Old medsurge Final

Increased Intracranial Pressure ICP

• pressure exerted by the volume of the intracranial contents within the cranial vault

• Core principles:

  • The cranial vault is comprised of brain tissue, blood, and CSF, which are typically in equilibrium and produce stable ICP.

  • Monroe-Kellie hypothesis – there is only so much space for each component. An increase in one will result in a change in the volume of the others to stabilize ICP.

• Etiologies:

  • Head injury/ trauma

  • Skull fracture

  • Hematoma

  • Brain tumors

  • meningitis complications

  • Subarachnoid hemorrhage

  • Toxic and viral encephalopathies

• Decreased cerebral perfusion → cerebral edema → shifting of brain tissue → herniation → death

NEVER DO A LUMBAR PUNCTURE

ICP parameters

• Normal ICP

  • 0-10mm Hg

  • 15 id high-normal

• Increased ICP

  • 16-20mm Hg]

• Danger zone

  • 25mm Ha

Movement can cause a transient increase in ICP, which should be momentary and self-regulate

Cushing’s triad

• Wide BP, Low Pulse, Irratic respirations

  • ex) BP 168/58, P 58, RR 10

Cushing’s response (also called Cushing’s reflex) is seen when cerebral blood flow decreases significantly.

ICP Clinical manifestations

Early

• Altered mentation

• Confusion

• irritability

• visual changes

• Pupillary changes (sluggish), impaired EOM (CN II, III, IV, VI)

• Focal weakness, hemiparesis

• Headache

  • Constant

  • Increasing in intensity

  • Aggravated by movement or straining

Late

• LOC → comatose (GCS 8 or less)

• FEVER

• VS changes

  • Decreased or erratic HR, RR

  • Increased SBP, pulse pressure (SBP-DBP)

• Irregular respiratory patterns

  • Cheyne-Stokes – long, labored, shallow, apnea

• Projectile vomiting 2/2 medullar depression

• Pressure on brainstem → hemiplegia, decorticate or decerebrate posturing, bilateral flaccidity

• Loss of brainstem reflexes – pupillary, corneal, gag, swallowing

ICP diagnostics

• Neuroimaging – CT, MRI most commonly

• Transcranial doppler – measures cerebral blood flow

• NEVER ATTEMPT LUMBAR PUNCTURE IN A PATIENT WITH SUSPECTED OR CONFIRMED INCREASED ICP

ICP complications

• Neuroendocrine derangements

  • Neurogenic diabetes insipidus → decreased ADH → volume depletion

    • Vasopressin

  • SIADH → increased ADH → volume overload

    • Urine output > 200 mL/hr for 2 consecutive hours

• Herniation → decreased cerebral blood flow → ischemia → infarction → brain death

ICP Monitoring

• Invasive

• Intraventricular catheter/extra-ventricular drain (EVD)

  • Complications include infection, meningitis, ventricular collapse, catheter occlusion, problems with monitoring system

  • Aseptic technique

  • Continuous drainage of CSF under pressure control is an effective method of treating intracranial hypertension.

• Subarachnoid screw/bolt

  • Complications include infection, screw occlusion by clot or brain tissue

  • output is recorded on an oscilloscope not requiring a ventricular puncture

ICP Medical Management

• Goal is to immediately 1) decrease cerebral edema, 2) decrease the volume of CSF or 3) decrease cerebral blood volume while maintaining cerebral perfusion

  • Osmotic diuretics

    • mannitol

    • 3% NS

  • Corticosteroids if 2/2 tumor

  • Fluid restriction

  • Draining CSF – via EVD, NOT LP

  • Reducing metabolic demands

    • fever management

    • hypothermia?

    • reduce O2 needed

  • Decompressive hemicraniectomy

    • last result

• Maintain hemodynamic stability, cerebral perfusion

  • Ionotropes (dobutamine, norepinephrine) → increased cardiac output

• Monitor fluids and electrolytes

  • Foley

  • Serum osmolality, electrolytes

ICP Nursing process

Assessment

• Pertinent PMHx – may be obtained from family/friends

• Initial neurologic exam must be as comprehensive as possible

  • Subsequent exams care more focused – pupil checks, specific CNs, GCS

• Monitoring of VS and ICP

Diagnoses

• Impaired breathing

• Risk for ineffective tissue perfusion

• Hypovolemia 2/2 fluid restriction

• Risk for infection associated with ICP monitoring

Beware of activities or interventions that may increase ICP, minimize intraabdominal/thoracic pressure

• Be mindful of patient positioning, movement, turning

• Avoid Valsalva – YES to stool softeners, NO to enemas; exhale with movement

• Space out nursing interventions, promote calm environment

• ICP should not increase beyond 25 mm Hg, and should normalize within ~ 5 min

• Otherwise, may need sedation

Planning

• Maintaining patent airway (A)

  • Suction with caution (up to 15s)

  • Pre-oxygenate with 100% O2 if on mechanical ventilator

  • Coughing discouraged bc increases ICP

Normalizing respiratory pattern (B)

Optimizing cerebral tissue perfusion (C)

• HOB @ 30-45º; keep head in neutral, midline position

• Hyperventilation → decreased PaCO2 → cerebral vasoconstriction?

