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Final Nursing 330
Terms in this set (448)
Noticing is the first step.
-Notice a change in the clinical situation that demands attention.
Focused observation, recognition of deviations from expected patterns. Objective/Subjective
-Developing sufficient understanding of a situation in order to determine an appropriate response
-It involves making sense of the data, prioritizing of data, development of an intervention plan.
"Walking into a room and breaking it down."
Processes used to break a situation down into its more basic elements
Immediate understanding of the situation
Telling and interpreting stories to make sense of and explain a situation
-Deciding on most appropriate course of action and carrying it out. The result of clinical reasoning
-May include no immediate actions.
Involves: development of calm and confident leadership, clear communication, well-planned
***Must be flexible
-Involves evaluation and analysis of choices and decisions made in clinical performance.
-Attending to patients responses while in process of acting.
Is it working? Is it effective?
Nursing Process Definition
Problem solving approach to the identification and treatment of patient problems that is the foundation of nursing practice
Data collection. Subjective and Objective. Foundation for appropriate diagnosis, planning, and interventions
Nursing Diagnosis Definition
Data analysis and problem identification. NANDA nursing approved.
-Follow this pattern: Identifying problem, etiology, signs and symptoms, R/T, and evidenced by
Priority setting. Identifying outcomes (NOC) and Determining Interventions (NIC)
-Goals should be time specific and measurable.
-Nursing Diagnosis directs the development of patients outcome or goals and identification of nursing interventions to accomplish the outcomes.
Nursing Implementation definition
Activation of the plan with the use of nursing intervention.
-Delegation and assignment
-Use good communication while delegating.
-Make sure to follow-up
-Delegation is transferring the authority or responsibility to perform a selected nursing task in a selected situation to a competent individual.
Different from delegation in that assignment is the distribution of work that each staff member is responsible for during a given work period
Five rights of Delegation
1. The Right Task
2. Under the right circumstances
3. To the right person
4. With the right direction and communication
5. Under the right supervision and evaluation.
American Nurses Association (ANA) definition of nursing
-The diagnosis and treatment of human responses to actual and potential problems.
-The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses, and advocacy in the care of individuals, families, communities, and populations.
Evidence-Based Practice (EBP)
A problem solving approach to clinical decision making.
-It involves the use of best available evidence in combination with clinical expertise and patient preferences and values to achieve desired outcomes
Why is EBP important in nursing practice?
Delivers the highest quality of care for the best patient outcomes
Role of the Nurse in Patient Teaching
-Interactive and dynamic process that involves a change in patients behaviors in order to maintain or improve health.
-Teaching patients about their health is often the one key nursing interventions that makes a difference in their lives.
What are things we would teach to a patient?
-Health promotion, prevention of disease, management of illness, and appropriate selection and use of treatment options.
-Must have knowledge of subject matter and good communication skills
Principles of Adult Education
1. The Learner's Need to know
2. The learner's readiness to learn?
3. The learner's prior experience
4. The Learner's motivation to learn
5. The Learner's orientation to learning
6. The learner's self-concept
Learner's Need To know
Patients needs to know why they should learn something, what they need to learn, and how it will benefit them.
Learner's Readiness to learn
Readiness and motivation to learn are high when facing new tasks.
-Health crisis provide opportunities for patients to learn and change behavior.
-Stress and anxiety may interfere with learning, thus requiring frequent reinforcement of content.
Learner's Prior Experience
Motivation is increased when patients already know something about the subject from past experience
Learner's Motivation to Learn
Patients prefer to apply learning immediately and long-term goals could less appeal to them
Learner's Orientation to Learning
Patients seek out various resources for specific learning and prefer to have choices
Patients need control and self-direction to maintain their sense of self-worth
Effective Communication skills
Assessment which includes physical characteristics, learning needs, readiness to learn, and learning styles.
-Plan to have discussion (teach back), lecture, demonstration/return demo (Show Back), role play, and learning materials.
Transtheoretical Model of Health Behavior Change
-Precontemplation, contemplation, preparation, action, maintenance, termination
-Patients is not considering a change, is not ready to learn
-Nurse provides support, increases awareness of condition. Describe benefits of change and risks of not changing
-Patients thinks about a change. May verbalize recognition of need to change.
-Nurse introduces what is involved in changing the behavior. Reinforce the stated need for change.
Patient begins to change behavior through practice. Tentative and may experience relapse.
-Nurse will reinforce behavior with reward, encourage self-reward, discuss choices to help minimize relapses and regain focus. Help patient plan to deal with potential relapses.
Patient practices the behavior regularly. Able to sustain the change.
-Nurse continues to reinforce behavior Provide additional teaching on the need to maintain changes.
Change has become part of the lifestyle. Behavior no longer considered a change.
-Nurse evaluates effectiveness of the new behavior. No further interventions needed.
Different Teaching Strategies
-Discussion "Teach back"
-Demonstration/Return Demonstration "show back"
Prevention of Chronic Illness
Eating healthy, being physically active, avoiding tobacco or harmful substances.
-Preventing and managing a crisis trying to prevent an acute exacerbation for the chronic illness
Preventing the disease-diet, exercise, immunizations.
Detecting of disease. Screenings (ex: SBE, testicular exam)
After disease process, chronic illness. Activities that limit disease progression.
Major Causes of Chronic Illness
Living longer, insufficient physical activity, lack of access to fresh fruits and vegetables, tobacco use, and alcohol consumption.
Characteristics of a chronic illness
Diseases prolonged, do not resolve spontaneously and are rarely cured completely.
-Results in limitations in physical function, work productivity, and quality of life for those affected
-Permanent impairments or deviations from normal.
-Nonreversible pathologic changes
-Special rehab required
-Need for long term medical management
Most common chronic illnesses in older adults
HTN, Arthritis, Heart Disease, Cancer, and Diabetes
Older Adult Woman
More likely to live alone, less likely to have health insurance, lack of formal work experience, cares for ill spouse, higher incidence of chronic health problems
Cognitively Impaired Older Adults
May experience a memory lapse or benign forgetfulness that is not related to cognitive impairment
Rural Older Adults Barriers
-Limited supply of healthcare workers and facilities
-Lack of equality health care
Having low income, reduced cognitive capacity, living alone, and lack of affordable housing
Frail Older Adults Barriers
Three of more following are present:
-Unplanned weight loss
-Poor endurance and energy
-Slownes and low activity levels.
SCALES Nutritional Assessment
-Loss or gain of weight
-Shopping and food preparation problems
Nursing Interventions to Assist Chronically Ill Older Adults
-Use of restraints (last resort)
-Adult Health Care
Common Problems of Older Adults related to Hospitalization
-High Surgical risk, acute confusional state, HAI's, and premature discharge in unstable condition.
-Identify adults over age 85 at risk for iatrogenic problems.
-Assistance with ADL's, IADL's, and medication.
-Implement standard protocols to screen at risk patients.
Care alternatives for older adults
-Adult Day Care Programs
-Home Health Care
-Long Term Care Facilities.
-Case Management (May use if family is out of town and needs a facilitator
The role of nurse in health promotion for older adults
They plan, educate about treatment plan, implement strategies for symptom management, and assess outcomes.
-Whatever the person is experiencing pain says it is. Subjective.
-Unpleasant sensory and emotional experience associated with actual or potential tissue damage.
Routes for Pain Meds: Oral
-Route of choice with functioning GI tract. Last longer than IV
Routes for Pain Meds: Transmucosal and Buccal Routes
-Exempts drug from first-pass effect. Allows the drug to enter the bloodstream and travel directly to the CNS.
-Occurs 5-7 minutes after administrations.
Routes for Pain Meds: Rectal
Least favorite route, Usually for patients with N/V.
Routes for Pain Meds: Transdermal
Patch. NONHAIRY SKIN. Absorption from the patchis slow.
Routes for Pain Meds: Parenteral Routes
-IM, IV, Subcutaneous
-IM route is very painful and can have unreliable absorption.
-IV is best route when fast analgesia is needed.
Routes for Pain Meds: Intraspinal Delivery
Highly potent. Smaller doses needed.
Physical and Psychologic Effects of Unrelieved Pain
-Unnecessary suffering, physical and psychosocial dysfunction, immunosuppression, impaired recovery from acute illness and surgery, and sleep disturbances.
-Increased heart rate and cardiac workload, increased muscular contraction and spasm, decreased GI motility and transit, increased breakdown of body energy stores
-Decrease tidal volume which could cause atelectasis
-Impaired cognitive function.
-Subjective Data: Health history, medications, illicit and herbal products
-Objective Data: Physical examination, evaluation of functional limitations, psychosocial evaluation including mood.
-Pain patterns (OLDCARTS)
-Impact of pain
-Patients beliefs, expectations and goals
-Sudden onset, less than 3 months' time for normal healing to occur. Mild to severe. Generally a precipitating event or illness can be identified.
Acute Pain Manifestations
-Manifestations: reflect sympathetic nervous system. Increased heart rate, increased RR, increased BP.
Acute Pain Treatment Goal
Control with eventual elimination
-Does not go away; characterized by periods of waxing and waning (Come and go)
Chronic Pain Manifestations
Decreased physical movements/activity, fatigue, withdrawal from others and social interaction.
-Can be disabling and accompanied by anxiety and depression.
Chronic Pain Treatment Goal
Focus on enhancing function and quality of life.
-May not be able to get the pain scale below a 3
-Do not produce tolerance or addiction
-Available without prescription.
Fun facts of Aspirin
-Effective for mild pain
-Use is limited due to increased risk for platelet dysfunction and bleeding (GI)
-Decreases risk for MI and Stroke events
-Used more as a cardioprotective measure.
Side effects of NSAIDS
Impairment of renal function, GI irritation, and ulceration.
-Bind to receptors in the CNS
-Inhibition of transmission of nociceptive input
-No analgesic ceiling
-Act on mu and kappa receptors.
Side effects of Opioids
-Common Side Effects: Constipation**, N/V, sedation, respiratory depression, and pruritus
-less common: urinary retention, myoclonus, dizziness, confusion, and hallucinations
What should patients also be receiving if they are taking an opioid?
