FREE 190 Flash Cards for Pathophysiology

Free 190 Flash Cards for Pathophysiology

Table of Contents

Abdominal abscess

Acute colititis

Acute Pyelonephritis

Acute Renal Failure

Acute Renal Failure

Acute Renal Failure

Resource

Amputation

Anaphylaxis

Anemia

Anxiety

Appendicitis

Aspiration Pneumonia

Asthma

Asthma

Asthma

Asthma

Atrial Fibrillation

Azotemia

Bi-Polar Disorder

Bowel resection

Brain Cancer

Breast cancer

Bronchial asthma

Bronchitis

Clostridium difficile

Candidiasis, esophageal and oral

Cancer

Cancer

Cardiac Catheterization

Cast Care

Cellulitis

Cerebrovascular accident (stroke)

Cerebrovascular Accident (stroke)

Cerebrovascular Accident/Stroke

Cervical stenosis (spondylosis)

Chemotherapy

CHF

Cholecystitis

Anticholinergics as ordered to decrease secretions (prevents biliary contraction)Cholecystectomy

Cholecystectomy

Cholecystectomy

Cholelithiasis

Chronic Kidney Failure

Definition

Chronic Obstructive Pulmonary Disease

Chronic Renal Failure (CRF, end stage renal disease, ESRD)

Colititis, acute

Colon Cancer

Colorectal Anastomosis

Colostomy

Congestive Heart Failure

Congestive Heart Failure

COPD

Coronary Artery Disease

Coronary Artery Disease

Crohn’s

Crohn’s disease

Crohns disease

Cystic Fibrosis

Cystic Fibrosis

Decubitis ulcer

Deep Vein Thrombosis

Deep Vein Thrombosis/Thrombophlebitis

Degenerative Joint Disease

Degenerative Joint Disease  (osteoarthritis)

Degenerative joint disease- DJD

Dehydration

Dementia

Diabetes

Diabetes Mellitis

Diabetes Mellitus

Diabetes Mellitus

Diabetic peripheral vascular disease

Diarrhea

Diverticulitis

Diverticulitis

Diverticulosis

Diverticulosis:

Epidural Catheter Insertion

Exploratory Laparotomy

Fever

Fibromyalgia

Fracture

Fracture

Fracture

Fracture

Fracture Care

Gallstones

Gastritis

Gastroesophageal Reflux Disease (GERD)  or acid reflux

Gastroesophageal Reflux Disease GERD

Gastrointestinal bleed, acute

Generalized anxiety disorder

Gout

Guillan-Barre Syndrome

Head injuries

Head Injury

Hip Replacement

HIV/AIDs

Hypercholesterolemia

Hyperlipidemia

Hypertension

Hypertension

Hypertension

Hypertension

Hypertension

Hypothyroidism

Hypoxemia

Hysterectomy, supracervial abdominal

Hysterectomy, Total Abdominal with bilateral salpingo oopherectomy

Ileus

Jaundice

Kidney Stone (nephrolithiasis)

Laminectomy

Lap Cholectomy

Leukemia, Ac (myelogenous)

Lithotripsy

Low back pain

Lumbar spinal stenosis

Macrocytic anemia

Malignant Tumors of Reproductive system

Meningitis

Multiple Myeloma

Myocardial Infarction

Narcolepsy

Nephrectomy

Nephrostomy Tube

Neuropathic pain

Non-Hodgkins’s lymphoma

Obesity

Obesity

Open reduction internal fixation (ORIF)

Osteoarthritis

Osteomyolitis

Ostomy care (continent diversion)

Ostomy – Ileostomy    (Lippincott 590-94 & lewis1085-6)

Ovarian Cancer

Pancreatitis

Pancreatitis

Peripheral arterial occlusive disease (aorta and distal arteries)

Peripheral Vascular Disease – (i.e. arterial occlusion)

Pleural effusion

Pleural Effusion

Pneumonia

Pneumonia

Pneumonia

Pneumothorax

Pressure Ulcer

Pressure Ulcers

Prostate Cancer

Pneumomediastinum

Post operative patient

Prostatectomy

Pulmonary Embolism

Pyelonephritis

Renal Insufficiency, Chronic

Rheumatoid Arthritis

Schizophrenia

Seborrheic dermatitis

Seizure disorder

Seizures

Sepsis

Shingles (herpes zoster)

Sigmoid colectomy

Skin Breakdown

Small Bowel Obstruction (SBO)

Soft tissue injury—Abrasion

Spinal Revision and Fusion

Splenectomy

Subdural Hematoma

Substance Abuse-Inhalants

Suicide

Post operative patient

TIA

Total hip Arthroplasty-THA

Total hip replacement

Total Knee Replacement

Total knee replacement

Transient Ischemic Attack

Transurethral Resection of the Prostate TURP

Urinary Retention

UTI

Uterine Fibroids

Vancomycin-Resistant Enterococci (VRE)

Vertigo

Vomiting

Weight Loss

Wound Infection

 

190 Flash Cards for Pathophysiology

Abdominal abscess

 

Definition

Intra-abdominal abscesses are localized collections of pus that are confined in the peritoneal cavity by an inflammatory barrier. This barrier may include the omentum, inflammatory adhesions, or contiguous viscera. The abscesses usually contain a mixture of aerobic and anaerobic bacteria from the GI tract.

Although multiple causes of intra-abdominal abscesses exist, the following are the most common: (1) perforation of a diseased viscus, which includes peptic ulcer perforation, (2) perforated appendicitis and diverticulitis, (3) gangrenous cholecystitis, (4) mesenteric ischemia with bowel infarction, and (5) pancreatitis or pancreatic necrosis progressing to pancreatic abscess.Microbiology includes a mixture of aerobic and anaerobic organisms.

 

S/S

-swelling

-bloating

-lack of appetite

-nausea

-vomiting

-rectal tenderness/fullness

-diarrhea

 

Nursing interventions

-empty and irrigate drain as ordered

-provide pain medication as ordered on a routine basis

– provide non-medication comfort measures in nursing scope of practice

-practice good hand hygiene before and after working with patient

 

Complications

 

Complications include recurrent abscesses, spontaneous rupture of an abscess, and occasionally, spread of the infection to the blood stream and widespread infection.

 

 

 

Acute colititis

 

Definition:

Inflammation of the colon. The major cause of acute colitis is infectious, with the incidence and organism varying widely on a geographic and socioeconomic basis
Ischemic colitis is a disease of the elderly and more affluent populations with an atherosclerotic prone diet. It can also be caused by infection including viruses, bacteria, fungus and parasites or vascular, usually small vessel disease.

 

Signs/Symptoms:

May be mild or severe

-persistent or recurrent diarrhea

-abdominal pain

-fever

-fatigue

-weight loss

-loss of appetite

 

Nursing Interventions:

Monitor vital signs

Monitor I/O’s

Pain assessment
 – location, intensity, type, quality, frequency
– does anything relieve it

Allow client extra time to eat

Excellent perineal is needed until the diarrhea is under control & after
– kept client clean, dry, and free of odor

Administer medications as ordered

 

Complications:

Bleeding

Ulceration

Perforation of the colon

Toxic megacolon

 

 

Acute Pyelonephritis

Definition

An acute infection and inflammatory disease of the kidney and renal pelvis involving one or both kidneys.

S/S

Fever, chills, costovertebral tenderness, flank pain (with or without radiation to groin), nausea, vomiting

Nursing interventions/Teaching

Assess vital signs frequently, and monitor intake and output; administer antiemetic medications to control nausea and vomiting. Administer antipyretic medications as prescribed and according to temperature. Correct dehydration by replacing fluids, orally if possible, or IV. Administer or teach self-administration of analgesic medications, and monitor their effectiveness. Use comfort measures such as positioning to locally relieve flank pain.

Complications

Renal abscess requiring treatment by percutaneous drainage or prolonged antibiotic therapy. Perhipheral abscess.

 

Source

(Lippincott Manual of Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers.  Pgs. 717-718),

 

Acute Renal Failure

Definition

A clinical syndrome characterized by rapid loss of renal function with progressive accumulation of nitrogenous waste products such as BUN and Creatinine.

S/S

Increased BUN, Creatinine, and Potassium, oliguria, producing more or less than urine than usual, feeling pressure when urinating, changes in the color of urine, foamy or bubbly urine, having to get up at night to urinate, swelling of the feet, ankles, hands, or face fatigue or weakness shortness of breath, ammonia breath or an ammonia or metal taste in the mouth, back or flank pain, itching, loss of appetite, nausea and vomiting, more hypoglycemic episodes, if diabetic.

Nursing interventions/Teaching

Monitor VS, monitor BUN and Creatinine levels, patient teaching, have patient exercise, monitor diet, watch for any signs of infection rejection or other illness, monitor electrolytes, strict I&O, daily weights, medication as ordered.

Complications

Anemia, metabolic acidosis, bone disease, cardiovascular disease, fluid overload, high potassium, phosphorus, CKD

 

Acute Renal Failure

Definition

Acute renal failure (ARF) is characterized by a rapid loss of renal function with elevation of blood urea nitrogen [BUN] and plasma creatinine levels. It is usually associated with oliguria (urine output of less than 30 ml/hr or less than 400 ml/day), although urine output may be normal or increased.

S/S

Fatigue, weakness, malaise, change in usual urination pattern, excessive weight gain or loss, nausea and vomiting, headache, blurred vision, shortness of breath.

Nursing interventions/Teaching

Manage fluid and electrolyte balance, monitor vital signs and laboratory/diagnostic studies, assess/document dietary intake measuring I&O accurately, and promote infection control.

Complications

Fluid retention, this may lead to swollen tissues, congestive heart failure or fluid in the lungs (pulmonary edema), a sudden rise in potassium levels in your blood, this could impair your heart’s ability to function and may be life-threatening, weak bones that fracture easily, anemia, stomach ulcers, changes in skin color, damage to your central nervous system, insomnia.

 

Acute Renal Failure

Definition

A syndrome of varying causation that results in a sudden decline in renal function. It is frequently associated with an increase in BUN and creatinine, oliguria (les than 500 mL urine/24h), hyperkalemia, and sodium retention.

S/S

  • Prerenal- decreased tissue turgor, dryness of mucous membranes, weight loss, hypotension, oliguria or anuria, flat neck veins, tachycardia
  • Postrenal- obstruction to urine flow, obstructive sx of BPH, possible nephrolithiasis
  • Intrarenal- presentation based on cause; edema usually present, changes in urine volume/serum concentrations of BUN, creatinine, K+

Nursing interventions/Teaching

Monitor for signs of hypo/hypervolemia, monitor I&O, monitor serum and urine electrolyte concentrations, daily weight, auscultate lung fields for rales, VS, monitor K+ levels, inspect neck veins for engorgement, signs of edema, watch for cardiac arrhythmias and CHF, instruct pt. on importance of diet: avoid foods high in K+, watch for infection, meticulous wound care, assess mental status.

Complications

Infection, arrhythmias R/T hyperkalemia, electrolyte abnormalities, GI bleeding due to stress ulcers, multiple organ systems failure.

 

Nursing Diagnosis

Fluid volume excess R/T decreased glomerular filtration rate and sodium retention.

Risk for infection R/T alterations in the immune system and host defenses.

Altered nutrition: less than body requirements R/T catabolic state, anorexia, and malnutrition associated with acute renal failure.

Risk for injury R/T GI bleeding.

Altered thought processes R/T the effects of uremic toxins on the CNS.
Acute Renal Failure

Definition

A syndrome of varying causation that results in a sudden decline in renal function. It is frequently associated with an increase in BUN and creatinine, oliguria, hyperkalemia, and sodium retention.

S/S

  • Prerenal – decreased tissue turgor, dryness of mucous membranes, weight loss, hypotension, oliguria or anuria, flat neck veins, tachycardia.
  • Postrenal – obstruction to urine flow, obstructive symptoms of BPH, possible nephrolithiasis.
  • Intrarenal – presentation based on cause; edema usually present. Changes in urine volume and serum concentrations of BUN, creatinine, potassium, and so forth, as described above.

Nursing interventions/Teaching

  • Monitor for signs and symptoms of hypovolemia or hypervolemia because regulating capacity of kidneys in inadequate.
  • Monitor urinary output and urine specific gravity; measure and record I & Os including urine, gastric secretions, stools, wound drainage, perspiration (estimate).
  • Monitor for all signs of infection. Be aware that renal failure patients do not always demonstrate fever and leukocytosis.
  • Remove bladder catheter as soon as possible; monitor for UTI.
  • Offer high-carbohydrate feedings because carbohydrates have a greater protein-sparing power and provide additional calories.
  • Examine all stools and emesis for gross and occult blood.
  • Watch for and report mental status changes – somnolence, lasstitude, lethargy, and fatigue progressing to irritability, disorientation, twitching, and seizures.
  • Recommend resuming activity gradually because muscle weakness will present from excessive catabolism.

Complications

Infection; Arrhythmias due to hyperkalemia; Electrolyte (sodium, potassium, calcium, phosphorus) abnormalities; GI bleeding due to stress ulcers; Multiple organ systems failure

Resource

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 710- 712.)
Amputation

Definition

Removing part or all of an extremity as to preserve extremity length and function while removing all infected, pathologic, or ischemic tissue.

S/S

N/A

Nursing interventions/Teaching

Monitor VS, monitor I&O and daily weights, Monitor for signs and symptoms of depression, patient teaching of amputation precautions, check dressing and change as ordered, do muscle strengthening exercises, encourage patient to exercise on their own, ROM, teach patient bandaging technique, use sockets on stump, position patient accurately, check skin integrity, check pain frequently, teach patient about phantom pain, special mattress if ordered

Complications

Irritation, infection, chest infections, angina, heart attacks and strokes, further operations, contractures, DVT, Phantom Limb pain

 

Amputation

Definition

Total or partial surgical removal of an extremity.

S/S

N/A

Nursing interventions/Teaching

Monitor fluid balance: watch for hypotension, tachycardia, diaphoresis, decreased alertness, excessive wound drainage, reinforce dressing, measure drainage, I/O’s.  Maintain tissue perfusion:  control edema, maintain pressure dressing.  Support effective coping:  Accept pt responses to loss of limb, encourage expression of fears, recognize that modification of body image takes time, encourage rehab, and encourage independence.  Control pain. Outcomes:  Vital signs stable, pressure dressing intact, stump elevated without edema, Patient participating in plan of care, expressing concerns about independence.  Verbalizes relief of incisional pain, dull phantom pain tolerable.

Complications

Infection, sepsis

 

Nursing Diagnosis

Risk for fluid volume deficit r/t hemorrhage.

Altered tissue perfusion r/t edema.

Inneffective coping r/t change in body image and self care.

Pain r/t surgical procedure, phantom sensation.

Impaired physical mobility r/t amputation.

 

Anaphylaxis

 

Definition:  Immediate, life-threatening systemic reaction that can occur on exposure to a particular substance.  Result of a Type 1 hypersensitivity rxn in which chemical mediators released from mast cells affect many types of tissue and organ systems.

May be caused by:

  • Immunotherapy
  • Stinging insects
  • Skin testing
  • Medications
  • Contrast media infusion
  • Foods
  • Exercise
  • Latex

 

Manifested by:

  • Respiratory – laryngeal edema, Bronchospasm, cough, wheezing, lump in throat
  • CV – hypotension, tachycardia, palpitations, syncope
  • Cutaneous – urticaria (hives), angioedema, pruritus, erythema (flushing)
  • GI – N,V,D, abd pain, bloating

 

Nursing Interventions:  – ID of S&S essential, a rxn occur quickly tends to be more severe.

 

  • Establish and maintain adequate airway and respiration – (if epinephrine has not stabilized Bronchospasm assist doc w/ endotracheal intibation,emergency tracheostomy as indicated)
  • Administer nebulized albuterol (bronchodilator) as ordered. Monitor HR ( inc w/ bronchodilators)
  • Provide O2 as ordered
  • Administer amophylline and corticosteroids as ordered.
  • Moniter BP w/ cont cuff
  • Administer rapid infusion of IV fluids to fill vasodilated circulatory system and raise BP.
  • Moniter CVP (central venous pressure) to ensure adequate fluid volume and to prevent fluid overload.
  • Insert indwelling catheter and monitor urine output hourly to ensure kidney perfusion.
  • Initiate titrate vasopressor as ordered, based on BP response.
  • Reduce anxiety – provide care in quick, confident manner
  • remain responsive to patient
  • keep family/sig other informed on patient’s condition and treatment given.

 

Complications:

  • Cardovascular collapse
  • Respiratory failure

 

Poss. Nursing Dx:

 

  • Impaired breathing r/t Bronchospasm and laryngeal edema
  • Decreased CO r/t vasodilation
  • Anxiety r/t resp distress and life-threatening situation

 

Anemia

Definition

A deficiency in the number of erythrocytes (red blood cells), the quantity of hemoglobin, and/or the volume of packed RBC’s or hematocrit.  It may be caused by blood loss, impaired production of erythrocytes, or increased destruction of erythrocytes.

S/S

Identified and classified by laboratory diagnosis (Hb), Palpitations, dyspnea, diaphoresis, cardiopulmonary complications, pallor, jaundice, pruritus, increased heart rate, MI, CHF peripheral edema, icteric conjunctiva, sclera, retinal hemorrhage, blurred vision, smooth tongue, tachycardia, systolic murmurs, angina, orthopnea, headache, vertigo, depression, anorexia, difficulty swallowing, sore mouth, bone pain, sensitivity to cold, weight loss, lethargy

Nursing interventions/Teaching

Subjective and objective data should be obtained.  Assess for manifestations of hypoxemia.  Teach effective breathing exercises and relaxation techniques.  Strive for a 1:3 rest/activity ratio.  Assist patient with ADL’s as needed.  Teach proper diet full of iron.  Monitor vital signs to evaluate activity tolerance.  Monitor HH.

Complications

High-output heart failure, Angina, Heart damage, Heart failure, Heart attack

 

Anxiety

Definition

The most common of all psych disorders.  The individual experiences physiologic, cognitive, and behavioral symptoms of anxiety. The common theme is that the pt experiences a level of anxiety that interferes with functioning in personal, occupational, and social areas.

S/S

The physiologic manifestations are related to the fight or flight response and result in cardiovascular, respiratory, neuromuscular, and gastrointestinal stimulation.  Cognitive symptoms include subjective feelings of apprehension, uneasiness, uncertainty, or dread.  Behavioral manifestations include irritability, restlessness, pacing, crying, and/or sighing.

Nursing interventions/Teaching

Help pt ID anxiety producing situations and plan for such events.  Assist pt to develop assertiveness and communication skills. Practice stress reduction techniques with pt.  Encourage pt to verbalize feelings of anxiety.  Administer prescribed anxiolytics to decrease anxiety levels.

 

Outcomes

Pt IDs stressors, demonstrates normal HR, RR, sleep pattern, and subjective feelings of anxiety.  Pt reports going to work, keeping appointments.  Pt uses coping strategies for situations that are anxiety provoking.  Pt demonstrates improved concentration and thought process through improved ability to problem solve, focus and think.  No injuries.

Complications

Increased risk of suicide and substance abuse/dependence disorders is possible with untreated somatoform disorder. Pt may also have co-existing medical condition that may go undiagnosed.  Careful screening is necessary to r/o medical problems.

 

Nursing Diagnosis

Anxiety r/t unexpected panic attacks or r/t re-experiencing traumatic events.

Altered thought processes r/t severe anxiety.

Social Isolation r/t avoidance behavior or r/t embarrassment and shame associated with symptoms.

Personal Identity Disturbance r/t traumatic event.

Risk for injury r/t compulsive behaviors.

 

Appendicitis

Definition

Inflammation of the vermiform appendix caused by an obstruction of the intestinal lumen from the infection, stricture, fecal mass, foreign body, or tumor.

S/S

Generalized or localized abdominal pain in the epigastric or periumbilical areas and upper right abdomen. Within 2-12 hours, the pain localizes in the right lower quadrant and intensity increases. Anorexia, moderate malaise, mild fever, nausea and vomiting. Usually constipation occurs; occasionally diarrhea. Rebound tenderness, involuntary guarding, generalized abdominal rigidity.

Nursing interventions/Teaching

  • Monitor pain level, including location, intensity, pattern.
  • Assist patient to comfortable positions, such as semi-Fowler’s and kees up.
  • Restrict activity that may aggravate pain, such as coughing and ambulation.
  • Apply ice bag to abdomen for comfort. • Monitor frequently for signs and symptoms of worsening condition indicating perforation, abscess, or peritonitis: increasing severity of pain, tenderness, rigidity, distention, ileus, fever, malaise, tachycardia.

Complications

Perforation (in 95% of cases); Abscess; Peritonitis

 

Resource

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 615-616.)

 

Aspiration Pneumonia

Definition

Refers to sequelae occurring from abnormal entry of secretions of substances into the lower airway.

S/S

Usually follows aspiration of from the mouth or stomach into trachea and lungs, loss of consciousness, depressed gag and cough reflexes, malaise, fever, chest pain, pleuritic cough (usually non-productive), shortness of breath, upper abdominal/loin pain, sputum, tachycardia, herpes labialis, dullness in chest to percussion, crackles in lungs, plural rub, cyanosis, hypotension, confusion, tachypnea, rales or wheezing in lungs

Nursing interventions/Teaching

Monitor VS frequently, IS, deep breathe and cough, dyspnea, ineffective airway clearance, hyperthermia, activity intolerance, monitor for signs of infection, monitor respiratory status, monitor for signs of inflammation, oxygen therapy if ordered, patient teaching, have patient do diaphragmatic breathing

Complications

Pleurisy, pleural effusion, atelectasis, delayed resolution, lungabscess, empyema, pericarditis, arthritis, meningitis, endocarditis, hypoxemia, tracheobronchial constriction, pneumothorax

 

Asthma

Definition

Lippencott, 921.   Bronchial asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role.  This inflammation causes wheezes, breathlessness, chest tightness, and coughing.  The episodes are associated with variable airflow obstruction that is often reversible either spontaneously or with treatment. Mast cells release chemical mediators that cause bronchioconstriction and increased mucous secretion in the bronchial tree.

S/S

Episodes of coughing, wheezing, dyspnea, and/or feeling chest tightness.

Nursing interventions/Teaching

Monitor v/s, degree of restlessness (indicator of hypoxia), Provide nebulization, O2 therapy as prescribed, encourage fluid intake (thins secretions), position to facilitate breathing (sitting upright, lean on table), pursed lip breathing, relieve anxiety. Outcome:  Pt’s symptoms reduced (wheezing, coughing, chest tightness, etc), peak flow improved.  Pt verbalizes relief of anxiety.

Complications

Status Asthmaticus.  This is a severe form of asthma in which the airway obstruction is unresponsive to usual drug therapy.  Contributing factors include: Infection, overuse of bronchodilators, aspiration of gastric acid, ingestion of aspirin in the aspirin-sensitive patient, inhalation of pollutants and allergens to which pt is sensitized.

 

Nursing Diagnosis

Innefective breathing pattern, r/t bronchospasm.

Anxiety, r/t fear of suffocating, difficulty in breathing, death.

 

Asthma

Definition

Achronic inflammatory disorder of the airways in which many cells and cellular elements play a role.

S/S

Episodes of coughing. Wheezing,Dyspnea,Feelin of chest tightness.

Nursing interventions/Teaching

  • Monitor vital signs, skin color, retraction, and degree of restlessness, which may indicate hypoxia.
  • Provide nebulization and oxygen therapy as prescribed.
  • Monitor airway function through peak flow meter or pulmonary finction testing to assess effectiveness of treatment.
  • Encourage intake of fluids to liquefy secretions.
  • Encourage patient to use adaptive breathing techniques (e.g. pursed –lip breathing) to decrease the work of breathing.

Complications

  • Angina pectoris or MI due to decreased coronary perfusion.
  • Left ventricular hypertrophy and CHF due to consistently elevated aortic pressure.
  • Renal failure due to thickening of renal vessels and diminished perfusion to the glomerulus.
  • Transient ischemic attacks (TIAs), stroke, or cerebral hemorrhage due to cerebral ischemia and arteriosclerosis.
  • Accelerated hypertension.

 

Resource

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 426-433.)

 

Asthma

Definition

Asthma is a chronic condition that occurs when the main air passages of your lungs, the bronchial tubes, become inflamed. The muscles of the bronchial walls tighten and extra mucus is produced, causing your airways to narrow. This can lead to everything from minor wheezing to severe difficulty in breathing. In some cases, your breathing may be so labored that an asthma attack becomes life-threatening.

S/S

Increased shortness of breath or wheezing, disturbed sleep caused by shortness of breath, coughing or wheezing, chest tightness or pain, increased need to use bronchodilators — medications that open up airways by relaxing the surrounding muscles, a fall in peak flow rates as measured by a peak flow meter.

Nursing interventions/Teaching

Maintain airway patency, assist with measures to facilitate gas exchange, administer medications as indicated, enhance nutritional intake, and provide information about disease process/prognosis and treatment regimen.

Complications

Severe shortness of breath, impaired gas exchange, respiratory imbalances (acidosis, alkalosis).

 

Asthma

Definition

A chronic inflammatory disorder of the airways in which inflammation causes varying degrees of obstruction in the airways.

S/S

Recurrent episodes of wheezing, breathlessness, chest tightness, cough, increase in existing hyperresponsiveness to a variety of stimuli; dry cough, full blown respiratory distress, prolongation of expiratory phase, nasal flaring, using accessory breathing muscles, retractions, irritability, lethargy, change in color, feeding difficulty, speaking difficulty, wheezing / poor air movement, breathing changes, sneezing, moodiness, headache, runny/stuffy nose, coughing, chin or throat itches, feeling tired, dark circles under eyes, trouble sleeping, poor tolerance for exercise, downward trend in peak flow number, sweating, decreased LOC

Nursing interventions/Teaching

Monitor patient’s vital signs, educate patient and family, assist patient to sitting position with head slightly flexed, encourage patient to take deep breaths, monitor respiratory and oxygenation status, regulate fluid intake, administer drug therapy, ausculate lung sounds periodically, have patient keep journal of triggers, keep patient comfortable so they have no anxiety

Complications

Sleeplessness, respiratory failure, pneumothorax, lung infections, chronic obstructive pulmonary disease, atelectasis, death (rarely), hospitilization, asphyxia

 

Atrial Fibrillation

Definition

An electrical rhythm disturbance of the heart affecting the atria. Abnormal electrical impulses in the atria cause the muscle to contract erratically and pump blood inefficiently. The atrial chambers are thus not able to completely empty blood into the ventricles.

S/S

Irregular heartbeat, rapid heartbeat, rapid beating of upper chest chambers, palpitations, chest pain, breathlessness, faintness, weakness, tiredness

Nursing interventions/Teaching

Monitor vital signs, provide comfort for the patient, carefully read EKG results

Complications

Stroke, heart failure, coronary thrombosis, embolism, death

 

Azotemia

Definition

A toxic condition characterized by abnormal and dangerously high levels of urea, creatinine, various body waste compounds, and other nitrogen rich compounds in the blood as a result of insufficient filtering of the blood by the kidneys. Also known as prerenal azotemia and uremia. Can be caused by medical conditions that impair blood flow to the kidneys (ex: CHF, shock, severe burns, prolonged vomiting or diarrhea).

 

S/S

decreased or no urine produced, fatigue, decreased alertness, confusion, pale skin color, rapid pulse, dry mouth, thirst swelling (edema, anasarca), orthostatic blood pressure (rises or falls, significantly depending on position)

Nursing interventions/Teaching

check labs (UA), VS, skin assessment, I&O, daily weight, edema, alteration in mucous membranes, check for exposure to potentially nephrotoxic drugs (NSAIDS, antibiotics), monitor serum and urine electrolyte levels, restrict salt and water intake, monitor acid/base balance, instruct pt. on diet, watch for cardiac arrhythmias and CHF, check for infection, LOC

Complications

acute renal failure, acute tubular necrosis, electrolyte abnormalities, infection, arrhythmias due to hyperkalemia

 

Nursing Diagnosis

Fluid volume excess R/T decreased glomerular filtration rate and sodium retention.

Altered thought processes R/T the effects of uremic toxins on CNS.

Altered nutrition: less than body requirements R/T catabolic state, anorexia, and malnutrition associated with acute renal failure.

Risk for infection R/T alterations in the immune system and host defenses.

 

Bi-Polar Disorder

Definition

A chronic mood syndrome that manifests as recurring mood episodes includes both periods of hypomania or maina, and depressive episodes.  Mania, hypomania, depression, and concurrent mania and depression characterize the mood episodes.

