Nursing 4 Final Review

Coronary Artery Disease/ACS:

Pathophysiology/Etiology: Deposits of CHOLESTEROL & LIPIDS within the intimal wall of
the artery.
~ CAD may be asymptomatic, or it may lead to angina pectoris, acute coronary
syndrome, MI, heart attack, dysrhythmias, heart failure, and even sudden death.
1. Identify risk factors & know difference between modifiable and nonmodifiable factors.
o Non-modifiable:
o Modifiable:
Age
Increased Serum Lipids
Gender
Hypertension
Ethnicity
Cigarette Smoking
Genetics
Obesity
Physical Activity
Diabetes Mellitus
Stress
2. Explain and be able to teach clients how to decrease risk factors.
Hypertension:
o Regular BP checkups
o Adequate BP medications
o Reduce salt intake
o Stop smoking
o Control/Reduce weight
o Exercise Regularly
Elevated Serum Lipids:
o Reduce total fat intake (especially animal fat)
o Maintain ideal body weight
o Exercise program
o Increase complex carbohydrates and vegetable protein in their diet
Stressful Lifestyle:
o Make your patient aware of problem
o Plan your day and life in general to reduce stressful situations.
o Realistic goals
o Prioritize
o Cope with stress
o Take a BREAK
o REST & SLEEP
Diabetes Mellitus:
o Follow recommended diet
o Reduce weight and control diet
o Monitor blood sugar levels
regularly and maintain adequate level.
Smoking:
o STOP smoking
o Change daily routines to stop smoking

o Find support systems to help you stop smoking

Physical Inactivity:
o Develop a routine that involves physical activity 3-4 times per week.
o Increase activities to a fitness level
3. Compare and contrast complications of CAD, their treatment which
includes
Angina Pectoris: chest pain resulting from reduced coronary blood flow
which causes a temporary imbalance between myocardial blood supply
and demand.
o Stable: Chest pain that subsides when the precipitation factor is
relieved.
Treatment: REST of Nitroglycerin
o Prinzmetals: Spasm of a major coronary artery.
Treatment: Calcium Channel Blockers
o Unstable: Occurs with increasing frequency (severity & duration)
Acute Coronary Syndrome: a condition of unstable cardiac ischemia.
ACS includes unstable angina & acute MI.
o Blood flow acutely reduced but no full occlusion of the coronary
artery
o Can involve more than one artery
Sudden Cardiac Death
Coronary Artery Disease:
o Medications
o Diagnostic testing
Cholesterol medications
H&P
Aspirin
ECG
Nitroglycerin
Cardiac Enzymes
Beta Blockers
Serum Lipids
Ace Inhibitor/Angiotensin Receptor Blockers
CBC/ABGs
Calcium Channel Blockers
C-Reactive Protein
Statins
Exercise Stress Test
Bile, Nicotinic, & Fibric Acid
Coronary Angiogram
o Treatment
Percutaneous coronary revascularization (PCR)
Stent replacement
CABG
o Nursing interventions
PREVENTION
Identify risk factors (health history, physical exam) after pt is
stabilized
Hemodynamic Monitoring
Continual ECG monitoring
IV therapy
Oxygen Therapy
Nitroglycerine
Morphine

E.

ASA
Beta Blockers
ACE Inhibitors
Patient Goals
Experience relief of pain
Have no progression of MI
Receive immediate and appropriate treatment
Cope effectively with associated anxiety
Cooperate with the rehabilitation plan
Modify or alter risk factors

4.

Nursing assessment for a patient with chest pain/angina?

P Precipitating Events (What were you doing prior to the pain?)
Q Quality of pain or discomfort (Describe the pain)
R Radiation of pain (Point with one finger where it hurts)
S Severity of pain (On a scale of 1-10 with 10 being the most severe
pain youve had, how would you rate your pain?)
T Timing (When did the pain begin?)
~ Medications for angina:
Nitrates
Beta Blockers
Calcium channel blockers
~ Complications of Angina:
Myocardial Infarction
Acute MI: Complete blockage = prolonged ischemia followed by
death of tissue

Acute Myocardial Infarction:

Angina (ischemia to cardiac cells)

Myocardial Infarction results from sustained ischemia

Irreversible cellular death

~ Medications for Acute MI:
ASA
o By ER personnel
Analgesics
o MS
Fibrinolytics
o Within the first 6 hours (Streptokinase)
Antidysrhythmics
o Atropine for bradycardia
o Verapimil for A-fib
~ Initial Treatment (MONA-B):

Morphine
Oxygen
Nitroglycerine
ASA (aspirin)
Beta Blocker

Heart Failure:

1. Pathophysiology
Inability of the ventricles to fill
o Preload- volume just before contraction
Inability of the heart to pump blood
o Afterload- force needed to eject blood into circulation
2. Risk Factors
*** CAD
***Advanced age
HTN

Diabetes
Smoking
Obesity
High Cholesterol

3. Causes of Heart Failure

Chronic Causes:
o CAD
o HTN
Causes of HF:
o RHF
o CHF
#1- Ischemia
o Cor pulmonale
o Valvular Disorders
#2o Anemia (causes a lack of O2 transport)
Cardiomyopathy
o Cardiomyopathy (muscle damage,
enlarged & weakened heart
o Bacterial Endocarditis (caused by IV drug use common in younger
patients
Acute Causes:
o MI
o Dysrhythmias
o PE
o Thyrotoxicosis (thyroid problem)
o Hypertensive crisis
o Rupture of papillary muscle
o Ventricular septal defect
o Myocarditis
4. Compensatory Mechanisms (Purpose is to try and maintain cardiac output (CO))
Frank-Startling Mechanism
o The greater the stretch the greater the force of contraction (increased CO),
until the heart gets stretched too much. The heart weakens, decreasing
CO, triggering the SNS.

Neuro-endocrine responses (least effective system)

o Increase SNS activation causes an increase of epinephrine and nor
epinephrine. Causing an increase in HR and a decrease in kidney perfusion

Myocardia (ventricular hypertrophy)

o Increase in cardiac workload causes the myocardial muscle to hypertrophy
and ventricles to dilate.
o Hypertrophy occurs when the heart has been stretched too much.
Thickening of the septal wall occur, occasionally resulting in conduction
problems. Surgery is done to try and thin the septal wall.

***Decreased renal perfusion = decreased urine output***

Cardiac Compensation: occurs when the mechanisms succeed in maintaining

an adequate CO that is needed for tissue perfusion.
Decompensation: Occurs when these mechanisms can no longer maintain
adequate CO and inadequate tissues perfusion results
Dilation: Enlargement of the chambers of the heart

4.

Systolic Failure
Ventricular (impaired contraction)
Due to:
o Cardiomyopathy, - dilating/weakening
o Ischemia lack of O2
o Infarction death due to ischemia
o Inflammation

5.

Diastolic Failure
Impaired ability of the ventricle to relax and fill
Due to:
o Ventricular hypertrophy
o Impaired relaxation of cardiac muscle
o Dysrhythmias

6.

Left Sided Heart Failure

Caused by CAD & HTN
Manifestations:
o PULMONARY Edema
o Nocturia
o Weight Changes
o Paroxysmal Nocturnal Dyspnea
o Activity intolerance, fatigue
o Dizziness, syncope
o If there is pulmonary congestion:
Dyspnea, SOB, cough, orthopnea, cyanosis

7.

Right Sided Heart Failure

Caused by conditions that restrict blood flow to the lungs (Acute/Chronic

pulmonary disease)
Manifestations:
o PERIPHERAL Edema in the feet/legs/sacrum
o Nocturia
o Weight Changes
o Paroxysmal Nocturnal Dyspnea
o GI congestion
Decreased appetite
Anorexia/Nausea
o Right upper quadrant pain from hepatomegaly
Liver/spleen congestion & swelling causing pain)
o JVD
Interventions:
o #1 give diuretics
o Daily weight
o Edema (pitting)
o Pulses
o Fatigue (space out activities)
o Girth measurements
8.

Acute Decompensation Heart

Pulmonary Edema
o Tachycardia
o Hypotension
o Hypoxemia
o Ventricular gallop
o PND

9.

Diagnostic:
Echocardiogram (#1)
o Shows you ejection fraction
BNP +

10. Drug Treatments

Diuretics:
Beta Blockers slowing of the heart
Vasodilators angina (nitro) & lowering BP
(reduces afterload)
Ace inhibitors pump easier, slows &
strengthens the HR
Angiotensin II- receptor blockers
Inotropic Agent
Sympathomimetic Agents
Antidysrhythmics
11.

Nursing Diagnosis:

Anxious
Pale, Cyanotic
Clammy col skin
Severe dyspnea
o Rate >30
o Blood tinged

Failure:

S/S of Improvement:
~ Increased urine output
~ Increased O2 saturation
levels
~ Decreased or no
crackles/rales

#1 Decreased CO
#2 Excess Fluid Volume
#3 Activity Intolerance
Knowledge Deficit
Ineffective Tissue Perfusion

Complete bed-rest
Causes:

12. Goals/Interventions:
~ Muscle atrophy
#1 Oxygen
I/O & Daily Weight
~ DVT
Medication Admin
Elevate HOB
~ Pneumonia
Breath/lung sounds
Oral care
Activity Intolerance: partial bed rest, oral care
o S/S of activity intolerance = decreased O2 & BP
Medication education
Home O2 administration? provide education
Lifestyle Changes:
o **Fluid restrictions
o **Low sodium diet
o Exercise
o Smoking cessation
BONUS: Pneumonia care: chlorahexadine
QUESTIONS:
~ What are the manifestations of lift-sided heart failure? - Pulmonary
congestion, backward effect
~ If a client has had a massive MI heart failure, which kind do you suspect?
Acute
~ In right sided heart failure the blood accumulates where? systemic venous
system
~ What is the #1 drug of choice for HF? Beta Blocker
*** If there is lung congestion = #1 drug is diuretics***

Pulmonary Embolism:

~ Etiology:
1. Risk Factors
Created by thrombus (DVT)
Or thrombus from right heart
2. R
3. Plan of Care (if we cant prevent):
Provide emotional support
Call rapid response team
Dangle legs on the side of the bed
Elevate head of bed

2.