• Monitor ABGs

Maintain negative fluid balance

• 3% saline

• Osmotic and loop diuretics

• Fluid restriction – assess VS, skin turgor, mucous membranes, urine output (Foley), serum/urine osmolality; oral hygiene, perioral care

• *Fluid replacement – slow to moderate rate

• Mannitol, hypertonic saline - fluid shifts from intracellular → intravascular

  • Increased cardiac workload – monitor for pulmonary edema, heart failure

    • monitor urine osmolality, obtain I/O, accurately record ICP readings

  • urine output is monitored hourly.

Preventing infection

• Aseptic technique when managing EVD system

• Always examine CSF

  • usually clear

• Monitor for meningitis

• Monitor for other signs of local, systemic infection

Monitoring and managing potential complications

• Assess, document, notify

• Monitor for sustained increased ICP

STROKE

• AKA CVA(cerebrovascular accident)

  • Sudden Impairment of cerebral circulation in 1 or more BV supplying the brain

  • Tissues fail to receive O2→necrosis

• Third leading cause of death

• Leading cause of long-term disability

• Symptoms and signs depend on the vascular territory affected in brain.

• Most common: middle cerebral artery

TYPES:

• Ischemic (87%)

  • Thrombotic (45%)

    • LVO’s/Large vessel occlusions

    • Small penetrating artery thrombosis/lacunar

  • Cryptogenic (30%)

    • unknown etiology

  • Cardioembolic (20%)

    • Afib

    • Valvular heart disease

  • Other (5%)

• Hemorrhagic

  • Intracerebral hemorrhage

  • Subarachnoid hemorrhage

  • Cerebral aneurysm

  • AVMs

• TIA

Transient Ischemic Attack (TIA)

• Temporary neurologic deficit(s) typically lasting < 1 hr with complete resolution within 24 hr

• Temporary interruption of BF

• Warning stroke/mini stroke

• Symptoms disappear in 10-20 minutes

• No evidence of ischemia on neuroimaging

• Increased risk of subsequent CVA

Ischemic Stroke

Disruption of blood flow → decreased cerebral perfusion/ischemia → cell death/infarction → loss of function

Caused by thrombosis or Embolis

• Thrombosis (blood clot) of cerebral arteries or intracranial vessels that occludes BF

  • Causes congestion and edema in vessel which leads to ischemia

• Embolism from a thrombus outside of brain (aorta, heart, common carotid artery)

  • Curs off circulation causes necrosis and edema

    • Embolism (sudden obstruction of bv by debris, which can be blood clots, plaque, bacteria, or air bubbles)

Ischemic Stroke Risk Factors

• Nonmodifiable

  • Genetic pre-disposition

  • Age > 55

  • Female sex

  • Race/ethnicity – AA, Hispanic/Latino

• Modifiable (table 62-1. p. 2035)

  • Carotid stenosis

  • Afib

  • HTN, DM, HLD

  • Hypercoagulable states

  • Sedentary lifestyle

  • OSA

  • Smoking

• Chronic conditions

  • SCD

  • Migraine with aura, vasospasm

    • Patent foramen ovale – clots can bypass lungs and enter brain

Ischemic Stroke Clinical manifestations

• Depend on location of stroke (i.e., what blood vessels are obstructed), size of the area of inadequate perfusion (penumbra), and amount of collateral blood flow

• Deficits typically opposite side of stroke

• Refer to NIHSS

• Altered mentation, cognition

• Dysarthria

  • A disturbance of speech due to emotional stress, to brain injury, or to paralysis, incoordination, or spasticity of the muscles used for speaking.

• Dysphagia

• Aphasia (receptive, expressive, global)

  • Impaired or absent comprehension or production of, or communication by, speech, reading, writing, or signs, caused by an acquired lesion of the dominant cerebral hemisphere

• Visual disturbances (e.g., homonymous hemianopsia)

• Heminumbness; hemiparesis (weakness), hemiplegia (paralysis)

• Hemineglect

• Changes in gait and/or coordination (ataxia)

Ischemic Stroke Nursing Considerations

• For every deficit, there is a nursing diagnosis (p. 2041-2048)

• Maintain patent airway

• Frequent neuro checks

  • Serial NIHSS

  • Things can turn on a dime – hemorrhagic conversion

• Continuous hemodynamic monitoring per unit protocol

  • Neuroendovascular stroke teams will often provide BP goals

• Monitor ICP – refer to earlier slides

• Monitor blood glucose

• Seizure precautions

• It’s not just about survivorship; it’s about recovery

• Family may become caregivers overnight

Nursing diagnosis

• Impaired breathing associated with neurologic dysfunction (brain stem compression, structural displacement)

