Med Surg Exam 1

disability

• restriction or lack of ability to perform an activity in a normal manner; the consequences of impairment in terms of a person's functional performance and activity

• ex. cerebral palsy, spinal cord injury, Down syndrome

developmental disability

• those that occur any time from birth to 22 years of age and result in impairment of physical or mental health, cognition, speech, language, or self-care

• some occur as a result of birth trauma or severe illness or injury at a very young age, whereas many developmental disabilities are genetic in origin

• ex. spina bifida, cerebral palsy, Down syndrome, muscular dystrophy, dwarfism, and osteogenesis imperfecta

acquired disability

• occur as a result of an acute and sudden injury --- e.g., traumatic brain injury; spinal cord injury; and traumatic amputation

• occur as a result of acute non-traumatic disorders --- e.g., stroke, myocardial infarction, or progression of a chronic disorder (e.g., arthritis, multiple sclerosis, Parkinson's disease)

intellectual disability

occurs before 18 years of age and is characterized by significant limitations in both intellectual functioning as well as in adaptive behavior, including many everyday social and practical skills

sensory disability

• impairment of the sense of sight, hearing, smell, touch, and/or taste

• Risks associated with sensory disabilities include isolation, reduced cognitive function, poor physical and psychological health, and increased risk of falls and hospitalization

• can be age related

chronic illness

• the experience of living with a chronic disease or condition; the person's perception of the experience and the person's and others' responses to the chronic disease or condition

• Americans living in rural communities are more likely to have chronic illness

• anything over 6 months

• do not always have a root cause

• Exacerbations cause baseline to lower

chronic disease

• medical or health problem with associated symptoms or disabilities that require long-term management; also referred to as non-communicable disease, chronic condition, or chronic disorder

models of disability

• Interface Model

• Medical Model

• Rehabilitation Model

• Biopsychosocial Model

interface model of disability

• looks at removing barriers to disability

• considers rather than ignores the diagnosis

• person with a disability, rather than others, defines the problems and seeks or directs solutions

• model aims to enhance inclusivity and participation for individuals with disabilities

• most appropriate for nurses

• promotes the view that people with disabilities are capable, responsible people who are able to function effectively despite having a disability

medical model of disability

• equates people who are disabled with their disabilities and views disability as a problem of the person, directly caused by disease, trauma, or other health condition

• management of the disability is aimed at cure or the person's adjustment and behavior change (interventions might involve surgery, medications, etc. with the goal to minimize or eliminate the impairment)

• viewed as promoting passivity and dependency

• people with disabilities are viewed as tragic

• health care providers, rather than people with disabilities, are viewed as the experts or authorities

• not a focus on living independently with the disability.

rehabilitation model of disability

• regards disability as a deficiency that requires a rehabilitation specialist or other helping professional to fix the problem

• emerged from the medical model

• people with disabilities are often perceived as having failed if they do not overcome the disability.

social model of disability

• views disability as socially constructed and as a political issue that is a result of social and physical barriers in the environment

• idea that disability can be overcome by removal of these barriers

biopsychosocial model of disability

• integrates the medical and social models to address perspectives of health from a biologic, individual, and social perspective

• this model looks at everything (biological, psychological, and social); treatment aims to treat all three domains

• this model is critiqued as still focusing on the disabling condition rather than the person's experience with the disability

people first language

• referring to the person first: "the patient with diabetes" rather than "the diabetic" or "the diabetic patient

• conveys the message that the person, rather than the illness or disability, is of greater importance to the nurse.

multiple chronic conditions (MCC)

• increases the complexity of care and often necessitates care by multiple health care specialists, a variety of treatment regimens, and prescription medications that may not interact

• at risk for conflicting medical advice, adverse effects of medications, unnecessary and duplicative tests, and preventable hospitalizations

• costs of health care increase with the number of chronic conditions a person has

caring for a patient with MCC

• encourage telehealth/telecare

• participate in blood pressure and diabetes screening, stroke risk assessments

• transitional care should be implemented --- conduct assessments of the patient as well as the family caregivers' ability to assist in the management of the patient in the home

• persistent adherence to therapeutic regimens (such as medications) --- If they aren't taking their medication, why aren't they taking it?

