Hepatitis:
Jaundice, anorexia, RUQ pain and tenderness, malaise, clay colored stools, tea colored urine,
pruritus: accumulation of bile salts under the skin, prolonged PT, liver fxn tests all elevated
Kidney FXNS:
Hepatic Encephalopathy:
GI Bleed:
Liv
er:
Alterations
in Protein
metabolism:
-Phenylkeonuria (PKU)- at birth error of phenylalanine utilization. Amino buildup
Test done 1-2 days after birth. Stick on heel
Nursing:
o Specially prepared milk substitutes-Lofenalac
o Low protein diet
-Gout: inborn error of purine metabolism
Disease in which defective metabolism of uric acid causes arthritis, especially in the smaller bones
of the feet, deposition of chalkstones, and episodes of acute pain.
High uric acid level- turns into joint deterioration
Nursing:
o Low purine diet no fish or organ meats
-Renal Failure: kidneys lose ability to remove waste and balance fluids.
Increased protein and albumin losses in urine
that leads to protein deficiency
Nursing Considerations:
o High calorie, low protein diet as
allowed by kidney function
Plan:
Diet high in protein, calories. Low fat and fiber. PN used for bowel rest
Meds: analgesics, anticholinergics, antibiotics, corticosteroids (reduce inflammation)
immune modulators, salicylate containing compounds.
ileostomy
Appendicits: appendix becomes
inflammed and filled with pus causing
pain.
Assessment
o Pain in right lower
quadrant
o Muscle guarding
o Low grade fever
Plan:
o No heating pads,
enemas, or laxatives
o Maintain NPO, IV fluids to
prevent dehydration
o Ice pack
o Observe for signs and
symptoms of peritonitis
(inflammation of the
membrane lining the
abdomen wall and
covering the abdominal
organs
Diverticular Disease: small, bulging
pouches develop in the digestive tract.
Assessment:
o Cramping in left lower quadrant. Relieved by passage of stool or gas.
o Fever, increased WBC, constipation alternating with diarrhea
Diagnose: infection, inflammation, obstruction of diverticula (sacs or pouches in intestinal wall).
Associated with deficency in fiber
Plan: antispasmodics, bulk laxatives, high fiber diet, Surgery( drain abcess, resect obstruction
Peritonitis: inflammation of the membrane lining the abdominal wall and abdominal organs.
Assessment:
o Abdominal pain, ascites
o Increased temp, leukocytosis
o Paralytic ileus (paralysis of the intestinal muscles)
Diagnose:
o Inflammation of part or all of the parietal and visceral surgaces of the abdominal cavity.
o Causes: ruptured appendix, ectopic pregnancy, perforated ulcer, bowel or bladder
Plan:
o Gastric decompression: monitor NG drainage
o Antibiotics, fluids, NPO, analgesics, semi fowlers position
Hirschusprungs Disease: Condition of the large intestine (colon) that casues difficulty passing stool.
Ganglionic disease of the intestinal tract, inadequate motility-
mechanic obstruction of intestine. Can be congenital defect.
Assessment:
o Newborn: doesnt pass meconium, refuse to suck,
abdominal distention
o Child: failure to gain weight, delayed growth,
constipation, alternate with diarrgea, foul smelling poop,
abdominal distention, peristalsis
Enemas, low fiber, high cal and protein diet
Oral antibiotics
Measure abdominal girth at level of umbilicus
Colostomy
Intussusception: part of the intestine telescopes into itself. Usually
the ileum into the cecum and colon
Assessment:
o Colicky abdominal pain, child screasms and draws
knees to abdomen
o Currant jelly like stools containing blood or mucus
o Tender distended abdomen
o Palpable sausage shaped mass in upper abdomen
o Usually happens in 3 months-3 years old
Plan:
o Nonsurgical:
Water soluble contrast, air pressure to push it out
o Surgical: manually reducing the telescoped part. Remove any damaged part of the bowels
Intestioal obstruction
Assessment:
o high pitched bowel sounds above area of obstruction and absent bowel sounds below area of
obstruction.
o Colicky abdominal pain and distention
o Obstipation- abesence of stool and gas
Diagnose:
o Mechanical obstruction: hernia, tumor, adhesions, strictures, intussception, vovlulus
(twisting of bowel)
o Nonmechanical: abdominal trauma, spinal injury, peritonitis, appendicitis, would
dishecience.
Plan:
o Instestinal decompression- may remove fluid or air
o Tubes
o Bowel surgery
Exploratory laprotomy: possible adhesion removal
Resection and anastomosis: disease portion of bowel removed and join the remaining
parts
Abdominal perineal resection: abdominal incision
Intestinal ostomies
o Fowlers position to facilitate breathing
Intestinal Ostomies for Fecal Diversion
Assessment: cancer of colon or rectum,
diverticulitis, intestinal obstruction
Diagnose: ostomy Is opening into colon to allow
passage of intestinal contents. Stoma is an
opening on abdomen where intestine is sutured
to skin
Plan:
o Observe and record condition of stoma:
first few days appears beefy red and
swollen
o Gradually becomes pink or red
o Notify HCP if
becomes black
or purple-
perfusion
problem
Colostomy irrigations
for sigmoid colostomy:
o Purpose is to
stimulate
emptying of
colon at
scheduled
times to avoid
need for
appliance.
Begins 5-7 days
postop
o Sit upright on
toilet performed
after meals.
