Treatment: 1. Maintain patent airway 2. O2 therapy 3. IV bolus insulin, then cont infusion 4. Fluid resuscitation 0.9% NaCl infusion 1L/hr until BP stable and blood glucose approaches 250 mg/dL 5% dextrose added to prevent hypogylcemia 5. Regular insulin via bolus then drip 0.1U/Kg/hr 6. Monitor K+- cause initially high but as add insulin, pushes K+ into cells resulting in vascular depletion K+
Hyperosmolar Hyperglycemic Syndromecharacterized by hyperglycemia, osmolar diuresis, and dehydration Acute Complications: S/S: 1. Dehydration 2. Tachycardia, hypotension 3. Hemiparesis 4. Somulance, decreased LOC 5. Hypernatremia & hypokalemia 6. Blood glucose>600mg/dL 7. Osmolality >330mOsm 8. Lactic acidosis, Azetemia (kidney), Lack ketones 9. Aplasia 10. E-lytes- hypernatremia, hypokalemia, hypochloremia, increased BUN, creatinine HCT & HgB
Maintain patent airway O2 therapy IV access Immediate Fluid resucitation 0.9%/.45% NaCl infusion 1L/hr until BP stable 5. Regular insulin via bolus, then by infusion 0.1U/Kg/hr. When glucose 250mg/dL dextrose added 6. Monitor VS, I/O, heart and elytes
1. 2. 3. 4.
Bradycardia:
s/s:
Cause: hypothermia, sleeping, athlete, parasympathomimetic drugs, carotid artery massage, valsalva manoeuvre, increased intracranial pressures, alcohol intoxication. Treatment: Atropine Pacemaker
Ventricular Tachycardia:
3 or more PVCs Life threatening because of decreased
Cause: fever, exercise, stress, heart dx stimulants Treatment: Administer prescribed meds: lidocaine, amiodarone, procainamide Cardioverson Defib if deteriorates to v-fib
Atrial Fibrillation
Ectopic foci cause atrium to have a rapid beat Rate 300-600bpm Ventricular rate 50180bpm No p wave- replaced by fibrillation waves Leads to stroke due to emboli
Cause: 1. Hypoxia 2. Mitral stenosis 3. Pericarditis 4. Hypertensive heart dx 5. HF 6. Cardiomyopathy 7. throxotoxicosis TX: Treat the cause Cardiac glycoside: Digoxin B- blocker: propanolol Ca2+ channel blocker: Verapamil Cardioversion: amiodarone, procainamide Coumadin (Warfarin) if cardioversion doesnt work
Ventricular Fibrillation:
3+ PVCs
Ventricles vibrating in a
Cause: 1. Acute MI 2. Hyperkalemia 3. Hypoxia 4. CAD: MI, cardiomyopathy 5. Acidosis 6. Drug toxicity TX: CPR, ACLS, countershock (defibrillator)
to increased ventricular irritability P waves are lost in QRS complex Wide, bizzar QRS complex Can lead to ventricular tachycardia Not strong enough to generate a pulse
Cause: 1. E-lyte imbalance 2. Hypokalemia 3. Digoxin toxicity 4. hypoxia 5. Stimulants 6. exercise TX: treat the cause 1. Na+ channel blockers: lidocaine, procainamide, amiodarone 2. B-blockers
Chest pain 2. SOB, Dypnea, weakness 3. Diaphoresis, increased temp 4. Palpitations & dysrhythmias 5. Tachycardia & tachypnea 6. EKG: elevated/depressed ST segment, inverted T wave, new Q wave 7. Increased heart enzymes 8. Hyperlipidemia 9. Increased homocystene levels 10. Increased c-reactive protein levels 11. Decreased/absent pulses 12. S3/s4 heart sounds 13. Denial symptoms, anxiety, fear
1.
EKG, O2, IV, nitroglycerin, morphine, aspirin, heparin, bblockers, ace inhibitor
3. ECG 4. PCI CABG 5. Rest 6. Monitor v.s and level fatigue 7. If dysrhythmias occur-assess BP,
Chronic stable angina- chest pain that occurs intermittently over a long period of time
s/s: Choking, burning heavy sensation Substernal, radiates arm, jaw, shoulders Last 5-15min Provoked by exertion ECG=ST depression=ischemia
TX: sublingual nitroglycerin, aspirin, antiplatelet therapy, ACE inhibitor, b-blocker, smoking cessation, diet, control diabetes, exercise.
