Complex 1 Exam 1 (kenzieflo_) (copy)

Cellulitis assessment

Cellulitis assessment

inflammatory response to normal flora entering the body caused by staph or strep

· Erythema (Redness)

· Warmth

· Fever/chills/diaphoresis

· Swelling (due to impaired circulation or high BMI)

· Pain

· Enlarged lymph nodes

Priority problems: pain and impaired circulation

Cellulitis pharm interventions

· ABX: Cephalexin (1st drug of choice)
o Trimethoprim
o Clindamycin
o Doxycycline
· NSAIDs: GI bleeding, take w/ food
· Opioids: NARCS-U

Cellulitis nursing interventions

· ABX (extra contraceptives, supra infections)
· Wound care
· RICE (ice first 24 hr, then warm compress)
· Sterline saline dressings

Cellulitis patient education

· Keep clean/moist
· Monitor for worsening infection(draw lines around it)
· Increased risk for cellulitis again!

Pneumonia assessment

"Sally Took Food Down Low Past Sandy's With Dunkin Donuts"
· SOB
· Tachypnea
· Fever/chills
· Diaphoresis
· Loss of appetite
· Pleuritic chest pain (report)
· Sputum (yellow green)
· Wheezing, coughing, crackles
· Decreased O2 sat - cyanosis
· Decreased LOC, VS

Pneumonia

an infection in the lungs caused by microbes which bring water into the lungs, making it difficult to breathe

Pneumonia Dx

Lab Tests:
- Sputum Culture & Sensitivity: older adults may have trouble expectorating
- CBC: elevated WBC
- ABGs: hypoxemia (decrease PaO2 less than 80)
Diagnostics:
- Chest X-Ray: consolidation (solidification, density) of lung tissue suggestive of pneumonia
- Pulse Ox: O2 saturation less then 95%

Pneumonia nursing interventions

· 2-3L fluids
· Increase protein, vitamin C
· Oxygen therapy
· High Fowler's
· Remove secretions
· Incentive spirometer 8-10x an hour
· Rest but also mobile
· Bronchodilators/anti-inflammatory

Pneumonia pharm interventions

- penicillins and cephalosporins (1ST) (take w/ food & monitor kidney function)

· Macrolides (azithromycin)

· Bronchodilators: (albuterol) : tremors, tachycardia

· Cholinergic antagonists (ipratropium): suck on hard candy, increase fluid

· Steroids: B before C, report black tarry stool, take w/ food, taper dose

Pneumonia patient education

· Rest

· Hand hygiene

· No smoking

· Immunizations: pneumonia vaccine & influenza

- pneumova (65 yrs old and every 5 yrs - unless underlying conditions like HIV/cancer)

TB symptoms

an infectious disease caused by Mycobacterium tuberculosis; transmitted through the airborne route and affects the lungs
think TB...
T: terrible cough (blood tinged) > 3 weeks
B: bad infection: low grade fever in the afternoon, night sweats, weight loss, TRAVEL/Immigration, purulent sputum

Tuberculosis safety concerns

· Airborne

· Negative flow room

· N95

· Mask outside room

· Cough in paper towel & trash it

Tuberculosis nursing interventions

· Promote activity
· Heated & humidified O2 therapy
· ABX therapy
· Nutrition: increase iron, protein, vitamins B & C (Meats and citrus fruits)

Tuberculosis pharm interventions - RIPE

LIVERRRR!!!
· Rifampin: liver, orange secretions
· Isoniazid: take vit. B6, nerve damage
· Pyrazinamide: increases uric acid (gout)
· Ethambutol: visual toxicity (have monthly visual tests) don't give to children < 8
Streptomycin Sulfate - for multi-drug resistant TB; can cause ototoxicity

Tuberculosis patient education

· Complete full course of ABX
· Sputum samples every 2-4 weeks
· meds last 6-12 months
· No alcohol bc RIPE!
· Hand hygiene, mask in public

Tuberculosis Dx

Mantoux Test/PPD

- 10mm (normal) = positive

- 5mm (immunocompromised) = positive

- positive test indicates an immune response to TB (immunity) (means they may not actually have it, but have had it in the past)

- chest x-ray to follow up positive result (detects ACTIVE TB)

- Sputum Culture (Acid-fast Bacilli Scan), Smear (tells if its active or latent)

When is a patient considered NOT active for TB?