• Teach pt about early signs of exacerbation

risk factors of HTN

• physical inactivity

• dyslipidemia

• chronic kidney disease

• diabetes

• •Microalbuminuria or GFR <60 mL/min

• drinking too much alcohol (i.e., more than two drinks per day for men and more than one drink per day for women)

• family history

• obesity

• smoking

• old age

clinical manifestations of HTN

• Early stages

  --- no manifestations other than inc. BP (silent killer)

• Late stages:

  --- Retinal and other eye changes

  --- Renal damage

  --- Myocardial infarction

  --- Cardiac hypertrophy

  --- Stroke

  --- CAD and angina

masked HTN

• blood pressure that is suggestive of hypertension that is paradoxically normal in health care settings

• high at home but not at the doctors office

white coat HTN

• hypertensive blood pressure readings in the health care setting that is paradoxically normal ranges in other settings

• high at the doctors office but never high at home

lifestyle modifications for HTN

• Weight loss (even losing 10 pounds can significantly lower BP)

• Limit alcohol use (1 glass a day for women, 2 for men)

• Increase aerobic exercise activity pattern (7 times a day 30 min every day of walking)

• Reduce sodium intake (less than 2g a day)

• Maintain adequate sources of dietary potassium, calcium and magnesium

• Smoking cessation

DASH diet

• DASH diet (dietary approaches to stop hypertension):

  --- lots of fruits and veggies

  --- whole grains

  --- foods high in K+ (3500-5000)

  --- low sodium (less than 2g a day) and fat

• limit alcohol consumption, regular physical activity, avoid tobacco use, and stress management

antihypertensive drug classes

• ACE inhibitors

  --- pril

  --- can cause hypotension, hyperkalemia, can cause coughing

• ARBS

  --- sartan

  --- do not take at the same time as ACE (wait 6 weeks)

  --- do not use w anything relating to potassium

• Alpha Blockers

  --- osin

  --- may be a second-line agent in men with BPH.

• Beta Blockers

  --- lol

  --- Not recommended as first-line antihypertensive agents unless the patient has HF or CAD

  --- dizziness, hypotension, bradycardia, fatigue, and depression

  --- use with caution in patients with asthma

• Calcium Channel Blockers

  --- dipine

  --- take on empty stomach, hypotension, pedal edema

• Diuretics

  --- ide

  --- thiazide: orthostatic HTN, eat K+, monitor electrolytes

  --- loop: (furosemide) monitor for hypokalemia and orthostatic HTN

  --- potassium-sparing: (spironolactone) hyperkalemia (if given ace or arb), effective for HTN when given with thiazide

stage 1 hypertension medication treatment

• african americans and patients >60: calcium channel blocker or thiazide diuretic

• non african american and patients <60: ACE-I or ARB

• low doses are initiated and increased gradually

• multiple meds may need to be increased

symptoms of target organ damage

• Angina

• shortness of breath

• altered speech

• altered vision

• nosebleeds

• headaches

• dizziness

• balance problems

• nocturia -- assess apical and peripheral pulses

Hypertensive crisis treatment

• may occur in patients with secondary hypertension, and in those whose hypertension has been poorly controlled, whose hypertension has been undiagnosed, or in those who have abruptly discontinued their medications (rebound HTN)

• patient needs to be admitted to the intensive care unit for continuous monitoring of BP and parenteral administration of an appropriate antihypertensive medication

• look for symptoms of target organ damage

hypertensive emergency

• blood pressure >180/120 mm Hg and must be lowered immediately to prevent further damage to target organs

• reduce blood pressure by no more than 25% in first hour

• reduce to 160/100 mm Hg within 2 to 6 hours

• then gradual reduction to normal 24 to 48 hours of treatment

• exceptions are ischemic stroke and aortic dissection

• Medications

  --- IV vasodilators: sodium nitroprusside, nicardipine, fenoldopam mesylate, enalaprilat, nitroglycerin

• need very frequent monitoring of BP and cardiovascular status

hypertensive urgency

• blood pressure >180/120 mm Hg but no evidence of immediate or progressive target organ damage

• oral agents can be administered with the goal of normalizing blood pressure within 24 to 48 hours

• fast-acting oral agents:

  --- Beta-adrenergic blocker—labetalol

  --- Angiotensin-converting enzyme inhibitor—captopril

  --- Alpha2-agonist—clonidine

• patient requires close monitoring of blood pressure and cardiovascular status

• assess for potential evidence of target organ damage

heart failure

• atherosclerosis of the coronary arteries is a primary cause of HF

• CAD is found in the majority of patients with HF

• when the left ventricle fails, increased fluid pressure is transferred back to the lungs causing damage to the right side of the heart

congestive heart failure

• failure of both the right and left ventricle

• when the left ventricle fails, increased fluid pressure is transferred back through the lungs, leading to damage of the right side of the heart

• When the right side loses pumping power, the blood backs up in the body's venous system

right sided heart failure

• can SEE

• viscera and peripheral congestion

• jugular venous distention (JVD)

• dependent edema

• hepatomegaly

• ascites

• weight gain

left sided heart failure

• pulmonary congestion, crackles

• S3 or "ventricular gallop"

• dyspnea on exertion (DOE)

• low O2 sat

• dry, nonproductive cough initially

• oliguria

ejection fraction

• when the ejection fraction gets less and less then the heart failure is not being managed correctly

• looking at the ejection fraction is a good indicator as to how your heart is working with hart failure

• An expected EF is 55% to 65%

• heart failure with reduced EF (systolic HF) - HFrEF --- EF 40% or less

• heart failure with preserved EF (diastolic HF)- HFpEF --- EF 50% or greater

• heart failure with midrange EF (diagnosis of exclusion) - HFmrEF ---EF 40% to 49%

class one heart failure

• no limitation of physical activity

• ordinary physical activity does not cause symptoms

class two heart failure

• slight limitation of physical activity; comfortable at rest

• ordinary physical activity causes symptoms

class three heart failure

• marked limitation of physical activity

• comfortable at rest but less than ordinary activity causes symptoms

class 4 heart failure

• severe limitation and discomfort with any physical activity

• symptoms present even at rest

• end stage heart failure

heart failure treatment

• oral and IV medications

• lifestyle modifications (diet and exercise)

• supplemental O2 (When it gets to end stage this is more common)

• surgical interventions: ICD and heart transplant

• comprehensive education and counseling to patient and family is needed

pulmonary edema

• sometimes referred to as acute decompensated heart failure

• happens during an exacerbation of HF

• all of the fluid fills up in your lungs (flash pulmonary edema)

• prevent by staying consistent with checking weight and medications

• symptoms:

  --- decreased O2 (breathlessness and a sense of suffocation,)

  --- increasingly restless and anxious

  --- pale to cyanotic membranes and hands

  --- fluid overload

  --- tachy

  --- confusion

  --- pink frothy sputum

digoxin

• improves contractility

• monitor for digitalis toxicity especially if patient is hypokalemic

signs of digitalis toxicity

• Anorexia

• nausea, vomiting

• blurred or yellow vision

• cardiac dysrhythmias

• confusion

• bradycardia

gerentolic considerations for HF

• May present with atypical signs and symptoms such as fatigue, weakness, and somnolence (depression)

• Decreased renal function can make older patients resistant to diuretics and more sensitive to changes in volume

• Administration of diuretics to older men requires nursing surveillance for bladder distention caused by urethral obstruction from an enlarged prostate gland

potential complications of a person with HF

• pulmonary edema

• hypotension, poor perfusion, and cardiogenic shock

• arrhythmias

• thromboembolism

• pericardial effusion

• pericardial sac around the heart fills with fluid

diuretics

• loop diuretics are normally the first to be administered

• Prior to administration of the diuretic, check for signs and symptoms of volume depletion, such as orthostatic hypotension, lightheadedness, and dizziness.

• check for signs of electrolyte imbalance

• administer early in the day to avoid nocturia

• Replace potassium with increased oral intake of food rich in potassium or potassium supplements

• Assess lungs sounds and edema to evaluate response to therapy

goals for a pt with HF

• Patient is eating a heart healthy diet

• Patient is able to ambulate without being short of breath

• Maintain weight (no weight gain)

• Patient is taking medications as prescribed

recommendations for a pt with HF

• Encourage regular physical activity; build up to about 30 minutes daily

• Pacing of activities; wait 2 hours after eating for physical activity

• Avoid activities in extreme hot, cold, or humid weather

• elevation of the head of bed to facilitate breathing and rest, support of arms

• Report a weight gain of more than 2-3lbs. in one day or 5 lbs in one week

• Document first urine of the morning, same scale, spot, and same clothes

• Take the diuretic in the morning

• maintain a fluid restriction

• Monitor for signs of excess fluid, hypotension, and symptoms of disease exacerbation

raynaud's phenomenon

• Intermittent arterial vasoocclusion, usually of the fingertips or toes (get white)