Unstable angina- occurs at rest, sleep, or worseningEMERGENCY Myocardial infarction-result of sustained ischemia necrosis due to halted perfusion
1. 2.
3. 4. 5. 6.
7.
8.
Pain not relieved by rest, position change or nitro SOB, weakness, pulmonary edema, dizziness, dysrhythmias Increased glucose, BP, HR Ashen, clammy skin Abn heart sounds Nausea & vomiting Fever Bibasilar crackles, sings rsided heart failure
Cause: rupture of athlerosclerotic plaque TX: ACS: 12 lead EKG, O2, IV access, Nitro, morphine, aspirin, heparin, beta blocker, ace inhib.
Drug therapy: nitro, low molecular weight heparin, antiplatelet (plavix), glycoprotein IIb/IIIa; 2. Coronary revascularization: PCI
1.
STEMI: immediate reperfusion therapy 1. PCI 2. Fibrinolytic therapy w/ streptokinase, alTplase 3. Emergent CABG
Defn: Diabetes Mellitus: abnormal insulin production, impaired insulin utilization, or both (type I/II).
Diagnostic tests: 1. Fasting glucose 126mg/dL 2. Random/casual plasma glucose level 200mg/dL 3. OGTT 200mg/dL w/ 75mg glucose load 4. A1C (glycosylated hemoglobin ), lipid profile, BUN, creatinine, elytes, TSH, 5. Urinalysis for ketones & glucose NSG: 1. Drug therapy: Insulin, Oral agents 2. Nutrition therapy 3. Exercise 4. Teach self- monitoring 5. transplant
S/S: Type 1:Chronic hyperglycemia, Polydipsia, Polyuria, Polyphagia, Weight loss, Weakness, Fatigue Type 2: fatigue, recurrent infections, prolonged wound healing, & visual changes
Definition: Head & Neck Cancer-squamous cell carcinoma arising from the mucus membranes: affects larynx, throat, trachea, tongue, salivary & parotid glands. Diagnostics: 1. CBC, PT, PTT, INR, urinalysis, renal & liver fxn tests, protein & albumin levels 2. X-ray of skull, neck, chest & sinuses 3. CT-head & neck, MRI, PET 4. Bone, brain & liver scan 5. Direct/indirect laryngoscopy 6. Panendoscopy 7. Biopsy NSG: radiation therapy, chemotherapy, targeted therapy, surgery, pre/postop care, teach about surgery, self-care airway, methods communication, sxn, pain control, critical care environment
Signs/symptoms: 1. Persistent sore throat or otalgia 2. Change voice quality, hoarseness, feeling of lump in throat 3. Oral leukoplakia or erythroplakia 4. Pain, dysphagia, decreased mobility tongue, cranial neuropathies, & airway obstruction 5. Weight loss 6. Lumps on head & neck 7. Laryngeal abnormalities
Signs/symptoms: 1. Sudden onset fever, chills, productive cough 2. Dyspnea, cyanosis, Pleuratic chest pain 3. Foul smelling sputum 4. Tachycardia, hypotension, fatigue 5. Anxiety & confussion, Change LOC & dehydration in elderly 6. Dullness to percussion, Bronchial BS, Wheezes & crackles 7. Flushed cheeks, resp. Grunting, nasal flaring 8. Decreased SaO2 & PaO2
Defn: destruction & cavity formation of lung tissue caused by mycobacterium tuberculosis.
Diagnostics: 1. Presence s/s 2. +ive acid-fast bacillus test, PPD or quantiferron TB gold test 3. +ive C&S 4. Chest x-ray NSG: 1. Combination therapy 2. Care hospitalized pt: use airborne precautions, teach about drugs, resistant strains TB, infection control, health & general care issues.