3 consecutive negative sputum cultures

pH

7.35-7.45 (acidosis-alkalosis)

PaCO2

35-45 (alkalosis-acidosis) - RESPIRATORY

HCO3

21-28 (acidosis-alkalosis) - METABOLIC

Respiratory alkalosis

(HYPERVENTILATION)

· Initial stages of pulmonary emboli

· Anxiety

· Asthma

· Fever

· High altitudes

· Pregnancy

- looks like: tachypnea, inability to concentrate, tinnitus, tingling, tachycardia, rapid & deep breaths

- breathing off way too much CO2

Metabolic alkalosis

caused by: loss of gastric juices, overuse of antacids, and potassium sparing diuretics

- looks like: tachycardia, tetany,(muscle contractions), confusion, depressed skeletal muscles

- treat with IV fluids and antiemetics(helps stop vomiting)

Asthma can begin as ...

respiratory alkalosis; pt breathing very fast breathing off CO2, then pt might tire out "Silent chest" --> low RR --> respiratory acidosis

Respiratory acidosis

(HYPOVENTILATION) - (breathing too shallow which causes CO2 levels to rise and buildups of acid which causes too little oxygen)
ex. drug overdose, pulmonary edema, chest trauma, airway obstruction
- looks like: initial tachycardia and hypertension which turns into bradycardia and hypotension over time, pale/cyanotic skin, shallow & rapid breathing

Metabolic acidosis

(diabetic ketoacidosis ---> give insulin)
· Any organ failure (except lungs)
· Salicylate OD
· Renal failure
· Severe diarrhea
· Sepsis
- VS: dysrhythmias, bradycardia, tachypnea, warm/dry/pink skin

Possible Diseases related Acid Base Balance

- convulsions
- coma
- respiratory arrest

Acid-base balance management of care

Balance is maintained by chemical, respiratory, and kidney function.
1. Encourage a healthy diet and physical activity
2. Limit alcohol
3. Encourage 6-8 cups of water daily
4. Maintain a healthy weight for height and body frame
5. Promote smoking cessation

Nasal Cannula

· 1-6L
FIO2% = 24-44%
· Prongs down, not up, tubing on top of ears and below chin
- patient can eat, talk and drink w/o removing O2

Simple facemask

· 5-8L
- FIO2: 40-60%
- covers the client's nose and mouth

Partial rebreather

· 6-11L
FIO2: 60&-80%
- allows patient to rebreathe up to 1/3 of exhaled air together with room air
- bag must stay inflated

Non-rebreather

· 10-15L
FIO2: 60%-95%
- delivers the HIGHEST CONC of O2
- flaps prevent room air from entering the mask
- bag must stay inflated

Venturi mask

· 4-10L
· Different valves
FIO2: 24-55%
- delivers the MOST PRECISE amount of O2
- very expensive
- best suited for patient who have chronic lung diseases

Oxygen delivery devices nursing interventions

· Check for skin breakdown
· NO smoking
· NO oil-based lubricants, jelly-based OK
· Provide humidification for 4L/min or more
· Cotton gown only

Asthma Patho

1. trigger factor
2. airway inflammation
3. hyper secretion of mucus, airway muscle contraction, swelling bronchial membranes
4. narrow breathing passages
5. wheezing, cough, shortness of breath, tightness in chest

Asthma assessment

"Daring Cats Always Climb Walls Before Taking Precious Mice"

- dyspnea (difficulty breathing)

- chest tightness

- anxiety/stress

- coughing

- wheezing

- barrel chest (air trapping)

- tachypnea/tachycardia

- prolonged exhalation

- mucus production

Asthma Dx

· Pulmonary function test: most accurate
· ABG: respiratory alkalosis
· Chest x-ray
· Sputum culture: if infection is suspected

