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SUBJECTIVE DATA: Obtain past health history: Lung cancer, COPD, DM, chronic debilitating disease, malnutrition, altered consciousness, immnosuppression, exposure to chemical toxins, dust or allergens. Medications: Antibiotics, corticosteroids, chemotherapy, or any other immunosuppressants. Surgery or other treatments: Recent abdominal or thoracic surgery, splenectomy, endotracheal intubation, or any surgery with general anesthesia, tube feedings. Obtain health perception health management by asking about smoking, alcohol intake, recent upper respiratory tract infection, and malaise. Nutritional metabolic by asking about anorexia, N/V, chills. Activity exercise by asking about prolonged bed rest or immobility, fatigue, weakness, dyspnea, couch, nasal congestion. Cognitive perceptual by asking if there is pain with breathing, chest pain, sore throat, HA, abdominal pain, and muscle aches.
OBJECTIVE DATA: Fever, restlessness, lethargy, splinting of affected area, tachypnea, pharyngitis, asymmetric chest movements or retraction, decreased excursion, nasal flaring, use of accessory muscles, grunting, crackles, friction rub on auscultation, dullness on percussion over consolidated areas, increased tactile fremitus on palpation, pink rusty purulent green yellow or white sputum, tachycardia, changes in mental status, ranging form confusion to delirium, leukocytosis, abnormal ABGs with decreased or normal PaO2, decreased PaO2, and increased pH initially and later decreased PaO2 and decreased pH, positive sputum on Gram stain and culture, patchy of diffuse infiltrates, abscesses, pleural effusion, or pneumothorax on chest x-ray.
Ask the patient about a previous history of TB, chronic illness, or any immunosuppressive medications. Obtain a social and occupational history to determine risk factors for transmission of TB. Assess the patient for productive cough, night sweats, afternoon temperature elevation, weight loss, pleuritic chest pain, and abnormal lung sounds. If the patient has a productive cough, early morning is the ideal time to collect sputum. Nursing diagnoses could include ineffective breathing pattern, ineffective airway clearance, noncompliance, and ineffective self-health management. The overall goal for the patient with TB is to comply with the therapeutic regimen, have no recurrence of disease, have normal pulmonary function, and take appropriate measures to prevent the spread of the disease. Patients admitted to ER should be triaged for the possibility of TB. Those that are positive would be placed on airborne isolation, receive a medical workup including chest x-ray sputum smear and culture, and receive appropriate drug therapy. Monthly sputum cultures are obtained until 2 consecutive specimens are culture negative. Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated. While still infectious, the patient should sleep alone, spend as much time possible outdoors, and minimize time in congregate settings or on public transportation. Teach the patient about the adherence with the prescribed regimen. Teach the patient to recognize the symptoms that indicate recurrence of TB.
Compression is essential for the treatment of CVI, venous ulcer healing, and prevention of ulcer recurrence. Moist environment dressings are the basis of wound care. Evaluate the nutritional status of patient making sure there is correct protein, calories, and nutrients being consumed. Long term management of venous leg ulcers should focus on teaching the patient self-care measures. Demonstrate the correct application of elastic compression stockings, and have the patient show back the skill. Prescription elastic compression stockings should be worn daily to reduce the occurrence of CVI. Stress the importance of regular replacement every 4-6 months. Instruct them to avoid trauma to the limbs, and teach them proper foot and leg care to avoid additional skin trauma. These patients have dry, flaky,itchy skin because of stasis dermatitis. Daily moisturizing decreases itching and prevents cracking of skin. Venous dermatitis may result from contact with sensitizing products such as antibacterial agents, additives in bandages or dressings, ointments containing lanolin alcohols or benzocaine, and other OTC creams or lotions with fragrance or preservatives. Assess the wound for signs of infection with each dressing change. Be certain to discuss activity guidelines and proper limb positioning. Instruct those with CVI with or without a venous ulcer to avoid standing or sitting from long periods. Standing/sitting for long periods with legs in a dependent position decreases blood flow to extremities. Also instruct them to frequently elevate their legs above the level of the heart to reduce edema. Encourage patients to begin a daily walking program once an ulcer heals.
Focus your attention on the prevention of emboli formation and reduction of inflammation Review with the patient any medications, vitamins, minerals, and dietary and herbal supplements being taken that may interfere with anticoagulant therapy.Depending on anticoagulant ordered, monitor INR, aPTT, ACT, anti-factor Xa levels, CBC, creatinine, factor X levels, hemoglobin, hematocrit, platelet levels and/or liver enzymes. Monitor for and reduce the risk of bleeding that may occur with anticoagulant therapy. Be aware that the risk of bleeding is greater in persons receiving LMWH or UH with an active gastroduodenal ulcer, prior bleeding history, low platelet count, hepatic or renal failure, rheumatic disease, cancer, or age greater than 85 years. Those receiving warfarin with an INR of 5.0 or more are also at increased risk for bleeding. In the event of anti-coagulation above target goals, give reversal agents (Protamine, Vitamin K) or make dosage adjustments as ordered. Early ambulation when compared with bed rest doesn't increase the short term risk of a PE in patients with VTE. In addition, early ambulation after acute VTE results in a more rapid decrease in edema and limb pain, fewer PTS symptoms , and better quality of life. Teach the patient and caregiver the importance of physical activity and assist the patient to ambulate several times a day. Early ambulation is encouraged. For those with acute VTE with severe edema and limb pain, bed rest with limb elevation may initially be prescribed. For home care educate the patient on the importance of elastic compression stockings. If appropriate tell patient to stop smoking and avoid all nicotine products. Instruct them to avoid constrictive clothing. Tell women to stop taking oral contraceptives. The overweight patient needs to not only limit calorie intake but also increase physical activity to achieve and maintain desired weight.
Results from abnormally high production or sustained secretion of ADH. ADH is released despite normal or low plasma osmolarity. This is characterized by fluid retention, serum hypoosmolarity, dilutional hyponatremia, hypochloremia, concentrated urine in the presence of normal or increased intravascular volume, and normal renal function. Most common cause is malignancy, especially small cell lung cancer.

