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PRETEST: BASIC CARE AND COMFORT




PRETEST: BASIC CARE AND COMFORT






PRETEST: BASIC CARE AND COMFORT





PRETEST: COORDINATED OF CARE



PRETEST: COORDINATED OF CARE






PRETEST: COORDINATED OF CARE





PRETEST: COORDINATED OF CARE




PRETEST: COORDINATED OF CARE

















PRETEST: HEALTH PROMOTION AND MAINTENANCE





PRETEST: HEALTH PROMOTION AND MAINTENANCE







PRETEST: SAFETY AND INFECTION CONTROL






PRETEST: SAFETY AND INFECTION CONTROL






PRETEST: SAFETY AND INFECTION CONTROL



1




I. Concepts of Management and Supervision


A.
Review standards/position statements of the following agencies before delegating any nursing tasks


1. State board of nursing

2. National Council of State Boards of Nursing (NCSBN)

3. Nursing organizations - publish position statements and define standards of practice

a. American Nurses Association (ANA) - interpretations or position statements

b. National league for Nursing (NLN)

c. National Federation of Licensed Practical Nurses (NFLPN)



4. Health care institutions






B. Nurses must understand the legal aspects of the nursing profession

1. Provide safe competent care

2. Advocate client's rights

3. Provide care that is within their scope of practice

4. Provide care that is consistent with established standards of care

C. Establishing priorities

1. Prioritizing involves decisions of which needs or problems require immediate attention or action and which
ones can be delayed until a later time if they are not urgent

2. Needs that are life-threatening or could result in harm to the client if left untreated are high priorities

3. Actual problems or needs have higher priority than potential problems or needs

4. Problems or needs identified by client are of a higher priority

5. Consider Maslow's principles (hierarchy of needs) or the ABCs (airway, breathing, circulation) of
emergency care to guide decisions

6. Mutual decision-making for priorities may be made with the client based on the client's physiologic needs,
desires, and safety.



D. Communication skills and conflict resolution


1. Communication

a. involves perception to receive a message

b. involves expectation - the unexpected may be ignore

c. makes demands on nurses to think and respond

d. is different than information







Don't Confuse these!
Scope of Practice - determined by a state's Nurse Practice Act
Standards of Practice - established by the nursing profession, i.e., the American Nurses
Association
Standard of Care - institutional policy and procedure documents
2




3. Causes of conflict

a. Inadequate communication

b. incorrect facts


c. unstable leadership or inadequate action plans

d. misunderstood roles or responsibilities

e. receiving directions from two or more delegators

f. lack of or limited staff input into decisions

g. inability to accept change

h. power issues



4. Prevention of conflict includes

a. allocating resources fairly

b. avoiding unexplained changes

c. clearly stating expectations

d. addressing staff fears



5. Dealing with conflict

a. take prompt action


b. help parties resolve conflict among themselves (communicate trust that
parties can accomplish resolution)

c. maintain an objective approach

d. avoid criticism


e. use problem solving approach

f. provide privacy for sensitive issues

g. negotiate for agreements- not winning or losing

h. focus on patient care interests

i. avoid emotional outbursts

j. include a third party when mediation seems the best choice


2. Types of communication

a. downward - used to relate organizational policy such as position
description and rules and regulations

b. upward - include such things as staff meetings

c. lateral - between staff members, i.e. to coordinate activities

d. diagonal - staff from different levels work together on a
project

3

E. Communication and collaboration techniques

1. SBAR technique - provides a standardized framework for communication between
members of the health care team

a. S =situation (a concise statement of the problem)

b. B =background (pertinent and brief information related to the situation)

c. A =assessment (analysis and considerations of options - what you
found/think)


d. R =recommendation (action requested/recommended - what you want)



2. "I PASS the BATON" - used to improve "handoffs" and transitions in health care, with
opportunities to ask questions, clarify, and confirm

a. I =introduction (introduce yourself and your role/job)

b. P =patient (name, identifiers, age, gender, location)

c. A =assessment (presenting chief complaint, vital signs and symptoms and
diagnosis)


d. S =situation (current status/circumstances, including code status, recent
changes, response to treatment)

e. S =safety concerns (critical lab values/reports, socio-economic factors,
allergies, alerts such as falls, isolation, etc.)

f. B =background (co-morbidities, previous episodes, current medications,
family history)


g. A =actions (what actions were taken or are required and provide brief
rationale)


h. T =timing (level of urgency and explicit timing, prioritization of actions)

i. O =ownership (who is responsible - nurse/doctor/team and
patient/family responsibilities)

j. N =next (what will happen next? anticipated change? what is the PLAN? what
is the contingency plan?)

3.

CUS - a process used to more effectively advocate for clients when there is a
concern

a. C =concern ("I am concerned...")

b. U =uncomfortable ("I am uncomfortable...")

c. S =safety ("this is unsafe...")


4


II. Delegation


A. Definitions


1. Delegation: a process by which responsibility and authority for performing tasks are transferred from
one individual to another who accepts that authority and responsibility

2. Delegation involves

a. responsibility: an obligation to accomplish a task

b. accountability: accepting ownership for the results or lack of

c. authority: right to act or empower over others



B. Delegation overview

1. A nurse can only delegate those tasks for which that nurse is responsible (as outlined in the
state's Nurse Practice Act)

2. The delegator remains accountable for the task

3. Along with responsibility for a task, the nurse who delegates must also transfer the authority
necessary to complete the task

4. The delegator knows how to perform the task being delegated

5. Delegation is a contractual agreement that is entered into voluntarily

6. Nursing tasks that may not be delegated include client assessment, professional nursing
judgement, planning of nursing care or the evaluation of the client's response, health teaching
or counseling





7.

Consider the scope of practice of nursing personnel (as determined by a state's Nurse Practice Act)


a. Registered Nurses (RNs):

i. baccalaureate prepared nurses are equipped to care for
individuals, families, groups and communities in both structured
and unstructured health settings
ii
.
associate degree prepared nurses are equipped to care for
individuals in a structured health care environment


b.
Licensed Practical or Vocational Nurses (LPN/VN)

i. assist in implementing a defined plan of care and to perform
procedures according to protocol
ii. assessment skills involve collecting data and are directed at
differentiating normal from abnormal
iii. may reinforce information that has been
given to the client by the RN
iv. competence to care for physiologically stable clients
with predictable conditions




c. Unlicensed Assistive Personnel (UAP)

i. because they are unlicensed, they have no scope of practice
ii. in general, nursing tasks that may be delegated include non-invasive and non-
sterile treatments
>
assist in a variety of direct client care activities or tasks,
e.g., bathing, transferring, ambulating, feeding, toileting,
and obtaining measurements (vital signs, height, weight,
intake and output, blood glucose levels)
>
perform indirect activities such as housekeeping,
transporting people and stocking supplies
iii. some states allow for the practice of medication administration in specific
settings by medication aides - refer to your state's Nurse Practice Act for
specific information










5








C. Steps of delegation - if allowed by your state's Nurse Practice Act

1. Right task - define the task and determine if it can be safely delegated

a. match the delegatee to the task

b. determine if the task is within the scope of practice for the delegatee

c. determine agency policies, procedures, and standards

d. understand standards of practice, e.g., the ANA or NAPNES Standards of Practice

e. remember - nursing tasks that be delegated to unlicensed assistive personnel (UAP) are intended to assist,
but not replace, the nurse


2. Right circumstances

a. determine if there is anything about the client's condition or the environment which would preclude this delegatee from
performing the task as delegated

b. determine if staff members have the resources, equipment, and supervision needed to work safely


3. Right person - is the right person delegating the right task to the right person to be performed on the right patient?

a. determine if staff members have the necessary knowledge, skills, and abilities (KSA) to perform the delegated tasks and if this
information is documented

b. determine if the client's condition is stable with predictable outcomes prior to delegating care



4. Right direction/communication - clearly communicate the specific steps of the task, expectation about performance, reporting, and
documentation of the task

a. potential problems and solutions are discussed

b. the nurse intervenes if necessary

c. staff members must be able to decline without jeopardizing their jobs


5. Right supervision/evaluation - appropriate monitoring, intervention, evaluation, and ongoing feedback

a. the nurse must have the appropriate skills to assist, teach and guide the individual who is completing the task

b. the nurse will determine if client needs were met

c. the nurse can continue or withdraw the delegation

d. problems, particularly and sentinel events, are clarified or reported to supervisors


D. Client care assignments

1. Assign the right task

2. Assign the task to the right person

3. The LPN may assign tasks to the unlicensed assistive personnel or nursing assistants (if allowed by that state's Nurse Practice
Act)


4. Unlicensed assistive persons (UAP) or nursing assistants cannot delegate to other UAPs or nursing assistants





Five Rights of Delegation

Right Task
Right Circumstances
Right Person
Right Direction/Communication
Right Supervision/Evaluation

The 4 C's of Communication
1. Clear - Does the team member understand what I am saying?
2. Concise - Have I confused the direction by giving too much unnecessary information?
3. Correct - Is the direction given according to policy, procedures, job description, and the law?
4. Complete - Does the delegatee have all the information necessary to complete the task?

6


III.Performance Improvement (Quality Assurance)


A. Quality: the degree to which client care services increase the probability of desired outcomes and reduce the probability of
undesired outcomes given the current state of knowledge

B. Performance improvement/assurance: the process of attaining a new level of performance or quality that is superior to any
previous one

C. Total quality Management: a philosophy that emphasizes a commitment to excellence throughout the organization

D. Six characteristics of total quality management

1. Focus on the customer, i.e., the client

2. Focus on outcomes

3. Total organizational involvement

4. Multi-professional approach

5. Use of quality tools and statistics for measurement

6. Identification of key areas for improvement with an emphasis on SAFETY



E. Mandated by The J oint Commission


IV. Nursing Care Delivery Systems

A. Functional nursing (task nursing)
1. Needs of patients are broken down into tasks
2. Tasks are assigned to various levels of health care workers according to licensure and skill
3. Example: LPN/VNs give medications and UAP (or nursing assistants) give bed baths for one group of patients

B. Team nursing
1. Most common nursing-care delivery system
2. A team of nursing personnel provides total patient care to a group of patients
3. Team leaders supervise client-care teams, which usually consist of an RN, PN, and an unlicensed assistive personnel (UAP)
4. Team leader reviews clients' plans of care and progress with team members during team conference

C. Total care (case method)
1. A registered nurse is responsible for all aspects of care of one or more patients
2. The LPN/VN may be assigned to assist the RN
3. This type of care is usually provided in areas requiring high level of nursing expertise, such as the critical care unit (CCU) or
the post-anesthesia recovery unit (PACU)

D. Primary nursing
1. The registered nurse is responsible for a work load of consistent clients
2. The primary nurse designs, implements and is accountable for the nursing care of those clients during their entire stay on the
unit

E. Practice partnerships
1. An RN and an assistant (UAP, PN, less-experienced RN, graduate nurse, or nurse intern) agree to be practice partners
2. Partners work together on same schedule with same group of clients
3. Senior partner directs the work of the junior partner within the scope of each partner's practice









Remember the steps in the Nursing Process - A Delicious PIE

A=Assessment
D=Diagnosis
P=Planning
I=Implementation
E=Evaluation

7

F. Case management
1. Model for identifying, coordinating, and monitoring the implementation of services needed to achieve desired client outcomes
within a specified period of time
2. Organizes client care by major diagnoses or diagnostic-related groups (DRGs)
3. A collaborative practice team defines the expected outcomes of care and care strategies for a client population by defining
critical paths.
4. A registered nurse manager is assigned to coordinate, communicate, collaborate, problem solve, facilitate and evaluate client
care for a group of clients
5. Case manager usually does not provide direct client care but supervises care provided by licensed and unlicensed nursing
personnel according to a critical path

6. Critical pathways are plans for providing care to the client and family
a) identify desired outcomes
b) state expected amount of time and resources to be used
c) focus on specific diagnoses or procedures that are high volume and or high resource use (and therefore costly)
d) promote collaboration among disciplines (health care professionals)

7. The essential components of case management include
a) collaboration of all health care team members
b) identification of expected patient outcomes with time frames
c) use of principles of continuous quality improvement (CQI) with variance analysis
d) promotion of professional practice

8. Client involvement and participation is key to successful case management

G. Differentiated practice
1. Identifies distinct levels of nursing practice based on defined abilities that are incorporated into job descriptions
2. Structures nursing roles according to education, experience, and competency

H. Client-centered care
1. Registered nurse coordinates a team of multi-functional unit-based caregivers
2. All patient care services are unit-based, including admission, discharge, diagnostic testing and support services
3. Uses unlicensed assistive personnel to perform delegated client care tasks

V. Information & Documentation

A. Types of patient records
1. Problem-oriented medical record (POMR)

a) a decision is made on the nature of the client's problem or problems and these problems are assessed regularly
b) recorded using a standardized format, by narrative notes in the S.O.A.P. format or by flow sheets
c) discharge summary relates the overall assessment of progress during treatment and plans for follow-up care, encouraging
continuity of care .
d) four parts
I. data base: the client's present health status
II. problem list: numbered list of health problem(s)
III. initial plan: plan to help overcome health problem(s)
IV. progress notes: all disciplines chart on the same page

2. Source-oriented
a) most traditional type of charting, with different disciplines charting on separate forms
b) drawback: records become very bulky, very quickly









Documentation has six key components (CO-ACTS)

Confidential
Organized (chronologically)
Accurate
Complete
Timely
Subjective and objective data

8

B. Methods (styles) of charting
1. Narrative charting
a. the nurse records observations, data (including reactions from the client) in a sequential and chronological order
b. baseline charted every shift
c. source-oriented

2. S-O-A-P: problem-oriented charting; comes from a medical model
a. S =subjective; what client tells you
b. O =objective; what you observe, see, etc.
c. A =assessment; what you think is going on based on the data
d. P =plan; what you are going to do

3. D-A-R
a. D =data - collecting information about a problem
b. A =action - the task to be completed about the problem
c. R =response - the client's response to the problem

4. Focus charting
a. charting on an acute condition, a potential problem, a treatment or procedure, or a client behavior
b. components of this type of charting include: information about the condition/problem, action, and client's responses

5. A P-I-E charting - uses the nursing process
a. A =assessment
b. P =problem
c. I =intervention
d. E =evaluation

6. Charting by exception
a. uses flowsheets
b. emphasis on abnormal (or what is abnormal for this particular client); normal routine is presumed as having been done,
without any problems

C. Documentation guidelines
1. General
A. Check that you have the correct chart
B. Record the facts as accurately as possible
C. Chart as you go
D. Never chart for another person
E. Do not mention incident reports
F. Avoid the use of abbreviations - when in doubt, write it out!

I. All health care institutions have a list of accepted abbreviations
II. Refer to the J oint Commission's official "Do Not Use" list of abbreviations

A. Never alter a client's record (altering a client chart is a criminal offense)
B. Six things that nurses must document

I. Assessment
II. Nursing diagnosis and client needs
III. Interventions
IV. Care provided
V. Client response to care
VI. Client's ability to manage continuing care after discharge

2. Legal guidelines for charting
A. electronic health record (EHR) charting
i. never share access or password with another person
ii. change your password frequently
iii. maintain confidentiality of documented information printed from the computer
iv. carefully check your information before you press enter
v. access information for clients under your care only
vi. log off when you are finished
vii. date and time are automatically recorded

9

B. paper-ink
i. DO
write in chronological order
use permanent black ink
chart the time and date for each entry
include consent for or refusal of treatment, client responses to interventions, calls made to other health care professionals
write legibly
cross through the error once, date and initial the change
correct any errors in a timely manner

ii. DO NOT
erase, scratch out or use correction fluid (Liquid Paper or Wite-Out)
document for others or change documentation by others
leave blank spaces
recopy any charting form
make photocopies without permission

VI. Legal Responsibilities
A. Sources of law
1. Federal Regulations
a. The Health Insurance Portability and Accountability Act (HIPAA)
b. The Americans with Disabilities Act (ADA)
c. The Mental Health Parity Act (MHPA)
d. The Patient Self-Determination Act (PSDA)
e. The Uniform Anatomical Gift Act and the National Organ Transplant Act

2. State law - Nurse Practice Act
a. passed by each state legislature to regulate the practice of nursing in that state
b. administered by the board of nursing in each state or jurisdiction
c. scope and responsibilities vary state-to-state, therefore nurses are responsible for knowing regulatory
requirements for nursing in each state where they are practicing
d. Nurse Practice Acts define
i. scope of practice (what the nurse is allowed to do)
ii. nursing titles that are allowed to be used
iii. qualifications for licensure
iv. actions that can or will happen if a nurse does not follow the nursing law

B. Types of law
1. Criminal Law
a. deals with acts of intentional harm to individuals and society as a whole
b. categorized as a felony or misdemeanor
c. the defendant is either guilty or not guilty
d. the burden of proof is "beyond a reasonable doubt"







2. Civil Law
a. deals with disputes between parties or negligent acts that cause harm to others protects the individual rights of people
b. deals with tort law - unintentional, quasi-intentional or intentional torts
c. the burden of proof is "preponderance of the evidence"
d. negligence and malpractice are examples of unintentional torts
i. negligence: a breach of the duty to provide nursing care to the client
ii. malpractice is professional negligence; the unintentional failure of an individual to perform or not perform an act that a
reasonable person would or would not perform in a similar set of circumstances
iii. negligence involves four legal concepts
REMEMBER IT!
A former client sues a nurse for negligence. The client must prove that the nurse
not only committed a breach of duty but that this breach of duty was the
proximate cause of any damages incurred by the client.

10

duty: nurses have a legal obligation to provide nursing care to clients
must meet a reasonable and prudent standard of care under the circumstances
must deliver care as any other reasonable and prudent nurse of similar education and experience would, under similar
circumstances

breach of duty: failure to provide expected, reasonable standard of care under the circumstances (includes errors of omission or
commission)
proximate cause
relationship between the breach of duty and the resulting injury
the injured party must prove that the nurse's action or omission led to the injury

damages: the injury and the monetary award to the plaintiff

VII. Professional Misconduct
A. The impaired professional
1. Remember that the impaired nurse is compromising client care
2. Be sure that the problem exists and can be proven
3. Communicate specific concerns to appropriate persons such as nurse manager or risk manager
4. Document incidents in terms of behaviors, specific times, dates - be objective
5. File a report according to the policies and procedures of the institution

B. Boundary violations
1. Definition: Actions that overstep established interpersonal boundaries to meet the needs of the nurse
2. Guiding principles in determining professional boundaries
a. nurse is responsible for setting and keeping boundaries
b. nurse must avoid simultaneous professional and personal relationship with same person
c. nurse must avoid flirtation

C. Consequence of professional misconduct
1. A board of nursing must protect the public and is required to take action against the licenses of nurses who have exhibited
unsafe nursing practice.
2. A state board of nursing may imposes penalties for professional misconduct, ranging from probation, censure, and
reprimand, to suspension or even revocation of licensure.

