ENDOCRINE

CONDITION Who is at risk? Signs/Symptoms Lab/Diagnostics Nursing Management

Hyperthyroid  Family history of
thyroid/AI disease
Primary vs secondary  Recent pregnancy
 Excess iodine
Graves, goiter,  Meds (amioadarone)
amiodarone-induced
Hypothyroid  Family history of thyroid
(Myxedema) disease
 History of autoimmune
Primary vs secondary disease (women)
 Aging
Hashimoto – hyper  Inadequate dietary iodine
then hypo  Previous tx for
hyperthyroidism
Hypoparathyroid  Family hx, heredity
 Neck sx/radiation
 Comorbidity
Hyperparathyroid  Menopause
 Prolonged Ca/vit. D
Primary: gland deficiency
enlargement; hyper-Ca  Neoplasm
 Tachycardia, a-fib
 Tremors
 Goiter
 Warm, moist skin
 Hair falls out
 Irritability
 Heat intolerance
 Hyperactiviy
 Weight loss
 Diarrhea
 Proptosis/exophthalmos
 Dry skin
 Cold extremities
 Hair breakage, dry hair
 Bradycardia
 Peripheral edema
 Delayed DTR relaxation
 Carpal tunnel
 Tiredness
 Amenorrhea
 Weakness
 Cold intolerance
 Difficulty concentrating
 Weight gain
 Constipation
 Hoarse voice
 Hypocalcemia
 Hyperphosphatemia
 Numbness, tingling
 Muscle cramps
 Chvostek’s Trousseau’s
 Bone fx/weakness
 Oliguria, kidney stones,
acidosis
 Weakness, fatigue,
 Serum antibodies  Tapazole, PTU
 Decreased TSH  Beta-blockers
 Increased T3 & T4  131I
 Uptake/suppression  Thyroidectomy
 Thyroid storm
o Assess for fever,
diaphoresis, S/S
o Antithyroid drugs
o Hormones
 Post-op
o Respiratory distress
o Hemorrhage
o Hypocalcemia
o Thyroid storm
 T4 and TSH  Levothyroxine (1º)
 Antibodies (Hashimoto)  TSH stimulation (2º)
 Myxedema crisis
o Cardiac – IV fluids
o Neuro
o Respiratory – monitor;
ventilator
o Rewarm
 Ca and P levels  Ca, calcitrol, vit. D
 Ca: decreased  Fall and fracture
 P: increased prevention
 Increased PTH  Parathyroidectomy + Ca
 Ca: increased supplements (1500-2000
 Bone density test = mg/day)
Osteopenia: weak bones o Hemorrhage
  Neck radiation depression, NM probs
Secondary: dx causing  Lithium (bipolar)  EKG changes, HTN
hypo-Ca  Constipation, peptic ulcer
Addison’s  Adrenal gland removal  Hypovolemia
1º adrenal  Autoimmune disorder  Fluid/electrolyte
insufficiency (AI)  Infections/invasive disease imbalance
 Postural hypotension
 LOC changes
 Hyperkalemia
 Fatigue, weakness
 GI complaints (slow)
 Decreased urine output
(adrenal crisis)
 Hyperpigmentation or
orange skin
 Decreased libido
Cushing’s – chronic  Obesity
exposure to cortisol  Moon face, acne
 Hirsutism – facial hair
1º: excess aldosterone  Buffalo hump, striae
by adrenal cortex  Plethora (excess
fluid/blood)
2º Caused by excess  HNT
renin  Fatigue, muscle weakness
 Hyperglycemia
Exogenous: excess
 Bruising
glucocorticoids (COPD,
 Depression to psychosis
RA)
 Osteoporosis
 Menstrual disorders,
 Sodium, potassium,
BUN levels (low Na, high
K, high BUN)
 Blood sugar (low)
 Cortisol levels (low)
 Urinary metabolites
 ACTH stimulation test
 Glucose (high)
 High WBC
 HypoK, HyperNa
 Serum/salivary cortisol
 Dexamethasone
suppression test
 24-hour urine (cortisol
and Cr)
 ACTH stimulation test
o Hypocalcemia
o Laryngeal spasm
o Neuro check –
electrolyte
imbalance
o Check voice
 Tx secondary disease
 Non-pharm tx
 Lab studies
 Nutrition
 Fluid – kidney stones
 Fall prevention
 Rest
 Analgesics/comfort
 Adrenal crisis
o Dehycration, fever,
hypoNa, hyperK,
vascular collapse,
death
o IV hydrocortisone
o Normal saline
o Vasopressors
o Electrolytes (Na)
 Hormone replacement
 Increase Na intake
 Treat hypoglycemia 1st
 Aldosterone antagonist
(spironolactone)
 Surgery
 decreased libido,
impotence
 Kidney stones
CARDIOVASCULAR
CONDITION Who is at risk? Signs/Symptoms Lab/Diagnostics Nursing Management
CAD Increasing age Atherosclerosis Lipid panel CV modifiable risk factor
Genetic predisposition Angina pectoris CRP – inflammation reduction
Gender - male Unstable angina Homocysteine – Physical activity
Diet Myocardial infarction inflammation Dietary changes
Sedentary lifestyle - obesity Sudden cardiac death Intravascular US Monitor weight, exercise, food
Smoking Supply & demand of myocardial Cardiac cath and intake
High LDL tissue percutaneous coronary Support groups
Low HDL Ischemia – ECG changes; angina intervention (PCI) Catheterization and PCI
High total cholesterol pectoris Coronary angiography Balloon or stent
HTN
DM
High CRP
Angina Pectoris Same as above Sudden onset of discomfort in Ca-channel blockers
chest, jaw, shoulder, back, or Nitrates
Stable – predictable, arm Beta-blockers
goes away with rest Activity restriction
Remove precipitating factors
Unstable – Supplemental O2 during pain
