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3611 Final Study Guide

Inflammation and immune response: Chp 19

Self-tolerance- ability to recognize normal body cells so they arent destroyedalong with invaders, only immune cells are capable of determining self by

proteins on membrane 5 manifestations of inflammation- natural immunity, provides immediate

protection against the effects of tissue injury and invading foreign proteins,immediate but short-term, nonspecific; start antibody-mediated and cell-mediatedactions to activate a full immune response; infection is accompanied byinflammation but infection can occur without it and inflammation does not alwaysmean infection is present.1) Pain2) Erythema3) Swelling4) Warmth

5) Loss of functionAll is caused by the three steps of the inflammatory responseStage I- constriction of vesslesStage II- (basophils)- increased blood flow, neutrophil production, edema andtenderness, formation of pussStage III- repair

Types of immunity:o Innate- born with- natural killer cells, mucous, skino Acquired is active or passive

Active- natural through exposure (chicken pox) & artificial (fromvaccines)

Passive- through breast milk, lasts 3 to 6 months Immunizations- artificial active immunity, created from dead and live viruses Immunoglobulin shots- artificial passive immunity, from antibodies produced by

another person or animal; tetanus, rabies, snake bites

Transplant medications-o Maintenance therapy- continuous immune suppression after transplant

Cyclosporine/Sandimune, azathioprine/Imuran,mycophenolate/CellCept, plus a steroid such as prednisone

o Rescue therapy- treats acute rejection episodes Antilymphocyte globulin, Muromonab

HIV/AIDS and End of Life:

Precautions- The best prevention for health care providers is the consistent useof standard precautions for all clients as recommended by the CDC.

Assessment findings in HIV + patients- n/v/d/weight loss, cough, night sweats,lymph, fatigue, fever, mental status change, dry skin, rashes, lesions, pain,discomfort

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o May not have any s&s or may have flu-like or lymph node swelling

How to prevent spread- Maintain standard precautions, Consider all blood andbodily fluids to be contaminated, Avoid contaminating outside of container whencollecting specimens, Do not recap needles and syringes, Cleanse work surface

areas with appropriate germicide, Clean up spills of blood and body fluidimmediately, Follow CDC recommendations for immunization of health careworkers

Patient teaching to prevent infections in AIDS patients- opportunistic infectionstake advantage of suppressed immune systems; teach pt to wash hands, a

Physical symptoms of impending death- pain, dyspnea, angina, nausea,vomiting, fatigue, weakness, distress, constipation, anorexia, delirium

Advanced directives- A document prepared by a competent individual specifyingwhat, if any, extraordinary actions the person would want when no longercapable of decisions about personal health care

Blood Transfusion: Checks before administering blood- compare the physicians prescription with

another RN and check the pts armband, examine the blood bag and compare toorderscheck Rh, expiration date, inspect color, for bubbles, cloudiness

Types of transfusions-o Red Blood Cell- anemia, trauma, surgery; for hemoglobin less than ,

check for compatibility, infuse for 2-4 hours, Rh + pts can receive Rh- butnot the other way

o Platelet- for pts who are actively bleeding, scheduled for invasive surgery,have thrombocytopenia, and below 20,000 platelet, dont use standardtransfusion sets, vital signs before at 15 min and after, pre-treat with

Benadryl and Tylenolo Plasma- fresh to replace blood volume, ABO compatibility required, infuse

over 30-60 minutes, pooled or single donors (single with history of febrileor allergy)

Needles less than 19 gauge with normal saline 0.9 NaCl

When complications occur stop transfusion immediately, attend to the pt and calldr

Oncology:

Biologic characteristics of normal cells: Have limited cell division Undergo apoptosis- death, 90-120 days Show specific morphology

Have a small nuclear-to-cytoplasmic ratio Perform specific differentiated functions

Adhere tightly together

Are non-migratory

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Grow in an orderly and well-regulated manner

Are contact inhibited Are euploid

Biologic characteristics of embryonic cells:

Have rapid and continuous cell division Do not respond to signals for apoptosis

Show anaplastic morphology- no differentiation Have large nuclear-to-cytoplasmic ratio