VIII. Client Rights
A. Privacy
1. Confidential information may only be released by signed consent of the client
2. Unauthorized release of client data may be an invasion of privacy
3. Health Insurance Portability and Accountability Act of 1996 (HIPAA)
a. provides individuals with access to their medical records and more control over how their personal health information is used
b. provides privacy protection for consumers of health care

4. Health care workers must release information when a court orders it or when statutes require it (as in child abuse or communicable
diseases)
5. Special regulations apply to release of information about psychiatric illness or HIV

B. Advance directives
1. As part of the Omnibus Budget Reconciliation Act (OBRA) of 1990, Congress established the Patient Self-Determination (PSDA);
this requires states to provide written information to clients outlining their rights to make health care decisions

2. These rights include:
a. the right to refuse or accept treatment
b. the right to formulate advance directives

3. Nurses and other members of the health care team are required to
a. assess the clients knowledge of advance directives and their status regarding the advance directive process
b. provide information and assistance to the client in developing advance directives
c. plan care that incorporates the clients decisions regarding advance directives Three common advance directives are:
i. living will - identifies what a client wishes for his care should he become unable to communicate these wishes
11

ii. durable power of attorney for health care decisions - the client has appointed a person to make decisions about their
care if they are unable to do so.
iii. do not resuscitate (DNR) status - this has been expanded to include identification of medications that may be given
without any defibrillation attempts (comfort measures only)
Follow the facility policy on obtaining and implementing DNR orders
Generally, the order must be written by a physician; some facilities may have a policy to allow verbal orders under
specific conditions
The order must be communicated clearly to all personnel caring for the client
The client or her or his health care proxy can withdraw the order at any time
A nurse who attempts to resuscitate a client with a valid DNR order may be committing battery

C. Refusal of treatment - competent clients may refuse treatment, even life-sustaining treatment

D. Freedom from protective devices (restraints)
1. Physical restraints/safety devices require a signed, dated health care provider's order specifying the type of restraint and a
time limit

2. Types of protective devices
a. Chemical - central nervous system depressants, paralytics
b. Physical - vests restraints, side rails

3. Use the least restrictive form of restraint/safety device
4. Know agency guidelines for use of restraints
5. You must document three factors
a. Why restraints/safety devices were used
b. How the client responded
c. Whether the client needs continued protective device

6. Restraining clients without consent or sufficient justification may be interpreted as false imprisonment

E. Informed consent
1. Basic requirements
a. Capacity
b. Voluntariness
c. Information
i. health care provider is legally obligated to provide a complete description of the treatment/procedure, description of the
potential harm, pain, and discomfort that may occur, options for other treatments, and the right to refuse treatment

ii. the nurse should verify client comprehends and consents to care

2. The client must understand
a. Purpose of the procedure and expected results
b. Anticipated risks and discomforts
c. Potential benefits
d. Any reasonable alternatives
e. That consent may be withdrawn at any time

3. Requirements for signing an informed consent form
a. Must be signed by a competent adult
b. Individual who is signing must be able to understand the information given by the health care professional (if the person is
unable to understand the information due to language barrier or hearing impairment, a trained medical interpreter must be present)

F. Transition planning - recognizes that clients are not discharged from care but moved across the continuum to another level of care

IX. Ethical Practice
A. Ethics
1. A theory or system of moral values, based on the ideas of right and wrong, good and bad
2. It governs our relationships with others
3. Influenced by our personal beliefs and values

12

B. Ethical principles
1. Respect for others: The right of the individual to make their own decision
2. Autonomy: Respect for an individuals right to self determination
3. Nonmaleficence: the principle of "do no harm"
4. Beneficence: do good and avoid evil
5. J ustice: the principle of fairness
6. Veracity: the ethical duty to tell the truth
7. Confidentiality: the respect for individual privacy
8. Fidelity: loyalty, faithfulness and honoring commitments





























QUIZ 1

Nurses have a legal duty to account for every task that they delegate. True False

Nurses have a legal duty to carry out the provider's written orders, whether they agree with them or not. True False

A nurse has a legal duty to report a co-worker who is violating a client's privacy. True False

A nurse has a legal duty to provide nursing care to the client, within the scope of the nurse's education and experience. True False

A nurse has a legal duty to abide by the scope of practice in the state's nurse practice act. True False

A nurse has a legal duty to meet a reasonable and prudent standard of care under the circumstances. True False

A nurse has a legal duty to provide Good Samaritan care at the site of a traffic accident. True False

A nurse has a legal duty to avoid negligence by either omission or commission. True False

A nurse has a legal duty to avoid professional misconduct. True False

A nurse has a legal duty to decide whether a client may or may not be restrained. True False

A nurse has a legal duty to prove that he or she was not the "proximate cause" of damage to a client. True False

A nurse has a legal duty to encourage the client to sign the consent form if the nurse believes the procedure will really benefit the client. True False

A nurse has a legal duty to explain (or verify that someone has explained) risks, consequences, and benefits to the client. True False

A nurse has a legal duty to advocate for the client and protect the client's autonomy as far as possible. True False

A nurse has a legal duty to use the most secure form of restraint if the provider orders restraints. True False



13





























































1. A client is diagnosed with confusion and anemia. While caring for this client, which task should the practical nurse assign to an
unlicensed assistive person (UAP)?
A. Test stool for occult blood
B. Assess mental status
C. Check for skin color changes
D. Assist client to select foods high in iron from the menu

2. A practical nurse (PN) is having difficulty reading a health care provider's written order from the prior shift. What action should the nurse
take?
A. leave the order for the oncoming staff to follow-up or interpret
B. call the pharmacy for assistance in the interpretation
C. ask the registered nurse (RN) to notify the health care provider for written clarification
D. contact the manager to report the problem with the legibility of the order

3. The nurse manager requests that the practical nurse (PN) staff form a task force to investigate and develop potential solutions to this
problem: excessive documentation with resultant overtime. The PN staff are to present a report on solutions at the next staff meeting.
This nurse manager's leadership style would be described as autocratic
A. autocratic
B. participative
C. laissez-faire
D. group

4. Which of these clients should a nurse assign to an unlicensed assistive personnel (UAP)?
A. a client diagnosed with peripheral vascular disease and an ulceration of the lower leg a new
B. admission with a history of diagnoses of transient ischemic attacks and dizziness
C. an older adult client with hypertension and a self-report of non-compliance
D. a preoperative client with a history of asthma awaiting surgery for an adrenalectomy

5. A nursing student is discussing the delegation of tasks to an unlicensed assistive personnel (UAP) with a preceptor. Which task
assigned to the UAP by the student indicates that the student is confused about delegation and needs help?
A. collect a sputum specimen before breakfast
B. provide discharge teaching
C. assist a client to ambulate after lunch
D. feed a two year-old in traction

6. A manager makes all decisions and rarely asks for staff input. The best description of this nurse manager's leadership style is
A. autocratic or authoritarian
B. ultraliberal or communicative
C. laissez faire or permissive
D. participative or democratic

7. Which one of these tasks should be assigned to the certified nursing assistant (CNA) by the practical nurse (PN)?
A. giving enemas until clear to a middle-aged man scheduled for a colonoscopy
B. assisting a client with colostomy care within 24 hours after surgery
C. performing a first time post-op dressing change on the abdomen
D. feeding a client who has difficulty swallowing within the initial 24 hours after a stroke

8. A practical nurse (PN) from the pediatric unit is assigned to work in a critical care unit. Which of these clients might the PN offer to be
assigned to provide care?
A. a young adult client who is in skeletal traction after a motor vehicle accident
B. a new admission of a young adult who reports left sided weakness from a probable stroke
C. a middle-aged client diagnosed with a possible myocardial infarction
D. a client diagnosed with multitrauma and with a history of a newly implanted pacemaker

9. A client diagnosed with head trauma is in a nonresponsive state. Vital signs are stable and breathing is regular and spontaneous. Which
documentation accurately describes the client's condition?
A. comatose, breathing unlabored
B. Glasgow Coma Scale 8, respirations regular
C. Glasgow Coma Scale 13, no ventilator required
D. appears to be sleeping, vital signs stable

14





























































10. A client exhibiting confusion has been placed in extremity restraints by an order of the health care provider. Which care task for this client
should a nurse assign to an unlicensed assistive personnel (UAP)?
A. monitor circulation to hands and feet
B. identify basic comfort needs during the shift
C. evaluate the client for safety issues
D. assist with activities of daily living

11. Upon completing a review of the admission documents, a nurse identifies that an 87 year-old client does not have an advance directive. What
action should the nurse take?
A. give information about advance directives
B. refer this issue to social services department
C. assume that the client wishes a full code
D. record this information on the chart

12. The practical nurse (PN) is caring for a client in isolation. Which task should the PN assign to an unlicensed assistive personnel (UAP)?
A. reinforce isolation precautions to any visitors
B. observe of the client's reaction to the isolation environment
C. monitor the client's thoughts about being in isolation
D. evaluate the visitors compliance with isolation measures

13. An unlicensed assistive personnel (UAP), who usually works on a medical-surgical unit, is assigned to work on an ortho-neuro unit. Which of
these questions should the UAP be asked by the nurse prior to making any assignments?
A. "How long have you been a UAP?
B. "Do you have your competency checklist for review?
C. "What type of care did you give on the medical-surgical unit?
D. "Are you comfortable caring for adults with broken bones?

14. A nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg
splint. Which activity should the UAP be involved with?
A. assist the client to transfer from a bed to a chair
B. screen for findings of redness overlying joints
C. encourage independence in self-care
D. monitor the client's response to activity

15. Which of these clients would be most appropriate for a practical nurse (PN) who has been reassigned to a different acute care unit to accept?
A. A client, admitted for a possible stroke, has unstable neurological findings
B. A confused client whose family complains about the nursing care given after the clients surgery
C. An older adult client diagnosed with cystitis has an indwelling urethral catheter
D. A trauma victim with multiple lacerations requiring complex dressings

16. When walking past a clients room, a nurse hears an unlicensed assistive personnel (UAP) talking to another UAP. Which one of these
statements requires further intervention by the nurse?
A. "Ill come back and make the bed after I go to the lab."
B. "If we work together we can get all of the client care completed."
C. "This client seems confused, we need to watch the client closely."
D. "Since I am late for lunch, would you do my client's accucheck glucose test?"

17. A nurse has been assigned to four residents. Which client should be seen first on the initial shift rounds?
A. an 86 year-old male diagnosed with hypertension has a reported BP of 180/90 after learning that a close friend had to be hospitalized
B. an 81 year-old female with a history of coronary artery disease (CAD) reported to have had dyspnea, nausea, and unusual discomfort in
the upper back
C. a 70 year-old male with history of heart failure (HF) reported going to the bathroom too much after taking a water pill
D. a 94 year-old female diagnosed with peripheral artery disease (PAD) cramp-like pains in both calf muscles during activities in physical
therapy


15























POINTS TO REMEMBER

Nursing practice is governed by legal restrictions and professional standards.
What a nurse can do depends on the nurse practice act in the state in which the nurse is licensed.
Each state defines what constitutes professional misconduct.
The state board of nursing has the authority to impose a penalty for professional misconduct.
Penalties include probation, censure, reprimand, suspension or revocation of the license.
Standards of nursing practice apply to all nurses in all practice settings.
Standards of care are based on facility policy and procedure, nursing education, experience, and publications of professional
nursing associations and accrediting groups.
To avoid negligence:
Know the standard of care
Deliver care that meets the standard and follows the facility's policies and procedures
Document care accurately and in a timely manner
The only employee of a health care organization who may be the legal witness to the signing of an advance directive is a clinical
social worker. It is at the discretion of each health care facility as to whether or not this is done. Always check the policy of your
facility. A relative or heir to the estate should never be the witness to the signing of an advance directive.
Ethics guide the nurse toward client advocacy and the development of a therapeutic relationship.
Ethical dilemmas result from conflicts in values.
An effective leader modifies his/her style according to the situational requirements.
Final responsibility for any delegated task resides with the registered nurse or the PN if the PN delegates to the UAP.
The registered nurse must monitor delegated tasks and evaluate the outcomes.
The practical nurse is responsible for client care assignments to be completed in a timely manner

18. To whom should the measurement and documentation of vital signs in a long-term care facility be assigned?
A. volunteer
B. registered nurse (RN)
C. practical nurse (PN)
D. unlicensed assistive personnel (UAP)

19. Which task for an older adult client who has a diagnosis of hyperglycemia should the nurse assign to an unlicensed assistive
personnel (UAP)?
A. check sensation in the extremities when in the room
B. observe for mental status changes every 4 hours
C. reinforce findings of hyperglycemia as the client asks
D. test blood sugar by peripheral sticks every 2 hours

20. Which newly admitted client would be appropriate for an assignment to an unlicensed assistive personnel (UAP)?
A. a client diagnosed with severe depression
B. a known heroin addict who exhibits findings of the withdrawal process
C. a client with a history of chronic peripheral vascular disease
D. a client with diagnoses of dehydration and anorexia

16



I. Safety

A. The Quality and Education for Safety in Nursing (QSEN) project

1. QSEN's goal: meet the challenge of preparing future nurses who will have the knowledge, skills
and attitudes (KSAs) necessary to continuously improve the quality and safety of the
healthcare systems within which they work

2. KSA for Safety: minimize the risk of harm to patients and providers through both system
effectiveness and individual performance

3. Safety is the primary concern when caring for clients




B. Fire, electrical and radiation safety

1. Fire safety

a. prevention

b. types of fire extinguishers and their uses

c. response to fire

d. examples of facility rescue plans:

i. P-R-C

Protect clients from injury

Report the fire

Contain the fire


ii. A-R-C-E

Activate fire alarm system

Rescue or remove clients

Contain fire by closing doors and windows

Extinguish flames with fire extinguishers

If there is a fire, remember R-A-C-E:
R=Rescue or remove clients
A=Activate fire alarm system
C=Contain fire by closing windows and doors
E=Extinguish flames (with fire extinguishers)


2. Electrical safety

3. Chemical safety: for all health care institutions, the Occupational Safety and Health
Administration (OSHA) suggests following its Material Safety Data Sheets (MSDS)

4. Radiation safety



C. Poison control

1. High risk groups are young children and older adults with impaired eyesight and diminished
memory
Caution! Do not induce vomiting if the poison contains alkaline or acid agents. Such poisons
include lye, household cleaners, oven cleaner, furniture polish, metal cleaners, battery acids, or
17

petroleum products.

2. Goals of therapies

a. before the body absorbs poison, either remove it, (either through vomiting or gastric lavage)
or neutralize it (using activated charcoal, for example)

b. give supportive care (manage shock, seizures, aspiration)

c. give the correct antidote to neutralize poison

d. speed the elimination of any absorbed poison




D. Fall & injury prevention

1. Assesses client for risk factors
Use the mnemonic FRAIL MOM & DAD for assessing the geriatric client in the primary care
setting:
Falls
Relative or caregiver strain
Activities of daily living
Incontinence
Living situation

Memory Impairment
Oculo-otic impairment (visual and auditory problems)
Malnutrition

Drugs
Advance directives
Depression

2. Guidelines to prevent client falls

3.
Assess age-specific safety risk factors




4. Safe patient-handling and movement

a. principles of manual client handling (to be used in conjunction with "safe patient handling"
techniques when handling and moving clients)

i. widen the base of support, keeping feet apart

ii. place bed at correct height (waist level)

iii. keep work directly in front of you (to avoid twisting the spine)

iv. keep client as close to your body as possible to minimize reaching


b. "safe patient handling"

i. use principles of body mechanics (above)

ii. know how the equipment works and match to the needs of the client and limitations of the
room/area



5. Sharps injuries
If you are stuck by a needle or other sharp object or get blood or other potentially infectious
materials in your eyes, nose, mouth, or on broken skin, you should immediately flood the exposed
area with water and then clean any wound with soap and water or available skin disinfectant.
18

Report the incident to your employer and seek medical attention right away

6. Biohazards

a. examples of biohazards in the workplace include chemotherapeutic agents, exposure to latex,
bloodborne pathogens

b. refer to OSHA for guidelines on handling and disposing of hazardous materials



E. Security plan

1. Required by the Joint Commission

2. Purpose

a. to manage the physical and personal security of clients, staff (including
addressing the risks of violence in the workplace) and individuals coming
to the organization's facilities

b. security of the established environment, equipment, supplies, and
information


II. Infection

A. Types of infections

1. Community acquired (CAI) - if the client develops an infection outside a health care
facility, e.g., a football player develops a staph infection following use of improperly
cleaned sports equipment

2. Health-care Acquired (HAI) - the client develops an infection while admitted to a health
care facility, e.g., a client develops a urinary tract infection following urinary
catheterization


Infection Type Examples
central nervous system infections meningitis, encephalitis
childhood & vaccine-preventable
infections
Varicella (chicken pox), diphtheria, tetanus, mumps
(infectious parotitis), pertussis (whooping
cough), poliomyelitis, rubella (German
measles), rubeola (measles)
gastrointestinal infections staphylococcal food poisoning, botulism
acute bacterial, viral gastroenteritis salmonella, gastroenteritis, viral hepatitis, Clostridium difficile
hemolymphatic infections mononucleosis, cytomegalovirus,
toxoplasmosis
respiratory infections influenza, tuberculosis, histoplasmosis, pharyngitis, scarlet fever,
rheumatic fever, pneumonia
sexually transmitted infections gonorrhea, chlamydia, syphilis, genital herpes, chancroid, AIDS,
genital warts
urinary tract infections
cystitis, pyelonephritis
19


B. Stages of an infectious process

1. Incubation period

2. Prodromal period

3. Illness period

4. Convalescent period


C. Complications of infection

1. Relapse - some infections may reactivate, often because they were not treated thoroughly or the
client did not comply

2. Local complications - local infections may form abscesses

3. Systemic complications - pathogen may enter bloodstream and cause septicemia



D. Chain of infection

1. Causative agent (pathogen)

2. Reservoir

3. Portal of exit - way to get out of host

4. Transmission route - way to reach new host

5. Portal of entry - way to gain entrance

6. Susceptible host

7. After the pathogen enters the host, illness depends on 4 factors

a. number of pathogen organisms

b. duration of the exposure

c. health status of host, including age, physical, mental, and emotional health

d. genetic status of host's immune system




III. Infection Control

A. Medical and surgical asepsis

1. Medical asepsis (or "clean technique")

2. Surgical asepsis

20


B. Precaution types

1. Standard precautions

a. used for care of all clients

b. used to prevent the spread of microorganisms

c. synthesize the major features of universal precaution and body substance isolation

i. universal (blood and body fluid) precautions - designed to reduce the risk of
transmission of bloodborne pathogens

ii. body substance or contact precautions - designed to reduce the risk of transmission of
pathogens from moist body substances


d. apply to

i. blood

ii. all body fluids, secretions, and excretions, except sweat, regardless of whether or not
they contain visible blood

iii. non-intact skin

iv. mucous membranes


e. designed to reduce the risk of transmission of microorganisms from both recognized and
unrecognized sources of infection in hospitals

f. personal protective equipment (PPE) - designed to reduce the risk of transmission of
microorganisms from both recognized and unrecognized sources of infection in health care
settings

i. gloves

ii. masks

iii. gowns

iv. protective eyewear

v. head coverings






2. Transmission-based precautions

a. (direct and indirect) contact precautions

i. direct contact transmission: microorganisms are transferred from one infected person
to another person without a contaminated intermediate object or person

ii. indirect contact transmission: transfer of an infectious agent through a contaminated
intermediate object or person (especially contaminated hands of health care workers)

iii. gown and gloves are required for all contact

iv. epidemiologically important organisms for contact transmission, e.g., VRE
(vancomycin resistant enterococcus); Clostridium Difficile (C. Diff.) infection, excessive
wound drainage; fecal incontinence
With Clostridium difficile (C. diff) infections, you must wash your hands with soap and water because
alcohol-based hand sanitizer does not kill the C. difficile spores.