Clinical manifestations: Increases permeability of the renal distal tubule and collecting duct, which leads to the re-absorption of water into circulation. Extracellular fluid volume expands, plasma osmolality declines, glomerular filtration rate increases, and sodium levels decline. Hyponatremia causes muscle cramping, pain, and weakness. Initially the patient displays thirst, dyspnea on exertion, and fatigue. Low urine output and increased body weight. As the serum sodium level falls, manifestations become more severe and include vomiting, abdominal cramps, muscle twitching and seizures. As plasma osmolality and serum sodium levels continue to decline, cerebral edema may occur which leads to lethargy, confusion, headache, seizures, and coma.

Nursing interventions: Be alert for low urine output with a high specific gravity, a sudden weight gain without edema, or a decreased serum sodium level. Monitor intake and output, vital signs and heart and lung sounds. Observe for signs of hyponatremia, including seizures, nausea and vomiting, muscle cramping, and decreased neurologic function. In acute care setting restrict the patient's total fluid intake to no more than 1000 mL/day and obtain daily weights. Position the head of the bed flat or elevated no more than 10 degrees to enhance venous return to the heart and increase left atrial filling pressure, thereby reducing the release of ADH. Frequent turning, positioning, and ROM exercise. Protect patient from injury. Provide frequent oral care.
Caused by a deficiency of production or secretion of ADH or a decreased renal response to ADH. The decrease in ADH results in fluid and electrolyte imbalances caused by increased urine output and increased plasma osmolality. Depending on the cause, it may be transient or a chronic, lifelong condition. Central DI results from an interference with ADH synthesis, transport, or release. Nephrogenic DI results from inadequate renal response to ADH despite presence of adequate ADH. Primary DI results from excessive water intake. Signs and symptoms include: Polydipsia, polyuria, excretion of large quantities of urine, urine osmolality of less than 100 mOsm/kg, serum osmolality is elevated, drinking large amounts of water, fatigued from nocturia and experience weakness. Nursing management includes early detection, maintenance of adequate hydration, and patient teaching for long term management. A therapeutic goal is maintenance of fluid and electrolyte balance. Monitoring of BP, HR, and urine output and specific gravity is essential and may be required hourly in the patient who is acutely ill. Monitor the level of consciousness and for signs of acute dehydration by assessing alertness, response to stimuli, mucous membranes, tachycardia, and skin turgor. Maintain an accurate record of intake and output and daily weights to determine fluid volume status. DDAVP, an analog of ADH, it's the hormone replacement drugs include aqueous vasopressin or lysine vasopressin. Watch for weight gain, headache, depression, restlessness, hyponatremia, pulse, BP, level of consciousness, fluid intake and output, and urine followup.
*Decreased amount of steroid in body
*All 3 classes of adrenal corticosteroids (glucocorticoids, mineralocorticoids, and androgens) are reduced. The most common cause in the U.S. is an autoimmune response. Adrenal tissue is destroyed by antibodies against the patients own adrenal cortex.
Symptoms include: Progressive weakness, fatigue, weight loss, anorexia, bronze colored pigmentation, orthostatic hypotension, hyponatremia, salt craving, hyperkalemia, nausea, vomiting, diarrhea, irritability and depression. Patients with adrenocortical insufficiency are at risk for acute adrenal insufficiency (addisonian crisis), a life threatening emergency caused by insufficient adrenocortical hormones or a sudden sharp decrease in these hormones (tachycardia, dehydration, N/V/D, pain in abdomen, and pain in extremities). Hydrocortisone, the most commonly used form of hormone therapy, has both glucocorticoid and mineralocorticoid properties. During stressful situations, the glucocorticoid dosage is increased ot prevent addisonian crisis. Mineralocorticoid replacement with fludrocortisone is administered daily. Increased salt needs to be added in the diet. Note changes in BP, weight gain, weakness, or other manifestations of Cushing's syndrome. Protect the patient from noise, light, and environmental temperature extremes. The patient cannot cope with the stresses because of the inability to produce corticosteroids. Teach patients to always wear a medical alert bracelet and have emergency kit. Encourage them to monitor stress. Exercise is good and watch levels of Na+ and infections
*Hyperactivity of thyroid gland with sustained increase in synthesis and release of TH. Occurs in women more than men with highest frequency in those 20-40. The most common form is Graves Disease. Other causes include toxic nodular goiter, thyroiditis, excess iodine intake, pituitary tumors, and thyroid cancer.

*Clinical Manifestations: Systolic hypertension, increased rate and force of cardiac contractions, bounding rapid pulse, increased cardiac output, increased respiratory rate, dyspnea on mild exertion, increased appetite, thirst, weight lost, increased peristalsis, warm smooth moist skin, hair loss, clubbing of fingernails, fine silky hair, fatigue, muscle weakness, nervousness, exhaustion, decreased fertility, intolerance to heat, elevated basal temperature, exophthalmos, goiter, and rapid speech.

