NRSE 470: FINAL Final Exam

Social determinants of health (SDOH)

• Impact health and wellness

• Health inequity based on environments where people are born, live and play

• Responsible for over 30% to 55%% of health outcomes.

• Examples…

  • Housing

  • Neighborhoods

  • Education

  • Job Opportunities

  • Racial Disparities

  • Pollution

  • Language

  • Health Literacy

Domains of SDOH as outlined by Healthy People 2030…

• Economic stability

• Education access and quality

• Health care access and quality

• Neighborhood and built environment

• Social and community context

  • Lack of support

Goal of Gender Affirming Care

• To improve the health, safety and well being of lesbian, gay, bisexual and transgender people

• Patients are made to feel comfortable, using preferred pronouns and building rapport with patients

Cancer: Modifiable Risk Factors

• Smoking

• Alcohol consumption

• Excess body weight

• Sedentary lifestyle

• Dietary habits

• Environmental factors

• UVA & UVB

Cancer: Non-modifiable Risk Factors

• Age

• Gender

• Family history

Primary Cancer Prevention

• Make sure to get screen regularly

• Perform self breast exams

• Receive all vaccines

• Stay away from saturated fats, sodium, alcohol and sugar

Angiogenesis

Cancer cells create their own blood supply which helps the cancer to survive and grow

Characteristics of Benign Cancer Cells

• Growth rate

  • Slow, progressive

• Cell differentiation

  • Well differentiated (cells resemble tissue of origin)

• Cell size & shape

  • Uniform

  • Regular nuclei

• Invasion

  • Encapsulated

  • Does not invade surrounding tissue

• Metastasis

  • Absent

• Recurrence after removal

  • Rare

• Effect on Host

  • Usually minimal, unless location interferes with vital functions

Characteristics of Malignant Cancer Cells

• Growth rate

  • Rapid & Uncontrolled

• Cell differentiation

  • Poorly differentiated

  • Undifferentiated (Anaplastic)

• Cell size & shape

  • Pleomorphic

  • Varying sizes / shapes of cells and nuclei

• Invasion

  • Invades and destroys surrounding tissue

• Metastasis

  • Frequently present via blood, lymph and direct seeding

• Recurrence after removal

  • Common

• Effect on Host

  • Severe can cause…

    • Cachexia

    • Organ failure

    • Death

Metastasis

Cancers may start out in one location and spread

Care for a patient receiving Chemo/ radiation

• Oral care during radiation

• After each meal use a non abrasive fluoride toothpaste with a soft bristled toothbrush

Cancer: What are some interventions to increase diet/intake?

• Eat small frequent meals

• Maximize calorie and protein intake

Cancer: Genetic Testing

• Biopsy, which may help treatment by identifying mutations responsive to certain therapies

• Changes in the BRAC 1 and BRAC 2 gene

  • Breast and Prostate cancer

Breast Cancer: Risk Factors

• Gene mutations

• Advanced age

• Family history

• Obesity

• Alcohol use

• Radiation exposure

• Breast disease

• Dense breast tissue

• Estrogen exposure

Lung Cancer: Risk Factors

• Smoking

• Radon gas

• Secondhand smoke

• Exposure to

  • Asbestos

  • Radiation

  • Air pollution

  • Diesel exhaust

  • Metals

  • Chemicals

Prostate Cancer: Risk Factors

• Age (50 and older)

• Family history

• Smoking

• Increased body weight

• Survival rates

• Racial disparities

  • Black individuals in the United States

Colorectal Cancer: Risk Factors

• Excess body weight

• Low activity level

• Smoking

• Diet

• Alcohol intake

• Medical conditions

Pancreatic Cancer: Risk Factors

• Smoking

• Medical conditions

• Family history

• Genetic conditions

• Increased body weight

• Alcohol consumption

Skin Cancer: Risk Factors

• Advanced age: Major risk factor

• Ultraviolet radiation

• Family history

• Advanced age

• Moles

• Immunosuppression

Brain and CNS Tumors: Risk Factors

• Environmental exposure

• Infection

• Older adults

Hospice care

• Terminal illness

• Focus is comfort, dignity and personal growth as the patient faces death.

• Care can be provided in an acute care, long term care facility or in the home.

