Med-Surg Study Guide Fall 2018
Seizures (6)
• Identify different types of Seizures
o Partial / Focal Seizures involves one hemisphere of the brain
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Complex Partial (Focal Motor Seizure)
• Impairment of awareness, associated with automatisms such as
o Lip smacking
o Chewing at clothes
o Fidgeting and other involuntary but coordinated movements
• Loss of consciousness or black out for several minutes
• Amnesia can occur immediately prior to and after seizures.
Simple Partial Sensory (Focal non-motor seizure)
• Unusual sensations affecting
o Vision
o Smell
o Taste
o Touch
o Hearing
• Consciousness maintained
Simple Partial Psychological (Focal non-motor seizure)
• Memory or emotional disturbances
• Déjà vu
• Consciousness maintained
Simple Partial Motor (Focal motor seizure)
• Unilateral abnormal extremity movement
o Head turning spasms
o Generalized Seizures involves two hemispheres of the brain
Grand Mal / Tonic-Clonic / Generalized
• Start by having an aura (seeing or hearing something that is not there)
o First experience unconsciousness, muscle stiffness followed by 1 -2 minutes of rhythmic jerking of extremities.
Biting of the tongue can occur
o Breathing can stop during tonic phase of irregular during colic phase.
Absence
• Brief loss of consciousness
• Simple staring episode
Myoclonic
• Can be symmetrical or asymmetrical
• Brief jerking or stiffening of extremities
• Last seconds
Clonic
• Repetitive jerking movements
• Muscle contracts then relaxes
• Lasts several minutes
Tonic
• Increase in muscle tone
o Muscle stiffness and rigidity
• Loss of consciousness
• Last about 30 seconds to several minutes.
• Associated autonomic manifestations
o Arrhythmia
o Apnea
o Vomiting
o Incontinence
Atonic /Akinetic
• Loss of muscle tone
• Frequently results in falling
• Postictal Phase
o After a seizure
o Fatigue and confusion
o Maintain side lying to prevent aspiration
o Suction as needed
o Assess and monitor vital signs
o Allow rest
o Determine trigger
• Nursing interventions/actions associated with seizure documentation
o Glasgow coma scale is used
o Seizure Precautions
Oxygen and suction apparatus available
Privacy provided as soon as possible
Side rails up and padded (can use blankets, towels, ect)
Bed in lowest position
Pillow under head
Patient in side-lying position (immediately post seizure)
o Document the events leading to and occurring during and after seizure
o Nursing Care during a seizure
Ease patient to the floor
Protect head with a pad to prevent injury
Loosen constrictive clothing and remove glasses
Push aside furniture that might injure patient
Do not attempt to open jaws that are clenched
Do not attempt to restrain the patient
o Seizure medications require that blood be monitored
o Document onset, duration and findings
Prior during and after seizure
Meningitis (5)
• Signs and Symptoms (subjective and objective)
Subjective Data (symptoms)
• Excruciating, constant headache
• Nuchal rigidity (stiff neck)
• Photophobia (sensitivity to light)
Objective Data (signs)
• Fever and chills
• N/V
• Altered LOC
o Confusion
o Disorientation
o Lethargy
o Difficulty arousing
o Coma
• Positive Kernig’s sign
o Resistance and pain with extension of the client’s leg from a flexed position
• Positive Brudzinski’s sign
o Flexion of the knees and hips occurring with deliberate flexion of the client’s neck
• Hyperactive deep tendon reflexes
• Tachycardia
• Seizures
• Red macular rash (meningococcal meningitis)
• Restlessness, irritability
• Risk Factors
o Viral Meningitis
Mumps, measles, herpes and arbo virus
No vaccinations available
o Fungal Meningitis
Fungal based infection due to cryptococcus neoformans
o Bacterial Meningitis
Otis media, pneumonia, sinusitis in which the organism is streptococcus pneumoniae or haemophillus influence
o Crowded living
• Diagnostic procedures and result of positive findings
o Laboratory Tests
Cerebral spinal
• Results indicative of meningitis
o Cloudy = bacterial
o Clear = viral
• Elevated WBC
• Elevated protein
• Decreased glucose (bacterial)
• Elevated CSF pressure
Counterimmunoelectrophresis CIE on CSF
• Detects whether viral or protozoa
• If patient received antibiotics before CSF were collected
CT/MRI
• Identify increased intracranial pressure (ICP) or abscess
• Complications associated with meningitis
o Intracranial pressure
o Abscess
o Seizures
o Complications
Increased ICP = brain herniation
• Nursing Actions
o Monitor for increasing ICP
Decreased LOC
Pupillary changes
Impaired extraocular movements
o Intervention to reduce ICP
Positioning with head of bead elevated to 30 deg.