unpredictable, may Assess: PQRST, hx, physical
involve clot, findings, VS, ECG changes
vasoconstriction, risk
for MI

Prinzmetal or
vasospastic

Myocardial Complications of angina (high Acute: chest pain more intense Troponin – 4-6 h post up to MONA - Dilate coronary
Infarction MI risk): than angina 4-7 days; serial pattern arteries
Increased angina duration, Diaphoresis Creatine kinase – (CK-NB) 6- Thrombolytics
frequency or at rest (unstable) SOB 8 h to 48-72 h CABG
ST or T wave changes Generalized weakness Myoglobin – damage to heart Prevent ACS: O2, vasodilate,
Signs of HF May mistake S/S for indigestion muscle reperfuse, prevent thrombus,
Pulmonary edema EKG changes – place in tele blood flow
Tachycardia IHI:
Hypotension 1- early admin of aspirin
2- aspirin @ d/c 325 mg
3- beta-blocker @ d/c
 4- ACEI/ARB if systoli
dysfunction
5- Reperfusion (PCI,
thrombolysis)
6- Smoking cessation
Rheumatic Heart Pharyngeal strep infection – Chest pain H&P Early antibiotic tx
Disease beta hemolytic Murmurs CRP Antibiotics, NSAIDs
AI response (women) Tachycardia ECG Steroids
EKG changes Antistreptolysin O titer Bed rest – decrease demand
Friction rub Pain relief
CHF Emotional support
Cardiomegaly Monitor for HF, change in
Mitral/aortic stenosis murmur
Pericarditis Infectious: Anginal-type pain or sharp Elevated WBCs Antibiotics
Lung/URI pleuritic-type pain Elevated ESR NSAIDs
Acute infectious: Non-infectious: Worse with inspiration, Elevated CRP Steroids
Dry vs exudative Uremia coughing, movement, deep Elevated CK-MB, Troponin Diuretics
Exudative decreases AMI breathing CXR – pericardial eff, cardiac Anticoagulant tx
CO and perfusion Cardiotomy Worse when lying flat enlargement Anti-anxiety agents
Acute non-infectious: Relieved by sitting up and Ca-Channel blockers
Blunt trauma leaning forward Nitrates
Surgery & other tissue injury Dyspnea Beta blockers
Autoimmune/acute infectious: Infectious: high fever, chills, ACEIs
Connective tissue disorders – high WBCs, joint pain, elevated ARBs
SLE, RA ESR
Drug reactions Anorexia, weight loss, nausea For pericarditis:
Rheumatoid heart disease ECG changes Pericardiocentesis
Pericardial friction rub Hemodynamic monitoring
Pericardial effusion ECG monitoring
Hoarseness, hiccups Fluid replacement
Myocarditis Pericarditis May involve: Elevated WBC Pericardiectomy or
Genetics? Heart valve function Elevated ESR pericardial window
Immunosuppression Mural endocardium – blood Elevated CRP Surgical resection
Acute: open heart surgery clots on heart wall Elevated CK-MB, Troponin
Infection elsewhere (viral, Septal defect ECG changes
bacterial, fungal Fatigue Enlarged heart and lung
AI/connective tissue dx Malaise congestion (CXR)
Drug reactions SOB Echo – depressed systolic
Sarcoidosis Fever function, dilated chambers,
Hypersensitive immune rxn GI upset pericardial effusion
Postcardiotomy syndrome Aching joints
Toxins CHF symptoms
 Chemicals SCD
Alcohol use
Nosocomial infections
Chest radiation
Endocarditis Recent dental sx Fever Mild elevation of WBC in IE
Illegal drug use Chills, Night sweats Elevated Erythrocyte
Acute: rapid onset, Weakened valves Tachycardia Sedimentation Rate (ESR) in
virulent Previous hx Fatigue IE
PNA Malaise Elevated CRP in IE
Subacute: low virulent Valve dysfunction Anorexia Elevated CK-MB, Troponin
organism Nosocomial infections Weight loss Conduction delay, ST changes
Chest trauma Headache CHF symptoms of ECG
Septal defects Arthralgias CXR – septic pulmonary
Bleeding gums Myalgias emboli
Long-term central line Back pain
Prosthetic valves Abdominal discomfort
Congenital heart disease Clubbing
Cellulitis Splinter hemorrhages on nails
Rheumatic fever Petechiae
Marfan’s syndrome Osler’s nodes (painful lesions))
HIV Janeway’s lesions
Roth’s spots on retina

Cardiac tamponade Pericarditis Chest pain worsened by deep
Thoracic surgery breathing or coughing
Trauma Difficulty breathing
Discomfort, sometimes relieved
by sitting upright or leaning
forward
Pale, gray, or blue skin -
cyanosis
Palpitations - tachycardia
Rapid breathing
Dizziness
Drowsiness
Weak or absent pulse
Anxiety
Decreased LOC
Mitral valve disease Pulmonary hypertension Regurgitation:
Decreased CO Dyspnea, weakness, fatigue
Increased pulse pressure Orthopnea, paroxysmal
Stenosis: nocturnal dyspnea, peripheral
Elevated venous pressure
Decreased CO
Decreased BP
Loss of tissue perfusion
Narrowed pulse pressure
<30 mmHg
Beck’s triad – low BP,
muffled heart sounds, JVD
Weak peripheral pulses
Pulsus paradoxus - >10 drop
in SBP during inspiration
ECG – low QRS
Murmurs
Echocardiogram