Patients should use a gentle stimulant laxative plus a stool softener to decrease constipation.
-Used in conjunction with opioids and nonopioids
-DO NOT GIVE WITH NSAIDS!!
-Decrease edema and inflammation.
Adjuvant Side Effects
-Hyperglycemia, fluid retention, dyspepsia, GI bleeding, impaired healing, muscle wasting, osteoporosis, adrenal suppression, and susceptibility to infection.
Non-drug Therapy for Pain
-Reduces dose of analgesic required and minimize side effects
-Includes massage, exercise, acupuncture, Heat, and Cold, distraction, hypnosis, imagery, relaxation.
Non-drug therapy: Massage
Many different techniques exist including movement of the hands or fingers over the skin slowly or briskly with long strokes or in circles or applying firm pressure to the skin to maintain contact while massaging the underlying tissues.
-Trigger point massage is circumscribed hypersensitive area within a tight band of muscle. It is caused by acute or chronic muscle strain and can often be felt as a tight knot under the skin.
Non-drug Therapy: Exercise
-Critical part of treatment plan for patients with chronic pain, particularly those with musculoskeletal pain.
-Exercise enhances circulation and cardiovascular fitness, reduces edema, increases muscle strength and flexibility, and enhances physical and psychosocial functioning.
Non-drug Therapy: Acupuncture
-Technique of traditional Chinese medicine in which very thin needles are inserted into the body at designated points.
-used for many different types of pain.
Non-drug Therapy: Heat Therapy
**ACHES AND STIFFENS
-Application of either moist or dry heat applied to the skin.
-Heat therapy can be either superficial or deeps.
-Heating pad, hot pack, hot moist compresses, warm wax, or a hot water bottle.
Non-drug Therapy: Cold Therapy
-Used for inflammation
-Application of either moist or dry cold to the skin
-Can be applied by the means of an ice bag, moist cold such as towels soaking in ice water, immersion in a bath or under running cold water.
-Cover the cold source with a cloth or towel.
Non-drug Therapy: Distraction
-Involves the redirection of attention away from the pain and onto something else. It is simple but a powerful strategy to relieve pain.
-Can be achieved by engaging the patient in any activity that can hold their attention (watching TV, movie, conversation, listening to music, playing a game)
Non-Drug Therapy: Hypnosis
-enables the patient to achieve a state of heightened awareness and focused concentration that can be used to alter the patient pain perception.
Nurse roles in pain management
-Assess pain characteristics
-Develop treatment plan for patients pain
-Evaluate whether current treatment plan is effective
-Teach patient and caregiver about treatment plan
-Implement discharge teaching about pain management
Communicates concern and affirms commitment to the patient.
-Planning and implementing treatment including education, advocacy, and support of the family and patient.
-Written agreement or treatment plan that describes the pain management.
Influence of patients beliefs and attitudes about pain assessment and management
-Fear of Addiction
-Fear of Tolerance
-Concern about side effects
-Fear of injections
-Desire to be "good" patient
-Desire to be stoic
-Forgetting to take analgesic
-Concern that pain indicates disease progression
-Sense of fatalism
Use of PCAs
-Patient is in control, nurse programs the machine.
-Its safe and push it if patients needs it
-A dose of opioid is delivered when the patients decides a dose is needed
-Widely for the management of acute pain, including postoperative pain and cancer pain.
-Begins with patient teaching.
-Teach the patient to administer the analgesic before pain intensity is greater than the patients desired pain intensity goal
Two major body fluid compartments
Intracellular and Extracellular
Inside the cells
1. Intracellular fluid (ICF)
2. 2/3 of body water
3. 40% body weight of an adult
Outside the cells
1. Extracellular Fluid (ECF)
2. 1/3 of body water.
a. Intravascular-1/3 of ECF, PLASMA
b. Interstitial-2/3 of ECF, fluid of the interstitium (the space between cells) and lymph.
c.Transcellular- the fluid in specialized cavities, GI tract, cerebrospinal fluid, peritoneal. Totals about 1 L at any given time. 3-6 L secreted and reabsorbed in the GI tract every day.
Osmolarity is the same inside the cell and outside of the cell- cell states the same
Solutes are less concentrated than the cells - cell swells.
Put in hypertonic solution
Solutes are more concentrated than he cells - cell shrinks
Put in hypotonic solution.
**Fluid volume deficit
-Abnormal loss of body fluids (diarrhea, fistula drainage, polyuria, hemorrhage, etc.)
-Not to be confused with dehydration which is a loss of pure water alone without corresponding loss of sodium.
-Diabetes insipidus, osmotic diuresis, overuse of diuretics, inadequate fluid intake, third-space fluid shifts (burns, intestinal obstruction)
Hypovolemia laboratory diagnostic findings
Increase sodium, increase specific gravity, increased BUN, Incraesed Hct, Increased Osmolality (ICF volume, decrease ECF volume), decrease Potassium
Hypovolemia clinical manifestations
Increased: temperature, pulse (thready), RR, thirst, weakness, dizziness.
Decreased: BP, weight, skin turgor, capillary refill, LOC
-Restlessness, drowsiness, lethargy, dry mucous membranes, seizures, coma
**Decreased cardiac output, decreased urine output.
Hypovolemia Nursing Implementation
-Level of consciousness
-Urine output (report if less than 30 CC/hr)
-Daily weight (best measure of fluid status)
-Slow position change
-Skin assessment and care: examine skin for turgor and mobility. Could be moist and cool due to vasoconstriction. Dry and wrinkled.
Hypovolemia Collaborative Care
-correct the underlying cause and replace both water and electrolytes needs
-Balanced IV solutions are usually given (Lactated Ringer's)
-Isotonic 0.9% NaCl is given when rapid volume replacement is indicated.
-Blood administered when volume loss is due to blood loss.
Fluid volume excess
-excessive intake of fluids
-Abnormal retention of fluids (ex: heart or renal failure)
-A shift of fluid from interstitial fluid into plasma fluid
-Long-term use of corticosteroids
-Heart failure, renal failure
Hypervolemia Laboratory Diagnostic Findings
-Decreased: Na, BUN, Hct, Osmolality (ICF volume, increased ECF volume), Albumin
Hypervolemia Clinical Manifestations
Increased: BP, RR, Pulse (Bounding, but rate can be normal), weight (2 lbs/24 hours), central venous pressure.
-Peripheral edema, headache, confusion, lethargy, dyspnea, orthopnea, crackels, pulmonary edema, confusion, edema, jugular vein distention, polyuria.
Hypervolemia Nursing Implementation
-Reduce IV flow rate
-Evaluate breath sounds and ABGs
-Treat with O2 and ordered Diuretics
-Reduce fluid and NA intake.
-Circulation/color (checking edema)
-turn, cough, and reposition Q2 hours
-Skin integrity due to edematous skin (may feel cool, taught, and hard)
Hypervolemia Collaborative Care
-Goal of treatment is removal of fluid without producing abnormal changes in the electrolyte composition or osmolality of the ECF.
-Find and treat underlying cause
-Diuretics and fluid restriction are primary treatment
-Restriction of sodium intake
-Main cation of the ECF
-Plays a major role in maintaining the concentration and volume
-Sodium is absorbed in the GI tract from food.
-Kidneys are primary regulator of sodium
Normal levels of Na
-Excessive sodium intake or elevated sodium occurring with water loss.
-Excessive Sodium via IV fluids.
-Inadequate water intake
-Excessive water loss: high fever, heatstroke, prolonged hyperventilation, diarrhea
-Disease States (diabetes insipidus, primary hyperaldosteronism, Cushing Syndrome, uncontrolled diabetes mellitus)
Hypernatremia Laboratory Diagnostic Findings
Sodium greater than 145
Hypernatremia Clinical Manifestations with decreased ECF volume
-Restlessness, agitation, twitching, seizures, coma, intense thirst, dry swollen tongue, sticky mucous membranes.
-Postural hypotension, decreased CVP, lethargy
Hypernatremia Clinical Manifestations with Normal/Increased ECF volume
-Restlessness, agitation, twitching, seizures, coma, intense thirst, flushed skin, weight gain, peripheral and pulmonary edema, increased BP, Increased CVP
Hypernatremia Nursing Implementation
-Treat the underlying cause
-In primary water deficit, the continued water loss must be prevented and water replacement must be provided. (IV solution of 5% dextrose in water or hypotonic saline may be given.)
-In sodium excess, the primary goal is to dilute the sodium concentrations with sodium-free IV fluids (such as 5% dextrose in water). Promote excretion of the excess sodium by administering diuretics, dietary sodium intake will also be restricted.
-Excessive Sodium loss
-GI loses (diarrhea, vomiting, fistulas, NG suction)
-Renal Losses (diuretics, adrenal insufficiency, NA wasting renal disease)
-Skin losses (burns, wound drainage)
-inadequate sodium intake (fasting diets)
-excessive water gain (excessive hypotonic IV fluids)
-Disease states (SIADH, heart failure, primary hypoaldosteronism)
What is SIADH
-Syndrome of antidiuretic hormone secretion.
-Abnormal retention of water.
Hyponatremia laboratory diagnostic findings
Sodium less than 135
Hyponatremia Clinical Manifestations with decreased ECF volume
Irritability, apprehension, confusion, dizziness, personality changes, tremor, seizures, coma
-Dry mucous membranes
-Postural hypotension, decreased CVP, decreased jugular vein filling, tachycardia, thread pulse
-Cold and clammy skin.
Hyponatremia Clinical Manifestation with normal/increase ECF volume
-headache, apathy, confusion, muscle spasms, seizures, coma.
-Nausea, vomiting, diarrhea, abdominal cramps.
-Weight gain, increased BP, increased CVP
Hyponatremia Nursing Implementation
-Caused by water excess.
-fluid restriction is often all that is needed to treat the problem.
-If severe symptoms occur, small amounts of IV hypertonic saline solution (3% NaCl) are given to restore the serum sodium level while the body is returning to a normal water balance.