Avoid coughing or straining
o Mannitol can be administered via IV
SIADH
• Abnormal circulation to the hypothalamic are of the brain, causing excess secretion of antidiuretic hormone (vasopressin)
• Nursing Actions
o Monitor for manifestations
Dilute blood
Concentrated urine
o Interventions
Administration of
• Demeclocycline
Restriction of fluid
Septic Emboli
• Septic emboli can form during meningitis and travel to other parts of the body, particularly the hands, but can feet too.
• Development of gangrene (amputation)
• Lead to disseminated intravascular coagulation or stroke
• Nursing Actions
o Monitor circulatory status of extremities and coagulation studies
o Report alterations immediately to provider
Overdose (3)
• Assessment of Patient with OD
o Signs and Symptoms
Respiratory depression
CNS depression
Decreased RR
Decreased bowel mobility
Pupillary constriction
Cyanotic
Sedated
Hx of abuse
• Nursing interventions/actions
o Obtain IV assess
o Airway
o Level of Consciousness
o Never leave patient unattended
o Monitor O2 levels
o Monitor RR
o Administer naloxone (Narcan)
• Antidote for OD on opioids
o Narcan
• What are the medication and drugs that are considered to be opioids
o Heroin
o Opium or paregoric
o Morphine
o Codeine
o Semisynthetic derivatives:
oxycodone (OxyContin)
methadone
meperidine (Demerol)
tramadol (Ultram)
fentanyl (Sublimaze)
• Acid/Base imbalance most likely that are seen with OD and intervention associated with that acid base imbalance
o Respiratory Acidosis
o Administer bicarbonate
DKA (2)
• Signs/Symptoms
Polyuria
Polydipsia
Polyphagia
Weight loss
GI effects
• N/V
• Abdominal pain
Blurred vision, headache, weakness
Orthostatic hypotension
Fruity odor to breath
Kussmaul respirations
Metabolic acidosis
Mental status change
BG > 730
Decreased reflexes
Decreased BP
Increased HR, increased RR
Labored breathing
• Risk Factors
o Hx of type 1 DM
o Illness or trauma
o Surgery
o Infection
o Stress
o Nonadherence
o Reduced or missed dose
o Thiazide diuretics
o Age over 40
• Nursing Actions/interventions
o Monitor vital signs
o LOC
o Assess for dehydration
o Cardiac monitoring
• Treatment
o Rapidly infuse isotonic fluid (0.9% sodium chloride
o Monitor for fluid excess
o Follow up with hypotonic fluid (0.45% sodium chloride)
o Serum glucose reaches 250 add glucose to IV
o Administer regular insulin as IV bolus 0.1 to 0.15
o IV provides immediate treatment DKA absorbs insulin slow and erratic = less than 200 is the goal
o Monitor potassium levels
o For severe acidosis administer sodium bicarbonate slow by IV infusion
o Monitor neurological changes
End-Stage COPD (1)
• How does COPD affect acid-base balance?