Signs/symptoms: 1. Persistent cough 2. Night sweats 3. Weight loss & anorexia 4. Dyspnea, hemoptysis, malaise & fatigue 5. Fever & chills 6. Dullness w;/ percussion 7. Bronchial BS 8. Crackles & wheezes 9. Enlarged lymph nodes
Lung caner
Diagnostics: 1.Chest x-ray, CT scan, MRI, PET 3.Thoracoscopy & thoracentesis 4.Sputum culture 5.Fiberoptic bronchoscopy & biopsy NSG & Collaborative: 1.Chemotherapy,Radiation therapy, Targeted therapy, Photodynamic therapy 3.Surgery 4.Pre & post-op care 5.Teach about procedure 6.Apply closed chest drainage 7.Drug therapy 8.Thoracentesis & pleurodesis 9.Pain management 10.Refer to hospice (terminal) 11.Refer family to American cancer society
Signs/Symptoms: Persistent Pneumonitis Persistent cough Anorexia Weight loss Nausea & vomiting Fatigue Hoarseness Unilateral diaphram paralysis Chest pain
Signs/Symptoms: Increased RR Change LOC Respiratory acidosis Cyanotic mucous membranes Decreased BS Increased AP chest diameter Increased intercostals space Increased expiratory phase Use of accessory muscles Pursed lipped bx Tachycardia Wheezes Inability to complete sentence
Signs/Symptoms: Rapid, shallow, paradoxical respirations Chest retraction Dyspnea Wheezes Hyperressonant on percussion Tachycardia Peripheral edema Decreased cap. Refill Clubbing of fingers Cyanosis of mucous membranes & nail beds Polycythemia Weight loss anorexia
Labs
Whole Blood:Plasma-55% blood volume, Blood cells-45% blood volume
Erythrocytes-4-5million/uL, lives 120dys 2. Thrombocytes-150,000-400,000uL, lives 5-9dys 3. WBC=4000-10000/mm Granulocyte
1.
Neutrophils-50-70%-acute inflammatory response Eosinophil-1-2%-antigen-antibody Basophil-0-2%-allergic rx Lymphocyte- B & T cell20-40% Monocyte-4-8%, Macrophage
Agranulocyte
ESR measures sedimentation rate RBCs in 1hr. Increase=acute/chronic inflammatory rx, malignacy, MI, & endstage renal dx 2. D-Dimer- measures fragment of fibrin that is formed as result fibrin degrdation & clot lysis N<250mcg/L
1.
Labs
Whole Blood:
Labs
3. Iron Studies:
4.
Serum iron- measures tot. Amt. Protein bound Fe circulating N=50-150mcg/dL Total iron-binding capacity (TIBC)- all proteins that act to bind/transport between tissues & bone marrow N=250-410mcg/dL Serum ferritin- iron storage protein N=10-300mcg/L Transferrin saturation-binds to iron. Increases in those w/ deficiency anemia N=215380mg/dL Best indicator of availability of iron
5. 6. 7.
Sickle cell test- exposes cells to deoxygenating agent Blood typing & Rh factor Bone Marrow & lymph node biopsy Schillings test (urine) N=10-40%
Summary
The hematological system consists of : 1. Blood-transports O2/CO2, wastes, & nutrients to and from the cells, maintain e-lyte & acid-base balance as well as protection from foreign invaders 2. Lymphatic system- carries fluid from interstitial spaces to the blood via subclavian veins as well as filters pathogens & foreign particles 3. Liver-filters, production procoagulants & hepcidin (regulates Fe3+ balance) 4. Spleen-storage of lymphocytes, monocytes, immunoglobins, RBCs & platelets. Also produces RBCs in the fetus & removes old & defective RBCs & recycles iron.
Summary
There are two types of bone marrow:
1. 2.
Red marrow is found in the flat & long bones of the body ex. Pelvic bones, flat bones of skull, ends long bones, scapula, sacrum, sternum, ribs & vertebrae. RBCs, WBCs & platelets arise from hematopoietic stem cell (erythropoietin causes differentiation).
Phases of Hemostasis
Vascular response
Platelet plug
Lysis of clot
Phases Hemostasis
1.
2.
3.
4.
Vascular response- upon injury immediate vasoconstriction occurs (20-30min), allowing platelets & clotting factors to be activated (activated injury & release factors like tissue factor). Platelet plug when activated, platelets release platelet factor 3, serotonin & adenosine diphosphate to enhance coagulation, adhesion (stickiness) & aggregation (clumping). Plasma clotting factors plasma clotting factors are stimulated via the intrinsic pathway by exposure to collagen due to endothial cell injury or via the extrinsic pathway due to exposure to tissue factor/tissue thromboplastin release from the tissues. These all lead to thrombin converting fibrinogen to fibrin. Lysis of the clot- the anticoagulation and fibrinolysis of the clot to limit its size or eliminate it. In anticoagulation , antithrombins like endogenous heparin & protein C& S are released. In fibrinolysis the clot is attacked when plasminogen is converted to plasmin (plasmin attacks and breaks fibrin into small pcs).