*Comparison of hyperthyroidism in younger and older adults:
-Grave's Disease in > 90% of cases
-Nervousness, irritability, Weight loss, heat intolerance, Warm, moist skin
-Goiter presents >90% of cases
-Exophthalmos present in 20-40% of cases
-Tachycardia and palpitations Common but without heart Failure.
-Graves diseases or toxic nodular goiter
-Anorexia, weight loss, apathy, lassitude, depression, confusion
-Goiters present in about 50% of cases
-Exophthalmos less common
-Angina, dysrhythmia, heart failure may occur

*The 2 primary lab findings used to confirm the diagnosis are decreased TSH levels and elevated free thyroxine (free T4) levels.

*Therapy includes antithyroid drugs, iodine, B-Adrenergic blockers, radioactive iodine therapy, and thyroidectomy. Thyroidectomy is indicated for those with a large goiter causing tracheal compression, been unresponsive to antithyroid therapy or has thyroid cancer.

*For acute thyrotoxicosis: administer medications that block TH production and the SNS. Provide supportive therapy, including monitoring for cardiac dysrhythmias and decompensation, ensuring adequate oxygenation, and administering IV fluids to replace fluid and electrolyte loss.
*Place the patient in a cool room away from very ill patients and noisy, high traffic areas, using light bed coverings and changing linen frequently if the patient is diaphoretic and encouraging and assisting with exercise involving large muscle groups to allow the release of nervous tension and restlessness.
*When subtotal thyroidectomy is treatment of choice, the patient must be adequately prepared to avoid postoperative complications. Before surgery, antithyroid drugs, iodine and b adrenergic blockers may be given to achieve a euthyroid state. Iodine reduces vascularization of the thyroid, reducing risk of hemorrhage. Assess the patient for signs of iodine toxicity such as swelling of the buccal mucosa and other mucous membranes, excessive salivation, N/V, skin reactions. If toxicity occurs, discontinue iodine administration and notify HCP.
* Postop complications include hypothyroidism, damage to or inadvertent removal of parathyroid glands causing hypoparathyroidism and hypocalcemia, hemorrhage, injury to the recurrent or superior laryngeal nerve, thyrotoxicosis and infection.
*Assess patient every 2 hours for 24 hours for signs of hemorrhage or tracheal compression, place patient in semi fowlers position, and monitor vitals and calcium levels. Check for tetany secondary to hypoparathyroidism. Monitor Trousseau's sign and Chvostek's sign.
Deficiency of TH that causes a general slowing of the metabolic rate. Iodine deficiency is the most common cause. The most common cause of primary hypothyroidism is atrophy of the thyroid gland. This is the end result of Hashimoto's thyroiditis or Graves' Disease. Cretinism is when it occurs in infancy. The symptoms include slowing of body processes, fatigued, lethargic, personality and mental changes, impaired memory, slowed speech, decreased initiative, depressed, weight gain, decreased cardiac contractility, decreased cardiac output, low exercise tolerance, SOB, anemia, bruise easily, myxedema, disturbed appearance. Common features of myxedema include dull, puffy skin, coarse, sparse hair, periorbital edema and prominent tongue. Levothyroxine is DOC to treat and is taken forever. You should carefully monitor patients taking this for cardiovascular issues, monitoring HR and report pulse greater than 100, promptly report chest pain, weight loss, nervousness, tremors, and insomnia. Monitor the patients progress by assessing vitals, body weight, fluid intake and output, and visible edema. Cardiac assessment is especially important because the cardiovascular response to HT determines the medication regimen. Note energy level and mental alertness, which should increase within 2-14 days and continue to improve steadily to normal levels. Teach the patient to immediately contact HCP if manifestations of overdose occur, such as orthopnea, dyspnea, rapid pulse, palpitations, chest pain, nervousness, or insomnia.
Regular consistent exercise is an essential part of diabetes and prediabetes management. ADA recommends performing 150 min/week of a moderate-intensity aerobic physical activity. They also encourage people with type 2 to perform resistance training 3 times a week in the absence of contraindications. Exercise decreases insulin resistance and can have a direct effect on lowering blood glucose. It contributes to weight loss, which also decreases insulin resistance. The therapeutic benefits of regular physical activity may result in a decreased need for diabetes medications to reach target blood glucose goals. Regular exercise can help reduce triglyceride and LDL cholesterol levels, increases HDL, reduce BP, and improve circulation. New exercise programs for diabetics should be started only after medical approval and they should start slow with a gradual progression towards desired goal. Patients who use insulin, sulfonylureas, or meglitinides are at an increased risk for hypoglycemia when they increase physical activity, especially if they exercise at the time of peak drug action or eat too little to maintain adequate blood glucose levels. This can occur if a normally sedentary patient with diabetes has an unusually active day. The glucose lowering effects of exercise can last up to 48 hours after the activity so its possible for hypoglycemia to occur long after the activity. Its recommended that patients who use meds that can cause hypoglycemia schedule exercise an hour after a meal or they have a 10-15 g carb snack and check their blood sugar before exercising. They can eat small carb snack every 30 min during exercise to prevent hypoglycemia. Patients using meds that place the at risk for hypoglycemia should always carry a fast acting source of carbs, such as glucose tablets or hard candies when exercising. Although exercise is generally helpful to blood glucose levels, strenuous activity can be perceived by the body as a stress, cause a release of counterregulatory hormones and a temporary elevation of blood glucose. In a person with type 1 diabetes who is hyperglycemic and ketotic, exercise can worsen these conditions. Therefore vigorous activity should be avoided if BS is over 250 and ketones are in urine. If hyperglycemia is present without ketosis, its not necessary to postpone exercise.
Subjective Data:
o It is important to assess for the presence of abdominal pain, nausea and vomiting, diarrhea, constipation, abdominal distention, jaundice, anemia, heartburn, dyspepsia, changes in appetite, hematemesis, food intolerance or allergies, excessive gas, bloating, melena, hemorrhoids, or rectal bleeding.
o Ask the patient about (1) history or existence of diseases such as gastritis, hepatitis, colitis, gallbladder disease, peptic ulcer, cancer, or hernias; (2) weight history; (3) past and current use of medications including herbal products and prior hospitalizations for GI problems.
o Many chemicals and drugs are potentially hepatotoxic and result in significant patient harm unless monitored closely.