S/S

Personality disturbance or disorder of temperament, seasonal depression, alcohol and/or substance abuse, rapid mood cycling, premenstrual dysphoria, impulse difficulties, interpersonal sensitivity, recurrent depression, mood instability, inflated sense of self-importance, decreased need for sleep, loud, rapid speech, racing thoughts, distractibility, agitation or restlessness, increase in goal-oriented activities, unwise involvement in pleasurable but potentially risky activities, significant changes in appetite and/or weight, loss of energy or fatigue, slowed speech, thinking, or body movements, recurring thoughts of death or suicide

Nursing interventions/Teaching

Support patient and family, educate patient and family, listen to patient talk, be patient with patient, monitor vital signs, monitor patient for other disorders, monitor I/O and daily weights, help patient with accurate perception, help patient with communication, encourage exercise

Complications

Personality disorders, anxiety disorders, anorexia nervosa, bulimia nervosa, attention deficit, hyperactivity disorders, suicide, sleep disorders

 

Bowel resection

Definition

Segmental excision of small and/or large bowels with varied approaches.

S/S

N/A

Nursing interventions/Teaching

VS, signs of infection and shock (fever, hypotension, tachycardia), I&O, abdominal assessment for increased pain and distention, bowel sounds (should be absent immediately post-op), dressing/incision/drainage, flatus/feces through stoma, N/V, NG aspirate, electrolytes, pain, weight.

 

Implementations- irrigate NG tube, thrombus precautions if ordered, turn/cough/deep breathe q2h, ambulation, dressing changes qd or prn, aseptic technique, advance diet as tolerated. Education- stoma care, diet- high fiber, low flatus, increase fluids, medication administration.

Complications

Paralytic ileus, paralytic obstruction, peritonitis, sepsis, anastomatic leakage, mucocutaneous separation, ischemia of stoma, stomal prolapse, peristomal hernia, self image deterioration.

 

Brain Cancer

Definition

Primary intracranial neoplasms are the result of proliferation of normal cells within the CNS.  These include tumors of the brain itself, the skull or meninges, the pituitary gland, and the blood vessels.  CNS tumors may also consist of metastatic tumors that spread from systemic organs.  Primary CNS tumors only rarely metastasize outside the CNS.

S/S

Generalized symptoms (due to ICP) headache (especially in the morning), vomiting, papilledema, malaise, altered cognition and consciousness.  Focal neurological deficits (related to region of tumors); Parietal area – sensory alterations, speech and memory disturbances; Frontal lobe – personality, behavior, and contra-lateral motor weakness; Temporal area & Occipital area – auditory hallucinations, visual field deficits; Cerebral area – coordination, gait, and balance disturbances, dysarthria. Seizures

Nursing interventions/Teaching

Provide analgesics around the clock at regular intervals that will not mask neurological changes.  Maintain the head of the bed at 15 to 30 degrees to reduce cerebral venous congestion.  Provide a darkened room or sunglasses if the patient is photophobic. Maintain a quiet environment to increase patient’s pain tolerance.  Provide scheduled rest periods to help patient recuperate from stress of pain. Alter diet as tolerated if pt has pain on chewing.  Collaborate with pt on alternative ways to reduce pain, such as use of music therapy.

Complications

Increased ICP and brain herniation, neurological deficits from expanding tumor or treatment

 

Breast cancer

Definition

A malignant neoplasm (usually an adenocarcinoma) of the breast. (Venes, D. (19th ed.) (2001). Taber’s Cyclopedic Medical Dictionary.  Philadelphia: F.A. Davis Company.  Pgs.277-280.)

A growth of abnormal cells in breast tissue that is irregular. (Hogan, M. A. & Hall, K. (2004). Pathophysiology: Reviews & Rationales.  New Jersey: Pearson Education, Inc.  Pgs. 358-360.)

S/S

Lump or thickening of breast tissue, usually painless in UOQ, and enlargement of axillary or supraclavicular lymph nodes. Nipple discharge – spontaneous, may be bloody, clear, or serous. Breast asymmetry – change in size or shape or abnormal contours,Nipple retraction or scaliness.

Late signs – pain, ulceration, edema, orange peel skin (peau d’orange) from the interference of lymphatic drainage. Manifestations from metastasis include bone pain, neurologic changes, weight loss, anemia, cough, shortness of breath, pleuritic pain, and vague chest discomfort.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 800-805.)

Nursing interventions/Teaching

Reducing Anxiety: Realize that diagnosis of breast cancer is a devastating emotional shock to the woman. Support patient through the diagnostic process. • Providing Information about Treatment: Involve patient in treatment planning. Describe surgical procedures. Prepare patient for the effects of chemotherapy; encourage patient to plan ahead for the common side effects of chemotherapy. • Strengthening Coping: Repeat information and speak in calm, clear manner. Display empathy and acceptance of patient’s emotions.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 800-805.)

Complications

Metastasis – most common sites: lymph nodes, lung, bone, liver, and brain.  Signs and symptoms of metastasis may include bone pain, neurologic changes, weight loss, anemia, cough, shortness of breath, pluritic pain, and vague chest discomfort.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 800-805.)

 

Bronchial asthma

Definition

Chronic inflammatory disorder of the airways in which many cells and cellular elements play a sole. Causes episodes of wheezing, breathlessness, chest tightness, and coughing (particularly at night) and airway hyper reactivity to various stimuli. Episodes usually associated with variable airflow obstruction that is of ten reversible either spontaneously or with treatment.

S/S

Episodes of coughing, wheezing, dyspnea, feeling of chest tightness.

Nursing interventions/Teaching

Encourage intake of fluids to liquefy secretions, instruct pt. on positioning to facilitate breathing, teach adaptive breathing techniques, monitor: VS/ skin color/ retraction/ degree of restlessness which may indicate hypoxia, provide nebulization and O2 therapy as prescribed, monitor airway function through peak flow meter or pulmonary function test, relieve anxiety, auscultation of lungs.

Complications

SOB, wheezing, coughing, chest tightness, apnea.

 

Nursing Diagnosis

Ineffective breathing pattern R/T bronchospasm.

Anxiety R/T fears of suffocating, difficulty in breathing, death.

 

Bronchitis

Definition

A condition that occurs when the inner walls that line the main air passageways of your lungs (bronchial tubes) become inflamed. Bronchitis often follows a respiratory infection such as a cold.

S/S

A cough that brings up yellowish-gray or green mucus (sputum), soreness and a feeling of constriction or burning in your chest, breathlessness, wheezing, chills, overall malaise and slight fever.

Nursing interventions/Teaching

Maintain airway patency, assist with measures to facilitate gas exchange, enhance nutritional intake, and prevent complications.

Complications

Chronic bronchitis, asthma or other lung disorders. Having chronic bronchitis also increases your risk of lung cancer.

 

Clostridium difficile

 

Definition

  1. difficile is a spore-forming bacillus that produces toxins that cause gastrointestinal illness. These spores are extremely resistant and can survive on contaminated surfaces for weeks or months.C. difficile is one of the most common causes of infectious diarrhea in long term care facilities – up to 7 % of residents become colonized with C-dif.

 

S/S

  • severe diarrhea
  • nausea
  • abdominal distention
  • fever
  • leukocytosis
  • dehydration
  • hypotension

 

Nursing Interventions

  • Avoid unnecessary use of antibiotics; if antibiotics are prescribed, make sure to give all doses on a regular schedule. Be aware of signs/symptoms of superinfection.
  • Proper hand hygiene – wash your hands thoroughly before and after caring for every patient.
  • When working with patient infected with C.difficile, always wear gloves.
  • Follow universal and contact precautions when caring for a patient with C. difficile.
  • Ensure that a patient that is positive for C. difficile is in an isolated room.
  • Use disinfectants to disinfect the patient’s room and anything that comes in and goes out of the patient’s room.
  • Encourage fluids to help maintain the patient’s fluid and electrolyte balances.
  • Restrict visitors to a patient with C. difficile – to help prevent spreading.

 

 

 

Complications

  1. dif can lead to toxic megacolon which can lead to bowel perforation and even death.

 


Candidiasis, esophageal and oral

 

Definition

Yeast infection of the mucous membranes of the mouth and tongue. Candida albicans is an organism that lives in the mouth and is kept in check by healthy organisms. When resistance to infection is low, the fungus can grow which causes lesions in the mouth, on the tongue, and down the throat.  People with HIV/AIDS are at an increased risk due to their immunosuppressed status. It can be disseminated throughout the entire body if not treated.

 

S/S

-whitish, velvety plaques in the mouth, throat and on the tongue

-under the whitish plaques, there are sores which may bleed

-increasing number and size of these lesions

-bad taste/foul odor coming from the mouth and in the mouth

 

Nursing interventions

Assess for mechanical agents or chemical agents such a frequent exposure to tobacco that could cause or increase trauma to the oral mucosal membranes.

Encourage fluid intake up to 3000ml per day, if not contraindicated.

Determine client’s usual method of oral care and address any concerns regarding oral hygiene.

Use tap water or normal saline to provide oral care; do not use mouthwashes containing alcohol or hydrogen peroxide.

 

Complications:

It can disseminate throughout the body, causing infections in the esophagus, the brain, the heart, joints, or eyes.

 

 

Cancer

Definition

Lippencott, 137.  Cancer is a disease of the cell in which the normal mechanisms of control of growth and proliferation are disturbed.  The results are distinct morphologic alterations of the cell and aberrations in tissue patterns.  The malignant cell is able to invade the surrounding tissue and regional lymph nodes.  Primary cancer usually has a predictable natural history and pattern of spread. Metastasis is the secondary growth of primary CA.  Lymph nodes are often the first site for metastases.

S/S

Symptoms will vary greatly depending on the primary site.

Nursing interventions/Teaching

Teach Cancer Prevention: Teach about diets low in fat, high in fiber.  Advise pt of the increased risk factors associated with smoking, obesity, and alcohol consumption.  Teach pt to avoid sun exposure btwn 10a-3p.  Routine screenings, self exams.  Prevent infection with those in therapy.  Monitor v/s Q4, have pt report any signs/symptoms of infection.  Reinforce good hygiene, encourage coughing, deep breathing.

Monitor WBC, H&H, avoid invasive procedures when platelet count less than 50,000.  Avoid use of aspirin, NSAIDS. No topical agents w/ radiation unless prescribed.    Outcome: Pt skin intact, w/out breakdown or signs of infection.  Pt afebrile, with no signs of infection.  No bruising, bleeding, dyspnea, oral lesions, or pain.  Pt maintains proper hygiene.  Pt tolerating small, frequent meals w/ antiemetic.

Complications

W/ radiation, complications depend on location, dose, overall pt health.  Chemo complications include: alopecia, anorexia, fatigue, n/v, mucositis, anemia, neutropenia, thrombocytopenia.

 

Nursing Diagnosis

Risk for infection r/t neutropenia.

Risk for bleeding r/t thrombocytopenia.

Fatigue r/t anemia,

Altered nutrition: less than body requirements r/t side effects of therapy.

Altered oral mucosa r/t stomatitis.

Altered body image r/t alopecia and weight loss.

Risk for impaired skin integrity r/t radiation tx.

 

Cancer

Definition

Lippencott, 137.  Cancer is a disease of the cell in which the normal mechanisms of control of growth and proliferation are disturbed.  The results are distinct morphologic alterations of the cell and aberrations in tissue patterns.  The malignant cell is able to invade the surrounding tissue and regional lymph nodes.  Primary cancer usually has a predictable natural history and pattern of spread. Metastasis is the secondary growth of primary CA.  Lymph nodes are often the first site for metastases.

S/S

Symptoms will vary greatly depending on the primary site.

Nursing interventions/Teaching

  1. Teach Cancer Prevention:Teach about diets low in fat, high in fiber.  Advise pt of the increased risk factors associated with smoking, obesity, and alcohol consumption.  Teach pt to avoid sun exposure between 10a-3p.
  2. Routine screenings, self exams.Prevent infection with those in therapy.
  3. Monitor v/s Q4, have pt report any signs/symptoms of infection.
  4. Reinforce good hygiene, encourage coughing, deep breathing.
  5. Monitor WBC, H&H, avoid invasive procedures when platelet count less than 50,000.
  6. Avoid use of aspirin, NSAIDS. No topical agents w/ radiation unless prescribed.

 

Outcome:  Pt skin intact, w/out breakdown or signs of infection. Pt afebrile, with no signs of infection. No bruising, bleeding, dyspnea, oral lesions, or pain.  Pt maintains proper hygiene.  Pt tolerating small, frequent meals w/ antiemetic.

Complications

W/ radiation, complications depend on location, dose, overall pt health.  Chemo complications include: alopecia, anorexia, fatigue, n/v, mucositis, anemia, neutropenia, thrombocytopenia.

Nursing Diagnosis:

  • Risk for infection r/t neutropenia.
  • Risk for bleeding r/t thrombocytopenia.
  • Fatigue r/t anemia, Altered nutrition: less than body requirements r/t side effects of therapy.
  • Altered oral mucosa r/t stomatitis.
  • Altered body image r/t alopecia and weight loss.
  • Risk for impaired skin integrity r/t radiation tx.

 

 

Candidiasis, Esophageal and Oral

 

Definition

Yeast infection of the mucous membranes of the mouth and tongue. Candida albicans is an organism that lives in the mouth and is kept in check by healthy organisms. When resistance to infection is low, the fungus can grow which causes lesions in the mouth, on the tongue, and down the throat.  People with HIV/AIDS are at an increased risk due to their immunosuppressed status. It can be disseminated throughout the entire body if not treated.

 

S/S

  • whitish, velvety plaques in the mouth, throat and on the tongue
  • under the whitish plaques, there are sores which may bleed
  • increasing number and size of these lesions
  • bad taste/foul odor coming from the mouth and in the mouth

 

Nursing interventions

Assess for mechanical agents or chemical agents such a frequent exposure to tobacco that could cause or increase trauma to the oral mucosal membranes.

Encourage fluid intake up to 3000ml per day, if not contraindicated.

Determine client’s usual method of oral care and address any concerns regarding oral hygiene.

Use tap water or normal saline to provide oral care; do not use mouthwashes containing alcohol or hydrogen peroxide.

 

Complications:

It can disseminate throughout the body, causing infections in the esophagus, the brain, the heart, joints, or eyes.

 

Cardiac Catheterization

Definition

Performed by insertion of a radiopaque catheter into the right or left side of the heart. For the right side of the heart, a catheter is inserted through an arm vein (basilica or cephalic) or a leg vein (femoral). The catheter is advanced through the vena cava, the right atrium, and the right ventricle. The catheter is further inserted into the pulmonary artery, and pressures are recorded. The catheter is then advanced until it is wedged or lodged into position. The pulmonary artery wedge position (wedge pressure) obstructs the flow and pressure from the right side of the heart and looks forward through the pulmonary capillary bed to the pressure in the left side of the heart. The wedge pressure is used to determine the function of the left side of the heart. The left heart catheterization is performed by insertion of a catheter into a femoral or brachial artery. The catheter is passed up the aorta, across the aortic valve, and into the left ventricle.

S/S

N/A

Nursing interventions/Teaching

Obtain consent, check for iodine sensitivity, withhold food and fluids for 6-18 hours prior to procedure, give sedative if ordered, inform patient about use of anesthesia, insertion of catheter, and feeling of warmth and fluttering sensation as catheter is passed through the heart.

Complications

Looping, kinking, or breaking off of catheter; blood loss; allergic reaction to contrast media; infection; thrombus formation; air or blood embolism; arrhythmias; MI; stroke; puncture of the ventricles, cardiac septum, or lung tissue; and, rarely, death.

 

Cast Care

Definition

Lippincott 973  A cast is an immobilizing device made up of layers of plaster or fiberglass bandages molded to the body part it encases; Many types and applications: partial and whole limb, trunk, body, spica (trunk and extremity)

S/S

N/A

Nursing interventions/Teaching

Assessment- Pain, swelling, discoloration (pale or blue), cool skin distal injury, paresthesia, paralysis, slow cap refill, pressure sores; Assess CV, respiratory, GI systems for possible complications due to immobility; Assess psych reactions to illness, cast, immobility; Interventions: keep dry,

don’t cover with plastic (causes condensation), no weight bearing on plaster cast for 24 hours; Pt ed : cast cleaning, keep alert to prevent falls, no objects under the cast – to avoid injury to the skin, “petal” edges or use moleskin padding; Inspect skin for signs of irritation; Assess neurovascular status; Apply ice bags as presribed; Assess pain levels; Isometric exercises; Pt to alert healthcare provider if excessive swelling, paresthesia, persistent pain, pain on passive stretch or paralysis;

 

Complications

Pressure can cause necrosis, sore and nerve palsies; Compartment syndrome: vascular insufficiency and nerve/muscle compression due to unrelieved swelling can irreversible damage to an extremity; Multi system problems: nausea/vomiting associated with cast syndrome, anxiety due to confinement, thrombophlebitis, possible pulmonary emboli, depression due to loss of control, dependence

 

Cellulitis

Definition

An inflammation of the subcutaneous tissue of the skin that results from an infectious process.  Lippincott 1026

S/S

Tender, warm, swollen and reddened area- well demarcated. Possible abscess or purulent discharge.

Nursing interventions/Teaching

Assessment: Observe for expanding borders and lymphatic streaking. Assess affected area.  Nursing Interventions: Protect Skin Integrity, Pain Management, Assess Site.  Labs: Blood cultures and culture of drainage.

Complications

Tissue necrosis, septicemia.

 

Nursing Diagnosis

Risk for Impaired Skin Integrity related to infectious process.

Pain related to inflammation of sub q tissue.

 

Cerebrovascular accident (stroke)

Definition

Onset and persistence of neurologic dysfunction lasting longer than 24 hours and resulting from disruption of blood supply to the brain and indicates infarction rather than ischemia.

S/S

HA, numbness, weakness, loss of motor ability, difficulty swallowing, aphasia, visual disturbances, altered cognitive abilities and psychological affect, self care deficit.

Nursing interventions/Teaching

VS, I&O, semifowlers/side rails in place, assess for fall status, exercise affected extremities with passive ROM, be aware of cognitive alterations and adjust interaction and environment accordingly, foster independence with ADLs (i.e. clothes with front closures, Velcro), help pt. relearn swallowing, encourage small frequent meals, inspect mouth for food collection and pocketing, encourage frequent oral hygiene, speak slowly/directly to pt. while facing them and minimize distractions, monitor bowel/bladder function, assess effectiveness of anticoagulation therapy.

Complications

Aspiration pneumonia, dysphagia, spasticity, DVT, pulmonary embolism, brain stem herniation, poststroke depression.

 

Cerebrovascular Accident (stroke)

Definition

The onset and persistence of neurologic dysfunction lasting longer than 24 hours and resulting from disruption of blood supply to the brain and indicates infarction rather than ischemia.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 458.)

S/S

Sudden weakness or numbness of the face, arm or leg ,Sudden loss of vision or dimming of vision, Sudden difficulty speaking or understanding speech, Sudden severe headache, Sudden falling, gait disturbance or dizziness.

(Venes, D. (19th ed.) (2001). Taber’s Cyclopedic Medical Dictionary.  Philadelphia: F.A. Davis Company.  CD-ROM.)

Nursing interventions/Teaching

  • Preventing Falls and Other Injuries
  • Maintain bed rest during acute phase (24-48 hours after onset of stroke) with head of bed slightly elevated and side rails in place.
  • Preventing Complications of Immobility: Use a foot board during flaccid period after stroke to keep foot dorsiflexed; avoid its use after spasticity develops.
  • Optimizing Cognitive Abilities: Be aware of the patient’s cognitive alterations, and adjust interaction and environment accordingly.
  • Facilitating Communication: Speak slowly, using visual cues and gestures; be consistent, and repeat as necessary.
  • Promoting Adequate Oral Intake: Encourage small, frequent meals, and allow plenty of time to chew and swallow.
  • Attaining Bladder Control:
  • Establish regular schedule of voiding – every 2-3 hours, correlated with fluid intake – once bladder tone returns. (Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. 543-544.)

Complications

Aspiration pneumonia; Dysphagia in 25-50% of patient after stroke; Spasticity, contractures; Deep-vein thrombosis, pulmonary embolism; Brain stem herniation; Poststroke depression

 

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 459.),

 

Cerebrovascular Accident/Stroke

Definition

A sudden loss of brain function caused by a blockage (ischemia) or rupture of a blood vessel to the brain, which results in the death of those brain cells.

S/S

Loss of muscular control, diminution or loss of sensation or consciousness, dizziness, slurred speech, or other symptoms that vary with the extent and severity of the damage to the brain, headache, aphasia, anosognosia, sensory loss, apraxia, personality change, possible cognitive impairment, urinary incontinence, dysphagia, ataxia, nausea, vomiting, visual disturbances, vertigo, unilateral hearing loss, hoarseness.

Nursing interventions/Teaching

Patient and family teaching of ways to prevent CVA’s, Antiplatelet drugs to prevent further strokes, daily weights, maintain a healthy diet, ensure patient airway, maintain adequate oxygenation, monitor vital signs, monitor neurologic status including level of consciousness, avoid neck flexion to avoid obstruction of arterial and venous blood flow, encourage use of incentive spirometry if ordered, assess range of motion, maintain and encourage exercise.

Complications

Greater neurological deficit, confidence interval, hypoalbuminemia, disability, advancing age, Depression, paralysis, coma, death, hemiparesis, vision problems, speech problems, recurrent strokes, cognitive deficits, emotional difficulties, daily living problems, pain, Spatial problems, Perception problems Impaired judgment, Short-term memory problems, Slowness, Cautious behavior

 

Cervical stenosis (spondylosis)

Definition

Narrowing of the spinal canal due to intervertebral discs losing water content/ becoming less spongy. (This reduces disc height and can cause the hardened disc to bulge into the spinal canal). These changes are common after age 50, rate of progression varies. Narrowing can pinch the spinal cord and nerve roots that can lead to myelopathy or radiculopathy.

S/S

(cervical stenosis does not generally have Sx; Sx are indicative of myelopathy or radiculopathy) pain in neck and arms, arm and leg dysfunction, (arm Sx= weakness, stiffness, or clumsiness) (leg Sx= weakness, frequent falls, difficulty walking) urinary urgency/ bowel and bladder incontinence can occur, increased knee and ankle reflexes.

Nursing interventions/Teaching

Assess pain, exercises to increase flexibility

Complications

myelopathy, radiculopathy

 

Chemotherapy

 

Definition:  Chemotherapy is the use of antineoplastic drugs to promote tumor cell destruction by interfering with cellular function and reproduction.

Goals of chemo:

  1. curative – complete response to tumor
  2. control – to extend life of pt when cure not possible
  3. palliative – reduction in tumor burden to relieve symptoms such as pain and improve quality of life.

 

Complications:

 

Nursing Interventions:

 

 

Risk Factors:

 

CHF

Definition

The clinical syndrome that results from the heart’s inability to pump the amount of oxygenated blood necessary to meet the metabolic requirements of the body.

S/S

Right sided (Backward): elevated pressure in systemic veins/capillaries, leading to edema, unexplained weight gain, liver congestion, distended neck veins, abnormal fluid in body cavities, weakness and nocturia. Left sided (Forward):  congestion in lungs due to backed up blood in the pulmonary veins/capillaries, SOB, cough (dry, non productive), fatigue, insomnia, tachycardia, s3 ventricular gallop.

Nursing interventions/Teaching

Maintain adequate Cardiac Output by promoting physical comfort, decreased exertion, frequent VS and heart sounds, and administer pharmacotherapy as prescribed.  Improving oxygenation by raising HOB, watch respiration rate, encourage deep breathing, small frequent feedings, and administer O2 as prescribed.  Improve activity intolerance by increasing activities gradually, assist pt with self care, be alert to signs of chest pain, etc.  Outcomes:  Normal HR, BP and RR.  ABGs normal, no wheezes, crackles, or pitting edema.

Complications

Cardiac dysrythmias, Myocardial failure, Digitalis toxicity, Pulmonary Infarction, pneumonia, emboli

 

Nursing Diagnosis

Decreased cardiac output r/t impaired contractility.

Impaired gas exchange, r/t alveolar edema due to elevated ventricular pressure.

Fluid Volume Excess r/t sodium and water retention

Activity intolerance r/t oxygen supply and demand imbalance

 

Cholecystitis

 

Definition:  Inflammation of the gallbladder usually assoc. w/ cholelithiasis.  It may be acute or chronic, and is associated with obstruction of gallstones or biliary sludge.  E. Coli  is the most common bacteria involved (strep and salmonellae are also common). Other etiologic factors are adhesions, neoplasms, anesthesia, and narcotics.

 

M/B   Vary from indigestion to mod to severe pain in RUQ, fever, jaundice.  This could be accompanied by nausea, restlessness, diaphoresis.  Manifestations of inflammation would be leukocytsis and fever, RUQ tenderness and abd rigitiy.  Symptoms of chronic cholecystitis include hx fat intolerance, dyspepsia, heartburn, and flatulence.

 

Clinical manifestations if bile duct obstructed:

  • Obstructive jaundice      –           no bile flow into duodenum
  • Dark amber urine          –           bilirubin in urine
  • No urobilinogen in urine             no bilirubin reaching SI to be converted to urobilinogen
  • Clay colored stools        –           “       “      “
  • Pruritis                          –           deposits of bile salts in skin tissues
  • Fatty food intolerance    –           no bile in SI for digestion
  • Bleeding tendencies      –           decr absorption vit K, therefore dec production PT

 

 

 

Complications:

  • Cholangitis – inflammation of biliary ducts
  • Billiary cirrhosis
  • Fistulas
  • Rupture of gall bladder – can produce bile peritonitis
  • carcinoma

 

Nursing Interventions:

  • relieving pain w/ analgesics as ordered
  • antibiotics as ordered
  • maintaining fluid and electrlyte balence
  • if N/V severe, gastric decompression
  • prepare  surgery

Anticholinergics as ordered to decrease secretions (prevents biliary contraction)
Cholecystectomy

Definition

Lippincott pg 636   Surgical removal of the gall bladder for acute and chronic cholecystitis [more than 600,000 performed each year in the U.S., second only to abortions (1.2 million)]

S/S

N/A

Nursing interventions/Teaching

Pre-op – IV fluids for hydration if pt has been vomiting; Antibiotics for acute cholecystitis; Pt education regarding procedure and post-op; Pt NPO after 2400 night before surgery and must void prior to surgery; Post-Op – Vital signs, LOC, pain level; Assess wound appearance; Monitor I& O’s ; Early ambulation to prevent thromboembolus and facilitate voiding and stimulate peristalsis.  Pt education- rapid post-op recovery should be expected, notify surgeon immediately of any subtle change in post-op course or persistent symptoms due to possible bile duct injury

Complications

Incisional infection, hemorrhage, bile duct injury (persistent pain, fever, abdominal distension, nausea, anorexia, or jaundice)

 

Cholecystectomy

Definition

Most often performed using a laparoscope, a pencil-thin tube with its own lighting system and miniature video camera. The laparoscope is inserted into the abdomen through a cannula. Only small incisions are required. The video camera produces a magnified view on a television monitor of the inside of the abdomen which allows the surgeon to see the surgery in detail. To remove the gallbladder, the surgeon uses tiny instruments inserted through several other small abdominal incisions. Occasionally an option is open surgery, in which the gallbladder is removed through a large abdominal incision.

S/S

N/A

Nursing interventions/Teaching

Pain management, monitor vital signs and laboratory/diagnostic studies, assess/document dietary intake measuring I&O accurately, and promote infection control.

Complications

After surgery the liver continues to produce enough bile to digest a normal diet, but the patient may experience more bowel movement than usual and that their consistency is less solid. For some people these changes can be major. In most cases the symptoms usually lessen over time.

 

Cholelithiasis

 

Definition:  Stones in the gall bladder.  The stones may be lodged in the neck of the gall bladder or cystic duct.  The actual cause is unknown.  It develops when the balance that keeps cholesterol, bile slats, and calcium in solution is altered so that precipitation occurs.  Conditions that upset the balance are infection, and disturbances in metabolism, and most clients have a liver saturated in cholesterol. Most stones are made out of cholesterol. Other components could be bile salts, bilirubin, Ca and protein.

 

Stones can remain in GB or migrate into cystic or common bile duct.