partially regulated by throbopoeitin Hypoxia stimulates release of erythropoeitin from the kidneys To evaluate rate & adequacey of erythrocyte production, do a reticulocyte count Iron is stored as either ferritin or hemosiderin in the bone marrow, spleen, liver & macrophages
transferrin saturated with Fe3+ indicates Fe3+ supply for developing RBCs Plasmin attacks either fibrin or fibrinogen by splitting the molecules into smaller elements- fibrin split products (FSP) or fibrin degradation products (FDP). Increased FSP leads to impaired platelet aggregation, reduced prothrombin & inability to stabilize fibrin
for clotting is thrombin, which converts fibrinogen to fibrin Hgb levels are used to determine the severity of anemia Iron should be given deep IM in upper quadrant of buttocks, w/ 2-3inch, 1920gauge needle using Z-track method. DO not massage site.
cobalamin related anemia because they lack intrinsic factor Puritis occurs due to increased serum & skin bile salts Iv dextran should not be mixed, give undiluted rate 1mL/min, then flush with NS Hepsidin is produced by the liver and is stimulated by iron overload or inflammation
can be evaluated by light palpation...deep cant be felt in adult Normal nodes are mobile, firm, and nontender to be considered a normal finding.
thrombocytopenic, pressure may be required for 5-10min or longer Cover the needle aspiration site with sterile pressure dressing
Hodgkins Dx
Malignant condition
(decreased production ALL blood cells) Tx: 1. Erythropoeitin 2. Blood transfusion Polycythemia: increased production RBC Tx: phlebotomy, hydration, myelosuppressive agent ex. hydroxyurea
characterized by the proliferation of giant & abnormal multinuclear cells called REED-STERNBERG cells in lymph nodes resulting in enlarged lymph nodes, spleen, & lymph tissue Tx: 1. chemotherapy
1. Teach pts that they are not able ingest cobalamin from diet
7.
8.
s/s hypoxia Sore tongue, red, swollen , smooth, beefy, glossitis Anorexia, weight loss N&V, abdominal pain Weakness & fatigue Parasthesia of feet & hands Balance & gait disturbance Impaired thought process
2. Drug therapy: Parentral cycanobalamin or hydrocolobalamin Itnranasal (Nascobal) 100mg cobalamin IM qd 2wks, then weekly until HCT normal, then monthly for life 3. Encourage rest when needed
Iron Deficiency Anemiabelow normal total body iron & inadequate Hgb production
Cause: 1. Inadequate dietary intake 2. Malabsorption Fe3+ due to gastronomy, severe diarrhea, removal/bipass duodenum 3. Blood loss- PUD, gastritis, esophagitis, hemorrhoids, neoplasia 4. hemolysis S/S: 1. Pallor, fatigue, bone pain 2. Headache, restlessness, dizziness, slowing thought process, irritability, depression, vertigo 3. Tafchycardi, palpitations, angina, HF 4. Cold intolerance 5. Tachypnea, orthopnea, dyspnea 6. Anorexia, hepato/splenomegaly, dysphagia
4.
5.
6.
suppliments For acute blood losstransfusion packed RBCs Teach Fe3+ colours stool black Monitor Hgb & RBC Teach cont take suppliment 2-3mths after HgB normal
Sickle cell anemia- an inherited disorder characterized by abnormal Hgb called Hgb-S. Cause: deprivation O2cell flattens and elongates
1.
2. 3.
4.
5.
6.
Instruct pt measures to prevent crisis ex. Avoid infections, dehydration, strenuous physical activity, emotional stress, tight clothing, & high altitudes Administer folic acid if indicated Provide support & family teaching- rev. Genetic implications & coping skills Manage priapism-instruct empty bladder @ onset attach, exercise & take warm bath. If persist >4hrs notify provider Inform experimental meds being evaluated-hydroxyurea, cetiedil citrate, pentoxifylline, & food additive vanilla Administer meds, OTC, opiods, increase oral/IV intake fluids, monito I/O, use small gauge needles, administer blood transufsion, encourage rest
S/S: 1. Jaundice 2. Enlarged skull & facial bones 3. Increased suscep. To infection esp. Osteomyelitis & pneumonia 4. Spleno/ hepato/cardiomegaly, gallstones 5. Tachycardia, flow murmurs 6. Thrombosis/hemorrhage causing paralysis, sensory deficits, death, retinal detachment, blindness, retinopathy 7. Acute chest syndrome, pulmonary HTN, pneumonia 8. Renal failure, hematuria 9. Hand-foot syndrome, osteonecrosis 10. Priapism 11. Stasis ulcers of hands, ankles, feet.
sickeling of cells increases viscosity blood stasis w/ enlargement & engorgement of organs, infarction w/ischemia & destruction RBCs
Urinary System
A. Kidney- removal of waste, acid-base balance, control
, reabsorption H2O, bicarb, regulate Ca2+ & PO4Collecting duct- reabsorption water (ADH required)
2. 3.
