Nursing Path o Cards

Table of Contents
Abdominal abscess 4 Chronic Obstructive Pulmonary Disease 49

Acute colititis 5 Chronic Renal Failure (CRF, end stage renal
Acute Pyelonephritis 6 disease, ESRD) 50
Acute Renal Failure 7 Colititis, acute 51
Acute Renal Failure 8 Colon Cancer 52
Acute Renal Failure 9 Colorectal Anastomosis 53
Resource 10 Colostomy 54
Amputation 12 Congestive Heart Failure 55
Anaphylaxis 13 Congestive Heart Failure 56
Anemia 14 COPD 57
Anxiety 15 Coronary Artery Disease 58
Appendicitis 16 Coronary Artery Disease 59
Aspiration Pneumonia 17 Crohns 60
Asthma 18 Crohns disease 61
Asthma 19 Crohns disease 62
Asthma 20 Cystic Fibrosis 63
Asthma 21 Cystic Fibrosis 64
Atrial Fibrillation 22 Decubitis ulcer 65
Azotemia 23 Deep Vein Thrombosis 66
Bi-Polar Disorder 24 Deep Vein Thrombosis/Thrombophlebitis67
Bowel resection 25 Degenerative Joint Disease 68
Brain Cancer 26 Degenerative Joint Disease (osteoarthritis)
Breast cancer 27 69
Bronchial asthma 28 Degenerative joint disease- DJD 70
Bronchitis 29 Dehydration 71
Clostridium difficile 30 Dementia 72
Candidiasis, esophageal and oral 31 Diabetes 73
Cancer 32 Diabetes Mellitis 74
Cancer 33 Diabetes Mellitus 75
Cardiac Catheterization 35 Diabetes Mellitus 76
Cast Care 36 Diabetic peripheral vascular disease 77
Cellulitis 37 Diarrhea 78
Cerebrovascular accident (stroke) 38 Diverticulitis 79
Cerebrovascular Accident (stroke) 39 Diverticulitis 80
Cerebrovascular Accident/Stroke 40 Diverticulosis 81
Cervical stenosis (spondylosis) 41 Diverticulosis: 82
Chemotherapy 42 Epidural Catheter Insertion 83
CHF 43 Exploratory Laparotomy 84
Cholecystitis 44 Fever 85
Anticholinergics as ordered to decrease Fibromyalgia 86
secretions (prevents biliary Fracture 87
contraction)Cholecystectomy 44 Fracture 88
Cholecystectomy 45 Fracture 89
Cholecystectomy 46 Fracture 90
Cholelithiasis 47 Fracture Care 91
Chronic Kidney Failure 48 Gallstones 92
Definition 48 Gastritis 93
Gastroesophageal Reflux Disease (GERD) Ostomy care (continent diversion) 140
or acid reflux 94 Ostomy Ileostomy (Lippincott 590-94 &
Gastroesophageal Reflux Disease GERD 95 lewis1085-6) 141
Gastrointestinal bleed, acute 96 Ovarian Cancer 142
Generalized anxiety disorder 98 Pancreatitis 143
Gout 99 Pancreatitis 144
Guillan-Barre Syndrome 100 Peripheral arterial occlusive disease (aorta
Head injuries 101 and distal arteries) 145
Head Injury 102 Peripheral Vascular Disease (i.e. arterial
Hip Replacement 103 occlusion) 146
HIV/AIDs 104 Pleural effusion 147
Hypercholesterolemia 105 Pleural Effusion 148
Hyperlipidemia 106 Pneumonia 149
Hypertension 107 Pneumonia 150
Hypertension 108 Pneumonia 151
Hypertension 109 Pneumothorax 152
Hypertension 110 Pressure Ulcer 153
Hypertension 111 Pressure Ulcers 154
Hypothyroidism 112 Prostate Cancer 155
Hypoxemia 113 Pneumomediastinum 156
Hysterectomy, supracervial abdominal 114 Post operative patient 157
Hysterectomy, Total Abdominal with Prostatectomy 158
bilateral salpingo oopherectomy 115 Pulmonary Embolism 159
Ileus 116 Pyelonephritis 160
Jaundice 117 Renal Insufficiency, Chronic 161
Kidney Stone (nephrolithiasis) 118 Rheumatoid Arthritis 162
Laminectomy 119 Schizophrenia 163
Lap Cholectomy 120 Seborrheic dermatitis 164
Leukemia, Ac (myelogenous) 121 Seizure disorder 165
Lithotripsy 122 Seizures 166
Low back pain 123 Sepsis 167
Lumbar spinal stenosis 124 Shingles (herpes zoster) 168
Macrocytic anemia 125 Sigmoid colectomy 169
Malignant Tumors of Reproductive system Skin Breakdown 170
126 Small Bowel Obstruction (SBO) 171
Meningitis 127 Soft tissue injuryAbrasion 172
Multiple Myeloma 128 Spinal Revision and Fusion 173
Myocardial Infarction 129 Splenectomy 174
Narcolepsy 130 Subdural Hematoma 175
Nephrectomy 131 Substance Abuse-Inhalants 176
Nephrostomy Tube 132 Suicide 177
Neuropathic pain 133 Post operative patient 178
Non-Hodgkinss lymphoma 134 TIA 179
Obesity 135 Total hip Arthroplasty-THA 180
Obesity 136 Total hip replacement 181
Open reduction internal fixation (ORIF) 137 Total Knee Replacement 182
Osteoarthritis 138 Total knee replacement 183
Osteomyolitis 139 Transient Ischemic Attack 184
2
Transurethral Resection of the Prostate Vancomycin-Resistant Enterococci (VRE)
TURP 185 189
Urinary Retention 186 Vertigo 190
UTI 187 Vomiting 191
Uterine Fibroids 188 Weight Loss 192
Wound Infection 193
3
Abdominal abscess
Definition
Intra-abdominal abscesses are localized collections of pus that are confined in the peritoneal cavity by an
inflammatory barrier. This barrier may include the omentum, inflammatory adhesions, or contiguous viscera. The
abscesses usually contain a mixture of aerobic and anaerobic bacteria from the GI tract.
Although multiple causes of intra-abdominal abscesses exist, the following are the most common: (1) perforation of
a diseased viscus, which includes peptic ulcer perforation, (2) perforated appendicitis and diverticulitis, (3)
gangrenous cholecystitis, (4) mesenteric ischemia with bowel infarction, and (5) pancreatitis or pancreatic necrosis
progressing to pancreatic abscess. Microbiology includes a mixture of aerobic and anaerobic organisms.
S/S
-swelling
-bloating
-lack of appetite
-nausea
-vomiting
-rectal tenderness/fullness
-diarrhea
Nursing interventions
-empty and irrigate drain as ordered
-provide pain medication as ordered on a routine basis
- provide non-medication comfort measures in nursing scope of practice
-practice good hand hygiene before and after working with patient
Complications
Complications include recurrent abscesses, spontaneous rupture of an abscess, and occasionally, spread of the
infection to the blood stream and widespread infection.
4
Acute colititis
Definition:
Inflammation of the colon. The major cause of acute colitis is infectious, with the incidence and organism varying
widely on a geographic and socioeconomic basis
Ischemic colitis is a disease of the elderly and more affluent populations with an atherosclerotic prone diet. It can
also be caused by infection including viruses, bacteria, fungus and parasites or vascular, usually small vessel
disease.
Signs/Symptoms:
May be mild or severe
-persistent or recurrent diarrhea
-abdominal pain
-fever
-fatigue
-weight loss
-loss of appetite
Nursing Interventions:
Monitor vital signs
Monitor I/Os
Pain assessment
- location, intensity, type, quality, frequency
- does anything relieve it
Allow client extra time to eat
Excellent perineal is needed until the diarrhea is under control & after
- kept client clean, dry, and free of odor
Administer medications as ordered
Complications:
Bleeding
Ulceration
Perforation of the colon
Toxic megacolon
5
Acute Pyelonephritis
Definition
An acute infection and inflammatory disease of the kidney and renal pelvis involving one or both kidneys.
S/S
Fever, chills, costovertebral tenderness, flank pain (with or without radiation to groin), nausea, vomiting
Nursing interventions/Teaching
Assess vital signs frequently, and monitor intake and output; administer antiemetic medications to control nausea
and vomiting. Administer antipyretic medications as prescribed and according to temperature. Correct dehydration
by replacing fluids, orally if possible, or IV. Administer or teach self-administration of analgesic medications, and
monitor their effectiveness. Use comfort measures such as positioning to locally relieve flank pain.
Complications
Renal abscess requiring treatment by percutaneous drainage or prolonged antibiotic therapy. Perhipheral abscess.
Source
(Lippincott Manual of Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 717-718),
6
Acute Renal Failure
Definition
A clinical syndrome characterized by rapid loss of renal function with progressive accumulation of nitrogenous
waste products such as BUN and Creatinine.
S/S
Increased BUN, Creatinine, and Potassium, oliguria, producing more or less than urine than usual, feeling pressure
when urinating, changes in the color of urine, foamy or bubbly urine, having to get up at night to urinate, swelling of
the feet, ankles, hands, or face fatigue or weakness shortness of breath, ammonia breath or an ammonia or metal
taste in the mouth, back or flank pain, itching, loss of appetite, nausea and vomiting, more hypoglycemic episodes,
if diabetic.
Monitor VS, monitor BUN and Creatinine levels, patient teaching, have patient exercise, monitor diet, watch for any
signs of infection rejection or other illness, monitor electrolytes, strict I&O, daily weights, medication as ordered.
Complications
Anemia, metabolic acidosis, bone disease, cardiovascular disease, fluid overload, high potassium, phosphorus,
CKD
7
Acute Renal Failure
Definition
Acute renal failure (ARF) is characterized by a rapid loss of renal function with elevation of blood urea nitrogen
[BUN] and plasma creatinine levels. It is usually associated with oliguria (urine output of less than 30 ml/hr or less
than 400 ml/day), although urine output may be normal or increased.
S/S
Fatigue, weakness, malaise, change in usual urination pattern, excessive weight gain or loss, nausea and vomiting,
headache, blurred vision, shortness of breath.
Manage fluid and electrolyte balance, monitor vital signs and laboratory/diagnostic studies, assess/document
dietary intake measuring I&O accurately, and promote infection control.
Complications
Fluid retention, this may lead to swollen tissues, congestive heart failure or fluid in the lungs (pulmonary edema), a
sudden rise in potassium levels in your blood, this could impair your heart's ability to function and may be life-
threatening, weak bones that fracture easily, anemia, stomach ulcers, changes in skin color, damage to your
central nervous system, insomnia.
8
Acute Renal Failure
Definition
A syndrome of varying causation that results in a sudden decline in renal function. It is frequently associated with
an increase in BUN and creatinine, oliguria (les than 500 mL urine/24h), hyperkalemia, and sodium retention.
S/S
Prerenal- decreased tissue turgor, dryness of mucous membranes, weight loss, hypotension, oliguria or
anuria, flat neck veins, tachycardia
Postrenal- obstruction to urine flow, obstructive sx of BPH, possible nephrolithiasis
Intrarenal- presentation based on cause; edema usually present, changes in urine volume/serum
concentrations of BUN, creatinine, K+
Monitor for signs of hypo/hypervolemia, monitor I&O, monitor serum and urine electrolyte concentrations, daily
weight, auscultate lung fields for rales, VS, monitor K+ levels, inspect neck veins for engorgement, signs of edema,
watch for cardiac arrhythmias and CHF, instruct pt. on importance of diet: avoid foods high in K+, watch for
infection, meticulous wound care, assess mental status.
Complications
Infection, arrhythmias R/T hyperkalemia, electrolyte abnormalities, GI bleeding due to stress ulcers, multiple organ
systems failure.
Nursing Diagnosis
Fluid volume excess R/T decreased glomerular filtration rate and sodium retention.
Risk for infection R/T alterations in the immune system and host defenses.
Altered nutrition: less than body requirements R/T catabolic state, anorexia, and malnutrition associated with acute
renal failure.
Risk for injury R/T GI bleeding.
Altered thought processes R/T the effects of uremic toxins on the CNS.
9
Acute Renal Failure
Definition
A syndrome of varying causation that results in a sudden decline in renal function. It is frequently associated with
an increase in BUN and creatinine, oliguria, hyperkalemia, and sodium retention.
S/S
Prerenal decreased tissue turgor, dryness of mucous membranes, weight loss, hypotension, oliguria or
anuria, flat neck veins, tachycardia.
Postrenal obstruction to urine flow, obstructive symptoms of BPH, possible nephrolithiasis.
Intrarenal presentation based on cause; edema usually present. Changes in urine volume and serum
concentrations of BUN, creatinine, potassium, and so forth, as described above.
Monitor for signs and symptoms of hypovolemia or hypervolemia because regulating capacity of kidneys in
inadequate.
Monitor urinary output and urine specific gravity; measure and record I & Os including urine, gastric
secretions, stools, wound drainage, perspiration (estimate).
Monitor for all signs of infection. Be aware that renal failure patients do not always demonstrate fever and
leukocytosis.
Remove bladder catheter as soon as possible; monitor for UTI.
Offer high-carbohydrate feedings because carbohydrates have a greater protein-sparing power and provide
additional calories.
Examine all stools and emesis for gross and occult blood.
Watch for and report mental status changes - somnolence, lasstitude, lethargy, and fatigue progressing to
irritability, disorientation, twitching, and seizures.
Recommend resuming activity gradually because muscle weakness will present from excessive catabolism.
Complications
Infection; Arrhythmias due to hyperkalemia; Electrolyte (sodium, potassium, calcium, phosphorus) abnormalities; GI
bleeding due to stress ulcers; Multiple organ systems failure
Resource
(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 710- 712.)
10
Amputation
Definition
Removing part or all of an extremity as to preserve extremity length and function while removing all infected,
pathologic, or ischemic tissue.
S/S
N/A
Monitor VS, monitor I&O and daily weights, Monitor for signs and symptoms of depression, patient teaching of
amputation precautions, check dressing and change as ordered, do muscle strengthening exercises, encourage
patient to exercise on their own, ROM, teach patient bandaging technique, use sockets on stump, position patient
accurately, check skin integrity, check pain frequently, teach patient about phantom pain, special mattress if
ordered
Complications
Irritation, infection, chest infections, angina, heart attacks and strokes, further operations, contractures, DVT,
Phantom Limb pain
11
Amputation
Definition
Total or partial surgical removal of an extremity.
S/S
N/A
Monitor fluid balance: watch for hypotension, tachycardia, diaphoresis, decreased alertness, excessive wound
drainage, reinforce dressing, measure drainage, I/Os. Maintain tissue perfusion: control edema, maintain
pressure dressing. Support effective coping: Accept pt responses to loss of limb, encourage expression of fears,
recognize that modification of body image takes time, encourage rehab, and encourage independence. Control
pain. Outcomes: Vital signs stable, pressure dressing intact, stump elevated without edema, Patient participating
in plan of care, expressing concerns about independence. Verbalizes relief of incisional pain, dull phantom pain
tolerable.
Complications
Infection, sepsis
Nursing Diagnosis
Risk for fluid volume deficit r/t hemorrhage.
Altered tissue perfusion r/t edema.
Inneffective coping r/t change in body image and self care.
Pain r/t surgical procedure, phantom sensation.
Impaired physical mobility r/t amputation.
12
Anaphylaxis
Definition: Immediate, life-threatening systemic reaction that can occur on exposure to a particular substance.
Result of a Type 1 hypersensitivity rxn in which chemical mediators released from mast cells affect many types of
tissue and organ systems.
May be caused by:
Immunotherapy
Stinging insects
Skin testing
Medications
Contrast media infusion
Foods
Exercise
Latex
Manifested by:
Respiratory laryngeal edema, Bronchospasm, cough, wheezing, lump in throat
CV hypotension, tachycardia, palpitations, syncope
Cutaneous urticaria (hives), angioedema, pruritus, erythema (flushing)
GI N,V,D, abd pain, bloating
Nursing Interventions: - ID of S&S essential, a rxn occur quickly tends to be more severe.
Establish and maintain adequate airway and respiration (if epinephrine has not stabilized Bronchospasm
assist doc w/ endotracheal intibation,emergency tracheostomy as indicated)
Administer nebulized albuterol (bronchodilator) as ordered. Monitor HR ( inc w/ bronchodilators)
Provide O2 as ordered
Administer amophylline and corticosteroids as ordered.
Moniter BP w/ cont cuff
Administer rapid infusion of IV fluids to fill vasodilated circulatory system and raise BP.
Moniter CVP (central venous pressure) to ensure adequate fluid volume and to prevent fluid overload.
Insert indwelling catheter and monitor urine output hourly to ensure kidney perfusion.
Initiate titrate vasopressor as ordered, based on BP response.
Reduce anxiety provide care in quick, confident manner
- remain responsive to patient
- keep family/sig other informed on patients condition and treatment given.
Complications:
Cardovascular collapse
Respiratory failure
Poss. Nursing Dx:
Impaired breathing r/t Bronchospasm and laryngeal edema

Decreased CO r/t vasodilation
Anxiety r/t resp distress and life-threatening situation
13
Anemia
Definition
A deficiency in the number of erythrocytes (red blood cells), the quantity of hemoglobin, and/or the volume of
packed RBCs or hematocrit. It may be caused by blood loss, impaired production of erythrocytes, or increased
destruction of erythrocytes.
S/S
Identified and classified by laboratory diagnosis (Hb), Palpitations, dyspnea, diaphoresis, cardiopulmonary
complications, pallor, jaundice, pruritus, increased heart rate, MI, CHF peripheral edema, icteric conjunctiva, sclera,
retinal hemorrhage, blurred vision, smooth tongue, tachycardia, systolic murmurs, angina, orthopnea, headache,
vertigo, depression, anorexia, difficulty swallowing, sore mouth, bone pain, sensitivity to cold, weight loss, lethargy
Subjective and objective data should be obtained. Assess for manifestations of hypoxemia. Teach effective
breathing exercises and relaxation techniques. Strive for a 1:3 rest/activity ratio. Assist patient with ADLs as
needed. Teach proper diet full of iron. Monitor vital signs to evaluate activity tolerance. Monitor HH.
Complications
High-output heart failure, Angina, Heart damage, Heart failure, Heart attack
14
Anxiety
Definition
The most common of all psych disorders. The individual experiences physiologic, cognitive, and behavioral
symptoms of anxiety. The common theme is that the pt experiences a level of anxiety that interferes with
functioning in personal, occupational, and social areas.
S/S
The physiologic manifestations are related to the fight or flight response and result in cardiovascular, respiratory,
neuromuscular, and gastrointestinal stimulation. Cognitive symptoms include subjective feelings of apprehension,
uneasiness, uncertainty, or dread. Behavioral manifestations include irritability, restlessness, pacing, crying, and/or
sighing.
Help pt ID anxiety producing situations and plan for such events. Assist pt to develop assertiveness and
communication skills. Practice stress reduction techniques with pt. Encourage pt to verbalize feelings of anxiety.
Administer prescribed anxiolytics to decrease anxiety levels.
Outcomes
Pt IDs stressors, demonstrates normal HR, RR, sleep pattern, and subjective feelings of anxiety. Pt reports going
to work, keeping appointments. Pt uses coping strategies for situations that are anxiety provoking. Pt
demonstrates improved concentration and thought process through improved ability to problem solve, focus and
think. No injuries.
Complications
Increased risk of suicide and substance abuse/dependence disorders is possible with untreated somatoform
disorder. Pt may also have co-existing medical condition that may go undiagnosed. Careful screening is
necessary to r/o medical problems.
Nursing Diagnosis
Anxiety r/t unexpected panic attacks or r/t re-experiencing traumatic events.
Altered thought processes r/t severe anxiety.
Social Isolation r/t avoidance behavior or r/t embarrassment and shame associated with symptoms.
Personal Identity Disturbance r/t traumatic event.
Risk for injury r/t compulsive behaviors.
15
Appendicitis
Definition
Inflammation of the vermiform appendix caused by an obstruction of the intestinal lumen from the infection,
stricture, fecal mass, foreign body, or tumor.
S/S
Generalized or localized abdominal pain in the epigastric or periumbilical areas and upper right abdomen. Within 2-
12 hours, the pain localizes in the right lower quadrant and intensity increases. Anorexia, moderate malaise, mild
fever, nausea and vomiting. Usually constipation occurs; occasionally diarrhea. Rebound tenderness, involuntary
guarding, generalized abdominal rigidity.
Monitor pain level, including location, intensity, pattern.
Assist patient to comfortable positions, such as semi-Fowlers and kees up.
Restrict activity that may aggravate pain, such as coughing and ambulation.
Apply ice bag to abdomen for comfort. Monitor frequently for signs and symptoms of worsening condition
indicating perforation, abscess, or peritonitis: increasing severity of pain, tenderness, rigidity, distention,
ileus, fever, malaise, tachycardia.
Complications
Perforation (in 95% of cases); Abscess; Peritonitis
Resource
(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 615-616.)
16
Aspiration Pneumonia
Definition
Refers to sequelae occurring from abnormal entry of secretions of substances into the lower airway.
S/S
Usually follows aspiration of from the mouth or stomach into trachea and lungs, loss of consciousness, depressed
gag and cough reflexes, malaise, fever, chest pain, pleuritic cough (usually non-productive), shortness of breath,
upper abdominal/loin pain, sputum, tachycardia, herpes labialis, dullness in chest to percussion, crackles in lungs,
plural rub, cyanosis, hypotension, confusion, tachypnea, rales or wheezing in lungs
Monitor VS frequently, IS, deep breathe and cough, dyspnea, ineffective airway clearance, hyperthermia, activity
intolerance, monitor for signs of infection, monitor respiratory status, monitor for signs of inflammation, oxygen
therapy if ordered, patient teaching, have patient do diaphragmatic breathing
Complications
Pleurisy, pleural effusion, atelectasis, delayed resolution, lungabscess, empyema, pericarditis, arthritis, meningitis,
endocarditis, hypoxemia, tracheobronchial constriction, pneumothorax
17
Asthma
Definition
Lippencott, 921. Bronchial asthma is a chronic inflammatory disorder of the airways in which many cells and
cellular elements play a role. This inflammation causes wheezes, breathlessness, chest tightness, and coughing.
The episodes are associated with variable airflow obstruction that is often reversible either spontaneously or with
treatment. Mast cells release chemical mediators that cause bronchioconstriction and increased mucous secretion
in the bronchial tree.
S/S
Episodes of coughing, wheezing, dyspnea, and/or feeling chest tightness.
Monitor v/s, degree of restlessness (indicator of hypoxia), Provide nebulization, O2 therapy as prescribed,
encourage fluid intake (thins secretions), position to facilitate breathing (sitting upright, lean on table), pursed lip
breathing, relieve anxiety. Outcome: Pts symptoms reduced (wheezing, coughing, chest tightness, etc), peak flow
improved. Pt verbalizes relief of anxiety.
Complications
Status Asthmaticus. This is a severe form of asthma in which the airway obstruction is unresponsive to usual drug
therapy. Contributing factors include: Infection, overuse of bronchodilators, aspiration of gastric acid, ingestion of
aspirin in the aspirin-sensitive patient, inhalation of pollutants and allergens to which pt is sensitized.
Nursing Diagnosis
Innefective breathing pattern, r/t bronchospasm.