o Respiratory Acidosis
o Excess CO2 left in alveoli due to inability to fully exhale = RESPIRATORY ACIDOSIS
o Mucous in bronchiole airways doesn’t allow CO2 to be expelled on expiration = inflammation of the bronchial tubes
• Treatment
o Bronchodilators = dilation of airways
Albuterol = rapid relief
Spiriva
Atrovent
o Corticosteroids = decrease inflammation and decrease mucous production
SoluMedrol
Prednisone
Symbicort
Fluticasone
• SE = easy bruising, increased Blood glucose, hypokalemia, poor wound healing
o Cholinergic antagonists = ipratropium = long acting
o Purse lip breathing, breath in bag
o No more than 4L
o Increase fluids
o Incentive spirometer
Normal Cardiac Conduction (9)
• Everything starts SA node (right atrium)
• Then to the AV node
• Through bundle branches
• Left bundle to purkinjie fibers
•
• Components of rhythm strip: PQRST
• How the PQRST correlates to depolarization and repolarization
o P wave
Atrial contraction = depolarization
Originates in the SA node
o QRS complex
Ventricle contraction = depolarization
o T wave
Ventricle relaxing = repolarization
o U wave (not common)
Resting of the purkinjie fibers
Seen when a patient has low potassium
o PR interval
Starts with atrial contraction (depolarization) ends at ventricular contraction AV conduction time = 0.12 – 0.20 sec
Starts at P wave ends @ Q wave
o ST segment
Repolarization
• Analyze rhythm strips: NSR, SB, ST (using 6 second method and 1500 rule)
o Sinus bradycardia = HR <60
o Sinus tachycardia = HR >100
• Treatment options for bradycardia
o Atropine IV every 3 to 5 minutes max dose 3.0 mg
o Pacemaker= transcutaneous pacing
o Treat underlying conditions
Hypothyroid
Obstructive sleep apnea
o Change medications
Myocardial Infarction (MI) (18)
• Stable angina VS. Acute Coronary Syndrome
o Angina
Tight squeezing
Heavy pressure
Constricting feeling in chest
Radiates to jaw, neck, arm
Pain unrelieved by rest or nitroglycerin lasting more than 15 min differentiates an MI from angina
Due to poor blood flow in the vessels of the heart the O2 decreases = blood flow to decrease)
o Stable angina (exertional)
Occurs during exercise or during emotional stress and is relieved by rest or nitroglycerin (expect)
Precipitated by exertion or stress
Relieved by rest and nitroglycerin
Symptoms last less than 15 minutes
Not associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis
o Unstable angina (preinfarction)
Occurs with exercise or rest
Increases in occurrence, severity and duration over time
Unpredictable
Lasts more than 15 minutes
• What is happening to the heart during an MI
o Blocked blood flow through one or more coronary arteries causing myocardial ischemia and possible necrosis.
• S/S ACS
o Chest pain that radiates to shoulder, arm, jaw
With or without exertion
o Shortness of breath
o Pressure
o Diaphoresis
o Nausea
o Anxiety
• Risk Factors for MI
o Increase in age
o Male gender
o Postmenopausal women
o Ethnic background
o Sedentary lifestyle
o Hypertension
o Tobacco use
o Hyperlipemia
LDL increase (bad)
Cholesterol increase needs to be under 200
HDL decrease (good)
o Obesity
o Execessive alcohol consumption
o DM; hypothyroidism
o Stress
o Meth/cocaine use
o Atherosclerosis (CAD)
• S/S of MI (Men and Women)
o Chest pain with radiation
o Back pain
o Restlessness
o Dyspnea
o Diaphoresis
o Increase HR
o HTN
o Nausea
o Pallor, cool, clammy skin
o Tachycardia and heart palpitations
o Vomiting
o Decrease LOC
o Will not have peripheral cyanosis
o Cyanotic with decreased cap refill
• Treatments for MI (procedures and Medications)
o Aspirin 81 mg
o Nitro
o O2
o Morphine
o Check HR/BP before each dose of Nitro
o CABG
o Angioplasty
o Pacemaker, cardiovert
o Beta Blocker
o Ace inhibitor
o Heparin
o CCB
o Statin therapy
o ECG
o Stress test
o Thallium Scan
o Lab Tests
Myoglobin=earliest marker of injury to cardiac or skeletal muscle
Troponin = indicates cardiac tissue damage
CKMB creatine kinase
o Cardiac Catherization
o PCI = door to balloon 60 minutes
• Nursing Interventions/actions associated with MI
Monitor
• V/S Q15 minutes until stable then every hour
• Serial ECG, continuous cardiac monitoring
• Location, precipitating factors, severity, quality, and duration of pain
• Hourly urine output
o Greater than 30 mL per hour -= renal perfusion
• Laboratory data
o Cardiac enzymes, electrolytes, ABGs
Administer oxygen: 2 to 4 L
Obtain and maintain IV access
Promote energy conservation
• Cluster nursing interventions
• Post op complications of PCI/PCTA
o Artery dissection = perforation of artery
o Cardiac tamponade = fluid accumulation to the pericardial sac
o Hematoma formation near insertion site = hold pressure for uncontrolled bleeding call provider
o Allergic reaction related to the contract dye
o External bleeding at insertion site
o Embolism
o Retroperitoneal bleeding behind the peritoneum due to puncture
o Restenosis of treated vessel = clot formation
o Acute Kidney injury = damage from the dye
• Activity and treatment after MI
o Avoid strenuous exercise for a specified period
o Report bleeding from site, chest pain, shortness of breath, changes in color or temperature of the extremity.