Cirrhosis: Chronic liver
damage from scarring and liver failure. Diseased liver and pain and edema in leg
Assessment:
o Digestive disturbances: indigestion,
dyspepsia (stomach pain), flutulence,
constipation, diarrhea, anorexia, weight
loss
o Circulatory: esophageal varices,
hematemesis, hemmorhage, ascites,
hemmorhoids, increased bleeding
tendencies, hemmorhoids, anemia,
edmea, spider anginomas
o Biliary: jaundice, pruritus, dark urine, clay
colored stools, increased abdominal girth
(distance around abdomen
o Compensated: vasuclar spiders, ankle
edema, indigestion, flatulence, abdominal
pain, enlarged liver
o Decompensated: ascites, jaundice, weight loss, purpura, epistaxis
Diagnose: normal liver tissue replaced with fibrosis and nodule formation
o Alcoholic Cirrhosis: due to alcoholism and poor nutrition
o Biliary Cirrhosis: result of chronic billart obstruction and infection
o Postnecrotic Cirrhosis: resuly of previous viral hepatitis
Complications: portal HTN with esophageal varices because of elevated pressure. Hemmorhage-
leading cause of death in clients with cirrhosis. Edema, ascites (accumulation of serous fluid in
periotoneal and abdomen from dehydration and hypokalemia, hepatic encephalopathy (coma)-
occurs with liver disease from accumulation of ammonia and other toxic metabolites in the blood,
sx asterixis (flapping tremor of hand when arm extended) jaundice. Hepatorenal syndrome: renal
failure, azotemia (elevated BUN), ascites
Plan:
o shunts to relieve portal HTN
o reduce ascites: sodium and fluid restrictions, diuretics
o TMT of bleeding esophageal varices
Balloon tamponade
Ensocopic sclerotherapy- causes varices to be fibrotic
Administer vasopressin or propanolol to lower pressure
Surgical bypass
Saline lavage
TIPS
Esophageal banding
Reyes Syndrome : causes confusion, swelling in the brain, and liver damage
Assessment:
o Fever, increased ICP, decreaed LOC, coma, decreased hepatic fxn, diagnosed by liver biopsy
o Link between use of aspirin with viral illness, assoc with URI and gastroenteritis
Cholecystitis (inflammation of the gallbladder, dont
eat fatty foods) Cholelithiasis (presence of stones in
gallbladder):
Risk factors: obesity, women (multiparous),
40+ years old usually, pregnancy,
hypothyroidism, increased serum cholesterol
Avoid fried foods, cheese, pork, alcohol
Laproscopic laser cholecystectomy: removal of
gallbladder by a laser.
Pancreatitis: inflammation of pancreas
Assessment: abdominal pain, vomiting 24-48
hours after heavy meal or alcohol, pain relief
with positioning, hypotension, acute renal
failure, grey blue discoloration around
umbilicus
From: alcoholism, bacterial or viral infection,
trauma, complication of mumps, meds-
thiazide diuretics, corticosteroids,
contraceptives
Plan:
o NPO, gastric decompression, meds (avoid meperdine because of toxicity), semifowlers
position, monitor for shock and hyperglycemia.
Periop Care:
Stress: vasovagal response (fainting)
Teaching:
Toddler: simple directions
Preschool and school-aged: allow to play with
equipment
Adolescent: expect resistance
Prevent or minimize the effects of separation on the
child:
Assign same nurse to care for the child
Bring toys from home
Table 2: prep for children
Supplements not to be taken near time of
surgery may affect anesthesia:
o echinacea
o garlic
o gingko
o ginseng
o Kava
o St. johns wort
o Eliminate all dietary supplements at least 2-3
wks before surgery
Intraop care:
Malignant hyperthermia:
inherited muscle disorder
chemically induced by
anesthesia, stop surery, treat
with 100% Oxygen, skeletal muscle relaxant, sodium bicarb
Postop care:
CV surgery after: monitor VS every 15 min x 4, q 30 minutes x2, q 1 hour x2, then PRN
Bowel surgery after: check bowels- if high pitched tympany=abnormal, keep NPO till bowel sounds are
present, check for distention, passage of flatus and stool.
GI tubes: upper: gastric decompression, lower: decompress bowel
Potential Complications of Surgery:
Hemmorhage: decreased BP, increased pulse, cold, clammy skin. Nursing: replace blood vol.
monitor VS
Shock: decreased BP, increased pulse, cold and clammy skin. Nursing: treat cause, oxygen, IV
fluids,
Atelectasis and pneumonia: dyspnea, cyanosis, cough, tachy, elevated temp, pain on affected side.
Nursing: experienced second day postop, suctioning, postural drainage, antibiotics, cough and turn
Embolism: dyspnea, pain, hemoptysis, restlessness, ABG- low O2, high CO2. Nursing: oxygen,
anticoagulant (heparin), IV fluids
Venous thromboembolism: positive ultrasound. Nursing: experiences 6-14 days up to 1 year later.
Anticoag therapy
Paralytic ileus: absent bowel sounds, no flatus or stool. Nursing: NG suction, IV fluids,
decompression tubes
Evisceration: protrusion of wound contents. Nursing: low fowlers no coughing, NPO, cover viscera
with sterile saline or wax paper
Diagnostic Test:
Arterial Diagnostic Tests:
Oscillometry: abnormal findings help to pinpoint the level of arterial occlusion
Angiography (arteriography): indicates abnormalities of blood flow due to arterial obstruction or
narrowing. Use contrast dye injected into arteries and x ray films are taken of vascular tree.
Venous Diagnostic Tests:
Phlebography: lack of filling of a vein is indicative of venous occlusion due to a thrombus. Insert dye
into vein
Isotope studies: helpful in diagnosing early formation of thrombi.
Respiratory/Cardiac Tests:
Pulmonary function: detects impaired pulm function. No smoking 4 hours before tests. Withhold
bronchodilators, breathe into machine.
Bronchoscopy: allows visualization of larynx, trachea, and mainstem bronchi. Possible to obtain
tissue biopsy, apply med, aspirate secretions for lab exam, aspirate a mucus plug causing airway
obstruction, remove aspirated foreign objects. Maintain NPO 6 hours before test.
Thoracentesis: aspiration of fluid or air from pleural space. To obtain specimen for analysis, relieve
lung compression, obtain lung tissue for biopsy, instill medications into pleural space.
Echo: noninvasive sound waves used to determine cardiac structures.
Cardiac cath: usually used with angiography. Evaluate ventricular function and obtain chamber
pressures. NPO 8-12 hours, signed permit, empty bladder
Neurological Tests:
Cerebral angiography: identifies aneurysms, vascular malformations, narrowed vessels. Dye
injected into femoral artery.