• Risk for ineffective tissue perfusion associated with the effects of increased ICP

• Hypovolemia associated with fluid restriction

• Risk for infection associated with ICP monitoring system (fiberoptic or intraventricular catheter)

Potential complications

• Brainstem herniation

• Diabetes insipidus

• SIADH

Hemorrhagic Clinical Manifestations

• Similar to ischemic stroke

• Poor prognosis depending on extent of bleed

• “Thunderclap” HA

  • worst headache they have ever had in life

• Nuchal rigidity

• Early changes in LOC

• N/V

• Seizures

• AVM – visual disturbances (visual loss, diplopia, ptosis), tinnitus, photophobia

Hemorrhagic Assessment and Diagnosis

• Similar to ischemic stroke

• CT, CTA (especially if suspected AVM, aneurysm)

• Toxicology screen when appropriate for patients < 40 years old

Hemorrhagic Complications and Management Goals

• Rebleeding or hematoma expansion

  • FFP, idarucizumab (DOAC reversal)

• Cerebral vasospasm  ischemia, seizures

• Acute hydrocephalus

• Increased ICP

• Others

  • Pain, fever

  • DVT

  • Hyper/hypoglycemia

• Surgery if indicated

  • Endovascular AVM, aneurysm repair (coiling, stenting, glue embolization)

• Refer to nursing considerations regarding ischemic stroke (minus the t-PA, thrombectomy)

Hemorrhagic Stroke Risk Factors

• Non-modifiable

  • Older age

  • Male sex

  • Race/ethnicity – Latino, AA, Japanese

• Modifiable

  • Uncontrolled HTN

Hemorrhagic Stroke

Etiology:

• Primary ICH

  • Spontaneous rupture of small vessels 2/2 uncontrolled HTN (80%)

  • Cerebral amyloid angiopathy (CAA) in older adults

  • Secondary ICH

  • AVM

  • Trauma

  • Tumors

  • Drugs (e.g., anticoagulants, cocaine, amphetamines)

• SAH

  • Cerebral aneurysm

  • AVM

Hyponatremia

Loss of sodium

<135 meq/L

Causes

• Excessive diuresis

• GI fluid loss

• Adrenocorticoid insufficiency

• V/D

• Diuretics

• excess oral fluids

• excess parenteral administration of dextrose and water

• excessive IV administration

weakness, apprehension, coma, peronality changes, lethargy, confusion, muscle cramps and twitching, seizures

Treatment:

• Restict fluid intake

• Hypertonic 3% NaCl slowly with caution

Hypernatremia

>145

water loss

Causes

• rapid infusion of hypertonic saline, sodium bicarbonate or isotonic saline

• drinking salt water

• ingestions a lot of salt without increasing water intake

• Excessive H2o loss

• diarrhea

• increase sensible loss

• diabetes insipidus

• decreased water intake

• withholding water'

• impaired thirst center

thirst, dry mouth, sticky mucous membrane, weak pulse, oliguria, anuria, Seizures, decreased reflexes, hallucinations, increased urine specific gravity, if severe: hallucinations, irritability, seizures

> 145 mEg/L

Treatment:

• Administer hypotonic solution, 0.45 NaCl or 0.3% NaCl

• If caused by diabetes insipidus give desopressin or vasopressin

fluid volume excess

Hypervolemia: increased volume in blood

Edema: excessive fluid in cells or intercellular tissues

• local or generalized

Third spacing: loss of extracellular fluid from vascular to other body components. Fluid trapped in space unable to be used

• ascites

• pleural effusion

Causes:

• inadequate water and sodium elimination

• excessive sodium intake in relation to output

• Excessive fluid intake in relation to output

Manifestations:

tachycardia, bounding pulse, hypertension, tachypnea, acute weight gain, peripheral edema/ascites, crackles heard in lungs, SOB, decreased hemoglobin and hot, decreased urine specific gravity, distended neck veins, increased GI motility, altered LOC

Sodium

regulate fluid volume, interact with calcium to maintain muscle contraction, stimulates conduction of nerve impulse.