  --- Raynaud's disease: primary or idiopathic

  --- Raynaud's syndrome: associated with other underlying disease such as scleroderma

• -Manifestations: sudden vasoconstriction results in color changes, numbness, tingling, and burning pain

• -Episodes brought on by a trigger such as cold or stress

• -Occurs most frequently in young women

• -Protect from cold and other triggers. Avoid injury to hands and fingers

• -Might see people wearing gloves

• pt should avoid cold and nicotine

diagnostic tests for vascular disorders

• these exams/diagnostic tests assess the pt's circulation

• Doppler ultrasound flow studies

  --- Ankle-brachial index (ABI)

  --- Measures blood flow

  --- Has to be normal when doing wound care

• Exercise testing

• Duplex ultrasonography

• Computed tomography scanning

• Angiography and magnetic resonance angiography

• Contrast phlebography (venography)

• Lymphoscintigraphy

S/S of arterial insufficiency

• intermittent claudication '

• Diminished hair growth on affected extremities

• Pain at rest

• Thick, brittle, slow growing nails

• shiny, thin, fragile, taught skin

• Dry, scaly skin

• Cool temperature

• Diminished or absent pulses

• rubor

• atrophy

• ulcerations

• check cap refill and pulses

intermittent claudication

• pain and discomfort in calf muscles while walking

• a condition seen in peripheral arterial disease

• a symptom of generalized atherosclerosis

• sensation of coldness or numbness

arterial issues

• put your legs down-so blood flows down-like an A (artery)

• Arterial issues lead to amputations because it goes out to the body and when that is obstructed that is when amputations occur

• lack of O2 reaching limb

• Compression on arterial problem make it worse

PAD

• Hallmark symptom is intermittent claudication (making the muscles ache and cramp up)

• Occurs with some degree of exercise or activity

• Relieved with rest

• Pain is associated with critical ischemia of the distal extremity and is described as persistent, aching, or boring (rest pain)

• Ischemic rest pain is usually worse at night and often wakes the patient

venous issues

• Warm packs applied to the affected extremity reduce the discomfort associated with DVT.

• The legs should be elevated frequently throughout the day (at least 15 to 20 minutes four times daily). At night, the patient should sleep with the foot of the bed elevated about 15 cm (6 inches)

• Prolonged sitting or standing in one position is detrimental; walking should be encouraged

• patient should avoid placing pressure on the popliteal spaces, as occurs when crossing the legs or sitting with the legs dangling over the side of the bed

• Compression of the legs with graduated compression stockings reduces the pooling of venous blood

• analgesic agents for pain relief are adjuncts to therapy

venous thromboembolism

• caused by a DVT and PE

risk factors for venous thromboembolism

• endothelial damage

• venous stasis

• altered coagulation

VTE prevention

• graduated compression stockings or SCD's (18hrs/day)- first rule out that the issue is not arterial

• move fingers, toes, ROM

• prophylactic anticoagulants (lovenox)

• Subcutaneous heparin or LMWH (-Someone might be on it because it will prevent blood clots- heparin just prevents new clots from forming it DOES NOT break it up)

• early ambulation (most important and works best). Best to ambulate at least 4-6 times per day walking up and down hallway

• leg exercises

homan sign

• pain in the calf after the foot is sharply dorsiflexed

• not a reliable sign of DVT because it can be elicited in any painful condition of the calf and has no clinical value in assessment for DVT.

chronic venous insufficiency

• venous circulation is inadequate due to partial vein blockage or leakage of venous valves

• Extremities with venous insufficiency must be carefully protected from trauma; the skin is kept clean, dry, and soft

venous ulcers

• pain described as aching or heavy

• foot and ankle may be edematous

• should still feel pulses

• typically large, superficial, and highly exudative

• venous ulcer requires as long as 6 to 12 months to heal completely

• More irregular looking and spread out

• Brown pigmentation from venous insufficiency

arterial ulcers

• diminshed to absent pulses

• More defined edges

• More red and localized

• small, circular, deep ulcerations on the tips of toes or in the web spaces between the toes

• often occur on the medial side of the hallux or lateral fifth toe and may be caused by a combination of ischemia and pressure