Transesophageal
echocardiography (TEE)
Pericardiocentesis
Hemodynamic monitoring
ECG monitoring
Fluid replacement
Pericardiectomy or
pericardial window
Surgical resection
ECG monitoring for a-fib
Monitor for cardiomegaly
Maintain CO and activity
tolerance
 Dyspnea edema Chest X-Ray Prevent complications:
A-fib Murmur Cardiac catheterization CHF
Murmur Cough, crackles ECG Acute pulmonary edema
Dry cough, dysphasia, bronchitis A-fib Cardiac MRI Thromboembolism
Fatigue, weakness Prolapse: Recurrent endocarditis
Right-sided heart failure Palpitations, irregular
Palpitations, angina heartbeat, chest pain, Increase CO
Crackles in lung bases Dizziness Prophylactic ABx
Hemoptysis Cardioversion
Anticoagulation
Aortic valve disease Decreased CO Regurgitation: Rest w/ limited activity
Exercise intolerance Murmur Digoxin – increase CO
Decreased DBP, widening pulse SX – open up valve, replace
Stenosis: pressure ring, new valve
Dyspnea, angina, fatigue, Pistol-shot femoral pulse Repair
syncope that increases with Head bobbing with heartbeat Balloon valvuloplasty
exertion Palpitations Valve annuloplasty
Murmur Waterhammer pulse Replacement
Increased pulmonary artery Dyspnea, orthopnea, PND
pressure Nocturnal angina w/ Gas exchange
Prominent S4 diaphoresis Activity intolerance
Lung congestion Bounding atrial pulse, apical Pain management
L and R sided HF displaced to left
Palpitations Inc SBP, dec DBP
Dizziness, exercise intolerance
L and R sided HF
Tricuspid valve Decreased CO Murmur
disorders Increased CVP R sided HF
Low CO
From rheumatic fever Dyspnea A-fib
Fatigue
Peripheral edema
Pulmonary hypertension
Pulmonic valve Dyspnea, fatigue Tall peaked T waves – atrial
disease Murmur hypertrophy
R sided HF A-fib
From congenital
anomalies
Dilated Primary: unknown etiology HF symptoms CXR Inotropics
cardiomyopathy Secondary: ischemia, viral Reduced tissue perfusion ECG Diuretics
infections Baked up pulmonary system Echo Antidysrhythmics
Follows MI and Alcohol intake, drug abuse Insidious onset Cardiac catheterization Rest
ventricular tissue Inherited disorders Mitral/tricuspid insufficiency Endomyocardial biopsy Palliative
remodeling Pregnancy Radionuclide study Heart transplant
CAD HTN Permanent mechanical assist
Genetic CAD devices
Idiopathic Viral myocarditis Detailed hx
Cocaine ADLs
Calcium overload Paced/reduced activity
Hyperlipidemia Positioning
Obesity O2 therapy
Hypertrophic DM LV hypertrophy Echo Find/treat underlying cause
obstructive Idiopathic Hypertrophy in septum CXR Control S/S
cardiomyopathy Chemotherapy Sudden death, severe HF ECG, resting & ambulatory Prevent progression
Genetic Dyspnea Cardiac catheterization Improve QOL
Usually <30 y/o Neuromuscular disorders Chest pain Endomyocardial biopsy Genetic testing
Sudden death Endocrine (DM, Cushing’s) Presyncope, syncope Radionuclide study Meds
Disorder of sarcomere Abnormal electrolytes Paroxysmal nocturnal dyspnea Activity restriction
Antiviral meds Fluid stabilization
Genetic Cardiac valve disease
HTN, Congenital heart disease
hypoparathyroidism Sleep apnea
Idiopathic Radiation therapy
Restrictive Amyloidosis, sarcoidosis Pulmonary/systemic congestion CXR Decrease cardiac workload
cardiomyopathy Smoking Dyspnea ECG Teach to avoid situations that
Familial cardiomyopathies Palpitations, fatigue, syncope, Echo impair venous filling or lower
Endocardial scarring Cardiac surgery angina, weakness, exercise Cardiac catheterization CO
Fibrosis & thickening Bacterial/parasitic infections intolerance Endomyocardial biopsy
Impaired diastolic Stress, sedentary lifestyle R or L sided HF Radionuclide study
stretch Toxins S3, systolic murmur
Ventricular stretch Pregnancy, PP period
Connective tissue disorders
Cocaine use Nutritional deficiency
Sarcoidosis
Restrictive pulmonary
disease
Arrhythmogenic Genetic Palpitations, light-headedness, Good family hx Heart transplant
Right Ventricular fatigue NO OTHER CURE
Cardiomyopathy Sudden cardiac death
RV: prominent neck veins, liver Antidysrhythmic
Electrical disturbance distention, swollen legs and Decrease workload
because of scarring in ankles Energy conservation
RV LV: (advanced stage) fatigue,
SOB
May involve LV
Peripheral arterial Older age Intermittent claudication Ankle-brachial index Lifelong aspirin tx
disease Male gender Muscle/limb weakness Treadmill exercise arterial Meds
African American Absent/diminished pulses studies Angioplasty
Smoking Poor hair growth Duplex US Stenting
DM Resting limb pain Segmental arterial pressures Radiation tx
Hyperlipidemia Paresthesia Angiography Percutaneous transluminal