Perform no specific (differentiated) functions

Adhere loosely together

Are able to migrate Are not contact inhibited

Are euploid

Commitment- day 8 in gestation

Benign cell growth: Continuous or inappropriate growth

Show specific morphology

Have a small nuclear-to-cytoplasmic ratio

Perform specific differentiated functions Adhere tightly together

Are non-migratory Grow in an orderly and well-regulated manner

Are euploid

Malignant cell growth: Demonstrate rapid or continuous cell division

Do not respond to signals for apoptosis

Show anaplastic morphology Have large nuclear-to-cytoplasmic ratio

Lose some or all differentiated functions Adhere loosely together

Are able to migrate Grow by invasion

Are not contact inhibited

Are aneuploidy

Risk factors for developing cancer:

80% of cancers are caused by external factors (also carcinogens) Chemical Carcinogenesis- air pollution, 30% tobacco use, drugs

Physical Carcinogenesis- radiation, chronic irritation, sunlight

Virus Carcinogenesis very few Dietary factors- high in red meat and fat, low in fiber; preservatives and nitrates

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Internal factors- immunosuppression, age, genetic predisposition

Primary intervention- removal or avoidance of causative factors; smoking cessation,removal of both breasts when only one is effected, vaccination, chemoprevention

Secondary intervention- screening for cancer or gene alteration; mammography,colonoscopy, CBE, PSA

Tertiary prevention- preventing secondary diseases/infections that are related toprimary diagnosis

Grading:

Describes how malignant the tumor is On the basis of cell appearance and activity compared to normal tissue

lowest-close to normal highest- G4

Gx- cannot be determined

G1- well differentiated and closely resemble normal cells they arose from G2- moderately differentiated and have few malignant characteristics

G3- poorly differentiated but tissue origin can be established, few normalcharacteristics

G4- retain no normal characteristics, difficult to determine origin

Staging:

Exact location of cancer and degree of metastasis at time of diagnosis

Clinical, surgical and pathologic- must have biopsy, tissue is the issue

TNM System- tumor nodes metastasis

Tumor growth= Doubling time- time it takes for tumor to double & Mitotic index-

% of dividing cells w/in tumor Metastasis is always stage 4

TNM-tumor nodes metastasis describe the anatomic extent of cancers, used forprognosis and treatment

Immune system during chemo:Nadir is the peak, when the WBC and bone marrow is the lowest; pt should watch forinfection and avoid crowds; dont give next chemo dose until WBC is back up, if gettingmultiple chemos you dont want nadirs at same time

Side effects of chemo: can give cytoprotectants to protect healthy cells Bone marrow suppression

o Bone Marrow Depression is the MOST serious side effect!!!!!o Neutropenia- 5,000-10,000o Thrombocytopenia- 150,000-400,000o Anemia- fatigue, sob, weakness- hgb- 14-18 RBC- 4.7-6.1 & 4.2-5.4o Know drugs for colonization

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Biologic response modifiers (BRMs) are defined as agents thatmodify the clientss biologic responses to tumor cells with beneficialresults

Cytokines and interlukens

Nausea and vomiting

o zofran, give 30 minutes before to allow time to work Mucositis/Stomatitis

o Adequate oral hygiene with soft bristle brushes and rinsing in betweeno Run toothbrush through the dishwasher daily

Alopecia- 4-6 weeks to grow backo Disturbed body image- plan ahead with wigs and scarfs; teach pt to avoid

sun

Changes in cognitive functiono More common with aggressive treatment, support the pt, warn the pt

before

Peripheral neuropathy

o Priority- prevent injury and falls Fatigue is biggest complaint

o Teach pt to spread out activities and rest between

Chemo on child-bearing years:

The pt should avoid becoming pregnant during treatment

Chemo is a teratogen

Men can sperm bank and women can freeze eggs

Extravasation- when a line with chemo becomes infiltrated, STOP THE IV

Causes pain, infection, and tissue loss Prevention is a priority, monitor the IV site Nurse needs to protect herself when giving chemo and when handling excreta