Cation

combines with Cl

Normal serum rate: 135-145 mEq/L

Regulated through:

• Dietary intake

• Excretion

• Kidneys

• Hormonal regulation

  • Aldosterone

  • ADH

Imbalance

• Hyponatremia

  • Serum sodium lvl: 115-139 mEq/L

• Hypernatremia

  • Serum sodium lvl: 148-154 mEq/L

Nursing interventions Hyponatremia

• Treat underlying conditions

• sodium replacement

• Water restrictions

• monitor I&O, labs, CNS changes, vital signs

• Initiate seizure precautions

Nursing interventions hypernatremia

• Gradual lowering of sodium via IV fluids

• Encourage water intake

• decrease sodium intake

• monitor I&O, labs, CNS changes, vital signs

• Initiate seizure precautions

Hypervolemia

ef:

Cause:

• kidney failure

• HF

• cirrhosis

• nephrotic syndrome

Clinical Manifestations

• Dyspnea

• Crackles

• Tachypnea

• Bounding rapid pulse

• Edema

• HTN

• Edema

• Ventricular gallop

• Clammy skin

Treatment

• Identify and treat underlying cause

• restrict sodium and fluid water intake

• id severe O2 therapy, morphine, IV diuretics, mechanical ventilation

Fluid volume excess Nursing interventions

• Position in semifolwers

• Obtain daily weight same time q day

• Assess lung sounds

• Monitor intake/output (I&O)

• Implement fluid & sodium restrictions per orders

• Administer O2 as prescribed and as needed

• Administer diuretics

Irritable Bowel syndrome Patho, risk factors, clinical manifestation

• Pathophysiology

  • recurrent abdominal pain associated with disordered bowel movements, which may include diarrhea, constipation, or both, without an identifiable cause

    • Genetics+envrionment

• Risk factors/complications

  • <45yrs

  • Women>Men

  • Air pollutant

  • Tobacco

  • Notern climate

  • Ashkenazi Jewish

  • Chronic stress

  • Sleep deprivation

  • Bacterial overgrowth

  • Genetics

  • Surgery infections (Giardia)

  • Inflammation

  • Food intolerance

• Clinical manifestations

  • Constipation

  • Diarrhea

  • Pain

  • Bloating

  • Abdominal distention

Irritable Bowel syndrome Assessment, diagnosis, Treatment

• Focused assessment

  • Critea to Define IBS 2 or more:

    • Abdominal pain related to defecation;

    • Abdominal pain associated with a change in frequency of stool;

    • Abdominal pain associated with a change in form/appearance of stool.

• Diagnosis

  • CBC

  • C-reactive protein

  • Fecal calprotectin

  • Serotoloci tests

  • Stool studies

  • colonoscopy

• Treatments/nursing interventions

  • LOW FODMAP diets

    • Fermentable Oligosaccharides (e.g., wheat, rye, asparagus, legumes, garlic, onions),

    • Disaccharides (lactose-containing foods such as milk, yogurt),

    • Monosaccharides (fructose-containing foods such as honey, agave nectar, figs, mangoes), And

    • Polyols (e.g., blackberries, lychee, and low-calorie sweeteners)

  • Antidiarrheal agents

    • Lomotil

  • Antidepressants

    • dicyclomine

  • Smooth muscle antispasmodic agents

  • Abx for diarrhea

  • Nurising interventions

    • Avoid fatigue

    • Reduce anxiety

    • Increase knowledge

    • Prevention of FV deficiet

    • Avoid complications

    • Restore bowel elimination

    • Educate

    • Releave Pain

  • Indications

    • Crohn’s disease: SBO, abscess, perforation, hemorrhage,
      fistula formation, strictures
      

    • Ulcerative colitis: colon cancer/colonic dysplasia, megacolon
      hemorrhage, perforation, strictures
      

  • Proctocolectomy (surgical excision of the colon and rectum)
    and
    total colectomy (surgical excision of the entire colon) with
    ileostomy (surgical opening into the ileum via stoma to allow
    drainage of bowel contents)

  • Curative for ulcerative colitis but not for Crohn’s
    99

Inflammatory Bowel disease

Ulcerative colitis

Crohns disease

Crohn’s disease

• Pathology:

  • Subacute and chronic inflamation of GI tract

  • skip lesions, cobblestome 1/1 ulcerations, fistulas, fissures, abscesses

  • Relapsing progressive

• Clinical manifestations:

  • Anorexia, wt loss, malnutrition

  • Steatorrhea

  • Dehydration

  • Location: Ileum, ascending colon (usually)

  • Crampy RUQ pain

  • Bleeding: Usually not, but if it occurs, it tends to be mild

  • Perianal: Common

  • Fistulas: Common

  • Diarrhea: Less severe

  • Abdominal Mass: Common

• Diagnostic Findings

  • Imaging- Abdomincal CT, MRI, US

  • Procedures: colonscopy+biopsy

  • Lab studies

    • CBC

    • Elevated ESR, CRP

    • B12 deficiency

    • Low serum albumin, protien

• Therapeutic management:

  • Corticosteroids, aminosalicylates (sulfasalazine)

  • Immunomodulators (e.g., azathioprine) or monoclonal antibodies (e.g., infliximab, adalimumab) may be tried if refractory to corticosteroids and aminosalicylates