b. droplet precautions - transmission involves contact of the conjunctivae or the mucous
membranes of the nose or mouth of a susceptible person with large particle droplets
containing microorganisms generated from someone who either exhibits a disease or
who is a carrier of the microorganism
21


i. respiratory droplets are generated when an infected person coughs, sneezes, or talks,
or during procedures such as suctioning, endotracheal intubation, cough induction by
chest physiotherapy and cardiopulmonary resuscitation

ii. when close contact (typically within 3 feet or less) between the source client and a
susceptible person is required, the use of a standard surgical mask is required

iii. epidemiologically important organisms for infectious agents transmitted through the
droplet route include group A streptococcus (for the first 24 hours of antimicrobial
therapy), adenovirus, rhinovirus, Neisseria meningitis, pertussis, influenza virus


c. airborne precautions - used when microorganisms dispersed through the air over long
distances remain infective over time and distance

i. preventing the spread of airborne pathogens requires

use of special air handling and ventilation systems

wearing respiratory protection with NIOSH-certified N95 or higher level respirator for
all healthcare workers


ii. epidemiologically important organisms for infectious agents transmitted through the
airborne route include rubeola virus (measles), varicella-zoster virus (chickenpox),
Mycobacterium tuberculosis


d. neutropenic precautions - used to prevent infection in clients who have neutropenia (low
white blood cell counts) or are immunocompromised

i. health care workers will wear gowns, masks, gloves when providing care

ii. strict hand washing

iii. client is in a private room

iv. visitors are restricted

v. no raw vegetables or fruits

vi. client should be instructed to bathe daily



C. Immunization - raises host resistance, defenses, and immunity

1. Acquired immunity

a. any form of immunity that is not innate

b. obtained during life

c. natural or artificial

i. naturally acquired immunity is obtained by

the development of antibodies resulting from an attack of infectious disease

the transmission of antibodies from the mother through the placenta to the fetus
or to the infant through the colostrum


ii. artificially acquired immunity is obtained by

vaccination

injection of an antiserum, also called an immune globulin such as a hepatitis
immune globulin, after hepatitis exposure


22


d. passive or active

i. passive immunity results from antibodies that are transmitted through

the placenta to the fetus

the colostrum to an infant

injection of antiserum (immune globulin) for treatment or prophylaxis


ii. passive immunity is not permanent and does not last as long as active immunity

iii. active immunity is when the body produces its own antibodies as a reaction to
exposure to an antigen






D. Disease reporting

1. Reporting of nationally notifiable diseases

a. voluntary - to the Centers for Disease Control and Prevention

b. mandated (by legislation or regulation) - at the state level


2. The list of notifiable diseases varies from state-to-state, but internationally quarantinable
diseases, e.g., cholera, plague, yellow fever, are reported in compliance with the World
Health Organization's International Health Regulations


IV. Emergency Preparedness and Response

A. Overview of emergency preparedness and response

1. An emergency can be brought on by a disaster, which is any event initiated by a
person or by nature, or a combination of both

2. A formal emergency preparedness plan of action is required to respond to a disaster

a. personal and family preparedness plan

b. formal institutional plan

i. internal disasters: events that occur within the healthcare facility, e.g., fire or
chemical spill

ii. external disasters: natural or man-made events that occur outside the
healthcare facility, e.g., tornado or airplane crash



3. The Federal Emergency Management Agency (FEMA) identifies

a. four disaster management phases:

i. mitigation

ii. preparedness

iii. response

iv. recovery


b. three levels of disaster, ranging from minor (Level III) to major (Level I)

i. Level I Disaster - requires state or federal assistance due to massive levels and
breadth of damage

ii. A Level II disaster - requires regional efforts and mutual aid from surrounding
communities

iii. Level III disaster - involves minor to average levels of damage; local emergency
response personnel and organizations are able to contain and deal effectively
23

with the disaster and its aftermath



4. Specific hazards associated with disasters

a. bioterrorism

b. chemical emergencies

c. radiation emergencies

d. mass casualties

e. natural disasters and severe weather

f. recent outbreaks and incidents, e.g., salmonella




B. Triage

1. In the community setting, for a disaster or war situation

a. brief assessment of victims, classifying them according to:

i. the severity of the injury

ii. urgency of treatment

iii. place for treatment


b. various rating systems exist and nurses should know and understand the rating
systems

i. treated first: individuals who have life-threatening injuries that are readily
correctable

ii. treated last: individuals who have no injuries, or noncritical injuries, and who are
ambulatory, as well as individuals who are dying or are dead



2. In the health care agency - emergency department triage involves dividing those who
need care into one of the following three categories:

a. emergent individuals who have life-threatening injuries and need immediate
attention are given the highest priority

b. urgent individuals with non-life-threatening injuries

c. nonurgent individuals with no immediate complications and who can wait for
treatment



Biological weapons, which include any organism or toxin found in nature that can be used to
incapacitate or kill an adversary, can be characterized by the following attributes: low visibility; high
potency; accessibility; and easy delivery.

C. Bacterial agents

1. Anthrax


a. causative agent: Bacillus anthracis
24


b. exposure:

i. integumentary system (most common): direct skin contact with spores; in nature, contact with
infected animals or animal products

ii. respiratory tract: inhalation

iii. gastrointestinal system: eating undercooked or raw infected dairy products

iv. oropharyngeal


c. exposed individuals do not spread infection

d. clinical indicators of anthrax infection: symptoms can appear within 7 days of coming in contact with the
bacterium for all types of anthrax

i. skin: localized itching followed by papular lesions that turns vesicular; becomes black eschar after 7 to 10
days

ii. inhalation: initially low-grade fever, cough, malaise, fatigue, myalgias, sweating, and chest discomfort
but progressing to high fever, respiratory distress, shock and death within 24 to 36 hours


e. treatment

i. decontamination

remove clothing; do not pull anything over the head

decontaminate in area outside of treatment area: using large amounts of water,
shower with soap or wash with soap and running water; flush eyes with running
water for 15 minutes


ii. antibiotics

ciprofloxacin hydrochloride (Cipro), drug of choice

penicillin G procaine (Wycillin)

doxycycline (Vibramycin)

note: do not use extended-spectrum cephalosporins or
trimethoprim/sulfamethoxazole due to resistance of anthrax to these drugs



f. vaccine available, but not to the general public



2. Plague

a. causative agent: Yersinia pestis

i. zoonotic infection carried on rodents and their fleas

ii. Y. pestis destroyed by sunlight and dryness, although bacterium can survive for 1 hour after release


b. exposed individuals can spread infection

c. disease states: bubonic plague, pneumonic plague and septicemic plague

d. clinical indicators of pneumonic plague

i. rapidly deteriorating pneumonia

ii. fever, chest pain, bloody or watery sputum


e. treatment: individuals with the plague need immediate treatment or death will occur within 24 hours after the
first symptoms

i. isolate exposed individuals

ii. treat with antibiotics
25


streptomycin

gentamycin (Garamycin)

doxycycline (Vibramycin)

ciprofloxacin hydrochloride (Cipro)


iii. supportive treatment: oxygen, IV fluids and respiratory support are usually needed


f. vaccine: not available


D. Viral agents

1. Smallpox


a. causative agent: variola virus

b. exposed individuals can spread infection via direct contact or prolonged face to face contact

c. clinical indicators of smallpox disease

i. initially (sometimes contagious): high fever (101 to 104 degrees Fahrenheit), malaise, head and body
aches

ii. rash (most contagious): start as small, red spots on the tongue and mouth; the spots become open
sores and, then, spread to the rest of the body becoming pustules that crust and scab-over

iii. individuals are contagious until all scabs have fallen off


d. treatment

i. no specific drug treatment or cure

ii. if the smallpox vaccine is given with 1 to 4 days after exposure to the disease, illness may be prevented
or be less severe

iii. individuals diagnosed with smallpox and everyone they have had close contact with will need to be
isolated


e. vaccine:

i. has not been given routinely in the U.S. since 1972

ii. it is unknown how long immunity lasts after immunization




2. Viral hemorrhagic fever (VHF)

a. used to describe a severe multisystem syndrome caused by four different families of viruses, including
arenaviruses, filoviruses, bunyaviruses, and flaviviruses

i. the vascular system is damaged and the bodys ability to regulate itself is impaired

ii. usually accompanied by hemorrhage, but this is not the life-threatening aspect of these diseases


b. disease states include: Ebola, Marburg, yellow fever, Argentine hemorrhagic fever
26



c. the viruses are zoonotic, residing in and totally dependent on their animal hosts

i. an animal reservoir host, e.g., rodents

ii. arthropod vector, e.g., ticks, mosquitoes


d. clinical indications of VHF

i. initially: high fever, muscle aches, weakness

ii. severe disease: subcutaneous and internal bleeding, bleeding from body orifices; shock, delirium, seizures,
and coma


e. treatment:

i. supportive therapy

ii. no effective treatment or cure


f. vaccine: vaccines only for yellow fever and Argentine hemorrhagic fever



E. Biological toxins ( chemical agents )

1. Sulfur mustard or mustard gas (H, HD, or HT): a blister agent/vesicant

a. human-made chemical warfare agent

i. powerful irritant and blistering agent that damages the skin, eyes, and respiratory tract

ii. damages DNA

iii. may smell like garlic, onions, or mustard

iv. effects of sulfur mustard usually last 1 to 2 days in environment, but can be present for
weeks to months in a cold climate

v. rarely fatal but potentially long term health effects


b. exposure to a vapor (released into the air), an oily-textured liquid (released into the water), or
to a solid form

c. clinical indications of exposure

i. skin: redness and itching immediately after exposure eventually resulting in yellow blistering

ii. eyes: irritation, pain, swelling, and tearing with mild to moderate exposure; severe
exposure can cause light sensitivity, pain, or blindness lasting up to 10 days

iii. respiratory tract: runny nose, sneezing, hoarseness, bloody nose, sinus pain, shortness of
breath, and cough

iv. digestive tract: abdominal pain, diarrhea, fever, nausea, vomiting


d. post exposure treatment: remove sulfur mustard from the body

i. antidote: none
27


ii. shower with soap or wash with soap and running water thoroughly; flush eyes with running
water for 15 minutes but do not cover eyes with bandages

iii. inhalation: leave area of exposure; get fresh air, provide oxygen, and support breathing





2. Sarin (GB) nerve gas

a. human-made chemical warfare agent

i. clear, colorless, tasteless liquid that can evaporate into a odorless gas

ii. extremely toxic, acts very quickly

iii. breaks down the enzyme acetylcholinesterase, which results in excessive concentrations of
acetylcholine in nerve synapses and leads to overstimulation of parasympathetic nerves in the
smooth muscles

iv. impairs normal functioning of nervous system

v. can cause seizures, loss of consciousness, and respiratory failure in minutes


b. exposure via inhalation, ingestion, and/or absorption through eyes and skin

c. clinical indications of exposure

i. low to moderate doses: runny nose, watery eyes, blurred vision, drooling, cough and chest
tightness, diarrhea, drowsiness, weakness, headache, changes in heart rate and blood pressure

ii. large doses: loss of consciousness, seizures, paralysis, respiratory failure


d. post-exposure treatment

i. antidotes: soldiers typically have a antidote kit containing these two medications

atropine (Atropine): binds to one type of acetylcholine receptor on the post-synaptic nerve

pralidoxime chloride (2-PAM chloride): blocks sarin from binding to any free
acetylcholinesterase


ii. decontaminate before transport to treatment facility

flush eyes first for 15 minutes

remove clothing (without pulling over the head) and shower with soap and large amounts of
water or 0.5 % solution of sodium hypochlorite (bleach), or use absorbent powders such as
flour or talcum powder


iii. do not induce vomiting if swallowed; administer activated charcoal

iv. note: can contaminate rescuers by direct contact or off-gassing vapor of contaminated skin or
clothing

v. supportive measures: maintain airway, assist ventilation, and protect client; administer
diazepam for seizure activity




3. Strychnine

a. the primary natural source: the plant Strychnos nux vomica

i. a strong poison; typically used to kill rats

ii. white, odorless, bitter crystalline powder

iii. very small amount able to cause extremely serious adverse effects

v. impairs functioning of neurotransmitters resulting in severe, painful muscle spasms without
28

affecting consciousness


b. exposure

i. injection (mixed with street drugs)

ii. ingestion (food or water contamination)

iii. inhalation (release into air, smoked or snorted in street drugs)


c. clinical indications of strychnine poisoning

i. initially or with low level exposure:

apprehension, agitation, painful muscle spasms

the client is conscious and in extreme pain


ii. later findings or high level exposure: uncontrollable arching of back and neck, hyperreflexia
and muscle twitches, rigid extremities, seizures, difficulty breathing, brain death


d. post exposure treatment: most victims die of asphyxia before reaching the hospital

i. no specific antidote exits

ii. decontaminate in area outside of treatment area

remove clothing; do not pull anything over the head to remove

using large amounts of water, shower with soap or wash with soap and running water

flush eyes with running water for 15 minutes


iii. do not induce vomiting or give fluids to drink

iv. supportive care

IV fluid resuscitation

cooling therapy for fever

anticonvulsants (diazepam, phenytoin, Phenobarbital), antispasmodic agents and muscle
relaxants




4. Ricin

a. a plant protein toxin derived from the beans of the castor plant

b. exposure: through air, food or water

i. in the form of a powder, a mist, a pellet

ii. may also be dissolved in water or weak acid


c. clinical indications: effects depend on whether it was inhaled, ingested, or injected; death can
occur within 36 to 72 hours of exposure

i. inhalation: respiratory distress, fever, cough, nausea, chest tightness; pulmonary edema

ii. ingestion: vomiting and diarrhea that may become bloody; dehydration; low blood pressure;
may include hallucinations, seizures and multi-system failure

iii. skin and eye exposure: redness and pain


d. post exposure treatment

e. treatment: get ricin off or out of the body as quickly as possible

i. no available antidote

ii. decontamination

shower with soap or wash with soap and running water thoroughly
29


flush eyes with running water for 15 minutes


iii. inhalation:

leave area of exposure to get fresh air

provide oxygen and support breathing


iv. ingestion

do not induce vomiting; remain NPO

administer large dose of activated charcoal

gastric lavage

aggressive fluid resuscitation and electrolyte repletion

if necessary, medicate to control seizures and treat hypotension




F. Radiation emergencies

1. Causes of radiation emergencies

a. radioactive material contaminates food/water

b. a bombing or destruction of a nuclear reactor

c. exploding a nuclear weapon

d. nuclear weapon attack

e. radiation dispersal device (dirty bomb)


2. Contamination via

a. wounds

b. ingestion

c. inhalation


3. Severity of signs and symptoms of radiation sickness depends on how much radiation has been
absorbed

a. mild radiation sickness (absorbed dose of 1-2 Gy): nausea and vomiting, headache, fatigue,
weakness within 24 to 48 hours after exposure

b. very severe radiation sickness (absorbed dose of 3.5-5.5 Gy): nausea and vomiting less than 30
minutes after exposure to radiation, dizziness, disorientation, hypotension; usually fatal


4. Treatment

a. get inside and stay in an undamaged building

b. decontamination

i. remove clothing and shoes

ii. gently washing with soap and water


c. for damaged bone marrow:

i. filgrastim (Neupogen): a protein-based medication which promotes the growth of white
blood cells

ii. pegfilgrastim (Neulasta): also increases white blood cells and prevents subsequent
infections


d. for internal contamination (chelating agents)

i. potassium iodide (KI): used to prevent absorption of radioiodine in the thyroid gland
30


ii. Prussian blue: a type of dye that binds to particles of radioactive elements (cesium and
thallium)

iii. diethylenetriaminepentaacetic acid (DTPA): binds to particles of the radioactive elements
plutonium, americium and curium


e. supportive treatment for infections, headache, fever, diarrhea, dehydration; end-of-life care



G. Mass casualties

1. Explosions or blasts can cause unique patterns of injury

a. primary: injury from over-pressurization force impact

b. secondary: injury from projectiles

c. tertiary: injury from displacement of victim by the blast wind

d. quaternary: all other injuries, i.e., burns, toxic exposures


2. Predominant injuries involve multiple penetrating injuries and blunt trauma

3. All bomb events have the potential for chemical and/or radiological contamination

4. Treatment

a. lung injuries

i. high flow oxygen sufficient to prevent hypoxemia via non-rebreather mask, CPAP or ET tube

ii. ensure tissue perfusion but avoid volume overload

iii. prompt decompression for clinical evidence of pneumothorax or hemothorax


b. abdominal injury: clinical signs can be subtle at first; observe for acute abdomen or sepsis

c. ear injuries: tinnitus or deafness will warrant written communication

d. admit 2
nd
and 3
rd
trimester pregnancies for monitoring

e. crush injuries: sudden release of a crushed extremity may result in reperfusion syndrome
(acute hypovolemia, renal failure, metabolic abnormalities)

i. IV fluid replacement (up to 1.5L/hour)

ii. to help prevent renal failure: mannitol to maintain diuresis at at least 30 mL/hour; dialysis
may be needed

iii. to treat acidosis: IV sodium bicarbonate until urine pH reaches 6.5 (to prevent myoglobin
and uric acid deposition in the kidneys)

iv. to treat hyperkalemia/hypocalcemia: calcium gluconate 10% 10 mL or calcium chloride
10% 5 mL IV over 2 minutes; sodium bicarbonate 1 mEq/kg IV push (slowly); regular insulin
5-10 unites and D5O 1-2 ampules IV bolus; kayexalate 25-50g with sorbitol 20% 100 mL PO
or PR

v. monitor injured areas for the 5 Ps: pain, paresthesia, paralysis, pulse, pallor

vi. monitor for sepsis


f. injuries resulting in non-intact skin or mucous membrane exposure

i. hepatitis B immunization (within 7 days)

ii. tetanus toxoid vaccine




H. Natural disasters and severe weather

1. Clustered under this category are: earthquakes, extreme heat, floods, hurricanes, tornadoes,
31

tsunamis, volcanoes, wildfires, landslides/mudslides, winter weather

2. Traumatic events following natural disasters are characterized by a sense of horror, helplessness,
serious injury, or the threat of serious injury or death

3. Emergency preparedness includes being ready for any type of hazard


A school nurse monitors a child with a history of tonic-clonic seizures. The school nurse should inform teachers that if the child falls to the floor
and experiences a seizure while in the classroom, the most important action to take during the seizure would be which action?

Provide privacy as much as possible to minimize frightening the other children
Move any chairs or desks at least three feet away from the child
Place the hands or a folded blanket under the head of the child
Note the sequence of movements with the time lapse of the event

The priority during seizure activity is to protect the child from physical injury. Place a pillow, folded blanket or the hands under the child's
head to prevent concussion or further head trauma. The other body parts are at less risk for injury.

A child is admitted with a diagnosis of suspected meningococcal meningitis. Which admission orders should a nurse implement first?

Institute seizure precautions
Notify of changes in neurologic status
Place on droplet precautions
Monitor vital signs every 30 minutes

Meningococcal meningitis is a bacterial infection that can be communicated to others. The initial therapeutic management of acute bacterial
meningitis includes use of respiratory/secretions droplet precautions, initiation of antimicrobial therapy, monitor neurological status along
with vital signs, institute seizure precautions, and lastly maintain optimum hydration. The first action for nurses to take is initiate necessary
droplet precautions to protect themselves and others from the possible infection. Viral meningitis, on the other hand, usually does not
require protective measures of isolation.


The nurse is attending an inservice about healthcare-associated infections (HAIs). Which factor is identified as the most common cause of HAIs
in the acute care setting?

Presence of an indwelling urinary catheter
Decreased mobility for a week or longer
Inadequate fluid intake over 72 hours
Existence of an intravenous access device

Catheter-associated urinary tract infections is the most common HAI in the acute care hospital setting. Surgical site infections, bloodstream
infections and pneumonia are the other categories of infections.