-To shrink cells.
-Vasopressin (drugs that block the activity of ADH are used)
-treatment for abnormal fluid loss includes fluid replacement with sodium-containing solutions.
-Major ICF cation
-Critical for many cellular and metabolic functions.
-Regulates intracellular osmolality and promotes cell growth.
-Diet is the source of potassium.
-Comes mainly from fruits, dried fruits, and vegetable.
-Kidneys are the primary routes for K loss.
-There is an inverse relationship between sodium and potassium reabsorption in the kidneys.
Normal levels of Potassium
-Excessive potassium intake (excessive or rapid parenteral administration, K-containing drugs, K-containing salt subs)
-Shift of potassium out of cells (acidosis, tissue catabolic (fever, sepsis, burns), Tumor lysis syndrome
-Failure to eliminate potassium (renal disease, potassium-sparing diuretics, adrenal insufficiency, ACE inhibitors)
Hyperkalemia Laboratory Diagnostic Finding
Potassium > 5.0
Hyperkalemia Clinical Manifestations
-Irritability, anxiety, abdominal cramping, diarrhea, weakness of lower extremities, paresthesias, irregular pulse, cardiac arrest if sudden or severe, cramping leg pain, ventricular fibrillation or cardiac standstill.
Hyperkalemia EKG Changes
-Tall, peaked T wave
-Prolongs PR interval
-ST segment depression
-Loss of P wave
-Ventricular standstill *********
Hyperkalemia Nursing Implementation
-Eliminate oral and parenteral K intake
-Intake Elimination of K (Diuretics, dialysis, KAYEXALATE!!, increased fluid intake can enhance renal K elimination)
-Force K from the ECF to the ICF by administer IV insulin along with glucose, IV Na bicarb in the correction of acidosis
-Reverse the membrane potential effects of the elevated ECF potassium by administering calcium gluconate IV
-In mild cases where the kidneys are functioning, it may be sufficient to withhold K from the diet and IV sources
-Potassium loss due: GI loss (diarrhea, vomiting, fistula, NG suction), Renal Loss (Diuretics, hyperaldosteronism), Dialysis
-Shift of Potassium into Cells (increased insulin, alkalosis, tissue repair, increased epinephrine due to stress)
-Lack of Potassium intake (starvation, diet low in potassium, failure to include potassium in parenteral fluids if NPO)
-Magnesium insufficiency: low magnesium which stimulates renin release/aldosterone which results in potassium excretion.
Hypokalemia Laboratory Findings
Potassium under 3.5
Hypokalemia Clinical Manifestations
-Fatigue, muscle weakness, leg cramps, N/V, paralytic ileus, soft flabby muscles, paresthesias, decreased reflexes, weak irregular pulse, polyuria, hyperglycemia, dysrhythmias
Hypokalemia EKG Changes
-ST segment depression
-Flattened T wave
-Presence of U wave
-enhanced digitalis effect
Hypokalemia Nursing Implementation
-Giving potassium chloride supplements and increasing dietary intake of potassium.
-for severe deficiencies, KCl is never given unless there is urine output of at least 0.5 ml/kg of body weight per hour.
SAFETY when giving Potassium Chloride for Hypokalemia
-KCl given IV must always be diluted.
-never Give KCL IV push or in concentrated amounts
-IV bags containing KCl should be inverted several times to ensure even distribution in the bag.
-Never add KCL to hanging IV bag to prevent giving a bolus dose.
-Preferred max is 40 mEq/L
-Should not excess 10 mEq per hour and should be administered by an infusion pump!
-assess site for phlebitis and infiltration
-Prevents hyperkalemia and cardiac arrest
*****MUST USE HEART MONITOR AND CANNOT CRUSH
Second most abundant intracellular cation.
-50-60% of the body's magnesium is contained in bone
-Functions as a coenzyme in the metabolism of carbohydrates and protein
-Also involved in metabolism of cellular nucleic acids and proteins
-MG balance is related to calclium and potassium balance all three cations should be assessed together.
-Excessive administration of mg for treatment of eclampsia
-Increase in magnesium intake accompanied by renal insufficiency or failure
-Increased intake or ingestion of products containing magnesium when renal insufficiency or failure present
Hypermagnesemia Laboratory Findings
Mg > 2.5
Hypermagnesemia Clinical Manifestations
Lethargy, drowsiness, N/V, deep tendon reflexes are lost, somnolence, respiratory and cardiac arrest
**IMPAIRED DEEP TENDON REFLEXES
-Flushed warn skin
-Decreased pulse and BP
Hypermagnesemia Nursing Implementation
-Prevention (persons with chronic kidney disease should not take mg-containing drugs)
-For emergency IV administration of calcium chloride or calcium gluconate
-Promote urinary excretion with fluid
-Person with impaired renal function will need dialysis
-Diarrhea, vomiting, chronic alcoholism, impaired GI absorption, malabsorption syndrome, prolonged malnutrition, large urine output, NG suction, Poor controlled diabetes mellitus, hyperaldosteronism
Hypomagnesemia Laboratory Findings
Mg < 1.5
Hypomagnesemia Clinical Manifestations
-Confusion, hyperactive deep tendon reflexes, insomnia, tremors, seizures, resembles hypocalcemia, cardiac dysrhythmias
Hypomagnesemia Nursing Implementation
-Oral supplements and increased dietary increase of foods high in Mg.
-Green veggies, nuts, bananas, oranges, peanut butter, chocolate.
-If condition is severe IV or IM mg should be administered but too rapid of administration can lead to cardiac arrest.
-Obtained from ingested foods.
-Functions: transmission of nerve impulses, myocardial contractions, blood clotting, formation of teeth and bone, muscle contractions.
-Changes in serum pH will alter the level of ionized calcium without altering the total calcium level.
-Calcium balance is controlled by the parathyroid hormone, calcitonin (produce in thyroid), and vitamin D (UV rays or diet)
Normal levels of Calcium
-Increased Total Calcium
-Malignancies with bone metastasis, prolonged immobilizations, hyperparathyroidism (two thirds of cases), Vitamin D overdose, thiazide diuretics, milk-alkali syndrome, cancer in plasma cells (Myloma
Hypercalcemia Laboratory Findings
Ca > 10.2
Hypercalcemia Clinical Manifestations
-Lethargy, weakness, depressed reflexes, decreased memory, confusion, personality changes, psychosis
-Anorexia, N/V, bone pain, fractures, polyuria, dehydration.
-Nephrolithiasis (kidney stones)
Hypercalcemia ECG Changes
-Shortened ST segment
-Shortened QT interval
-Increased digitalis effect
Hypercalcemia Nursing Implementation
-Promotion of excretion of calcium in urine by administration of loop diuretic and hydration of the patient with isotonic saline.
-Pt. must drink 3000-4000 mL of fluid daily to promote the renal excretion of calcium to decrease the possibility of kidney stone formation.
-Synthetic calcitonin can also be administered to lowe rserum calcium levels
-A diet low in calcium may be prescribed.
-Mobilization with weight-bearing activity is encouraged to enhance bone mineralization
-Plicamycin and Pamidronate
-Contraction of facial muscles in response to light tap over the facial nerve in front of ear
-USED FOR HYPOCALCEMIA
-Carpal spasm induced by inflating a BP cuff above the systolic pressure for a few minutes
-USED FOR HYPOCALCEMIA
-Decreased total calcium
-Chronic kidney disease
-Vitamin D deficiency
-Decreased serum albumin
-laxative abuse or malabsorption syndromes
-Decreased ionized calcium (alkalosis, excess administration of citrated blood)
Hypocalcemia Diagnostic Findings
Ca < 8.6
Hypocalcemia Clinical Manifestations
-Depression, anxiety, confusion
-Numbness and tingling in extremities and region around mouth.
-hyperreflexia, muscle cramps.
-Chvostek's sign and Trousseau's Sign
-Fracture or respiratory arrest
Hypocalcemia Nursing Implementation
-Treat the underlying causes
-Oral or IV calcium supplements
**Avoid IM to avoid local reactions
-Diet high in calcium
-treat pain and anxiety to prevent hyperventilation (Respiratory alkalosis)
-Measure to promote CO2 retention to help control muscle spasm and other symptoms of tetany until calcium is corrected.
-Primary anion in the ICF and is essential to the function of muscles, RBCs, and the nervous system.
-Is deposited with calcium for bone and tooth structure.
-Involved in acid-base buffering system, the mitochondrial energy production of ATP, cellular uptake and use of glucose, and the metabolism of carbohydrates, proteins, and fats
-Maintenance of normal phosphate balance requires adequate renal functioning because the kidneys are the major route of phosphate excretion.
Relationship between Phosphate and Calcium
A reciprocal relationship exists between phosphorus and calcium.
-High serum phosphorus levels tend to lead to cause a low calcium concentration in the serum.
-Enemas containing phosphorus (fleet enema)
-Large Vitamin D intake
-Sickle cell anemia
Hyperphosphatemia Laboratory Findings
Phosphate > 4.4
Hyperphosphatemia Clinical Manifestations
-Muscles problems, tetany
-Deposition of calcium-phospate precipitates in skin, soft tissue, cornea, viscera, blood vessels.
-Numbness and tingling in extremities
Hyperphosphatemia Nursing Implementation
-Identifying and treating underlying cause
-Restrict foods and fluids high in phosphorus (dairy products)
-Calcium supplements, phosphate-binding agents or gels.
-Nutritional recovery syndrome
-Reversal or treatment of starvation
-Glucose administration or therapy
-Total parenteral nutrition
-recovery from diabetic ketoacidosis
Hypophosphatemia Laboratory Findings
Phospate < 2.4
Hypophoshatemia Clinical Manifestations
-CNS dysfunction (Confusion, Coma)
-Muscle weakness (respiratory muscle weakness and difficulty weaning)
-Renal tubular wasting of Mg, Ca, and bicarb
-Cardiac problems (dysrhythmias, decreased stroke volume)
-Osteomalacia (weak bones)
Hypophosphatemia Nursing Implementation
-Oral supplementation and ingestion of foods high phosphorus
-IV administration of sodium phosphate or potassium phosphate
-Requires monitoring sudden symptoms of hypocalcemia can occur
-Foods that contain phosphates (dairy!!)