  • Antibiotics

  • Parenteral nutrition

  • Partial or complete colectomy, with ileostomy or anastomosis

  • Rectum can be preserved in some patients

  • Recurrence common

Ulcerative colitis

• Patho:

  • Inflammatory disease of the
    mucosal and submucosal layers of the colon and rectum

  • Mucosal ilceration→ exposure of capillaries→ bleeding

  • Relapsing and remitting (flares and heels)

• S&S

  • Bleeding: Common-severe

  • Fever, anorexia, wt loss, Vomitting

  • LLQ cramping releaved by poopining

  • Perianal: Rare

  • Fistulas: Rare

  • Diarrhea: severe

  • Abdominal Mass: rare

• Diagnostic Findings

  • Imaging- abdominal XR, CT, MRI, US

  • Procedures-colonoscopy+biospy

  • Lab studies

    • CBC: anemia, leukocytosis

    • CMP: electrolyte abnormalities

    • Elevated ERS

    • Stool sample

      • r/o parasites

      • + blood

    • Hypoalbumenia

• Complications

  • Perforation

  • Bleeding

  • Osterporotic fractures

  • Colon cancer

  • Toxic megacolon

• Therapeutic management:

  • Corticosteroids, aminosalicylates (sulfasalazine) useful in preventing recurrence

  • Immunomodulators (e.g., azathioprine) or monoclonal antibodies (e.g., infliximab, adalimumab) may be tried if refractory to corticosteroids and aminosalicylates

  • Bulk hydrophilic agents

  • Antibiotics

  • Proctocolectomy, with ileostomy

  • Rectum can be preserved in only a few patients “cured” by colectomy

Hepatitis

• Pathophysiology

  • 5 types

  • Hepatitis A -avoid causative agent, No treatment

  • Hepatitis B – Interferon-education

  • Hepatitis C – Interferon & Ribavirin

  • Hepatitis D – No treatment

  • Hepatitis E – No treatment

    • Avoid ETOH

    • GOOD HANDWASHING

  • Reportable, communicable disease

• Clinical manifestations

  • Fatigue

  • Jaundice (yellowing of skin/eyes)

  • Anorexia, nausea, vomiting

  • RUQ abdominal pain

  • Dark urine, pale stools

  • Fever (in acute cases)

  • Hepatomegaly (enlarged liver)

  • Joint pain (arthralgia), especially in HBV and HCV

• Risk factors/complications

  • V drug use

  • Unprotected sex (especially HBV, HCV)

  • Healthcare exposure (needlesticks)

  • Travel to endemic areas (HAV, HEV)

  • Blood transfusions before 1992 (HCV risk)

  • Poor sanitation (HAV, HEV)

  • Chronic hepatitis → cirrhosis → liver failure → liver cancer (especially HBV and HCV)

Hepatitis focused assessment and Treatments

• Focused assessment

  • Assess for jaundice, fatigue, RUQ tenderness

  • Monitor liver function tests (AST, ALT, bilirubin)

  • Assess for bleeding/bruising (decreased clotting factors in liver disease)

  • Monitor for neurological changes (hepatic encephalopathy)

  • Ask about risk factors (travel, drug use, sex, needle sharing)

• Treatments/nursing interventions

  • Promote rest and balanced nutrition (small frequent meals)

  • Avoid alcohol and hepatotoxic drugs (e.g., acetaminophen)

  • Educate on infection control (handwashing, safe sex, no sharing razors/needles)

  • Administer medications as prescribed (e.g., Interferon, Ribavirin)

  • Monitor labs (LFTs, CBC, coagulation panel)

  • Encourage vaccination for Hep A & B (prevention)

  • Prepare for possible liver biopsy or transplant evaluation in chronic cases

  • Report to public health as required

Cirrhosis      

• Compensated and decompensated

  • Compensated

    • Liver can still perform essential functions, often without noticeable symptoms

  • Decompensated

    • noticeable symptoms, can’t function

• Pathophysiology

  • Extensive, irreversible scarring of the liver->impairments in BF and lymph flow

  • Cause: chronic reaction to hepatic inflammation or necrosis

  • Laennec: Alcohol induced

  • Post necrotic: viral hepatitis/drugs

  • Biliary: chronic biliary obstruction and infection

  • Cardiac: chronic Rt side HF causing elevated venous pressure & liver congestion

• Clinical manifestations

  • Compensated: no obvious symptoms

  • Decompensated: ascites, jaundice, hepatic, encephalopathy or variceal bleeding

  • Liver enlargement

  • Portal obstruction & asities

    • dullness or fluid wave on percussion

  • Infection & peritonitis

    • dx by paracentesis

    • spontanious bacteriola peritonitis

  • GI varices

  • Edema extremities

  • Vitamin deficiency ACK, anemia

  • Mental deterioration

• Risk factors/complications

  • Fatal without transplan

Renal Gerontologic Considerations

• GFR decreases between ages 35 to 40yrs

  • 1 mL/min continues thereafter each year

• Older adults susceptible to acute and chronic kidney injury

• Older adults are more prone to develop hypernatremia and fluid volume deficit, because increasing age is also associated with diminished osmotic stimulation of thirst