4.
5. 6.
Renal artery & veins- 1200mL/min perfuse the kidneys Ureters- carry urine from kidneys to bladder Bladder- fxns store urine & help eliminate waste Urethra- conduit urine removal to outside body Urethralvesical unit0 bladder, urethra & pelvic floor
urgency, nocturia, overflow incontinence 7. Increased prevalence unstable bladder contractionsoveractive bladder 8. Prostetic enlargement- hesitancy, frequency, urgency, nocturia, retention
Urinary System
Azotemia- an
accumulation of nitrous waste products Glomerular filtration rateN-39-90mu/min, calculation of the rate of glomerular filtration Iterstitial cystitis- chronic & painful inflammation of bladder Uremic frost- deposits of urea crystals on the skin of one who has severely impaired kidneys
massive loss fo protein in the urine due to increased glomerular permeability leading to decrease in oncotic pressure & edema Renal colic- intenser intermittent pain resulting from renal calculi in the kidney or uriter. Begins kideny radiates to abdomen, genitals & legs
Creatine clearance- approximates GFR N=85135mL/min; evaluates glomerular filtration rate, levels increased as renal fxn diminishes
NSG: Collect 24hr urine specimen Discard 1st and collect rest 24hrs
Urinary System
3. BUN- I.Ds renal problems. Concentration urea in
1.5mg/dL 5. Intavenous pyelogram (IVP)- xray of urinary tract after injection contrast material
NSG: assess labs, report BUN>40mg/dLcathartic enema before, NPO 8hrs, assess iodine allergy, metalic taste, after procedure force fluids to flush material
Urinary System
6.
7.
8.
Cystogram- visualize bladder & eval. Vesicoureteral reflux Renal scan- eval anatomical structures, perfusion, fxn kidney
NSG: inform pt no pain/discomfort should be felt
Urinary System
9.
NSG: type & cross-match, informed consent, pt hx coag, status, meds, CBC etc, after apply pressure dressing & keep on affected side 30-60min, bed rest 24hrs, VS q5-10min 1st hr, assess flank pain, hypotension, decreased HCTm increased temp, chills, urinary frequency, dysuria, & serial urine specimens, check blood urine, avoid lifting heavy objects 57dys 10. Glomerular filtration rate=amt. Blood filtered by
glomerulus N=125mL/min 11. Urinalysis- provides info kidney fxn note colour, opacity, odour, sp.gr, osmolality, pH, as well as presence glucose, ketones, proteins, RBCs
Labs: 1. Urinalysis- i.d presence nitrate (indicates bacteremia), WBC, & leukocyte esterase (indicates presence WBC) 2. Culture & sensitivity- clean catch, refrigerate on collection & culture w/in 24hrs 3. Intravenous pyelogram or CT when urinary obstruction suspected
INT:
1.
2.
3. 4. 5.
6.
Antimicrobial therapy- trimethoprim sulfamethoxazole (TMP-SMX), Fluroquinolones, OTC agents Provide pain relief- heat to perenium, encourage hot bath Promote measures to prevent infection Promote measures to maintain fluid & elyte balance Provide client & family teaching- empty bladder regularly & completely, evacuating the bowel regularly, wiping from front to back, drink adequate fluids daily Promote client & family coping
s/s: Polynephritis- inflammation of 1. mild fatigue, Sudden onset chills, the renal parychema & fever, vomiting, malaise, flank pain collecting system & costovertebral tenderness on Cause: affected side Infection of lower urinary tract by 2. Dysuria, Urinary urgency, Urinary way of ascending urethral rout e.coli frequency vesicoureteral reflux (backward
movement from lower to upper urinary tract), dysfxn lower urinary tract fxn- ex. Obstruction from benighn prostetic hyperplasia or urinary stone Long-term catherization Acute pyelonephritis leads chronic pyelonephritis which can progress to end-stage renal dx when both kidneys involved LABS: uranalysis, culture &sensitivity, gram stain, CBC, IVP, & CT
INT:
1. 2.
3.
4.