Reducing risk factors (Prevention):

Encourage mobility after surgery or
illness
Compression stocking while in bed &

O2 administration
Analgesics
Pulmonary artery and wedge pressures are monitored (ICU)

4.

Diagnostic test
Plasma D-dimmer elevated shows presence of a clot
Chest CT with contrast
Lung scan shows what is perfused and what is ventilated
Pulmonary angiography: video-camera
ETCO2 (end-tidal carbon dioxide): breathing into an apparatus, it will be elevated
because
Coagulation studies: PTT tells us the response to the treatment and before tells
us the baseline

5.

Treatment
*****PREVENTIONS*****
death occurs within 2 hours of PE
Pharmacology:
o Anticoagulant:
Heparin (hep-p) we want to take pTT
Antidote = protamine sulfate
Formula for therapeutic range: 1.5-2x the normal range
Coumadin (din-INR)
Antidote = vitamin K
Formula for therapeutic range: 2-3x the normal range
Takes 5-6 days to take effect so heparin is administered until
then.
Fibrinolytic therapy (Streptokinase, -ase)
Breaks down the clots
Dont use until 10day-3weeks after surgery because of incision
bleeding
Dont use unless you have to because it can cause cerebral
bleeding

6.

Nursing Diagnosis:
#1 - Impaired Gas Exchange
#2 Decreased Cardiac Output
#3 Ineffective Protection (bleeding)
Impaired Breathing Pattern
Anxiety
o Provide calm environment, hold their hands, were right here, your not
alone, therapeutic touches, breathe
Fear

7. Nursing Interventions
Health History & Physical (AFTER patient is
stabilized)
Oxygenation SATs to 95%
Provide comfort so pt has no fear
Pain relief
o Morphine relieves anxiety & reduces
pain
Tissue perfusion
o Pulses
o Temperature of extremities
o Cap refill
o Color cyanosis of the lips

Impaired Gas Exchange

o Heart sounds
o Ejection fraction
o Lung sounds,
oxygenation
Decreased Cardiac Output
o I/O
o Edema
Ineffective protection
o High risk for bleeding
o No flossing, no shaving
o Use a soft toothbrush
o No contact sports
o No bearing down (blood

QUESTIONS:
~ S/S of PE? Dyspnea, sob, chest pain, cough, tachycardia, tachypnea, crackles, &
low grade fever.
~ What are the purposes of the analgesics? anxiety, relieve pleuritic pain
~ What other perfusion concept tests are performed? EKG, ABGs, Chest x-ray
~ What medication would you use to stop the bleeding of a patient on
Coumadin? Vitamin K
~ The doctor has ordered fibrinolytics for your patient with the PE, what in
your patients history would make you question the order? - Patient has a
history of recent CVA
~ What is the nurses primary role as it relates to PE? Prevention
~ What are the risk factors for PE? similar risk factors to

Deep Vein

Thrombus (DVT):
o Stasis of blood, Bessel damage, and increased blood coagulability (causes of
DVT)
Hospitalization, surgery, immobilization, certain cancers, trauma,
pregnancy, use of oral contraceptives, or hormone replacement therapy.
(more common in women)
Other risk factors: orthopedic procedures (hip/knee surgery), A-fib, MIs, &
ischemic stroke
o Vessel trauma stimulates the clotting cascade. Platelets aggregate at the site,
particularly when venous stasis is present. Clot forms, the inflammatory
response is triggered, causing tenderness, swelling, and erythema in the area of
the thrombus. Thrombus floats in the vein, pieces may break loose and travel
though the circulation (emboli). Fibroblasts eventually invade the thrombus,
scarring the vein wall and destroying venous valves. Although patency of the
vein may be restored, valve damage is permanent. (Most common in the
calf/pelvic area)

o S/S of DVT = Usually asymptomatic, dull aching pain in affected extremity,

especially when walking, possible tenderness, warmth, erythema along affected
vein, cyanosis and edema of affected extremity, and Homans sign (pain in the
calf when the foot is dorsiflexed).

Cardiomyopathy:

1. Risk Factors
HTN
Excessive alcohol consumptions
Valvular disease
Idiopathic

~ 50% die within 5yrs of diagnosis

~ 75% die within 10yrs of diagnosis

~ Dilated Cardiomyopathy
*** This is because people
Pathophysiology
RARELY make necessary lifestyle
o Dilation of the heart
modifications***
chamber impairs ventricular
contraction
o Caused by: idiopathic (secondary: due to alcohol)
o S/S: Right & Left sided failure occurs
Medications
Diagnostic Testing
o Myocardial biopsy
~ Hypertrophic Cardiomyopathy
o CT scan
Pathophysiology
o Echocardiogram ejection
o Left ventricular hypertrophy &
fraction (normal 50-70)
decrease compliance
Treatment
o Caused by: hereditary, young
o Surgery to reduce excess
athletes
o
S/S: During or after physical
muscle
activity
Medications
~ Restrictive Cardiomyopathy
o Beta Blocker
Pathophysiology
Diagnostic Testing
o Rigid ventricular walls that impairs
o Myocardial biopsy
filling
o CT scan
o Caused by:
o Echocardiogram ejection
o S/S: Heart failure and decrease
fraction (normal 50-70)
tissue perfusion
Medications
Diagnostic Testing
o Myocardial biopsy
o CT scan
o Echocardiogram ejection fraction (normal 50-70)
Treatment
o Surgery not an option
o Restrict Exercise:

Nursing Interventions:

o Palliative Care:
Ask if they have an Advance Directive
Talk to someone in the family (who is the family member in charge?)
Are they at peace?
Do they have any unresolved issues?
o H&P
o During a chest x-ray on the heart, the point of maximum impulse will be
shifted towards the midline of the body
o #1 Oxygen
o I/O
o Daily Weight
o Medication Admin
o Elevate HOB
o Breath/lung sounds
o Oral care
o Activity Intolerance: partial bed rest, oral care
S/S of activity intolerance = decreased O2 & BP
o Med education
o Home O2 administration? provide education
o Lifestyle Changes:
**Fluid restrictions
**Low sodium diet
Exercise (except for restrictive cardiomyopathy)
Smoking cessation

Arteriogram (or angiography)

An imaging test that uses x-rays and a special dye to see inside the arteries.
It can be used to view arteries in the heart, brain, kidney, eyes, lungs,
legs/arms, and chest/abdomen.
o Contrast is injected into an artery or vein.
o Injection into an artery takes more preparation and care. Most of the
time, an artery in the groin will be used.
o X-rays are taken to see how the dye flows through your bloodstream.
Checks for blocked or damaged arteries.
o NPO a few hours before the test. Lots of fluids given after the test.

Gallbladder disease:
~
~
~
~
~

Gallstones migrate to the ducts and cause cholangitis

Cholecystitis (inflammation of the gallbladder) pain longer than 12-18 hours
Cholelithiasis: is the formation of stones (calculi or gallstones)
Cholangitis: inflammation of the duct
Biliary colic: a severe, steady pain in the epigastric region or RUQ of the abdomen

Manifestatio
ns

Cholelithiasis (gallstones)

Cholecystitis (inflammation of
gallbladder)

Pain

~ Abrupt onset
~ Severe, steady
~ Localized to epigastrium & RUQ
~ May radiate to back, right
scapula, & shoulder
~ Lasts 30min-5hours

Associated
~ Nausea/Vomiting
Symptoms
Complication
s

~ Cholecystitis
~ Common bile duct obstruction
with possible jaundice & liver
damage
~ Common duct obstruction with
pancreatitis

~ Abrupt onset
~ Severe, steady
~ Generalized in RUQ
~ May radiate to back, right scapula, &
shoulder
~ Lasts 12-18 hours
~ Aggravated by movement, breathing
~ Anorexia, Nausea, Vomiting
~ RUQ tenderness & guarding
~ Chills & fever
~ Gangrene & perforation with peritonitis
~ Chronic cholecystitis
~ Empyema
~ Fistula Formation
~ Gallstone ileus

*******Colored parts identify SIMILARITIES between the two*******

Diagnostic Test:
Risk Factors:
o Serum bilirubin
o Age
o CBC
o Family History of gallstones
o Serum amylase and lipase
o Race or ethnicity: Native
o Abd x-ray (enlargement)
American, Northern European
o Ultrasound sonogram (enlargement, fluid, stones)
heritage
o Oral cholecystogram,
o Obesity, hyperlipidemia
o Gallbladder scans
o Rapid weight loss
o Females & use of oral
Treatment:
contraceptives
o Infection (-statins)- the risk for gallstones
o Biliary stasis: pregnancy,
o Cholesterol CHANGE DIET!
fasting, prolonged parenteral
o Bile salts they break down fat
nutrition
o Surgery: laparoscopy, laparotomy
Cholecystectomy:
Open gallbladder removal through a surgical opening not through a
scope.
5-7inch cut in the URQ, just below the ribs.
Done under general anesthesia. Surgery takes about 1 hour.
A cholangiogram may be done during the surgery. Dye is placed
through the bile duct, showing a roadmap of the gallbladder area.
Helps locate any other gallstones and remove them.
Before surgery: CBC, Electrolytes, EKG, X-rays, ultrasounds,
determine pregnancy status, what
medications/vitamins/supplements the patient is taking. Doctor may
have patient discontinue aspirin, ibuprofen, vit. E, warfarin.
Ask doctor about which meds are ok to continue on the day of
the surgery.
Patient may have to clean out colon or intestines (Go-lite)
Day of surgery: Do not eat or drink anything after midnight. Take
medications that were okayed by your doctor (SMALL sip of water),
shower the night before.

