NCLEX must knows pt.2

orange = CV, Teal = GI

Pericarditis

• inflammation of the pericardium

• causes

  • infection

  • tumor

  • drugs

• assessment findings

  • sharp chest pain

  • tachypnea

  • fever, chills

  • weakness

• Tx - NSAIDs

Pericardial Effusion

• collection of fluid in the pericardiacl sac

• impairs cardiac function if severe

  • obstructive cardiogenic shock

• assessment findings

  • chest pain

  • muffled heart sounds

• Tx- pericardiocentesis

cardiac tamponade

• blood, fluid, or exudate have leaked into pericardial sac

• causes: MVC R ventricular biopsy, pericarditis, CABG

• assessment

  • chest pain

  • SOB

  • decreased CO

  • muffled/distant heart sounds

  • JVD

  • narrowed pulse pressure (<40)

• Tx- pericardiocentesis and surgery

• note: Posisitve pressure ventilation (PPV) is detrimental to cardaic tamponade pts bc it increases intrathoracic pressure which decreases venous return to the heart

Endocarditis

• infection and inflammation of the endocardium- valves

• can lead to

  • valve abnormalities

    • stenosis

    • regurgitation

  • poor cardiac output

  • bacteremia

  • bacterial emboli

• Tx- abx

Left-sided Heart Failure

• left side of heart cannot move blood out to body

• blood is backing up into the lungs

• assessment

  • pulmonary congestion

  • wet lung sounds

  • dyspnea

  • cough

  • blood tinged sputum

  • S3

  • orthopnea

  • “FORCED”

    • Fatigue

    • Orthopnea

    • Rales/restlessness

    • Cyanosis/confusion

    • Extreme weakness

    • Dyspnea

• #1 cause is HTN

Right sided Heart Failure

• right side of heart cannot move blood to lungs

• blood is backing up into the body

• assessment

  • JVD

  • hepatomegaly

  • splenomegaly

  • ascites

  • weight gain

  • fatigue

  • anorexia

  • “BACONED”

    • Bloating

    • Anorexia

    • Cyanosis

    • Oliguria

    • Nausea

    • Edema

    • Distended neck veins (JVD)

• caused by left sided heart failure

Heart Failure Tx

• decrease the workload of the heart

• primary strat is to decrease afterload

  • ACE inhibitors

    • increase stroke volume

  • ARBS

    • ↑ CO

• ↑ contractility- Digoxin

• Diuresis

  • ↓ excess fluid

HF pt education

• take diuretic meds in the AM

• monitor electrolyte lvls while on diuretics

• low sodium diet- helps ↓ fluid

• elevate HOB- will help w diuresis

• Daily weights!

  • same time, scale, clothes

• report any increase of 2-3 lbs in one day

small intestines

• receive digesting enzymes from the pancreas and liver

  • via pancreatic and common bile ducts

• churn and mix ingested food, making it into chyme

• absorb nutrients

• move the food along its entire length, into the colon

gallbladder

• stores bile (made by liver) and releases it into duodenum of small intestine

• bile

  • emulsifies lipids so they can be absorbed

  • greenish, yellowish, brown substance

  • very alkaline

exocrine function of pancreas

• produces and releases digestive enzymes

  • Trypsin: break down proteins

  • Amylase: breaks down carbohydrates

  • Lipase: breaks down fats

• enzymes released into duodenum

Total Parenteral Nutrition (TPN)

• aka hyperalimentation

• contains

  • dextrose

  • amino acids

  • electrolytes

• indications

  • enteral nutrition contraindicated

  • high risk for aspiration

  • GI tract obstruction

• complications

  • infection

    • bag and tubing changed q24h

    • refrigerated until ready to hang

  • fluid overload

    • daily weights

    • check electrolytes

  • hypo/hyperglycemia

    • do not turn on or off suddenly

      • if you run out of TPN, give dextrose 10% at the SAME rate the TPN was running

    • titrate up when turning on and down when turning off

    • check BG q4-6h

  • embolism

• Central line preferred!

ondansetron

• class- antiemetic

• indication- N/V

• action- blocks effects of serotonin on vagal nerve and CNS

• nursing considerations

  • administer slowly. Fast push can cause QT prolongation and VT

    • torsades de pointes vtach

Famotidine

• class- H2 receptor antagonist- antihistamine

• indication- short term Tx of gastric and duodenal ulcers, GERD, Zollinger-Ellison syndrome, hypersecretion of stomach acid conditions, chronic NSAID/ASA use and GI distress