o Restrict lifting
o If placed on anticoagulation therapy = take medication at same time everyday = have blood test to determine therapeutic levels
Avoid activities that can cause bleeding
Use soft toothbrush
Wear shoes when out of bed
Electric razor
o Encourage lifestyle changes
Manage weight
Consume a low-fat / low-cholesterol diet
Exercise regularly
Stop smoking
Decrease alcohol intake
• ECG/EKG changes associated with MI
o T-wave inversion indicates ischemia which can progress to infarction
o ST-segment elevation indicates injury
o Abnormal Q wave indicates necrosis
o STEMI = left main widow maker occlusion
o NONSTEMI = purkinje fibers involved
Heart Failure (HF) (10)
• S/S left HF and S/S right HF
• Signs & Symptoms
• Left sided failure (blood backing up in lungs) Right sided failure (blood backing
o up Venus system = edema)
• *Dyspnea, orthopnea (shortness of breath while *Jugular vein distention
• Lying down), nocturnal dyspnea *Ascending dependent edema (legs,
• *Fatigue ankles, sacrum)
• *Displaced apical pulse (hypertrophy) *Abdominal distention, ascites
• *S3 heart sound (gallop) *Fatigue, weakness
• *Pulmonary congestions (dyspnea, cough, *Nausea and anorexia
• Bibasilar crackles) *Polyuria at rest (nocturnal)
• *Frothy sputum (can be blood-tinged) *Liver enlargement (hepatomegaly)
• *Altered mental status and tenderness
• *Manifestations of organ failure, such as *Weight Gain
• Oliguria (decrease in urine output)
• Treatment
o Diuretics
o Ace inhibitors = Valsartan
o ARB’s
o CCB;s
o Digoxin = strengthens heart
o Beta Blockers
o Vasodilators = Nitro
o Warfarin, Plavix, blood thinner
• How to monitor HF – patient education
o Daily weight
o Diet = low sodium
o Smoking cessation
o Position: high fowlers
o Monitor VS
o Monitor lab work
o Heart rate = below 60 do not administer digitalis = listen to apical for a full minute
• Nursing actions/interactions associated with monitoring HF
o AROM
o Fluid restriction
o Low sodium diet
o Weights
o I & O
o Medications =
diuretics
digitalis = increase myocardial contraction which slows conduction
• normal 0.5 -2
Ace inhibitors = biggest side effects = cough
Dobutamine for severe heart failure
Digoxin = decrease in potassium
• Toxic s/s = halos, vision changes, arrythmias, N/V
Oxygen above 92%
o Monitor labs
o Administer medications
• Patient Education
o Low sodium diet
o Emotional support
o Effective breathing techniques
o Daily weight at same time everyday notify dr. if more than 2lbs in a day or 5lb in a week.
o Report swelling of feet or ankles
o Report shortness of breath
o Common adverse effects of medication
• Key assessments with meds associated with HF
o Respiratory assessment
o Auscultation
o Urinary output
o Weight
o I & O
o Blood Pressure
o Ascites
• Patient education on meds used to treat HF
o Lisinopril
Hypotension
Increased serum potassium
Worsening renal function
Cough
o Losartan
Hypotension
Increased serum potassium
Worsening renal function
o Hydralazine
Hypotension
o Metoprolol
Decreased heart rate
Hypotension
Dizziness
Fatigue
o Diuretics
Electrolyte imbalances
Renal dysfunction
Decreased
BP
I & O
Daily weights
Hypokalemia
Hypernatremia
o Spironolactone
Hyperkalemia
Hyponatremia
o Digoxin
Bradycardia
Toxicity
Hemophilia (6)
• Both types of hemophilia are inherited as X linked traits so mostly men are affected
o Hemophilia A (factor VIII deficiency) measured by aPTT (intrinsic Pathway)
o Hemophilia B (Christmas Disease, factor IX deficiency) measured by aPTT (intrinsic Pathway)
• Treatment
o Replacement of the missing factor VIII or IX
o Fresh frozen plasma
o Recumbent (manmade) factor treatment
o aPTT = 30 - 35
• Nursing actions/interventions when caring for hemophiliac
