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81 Cards in this Set

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Acute appendicitis (fever, tachy, hypotension) what complication occurs
it can eventually rupture the infection from a ruptured appendix may lead to an abscess or peritonitis, and abcess. Perforation generally occurs 24 hours after the onset of pain. Symptoms include a fever of 100 F/ 37.7C or higher, a toxic appearance, and continued abdominal pain or tenderness.
What happens if not treated
Chronic constipation, what can happen?
hypertension
hemmorrhoids
fissures
megacolon
fecal impaction
5 things
Initial treatment plan for a pt. with acute pancreatitis
fluid, colloid and electrolyte replacement is the major focus of medical management
NG tube
H2 blocking and antiemetic medications may also be helpful.
Pain with cholelithiasis; location
right upper quadrant pain that radiates to the back or shoulder, indigestion, nausea, or fullness, particularly following a meal
Where and when?
Small bowel obstruction and treatments
crampy pain that is wavelike and colicky. No stool. Vommiting possibly of fecal matter, abd tenderness
tx decompression of the bowel by NG tube. Occasionally surgery to repair adhesions and hernia
what is the pain feel like and what to look for. What will the dr order?
Characteristic of coffee ground emesis
This is bloody emesis that looks like coffee grounds because of the stomach acid.
What does it look like coffee grounds and why?
What is a spinal cord injury
Spinal cord injury refers to damage to the spinal cord due to contusion, laceration, compression or transection. Damage may occur as a result of primary injury to the spinal cord or as a result of swelling.
What are the clinical manifistations of a spinal cord injury
Clinical manifestations depend on the level at which the injury occurred and the extent of the damage to the spinal cord. In incomplete spinal cord injuries, there are variable degrees of motor or sensory function that may be preserved. In complete spinal cord injury, all motor and sensory function is permanently lost, and changes in bowel and bladder function and loss of vascular tone (vasodilation) occur. Paraplegia indicates that the injury affects the lower extremities and possibly the trunk. Quadriplegia means that the injury affects the lower extremities as well as all or part of the upper extremities. Respiratory function may also be affected if the injury is above the level of the diaphragm (C4) and/or the intercostals muscles (T1 to T11). Recovery of neurological function depends on the degree of damage to the spinal cord.
How are spinal cord injuries diagnosed
diagnosed using careful neurologic examination, CT scan, and x-ray. MRI may also be helpful in diagnosing ligamentous injury.
How are spinal cord injuries managed
Whenever the mechanism of injury could have caused a spinal injury, precautions are always taken to prevent further injury, even when function is apparently intact (e.g. immobilization of the spine using a cervical collar and/or backboard). Emergency management also includes ventilatory support, management of shock, high doses of methylprednisolone to prevent further spinal cord damage from swelling, skeletal traction (halo brace or tongs), and surgical stabilization of the vertebral column
Goal for pt with spinal cord injury
Goals for the patient with include promoting breathing and airway clearance, optimizing mobility and self-care, promoting adaptation to motor and sensory impairment, maintaining skin integrity, maintaining bowel and bladder elimination, and providing comfort measures.
Complications of spinal cord injury
Spinal shock - loss of reflexes & flaccid paralysis below the level of injury
Neurogenic shock - loss of vasomotor tone below the level of injury, causing vasodilation
Pressure ulcers
Urinary tract infection
Respiratory tract infection
Impaired temperature regulation (poikilothermia)
Deep vein thrombosis and pulmonary embolism
Paralytic Ileus and peptic ulcer
Autonomic dysreflexia - noxious stimuli below the level of injury causes hypertension (can be severe), pounding headache, goosebumps, nasal congestion
autoimmune destruction of myelin
MS. autoimmune disorder that causes progressive demyelination of the nerves in the brain and spinal cord. Plaques replace the myelin and further hinder the transmission of impulses. This may occur anywhere in the central nervous system. Eventually, the axon itself is damaged and damage is irreversible. The exact cause or trigger is still unknown.
