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ENDOCRINECONDITIONWho is at risk?Signs/SymptomsLab/DiagnosticsNursing ManagementHyperthyroidPrimary vs secondaryGraves, goiter, amiodarone-inducedFamily history of thyroid/AI diseaseRecent pregnancyExcess iodineMeds (amioadarone)Tachycardia, a-fibTremorsGoiterWarm, moist skinHair falls outIrritabilityHeat intoleranceHyperactiviyWeight lossDiarrheaProptosis/exophthalmosSerum antibodiesDecreased TSHIncreased T3 & T4Uptake/suppressionTapazole, PTUBeta-blockers131IThyroidectomyThyroid stormAssess for fever, diaphoresis, S/SAntithyroid drugsHormonesPost-opRespiratory distressHemorrhageHypocalcemiaThyroid stormHypothyroid(Myxedema)Primary vs secondaryHashimoto – hyper then hypoFamily history of thyroid diseaseHistory of autoimmune disease (women)AgingInadequate dietary iodinePrevious tx for hyperthyroidismDry skinCold extremitiesHair breakage, dry hairBradycardiaPeripheral edemaDelayed DTR relaxationCarpal tunnelTirednessAmenorrheaWeaknessCold intoleranceDifficulty concentratingWeight gainConstipationHoarse voiceT4 and TSHAntibodies (Hashimoto)Levothyroxine (1?)TSH stimulation (2?)Myxedema crisisCardiac – IV fluidsNeuroRespiratory – monitor; ventilatorRewarmHypoparathyroidFamily hx, heredityNeck sx/radiationComorbidityHypocalcemiaHyperphosphatemiaNumbness, tinglingMuscle crampsChvostek’s Trousseau’sCa and P levelsCa: decreasedP: increasedCa, calcitrol, vit. DFall and fracture preventionHyperparathyroidPrimary: gland enlargement; hyper-CaSecondary: dx causing hypo-CaMenopauseProlonged Ca/vit. D deficiencyNeoplasmNeck radiationLithium (bipolar)Bone fx/weaknessOliguria, kidney stones, acidosisWeakness, fatigue, depression, NM probsEKG changes, HTNConstipation, peptic ulcerIncreased PTHCa: increasedBone density test = Osteopenia: weak bonesParathyroidectomy + Ca supplements (1500-2000 mg/day)HemorrhageHypocalcemiaLaryngeal spasmNeuro check – electrolyte imbalanceCheck voiceTx secondary diseaseNon-pharm txLab studiesNutritionFluid – kidney stonesFall preventionRestAnalgesics/comfortAddison’s1? adrenal insufficiency (AI)Adrenal gland removalAutoimmune disorderInfections/invasive diseaseHypovolemiaFluid/electrolyte imbalancePostural hypotensionLOC changesHyperkalemiaFatigue, weaknessGI complaints (slow)Decreased urine output (adrenal crisis)Hyperpigmentation or orange skinDecreased libidoSodium, potassium, BUN levels (low Na, high K, high BUN)Blood sugar (low)Cortisol levels (low)Urinary metabolitesACTH stimulation testAdrenal crisisDehycration, fever, hypoNa, hyperK, vascular collapse, deathIV hydrocortisoneNormal salineVasopressorsElectrolytes (Na)Hormone replacementIncrease Na intakeTreat hypoglycemia 1stCushing’s – chronic exposure to cortisol1?: excess aldosterone by adrenal cortex2? Caused by excess reninExogenous: excess glucocorticoids (COPD, RA)ObesityMoon face, acneHirsutism – facial hairBuffalo hump, striaePlethora (excess fluid/blood)HNTFatigue, muscle weaknessHyperglycemiaBruisingDepression to psychosisOsteoporosisMenstrual disorders, decreased libido, impotenceKidney stonesGlucose (high)High WBCHypoK, HyperNaSerum/salivary cortisolDexamethasone suppression test24-hour urine (cortisol and Cr)ACTH stimulation testAldosterone antagonist (spironolactone)SurgeryCARDIOVASCULARCONDITIONWho is at risk?Signs/SymptomsLab/DiagnosticsNursing ManagementCADIncreasing ageGenetic predispositionGender - maleDietSedentary lifestyle - obesitySmokingHigh LDLLow HDLHigh total cholesterolHTNDMHigh CRPAtherosclerosisAngina pectorisUnstable anginaMyocardial infarctionSudden cardiac deathSupply & demand of myocardial tissueIschemia – ECG changes; angina pectorisLipid panelCRP – inflammationHomocysteine – inflammationIntravascular USCardiac cath and percutaneous coronary intervention (PCI)Coronary angiographyCV modifiable risk factor reductionPhysical activityDietary changesMonitor weight, exercise, food intakeSupport groupsCatheterization and PCIBalloon or stentAngina PectorisStable – predictable, goes away with restUnstable – unpredictable, may involve clot, vasoconstriction, risk for MIPrinzmetal or vasospasticSame as aboveSudden onset of discomfort in chest, jaw, shoulder, back, or armCa-channel blockersNitratesBeta-blockersActivity restrictionRemove precipitating factorsSupplemental O2 during painAssess: PQRST, hx, physical findings, VS, ECG changesMyocardial