Which nursing action is a priority for a client during a seizure?

observe the sequence of movements
protect the client from injury
suction the oropharynx
loose restrictive clothing

The priority during a seizure is to protect the client. Next, it is a priority to observe, and then record what movements are seen during a
seizure. The diagnosis and subsequent treatment often rests on the seizure description. Suctioning may be done after seizure activity, as well
as loosening clothing.

Parents call the emergency department to report that their toddler has swallowed a granular drain cleaner. The triage nurse instructs them to
call for emergency transport to the hospital. The practical nurse anticipates that the triage nurse suggested giving the toddler sips of which
substance while waiting for an ambulance?

Lemonade
Tea
Coca-Cola or other similar beverage
Water

Small amounts of water (or milk) will dilute a granular material if performed within 30 minutes after ingestion. The other substances have
the potential to cause a reaction with the drain cleaner, which would result in more damage.
Test-taking Tips: Remember that safety always takes priority when it is an option and the question is about the priority.

32


There is an external disaster situation and an overflow of victims is being sent to an urgent care facility. The licensed
practical nurse understands that the registered nurse will use which type of leadership skill to manage this situation?

A. Share decision-making with others
B. Assume a decision-making role
C. Use a laissez-faire approach
D. Seek input from staff

Authoritarian (or autocratic) leadership assumes that decision-making is the role of the leader, with little input by subordinates. This
leadership style is very efficient and best used in emergency and crisis situations.


A client is admitted with diagnosis of a right upper lobe infiltrate and to rule out active tuberculosis (TB). What type of transmission-based
precautions should a nurse institute?

A. Airborne
B. Standard
C. Droplet
D. Contact

Airborne precautions include an OSHA mandated/NIOSH certified respirator, negative pressure in a private room with the door closed or a
semiprivate room with both clients diagnosed with the same disease (called cohorts), and limited movements or transport of the client. If
these clients have to leave the room, they must wear a mask. A tight fitting, high-efficiency mask such as the particulate HEPA filtered
respirator mask is required when caring for clients who have suspected communicable disease of the airborne variety. Active TB, measles
and chicken pox require airborne precautions. Droplet precautions are used for influenza, whooping cough and mumps. Contact precautions
are for active HSV lesions, VRE, MRSA, lice, scabies, RSV and impetigo.


When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event that these do not
match, what is the priority action of the nurse?

A. Change whichever item is incorrect to the correct information
B. Notify the admissions office and wait to apply the bracelet
C. Make a corrected identification bracelet on the unit for the client
D. Use the bracelet and admission form until a replacement is supplied

The admissions office has the responsibility to verify the clients identity and keep all the records in the system consistent. Changes made by
the nurse put the client at risk for misidentification. Using an incorrect or unofficial identification bracelet is unsafe. Making a new bracelet
on the unit is usually inappropriate.


When a client is diagnosed with active tuberculosis, the public health department is to be notified for what reason?

A. Contacts need to be traced and screened
B. Follow-up with additional tests is
C. The incidence of tuberculosis is tracked correct response
D. Disease statistics need to be maintained

Active tuberculosis is a reportable disease because persons who had contact with the client must be traced, evaluated for the disease and
possibly treated prophalactally. Statistics are kept; however, that is not the reason for required reporting.

The 75 year-old client has an appointment for a screening scan for osteoporosis. The nurse understands that which finding is a risk factor for
osteoporosis?

A. Drinks two ounces of red wine daily
B. Has used steroids for arthritis for more than two years
C. Reports late menarche and menopause
D. Walks two miles every other day

A dual energy x-ray absorptiometry (DXA) scan is used to screen for osteoporosis. While there are many causes of osteoporosis, the use of
steroids over time increases the risk for osteoporosis. Other risk factors include low bone mass, poor calcium absorption, lack of weight-
bearing exercise, and moderate to high alcohol ingestion. A late menopause would have increased the client's supply of estrogen, which
would help prevent osteoporosis.





33

Which bed position is preferred to use with a client who is on a fall risk prevention protocol in an extended care facility? .

A. lower side rails up with the bed placed facing the doorway and against the wall
B. head slightly elevated, and the bed height in the lowest position
C. bed height in the lowest position, wheels locked, and the bed placed against the wall
D. all four side rails up and the wheels locked with assignment of the bed closest to door

It is no longer advisable to use or have both lower side rails on a bed. Placement of the bed against the wall permits getting out of bed on
only one side. Locking the wheels keeps the bed from sliding. Keeping the bed in the lowest position provides a shorter distance to the
ground if the client chooses to get out of bed. If using side rails, the two top rails and one bottom rail pulled up is acceptable. If all 4 are
pulled up, an order for protective restraints is needed and usually has to be renewed every 48 to 72 hours, along with more frequent and
specific documentation.

Which type of transmission-based precaution is appropriate to use when the nurse is performing postmortem care on a deceased client who
was diagnosed with methicillin resistant staphylococcus aureus (MRSA)?

A. Airborne
B. Droplet
C. Compromised host
D. Contact

The resistant bacteria of MRSA remain alive for up to three days after death. Therefore, contact precautions must still be implemented. Also,
the deceased body needs to be labeled so that the funeral home staff can protect themselves as well. Gown and gloves are required, and
masks if splashes are anticipated.


The nurse is reviewing discharge orders for a client who has been prescribed daily warfarin (Coumadin) for the next six months. Which of these
points should be emphasized during the discharge instructions?

A. Report any changes in the color of your stools and urine
B. Use a nonsteroidal antiinflammatory drug for headache pain
C. Use a soft toothbrush
D. Eliminate all dark green leafy vegetables from your diet

The client should notify the health care provider for color changes to stool or urine; blood will make the stool dark brown or black and the
urine more of a rusty red color. The client should use a soft-bristled toothbrush to avoid irritating the gums. Dark green leafy vegetables
contain vitamin K, which plays a major role in blood clotting; the client should restrict, but not eliminate these foods from the diet. Taking
NSAIDs with warfarin can greatly increase the risk of bleeding; alternative pain medications should be discussed with the health care
provider.

A client who has an infected leg wound from a motorcycle accident, has returned home from the hospital. The client was ordered to keep the
affected leg elevated and is on contact precautions. The client asks a home health nurse Can my friends come to visit me? The appropriate
response from the nurse should be which of these?

A. There are no special requirements for your visitors.
B. Visitors must wear a mask and a gown.
C. Visitors should wash their hands before and after touching you anywhere.
D. Gloves should be worn if visitors touch you.

Gown and gloves are worn by persons coming in contact with the wounds or infected equipment. Visitors should wash their hands before
and after touching the client.

A nurse is assigned to a client with human immunodeficiency virus (HIV) infection. The client also has a secondary herpes simplex 1 (HSV 1)
infection. The nurse should care for the client based on knowledge that which of the following options is the most likely cause of the HSV 1
infection?

A. Emotional stress caused by the chronic diseases
B. Poor oral hygiene often associated with such infections
C. Reaction to the multiple prescribed medications
D. Immunosuppression caused by the hiv infection

Associate HIV with the word "immunosuppression." The person's weakened immune system results in frequent secondary infections, like
herpes simplex virus 1 (HSV 1), candidiasis, cytomegalovirus (CMV) and pneumocystis carinii pneumonia (PCP). Poor oral hygiene would not
cause HSV, nor would medications.





34

A nurse is stuck in the hand by an exposed needle left in a client's bed linen. What immediate action should the nurse take?

A. Immediately wash hands with
B. Notify the supervisor and risk management
C. Look up the policy on needle sticks
D. Contact employee health services

The immediate action of vigorously washing the hands will help remove possible contamination. If the site bleeds it will help cleanse the
contaminate. Then, the sequence of actions would be options "notify", "look up", and "contact."

A health care provider has written an order for a nurse to change the dressings and clean the incision on a postsurgical client. Which process
should a nurse use to clean the surgical incision?

A. Scrub lightly around the incision without touching the incision itself
B. Clean from the top to the bottom of the incision using slow downward strokes
C. Start at the incision and clean in an outward direction from the incision
D. Use a circular motion to clean from the bottom to the top of the incision

In order to prevent the introduction of microorganisms into the surgical incision during cleaning, follow the principle to clean from the area
of least contaminated to most contaminated. Recall tip: clean to dirty.

The nurse is working on a medical-surgical unit. The nurse understands that contact precautions, in addition to standard precautions, should be
implemented for a client with which of these health concerns?

A. Mononucleosis
B. Herpes simplex virus (HSV)
C. Scarlet fever
D. Viral pneumonia

Health care workers should use standard precautions with all clients. Contact precautions are required to protect against either direct or
indirect transmission of an illness. Clients with the viral infection HSV should be placed on contact precautions until the lesions have crusted
over. Mononucleosis and viral pneumonia require only standard precautions. Clients diagnosed with scarlet fever will be placed on droplet
precautions for about 24 hours.


The nurse is teaching a new nurse about techniques used to protect clients. In response to a question, the nurse clarifies that surgical asepsis
differs from medical asepsis in that surgical asepsis requires staff?

A. Wash hands prior to applying a clean dressing
B. Wear gloves when giving parenteral medications
C. Double bag soiled linens removed from the room
D. Maintain sterility during intravenous catheter insertion

All invasive procedures or entry into a bodily orifice or vessel require sterile technique, which is a part of surgical asepsis. Three options are
actions related to medical asepsis.

During the collection of data about the home care for a client with Alzheimer's disease, a priority for a nurse to document is which piece of
information?

A. Any nutritional intake changes
B. The use of over the counter medications
C. The presence of environmental hazards
D. The familys use of respite care

A safe environment for the client with increasing memory loss is a priority focus of home care. Note that the other options would be included
in the documentation with importance being in this order: "environmental hazards", "over the counter medications", "intake changes" and
then "respite care." The question is asking the reader to prioritize.







35

Points to Remember
Safety

Safety is the primary concern when caring for clients.

The goal of the Quality and Education for Safety in Nursing (QSEN) project is to meet the challenge of preparing future nurses
who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the
healthcare systems within which they work.

Falls are the most frequent cause of injury for elderly clients in acute care.

Know the institution's plan for fire drills and evacuation.

Know the emergency phone number for reporting fire.

Know locations of all fire alarms, exits, and extinguishers.

ARCE, RACE, or PRC - find out which one is the procedure suggested by your institution.

Turn off all oxygen supplies in the area of the fire.

In a fire, never use an elevator - use the stairs.

In a fire, close all doors and windows.

Only certain electrical outlets access the emergency generators in a power failure; know which ones they are.

Know your agency's policy for cleaning up a biohazardous spill.

Safety devices, such as restraints, are used only as a last resort.

Use the least restrictive immobilizing device possible for the situation.

Poisons

Never induce vomiting unless instructed to do so by a poison center or health care provider.

If you suspect someone has taken poison, take the poisonous substance with you to the emergency room.

Call the local poison control center to determine appropriate treatment for the specific poison.

Infection

Infection control with the use of standard precautions, transmission precautions and medical and surgical asepsis decreases
the spread of infection.

The major sites for healthcare acquired infections (HAI) are urinary and respiratory tracts, blood, and wounds.

All healthcare acquired (HAI) infections that occur in hospitals must be tracked and recorded by risk management.

Hand washing is the most effective method of preventing infection; friction is the most important variable.

Standard precautions are used for contact with all body fluids (except sweat).

Standard precautions are used for all clients and transmission precautions are used for all clients with transmittable organisms.

Special (N95) respirator masks are necessary to care for clients under airborne precautions who have tuberculosis or other
airborne infectious conditions.

Protective (neutropenic) isolation is used for clients with immunosuppression and low white blood counts.

Disease reporting of "notifiable diseases" is mandated at the state level (through legislation or regulation).

Emergency Preparedness and Response

Triage in a health care setting is different from that in a community or field setting.

Specific hazards associated with disasters include

bioterrorism, e.g., anthrax, plague (bacterial agents): smallpox, viral hemorrhagic fever (viral agents)

chemical emergencies

radiation emergencies

mass casualties

natural disasters and severe weather

recent outbreaks and incidents, e.g., salmonella, E. coli, H1N1 (influenza), melamine (in food products)


36



I. Family Planning

A. Contraception - the voluntary prevention of pregnancy

1. Attitudes toward contraception

a. shaped by religious beliefs and culture

b. influenced by family or social attitudes

c. affected by socioeconomic status


2. Contraception only works if the user

a. accepts the method

b. understands it

c. is motivated to use it correctly


3. Practical nurse's role in family planning

a. reinforce teaching by health care providers on methods of contraception

b. encourage questions

c. provide opportunity for woman (and partner) to discuss feelings about contraception

d. have user explain chosen method ("say back")

e. clarify any misunderstandings





B. Sterilization

1. Surgical procedures intended to render the person infertile

2. Most states prohibit sterilization of minors or mentally incompetent persons

3. Methods

a. male: vasectomy


b. female: removal of ovaries or uterus, tubal ligation



4. Informed consent by a health care provider must include:

a. an explanation of risks, benefits, and alternatives

b. a statement that sterilization is meant to be permanent and irreversible

c. a mandatory 30-day waiting period from the time the consent is signed until surgery may occur

d. wording in person's native language or interpreter must be provided



37

C. Interruption of pregnancy (abortion)

1. Types

a. therapeutic: medical indications; physical or psychiatric reasons

b. elective (voluntary): nonmedical indications

c.
spontaneous (involuntary): initially occurs without medical intervention

i. 1 in 4 pregnancies ends in "miscarriage"


ii.
bleeding and loss of the pregnancy = loss of a hoped for, dreamed of baby

provide information and support women and their families experiencing a perinatal
loss

nurses offer supportive statements, such as "I am sorry for your loss" or "I am sorry
this is happening to you"





2. Methods

a. first trimester: menstrual extraction; dilation and curettage (D&C); suction or vacuum aspiration;
mifepristone (RU-486) and misoprostol (Cytotec) - when 8 weeks pregnant or less

b. second trimester: dilation and evacuation (D&E); saline injection; prostaglandins (vaginal)


3. Possible complications

a. most common: infection; retained products of conception or intrauterine blood clots; continuing
pregnancy; cervical or uterine trauma; and excessive bleeding; disseminated intravascular coagulation
(DIC)

b. D&C - may perforate uterus

c. suction - may invert uterus

d. saline injection - fluid and electrolyte imbalance and cardiac dysrhythmias


4. Legal issues: laws vary regarding abortion in each state of practice


II. Uncomplicated Pregnancy

A. Preconception health - reinforce teaching regarding

1. Lifestyle for optimal health

2.
Balanced diet, including folic acid (which is critical prior to pregnancy and during the first trimester)

a. recommendation: women of childbearing age should have a daily intake of 400 mcg

b. if there is iron deficiency anemia, then the daily dose of folic acid is 1 mg/day


3. Fertility awareness

4. Stress management

5. Avoidance of harmful or teratogenic substances

6. Safe sex

7. Risk awareness - tobacco, alcohol and drug use, lifestyle, home remedies

8. Parenting responsibilities - environmental, social, work, financial


B. Conception

1. Factors influencing conception

a. hormone cycles

b. cervical mucus

c. sperm number and motility

d. ovulation
38


e. general health of both partners


2. Occurs when ovum is penetrated by sperm to result in fertilization

3. Male gamete determines sex of child at fertilization

4. Fertilization typically occurs in outer third of the fallopian tube

5. Single or multiple fertilizations are possible



C. Implantation

1. Usually occurs 7 to 10 days after fertilization

2. Trophoblast secretes enzymes which enable it to burrow into endometrium

3. Trophoblast develops chorionic villi which secrete human chorionic gonadotropin (HCG)

a. hCG inhibits further ovulation by stimulating secretion of estrogen and progesterone

b. nausea, vomiting, "morning sickness" in first trimester is attributed to hCG

c. hCG is detected by lab tests for pregnancy as early as 6 days after conception in blood and 26 days
after conception in urine

i. over-the-counter pregnancy kits give varying results

ii. women should be advised to seek advice from health care provider early in the event of an ectopic
pregnancy (which will result in a positive reading)




D. Fetal development

1. Embryo

a. most critical developmental period

b. developing areas most vulnerable to teratogens

c. the basic structure of all major body organs and main external features are all formed


2. Fetal development

3. Fetal-placental unit

a. oxygenation

b. nutrition

c. hCG levels

d. screening for fetal problems

i. daily count of fetal movements

ii. non stress test

iii. basic ultrasound screening






39


E. Maternal health in pregnancy

1. All physiological systems must adapt in pregnancy

2. Psychologic adaptations

a. maternal emotional responses

b. paternal emotional responses

c. maternal role tasks of pregnancy

d. other factors that affect adaptation

i. support systems - grandparents, siblings, others in household, partners

ii. cultural influences

iii. religious beliefs

iv. developmental needs of family and parents

v. previous experience with pregnancy

vi. health beliefs

vii. economic factors

viii. stress management or coping resources

ix. socioeconomics - housing, transportation, finances, proximity to health care agencies




F. First trimester - data collection

1. Initial history

a. general health

b. family health/partner's health history

c. current health status

d. reproductive summary (gravida, parity)

i. past pregnancies

ii. current pregnancy (subjective findings)


e. social factors - housing, transportation, finances, proximity to health care facility

f. lifestyle, including risky behaviors

g. nutritional intake - foods, beverages, amounts, times eaten

h. cultural and religious practices

i. risk factors of pregnancy



40


2.
Initial physical exam

a. baseline vital signs and weight/height - by PN

b. head-to-toe assessment/general well-being assessment - parts by PN

c. breast examination - by health care provider

d. abdominal examination - by health care provider

e. pelvic exam/pap smear/cultures as indicated by health care provider


g. PN role is to obtain, document, and report client stated findings
f. findings of pregnancy

i. presumptive/possible

subjective findings and objective signs reported by woman, including amenorrhea, fatigue, nausea
and vomiting, breast changes, elevation of basal body temperature, skin changes

findings may be caused by conditions other than pregnancy


ii. probable: changes observed by examiner

Chadwick's sign: increased vaginal vascularity contributes to bluish purple hue of the cervix, vagina
and vulva

Hegar's sign: increased vascularity and softening of uterine isthmus

Goodell's sign: cervical softening caused by stimulation from estrogen and progesterone


iii. positive: signs attributed only to presence of fetus, e.g., fetal heart tones, visualization of fetus,
palpating fetal movements



3. Laboratory tests

a. urinalysis for glucose, protein, blood, and bacteria

b. urine or blood hCG levels

c. complete blood count

d. blood types and Rh factor

e. rubella titer

f. screening for syphilis

g. cervical culture for Chlamydia and gonorrhea

h. hepatitis B surface antigen (HBsAG)

i. hepatitis B surface antibody (HBsAB)

j. Pap smear

k. tuberculin skin test

l. HIV antibody (with client permission)