Objective Data
o Physical examination
Mouth. The lips are inspected for symmetry, color, and size. The lips, tongue, and buccal mucosa are observed for lesions, ulcers, fissures, and pigmentation.
Abdomen. First inspect, then auscultate, percuss, and lastly palpation. The skin is assessed for changes (color, texture, scars, striae, dilated veins, rashes, and lesions), symmetry, contour, observable masses, and movement.
Auscultation of the four quadrants of the abdomen includes listening for increased or decreased bowel sounds and vascular sounds.
Percussion of the abdomen is done to determine the presence of distention, fluid, and masses. Lightly percuss all four quadrants of the abdomen in a clockwise fashion.
Light palpation is used to detect tenderness or cutaneous hypersensitivity, muscular resistance, masses, and swelling.
Deep palpation is used to delineate abdominal organs and masses. Rebound tenderness indicates peritoneal inflammation.
During inspection the liver edge should feel firm, sharp, and smooth. The surface and contour and any tenderness is described.
The spleen is normally not palpable. If palpable, manual compression of an enlarged spleen may cause it to rupture.
The perianal and anal areas are inspected for color, texture, lumps, rashes, scars, erythema, fissures, and external hemorrhoids.
Each patient with a history of prolonged and persistent nausea or vomiting requires a thorough nursing assessment before you develop a specific plan of care. Although numerous conditions are associate with N/V, you should have a basic understanding of the more common conditions and be able to identify the patient who is at high risk. Knowledge of the physiologic mechanisms involved in N/V is important in the assessment process. Past health history should include past GI disorders, chronic indigestion, food allergies, pregnancy, infection, CNS disorders, recent ravel, bulimia, metabolic disorders, cancer, cardiovascular disease, renal disease. Obtain history of medications including antiemetics, digitalis, opioids, ferrous sulfate, aspirin, aminophylline, alcohol, antibiotics, general anesthesia, and chemo. Ask about any past or recent surgeries. Within nutritional-metabolic pattern, ask about the amount, frequency, character, and color of the vomit, if there are any dry heaves, anorexia or weight loss. Ask about any weakness or fatigue regarding activity-exercise patterns. Cognitive-perceptual pattern asking about abdominal tenderness and pain. Ask about any stress or fear that they feel. Objective data includes checking for lethargy, sunken in eyeballs, pallor, dry mucous membranes, poor skin turgor, the amount frequency, character (projectile), content and color of vomit (red, coffee grounds, green-yellow). Assess Urinary output for it being concentrated and decreased in amount. Possible diagnostic findings could include serum electrolytes (esp hypokalemia), metabolic alkalosis, abnormal upper GI findings on endoscopy or abdominal x-rays.
The use depends on the cause of N/V. Because the cause cannot always be readily determined, use drugs with caution. Using antimetics before determining the cause can mask the underlying disease process and delay diagnosis and treatment. Many antiemetic drugs act in the CNS via the CTZ to block neurochemicals that trigger N/V. Be cautious with Promethazine Injection: it should not be administered into an artery or under skin because of risk of severe tissue injury including gangrene; when it is administered IV, it can leach out from vein and cause serious damage to surrounding tissue; deep muscle injection is preferred route of injection administration. Also be cautious with Metoclopramide (Reglan): Chronic use or high doses can carry the risk of tardive dyskinesia; tardive dyskinesia is a neurologic condition characterized by involuntary movements; with discontinuation of this drug, the tardive dyskinesia persists. The serotonin receptor antagonists are effective in reducing cancer chemotherapy induced vomiting caused by delayed gastric emptying and also the N/V related to migraine HA and anxiety. Serotonin antagonists are also used in prevention and treatment of postop N/V. Decadron is used in the management of both acute and delayed cancer chemo induced emesis, usually in combination with other antiemetics such as Zofran, and Emend. Marinol is an orally active cannabinoid that is used alone or in combination with other antiemetics for the prevention of chemo induce emesis. Because of the potential for abuse, as well as drowsiness and sedation, this is used only when other therapies aren't effective. Acupressure or acupuncture at specific points can be effective. Some patients use herbs such as ginger and peppermint oil. Relaxation breathing exercises, changes in body position, or exercise may be helpful for some.
During an acute exacerbation of an ulcer, the patient often complains of increased pain and nausea and vomiting, and some may have evidence of bleeding. Many patients attempt to cope with the symptoms at home before seeking medical assistance During acute phase pt may be NPO for a few days, have a NG tube inserted and connected to intermittent suction and have IV fluid replacement. Explain to pt reasons for therapies so they understand that the advantages far outweigh any temporary discomfort. Regular mouth care alleviates the dry mouth. Cleansing and lubrication of the nares facilitate breathing and decrease soreness. Analysis for blood, bile, or other substances. When stomach is empty of gastric secretions the ulcer pain diminishes and ulcer healing begins. The volume of fluid lost, the patient's signs and symptoms and lab test determine the type and amount of IV fluids administered. Be aware that other health problems may be adversely affected by the type or amount of fluid used. Take vitals initially and at least hourly to detect and treat shock. Physical and emotional rest is conductive to ulcer healing. the pt's immediate environment should be quiet and restful. the use of a mild sedative or tranquilizer has beneficial effects when pt is anxious and apprehensive. Use good judgement before sedating a person who is becoming increasingly restless because the drug could mask the signs of shock secondary to upper GI bleeding. If pt condition improves without worsening of symptoms, the regimen outlined for conservative therapy is followed. However, complications such as hemorrhage, perforation, and obstruction can occur.
