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48 Hour Cram Sheets for Med Surg

BRAIN TUMOR

48 Hour Cram
Sheets for Med Surg

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48 Hour Cram Sheets for Med Surg
BRAIN TUMOR

Table of Contents
1. CANCER (ONCOLOGY) ...................................................................................................................... 7
BRAIN TUMOR...................................................................................................................................... 7
COLON CANCER.................................................................................................................................... 8
LEUKEMIA............................................................................................................................................. 9
OVARIAN CANCER .............................................................................................................................. 11
PROSTATE CANCER ............................................................................................................................ 12
PANCREATIC CANCER ......................................................................................................................... 13
2. NEURO: CNS ................................................................................................................................... 15
ALZHEIMERS ....................................................................................................................................... 15
BRAIN TUMORS .................................................................................................................................. 17
CEREBERAL VASCULAR ACCIDENT (CVA) ........................................................................................... 18
EPILEPSY ............................................................................................................................................. 20
HEAD INJURY ...................................................................................................................................... 23
MULTIPLE SCLEROSIS (MS)................................................................................................................. 24
MENINGITIS........................................................................................................................................ 25
PARKINSON’S ..................................................................................................................................... 26
SEIZURE .............................................................................................................................................. 27
SPINAL INJURY.................................................................................................................................... 30
3. NEURO: PNS ................................................................................................................................... 32
GUILLAIN-BAR SYNDROME ................................................................................................................ 32
MYASTHENIA GRAVIS ......................................................................................................................... 33
4. GASTRO INTESTINAL (Lower) ......................................................................................................... 36
APPENDICITIS ..................................................................................................................................... 36
SBO (SMALL BOWEL OBSTRUCTION) ................................................................................................. 37
CONSTIPATION ................................................................................................................................... 38
HERNIA ............................................................................................................................................... 39
PARALYTIC ILEUS ................................................................................................................................ 40
ISCHEMIC BOWEL/COLITIS ................................................................................................................. 41
VOLVULUS .......................................................................................................................................... 42
DIVERTICUITIS .................................................................................................................................... 43
RESECTION OF INTESTINES ................................................................................................................ 44

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48 Hour Cram Sheets for Med Surg
BRAIN TUMOR

INFLAMMATORY BOWEL DISEASE ..................................................................................................... 46


COLORECTAL CANCER ........................................................................................................................ 46
5. ORTHOPEDICS (BONES) .................................................................................................................. 48
HIP FRACTURE .................................................................................................................................... 48
TOTAL KNEE REPLACEMENT (TKR) ..................................................................................................... 49
LONG BONE INJURY ........................................................................................................................... 50
OSTEOARTHRITIS (OA) ....................................................................................................................... 51
RHUMATOID ARTHRITIS (RA) ............................................................................................................. 52
GOUT .................................................................................................................................................. 53
6. VASCULAR DISORDERS ................................................................................................................... 55
PAD (PERIPHERAL ARTERY DISEASE) .................................................................................................. 55
PVD (PERIPHERAL VASCULAR DISEASE) ............................................................................................. 56
ANEURYSMS ....................................................................................................................................... 58
7. RESPIRATORY ................................................................................................................................. 60
ASTHMA ............................................................................................................................................. 60
BRONCHITIS ....................................................................................................................................... 61
COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE) ................................................................... 62
EMPHYSEMA ...................................................................................................................................... 63
HEMOTHORAX ................................................................................................................................... 64
PNEUMOTHORAX............................................................................................................................... 65
PNEUMONIA ...................................................................................................................................... 66
PULMONARY EMBOLISM ................................................................................................................... 67
RESPIRATORY FAILURE ....................................................................................................................... 68
TUBERCULOSIS ................................................................................................................................... 69
URI (UPPER RESPIRATORY INFECTION) ............................................................................................. 70
8. CARDIAC (HEART) ........................................................................................................................... 71
ANGINA .............................................................................................................................................. 71
ARRHYTHMIAS ................................................................................................................................... 72
ACUTE CORONARY SYND. (ACS) ......................................................................................................... 73
ATRIAL FIBRILLATION (A-FIB) ............................................................................................................. 74
CARDIOGENIC SHOCK......................................................................................................................... 75
CABG (Coronary Artery Bypass Graft) ................................................................................................ 76

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48 Hour Cram Sheets for Med Surg
BRAIN TUMOR

CHF (Congestive Heart Failure) .......................................................................................................... 77


CAD (Coronary Artery Disease) .......................................................................................................... 78
HTN (Hypertension) ........................................................................................................................... 79
HYPERLIPIDEMIA (High Cholesterol) .................................................................................................. 80
9. ENDOCRINE .................................................................................................................................... 81
DIABETES TYPE I ................................................................................................................................. 81
DIABETES TYPE II ................................................................................................................................ 82
HYPOGLYCEMIA ................................................................................................................................. 83
HYPERGLYCEMIA ................................................................................................................................ 84
DIABETIC KETOACIDOSIS (DKA).......................................................................................................... 86
10. GALLBLADDER & LIVER & APPENDIX.......................................................................................... 87
APPENDICITIS ..................................................................................................................................... 87
CHOLECYSTITIS ................................................................................................................................... 88
HEPATITIS ........................................................................................................................................... 89
PANCREATITIS .................................................................................................................................... 90
CIRRHOSIS .......................................................................................................................................... 91
11. KIDNEY (RENAL).......................................................................................................................... 93
ACUTE RENAL FAILURE (ARF) ............................................................................................................. 93
CHRONIC RENAL FAILURE (CRF) ......................................................................................................... 95
CHRONIC RENAL INSUFFICIENCY........................................................................................................ 96
NEPHROTIC SYNDROME..................................................................................................................... 97
KIDNEY STONES .................................................................................................................................. 98
GLOMERULONEPHRITIS ..................................................................................................................... 99
TURP (Trans urethral resection of prostate) .................................................................................... 101
URINARY TRACT INFECTION (UTI) .................................................................................................... 102
BPH (Benign Prostate Hypertrophy) ................................................................................................ 103
12. WOMEN’s HEALTH ................................................................................................................... 104
UTERINE FIBROIDS ........................................................................................................................... 104
OVARIAN CANCER ............................................................................................................................ 105
13. Bibliography ............................................................................................................................. 106

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48 Hour Cram Sheets for Med Surg
BRAIN TUMOR

With over 8 years in the medical field, Mike Linares has worked both out in
the field on an Ambulance in the dangerous streets of Los Angeles County
and the in crazy busy the Emergency Rooms. Coupled with his passion for
teaching & desire to help other students and mixed with his chronic typpos
and bad grammmer, SIMPLEnursing.com was born to not only help his
fellow RN students, but nursing students worldwide.

"I hope you enjoy the valuable jewels that Simplenursing.com has to offer.
If so please let me know! I am a real person & I´d love to hear your
thoughts good or bad on Face book, Twitter, or Youtube."

Committed to Your Success, Mike

P.S.Feel free to Face book, Twitter, or Youtube me!!

Mike Linares
Student Nurse Mentor & Certified EKG Instructor

HOW THIS WHOLE THING CAME TO BE...


Before Helping Multiple Successful Nursing Students
Excel I Was The "Drone" Nursing Student Working Too
Hard & Eventually I FAILED OUT of Nursing School.

Before Helping Hundreds of Struggling Nursing Students Reach Graduation Day & Before Becoming a
Student Nurse Mentor & Certified EKG Instructor, I Myself Was A Struggling "At Risk" Student Nurse
Drowning In My Books & Lost In Clinical.
I was that struggling student working full time in the Emergency Room at one of those
MEGA hospitals in Orange, California. I worked as an EMT aka a "medic" for 8 years
prior to failing out. I knew how to take care patients, I knew the basics of the ABCs of
basic life support, I knew how to take vital signs and how to fix minor injuries. I thought I
had enough experience to skate right through nursing school, I remember thinking "how
hard can it be" right?
After two semesters, I FAILED out of the Program.

I felt defeated, depressed and like a loser. It was one of the lowest points of my life.

Sitting in my room practically bawling my eyes out, I remember quotes my mom and
dad used to encourage me with, "son, whatever doesn´t kill you, Makes you Stronger" &
" Failing is Not a Bad Thing, As long as learn, become better, and NEVER EVER QUIT"

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48 Hour Cram Sheets for Med Surg
BRAIN TUMOR

My Clinial FAILURE form had bold red letters stating:


LACK In Prepared
LACK Organizational Skills
LACK Critical Thinking with Nursing Process

Ending with:
"able to return next semester contingent upon demonstrating INCREASED
COMPETANCIES in these core areas."

"NEVER GIVE UP!!" my mom & dad used to tell me, so I set out on a Quest
to develop a system to make Simplify Nursing School!

What Happened Next Might Surprise you,

In a systematic way to put all the "core competencies" of nursing school that instructors look for to
pass students. My quest was to make it SIMPLE first and foremost, by cutting out the fluff and getting
down to the nitty critty making it easier.

The Goal Was To Make A Simple System...


And the best part is it was really helping myself and other students in my class pass their tests when I
would share with them my strategies and systems to help them pass their tests without having to
memorize everything in the book!

This is where my mentoring for student nurses began.


That's when something clicked and everything changed for me.

It was like I had an Ah - HA moment!

At that moment I realized there are better, more predictable, and more low cost ways to get higher test
scores and have more critical thinking skills than the money I had been spending on dead end study
books that claimed to help but really just confuse me more.

I needed simplicity!!!

Within the next six months I had created over 27 different student help systems, strategies and tactics
that produced better results for me - some better than others.

Then over the next few semesters I tracked, tested, and tweaked each system until my students were
passing with a 82% or better on each and every test, 2 students being out of School for over 25 years
& coming back to score 94% on their EKG cardiac test! Truly amazing & truly making me proud to be
their mentor.