After surgery: 1-4days in the hospital. Use of incentive spirometer,

dangle legs progressing to ambulation, IV fluids, soft foods, shower
24hrs after surgery, compression stockings, pain & infection
management.

Nursing Interventions:
o H&P
o NPO with NG tube
o Pain meds
Every couple hours check patient
o Positioning!! Elevate HOB, pillow for splinting, only minimal walking
o Vitals (temperature) S/S of infection (sepsis)
o Diet Education
Pale clay colored stool will over time return to the color brown (after 2-3
weeks)
o Herb Goldenseal- stimulates secretion of bile and bilirubin, inhibits the growth of
many common pathogens (including those known to infect the gallbladder)
Nursing Diagnosis:
o #1 Pain
o #2 Nutrition
o #3 Risk for Infection (elderly patients over 65- Infection is #1 NX)

Inflammatory Bowel Disease:

Diagnostics:
o #1 Colonoscopy
o Sigmoid
o Barium (GI series)
Upper- oral
Lower enema
o Stool (rule out flu, meds, c-diff)
o CBC- anemia, infection
o Sed rate elevated
o Liver function test normal
o Vitamins malnutrition
o Albumin decreased

Pathophysi
ology
/Etiology:

BEFORE (BARIUM) PROCEDURE:

o A low-fiber diet is given for 1-2
days before the test.
o A clear liquid diet and laxatives
are given the evening before
the test.
o NPO after midnight the day of
the test
o Cleansing enemas may be

Ulcerative Colitis:

Crohn Disease:

~ Chronic intermittent colitis (comes for

1-3 months and goes from monthsyears) involves only part of the colon
(distal colon)
~ Fulminant colitis (involves the entire
colon)
~ Risk for developing cancer after 10
years
~ Area of chronic inflammation of the

~ Chronic inflammation of the GI

mucousa occurring anywhere from
mouth to anus. (most commonly the
ilium: malabsorbtion)
~ Lesions have cobblestone
appearance (healthy tissue/bad tissue
are checkered)
~ Peak incidence between 10-30 years
~ No bleeding unless the colon is

Clinical
Manifestati
ons:

Acute
Complicati
ons:

(Emergency
situ.)

S/S of Toxic
Megacolon:

mucosa & sub-mucosa is infected in the

colon & rectum
~ Peak incidence between 15-35 & 5070 years.
~ Starts in the rectum and travels
upward
~ Bloody mucus diarrhea
~ Nocturnal diarrhea
~ Mild= fewer than 5 stools per day
~ Severe= 6-30 liquid stools per day
~ Abdominal pain LLQ
~ Tenesmus Painful urge with
ineffective ability to empty (pain
relieved with defecation).
~ Hypoalbuminemia
~ Fatigue, anorexia (weight loss),
weakness, malnutrition, & anemia
~ Hemorrhage hypovolemic
shock/death
~ Toxic megacolon dilated colon 6cm
(should be able to palpate)
obstruction, perforation
~ Colon perforation holes in the colon
with contents leaking out (septic shock,
peritonitis, death)
~ Strictures= obstruction, perforation
~ Colorectal Cancer
~ Hypotension give fluids
~ Abdominal cramping
~ Tenderness
~ Decreased output (r/t blockage)
~ Orthostatic hypotension
~ Fever, Tachycardia

involved
~ The risk for cancer is less
~ The most serious part is: it effects
nutrition
~ Diarrhea a 5-6 liquid to semi-formed
stools per day (electrolyte imbalances)
~ Malnutrition
~ Fever (due to perforation)
~ Abdominal pain LRQ
~ Tender mass in LRQ
~ Borborygami high pitched bowel
sounds
~ Fatigue, weight loss
~ Strictures (lumen narrows)
~ Obstruction
~ Peri-anal & recto vaginal fistulas
(where fecal matter exits through the
vagina)
~ Perforation
~ Sepsis
~ Death
~ Malabsorption (dehydration)
~ Colon Cancer

Nursing Care:
o #1 intervention: Control inflammatory process & relieve symptoms treat in
steps:
Anti-inflammatory (sulfasalazine) it coats the intestines
Corticosteroid drug (acute episodes) it may come back
o Teach: risk for infection, avoid sick people, avoid large crowds
Immunosuppressant (Imuran, Sandimmune)
o Correct metabolic & nutritional problem
Elemental diet Ensure (Better than TPN because there are less side
effects - infection)
High caloric high vitamin high protein low residue (non-fiber) milk
free diet = white rice, jello, broth.
TPN only for severe cases (we want the bowels to rest and have no
BMs.)
o Promote healing
Physical and emotional rest

o Activity: Low impact exercises: yoga, pilates, tai chi, yoga

Surgery:
o Colectomy, ileostomy, ostomy
o Need for surgery is based upon: obstruction, perforation, internal/external
fistula, abscess, and perianal complication

Nursing Diagnosis:
o #1 diarrhea (Inflammation)-- (Lomotil DO NOT give antidiarrheals in an acute
case.)
In a non acute phase it might be ok to give antidiarrheals
o Pain
o Disturbed body image (support groups, ALWAYS provide maximum privacy)
o Fluid Volume Deficit
o Imbalanced nutrition (Ensure, Diet, TPN, diet consult)
o Risk for Impaired Tissue Integrity

Nursing Interventions:
o Nutrition
o Stool Count (if it is liquid consistency put it in the chart as output)
o DRINK WATER
o Colostomy care
o Daily weights
o Peri-anal skin care
o NGT care
o Initially patient will be NPO after surgery.
o Monitor Labs:
Anemia in both (Crohns & ulcerative cholitits)
Crohns because of malnutrition

Ostomy Care:
Perform hand hygiene.
Put on gloves.
Remove the pouch from the stoma.
Inspect the stoma.
It should appear moist, shiny, and pink.
The peristomal area should be intact, and the skin should appear healthy.
Use mild soap and water to cleanse the skin, then dry it gently and completely.
Apply paste if used.
Measure and draw where to cut the skin barrier, allowing only the stoma to
appear through the opening.
o Cut the opening in the skin barrier
o
o
o
o
o
o
o
o
o

o
o
o
o
o

If necessary, apply barrier pastes to creases.

Apply the skin barrier and pouch.
Fold the bottom of the pouch and place the closure clamp on the pouch.
Dispose of the used pouch.
Remove the gloves and perform hand hygiene.

~ Patient teaching:
Healthy stoma appears pink/red & moist. It should protrude a out in from
abdominal wall
Report if stoma turns dusky, brown, black, or white
Clean with mild, pH-based soap or no soap at all just water. (Alcohol,
Betadine, or oil-based soaps can interefere with the adhesion of skin barrier
& could promote skin breakdown.
Measure the stoma with each pouch change. Notify doctor if any of the
following occur:
o increased pain in the abdomen or the incision; fever, redness, or drainage
of the incision; or irritation, redness, or breakdown of the peristomal skin
o a change in bowel habits, such as diarrhea or constipation
o skin irritation unrelieved by a properly fitting pouching system
o problems obtaining a good seal of the wafer or skin barrier
o a hernia or bulge around the stoma
o narrowing of the stoma lumen
o separation of the stoma from the abdominal surface
o lacerations or cuts in the stoma

Exercise: no contact sports (focus on cardio & musculoskeletal fitness)

Empty bag when it is 1/3 full.
~ Food Education:
Foods that cause loose stool:
o Chocolate, dried beans, fried foods, highly spiced foods, leafy green
vegetables, & raw fruits & vegetables.
Foods difficult to digest or cause blockage (AVOID):
o Stringy meats, coconut, cole slaw, rasins, mushrooms, popcorn,
caraway seeds, berries, celery, fresh tomatoes, & some shellfish.
Stool thickening foods:
o Applesauce, bananas, bread, cheese, yogurt, pasta, pretzels, rice,
tapioca, & creamy peanut butter.
Odorous Foods:

o Asparagus, beans, cabbage, eggs, fish, garlic, onions, & some spices.

Nasogastric Tubes (NGT) patients are NPO:

o X-ray must be taken to confirm placement

o Can administer medications through NGT - crushed
o Provide good oral hygiene @ regular & frequent intervals. Offer water or
mouthwash to rinse the mouth every hour. Assist patient to brush teeth every 4
hours.
o Keep nostrils free of accumulation of dried secretions
o Apply lubricant such as Vaseline to the lips & nostrils
o Monitor LOC & swallowing ability
o Assess gag reflex & cough
o Assess pulmonary status for clinical evidence of aspiration
o Auscultate bowel sounds to evaluate bowel motility.
o Keep suction setup available
o Thicken liquids if needed &/or cut food into small pieces
o Crush pills or place them in food
o Patient should be at 90-degree angle & Maintain upright 30-45min after feedings

Tube feedings (ATI fundamentals p.590):

Prepare the formula, tubing, and infusion device.

o Check expiration dates and note the content of the formula.
o Assure that the formula is at room temperature.
o Set up the feeding system via gravity or pump.
o Mix or shake the formula, fill the container, prime the tubing, and clamp it.
Assist the client to Fowlers position or elevate the head of the bed to a
minimum of 30.
Monitor tube placement.
o Check gastric contents for pH. A good indication of appropriate placement
is obtaining gastric contents with a pH between 0 and 4.
o Aspirate for residual volume; intestinal residual should be less than 10 mL,
and gastric residual less than 100 mL.
o Note the appearance of the aspirate.
o Return aspirated contents or follow facility protocol.
Flush the tubing with 30 to 60 mL of tap water.
Administer the formula.
o Intermittent feeding
o Have the formula and a 60-mL syringe prepared.
o Remove the plunger from the syringe.
o Hold the tubing above the instillation site.
o Open the stopcock on the tubing, and insert the barrel of the syringe with
the end up.
o Fill the syringe with 40 to 50 mL of formula.
o If using a feeding bag, fill the bag with the total amount of formula
prescribed for one feeding, and hang it to drain via gravity until empty
(about 30 min).
o If using a syringe, hold it high enough for the formula to empty gradually
via gravity.