Health Problems that lead to acid-base imbalance
-Vomiting and diarrhea
-Respiratory conditions: COPD
Metabolic Acidosis Etiology
-Base Bicarb Deficit
-Acid builds up!!
-Occurs when acid other than carbonic acid accumulates in the body or when bicarb is lost from body fluids.
What can cause Metabolic Acidosis
-Renal tubular acidosis
-In renal disease the kidneys lose their ability to reabsorb HCO3 and secrete H+
Metabolic Acidosis Clinical Manifestations
-Kussmaul Respirations (deep rapid!)
-N/V diarrhea, abdominal pain
-Decrease blood prssure
-Warm, flushed skin
Metabolic Acidosis Laboratory Diagnostic Findings
Metabolic Acidosis Nursing Implementations
-Increase Co2 excretion by the lungs (Kussmaul Respiration)
Metabolic Alkalosis Etiology
-Affect the base bicarb
-Base Bicarb Excess
-Occurs when a loss of acid or a gain in bicarb occurs
-Excess gastric suctioning
-Excess NaHCO intake
Metabolic Alkalosis Laboratory Findings
-Increase plasma pH
-Increase PaCo2 (for compensation)
Metabolic Alkalosis Clinical Manifestations
-Dizziness, irritability, nervousness, confusion, tachycardia, dysrhythmias, N/V, anorexia
-Tetany, tremors, tingling of fingers and toes
-Muscle cramps, hypertonic muscles
-Hypoventilation (Compensatory mechanism by the lungs)
Metabolic Alkalosis Nursing Implementations
-Decreased respiratory rate to increase plasma CO2
-Renal excretion of bicarb
-Want to retain CO2 in the lungs
Respiratory Acidosis Etiology
-Occurs when there is hypoventilation
-Hypoexmia from acute pulmonary disorders
What causes CO2 retention?
COPD, Chest wall abnormality (obesity), severe pneumonia, atelectasis, respiratory muscle weakness, Mechanical Hypoventilation
Respiratory Acidosis Laboratory Findings
-Decrease pH, Increase PaCO2
-High HCO3 (compensatory)
Respiratory Acidosis Clinical Manifestations
Drowsiness, disorientation, dizziness, headache, coma, Decrease BP, V-Fib, warm flushed skin, seizures, hypoventilation with hypoxia
Respiratory Acidosis Nursing Implementations
-Kidneys conserve bicarb and secrete increased concentrations of hydrogen ion into the urine
Respiratory Alkalosis Etiology
-Occurs with hyperventilation
-Too much CO2 is being released
-Hypoxemia from acute pulmonary disorders.
-Hyperventilation (caused by hypoxia, pulmonary emboli, anxiety, fear, pain, exercise, fever, pregnancy)
-Stimulated respiratory center (caused by septicemia, encephalitis, brain injury)
Respiratory Alkalosis Laboratory Findings
-Decrease PaCo2 (or normal)
Respiratory Alkalosis Clinical Manifestations
-Lethargy, light-headedness, confusion, tachycardia, dysrhythmias
-N/V, epigastric pain, tetany, numbness, tingling of extremities, hyperflexia, seizures, hyperventilation
Respiratory Alkalosis Nursing Implementations
-Compensated respiratory alkalosis is rare because of aggressive treatment of causes of hypoxemia
-Shifting of bicarb into cells in exchange for CL may occur.
Hypotonic Maintenance Fluids
-Provides more water than electrolytes
-Dilutes the ECF osmosis then produces movement of water from ECF to ICF
Isotonic Maintenance Fluids
-Expands only the ECF
-Ideal for fluid replacement with ECF volume deficit
What is Lactated Ringers
-Contains Na, K, Cl, Calcium, Lactate (precursor of bicarb) in the same concentrations about as the ECF
-Used to treat losses from burns and lower GI
Hypertonic Maintenance Fluids
-Rises the osmolality of the ECF and expands it
-Useful in hypovolemia and hyponatremia
-Requires frequent monitoring of BP lung sounds, and serum sodium levels.
-Need to monitor for pulmonary edema
-Concentrated dextrose and water solution (10% or higher!)
-Solution greater than 10% must be through a central line
If high patient is in respiratory acidosis
-If low, patient is in respiratory alkalosis
-If high, patient is in metabolic alkalosis
-If low, patient is in metabolic acidosis
Risks for osteoarthritis
-Women (Due to estrogen reduction at menopause)
-Aging (but not normal part of aging)
-Occupational injury (kneeling, bending over)
Etiology and Pathophysiology Osteoarthritis
-Osteoarthritis slowly progressive noninflammatory disorder of the synovial joints
-OA results from cartilage damage that triggers a metabolic response level of chondrocytes.
-Cartilage becomes dull, yellow, granular, soft, and less elastic
-The body's attempt at cartilage repair cannot keep up with destruction that is occurring.
True or False: Osteoarthritis deals with inflammation
Osteoarthritis Diagnostic and Lab Findings
-Detect joint changes through bone scan, CT scan, MRI, detect joint space narrowing bony sclerosis, osteocyte formation through X-Ray.
-Routine blood tests are useful in screening for related conditions and establishing baselines from therapy.
Osteoarthritis Clinical Manifestations
-NOT SYSTEMIC (fatigue, fever, organ involvement)
-Joint pain that worsens with use; relieved by rest.
-Pain worsens in inclimate weather
-Stiffness after, especially in the morning.
-Affects joints asymmetrically.
Grating sensation caused by loose particles of cartilage in the joint cavity. Mostly in knees
Which locations are most common for osteoarthritis
-Knees, hips, DIP (distal interphalangeal) PIP (proximal), MTP (metacarpophalangeal), Spine (Cervical and lower lumbar)
Deformity for Osteoarthritis
-Herberden nodes (DIP)
-Bouchard Nodes (PIP)
-Both are red, swollen, and tender.
-Bow-legged appearance due to knee OA.
-Changes our gait uneven leg length due to loss of cartilage in hip.
Early Stages Osteoarthritis
-Rest relieves the pain
Later Stages Osteoarthritis
Pain with rest and sleep is disturbed because of pain and increased joint discomfort
Collaborative Care for Osteoarthritis
-Balance of rest and activity.
-Rest during periods of acute inflammation.
-Do not keep immobilized for more than one week.
-Modify usual activities
Nondrug therapy for Osteoarthritis
-Heat/Cold: Heat for stiffness, Cold for Inflammation.
-Regular ROM exercises
-Warm up before exercise
Drug Therapy for Osteoarthritis
-Acetaminophen (Tylenol) -1000 mg every 6 hours. DO NOT EXCEED 4 grams a day.
-Capsaicin cream (rub on knees, don't wrap the joints after putting on, wash hand after using it)
-NSAIDS (start at a low OTC dose (200mg) and increase as needed. GI bleeding risks.
-Hyaluronic acid: contributes to viscosity and elasticity of synovial fluid.
Surgical Therapy for osteoarthritis
-Debridement is usually not recommended
-Effective in reducing pain and improving function when it is used to.
-Repair ligaments tears, remove bone bits or cartilage
Overall goals of Nursing management of Osteoarthritis
-Maintain or improve joint function through a balance of rest and activity.
-Use joint protection measures to improve activity intolerance.
-Achieve independence in self-care and maintain optimal role function.
Patient Teaching Osteoarthritis
-Information about nature and treatment of disease and pain management
-Correct posture and body mechanics
-Correct use of assistive devices
-Principles of joint protection and energy conservations.
-Weight and stress management
-Therapeutic exercise program.
Home Care for Osteoarthritis
-Modified for safety
-Remove scatter rugs, provide railing at stairs and bathtubs, use night lights, wear well-fitting support shoes, use assistive devices.
Glucosamine and Chrondroitin
-May stop or slow osteoarthritis progression
-Stimulates cartilage and synovial fluid production
-Suppresses cytokines that cause inflammation and degradation
-Side Effects: Nausea, Heartburn
-Can be suggested to patients who are unable to take celecoxib or other NSAIDS
-Discontinue if no effects after consistent use over 90-120 days
-May increase risk of bleeding
-May decrease effectiveness of insulin or other drugs used to control blood glucose
How to care for a patient with Hearing Impaired
-Draw attention with hand motions, have speakers face in good light,
-Avoid covering mouth
-Avoid chewing, eating
-Maintain eye contact
-Avoid Distracting Environment
-Use touch, move closer to better ear, avoid light behind speaker, speak normally and slowly.
-Do not over exaggerate facial expressions, do not over enunciate, use simple sentences, do not shout, speak in normal voice.
How to care for a patient with visual impaired
-Braille or audio books for reading and cane or guide dog for ambulation. Recommend sitting closer to television and increase lighting
-Always communicate in a normal conversational tone and manner with the patient and address them, not the caregiver.
-Orientation to the environment lessens the patients anxiety or discomfort and facilitates independence
-Identify one object in a new area as the focal point and describe the location of objects in relation to it.
-Stand in front and to one side of patient and offer elbow for the patient to hold.
-Implanted hearing system is available to treat moderate to severe sensorineural hearing loss (sound processor, sensor, and driver)
-Speech (lip) reading can be helpful in increasing communication.
-Cochlear implant is used as a device for people with severe to profound sensorineural hearing loss.
-Should be fitted by an audiologists or a speech and hearing specialist.
-It works as a simple amplifier
-It used to improve hearing with constistent use
-Use of the hearing aid should be restricted to quiet situation in the home. The patient must first adjust to voices and household sounds.
-Adjustment to different environments should be gradual. When the hearing aid is not being used it should be placed in dry, cool area where it will not be damaged.
-Ear molds should be cleaned weekly and a battery last about 1 week.
The use of cochlear implants
-Hearing device for people with severe to profound sensorineural hearing loss. The ideal candidate is one who has become deaf after acquiring speech and language.