InfarctionComplications of angina (high MI risk):Increased angina duration, frequency or at rest (unstable)ST or T wave changesSigns of HFPulmonary edemaTachycardiaHypotensionAcute: chest pain more intense than anginaDiaphoresisSOBGeneralized weaknessMay mistake S/S for indigestionTroponin – 4-6 h post up to 4-7 days; serial patternCreatine kinase – (CK-NB) 6-8 h to 48-72 hMyoglobin – damage to heart muscleEKG changes – place in teleMONA - Dilate coronary arteriesThrombolyticsCABGPrevent ACS: O2, vasodilate, reperfuse, prevent thrombus, blood flowIHI:early admin of aspirinaspirin @ d/c 325 mgbeta-blocker @ d/cACEI/ARB if systoli dysfunctionReperfusion (PCI, thrombolysis)Smoking cessationRheumatic Heart DiseasePharyngeal strep infection – beta hemolyticAI response (women)Chest painMurmursTachycardiaEKG changesFriction rubCHFCardiomegalyMitral/aortic stenosisH&PCRPECGAntistreptolysin O titerEarly antibiotic txAntibiotics, NSAIDsSteroidsBed rest – decrease demandPain reliefEmotional supportMonitor for HF, change in murmurPericarditisAcute infectious:Dry vs exudativeExudative decreases CO and perfusionInfectious:Lung/URI Non-infectious:UremiaAMICardiotomyAcute non-infectious:Blunt traumaSurgery & other tissue injuryAutoimmune/acute infectious:Connective tissue disorders – SLE, RADrug reactionsRheumatoid heart diseaseAnginal-type pain or sharp pleuritic-type painWorse with inspiration, coughing, movement, deep breathingWorse when lying flatRelieved by sitting up and leaning forwardDyspneaInfectious: high fever, chills, high WBCs, joint pain, elevated ESRAnorexia, weight loss, nauseaECG changesPericardial friction rubPericardial effusionHoarseness, hiccupsElevated WBCsElevated ESRElevated CRPElevated CK-MB, TroponinCXR – pericardial eff, cardiac enlargementAntibioticsNSAIDsSteroidsDiureticsAnticoagulant txAnti-anxiety agentsCa-Channel blockersNitratesBeta blockersACEIsARBsFor pericarditis:PericardiocentesisHemodynamic monitoringECG monitoringFluid replacementPericardiectomy or pericardial windowSurgical resectionMyocarditisPericarditisGenetics?ImmunosuppressionAcute: open heart surgeryInfection elsewhere (viral, bacterial, fungalAI/connective tissue dxDrug reactionsSarcoidosisHypersensitive immune rxnPostcardiotomy syndromeToxinsChemicalsAlcohol useNosocomial infectionsChest radiationMay involve:Heart valve functionMural endocardium – blood clots on heart wallSeptal defectFatigueMalaiseSOBFeverGI upsetAching jointsCHF symptomsSCDElevated WBCElevated ESRElevated CRPElevated CK-MB, TroponinECG changesEnlarged heart and lung congestion (CXR)Echo – depressed systolic function, dilated chambers, pericardial effusionEndocarditisAcute: rapid onset, virulentSubacute: low virulent organismRecent dental sxIllegal drug useWeakened valvesPrevious hxPNAValve dysfunctionNosocomial infectionsChest traumaSeptal defectsBleeding gumsLong-term central lineProsthetic valvesCongenital heart diseaseCellulitisRheumatic feverMarfan’s syndromeHIVFeverChills, Night sweatsTachycardiaFatigueMalaiseAnorexiaWeight lossHeadacheArthralgiasMyalgiasBack painAbdominal discomfortClubbingSplinter hemorrhages on nailsPetechiaeOsler’s nodes (painful lesions))Janeway’s lesionsRoth’s spots on retinaMild elevation of WBC in IEElevated Erythrocyte Sedimentation Rate (ESR) in IEElevated CRP in IEElevated CK-MB, TroponinConduction delay, ST changesCHF symptoms of ECGCXR – septic pulmonary emboliCardiac tamponadePericarditisThoracic surgeryTraumaChest pain worsened by deep breathing or coughingDifficulty breathingDiscomfort, sometimes relieved by sitting upright or leaning forwardPale, gray, or blue skin - cyanosisPalpitations - tachycardiaRapid breathingDizzinessDrowsinessWeak or absent pulseAnxietyDecreased LOCElevated venous pressureDecreased CODecreased BPLoss of tissue perfusionNarrowed pulse pressure <30 mmHgBeck’s triad – low BP, muffled heart sounds, JVDWeak peripheral pulsesPulsus paradoxus - >10 drop in SBP during inspirationECG – low QRSPericardiocentesisHemodynamic monitoringECG monitoringFluid replacementPericardiectomy or pericardial windowSurgical resectionMitral valve diseasePulmonary hypertensionDecreased COIncreased pulse pressureStenosis:DyspneaA-fibMurmurDry cough, dysphasia, bronchitisFatigue, weaknessRight-sided heart failurePalpitations, anginaCrackles in lung basesHemoptysisRegurgitation:Dyspnea, weakness, fatigueOrthopnea, paroxysmal