Anxiety, r/t fear of suffocating, difficulty in breathing, death.
18
Asthma
Definition
A chronic inflammatory disorder of the airways in which many cells and cellular elements play a role.
S/S
Episodes of coughing. Wheezing,Dyspnea,Feelin of chest tightness.
Monitor vital signs, skin color, retraction, and degree of restlessness, which may indicate hypoxia.
Provide nebulization and oxygen therapy as prescribed.
Monitor airway function through peak flow meter or pulmonary finction testing to assess effectiveness of
treatment.
Encourage intake of fluids to liquefy secretions.
Encourage patient to use adaptive breathing techniques (e.g. pursed lip breathing) to decrease the work
of breathing.
Complications
Angina pectoris or MI due to decreased coronary perfusion.
Left ventricular hypertrophy and CHF due to consistently elevated aortic pressure.
Renal failure due to thickening of renal vessels and diminished perfusion to the glomerulus.
Transient ischemic attacks (TIAs), stroke, or cerebral hemorrhage due to cerebral ischemia and
arteriosclerosis. Retinopathy.
Accelerated hypertension.
Resource
19
Asthma
Definition
Asthma is a chronic condition that occurs when the main air passages of your lungs, the bronchial tubes, become
inflamed. The muscles of the bronchial walls tighten and extra mucus is produced, causing your airways to narrow.
This can lead to everything from minor wheezing to severe difficulty in breathing. In some cases, your breathing
may be so labored that an asthma attack becomes life-threatening.
S/S
Increased shortness of breath or wheezing, disturbed sleep caused by shortness of breath, coughing or wheezing,
chest tightness or pain, increased need to use bronchodilators medications that open up airways by relaxing the
surrounding muscles, a fall in peak flow rates as measured by a peak flow meter.
Maintain airway patency, assist with measures to facilitate gas exchange, administer medications as indicated,
enhance nutritional intake, and provide information about disease process/prognosis and treatment regimen.
Complications
Severe shortness of breath, impaired gas exchange, respiratory imbalances (acidosis, alkalosis).
20
Asthma
Definition
A chronic inflammatory disorder of the airways in which inflammation causes varying degrees of obstruction in the
airways.
S/S
Recurrent episodes of wheezing, breathlessness, chest tightness, cough, increase in existing hyperresponsiveness
to a variety of stimuli; dry cough, full blown respiratory distress, prolongation of expiratory phase, nasal flaring,
using accessory breathing muscles, retractions, irritability, lethargy, change in color, feeding difficulty, speaking
difficulty, wheezing / poor air movement, breathing changes, sneezing, moodiness, headache, runny/stuffy nose,
coughing, chin or throat itches, feeling tired, dark circles under eyes, trouble sleeping, poor tolerance for exercise,
downward trend in peak flow number, sweating, decreased LOC
Monitor patients vital signs, educate patient and family, assist patient to sitting position with head slightly flexed,
encourage patient to take deep breaths, monitor respiratory and oxygenation status, regulate fluid intake,
administer drug therapy, ausculate lung sounds periodically, have patient keep journal of triggers, keep patient
comfortable so they have no anxiety
Complications
Sleeplessness, respiratory failure, pneumothorax, lung infections, chronic obstructive pulmonary disease,
atelectasis, death (rarely), hospitilization, asphyxia
21
Atrial Fibrillation
Definition
An electrical rhythm disturbance of the heart affecting the atria. Abnormal electrical impulses in the atria cause the
muscle to contract erratically and pump blood inefficiently. The atrial chambers are thus not able to completely
empty blood into the ventricles.
S/S
Irregular heartbeat, rapid heartbeat, rapid beating of upper chest chambers, palpitations, chest pain,
breathlessness, faintness, weakness, tiredness
Monitor vital signs, provide comfort for the patient, carefully read EKG results
Complications
Stroke, heart failure, coronary thrombosis, embolism, death
22
Azotemia
Definition
A toxic condition characterized by abnormal and dangerously high levels of urea, creatinine, various body waste
compounds, and other nitrogen rich compounds in the blood as a result of insufficient filtering of the blood by the
kidneys. Also known as prerenal azotemia and uremia. Can be caused by medical conditions that impair blood flow
to the kidneys (ex: CHF, shock, severe burns, prolonged vomiting or diarrhea).
S/S
decreased or no urine produced, fatigue, decreased alertness, confusion, pale skin color, rapid pulse, dry mouth,
thirst swelling (edema, anasarca), orthostatic blood pressure (rises or falls, significantly depending on position)
check labs (UA), VS, skin assessment, I&O, daily weight, edema, alteration in mucous membranes, check for
exposure to potentially nephrotoxic drugs (NSAIDS, antibiotics), monitor serum and urine electrolyte levels, restrict
salt and water intake, monitor acid/base balance, instruct pt. on diet, watch for cardiac arrhythmias and CHF, check
for infection, LOC
Complications
acute renal failure, acute tubular necrosis, electrolyte abnormalities, infection, arrhythmias due to hyperkalemia
Nursing Diagnosis
Fluid volume excess R/T decreased glomerular filtration rate and sodium retention.
Altered thought processes R/T the effects of uremic toxins on CNS.
Altered nutrition: less than body requirements R/T catabolic state, anorexia, and malnutrition associated with acute
renal failure.
Risk for infection R/T alterations in the immune system and host defenses.
23
Bi-Polar Disorder
Definition
A chronic mood syndrome that manifests as recurring mood episodes includes both periods of hypomania or
maina, and depressive episodes. Mania, hypomania, depression, and concurrent mania and depression
characterize the mood episodes.
S/S
Personality disturbance or disorder of temperament, seasonal depression, alcohol and/or substance abuse, rapid
mood cycling, premenstrual dysphoria, impulse difficulties, interpersonal sensitivity, recurrent depression, mood
instability, inflated sense of self-importance, decreased need for sleep, loud, rapid speech, racing thoughts,
distractibility, agitation or restlessness, increase in goal-oriented activities, unwise involvement in pleasurable but
potentially risky activities, significant changes in appetite and/or weight, loss of energy or fatigue, slowed speech,
thinking, or body movements, recurring thoughts of death or suicide
Support patient and family, educate patient and family, listen to patient talk, be patient with patient, monitor vital
signs, monitor patient for other disorders, monitor I/O and daily weights, help patient with accurate perception, help
patient with communication, encourage exercise
Complications
Personality disorders, anxiety disorders, anorexia nervosa, bulimia nervosa, attention deficit, hyperactivity
disorders, suicide, sleep disorders
24
Bowel resection
Definition
Segmental excision of small and/or large bowels with varied approaches.
S/S
N/A
VS, signs of infection and shock (fever, hypotension, tachycardia), I&O, abdominal assessment for increased pain
and distention, bowel sounds (should be absent immediately post-op), dressing/incision/drainage, flatus/feces
through stoma, N/V, NG aspirate, electrolytes, pain, weight.
Implementations- irrigate NG tube, thrombus precautions if ordered, turn/cough/deep breathe q2h, ambulation,
dressing changes qd or prn, aseptic technique, advance diet as tolerated. Education- stoma care, diet- high fiber,
low flatus, increase fluids, medication administration.
Complications
Paralytic ileus, paralytic obstruction, peritonitis, sepsis, anastomatic leakage, mucocutaneous separation, ischemia
of stoma, stomal prolapse, peristomal hernia, self image deterioration.
25
Brain Cancer
Definition
Primary intracranial neoplasms are the result of proliferation of normal cells within the CNS. These include tumors
of the brain itself, the skull or meninges, the pituitary gland, and the blood vessels. CNS tumors may also consist of
metastatic tumors that spread from systemic organs. Primary CNS tumors only rarely metastasize outside the
CNS.
S/S
Generalized symptoms (due to ICP) headache (especially in the morning), vomiting, papilledema, malaise, altered
cognition and consciousness. Focal neurological deficits (related to region of tumors); Parietal area - sensory
alterations, speech and memory disturbances; Frontal lobe personality, behavior, and contra-lateral motor
weakness; Temporal area & Occipital area auditory hallucinations, visual field deficits; Cerebral area
coordination, gait, and balance disturbances, dysarthria. Seizures
Provide analgesics around the clock at regular intervals that will not mask neurological changes. Maintain the head
of the bed at 15 to 30 degrees to reduce cerebral venous congestion. Provide a darkened room or sunglasses if
the patient is photophobic. Maintain a quiet environment to increase patients pain tolerance. Provide scheduled
rest periods to help patient recuperate from stress of pain. Alter diet as tolerated if pt has pain on chewing.
Collaborate with pt on alternative ways to reduce pain, such as use of music therapy.
Complications
Increased ICP and brain herniation, neurological deficits from expanding tumor or treatment
26
Breast cancer
Definition
A malignant neoplasm (usually an adenocarcinoma) of the breast. (Venes, D. (19th ed.) (2001). Tabers Cyclopedic
Medical Dictionary. Philadelphia: F.A. Davis Company. Pgs.277-280.)
A growth of abnormal cells in breast tissue that is irregular. (Hogan, M. A. & Hall, K. (2004). Pathophysiology:
Reviews & Rationales. New Jersey: Pearson Education, Inc. Pgs. 358-360.)
S/S
Lump or thickening of breast tissue, usually painless in UOQ, and enlargement of axillary or supraclavicular lymph
nodes. Nipple discharge spontaneous, may be bloody, clear, or serous. Breast asymmetry change in size or
shape or abnormal contours,Nipple retraction or scaliness.
Late signs pain, ulceration, edema, orange peel skin (peau dorange) from the interference of lymphatic drainage.
Manifestations from metastasis include bone pain, neurologic changes, weight loss, anemia, cough, shortness of
breath, pleuritic pain, and vague chest discomfort.
Reducing Anxiety: Realize that diagnosis of breast cancer is a devastating emotional shock to the woman. Support
patient through the diagnostic process. Providing Information about Treatment: Involve patient in treatment
planning. Describe surgical procedures. Prepare patient for the effects of chemotherapy; encourage patient to plan
ahead for the common side effects of chemotherapy. Strengthening Coping: Repeat information and speak in
calm, clear manner. Display empathy and acceptance of patients emotions.
Complications
Metastasis most common sites: lymph nodes, lung, bone, liver, and brain. Signs and symptoms of metastasis
may include bone pain, neurologic changes, weight loss, anemia, cough, shortness of breath, pluritic pain, and
vague chest discomfort.
27
Bronchial asthma
Definition
Chronic inflammatory disorder of the airways in which many cells and cellular elements play a sole. Causes
episodes of wheezing, breathlessness, chest tightness, and coughing (particularly at night) and airway hyper
reactivity to various stimuli. Episodes usually associated with variable airflow obstruction that is of ten reversible
either spontaneously or with treatment.
S/S
Episodes of coughing, wheezing, dyspnea, feeling of chest tightness.
Encourage intake of fluids to liquefy secretions, instruct pt. on positioning to facilitate breathing, teach adaptive
breathing techniques, monitor: VS/ skin color/ retraction/ degree of restlessness which may indicate hypoxia,
provide nebulization and O2 therapy as prescribed, monitor airway function through peak flow meter or pulmonary
function test, relieve anxiety, auscultation of lungs.
Complications
SOB, wheezing, coughing, chest tightness, apnea.
Nursing Diagnosis
Ineffective breathing pattern R/T bronchospasm.
Anxiety R/T fears of suffocating, difficulty in breathing, death.
28
Bronchitis
Definition
A condition that occurs when the inner walls that line the main air passageways of your lungs (bronchial tubes)
become inflamed. Bronchitis often follows a respiratory infection such as a cold.
S/S
A cough that brings up yellowish-gray or green mucus (sputum), soreness and a feeling of constriction or burning in
your chest, breathlessness, wheezing, chills, overall malaise and slight fever.
Maintain airway patency, assist with measures to facilitate gas exchange, enhance nutritional intake, and prevent
complications.
Complications
Chronic bronchitis, asthma or other lung disorders. Having chronic bronchitis also increases your risk of lung
cancer.
29
Clostridium difficile
Definition
C. difficile is a spore-forming bacillus that produces toxins that cause gastrointestinal illness. These spores are
extremely resistant and can survive on contaminated surfaces for weeks or months. C. difficile is one of the most
common causes of infectious diarrhea in long term care facilities up to 7 % of residents become colonized with C-
dif.
S/S
severe diarrhea
nausea
abdominal distention
fever
leukocytosis
dehydration
hypotension
Nursing Interventions
Avoid unnecessary use of antibiotics; if antibiotics are prescribed, make sure to give all doses on a regular
schedule. Be aware of signs/symptoms of superinfection.
Proper hand hygiene wash your hands thoroughly before and after caring for every patient.
When working with patient infected with C.difficile, always wear gloves.
Follow universal and contact precautions when caring for a patient with C. difficile.
Ensure that a patient that is positive for C. difficile is in an isolated room.
Use disinfectants to disinfect the patients room and anything that comes in and goes out of the patients
room.
Encourage fluids to help maintain the patients fluid and electrolyte balances.
Restrict visitors to a patient with C. difficile to help prevent spreading.
Complications
C. dif can lead to toxic megacolon which can lead to bowel perforation and even death.
30
Candidiasis, esophageal and oral
Definition
Yeast infection of the mucous membranes of the mouth and tongue. Candida albicans is an organism that lives in
the mouth and is kept in check by healthy organisms. When resistance to infection is low, the fungus can grow
which causes lesions in the mouth, on the tongue, and down the throat. People with HIV/AIDS are at an increased
risk due to their immunosuppressed status. It can be disseminated throughout the entire body if not treated.
S/S
-whitish, velvety plaques in the mouth, throat and on the tongue
-under the whitish plaques, there are sores which may bleed
-increasing number and size of these lesions
-bad taste/foul odor coming from the mouth and in the mouth
Assess for mechanical agents or chemical agents such a frequent exposure to tobacco that could cause or
increase trauma to the oral mucosal membranes.
Encourage fluid intake up to 3000ml per day, if not contraindicated.
Determine clients usual method of oral care and address any concerns regarding oral hygiene.
Use tap water or normal saline to provide oral care; do not use mouthwashes containing alcohol or hydrogen
peroxide.
Complications:
It can disseminate throughout the body, causing infections in the esophagus, the brain, the heart, joints, or eyes.
31
Cancer
Definition
Lippencott, 137. Cancer is a disease of the cell in which the normal mechanisms of control of growth and
proliferation are disturbed. The results are distinct morphologic alterations of the cell and aberrations in tissue
patterns. The malignant cell is able to invade the surrounding tissue and regional lymph nodes. Primary cancer
usually has a predictable natural history and pattern of spread. Metastasis is the secondary growth of primary CA.
Lymph nodes are often the first site for metastases.
S/S
Symptoms will vary greatly depending on the primary site.
Teach Cancer Prevention: Teach about diets low in fat, high in fiber. Advise pt of the increased risk factors
associated with smoking, obesity, and alcohol consumption. Teach pt to avoid sun exposure btwn 10a-3p. Routine
screenings, self exams. Prevent infection with those in therapy. Monitor v/s Q4, have pt report any
signs/symptoms of infection. Reinforce good hygiene, encourage coughing, deep breathing.
Monitor WBC, H&H, avoid invasive procedures when platelet count less than 50,000. Avoid use of aspirin,
NSAIDS. No topical agents w/ radiation unless prescribed. Outcome: Pt skin intact, w/out breakdown or signs of
infection. Pt afebrile, with no signs of infection. No bruising, bleeding, dyspnea, oral lesions, or pain. Pt maintains
proper hygiene. Pt tolerating small, frequent meals w/ antiemetic.
Complications
W/ radiation, complications depend on location, dose, overall pt health. Chemo complications include: alopecia,
anorexia, fatigue, n/v, mucositis, anemia, neutropenia, thrombocytopenia.
Nursing Diagnosis
Risk for infection r/t neutropenia.
Risk for bleeding r/t thrombocytopenia.
Fatigue r/t anemia,
Altered nutrition: less than body requirements r/t side effects of therapy.
Altered oral mucosa r/t stomatitis.
Altered body image r/t alopecia and weight loss.
Risk for impaired skin integrity r/t radiation tx.
32
Cancer
Definition
Lippencott, 137. Cancer is a disease of the cell in which the normal mechanisms of control of growth and
proliferation are disturbed. The results are distinct morphologic alterations of the cell and aberrations in tissue
patterns. The malignant cell is able to invade the surrounding tissue and regional lymph nodes. Primary cancer
usually has a predictable natural history and pattern of spread. Metastasis is the secondary growth of primary CA.
Lymph nodes are often the first site for metastases.
S/S
Symptoms will vary greatly depending on the primary site.
1. Teach Cancer Prevention: Teach about diets low in fat, high in fiber. Advise pt of the increased risk
factors associated with smoking, obesity, and alcohol consumption. Teach pt to avoid sun exposure
between 10a-3p.
2. Routine screenings, self exams. Prevent infection with those in therapy.
3. Monitor v/s Q4, have pt report any signs/symptoms of infection.
4. Reinforce good hygiene, encourage coughing, deep breathing.
5. Monitor WBC, H&H, avoid invasive procedures when platelet count less than 50,000.
6. Avoid use of aspirin, NSAIDS. No topical agents w/ radiation unless prescribed.
Outcome: Pt skin intact, w/out breakdown or signs of infection. Pt afebrile, with no signs of infection. No bruising,
bleeding, dyspnea, oral lesions, or pain. Pt maintains proper hygiene. Pt tolerating small, frequent meals w/
antiemetic.
Complications
W/ radiation, complications depend on location, dose, overall pt health. Chemo complications include: alopecia,
anorexia, fatigue, n/v, mucositis, anemia, neutropenia, thrombocytopenia.
Nursing Diagnosis:
Risk for infection r/t neutropenia.

Risk for bleeding r/t thrombocytopenia.
Fatigue r/t anemia, Altered nutrition: less than body requirements r/t side effects of therapy.
Altered oral mucosa r/t stomatitis.
Altered body image r/t alopecia and weight loss.
Risk for impaired skin integrity r/t radiation tx.
33
Candidiasis, Esophageal and Oral
Definition
Yeast infection of the mucous membranes of the mouth and tongue. Candida albicans is an organism that lives in
the mouth and is kept in check by healthy organisms. When resistance to infection is low, the fungus can grow
which causes lesions in the mouth, on the tongue, and down the throat. People with HIV/AIDS are at an increased
risk due to their immunosuppressed status. It can be disseminated throughout the entire body if not treated.
S/S
whitish, velvety plaques in the mouth, throat and on the tongue
under the whitish plaques, there are sores which may bleed
increasing number and size of these lesions
bad taste/foul odor coming from the mouth and in the mouth
Assess for mechanical agents or chemical agents such a frequent exposure to tobacco that could cause or
increase trauma to the oral mucosal membranes.
Encourage fluid intake up to 3000ml per day, if not contraindicated.
Determine clients usual method of oral care and address any concerns regarding oral hygiene.
Use tap water or normal saline to provide oral care; do not use mouthwashes containing alcohol or hydrogen
peroxide.
Complications:
It can disseminate throughout the body, causing infections in the esophagus, the brain, the heart, joints, or eyes.
34
Cardiac Catheterization
Definition
Performed by insertion of a radiopaque catheter into the right or left side of the heart. For the right side of the heart,
a catheter is inserted through an arm vein (basilica or cephalic) or a leg vein (femoral). The catheter is advanced
through the vena cava, the right atrium, and the right ventricle. The catheter is further inserted into the pulmonary
artery, and pressures are recorded. The catheter is then advanced until it is wedged or lodged into position. The
pulmonary artery wedge position (wedge pressure) obstructs the flow and pressure from the right side of the heart
and looks forward through the pulmonary capillary bed to the pressure in the left side of the heart. The wedge
pressure is used to determine the function of the left side of the heart. The left heart catheterization is performed by
insertion of a catheter into a femoral or brachial artery. The catheter is passed up the aorta, across the aortic valve,
and into the left ventricle.
S/S
N/A
Obtain consent, check for iodine sensitivity, withhold food and fluids for 6-18 hours prior to procedure, give sedative
if ordered, inform patient about use of anesthesia, insertion of catheter, and feeling of warmth and fluttering
sensation as catheter is passed through the heart.
Complications
Looping, kinking, or breaking off of catheter; blood loss; allergic reaction to contrast media; infection; thrombus
formation; air or blood embolism; arrhythmias; MI; stroke; puncture of the ventricles, cardiac septum, or lung tissue;
and, rarely, death.
35
Cast Care
Definition
Lippincott 973 A cast is an immobilizing device made up of layers of plaster or fiberglass bandages molded to the
body part it encases; Many types and applications: partial and whole limb, trunk, body, spica (trunk and extremity)
S/S
N/A
Assessment- Pain, swelling, discoloration (pale or blue), cool skin distal injury, paresthesia, paralysis, slow cap
refill, pressure sores; Assess CV, respiratory, GI systems for possible complications due to immobility; Assess
psych reactions to illness, cast, immobility; Interventions: keep dry,
dont cover with plastic (causes condensation), no weight bearing on plaster cast for 24 hours; Pt ed : cast cleaning,
keep alert to prevent falls, no objects under the cast to avoid injury to the skin, petal edges or use moleskin
padding; Inspect skin for signs of irritation; Assess neurovascular status; Apply ice bags as presribed; Assess pain
levels; Isometric exercises; Pt to alert healthcare provider if excessive swelling, paresthesia, persistent pain, pain
on passive stretch or paralysis;
Complications
Pressure can cause necrosis, sore and nerve palsies; Compartment syndrome: vascular insufficiency and
nerve/muscle compression due to unrelieved swelling can irreversible damage to an extremity; Multi system
problems: nausea/vomiting associated with cast syndrome, anxiety due to confinement, thrombophlebitis, possible
pulmonary emboli, depression due to loss of control, dependence
36
Cellulitis
Definition
An inflammation of the subcutaneous tissue of the skin that results from an infectious process. Lippincott 1026
S/S
Tender, warm, swollen and reddened area- well demarcated. Possible abscess or purulent discharge.
Assessment: Observe for expanding borders and lymphatic streaking. Assess affected area. Nursing Interventions:
Protect Skin Integrity, Pain Management, Assess Site. Labs: Blood cultures and culture of drainage.
Complications
Tissue necrosis, septicemia.
Nursing Diagnosis
Risk for Impaired Skin Integrity related to infectious process.
Pain related to inflammation of sub q tissue.
37
Cerebrovascular accident (stroke)
Definition
Onset and persistence of neurologic dysfunction lasting longer than 24 hours and resulting from disruption of blood
supply to the brain and indicates infarction rather than ischemia.
S/S
HA, numbness, weakness, loss of motor ability, difficulty swallowing, aphasia, visual disturbances, altered cognitive
abilities and psychological affect, self care deficit.
VS, I&O, semifowlers/side rails in place, assess for fall status, exercise affected extremities with passive ROM, be
aware of cognitive alterations and adjust interaction and environment accordingly, foster independence with ADLs
(i.e. clothes with front closures, Velcro), help pt. relearn swallowing, encourage small frequent meals, inspect mouth
for food collection and pocketing, encourage frequent oral hygiene, speak slowly/directly to pt. while facing them
and minimize distractions, monitor bowel/bladder function, assess effectiveness of anticoagulation therapy.
Complications
Aspiration pneumonia, dysphagia, spasticity, DVT, pulmonary embolism, brain stem herniation, poststroke
depression.
38
Cerebrovascular Accident (stroke)
Definition
The onset and persistence of neurologic dysfunction lasting longer than 24 hours and resulting from disruption of
blood supply to the brain and indicates infarction rather than ischemia.
(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 458.)
S/S
Sudden weakness or numbness of the face, arm or leg ,Sudden loss of vision or dimming of vision, Sudden
difficulty speaking or understanding speech, Sudden severe headache, Sudden falling, gait disturbance or
dizziness.
(Venes, D. (19th ed.) (2001). Tabers Cyclopedic Medical Dictionary. Philadelphia: F.A. Davis Company. CD-
ROM.)
Preventing Falls and Other Injuries
Maintain bed rest during acute phase (24-48 hours after onset of stroke) with head of bed slightly elevated
and side rails in place.
Preventing Complications of Immobility: Use a foot board during flaccid period after stroke to keep foot
dorsiflexed; avoid its use after spasticity develops.
Optimizing Cognitive Abilities: Be aware of the patients cognitive alterations, and adjust interaction and
environment accordingly.
Facilitating Communication: Speak slowly, using visual cues and gestures; be consistent, and repeat as
necessary.
Promoting Adequate Oral Intake: Encourage small, frequent meals, and allow plenty of time to chew and
swallow.
Attaining Bladder Control:
Establish regular schedule of voiding every 2-3 hours, correlated with fluid intake once bladder tone
returns. (Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers.
Pgs. 543-544.)
Complications
Aspiration pneumonia; Dysphagia in 25-50% of patient after stroke; Spasticity, contractures; Deep-vein thrombosis,
pulmonary embolism; Brain stem herniation; Poststroke depression
(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 459.),
39
Cerebrovascular Accident/Stroke
Definition
A sudden loss of brain function caused by a blockage (ischemia) or rupture of a blood vessel to the brain, which
results in the death of those brain cells.
S/S
Loss of muscular control, diminution or loss of sensation or consciousness, dizziness, slurred speech, or other
symptoms that vary with the extent and severity of the damage to the brain, headache, aphasia, anosognosia,
sensory loss, apraxia, personality change, possible cognitive impairment, urinary incontinence, dysphagia, ataxia,
nausea, vomiting, visual disturbances, vertigo, unilateral hearing loss, hoarseness.
Patient and family teaching of ways to prevent CVAs, Antiplatelet drugs to prevent further strokes, daily weights,
maintain a healthy diet, ensure patient airway, maintain adequate oxygenation, monitor vital signs, monitor
neurologic status including level of consciousness, avoid neck flexion to avoid obstruction of arterial and venous
blood flow, encourage use of incentive spirometry if ordered, assess range of motion, maintain and encourage
exercise.
Complications
Greater neurological deficit, confidence interval, hypoalbuminemia, disability, advancing age, Depression, paralysis,
coma, death, hemiparesis, vision problems, speech problems, recurrent strokes, cognitive deficits, emotional
difficulties, daily living problems, pain, Spatial problems, Perception problems Impaired judgment, Short-term
memory problems, Slowness, Cautious behavior
40
Cervical stenosis (spondylosis)
Definition
Narrowing of the spinal canal due to intervertebral discs losing water content/ becoming less spongy. (This reduces
disc height and can cause the hardened disc to bulge into the spinal canal). These changes are common after age
50, rate of progression varies. Narrowing can pinch the spinal cord and nerve roots that can lead to myelopathy or
radiculopathy.
S/S
(cervical stenosis does not generally have Sx; Sx are indicative of myelopathy or radiculopathy) pain in neck and
arms, arm and leg dysfunction, (arm Sx= weakness, stiffness, or clumsiness) (leg Sx= weakness, frequent falls,
difficulty walking) urinary urgency/ bowel and bladder incontinence can occur, increased knee and ankle reflexes.
Assess pain, exercises to increase flexibility
Complications
myelopathy, radiculopathy
41
Chemotherapy
Definition: Chemotherapy is the use of antineoplastic drugs to promote tumor cell destruction by interfering with
cellular function and reproduction.
Goals of chemo:
1. curative complete response to tumor
2. control to extend life of pt when cure not possible
3. palliative reduction in tumor burden to relieve symptoms such as pain and improve quality of life.
Complications:
Risk Factors:
42
CHF
Definition
The clinical syndrome that results from the hearts inability to pump the amount of oxygenated blood necessary to
meet the metabolic requirements of the body.
S/S
Right sided (Backward): elevated pressure in systemic veins/capillaries, leading to edema, unexplained weight
gain, liver congestion, distended neck veins, abnormal fluid in body cavities, weakness and nocturia. Left sided
(Forward): congestion in lungs due to backed up blood in the pulmonary veins/capillaries, SOB, cough (dry, non
productive), fatigue, insomnia, tachycardia, s3 ventricular gallop.
Maintain adequate Cardiac Output by promoting physical comfort, decreased exertion, frequent VS and heart
sounds, and administer pharmacotherapy as prescribed. Improving oxygenation by raising HOB, watch respiration
rate, encourage deep breathing, small frequent feedings, and administer O2 as prescribed. Improve activity
intolerance by increasing activities gradually, assist pt with self care, be alert to signs of chest pain, etc. Outcomes:
Normal HR, BP and RR. ABGs normal, no wheezes, crackles, or pitting edema.
Complications
Cardiac dysrythmias, Myocardial failure, Digitalis toxicity, Pulmonary Infarction, pneumonia, emboli
Nursing Diagnosis
Decreased cardiac output r/t impaired contractility.
Impaired gas exchange, r/t alveolar edema due to elevated ventricular pressure.
Fluid Volume Excess r/t sodium and water retention
Activity intolerance r/t oxygen supply and demand imbalance
43
Cholecystitis
Definition: Inflammation of the gallbladder usually assoc. w/ cholelithiasis. It may be acute or chronic, and is
associated with obstruction of gallstones or biliary sludge. E. Coli is the most common bacteria involved (strep and
salmonellae are also common). Other etiologic factors are adhesions, neoplasms, anesthesia, and narcotics.
M/B Vary from indigestion to mod to severe pain in RUQ, fever, jaundice. This could be accompanied by nausea,
restlessness, diaphoresis. Manifestations of inflammation would be leukocytsis and fever, RUQ tenderness and
abd rigitiy. Symptoms of chronic cholecystitis include hx fat intolerance, dyspepsia, heartburn, and flatulence.
Clinical manifestations if bile duct obstructed:

Obstructive jaundice - no bile flow into duodenum
Dark amber urine - bilirubin in urine
No urobilinogen in urine no bilirubin reaching SI to be converted to urobilinogen
Clay colored stools -
Pruritis - deposits of bile salts in skin tissues
Fatty food intolerance - no bile in SI for digestion
Bleeding tendencies - decr absorption vit K, therefore dec production PT
Complications:
Cholangitis inflammation of biliary ducts
Billiary cirrhosis
Fistulas
Rupture of gall bladder can produce bile peritonitis
carcinoma
relieving pain w/ analgesics as ordered
antibiotics as ordered
maintaining fluid and electrlyte balence
if N/V severe, gastric decompression
prepare surgery
Anticholinergics as ordered to decrease secretions (prevents biliary contraction)
44
Cholecystectomy
Definition
Lippincott pg 636 Surgical removal of the gall bladder for acute and chronic cholecystitis [more than 600,000
performed each year in the U.S., second only to abortions (1.2 million)]
S/S
N/A
Pre-op IV fluids for hydration if pt has been vomiting; Antibiotics for acute cholecystitis; Pt education regarding
procedure and post-op; Pt NPO after 2400 night before surgery and must void prior to surgery; Post-Op Vital
signs, LOC, pain level; Assess wound appearance; Monitor I& Os ; Early ambulation to prevent thromboembolus
and facilitate voiding and stimulate peristalsis. Pt education- rapid post-op recovery should be expected, notify
surgeon immediately of any subtle change in post-op course or persistent symptoms due to possible bile duct injury
Complications
Incisional infection, hemorrhage, bile duct injury (persistent pain, fever, abdominal distension, nausea, anorexia, or
jaundice)
45
Cholecystectomy
Definition
Most often performed using a laparoscope, a pencil-thin tube with its own lighting system and miniature video
camera. The laparoscope is inserted into the abdomen through a cannula. Only small incisions are required. The
video camera produces a magnified view on a television monitor of the inside of the abdomen which allows the
surgeon to see the surgery in detail. To remove the gallbladder, the surgeon uses tiny instruments inserted through
several other small abdominal incisions. Occasionally an option is open surgery, in which the gallbladder is
removed through a large abdominal incision.
S/S
N/A
Pain management, monitor vital signs and laboratory/diagnostic studies, assess/document dietary intake measuring
I&O accurately, and promote infection control.
Complications
After surgery the liver continues to produce enough bile to digest a normal diet, but the patient may experience
more bowel movement than usual and that their consistency is less solid. For some people these changes can be
major. In most cases the symptoms usually lessen over time.
46
Cholelithiasis
Definition: Stones in the gall bladder. The stones may be lodged in the neck of the gall bladder or cystic duct. The
actual cause is unknown. It develops when the balance that keeps cholesterol, bile slats, and calcium in solution is
altered so that precipitation occurs. Conditions that upset the balance are infection, and disturbances in
metabolism, and most clients have a liver saturated in cholesterol. Most stones are made out of cholesterol. Other
components could be bile salts, bilirubin, Ca and protein.
Stones can remain in GB or migrate into cystic or common bile duct.
M/B: severe pain RUQ or none at all, depends whether the stones are stationary or mobile, and whether
obstruction is present. If pain excruciating, it is usually accompanied by tachycardia, and diaphoresis usually
occurs 3-6 hours after heavy meal.
Clinical manifestations if bile duct obstructed:

Obstructive jaundice - no bile flow into duodenum
Dark amber urine - bilirubin in urine
No urobilinogen in urine no bilirubin reaching SI to be converted to urobilinogen
Clay colored stools -
Pruritis - deposits of bile salts in skin tissues
Fatty food intolerance - no bile in SI for digestion
Bleeding tendencies - decr absorption vit K, therefore dec production PT
Complications:
Cholecystitis
Cholangitis inflammation of biliary ducts
Billiary cirrhosis
Peritonitis
carcinoma
relieving pain
maintaining normal fluid volume
only foods as tolerated can cause irritation and stimulation to GB, if surg - npo
prepare for poss surgery
teach pt proper diet - low in fat, wt reduction (usually), and fat soluble vit.
47
Chronic Kidney Failure
Definition
Chronic kidney failure (CKF) involves progressive, irreversible destruction of the nephrons in both kidneys.
S/S
Fatigue, weakness, change in usual urination pattern, nausea and vomiting, headache, blurred vision, dyspnea,
persistent itching.
dietary intake measuring I&O accurately, and promote infection control.
Complications
Anemia, high blood pressure, congestive heart failure, bone disease, digestive tract problems, loss of mental
functioning (dementia), sleep disorders.
48
Chronic Obstructive Pulmonary Disease
Definition
Chronic obstructive pulmonary disease (COPD) is a group of lung diseases that makes it hard for a person to
breathe. In COPD, airflow through the airways (bronchial tubes) within the lungs is partially blocked, resulting in
difficulty breathing. As the disease progresses breathing becomes more difficult, and it may become difficult to
carry out everyday activities.
S/S
Mild COPD (stage 1) - May have a chronic and productive cough that often brings up an increased amount of
sputum (mucus) from the lungs, impaired lung function (greater than 80% forced expiratory volume [FEV]) with no
symptoms (only noticeable with lung tests), may have shortness of breath and wheezing. Moderate COPD (stage
2) - A chronic, productive cough, which often brings up a large amount of mucus from the lungs, shortness of
breath and fatigue with exercise and strenuous daily activities, difficulty sleeping (a person may wake up feeling
short of breath or coughing), occasional COPD exacerbations, which are fairly rapid, sometimes sudden, worsening
in a person's usual shortness of breath, impaired lung function (30% to 79% FEV).
Maintain airway patency, assist with measures to facilitate gas exchange, administer medications as indicated,
enhance nutritional intake, and prevent complications.
Complications
Severe shortness of breath, impaired gas exchange, respiratory imbalances (acidosis, alkalosis).
49
Chronic Renal Failure (CRF, end stage renal disease, ESRD)
Definition
Progressive deterioration of renal function, which ends fatally in uremia and its complications, unless dialysis or
kidney transplant is performed.
S/S
Anorexia, N/V, hemorrhage, ulceration of GI tract, HTN, pericarditis, pulmonary edema, fatigue, HA, peripheral
neuropathy, seizure, glucose intolerance, hyperlipidemia, hyperkalemia, hypocalcemia, pallor, ecchymosis, uremic
frost, anemia, defect in quality of platelets, personality change, cognitive disorder.
Maintain fluid and electrolyte balance, adequate nutrition, maintain skin integrity, prevent constipation, inspect
ROM/ muscle strength, drink
Limited amounts, encourage activity as tolerated, assess pt. understanding of treatment regimen as well as
concerns and fears, promote decision making by pt.
Complications
Death
50
Colititis, acute
Definition
Inflammation of the colon. The major cause of acute colitis is infectious, with the incidence and organism varying
widely on a geographic and socioeconomic basis
Ischemic colitis is a disease of the elderly and more affluent populations with an atherosclerotic prone diet. It can
also be caused by infection including viruses, bacteria, fungus and parasites or vascular, usually small vessel
disease.
Signs/Symptoms:
May be mild or severe
persistent or recurrent diarrhea
abdominal pain
fever
fatigue
weight loss
loss of appetite
Monitor vital signs
Monitor I/Os
Pain assessment
- location, intensity, type, quality, frequency
- does anything relieve it
Allow client extra time to eat
Excellent perineal is needed until the diarrhea is under control & after
- kept client clean, dry, and free of odor
Administer medications as ordered
Complications:
Bleeding
Ulceration
Perforation of the colon
Toxic megacolon
51
Colon Cancer
Definition: Malignancies of the colon and rectum. 2nd most common visceral ca in US. Nearly all
adenocarcinomas. Risk factors include following:
Age increases sharply post 40, 90% of patients w/ colon ca over 50
Previous hx of colon ca
Family hx present in 25% of pts
Polyposis syndrome
Chronic ulcerative colitis, Cohns disease
Higher industrialized countries- possible diet related
Manifested by:
1. Right Sided Lesion: Change in bowel habits, usually D, vague abd discomfort, black terry stools, anemia,
weakness, wt loss, palpable mass in rt lower quadrant.
2. Left sided lesion: (usually can detect earlier than rt due to smaller lumen) change in bowel habits,
increasing constipation, bouts of D (due to part obst), bright streaked red blood in stool, cramping pain, wt
loss, anemia, palpable mass.
3. Rectal lesion: change in bowel habits w/ poss. urgent need to defecate, alternating const w/ D, narrowed
caliber of stool, bright red stool, feeling of incomplete evacuation, rectal fullness to dull constant ache.
Achieving adequate nutrition high calorie, low residual diet, smaller meals several times throughout day,
maintain hydration via IV therapy, observe I&O d/t fluid losses - V/ D
Relieving constipation/diarrhea Monitor amount, consistency, freq, color of stool; use laxatives as
needed; adequate fluids. (foods w/ slow transit time in colon bananas, rice pb, pasta.
Relieving pain administer analgesics as needed as ordered and evaluate; investigate other approaches
i.e. relaxation, repositioning, imaging, laughter, music, reading, touch.
Maintaining energy level activity plan (assess limits) w/ freq rest periods; administer blood products as
ordered.
Minimizing fear encourages pt/fam to express feelings; acknowledge normal to have neg feelings;
provide info to answer questions and refer to support groups.
Patient education resources on chemo or radiation treatment, colostomy management, initiate home care
management
Complications:
Hemorrhage
Obstruction
Anemia
Poss. Nursing DX:

Altered nutrition: less than body requires r/t malignancy effects and wt loss
Constipation and/or Diarrhea r/t change in bowel lumen
Pain r/t malignancy, inflammation, and poss. intestinal obstruction
52
Colorectal Anastomosis
Definition
Closing off of a colostomy site. The bowel is freed from the skin and the body wall and reattached to the intestine.
The wound where the colostomy once was is then closed off.
Nursing implications
Excessive bleeding, surgical wound infection, thrombophlebitis, pneumonia, pulmonary embolism, increased pain
swelling redness drainage or bleeding in the surgical area, headache, muscle aches, dizziness, or fever, increased
abdominal pain or swelling, constipation, nausea or vomiting or diarrhea.
Complications
Infection of wound site

Weakness at colostomy site
Diarrhea
Bleeding at rectum
Incontinence of stool
Irregularity
53
Colostomy
Definition
An opening between the colon and the abdominal wall. The proximal end of the colon being sutured to the skin.
S/S
Monitor vital signs, assess stoma frequently, assist patient to adapt psychologically, assess peristomal skin for
erythema itching or burning, assess skin for sings of breakdown, clean area and change dressing as ordered, apply
skin barrier to protect skin, patient teaching on the effects of food on stoma output, patient teaching on stoma care,
teach importance of maintenance and follow-up care, observe and collect drainage frequently, make sure pouch fits
snugly around skin, Irrigate colostomy as ordered, describe potential resources to assist with emotional and
psychological adjustment, assess for pain, I and O,
Excessive bleeding, surgical wound infection, thrombophlebitis, pneumonia, pulmonary embolism, increased pain
swelling redness drainage or bleeding in the surgical area, headache, muscle aches, dizziness, or fever, increased
abdominal pain or swelling, constipation, nausea or vomiting or black, tarry stools, Necrosis of stomal tissue,
retraction of stoma, prolapse of stoma, stenosis of the stoma, parastomal hernia
Complications
54
Congestive Heart Failure
Definition
Inability of the heart to generate an adequate cardiac output to perfuse vital tissues.
S/S
Shortness of breath, fatigue, peripheral edema, persistent wheezing or cough with white or pink blood-tinged
phlegm, pronounced neck veins, swelling of the abdomen, rapid weight gain from fluid retention, lack of appetite or
nausea, difficulty concentrating or decreased alertness, irregular or rapid heartbeat.
Monitor cardiac output by auscultating apical pulse, assess heart rate and rhythm, monitor I & O ratios for fluid
management, assess patients response to activity, and teach regarding condition, treatment regimen, and self-
care.
Complications
Mild to moderate heart failure may have little effect on your life. However, severe heart failure can be life-
threatening. It can lead to sudden death or cardiac arrest.
55
Congestive Heart Failure
Definition
An abnormal condition involving impaired cardiac pumping. Associated with numerous types of heart disease.
S/S
Hypertension, obesity, high serum cholesterol, increased heart rate, increased respiratory rate, irritabilty,
restlessness, sudden weight gain, edema, diaphoresis, cough, congestion, wheezing, decrease in activity level,
decrease in urine output, pale or mottled skin, fluid in the lungs, fatigue, weakness, sleeping problems, loss of
appetite
Monitor vital signs, monitor input and output, ambulate patient, monitor cardiac output, daily weights, position to
alleviate dyspnea, monitor oxygen therapy
Complications
Pulmonary edema, pulmonary congestion, heart enlargement, heart hypertrophy, irregular heartbeat, cardiac
arrest, sudden death
56
COPD
Definition
A term that refers to a group of conditions characterized by continued increased resistance to expiratory airflow.
Includes chronic bronchitis and pulmonary emphysema
S/S
Chronic Bronchitis: Is insidious, develops over many years. Productive cough, lasting at least three months a year
for two successive years.
Production of thick, gelatinous sputum, greater amount produced during infection. Wheezing and dyspnea as
disease progresses. Emphysema:
Gradual onset, steadily progressive. Dyspnea, decreased exercise tolerance, cough may be minimal, except with
infection. Sputum is mild, sparse.
Barrel chest due to air trapping.
Teach smoking cessation, humidify O2, administer bronchodilaters as prescribed. Teach pursed lip breathing,
incentive spirometer. Teach position of comfortleaning trunk forward with arms on fixed object. Monitor O2 sats,
supplement as needed. Minimize CO2 retention.
Outcomes: Pt reports less dyspnea, effectively using pursed lip breathing. Tolerating small, frequent meals, weight
stable.
Complications
Respiratory failure, Pneumonia, Right sided heart failure, depression, skeletal muscle dysfunction.
Nursing Diagnosis
Ineffective airway clearance r/t bronchoconstriction
Increased mucous production, ineffective cough.
Ineffective breathing pattern r/t chronic airflow limitation
Risk for infection r/t compromised pulmonary function and defense mechanisms
Activity intolerance r/t compromised pulmonary function
Resulting in dyspnea, fatigue.
57
Coronary Artery Disease
Definition
Characterized by the accumulation of fatty deposits along the innermost layer of the coronary arteries. The lesion
(plaque) can cause a critical narrowing of the coronary arterial lumen, resulting in decreased coronary bloodflow
and an inadequate supply of O2 to the heart muscle. Smokers, high cholesterol, and HTN are predisposed.
Lippencott, 356.
S/S
Stable angina pectoris (precipitated by physical exertion), unstable angina pectoris (occurring at restprecursor to
MI, does not go away with nitro.), these conditions may cause numbness or tingling in the arms, diaphoresis
tachycardia, increased blood pressure, radiating pain to the jaw, neck, shoulders, arms, or hands. Most often
occurs on the left side.
Relieve pain: Place pt in comfortable position, administer O2 if prescribed, obtain vital signs, administer anti
anginal meds as prescribed, report findings to HCP, monitor for relief of pain or pain progression, determine
intensity of pain, observe for signs and symptoms, reinforce importance of pt notifying nursing staff whenever
angina pain is experienced. Decrease anxiety. Outcome: Pt verbalizes relief of pain. Pts BP and HR stable. Pt
verbalizes lessening anxiety, ability to cope.
Complications
Sudden death due to lethal dysrythmias, CHF, MI
Nursing Diagnosis
Pain r/t imbalance in O2 supply and demand. Decreased cardiac output r/t reduced preload, afterload, contractility
and heart rate secondary to hemodynamic effects of drug therapy. Anxiety r/t chest pain, uncertain prognosis, and
threatening environment.
58
Coronary Artery Disease
Definition
Any vascular disorder that narrows or occludes the coronary arteries; the most common cause of coronary
obstruction is atherosclerosis.
S/S
Chest pain, shortness of breath, fatigue, nausea and vomiting.
Pain management, monitor VS assessing for signs and symptoms of heart failure, anxiety control, and patient
teaching regarding condition, treatment needs, and self-care for management of disease.
Complications
Heart attack, stroke, death.
59
Crohns
Definition: Chronic idiopathic inflammatory disorder that can affect any part of the GI tract, usually the small and
large intestines. It is predominantly a transmural disease of the bowel wall.
Etiology unknown, possibly genetics, environmental agents, immunologic imbalances, defect in repair of mucosal
injury leading to chronic condition, and cigarette smoking,
Manifested by:
Crampy pain RLQ
Crohnic diarrhea poss bloody stools or steatorrhea
Fever may indication infecton
Palpable RLQ fullness or mass corresponds to adherent loops of bowel or abscess.
Rectal examination may reveal perirectal abscess
Inflammatory patter may display malabsorption, weight loss, less abd pain
Fibrostenotic pattern - may display SBO, abd pain, N, V, bloating
Perforating pattern may display sudden profuse D d/t enteric fistula, fever, localized tenderness d/t
abscess, recurrent UTIs.
Complications:
Abscess
Strictures may result from inflammation, edema, abscess, fibrostenosis
Hemorrhage, bowel perf, int o
Nutritional deficiencies avoidance and malabsorption
Dehydration and electrolyte disturbances
Peritonitis and sepsis
Increased risk of colon ca
60
Crohns disease
Definition
A chronic idiopathic inflammatory disease that can affect any part of the GI tract, usually the small and large
intestines. It is predominantly a transmural disease of the bowel wall.
S/S
Crampy pain usually in the right lower quadrant. Chronic diarrhea usually consistency is soft or semi-liquid.
Bloody stools or steatorrhea may occur. Fever may indicate infectious complication, such as abscess. Fecal
urgency and tenesmus. Palpable right lower quadrant fullness or mass may be palpated, which corresponds to
adherent loops of bowel or abscess. Rectal exam may reveal a perirectal abscess, fistula, fissure, or skin tags,
which represent healed perianal lesions
Encourage diet that is low in residue, fiber, and fat and high in calories, protein, and carbohydrates, with vitamin
and mineral supplements.
Monitor weight daily. Provide small, frequent feedings to prevent distention. Monitor intake and output. Provide
fluids as prescribed to maintain hydration (1,000 mL/24 hours is minimum intake to meet body fluid needs).
Monitor electrolytes (especially potassium) and acid-basebalance, because diarrhea can lead to metabolic acidosis.
(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott- Raven Publishers. Pgs. 623-626.)
Complications
Abscess (occurs in 20%), and fistula (occurs in 40%). Strictures may result from inflammation, edema, abscess,
adhesions, but usually from fibrostenosis. Hemorrhage, bowel perforation, intestinal obstruction. Nutritional
deficiencies: poor caloric intake due to food avoidance, malabsorption of bile salts and fat, vitamin B12 deficiency
with ileal disease, short-gut syndrome after extensive surgical resections. Dehydration and electrolyte
disturbances; Peritonitis and sepsis. Believed to have increased risk of small bowel and colorectal cancers.
61
Crohns disease
Definition
Chronic, idiopathic inflammatory disease of the GI tract. Small and Large intestines affected the most. It is
predominantly a disease of the bowel wall.
S/S
Characterized by exacerbations and remissionsmay be abrupt or insidious. Crampy pain, usually in RLQ,
chronic diarrhea, fever may indicate abscess, fecal urgency, palpable RLQ fullness, skin tags in rectum, possible
weight loss, malabsorption, fistulas or tenderness.
Encourage low residue, fat and fiber diet along with diet high in calories, protein, and carbohydrates. Vitamin
supplements, daily weight, small, frequent feedings. Pt participation in meal planning. Monitor I/Os, Provide fluids
as prescribed to avoid dehydration. Outcomes: Pt displays improved nutritional intake, weight is stable. Adequate
fluid intake, no evidence of dehydration, electrolytes within normal limits. Pt demonstrates relief of pain and
symptoms are manageable. Pt verbalizes improved attitude about ways to live with disease.
Complications
Abscess (occur in 20%), fistulae (occur in 40%), Strictures resulting from adhesions, inflammation, edema, abscess
or fibrostenosis. Hemorrhage, bowel perforation or obstruction. Nutritional deficiencies, Dehydration, electrolyte
imbalances, peritonitis, sepsis, increased risk of small bowel and colorectal cancers.
Nursing Diagnosis
Altered nutrition: less than body requirements r/t pain/nausea. Fluid Volume Deficit r/t diarrhea. Pain r/t
inflammatory disease of the small intestine. Ineffective Individual Coping r/t feelings of rejection, embarrassment.
62
Cystic Fibrosis
Definition
An autosomal recessive, multisystem disease characterized by altered function of the exocrine glands involving
primarily the lungs, pancreas, and sweat glands.
Signs/Symptoms
Meconium ileus in the newborn infant
Childhood manifestations such as:
-failure to grow
-clubbing
-persistent cough with mucous production
-tachypnea
-large, frequent bowel movements
In adults:
Frequent cough that over time becomes persistent and produces viscous, purulent often greenish colored sputum.
Recurring lung infections such as bronchiolitis, bronchitis, pneumonia.
Nursing Interventions
Promote clearance of the secretions
Provide adequate nutrition
63
Cystic Fibrosis
Definition:
An autosomal recessive, multisystem disease characterized by altered function of the exocrine glands involving
primarily the lungs, pancreas, and sweat glands.
Signs/Symptoms:
Meconium ileus in the newborn infant
Childhood manifestations such as:
-failure to grow
-clubbing
-persistent cough with mucous production
-tachypnea
-large, frequent bowel movements
In adults:
Frequent cough that over time becomes persistent and produces viscous, purulent often greenish colored sputum.
Recurring lung infections such as bronchiolitis, bronchitis, pneumonia.
Promote clearance of the secretions
Provide adequate nutrition
Complications:
Chronic infections
Hemoptysis
Pulmonary hypertension
Death
64
Decubitis ulcer
Definition
A localized area, usually over a bony prominence, of tissue necrosis caused by unrelieved pressure that occluded
blood glow to the tissues.
S/S
Is very dependent upon the stage it is in. Stage one is an alteration of intact skin. The area may be warmth or cool
to the touch and feel firm or boggy. The ulcer will be red and will not go away after touching it. Stage two involves
the loss of epidermis, dermis or both. It may look like a blister. Stage three is full thickness skin loss and it may be
necrotic. The ulcer presents clinically as a deep crater. Stage four is all the way down. The muscle or bone may
be seen.
Assess causative factor to reduce or eliminate that factor. Assess stage and document characteristics on a regular
basis. Use pressure relief devices. Use assistive devices. Protect patients skin from excess moisture. Offer
vitamin and mineral supplements. Teach family and patient about causative factor. Make patient feel as
comfortable as possible. Turn as needed, at least Q4H.
Complications
Pain, cellulitis, osteomyolitis, septic arthritis, loss of function, high risk of amputation, infection, hygiene problems,
loss of joint integrity, impaired healing, loss of ADL, sepsis
65
Deep Vein Thrombosis
Definition
Thrombophlebitis is a condition in which a clot forms in a vein, associated with inflammation/trauma of the vein wall
or a partial obstruction of the vein.
S/S
Generalized or extremity weakness, Tachycardia, pulse may be diminished, Skin color/temperature in affected
extremity (calf/thigh): pale, cool, edematous (DVT); pinkish red, warm along the course of the vein (superficial)
Positive Homans sign (absence does not rule out DVT), Poor skin turgor, dry mucous membranes (dehydration
predisposes to hypercoagulability) Obesity (predisposes to stasis and pelvic vein pressure) Edema of affected
extremity (present with thrombus in small veins or major venous trunks). Throbbing, tenderness, aching pain
aggravated by standing or movement of affected extremity, groin tenderness, Guarding of affected extremity,
Fever, chills.
Maintain/enhance tissue perfusion, facilitate resolution of thrombus.
Promote optimal comfort.
Prevent complications.
Provide information about disease process/prognosis and treatment regimen. Hematocrit: Hemoconcentration
(elevated Hct) potentates risk of thrombus formation. Coagulation profile: Levels of PT, PTT, and platelets may
reveal hypercoagulability. Venography: Radiographically confirms diagnosis through changes in blood flow and/or
size of channels. Note: This study carries a risk of inducing DVT and therefore is reserved for patients with negative
or difficult-to-interpret noninvasive studies in the presence of high clinical suspicion. MRI: May be useful in
assessing blood flow turbulence and movement, venous valvular competence. Promote bedrest initially, with legs
elevated above heart level during acute phase. Instruct patient to avoid rubbing/ massaging the affected extremity.
Encourage deep-breathing exercises. Increase fluid intake to at least 2000 mL/day, within cardiac tolerance.
Medications: Anti-coagulants, ASA
Complications
Surgical intervention, Ventilatory assistance (mechanical), Fractures, Psychosocial aspects of care
66
Deep Vein Thrombosis/Thrombophlebitis
Definition
Occurs when a blood clot and inflammation develop in one or more veins.
S/S
Warmth, tenderness, and pain in the affected area, redness, and swelling.
Evaluate circulatory and neurological studies of involved extremity, administer anticoagulants as indicated, utilize
pain management techniques, and monitor VS.
Complications
Pulmonary embolism, heart attack, or stroke. May also damage valves in the legs causing varicose veins, swelling,
skin discoloration, or vein obstruction.
67
Degenerative Joint Disease
Definition
The breakdown of joint cartilage that may affect any joint in your body, including those in your fingers, hips, knees,
lower back and feet.
S/S
Pain in a joint during or after use, or after a period of inactivity, discomfort in a joint before or during a change in the
weather, swelling and stiffness in a joint, particularly after using it, bony lumps on the middle or end joints of your
fingers or the base of your thumb, loss of joint
flexibility.
Promote optimal mobility, reduce discomfort/pain.
Complications
Pain, from mild to debilitating.
68
Degenerative Joint Disease (osteoarthritis)
Definition
Is a chronic, noninflammatory, slowly progressing disorder that causes deterioration of the articular cartilage. It
affects weight bearing joints as well as interphalangeal joints. Lippencott, 1010.
S/S
Pain, due to inflammation of the joint, bone spurs. Affects those 50-90, w/ obesity and aging the major contributing
factors.
Relieve pain: Advise pt to take prescribed NSAIDS, rest, encourage use of splints, braces, etc. Apply heat as
prescribed, encourage weight loss, advise corrective shoes, teach correct posture. Teach ROM exercises,
isometric exercises, use assistive devices for grooming and eating. Suggest swimming, refer to The Arthritis
Foundation, 1.800.933.0032. Outcomes: Pt reports reduction in pain while ambulatory. Pt performs ROM
exercises. Pt dresses, bathes, and grooms self with assistive devices.
Complications
Limited mobility. Neurological defects associated with spinal involvement.
Nursing Diagnosis
Pain r/t joint degeneration and muscle spasm.
Impaired physical mobility r/t pain and limited joint motion.
Self care deficit r/t pain and limited joint movement.
69
Degenerative joint disease- DJD
Definition
A noninflammatory, progressive disorder of movable joints, particularly weight-bearing joints; characterized by the
deterioration of articular cartilage and pain with motion.
S/S
Discomfort and pain, disability specific to the involved joint, joint pain, difficulty sitting down, joint stiffness in early
morning, crepitation, bony enlargements, loss of joint function, diminished ability to independently perform self-care,
Nutritional counseling, rest and joint protection, use of assistive devices, therapeutic exercise, heat and cold,
assess and monitor vital signs, assess the type of pain, assess the duration of pain, use of massaging, assess the
severity of the pain, watch I & O and daily weights, avoid forceful repetitive movements, avoid positions of joint
deviation and stress, use good posture and proper body mechanics, teach patient how to relieve pain and stress on
joints.
Complications
70
Dehydration
Definition
pg 435, Nursing Diagnosis Handbook. Decreased intravascular, interstitial, and/or intracellular fluid. (refers to
dehydration, water loss alone w/out change in sodium level)
S/S
decreased urine output, increased urine concentration, weakness, sudden weight loss, decreased venous filling,
increased body temperature, decreased pulse volume/pressure, change in mental state, elevated hematocrit,
decreased skin/tongue turgor, dry skin/mucous membranes, thirst, increased pulse, decreased BP.
Monitor for existence of factors relating to deficient fluid volume, watch for signs of hypovolemia (weakness,
restlessness, muscle cramps), monitor I/Os, monitor daily weights, orthostatic BPs, administer
antidiarrheals/antiemetics as prescribed, assist with ambulation due to dizziness, promote skin integrity.
Outcomes: Client will maintain urine output of more than 1300ml/day (30 ml/hr). Client will maintain normal BP,
Pulse, Temp. Patient will maintain elastic skin turgor, moist tongue, and mucous membranes, and LOC.Patient will
explain measures that indicate the need to consult with healthcare provider.
Complications
electrolyte imbalance, constipation, bowel obstruction
Nursing Diagnosis:
Fluid volume deficit, r/t (any number of factors)
71
Dementia
Definition
A chronic disturbance involving multiple cognitive deficits, including memory impairment. Primary dementia is a
degenerative disorder that is progressive, irreversible, and not due to any other condition (i.e. dementia of
Alzheimers type). Secondary dementias occur as a result of another pathologic process i.e. TB, chronic meningitis.
S/S
Fluctuating levels of awareness, confused/disoriented, disturbed memory, alteration in sleep/wake cycle, perceptual
disturbances, personality change, apathy, inability to learn new material.
1) speak slowly and use short, simple words and phrases 2) consistently ID yourself and address pt. by name 3)
focus on one thing at a time and review 4) acknowledge feelings 5) keep area well lit 6) keep personal items in view
7) encourage/assist with ADLs 8) monitor I&O, weight 9) identify stressors 10) encourage participation in simple
activities.
Complications
without accurate diagnosis and treatment secondary can become permanent, falls, self inflicted injury, aggression
or violence toward self/ others, wandering events, depression.
72
Diabetes
Definition
A multisystem disease related to abnormal insulin production, impaired insulin utilization, or both.
S/S
Increased thirst, increased hunger (especially after eating), dry mouth, frequent urination, unexplained weight loss
or gain, fatigue, blurred vision, labored, heavy breathing (Kussmaul respirations), slow-healing sores or cuts,
frequent infections, numbness or tingling of the hands and feet, red, swollen, tender gums.
dietary intake measuring I&O accurately, promote infection control, and patient teaching of management of the
disease.
Complications
Low/high blood sugar, increased blood acids, nerve damage (neuropathy), kidney damage (nephropathy), eye
damage, heart and blood vessel disease, and infections.
73
Diabetes Mellitis
Definition
Metabolic disorder characterized by hyperglycemia. Results from defective insulin production, secretion, or
utilization. (Beta cell) Lippencott, 841. Type 1 (IDDM): Little to no endogenous insulin, requires injections to
control diabetes and prevent ketoacidosis. Autoimmune/viral component. Can be genetic. Type 2 (NIDDM):
Combo of insulin resistance and insulin deficiency. 90% are this type. Hereditary, obesity contributes.
S/S
Type 1: Presentation is rapid, with polydipsia, polyuria, and weight loss.; Type 2: Presentation is slow, insidious
with fatigue, weight gain, poor wound healing, and recurring infections.
Assess level of knowledge. Assess adherence to diet therapy, exercise regimen. Assess for signs of hypoglycemia
(diaphoresis, tremors, confusion, tachycardia, nervousness). Perform thorough skin assessment. Get immediate
help for signs of ketoacidosis (fruity breath odor, Kussmaul breathing, n/v, altered LOC). Outcome: Pt maintains
ideal body weight, Pt demonstrates self injection of insulin w/ minimal fear, Pt verbalizes appropriate use and action
of oral hypoglycemic agents, Exercises daily, Hypoglycemia identified and treated appropriately.
Complications
Hypoglycemia due to imbalance in food, activity, insulin. DKA (in Type 1) during times of illness produces
hyperglycemia, ketonuria, dehydration, acidosis. Peripheral vascular disease. CAD due to vessel deterioration and
arteriosclerosis caused by hyperglycemia. Cerebrovascular disease. Retinopathy. Peripheral Neuropathy.
Nursing Diagnosis
Altered Nutrition: more than body requirements.