o Sign/Symptoms
Lethargy
Joint pain
o Prevent bleeding
o Safety precautions (fall precautions)
o Avoid IM injections
o Avoid meds that may encourage bleeding
o Monitor for internal bleeding
Coffee ground emesis
Cola colored urine
Tarry stools
• Patient education on living with hemophiliac
o Can’t take aspirin/NSaids
o Before dentist replace factors
o Protect from injuries
o Soft bristle tooth brush
o Electric razor
o RICE
o Apply pressure to cuts
o Genetic counseling
Leukemia (AML, ALL, CML, CLL) (10)
• Commonalities of all leukemia’s
o Unregulated Proliferation of leukocytes in the bone marrow
o Later stage of proliferation leaves little to no room for normal cell production
o Exposure to radiation or chemicals, certain genetic disorders, and viral infections
• Assessment findings of low platelets
o Easy/excessive bruising
o Petechia on lower limbs
o Prolonged bleeding
o Bleeding gums
o Nose bleeds
o Blood in urine or stools
• Potential complications associated with leukemia (the TOP potential complications)
o Infection
• S/S of each leukemia and treatment regimen for all leukemia’s and complications:
o Acute Myeloid Leukemia results from a defect in the hematopoietic stem cell that differentiates into all myeloid cells.
Symptoms arise from insufficient production of normal blood cells
• Fever, infection
• Weakness fatigue
• Dyspnea on exertion
• Anemia = pallor
• Petechiae
• Ecchymosis
• Bleeding tendencies
Treatment of AML
• Aggressive Administration of chemo called induction therapy, which usually requires hospitalization
• Complications:
o Bleeding
o Infection
o Chronic Myeloid Leukemia (CML) arises from a mutation in the myeloid stem cell
Malaise
Anorexia
Enlarged/tender liver
Weight loss
Leukocyte above 100,000
Treatment
• Tyrosine Kinase inhibitor (Gleevec) blocks signals within leukemia cells
• Complications
o Fatigue
o Anemia
o Acute lymphocytic Leukemia (ALL) results from an uncontrolled proliferation of immature cells derived from the lymphoid stem cell
Enlarged liver & spleen with pain
Bone pain
Headache, vomiting
Treatment
• Chemotherapeutic, dexamethasone, L Asparaginase treatment
• Complications
o Tumor lysis syndrome
o Renal failure
o Sepsis
o Bleeding
o Neuropathy
o Encephalopathy
o Chronic lymphocytic Leukemia (CLL) (most common) derived from a malignant clone of B lymphocytes
Lymphadenopathy
Splenomegaly
Fever
Weight loss
anemia
Treatment
• Immunotherapeutic antibody with chemotherapy agents
• Complications
o Frequent infections
o Switch to more aggressive cancer
• Patient education
o Prescribed medications
o Dx and Tx
o Adverse effects to be looked for
o S/S of infection and bleeding
o Limit contact with infectious people
o Immunizations not good for chemo patients
o No fresh fruits or vegetable
o No plants
o Low bacteria diet
o Low fever is not good
• Induction therapy *acute myeloid leukemia*
o Aggressive administration of chemo
Aim is to destroy leukemic cells, but also eradicates normal myeloid cells in which the patient becomes severely neutropenic
o *Requires hospital stay*
• Therapeutic communication
o Improve self-care, self-esteem, anxiety and grief with empathetic listening and realistic reassurance
Liver Failure (8)
• Pathophysiology
o Build up of ammonia in the liver
o Liver not getting rid of toxins like it should
• Portal hypertension – complications from this, nursing care associated with, and assessment
o Bleeding esophageal varices
o Replace blood
o Monitor V/S
o AdministerO2
o Decrease bleeding
Vasopressin
Somatostatin
Octreotide
• Hepatic encephalopathy
o No longer able to detox the blood
o GI toxins circulate freely to brain causing loss of brain function because liver isn’t removing toxins.
