity:
Graduated exercise program.
Elevation of extremity with severe edema.
Protection of feet from injury.
Avoid exposure to cold, caffeine and nicotine.
Medications that decrease blood viscosity.
Measures to decrease hypertension and blood glucose levels.
Percutaneous transluminal angioplasty.
Arterial grafting surgical procedures.
Educate the client about risk factor reduction.
Educate the client about graduated exercise programs.
Educate client about protection from injury and foot care.
Administer medications and observe for adverse reactions.
Educate the client about compliance with medication regimen and possible adverse reactions.
Care for client during perioperative period.
Inflammatory process that results in edema of lung tissues and extravasation of fluid into alveoli causing hypoxia; indications include fever, leukocytosis, cough productive of rust-colored, green, or whitish-yellow sputum, dyspnea, pleuritic pain, tachycardia; nursing considerations include administer antibiotics, assess vital signs every 4 hours, cough and deep breathe q 2 hours, assess breath sounds, incentive spirometer, encourage fluids to 3,000 mL/24 hours, semi-Fowler's position, administer oxygen therapy.
Pneumonia is an acute infection of the lung parenchyma with impaired gas exchange.
Signs and Symptoms:
Nonproductive or productive cough
Pleuritic chest pain
Shortness of breath
Dullness with percussion
increased tactile fremitus
Crackles or sonorous wheezes
Whispered pectoriloquy, bronchophony, egophony
Assess for manifestations of complications.
Teach patient cough and deep breathing techniques.
Teach patient use of incentive spirometry.
Administer oxygen as ordered and monitor for therapeutic effect.
Administer medications and monitor for adverse reactions.
Increase fluid intake.
Teach patient importance of influenza and pneumococcal vaccines.
Teach patient to complete antibiotic therapy as prescribed.
Used to assess metabolic and physiologic function of the brain to diagnose stroke, brain tumor, epilepsy, Parkinson's disease, and head injury; preparation includes withhold caffeine, alcohol, and tobacco for 4 hours before the test, according to agency policy; NPO status (nothing by mouth) for 6-12 hours before the procedure; encourage fluids after the procedure.
Positron emission tomography (PET) is a computer-based nuclear imaging technique that creates images of organ function.
PET is useful in showing brain changes in Alzheimer's disease; Parkinson's disease; brain tumor; stroke; and sometimes mental illness, drug therapy, and surgery. It is also used to diagnose cardiac dysfunction.
PET scanning has proved useful in research settings and is becoming more available clinically.
Explain what is involved in the testing procedure. Assure the patient that the test will not involve exposure to dangerous levels of radiation.
Have the patient refrain from using tobacco and ingesting caffeine for 4 hours before the procedure.
Explain that the test may require insertion of an I.V. catheter. Caution about the sensations (dizziness, lightheadedness, headache) that the patient may experience as a result of the intravenous injection of the radioactive substance.
Encourage the patient to perform relaxation exercises, which may reduce anxiety.
Encourage the patient to resume normal activities, as ordered.
Age-related hearing loss caused by inner ear changes; decreased ability to hear high pitched sounds; nursing care of the deaf/hard-of-hearing client includes enhancing communication by positioning self directly in front of the client, providing a well-lit, quiet room, getting the client's attention, moving close to the better ear, if appropriate, speaking clearly and slowly, not shouting, keeping hands and other objects away from the mouth when speaking, having client repeat statements, using appropriate hand motions, writing messages down if client is able to read.
Presbycusis is bilateral and progressive hearing loss, especially the inability to hear high-pitched tones that accompanies the process of aging.
Signs and Symptoms:
Tinnitus (ringing in the ears)
Inability to hear in group settings
Speech deterioration (hearing guides the voice in pronunciation)
Assess the degree of hearing impairment without shouting.
Explain the cause of the hearing loss and the medical treatment options.
Emphasize the danger of excessive exposure to noise, and encourage the use or protective devices.
Approach patient within his visual range.
Write instructions, if necessary, on a tablet to make sure the patient understands what you are saying.
Provide support and encouragement for a patient learning to use hearing aids.
Pulmonary embolism is an obstruction of the pulmonary artery, usually caused by embolus from lower extremity thrombosis; indications include pleuritic or anginal chest pain, acute dyspnea, restlessness and apprehension; nursing care includes administering IV heparin, elevating head of bed, administering prescribed oxygen.