Diverticulitis
refers to sac-like pouches that form in the lining of the bowel. This can occur due to years of straining to have bowel movements (because of low fiber diet). Develops when diverticulum become inflamed and infected. This can occur as a result of stool and bacteria becoming trapped in the diverticula. Diverticulitis can sometimes lead to abscesses and/or peritonitis.
Lab values with diverticultitis
High wbc count
Myasthenia gravis
is an autoimmune disease that affects the neuromuscular junction. It occurs when the body's own antibodies block the transmission of the neurotransmitter acetylcholine.
Myasthenia gravis s/s
characterized by weakness, usually beginning with the muscles of the eyes. Double vision (diplopia) or drooping eyelids may occur. It may also affect speech, facial expression, or swallowing. may eventually affect respiratory and overall muscle functioning.
How is myasthenia gravis dx?
diagnosed using anticholinesterase testing. In this test, Tensilon is injected slowly. If muscle weakness immediately improves, the test is positive.
Treatment of myasthenia gravis
Treatment of involves removing circulating antibodies and improving function. This involves the administration of antichilonesterase agents, plasmapheresis, immunosuppressive therapy and removal of the thymus gland.
Caring for a patient with amyotrophic lateral sclerosis (ALS)
There is no cure or treatment. Management is aimed at optimizing functioning and improving quality of life. Riluzole has been shown to prolong the life of patients. Antispasticity medications may improve spasticity. Other measures that may be used include assistance with ventilation and percutaneous enteral feeding. Decisions about care are made with consideration of prognosis and quality of life.
S/S of ischemic stroke
Confusion or change in mental status
Cognitive changes - memory losses, impaired attention, judgment, etc.
Emotional changes - depression, emotional lability, anger, etc.
Hemiplegia - paralysis on one side of the body
Hemiparesis - weakness on one side of the body
Dysarthria - difficulty speaking
Dysphagia - difficulty swallowing
Paresthesia - numbness or tingling on one side of the body
Homonymous hemianopsia - loss of half of the visual field in each eye
Receptive or expressive aphasia - difficulty with understanding or expressing speech/language
What is ICP?
The brain is located in the cranium, an enclosed space with little room for expansion. Intracranial pressure (ICP) is the pressure exerted on the brain by three components: the brain, cerebrospinal fluid, and the blood supply. Increased intracranial pressure (IICP) occurs when there is an increase in any of these components
s/s of increased icp?
headache, nausea, vomiting, and altered level of consciousness. As ICP increases further, alterations in breathing pattern, changes in papillary dilation, and changes in vital signs can occur.
Causes of increased icp?
Swelling due to head injury
Bleeding due to head injury, rupture of aneurysm, or cerebrovascular accident
Intracranial tumors
Hydrocephalus
Meningitis
Encephalitis
Status epilepticus
What is Bell's Palsy?
a unilateral facial weakness or paralysis due to inflammation of the seventh cranial nerve (facial nerve). The patient may also experience pain, increased tearing, and difficulty eating and/or speaking.
Treatment of Bell's Palsy?
Most patients recover spontaneously in three to five weeks. Analgesics and anti-inflammatory medications may be used to decrease inflammation and pain
DI Diabetes Insipidus
is a disorder of the posterior pituitary gland that causes a deficiency in antidiuretic hormone (vasopressin). It could also occur with meningitis, encephalitis, TB, tumors, head injury, or failure of the kidneys to respond to ADH.
Manifistations of DI
nclude copious amounts of very dilute urine production, with a low specific gravity (1.001-1.005), and drastically increased thirst. Limiting fluids leads to severe dehydration and hypernatremia.
How is DI dx?
diagnosed using a fluid deprivation test. Inability to increase osmolality and urine specific gravity is diagnostic of DI. Plasma levels of ADH, urine osmolality, and vasopressin trial may also be helpful. Other tests are also performed to identify the underlying cause.