• Holistic, treating the whole person, including caregivers and family members​​​​​​​

Liver Function

• Filters toxins

• Detoxifies your blood produces

• Glucagon plays a vital role with coagulations factors

Primary cause of Liver Cirrhosis

• Viral is the most common type

• Acute or chronic exposure to alcohol or some kind of virus that affects the liver

• Repetitive exposure to pathogens

  • Acetaminophen toxicity

    • Alcohol abuse can damage the liver tissue that can lead to scarring

Thrombocytopenia

• Low platelet count

• Issue with clotting & bruising

Patients with Thrombocytopenia can have…

• Poor PT/INR

• Risk for falls/bleeding

• Fatigue

• Confusion

• Increased weakness

Thrombocytopenia: Diet Modification

• Fresh fruits/ veggies

• Healthy fats

• Whole grain

• Limit…

  • Alcohol

  • Sugar

  • Saturated fat

  • High sodium foods

  • Red meats

Bleeding Precautions

• Soft bristled toothbrush

• Electric razor

• Avoid Aspirin & NSAIDs

• Avoid contact sports

Hypervolemia: Interventions

• Diuretics: Eliminates excessive fluids

• Fluids and sodium restriction

Hepatic Encephalopathy

• Found in End stage cirrhosis

• Brain isn't functioning properly

• Clinical Manifestations

  • Confusion

  • Coma

  • Seizures

  • Altered Mental Status

• Can be misinterpreted to be confused with dementia or delirium in older clients

Hepatic Encephalopathy: Treatments

• -Lactulose which is laxative

• -Helps get rid of the built up ammonia which would cause the patient to be more confused

• If there body can't naturally rid of the ammonia it goes straight to the brain causing neurological dysfunctions

• Effectiveness of Lactulose

  • Improvement levels of consciousness

Cholecystitis

• Inflammation of the gallbladder

• Can be acute or chronic

• Acute cause

  • Due to being NPO on TPN

• Caused by the blocking of the common bile duct

Cholecystitis: Risk Factors

• High fat diet

• Females

• Hormonal therapy

• Pregnancy

• Obesity

• Family history

• Patients older than 65 years old

Cholecystitis: Clinical Manifestations

• Right upper quad pain

• Nausea

• Vomiting

• Fever

• Jaundice (rare)

• May mimic cardiac symptoms

  • Thorough cardiac assessment needed

Cholecystitis: Fluid & Electrolyte Imbalances

• Patient will experience

  • Decrease appetite

  • Nausea

  • Vomiting leading to dehydration

• Patient will be NPO they require…

  • IV fluids for rehydration

  • Monitor electrolytes

    • IV electrolytes correction

Cholecystitis: Patient Education

• Dietary changes

  • Reduce fried and fatty foods

  • Eat lean protein

    • Fish

  • Maintain hydrated with fluids

• Encourage regular exercise and weight management'

• Get your electrytes montiored

Cholecystitis: Treatments and Therapies

• NPO status to rest gallbladder

• IV fluids and antibiotics

• Cholecystectomy

  • Removal of Gallbladder

  • Delayed treatment

    • Can cause peritonitis

    • Rigid abdomen

Pancreatitis: Clinical Manifestations

• Nausea

• Vomiting

• Severe abdominal pain

• Grey Turner’s (flanks)

• Cullen’s (belly button)

• Fox’s sign (thigh / /hip area)

Pancreatitis: Labs & Diagnostics

• Labs:

  • Blood amylase

  • WBC count

  • Platelets

  • Blood Ca & Mg

  • Liver enzymes & bilirubin

  • Serum glucose

  • ESR

• Diagnostic

  • CT scan (With contrast)

Pancreatitis: Nursing Intervention

• Keep patient NPO

• Give patients fluids

• Pain management

• NSAIDS

  • Mild moderate pain

• Morphine or hydromorphone

  • Acute pain

• Antibiotics

• Proton Pump Inhibitors

  • reduce the production of stomach acid

• Pancreatic Enzymes

Pancreatitis: Risk Factors

• Alcohol abuse

• Smoking

• Increased age

• Family History

Bariatric surgery

• Restrictive

  • Bariatric banding

• Malabsorptive

  • Roux Y gastric bypass

• Nursing care

  • DVT prevention

• Complication

  • Dehydration

  • Malabsorption

  • LIFE threatening: Anastomotic Leak

Anastomotic Leak: Clinical Manifestations

• Back pain

• Increasing abdominal pain

• Shoulder pain

• Restless

• Tachycardic

Review normal ranges for kidney Labs (BUN, CR, eGFR)