Vesicants-o Antitiumor antibiotics- Dantiomycin, Mitoxantrone (end in icin)o Antimitotics- Vincristine (stat with vin)

Nursing care of immunosuppressed:

Place the client in a private room

Use good hand-washing before touching the client or belongings

Room and bathroom cleaned at least daily No supplies from common areas

Limit personnel caring for client

Monitor V/S qhr for 4 hrs; temperature elevation

Inspect mouth q 8 hrs Inspect skin & mucous membranes (especially anal area) for fissures & abcesses

at least q 8 hrs

Inspect open areas, such as IV sites, q4 hrs for signs of infection

Change IV tubing daily

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Change wound dressings daily

Culture suspicious areas Cough & deep breathing exercises

Keep frequently used equipment in the room for use by client only

Limit visitors to healthy adults

Wear a mask to enter room Strict aseptic technique for invasive procedures Monitor WBCs: especially the ANC, daily

Avoid the use of indwelling catheters

Keep fresh flowers and potted plants out of the clients room Teach the client to eat a low-bacteria diet

Types of radiation:

External radiation/teletherapy Internal radiation/brachytherapy- pt is radioactive

o Unsealed- eliminated in waste products for 48 hourso Solid- implanted within or near a tumor, 2 to 3 dayso Nurses need to protect their self and limit time in room

Types of biopsies:

Hormone cancer treatment:Some hormones make tumors grow faster, decrease the amount of hormones to slowgrowth

Can cause opposite sex traits to grow- gynecomastia in men, hair in womenTissues?

Cancer Emergencies:

Sepsis and DIC- in leukemia, adenocarcinomas in lung, pancreas, stomach,prostate

SIDH- carcinoma in lung, brain tumors

Hypercalcemia- bone metastasis Tumor lysis syndrome- leukemia, lymphoma, lung, multiple myeloma

Breast Cancer:

Testicular- 15 to 34Breast- over 65

BSE- The goal of screening for breast cancer is early detection because breast self-examination cannot prevent breast cancer.

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Early detection reduces mortality rate.

Teach breast self-examination. Most breast lumps are found by the women themselves or by their sexual partner

Best time is a week after period ends (5-10 days after menses ends)

If not having regular periods, then BSE should be on the same day of the month

CBE-

every 3 years for women 20-39 every year for women 40 and over & for mammogram

American Cancer Society/Reach to Recover- breast cancer survivors that meet withpeople going through similar experiences, women whove had mastectomy

Psychosocial/Emotional support-

Is there someone to assist her with treatment choices, the pt should not go alone Is the patient in pain?

1) Fear of cancer2) Threats to body image, sexuality, intimacy3) Decisional conflict related to treatment options4) Uncertainty about treatment outcome and survival

Breast reconstruction:

Breast expanders- saline or gel used after surgery to lead to implants

Autologus- uses the pts own skin, fat, and muscle flap

Mastectomy-

Modified radical- muscle left intact; tissue, nipple, nodes removed

Simple- tissue and nipple removed; nodes left Lumpectomy with node dissection- only tumor and nodes are removed

HTN:Types of htn-

Malignant- > 200/150 rapid, morning ha, blurred vision, dyspnea, 30-50 yr old

Primary- no known cause; risk factors- family, ^ Na & calories, sedentary,African American, hyperlipidemia, caffeine, alcohol

Secondary- renal problems, primary aldosteronism, cushings,pheochromocytoma, aorta contraction, brain tumors, pregnancy, drugs- steroids,estrogen, decongestants

Pre-hypertension: 120-139/80-89Stage 1: 140-159/90-99Stage 2: >160/ >100

Lifestyle changes/diet to decrease HTN:

Sodium restriction- reduce packaged meals and fast food

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Weight maintenance

Reduce alcohol and stress Stop smoking

Exercise

Diet instructions in pts with hyperlipidemia:Low cholesterol, including cholesterol found in muffins and pastries

Types of blood pressure meds:

Calcium channel blockers- cardiazem & verapamil;

