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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.
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
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.
7.
9.
Diagnostic:
Echocardiogram (#1)
o Shows you ejection fraction
BNP +
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.
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
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)
Cardiomyopathy:
1. Risk Factors
HTN
Excessive alcohol consumptions
Valvular disease
Idiopathic
~ 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
Gallbladder disease:
~
~
~
~
~
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
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)
Pathophysi
ology
/Etiology:
Ulcerative Colitis:
Crohn Disease:
Clinical
Manifestati
ons:
Acute
Complicati
ons:
(Emergency
situ.)
S/S of Toxic
Megacolon:
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
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
~ 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
o Asparagus, beans, cabbage, eggs, fish, garlic, onions, & some spices.
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
Bowel Obstruction:
Latex Reactions:
~ 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.
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
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.
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)
Nursing Diagnosis:
Nursing Interventions:
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
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
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 **
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
Pharmacological Treatment:
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
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
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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)
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
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
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
~ Chemistry:
~ CBC:
Sodium: 135 - 145mEq/L
RBC count = (Male: 5-6, Female: 4 Potassium: 3.5 - 5.0mEq/L
5.5)
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
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