Asthma nursing interventions

· Monitor cardiac rate/rhythm

· Rest periods

- SILENT CHEST = EMERGENCY

· High Fowler’s

· Incentive spirometer

· O2 therapy if <90%

Asthma pharm interventions

· Adrenergic stimulants (inhalers)

- SABA (albuterol): rapid relief

- Ipratropium: long-acting & prevent bronchospasms; dry mouth, can't see, pee, poop

- Theophylline: use only when other treatments are ineffective; monitor blood levels for toxicity

LABA (salmeterol), prevent attack doesn't treat

Anti-Inflammatory:

- Montelukast: Take daily @ night, Suicidal ideation, liver

o Tachycardia

o Dry mouth

o Nausea

o Diarrhea

· Steroids: B before C (beclamethasone, decadron)

o Monitor for black tarry stools

o hyperglycemia

o Take with food

Asthma patient education

· Hot water to eliminate dust
· Increase fluids
· Incentive spirometer
· Vitamins C & E
· Exercise

Chronic Obstructive Pulmonary Disease (COPD)

permanent, destructive pulmonary disorder that is a combination of chronic bronchitis and emphysema - patients struggle to exhale all the CO2; hypoxic drive of breathing (low O2)- tripod position

Bronchitis

inflammation of the bronchi and bronchioles due to chronic exposure to irritants- a build-up of too much mucus/irritation- productive cough lasting 3 or more months for 2 consecutive years

Emphysema

the loss of lung elasticity and hyperinflation of lung tissue(damage the alveoli in lungs)

COPD health promotion

· Smoking cessation
· Influenza & pneumonia vaccine

COPD assessment

"David Prepared His Crackers Really Late Down Broad"

- dyspnea upon exertion

- productive cough that is most severe upon rising in the morning

- hypoxemia

- crackles and wheezes

- rapid and shallow respirations

- Late signs: clubbing of fingers & toes, pallor and cyanosis

- decreased O2 sat (88%-92% normal)

- barrel chest and hyperresonance on percussion due to "trapped air" (EMPHYSEMA)

-TRIPOD position helps

COPD nursing interventions

· Rest between meals

· High protein, high fat, low carb.

· High calorie foods

· Frequent, small meals

· 2-3L of fluids

· Regular exercise, walking

· High Fowler’s

· Incentive spirometer

· O2 therapy (start low- low flow)

· Monitor weight

· Pursed lip breathing

COPD pharm interventions (Chronic Meds Save Lungs!)

· Corticosteroids: increased glucose, black tarry stool, take w food, taper dose
· Theophyllines & mucolytics: can be toxic/ to loosen secretions
· Short-acting bronchodilators & long-acting bronchodilators: monitor HR, suck on hard candies

FVC and FEV1 will be ___ in COPD patients

decreased

Fibromyalgia

a chronic pain syndrome which manifests as pain, stiffness, and tenderness at trigger pointsin the body(nerve endings or synapses)

- pain is typically described as a burning, gnawing pain

- client also experiences chronic fatigue, sleep disturbances, and functional impairment

Fibromyalgia assessment

· Mild-severe fatigue
· Sleep disturbances
· Pain/tenderness depending on stress, activity, & weather
· HA
· Depression
· Memory difficulties
· Abd. Pain, heartburn
· Constipation/diarrhea
· Urinary frequency, urgency
· Visual changes

Fibromyalgia pharm interventions

SNRIs (duloxetine) and anticonvulsants (pregabalin) decrease nerve pain - no alcohol, SNRIs can cause drowsiness/sleepiness

- NSAIDs decrease pain/inflammation

- contraindicated for clients who have impaired kidney function, don't take on an empty stomach

- TCAs (-triptyline & trazodone) - can cause confusion/ortho hypo, traz med of choice for older adults

- Combo meds (Tramadol) - tricyclic & opioid components

Fibromyalgia nursing interventions

· Exercise programs
· Emotional support

Fibromyalgia patient education

- complementary and alternative therapies (acupuncture, stress management, tai chi, hypnosis)