o Continue to refill the syringe until the amount prescribed for the feeding is
instilled.
o Follow with 60 to 100 mL of tap water (or the amount prescribed) to flush
the tube and prevent clogging.
Continuous-drip feeding
o Connect the feeding bag system to the feeding tube.
o If using a pump, program the instillation rate as prescribed, & set total
volume to instill.
o Start the pump.
o Flush the enteral tubing with 30 to 60 mL of irrigant, usually tap water,
every 4 to 6 hr, and check tube placement again.
Monitor intake and output and include 24-hr totals.
Monitor capillary blood glucose every 6hr until the maximum administration rate
is reached and maintained for 24 hr.
An infusion pump is required for intestinal tube feedings.
Follow the manufacturers recommendations for formula hang time. Unused
formula should be refrigerated and discarded after 24 hr.
Gastric residual should be checked every 4 to 8 hr. Facility protocol specifies the
actions to take based on the amount of residual obtained.
Delegation of this skill to assistive personnel is inappropriate.
Complications:
When gastric residual exceeds 100 mL (10 mL for intestinal placement)
o Withhold the feeding.
o Notify the provider.
o Maintain semi-Fowlers position.
o Recheck residual in 1 hr or as prescribed.
Diarrhea three times or more in a 24-hr period
o Notify the provider.
o Confer with the dietitian.
o Provide skin care and protection.
Nausea or vomiting
o Withhold the feeding.
o Turn the client to the side.
o Notify the provider.
o Check the tubes patency.
o Aspirate for residual.
o Auscultate for bowel sounds.
Aspiration of formula
o Withhold the feeding.
o Turn the client to the side.
o Suction the airway.
o Provide oxygen if indicated.
o Monitor the clients vital signs for elevated temperature.
o Auscultate breath sounds for increased congestion.
o Notify the provider.
o Obtain a chest x-ray.
Skin irritation around the tubing site

o Provide a skin barrier from any drainage at the site.

o Monitor the tubes placement.

Bowel Obstruction:

Is the leading indication for surgery in Crohns disease.

Psychogenic factors are the most common causes of chronic constipation.
(EX: postponing defecation, Overuse of laxatives & enemas, cathartic
colon = impaired colonic motility and changes in bowel structure) mimics
ulcerative colitis in that the normal pouch-like or saccular appearance of
the colon is lost. Other causes include tumors, scar tissues, hernia, or
severe constipation.
Symptoms: frequent to no flatus, abdominal distention/cramping/discomfort,
diminished appetite, rock hard stools, watery mucus or foul-smelling liquid
stool if partially blocked.
If bowel obstruction is suspected/confirmed: patient is NPO & an NGT is
placed (tube removes fluids and gases).

Latex Reactions:

1. Irritant contact dermatitis:

Is a common reaction and is not an allergy
Itchy, dry, and irritated hands are the result of frequent hand washing and
incomplete drying, use of hand sanitizers, and friction irritation from glove
powder
Anyone who wears powdered latex gloves can develop this
however, in atopic individuals, contact dermatitis can be a sign of impending
hypersensitivity if exposure to latex continues.
2. Allergic contact dermatitis:
Is usually a sensitivity to chemicals used to make gloves, rather than to proteins
from the natural rubber itself. Any of these can cause a contact dermatitis 24-48
hours after exposure, which can spread to other areas, including the face, if
touched. Symptoms usually resolve spontaneously.
The reaction, though, is more severe, spreads to more parts of the body, and
lasts longer.
3. Immediate allergic reactions (latex hypersensitivity):
The most serious reaction to latex
It can show up as rhinitis with hay fever-like symptoms, conjunctivitis (pink eye),
cramps, hives, and severe itching
It is rare, but symptoms may progress to include rapid heartbeat, tremors, chest
pain, difficulty breathing, low blood pressure, anaphylactic shock, or potentially,
death.
~ S/S = hives, N/V, abdominal cramping , facial swelling, itchey, watery eyes

~ What precautions should the nurse take when caring for a client with
an allergy to latex?
Precautions:
o keep a written record of reactions/ causes
o differentiate between lifethreatening/mild reactions
o may develope over time

o Pay attention to diet (what did you eat before? What were you exposed to
before?)
7. Explain why the hospital dietician should be aware of Mr. Cumming's
allergy to latex.
~ The dietician needs to be aware of Mr. Cumming's allergy to latex because this can
also affect his diet choices. Some foods are can also lead to allergic reactions in people
with latex allergies. These foods include: avocado, banana, chestnut, potato, tomato,
kiwi, pineapple, papaya, eggplant, melon, passion fruit, mango, wheat, and cherimoya.
Symptoms can range from oral allergy syndrome to anaphylaxis. This is important
information for the dietician to help plan the diet of the patient with IBD.

In Class Questions:
o What is Phagocytosis? Process the body uses to destroy organisms
o When does hyperemia occur? After the release of the histamines, kinins, &
prostaglandins
o What causes the signs of edema? Fluid leaking into the interstitial spaces &
vascular permeability increases @ site.
o What causes the pain? Pressure of fluid on the nerve endings
o Which exudate might you want to call your MD? Depends on the amount and the
cause
o What is your assessment? History & physical, will be guided by the body
involved, and will be determined by laboratory values.
o What will your nursing care include? Nutrition, Medications, Hydration, Prevention
o Why is a sonogram good for the elderly: they dont have the usual s/s &
complications can occur sooner
o What antibiotic is started with appendicitis? Cephalosporin
o Can you give analgesics to a patient who is pending surgery for appendicitis? Yes
if it is not a narcotic that will make them loopy or sleepy, AND yes because we
KNOW they have appendicitis.
o What is the Primary cause of gallstones - Cholesterol
o What would your nursing interventions include: NPO (NGT- turn off suction and
listen to bowel sounds, 5min per quadrant) IV, Pain management, I/o, frequent
vitals, provide rest and quiet environment ANSWER---- More that what is above
o What are you teaching?- Low carb and low fat diet (diet and exercise go together)
o How long does a patient need to have diarrhea before it is considered chronic? 4
weeks
o Who are the most vulnerable to severe diarrhea? Infants & Elderly (dehydration
for the infants and weakened immune system for the elderly)
o Nursing goals of the patient with acute abdominal pain? #1 Resolution of inflammation
(inflammation relieves pain), Relief of abdominal pain, free from complications, normal
nutritional status.
o What is tenesmus? Painful urge with ineffective ability to empty.
o If your patient has severe UC what other S/S would you inspect? Fatigue,
anorexia, weakness, malnutrition, & anemia
o When the jejunum and ilium are affected what effect does it have on the body?
Malnutrition, Malabsorption, & Anemia

o What is the term for excessive loud hyperactive bowel sounds? Borborygmi
o If the stomach & duodenum is involved what would you see? Nausea/vomiting &
epigastric pain

Anaphylaxis:
o Rapid release of the chemical mediators of inflammation on a large scale
throughout the body.
~ Give epinephrine!! What concentration?
Depends what phase of anaphylaxis pt is in. Severe anaphylaxis =
IM 0.1-0.5mg (single dose cannot exceed 1mg!!) Q10-15min for anaphylactic
shock; IV 0.1-0.25mg Q5-15min
Not sure if she will ask this but ACLS/CPR you give pt EPI 1mg IV Q35min

Rheumatoid Arthritis:
Pathophysiology:
RA is a chronic systemic autoimmune disorder (a disease caused by abnormal,
overactive functioning of the immune system that produces a response against
the bodys own cells and tissues, normally resulting in damage to the tissues).
RA causes inflammation of connective tissue, primarily in the joints.
The synovial membrane is damaged by the inflammatory and immune
processes. Damage to the cartilage is due to at least three processes:
o 1) Neutrophils, T cells, and other synovial fluid cells are activated and
degrade the surface layer of the articular cartilage.
o 2) Cytokines, especially interleukin-1 and tumor necrosis factor alpha,
cause the chondrocytes to attack the cartilage.
o 3) The synovium digests nearby cartilage, releasing inflammatory
molecules containing interleukin-1 & tumor necrosis factor alpha.
Inflammation also causes hemorrhage, coagulation, and deposits of fibrin on te
synovial membrane, in the intracellular matrix & synovial fluid.
The formation of pannus (granulation tissue) leads to scar tissue formation that
immobilizes the joint.
Etiology: UNKNOWN!
Risk Factors:
Family history
Heavy smokers
Women 3x more than men
Age: 40-60
Clinical Manifestations:
Affects the joints (mostly upper joints)
o Appear red, hot, swollen, tender to palpation, decreased ROM, weakness
o Hands/Fingers:
Swan-neck deformity: hyperextension of the proximal
interphalangeal (PIP) joints with compensatory flexion of the distal
interphalangeal (DIP) joints.

Boutonnire deformity: avulsion of extensor hood of the proximal

interphalangeal joint.
o Knees:
Instability of the knee joint, quadriceps atrophy, contractures, and
valgus (knock-knee) deformities.
o Ankles/Feet:
Hallux valgus: Deviation of the great toe toward other digits of the
foot.
Strictures
Pain and stiffness lasting more than an hour & occurs after being inactive for 4+
hours.
Systemic Manifestations:
o Weight loss, loss of appetite, fatigue, tachycardia, fever, anaphylaxis.
Extra-Articular Manifestations:
o Seen with high levels of circulating rheumatoid factor. Anemia, skeletal
muscle atrophy. Rheumatoid nodules (granulomatous lesions that are firm
and either movable or fixed). Can be found in the heart, lungs, intestinal
tract, & dura.
Disease progression is fastest during the first 6 years.

