Exam 1 NURS357

Med/Surg (357) - Inflammation, Infection, COVID, UTI, HIV, Cardiac pt 1/2

Inflammation

* second line of defense
* non-specific response to any tissue injury

inflammation purpose

Neutralize and dilute the inflammatory agent, remove necrotic material, establish environment suitable for healing and repair

Local clinical manifestations of inflammation

redness (vasodilation), swelling (fluid shift to interstitial spaces), heat (increase metabolism), pain(change in pH, nerve stimulation, pressure), loss of function (swelling and pain)

Systemic clinical manifestations of inflammation

increase WBC (shift to left, increase release from bone marrow), fever (cytokines), increase pulse and respiratory rate, malaise, nausea, anorexia

local inflammation (lab/sub/odj data)

observation - 5 signs (redness, swelling, heat, pain, loss of function

systemic inflammation (lab, subj/obj data)

* diagnostic - lab
* assessment - vital signs and observations

Nursing care and inflammation

prevent infection, trauma, surgery

promote healing

* nutrition
* early recognition
* access to health care

medical treatment for inflammation and risks if untreated

* physical - clinical manifestations and vital signs
* RICE
* Fever management - drug therapy, environmental controls
* Pain management - pharmacologic and non-therapies

Clinical manifestations of SIRS to septic shock

Septic shock s/s

Persistent hypotension, despite fluid resuscitation, vasopressor support, results in profound circulatory and cellular dysfunction associated with an increased risk of death (40% mortality)

Systemic s/s

Fever, decrease LOC, tachycardia, tachypnea, hypotension, hypoxemia, malaise, anorexia

Stop the cascade

Cultures and sensitivity before admin antibiotics, administer broad spectrum first --> narrow spectrum, O2 support, push fluids to keep BP up vasopressors

Infection

* invasion of host body by disease causing pathogens
* multistep process
* invade
* multiply
* produce disease
* cause harm to host

Local (contained) infection manifestations

* limited to specific body part
* pain, redness, swelling, temp, motion
* change in vital sign

Disseminated infection

spread of microorganisms beyond initial site

Systemic (diffused) infection

* Spread extensively throughout the body
* malaise, anorexia, altered MS
* lymph node enlargement
* change in renal function and/or cardiac output

Infection diagnostics

* CBC
* Leukocytosis – increase WBC (normal: 4,500-11,000)
* Differential – left shift
* Blood cultures
* This must be done before the antibiotics are given to the patient
* Urinary culture

Nursing diagnosis (infection)

1. risk for shock
2. impaired tissue integrity

nursing management (w/ infection)

1. assessment
2. administer antibiotics/antifungals (after culture)
3. address fever and discomfort
4. encourage fluid intake


1. IV line
5. ongoing monitoring


1. urine output very important
6. Emotional support

Healthcare associated infections (HAI’s)

CLABSI, CAUTI, surgical site infection, ventilator associated events

common pathogens: MRSA, C. diff

endogenous

from patient themselves

exogenous

from hospital

Iatrogenic

from intervention procedure

Risk factors for HAI’s

i. Hospital environment
ii. Immune deficiencies
iii. Age
iv. Stress
v. Nutrition
vi. Medications

Tier one (standard)

applies to all patients, contact with blood or bodily fluids

Tier two (transmission-based precautions)

i. Contact – direct contact (MRSA, VRE)
ii. Droplet – greater than 5 microns (Pneumonia)
iii. Airborne – less than 5 microns (TB, Varicella)

Compromised defenses of susceptible host

i. Neutropenic/reverse
ii. Chemo, steroid, compromised skin integrity
iii. Hygiene, immunization, nutrition, stress, hydration, rest and sleep

Hour 1 Bundle

ii. Measure lactic acid – greater than 2, recheck within 3 hours
iii. Blood culture before antibiotics
iv. Administer broad spectrum antibiotics
v. Rapid fluid infusion – isotonic IV

Sepsis prevention

aseptic care, prophylaxis, patient teaching

Sepsis treatment

A – support oxygenation
B – may require ventilation
C – optimize fluid status – IVT

Sepsis IV treatments

* large bore catheters
* crystalloids
* Colloids (blood, albumin)