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48 Hour Cram Sheets for Med Surg
BRAIN TUMOR
1. CANCER (ONCOLOGY)
DIAGNOSIS/PATHO DATA ACTION RESPONSE
BRAIN TUMOR Assess: Neurological status, ALOC, Nursing Interventions: Nursing Dx:
worsening symptoms/impairment, Pharm: **DEPENDS ON -Disturbed Body Image r/t
↑ICP SIZE & TYPE OF TUMOR, AS changes in the structure and
Patho: Defined as an intracranial solid
Vitals: Normal, until near death WELL AS OVERALL HEALTH function of the brain/body
neoplasm, or an abnormal growth of
S/S & PHYS. EXAM: STATUS: -Fear r/t recent diagnosis and
cells in brain or central spinal canal. No
- Headache - Chemotherapy unknown future
known cause or risk factor.
-Nausea/Vomiting Targeted therapy:
Graded as: low, intermediate or high
-ALOC/Changes in speech, vision or -Avastin/bevacizumab (for Pt. Goals/ Evaluation:
Can be located in several areas of the
hearing glioblastoma) -Pt will verbalize concerns and
brain: - Afinitor/everolimus (used
-Issues with gait, balance or walking fears about body, self
to treat a benign brain tumor)
-Changes in mood, personality, perception and change of
Alternative Medicine:
ALOC lifestyle
-Acupuncture
-Memory problems/inability to -Pt will verbalize anxiety as well
-Hypnosis
concentrate as ways to reduce it/minimize
-Music Therapy
- Seizures/Convulsions with it.
-Relaxation Techniques
-Muscle twitching/jerking
-Numbness/Tingling in extremities
Pt. Ed: Referral to OT, PT,
ST (Speech therapy) and
Labs: Spinal tap, biopsy
tutoring (if child, and
Dx Tests: Neurological exam, MRI,
learning/memory problems
-Healthy cells transform/mutate into CT Scan, Angiogram
Surgery: Removal of
malignant cells upon exposure to certain tumor (If able to)
etiologic factors such as: Viruses,
Chemicals, and Physical agents. When
cells are malignant, they can metastasize
into tissues surrounding the area, to the
lymph nodes and lymphatic system, the
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48 Hour Cram Sheets for Med Surg
COLON CANCER
blood, and system wide to other
organs/cavities.
(Most common types of brain
tumors/locations)
COLON CANCER Assess: Last Colonoscopy? Nursing Interventions: Nursing Dx:
RISK FACTORS: Pharm: Chemotherapy, -Anticipated loss of
-Older Adult men/women Radiation therapy, and physiological well-being r/t loss
Patho: Colon cancer occurs in the
-Race (African-American) Targeted drug therapy of body part, change in body
lower part of the digestive system.
-Genetic/Family history/Personal (bevacizumab/Avastin, function, change in lifestyle and
Cancer in the colon can begin as small
Hx cetuximab/ Erbitux, perceived potential death of
benign clumps in the colon, known as
-Diet high in red meat and fat and panitumumab/Vectibix and patient
adenomatous polyps.
low in fiber regorafenib/Stivarga) -Situational low self-esteem r/t
In time, these polyps can develop into
-Inflammatory bowel diseases disfiguring surgery,
colon cancer.
Pt. Ed: Maintenance of chemotherapy or radiotherapy
The American Cancer Society 7 Colostomy bag/care if side effects, e.g., loss of hair,
WARNING SIGNS for Cancer: needed, returning for nausea/vomiting, weight loss,
C – Change in bowel/bladder habits testing, side effects of anorexia, impotence, sterility,
A – A sore that that doesn’t heal meds/ colostomy bag, overwhelming fatigue,
U – Unusual Bleeding/Discharge support system uncontrolled pain
T – Thickening/lumps in
breast/body Surgery: Removal of Pt. Goals/ Evaluation:
I – Indigestion/Difficulty swallowing polyps (If possible), Partial -Pt will continue daily activities,
O – Obvious change in wart/mole Colostomy, Full identify feelings and fears
N - Nagging, coughing or colostomy/surgical removal towards lifestyle change and
hoarseness diagnosis, Pt will understand
and verbalize the grieving and
Vitals: Normal unless distressed death process
-Healthy cells transform/mutate into S/S & PHYS. EXAM: - Pt will verbalize acceptance of
malignant cells upon exposure to certain diagnosis, control over health
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48 Hour Cram Sheets for Med Surg
LEUKEMIA
etiologic factors such as: Viruses, - Change in your bowel habits status and demonstrate
Chemicals, and Physical agents. When (diarrhea, constipation, utilization of support systems
cells are malignant, they can metastasize consistency) and therapy as prescribed
into tissues surrounding the area, to the - Blood in your stool
lymph nodes and lymphatic system, the - Persistent abdominal discomfort,
blood, and system wide to other such as cramps, gas or pain
organs/cavities. All cancers are staged - Feeling your bowel doesn't empty
between I-IV, with Stage I being the least completely
severe and Stage IV being the most - Weakness/fatigue
severe. - Unexplained weight loss
Labs: Stool sample to check for
blood or dead cancerous cells
Dx Tests: Colonoscopy, CT Scan
LEUKEMIA Assess: Nursing Interventions: Nursing Dx:
RISK FACTORS: (**Depends on type of - Pain r/t enlarged organs/
Patho: MALIGNANCIES OF THE BLOOD-
-Genetic/Family history: Leukemia, severity and Age lymph nodes and treatment for
FORMING CELLS:
- Philadelphia chromosome: DNA of Patient) diagnosis
exchange between chromosomes 9 Pharm: Chemotherapy, -Risk for infection r/t
& 22, creating an oncogene Radiation, Biological compromised immune system
- Li-Fraumeni syndrome: an therapy, Targeted Therapy
inherited mutation in a tumor- (Imatinib/Gleevec & Pt. Goals/ Evaluation:
suppressor gene (TP53) dasatinib/ Sprycel), Stem - Pt will report pain at tolerable
-Exposure to: Radiation, Benzene, Cell Transplant level and verbalize ways to
Cigarette smoke Pt. Ed: DON’T WAIT TO manage it
-Down syndrome GET TREATMENT! TIMING - Pt will identify signs and
IS IMPORTANT! Know the symptoms of infection and
The American Cancer Society 7 side effects of medication verbalize ways to minimize
WARNING SIGNS for Cancer: as well as supportive chances of infection
C – Change in bowel/bladder habits measures:
-Healthy cells transform/mutate into A – A sore that that doesn’t heal - Vaccines
malignant cells upon exposure to certain U – Unusual Bleeding/Discharge - Blood/Platelet
etiologic factors such as: Viruses, Transfusions
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48 Hour Cram Sheets for Med Surg
LEUKEMIA
Chemicals, and Physical agents. When T – Thickening/lumps in - Antibiotics
cells are malignant, they can metastasize breast/body - Analgesics for Pain
into tissues surrounding the area, to the I – Indigestion/Difficulty swallowing - Immunoglobulins
lymph nodes and lymphatic system, the O – Obvious change in wart/mole - Red & White cell growth
blood, and system wide to other N - Nagging, coughing or factors
organs/cavities. All cancers are staged hoarseness
between I-IV, with Stage I being the least Surgery: Removal of
severe and Stage IV being the most spleen (if inflamed)
severe.
Vitals: Normal unless distressed
S/S & PHYS. EXAM:
- Fever/Night sweats
- Swollen lymph nodes (usually
painless)
- Feelings of fatigue, tiredness
- Easily bleeding or bruising, causing
bluish or purplish patches on the
skin/nosebleeds
- Frequent infections
- Bone/joint pain
- Unexplained weight loss/Anorexia
-Enlargement of the spleen or liver,
which can lead to abdominal
pain or swelling
- Red spots on the skin (petechiae)
(** If leukemia cells have infiltrated
the brain: headaches,
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48 Hour Cram Sheets for Med Surg
OVARIAN CANCER
seizures, confusion, loss of muscle
control, and vomiting may occur)
Labs: Abnormal blood test, bone
marrow tests, genetic testing
Dx Tests: Chest X-Ray, Lumbar
puncture, MRI, CT Scan
OVARIAN CANCER Assess: Nursing Interventions: Nursing Dx:
Assess for menstrual Pharm: Chemotherapy - Pain r/t enlarged organs/
Patho: Cancer of the ovaries:
cycle/ovulation history of patient (carboplatin and paclitaxel) lymph nodes and treatment for
and family… Pt. Ed: Educate patient on diagnosis
Most At Risk: side effects of -Risk for infection r/t
-Staring period at young age chemotherapy, changes in compromised immune system
-Ending period (Menopause) at hormone levels due to
older age diagnosis and possible Pt. Goals/ Evaluation:
-Never been pregnant (nulliparity) hormonal side effects, as - Pt will report pain at tolerable
-Frequent cycles well as ways to prevent level and verbalize ways to
**10% are genetic and can be infection as patient will be manage
tested for BRCA1 and BRCA2 gene immunocompromised. - Pt will identify signs and
-Healthy cells transform/mutate into
changes (mutations) symptoms of infection and
malignant cells upon exposure to certain
Surgery: “Surgical verbalize ways to minimize
etiologic factors such as: Viruses,
Debulking”, where the chances of infection
Chemicals, and Physical agents. When
The American Cancer Society 7 abdomen is cleared of all
cells are malignant, they can metastasize
WARNING SIGNS for Cancer: masses, with NONE over
into tissues surrounding the area, to the
C – Change in bowel/bladder habits the size of 1 cm. Removal
lymph nodes and lymphatic system, the
A – A sore that that doesn’t heal of Ovaries/Fallopian tubes
blood, and system wide to other
U – Unusual Bleeding/Discharge (Salpingo-oophorectomy),
organs/cavities. All cancers are staged
T – Thickening/lumps in removal of uterus
between I-IV, with Stage I being the least
breast/body (hysterectomy) or
severe and Stage IV being the most
I – Indigestion/Difficulty swallowing omentum (omenectomy)
severe.
O – Obvious change in wart/mole and Lymph node dissection
may be needed based on
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48 Hour Cram Sheets for Med Surg
PROSTATE CANCER
N - Nagging, coughing or the severity of the
hoarseness tumor(s).
Vitals: Normal unless distressed
S/S & PHYS. EXAM:
-Fatigue
-Abdominal/pain swelling
-Swelling of legs
-Shortness of Breath
-Changes in bladder/bowel habits
Labs: Genetic testing, Biopsy (if
needed), CA-125 Cancer Screening
blood Test (MAY be elevated but
not guaranteed)
Dx Tests: Ultrasound, CT Scan
PROSTATE CANCER Assess: Nursing Interventions: Nursing Dx:
Assess for Risk Factors: Pt/Family hx Pharm: Chemotherapy, -Altered urinary elimination r/t
Patho:
of BPH and prostate cancer, MEN Biological therapy, enlarged prostate and bladder
Cancer of the prostate gland:
OVER 40, African American, Obese Hormone therapy: distension
The American Cancer Society 7 Luteinizing Hormone – -Risk for infection r/t surgical
WARNING SIGNS for Cancer: Release Hormone/LH-RH procedure/immunocompromise
C – Change in bowel/bladder habits (To Stop the release of
A – A sore that that doesn’t heal testosterone, such as Pt. Goals/ Evaluation:
U – Unusual Bleeding/Discharge LUPRON, TRELSTAR, -Patient will maintain effective
T – Thickening/lumps in ZOLIDEX) voiding measures within limits
-Healthy cells transform/mutate into breast/body Pt. Ed: Encourage of his/her condition
malignant cells upon exposure to certain I – Indigestion/Difficulty swallowing medication compliance, as - Pt will identify signs and
etiologic factors such as: Viruses, O – Obvious change in wart/mole well as the importance of symptoms of infection and
Chemicals, and Physical agents. When N - Nagging, coughing or check-ups/colonoscopy as verbalize ways to minimize
cells are malignant, they can metastasize hoarseness recommended by doctor. chances of infection
into tissues surrounding the area, to the Inform patient of side
lymph nodes and lymphatic system, the Vitals: Normal unless distressed effects of prostate cancer,
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PANCREATIC CANCER
blood, and system wide to other S/S & PHYS. EXAM: including ERECTILE
organs/cavities. All cancers are staged - Urinary problems DYSFUNCTION, and
between I-IV, with Stage I being the least - Decreased force in the urine encourage them to utilize
severe and Stage IV being the most stream support system/
severe. - Blood in semen affection/coping skills.
- Erectile dysfunction Refer to support group.
- Pelvic Discomfort Also ambulation and
- Pain in Bone catheter care after surgery.
Labs: PSA (Prostate Specific Surgery: Freezing Prostate
Antigen) Level, Biopsy tissue, Removal of
Dx Tests: Ultrasound, DRE (digital Prostate, remove the
rectal exam) testicles (orchiectomy)
PANCREATIC CANCER Assess: Nursing Interventions: Nursing Dx:
Assess for Risk Factors: **THIS CANCER IS -Fear r/t recent diagnosis and
Patho:
- Chronic pancreatitis USUALLY DIAGNOSED AT unknown future
Cancer of the Pancreas, NO KNOWN
- Personal or family history of VERY LATE STAGES DUE TO -Risk for infection r/t surgical
CAUSE!
pancreatic cancer IT’S ASYMPTOMATIC procedure/immunocompromise
- Smoking/Excessive drinking NATURE
- Obese Pharm: Analgesics for Pt. Goals/ Evaluation:
- Diabetes pain, Chemotherapy, -Pt will verbalize anxiety as well
- African-American Targeted therapy, as ways to reduce it/minimize
- Family history of genetics that Radiation therapy with it.
can increase cancer risk - Pt will identify signs and
Pt. Ed: THE HEALING symptoms of infection and
The American Cancer Society 7 PROCESS AFTER THE verbalize ways to minimize
-Healthy cells transform/mutate into WARNING SIGNS for Cancer: WHIPPLE PROCEDURE IS chances of infection
malignant cells upon exposure to certain C – Change in bowel/bladder habits VERY LONG!
etiologic factors such as: Viruses, A – A sore that that doesn’t heal Surgery: WHIPPLE
Chemicals, and Physical agents. When U – Unusual Bleeding/Discharge PROCEDURE (removal of
cells are malignant, they can metastasize T – Thickening/lumps in head of pancreas, and
into tissues surrounding the area, to the breast/body portion of small intestine
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48 Hour Cram Sheets for Med Surg
PANCREATIC CANCER
lymph nodes and lymphatic system, the I – Indigestion/Difficulty swallowing (duodenum), gallbladder
blood, and system wide to other O – Obvious change in wart/mole and part of your bile duct.
organs/cavities. All cancers are staged N - Nagging, coughing or Part of stomach may be
between I-IV, with Stage I being the least hoarseness removed in addition. The
severe and Stage IV being the most remaining parts of your
severe. pancreas are reconnected
Vitals: Normal unless distressed to the Patient’s stomach
S/S & PHYS. EXAM: and intestines to allow the
(**Can be asymptomatic) digestion of food.
- Yellowing of your skin and the -Also, removal of cancer on
whites of your eyes (jaundice) tail of Pancreas if possible
- Upper abdominal pain (can
radiate to back)
- Weight Loss/ Anorexia
- Depression
- Blood clots
Labs: Biopsy, Blood tests: CMP,
CA 19-9 (Tumor Marker), CEA
(Carcinogen Embryonic Antigen),
Serum Amylase, Fecal Fat, Lipase,
Stool Trypsin
Dx Tests: Ultrasound, MRI, CT
Scan, Endoscopic Ultrasound (EUS),
Endoscopic retrograde cholangio-
pancreatography (ERCP)
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ALZHEIMERS
2. NEURO: CNS
DIAGNOSIS/PATHO DATA ACTION RESPONSE
ALZHEIMERS Assess: Use GLASCOW/COMA SCALE (see Nursing Interventions: Nursing Dx:
below), LOC, Advancement of disease, ADL Pharm: -Altered urinary
Patho: The most common cause of
issues (speak to caretaker if any) Degree of Cholinesterase Inhibitors: and bowel
Dementia in older adults. This disease is
Memory loss, Motor function, reflexes, -Donepezil elimination r/t
progressive and is marked by impaired
speech, cognition, affect -Galantamine cognitive
memory and thinking skills. The classic
NMDA Antagonist: impairment and
neuropathology findings in AD include
-Memantine loss of muscle
amyloid plaques, neurofibrillary tangles,
Selective Serotonin Reuptake tone
and synaptic and neuronal cell death.
Inhibitors (SSRI’s): - Self-care deficit
-Citalopram r/t cognitive
-Paroxetine impairment and
Anti-Anxiety Meds: physical
-Lorazepam limitations
- Oxazepam
Pt. Goals/
Vitals: ↑BP & ↑Pulse (May indicate ↑ Pt. Ed: **Education is better Evaluation:
Cranial pressure) absorbed by the Caretaker; as -Pt will identify
S/S & PHYS. EXAM: the patient may not be a need to
STAGES: reliable source to remember urinate/defecate
1. Mild – Slow and gradual progression of Have clocks, calendars and and/or understand
decline of intellectual activity; loss of personal items in clear view. the need for
energy/drive, difficulty learning Speak in short phrases/words. assistance with
2. Moderate – Evident deterioration. Speak slowly. Assess vital these activities
Client can’t remember address/phone signs/Neuro status. Identify -Pt will identify
number. Memory gaps, decreased threats to patient’s safety. need to
hygiene, memory gaps, mood swings, Review all meds patient is urinate/defecate
paranoia, anger, jealousy and apathy. Full- taking, use family to obtain and/or understand
time care needed. history. the need for
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48 Hour Cram Sheets for Med Surg
ALZHEIMERS
3. Moderate to Severe- Repeated Surgery: None available at this assistance with
instructions needed. Inability to recognize time these activities
common items and perform simple tasks.
Patient wanders a lot. Client is a danger to
himself. TOTAL CARE NEEDED.
4. Late- Client becomes unable to read or
write. Bunted emotions, loses ability to
talk and walk. STUPOR AND COMA…
**DEATH SECONDARY TO INFECTION AND
CHOKING
Labs: Genetic testing for gene (APOE-e4)
& Autosomal Dominant Alzheimers disease
(ADAD) to indicate likelihood of having
disease
Dx Tests: Physical exam, Neuro exam,
Mental status tests
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48 Hour Cram Sheets for Med Surg
BRAIN TUMORS
BRAIN TUMORS Assess: Neuro exam, Head to toe Nursing Interventions: Nursing Dx:
assessment, Assess coordination Pharm: (Depends on size and -Acute pain r/t
Patho: Brain tumors may be classified
Vitals: location of the tumor) tumor and
into several groups: those arising from the
Severe headache in the morning, Radiation Therapy, increased
coverings of the brain (e.g., Dural
increased when coughing, bending Chemotherapy, Medications to intercranial
meningioma), those developing in or on
Convulsions reduce ICP (Mannitol), Anti- pressure
the cranial nerves (e.g., acoustic
convulsants, Analgesics -Anxiety r/t
neuroma), Signs of increased intra-cranial pressure: (**All prn, depending on unknown future
Those originating with in brain tissue and blurred vision, nausea, vomiting, decreased situation) after surgery,
metastatic lesions originating elsewhere in Auditory function, changes in vital signs,
Pt. Ed: Caregiver information cognitive
the body. Tumors of the pituitary and aphasia.
about assistance with ADL’s, impairment and
pineal glands and of cerebral blood vessels Changes in personality
keeping up with check-ups, health issues.
are also types of brain tumors. Relevant Impaired memory options of care/symptom relief, Pt. Goals/
clinical considerations include the location
Natural disturbance of taste support groups, Evaluation:
and the histology character of the tumor.
communication with medical -Pt will verbalize
Tumors may be benign or malignant. A Classic triad:
personnel and sources pain level using
benign tumor CAN BE SERIOUS!! If occurs o Headache
o Papilledema (intra-ocular pressure)
Surgery: Surgery if possible to numeric chart or
in a vital area and can grow large enough
o Vomiting remove tumor (Depends on “FACES” chart, as
to have effects as serious as those of a
S/S & PHYS. EXAM: size, location and degree of well as ways to
malignant tumor.
Labs: Blood & Urine tests, Biopsy damage if removed) reduce/treat pain
Dx Tests: MRI, Functional MRI (fMRI) CT -Pt will verbalize
Scan, Angiogram, Brain Scan, Diffusion anxiety as well as
Tensor Imaging (DTI), Positron Emission ways to reduce
technology (PET Scan), Bone Scan it/minimize with it.
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CEREBERAL VASCULAR ACCIDENT (CVA)
CEREBERAL VASCULAR Assess: Assess for ALOC, change in Nursing Interventions: Nursing Dx:
ACCIDENT (CVA) speech/mental status, aphagia, dysphagia, Pharm: (Depends on type/ -Ineffective
visual disturbance, loss of balance, cause) Cerebral Tissue
Patho: *Commonly referred to as
coordination, sudden SEVERE headache -Aspirin Perfusion
Stroke or “Brain attack”. In a stroke, the
Vitals: ↑Pain -TPA (“Clot Buster”): Given -Impaired physical
sudden interruption of blood supply to
S/S & PHYS. EXAM: within first 3-4.5 hours as mobility r/t
areas of the brain results in cerebral
Stroke indicated. ***TPA neuromuscular
necrosis and impaired cerebral -Hemiplegia and sensory deficit CONTRAINDICATIONS involvement:
metabolism, which permanently damages -Aphasia (impairment may be in speaking, Intercranial hemorrhage, cognitive
brain tissues and produces focal listening, writing, or comprehending,
internal bleeding, recent impairment,
neurologic deficit of varying severity. A Most cases are mixed expressive and
receptive). trauma/surgery in last 3 mos., perceptual
cerebral aneurysm is prone to rupture,
-Hemipoeis – weakening of one side uncontrolled hypertension impairment,
which causes blood to leak into the sub-
-Unilateral neglect of paralyzed side -Anticoagulants/Anti-platelets paresthesia,
arachnoid space (and sometimes into
-Bladder impairment Pt. Ed: Watch for signs of weakness
brain tissue, where it forms a clot), -Possibly respiratory impairment bleeding/hemorrhage/Stroke,
resulting in increased intracranial pressure -Impaired mental activity and psychological blood tests as requested, Pt. Goals/
(ICP) and brain tissue damage deficits/ALOC
control Hypertension & Evaluation:
-In a TIA, there is a temporary decrease in -STROKE: F-A-S-T – Face, affect, smile,
diabetes, maintain diet low in -Pt will maintain
blood flow to a specific region of the -Transient Ischemic Attack
saturated fat, and exercise as improved/usual
brain, but there is no necrosis of brain -Temporary loss of consciousness or advised. QUIT SMOKING! Drink cognition, LOC and
tissue. The symptoms (lasting seconds to dizziness
-Paresthesias
moderately/stop drinking. If motor/sensory
hours) produce transient neurologic
-Garbled speech trouble communicating, utilize function
deficits that completely clear within 12 to
-Cerebral aneurysm props/tools, If physical -Pt will
24 hours.
-Blurred vision and headache ailments, utilize tools to assist maintain/increase
in mobility, join a support function, of
Signs and symptoms of ICP group/obtain emotional affected body part
-Nuchal rigidity and pain on neck support. or compensatory
movement
-Photophobia
Surgery: body part
FOR CLOTS:
Labs: Urinalysis, Lumbar Puncture, brain Mechanical removal of clot,
biopsy Carotid endarterectomy
FOR HEMHORRAGING:
-Coiling
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CEREBERAL VASCULAR ACCIDENT (CVA)
Dx Tests: CT Scan, MRI, Carotid Doppler, -Surgical Clipping
EKG, ECG, cerebral arteriogram, magnetic -Surgical AVM removal
resonance angiogram -Intracranial bypass
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EPILEPSY
EPILEPSY Assess: ASSESS FOR SAFE Nursing Interventions: Nursing Dx:
ENVIRONMENT WHILE PATIENT IS Pharm: Dilantin, -Low self-esteem
Patho: A disorder involving abnormal,
SEIZING! Maintain patent airway (Good to Phenobarbital, Tegretol, r/t social role
sudden discharge of electrical activity in
position the patient side-lying) Initiate Depakote, Valium, Klonopin, changes, loss of
the brain. Epilepsy is not a singular
seizure precautions/protect client from Pt. Ed: Adherence to control and stigma
disease, but is heterogeneous in terms of
injury. DOCUMENT THE SEIZURE!! medication regimen as well as associated with
clinical expression, underlying etiologies,
(Precipitating factors, type, duration, contra-indications and side disease
and pathophysiology . As such, specific
behavior before, during and after seizure/ effects! -Risk for
mechanisms and pathways underlying
aka “Postictal phase”, and if incontinent) Surgery: Removal of anterior Trauma/Suffocatio
specific seizure types may vary. Epileptic
temporal lobe (For partial n r/t loss of
seizures are broadly classified according to
Vitals: ↑TEMP, ↑HR, ↓BP epilepsy/seizures), Usually in consciousness,
their site of origin and pattern of spread.
S/S & PHYS. EXAM: children: hemispherectomy, coordination,
Sensory/Thought: corpus callosotomy (separating weakness and
o Black out/Loss of consciousness of nerve fibers that connect the reduced
o Confusion two sides of the brain) muscle/sensation
o Deafness/Sounds
o Electric Shock Feeling
o Spacing out Pt. Goals/
o Out of body experience Evaluation:
o Visual loss or blurring -Pt will verbalize
Emotional: concerns and fears
o Fear/Panic about body, self
o Pleasant feeling perception and
Physical: change of lifestyle
o Chewing movements -Pt will verbalize
o Convulsion understanding of
o Difficulty talking/Drooling factors that
o Eyelid fluttering/rolling contribute to
o Falling down trauma during a
o Foot stomping seizure, pt will be
o Hand waving
aware of seizure
o Inability to move
o Incontinence
precautions that
o Lip smacking/Making sounds should be utilized,
o Shaking especially by
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EPILEPSY
o Staring caretaker, family
o Stiffening or friend
o Swallowing
o Sweating
o Teeth clenching/grinding
o Tongue biting
o Twitching movements
o Breathing difficulty
o Tachycardia
o Bruising
o Difficulty talking
CLASSIFIED AS GENERALIZED OR FOCAL: o Injuries
Generalized: o Sleeping
1. Tonic-clonic (grand-mal) Seizure: This o Exhaustion
seizure causes you to lose consciousness o Headache
and often collapse. Your body becomes o Nausea
stiff during what's called the "tonic" phase. o Pain
During the "clonic" phase, muscle o Thirst
contractions cause your body to jerk. o Weakness
2. Absence (petit mal) Seizure: During o Urge to urinate/defecate