HTN Poor healing CT angioplasty
MRI/MRA Arterial bypass
Amputation
Acute arterial ischemia:
immediate heparin tx or
embolectomy
Peripheral venous Swelling, tightness, discomfort Streptokinase (not for DVT)
disease in one or both Les Vena cava filters – prevents
Unilateral = DVT PE, stroke
Stasis dermatitis, stasis ulcers
Varicose veins Older age Dilated tortuous veins Ligation
Female Often none Stripping
Obesity Sensation of heaviness, Laser therapy
Jobs w/ prolonged standing tiredness, itching Radiofrequency ablation of
Low-fiber diet Visible during pregnancy or vein
Smoking menstruation Wear compression stockings
HTN Recurrence after venous sclerotherapy
Pregnancy Avoid venous pooling
Injury Walking program, weight loss
DVT Immobility – SCI, paresis Virchow’s triad: Duplex US Early ambulation as tolerated
Fx of pelvis, hip, long bones Venous stasis Venography Elevate 10 to 20º above level
Multiple trauma, burns, sx, Damage of endothelium CT and MRI of heart
infection, inflammation Hypercoagulability Venous duplex imaging Moist heat
Hypercoagulability states Asymptomatic until PE Photoplethysmography AVOID MASSSAGING
Previous DVTs, PE Unilateral pain, edema, warmth, Ambulatory venous pressure Graduated compression
Malignancy tenderness stockings
MI, HF, respiratory failure, Slightly puffier than other leg Anticoagulants (heparin,
sepsis, ulcerative colitis Homan’s sign thrombin inhibitors, warfarin)
ICU admission Venous thrombectomy
Age >40 Percutaneous interruption of
Obesity vena cava
Immobility 3 days or more AROM, PROM
Varicose veins Avoid prolonged sitting,
Pregnancy, PP standing, crossing legs
Oral contraceptive use Intermittent pneumatic
 Central venous catheters devices
Major surgery Venous foot pumps

Abdominal aortic Often asymptomatic Abdominal imaging (X-rays) Monitor growth with
aneurysms and Pain with gnawing quality, CT – size and location abdominal US q6 months
dissection unaffected by movement, lasts Aortic angiography Maintain normal BP - meds
for hours/days Abdominal US Smoking cessation
Dissection Pain in abdomen, flank, back Abdominal angiography Control of fasting lipid
Life-threatening, tear Pulsatile abdominal mass MRA D/C steroids
in the lumen AAA >3cm in diameter Endovascular stent graft
Diminished blood Surgical repair, endovascular
supply distal to repair
dissection Monitor S?S of impending
rupture:
Restlessness
Abdominal pain, tenderness
Prep for emergent sx
Post-op care:
Risk factor reduction
Wound care
Activity restriction
Medication regime
Reportable symptoms
Meds if <5.5 cm
Heart Failure HTN Activity intolerance LV systolic dysfunction: Cool forearms and legs
CAD Fluid retention Volume overload Assess response to diuresis
Neurohormonal Dilated cardiomyopathy SOB Decreased contractility Assess CO
response Hyperlipidemia Fatigue LVEF < 40% to 45% Monitor I&O
SNS activation Metabolic syndrome L-sided: fatigue, activity Monitor for dysrhythmias
RAAS activation – Obesity intolerance, SOB, cough, Diastolic Dysfunction Encourage increasing levels of
sodium and fluid Sedentary lifestyle orthopnea, paroxysmal HF with normal LVEF activity
retention, myocardial Smoking nocturnal dyspnea Slow relaxation Perform ADLs
hypertrophy Valvular abnormalities R-sided: abdominal bloating and HTN, DM, obesity, a-fib Patient knowledge of dx
Cardiac remodeling Age discomfort, poor appetite, Reduced stroke volume O2 sat – administer O2
Family hx of CAD nausea Stiff heart Assess temperature
Exacerbation and Gender Bivent: combination of L and R Assess for cyanosis
stabilization Genes CBC – anemia, liver/renal Assess neuro status
Confusion, forgetfulness, loss of BNP – LV stretch, high Auscultate
concentration, disorientation High microalbumin
Cardiac cachexia Electrolytes & Cr Meds
JVD Liver function test Cardiac devices
Crackles Urinalysis Control comorbidities
 Cough Serum ferritin Control volume status
Lipid panel Cardiac transplant or
Abrupt decline in CO: Digoxin level mechanical assist device
Narrow pulse pressure ABGs
Althered mentation Reduce readmission
Hypotension CXR – enlarged heart, patchy Palliative care
Resting tachycardia infiltrates
Oliguria EKG Echo, ACEI or ARB if EF<40%
Tachypnea Echo – ejection fraction unless C/I
Cardiac cath R or L Smoking cessation
Selective coronary Fluid restriction
angiography Dietary changes
Cardiac MRI Refer to community resources
Educate: meds, activity,
weight

UNLOAD FAST
upright
nitrates
lasix
oxygen
aminophyllin
digoxin
fluid restriction
after load - decrease
sodium restriction
test - digoxin levels, ABGs,