CT: detects hemorrhage, infarction, abcesses, and tumors
Myelogram: visualizes spinal column and subarachnoid space. Injects dye so make sure to check
allergies.
PET: used to assesses metabolic and physiologic fxn of brain, diagnose stroke, brain tumor,
epilepsy, PD, head injury.
Liver Function Tests:
Protein studies Serum albumin: proteins are produced by the liver, levels may diminish in hepatic
disease, severely decreased serum albumin results in generalized edema.
PT and PTT: may be prolonged in hepatic disease, in liver disease PTT prolonged due to lack of
vitamin K
Liver enzymes: AST and ALT and LDH are released into the bloodstream.
Blood ammonia: liver converts ammonia to urea. With liver disease, ammonia levels rise.
Bilirubin: detect presence of bilirubin due to hemolytic or liver disease.
GI Tests:
Stomach/esophagus endoscopy: visualization of esophagus by tube through the mouth to stomach
looking for ulcers, tumors, or obtain tissue or fluid samples.
Sigmoidoscopy/Proctoscopy: direct visualization of the sigmoid colon, rectum, and anal canal.
Amylase: diagnose pancreatitis and acute cholecystitis. Normal 6-160
Lipase: diagnose pancreatitis, biliary obstruction, hepatitis, cirrhosis.
Gastric aspirate: aspiration of gastric contents to evaluate for presence of abnormal constituents
such as blood, abnormal bacteria, abnormal pH, malignant cells.
Paracentesis: needle aspiration of fluid in abdominal cavity used for diagnostic exam of ascetic fluid
and tmt of massive ascites resistant to other therapies.
Reproductive Tests:
Culdoscopy: visualization of ovaries, fallopian tubes, uterus via vagina.
Urinary System Diagnostic Tests:
Cystometrogram: identify bacteria in urine.
Cystomertrogram: test of muscle tone.
Cystoscopy: bladder and urethra visualization
Schilling Test: diagnoses vit B12 deficiency (pernicious anemia)
Therapeutic Procedures:
Chest physiotherapy:
o Diaphragmatic or abdominal breathing: client positioned on back with knees bent, place
hands no abdomen
o Pursed lip breathing
o Postural drainage use gravity to facilitate removal of bronchial secretions
o Percussion and vibration, IS
Suctioning:
o Hyperoxygenate before, during, and after suctioning.
o Semi-fowlers
o Complications:
Hypoxia, bronchospasm, vagal stimulation, tissue trauma, cardiac dysrhythmias,
infection
Trach Care:
o Perform every 8 hours and as needed.
o Hyperoxygenate or deep breathe
o Clean cannula with hydrogen peroxide if reusable cannula
o Purpose of cuff: prevents aspiration of fluids, inflated during cont. mechanical ventilation,
during and after eating, during and 1 hour after a tube feeding, when client is unable to oral
secretions, check cuff pressure every 8 hours, maintain at less than 25 cm.
o Complications:
Airways obstruction, infection, trachial necrosis
Chest Tubes:
o Intrapleural drainage system with one or more chest catheters held in pleural space by
suture to chest wall.
o Fill water seal chamber with sterile water
o Chest tubes are only clamped momentarily to check for air leaks and change the drainage
apparatus.
o Gently milk tubing in direction of drainage as needed if agency allows.
o Fluctuations of fluid in water seal chamber., stops fluctuating when:
Lung re-expands
Tubing is obstructed
Loop hangs below rest of tubing. Suction is not working.
o Complications:
Observe for constant bubbling in the water-seal chamber, indicates air leak in
drainage system
NG tubes:
o Levin, salem sump, sengstaken-Blackemore, Keofeed/Dobhoff,cantor, miller-abbott, harris
o Instill 15-30 ml of saline before and after each dose of medication and tube feeding, after
checking residuals, every 46 hours with cont. feedings, when feeding discont.
Surgical Drains:
o Penrose: simple latex drain.
o T Tube: used after gallbladder surgery. Placed in common bile duct to allow passage of bile.
Monitor drainage, keep below waist, may have bile secretions.
o Jackson Pratt: portable wound self suction device with reservoir.
o Hemovac: larger portable wound self suction device within reservoir. Used after mastectomy.
Medical Emergencies!
Upper airway obstruction:
If conscious: 5 back blows between shoulder blade with heel of hand, Heimlich maneuver, alternate
Unconscious: CPR, remove visible object.
Airway intubation:
o ET tube: passed through nose or mouth into trachea.
o Trach: surgical incision made into trachea through throat. Cuff is used to prevent aspiration
and facilitate mechanical ventilation. Indications: noisy respirations, restlessness, increased
pulse, increased resps, presence of mucus in the airway.
Cardiopulmonary Arrest:
Failure to institute ventilation within 4-6 minutes will result in cerebral anoxia and brain damage.
BLS. Compression rate at least 100 minute
o Compression depth: adults at least 2 in. children at least anterior posterior diameter or 2
in. infants at least diameter or about 1.5 in.
o Compression to ventilation: 30:2 adult. 30:2 with single rescuer. 15:2 2 HCP
Croup Syndromes: Acute Epiglottis, Acute Laryngotracheobronchitits
Bark like cough, use of accessory muscle, dyspnea, inspiratory stridor, cyanosis, decrease in noisy
respirations may indicate decompensation.
Viral infection in the area of larynx
Narrowed airway in children
MI:
Chest pain: severe crushing, prolonged, unrelieved by rest or nitros. Women may present with
atypical symptoms (fatigue, SOB)
Shock: systolic BP below 80, gray facial color, lethargy, cold diaphoresis, peripheral cyanosis, tachy,
brady, weak pulse.