nocturnal dyspnea, peripheral edemaMurmurCough, cracklesA-fibProlapse:Palpitations, irregular heartbeat, chest pain, DizzinessMurmursEchocardiogramTransesophageal echocardiography (TEE)Chest X-RayCardiac catheterizationECGCardiac MRIECG monitoring for a-fibMonitor for cardiomegalyMaintain CO and activity tolerancePrevent complications:CHFAcute pulmonary edemaThromboembolismRecurrent endocarditisIncrease COProphylactic ABx CardioversionAnticoagulationRest w/ limited activityDigoxin – increase COSX – open up valve, replace ring, new valveRepairBalloon valvuloplastyValve annuloplastyReplacementGas exchangeActivity intolerancePain managementAortic valve diseaseDecreased COExercise intoleranceStenosis:Dyspnea, angina, fatigue, syncope that increases with exertionMurmurIncreased pulmonary artery pressureProminent S4Lung congestionL and R sided HFPalpitationsRegurgitation:MurmurDecreased DBP, widening pulse pressurePistol-shot femoral pulseHead bobbing with heartbeatPalpitationsWaterhammer pulseDyspnea, orthopnea, PNDNocturnal angina w/ diaphoresisBounding atrial pulse, apical displaced to leftInc SBP, dec DBPDizziness, exercise intoleranceL and R sided HFTricuspid valve disordersFrom rheumatic feverDecreased COIncreased CVPDyspneaFatiguePeripheral edemaPulmonary hypertensionMurmurR sided HFLow COA-fibPulmonic valve diseaseFrom congenital anomaliesDyspnea, fatigueMurmurR sided HFTall peaked T waves – atrial hypertrophyA-fibDilated cardiomyopathyFollows MI and ventricular tissue remodelingCADGeneticIdiopathicPrimary: unknown etiologySecondary: ischemia, viral infectionsAlcohol intake, drug abuseInherited disordersPregnancyHTNCADViral myocarditisCocaineCalcium overloadHyperlipidemiaObesityDMIdiopathicChemotherapyGeneticNeuromuscular disordersEndocrine (DM, Cushing’s)Abnormal electrolytesAntiviral medsCardiac valve diseaseCongenital heart diseaseSleep apneaRadiation therapyAmyloidosis, sarcoidosisSmokingFamilial cardiomyopathiesCardiac surgeryBacterial/parasitic infectionsStress, sedentary lifestyleToxinsPregnancy, PP periodConnective tissue disordersNutritional deficiencyHF symptomsReduced tissue perfusionBaked up pulmonary systemInsidious onsetMitral/tricuspid insufficiencyCXRECGEchoCardiac catheterizationEndomyocardial biopsyRadionuclide studyInotropicsDiureticsAntidysrhythmicsRestPalliativeHeart transplantPermanent mechanical assist devicesDetailed hxADLsPaced/reduced activityPositioningO2 therapyHypertrophic obstructive cardiomyopathyUsually <30 y/oSudden deathDisorder of sarcomereGeneticHTN, hypoparathyroidismIdiopathicLV hypertrophyHypertrophy in septumSudden death, severe HFDyspneaChest painPresyncope, syncopeParoxysmal nocturnal dyspneaEchoCXRECG, resting & ambulatoryCardiac catheterizationEndomyocardial biopsyRadionuclide studyFind/treat underlying causeControl S/SPrevent progressionImprove QOLGenetic testingMedsActivity restrictionFluid stabilizationRestrictive cardiomyopathyEndocardial scarringFibrosis & thickeningImpaired diastolic stretchVentricular stretchCocaine useSarcoidosisRestrictive pulmonary diseasePulmonary/systemic congestionDyspneaPalpitations, fatigue, syncope, angina, weakness, exercise intoleranceR or L sided HFS3, systolic murmurCXRECGEchoCardiac catheterizationEndomyocardial biopsyRadionuclide studyDecrease cardiac workloadTeach to avoid situations that impair venous filling or lower COArrhythmogenic Right Ventricular CardiomyopathyElectrical disturbance because of scarring in RVMay involve LVGeneticPalpitations, light-headedness, fatigueSudden cardiac deathRV: prominent neck veins, liver distention, swollen legs and anklesLV: (advanced stage) fatigue, SOBGood family hxHeart transplantNO OTHER CUREAntidysrhythmicDecrease workloadEnergy conservationPeripheral arterial diseaseOlder ageMale genderAfrican AmericanSmokingDMHyperlipidemiaHTNIntermittent claudicationMuscle/limb weaknessAbsent/diminished pulsesPoor hair growthResting limb painParesthesiaPoor healingAnkle-brachial indexTreadmill exercise arterial studiesDuplex USSegmental arterial pressuresAngiographyCTMRI/MRALifelong aspirin txMedsAngioplastyStentingRadiation txPercutaneous transluminal angioplastyArterial bypassAmputationAcute arterial ischemia: immediate heparin tx or embolectomyPeripheral venous diseaseSwelling, tightness, discomfort in one or both LesUnilateral = DVTStasis dermatitis, stasis