med surg unit 3

what is included in assessment of visual function?

PMH, occupation, medication, allergies, eye trauma, eye surgery, family history, dietary history (vitamin deficiencies), use of protective eye equipment

inspection: symmetry, exophthalmos, enophthalmos

what are some tests of visual function?

vision testing: snellen (visual acuity), rosenbaum or jaeger card (near vision), ishihara chart (color vision), confrontation test, corneal light reflex & cardinal positions (CN 3, 4, 6), pupillary light reflex

ophthalmic exam: visualization of strictures, pupil dilation, red reflex

slit lamp testing: 3d image of eyes

intraocular pressure testing: normal is 10 to 21

corneal staining: shows damage, foreign bodies, or scratches in cornea

fluorescein angiography: better imaging of eye & vessels of the eye, shows hemorrhaging in the retina, macular degeneration, tumors, etc.

CT/MRI/ultrasonography

radioisotope scanning: differentiates between normal & malignant tissues

what are some age-related changes of the visual system?

pupil: smaller & less responsive to light

lens: presbyopia (changes in elasticity; use reading glasses to correct), yellowing (can cause difficulty recognizing colors)

floaters, dryness, reduced blood flow, decreased visual fields (due to decreased eye lid elasticity & tone)

what are the clinical manifestations of visual acuity disorders?

myopia: nearsightedness

hyperopia: farsightedness

how do you manage visual acuity disorders?

treat with corrective lenses

teaching: proper care, storage, etc. of lenses, report visual changes

what is conjunctivitis?

pink eye

what are the clinical manifestations of conjunctivitis?

tearing, lid crusting, “gritty” feeling or sensation of a foreign body, purulent discharge, pink/inflamed sclera, itchy eyes, photophobia (with chlamydial conjunctivitis)

how do you manage conjunctivitis? (each type)

comfort care includes cold compress & protection from the sun

all types need hand hygiene!

allergic: topical steroid & eye drops, removal of allergen

bacterial: antibiotic ointment or drops

viral: cold compress, eye lubricants & ocular decongestants

chlamydial: systemic antibiotics, medical treatment of infected partner

what are cataracts?

cloudiness of lens, decreasing vision

what are the clinical manifestations of cataracts?

clouded, blurred, or dim vision, night vision difficulty, sensitivity to light/glare, halo vision, color fading, double vision in a single eye

how do you manage cataracts? (treatment, pre, post)

treatment: phacoemulsification (removal & replacement of another lens), intra/extracapsular cataract extraction

prior to surgery, use eyedrops to dilate/paralyze the eye

interventions: elevate HOB, position patient on back or nonoperative side to promote drainage & decrease IOP, eye patch

what is glaucoma?

increased IOP that results in damage to the optic nerve

what are the clinical manifestations of glaucoma? (each type)

open angle: no early symptoms, gradual peripheral vision loss

angle closure: headache, eye pain, nausea, blurred vision, rainbow around lights at night

normal tension: optic nerve damage, vision loss despite normal IOP

secondary: another injury/illness

pediatric: peripheral vision starts to decrease, leading to tunnel vision

how do you manage glaucoma? (prevention, treatment)

prevention with regular eye examination

treatment: medicated eye drops, surgery

what is retinal detachment & what are the types?

retina is pulled or lifted from original position

rhegmatogenous: tear in retina, fluid enters & moves retina (most common)

tractional: separation of retina from pigment because of scar tissue (least common)

exudative: separation of retina because of inflammation & fluid leaking

what are the clinical manifestations of retinal detachment?

sudden or gradual increase in number of floaters, light flashes, appearance of a curtain over field of vision

how do you manage retinal detachment? (treatment, interventions)

treatment: laser photocoagulation, panretinal photocoagulation (multiple laser burns to shrink vessels), cryopexy, pneumatic retinopexy (bubble of gas to seal), scleral buckling (reduction in size of eye ball), vitrectomy (removal of foreign body or repair of trauma)

interventions: rest & calm environment, avoid straining, eye patch/dark glasses, eye drops, prevent increased IOP

what are the clinical manifestations of macular degeneration? (each type)

dry: gradual blurring of central vision, difficulty recognizing faces, slow onset

wet: quick loss of central vision

how do you manage macular degeneration? (goal, each type)

no cure, so goal is to preserve vision that isn’t already lost

dry: high dose antioxidants & zinc, ARED formula

wet: photodynamic therapy, anti-VEGF therapy (slows down progression of loss), laser surgery (some can benefit, but concern of destruction)

what is corneal abrasion?