• patient may also complain of digital or forefoot pain at rest

• can lead to amputation

management of leg ulcers

• Oral antibiotics usually are prescribed because topical antibiotics promote antimicrobial resistance

• compression therapy

  --- ABI that exceeds 0.80 is the threshold for applying compression

• cleansing and debridement of wound

• adequate nutrition: protein; vitamins C and A; iron; zinc

• avoid heat sources

• physical activity initially restricted to promote healing; gradual progression of activity

complications of leg ulcers

• infection

• gangrene

  --- normally has to be amputated, odorous, green

varicose veins

• elevate the legs 3 to 6 inches higher than heart level

• symptoms include dull aches, muscle cramps, increased muscle fatigue in the lower legs, ankle edema, and a feeling of heaviness of the legs.

• encourage to walk 30 minutes each day if there are no contraindications

• if only the superficial veins are affected, the person may have no symptoms but may be concerned by the appearance of the veins

• duplex ultrasound scan

cellulitis

• localized swelling or redness, fever, chills, sweating

• elevate affected area 3 to 6 inches above heart level

• apply cool packs to the site every 2 to 4 hours until the inflammation has resolved, and then transition to warm packs

amputation

• frequently check for blisters and alterations, if present they cannot wear the prosthetic

• also look out for infections and skin breakdown

• phantom limb pain --- patient's get medication for this

goals and actions for an amputee

• pain relief

  --- administer analgesic or other medications as prescribed

  --- putting a light sandbag on residual limb

• grief and body image

  --- encourage patient to look at, feel, and care for the residual limb

  --- help patient set realistic goal

• independent self-care

  --- encourage active participation in care

  --- continue support in rehabilitation facility or at home

  --- focus on safety and mobility

physical mobility for an amputee

• proper positioning of limb; avoid abduction, external rotation and flexion

• turn frequently; prone positioning if possible

• use of assistive devices

• ROM exercises

• muscle‐strengthening exercises

• "Preprosthetic care"; proper bandaging, massage, and "toughening" of the residual limb

risk factors for stroke

• hypertension (number one modifiable risk factor)

• smoking

• contraceptives

• obesity

• diabetes

• cardiovascular disease

ischemic stroke

• disruption of the blood supply caused by an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue

• symptoms depend on the location and size of the affected area

• window for tPA is 3-4 hours after onset

• when a person has a stroke and has hypertension, doctors want to keep the BP a little high to maintain perfusion to the brain

left sided ischemic stroke

• aphasia

• altered intellectual ability (confusion/change in mental status)

• slow cautious behavior

• trouble speaking or understanding speech

• anger/depression

• numbness or weakness of face, arm, or leg, especially on one side

• difficulty in walking, dizziness, or loss of balance or coordination

• sudden, severe headache

right sided ischemic stroke

• spatial perceptual deficit

• increased distractibility

• impulsive behavior, poor judgment

• lack of awareness of deficits

• numbness or weakness of face, arm, or leg, especially on one side

• difficulty in walking, dizziness, or loss of balance or coordination

• sudden, severe headache

BE FAST

• B: balance- loss of balance

• E: eyes- loss of or change in vision

• F: face- face drooping/weakness

• A: arms- weakness in arms/legs

• S: speech- slurred speech, trouble speaking, trouble understanding speech

• T: time- note the time of symptoms and call 911

stroke terms

• Hemiplegia- paralysis of one side

• Hemiparesis- weakness of one side

• Dysarthria- weakness in the speech muscles

• Expressive aphasia- understand speech, but they have difficulty speaking fluently themselves

• Receptive aphasia- able to speak well and use long sentences, but what they say may not make sense

• Hemianopsia- loss of vision in half of vision field in an eye

• Agnosia- inability to determine sensation. Can feel a cat but not be able to express that it is a cat

TIA

• temporary neurologic deficit resulting from a temporary impairment of blood flow

• "Warning of an impending stroke"

• diagnostic workup is required to treat and prevent irreversible deficits

• warning that a CVA is coming

• CT scan is performed within 20 min

medical management of ischemic stroke

Pharmacologic (prophylactic) **Coumadin (Warfarin)

• international normalized ratio (INR) target is 2 to 3

platelet aggregation inhibitors -If warfarin contraindicated, aspirin and clodripel is the best option or if the patient has had a minor ischemic stroke or what is considered a TIA with a high risk of having stroke, and they did not receive thrombolytic therapy, they may receive two platelet-inhibiting medications

statins (cholesterol reduction)

