NURSING PROCESS The nursing process is a problem-solving approach that enables the nurse to provide care in an organized scientific

manner. The goal of the nursing process is to alleviate, minimize, or prevent actual or potential health problems. The nursing process can be applied in any interaction that involves a nurse and a client. The process can take place in a variety of settings, including a hospital, community setting, private home, or long term care facility. The 5 steps/components of NURSING PROCESS are, assessment, nursing diagnosis, planning, implementation, and evaluation. 5 Components/ Steps of Nursing Process ASSESSMENT The nurse collects data about the health status of the client. The data is subjective and objective. Subjective data is usually documented in the clients own words. This data includes such things as previous experiences, and sensations or emotions that only the client can describe. The Objective data is obtained by the health team, through observation, physical examination, or/and diagnostic testing. Objective data can be seen or measured. Sources of subjective data and objective data are the client, the family and significant others, medical records, and other health care team members. Assessment includes, the "HEALTH HISTORY" and "physical assessment". Physical assessment can be broken down into four components (2); * Inspection, * Palpation, * Percussion, * Auscultation. INSPECTION: Inspection is the visual examination of the client. Guidelines for Effective Inspection * Be systematic * Fully expose the area to be inspected;cover other body parts to respect the client's modesty. * Use good light, preferably natural light. * Maintain comfortable room temperature. * Observe color, shape, size, symmetry,position,and movement * Compare bilateral structures for similarities and differencess. PALPATION: Palpation uses the sense of touch to assess various parts of the body and helps to confirm findings that are noted on inspection. The hands, especially the finger tips are used to assess skin temperature,check pulses, texture, moisture, masses, tenderness , or pain. Ask the Client for permission first and explain to your client what you intend to examine. Establish client trust with being professional. Please remember to use warm hands. Any tender areas should be palpated last. Types of Palpation: 1. Light Palpation:To check muscle tone and assess for tenderness 2. Deep Palpation:To identify abdominal organs and abdominal masses. PERCUSSION: Percussion is the striking of the body surface with short, sharp strokes in order to produce palpable vibrations and characteristic sounds. It is used to determine the location, size, shape, and density of underlying structures; to detect the presences of air or fluid in a body space; and to elicit tenderness. (2) Note when examining Abdomen, you auscultate first followed by percussion then palpation. Types of Percussion 1.Direct Percussion: Percussion in which one hand is used and the striking finger of the examiner touches the surface being percussed. 2. Indirect Percussion: Percussion in which two hands are used and the flexor strikes the finger of the examiner's other hand, which is in contact with the body surface being percussed. 3. Blunt Percussion: Percussion which the ulnar surface of the hand or fist is used in place of the fingers to strike the body surface, either directly or indirectly. Percussion Sounds * Resonance: A hollow sound. * Hyper-resonance: A booming sound. * Tympani: A musical sound or drum sound like that produced by the stomach. * Dullness: Thud sound produced by dense structures such as the liver, and enlarged spleen, or a full bladder. * Flatness: An extremely dull sound like that produced by very dense structures such as muscle or bone. AUSCULTATION: Auscultation is listening to sounds produced inside the body. These include breath sounds, heart sounds, vascular sounds, and bowel sounds. It is used to detect the presence of normal and abdominal sounds and to assess them in terms of loudness, pitch, quality , frequency and duration.

NURSING DIAGNOSIS: The nursing diagnosis is derived from data gathered during the assessment. Health problems or potential health problems are identified and formulated into nursing diagnosis. Nursing Diagnosis is the basis for planning nursing interventions that help prevent, minimize or alleviate specific health issues. A Medical Diagnosis is much different than nursing diagnosis; it is used to define etiology of the disease. It only focuses is on the function and malfunction of a specific organ system. The two are very different. A Nursing Diagnosis is written in a format called "PES ", developed by NANDA(1). * "P" stands for PROBLEM * "E "stands for ETIOLOGY or cause of problem * "S "stands SIGNS and SYMPTOMS of problem By using all of the components of the nursing diagnosis, the problem is clearly communicated to everyone involved in the clients care. Measurement Criteria: 1. Diagnosis are derived from the assessment data 2. Diagnosis is validated with the client. 3. Diagnosis is documented to aid in the expected outcomes and plan of care. PLANNING The planning phase of the Nursing Process involves the devlopment of a nursing care plan for the client based on the nursing diagnosis. The nursing care plan is a communication tool used by Nurses to care for their clients. Care plans that are kept up to date are vital tools to provide continuity of care, prevent complications and provide for health teaching and discharge planning. Goals should be stated in terms of client outcomes. Nursing outcomes examples are: Skin and Mucous Membranes, Wound Healing, Primary Intention, and Urinary Continence. Each of these nursing sensitive outcomes is labeled, defined, and includes criteria for the assessing the status of the outcome over time. Nursing orders are the actions for interventions prescribed to help achieve the stated goals and objectives. When writing nursing orders remember to include: 1. What 2. Where 3. When 4. How much 5. and How long. The steps in Nursing Care Planning are: 1. Determine priorities from the list of nursing diagnoses. 2. Set long-term and short-term gols to determine outcomes of care. 3. Develop objectives to reach the goals. 4. And Write nursing orders to direct care to meet the goals. Measurement Criteria: 1. The plan is individualized to the client's condition. 2. The plan is developed with the client and significant others if appropriate. 3. The plan reflects current nursing practice. 4. The plan is documented. 5. The plan provides for continuity of care. IMPLEMENTATION Implementation is the actual performance of the nursing interventions identified in the care plan. The implementations are coordinated with other members of the health care team who have direct care of the client. These interventions include , but are not limited to; health teaching, direct client care, medical treatments, medications, and dressing changes. Nurses provide care to achieve established goals of care and then communicate the nursing interventions by documenting and reporting. Not all interventions are planned. The nurse must use her critical thinking skills to respond to an unexpected crisis. Measurement Criteria: 1. Interventions are consistent with the established plan of care. 2. Interventions are implemented in a safe and appropriate manner. 3. Interventions are documented according to Nursing Standards. EVALUATION Evaluation is an ongoing process that enables the nurse to determine what progress the patient has made in meeting the goals for care. The outcome criteria provide measures for determining outcomes of care. Please Note that the nurse is not evaluating nursing interventions. In assessing outcomes of care, determine whether goals have been met, partially met, or not met at all. If the goals have not been met it will be necessary to re-evaluate the plan. The plan may need to be altered , to do this you will need to do a new assessment. Evaluation also provides data for Quality Assurance audits. Measurement Criteria: 1. Evaluation is systematic and ongoing. 2. The client's response to interventions is documented. 3. The effectiveness of interventions is evaluated in relation to outcomes.

4. Ongoing assessment data are used to revise diagnosis, outcomes, and the plan of care are documented according to nursing standards. 5. The client, significant others, and the health care providers are involved in the evaluation process, when appropriate.

Addisons Disease

Etiology and Pathophysiology

An adrenocortical disorder exhibited by secretion of adrenocortical hormones glucocorticoids, mineralocorticoids (aldosterone), and androgens, which stress response

Occurs secondary to surgical removal of adrenal glands, autoimmune or idiopathic causes, abrupt cessation of steroid therapy, or infection

Signs and Symptoms

K, Na, dehydration, serum glucose, weakness, diarrhea, confusion

BP, weight, bronze-colored skin

ACTH, serum cortisol, 17-ketosteroids, 17-hydroxysteroids

Addisonian crisis: Pallor or cyanosis, anxiety, P, R, BP secondary to acute stress (surgery, emotions, cold exposure, infection)

Treatment

Glucocorticoid and mineralocorticoid replacement (dose under stress to risk of Addisonian crisis)

F&E replacement

Nursing Management

Monitor for S&S of Addisonian crisis

Encourage protein and carbohydrate diet with added salt

Schedule rest periods

Teach need for lifelong therapy, avoidance of stress, and use of medical alert band Anemia Labels: Anemia, Aplastic Anemia, Hemolytic anemia, Macrocytic Anemia,Microcytic Anemia, Normocytic Anemia, Nursing Management of anemia,pernicious anemia, Sickle cell crisis, thrombocytopenia

Etiology and Pathophysiology

RBCs secondary to blood loss, production or destruction of RBCs; O2 carrying capacity of blood, cardiac workload, heart failure

Signs and Symptoms

P, R, fatigue, weakness, pallor, confusion, Hgb, Hct

Treatment

Correct cause, provide O2, administer transfusions (whole blood, packed RBCs), administer meds depending on type