• Normal Glomerular Filtration Rate (GFR): 90 to 120 mL/min

• Normal BUN: 7 to 20

• Normal Creatinine: Male: <1.4 Females: <1.2

Acute Kidney Injury

• Sudden loss of kidney function

• Usually reversible

• Can lead to Heart Failure and Cardiovascular related mortality

• With electrolytes and fluid being altered kidneys can't filter urine properly

Acute Kidney Injury: Clinical Manifestations

• Decreased H & H

• HYPOnatremia

• HYPERkalemia

• HYPERphosphatemia

• HYPOcalcemia

Kidney Transplant

• Pre op

• Dialysis 24 hours before the surgery

• prophylaxis meds: antibiotics, immunosuppressant

• POST op

• 30ml of urine an hour

• Monitor for infection and organ rejection

• stool softeners

• Patient Education

  • Low fat, High fiber and protein diet

  • Adequate intake of phosphates, potassium and magnesium

  • Restricting sodium

  • Avoid straining and contact sports

Kidney Transplant: Organ rejection

• Monitor, Monitor, Monitor

• Lifelong immunosuppressants

• treatment: Remove the kidney

Diabetic ketoacidosis AND Hyperosmolar Hyperglycemic State

• Lack of insulin

• Usually in patients with Type 1 diabetes

Diabetic ketoacidosis AND Hyperosmolar Hyperglycemic State: Causes

• Low income, homelessness, and lack of health insurance

• Elevated HbA1c

• Taking antipsychotic or antidepressant medications

• Acute infection or illness

• Excessive alcohol consumption

• Use of illicit drugs, especially cocaine

• Blood glucose levels that are not well managed

• Polypharmacy

Diabetic ketoacidosis AND Hyperosmolar Hyperglycemic State: Risk Factors

• Result of physical stress on the body- examples:

  • Injury

  • Illness

  • Infection

  • Surgery

  • Excessive alcohol use

  • New onset diabetes

  • Elevated HbgA1C

  • Illicit drug use

  • Noncompliance with insulin therapy

  • Medications

    • Corticosteroids

    • Antipsychotics

    • Antidepressants

Diabetic ketoacidosis: Clinical Manifestations

• Metabolic acidosis

• Muscle weakness

• Dehydration leading to decreased cardiac output

• Loss of electrolytes

• Cardiac arrhythmias

• Kussmaul respirations

• Deep, rapid, labored breathing

• Decrease perfusion to the kidneys

Hyperglycemic Hyperosmolar State: Clinical Manifestations

• More profound neurological manifestations

• Muscle weakness

• Profound dehydration

• Thromboembolic disease (clot risk)

• Decreased perfusion to the kidneys

• Acute Kidney Injury

• Loss of electrolytes

• Cardiac arrhythmias

Diabetic ketoacidosis AND Hyperosmolar Hyperglycemic State: Labs & Diagnostics

• Serum blood glucose’

• Serum Bicarb: LESS THAN 15

• Complete blood count: WBC

• Electrolytes

• ABGs

• Anion gap

• Serum osmolality

• Urine studies

• Ketones present in urine for DKA

• Chest X-Ray

• ECG

• Blood and Urine Cultures

Diabetic ketoacidosis AND Hyperosmolar Hyperglycemic State: Treatments & Therapies

• Restore circulatory volume

• Treating hyperglycemia

• Correcting electrolyte imbalances

• Monitor potassium levels

  • Cannot be replaced too quickly

  • Potassium is LESS than 3.3 that needs to be treated prior to start an insulin drip

  • Potassium that 3.3 to 5 can be given along side insulin drip

  • Potassium reaches 5 replacements stop and just monitor

• Treating any underlying causes.

• Insulin drip based on patient’s weight

• Monitor their Anion gap

Expected findings of Diabetic ketoacidosis AND Hyperosmolar Hyperglycemic State

• Dehydration

• Electrolyte Imbalance

Diabetes Insipidus

• Body does NOT MAKE enough Antidiuretic hormone

• Cause

  • damage to pituary and hypothalamus gland

  • High Urine output

  • Hypernatremia

• Complications

  • Dehydration

  • Electrolyte imbalance

Diabetes Insipidus: Clinical Manifestations

Diabetes Insipidus: Treatments

• Medication

  • Desmopressin

• Treat the underlying cause

• Restore water balance and normalize Antidiuretic hormone

(Syndrome of Inappropriate Antidiuretic Hormone Secretion) SIADH

• Body makes TOO MUCH Antidiuretic hormone

• Causes

  • Stroke

  • Head trauma

  • Brain tumors

• Risk Factor

  • Repetitive damage to the pituitary or hypothallus

(Syndrome of Inappropriate Antidiuretic Hormone Secretion) SIADH: Clinical Manifestations