Administer oral/parentral antibiotics Teach need cont meds as prescribed &need for follow-up urine culture, encourage drink 3L fluid daily, rest to increase pt comfort, prophylaxis w/low dose antibiotics for those recurrent infections Maintain sufficient perfusion to kidneys to protect from injury Surgery: pyelolithotomy, nephrectomy, uretral diversion or reimplantation
Renal colic (severe pain) N&V Heamturia, oliguria, anuria Flank pain Uretral spasm or colic Increased turbididty & odour urine Bladder distension, diaphoresis, pale ashen skin
INT: 1. Drug therapy: opiods, NSAIDS ex. Ketorolac, spasmolytic agents ex. Oxybutylnin chloride 2. Asses response drug therapy 3. Encourage ambulation & upright position to drain renal calyx & pass renal calculi 4. Assis pt comfortable position & use relaxation techniques 5. Lithotripsy or extracorporeal shock wave lithotripsy 6. Surgery: Stone removal via nephrolithotomy: post op- assess urine q 1-2hrs for 24hrs, strain pts urine, monitor for infection: obtain C&S, administer antibiotics, ensure nurtition& fluids 7. Administer drug therapy & assess adverse rx: broad spectrum antibiotics ex. Aminoglycosised & cephalosporines, acetohydroxamic acid (Lithostat) & hydroxyurea (hydrea) for those w/ struvite stones, thiazide diuretics tx hypercalciuria, allopuinol(Zyloprim)-tx hyperoxaluria or gout, alpha-mercaptopropionyl glycine (AMPG) & captopril (capotea) tx cystinure.
Bladder cancer- malignant tumours of the urotheluim in the kidney, renal pelvis, ureters, urinary bladder, & urethra (arise form transitional cells) Cause: Tobacco use, exposure chemicals, Schistosoma haematobium infection, excessive use drugs containing phenacetin, long-term use cyclophosphamide (lytoxan, procytox) s/s: 1. Gross, painless hematurea (RBC, WBC) 2. Bladder irritability w. Dysuria, frequency & urgency 3. Oliguria 4. Sp.gr=1.010, osmolality 300,Osm/KG 5. Fluid retention- distended neck veins, bounding pulse, edema, HTN, metabolic acidosis, altered K+, Na+, anemia, Ca2+ deficiency, neurologic changes 6. +ive cytoscopy & biopsy
INT: Non-surgical: 1. Prophylactic immunotherapy w/ intravesical instillation of bacille calmette guerin (BCG) to prevent recurrance of superficial bladder cancers 2. Multiagent chemotherapy 3. Radiation therapy Surgical: 1. Transurethral resection of bladder tumor or partial cystectomy 2. Complete cystectomy w/ ureter diversion into an ileal conduite (internal pouch), continent pouch, bladder reconstructed- neopbladder (constructed from bowel) & ureterosigmoidostomy- ureters placed in constructed segment sigmoid colon. *ureterostomy- ureters placed on skin surface as one /two stomas that drain urine into an external pouching system 3. Pre-op care 4. Post-op care: check UOP, assess wound & drainage, irrigation & intermittent catheterization of neobladder, teach pt cues to void that have neobladder,
Acute renal failureCause: 1. Pre-renal azotremia 2. Post renal obstruction 3. Intrarenal acute failure s/s: 1. Altered UOP (oliguria, anuria, polyuria) 2. HTN/hypotension 3. Tachypnea 4. s/ sfluid overload or dehydration 5. Uranalysis: pre-renal azotemia >900mOsm/Kg, post-renal =N, intra-renal failure <250mOsm/Kg 6. Urine sodium: pre-renal azotemia <20meq/L, postb=obstruction=N, intra-renal failure>27meq/L 7. Blood analysis: Increased BUN, serum creatinine K+, decreased pH, bicarb, Hb, HCT
INT: goal eliminate cause, tx s/s 1. Administer prescribed meds 2. Manage underlying problem 3. Monitor K+, restrict dietary K+, monitor heart, prepare administer insulin & glucose (drives K+ back into cell) 4. Assess fluid balance, restrict intake to 24hr output plus 500mL 5. Monitor for acidosis, administer alkalinizing agents, monitor ABG, prepare institute vent measures 6. Prevent infection: assess infection, do not leave catheter in place, admin. Prophylactic antibiotics, monitor: hyperphosphatemia, serum phosphate levels , admin phosphate binding agent 7. Instruct client restrict Na+ intake, drink fluids & follow low phosphate diet 8. Monitor hypercalcemia, admin Ca2+ suppliments, 9. Prevent GI bleed by administering histamine receptor antagonist & proton pump inhibitor 10. Promote comfort & bed rest 11. Provide high cal, low protein diet 12. If indicated prepare for dialysis to correct hyperkalemia, fluid overload, acidosis, or severe, uremia
INT: 1. Administer meds Chronic renal failure2. Maintain strict fluid control, I/O, daily result of irreversible loss of weights, encourage high calorie, low protein diet w/ low sodium, potassium, fxnal renal tissue activity & rest s/s: 1. decreased renal reserve, 3. Peritoneal dialysis if indicated- monitor renal insufficiency-polyuria, s/s peritonitis nocturia, s/s mild anemia 2. Endstage: edema, HF, e-lyte 4. Prepare hemodyalysis if indicatedimbalance, HTN, provide shunt care, assess complications tamponade, pericarditis, effusion, arrythmias, (bleeding, hypovolemia, hypotension, anorexia, N&V, stomatitis, dialysis, disequillibrium sydromeuremic halitosis, gastritis & bleeding, diarrhea, headache, confusion, seizures. constipation, pallor, 5. Prepare client transport- provide post-op jaundice, dryness, confusion, uremic frost, drowsiness, care, monitor s/s complications ex. Graft confusion, coma tremors, rejection, increased WBC, e-lyte twitching disturbance, abn renogram & infection stemming from immunosupressive LabsDx: anemia, increased BUN & therapy creatinine, P3+, decreased 6. Provide referral Ca2+, serum protein, pH
Prosthetic hypertrophy- enlarged prostate resulting in increased # epithilial cells & stromal tissue, causes bladder outlet obstruction, aging & endocrine changes
s/s:
1.