Signs and Symptoms:
Anginal or pleuritic chest pain
Productive cough (sputum may be blood-tinged)
Splinting of the chest
-Maintain adequate cardiovascular and pulmonary function as the obstruction resolves and prevent recurrence
-Oxygen therapy, as needed
-Anticoagulation therapy (with heparin), to inhibit new thrombus formation
-Antibiotic therapy (not anticoagulation), for septic emboli
-Thrombolytic therapy (with tissue plasminogen activator or streptokinase), to enhance fibrinolysis of the pulmonary emboli and remaining thrombi
-Surgery, to remove clot or interrupt the inferior vena cava; indicated for patients for whom anticoagulants are contraindicated
-Give oxygen by nasal cannula or mask
-Check arterial blood gas levels if fresh emboli or dyspnea worsens
-Be prepared to provide equipment for endotracheal tube intubation and assisted ventilation if breathing is severely compromised
-Administer heparin as ordered via I.V. push or continuous drip
-Monitor coagulation studies daily
-Help prevent future thrombus formation after patient is stable
-Encourage her to move about often
-Assist with isometric and range-of-motion exercises
-Evaluate patient; vital signs should be within the normal range
-Warn patient not to cross legs; this promotes thrombus formation
-Encourage family participation in care
-Advise patient to watch for signs of bleeding from anticoagulants
-Caution patient to avoid taking any additional medications without consulting her physician
Hereditary severe chronic anemia condition in which abnormal hemoglobin distorts erythrocytes, increases their fragility, and causes them to become sickled in shape and rigid; periods of exacerbation called crises occur; indications are systemic and include chronic anemia (hemoglobin, 6 to 9 g/dL), possible growth retardation and delayed sexual maturity, pain (often especially focused on joints), swelling, jaundice, priapism, impaired renal function, cardiac murmurs, altered pulmonary function, increased susceptibility to infection; interventions include rest, oxygen, IV fluids and electrolytes, sedation, analgesia, possible transfusion; nursing interventions include promote rest, administer analgesia as prescribed and teach use of patient-controlled analgesia (PCA) pump as indicated, administer oxygen, maintain I and O and ensure adequate fluid intake, monitor for infection, encourage activity as tolerated when not in crisis.
Tissue deoxygenation causes rigid, fragile, sickle-shaped red blood cells in people who inherit two HbS genes.
To view an image of a sickled red blood cell in comparison to a normal red blood cell, see figure.
Sickled red blood cells aggregate and create a semisolid gel that obstructs blood vessels.
Circulation becomes impaired
Signs and Symptoms:
Aching bones and swelling of the joints
Increased susceptibility to infection
Chronic fatigue and pallor
Chest pain and tachycardia
Diastolic and systolic murmurs
Exertional or unexplained dyspnea
Hepatomegaly (enlargement of the liver)
Cardiomegaly (enlargement of the heart)
Ischemic leg ulcers (especially of the ankles)
During a painful vaso-occlusive crisis:
Severe abdominal , thoracic, muscular, or bone pain
Increased likelihood of jaundice and dark urine
Damage to the spleen
Although there is no cure for sickle cell anemia, treatment is preventative and palliative.
Primary treatment modalities include
-Bone marrow transplant (BMT), hydroxyurea, arginine, long-term red blood cell (RBC) transfusion
-During painful vaso-occlusive crisis (the most common type of crisis), acute sequestration crisis, or aplastic crisis:
Sedation, analgesia, blood transfusions, oxygen therapy, oral and intravenous fluids (large amounts of both), analgesics (to relive pain)
Other treatments include:
Polyvalent pneumococcal and Haemophilus influenzae B vaccinations; anti-infectives, helps minimize complications
Chelating agents (e.g., deferoxamine), prevents iron overload from frequent blood transfusions
Antisickling agents (e.g., sodium cyanate); however, side effects can be serious
Iron supplement, if folic acid levels are low
Genetic counseling, especially for carriers of the sickle cell (HbS) gene
Instruct patient on the ways in which to avoid a sickle cell crisis (e.g., preventing infections).
-Advise patient to avoid tight clothing that restricts circulation.
-Instruct patient to see a physician immediately when she has an infection.
-Monitor patient regularly for pain and infection.
During a crisis:
Provide effective pain management, including opioid analgesics, if needed or as prescribed; assess pain frequently (using scale of 1 to 10)
Apply warm compresses to painful areas (Never use cold compresses)
Cover patient with a blanket
Give analgesic-antipyretic, such as aspirin or acetaminophen, as ordered
Encourage bed rest; place patient in sitting position
Indications include loss of motor and sensory function below level of injury, spinal shock symptoms (flaccid paralysis, complete loss of all sensation, decreased pulses, suppression of somatic and visceral reflexes), postural hypotension, edema, alteration in normal thermoregulation; nursing considerations include skeletal tractions, administer steroid therapy, move client by log-rolling technique, provide good skin care, provide emotional support, ensure adequate nutrition, bladder and bowel training, catheterization, client and family education to cope with detailed care at home, prevent complication of autonomic dysreflexia.