Management of DI
Management involves replacement of ADH, fluid replacement, and correction of the underlying cause. Desmopressin (DDAVP), or synthetic vasopressin, is administered. Careful monitoring for signs and symptoms of dehydration is essential.
Cushing's syndrome
refers to elevated corticosteroid levels. It may be caused by excessive administration of corticosteroid medications, tumor, or overproduction by the adrenal cortex.
Clinical manifestations of Cushing's sydrome
obesity, hypertension, "moon face," "buffalo hump," thin arms and legs, thin skin, ecchymosis, hypertension, hyperglycemia, and hypokalemia.
Dx of Cushing's syndrome
Dexamethasone and cortisol suppression tests and measurement of ACTH by radioimmunoassay.
T, ultrasound, or MRI may be helpful in identification of a tumor.
Tx Cushing's syndrome
transsphenoidal hypophysectomy (surgical removal of the pituitary gland) or adrenalectomy, depending on the primary cause. Once the adrenal or pituitary gland is removed, lifelong replacement of corticosteroids is required. Reduction of administration of corticosteroids may be indicated, when possible to treat the underlying disease.
What is a risk of withdrawing steroids to quickly?
Addisonian crisis
Nursing interventions with Cushing's Syndrome
decreasing risk of injury and infection, encouraging rest and activity, promoting skin integrity, promoting positive body image and thought processes, and managing complications
Hyperparathyroidism
an overproduction of parathormone in the parathyroid glands.
Hyperparathyroidism results in high serum calcium levels and low phosphate levels.
s/s of hyperparathyroidism
include signs and symptoms of bone demineralization (osteoporosis, fractures) or renal calculi
DX of Hyperparathyroidism
Diagnosis is made by persistently elevated levels of calcium and parathormone. Skeletal x-rays and biopsies are also helpful.
tx of Hyperparathyroidism
hydration therapy, increasing mobility to decrease bone loss, dietary modifications, and medications.
Trigeminal neuralgia
abrupt onset and subsiding of pain in the areas innervated by the fifth cranial nerve (trigeminal nerve). It is generally described as shooting or stabbing pain or muscle contraction on one side of the face near the mouth or eye. It is most commonly seen in patients with MS. Pain and spasms can be triggered by stimulating the nerve with activities such as washing the face or brushing the teeth.
tx of Trigeminal neuralgia
Antiseizure medications are effective in relieving pain in most patients. Surgery may be indicated when medications fail to control the pain.
Parkinson's disease
degenerative neurological disorder associated with decreased levels of the neurotransmitter dopamine. The loss of dopamine is associated with increased excitatory function of the muscles. The cause is unknown, but may be related to trauma, atherosclerosis, genetics, medications, environmental toxins, or free radical damage.
Symptoms of Parkinson's disease
Symptoms usually develop slowly and begin over the age of fifty. Major signs include resting tremors, rigidity (stiffness), and bradykinesia (slow movements). The patient may also develop a shuffling gait; soft, slurred speech; forward stooping posture; diaphoresis; flushing; hypotension; depression; dementia; and other mental changes as the disease progresses.
tx of Parkinson's disease
Since there is no cure, treatment is aimed at symptom management. Levodopa is considered the standard treatment, but is not begun until significant symptoms occur due to adverse effects. Levodopa is converted to dopamine and relieves symptoms. However, over time, it becomes less effective and adverse effects become more severe. Levodopa is given in combination with carbidopa. Over time, tardive dyskinesia (involuntary movements) develops. Anticholinergic medication, antiviral medications, dopamine agonists, MAO inhibitors, COMT inhibitors, antidepressants, and antihistamines may also be used. Surgery may be helpful in some cases. Planning for patients with disease focuses on improving function and self-care, maintaining bowel and bladder elimination, enhancing swallowing, improving communication and use of assistive devices, and supporting coping and family processes.
dx of Parkinson's disease
There is no definitive test Diagnosis is made by history and the presence of symptoms.
Hemoglobin A1C
Hemoglobin A1C (glycosylated hemoglobin) - used to evaluate blood glucose control over the previous 8-12 weeks.