Effects on Perfusion:
Increase risk for Coronary Heart Disease (CHD)
o Direct effects on the blood vessels due to inflammatory markers being
more predictive of future cardiovascular disease.
o Increased risk for having low HDL levels, high cholesterol & triglyceride
levels, high BP, and high homocystine levels.
o The damaging SE that many medications (steroids) often have on coronary
vessels.
Diagnostic Tests:
CBC
Erythrocyte Sedimentation Rate (ESR)
Rheumatoid factors
X-rays of affected joints
Synovial fluid examination
Cyclic citrullinated peptide (anti CCP) positive indicates RA
GOALS:
Slow the progression of the disease
o Relieve pain, Reduce inflammation, Slow/stop joint damage, Improve ability
to function
Pharmacological Treatment:
#1-NSAIDs (aspirin ASA)
For pain: 325-400mg/day take with food, milk, meals, antacids. NOT
WATER!
For full anti-inflammatory effect 3-4 doses of 325mg/day
Stop taking aspirin if tinnitus occurs, reduce to two pills

Other NSAID side effects: GI irritation, ulceration, bleeding,

aggravation of IBDs and can be toxic to the kidneys.
Therapeutic blood level = 15-30mg/dL
#2-corticosteroids
only drug that slows the progression
Long term use SE: poor wound healing, increased risk of infection
osteoporosis, and GI bleeding. (Rebound effects if discontinued
quickly) Wean off slowly
#3 immunosuppressants/immunoglobulins:
o When you have autoimmune problem you have too much immunity so you
give them immunosuppressants so that the levels decrease in the body.
o Takes 2-4 weeks to produce a beneficial effect
o SE include: Gastric irritation & stomatitis (Controlled w/ folic acid taken
congruently)
o Toxic affects are increased with alcoholism, diabetes, obesity, advanced
age, & renal disease
Antirheumatic drugs
Disease-Modifying Drugs:
o Beneficial effects are not apparent for several weeks. They cause clinical
improvement & decreased disease activity. ALL of these are fairly toxic,
close monitoring is needed.
o Gold salts (HURTS! inj.) Monitor UA/CBC, flushing, fainting, dizziness,
anaphylaxis
o Antimalarial (Plaquonil 200-600mg daily w/ meals, every 6 months
have an eye exam- can cause pigmentary retinitis/vision loss,
contraindicated in pregnancy)
o Sulfasalazine (2g/day in divided doses w/ meals. Maintain high fluid
intake, can cause yellow-orange skin or urine discoloration, regular CBCs
necessary. Toxic effects include: bone marrow suppression, proteinuria, &
nephrosis.
o d-penicillamine (125mg daily increased to 1,000-1,500mg/day. Monitor
UA/CBC, administer on an empty stomach. 2-3 months before benefit is
seen.

Surgery (shoulders & knees most common):

Synovectomy (excision of synovial membrane)
Arthrodesis (Fusion of the joint = neck, cervical spine, wrists, ankles)
Arthroplasty (total joint replacement)
Plasmapheresis (removal of circulating antibodies)
Total lymphoid irradiation (decreases total lymphocyte levels, although serious
SE occur)
Other Therapies:
Hot/Cold therapy
Exercise:
o Isometric exercises: used to improve muscle strength without increasing
joint stress
o Isotonic exercises: improve muscle strength and preserve function.

Hydrotherapy (water aerobics, swimming): decrease joint inflammation

Occupational Therapy: tools are given to help perform ADLs
Nutrition/Dietary supplement (vitamins, herbs, blueberries, omega-3 fatty acids)
Acupuncture
Assistive devices & splints (reduces unwanted motion and provides local joint
rest)
o The best splint for the hip is ling prone for several hours a day on a firm
bed.

Nursing Diagnosis/Interventions:
#1 PAIN r/t joint inflammation
o hot/cold therapy
o 0-3 = distraction, massage, not move affected joint, however no bed rest
because contractures can form.
Fatigue r/t chronic pain & complications of disease
o Balance between exercise & rest
o ROM exercises, improve ability to function.
o Support groups
Disturbed body image r/t joint deformities
o Encourage self care
o Support groups encourage vocalization of feelings
Impaired Physical Mobility r/t joint stiffness
o ROM exercises, improve ability to function.
o Occupational therapy
Ineffective Role Performance r/t pain & activity intolerance
o Support groups encourage vocalization of feelings
o Discuss effects on life and identify strategies to cope and solve issues.
Activity Intolerance r/t chronic pain
o Balance between exercise & rest
o ROM exercises, improve ability to function.
Anxiety r/t stress of chronic illness
o Support groups encourage vocalization of feelings
Patient Education/Teaching:
Diet, Stress Reduction & Management, Exercise, Adequate Sleep
Never attempt an activity that cannot be stopped immediately if it proves
beyond your power to complete it.
Respect pain as a warning signal. When you experience pain, change your
method of doing things, use equipment or tools if necessary & take intermittent
rest periods.
Use the strongest joints available for an activity & Avoid stress toward a position
of deformity
Avoid activities that need a tight grip, such as writing, wringing, and unscrewing.

Systemic Lupus Erythematosus:

Patho/Etiology:

Risk

Chronic, inflammatory, connective tissues disease that affects almost all body
systems, including musculoskeletal system, and is characterized by remissions
and exacerbations.
Large variety of autoantibodies (antibodies that react to the clients own tissues)
against normal body components such as nucleic acids, erythrocytes,
coagulation proteins, lymphocytes, & platelets. Autoantibodies attack on a
cellular level.
SLE autoantibodies react with their corresponding antigen to form immune
complexes, which are then deposited in the connective tissues of the blood
vessels, lymphatic vessels, and other tissues triggering an inflammatory
response leading to local tissue damage.
Etiology: Unknown
o Human leukocyte antigen (HLA) genes are seen more frequently in ppl
with SLE.
o Genetic, environmental, & hormonal factors all play a role.
Factors:
Women of child bearing age (30-40)
Hispanic, Asian, African American
Medically induced: isoniazid (INH)- for TB, hydralazine.

Clinical Manifestations:
3 types of Lupus:
o Systemic Lupus: cardiovascular, central nervous, hematological,, kidneys,
lungs, & musculoskeletal.
o Drug induced lupus: Manifestations disappear when med is discontinued.
o Discoid lupus: limited to the skin
50% show Renal manifestations
***Leading cause of death is infection: pneumonia & sepsis***
Early signs of SLE mimic the S/S of RA
o Swelling, fever, loss of appetite, malaise, weight loss, poly-arthritis &
multiple arthragias
Raynauds phenomenon cold fingertips (pale, cyanotic fingers)
Butterfly rash, photosensitivity to the sun.
Painful or swollen joints/muscle pain
Unexplained fever
Unusual loss of hair
Edema in legs & around the eyes
Ulcers in the mouth
Enlarged glands
Extreme fatigue
Diagnostic Tests:
Anti-DNA antibody testing
Erythrocyte sedimentation rate (ESR) 100mm/hr or greater
Serum complement levels (values are decreased)

CBC leukopenia, anemia, lymphocytopenia, possible thrombocytopenia

Urinalysis: mild proteinuria, hematuria
Kidney biopsy: assess severity of renal lesions

Pharmacological Treatment: SAME AS FOR RA!!!

Other Therapies:

Stress management: Yoga, guided imagery, massage, aroma therapy

Nursing Diagnosis:

Risk for Impaired Skin Integrity r/t immunologic deficit

Risk for Infection r/t immunosuppressive medications
Risk for Ineffective Tissue Perfusion (renal) r/t interrupted blood flow in the
kidneys
Risk for Activity Intolerance r/t chronic disease
Disturbed Body Image r/t side effects of medications and skin alterations
Chronic Pain r/t joint inflammation & injury
Compromised Family Coping r/t demands of chronic illness with unknown
outcome.

Nursing Interventions:

Promoting Skin Integrity

o Assess clients knowledge of SLE (teach)
o Discuss relationship between sun exposure & disease activity.
o Keep skin clean and dry
o Encourage good hygienic measures & a mild soap (Oral care!)
o Recommend limited use of cosmetics (can irritate the skin)
o Avoid fluorescent lighting
Prevent infection
o Encourage to keep up with immunizations & yearly flu vaccine
o Good hygiene.
o Immunosuppressant Interventions:
Monitor blood count, with particular attention to the WBC and
platelet counts. Notify the physician if WBCs fall below 4,000 or
platelets below 75,000
Monitor renal and liver function studies, including creatinine, blood
urea nitrogen, creatinine clearance, and liver enzyme levels.
Oral preparations should be administered with food to minimize
gastrointestinal effects. Antacids may be ordered.
Increase fluids to maintain good hydration and urinary output
(Monitor I/O)!
Monitor for S/S of abnormal bleeding (bleeding gums, bruising,
petechiae, joint pain, hematuria, and black or tarry stools.
Use meticulous hand washing and other appropriate measures to
protect the client from infection. Assess for S/S of infection.

Pulmonary fibrosis is a potential adverse effect of

cyclophosphamide. Therefore, monitor the results of pulmonary
function studies, and be alert to clinical signs of dyspnea or cough.
Maintain fluid balance (Monitor I/O, Electrolyte imbalance, & Excess fluid= renal
dysfunction)
Promote adequate nutrition (well balanced died fluid intake)
Promote Rest & Comfort (physical therapist to increase muscle strength)
Manage Side Effects of Medications (eye exams, gastric bleeding)
Provide Emotional Support
Avoidance of Triggers
MODERATE exercise
Ineffective Protection
o Wash hands (before & after helping client)
o Use strict aseptic techniques when caring for IV lines, catheter, or wound
care.
o Assess frequently for infection. Monitor temp every 4hrs. Assess for S/S of
cellulitis (tenderness, redness, swelling, & warmth). Report S/S of infection
to physician!!
o Monitor Labs: CBC, organ function tests, WBCs, myocardial enzymes,
electrolytes.
o REVERESE ISOLATION
o Adequate nutrition, supplements, fluids.
o Monitor for potential adverse SE of medications (thrombocytopenia,
bleeding, fluid retention, hypertension, loss of bone density, osteoporosis,
renal/hepatic toxicity, hypervolemia.