Spinal cord injury/rehabilitation potential
C3 and above: unable to care for self, life-sustaining ventilatory support essential
C4: unable to care for self, may self-feed with powered devices (depending on respiratory function)
C5: can drive electric wheelchair, may be able to feed self with powered devices
C6: may self-propel a lightweight wheelchair, may feed self with devices, can write and care for self, can transfer from chair to bed
C7: can dress lower extremities, minimal assistance needed, independent in wheelchair, can drive car with hand controls
C8: same as C7; in general, activities easier
T1-T4: some independence from wheelchair, long leg braces for standing exercises
T5-L2: still requires wheelchair, limited ambulation with long-leg braces and crutches
L3-L5: may use crutches or cane for ambulation
Spinal cord injury (SCI) may be incomplete, with some loss of motor function and sensation, or complete, with paralysis below the level of the lesion.
Signs and Symptoms:
Acute pain in back or neck, possibly radiating
Sensory and motor paralysis
Loss of bladder and bowel control
Loss of thermoregulation
-Incomplete spinal cord lesion
Central Cord Syndrome: some loss of motor function and sensation, some bowel/bladder dysfunction
Anterior Cord Syndrome: loss of sensations of pain and temperature, and motor function below level of injury; sensations of light touch, position, and vibration remain
Brown-Squard Syndrome (Lateral Cord Syndrome): ipsilateral paralysis or paresis; ipsilateral loss of sensations of touch, pressure, and vibration; contralateral loss of pain and temperature
-Complete spinal cord lesion
Paralysis of the lower body (paraplegia)
Paralysis of all four extremities (quadriplegia)
Immobilization with head and neck in neutral position
Transport to spinal injury or trauma center
Administration of high-dose corticosteroids
Administration of oxygen
Immobilization, traction, and reduction
Monitor patient's airway and respiratory status.
Maintain patient's proper body alignment, repositioning and helping patient move as necessary.
Assist patient with adaptation to sensory and perceptual alterations.
Reposition patient every two hours to prevent pressure ulcers.
Educate patient on bowel and bladder training.
Monitor patient for complications.
Educate patient on self-care and encourage rehabilitation.
Surgical removal of stapes and replacement with a prosthesis to treat hearing loss caused by otosclerosis; postoperative care includes reinforcing dressing; avoiding blowing nose, sneezing, and coughing; positioning on unaffected side; observing for facial nerve damage, infection, vertigo, tinnitus; instructing client to avoid getting water in the ear, flying, drafts, and crowds of people with upper respiratory infections.
Stapedectomy is used as a treatment for otosclerosis, in which the growth of new, abnormal spongy bone causes fixation of the stapes and prevents it from vibrating and conducting sound.
Provides better sound conduction for bone disorder in ear
Monitor patient for complications.
Instruct patient to keep ear clean and dry and to take antibiotics to prevent infection.
Instruct patient to avoid blowing nose, sneezing, or coughing; heavy lifting; and air travel.
Sudden disruption in blood supply to brain resulting in a sudden loss of brain function that may be temporary or permanent; caused by thrombosis, embolism, ischemia, or hemorrhage; indications include loss of movement, thought, memory, speech, or sensation; nursing responsibilities include encouraging the client to attain maximum independence, stimulating multiple senses, repeating directions and breaking down tasks into components, facing the client and speaking clearly and slowly, giving the client time to respond, maintaining skin integrity and providing exercises (ROM and facial), self-care activities, and teaching. Most common headache; indications include mild to moderate pressure or tightness, bilateral, discomfort worse with activity; nursing considerations include careful assessment of onset of symptoms and triggers, instruct about analgesics, relaxation techniques, massage, moist hot packs to neck.
Tension headaches are very common, and are usually less severe and debilitating than migraines.
Signs and Symptoms:
Tension headaches may be occasional or chronic with pain described as follows:
Steady, unremitting pressure around the forehead, temples, or back of the neck
Band-like pain around the head
The sensation of a weight on the head
Analgesics (e.g. acetaminophen, aspirin, ibuprofen)
Tension headaches do not indicate a more serious condition. However, it is important that the nurse establish that the patient is, in fact, experiencing tension headaches. Thus, the nurse should:
Record a general health history, to eliminate the possibility of a more dangerous underlying problem (e.g., brain tumors, meningitis, severe hypertension, aneurysm).