Beta Blockers- anteolol & metoprolol; erectile dysfunction, depression ACE inhibitors- lisinopril; cough

Diuretics- hctz- dehydration and hypokalemia; adolactone- hyperkalemia

Monitoring fluid volume in CHF:Weight is the best indicator

Left Sided Heart Failure: respiratory symptoms, usually begins with leftFirst system could be dyspnea on exertion, having to stop while walking up stairs

o Poor COo Resp- usually more than 20 breaths/mino Pulmonary congestiono Decreased tissue profusiono Fatigue (decreased O2)o Weakness (decreased O2)o Oliguria- nocturia

o Angina (decreased O2)o Palloro Weak peripheral pulseso Cool extremitieso OVERALL PULMOARY CONGESTION

o Hack/cough- worse at nighto Dyspneao Crackles/wheezeso Pulmonary edema- frothy pink sputumo S3/S4 gallop

Right Sided Heart Failure: systemic symptomsRight sided w/o left is usually a result of COPD or pulmonary hypertension

o Increased systemic venous pressureso JVT, hepatomegaly/splenomegaly, asciteso Dependent edema- feet/ankles- not best indicator of fluid retention. Weight is.o Bed rest edema- sacrumo Swollen hand/fingers- rings are tighter/ socks leave imprintso Weight gain- DW are best indicators

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o Poss. Increased BP- FVE/ poss. Decreased BP- due to failureo Anorexia/nauseao Polyuria- nocturiao OVERALL SYSTEMIC CONGESTION

Patient teaching CHF:MAWDS:

Medications:o Take meds as prescribed keep refills filledo Know why the drug is taken and side effects of eacho Avoid NSAIDs

Activity:o Stay as active as possible/ dont overdo ito Know your limitso Be able to keep a conversation while exercising

Weight:o Weigh each day at same time/ same scale/ same clotheso Monitor for fluid retention

Diet:o Limit sodium to 2-3 g/dayomit table salt and dont cook with it, dont use

condiments, dont eat pickled or smoked foodo Limit fluid to 2L/day

Symptoms:o New or worsening symptoms/ notify physician immediately

Respiratory:

Oxygen therapy:4 mL requires humidifierNasal canula for 1-2L, venturi mask is more preciseWill stop drive to breathe on pts who have emphysema or chronic hypoxemia

Thorancentesis:

A thoracentesis is the removal of pleural fluid/air from the pleural space.

Done for diagnosis or treatment.

Inform the pt. of a stinging upon administration of the anesthetic.

Stress the importance of NOT MOVING DURING PROCEDUCRE- risk for lungpuncture.

Ask about allergies to any anesthetics betadine/ shellfish etc. Procedure is generally performed at the bed side and a consent is imperative

prior to

Doc is responsible for getting that consent No more than 1000ml of fluid is pulled to prevent re-expansion pulmonary edema

If having a biopsy a second needle will be inserted.

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Follow up care: a chest x-ray is done to rule out pneumothorax or medialstinal

shift(THORACIC STRUCTURES SHIFT TOWARD ONE SIDE) Monitor vitals, auscultate esp the affected side.

Monitor dressings and site.

Promote deep breathing and coughing promoting expansion of lung.

Monitor for a PNEUMOTHORAX: lung collapse usually within first 24 hours.o Pain on affected side- worse at end of inhalation/exhalation.o Rapid heart rate, shallow respirations, air hunger, affected side doesnt

moveo Trachea pulled to affected side

Suctioning:

Wear protective gear/standard precautions

THIS IS A STERILE PROCEDURE Check suction and occlude till 80-120mm Hg is obtained Pre-oxygenate for 30sec-3 mins- need at least 3 hyperinflations/sync with

inhalation

Insert suction till resistance

Withdraw at a rate of 1-2cm and apply suction intermittently with a twirl motion

Only go 10-15 seconds Then hyperoxygenate for 1-5 mins

Repeat only up to 3 times

Reassess breath sounds post suctioning

SUCTIONING IS ONLY DONE UPON ADVENTAGEOUS SOUNDS/PRN

Pack year- # of packs X # of years

Fluid and Electrolyte: fluid sheet

Normal values:Na+- 135 to 145K+- 3.5 to 5Ca+- 8.5 to 10.5Phos- 3 to 4.5Mg+- 1.5 to 2Cl100 to 106