Fear r/t insulin injection.
Risk for impaired skin integrity r/t decr sensation/circulation.
Ineffective coping r/t complex care regimen/chronic disease.
74
Diabetes Mellitus
Definition
A multi-system disease related to abnormal insulin production, impaired insulin utilization, or both.
S/S
N/A
Ample Patient teaching, monitor VS, daily weights, Accu checks, exercise, dental examination, podiatric
examination, monitor nutritional status,calorie count diet, monitor lab results, provide support group information
Complications
Heart disease, stroke, blindness, lower limp amputations, obesity, renal failure, neuropathy, vagal dysfunction,
retinopathy, diabetic ketoacidois
75
Diabetes Mellitus
Definition: DM is a disorder of carb, protein, and fat metabolism resulting from an imbalance between insulin
availability and insulin need. It can occur by
Insulin deficiency
Impaired release of insulin by pancreatic beta-cells
Inadequate or defective receptors
Production of inactive insulin or
Insulin that is destroyed before it can carry out its action
A person with uncontrolled dm is unable to transport glucose into fat and muscle cells. RESULT: body cells starved,
and breakdown of fat and protein is increased.
Manifested by: (onset abrupt w/ type 1, and insidious w/ type 2)

Wt loss, fatigue (body lacks needed E from glucose)
Polyuria (frequent urination)
Polydipsia (excessive thirst)
Polyphagia (excessive hunger) result of cellular malnourishment (glucose cant get swept into cells by
broom (insulin)
Blurred vision
Poor wound healing
Recurrent infections (particularly skin)
Ketoacidosis
Check blood glucose (looking for hypo- and hyperglycemia)
Insulin as ordered demonstrate and explain procedure for self -injection
Prevent infection/maintain skin integrity
o Any lesion, decrease pulses , change in skin color, temp, and sensation evaluated and treated
asap.
o Any foot wounds/injuries treated immediately elevate, avoid wt bearing, wet to dry dressing
applied as ordered, antibiotics as ordered.
Nutritional therapy
Exercise therapy/improving activity tolerance enhances action of insulin
Pt education health maintenance: lifestyle, exercise, travel, foot care guidelines, insulin management,
dietary considerations.
Chronic Complications:
Cerebrovascular disease htn H lipids, smoking, uncontrolled glucose increase risk CVA/TIA
CAD hyperglycemia contributes to atherosclerosis/vessel deterioration
PVD 50% amputations related to DM
Retinopathy sclerosis of vessels of eye (blindness)
Nephropathy renal vessel sclerosis, thickening glomular basement membrane
Sexual disfunction
Orthostatic hypotension
76
Diabetic peripheral vascular disease
Definition
Hardening of the arteries due to diabetes.
S/S
Urine that is foamy in appearance, foot ulcers, claudication (pain in legs while walking), loss of sensation in hands
or feet, HTN, chest pain, edema, weight gain, blurry vision.
Physical examination/ change in skin integrity, tibial/pedal pulses, capillary refill, skin: pale/cool, instruct pt. on foot
care guidelines, smoking cessation, safe exercise.
Complications
claudication, absent pedal pulses, ischemic gangrene, necrosis, amputation.
Nursing Diagnosis:
Risk for impaired skin integrity R/T decreased sensation and circulation to lower extremities.
Ineffective coping R/T chronic disease and complex care regimen.
Knowledge deficit R/T foot care, exercise, diet, and smoking.
77
Diarrhea
Definition
Loose, watery stools occurring more than three times in one day--is a common problem that usually lasts a day or
two and goes away on its own without any special treatment. However, prolonged diarrhea can be a sign of other
problems. People with diarrhea may pass more than a quart of stool a day.
Signs/symptoms
Diarrhea may be accompanied by cramping abdominal pain, bloating, nausea, or an urgent need to use the
bathroom. Depending on the cause, a person may have a fever or bloody stools.
Diarrhea can be either acute or chronic.
Give prescribed medications to help alleviate symptoms.

Maintain electrolyte levels, you could have broth or soups, which contain sodium, and fruit juices, soft fruits, or
vegetables, which contain potassium.
Monitor vital signs closely.
Assess for signs of infection.
Complications
-dehydration
-can lead to death if severe enough and untreated
78
Diverticulitis
Definition
Inflammation of the diverticula, (saccular dilation or outpouching of the mucosa through the circular smooth muscle
of the intestinal wall.). Most commonly found in the sigmoid colon.
S/S
Majorities of pt. have no symptoms. Those with symptoms have: crampy abdominal pain in lower left quadrant that
is relieved by passage of flatus, alternating constipation and diarrhea, abdominal pain that is localized over area of
colon, fever, chills, nausea, anorexia, elevated WBC count, afebrile
High-fiber diet, dietary fiber supplements, stool softeners, anticholingergics, mineral oil, bedrest, clear liquid diet,
oral antibiotics, NG suction, patient teaching about diet, increased fluid intake, assess pt. for bowel spasms, teach
patient to avoid: straining with stool vomiting bending lifting and tight clothing, NPO status, assess pt. for signs of
possible peritonitis, ambulating if acute attack occurs, monitor WBC count, provide patient with a full explanation of
his/her status
Complications
Perforation with peritonitis, abscess and fistula formation, bowel obstruction, urethral obstruction, bleeding
79
Diverticulitis
Definition: Results when one or more diverticula become inflamed and usually perforate the thin diverticular wall.
The inflammation may be caused by a combination of a fecal plug and accumulating bacteria. If diverticulum
perforates, local abscess or peritonitis may occur. Uninflammed or minimally inflamed diverticula may erode
arterial branches causing acute massive rectal bleeding.
15% of people with Diverticulosis will develop diverticulitis.
Manifested by:
Mild:
Bouts of soreness, mild lower abd cramps
Bowel irregularity, constipation, diarrhea
Mild nausea, gas, low grade fever, and leukocytosis
Severe:
Crampy pain in LLQ abd
Low grade fever, leukocytosis
Ruptured diverticular near blood vessel, massive hemorrhage
Sometimes fistula form with adjacent small bowel, bladder, vagina, perianal area or skin.
Sepsis may spread via portal vein to liver
Chronic div. may cause adhesions which narrow bowels opening causing partial or complete obstruction.
Urinary frequency and dysuria are assoc w/ bladder involvement in inflammatory process.
1. Achieving pain relief:

Observe s/s pain, type, and severity
Administer nonopiate analgesics as prescribed (opiates may mask perforation)
Anticholinergics as prescribed decrease colon spasm
2. Auscultate bowel sounds to monitor motility, palpate abd to determine rigidity or tenderness r/t perforation or
peritonitis.
3. Maintain adequate nutrition high soft residue and low in sugar, bran products, monitor I&O.
4. Promoting normal bowel elimination:
Encourage fluids if constipated
Observe color, consistency and freq of stools.
5. Patient education
Complications:
Hemorrhage from colonic deverticula
Bowel obstruction
Fistula formation
Septicemia
80
Diverticulosis
Definition
Pg 617, Lippencott. Marks the formation of diverticula, which are herniations in the mucosal and submucosal
layers of the colon at weak points where nutrient blood vessels penetrate the colon walls. Causes are unclear, but
contributing factors may include a low residue diet. Most often occurs in persons over 60. Diverticulitis results
when one or more diverticula become inflamed and perforate the wall. An abscess or peritonitis may occur from
this.
S/S
May be asymptomatic, crampy abdominal pain(LLQ), bowel irregularity (constipation/diarrhea), periodic abdominal
distension, sudden massive hemorrhage may be first symptom.
Pain relief, intervene when appropriate. Auscultate bowel sounds. Follow prescribed diet, high in soft residue, low
in sugar. Emphasize that proper food intake influences how the intestinal tract functions. Observe color, frequency,
consistency of stools. Encourage fluids. Refer to nutritionist. Outcomes: Pt will consume a prescribed diet and
relay what foods to include/avoid. Pt will express relief in pain and has a decrease in symptoms.
Complications
Hemorrhage, bowel obstruction, fistula formation, septicemia.
Nursing Diagnosis:
Pain r/t intestinal discomfort
Altered nutrition: less than body requirements r/t nausea, vomiting, diarrhea
Constipation or Diarrhea r/t disease process
Knowledge deficit of the relationship between diet and diverticular disease
81
Diverticulosis:
Definition: Formation of pockets or herniations of the mucosal and submucosal layers of the colon which develop
at weak points (where nutrient blood vessels penetrate the colon wall).
Causes unclear, intraluminal pressure plays a role this may be caused by a low residue diet.
Occurs in most people over 60.
Manifested by:
Prediverticular:
May be asymptomatic
Abd pain, worsens after eating and before bms
C, D
Diverticulosis:
Asymptomatic
Crampy abd pain
Bowel irregularity C and/or D
Periodic abd distention
Sudden massage hemorrhage may be first symptom
Management:
Prediverticular:
High-fiber diet
Bran therapy, Metamucil
Diverticulosis:
High fiber diet
Avoid large seeds, nuts clog diverticular sac
Stool softeners: bran therapy, colace
Liquid or low residue diet minimize symptoms, irritation and progression to diverticulitis
Complications:
Hemorrhage from colonic diverticulas usually rt colon
Bowel obstruction
Fistula formation
septicemia
Poss. Nursing DX:
pain r/t intestinal discomfort, d, and/or c

altered nutrition: less than body requirements r/t d, fluid and electrolyte loss, n, and v
Knowledge deficit or relationship between diet and diverticular disease.
82
Epidural Catheter Insertion
Definition: An epidural catheter is a very fine plastic catheter (tube) that is placed through the skin into the epidural
space in your spine. This temporary catheter is left in place for a defined period of time; normally less than (2)two
weeks. The catheter allows access to the epidural space to inject medication such as local anesthetics and/or
narcotics for relief of pain. Temporary epidural catheters are used for tempory treatment of painful conditions that
require pain control for intensive physical therapy and/or joint mobilization. They are also used prognostically for
trials of spinal medications prior to placement of permanent implanted ports or programmable pumps.
Complications: The temporary epidural catherter placement is a safe minor surgical procedure but, as with any
procedure, it has risks as well as benefits.
Infection and/or local bleeding
Numbness and/or weakness and/or sedation (respiratory)

1. Screen for pain at each visit: location, duration, quality, and impact. using a pain intensity scale and
impact on daily activities.
2. Assess relief from medications and duration of relief.
3. Administer drugs orally whenever possible avoid IM, try ATC rather than PRN
4. Convey impression, pt pain understood and can be controlled.
5. Reevaluate pain frequently.
6. Use alternative measures to relieve pain: guided imagery, relaxation, biofeedback.
7. Provide ongoing support and open communication.
8. Provide education of meds.
9. Take measures to prevent and treat side effects of opiates ie constipation, N, sedation.
83
Exploratory Laparotomy
Definition:
Abdominal exploration is a type of surgery where the abdomen is opened (laparotomy) and explored (exploratory
laparotomy) for examination and treatment of problems. The surgeon makes an incision into the abdomen and
examines the abdominal organs. The size and location of the incision depends on the clinical situation. Biopsies
can be taken and diseased areas can be treated. When the treatment is complete, the incision is closed.
The abdomen contains many vital organs: the stomach, the small intestine (ileum), the large intestine (colon), the
liver, the spleen, the gallbladder, the pancreas, the uterus, the Fallopian tubes, the ovaries, the kidneys, the
ureters, the bladder, and many blood vessels (arteries and veins). Some problems inside the abdomen can be
easily diagnosed with non-invasive tests, such as X-rays and CT scans, but many problems require surgery to
"explore" the abdomen (exploratory laparotomy) to obtain an accurate diagnosis.
While the patient is deep asleep and pain-free (general anesthesia), the surgeon makes an incision into the
abdomen and examines the abdominal organs. The size and location of the incision depends on the clinical
situation. Biopsies can be taken and diseased areas can be treated. When the treatment is complete, the incision is
closed.
An exploratory laparotomy may be recommended when there is abdominal disease from an unknown cause (to
diagnose).
Diseases that may be discovered by exploratory laparotomy include:

Ac appendicitis
pancreatitis
pockets of infection ie. retroperitoneal abscess, abdominal abcsess, pelvic abscess.
Endometriosis: presence of uterine tissue (endometrium) in the abdomen
Salpingitis: inflammation of the Fallopian tubes
Adhesions: scar tissue in the abdomen
Cancer (of the ovary, colon, pancreas, liver) and to determine extent
Diverticulitis: inflammation of an intestinal pocket
hole in the intestine (intestinal perforation)
ectopic pregnancy - in the abdomen instead of uterus
84
Fever
Definition
A rise in the temperature of the body above its normal range. Normal temperatures vary slightly from person to
person. A significant fever is an oral or ear temperature of 102 F or a rectal temperature above 103 F. Fever is
the body's natural response to infection. A part of the brain called the hypothalamus raises the body temperature to
create an environment that is unfavorable for the bacteria or viruses that cause infectious disease.
S/S
Headache
Muscle aches
Generalized weakness
Lack of appetite
Dehydration
Sweating/shivering
Depending on the reason for the fever, nursing interventions may include: administration of antibiotics or non-
steroidal anti-inflammatory (NSAIDS); encouraging fluids to prevent dehydration, application of cool compresses or
a cool bath; encouraging rest.
Complications:
Very high fevers, between 103F and 106F, may cause hallucinations, confusion, irritability and even convulsions
85
Fibromyalgia
Definition
is a syndrome characterized by fatigue, diffuse muscle pain and stiffness, sleep disturbance, and tender points on
physical examination.
S/S
Fatigue,Generalized muscle pain and stiffness,Poor or nonrestorative sleep,Irritable bowel syndrome,Tension
headaches,Paresthesias,Sensation of swollen hands,Presence of pain in 11 to 18 defined tender point sites
Encourage regular use of analgesics and antidepressants as directed. Encourage regular exercise routine,
including stretching, aerobic activity, and muscle strengthening exercises. Suggest referrals to physical therapist
or pain specialists for additional pain control modalities as needed. Suggest regular nighttime ritual to promote
sleep. Encourage patient to look at fibromyalgia as a chronic condition that can be controlled.
Complications
Deconditioning; Work disability; Inability to fulfill social role; Unnecessary diagnostic and therapeutic maneuvers
86
Fracture
Definition
1. Sudden breaking of a bone. 2. A break of a bone. Blow-out fracture - A fracture of the floor of the orbit in which
fragments are displaced downward by a blow to the eye or periorbital area
ROM.)
S/S
Malocclusion,Asymmetry,Abnormal mobility,Crepitus (grating sound with movement),Pain,Tenderness. Tissue
injury: Swelling,Ecchymosis,Bleeding,Pain
(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs.
542.)
Preventing Aspiration: Maintain elevated airway. Elevate head of be 30-45 degrees, or position leaning over a
bedside stand to reduce edema and improve handling of secretions. Maintaining Nutritional Status: Administer
liquid diet as prescribed; place straw against teeth or trough any gaps in teeth. Teeth may initially be sensitive to
hot and cold. Increasing Comfort: Administer liquid or a suspension of analgesics as prescribed avoid narcotics
on an empty stomach, which may cause nausea and vomiting. Strengthening Body Image: Provide firm
reassurance regarding progress to reduce anxiety and allay fears. Preventing Complications: Provide mouth care
every 2 hours while awake for the first several days, then 4-6 times per day. Patient Education and Health
Maintenance: Encourage adequate nutrition inform the patient and family that foods can be blended and thinned
with juices or broths to a consistency that can be taken through a straw.
Complications
Airway obstruction, aspiration; Hemorrhage, infection; Disfigurement; Extraocular muscle entrapment/orbital globe
displacement with resultant visual disturbance
87
Fracture
Definition
A break in the continuity of bone. A fracture occurs when stress placed on the bone is greater than the bone can
absorb. Muscles, blood vessels, nerves, tendons, joints, and other organs may be injured when a fracture occurs.
S/S
Pain at injury site, swelling, tenderness, deformity, loss of function, ecchymosis, parasthesia
Prevent Neurovascular compromise by monitoring for compartment syndrome, diminished circulation, compressed
nerves. Pain, parathesia, pallor, pulselessness, palpate5 Ps. Prevent development of pressure ulcer from
inactivity. Monitor pain and administer drugs as prescribed. Monitor for fatty emboli. Outcomes: No calf pain
reported (Homans), Afebrile, Pt performing ROM correctly, Vitals signs stable
Complications
Muscle atrophy, loss of ROM, pressure sores, constipation, diminished respiratory/GI function. Also, venous
stasis, infection, shock, emboli.
Nursing Diagnosis:
Pain r/t injury.
Impaired physical mobility r/t injury.
88
Fracture
Definition
1. Sudden breaking of a bone. 2. A break of a bone. closed fracture - A fracture of the bone with no skin wound.
ROM.)
S/S
Physical Findings: Pain at site of injury, Swelling, Tenderness, False motion and crepitus (grating sensation),
Deformity, Loss of function, Ecchymosis, Paresthesia,Altered Nerovascular Status: Progressive uncontrollable pain,
Pain on passive movement, Altered sensations (paresthesia), Loss of active motion, Diminished capillary refill
response, Pallor,Shock: Bone is very vascular, Covert hemorrhage into soft tissues (especially with femoral
fracture) or body cavity, as with pelvic fracture, May be fatal if not detected.
Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 1002.)
Teach patient proper body alignment when applying and using external fixation device, most commonly with joints
in neutral position. Teach patient and significant other active and/or passive ROM of adjacent joints q8h as
appropriate. Monitor neurovascular condition at regular intervals by checking temperature (circulation), movement,
and sensation in affected extremity. In the absence of signs of thrombosis, encourage patient to perform calf-
pumping ankle-circle exercises. Assist in use of a pain intensity rating scale to evaluate pain and analgesic relief
on a scale of 0 (no pain) to 10 (worst pain imaginable).
(Swearingen, P. L. (2004) All-in-One Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and
Psychiatric Nursing Care Plans. St. Louis: Mosby, Inc. Pgs. 543.)
Complications
Muscle atrophy, loss of strength and endurance; Loss of ROM joint contracture; Pressure sores at bony
prominences; Diminished respiratory, cardiovascular, GI function, resulting in pooling of respiratory secretions,
orthostatic hypotension, anorexia, constipation, etc.
89
Fracture
Definition
A disruption or break in the continuity of the structure of bone.
S/S
Immediate localized pain & tenderness, or loss of function, inability to bear weight on or use the affected part,
edema & swelling, muscle spasms, deformity, ecchymosis, grating/ crepitation, numbness, tingling, loss of distal
pulses, open wound over injured site/ exposure of bone.
Monitor vital signs, level of consciousness, O2 sat, peripheral pulses, pain, monitor for compartment syndrome,
monitor for fat emboli, monitor skin integrity, anatomic realignment of bone fragments (reduction), immobilization to
maintain realignment, restoration of normal or near normal function, treat life threatening injuries first, ensure
airway, breathing, & circulation, control external bleeding with direct pressure or sterile pressure dressings, splint
joints above and below fx site, check neurovascular status, distal to injury before & after splinting, elevate injured
limb if possible, do not attempt to straighten fx or dislocated joints, do not manipulate protruding bone ends, apply
ice packs to affected area, obtain x-ray of affected limb, administer tetanus prophylactically, mark location of pulses
to facilitate repeat assessment.
Complications
Delayed union, nonunion, malunion, angulation, pseudoarthrosis, refracture, myosilis ossifications, compartment
syndrome (excessive pain, pain with passive stretch, pallor, parasthesia, paralysis, pulselessness), fat emboli
syndrome (dyspnea, CP), DVTs, infection, venous thrombosis.
90
Fracture Care
Definition
Lippincott pg 1001 A fracture is a break in the continuity of a bone. Muscles, blood vessels, nerves, tendons, joints
and other organs may be injured when a fracture occurs. Pt education- rapid post-op recovery should be expected,
notify surgeon immediately of any subtle change in post-op course or persistent symptoms due to possible bile duct
injury
Types: Complete involves entire cross-section of the bone, usually displaced (not normal positioning) Pt
education- rapid post-op recovery should be expected, notify surgeon immediately of any subtle change in post-op
course or persistent symptoms due to possible bile duct injury Incomplete- involves a portion of cross-section or
may be longitudinal Pt education- rapid post-op recovery should be expected, notify surgeon immediately of any
subtle change in post-op course or persistent symptoms due to possible bile duct injury
Closed (simple)- skin (mucous membrane) not broken Pt education- rapid post-op recovery should be expected,
injury
Open (compound)- skin (mucous membrane) broken Pt education- rapid post-op recovery should be expected,
injury Pathologic- through an area of diseased bone (osteoporosis, bone cyst, bone tumor, bony metastisis) Pt
education- rapid post-op recovery should be expected, notify surgeon immediately of any subtle change in post-op
course or persistent symptoms due to possible bile duct injury Many factors influence diagnosis, management and
care- including type, location and severity of fracture and soft tissue damage. Also age and health status of pt,
including type and extent of other injuries
S/S
Management- 3 steps: Reduction- setting the bone Pt education- rapid post-op recovery should be expected, notify
surgeon immediately of any subtle change in post-op course or persistent symptoms due to possible bile duct injury
Immobilization- to maintain reduction until bone heals*
Pt education- rapid post-op recovery should be expected, notify surgeon immediately of any subtle change in post-
op course or persistent symptoms due to possible bile duct injury; Rehabilitation- to regain normal function; All
management and care approaches vary by site and type of fx. Assess for VS, check lab values, monitor I & Os,
evaluate changes in mental status; Encourage coughing, deep breathing; Assess pain levels; Assess for
neurovascular compromise: pain, weakness, paresthesia, poor capillary refill response, skin color, elevated
comparted pressure, pulselessness; Pt education: rehabilitation, PT/OT assessment, nutrition, follow up case
Complications: muscle atrophy due to immobilization, loss of ROM due to joint contracture; Pressure sores due to
bed rest or devices pressing on skin; Diminished CV, GI function, constipation ; Infection; Thromboembolism;
Shock especially with open fractures; Pulmonary emboli; Change in behavior/cerebral functioning may be an
early indicator of cerebral anoxia from shock or pulmonary or fatty emboli.
91
Gallstones
Definition
Solid deposits of cholesterol or calcium salts that form in the gallbladder or nearby bile ducts.
S/S
Chronic indigestion, sudden, steady and moderate to intense pain in the upper-middle or upper-right abdomen,
nausea and vomiting. If stones have blocked the bile ducts, other S/S may include: Jaundice, clay-colored stools,
tea or coffee colored urine, and a high fever with shaking chills if an infection in the biliary system (cholangitis)
develops as a result of the obstruction.
Complications
Cholecystitis, cholangitis, acute pancreatitis, gallbladder cancer.
92
Gastritis
Definition
The inflammation of the gastric mucosa, acute or chronic
S/S
Nausea, Vomiting, Feeling of Fullness Cramping; Upper abdominal pain, Belching, Malaise, Anxiety
Assess; S/S & reactions to Tx I/O Electrolyte Signs of GI bleeding; bloody NG drainage, melena; Hemorrhagic
shock; (HCT/Hemoglobin) V/S N/V diarrhea, abd pain, fever Implement: Med Administration of
antacids/anticholinergics/antibiotics as ordered; NG tube if ordered; Administer iced saline lavage, vasopressin or;
epinephrine to control bleeding as prescribed; Prepare client for endoscopic laser photocoagulation to control
bleeding Educate:S/S; requiring medical intervention Med administration; Instruct client and family regarding
disease process, procedures, tx, home care, and follow up; Include teaching on: Drug therapy, diet, activity and
restrictions
Complications
Severe loss of blood from GI bleed, Gastric Cancer
93
Gastroesophageal Reflux Disease (GERD) or acid reflux
Definition
Is a condition where gastric contents flow back into the esophagus due to incompetent lower esophageal sphincter.
Esophagitis, or inflammation of the esophageal mucosa, may result.
(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs.597-598.)
S/S
Heartburn, often 30-60 minutes after a meal and with reclining positions. Complaints of spontaneous reflux
(regurgitation) of sour or bitter gastric contents into the mouth. Dysphagia is a less common symptom. Atypical
chest pain, hoarsness, chronic cough, bronchospasm (asthma/wheezing), and odynophagia (sharp substernal pain
on swallowing).
Teach patient about prescribed medications, side effects, and when to notify the health care provider. Inform the
patient regarding medications that may exacerbate symptoms. Advise the patient to sit or stand when taking any
solid medications: emphasize the need to follow the drug with at least 100 mL of liquid. Emphasize to the patient
and family what foods and activities to avoid: fatty foods, garlic, onions, alcohol, coffee, and chocolate; straining,
bending over, tight-fitting clothes, smoking. Encourage the patient to sleep with the head of the bed elevated (not
pillow elevation). Encourage a weight-reduction program if the patient is overweight to decrease intra-abdominal
pressure.
Complications
Esophageal stricture formation; Ulceration of the esophagus, with or without fistula formation; Aspiration, may be
complicated by pneumonia; Development of Barretts esophagus presence of columnar epithelium above the
gastroesophageal junction associated with adenocarcinoma of the esophagus.
94
Gastroesophageal Reflux Disease GERD
Definition
The reflux of chime (acid and pepsin) from the stomach through the lower esophageal sphincter to the esophagus.
S/S
Heartburn, acid regurgitation, dysphagia, chronic cough, asthma, and upper abdominal pain.
Monitor VS, monitor I & O and correlate with weight changes, administer medications as indicated, utilize pain
management techniques.
Complications
Esophageal narrowing (stricture), esophageal ulcer, Barretts esophagus (a change in the color and composition of
the esophagus, increasing the risk of esophageal cancer).
95
Gastrointestinal bleed, acute
Definition:
A sign of disease or abnormality within the gastrointestinal tract involving the presence of blood or hemoglobin the
stool. Upper GI bleeding is considered any source located between the mouth and outflow tract of the stomach.
Lower GI bleeding is considered any source located from the outflow tract of the stomach to the anus (small and
large bowel).
Signs/symptoms
-black/tarry stools
-blood in the stool
-vomiting blood or a dark material that looks like coffee grounds
Continued close observation for more bleeding
Close observation of B/P
Inspect the abdomen for injury and scars of past surgeries- do a complete physical assessment
Consider placing drains, e.g., nasogastric tube to reduce the risk of vomiting and aspiration, indwelling urinary
catheter to monitor urinary output.
Complications: Prolonged microscopic bleeding can lead to massive losses of iron and subsequent anemia.
Acute massive bleeding can lead to hypovolemia, shock, and even death.
96
Gastrointestinal bleed, acute
Definition:
A sign of disease or abnormality within the gastrointestinal tract involving the presence of blood or hemoglobin the
stool. Upper GI bleeding is considered any source located between the mouth and outflow tract of the stomach.
Lower GI bleeding is considered any source located from the outflow tract of the stomach to the anus (small and
large bowel).
Signs/symptoms
-black/tarry stools
-blood in the stool
-vomiting blood or a dark material that looks like coffee grounds
Continued close observation for more bleeding
Close observation of B/P
Inspect the abdomen for injury and scars of past surgeries- do a complete physical assessment
Consider placing drains, e.g., nasogastric tube to reduce the risk of vomiting and aspiration, indwelling urinary
catheter to monitor urinary output.
Complications: Prolonged microscopic bleeding can lead to massive losses of iron and subsequent anemia.
Acute massive bleeding can lead to hypovolemia, shock, and even death.
97
Generalized anxiety disorder
Definition
Excessive anxiety and worry predominating for at least 6 mo.
ROM.)
S/S
Motor tension (e.g. trembling, restlessness, inability to relax, sleep disturbances, and fatigue),Autonomic
hyperactivity (e.g. sweating, palpations, cold clammy hands, urinary frequency, lump in throat, pallor or flushing,
increased pulse, and rapid respirations),Apprehensiveness (e.g. worry, dread, fear, rumination, insomnia, and
inability to concentrate),Hypervigilance (e.g. feeling edgy, scanning the environment, difficulty concentrating, and
distractibility),
Help patient identify anxiety-producing situations and plan for such events. Assist patient to develop assertiveness
and communication skills. Practice stress-reduction techniques with patient. Teach patient to monitor for
objective and subjective manifestations of anxiety.
Complications
Tachycardia, tachypnea,
98
Gout
Definition
A disorder of purine metabolism, characterized by elevated uric acid levels and deposition of urate (usually in the
form of crystals) in joints and other tissues. It generally affects one joint (often the first metatarsophalangeal joint
AKA podagra or great toe). Other joints can be affected, such as ankle, tarsals, knee; upper extremities are less
commonly involved.
S/S
Pain, warmth, erythema, and swelling of tissue surrounding the affected joint. Fever may occur,Onset of symptoms
is sudden; intensity is severe. Duration of symptoms is self-limiting; last approximately 3-10 days without treatment.
Administer and teach self-administration of pain relieving medications as prescribed. Encourage adequate fluid
intake to assist with excretion of uric acid and to decrease likelihood of stone formation. Instruct patient to take
prescribed medications consistently because interruptions in therapy can precipitate acute attacks. Elevate and
protect affected joint during acute attack. Assist with activities of daily living. Encourage
exercise and maintenance of routine activity in chronic gout, except during acute attacks. Protect draining tophi by
covering and applying antibiotic ointment as needed.
Complications
Uric acid kidney stone. Urate nephropathy. Erosive, deforming arthritis.
99
Guillan-Barre Syndrome
Definition
Lippencott, 478. Acute, rapidly progressing, inflammatory demyelinating polyneuropathy of the peripheral sensory
and motor nerves. Most often characterized by muscular weakness and distal sensory loss. Must be IDd quickly.
Mortality rate: 5%. Autoimmune, viral infection may
S/S
Parasthesias, and symmetric, progressive muscle weakness usually going from legs to trunk to upper extremities,
facial muscles. Decreased or absent tendon reflexes, autonomic dysfunction (inc HR, postural hypotension),
Decreased breath sounds and depth of respirations, muscle spasms. Difficulty swallowing, chewing.
Avoid narcotics and sedatives, which may decrease respirations. Watch respiratory status closely for decreased
depth and rate of respirations. Position patient correctly, teach ROM exercises. Promote adequate nutrition,
relieve pain, reduce anxiety. Outcome: Respirations will be 14-20, deep and unlabored. No pressure sores or
edema present. Gag reflex present. Pt verbalizes decreased pain, reduced anxiety. ROM exercises performed by
pt every 2 hours.
Complications
Respiratory failure, cardiac dysrythmias, complications of immobility or paralysis, anxiety or depression.
Nursing Diagnosis: Inneffective breathing pattern r/t weakness of respiratory muscles. Impaired physical mobility,
r/t parasthesia. Anxiety, r/t deteriorating physical condition and communication difficulties.
100
Head injuries
Definition
these include Fx to the skull or face, direct injury to the brain (i.e. bullet), indirect injury (i.e. concussion, contusion,
or intracranial hemorrhage). Fx skull= open head injury, intact skull= closed head injury. These commonly occur
from motor vehicle accidents, falls, or assaults. Note= Concussion is a temporary loss of consciousness resulting
from transient interruption in normal brain function. Contusion is bruising of the brain;small amount of bleeding into
tissue. Intracranial hemorrhage is significant bleeding into a space or a potential space between the skull and the
brain. Mortality rate increases due to increased pressure and potential for brain herniation.
S/S
Primary interventions- 1) open airway using jaw thrust method; keep oral suction at hand 2) high flow O2 to prevent
anoxia 3) maintain respirations at 20-25 to increase CO2 levels to reduce cerebral edema; use bag valve mask 4)
control bleeding with loose dressing only; no pressure 5) start an IV line to keep vein open
Subsequent assessment- obtain history, assess LOC/ Glasgow coma score, monitor VS 9 watch for HTN,
decreased Hr, increased respirations, increased temp, and dysrhythmias), unequal/unresponsive pupils, personality
change, impaired vision, sunken eyes, seizure, periorbital ecchymosis, rhinorhea, and Battles sign (bluish
discoloration behind the ears that indicates possible basal skull Fx)
101
Head Injury
Definition
Includes any trauma to the scalp, skull, or brain. It is used primarily to signify cranio-cerebral trauma, which
includes an alteration in consciousness, no matter how brief.
S/S
Change in level of consciousness, dilation of pupils, ptosis, disorientation, behavioral disorder, headache, blood or
clear fluid dripping from nose or ears, scalp lacerations, breaks or depressions of skull, unequally dilated pupils,
blackened eyes, asymmetry of face, garbled or slurred speech, vomiting, paralysis or rigidity of limbs, disturbance
of gait, loss of bowel or bladder control, confusion, drowsiness, low breathing rate or drop in blood pressure,
convulsions, fracture in the skull or face, facial bruising, swelling at the site of the injury, irritability, restlessness,
clumsiness, lack of coordination, blurred vision, inability to move one or more of your limbs, stiff neck, inability to
hear, see, taste, or smell, seizures
Ensure patient airway, stabilize patient position, control external bleeding, maintain patient temperature, monitor
vital signs, monitor level of consciousness, monitor cardiac rhythm, and pupil size ad reactivity, monitor gag reflex,
do ROM with patient, talk to patient when approaching them, pain management
Complications
Epidural hematoma, hemorrhage, subdural hematoma, intracerebral hematoma, death, seizures, skull fracture,
concussion, brain swelling, raised intracranial pressure, brain injury, mild traumatic brain injury, brain damage, brain
compression, meningitis, hydrocephalus, vascular injuries
102
Hip Replacement
Definition
The replacement of a severely damaged hip with an artificial joint. Pg 993, Lippencott.
S/S
N/A
Roll to unaffected side only, use abductor splint, assess CMSPI, Remove TEDs for 30 minutes, BID. Teach hip
precautions, use elevated toilet seat, reinforce PT, proper hand hygiene, wound inspection, pl exi-pulses, leg
pumps (dorsiflex/plantarflex), IS, cough and deep breathe, clear liquid DAT, monitor for blood loss (H&H), Bowel
sounds present? Flatus? Monitor pain levels. Outcome: Pt maintains hip in anatomically correct position as
evidenced by normal hip contour, both legs same length, and legs/hips in abduction.
Complications
Nursing Diagnosis: Risk for injury: Hip dislocation. Risk Factors: Improper positioning, movement of joint beyond
prescribed range.
103
HIV/AIDs
Definition:
Acquired immunodeficiency syndrome caused by a virus that replicates in and kills helper T
cells. The virus that causes AIDS attacks CD4 cells. It uses these cells as a breeding ground
for new virus particles. Eventually the CD4 cells are killed by the virus. As the number of CD4
cells decreases, the risk of getting an opportunistic illness increases. There is no cure for
HIV/AIDs; it leads to death, usually from an opportunistic infection.
S/S
-candidiasis in the mouth, throat
-rapid weight loss from an unknown cause
-appearance of swollen or tender glands in the neck, armpits, groin for no apparent reason,
lasting more than 4 weeks
-persistent diarrhea
-night sweats (soaking night sweats) of unknown origin
-appearance of purple spots on the surface of the skin, mouth, anus
Manipulate the environment to promote periods of uninterrupted rest.
Identify and develop the patients coping mechanisms, strengths, and resources for support
Encourage the patient to express their feelings and concerns.
Accept the patients feelings of powerlessness as normal.
Minimize patients risk of infection by washing hands, wearing gloves, monitoring their
temperature, monitoring their WBC count.
Offer frequent oral care to patient.
Provide small, frequent meals to increase energy
Establish a regular sleeping pattern
Complications:
Wasting syndrome
Toxoplasmosis of the brain
Recurrent pneumonia pneumocystis carnii
Lymphoma
Kaposis sarcoma
Encephalopathy
Death
104
Hypercholesterolemia
Definition
Lippincott pg 369 (Hyperlipidemia) A metabolic abnormality resulting in elevated serum total cholesterol.
Contributes to the primary risk factor for atherosclerosis and coronary artery disease.
S/S
Lab test results for Total Cholesterol (TC) and High Density Lipoproteins (HDLs)- usually asymptomatic until
significant target organ damage is done, possible chest pain, MI, TIA, stroke
Pt education, obtain nutritional consult, explain goal lab result numbers for LDL, HDL Interventions include
multidimensional approach: diet, exercise, weight loss and drug treatments, smoking cessation if required
Complications
Disability from myocardial infarction, stroke and lower extremity ischemia.
105
Hyperlipidemia
Definition
A group of metabolic abnormalities resulting in combinations of elevated serum total cholesterol, elevated low-
density lipoprotein, elevated triglycerides, and decreased high-density lipoproteins. Primary risk factor for
atherosclerosis and coronary artery disease.
S/S
usually asymptomatic until significant target organ damage is done (chest pain, MI; TIA, stroke). May be metabolic
signs such as corneal arcus, xanthoma, xanthelasma, and pancreatitis. Intermittent claudication, arterial occlusion
of lower extremities.
obtain medical/ diet Hx, examine for PVD, educate on diet and exercise, encourage smoking cessation.
Complications
Disability from MI, stroke, and lower extremity ischemia.
106
Hypertension
Definition
is a disease of vascular regulation in which the mechanisms that control arterial pressure within the normal range
are altered. The basic explanation is that blood pressure is elevated when there is increased cardiac output plus
increased peripheral vascular resistance.
S/S
Usually asymptomatic,May cause headache, dizziness, blurred vision when greatly elevated. Blood pressure
readings of 140/90 or more.
Explain the meaning of high blood pressure, risk factors, and their influences on the cardiovascular, cerebral, and
renal systems. Stress that there can never be total cure, only control. Of essential hypertension; emphasize the
consequences of uncontrolled hypertension. Enlist the patients cooperation in redirecting lifestyle in keeping with
the guidelines of therapy, acknowledge the difficulty, and provide support and encouragement. Develop a plan of
instruction for medication self-management. Instruct the patient regarding proper method of taking blood pressure
at home and at work if health care provider so desires. Inform patient of desired range and the readings that are to
be reported.
Complications
Hypoxia; ARDS; Respiratory failure
107
Hypertension
Definition
Disease of vascular regulation in which the mechanisms that control arterial pressure within the normal range are
altered. BP = increased with increased cardiac output, increased peripheral vascular resistance. Lippencott, 427.
S/S
Usually asymptomatic, may cause headache, dizziness, blurred vision when greatly elevated. BP readings:
Optimal:<120/<80; Normal:<130/<85; High Normal:130-139/85-89; Stage 1:140-159/90-99; Stage 2:160-179/100-
109; Stage 3: > 180/>110
Stress control, not cure. Emphasize consequences of uncontrolled HTN. Teach. Explain meaning of high BP, risk
factors, influence on systems. Report dyspnea, edema, chest pain, nose bleeds, and weight gain. Outcome: Pt
demonstrates increased knowledge about high BP, med effects, prescribed activities. Pt takes meds, keeps follow
ups.
Complications
Angina Pectoris or MI due to decreased coronary perfusion, Left ventricular hypertrophy and CHF due to
consistently elevated aortic pressure,
Renal failure due to thickening of renal vessels (diminishes perfusion to glomerulus), TIA, stroke or cerebral
hemorrhage due to cerebral ischemia/arteriosclerosis, retinopathy, and accelerated HTN.
Nursing Diagnosis: Knowledge deficit r/t cognitive limitation, lack of interest, or lack of information.
108
Hypertension
Definition
Consistent elevation of systemic arterial blood pressure.
S/S
Excessive perspiration, muscle cramps, weakness, frequent urination, rapid or irregular heartbeat (palpitations).
Monitor VS, auscultate heart tones and breath sounds, assess patients response to activity, manage pain, teach
regarding condition, treatment plan, self-care (importance of nutrition and diet).
Complications
Atherosclerosis, arteriosclerosis, left ventricular hypertrophy, stroke, weakened or narrowed blood vessels in the
kidneys, thickened, narrowed, or torn blood vessels in the eyes. Uncontrolled high blood pressure has been linked
to cognitive decline and dementia.
109
Hypertension
Definition
Sustained elevation of Blood Pressure. Systolic > or = 140 / Diastolic > or = 90 mmHg
S/S
Frequently asymptomatic, fatigue, activity tolerance, dizziness, palpitations, angina, dyspnea
Periodic monitoring of BP, Nutritional therapy, restrict sodium, weight, restrict cholesterol and saturated fats,
maintain adequate intake of K, Ca, and Mg, physical activity, cessation of smoking, modification of alcohol intake,
antihypertensive drugs diuretics, adrenergic inhibitors, direct vasodilators, angiotensin inhibitors, Ca channel
blockers, stress management relaxation.
Complications
Target organ diseases (hypertensive heart disease), brain (cerebrovascular disease), peripheral vascular disease,
kidney (nephrosclerosis), and eyes (retinal damage), adverse effects from antihypertensive therapy, hypertensive
crisis, and stroke
110
Hypertension
Definition: A disease of the vascular system where by there is an increased cardiac output and increased
peripheral vascular resistance. Essential hypertension is defined as diastolic pressures greater that 90 mmHg or
systolic pressure greater than 140 mmHg. The cause of essential HTN is unknown. However, there is a
correlation with family hx, excessive dietary sodium intake or retention, insulin resistance, and hyperactivity of
sympathetic vasoconstriction nerves.
M/B:
Early: no symptoms
headache most common
Severe cases: dizziness, nausea, vomiting, confusion (can signify encephalopathy)
Visual disturbances, renal insufficiency, aortic dissection, HTN crisis
Complications: Blood vessel damage occurs through arteriosclerosis in which smooth muscle cell proliferation,
lipid infiltration, and Ca accumulation occur.
Causes damage to: (Target organ diseases)
Heart ventricular hypertrophy, CHF
Eyes damage to retina, blindness
Brain CVA
Kidneys nephrosclerosis, renal insuff, RF
Peripheral vasculature peripheral vascular disease, HTN crisis
Recommend change in life style: diet control, wt loss, ^ activity, lower stress
Nutritional status: 2-6 g Na, BMI < 25
Monitor orthostatic hypotension (sudden position changes)
Monitor vitals, I&O, test for edema
Monitor wt.
Teach pt to check BP @ home, and stress med follow up for lifetime
Avoid smoking
Medications:
Always monitor HR and BP prior to administration of hypertensives
*hold if systolic < 100mmHg
*hold if HR < 60 BPM
Diuretics - inhibits NaCl from reabsorbing - ^ excretion of Na & Cl, water follows, thereby lowering BP.
Beta blockers
Calcium channel blockers - block movement of Ca into cells causes vasodilation and decreased SVR
ACE inhibitors - inhibits angiotension I to convert into II, which would prevents vasoconstriction from
occurring.
Vasodilators reduces BP by direct arterial vasodilation
Risk Factors:
Family hx
Age appears between 30-50, over 50 ^ incidence
Race blacks ^%
Gender men ^ risk at 55, equal 55-74, female ^ risk over 74
Stress environmental, personality, physiologic events
Nutrition - ^ Na intake, low K, Ca, Mg
- ^alcohol, drugs (legal/illegal) ie cold meds
- Smoking, caffeine, overweight
111
Hypothyroidism
Definition
Under active thyroid disease. When your thyroid does not produce the adequate amount of hormones to maintain
the balance of chemical reactions in your body.
S/S
Fatigue and sluggishness, increased sensitivity to cold, constipation, pale, dry skin, puffy face, hoarse voice,
elevated blood cholesterol level, unexplained weight gain, muscle aches, tenderness and stiffness, especially in
your shoulders and hips, pain and stiffness in your joints and swelling in your knees or the small joints in your
hands and feet, muscle weakness, especially in your lower extremities, heavier than normal menstrual periods,
depression.
Monitor VS, monitor I & O and correlate with weight changes, administer medications as indicated, reduce
metabolic demands and support cardiovascular function.
Complications
Goiter, heart problems, mental health issues, myxedema, birth defects.
112
Hypoxemia
Definition
Respiratory failure is an alteration in the function of the respiratory system that causes the PaO2 to fall below 50
mm Hg (hypoxemia) or PaCO2 to rise above 50 mm Hg (hypercapnia), as determined by arterial blood gas (ABG)
analysis. Respiratory failure is classified as acute, chronic, or combined acute and chronic. (Lippincott Manual of
Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers.
S/S
Restless ness,Agitation,Dypnea,Disorientation,Confusion,Delirium,Loss of conciousness,
(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 270-273)
Administer antibiotics, cardiac medications, and diuretics as ordered for underlying disorder. Administer oxygen to
maintain PaO2 fo 60 m Hg or SaO2 >90% using devices that provide increased oxygen concentrations (aerosol
mask, partial rebreathing mask, nonrebreathing mask). Monitor fluid balance by intake and output measurement,
urine specific gravity, daily weight, and direct measurement of pulmonary capillary wedge pressure to detect
presence of hypo/hypervolemia. Provide measure to prevent atelectasis and promote chest expansion and
secretion clearance, as ordered (incentive spirometer, nebulization, head of bed elevated 30 degrees, turn
frequently out of bed). Administer medications to increase alveolar ventilation bronchodilators to reduce
bronchospasm, corticosteroids to reduce airway inflammation.
Complications
Oxygen toxicity if prolonged highFIo2 required. Barotrauma from mechanical ventilation intervention.
(Lippincott Manual of Nursing Practice.(7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 270-273),
113
Hysterectomy, supracervial abdominal
Definition
Hysterectomy is a very common operation. The uterus may be completely or partially removed, and the tubes
and ovaries may also be removed at the time of hysterectomy. A partial (or supracervical) hysterectomy is
removal of just the upper portion of the uterus, leaving the cervix intact. Abdominal hysterectomy includes a wide
incision which is used to open the abdominal area, from which the surgeon removes the uterus.
Nursing interventions:
Obtain a prescription to administer opioid analgesia
Use a preventive approach with opiod analgesics to keep pain at or below an acceptable level.
In addition to use of analgesics, support client's use of nonpharmacological methods to control pain, such as
distraction, imagery, relaxation, massage, and heat and cold application.
Plan care activities around periods of greatest comfort whenever possible.
Encourage client to make choices and participate in planning of care and scheduled activities.
Monitor for signs of infection.
Complications
- infection of surgical site
- urinary tract infections
- excessive bleeding
- damage to nerve structures important to bladder and sexual function
- Pulmonary embolism
- Perforation of the bowel
- Fistulas
- Dehiscence
- Muscle weakness in the pelvic area
114
Hysterectomy, Total Abdominal with bilateral salpingo oopherectomy
Definition: During a total abdominal hysterectomy, the doctor removes the uterus, including the cervix. The scar
may be horizontal or vertical. Cancer of the ovary and uterus, endometriosis, and large uterine fibroids are treated
with total abdominal hysterectomy. TAH may also be done in some unusual cases of very severe pelvic pain, after
a very thorough evaluation to identify the cause of the pain, and only after several attempts at non-surgical
treatments.
Oopherectomy is the surgical removal of the ovary while salpingo-oopherectomy is the removal of the ovary and its
adjacent fallopian tube. These two procedures are performed for cancer of the ovary, removal of suspicious ovarian
tumors, or Fallopian tube cancer (very rare). They may also be performed due to complications of infection, or in
combination with hysterectomy for cancer. (Occasionally, a women with inherited types of cancer of the ovary or
breast will have an oopherectomy as preventative surgery in order to reduce the risk of future cancer of the ovary
or breast. )
Complications and risk factors:
Patient may experience urinary retention from edema or nerve trauma normally a catheter is used to
prevent this.
Abdominal distention from sudden release pressure on intestines
DVT
Emotional loss for loosing the ability to bear children.
When ovaries removed, surgical menopause symptoms are as such, could be more severe due to
sudden withdrawal of hormones.
Abdominal dressing should be checked frequently for bleeding during the first 8 hours after surgery.
Restrict foods and fluids if patient nauseated.
DVT precautions frequent position changes, avoid high Fowlers, avoid pressure under knees (pooling),
ted hose
Give understanding care and provide discharge teaching avoid heavy lifting for 2 months, no intercourse
for 4-6 weeks, also provide knowledge vaginal sensation may be temporarily lost. Activities increasing
pelvic congestion should be avoided such as jogging, walking briskly, dancing. (Alt- swimming). Girdle may
be helpful
Follow protocol for hormone replacement therapy to prevent estrogen deficiency
Types of procedures involving female reproductive system:

Subtotal hysterectomy removal of uterus w/o cervix (rarely done today)
Total hysterectomy removal of uterus and cervix
Panhysterectomy (TAH-BSO) removal of uterus, cervix, fallopian tubes, ovaries
Vaginectomy removal of the vagina
Supracervical hysterectomy hyst and leaving in the cervix
Radical hysterectomy panhysterectomy, partial vaginectomy, dissection of lymph nodes, pelvis
Pelvic exenteration rad hyst, tot vag, removal of bladder w/ diversion of urinary system (neph tube) and
resection of bowel with colostomy.
Anterior pelvic exenteration above w/o bowel resection
Posterior pelvic exenteration above w/o bladder removal
Simple vulvectomy exc of vulva and wide margin of skin
Radical vulvectomy exc of tissure from anus to few cm above symphasis pubis (skin, labia majora and
minora,k and clitoris) with superficial and deep lymph node dissection.
More info side note:

Vaginal hyst- if uterus removed through vagina (not abdomen)
Lap assisted vaginal hysterectomy (LAVH) laparoscope inserted through belly button, and other parts of
abdomen and female parts removed through vagina.
115
Ileus
Definition
an intestinal obstruction. The term originally meant colic due to intestinal obstruction. It is characterized by loss of
the forward flow of intestinal contents, often accompanied by abdominal cramps; constipation; fecal vomiting;
abdominal distention; and collapse. (Venes, D. (19th ed.) (2001). Tabers Cyclopedic Medical Dictionary.
Philadelphia: F.A. Davis Company. P. 1016.)
S/S
Abdominal distention,Pain,Absent bowel sounds,(Internet. Yahoo! Health Encyclopedia.
http://health.yahoo.com/health/ency/adam/000260.)
Measure abdominal girth frequently to detect progressive distention. Administer prescribed medication and
monitor for bowel motility as well as adverse effects. A nasogastric (NG) or nasointestinal tube is inserted as
prescribed. Monitor vital signs for a drop in blood pressure, metabolic acidosis, or infection, IV fluids are
instituted, renal function is assessed, and fluid and electrolyte balance is monitored.
(Venes, D. (19th ed.) (2001). Tabers Cyclopedic Medical Dictionary. Philadelphia: F.A. Davis Company. P. 1016.)
Complications
Jaundice; Electrolyte imbalance; Peritonitis; Appendicitis
(Internet. Yahoo! Health Encyclopedia. http://health.yahoo.com/health/ency/adam/000260.)
116
Jaundice
Definition
Jaundice is not an illness, but a medical condition in which too much bilirubin - a compound produced by the
breakdown of hemoglobin from red blood cells - is circulating in the blood. The excess bilirubin causes the skin,
eyes and the mucus membranes in the mouth to turn a yellowish color.
S/S
Yellow discoloring of the skin, whites of the eyes and mucus membranes, dark urine, nausea, itching, light-colored
stool (gray or yellow), abdominal pain or swelling.
Monitor vital signs and laboratory/diagnostic studies, assess/document dietary intake measuring I&O accurately,
and promote infection control.
Complications
Depends on the cause.
117
Kidney Stone (nephrolithiasis)
Definition: Stones are formed in the urinary tract from the kidney to the bladder by the crystallization of substances
excreted in the urine. Most are composed of ca oxalate crystals. The rest are composed of uric acid, struvite (mg,
ammonia, phosphate), or cystine (aa).
-higher incidence in men (20-40)

-spontaneous stone passage in 80%
-some lodge in renal pelvis, ureters, bladder neck causing obstruction can lead to nephron damage.
Risk Factors:
Metabolic abnormalities result in high ca levels in urine
I.e. hyperparathyroidism
o Climate warm climate, increase fluid loss, increase [solute] of urine.

o Diet high intake proteins (increase uric acid excretion)
-excess tea or fruit juices
-excess intake of ca, vit d
o Genetic factors fm hx of stone form, gout, cystinuria, renal acidosis
o Life Style- sedentary
Manifested by: (When they obstruct urinary flow)

Abdominal or flank pain (sever) immediate relief after passage
Hematuria
Renal colic
Nausea/vomiting
o pain management
o control/monitor for infection
o educate patient on diet
- 2000-3000 ml daily
- Diet low in sugar and animal proteins
- Increase fiber intake
- Save stone for analysis
Complications:
o Obstruction
o Infection
o Impaired renal function
Poss. Nursing Dx:
o Pain r/t obstruction, abrasion and inflammation of urinary tract by migration of stones.
o Altered urinary elimination r/t blockage of urine flow by stones.
o Risk for infection r/t obstruction of urine flow
118
Laminectomy
Definition
Excision of a vertebral posterior arch and is commonly performed for injury to the spinal column or to relieve
pressure/pain in the presence of a herniated disc. May be done with or without fusion of vertebrae.
S/S
Outcomes- Neuro function maintained/improved. Complications prevented. Limited mobility achieved with potential
for increasing mobility.
Condition/prognosis, therapeutic regimen, and behavior/lifestyle changes are understood.
Monitor Vs, I&O, drainage. Keep pt. flat for several hours, assess neuro, assess for signs of edema (i.e. face and
neck for cervical laminectomy), logroll pt. to avoid twisting/flexing of back, limit activities, provide firm mattress,
apply brace/collar, encourage coughing/deep breathing, monitor labs, assess pain, relaxation, restful environment,
assess bowel sounds, assist with range of motion, encourage early ambulation, apply heat/cold.
Complications
119
Lap Cholectomy
Definition: removal of the gall bladder via laparoscopy using a dissection laser. (92% of choles done
laparoscopically)
1cm puncture made slightly above umbilicus (surgeon inflates abd cavity w/ 3-4 L co2 to improve visability). A lap
w/ camera inserted into abd. Two additional puncture made just below ribs (one on rt of axillary line, and other on
the rt midclavicular line). These punctures used for insertion of grasping forceps. A dissection laser inserted into
4th puncture, which is made just rt of midsection. Using closed-circuit monitors ot view the abd cavity, the surgeon
retracts and dissects the gallbladder and removes with grasping forceps.
Vitals q15 x4, q30 x2, q1h x4
Monitor for complications, such as bleeding
Make patient comfortable
Prepare for discharge
TCDB and ambulation
Pain control
Clear liquids
Monitor drainage if T-tube or JP tubes are used.
Risk Factors and Complications:

Contraindications to do the surgery would be peritonitis, cholangitis, gangrene or perforation of the GB.
Minimal post op complications. Compared to an incisional cholectomy, decreased post op pain, shorter hospital
stay, earlier to work and full activity.
The main complication is injury to the common bile duct.
120
Leukemia, Ac (myelogenous)
pg 874 lippincott
Definition:
Leukemias are malignant disorders of the blood and bone marrow that result in an accumulation of dysfunctional
immature cells (myeloblasts precursors to granulocytes) that are caused by a lack of regulation of cell division. It
is characterized by a rapid progression of symptoms.
There is an increased in incidence with advancing age peak (60-70).
ac lymphocytic leukemia - When lymphocytes are predominantly malignant.

ac myelogenous leukemia when monocytes or granulocytes are predominant.
(So basically, it attacks the defense cells of the immune system)
Manifested by:
Fatigue and weakness, headache, mouth sores, minimal hepatosplenomegaly and lymphadenopathy, anemia,
bleeding, fever, infection, and sternal tenderness.
Lab findings:
low RBC, H &H, platelet
low to high WBC count w/ myeloblasts
greatly hypercellular bone marrow w/ myeloblasts
121
Lithotripsy
Definition: Lithotripsy (L) is a way to eliminate urinary calculi (kidney stones) non-invasively. L. techniques include
percutaneous ultrasonic L, electrohydraulic L, Shock wave and laser lithotripsy. Most common: Shockwave and
Laser Lithotripsy
A shock wave characterized as very rapid increase in pressure. It transmits harmlessly through soft tissue (passes
through kidney) and strikes the stone. Initially the stone cracks. With successive shocks the stone eventually
reduces to small particles, which are hopefully flushed out of kidneys naturally while urinating.
- Takes about 1 hr, up to 8000 shocks can be administered.
- Anesthesia necessary to keep patient still during procedure.
Complications:
Hematuria common s/p lithotripsy.