Oliguria
Low grade fever
ESR-elevated
CK-MB first enzyme to be elevated after MI
LDH appears
Myoglobin rise within 1 hour
EKG: ST segment elevation, T wave inversion, Q wave formation
Plan:
o Provide thrombolytic therapy TPA: to dissolve thrombus in coronary artery
o Watch intake to not facilitate CHF or too little-dehyrdation
o Prevent complications: dysrhythmias, shock, CHF, rupture of heart muscle, PE, recurrent MI
Healing not complete 6-8 weeks
Dysrhythmias:
Dizziness, syncope, chest pain, abnormal pulse rate
Sinus Dysrhythmias: originate in SA node.
o Tachy. HR increased. Causes- pain, exercise, hypoxia, PE, hemorrhage, hyperthyroidism,
fever. SX: dizzy, dyspnea, hypotension, palpitations
TMT: BB, CCB, cardioversion
o Brady: vagal stimulation causes SA node to depress. HR decreased. Causes: MI, Valsalva
maneuver, vomiting, arteriosclerosis, ischemia, hyperkalemia, Digitalis or propranolol. SX:
pale, cool, hypotension, syncope, dyspnea, weak
TMT: atropine or pacemaker
Atrial Dysrhythmias: stimulation outside of SA node but within the atria
o PAC: ectopic focus within one of the atria fires prematurely. Causes: emotional disturbances,
tobacco, fatigue, caffeine, normal in some ppl. SX: sense of skipped beat
o Atrial Flutter: ectopic focus in atrial wall causing atrium to contract 250-400xmin. Causes:
stress, hypoxia, drugs, chronic heart disease, HTN. SX: chest discomfort, hypotension.
sawtooth
TMT: vagal maneuvers, adenosine, cardioversion or ablation
o Atrial fibrillation: rapid disorganized twitching of atrial muscle. Cause: chronic lung disease,
HF< rheumatic heart disease, HTN. SX: stroke symptoms, hypotension, syncope, dyspnea.
TMT: CCP (diltizem) BB (-olol) digoxin, cardioversion, warfarin
Ventricular Dysrhythmias: occur when one or more ectopic foci arise within the ventricles
o PVC: Causes: ischemia due to MI, infxn, mechanical damage due to pump failure, deviations
of electrolyte imbalances, nicotine, caffeine, tea, alcohol, drugs (dig, resperine) anxiety, lung
disease. SX: angina, SOB, heart flip feeling
TMT: amiodarone, BB, procainamide
o V-tach: 3 or more PVCs occurring in a row at a rate exceeding 100 bpm (severe myocardial
irritability). Causes: large MI, low ejection. SX: hypotension, PE, confusion, cardiac aresst
TMT: procainamide, sotalol, amiodarone, mag, isoproterenol, CPR, defibrillation, epi,
amiodarone.
o V-fib: very rapid rate. Most serious of all dysrhythmias because of potential cardiac
standstill. Causes: acute MI, HTN, rheumatic or arteriosclerotic heart disturbances or
hypoxia. SX: unresponsive, pulseless, apneic.
TMT: CPR; unless blood flow is restored by CPR and the dysrhythmia is interrupted by
defibrillation, death will occur within 90s-5 minutes
o Heart Block: delay in conduction of impulses within AV system
First degree: AV junction conducts all impulses, but slower than normal HR. Causes:
digitalsis, CCB, BB, MI, increased vagal tone. SX: asymptomatic
Second Degree: AV junction conducts only some impulses arising in the atria. Causes:
infections, digitalsis toxicity, CAD. SX: may note hypotension, dyspnea, syncope.
Tmt: atropine, pacemaker
Third degree heart block: Blocks all impulses to the ventricles, causing the atria and
ventricles to dissociate and beat independently. V- rate is low 20-40 bpm. Causes:
congenital defects, vascular insufficiency, fibrosis of myocardial tissue, MI. SX: shock,
syncope
TMT: pacemaker, atropine, epi. Treat immediately because could lead to
death.
Diagnostic Tests: EKG, ABGs, Holter recorder (24 hour continuous EKG tracing, client keeps diary of
activities), Cardiac cath and angiography, Echo, stress test.
Medications: Antiarrythmias (lidocaine, quinidine, procanimide), antilipid (lovastatin,
cholestyramine), defibrillation, pacemakers
Head injury:
o Skull fracture: Battles sign (ecchymosis over mastoid bone), raccoon eyes, rhinorrhea, otorrhea
(middle ear infxn.
o Concussion: mental confusion or LOC, headache, no residual neurological deficit, possible loss of
memory surrounding event, long term effects-lack of concentration, personality changes.
o Contusion: varies from slight depression of consciousness to coma, decorticate posturing,
decerebrate posturing (deeper dysfxn), cerebral edema.
o Laceration: penetrating trauma with bleeding
o Hematoma:
o Epidural: short period of unconsciousness, ipsilateral pupillary dilation, weakness of
extremities
o Subdural: decreased LOC, ipsilateral dilation, weakness, personality changes.
o Plan/Implementation:
o Hypothermia- to decrease metabolic demands
o Barbiturate therapy: to decrease cerebral metabolic rate
Chest trauma:
o Flail Chest: affected side goes down with inspiration and up during expiration. Segment of rib cage
breaks. Monitor for shock.
o Open Pneumothorax: sucking sound on both inspiration and expiration, pain, hyperresonance,
diminished breath sounds on affected side. Penetrating chest wound causing interpleural space to
open to atmospheric pressure=collapsed lung. Thoracentesis, chest tubes
o Pneumothorax: dyspnea, pleuritic pain, cyanosis, absent or restricted movement on affected side.
Collapse of lung due to air in the pleural space
o Spontaneous
o Tension-pressure builds up; shifting of heart and great vessels
o Hemothorax: blood in pleural space
Abdominal Injuries
o Penetrating: sx of hemorrhage. Open wound resulting in hemorrhage, increased risk of infxn.
o Blunt: abdominal pain, distention, shock, ecchymosis (around umbilicus- Cullens sign), bruits
indicating renal artery injury, Balances sign (resonance over spleen with client on left side-
indicates rupture of spleen. IV with large bore needle in upper extremity.