-It sends information that covers the entire range of sound frequencies
-The system works through direct bone conduction and integrates with the skull bone over time.
Normal Glucose Levels
IFG Normal levels
Prediabetic IFG Levels
Diabetes IFG Levels
Fasting glucose is over 126
IGT 2-hour plasma glucose levels Prediabetic
Glucose levels are between 140-199 mg/dL
Hemoglobin AIC Normal Values
Hemoglobin AIC Prediabetic
Hemoglobin AIC Diabetic
Diabetic Two-Hour OGTT levels
Over 200 mg/dL
-Glucose load of 75 g is used
What is diabetes the leading cause of?
End-stage renal disease
Nontraumatic lower limb amputations
What is insulin produced by?
B cells from the pancreas
How is insulin released in the body?
-Released continuously in small increments (basal rate) with increased amounts released after food (bolus)
What does insulin do?
Promotes glucose transport from bloodstream across cell membrane to cytoplasm of cell.
-Decreases glucose in the bloodstream.
What tissues are insulin-dependent tissues
Skeletal muscle and adipose tissue
Counterregulatory Hormones Actions
-Oppose effects of insulin
-Increase blood glucose levels
-Provide regulated release of glucose for energy
-Help maintain normal blood glucose levels
-Glucagon, Epinephrine, Growth hormone, Cortisol
What is type 1 diabetes known as?
"Juvenile-onset" or "Insulin-dependent"
Pathophysiology of Type 1 Diabetes
-End result of long-standing process
-Progressive destruction of pancreatic B cells by body's own T cells
Type 1 Diabetes Onset of Disease
Long preclinical period
-Antibodies present for months to yeas before symptoms occur.
Prediabetes Characterized by
-Impaired fasting glucose (IFG) glucose levels between 100-125 mg/dL
-Impaired Glucose Tolerance (IGT) 2 hour plasma glucose levels are between 140-199 mg/dL
-Hemoglobin AIC is in range of 5.7-6.4%
What is the major distinction between type 1 and type 2 diabetes?
Type 2 is the presence of endogenous insulin in type 2
Pathophysiology of Type 2
-Pancreas continues to produce some endogenous (self-made) insulin
-Insulin produced is insufficient or is poorly utilized by tissues.
Contributing Factors for Type 2
-Genetic Mutations (lead to insulin resistance, increased risk for obesity)
Metabolic Syndrome and Diabetes
-Cluster of abnormalities that increase risk for cardiovascular disease and diabetes
-Characterized by insulin resistance
-They have increased insulin levels, increased triglycerides, LDLs, Decrease HDLs, Hypertension.
-Risk factors: Central obesity, sedentary lifestyle, urbanization, certain ethnicities
-MAIN GOALS: Nutrition and Exercise
Facts about Gestational Diabetes
-Develops during Pregnancy
-Detected at 24-28 weeks of gestation
-Usually normal glucose levels at 6 weeks post partum
-Increased risk for C-section, perinatal death, and neonatal complications.
-increased risk for developing type 2 in 5-10 years.
-Therapy: First nutritional, second insulin
Secondary Diabetes Results from?
Clinical Manifestations for Type 1 Diabetes Mellitus
-Polyuria caused by osmotic effect of glucose
-Polydipsia (excessive thirst) caused by osmotic effect of glucose
-Polyphagia (excessive hunger) caused by cellular malnourishment when glucose cannot be used for energy.
Clinical Manifestations for Type 2 Diabetes Mellitus
-Prolonged wound healing
Diabetes Diagnostic Studies
-AIC > 6.5%
-Fasting plasma glucose level > 126 (No caloric intake for at least 8 hours)
-Random or casual plasma glucose measurement >200 mg/dL plus symptoms
-Two-hour OGTT level >200 mg/dL when a glucose load of 75 g is used
Why is the Hemoglobin A1C test useful?
-Shows the amount of glucose attached to hemoglobin molecules over RBC life span (approx. 120 days)
Exercise and Blood Glucose Levels
-Essential part of diabetes management
-Exercises increase insulin receptor sites
-Lowers blood glucose levels
-Contribute to weight loss
-Several small carbohydrate snacks can be taken every 30 minutes during exercise to prevent hypoglycemia.
-The glucose lowering effects of exercise can last up to 48 hours after the activity. Possible that hypoglycemia can occur long after therapy.
When should diabetes patients not exercise?
When blood glucose levels are under 100.
Controlling blood sugar while sick
-Increase blood glucose level, continue regular meal plan.
-Increase noncaloric fluids.
-Continue taking oral agents and insulin.
-Monitor glucose levels every 4 hours.
-If type 1 and have a blood glucose greater than 240 should test urine for ketones every 3-4 hours
-When illness causes patients to eat less than normal, they should take OA's, noninsulin agents, and insulin as prescribed.
Goals of Diabetes Management
-Prevent acute complications
-Delay onset and progression of long-term complications.
Nutritional Therapy for Diabetes
-Type 1 meal plan is based on individuals usual food intake and is balanced with insulin and exercise patterns.
-Type 2 is calorie reduction and manage diet.
How do you pull up insulin ?
Push air in cloudy first
Push air in clear
Pull up clear
Pull up cloudy
Storage of Insulin
-Do not heat/freeze
-In-use vials may be left at room temperature for up to 4 weeks.
-Extra insulin should be refrigerated
-Avoid exposure to direct sunlight
-Prefilled syringes are stable for one week
Fastest absorption site for injections
Why do we want to rotate injections sites?
To prevent lipodystrophy (Fatty masses)
Basal dose of insulin
-Usually at bedtime
-Released steadily and continously
-CANNOT BE MIXED
Boluc Dose of insulin
Short acting/rapid acting before meals.
What is DKA?
-Caused by profound deficiency of insulin
-When there is no insulin in body, glucose cannot be used and the body breaks down fat for energy.
-When fat breaks down, acids (ketones) build up in the blood.
-Very high levels of glucose and high level of acids lead to severe loss of body fluids (dehydration) and other dangerous chemical changes.
What is DKA characterized by?
Precipitating Factors in DKA
-Illness, infection, inadequate insulin dosage, undiagnosed type 1, poor self-management, neglect
What is DKA most likely going to cause due to ketones ?
Signs and Symptoms of DKA
-Lethargy/Weakness (early symptoms)
-Poor skin turgor
-Dry mucous membranes
-Abdominal pain (anorexia, vomiting)
-Kussmaul Respirations (to reverse metabolic acidosis)
-Sweet fruity odor.
How to correct DKA
-IV infusion of 0.45% or 0.9% NaCl to restore urine output and raise blood pressure.
-When blood glucose levels approach 250 mg/dl 5% dextrose needs to be added to regimen to prevent hypoglycemia.
-Insulin is withheld until fluid resuscitation has begun
-Bolus followed by insulin drip.
Lab Findings for DKA
-Blood sugar over 250
-pH less than 7.3
-Bicarb < 16 with ketones
When should a patient test their BS?
-Before meals, two hours after meals, when hypoglycemia is suspected, during illness, before/during/after exercise
Body puts out overdose of insulin which lowers blood sugar and then counterregulatory hormones are released which makes blood sugar increase
High blood sugar in morning after waking because of release of growth hormone and cortisol in predawn hours.
-Used for Grave's Disease
-inhibit synthesis of thyroid hormone
-Improve in 1-2 weeks
-Good results in 4-8 weeks
-Therapy for 6-15 months
-Pt. must be compliant because results take time.
What is the first line anti-thyroid?
PTU. Blocks conversion of T3 and T4.
-It is known to achieve a euthyroid state before surgery and radiation therapy.
-Must be taken 3 times a day and rapidly reduces symptoms
How to treat exophthalmos
-Grave's disease (hyperthyroidism)
-Protrusion of eyeballs from the orbits.
-Impaired drainage from orbit.
-Increased fat and edema in retroorbital tissues.
-Might need help closing eyes.
-Want to elevate the head of the bed.
-Eyelids become dry and irritable.
-Might have to tape eyelids shut.
Preoperative care for bilateral adrenalectomy
-Patients should be in optimal physical condition, control hypertension and hyperglycemia, hypokalemia must be corrected with diet and potassium supplements, high protein diet, teaching depends on surgical approach.
-Should include postoperative care (Nasogastric tube, urinary catheter, IV therapy, Central venous pressure monitoring, leg compression devices)
Postoperative care for Bilateral Adrenalectomy
-Risk of hemorrhage is increased because of high vascularity of adrenal glands.
-Manipulation of glandular tissue may release hormones into circulation.
-BP, fluid balance, and electrolyte levels tend to be unstable because of hormone fluctuations.
-High doses of corticosteroids administered by IV during and several days after surgery.
-report any significant changes in vital signs
-Critical instability ranges from 24-48 hours.
-Morning urine levels of cortisol are measured to evaluate the effectiveness of surgery
What are signs of hypocorticolism
-Vomiting, increased weakness, dehydration, hypotension
What might a patient complain of after having a bilateral adrenalectomy?
Painful joints, pruritus, peeling skin, severe emotional disturbances.
Home care after a bilateral adrenalectomy
Discharge instructions based on lack of endogenous corticosteroids
-Wear medic alert bracelet at all times
-avoid exposure to stress, extremes of temperature and infection.
-Lifetime replacement therapy is required for many patients.
What is levothyroxine (Synthroid)?
-Drug of choice for hypothyroidism
-Must take regularly
-Most carefully monitor patients with cardiovascular disease who take drugs
-Monitor heart rate and report greater than 100 beats/min or an irregular heartbeat ****
What side effects might a patient have on levothyroxine and what should be report?
-Promptly report chest pain, weight loss, nervousness, tremors, and/or insomnia.
-Angina, dysrhythmias, tachycardia, tremor, nervousness, insomnia, heat intolerance, sweating.
What do we use in prep for thyroidectomy ?
-Iodine and PTU
-Large doses rapidly inhibit synthesis of T3 and T4 and block their release into circulation.