Blood Types Rh Factor


41


4. Psychological assessment

i. emotional response to pregnancy - ambivalence is a normal expectation during first trimester

ii. family relationships - with partner, parents, other children

iii. support systems

iv. developmental tasks/maternal tasks

v. learning needs


5. Gestational assessment performed by health care provider

i. ultrasound to confirm (dates versus measurements/crown-rump length)

ii. best determined in the first trimester scan (most accurate +/- one week)

iii. confirms viability

iv. identifies multiple gestation


6. Nursing care

i. build rapport

ii. discuss pregnancy confirmation

iii. calculate due date: Naegele's Rule (when first day of last normal period = N, then due date is N plus 7 days,
minus 3 months, plus 1 year)
Example: If June 10, 2012 = first day of last menstrual period
6 10 2012
-3 +7 +1
3 17 2013
Then estimated date of birth (EDB) = March 17, 2013



iv. discuss maternal physical changes

v. review development of embryo and fetus

vi. return scheduling - plan antepartal schedule of visits

vii. review and reinforce - identify learning needs, refer as needed


viii. risk assessment, with recommendations

ix. recommend prenatal multivitamins, as well as folic acid and iron supplements (first trimester may have
tolerance problems due to "morning sickness")

x. review anticipatory guidance

discomforts and remedies

breast tenderness - wear firm, supportive bra

fatigue - frequent periods of rest; balanced diet and iron supplements to prevent
anemia, dry toast for morning sickness

nausea - small, frequent meals including dry crackers and/or toast with tea; avoid
greasy, fried foods

rest and exercise (including Kegel exercise)
42


diet and fluid intake

medications - avoid tobacco, alcohol, other substances

safety - avoid hot tubs, virus exposure, contagious diseases

referrals - to childbirth or other classes

warning signs of problems during pregnancy




7. Role of expectant woman and partner

i. keep appointment schedule (usually monthly visits unless complications arise)

ii. maintain healthy lifestyle

iii. follow diet and take recommended vitamins

iv. cope safely with discomforts

v. discuss sexual feelings and needs

vi. promptly report warning signs in pregnancy



8. Second trimester - routine monthly data collection

a. report of current findings

b. visualize fetal outline

c. palpate fetal outline using Leopold maneuvers (performed by RN and health care provider)

d. fetus

i. activity (date of quickening)

ii. heart rate


e. gestational age assessment - PN to have knowledge of these but not necessarily perform

i. estimated after duration of pregnancy and estimated date of birth (EDB) are determined

ii. determined by

first uterine size estimate

fetal heart first heard

date of quickening

current fundal height

current week of gestation

ultrasound

reliability of dates



f. physical exam by health care provider

i. compare weight, vital signs to baseline

ii. fundal height
uterus becomes an abdominal organ
height of fundus in centimeters is approximately same as number of weeks gestation




g. laboratory tests

i. urinalysis for protein, glucose and ketones

ii. quad screen at 16 to 18 weeks gestation - to test for chromosomal and congenital malformations

human chorionic gonadotropin (hCG)

alpha-fetoprotein (AFP)

estradiol (E2)
43


inhibin A


iii. gestational diabetes screening (24 to 28 weeks gestation)

non-fasting 1 hour (50 g) glucola screening performed; if greater than 140 mg/dL then next
step is 3 hour oral glucose tolerance test (OGTT)

OGTT - diagnostic for GDM when (2) out of the (4) values meet or exceed normal limits


iv. viral screening for HIV, hepatitis, etc., if indicated

v. tuberculin test (can be done in first or second trimester only)

vi. possible amniocentesis - usually scheduled between the 15th and 18th week of pregnancy


h. psychological data collection

i. interest turns to fetus and its well-being

ii. emotional response

iii. start initial birthing classes


i. nursing care

i. discuss birth plan

ii. offer anticipatory guidance related to

adapting employment to motherhood

safety

discomforts and remedies

travel, exercise, nutrition

sexual relations

childbirth education

body image changes

problems presented by woman or partner



j. role of expectant woman and partner

i. keep appointments (monthly)

ii. verbalize concerns

iii. modify lifestyle as needed; eat balanced diet

iv. use safe remedies, such as small, low-fat meals for heartburn

v. discuss emotional responses and birth plan

vi. enroll in and attend childbirth education

vii. develop prenatal attachment, prepare other children for new siblings

viii. report warning signs



9. Third trimester - regular data collection

a. current health status

b. comfort and mobility

c. physical examination

i. comparison to baseline

weight gain pattern

vital signs


ii. fundal growth
44


iii. fetal assessment

kick counts

fetal heart rate

assessing the passenger , including presentation, position and size of fetus


iv. pelvic examination

v. observe for fluid retention (indicating preeclampsia, also called pregnancy-induced hypertension)

vi. test maternal deep tendon reflexes of the extremities



REMEMBER IT
The delivery process is described in these terms:

Fetal Station: the relationship between the presenting part of the baby with the mother's pelvis
Fetal Lie: the relationship between the head to tailbone axis for both the fetus and the mother
Fetal Attitude: the relationship of the fetal body parts to one another
Fetal Presentation: portion of the fetus that enters the pelvic inlet first (cephalic, breech, shoulder)


d. laboratory tests

i. urinalysis for protein, glucose, ketones

ii. antibody screen at 28 weeks gestation if client is Rh-negative

iii. cervical culture for group B streptococcus at 34 to 36 gestation

iv. hemoglobin and hematocrit


e. psychological data collection

i. partner supports in childbirth classes

ii. anticipatory excitation of birth

iii. coping with third trimester physical discomforts


f. nursing care

i. reinforcing information and education presented by RN, physician and/or certified nurse midwife

ii. administer Rh immune globulin to Rh-negative woman (24 to 28 weeks) to prevent erythroblastosis
fetalis

iii. offer anticipatory guidance related to

discomforts and remedies

body mechanics and safety

birth options, feeding choices, plans for newborn care

recognizing onset of labor

reportable warning signs



g. role of expectant woman and partner

i. keep appointments (visits scheduled every two weeks or weekly)

ii. prepare for role change; support each other; discuss sexual needs

iii. use safe remedies for discomforts (such as lateral posture for sleep)

iv. practice relaxation and breathing techniques; perform fetal movement count daily

v. follow dietary and fluid advice

vi. maintain safety in daily activities

vii. meet psychological tasks
45


viii. arrange hospital or home birth, plan newborn feeding; learn newborn needs

ix. recognize signs of labor with proper actions

x. report warning signs



III. Uncomplicated Labor and Birth

A. Processes of labor

1. Factors affecting labor include the five P's: passageway, passenger, powers, position and psyche

a. passageway, i.e., bony pelvis and soft tissues of cervix, pelvic floor, vagina, and introitus

i. inlet

ii. outlet

iii. size

iv. types


b. passenger (fetus)

i. fetal head diameter

ii. position

iii. presentation

iv. station


c. powers

i. primary

uterine contractions
frequency
duration
intensity
rest phase

responsible for effacement and dilation of cervix


ii. secondary (bearing down efforts)

aids in expelling fetus

diaphragm and abdominal muscles



d. position of laboring woman

i. for comfort and safety

ii. fetus has better oxygenation if mother lies on her side

iii. determined by woman's preference

iv. constrained by condition of woman and fetus, environment, and health provider's
confidence in assisting birth in a specific condition or position


e. psychology of birth





2. Early signs of labor versus true labor

3. Duration of stages and phases varies with parity, fetal presentation, position and station

4. Maternal systems adaptations

a. reproductive

i. effacement

vaginal part of cervix progressively shortens and its walls thin
46


effacement is noted as a percentage from 0% (non-effaced) to 100% (fully effaced)


ii. cervical dilation: progressive enlargement of the cervical os from less than 1 centimeter to 10
centimeters (dilation complete at 10 centimeters)


b. cardiovascular

i. as labor progresses, cardiac output increases between contractions

ii. BP rises with contractions and with voluntary bearing down

iii. BP can vary with mother's position, anxiety and pain

iv. pulse rate rises slowly and progressively


c. respiratory

i. mother consumes more oxygen

ii. pain or anxiety can cause hyperventilation

iii. respiratory alkalosis, hypoxia or hypocapnia can occur


d. renal

i. uterus may squeeze ureters and impede urine flow

ii. trace amounts of protein in urine are common


e. gastrointestinal

i. decreased peristalsis and absorption

ii. stomach is slower to empty (gastric emptying is delayed)

iii. nausea and vomiting are common, expected


f. musculoskeletal

i. diaphoresis, fatigue, proteinuria and possible increased temperature cause marked increase in
muscle activity

ii. backache, joint aches

iii. leg cramps


g. endocrine - progestin levels drop and as a result the labor process begins



5. Laboring mother's behavioral changes are affected by

a. stage and phase of labor

b. psychological responses to pain

c. preparation for labor

d. presence of support person

e. coping style

f. culture

g. previous childbirth experience

h. feelings about this pregnancy



6. Fetal adaptations



a. mechanisms of labor (cardinal movements)
i. engagement

ii. descent

iii. flexion
47


iv. internal rotation

v. extension

vi. external rotation

vii. expulsion



b. fetal circulation

i. decreases when uterus contracts

ii. maximum oxygenation during rest phase between contractions

iii. fetal monitoring




B. Labor and Birth (intrapartum)

1. First stage of labor: latent phase - lasts approximately 8 hours for the primipara and 4 to 5 hours for
the multipara

a. data collection

i. history

ii. critical data
due date
onset, frequency and duration of contractions
membranes intact or leaking
gravida and parity


iii. general health history

iv. reproductive history

v. prenatal care

vi. social history

vii. lifestyle - risky behaviors

viii. allergies - medications, foods, environment

ix. family history

x. childbirth preparation

xi. risk factors including

problems identified on antepartal record

preterm labor - effective, ineffective actions

reduced or absent fetal activity - first noticed

prolonged ruptured membranes - the longer the membranes have been ruptured,
the greater the possibility for infection

acute health problems - respiratory, circulatory
48


infection - acute/chronic

bleeding with pain (risk abruptio placenta)

bleeding without pain (risk placenta previa)

substance abuse - type, frequency, history





b. physical examination

i. baseline vital signs compared to antepartal chart

ii. weight (do not accept a verbal weight)

iii. intake and output within last 8 to 24 hours

iv. contractions - mild and irregular, more than 10 minutes apart lasting about 30 seconds


v. Leopold's maneuvers - by RN, certified nurse midwife or physician/health care provider

vi. fetal activity and heart rate

vii. pelvic exam - by health care provider

confirm true labor

identify fetal position, presentation, station

membranes - may be intact or ruptured


viii. head-to-toe assessment - by health care provider



c. laboratory tests - compare values to antepartal records

i. complete blood count (CBC)

ii. blood type and Rh factor

iii. urinalysis for protein



d. psychological data

i. response of client to mild irregular contractions

ii. expectation and knowledge about birth and labor process

iii. learning needs

iv. developmental level

v. support systems available during labor

vi. cultural influences on labor and care

vii. behavioral responses, i.e., excited, talkative

viii. strategies used to cope with pain of labor



e. nursing care: role of PN is assisting the registered nurse (RN), certified midwife and physician

i. promote comfort through ambulation, position changes, shower, whirlpool

ii. reinforce information about learning needs for labor and birth

iii. review birth plan
49


iv. understand information about intermittent/continuous electronic fetal monitoring



f. role of mother and/or support person, which may include a doula

discuss questions and concerns

use appropriate relaxation methods for early labor

adapt the environment to cultural beliefs

mother to empty bladder frequently

report physical changes promptly

participate in the labor process



2. First stage of labor: active phase - lasts approximately 4 hours for the primapara and 2 hours for the
multipara

a. data collection

i. physical

compare current vital signs to baseline; check hourly

monitor contractions: increased intensity, moderate to strong by palpation, more
regular about 3 to 5 minutes apart lasting 45 seconds

observe membranes: intact or ruptured

measure fetal heart rate every 15 to 30 minutes (or continuously)



ii. psychological: emotional response to increasing frequency, duration and intensity of
contractions


iii. behavioral changes
inwardly-focused
limits interactions with others
absorbed in the work of labor



b. nursing care: role of PN is to assist the RN, certified nurse midwife and physician/health care
provider

i. encourage ambulation or position changes until membranes rupture

ii. promote drug-free comfort measures, e.g., effleurage, massage, hydrotherapy, relaxation and
paced breathing, labor support

iii. parenteral analgesia (meperidine [Demerol], fentanyl [Sublimaze], butorphanol [Stadol],
nalbuphine [Nubain]) - birth should occur less than 1 hour or more than 4 hours after
administration of opioids (to decrease chance of CNS depression in newborn)

iv. support laboring client's decision for regional anesthesia (pudendal block, epidural block, spinal
block or paracervical nerve block)
50




c. role of mother and/or support person

i. continue effective breathing and relaxation techniques

ii. alter mother's position for comfort

iii. maintain bed rest (lateral position preferred) after membranes rupture; lateral position
promotes optimal uteroplacental and renal blood flow and increases oxygen saturation

iv. communicate questions and concerns

v. report physical changes promptly




3. First stage of labor: transitional phase - approximately 10 to 15 minutes in length

a.
data collection

i. physical

health care provider performs pelvic exam

dilation 8 to 10 centimeters

membranes ruptured; check character of amniotic fluid

fetal descent and station

monitor vital signs every 15 to 30 minutes, compare with baseline

monitor contractions: strong palpation, more painful, every 1.5 to 2 minutes, lasting 60
to 90 seconds

measure fetal heart rate every 15 minutes

findings of approaching delivery:
perineum will bulge with contractions
nausea and vomiting
trembling
strong urge to push and a feeling of need to defecate
diaphoresis
increasing bloody show



ii. psychological and emotional responses

emotional response to increased pressure and contraction intensity

irritability, tension, loss of control

amnesia between contractions

feelings of loss of control;


iii. behavioral responses

loss of control

inability to follow directions during contractions

irritability and tension



b.
nursing care: role of PN is to assist the RN, certified nurse midwife and physician/health care
51

provider

i. maintain safety, e.g., side rails up and in lateral position

ii. follow standard precautions

iii. monitor for urge to bear down - suggest open-glottal breathing with contractions to avoid a
bearing-down effort

iv. minimize hyperventilation

v. promote rest and relaxation techniques between contractions



c. role of mother and/or support person:

i. communicate physical changes promptly

ii. continue effective breathing techniques

iii. maintain lateral position as much as possible

iv. participate in the labor process




4. Second stage of labor: complete dilation through birth - approximately 30 to 50 minutes for the
primipara and 20 minutes for the multipara

a. data collection and observation

i. physical

fetal crowning


increased bloody show

mother pushes involuntarily - open glottis pushing is recommended

fetal heart rate response to contractions and pushing (expected decrease), check every
5 to 15 minutes

strong contractions to palpation every 2 to 3 minutes lasting 60 to 90 seconds



ii. psychological

emotional response to perineal pressure

relief at labor's end


iii. behavioral responses

irritable, apprehensive in early second stage

excited

responsive

focused on newborn
52


more in control after birth



b. nursing care: role of PN is to assist the RN, certified nurse midwife and physician/health care
provider

i. pushing can either follow the mother's spontaneous urge or be directed by health care provider
(physician or certified nurse midwife)

ii. position mother to aid delivery

iii. assist with delivery of the newborn

clear newborn airway - first priority; newborns are nasal breathers

dry newborn skin - wrap in warm blanket to maintain warmth

place newborn with mother as appropriate - usually over mother's chest or upper
abdomen

inform the couple of the newborn's gender and condition

reinforce any information on the repair of episiotomy or lacerations


iv. monitor uterine contraction; fundus should be firm post-delivery

v. follow Standard Precautions


c. role of mother and/or support person

i. breathe effectively

ii. push with and relax after contractions - contractions occur every 2 to 3 minutes and last 60 to 90
seconds

iii. follow directions to stop pushing

iv. hold and bond with newborn




5. Third stage of labor: placental separation and expulsion - lasts approximately 5 to 30 minutes

a. data collection

i. physical

sudden trickle or gush of blood from vaginal opening

umbilical cord lengthens

uterine contractions continue


ii. psychological

emotional response to newborn's birth

concern for condition of newborn


iii. behavioral responses

continues to focus on newborn

may ask support person to assist in needs



b. nursing care: role of PN is to assist the RN, certified nurse midwife and physician/health care
provider

i. monitor maternal vital signs

ii. monitor effects of oxytocic drugs

iii. document promptly and accurately


c. role of mother and/or support person

i. refrain from pushing during placental stage
53



ii. hold and talk to newborn

iii. initiate lactation if planned




6. Fourth stage of labor: maternal mother (1 to 2 hours after birth)

a. data collection

i. physical

monitor vital signs (every 15 minutes) for comparison to intrapartal data

observe for:

uterine contraction, reflected in firm fundus

vaginal bleeding: lochia, number and percent saturation of pads

trembling or chills - expected and normal

bladder distention - relieve quickly if present

fundal height - midline and above umbilicus is normal

venous thrombosis

observe episiotomy or repaired lacerations


ii. psychological

emotional response to birth

early interaction with newborn

sense of peace and excitement


iii. behavioral response

family interaction is increased; talkative

notification of others about newborn

may report varying degrees of fatigue or simply sleep

may report uterine cramp-like discomfort

attachment process begins with the newborn



b. nursing care: role of PN is assisting the registered nurse (RN), certified midwife and physician

i. assist to void, monitor urinary output, avoid bladder distension

ii. massage the fundus if soft or flabby

iii. monitor bleeding and clots

iv. inspect the perineum for bruises, swelling

v. help with hygiene, perineal care

vi. monitor oxytocic drugs or IV fluids

vii. offer food and fluids

viii. help with ambulation

ix. monitor recovery from regional anesthesia
54


x. administer pain medication as prescribed

xi. facilitate first breast feeding if indicated

xii. administer rubella vaccination or Rh immune globulin (RhoGAM) if indicated


c. role of mother and/or support person

i. verbalize questions and concerns

ii. report physical changes promptly

iii. ask for pain relief as necessary

iv. bond, hold, talk with the newborn




IV. Normal Postpartum

A. Maternal adaptations: birth (before discharge from hospital) to 6 weeks (puerperium)

1. Systems adaptations

a. reproductive

i. uterine contraction with fundus moving downward

ii. lochia with minimal clots (rubra)

iii. perineal healing - approximation of any wound edges


b. cardiovascular - vital signs return to base line with decrease circulating blood volume

c. respiratory - less strain and dyspnea

d. renal - improved blood flow

e. gastrointestinal - less indigestion

f. integumentary - pigmentation changes fade

g. endocrine

i. estrogen - drops at birth; lowest one week postpartum

ii. progesterone - drops at birth; undetectable 72 hours postpartum

iii. oxytocin - stimulates uterine contraction and milk letdown reflex

iv. prolactin - stimulates milk production when nipples stimulated



2. Psychological adaptations

a. emotional responses

i. taking-in phase 24 to 48 hours

ii. taking-hold phase 48 to 72 hours


b. interaction with newborn

c. family dynamics and bonding

d. role change in first 24 hours





3. Initial postpartum history - assist RN collect data

a. labor and birth information

b. present findings

c. health history

d. reproductive summary

e. social factors

f. cultural and religious practices
55


g. lifestyle

h. diet history

i. risk factors

i. identified in pregnancy

ii. related to labor or birth

iii. adolescent parenting

iv. substance abuse

v. nutritional alterations

vi. family relationships

vii. economic strain such as poverty, single parenthood

viii. disability

ix. transportation and distance to health care services



4. Laboratory data

a. hemoglobin and hematocrit

b. rubella titer

c. blood type and Rh factor

d. cultures if indicated



5. Data collection

a. physical examination - B.U.B.B.L.E. assessment

i. monitor vital signs and compare to intrapartal data

ii. assist with head-to-toe assessment

iii. observe examination of fundal height

at umbilicus (size and consistency of firm grapefruit) after birth

1 finger above the level of the umbilicus on day 1 (first 12 hours)

nonpalpable and behind symphysis pubis by day 10


iv. observe lochia

i. rubra (red) on days 1 to 3

ii. serosa (pink to brown) on days 3 to 7

iii. alba (creamy white) on or around day 10


v. observe perineum and repaired episiotomy or lacerations

vi. observe legs for edema, Homan's sign

vii. check for common problems

i. breast engorgement; sore nipples

ii. afterpains

iii. bladder distention; altered bowel function; hemorrhoids

iv. swelling and discomfort from episiotomy



b. psychological

a. initial emotional response to labor/birth

b. response to pain

c. early interactions with newborn
56


d. family support and interactions

e. cultural and/or religious practices



REMEMBER IT
Postpartum assessment: BUBBLE

B=Breasts
U=Uterus
B=Bowels
B=Bladder
L=Lochia
E=Episiotomy/C-section incision

E---can also stand for maternal emotions about the
outcomes of the birth and the new baby