BNP

7 Key interventions
LVS heart function assess
ACEI/ARB @ d/c
Anticoagulant w/ a-fib
Flu vaccine
Pneumococcal vaccine
Smoking cessation counsel
D/C instructions: activity,
diet, meds, follow-up, weight,
worsening S/S
RESPIRATORY
CONDITION Who is at risk? Signs/Symptoms Lab/Diagnostics Nursing Management
Obstructive Sleep Obesity Adequate hours of sleep but no Polysomnography in sleep Change of sleep position
Apnea Smoking energy the rest of the day laboratory Weight loss
Age > 65 Inability to concentrate H&P CPAP or BiPAP
Male gender Irritability Denoidectomy
Postmenopausal females Uvulectomy
Upper airway Foreign bodies
obstruction Infectin
Smoke
Life-threatening Anaphylactic reaction
Angioedema
Head and Neck Smoking Radiation therapy –
Cancer Excessive alcohol dysphagia, nutrition
Chemotherapy
Radical neck dissection – puts
airway at risk
Laryngectomy:
Good suctioning
Care of permanent trach
Communication support
Nutrition – dysphagia
Body image issue
Maintain airway/ventilation
Wound care
Bleeding –behind neck
Pain management
Nutrition
Speech/language rehab –
esophageal speech
Stoma care
Smoking cessation
Psychosocial
High risk for lower airway
infection
Pneumonia Antibiotic therapy Dyspnea CXR – usually upper lobe Administer ABx
Immunocompromised Hypoxemia densities Airway – O2 sat > 93%
Stroke, trach, dysphagia, near Ventilation-perfusion mismatch Nutrition, hydration
drowning, post op N/V Fever, chills Small, frequent, high-carb,
Increased RR high-protein meals
Rusty bloody sputum Bronchodilators
Crackles Suction, C&DB
X-ray abnormalities IS
Non-respiratory symptoms Gradual increase in activity,
Dehydration sit up for meals
 Nutrition, fluid
Avoid exposure to others with
infections
Meds
S/S to watch out for
Pulmonary HIV/AIDS Dyspnea Tuberculin skin test – read Drug tx
tuberculosis Immunocompromised Weight loss 48-72 hours, 10mm (5mm Negative pressure room
Cough for immunocompromised) Airborne isolation until 3
Sputum production CXR – if BCG vaccinated sputum cultures are neg
Sleep disturbances Acid-fast bacillus smear – 3 Pain management
Rust colored sputum positives on 3 different days Fatigue management
Night sweats Sputum culture Good nutrition
Low grade fever
Advanced:
Activity intolerance, fatigue
Low grade fever, night sweats
Blood-streaked sputum
Dullness w/percussion over
involved area
Bronchial breath sounds,
increased transmission of
whispered sound
Lung abscess Pus in the lung itself High-dose antibiotics
Fever
Necrotizing PNA Chills
Bacterial, fungal,
parasitic
Pulmonary Chest tube for pleural effusion Pus in pleural space Drainage of pus
empyema Re-expand the lung
Control the infection
COPD: Emphysema Dyspnea/wheezing ABG: Assess O2 first
Use of accessory muslces PaO2 <80-50 mmHg Admin O2
Vent/perfusion mismatch PaCO2 – increased to 50
Decreased forced expiratory Antibiotics - infection
volume Polycythemia vera – high Bronchodilators – reduce
Involvement of alveoli H/H airway resistance
Cachexia Sputum samples Anticholinergics –
Barrel chest Serum electrolytes bronchodilate and decreases
Changed muscle definition Serum AAT levels secretions
Clubbing – chronic hypoxia CXR: Corticosteroids – decrease
COPD: Chronic Dyspnea/wheezing Emphysema = Lots of black inflammation, decrease
bronchitis Use of accessory muslces space/air bronchoconstriction
 Vent/perfusion mismatch
Decreased forced expiratory
volume
Involves airway
Inflamation, vasodilation,
congestion, mucosal edema,
bronchospasm
Airway enlargement
Large amount of thick mucus
Hypoxemia
Acidosis
Respiratory infections
Cardiac failure – cor pulmonale
Cardiac dysrhythmias
Clubbing – chronic hypoxia
Pleural effusion CHF
Bacterial PNA
Malignancy
Bronchitis = not enough air,
clouding over
Pulmonary function test
Impaired gas exchange;
Airway
Cough & DB
O2 therapy
Pulmonary rehab
Ineffective breathing pattern
Specific breathing techniques
Positioning – dyspnea
Energy conservation
Diaphragmatic breathing
Pursed-lip breathing
Relaxation techniques
Positioning
Ineffective airway clearance
Chest physiotherapy w/
postural drainage
Suctioning
Positioning
Hydration
RT – flutter valve
Tracheostomy
Imbalanced nutrition
Activity intolerance
Anxiety
Potential for PNA
Avoid large crowds
PNA vaccine
Flu vaccine
Indwelling pleural catheter
w/ intermittent drainage
Pleural-peritoneal shunt
Thoracentesis
Pleurodesis
Pleurectomy
Chest tube – pleural space
 Repiratory assessment
Assess site
Assess system – upright,
below chest, patent, water
levels, no air leaks, drainage,
tubing - kinks

RENAL
CONDITION Who is at risk?