• Slow response to sudden physiologic changes

• Diminished osmotic stimulation of thirst

• Urinary incontinence is present in 15% to 30% of community-dwelling older adults, 50% of older adults who are institutionalized, and 30% of older adults who are hospitalized

• Incomplete emptying of the bladder

• A fluid balance deficit in older adults can lead to falls, medication toxicity, constipation, urinary tract and respiratory tract infections, delirium, seizures, electrolyte imbalances, hyperthermia, and delayed wound healing.

Lower Urinary Tract Infections

Causes: bacteria colonize the urinary tract, backward flow of urine from the bladder into the ureters, obstruction of free flowing urine

• The most common cause of UTIs occur when fecal organisms ascend from the perineum to the urethra and bladder

Cystitis

• (inflammation of the urinary bladder),

Prostatitis

• (inflammation of the prostate gland), and bacterial

urethritis

• inflammation of the urethra)

• Females at greater risk due to short urethra

• Assess patients for dysuria, frequency, urgency, nocturia, incontinence, suprapubic or pelvic pain, UA, Urine C&S

• Bacteriuria increases with age (women > men)

• UTI is the most common infection of elderly

• Initiate ABT orders – decrease s/s, prevent complications

• Encourage fluids to flush bacteria and promote renal blood flow

• Patient education. Review “Nursing Process – The Patient with a Lower Urinary Tract Infection”

NURSING DIAGNOSIS

• Acute pain associated with infection within the urinary tract

• Lack of knowledge about factors predisposing the patient to infection and recurrence, detection and prevention of recurrence, and pharmacologic therapy

Neurogenic Bladder

• Urinary incontinence resulting from a neurological disorder

• Causes: spinal cord injuries, spinal tumors, congenital spinal disorders, infections, or complications of disease processes such as diabetes and multiple sclerosis

• Types: Spastic bladder and flaccid bladder. Spastic bladder empties on reflex. Flaccid bladder empties by overflow incontinence

• Assessment: UA, skin integrity, I&O, residual urine, assess for sensory awareness of bladder fullness

• Complications: infection, kidney stones

• Nursing management: prevent over-distention of the bladder, encourage low calcium diet, encourage fluid intake, bladder retraining

Upper Urinary Tract infections

• Acute pyelonephritis

  • a bacterial infection causing inflammation of the kidents andis one of the most common diseases of the kidneys. It occurs as a complication of an ascending urinary tract infection which spreads from the bladder to the kidneys and their collecting systems.

• Chronic pyelonephritis

  • unclear cause

  • can be caused by reflux nephropathy

    • kidneys are damaged by backward flow of urine back into kidney due to leaky valve

• Renal Abscess

  • occurs within kidney tissue

• Interstitial nephritis

  • Causing inflammation around tubules

  • lowers person ability to clean their body and produce urine

• Perineal abscess

  • occurs around one or both kidneys

Human Papilloma Virus (HPV)

• One of the most common STI

• Commonly asymptomatic

• Chronic condition

• Virus stay in nerve cells

• Sexual contact

• Gardasil vaccine can prevent some types

Human Papilloma Virus (HPV) Transmission

• Unprotected Vaginal, anal, oral sex

• Mother to baby: pregnancy , labor, birth

• Can lead to cancers

  • Female

  • Male

  • Both

• Typically asymptomatic

Gardasil 9

indication: HPV

MOA: Recombinant vaccine inducing antibody production

AE: Injection site reactions, headache, fever, fainting (vasovagal), syncope

Nursing Considerations:

• Give IM in deltoid

• Monitor 15 mins post-injection (fainting risk)

• Series of 2 or 3 doses depending on age

Chlamydia Trachomatis & Neisseria Gonorrhea

• More prevalent in females 15-24

  • C. Trachomatis common with young women 15-24

• Most commonly reported infectious diseases

Chlamydia Trachomatis & Neisseria Gonorrhea: Clinical Manifestations

• General

  • Fever

  • Purulent drainage

  • Foul odor discharge

  • Typically painless

  • Visualization of site

  • Joint pain

• Women

  • Both commonly don’t cause symptoms in women

  • Uterine tenderness

  • Mucopurulent cervicitis with exudates in endocervical canal

  • GONORRHEA: present with UTI or Vaginitis

• Men

  • More likely to have symptoms

  • Can be asymptomatic with both

  • Inguinal lymph node swelling

  • Buring during voiding

  • Penile discharge

  • GONORRHEA: painful, swollen testicles

Chlamydia Trachomatis & Neisseria Gonorrhea: Complications

• Women:

  • Pelvic Inflammatory disease PID

  • Ectopic pregnancy

  • infertility

• Men:

  • Epididymitis

    • Can lead to infertility

    • Painful

• GONORRHEA: Both sexes

  • Arthritis

  • Bloodstream infection

Chlamydia Trachomatis & Neisseria Gonorrhea: Assessment and Diagnostic Findings

• Assess for fever, discharge, and signs of arthritis

• Gram stain in lab

• Culture

  • Male

    • Urethra

    • Anal canal

    • Pharynx cultures

  • Female

    • Urethra

    • Anal canal

    • Pharynx cultures

• Nucleic acid amplification tests (NAAT)

• Annual testing for women <25yrs who are sexually active, or > 25 with new or multiple sexual partners

• Pregnant women =chlamydia testing bc 70% asymptomatic

Chlamydia Trachomatis & Neisseria Gonorrhea: Medical management

• Dual therapy bc patients are often coninfected

  • dual therapy is recommended, even if only gonorrhea has been laboratory proven

• Serologic testing

• If the patient reports a new episode of symptoms or tests are positive for gonorrhea again, the most likely explanation is reinfection rather than treatment failure.

Chlamydia Trachomatis & Neisseria Gonorrhea: Nursing management

• Reportable communicable diseases

• reported to the local public health department to ensure follow-up of the patient.

• Prevention education: adolescence and young adult

• Pregnancy: routine screening for chlamydia.

• Teach abstinence, limiting sexual partners, using condoms, age of initial sexual exposure

Chlamydia Trachomatis & Neisseria Gonorrhea: Patient education

• Medication adherence

• Sexual adherence

  • 5P’s

    • Partners

    • Prevention

    • Pregnancy

    • Protection

    • Past histories

Chlamydia Trachomatis & Neisseria Gonorrhea: Nursing Diagnoses

• Knowledge deficit

• Anxiety

• Nonadherence

ceftriaxone

Indication: N. Gonorrhea, UTI, ROUTE: IV, IM

MOA: Inhibits bacterial cell wall synthesis (β-lactam antibiotic)

AE:

• CNS: fever, taste disturbance, headache, dizziness.

• CV: IV site phlebitis, flushing.

• GI: diarrhea, nausea, vomiting.

• GU: increased BUN level, increased creatinine level, moniliasis, vaginitis.

• Hematologic: anemia, eosinophilia, thrombocytosis, leukopenia.

• Hepatic: increased transaminase levels.

• Skin: pain, induration, and tenderness at injection site, rash, diaphoresis.

• Other: hypersensitivity reactions, chills.

Nursing Considerations:

• IM injection can be painful (may mix with lidocaine)

• Check allergy history (esp. penicillin cross-reaction)

• Assess for cephalosporin allergy

• Monitor PT and INR

• Monitor Diarrhea

Venous Thromboembolism (DVT)

• Risk factors

• Endothelial damage

  • Venous stasis

  • Altered coagulation

• Manifestations

  • Deep veins

  • Superficial veins

• Complications of Venous Thrombosis

  • Chronic venous occlusion

  • Pulmonary emboli from dislodged thrombi

  • Valvular destruction:

  • Chronic venous insufficiency

  • Increased venous pressure

  • Varicosities

  • Venous ulcers

Physical Assessment of cardiovascular system: Skin

• P’s=acute abduction of atrial BF in extremities

  • Pain

  • Pulselessness

  • Pallor

  • Paresthesia

  • Poikothermia

  • Paralysis

• Major blood vessels of the arms and legs may be used for catheter insertion. During these procedures, systemic anticoagulation with heparin is necessary, and bruising or small hematomas may occur at the catheter access site.

• Large hemaromas sus

• Peripehral edema

  • Edema of feet, legs, and ankles

  • HF, PVD, DVT, chronic venous insufficiency

  • 0, 1, 2, 3, 4

• Prolonged capillary refill

• Clubbing

  • Chronic hemoglobin desaturation=congenital HD

• Chronically reduced O2

  • Hair loss

  • Brittle nails

  • Drys skin

  • Uclers

  • Skin color changes

Heart Failure

Chronic condition

Acute on chronic exacerbations

Types

• Left sided

• Right sided

Diagnostic Assessment

• Imaging

  • CXR: enlarged heart (NOT DIAGNOTIC)

  • Vascular engorgement, cardiomegaly, or pleural effusions

  • Echocardiogram (best diagnostic tool):

    • EF

    • Valvular changes, chamber enlargement

    • Pericardial effusion

    • Blood clots

    • Cardiac wall motion

    • BNP: Brain natriuretic peptide

      • higher number= more intense the HF

      • norms: <100pg/mL

      • suggests HF: 100-299

      • Mild HF: 300-599

      • Moderate HF: 600-899

      • Severe HF: >900

• ECG

• Stress testing

• Cardiac Catheterization

Heart Failure: Interventions

• Pharmacologic

  • Diuretic

  • Beta blockers

• Iv Infusion of Inotropic

  • Inotropic agents, or inotropes, are drugs that change the force of a heart's contractions. Inotropes can be positive or negative, depending on whether they strengthen or weaken the heartbeat

  • Positive inotropes

  • Used when the heart is too weak to pump enough blood, such as when the heart can't get enough blood to the body. Positive inotropes strengthen the heart's contractions, which increases cardiac output and the amount of blood the heart pumps.