Nursing Management

Monitor S&S; balance rest/activity; protein diet; teach ironsupplements will cause black stools and constipation; packed red blood cells if ordered

Microcytic Anemia

Etiology and pathophysiology: Iron secondary to dietary intake (vegetarians, teens); blood loss from GI bleeding (ulcers, cancer, inflammation) or menorrhagia; iron absorption after gastric surgery Signs and symptoms: MCV <80fl; style="font-weight: bold; color: rgb(0, 0, 153);">Treatment: Oral iron best absorbed with pH (give with vitamin C between meals); use straw with liquid iron (stains teeth); dietary sources of iron (raisins, eggs, meat [liver], green vegetables)

Macrocytic Anemia

 Etiology and pathophysiology: Folate due to dietary intake; alcohol; B12 deficiency due to lack of intrinsic factor (pernicious anemia); folate absorption after gastric surgery or Crohns disease Signs and symptoms: MCV >100fl; folate; B12 (Schilling Test for pernicious anemia); sore, smooth, red, tongue; diarrhea; neuro changes due to myelin (paresthesias, ataxia); screen for stomach Ca Treatment: Oral folic acid; avoid alcohol; IM B12; dietary sources of folic acid (green vegetables, liver, mushrooms)

Normocytic Anemia

Etiology and pathophysiology: -Hemolytic anemia (HA): RBCs break down rapidly bone marrow release of reticulocytes; examples: sickle cell anemia, toxins, thalassemia, G-6-PD deficiency -Anemia in renal disease: erythropoietin RBC synthesis

Signs and symptoms: MCV 80-100fl; HA reticulocytes; jaundicedue to Hgb breakdown; hepatomegaly; sickle cell vaso-occlusive crisis tissue hypoxia, necrosis, pain

Acute hemolysis: T, chills, abdominal and back pain, hemoglobinuria Treatment: Sickle cell anemia: bone marrow transplant, hydroxyurea Sickle cell crisis: Analgesic, hydration, O2 Renal disease: Iron, folate, recombinant erythropoietin

Aplastic Anemia

Etiology and pathophysiology: Bone marrow stem cells destroyed RBCs, WBCs (neutropenia) and platelets (thrombocytopenia); idiopathic or caused by radiation, infection, or chemicals

Signs and symptoms: MCV >100fl; no reticulocytes; WBCs, platelets; infection; bleeding (purpura, retinal hemorrhage)

Treatment: Bone marrow transplant; peripheral blood stem cell transplant; immunosuppressants (cyclosporine) Ischemic Heart Disease (IHD) (Myocardial Infarction, Angina Pectoris) Etiology and Pathophysiology Fatty deposits in intima of coronary arteries triggers inflammatory process plaques (atheromas) further obstruction of blood flow chest pain secondary to myocardial ischemia (angina pectoris) Rupture of atheroma thrombus severe ischemia and myocardial cell death (myocardial infarction [MI]) Other causes of MIs include myocardial O2 supply (2 degrees vasospasm, hemorrhage) or O2 demand (2 degrees cocaine, hyperthyroidism) Risk Factors Aging, family history, race (African Americans), gender (males more than premenopausal females) HTN, diabetes mellitus, metabolic syndrome (insulin resistance, abdominal obesity, abnormal lipid profile Modifiable risk factors: smoking, obesity, sedentary lifestyle Cholesterol, triglycerides, LDL, HDL, C-reactive protein (CRP) Signs and Symptoms Angina Chest pain/pressure may be substernal and/or radiate to neck, jaw, left arm Precipitated by exertion (O2 demand), cold exposure (vasoconstriction), stress (sympathetic nervous system activity O2 demand), heavy meal (blood diverted to GI tract blood to heart) Pain subsides with rest and/or nitroglycerin Myocardial Infarction

 May have sudden chest pain (see Angina) unrelieved by rest/nitroglycerin SOB; restlessness; dysrhythmias Pulse deficit if atrial fibrillation Cool, pale, clammy skin; diaphoresis; N&V Early S&S in women: Overwhelming fatigue, dizziness, indigestion, anxiety, trouble sleeping Diagnosis ECG: ST segment, inverted T wave, presence of Q wave Echocardiogram identifies ventricular wall motion and ejection fraction Myoglobin (1st to rise, but returns to normal in 12hr) Creatine kinase (CK) Isoenzyme specific to heart muscle: CK-MB, which 4-6hr after MI, cardiac troponin T (cTnT) and I (cTnl), which remains for 3-12hr after MI Treatment (Cardiac Demands and O2 to Cardiac Muscle) Angina Modifiable risk factors, percutaneous coronary interventional procedures (PCTA, atherectomy, stent); CABG Meds: nitroglycerin, beta-blockers, calcium channel blockers, antiplatelets, anticoagulants, antilipidemics O2 prn; cardiac rehab to exercise tolerance and quality of life Myocardial Infarction Provide O2, morphine to pain, ACE inhibitors to cardiac workload IV thrombolytic within 3hr of start of MI to dissolve clot and damage Emergency PCI Nursing Management Angina Monitor S&S, balance activity/rest, give sublingual nitroglycerin and O2 prn Teach about meds and to modifiable risk factors Myocardial Infarction Monitor S&S, HOB, anxiety Maintain IV access (avoid fluid overload) Identify complications (heart failure, pulmonary edema, dysrhythmias, cardiogenic shock) Give prescribed thrombolytic, analgesics, beta-blockers, ACE inhibitors, anticoagulants, stool softeners Maintain BR until stable Percutaneous transluminal coronary angioplasty (PCTA) Monitor for bleeding (restlessness, back pain due to retroperitoneal bleed, P, BP, Hgb/Hct) Apply pressure to insertion site, keep hip extended Assess pulses of distal extremity Postoperative coronary artery bypass graft (CABG) Monitor hemodynamic status, which may be (due to heart failure or fluid overload) or (due to fluid deficit or bleeding) Assess pulses below vein harvest site Monitor ECG for dysrhythmias Assess urine output (if <30mL/hr, may indicate renal perfusion) Monitor electrolytes and coagulation profile Maintain chest tube drainage and ventilator as needed, then encourage incentive spirometer, splinting, coughing, and deep breathing Provide for alternate communication while intubated Provide pain control Refer to cardiac rehab and Mended Hearts Club Aortic Aneurysm Labels: Aneurysm, Aorta, Aortic Aneurysm, Atherosclerosis, congenital weakness, Dissecting aneurysm, infection, inflammation, protrusion, trauma,Weakness in vessel

Etiology and Pathophysiology Weakness in vessel protrusion and possible rupture Risk Factors Atherosclerosis, trauma, congenital weakness, infection, inflammation HTN, smoking Signs and Symptoms May be symptom-free; may be able to palpate a pulsating mass Dissecting aneurysm: Sudden severe chest pain extending to back, shoulder, epigastrium, abdomen; diaphoresis; P Treatment Confirm diagnosis with CT, MRI, sonogram Repair with graft BP with antihypertensives to risk of rupture or extension Nursing Management Monitor BP, Hgb/Hct Assess for sudden pain (may signal impending rupture) Teach to avoid activities that intra-abdominal pressure (sneezing, coughing, vomiting, straining at stool) Arterial Insufficiency Labels: Arterial Insuifficiency, Atherosclerosis, gangrene, intermittent claudication, ischemia of extremeties, ischemia of extremities

Etiology and Pathophysiology Atherosclerosis ischemia of extremities (incidence in distal legs); sensation risk of injury

Risk Factors Age, males, heredity,smoking, obesity Inactivity, HTN, hyperlipidemia, diabetes

Signs and Symptoms Leg pain when walking relieved by rest (intermittent claudication) Cool, pale, shiny leg with faint/absent pulse Hair; thick yellow toenails, toe ulcer, gangrene

Treatment Risk factors Meds to platelet aggregation and flow Bypass grafts

Nursing Management Assess S&S Position legs than heart Apply warmth to abdomen, local heat if ordered Teach to smoking, cold exposure and constrictive clothing Foot care: Inspect and protect feet, wear shoes and socks, dry feet well; dressings as ordered Bleeding Disorders During Pregnancy Labels: bicol nurse, Bicol Nurses, Bleeding in Pregnancy, FILIPINO NURSE, intrapartum Hemorrage, vaginal bleeding Bleeding Disorders During Pregnancy

First Trimester Bleeding Abortion or Ectopic

A. Abortions termination of pregnancy before age of viability (before 20 weeks)

Causes: 1.) chromosomal alterations

2.) blighted ovum

3.) plasma germ defect

Classifications:

1. Threatened pregnancy is jeopardized by bleeding and cramping but the cervix is closed 2. Inevitable moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)

Types:

1.) Complete all products of conception are expelled. No mgt just emotional support!