Most reliable indicators for fluid loss or fluid gain:Weight!Fluid overload- bounding and increased pulseDehdryation-fluids V/D, decreased intake, fever, infection, diabetes insidious,diaphoresis, surgery, NG

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Effects of edema on skin:More likely to develop pressure ulcers, risk for decreased skin integrity

IV solutions:

Normal saline- expand volume, KVO, dilute med, isotonicLactated ringers- fluid resuscitation, isotonicD5W- hypotonic, metabolizes glucose; not for peds or head injuryD51/2W- Na and volume replacement, hypertonic, go slow and monitor

Assessment for F & E imbalances:Daily weight, DTR, check lungs, edema, I&O

Thyroid/Parathyroid/Adrenal/Pituitary:

Thyroid storm: LIFE THREATENINGAcute exacerbation of S & S: maintain airwayFeverHeart failureShockHyperthermiaTachycardia, HypertensionConfusionSeizures Coma

Hyperthyroid: manifestations are called thyrotoxicosisDiaphoresis, thinning of hair, chest pain, tachycardia, weifht loss, increased

appetite, muscle wasting and weakness, blurred vision, tremors, insomnia, increasedmetabolic rate, heat intolerance, low-grade fever, decreased attention span,restlessness, manic behavior, increased libido, amenorrhea, goiter, decreased WBC,enlarged spleen

Txthionamides and beta-adrenergic blocking drugs, radioactive iodine for moresevere cases (decrease blood flow), thyroidectomy when drug therapy is unsuccessful

Hypothyroid: manifestations are a result of decreased metabolism from low levels ofthyroid hormone, most cases are a result of tx of hyperthyroid

Cool & dry skin, poor wound healing, bradycardia, decreased metabolism andcold tolerance, apathy, depression, decreased libido and prolonged menstrual periods,anemia, periorbital edema

Thionamides- reduces manifestations of hyperthyroidism by inhibiting the formation ofnew thyroid hormonesPropylthiouracil -prevents T4 to T3 and inhibits binding of iodide -q8h

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avoid ill ppl

report dark urine, jaundice, and bruising check for weight gain, brady, cold intolernace -reduce blood cell counts and

immune response

liver toxicity

Methimazole-Inhibits thyroid binding of iodide -q8h notify if become preg.

possible joint & muscle pain check weight gain, brady, cold intolerance

causes birth defectsLithium

(when pt cant take thionamide)

Inhibits release of hormones temporarily -q8h -drink 3-4 qts -check for weight gain, brady, cold int. -increase urine output and can cause

dehyd.

Iodine containing agents- Rapidly inhibits thyroid hormone release temp. resolves cardiac problems. Not

for long term 1h after thionamide

check for fever, rash, metallic taste, mouth sores, sore throat, gi distress -thionamide prevents initial hormone increase

I31- kills thyroid, will need synthroid

Iodine deficiency: causes hypothyroid; iodine added to salt

Removal of parathyroid:

Sometimes accidently removed during total thyroidectomy, damaged, or bloodsupply is impaired. Causes PTH levels to decrease and hypocalcemia.

Hypocalcemia- Tetany,Chvosteks Sign, Trousseaus Sign, circumoralparansthesia

Addisons:

primary, secondary- sudden cessation of long-term high-dose steroids, thebodies need for steroid becomes greater than what it can produce

Clinical- bronze pigmentation, hypoglycemia, postural hypotension, weight loss,weakness, changes in body hair distribution

Adrenal crisis- severe fatigue, dehydration, vascular collapse, renal shutdown,hyponatremia, hyperkalemia

Tx- steroid therapy and fluid replacement

Cushings: caused by over use of steroids

Clinical manifestations- hyperglycemia, thin skin, purple striae, GI distress fromincrease acid, moon face, gynecomastia, osteoporosis, fat deposits, increased

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susceptibility to infection, irritable, personality changes, edema from fluid andNa+ retention, amenorrhea and hirsutism in women

Tx- adrenalectomy, hypophysectomy

Corticosteroid therapy:

take with food, weigh daily or 3 X a week, monitor bp for hypertension, reports&s of weight gain, round face, fluid retention, edema, and report illness such assevere diarrhea, vomiting, and fever because they may need an increased dose.Causes hyperglycemia and must taper off.