A long term measure of glucose control that is a result of glucose attaching to hemoglobin for the life of the red blood cell (120 days). The goal of diabetes therapy is a normal to near normal level of glycosylated hemoglobin, the same as in the nondiabetic population.
Nursing Interventions for patients with Endocrine disorders
Monitor VS, O2 saturation, and lab studies.
Maintain fluid and electrolyte balance.
Improve nutritional intake.
Reduce anxiety.
Improve self-care.
Ensure safety.
Manage and prevent complications.
Encourage patient to express feelings.
Patient and family education
Disease process & management
Stress management
Exercise and food management
Blood glucose monitoring and insulin/oral agent administration
Sick day protocol
Recognition of complications
Assessment and management of complications
Potential Nursing Diagnoses for patients with Endocrine disorders
Altered Nutrition
Fluid and electrolyte imbalance
Altered skin integrity
Body image disturbance
Activity intolerance
Altered cardiac output
Ineffective management of therapeutic regimen
Syndrome of Inappropriate Antidiuretic Hormone
Syndrome of Inappropriate Antidiuretic Hormone (SIADH) is caused by excessive ADH secretion form the pituitary gland. This may also develop in patients with bronchogenic cancer, pneumonia, pneumothorax, and other disorders of the lungs, head injury, brain tumor, or infection.
s/s Syndrome of Inappropriate Antidiuretic Hormone
Patients retain fluids and develop dilutional hyponatremia.
dx of Syndrome of Inappropriate Antidiuretic Hormone
sodium levels and correlating with a causative factor.
management of Syndrome of Inappropriate Antidiuretic Hormone
Management involves identification and treatment of the underlying cause, fluid restriction, and diuretic therapy. Careful monitoring for signs and symptoms of fluid volume overload and neurological assessment (because of hyponatremia) are essential
Addison’s disease
insufficiency of hormones from the adrenal cortex. It is often autoimmune or idiopathic. Administration of corticoids can also cause the adrenals to decrease production.
Clinical manifestations of Addison’s disease
Clinical manifestations include weakness, anorexia, pigmentation (bronzing) of the skin, hypoglycemia, hyperkalemia, emotional lability, depression, leukocytosis (elevated WBC's) and confusion. Hypernatremia and dehydration may also be present.
Addisonian Crisis
inability of the body to respond to stress.
Dx of Addisonian crisis
Diagnosis is confirmed by decreased levels of adrenocortical hormones and decreased cortisol levels.
management of Addisonian crisis
Management is aimed at managing and correcting circulatory shock -administering intravenous fluids, positioning the client with the head down and legs elevated and replacing corticosteroids. Lifelong replacement of corticosteroids may be necessary if the adrenal cortex does not regain function. Additional doses of corticosteroids may be necessary prior to stressful events or procedures.
s/s of addisonian crisis
characterized by acute hypotension and shock, nausea, abdominal pain, headache and confusion.
Hyperglyecemichyperosmolar nonketotis syndrome
similar to DKA, except there is enough insulin to prevent the breakdown of fat and cause ketoacidosis. Therefore, onset may be slower, allowing for higher blood glucose levels and more profound dehydration.
s/s of
Hyperglyecemichyperosmolar nonketotis syndrome
Hypotension
Profound dehydration
Tachycardia
Neurological changes
management of Hyperglyecemichyperosmolar nonketotis syndrome
Intravenous insulin administration
Intravenous fluids
Correction of electrolyte imbalance
Correction of acidosis
Careful patient monitoring (these patients are usually managed in the ICU setting)
Diabetic ketoacidosis (DKA)
caused by an absence of insulin, causing hyperglycemia, severe dehydration, electrolyte imbalance and acidosis
Management of Diabetic ketoacidosis (DKA)
Intravenous insulin administration
Intravenous fluids
Correction of electrolyte imbalance
Correction of acidosis
Careful patient monitoring (these patients are usually managed in the ICU setting)
patho of Diabetic ketoacidosis
Blood glucose levels may vary from 300 to 800mg/dL, or higher. Without insulin, glucose cannot move into the cells. The cells then direct the liver to break down glycogen, leading to further increase in blood sugar levels. Glucose in the urine causes increased urine output (osmotic diuresis), leading to dehydration and electrolyte imbalance. In addition, the breakdown of fats leads to the formation of ketone bodies, causing metabolic acidosis.