Shock:
o Cool, clammy skin, cyanosis, decreased cap refill, restlessness, weakness, metabolic acidosis,
tachy, respirations shallow, increased muscle weakness, oliguria, increased urine specify.
o Sudden reduction of oxygen and nutrients, decreased blood volume causing reduction in venous
return, decreased CO, decrease in arterial pressure
o Types of shock:
o Hypovolemic: loss of fluid from circulation
Hemmorhagic shock
Cutaneous shock-burns resulting in external fluid loss
DKA
Diabetes insipidus
GI obstruction
Excessive use of diuretics
o Cardiogenic shock: inadequate vascular tone
MI
Dysrhythmias
Pump failure
o Distributive Shock: inadequate vascular tone
Neural: induced loss of vascular tone: anesthesia, pain, insulin shock, spinal cord
injury
Chemical: induced loss of vascular tone: toxic shock, anaphylaxis, capillary leak-
burns, decreased serum protein levels
o Plan:
Low dose-corticosteroids for septic shock
Medications to vasoconstrict and improve myocardial contractility.
Medications used to restore BP, adrenergic/sympathomimetic (dobutamine
hydrochloride)
Increased Intracranial pressure
o Earliest sign- altered LOC, restlessness, confusion, pupillary changes.
o Late signs: increased BP, decreased pulse
o Glasgow: 3-8 indicates severe head trauma; score of 15 indicates client is alert and oriented
o Diagnostic tests: lumbar puncture, EEG, myelogram
o Causes: cerebral edema, hemorrhage, space occupying lesions
o Complications: cerebral hypoxia, decreased cerebral perfusion, herniation-pupil constriction
o Plan:
o Monitor VS hourly: be alert for increased systolic pressure, widening pulse pressure, and
brady (Cushings triad)
o Monitor pupillary changes
o Glasgow
o Elevate head 30-45 degree to promote venous drainage from brain
o Avoid neck flexion, head rotation, coughing, sneezing, bending fwd
o Reduce environmental stimuli
o Prevent valsava maneuver, teach client to exhale while turning or moving
o Restrict fluids 1200-1500
o Administer meds:
Osmotic diuretics: reduce fluid vol (mannitol)
Corticosteroids: reduce cerebral edema (dexamethasone)
Antiseizure meds (diazepam, phenytoin, phenobarbital)
Seizures:
o Causes: epilepsy, fever, head injury, HTN, CNS infxn, brain tumor, drug withdrawal, stroke
o Plan:
o raise side rails
o ease client to floor
o loosen restrictive clothing
o do not insert anything by mouth!
o Types of seizures:
o Tonic-Clonic: aura. Starts with tonic (stiffening) clonic (jerking). May have bladder incont.
Hard to arouse. Fall asleep. All age groups
o Absence: staring spell, lip smacking, chewing. Children.
o Myoclonic: brief muscular contraction involving one or more limbs, trunk. Children
o Infantile Spasms: gross flexion, extension of limbs treated with ACTH. Infants and children
o Atonic Seizures: sudden loss of muscle tone and posture control, child drops to floor. (infants
and children).
o Tonic seizure: stiffening of limbs. Infants and children
o Partial seizures: Jacksonian, focal seizure, starting at one location, may spread. All ages
o Sensory: tingling, numbness of body part, visual, olfactory, taste sx. All ages
o Affective: inappropriate fear, laughter, depersonalization. All ages
o After seizure:
o Provide description of seizure in record:
Circumstances surrounding seizure
How seizure started (location of first tremors)
Type of body movements
Areas of body involved
Incont
Duration of each phase
o To prevent seizures:
o Administer anticonvulsant (phenytoin, phenobarbital)
o Avoid seizure triggers: alcohol, stress, caffeine, fever, hyperventilation
o Alternative therapies:
Ketogenic diet to prevent seizures:
High in fat, low in carbs. Mimics effect of fasting
Suppresses many seizures
Stroke
o Confusion
o Bladder
o Aphasia
o Hemiphlegia
o Bladder and bowel incont.
o Hemianopia: loss of half of visual field
o Emotional lability (changes easy)
o Dysphagia
o Causes: thrombosis, embolism, hemorrhage
o Risk factors: age, HTN, diabetes mellitus, TIAs, smoking, elevated blood lipids, oral contraceptives,
atrial fibrillation
o Plan:
o Immediate Care: maintain patent airway, minimize activity, keep head elevated 15-30
degree to prevent increases intracranial pressure, administer thrombolytic within 3 hours of
onset sx.
o Intermediate: place food on unaffected side of mouth, semisolid food- easiest to swallow,
maintain upright position for 30-45 minutes after eating, monitor elimination, do not
approach from visually impaired side, encourage use of affected side
Spinal cord injury
o Loss of motor and sensory function below level of injury.
o Spinal shock sx:
o Flaccid paralysis of skeletal muscles, complete loss of all sensation, decreased pulses, brady,
suppression of somatic and visceral reflexes, postural hypotension, edema
o Diagnose:
o Categories of neurological deficit:
Complete: no voluntary motor activity or sensation below level of injury
Incomplete: some voluntary motor activity or sensation below level of injury
Tetraplegia (quadriplegia)
o Causes: trauma due to accidents, occurs predominately in young white males (15-30),
substance abuse, neoplasms
o Immobilize cervical spine:
Skeletal traction: Gardner-Wells, Crutchfield, Vinke tongs, halo traction
Surgical stabilization: reduction and stabilization by fusion, wires, and plates
o Administer steroid therapy and antispasmodics (baclofen, diazepam)
o Prevent complications of autonomic hyperreflexia (dysreflexia)
Occurs in clients with spinal cord lesions above T6 after spinal shock
Sx: pounding headache, profuse sweating, especially of forehead, nasal congestion,
piloerection (goose flesh, hair sticks up on arms), brady, HTN
Give hydralazine may be given slowly IV (to decrease BP)
Adrenal Disorders
o Adrenal cortex: glucocorticoids, mineralcoritcoids, androgen
and estrogen
o Adrenal medulla: norepi,epi
o Addisons: hypocorticolism- adrenal glands dont produce
enough hormones (mineralcorticoids, glucocorticoids,
androgens)
o High protein, high carb, high sodium, low K diet
o Monitor for hypoglycemia, hyponatremia
o Avoid factors that precipitate Addisonian crisis (NV,
abdominal pain, fever, extreme weakness, severe
hypoglycemia, hyperkalemia, dehydration, BP falls-
leading to shock and coma): stress, inadequate steroid
replacement
o Fatigue, weakness, dehydration, decrease BP,
hyperpigmentation, decrease resistance to stress,
alopecia, weight loss, depression, lethargy, emotional
lability
o Decrease sodium, blood vol+shock, blood sugar+insulin
shock
o Increased potassium
o Diagnose: CT, MRI, Hyperkalemia, hyponatremia, decrease plasma cortisol, urinary, ACTH
o TMT: hormone replacement
o TMT of Addisonian Crisis: administer hydrocortisone therapy, IV glucose, glucagon, insulin
with dextrose in normal saline
o Cushings Disease(hypercortisolism): Adrenal gland produces too much cortisol
o Fatigue, weakness, osteoporosis, muscle wasting, cramps, edema, increase BP, purple skin
striations, hirsutism, emaciation, depression, decreased resistance to infxn, moon face,
buffalo hump, obese trunk, mood swings, masculinization in females, blood sugar imbalance.