Health Maintenance
o Assess clients ability to maintain optimal health, identifying physical &
psychosocial factor that may affect health maintenance.
o Encourage client and family to express their feelings and questions
o Refer to a counselor if needed &/or support groups.

Patient Teaching:

GOOD HYGIENE
Sun exposure:
o Avoid being out of doors during suns greatest intensity (10am-3pm)
o Use sunscreen ALL the time (100% of the time) apply 30min before going
out
o Use SPF 15 or higher
o Reapply sunscreen after swimming, exercising, or bathing.
o Wear loose clothing with long sleeves & wide brimmed hats when
outdoors.
Stress reduction
o Stress triggers flare ups (exacerbation)
Immunosuppressive Medication Teaching:
o Avoid large crowds and situations where you might be exposed to
infections.
o Report S/S of infection= chills fever, sore throat, fatigue, malaise

o Use contraceptive measures to prevent pregnancy while you are taking

these drugs, because they may increase the risk of birth defects.
o Avoid using aspirin or ibuprofen while taking these drugs. Report any S/S
of bleeding
o Be aware that menstruation may stop while taking cyclophosphamide,
they will resume after the drug is discontinued & Report difficulty
breathing or coughing.
Importance of skin care
The significance of wearing a MedicAlert tag that identifies their
condition/therapy.
He need to follow the prescribed treatment plan, including rest & exercise,
medications, & follow up appointments. Discuss manifestations of an acute
episode (flare up) and stress the importance of contacting the physician
promptly if any of the manifestations occur.
Use of oral contraceptives or alternative methods of birth control. Pregnancy
contraindicated with women who have SLE still can have a baby but requires
INCREDIBLE monitoring.
Women should have gynecologic and breast examinations & men should have
prostate examinations yearly. Regular screenings for cholesterol and blood
pressure.

HIV/AIDS:
Pathophysiology/Etiology:
HIV Retrovirus: meaning that it carries its genetic information in RNA
Transmitted by direct contact with infected blood and body fluids AIDS
(Acquired immunodeficiency syndrome) is the final, fatal stage of HIV AIDS
~ How HIV results in immunodeficiency:
HIV is a blood borne pathogen with the typical routes of transmission: blood or
blood products, intravenous drug abuse, both heterosexual and homosexual activity,
and maternal-child transmission before or during birth. It infects and destroys the Th
cell/CD4 cells, which is necessary for the development of both plasma cells and
cytotoxic T cells. HIV is a retrovirus it can carry genetic information in the form of RNA
rather than DNA. It uses enzyme reverse transcriptase to convert RNA into double
stranded DNA. The virus then uses integrase to insert the new DNA into the infected
cells genetic material where it may remain dormant. If the cell is activated, translation
of the viral information may be initiated, resulting in the formation of new virions
(reproduce outside a host), lysis and death of the infected cell, and shedding of
infections HIV particles.
Depletion of CD4+ cells causes a severely diminished response to a wide array
of infectious pathogens and malignant tumors.
Seroconvesion: antibodies are produced to the inactive HIVs proteins (in their
infected cells). They are detectable 6 weeks 6 months after initial infection.
Window period: when patient is infected but not yet testing HIV positive. This is
during the seroconversion time (6 weeks 6 months and up to 1 year). Patient
can still infect others!
Risk Factors:
In the US: 75% from heterosexual contact, 25% injection drug users

Bisexuals, gays, multiple partners, prostitutes, females (Hispanics & African

American)
Unprotected sex, anal sex
IV drug users or Partners of IV drug users
Partiers: drugs/alcohol
Receiving blood transfusion
Health Care: interaction with HIV patients, needle sticks
Poverty: less access to preventative health care & health care education
Pregnancy & Breast-Feeding: avoid pregnancy if possible, HIV can be transmitted
to the fetus
Older Age (50+): immunocompromised, unsafe sex, under diagnosed, over
looked

Clinical Manifestations:
Acute Retroviral Syndrome or Primary HIV Infection
o Fever
o Headache
o Sore throat
o Rash
o Arthralgias & Myalgias
o N/V/Abdominal cramping
o Lymphadenopathy
** The length of the asymptomatic (latent/chronic phase) period varies: 810+ years **

Acute Disease Symptom progressed to AIDS

o General malaise, fatigue
o Low-grade fever
o Night sweats
o Involuntary weight loss (10lbs or more)
o Skin dryness or rashes
o Muscle wasting
T Cell Levels
o Normal: 600-1200/mm3, healthy individuals are usually > 800 unless sick]
o HIV positive patient: 0-500/mm3
o AIDS patient: <200/mm3 AND are symptomatic.
(If you are not symptomatic you are only HIV positive)
o Laboratory findings:
- Category 1: >500/mm3 (good immune system, opportunistic infection
is unlikely)
- Category 2: 200-499/mm3 (Immunodeficiency)
- Category 3: <200/mm3 = AIDS
- End Stage: <50/mm3
o Clinical findings:
- Category A: asymptomatic
- Category B: some less manifestations of immune deficiency (200499/mm3)
Candidiasis, Oral (thrush)
Herpes zoster, Shingles (<350/mm3)
Fever 101.3F (38.5C)

Category C: AIDS defining illnesses present (<200/mm3)

Candidiasis, Bronchi, trachea, lungs or esophagus
Kaposis sarcoma
Pneumocystis jirovecii

~ Once diagnosed with AIDS survival time is estimated to be 2-3 years ~

Neurological Manifestations (40-60%)

o AIDS Dementia Complex: (irreversible)
Fluctuating memory loss
Confusion, difficulty concentrating
Lethargy
Diminished motor speed
Late stages: ataxia, tremor, spasticity, incontinence, parapalegia
o Delirium (reversible)
o Toxoplasmosis:
Space-occupying lesions that may cause headache, altered mental
status, and neurologic deficits.
Peripheral nervous system Manifestations (30%)
o Numbness, tingling & pain in the lower extremities (resulting in progressive
paralysis)
Opportunistic Infections (<500/mm3):
o Pneumocystic carini (MOST COMMON First S/S of AIDS in undiagnosed
patients)
o Tuberculosis
o Candidiasis
o Mycobacterium avium complex
o Yeasts
Men: appears anywhere they sweat
Women: vaginal test for HIV & diabetes
Secondary Cancers
o Kaposis Sacroma (most common)
o Lymphomas
o Cervical cancer (get checked every 6-12months)

Diagnostic Tests:
ELISA: positive or negative, you do it twice (if its positive the first time do it
again, if its positive the second time then you do the Western Blot)
Western Blot
HIV viral load test: tells you the progression of the disease
CBC: looking for infection (WBC), and anemia (HIV drugs can cause anemia)
CD4 cell count: same as T4 cell count
Blood cultures

Liver function (obtaining a baseline)

Lung studies/chest x-ray (obtaining a baseline)
TB

Pharmacological Treatment:

** Test for pregnancy before administering drugs **

Four foci of treating HIV:
o To suppress the infection itself, decreasing symptoms and prolonging life
o To provide prophylaxis of opportunistic infections
o To simulate hematopoietic response
o To treat opportunistic infections and malignancies
Antiretroviral Therapies: stop or suppress the activity of a retrovirus, preventing
further weakening of the immune system & thereby minimizing opportunistic
infections.
HAART:
first NRTI (AZT-zidovudine)
second NRTI (Didanosine *chew* or lamivudine)
NNRTI (Nevirapine)
OR
PI (indinavir, ritronavir, saquinavir)
o Major adverse reactions (cause non-adherence to meds)
o Side Effects: N/V, body fat, SOB, weak bones, skin rash, skeletal muscle
wasting, insulin resistant.
Effectiveness of treatment is monitored by viral load and CD4 counts.
o Positive results = >350/mm3
o Treatment recommended = <200/mm3
Four classes of medications:
o NRTI nucleotide reverse transcriptase inhibitors
Zidovudine (AZT)
Purpose: to slow progression of the disease
Given when CD4 count <500/mm3
Didanosine (DDI, Videx)
Given with AZT
Inhibits replication within the cells & increase CD4 levels.
Lamivudine
Used for low CD4 counts or symptomatic disease as a first-line
treatment combination with AZT.
Combivir = Lamivudine + Zidovudine
Used to decrease zidovudine-resistant HIV strains because
most patients get resistant to AZT within 6-8days.
o NNRTI non-nucleotide reverse transcriptase inhibitors
Nevirapine (Viramune)
Used in combination with NRTI & PI
One limitation to NNRTIs is the high incidence of cross-resistance to
NRTIs
Only one NNRTI should be used at the same time.

o PI protease inhibitors
Target the protein that the HIV needs to grow
Elevates cholesterol & triglycerides, insulin resistance & diabetes
mellitus, and changes in body fat composition: fat deposition in
the midsection, breasts, & neck. Atrophy in the face, buttocks, &
extremities.
Lipodystrophy: abdominal obesity & skeletal wasting.
Put on atorvastatin/provastatin to combat fat distribution problem.
Indinavir (Crixivan)
Used in combination with NRTI to treat progression of disease.
o Entry inhibitors
Enfuvirtide (Fuzeon)
Prevent HIV from entering target cells by binding to the protein
envelope.
o Interferons
Naturally occurring lymphokines (can use alone or in combination)
Used to treat Kaposis Sarcoma
o Prophylactic Antibiotics (Bactrim Sulfa drug) if CD4 <250. This is a
preventative measure against opportunistic infections. Because it is
preventative its a small dose.
Do NOT take Garlic or St. Johns Wart it interferes with meds.