• action- blocks release of histamine which means its blocking the secretion of gastric acid and pepsin

• nursing considerations

  • monitor CBC and kidney function

  • can be given with meals

  • peak absorption of famotidine is within 2-3 hrs

  • available OTC in lower strengths. teach pts to only take as directed and for short durations

  • famotidine less likely to interact w other drugs so it is DOC when pts are on multiple drugs esp if the others have therapeutic/toxic level concerns

Omeprazole

• class: proton-pump inhibitor (PPI) (-azole)

• indication: GERD, ulcers

• action: prevents the transport of H ions into the gastric lumen by binding to gastric parietal cells to decrease gastric acid production

• nursing considerations

  • administer 30-60 minutes before meals

  • report black, tarry stools

    • indicates upper GI bleed

Sucralfate

• class- disaccharide sulfates. it contains aluminum hydroxide and sucrose

• indication- short-term Tx of duodenal or gastric ulcers, peptic esophagitis, NSAID/ASA induced GI damage

• action- promotes healing of ulcers by providing a barrier over them. it creates a paste when exposed to hydrochloric acid and binds to proteins that are excreted by damaged cells in ulcerated tissue

• nursing consideration

  • take on empty stomach 1 hr before meals or 2 hrs after meals and at bedtime.

    • often given up to 4x daily

  • don’t give within 30 min of antacids as they can ↓ effectiveness of sucralfate

  • take care giving antacids that contain aluminum to kidney failure pts bc aluminum toxicity

  • monitor BG in diabetics as sucralfate contains sucrose

• can ↓ the bioavailability of warfarin, digoxin, and phenytoin, levothyroxine, and several classes of abx. separate these drugs from sucralfate for at least 2 hrs

other than nutrition, what can NG tubes be used for?

removal of stomach contents after overdose

With NG tubes, if you have a residual over ___ mL, you want to hold the feed and call PHCP.

500 mL

blakemore tube

• tube inserted thru nose down esophagus and into the stomach w balloons that can be inflated to stop bleeding esophageal varices

• aka Sengstaken-Blakemore or Minnesota tube

• must keep a pair of scissors at the bedside in case of emergency!

  • if balloon becomes dislodged, it can compress trachea

  • cut the gastic balloon port to deflate it quickly so you can pull out tube

When administering Nitroprusside, which lab value should be monitored?

Thiocyanate levels

renal infarction

• can manifest as a result of infective endocarditis

• In a renal infarction, the septic emboli get lodged in the renal artery, creating significant pain and decreasing the blood flow to the affected kidney.

• presents with flank pain or even microscopic/frank hematuria

Esophageal Varices

• dilated mucosal veins in the esophagus

• can burst and bleed

• life-threatening emergency

• causes

  • liver disease

  • alcoholism

• Tx

  • blakemore tube

  • surgery

Gastroesophageal reflux disease (GERD)

• acid and refluxes from the stomach into the esophagus, causing esophagitis

• conditions that increase abd pressure increase risk for GERD

  • vomiting, coughing, lifting, bending, obesity

• Tx

  • sit upright after meals

  • small, frequent meals

  • H2 blockers

  • PPIs

• Complication

  • Barrett’s esophagus- extended period of reflux changes esophagus and causes presence of precancerous or cancerous cells

Gastritis

• inflammatory disorder of the gastric mucosa

• acute gastritis

  • associated with Helicobacter pylori, NSAIDs, drugs, chemicals

• clinical manifestations

  • vague abd discomfort, epigastric tenderness, and bleeding

• Tx

  • Healing usually occurs spontaneously within a few days

  • D/C NSAIDs

  • H2 receptor blockers

  • PPIs

  • abx if due to H. pylori

gastric ulcer

• cause

  • H. pylori

  • overuse of NSAIDs

• Sx

  • pain 1-2 hrs after meal

  • abd pain aggravated by eating

  • vomiting

  • weight loss

  • hematemesis if hemorrhage occurs

• Tx

  • treat H. pylori w abx

  • reduce stomach acid

    • H2- receptor blocker

    • PPI

Duodenal ulcer

• cause

  • H. pylori

  • overuse of NSAIDs

• Sx

  • pain 2-4 hrs after meals

  • food may relieve pain

  • weight gain

  • Melena if hemorrhage occurs

• Tx

  • abs

  • H2 receptor blockers & PPIs

Crohn’s Disease

• inflammation and erosion of the ileum and anywhere throughout the small and large intestines