o Hypersecretion of adrenal hormone (mineralcocorticoids, glucocorticoids, androgens),
increase sodium, blood vol, BP, BS+ketoacidosis
o Decrease potassium
o Diagnose: skull films, BS analysis, hypokalemia, hypernatremia, plasma cortisol level
o TMT: hypophysectomy, adrenalectomy
o TMT: assure client most physical changes are reversible with TMT, observe for hyperactivity,
GI bleeding, FVO, administer aminoglutethimide or metyrepaone to decrease cortisol
production, monitor for shock, HTN
Pheochrmocytoma
o Intermittent HTN, increase HR, NV, weightloss, hyperglycemia, glucosuria, polyuria, diaphoresis,
pallor, tremor, pounding headache, weakness, visual disturbance during hypertensive episodes,
pain, urinary vanillymandelic acid (VMA) test (24 hr urine for VMA- breakdown product of
catecholamine metabolism-food affecting VMA excretion excluded 3 days before test- coffee, tea,
bananas, chocolate, vanilla.
o Diagnose: hypersecretion of catecholamines (epi and norepi) activate fight or flight response due to
secreting tumors.
o Plan: avoid stress, avoid chilling, avoid caffeine, tea, cola, foods containing tyramine, limit activity,
administer adrenergic blocking agents, apresoline for hypertensive crisis,
o TMT: adrenalectomy or medullectomy
Cancer
o Change in bowel, bladder habits, sore that does not heal, unusual bleeding or discharge, thickening
or a lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in wort or
mole, nagging cough, hoarseness
o Risk factors:
o Immunosuppression, advancing age, genetic predisposition
o Physical: radiation, chronic irritation
o Chemical: food additive: nitrites, industry: asbestos, pharmaceutical: stillbesterol, smoking,
alcohol
o Genetic, viral (Epstein- Barr virus, Burkitts lymphoma
o Stress
o Common cancer types: caucasion: lung, breast, colorectal, prostate. AA: lung, prostate, breast,
colorectal, uterine. Asian: breast, colorectal, prostate, lung, stomach. Hispanic: prostate, breast,
colorectal, lung
o Classifications: carcinoma: epithelial tissue, sarcoma: connective tissue, lymphoma: lymphoid
tissue, Leukemia: blood forming tissue (WBC and platelets)
o Plan:
o Cancer prevention: avoid known carcinogens (dont smoke, wear sunscreen, eliminate
asbestos in building), avoid excessive intake of animal fat, avoid nitrates found in lunch
meats, sausage, and bacon, decrease intake of red meat, limit alcohol intake, increase
intake of bran, broccoli, cauliflower, brussels sprouts, cabbage, foods high in vit A and C
o Chemo:
Teletherapy (radiotherapy):
External radiation (cobalt): leave radiology markings intact on skin, avoid
creams, lotions, deodorants, perfumes, use lukewarm water to cleanse area,
assess skin for redness, cracking, no hot water bottle, tape, wear cotton
clothing.
Brachytherapy (internal radiation): cesium, radium, gold
Sealed source (cesium)-mechanically positioned source of radioactive material
placed in body cavity or tumor. Lead container and long handled forceps in
room in event of dislodgment, save all dressings and bed linens until source is
removed, urine and feces not radioactive, do not stand close or in line with
radioactive source
Unsealed source of radiation, unsealed liquid given orally or instilled in body
cavity. All body fluids contaminated, greatest danger from body fluids during
first 24-96 hours
Nursing for internal radation:
o Assign client private room, wear dosimeter film badge at all times
when interacting with client (offers no protection but measures amount
of exposure), do not assign pregnant nurse, limit close contact to 30
minutes per 8 hour shift, provide shield in room.
Avoid use of soaps, powders, lotions, wear cotton, loose fitting clothing.
Mouth care: Stomatisis: develops 5-14 days after chemo begins. Sx: erythema,
ulcers, bleeding. Rinse with saline or chlorhexidine; avoid hot temp or spicy foods,
topical antifungals and anesthetics
Nutritional changes: anorexia, malabsorption and cahchexia (wasting), conform food
to clients preferences
Pain relief 3 step ladder
Mild: nonnarcotic meds (acetaminophen) along with antiemetics,
antidepressants, glucocorticoids
Moderate pain: weak narcotics (codeine) and nonnarcotic
Severe pain: strong narcotics- morphine
-Leukemia: neoplastic disease that involves the blood forming tissues of the bone marrow, spleen, and
lymph nodes; abnormal, uncontrolled, and destructive proliferation of one type of white cell.
o Ulcerations of mouth and throat, pneumonia, septicemia, altered leukocytes, anemia, fatigue,
lethargy, bone and joint pain, hypoxia, bleeding gums, ecchymosis, petechiae, retinal hemorrhage,
weakness, pallor, weight lost, heptomegaly, splenomegaly, disorientation, convulsions
o Diagnose: bone marrow aspiration. Complications: osteomyelitis, bleeding, puncture of vital organs
o Classification of leukemia:
o Acute: rapid onset and progresses to a fatal termination within days to months; more
common among children and young adults.
o Chronic: gradual onset with a slower more protracted course, more common in age 25-60
o Plan: assess for signs of bleeding, good mouth care, high cal diet, freq feedings of soft easy to eat
food, antiemetics, neutropenia, strict handwashing, prevent skin breakdown, administer blood
transfusions,
-Skin Cancer: major risk factor is overexposure to sun.
o Basal cell carcinoma: most common type of skin cancer rarely metastasize but commonly reoccurs.