• Octreotide / Somatostatin use
o Lowers blood pressure in the liver, to reduce vasoconstriction, to reduce blood flow to decrease bleeding
• s/s of liver failure
o jaundice
o ascites
o portal HTN
o Weakness, fatigue or malaise from alterations in metabolism of fats, proteins, and glucose
o Anorexia or poor nutritional status due to poor GI blood flow
o Bleeding/bruising from altered coagulation factors
o Jaundice from decreased bilirubin uptake and conjugation
o Encephalopathy – characterized by CNS disturbances ranging from lack of attention to confusion and coma
o Hypotension and fluid/electrolyte imbalance due to decrease of plasma proteins in the liver
o Right UQ tenderness
o Decreased BP
o Tachycardia
o Edema
o Increased ICP
o Decreased LOC
• Lactulose use and desired outcome
o Given for constipation and given to prevent or treat hepatic encephalopathy to decrease ammonia
• Liver panel labs
o Serum aminotransferase
AST, ALT, GGT, GGTP, LDH
o Serum protein studies
o Direct and indirect serum bilirubin, 0.3-1 mg
o urine bilirubin,
o PT
o Serum alkaline phosphatase
o Serum ammonia
o cholesterol
Huntington’s disease (1)
• Pathophysiology
o Part of the DNA Abnormally repeats itself more than it should due to genetic defect.
o Nerve cells in the brain degenerate from abnormal repetition
o Degeneration of Cerebral cortex and basal ganglia leads to progressive chorea (dancelike movements) (flare ups possible)
o Final stage is mental deterioration, which leads to dementia (5 stages)
o Hereditary autosomal dominant
o chronic progressive
o No cure progressively gets worse leads to Suicide
o
Parkinson’s (3)
• S/S (acetylcholine increases and dopamine decreases)
o Tremors
Slow, unilateral resting tremor = pill rolling gesture between fingers
o Rigidity
Passive movement of an extremity may cause the limb to move in jerky increments = lead-pipe or cogwheel movements
Involuntary stiffness of the arms, legs, face and posture are common
May complain of shoulder pain early due to rigidity
o Bradykinesia
Overall slowing of movement
Take longer to complete activities
Difficulty initiating movement = rising from sitting position or turning in bed
o Postural changes
Postural and gait problems
• Loss of postural reflexes
o Walks with head bent forward
o Walks with a propulsive gait
Caused by forward flexion of the neck, hips, knees, and elbows
• Shuffling gait
• Place patient at risk for falls
o Autonomic symptoms
Excess and uncontrolled sweating
Drooling
Paroxysmal flushing
Orthostatic hypotension
Gastric and urinary retention
Constipation
Sexual dysfunction
Dysphagia = choking
Vision and olfactory changes
o Psychiatric changes
Depression
Anxiety
Dementia (progressive mental deterioration)
• Delirium
• Hallucination
Depression and anxiety
• Cognitive changes
o Attention difficulty
o Diminished executive functions
o Decreased thinking
o Word-finding challenges
o Hypokinesia
Abnormally diminished movement may appear after a tremor
Freezing phenomenon = inability to perform active movement extreme form of bradykinesia
o Dyspnea
Voice impairment or altered voice production
o Drools
o Risk for choking and aspiration
• Patient Education
o Nutritional needs
Dietary restriction
Managing dysphagia
Preventing aspiration
o Promoting speech and communication skills
Speech exercises
Communication techniques
Breathing exercises
o Managing constipation
Fluid intake
Bowel routine
o Managing urinary problems
Functional incontinence
Retention (catheter care)
o Avoiding effects of immobility and promoting the advantage of preventive care
Skin breakdown (frequent turning, pressure release, skin care)
Pneumonia (deep breathing, movement)
Contractures (ROM)
o Promoting benefits of daily exercise
o Ensuring safe walking and balancing
o Using appropriate coping mechanisms and diversional activities
Guillain Barre Syndrome (2)
• S/S
o Muscle weakness
Begins in the legs and progresses upward
o Diminished reflexes of lower extremities
Hyporeflexia and weakness progress to tetraplegia
o Sensory symptoms
Paresthesia of the hands and feet
Pai related to the demyelination of sensory fibers
o Bilateral paresthesia progressing to paralysis
o Pain
o Respiration
o Talking
o Swallowing
o Bowel and bladder function
o Cardiovascular
Tachycardia or bradycardia
Hypertension or orthostatic hypertension
o Does not affect cognitive function or LOC
o Areflexia and ascending weakness
• Pathophysiology
o Result of a cell-mediated and humoral immune attack on the peripheral nerve myelin proteins that cause inflammatory demyelination
o Cause is a molecular mimicry = an infection organism contains an amino acid that mimics the peripheral nerve myelin protein
o Immune system cannot distinguish between tow proteins and attacks and destroys peripheral nerve myelin.