After the acute stroke period, antihypertensive medications are also used, if indicated, for secondary stroke prevention**(ACE) inhibitors and thiazide diuretics** may also have benefits in stroke prevention

t-PA

tPA

• -IV administration over 1 hour -only used for ischemic stroke verified by CT scan

• -administration must begin within 3 hours of symptom onset

• Assessments to do if a patient is getting tPA: watch out for neurological status and bleeding ( if a patient has a big bleed such as GI they are contraindicated)

• The goal is for intravenous (IV) t-PA to be given within 45 minutes of the patient arriving to the ED

• continuous hemodynamic monitoring and neurologic assessment

• two or more IV sites are established prior to administration of t-PA (one for the t-PA and the other for administration of IV fluids)

recovering from an ischemic stroke

• check for gag reflex

• change positions—every 2 hours

• exercise: passive or active ROM four or five times day

• assist patient out of bed as soon as possible

• use of assistive devices and modification of clothing

• have patient sit upright, preferably out of bed, to eat

• chin tuck or swallowing method

• use of thickened liquids or pureed diet

• assessment of voiding and scheduled voiding

• measures to prevent constipation: fiber, fluid, toileting schedule

hemorrhagic stroke

• caused by bleeding into brain tissue, the ventricles, or subarachnoid space

• due to very high BP

• ICP increases caused by blood in the subarachnoid space

• 30-40 degrees (semi fowlers) when the patient is experiencing inter cranial pressure (ICP)

manifestations of hemorrhagic stroke

• severe headache

• early and sudden changes in LOC

• vomiting

• bleeding

medical management of hemorrhagic stroke

• prevention: control of hypertension.

• diagnosis: CT scan, cerebral angiography, lumbar puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhage.

• care is primarily supportive.

• bed rest with sedation.

• oxygen

• treatment of vasospasm, increased ICP, hypertension, potential seizures, and prevention of further bleeding.

• don't want the patient constipated, vomiting, coughing sneezing, etc. it can increase ICP and be deadly for the patient

• put seizure precautions in place

recovering from a hemorrhagic stroke

• provide a nonstimulating environment, prevent increases in ICP, prevent further bleeding

• absolute bed rest with HOB 30 degrees

• avoid all activity that may increase ICP or BP; Valsalva maneuver, acute flexion or rotation of neck or head

• stool softener and mild laxatives

• nonstimulating, nonstressful environment; dim lighting, no reading, no TV, no radio

• visitors are restricted

• analgesic agents may be prescribed for head and neck pain.

• fever should be treated with acetaminophen not ibuprofen

manifestations of anemia

• weakness

• fatigue

• pallor

• syncope

• dyspnea

• tachycardia

• beefy red tongue

• Pica (causes cravings for things that are not food)

• Angular cheilitis (redness around the mouth)

management of anemia

• transfusions (if hemoglobin is below 8 there will be an infusion)

• TEACH PTS THE DIFFERENCE BTWN GI BLEED and DARK STOOL FROM IRON (harder stools bc of constipation)

• heart failure and kidney patients should be careful when getting infusions. They get Lasix in between infusions to get rid of fluids

polycytemia vera

• increased volume of RBCs

• treatment not needed if condition is mild

• treat underlying cause

• therapeutic phlebotomy (consistently drawing blood to get rid of extra RBCs)

potential complications of an anemic person

• heart failure

• angina

• paresthesias

• confusion

• injury related to falls

• depressed mood

iron deficiency anemia

• have a smooth, red tongue; brittle and ridged nails; and angular cheilosis

• replenishing iron stores takes several months (6 to 12 months)

• Food sources rich in iron: --- include organ meats ( beef or calf's liver, chicken liver), other meats, beans (e.g., pinto, black, and garbanzo beans), leafy green vegetables, raisins, and molasses

• vitamin c improves iron absorption

• Oral iron is best absorbed on an empty stomach- take 1-2 hours before meals

• antacids and dairy products should be avoided with iron as they can greatly diminish its absorption

• Oral iron replacement therapy may change the color of the stool but should not cause a false-positive result for occult blood on stool analysis.