 

M/B:  severe pain RUQ or none at all, depends whether the stones are stationary or mobile, and whether obstruction is present.  If pain excruciating, it is usually accompanied by tachycardia, and diaphoresis – usually occurs 3-6 hours after heavy meal.

 

Clinical manifestations if bile duct obstructed:

  • Obstructive jaundice      –           no bile flow into duodenum
  • Dark amber urine          –           bilirubin in urine
  • No urobilinogen in urine             no bilirubin reaching SI to be converted to urobilinogen
  • Clay colored stools        –           “       “      “
  • Pruritis                          –           deposits of bile salts in skin tissues
  • Fatty food intolerance    –           no bile in SI for digestion
  • Bleeding tendencies      –           decr absorption vit K, therefore dec production PT

 

 

 

 

Complications:

  • Cholecystitis
  • Cholangitis – inflammation of biliary ducts
  • Billiary cirrhosis
  • Peritonitis
  • carcinoma

 

Nursing Interventions:

  • relieving pain
  • maintaining normal fluid volume
  • only foods as tolerated –can cause irritation and stimulation to GB, if surg – npo
  • prepare for poss surgery
  • teach pt proper diet  – low in fat, wt reduction (usually), and fat soluble vit.

 

 

 

 

 

Chronic Kidney Failure

Definition

Chronic kidney failure (CKF) involves progressive, irreversible destruction of the nephrons in both kidneys.

S/S

Fatigue, weakness, change in usual urination pattern, nausea and vomiting, headache, blurred vision, dyspnea, persistent itching.

Nursing interventions/Teaching

Manage fluid and electrolyte balance, monitor vital signs and laboratory/diagnostic studies, assess/document dietary intake measuring I&O accurately, and promote infection control.

Complications

Anemia, high blood pressure, congestive heart failure, bone disease, digestive tract problems, loss of mental functioning (dementia), sleep disorders.

 

Chronic Obstructive Pulmonary Disease

Definition

Chronic obstructive pulmonary disease (COPD) is a group of lung diseases that makes it hard for a person to breathe. In COPD, airflow through the airways (bronchial tubes) within the lungs is partially blocked, resulting in difficulty breathing. As the disease progresses breathing becomes more difficult, and it may become difficult to carry out everyday activities.

S/S

Mild COPD (stage 1) – May have a chronic and productive cough that often brings up an increased amount of sputum (mucus) from the lungs, impaired lung function (greater than 80% forced expiratory volume [FEV]) with no symptoms (only noticeable with lung tests), may have shortness of breath and wheezing. Moderate COPD (stage 2) – A chronic, productive cough, which often brings up a large amount of mucus from the lungs, shortness of breath and fatigue with exercise and strenuous daily activities, difficulty sleeping (a person may wake up feeling short of breath or coughing), occasional COPD exacerbations, which are fairly rapid, sometimes sudden, worsening in a person’s usual shortness of breath, impaired lung function (30% to 79% FEV).

Nursing interventions/Teaching

Maintain airway patency, assist with measures to facilitate gas exchange, administer medications as indicated, enhance nutritional intake, and prevent complications.

Complications

Severe shortness of breath, impaired gas exchange, respiratory imbalances (acidosis, alkalosis).

 

Chronic Renal Failure (CRF, end stage renal disease, ESRD)

Definition

Progressive deterioration of renal function, which ends fatally in uremia and its complications, unless dialysis or kidney transplant is performed.

S/S

Anorexia, N/V, hemorrhage, ulceration of GI tract, HTN, pericarditis, pulmonary edema, fatigue, HA, peripheral neuropathy, seizure, glucose intolerance, hyperlipidemia, hyperkalemia, hypocalcemia, pallor, ecchymosis, uremic frost, anemia, defect in quality of platelets, personality change, cognitive disorder.

Nursing interventions/Teaching

Maintain fluid and electrolyte balance, adequate nutrition, maintain skin integrity, prevent constipation, inspect ROM/ muscle strength, drink

Limited amounts, encourage activity as tolerated, assess pt. understanding of treatment regimen as well as concerns and fears, promote decision making by pt.

Complications

Death

 

Colititis, acute

 

Definition

Inflammation of the colon. The major cause of acute colitis is infectious, with the incidence and organism varying widely on a geographic and socioeconomic basis
Ischemic colitis is a disease of the elderly and more affluent populations with an atherosclerotic prone diet. It can also be caused by infection including viruses, bacteria, fungus and parasites or vascular, usually small vessel disease.

 

Signs/Symptoms:

May be mild or severe

  • persistent or recurrent diarrhea
  • abdominal pain
  • fever
  • fatigue
  • weight loss
  • loss of appetite

 

Nursing Interventions:

Monitor vital signs

Monitor I/O’s

Pain assessment
 – location, intensity, type, quality, frequency
– does anything relieve it

Allow client extra time to eat

Excellent perineal is needed until the diarrhea is under control & after
– kept client clean, dry, and free of odor

Administermedications as ordered

 

Complications:

Bleeding

Ulceration

Perforation of the colon

Toxic megacolon

 

Colon Cancer

 

Definition:  Malignancies of the colon and rectum. 2ndmost common visceral ca in US.  Nearly all adenocarcinomas. Risk factors include following:

  • Age – increases sharply post 40, 90% of patients w/ colon ca over 50
  • Previous hx of colon ca
  • Family hx – present in 25% of pts
  • Polyposis syndrome
  • Chronic ulcerative colitis, Cohn’s disease
  • Higher industrialized  countries- possible diet related

 

Manifested by:

 

  1. Right Sided Lesion:  Change in bowel habits, usually D, vague abd discomfort, black terry stools, anemia, weakness, wt loss, palpable mass in rt lower quadrant.
  2. Left sided lesion:   (usually can detect earlier than rt due to smaller lumen) change in bowel habits, increasing constipation, bouts of D (due to part obst), bright streaked red blood in stool, cramping pain, wt loss, anemia, palpable mass.
  3. Rectal lesion:  change in bowel habits w/ poss. urgent need to defecate, alternating const w/ D, narrowed caliber of stool, bright red stool, feeling of incomplete evacuation, rectal fullness to dull constant ache.

 

 

Nursing Interventions:

  • Achieving adequate nutrition – high calorie, low residual diet, smaller meals several times throughout day, maintain hydration via IV therapy, observe I&O d/t fluid losses  – V/ D
  • Relieving constipation/diarrhea – Monitor amount, consistency, freq, color of stool; use laxatives as needed; adequate fluids. (foods w/ slow transit time in colon – bananas, rice pb, pasta.
  • Relieving pain – administer analgesics as needed as ordered and evaluate; investigate other approaches i.e. – relaxation, repositioning, imaging, laughter, music, reading, touch.
  • Maintaining energy level – activity plan (assess limits) w/ freq rest periods; administer blood products as ordered.
  • Minimizing fear – encourages pt/fam to express feelings; acknowledge normal to have neg feelings; provide info to answer questions and refer to support groups.
  • Patient education – resources on chemo or radiation treatment, colostomy management, initiate home care management

 

Complications:

  • Hemorrhage
  • Obstruction
  • Anemia

 

Poss. Nursing DX:

  • Altered nutrition: less than body requires r/t malignancy effects and wt loss
  •  Constipation and/or Diarrhea r/t change in bowel lumen
  • Pain r/t malignancy, inflammation, and poss. intestinal obstruction

 

Colorectal Anastomosis

 

Definition

 

Closing off of a colostomy site. The bowel is freed from the skin and the body wall and reattached to the intestine. The wound where the colostomy once was is then closed off.

 

Nursing implications

 

Excessive bleeding, surgical wound infection, thrombophlebitis, pneumonia, pulmonary embolism, increased pain swelling redness drainage or bleeding in the surgical area, headache, muscle aches, dizziness, or fever, increased abdominal pain or swelling, constipation, nausea or vomiting or diarrhea.

 

Complications

 

Infection of wound site

Weakness at colostomy site

Diarrhea

Bleeding at rectum

Incontinence of stool

Irregularity

 

 

Colostomy

Definition

An opening between the colon and the abdominal wall.  The proximal end of the colon being sutured to the skin.

S/S

Monitor vital signs, assess stoma frequently, assist patient to adapt psychologically, assess peristomal skin for erythema itching or burning, assess skin for sings of breakdown, clean area and change dressing as ordered, apply skin barrier to protect skin, patient teaching on the effects of food on stoma output, patient teaching on stoma care, teach importance of maintenance and follow-up care, observe and collect drainage frequently, make sure pouch fits snugly around skin, Irrigate colostomy as ordered, describe potential resources to assist with emotional and psychological adjustment, assess for pain, I and O,

Nursing interventions/Teaching

Excessive bleeding, surgical wound infection, thrombophlebitis, pneumonia, pulmonary embolism, increased pain swelling redness drainage or bleeding in the surgical area, headache, muscle aches, dizziness, or fever, increased abdominal pain or swelling, constipation, nausea or vomiting or black, tarry stools, Necrosis of stomal tissue, retraction of stoma, prolapse of stoma, stenosis of the stoma, parastomal hernia

Complications

 

Congestive Heart Failure

Definition

Inability of the heart to generate an adequate cardiac output to perfuse vital tissues.

S/S

Shortness of breath, fatigue, peripheral edema, persistent wheezing or cough with white or pink blood-tinged phlegm, pronounced neck veins, swelling of the abdomen, rapid weight gain from fluid retention, lack of appetite or nausea, difficulty concentrating or decreased alertness, irregular or rapid heartbeat.

Nursing interventions/Teaching

Monitor cardiac output by auscultating apical pulse, assess heart rate and rhythm, monitor I & O ratios for fluid management, assess patient’s response to activity, and teach regarding condition, treatment regimen, and self-care.

Complications

Mild to moderate heart failure may have little effect on your life. However, severe heart failure can be life-threatening. It can lead to sudden death or cardiac arrest.

 

Congestive Heart Failure

Definition

An abnormal condition involving impaired cardiac pumping.  Associated with numerous types of heart disease.

S/S

Hypertension, obesity, high serum cholesterol, increased heart rate, increased respiratory rate, irritabilty, restlessness, sudden weight gain, edema, diaphoresis, cough, congestion, wheezing, decrease in activity level, decrease in urine output, pale or mottled skin, fluid in the lungs, fatigue, weakness, sleeping problems, loss of appetite

Nursing interventions/Teaching

Monitor vital signs, monitor input and output, ambulate patient, monitor cardiac output, daily weights, position to alleviate dyspnea, monitor oxygen therapy

Complications

Pulmonary edema, pulmonary congestion, heart enlargement, heart hypertrophy, irregular heartbeat, cardiac arrest, sudden death

 

COPD

Definition

A term that refers to a group of conditions characterized by continued increased resistance to expiratory airflow. Includes chronic bronchitis and pulmonary emphysema

S/S

Chronic Bronchitis:  Is insidious, develops over many years.  Productive cough, lasting at least three months a year for two successive years.

Production of thick, gelatinous sputum, greater amount produced during infection.  Wheezing and dyspnea as disease progresses.  Emphysema:

Gradual onset, steadily progressive.  Dyspnea, decreased exercise tolerance, cough may be minimal, except with infection. Sputum is mild, sparse.

Barrel chest due to air trapping.

Nursing interventions/Teaching

Teach smoking cessation, humidify O2, administer bronchodilaters as prescribed.  Teach pursed lip breathing, incentive spirometer.  Teach position of comfort—leaning trunk forward with arms on fixed object.  Monitor O2 sats, supplement as needed.  Minimize CO2 retention.

 

Outcomes:  Pt reports less dyspnea, effectively using pursed lip breathing. Tolerating small, frequent meals, weight stable.

Complications

Respiratory failure, Pneumonia, Right sided heart failure, depression, skeletal muscle dysfunction.

 

Nursing Diagnosis

Ineffective airway clearance r/t bronchoconstriction

Increased mucous production, ineffective cough.

Ineffective breathing pattern r/t chronic airflow limitation

Risk for infection r/t compromised pulmonary function and defense mechanisms

Activity intolerance r/t compromised pulmonary function

Resulting in dyspnea, fatigue.

 

Coronary Artery Disease

Definition

Characterized by the accumulation of fatty deposits along the innermost layer of the coronary arteries. The lesion (plaque) can cause a critical narrowing of the coronary arterial lumen, resulting in decreased coronary bloodflow and an inadequate supply of O2 to the heart muscle. Smokers, high cholesterol, and HTN are predisposed.  Lippencott, 356.

S/S

Stable angina pectoris (precipitated by physical exertion), unstable angina pectoris (occurring at rest—precursor to MI, does not go away with nitro.), these conditions may cause numbness or tingling in the arms, diaphoresis tachycardia, increased blood pressure, radiating pain to the jaw, neck, shoulders, arms, or hands.  Most often occurs on the left side.

Nursing interventions/Teaching

Relieve pain:  Place pt in comfortable position, administer O2 if prescribed, obtain vital signs, administer anti anginal meds as prescribed, report findings to HCP, monitor for relief of pain or pain progression, determine intensity of pain, observe for signs and symptoms, reinforce importance of pt notifying nursing staff whenever angina pain is experienced.  Decrease anxiety.  Outcome:  Pt verbalizes relief of pain.  Pt’s BP and HR stable.  Pt verbalizes lessening anxiety, ability to cope.

Complications

Sudden death due to lethal dysrythmias, CHF, MI

 

Nursing Diagnosis

Pain r/t imbalance in O2 supply and demand.  Decreased cardiac output r/t reduced preload, afterload, contractility and heart rate secondary to hemodynamic effects of drug therapy. Anxiety r/t chest pain, uncertain prognosis, and threatening environment.

 

Coronary Artery Disease

Definition

Any vascular disorder that narrows or occludes the coronary arteries; the most common cause of coronary obstruction is atherosclerosis.

S/S

Chest pain, shortness of breath, fatigue, nausea and vomiting.

Nursing interventions/Teaching

Pain management, monitor VS assessing for signs and symptoms of heart failure, anxiety control, and patient teaching regarding condition, treatment needs, and self-care for management of disease.

Complications

Heart attack, stroke, death.

 

Crohn’s

 

Definition:  Chronic idiopathic inflammatory disorder that can affect any part of the GI tract, usually the small and large intestines.  It is predominantly a transmural disease of the bowel wall.

Etiology unknown, possibly genetics, environmental agents, immunologic imbalances, defect in repair of mucosal injury leading to chronic condition, and cigarette smoking,

 

Manifested by:

  • Crampy pain – RLQ
  • Crohnic diarrhea – poss bloody stools or steatorrhea
  • Fever may indication infecton
  • Palpable RLQ fullness or mass – corresponds to adherent loops  of bowel or abscess.
  • Rectal examination may reveal perirectal abscess
  • Inflammatory patter – may display malabsorption, weight loss, less abd pain
  • Fibrostenotic pattern –  may display SBO, abd pain, N, V, bloating
  • Perforating pattern – may display sudden profuse D d/t enteric fistula, fever, localized tenderness d/t abscess, recurrent UTI’s.

 

 

 

Nursing Interventions:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complications:

 

  • Abscess
  • Strictures – may result from inflammation, edema, abscess, fibrostenosis
  • Hemorrhage, bowel perf, int o
  • Nutritional deficiencies – avoidance and malabsorption
  • Dehydration and electrolyte disturbances
  • Peritonitis and sepsis
  • Increased risk of colon ca

 

 

 

Crohn’s disease

Definition

A chronic idiopathic inflammatory disease that can affect any part of the GI tract, usually the small and large intestines. It is predominantly a transmural disease of the bowel wall.

 

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 623-626.)

S/S

Crampy pain usually in the right lower quadrant. Chronic diarrhea – usually consistency is soft or semi-liquid. Bloody stools or steatorrhea may occur. Fever may indicate infectious complication, such as abscess. Fecal urgency and tenesmus. Palpable right lower quadrant fullness or mass may be palpated, which corresponds to adherent loops of bowel or abscess. Rectal exam may reveal a perirectal abscess, fistula, fissure, or skin tags, which represent healed perianal lesions

 

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 623-626.)

Nursing interventions/Teaching

Encourage diet that is low in residue, fiber, and fat and high in calories, protein, and carbohydrates, with vitamin and mineral supplements. •

Monitor weight daily. • Provide small, frequent feedings to prevent distention. • Monitor intake and output. • Provide fluids as prescribed to maintain hydration (1,000 mL/24 hours is minimum intake to meet body fluid needs). • Monitor electrolytes (especially potassium) and acid-basebalance, because diarrhea can lead to metabolic acidosis.

 

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott- Raven Publishers. Pgs. 623-626.)

Complications

Abscess (occurs in 20%), and fistula (occurs in 40%).  Strictures – may result from inflammation, edema, abscess, adhesions, but usually from fibrostenosis.  Hemorrhage, bowel perforation, intestinal obstruction.  Nutritional deficiencies: poor caloric intake due to food avoidance, malabsorption of bile salts and fat, vitamin B12 deficiency with ileal disease, short-gut syndrome after extensive surgical resections.  Dehydration and electrolyte disturbances; Peritonitis and sepsis.  Believed to have increased risk of small bowel and colorectal cancers.

 

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 623-626.)

 

Crohns disease

Definition

Chronic, idiopathic inflammatory disease of the GI tract.  Small and Large intestines affected the most.  It is predominantly a disease of the bowel wall.

S/S

Characterized by exacerbations and remissions—may be abrupt or insidious.  Crampy pain, usually in RLQ, chronic diarrhea, fever may indicate abscess, fecal urgency, palpable RLQ fullness, skin tags in rectum, possible weight loss, malabsorption, fistulas or tenderness.

Nursing interventions/Teaching

Encourage low residue, fat and fiber diet along with diet high in calories, protein, and carbohydrates. Vitamin supplements, daily weight, small, frequent feedings.  Pt participation in meal planning.  Monitor I/Os, Provide fluids as prescribed to avoid dehydration.  Outcomes:  Pt displays improved nutritional intake, weight is stable.  Adequate fluid intake, no evidence of dehydration, electrolytes within normal limits.  Pt demonstrates relief of pain and symptoms are manageable.  Pt verbalizes improved attitude about ways to live with disease.

Complications

Abscess (occur in 20%), fistulae (occur in 40%), Strictures resulting from adhesions, inflammation, edema, abscess or fibrostenosis.  Hemorrhage, bowel perforation or obstruction.  Nutritional deficiencies, Dehydration, electrolyte imbalances, peritonitis, sepsis, increased risk of small bowel and colorectal cancers.

 

Nursing Diagnosis

Altered nutrition: less than body requirements r/t pain/nausea.  Fluid Volume Deficit r/t diarrhea.  Pain r/t inflammatory disease of the small intestine. Ineffective Individual Coping r/t feelings of rejection, embarrassment.

 

Cystic Fibrosis

 

Definition

An autosomal recessive, multisystem disease characterized by altered function of the exocrine glands involving primarily the lungs, pancreas, and sweat glands.

 

Signs/Symptoms

Meconium ileus in the newborn infant

Childhood manifestations such as:

-failure to grow

-clubbing

-persistent cough with mucous production

-tachypnea

-large, frequent bowel movements

In adults:

Frequent cough that over time becomes persistent and produces viscous, purulent often greenish colored sputum.

Recurring lung infections such as bronchiolitis, bronchitis, pneumonia.

 

Nursing Interventions

Promote clearance of the secretions

Provide adequate nutrition

 

Cystic Fibrosis

 

Definition:

An autosomal recessive, multisystem disease characterized by altered function of the exocrine glands involving primarily the lungs, pancreas, and sweat glands.

 

Signs/Symptoms:

Meconium ileus in the newborn infant

Childhood manifestations such as:

-failure to grow

-clubbing

-persistent cough with mucous production

-tachypnea

-large, frequent bowel movements

In adults:

Frequent cough that over time becomes persistent and produces viscous, purulent often greenish colored sputum.

Recurring lung infections such as bronchiolitis, bronchitis, pneumonia.

 

Nursing Interventions:

Promote clearance of the secretions

Provide adequate nutrition

 

Complications:

Chronic infections

Hemoptysis

Pulmonary hypertension

Death

 

 

Decubitis ulcer

Definition

A localized area, usually over a bony prominence, of tissue necrosis caused by unrelieved pressure that occluded blood glow to the tissues.

S/S

Is very dependent upon the stage it is in.  Stage one is an alteration of intact skin.  The area may be warmth or cool to the touch and feel firm or boggy.  The ulcer will be red and will not go away after touching it. Stage two involves the loss of epidermis, dermis or both.  It may look like a blister.  Stage three is full thickness skin loss and it may be necrotic.  The ulcer presents clinically as a deep crater.  Stage four is all the way down.  The muscle or bone may be seen.

Nursing interventions/Teaching

Assess causative factor to reduce or eliminate that factor.  Assess stage and document characteristics on a regular basis.  Use pressure relief devices.  Use assistive devices.  Protect patient’s skin from excess moisture.  Offer vitamin and mineral supplements.  Teach family and patient about causative factor.  Make patient feel as comfortable as possible.  Turn as needed, at least Q4H.

Complications

Pain, cellulitis, osteomyolitis, septic arthritis, loss of function, high risk of amputation, infection, hygiene problems, loss of joint integrity, impaired healing, loss of ADL, sepsis

 

Deep Vein Thrombosis

Definition

Thrombophlebitis is a condition in which a clot forms in a vein, associated with inflammation/trauma of the vein wall or a partial obstruction of the vein.

S/S

Generalized or extremity weakness, Tachycardia, pulse may be diminished, Skin color/temperature in affected extremity (calf/thigh): pale, cool, edematous (DVT); pinkish red, warm along the course of the vein (superficial) Positive Homans’ sign (absence does not rule out DVT), Poor skin turgor, dry mucous membranes (dehydration predisposes to hypercoagulability) Obesity (predisposes to stasis and pelvic vein pressure) Edema of affected extremity (present with thrombus in small veins or major venous trunks). Throbbing, tenderness, aching pain aggravated by standing or movement of affected extremity, groin tenderness, Guarding of affected extremity, Fever, chills.

Nursing interventions/Teaching

Maintain/enhance tissue perfusion, facilitate resolution of thrombus.

Promote optimal comfort.

Prevent complications.

Provide information about disease process/prognosis and treatment regimen.  Hematocrit: Hemoconcentration (elevated Hct) potentates risk of thrombus formation. Coagulation profile: Levels of PT, PTT, and platelets may reveal hypercoagulability. Venography: Radiographically confirms diagnosis through changes in blood flow and/or size of channels. Note: This study carries a risk of inducing DVT and therefore is reserved for patients with negative or difficult-to-interpret noninvasive studies in the presence of high clinical suspicion.  MRI: May be useful in assessing blood flow turbulence and movement, venous valvular competence. Promote bedrest initially, with legs elevated above heart level during acute phase. Instruct patient to avoid rubbing/ massaging the affected extremity. Encourage deep-breathing exercises. Increase fluid intake to at least 2000 mL/day, within cardiac tolerance. Medications: Anti-coagulants, ASA

Complications

Surgical intervention, Ventilatory assistance (mechanical), Fractures, Psychosocial aspects of care

 

Deep Vein Thrombosis/Thrombophlebitis

Definition

Occurs when a blood clot and inflammation develop in one or more veins.

S/S

Warmth, tenderness, and pain in the affected area, redness, and swelling.

Nursing interventions/Teaching

Evaluate circulatory and neurological studies of involved extremity, administer anticoagulants as indicated, utilize pain management techniques, and monitor VS.

Complications

Pulmonary embolism, heart attack, or stroke. May also damage valves in the legs causing varicose veins, swelling, skin discoloration, or vein obstruction.

 

Degenerative Joint Disease

Definition

The breakdown of joint cartilage that may affect any joint in your body, including those in your fingers, hips, knees, lower back and feet.

S/S

Pain in a joint during or after use, or after a period of inactivity, discomfort in a joint before or during a change in the weather, swelling and stiffness in a joint, particularly after using it, bony lumps on the middle or end joints of your fingers or the base of your thumb, loss of joint

flexibility.

Nursing interventions/Teaching

Promote optimal mobility, reduce discomfort/pain.

Complications

Pain, from mild to debilitating.

 

Degenerative Joint Disease (osteoarthritis)

Definition

Is a chronic, noninflammatory, slowly progressing disorder that causes deterioration of the articular cartilage.  It affects weight bearing joints as well as interphalangeal joints.   Lippencott, 1010.

S/S

Pain, due to inflammation of the joint, bone spurs.  Affects those 50-90, w/ obesity and aging the major contributing factors.

Nursing interventions/Teaching

Relieve pain:  Advise pt to take prescribed NSAIDS, rest, encourage use of splints, braces, etc.  Apply heat as prescribed, encourage weight loss, advise corrective shoes, teach correct posture.  Teach ROM exercises, isometric exercises, use assistive devices for grooming and eating. Suggest swimming, refer to The Arthritis Foundation, 1.800.933.0032.  Outcomes: Pt reports reduction in pain while ambulatory.  Pt performs ROM exercises.  Pt dresses, bathes, and grooms self with assistive devices.

Complications

Limited mobility. Neurological defects associated with spinal involvement.

 

Nursing Diagnosis

Pain r/t joint degeneration and muscle spasm.

Impaired physical mobility r/t pain and limited joint motion.

Self care deficit r/t pain and limited joint movement.

 

Degenerative joint disease- DJD

Definition

A noninflammatory, progressive disorder of movable joints, particularly weight-bearing joints; characterized by the deterioration of articular cartilage and pain with motion.

S/S

Discomfort and pain, disability specific to the involved joint, joint pain, difficulty sitting down, joint stiffness in early morning, crepitation, bony enlargements, loss of joint function, diminished ability to independently perform self-care,

Nursing interventions/Teaching

Nutritional counseling, rest and joint protection, use of assistive devices, therapeutic exercise, heat and cold, assess and monitor vital signs, assess the type of pain, assess the duration of pain, use of massaging, assess the severity of the pain, watch I & O and daily weights, avoid forceful repetitive movements, avoid positions of joint deviation and stress, use good posture and proper body mechanics, teach patient how to relieve pain and stress on joints.

Complications

 

Dehydration

Definition

pg 435, Nursing Diagnosis Handbook.  Decreased intravascular, interstitial, and/or intracellular fluid.  (refers to dehydration, water loss alone w/out change in sodium level)

S/S

decreased urine output, increased urine concentration, weakness, sudden weight loss, decreased venous filling, increased body temperature, decreased  pulse volume/pressure, change in mental state, elevated hematocrit, decreased skin/tongue turgor, dry skin/mucous membranes, thirst, increased pulse, decreased BP.

Nursing interventions/Teaching

Monitor for existence of factors relating to deficient fluid volume, watch for signs of hypovolemia (weakness, restlessness, muscle cramps), monitor I/O’s, monitor daily weights, orthostatic BPs, administer antidiarrheals/antiemetics as prescribed, assist with ambulation due to dizziness, promote skin integrity. Outcomes:  Client will maintain urine output of more than 1300ml/day (30 ml/hr).  Client will maintain normal BP, Pulse, Temp.  Patient will maintain elastic skin turgor, moist tongue, and mucous membranes, and LOC.Patient will explain measures that indicate the need to consult with healthcare provider.

Complications

electrolyte imbalance, constipation, bowel obstruction

 

Nursing Diagnosis:

Fluid volume deficit, r/t (any number of factors)

 

Dementia

Definition

A chronic disturbance involving multiple cognitive deficits, including memory impairment. Primary dementia is a degenerative disorder that is          progressive, irreversible, and not due to any other condition (i.e. dementia of Alzheimer’s type). Secondary dementias occur as a result of another pathologic process i.e. TB, chronic meningitis.

S/S

Fluctuating levels of awareness, confused/disoriented, disturbed memory, alteration in sleep/wake cycle, perceptual disturbances, personality change, apathy, inability to learn new material.

Nursing interventions/Teaching

1) speak slowly and use short, simple words and phrases 2) consistently ID yourself and address pt. by name 3) focus on one thing at a time and review 4) acknowledge feelings 5) keep area well lit 6) keep personal items in view 7) encourage/assist with ADLs 8) monitor I&O, weight 9) identify stressors 10) encourage participation in simple activities.

Complications

without accurate diagnosis and treatment secondary can become permanent, falls, self inflicted injury, aggression or violence toward self/ others, wandering events, depression.

 

Diabetes

Definition

A multisystem disease related to abnormal insulin production, impaired insulin utilization, or both.

S/S

Increased thirst, increased hunger (especially after eating), dry mouth, frequent urination, unexplained weight loss or gain, fatigue, blurred vision, labored, heavy breathing (Kussmaul respirations), slow-healing sores or cuts, frequent infections, numbness or tingling of the hands and feet, red, swollen, tender gums.