Small waxy nodule on sun exposed areas of body. May ulcerate and freckle
o Squamous cell carcinoma: may metastasize to blood or lymph. Rough, thick, scaly tumor seen on
arms or face
o Malignant melanoma: most lethal of skin cancers; highest risk persons with fair complexions, blue
eyes, red or blonde hair, freckles; metases to bone, liver, spleen, CNS, lung, lymph. Variegated color
(brown, black mixed with gray or white) circular lesion with irregular edges seen on trunk or legs.
o Diagnose by skin lesion biopsy
Intracranial Tumors:
o Seizures- more cortex, papilledema, personality disturbances- frontal lobe
o Diagnose: classified according to location:
o Supraterntorial- incision behind hairline, surgery within the cerebral hemisphere
o Infratentorial: incision made at nape of neck around occipital love; surgery within brain stem
and cerebellum
o Plan: elevate HOB 30-45 degress after supratentorial surgery. Position client flat and lateral on
either side after infratentorial.
o Observe for complications: respiratory difficulties, increased ICP, hyperthermia, meningitis,
wound infection
o Admnister medications: corticosteroids, osmotic diuretics, mild analgesic, anticonvulsants,
antiemetics, no narcotics because changes in LOC)
Carcinoma on Larnynx
o Pain radiating to the ears, hoarsenss, dysphagia, foul breath, dyspnea, enlarged cervical nodes,
hemoptysis
o Causes: industrial chemicals, cigarette smoking, alcohol, chronic laryngitis, straining of vocal cords,
family hx
o Observe for post-op difficulties: fistula, respiratory difficulties, stenosis of trachea, rupture of carotid
o Communicate with esophageal speech, artificial larynx- mechanical device
o Radiation therapy
Mobility
o Lumbar lordosis: exaggerated concavity in the lumbar region
o Kyphosis: exaggerated convexity in the thoracic region
o Scoliosis: lateral curvature of a portion of the vertebral column
Immobility:
o Isometric exercise: alternate contraction and relaxation of muscle without moving joint.
Maintenance of muscle strength when joint immobilized
o Therapeutic positions:
o Supine: avoid hip flexion (which can compress arterial flow)
o Prone: promotes extension of hip joint. Not good for ppl with CVD or respiratory issues
o Head elevated: increases venous return, max lung expansion
o Modified Trendelenburg: increases blood return to het. Relieves pressure on lumbosacral
area
o Elevation of extremity: increases venous
return, decreases blood vol to extremity.
o Crutches: 8-10 in. out to side. Elbows flexed 20-30
degree angle
o GOING UPSTAIRS GOOD LEG FIRST,
CRUTCHES, THEN BAD LEG
o VISE VERSA GOING DOWN.
o UP WITH THE GOOD DOWN WITH THE
BAD
o Cane: hold cane in hand opposite affected extremity.
Advance cane then leg
Joint Disorders
Pagets Disease:
o Pain, bowed legs, decreased
height, shortened trunk with
long arms, enlarged skull, long
bone spine and rib pain, kyphosis, excessive bone resorption. Bone is excessively broken down
Bursitis:
o Pain due to inflammation, decreased mobility
o Inflammation of connective tissue sac between muscles, tendons, and bones.
o Promote ROM, cortisone injection
Osteoporosis:
o Kyphosis, low back pain (hips and spine)
o Reduction in bone mass with no changes in mineral composition. Degenerative disease, loss of
bone density and tensile strength
o Diagnosed by bone mineral density: less of equal to 2.5=osteoporosis
o ROM exercise, physiotherapy, calcitonin, raloxifene, estrogen
Osteomyelitis:
o Pain, swelling, warmth on affected area, elevated ESR, leukocytosis (increase in WBC)
o Infection of the bone
Osteolmalacia:
o Decalcification of bones due to inadequate intake of vitamin D, absence of exposure to sunlight,
CKD
o Give vitamin D rich foods: milk, eggs, vitamin D
enriched cereals, bread
Spina Bifida/Neural tube defects:
o Dimpling at the site- spina bifida occulta
o Bulging sac like lesion filled with spinal fluid and
covered with a thin, bluish, ulcerated skin-
meningocele
o Bulging sac like lesion filled with spinal fluid and
spinal cord-myelomeningocele.
o Hydrocephalus increases risk, paralysis of lower
extremities, musculoskeletal deformities: club feet,
dislocated hips, kyphosis, scoliosis, neurogenic
bladder
o Risk factor is folic acid deficiency
o Plan:
o No tmt for occulta
o Surgical repair for meningocele/myelomeningocele
o Position client on abdomen or semiprone with sandbags
Neuromuscluar Disorders:
o Cerebral Palsy: athetosis (abnormal muscle contractions), spasticity, rigidity, ataxia, atonicity.