Vitamin B12 deficiency

• can occur in patients with disorders such as inflammatory bowel disease, or in patients who have had GI surgery such as ileal resection, bariatric surgery, or gastrectomy

• dairy, red meat, eggs, fish, fortified cereal

thrombocytopenia

• When platelet counts fall to 20,000/mm3 or less, petechiae may occur

• The most common cause of increased platelet destruction is immune thrombocytopenic purpura

• promote safety and it should include fall prevention, particularly for older adults and those who are frail.

ITP nurse management

• common signs of thrombocytopenia include easy bruising, heavy menses, and petechiae on the extremities or trunk

• H. pylori infection is associated with ITP

• sulfa-containing medications and others may interfere with platelet function (e.g., aspirin, NSAIDs)

• nurse must assess for a history of recent viral illness and reports of headache, visual disturbances, and other symptoms that may indicate intracranial bleeding

• neurological assessment should be performed

• Patient and family education should address signs of exacerbation (e.g., petechiae and ecchymoses)

• Bone mineral density should be monitored, and patients may benefit from supplemental calcium, vitamin D, and bisphosphonate to reduce risk for significant bone disease

ITP patient teaching

• avoid asprin and NSAIDS (contain sulfa)

• avoid constipation, straining, and vigorous flossing of the teeth.

• electric razors should be used for shaving and soft-bristled toothbrushes should be used for dental hygiene

• patients and their partners should be counseled to avoid vigorous sexual intercourse when platelet counts are low

• increase in fatigue

HIT nurse management

• immediate cessation of heparin and initiation of another form of anticoagulation

• Monitor platelet count for all clients receiving heparin (drop 50% of baseline

• Argatroban, a thrombin inhibitor, is an FDA-approved anticoagulant for the treatment of HIT

• Education of need to avoid heparin products as can reactivate

blood transfuion reaction s/s

• fever

• chills

• respiratory distress

• low back pain

• nausea

• pain at the IV site,

blood administration procedure

• determine the clients previous history (allergies and previous transfusion reactions)

• Assess the client, obtain vital signs for baseline, and teach signs of a transfusion reaction and how to call for help.

• Set the infusion pump to deliver blood over 2-4 hours as prescribed but NO LONGER THAN 4 hours

• Rapid infusion of the blood puts the client at greater risk for transfusion reaction and fluid volume overload.

• monitor pt during the first 15 min for reaction

steps to take if there is a reaction

• Stop

• Assess

• Notify primary provider and implement prescribed treatments. Continue to monitor

• Return blood

• Obtain any samples needed

• Document

asthma

• symptoms are cough, dyspnea, and wheezing

• As the exacerbation progresses, diaphoresis, tachycardia, and a widened pulse pressure may occur along with hypoxemia and central cyanosis (a late sign of poor oxygenation), chest tightness

• symptom control includes using immediate intervention to diminish bronchoconstriction, which prevents increased anxiety resulting from progressive dyspnea

• poor symptom control increases the risk of exacerbations

complications of asthma

• status asthmaticus

• respiratory failure

• pneumonia

• atelectasis

status asthmaticus

• labored breathing, prolonged exhalation, distended neck veins

• wheezing (as the obstruction worsens, the wheezing may disappear; this is frequently a sign of impending respiratory failure.

• patient is treated initially with a short-acting beta-2-adrenergic agonist first then corticosteroids

• patient requires supplemental oxygen (partial or complete non-rebreathing mask) and IV fluids for hydration (to treat dyspnea, central cyanosis, and hypoxemia)

• increasing PaCO2 (to normal levels or levels indicating respiratory acidosis) is a danger sign signifying impending respiratory failure.

• NO SEDATIVES

• can give magnesium sulfate (smooth muscle relaxation)

nursing management for status asthmaticus

• monitors the patient for the first 12 to 24 hours, or until the severe exacerbation resolves.

• assesses the patient's skin turgor for signs of dehydration

• patient's energy needs to be conserved, and his or her room should be quiet and free of respiratory irritants, including flowers, tobacco smoke, perfumes, or odors of cleaning agents

quick relief asthma medications

• beta2-adrenergic agonists (albuterol, levalbuterol, pirbuterol)

• anticholinergics (ipratropium)

long acting asthma medications

• Corticosteroids

  --- decrease peak flow variability

  --- inhaled Long-acting beta2-adrenergic agonists Leukotriene modifiers

  --- montelukast, zafirlukast, and zileuton