  • idiopathic inflammatory disorder; affects any part of the digestive tract, from mouth to anus

• Granulomatous colitis, ileocolitis, or regional enteritis

• difficult to differentiate from ulcerative colitis

  • similar risk factors and theories of causation

Ulcerative Colitis

• inflammation of the large intestines

• chronic inflammatory disease that causes ulceration of the colonic mucosa

  • sigmoid colon and rectum

• common in 20-40 y/o age range and ppl of jewish descent

• suggested causes

  • infectious, immunologic (anticolon antibodies), dietary, genetics

• pathophysiology

  • lesions are continuous with no skipped lesions, are limited to the mucosa, and are not transmural

Diverticular Disease

• Diverticula- Herniation of mucosa through the muscle layers of the colon wall

• Diverticulosis- asymptomatic diverticular disease

• diverticulitis- inflammatory stage of diverticulosis

• Possible causes

  • decreased dietary fiber

  • abnormal neuromuscular function

  • alterations in intestinal motility

  • >60 years of age

• assessment

  • rebound tenderness

  • cramping

  • diarrhea

  • vomiting

  • dehydration

  • weight loss

  • rectal bleeding

  • bloody stools

  • anemia

  • fever

• Tx

  • low fiber diet- food with casings can get stuck in pockets and cause inflammation

  • avoid cold or hot foods

  • no smoking

  • antidiarrheals

  • abx

  • steroids

  • in severe cases may end up surgically removing the affected portion of the intestines

    • ileostomy

    • colostomy

Intestinal obstruction

• any condition that prevents the flow of chyme through the intestinal lumen or failure of normal intestinal motility in the absence of an obstructing lesion

• clinical manifestations

  • small intestine obstruction

    • colicky pains caused by intestinal distention, followed by nausea and vomiting

  • large intestine obstruction

    • hypogastric pain and abd distention

Appendicitis

• inflammation of the appendix

• most common age = 10 yrs old

• most common abd surgery in children

• perforation more common in children

• pain

  • begins as dull, steady periumbilical pain

  • over 4-6 hrs, pain progresses and localizes to RLQ

  • Sudden relief of pain may indicate appendix rupture

    • can lead to peritonitis

  • (+) McBurney’s sign: significant pain upon palpation

• Tx

  • appendectomy

  • pre-op

    • no heat- can aggravate inflamed appendix and cause rupture

    • position R side, low fowlers for comfort

  • post-op

    • IVF, IV abx

    • pain management

    • NPO until return of bowel sounds

    • wound care

Pancreatitis

• inflammation of the pancreas

• # 1 cause = alcoholism

• pathophysiology

  • digestive enzymes activate inside of the pancreas

  • this causes autodigestion of the pancreas

• assessment

  • pain- increases with eating due to increased digestie enzymes

  • abd distention; possible ascites

  • abd mass- the hard pancreas

  • rigid abd

  • cullen’s sign- c shaped brusing above umbilicus

  • gray turner’s sign- bruising along the flank

  • fever

  • N/V

  • jaundice

  • hypotension- pt losing fluid into 3rd spaces

• labs

  • increased WBC

  • increase serum lipase (pancreatic enzymes)

• interventions- PANCREAS

  • Pain control

  • Antispasmodic rugs to reduce gut motility

  • NPO/NGT suction, TPN- pancreatic rest

  • Calcium replacement bc hypocalcemia

  • Replace fluids and electrolytes

  • Elevated enzymes (check amylase and lipase)

  • Antibiotics with fever

  • Steroids- corticosteroids for acute attacks

Cholelithiasis

• aka gallstones

• hardened deposits of bile in the gallbladder

  • can be the size of a grain of rice up to the size of a golf ball

• causes

  • hyperlipidemia

  • hyperbilirubinemia

• assessment

  • sudden, sharp RUQ pain

  • pain worsens continually

    • can radiate to back and between shoulder blades or R shoulder

    • gets worse at night or after a fatty meal

  • N/V

• Tx

  • cholecystectomy

Cholecystitis

• inflammation of the gallbladder

• causes

  • cholelithiasis, infection, blocked bile duct

• clinical manifestations

  • fever, leukocytosis, rebound tenderness, and abd muscle guarding

• Tx

  • pain control

  • replacement of fluids and electrolytes

  • fasting

  • abx administration

  • perforated gallbladder: immediate cholecystectomy

Hepatitis

• inflammation of the liver

• can progress to cirrhosis

• Types A, B, C, D, and E- caused by different viral infections

• severe cases can lead to a hepatic coma (hepatic encephalopathy)