ulcersStreptokinase (not for DVT)Vena cava filters – prevents PE, strokeVaricose veinsOlder ageFemaleObesityJobs w/ prolonged standingLow-fiber dietSmokingHTNPregnancyInjuryDilated tortuous veinsOften noneSensation of heaviness, tiredness, itchingVisible during pregnancy or menstruationRecurrenceLigationStrippingLaser therapyRadiofrequency ablation of veinWear compression stockings after venous sclerotherapyAvoid venous poolingWalking program, weight lossDVTImmobility – SCI, paresisFx of pelvis, hip, long bonesMultiple trauma, burns, sx, infection, inflammationHypercoagulability statesPrevious DVTs, PEMalignancyMI, HF, respiratory failure, sepsis, ulcerative colitisICU admissionAge >40ObesityImmobility 3 days or moreVaricose veinsPregnancy, PPOral contraceptive useCentral venous cathetersMajor surgeryVirchow’s triad:Venous stasisDamage of endotheliumHypercoagulabilityAsymptomatic until PEUnilateral pain, edema, warmth, tendernessSlightly puffier than other legHoman’s signDuplex USVenographyCT and MRIVenous duplex imagingPhotoplethysmographyAmbulatory venous pressureEarly ambulation as toleratedElevate 10 to 20? above level of heartMoist heatAVOID MASSSAGINGGraduated compression stockingsAnticoagulants (heparin, thrombin inhibitors, warfarin)Venous thrombectomyPercutaneous interruption of vena cavaAROM, PROMAvoid prolonged sitting, standing, crossing legsIntermittent pneumatic devicesVenous foot pumpsAbdominal aortic aneurysms and dissectionDissectionLife-threatening, tear in the lumenDiminished blood supply distal to dissectionOften asymptomaticPain with gnawing quality, unaffected by movement, lasts for hours/daysPain in abdomen, flank, backPulsatile abdominal massAbdominal imaging (X-rays)CT – size and locationAortic angiographyAbdominal USAbdominal angiographyMRAAAA >3cm in diameterMonitor growth with abdominal US q6 monthsMaintain normal BP - medsSmoking cessationControl of fasting lipidD/C steroidsEndovascular stent graftSurgical repair, endovascular repairMonitor S?S of impending rupture:RestlessnessAbdominal pain, tendernessPrep for emergent sxPost-op care:Risk factor reductionWound careActivity restrictionMedication regimeReportable symptomsMeds if <5.5 cmHeart FailureNeurohormonal responseSNS activationRAAS activation – sodium and fluid retention, myocardial hypertrophyCardiac remodelingExacerbation and stabilizationHTNCADDilated cardiomyopathyHyperlipidemiaMetabolic syndromeObesitySedentary lifestyleSmokingValvular abnormalitiesAgeFamily hx of CADGenderGenesActivity intoleranceFluid retentionSOBFatigueL-sided: fatigue, activity intolerance, SOB, cough, orthopnea, paroxysmal nocturnal dyspneaR-sided: abdominal bloating and discomfort, poor appetite, nauseaBivent: combination of L and RConfusion, forgetfulness, loss of concentration, disorientationCardiac cachexiaJVDCracklesCoughAbrupt decline in CO:Narrow pulse pressureAlthered mentationHypotensionResting tachycardiaOliguriaTachypneaLV systolic dysfunction:Volume overloadDecreased contractilityLVEF < 40% to 45%Diastolic DysfunctionHF with normal LVEFSlow relaxationHTN, DM, obesity, a-fibReduced stroke volumeStiff heartCBC – anemia, liver/renalBNP – LV stretch, highHigh microalbuminElectrolytes & CrLiver function testUrinalysisSerum ferritinLipid panelDigoxin levelABGsCXR – enlarged heart, patchy infiltratesEKGEcho – ejection fractionCardiac cath R or LSelective coronary angiographyCardiac MRICool forearms and legsAssess response to diuresisAssess COMonitor I&OMonitor for dysrhythmiasEncourage increasing levels of activityPerform ADLsPatient knowledge of dxO2 sat – administer O2Assess temperatureAssess for cyanosisAssess neuro statusAuscultateMedsCardiac devicesControl comorbiditiesControl volume statusCardiac transplant or mechanical assist deviceReduce readmissionPalliative careEcho, ACEI or ARB if EF<40% unless C/ISmoking cessationFluid restrictionDietary changesRefer to community resourcesEducate: meds, activity, weightUNLOAD FASTuprightnitrateslasixoxygenaminophyllindigoxinfluid restrictionafter load - decreasesodium restrictiontest - digoxin levels, ABGs, BNP7 Key interventionsLVS heart function assessACEI/ARB @ d/cAnticoagulant w/ a-fibFlu vaccinePneumococcal vaccineSmoking cessation counselD/C instructions: activity, diet, meds, follow-up, weight, worsening S/SRESPIRATORYCONDITIONWho is at risk?Signs/SymptomsLab/DiagnosticsNursing