these brief episodes, you lose awareness
and stare blankly. Usually, there are no
other symptoms.
3. Myoclonic Seizure: These very brief
seizures cause your body to jerk, as if
shocked by electricity, for a second or
two. The jerks can range from a single
muscle jerking to involvement of the entire
body.
4. Clonic Seizure: This seizure cause
rhythmic jerking motions of the arms Labs: CBC, Glucose, CSF (cerebral spinal
and legs, sometimes on both sides of your fluid) analysis, Blood Culture (To rule out
body. infection
5. Tonic Seizure: Tonic seizures cause Dx Tests: EEG, MRI, CT Scan, PET Scan,
your muscles to suddenly stiffen, ECG
sometimes for
as long as 20 seconds. If you're standing,
you'll typically fall.
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EPILEPSY
6. Akinetic or Atonic Seizure: This seizure
causes your muscles to relax or lose
strength, particularly in the arms and legs.
Although you usually remain conscious, it
can cause you to suddenly fall and lead to
injuries. These seizures also are called
"drop attacks"
FOCAL SEIZURES
1. Simple Focal Seizure: During these
seizures, you remain conscious although
some people can't speak or move until the
seizure is over. Uncontrolled movements,
such as jerking or stiffening, can occur
throughout your body. You also may
experience emotions such as fear or rage
or even joy; or odd sensations, such as
ringing sounds or strange smells.
2. Complex Focal Seizure: During these
seizures, you are not fully conscious and
may
appear to be in a dreamlike state. Typically,
they start with a blank stare. You may
involuntarily chew, walk, fidget, or perform
other repetitive movements or simple
actions, but actions are typically
unorganized or confused
3. Secondarily Generalized Seizure:
These seizures begin as a focal seizure and
develop
Into generalized ones as the electrical
abnormality spreads throughout the brain.
When the seizure begins, you may be fully
conscious but then lose consciousness and
Experience convulsions as it develops.
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HEAD INJURY
HEAD INJURY Assess: Perform Neuro assessment, Nursing Interventions: Nursing Dx:
Assess for ALOC, Signs of confusion, Pharm: Analgesics, Mannitol, -Ineffective
Patho: brain injuries can be classified
as traumatic or acquired, with additional
bleeding/CSF in ears (halo sign), Assess Lasix, barbiturates, Cerebral Tissue
types under each heading. All brain injuries intracranial pressure (Shouldn’t exceed 20- corticosteroids Perfusion
are described as either mild, moderate, or 25mmHg) Monitor MAP (Keep above Pt. Ed: Inform patient of signs -Impaired physical
severe. 90mmHg), Elevate HOB to 30°, Monitor and symptoms of ICP, confirm mobility r/t
Traumatic Brain Injury vital signs/ABG’s understanding of treatment neuromuscular
Traumatic brain injury is a result of an Vitals: ↑PAIN, may have ↑TEMP and/or regimen including medication, involvement:
external force to the brain that results in a
↑↓BP (depending on Injury) drains, etc. Communicate with cognitive
change to cognitive, physical, or emotional
functioning. The impairments can be family for signs of worsening impairment,
temporary or permanent S/S & PHYS. EXAM: condition and allow them to perceptual
(Symptoms depend on the severity and voice concerns. impairment,
Acquired Brain Injury distribution of brain injury) Surgery: To relieve excessive paresthesia,
An acquired brain injury is an injury to the -A common manifestation is loss of fluid/ICP (May install a drain), weakness
brain that is not hereditary, congenital, consciousness, ranging from a few minutes
to 1 hour or longer
“Bone Flap” removed to relieve
degenerative, or the result of birth trauma.
-Ecchymosis may be seen over the mastoid pressure, Removal of Pt. Goals/
Acquired brain injury generally affects cells
throughout the entire brain. (Battle’s sign) hematoma Evaluation:
-CT scan may reveal the area that is -Pt will maintain
contused or injured X-Rays may reveal skull improved/usual
fractures cognition, LOC and
Bloody spinal fluid suggests brain motor/sensory
laceration or contusion
-Brain injury may have various signs,
function
including altered level of conscious-ness, -Pt will
pupil abnormalities, altered or absent gag maintain/increase
reflex or corneal reflex, neurologic deficits, function, of
change in vital signs (e.g. respiration affected body part
pattern, hypertension, bradycardia), or compensatory
A. Direct injury: Depression of skull, hyperthermia or hypothermia, and sensory,
body part
Direct injury or skull fracture vision or hearing impairment
B. Blow to head: Blow to the skull -Signs of a post-concussion symptoms may
that may move the brain to a point include headache, dizziness, anxiety,
which can cause damage to irritability, and lethargy
vessels or veins, contusion or -In acute or sub-acute subdural hematoma,
hematoma changes in level of consciousness, papillary
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MULTIPLE SCLEROSIS (MS)
C. Rebound/Contrecoup Injury: signs, hemiparesis, coma, hyper-tension,
Rebound of cranial contents an bradycardia, and slowing respiratory rate
cause an injury of the head on the are signs of expanding mass
OPPOSITE side of injury. Also
known as contrecoup injury Labs: Na, Mg, PTT, aPTT, Platelets, BAC,
renal function
Dx Tests: MRI, CT scan, EEG, X-Ray
MULTIPLE SCLEROSIS (MS) Assess: Assess for cognitive, sensory and Nursing Interventions: Nursing Dx
physical impairment, pain, Pharm: -Impaired physical
Patho: REMEMBER! MS, Myelin Sheath!!
Demyelination of nerve fibers within long
numbness/paresthesia, extreme fatigue -Immuno-suppressants to mobility r/t
conducting pathway of spinal cord and and inflammation. Also assess for reduce exacerbation: (Avonex neuromuscular
brain. medication adherence IM weekly), Betaseron involvement:
Impaired transmission of never Vitals: (Subcut), Copaxone (Subcut) cognitive
impulses. S/S & PHYS. EXAM: -For muscle spasicity/tremors: impairment,
-Spastic weakness – the most common Neurontin, Baclofen, perceptual
Degenerative changes myelin sheath
sign Clonazapam impairment,
are scattered irregularly throughout the
central -Charcots Triad: A combination of -For Urinary Problems: parasthesia,
nervous system. Nerve axon also symptoms that includes nystagmus,
Ditropan, Detrol weakness
deteriorates. The areas involved are not intention tremor (motor weakness in -For sexual Dysfunction: Viagra -Ineffective
consistent when it comes to deterioration coordination), scanning speech which is -Depression: Zoloft. Prozac individual coping
thereby showing the signs and symptoms elicited by slowing enunciation with -Fatigue: Provigil, Symmetrel r/t uncertainty of
appear whenever the nerve conduction is tendency to hesitate at beginning of a course of MS
interrupted word. Pt. Ed:
-There are periods of remission also,
Hyper-emotions as well as euphoria 1. Self-Injection techniques Pt. Goals/
however there are cases that symptoms are
exacerbated especially when nerve impulse Visual disturbances 2. Promote independence Evaluation:
travel through the patchy never fibers. 3. Self-Catheterization -Pt will maintain/
Nausea/Vomiting
4. Promote exercise daily, with increase function,
Urinary retention or urinary incontinence fall precautions of affected body
Dysphagia (difficulty in swallowing) 5. Injury Prevention part or
Ataxia (decreased coordination)
6. Stress reduction and immune compensatory
support to avoid infection body part
Labs: CSF Analysis
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MENINGITIS
Dx Tests: MRI (Will show sclerotic -Pt will verbalize
patches brain/spinal cord) Surgery: None available at this acceptance of
time diagnosis, control
over health status
and demonstrate
utilization of
support systems
MENINGITIS Assess: MONITOR TEMPERATURE!! Nursing Interventions: Nursing Dx:
Extremely high temp can be fatal. Assess Pharm: IV Antibiotics -Pain r/t acute
Patho: Meningitis is the inflammation of
the protective membranes covering the
for ALOC, Pain, sensory (Rifampin/Vancomycin) condition
central awareness/response Pt. Ed: Sit patient in - Risk for infection
nervous, known collectively as the Vitals: TEMP, PAIN comfortable position with transmission r/t
meninges. S/S & PHYS. EXAM: adequate neck support, reduce contagious nature
Meningitis can be caused from a direct -Fever environmental stimuli/stress, of organism
spread of a severe infection such as an ear -Nuchal (Neck) Rigidity/Pain/tenderness monitor hydration, antibiotics,
infection or sinus infection. In some cases,
-Loss of appetite seizure precautions Pt. Goals/
meningitis is noted after head trauma or
an injury to the head or brain. There are
-Difficulty swallowing. Surgery: N/A Evaluation:
several causes of meningitis: Bacterial -Anorexia/vomiting -Pt will verbalize
infection, Viral infection, Fungal -Poor skin turgor/dry mucous membranes pain level using
infection, A reaction to medications, A Labs: CSF Analysis numeric chart or
reaction to medical treatments, Lupus, Dx Tests: Lumbar puncture/spinal Tap “FACES” chart, as
Some forms of cancer, A trauma to the well as ways to
head or back. Anyone can catch reduce/treat pain
meningitis. This is especially true if your
immune system is weak. -Initiate infection
precautions and
antibiotic therapy
as ordered
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PARKINSON’S
PARKINSON’S Assess: Assess for the 4 Cardinal signs of Nursing Interventions: Nursing Dx:
Parkinson’s: Pharm: Depends on -Impaired physical
Patho: Parkinson’s disease is a slowly
1. Resting tremor age/severity: mobility r/t
progressive degenerative neurological
2. Rigidity - Carbidopa/Levodopa neuromuscular
disorder caused by the loss of nerve cell
3. Bradykinesia therapy involvement:
function in the basal ganglia. Loss of nerve
4. Postural instability - Dopamine Agonists tremors, muscle
cells in the substantia nigra causes a
*PATIENT IS A FALL RISK! - Anticholinergics rigidity, weakness
reduction of dopamine production.
Vitals: Normal, unless distressed - MAO-B Inhibitors -Self care deficit
Dopamine is the neurotransmitter
S/S & PHYS. EXAM: - COMT Inhibitors r/t neuromuscular
essential for such functions as control of
weakness,
posture, supporting the body in an upright
Pt. Ed: Assistance with ADL’s, decreased
position and voluntary motions.
Caretaker info, important strength and loss
information regarding the of muscle control/
disease and depression, coordination,
Surgery: None at this time cognitive changes
& postural
changes
-Tremor (rhythmic, purposeless, fine Pt. Goals/
trembling, quivering movement), resting Evaluation:
or passive -Pt will maintain/
tremor increase function,
-Muscle rigidity (stiffness seen with of affected body
resistance to passive muscle stretching), part or
cogwheel compensatory
rigidity body part
-Akinesia (loss of movement) and -Pt and caretaker
bradykinesia (slowness of voluntary will verbalize
movement and speech) understanding of
-Mask-like expression physical, cognitive
-Dysphagia (difficulty of swallowing) and emotional
-Monotonous speech limitations due to
-Postural disturbances (stooped posture, diagnosis
shuffling gait, broad-based turns)
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SEIZURE
-Generalized muscle fatigue
-Cognitive changes (impaired memory,
depression)
-Drooling
-Constipation
-Orthostatic hypotension
- Urinary dysfunction
Labs: NONE YET! Specialized imaging
centers may have Brain Scans to measure
dopamine and metabolism of brain, as
well as genetic disposition/Biological
marker
Dx Tests: NONE YET! (A neurologist will
diagnose based on history and symptoms)
SEIZURE Assess: ASSESS FOR SAFE Nursing Interventions: Nursing Dx:
ENVIRONMENT WHILE PATIENT IS Pharm: Dilantin, -Low self-esteem
Patho: A disorder involving abnormal,
SEIZING! Maintain patent airway (Good to Phenobarbital, Tegretol, r/t social role
sudden discharge of electrical activity in
position the patient side-lying) Initiate Depakote, Valium, Klonopin, changes, loss of
the brain. Epilepsy is not a singular
seizure precautions/protect client from Pt. Ed: Adherence to control and stigma
disease, but is heterogeneous in terms of
injury. DOCUMENT THE SEIZURE!! medication regimen as well as associated with
clinical expression, underlying etiologies,
(Precipitating factors, type, duration, contra-indications and side disease
and pathophysiology. As such, specific
behavior before, during and after seizure/ effects! -Risk for Trauma/
mechanisms and pathways underlying
aka “Postictal phase”, and if incontinent) Surgery: Removal of anterior Suffocation r/t loss
specific seizure types may vary. Epileptic
temporal lobe (For partial of consciousness,
seizures are broadly classified according to
Vitals: ↑TEMP, ↑HR, ↓BP epilepsy/seizures), Usually in coordination,
their site of origin and pattern of spread.
S/S & PHYS. EXAM: children: hemispherectomy, weakness and
Sensory/Thought: corpus callosotomy (separating reduced
o Black out/Loss of consciousness of nerve fibers that connect the muscle/sensation
o Confusion two sides of the brain)
o Deafness/Sounds
Pt. Goals/
o Electric Shock Feeling
o Spacing out Evaluation:
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SEIZURE
o Out of body experience -Pt will verbalize
o Visual loss or blurring concerns and fears
Emotional: about body, self
o Fear/Panic perception and
o Pleasant feeling change of lifestyle
Physical: -Pt will verbalize
o Chewing movements understanding of
o Convulsion factors that
o Difficulty talking/Drooling contribute to
o Eyelid fluttering/rolling trauma during a
o Falling down
seizure, pt will be
o Foot stomping
o Hand waving aware of seizure
o Inability to move precautions that
o Incontinence should be utilized,
o Lip smacking/Making sounds especially by
o Shaking caretaker, family
o Staring or friend
o Stiffening
o Swallowing
o Sweating
o Teeth clenching/grinding
o Tongue biting
o Twitching movements
o Breathing difficulty
o Tachycardia
CLASSIFIED AS GENERALIZED OR FOCAL: o Bruising
o Difficulty talking
Generalized:
o Injuries
1. Tonic-clonic (grand-mal) Seizure: This o Sleeping
seizure causes you to lose consciousness o Exhaustion
and often collapse. Your body becomes o Headache
stiff during what's called the "tonic" phase. o Nausea
During the "clonic" phase, muscle o Pain
contractions cause your body to jerk. o Thirst
2. Absence (petit mal) Seizure: During o Weakness
these brief episodes, you lose awareness o Urge to urinate/defecate
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SEIZURE
and stare blankly. Usually, there are no
other symptoms.
3. Myoclonic Seizure: These very brief
seizures cause your body to jerk, as if
shocked by electricity, for a second or
two. The jerks can range from a single
muscle jerking to involvement of the entire
body.
4. Clonic Seizure: This seizure cause
rhythmic jerking motions of the arms Labs: CBC, Glucose, CSF (cerebral spinal
and legs, sometimes on both sides of your fluid) analysis, Blood Culture (To rule out
body. infection
5. Tonic Seizure: Tonic seizures cause Dx Tests: EEG, MRI, CT Scan, PET Scan,
your muscles to suddenly stiffen, ECG
sometimes for
As long as 20 seconds. If you're standing,
you'll typically fall.
6. Akinetic or Atonic Seizure: This seizure
causes your muscles to relax or lose
strength, particularly in the arms and legs.
Although you usually remain conscious, it
can cause you to suddenly fall and lead to
injuries. These seizures also are called
"drop attacks"
FOCAL SEIZURES
1. Simple Focal Seizure: During these
seizures, you remain conscious although
some people can't speak or move until the
seizure is over. Uncontrolled movements,
such as jerking or stiffening, can occur
throughout your body. You also may
experience emotions such as fear or rage
or even joy; or odd sensations, such as
ringing sounds or strange smells.
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SPINAL INJURY
2. Complex Focal Seizure: During these
seizures, you are not fully conscious and
may
Appear to be in a dreamlike state.
Typically, they start with a blank stare. You
may
involuntarily chew, walk, fidget, or perform
other repetitive movements or simple
actions, but actions are typically
unorganized or confused
3. Secondarily Generalized Seizure:
These seizures begin as a focal seizure and
develop
Into generalized ones as the electrical
abnormality spreads throughout the brain.
When the seizure begins, you may be fully
conscious but then lose consciousness and
Experience convulsions as it develops.
SPINAL INJURY Assess: ABC’s!! For reflexes, response to Nursing Interventions: Nursing Dx:
stimuli and level of injury, Neuro-exam! Pharm: None at this time to -Impaired physical
Patho: Spinal cord injuries cause myelo-
pathy or damage to white matter or
TREAT, but mobility r/t
myelinated fiber tracts that carry signals to (GLASCOW COMA SCALE): methylprednisolone/Solumedr neuromuscular
and from the brain. It also damages gray ol may be given as medication involvement:
matter in the central part of the spine, to treat ACUTE spinal injury sensory/
causing segmental losses of interneurons Pt. Ed: Assistance with ADL’s perceptual
and motorneurons. Spinal cord injury can as needed, PT to become impairment,
occur from many causes, including: adjusted to parasthesia,
-Trauma such as automobile crashes, falls,
gunshots, diving accidents, war injuries,
wheelchair/prosthesis, weakness
etc. Psychological care to deal with -Low self-esteem
-Tumors such as right, ependymomas, mental aspect of the loss, r/t social role
astrocytomas, and metastatic cancer. catheter care as needed, changes, loss of
-Ischemia resulting from occlusion of avoiding pressure ulcers/self control and recent
spinal blood vessels, including dissecting care diagnosis
aortic aneurysms, emboli, arteriosclerosis.
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SPINAL INJURY
-Developmental disorders such as spina Surgery: None at this time for Pt. Goals/
bifida, meningomyolcoele, and other parasthesia, but surgery may be Evaluation:
Neurodegenerative diseases, such as required to remove bone -Pt will maintain
Friedreich’s ataxia, spinocerebellar ataxia,
fragments (if any), or further function, of
etc.
-Demyelinative diseases, such as secure the spine to prevent unaffected body
Multiple Sclerosis. deformity. parts or
-Transverse myelitis, resulting from spinal compensatory
cord stroke, inflammation, or other causes body parts as well
-Vascular malformations, such as arterio- as correctly
venous malformation (AVM), dural utilizing support
Arteriovenous fistula (AVF), spinal
and assistive
hemangioma, cavernous angioma and
Aneurysm. devices
-Pt will verbalize
concerns and fears
about body, self
perception and
Vitals: DEPENDS ON THE INJURY!! change of lifestyle
S/S & PHYS. EXAM:
-Impaired physical mobility
-Disturbed sensory perception
-Acute pain
-Anticipatory grieving
-Low self-esteem
-Constipation or bowel incontinence
-Impaired urinary elimination
Labs: N/A
Dx Tests: CT Scan, MRI, X-Ray
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GUILLAIN-BAR SYNDROME
3. NEURO: PNS
DIAGNOSIS/PATHO DATA ACTION RESPONSE
GUILLAIN-BAR SYNDROME Assess: Asses for S/S of Nursing Interventions: Nursing Dx:
ARDS! Assess respiratory Pharm: Plasmapheresis, IVIG -Ineffective
Patho: Guillain-Barré syndrome is the result of a cell-
status, monitor VS and ECG, (IV Immunoglobulin), breathing
mediated and humoral immune attack on peripheral
Monitor for infection and Analgesics as needed pattern r/t
nerve myelin proteins that causes inflammatory
signs of progression Pt. Ed: Healing/recovery time respiratory
demyelination. With the autoimmune attack, there is an
Vitals: HR, BP may take up to 2 years. muscle weakness
influx of macrophages and other immune-mediated
S/S & PHYS. EXAM: Referral to PT, OT, RT & ST or paralysis,
agents that attack myelin, cause inflammation and leave
Autonomic changes: (Speech therapy), educate decreased cough
the axon unable to support nerve conduction o Tachycardia, bradycardia, patient on strategies to reflex and
hypertension, or orthostatic prevent immobilization
hypotension
complications/immobility -Impaired
o Increased sweating
o Increased salivation Surgery: Laminectomy physical mobility
o Constipation (Remove portion of the r/t
vertebrae) Diskectomy neuromuscular
Other Symptoms: (Removal of herniated disk), involvement:
-Dyskinesia (inability to Spinal Fusion (Fusion of cognitive
executive involuntary vertebrae via the spinal impairment,
movements) process by using a bone graft) perceptual
-Weakness usually begins in impairment,
the legs and progress upward paresthesia,
(ascending paralysis) weakness
-Hyporeflexia (decreased
DTRs) Pt. Goals/
-Paresthesia (numbness), Evaluation:
clumsiness -Pt will maintain
-Blindness patent airway,
-Inability to swallow demonstrate
(dysphagia) or clear secretions effective
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MYASTHENIA GRAVIS
-Alternate breathing
hypotension/hypertension - pattern and
Arrhythmias show evidence
Labs: Lumbar Puncture of adequate
Ganglioside Antibody tests oxygenation
Dx Tests: MRI, Pulmonary -Pt will maintain/
Function tests, Nerve increase
conduction test, EMG function, of
(Electromyography) affected body
part or
compensatory
body part
MYASTHENIA GRAVIS Assess: Assess for Nursing Interventions: Nursing Dx:
Respiratory status/ABC’s, Pharm: Anticholinesterase -Impaired gas
Patho: In myasthenia gravis, antibodies directed at the
patent airway, progression of medications (Atropine is the exchange, r/t
acetylcholine receptor sites impair transmission of
deterioration, muscle wasting. antidote), Pyridostimine, ineffective
impulses across the myoneural junction. Therefore, fewer
Also assess for factors that IMMUNOSUPPRESANTS: breathing
receptors are available for stimulation, resulting in
can contribute to Prednisone, Azathioprine (A pattern and
voluntary muscle weakness that escalates with continued
exacerbation: cytotoxic med), muscle weakness
activity… 80% of people with myasthenia gravis have
-Infection Plasmapheresis, IVIG (IV -Risk for
either thymic hyperplasia or a thymic tumor, and the
-Pregnancy Immunoglobulin), Analgesics aspiration r/t
thymus gland is believed to be the site of antibody
-Stress/Fatigue as needed difficulty
production
-Pregnancy Pt. Ed: Importance swallowing
-Increase in body temp/fever medication compliance,
- Non-Compliance with meds Aspiration precautions – Pt. Goals/
Watch amount and Evaluation:
Vitals: TEMP consistency of food as well -Pt will maintain
S/S & PHYS. EXAM: scheduling feedings during patent airway,
peak times of medication demonstrate
effect. Grouping ADL’s and effective
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MYASTHENIA GRAVIS
-Ptosis - check palpebral implementing rest periods, breathing
fissure for drooping of upper referral to speech therapy and pattern and
eyelids support (MG Foundation of show evidence
America) of adequate
oxygenation
Surgery: Thymectomy -No aspiration
(Excision of the thymus) will occur.
Patient and
patients family
will verbalize
understanding of
aspiration risk
-Double vision
-Mask like facial expression
-Weakened laryngeal muscles
leads to dysphagia (difficulty
of swallowing, without food)
-Hoarseness of voice
-Respiratory muscle weakness
leads to respiratory arrest
-Extreme muscle weakness
especially during activity or
exertion in AM
Labs: Edrophonium Choride
(TENSOLIN IV TEST) – If given
and after 5 minutes
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MYASTHENIA GRAVIS
symptoms are relived, it is
considered a positive test for
MG) Serum Acetylcholine
Receptor Antibody test)
Dx Tests: MRI, EMG
(Electromyography)
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APPENDICITIS
4. GASTRO INTESTINAL (Lower)
DIAGNOSIS/PATHO DATA ACTION RESPONSE
APPENDICITIS Assess: For guarding, with pain Nursing Interventions: Nursing Dx:
in RLQ, Positive McBurney’s sign Pharm: PAIN MANAGEMENT -Acute pain r/t inflammation
Patho: Appendicitis is usually caused by
(Pain located the right side of & ANTIBIOTICS UNTIL of tissues
blockage of the lumen of the appendix.
abdomen, located 1/3 the SURGERY!! Continue after -Risk for infection r/t
Obstruction causes the mucus produced
distance from the anterior surgery as well. Possibly blood if Inadequate primary
by mucous appendix suffered dam. The
superior iliac spine to lost in surgery. defenses/surgery/perforation
longer the mucus is more and more, but
the umbilicus): Pt. Ed: Avoid applying heat to of tissues
the elastic wall of the appendix has
the area, Monitor for
limitations that lead to increased intra-
signs/symptoms of infection, Pt. Goals/ Evaluation:
luminal pressure. These pressures will
mobility after surgery - Pt will report pain at
impede the flow of lymph resulting in
Surgery: APPENDECTOMY! tolerable level and verbalize
mucosal edema and ulceration. At that
**Must remove before ways to manage it
time there was marked focal acute
appendix perforation– CAN -Pt will show no signs of
appendicitis with epigastric pain. If the
CAUSE SEPTIC SHOCK!! Patient infection including: Elevated
flow is disrupted arterial wall infarction
will notice a “Sudden relief of temperature, WBC count, as
will occur followed by gangrene
pain” which is a BAD SIGN!! well as pain and swelling at
appendix. This stage is called
Vitals: TEMP Abdomen will become rigid, incision site
appendicitis gangrenosa. If the appendix
S/S & PHYS. EXAM: Aching fever will SPIKE!
wall fragile, there will be a perforation,
pain that begins around your
called perforated appendicitis.
navel and often shifts to your
lower right abdomen. The pain
occurs when you apply pressure
to your lower right abdomen