o Autoimmune attack = influx of macrophages and other immune-mediated agents that attack myelin and cause inflammation and destruction == interruption of nerve conduction and axonal loss
• Assessment
o Patient presents with
Minor febrile illness 2-4 weeks before current symptoms
Symmetric weakness
Diminished reflexes
Upward progression of motor weakness
o Hx of a viral illness
o Stiffness
o Dyspnea on exertion
o Paresthesia in legs
• Treatment and Interventions to avoid complication associated with Guillain Barre
o Medical Management
GBS medical emergency require ICU
Respiratory therapy or mechanical ventilation (elective intubation b4 onset of muscle fatigue)
Preventing complication with immobility
• Anticoagulants
• Sequential compression booth prevents VTE and DVT and PE
• ROM exercises twice a day
• Position changes
• Adequate hydration
• Padding for bony prominences, elbows and heels
ECG monitoring
• Tachycardia and hypertension treated with short acting medications such as alpha-adrenergic blocking agents =important because autonomic dysfunction is very labile.
Hypotension is managed by increased the amount of IV fluid administered
Suctioning
Nutrition
Improving communication (establish blinking or some form of communication)
Decrease fear and anxiety
o Diagnostics
Liver function increased
Creatinine phosphokinase and ESR increased
CSF analysis increased WBC, increased protein, increased pressure
HIV/AIDS (8)
• Acquired immunodeficiency syndrome
• Risk Factors
o Unprotected sex
o Multiple sex partners
o Occupational exposure (healthcare workers)
o Perinatal exposure
o Blood transfusions
o IV drug use with contaminated needles
• Patient Education
o Practice good hygiene
o Avoid crowded areas or traveling to other countries
o Avoid raw foods
Fruit
Vegetables
Undercooked meats
Fish or eggs
o Avoid cleaning cat liter boxes = toxoplasmosis
o Clean house
o Wash dishes in hot water
o Transmission, infection control measures, safe sex practices
o Well-balanced diet
o Medication administration/side effects = adhere to antiretroviral dosing schedule
o Infection needs to be reported immediately
o Instruct the client about the need for frequent follow up monitoring for CD4+ and viral load counts
o Constructive coping mechanisms
• Safe condom use
o Always use latex condoms. If the patient is allergic to latex, nonlatex condoms should be used; however, they will not protect against HIV infection.
o Not reuse condoms.
o Avoid using cervical caps or diaphragms without using a condom as well.
o How to safely use a condom
Put on a new condom before any kind of sex.
Hold the condom by the tip to squeeze out the air.
Unroll the condom all the way over the erect penis.
Have sex.
Hold the condom so it cannot come off the penis.
Pull out.
Use a new condom if you want to have sex again or if you want to have sex in a different place (e.g., in the anus and then in the vagina).
• Safe sex practices
o Abstain from exchanging sexual fluids (semen and vaginal fluid).
o Reduce the number of sexual partners to one.
o Always use dental dams for oral–genital or anal stimulation.
o Avoid anal intercourse, because this practice may injure tissues; if not possible, use lubricant—there are water and silicone-based products designed for anal sex.
o Avoid manual–anal intercourse (“fisting”).
o Avoid sharing needles, razors, toothbrushes, sex toys, or blood-contaminated articles.
• Opportunistic Infections
o Bacterial diseases
TB, bacterial pneumonia, septicemia (blood poisoning)
o HIV associated malignancies
Kaposi’s sarcoma, lymphoma and squamous cell carcinoma
o Viral diseases
Cytomegalovirus, herpes simplex and herpes zoster virus
o Fungal Diseases
Pneumocystis Jirovecii pneumonia (PCP), candidiasis, cryptococcosis, and penicilliosis
o Protozoal diseases
PCP, toxoplasmosis, micorsporidiosis, cryptosporidiosis, isosporiasis and leishmaniasis
o Infections
Pneumonia
Meningitis
Esophageal candidiasis
TB
Hep B and C
Cancer
• Complications associated with HIV and care of these complications
o Opportunistic Infections
Administer medications
Nutrition important
Maintain electrolytes
Skin breakdown
o Wasting Syndrome
Nutrition by TPN
Monitor weight, calorie counts, I & O
Snacks and supplements
Decrease fat
Rinse mouth several times daily with saline or sodium bicarbonate and sterile water
Six small meals high protein
o Fluid/Electrolyte Imbalance
Monitor fluid /electrolytes
Report abnormal laboratory values
Encourage 2000 to 3000 ml of fluid daily
o Seizures
Maintain patient’s safety
• Comprehensive assessment (what is included?)