  • A- contaminated food or water; typ self-limiting; no risk chronic infection

  • B- contact w infected body fluids; acute supportive chronic antiviral therapy w or w/o interferon; yes risk for chronic infection

  • C- contact w infected body fluids; direct-acting antivirals (DAAs); yes risk for chronic infection

    • leading cause of end-stage liver disease worldwide

  • D- contact w infected body fluids; no specific tx, peglated interferon may help; yes risk for chronic infection

  • E- contaminated food or water; typ self-limiting; no risk chronic infection

lactulose

• bacteria in the colon digests lactulose into chemicals that bind ammonia

• used to decrease ammonia in hepatic encephalopathy

hepatic encephalopathy

• assessment

  • fetor

  • changes in LOC

  • neuromuscular disturbances- asterixis, hyperreflexia

  • sleep, mood, and speech problems

• Tx

  • decrease ammonia

    • lactulose

    • abx (neomycin or rifaximin)

      • reduces bacterial production of ammonia

    • decreased protein in diet

    • monitor serum ammonia

  • decrease fluid retention

    • potassium-sparing diuretics

  • avoid CNS depressants

Cirrhosis

• chronic disease of the liver marked by degeneration of cells, inflammation, and fibrous thickening of tissue

• liver cells destroyed and replaced with scar tissue

• This impairs blood flow to liver, causing portal HTN

• primary causes- “ABCD”

  • Alcohol

  • B hepatitis B

  • C hepatitis C

  • Diet

• assessment

  • palpable, firm liver

  • ascites, edema

  • abd pain, bloating, dyspepsia, poor appetite

  • spider angiomas

  • jaundice

  • anemia!!

• abnormal labs

  • decreased serum albumin

  • increased serum liver enzymes- ALT/AST

• Tx

  • antacids

  • vitamins

  • diuretics

  • paracentesis

  • strict I&Os

  • daily weights

  • Be v careful w drug doses bc liver cant metabolize well. most doses need to be decreased. esp w

    • narcotics

    • acetaminophen

  • low protein, low sodium diet

  • bleeding precautions

  • skin care

Amphotericin b

• potent IV antifungal

• associated with several electrolyte imbalances, including hypokalemia

• causes potassium to shift into the cells

• it can have some effect on lipid metabolism, but the key lab value to monitor is potassium

Rivastigmine

• indicated for use in dementia

• increases acetylcholine in CNS through revrsible inhibition of its hydrolysis by cholinesterase

• comes in patch and tablet

• adverse effects

  • N/V, weight loss, HTN, bradycardia

Phenelzine

• MAOI

• avoid foods high in tyramine like smoked bacon

  • can cause hypertensive crisis

post op tonsillectomy diet

• foods that are soft, not hot, non-acidic, and do not have jagged edges

• ice chips are okay cause they melt in the mouth ig??

Oxybutynin

• anticholinergic used to treat urinary bladder urgency and incontinence

Metoclopramide

• dopamine antagonist

• effective for migraine-associated nausea and some HA relief

• commonly used as adjunct Tx in emergency settings

Mechanical ventilation can cause stress ulcer. meds? complication?

• PPI or H2 blocker

• stress ulcer may lead to GI bleed

Before IV urography (pyelogram), what must pt do?

• take a laxative the night before to clear the bowels

• this is to ensure adequate visualization of urinary tract

• during procedure, pt will empty bladder, IV contrast given, and series of x-ray and fluoroscopy used to observe passage of urine from renal pelvis to bladder

Rule of Nines for burns

• head - 9%

• chest - 18%

• abdomen - 18%

• each leg- 18%

• each arm - 9%

• genitals - 1%

Nicardipine

• CCB

• given during hypertensive emergency

• administer with infusion pump while pt receives continuous cardiac monitoring

Restlessness indicates:

• hypoxia!

Hydralazine

• arteriolar vasodilator

• intended for HTN

• pt at risk for falls bc of orthostatic hypotension!!!