6. Nursing care: role of PN is assisting RN as a provider of care

a. maintain a caring relationship

b. reinforce with mother the physical changes and expected findings

c. respond to questions and concerns

d. promote physical comfort and rest

e. offer analgesics for pain relief

f. reinforce information of specifics for fundal massage

g. encourage frequent emptying of bladder

h. reinforce perineal hygiene and care

i. encourage ambulation

j. help with initial lactation if indicated

k. offer food and fluids

l. identify and report problems promptly

m. document data and care


7. Role of mother and/or support person

a. express questions and concerns

b. hold and interact with the newborn and each other

c. participate with rooming-in if indicated

d. report physical or emotional changes promptly



B. Postpartum discharge planning and reinforcement of initial teaching (24 to 48 hours)

1. Data collection based on adaptations

a. self-assessment by mother

b. reportable findings



2. Nursing care: role of PN is assisting the RN as a provider of care

a. report mother's learning needs

b. anticipatory guidance: self care
57


i. episiotomy/perineal care

ii. vaginal discharge

iii. balanced diet for health and lactation

iv. activity and rest

v. breast and nipple care

vi. resources for questions and concerns

vii. family involvement at home

viii. return of menses

ix. sexual needs

x. family planning options

xi. reportable conditions (mother and baby)

xii. adjustment to parenthood



c. anticipatory guidance: lactation

i. early and frequent nursing

ii. positions for comfort

iii. pumping and storing milk


d. administer prophylaxis for Rh negative mother

e. reinforce for mother to keep using multivitamins and iron for at least 6 to 8 weeks postpartum


3. role of mother and/or family

a. seek answers to questions and concerns

b. report physical or emotional problems promptly

c. use resources as needed

d. increase activities gradually

e. integrate newborn into family




C. Follow-up home visit (2 to 4 days after discharge)

1. Data collection

a. self-assessment by mother

b. physical

i. vital signs

temperature greater than 100.4 F (38 C) in the first 24 hours after delivery may indicate
dehydration

temperature greater than 100.4 F (38 C) hours apart after the first 24 hours after delivery
for 2 consecutive days may indicate a postpartum infection


ii. breasts filling - engorgement

iii. nipples intact

iv. uterine contraction and descent- fundus should be firm

v. lochia serosa

vi. perineal healing

vii. lower extremities - edema diminishing
58


viii. comfort

ix. elimination - bowel movement and voiding difficulties

x. fatigue/energy level/sleep pattern


c. psychological and social

i. emotional responses and coping; evaluate depression or "baby blues" days

ii. taking- hold phase

iii. parent-newborn interaction

iv. family dynamics

v. financial concerns

vi. health care follow-up concerns

vii. support network




2. Nursing care: role of PN is to assist the RN as a provider of care

a. continue caring relationship

b. respond to questions and concerns

c. show interest in newborn and siblings

d. evaluate safety in newborn care

e. reinforce nurturing behaviors

f. identify problems or risky behaviors (mother and baby) - report promptly

g. remind mother of follow-up visit date


3. Role of mother and family

a. verbalize questions and concerns

b. report physical changes/problems promptly

c. demonstrate safe newborn care



D. Follow-up clinic or office visit (3 to 6 weeks postpartum)

1. Data collection

a. involution of uterus is complete

b. letting-go behaviors expected

c. lactation established if selected this option

d. check vital signs and weight


2. Nursing care: role of PN is to assist the RN as a provider of care

a. review health maintenance and promotion teaching

b. reinforce teaching of self and newborn care

c. respond to questions and concerns

d. refer to resources

i. supplement teaching with tools appropriate to level of education

ii. refer needs related to fertility awareness and birth control



3. Role of mother and/or family

a. incorporate newborn into the family unit

b. follow suggestions for a healthy lifestyle to eliminate risky behaviors

c. report reproductive health problems promptly
59


d. schedule regular health care visits for self and newborn

e. demonstrate safe self care and newborn care




V. Normal Newborn

A. Immediate care - birth to 2 hours after delivery

1. Systems adaptations

a. fetal to newborn circulation

b. approach newborn care with the focus that all systems are immature initially

c. reflexes are present to protect infant until systems mature

d. reflexes disappear in a cephalocaudal (head-to-toe) manner


2. Data collection

a. respirations - determine respiratory effort, rate and pattern

b. Apgar Score


c. appearance


d. body temperature - risk of cold stress

e. umbilical cord - clamped without bleeding/drainage


3. Management actions by provider of care - PN may assist as directed

a. maintaining open airway

b. maintain body heat- dry the skin, wrap, put cap on baby or place in radiant warmer

c. ensuring safety

d. clamping the cord

e. take blood samples

f. identify mother and newborn

g. instilling prophylactic eye treatment

h. support and foster parent contact

i. document assessments and care





60


B. Newborn care - birth until discharge

1. Data collection

a. history

i. antepartal data

ii. labor and birth information

iii. risk factors - before, during, and after birth


b. physical examination of newborn

i. axillary temperature (97.9 - 99.7 F [36.6 - 37.7 C])

ii. apical heart rate (110 to 160 beats per minute; 110 beats per minute at rest or sleep)

iii. blood pressure (50 to 75 mm Hg)

iv. respirations (30 to 60 per minute)

v. pain assessment - Neonatal Pain and Sedation Scale (NPASS)

vi. weight

vii. measurements of length and head, chest and abdominal circumference

viii. head-to-toe assessment

ix. reflexes

x. growth and gestational age assessment (using Ballard Maturational Assessment of
Gestational Age tool)


c. normal characteristics and common variations

i. caput succedaneum

ii. cephalohematoma

iii. molding


d. sensory responses

i. startle reflex

ii. fencing reflex

iii. extrusion reflex


e. behavioral responses - sleep state, quiet but alert state, crying state

f. elimination - first meconium stool within 24 hours, then continues to occur for up to 72 hours

g. laboratory data

i. complete blood count

hemoglobin should be between 14.5 - 22 g/dL

hematocrit should be between 44 - 72%


ii. blood type and Rh factor

iii. direct Coombs' antibody test (infant)

iv. glucose level (40 - 60 mg/dL iif newborn is symptomatic of IgA)

v. urinalysis for urine culture if indicated

vi. screening as indicated, e.g., sickle cell screening, Tay Sachs disease

vii. bilirubin levels 0-1 mg/dL

appearance of jaundice during the first day of life indicates a pathological process

evaluation is indicated with hyperbilirubinemia (15 mg/dL or greater for term infant, 10
mg/dL or greater for preterm infant)


viii. thyroid screen
61


ix. hearing screening






2. nursing care: role of PN is assisting the RN as a provider of care

a. report any vital signs outside normal range

b. keep the baby warm

c. clear the baby's airway as needed, especially nares, since newborns are obligate nasal breathers

d. position baby (on back or side)

e. document findings

f. share findings with parents as appropriate

g. report problems to RN

h. administer vitamin K and hepatitis B vaccine as prescribed

i. observe behavioral and neurological changes

j. note first void and stool within 24 hours

k. assist with feedings

l. screening for phenylketonuria (PKU) after initial 24 to 48 hours and after adequate protein (milk)
intake (test is invalid with inadequate protein intake)

m. routine cord care with every diaper change




3. reinforcing teaching of parents

a. nurturing behaviors

b. newborn care

i. safety

use of car seat

fall prevention while carrying infant

suffocation prevention

sleep position on back


ii. feedings

iii. hygiene

iv. cord care - keep cord clean and dry; usually falls off by postpartum day 10

v. circumcision care


c. elimination patterns

d. mother's initial weight loss - 12 to 15 pounds after delivery; additional five pounds within the first
week and ten pounds in the next six weeks
62


e. newborn's weight loss - up to ten percent loss of initial weight within the first ten days of life is
expected

f. newborn stimulation

g. positioning and holding during and after feedings


4. role: mother and family should

a. express questions and concerns

b. bond and attach to newborn

c. recognize newborn as a separate person

i. call baby by name

ii. note unique things about baby


d. describe and implement cultural or religious beliefs

e. demonstrate caregiving skills

f. introduce siblings to newborn


C. Discharge instructions - reinforce information provided by RN and health care team

1. Expected findings discussed by provider of care

2. Follow-up laboratory tests

i. phenylketonuria (PKU)

ii. bilirubin test


3. Reportable signs

a. fever - any elevation is a concern for infection or dehydration

b. vomiting

i. frequency, color, force it projectile?

ii. how it differs from normal 'spitting up'


c. stool changes; diarrhea

i. for frequency, color, smell

ii. lack of stool or ribbon-like or mucoid


d. behavioral changes - irritability or inability to awaken

e. feeding problems - retention or intake; new versus present at birth

f. skin

i. rash - newly developed versus present from birth

ii. jaundice - expected from 48 to 72 hours after birth



4. Resources

a. newborn nursery staff, well baby clinic staff

b. pediatrician

c. infant CPR courses

d. family members

e. support groups, such as La Leche League, church, or other local

f. telephone numbers, such as Poison Control Center, clinic, abuse hot lines






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D. Follow-up home visit

1. Mother's adaptation (compare to hospital records)

2. Physical findings of newborn (compare to hospital records)

a. vital signs

b. weight

c. head-to-toe examination

d. reflexes

e. behavior

f. sensory responses

g. elimination patterns

h. contentment and sleep

i. feeding

j. hygiene


3. Home environment

4. Psychological and social findings

a. interaction between family and newborn

b. emotional responses of family to newborn and each other

c. responses to newborn cues



5. Nursing care - role of PN is assisting the RN as a provider of care

a. establish caring relationship

b. display interest in the newborn

c. encourage questions

d. respond to concerns and questions

e. share data collection findings with family

f. demonstrate care giving skills as needed

g. review newborn feeding needs, patterns, common problems

h. reinforce parenting behaviors

i. remind parents about well-baby schedule and immunizations

j. review postpartum reportable findings for mother

k. review reportable signs for infant


6. Role of family

a. express questions and concerns

b. incorporate newborn into family

c. provide safe, nurturing care

d. recognize reportable signs

e. plan/implement well baby follow-up care








64

Fetal movement count during the third trimester should be at least 5 movements per day. True False

The fourth stage of labor is placental separation and expulsion. True False

When the fetus is active, its heart rate should increase by about 15 beats per minute. True False

Most pregnancy tests measure the level of estrogen in the woman's blood. True False

One of the first signs of pregnancy is Chadwick's sign, which is the softening of the cervix. True False

The nurse will give Rh immune globulin (RhoGAM) to a Rh negative women after a miscarriage (spontaneous abortion). True False

Chloasma is the first milk the new mother produces. True False

The fetus receives more oxygenated blood when the laboring mother lies on her side. True False

A gravida 3, para 3 woman should be rushed to the delivery room once engagement has occurred. True False

An APGAR score of 2 for appearance means the newborn's fingers and toes are bluish in color. True False

A baby tapped briskly on the bridge of the nose will close both eyes. True False

About 5 days after delivery, lochia is pink-brown in color. True False

Common issues on the first postpartum day include after pains and episiotomy discomfort and swelling. True False

A woman cannot become pregnant when she is breastfeeding. True False

The safest time for the fetus is to give the mother analgesia when her cervix is dilated 8 to 10 centimeters. True False


VI. Growth and Development: Infant Through Older Adult

A. Growth and development - an overview

1. Patterns of growth and development

a. cephalocaudal development: head to feet, occurs first two years of life

b. proximodistal development: near to far, or central to peripheral

c. differentiation: from simple operations to more complex activities and functions, i.e.,
concrete to abstract thinking, gross to fine motor skills


2. Growth measures

a. height

b. weight

c. frontal-occipital circumference


3. Theories of development

a. Piaget's theory of cognitive development

b. Erikson's theory of psychosocial development

c. Kohlberg's theory of moral development


d. language development


4. Assessment of growth and development: Denver II developmental screening test

a. role of PN is to assist in process

b. screens children from birth through six years

c. assesses four skills

i. personal-social

ii. fine motor adaptive

iii. language
65


iv. gross motor






B. Infancy (up to 12 months)

1. Growth

a. period of very rapid growth

b. doubles birth weight at 6 months, triples at 1 year

c. by 1 year birth length has increased by almost 50% (occurs mainly in trunk)

d. by 1 year head circumference equals chest circumference

e. posterior fontanel closes at 6 to 8 weeks of age

f. anterior fontanel closes at 12 to 18 months of age

g. tooth eruption begins at 5 to 6 months

h. 6 to 8 teeth by one year



2. Motor development

a. sits without support at 6 to 8 months of age

b. rolls completely over at 6 months

c. vocalization at 8 months of age

d. pincer grasp at 9 to 11 months of age

e. crawling or creeping 6 to 7 months

f. stands alone 10 to 12 months

g. cruises (walks holding on) 10 to 12 months

h. walks independently at 12 to 15 months of age

i. begin feeding self at 11 months


3. Cognitive: Piaget's sensorimotor period

4.
Psychological: Erikson's developmental task of trust vs. mistrust

a. lays foundation for other developmental tasks

b. stranger anxiety/separation anxiety begin


5. Language development

a. cries, smiles, coos by 3 months

b. produces chained syllables by 6 months

c. says two or more words by 1 year

d. understands meaning of "no" by 11 months

e. can follow simple directions at 1 year

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6. Play is solitary

a. initially with rattles or mobiles

b. game playing such as peek-a-boo and pat-a-cake by ten months


7. Common fears

a. from birth to 3 months - fears sudden movements, loud noises, and loss of physical support

b. from 4 to 12 months - fears strangers, strange objects, heights, and anticipation of previous
uncomfortable situations


8. Suggested toys

a. birth to 6 months - mobiles, unbreakable mirrors, music boxes, rattles

b. 6 to 12 months - blocks, nesting boxes or cups, simple take apart toys, large ball, large puzzles,
jack in the box, floating toys, teething toys, activity box, push-pull toys





C. Toddlerhood (1 to 3 years)

1. Growth

a. gains 1.8 to 2.7 kilograms (4 to 6 pounds) per year

b. grows 7.5 centimeters (3 inches) per year (occurs mainly in legs)

c. lordosis and potbelly are characteristic

d. head circumference usually equal to chest circumference by one-two years of age

e. primary dentition complete by 30 months



2. Motor development

a. walking improves

b. runs

c. begins to climb and walk up and down stairs with help

d. builds tower of six blocks by age 2 years and eight blocks by age 3 years

e. by end of toddlerhood can copy a circle on paper

f. dresses self in simple clothing

g. begin potty training - bladder control is often more difficult to attain than bowel control


3. Cognitive: Piaget's period of preoperational thought

4. Psychological: Erikson's developmental task of autonomy vs shame and doubt

a. separation anxiety peaks during toddlerhood

b. toilet training begins

c. discipline becomes necessary

d. ritualistic: need to maintain sameness and reliability

e. negativism: persistent negative response to requests - "no"

f. frustration may result in temper tantrums or regression

g. imitation of parents / caretakers - walks in parents' shoes

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5. Moral development: Kohlberg's preconventional or premoral level

6. Language development

a. vocabulary grows from four to six words at 15 months to over 300 words by age 2

b. "no!", "me", and "mine!" are key words

c. ability to understand speech is much greater than the number of words the child can say

d. uses multi-word sentences by age two


7. Play is parallel - child plays next to others with no interaction with others

8. Common fears include the dark, being alone, separation from parents, some animals, and loud
machines

9. Suggested toys: push-pull toys, finger paints, thick crayons, riding toys, balls, blocks, puzzles, simple
tape recorder, housekeeping toys, puppets, cloth picture books, large beads to string, toy
telephone, water toys, sand box, play dough or clay, chalk and chalkboard



D. Preschool age (3 to 6 years)

1. Growth

a. average weight gain about 2 to 3 kilograms (5 pounds) per year

b. height: increase of 6.75 to 7.5 centimeters (2.5 to 3 inches) per year (occurs in legs)



2. Motor development

a. very active

b. can hop on one foot

c. pedals tricycle

d. refinement of previous learned motor skills - gross and fine motor

e. draws a person with one body part/year

f. consistent day and night dryness (bowel and bladder control) should by achieved by 5 years of
age or further evaluation is warranted


3. Cognitive: Piaget's period of preoperational thought

4. Psychological: Erikson's developmental task of initiative vs. guilt

a. sexual curiosity

b. imitation of adult roles or make believe characters with dress-up games

c. magical thinking

d. makes up rules when playing games


5. Moral development - Kohlberg

a. 2 to 4 years: punishment and obedience

b. 4 to 7 years: naive instrumental orientation


6. Language development

a. by age 5, has vocabulary of 2,100 words
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b. knows name and address

c. asks questions constantly

d. uses fantasy in stories

e. "Why?" is favorite word


7. Preschool play is associative and cooperative - child interacts with others

a. dress-up in costumes or uses items to make a costume

b. fantasy play

c. imaginary playmates

d. little interest in following rules when playing games


8. Common fears of preschool child include body mutilation, animals, supernatural beings, monsters,
ghosts, unfamiliar routines, separation from trusted adults, and abandonment, annihilation

9. Suggested toys: tricycle, gym and sports equipment, sandboxes, blocks, books, puzzles, computer
games, dress-up clothes, blunt scissors, picture games, construction sets, musical instruments, cash
registers, simple carpentry tools


E. School age (6 to 12 years)

1. Growth

a. growth is slow and steady until growth spurt of adolescence

b. weight gain an average of 2 to 3 kilograms (4.5 to 6.5 pounds) per year

c. brain fully developed in size

d. height: average growth of 5 centimeters (2 inches) per year

e. loss of deciduous teeth and acquisition of permanent teeth in early school age years, usually by 8
years of age

f. child is usually lean, but some may become overweight depending on eating habits and activity

g. eyesight maximally developed by 8 years of age; common to establish a need for glasses in the
mid-school-age years



2. Motor development

a. full of energy

b. rides bicycle and plays active games

c. most enjoy physical activity

d. writes in cursive

e. more awkward as adolescence approaches

3. Cognitive: Piaget's period of concrete operations

4. Psychological: Erikson's developmental task of industry vs. inferiority

a. develops a sense of accomplishment through completion of tasks

b. joins clubs
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c. has same-sex friends

d. peer approval is strong motivating power



5. Moral development - Kohlberg

a. develops a moral code and social rules

b. views rules as necessary principles of life, not just as dictates from authority by age 12

c. can judge flexibly and decide if rules apply to a given situation by age 12


6. Language development

a. vocabulary of approximately 14,000 words

b. reading skills improve dramatically



7. Play is cooperative with a focus and concern about the rules of a game

a. sports and games with rules

b. fantasy play in early school-age years

c. clubs

d. hero worship

e. cheating may begin in later school-age years



8. Suggested toys and activities: board or computer games, books, initiated collections, scrapbooks,
sewing, cooking, carpentry, gardening, painting