o
• CD4 counts
o
Multiple Sclerosis (MS) (4)
• Pathophysiology
o Sporadic patches of demyelination occurs on the myelin sheath of neurons in the CNS
• Risk Factors
o Family Hx
o Norther European ancestry
o Occurs more in women
• S/S
o Dysarthria, dystonia, dysphagia
o Muscle weakness
o Spasticity, hyperreflexia
o Gait ataxia
o Impaired balance
o Paralysis
o Positive Babinski
o FATIGUE
o Tremor
o Facial paralysis
o Cognitive dysfunctions
o Speech problems, hearing loss
• Interventions / Medication Management
o Provide support
o Apply pression stockings
o Avonex IM or SubQ
Myasthenia Gravis (MG) (3)
• Pathophysiology
o Blood cells and the thymus gland produce antibodies that block, destroy or weaken neuroreceptors primarily acetylcholine
o # of acetylcholine is decreased in the postsynaptic muscle membranes
• S/S
o Sleepy, mask like face
o Drooping jaw
o Ptosis
o Muscle weakness with activity
o Diplopia
• Treatment/med management
o Thymectomy
o Ice pack
Decrease ptosis after ice for 60 seconds to the closed eyes
• How is it diagnosed?
o Tensilon test
Administer tensilon that improves strength by increasing response to nerve impulses
• Plasmapheresis
o Treatment of diseases that attack the bodies systems autoimmune disease purification of the blood
Pancreatitis (7)
• Pathophysiology
o Self-digestion of the pancreas by its own proteolytic enzymes, principally trypsin, cause pancreatitis
• Risk Factors
o Biliary tract disease
o Alcohol abuse
o Abdominal trauma
o Smoking
o obesity
o Drugs like sulfonamides, diuretics, adenosine and pentamidine
o Infections, mumps, hep B, aspergillus cytomegalovirus and mycoplasma
o Mutations
o Obstruction
o Systemic disease
o Gastrointestinal surgery
o Metabolic disturbances
• Whipple Procedure
o Pancreaticoduodenectomy (Whipple procedure or resection) is used for potentially resectable cancer of the head of the pancreas.
o This procedure involves removal of the gallbladder, a portion of the stomach, duodenum, proximal jejunum, head of the pancreas, and distal common bile duct
Cholecystitis (5)
• S/S
o Pain and tenderness in Right upper abdomen often radiating to the right shoulder
o Nausea
o Vomiting
o Fullness
o Abdomen distention
o Jaundice
o Clay-colored stools
o Fatty stools (steatorrhea)
o Dark urine
• Risk Factors
o Obesity
o Women
o Weight changes
o Weight loss
o Increase dose of estrogen
o Decrease does of estrogen
o High fat diet
o Cystic Fibrosis
o Diabetes
• Complications after surgery
o Bile Peritonitis
o Atelectasis
o Bill duct injury
o Small bowel injury
o Infection
o Ileus
o Retention
o Bleeding
• Diet Orders
o Low fat diet
• Complications of gallbladder disease
o Water retention
o Empyema, hydrops, mucocele (mucal cyst) and gangrene
o Chronic cholecystitis
o Perforation with peritonitis
o Fistula formation
• Patient Education
o Avoid fatty foods and alcohol
o Avoid gas forming foods beans broccoli, cauliflower, broccoli)
o Take fat soluble vitamins
o Signs and symptoms of complications
o Cough and deep breathing after surgery
o Exercise
o Lose weight
Tuberculosis (TB) (2)
• Mantoux test
o An intradermal injection of an extract of the tubercle bacillus is made
o Read 48 to 72 hr
o Positive test = an induration palpable, raised, hardened area
Indicates that a person has developed an immune response to TB does not confirm that the disease is present
• Precautions for a patient with TB
o Wear a N95 HEPA filter or powered air purifying respirator
o Place patient in a negative-airflow room
o Airborne precautions
o Barrier protection
o Client wear surgical mask if being moved to other areas in the hospital [Show Less]