Nursing interventions/Teaching

Manage fluid and electrolyte balance, monitor vital signs and laboratory/diagnostic studies, assess/document dietary intake measuring I&O accurately, promote infection control, and patient teaching of management of the disease.

Complications

Low/high blood sugar, increased blood acids, nerve damage (neuropathy), kidney damage (nephropathy), eye damage, heart and blood vessel disease, and infections.

 

Diabetes Mellitis

Definition

Metabolic disorder characterized by hyperglycemia.  Results from defective insulin production, secretion, or utilization. (Beta cell) Lippencott, 841.  Type 1 (IDDM):  Little to no endogenous insulin, requires injections to control diabetes and prevent ketoacidosis.  Autoimmune/viral component.   Can be genetic. Type 2 (NIDDM):  Combo of insulin resistance and insulin deficiency.  90% are this type.  Hereditary, obesity contributes.

S/S

Type 1:  Presentation is rapid, with polydipsia, polyuria, and weight loss.; Type 2:  Presentation is slow, insidious with fatigue, weight gain, poor wound healing, and recurring infections.

Nursing interventions/Teaching

Assess level of knowledge. Assess adherence to diet therapy, exercise regimen.  Assess for signs of hypoglycemia (diaphoresis, tremors, confusion, tachycardia, nervousness).  Perform thorough skin assessment.  Get immediate help for signs of ketoacidosis (fruity breath odor, Kussmaul breathing, n/v, altered LOC).  Outcome: Pt maintains ideal body weight, Pt demonstrates self injection of insulin w/ minimal fear, Pt verbalizes appropriate use and action of oral hypoglycemic agents, Exercises daily, Hypoglycemia identified and treated appropriately.

Complications

Hypoglycemia due to imbalance in food, activity, insulin.  DKA (in Type 1) during times of illness produces hyperglycemia, ketonuria, dehydration, acidosis.  Peripheral vascular disease. CAD due to vessel deterioration and arteriosclerosis caused by hyperglycemia.  Cerebrovascular disease.  Retinopathy.  Peripheral Neuropathy.

 

Nursing Diagnosis

Altered Nutrition: more than body requirements.

Fear r/t insulin injection.

Risk for impaired skin integrity r/t decr sensation/circulation.

Ineffective coping r/t complex care regimen/chronic disease.

 

Diabetes Mellitus

Definition

A multi-system disease related to abnormal insulin production, impaired insulin utilization, or both.

S/S

N/A

Nursing interventions/Teaching

Ample Patient teaching, monitor VS, daily weights, Accu checks, exercise, dental examination, podiatric examination, monitor nutritional status,calorie count diet, monitor lab results, provide support group information

Complications

Heart disease, stroke, blindness, lower limp amputations, obesity, renal failure, neuropathy, vagal dysfunction, retinopathy, diabetic ketoacidois

 

Diabetes Mellitus

 

Definition:  DM is a disorder of carb, protein, and fat metabolism resulting from an imbalance between insulin availability and insulin need.  It can occur by

  • Insulin deficiency
  • Impaired release of insulin by pancreatic beta-cells
  • Inadequate or defective receptors
  • Production of inactive insulin or
  • Insulin that is destroyed before it can carry out its action

A person with uncontrolled dm is unable to transport glucose into fat and muscle cells. RESULT: body cells starved, and breakdown of fat and protein is increased.

 

Manifested by:   (onset abrupt w/ type 1, and insidious w/ type 2)

  • Wt loss, fatigue (body lacks needed E from glucose)
  • Polyuria (frequent urination)
  • Polydipsia (excessive thirst)
  • Polyphagia (excessive hunger) – result of cellular malnourishment (glucose can’t get swept into cells by broom (insulin)
  • Blurred vision
  • Poor wound healing
  • Recurrent infections (particularly skin)
  • Ketoacidosis

 

 

 

Nursing Interventions:

  • Check blood glucose (looking for hypo- and hyperglycemia)
  • Insulin as ordered – demonstrate and explain procedure for self -injection
  • Prevent infection/maintain skin integrity
    • Any lesion, decrease pulses , change in skin color, temp, and sensation evaluated and treated asap.
    • Any foot wounds/injuries treated immediately – elevate, avoid wt bearing, wet to dry dressing applied as ordered, antibiotics as ordered.
  • Nutritional therapy
  • Exercise therapy/improving activity tolerance – enhances action of insulin
  • Pt education health maintenance: lifestyle, exercise, travel, foot care guidelines, insulin management, dietary considerations.

 

Chronic Complications:

  • Cerebrovascular disease –htn H lipids, smoking, uncontrolled glucose increase risk CVA/TIA
  • CAD – hyperglycemia contributes to atherosclerosis/vessel deterioration
  • PVD – 50% amputations related to DM
  • Retinopathy – sclerosis of vessels of eye (blindness)
  • Nephropathy – renal vessel sclerosis, thickening glomular basement membrane
  • Sexual disfunction
  • Orthostatic hypotension

 

Diabetic peripheral vascular disease

Definition

Hardening of the arteries due to diabetes.

S/S

Urine that is foamy in appearance, foot ulcers, claudication (pain in legs while walking), loss of sensation in hands or feet, HTN, chest pain, edema, weight gain, blurry vision.

Nursing interventions/Teaching

Physical examination/ change in skin integrity, tibial/pedal pulses, capillary refill, skin: pale/cool, instruct pt. on foot care guidelines, smoking cessation, safe exercise.

Complications

claudication, absent pedal pulses, ischemic gangrene, necrosis, amputation.

 

Nursing Diagnosis:

Risk for impaired skin integrity R/T decreased sensation and circulation to lower extremities.

Ineffective coping R/T chronic disease and complex care regimen.

Knowledge deficit R/T foot care, exercise, diet, and smoking.

 

 

Diarrhea

 

Definition

Loose, watery stools occurring more than three times in one day–is a common problem that usually lasts a day or two and goes away on its own without any special treatment. However, prolonged diarrhea can be a sign of other problems. People with diarrhea may pass more than a quart of stool a day.

 

Signs/symptoms

Diarrhea may be accompanied by cramping abdominal pain, bloating, nausea, or an urgent need to use the bathroom. Depending on the cause, a person may have a fever or bloody stools.

Diarrhea can be either acute or chronic.

 

Nursing interventions

 

Give prescribed medications to help alleviate symptoms.

Maintain electrolyte levels, you could have broth or soups, which contain sodium, and fruit juices, soft fruits, or vegetables, which contain potassium.

Monitor vital signs closely.

Assess for signs of infection.

 

Complications

 

-dehydration

-can lead to death if severe enough and untreated

 

 

Diverticulitis

Definition

Inflammation of the diverticula, (saccular dilation or outpouching of the mucosa through the circular smooth muscle of the intestinal wall.).  Most commonly found in the sigmoid colon.

S/S

Majorities of pt. have no symptoms.  Those with symptoms have: crampy abdominal pain in lower left quadrant that is relieved by passage of flatus, alternating constipation and diarrhea, abdominal pain that is localized over area of colon, fever, chills, nausea, anorexia, elevated WBC count, afebrile

Nursing interventions/Teaching

High-fiber diet, dietary fiber supplements, stool softeners, anticholingergics, mineral oil, bedrest, clear liquid diet, oral antibiotics, NG suction, patient teaching about diet, increased fluid intake, assess pt. for bowel spasms, teach patient to avoid: straining with stool vomiting bending lifting and tight clothing, NPO status, assess pt. for signs of possible peritonitis, ambulating if acute attack occurs, monitor WBC count, provide patient with a full explanation of his/her status

Complications

Perforation with peritonitis, abscess and fistula formation, bowel obstruction, urethral obstruction, bleeding

 

Diverticulitis

 

Definition:  Results when one or more diverticula become inflamed and usually perforate the thin diverticular wall.  The inflammation may be caused by a combination of a fecal plug and accumulating bacteria.  If diverticulum perforates, local abscess or peritonitis may occur.  Uninflammed or minimally inflamed diverticula may erode arterial branches causing acute massive rectal bleeding.

15% of people with Diverticulosis will develop diverticulitis.

 

Manifested by:

Mild:

  • Bouts of soreness, mild lower abd cramps
  • Bowel irregularity, constipation, diarrhea
  • Mild nausea, gas, low grade fever, and leukocytosis

 

Severe:

  • Crampy pain in LLQ abd
  • Low grade fever, leukocytosis
  • Ruptured diverticular – near blood vessel, massive hemorrhage
  • Sometimes fistula form with adjacent small bowel, bladder, vagina, perianal area or skin.
  • Sepsis may spread via portal vein to liver
  • Chronic div. may cause adhesions which narrow bowel’s opening causing partial or complete obstruction.
  • Urinary frequency and dysuria are assoc w/ bladder involvement in inflammatory process.

 

 

 

 

 

Nursing Interventions:

 

  1. Achieving pain relief:

Observe s/s pain, type, and severity

Administer nonopiate analgesics as prescribed (opiates may mask perforation)

Anticholinergics as prescribed – decrease colon spasm

  1. Auscultate bowel sounds to monitor motility, palpate abd to determine rigidity or tenderness r/t perforation or peritonitis.
    3.  Maintain adequate nutrition – high soft residue and low in sugar, bran products, monitor I&O.
  2. Promoting normal bowel elimination:

Encourage fluids if constipated

Observe color, consistency and freq of stools.

  1. Patient education

 

Complications:

  • Hemorrhage from colonic deverticula
  • Bowel obstruction
  • Fistula formation
  • Septicemia

 

Diverticulosis

Definition

Pg 617, Lippencott.  Marks the formation of diverticula, which are herniations in the mucosal and submucosal layers of the colon at weak points where nutrient blood vessels penetrate the colon walls.  Causes are unclear, but contributing factors may include a low residue diet.  Most often occurs in persons over 60.  Diverticulitis results when one or more diverticula become inflamed and perforate the wall.  An abscess or peritonitis may occur from this.

S/S

May be asymptomatic, crampy abdominal pain(LLQ), bowel irregularity (constipation/diarrhea), periodic abdominal distension, sudden massive hemorrhage may be first symptom.

Nursing interventions/Teaching

Pain relief, intervene when appropriate.  Auscultate bowel sounds.  Follow prescribed diet, high in soft residue, low in sugar.  Emphasize that proper food intake influences how the intestinal tract functions. Observe color, frequency, consistency of stools.  Encourage fluids.  Refer to nutritionist.  Outcomes: Pt will consume a prescribed diet and relay what foods to include/avoid.  Pt will express relief in pain and has a decrease in symptoms.

Complications

Hemorrhage, bowel obstruction, fistula formation, septicemia.

 

Nursing Diagnosis:

Pain r/t intestinal discomfort

Altered nutrition: less than body requirements r/t nausea, vomiting, diarrhea

Constipation or Diarrhea r/t disease process

Knowledge deficit of the relationship between diet and diverticular disease

 

Diverticulosis:  

 

Definition:  Formation of pockets or herniations of the mucosal and submucosal layers of the colon which develop at weak points (where nutrient blood vessels penetrate the colon wall).

Causes unclear, intraluminal pressure plays a role – this may be caused by a low residue diet.

Occurs in most people over 60.

 

Manifested by:

Prediverticular: 

  • May be asymptomatic
  • Abd pain, worsens after eating and before bm’s
  • C, D

 

Diverticulosis:

  • Asymptomatic
  • Crampy abd pain
  • Bowel irregularity – C and/or D
  • Periodic abd distention
  • Sudden massage hemorrhage – may be first symptom

 

 

 

Management:

Prediverticular:

  • High-fiber diet
  • Bran therapy, Metamucil

 

Diverticulosis:

  • High fiber diet
  • Avoid large seeds, nuts – clog diverticular sac
  • Stool softeners: bran therapy, colace
  • Liquid or low residue diet – minimize symptoms, irritation and progression to diverticulitis

 

Complications:

  • Hemorrhage from colonic diverticula’s – usually rt colon
  • Bowel obstruction
  • Fistula formation
  • septicemia

 

Poss. Nursing DX:

 

  • pain r/t intestinal discomfort, d, and/or c
  • altered nutrition: less than body requirements r/t d, fluid and electrolyte loss, n, and v
  • Knowledge deficit or relationship between diet and diverticular disease.

 

Epidural Catheter Insertion

 

Definition:  An epidural catheter is a very fine plastic catheter (tube)  that is placed through the skin into the epidural space in your spine. This temporary catheter is left in place for a defined period of time; normally less than (2)two weeks. The catheter allows access to the epidural space to inject medication such as local anesthetics and/or narcotics for relief of pain. Temporary epidural catheters are used for tempory treatment of painful conditions that require pain control for intensive physical therapy and/or joint mobilization.  They are also used prognostically for trials of spinal medications prior to placement of permanent implanted ports or  programmable pumps.

Complications:  The temporary epidural catherter placement is a safe minor surgical procedure but, as with any procedure, it has risks as well as benefits.

  • Infection and/or local bleeding
  • Numbness and/or weakness and/or sedation (respiratory)

Nursing Interventions:

 

  1. Screen for pain at each visit: location, duration, quality, and impact. – using a pain intensity scale and impact on daily activities.
  2. Assess relief from medications and duration of relief.
  3. Administer drugs orally whenever possible – avoid IM, try ATC rather than PRN
  4. Convey impression, pt pain understood and can be controlled.
  5. Reevaluate pain frequently.
  6. Use alternative measures to relieve pain: guided imagery, relaxation, biofeedback.
  7. Provide ongoing support and open communication.
  8. Provide education of meds.
  9. Take measures to prevent and treat side effects of opiates – ie constipation, N, sedation.

 

 

 

 

Exploratory Laparotomy

 

Definition:

Abdominal exploration is a type of surgery where the abdomen is opened (laparotomy) and explored (exploratory laparotomy) for examination and treatment of problems. The surgeon makes an incision into the abdomen and examines the abdominal organs. The size and location of the incision depends on the clinical situation. Biopsies can be taken and diseased areas can be treated. When the treatment is complete, the incision is closed.

The abdomen contains many vital organs: the stomach, the small intestine (ileum), the large intestine (colon), the liver, the spleen, the gallbladder, the pancreas, the uterus, the Fallopian tubes, the ovaries, the kidneys, the ureters, the bladder, and many blood vessels (arteries and veins). Some problems inside the abdomen can be easily diagnosed with non-invasive tests, such as X-rays and CT scans, but many problems require surgery to “explore” the abdomen (exploratory laparotomy) to obtain an accurate diagnosis.

While the patient is deep asleep and pain-free (general anesthesia), the surgeon makes an incision into the abdomen and examines the abdominal organs. The size and location of the incision depends on the clinical situation. Biopsies can be taken and diseased areas can be treated. When the treatment is complete, the incision is closed.

An exploratory laparotomy may be recommended when there is abdominal disease from an unknown cause (to diagnose).

Diseases that may be discovered by exploratory laparotomy include:

  • Ac appendicitis
  • pancreatitis
  • pockets of infection ie. retroperitoneal abscess, abdominal abcsess, pelvic abscess.
  • Endometriosis:  presence of uterine tissue (endometrium) in the abdomen
  • Salpingitis:  inflammation of the Fallopian tubes
  • Adhesions:  scar tissue in the abdomen
  • Cancer  (of the ovary, colon, pancreas, liver) – and to determine extent
  • Diverticulitis:  inflammation of an intestinal pocket
  • hole in the intestine (intestinal perforation)
  • ectopic pregnancy –  in the abdomen instead of uterus

 

Fever

 

Definition

A riseinthetemperatureofthe body above its normal range. Normal temperatures vary slightly from person to person.  A “significant” fever is an oral or ear temperature of 102 F or a rectal temperature above 103 F. Fever is the body’s natural response to infection. A part of the brain called the hypothalamus raises the body temperature to create an environment that is unfavorable for the bacteria or viruses that cause infectious disease.

 

S/S

Headache

Muscle aches

Generalized weakness

Lack of appetite

Dehydration

Sweating/shivering

 

 

Nursing interventions

Depending on the reason for the fever, nursing interventions may include: administration of antibiotics or non-steroidal anti-inflammatory (NSAIDS); encouraging fluids to prevent dehydration, application of cool compresses or a cool bath; encouraging rest.

 

Complications:

Very high fevers, between 103ºF and 106ºF, may cause hallucinations, confusion, irritability and even convulsions

 

Fibromyalgia

Definition

is a syndrome characterized by fatigue, diffuse muscle pain and stiffness, sleep disturbance, and tender points on physical examination.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 953-954.)

S/S

Fatigue,Generalized muscle pain and stiffness,Poor or nonrestorative sleep,Irritable bowel syndrome,Tension headaches,Paresthesias,Sensation of swollen hands,Presence of pain in 11 to 18 defined tender point sites

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 953-954.)

Nursing interventions/Teaching

Encourage regular use of analgesics and antidepressants as directed. • Encourage regular exercise routine, including stretching, aerobic activity, and muscle strengthening exercises. • Suggest referrals to physical therapist or pain specialists for additional pain control modalities as needed.  Suggest regular nighttime ritual to promote sleep. • Encourage patient to look at fibromyalgia as a chronic condition that can be controlled.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 953-954.)

Complications

Deconditioning; Work disability; Inability to fulfill social role; Unnecessary diagnostic and therapeutic maneuvers

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 953-954.)

 

Fracture

Definition

  1. Sudden breaking of a bone. 2. A break of a bone. Blow-out fracture – A fracture of the floor of the orbit in which fragments are displaced downward by a blow to the eye or periorbital area

(Venes, D. (19th ed.) (2001). Taber’s Cyclopedic Medical Dictionary.  Philadelphia: F.A. Davis Company.  CD-ROM.)

S/S

Malocclusion,Asymmetry,Abnormal mobility,Crepitus (grating sound with movement),Pain,Tenderness. Tissue injury: Swelling,Ecchymosis,Bleeding,Pain

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs.

542.)

Nursing interventions/Teaching

Preventing Aspiration: Maintain elevated airway. Elevate head of be 30-45 degrees, or position leaning over a bedside stand to reduce edema and improve handling of secretions. • Maintaining Nutritional Status: Administer liquid diet as prescribed; place straw against teeth or trough any gaps in teeth. Teeth may initially be sensitive to hot and cold. • Increasing Comfort: Administer liquid or a suspension of analgesics as prescribed – avoid narcotics on an empty stomach, which may cause nausea and vomiting. • Strengthening Body Image: Provide firm reassurance regarding progress to reduce anxiety and allay fears. • Preventing Complications: Provide mouth care every 2 hours while awake for the first several days, then 4-6 times per day. • Patient Education and Health Maintenance: Encourage adequate nutrition – inform the patient and family that foods can be blended and thinned with juices or broths to a consistency that can be taken through a straw.

(Lippincott Manual of Nursing Practice. (7thed.) (2001). Philadelphia: Lippincott-Raven Publishers.  Pgs. 543-544.)

Complications

Airway obstruction, aspiration; Hemorrhage, infection; Disfigurement; Extraocular muscle entrapment/orbital globe displacement with resultant visual disturbance

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 543.)

 

Fracture

Definition

A break in the continuity of bone. A fracture occurs when stress placed on the bone is greater than the bone can absorb.  Muscles, blood vessels, nerves, tendons, joints, and other organs may be injured when a fracture occurs.

S/S

Pain at injury site, swelling, tenderness, deformity, loss of function, ecchymosis, parasthesia

Nursing interventions/Teaching

Prevent Neurovascular compromise by monitoring for compartment syndrome, diminished circulation, compressed nerves.   Pain, parathesia, pallor, pulselessness, palpate—5 P’s.  Prevent development of pressure ulcer from inactivity.  Monitor pain and administer drugs as prescribed.  Monitor for fatty emboli.  Outcomes:  No calf pain reported (Homan’s), Afebrile, Pt performing ROM correctly, Vitals signs stable

Complications

Muscle atrophy, loss of ROM, pressure sores, constipation, diminished respiratory/GI  function.  Also, venous stasis, infection, shock, emboli.

 

Nursing Diagnosis:

Pain r/t injury.

Impaired physical mobility r/t injury.

 

Fracture

Definition

  1. Sudden breaking of a bone. 2. A break of a bone. closed fracture – A fracture of the bone with no skin wound. (Venes, D. (19th ed.) (2001). Taber’s Cyclopedic Medical Dictionary. Philadelphia: F.A. Davis Company.  CD-ROM.)

S/S

Physical Findings: Pain at site of injury, Swelling, Tenderness, False motion and crepitus (grating sensation), Deformity, Loss of function, Ecchymosis, Paresthesia,Altered Nerovascular Status: Progressive uncontrollable pain, Pain on passive movement, Altered sensations (paresthesia), Loss of active motion, Diminished capillary refill response, Pallor,Shock: Bone is very vascular, Covert hemorrhage into soft tissues (especially with femoral fracture) or body cavity, as with pelvic fracture, May be fatal if not detected.

Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 1002.)

Nursing interventions/Teaching

Teach patient proper body alignment when applying and using external fixation device, most commonly with joints in neutral position. • Teach patient and significant other active and/or passive ROM of adjacent joints q8h as appropriate. • Monitor neurovascular condition at regular intervals by checking temperature (circulation), movement, and sensation in affected extremity. • In the absence of signs of thrombosis, encourage patient to perform calf-pumping ankle-circle exercises. • Assist in use of a pain intensity rating scale to evaluate pain and analgesic relief on a scale of 0 (no pain) to 10 (worst pain imaginable).

(Swearingen, P. L. (2004) All-in-One Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric Nursing Care Plans. St. Louis: Mosby, Inc.  Pgs. 543.)

Complications

Muscle atrophy, loss of strength and endurance; Loss of ROM – joint contracture; Pressure sores at bony prominences; Diminished respiratory, cardiovascular, GI function, resulting in pooling of respiratory secretions, orthostatic hypotension, anorexia, constipation, etc.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers.  Pgs. 1004.)

 

Fracture

Definition

A disruption or break in the continuity of the structure of bone.

S/S

Immediate localized pain & tenderness, ¯ or loss of function, inability to bear weight on or use the affected part, edema & swelling, muscle spasms, deformity, ecchymosis, grating/ crepitation, numbness, tingling, loss of distal pulses, open wound over injured site/ exposure of bone.

Nursing interventions/Teaching

Monitor vital signs, level of consciousness, O2 sat, peripheral pulses, pain, monitor for compartment syndrome, monitor for fat emboli, monitor skin integrity, anatomic realignment of bone fragments (reduction), immobilization to maintain realignment, restoration of normal or near normal function, treat life threatening injuries first, ensure airway, breathing, & circulation, control external bleeding with direct pressure or sterile pressure dressings, splint joints above and below fx site, check neurovascular status, distal to injury before & after splinting, elevate injured limb if possible, do not attempt to straighten fx or dislocated joints, do not manipulate protruding bone ends, apply ice packs to affected area, obtain x-ray of affected limb, administer tetanus prophylactically, mark location of pulses to facilitate repeat assessment.

Complications

Delayed union, nonunion, malunion, angulation, pseudoarthrosis, refracture, myosilis ossifications, compartment syndrome (excessive pain, pain with passive stretch, pallor, parasthesia, paralysis, pulselessness), fat emboli syndrome (dyspnea, CP), DVT’s, infection, venous thrombosis.

 

Fracture Care

Definition

Lippincott pg 1001  A fracture is a break in the continuity of a bone.  Muscles, blood vessels, nerves, tendons, joints and other organs may be injured when a fracture occurs. Pt education- rapid post-op recovery should be expected, notify surgeon immediately of any subtle change in post-op course or persistent symptoms due to possible bile duct injury

 

Types: Complete – involves entire cross-section of the bone, usually displaced (not normal positioning) Pt education- rapid post-op recovery should be expected, notify surgeon immediately of any subtle change in post-op course or persistent symptoms due to possible bile duct injury Incomplete- involves a portion of cross-section or may be longitudinal Pt education- rapid post-op recovery should be expected, notify surgeon immediately of any subtle change in post-op course or persistent symptoms due to possible bile duct injury

 

Closed (simple)- skin (mucous membrane) not broken Pt education- rapid post-op recovery should be expected, notify surgeon immediately of any subtle change in post-op course or persistent symptoms due to possible bile duct injury

 

Open (compound)- skin (mucous membrane) broken Pt education- rapid post-op recovery should be expected, notify surgeon immediately of any subtle change in post-op course or persistent symptoms due to possible bile duct injury Pathologic- through an area of diseased bone (osteoporosis, bone cyst, bone tumor, bony metastisis) Pt education- rapid post-op recovery should be expected, notify surgeon immediately of any subtle change in post-op course or persistent symptoms due to possible bile duct injury Many factors influence diagnosis, management and care- including type, location and severity of fracture and soft tissue damage. Also age and health status of pt, including type and extent of other injuries

S/S

Management- 3 steps: Reduction- setting the bone Pt education- rapid post-op recovery should be expected, notify surgeon immediately of any subtle change in post-op course or persistent symptoms due to possible bile duct injury Immobilization- to maintain reduction until bone heals*

Pt education- rapid post-op recovery should be expected, notify surgeon immediately of any subtle change in post-op course or persistent symptoms due to possible bile duct injury; Rehabilitation- to regain normal function; All management and care approaches vary by site and type of fx.  Assess for VS, check lab values, monitor I & O’s, evaluate changes in mental status; Encourage coughing, deep breathing; Assess pain levels; Assess for neurovascular compromise: pain, weakness, paresthesia, poor capillary refill response, skin color, elevated comparted pressure, pulselessness; Pt education: rehabilitation, PT/OT assessment, nutrition, follow up case

Nursing interventions/Teaching

Complications: muscle atrophy due to immobilization, loss of ROM due to joint contracture; Pressure sores due to bed rest or devices pressing on skin; Diminished CV, GI function, constipation ; Infection; Thromboembolism; Shock – especially with open fractures; Pulmonary emboli; Change in behavior/cerebral functioning may be an early indicator of cerebral anoxia from shock or pulmonary or fatty emboli.

 

Gallstones

Definition

Solid deposits of cholesterol or calcium salts that form in the gallbladder or nearby bile ducts.

S/S

Chronic indigestion, sudden, steady and moderate to intense pain in the upper-middle or upper-right abdomen, nausea and vomiting.  If stones have blocked the bile ducts, other S/S may include: Jaundice, clay-colored stools, tea or coffee colored urine, and a high fever with shaking chills if an infection in the biliary system (cholangitis) develops as a result of the obstruction.

Nursing interventions/Teaching

Pain management, monitor vital signs and laboratory/diagnostic studies, assess/document dietary intake measuring I&O accurately, and promote infection control.

Complications

Cholecystitis, cholangitis, acute pancreatitis, gallbladder cancer.

 

Gastritis

Definition

The inflammation of the gastric mucosa, acute or chronic

S/S

Nausea, Vomiting, Feeling of Fullness Cramping; Upper abdominal pain, Belching, Malaise, Anxiety

Nursing interventions/Teaching

Assess; S/S & reactions to Tx I/O Electrolyte Signs of GI bleeding; bloody NG drainage, melena; Hemorrhagic shock; (HCT/Hemoglobin) V/S N/V diarrhea, abd pain, fever  Implement: Med Administration of antacids/anticholinergics/antibiotics as ordered; NG tube if ordered; Administer iced saline lavage, vasopressin or; epinephrine to control bleeding as prescribed; Prepare client for endoscopic laser photocoagulation to control bleeding  Educate:S/S; requiring medical intervention Med administration; Instruct client and family regarding disease process, procedures, tx, home care, and follow up; Include teaching on: Drug therapy, diet, activity and restrictions

Complications

Severe loss of blood from GI bleed, Gastric Cancer

 

Gastroesophageal Reflux Disease (GERD)  or acid reflux

Definition

Is a condition where gastric contents flow back into the esophagus due to incompetent lower esophageal sphincter. Esophagitis, or inflammation of the esophageal mucosa, may result.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs.597-598.)

S/S

Heartburn, often 30-60 minutes after a meal and with reclining positions. Complaints of spontaneous reflux (regurgitation) of sour or bitter gastric contents into the mouth. Dysphagia is a less common symptom. Atypical chest pain, hoarsness, chronic cough, bronchospasm (asthma/wheezing), and odynophagia (sharp substernal pain on swallowing).

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 597-598.)