Urinary retention, difficulty voiding, dribbling @ end urination, urinary frequency, urgency, dysuria, bladder pain, nocturia, incontinence
Those decrease dihydrotestosterone (DHT) levels: finasteride (Proscar), utasteride (Avodart) Alpha-blocking agent that decrease urethral pressure & improve flow: Tamsulosin (Flomex), Alfuzosin (Uroxatral), Doxazosin (cardura), Terazosin (Hytrin)
3. 4. 5.
Labs/Dx: Physical exam- digital rectal exam (DRE) for prostate size, symmetry & consistency Urinalysis w/ C&S Post-void residual urine volume to assess degree of urine flow obstruction Prosthetic specific antigen (PSA) to rule our cancer RBC & WBC in urine
6. 7.
Release prostetic fluide w/ frequent sex Teach avoid bladder distension: avoid drinking large amts fluid, alcohol, diuretics & caffine, void as soon as possible, avoid drugs causing retention Minimally invasice-techniques: transurethral neddle abilation to shrink prostate (TUNA), transurethral microwave therapy (TUMT) to destroy excess tissue, interstitial laza coagulation, placement prostetic stent into urethra Surgery: transurethral transection of prostate (TURP) cuts prostate into pcs & removes via urethra Holmium laser enucleation of prostate (HoLEP) & transurethral ultrasound guided laser incision of the prostate (TULIP)
obstruction monitor UOP Instruct increase fluids Observe complications TURD Teach pt that sexual fxn should not be affected after TURP but that retrograde ejaculation is possible
2.
Dysuria hesitancy, dribbling, frequency, urgency, hematuriasm nocturia, retention Pain lumbosacral area radiating down hips or leg
Lab & DX: 1. Digital rectal exam (DRE) 2. Increase levels comlexed prostatespecific antigen (cPSA>3.4ng/mL 3. Icnrease serum acid phosphtase 4. Transrectal ultrasound (TRUS) of prostate 5. Prostate tissue biopsy 6. Lymph node biopsy 7. CT & MRI
INT: 1. Watchful waitin w/ PSA & DREs to monitor progress 2. Surgery for those w/ stage AB: radical prostectomy- TURP to promote urination, bilateral orchiectomy(removal testicles) to slow spread cancer by removing source testosterone, laparoscopic radical prostatectomy (LRP) for those w/ PSA<10ng/mL, tranditional open radical prostatectomy
Pre-op care: teach about location incision, indwelling catheter, placement drains, & poss temporary erectile dysfxn, encourage express fears, reinforce surgeons explanation
4.
Post-op care:-encourage use PCA as needed, assist getting out of bed & in chair night surgery & ambulate next day, use compression stockings till ambulate, monitor DVT & PE, I/O, clean urinary meatus, avoid rectal procedures or tx, teach how use leg bag, teach not strain during bowel movement, external & internal radiation therapy, hormone therapy, chemotherapy, cryotherapy
s/s: 1. HTN 2. Paroxysmal nocturnal dyspnea, dyspnea on exertion, orthopnea 3. Wheezing & crackles 4. hypoxia, resp. Acidosis 5. Cough w/ pink frothy sputum, pulmonary edema 6. S3/4 heart sounds 7. Palpitations 8. Dysrhythmias
s/s: Weakness, fatigue, synchope Hepatomegaly, splenomegaly Ascites depedent pitting edema Jugular vein distention Hepatojugular reflex Oligura Dysrhythmias Elevate central venous/right atrial pressure 10. Nausia, vomiting, anorexia, abdominal distension 11. Weight gain
1. 2. 3. 4. 5. 6. 7. 8. 9.