F. Adolescence (age 13 to 19)

1. Growth

a. boys increase in muscle mass; girls increase in fat deposits

b. may experience growth spurts; most aggressive growth period in lifetime

c. Tanner Stages and pubertal changes - development of primary and secondary sex
characteristics

d. dentition is complete - all permanent teeth


2. Motor development

a. increase in gross and fine motor abilities

b. increase in risk-taking behaviors


3. Cognitive: Piaget's period of preoperational thought


4. Psychological: Erikson's developmental task of identity vs. role confusion

a. begins to develop a sense of "I"

b. peers become most significant group

c. separates from parents



5. Moral development - Kohlberg

a. healthy adolescents consolidate moral development

b. understand that rules are not absolutes, but cooperative agreements that can be changed to fit
the situation

c. judge themselves by internalized ideals
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d. group values become less significant in later adolescence

e. sense of right and wrong develops from applying values to daily decisions

6. Language development - increases as cognitive skills increase


7. Play and recreation

a. centers around social interactions: expanding peer life

b. sporting and cultural activities

c. small group activities




G. Early adulthood (post-adolescence through age 40)

1. Physical development

a. period of optimal physical function

b. typically free of acute or chronic illness

c. effects of aging begin around age 20

d. musculoskeletal system

i. growth completed about age 25

ii. well-developed and coordinated


e. cardiovascular system

i. strength peaks about age 30

ii. men more likely to have higher cholesterol levels

iii. blood pressure changes noted by race, sex and weight


f. gastrointestinal system

i. after age 30, digestive juices decrease

ii. wisdom teeth emerge

iii. weight may change as a result of environment, diet and exercise


g. reproductive system

i. fully mature in 20s

ii. optimal reproductive time between 20 and 30 years of age for women




2. Psychosocial development

a. Erikson's developmental task of intimacy vs. isolation

b. become more self-directive in the twenties

c. may question previous life choices

d. adult roles emerge, i.e., work, intimacy, parenting, social purpose

e. developmental and situational stressors are great


3. Cognitive development

a. development of brain cells peaks during twenties

b. continue to develop a higher level of cognitive functioning

c. can think abstractly

d. now can perceive many different points of view

e. more realistic and objective

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4. Health risks

a. emotional stress - peer pressure to engage in risky behaviors

b. injuries - leading cause of death

i. motor vehicle accidents

ii. firearm-related homicides

iii. suicides

iv. intimate partner violence


c. sexually transmitted infections - multiple sex partners

d. substance abuse - tobacco, alcohol, illegal drugs

e. nutrition



5. Psychosocial development

a. Erikson's developmental task of intimacy vs. isolation

b. become more self-directive in the twenties

c. may question previous life choices

d. adult roles emerge, i.e., work, intimacy, parenting, social purpose

e. developmental and situational stressors are great


6. Cognitive development

a. development of brain cells peaks during twenties

b. continue to develop a higher level of cognitive functioning

c. can think abstractly

d. now can perceive many different points of view

e. more realistic and objective


7. Health risks

a. emotional stress - peer pressure to engage in risky behaviors

b. injuries - leading cause of death

i. motor vehicle accidents

ii. firearm-related homicides

iii. suicides

iv. intimate partner violence


c. sexually transmitted infections - multiple sex partners

d. substance abuse - tobacco, alcohol, illegal drugs

e. nutrition


8. Health promotion

a. routine health tests and screenings

b. safety

c. nutrition, exercise, elimination

d. social interactions, goal setting



H. Middle adulthood (40 to 65 years)

1. Physical development

a. signs of normal aging begin to show; pattern of aging is unique in each person but with similar
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elements

b. subtle but gradual decline in most body systems

c. integumentary system

i. redistribution of pigment in hands ("age spots")

ii. graying of hair

iii. progressive decrease in skin turgor


d. respiratory system

i. anteroposterior diameter of chest increases

ii. respiratory rate 16 to 20 breaths per minute

iii. normal breath sounds


e. cardiovascular system

i. normal heart sounds

ii. pulse 60 to 100 beats per minute

iii. blood pressure:

systolic 95 to 135 mm Hg

diastolic 60 to 85 mm Hg



f. sensory

i. visual acuity decreases

ii. presbyopia




g. reproductive system and sexuality - sexual interest in later life reflects life-long patterns

i. female

ovaries gradually atrophy causing a drop in estrogen

results in gradual changes in menstrual cycle and flow

perimenopause: time period prior to menopause when periods become variable;
ranges from one to ten years

menopause: no menstrual periods for 12 months

diminished estrogen production results in: hot flashes, headache, palpitations, mood
swings, and vaginal dryness and atrophy resulting in itching, burning, and/or painful
intercourse, insomnia, frequent urinary tract infections and urinary urgency

actions to minimize findings: balanced diet, exercise (at least 30 minutes per day),
estrogen replacement therapy and complementary and alternative therapies (CAT)
including herbs, vitamin E

may gain a new sexual interest

complications

osteoporosis

cystocele or rectocele
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uterine prolapse

heart disease risk




ii. male

libido remains consistent

sperm count reduced

slower to achieve erection and ejaculation

prostatic enlargement common (benign)

andropause - decreased androgen levels with no physical findings; symptoms include
insomnia, fatigue, and circulatory problems



2. Cognitive

a. peak of intellectual development

b. no longer views self as invincible

c. chooses conflicts and battles to fight or get involved in


3. Psychosocial development

a. Erikson's developmental task of generativity vs. stagnation

b. midlife transition: time for assessing one's life structure

c. community involvement peaks

d. role reversal takes place with parents

e. awareness of one's own mortality


4. Threats to health and safety - depends on lifestyle choices and aging process

I. Older adult (over age 60)

1. Biological theories of aging - no two individuals age identically

a. Cross-Linking theory (also called the Glycosylation Theory of Aging)

b. immunological theory

c. free radical theory

d. stress theory

e. error theory (genetic mutations)

f. biological clock or genetic programming


2. Psychosocial theories of aging

a. disengagement theory

b. activity theory

c. continuity theory


3. Developmental tasks of elderly adult
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a. Erikson's developmental task of ego integrity vs. despair

b. accept self as an aging person; coping with physiological changes

c. adjust to decreasing physical abilities

d. adjust to retirement and with potential reduced income

e. adjust to death of spouse; redefining relationships with children

f. maintain satisfactory living arrangements, and quality of life



4. Physical systems

a. integumentary system

i. dry, thin, scaly skin

ii. decreased perspiration

iii. decreased elasticity and subcutaneous layer

iv. senile purpura

v. spotty pigmentation

vi. slower healing


b. respiratory system

i. reduced vital capacity

ii. increased airway resistance

iii. kyphosis may cramp lung expansion

iv. decreased lung expansion


c. cardiovascular system

i. decreased cardiac output and reserve

ii. baseline systolic blood pressure may rise

iii. peripheral pulses may be weaker


d. gastrointestinal system

i. abdominal muscle tone decreases

ii. less saliva; decreased thirst perception

iii. less gastric motility, less gastric juices, with less absorption - potential for malnutrition and
indigestion

iv. food appeals less secondary to decreases taste perception; slower gastric emptying

v. decreased peristalsis - constipation common

vi. decreased hepatic clearance of drugs and other substances



e. urinary system

i. decreased renal filtration

ii. decreased bladder capacity

iii. female

urgency

stress incontinence

menopause


iv. male

urinary frequency
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benign prostatic hypertrophy contributes to urine retention

andropause


v. sexual function depends on general health, psychological health, types of medication and a partner


f. musculoskeletal system

i. reduced muscle mass and strength

ii. decreased joint mobility and decreased range of motion

iii. decreased endurance

iv. postmenopausal women - bone demineralization


g. nervous system

i. decreased rate of voluntary or automatic reflexes, decreased nerve conduction velocity

ii. sleep cycle changes, frequent awakening, decreased deep sleep

iii. impaired thermoregulation

iv. decreased balance and spatial orientation


h. sensory changes

i. decreased visual acuity

ii. decreased accommodation

iii. presbyopia

iv. decreased hearing acuity (presbycusis)

v. decreased pitch discrimination - minimal ability to hear high-pitched sounds

vi. taste buds atrophy

vii. decreased sense of smell

viii. decreased heat, cold, touch, pressure perception


i. immune system

i. lower base line temperature

ii. decreased immune response - increased infection risk


5. Cognitive changes

a. expected: gradual decrease short-term memory, narrowed interests

b. unexpected: occur when cerebral dysfunction, trauma, or hypoxia is present

c. intelligence does not decrease


6. Psychosocial

a. Erikson's developmental theory of ego integrity vs. despair

b. personality, creativity, values, and adaptability remain constant

c. retirement: change in occupational and social roles; economic changes

d. facing multiple losses and grief response

e. isolation: social, attitudinal, behavioral, geographic


7. Sexual function will depend on general health, psychological health, medications

8. Threats to health and safety

9. Housing - safety is the priority and functional needs met

a. home: single family, apartment, and retirement community

b. assisted living

c. day care
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d. respite care

e. long-term care


VII. Health & Health Promotion

A. Definitions

1. Health

a. Traditional Western model: "freedom from disease"

b. World Health Organization (1958): a "state of complete physical, mental and social
wellbeing and not merely the absence of disease and infirmity"


2. Wellness: a multidimensional state of being; functioning at maximum potential, regardless of
state of health

3. Health promotion behavior: behavior in which the client views health as a goal and engages in
behaviors designed to achieve or maintain that goal

4. Health care: includes prevention, early detection, treatment and rehabilitation for clients with
potential for or existing illness or disability

5. Health belief model

a. Psychological and behavioral theory

b. Attempts to explain individual health behaviors

c. Health behaviors are based on three factors

i. the individual's perception of susceptibility of illness

ii. the individual's perception of seriousness of the illness

iii. the likelihood that the person will take preventive action


d. Modifying factors

i. cultural beliefs

ii. economics

iii. political factors

iv. social factors

v. personal beliefs





B. Healthy People 2020

1. The US Department of Health and Human Services originally released Healthy People in 1990

2. Statement of national health objectives designed to identify the most significant preventable
threats to health and to establish national goals to reduce these threats

3. The goals of the project

a. increase quality and years of healthy life

b. eliminate health disparities



C. The Patient Protection and Affordable Care Act (Public Law 111-148) - also known as "Obamacare"
(2010):

1. Provides for quality and affordable health care for all Americans

2. 10 titles or sections, including the following provisions:

a. Title II: expands Medicaid coverage

b. Title III: closes the gap in prescription drug coverage in Medicare (Part D)

c. Title IV: establishes the National Prevention, Health Promotion, and Public Health Council - for
supporting preventative health care

d. Title VIII: establishes the Community Living Assistance Services and Supports (CLASS Act) - for
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support for people with disabilities



D. Health promotion model

1. Developed by Nola Pender (1982; revised 1996)

2. Health promotion depends on seven factors of cognition-perception

a. importance of health to the person

b. perceived control of health

c. perceived self-efficacy

d. definition of health

e. perceived health status

f. perceived health benefits from the health-promoting behavior

g. perceived barriers to the health-promoting behavior



E. Disease prevention behaviors: behaviors designed to decrease the likelihood/risk of illness

1. Primary prevention

a. health promotion and disease prevention

b. applied to clients considered physically and emotionally healthy

c. example: exercise programs, healthy diet


2. Secondary prevention

a. early detection of illness

b. focuses on individuals who are experiencing health problems and illnesses and who are at risk
for complications

c. activities are directed at diagnosis and prompt treatment

d. example: breast self examination, cholesterol screening


3. Tertiary prevention

a. prevention of further deterioration in disease or disability

b. occurs when a defect or disability is permanent and irreversible

c. activities are directed at rehabilitation

d. example: alcoholics anonymous



F. Health screening risk appraisal

1. Used to analyze all that is known about a person's entire life situation, including personal and family
medical history, occupation, and social environment in order to estimate his or her risk of disability
or death as compared with the national averages

2. Can prevent or minimize illness and disability


REMEMBER IT
Primary - Prevent
Secondary - Screen
Tertiary - Treat


G. Risk factors - probability of acquiring a particular health problem

1. Varies with age, race, ethnicity, gender

2. Risk increases with certain lifestyle choices, such as smoking, occupation, diet, environment

3. Modifiable risk factors include such things as occupation, work stress, and diet

4. Non-modifiable risk factors include race, age and gender
78


5. Examples: risk factors are important in

a. coronary artery disease

i. history of smoking

ii. history of high cholesterol

iii. genetic predisposition

iv. obesity


b. cancer (general)

i. high consumption of caffeine

ii. genetic predisposition

iii. environmental exposure to carcinogens


c. colon cancer

i. over 50 years of age

ii. family history of colon polyps or cancer

iii. urban living

iv. diet high in fats and low in fiber


d. tuberculosis

i. history of exposure to someone with tuberculosis (TB)

ii. history of travel or living outside United States

iii. history of prison time

iv. HIV infection

v. cancer chemotherapy

vi. malnutrition

vii. homelessness

viii. history of intravenous drug use

ix. medical workers



e. diabetes: candidates for screening

i. strong family history of diabetes mellitus

ii. markedly obese

iii. obstetrical history of babies weighing over nine pounds at birth

iv. obstetrical history of miscarriage or fetal death

v. pregnant women between 24 to 28 weeks gestation

vi. history of gestational diabetes





H. Risky behaviors - behaviors that impact the health of individuals

1. Adolescence (12 to 19 years)

a. eating disorders

i. anorexia nervosa - restrictive eating

ii. bulimia nervosa - binge eating followed by purging


b. injury prevention

i. wearing of seat belts
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ii. wearing of helmets

iii. sports injuries

iv. homicide and suicide


c. substance abuse

i. tobacco

ii. underage drinking

iii. illicit drug use


d. sexual behavior

i. number of sex partners

ii. use of contraception

iii. unintended pregnancy

iv. exposure to sexually transmitted infections - use of condoms



2. Young adult (post-adolescence through age 40)

a. eating disorders - onset of obesity

b. injury prevention

i. motor vehicle accidents

ii. occupational hazards

iii. homicide and suicide


c. substance abuse

i. tobacco

ii. alcohol use

iii. illicit drug use


d. sexual behavior

i. sexually transmitted disease - use of condoms

ii. unintended pregnancy


e. stress

i. changing roles

marriage

beginning a new family

starting a new job


ii. depression



3. Middle adult (40 to 65 years)

a. obesity

b. lack of exercise

c. substance abuse

i. tobacco

ii. alcoholism

iii. illicit drug use


d. lack of preventative health care

e. stress
80


i. job

ii. family / divorce

iii. acceptance of aging



4. Older adult (age 65 and older)

a. obesity

b. lack of exercise

c. substance abuse

i. tobacco

ii. alcoholism

iii. illicit drug use


d. injury prevention

i. falls

ii. seat belts

iii. suicide

iv. multiple medications




I. Screening recommendations for the average American

1. For everyone

a. Cholesterol - baseline at age 20; every 5 years if normal

b. Blood pressure screening ( measuring blood pressure )

c. Colonoscopy (visualization of the entire colon) - once every 10 years after turning 50 (unless
there is a family history)

d. Guaiac test for occult blood every year after the age of 50

e. Tuberculosis skin test (intradermal injection of antigen), followed by chest x-ray if positive results

f. Diabetes - fasting plasma glucose (ideally 8 to 12 hours fasting)

g. Vision - regular check-ups

h. Dental - regular check-ups and cleanings should be performed every six months

i. Hearing - recommended every 10 years; every 3 years after age 50

j. Well child care - birth to age 6

k. Physical exam - every 1 to 5 years depending on risk factors and health concerns

l. Scoliosis screening - onset of adolescence

m. Immunizations (non-childhood) - tetanus booster (every 10 years), influenza, pneumococcal and
Zostavax (for shingles) vaccines


2. Women

a. mammography

b. clinical breast exam

c. monthly breast self exam

d. Papanicolaou test (or Pap smear) - no later than age 21


3. Men

a. prostate-specific antigen (PSA) test - routine screening no longer recommended

b. digital rectal exam

c. testicular self-exam - starting at age 15


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J. Compliance

1. Definition: adherence to therapeutic recommendations

2. Factors influencing compliance

a. personal meaning and perceptions: knowledge, values, beliefs, outcome expectations

b. social factors: environmental context, social relationships, social support, societal norms,
economic resources

c. deficiencies in the health care system: access, costs, wait time, monolingual services



K. Noncompliance

1. An individual's informed decision not to initiate or adhere to a therapeutic recommendation

2. An individual is unable or unwilling to alter habitual behaviors or adopt new behaviors necessary to
a prescribed therapeutic regime


VIII. Health Data Collection

A. Purposes

1. Data collection

2. Supplement, confirm or refute historical data

3. Identify changes in client's status

4. Instruct about healthy behaviors, health risks, and health promotion

5. Report results to health care provider


B. Types - comprehensive, problem-centered, follow-up, emergency

C. History

1. Present health/history of present illness

a. onset

b. location of symptoms (or pain)

c. quality of discomfort

d. precipitating or aggravating factors

e. duration of symptoms

f. associated symptoms


2. General health status (as perceived by the individual)

3. Medical and surgical history - events, treatment and outcomes, allergies, immunization status

4. Family history and risk factors - lifestyle, genetic

5. Social history

6. Occupation

7. Leisure activities and exercise regimen

8. Sleep patterns

9. Nutrition

10. Medications, including prescription, over-the-counter, substance use/abuse, tobacco use

11. complementary and alternative therapies (CAT)

12. psychosocial factors and support systems



D. Physical exam

1. Recommended equipment

2. Assist client into position
82


a. Fowler's - anterior, posterior for breath sounds

b. supine and dorsal recumbent (for abdominal assessment)


3. Ensure privacy

4. Collect data about general appearance and behaviors

a. gender and race

b. age

c. obvious signs of distress

d. body type

e. posture

f. gait

g. body movements

h. hygiene

i. dress

j. affect and mood

k. speech


5. Measure vital signs

a. pulse: rate, rhythm, force or strength

b. respiration: rate, rhythm, quality

c. body temperature

i. oral range: 97.5 - 99.5 F (36.4 - 37.5 C)

ii. measure core temperature: rectal, tympanic, esophageal, temporal artery, gastrointestinal
radio pill, urinary bladder

iii. measure surface temperature: skin, axilla, or mouth

iv. body temperature normally varies with age, exercise, hormone levels, circadian rhythm (time
of day), stress, the environment



6. Measure height and weight

a. height-for-age reference charts

b. measuring height with client standing or lying down; proxy measurements such as arm span may
also be used



E. Physical exam techniques

1. Inspection

a. process of observing the differences between normal physical findings and deviations

b. requires knowledge of normal physical findings throughout the lifespan

c. principles of inspection

i. in good lighting and with whole body part visible

ii. observe each area for size, shape, color, and position

iii. compare body parts bilaterally for symmetry



2. Palpation

a. use touch to assess rigidity, resilience, texture, temperature, moisture, vibration, pulsation,
location and size, crepitations, masses, tenderness and mobility

b. palpation may be either light or deep in pressure

i. use light palpation to determine surface characteristics
83


ii. deep palpation usually depresses the area by 1 to 2 inches; use it to examine specific organs


c. use palmar surface of fingers to determine position, texture, size, consistency, and pulsation;
also presence and shape of mass

d. use back of hand or inner aspect of wrist to test temperature

e. use palm of hand to sense vibration


3. Percussion

a. tap the body with fingertips to detect fluid, or to assess location, size, density (air, fluid, solid) of
a structure and borders of organs

b. tapping the body penetrates produces vibration and sound waves which are heard as percussion
tones

c. methods

i. direct: striking the body surface with two fingers

ii. indirect: striking the middle finger of the stationary hand on the back surface with the
dominant hand, rather than the body surface, while keeping the palm and remaining fingers
off the body


d. character of percussion sounds depends on the density of the tissue being percussed