• Urine output decrease

• Hyponatremia

• Neurological manifestations can occur

• Seizure

• Cerebral edema

• Coma

(Syndrome of Inappropriate Antidiuretic Hormone Secretion) SIADH: Treatments

• Fluids

• 3% sodium chloride

• Monitoring sodium intake hourly

• DO NOT REPLACE SODIUM TOO QUICKLY

• Foods high in sodium

• NORMAL SODIUM: 135 to 145

SIADH: Hyponatremia

• Watch for neurological symptoms

  • Seizures

  • Cerebral edema

  • Coma

• Can lead to…

  • Muscle cramping

  • Headaches

  • N/V

  • Fatigue

Cataract: Clinical Manifestations

• Vision is not clear

• Hazy

• Pain free

Cataract: Risk Factors

• Age

• Diabetes

• Hypertension

• Traumatic eye injury / surgery

• Use of Steroids

• Overexposure to sun or ultraviolet (UV) rays

• Smoking

• Alcohol Use disorder

• Obesity

Cataract: Role of the Nurse

• Stop smoking

• Diet

  • Leafy green vegetables

• Protect eyes from sunlight

• Fall Risk

• Use of visual aids

  • Magnifier

  • Large print materials

Cataract: Treatments

• Visual acuity

• Snellen eye chart.

• Cataract extraction surgery

Increase risk of hearing loss: Modifiable Risk Factors

• Exposure to loud noises

• Smoking

• Hypertension

• Ototoxic meds

Increased Intracranial Pressure: Clinical Manifestations

• Cushing Triad

  • Hypertension with widening pulse pressure

  • Bradycardia

  • Irregular respirations

• Headache

• Blurred or double vision

• Confusion

• Vomiting

• Drowsiness

What does Cushing's triad tell us

• Late finding

• Indicates life threatening condition caused by increased Intracranial Pressure

• Hypertension

• Bradycardia

• Irregular respirations

Intracranial Pressure: Medications

• Used to decrease pressure

• Mannitol

• Corticosteroids

Decorticate

• Flexor

• Arms are like “C”s

• Moves in toward the “Cord”

• Problems With Cervical Spinal Tract or Cerebral Hemisphere.

• Better survival rate

Decerebrate

• Extensor

• Arms are like “e”s

• Problems Within Midbrain or Pons.

• More dangerous

Glasgow Coma Scale

• Eye Opening, Verbal response, Motor response

• Lower the number the worse the brain injury is

Stroke: Clinical Manifestations

• Severe headache

• Vertigo

• Gait impairment

• Trouble articulating

• Unilateral numbness

• Hemiparesis (one-sided muscle weakness)

• Expressive & Receptive Aphasia

• Loss of depth perception

• Vision changes

• Agnosia

• Inability to recognize familiar people, objects or sounds

Stroke: Risk Factors

• Hypertension

• Hyperlipidemia

• Diabetes

• Smoking/ alcohol / substance

Stroke: Ischemic

• Caused by a blockage of circulation to the brain

• Risk Factor: A-Fib not on anticoagulants

Ischemic Stroke: Treatment

• tPA

  • Given within 3 to 4 hours of the initial manifestations

  • Unless contraindicated by factors: Presence of active bleeding

  • Breaks down the clot

  • Restores blood flow

Stroke: Hemorrhagic

• Occur secondary to a ruptured artery or aneurysm.

• The prognosis for a patients is poor due to the amount of ischemia and increased intracranial pressure (ICP) caused by the expanding collection of blood

Stroke: Treatment

• Thrombolytic medication

  • Anticoagulants

  • Antiplatelets

  • Antiepileptics

  • Antihypertensives

• Other medications

  • Stool softeners, antianxiety

• Angioplasty

  • open up narrowed or blocked arteries

• Thrombectomy

  • removing a blood clot (thrombus) from a blood vessel.