THEN, release the pressure on
that area. When released, the
Pt. will feel A LOT of pain!!
(REBOUND TENDERNESS!!) Pain
that worsens if you cough, walk
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SBO (SMALL BOWEL OBSTRUCTION)
or make other jarring
movements, also Nausea,
Vomiting, Loss of appetite, Low-
grade fever, Constipation,
Inability to pass gas, Diarrhea,
Abdominal swelling
Labs: WBC, CBC, hematologic
tests pre-surgery
Dx Tests: CT scan/Ultrasound
to assess for appendicitis,
SBO (SMALL BOWEL Assess: Observe and palpate Nursing Interventions: Nursing Dx:
OBSTRUCTION) abdomen for swollen/tender Pharm: Stool Softener, -Deficient Fluid
areas and lump, Listen to bowel STIMULANT Laxative Volume related to
Patho: Intestinal contents, fluid and gas
sounds (or absence of), Assess Pt. Ed: eat foods high in fiber, nausea/vomiting, fever or
accumulative above the intestinal
for signs of perforation and drink lots of liquids diaphoresis
obstruction. The abdominal distention
sepsis/septic shock -Acute Pain related to
and retention of fluid reduce the
Vitals: TEMP Surgery: Laparoscopy, or intestinal blockage, distention
absorption of fluids and stimulate more
S/S & PHYS. EXAM: Surgical Removal (For complete and rigidity
gastric secretion. With increasing
- Cramping intermittent strangulation)
distention, pressure within the intestinal
abdominal pain Pt. Goals/ Evaluation:
lumen increases, causing a decrease in
- Nausea -Pt will demonstrate normal
venous and arteriolar capillary pressure.
- Vomiting vital signs, balanced input and
This causes edema, congestion,
- Diarrhea output
necrosis and eventual rupture or
- Constipation
perforation of the intestinal wall, with - Pt will report pain at
- Inability to have a bowel
resultant peritonitis. Reflux vomiting tolerable level and verbalize
movement/ pass gas
may be caused by abdominal distention. ways to manage it
- Swelling of the abdomen
Vomiting results in a loss of hydrogen
(distention)
ions and potassium from the stomach,
-Bad breath
leading to a reduction of chlorides and
Labs: Serum chemistry, BUN,
potassium in the blood and to metabolic
Creatinine, CBC, WBC,
alkalosis. Dehydration and acidosis
Urinalysis
develop from loss of water and sodium.
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CONSTIPATION
With acute fluid losses hypovolemic
shock may occur. Dx Tests: Abdominal X-RAY, CT
Scan
CONSTIPATION Assess: For signs of bowel Nursing Interventions: Nursing Dx:
obstruction Pharm: Stool softeners, -Altered bowel elimination r/t
Patho:
Vitals: PAIN Laxatives low-fiber diet/inactivity
Constipation, costiveness, or
S/S & PHYS. EXAM: Pt. Ed: Stick to diet high in -Alteration in Nutrition: Less
irregularity, is a condition of the
- Pass fewer than three stools a fiber, Know/PREVENT CAUSES: Than Body
digestive system in which a person
week -Anal fissure Requirements related to loss
experiences hard feces that are difficult
- Hard stools -Bowel Obstruction of appetite/pain
to expel. This usually happens because
- Excessive strain during bowel -Colon Cancer
the colon absorbs too much water from
movements -Bowel Stricture (Narrowing of Pt. Goals/ Evaluation:
the food. If the food moves through the
- A sense of rectal blockage Colon) -Bowel Elimination as
gastro-intestinal tract too slowly, the
- Have a feeling of incomplete -Abdominal/Rectal Cancer evidenced by Comfort of
colon may absorb too
evacuation after having a bowel passage of stool, stool is soft
much water, resulting in feces that are
movement Surgery: Bowel obstruction and formed, passage of stool
dry and hard. Defecation may be
- Need to use manual removal if needed is achieved without aids
extremely painful, and in severe cases
maneuvers to have a bowel -Pt will report desire to eat,
(fecal impaction) lead to symptoms of
movement, such as finger achieves an adequate
bowel obstruction
evacuation or manipulation of Nutritional intake, Avoidance
your lower abdomen of irritating foods, increased
Causes of constipation:
awareness of dietary
-Diet
Labs: Blood tests for hormone management and relief of
-Hormones
imbalances pain.
-Anatomical a side effect of medications
(Opiates/Narcotics) Dx Tests:
-An illness or disorder -Barium studies to look for
obstruction of the colon
-Colonoscopy to look for
obstruction of the colon
-Sigmoidoscopy
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HERNIA
HERNIA Assess: Palpate for mass, Nursing Interventions: Nursing Dx:
Auscultate for bowel sounds! Pharm: Analgesics for pain, -Pain r/t abdominal swelling
Patho: When part of an internal organ
ABSENCE OF BOWEL SOUNDS stool softeners and pressure
bulges through a weak area of muscle.
COULD INDICATE Pt. Ed: Hernias are common. -Risk for infection r/t
There are several types of hernias,
STRANGULATION F HERNIA, A They can affect men, women abdominal mass/obstruction
including:
MEDICAL EMERGENCY!! This and children. A combination of
strangulation can lead to: muscle weakness and straining, Pt. Goals/ Evaluation:
OBSTRUCTION, ISCHEMIA, such as with heavy lifting, might - Pt will report pain at
NECROSIS, AND PERFORATION! contribute. Some people are tolerable level and verbalize
Vitals (Strangulation): TEMP, born with weak abdominal ways to manage it
HR muscles and may be more likely -The patient will remain free
S/S & PHYS. EXAM: to get a hernia. from signs or symptoms of
INGUINAL: Surgery: Surgical repair of infection
-BUMP/Bulge in groin/testicles hernia a.k.a. Minimally Invasive
-Burning or tenderness Inguinal Hernia Repair (MIIHR),
-Inguinal: in the groin(most common -Pain when lifting something Herniorraphy laparoscopic
type Think, “IN-GROINial” heavy or when exercising repair
-Umbilical: around the belly button -Pressure in the groin or thigh
- Incision, through a scar HIATAL:
- Hiatal, a small opening in the -Acidic taste in the mouth
diaphragm where the upper part of the - Belching
stomach can move up into the chest - Difficulty swallowing
-Congenital diaphragmatic: A birth - Epigastric pain/ burning (Can
defect that requires surgery be from the stomach area up to
the mouth)
SIDE VIEW: - Heartburn/Indigestion
- Nausea/ Vomiting
UMBILICAL:
-BUMP/Bulge near umbilical
area
-Burning or tenderness
-Pain when lifting something
heavy or when exercising
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PARALYTIC ILEUS
-Pressure in abdomen
Labs: WBC’s
Dx Tests: Barium Swallow w/
Flouroscopy, X-RAY, Physical
exam
PARALYTIC ILEUS Assess: Presence of bowel Nursing Interventions: Nursing Dx:
sounds, Pharm/TX: NG Tube w/ -Impaired bowel elimination
Patho: Paralytic ileus is the occurrence
Vitals: N/A (See S & S below ) Continuous suction, Fluid and r/t constipation and
of intestinal blockage in the absence of
S/S & PHYS. EXAM: Electrolyte replacement, decreased dietary intake
an actual physical obstruction. This type
- Abdominal swelling, distension Pt. Ed: Avoid opiods and -Risk for shock r/t lack of body
of blockage is caused by a malfunction in
or bloating anticholingergics. fluid volume
the nerves and muscles in the intestine-
-Constipation Common causes of Paralytic
impairing digestive movement. Causes
-Diarrhea Ileus: Pt. Goals/ Evaluation:
include: Electrolyte imbalances,
-Foul-smelling breath -Appendicitis -Bowel Elimination as
gastroenteritis, appendicitis,
-Gas -Botulism evidenced by Comfort of
pancreatitis, surgical complications, and
-Absent bowel sounds -Certain medications, such as passage of stool, stool is soft
obstruction of the mesenteric artery,
-Nausea w/without vomiting opiates/ sedatives and formed, passage of stool
which supplies blood to the abdomen.
- Stomach pain/spasms -Diabetic ketoacidosis (DKA) is achieved without aids
Certain drugs and medications, such as
-Electrolyte imbalance -Pt will exhibit stable vital
opioids/sedatives, can cause ileus by
Labs: N/A -Gastroenteritis signs, consistently stable
slowing peristalsis (contractions that
Dx Tests: CT w/ Contrast, X- -Neonatal necrotizing input and output, as well as
propel food through the
Rays, Clinical Evaluation enterocolitis (disease that satisfactory fluid and
digestive tract)
causes death of intestinal tissue nutritional intake to meet the
in newborns) patients specific needs and
avoid shock
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ISCHEMIC BOWEL/COLITIS
-Obstruction of the mesenteric
artery, which supplies blood to
the abdomen
-Pancreatitis
-Surgical complications
Surgery: Colonoscopic
decompression, cecostomy
(RARELY)
ISCHEMIC BOWEL/COLITIS Assess: For signs and Nursing Interventions: Nursing Dx:
symptoms of sock/infection Pharm: IV fluids, Antibiotics (to -Risk for shock r/t inadequate
Patho: Ischemia occurs secondary to
Vitals: TEMP/ HR, BP (if prevent infection) Treatment tissue perfusion
hypo-perfusion of an intestinal
shock) for comorbidity/ underlying -Impaired bowel elimination
segment. When hypo-perfusion occurs,
S/S & PHYS. EXAM: condition (Ex.- CHF) r/t constipation and
collateral blood flow may preclude or
Abdominal pain: Pt. Ed: AVOID decreased dietary intake
minimize ischemia; however, the regions
o Abdominal pain is usually VASOCONSTRICTORS!!
of the intestine with a solitary arterial
worse after meals and may be Surgery:
supply, and the watershed areas, are
suddenly severe IF NEEDED (Depending on the Pt. Goals/ Evaluation:
both at increased risk of developing
o Cramping abdominal pain Cause), Surgery to: -Pt will exhibit stable vital
ischemia. The degree of intestinal injury
o Generalized abdominal pain -Remove dead/ischemic tissue signs, consistently stable
is dependent on the duration and
o Upper/Lower abdominal pain -Bypass/Repair blockage in input and output, as well as
severity of ischemia.
Abdominal tenderness intestine/intestinal artery satisfactory fluid and
-In turn, Ischemia can cause Acute or
o Right lower abdominal -Repair a hole in your colon nutritional intake to meet the
sub-acute mucosal sloughing and
tenderness - Remove part of intestinal tract patients specific needs and
ulcerations. The loss of the mucosal
o Left lower abdominal that is narrowed/causing a avoid shock
barrier allows for bacterial translocation
tenderness blockage -Bowel Elimination as
and toxin absorption. Re-perfusion injury
o Right upper abdominal evidenced by Comfort of
can also occur if blood supply is re-
tenderness passage of stool, stool is soft
established after a prolonged
o Left upper abdominal and formed, passage of stool
interruption. Segments of bowel which
tenderness is achieved without aids
do not cause acute necrosis or
o Upper abdominal tenderness
perforation can heal with stenosis or
o Lower abdominal tenderness
stricture. These can cause ischemic
Blood in the stool:
bowel disease with long-term effects
o Black stool
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VOLVULUS
that can be: Mild and chronic or acute o Rectal bleeding
and resolved. o Red stools
o Maroon stools
o Constipation
o Indigestion
o Diarrhea
o Nausea/Vomiting
o Anorexia
Labs: ↑WBC, Blood in GI Tract
Dx Tests: Cinical Assessment,
Endoscopy, Angiogram, Doppler
Ultrasound or CT Scan of
Abdomen
VOLVULUS Assess: Auscultate for high- Nursing Interventions: Nursing Dx:
pitched bowel sounds, “rushing” Pharm: Analgesics for pain, -Ineffective breathing pattern
Patho: A volvulus is a bowel
sounds or absence of bowel antibiotics for infection, IV Fluid r/t abdominal distension
obstruction with a loop of bowel that has
sounds replacement to facilitate interfering with normal lung
abnormally twisted on itself
Vitals: ↓BP, ↑HR, ↑TEMP perfusion and prevent shock expansion
(Signs of infection/Shock) Pt. Ed: -Ineffective tissue perfusion:
S/S & PHYS. EXAM: -Smaller feedings are GI r/t bowel obstruction
-Severe abdominal pain recommended, because large
-Nausea quantities of food overload the Pt. Goals/ Evaluation:
-Vomiting (A lot of Bile) stomach and promote gastric -Pt will exhibit normal
-Bloody Stools reflux. breathing pattern, effective
-Abdominal Distension -Encourage to eat slowly and depth, and report little to
-Palpable Mass to chew all food thoroughly so know difficulty breathing as
that it can pass easily into the well as Sp02 within normal
Strangulating obstruction is obstruction Labs: Stool Sample, stomach limits for patient
with compromised blood flow; it occurs Blood/Electrolyte abnormalities -Pt will exhibit stable vital
in nearly 25% of patients with small- (↓Na, K, Chl. r/t vomiting), ↑HG Surgery: Surgical repair of signs, consistently stable
bowel obstruction. It is usually & WBC’s (r/t strangulation) Volvulus input and output, as well as
associated with hernia, volvulus, and satisfactory fluid and
intussusceptions. Strangulating nutritional intake to meet the
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DIVERTICUITIS
obstruction can progress to infarction Dx Tests: Upper GI X-ray WILL patients specific needs and
and gangrene in as little as SHOW “COFFEE BEAN SIGN → ) avoid shock
6 h. Barium enema, CT scan
DIVERTICUITIS Assess: Auscultate for ↓Bowel Nursing Interventions: Nursing Dx:
sounds Pharm: Analgesics/Pain -Pain r/t inflamed bowel and
Patho: Diverticulitis is a common
Vitals: ↑HR, ↑RR, ↑TEMP Management, Bulk Laxatives, possible peritonitis
digestive disease particularly found in
S/S & PHYS. EXAM: Stimulant Laxatives, Saline -Impaired bowel elimination
the large intestine. Diverticulitis
-Tenderness, usually in the LLQ Laxatives, Stool softeners, r/t constipation and
develops from diverticulosis, which
(left lower quadrant) Antibiotics such as decreased dietary intake
involves the formation of pouches
-Bloating or gas Metronidazole (FLAGYL),
(diverticula) on the outside of the colon.
-Fever and chills Antisposmodics Pt. Goals/ Evaluation:
Diverticulitis results if one of these
-Nausea and vomiting - Pt will report pain at
diverticula becomes inflamed.
-Anorexia Pt. Ed: tolerable level and verbalize
Labs: ↑WBC’s, ↓H&H Risk Factors for Dicerticula: ways to manage it
Dx Tests: Abdominal X-Ray, • Low-fiber diet -Bowel Elimination as
colonoscopy, barium enema • Chronic constipation evidenced by Comfort of
• Obesity passage of stool, stool is soft
Risk Factors for Diverticulitis: and formed, passage of stool
• Bacteria / food trapped in is achieved without aids
diverticula
• Infection/Inflammation
• Most common site for
diverticulitis is the Sigmoid
colon, because of fecal masses
that irritate and increase
pressure in the colon.
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RESECTION OF INTESTINES
Surgery: To remove the
diseased/infected part of colon
RESECTION OF INTESTINES Assess: For signs of infection, Nursing Interventions: Nursing Dx:
peritonitis, shock Pharm: Enema, Antibiotics, -Pain r/t inflamed bowel and
Patho: Small bowel resection is surgery
Vitals: TEMP Analgesics for pain, IV Fluids, possible peritonitis
to remove part or all of your small
S/S & PHYS. EXAM: Depends Anesthesia -Impaired bowel elimination
bowel. It is done when part of your small
on the reason for bowel Pt. Ed: BOWEL PREP!! r/t constipation and
bowel is blocked or diseased. The small
resection surgery! Many If you have laparoscopic decreased dietary intake
bowel is also called the small intestine.
diseases or ailments can lead to surgery:
Most digestion (breaking down and
this surgery s an option -You will have 3 - 5 small cuts in Pt. Goals/ Evaluation:
absorbing
(Cancer? Polyp Groths? your lower belly. The surgeon - Pt will report pain at
nutrients) of the food you eat takes place
Tumors?) will pass a camera tolerable level and verbalize
in the small intestine.
Labs: CBC and medical instruments ways to manage it
Dx Tests: Abdominal through these cuts -Bowel Elimination as
Ultrasound, CT Scan, EKG, Chest -You may also have a cut of evidenced by Comfort of
X-Ray, about 2 to 3 inches if your passage of stool, stool is soft
surgeon needs to put a hand and formed, passage of stool
inside your belly to feel the is achieved without aids
intestine or remove the -The patient will remain free
diseased segment from signs or symptoms of
-Your belly will be filled with gas infection
to expand it. This makes it easy
for the surgeon to see
and work
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RESECTION OF INTESTINES
If you have open surgery, you
will probably have a cut about
6 inches long in your mid-belly:
-Your surgeon will locate the
part of your small intestine that
is diseased
-Then your surgeon will put
clamps on both ends of this part
to close it off
-The surgeon will remove the
diseased part
In both kinds of surgery:
-If there is enough healthy small
intestine left, your surgeon will
sew or staple the healthy ends
of the small intestine back
together
-If you do not have enough
healthy small intestine to
reconnect, your surgeon will
make an opening called a
stoma through the skin of your
belly. Your small intestine will
be attached to the outer wall
of your belly. Stool will go
through the stoma into a
drainage bag outside your
body. This is called an
ileostomy. The ileostomy may
either be short term or
permanent
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INFLAMMATORY BOWEL DISEASE
INFLAMMATORY BOWEL Assess: Color, volume Nursing Interventions: Nursing Dx:
DISEASE frequency and consistency of Pharm: Anti-Diarrheals, -Pain r/t inflamed bowel
stools, monitor F&E levels for Aminosalicyates (5-ASA’s), -Impaired bowel elimination
Patho:
dehydration Immune Modulators (Humira), r/t constipation and
CROHNS!!
Ulcerative colitis Vitals: TEMP (Low-grade) TPN, Corticosteroids, decreased dietary intake
• Is an inflammatory disease of the S/S & PHYS. EXAM: Multivitamin and supplemental
submucosal layer of the colon and CROHNS!! Iron,
rectum characterized by continuously Ulcerative colitis Pt. Ed: Refrain from foods that Pt. Goals/ Evaluation:
occurring ulcerations and shedding of • Severe diarrhea containing can be irritating to the bowel! - Pt will report pain at
intestinal epithelium. Fat deposits and pus, blood and mucosa Oral fluids, tolerable level and verbalize
muscular hypertrophy result in a narrow, • Abdominal cramping and Surgery: IF needed, ways to manage it
short, and thickened bowel.
tenderness, fever Proctolectomy with Ileostomy/ -Bowel Elimination as
• Anorexia and weight loss Colectomy with ileostomy evidenced by Comfort of
• Usually occurs in the passage of stool, stool is soft
descending colon and rectum and formed, passage of stool
Labs: H&H, C-Reactive protein, is achieved without aids
WBC,
Dx Tests: Abdominal X-Ray
COLORECTAL CANCER Assess: Risk factors of colon Nursing Interventions: Nursing Dx:
cancer, Recently changed bowel Pharm: Analgesics for pain -Anticipatory grieving r/t
Patho: Colorectal cancer is a disease in
habits Pt. Ed: Don’t miss your annual change in body function and
which normal cells in the lining of the
Vitals: Normal unless infection, checkups!! Use of colostomy perceived potential death of
colon or rectum begin to change, start to
possibly TEMP bag, avoid food that cause odor patient
grow uncontrollably, and no longer die.
S/S & PHYS. EXAM: and gas, Medical supply stores - Disturbed body image r/t
These changes usually take years to
Ascending (Right) Colon Cancer locally to obtain bags/materials loss of diseased body
develop; however, in some cases of
-Occult blood in stool part/loss of good health
hereditary disease, changes can occur
-Anemia
within months to years. Both genetic and
-Anorexia and weight loss Surgery: Colostomy
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COLORECTAL CANCER
environmental factors can cause the -Abdominal pain above Pt. Goals/ Evaluation:
changes. Initially, the cell growth appears umbilicus -Pt will identify and express
as a benign (noncancerous) polyp that -Palpable mass feelings appropriately,
can, over time, become a cancerous Distal Colon/Rectal Cancer verbalize understanding of
tumor. If not treated or removed, a -Rectal bleeding the dying process, and
polyp can become a potentially life- -Changed in bowel habits support to cope
threatening cancer. Recognizing and -Constipation or Diarrhea - Client will discuss concerns,
removing -Pencil or ribbon – shaped stool what to expect after
precancerous polyps before they - Tenesmus chemo/surgery, and ways to
become cancer can prevent colorectal -Sensation of incomplete bowel limit anxiety about body
cancer! emptying image
Dukes’ Classification of
Colorectal Cancer
-Stage A: Confined bowel
mucosa, 80-90% 5-year survival
rate
-Stage B: Invading muscle wall
-Stage C: Lymph node
involvement
-Stage D: Metastases or locally
unresectable tumor, less than
5% 5-year survival rate
Labs:
Dx Tests: Colonoscopy
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HIP FRACTURE
5. ORTHOPEDICS (BONES)
DIAGNOSIS/PATHO DATA ACTION RESPONSE
HIP FRACTURE Assess: For Nursing Interventions: Nursing Dx:
Hemhorrage and Pharm: Analgesics for pain, Antibiotics -Pain r/t injury
Patho: Fracture pathophysiology includes
SHOCK!! **ALSO for surgery prep, FLUIDS/BLOOD as -Risk for Shock r/t
cortical disruption, peri-osteal damage, and
ASSESS for distal necessary, *** blood loss/Injury
damage to the intra-medullary and cancellous
pulses to ensure Pt. Ed: Instruct client regarding
architecture. Histomorphometric studies have
circulation! Observe fracture Pt. Goals/ Evaluation:
shown that cortical thinning and some decrease
for signs of thrombo- healing process, diagnostic procedures, - Pt will report pain at
in trabecular bone mass and connectivity can be
phlebitis, report treatment and its complications, home tolerable level and
seen especially in Osteoporosis suggesting a
immediately care, daily activities, diet, restrictions verbalize ways to
lower quality of bone, and thus decreased
and follow-up. Encourage fluid intake manage it
mechanical strength resulting in fracture. An
Vitals: PAIN, BP, and high protein, high vitamin, high- -Pt will show signs of
age-related decline in osteocyte viability has
HR, calcium diet. Teach the client adequate tissue
also been observed in experimental studies. An
S/S & PHYS. EXAM: appropriate crutch walking perfusion including
inflammatory response also occurs following
-Inability to move techniques stable vital signs and
fractures of the proximal femur.
immediately after a fall fluid status
-Severe pain in your Surgery: Hip Fracture repair, specific to
hip or groin injured site:
-Inability to put weight
on your leg on the side
of your injured hip
-Stiffness, bruising and
swelling in and around
your hip area
-Shorter leg on the side
of your injured hip
-Turning outward of
your leg on the side of
your injured hip
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TOTAL KNEE REPLACEMENT (TKR)
Labs: CBC, PTT, PT,
INR, H&H
Dx Tests: X-RAY of
Hip, MRI
TOTAL KNEE REPLACEMENT (TKR) Assess: Assess Nursing Interventions: Nursing Dx:
wound/surgical Pharm: Anti-Coagulants, -Pain r/t surgical
Patho: Knee replacement, or knee
incision for signs and NSAIDS/Analgesics for pain (Including procedure
arthroplasty, is a surgical procedure to replace
symptoms of infection Morphine PCA) -Impaired mobility r/t
the weight bearing surfaces of the knee joint to
following surgery and Pt. Ed: The operation typically involves injury/recent surgery
relieve the pain and disability of osteoarthritis.
for signs of shock, for substantial postoperative pain, and includes
It may be performed for other knee diseases vigorous physical rehabilitation. The recovery
pain, extreme Pt. Goals/ Evaluation:
such as rheumatoid arthritis and psoriatic period may be 6 weeks or longer and may
shortening, circulation/ - Pt will report pain at
arthritis. In patients with severe deformity from involve the use of mobility aids (e.g. walking
neurovascular status tolerable level and
advanced rheumatoid arthritis, trauma, or long frames, canes, crutches) to enable the
Vitals: PAIN, HR, verbalize ways to
standing Osteo- arthritis, the surgery may be patient's return to preoperative mobility. Use
RR of helpful items such as toilet seat extender,
manage it
more complicated and carry higher risk. Osteo-
S/S & PHYS. EXAM: Exercises to reduce risk of DVT -Patient will show signs
porosis does not typically cause knee pain,
Signs/Symptoms of Surgery: TKR is the surgery! and verbalize effective
deformity, or inflammation and is not a reason
whatever injury is ways to properly
to perform knee replacement.
causing the need for mobilize using
Other major causes of debilitating pain include
surgery! For Example… tools/physical
meniscus tears, cartilage defects, and ligament
-Pain assistance provided
tears. Debilitating pain from osteoarthritis is
-Inflammation
much more common in the elderly. Knee
-Difficulty moving your
replacement surgery can be performed as a
knee
partial or a total knee replacement. In general,
-Popping/Clicking of
the surgery consists of replacing the diseased or
knee
damaged joint surfaces of the knee with metal
-Joint Pain/Stiffness
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LONG BONE INJURY
and plastic components shaped to allow -Lack of range of
continued motion of the knee. motion
Labs: PT, PTT/INR,
CBC, H&H
Dx Tests: X-Ray, MRI,
Bone Scan
LONG BONE INJURY Assess: Distal Nursing Interventions: Nursing Dx:
pulses/neurovascular Pharm: Analgesics for pain -Pain r/ injury
Patho: When a bone is broken, the
status, signs of Pt. Ed: Instruct client about restrictions - Risk for peripheral
periosteum and blood vessels in the cortex,
infection, range of like not bending at waist or sitting with Neurovascular
marrow, and surrounding soft tissues are
motion, complications Buck traction and not turning below the dysfunction
disrupted. Bleeding occurs from the damaged
waist with Russell traction. Encourage
ends of the bone and from the neighboring soft