ManagementObstructive Sleep ApneaObesitySmokingAge > 65Male genderPostmenopausal femalesAdequate hours of sleep but no energy the rest of the dayInability to concentrateIrritabilityPolysomnography in sleep laboratoryH&PChange of sleep positionWeight lossCPAP or BiPAPDenoidectomyUvulectomyUpper airway obstructionLife-threateningForeign bodiesInfectinSmokeAnaphylactic reactionAngioedemaHead and Neck CancerSmokingExcessive alcoholRadiation therapy – dysphagia, nutritionChemotherapyRadical neck dissection – puts airway at riskLaryngectomy:Good suctioningCare of permanent trachCommunication supportNutrition – dysphagiaBody image issueMaintain airway/ventilationWound careBleeding –behind neckPain managementNutritionSpeech/language rehab – esophageal speechStoma careSmoking cessationPsychosocialHigh risk for lower airway infectionPneumoniaAntibiotic therapyImmunocompromisedStroke, trach, dysphagia, near drowning, post op N/VDyspneaHypoxemiaVentilation-perfusion mismatchFever, chillsIncreased RRRusty bloody sputumCracklesX-ray abnormalitiesNon-respiratory symptomsDehydrationCXR – usually upper lobe densitiesAdminister ABxAirway – O2 sat > 93%Nutrition, hydrationSmall, frequent, high-carb, high-protein mealsBronchodilatorsSuction, C&DBISGradual increase in activity, sit up for mealsNutrition, fluidAvoid exposure to others with infectionsMedsS/S to watch out forPulmonary tuberculosisHIV/AIDSImmunocompromisedDyspneaWeight lossCoughSputum productionSleep disturbancesRust colored sputumNight sweatsLow grade feverAdvanced:Activity intolerance, fatigueLow grade fever, night sweatsBlood-streaked sputumDullness w/percussion over involved areaBronchial breath sounds, increased transmission of whispered soundTuberculin skin test – read 48-72 hours, 10mm (5mm for immunocompromised)CXR – if BCG vaccinatedAcid-fast bacillus smear – 3 positives on 3 different daysSputum cultureDrug txNegative pressure roomAirborne isolation until 3 sputum cultures are negPain managementFatigue managementGood nutritionLung abscessNecrotizing PNABacterial, fungal, parasiticPus in the lung itselfFeverChillsHigh-dose antibioticsPulmonary empyemaChest tube for pleural effusionPus in pleural spaceDrainage of pusRe-expand the lungControl the infectionCOPD: EmphysemaDyspnea/wheezingUse of accessory muslcesVent/perfusion mismatchDecreased forced expiratory volumeInvolvement of alveoliCachexiaBarrel chestChanged muscle definitionClubbing – chronic hypoxiaABG:PaO2 <80-50 mmHgPaCO2 – increased to 50Polycythemia vera – high H/HSputum samplesSerum electrolytesSerum AAT levelsCXR:Emphysema = Lots of black space/airBronchitis = not enough air, clouding overPulmonary function testAssess O2 firstAdmin O2Antibiotics - infectionBronchodilators – reduce airway resistanceAnticholinergics – bronchodilate and decreases secretionsCorticosteroids – decrease inflammation, decrease bronchoconstrictionImpaired gas exchange;AirwayCough & DBO2 therapyPulmonary rehabIneffective breathing patternSpecific breathing techniquesPositioning – dyspneaEnergy conservationDiaphragmatic breathingPursed-lip breathingRelaxation techniquesPositioningIneffective airway clearanceChest physiotherapy w/ postural drainageSuctioningPositioningHydrationRT – flutter valveTracheostomyImbalanced nutritionActivity intoleranceAnxietyPotential for PNAAvoid large crowdsPNA vaccineFlu vaccineCOPD: Chronic bronchitisDyspnea/wheezingUse of accessory muslcesVent/perfusion mismatchDecreased forced expiratory volumeInvolves airwayInflamation, vasodilation, congestion, mucosal edema, bronchospasmAirway enlargementLarge amount of thick mucusHypoxemiaAcidosisRespiratory infectionsCardiac failure – cor pulmonaleCardiac dysrhythmiasClubbing – chronic hypoxiaPleural effusionCHFBacterial PNAMalignancyIndwelling pleural catheter w/ intermittent drainagePleural-peritoneal shuntThoracentesisPleurodesisPleurectomyChest tube – pleural spaceRepiratory assessmentAssess siteAssess system – upright, below chest, patent, water levels, no air leaks, drainage, tubing - kinksFlap or shunt if pneumothorax - airRENALCONDITIONWho is at risk?Signs/SymptomsLab/DiagnosticsNursing ManagementPolycystic kidney diseaseCongenital anomalyAbdominal/flank painHTNIncreased abd girthConstipationBloody/cloudy urineKidney stonesUremia and deathUltrasonography, tomography, radioisotope scansRetrograde ureteropyelographyUrinalysis - for protein/bloodSerum Cr >1.5 mg/dLBUN >25 mg/dLPreserve renal fxn, prevent complicationsControl HTNDialysisHydronephrosis Also:Hydroureter Urethral strictureEnlarged prostateUrethral/ureteral stricturesRenal calculiAbdominal tumorsBlood clotsUreteritis/prostatitisNeurogenic bladderCongenital abnormalitiesSlight discomfortSlightly decreased urine flowAcute: Severe, colicky renal/flank painChronic: vague abd/back painMay be unilateralFever, nauseaPain on urinationIntravenous pyelogram (IVP)Renal USBUN, Cr, Cr clearanceTreat cause of obstructionRemove obstruction Prostatectomy Dilation of stricture Sx removal of stone/tumorNephrostomy tube Diet low in protein, Na, K Check for bleeding, hematuria, infectionPyelonephritisWomenInability to empty bladderSexually activePregnancyDiabetesCompromised renal functionInstrumentationFever, chills, tachycardia, tachypneaFlank/back/loin painAbdominal discomfortN/V, urgency, frequency, nocturiaMalaise or fatigueChronic: HTN HypoNa Decreased concentration HyperK and acidosisUrinalysis Cloudy urine Foul smelling urine Low specific gravity Proteinuria Hematuria Positive WBC CastsUrine cultureKUBAntipyreticsClean-catch urine specimenAntibiotic tx2,000-3,000 mL fluids/dayActivity & restUrinary analgesicsGlomerulonephritisMay cause nephrotic syndromePrior strep infection - acuteMalesYounger age (5-15 y/o)SLEDMGoodpasture’s syndromeBlood in urine (dark, rust-colored, brown)Foamy urine (excess protein)Edema (generalized)Acute: no pus, no bacteriaHTNHypoalbuminemiaHigh cholesterolN/V, fever, rashLow urine outputUrinalysis Proteinuria Hematuria CastsElevated CrDecreased Cr clearanceElevated serum antistreptolysin-O titerChronic:BPI&ODaily weightDietary plan (low protein, low Na)Diuretics & anti-HTNCorticosteroidsPlasmapheresisTeaching: Nutrition, meds, skin care (pruritis, edema), infectionsNephrotic syndromeDiabetesDrugs that cause kidney damageGlomerulonephritisHigh levels of protein in urine – foamy urineLow levels of protein in blood - hypoalbuminemiaEdema (generalized)High cholesterolHTNLow urine outputUrinalysis Protein (high)Serum protein (low)Lipid panel (high cholesterol)Address underlying causeMay develop CKD -> ESRDCorticosterioidsACEI – BP down, decrease protein lossHeparinLow-salt dietMild diureticsAcute renal failureSudden onset, reversibleIncreased ageVascular diseaseDiabetesEarly signs:OliguriaAzotemiaAnuriaLate signs (systemic):SEE BELOWHTN or hypotensionAnasarca (total edema)Coagulation changesMetabolic acidosis – ammonia-breath, Kussmaul’sHyperK – cardiac arrestHypoNa, fluid overloadTumorlike calcium precipitatesBUN, Cr, K, PO4 – increasedNa, Ca – decreasedU/A: RBCs, casts, proteinuria, low sp.gr. low osmolalityGFR – lower than 40 or decreased by >75% (failure)Maintain fluid balanceProtein intake 0.8 g/kg/day25-35 kcal/kg – high carbMonitor KAdjust meds, avoid NSAIDs, ACEIAvoid Mg antacidsControl metabolic acidosisStrict aseptic techniqueRemove indwelling cathsAvoid nephrotoxic agentsCKDChronic renal failureESRD (loss of 7/8 of filtration capacity)Insidious, chronic, irreversibleAfrican AmericanMenAge 65 and olderHereditary diseases: polycystic kidney disease, Alport syndromeDiabetesHTNUrinary tract obstructionChronic glomerulonephritisChronic infectionAcute tubular necrosisNephrotoxic agents (antibiotics, NSAID, contrast media)Neuro: confusion, lethargy, decreased LOC, stuporGI: N/V, anorexia, distention, constipation or diarrheaRespiratory: crackles, pulmonary edema, pleural eff, risk for infectionCV: tachycardia, dysrhythmia, rub, pericarditis, inc BPSkin: dry, pruritis, edema, bruising, pallor, uremic frostHyperK, HypoNa, HypoCa, hyper-PO4Increased BUN and CrIncreased BUN/Cr ratioIncreased serum PO4K normal or elevatedDecreased Na, HCO3 and CaRenal failureOliguria/anuriaAzotemia (high BUN)Watch for infectionsMonitor drug levelsLow protein, low Na, low K levelsMonitor electrolytesPrevent injuryFatigue/weaknessMonitor ECG, neuroDialysisMonitor H&HAdminister epogenSkin integrityPeritoneal DialysisComplications:Infection – biggest riskPeritonitis – rigid, board-like abdomenPoor dialysate flowDialysate leakageNote dwell time, initiate outflowShould be getting more than what was put in, clear fluidUse gravity to get extra fluid outWarm fluid to prevent painNo heparinEvaluate VS, weight, labsMonitor for respiratory distress, pain, discomfortHemodialysisHyperkalemia (also Kayexalate, glucose & insulin, bicarb, calcium gluconate)Complications:Thrombosis/stenosisInfectionAneurysmIschemiaHeart failureDialysis disequilibrium syndromeCNS – big change in osmolality cause fluid shift into cerebral cavity = cerebral edema: HA, dizziness, disorientation, restlessness, blurred visionConfusion, seizures, coma, deathC/I: hemodynamic instability, lack of access, inability to anticoagulatePlanning:MedsMeals – no meals right beforeActivities – no heavy lifting, no BP on side with lineNo invasive procedures or blood drawsWeight, BP, labsAssess for hypotension, HA, N/V, malaise, dizziness, muscle cramps, bleedingNEUROLOGICALCONDITIONWho is at risk?Signs/SymptomsLab/DiagnosticsNursing ManagementMultiple SclerosisWomen (AI)Cold climatesGenetic factorsRemission and exacerbationExacerbation: triggered by fatigue, stress, illnessFatigueMuscle control difficultiesFlexor spasms at nightIntention tremorsGait disturbancesBlurred vision, diplopia, nystagmusTinnitus, vertigoHypalgesia – decreased feelingNumbness, tingling, burningBowel/bladder dysfunctionLate cognitive changes in memory, concentration, judgment, depressionMore on symptomatologyCSF studies:Elevated IgGsPresence of oligoclonal bandsMRI: white matter lesionsGenetic markersCBC outside normalR/O syphilis, HIV, heavy metal poisoning, stroke, brain tumorMotor function, ADLsSymptom mgmt.Self-care and safetyEnergy, ability to perform ADLsAbility to void normallyMeds for paresthesias, pain, bowel dysfunctionSteroids for exacerbationsBiological modifiersAntidepressantsNO CUREEducation:Avoid stress, extreme temps, infectionsExercise & mobility programAmyotrophic Lateral Sclerosis (ALS)Genetic/family hxMen in their 30sSlurred speech - dysarthria FallingNo cognitive defects, always motorUpper and lower motor weaknessMuscle atrophyDysphagia, fasciculationsSpasticity, cramping, fatigueTwitching of limb, tongueDyspneaEMG: fibrillationsCBC outside normalGenetic markersR/O syphilis, HIV, heavy metal poisoning, stroke, brain tumorADLs and muscle functionAntispasticity medsExercise & mobility programPeriods of restManage swallowing, respSupport groupsGuillain Barre SyndromePrevious viral infectionMotor weaknessAreflexiaFlaccid paralysisAscending (sometimes descending) symmetrical weakness progressionParesthesia and painAutonomic changesNo pupillary/cerebral S/SChanges in cardinal vision, diplopiaCBC outside normalComprehensive baseline assessmentOngoing monitoringAssess painProvide support for fearful patientsAntivirals – reversiblePain managementNO CORTICOSTEROIDSIV immunoglobulinPlasmapheresisIneffective Breathing PatternCardiac DysfunctionMyasthenia GravisFACE – cranial nervesThymomaMyasthenic crisis: increased droopy eyeCholinergic crisis: abdominal cramps, diarrhea, bronchospasm, increased secretionsBoth muscle weaknessYounger women, older menSpecific muscle weaknessVoluntary muscle fatiguePtosis (droopy eyelids)DiplopiaDysarthria (speech)Dysphagia (swallowing)Snarling lookNO COGNITIVETensilon testing –increase Ach if improved, myasthenic crisisEMG: fibrillationsCBC outside normalR/O syphilis, HIV, heavy metal poisoning, stroke, brain tumorPeriods of rest around mealtimesCholinergic crisis – overmedication; withhold meds; atropine, airwayMyasthenic crisis – undermedication; maintain respiratory fxn; reintroduce meds little by littleCholinesterase-inhibitorsImmunosuppressantsPlasmapheresis in crisisIV immunoglobulins in crisisThymectomyAdminister meds w/ food to prevent aspirationMonitor airway, swallowingPromote self-careAssist w/ communicationNutritional supportEye protectionAvoid infection, stress, overheatingParkinson’sCPK levels: elevatedAbnormal EEGGenetic markersR/O syphilis, HIV, heavy metal poisoning, stroke, brain tumorR/O hypo/hyperthyroidAlzheimer’sCPK levels: elevatedMRI: brain atrophyCRP levels: elevatedGenetic markersR/O syphilis, HIV, heavy metal poisoning, stroke, brain tumorR/O hypo/hyperthyroidMeningitisBacterial is most dangerousViral: self-limiting, more common, less fatalBacterial:ImmunocompromisedMalnutritionAlcoholismDMRecent dental txBacterial sinus infectionsMeningismus (irritation)PhotophobialNuchal rigidityKernig’s sign (bend hip)Brudzinski’s sign (bend neck)Severe headacheHigh feverSeizures at onsetAltered LOC late signHx of illnesses, dental tx, traumaLumbar punctureCounterimmuno-electrophoresisPCRProphylactic