disruption of the cornea from physical or chemical trauma

what are the clinical manifestations of corneal abrasion?

eye pain, photophobia, squinting, tearing, blurred vision, sensation of a foreign body in the eye

how do you manage corneal abrasion? (treatment, teaching)

treatment: antibiotic eye drops, surgery for deep abrasion

teaching: tetanus vaccine, sunglasses, follow-up care

what is eye trauma?

visual loss related to blunt or penetrating trauma

what are the clinical manifestations of eye trauma?

eye pain, edema, scleral discoloration, blurred, double, or loss of vision, excessive tearing, N/V related to increased IOP

how do you manage eye trauma? (interventions/treatment)

rest, eye patch, elevated HOB to decrease IOP, eye drops prescribed for blunt trauma (ex: antibiotic for penetrating eye trauma)

what is included in assessment of auditory function?

detailed patient history (noise exposure, hyperacusis, genetic conditions, etc.), current health, past illnesses, smoking history, medication, personal hygiene, allergies, family history

inspection: symmetry, swelling, lesions, evaluation of tympanic membrane (color, translucency, position, white patches due to scarring)

what are some tests of auditory function?

voice test, watch test (high frequency), audioscopy (headphones with different frequencies)

tuning fork: weber test (midline of skull), rinne test (mastoid process)

audiometry, tympanometry, electronystagmography (not with pacemakers), CT/MRI

what are some interventions for hearing protection?

protection from excessive noise

teaching: relationship between volume levels & hearing loss, waterproof earplugs, risk of cotton swabs

what are the types of hearing loss?

conductive: physical obstruction

sensorineural: deficit in cochlea, cranial nerve 8, or brain

mixed: profound with both conductive & sensorineural injuries

how do you assess for hearing loss?

history, otoscopic examination, tympanometry, acoustic reflex, CT/MRI

how do you treat hearing loss?

myringotomy, tympanoplasty, hearing aids, cochlear implants

what are the clinical manifestations of external otitis?

swelling in & around ear, tender external ear, erythema in canal, scant clear drainage from ear canal

how do you treat external otitis?

tylenol/motrin, topical agents

what are the clinical manifestations of otitis media?

ear pain, pulling on ear (children), trouble sleeping or laying flat, fever, bloody drainage or pus (with ruptured eardrum), refusing to eat (children)

how do you manage otitis media? (treatment, teaching)

OTC meds, oral antibiotics, tympanocentesis, myringotomy

teaching: complete course of antibiotics, elevate HOB, avoid getting water in the ear

what are the clinical manifestations of tinnitus?

ringing, buzzing, roaring, clicking, whistling, or hissing in the ear

how do you manage tinnitus?

find/treat underlying cause, reduce symptoms (xanax, benadryl, gabapentin, TCAs, etc.)

what are the clinical manifestations of vertigo?

spinning sensation at rest or with minimal movement, imbalance & lightheadedness, N/V, hearing loss

how do you manage vertigo?

find/treat underlying cause

teaching: diet, positioning, safety

what is meniere’s disease?

inner ear disorder that affects balance & hearing

triad of vertigo, tinnitus, & hearing loss

excess of endolymphatic fluid

what are the clinical manifestations of meniere’s disease?

daily to rare symptomology

vertigo, N/V/D, hearing loss, tinnitus, headaches, abdominal pain, uncontrollable eye movements, worsening with sudden movements

how do you manage meniere’s disease?

symptomatic relief, pharmacology, surgery

teaching: position, adequate sleep, exercise, diet

what are some age-related changes of the auditory system?

outer ear: coarse/stiff cilia, accumulation & oxidation of cerumen, atrophy of apocrine glands

middle ear: stiff tympanic membrane, calcification of ossicles

inner ear: presbycusis (age-related hearing loss)

what are some practices of therapeutic communication with hearing impaired patients?

good lighting (including no light behind speaker), avoid covering mouth/face, avoid chewing, closer to better ear, eye contact

speak normally & slowly, don’t overexaggerate facial expressions or overenunciate, use simple sentences or rephrase, don’t shout

what are some ototoxic medications?

antibiotics, diuretics, NSAIDs, chemotherapeutic agents, other miscellaneous medications

what is included in the history of neurological assessment?

chief complaint, medical history, allergies, medications, social history

what is included in the physical assessment of neurological function?

level of consciousness, glasgow coma scale, mini-mental status examination

ICP (normal is 0 to 15)

what are some diagnostic studies relevant to neurological function & what are the considerations related to those?