Nursing interventions/Teaching

Teach patient about prescribed medications, side effects, and when to notify the health care provider. • Inform the patient regarding medications that may exacerbate symptoms. • Advise the patient to sit or stand when taking any solid medications: emphasize the need to follow the drug with at least 100 mL of liquid. • Emphasize to the patient and family what foods and activities to avoid: fatty foods, garlic, onions, alcohol, coffee, and chocolate; straining, bending over, tight-fitting clothes, smoking. • Encourage the patient to sleep with the head of the bed elevated (not pillow elevation). • Encourage a weight-reduction program if the patient is overweight – to decrease intra-abdominal pressure.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 597-598.)

Complications

Esophageal stricture formation; Ulceration of the esophagus, with or without fistula formation; Aspiration, may be complicated by pneumonia; Development of Barrett’s esophagus – presence of columnar epithelium above the gastroesophageal junction associated with adenocarcinoma of the esophagus.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 597-598.)

 

Gastroesophageal Reflux Disease GERD

Definition

The reflux of chime (acid and pepsin) from the stomach through the lower esophageal sphincter to the esophagus.

S/S

Heartburn, acid regurgitation, dysphagia, chronic cough, asthma, and upper abdominal pain.

Nursing interventions/Teaching

Monitor VS, monitor I & O and correlate with weight changes, administer medications as indicated, utilize pain management techniques.

Complications

Esophageal narrowing (stricture), esophageal ulcer, Barrett’s esophagus (a change in the color and composition of the esophagus, increasing the risk of esophageal cancer).

 

Gastrointestinal bleed, acute

 

Definition:

A sign of disease or abnormality within the gastrointestinal tract involving the presence of blood or hemoglobin the stool. Upper GI bleeding is considered any source located between the mouth and outflow tract of the stomach. Lower GI bleeding is considered any source located from the outflow tract of the stomach to the anus (small and large bowel).

Signs/symptoms

-black/tarry stools

-blood in the stool

-vomiting blood or a dark material that looks like coffee grounds

Nursing Interventions:

Continued close observation for more bleeding

Close observation of B/P

Inspect the abdomen for injury and scars of past surgeries- do a complete physical assessment

Consider placing drains, e.g., nasogastric tube to reduce the risk of vomiting and aspiration, indwelling urinary catheter to monitor urinary output.

Complications:Prolonged microscopic bleeding can lead to massive losses of iron and subsequent anemia.  Acute massive bleeding can lead to hypovolemia, shock, and even death.

 

 

Gastrointestinal bleed, acute

 

Definition:

A sign of disease or abnormality within the gastrointestinal tract involving the presence of blood or hemoglobin the stool. Upper GI bleeding is considered any source located between the mouth and outflow tract of the stomach. Lower GI bleeding is considered any source located from the outflow tract of the stomach to the anus (small and large bowel).

Signs/symptoms

-black/tarry stools

-blood in the stool

-vomiting blood or a dark material that looks like coffee grounds

Nursing Interventions:

Continued close observation for more bleeding

Close observation of B/P

Inspect the abdomen for injury and scars of past surgeries- do a complete physical assessment

Consider placing drains, e.g., nasogastric tube to reduce the risk of vomiting and aspiration, indwelling urinary catheter to monitor urinary output.

Complications: Prolonged microscopic bleeding can lead to massive losses of iron and subsequent anemia.  Acute massive bleeding can lead to hypovolemia, shock, and even death.

 

 

Generalized anxiety disorder 

Definition

Excessive anxiety and worry predominating for at least 6 mo.

(Venes, D. (19th ed.) (2001). Taber’s Cyclopedic Medical Dictionary.  Philadelphia: F.A. Davis Company.  CD-ROM.)

S/S

Motor tension (e.g. trembling, restlessness, inability to relax, sleep disturbances, and fatigue),Autonomic hyperactivity (e.g. sweating, palpations, cold clammy hands, urinary frequency, lump in throat, pallor or flushing, increased pulse, and rapid respirations),Apprehensiveness (e.g. worry, dread, fear, rumination, insomnia, and inability to concentrate),Hypervigilance (e.g. feeling edgy, scanning the environment, difficulty concentrating, and distractibility),

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 1628.)

Nursing interventions/Teaching

Help patient identify anxiety-producing situations and plan for such events. • Assist patient to develop assertiveness and communication skills. • Practice stress-reduction techniques with patient. • Teach patient to monitor for objective and subjective manifestations of anxiety.

Complications

Tachycardia, tachypnea,

 

Gout 

Definition

A disorder of purine metabolism, characterized by elevated uric acid levels and deposition of urate (usually in the form of crystals) in joints and other tissues. It generally affects one joint (often the first metatarsophalangeal joint AKA podagra or great toe). Other joints can be affected, such as ankle, tarsals, knee; upper extremities are less commonly involved.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 948.)

S/S

Pain, warmth, erythema, and swelling of tissue surrounding the affected joint. Fever may occur,Onset of symptoms is sudden; intensity is severe. Duration of symptoms is self-limiting; last approximately 3-10 days without treatment. (Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 949.)

Nursing interventions/Teaching

Administer and teach self-administration of pain relieving medications as prescribed. • Encourage adequate fluid intake to assist with excretion of uric acid and to decrease likelihood of stone formation. • Instruct patient to take prescribed medications consistently because interruptions in therapy can precipitate acute attacks. • Elevate and protect affected joint during acute attack. • Assist with activities of daily living. • Encourage

exercise and maintenance of routine activity in chronic gout, except during acute attacks. • Protect draining tophi by covering and applying antibiotic ointment as needed.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers.  Pgs. 950.)

Complications

Uric acid kidney stone. Urate nephropathy.  Erosive, deforming arthritis.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 949.)

 

Guillan-Barre Syndrome

Definition

Lippencott, 478.  Acute, rapidly progressing, inflammatory demyelinating polyneuropathy of the peripheral sensory and motor nerves. Most often characterized by muscular weakness and distal sensory loss.  Must be ID’d quickly. Mortality rate: 5%.  Autoimmune, viral infection may

S/S

Parasthesias, and symmetric, progressive muscle weakness usually going from legs to trunk to upper extremities, facial muscles.  Decreased or absent tendon reflexes, autonomic dysfunction (inc HR, postural hypotension), Decreased breath sounds and depth of respirations, muscle spasms. Difficulty swallowing, chewing.

Nursing interventions/Teaching

Avoid narcotics and sedatives, which may decrease respirations. Watch respiratory status closely for decreased depth and rate of respirations.  Position patient correctly, teach ROM exercises.  Promote adequate nutrition, relieve pain, reduce anxiety.  Outcome: Respirations will be 14-20, deep and unlabored.  No pressure sores or edema present.  Gag reflex present.  Pt verbalizes decreased pain, reduced anxiety.  ROM exercises performed by pt every 2 hours.

Complications

Respiratory failure, cardiac dysrythmias, complications of immobility or paralysis, anxiety or depression.

Nursing Diagnosis: Inneffective breathing pattern r/t weakness of respiratory muscles.  Impaired physical mobility, r/t parasthesia.  Anxiety, r/t deteriorating physical condition and communication difficulties.

 

Head injuries

Definition

these include Fx to the skull or face, direct injury to the brain (i.e. bullet), indirect injury (i.e. concussion, contusion, or intracranial hemorrhage). Fx skull= open head injury, intact skull= closed head injury. These commonly occur from motor vehicle accidents, falls, or assaults. Note= Concussion is a temporary loss of consciousness resulting from transient interruption in normal brain function. Contusion is bruising of the brain;small amount of bleeding into tissue. Intracranial hemorrhage is significant bleeding into a space or a potential space between the skull and the brain. Mortality rate increases due to increased pressure and potential for brain herniation.

S/S

Primary interventions- 1) open airway using jaw thrust method; keep oral suction at hand 2) high flow O2 to prevent anoxia 3) maintain respirations at 20-25 to increase CO2 levels to reduce cerebral edema; use bag valve mask 4) control bleeding with loose dressing only; no pressure 5) start an IV line to keep vein open

Nursing interventions/Teaching

Subsequent assessment- obtain history, assess LOC/ Glasgow coma score, monitor VS 9 watch for HTN, decreased Hr, increased respirations, increased temp, and dysrhythmias), unequal/unresponsive pupils, personality change, impaired vision, sunken eyes, seizure, periorbital ecchymosis, rhinorhea, and Battles sign (bluish discoloration behind the ears that indicates possible basal skull Fx)

 

Head Injury

Definition

Includes any trauma to the scalp, skull, or brain.  It is used primarily to signify cranio-cerebral trauma, which includes an alteration in consciousness, no matter how brief.

S/S

Change in level of consciousness, dilation of pupils, ptosis, disorientation, behavioral disorder, headache, blood or clear fluid dripping from nose or ears, scalp lacerations, breaks or depressions of skull, unequally dilated pupils, blackened eyes, asymmetry of face, garbled or slurred speech, vomiting, paralysis or rigidity of limbs, disturbance of gait, loss of bowel or bladder control, confusion, drowsiness, low breathing rate or drop in blood pressure, convulsions, fracture in the skull or face, facial bruising, swelling at the site of the injury, irritability, restlessness, clumsiness, lack of coordination, blurred vision, inability to move one or more of your limbs,  stiff neck, inability to hear, see, taste, or smell, seizures

Nursing interventions/Teaching

Ensure patient airway, stabilize patient position, control external bleeding, maintain patient temperature, monitor vital signs, monitor level of consciousness, monitor cardiac rhythm, and pupil size ad reactivity, monitor gag reflex, do ROM with patient, talk to patient when approaching them, pain management

Complications

Epidural hematoma, hemorrhage, subdural hematoma, intracerebral hematoma, death, seizures, skull fracture, concussion, brain swelling, raised intracranial pressure, brain injury, mild traumatic brain injury, brain damage, brain compression, meningitis, hydrocephalus, vascular injuries

 

Hip Replacement

Definition

The replacement of a severely damaged hip with an artificial joint. Pg 993, Lippencott.

S/S

N/A

Nursing interventions/Teaching

Roll to unaffected side only, use abductor splint, assess CMSPI,  Remove TEDs for 30 minutes, BID.  Teach hip precautions, use elevated toilet seat, reinforce PT, proper hand hygiene, wound inspection, pl exi-pulses, leg pumps (dorsiflex/plantarflex), IS, cough and deep breathe, clear liquid DAT, monitor for blood loss (H&H), Bowel sounds present? Flatus? Monitor pain levels.  Outcome:  Pt maintains hip in anatomically correct position as evidenced by normal hip contour, both legs same length, and legs/hips in abduction.

Complications

Nursing Diagnosis: Risk for injury:  Hip dislocation.  Risk Factors: Improper positioning, movement of joint beyond prescribed range.

 

HIV/AIDs

 

Definition:

Acquired immunodeficiency syndrome – caused by a virus that replicates in and kills helper T cells. The virus that causes AIDS attacks CD4 cells. It uses these cells as a “breeding ground” for new virus particles. Eventually the CD4 cells are killed by the virus. As the number of CD4 cells decreases, the risk of getting an opportunistic illness increases. There is no cure for HIV/AIDs; it leads to death, usually from an opportunistic infection.

 

S/S

-candidiasis in the mouth, throat

-rapid weight loss from an unknown cause

-appearance of swollen or tender glands in the neck, armpits, groin for no apparent reason, lasting more than 4 weeks

-persistent diarrhea

-night sweats (soaking night sweats) of unknown origin

-appearance of purple spots on the surface of the skin, mouth, anus

 

Nursing Interventions:

Manipulate the environment to promote periods of uninterrupted rest.

Identify and develop the patient’s coping mechanisms, strengths, and resources for support

Encourage the patient to express their feelings and concerns.

Accept the patient’s feelings of powerlessness as normal.

Minimize patient’s risk of infection by washing hands, wearing gloves, monitoring their temperature, monitoring their WBC count.

Offer frequent oral care to patient.

Provide small, frequent meals to increase energy

Establish a regular sleeping pattern

 

Complications:

Wasting syndrome

Toxoplasmosis of the brain

Recurrent pneumonia – pneumocystis carnii

Lymphoma

Kaposi’s sarcoma

Encephalopathy

Death

 

 

Hypercholesterolemia

Definition

Lippincott pg 369 (Hyperlipidemia) A metabolic abnormality resulting in elevated serum total cholesterol. Contributes to the primary risk factor for atherosclerosis and coronary artery disease.

S/S

Lab test results for Total Cholesterol (TC) and High Density Lipoproteins (HDL’s)- usually asymptomatic until significant target organ damage is done, possible chest pain, MI, TIA, stroke

Nursing interventions/Teaching

Pt education, obtain nutritional consult, explain goal lab result numbers for LDL, HDL Interventions include multidimensional approach: diet, exercise, weight loss and drug treatments, smoking cessation if required

Complications

Disability from myocardial infarction, stroke and lower extremity ischemia.

 

Hyperlipidemia

Definition

A group of metabolic abnormalities resulting in combinations of elevated serum total cholesterol, elevated low-density lipoprotein, elevated triglycerides, and decreased high-density lipoproteins. Primary risk factor for atherosclerosis and coronary artery disease.

S/S

usually asymptomatic until significant target organ damage is done (chest pain, MI; TIA, stroke). May be metabolic signs such as corneal arcus, xanthoma, xanthelasma, and pancreatitis. Intermittent claudication, arterial occlusion of lower extremities.

Nursing interventions/Teaching

obtain medical/ diet Hx, examine for PVD, educate on diet and exercise, encourage smoking cessation.

Complications

Disability from MI, stroke, and lower extremity ischemia.

 

Hypertension

Definition

is a disease of vascular regulation in which the mechanisms that control arterial pressure within the normal range are altered. The basic explanation is that blood pressure is elevated when there is increased cardiac output plus increased peripheral vascular resistance.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 421-427.)

S/S

Usually asymptomatic,May cause headache, dizziness, blurred vision when greatly elevated. Blood pressure readings of 140/90 or more.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 421-427.)

Nursing interventions/Teaching

Explain the meaning of high blood pressure, risk factors, and their influences on the cardiovascular, cerebral, and renal systems. • Stress that there can never be total cure, only control. Of essential hypertension; emphasize the consequences of uncontrolled hypertension. • Enlist the patient’s cooperation in redirecting lifestyle in keeping with the guidelines of therapy, acknowledge the difficulty, and provide support and encouragement. • Develop a plan of instruction for medication self-management. • Instruct the patient regarding proper method of taking blood pressure at home and at work if health care provider so desires. Inform patient of desired range and the readings that are to be reported.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 421-427.)

Complications

Hypoxia; ARDS; Respiratory failure

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 421-427.)

 

Hypertension

Definition

Disease of vascular regulation in which the mechanisms that control arterial pressure within the normal range are altered.  BP = increased with increased cardiac output, increased peripheral vascular resistance. Lippencott, 427.

S/S

Usually asymptomatic, may cause headache, dizziness, blurred vision when greatly elevated.  BP readings:  Optimal:<120/<80; Normal:<130/<85; High Normal:130-139/85-89; Stage 1:140-159/90-99; Stage 2:160-179/100-109; Stage 3: > 180/>110

Nursing interventions/Teaching

Stress control, not cure. Emphasize consequences of uncontrolled HTN.  Teach. Explain meaning of high BP, risk factors, influence on systems.  Report dyspnea, edema, chest pain, nose bleeds, and weight gain.  Outcome:  Pt demonstrates increased knowledge about high BP, med effects, prescribed activities. Pt takes meds, keeps follow ups.

Complications

Angina Pectoris or MI due to decreased coronary perfusion, Left ventricular hypertrophy and CHF due to consistently elevated aortic pressure,

Renal failure due to thickening of renal vessels (diminishes perfusion to glomerulus), TIA, stroke or cerebral hemorrhage due to cerebral ischemia/arteriosclerosis, retinopathy, and accelerated HTN.

Nursing Diagnosis: Knowledge deficit r/t cognitive limitation, lack of interest, or lack of information.

 

Hypertension

Definition

Consistent elevation of systemic arterial blood pressure.

S/S

Excessive perspiration, muscle cramps, weakness, frequent urination, rapid or irregular heartbeat (palpitations).

Nursing interventions/Teaching

Monitor VS, auscultate heart tones and breath sounds, assess patient’s response to activity, manage pain, teach regarding condition, treatment plan, self-care (importance of nutrition and diet).

Complications

Atherosclerosis, arteriosclerosis, left ventricular hypertrophy, stroke, weakened or narrowed blood vessels in the kidneys, thickened, narrowed, or torn blood vessels in the eyes. Uncontrolled high blood pressure has been linked to cognitive decline and dementia.

 

Hypertension

Definition

Sustained elevation of Blood Pressure. Systolic > or = 140 / Diastolic > or = 90 mmHg

S/S

Frequently asymptomatic, fatigue, ¯ activity tolerance, dizziness, palpitations, angina, dyspnea

Nursing interventions/Teaching

Periodic monitoring of BP, Nutritional therapy, restrict sodium, ¯ weight, restrict cholesterol and saturated fats, maintain adequate intake of K, Ca, and Mg, physical activity, cessation of smoking, modification of alcohol intake, antihypertensive drugs – diuretics, adrenergic inhibitors, direct vasodilators, angiotensin inhibitors, Ca channel blockers, stress management – relaxation.

Complications

Target organ diseases (hypertensive heart disease), brain (cerebrovascular disease), peripheral vascular disease, kidney (nephrosclerosis), and eyes (retinal damage), adverse effects from antihypertensive therapy, hypertensive crisis, and stroke

 

Hypertension

 

Definition:   A disease of the vascular system where by there is an increased cardiac output and increased peripheral vascular resistance.  Essential hypertension is defined as diastolic pressures greater that 90 mmHg or systolic pressure greater than 140 mmHg.  The cause of essential HTN is unknown.  However, there is a correlation with family hx, excessive dietary sodium intake or retention, insulin resistance, and hyperactivity of sympathetic vasoconstriction nerves.

M/B:

  • Early: no symptoms
  • headache most common
  • Severe cases: dizziness, nausea, vomiting, confusion (can signify encephalopathy)

Visual disturbances, renal insufficiency, aortic dissection, HTN crisis

 

Complications:  Blood vessel damage – occurs through arteriosclerosis in which smooth muscle cell proliferation, lipid infiltration, and Ca accumulation occur.

Causes damage to: (Target organ diseases)

  • Heart – ventricular hypertrophy, CHF
  • Eyes – damage to retina, blindness
  • Brain – CVA
  • Kidneys – nephrosclerosis, renal insuff, RF
  • Peripheral vasculature – peripheral vascular disease, HTN crisis

 

Nursing Interventions:

  • Recommend change in life style: diet control, wt loss, ^ activity, lower stress
  • Nutritional status: 2-6 g Na, BMI < 25
  • Monitor orthostatic hypotension (sudden position changes)
  • Monitor vitals, I&O, test for edema
  • Monitor wt.
  • Teach pt to check BP @ home, and stress med follow up for lifetime
  • Avoid smoking

 

 

Medications:

Always monitor HR and BP prior to administration of hypertensives

*hold if systolic < 100mmHg

*hold if HR < 60 BPM

 

  • Diuretics–  inhibits NaCl from reabsorbing – ^ excretion of Na & Cl, water follows, thereby lowering BP.
  • Beta blockers
  • Calcium channel blockers– block movement of Ca into cells – causes vasodilation and decreased        SVR

 

  • ACE inhibitors–  inhibits angiotension I to convert into II, which would prevents vasoconstriction from occurring.
  • Vasodilators – reduces BP by direct arterial vasodilation

 

Risk Factors:

 

  • Family hx
  • Age – appears between 30-50, over 50 ^ incidence
  • Race – blacks ^%
  • Gender – men ^ risk at 55, equal 55-74, female ^ risk over 74
  • Stress – environmental, personality, physiologic events
  • Nutrition – ^ Na intake, low K, Ca, Mg
  • ^alcohol, drugs (legal/illegal) ie cold meds
  • Smoking, caffeine, overweight

 

Hypothyroidism

Definition

Under active thyroid disease. When your thyroid does not produce the adequate amount of hormones to maintain the balance of chemical reactions in your body.

S/S

Fatigue and sluggishness, increased sensitivity to cold, constipation, pale, dry skin, puffy face, hoarse voice, elevated blood cholesterol level, unexplained weight gain, muscle aches, tenderness and stiffness, especially in your shoulders and hips, pain and stiffness in your joints and swelling in your knees or the small joints in your hands and feet, muscle weakness, especially in your lower extremities, heavier than normal menstrual periods, depression.

Nursing interventions/Teaching

Monitor VS, monitor I & O and correlate with weight changes, administer medications as indicated, reduce metabolic demands and support cardiovascular function.

Complications

Goiter, heart problems, mental health issues, myxedema, birth defects.

 

Hypoxemia

Definition

Respiratory failure is an alteration in the function of the respiratory system that causes the PaO2 to fall below 50 mm Hg (hypoxemia) or PaCO2 to rise above 50 mm Hg (hypercapnia), as determined by arterial blood gas (ABG) analysis. Respiratory failure is classified as acute, chronic, or combined acute and chronic.  (Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers.

S/S

Restless ness,Agitation,Dypnea,Disorientation,Confusion,Delirium,Loss of conciousness,

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 270-273)

Nursing interventions/Teaching

Administer antibiotics, cardiac medications, and diuretics as ordered for underlying disorder. • Administer oxygen to maintain PaO2 fo 60 m Hg or SaO2 >90% using devices that provide increased oxygen concentrations (aerosol mask, partial rebreathing mask, nonrebreathing mask). • Monitor fluid balance by intake and output measurement, urine specific gravity, daily weight, and direct measurement of pulmonary capillary wedge pressure to detect presence of hypo/hypervolemia. • Provide measure to prevent atelectasis and promote chest expansion and secretion clearance, as ordered (incentive spirometer, nebulization, head of bed elevated 30 degrees, turn frequently out of bed). • Administer medications to increase alveolar ventilation – bronchodilators to reduce bronchospasm, corticosteroids to reduce airway inflammation.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 717-718)

Complications

Oxygen toxicity if prolonged highFIo2 required.  Barotrauma from mechanical ventilation intervention.

(Lippincott Manual of Nursing Practice.(7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 270-273),

 

Hysterectomy, supracervial abdominal

 

Definition

Hysterectomy is a very common operation. The uterus may be completely or partially removed, and the tubes and ovaries may also be removed at the time of hysterectomy. A partial (or supracervical) hysterectomy is removal of just the upper portion of the uterus, leaving the cervix intact. Abdominal hysterectomy includes a wide incision which is used to open the abdominal area, from which the surgeon removes the uterus.

Nursing interventions:

Obtain a prescription to administer opioid analgesia

Use a preventive approach with opiod analgesics to keep pain at or below an acceptable level.

In addition to use of analgesics, support client’s use of nonpharmacological methods to control pain, such as distraction, imagery, relaxation, massage, and heat and cold application.

Plan care activities around periods of greatest comfort whenever possible.

Encourage client to make choices and participate in planning of care and scheduled activities.

Monitor for signs of infection.

Complications

– infection of surgical site

– urinary tract infections

– excessive bleeding

– damage to nerve structures important to bladder and sexual function

-Pulmonary embolism

– Perforation of the bowel

– Fistulas

– Dehiscence

– Muscle weakness in the pelvic area

 

 

Hysterectomy, Total Abdominal with bilateral salpingo oopherectomy

 

 

Definition:   During a total abdominal hysterectomy, the doctor removes the uterus, including the cervix. The scar may be horizontal or vertical.  Cancer of the ovary and uterus, endometriosis, and large uterine fibroids are treated with total abdominal hysterectomy. TAH may also be done in some unusual cases of very severe pelvic pain, after a very thorough evaluation to identify the cause of the pain, and only after several attempts at non-surgical treatments.

Oopherectomy is the surgical removal of the ovary while salpingo-oopherectomy is the removal of the ovary and its adjacent fallopian tube. These two procedures are performed for cancer of the ovary, removal of suspicious ovarian tumors, or Fallopian tube cancer (very rare). They may also be performed due to complications of infection, or in combination with hysterectomy for cancer. (Occasionally, a women with inherited types of cancer of the ovary or breast will have an oopherectomy as preventative  surgery in order to reduce the risk of future cancer of the ovary or breast. )

Complications and risk factors:

  • Patient may experience urinary retention – from edema or nerve trauma – normally a catheter is used to prevent this.
  • Abdominal distention – from sudden release pressure on intestines
  • DVT
  • Emotional loss for loosing the ability to bear children.
  • When ovaries removed, surgical menopause – symptoms are as such, could be more severe due to sudden withdrawal of hormones.

 

Nursing Interventions:

  • Abdominal dressing should be checked frequently for bleeding during the first 8 hours after surgery.
  • Restrict foods and fluids if patient nauseated.
  • DVT precautions – frequent position changes, avoid high Fowlers, avoid pressure under knees (pooling), ted hose
  • Give understanding care and provide discharge teaching – avoid heavy lifting for 2 months, no intercourse for 4-6 weeks, also provide knowledge vaginal sensation may be temporarily lost. Activities increasing pelvic congestion should be avoided such as jogging, walking briskly, dancing. (Alt- swimming). Girdle may be helpful
  • Follow protocol for hormone replacement therapy to prevent estrogen deficiency

 

 

Types of procedures involving female reproductive system:

  • Subtotal hysterectomy – removal of uterus w/o cervix (rarely done today)
  • Total hysterectomy – removal of uterus and cervix
  • Panhysterectomy – (TAH-BSO) removal of uterus, cervix, fallopian tubes, ovaries
  • Vaginectomy – removal of the vagina
  • Supracervical hysterectomy – hyst and leaving in the cervix
  • Radical hysterectomy – panhysterectomy, partial vaginectomy, dissection of lymph nodes, pelvis
  • Pelvic exenteration – rad hyst, tot vag, removal of bladder w/ diversion of urinary system (neph tube) and resection of bowel with colostomy.
  • Anterior pelvic exenteration – above w/o bowel resection
  • Posterior pelvic exenteration – above w/o bladder removal
  • Simple vulvectomy – exc of vulva and wide margin of skin
  • Radical vulvectomy – exc of tissure from anus to few cm above symphasis pubis (skin, labia majora and minora,k and clitoris) with superficial and deep lymph node dissection.

 

More info side note:

  • Vaginal hyst- if uterus removed through vagina (not abdomen)
  • Lap assisted vaginal hysterectomy (LAVH) – laparoscope inserted through belly button, and other parts of abdomen and female parts removed through vagina.

 

 

 

Ileus

Definition

an intestinal obstruction. The term originally meant colic due to intestinal obstruction. It is characterized by loss of the forward flow of intestinal contents, often accompanied by abdominal cramps; constipation; fecal vomiting; abdominal distention; and collapse. (Venes, D. (19th ed.) (2001). Taber’s Cyclopedic Medical Dictionary. Philadelphia: F.A. Davis Company. P. 1016.)

S/S

Abdominal distention,Pain,Absent bowel sounds,(Internet. Yahoo! Health Encyclopedia. http://health.yahoo.com/health/ency/adam/000260.)

Nursing interventions/Teaching

Measure abdominal girth frequently to detect progressive distention. • Administer prescribed medication and monitor for bowel motility as well as adverse effects. • A nasogastric (NG) or nasointestinal tube is inserted as prescribed. • Monitor vital signs for a drop in blood pressure, metabolic acidosis, or infection,• IV fluids are instituted, renal function is assessed, and fluid and electrolyte balance is monitored.

(Venes, D. (19th ed.) (2001). Taber’s Cyclopedic Medical Dictionary.  Philadelphia: F.A. Davis Company.  P. 1016.)

Complications

Jaundice; Electrolyte imbalance; Peritonitis; Appendicitis

(Internet. Yahoo! Health Encyclopedia. http://health.yahoo.com/health/ency/adam/000260.)

 

Jaundice

Definition

Jaundice is not an illness, but a medical condition in which too much bilirubin – a compound produced by the breakdown of hemoglobin from red blood cells – is circulating in the blood. The excess bilirubin causes the skin, eyes and the mucus membranes in the mouth to turn a yellowish color.

S/S

Yellow discoloring of the skin, whites of the eyes and mucus membranes, dark urine, nausea, itching, light-colored stool (gray or yellow), abdominal pain or swelling.

Nursing interventions/Teaching

Monitor vital signs and laboratory/diagnostic studies, assess/document dietary intake measuring I&O accurately, and promote infection control.

Complications

Depends on the cause.