Pain
Temporary bleeding around kidney
Occasionally, if the stone obstructs the flow of urine, the patient experiences severe pain (renal colic). This pain can
be controlled by introducing a stent into the ureter. The stent is basically a tube which is placed in the ureter and
allows the urine to drain past the obstruction. The stent may be left in after lithotripsy in case of obstruction due to
fragments becoming lodged in the ureter. Stent usually removed w/in 1-2 weeks.
Give prescribed narcotic analgesic, monitor pt for pain closely
Monitor respirations and BP
Encourage pt to find comfortable position
Administer antiemetics as indicated for nausea
Risk Factors:
Urinary infection
Damage to ureter caused by stent (if used)
Possible Nursing Dx:

Pain r/t inflammation, obstruction, and abrasion of urinary tract by migration of stones.
Altered urinary elimination r/t blockage of urine flow by stones
Risk for infection r/t obstruction of urine flow and instrumentation during treatment.
Benefits of less invasive surgery:

Shorter hospital stay
Pts earlier return to health
All invasive procedures carry a higher risk of infection complications than non-invasive procedures such as lithotripsy. Some other methods to
remove kidney stones:
Ureteroscopy - (for distal urethral calculi)insertion via the urethra following w/ stone fragmentation and removal by mechanical
means.
Percutaneous nephrolithotomy - (for stones larger than 2.5 cm) removal of stone through puncture into kidney (from patients side)
122
Low back pain
Definition
Characterized by an uncomfortable or acute pain in the lumbosacral area associated with severe spasm of the
paraspinal muscles often with radiating pain. Causes include: mechanical (i.e. sprain), degenerative or herniated
disc, arthritis, tumor, and bone disease.
S/S
Pain localized or radiating to the buttocks or to one or both legs. Paresthesias, numbness, and/or weakness of
lower extremities. Spasm in acute phase. Bowel/bladder dysfunction in cauna equina syndrome.
Assess pain/ administer prescribed meds. Keep pillow between flexed knees while lying on side. Use of firm
mattress to reduce strain. Apply heat/cold as ordered. Encourage ROM, avoid long periods of sitting. Teach good
body mechanics. Avoid fatigue, standing for long periods of
Complications
Spinal instability, infection, sensory, and motor deficits. Chronic pain. Malingering and other psychosocial reactions.
123
Lumbar spinal stenosis
Definition
Narrowing of the spinal canal in the lumbar area (low back). Natural degenerative changes cause discs to lose fluid
and height, resulting in disc bulging. Small joints in the back part of the spine develop spurs or osteophytes. This
narrowing can, if critical, cut off blood supply to nerve roots that provide sensation and motor power to legs.
S/S
Back and/or leg pain, numbness, weakness.
Pain assessment/control, physical therapy, and bracing.
Complications
Impaired ambulation related to pain.
124
Macrocytic anemia
Definition
Large RBC; cause defective RBC maturation- they are more easily destroyed.
S/S
Sore tongue, anorexia, N/V, abdominal pain, weakness.
Assess- B12 vitamin level, folic acid, MCH lab, GI discomfort, skin/tissue condition, capillary refill, skin color, VS,
O2 sat Implement- B12 injections if pernicious anemia is diagnosed, diet, folic acid administration if prescribed
Educate- alcohol withdrawal/cessation, med administration, foods good for type of anemia
Complications
ADL difficulty, fatigue, hypoxemia
125
Malignant Tumors of Reproductive system
Definition: Malignant tumors of the reproductive system can be found in the cervix, endometrium, ovaries, vagina,
and vulva.
Cancer cells go through various stages:
Inititiation mutation in cells genetic structure
Promation- promoting factors are dietary fat, obesity, cigarette smoking, etoh, stress.
Progression increased growth rate of tumor and increased invasiveness and poss metastasis.
Metastasis spread of ca from initial site to distant site.
Manifested by:
Leukorrhea
Irregular vaginal bleeding
Vaginal discharge
Increase in abdominal pain or pressure
Bowel and bladder distention
Health promotion routine screening
Educate about risk factors condoms, fewer sexual partners, high fat diet (^ovarian ca)
Achieve satisfactory pain and symptom management
Each patients concerns approached and evaluated individually. Recognize some women may have
anxiety (surgery), others guilt, anger, embarrassment, some may relieved of not having periods.
If has surgery follow post op protocol
Complications:
Malignancy
Emotional
Treatment surgery, chemo, radiation
Death
Poss. Nursing Dx:

Anxiety r/t threat of malignancy and lack of knowledge about the disease process and prognosis.
Acute pain r/t pressure secondary to enlarging tumor
Disturbed body image r/t loss of body past and good health
Ineffective sexual patterns r/t physiologic limitations and fatigue
Ineffective breathing r/t ascites an effusions
Anticipatory grieving r/t poor prognosis of advanced disease
126
Meningitis
Definition
Lippencott, 466. Meningitis is the inflammation of the meninges lining the brain and spinal cord. Pathogenic
organisms cross the blood-brain barrier, invade the SAS, and cause an inflammatory response.
S/S
Headache, fever, altered LOC, petechia, photophobia, onset may be several hours or several days.
Reduce fever, maintain fluid balance (IV overload may make cerebral edema worse), assess neuro and vital signs
frequently, reduce pain. Outcome:Pt will be afebrile. Pt will have adequate urine output. Pt will have no pain. Pt
returned to optimum level of functioning.
Complications
Seizures, cerebral edema which may lead to compression of the brainstem, deafness, paresis, cranial nerve
disorders
Nursing Diagnosis: Pain, r/t meningeal irritation. Impaired physical mobility r/t prolonged bedrest. Risk for fluid
volume deficit, r/t fever,
decreased intake.
127
Multiple Myeloma
Definition: A condition where plasma cells infiltrate the bone marrow and destroy bone. Plasma cells are activated
B-cells which produce immunoglobulins (antibodies which normally protect the body). In mm the malignant plasma
cells produce abnormal and excessive amounts of immunoglobulin (proteins) and cytokines which play a role in the
destruction process of the bone.
A pt usually lives for 2 years if untreated. Incidence is 4 per 100,000 people. The cause is unknown. Exposure to
radiation, organic chemical pesticides, genetic factors, and viral infection may play a role.
Manifested by:
Constant severe bone pain caused by bone lesions and pathologic fractures; sites include thoracic and
lumbar vertebrae, ribs, skull, pelvis, and proximal long bones.
Fatigue and weakness r/t anemia caused by crowding of marrow by plasma cells.
Proteinuria and renal insufficiency
Electrolyte disturbances: inc Ca (bone destruction), hyperuricemia (cell death, renal insufficiency)
Control pain location/intensity/characteristic, administer pain meds ATC, teach nonpharm methods,
assess
Promote mobility encourage pt to wear back brace for lumbar lesions, recommend phys. therapy consult,
discourage bed rest, assist pt to avoid injury.
Relieving fear develop trusting supportive relationship w/ patient and sig others with an open line of
communication, encourage pt to use own support network.
Monitoring for complications report sudden, severe pain (especially of back), watch for nausea,
drowsiness, confusion, polyuria ( d/t high calcium- d/t bone destruction)
Monitor labs: calcium, bun creatinine and urine protein to check for RI (d/t to nephrotoxity of abn proteins in
multiple myeloma.
Increase fluid intake, monitor I&O, weigh daily
Community and home care considerations
Patient education and health maintenance
Complications:
Pathologic fx, spinal cord compression
Recurrent infections- primarily bacterial
Electrolyte abnormalities (hypercalemia,hyperphosphatemia)
Renal failure, pyelonephritis
Bleeding
Thromboembolic complications caused by hyper viscosity
Pts have a median survival of 3-4 years
Poss. Nursing Dx:

Pain (bone) r/t to destruction of bone and possible pathologic fxs.
Impaired physical mobility r/t pain and possible fx.
Fear r/t poor prognosis
Risk for injury r/t complications of disease process.
128
Myocardial Infarction
Definition:
(Lippencott, 361) process by which one or more regions of the heart muscle experience a sever and prolonged
decrease in oxygen supply because of insufficient coronary blood flow.. Subsequently, death to myocardial tissue
ensues. May be sudden or gradual. Progression of event to completion could take from 3-6 hours.
S/S:
Chest pain (severe, crushing, steady substernal pain), Not relieved by SL vasodilators, may radiate (arms, back,
jaw), may produce anxiety/fear (increased HR, pulse, BP, RR), diaphoresis, cool and clammy skin, pallor,
hyper/hypotension, brady or tachycardia, lasts longer than 15 minutes, premature ventricular/atrial beats,
palpitation, dyspnea, confusion, restlessness, n/v or hiccups.
Nursing Diagnosis: Pain r/t imbalance in O2 supply, Anxiety r/t chest pain/fear of death, decreased cardiac output
r/t impaired contractility, Activity intolerance r/t insufficient oxygenation
Reduce pain (administer O2 by NC as prescribed, SL nitro as prescribed, pain is priorityadminister narcotics as
prescribed), alleviate anxiety (administer anxiolytics as prescribed, explain all procedures, limit visitors, back
massage, guided imagery), increase activity intolerance (minimize interruptions, promote rest, comfortable room
temp, assist pt with activities, elevate feet to promote venous return)
Complications:
Arrhythmias, cardiac failure, CHF, cardiogenic shock, ischemia, thrombus formation, cardiac tamponade,
pericarditis
129
Narcolepsy
Definition
a neurological disorder characterized by abnormalities of REM sleep, some abnormalities of non-REM sleep, and
excessive daytime somnolence.
S/S
excessive daytime sleepiness, cataplexy (abrupt loss of muscle tone after emotional stimulation such as laughter,
anger), sleep paralysis (powerless to move limbs, speak, open eyes, or breathe deeply while fully aware of
condition), hypnagogic hallucinations associated with drowsiness before sleep/usually visual or auditory, inability to
focus vision, nocturnal sleep disturbance
review daily schedule, help pt. develop non-drug therapies (exercise, diet), administer or teach self administration
of meds (advise of side effects and use of only prescribed amounts), schedule rest periods of 10-20 minutes two to
three times a day, encourage caffeinated drinks at small intervals during the day to maintain energy, plan
diversional activities and relaxation during periods of fatigue, assist pt in identifying triggers, encourage support
groups/community resources, encourage medic alert bracelet.
Complications
injury R/T falling asleep, psychosocial problems such as disturbed relationships, loss of employment and
depression
Nursing Diagnosis: Sleep pattern disturbance R/T disease process. Fatigue R/T disrupted nighttime sleep.
Ineffective individual coping R/T interference with activity.
130
Nephrectomy
Definition
A nephrectomy is an operation to remove a kidney
S/S
N/A
Monitor vital signs, Assess color, motion, sensation, pedal pulses, prevent infection, wash hands, inspect wounds,
cough, deep breathe, I.S.,
Compression dressing to wound, Ant-embolic stockings, Thromboguards, Foley catheter, Emphasize turning and
ambulation of patient, Push liquids, teach any home care Tx, Monitor labs
Complications
Blood clots, Infection, Actelectasis
131
Nephrostomy Tube
Definition: A nephrostomy is used as a temporary measure to drain urine from the kidney. It is a tube inserted
when the normal pathway from the kidney to the bladder has become obstructed. It is inserted directly into the
pelvis of the kidney and attached to connecting tubing for drainage. NT are temporary, but can stay in place for
several weeks if necessary.
Complications: Infections and secondary stone formations are complications assoc. w/ NT insertion.
Tube should never be kinked or clamped (unless ordered by phys.), and intact.
If excessive drainage around tube, check for patency.
If irrigation ordered, strict aseptic technique required.
--No more than 5ml of sterile saline solution gently instilled to prevent over distention of kidney pelvic and
renal damage.
Assess skin integrity around the tube.
Monitor I/O, notice if changes in appearance or foul odor, or low drainage.
Monitor for infection.
Risk Factors:
Infection
Secondary stone formation
Poss. Nursing Dx:

Altered urinary elimination r/t urinary diversion
Pain r/t surgery
Body image disturbance r/t urinary diversion
Actual Procedure
Using ultra sound, kidney located. Local anaesthetic is injected over the site of the kidney in the lower back. When
the anaesthetic has taken effect, a fine needle is inserted into the kidney pelvis. Sometimes x-ray dye is injected
and an x-ray taken to show where the blockage is exactly. A fine wire is then threaded through the needle. A
narrow tube is then inserted over the wire and gently pushed into the kidney pelvis. The wire is removed and after
fixing the tube to the skin with a couple of stitches, a drainage bag is attached to the tube that can be emptied by
nursing staff.
132
Neuropathic pain
Definition - results from nerve injury or compression. Includes phantom pain and postherpetic neuralgia. Usually
associated with abnormal sensations such as paresthesias.
S/S
Described as burning, shooting, electric, and lancinating. It can be constant or sporadic. Fatigue from sleep
disturbance, loss of appetite or weight loss, anxiety or depression, change in self-concept and/or quality of life.
pain assessment/medication (nsaids, opioids), guided imagery, relaxation, biofeedback, support and open
communication, education on pain meds
Complications
133
Non-Hodgkinss lymphoma
Definition: NHLs are a heterogeneous group of malignant neoplasms of the immune system affecting all ages.
They are classified according to different cellular and lymph node characteristics. It is the most common
hematologic ca and 5th leading cause of ca death. The more aggressive lymphomas are more responsive to
treatment and are more likely to be cured. Indolent lymphomas have a naturally long course, but are more difficult
to treat.
Higher incidence in immunosuppressed patients and increased age.
Manifested by:
Painless enlargement of lymph nodes (unilateral), fever, chills, night sweats, wt loss.
Various symptoms occur w/ pulmonary involvement, superior vena cava obstruction, hepatic or bone involvement.
*Treat: Radiation (palliative not curative), and chemo
Minimize risk of infection strict protected environment, strict hand washing. Avoid invasive procedures.
Asses vitals and LOC, mucous membranes for infection.Obtain cultures, notify physician for T>101.1
Patient education infection precautions, follow up visits, provide information on
American Ca Society
Complications:
From radiation and chemotherapy
Depends on extent of malignancy splenomegaly, hepatomegaly, thromboembolic complications, spinal
cord compression.
134
Obesity
Definition
An abnormal increase in the proportion of fat cells, mainly in the viscera and subcutaneous tissues of the body.
Morbid obesity is when weight exceeds 100% ideal body weight.
S/S
Sleep apnea, obesity-hypoventilation syndrome, disturbances of weight bearing joints, increased sweat and skin
secretions, Shortness of breath, weight gain, increase in appetite, hypertension
Monitor vital signs, daily weights, intake and output, reinforce diet control, patient teaching, exercise, behavior
therpay, physical therapy, medication if ordered, decrease in smoking or alchol use
Complications
Diabetes, heart problems, High blood pressure, gallbladder disease, some types of cancer, high cholesterol, stroke,
cardiac arrest, osteoarthritis, sleeping and breathing problems, Reduced Life Span, gynecological problems,
dysmenorhea, high triglycerides, poor socio-economic status, diverticular disease, urinary stress incontinence,
menstrual problems, amenorhea, high cholesterol, liver disease, depression, kidney disease shortness of breath,
osteoporosis, complication of pregnancy, decreased freedom of movement, hypothyroidism, degenerative arthritis
135
Obesity
Definition
an overabundance of body fat resulting in body weight of 20% or more than the average weight for the persons
age, height, sex, and body frame
S/S
Body weight greater than 20% of acceptable weight for height or BMI greater than 30; increased weight correlated
with increased incidence of
CVD and DM
obtain a complete nutritional assessment (possibly with a nutritionist), assess behavioral/emotional components of
eating, coping mechanisms, assess past successes/failures with dieting, assist pt. with assessing current dietary
habits/forming a diet plan, suggest behavior modification strategies, provide emotional support, provide alternative
coping mechanisms, assess pt. toleration of exercise
Complications
Risk factor for: diabetes, gall bladder disease, osteoarthritis of weight-bearing joints, HTN, and coronary artery
disease. Vitamin/mineral deficiencies because of surgical intervention and/or severely restricted diet.
Nursing Diagnosis: Altered nutrition: more than body requirements R/T high calorie, high fat diet, and limited
exercise. Self-esteem disturbance R/T weight.
136
Open reduction internal fixation (ORIF)
Definition
Open reduction is the correction of bone alignment through a surgical incision. Internal fixation is the securing of
the bones via wire, screws, pins, plates, intramedullary rods, or nails internally.
S/S
N/A
Early initiation of ROM if joint is affected, CPM, or ambulation to prevent scarring, adhesions, provide quicker
healing of cartilage, and decrease in arthritis. Provide proper use of traction if ordered. Administer pain
medications as needed or ordered. Assess vital signs. Monitor for signs of infection: redness, warmth to affected
area, malodorous discharge.
Complications
Infection, complications associated with anesthesia.
137
Osteoarthritis
Definition - or degenerative joint disease, is a chronic, noninflammatory, slowly progressing disorder that causes
deterioration of articular cartilage. It affects weight bearing joints (hips and knees) as wells as joints of the distal
interphalangeal and proximal interphalangeal joints of the fingers.
(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 1011-
1013.)
S/S
Pain,Stiffness,Enlargement or swelling,Tenderness,Limited range of motion,Muscle wasting,Partial
dislocation,Deformity,
(Huether, S. E. & McCance K. L. (2nd ed.) (2000) Understanding Pathophysiology. St. Louis: Mosby, Inc.
Pgs.1049-1051.)
Advise patient to take prescribed NSAIDs or over-the-counter analgesics as directed to relieve inflammation and/or
pain. , Provide rest for involved joints excessive use aggravates the symptoms and accelerates degeneration.
Have prescribed rest periods in recumbent position.
Encourage activity as much as possible without causing pain. Teach ROM exercises to maintain joint mobility and
muscle tone for joint
support, to prevent capsular and tendon tightening, and to prevent deformities. Avoid flexion and adduction
deformities. Suggest swimming or water aerobics as a form of nonstressful exercise to preserve mobility.
1013.)
Complications
Limited mobility. Neurologic deficits associated with spinal involvement.
1013.)
138
Osteomyolitis
Definition
A severe infection of the bone, bone marrow, and surrounding soft tissue
S/S
Fever, night sweats, chills, restlessness, nausea, malaise, constant bone pain that is unrelieved by rest and
worsens with activity, swelling, tenderness, warmth at site of infection, restricted movement, drainage from sinus
tracts to skin, elevated WBC count, elevated sed rate, soft tissue edema of surrounding area
Monitor VS, monitor IV or oral antibiotic therapy, assess pain level frequently, use gentle handling and support
when moving extremity, monitor the prescribed immobilization device and maintain patients body in correct
alignment, teach patient to use assistive devices if able to ambulate, elevate extremity, teach patient about using
distraction relaxation and breathing, teach patient about proper diet and physical rehabilitation, ROM on extremity,
monitor for footdrop,
Complications
Septicemia, septic arthritis, pathologic fractures, squamous cell carcinoma, amyloidosis
139
Ostomy care (continent diversion)
Definition
Assessment- inspect stoma with pouch change (should be moist and red), measure stoma (shrinkage), VS, pain,
body image/altered feelings of self,I&O, lab values, electrolytes, weight, bowel sounds
S/S
N/A
Implement- clean with warm water and dry, adhesive backing 1/16 to 1/8 inch larger than stoma base,
transparent/odor proof pouch, irrigate and cleanse periodically, consult with ostomy nurse, aseptic technique with
bandaged wounds Education- future expectations, changing ostomy bag, signs/Sx of infection and skin break
down, increase fluid intake
Complications
Skin breakdown, infection, disturbed body image
140
Ostomy Ileostomy (Lippincott 590-94 & lewis1085-6)
Definition: A surgical procedure in which an opening is made to allow passage of intestinal contents from the bowel
to the incision/stoma. The stoma (opening surface of abd) is created when the intestine is brought through the abd
wall and sutured to the skin, where fecal matter is diverted through. It may be permanent or temporary. There are
various types:
1. Ileostomy opening from ileum to through abd wall. ( aka conventional or Brooke Ileostomy)
2. Cecostomy opening from cecum to abd wall. (uncommon, as well as ascending colon) are
usually temporary.
3. Colostomy- opening between colon and abd wall. Proximal end of colon sutured to the skin.
Ileostomy:
Stool consistency liquid to semi liquid
Fluid requirement increased
Bowel regulation no
Pouch and skin barriers yes
Irrigation no
Indications for surgery:
ulcerative colitis, Cohns, diseased colon, birth defect, familial polypsis,
Complications:
stomal ischemia, stricture, or stenosis
stomal prolapse
peristomal hernia
peristomal skin breakdown
mucocutanious separation ( between skin and stoma)
educating patient surgical procedure, Ostomy teaching, include fam, clarify misunderstanding
promote positive self image
reduce anxiety gradual steps toward independent care
maintain skin integrity emptying 1/3 to full
maximize nutritional intake avoid foods stimulate elimination, consistent moderate diet habits, nutritionist
consult, weigh QD
achieving sexual well being discuss ways to conceal pouch, diff positions, counseling
Characteristics of stomas:
- pink, red, moist, bleeds slightly when rubbed, no felling to touch, stool functions involuntary, post op
swelling decreased over several months.
141
Ovarian Cancer
Definition
Malignant neoplasm of the ovaries.
S/S
General abdominal discomfort (gas, indigestion, pressure, bloating, cramps), sense of pelvic heaviness, loss of
appetite, feeling of fullness, and change in bowel habits.
Complications
Death
142
Pancreatitis
Definition
An inflammatory process of the pancreas, with the degree of inflammation varying from mild edema to severe
hemorrhagic necrosis. Some patients recover completely; others have recurring attacks; still others develop
chronic pancreatitis. Acute pancreatitis can be life threatening.
S/S
Severe abdominal pain, usually in the upper mid-abdomen, possibly penetrating to the back, abdominal swelling ,
nausea and vomiting , weight
loss, mild jaundice, or a yellow tint to the skin, fever and chills, excessive sweating, clammy skin, rapid heart beat,
shallow, rapid breathing, light colored and greasy stools, which are more common in chronic pancreatitis
Vital Signs ; Give prescribed medication for pain management, nausea and vomiting; Put patient in comfortable
position and frequent changes in position; Frequent oral and nasal care if NG tube is in place; Observe for fever
and other manifestations of infection; Make sure the patient turns,coughs and deep breathes to prevent respiratory
infections; Teaching on preventing infection and detecting complications Medical Tx:Drug Therapy, Management
of pain; Prevention or alleviation of shock reduction of pancreatic secretions; Control of fluid and electrolyte
imbalance; Prevention or treatment of infections; Surgical removal of precipitating cause, if possible.
Complications
Obstruction of the small intestine or bile ducts ; Pancreatic insufficiency ; diabetes ; fat malabsorption; Ascites ;
Pancreatic pseudocysts (fluid collections), which may become infected ; Blood clots in the splenic vein ;
143
Pancreatitis
Definition
Inflammation of the pancreas, ranging from mild edema to extensive hemorrhage, resulting from various insults to
the pancreas. Chronic pancreatitis is defined as the persistence of pancreatic cellular damage after an acute
inflammation and decreased endocrine and exocrine function.
S/S
Pain in LUQ, weight loss, nausea/vomiting, anorexia, malabsorption and steatorrhea appear late in disease, DM
Control pain, improve nutritional status (pancreatic enzymes w/ meals, antacids, monitor blood glucose), Patient
Education and Health Maintenance (stress that no treatment will be effective with continued alcohol consumption)
Outcomes: Pt verbalizes pain level reduced, Weight stabilized, Pt verbalizes understanding of consequences of
continued alcohol consumption.
Complications
Pancreatic pseudocyst, ascites, pleural effusion, GI hemorrhage, Biliary tract obstruction, pancreatic fistula
Nursing Diagnosis: Pain related to chronic insult to pancreas. Altered nutrition:Less than body requirements r/t fear
of eating, malabsorption, and glucose intolerance.
144
Peripheral arterial occlusive disease (aorta and distal arteries)
Definition
Form of arteriosclerosis in which the peripheral arteries become blocked. Chronic occlusive arterial disease occurs
much more frequently than does acute (which is the sudden and complete blocking of a vessel by a thrombus or
embolus).
S/S
1) aortoiliac- mesenteric ischemia (pain after eating), unintentional weight loss, renal insufficiency, poorly controlled
HTN, impotence, intermittent claudication 2) femoral, popliteal, and distal arteries- intermittent claudication, rest
pain, dependant rubor (dusky purple color of extremity when in dependant position; pallor when elevated),
numbness/tingling of feet/toes, tissue loss/nonhealing ulcers, trophic changes (hair loss, thick toe nails, thin/shiny
skin, cool temp of extremity)
frequent neurovascular checks, inspect for ulceration, provide and encourage well balanced diet, encourage
ambulation/ROM to increase circulation, pain meds conducive to ambulation, foot care (i.e. tight fitting socks,
shoes, apply lanolin to prevent skin cracking), teach pt. to avoid crossing legs/sitting in one position too long.
Complications
Ulceration with slow healing, gangrene sepsis, severe occlusion may necessitate limb or partial limb amputation
Nursing Diagnosis: Altered tissue perfusion (peripheral) R/T decreased arterial blood flow. Sensory/Perceptual
alteration (tactile) of lower extremities. Risk for infection R/T decreased arterial flow.
145
Peripheral Vascular Disease (i.e. arterial occlusion)
Definition: Disorders of the circulation in the extremities. (Very similar to the disorders affecting the coronary and
cerebral arteries) The leading cause of PVD Is atherosclerosis, a gradual thickening of the arteries, which
progressively narrows the lumen, which leads to ischemia, pain and inflammation, impaired function, in
progressing cases infarction, and tissue necrosis.
Risk Factors:
Cigarette smoking
Hyperlipidemia
Hypertension
Diabetes mellitus
Obesity & fam hx
Manifested by:
Intermittent claudication (ischemic muscle pain brought on by activity, relief w/ rest)
Delayed capillary refill
Occlusion in extremity
Sudden onset acute pain, numbness, tingling
Weakness
Pallor and coldness
Pulses absent below occlusion
Visual assessment skin integrity, assoc w/ diminished circulation
Palpate pulses
Thrombolytic therapy as ordered attempt to dissolve clot
Anticoagulant therapy as ordered prevent extension of embolus
Extremity protected from injury.
Take precautions needed for surgery , i.e. NPO (possible embolectomy)
Complications of PVD in a diabetic patient:

Combine sensory neuropathy, PVD, DM, clotting abnormalities, impaired immune function is very conducive
making a mountain out of a molehill in foot complications like lesions.
- High sugar environment allowing bacteria to grow, blood is viscous.
- Patient doesnt feel pain from lesion due to neuropathy disregards
- Maybe patient doesnt see it due to retinol neuropathy
- Impaired immune response due to sclerosis of vessels
Look for:
- Changes in skin integrity, color, gangrenous?
- Decreased lower leg hair
- Decreased or absent pulses, poor cap refill
- Extremity cool, pallor
Treatment:
- ASAP, to prevent infection
- mild antiseptic, antibiotics as ordered
- rest affected leg to promote circulation and wound healing
- avoid anything constricting to skin, i.e. tape
146
Pleural effusion
Definition
Collection of fluid in the pleural space.
S/S
Progressive dyspnea, decreased movement of the chest wall, pleuritic pain, fever, night sweats, cough, and weight
loss.
Auscultate breath sounds, noting adventitious sounds, monitor vital signs and laboratory/diagnostic studies,
assess/document dietary intake measuring I&O accurately, and promote infection control.
Complications
Congestive heart failure.
147
Pleural Effusion
Definition: Excess fluid in the pleural space. Causes are many and include lung ca, chest trauma, heart
failure, hepatic diseases, hypoalbuminemia, pleural infection, malignancy, myxedema, pancreatitis,
TB, and pulmonary embolism. Is a sign of a disease and not a disease in its self. Has 2 types:
transudative or exudative. Exudative is caused from inflammation.
M/B: Decreased breath sounds, dyspnea, fever, pleuritic chest pain, and malaise.
Chest X-ray will show fluid in dependent regions. Dullness to percussion.
Pleural effusions due to malignant diseases tend to reoccur and accumulate.
Administer O2 to improve oxygenation, treat underlying cause, prepare patient for thoracentesis, explain
procedure to patient, explain to patient the importance of informing you if there is any increased difficultly in
breathing.
Watch for respiratory distress. Have patient deep breathe, cough and use incentive spirometer.
If patient has chest tubes, use aseptic technique for dressing changes. Ensure patency of tube by
watching for bubbles in seal chamber. Record drainage of tube. If chest tube comes out, cover hole with
petroleum gauze and call MD.
Complications: Respiratory distress, pneumothorax, collapsed lung, infection, adhesions from recurrent
effusions.
148
Pneumonia
Definition
Is an inflammatory process, involving the terminal airways and alveoli of the lung, caused by infections agents.
S/S
Sudden onset; shaking chill; rapidly rising fever of 101-1050F,Cough productive of purulent sputum. Pleuritic chest
pain aggravated by respiratory/coughing. Dyspnea, tachypnea accompanied by respiratory grunting, nasal flaring,
use of accessory muscles or respiration, fatigue. Rapid, bounding pulse.
Observe for cyanosis, dyspnea, hypoxia, and confusion, indicating worsening condition. Follow ABGs/oxygen
saturation to determine oxygen need and response to oxygen therapy. Administer oxygen at concentration to
maintain acceptable oxygen saturation level. Obtain freshly expectorated sputum for Grams stain and culture,
preferably early morning specimen, as directed. Encourage patient to cough. Retained secretions interfere with
gas exchange. Suction as necessary. Humidify air or oxygen therapy to loosen secretions and improve ventilation.
Complications
Pleural effusion. Sustained hypotension and shock, especially in gram-negative bacterial disease, particularly in
the elderly. Superinfection: pericaditis, bacteremia, and meningitis. Delirium this is considered a medical
emergency. Atelectasis due to mucous plug. Delayed resolution.
149
Pneumonia
Definition
Inflammatory process, involving the terminal airways and alveoli of the lung, caused by infectious agents. Classified
according to causative agent.
S/S
(sudden onset- shaking chill, rapidly rising fever of 39.5 to 40.5 Celsius or 101 to 105 Fahrenheit) cough productive
of purulent sputum, pleuritic chest pain aggravated by respiration/coughing, rapid/bounding pulse, dyspnea,
tachypnea accompanied by respiratory grunting, nasal flaring, use of accessory muscles of respiration, fatigue.
Observe for cyanosis, dyspnea, hypoxia, and confusion. Follow ABG/SaO2 to determine oxygen need, humidify O2
to loosen secretions, place pt. in upright position, encourage activity, encourage coughing, auscultate chest for
crackles and rhonchi, demonstrate how to splint chest while coughing, VS, encourage fluid intake.
Complications
Pleural effusion, sustained hypotension and shock (especially in gram negative bacterial disease, particularly in the
elderly), superinfection (pericarditis, bacteremia, and meningitis), delirium (this is considered a medical
emergency), atelectasis (due to mucous plugs), delayed resolution
Nursing Diagnosis: Impaired gas exchange R/T decreased ventilation secondary to inflammation and infection
involving distal airspaces. Ineffective airway clearance R/T excessive tracheobronchial secretions. Pain R/T
inflammatory process and dyspnea. Risk for injury R/T resistant infection.
150
Pneumonia
Definition
Inflammatory process, involving the terminal airways and alveoli of the lung. It is caused by
infectious agents. Classified according to causative agent. bacteria, fungi, or candida. It is seen most commonly
in people that are immunocompromised.
S/S
Sudden onset- shaking chill, rapidly rising fever of or 101 to 105 F, cough productive of purulent sputum.
Pleuritic chest pain aggravated by respiration/coughing
Rapid/bounding pulse
Dyspnea, tachypnea accompanied by respiratory grunting, nasal flaring, use
of accessory muscles of respiration, fatigue.
Improve gas exchange - Observe for cyanosis, dyspnea, hypoxia, and confusion. Follow ABG/SaO2 to
determine oxygen need, humidify O2 to loosen secretions.
Place pt. in upright position, encourage activity, encourage deep breathing and coughing
Auscultate chest for crackles and rhonchi.
Enhance air way clearance deep breathing, increase fluids, humidify air, chest wall percussion.
Relieve pleuritic pain comfortable positioning and changing positions prevents pooling. Administer
analgesics as ordered.
Monitor for complications observe vitals, auscultate lungs, observe mental status.
Special nursing surveillance for immunocompromised may have little or no fever.
Complications
Pleural effusion, sustained hypotension and shock (especially in gram negative bacterial disease, particularly in the
elderly), superinfection (pericarditis, bacteremia, and meningitis), delirium (this is considered a medical
emergency), atelectasis (due to mucous plugs), delayed resolution.
Nursing Diagnosis:
1. Impaired gas exchange R/T decreased ventilation secondary to inflammation and infection
involving distal airspaces.
2. Ineffective airway clearance R/T excessive tracheobronchial secretions.
3. Pain R/T inflammatory process and dyspnea.
4. Risk for injury R/T resistant infection.
151
Pneumothorax
Definition
A condition in which air gets between the lungs and the chest wall.
S/S
Sudden, sharp chest pain, shortness of breath, chest tightness.
Promote/maintain lung re-expansion for adequate oxygenation/ventilation, minimize/prevent complications, reduce
discomfort/pain.
Complications
May be life-threatening if left untreated.
152
Pressure Ulcer
Definition
Also known as skin breaks down, is a localized area (usually over a bony prominence) of tissue necrosis caused by
unrelieved pressure that occludes blood flow to the tissues. Factors that influence the development of pressure
ulcers include the amount of pressure (intensity), the length of time the pressure is exerted on the skin (duration),
and the ability of the patients tissue to tolerate the externally applied pressure. Besides pressure, shearing force,
friction, and excessive moisture contribute to ulcer formation.
S/S
STAGE ONE-A reddened area on the skin that when pressed is non-blanchable. This indicates a pressure ulcer is
starting to develop. May have changes in one or more of the following: Skin temperature (warmth or coolness),
Tissue Consistency (Firm or Boggy feel) and Sensation (Pain and Itching).
STAGE TWO-Partial-thickness skin loss involving the epidermis, dermis or both. The ulcer is superficial and
presents clinically as an abrasion, blister, or shallow crater.
STAGE THREE-Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend
down to, but not through, underlying fascia.
STAGE FOUR-Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or
supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts may also be associated with
STAGE IV pressure ulcers.
Assess causative factors such as activity, mobility, presence or absence of sensory deficits, nutrition and hydration
status, circulation, and oxygenation, skin moisture status to reduce or eliminate factors that contribute to
development or progression of the pressure ulcer; Assess stage and document wound characteristics on a regular
basis in relation to location, width, and depth of wound, amount of granulation tissue visible and/or epithelialization,
necrotic tissue, local or systemic infection, presence and character of exudates, including volume, color
consistency, and odor to provide baseline and ongoing data for monitoring pressure ulcer.; Use pressure relief
devices (e.g., foam boots, wheelchair cushions); Institute and document position change schedule q2hr to avoid
prolonged pressure in one area.; Keep heels off of bed. Keep head of bed at or below 30-degree angle and flat
when not contraindicated to avoid sacral, buttock, and heel pressure.; Use assistive devices (e.g., trapeze, turning
sheets, lifts) to aid patient movement.; Protect patients skin from excess moisture to prevent maceration.; Institute
2000 to 3000 calories/day (more if increased metabolic demands), 2000 ml/day of fluid to provide calories, protein,
and fluids necessary for tissue repair.; Offer vitamin and mineral supplements if there are deficiencies.; Initiate
prescribed tx based on pressure ulcer characteristics and in accordance with AHCPR 1994 guidelines.; Assess the
psychosocial impact of pressure ulcer on the patient and caregivers and provide support or make referrals to other
health care providers as indicated.; Teach patient and family about cause, prevention, and tx of pressure ulcer to
prevent recurrence.
Complications
Infection; Amyloidosis; Endocarditis; Meningitis; Peptic Arthritis; Squamous Cell Carcinoma (in the ulcer); Systemic
Complications of Topical Treatment; Maggot Infestation
153
Pressure Ulcers
Definition: A pressure ulcer is a localized area (usually over a bony prominence) of tissue necrosis caused by
unrelieved pressure that occludes blood flow to the tissues. Most common site being the sacrum the heels second.
Factors influence the pr ulcer are the following:
Intensity
Duration
Patients tolerance or if cognitive
Friction and excessive moisture also contribute
Manifested by:
Stage 1:
Skin intact
Skin T warm
Tissue firm, persistant redness
Stage 2:
Partial thickness skin loss (involve epidermis,dermis, or both)
Superficial blister, abrasion, shallow crater
Stage 3:
Full thickness skin loss
Damage or necrosis of sub Q tissue, extend down to- not through
Presents as deep crater w/ or w/o undermining adjacent tissue
Stage 4:
Full thickness skin loss, extensive distruction, tissue necrosis
Damage to muscle, bone, supporting structures
Nursing Interventions: ***PREVENTION

Relief of pressure
Measure size of wound
Debridement, wound cleaning
Application of dressing
Poss operative care needed: i.e. skin graft, skin flaps, musculocutaneous flaps
Complications:
Stage increasing to next level
Necrosis
Infection
Septicemia
Amputation
Poss. Nursing Dx:

Impaired skin integrity r/t pressureand inadequate circulation m/b evidence of pressure ulcer.
154
Prostate Cancer
Definition
A malignant tumor (almost always an adenocarcinoma) of the prostate gland.
(Venes, D. (19th ed.) (2001). Tabers Cyclopedic Medical Dictionary. Philadelphia: F.A. Davis Company. P.1692.)
S/S
Most early-stage prostate cancers are asymptomatic. Symptoms due to obstruction of urinary flow: hesitancy and
straining to void, frequency, nocturia; diminution in size and force of urinary stream. Symptoms due to metastases:
pain in lumbosacral area radiating to hips and down legs (from bone metastases); perineal and rectal discomfort;
anemia, weight loss, weakness, nausea, oliguria (from uremia); hematuria (from urethral or bladder invasion, or
both); lower extremity edema occurs when pelvic node metastases compromise venous return.
Help patient assess the impact of the disease and treatment options on quality of life. Give repeated explanations
of diagnostic tests and treatment options; help patient gain some feeling of control over disease and decisions.
Help patient/family set reachable goals. Let patient know that decreased libido is expected after hormonal
manipulation therapy and impotence may result from some surgical procedures and radiation. Expect patients
behavior to reflect depression, anxiety, anger, and regression. Encourage ventilation of feelings and communication
with partner.
Complications
Bone metastasis vertebral collapse and spinal cord compression, pathologic fractures; Complications of
treatment.
155
Pneumomediastinum
Definition: Free air or gas contained within the mediastinum, which originates from the alveolar space or
conducting airways. (The space in the chest between two lungs)
S/S: neck and chest pain, dyspnea, fever, dysphonia (hoarseness), throat pain and jaw pain.
Nursing Intervention/Teaching:
Avoid high risk activities: those involving the Valsalva maneuver; wind instruments, diving, weight lifting. Maintain
good asthma control, vaccinations are current: influenza and pertussi, avoid smoking and inhalation of illicit drugs.
Complications: Subcutaneous emphysema, hypotension, mediastinitis and pneumothorax.
156
Post operative patient
Definition
Pg 119, Lippencott. General guidelines for most post operative scenarios.
1. Maintain adequate fluid volume by administering IV or po fluids as prescribed, recognize evidence of
electrolyte imbalance.
2. Assess pain levels and administer analgesics as prescribed, position patient to maximize comfort.
3. Perform good hand washing before and after contact with patient, inspect dressings and reinforce if
necessary.
4. Encourage coughing, deep breathing, use of incentive spirometer (if ordered).
5. Assess for n/v and administer anti-nausea meds as prescribed, assess bowel sounds frequently.
6. Provide therapeutic environment (room temp, clean bedding, lights, etc), post op vitals.
Outcomes: Pt will report adequate pain control. Pt will breathe deeply and use IS every hour. Pts input and
output will remain equal with no visible signs of imbalance. Pt will be
free of n/v.
Complications
Postoperative pain, shock, hemorrhage, DVT, atelectasis, aspiration, pneumonia, PE, urinary retention, bowel
obstruction, hiccups, wound infection, wound dehiscence, and psychological disturbances.
Nursing Diagnosis:
Ineffective airway clearance r/t anesthesia and or pain meds.
Risk for fluid volume deficit r/t blood loss, food and fluid deprivation, vomiting, etc.
Pain, r/t surgical incision and trauma.
157
Prostatectomy
Definition
The excision of part or all of the prostate gland.
(Venes, D. (19th ed.) (2001). Tabers Cyclopedic Medical Dictionary. Philadelphia: F.A. Davis Company. P.1692.)
S/S
N/A
Maintain patency of urethral catheter placed after surgery. Assess degree of hematuria and any clot formation;
drainage should become light pink within 24 hours. Administer IV fluids as ordered, and encourage oral fluids
when tolerated to ensure hydration and urine output. After 24 hours, encourage ambulation to prevent venous
thrombosis, pulmonary embolism, and hypostatic pneumonia. Observe urine for cloudiness or odor, and obtain
urine for evaluation of infection as ordered. Administer pain medication, or monitor PCA as directed. Provide
realistic expectations about postoperative discomfort and overall progress. Tell patient to avoid sexual intercourse,
straining at stool, heavy lifting, and long periods of sitting for 6 to 8 weeks after surgery. Advise follow-up visits after
treatment because urethral stricture or bladder neck contracture may occur.
Complications
Incontinence; Impotence; Infertility; Retrograde ejaculation; Urethral stricture
158
Pulmonary Embolism
Definition
A pulmonary embolism arises from thrombi in the venous circulation (and from other sources). The most common
source is the deep veins of the legs. The thrombus breaks loose and travels and an embolus until it lodges in the
pulmonary vasculature.
S/S
Dependent upon the size and number of blood vessels occluded. Anxiety, sudden onset of unexplained dyspnea,
tachypnea, tachycardia, cough, pleuritic chest pain, hemoptysis, crackles, fever, accentuation of the pulmonic heart
sound, sudden change in mental status, hypoxia, sudden collapse of patient with shock, no pain if massive PE,
rapid pulse, decreased blood pressure, slight fever, productive cough with blood-streaked sputum
Bed rest in a semi-fowler position, maintain and monitor IV line, patient teaching of PE, oxygen therapy as ordered,
careful monitoring of vital signs as well as ECG, ABG, and lung sounds, provide emotional support, explain
importance of, monitor labs such as PT, PTT, INR
Complications
Pulmonary infarction, alveolar necrosis, hemorrhage, infection of tissue, abscess, pulmonary hypertension,
hypoxemia, dilation and hypertrophy of right ventricle, rapid death
159
Pyelonephritis
Definition
An acute infection and inflammatory disease of the kidney and renal pelvis involving one or both kidneys.
S/S
Fever, Chills, Costovertebral tenderness, Flank pain (with or without radiation to groin). Nausea, Vomiting,
Assess vital signs frequently, and monitor intake and output; administer antiemetic medications to control nausea
and vomiting. Administer antipyretic medications as prescribed and according to temperature. Correct
dehydration by replacing fluids, orally if possible, or IV. Administer or teach self-administration of analgesic
medications, and monitor their effectiveness. Use comfort measures such as positioning to locally relieve flank
pain.
Complications
Renal abscess requiring treatment by percutaneous drainage or prolonged antibiotic therapy. Perhipheral abscess.
(Lippincott Manual of Nursing Practice. (7th ed.) (2001). Philadelphia: Lippincott-Raven Publishers. Pgs. 717-718),
160
Renal Insufficiency, Chronic
Definition:
It is the progressive inability, over months to years, of the kidneys to respond to changes in body fluids and
electrolyte composition with an inability of the kidneys to produce sufficient urine, GFR is less than 20% of normal
and serum creatinine is greater than 5mg/dl. There are 3 stages to CRF early, second and third stage.
Signs/symptoms
-in the early stage patient remains free of symptoms and BUN and creatinine are normal
- in the 2nd stage there is a slight rise in BUN and creatinine; few symptoms may be present including oliguria or
polyuria
-in the 3rd stage, there is a sharp increase in BUN and creatinine; symptoms of oliguria and uremia are present.
- Admininister diuretics, antihypertensives; ACE inhibitors as ordered
- Maintain fluid and dietary restrictions; refer for dietary consultations if necessary
- Limit Na and protein, and high CHO
- Monitor lab values
- Provide oral hygiene at least every 4 hours
- Monitor activity level and fatigability
- Arrange mealtime and activities per client preferences and procedures.
161
Rheumatoid Arthritis
Definition
Is a general term used to describe what may be a heterogeneous group of inflammatory diseases that affect joints
and other organ systems.
S/S
Bilateral, symmetric arthritis affects any diarthrodial joint, but most often involves the hands, wrists, knees, and feet.
Rheumatic nodule elbows, occiput, sacrum. Acute pericarditis. Asymptomatic pulmonary disease. Carpal
tunnel syndrome. Fever, fatigue, weight loss.
Apply local heat or cold to affected joints for 15 to 20 minutes, three to four times a day. Avoid temperatures likely
to cause skin or tissue damage by checking temperature of warm soaks or by covering cold packs with a towel.
Encourage warm bath or shower in the morning to decrease morning stiffness. Encourage exercise consistent
with degree of disease activity. Promote pain relief before self-care activities.
Assist with problem-solving approach to explore options and to gain control of problem areas.
Complications
Loss of joint function because of bony adhesions and damage of supporting structures. Anemia of chronic disease.
162
Schizophrenia
Definition:
A chronic, severe, and disabling brain disease, affecting approximately 1% of the population with no known single
cause it also tends to run in families.
S/S
People suffering from schizophrenia often suffer symptoms such as hallucinations/delusions, hearing voices not
heard by others, beliefs that other people are reading their minds, controlling their thoughts and trying to hurt them
(paranoia). They may also have distorted perceptions of reality, and their speech and thought processes can also
be so disorganized that they may be incomprehensible to others. They also tend to withdraw socially and isolate
themselves.
-Ensuring that the patient with schizophrenia takes their medications on a regular basis while hospitalized.
-Educating the patient and the patients family about the importance of the patient taking their medications on a
regular basis not to stop when they feel better.
-Providing additional resources to the patient and their family such as outpatient resources psychotherapists,
social services, additional sources of education, self-help groups, etc.
- Encourage simple concrete tasks requiring minimal concentration, such as self-care needs.
- Give support to family.
- Plan simple daily routine.
- Continue speaking to pt. even if he or she appears withdrawn.
- Provide milieu that provides sense of security & safety
- Provide activities that distract pt. from hallucinations
Complications:
There is no cure for schizophrenia, only management of the symptoms/signs. If these are not managed, persons
with schizophrenia are more apt to commit suicide; 10-13%, especially young males.
Substance abuse may be as high as 60% in schizophrenic pts.
Violent behavior - common in acute schizophrenic states and relapses.
Can have real difficulty holding down a job; taking care of themselves.
163
Seborrheic dermatitis
Definition
Chronic, superficial inflammatory skin disorder
S/S
Crusted pinkish or yellowish patches. Loose scales that may be dry, moist, or greasy. Mild itching. Affects the
scalp, eyebrows, eyelids, nasolabial creases, lips, ears, chest, axillae, umbilicus, and groin.
Educate pt. on chronic nature and that condition may be exacerbated by perspiration, neuroleptic drugs, and
emotional stress. (This disease is seen more often in patients with HIV, Parkinsons, DM, epilepsy, and
malabsorption syndromes). Educate pt. on topical prescription use (this can include: selenium sulfide, tar, zinc, or
resorcinol shampoo; corticosteroid lotions or creams)
Complications
164
Seizure disorder
Definition
sudden alteration in normal brain activity that causes distinct changes in behavior and body function. They are
thought to result from disturbances in brain cells that cause them to give off abnormal, recurrent, uncontrolled
electrical discharges. (Also known as epileptic seizures or if recurrent epilepsy)
S/S
Impaired consciousness, disturbed muscle tone or movement, disturbances of behavior-mood sensation- or
perception, disturbance of autonomic function
maintain patent airway, monitor serum levels for therapeutic range of meds, monitor for med toxicity, provide safe
environment, do not restrain or place anything in mouth during seizure, lay on side to prevent aspiration, stress
importance of medication regimen, teach stress reduction techniques, avoid alcohol, provide info on support
groups/counseling
Complications
Status epilepticus, injury due to fall
Nursing Diagnosis: Altered cerebral tissue perfusion R/T seizure activity. Risk for injury R/T seizure activity.
Ineffective individual coping R/T psychosocial and economic consequences of epilepsy.
165
Seizures
Definition
A paroxysmal, uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Often
symptoms of underlying illness.
S/S
Sleeping problems, staring spells, appearing withdrawn, sleepwalking, night terrors, noise sensitive, temperature
sensitive, touch sensitive, difficulty getting along with peers, memory losses, word finding problems, headaches,
fatigue in the mornings, leg pains, moody, emotional, clumsiness, easily distracted, lack of coordination, confusion,
sleep deprivation, physically weak, vertigo, ringing in the ears, disorientation, excessively fearful, impulsivity,
confused speech, taste disturbances
Talk calmly to patient, do not attempt to force anything in the patient's mouth, protect the patient from harm, place
the patient on his side after the convulsion to keep the airway clear, allow patient to sleep after the seizure, ensure
patient airway, suction as needed, monitor vital signs, do not restrain, remove or loosen tight clothing, monitor level
of consciousness, monitor oxygen saturation, monitor pupil size and reactivity, reassure and orient the patient after
a seizure, monitor input and output, assess risk for injury, patient teaching, family teaching
Complications
Choking, epilepsy, brain damage, other neurological complications, weakness, facial drop, meningitis, coma,
myocarditis, arrhythmias, pneumonia, liver dysfunction, diffuse bleeding, Jarisch-Herxheimers reaction.
166
Sepsis
Definition
Blood-borne infection
S/S
Severe infection, fatigue, fever, malaise, Nausea, Vomiting
Assess; Wound culture/blood culture Hematocrit/CBC lab electrolyte; balance Prothrombin time; Hand hygiene
Surgical aseptic technique Vital Signs/temperature; inspect wound/drainage; Mouth/vagina care-inspect for yeast
pedal pulses skin color, temp, moisture Homans sign; Edema Breath sounds. Implement: Position change
frequently Prevent spread (sneezing into tissues/coughing/sneezing) Bed rest Prevent shaking chills and sweating
(gown/linen change) Meds administration anti pyretic/antibiotic. Frequent baths Cooling blanket Education: Disease
process Mode of infection Drug therapy Diet S/S that need Dr. consult
Complications
Anemia Respiratory distress Hypothermia/hyperthermia hypotension; Edema; Pyarthrosis Seizures
hepatosplenomegaly hemorrhage jaundice, meningitis
167
Shingles (herpes zoster)
Definition
An inflammatory condition in which a virus produces a painful vesicular eruption along the distribution of the nerves
from one or more dorsal root ganglia; prevalence increases with age.
S/S
1) eruption may be accompanied or precede by fever, malaise, HA, or pain; pain may be burning, lancinating,
stabbing, or aching 2) inflammation; usually unilateral 3) vesicles appear in 3-4 days: A) characteristic patches of
grouped vesicles appear on erythematous, edematous skin B) early vesicles contain serum; they later rupture and
form crusts C) scarring usually does not occur unless they are deep and involve the dermis
Assess pain, apply wet dressings to cool and dry inflamed areas by means of evaporation, teach
relaxation/distraction techniques, teach proper
hand washing to avoid spread, advise pt. not to open blisters to avoid secondary scarring and infection, apply
antibacterial ointments (after acute stage), administer antiviral medication
Complications
1) chronic pain syndrome (constant aching/burning or intermittent lancinating pain or hyperesthesia of affected skin)
2) ophthalmic complications (keratitis, uveitis, corneal ulceration, possible blindness) 3) hearing deficit, vertigo,
facial weakness 4) visceral dissemination- pneumonitis, esophagitis, enterocolitis, myocarditis, pancreatitis
Nursing Diagnosis: Pain R/T inflammation of cutaneous nerve endings. Impaired skin integrity R/T rupture of
vesicles.
168
Sigmoid colectomy
Definition
This type of surgery involves removing the section of the bowel containing the cancer, and then rejoining the two
ends of the bowel. It is a removal of the sigmoid colon -this type of surgery involves joining your bowel together in
the upper area of the rectum.
-give pain medications at prescribed intervals to help avoid breakthrough pain