Polycystic kidney Congenital anomaly
disease
Hydronephrosis Enlarged prostate
Urethral/ureteral strictures
Also: Renal calculi
Hydroureter Abdominal tumors
Urethral stricture Blood clots
Ureteritis/prostatitis
Neurogenic bladder
Congenital abnormalities
Signs/Symptoms
Abdominal/flank pain
HTN
Increased abd girth
Constipation
Bloody/cloudy urine
Kidney stones
Uremia and death
Slight discomfort
Slightly decreased urine flow
Acute: Severe, colicky
renal/flank pain
Chronic: vague abd/back pain
May be unilateral
Fever, nausea
Pain on urination
Lab/Diagnostics
Ultrasonography,
tomography, radioisotope
scans
Retrograde
ureteropyelography
Urinalysis - for
protein/blood
Serum Cr >1.5 mg/dL
BUN >25 mg/dL
Intravenous pyelogram (IVP)
Renal US
BUN, Cr, Cr clearance
Flap or shunt if
pneumothorax - air
Nursing Management
Preserve renal fxn, prevent
complications
Control HTN
Dialysis
Treat cause of obstruction
Remove obstruction
Prostatectomy
Dilation of stricture
Sx removal of stone/tumor
Nephrostomy tube
Diet low in protein, Na, K
Check for bleeding,
hematuria, infection

Pyelonephritis Women Fever, chills, tachycardia, Urinalysis Antipyretics

Inability to empty bladder tachypnea Cloudy urine Clean-catch urine specimen
Sexually active Flank/back/loin pain Foul smelling urine Antibiotic tx
Pregnancy Abdominal discomfort Low specific gravity 2,000-3,000 mL fluids/day
Diabetes N/V, urgency, frequency, Proteinuria Activity & rest
Compromised renal function nocturia Hematuria Urinary analgesics
Instrumentation Malaise or fatigue Positive WBC
Chronic: Casts
HTN Urine culture
HypoNa KUB
Decreased concentration
HyperK and acidosis
Glomerulonephritis Prior strep infection - acute Blood in urine (dark, rust-
Males colored, brown)
May cause nephrotic Younger age (5-15 y/o) Foamy urine (excess protein)
syndrome SLE Edema (generalized)
DM Acute: no pus, no bacteria
Goodpasture’s syndrome HTN
Hypoalbuminemia
High cholesterol
N/V, fever, rash
Low urine output
Nephrotic syndrome Diabetes High levels of protein in urine –
Drugs that cause kidney damage foamy urine
Glomerulonephritis Low levels of protein in blood -
hypoalbuminemia
Edema (generalized)
High cholesterol
HTN
Low urine output
Acute renal failure Increased age Early signs:
Vascular disease Oliguria
Sudden onset, Diabetes Azotemia
reversible Anuria
Late signs (systemic):
SEE BELOW
HTN or hypotension
Anasarca (total edema)
Coagulation changes
Metabolic acidosis – ammonia-
breath, Kussmaul’s
HyperK – cardiac arrest
HypoNa, fluid overload
Tumorlike calcium precipitates
CKD African American Neuro: confusion, lethargy,
Chronic renal failure Men decreased LOC, stupor
ESRD (loss of 7/8 of Age 65 and older GI: N/V, anorexia, distention,
filtration capacity) Hereditary diseases: polycystic constipation or diarrhea
kidney disease, Alport syndrome Respiratory: crackles,
Insidious, chronic, Diabetes pulmonary edema, pleural eff,
irreversible HTN risk for infection
Urinalysis
Proteinuria
Hematuria
Casts
Elevated Cr
Decreased Cr clearance
Elevated serum
antistreptolysin-O titer
Urinalysis
Protein (high)
Serum protein (low)
Lipid panel (high cholesterol)
BUN, Cr, K, PO4 – increased
Na, Ca – decreased
U/A: RBCs, casts, proteinuria,
low sp.gr. low osmolality
GFR – lower than 40 or
decreased by >75% (failure)
Increased BUN and Cr
Increased BUN/Cr ratio
Increased serum PO4
K normal or elevated
Decreased Na, HCO3 and Ca
Renal failure
Chronic:
BP
I&O
Daily weight
Dietary plan (low protein, low
Na)
Diuretics & anti-HTN
Corticosteroids
Plasmapheresis
Teaching:
Nutrition, meds, skin care
(pruritis, edema), infections
Address underlying cause
May develop CKD -> ESRD
Corticosterioids
ACEI – BP down, decrease
protein loss
Heparin
Low-salt diet
Mild diuretics
Maintain fluid balance
Protein intake 0.8 g/kg/day
25-35 kcal/kg – high carb
Monitor K
Adjust meds, avoid NSAIDs,
ACEI
Avoid Mg antacids
Control metabolic acidosis
Strict aseptic technique
Remove indwelling caths
Avoid nephrotoxic agents
Watch for infections
Monitor drug levels
Low protein, low Na, low K
levels
Monitor electrolytes
Prevent injury
Fatigue/weakness
 Urinary tract obstruction
Chronic glomerulonephritis
Chronic infection
Acute tubular necrosis
Nephrotoxic agents (antibiotics,
NSAID, contrast media)
Peritoneal Dialysis
Hemodialysis Hyperkalemia (also Kayexalate,
glucose & insulin, bicarb,
calcium gluconate)
NEUROLOGICAL
CONDITION Who is at risk?