 

Kidney Stone (nephrolithiasis)

 

Definition:  Stones are formed in the urinary tract from the kidney to the bladder by the crystallization of substances excreted in the urine.  Most are composed of ca oxalate crystals. The rest are composed of uric acid, struvite (mg, ammonia, phosphate), or cystine (aa).

 

-higher incidence in men (20-40)

-spontaneous stone passage in 80%

-some lodge in renal pelvis, ureters, bladder neck causing obstruction – can lead to nephron             damage.

 

Risk Factors:

  • Metabolic – abnormalities result in high ca levels in urine

I.e. hyperparathyroidism

 

  • Climate – warm climate, increase fluid loss, increase [solute] of urine.
  • Diet – high intake proteins (increase uric acid excretion)

-excess tea or fruit juices

-excess intake of ca, vit d

  • Genetic factors – fm hx of stone form, gout, cystinuria, renal acidosis
  • Life Style- sedentary

 

Manifested by:  (When they obstruct urinary flow)

  • Abdominal or flank pain (sever) – immediate relief after passage
  • Hematuria
  • Renal colic
  • Nausea/vomiting

 

Nursing Interventions:

  • pain management
  • control/monitor for infection
  • educate patient on diet
  • 2000-3000 ml daily
  • Diet low in sugar and animal proteins
  • Increase fiber intake
  • Save stone for analysis

 

 

Complications:

  • Obstruction
  • Infection
  • Impaired renal function

 

 

Poss. Nursing Dx:

 

  • Pain r/t obstruction, abrasion and inflammation of urinary tract by migration of stones.
  • Altered urinary elimination r/t blockage of urine flow by stones.
  • Risk for infection r/t obstruction of urine flow

 

Laminectomy

Definition

Excision of a vertebral posterior arch and is commonly performed for injury to the spinal column or to relieve pressure/pain in the presence of a herniated disc. May be done with or without fusion of vertebrae.

S/S

Outcomes- Neuro function maintained/improved. Complications prevented. Limited mobility achieved with potential for increasing mobility.

Condition/prognosis, therapeutic regimen, and behavior/lifestyle changes are understood.

Nursing interventions/Teaching

Monitor Vs, I&O, drainage. Keep pt. flat for several hours, assess neuro, assess for signs of edema (i.e. face and neck for cervical laminectomy), logroll pt. to avoid twisting/flexing of back, limit activities, provide firm mattress, apply brace/collar, encourage coughing/deep breathing, monitor labs, assess pain, relaxation, restful environment, assess bowel sounds, assist with range of motion, encourage early ambulation, apply heat/cold.

Complications

 

Lap Cholectomy

 

Definition:  removal of the gall bladder via laparoscopy using a dissection laser. (92% of chole’s done laparoscopically)

 

1cm puncture made slightly above umbilicus (surgeon inflates abd cavity w/ 3-4 L co2  to improve visability).  A lap’ w/ camera inserted into abd.  Two additional puncture made just below ribs (one on rt of axillary line, and other on the rt midclavicular line).  These punctures used for insertion of grasping forceps.  A dissection laser inserted into 4thpuncture, which is made just rt of midsection.  Using closed-circuit monitors ot view the abd cavity, the surgeon retracts and dissects the gallbladder and removes with grasping forceps.

 

 

 

Nursing Interventions:

  • Vitals q15 x4, q30 x2, q1h x4
  • Monitor for complications, such as bleeding
  • Make patient comfortable
  • Prepare for discharge
  • TCDB and ambulation
  • Pain control
  • Clear liquids
  • Monitor drainage if  T-tube or JP – tubes are used.

 

 

Risk Factors and Complications:

Contraindications to do the surgery would be peritonitis, cholangitis, gangrene or perforation of the GB.

Minimal post op complications.  Compared to an incisional cholectomy, decreased post op pain, shorter hospital stay, earlier to work and full activity.

The main complication is injury to the common bile duct.

 

 

Leukemia, Ac (myelogenous)

 

pg 874 lippincott

 

Definition:

Leukemia’s are malignant disorders of the blood and bone marrow that result in an accumulation of dysfunctional immature cells (myeloblasts – precursors to granulocytes) that are caused by a lack of regulation of cell division.  It is characterized by a rapid progression of symptoms.

There is an increased in incidence with advancing age – peak (60-70).

 

ac lymphocytic leukemia – When lymphocytes are predominantly malignant.

ac myelogenous leukemia – when monocytes or granulocytes are predominant.

 

(So basically, it attacks the defense cells of the immune system)

 

Manifested by:

Fatigue and weakness, headache, mouth sores, minimal hepatosplenomegaly and lymphadenopathy, anemia, bleeding, fever, infection, and sternal tenderness.

 

Lab findings:

  • low RBC, H &H, platelet
  • low to high WBC count w/ myeloblasts
  • greatly hypercellular bone marrow w/ myeloblasts

 

 

 

Lithotripsy

 

Definition:  Lithotripsy (L) is a way to eliminate urinary calculi (kidney stones) non-invasively. L. techniques include percutaneous ultrasonic L, electrohydraulic L, Shock wave and laser lithotripsy. Most common: Shockwave and Laser Lithotripsy

 

A shock wave characterized as very rapid increase in pressure.  It transmits harmlessly through soft tissue (passes through kidney) and strikes the stone. Initially the stone cracks. With successive shocks the stone eventually reduces to small particles, which are hopefully flushed out of kidneys naturally while urinating.

– Takes about 1 hr, up to 8000 shocks can be administered.

– Anesthesia necessary to keep patient still during procedure.

 

Complications:

 

  • Hematuria common s/p  lithotripsy.
  • Pain
  • Temporary bleeding around kidney

Occasionally, if the stone obstructs the flow of urine, the patient experiences severe pain (renal colic). This pain can be controlled by introducing a stent into the ureter. The stent is basically a tube which is placed in the ureter and allows the urine to drain past the obstruction. The stent may be left in after lithotripsy in case of obstruction due to fragments becoming lodged in the ureter. Stent usually removed w/in 1-2 weeks.

 

Nursing Interventions:

  • Give prescribed narcotic analgesic, monitor pt for pain closely
  • Monitor respirations and BP
  • Encourage pt to find comfortable position
  • Administer antiemetics as indicated for nausea

 

Risk Factors:

  • Urinary infection
  • Damage to ureter caused by stent (if used)

 

Possible Nursing Dx:

  • Pain r/t inflammation, obstruction, and abrasion of urinary tract by migration of stones.
  • Altered urinary elimination r/t blockage of urine flow by stones
  • Risk for infection r/t obstruction of urine flow and instrumentation during treatment.

 

 

Benefits of less invasive surgery:

  • Shorter hospital stay
  • Pt’s earlier return to health

All invasive procedures carry a higher risk of infection complications than non-invasive procedures such as lithotripsy. Some other methods to remove kidney stones:

 

  • Ureteroscopy – (for distal urethral calculi)insertion via the urethra following w/ stone fragmentation and removal by mechanical means.
  • Percutaneous nephrolithotomy –  (for stones larger than 2.5 cm) removal of stone through puncture into kidney (from patient’s side)

 

Low back pain

Definition

Characterized by an uncomfortable or acute pain in the lumbosacral area associated with severe spasm of the paraspinal muscles often with radiating pain. Causes include: mechanical (i.e. sprain), degenerative or herniated disc, arthritis, tumor, and bone disease.

S/S

Pain localized or radiating to the buttocks or to one or both legs. Paresthesias, numbness, and/or weakness of lower extremities. Spasm in acute phase. Bowel/bladder dysfunction in cauna equina syndrome.

Nursing interventions/Teaching

Assess pain/ administer prescribed meds. Keep pillow between flexed knees while lying on side. Use of firm mattress to reduce strain. Apply heat/cold as ordered. Encourage ROM, avoid long periods of sitting. Teach good body mechanics. Avoid fatigue, standing for long periods of

Complications

Spinal instability, infection, sensory, and motor deficits. Chronic pain. Malingering and other psychosocial reactions.

 

Lumbar spinal stenosis

Definition

Narrowing of the spinal canal in the lumbar area (low back). Natural degenerative changes cause discs to lose fluid and height, resulting in “disc bulging”. Small joints in the back part of the spine develop “spurs” or osteophytes. This narrowing can, if critical, cut off blood supply to nerve roots that provide sensation and motor power to legs.

S/S

Back and/or leg pain, numbness, weakness.

Nursing interventions/Teaching

Pain assessment/control, physical therapy, and bracing.

Complications

Impaired ambulation related to pain.

 

Macrocytic anemia

Definition

Large RBC; cause defective RBC maturation- they are more easily destroyed.

S/S

Sore tongue, anorexia, N/V, abdominal pain, weakness.

Nursing interventions/Teaching

Assess- B12 vitamin level, folic acid, MCH lab, GI discomfort, skin/tissue condition, capillary refill, skin color, VS, O2 sat  Implement- B12 injections if pernicious anemia is diagnosed, diet, folic acid administration if prescribed  Educate- alcohol withdrawal/cessation, med administration, foods good for type of anemia

Complications

ADL difficulty, fatigue, hypoxemia

 

Malignant Tumors of Reproductive system

 

Definition:  Malignant tumors of the reproductive system can be found in the cervix, endometrium, ovaries, vagina, and vulva.

Cancer cells go through various stages:

  • Inititiation – mutation in cells genetic structure
  • Promation- promoting factors are dietary fat, obesity, cigarette smoking, etoh, stress.
  • Progression – increased growth rate of tumor and increased invasiveness and poss metastasis.
  • Metastasis – spread of ca from initial site to distant site.

 

Manifested by:

  • Leukorrhea
  • Irregular vaginal bleeding
  • Vaginal discharge
  • Increase in abdominal pain or pressure
  • Bowel and bladder distention

Nursing Interventions:

  • Health promotion – routine screening
  • Educate about risk factors – condoms, fewer sexual partners, high fat diet (^ovarian ca)
  • Achieve satisfactory pain and symptom management
  • Each patients concerns approached and evaluated individually. Recognize some women may have anxiety (surgery), others guilt, anger, embarrassment, some may relieved of not having periods.
  • If has surgery – follow post op protocol

 

 

 

 

Complications:

  • Malignancy
  • Emotional
  • Treatment – surgery, chemo, radiation
  • Death

 

Poss. Nursing Dx:

  • Anxiety r/t threat of malignancy and lack of knowledge about the disease process and prognosis.
  • Acute pain r/t pressure secondary to enlarging tumor
  • Disturbed body image r/t loss of body past and good health
  • Ineffective sexual patterns r/t physiologic limitations and fatigue
  • Ineffective breathing r/t ascites an effusions
  • Anticipatory grieving r/t poor prognosis of advanced disease

 

Meningitis

Definition

Lippencott, 466.  Meningitis is the inflammation of the meninges lining the brain and spinal cord.  Pathogenic organisms cross the blood-brain barrier, invade the SAS, and cause an inflammatory response.

S/S

Headache, fever, altered LOC, petechia, photophobia, onset may be several hours or several days.

Nursing interventions/Teaching

Reduce fever, maintain fluid balance (IV overload may make cerebral edema worse), assess neuro and vital signs frequently, reduce pain.  Outcome:Pt will be afebrile.  Pt will have adequate urine output.  Pt will have no pain.  Pt returned to optimum level of functioning.

Complications

Seizures, cerebral edema which may lead to compression of the brainstem, deafness, paresis, cranial nerve disorders

Nursing Diagnosis: Pain, r/t meningeal irritation.  Impaired physical mobility r/t prolonged bedrest.  Risk for fluid volume deficit, r/t fever,

decreased intake.

 

Multiple Myeloma

 

Definition:   A condition where plasma cells infiltrate the bone marrow and destroy bone.  Plasma cells are activated B-cells which produce immunoglobulins (antibodies which normally protect the body). In mm the malignant plasma cells produce abnormal and excessive amounts of immunoglobulin (proteins) and cytokines which play a role in the destruction process of the bone.

A pt usually lives for 2 years if untreated. Incidence is 4 per 100,000 people. The cause is unknown. Exposure to radiation, organic chemical pesticides, genetic factors, and viral infection may play a role.

 

Manifested by:

  • Constant severe bone pain caused by bone lesions and pathologic fractures; sites include thoracic and lumbar vertebrae, ribs, skull, pelvis, and proximal long bones.
  • Fatigue and weakness r/t anemia caused by crowding of marrow by plasma cells.
  • Proteinuria and renal insufficiency
  • Electrolyte disturbances: inc Ca (bone destruction), hyperuricemia (cell death, renal insufficiency)

Nursing Interventions:

  • Control pain – location/intensity/characteristic, administer pain meds ATC, teach nonpharm methods, assess
  • Promote mobility – encourage pt to wear back brace for lumbar lesions, recommend phys. therapy consult, discourage bed rest, assist pt to avoid injury.
  • Relieving fear – develop trusting supportive relationship w/ patient and sig others with an open line of communication, encourage pt to use own support network.
  • Monitoring for complications – report sudden, severe pain (especially of back), watch for nausea, drowsiness, confusion, polyuria ( d/t high calcium- d/t bone destruction)
  • Monitor labs: calcium, bun creatinine and urine protein to check for RI (d/t to nephrotoxity of abn proteins in multiple myeloma.
  • Increase fluid intake, monitor I&O, weigh daily
  • Community and home care considerations
  • Patient education and health maintenance

 

 

 

 

Complications:

  • Pathologic fx, spinal cord compression
  • Recurrent infections- primarily bacterial
  • Electrolyte abnormalities (hypercalemia,hyperphosphatemia)
  • Renal failure, pyelonephritis
  • Bleeding
  • Thromboembolic complications caused by hyper viscosity
  • Pts have a median survival of 3-4 years

 

Poss. Nursing Dx:

  • Pain (bone) r/t to destruction of bone and possible pathologic fxs.
  • Impaired physical mobility r/t pain and possible fx.
  • Fear r/t poor prognosis
  • Risk for injury r/t complications of disease process.

 

Myocardial Infarction

 

Definition:

(Lippencott, 361)  process by which one or more regions of the heart muscle experience a sever and prolonged decrease in oxygen supply because of insufficient coronary blood flow.. Subsequently, death to myocardial tissue ensues. May be sudden or gradual. Progression of event to completion could take from 3-6 hours.

 

S/S:

Chest pain (severe, crushing, steady substernal pain), Not relieved by  SL vasodilators, may radiate (arms, back, jaw), may produce anxiety/fear (increased HR, pulse, BP, RR), diaphoresis, cool and clammy skin, pallor, hyper/hypotension, brady or tachycardia, lasts longer than 15 minutes, premature ventricular/atrial beats, palpitation, dyspnea, confusion, restlessness, n/v or hiccups.

 

Nursing Diagnosis:  Pain r/t imbalance in O2 supply, Anxiety r/t chest pain/fear of death, decreased cardiac output r/t impaired contractility, Activity intolerance r/t insufficient oxygenation

 

Nursing interventions:

Reduce pain (administer O2 by NC as prescribed, SL nitro as prescribed, pain is priority—administer narcotics as prescribed), alleviate anxiety (administer anxiolytics as prescribed, explain all procedures, limit visitors, back massage, guided imagery), increase activity intolerance (minimize interruptions, promote rest, comfortable room temp, assist pt with activities, elevate feet to promote venous return)

 

Complications:

Arrhythmias, cardiac failure, CHF, cardiogenic shock, ischemia, thrombus formation, cardiac tamponade, pericarditis

 

 

Narcolepsy

Definition

a neurological disorder characterized by abnormalities of REM sleep, some abnormalities of non-REM sleep, and excessive daytime somnolence.

S/S

excessive daytime sleepiness, cataplexy (abrupt loss of muscle tone after emotional stimulation such as laughter, anger), sleep paralysis (powerless to move limbs, speak, open eyes, or breathe deeply while fully aware of condition), hypnagogic hallucinations associated with drowsiness before sleep/usually visual or auditory, inability to focus vision, nocturnal sleep disturbance

Nursing interventions/Teaching

review daily schedule, help pt. develop non-drug therapies (exercise, diet), administer or teach self administration of meds (advise of side effects and use of only prescribed amounts), schedule rest periods of 10-20 minutes two to three times a day, encourage caffeinated drinks at small intervals during the day to maintain energy, plan diversional activities and relaxation during periods of fatigue, assist pt in identifying triggers, encourage support groups/community resources, encourage medic alert bracelet.

Complications

injury R/T falling asleep, psychosocial problems such as disturbed relationships, loss of employment and depression

Nursing Diagnosis: Sleep pattern disturbance R/T disease process. Fatigue R/T disrupted nighttime sleep. Ineffective individual coping R/T interference with activity.

 

Nephrectomy

Definition

A nephrectomy is an operation to remove a kidney

S/S

N/A

Nursing interventions/Teaching

Monitor vital signs, Assess color, motion, sensation, pedal pulses, prevent infection, wash hands, inspect wounds, cough, deep breathe, I.S.,

Compression dressing to wound, Ant-embolic stockings, Thromboguards, Foley catheter, Emphasize turning and ambulation of patient, Push liquids, teach any home care Tx, Monitor labs

Complications

Blood clots, Infection, Actelectasis

 

Nephrostomy Tube

 

Definition:  A nephrostomy is used as a temporary measure to drain urine from the kidney. It is a tube inserted when the normal pathway from the kidney to the bladder has become obstructed.  It is inserted directly into the pelvis of the kidney and attached to connecting tubing for drainage. NT are temporary, but can stay in place for several weeks if necessary.

 

Complications:  Infections and secondary stone formations are complications assoc. w/ NT insertion.

 

Nursing Interventions:

  • Tube should never be kinked or clamped (unless ordered by phys.), and intact.
  • If excessive drainage around tube, check for patency.
  • If irrigation ordered, strict aseptic technique required.
  • –No more than 5ml of sterile saline solution gently instilled to prevent over distention of kidney pelvic and renal damage.
  • Assess skin integrity around the tube.
  • Monitor I/O, notice if changes in appearance or foul odor, or low drainage.
  • Monitor for infection.

 

Risk Factors:

  • Infection
  • Secondary stone formation

 

Poss. Nursing Dx:

  • Altered urinary elimination r/t urinary diversion
  • Pain r/t surgery
  • Body image disturbance r/t urinary diversion

 

Actual Procedure

 

Using ultra sound, kidney located.  Local anaesthetic is injected over the site of the kidney in the lower back. When the anaesthetic has taken effect, a fine needle is inserted into the kidney pelvis. Sometimes x-ray dye is injected and an x-ray taken to show where the blockage is exactly. A fine wire is then threaded through the needle. A narrow tube is then inserted over the wire and gently pushed into the kidney pelvis. The wire is removed and after fixing the tube to the skin with a couple of stitches, a drainage bag is attached to the tube that can be emptied by nursing staff.

 

Neuropathic pain

Definition – results from nerve injury or compression. Includes phantom pain and postherpetic neuralgia. Usually associated with abnormal sensations such as paresthesias.

S/S

Described as burning, shooting, electric, and lancinating. It can be constant or sporadic. Fatigue from sleep disturbance, loss of appetite or weight loss, anxiety or depression, change in self-concept and/or quality of life.

Nursing interventions/Teaching

pain assessment/medication (nsaids, opioids), guided imagery, relaxation, biofeedback, support and open communication, education on pain meds

Complications

 

Non-Hodgkins’s lymphoma

 

Definition:  NHL’s are a heterogeneous group of malignant neoplasms of the immune system affecting all ages.  They are classified according to different cellular and lymph node characteristics. It is the most common hematologic ca and 5thleading cause of ca death.  The more aggressive lymphomas are more responsive to treatment and are more likely to be cured. Indolent lymphomas have a naturally long course, but are more difficult to treat.

Higher incidence in immunosuppressed patients and increased age.

 

Manifested by:

Painless enlargement of lymph nodes (unilateral), fever, chills, night sweats, wt loss.

Various symptoms occur w/ pulmonary involvement, superior vena cava obstruction, hepatic or bone involvement.

*Treat: Radiation (palliative not curative), and chemo

 

 

 

Nursing Interventions:

  • Minimize risk of infection – strict protected environment, strict hand washing.  Avoid invasive procedures. Asses vitals and LOC, mucous membranes for infection.Obtain cultures, notify physician for T>101.1
  • Patient education – infection precautions, follow up visits, provide information on
    American Ca Society

 

 

Complications:

  • From radiation and chemotherapy
  • Depends on extent of malignancy – splenomegaly, hepatomegaly, thromboembolic complications, spinal cord compression.

 

Obesity

Definition

An abnormal increase in the proportion of fat cells, mainly in the viscera and subcutaneous tissues of the body. Morbid obesity is when weight exceeds 100% ideal body weight.

S/S

Sleep apnea, obesity-hypoventilation syndrome, disturbances of weight bearing joints, increased sweat and skin secretions, Shortness of breath, weight gain, increase in appetite, hypertension

Nursing interventions/Teaching

Monitor vital signs, daily weights, intake and output, reinforce diet control, patient teaching, exercise, behavior therpay, physical therapy, medication if ordered, decrease in smoking or alchol use

Complications

Diabetes, heart problems, High blood pressure, gallbladder disease, some types of cancer, high cholesterol, stroke, cardiac arrest, osteoarthritis, sleeping and breathing problems,  Reduced Life Span,  gynecological problems, dysmenorhea, high triglycerides, poor socio-economic status, diverticular disease, urinary stress incontinence, menstrual problems, amenorhea, high cholesterol, liver disease, depression, kidney disease shortness of breath, osteoporosis, complication of pregnancy, decreased freedom of movement, hypothyroidism, degenerative arthritis

 

Obesity

Definition

an overabundance of body fat resulting in body weight of 20% or more than the average weight for the person’s age, height, sex, and body frame

S/S

Body weight greater than 20% of acceptable weight for height or BMI greater than 30; increased weight correlated with increased incidence of

CVD and DM

Nursing interventions/Teaching

obtain a complete nutritional assessment (possibly with a nutritionist), assess behavioral/emotional components of eating, coping mechanisms, assess past successes/failures with dieting, assist pt. with assessing current dietary habits/forming a diet plan, suggest behavior modification strategies, provide emotional support, provide alternative coping mechanisms, assess pt. toleration of exercise

Complications

Risk factor for: diabetes, gall bladder disease, osteoarthritis of weight-bearing joints, HTN, and coronary artery disease. Vitamin/mineral deficiencies because of surgical intervention and/or severely restricted diet.

Nursing Diagnosis: Altered nutrition: more than body requirements R/T high calorie, high fat diet, and limited exercise. Self-esteem disturbance R/T weight.

 

Open reduction internal fixation (ORIF)

Definition

Open reduction is the correction of bone alignment through a surgical incision.  Internal fixation is the securing of the bones via wire, screws, pins, plates, intramedullary rods, or nails internally.

S/S

N/A

Nursing interventions/Teaching

Early initiation of ROM if joint is affected, CPM, or ambulation to prevent scarring, adhesions, provide quicker healing of cartilage, and decrease in arthritis.  Provide proper use of traction if ordered.  Administer pain medications as needed or ordered. Assess vital signs.  Monitor for signs of infection: redness, warmth to affected area, malodorous discharge.

Complications

Infection, complications associated with anesthesia.

 

Osteoarthritis

Definition – or degenerative joint disease, is a chronic, noninflammatory, slowly progressing disorder that causes deterioration of articular cartilage. It affects weight bearing joints (hips and knees) as wells as joints of the distal interphalangeal and proximal interphalangeal joints of the fingers.

(LippincottManual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers.  Pgs. 1011-1013.)

S/S

Pain,Stiffness,Enlargement or swelling,Tenderness,Limited range of motion,Muscle wasting,Partial dislocation,Deformity,

(Huether, S. E. & McCance K. L. (2nd ed.) (2000) Understanding Pathophysiology.  St. Louis: Mosby, Inc.  Pgs.1049-1051.)

Nursing interventions/Teaching

Advise patient to take prescribed NSAIDs or over-the-counter analgesics as directed to relieve inflammation and/or pain. ,• Provide rest for involved joints – excessive use aggravates the symptoms and accelerates degeneration. Have prescribed rest periods in recumbent position. •

Encourage activity as much as possible without causing pain. • Teach ROM exercises to maintain joint mobility and muscle tone for joint

support, to prevent capsular and tendon tightening, and to prevent deformities. Avoid flexion and adduction deformities. • Suggest swimming or water aerobics as a form of nonstressful exercise to preserve mobility. (Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers.  Pgs. 1011-1013.)

Complications

Limited mobility. Neurologic deficits associated with spinal involvement.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 1011-1013.)

 

Osteomyolitis

Definition

A severe infection of the bone, bone marrow, and surrounding soft tissue

S/S

Fever, night sweats, chills, restlessness, nausea, malaise, constant bone pain that is unrelieved by rest and worsens with activity, swelling, tenderness, warmth at site of infection, restricted movement, drainage from sinus tracts to skin, elevated WBC count, elevated sed rate, soft tissue edema of surrounding area

Nursing interventions/Teaching

Monitor VS, monitor IV or oral antibiotic therapy, assess pain level frequently, use gentle handling and support when moving extremity, monitor the prescribed immobilization device and maintain patient’s body in correct alignment, teach patient to use assistive devices if able to ambulate, elevate extremity, teach patient about using distraction relaxation and breathing, teach patient about proper diet and physical rehabilitation, ROM on extremity, monitor for footdrop,

Complications

Septicemia, septic arthritis, pathologic fractures, squamous cell carcinoma, amyloidosis

 

Ostomy care (continent diversion)

Definition

Assessment- inspect stoma with pouch change (should be moist and red), measure stoma (shrinkage), VS, pain, body image/altered feelings of self,I&O, lab values, electrolytes, weight, bowel sounds

S/S

N/A

Nursing interventions/Teaching

Implement- clean with warm water and dry, adhesive backing 1/16 to 1/8 inch larger than stoma base, transparent/odor proof pouch, irrigate and cleanse periodically, consult with ostomy nurse, aseptic technique with bandaged wounds  Education- future expectations, changing ostomy bag, signs/Sx of infection and skin break down, increase fluid intake

Complications

Skin breakdown, infection, disturbed body image

 

Ostomy – Ileostomy     (Lippincott 590-94 & lewis1085-6)

 

Definition:  A surgical procedure in which an opening is made to allow passage of intestinal contents from the bowel to the incision/stoma.  The stoma (opening surface of abd) is created when the intestine is brought through the abd wall and sutured to the skin, where fecal matter is diverted through.  It may be permanent or temporary. There are various types:

 

  1. Ileostomy – opening from ileum to through abd wall. ( aka conventional or Brooke Ileostomy)
  2. Cecostomy – opening from cecum to abd wall. (uncommon, as well as ascending colon) are                                        usually temporary.
  3. Colostomy- opening between colon and abd wall. Proximal end of colon sutured to the skin.

Ileostomy:

Stool consistency – liquid to semi liquid

Fluid requirement – increased

Bowel regulation             – no

Pouch and skin barriers – yes

Irrigation                         – no

Indications for surgery:

– ulcerative colitis, Cohn’s, diseased colon, birth defect, familial polypsis,

 

 

 

Complications:

  • stomal ischemia, stricture, or stenosis
  • stomal prolapse
  • peristomal hernia
  • peristomal skin breakdown
  • mucocutanious separation ( between skin and stoma)

 

 

Nursing Interventions:

  • educating patient – surgical procedure, Ostomy teaching, include fam, clarify misunderstanding
  • promote positive self image
  • reduce anxiety – gradual steps toward independent care
  • maintain skin integrity – emptying 1/3  to ½ full
  • maximize nutritional intake – avoid foods stimulate elimination, consistent moderate diet habits, nutritionist consult, weigh QD
  • achieving sexual well being – discuss ways to conceal pouch, diff positions, counseling

 

Characteristics of stomas:

– pink, red, moist, bleeds slightly when rubbed, no felling to touch, stool functions involuntary, post op swelling decreased over several months.

 

Ovarian Cancer

Definition

Malignant neoplasm of the ovaries.

S/S

General abdominal discomfort (gas, indigestion, pressure, bloating, cramps), sense of pelvic heaviness, loss of appetite, feeling of fullness, and change in bowel habits.

Nursing interventions/Teaching

Pain management, monitor vital signs and laboratory/diagnostic studies, assess/document dietary intake measuring I&O accurately, and promote infection control.

Complications

Death

 

Pancreatitis

Definition

An inflammatory process of the pancreas, with the degree of inflammation varying from mild edema to severe hemorrhagic necrosis.  Some patients recover completely; others have recurring attacks; still others develop chronic pancreatitis.  Acute pancreatitis can be life threatening.