2.) Incomplete Placental and membranes retained. Mgt: D&C

Incompetent cervix abortion

McDonalds procedure temporary circlage on cervix

S/E; infection. During delivery, circlage is removed. NSD

Sheridan permanent surgery cervix. CS

c. Habitual 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix.nd trimester Present 2

d. Missed fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy cease. (-) preg test, scanty dark brown bleeding

Mgt: induced labor with oxytocin or vacuum extraction

5.) Induced Abortion therapeutic abortion to save life of mom. Double effect choose between lesser evil.

1. Ectopic Pregnancy occurs when gestation is located outside the uterine cavity. common site: tubal or ampular

Dangerous site - interstitial

Types:

a.) Ruptured

- missed period

- abdominal pain within 3 -5 weeks of missed period (maybe generalized or one sided)

- scant, dark brown, vaginal bleeding

Nursing care:

-Vital signs

-Administer IV fluids

-Monitor for vaginal bleeding -Monitor I & O

b.)Tubal rupture

- sudden , sharp, severe pain. Unilateral radiating to shoulder.

shoulder pain (indicative of intraperitoneal bleeding that extends to diaphragm and phrenic nerve)

- + Cullens Sign bluish tinged umbilicus signifies intra peritoneal bleeding

-syncope (fainting)

Management:

- Surgery depending on side

- Ovary: oophrectomy - Uterus : hysterectomy

Second trimester bleeding

C. Hydatidiform Mole bunch or grapes or gestational trophoblastic disease. with fertilization. Progressive degeneration of chorionic villi. Recurs.

- gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed form the selling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46 XX, it grows & enlarges the uterus vary rapidly.

Medication: Methotrexate to prevent choriocarcinoma

Assessment:

Early signs - vesicles passed thru the vagina

Hyperemesis gravidarium increase HCG

Fundal height

Vaginal bleeding( scant or profuse)

Early in pregnancy

-High levels of HCG

-Preeclampsia at about 12 weeks

Late signs -hypertension before 20th week

-Vesicles look like a snowstorm on sonogram

-Anemia

-Abdominal cramping

Serious complications

hyperthyroidism

Pulmonary embolus

Nursing care:

Prepare D&C

Do not give oxytoxic drugs

Teachings:

Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus and rising titer could indicative of choriocarcinoma

Avoid pregnancy for at least one year Third Trimester Bleeding Placenta Anomalies

1. Placenta Previa it occurs when the placenta is improperly implanted in the lower uterine segment, sometimes covering the cervical os. Abnormal lower implantation of placenta.

- candidate for CS

Symptoms : Bright red and Painless Vaginal bleeding

Diagnosis:

Ultrasound

Avoid: sex, IE, enema may lead to sudden fetal blood loss

Double set up: delivery room may be converted to OR

Assessment:

- Engagement (usually has not occurred)

- Fetal distress

- Presentation ( usually abnormal)

Complication: sudden fetal blood loss

Nursing Care

-NPO

-Bed rest

-Prepare to induce labor if cervix is ripe

-Administer IV

2. Abruptio Placenta it is the premature separation of the placenta form the implantation site. It usually occurs after the twentieth week of pregnancy.

Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.

Assessment:

-Concealed bleeding (retroplacental)

-Couvelaire uterus (caused by bleeding into the myometrium)

-inability of uterus to contract

-Severe abdominal pain

-Dropping coagulation factor (a potential for DIC)

Complications:

-Sudden fetal blood loss -Placenta previa & vasa previa

Nursing Care:

-Infuse IV -prepare to administer blood -Type and crossmatch

-Monitor FHR -Insert Foley -Measure blood loss

-Report s/sx of DIC -Monitor v/s for shock -Strict I&O

3. Placenta succenturiata 1 or 2 more lobes connected to the placenta by a blood vessel may lead to retained placental fragments if vessel is cut. 4. Placenta Circumvalata fetal side of placenta covered by chorion 5. Placenta Marginata fold side of chorion reaches just to the edge of placenta 6. Battledore Placenta cord inserted marginally rather then centrally 7. Placenta Bipartita placenta divides into 2 lobes 8. Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta 9. Vasa Previa velamentous insertion of cord has implanted in cervical OS Burns Labels: Burn management, Burns, depth, Nurn PAtient, nursing management, Phases of burn, signs and symptoms

Burns

Thermal, electrical, or chemical trauma tissue destruction; intensity and duration of heat determine depth of destruction; prognosis depends on location and % of total body surface area (TBSA) involved.

Terms

Extent of burn (rule of nines): Body divided into sections by % to quickly assess TBSA involved; head and neck (9%), each arm (9%), anterior trunk (18%), posterior trunk (18%), each leg (18%), perineum (1%) Minor: 15%TBSA; face, hands, feet, and genitals not involved Moderate: Partial thickness 15-25% or full thickness 10% Major: Partial thickness

25%; full thickness

10%; burns of face, hands, feet, or genitals, other complications

Depth of burn: Partial-thickness (superficial): Includes epidermis, may include top layer of dermis; erythema, pain, blanching with pressure Partial-thickness (deep): Includes deeper layer of dermis; erythema, hypersensitive to touch/air, moderate to severe pain, moist blebs, blisters Full-thickness: Extends through dermis and may involve underlying tissue; pale, white, or brown charred appearance (eschar), edema, absence of pain but severe pain in surrounding tissue, burn odor Inhalation injury: Facial burns, singed nostril hair, sooty sputum, voice change, blisters in mouth or throat, dyspnea

Burn Phases

Emergent or Immediate Resuscitative Phase Onset of injury to 5 or more days; usually 24-48hr; from fluid loss and edema formation until diuresis begins

Acute Phase Weeks or months; from mobilization of extracellular fluid to diuresis; burned area is covered by skin grafts or until wounds heal

Rehabilitation Phase

Two wk to 2-3mo; major wound closure to achievement of maximal physical and psychosocial adjustment; mature healing of skin may take 6mo-2yr

Signs and Symptoms

Emergent or immediate resuscitative phase: Shock from pain and hypovolemia; fluid shift to interstitial and 3rd spaces; edema; adynamic ileus; shivering related to heat loss, anxiety, pain; altered mental state (hypoxia due to smoke inhalation, pain meds); Hct; impairment of immune system (WBC)

Acute phase: Edema; necrotic tissue sloughs; granulation occurs in partial-thickness burns (10-14 days)

Rehabilitation phase: Flat, pink new skin becomes raised and hyperemic in 4-6wk and will cause joint flexion and fixation (contracture) if not prevented; altered contour (slightly elevated and enlarged over

Treatment

At the scene of burn: Put out flames; maintain airway, breathing, circulation; first aid to prevent shock and respiratory distress; apply cool water briefly to trauma and pain (avoid ice damage); remove clothing and jewelry to prevent constriction related to edema; leave adherent clothing; cover with sterile/clean dressing (no ointments); rapid sustained flushing of skin/eyes if chemical burn

In the hospital: May require intubation, O2, mechanical ventilator; extent and depth of burns assessed; hemodynamic monitoring; fluid replaced using an established formula (1/2 of fluids in first 8hr and other 1/2 over next 16hr); prevention of electrolyte imbalance (hyper/hypokalemia and hyper/hyponatremia); IV narcotic analgesics; wound care; tetanus toxoid; ECG for electrical burns; meds to prevent Curlings ulcer; calorie, protein diet, vitamins and iron; pressure garments (scars); splints (contractures)

During rehabilitation: PT, OT, vocational education; reconstruction (cosmetic, functional); counseling to manage

Nursing Care

Emergent or immediate resuscitative phase: Maintain respirations; maintain patent airway (suction, endotracheal tube, mechanical ventilator); monitor ABGs, O2 sat, breath sounds; place in Fowlers position; coughing; teach incentive spirometry; monitor fluid shift from intravascular to interstitial space Acute phase: Monitor fluid shift from interstitial to intravascular space