- wash hands thoroughly before and after changing wound dressing.
-monitor vital signs
-monitor for signs of infection
-answer questions about the surgery and management of the stoma
-help keep the patient as comfortable as possible give back massage, apply lotion, etc.
- encourage patient to make choices and participate in planning of care and schedule activities.
-plan care activities around periods of greatest comfort whenever possible.
Complications
-infection
-bleeding
- leaking from the bowel
-blood clots
169
Skin Breakdown
Definition
Lippincott 183 Pressure sores- Decubitus ulcers- these are localized ulcerations of the skin or deeper structures-
most commonly resulting from prolonged periods of bed rest in acute or long term care facilities.
S/S
Staging- Stage 1- erythema- non blanching redness; Stage 2- dermal breakdown; Stage 3- full thickness skin
breakdown; Stage 4- bone, muscle and supportive tissue involvement
Prevention: Skin inspection several times daily, assess and intervene if incontinence occurs; Encourage ambulation
and exercise; Relieve the pressure; Reposition every 2 hours; Use of air mattress as prescribed; Wound Care:
clean and disinfect, dress as ordered, use of antibiotics as prescribed; Follow up- continue nutritional assessment,
avoid pressure, shearing, moisture
Complications
170
Small Bowel Obstruction (SBO)
Definition
A mechanical or neurological abnormality inhibiting the normal flow of gastric or intestinal contents. Obstructions
may result from scar tissue formation, cancer, or strangulated hernias; all are mechanical barriers to the normal
flow of gastric or intestinal contents. A neurological obstruction, in the form of a paralytic ileus, causes interference
with innervation, thus hindering normal peristaltic activity.
S/S
Abnormal pain and distention in abdomen; projectile vomiting and nausea; and possible absence of bowel sounds
or increase in bowel sounds.
Cramping, Obstipation (chronic constipation) .
Assess and document s/s and reactions to treatments. Monitor vital signs at least q4h. Record I&Os. Monitor the
decompression tube and assess quantity and character of drainage. Provide mouth care while patient is intubated.
Administer prescribed medication and monitor for side effects. Maintain NPO. Monitor the states of distention and
hydration. Provide routine postoperative care if pt undergoes surgery.
Complications
Dehydration d/t loss of water, sodium, and chloride. Peritonitis, shock d/t loss of electrolytes, death d/t shock
171
Soft tissue injuryAbrasion
Definition
Superficial loss of skin resulting from rubbing or scraping the skin over a rough or uneven surface.
S/S
Pain at injury site, swelling, tenderness, bleeding, open areas of skin
Primary: Control Bleeding. Secondary: Wound prep; saline or sterile water irrigation, anesthetizing if necessary
and as prescribed. Debridement performed as prescribed. Application of hydrophyllic dressing allows exudates to
pass through to second absorbent layer in this dressing without wetting contact layer. (Adaptic, petroleum gauze,
Xeroform gauze) Apply outer wrap to hold dressing in place. Tetanus prophylaxis may be indicated. Inform patient
that pain is worse in the first 24-48 hours. Elevation helps to prevent fluid accumulation in interstitial spaces.
Teach patient signs and symptoms of infection. Outcomes: Pt is infection free. Pt has no pain. Pt is able to
verbalize how to change the dressings at home, and can state signs and symptoms of infection.
Complications
Infection
Nursing Diagnosis: Pain, r/t injury. Impaired physical mobility.
172
Spinal Revision and Fusion
Definition
Surgery performed by insertion of an interbody cage device. This is used to correct an existing mechanical
deformation, provide stability to the segment until arthrodesis is obtained, provide the best possible environment for
successful arthrodesis, and achieve this with limited morbidity associated with their use. (arthrodesis = surgical
immobility of a joint)
S/S
N/A
Provide stability of spine (brace use, log rolling, etc.), administer medications for pain and/or antibiotics as
prescribed, dressing change as ordered,reposition patient to prevent skin breakdown, assess vital signs, assist in
ambulation, assess for signs of thrombus or embolus due to decreased mobility
Complications
Infection, need for additional surgery, severe pain, interbody device migration, Titanium debris has been shown to
stimulate a macrophage cellular response and cytokine release, which could possibly have a deleterious effect on
spinal tissues.
173
Splenectomy
Definition
Removal of spleen
S/S
N/A
Maintain effective breathing pattern. Monitor for hemorrhage. Avoid thromboembolitic complicationsmonitor Plt
count, advise pt to report chest pain, SOB or weakness. Prevent infection by assessing incision and good hand
hygiene. Relieve pain with analgesics as prescribed. Outcome: Pt verbalizes decreased pain. Pt is afebrile, no
purulent drainage from incision. Pt respirations are unlabored, breath sounds clear. Vital signs stable, abdominal
girth unchanged.
Complications
Pancreatitis, fistula formation: tail of pancreas is anatomically close to splenic hilum. Hemorrhage. Atelectasis,
pneumonia and OPSIOverwhelming Post Splenectomy Infection (life threatening bacterial infection). Peritonitis,
sepsis.
Nursing Diagnosis: Ineffective breathing pattern r/t pain, incision. Risk for FVDr/t hemorrhage. Risk for injury r/t
thrombocytosis. Risk for infection r/t surgical incision. Pain r/t surgical incision.
174
Subdural Hematoma
Definition
Occurs from bleeding between the dura mater and the arachnoid layer of the meningeal covering of the brain.
Usually results from injury to the brain substance and its parenchymal vessels.
S/S
May be asymptotic. Deterioration, unconsciousness, improvement, dilation of pupils, ptosis, nonspecific non-
localizing progression, alteration in LOC, headache, slurred speech, one sided weakness, drowsiness, confusion,
pain, bleeding, paralysis, raised intracranial pressure, vomiting, severe headaches, seizures,
Comfort patient from pain, monitor vital signs, watch for infection, monitor neural function, help patient with motor
ability, refer family to support groups
Complications
Temporary brain damage, permanent brain damage, death
175
Substance Abuse-Inhalants
Definition
Maladaptive pattern of substance use leading to clinically significant impairment or distress.
S/S
Abrupt changes in work or school attendance, unusual flare-ups or outbreaks of temper, withdrawal from
responsibility, general changes in overall attitude, deterioration of physical appearance and grooming, substance
odor on breath and clothes, runny nose, watering eyes, drowsiness or unconsciousness, poor muscle control,
laughing uncontrollably, periods or euphoria, poor nutrition and fluid intake
Monitor vital signs, monitor patient for drug dependency with appropriate medication, develop an accepting
relationship with patient, set limits on behavior, support and redirect defenses, use therapeutic language, educating
patient and family, help patient find a support group, maintain confidentiality, help prevent relapse,
Complications
Suicide, respiratory arrest, tachycardia, arrhythmias, nervous system damage, polyneuropathy, myelopathy,
vomiting, diarrhea, increased health problems, death
176
Suicide
Definition
Intentionally causing ones own death.
(Venes, D. (19th ed.) (2001). Tabers Cyclopedic Medical Dictionary. Philadelphia: F.A. Davis Company. P. 1997.)
S/S
Suicide ideation, Previous suicide attempts, Self-harming behaviors, Associated psychiatric illness (affective
disorders and substance abuse; conductive disorders and depression in youth).
1094.)
Use crisis intervention to determine suicide potential, discover areas of depression and conflict, find out about the
patients support system, and determine whether hospitalization, psychiatric referral, and so forth is warranted.
Treat the consequences of the suicide attempt (e.g. gunshot wound, drug overdose). Prevent further self-injury
a patient ho has made a suicide gesture may do so again. Admit to intensive care unit (if condition warrants),
arrange follow-up care, or admit to psychiatric unit, depending on assessment of suicide potential.
1094.)
Complications
Death; Permanent health disorders; Harming other people or living things
177
Post operative patient
Definition
Pg 119, Lippencott. General guidelines for most post operative scenarios.
S/S
N/A
Maintain adequate fluid volume by administering IV or po fluids as prescribed, recognize evidence of electrolyte
imbalance, assess pain levels and administer analgesics as prescribed, position patient to maximize comfort,
perform good hand washing before and after contact with patient, inspect dressings and reinforce if necessary,
encourage deep breathing, assess for n/v and administer anti-nausea meds as prescribed, assess bowel sounds
frequently, provide therapeutic environment (room temp, clean bedding, lights, etc), post op vitals. Outcomes: Pt
will report adequate pain control. Pt will breathe deeply and use IS every hour. Pts input and output will remain
equal with no visible signs of imbalance. Pt will be free of n/v.
Complications
Postoperative pain, shock, hemorrhage, DVT, atelectasis, aspiration, pneumonia, PE, urinary retention, bowel
obstruction, hiccups, wound infection, wound dehiscence, and psychological disturbances.
Nursing Diagnosis: Innefective airway clearance r/t anesthesia and or pain meds. Risk for fluid volume deficit r/t
blood loss, food and fluid deprivation, vomiting, etc. Pain, r/t surgical incision and trauma.
178
TIA
Definition
Lippencott, 457. Cerebrovascular insufficiency is an interruption or inadequate blood flow to a focal area of the
brain resulting in transient or permanent neurological dysfunction. TIAs last less than 24 hours, as compared to
strokes (CVAs) which last longer than 24 hours.
S/S
Unilateral weakness, unilateral numbness, aphasia, dysarthria, vertigo, dysphagia, carotid bruits, headaches, visual
difficulties and altered cognitive abilities.
Teach pt signs and symptoms of TIAs and of the need to notify HCP immediately. Administer anticoagulants,
antihypertensives, or other meds as prescribed. Outcomes: Pt is alert w/out neurologic defects. Respirations are
unlabored, v/s stable, no swelling of neck, pt reports relief of pain. Pt able to discuss risk factors to prevent stroke:
obesity, smoking, HTN.
Complications
Complete ischemic stroke.
Nursing Diagnosis: Altered Cerebral Tissue Perfusion r/t underlying arteriosclerosis. Risk for injury: stroke.
179
Total hip Arthroplasty-THA
Definition
The reconstruction or replacement of a joint in the hip, performed to relieve pain, improve or maintain ROM, and
correct deformity.
S/S
Roll to unaffected side only, abductor splint, assess CMSP, AE hose, remove AE hose as ordered, teach patient
hip precautions, toilet seat extender, exercising reinforcement, wash hands and inspect wound to prevent infection,
plexi-pulses if ordered, ROM specifically dorsal flexion and plantar flexion, cough and deep breathe, if odered
reinforce use of IS, check bowel sounds, monitor for blood loss, foam abduction pillow between legs to keep knees
apart, encourage PT,
Infection of wound, DVT, fatty emboli, dislocation, pneumonia,
Complications
180
Total hip replacement
Definition
The replacement of a severely damaged hip with an artificial joint. Most consist of metal femoral component topped
by a spherical ball fitted into a plastic acetabular socket.
S/S
N/A
Use an abduction splint or pillows while assisting patient to get out of bed. , Keep the hip at maximum extension.
Instruct patient to pivot on unoperated extremity. , Assess patient for orthostatic hypotension. When patient is
ready to ambulate, teach him or her to advance to walker and then advance the operated extremity to the walker,
permitting weight bearing as prescribed. Encourage patient to continue to wear elastic stockings after going home
until full activities are resumed. Ensure that patient avoids excessive hip adduction, flexion, and rotation for 6
weeks after hip arthroplasty. Avoid sitting in low chair/toilet seat to avid flexing hip more than 90 degrees. Keep
knees apart, do not cross legs. Limit sitting to 30 minutes at a time to minimize hip flexion and the risk of
prosthetic dislocation and to prevent hip stiffness and flexion contracture. Avoid internal rotation of the hip.
Follow weight-bearing restrictions from surgeon. Advise patient to notify all health care providers about prosthetic
joint because prophylactic antibiotic will be needed if undergoing any procedure known to cause bacteremia (tooth
extraction, manipulation of GI tract).
Complications
Infection (skin and/or bone); Thromboembolsim; Orthostatic hypotension; Dislocation or subluxation of affected
joint.
181
Total Knee Replacement
Definition
Lippincott pg 993 Total knee arthoplasty (reconstructive surgery to restore joint movement and function and to
relieve pain)- an implant procedure in which the tibial, femoral and patellar joint surfaces are replaced because of
destroyed knee joint.
S/S
N/A
Pre-Op teaching pt. re post-op regimen: exercise program, transfers keeping hip flexion limits < 45 degrees; non
and partial weight bearing ambulation with aids (walker, crutches); Use of appropriate splints, immobilizers or
continuous passive motion machines demonstrated; TED hose- remove b.i.d. 30 mins, inspect skin; Skin prep with
anti-microbial solution- help prevent infections; Antibiotics administered as prescribed for therapeutic blood level
before and after surgery*; Post-Op Knee may be immobilized or CPMotion to facilitate joint healing and ROM;
Thromboguards to prevent thromboembolism while pt is in bed; Assess hydration, protein & caloric intake to
maximize healing and reduce risk of complications by providing IV fluids, vitamins and nutritional supplements as
needed; Evaluate for infection, pt at risk for osteomylitis; Encourage coughing and deep breathing, Incentive
Spirometer if ordered; Use of urinal or bedpan, preferable to indwelling catheter to reduce risk of UT; Monitor for
hemorrhage and shock from internal bleeding
Complications
Compartment syndrome, shock, osteomylitis, pneumonia, ateletasis, wound infection, thrombo and fatty embolism
182
Total knee replacement
Definition
An implant procedure in which tibial, femoral, and patellar joint surfaces are replaced because of destroyed knee
joint.
S/S
N/A
The knee may be immobilized in extension with a firm compression dressing and an adjustable soft extension splint
or long-leg plaster cast. Leg is elevated on pillows to control swelling. Alternatively, continuous passive motion
may be started to facilitate joint healing and restoration of joint ROM. Prevent thromboembolism by continuous
use of sequential compression devices while patient is in bed. Discontinue when patient is ambulatory. Within 2
days after surgery, short periods of standing may be ordered. Monitor for orthostatic hypotension. Weight bearing
may be limited with ingrowth prosthesis to prevent disruption of bone growth. Change position every 2 hours
mobilizes secretions and helps prevent bronchial obstruction.
Complications
Infection (skin and/or bone); Thromboembolsim; Orthostatic hypotension; Dislocation or subluxation of affected
joint.
183
Transient Ischemic Attack
Definition
Platelet clumps causing an intermittent blockage of circulation or spasm.
S/S
Sudden weakness, paralysis in the face, arm, or leg, typically on one side of the body, slurred or garbled speech or
difficulty understanding others, sudden blindness in part of the visual field, dizziness, and loss of balance or
coordination.
Monitor VS, monitor and document neurological status frequently, assess functional ability, assess type/degree of
communication dysfunction.
Complications
stroke
184
Transurethral Resection of the Prostate TURP
Definition
A surgical procedure involving removal of the prostate.
S/S
N/A
Monitor vital signs (Post Op Procedure); Monitor CBI for 24 hrs or until no clots are noted draining from the
bladder; Blood Clots are normal for first 24-36 hrs. However, large amts of bright red blood in the urine can indicate
hemorrhage; If on Coumadin therapy, monitor INR and PT labs; Anti-Embolic hose; Activity (as prescribed); The
catheter should be connected to a closed drainage system and not disconnected unless it is being removed,
changed or irrigated; Secretions around the meatus can be cleansed daily with soap and water; Activities that
increase abdominal pressure, such as sitting or straining to have a bowel movement, should be avoided; Bladder
spasms occur as a result of irrigation of the bladder mucosa from insertion a resectoscope, presence of a catheter,
or clots leading to obstruction of the catheter. The patient should be instructed not to attempt to urinate around the
catheter because this increases the likelihood of a spasm. If spasms continue then catheter should be checked for
clots.; Give prescribed medications for pain and spasms; Teach patient Kegel exercises for sphincter tone to help
with urinary incontinence or dribbling; Teach patient about other options such as a continence clinic, penile clamp,
condom catheter, or incontinent briefs; Observe for signs of infection (check external wound for redness, heat,
swelling, and purulent draining; Give antibiotics (as prescribed) for infections; Rectal temperatures and enemas
should be avoided; Dietary intervention (a diet high in fiber) and stool softeners can be provided as prescribed ;
Provide patient with help if sexual problems occur (treatments and counseling)
Complications
Infection; Acute Pain; Potential Complications: Hemorrhage
185
Urinary Retention
Definition
The inability to empty the bladder despite micturition or the accumulation of urine in the bladder because of an
inability to urinate
S/S
The condition is characterized by frequent, strong urges to urinate accompanied by an inability to actually pass very
much urine. There may be dribbling or leakage during the day and while you are asleep. You may need to push in
order to start urination
Assess, record, and report Signs and Sx and reactions to Tx; Monitor I&Os; Monitor Labs (BMP); Report abnormal
findings; Teach patient strategies to minimize risk including intake of large volumes of fluid over a brief period; A
patient unable to urinate is advised to drink a cup of coffee or brewed caffeinated tea to maximize urinary urgency
and to sit in a tub of warm water or take a warm shower and attempt to urinate while in the tub or shower (if does
not help then seek immediate care); Patient can be managed by behavioral methods (e.g., habit training to
negotiate goal for voiding frequency, pelvic muscle training, prompted toileting), and indwelling or intermittent
catheterization, surgery or medications; Instruct client and family regarding disease process, procedures, surgeries,
tx, home care, and follow up
Complications
Urinary Tract Infections; Kidney Problems
186
UTI
Definition
The presence of pathogenic organisms in the urinary tract. Can be with or w/out symptoms. Lippencott, 714.
S/S
Dysuria, frequency, urgency, nocturia, pain, discomfort, microscopic or gross hematuria.
Encourage rest, fluids, antibiotic intake and analgesics if needed. Increase understanding of preventative
measures, educate and maintain health. Avoid external irritants, void after intercourse, cleanse peri area front to
back. Outcome: Pt verbalizes relief of symptoms. Pt verbalizes self care measures to prevent recurrences.
Complications
Pyelonephritis, or hematogenous spread resulting in sepsis.
Nursing Diagnosis: Pain r/t inflammation of bladder mucosa. Knowledge deficit r/t prevention of recurring UTIs.
187
Uterine Fibroids
Definition: Uterine fibroids (leiomyomata) are by far the most common reason a hysterectomy is performed. Uterine
fibroids are benign growths of the uterus, the cause of which is unknown. Although they are benign, uterine fibroids
can cause medical problems, such as excessive bleeding, for which hysterectomy is sometimes recommended
Manifested by:
No symptoms
Excessive bleeding
Painful intercourse
Abdominal discomfort due to pressure on surrounding area (rectum, bladder)
Enlarged uterus distorted by masses
Nursing Interventions: If have surgery, follow protocol for post op care.
Complications:
Persistant heavy bleeding causing anemia
Large rapidly growing tumors
Poss. Treatment; (Collaborative)

Hysterectomy
Myomectomy if women wish to have children only fibroid is removed.
Leupron used preoperatively to shrink size of tumor
188
Vancomycin-Resistant Enterococci (VRE)
Definition: Enterococcus are bacteria that live in the digestive and genital tracts: normally benign. Vancomycin is
a powerful antibiotic, one that is the last resort and limited to the use against bacteria that already resisitant to
penicillin and other antibiotics. VRE is a mutant strain of enterococcus that originally develops in individuals who
are exposed to the antibiotic.
S/S: Infected patients: Diarrhea, UTIs, fever pus in the wounds and increased white blood cells. Colonized
patients: carry but no signs and symptoms.
Nursing Intervention/Teaching: Isolate patient in private room, wash hands with antiseptic soap, wear gloves and
gown for patines contact, teach appropriate use of antibiotic use with family/patient, and avoid sharing patient care
equipment.
Complications: Easily spread to immuno-compromised patients/elderly, renal insufficiency, endocarditis,

meningitis, bacteremia/septicemia and even death.
189
Vertigo
Definition
Dizziness that creates the sense that you or your surroundings are spinning or moving.
S/S
A sense that you or your surroundings are spinning or moving, a loss of balance, nausea,unsteadiness, wooziness,
lightheadedness, faintness, weakness, fatigue, difficulty concentrating, blurred vision following quick head
movements.
Assist patient with ambulation to prevent falls and injury, assist patient to have independence in ADLs if able.
Complications
Dizziness can increase your risk of falling. Accidents while driving a car or operating heavy machinery are more
likely. You may also experience long-term consequences if an existing health condition that may be causing your
dizziness goes untreated.
190
Vomiting
Definition: Forceful ejection of partially digested food and secretions (emesis) from the upper G.I. Vomiting is a
complex act that requires that coordinated activities of several structures.
S/S: Dry skin, decreased skin turgor, decreased urine output, hypotension (postural), decreased intake, dry
mucous membranes.
Nursing Intervention/Teaching: Assess for sign of dehydration, administer and monitor the amount and type of
IV fluids, provide small amounts of clear liquids, record vomitus amount and frequency, weigh patient daily, monitor
lab results: sodium, potassium and chloride, assess patients interest in food, assure patient appetite will return,
instruct patient to resume eating cautiously with bland, nonirritating foods in small amounts.
Complications: Dehydration, cardiac and or renal insufficiency, fluid/electrolyte imbalance, CHF, renal disease
(excessive replacement of fluid/electrolyte replacement).
191
Weight Loss
Definition:
An unexpected weight loss of 5% to 10% of body weight in 6 months or less, involuntary/unintentional.
S/S:
Decreased weight, fatigue, lethargy, vomiting, diarrhea, tremors, palpitations, fainting, hair loss and depression, just
to name a few.
Nursing Intervention/Teaching:
Once a patient has a physician rule out any illness, then the interventions can begin.
Complications:
Stomach tumor, hidden infection, over-active thyroid, depressive illness, malabsorption celiac disease,
inflammatory disease crohns disease, pancreas, liver disease, cancer and/or diabetes.
192
Wound Infection
Definition
Traumatic wound (break in the skin) shows signs of infection; Includes sutured wounds, puncture wounds, scrapes;
Most contaminated wounds become infected 24 to 72 hours after the initial break in the skin.
S/S
Pus or cloudy fluid draining from the wound; Pimple or yellow crust formed on the wound (impetigo); Scab has
increased in size; Increasing redness around the wound (cellulitis); Red streak is spreading from the wound toward
the heart (lymphangitis); Wound has become extremely tender; Pain or swelling increasing after 48 hours since the
wound occurred; Wound has developed blisters or black dead tissue (gangrene and myonecrosis); Lymph node
draining that area of skin may become large and tender (lymphadenitis); Onset of widespread bright red sunburn-
like rash; Onset of fever; Wound hasn't healed within 10 days after the injury
Warm Soaks or Local Heat: If the wound is open, soak it in warm water or put a warm wet cloth on the wound for
20 minutes 3 times per day. Use a warm saltwater solution containing 2 teaspoons of table salt per quart of water.
If the wound is closed, apply a heating pad or warm, moist washcloth to the reddened area for 20 minutes 3 times
per day; Antibiotic Ointment: Apply an antibiotic ointment 3 times a day. If the area could become dirty, cover with
a Band-Aid or a clean gauze dressing; Pain Medication: For pain relief, take acetaminophen every 4-6 hours (e.g.
Tylenol; adult dosage 650 mg) OR ibuprofen every 6-8 hours (e.g. Advil, Motrin; adult dosage 400 mg); Do not take
ibuprofen if you have stomach problems, kidney disease, are pregnant, or have been told by your doctor to avoid
this type of anti-inflammatory drug. Do not take ibuprofen for more than 7 days without consulting your doctor;
Teach patient about importance of hand washing and infection control
Complications
Septicemia, Morbidity
193
194

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Table of Contents

Abdominal abscess 4 Chronic Obstructive Pulmonary Disease 49

Poss. Nursing Dx:

Impaired breathing r/t Bronchospasm and laryngeal edema

Innefective breathing pattern, r/t bronchospasm.

Risk for infection r/t neutropenia.

Altered oral mucosa r/t stomatitis.

Altered body image r/t alopecia and weight loss.

Risk for impaired skin integrity r/t radiation tx.

Clinical manifestations if bile duct obstructed:

Anticholinergics as ordered to decrease secretions (prevents biliary contraction)

Stones can remain in GB or migrate into cystic or common bile duct.

Clinical manifestations if bile duct obstructed:

Poss. Nursing DX:

Infection of wound site

Altered Nutrition: more than body requirements.

Manifested by: (onset abrupt w/ type 1, and insidious w/ type 2)

Give prescribed medications to help alleviate symptoms.

1. Achieving pain relief:

Poss. Nursing DX:

pain r/t intestinal discomfort, d, and/or c

Infection and/or local bleeding

Numbness and/or weakness and/or sedation (respiratory)

Diseases that may be discovered by exploratory laparotomy include:

pockets of infection ie. retroperitoneal abscess, abdominal abcsess, pelvic abscess.

Endometriosis: presence of uterine tissue (endometrium) in the abdomen

Salpingitis: inflammation of the Fallopian tubes

Adhesions: scar tissue in the abdomen

Diverticulitis: inflammation of an intestinal pocket

hole in the intestine (intestinal perforation)

ectopic pregnancy - in the abdomen instead of uterus

-blood in the stool

-vomiting blood or a dark material that looks like coffee grounds

Continued close observation for more bleeding

Close observation of B/P

-blood in the stool

-vomiting blood or a dark material that looks like coffee grounds

Continued close observation for more bleeding

Close observation of B/P

Obtain a prescription to administer opioid analgesia

Plan care activities around periods of greatest comfort whenever possible.

Monitor for signs of infection.

- infection of surgical site

- urinary tract infections

- damage to nerve structures important to bladder and sexual function

- Perforation of the bowel

- Muscle weakness in the pelvic area

Types of procedures involving female reproductive system:

More info side note:

-higher incidence in men (20-40)

o Climate warm climate, increase fluid loss, increase [solute] of urine.

Manifested by: (When they obstruct urinary flow)

Poss. Nursing Dx:

Risk Factors and Complications:

ac lymphocytic leukemia - When lymphocytes are predominantly malignant.

(So basically, it attacks the defense cells of the immune system)

Hematuria common s/p lithotripsy.

Possible Nursing Dx:

Benefits of less invasive surgery:

Poss. Nursing Dx:

Poss. Nursing Dx:

Poss. Nursing Dx:

Complications of PVD in a diabetic patient:

Nursing Interventions: ***PREVENTION