Crystalloids

a. Stay in the vascular system
b. Electrolytes flow across the membrane to it into cells and body tissues
c. Increase fluid volume in both interstitial and intravascular spaces
d. Types: hypotonic, hypertonic and isotonic

Colloids (blood, albumin)

a. Contains large molecules do not pass membrane
b. When infused, remain in vascular system  expand the intravascular volume
c. “Volume expanders”
d. Increase flow of fluids

Complicated sepsis treatments

* vasopressor
* norepinephrine, dopamine
* MAP >65 mmHg

Nursing diagnosis (sepsis)

* risk for infection/shock
* ineffective tissue perfusion
* anxiety

Sepsis (ongoing monitoring)

i. v/s, LOC, urinary output, and organ function

Population more at risk for sepsis

* 2-3 times higher than younger people
* UTI more common in adults residing in long-term facilities, with indwelling catheters
* Atypical manifestations
* cognitive and behavioral change appear as symptoms before fever, pain or alterations in lab values
* do not rely on rely on fever to indicate infections in older adults

COVID risk, prevention and care considersations

* ssRNA found in humans and other mammals
* cause common cold symptoms
* target respiratory system
* transmission
* via respiratory droplets from face-to-face
* prevention
* i. keep 6 ft apart from other people
ii. wear mask
iii. indoor ventilation
iv. wear medical masks
v. hand hygiene

Cystitis

Infection of the bladder

Symptoms of cystitis

Dark, blood urine, pain in lower stomach, pain and burning during urination, strong selling, sick and tired

Urethritis

* Infection of urethra, often related to STI
* colonization of the vaginal introitus or urethra, ascends by urethra into bladder

UTIs causes

i. Gram negative bacterium – e coli (most common)
ii. Sometimes simultaneous infection with multiple pathogen

UTIs Risk Factors

i. Inadequate fluid consumption
ii. Urinary catheter use
iii. UT obstruction
iv. Vesicoureteral reflux
v. Urinary stasis
vi. Bowel incontinence
vii. Immobility
viii. Poor personal hygiene
ix. Immunosuppression
x. Sexual activity

Medical and Nursing management of UTI’s

* Antibiotic therapy based on culture and sensitivity of the bacteria
* Warm compresses and sitz bath
* Increase fluid intake (avoid citrus or caffeine)
* I/O, VS, voiding patterns and pain

Crucial education w/ UTI patient

a.      Encourage increase oral fluid

b.      Personal hygiene

c.      Take antibiotics as prescribed

d.      Emptying the bladder at least every 4 hours

Lab and diagnostic data (UTI)

Urine analysis (WBC, hematuria), blood culture

Special considerations and teaching points (UTI)

* Older adults present with confusion rather than fever
* Risk increases with catheter use
* Perineal care
* Empty bladder before and after intercourse

Pathophysiology and transmission of HIV

Clinical manifestations of HIV

How HIV is diagnosed

main goal of antiretroviral therapy and goals of care for HIV patients

HIV/AIDS patient teaching

* gerontologic consideration
* increasing rates of HIV disease among older adults
* Death rate from opportunistic infections reduced
* people 60 and older are increasingly being infected

Assessment of HIV

History, risk factors, physical, depends on stage of disease

Asymptomatic infection (HIV)

Vague or no symptoms, if not diagnosed, HIV can develop into AIDS

Acute infection (HIV)

2-4 weeks after infection and manifest as flu-like symptoms, patient highly contagious

Symptomatic infection (HIV)

CD4T cell count drops below 200 and patient is incredibly susceptible to infection

Lab and diagnostic data (HIV)

Rapid HIV, antigen/antibody immunoassay, WBC, CD4/CD8 ratio, CD4 sub 200 = AIDS, viral load

Nonmodifiable risk factors of CAD

age, gender, ethnicity, family history and genetic predispositions

Modifiable risk factors of CAD

stress, substance abuse, elevated serum lipids, hypertension, tobacco use

Asymptomatic (CAD)

silent ischemia

Symptomatic (CAD)

angina

S/S (CAD)

acute onset of chest pain, SOB, Diaphoresis, difficulty breathing, jaw/back/arm pain, nausea/vomiting, extreme fatigue

Women and Older Adults (atypical chest pain)

unexplained anxiety, shoulder pain, throat or toothache, pain under breastbone or stomach