RN Responsibilities:

o AZT (Zidovudine):
Contraindicated if CD4 >350, but will start if S/S of AIDS is severe
Assess adverse reactions: Nausea & Headache are common, if they
are unmanageable with drugs then a change in drug might be
considered.
Nausea & neutropenia are treated with erythropoietin (Epoetin Alfa)
& granulocyte colony-stimulating factor (filgrastim).
Give meds for N/V = Zofran
Assess CBC with differential & creatine phosphokinase.
(Anemia/Neutropenia)
Administer PO (swallow whole)
Give appetite activator = Megace
Give 30min before OR 60min after meals
Teaching:
Doesnt treat but slows progression of the disease & reduces
S/S
Take 30 before OR 60min after meals
That they are still capable of infecting others
Notify physician if S/S of infection develop
Continue all scheduled follow-up visits & laboratory studies to
monitor for drug toxicity.
Consult with physician before taking any OTC drugs.
o DDI (Didanosine):
Chew or dissolve in 1oz of water

Interferes with absorption of ketaconolazone & dapsone (drug for

fungal infections) should be scheduled at least 2hr apart.
Contraindicated in previous episodes of pancreatitis & impaired
renal/liver func.
Baseline test Liver function (BEFORE starting therapy)
Monitor bilirubin levels DDI affects kidney function (stop if toxicity
occurs)
Monitor Amylase & AST levels for Liver toxicity (stop if toxicity
occurs)
Monitor CBC (ANEMIA)
Has an increase risk for causing pancreatitis, peripheral neuropathy,
diarrhea, depression, dry mouth, & other adverse effects. Notify
physician if they occur and stop the drug.
Do not administer DDI with: vincristine, rifamphin, pentamidine,
ethambutol, metronidazole, or IV pentamidine & trimethoprimsulfamethoxazole.
Teaching:
Take on an empty stomach at least 1 hour before or 2 hours
after meals.
Do not use alcohol while taking DDI, causes s risk for
pancreatitis.
Stop the drug & call doctor if N/V, abdominal pain, or diarrhea
develops
Call the doctor if extremity pain, weakness, numbness, or tingling
occurs. Report any unusual bleeding, bruising, fatigue, fever,
persistent sore throat.
Nursing Diagnosis:
***#1 Diagnosis: Depends on the patient and the stage of disease***
Knowledge Deficit
Ineffective Therapeutic Regiment
Ineffective Protection
Risk for Infection
Ineffective Universal Precautions
Imbalanced Nutrition: Less than body requirements
o Assess nutritional status: weight, body mass, caloric intake & laboratory
studies
o Identify possible causes of altered nutrition
o Administer medications for candidiasis (to improve oral intake)
o Administer antidiarrheal medications after stool and antiemetics before
meals. Provide antipyretics as needed to control fever (reducing metabolic
demand)
o Provide a high protein & kilocalorie diet.
o Offer soft foods, and in small portions
o Involve the client in planning meals.
o Assist with feeding if needed & oral hygiene
o Provide supplementary vitamins, Ensure.
o Administer appetite stimulants: megestrol (Megace) & dronabinol (Marinol)

Ineffective Health Maintenance

o Proper nutrition
o Good hygiene
o Immunizations
Annual flu shot & TB testing
Ever 3 years: pneumococcal
Every 8-10 years: tDAP
Shingles, Hep B, Hep C.
o Safe Sex Education
o Med Compliance
o Exercise, Sleep, Stress Management.
o Stay away from large crowds (infection prevention)

Nursing Interventions:
PREVENTION/Education
o Post Exposure Prophylaxis: put them on meds for 6-9months
If patient or health care worker is exposed through needle sticks or
cuts with a sharp object, contact with mucous membrane or
nonintact skin, semen, vaginal secretions, and fluids contaminated
with visible blood. (Must be started IMMEDIETALY)
HAART:
2 nucleoside reverse transcriptase inhibitors (NRTIs) for lowerrisk exposures and the additional of a third drug for higher-risk
exposure.
A 4 week course of treatment is recommended starting within
72hour but preferably 2-3 hours of exposure.
Testing (early detection)
Promoting Health Maintenance/Education
o Standard precautions (at minimum)
Treating patients in an extremely hygienic manner (or like every
patient has HIV)
Blood of newborns must also be considered infectious

Treatment of disease/Education
o Adherence to medical regiment:
Non-adherence = increased morbidity and mortality.
Education on purpose and benefits of adhering to the medication
regimen.
Positive reinforcement
Discover other reasons for non-adherence and collaborate to solve
problem
Emotional Support (Coping) & referrals

Patient Teaching:
Safe sex:
o Hugging, cuddling, nonsexual contact, use of latex condoms & spermicidal
lubricant, and mutual masturbation as an alternative.

o
o
o
o
o
o
o
o
o
o
o
o
o

Encourage discussion of fears and concerns with the significant other.

Support groups (couple or singles therapy)
Practice mutual monogamy (or limit the number of sex partners)
Do no engage in unprotected sex especially if the HIV status of the partner
is unknown.
When entering a new monogamous relationship both partners should be
tested.
Use latex condoms for oral, vaginal, or anal sex: avoid natural or animal
skin condoms
Do not use an oil-based lubricant such as petroleum jelly, which can result
in condom damage; water based lubricants are acceptable
Women should carry and use a female condom
Remember that use of other means of birth control (oral contraceptives,
etc) provide no protection against HIV.
Engage in safer sexual practices that are less damaging to sensitive
tissues (e.g. mutual masturbation & avoiding anal or oral sex)
Do not use drugs or alcohol
Do no share needles, razors, toothbrushes, sexual toys, or other items that
may be contaminated with blood or bodily fluids.
If HIV positive:
Do not engage in unprotected sexual activity
Inform all current and former sexual partners of HIV status
Inform all health care personnel of HIV status
Do not donate blood, plasma, blood products, sperm, organs, or
tissue
If female, do not become pregnant.

In Class Questions:
o To thoroughly assess the immune system the nurse must- Integrate both health
history & physical
o What do you see in RA that is different from the IBD patient? Stiffness in the AM
if you have inactivity for about 4hr stiffness may come back again (osteoarthritisonce a day in the morning)
o If there is no specific dietary plan when would we change a client diet? when the
patient has kidney involvement.
o Women have increased vaginal yeast make them take two tests (HIV test &
diabetes)

Reverse Isolation (Neutropenic) Precautions:

o Purpose: to protect the patient not the nurse. Used for patients with extensive
burns, immunocompromised patients.
o Single room equipped with positive air pressure, to force suspended particles
down & out of the room. (Sign on the door should be up with a cart of
supplies next to it.

o Thorough hand-hygiene techniques (wash hands before and after donning on

gloves.)
o Limitation of traffic into the room. (visitors)
o Gowns, gloves, and masks by facility staff and visitors. (Sterile gloves, gown,
& make may be necessary depending on severity of patients condition)
***Dont allow sick visitors!***
o Sterile linens, gowns, gloves, and head and shoe coverings. Any items taken
into the room may be sterilized or disinfected.
o Diet: elimination of raw fruits/vegetables (only cooked foods and sterile beverages
may be allowed)
o Thermometer, stethoscope, BP cuff should all stay in the room. (Keep supplies
in a clean enclosed cart or in an anteroom outside the room.
o Avoid removing patient from room as much as possible. If they must move
make sure they wear a gown and mask.
o Dont perform invasive procedures, such as urethral catheterization, unless
absolutely necessary
o Instruct house-keeping to follow Isolation Precautions.

Nephritis
Risk

Factors
Diabetes Mellitus &/or HTN r/t vascular damage
Bladder infections travels backwards to the kidneys
OTC meds overuse (tylenol, ibuprofen, advil)
Trauma (blunt force, gun wound, car accident)
Family history
Other diseases: AIDS, SLE, Sickle Cell Anemia

Diagnostic Tests:
Throat or skin culture looking for strep (Group A, beta hemolytic strep)
Antistreptolysin O (ASO) titer strep test
ESR will be elevated
KUB = kidney, urinary, bladder X-RAY
o Acute- kidney will be enlarged
o Chronic kidney will be smaller (it shrinks)
Kidney scan (with dye) glomerular diseases causes the uptake & excretion of
dye are delayed
Kidney biopsy (PAINFUL, test of choice!! Tells type of nephritis & type
of treatment needed) avoiding giving unnecessary antibiotics.
BUN: will be elevated (50= moderate impairment, over 100= severe impairment
no recovery)
Serum creatinine: normal levels are lower in older adults (<4mg/dL = severe
impairment)
Urine creatinine:
Creatinine clearance: amount of blood cleared of creatinine in 1min, decreased
in kidney disorders & older adults
Serum Electrolytes (hyper-) All elevated
Urinalysis: shows RBCs, WBCs, protein. (24hr urine specimen sample) ODOROUS

Treatment:
~ Pharmacologic Therapies
Aimed at treating the underlying cause
Avoid nephrotoxic drugs
o Strong antibiotics like: streptomycin, vancomycin, gentamycin,
aminoglycoside antibiotics
Immunosuppressive therapy (Risk for infection)
Pathophysiology
Manifestations
~ Inflammation of the glomerular capillary
Glomerulonephr membrane (occurs 10-14 days after
~ Many are asymptomatic
itis
infection)
~ Etiology:
~ Abrupt onset:
Infection
Flank or mid-abdominal
pain
DM