Many cases can be prevented by increasing dietary intake, fluid intake and exercise. Laxatives and enemas may be used to treat acute constipation but are used cautiously because overuse leads to chronic constipation. The choice of laxative or enema depends on the severity of constipation and patients health. Daily bulk forming preparations are used to prevent constipation because they work like dietary fiber and don't cause dependence. Stool softeners are also used. Bisacodyl tablets and suppositories, milk of magnesia, and lactulose act more rapidly. They are also more likely to cause dependence. Methylnaltrexone is a peripheral opiate receptor antagonist that decreases constipation caused by opioid use. The drug is administered SC. This does not block analgesic effects.Enemas are fast acting and beneficial for immediate treatment of constipation, but must be used cautiously. Soapsuds enemas produce inflammation of colon mucosa, tap water enemas can potentially lead to water intoxication and sodium phosphate enemas may cause electrolyte imbalances in pt with cardiac and renal problems. Biofeedback therapy may benefit pt who are constipated as a result of anismus (uncoordinated contraction of anal sphincter during straining). For the pt whose perceived constipation is RT rigid beliefs regarding bowel function, initiate a discussion about these concerns. Give appropriate info on normal bowel function and discuss the adverse consequences of excessive use of laxatives and enemas. A pt with severe constipation RT bed immobility or mechanical disorders may require more intensive treatment. Diagnostic studies include anorectal manometry, GI tract transit studies, and sigmoidoscopic rectal biopsies. In a pt with unrelenting constipation, a subtotal colectomy with ileorectal anastomosis may be performed.
Ingestion of infectious organisms is the primary cause of acute diarrhea. Viruses cause most cases of infectious diarrhea in the U.S. Although viral infections can be deadly, they are usually short lived (48hrs) and mild. Therefore most pt rarely seek treatment. Bacterial infections are also common. E coli is the most common cause of bloody diarrhea in the U.S. ITs transmitted by inadequately cooked beef or chicken contaminated with the bacteria or in fruits and veggies exposed to contaminated manure. Other pathologic E coli strains are endemic in developing countries and are common causes of travelers diarrhea. Giardia lamblia is the most common intestinal parasite that causes diarrhea in the US. Infectious organisms attack the intestines in different ways. Some alter secretion and/or absorption of the enterocytes of the small intestine without causing inflammation. Others impair absorption by destroying cells, cause inflammation in the colon, and produce toxins that also cause damage. Organisms enter the body in contaminated food or contaminated drinking water.Travelers often get diarrhea, especially if they travel to countries with poorer sanitation. AN infection can also be transmitted from one individual to another via the fecal oral route. An individual's susceptibility to pathogenic organisms is influenced by age, gastric acidity, intestinal microflora and immunocompetence. Older adults are most likely to suffer life threatening diarrhea. Since stomach acid kills ingested pathogens, medications designed to decrease stomach acid increase the likelihood that pathogens will survive. The healthy human colon contains short chain fatty acids and bacteria such as E coli. These organisms aid in fermentation and provide a microbial barrier against pathogenic bacteria. Antibiotics kill off the normal flora, making the individual more susceptible to pathogenic organisms. C diff is the most serious antibiotic-associated diarrhea and is becoming more prevalent. Probiotics may be helpful in preventing antibiotic induced diarrhea in some pts. People who are immunocompromised because of disease or immunosuppressive meds are susceptible to GI tract infection. Patients who are immunocompromised received jejunal enteral nutrition are especially prone to C. diff and other foodborne infections. Jejunostomy and nasointestinal feedings which bypass stomachs acid environment do not contain the poorly digestible fiber that is necessary for the survival of normal colonic bacteria. Not all diarrhea is due to infection. Drugs and specific food intolerances can cause diarrhea. ALso, large amounts of undigested carbs in the bowel produce an osmotic diarrhea that promotes rapid transit and prevents absorption of fluid and electrolytes. Lactose intolerance and certain laxative produce an osmotic diarrhea. Bile salts and undigested fats also lead to excessive fluid secretion in the GI tract. THe diarrhea from celiac disease and short bowel syndrome results from malabsorption in the small intestine.