Review medication history; some drugs may cause headaches (e.g., antihypertensives).
Establish an occupational history.
Ask about sleep patterns, emotional issues, and sources of stress.
Inquire about exposure to toxic substances.
Ask patient to describe:
Inform patient of treatments.
Offer prevention strategies (e.g., avoiding activities that precipitate headache).
Important to assess the gag reflex in a client who has a decreased level of consciousness before giving anything by mouth; to test the gag reflex the nurse looks for bilateral contraction of the palatial muscles initiated by stroking or touching either side of the posterior pharynx or soft palate with a tongue blade; if reflex weak or absent, client is in danger of aspirating.
Test patient's motor function by using tongue depressor, asking patient to open mouth wide and say "ah." Observe movement of uvula and soft palate.
Using the tongue depressor, touch the patient's posterior pharynx to test the patient's gag reflex. Be sure to warn the patient that you are going to do this.
Observe patient's ability to swallow; give the patient a cup of water to drink.
-CN IX (glossopharyngeal)
Sensory: Contains sensory fibers for taste on the posterior third of the tongue and sensory fibers of the pharynx that result in the gag reflex when stimulated
Motor: Provides secretory fibers to the parotid salivary glands; promotes swallowing
-CN X (vagus)
Sensory: Carries sensations from the throat, larynx, heart, lungs, bronchi, gastrointestinal tract, and abdominal viscera
Motor: Promotes swallowing, talking, and production of digestive juices
Trigeminal neuralgia (tic douloureux) is a condition of the trigeminal nerve causing involuntary contraction of facial muscles and episodes of extreme facial pain.
Type of neuralgia involving one or more branches of the 5th cranial nerve; caused by infections of sinuses, teeth, mouth, or irritation of the nerve from pressure; indications include stabbing or burning facial pain that is excruciating, unpredictable, and paroxysmal; twitching, grimacing of facial muscles; nursing considerations include identify and avoid stimuli that exacerbate the attacks, administer anticonvulsants and analgesics, avoid rubbing the eye, and chew on opposite side of the mouth.
Signs and Symptoms:
Unilateral shooting and stabbing sensation in the face
Paroxysm triggered by touching (i.e., washing, shaving, chewing)
Alcohol or phenol injection
Microvascular decompression of the trigeminal nerve
Percutaneous radiofrequency trigeminal gangliolysis
Help patient recognize triggers of facial pain and instruct in self-care.
Monitor patient for anxiety, depression, and insomnia.
Assess patient for facial motor and sensory deficits in the three branches of the trigeminal nerve.
Assess the eye on the affected side for irritation and redness.
Instruct patient not to rub eye or chew on affected side until numbness wears off.
Monitor patient for difficulty in eating and swallowing foods of various consistencies.
Infectious disease of insidious onset that primarily affects the lungs; signs/symptoms include fatigue, lethargy, anorexia, weight loss, low-grade fever, and productive cough of mucopurulent sputum; diagnosis: Mantoux test, sputum positive for acid-fast bacilli and chest X-ray; treatment includes chemotherapy, 9-month regimen of isoniazid combined with streptomycin, ethambutol, rifampin, or pyrazinamide; instruct client to cover mouth and nose with tissue when coughing, sneezing, laughing, and burn tissues, good handwashing, good nutrition, must take full course of medications, encourage to return to clinic for sputum smears.
Signs and Symptoms:
Weight loss and anorexia
Altered mental status (in elderly patients)
TB vaccine can be up to 76% effective
First-line TB Medications:
Antibiotic regimen initially consists of at least four drugs
Antibiotics should be taken for 6-12 months
Strict adherence to treatment protocols to avoid resistance
Directly observed treatment is used when compliance is suspect
-Because TB is spread through airborne transmission, follow airborne precautions
-Place patient in a private room with monitored negative air pressure.
-Perform 6 to 12 air changes per hour.
-Transport patient out of room only when necessary, and with use of a surgical mask.
-Appropriate discharge of air outside, or monitored filtration if air is re-circulated.
-Keep door closed and patient in room.
-Use respiratory protection when entering room.
Consult the Centers for Disease Control and Prevention (CDC) Guidelines.
-Instruct patient how to keep airways clear (adequate hydration, proper posture).
-Teach patient proper hygiene, so that opportunities for transmission are minimized.