All Phases Maintain fluid balance: Monitor S&S of fluid shifts, edema, daily weight, I&O, hemodynamic status; give po fluids when ordered Maintain circulation: Provide IV F&E, colloids as ordered, maintain urinary output 30-50mL/hr, systolic BP 100mmHg, and pulse 120bpm Prevent infection: Assess for S&S of infection (T and WBC, wound bed and donor sites for purulent drainage, edema, redness); use contact precautions; give systemic/topical antimicrobials/antibiotics; provide surgical aseptic wound care as ordered Manage pain: Give pain meds before procedures and routinely before

pain; use nonpharmacological interventions (distraction); use lifting sheet; keep room temperature 80-85F, humidity 40%, prevent drafts Maintain nutrition: NPO initially, high-calorie, high-protein diet with supplements when able, tube feedings or parenteral nutrition Provide emotional support: Address fear, grief, altered role, body image (explain that edema will subside in 2-4 days); explain all care Maintain bowel function: Assess bowel function, maintain NGT to decompression (N&V, aspiration, ileus formation) Ongoing care: Assist with hydrotherapy, debridement, grafting; plan for rest; maintain mobility and prevent contractures (positioning, splints, ambulation, ROM); teach use of pressure garments and skin lubrication; self-care activities when able

Rehabilitation phase: Continue monitoring for infection and providing nutritional support until skin coverage is achieved; protect new skin from injury; teach: self-care, wound care; reassure appearance will continue to improve over time; refer to support group. Characteristics of A Critical Thinker Labels: critical thinker, critical thinking, good nurse

Critical Thinker

Curiousity:

* The desire, not just to know, but to understand how and why, to applyknowledge.

Systemic Thinking:

* Uses an organized approach to problem solving, rather than knee-jerk responses

Analytical:

* Applies knowledge from various disciplines, approaches a problem by examining the parts ands seeing how they fit together

Open-Minded:

* Willing to consider various alternatives

Self-confident:

* Sense of assurance that the problem solving process produces a good conclusion/plan

Maturity:

* Recognition that many variables are at work in patient situations, and sometimes the best plans do not work

Truth-seeking:

* Eager to know, asking questions, seeking answers, reevaluates "common knowledge" Cushings Syndrome Labels: cushings dse, Cushings dse Nursing Management, cushings treatment, Cushings Syndrome, Etiology and Pathophysiology

Etiology and Pathophysiology

An adrenocortical disorder exhibited by secretion of cortical hormones (androgens, mineralocorticoids, glucocorticoids) immune response,

Na, water retention, serum glucose

Occurs secondary to adrenal tumor, or ACTH from pituitary, steroidtherapy

Risk women 20-40yr

Signs and Symptoms

K, Na, hypervolemia, edema

Truncal obesity, buffalo hump, moon face, acne, hirsutism, purple abdominal striae

Libido

Muscle wasting thin extremities

Glucose, serum cortisol, 17-ketosteroids, 17-hydroxysteroids

ACTH (unless secondary to a pituitary problem)

Risk of infection, osteoporosis, psychosis

Treatment

Adrenalectomy, removal of pituitary tumor (hypophysectomy) depending on cause

If resulting from steroid therapy, D/C steroids slowly

Treat complications (DM, osteoporosis)

Nursing Management

Monitor for S&S

Encourage Na and altered K in diet

Protect from infection

Teach use of medical alert band and protection from injury (fractures secondary to osteoporosis)

Provide emotional support for altered body image and labile mood Diabetes Mellitus (DM) Labels: Bicol Nurses, Diabetes Mellitus, DM Nursing management, DM Pathophysiology, IDDM, Insulin dependent diabetes mellitus, NDDM, non- insulin dependent diabetes mellitus Diabetes mellitus (DM) is a chronic metabolic disorder caused by an absolute or relative deficiency of insulin, an anabolic hormone. Normal glucose metabolism: Blood glucose regulated by insulin andglucagon. Insulin and glucagons are hormones. Glucose is stored as glycogen in liver and muscles or as fat in adipose tissue. Insulin: Secreted by beta cells in Islets of Langerhans in pancreas. Insulin decreases blood glucose by promoting its entry into cells. Glucagon: Secreted by alpha cells in pancreas as blood glucose falls. Promotes release of glycogen from liver. Etiology and Pathophysiology Decreased amount of insulin or response to insulin leads to blood glucose (hyperglycemia) Type 1 10% of DM; beta cell destruction little or no insulin for cellular metabolism of glucose; requires exogenous insulin; Type 1 DM is associated with specific human leukocyte antigens (HLA), autoantibodies,

viruses. Presents at >30yr old Type 2 90% of DM; sensitivity to insulin (insulin resistance) and secretion of insulin; may be controlled by diet, exercise, and hypoglycemics; may need insulin when stressed; Type 2 DM is associated with obesity, genetics, inactivity, gestational diabetes. Usually presents at >45yr old Signs and Symptoms The 3 Ps: Polyuria, Polydipsia, Polyphagia (excessive urination, thirst, hunger) Fasting blood glucose >126mg/dL, random blood glucose >200mg/dL Glycosylated hemoglobin (HbA1C) level indicates lack of glucose control over prior 3mo; glycosuria Healing Type 1: weight; Type 2: weight Treatment Regular exercise to control weight and insulin resistance Calorie diet (50-60% carbohydrates, 20% protein, 20-30% fat) based on glycemic food index; soluble fiber slow glucose absorption Insulin and/or oral hypoglycemics Pancreatic or Islets of Langerhans transplants Treatment of DKA and HHNS: IVF, rapid acting insulin, eventual Na and K replacement Treatment of hypoglycemia: 10-15g of simple sugar followed by complex carbohydrate and protein if conscious; glucagon injection or 50% dextrose IV if unconscious Nursing Management Monitor S&S Provide foot care: Inspect daily for lesions Wash/dry between toes daily, wear socks and well-fitting shoes, avoid heat/cold Encourage weight control efforts and need for continued medical supervision (certified diabetic educator, dietician, podiatrist, ophthalmologist) Provide emotional support Teach self-monitoring of blood glucose (SMBG) and urine testing for ketones if hyperglycemic Teach S&S and management of hyperglycemia, hypoglycemia, and med administration Explain need for medical alert ID Emphysema Labels: bicol nurse, bicol. nursing emphysema. emphysema management,Emphysema

Etiology and Pathophysiology Alveolar wall distention surface area for gas exchange, air trapping, and residual volume work to exhale, barrel chest, chronic hypercapnia; may right-sided heart failure (cor pulmonale) Risk Factors Age, smoking, secondhand smoke, inhaled pollutants Alpha antitrypsin deficiency Signs and Symptoms Barrel chest, clubbing of fingers Pursed-lip breathing, forced expiratory volume Bronchodilators ineffective (unlike asthma) Treatment Smoking cessation O2; meds: steroids and bronchodilators Lung transplant Nursing Management Give O2 at 2L because with emphysema excessive exogenous O2 diminishes the respiratory drive and results in breathing and CO2 retention (CO2 narcosis). Normally CO2 stimulates breathing. With emphysema there is chronic CO2 and as a result low O2 stimulates breathing Teach diaphragmatic and pursed-lip breathing to extend exhalation and keep alveoli open Urinary Tract Infections (UTI)

Lower UTI: Urethritis, Cystitis Pathophysiology Ascending pathogens such as E. coli cause inflammation of the urethra(urethritis) and inflammation of the bladder (cystitis)

Risk Factors Catheterization, female gender, incontinence, age, DM

Signs and Symptoms Frequency, urgency, burning Bacteria, RBC, and WBC in urine, serum WBC

Upper UTI: Pyelonephritis

Pathophysiology Urine reflux from bladder into ureters (ureterovesical reflux) orobstruction causes inflammation of the renal pelvis

Risk Factors Calculi, stricture, enlarged prostate, incompetent ureterovesical valve

Signs and Symptoms T, chills, N&V Tender costovertebral angle (flank pain)

Glomerulonephritis

Pathophysiology Infections elsewhere in the body precipitate inflammation of glomerularcapillaries

Risk Factors Beta hemolytic streptococcal throat infections Bacterial, viral, or parasitic infection elsewhere in the body Exogenous antigens (e.g., medication)

Signs and Symptoms Hematuria, proteinuria, urination

Treatment Urine and blood cultures prn Antibiotics, antispasmodics, urinary tract antiseptics, sulfonamides,urinary tract analgesicphenazopyridine (Pyridium) Sepsis requires IV fluid volume replacement, antibiotics, and nutritionalsupport Nursing Monitor S&S, C&S to determine appropriateness of antibiotic, fluidsto 3-4L daily, empty bladder q3-4hr, perineal care Indwelling catheter: Surgical asepsis during insertion, closed system,secure to leg to prevent movement in and out of urethra, keep collectionbag lower than bladder Hyperthyroidism (Diffuse Toxic Goiter or Graves Disease) Labels: Diffuse Toxic Goiter, Graves Disease, Hyperthyroidism,Hyperthyroidism Etiology and pathophysiology, hyperthyroidism Nursing management, hyperthyroidism Treatment, Hypothyroidism signs and symptoms

Hyperthyroidism is the term for overactive tissue within the thyroidgland, resulting in overproduction and thus an excess of circulating free thyroid hormones: thyroxine (T4), triiodothyronine(T3), or both.