Preoperative care for thyroidectomy
-Alleviate signs/symptoms of thyrotoxicosis
-Control cardiac problems
-Assess signs for iodine toxicity
-Oxygen, suction equipment, and tracheostomy tray are available in room.
-want to educate the importance of pain control so patient stays mobile.
-Practice with a spirometer and do deep breathing exercises
-Change positions every 2 hours and cough to prevent pneumonia
-Talk about importance of leg exercises to prevent blood clots
-Support the head while turning in bed to not open incision site
-Practice ROM on neck
-Inform of potential speaking difficulty shortly after surgery.
Postoperative Care for thyroidectomy
-Assess every 2 hours for 24 hours for signs of hemorrhage or tracheal compression (irregular breathing, neck swelling, frequent swallowing, choking)
-Placing the patient in semi fowlers position and supporting the head with pillows (avoid flexion of neck for tear sutures)
-Monitor vital signs and calcium levels (watch for tetany, trousseaus and chvosteks sign)
-Evaluate any speaking difficulties
Discharge instructions after a thyroidectomy
-Thyroid hormone balance should be monitored
-Needs to take a synthetic thyroid hormone for the rest of life to prevent hypothyroidism
-Caloric intake should be reduced
-Adequate iodine is necessary
-Perform regular exercise
-Avoidance of high environmental temperatures
Common clinical manifestations of Cushing Syndrome
-Related to excess corticosteroids
-Weight gain is the most common feature (trunk, face [moon], cervical area, transient weight gain from sodium and water retention.)
-Hyperglycemia, thinning of hair, acne, red cheeks, buffalo hump (neck), moon face, weight gain, purple striae, slow wound healing, incresed body and facial hair, pendulous abdomen, thin skin and subcutaneous tissue, thin extremities with muscle atrophy.
Rescue plan for asthma
Pt. can take 2-4 puffs of a SABA every 20 minutes three times as a rescue plan.
Facts about wheezing
-The louder wheezing may actually occur in the airways that are responding to therapy as airflow in the airway increases.
-As improvement continues, airflow increases, breath sounds increase, and wheezing decreases.
How to help decrease anxiety for a patient having an asthma attack
-Position pt. comfortably (usually sitting to maximize chest expansion)
-Stay with patient (until RR has slowed)
-Talking down can help pt. to remain calm
-Gain eye contact with patient and use a firm, calm voice to coach the pt. in using pursed lip breathing and abdominal breathing.
Intermittent and Persistent Asthma Facts
Patients in all categories of asthma require a short-term "rescue medication"
-normally a SABA
Mild Exacerbation of Asthma
-The patient has difficult breathing only with activity and may feel that they "cant get enough air"
-Relieved at home promptly with a SABA
-Patients are instructed to take 2-4 puffs of albuterol every 20 minutes three times to gain rapid control of symptoms
-Occasionally will need oral corticosteroids to decrease airway inflammation
Moderate Exacerbation of Asthma
-Dyspnea interferes with usual activities and peak flow is 40-60% of personal best
-Usually comes to ED or health care to get help
-Relief is provided with SABA and oral corticosteroids
-Oxygen can be used with both mild and moderate to maintain SpO2 at 90%
Severe and Life-Threatening Asthma Exacerbations
-Focuses on correcting hypoxemia and improving ventilation
-Continuous SABA administration and ipratropium
-Severe: oral systemic corticosteroids are given to those who don't respond to SABA
-Life Threatening: IV corticosteroids are administered and then tapered off rapidly.
-Administered every 4-6 horus although peak effect is not apparent for 4-12 hours.
When do we give IV magnesium sulfate?
-During life threatening asthma
-May be administered to adults with a very low FEV or peak flow less than 40% or those who fail to respond to therapy.
>80% of personal best, stay on meds
50-80% of personal best, indicates caution b/c something is triggering asthma.
<50% of personal best
-Indicates a serious problem
-Action must be taken with a health care provider
-Airway is closing.
Why is pursed lip breathing important?
Prolongs exhalation and thereby prevents bronchiolar collapse and air trapping
What do we teach patients about pursed lip breathing?
-Teach pts to use just enough positive pressure b/c excessive resistance may increase the work of breathing, slows RR, and is easy to learn.
-Relax neck/shoulder, breath in normally through nose for two counts, pucker lips and breath out slowly and gently for a 4 count.
What causes cor pulmonale?
-High blood pressure in the arteries of the lungs is called pulmonary hypertension.
-The right side of the heart has a harder time pumping blood to the lungs when this happens.
-If high pressure continues it puts a strain on the right side of the heart resulting in cor pulmonale
What is cor pulmonale ?
Enlargement of the right ventricle secondary to diseases of the lung, thorax, or pulmonary circulation.
Common symptoms of cor pulmonale?
Dyspnea on exertion, lethargy, and fatigue
Physical signs of cor pulmonale
-Evidence of right ventricular hypertrophy on an ECG and an increase in intensity of the second heart sound.
-BNP levels will be falsely elevated as the cause of the heart failure is the lung disease.
-Dyspnea, distended neck veins, heptatomegaly with upper quadrant tenderness, peripheral edema, weight gain.
Management of cor pulmonale
-Treat the underling condition
-Long term low flow O2 therapy to correct the hypoxemia will reduce vasoconstriction and pulmonary hypertension
-Diuretics and low sodium diet will help decrease plasma volume and reduce the workload on the heart.
-Bronchodilator therapy is indicated if the underlying respiratory problem is due to obstructive disorders.
COPD & Exercise
-Exercise training leads to energy conservation.
-In upper extremities, it may improve muscle function and reduce dyspnea.
-Modify ADLs to conserve energy
-Teach patient to coordinate their efforts and breathing.
-Walk 15 - 20 minutes a day at least 3 times a week with gradual increases
-Can take their B2-Adrenergic Agonist approx 10 minutes before exercising.
-Pulse rate should not exceed 75-80% of maximum HR (220-age)
-Adequate rest should be allowed
-Exercise induced dyspnea is normal but it should return to baseline within 5 minutes after exercise
How long should a patient wait after exercise to take medication
B2-Adrenergic agonist should be taken 5 minutes after exercise to allow the body the try and recover.
Diagnostic Tests COPD
-History and Physical Exam
-Pulmonary function tests: bronchodilators are held before pulmonary function.
-Serum alpha1-antitrypsin levels
-ABGs: Low PaO2, increase PaCO2, Decrease pH, High bicarb found in late stages of COPD (Respiratory acidosis)
-6 minute walk test
-ECG: Show signs of right ventricular failure
What type of mask is the most useful for COPD and why?
-High flow delivery device that delivers fixed concentrations independent of patients respiratory patterns
-Can deliver precise, high flow rates of O2
Best position for taking BP
-Patients should be seated quietly for 5 minutes in a chair, with feet on the floor and arms supported at heart level.
-Appropriately sized cuff to ensure accurate readings.
-Measure BP in the nondominant arm or arm with the higher BP
-Measure first thing in the morning and at night before going to bed.
What to teach patients about prehypertension
-Measure BP regularly
-Lifestyles alterations including exercise, cessation of smoking, restrict sodium, lose weight, restrict cholesterol and saturated fats, moderate alcohol consumption, antihypertensive drugs.
Normal Levels of BP
SBP: < 120
DBP: < 80
Hypertension Stage 1 levels
Hypertension Stage 2 levels
Lifestyle Modifications to decrease BP
-Weight reduction: weight loss of 22 lb (10 kg) may decrease SBP by approx 5-20 mmHg
-DASH eating plan
-Dietary sodium reduction: <2300 mg
-Moderate alcohol consumption (2 for men, 1 for women)
-Physical activity (at least 30 minutes most days of the week)
-Avoidance of tobacco products
-Psychosocial risk factors
Facts about Isolated Systolic Hypertension
-Average SBP >140 with an average DBP <90.
-More common in older adults due to changes in BP patterns
-SBP rises with age
-Caused by loss of elasticity in large arteries from atherosclerosis
-Control decreases the incidence of stroke, heart failure, and death.
Pathophysiology of primary hypertension
-Insulin resistance and hyperinsulinemia (high insulin concentration stimulates SNS activity and impairs nitric oxide, mediated vasodilation)
-Altered renin-angiotensin mechanism
-Endothelial cell dysfunction
-Water and sodium retention.
Risk factors for primary hypertension
-Age, alcohol, cigarette smoking, diabetes, elevated serum lipids, excecss dietary sodium, gender, family history, obesity, ethnicity, sedentary lifestyle, socioeconomic status, stress.
-Elevated BP with a specific cause
-Contributing factors: coarctation of aorta, renal disease, endocrine disorders, neurologic disorders, cirrhosis, sleep apnea.
General instructions for a patient recently diagnosed with hypertension
-Provide numeric value of the patients BP and explain what it means
-Encourage to monitor BP
-Inform that hypertension is usually asymptomatic and symptoms do not reliably indicate BP levels.
-Explain that therapy will not cure but should control hypertension
-Explain the potential dangers of uncontrolled hypertension.
What is heart failure?
-Abnormal clinical syndrome involving cardiac pumping and/or filling
-The heart is unable to produce adequate cardiac output to meet metabolic needs
What is cardiac output?
Amount of blood volume pumped in the body in one minute
What is heart failure characterized by?
-Reduced exercise intolerance
-Diminished quality of life
-Shortened life expectancy.
What is systolic heart failure?
Results from the inability of the heart to pump the blood effectively.
-Inability to pump blood forward
What is the hallmark finding of systolic heart failure?
Decrease in the left ventricular ejection fraction (EF)
Normal is 55-70
Systolic failure is caused by what?
-Impaired contractile function (MI)
-Increased Afterload (Hypertension)
-Cardiomyopathy: weakness to heart muscle
-Mechanical abnormalities (Valve disease)
What is diastolic failure
-Impaired ability of the ventricles to relax and fill during diastole, resulting in decreased stroke volume and CO.
How is diastolic failure diagnosed?
-Based on the presence of pulmonary congestion, pulmonary hypertension, ventricular hypertrophy
What is Diastolic failure caused by?