CT: contrast precautions

PET scan: NPO for 6 to 12 hours prior, no caffeine for 24 hours prior, patient must lie still

MRI: no metal objects, medicate for anxiety, hydration with contrast

cerebral angiography: NPO midnight before procedure, patient education, contrast precautions, assessment of site & peripheral vascular system, bleeding precautions

EEG: no caffeine 8 to 12 hours prior, wash hair & avoid hair products

lumbar puncture: hold antiplatelets, bleeding precautions, check coag studies, lay flat for 4 to 6 hours, encourage fluids

myelography: contrast precautions

what is the appropriate management of seizures? (diagnosis, interview, precautions, interventions, teaching)

diagnostics: CT/MRI, EEG, labs

patient interview: number, duration, patterns, aura, head trauma, medical conditions, herbal products

precautions: oxygen, suction, padded rails (if allowed), nothing in the mouth

during seizure: turn patient, maintain airway, monitor oxygen, protect from injury, observe, recovery position, document

education: medication, medical alert bracelet, driving restrictions, diet, stress reduction, seizure diary

how do you manage viral vs. bacterial meningitis?

bacterial: antibiotics (penicillin, cephalosporins), decreased ICP (anti-inflammatories, pain management, fever management, anti-seizures, diuretics, HOB elevation), bedrest, clear liquids

viral: discontinue antibiotics, manage symptoms

how do you identify cluster vs. tension vs. migraine headaches?

cluster: one-sided, restlessness, sensitivity to light, altered HR & BP, uncontrollable tears

tension: bilateral & usually frontal or temporal with episodic, constant pressure, sensitivity to light, & scalp soreness with chronic

migraine: usually predictable, throbbing or pulsating pain, motor weakness, language disturbances, pupillary or visual changes

how do you manage cluster vs. tension vs. migraine headaches? (diagnosis, teaching)

rule out life-threatening causes, recommend headache diary

diagnostics: CBC, blood culture, CRP, CSF testing, CT/MRI, LP, EEG, sleep study

lifestyle modifications: identify & avoid triggers, regular meals & fluid intake, consistent sleep habits, alternative therapies

how do you treat cluster vs. tension vs. migraine headaches?

cluster: triptans, oxygen therapy, preventative measures (CCBs, anti-seizures, melatonin, nerve blocks, deep brain stimulation)

tension: treat underlying causes, acetaminophen, NSAIDs, sedatives, muscle relaxers, preventative measures (TCAs, anti-seizures)

migraine: pain management, abortive therapy (ASA or NSAIDs with caffeine during aura), preventative measures (BBs or CCBs, anti-seizures, TCAs, SSRIs, botox)

how do you assess for & manage encephalitis? (diagnosis, manifestations, interventions)

diagnostics: CT/MRI, PET, EEG, blood test for viral RNA, CSF culture by LP

manifestations: altered mental status to coma, hemiparesis, tremors, seizures, cranial nerve palsies, personality changes, memory impairment, amnesia, photo/phonophobia, increased ICP

interventions: teaching, mosquito control, frequent assessment, symptom management, antivirals

what is included in assessment of the musculoskeletal system?

PMH, history of present illness or chief complaint

physical: posture, gait, joint mobility, sensation, pulse assessment, muscle tone & strength

what are some diagnostic studies for the musculoskeletal system & what are nursing considerations relevant to those?

laboratory studies: calcium, vitamin D, phosphorous, calcitonin & PTH, estrogen (urine test)

imaging: x-ray, CT/MRI, arthrogram, bone mineral density studies, bone scan, electromyography (muscle response), arthroscopic examination

arthrocentesis (test the fluid)

what are some age-related changes of the musculoskeletal system?

bone density, posture, gait, cartilage, connective tissue, joints

water loss (increased rigidity), sarcopenia

care: regular weight-bearing activities, review medications, yearly eye examinations, follow-up, home safety review

how do you manage total joint replacement? (pre, post, teaching)

weight management, activity modification, nonsteroidal therapy

pre-op: screening, CBC, coag studies, BMP, teaching

post-op: vitals, pain management, neuro assessment, labs, mobility, prevention of complications, wound care, positioning, DVT prophylaxis

teaching: slip resistant socks, removal of rugs, reduced hip flexion (no crossing legs)

what is the pathophysiology of osteomyelitis?