S/S

Severe abdominal pain, usually in the upper mid-abdomen, possibly penetrating to the back, abdominal swelling , nausea and vomiting , weight

loss, mild jaundice, or a yellow tint to the skin, fever and chills, excessive sweating, clammy skin, rapid heart beat, shallow, rapid breathing, light colored and greasy stools, which are more common in chronic pancreatitis

Nursing interventions/Teaching

Vital Signs ; Give prescribed medication for pain management, nausea and vomiting; Put patient in comfortable position and frequent changes in position; Frequent oral and nasal care if NG tube is in place; Observe for fever and other manifestations of infection; Make sure the patient turns,coughs and deep breathes to prevent respiratory infections; Teaching on preventing infection and detecting complications Medical Tx:Drug Therapy, Management of pain; Prevention or alleviation of shock reduction of pancreatic secretions; Control of fluid and electrolyte imbalance; Prevention or treatment of infections; Surgical removal of precipitating cause, if possible.

Complications

Obstruction of the small intestine or bile ducts ; Pancreatic insufficiency ; diabetes ; fat malabsorption; Ascites ; Pancreatic pseudocysts (fluid collections), which may become infected ; Blood clots in the splenic vein ;

 

Pancreatitis

Definition

Inflammation of the pancreas, ranging from mild edema to extensive hemorrhage, resulting from various insults to the pancreas.   Chronic pancreatitis is defined as the persistence of pancreatic cellular damage after an acute inflammation and decreased endocrine and exocrine function.

S/S

Pain in LUQ, weight loss, nausea/vomiting, anorexia, malabsorption and steatorrhea  appear late in disease, DM

Nursing interventions/Teaching

Control pain, improve nutritional status (pancreatic enzymes w/ meals, antacids, monitor blood glucose), Patient Education and Health Maintenance (stress that no treatment will be effective with continued alcohol consumption)  Outcomes:  Pt verbalizes pain level reduced, Weight stabilized, Pt verbalizes understanding of consequences of continued alcohol consumption.

Complications

Pancreatic pseudocyst, ascites, pleural effusion, GI hemorrhage, Biliary tract obstruction, pancreatic fistula

Nursing Diagnosis: Pain related to chronic insult to pancreas. Altered nutrition:Less than body requirements r/t fear of eating, malabsorption, and glucose intolerance.

 

Peripheral arterial occlusive disease (aorta and distal arteries)

Definition

Form of arteriosclerosis in which the peripheral arteries become blocked. Chronic occlusive arterial disease occurs much more frequently than does acute (which is the sudden and complete blocking of a vessel by a thrombus or embolus).

S/S

1) aortoiliac- mesenteric ischemia (pain after eating), unintentional weight loss, renal insufficiency, poorly controlled HTN, impotence, intermittent claudication 2) femoral, popliteal, and distal arteries- intermittent claudication, rest pain, dependant rubor (dusky purple color of extremity when in dependant position; pallor when elevated), numbness/tingling of feet/toes, tissue loss/nonhealing ulcers, trophic changes (hair loss, thick toe nails, thin/shiny skin, cool temp of extremity)

Nursing interventions/Teaching

frequent neurovascular checks, inspect for ulceration, provide and encourage well balanced diet, encourage ambulation/ROM to increase circulation, pain meds conducive to ambulation, foot care (i.e. tight fitting socks, shoes, apply lanolin to prevent skin cracking), teach pt. to avoid crossing legs/sitting in one position too long.

Complications

Ulceration with slow healing, gangrene sepsis, severe occlusion may necessitate limb or partial limb amputation

Nursing Diagnosis: Altered tissue perfusion (peripheral) R/T decreased arterial blood flow. Sensory/Perceptual alteration (tactile) of lower extremities. Risk for infection R/T decreased arterial flow.

 

Peripheral Vascular Disease – (i.e. arterial occlusion)

 

Definition:  Disorders of the circulation in the extremities. (Very similar to the disorders affecting the coronary and cerebral arteries) The leading cause of PVD Is atherosclerosis, a gradual thickening of the arteries, which progressively narrows the lumen, which leads to  ischemia, pain and inflammation,  impaired function, in progressing cases infarction, and tissue necrosis.

 

Risk Factors:

  • Cigarette smoking
  • Hyperlipidemia
  • Hypertension
  • Diabetes mellitus
  • Obesity & fam hx

 

Manifested by:

  • Intermittent claudication (ischemic muscle pain – brought on by activity, relief w/ rest)
  • Delayed capillary refill

 

Occlusion in extremity

  • Sudden onset acute pain, numbness, tingling
  • Weakness
  • Pallor and coldness
  • Pulses absent below occlusion

 

 

Nursing Interventions:

  • Visual assessment – skin integrity, assoc w/ diminished circulation
  • Palpate pulses
  • Thrombolytic therapy as ordered – attempt to dissolve clot
  • Anticoagulant therapy as ordered – prevent extension of embolus
  • Extremity protected from injury.
  • Take precautions needed for surgery , i.e. NPO (possible embolectomy)

 

Complications of PVD in a diabetic patient: 

Combine sensory neuropathy, PVD, DM, clotting abnormalities, impaired immune function is very conducive making a mountain out of a molehill in foot complicationslike lesions.

  • High sugar environment allowing bacteria to grow, blood is viscous.
  • Patient doesn’t feel pain from lesion due to neuropathy – disregards
  • Maybe patient doesn’t see it due to retinol neuropathy
  • Impaired immune response due to sclerosis of vessels

 

Look for:

  • Changes in skin integrity, color, gangrenous?
  • Decreased lower leg hair
  • Decreased or absent pulses, poor cap refill
  • Extremity cool, pallor

Treatment:

  • ASAP, to prevent infection
  • mild antiseptic, antibiotics as ordered
  • rest affected leg to promote circulation and wound healing
  • avoid anything constricting to skin, i.e. tape

 

Pleural effusion

Definition

Collection of fluid in the pleural space.

S/S

Progressive dyspnea, decreased movement of the chest wall, pleuritic pain, fever, night sweats, cough, and weight loss.

Nursing interventions/Teaching

Auscultate breath sounds, noting adventitious sounds, monitor vital signs and laboratory/diagnostic studies, assess/document dietary intake measuring I&O accurately, and promote infection control.

Complications

Congestive heart failure.


Pleural Effusion

 

Definition:        Excess fluid in the pleural space.  Causes are many and include lung ca, chest trauma, heart failure, hepatic diseases, hypoalbuminemia, pleural infection, malignancy, myxedema, pancreatitis, TB, and pulmonary embolism. Is a sign of a disease and not a disease in it’s self. Has 2 types: transudative or exudative. Exudative is caused from inflammation.

 

 

 

M/B:              Decreased breath sounds, dyspnea, fever, pleuritic chest pain, and malaise.

Chest X-ray will show fluid in dependent regions. Dullness to percussion.

Pleural effusions due to malignant diseases tend to reoccur and accumulate.

 

 

Nursing Interventions:

  • Administer O2 to improve oxygenation, treat underlying cause, prepare patient for thoracentesis, explain procedure to patient, explain to patient the importance of informing you if there is any increased difficultly in breathing.
  • Watch for respiratory distress. Have patient deep breathe, cough and use incentive spirometer.
  • If patient has chest tubes, use aseptic technique for dressing changes. Ensure patency of tube by watching for bubbles in seal chamber. Record drainage of tube. If chest tube comes out, cover hole with petroleum gauze and call MD.

 

 

Complications:      Respiratory distress, pneumothorax, collapsed lung, infection, adhesions from recurrent effusions.

 

 

Pneumonia

Definition

Is an inflammatory process, involving the terminal airways and alveoli of the lung, caused by infections agents. (Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers.  Pgs. 275-280.)

S/S

Sudden onset; shaking chill; rapidly rising fever of 101-1050F,Cough productive of purulent sputum. Pleuritic chest pain aggravated by respiratory/coughing. Dyspnea, tachypnea accompanied by respiratory grunting, nasal flaring, use of accessory muscles or respiration, fatigue. Rapid, bounding pulse.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 275-280.)

Nursing interventions/Teaching

Observe for cyanosis, dyspnea, hypoxia, and confusion, indicating worsening condition. • Follow ABGs/oxygen saturation to determine oxygen need and response to oxygen therapy. • Administer oxygen at concentration to maintain acceptable oxygen saturation level. • Obtain freshly expectorated sputum for Gram’s stain and culture, preferably early morning specimen, as directed. • Encourage patient to cough. Retained secretions interfere with gas exchange. Suction as necessary. • Humidify air or oxygen therapy to loosen secretions and improve ventilation. (Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers.  Pgs. 275-280.)

Complications

Pleural effusion.  Sustained hypotension and shock, especially in gram-negative bacterial disease, particularly in the elderly. Superinfection: pericaditis, bacteremia, and meningitis.  Delirium – this is considered a medical emergency.  Atelectasis – due to mucous plug.  Delayed resolution.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 275-280.)

 

Pneumonia

Definition

Inflammatory process, involving the terminal airways and alveoli of the lung, caused by infectious agents. Classified according to causative agent.

S/S

(sudden onset- shaking chill, rapidly rising fever of 39.5 to 40.5 Celsius or 101 to 105 Fahrenheit) cough productive of purulent sputum, pleuritic chest pain aggravated by respiration/coughing, rapid/bounding pulse, dyspnea, tachypnea accompanied by respiratory grunting, nasal flaring, use of accessory muscles of respiration, fatigue.

Nursing interventions/Teaching

Observe for cyanosis, dyspnea, hypoxia, and confusion. Follow ABG/SaO2 to determine oxygen need, humidify O2 to loosen secretions, place pt. in upright position, encourage activity, encourage coughing, auscultate chest for crackles and rhonchi, demonstrate how to splint chest while coughing, VS, encourage fluid intake.

Complications

Pleural effusion, sustained hypotension and shock (especially in gram negative bacterial disease, particularly in the elderly), superinfection (pericarditis, bacteremia, and meningitis), delirium (this is considered a medical emergency), atelectasis (due to mucous plugs), delayed resolution

Nursing Diagnosis: Impaired gas exchange R/T decreased ventilation secondary to inflammation and infection involving distal airspaces. Ineffective airway clearance R/T excessive tracheobronchial secretions. Pain R/T inflammatory process and dyspnea. Risk for injury R/T resistant infection.

 

Pneumonia

Definition

Inflammatory process, involving the terminal airways and alveoli of the lung. It is caused by                                                                                            infectious agents. Classified according to causative agent.  – bacteria, fungi, or candida. It is seen most commonly in people that are immunocompromised.

S/S

  • Sudden onset- shaking chill, rapidly rising fever of or 101 to 105 F, cough productive of purulent sputum.
  • Pleuritic chest pain aggravated by respiration/coughing
  • Rapid/bounding pulse
  • Dyspnea, tachypnea accompanied by respiratory grunting, nasal flaring, use

of accessory muscles of respiration, fatigue.

Nursing interventions/Teaching

  • Improve gas exchange – Observe for cyanosis, dyspnea, hypoxia, and confusion. Follow ABG/SaO2 to determine oxygen need, humidify O2 to loosen secretions.

Place pt. in upright position, encourage activity, encourage deep breathing and coughing

Auscultate chest for crackles and rhonchi.

  • Enhance air way clearance – deep breathing, increase fluids, humidify air, chest wall percussion.
  • Relieve pleuritic pain – comfortable positioning and changing positions – prevents pooling. Administer analgesics as ordered.
  • Monitor for complications – observe vitals, auscultate lungs, observe mental status.
  • Special nursing surveillance for immunocompromised – may have little or no fever.

Complications

Pleural effusion, sustained hypotension and shock (especially in gram negative bacterial disease, particularly in the elderly), superinfection (pericarditis, bacteremia, and meningitis), delirium (this is considered a medical emergency), atelectasis (due to mucous plugs), delayed resolution.

Nursing Diagnosis:

  1. Impaired gas exchange R/T decreased ventilation secondary to inflammation and infection involving distal airspaces.
  2. Ineffective airway clearance R/T excessive tracheobronchial secretions.
  3. Pain R/T inflammatory process and dyspnea.
  4. Risk for injury R/T resistant infection.

 

 

Pneumothorax

Definition

A condition in which air gets between the lungs and the chest wall.

S/S

Sudden, sharp chest pain, shortness of breath, chest tightness.

Nursing interventions/Teaching

Promote/maintain lung re-expansion for adequate oxygenation/ventilation, minimize/prevent complications, reduce discomfort/pain.

Complications

May be life-threatening if left untreated.

 

Pressure Ulcer

Definition

Also known as skin breaks down, is a localized area (usually over a bony prominence) of tissue necrosis caused by unrelieved pressure that occludes blood flow to the tissues.  Factors that influence the development of pressure ulcers include the amount of pressure (intensity), the length of time the pressure is exerted on the skin (duration), and the ability of the patient’s tissue to tolerate the externally applied pressure.  Besides pressure, shearing force, friction, and excessive moisture contribute to ulcer formation.

S/S

STAGE ONE-A reddened area on the skin that when pressed is non-blanchable.  This indicates a pressure ulcer is starting to develop. May have changes in one or more of the following: Skin temperature (warmth or coolness), Tissue Consistency (Firm or Boggy feel) and Sensation (Pain and Itching).

STAGE TWO-Partial-thickness skin loss involving the epidermis, dermis or both.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

STAGE THREE-Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.

STAGE FOUR-Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures (e.g., tendon, joint capsule).  Undermining and sinus tracts may also be associated with STAGE IV pressure ulcers.

Nursing interventions/Teaching

Assess causative factors such as activity, mobility, presence or absence of sensory deficits, nutrition and hydration status, circulation, and oxygenation, skin moisture status to reduce or eliminate factors that contribute to development or progression of the pressure ulcer; Assess stage and document wound characteristics on a regular basis in relation to location, width, and depth of wound, amount of granulation tissue visible and/or epithelialization, necrotic tissue, local or systemic infection, presence and character of exudates, including volume, color consistency, and odor to provide baseline and ongoing data for monitoring pressure ulcer.; Use pressure relief devices (e.g., foam boots, wheelchair cushions); Institute and document position change schedule q2hr to avoid prolonged pressure in one area.; Keep heels off of bed.  Keep head of bed at or below 30-degree angle and flat when not contraindicated to avoid sacral, buttock, and heel pressure.; Use assistive devices (e.g., trapeze, turning sheets, lifts) to aid patient movement.; Protect patient’s skin from excess moisture to prevent maceration.; Institute 2000 to 3000 calories/day (more if increased metabolic demands), 2000 ml/day of fluid to provide calories, protein, and fluids necessary for tissue repair.; Offer vitamin and mineral supplements if there are deficiencies.; Initiate prescribed tx based on pressure ulcer characteristics and in accordance with AHCPR 1994 guidelines.; Assess the psychosocial impact of pressure ulcer on the patient and caregivers and provide support or make referrals to other health care providers as indicated.; Teach patient and family about cause, prevention, and tx of pressure ulcer to prevent recurrence.

Complications

Infection; Amyloidosis; Endocarditis; Meningitis; Peptic Arthritis; Squamous Cell Carcinoma (in the ulcer); Systemic Complications of Topical Treatment; Maggot Infestation

 

Pressure Ulcers

 

Definition:  A pressure ulcer is a localized area (usually over a bony prominence) of tissue necrosis caused by unrelieved pressure that occludes blood flow to the tissues.  Most common site being the sacrum the heels second. Factors influence the pr ulcer are the following:

  • Intensity
  • Duration
  • Patient’s tolerance or if cognitive
  • Friction and excessive moisture also contribute

 

Manifested by:

 

Stage 1:

  • Skin intact
  • Skin T warm
  • Tissue firm, persistant redness

Stage 2:

  • Partial thickness skin loss (involve epidermis,dermis, or both)
  • Superficial – blister, abrasion, shallow crater

Stage 3:

  • Full thickness skin loss
  • Damage or necrosis of sub Q tissue, extend down to- not through
  • Presents as deep crater w/ or w/o undermining adjacent tissue

Stage 4:

  • Full thickness skin loss, extensive distruction, tissue necrosis
  • Damage to muscle, bone, supporting structures

 

 

 

Nursing Interventions:  ***PREVENTION

  • Relief of pressure
  • Measure size of wound
  • Debridement, wound cleaning
  • Application of dressing
  • Poss operative care needed: i.e. – skin graft, skin flaps, musculocutaneous flaps

 

Complications:

  • Stage increasing to next level
  • Necrosis
  • Infection
  • Septicemia
  • Amputation

 

Poss. Nursing Dx:

Impaired skin integrity r/t pressureand inadequate circulation m/b evidence of pressure ulcer.

 

 

 

Prostate Cancer

Definition

A malignant tumor (almost always an adenocarcinoma) of the prostate gland.

(Venes, D. (19th ed.) (2001). Taber’s Cyclopedic Medical Dictionary.  Philadelphia: F.A. Davis Company.  P.1692.)

S/S

Most early-stage prostate cancers are asymptomatic. Symptoms due to obstruction of urinary flow: hesitancy and straining to void, frequency, nocturia; diminution in size and force of urinary stream. Symptoms due to metastases: pain in lumbosacral area radiating to hips and down legs (from bone metastases); perineal and rectal discomfort; anemia, weight loss, weakness, nausea, oliguria (from uremia); hematuria (from urethral or bladder invasion, or both); lower extremity edema – occurs when pelvic node metastases compromise venous return.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 735-736.)

Nursing interventions/Teaching

Help patient assess the impact of the disease and treatment options on quality of life. • Give repeated explanations of diagnostic tests and treatment options; help patient gain some feeling of control over disease and decisions. • Help patient/family set reachable goals. • Let patient know that decreased libido is expected after hormonal manipulation therapy and impotence may result from some surgical procedures and radiation. • Expect patient’s behavior to reflect depression, anxiety, anger, and regression. Encourage ventilation of feelings and communication with partner.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 735-736.)

Complications

Bone metastasis – vertebral collapse and spinal cord compression, pathologic fractures; Complications of treatment.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 735-736.)

 

Pneumomediastinum

 

Definition:  Free air or gas contained within the mediastinum, which originates from the alveolar space or conducting airways. (The space in the chest between two lungs)

 

 

S/S:neck and chest pain, dyspnea, fever, dysphonia (hoarseness), throat pain and jaw pain.

 

Nursing Intervention/Teaching:

Avoid high risk activities: those involving the Valsalva maneuver; wind instruments, diving, weight lifting.  Maintain good asthma control, vaccinations are current: influenza and pertussi, avoid smoking and inhalation of illicit drugs.

 

Complications:  Subcutaneous emphysema, hypotension, mediastinitis and pneumothorax.

 

 

Post operative patient

Definition

Pg 119, Lippencott.  General guidelines for most post operative scenarios.

 

Nursing interventions/Teaching

  1. Maintain adequate fluid volume by administering IV or po fluids as prescribed, recognize evidence of electrolyte imbalance.
  2. Assess pain levels and administer analgesics as prescribed, position patient to maximize comfort.
  3. Perform good hand washing before and after contact with patient, inspect dressings and reinforce if necessary.
  4. Encourage coughing, deep breathing, use of incentive spirometer (if ordered).
  5. Assess for n/v and administer anti-nausea meds as prescribed, assess bowel sounds frequently.
  6. Provide therapeutic environment (room temp, clean bedding, lights, etc), post op vitals.

 

Outcomes:  Pt will report adequate pain control.  Pt will breathe deeply and use IS every hour.  Pt’s input and output will remain equal with no visible signs of imbalance.  Pt will be

free of n/v.

Complications

Postoperative pain, shock, hemorrhage, DVT, atelectasis, aspiration, pneumonia, PE, urinary retention, bowel obstruction, hiccups, wound infection, wound dehiscence, and psychological disturbances.

Nursing Diagnosis:

Ineffective airway clearance r/t anesthesia and or pain meds.

Risk for fluid volume deficit r/t blood loss, food and fluid deprivation, vomiting, etc.

Pain, r/t surgical incision and trauma.

 

 

Prostatectomy

Definition

The excision of part or all of the prostate gland.

(Venes, D. (19th ed.) (2001). Taber’s Cyclopedic Medical Dictionary.  Philadelphia: F.A. Davis Company.  P.1692.)

S/S

N/A

Nursing interventions/Teaching

Maintain patency of urethral catheter placed after surgery. • Assess degree of hematuria and any clot formation; drainage should become light pink within 24 hours. • Administer IV fluids as ordered, and encourage oral fluids when tolerated to ensure hydration and urine output. • After 24 hours, encourage ambulation to prevent venous thrombosis, pulmonary embolism, and hypostatic pneumonia. • Observe urine for cloudiness or odor, and obtain urine for evaluation of infection as ordered. • Administer pain medication, or monitor PCA as directed. • Provide realistic expectations about postoperative discomfort and overall progress. Tell patient to avoid sexual intercourse, straining at stool, heavy lifting, and long periods of sitting for 6 to 8 weeks after surgery. Advise follow-up visits after treatment because urethral stricture or bladder neck contracture may occur.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 708-710.)

Complications

Incontinence; Impotence; Infertility; Retrograde ejaculation; Urethral stricture

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 708-710.)

 

Pulmonary Embolism

Definition

A pulmonary embolism arises from thrombi in the venous circulation (and from other sources).  The most common source is the deep veins of the legs. The thrombus breaks loose and travels and an embolus until it lodges in the pulmonary vasculature.

S/S

Dependent upon the size and number of blood vessels occluded.  Anxiety, sudden onset of unexplained dyspnea, tachypnea, tachycardia, cough, pleuritic chest pain, hemoptysis, crackles, fever, accentuation of the pulmonic heart sound, sudden change in mental status, hypoxia, sudden collapse of patient with shock, no pain if massive PE, rapid pulse, decreased blood pressure, slight fever, productive cough with blood-streaked sputum

Nursing interventions/Teaching

Bed rest in a semi-fowler position, maintain and monitor IV line, patient teaching of PE, oxygen therapy as ordered, careful monitoring of vital signs as well as ECG, ABG, and lung sounds, provide emotional support, explain importance of, monitor labs such as PT, PTT, INR

Complications

Pulmonary infarction, alveolar necrosis, hemorrhage, infection of tissue, abscess, pulmonary hypertension, hypoxemia, dilation and hypertrophy of right ventricle, rapid death

 

Pyelonephritis 

Definition

An acute infection and inflammatory disease of the kidney and renal pelvis involving one or both kidneys.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 717-718)

S/S

Fever,• Chills, Costovertebral tenderness, Flank pain (with or without radiation to groin). Nausea, Vomiting,

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 717-718)

Nursing interventions/Teaching

Assess vital signs frequently, and monitor intake and output; administer antiemetic medications to control nausea and vomiting. • Administer antipyretic medications as prescribed and according to temperature. • Correct dehydration by replacing fluids, orally if possible, or IV. • Administer or teach self-administration of analgesic medications, and monitor their effectiveness. • Use comfort measures such as positioning to locally relieve flank pain.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 717-718)

Complications

Renal abscess requiring treatment by percutaneous drainage or prolonged antibiotic therapy. Perhipheral abscess.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 717-718),

 

Renal Insufficiency, Chronic

 

Definition:

It is the progressive inability, over months to years, of the kidneys to respond to changes in body fluids and electrolyte composition with an inability of the kidneys to produce sufficient urine, GFR is less than 20% of normal and serum creatinine is greater than 5mg/dl. There are 3 stages to CRF – early, second and third stage.

 

Signs/symptoms

-in the early stage – patient remains free of symptoms and BUN and creatinine are normal

– in the 2ndstage – there is a slight rise in BUN and creatinine; few symptoms may be present  including oliguria or polyuria

-in the 3rdstage, there is a sharp increase in BUN and creatinine; symptoms of oliguria and uremia are present.

 

 

Nursing Interventions:

  • Admininister diuretics, antihypertensives; ACE inhibitors as ordered
  • Maintain fluid and dietary restrictions; refer for dietary consultations if necessary
  • Limit Na and protein, and high CHO
  • Monitor lab values
  • Provide oral hygiene at least every 4 hours
  • Monitor activity level and fatigability
  • Arrange mealtime and activities per client preferences and procedures.

 

 

 

 

Rheumatoid Arthritis

Definition

Is a general term used to describe what may be a heterogeneous group of inflammatory diseases that affect joints and other organ systems.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 942-944.)

S/S

Bilateral, symmetric arthritis affects any diarthrodial joint, but most often involves the hands, wrists, knees, and feet. • Rheumatic nodule – elbows, occiput, sacrum. • Acute pericarditis. • Asymptomatic pulmonary disease. • Carpal tunnel syndrome. • Fever, fatigue, weight loss.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 942-944.)

Nursing interventions/Teaching

Apply local heat or cold to affected joints for 15 to 20 minutes, three to four times a day. Avoid temperatures likely to cause skin or tissue damage by checking temperature of warm soaks or by covering cold packs with a towel. • Encourage warm bath or shower in the morning to decrease morning stiffness. • Encourage exercise consistent with degree of disease activity. • Promote pain relief before self-care activities. •

Assist with problem-solving approach to explore options and to gain control of problem areas.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 942-944.)

Complications

Loss of joint function because of bony adhesions and damage of supporting structures.  Anemia of chronic disease.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 942-944.)

 

Schizophrenia

 

Definition:

A chronic, severe, and disabling brain disease, affecting approximately 1% of the population with no known single cause – it also tends to run in families.

 

S/S

People suffering from schizophrenia often suffer symptoms such as hallucinations/delusions, hearing voices not heard by others, beliefs that other people are reading their minds, controlling their thoughts and trying to hurt them (paranoia). They may also have distorted perceptions of reality, and their speech and thought processes can also be so disorganized that they may be incomprehensible to others. They also tend to withdraw socially and isolate themselves.

 

Nursing interventions:

-Ensuring that the patient with schizophrenia takes their medications on a regular basis while hospitalized.

-Educating the patient and the patient’s family about the importance of the patient taking their medications on a regular basis – not to stop when they “feel better.”

-Providing additional resources to the patient and their family such as outpatient resources – psychotherapists, social services, additional sources of education, self-help groups, etc.

– Encourage simple concrete tasks requiring minimal concentration, such as self-care needs.

– Give support to family.

– Plan simple daily routine.

– Continue speaking to pt. even if he or she appears withdrawn.

– Provide milieu that provides sense of security & safety

– Provide activities that distract pt. from hallucinations

 

Complications:

There is no cure for schizophrenia, only management of the symptoms/signs. If these are not managed, person’s with schizophrenia are more apt to commit suicide; 10-13%, especially young males.

Substance abuse may be as high as 60% in schizophrenic pts.

Violent behavior – common in acute schizophrenic states and relapses.

Can have real difficulty holding down a job; taking care of themselves.

 

 

Seborrheic dermatitis

Definition

Chronic, superficial inflammatory skin disorder

S/S

Crusted pinkish or yellowish patches. Loose scales that may be dry, moist, or greasy. Mild itching. Affects the scalp, eyebrows, eyelids, nasolabial creases, lips, ears, chest, axillae, umbilicus, and groin.

Nursing interventions/Teaching

Educate pt. on chronic nature and that condition may be exacerbated by perspiration, neuroleptic drugs, and emotional stress. (This disease is seen more often in patients with HIV, Parkinsons, DM, epilepsy, and malabsorption syndromes). Educate pt. on topical prescription use (this can include: selenium sulfide, tar, zinc, or resorcinol shampoo; corticosteroid lotions or creams)

Complications

 

Seizure disorder

Definition

sudden alteration in normal brain activity that causes distinct changes in behavior and body function. They are thought to result from disturbances in brain cells that cause them to give off abnormal, recurrent, uncontrolled electrical discharges. (Also known as epileptic seizures or if recurrent epilepsy)

S/S

Impaired consciousness, disturbed muscle tone or movement, disturbances of behavior-mood sensation- or perception, disturbance of autonomic function

Nursing interventions/Teaching

maintain patent airway, monitor serum levels for therapeutic range of meds, monitor for med toxicity, provide safe environment, do not restrain or place anything in mouth during seizure, lay on side to prevent aspiration, stress importance of medication regimen, teach stress reduction techniques, avoid alcohol, provide info on support groups/counseling

Complications

Status epilepticus, injury due to fall

Nursing Diagnosis: Altered cerebral tissue perfusion R/T seizure activity. Risk for injury R/T seizure activity. Ineffective individual coping R/T psychosocial and economic consequences of epilepsy.

 

Seizures

Definition

A paroxysmal, uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Often symptoms of underlying illness.