Vitals: PAIN, HR, client verbalize feelings and problems Pt. Goals/ Evaluation:
tissue. A clot (hematoma) forms within the
RR regarding fracture. - Pt will report pain at
medullary canal, between the fractured ends of
S/S & PHYS. EXAM: tolerable level and
the bone, and beneath the periosteum. Bone
-Pain at site verbalize ways to
tissue immediately adjacent to the fracture dies.
-Edema/swelling manage it
This necrotic tissue along with any debris in the
-Decreased range of -Pt will maintain
fracture area stimulates an intense
motion adequate tissue
inflammatory response characterized by
-Pressure at site perfusion AEB palpable
vasodilation, exudation of plasma and
-Muscle Spasms pulses, skin warm and
leukocytes, and
dry, normal sensation,
infiltration by inflammatory leukocytes and
Labs: CBC, H&H PT, stable vital signs, and
mast cells. Within 48 hours after the injury,
PTT/INR adequate urinary
vascular tissue invades the fracture area from
Dx Tests: X-RAY, MRI output for patient.
surrounding soft tissue and the marrow cavity,
and blood flow to the entire bone is increased.
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OSTEOARTHRITIS (OA)
Surgery: Repair as needed
OSTEOARTHRITIS (OA) Assess: For Nursing Interventions: Nursing Dx:
contributing factors Pharm: NSAIDS, Corticosteroids, Topical -Acute Pain r/t
Patho: The most common form of arthritis. such as: analgesics distension of tissues
It causes the deterioration of the joint cartilage -Female Pt. Ed: Safe use of mobility devices -Impaired physical
and formation of reactive new bone at the -Aging provided, Correctly performing exercises mobility r/t skeletal
margins and subchondral areas of the joint. This -Metabolic Disease as prescribed/treatment plan, physical deformity
chronic degeneration results from a breakdown -Smoker therapy, prevention of complication,
of chondrocytes, most often in the hips and -Obesity immuno-suppression caused by steroid Pt. Goals/ Evaluation:
knees. Osteoarthritis occurs equally in both -Repetitive use/abuse use - Pt will report pain at
sexes after age 40. of Joints Surgery: Total Joint arthroplasty, total tolerable level and
The earliest symptoms appear in middle age joint replacement as required verbalize ways to
and progress with advancing age. Depending on Vitals: PAIN manage it
the site and severity of joint involvement, S/S & PHYS. EXAM:
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RHUMATOID ARTHRITIS (RA)
disability can range from minor limitation of the -Joint pain -Pt will maintain a
fingers to near immobility in persons with hip or -Joint stiffness position with absence r
knee disease. Progression rates vary; joints may -Joint tenderness limitation of
remain stable for years in the early stage of -Limited range-of- contractures, and
deterioration. motion display
-Crepitus (crackling, techniques/behaviors
grinding noise with that enable
movement) continuation of
-Joint effusion activities
(swelling)
-Local inflammation
-Bony enlargements
and osteophyte
formation
Labs:
Dx Tests: Bone scan,
Dual Energy X-Ray
Absorptiometry Scan
(DEXA-Scan)
RHUMATOID ARTHRITIS (RA) Assess: For Nursing Interventions: Nursing Dx:
contributing factors Pharm: NSAIDS, Corticosteroids, -Acute Pain r/t
Patho: Rheumatoid arthritis (RA) is a chronic,
such as: Disease Modifying Anti-Rheumatic distension of tissues
systemic inflammatory disorder that may affect
-Female drugs (DMARDs) like METHOTREXATE, -Impaired physical
many tissues and organs, but principally attacks
-Physical and LEFLUNOMIDE, BIOLOGIC RESPONSE mobility r/t skeletal
the joints producing an inflammatory synovitis
Emotional Stress MODIFIERS (BRM) administered deformity
that often progresses to destruction of the
-Young to middle age parenterally HUMIRA, ENBREL
articular cartilage and ankylosis of the joints.
-Family History Pt. Ed: Use of mobility devices and Pt. Goals/ Evaluation:
Rheumatoid arthritis can also produce diffuse
safety, prevention of - Pt will report pain at
inflammation in the lungs, pericardium, pleura,
Vitals: PAIN infection/complications, Physical therapy tolerable level and
and sclera, and also nodular lesions, most
S/S & PHYS. EXAM: exercises/Rehab, verbalize ways to
common in subcutaneous tissue under the skin.
-Tender, warm, manage it
Although the cause of rheumatoid arthritis is
swollen joints Surgery: Total Joint arthroplasty, total -Pt will maintain a
unknown, autoimmunity plays a pivotal role in
joint replacement as required position with absence r
its
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GOUT
chronicity and progression. About 1% of the -Morning stiffness that limitation of
world’s population is afflicted by rheumatoid may last for hours contractures, and
arthritis, women three times more often than -Firm bumps of tissue display
men. Onset is most frequent between the ages under the skin on your techniques/behaviors
of 40 and 50, but people of any age arms (rheumatoid that enable
can be affected. It can be a disabling and painful nodules) continuation of
condition, which can lead to substantial loss of -Fatigue, fever and activities
functioning and mobility. It is diagnosed chiefly weight loss
on symptoms and signs, but also with blood
tests (especially a test called rheumatoid factor) Labs: Positive
and X-rays. Diagnosis and long-term Rheumatoid factor,
management are synovial fluid analysis,
typically performed by a rheumatologist, an antinuclear antibody
expert in the diseases of joints and connective test, Erythrocyte
tissues. sedimentation rate, C-
Reactive protein
Dx Tests: X-Ray, MRI
GOUT Assess: Nursing Interventions: Nursing Dx:
Vitals: Pharm: -Impaired Physical
Patho: Gout is a disorder of purine metabolism
S/S & PHYS. EXAM: Short-Term Relief: Corticosteroids, Mobility r/t pain
characterized by elevated uric acid levels with
-Intense joint pain. Ibuprofen/ NSAIDS, Colchicines **DO
deposition of urate crystals in joints and other
Gout usually affects NOT TAKE ASPIRIN, AS IT CAN RAISE Pt. Goals/ Evaluation:
tissues. High uric acid levels result from
the large joint of your URIC ACID LEVELS IN THE BLOOD! -Patient will show signs
decreased excretion of uric acid (90% of cases)
big toe, but it can Uricosuric agents (Help to increase and verbalize effective
due to a wide variety of causes. The disorder
occur in elimination of uric acid by the kidneys) ways to properly
may progress from an asymptomatic stage
your feet, ankles, Xanthine oxidase inhibitors (decreases mobilize using
through acute gouty arthritis, to chronic
knees, hands and uric acid production by the body) tools/physical
tophaceous gout.
wrists. The pain is likely Colchicine (prevents flare-ups during the assistance provided
to be most severe
first months you have gout and are
within the
taking other medicines to lower uric acid
first 12 to 24 hours
levels)
after it begins.
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GOUT
-Lingering discomfort. Pegloticase (Krystexxa) Last resort, for
After the most severe Gout that hasn't responded to other
pain subsides, some treatment.
joint discomfort may Pt. Ed: Obesity, Excessive alcohol
last from a few days to intake, Meats and fish high in purine and
a few weeks. Later diuretics can cause Gout to flare up.
attacks are likely to last Complications include erosive deforming
longer and affect more arthritis, uric acid kidney stones, and
joints. urate nephropathy caused by hyper-
-Inflammation and uricemia. Utilize rest periods to minimize
redness. The affected additional pain.
joint or joints become
swollen, tender and Surgery:
red.
Labs: Uric Acid
Dx Tests:
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PAD (PERIPHERAL ARTERY DISEASE)
6. VASCULAR DISORDERS
DIAGNOSIS/PATHO DATA ACTION RESPONSE
DX: Assess: Assess skin Nursing Nursing Dx:
for: Dependent Interventions: -Chronic pain r/t
PAD (PERIPHERAL ARTERY DISEASE) rubor, cyanosis, Pharm: Anti- intermittent
ulcers, gangrene, coags: (Heparin, claudication/ischemia
Patho: Peripheral ARTERIAL disease (PAD) is a systemic decreased sensation Lovenox, Aspirin, -Activity intolerance r/t
atherosclerotic process for which the major risk factors are similar or pulses Coumadin), Anti- peripheral oxygen supply
to those for atherosclerosis in the carotid, coronary, and other Vitals: Cap Refill, Platelets (Trental, and demand
vascular beds. Among the traditional risk factors for PAD, those Unequal/Weak Plavix), Vasodilators - Risk for impaired skin
with the strongest associations are advanced age, smoking, and Pulses, Pain (Isoxsuprine, integrity r/t altered
diabetes mellitus. More recently, a number of nontraditional risk S/S & PHYS. EXAM: papaverine) circulation/sensation
factors for PAD have also been recognized. This article briefly Painful cramping in Pt. Ed: Good foot
reviews the pathophysiology of PAD and the your hip, thigh or calf care, do not cross Pt. Goals/ Evaluation:
evidence supporting established and emerging risk factors for its muscles after legs, stop smoking, -Client will report
development. activity, such as regular exercise, increased comfort level
walking or climbing healthy diet, and adequate pain
stairs (inter-mittent monitor/report control
claudication), Leg symptoms - Client will demonstrate
numb-ness or Surgery: increased tolerance to
weakness, Cold Angioplasty, Arterial physical activity and
feeling in your lower revasculartization, utilize the use of rest
leg or foot, especially artherectomy, periods
when compared with arterial bypass (at -Client will be free from
the other leg, Sores arterial blockage), signs of impaired skin
on your toes, feet or thrombectomy integrity during their
legs that won't heal, hospital stay.
A change in the color
of your legs, Hair loss
or slower hair
growth on your feet
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PVD (PERIPHERAL VASCULAR DISEASE)
and legs, Slower
growth of your
toenails, Shiny skin
on your legs, No
pulse/weak pulse in
your legs or feet, ED
in men
Labs: Total
Cholesterol, LDL
(Lousy Cholest.), HDL
(Happy Cholest.),
Lipids, Triglycerides
Dx Tests:
Angiogram, Exercise/
Stress Test, Skin
temperature studies,
Oscillometry
Dx: Assess: Cool, brown Nursing Interventions: Nursing Dx:
skin, Edema, ulcers, Pharm: Anti-coags: (Heparin, - Ineffective Tissue Perfusion:
PVD (PERIPHERAL VASCULAR pain, Normal or Lovenox, Aspirin, Coumadin), peripheral r/t interruption of
decreased pulses, Pt. Ed: Good foot care, do not vascular flow
DISEASE)
open wounds cross legs, stop smoking, regular -Ineffective health maintenance r/t
Patho: Peripheral VASCULAR disease, also Vitals: Cap Refill, exercise, healthy diet, deficient knowledge regarding
known as arteriosclerosis obliterans, is Unequal/Weak monitor/report symptoms, avoid disease process
primarily the result of athero-sclerosis. The Pulses, Pain extreme temperatures, Use TED
atheroma consists of a core of cholesterol S/S & PHYS. EXAM: hose/Compression stockings
joined to proteins with a fibrous The most common Surgery: thrombectomy, Pt. Goals/ Evaluation:
intravascular covering. This process may symptom of peripheral Angioplasty, Arterial -Pt. will demonstrate adequate
gradually progress to complete occlusion of vascular disease in the revasculartization, tissue perfusion AEB palpable
medium and large arteries. The disease legs is pain in one or artherectomy, arterial bypass (at peripheral pulses, and warm and dry
typically is segmental, with significant both calves, thighs, or
arterial blockage) skin
variation from patient to patient. Vascular hips. The pain usually
occurs while you are
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PVD (PERIPHERAL VASCULAR DISEASE)
disease may manifest acutely when walking or climbing -Pt. will verbalize understanding of
thrombi, emboli, or acute trauma stairs and stops when the disease process and adhere to
compromises perfusion. Thromboses often you rest. This is because the prescribed medication regimen
occur in the lower extremities more the muscles' demand for
blood increases during
frequently than in the upper extremities.
walking and other
Multiple factors pre-dispose patients for exercise. The narrowed
thrombosis. These factors include sepsis, or blocked arteries
hypotension, low cardiac output, cannot supply more
aneurysms, aortic dissection, bypass grafts, blood, so the muscles
and underlying atherosclerotic narrowing of are deprived of oxygen
the arterial lumen. Emboli, the most and other nutrients. This
common cause of sudden ischemia, usually pain is called
are of cardiac origin (80%); they also can intermittent (comes and
originate from proximal atheroma, tumor, goes) claudication. It is
usually a dull, cramping
or foreign objects. Emboli tend to lodge at
pain. It may also feel like
artery bifurcations or in areas where vessels a heaviness, tightness,
abruptly narrow. The femoral artery or tiredness in the
bifurcation is the most common site (43%), muscles of the legs.
followed by the iliac arteries (18%), the Cramps in the legs have
aorta (15%), and the popliteal arteries several causes, but
(15%). cramps that start with
exercise and stop with
rest most likely are due
to intermittent. When
the blood vessels in the
legs are completely
blocked, leg at night is
very typical, and the
individual almost always
hangs his or her feet
down to ease the pain.
Hanging the legs down
allows for blood to
passively flow into the
distal part of the legs
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ANEURYSMS
Labs: Total
Cholesterol, LDL
(Lousy Cholest.), HDL
(Happy Cholest.),
Lipids, Triglycerides
Dx Tests: Isotope
Studies, Ultra-Sonic
flow detection
Doppler Studies,
Venous Pressure
measurements
Dx: Assess: For Nursing Interventions: Nursing Dx:
increasing severity of Pharm: Pre-surgical -Risk for deficient fluid
ANEURYSMS symptoms, **SUDDEN Meds/Antibiotics, Anti- volume r/t potential
RELIEF OF A PAINFUL Hypertensives (to reduce blood hemorrhage
Patho: An aneurysm is a permanent localized dilation ANUERYMS IS A BAD pressure and decrease a chance -Fear/Anxiety r/t
of an artery. This can enlarge the artery. The locations SIGN!! LIKELY MEANS of rupture), Beta Blockers, emergency condition
can differ, as well as the type and how they form, with THAT THE ANUERYSM Calcium Channel Blockers,
DISSECTING being the most life-threatening: HAS RUPTURED AND
Vasodilators, Anti-Lipid/Plaque Pt. Goals/ Evaluation:
IMMEDIATE SURGERY
IS REQUIRED!!
meds (STATINS!) -Pt will show no signs of
Vitals: HR (Weak Pt. Ed: Reduce stress, STOP hypovolemia/shock, and
pulses distal to SMOKING!! Lower BP, Healthy maintain fluid and
aneurysm), BP, Diet/Lifestyle, Monitor changes electrolytes within
RR to doctor, adhere to medication acceptable levels for
S/S & PHYS. EXAM: regimen. Patient
1. AORTIC: AAA Surgery: Open abdominal -Pt will verbalize fears
Types/Location: (Abdominal Aortic Chest repair, Endovascular and Anxiety and ways to
1. AORTIC Aneurysm) w/ Repair (Aneurysm not removed cope with such fears
2. CEREBERAL gnawing pain/pulsing but strengthened):
3. PERIPHERAL in abdomen/back,
Thoracic Aortic
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ANEURYSMS
Aneurysm : Pain
radiates up to jaw,
neck,
coughing/hoarseness,
shoulder blade pain.
2. CEREBERAL:
Aneurysm in brain,
“Worst headache of
your life”,
nausea/vomiting,
pain behind eyes,
3. PERIPHERAL: ,
Pulsations, pains and
sores in extremities,
also gangrene (due to
lack of circulation)
Labs: Blood work
such as Hg and Hct,
Coags, checking for
bleeding, monitoring
for signs of
hypovolemia
Dx Tests:
Ultrasound,
Echocardiogram,
Angiogram, MRI, CT
Scan
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ASTHMA
7. RESPIRATORY
DIAGNOSIS/PATHO DATA ACTION RESPONSE
ASTHMA Assess: Assess for change in Nursing Interventions: Nursing Dx:
skin color/cyanosis, use of Pharm: PREVENTATIVE THERAPY: -Activity Intolerance r/t
Patho: Bronchial asthma is a
accessory muscles/labored (Flovent, Serevent, Singulair) RESCUE energy shift to meet muscle
chronic inflammatory disease of the
breathing (Is this an attack or DRUGS (Albuterol, Atrovent, needs for breathing to
airways, associated with recurrent,
emergency?) Also changes in Theophylline) overcome airway
reversible airway obstruction with
mentation/ALOC Pt. Ed: STOP SMOKING!! Adhere to obstruction
intermittent episodes of wheezing
Vitals: Shallow RR medication regimen as prescribed, -Anxiety r/t inability to
and dyspnea. Bronchial hyper-
(Commonly with Audible Reduce stress, monitor symptoms daily breathe effectively
sensitivity is caused by various
Wheezing), HR during especially signs of an attack, report -Ineffective breathing
stimuli, which innervate the vagus
attacks increasing symptoms to doctor. pattern r/t anxiety
nerve and beta adrenergic receptor
S/S & PHYS. EXAM: Surgery: N/A
cells of the airways, leading to
Feeling of tightness in the Pt. Goals/ Evaluation:
bronchial smooth muscle
chest, difficulty in breathing or -the patient will be able to
constriction, hypersecretion of
shortness of breath, wheezing, demonstrate
mucus, and mucosal edema.
coughing (particularly at behaviors to improve
night). airway clearance
Labs: O2/cap. Refill, -Client will report ability to
hypoxemia breathe comfortably
Dx Tests: Chest X-Rays, &
Pulmonary Fx tests:
Forced Vital Capacity/FVC
(Volume of air exhaled from
full inhalation to full
exhalation), Forced Expiratory
Volume in the first
Second/FEV1 (Vol. of air blown
out as hard as possible in the
first SECOND of the most
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BRONCHITIS
forceful exhalation after the
greatest inhalation & Peak
Expiratory Flow (Fastest
airflow reached at any time
during exhalation)
BRONCHITIS Assess: Assess respiratory Nursing Interventions: Nursing Dx:
rate, depth. Note use of Pharm: Antibiotics for infection, Cough -Ineffective airway
Patho: Bronchitis is an
accessory muscles, pursed lip meds/Expectorants, NSAIDS clearance r/t excessive
inflammation of the air passages
breathing, Inability to speak. Pt. Ed: STOP SMOKING!! Adhere to thickened mucus secretion
within the lungs. It occurs when the
Evaluate level of activity medication regimen as prescribed, -Anxiety r/t potential
trachea (windpipe) and the large and
tolerance. Reduce stress, monitor symptoms daily chronic condition
small bronchi (airways) within the
Vitals: RR, especially signs of an attack, report
lungs become inflamed because of
S/S & PHYS. EXAM: increasing symptoms to doctor. Pt. Goals/ Evaluation:
infection or other causes.
Chronic Bronchitis: Surgery: N/A -Client will demonstrate
History of productive cough effective coughing and clear
that lasts 3 months per year breath sounds
for 2 consecutive years, -Client will identify,
Persistent cough, known as verbalize, and demonstrate
smoker’s cough usually in cold techniques to control
weather, Persistent sputum anxiety.
production, Recurrent acute
respiratory infection, Dusky
color leading to cyanosis,
Clubbing of fingers
Labs: O2/cap. Refill,
hypoxemia, H&H
Dx Tests: Chest X-RAY,
Sputum test, Pulmonary FX
Tests (See above)
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COPD (CHRONIC OBSTRUCTIVE PULMONARY DISEASE)
COPD (CHRONIC Assess: Assist patient to Nursing Interventions: Nursing Dx:
OBSTRUCTIVE PULMONARY assume position of comfort Pharm: Short and long acting -Activity intolerance r/t
DISEASE) (ex. Elevate head of bed, Bronchodilators (tiotropium (Spiriva) imbalance between oxygen
encourage patient to lean on salmeterol (Serevent) formoterol supply and demand
Patho: COPD disrupts airway
side bed table (Perforomist), OXYGEN! -Ineffective Health
dynamics, resulting in obstruction of
or sit on the edge of the bed Pt. Ed: STOP SMOKING!! Adhere to Maintenance r/t deficient
airflow into or out of the lungs.
Vitals: RR (Shallow) medication regimen as prescribed, knowledge regarding care
Chronic Bronchitis: Hypertrophy and
S/S & PHYS. EXAM: Chronic Reduce stress, monitor symptoms daily of disease
hypersecretion in goblet cells and
cough, SOB while performing especially signs of an attack, report
bronchial mucus glands leading to
ADL’S (dyspnea), Frequent increasing symptoms to doctor. Pt. Goals/ Evaluation:
increased sputum secretions,
respiratory infections, *Alternate activity and rest periods to -Client will participate in
bronchial congestion, narrowing of
Cyanosis, Fatigue, Producing a prevent fatigue physical activity and
bronchioles, and small bronchi.
lot of mucus/ Surgery: Lung Reduction, Lung demonstrate appropriate
Emphysema: Increased size of air
phlegm/sputum), Wheezing Transplant **For selected cases only, changes in heart rate,
spaces (i.e. “dead space”) with loss of
Labs: ABG’s, H&H, O2 end-stage COPD breathing rate and blood
elastic recoil of lung due to
Dx Tests: Chest X-RAY, pressure
hyperinflation of distal airways
Sputum test, Pulmonary FX -Client will follow mutually
causing airway obstruction.
Tests (See above), & agreed health maintenance
Destruction of alveolar walls and
Spirometry plan
diffuse airway narrowing causes
resistance to airflow because of loss
of supporting structure and
bronchospasm further impede
airflow.
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EMPHYSEMA
EMPHYSEMA Assess: Assess for signs Nursing Interventions: Nursing Dx:
and symptoms of hypoxia and Pharm: Bronchodilators, Expectorants, -Activity intolerance r/t
Patho: Decreased pulmonary
hypercapnia, Monitor/record Corticosteroids, Oxygen imbalance between oxygen
elastic recoil. At any pleural pressure,
blood gas examination, Pt. Ed: STOP SMOKING!! Adhere to supply and demand
the lung volume is higher than
examine trend in the increase medication regimen as prescribed, -Ineffective Health
normal. Additionally, the altered
or decrease in PaO2 or PaCO2 Reduce stress, monitor symptoms daily Maintenance r/t deficient
relation between pleural and
Vitals: RR especially signs of an attack, report knowledge regarding care
alveolar pressure facilitates
(SOB/Adventitious lung increasing symptoms to doctor. of disease
expiratory dynamic compression of
sounds), HR, O2 *Alternate activity and rest periods to
airways. Such compression limits
S/S & PHYS. EXAM: prevent fatigue Pt. Goals/ Evaluation:
airflow during forced expiration and,
Shortness of Breath, Rapid Surgery: Lung Reduction, Lung -Client will participate in
in severe instances, during tidal
Breathing, Chronic Cough Transplant **For selected cases only, physical activity and
expiration. Another factor
(With or Without Sputum), Emphysema NOT caused by smoking demonstrate appropriate
contributing to airflow limitation is
Wheezing, Reduced Exercise changes in heart rate,
disease of the airways,
Tolerance, Loss of Appetite breathing rate and blood
both large and small. In general,
Leading to Weight Loss, Barrel pressure
patients with relatively pure
Chest -Client will follow mutually
emphysema maintain blood gases in
Labs: CBC, O2, ABG’S agreed health maintenance
or near the normal range until very
Dx Tests: Chest X-RAY, plan
late in their course. PaO2 is
Pulmonary Fx Tests, CT scan
maintained because of the preserved
matching of ventilation and
perfusion as alveolar walls are
destroyed. PaCO2 is maintained
because the ventilatory response to
CO2 is not usually impaired. It is not
clear why patients who are
categorized clinically as "chronic
bronchitics" are more likely to
respond to an increased flow-
resistive work of breathing by
hypoventilating. Physical findings in
emphysema are not specific.
Radiologic changes are insensitive
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HEMOTHORAX
and are of less value than physiologic
measurements.
HEMOTHORAX Assess: Trauma (penetrating Nursing Interventions: Nursing Dx:
or blunt) Signs of Shock or Pharm: Oxygen, Morphine/ analgesics -Deficient Fluid Volume r/t
Patho: Roughly Translated,
Arrest for pain, Antibiotics for infection blood in pleural space
HEMOTHORAX means blood (HEMO)
Vitals: O2 Sat, RR, HR Pt. Ed: Sit in High-Fowlers, Monitor -Ineffective breathing
in the pleural cavity (THORAX). This
S/S & PHYS. EXAM: Dyspnea, chest tube/dressing pattern r/t chest pain/lung
condition can be caused by a number
Cyanosis, Tachypnea, Surgery: Chest tube insertion/ injury
of factors, when anything penetrates
Hyperventilation, Dullness on drainage system
the pleural wall causing blood to
percussion, Pt. Goals/ Evaluation:
enter the pleural space, including a
Diminished/Absent lung -Patient will maintain blood
gun shot wound or stabbing. A
sounds pressure, pulse, body
hemothorax is managed by removing
Retained Hemothorax: In this temperature and breathing
the source of bleeding and by
case, patients can be hypoxic, patterns within acceptable
draining the blood already in the
short of breath, or in some range for patient
thoracic cavity. Blood in the cavity
cases, the retained -
can be removed by inserting a drain
hemothorax can become
(chest tube) in a procedure called a
infected (empyema).
tube thoracostomy. Usually the lung
Labs: H& H, CBC, Red Blood
will expand and the bleeding will
Cell, ABG’s, PT, INR
stop after a chest tube is inserted.
Dx Tests: Chest X-Ray ,
The blood in the chest can thicken as
Thoracentesis, MRI
the clotting cascade is activated
when the blood leaves the blood
vessels and is activated by the
pleural surface, injured lung or chest
wall, or contact with the chest tube.
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PNEUMOTHORAX
As the blood thickens, it can clot in
the pleural space (leading to a
retained hemothorax) or within the
chest tube, leading to chest tube
clogging or occlusion. Chest tube
clogging or occlusion can lead to
worse outcomes as it prevents
adequate drainage of the pleural
space, contributing to the problem of
retained hemothorax.
PNEUMOTHORAX Assess: Trauma (penetrating Nursing Interventions: Nursing Dx:
or blunt) Signs of Shock or Pharm: Oxygen, Morphine/ analgesics -Ineffective Breathing
Patho: Pneumothorax refers to gas
Arrest for pain, Antibiotics for infection, O2 pattern r/t decreased lung
within the pleural space. Normally,
Vitals: O2 Sat, RR, HR Pt. Ed: Sit in High-Fowlers, Monitor expansion
the alveolar pressure is greater than
S/S & PHYS. EXAM: Dyspnea, chest tube/dressing, verbalize signs of - Risk for Suffocation r/t
the intrapleural pressure, while the
Cyanosis, Tachypnea, infection, medication compliance dependence on external
intrapleural pressure is less than
Hyperventilation, Dullness on Surgery: Chest tube insertion device (Chest Tube)
atmospheric pressure.
percussion,
Therefore, if a communication
Diminished/Absent lung Pt. Goals/ Evaluation:
develops between an alveolus and
sounds -Pt will establish a normal
the pleural space or between the
Labs: H& H, CBC, Red Blood and effective breathing
atmosphere and the pleural space,
Cell, ABG’s, PT, INR pattern with ABG’s within
gases will follow the pressure
Dx Tests: Chest X-Ray , normal range for patient
gradient and flow into the pleural
Thoracentesis, MRI -Pt will recognize need for
space. This flow will continue until
assistance to prevent
the pressure gradient no longer
complications
exists or the abnormal
communication has been sealed.
Since the thoracic cavity is normally
below its resting volume, and the
lung is above its resting volume, the
thoracic cavity enlarges and the lung
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PNEUMONIA
becomes smaller when a
Pneumothorax develops.
-A tension Pneumothorax is a
medical emergency and occurs when
the intrapleural pressure exceeds
atmospheric pressure, especially
during expiration, and results from a
ball valve mechanism that promotes
inspiratory accumulation of pleural
gases. The build-up of pressure
within the pleural space eventually
results in hypoxemia and respiratory
failure from
compression of the lung.
PNEUMONIA Assess: For respiratory Nursing Interventions: Nursing Dx:
shock, abnormal sputum, Fluid Pharm: Antibiotics, Antipyretics, anti- -Impaired gas exchange r/t
Patho: Pneumonia is an acute
status inflammatory, bronchodilators changes in alveolar
inflammatory disorder of lung
Vitals: Pt. Ed: Medication membrane
parenchyma that results in edema of
S/S & PHYS. EXAM: Administration/compliance, -Ineffective airway
lung tissues and movement of fluid
Tachypnea, Tachycardia, Pneumonia/Influenza vaccine clearance r/t inflammation
into the alveoli. These impair gas
Crackles, Productive cough, Surgery: chest tube/Thoracentesis and secretion build-up
exchange resulting in hypoxemia.
WBC, O2 Sat. Dyspnea w/
Pneumonia can be classified in
Pleural pain, chills, fever, Pt. Goals/ Evaluation:
several ways. Based on microbiologic
diaphoresis -Pt will show improved
etiology, it may be viral, bacterial,
Labs: WBC, Sputum culture ventilation and gas
fungal, protozoa, myobacterial,
and sensitivity (C&S) exchange,
mycoplasmal, or rickettsial in origin.
Dx Tests: Chest X-Ray, Pulse -Pulmonary Ventilation is
Based on location, pneumonia may
Oximetry adequate with no secretion
be classified as broncho-pneumonia,
build-up
lobular pneumonia, or lobar
pneumonia. Broncho-pneumonia
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PULMONARY EMBOLISM
involves distal airways and alveoli;
lobular pneumonia, part of the lobe;
and labor pneumonia, the whole
lobe.
PULMONARY EMBOLISM Assess: Respiratory Status Nursing Interventions: Nursing Dx:
and Vital signs, IV access, Signs Pharm: Anti-thrombolytics/clot- -Impaired gas exchange r/t
Patho: A thrombus that has
of Stroke/Shock, Position of busters (tPA if within 3 Hour time decreased pulmonary
separated from its site of origin
comfort/HIGH FOWLERS frame) , Anticoagulants, OXYGEN perfusion
travels through the circulation to the
Vitals: HR, O2 Sat. Pt. Ed: Follow up on labs (PT/INR), -Acute Pain r/t pulmonary
inferior vena cava. The right ventricle
RR (Dyspnea) Report new symptoms/worsening pain. flow obstruction
pumps this thrombus to the
S/S & PHYS. EXAM: Preventative measures/ medication ,
pulmonary arteries where the
*PETICHIAL RASH PRESENT Dietary precautions (Vitamin K), Pt. Goals/ Evaluation:
thrombus
WITH FAT EMBOLISM! Chest Bleeding Precautions, Follow up on -Pt will demonstrate
finally lodges. PE may occur singly or
Pain, Anxiety, Diaphoresis, PT/INR improved ventilation and
multiply. They can be microscopic in
Pleural Effusion, Surgery: Embolectomy, Vena Cava adequate oxygenation as
size or be big enough to occlude the
crackles/cough filter evidenced by ABG’s within
major branches of the pulmonary
Labs: D-dimer, H&H, CBC normal limits for patient
artery. Recurrent PE may gradually
Dx Tests: Chest X-Ray, MRI, -Pt. will report pain at a
obstruct the pulmonary vasculature
Pulmonary Angiography comfortable and tolerable
and ultimately lead to chronic
level
obstructive pulmonary hypertension
and cor pulmonale.
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RESPIRATORY FAILURE
RESPIRATORY FAILURE Assess: Chest Pain, SOB, Nursing Interventions: Nursing Dx:
Restless, anxiety, confusion, Pharm: Oxygen, Diuretics (Lasix), -Ineffective breathing
Patho: Respiratory failure can arise
**ASSESS FOR SIGNS OF Nitroglycerin (To reduce preload/ pattern r/t decreased lung
from an abnormality in any of the
SHOCK afterload), Morphine compliance
components of the respiratory
Vitals: RR, HR, O2, (Pain/Venodilation), Beta2 Agonists -Impaired respiratory
system, including the airways,
BP (Albeuterol, Terbutaline), Atrovent, function r/t inability to
alveoli, central nervous system (CNS),
S/S & PHYS. EXAM: Corticosteroids (Methylprednisolone) maintain adequate
peripheral nervous system,
Bluish coloration of the lips or Pt. Ed: Sit in a position of comfort oxygenation of the
respiratory muscles, and chest wall.
fingernail, Confusion or loss of (one that promotes effective breathing) respiratory tract and
Patients who have hypoperfusion
consciousness, Fainting or such as High Fowlers, medication perfusion of oxygen
secondary to cardiogenic,
change in level of compliance, Oxygen use and need,
Hypovolemic, or septic shock often
consciousness or lethargy report new/worsening symptoms. Pt. Goals/ Evaluation:
present with respiratory failure.
Fatigue, Irregular heart rate Surgery: Tracheotomy/Ventilator if -Pt will report ability to
(arrhythmia), Rapid breathing needed, (AIRWAY IS ALWAYS #1!!), breathe comfortably and
(tachypnea) or shortness of Lung Transplant (if eligible) -Client will exhibit positive
breath signs of perfusion including
Labs: CBC, Chem Panel, O2 Sat. levels and ABG’s
Serum Creatinine Kinease & within normal patient limits
Troponin (To rule out MI) and
TSH (To rule out
hypothyroidism)
Dx Tests: Monitor location of
embolism if any, Chest X-Ray,
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TUBERCULOSIS
TUBERCULOSIS Assess: *AIRBORNE Nursing Interventions: Nursing Dx:
ISOLATION PRECAUTIONS!! Pharm: -Ineffective breathing
Patho: Tuberculosis is an infectious
Assess Lung sounds, COMBINATION DRUG THERAPY: pattern related to
disease caused by the Myobacterium
Hemoptysis, Monitor Isonazid (INH), Rifampin, Pyrazinamide, acute infection and
Tuberculosis. Transmission occurs
Liver/Kidney function Streptomycin, Ethambutol decreased lung
when droplet nuclei are produced
Vitals: TEMP (low grade) Pt. Ed: Prevent the spread of this capacity
form an infected person’s coughs or
S/S & PHYS. EXAM: Cough, airborne infection! Practice good hand -Risk for infection (spread)
sneezes. (AIRBORNE ROUTE). If
Hemoptysis, Low grade hygiene, cover mouth when coughing or r/t lowered
inhaled, tubercle bacillus settles in
fever/NIGHT SWEATS, sneezing, ensure medication resistance/suppressed
the alveolus and infection occurs,
Anorexia/Weight-loss, compliance as well as diligent follow up inflammatory process
with alveolocapillary dilation and
Malaise/Fatigue appointments
endothelial swelling. The incubation
Labs: POSITIVE Sputum *AS A MEDICAL PROFESSIONAL, ALL Pt. Goals/ Evaluation:
time for TB is 4 to 8 weeks. TB is
Culture for for acid-fast DIAGNOSED CASES OF TB MUST BE - Pt’s breathing will return
usually asymptomatic in primary
bacillus (AFB), Serum analysis, REPORTED TO LOCAL/STATE HEALTH to rate and pattern within
infection. The risk of TB is a higher in
Serum Analysis QFT-G DEPARTMENT! their normal limits
older people who have close contact
(Quantiferon Tuberculosis - Surgery: N/A -Pt will exhibit minimal or
with a newly diagnosed TB
Gold) no signs of infection.
patient, those who have TB before,
Dx Tests: Chest X-RAY,
gastrectomy patients, and those
Mantoux Tuberculin skin test
affected with diabetes mellitus. The
(TST)
aging process weakens the immune
system, further increasing the
likelihood of tubercular infection in
older adults.
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URI (UPPER RESPIRATORY INFECTION)
URI (UPPER RESPIRATORY Assess: Lung breath sounds, Nursing Interventions: Nursing Dx:
INFECTION) labor of breathing, cough, Pharm: Treat the cause! If infection -ineffective Airway
related symptoms (strep throat, epiglottitis & bacterial Clearance related to
Patho: A URI is a common infection
Vitals: Temp sinusitis): Antibiotics, Common cold thick secretions and airway
that affects the nose, throat and
S/S & PHYS. EXAM: Itchy, (Can only treat symptoms) with obstructions
airways. Caused by Bacteria and
watery eyes, nasal discharge, Tylenol/NSAID’s for fever/body aches, -Acute pain r/t swelling in
Viruses, this type of infection is very
nasal congestion, Steriods for broncho-inflammation, & throat
common and contagious as well.
Sneezing, sore throat, cough, Decongestants for nasal issues.
Examples include:
head- ache, fever, malaise, Pt. Ed: Decongestants are NOT Pt. Goals/ Evaluation:
Sinus infection, Common Cold (aka
fatigue, weakness, muscle recommended for Pt’s w/ high BP. -Pt will be able to cough
Rhinitus) nasopharyngitis,
pain Surgery: N/A effectively and
Laryngitis, Laryngotracheitis, and
Labs: Sputum/Culture clear own secretions, and
Tracheitis
Dx Tests: Sputum/Culture, maintain patency of airway
The common time of occurrence is in
Rapid strep test (if suspected), and had clear breath
the winter months, from September
Monospot test (If enlarged sounds
to March.
lymphnodes/Mono -Patient will report relief of
suspected), and pain with analgesic
Allerfy/Asthma evaluation administration
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ANGINA
8. CARDIAC (HEART)
DIAGNOSIS/PATHO DATA ACTION RESPONSE
ANGINA
Assess: Vital signs/pain such as Nursing Interventions: Nursing Dx:
Patho: Basic term for “Chest Pain”.
facial grimacing, rubbing of neck or Pharm: M – O – N – A -Acute Pain r/t
Commonly assoc. w/ CAD,
jaw, reluctance to move, increased MORPINE (Pain mgmt, last resort, decreased
cholesterol & plaque in vessels.
blood pressure, and tachycardia. can numb Pt./mask symptoms) myocardial blood
Triggered by phys. Activity/stress. SNS
Vitals: BP, HR, O2 SAT OXYGEN (O2 to left ventricle) flow
sys. Activates vasoconstriction of
S/S & PHYS. EXAM: pain (May NITROGYLCERIN ( vasodilation) -Activity Intolerance
vessels… smaller tube brings more O2
radiate down L arm), SOB, **Contraindicated in Pts on r/t acute
back to heart, brain and lungs, where it
Diaphoresis/Cool/Clammy skin, Vasodilators/Viagra! pain/dysrhythmias
is needed most. 2 types:
Syncope, anxiety ASPIRIN (Breaks up congregating plts)
Stable: caused by phys. Activity, but
Labs: Cardiac Enzymes, *Position Pt. in Semi-Fowlers Pt.
stops when activity stops. STABLE
Cholesterol/Lipids, H&H position. Goals/Evaluation:
STOPS!
Dx Tests: EKG, Echocardiogram, Pt. Ed: NO smoking, healthy diet, -Patient will be free
Unstable: Even after stopping activity,
Stress test, Angiogram limit sodium, exercise program, from pain, maintain
pain is still there. May be due to
stress, cholesterol, BP stable vital signs and
blockage/clot in artery, or a clot that
Surgery: Angioplasty/Stent, CABG show no visual signs
becomes loose as the vessels shrink
to check for and clear blockage if of pain
and expand. Lack of O2 to heart…Can
present. -Pt. will demonstrate
lead to MI/ Ischemia!!
tolerance to
activity. Assess
effectiveness of nitro;
assess vital signs,
pain control, as well
as Pt. S/S and EKG for
any sign of
infarction/
arrhythmias.
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ARRHYTHMIAS
ARRHYTHMIAS Assess: Assess and record Nursing Interventions: Nursing Dx:
apical pulse, peripheral pulses, Pharm: OXYGEN! Nitro -Activity intolerance
Patho: Disturbance in impulse
blood pressure, capillary filling time, (Vasodilator) r/t decreased cardiac
formation/conduction/communication.
fluid intake/output, and skin for RX Depends on the Arrhythmia: output
4 TYPES: Suppressed Automaticity (SA
striped skin, skin color, edema, PSVT/WPW Synd/A-Flutt: Diltiazem, -Decreased cardiac
node doesn’t fire effectively/up to
temperature, diaphoresis. Adenosine (Slows Vent. Rate by output r/t altered
speed, can lead to Pacemaker
Vitals: Pain, Change in AV Block). Digoxin (Supraventricular electrical conduction
Placement), Enhanced Automaticity
HR/Rhythm, O2, BP Arrhythmias)
(Can result in multiple arrhythmias,
S/S & PHYS. EXAM: Palpitations (a Pt. Ed: Report S/S to Physician, Pt.
ATRIAL & FIB. due to increased
feeling of skipped heart beats, Limit salt intake, Monitor B/P, Follow Goals/Evaluation:
rate/impulse) Triggered Activity (An
fluttering or feeling that your heart is up with meds as prescribed, DO NOT -Patient will
early or late depolarizations can
"running away"). Pounding in your take nitro w/ other Vasodilators like participate in phys.
trigger/ precipitate Ventricular
chest, Dizziness/ Syncope, SOB, Chest Viagra, Monitor BP/HR/Daily weights Activity with
arrhythmias… EX: torsades de pointes,
discomfort, Weakness or fatigue Surgery: Pacemaker to regulate appropriate changes
Digoxin Toxicity) & Re-entry (Current or
(feeling very tired). heart rate, Cardio-aversion, Vagal in vital signs.
past MI/infarction/scarring or a block
Labs: ECG/EKG, no blood tests to Stimulation (Temporary) -Patient will
at a node can conceal accessory
determine. demonstrate
pathways and cause the re-entry of the
Dx Tests: EKG adequate cardiac
conduction signal in the heart.
output AEB: BP, HR
and Rhythm within
normal parameters
for Patient and
without pain.
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ACUTE CORONARY SYND. (ACS)
ACUTE CORONARY SYND. Assess: Reported Pain, BP, Apical Nursing Interventions: Nursing Dx:
(ACS) HR & Urinary output. Pharm: Depends on the lipid levels, -Decreased cardiac
Vitals: Pain, BP, HR & O2 but most commonly used are the output r/t ischemia
Patho: Acute coronary syndrome is a
(may lead to bradycardia/inadequate “Statins” (ex. Atorvastatin/Lipitor, -Acute pain r/t
term used for any condition brought on
perfusion) Rosuvastatin/Crestor) myocardial issue
by sudden, reduced blood flow to the
S/S & PHYS. EXAM: Chest pain, Pt. Ed: Modify common risk factors, damage r/t
heart. Can be chest pain you feel
Referred pain, N/V, SOB, Diaphoresis including: Smoking, Tobacco use, inadequate blood
during a heart attack, or chest pain you
& Anxiety Diet, Exercise, Stress, Alcohol Use supply.
feel while you're at rest or doing light
Labs: Cholesterol, Triglycerides, Surgery: Angioplasty, Stent/Balloon
physical activity (unstable angina). It is
Blood Glucose, Serum Lipid levels placement, CABG if necessary. Pt.
believed that atherosclerotic plaque
Dx Tests: EKG (To rule out MI), Goals/Evaluation:
ruptures in the artery, resulting in clot
Computed tomography coronary -Patient will
formation and vasoconstriction, thus
angiography (CTCA), Angiogram (To demonstrate
leading to decreased cardiac output.
determine blockage, if any) adequate cardiac
The “Freeways”/ Arteries of your heart
output AEB: BP, HR
become blocked or Jammed.
and Rhythm within
normal parameters
for Patient and
without pain.
-Pt. will report that
pain management
regimen is
satisfactory to pain
tolerance standards.
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ATRIAL FIBRILLATION (A-FIB)
ATRIAL FIBRILLATION (A-FIB)
Assess: Pulses, urine output, blood- Nursing Interventions: Nursing Dx:
Patho:
tinged sputum, EKG strip & SIGNS of Pharm: Calcium Channel Blockers -Decreased Cardiac
1. Primary arrhythmia in the absence of
STROKE (ALOC, changes in speech, (Diltiazem), Antidysrhythmics Output r/t altered
identifiable structural heart disease
motor function, or facial droop) Amioderone (Unlabeled use), & electrical conduction
2. Secondary arrhythmia in the absence
Vitals: HR (Up to 350-600 Atrial Anticoagulants (Heparin, Coumadin, -Activity intolerance
of structural heart disease but in the
BPM) BP (r/t Cardiac output) Lovenox) r/t decreased cardiac
presence of systemic abnormality that
S/S & PHYS. EXAM: Palpitations, Pt. Ed: Advise Pt on blood thinners output
predisposes the individual to the
Dyspnea, Pulmonary edema, Signs of that regular blood tests may be
arrhythmia
cerebrovascular insufficiency, required, to take caution as excessive Pt. Goals/
3. Secondary arrhythmia associated
fatigue, distended jug. veins, bleeding may occur. Evaluation:
with cardiac disease that affects the
Labs: PT, PTT, INR, H&H, EKG Surgery: Cardioversion, Radio- -Patient will display
atria
Dx Tests: Trans-esophageal frequency Catheter Ablation (Creates adequate cardiac
CAN BE: Acute, Chronic, and
electrocardiogram (TEE) to assess for scar tissue to defer abnormal output AEB Pt’s
Lone/Primary.
signs of clots BEFORE cardioversion. pathways/rhythms of A-fib) & “Maze BP/HR/Rhythm are in
- Acute AF: This has an onset within 24-
Physiologic Mapping Studies (Before Procedure” (usually performed with normal parameters
48 hours of the causative event and
MAZE procedure) CABG, sutures are strategically placed for the client.
usually converts spontaneously or in
to prevent electrical circuits from -Patient will
response to an antiarrhythmic agent
causing AF) & Pacemaker implant. participate in phys.
(cardioversion).
Activity with
- Chronic AF - The most debilitating
appropriate changes
form of AF because of its abrupt onset.
in vital signs.
It may be persistent or permanent,
requires int./TX by cardioversion to
sinus rhythm.
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CARDIOGENIC SHOCK
CARDIOGENIC SHOCK Assess: Signs of inadequate tissue Nursing Interventions: Nursing Dx:
perfusion, including: Pulse, muscle Pharm: Meds to reverse shock: -Altered tissue
Patho: Signs and symptoms of
weakness, metabolic acidosis, Dopamine and dobutamine (to perfusion
cardiogenic shock reflects the nature of
shallow respirations, tachycardia, improve cardiac (cardiopulmonary)
the circulation/
cool, clammy skin. contractility), Vasopressors (Nitro), r/inadequate cardiac
patho of heart failure.
Vitals: HR, BP, RR, Epinepherine, Norepinepherine, output
MI/Dysrrhythmias and
O2/Cap. Refill, Temp. Fluids
Cardiomyopathies cause heart damage
S/S & PHYS. EXAM: Anxiety, (Blood/Plasma/Platelets/Crystalloids/ Pt.
resulting in decreased cardiac output,
restlessness, altered mental state Colloids), Diuretics (Lasix, HCTZ), Goals/Evaluation:
BP out of artery to the vital organs.
due to decreased cerebral perfusion Oxygen Circulation status;
Blood flow to coronary arteries
and Pt. Ed: Teach Pt. how to reduce Cardiac pump
Oxygen to the heart leading to
subsequent hypoxia. Hypotension controllable risk factors for heart effectiveness; Tissue
ischemia and Heart's ability to
due to decrease in cardiac output. disease. Encourage attendance perfusion:
pump, thus causing inadequate
Rapid/weak/thready pulse, Ensure the patient understands the Cardiopulmonary,
perfusion of body tissues = SHOCK
tachycardia, Cool/clammy/mottled medication prescribed. Cerebral, Renal,
skin, Distended jugular veins. Oliguria Surgery: Immediate re-perfusion (Pt Peripheral; Vital sign
Labs: ABG’s (For signs of acidosis) is taken to Cardiac Cath. Lab and status *Evaluate for
as well as CVP (Central Venous immediate Left sided heart signs of
Pressure) Hemodynamic monitoring, catheterization, PCI (Percutaneaous arrhythmia/MI/Shock
H&H, CK-MB/Cardiac panel to rule Coronary Intervention) stent/balloon. to prevent relapse.
out MI. *Pt. may be intubated/on ventilator Assess Pt’s vital signs
Dx Tests: EKG, Echocardiogram for O2 support for values within
acceptable limit.
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CABG (Coronary Artery Bypass Graft)
CABG (Coronary Artery Assess: Signs of anxiety, decreased Nursing Interventions: Nursing Dx:
Bypass Graft) cardiac output/Hemodynamics, chest Pharm: O2, Aspirin, Heparin/ - Risk for reduced
pain, and feeling of impending doom. Lovenox/Coumadin, Nitro for chest cardiac output r/t
Patho: Essentially Building a “SIDE-
Assess pulses, heart rate, EKG and O2 pain depressed cardiac
STREET” The occluded coronary arteries
perfusion, Pre/Post Op. Pt. Ed. and function
are bypassed with the client’s own venous
or arterial blood vessel or synthetic grafts. allergies. Pt. Ed: Schedule uninterrupted - Risk for bleeding r/t
The internal mammary artery (IMA) is the rest/sleep periods, assistance incision site/surgery
best choice for success over a long period Vitals: O2, BP, Peripheral with/Early ambulation, Turn, Cough, - Anxiety r/t
of time for patency. Recommended for pulses, RR Deep breath as ordered, monitor site surgery/hospital stay.
patients that do not respond to other S/S & PHYS. EXAM: Pt may be for signs of infection/bleeding
forms of medication and treatment Other grimacing, chest pain, SOB, Tacypnea, Surgery: CABG is the surgery! Pt. Goals/
indications include: Angina with 50% or arrhythmias/elevated ST wave, JVD, AFTER CABG: Observe for ALOC, Evaluation : Patient
more occlusion of main Coronary artery ALOC will be able to
that cannot be stented, Acute
demonstrate
MI/Cardiogenic shock, Ischemia with heart
Labs: Cardiac enzymes, ABG, hemodynamic
failure, Valvular disease, coronary arteries
not suitable for Percutaneaous Cholesterol, Lipids stability such as
transluminal coronary angioplasty (PTCA), Dx Tests: EKG, PTCA, Echo- stable blood pressure
or those who have signs of ischemia or cardiogram, Stress test and adequate cardiac
pending MI after PTCA. output
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CHF (Congestive Heart Failure)
CHF (Congestive Heart Failure) Assess: Apical pulses for Rate/Rhythm, Nursing Interventions: Nursing Dx:
Assess skin for pallor/cyanosis, Monitor Pharm: O2, Diuretics, as indicated - Decreased cardiac
Patho: Heart failure means the tissues of urine output for decrease, and dark
the body are temporarily not receiving as
Pt. Ed: Fluid/Sodium restriction, output r/t impaired
concentrated urine. ALOC Combine ADL’S/Alternate breaks, cardiac function
much blood and oxygen as needed. Vitals: O2, HR,
Whether acute or chronic, there is much Relaxation/ Stress, - Excessive fluid
S/S & PHYS. EXAM: Dysrhythmias
risk associated with Heart Failure, each set Left-sided heart failure
Surgery: Heart Transplant is volume r/t impaired
of systems assoc. w/ a side of the heart *Dyspnea on exertion or orthopnea ULTIMATE CHOICE, but if not, VAD excretion of sodium
(see next column) Think ANATOMICALLY: *Moist crackles on lung auscultation (Ventricular Assist Device *usually and water
The two upper chambers are called atria *Frothy, blood-tinged sputum used as a bridge until surgery), PLV - Impaired gas
and the two lower chambers are called *Tachycardia with S3 heart sound (Partial Left Ventriculectomy), exchange r/t
ventricles. The right atrium and right *Pale, cool extremities Endoventricular Circular Patch, Acorn excessive fluid in
ventricle receive blood from the body * Peripheral and central cyanosis Cardiac Support Device, Myosplint interstitial space of
through the veins (DE-OXYGENATED) and * peripheral pulses, capillary refill
then pump the blood to the lungs. The left
lungs/alveoli
time * urinary output (<30 ml/hour)
atrium and left ventricle receive blood *Fatigue* Insomnia/restlessness
from the lungs and pump it out through Pt. Goals/
Right-sided heart failure
the aorta into the arteries (OXYGENATED), * Dependent pitting edema (peripheral
Evaluation :
which feed all organs and tissues of the and sacral) * Weight gain * Nausea/ - The patient will be
body with oxygenated blood. Because the anorexia Jugular vein distention (JVD) able to display vital
left ventricle has to pump blood to the * Hepatomegaly, ascites or weakness signs within
entire body, the LEFT VENTRICLE a Left and right-sided heart failure: acceptable limits,
stronger pump than the right ventricle. *Cardiomegaly dysrhythmias
*Vascular congestion of lung fields controlled and no
*Electrocardiogram identifies symptoms of failure.
hypertrophy or MI/damage
ABG (Arterial blood gas) studies reveal
decreased partial pressure of arterial
oxygen (95%),
Labs: ABG, Cardiac Enzymes
Dx Tests: EKG, PTCA, Echo-
cardiogram, Stress test
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CAD (Coronary Artery Disease)
CAD (Coronary Artery Assess: Pain, anxiety, Activity Nursing Interventions: Nursing Dx:
Disease) intolerance, Pharm: Cholesterol meds (STATINS), - Acute pain related
Vitals: BP, HR , Cap. Refill Nitro for Chest Pain, Anti- to the imbalance o
Patho: Chronic disease of the
time/ Oxygenation platelets/Anti-Coagulants myocardial oxygen
Coronary arteries, where over time
S/S & PHYS. EXAM: Pt. Ed: Healthy diet, exercise as supply and demand.
plaque has built up and hardening has
-Angina directed by doctor - Ineffective tissue
occurred causing a “narrowing” of the -Nausea and vomiting Surgery: Angioplasty, Stent/Balloon perfusion related to