bacterial invasion, inflammation, thrombus formation, ischemia/necrosis

what are the clinical manifestations of osteomyelitis?

fever, nausea, chills, malaise, redness, swelling, warm to touch

*think infection

how do you manage osteomyelitis? (diagnosis, treatment, complications)

bone biopsy is gold standard for diagnosis

surgery: debridement, incision

medications: antibiotic therapy, opioid analgesia

complications: sepsis, amputation, cancer

what are the clinical manifestations of bone cancer?

pain, swelling, redness, decreased ROM, fracture

how do you manage bone cancer? (diagnosis, treatment, complications, teaching)

bone biopsy is definitive for bone cancer

treatment: radiation, chemo, pain management, surgery (removal, TJR, allograft, vascular grafting)

complications: delayed wound healing, osteomyelitis, hypercalcemia, amputation

teaching: high-protein diet, safe environment, radiation/treatment

what is the pathophysiology of strains & sprains?

strain (tendon): 1st through 3rd degrees (2nd has severe muscle spasms, 3rd is rupture, internal bleeding, etc.)

sprain (ligament): 1st through 3rd degrees (2nd has altered mobility, 3rd is complete tearing, inability to ambulate, etc.)

what are some diagnostic studies for strains & sprains?

x-ray (shows absence of fracture), ultrasound, MRI (more definitive but more expensive)

how do you manage strains & sprains? (teaching, interventions, treatment)

teaching: warm-up & stretching, supportive bandages & wraps

assess 6 P’s

RICE, NSAIDs, surgery

what are the clinical manifestations of fractures?

edema, pain/tenderness, muscle spasm, deformity, ecchymosis/contusion, loss of function

what are some diagnostic studies for fractures?

history/physical, chronic illness, medications, potential abuse, radiography or CT

how do you manage fractures? (treatment, interventions)

fracture reduction, fracture immobilization (casts with RICE, fixation), traction (don’t adjust weights)

neurovascular assessments, prevent DVT/PE, analgesics & antispasmodics, tetanus vaccine, anticoagulants, antibiotic prophylaxis

ice, elevation, wound/pin care, mobility, pulmonary hygiene, hydration/nutrition

what are the clinical manifestations of meniscus injuries?

pain, click/pop/lock

what are some diagnostic studies for meniscus injuries?

mcmurray’s test, MRI

how do you treat meniscus injuries?

rest, ice, NSAIDs, surgery (post-op teaching)

how do you manage amputation? (goals, complications, interventions, post)

control of bleeding, reattachment, prosthetics

complications: hemorrhage, infection, contractures, phantom limb pain, neuromas

assess 6 P’s, document color, edema, wounds, necrosis, & hair distribution

post-op: don’t prop up limb, monitor bleeding, broad-spectrum antibiotics with infection, pain management (opioids, antidepressants & anticonvulsants with phantom pain, relaxation, guided imagery, support system, & mirror therapy for nonpharmacological interventions)

compression dressing, drains, wrapping (anchor at next highest joint)

prevent flexion contractures (trapeze, turn q2h, no pillow under limb, lie prone a few times a day)

what is the pathophysiology of carpal tunnel syndrome?

medial nerve compression

what are the clinical manifestations of carpal tunnel syndrome?

decreased fine motor function, pain, numbness, weakness, swelling, clammy hands, brittle nails

what are some diagnostic studies for carpal tunnel syndrome?

phalen’s test, tinel’s sign, nerve conduction studies, electromyography

what are the targets & actions of hormones excreted by endocrine glands?

hypothalamus: targets anterior pituitary

anterior pituitary: ACTH (targets adrenal cortex to release mineralocorticoids & glucocorticoids), TSH (targets thyroid to release T3 & T4), LH & FSH, GH, prolactin, MSH

posterior pituitary: ADH (targets distal tubules of kidneys), oxytocin (targets uterus & mammary glands)

adrenals: mineralocorticoids, glucocorticoids, & sex hormones target distal tubules of kidneys, liver, & body cells; catecholamines

thyroid: T3, T4, & calcitonin target body cells

parathyroid: PTH in response to low serum calcium (targets bones, kidneys, intestines, etc.)

gonads: progesterone, estrogen, testosterone

islet cells: insulin, glucagon

what is included in assessment of the endocrine system?

comprehensive family history (genetics can play a role), endocrine disorders

what is included in the physical assessment of the endocrine system?