-Left ventricular hypertrophy from chronic hypertension from overworking
-Aortic stenosis (sitting and clotting)
Compensatory Mechanisms: SNS activation
-First and least effective
-Release of catecholamines (epinephrine and norepinephrine)
What do catecholamines do?
-Increase Heart Rate
-Increase myocardial contractility
-Peripheral vasoconstriction (toes and fingers; causes blood to go to organs)
-This exhausts the heart
Compensatory Mechanisms: RAAS
Kidneys release renin-converts angiotensinogen to angiotensin I-angiotensin I is converted to angiotensin II by a converting enzyme made in the lungs.
What does angiotensin II cause?
-Adrenal cortex to release aldosterone (sodium and water retention)
-Increased peripheral vasoconstriction (increases BP)
Consequence of compensatory mechanisms
-Enlargement of the chambers of the heart that occurs when pressure in the left ventricle is elevated.
-Initially an adaptive mechanism to cope with increasing blood volume
-Eventually this mechanisms becomes inadequate because the elastic elements of the muscle fibers are overstretched and can no longer contract effectively, and CO decreases
Consequence of compensatory mechanisms
-Increase in muscle mass and cardiac wall thickness in response to chronic dilation, resulting in: poor contractility, higher O2 needs, poor coronary artery circulation, risk for ventricular dysrhythmias
Counte regulatory processes
-Released from vascular endothelium in response to compensatory mechanisms
-NO relaxes arterial smooth muscle, resulting in vasodilation and decreased afterload.
What is left-sided HF
Most common from left ventricular dysfunction
(MI, hypertension, CAD, cardiomyopathy- weakening of the heart muscle)
-Backup of blood into the left atrium and pulmonary veins.
-Backs up into lungs.
What happens with an increase in pulmonary pressure in left-sided heart failure?
-Fluid leakage causing: pulmonary congestion, edema, crackles in the lungs.
What is right-sided HF
-HF from left-sided HF, cor pulmonale, right ventricular MI
-Backup of blood into the right atrium and venous systemic circulation
-Want to let the fluid out!!
Medications for right-sided HF
-ACE Inhibitors, Beta blockers, calcium channel blockers, diuretics
Clinical manifestations of right-sided HF
-Jugular venous distention
-Vascular congestion of GI tract
Risks and Etiologies for HF
-CAD and advancing age are the primary risk factors.
-Other factors: HTN, diabetes, cigarette smoking, obestiy, and high serum cholesterol
Diagnostic studies of HF
-History and physical examination
-Lab Studies (Cardiac enzymes, BNP) *Cardiac enzyme if MI is suspected, checking triponen. BNP normal levels are <100
Clinical Manifestations of Heart Failure
-Fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, persistent dry cough, unrelieved with position change.
-Tachycardia, dependent edema
-Sudden weight gain of >3 lbs in 2 days or 3-5 in one week
-Skin dusky cool damp to touch
-Lower extremities are shiny and swollen, diminished or absent hair growth, pigment changes
-Restlessness, confusion, decreased memory
Complications of Heart Failure
-High Risk for fatal dysrhythmias
-HF can lead to severe hepatomegaly
-Renal insufficiency or failure.
-Promotes thrombus/embolus formation, increasing risk for stroke.
**Want to give an anticoagulant
Main treatment goals for HF
-Treat the underlying cause
-Provide treatment to alleviate symptoms
-Improve ventricular function
-Improve quality of life
-Preserve target organ function
-Improve mortality and morbidity
-Take care of edema
What do diuretics do?
-Mobilize edematous fluid
-Reduce pulmonary pressure
-Act on kidneys
-Promotes excretion of sodium and water.
What types of diuretics are usually first choice
What are ACE inhibitors?
-Primary drug of choice for blocking the RAAS system
-Produces a significant increase in CO
-May decrease BP
What are vasodilators?
-Cause vasodilation by acting directly on smooth muscle of the vessel wall
-Relaxes the arteries
-Decreases the work of the heart
-Relaxes the veins and the arteries
What side effects come along with vasodilators?
Headaches and dizziness
Combination drug. Used for treatment of HF in African Americans who are already being treated with standard therapy.
-Only approved for this ethnic group.
-Directly block the negative effects of SNS in the failing heart.
Possible diagnostic findings from HF
-Altered serum electrolytes
-Increased creatinine or liver function tests
-Chest X-ray demonstrating cardiomegaly
-Interstitial pulmonary edema
NANDA for Heart Failure
-Excess fluid volume
-Impaired gas exchange
-Decreased cardiac output
Palliative and End-of-Life Care for HF
-Difficult to assess the prognosis of the disease
-Patients are eligible for hospice when a physician certifies that they are likely to have a life expectancy of 6 months or less.
-Goals are comfort and relief of suffering.
BUN: Blood urea Nitrogen
What does a BMP include?
Sodium, potassium, calcium, magnesium, chloride, BUN
BNP normal levels
What is troponin and levels
Specific enzyme in cardiac muscles
Suspected myocardial injury: 0.5-2.3
Positive for myocardial injury: greater than 2.3
What is creatine kinase and what are normal values?
-Enzyme in heart, skeletal, and brain tissue; released when there is myocardial and muscle injury.
Normal level is 20-200
Isoenzyme primarily in cardiac muscle
4-6% of total creatine kinase are indicative of MI
What is the front-line therapy for heart failure?
Diuretics, ACE inhibitors, beta blockers.
How to treat patients on acute decompensated heart failure (ADHF)
-Circulatory assist devices
-Sodium and possibly, fluid-restricted diet
-High fowler's Position
-O2 by mask or nasal cannula
-Vital signs, urinary output at least q1hr.
-Endotracheal intubation and mechanical ventilation
-Continuous ECG and pulse oximetry monitoring
Teaching for ADHF
-Obtain flu vaccination
-Plan a regular daily rest and activity program.
-Avoid emotional upsets
-Take each drug as prescribed
-Develop to ensure medications have been taken.
-Take the pulse rate each day before taking medications.
-Know target BP limits
-Weigh daily at the same time each day, and wearing similar clothes
-Eat smaller, more frequent meals.
-Avoid extremes of heat and cold
What should a patient report during ADHF
-Weight gain of 3 lbs in a week
-Waking up breathless at night
-Frequent dry, hacking cough, especially when lying down
-Fatigue or weakness
-swelling of ankles, feet, abdomen, face
-Nausea with abdominal swelling, pain, and tenderness
-Dizziness or fainting.
What does an echocardiogram do?
Uses ultrasound waves to record the movement of the structures of the heart.
What does an electrocardiogram due?
-The basic P, QRS, and T waveforms are used to assess cardiac function.
-Deviations from the normal sinus rhythm can indicate abnormalities in heart function.
What essential nutrient does a patient with anemia need?
Clinical Manifestations for Anemia
-Pallor due to decrease hemoglobin and decrease blood flow to skin
ND for Anemia
-Altered nutrition: less than body requirements
-Ineffective self-health management
Mild states of Anemia
-Symptoms include palpitations, dyspnea, mild fatigue
Moderate states of Anemia
-Increase in palpitations, "bouding pulse", dyspnea, "roaring in the ears", fatigue
Severe States of Anemia
-Hemoglobin less than 6.
-Pallor, jaundice, pruritus, blurred vision, glossitis, sensitivity to cold, weight loss, increase in Cardio/resp.
What types of foods are high in iron
-Liver and muscle meats, eggs, dried fruits, legumes, dark green leafy vegetables, whole-grain and enriched bread and cereals, potatoes
Nursing Actions for patients with Anemia
-Want to give blood product transfusions, drug therapy, volume replacement, dietary and lifestyle changes.
-Oxygen therapy, patient teaching.
How to care for a patient with incontinent urine?
-Timed voiding, habit training, prompted voiding.
-Encourage lifestyle modifications: smoking cessation, weight reduction, good bowel regimen, reduction of bladder irritants, fluid modifications.
What is stress incontinence?
-Sudden increase in intraabdominal presssure increase involuntary leakage of small amounts of urine.
-Can occur during coughing, laughing, sneezing, or physical activities such as heavy lifting or exercising.
-Leakage is usually in small amounts and may not be daily.
-Most common in women.
How do we treat stress incontinence?
Pelvic floor exercises-kegels
-Weight loss if pt. is obese
-Cessation of smoking, surgery, child birth trauma, incontinence aids.
-Females: topical estrogen, vaginal pessary (supportive structure to hold muscles up)
-Males: External condom catheter, penile clamp.
What is urge incontinence?
-Urinary urgency precedes with leakage of urine.
-Uncontrolled contraction or overactivity of detrusor muscle
-Over active bladder symptoms
-CNS alteration: tumor, parkinson's
-Bladder alteration: radiation
Treatment of urge incontinence
-History of underling cause (treat)
-Bladder retraining (going on a time)
-Calcium channel blockers
-OXYBUTYNIN (Relaxes bladder)
What is overflow incontinence?
-"Overfull bladder" occurs when the pressure of urine in overfull bladder overcomes sphincter control.
-Underactivity of detrusor muscle
-May not be emptying the bladder well enough.
-Leaking urine during day and night.
How to treat overflow incontinence
-A Adrenergic Blockers
-Bethanechol: Enhance bladder contractions
-Crede maneuver (direct pressure over bladder)
-Vaginal pessary to support pelvic organs
What is functional incontinence?
-Leakage of urine due to cognitive, functional, or environmental factors.
How to treat functional incontinence?
Regular toileting (Every 2-3 hours)
-Easy access to toilet
-Lighting at night
-Clothing alterations (loose)
Whats the most common route of catheterization?
-Involves the insertion of a catheter through the external meatus into the urethra, past the internal sphincter, and into the bladder.
-Use a sterile, closed drainage system in short-term catheterization.
-Empty the collecting bag regularly and keep it below the level of the bladder
-Provide perineal care (once or twice a day and when necessary) including cleaning the meatus-catheter junction with soap and water.