artery walls, similar to a “TRAFFIC JAM” -Dizziness and syncope placement, CABG myocardial ischemia
on the freeway… LESS LANES ARE -Diaphoresis clammy skin and decreased
OPEN! Because of this, the built-up -Apprehension or a sense of impending
cardiac output.
plaque can occlude partially (causing doom
- Anxiety related to
stable angina) or completely (Causing Labs: Lipids, Cholesterol
pain, feeling of
UNSTABLE angina). Dx Tests: Echocardiogram, Stress
impending doom,
test, Angiogram
lifestyle
changes/diagnosis of
CAD.
Pt. Goals/
Evaluation: Reduce
pain, Prevent angina
episodes by
balancing
rest/activity, achieve
and maintain a
suitable blood
pressure for patient.
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HTN (Hypertension)
HTN (Hypertension) Assess: Headache Nursing Interventions: Nursing Dx:
Vitals: HR BP: Pharm: Beta Blockers (Metropolol, -Ineffective health
Patho: Chronic High Blood pressure
Atenolol, Carvedilol *BETA BLOCKERS maintenance r/t
due to some or a combination of many
like to LOL!! ) Diuretics (Aldactone, deficient knowledge
factors/Imbalances in the body. When
Furosemide, HCTZ), ACE Inhibitors, of disease process
blood volume falls or blood flow to the
Calcium Channel Blockers, - Risk for prone
kidneys decreases, juxtaglomerular
Vasdilators behavior r/t lack of
cells in the kidneys secrete renin into
Pt. Ed: Monitor Blood Pressure knowledge about the
the bloodstream. In sequence, renin
Daily, Daily weights, side effects of disease
and angiotensin converting enzyme
meds, Modifiable risk factors
(ACE) act on their substrates to S/S & PHYS. EXAM: Surgery: May need surgery to repair Pt. Goals/
produce the active hormone Headache, dizziness, blurred vision, damage caused by chronic Evaluation:
angiotensin II, which raises blood nausea/vomiting, chest pain, SOB. hypertension, such as aneurysm -Pt will verbalize
pressure in two ways. First, angiotensin Heart attack, CHF, Stroke or transient
repair, kidney transplant/Dialysis, understanding of
II is a potent vasoconstrictor; it raises ischemic attack (TIA), Kidney failure, CABG disease process
blood pressure by increasing systemic Eye damage with progressive vision -Pt will check BP daily
vascular resistance. Second, it loss, Peripheral arterial disease and report significant
stimulates secretion of aldosterone, causing leg pain with walking changes
which increases re-absorption of (claudication), Aneurysms -Pt will adhere to
sodium ions and water by the kidneys. Labs: BP in all extremities, Checking
medication regimen
The water reabsorption increases total regularly -Pt will adhere to
blood volume, which increases blood Dx Tests: No DX tests are necessary,
ordered low salt diet
pressure. except when determining secondary
and exercise regimen
causes such as Renal Disease,
-Pt will change
Diabetes, and Atherosclerosis. Can modifiable risk
use an EKG to determine the level of factors
cardiac involvement.
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HYPERLIPIDEMIA (High Cholesterol)
HYPERLIPIDEMIA (High Assess: What is the Pt.’s diet? Any Nursing Interventions: Nursing Dx:
Cholesterol) past problems/family Hx of high Pharm: Statins! STATINS, STOP! -Inadequate
cholesterol? Is the Pt. Taking (Atorvastatin, Simvastatin, perfusion of body
Patho: Hyperlipidemia is an excess of
medication for it? Associated Lovastatin) Fibric Acids (Advicor, tissues r/t
fatty substances called lipids, largely
Diseases/Dx… Palpate pulses, assess Tricore) interruption of
cholesterol and triglycerides, in the
distal pulses for circulation, assess Pt. Ed: Modify diet/exercise, vascular flow
blood. It is also called hyper-
pulses for bruit compliance with medication, report - Insufficient
lipoproteinemia because these fatty
Vitals: BP new symptoms immediately. knowledge r/t
substances travel in the blood attached
S/S & PHYS. EXAM: Surgery: Stent/Balloon, CABG, disease process
to proteins. This is the only way that
Cholesterol/Lipid levels, May be angioplasty
these fatty substances can remain
obese, may have associated chest Pt.
dissolved.
pain, SOB, Cap. Refill/ Goals/Evaluation:
Circulation, Unequal pulses -Pt will verbalize
Labs: Total Cholesterol, HDL, understanding of
LDL, Lipid Panel, Triglycerides healthy diet and
Dx Tests: Angiogram, exercise
Echocardiogram, Stress test -Pt. will be able to
state modifiable
factors
-Pt. will adhere to a
specific medication
regimen to reduce
cholesterol levels in
body
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DIABETES TYPE I
9. ENDOCRINE
DIAGNOSIS/PATHO DATA ACTION RESPONSE
DIABETES TYPE I Assess: For signs of Nursing Interventions: Nursing Dx:
hyperglycemia & Pharm: Insulin! -Risk for infection r/t
Patho: Diabetes Mellitus (DM)
hypoglycemia! Pt. Ed: Insulin compliance (maintain normal high glucose levels
is a chronic metabolic disorder
Vitals: HR, BP (Long- range!), Do not stop taking insulin if within normal -Lack of knowledge
caused by an absolute or relative
term) range! Diet management, education on the signs of r/t disease process
deficiency of insulin, an anabolic
S/S & PHYS. EXAM: The 3 hypo/hyperglycemia, long term education for
Hormone. Type 1 diabetes
P’s! POLURIA, POLYPHAGIA, complications, foot care, med-alert bracelet, “SICK Pt. Goals/
mellitus can occur at any age and
POLYDIPSIA! Extreme thirst, DAY RULES”: Evaluation:
is characterized by the marked
frequent urination, -Pt. will take proper
and progressive inability of the
drowsiness, lethargy, precautions and
pancreas to secrete insulin
increased appetite, sudden verbalize signs and
because of autoimmune
weight loss for no reason, symptoms of
destruction of the beta cells. It
sudden vision changes, sugar infection
commonly occurs in children,
in urine, ketones in urine, -Pt will be able to
with a fairly abrupt onset;
heavy or labored breathing, verbalize
however, newer antibody tests
unconsciousness understanding of
have allowed for the
Labs: Fasting plasma *EXAMPLE of Insulin Times (See you School/Hospital disease process and
identification of more people
glucose of 126 mg/dL or book/policy): daily management
with the new-onset adult form of
greater, Random plasma regimen
type 1 diabetes mellitus called
glucose of 200 mg/dL greater,
latent autoimmune diabetes of
Glucose tolerance test,
the adult (LADA). These patients
HbA1c, ABG’s, electrolytes,
are dependent on exogenous
Urine glucose tests, Thyroid
insulin. Type 1 diabetes
function
(formerly called juvenile-onset
Dx Tests: Same as labs
or insulin-dependent diabetes),
accounts for 5% to 10% of all
Surgery: N/A, unless organ
people with diabetes. In Type 1
complication as needed
diabetes, the body’s immune
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DIABETES TYPE II
system destroys the cells that
release insulin, eventually
eliminating insulin production
from the body. Without insulin,
cells cannot absorb sugar
(glucose), which they need to
produce energy.
DIABETES TYPE II Assess: Sign of Nursing Interventions: Nursing Dx:
Hyperglycemia, HHS Pharm: Anti-diabetic drugs, insulin as needed -Risk for infection r/t
Patho: Type 2 diabetes mellitus
(Hyperglycemic Pt. Ed: Teach strategies to prevent HHS, Regular high glucose levels
occurs when the pancreas
Hyperosmolar State) monitor blood glucose, adherence to insulin -Lack of knowledge
produces insufficient amounts of
Vitals: HR, BP (Long- regimen, regular blood tests, monitor for long term r/t disease process
the hormone insulin and/or the
term) effects
body’s tissues become resistant
S/S & PHYS. EXAM: Any Surgery: N/A Pt. Goals/
to normal or even high levels of
symptoms of DM Type 1, Evaluation:
insulin. This causes high blood
recurring or hard-to heal skin, -Pt. will take proper
glucose (sugar) levels, which can
gum or urinary tract precautions and
lead to a number of
infections, drowsiness, verbalize signs and
complications if untreated. Type
tingling of hands and feet, symptoms of
2 diabetes is a chronic medical
itching of skin and genitals. infection
condition that requires regular
Labs: Fasting plasma -Pt will be able to
monitoring and treatment.
glucose of 126 mg/dL or verbalize
Treatment, which includes
greater, Random plasma understanding of
lifestyle adjustments, self-care
glucose of 200 mg/dL greater, disease process and
measures, and sometimes
Glucose tolerance test, daily management
medications, can control blood
HbA1c, ABG’s, electrolytes, regimen
glucose levels in the near-normal
Urine glucose tests, Thyroid
range and
function
Minimize the risk of diabetes-
Dx Tests: N/A
related complications. Type 2
diabetes accounts for around
85% of all people with diabetes.
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HYPOGLYCEMIA
HYPOGLYCEMIA Assess: For tachycardia, Nursing Interventions: Nursing Dx:
diaphoresis, weakness, Pharm: Glucose Tabs/Glucagon! 15g of fast- acting -Risk for
Patho: Hypoglycemia, also
anxiety, ALOC Carbs (fruit juice, candies, honey) complications r/t
called low blood glucose or low
Vitals: HR, BP Pt. Ed: Knowledge of signs and symptoms of low glucose levels
blood sugar, occurs when blood
S/S & PHYS. EXAM: COLD hypoglycemia, ways to alleviate, Dietary -Risk for Infection r/t
glucose drops below normal
& CLAMMY = NEED SOME recommendations altered body
levels. Glucose, an important CANDY Hypoglycemia causes Surgery: N/A functions
source of energy for the body, symptoms such as hunger,
comes from food. Carbohydrates shakiness, nervousness, To Help you remember… Pt. Goals/
are the main dietary source of sweating, dizziness or light- Evaluation:
glucose. Rice, potatoes, bread, headedness, sleepiness, -Pt will be free from
tortillas, cereal, milk, fruit, and confusion, difficulty speaking, complications and
sweets are all carbohydrate-rich anxiety, weakness verbalize signs of
foods. After a meal, glucose is *Hypoglycemia can also hypoglycemia
absorbed into the bloodstream happen during sleep: Some -Pt will be free from
and carried to the body's cells. signs of hypoglycemia during infection and
Insulin, a sleep include: verbalize signs of
hormone made by the pancreas, crying out or having infection, as well as
helps the cells use glucose for nightmares, finding pajamas proper hand hygiene
energy. If a person takes in more or sheets damp from
glucose than the body needs at perspiration, feeling tired,
the time, the body stores the irritable, or confused after
extra glucose in the liver and waking up
muscles in a form called Labs: Blood Glucose test
glycogen. The body can use Dx Tests:
glycogen for energy between
meals. Extra glucose can also be
changed to fat and stored in fat
cells. Fat can also be used for
energy. When blood glucose
begins to fall, glucagon-another
hormone made by the pancreas-
signals the liver to break down
glycogen and release glucose into
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HYPERGLYCEMIA
the bloodstream. Blood glucose
will then rise toward a normal
level. In some people with
diabetes, this glucagon response
to hypoglycemia is impaired and
other hormones such as
epinephrine, also called
adrenaline, may raise the blood
glucose level. But with diabetes
treated with insulin or pills that
increase insulin production,
glucose levels can't easily return
to the normal range.
HYPERGLYCEMIA Assess: For general Nursing Interventions: Nursing Dx:
appearance of patient, signs Pharm: Depends on need!! Can take “anti-diabetic -Ineffective
Patho: High levels of serum
of DKA/HHS pills (Glyburide, Metformin) also INSULIN, as management of
glucose are excreted in the
Vitals: Temp prescribed, many also be given in a insulin pump. therapeutic regimen
kidneys, causing glycosuria which
S/S & PHYS. EXAM: HOT & Pt. Ed: Diet and exercise regimen should be r/t deficient
can lead to excessive osmotic
DRY = SUGAR HIGH, followed as prescribed by doctor. knowledge of
diuresis (polyuria). The impact of
Frequency in urination, Surgery: N/A disease process
polyuria would cause excessive
Thirst, Dry mouth, Urination -Risk for unstable
fluid loss, and
at night, Drowsiness or blood glucose r/t
followed the loss of potassium,
fatigue, Loss of weight, deviation from
sodium and phosphate. Due to
Increase in appetite, Slow normal range
lack of insulin the glucose cannot
healing of wounds, Blurriness
be converted into glycogen to
in vision, Dry and itchy skin, Pt. Goals/
increase blood sugar levels and
Rapid loss in weight, Evaluation:
hyper-glycemia occurs. The
Unconsciousness, Increased -Pt will verbalize
kidneys cannot resist
confusion or drowsiness, understanding of
hyperglycemia, and cannot filter
Breathing difficulty, Dizziness proper care and
out and absorb the amount of
when you stand up, Coma testing of blood
glucose in the blood. The sugar,
sugar as well as the
which absorbs all the excess
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HYPERGLYCEMIA
water removed with the urine is Labs: Blood Glucose, A1c, prescribed
called glycosuria. In glycosuria, Glucose tolerance test medications to
some water is lost in the urine, Dx Tests: Same as above manage it
called POLYURIA. Polyuria results -Pt will maintain
in intracellular dehydration, blood glucose level
which will stimulate the thirst within healthy limits
center so that patients will feel of the patient’s
constantly thirsty, so the patient condition.
will continue to drink and have
POLYDIPSIA. The lack of insulin
production will cause a decrease
in glucose transport into the cells
so the cells are starved of food
and stores carbohydrates, fats
and proteins to be depleted.
Because it is used to burn as fuel
the body, then the client will feel
hungry and eat, known as
POLYPHAGIA. Failure to restore
the body's homeostasis situation
will lead to hyper-glycemia,
hyperosmolar, excessive osmotic
diuresis and dehydration. Central
nervous system dysfunction due
to transport
oxygen to the brain disorder can
result in a coma.
Hemoconcentration increases
the blood viscosity (Thickness)
which may lead to the formation
of blood clots, thrombo-
embolism, cerebral infarction,
heart.
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DIABETIC KETOACIDOSIS (DKA)
DIABETIC Assess: For hyperglycemia, Nursing Interventions: Nursing Dx:
KETOACIDOSIS (DKA) Acetone (FRUITY) Breath, Pharm: REGULAR INSULIN! (IV @ 0.1 mg/kg/hr) -Imbalanced
ALOC, Orthostatic Saline/Fluids (To make up for body losses), nutrition less than
Patho: Diabetic ketoacidosis is a
Hypotension ELECTROLYTES as needed (ex. Potassium) body requirements
serious complication of diabetes
Vitals: HR, BP Pt. Ed: Proper testing of blood sugar, verbalization r/t biological factors
that occurs when your body
S/S & PHYS. EXAM: N/V, on signs/symptoms of DKA. “Sick Day Rules” , Teach -Knowledge
produces very high levels of
ABD pain, Exacerbated strategies to prevent DKA deficient (learning
blood acids called ketones.
Polyuria, Polydipsia and Surgery: N/A need) r/t condition/
Diabetic ketoacidosis develops
Polyphagia, ALOC, treatment regimen,
when you have too little insulin
weak/rapid pulse, Orthostatic self-care,
in your body. Insulin normally
hypotension, Kussmaul’s
plays a key role in helping sugar
respirations, blurred vision, Pt. Goals/
(glucose) which is a major source
headache, FRUITY BREATH!! Evaluation:
of energy for your muscles and
Labs: Blood Glucose! (CAN -Pt will maintain
other tissues — enter your cells.
VARY FROM 300-800MG/dL homeostasis and be
Without enough insulin, your
OR MORE!) ABG’s, CBC, free from signs of
body begins to breaks down fat
Chem 7 (To assess body for malnutrition
as an alternate fuel. In turn, this
dehydration/shock) -Pt will verbalize
process produces toxic acids in
Dx Tests: Same as above understanding of
the bloodstream called ketones,
condition/disease
eventually leading to diabetic
process and
ketoacidosis if untreated.
signs/symptoms of
complications
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APPENDICITIS
10. GALLBLADDER & LIVER & APPENDIX
DIAGNOSIS/PATHO DATA ACTION RESPONSE
Dx: Assess: For guarding, with pain in RLQ, Nursing Interventions: Nursing Dx:
Positive McBurney’s sign (Pain located the Pharm: PAIN -Acute pain r/t inflammation
APPENDICITIS right side of abdomen, located 1/3 the MANAGEMENT & of tissues
distance from the anterior superior iliac spine ANTIBIOTICS UNTIL -Risk for infection r/t
Patho: Appendicitis is usually to the umbilicus): SURGERY!! Continue Inadequate primary
caused by blockage of the lumen after surgery as well. defenses/surgery/perforation
of the appendix. Obstruction Possibly blood if lost in of tissues
causes the mucus produced by surgery.
mucous appendix suffered dam. Pt. Ed: Avoid applying Pt. Goals/ Evaluation:
The longer the mucus is more and heat to the area, - Pt will report pain at
more, but the elastic wall of the Monitor for tolerable level and verbalize
appendix has limitations that lead signs/symptoms of ways to manage it
to increased intra-luminal infection, mobility after -Pt will show no signs of
pressure. These pressures will surgery infection including: Elevated
impede the flow of lymph Surgery: temperature, WBC count,
resulting in mucosal edema and Vitals: TEMP APPENDECTOMY! as well as pain and swelling
ulceration. At that time there was S/S & PHYS. EXAM: Aching pain that begins **Must remove before at incision site
marked focal acute appendicitis around your navel and often shifts to your appendix perforation–
with epigastric pain. If the flow is lower right abdomen. The pain occurs when CAN CAUSE SEPTIC
disrupted arterial wall infarction you apply pressure to your lower right SHOCK!! Patient will
will occur followed by gangrene abdomen THEN, releases the pressure on that notice a “Sudden relief
appendix. This stage is called area. When released, the Pt. will feel A LOT of of pain” which is a BAD
appendicitis gangrenosa. If the pain!! (REBOUND TENDERNESS!!) Pain that SIGN!! Abdomen will
appendix wall fragile, there will be worsens if you cough, walk or make other become rigid, fever will
a perforation, called perforated jarring movements, also Nausea, Vomiting, SPIKE!
appendicitis. Loss of appetite, Low-grade fever,
Constipation, Inability to pass gas, Diarrhea,
Abdominal swelling
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CHOLECYSTITIS
Labs: WBC, CBC, hematologic tests pre-
surgery
Dx Tests: CT scan/Ultrasound to assess for
appendicitis,
Dx: Assess: For RUQ Epigastric pain, jaundice, Nursing Interventions: Nursing Dx:
contributing factors: Pharm: Analgesics, -Acute pain r/t
CHOLECYSTITIS THE 5 F’S!! Female, Forty, Fat, Fertile, Family Antiemetics, obstruction/spasm
Hx Anticholinergics, -Risk for deficient fluid
Patho: “INFLAMMATION OF THE Vitals: Temp, BP/HR (r/t Pain) Antibiotics, volume r/t excessive losses
GALLBLADDER” One of the most S/S & PHYS. EXAM: Nausea/ vomiting, Ursodeoxyxholic Acid due to vomiting
common types of cholecystitis is Tenderness in the right abdomen, Fever, Pain (Urso) to internally break
acute cholecystitis. This is when that gets worse during a deep breath, Dark up stones if possible Pt. Goals/ Evaluation:
the onset of inflammation of the colored urine, Pain for more than 6 hours, Pt. Ed: Manage a low- -Pt will report pain at
gallbladder is sudden and intense, particularly after meals. fat diet & exercise tolerable level and verbalize
with fast progression of the Labs: CBC, WBC, Liver Fx Tests, program, Care of T-Tube ways to manage it
disease. More often than not, the Amylase/Lipase Levels if sent home with one, -Pt will show evidence of
inflammation is caused due to Dx Tests: Ultrasound, Hepatobiliary scan, Prevent “Dumping adequate fluid volume by:
obstruction of the bile duct, which Endoscopic Retrograde Syndrome”: stable vital signs, moist
is known as calculous Cholangiopancreatography (ERCP), mucus membranes, good
cholecystitis, as they are caused Cholangiography, Abdominal X-RAY skin turgor, and urine output
due to gallstones, or cholelithiasis. within normal level for
There are other causes of acute patient
cholecystitis as well, such as
ischemia, chemical poisoning,
motility disorders, infections with
protozoa, collagen disease,
allergic reactions, etc. The
obstruction results in gallbladder Surgery:
distension, which results in edema Sphinterectomy with
of the cells lining the gallbladder. stone removal with
The lining wall of the gallbladder ERCP, Extracorporeal
may eventually undergo necrosis Shock Wave Lithotripsy
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HEPATITIS
and gangrene, which is known as (ESWL) to break up small
gangrenous cholecystitis. stones, Cholecystectomy
Dx: Assess: Depends on the type! Type B & C Nursing Interventions: Nursing Dx:
may be ASYMPTOMATIC, Type A can cause Pharm: -Fatigue r/t decreased
HEPATITIS “Flu-like” Symptoms, *SPECIFIC TO TYPE AND metabolic energy production
Vitals: Fever most common SYMPTOMS: -Risk for deficient fluid r/t
Patho: Inflammation that S/S & PHYS. EXAM: Circulation problems -Treat Symptoms for altered clotting factors (Hep
spreads to the liver (hepatitis) can (only toxic/drug-induced hepatitis), Dark urine, TYPE A C) or vomiting/anorexia (HEP
be caused by infection by viruses Dizziness (only toxic/drug-induced hepatitis), -Anti-viral drugs for TYPE A) and altered body
and toxic reactions to drugs and Drowsiness (only toxic/drug-induced hepatitis), B & C: Penginterferon- chemistry
chemicals. Basic functional units Enlarged spleen (only alcoholic hepatitis), alpha 2B (PEGLNTRON)
of the liver are called lobules, and Headache (only toxic/drug-induced Pt. Ed: PREVENT Pt. Goals/ Evaluation:
these units are unique because hepatitis),Hives, Itchy skin, Light colored feces, SPREAD OF INFECTION! -Pt will report increased
they have their own blood supply. the feces may contain pus, Yellow skin, whites Wash hands, Vaccines energy and is able to
Disruption of the normal blood of eyes, tongue (jaundice) for Types A & B, Avoid participate in ADL’s
supply to the cells causes hepatic “High-Risk” Behaviors - Pt will show evidence of
necrosis and damage to liver cells. such as unprotected sex, adequate fluid volume by:
After passing his time, the liver sharing/using unclean stable vital signs, moist
cells become damaged & needles, blood-to-blood mucus membranes, good
eliminated from the body by the contact, *NOT ELIGIBLE skin turgor, and urine output
immune system response and TO DONATE BLOOD within normal level for
replaced by new cells of a healthy Surgery: Liver patient
liver. Therefore, most clients who transplant if eligible
have hepatitis recovered with (Type C)
normal liver function.
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PANCREATITIS
Labs: Hepatitis Virus Panel, Antibody/Antigen
tests
Dx Tests: Liver Biopsy
Dx: Assess: For contributing factors such as: Nursing Interventions: Nursing Dx:
1. Excessive alcohol/drug use Pharm: Antibiotics, -Acute pain r/t obstruction of
PANCREATITIS 2. Gallstones Opiod analgesics/Pain pancreatic bile
3. Infection meds (Demorol is ducts/inflammation
Patho: Pancreatitis is an 4. Blunt Abdominal Trauma CONTRAINDICATED!), -Risk for deficient fluid
inflammatory disease, which 5. Surgical trauma/manipulation Anticholinergics, volume r/t loss of fluid from
varies in severity from mild to Also… TURNER’s SIGN (Bruising between the Pancreatic enzymes, vomiting/gastric suction
severe. Factors determining the last rib and the top of the hip) & CULLEN’s Proton pump inhibitors
severity of pancreatitis are not SIGN (Bruising of fatty tissue around umbilicus) (Omeprozole/Prilosec), Pt. Goals/ Evaluation:
known. It is generally believed TPN -Patient will report
that the earliest events in the Vitals: TEMP, HR, Sometimes BP controlled/relief of pain, and
evolution of acute pancreatitis S/S & PHYS. EXAM: Pt. Ed: adhere to medication
lead to premature intra-acinar cell regimen
activation
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CIRRHOSIS
of digestive zymogens and that Signs and symptoms of acute pancreatitis -Take Pancreatic - Pt will show evidence of
those enzymes, once activated include: enzymes before meals adequate fluid volume by:
cause acinar cell injury. Recent -Abdominal pain to the upper quadrants, and snacks stable vital signs, moist
studies have suggested that the radiates to the clients back and worsens after -High caloric diet/needs mucus membranes, good
ultimate severity of resulting meals -NO ALCOHOL! (Refer to skin turgor, and urine output
pancreatitis may be determined -Nausea and vomiting program as needed) within normal level for
by -Tenderness on the abdomen -Limit fat intake patient
events which occur subsequent to Signs and symptoms of chronic pancreatitis -Follow up with all
acinar cell injury. These include include: appts/lab work
inflammatory cell recruitment and -Upper abdominal pain
activation as well as the -Indigestion
generation and release of -Sudden weight loss Surgery: N/A (Unless
cytokines and other chemical -Steatorrhea (oily, foul smelling stools) eligible for transplant,
mediators of inflammation. ALCOHOL & DRUG
Labs: Liver enzymes, Bilirubin, Pancreatic RELATED NOT ELIGIBLE)
enzymes
Dx Tests: CT w/ contrast
Dx: Assess: For signs of Jaundice/Liver failure, Nursing Interventions: Nursing Dx:
ALOC, Contributing factors Pharm: Diuretics (Lasix, -Imbalanced Nurtrition: less
CIRRHOSIS Vitals: RR, Aldactone), Flagyl (to than body requirements r/t
S/S & PHYS. EXAM: reduce bacteria in poor nutrition and
Patho: A CHRONIC liver disease EARLY STAGE: intestine), Lactulose to nausea/vomiting
characterized by an irreversible -Enlarged Liver Ammonia, supplemental -Fluid volume excess r/t
scarring of the liver. This extensive compromised regulatory
-GI Disturbances vitamins, PPI’s
scarring causes a disruption in the
-Jaundice (Prevacid), Albumin (to mechanism and excessive
normal function of the liver. The liver