• Carotid Endarterectomy

  • removing plaque buildup from the carotid arteries

Stroke patients are at risk for…

Aspiration

Stroke: FAST Teaching

• F: Facial drooping

• A: Arm weakness

• S: Speech

• T: Time

Spinal Cord Injury: Precautions

• Spinal precautions

  • Stabilize neck on flat board

  • Log roll

Spinal Cord Injury: Risk Factors

• Motor vehicle accident

• Common cause for Older Adults: FALLS

• Acts of violence

• Sports related

• More common in men than females

Spinal Cord Injury: Classification

• Classified on where the injury is located

• Types

• Impact –consistent compression

• Impact – intermittent compression

• distraction injury

• transection and laceration

Spinal Cord Injury: Clinical Manifestations

• C1 to C4

  • Ventilator dependence

• C1 to C8

  • Limited proprioception (the body's sense of its own position, movement, and orientation in space)

• T1 to T8

  • Affects trunk movements

  • Lack of abdominal control

• T9 to T12

  • Limited abdominal control

• L1 to S5

  • Loss of bowel and bladder functioning

  • Affects sexual function

Spinal Cord Injury: Testing

• CT scan

• MRI

• X - RAY

Neurogenic Shock

• Medical emergency

• within the first 24 hours

• Cant regulate blood pressure , heart rate, temperature

• Inadequate blood flow to vital organs

• Clinical Manifestations

  • Hypotension

  • Bradycardia

  • Warm dry flushed skin below the level of injury

Spinal Cord Injury: Treatments

• Pain control – pharmacology

• Physical Therapy, Occupational Therapy, and Speech Therapy.

• Trach care

• Treatment depends on symptoms

• DVT care

  • Compression Stocking

  • Blood Thinners

  • Lifestyle Changes

Autonomic Dysreflexia

• Life-threatening increase in blood pressure in people with spinal cord injuries at or above the T6 level

• Usually after the 1st year after injury

Autonomic Dysreflexia: Triggers

• Pain

• Full bladder

• Impaction / Constipation

Autonomic Dysreflexia: Clinical Manifestations

• Hypertension

• Headache

• Flushing or sweating of the face, neck and shoulders

DVT: Assessment Findings

• Redness or warmth unilaterally

• D-dimer

• Ultrasound

Coup Injury

A traumatic brain injury that occurs at the site of impact

Contrecoup Injury

A traumatic brain injury that occurs on the side of the brain opposite the initial impact to the head

Patient population High risk for TBI?

• Older population

  • Fall Risk

• Young adults

  • Motor vechicle accidents

  • Sports

  • Risky Behaviors

Head Injury : Clinical Manifestations

• Loss Of Consciousness - Difficulty waking

• Pupillary dilation

• Headache

• nausea

• Agnosia

• Ataxia

• Aphasia

• Loss of balance , Weakens of limbs

• Personality changes, Amnesia

• “Halo sign”

• Indication of CSF leak

• Runny nose, fluid coming out of ear’

• Yellow ring our the fluid indicates leak

• Symptom management heals on its own

Head Injury: Complications

• Cushing's Triad

  • Late finding

  • Hypertension

  • Low Blood respirations

  • Bradycardia: Low heart rate

  • Widening pulse pressure

• Frequent neuro checks: Glowscow Coma Scale

  • Opening eyes: 1-4

  • Verbal response: 1-5

  • Motor Response: 1-6

• Increased Intracranial Pressure

• Brain Herniation

• Pulmonary Edema

Head Injury: Treatment/ Therapy/ interventions

• Frequent Assessment

• Medications

• Anti-Seizure meds

• Decrease ICP

• Barbiturates

• Opioids

• Craniotomy

• Therapeutic hypothermia

• gets the brain swelling down

• Spinal precautions

• Collar / back board / log rolling

Subarachnoid Hemorrhage

• Blood is between arachnoid membrane and the pia membrane; typically from a burst aneurysm

• High mortality if left untreated

• Risk of rebleeding increasing mortality

• Causes

  • Aneurysm rupture

  • Uncontrolled hypertension

  • High mortality rate if left untreated

• Frequent monitoring

  • Complete the Glowscow Coma Scale

• Monitor for signs of…

  • Brain Herniation

  • Intracranial pressure

• Clinical Manifestations

  • “I have the worst headache of my entire life”

  • Nausea / Vomiting

Seizure Precaution

• Hospital setting

• Suction and oxygen at bedside

• Closely monitored

• May give ativan

• Do not restrain patient

• Do not put anything in mouth

• Clear the area

• Turn on their side

• Time the seizure

• They might bite tongue while seizing

• Padded siderail

• Bed in a low position

• make sure they lay on their Left side