Precipitating factors for angina

overstressing the heart, temperature extremes, strong emotions, consumption of heavy meal, sexual activity, tobacco use, stimulants, circadian rhythm (early morning)

Stable angina

predictable and consistent pain that occurs on exertion and is relieved by rest

Unstable angina symptoms

occur more freq and last longer than in stable angina, pain threshold is lower, pain may occur at rest

Intractable (refractory)

severe incapacitating chest pain

Variant

pain at rest with reversible ST-segment elevation; thought to be caused by coronary artery vasospasm

Silent ischemia

no sub data (patient is asymptomatic), objective evidence of ischemia (ECG changes with a stress test

Diagnoses of angina

thorough history related to s/s of ischemia, chest x-ray, ECG, biomarkers, exercise stress test, nuclear scan or invasive procedure (cardiac cath)

Treatment of angina

goal: decrease O2 demand, increase O2 supply, pharmacologic therapy, reperfusion procedures (PCI, PTCA, CABG)

What is ACS?

unstable angina, MI: sudden blockage of blood flow, duration: 15 mins or more

What is an MI?

coronary occlusion or heart attack, area of the myocardium is permanently destroyed, infraction over mins/hrs

Classic S/S (ACS)

early signs, prior to more serious ACS events, onset of ACS (4 or more)

Atypical S/S (elderly, diabetics)

unusual fatigue or SOB

Asymptomatic (ACS)

silent ischemia

CK-MB

*earliest increase 4-8hrs, peak 12-24 hrs, return to normal 3-4 days

Myoglobin

*earliest increase 1-3hrs, peak 4-12 hrs, return to normal 12 hours

Troponin T or I

*earliest increase 3-4 hours, peak 4-24 hrs, return to normal 1-3 weeks

Caring for a patient with ACS

Goal \= relieve pain, prevent, or minimize myocardial tissue death and to prevent complications

Thrombolytic therapy

within 4 hours of symptom onset

Percutaneous coronary intervention

w/ or w/o stent placement

Immediate MONA

morphine, oxygen, nitroglycerin, ASA (Plavix)

Initial Interventions

12 lead ECG, upright position, oxygen (> 93%), IV access, nitroglycerin, ASA, Morphine

Ongoing monitoring and care

Treat dysrhythmias, vital sign (daily weight), bed rest/limit activity for 12-24 hours, IM injections

Unstable Angina or NSTEMI

Duel antiplatelet therapy and heparin, Cardiac catheterization with PCI once stable (Balloon, stent)

Emergent PCI (cardiac cath)

Treatment of choice for confirmed STEMI, Goal:

Thrombolytic therapy (no cath lab)

For patients with NSTEMI or STEMI, Given IV within 30 min of arrival to ED, Patient selection critical (any bleeding disorders), Draw blood and start 2 IV sites (given blood supplement is common), Return of ST segment to baseline best sign

IV heparin

prevent re-occlusion

Coronary Artery Bypass (CABG)

Using another artery to replace the artery with the blockage to bypass the blockage, Recover in ICU \> Med/Surg \> Rehab

Nutritional Therapy

Initially NPO, Progress to low salt, sat fat, cholesterol

Cardiac Rehab

Medically supervised program designed to improve cardiovascular health (Exercise, Education for heart-healthy living, Counseling to reduce stress – id and tackle everyday source of stress)

Nursing diagnoses

Decreased cardiac output, anxiety acute pain, activity intolerance, ineffective management

Stenosis

not opening correctly

Regurgitation

not closing correctly

Valve prolapse

valve bulging into the chamber

Mitral valve stenosis

dyspnea on exertion, hemoptysis fatigue, A-fib, palpitation, load, accentuated S1, low-pitched, diastolic murmur

Mitral valve regurgitation

acute: poorly tolerated, new systolic murmur with pulmonary edema and cardiogenic shock develop rapidly, chronic: weak, fatigue, exertional dyspnea, palpitations, S3 gallop, systolic murmur

Mitral Valve Prolapse

palpitations, dyspnea, chest pain, activity intolerance, syncope, systolic murmur

Aortic valve stenosis

angina, syncope, dyspnea on exertion, heart failure, normal or soft S1, diminished or absent S2, systolic murmur, prominent S4