-DO NOT USE LOTION OR POWDER
Treatment for diarrhea
-Obtain stool specimen
-Actions for bowel rest (NPO and liquid diet)
-Instruct patient to inform stall of each stool
-DO NOT TAKE OTC
-Good hygiene care
-Good skin care
Tests for Diarrhea
-Personal contacts, foods, stool specimens for bacteria, fat, blood, and mucous
-Biopsy of intestine
-Measure stool electrolytes
Foods high in fiber?
-Raw vegetables and fruits, beans, cereals (All Bran, oatmeal)
Stage 1 pressure ulcer
Intact skin with nonblanchable (no white spots!)
-Usually over a bony prominence
-Possible indicators could be skin temperature and tissue consistency and pain.
-May appear with red, blue, or purple hues in darker skin tones
Stage 2 pressure ulcer
-Partial thickness loss of dermis manifesting as a shallow open ulcer with a red-pink wound bed without slough.
-May also manifest an intact or open/ruptured serum-filled blister
Stage 3 Pressure Ulcer
-Full thickness tissue loss.
-Subcutaneous fat may be visible but no bone, tendon, or muscle exposed.
-Slough may be present but does not obscure the depth of tissue.
Stage 4 Pressure Ulcer
-Full-thickness loss with exposed bone, tendon, or muscle.
-Slough or eschar may be present on some parts of the wound bed.
-Often includes undermining and tunneling.
Nursing Interventions for Pressure Ulcers
-Assess skin thoroughly at all times
-Use braden every 8 hours
-Remove excessive moisture
-Avoid massage over bony prominences
-Use lift sheets
-Position with pillows or elbow and heel protectors.
-Cleanse skin as soon as incontinence occurs
Treatment of wounds
-Keep ulcer bed moist
-Cleanse with nontoxic solution
-ALWAYS NORMAL SALINE
-use adhesive membrane, ointment, or wound dressing.
-Verify good nutrition
-Teach self-care and signs of breakdowns.
Factors the influence the development of Pressure Ulcers
-The amount of pressure (intensity)
-The length of time the pressure is exerted on skin (duration)
-Ability of patients tissue to tolerate the externally applied pressure.
Risk factors for Pressure Ulcers
-Elevated body temperature
-Low diastolic BP (<60 mmHg)
Acute pain related to headache as evidenced by complain of (describe pain)
What is tension headaches?
-Pain is a band squeezing around head.
-Bilateral, pressure at base of skull.
-Constant squeezing tightness.
-30 minutes-7 days
-May involve sensitivity to light and sound
Diagnostic Studies for tension headache
-Electromyography (EMG) to reveal muscle contraction
-Examination for muscle tension
Drug Therapy for Tension Headache
-Symptomatic: mild-moderate headache treated with asprin, acetaminophen, or an NSAID. Muscle relaxant, sedative, tranquilizer
-Prophylactic: Tricylic antidepressants, topiramate, divalproex
What are migraine headache?
-Unilateral, may switch sides
-Throbbing with synchronous pulse
Migraine headache triggers
-Menstruation, head trauma, physical exertion, fatigue, stress, missed meals, weather, drugs, or food
Clinical manifestations migraine headache
-Generalized edema, irritability, pallor, N/V, sweating, "hibernation"
Migraine Diagnostic Studies
-Based on history, MRI/CT rule out disease/trauma
Migraine Drug Therapy: Symptomatic
-Mild to moderate headache: NSAID, Aspirin, or caffeine-containing combination analgesics
-Moderate to Severe: Triptans first line of therapy. Take when migraine comes. Used to reduce neurogenic inflammation of cerebral blood vessels.
Migraine Drug Therapy: Prophylactic
-Antiseizure, botox, antidepressants.
What are cluster headaches
-Rare form with sharp, stabbing pain.
-Pain in eye and around one eye, radiating to the temple, forehead, cheek, nose, or gums.
-Severe and bone crushing.
-happens when sleeping
-Involves trigeminal nerve
How long do cluster headaches last?
5 min-3 hours.
-Weeks to months at a time followed by periods of remission.
How are cluster headaches diagnosed?
-By history, CT/MRI/MRA or lumbar puncture to rule out disease/trauma, headache diary.
Symptomatic drug therapy for Cluster
-Acute treatment is inhalation of 100% oxygen at 6-8 L/min for 10-20 minutes.
-Sumatriptan also effective for acute cluster headache.
Prophylactic drug therapy for Cluster
-Verapamil, Lithium, Ergotamine, Divalproex, Melatonin, or antiseizure medications
Characterized by bilateral synchronous epileptic discharges in brain from seizure onset.
-NO warning or aura as entire brain is affected.
-Loss of consciousness from seconds to minutes
-Characterized by loss of consciousness and falling
-Body stiffens (tonic phase 10-20 seconds)
-Subsequent jerking of extremities (clonic 30-40)
-Cyanosis, excessive salivaton, and tongue or cheek biting may occur.
Which type of seizure is the most common
Postictal Phase for Tonic-Clonic is characterized by
-Muscle soreness, fatigue
-Patient may sleep for hours
-May not feel normal for days
-No memory of seizure
Etiology For Tonic-Clonic
-Head trauma, drug-related processes, infectious processes, intracranial events, metabolic imbalances, medical disorders
Drug Therapy for Tonic-Clonic
Typical Absence Seizure
-Occurs only in children and rarely into adolescence
-May cease or develop into another type
-Typical symptom is staring spell for only a few seconds and usually goes unnoticed.
Characteristics of Typical Absence Seizure
-Unconsciousness can occur
-Often precipitated by hyperventilation and flashing lights
-When untreated seizures can happen up to 100 times a day
Atypical Absence Seizures
-Involves staring and other signs/symptoms
-Brief warning, peculiar behavior during seizure; confusion after
-Characterized by sudden, excessive jerk of body and extremities
-Can be forceful enough to cause a fall.
-Brief and may occur in clusters.
Primary drugs for myoclonic seizure
-Tonic episode or paroxysmal loss of muscle tone and person falls.
-Consciousness usually returns by time person hits ground and can resume normal activity.
-Risk for head injury
-Involve sudden onset of decreased exterior muscle tone
-Patient often falls
-Increased tone in extensor muscles
-Begins with loss of consciusness and sudden loss of muscle tone
-Followed by limb jerking.
-Referred to partial seizure focal seizures.
-Caused by focal irritation.
-Localized brain involvement
-Symptoms related to brain site
-Can spread to involve entire brain.
Simple Focal Seizures
-Do not involve loss of consciousness.
-Less than one minute
-Motor, sensory, autonomic phenomena, or combo.
-Person remains conscious and experiences unusual feelings or sensations that can take many forms
Complex Focal Seizures
-Involve variety of behavioral, emotional, affective, and cognitive function;
-Longer than a minute
-Most common involves lip smacking and automatism
Characteristics complex focal seizures
-Over a minute, confusion, disoriented
-Dreamlike experience and patients displays strange behavior.
What is Status Epilepticus
Continuous seizures-medical emergency.
-Can damage brain
What is the most dangerous type of status epilepticus
How do we treat status epilepticus
-Monitor brain with EEG.
-Status epilepticus treated with IV lorazepam and diazepam
-Must be followed with long-acting drugs
Education over Anti-Seizure Medication
-Aimed at prevention of seizure activity.
-Monitor drug serum levels**
-Drugs are for lifetime
-Take medications as prescribed
-Report concerns with medications
-Do not adjust/stop medication abruptly.
-Avoid fatigue, loss of sleep
How to wean off of seizure medication
-The patient must be seizure free for a prolonged period of time (like 2-5 years) and have normal neurologic examination and EEG
-Serum levels of drugs should be monitored.
What do you do if your patient is having a seizure?
-Ensure patent airway, protect patient from injury, do not restrain, remove or loosen tight clothing, establish IV access, stay with patient until seizure passes, anticipate medications, suction as needed
-Assess ventilations if patient does not breath spontaenously.
-RECORD HOW LONG SEIZURE LASTS, WATCH FOR TRAUMA, SAFETY FIRST
Types of medications that could be given for seizures
How do we measure for antiseizure med toxicity
-Measure plasma levels of antiseizure drugs
How to care for a patient with Parkinson's Disease
-Maximize neurologic function
-Maintain independence in ADL's
-Promote physical exercise and well-balanced diet which can limit the consequences from decreased mobility
-Teach maintenance of good health, independence, and avoidance of complication.
What type of nursing interventions can we do for a patient with Parkinson's
-Educate to get out of a chair by using arms and placing the back legs on small blocks
-Remove rugs and excess furniture
-Simplify clothing from buttons and hooks
-Elevated toilet seats
-Need food that is easily chewed
-Should be cut into small bites and have several small meals to prevent fatigue
-Provide ample time to avoid frustration
ND for Parkinson's
-Impaired physical mobility
-Imbalanced nutrition: less than body requirements
-Impaired Verbal Communication
-Deficient Diversional Activity
How to relieve bradykinesia
Problem can be alleviated by consciously thinking about stepping over a line on the floor, lifting toes when stepping, one step back and two step forward.
Classic Triad of PD
-Tremor, Rigiditiy, Bradykinesia
-More prominent at rest, diaphragm, tongue, lips, and jaws
-Aggravated by stress/increased concentration
-Resistance to passive ROM, cogwheel rigidity-tension in a muscle which gives way in little jerks when the muscle is passively stretched.
-often c/o tiredness, achy pain
-Slowing down in initiation and execution of movement.
-Blinking, arm swing when walking, swallowing of saliva, facial/hand movement when self-expressing, posture changes-stoop
Nonmotor symptoms of Parkinson's
Depression, anxiety, fatigue, pain, constipation, sleep problems, short-term memory loss, impotence, short-term memory impairment, sleep problems
Beginning stages of Parkinson's
-May involve only mild tremor, slight limp, or decrease arm swing
Later Stages of Parkinson's
May have shuffling, propulsive gait with arms flexed, and loss of postural reflexes
Goals for patients with Parkinson's
-Maximize neurologic function
-Maintain independence in activities of daily living (ADLs) for as long as possible
-Optimize psychosocial well-being
-Promote physical exercise and a well-balanced diet.
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