• hydralazine toxicity s/s: hypotension, tachycardia, HA, and generalized skin flushing

• reflex tachycardia may occur bc as BP declines, HR will increase to maintain CO

A patient with asthma exacerbation experiences a sudden absence of wheezing. What does this indicate?

Respiratory arrest

Before administering IV potassium, nurse should verify what in order to avoid hyperkalemia?

• urinary output

• note: peripheral IV potassium should be administered at 10 mEq/hr

  • maximum of 40 mEq/hr in central line

hypovolemic shock

• not enough blood to enter heart (preload), which decreases CO

  • body will vasoconstrict to compensate

• causes

  • hemorrhage

  • traumatic injury

  • dehydration

    • vomiting/diarrhea

  • burns

• assessment

  • weak

  • pale, cool, clammy

  • tachycardic, hypotension

  • anxious

  • decreased LOC

  • decreased UOP

• Tx

  • fix the cause

    • stop vomiting, diarrhea, bleeding (repair in OR)

  • replace volume

    • isotonic IVF (NS, LR)

    • blood products

  • support perfusion

    • vasopressors

cardiogenic shock

• heart fails to pump sufficient blood out bc obstruction or weak heart muscle

• causes

  • MI

  • cardiac tamponade

  • pulmonary embolism

• assessment

  • decreased perfusion

    • hypotension

    • weak pulses

    • cool, pale, clammy

    • decreased UOP

    • decreased LOC

  • volume overload

    • JVD

    • crackles

    • SOB

    • muffled heart sounds

    • S3

• Tx

  • treat the cause

    • MI- PCI, CABG

    • PE- thrombolytics

    • Tamponade- pericardiocentesis

  • improve contractility

    • dopamine

    • dobutamine

  • decrease afterload

    • diuretics

    • dobutamine

cardiac tamponade

• too much fluid fills in the pericardial saac

• leads to increased pressure in the heart

• s/s muffled heart sounds, JVD, hypotension, and pleural friction rub

• Tx- pericardiocentesis

distributive shock

• immune or autonomic response that alters vascular tone and causes massive peripheral vasodilation

• causes

  • anaphylactic- allergic reaction

  • neurogenic- SCI

  • septic- systemic infection

    • causes release of inflammatory cytokines

• assessment

  • decreased oxygen

  • hypotension

  • tachycardia

  • tachypnea

  • warm, flushed skin

  • decreased LOC

• Tx

  • anaphylactic

    • epinephrine

    • corticosteroids

    • bronchodilators

  • neurogenic

    • cooling

    • supportive care

  • septic

    • IV abx- get cultures

    • IVF

      • 20 mL/kg up to 3 times

      • if still hypotensive, vasopressors!

Traction Positioning

• uses a pulling force to realign a bone

• skeletal

  • uses screws/pins into the bone

  • 15 - 30 lbs of pulling force

  • ex: halo traction

• skin

  • decreases muscle spasms

  • 5 - 10 lbs of pulling force

  • ex: buck traction

• nursing actions

  • monitor circulation q1h for first 24 hrs and then q4h after that

  • pin site care

    • use of saline/vaseline dressings q8-12h

  • s/s of pin site infection

    • loose pins

    • purulent drainage from pins

      • clear drainage is expected finding

    • odor

    • fever

Bedside Mobility Assessment Tool (BMAT)

• sit and shake

  • how is their trunk strength, seated balance, and cognition?

• stretch and point

  • how is their lower extremity stability and strength?

• stand

  • can they stand? strength from sitting to standing?

• walk

  • how is their standing balance? assess their gait while walking

immobility complications

• skin breakdown- pressure ulcers

• contractures

• muscular weakness

• muscular atrophy

• loss of calcium from the bones

  • osteoporosis

  • hypercalcemia

  • renal calculi

• atelectasis- pneumonia

• venous stasis- DVT

Braden Scale

• scoring- 15-16 = mild risk, 12-14 = moderate risk, <11 = severe risk

• open sores can lead to infection!

devices that promote venous return

• TED hose

• compression stockings

• Sequential compression devices (SCDs)

BMI calculation

BMI = weight (kg) / height² (m²)

ex. 57 kg pt 1.52 m tall. = 57/2.3104 = 24.671

• <18.5 = underweight

• 18.5 - 24.9 = normal weight

• 25.0 - 29.9 = overweight

• > 30 = obese

TPN

• IV nutrition

• central line is preferred!!