Etiology and Pathophysiology

Diffuse toxic goiter (Graves disease) or autoimmune condition secondary to infection, crisis or stress. This leads to thyroid-specific suppressor T-cell lymphocytes, which leads to T3 (triiodothyronine) and/or T4 (thyroxine). The result is an metabolic rate and sensitivity to catecholamines

Sudden severe hyperthyroidism is called thyrotoxicosis or thyroid storm

Hyperthyroidism generally occurs between 20 and 40yr old and is more common in females

Signs and Symptoms

T, P, R, and BP; heart failure, enlargement of gland

Hunger, diarrhea, weight

Tremors, nervousness, bulging eyes (exophthalmos)

Osteoporosis, amenorrhea

Sweating, flushed skin, heat intolerance

Radioactive iodine uptake, T3, T4, TSH

Thyrotoxicosis: T, P >120, delirium, coma

Treatment

Radioactive iodine destroys thyroid cells

Propylthiouracil or methimazole to T4

Subtotal thyroidectomy (iodide before to vascularity)

Nursing Management

Monitor for S&S of thyrotoxicosis

Provide calm, cool environment

Protein, calorie diet

Teach S&S of hypothyroidism, which may occur with treatment

 Give eye care (drops, patches) prn

Thyrotoxicosis: Hypothermia blanket, oxygen, propranolol, steroids, propylthiouracil, iodide Hypothyroidism (Myxedema coma) Labels: Hypothyroidism, Hypothyroidism Nursing management,Hypothyroidism pathophysiology, Hypothyroidism signs and symptoms,Myxedema coma, Treatment

Hypothyroidism is a condition characterized by abnormally lowthyroid hormone production. There are many disorders that result in hypothyroidism. These disorders may directly or indirectly involve the thyroid gland. Because thyroid hormone affects growth, development, and many cellular processes, inadequate thyroid hormone has widespread consequences for the body.

Etiology and Pathophysiology

Primary Hypothyroidism Autoimmune lymphocytic destruction (Hashimotos thyroiditis); secondary to toxic effect of hyperthyroidism therapy, atrophy with aging, genetics, iodides, lithium

Secondary Hypothyroidism Hypothalamus and/or pituitary problems thyrotropin releasing hormone (TRH) or thyroid stimulating hormone (TSH)

Signs and Symptoms

Weight, lethargy, dry pale skin, brittle hair/nails

T, P, R, cold intolerance

Dull expression, apathy

Constipation, deafness, enlarged tongue, periorbital edema, anemia

T3, T4, TSH

Sensitivity to CNS depressants, cholesterol, HDL, LDL

Severe hypothyroidism (myxedema) may cause coma

Treatment

Hormone replacement with levothyroxine

TSH levels are monitored as dose is gradually to determine optimum dose

Nursing Management

Monitor S&S, rest, keep warm

Explain that symptoms will improve with hormone replacement

Teach S&S of and thyroid function

Teach to fluids and fiber to constipation

Monitor for toxic effects of drugs (especially CNS depressants) secondary to metabolism Intravenous Access Labels: bicol nurse, Bicol Nurses, FILIPINO NURSE, Intravenous line IV,IV Access, IV insertion, Peripheral Intravenous access Indications By starting a peripheral IV, you gain access to the peripheral circulation of a patient, which will enable you to sample blood as well as infuse fluids and IV medications. IV access is essential to manage problems in all critically ill patients. High volume fluid resuscitation may be required for the trauma patient, in which case at least two large bore (14-16 G) IV catheters are usually inserted. All critically ill patients require IV access in anticipation of future potential problems, when fluid and/or medication resuscitation may be necessary.

Contraindications Some patients have anatomy that poses a risk for fluid extravasation or inadequate flow and peripheral IVs should be avoided in these situations. Examples include extremities that have massive edema, burns or injury; in these cases other IV sites need to be accessed. For the patient with severe abdominal trauma, it is preferable to start the IV in an upper extremity because of the potential for injury to vessels between the lower extremities and the heart. For the patient with cellulitis of an extremity, the area of infection should be avoided when starting an IV because of the risk of inoculating the circulation with bacteria. As well, an extremity with an indwelling fistula or on the same side of a mastectomy (occasionally a problem) should be avoided because of concerns about adequate vascular flow.

Complications The main complications of an IV catheter are infection at the site and development of superficial thrombophlebitis in the vein that is catheterized. It is also common for the IV sites to leak interstitially.

Universal precautions The potential for contact with a patient's blood while starting an IV is high and increases with the inexperience of the operator. Gloves must be worn while starting an IV and if the risk of blood splatter is high, such as an agitated patient, the operator should consider face and eye protection as well as a gown. Traumaprotocol calls for all team members to wear gloves, face and eye protection and gowns. As well, once removed from the protective sheath, IV catheters should either go into the patient or into an appropriate sharps container.

Important: Recapping needles, putting catheters back into their sheath or dropping sharps to the floor (an unfortunately common practice in trauma) should be strictly avoided. Recapping of needles is one of the commonest causes of preventable needle stick injuries in health care workers.

Peripheral IV sites Generally IV's are started at the most peripheral site that is available and appropriate for the situation. This allows cannulation of a more proximal site if your initial attempt fails. If you puncture a proximal vein first, and then try to start an IV distal to that site, the fluid may leak from the injured proximal vessel. The preferred site in the emergency department is the veins of the forearm, followed by the median cubital vein that crosses the antecubital fossa. In trauma patients, it is common to go directly to the median cubital vein as the first choice because it will accommodate a large bore IV and it is generally easy to catheterize. In circumstances where the veins of the upper extremities are inaccessible, the veins of the dorsum of the foot or the saphenous vein of the lower leg can be used. In circumstances in which noperipheral IV access is possible a central IV can be started.

Equipment All necessary equipment should be prepared, assembled and available at the bedside prior to starting the IV. Basic equipment includes: gloves and protective equipment appropirate size catheter 14-25 G IV catheter non-latex tourniquet alcohol swab/other cleaning instrument

 non-sterile 2x2 gauze sterile 2x2 gauze (this is not practiced in nursing) 6x7cm Tegaderm Transparent Dressing 3 pieces of 2.5 cm tape approximately 10 cm in length IV bag with solution set (tubing) (flushed and ready) or saline lock sharps container

To prepare the IV line, protective caps are removed from the fluid bag and the spiked end of the IV tubing. The regulating clamp for the IV line should be closed. The spiked end of the IV tubing is inserted into the receptacle on the IV bag while holding the IV bag inverted. The bag is then held upright with the IV line hanging from the bottom. The drip chamber should be filled half-way by pinching it and releasing. Following this the bag should be hung for the IV pole, at a point above the patient, and the regulating clamp should be opened to "flush" the line of air bubbles prior to connection to the patient.