· NSAIDS: take with food

· SNRIs: avoid alcohol

· Limit caffeine

· Develop sleep routine

Psoriasis

an autoimmune skin disorder characterized by scaly dermal patches and caused by overproduction of keratin
- primarily on scalp, elbows, knees, sacrum; may have pitting or crumbling nails
- can cause psoriatic arthritis
- Reddened, thick skin with silvery white scales
- Bleeding w removal of scales

Psoriasis pharm interventions

· Corticosteroids: monitor for hyperpigmentation, atrophy
· Vitamin D analogs (calcitriol): limit sun exposure bc cancer
· Cytotoxic meds (methotrexate): avoid alcohol
· Photochemotherapy and Ultraviolent Light (PUVA)

Psoriasis patient education

· Use baths w emollients & oatmeal

· DO not pick/scratch lesions

- ensure the client wears eye protection during treatment and for 24 hrs following treatmentindoors and outside

Dermatitis

AKA pruritus; an inflammation of the skin resulting form exposure to allergens that caused changes in the skin structure or tissue destruction
- ALL dermatitis itches

Dermatitis pharm interventions

· Steroids: avoid on infected lesions
· Antihistamines: cause photosensitivity
· Topical immunosuppressants: monitor for burning sensation

Stage 1 pressure ulcer

Non-blanchable erythema of intact skin

- put the HOB in low-Fowler's or flat if the patient can tolerate it

- use a clear dressing or foam

Treatment: float the heels, pressure-relieving devices, encourage turning, better nutrition

Stage 2 pressure ulcer

- Partial-thickness skin loss with exposed dermis

- looks like a ruptured blister or shallow open ulcer (reddish-pinkish)

- no slough

- Place dressing (hydrocolloid dressing)

· Increase protein, zinc, vitamins A, C, E

- Pain control

Stage 3 pressure ulcer

Full-thickness skin loss

- visible adipose tissue w/ possible granulation tissue (good sign)

- debride or use proteolytic enzymes to remove slough

- may need antibiotics

Stage 4 pressure ulcer assessment

Full-thickness skin and tissue loss

- rid the infection prior to treating wound

- offload pressure

- warm soaks may increase the risk for infection (wound irrigation is ok)

- may need a skin graft

- dressing changes are painful, so give meds 30 mins before

Treatment: keep moist, change dressing frequently, nutritional supplements, antibiotics, fill the dead space (w/ gauze or gel)

Unstageable pressure ulcer assessment

· Obscured full-thickness skin & tissue loss
· Stage cannot be determined due to slough/eschar

Pain: Assessment

PAIN IS SUBJECTIVE (client is the most reliable source)

Components of a Focused Pain Assessment:

Location

Quality

Measures (intensity/severity)

Timing

Setting (how pain affects ADLs)

Associated manifestations

Aggravating/relieving factors

Pain expected Findings

- Acute Pain: increased BP, HR, and RR
- Facial expressions (grimacing, wrinkled forehead) and body movements (restlessness, pacing, guarding)
- Moaning, crying
- Decreased attention span

Pain: Pharmacological interventions/Medication education

ANALGESICS

- Non-opioid analgesics: mild to moderate pain; antipyretic and anti-inflammatory effects; ensure 50kg clients do not exceed 4g/day of acetaminophen

- Opioid analgesics: moderate to severe pain; NARCS U; can be titrated upwards (morphine)

- Adjuvant analgesics (used for chronic pain)(largest group): enhance the effects of non-opioids, help alleviate other manifestations that aggravate pain, and treat neuropathic pain (ketamine)(amitriptyline- makes you drowsy)(benzodiazepines- diazepam), (methotrexate)

- *PCA pumps*: self-administration of opioids

PCA Pump

a medication delivery system that allows clients to self-administer safe doses of opioids

- small, frequent doses ensure consistent plasma levels

- less lag time between identified need and delivery of meds = increased sense of control; decreased amount of meds

- morphine & hydromorphone common

- client is the only person to push the PCA button

Pain Complications

- under-treatment of pain can lead to increased anxiety w/ acute pain and depression with chronic pain

- Sedation, respiratory depression, and coma can occur as a result of overdosing (sedation before respiratory depression)

Inflammation

Gallbladder Disease:

- Cholelithiasis/Cholecystitis Inflammatory Bowel Syndrome - (Ulcerative Colitis/Crohn's)

Peptic Ulcer Disease (PUD)

Cholelithiasis/Cholecystitis assessment

· Sharp pain in RUQ that radiates to right shoulder

Murphy's sign: client holds their breath when you palpate the RUQ

- intense pain after ingestion of high-fat food

- Blumberg's sign: rebound tenderness

· Dyspepsia(indigestion), belching(burping) flatulence (farting)

· Fever

- dark urine

- clay colored stools (sign of obstruction)

Cholelithiasis/Cholecystitis nutrition

- adhere to a low-fat diet (reduce dairy avoid fried foods, chocolate, gravy)

- small, frequent meals

- Avoid gas-forming foods (beans, cabbage, cauliflower, broccoli)

- take fat-soluble vitamins

- must be NPO before surgery

- eat HDL sources (seafood, nuts, olive oil)

Ulcerative Colitis

primarily in the large intestine (rectosigmoid colon) and the rectum; affects the inner lining of intestinal wall

Ulcerative colitis assessment

· Abdominal pain, cramping in LLQ
· Anorexia & weight loss
· Diarrhea (5-30 stools/day) with blood, mucus, pus
· Abdominal distension, tenderness, firmness, high-pitched bowel sounds, fever

Crohn's assessment

· Abdominal pain, cramping in RLQ

· Anorexia & weight loss

· Diarrhea (5 stools/day) with mucus or pus NO BLOOD

· Abdominal distension, tenderness, firmness, high-pitched bowel sounds, fever

· Steatorrhea - excess fat in your stool

UC/Crohn's diagnostic procedure

Ulcerative Colitis =
- Colonoscopy & sigmoidoscopy will help determine ulcerative colitis - visualizes the rectum and large instestine
- Barium enema
- CT scan or MRI - identify presence of abscesses
- Stool examination - presence of parasites or microbes

Crohn's
- endoscopy (Colonoscopy & sigmoidoscopy & Proctosigmoidoscopy - identify inflamed tissue)
- barium enema
- abdominal ultrasound, X-ray, CT scan - show bowel thickening
(ex. Skip lesion=crohn's)

UC/Crohn's nutrition

· High protein
· High calorie
· LOW fiber
· Avoid whole grains, fruits, seeds, beans, nuts
· Small, frequent meals
· Avoid caffeine & alcohol

Peptic Ulcer Disease

an erosion of the mucosal lining of the stomach, esophagus, or duodenum
- most common in the duodenum

PUD assessment

· Dyspepsia, heartburn, N/V
· Uncomfortable Fullness/hunger
· Dull, gnawing pain or burning sensation at mid-epigastrium or back
· Blood emesis/stools
· Weight loss

PUD Dx

· H&H

· H.Pylori testing

· Stool sample

· BUN/Cr: increased

· Electrolytes

Diagnostic Tests:

Esophagogastroduodenoscopy (EGD):

- provides a definitive diagnosis of peptic ulcers and can be repeated to evaluate the effectiveness of treatment. Gastric samples are obtained to test for H. pylori.

- NPO 6-8hrs before and until return of gag reflex

- patient is moderately sedated so monitor VS

PUD nursing interventions

- relieve pain
- reduce anxiety
- encourage rest periods
- maintain optimal nutritional status
- monitor and maintain potential complications (hemorrhage, perforation/penetration, and gastric outlet obstruction)

PUD pharm interventions

· ABX
· PPI:(-azole): suppress gastric acid secretion do not crush or chew, take in morning
· Antacids: take after 1-2 hour of other meds
· Mucosal protectants: (sucralfate) - coats the ulcer and protects in. take 1 hr before meal/bedtime; avoid aspirin

PUD patient education

· Lie down after meal
· High protein, high fat, low fiber
· Low-moderate carbs
· Avoid milk & sugar
· Avoid alcohol & caffeine

Hypovolemia (fluid deficit) assessment

· Hypothermia, tachycardia thready pulse, orthostatic hypotension, tachypnea, hypoxia
· Dizziness, confusion, weakness, fatigue
· Dry furrowed tongue, N/V, acute weight loss