• made of proteins, dextrose, lipids, vitamins, minerals, electrolytes

  • bacteria loves sugar!

  • high infection risk!!!

• change TPN tubing q24h bc sugar sticky

• if you run out of TPN, hang D10 at same rate as TPN was running

postmortem care

• lines/tubes

  • autopsy- keep all lines/tubes in place

  • no autopsy- remove all lines/tubes

• client care

  • place pillow under head

  • put in dentures

  • close eyes

  • assess for specific religious/cultural practices

assistive devices - walker

• stand in center of walker

• slide walker forward 6-8 inche

• keep all 4 feet of walker on the ground

• step forward with bad leg

  • keep weight on walker and unaffected leg

• bring good leg up to walker

assistive devices- cane

• cane goes on good side

• slight bend at the elbow

• cane moves forward 6-10 inches

• bad leg moves forward with cane

• good leg then moves past the cane

assistive devices- crutches

• 2-3 finger spaces b/w armpit and crutch

• use shoulders and arms for strength

• slight bend through the elbows

• 2-point gait

  • requires partial weight bearing on both feet

  • move R leg forward with left crutch at same time and vice versa

• 3-point gait

  • non-weight bearing and can progress to partial weight bearing

  • crutches advanced with affected leg

  • unaffected leg brought forward

• swing-through gait

  • for non-weight bearing or partial weight bearing clients

    • required balance and coordination

  • stand on unaffected leg

  • move both crutches forward ab a foot

  • brace the hand grips for support

  • swing both legs through the crutches

• 4-point gait

  • only 1 point moving at a time

  • move R crutch forward

  • move L leg forward

  • move L crutch forward

  • move R leg forward

• stairs with crutches

  • up with the good and down with the bad!

Methotrexate

• class- DMARD

• indication- Rheumatoid arthritis

• action- reduce joint destruction and slow disease progression by interfering in immune and inflammatory responses

• nursing considerations

  • lifelong therapy; treats sx but disease continues to progress

  • must treat RA aggressively: start a DMARD early- within 3 months of RA

    • can be possible to delay or even prevent serious joint injury

Allopurinol

• class- hypouricemic agent

• indication- Gout

• action- inhibits xanthine oxidase to prevent uric acid from forming

  • uric acid: byproduct of breakdown of purines

• nursing considerations

  • monitor for side effects of leukopenia, fever & rash

  • dosage must be individualized

  • teach to avoid foods high in purine

    • beer, wine, cheeses, beans, anchovies, sardines, liver, kidneys, cream

Alendronate

• class- biphosphonate

• indication- osteoporosis

• action- decreases bone resorption by osteoclasts

• nursing considerations

  • SE- esophagitis

    • contraindicated in pts w pre-existing esophageal disorder

  • take with a full glass of water

  • remain upright for 30 min after taking ( do not take supine or lie down after taking)

  • if difficulty or pain with swallowing, or heartburn develops, pts should d/c med and contact PHCP

Baclofen

• class- centrally acting muscle relaxer

• indication- muscle spasticity: MS, CP, SCI

• action- acts within the spinal cord to suppress hyperactive reflexes involved in the regulation of muscle movement

• nursing considerations

  • monitor for CNS depression

  • do not discontinue abruptly- taper over 1-2 wks

    • can cause a seizure

spiral Fx

• esp in peds or elderly, suspect abuse

• caused by twisting force

traction nursing considerations- TRACTION

• T- temperature

• R- ropes (should be hanging freely)

• A- alignment

• C- circulation

• T- tension (no tension on skin. high risk for skin breakdown!)

• I- intake (monitor I&O)

• O- overhead trapeze ( bar overhead to help w ROM)

• N- no weights on floor

Rheumatoid Arthritis

• chronic systemic inflammatory disease that leads to destruction of connective tissue and synovial membrane within the joints

• weakens the joint, leading to dislocation and deformity of the joint

• pannus forms at the junction of synovial tissue and articular cartilage and projects into the joint space which causes necrosis

• RA exacerbations or “flares” occur during periods of fatigue and stress (emotional or physical)