head to toe (misshapen forehead, bulging eyeballs, etc.), inspection, auscultation, palpation (ex: thyroid)

what are some age-related changes of the endocrine system?

hypoactive function/downregulation (decreased number of receptors on target tissue), chronic diseases, decreased hormone production, secretion rates, & tissue responsiveness, compensatory responses (ex: higher BG due to higher insulin resistance), decreased metabolism

what are the clinical manifestations of hypopituitarism?

decrease in ACTH (decreased mineralo & glucocorticoids): hyponatremia, hypotension, hyperkalemia, decreased cortisol, hypoglycemia

decrease in TSH (decreased thyroid hormones): low metabolism, fatigue, etc.

decrease in LH & FSH: sexual dysfunction

decrease in GH: children = dwarfism, adults = osteoporosis

what are some diagnostic studies for hypopituitarism?

serum studies

how do you manage hypopituitarism? (teaching, interventions/treatment)

report s/s of adrenal insufficiency

vitals (risk for hypotension), monitor bone density, fall precautions, vitamin D & calcium supplementation, hormonal replacement, PT

what are the clinical manifestations of hyperpituitarism?

headaches & visual changes with hypersecreting tumor

increase in ACTH (increased mineralo & glucocorticoids): hypernatremia, hypertension, hypokalemia, increased cortisol, hyperglycemia

increase in TSH (increased thyroid hormones): high metabolism, insomnia, etc.

increase in GH: children = gigantism, adults = acromegaly

what are some diagnostic studies for hyperpituitarism?

serum studies

how do you manage hyperpituitarism? (treatment, interventions, post)

transsphenoidal hypophysectomy

vitals, neuro assessment, I & O, labs, daily weights, report changes

post-surgery: HOB to 45º, neuro assessment, watch for CSF drainage through nose, avoid increased ICP, frequent oral care, report signs of DI & meningitis, I & O, medicate for pain (mild analgesics)

what are the clinical manifestations of diabetes insipidus?

polyuria, polydipsia, nocturia

low ADH

what are some diagnostic studies for diabetes insipidus?

serum & urine electrolytes, urine specific gravity, CT/MRI (look for damage, tumor, or trauma)

how do you manage diabetes insipidus? (treatment, interventions)

fluid replacement (oral & IV hypotonic), desmopressin, pitressin

vitals (monitor for hypotension & tachycardia), daily weights, I & O, serum sodium & osmolality, adequate fluid intake

what are the clinical manifestations of syndrome of inappropriate antidiuretic hormone?

unusual clinical presentation

hyponatremia (causing anorexia, nausea, malaise, HA, irritability, confusion, weakness), scant urine output with increased urine specific gravity

high ADH

what are some diagnostic studies for syndrome of inappropriate antidiuretic hormone?

trending urine specific gravity, serum & urine osmolarity, serum & urine electrolytes

how do you manage syndrome of inappropriate antidiuretic hormone? (interventions)

for hyponatremia: fluid restriction, 3% NS if severe, diuretics

monitor: neuro status, I & O, sodium, skin integrity, signs of fluid overload

seizure precautions

what is addison’s disease?

adrenal cortex insufficiency

what are the clinical manifestations of adrenal cortex insufficiency?

bronze/dark/hyperpigmentation, vitiligo, fatigue, weakness, anorexia/weight loss, dehydration, hypotension, hypoglycemia, emotional lability

what are some lab findings for adrenal cortex insufficiency?

decreased sodium, increased potassium, decreased glucose, low cortisol

how do you manage adrenal cortex insufficiency? (treatment/interventions)

IV fluids, electrolyte replacement, corticosteroids, fall risk, assess for hypotension & hypoglycemia

adrenal crisis is an emergency!

what are the types of adrenal cortex hyperfunction?

cushing’s disease (hypercortisolism) & conn’s disease (hyperaldosteronism)

what are the clinical manifestations of cushing’s disease?

thin skin, hyperglycemia, depression, moon face, buffalo hump, truncal obesity, hirsutism (male hair growth), oily skin, weight gain, fluid overload/edema, higher risk of infection, loss of bone density

how do you manage cushing’s disease? (interventions)

monitor cortisol levels, suppression tests, serum electrolytes, etc., overnight dexamethasone suppression test, prevent complications associated with fluid overload, changes in immune status, skin integrity, & bone structure

what are the clinical manifestations of conn’s disease?

HTN, hypernatremia, hypokalemia, headache