A thorough and accurate assessment is an essential first step as you begin care of the patient admitted with upper GI bleeding. The patient may not be able to provide specific information about the cause of the bleeding until immediate physical needs are met. Perform an immediate assessment while you are getting pt ready for initial treatment. the assessment includes the patients LOC, vitals, skin color, and capillary refill. Check the abdomen for distention, guarding and peristalsis. Immediate determination of vitals indicates whether the patient is in shock from blood loss and also provides a baseline BP and pulse for monitoring the progress of treatment. Signs and symptoms of shock include low BP, rapid weak pulse, increased thirst, cold clammy skin and restlessness. Monitor the pt vitals every 15-30 minutes and inform health care provider of any significant changes. Once the immediate interventions have begun, the pt or caregiver should answer the following questions: Is there a history of previous bleeding episodes? Has the patient received blood transfusions in the past and were there any transfusion reactions? Are there any other illnesses or medications that may contribute to bleeding or interfere with treatment? Does the patient have a religious preference that prohibits the use of blood or blood products? Subjective data should include gathering of information: precipitating events before bleeding episode, previous bleeding episodes and treatment, PUD, esophageal varices, esophagitis, acute and chronic gastritis, stress related mucosal disease. Medication gathering for usage of aspirin, NSAIDs, corticosteroids, and anticoagulants. Ask about family history of bleeding, smoking and alcohol use. Any N/V, weight loss or thirst? Diarrhea, black tarry stools, decreased urine output and sweating? Weakness, dizziness and fainting with activity. Epigastric pain or abdominal cramps. Any acute or chronic stress. For the objective assessment look for this material: fever, clammy cool pale skin, pale mucous membranes, nail beds and conjunctiva, spider angiomas, jaundice, peripheral edema, rapid shallow respirations, tachycardia, weak pulse, orthostatic hypotension, slow cap refill, red or "coffee ground" vomit, tense rigid abdomen, ascites, hypoactive or hyperactive bowel sounds, black tarry stool, decreased urine output or concentrated urine, agitation, restlessness, decreased LOC. Possible diagnostic findings could include decreased hematocrit and hgb, hematuria, guaiac positive stools, emesis or gastric aspirate, decreased levels of clotting factors, increased liver enzymes, and abnormal endoscopy results.
Approach the pt in a calm manner to help decrease the level of anxiety. Use caution when administering sedatives for restlessness because it is one of the warning signs of shock and may be masked by the drugs. Once an infusion has been started, maintain the IV line for fluid or blood replacement. An accurate intake and output record is essential so that the patient's hydration status can be assessed. Measure the urine output hourly. If the patient has a central venous pressure line or pulmonary artery catheter in place, record these readings every 1-2 hours. Hemodynamic monitoring provides an accurate and quick assessment of blood flow and pressure within the cardiovascular system. Observe the older adult or the patient with a history of cardiovascular problems closely for signs of fluid overload. However, volume and pulmonary edema are concerns in all patients who are receiving large amounts of IV fluids within a short time.Auscultate breath sounds and closely observe the respiratory effort. Keep HOB elevated to provide comfort and prevent aspiration. ECG monitoring is also used to evaluate cardiac function. Close monitoring of vitals, especially in the pt with cardiovascular disease, is important because dysrhythmias may occur. When an NG tube is inserted, pay special attention to keeping it in proper position and observe the aspirate for blood. Although room temperature, cool, or iced gastric lavage is used in some institutions, its effectiveness as a treatment for upper GI bleeding is questionable. when lavage is used, approximately 50-100 mL of fluid is instilled at a time into the stomach. The lavage fluid may be aspirated from the stomach or drained by gravity. When aspiration is the method used, its important not to aspirate if resistance is felt. The tip of the NG tube may be up against the gastric mucosal lining. When resistance is a factor, use the gravity method. Assess the stools for blood. Black tarry stools are not usually associated with a brisk hemorrhage but are indicative of prolonged bleeding. Menses an bleeding hemorrhoids should be ruled out as possible sources of blood in the stools. When vomit contains blood but the stool contains no gross or occult blood, the hemorrhage is considered to have been of short duration. When oral nourishment is begun, observe the pt for symptoms of N/V and a recurrence of bleeding. Feedings initially consist of clear fluids and are given hourly until tolerance is determined. Gradual introduction of foods follows if the pt exhibits no signs of discomfort. When the hemorrhage is the result of chronic alcohol abuse, closely observe pt for delirium tremens as withdrawal from alcohol takes place. Symptoms indicating the beginning of delirium tremens are agitation, uncontrolled shaking, sweating and vivid hallucinations.
• Past Health History: question the pt about history or presence of diseases related to renal problems. (HTN, DM, gout and other metabolic problems, connective tissue disorders(SLE, Sclerodermal) skin or URI of strep orgin, TB, hepatitis, nurological disorders (stroke/back injury) or trauma.) Note specifically urinary problems such as cancer, infections, BPH, and calculi.
• Medication: past and current. Include over the counter drugs, prescriptions, and herbs. Many drugs are nephrotoxic. Certain drugs alter Urine output and character (dieretics). A number of drugs change the color of the urine (Macrodantin and Phenazopyridine). Anticoagulants may cause blood in the urine. Many antidepressant, CCB, antihistamine, and drugs for MS effect the bladders ability to relax and flex.
• Surgery: previous urinary problems, including problems with pregnancy. Past sugeries, pelvic surgery, or urinary track interments, ask about any radiation or chemotherapy treatment.