Irritability
SLE
Malaise
Trauma/injury
Fever
~ Glomerular damage occurs as a result of
an immune complex reaction that localizes
Hematuria tea colored
on the glomerular capillary wall.
~ Antibody-antigen complexes become
~ 50% of people with
Acute
lodged in the glomeruli, leading to
glomerulonephritis will have
Proliferative
inflammation & obstruction.
hematuria
Glomerulonephr ~ Glomerular membranes are thickened and
itis
capillaries in the glomeruli are obstructed by ~ Dependent & mild
damaged tissue cells, leading to GFR.
periorbital edema more
~ Vascular permeability , allowing protein, severe cases
RBCs, & red cell casts to be excreted.
(ascites/pulmonary effusion =
~ Na+ & H2O are retained, expanding the
dyspnea, cough, & crackles)
intravascular & interstitial compartments =
edema.
~ Acute hypertension may
Chronic
~ Typically the end stage of other
cause an encephalopathy =
Proliferative
glomerular disorders such as rapidly
headache, N/V, irritability,
Glomerulonephr progressive glomerulonephritis (RPGN),
lethargy, & seizures.
itis
lupus nephritis (nephritis caused by SLE), &
diabetic neuropathy.
~ Elderly: fewer symptoms=
~ Slow, progressive destruction of the
nausea, malaise, arthralgias,
glomeruli & a gradual decline in renal
& proteinuria. They may or
function are characteristic.
may not have a fever, BP
~ Kidney function decrease in size
does NOT increase (less or no
symmetrically, & their surfaces become
edema).
granular or roughened. Eventually, entire
nephrons are lost.
~ Symptoms develop slowly & disease is
often not recognized until signs of renal
failure develop.
Autoimmune response caused ~ Abrupt onset:
Acute postby:
Hematuria (brown/cola colored)
infectious
~ Group A beta-hemolytic
Proteinuria
Glomerulonephr streptococcus infection
Salt & Water retention (HTN/edema)
itis (APIGN)
~ Staphylococcus

~ Pneumococcus
~ Coxsackie virus

~ Edema mostly in the face & eyes,

partially dependent edema (upper &
lower extremities)
Azotemia 10-14 days after infection
(S/S= in BUN, patient will be itchy,
crystallization causes grayish color
ashen looking)
Fatigue, anorexia, N/V, headache
o Prednisone, Cyclophosphamide (Cytoxan) & azathioprine (Imuran) are
prescribed in conjunction with corticosteroids.
o Ace inhibitors they work on the protein and stopping protein loss lowering BP/vasodilation (EX:
NSAIDs: reduce proteinuria in some clients, but can also increase Na+ & H2O
retention.
Antihypertensives (managing BP) & Diuretics
~ Clinical Therapies
Plasmapheresis removal of damaging antibodies from the plasma, then
returning the plasma. It works temporarily do it about every 6months
Best rest
Sodium Restriction 1-2g/day (management of edema)
Dietary protein might be implemented if azotemia is present.
o Eat complete proteins: milk, eggs, cheese, meats, poultry, fish, & soy.
o NOT incomplete proteins: vegetables, breads, cereals/grains, legumes,
seeds, & nuts

Nursing Diagnosis:
Excess Fluid Volume
Risk for Infection
Risk for Impaired Skin Integrity
Risk for Imbalanced Nutrition: Less Than Body Requirements
Fatigue
Nursing Interventions/Goals:
Maintain or regain normal urine
output
Meet nutritional needs
Avoid infections
Maintain skin integrity
Bed rest

Normal Changes of Aging:

Encourage ROM, REAL bed rest relaxing

I/O monitoring
Prevent infection
Prevent skin breakdown
Meet nutritional needs
Renal diet: low sodium, decreased
protein

Perfusion
o Stiffening of heart valves (cardiac conductivity altered)
o Increased risk for conduction disturbances (tachy-arrhythmias, HR r/t
stress)
o Decreased baroreceptor sensitivity with potential for postural hypotension.
o Loss of arterial elasticity with risk for isolated systolic HTN & left ventricular
hypertrophy.
o Resting cardiac output maintained

o Increased risk for silent MI

o Decreased renin, angiotensin, & aldosterone production
o Arterial stiffening = to decline in peripheral & vital organ perfusion (nonpalpable pulses)
o Veins thicken, valvular reflux contributes to varicosities, & dependency edema.
Immunity
o Immune function declines with aging
External factors: nutritional status, chemical exposure, ultraviolet
radiation, environmental pollution.
Internal factors: genetics, neurologic/endocrine systems,
chronic/prior illnesses, and individual anatomic and physiologic
variations.
Decrease in immune response
Lowered resistance to infections
Poor response to immunizations
Hypersensitivity response is reduced or delayed
Autoantibodies more common

Normal Lab Values:

~ Chemistry:
~ CBC:
Sodium: 135 - 145mEq/L
RBC count = (Male: 5-6, Female: 4 Potassium: 3.5 - 5.0mEq/L
5.5)

WBC count = (4,500-10,000)

Chloride: 97 - 107mEq/L
Hemoglobin = (Male: 14-18, Female:
Calcium: 8.2-10.2mg/dL
12-16)
Magnesium: 1.5 - 2.5mEq/L
Hematocrit = (Male: 40-54%, Female:
Phosphate: 2.4 4mg/dL
36-46%)
~ Urinalysis:
Platelet count = 115-450 (7.0-10.2)
pH: 4.6-8
Albumin (3.5-5.5g/dL):
Specific gravity: 1.005 1.030
o 1-40yr: 3.7 - 5.1
Serum osmolality: 280 - 300
o 41-60yr: 3.4 - 4.8
BUN: 8-21mg/dL
o 61-90 yr: 3.2 - 4.6
Creatinine:
o 90 and older: 2.9 4.5
o Male: 0.6 - 1.4
~ ABGs:
o Female: 0.5 - 1
pH: 7.35-7.45
Negative for protein, bilirubin, glucose,
Co2: 35-45
ketones, blood, nitrates, leukocytes

D&C re IV fluid rates and intake and output/medications

amounts???
~ ICE chips: 240mL of water in a cup A full cup of ice chips is 120mL - fluids

Medications:

Digoxin:
Action: (antiarrhymics) Increases the force of myocardial contraction
SE: arrhythmias, bradycardia, anorexia/N/V.

Monitor ECGs & TEACH patient to call doctor if pulse is <60 or >100 BEFORE
taking next dose.
~ Digitalis Toxicity:
A complication of digoxin therapy, may occur when someone take too much of
the drug at once, a build up of the drug overtime, or a decreased tolerance to
the drug.
Patients with heart failure take diuretics, which cause loss of fluids (mostly
potassium), this increases the risk of digitalis toxicity. Can also occur in patients
with low levels of magnesium.
S/S = confusion, irregular pulse, loss of appetite, N/V/D, palpitations, vision
changes (blind spots, blurred vision, changes in how colors look, or seeing
spots), decreased urine output, difficulty breathing when lying down, excessive
nighttime urination, overall swelling.
Diagnostics: ECG, CBC, Kidney function (BUN/Creatinine), K+ levels, Mg+ levels,
digoxin tests.
Treatment: Overdose = CPR (if not breathing), pump their stomach, give
activated charcoal
Lasix
Lasix is a loop diuretic that is used for heart failure and HTN. It works by
preventing reabsorption of sodium and chloride in the loop of Henle region of the
nephron. Increases renal excretion of water, sodium, chloride, magnesium,
potassium, and calcium. This is particularly beneficial when CO and renal flow
are severely diminished. When given IV, diuresis begins in 5min. When given
PO, onset is 30-60min.
Specific teaching: Need to monitor K levels before admin because this has
potential for electrolyte imbalances. Preg category C.
Adverse: hypovolemia, OH, dehydration, electrolyte imbalance
Statins
Lipid lowering agents that lowers total LDL cholesterol and triglycerides.
Report unexplained muscle weakness and pain
Avoid grapefruit juice, give in evening,
Statins are used for preventing and treating atherosclerosis that causes chest
pain, heart attacks, strokes, and intermittent claudication in individuals who
have or are at risk for atherosclerosis.
Heparin
Prevents conversion of prothrombin to thrombin and the conversion of fibrinogen
to fibrin.(LIVER is responsible for fibrinogen production)
Quick onset, given IV or subcut in emergencies. Short half life
Anitdote is protamine sulfate
PTT is the test used. Equation is 1.5-2.5 X baseline= therapeutic range.
Heparin can cause "HITT" heparin induced thrombocytopenia and thrombosis
Used for: PE
Zestril (Lisinopril) & Captopril:
Ace inhibitors
ACEI work in the RAAS, reducing BP through PVR and CO

Reduces afterload and improves CO and renal blood flow by preventing

conversion of angiotensin 2 and vasodilating
Monitor BP and P before and after admin. Teach to change positions slowly. Teach
side effects(dry cough). Take Catopril 1hr prior to meals
Used for: heart failure, HTN

Phenergan (IBD)
Class: antiemetic
Action: Relief of symptoms of histamine excess usually seen in allergic
conditions. Diminished nausea or vomiting, and sedation.
Side effects: confusion, disorientation, sedation, dizziness
PO: Administer with food, water, or milk to minimize GI irritation. Tablets may be
crushed and mixed with food or fluids for patients with difficulty swallowing.
IM: Administer deep into well-developed muscle. SubQ or inadvertent intraarterial administration may cause severe tissue necrosis.
Demerol (IBD)
Class: opioid analgesic
Action: Binds to opiate receptors in the CNS. Alters the perception of and
response to painful stimuli, while producing generalized CNS depression.
Decreases severity of pain.
NSAID
For pain: 325-400mg/day take with food, milk, meals, antacids. NOT WATER!
For full anti-inflammatory effect 3-4 doses of 325mg/day
Stop taking aspirin if tinnitus occurs, reduce to two pills
Other SE: GI irritation, ulceration, bleeding, aggravation of IBDs and can be toxic
to the kidneys.
Therapeutic blood level = 15-30mg/dL
Prednisone
only drug that slows the progression of RA
Long term use SE: poor wound healing, increased risk of infection osteoporosis,
and GI bleeding. (Rebound effects if discontinued quickly) Wean off slowly