Cortical hormones:

Anterior pituitaryo Growth hormoneo TSH- synthesis and release of thyroid hormones

Hyperthyroid hypothyroid

o ACTH-release of steroids (adrenal cortex) Hypo- addisons Hyper- cushings

Posterior pituitaryo Vasopressin/ADH

Hypo- diabetes insipidus Hyper- SIADH

Parathyroid Adrenal glands

o Adolsterone (mineralcorticoids) Hyperaldosteronism

o Adrenal medulla- catecholamines Pheochromocytoma

Removal of gland = will need hormones for life

Diabetes inspidious:

water metabolism problem caused by insufficient ADH

S&S- dehydration, thirst, dilute urine

Medication monitoring- IM or IV ADH can cause ulceration of the mucousmembranes, chest tightness, pulmonary inhalation.

Priority nursing- aimed at early detection of dehydration and maintaining

hydration monitor I&O, weight, specific gravity Teaching- lifelong desmopressin/vasopressin therapy for those with severe DI,

teach that polyuria and polydipsia are signals of needing another dose. Drugscan cause fluid overload and water toxicity. Teach pts to weight themselves dailyand report weight gain. Wear medical alert bracelet and notify provider of acuteconfusion or persistant headache.

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SIADH:

vasopressin is secreted even when plasma osmolarity is low or normal, inhibitsADH production and secretion. Water is retained resulting in hyponatremia.

Causes- head trauma, cancer, tb, cerebrovascular disease Tx- fluid restriction, monitor for overload, diuretics

Nursing- check for thrush as a result of antibiotico Provide safe environment when Na levels fallo Neurological assessment

Pituitary surgery:Hypophysectomy- surgical removal of the pituitary gland and tumor to treathyperpituitarism

Pre-op- do not brush teeth, cough, sneeze, blow nose, lean forward

Post-op- teach pt to report postnasal dripo Observe for CSF, LOC, ICP, and diabetes insipidus, decreasedo Vision and strength of extremities

o ICP- straining during bowel, bending over, coughingo CSF- halo effect, yellow/clear drainageo Decreased sensation and loss of smell for 3 to 4 monthso No tooth brushing for 2 weeks

Diabetes:

Diabetes mellitus: chronic hyperglycemia resulting from problems with insulinsecretion, insulin action, or both.

Diabetes Type 1:Autoimmune- beta cell destructionNO insulin, must take insulin, no oral medsS&S- weight loss, thirst, abruptYounger than 30Ketones

Diabetes Type 2:Insulin resistance, relative deficiency, secretory deficiencyPolyuria, polyphagia, polydipsia15 % familial

Patho- dysfunctional beta cells50, obese, no exerciseMay take orals and/or insulinSyndrome X- weight in midsection, high bp, cholesterol, sugar

Glucagon- counter regulator to insulin, causes release of glucose from cells whenglucose levels are low, prevents hypoglycemia

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Insulin- key to membranes for glucose, reaches liver first to promote the production andstorages of glycogen and inhibits glycogen breakdown into glucose (glycogenesis);increases protein and lipid synthesis; inhibits liver glycogenolysis, ketogenesis, andglucogenosis

Polyuria-results from osmotic diuresis caused by excess glucose in the urinePolydipsia- resulting from dehydration caused by polyuriaPolyphagia- cell starvation from lack of glucose

Insulin:

Rapid acting- 15 min onset, 2 hour peak, 5 hr duration

Short acting- 30-60 min onset, 2-4 hr peak, 5-7 duration Intermediate acting- 1-2 hour onset, 4-12 hr peak, 16-24 duration