• Health perception health management pattern: Abnormal kidney function may be suggested by changes in weight and appetite, excess thirst, fluid retention, and complains of HA, pruritus, blurred vision, or "feeling tires all the time". An older adult may report unlocalized discomfort and malaise as sypt. Of a UTI. Family members may report disorientation/ confusion in old pt with UTI. Take an occupational history bc exposure to certain chemicals effect the kidneys and urinary system. Aromatic amines and some organic chemicals may increase bladder cancer. Textile workers, painters, hairdressers, and industrial workers have high incidence of bladder tumors. Cigarettes may cause cancers. Inspect where the pt has lived. Pt living in certain spots in the US (Great Lakes, SW, SE) have higher incident of urinary calcui, possibly by the high mineral content of soil and water. Pt from Africa and eastern countries for parasites can cause cancers.
• Nutritional-metabolic pattern: the quantity and types of fluid a pt drinks are important in relation to urinary tract disease. Dehydration leads to UTIs, calculi, and kidney failure. DAIRY products high in PROTIEN may lead to calculi formation. Asparagus my cause urine to smell. Beets cause red urine. Caffeine, alcohol, soda, sweeteners, and spicy food may irritate the Urinary Tract. Green teas may cause diereses. Fluid retention may manifest as weight gain. It is important to gather information on vitamins, minerals, and supplements.
• Elimination: Question voiding frequencys, pelvic organ prolaspe, vaginal prolapsed, may cause a change in frequency, urgency, and incontinence. Other things to question: Hesitancy, change in stream, retention, dysuria, nocturia, dribbling. If blood is present in urine, it needs to be determined at what stage the blood is mixing with the urine. Problems with fecal incontinence may signal bladder problems because of the shared nerve pathway. Constipation and impaction and cause urinary obstruction causing inadequate bladder emptying, overflow incontinence and infection. Assess for patients use of catheters, valsalva maneuver, and pressing on the lower abd (crede's method).
• Activity-Excersise pattern: Assess level of activity. A sedentary person has stastis urine and is more prone to infection than an active person. A person with demineralization due to lack of activity causeing high Ca levels. An active person may find activity irritates their problems. pt with weak pevic floor muscles or prostate surgery may leak urine while doing activity.
• Sleep-Rest Pattern: Nocturia that can lead to sleep deprivation, daytime sleepiness or fatigue. Nocturia may be related to polyuria, secondary to kidney disease, poorly controlled DM, alcoholism, excess fluid intake, and obstructive sleep apnea. Assess the pt patterns and pain if they are affected by nocturia. Getting up once during the night is normal. If more than once assess there activity and amount of liquid before bedtime.
• Cognitive perceptual pattern: levels of mobility, visual acuity, and dexterity are important factors to determine for a pt to manage his or her own care at home. Determine if the pt is alert and able to follow instruction. Document the cause and previous management of incontinence. Pain is a big problem with renal issues. Document location, character and duration. Symptoms without pain are also significant bc many UT tumors are painless in early stages.
• Urinary problems may cause selfesteem issues and negative body images. This could also cause a problem with sexual function. Urinary problems can effect a pt ability to work and relationships with other. Chronic dialysis may make a pt unemployable.
• Inspection: assess for changes in the following:
• Skin: pallor, yellow-gray cast, excoriations, changes in turgor, bruises, texture (e.g., rough, dry skin)
• Mouth: stomatitis, ammonia breath odor
• Face and extremities: generalized edema, peripheral edema, bladder distention, masses, enlarged kidneys
• Abdomen: striae, abdominal contour for midline mass in lower abdomen (may indicate urinary retention) or unilateral mass (occasionally seen in adult, indicating enlargement of one or both kidneys from large tumor or polycystic kidney)
• Weight: weight gain secondary to edema; weight loss and muscle wasting in renal failure
• General state of health: fatigue, lethargy, diminished alertness
• Palpation: The kidneys are posterior organs protected by the abdominal organs, the ribs, and the heavy back muscles. A landmark useful in locating the kidneys is the costovertebral angle (CVA) formed by the rib cage and the vertebral column.
• The normal-sized left kidney is rarely palpable because the spleen lies directly on top of it.
• Right kidney may be palpable (see next slide).
• The urinary bladder is normally not palpable unless it is distended with urine. If the bladder is full, it may be felt as a smooth, round, firm organ and is sensitive to palpation.
• To palpate the right kidney, place your left (anterior) hand behind and support the patient's right side between the rib cage and the iliac crest (Fig. 45-6).
• Elevate the right flank with the left hand. Use your right hand to palpate deeply for the right kidney.
• The lower pole of the right kidney may be felt as a smooth, rounded mass that descends on inspiration. If the kidney is palpable, note its size, contour, and tenderness.
• Kidney enlargement is suggestive of neoplasm or other serious renal pathologic conditions.
• The bell of the stethoscope may be used to auscultate over both CVAs and in the upper abdominal quadrants. With this technique, the abdominal aorta and renal arteries are auscultated for a bruit (an abnormal murmur), which indicates impaired blood flow to the kidneys.
• Use the diaphragm of the stethoscope to auscultate the bowels because they too may affect the urinary system.
1. Urinalysis: General exam of urine to establish baseline info or provide data to establish a tentative diagnosis and determine whether further studies are needed. You should try to obtain first urinated morning specimen. Ensure specimen is examined within 1 hour of urinating. Before collecting, wash perineal area.