9.
Diet therapy O2, bed rest, semifowlers Assessemntscardiovascular, VS Foley catheter Morphine Diuretics: Lasix Cardiac glycosieds: Digoxin Cardiac stimulants: dopamine (Intropin), dobutamine (Dobutrex) Nitrates vasodilators
10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
Fluid restriction Diet theapy teaching Daily weights Medication administration, teaching Measure abdominal girths Assess peripheral edema Cardiovasculare assessments CVP readings Rest periods Monitor e-lytes, I/O Skin care
Dyspnea Crackles Pink frothy sputum Tachycardia Anxiety, aggitation Diaphoresis Cold, clamy skin Chest pain
TX: 1. Diuretics 2. Vasodilators 3. Cardiac stimulantsdopamine, dobutamine 4. Nitrates 5. May be intubated 6. Bed rest 7. Cronchodilators: aminophylline 8. Nsg care
Types: external temporary- surgery, emerg situations, control dysrhythmias, perminant- conduction system problems INT: 1. Cardiac monitor 2. Monitor s/s infection 3. Education:
Take pulse Send rhythm strip Avoid contact sports Wear medic alert braclet Carry info on pacemaker Safety measures s/s malfxn
INT:
Drug therapy: Lidocaine, pronestyl Potassium suppAntogoags- aspirin, heparin Nitrates- IV notroglycerin B-blockers-lopressor Morphine Pharmacologic INT Angina & MI: 1. Nitrates: NTG, NTG ointment, transder, nitrodur, isordil 2. B-blocker: inderol, corgard 3. Ca2+ channel blockers: procardia, calan, cardizem 4. Antianxiety: ativan, xanax 5. Anagesics: morphine 6. Antihyperlipidemics: lipitor, mevacor, zocar report jaundice, dark urine, RUQ tenderness, fatigue 7. Surgery: Laser angioplasty, PTCA
1. 2. 3. 4. 5. 6.
Cardiac drugs
Vasodilators: 1. Decrease preload, afterload, workload of heart 2. Vasodilate coronary arteries and indirectly peripheral vasodilation S.E: headache, hypotension Ca2+ channel blockers: 1. Vasodilation coronary & systemic 2. Slows HR 3. Decrease heart demand O2, afterload, BP S.E: hypotension, bradycardia
Cardiac drugs
B-Blockers: 1. Decrease contractility, HR, BP, heart demad O2 S.E: bradycardia, hypotension, wheezing, depression, sexual dysfxn Ca2+ channel blockers: 1. Vasodilation coronary & systemic 2. Slows HR 3. Decrease heart demand O2, afterload, BP S.E: hypotension, bradycardia
Vague sensation, feeling strange Choking, squeezing, suffocating sensation Pain down arms, neck, back Pain relieved by rest or cessation of activity, NTG admin
Inflow obstructions involve distal end aorta, common internal and external iliac arteries Outflow obstructions involve femoral, popliteal & tibial arteries
s/s:
1. 6 Ps: pain, pallor, poulselessness, paresthesia,
poikiliothermia, paralysis Tx: anticoags, throbectomy, TPA, steptakinas, monitor for hemorrhage
4. 5. 6.
Bedrest, elevate extremity (until thrombus stable) War, moist heat anticoag therapy: heparin, monitor PTT (have protamine sulfate availe), LMWH (enoxapprin lovenox admin SQ), coumadinonset 4872hrs, keep VitK on handNSG: bleeding precautions, SQ technique (no IM), give same time each day, S.E, teach importance blood draws, avoide Vit. K rich foods, med alert bracelt) Elastic stockings analgesics thrombectomy
Raynauds Phenomenon- arterial spasm feet & hands, assoc. Lupus & rheumatoid arthrisits
s/s:
1. 2.
3.
Pallor, cyanosis, hyperthermia (white, blue, red) Coldness & numbing, throbbing, aching pain, tingling swelling Pulse never lost Warm clothing Stop smoking Vasodilators, ca2+ channel blockers, sm. Relaxants Decrease stress Protect form cold
Tx: 1. 2. 3. 4. 5.