Establishing a peripheral intravenous line 1. Assemble your equipment. 2. Don a pair of appropriately sized non-latex examination gloves. 3. Apply tourniquet to the IV arm above the site. 4. Visualize and palpate the vein. 5. Cleanse the site with a chlorhexidine swab using an expanding circular motion. 6. Prepare and inspect the catheter: Remove the catheter from the package. Push down on the flashback chamber to ensure it is tight. Remove the protective cover. Inspect the catheter and needle for any damage or contaminants. Spin the hub of the catheter to ensure that it moves freely on the needle Do not move the catheter tip over the bevel of the stylet. 7. Stabilize the vein and apply countertension to the skin. 8. Insert the stylet through the skin and then reduce the angle as you advance through the vein. 9. Observe for "flash back" as blood slowly fills the flash back chamber. 10. Advance the needle approximately 1 cm further into the vein. 11. Holding the end of the catheter with your thumb and index finger, pull the needle (only) back 1 cm with your middle finger. 12. Slowly advance the catheter into the vein while keeping tension on the vein and skin. 13. Remove the tourniquet. 14. Secure the catheter by placing the Tegaderm over the lower half of the catheter hub taking care not to cover the IV tubing connection 15. Occlude the distal end of the catheter with the 3rd, 4th and 5th fingers of your non-dominant hand. 16. Secure the catheter hub with your thumb and index finger and carefully remove the needle. 17. Place the needle into the sharps container. 18. Remove the cover from the end of the IV tubing and insert the IV tubing into the hub of the catheter. 19. Secure the tubing to the catheter by screwing the Luer Lock tight. 20. Open up the IV roller clamp and observe for drips forming in the drip chamber. 21. Check that the IV is infusing into the vein by occluding the vein distal to the catheter and observing that the drips stop forming and then restart once the vein is released. 22. Adjust the IV drop to keep the vein open rate (TKVO) of approximately 30 - 60 mL/hr (one drop every 5 - 10 seconds for 10 gtts/mL solution set). 23. Place a piece of tape over the catheter hub. 24. Make a small (kink free) loop in the IV tubing and place a second piece of tape over the first (piece of tape) to secure the loop. 25. Place a third piece of tape over the IV tubing above the site. 26. Ensure that the IV is properly secured and infusing properly. 27. Ensure that all "sharps" are placed in the sharps container. Lung Cancer Etiology and Pathophysiology Altered DNA alters cellular replication; may be primary or metastatic; often metastasizes to lymph nodes, bone, brain before diagnosis Types: Adenocarcinoma, small cell (oat cell), large cell (undifferentiated), and squamous cell carcinoma Risk Factors

 Smoking, heredity, intake of fruits and vegetables Exposure to asbestos or radon Signs and Symptoms Dry, chronic cough; hoarseness Weight, lymphadenopathy Sputum positive for cytology Chest x-ray indicates lesion and possible effusion Biopsy indicates source (primary or secondary) Treatment Lobectomy, pneumonectomy Chemotherapy, radiation, palliative care (pain) Nursing Management Lobectomy: Manage chest tubes Pneumonectomy: Place on operative side Chemotherapy: Manage side effects; hospice prn Drug Toxicities Labels: antidote, drug action, Drug Toxicities, normal range, nursing management, sign and symptoms, toxic levels Digoxin 2 Lithium 2 Aminophylline 20 Dilantin 20 Acetaminophen 200

Digoxin Brand Name: Lanoxin Toxicity: 2 Normal Range: 0.5-1.5 meq/L Indication: Congestive Heart Failure Classification: Cardiac Glycoside Mechanism of Action: Increase force of Myocardial Contraction Increase force of Cardiac Contraction Increase Cardiac Output Nursing Management: Check Apical Pulse Rate HR < 60bpm- Notify the Physician

S/S: Anorexia Nausea and Vomiting Diarrhea Confusion Photophobia Xantopsia

Antidote: DIGIBIND

Lithium Brand Name: Lithane Toxicity: 2 Normal Range: 0.6-1.2 meq/L Indication: Bipolar Disorder (Anti-Manic) Mechanism of Action: Decrease ACTH Decrease Norepinephrine Decrease Serotonin Nursing Management: Force Fluid (2-3 L) Increase Sodium Intake (4-10 g/daily to prevent dehydration)

S/S:

 Anorexia Diarrhea Dehydration Hypothyroidism Fine Tremors

Aminophylline/Theophylline Brand Names: Elixophyllin Toxicity: 20 Normal Range: 10-19meq/100ml Indication: COPD Classification: Bronchodilator Mechanism of Action: Bronchodilator- dilates the bronchial tree thereby allowing more air to enter the lungs. Nursing Management: Avoid Caffeine S/S: Tachycardia CNS excitability Irritability and Agitation Restlessness Tremors

Dilantin/Phenytoin Toxicity: 20 Normal Range: 10-19 meq/L Classification: Anti-Convulsant Mechanism of Action: Suppresses the paroxysmal electrical activity that makes up focal lesions. Blocks post-tetanic potentiation (PTT). PTT is an important mechanism in the development of high frequency trains of impulses in excitatory brain circuits; the spread of this activity to adjacent neurons and propagation to distant neuronal aggregates results in uncontrolled spread of excitation of the whole brain leading to a tonic-clonic seizure. Nursing Management: It is only mixed with 0.9 plain NSS or NaCl to prevent crystals or precipitate. Given via: Sandwich Method Instruct client to avoid alcohol- CNS depression, may lead to seizure. S/S: Gingival Hyperplasia Instruct client to massage his gums Hairy Tongue Ataxia (+) Rhombergs Test Nystagmus Acetaminophen Brand Name: Tylenol Toxicity: 200 Indication: Osteoarthritis Classification: Anti- Narcotic Analgesic Mechanism of Action: Acetaminophen is used for the relief of fever as well as aches and pains associated with many conditions. Relieves pain in mild arthritis but has no effect on the underlying inflammation, redness, and swelling of the joint.

S/S:

Jaundice Abdominal Pain Vomiting

Antidote: Acetylceisteine Nursing Management: Prepare suction apparatus. Pain Assessment (Pnemonics) Labels: NCLEX Pain, Nursing Care, Nursing Pain, Nursing Pnemonics,Pain Assessment, Pain response

P: Provokes/point. What causes the pain? Point to the pain?

Q: Quality. Is it dull, achy, sharp, stabbing, pressuring, deep, etc.?

R: Radiation/relief. Does it radiate? What makes it better/worse?

S: Severity/S&S. Rate pain on 110 scale. What S&S are associated with the pain (dizziness, diaphoresis, dyspnea, abnormal VS)? T: Time/onset. When did it start? Is it constant or intermittent? How long does it last? Sudden or gradual onset? Frequency?

Nursing Care

Assess pain: Use tools/scales

Provide comfort: Positioning, rest

Validate pts pain: Accept that pain exists

Relieve anxiety/fears: Answer questions, provide support

Teach relaxation techniques: Rhythmic breathing, guided imagery

Provide cutaneous stimulation: Backrub, heat and cold therapy

Decrease irritating stimuli: Bright lights, noise, room temp

Use distraction (for mild pain): Soft music; encourage TV/reading

Provide pharmacologic relief: Administer meds as ordered

Evaluate pt response: Document; modify plan Nursing Equivalents Tip: Memorize, memorize equivalencies. When using the metric system, remember the rules for moving the decimal. If you know one equivalent within a system, then you can use ratio and proportion to solve conversions. The ideal is to avoid the apothecary system. The metric system is the ideal system for measurements. 1 kilogram (kg) 2.2 pounds (lb) 1 pound (lb) 1 kilogram (kg) 1 gram (g or gm) 1 milligram (mg) 1 gram (gm) 1 cc (cubic centimeter) 1 inch (in) 1 grain (gr) 1 (household) cup 8 ounces (oz) 16 ounces (oz) 1 ounce (oz) 1 teaspoon (tsp) 1 dram 1 tablespoon ( T or tbs) 453.6 grams (g or gm) (use 454) 1000 grams (g or gm) 1000 mg (milligrams) 1000 micrograms (mcg, but should always be written out to avoidtranscription errors) 1 ml (milliliter) [Preferred term] 1 ml (milliliter) 2.54 cm (centimeters) 60 mg (milligrams) 240 ml (milliliter) 1 (measuring) cup 1 pint (pt) 30 ml (milliliter) 5 ml (milliliter) (not 4-5) 4 ml (milliliter) [archaic use] 15 ml (milliliter)

2 tablespoons (T or tbs) 3 teaspoons (tsp) 1 teaspoon (tsp) 1 milliliter (ml) 1 milliliter (ml) 1 liter (L) 37.0 C (Centigrade degrees)

1 Ounce 1 tablespoon ( T or tbs) 75 gtt (drops) 16 minims (not 15-16) 15 gtt (drops) 1000 ml (milliliter) 98.6 F (Fahrenheit degrees)

Pneumonia Labels: interventions for pneumonia, Nursing management of pneumonia,Pneumonia

Etiology and Pathophysiology

Microorganisms from upper airway/blood, aspiration of food/gastric contents inflammation (exudate and WBCs into alveoli) consolidation,ventilation, and diffusion Aerosolized or droplet transmission

Risk Factors Age, smoking, immunosuppression Winter (Streptococcal pneumonia), summer and fall (Legionella)