Hypovolemia (fluid deficit) nursing interventions

· PO or IV rehydration therapy

· Monitor weight every 8 hours while fluid replacement is in progress, VS, I&O, LOC

· Call light nearby

· Change positions slowly

Hypovolemia (fluid deficit) pharm interventions

· Antiemetic · Antidiarrheal

Hypervolemia (fluid excess) assessment

· Bounding pulse, HTN, tachypnea
· Weakness, visual changes, altered LOC, seizures
· Crackles, cough, dyspnea
· Peripheral edema, weight gain, distended neck veins
· Increased urine output
· Skin cool to touch

Fluid Volume Excess (FVE): Pharmacological Interventions/Medication Education

Diuretics and a low-sodium diet

Hypervolemia (fluid excess) nursing interventions

· Administer diuretics

· Restrict fluid & sodium

· Monitor I&O, weight, breath sounds

(- report a 1 to 2 lb weight gain in 24 hrs, or a 3 lb gain in 1 week)

· Monitor electrolytes

Hyponatremia (low sodium) assessment

· Diminished peripheral pulses
· Hypothermia, tachycardia rapid thready pulse, hypotension
· HA, confusion, lethargy, muscle weakness
· Sodium <136

Hyponatremia (low sodium) nursing interventions

· Encourage sodium (beef broth, tomato soup)
· LR, 0.9% isotonic saline
· Monitor I&O, daily weight, LOC, VS

Hypernatremia (high sodium) assessment

· Hyperthermia, tachycardia orthostatic hypotension
· Restlessness, muscle twitching, decreased DTRs, seizure, coma
· N/V, anorexia, thirst
· Sodium >145

Hypernatremia (high sodium) nursing interventions

· Monitor LOC, VS, heart rhythm, I&O
· Auscultate lung sounds
· Daily weight
· 0.3% Sodium chloride hypotonic

Hypokalemia (low potassium) assessment

· <3.5
· Decreased BP, orthostatic hypotension thready, weak pulse
· Altered mental status, anxiety, lethargy, coma
· Flattened T wave, prolonged QT interval
· Hypoactive bowel sounds, N/V, constipation, abd. distension
· Weakness, decreased DTR
Shallow breathing

Hypokalemia (low potassium) nursing interventions

· Administer potassium replacement (NEVER IV push)
· Monitor cardiac rhythm
· Monitor LOC, bowel sounds
· Monitor O2 levels
· Assess DTRs
· Fall precautions

Hyperkalemia (high potassium) assessment

· >5.0
· Slow, irregular pulse, hypotension
· Restlessness, irritability, paralysis
· Peaked T waves, widened QRS
· Diarrhea, hyperactive bowel sounds
· Oliguria

Hyperkalemia (high potassium) nursing interventions

· Monitor cardiac rhythm, I&O
· Assess for muscle weakness
· Promote potassium restricted diet
· Monitor blood potassium levels
· Calcium gluconate (severe)

Hyperkalemia (high potassium) pharm interventions

· Loop diuretics (furosemide)
· Cation exchange resins: adhere to potassium-restricted diet (no legumes, lean, meat)
· Albuterol
· IV insulin & glucose

Hypomagnesemia (low magnesium) assessment

· <1.3
· Dysrhythmias or ECG changes (ST depression, prolonged QR)
· Hyperactive DTRs, paresthesia, muscle tetany, seizures
· Positive Chvostek's & Trousseau's signs
· Hypoactive bowel sounds, abdominal distention, constipation
Apathy or agitation

Hypomagnesemia (low magnesium) nursing interventions

· High magnesium foods (veggies, nuts, whole grains, seafood)
· IV mag sulfate
· Monitor DTRs hourly

Hypermagnesemia (high magnesium) assessment

· >2.1
· Bradycardia, dysrhythmias, hypotension
· Diminished DTRs, drowsiness, lethargy, coma
· Hyperactive bowel sounds, diarrhea

Hypermagnesemia (high magnesium) nursing interventions

· Tell client to avoid green leafy veggies, whole grains, nuts
· Administer IV calcium gluconate & diuretics