Diabetes mellitus
disease that results in hyperglycemia due to defects in secretion of insulin (pancreatic hormone produced in the beta cells that controls blood sugar).
Type I diabetes
pancreatic beta cells are destroyed by an autoimmune process and produce little or no insulin. usually has an acute onset.
Type II diabetes
patients demonstrate resistance to insulin and decreased insulin production. Onset is slower and usually develops in older, obese clients.
subtotal thyroidectomy
The surgical removal of about five sixths of the thyroid tissue practically ensures a prolonged remission in most patients with exophthalmic goiter. Its use today is reserved for large goiter, presence of obstructive symptoms, pregnant women, or when there is a need for rapid normalization of thyroid function. (page 1224)
Post surgical care of subtotal thyroidectomy
in addition to routine post-operative nursing care, post-surgical care following a thyroidectomy includes careful assessment of the back of the neck as well as the dressings for bleeding, respiratory depression and airway obstruction from swelling and pain.
ototoxicity and medications involved
Diuretics, chemotherapeutic agents, antimalarial agents, anti-inflammatory agents, chemicals, aminoglycoside antibiotics, other antibiotics, metals. (page 1812)
Meniere’s disease and hearing loss?
It is a condition of the inner ear characterized by a triad of symptoms: episodic vertigo, tinnitus, and fluctuating sensorineural hearing loss.
involuntary rhythmic eye movement?
Nystagmus: Involuntary oscillation/rhythmic movement of the eyeball. Nystagmus (uncontrollable eye movements) can be noted in a patient during a severe Meniere's attack due to the whirling, dizzy sensation of vertigo.
cataracts
Most commonly related to the aging process, cataracts are a clouding of the lens that results in a blurring of normal vision. It is known that certain diseases such as diabetes and prolonged exposure to sunlight (ultraviolet light) can contribute to cataract formation.
macular degeneration
common cause of vision loss in individuals over the age of 60. May lead to blindness, but most commonly various degrees of central vision loss occur.
detached retina
separation of the retina from the back of the eye. This separation deprives the outer retina from oxygen and nutrients and disrupts communication from the retinal pigment epithelium to the photoreceptors of the eye.
s/s of detached retina
A sudden onset of "floaters" or light flashes may be the first symptoms an individual experiences. A dark curtain or shadow noted in the vision of one eye can also be a manifestation of retinal detachment. Patients do not complain of pain.
Nursing diagnosis for cataract surgery
Visual disturbances or other alterations in visual acuity affect many other aspects of functioning. Your nursing diagnoses should reflect your patient's individual needs. Almost universally, a diagnosis of "risk for injury" should be addressed if the patient is experiencing a non-corrected visual impairment. Clients with newly acquired visual problems may experience psychological distress or social isolation related to their impairment.
detached retina
is a separation of the retina from the back of the eye. This separation deprives the outer retina from oxygen and nutrients and disrupts communication from the retinal pigment epithelium to the photoreceptors of the eye.
s/s of detached retina
A sudden onset of "floaters" or light flashes may be the first symptoms an individual experiences. A dark curtain or shadow noted in the vision of one eye can also be a manifestation of retinal detachment. Patients do not complain of pain.
Nursing diagnosis for cataract surgery
Visual disturbances or other alterations in visual acuity affect many other aspects of functioning. Your nursing diagnoses should reflect your patient's individual needs. Almost universally, a diagnosis of "risk for injury" should be addressed if the patient is experiencing a non-corrected visual impairment. Clients with newly acquired visual problems may experience psychological distress or social isolation related to their impairment.