Signs and Symptoms T and WBC, adventitious breath sounds, cough, sputum (character depends on organism) Chest x-ray indicates patchy or lobe consolidation or infiltrates

Treatment Antibiotic regime based on organism Replace fluid losses secondary to T and R

Nursing Management Chest PT, if ordered; fluids Teach transmission (hand washing, tissue disposal) Teach need to finish med regime to recurrence or resistance Nursing Precautions Labels: airborne, contact precaution, droplet, June 2008 Nursing Board Exam Hot topics, NCLEX, Nursing Precautions, Standard precaution. transmission based precaution

STANDARD PRECAUTIONS

Perform hand hygiene before and after care and when soiled; most important way to preventinfection Use personal protective equipment (PPE) if touching, spilling, or splashing

of blood or body fluids is likely; use gloves, gowns, mask, goggles, shields, aprons, head and foot protection Discard disposable items in fluid-impermeable bag and contaminated items in Biohazard Red Bag Do not recap used needles; dispose in sharps container Hold linen away from body; place in impermeable bag in a covered hamper; do not let hampers overflow Place lab specimens in a leak-proof transport bag without contaminating the outside; label with biohazard sticker and patient information Institute procedure for accidental exposure: Wash area, report to supervisor, receive emergency care, seek referral for follow-up Receive hepatitis B vaccine Assign patient to private room if hygiene practices are unacceptable Avoid eating, drinking, touching eyes, applying makeup in patient areas

Transmission-Based Precautions

AIRBORNE Used for microorganisms that spread through air (droplet nuclei 5m [e.g., TB, measles, chicken pox]) Private room; negative air pressure room; door closed; high-efficiency disposable mask (replace when moist) or particulate respirator (e.g., for TB); transport patient with mask, teach to dispose soiled tissues in fluidimpervious bag at bedside

DROPLET Used for microorganisms spread by large-particle droplets (droplet nuclei 5m, (e.g., pneumonia [streptococcal, mycoplasmal, meningococcal], rubella, mumps, influenza, adenovirus) Private room if available or cohort pts, mask when within 3ft of pt, door open, mask for pt when transporting, teach to dispose soiled tissues in fluid-impervious bag at bedside

CONTACT Used for organisms spread by direct or indirect contact; methicillinresistant S. aureus (MRSA), vancomycin-resistant enterococcus (VRE), vancomycin intermediate-resistant S. aureus (VISA); enteric pathogens (e.g., E. coli, C. difficile), herpes simplex, pediculosis,hepatitis A and E, varicella zoster, respiratory syncytial virus Private room or cohort pts; gowns, gloves over-gown cuffs; dedicate equipment

TRACHEOSTOMY TUBES Definitions: TRACHEOTOMY: Incision made below the cricoid cartilage through the 2nd-4th tracheal rings TRACHEOSTOMY: The opening or stoma made by this incision. TRACHEOSTOMY TUBE: Artificial airway inserted into the trachea during tracheotomy INDICATIONS FOR TRACHEOSTOMY Bypass acute upper airway obstruction. Chronic upper airway obstruction. Facilitate weaning from mechanical ventilation by decreasing anatomical deadspace. Prevention / treatment of retained tracheobronchial secretions. Prevention of pulmonary aspiration. COMPONENTS OF TRACHEOSTOMY TUBE 1. Outer tube

2. Inner tube: Fits snugly into outer tube, can be easily removed for cleaning. 3. Flange: Flat plastic plate attached to outer tube - lies flush against the patients neck. 4. 15mm outer diameter termination: Fits all ventilator and respiratory equipment. All remaining features are optional 5. Cuff: Inflatable air reservoir (high volume, low pressure) - helps anchor the tracheostomy tube in place and provides maximum airway sealing with the least amount of local compression. To inflate, air is injected via the... 6. Air inlet valve: One way valve that prevents spontaneous escape of the injected air. 7. Air inlet line: Route for air from air inlet valve to cuff. 8. Pilot cuff: Serves as an indicator of the amount of air in the cuff 9. Fenestration: Hole situated on the curve of the outer tube - used to enhance airflow in and out of the trachea. Single or multiple fenestrations are available. 10. Speaking valve / tracheostomy button or cap: Used to occlude the tracheostomy tube opening (a) former - during expiration to facilitate speech and swallow, (b) latter - during both inspiration and expiration prior to decannulation. BEDSIDE EQUIPMENT Every patient with a tracheostomy tube should have the following equipment available at the bedside: Spare tracheostomy tubes Same size and type as patient is wearing. Smaller size Tracheal dilator. Suctioning equipment Suction machine fitted with filter; suction tubing; suction catheters (see suctioning page for sizes); gloves (as below); bottle of sterile water to rinse tubing - change daily. Ensure equipment is assembled and working properly. Humidification equipment Equipment depends on method used - see humidification page. Ensure equipment is assembled and working properly. Gloves Non-sterile ** Sterile gloves (for suctioning) Infectious waste bag Dry clean container for holding the speaking valve, occlusive cap/button or spare inner cannula when not in use. (Get from theatre) **Natural rubber latex gloves to be used by all except those who have latex allergy. Nitrile gloves to be used by those with latex allergy. CARE OF THE INNER CANNULA, STOMA SITE AND TRACHEOSTOMY TIES Purpose: 1. To maintain a patent airway. 2. To prevent infection. 3. To maintain skin integrity. 4. To prevent tube displacement FREQUENCY OF CLEANING Inner Cannula: 1.Check every shift 2.Clean PRN Stoma: 1.PRN to keep clean and dry Ties: 1.PRN to keep clean and dry EQUIPMENTS FOR STOMA CARE 1. Dressing trolley Dressing pack 2. Pair of sterile gloves Unsterile gloves 3. Normal saline solution Scissors 4. Lyofoam dressing Suctioning equipment 5. New trach. ties 6. Infectious waste bag (Sterile pipe cleaners - single use only) To check inner cannula: -Wash hands. -Wearing a non-sterile glove, -remove inner cannula. -Handle only the outer portion of the cannula. -If clean, reinsert and lock into place. -If soiled - continue with step (d) below. (a) Wash hands. (b) Wearing unsterile gloves remove and dispose of the soiled dressing. (c) Wash hands. Put on sterile gloves. (d) First, remove and clean the inner cannula using sterile pipe cleaners and normal saline. Dry. Reinsert. (e) Secondly, clean the stoma site using gauze and normal saline. Pat dry. Apply lyofoam / keyhole dressing if necessary. (f) Lastly, if ties are soiled and need changing, have a second nurse hold the tracheostomy tube securely in place, remove and replace tracheostomy ties. (Leave 1 finger space between ties and the patients neck.) (g) Ensure patient comfort. (h) Discard of used equipment as per hospital policy. (i) Wash Hands. (j) Document procedure in the patients notes. Note: Leave first dressing intact for 24hrs if possible as the tracheostomy is a fresh wound.

SUCTIONING VIA A TRACHEOSTOMY TUBE

Purpose: To maintain a patent airway by removing endotracheal secretions. FREQUENCY OF SUCTIONING 1. Suctioning is performed only as needed 2. Be aware that suctioning will be needed more frequently in the immediate post-operative period WORKING OUT SUCTION CATHETER SIZE Size of trach. tube (mm) x 3 2 E.g. 8 x 3 = size 12 suction 2 catheter Instructions: (a) Explain the procedure to the patient - wash hands, put on gloves. Put on apron and fluid shield mask if necessary for standard (universal) precautions). Turn onsuction apparatus and test that vacuum pressure is < -150mmHg. (b) Open / expose only the vacuum control segment of the suction catheter and attach to the suctiontubing. (c) Put on disposable sterile gloves over the non-sterile gloves and withdraw the sterile catheter from the protective sleeve. (d) Maintaining sterility, insert the suction catheter with NO suction applied until resistance is met, then pull back about 1-2 cms before applying continuous suction as the catheter is smoothly withdrawn from airway. NOTE: Recommended suction time (i.e. from insertion to removal of suction catheter) = <15secs -Use a new sterile catheter for each suction pass. -No more than 3 passes recommended per treatment. (e) On completing procedure, ensure patient comfort, discard of equipment as per hospital policy, wash hands and document procedure in the patients notes.