  • Negative inotropes

  • Used when the heart is working too hard, such as when a patient has high blood pressure, chest pain, or an abnormal heart rhythm. Negative inotropes weaken the heart's contractions.

  • Examples of positive inotropic medications include digoxin, dobutamine, and milrinone.

  • Clonidine and Atenolol are examples of negative inotropic medications

• Nutritional therapy

  • Dash diet

  • Low sodium

  • No canned food

  • No processed foods

Heart Failure: Nursing process & Patient education

• Care

  • Focus

    • Effectiveness of therapy

    • Patient’s self-management

    • S&S if increased HF

    • Emotional or psychosocial response

  • Health history

  • PE

    • Mental status; lung sounds: crackles and wheezes; heart sounds: S3; fluid status or signs of fluid overload; daily weight and I&O; assess responses to medications

• Patient education

  • Medications

  • Diet: low-sodium diet and fluid restriction

  • Monitoring for signs of excess fluid, hypotension, and symptoms of disease exacerbation, including daily weight

  • Exercise and activity program

  • Stress management

  • Prevention of infection

  • Know how and when to contact health care provider

  • Include family in education

Heart Failure: Nursing Diagnosis

• Activity intolerance related to decreased CO

• Excess fluid volume related to the HF syndrome

• Anxiety-related symptoms related to complexity of the therapeutic regimen

• Powerlessness related to chronic illness and hospitalizations

• Ineffective family therapeutic regimen management

Pump Failure

• Inadequate peripheral blood flow occurs when the heart’s pumping action becomes inefficient

• Heart failure with reduced left ventricular ejection fraction (HFrEF; also called systolic HF) causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output, which results in inadequate arterial blood flow to the tissues.

• Heart failure with preserved left ventricular ejection fraction (HFpEF; also called diastolic HF) causes systemic venous congestion and a reduction in forward flow

Coronary Vascular Disorders

Coronary Atherosclerosis

Angina Pectoris

Acute Myocardial Infarction

Coronary Atherosclerosis

• Most common CAD disease

• Abnormal accumulation of lipid, or fatty substances, and fibrous tissue in the lining fom arterial blood vessels blocks the coronary arteries and reduces blood to the myocardium

Coronary Atherosclerosis: Clinical Manifestations

• Depends on location and degree of narrowing

• Ischemia

• Angina pectoris

• Sudden cardiac death

• Epigastric distress

• Pain that radiates to the jaw or left arm

• Older & diabetes SOB

• Women atypical

  • Indigestion

  • Nausea

  • Palpations

  • Numbness

Coronary Atherosclerosis: Risk Factors

• Elevated LDL

• Diabetes

• Peripheral arterial disease

• Abdominal aortic aneyurism

• Older

• Large abdominal circumference

• Hypertension

• Reduced HDL

Angina Pectoris

• Angina=chest pain

  • A Syndrome characterized by episodes or paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow

  • SOB, diaphoresis, palpitations, fatigue, N/V

  • Physical exertion or emotional stress increases myocardial oxygen demand, and the coronary vessels are unable to supply sufficient blood flow to meet the oxygen demand

  • Can radiate across chest to arms, jaw, shoulders, upper back or epigastrium

    • Radiation to arm and hands described as numbness and tingling

• Stable angina: more O2 than heart can handle

• Unstable: acute coronary syndrome. It is characterized by sudden and unexpected chest pain, typically while at rest, and it can persist longer than stable angina. This condition is a sign that your heart is not getting enough oxygen, and it requires immediate medical intervention.

• Variant: random angina

• Acronym: PQRST

  • P:

  • Q

  • R

  • S

  • T

• Aggravating factors

  • Physical exertion, emotional upset, eating large meal, or exposure to extremes in temperature

• Treatment

  • Rest, nitroglycerin, O2

  • MONA

Acute Myocardial Infarction

Emergency

AKA coronary occlusion, Heart attack

Acute Myocardial Infarction: Interventions

• Pharmacologic

  • Nitrate

  • Beta-Adrenergic blockers

  • Antiplatelet

  • Calcium-Channel blocker

• PCI

  • Cardiac catherterization

  • Percutaneus coronary intervention

  • Coronary artery stent

• Surgical Intervention

  • Coronary artery bypass graft (CABG)