• assessment findings

  • inflammation, tenderness, stiffness of the joint

  • decreased ROM in joints

  • moderate to severe pain with morning stiffness lasting longer than 30 min

  • joint deformities

  • spongy, soft feeling in joints

    • might even feel warm reddened boggy

  • elevated ESR and positive rheumatoid factor

  • x-ray shows joint deterioration

  • synovial fluid shows inflammation

• Tx- no cure

  • NSAIDs, DMARDs, glucocorticoids

  • preserve joint function

  • heat or cold therapy as prescribed

  • encourage consistent exercise program

  • avoid weight bearing on inflamed joints

  • surgical:synovectomy, arthrodesis, joint replaccement

Osteoarthritis S/S- “OSTEO”

• O- outgrowths

  • bone spur formations

  • Heberden’s node: close to fingernail

  • Bouchard’s node: middle finger joint

• S- stiffness

  • in the morning

  • lasting less than 30 min

• T- tenderness

  • hard, bony, tender joints

• E- exacerbated by exercise

  • crepitus w movement

  • pain w activity- goes away w rest

• O- only in the joints

  • not systemic- no inflammation, redness, fever, fatigue, or other such sx

Gout

• body cannot control uric acid production or exertion

• high uric acid builds up in the body

• uric acid crystallizes and deposits in connective tissue

• causes inflammation and destruction of joints

• most common location- big toe

• complication- gouty arthritis

• assessment

  • pain- gets worse as the day goes on

  • inflammation

  • redness

  • decreased mobility

    • very stiff

    • intense pain with pressure

  • Tophi

    • large clumps of uric acid crystals that have accumulated over time

    • white/yellow

    • can permanently damage joints

    • high uric acid level

• nursing interventions

  • alternate cold and warm compresses

  • hydration

  • bed rest

  • NSAIDs

  • corticosteroids

  • allopurinol

    • prevents future attacks- does not tx current sx

    • decreases production of uric acids

  • low purine diet- avoid

    • red meat, organ meat, seafood, alcohol

Myopathy

• primary muscle disorder causing weakness and atrophy

• assessment findings:

  • decreased muscle strength and tone

• causes

  • drugs

  • alcohol abuse

  • idiopathic

Rhabdomyolysis

• injury to skeletal muscle

  • burns

  • trauma

  • compartment syndrome

• muscles release intracellular contents into the blood

  • myoglobin- protein that helps form muscle

  • creatinine kinase- muscle byproduct

  • potassium

  • phosphorus

• these substances become toxic in circulation

• major kidney damage as nephrons try to filter toxins out

• S/S

  • vomiting

  • bruising (ecchymosis)

  • fatigue

  • muscle weakness

  • dark urine (cola colored!)

• Tx

  • fluids- NS, flushes kidneys

• diuretics

  • decreased swelling

  • increase UOP

  • flush out toxins

• dialysis

  • if K too high or kidneys unable to clear the toxins on their own

• bedrest

• monitor electrolytes and CK

  • telemetry!!

Naegele’s rule

1st day of last menstrual period + 7 days - 3 months + 1 year = estimated due date (EDD)

Early decelerations are caused by:

• head compression

• normal and no need to intervene

variable decelerations

• we should see variability of 6-25 BPM.

• indicates healthy nervous system

• we want to see this moderate variability- reassuring

fetal bradycardia

• HR <110 for 10 minutes or more sustained

• due to prolonged cord compression, umbilical cord prolapse, anesthetic medications, fetal heart abnormalities

• tx - side lying mom, IVF, O2, notify PHCP, stay at bedside w mommy

fetal tachycardia

• HR >160 for 10 min or longer

• due to maternal fever/infection, fetal hypoxia, maternal hyperthyroidism, cocaine use

• tx underlying cause

• fetal tachycardia + decreased variability = severe fetal distress!

late decelerations

• decel happens after peak of contraction

• prolonged return to baseline

• cause is uteroplacental insufficiency (bc decreased BF to baby, fetal hypoxia)

• LION PIT

  • s is also prep for surgery (C-sec)

variable decelerations

• FHR tracing drops and comes back up rapidly

• due to umbilical cord compression

  • increased fetal BP which leads to decreased FHR

• tx

  • put mom in trendelenburg

  • knee-chest position

  • LION PIT

  • amnioinfusion PRN - for oligohydramnios

    • synthetic amniotic fluid

VEAL CHOP

Tumor lysis syndrome

• Many cancer cells die in a short period

• contents released into bloodstream

• hyperkalemia

• hyperuricemia

• hyperphosphatemia

• hypocalcemia