HUMIDIFICATIONOF INSPIRED GASES Purposes: 1. To prevent drying of pulmonary secretions. 2..To preserve muco-ciliary function. NOTE: All patients with tracheostomy tubes require humidification of inspired gases. CHOOSING METHOD A) HEATED HUMIDIFIERS - Recommended for: patients with new tracheostomy tubes dehydrated patients immobile patients patients with tenacious secretions B) HEAT MOISTURE EXCHANGE FILTERS - Recommended for: patients that are adequately hydrated mobile patients Not suitable for patients with copious secretions C) NEBULIZERS - nebulized normal saline is effective in helping to loosen secretions and soothing irritable airways. EQUIPMENTS NEEDED A) * Heating unit, * Sterile water , * Oxygen tubing, * Tracheostomy mask. B) * Heat moisture exchange filter * Oxygen tubing to fit filter if O2 therapy requested C) * Nebulizer * Oxygen tubing * Sterile saline The method used for humidification can be altered as the patients condition changes Do not combine methods - use one at a time. . NURSING MANAGEMENT HEATED HUMIDIFERS Set up as per operators manual. Monitor temperature of inspired gases. This is easily achieved if the system used has a digital temperature display. If it does not, then test the temperature by holding the oxygen tubing against a clean bared inner arm. Gas flow should feel at body temperature. Monitor water level and change bottles PRN. If condensation collects in tubing, - drain tubing into a sterile jug and dispose of into sluice. Using clean technique, change all tubing weekly. (Date tubing when changed)

HEAT MOISTURE EXCHANGERS Change daily and PRN to keep clean and dry. (Swedish noses/thermovents can be easily coughed off - apply new Swedish nose each time this happens). Discard of soiled Swedish noses in infectious waste.

NEBULIZERS Administer as prescribed. Wash in warm soapy water, rinse and dry thoroughly after each treatment. CARE OF CUFFED TRACHEOSTOMY TUBE Immediately post-operatively - to prevent aspiration of blood or serous fluid from the wound INDICATIONS FOR CUFFED TUBE To seal the trachea during mechanical ventilation To seal the trachea during swimming! To prevent aspiration of leakage from

tracheo-oesophageal fistula To prevent aspiration due to laryngeal incompetence

NURSING MANAGEMENT It is unusual for ward patients to need their cuff inflated.

Tracheostomy cuff is inflated only - (a) if the patient is being mechanically ventilated, (b) if inflation is specifically ordered by doctor. Check with doctor that it is OK to do so , and then proceed with cuff deflation......

Patients can be extremely sensitive to changes in cuff pressure. A little coughing is not unusual during manipulation. Take care to explain the procedure to the patient and to inflate / deflate the cuff slowly.

To deflate cuff: First, suction the oropharynx to remove any secretions that may have pooled on top of the inflated cuff. Then, using a syringe, slowly aspirate air from the air inlet port. Once deflated, expiratory noises may be heard as air passes up around the tracheostomy tube. Reassure the patient that these are normal and will settle.

To inflate cuff: Inject approximately 5-7mls of air via the air inlet port to achieve airway seal. A one-way valve system prevents injected air from escaping. NOTE: If used correctly, there is no need for low pressure cuffs to be deflated ever hour. (Powaser et al 1976, Bryant et al 1971) Cuff pressures can be measured by using a spirometer attached to the air inlet port of the tracheostomy tube. Recommended cuff pressure is <25mmhg.> CARE OF FENESTRATED TRACHEOSTOMY TUBE USES OF FENESTRATED TUBES 1. To facilitate / improve speech - The fenestration (hole) allows increased volumes of air to be forced up through the larynx during exhalation. 2. To improve swallow function - Restoring more normal airflow restores some of the protective mechanisms of normal swallow.

NURSING CONSIDERATIONS WHEN USING FENESTRATED TUBES. A fenestrated tracheostomy tube can only function as such if both the outer and inner cannulas contain a fenestration (hole)!

The fenestration allows secretions as well as air to pass up and down the patients airway. If needed, give the patient a sputum container or tissues and bag for secretions.

Speaking: Speech is facilitated by inserting the fenestrated inner cannula, and occluding the tracheostomy tube opening by using one of the following: (CUFF SHOULD BE DEFLATED) a) the patients finger b) a speaking valve c) a decannulation plug / cap / button. Suctioning: If suctioning is required, change to a non-fenestrated inner cannula. This is to prevent the suction catheter passing through the fenestration and traumatising the delicate lining of the posterior tracheal wall. Eating: While using a fenestrated tube restores some of the normal swallow protection mechanisms, nurses should be aware of and observe for signs of aspiration. Swallowing is further improved by having the cuff deflated and the tracheostomy opening occluded at the moment of swallow methods outlined above. Cleaning of a fenestrated inner cannula is the same as for non-fenestrated tube. Store cleaned speaking valve, cap and spare inner cannula in a sealed, clean, dry container at the patients bedside (specimen containers available from theatre). CARE OF PASSY MUIR SPEAKING VALVE

HOW IT WORKS The speaking valve contains a movable plastic disc that opens on inspiration but closes on expiration. This means that during expiration no air can escape through the tracheostomy tube opening. It is redirected up through the larynx instead.

CLEANING INSTRUCTIONS -Clean daily - as per inner cannula or Wash in soapy water. -Rinse thoroughly in cool-tepid water (not hot). -Air dry. -WHILE WEARING THE VALVE, THE PATIENT WILL NOTICE. Air exhaling via the nose and mouth.

 Speech is improved, full sentences are possible. Expectoration returns to the normal route, i.e. the oral cavity. Patients are able to blow their nose/sneeze Oral + nasal secretions lessen because of evaporation of secretions as air is exhaled. Occassional dryness of mucosa may occur. Lung backpressure - normal feeling of Energy levels may increase. Strong coughing may blow off valve. restored volume - may take getting used to.

NURSING CONSDERATIONS WITH THE PASSY MUIR VALVE.

To use the valve the tracheostomy cuff should be deflated (see page on cuff care) To use the valve patients should also be medically stable, and have enough pulmonary compliance to exhale around the tracheostomy tube, and out through the nose and mouth. Stay with the patient during first wearing. (i.e.5-10mins or until patient is confident wearing valve). Increase wear-time as tolerated. Ensure patient has a sputum container or tissues and bag for orally expectorated secretions. Increased mouthcare is necessary if the patient experiences dry mouth. Assess the patients work of breathing. Observe for adequate exhalation - so that stacking of breaths is avoided Tuberculosis (TB) Labels: Nursing management of Tuberculosis, PTB, Pulmonary tuberculosis,TB, Tuberculosis, Tuberculosis Nursing

Etiology and Pathophysiology Mycobacterium tuberculosis granulomas of bacilli that become fibrous tissue mass (Ghon tubercle) that can calcify or ulcerate and free bacilli Miliary TB: Bacilli may travel to bone, kidneys, or brain Risk Factors Immune response (HIV, steroids), crowded living conditions Alcoholism, malnutrition Signs and Symptoms Night sweats, weight, cough, hemoptysis +PPD/Mantoux of 10mm induration indicates immune response +Chest x-ray, acid fast bacteria in sputum Treatment Combination of antituberculars for 6-12mo Prophylactic INH for exposure Nursing Management Use airborne precautions during active disease Teach need for long-term compliance with meds Urolithiasis (Kidney Stones, Calculi) Pathophysiology Urinary stasis or chemical environment that precipitation andcrystallization of minerals. Stones form, which obstruct the ureter andresult in hydroureter and hydronephrosis Components of calculi vary: Calcium with phosphorous or oxalate (75%), uric acid (10%), struvite (15%), or cystine (1%) Stones can recur Risk Factors 30-50yr, male gender, dehydration, diet with dairy and vitamin D UTIs (struvite), hyperparathyroidism (calcium), gout and myeloprolificdisease increase uric acid Signs and Symptoms Pain; depending on stone location, may have little or no pain ranging tosevere pain radiating from flank to bladder or genitals

 N&V, hematuria, pallor, diaphoresis, UTI Treatment Opioids, NSAIDs, hydration Lithotripsy (extracorporeal shock wave, percutaneous ultrasonic, or laser) Calcium stones: ammonium chloride to acidify urine, thiazide diuretics Uric acid stones: allopurinol, urine pH Diet based on stone composition Nursing Management Monitor S&S, strain urine, fluids to 3-4L daily Control pain Calcium stones: Acid ash diet with dairy, protein, and sodium intake Uric acid stones: Alkaline ash diet with purine (organ meat) intake Oxalate stones: Tea, spinach, nuts, chocolate, and rhubarb intake