Multiple Sclerosis Women (AI)
Cold climates
Genetic factors
CV: tachycardia, dysrhythmia,
rub, pericarditis, inc BP
Skin: dry, pruritis, edema,
bruising, pallor, uremic frost
HyperK, HypoNa, HypoCa,
hyper-PO4
Complications:
Infection – biggest risk
Peritonitis – rigid, board-like
abdomen
Poor dialysate flow
Dialysate leakage
Complications:
Thrombosis/stenosis
Infection
Aneurysm
Ischemia
Heart failure
Dialysis disequilibrium
syndrome
CNS – big change in osmolality
cause fluid shift into cerebral
cavity = cerebral edema: HA,
dizziness, disorientation,
restlessness, blurred vision
Confusion, seizures, coma, death
Signs/Symptoms
Remission and exacerbation
Exacerbation: triggered by
fatigue, stress, illness
Fatigue
Muscle control difficulties
Flexor spasms at night
Intention tremors
Gait disturbances
Oliguria/anuria
Azotemia (high BUN)
Lab/Diagnostics
More on symptomatology
CSF studies:
Elevated IgGs
Presence of oligoclonal bands
MRI: white matter lesions
Genetic markers
CBC outside normal
R/O syphilis, HIV, heavy
Monitor ECG, neuro
Dialysis
Monitor H&H
Administer epogen
Skin integrity
Note dwell time, initiate
outflow
Should be getting more than
what was put in, clear fluid
Use gravity to get extra fluid
out
Warm fluid to prevent pain
No heparin
Evaluate VS, weight, labs
Monitor for respiratory
distress, pain, discomfort
C/I: hemodynamic instability,
lack of access, inability to
anticoagulate
Planning:
Meds
Meals – no meals right before
Activities – no heavy lifting,
no BP on side with line
No invasive procedures or
blood draws
Weight, BP, labs
Assess for hypotension, HA,
N/V, malaise, dizziness,
muscle cramps, bleeding
Nursing Management
Motor function, ADLs
Symptom mgmt.
Self-care and safety
Energy, ability to perform
ADLs
Ability to void normally
Meds for paresthesias, pain,
bowel dysfunction
 Blurred vision, diplopia,
nystagmus
Tinnitus, vertigo
Hypalgesia – decreased feeling
Numbness, tingling, burning
Bowel/bladder dysfunction
Late cognitive changes in
memory, concentration,
judgment, depression
Amyotrophic Lateral Genetic/family hx Slurred speech - dysarthria
Sclerosis (ALS) Men in their 30s Falling
No cognitive defects, always
motor
Upper and lower motor
weakness
Muscle atrophy
Dysphagia, fasciculations
Spasticity, cramping, fatigue
Twitching of limb, tongue
Dyspnea
Guillain Barre Previous viral infection Motor weakness
Syndrome Areflexia
Flaccid paralysis
Ascending (sometimes
descending) symmetrical
weakness progression
Paresthesia and pain
Autonomic changes
No pupillary/cerebral S/S
Changes in cardinal vision,
diplopia
Myasthenia Gravis Younger women, older men Specific muscle weakness
Voluntary muscle fatigue
FACE – cranial nerves Ptosis (droopy eyelids)
Thymoma Diplopia
Dysarthria (speech)
Myasthenic crisis: Dysphagia (swallowing)
increased droopy eye Snarling look
Cholinergic crisis: NO COGNITIVE
abdominal cramps,
metal poisoning, stroke,
brain tumor
EMG: fibrillations
CBC outside normal
Genetic markers
R/O syphilis, HIV, heavy
metal poisoning, stroke,
brain tumor
CBC outside normal
Tensilon testing –increase
Ach if improved, myasthenic
crisis
EMG: fibrillations
CBC outside normal
R/O syphilis, HIV, heavy
metal poisoning, stroke,
brain tumor
Steroids for exacerbations
Biological modifiers
Antidepressants
NO CURE
Education:
Avoid stress, extreme temps,
infections
Exercise & mobility program
ADLs and muscle function
Antispasticity meds
Exercise & mobility program
Periods of rest
Manage swallowing, resp
Support groups
Comprehensive baseline
assessment
Ongoing monitoring
Assess pain
Provide support for fearful
patients
Antivirals – reversible
Pain management
NO CORTICOSTEROIDS
IV immunoglobulin
Plasmapheresis
Ineffective Breathing Pattern
Cardiac Dysfunction
Periods of rest around
mealtimes
Cholinergic crisis –
overmedication; withhold
meds; atropine, airway
Myasthenic crisis –
undermedication; maintain
respiratory fxn; reintroduce
meds little by little
diarrhea, Cholinesterase-inhibitors
bronchospasm, Immunosuppressants
increased secretions Plasmapheresis in crisis
Both muscle weakness IV immunoglobulins in crisis
Thymectomy
Administer meds w/ food to
prevent aspiration
Monitor airway, swallowing
Promote self-care
Assist w/ communication
Nutritional support
Eye protection
Avoid infection, stress,
overheating
Parkinson’s CPK levels: elevated
Abnormal EEG
Genetic markers
R/O syphilis, HIV, heavy
metal poisoning, stroke,
brain tumor
R/O hypo/hyperthyroid
Alzheimer’s CPK levels: elevated
MRI: brain atrophy
CRP levels: elevated
Genetic markers
R/O syphilis, HIV, heavy
metal poisoning, stroke,
brain tumor
R/O hypo/hyperthyroid
Meningitis Bacterial: Meningismus (irritation) Hx of illnesses, dental tx, Prophylactic ABx, broad-
Immunocompromised Photophobial trauma spectrum