S/S

Sleeping problems, staring spells, appearing withdrawn, sleepwalking, night terrors, noise sensitive, temperature sensitive, touch sensitive, difficulty getting along with peers, memory losses, word finding problems, headaches, fatigue in the mornings, leg pains, moody, emotional, clumsiness, easily distracted, lack of coordination, confusion, sleep deprivation, physically weak, vertigo, ringing in the ears, disorientation, excessively fearful,  impulsivity, confused speech, taste disturbances

Nursing interventions/Teaching

Talk calmly to patient, do not attempt to force anything in the patient’s mouth, protect the patient from harm, place the patient on his side after the convulsion to keep the airway clear, allow patient to sleep after the seizure, ensure patient airway, suction as needed, monitor vital signs, do not restrain, remove or loosen tight clothing, monitor level of consciousness, monitor oxygen saturation, monitor pupil size and reactivity, reassure and orient the patient after a seizure, monitor input and output, assess risk for injury, patient teaching, family teaching

Complications

Choking, epilepsy, brain damage, other neurological complications, weakness, facial drop, meningitis, coma, myocarditis, arrhythmias, pneumonia, liver dysfunction, diffuse bleeding, Jarisch-Herxheimer’s reaction.

 

Sepsis

Definition

Blood-borne infection

S/S

Severe infection, fatigue, fever, malaise, Nausea, Vomiting

Nursing interventions/Teaching

Assess; Wound culture/blood culture Hematocrit/CBC lab electrolyte; balance Prothrombin time; Hand hygiene Surgical aseptic technique Vital Signs/temperature; inspect wound/drainage; Mouth/vagina care-inspect for yeast pedal pulses skin color, temp, moisture Homans’ sign; Edema Breath sounds.  Implement: Position change frequently Prevent spread (sneezing into tissues/coughing/sneezing) Bed rest Prevent shaking chills and sweating (gown/linen change) Meds administration anti pyretic/antibiotic. Frequent baths Cooling blanket Education: Disease process Mode of infection Drug therapy Diet S/S that need Dr. consult

Complications

Anemia Respiratory distress Hypothermia/hyperthermia hypotension; Edema; Pyarthrosis Seizures hepatosplenomegaly hemorrhage jaundice, meningitis

 

Shingles (herpes zoster)

Definition

An inflammatory condition in which a virus produces a painful vesicular eruption along the distribution of the nerves from one or more dorsal root ganglia; prevalence increases with age.

S/S

1) eruption may be accompanied or precede by fever, malaise, HA, or pain; pain may be burning, lancinating, stabbing, or aching 2) inflammation; usually unilateral 3) vesicles appear in 3-4 days: A) characteristic patches of grouped vesicles appear on erythematous, edematous skin  B) early vesicles contain serum; they later rupture and form crusts C) scarring usually does not occur unless they are deep and involve the dermis

Nursing interventions/Teaching

Assess pain, apply wet dressings to cool and dry inflamed areas by means of evaporation, teach relaxation/distraction techniques, teach proper

hand washing to avoid spread, advise pt. not to open blisters to avoid secondary scarring and infection, apply antibacterial ointments (after acute stage), administer antiviral medication

Complications

1) chronic pain syndrome (constant aching/burning or intermittent lancinating pain or hyperesthesia of affected skin) 2) ophthalmic complications (keratitis, uveitis, corneal ulceration, possible blindness) 3) hearing deficit, vertigo, facial weakness 4) visceral dissemination- pneumonitis, esophagitis, enterocolitis, myocarditis, pancreatitis

Nursing Diagnosis: Pain R/T inflammation of cutaneous nerve endings. Impaired skin integrity R/T rupture of vesicles.

 

Sigmoid colectomy

 

Definition

This type of surgery involves removing the section of the bowel containing the cancer, and then rejoining the two ends of the bowel. It is a removal of the sigmoid colon -this type of surgery involves joining your bowel together in the upper area of the rectum.

 

Nursing interventions

 

-give pain medications at prescribed intervals to help avoid breakthrough pain

– wash hands thoroughly before and after changing wound dressing.

-monitor vital signs

-monitor for signs of infection

-answer questions about the surgery and management of the stoma

-help keep the patient as comfortable as possible – give back massage, apply lotion, etc.

– encourage patient to make choices and participate in planning of care and schedule activities.

-plan care activities around periods of greatest comfort whenever possible.

 

Complications

-infection

-bleeding

– leaking from the bowel

-blood clots

 

 

 

Skin Breakdown

Definition

Lippincott 183  Pressure sores- Decubitus ulcers- these are localized ulcerations of the skin or deeper structures- most commonly resulting from prolonged periods of bed rest in acute or long term care facilities.

S/S

Staging- Stage 1- erythema- non blanching redness; Stage 2- dermal breakdown; Stage 3- full thickness skin breakdown; Stage 4- bone, muscle and supportive tissue involvement

Nursing interventions/Teaching

Prevention: Skin inspection several times daily, assess and intervene if incontinence occurs; Encourage ambulation and exercise; Relieve the pressure; Reposition every 2 hours; Use of air mattress as prescribed; Wound Care: clean and disinfect, dress as ordered, use of antibiotics as prescribed; Follow up- continue nutritional assessment, avoid pressure, shearing, moisture

Complications

 

Small Bowel Obstruction (SBO)

Definition

A mechanical or neurological abnormality inhibiting the normal flow of gastric or intestinal contents. Obstructions may result from scar tissue formation, cancer, or strangulated hernias; all are mechanical barriers to the normal flow of gastric or intestinal contents. A neurological obstruction, in the form of a paralytic ileus, causes interference with innervation, thus hindering normal peristaltic activity.

S/S

Abnormal pain and distention in abdomen; projectile vomiting and nausea; and possible absence of bowel sounds or increase in bowel sounds.

Cramping, Obstipation (chronic constipation) .

Nursing interventions/Teaching

Assess and document s/s and reactions to treatments.  Monitor vital signs at least q4h.  Record I&O’s.  Monitor the decompression tube and assess quantity and character of drainage. Provide mouth care while patient is intubated.  Administer prescribed medication and monitor for side effects.  Maintain NPO.  Monitor the states of distention and hydration.  Provide routine postoperative care if pt undergoes surgery.

Complications

Dehydration d/t loss of water, sodium, and chloride. Peritonitis, shock d/t loss of electrolytes, death d/t shock

 

Soft tissue injury—Abrasion

Definition

Superficial loss of skin resulting from rubbing or scraping the skin over a rough or uneven surface.

S/S

Pain at injury site, swelling, tenderness, bleeding, open areas of skin

Nursing interventions/Teaching

Primary:  Control Bleeding.  Secondary: Wound prep; saline or sterile water irrigation, anesthetizing if necessary and as prescribed.  Debridement performed as prescribed.  Application of hydrophyllic dressing allows exudates to pass through to second absorbent layer in this dressing without wetting contact layer.  (Adaptic, petroleum gauze, Xeroform gauze) Apply outer wrap to hold dressing in place.  Tetanus prophylaxis may be indicated.  Inform patient that pain is worse in the first 24-48 hours.  Elevation helps to prevent fluid accumulation in interstitial spaces.  Teach patient signs and symptoms of infection.  Outcomes:  Pt is infection free.  Pt has no pain.  Pt is able to verbalize how to change the dressings at home, and can state signs and symptoms of infection.

Complications

Infection

Nursing Diagnosis: Pain, r/t injury.  Impaired physical mobility.

 

Spinal Revision and Fusion

Definition

Surgery performed by insertion of an interbody cage device.  This is used to correct an existing mechanical deformation, provide stability to the segment until arthrodesis is obtained, provide the best possible environment for successful arthrodesis, and achieve this with limited morbidity associated with their use. (arthrodesis = surgical immobility of a joint)

S/S

N/A

Nursing interventions/Teaching

Provide stability of spine (brace use, log rolling, etc.), administer medications for pain and/or antibiotics as prescribed, dressing change as ordered,reposition patient to prevent skin breakdown, assess vital signs, assist in ambulation, assess for signs of thrombus or embolus due to decreased mobility

Complications

Infection, need for additional surgery, severe pain, interbody device migration, Titanium debris has been shown to stimulate a macrophage cellular response and cytokine release, which could possibly have a deleterious effect on spinal tissues.

 

Splenectomy

Definition

Removal of spleen

S/S

N/A

Nursing interventions/Teaching

Maintain effective breathing pattern.  Monitor for hemorrhage.  Avoid thromboembolitic complications—monitor Plt count, advise pt to report chest pain, SOB or weakness.  Prevent infection by assessing incision and good hand hygiene.  Relieve pain with analgesics as prescribed.  Outcome:  Pt verbalizes decreased pain.  Pt is afebrile, no purulent drainage from incision. Pt respirations are unlabored, breath sounds clear.  Vital signs stable, abdominal girth unchanged.

Complications

Pancreatitis, fistula formation: tail of pancreas is anatomically close to splenic hilum.  Hemorrhage.  Atelectasis, pneumonia and OPSI—Overwhelming Post Splenectomy Infection (life threatening bacterial infection).  Peritonitis, sepsis.

Nursing Diagnosis: Ineffective breathing pattern r/t pain, incision. Risk for FVDr/t hemorrhage.  Risk for injury r/t thrombocytosis.  Risk for infection r/t surgical incision.  Pain r/t surgical incision.

 

Subdural Hematoma

Definition

Occurs from bleeding between the dura mater and the arachnoid layer of the meningeal covering of the brain. Usually results from injury to the brain substance and its parenchymal vessels.

S/S

May be asymptotic. Deterioration, unconsciousness, improvement, dilation of pupils, ptosis, nonspecific non-localizing progression, alteration in LOC, headache, slurred speech, one sided weakness, drowsiness, confusion, pain, bleeding, paralysis, raised intracranial pressure, vomiting, severe headaches, seizures,

Nursing interventions/Teaching

Comfort patient from pain, monitor vital signs, watch for infection, monitor neural function, help patient with motor ability, refer family to support groups

Complications

Temporary brain damage, permanent brain damage, death

 

Substance Abuse-Inhalants

Definition

Maladaptive pattern of substance use leading to clinically significant impairment or distress.

S/S

Abrupt changes in work or school attendance, unusual flare-ups or outbreaks of temper, withdrawal from responsibility, general changes in overall attitude, deterioration of physical appearance and grooming, substance odor on breath and clothes, runny nose, watering eyes, drowsiness or unconsciousness, poor muscle control, laughing uncontrollably, periods or euphoria, poor nutrition and fluid intake

Nursing interventions/Teaching

Monitor vital signs, monitor patient for drug dependency with appropriate medication, develop an accepting relationship with patient, set limits on behavior, support and redirect defenses, use therapeutic language, educating patient and family, help patient find a support group, maintain confidentiality, help prevent relapse,

Complications

Suicide, respiratory arrest, tachycardia, arrhythmias, nervous system damage, polyneuropathy, myelopathy, vomiting, diarrhea, increased health problems, death

 

Suicide

Definition

Intentionally causing one’s own death.

(Venes, D. (19th ed.) (2001). Taber’s Cyclopedic Medical Dictionary.  Philadelphia: F.A. Davis Company.  P. 1997.)

S/S

Suicide ideation,• Previous suicide attempts,• Self-harming behaviors,• Associated psychiatric illness (affective disorders and substance abuse; conductive disorders and depression in youth).

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 1093-1094.)

Nursing interventions/Teaching

Use crisis intervention to determine suicide potential, discover areas of depression and conflict, find out about the patient’s support system, and determine whether hospitalization, psychiatric referral, and so forth is warranted. • Treat the consequences of the suicide attempt (e.g. gunshot wound, drug overdose). • Prevent further self-injury – a patient ho has made a suicide gesture may do so again. • Admit to intensive care unit (if condition warrants), arrange follow-up care, or admit to psychiatric unit, depending on assessment of suicide potential.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 1093-1094.)

Complications

Death; Permanent health disorders; Harming other people or living things

 

Post operative patient

Definition

Pg 119, Lippencott.  General guidelines for most post operative scenarios.

S/S

N/A

Nursing interventions/Teaching

Maintain adequate fluid volume by administering IV or po fluids as prescribed, recognize evidence of electrolyte imbalance, assess pain levels and administer analgesics as prescribed, position patient to maximize comfort, perform good hand washing before and after contact with patient, inspect dressings and reinforce if necessary, encourage deep breathing, assess for n/v and administer anti-nausea meds as prescribed, assess bowel sounds frequently, provide therapeutic environment (room temp, clean bedding, lights, etc), post op vitals. Outcomes:  Pt will report adequate pain control.  Pt will breathe deeply and use IS every hour.  Pt’s input and output will remain equal with no visible signs of imbalance.  Pt will be free of n/v.

Complications

Postoperative pain, shock, hemorrhage, DVT, atelectasis, aspiration, pneumonia, PE, urinary retention, bowel obstruction, hiccups, wound infection, wound dehiscence, and psychological disturbances.

Nursing Diagnosis: Innefective airway clearance r/t anesthesia and or pain meds.  Risk for fluid volume deficit r/t blood loss, food and fluid deprivation, vomiting, etc. Pain, r/t surgical incision and trauma.

 

TIA

Definition

Lippencott, 457. Cerebrovascular insufficiency is an interruption or inadequate blood flow to a focal area of the brain resulting in transient or permanent neurological dysfunction.  TIAs last less than 24 hours, as compared to strokes (CVAs) which last longer than 24 hours.

S/S

Unilateral weakness, unilateral numbness, aphasia, dysarthria, vertigo, dysphagia, carotid bruits, headaches, visual difficulties and altered cognitive abilities.

Nursing interventions/Teaching

Teach pt signs and symptoms of TIAs and of the need to notify HCP immediately.  Administer anticoagulants, antihypertensives, or other meds as prescribed.    Outcomes: Pt is alert w/out neurologic defects. Respirations are unlabored, v/s stable, no swelling of neck, pt reports relief of pain.  Pt able to discuss risk factors to prevent stroke: obesity, smoking, HTN.

Complications

Complete ischemic stroke.

Nursing Diagnosis: Altered Cerebral Tissue Perfusion r/t underlying arteriosclerosis.  Risk for injury: stroke.

 

Total hip Arthroplasty-THA

Definition

The reconstruction or replacement of a joint in the hip, performed to relieve pain, improve or maintain ROM, and correct deformity.

S/S

Roll to unaffected side only, abductor splint, assess CMSP, AE hose, remove AE hose as ordered, teach patient hip precautions, toilet seat extender, exercising reinforcement, wash hands and inspect wound to prevent infection, plexi-pulses if ordered, ROM specifically dorsal flexion and plantar flexion, cough and deep breathe, if odered reinforce use of IS, check bowel sounds, monitor for blood loss, foam abduction pillow between legs to keep knees apart, encourage PT,

Nursing interventions/Teaching

Infection of wound, DVT, fatty emboli, dislocation, pneumonia,

Complications

 

Total hip replacement

Definition

The replacement of a severely damaged hip with an artificial joint. Most consist of metal femoral component topped by a spherical ball fitted into a plastic acetabular socket.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 993-

S/S

N/A

Nursing interventions/Teaching

Use an abduction splint or pillows while assisting patient to get out of bed. ,• Keep the hip at maximum extension. Instruct patient to pivot on unoperated extremity. ,• Assess patient for orthostatic hypotension. • When patient is ready to ambulate, teach him or her to advance to walker and then advance the operated extremity to the walker, permitting weight bearing as prescribed. • Encourage patient to continue to wear elastic stockings after going home until full activities are resumed. • Ensure that patient avoids excessive hip adduction, flexion, and rotation for 6 weeks after hip arthroplasty. • Avoid sitting in low chair/toilet seat to avid flexing hip more than 90 degrees. • Keep knees apart, do not cross legs. • Limit sitting to 30 minutes at a time – to minimize hip flexion and the risk of prosthetic dislocation and to prevent hip stiffness and flexion contracture. • Avoid internal rotation of the hip. • Follow weight-bearing restrictions from surgeon. Advise patient to notify all health care providers about prosthetic joint because prophylactic antibiotic will be needed if undergoing any procedure known to cause bacteremia (tooth extraction, manipulation of GI tract).

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 993-995.)

Complications

Infection (skin and/or bone); Thromboembolsim; Orthostatic hypotension; Dislocation or subluxation of affected joint.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 993-995.)

 

Total Knee Replacement

Definition

Lippincott pg 993  Total knee arthoplasty (reconstructive surgery to restore joint movement and function and to relieve pain)- an implant procedure in which the tibial, femoral and patellar joint surfaces are replaced because of destroyed knee joint.

S/S

N/A

Nursing interventions/Teaching

Pre-Op – teaching pt. re post-op regimen: exercise program, transfers keeping hip flexion limits < 45 degrees; non and partial weight bearingambulation with aids (walker, crutches); Use of appropriate splints, immobilizers or continuous passive motion machines demonstrated; TED hose- remove b.i.d. 30 mins, inspect skin; Skin prep with anti-microbial solution- help prevent infections; Antibiotics administered as prescribed for therapeutic blood level before and after surgery*; Post-Op – Knee may be immobilized or CPMotion to facilitate joint healing and ROM; Thromboguards to prevent thromboembolism while pt is in bed; Assess hydration, protein & caloric intake to maximize healing and reduce risk of complications by providing IV fluids, vitamins and nutritional supplements as needed; Evaluate for infection, pt at risk for osteomylitis; Encourage coughing and deep breathing, Incentive Spirometer if ordered; Use of urinal or bedpan, preferable to indwelling catheter to reduce risk of UT; Monitor for hemorrhage and shock from internal bleeding

Complications

Compartment syndrome, shock, osteomylitis, pneumonia, ateletasis, wound infection, thrombo and fatty embolism

 

Total knee replacement

Definition

An implant procedure in which tibial, femoral, and patellar joint surfaces are replaced because of destroyed knee joint.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 993-995.)

S/S

N/A

Nursing interventions/Teaching

The knee may be immobilized in extension with a firm compression dressing and an adjustable soft extension splint or long-leg plaster cast. • Leg is elevated on pillows to control swelling. • Alternatively, continuous passive motion may be started to facilitate joint healing and restoration of joint ROM. • Prevent thromboembolism by continuous use of sequential compression devices while patient is in bed. Discontinue when patient is ambulatory. • Within 2 days after surgery, short periods of standing may be ordered. Monitor for orthostatic hypotension. Weight bearing may be limited with ingrowth prosthesis to prevent disruption of bone growth. • Change position every 2 hours – mobilizes secretions and helps prevent bronchial obstruction.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 993-995.)

Complications

Infection (skin and/or bone); Thromboembolsim; Orthostatic hypotension; Dislocation or subluxation of affected joint.

(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 993-995.)

 

Transient Ischemic Attack

Definition

Platelet clumps causing an intermittent blockage of circulation or spasm.

S/S

Sudden weakness, paralysis in the face, arm, or leg, typically on one side of the body, slurred or garbled speech or difficulty understanding others, sudden blindness in part of the visual field, dizziness, and loss of balance or coordination.

Nursing interventions/Teaching

Monitor VS, monitor and document neurological status frequently, assess functional ability, assess type/degree of communication dysfunction.

Complications

stroke

 

Transurethral Resection of the Prostate TURP

Definition

A surgical procedure involving removal of the prostate.

S/S

N/A

Nursing interventions/Teaching

Monitor vital signs (Post Op Procedure); Monitor CBI  for 24 hrs or until no clots are noted draining from the bladder; Blood Clots are normal for first 24-36 hrs.  However, large amts of bright red blood in the urine can indicate hemorrhage; If on Coumadin therapy, monitor INR and PT labs; Anti-Embolic hose; Activity (as prescribed); The catheter should be connected to a closed drainage system and not disconnected unless it is being removed, changed or irrigated; Secretions around the meatus can be cleansed daily with soap and water; Activities that increase abdominal pressure, such as sitting or straining to have a bowel movement, should be avoided; Bladder spasms occur as a result of irrigation of the bladder mucosa from insertion a resectoscope, presence of a catheter, or clots leading to obstruction of the catheter.  The patient should be instructed not to attempt to urinate around the catheter because this increases the likelihood of a spasm. If spasms continue then catheter should be checked for clots.; Give prescribed medications for pain and spasms; Teach patient Kegel exercises for sphincter tone to help with urinary incontinence or dribbling; Teach patient about other options such as a continence clinic, penile clamp, condom catheter, or incontinent briefs; Observe for signs of infection (check external wound for redness, heat, swelling, and purulent draining; Give antibiotics (as prescribed) for infections; Rectal temperatures and enemas should be avoided; Dietary intervention (a diet high in fiber) and stool softeners can be provided as prescribed ; Provide patient with help if sexual problems occur (treatments and counseling)

Complications

Infection; Acute Pain; Potential Complications: Hemorrhage

 

Urinary Retention

Definition

The inability to empty the bladder despite micturition or the accumulation of urine in the bladder because of an inability to urinate

S/S

The condition is characterized by frequent, strong urges to urinate accompanied by an inability to actually pass very much urine. There may be dribbling or leakage during the day and while you are asleep. You may need to push in order to start urination

Nursing interventions/Teaching

Assess, record, and report Signs and Sx and reactions to Tx; Monitor I&O’s; Monitor Labs (BMP); Report abnormal findings; Teach patient strategies to minimize risk including intake of large volumes of fluid over a brief period; A patient unable to urinate is advised to drink a cup of coffee or brewed caffeinated tea to maximize urinary urgency and to sit in a tub of warm water or take a warm shower and attempt to urinate while in the tub or shower (if does not help then seek immediate care); Patient can be managed by behavioral methods (e.g., habit training to negotiate goal for voiding frequency, pelvic muscle training, prompted toileting), and indwelling or intermittent catheterization, surgery or medications; Instruct client and family regarding disease process, procedures, surgeries, tx, home care, and follow up

Complications

Urinary Tract Infections; Kidney Problems

 

UTI

Definition

The presence of pathogenic organisms in the urinary tract.  Can be with or w/out symptoms.  Lippencott, 714.

S/S

Dysuria, frequency, urgency, nocturia, pain, discomfort, microscopic or gross hematuria.

Nursing interventions/Teaching

Encourage rest, fluids, antibiotic intake and analgesics if needed.  Increase understanding of preventative measures, educate and maintain health.  Avoid external irritants, void after intercourse, cleanse peri area front to back. Outcome:  Pt verbalizes relief of symptoms.  Pt verbalizes self care measures to prevent recurrences.

Complications

Pyelonephritis, or hematogenous spread resulting in sepsis.

Nursing Diagnosis: Pain r/t inflammation of bladder mucosa. Knowledge deficit r/t prevention of recurring UTIs.

 

Uterine Fibroids

 

Definition:  Uterine fibroids (leiomyomata) are by far the most common reason a hysterectomy is performed. Uterine fibroids are benign growths of the uterus, the cause of which is unknown. Although they are benign, uterine fibroids can cause medical problems, such as excessive bleeding, for which hysterectomy is sometimes recommended

 

Manifested by:

  • No symptoms
  • Excessive bleeding
  • Painful intercourse
  • Abdominal discomfort – due to pressure on surrounding area (rectum, bladder)
  • Enlarged uterus – distorted by masses

 

Nursing Interventions:  If have surgery, follow protocol for post op care.

 

Complications:

  • Persistant heavy bleeding causing anemia
  • Large rapidly growing tumors

 

Poss. Treatment; (Collaborative)

  • Hysterectomy
  • Myomectomy – if women wish to have children – only fibroid is removed.
  • Leupron – used preoperatively to shrink size of tumor

 

 

Vancomycin-Resistant Enterococci (VRE)

 

Definition:  Enterococcus are bacteria that live in the digestive and genital tracts: normally benign. Vancomycin is a powerful antibiotic, one that is the last resort and limited to the use against bacteria that already resisitant to penicillin and other antibiotics.  VRE is a mutant strain of enterococcus that originally develops in individuals who are exposed to the antibiotic.

 

S/S:Infected patients:  Diarrhea, UTI’s, fever pus in the wounds and increased white blood cells. Colonized patients: carry but no signs and symptoms.

 

Nursing Intervention/Teaching: Isolate patient in private room,wash hands with antiseptic soap, wear gloves and gown for patines contact, teach appropriate use of antibiotic use with family/patient, and avoid sharing patient care equipment.

 

Complications:  Easily spread to immuno-compromised patients/elderly, renal insufficiency, endocarditis, meningitis, bacteremia/septicemia and even death.

 

 

Vertigo

Definition

Dizziness that creates the sense that you or your surroundings are spinning or moving.

S/S

A sense that you or your surroundings are spinning or moving, a loss of balance, nausea,unsteadiness, wooziness, lightheadedness, faintness, weakness, fatigue, difficulty concentrating, blurred vision following quick head movements.

Nursing interventions/Teaching

Assist patient with ambulation to prevent falls and injury, assist patient to have independence in ADLs if able.

Complications

Dizziness can increase your risk of falling. Accidents while driving a car or operating heavy machinery are more likely. You may also experience long-term consequences if an existing health condition that may be causing your dizziness goes untreated.

 

Vomiting

 

Definition:  Forceful ejection of partially digested food and secretions (emesis) from the upper G.I. Vomiting is a complex act that requires that coordinated activities of several structures.

 

S/S:  Dry skin, decreased skin turgor, decreased urine output, hypotension (postural), decreased intake, dry mucous membranes.

 

Nursing Intervention/Teaching:  Assess for sign of dehydration, administer and monitor the amount and type of IV fluids, provide small amounts of clear liquids, record vomitus amount and frequency, weigh patient daily, monitor lab results: sodium, potassium and chloride, assess patients interest in food, assure patient appetite will return, instruct patient to resume eating cautiously with bland, nonirritating foods in small amounts.

 

Complications:  Dehydration, cardiac and or renal insufficiency, fluid/electrolyte imbalance, CHF, renal disease (excessive replacement of fluid/electrolyte replacement).

 

 

Weight Loss

 

Definition:

An unexpected weight loss of 5% to 10% of body weight in 6 months or less, involuntary/unintentional.

 

S/S:

Decreased weight, fatigue, lethargy, vomiting, diarrhea, tremors, palpitations, fainting, hair loss and depression, just to name a few.

 

Nursing Intervention/Teaching:

Once a patient has a physician rule out any illness, then the interventions can begin.

 

Complications:

Stomach tumor, hidden infection, over-active thyroid, depressive illness, malabsorption – celiac disease, inflammatory disease – crohn’s disease, pancreas, liver disease, cancer and/or diabetes.

 

 

Wound Infection

Definition

Traumatic wound (break in the skin) shows signs of infection; Includes sutured wounds, puncture wounds, scrapes; Most contaminated wounds become infected 24 to 72 hours after the initial break in the skin.

S/S

Pus or cloudy fluid draining from the wound; Pimple or yellow crust formed on the wound (impetigo); Scab has increased in size; Increasing redness around the wound (cellulitis); Red streak is spreading from the wound toward the heart (lymphangitis); Wound has become extremely tender; Pain or swelling increasing after 48 hours since the wound occurred; Wound has developed blisters or black dead tissue (gangrene and myonecrosis); Lymph node draining that area of skin may become large and tender (lymphadenitis); Onset of widespread bright red sunburn-like rash; Onset of fever; Wound hasn’t healed within 10 days after the injury

Nursing interventions/Teaching

Warm Soaks or Local Heat: If the wound is open, soak it in warm water or put a warm wet cloth on the wound for 20 minutes 3 times per day.  Use a warm saltwater solution containing 2 teaspoons of table salt per quart of water. If the wound is closed, apply a heating pad or warm, moist washcloth to the reddened area for 20 minutes 3 times per day; Antibiotic Ointment: Apply an antibiotic ointment 3 times a day.  If the area could become dirty, cover with a Band-Aid or a clean gauze dressing; Pain Medication: For pain relief, take acetaminophen every 4-6 hours (e.g. Tylenol; adult dosage 650 mg) OR ibuprofen every 6-8 hours (e.g. Advil, Motrin; adult dosage 400 mg); Do not take ibuprofen if you have stomach problems, kidney disease, are pregnant, or have been told by your doctor to avoid this type of anti-inflammatory drug. Do not take ibuprofen for more than 7 days without consulting your doctor; Teach patient about importance of hand washing and infection control

Complications

Septicemia, Morbidity

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Author: Nurse Barbie

Hello, I'm Nurse Barbie, I have always wanted to be a nurse and help others for as long as I can remember. As an RN Student on a four year program, I believe in helping other students from experience. That Is my way of paying It forward, and karma always pays us back.