Long acting- no peak, 2-4 onset, 24 duration

Insulin teaching:

Rotate site every week but never in the same exact area Dont give in legs before exercising Clear before cloudy

Oral antidiabetics: med sheet

Exercise:

Check blood sugar before, if over 250 check ketones

Ketones- no exercise Sugar less than 80 or greater than 250- no exercise

When blood sugar is excessive or when there is lack of insulin, sugar will

increase No insulin within 1 hour

Stay hydrated Will need extra snacks and carbs to compensate

Modifications of exercise:

Retinopathy- avoid valsalva maneuver

Neuropathy- non-weigh bearing exercise to prevent injury Autonomic neuropathy- be mindful of impaired temp control, impaired thirst,

orthostatic hypotension

Glucosuria:Excretion of glucose in the urineMust be over 220

Diet:

Protein- 15 to 20% (10% in nephropathy)

Carbs- 45 to 65% minimum of 130g a day

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Fat- less than 7%

Cholesterol- less than 200 mg Fish twice a week

Increase fiber gradually to 14 g per 1000 cals, sudden increase can causehypoglycemia, fiber improves carb metabolism and lowers cholesterol

Emotional stress, sickness, and injury can raise a persons need for insulin. Type 2 canhave ketones during stress or infection

Acute complications:

Diabetic ketoacidosis- sudden, kussmaul resp, sugar over 300, ketones, N/V/abpain

HHS- gradual, elderly type 2, dehydration, sugar over 600, confusion Hypoglycemia

Hypoglycemia: occurs when there is an abrupt decline in glucose levels either from toomuch insulin or lack of good, can occur when glucose drops a very high level to a highlevel (250 to 180)

S&S- sudden onset of hunger, diaphoresis, weakness, nervousness, heartpounding, headache, confusion, slurred speech, irritable, coma

Mild- < 60o Give 10-15 g of carbso Repeat in 10 minutes if still have symptoms, eat within 15-30 min.

Moderate-

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with dm have cardio disease. Prevent by reducing weight, intake of cholesterol,and saturated fats.

Cerebrovascular disease- Damages cerebrovascular circulation and is a riskfactor for stroke, hypertension, and other complications. Elevated glucose at thetime of stroke lead to greater brain injury and higher mortality. Keep glucose

within normal ranges.

Microvascular complications: more directly related to hyperglycemia

Eye and vision- legal blindness is 25 X more likely, retinopathy withneovascularization leads to hemorrhage and more vision loss due to poor eyecirculation. Hyperglycemia causes blurred vision. Hypoglycemia causes doublevision. Increased risk for glaucoma and cataracts. Hyperglycemia andhypertension increases rate of retinopathy in pts with type 1.

o Should have eye exams every year because retinopathy is directly relatedto duration of dm.

Diabetic neuropathy- progressive deterioration of nerves that result in loss of

nerve function. Sensory nerve damage can lead to chronic pain or loss ofsensation. Damage to motor nerves results in weakness. Damage to autonomicnerve fibers can cause dysfunction in every part of the body.

o Keeping glucose in normal ranges can delay the onset of neuropathy.o Medications- anti-seizure meds like Neurontin prevent nerve paino Proper foot care, shoes, and proper treatment for wounds.

Nephropathy- pathologic change in the kidney that reduces kidney function andleads to kidney failure. DM is the leading cause of renal failure. Earliest sign ismicroalbuminuria. Chronic hyperglycemia can cause hypertension in kidneyblood vessels and excess kidney perfusion. Hypertension greatly speeds theprocess of nephropathy.

o Low protein diet, teach importance of diet and compliance with meds Erectile dysfunction- occurs faster than in the general population; most men with

diabetic neuropathy have ED.