ABx, broad-spectrumMannitolAnticonvulsantsSteroidsPain managementAntipyreticsEncephalitisUsually viralMosquito bitesWarmer climatePostviral from measles, mumps, chickenpox+ Kernig’s & Brudzinski’sBrain hemorrhage/necrosisSevere headacheFeverN/VConfusionALOCFocal deficits – motor weaknessSeizuresBizzarre behaviorCerebral edema – seizures, loss of sensation, speech, hearing, consciousnessDeath if untreatedLumbar punctureLow glucoseHigh proteinHigh WBCsMRICT scanBlood/urine/throat CXEEGBrain biopsySupport respirationsManage ICPNutritional supportI&OAntiviralsDexamethasone to reduce cerebral edemaAntiepilepticsPain managementAntipyreticsSeizuresStatus Epilepticus30 minutes of seizure activity2+ w/o full consciousness in betweenRespiratory/CV failureUncontrolled motor activityDroolingAirway problems AuraPupillary constriction or dilationLoss of consciousnessCyanosisUrinary incontinenceCT scan for structural problemsEEGs – what seizure looks likeISAP – location of seizureAirway – lie on sideSafety precautionsAnti-epileptics – S/E, toxicitySx resectionAnxietyKnowledge deficitFearRisk for InjuryTime the seizureSPINAL CORD INJURIESCONDITIONWho is at risk?Signs/SymptomsLab/DiagnosticsNursing ManagementHyperflexion injuriesMVA (sudden deceleration)Where is the level of injury – how much function can a pt haveUmbilicus at T10Clavicle C3-C4Finger movement if injury is lower than C7C6 and above – no hand movement, may be able to drive a chairT6 – lower extremities affectedAirway and respirationsShock, CV problemsHemorrhageLOC – use GCSStabilize spine at level of injuryHigh dose glucocorticoid – anti-inflammatorySX management – unstable fracture, cord compression (laminectomy, fusion)Skin breakdown preventionBowel/bladder/sexual fxnAssess for autonomic dysreflexia, managePsychosocial changesRehab:Motor functionCommunicationThen:Bowel/bladderAdaptationHyperextension injuriesAge – degenerative changesMVARotational injuriesSudden impact from high-energy trauma MVA both sidesCompression InjuriesFall from a heightDiving into shallow pondAge – degenerative changesPenetrating injuriesProjectile injuryCervical spine injuriesC1-C3 – breathing muscles paralyzedC4-8 – impaired breathingRisk for PNA, atelectasisRisk for PEFixed skeletal traction Pin site care, monitor traction ropeHalo fixation, cervical tongsStryker frameAssisted coughing, ISThoracic & Lumbosacral injuriesT1-T11 – impaired coughT12 and below – breathing and coughing normalBody castBraces or corsetSpinal shockImmediately after a spinal injuryFlaccid paralysisLoss of reflexes below lesionBradycardiaParalytic ileusHypotension (SBP<90 - treat)Meds to increase BPCV assessmentManage temperature (hypothermia)Secondary injuryAfter a spinal injuryNeurogenic shockHypovolemic shockSpinal shock Decreased ANS responseBradycardiaHypotensionStabilize cordChronic SCIHypotensionBradycardiaEdema of LEWeak coughRounded abdomenSpasticityTemperature intolerancePainAutonomic Hyperreflexia (autonomic dysreflexia)Response to noxious stimulusDistended bladderPressure ulcerTight clothingHigh BP - severeBradycardiaSevere HANasal stuffinessFlushingRaise HOB to 90, lower legsLoosen tight clothingCheck urineCheck bowelsCheck for painful thingsRemove causeBP reduction - medsSpasticityMay occur weeks to months after SCIPainStretchingInfectionSkin breakdownMuscle spasmsPerform daily ROM exerciseMonitor for skin breakdownMeds (Baclofen, Valium)Skin BreakdownImpaired tissue perfusionTissue hypoxiaWeight shifts q15minTurn q2-3hSkin checksGU/BowelSpinal tracts disruptedLong-term catheterizationLoss of fxn S1-S4Loss of urge to urinate, control of sphincterInability to sense fullnessUTIHydronephrosisDecline in renal fxnRenal calculiConstipationIncontinenceHemorrhoidsIleusFoleySuprapubic catheterIntermittent cathMitrofanoff (sx – use appendix between bladder and stoma)Meds for BMScheduled BMSexualSCILoss of psychogenic erectionReflex (physical stimulation) may still be presentViagraInjection therapyVacuum pumpSurgical implantPsychosocialLoss of body image, independence, control, economic securityLifestyle changesStress, strain on relationshipsWithdrawal from socialAvoid eye contactRefuse to participateMonitor for inadequate copingEncourage to discuss feelingsAllow to participate in decision-making ................
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