Neonate: cant hold head up, feeble cry, inability to feed. Infant: FTT. Toddler: intellectual delay,
physical delay
o Voluntary muscles poorly controlled due to brain damage.
o TMT: ambulation devices, surgical lengthening of heel cord to promote stability and function
o Medications: muscle relaxant, tranquilizers, anticonvulsants, intrathecal pump, baclofen
o Never tilt head back when feeding because of choking. High cal diet
o Muscular dystrophy: muscle weakness, lordosis/scoliosis, waddling gait, joint contractures,
stumbling falling
o Progressive muscle weakness, atrophy of voluntary muscle, no nerve effect. Genetic
o Diagnostic: CPK, abnormal electromyogram, abnormal muscle biopsy.
o TMT: intense PT, active and passive ROM. Light spinal braces or long leg may help
ambulation
o Prevent contractures
o Parkinsons Disease: tremors (pill rolling motion), akinesia (loss of automation), rigidity, weakness,
motorized propulsive gait, slurred monotone speech, dysphagia, salivation, constipation,
depression, dementia
o Deficiency of dopamine; increased acetylcholine levels
o Encourage finger exercises, ROM, goose stepping walk, walk with wider base, concentrate on
swinging arms while walking
o Educate family: does not lead to paralysis, intellect not impaired, sight and hearing are
intact, disease is progressive but slow
o Medications: dopaminergics- levodopa, amantadine, antivirals
o Myasthenia Gravis: muscular weakness produced by repeated movements soon disappears
following rest, diplopia, ptosis, impaired speech, dysphagia, resp distress, periods of remission and
exacerbations
o Deficiency of acetylcholine at myoneural junction. Etiology unclear, chronic progressive
intellect intact
o Diagnosed by injecting antichonesterase and seeing positive result
o Avoid factors that could precipitate MG crisis: infections, emotional upsets, use of
streptomycin, neomycin- produce muscle weakness.
o MG: crisis: sudden inability to swallow, speak or maintain airway.
o Multiple Sclerosis: early: vision, motor sensation changes. Late: cognitive and bowel changes.
Muscular incoordination ataxia, spasticity, intention tremors, nystagmus, incont, sexual dysfxn
o Demyelination of white matter throughout brain and spinal cord, leads to paraplegia or
complete paralysis
o ROM, warm baths, encourage 2000 ml fluid intake daily, use cane or walker, use weighted
bracelets and cuffs to stabilize upper extremities, bladder and bowel training, no tetracycline
or neomycin because increase muscle weakness with MS
o Lou Gehrigs Disease:
o Tongue, fatigue, atrophy with fasciculation (brief muscle twitching), dysphagia, aspiration,
progressive muscular weakness, muscular wasting, atrophy, spasticity, usually begins in
upper extremities, emotional lability, cognitive dysfunction, no alteration in autonomic,
sensory, or mental function
o Diagnose: progressive, degenerative disease involving lower motor neurons of spinal cord
and cerebral cortex, leads to mix of spastic and atrophic changes in cranial and spinal
musculature.
o Plan: progressive terminal disease
Thyroid Disorders:
Myxedema
(hypothyroidism):
o Decrease in
BMR, T3, T4,
and an increase in TSH, decreased activity level, sensitive to cold, obese, alopecia, dry skin
and hair, decreased ability to perspire, slowed physical and mental function
o Plan: instruct about causes of myxedema coma: acute illness, surgery, chemo, discontinuing
med), be patient, allow extra time for them, provide blankets and extra clothing, keep room
at 75 degrees.
Graves Disease (Hyperthyroidism):
o Increased BMR, T3, T4, high titer anti-thyroid, hyperactive, sensitive to heat, weight loss,
tachy,
exophthalmos, fine
soft hair,
accelerated
physical and
mental functions
o Plan: limit activities
to quiet ones,
restrict visitors and
control choice of
roommate, avoid
stimulants, use
calm unhurried
manner
Parathyroid Disorders:
Hypoparathyroidism:
o Tetany, muscle spasms, clonic convulsions,
paresthesia, tachy, positive chvostek and Trousseus
sign, anxiety, depression, dysphagia. Decreased calcium, PTH and increased phos.
Hyperparathyroidism:
o Fatigue, muscle weakness, cardiac dysrhythmias, emotional irritability, renal caniculi,
pancreatitis, peptic ulcer, benign parathyroid tumor, neck trauma, increased in calcium and
parathyroid hormone, decrease in phos.
Transmission Precautions:
Airborne: private room with monitored negative air pressure. Door kept closed, wear a N-95 HEPA
filter. TB, measles, rubella, shingles, chicken pox
Droplet: private room, wear mask if coming into close contact, door may remain opne, pneumonia,
Flu, mumps, pertussis
Contact: herpes, MRSA, C-diff, scabies, RSV, rotavirus, hepatitis A
Tuberculosis:
Progressive
fatigue, anorexia,
weight loss,
irregular menses,
low grade fever,
night sweats,
irritable, coughs
sometimes with
blood, chest tight,
dyspnea, dull
aching chest
Lyme Disease:
Rash
(erythematous
papule that
develops into
lesions), flu like sx,
cardiac conduction
defects,
neurological
disorders
(paralysis).
Multisystem
infection
transmitted to
humans by tick
bite, most common
during summer
months.
Antibiotics:
doxycycline,
ceftriaxone,
azithromycin
STI:
Syphilis: treat with
penicillin,
erythromycin,
ceftriaxone,
tetracyclines. Copper colored rash on palms and soles, low grade fever. Reportable disease
Gonorrhea: thick discharge from vagina or urethra. Usually asymptomatic in females, pain with
intercourse. Yellow green discharge. Ceftriaxone, doxycycline, azithromycin, monitor for
inflammatory disease.
Genital Herpes: painful vesicular genital lesions, difficulty voiding, acyclovir, sitz baths, must notify
sexual contacts, precautions with vaginal delivery.
Chlamydia: dysuria, frequent urination, thick discharge, pelvic pain, painful menses. Treat with
azithromycin, -cycline. Must notify contacts
Cytomegalovirus: fever, malaise, visual impairment, adrenalitis, hepatitis, disseminated infection
Kaposis sarcoma: small purplish brown, no painful, diagnosed by biopsy
Botulism: drooping eyelids, weakened jaw, dysphasia, blurred vision, symmetric descending weakness,
may cause death. Contaminated food: 12-36 hours, aerosol inhalation: 24-72 hours. No person to person
transmission.