2. Creatinine Clearance: Creatinine is a waste product of protein breakdown. Clearance of creatinine by kidney approximates the GFR. Its reference interval is 70-135. You should collect 24 hr urine. Discard first urination when started. Save from all urinations in 24 hours. Instruct patient to urinate at end of 24 hours and add the specimen to collection.

3. Urine Culture "clean catch" "midstream": Confirms suspected UTI and identifies causative organisms. Normally bladder is sterile but urethra contains bacteria and a few WBCs. IF properly collected, <10 to the 3rd indicate no infection. And greater than 10 to the 5th indicate infection. Contain sterile field for catch of urine. Touch only the outside of the container. Teach pt what to do.

4. BUN: Used to detect renal problems. Concentration of urea in blood is regulated by rate at which kidney excretes urea. Reference interval is 6-20. While interpreting be aware that nonrenal factors may cause increase. (ex. Rapid cell destruction from infections, fever, GI bleed, trauma, athletic activity, corticosteroid theropy, and muscle breakdown.

5. Creatinine: {0.6-1.3} More reliable than BUN as a determinant of renal function. It is end product of muscle and protein metabolism and is released at a constant rate. Explain the test and watch for post puncture bleeding.

6. IVP: Visualizes urinary tract after IV injection of contrast media. Presence, position, size and shape of kidneys ureters and bladder are evaluated. Cysts tumors lesions and obstructions cause a distortion in normal appearance of these. Patient with significantly decreased renal function should not have IVP because contrast media can be nephrotoxic and worsen renal function. Night before, give cathartic or enema to empty colon. Before, assess for iodine sensitivity to avoid anaphylactic reaction. Inform patient that procedure involves lying on table and having serial x-rays taken. Advise that during injection of contrast material, warmth a flushed face and salty taste may occur. After procedure, force fluids.
Subjective data
• Nausea, vomiting, anorexia, chills, nocturia, frequency, urgency
• Suprapubic/lower back pain, bladder spasms, dysuria, burning sensation on urination
• Objective data
• Fever
• Hematuria, foul-smelling urine, tender, enlarged kidney
• Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP
• take full course of antibiotics, increase fluids, voiding ( 3 to 4 hours), Void after intercourse, Use alternate birth control, Follow up care
• monitor for signs of improvement of symptoms
• persistence of lower tract symptoms / onset of flank pain / fever: should be reported immediately

• Antibiotics:
o Trimethoprim/sulfamethoxazole (TMP/SMX)
Taken twice a day
E. coli resistance to TMP-SMX ↑
o Fluoroquinolones
Treat complicated UTIs
Example: ciprofloxacin (Cipro)
o Nitrofurantoin (Macrodantin)
Given three or four times a day
Long-acting preparation (Macrobid) is taken twice daily
o Ampicillin, amoxicillin, cephalosporins
Treat uncomplicated UTI
o Selected on empiric therapy or results of sensitivity testing
o Uncomplicated cystitis
Short-term course (1 to 3 days)
o Complicated UTIs
Long-term treatment (7 to 14 days)
o The collaborative care and drug therapy for cystitis are summarized in Table 46-4. Many residents of long-term care facilities, especially women, have chronic asymptomatic bacteriuria. However, usually only symptomatic UTIs are treated. First-choice drugs to empirically treat uncomplicated or initial UTIs are trimethoprim/sulfamethoxazole (TMP/SMX) (Bactrim, Septra), nitrofurantoin (Macrodantin), and fosfomycin (Monurol).

o Nitrofurantoin (Furadantin, Macrodantin)
Avoid sunlight. Use sunscreen; wear protective clothing.
Notify health care provider immediately if fever, chills, cough, chest pain, dyspnea, rash, or numbness or tingling of fingers or toes develops.
Prophylactic or suppressive antibiotics sometimes administered to patients with repeated UTIs

• Analagetics
o Methenamine/phenyl salicylate (Urised)
Used in combination with antibiotics
Used to relieve UTI symptoms
Preparations with methylene blue tint urine blue or green
o Phenazopyridine (Pyridium)
Used in combination with antibiotics
Provides soothing effect on urinary tract mucosa
Stains urine reddish orange
Can be mistaken for blood and may stain underclothing
Pyridium--Although this drug is typically effective in relieving the transient acute discomfort associated with a UTI, the nurse should advise patients to avoid long-term use of phenazopyridine because it can produce hemolytic anemia.
o Prerenal causes are factors external to the kidneys (e.g., hypovolemia) that reduce renal blood flow and lead to decreased glomerular perfusion and filtration.
Dehydration, hemorage, gi loseess, excessive dieresis, hypoalbumin, burns,cardiac dysrythmias, HF, MI, septic shock, anaohylaxis, embolism.

o Intrarenal causes include conditions that cause direct damage to the renal tissue, resulting in impaired nephron function. Acute tubular necrosis accounts for most cases of intrarenal failure.
Drugs, contrast medium, blood transfusion reaction, crush injury, chemical exposure, allergies, infection, ischemia, toxemia of pregnancy, malignant HTN, SLE.

o Postrenal causes involve mechanical obstruction of urinary outflow. Common causes are benign prostatic hyperplasia, prostate cancer, calculi, trauma, and extrarenal tumors.
BPH, bladder cancer, calculi formation, neuromuscular disorder, spinal cord disease, strictures, Trauma.
• The RIFLE classification (risk, injury, failure, loss, and end-stage disease) is used to describe and standardize the stages of AKI.
• Clinically, AKI may progress through three phases: oliguric, diuretic, and recovery. In some situations, the patient does not recover from AKI and chronic kidney disease (CKD) results, eventually requiring dialysis or a kidney transplant.
o Oliguric Phase
Fluid and electrolyte abnormalities and uremia occur during the oliguric phase.
The most common initial manifestation of AKI is oliguria.
Common electrolyte abnormalities include hyperkalemia, hyponatremia, and hypocalcemia. Elevated BUN and creatinine levels are found. Other findings include metabolic acidosis, anemia, and platelet abnormalities.
The most common cause of death in patients with AKI is infection.
Neurologic changes can occur as the nitrogenous waste products increase.
o The diuretic phase begins with a gradual increase in daily urine output of 1 to 3 L/day but may reach 3 to 5 L or more. The nephrons are still not fully functional. The uremia may still be severe, as reflected by low creatinine clearances, elevated serum creatinine and BUN levels, and persistent signs and symptoms.
o The recovery phase begins when the glomerular filtration rate (GFR) increases, allowing the BUN and serum creatinine levels to plateau and then decrease. Renal function may take up to 12 months to stabilize.
• The diagnosis of AKI is based on the history and physical as well as changes in urine output and serum creatinine.