Foot care:

Inspect feet daily

Lotion to feet but not between toes

Leather closed toed shoes, alternating days

Dont smoke See dr asap for blisters, sores, infection

Check water with wrist (decreased sensation in feet)

Do not cross legs, wear garters or tight socks, soak feet

Musculoskeletal/connective tissue:

Cast care:

Neuro checks qhr for 24 hours, check for swelling, color, sensation

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Elevate extremity above heart on pillows, ice for 24 to 48 hours

Allows early mobilization and reduce pain by immobilizing the affected part Petaling- removes rough edges

Window to care for open skin keep piece to cover

Traction- pulling force to provide reduction, alignment, and rest; weights are prescribedand should be off the floor and not handled by cna; skin checks q8; painful musclespasms- try realigning pt first

Osteoarthritis:

Progressive deterioration of cartilage in one more joints, esp weight bearing

Risk factors- aging, obesity, smoking, trauma Prevention- normal body weight, dont smoke, avoid stressful activities like

jogging, wear supportive shoes, avoid risk seeking activities

Tx- nsaids, joint replacement, steroid shots, glucosamine, etc.

Hip replacement: Immobilize hip and align with thigh Keep hip at less than 90 degree angle

Early ambulation to prevent dvt- day after

Dislocation- acute pain, adduction, shortening

Infection can occur years later- acute pain

Check cap refill, distal pulses, sensation

H&h checked 1-2 days after

Compartment syndrome:

Assessment: swelling, erythema, disproportionate pain, decreased circulation Tx- fasciotomy; must be done w/in 4 to 6 hrs to prevent neuro damage

Fat embolism:

Confusion, tachypnea, petechiae on the chest, first sign is often decreased RR

Check airway and apply O2!

Osteomyelitis:

Surgery- for pts with chronic infection, sequestrectomy to debride necrotic boneand allow revasularization; neuro checks frequently bc swelling is normal;

amputation as a last resort May need PICC line Hyperbaric chamber to diffuse O2 into tissue to promote healing

May need oral abx after IV, take all of it!

Contact precautions for drainage Sterile dressing change and irrigation

Abx must penetrate the bone to be effective, abx beads or picc

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Osteoporosis:

Chronic metabolic disease, bone loss cause decreased density of bones causingfractures

High risk- women, white/Asian, slender, sedentary, alcohol, cigarettes, over 65,over 75 in men, low calcium, hormone deficiency

Prevention- adequate calcium and walking 30 min 3-5X a week, baseline dxa at35

Injury prevention- fall risk, move with bed sheet

Meds:o All prevent bone loss and increase densityo Evista- estrogen modulator, monitor liver function and teach signs of dvt

(60 mg)o Calcium carbonate/os cal- cost effective, take 1/3 dose at night, take

with full glass of water (1-1.5g)o Premarin (estrogen/progesterone)- can cause endo and breast cancer,

teach importance of gyno and breast exams, observe for dvt (1.25 mg to

2.5 mg)o Calcimar/calcitonin- alternate nares, monitor renal function and vit D

level, s.e.- n/v/ha/flushing (200 units)o Fosamax (bisophosphonates)- take on an empty stomach in the

morning, stay upright for 30 minutes, no food or water for 30 minutes, cancause esophagus problems

5 mg for prevention 10 mg for treatment

o Boniva is a bisophosphonate too- taken once a month

Rheumatoid arthritis:

Autoimmune disorder that attacks joints; joint stiffness in morning; Tx- nsaids

o Dmards- slow progression; strict bc and no alcohol, immunosuppression

SLE-

Chronic progressive ctd that can cause organs and sustems to fail

Spontaneous remission and flares Vasculitis- caused by inflammation and damage from immune complexes forming

serum in tissue

Scaly, red, inflamed rash on face

Pleural effusion/pneumonia, fever, fatigue, anorexia, joint inflammation, ab pain,

nephritis Aggressive treatment with immunosuppressive drugs Teach sunscreen and skin care with mild products

Bone cancer- increased calcium and ALP

Carpal tunnel:

Repetitive stress injury

8/2/2019 3611 Final

20/20

Positive phalens and tinels sign

Symptoms- numbness and tingling NSAIDs and splint

Surgery- relieve pressure on median nerve by nerve decompressiono When caused by RA- synovectomy- removal of excess synovium