is a very important organ that -Weight Loss decrease ascites) fluid/ sodium intake
functions in the body to help: LATE STAGE:
-Store Blood Sugar (as GLYCOGEN) -Small/Nodular Liver Pt. Ed: Pt. Goals/ Evaluation:
-Produce Bile (TO DIGEST FOOD) -Ascites -NO ALCOHOL! -Pt will exhibit no further
-Filter out toxins/wastes in blood -Splenomegaly Referral to TX Program if signs of malnutrition and
stream (INCLUDING -Esophogeal Varices/Coughing up blood needed show weight gain
DRUGS/ALCOHOL) - Dyspnea -Follow Dietary appropriate for body.
- Pruitis guidelines for condition
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CIRRHOSIS
-Manufacturing proteins in the blood - Clay colored stools, TEA colored Urine - Bleeding -Patient will maintain stable
that assist in clotting and oxygen precautions/Risk for fluid volume AEB vital signs
transport Labs: Liver enzymes, Bilirubin, H&H, bleeding within normal range,
-Helps to break down fat/produce hematologic testing, WBC, PLT’s, CBC, PT, INR balanced I&O
cholesterol
& AMMONIA (Could indicate hepatic Surgery: Transplant
encephalopathy) (*ONLY IF ELIGIBLE!! Will
CONTRIBUTING FACTORS:
Dx Tests: MRI/ULTRASOUND for Liver size not be a candidate if
-Excessive Alcohol (Laennec’s)
(EARLY stages will be LARGE, Later stages of alcoholic/drug related)
-Post Necrotic (r/t
Hepatitis/chemicals)
cirrhosis will be small/nodular) Remember:
-Billiary Disease “If SIR ‘ROHSIS’ gets to a party EARLY, then
-SEVERE Right-sided heart failure he’s LARGE and in charge… if he gets there
LATER, he will be NODDED at and SMALL”
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ACUTE RENAL FAILURE (ARF)
11. KIDNEY (RENAL)
DIAGNOSIS/PATHO DATA ACTION RESPONSE
ACUTE RENAL FAILURE Assess: Oliguria ( 400 ml/day Nursing Interventions: Nursing Dx:
(ARF) for onset of ARF), Then diuresis Pharm: TREAT THE CAUSE!! -Fluid Volume excess
as it progresses toward recovery Electrolyte Imbalances- related to compromised
Patho: An acute and abrupt
(4,000-5,000 ml/day) HYPERKALEMIA: Kayexalate (Usually regulatory mechanism
decrease in renal function; usually
Vitals: BP, TEMP given by enema) (renal failure)
caused by: Trauma, allergic
S/S & PHYS. EXAM: ANEMIA: EPOGEN (Procrit) -Risk for infection r/t
reactions, Kidney stones drug
Dizziness, Dry mouth, PHOSPHATE / CALCIUM: PHOSLO, altered immune
overdose and shock.
hypotension, CALCUM ACETATE functioning
REMEMBER!! Your kidneys and your
Tachycardia, Thirst, Weight loss Diuretics (as directed)
Glomeruli are like your “Washing
Pt. Goals/ Evaluation:
Machine”…. And wash and filter out
Labs: BUN, Creatinine and Pt. Ed: -Fluid volume will be
your blood… helping excrete waste
Potassium (Will be ), Adhere to diet: within normal limits for
products through urine!
Dx Tests: Assess cause! If OLIGURIC PHASE: Protein, patient and homeostasis
TRAUMA, may need CT / Potassium, Carb will be achieved.
Ultrasound. If INFECTION, C&S DIURESIS PHASE: Protein, Calorie, -Pt will show no signs or
(Culture and Sensitivity). If Restricted Fluids (As indicated), Bed symptoms of infection
KIDNEY STONES/TUMOR, rest in Oliguric Phase, Dialysis as prior to discharge
CT/MRI/Ultra- sound ordered.
Also…. Daily weights, Monitor I&O’s
Surgery: N/A unless needed for
kidney stones/trauma
STAGES:
Phase 1. Onset
ARF begins with the underlying
clinical condition leading to tubular
necrosis (Ex. hemorrhage, which
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ACUTE RENAL FAILURE (ARF)
reduces blood volume and renal
perfusion. If adequate treatment is
provided in this phase then the
individual's prognosis is good.
Phase 2. Maintenance
A persistent decrease in GFR and
tubular necrosis characterizes this
phase. Oliguria is often present
during the beginning of this phase.
Efficient elimination of metabolic
waste, water, electrolytes, and acids
from the body cannot be performed
by the kidney during this phase.
Therefore, azotemia, fluid retention,
electrolyte imbalance and metabolic
acidosis occurs. The patient is at risk
for heart failure and pulmonary
edema during this phase because of
the salt and water retention.
Phase 3. Recovery
Renal function of the kidney
improves quickly the first five to
twenty-five days of this phase. It
begins with the recovery of the GFR
and tubular function (BUN and serum
Creatinine stabilize). Improvement in
renal function may take up to a year
as more nephrons regain function.
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CHRONIC RENAL FAILURE (CRF)
CHRONIC RENAL FAILURE Assess: For contributing factors Nursing Interventions: Nursing Dx:
(CRF) such as: Diabetes (Leading Pharm: ANEMIA: EPOGEN (Procrit) -Impaired urinary
Cause), Uncontrolled HTN, PHOSPHATE / CALCIUM: PHOSLO, elimination r/t effects of
Patho: Progressive, long-term
Chronic Glomerularnephritis, CALCUM ACETATE, also: BLOOD disease, need for dialysis
failure of kidney function. This is an
Congenital Kidney Disease, TRANSFUSION if necessary -Fatigue r/t effects of
IRREVERSIBLE condition that can only
Pyelonephritis, Ethnicity (African HEMODIALYSIS!! (Can be in hospital, or chronic anemia and
be corrected by regular dialysis or
American, Native American & at home/Peritoneal) uremia
kidney transplant, or will be terminal.
Asian).
Chronic renal failure can be present
Pt. Ed: Monitor electrolyes, BP (For Pt. Goals/ Evaluation:
for many years before you notice any
Vitals: BP HTN), Strict I&O’s, RENAL DIET, -Patient will maintain
symptoms. If your doctor suspects
S/S & PHYS. EXAM: increased Meticulous skin care. Dialysis effective voiding
that you may be likely to develop
urination (especially at night), Education! Based on the type, measures within limits of
renal failure, he or she will probably
decreased urination, blood in schedule, at home or in facility. his/her condition
catch it early by conducting regular
the urine (not a common -Pt will state that he/she
blood and urine tests. If regular
symptom of chronic renal Surgery: Kidney Transplant (if is able to accomplish
monitoring isn't done, the symptoms
failure) urine that is cloudy or needed/eligible) ADL’s with minimal
may not be detected until the
tea-colored assistance by utilizing rest
kidneys have already been damaged.
MORE SERIOUS S&S: periods
Some of the symptoms, such as
Puffy eyes, hands, and feet DIALYSIS:
fatigue - may have been present for
(edema), High BP, fatigue,
some time, but come on gradually,
shortness of breath
and may not be noticed or attributed
loss of appetite,
to kidney failure.
nausea/vomiting (common
symptom), thirst, bad taste in
TYPES:
the mouth or bad breath, weight
loss, persistent itchy skin,
muscle twitching or cramping,
yellowish-brown tint to the skin
Labs: BUN/Cr, Kidney Fxn
Tests, GFR
Dx Tests: Ultrasound/Biopsy
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CHRONIC RENAL INSUFFICIENCY
CHRONIC RENAL Assess: Nursing Interventions: Nursing Dx:
INSUFFICIENCY Vitals: Pharm: ANEMIA: EPOGEN (Procrit) -Impaired urinary
S/S & PHYS. EXAM: PHOSPHATE / CALCIUM: PHOSLO, elimination r/t effects of
(aka, END STAGE RENAL FAILURE/
-anemia (may begin earlier than CALCUM ACETATE, also: BLOOD disease, need for dialysis
END-STAGE RENAL DISEASE)
this) easy bleeding and bruising TRANSFUSION if necessary -Fatigue r/t effects of
Patho: This is a long-term
-Headache HEMODIALYSIS!! (Can be in hospital, or chronic anemia and
condition caused by several factors!!
-Fatigue (more than normal or at home/Peritoneal) uremia
Diabetes is a common one…
usual )and weakness
Remember the washing machine that
-Mental symptoms such as Pt. Ed: Monitor electrolyes, BP (For Pt. Goals/ Evaluation:
is your kidneys? Chronic high blood
ALOC/confusion, inability to HTN), Strict I&O’s, RENAL DIET, -Patient will maintain
sugar increases the blood’s viscosity,
concentrate Meticulous skin care. Dialysis effective voiding
much like putting cement in a
-Nausea, vomiting, anorexia & Education! Based on the type, measures within limits of
washing machine and expecting it to
thirst schedule, at home or in facility. his/her condition
work the same! This “syrupy” blood
-Muscle cramps, muscle -Pt will state that he/she
can reduce blood flow, oxygen
twitching Surgery: Dialysis, Kidney Transplant (if is able to accomplish
transport, and necrosis. Very similar,
-Nocturia eligible) ADL’s with minimal
HYPERTENSION can cause the same
-Numb sensation in the assistance by utilizing rest
problem. If there is too much water
extremities periods
filtering through your
-Diarrhea
Glomeruli/washing machine, it
- Itchy skin/Eyes
CANNOT work the way it needs to!!
-Grayish complexion, can also be
Thus causing LOW GLOMERULAR
yellowish-brownish tone
FILTRATION RATE ( GFR).
-Generalized Edema (more than
Remember, ONCE THESE
you had while in advanced renal
GLOMERULI DIE, THEY CANNOT
failure, and most likely in the
HEAL AND RETURN TO NORMAL!
feet and/or ankles)
Causes kidney death!!
-SOB (due to fluid in the lungs,
anemia)
End Stage Renal Disease is technically
-Hypertension
that last phase of the above renal
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NEPHROTIC SYNDROME
conditions, with manifestations and -Decreased sex drive
signs/symptoms usually indicating -Decreased urine output
the need for dialysis and transplant.
KIDNEY FUNCTION IS DOWN TO 10- Labs: GFR, BUN, Cr, CBC,
15% Electrolytes
Dx Tests: Biopsy, Ultrasound,
CT (NO CONTRAST due to kidney
fxn)
NEPHROTIC SYNDROME Assess: Edema, usually starts Nursing Interventions: Nursing Dx:
with eyes), Massive Proteinuria, Pharm: Corticosteroids (Prednisone), -Excess fluid volume r/t
Patho: auto-immune “Body is
Pallor, Anorexia Diuretics (LASIX), Salt-poor Albumin compromised regulatory
attacking itself”… The big “NERF
mechanism
BALLS OF PROTEIN” are let through
Vitals: BP Pt. Ed: Maintain Diet: -Activity intolerance r/t
the once tight-knit net of the
S/S & PHYS. EXAM: - SODIUM generalized edema
Glomeruli. This disorder consists of
-Hypoalbuminemia (low level of - POTASSIUM
PROTEIN WASTING (Proteinuria)
albumin in the blood) - CALORIE Pt. Goals/ Evaluation:
which occurs as a result of diffuse
-Proteinuria (Protein in urine) -Moderate PROTEIN -Patient was able to
glomelular damage. Proteinuria
-Edema (Starts w/ eyes, then Aeseptic techniques (To prevent display stable weight, vital
occurs because of changes to
systemic, called ANASARCA) infection) signs within patient’s
capillary endothelial cells, the
-Hypercholesterolemia (high -Bed rest to preserve renal function normal range, and nearly
glomerular basement membrane
level of cholesterol in the blood) -Daily Weights/ I&O’s absence/ reduction of
(GBM), which normally filters serum
-Hematuria (blood in urine) edema.
protein selectively by size and
- Ascities Surgery: N/A
charge:
- Oiliguria
- Anorexia
- Malaise
- Nausea
Labs: Protein (For
Hypoalbuminuria), CBC, Urine
(HYPERalbuminuria, meaning
the protein is NOT in the blood
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KIDNEY STONES
where it should be, but in the
Urine)
Dx Tests: Kidney Biopsy
KIDNEY STONES Assess: For passing of stones Nursing Interventions: Nursing Dx:
(Strain Urine), Hx or Risk for Pharm: NARCOTICS for PAIN -Acute pain r/t
Patho: Kidney stones (renal-
Kidney stones, Pain Mgmt MANAGEMENT!! Also FLUIDS to help Inflammation/obstruction,
lithiasis) are small, hard deposits that
Vitals: BP, HR Flush/Pass stone, Corticosteroids for and abrasion of urinary
form inside your kidneys. The stones
S/S & PHYS. EXAM: Inflammation, as well as Anti- tract by migration of
are made of mineral and acid salts.
Severe pain in the side and back, sposmotics stones.
Kidney stones have many causes and
below the ribs, Pain that spreads -Altered urinary
can affect any part of your urinary
to the lower abdomen and groin, Pt. Ed: Report increasing pain, or Elimination
tract — from your kidneys to your
Pain that comes in waves and feeling of “Passing Stone”. Drink LOTS
bladder. Often, stones form when
fluctuates in intensity of fluids to promote passing. Refrain Pt. Goals/ Evaluation:
the urine becomes concentrated,
(SPOSMOTIC PAIN) Pain on from foods that may contribute to -Pt will report pain as
allowing minerals to crystallize and
urination, Pink, red or brown stone formation, Foods that contain “tolerable” and verbalize
stick together.
urine, Cloudy or foul-smelling high levels of OXYLATE, including: ways to distract
urine, Nausea/vomiting, Peanuts, rhubarb, spinach, beets, choc themselves from pain
Persistent urge to urinate, olate and -Pt will show an adequate
Frequent urination, Fever and sweet potatoes urinary output for their
chills (if infection is present) status/condition
Labs: Calcium, Uric Acid, Urine Surgery: Surgical removal of stones as
(For sediments/Minerals) needed
Dx Tests: Ultrasound, CT SCAN,
ABD X-ray
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GLOMERULONEPHRITIS
GLOMERULONEPHRITIS Assess: Contributing Factors Nursing Interventions: Nursing Dx:
such as: Recent Tonsillitis, Pharm: - Acute pain r/t edema of
Patho: Antibody reaction
Pharyngitis or STREP! Also Flank -Penicillin (For Strep) kidney
SECONDARY to infection else ware
or Abdominal Pain -Corticosteroids (For inflammation) -Imbalanced Nutrition,
inside the body. SAME
-Anti-hypertensives (For BP) Less than body
INFLAMMATION, DIFFERENT CAUSE!
Vitals: BP, TEMP requirements r/t
The initial reaction is usually either
S/S & PHYS. EXAM: Pt. Ed: Bed rest during acute phase, anorexia/restrictive diet
an upper respiratory infection or skin
Pink or cola-colored urine from Patient can resume normal
infection due to group A beta-
red blood cells in your urine activities gradually as symptoms
hemolytic Streptococcus. This leads
(Hematuria), Frothy urine due to subside. Diet: Calories, Protein,
to the formation of an antigen-
Proteinuria, Hypertension, Sodium, Potassium, Fluids. Pt. Goals/ Evaluation:
antibody reaction. It is followed by
Edema (with swelling evident in Hand hygiene, prevent contact with -Pt will report pain as
the release of a membrane-like
your face, hands, feet and infected people. “tolerable” and verbalize
material from the organism into the
abdomen) Fatigue (from anemia -Monitor intake and output/daily ways to distract
body’s circulation. Antibodies
or kidney failure) Weight themselves from pain
produced react against the
-Teach Pt. to report peripheral edema -Pt will be free from signs
glomerular tissue, thus forming
Labs: BUN, Creat. WBC’s or the formation of ascites. of malnutrition and
immune complexes. The immune
RBC’s/ Hgb -Explain to the patient taking diuretics verbalize understanding
complexes become trapped in the
Urine RBC’s, Spec. Gravity They may experience orthostatic of proper diet for
glomerular loop and cause an
hypotension and dizziness when condition/disease process
inflammatory reaction in the affected
Dx Tests: changing positions quickly
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GLOMERULONEPHRITIS
Glomeruli. Changes in the glomerular -Light microscopy: Enlarged
capillaries REDUCE GFR, thereby Glomeruli with exudation of Surgery: N/A
allowing passage of blood cells and neutrophils
protein into the infiltrate, and -Immunnofluorescent
reducing the amount of sodium and microscopy: Granular pattern of
water that is passed into the tubules immuno-globulin deposition
for reabsorption. This affects the -Electron microscopy: reveals
vascular tone and permeability of the electron dense humps (immune
kidney, resulting to tissue injury. complex) on the epithelial side
of glomerular basal membrane
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TURP (Trans urethral resection of prostate)
TURP (Trans urethral Assess: For signs of shock or Nursing Interventions: Nursing Dx:
resection of prostate) blockage, monitor and maintain Pharm: Narcotics for pain and to -Acute pain r/t incision,
indwelling catheter/Irrigation, prevent/decrease bladder spasm, bladder irrigation, bladder
Patho: The process by which the
also ASSESS FOR TURP FOR BPH: spasms
enlarged portion of the prostate
SYNDROME! (Cluster of Urinary Antibiotics, Alpha-Blocker -Risk for urinary retention
(BPH) is removed by an endoscopic
manifestations as the result of Meds (To promote urinary flow, such as r/t Obstruction of urethra
instrument.
absorbing fluids during irrigation FLOMAX), Enzyme inhibitors (To catheter with clots
through prostate tissue causing: decrease size of Prostate, such as
ALOC, Bradycardia, AVODART / PROSCAR Pt. Goals/ Evaluation:
Hyponatremia, N/V, Pt. Ed: TURP rarely causes erectile -Pt will report pain as
Hypo/Hyper- tension) dysfunction, but may trigger retrograde “tolerable” and verbalize
ejaculation because removal of the ways to distract
Vitals: TEMP prostatic tissue at the bladder neck can themselves from pain
S/S & PHYS. EXAM: cause seminal fluid to flow backward -Pt will show an adequate
-Urgency/Frequency of urination into the bladder rather forward urinary output for their
-Abdominal straining through the urethra during ejaculation. status/condition
-Nocturia
-Impairment of size and force of Surgery: THIS IS THE SURGERY!
TURP (Transurethral Resection of the stream/ Intermittent hesitancy
Prostate) is the most common procedure -Incomplete bladder emptying
used to treat BPH. It can be carried out -Terminal dribbling
through endoscopy. The surgical and -Dysuria
optical instrument is introduced directly -Eventual renal failure from
through the urethra to the prostate, urinary obstruction
which can then be viewed directly. The
Labs: PSA- Prostate Specific
gland is removed in small chips with an
Antigen to test for BPH
electrical cutting loop. This procedure,
which requires no incision, may be used Dx Tests: Digital Rectal Exam,
for glands of varying size and is ideal for Cytoscopy
patients who have small glands and for
those who are considered poor surgical
risks. Newer technology uses bipolar
electrosurgery and reduces the risk of
TURP syndrome (hyponatremia,
hypovolemia).TURP usually requires an
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URINARY TRACT INFECTION (UTI)
overnight hospital stay. Urethral
strictures are more frequent than with
(non-trans-urethral procedures, and
repeated procedures may be necessary
because the residual prostatic tissue
grows back.
URINARY TRACT INFECTION Assess: For kidney pain Nursing Interventions: Nursing Dx:
(UTI) Vitals: TEMP (Infection) Pharm: Antimicrobial (Sulfonamides, -Acute Pain r/t
S/S & PHYS. EXAM: UNLESS ALERGIC!! THEN, Bactrim or inflammation of urinary
Patho: A urinary tract infection
-Burning sensation at the start of Macrodantin) tract
(UTI) may occur in the bladder,
urination Pt. Ed: FLUIDS!! Also cranberry juice, -Urinary retention r/t
where it is called cystitis, or in the
-Uncomfortable pressure above WIPE FROM FRONT TO BACK!! Just acute condition
urethra, where it is called urethritis.
pubic bone think of my song… “I GOT ANOTHER
Upper tract infection results in
-Fullness in rectum (in men only) UTI!... DON’T SAY I DON’T KNOW HOW Pt. Goals/ Evaluation:
pyelonephritis. Most UTIs result from
-Small amount of urine, despite TO WIPE!!” Women (You have shorter -Pt will report pain as
ascending infections by bacteria that
urge to urinate (DYSURIA) Urethras): Avoid bubble baths, VOID “tolerable” and verbalize
have entered through the urinary
-Irritability (in children only) AFTER SEX, Wear cotton underwear. ways to distract
meatus but some may be caused by
-Abnormal eating (in children themselves from pain
hematogenous spread. UTIs are
only) Surgery: N/A -Pt will show an adequate
much common in females because
urinary output for their
the shorter female urethra makes
Labs: Urine C&S, WBC status/condition
them more vulnerable to entry of
Dx Tests: N/A
organisms from surrounding
structures (vagina, periurethral
glands, and rectum).
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BPH (Benign Prostate Hypertrophy)
BPH (Benign Prostate Assess: DRE (Digital Rectal Nursing Interventions: Nursing Dx:
Hypertrophy) Exam) to check for enlargement Pharm: Urinary Antibiotics, Alpha- - Acute pain r/ t mucosal
of prostate, Assess for Blocker Meds (To promote urinary flow, Irritation: bladder
Patho: As males age, production
history/family hx of BPH such as FLOMAX), Enzyme inhibitors (To distention
of androgenic hormones decreases,
Vitals: ↑TEMP decrease size of Prostate, such as & urinary infection
causing an imbalance in
S/S & PHYS. EXAM: AVODART / PROSCAR -Urinary retention r/t
androgen and estrogen levels and
-Urgency/Frequency of urination mechanical obstruction/
high levels of dihydrotestosterone,
-Abdominal straining Pt. Ed: If you require TURP: Rarely enlarged prostate
the main prostatic
-Nocturia causes erectile dysfunction, but may
intracellular androgen.
-Impairment of size and force of trigger retrograde ejaculation because Pt. Goals/ Evaluation:
stream/ Intermittent hesitancy removal of the prostatic tissue at the -Pt will report pain as
-Other causes of Benign prostatic
-Incomplete bladder emptying bladder neck can cause seminal fluid to “tolerable” and verbalize
hyperplasia (BPH) include:
-Terminal dribbling /Dysuria flow backward into the bladder rather ways to distract
o Neoplasm
-Eventual renal failure from forward through the urethra during themselves from pain
o Arteriosclerosis
urinary obstruction ejaculation. -Pt will show an adequate
o Inflammation
Labs: PSA- Prostate Specific Surgery: TURP! urinary output for their
o Metabolic Imbalance
Antigen to test for BPH, Urine status/condition
o Nutritional disturbances.
culture, Blood test/Clotting
studies
Dx Tests: Digital Rectal Exam,
Cytoscopy, Ultrasound
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UTERINE FIBROIDS
12. WOMEN’s HEALTH
DIAGNOSIS/PATHO DATA ACTION RESPONSE
UTERINE FIBROIDS Assess: Location of pain Nursing Interventions: Nursing Dx:
(For medication and Pharm: Analgesics for pain, -Acute Pain r/t
Patho:
assessment of Hormone therapy as needed, Inflammation of
Benign Fibroid tumors on the uterine muscle. Also known
complications) On a scale Antibiotic if surgery Uterus
as “Myoma”. Can be as small as an apple seed or grow as
of 1-10, Physical exam Pt. Ed: Common in young -Anxiety r/t changes
big as a grapefruit. There could be one, or MANY. Cause is
Vitals: Not usually, but… African American women, in health status
unknown, but over 80% of women have some type of
↑HR (If in pain), ↓(If Family history of fibroids,
fibroids in their life.
loosing fluid/shock) Obese, Age 30+, and eating a Pt. Goals/
S/S & PHYS. EXAM: lot of red meat/pork Evaluation:
-Pelvic Pain Surgery: To remove - Pt will report pain at
-Pelvic Pressure mass/part of reproductive as tolerable level and
-Hyper Menhorrhea necessary per patients verbalize ways to
-Pain during sex situation (Myoectomy, manage it
-Lower back pain Hysterectomy), Endometrial -Client will report
-Abdominal Distension Ablation, Fibroid Ablation, reduced anxiety level,
-Frequent Urination Uterine Fibroid Embolisation ways to reduce
anxiety, and
Labs: Hormone Levels, understanding of
CBC, PTT/INR, H&H diagnosis/health
Dx Tests: Physical exam, process
ultrasound, CT scan, MRI,
Hysteroscopy,
hysterosalpingiogram
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OVARIAN CANCER
OVARIAN CANCER Assess: Assess for risk Nursing Interventions: Nursing Dx:
Factors- Pharm: Chemotherapy and -Anxiety r/t
Patho: Cancerous growth, originating from different
-Over 40 y/o Radiation as needed prognosis, lack of
parts of the ovary:
-Nulliparity/First Pt. Ed: Genetic testing for knowledge of disease
pregnancy age 30+ risk, Check-up for process and threat of
-Family history of ovarian, reoccurrence (CA-125 Blood malignancy
breast or colon cancer test/HE-4) , signs and - Disturbed body
-Dysmenhorrea/heavy symptoms of reoccurrence, image r/t loss of
bleeding side effects of diseased body
-Hormone replacement chemo/medications part/loss of good
therapy Surgery: Surgery to remove health
-Use of fertility diseased parts as needed
medications Pt. Goals/
Evaluation:
Vitals: Normal, unless -Client will report
septic reduced anxiety level,
Contributing Factors: S/S & PHYS. EXAM: ways to reduce
-Over 40 Labs: CA-125 Blood test anxiety, and
-Never been Pregnant OR (35 u/ml= ABNORMAL) understanding of
-First pregnancy after 30 years of age Dx Tests: Intra-Vaginal diagnosis/health
-Family hx of ovarian, breast, or colon cancer Ultrasound, Pelvic Exam process
-Hx of Dysmenorrhea or heavy breathing - Client will discuss
-Hormone replacement therapy concerns, what to
-Infertility medication use expect after
chemo/surgery, and
ways to limit anxiety
about body image
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OVARIAN CANCER

13. Bibliography
Ebersole, P., Hess, P., Touhy, T.A., Schmidt Logan, A., & Jett, K. (2008) Toward healthy aging: Human
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Grodner, M., Long, S., & Walkingshaw,B.C. (2007). Foundations and clinical application of nutrition: A
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Ignatavicius, D. D., & Workman, M. L. (2010). Medical-Surgical nursing (6th ed.). St. Louis, MO: Saunders.
Lowdermilk, D.L.,& Perry, S.E. ( 2007) . Maternity & women’s health care (9th ed.). St. Louis, MO: Mosby.
Lehne, R.A. (2010). Pharmacology for nursing care (7th ed.). St. Louis, MO: Saunders.
Lilley, L. L., Harrington, S., & Snyder, J.S. (2007). Pharmacology and the nursing process (5th ED.). St.
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Roach, S. S.,& Ford, S. M. (2008). Introductory clinical pharmacology. Philadelphia, PA: Lippincott Williams
& Wilkins.
Smeltzer, S. C., Bare, B.G., Hinkle, J. L., & Cheever, K.H. ( 2008). Brunner and Suddarth’s textbook of
medical-surgical nursing ( 11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

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