Bacterial is most Malnutrition Nuchal rigidity Lumbar puncture Mannitol
dangerous Alcoholism Kernig’s sign (bend hip) Counterimmuno- Anticonvulsants
DM Brudzinski’s sign (bend neck) electrophoresis Steroids
Viral: self-limiting, Recent dental tx Severe headache PCR Pain management
more common, less Bacterial sinus infections High fever Antipyretics
fatal Seizures at onset
Altered LOC late sign
Encephalitis Mosquito bites + Kernig’s & Brudzinski’s Lumbar puncture Support respirations
Warmer climate Brain hemorrhage/necrosis Low glucose Manage ICP
Usually viral Postviral from measles, mumps, Severe headache High protein Nutritional support
chickenpox Fever High WBCs I&O
 N/V MRI Antivirals
Confusion CT scan Dexamethasone to reduce
ALOC Blood/urine/throat CX cerebral edema
Focal deficits – motor weakness EEG Antiepileptics
Seizures Brain biopsy Pain management
Bizzarre behavior Antipyretics
Cerebral edema – seizures, loss
of sensation, speech, hearing,
consciousness
Death if untreated
Seizures Uncontrolled motor activity CT scan for structural Airway – lie on side
Drooling problems Safety precautions
Status Epilepticus Airway problems EEGs – what seizure looks Anti-epileptics – S/E, toxicity
30 minutes of seizure Aura like Sx resection
activity Pupillary constriction or ISAP – location of seizure Anxiety
2+ w/o full dilation Knowledge deficit
consciousness in Loss of consciousness Fear
between Cyanosis Risk for Injury
Respiratory/CV failure Urinary incontinence Time the seizure
SPINAL CORD
INJURIES
CONDITION Who is at risk? Signs/Symptoms Lab/Diagnostics Nursing Management
Hyperflexion MVA (sudden deceleration) Where is the level of injury – Airway and respirations
injuries how much function can a pt Shock, CV problems
Hyperextension Age – degenerative changes have Hemorrhage
injuries MVA Umbilicus at T10 LOC – use GCS
Clavicle C3-C4 Stabilize spine at level of
Rotational injuries Sudden impact from high-energy Finger movement if injury is injury
trauma MVA both sides lower than C7 High dose glucocorticoid –
Compression Fall from a height C6 and above – no hand anti-inflammatory
Injuries Diving into shallow pond movement, may be able to SX management – unstable
Age – degenerative changes drive a chair fracture, cord compression
Penetrating injuries Projectile injury T6 – lower extremities (laminectomy, fusion)
affected Skin breakdown prevention
Bowel/bladder/sexual fxn
Assess for autonomic
dysreflexia, manage
Psychosocial changes
Rehab:
Motor function
Communication
Then:
 Bowel/bladder
Adaptation
Cervical spine C1-C3 – breathing muscles paralyzed Fixed skeletal traction
injuries C4-8 – impaired breathing Pin site care, monitor traction rope
Risk for PNA, atelectasis Halo fixation, cervical tongs
Risk for PE Stryker frame
Assisted coughing, IS
Thoracic & T1-T11 – impaired cough Body cast
Lumbosacral injuries T12 and below – breathing and coughing normal Braces or corset
Spinal shock Immediately after a spinal injury Meds to increase BP
Flaccid paralysis CV assessment
Loss of reflexes below lesion Manage temperature (hypothermia)
Bradycardia
Paralytic ileus
Hypotension (SBP<90 - treat)
Secondary injury After a spinal injury
Neurogenic shock Stabilize cord
Hypovolemic shock
Spinal shock
Decreased ANS response
Bradycardia
Hypotension
Chronic SCI Hypotension Rounded abdomen
Bradycardia Spasticity
Edema of LE Temperature intolerance
Weak cough Pain
Autonomic Response to noxious stimulus High BP - severe Raise HOB to 90, lower legs
Hyperreflexia Distended bladder Bradycardia Loosen tight clothing
(autonomic Pressure ulcer Severe HA Check urine
dysreflexia) Tight clothing Nasal stuffiness Check bowels
Flushing Check for painful things
Remove cause
BP reduction - meds
Spasticity May occur weeks to months Pain Muscle spasms Perform daily ROM exercise
after SCI Stretching Monitor for skin breakdown
Infection Meds (Baclofen, Valium)
Skin breakdown
Skin Breakdown Impaired tissue perfusion Weight shifts q15min
Tissue hypoxia Turn q2-3h
Skin checks
GU/Bowel Spinal tracts disrupted Loss of fxn S1-S4 Foley
 Long-term catheterization Loss of urge to urinate, control Suprapubic catheter
of sphincter Intermittent cath
Inability to sense fullness Mitrofanoff (sx – use appendix
UTI between bladder and stoma)
Hydronephrosis Meds for BM
Decline in renal fxn Scheduled BM
Renal calculi
Constipation
Incontinence
Hemorrhoids
Ileus
Sexual SCI Loss of psychogenic erection Viagra
Reflex (physical stimulation) Injection therapy
may still be present Vacuum pump
Surgical implant
Psychosocial Loss of body image, Monitor for inadequate
independence, control, coping
economic security Encourage to discuss feelings
Lifestyle changes Allow to participate in
Stress, strain on relationships decision-making
Withdrawal from social
Avoid eye contact
Refuse to participate