4. Auscultation

a. listening (with unassisted ear or stethoscope) to sounds made by the body

b. stethoscope

i. bell - low pitched sounds

ii. diaphragm - high pitched sounds


c. assess presence of sounds and their character

i. frequency (high or low pitch)

ii. loudness (loud or soft)

iii. quality (blowing, gurgling, booming, muffled thud, hollow, flat, absolute dullness)

iv. duration (short, moderate, long)



5. Olfaction: use of sense of smell to differentiate common body odors from abnormal ones



IX. Health Data Collection by Body Part

A. Eye

1. History

a. presenting problem or injury

b. presence of visual changes

c. night blindness

d. associated findings - pain, redness, swelling, discharge

e. onset

f. precipitating factors

g. aggravating or alleviating factors

h. past history

i. family history

j. lifestyle factors: occupational exposure to irritating substances, sun exposure

k. medications - specifically for eyes or any that may have ocular side effects
84


l. self-care abilities

m. use of corrective lenses



2. Vision tests

a. distant vision - Snellen E chart

b. near vision - Rosenbaum chart held at "reading" distance (or 12 to 14 inches from eyes)

c. visual fields


3. Extraocular muscle function: six cardinal fields of gaze

a. corneal light reflex

b. cover test

c. positions test


4. External eye structures: inspection

a. symmetry

b. eyelids and eyelashes

c. eyeball position

d. bulbar conjunctiva and sclera

e. lacrimal apparatus

f. cornea and lens

g. iris and pupil

h. papillary reaction to light

i. accommodation of pupils


5. Internal eye structures and red reflex

a. using ophthalmoscope, inspect internal eye

b. observe red reflex

c. inspect retinal vessels and background color


6. Older adult considerations

a arcus senilis

b. pupils often miotic (smaller) with slower dilation and adaptation to dark

c. iris and retina may appear paler

d. decrease tear production resulting in dryness

e. disc may be slightly smaller and more opaque

f. presbyopia

g. color perception diminished and cool color distortion




B. Ear

1. History

a. presenting problem or injury
85


b. presence of hearing loss

c. use of hearing assistance

d. associated findings - earache, discharge, tinnitus, vertigo

e. onset

f. precipitating factors

g. aggravating and alleviating factors

h. lifestyle factors: swimming, musician, occupation, environmental noise exposure

i. medical history

j. family history of allergy or hearing disease

k. medications


l. self-care behaviors



2. Inspection - external ear

a. observe size, shape and symmetry of both ears

b. auricles are normally level with each other, and upper point of attachment is in a straight line
with the lateral canthus of the eye

c. inspect ear skin for color, lesions, rash and scaling

d. inspect area behind auricle for tophus


3. Palpation

a. palpate auricle, tragus and mastoid area for tenderness and elevated local temperature

b. normal findings: auricle is normally smooth without lesions

c. estimate size of external auditory meatus


4. Inspection - ear canal

a. adult: grasp auricle and pull up and back to straighten external ear canal before inserting
otoscope or light

b. child: grasp auricle and pull down and back

c. inspect ear canal for redness, swelling, discharge, crusting and foreign bodies

d. expect cerumen (ear wax) - genetically determined

i. dry and flaky (frequently Asians and American Indians)

ii. wet - honey to dark brown (frequently Blacks and Caucasians)
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5. Hearing acuity

a. gross hearing is tested by client's response to normal conversation

b. whispered word or ticking watch test

c. health care practitioner tests

i. Weber test - hearing test using a vibrating tuning fork that is held at various points along the
midline of the skull and face (bone conduction only); used to detect hearing loss

ii. Rinne test - compares sound conduction of air versus bone; normally air conduction (AC) is
greater than bone conduction (BC)



6. Older adult considerations

a. ear lobes may appear pendulous

b. presbycusis - starting at age 50, slowly progressive

c. cerumen dries and accumulates, reducing acuity


C. Mouth and pharynx

1. Inspection - normal findings

a. temporomandibular joint - smooth jaw excursion; easy mobility

b. lips and buccal mucosa - symmetrical, pink; smooth and moist

c. teeth and gums - 32 adult teeth; pink gums

d. tongue - symmetry; pink; moist; papilla present

e. hard and soft palate - hard palate is pale, immovable with transverse rugae; soft palate is pink
and movable

f. oropharynx - symmetrical; midline uvula, tonsils may be present on either side



2. Older adult considerations

a. mucosa drier, decreased saliva

b. soft tissue atrophy (tongue), smoother, loss of taste buds, sense of taste may be diminished

c. teeth may appear longer, yellowed, surface abraded
87


d. tooth loss may occur with osteoporosis



D. Skin

1. General appearance - inspection is integrated throughout the head-to-toe exam

a. color

i. varies with body part, and from person to person

ii. color ranges

"white" skin: ivory or light pink to ruddy pink

dark skin: light to dark brown or olive


iii. alterations in skin color

hyperpigmentation

hypopigmentation

cyanosis

jaundice

erythema

pale or pasty

mottled




b. moisture

c. temperature

d. texture: varies from part to part

i. smooth or rough

ii. supple or tight

iii. indurated



e. turgor

i. decreases with normal aging in older adults

ii. check turgor over forehead or sternum (use of hand or forearm is inaccurate) and note how
quickly it returns to its previous state

iii. decreased in dehydration

iv. usually unable to check in toddlers and infants


f. vascularity

i. in older adults - capillaries are more fragile (senile purpura)

ii. petechiae: flat red or purple freckles


g. edema
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i. peripheral

ii. generalized (anasarca)

iii. ascites (around abdomen)

iv. pitting (grading scale +1, +2, +3, +4) or non-pitting




h. lesions

i. normal finding: free of lesions

ii. primary lesions

macule

papule

patch

plaque

vesicle

bulla

pustule

nodule


iii. secondary lesions (arise from primary)

scale

crust

lichenification

scar

excoriation

ulcer

fissure

keloid

erosion



iv. note: color, drainage (exudates), texture, size, shape, type, grouping, location and distribution



i. hair

i. hirsutism

ii. alopecia


j. nails - normal capillary refill is less than three seconds

k. factors affecting skin condition

i. hygiene

ii. nutritional status

iii. underlying disorders



89

2. Older adult considerations

a. thinner skin and subcutaneous tissue

b. "liver spots" - small, flat, brown macules

c. hypopigmented patches

d. skin is drier, especially on lower extremities

e. less perspiration

f. all skin becomes less elastic and more sagging

g. toenails may be thick, distorted, and yellowish

h. lesions: cherry angiomas, senile keratosis, atrophic warts

i. graying, thinning hair



E. Heart

1. Assess the heart through the anterior thorax (front chest)



2. Inspection and palpation

a. client in supine position or with head elevated at 35 to 45 degrees

b. apical impulse

i. fourth or fifth left intercostal space, mid-clavicular line

ii. may or may not be seen

iii. normally a short, gentle tap


c. pulse deficit: take and compare apical and radial pulse

d. anatomical landmarks of the heart

i. second right intercostal space - aortic area

ii. second left intercostal space - pulmonic area

iii. third left intercostal space - Erb's point

iv. fourth left intercostal space - tricuspid area

v. fifth left intercostal space - mitral (apical) area

vi. epigastric area at tip of sternum





F. Vasculature

1. Blood pressure

a. reflects relationship between cardiac output, peripheral vascular resistance, blood volume and
viscosity, and arterial elasticity
90




b. factors influencing blood pressure

i. age

ii. stress

iii. race

iv. drugs

v. diurnal (day-night) variations

vi. gender

vii. weight

viii. hydration status

ix. skill of person assessing blood pressure


c. alterations in blood pressure

i. hypertension: blood pressure (BP) greater than 140/90 mm Hg

ii. hypotension: systolic BP less than 100 mm Hg

iii. range of normal blood pressure

child under age 2, weighing at least 2700 g: use flush technique, 30 to 60 mg Hg

child over age 2 years-old: 85 to 95/50 to 65 mm Hg

school age: 100 to 110/50 to 65 mm Hg

adolescent: 110 to 120/65 to 85 mm Hg

adult: < 130 mm Hg Systolic / < 85 mm Hg diastolic





2. Internal carotid arteries in neck


a. palpate each separately along margin of sternocleidomastoid

b. normal findings: strong thrusting pulse

c. auscultate both sides

d. normal findings: no sound heard

e. constriction causes bruit

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3. Jugular veins

a. client in supine position with head elevated at 35 to 45 degrees

b. normal findings: pulsations not evident

c. jugular venous distension (JVD): bulging, distension, or protrusion at 45 degrees


4. Peripheral arteries and veins

a. pulse

i. locations

ii. normal range of peripheral pulses

infants: 120 to 160 beats per minute; as low as 110 beats per minute at rest

toddlers: 90 to 140 beats per minute

preschool and school age: 75 to 110 beats per minute

adolescent and adult: 60 to 100 beats per minute


iii. factors affecting rate

exercise

body temperature - each degree (Fahrenheit) elevation above normal causes an increase of 7
to 10 beats per minute

stress, emotions

drugs

hemorrhage - less blood in the body requires more pumping per minute

postural changes

pulmonary conditions causing poor oxygenation

hydration status

environmental temperature


iv. rhythm - regular (normal) or irregular

v. strength

reflects volume of blood ejected with each beat

grading system


vi. equality

vii. alterations, e.g., heart murmurs

viii. dysrhythmias - extra or skipped beats


b. tissue perfusion

i. temperature, movement, sensation

ii. color: pale, cyanosis

iii. clubbing - indicates chronic hypoxia
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iv. edema

v. skin and nail texture

vi. hair distribution on lower extremities - absence suggests arterial insufficiency

vii. presence of ulcers

toe location - arterial insufficiency; gangrene risk

ankle location - venous insufficiency




G. Lymphatics

1. Retrieves excess fluid from tissue spaces and returns it to the bloodstream

a. conserves fluid and plasma proteins

b. is a major component of the immune system

c. absorbs lipids from the intestinal track

d. without lymphatic drainage, fluid remains in the interstitial spaces and produces edema


2. Two major trunks

a. right lymphatic duct empties into right subclavian vein

b. thoracic duct - drains remaining body


3. Lymph nodes


a. cervical - drains the head

b. axillary - drains the breast and upper arm

c. epitrochlear - in the antecubital fossa and drains the hand and lower arm

d. inguinal - in the groin and drains the lower extremities, external genitalia, and abdominal wall


4.
Head and Neck

a. preauricular - in front of the ear

b. posterior auricular (mastoid)

c. occipital - base of skull

d. submental - midline, behind tip of mandible

e. submandibular - halfway between angle and tip of mandible

f. superficial cervical - overlying the sternomastoid muscle

g. deep cervical - deep under the sternomastoid muscle

h. posterior cervical - in posterior triangle along edge of trapezius

i. supraclavicular - just above and behind the clavicle


5. Related organs

a. tonsils

b. thymus

c. spleen


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H. Lungs

1. History - smoking, infections, pain, discomfort, dyspnea with or without activity, fever - spike, low-
grade


2. Inspection

a. general appearance

i. respiratory effort - breathing should be quiet and easy

ii. depth - normal, deep, shallow


b. normal rates of respiration at rest

i. newborn: 30 to 60 breaths per minute

ii. infant: 30 to 50 breaths per minute

iii. toddler: 25 to 35 breaths per minute

iv. school age: 20 to 30 breaths per minute

v. adolescent & young adult: 14 to 20 breaths per minute

vi. older adult: 12 to 20 breaths per minute


c. respiration involves ventilation, diffusion, and perfusion of gases


d. factors influencing respirations

i. anxiety

ii. pain

iii. stress

iv. anemia

v. posture

vi. exercise

vii. drugs: narcotics, amphetamines, neuroleptics, antidepressants


e. rhythm: regular, irregular; normal finding: regular

f. skin color: pink, pale, cyanosis; in dark skinned person check oral mucosa

g. chest wall

i. normal findings: symmetrical with bilateral muscle development

ii. anterior-posterior (A-P) to transverse ratio; increases with normal aging

iii. barrel chest - suggests chronic lung disease




3. Palpation

a. feel for abnormalities such as masses, lesions, scars, swelling, crepitus, asymmetry

b. crepitus indicates air in subcutaneous tissue usually due to pneumothorax
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c. tactile (vocal) fremitus: ask client to repeat "99"

i. symmetrical vibration felt when patient speaks

ii. increased over areas of consolidation



4. Percussion - normal findings: resonance heard throughout lung fields

5. Auscultation with stethoscope

a. normal findings: clear breath throughout all lung fields

b. whispered pectoriloquy

i. client whispers "one, two, three"

ii. over normal areas of the lung, only muffled faint sounds are heard

iii. over consolidated areas, the words are more distinct


c. egophony

i. client says "E"

ii. over consolidated areas, the sound is a nasal "A"



6. Alterations in lung function

a. cough - productive/nonproductive

b. expectoration

c. dyspnea

d. bradypnea

e. tachypnea

f. hyperpnea

g. apnea

h. Cheyne-Stokes respiration

i. Kussmaul's breathing

j. Biot's breathing

k. grunting

l. retractions

m. hemoptysis

n. pleural pain

o. accessory muscle use

p. cyanosis

q. adventitious sounds

i. crackles Listen

ii. pleural friction rub

iii. rhonchi

iv. stridor Listen

v. wheeze Listen

vi. whispered pectoriloquy Listen


r. pursed-lip breathing
i. prolonged exhalation
95


ii. breathing out through puckered lips



7. Pediatric variations

a. increased risk of obstruction from mucus, edema, or foreign body due to the following:

i. smaller, shorter, more pliable airways

ii. underdeveloped supporting cartilage


b. flexible larynx more susceptible to spasm

c. immature immune system

d. incomplete myelinization

e. increased basal metabolic rate

f. decreased ability to mobilize secretions

g. less forceful cough


I. Breasts

1. Inspection (performed with client in lying, sitting, or standing position)

a. size - vary from convex to pendulous


b. symmetry (the left breast is commonly larger than the other)

c. skin - smooth even color, venous pattern, possibly a few hairs around areola

d. alterations

i. retraction of nipples

ii. dimpling of breast tissue

iii. lesions

iv. edema

v. inflammation

vi. pregnancy and lactation

enlargement of breasts bilaterally

soreness of nipples during lactation

possible striae



e. nipple and areola

i. size - varies with individuals

ii. color - ranges from pink to brown

iii. shape symmetrical

areola - round or oval

nipples - usually protrude


iv. symmetry - normally symmetrical
96


v. direction - normally nipples point in same direction

vi. alterations

discharge

inverted nipples - unilateral more of a concern than bilateral

bleeding





2. Palpation - breast

a. lymph nodes - normal findings: not palpable

b. breast tissue

i. client in supine position with hands placed behind neck

ii. methods of examining breast tissue

clockwise or counterclockwise circling breast from nipple outward

back and forth with fingers moving up and down each breast (recommended method)

cover entire thoracic area, including axillary area


iii. consistency

varies widely from person to person

normal findings: dense, firm and elastic


iv. alteration - fibrocystic disease of the breast


v. older adult considerations

relaxed breasts

may appear elongated or pendulous

decrease in glandular tissue




J. Abdomen

1. History

a. pain (location), bowel habits, dietary problems, weight change, difficulty swallowing, flatulence,
belching, heartburn, anorexia, nausea, vomiting, cramping, hemorrhoids

b. changes in micturition including: change in amount and color of urine, irritation of the lower
urinary tract, obstruction of the urinary tract, urinary incontinence, urinary tract pain with
voiding or bladder spasms

c. medications


2. Inspection

a. landmarks

i. xiphoid process - marks upper boundary

ii. symphysis pubis - marks lower boundary

iii. abdomen divided into four quadrants: RUQ, RLQ, LUQ, LLQ
97




b. normal findings
i. skin texture and color should be consistent with rest of body

ii. striae may be present

iii. umbilicus is normally flat or inverted midway between xiphoid and symphysis pubis

iv. abdomen may be flat, rounded or concave; all three are normal if there is symmetry

v. may note peristalsis movement or aortic pulse normally

vi. voiding: steady, straight stream with no pain or post void dribble




3. Auscultation - perform before percussion and palpation to obtain baseline bowel sounds

a. bowel motility (normal findings) - bowel sounds audible in all quadrants, about 5 to 30 times per
minute

i. start in right lower quadrant (RLQ)

ii. if bowel sounds are present in the RLQ, indicates no obstruction above in the large intestine


b. vascular sounds - normal findings

i. no vascular sounds over aorta, femoral or iliac arteries

ii. renal artery bruits may be heard



4. Percussion - normal findings:

a. tympany over stomach and intestines

b. dullness over liver, spleen, pancreas, kidneys and distended (greater than 150 mL) bladder


5. Palpation

a. light palpation - gently depress 1 centimeter, moving to each quadrant

b. deep palpation - depress 5 to 8 centimeters; use one hand over another (bimanual) for obese
abdomen

c. normal findings - soft with no palpable masses, no tenderness or rigidity

d. bladder noted as a bulge in abdomen at the suprapubic area when filled with more than 500 mL of
urine


6. Alterations

a. distention

b. ascites

c. paralytic ileus

d. borborygmus

e. guarding

f. tenderness
98


g. pain


7. Older adult considerations

a. increased fat deposits over abdominal area

b. abdominal muscle tone more lax


K. Female reproductive system

1. History: sexual activity, sexually transmitted infection, vaginal discharge, menstrual history,
obstetrical history, contraception, self-care behaviors


2. Inspection - normal findings

a. hair distribution - variable; usually inverted triangle starting at symphysis pubis

b. skin of perineum smooth, clean, slightly darker than other skin, no lesions

c. labia majora may be closed or gaping

d. clitoris - about 2 centimeters in length and 0.5 centimeters in width

e. urethral orifice intact, pink without irritation, midline

f. vaginal orifice ranges from thin, vertical slit to large orifice with moist tissue

g. anus moist and hairless; skin more darkly pigmented


3. Older adult considerations

a. labial folds flatten

b. perineum paler

c. meatus usually more posterior

d. natural lubrication decreased

e. vagina shortens with age

f. uterus diminishes in size

g. ovaries atrophy with age

h. pubic hair decreases



L. Male reproductive system


1. History: sexual activity, sexual history, sexually transmitted infection, contraception, surgery,
associated urinary problems, self-care behaviors
99




2. Inspection

a. external genitalia

i. hair distribution varies; usually diamond shaped, extends from base of penis over symphysis
pubis up to umbilicus; coarse and curly

ii. penis shaft, corona, prepuce, glans

iii. urethral meatus is slit like opening positioned on ventral surface, millimeters from tip of
glans; opening should be glistening and pink

iv. scrotum

skin more darkly pigmented; more wrinkled; usually loose

symmetry - left testicle is lower than right

size - changes with temperature


v. inguinal canal (normal finding) - no bulging



3. Palpation

a. penis

i. smooth without lesions

ii. foreskin, if uncircumcised, should retract easily

iii. small amount of thick white secretion (smegma) between glans and foreskin is normal


b. testicle - ovoid; ranges from 2 to 4 centimeters in diameter, smooth and rubbery; non-tender;
rope-like structure posteriorly is the epididymis

c. scrotum - without lesions; spermatic cords smooth and non-tender

d. inguinal area - inguinal lymph nodes not palpable, no bulges


4. Older adult considerations

a. pubic hair - thinning, grey

b. penis - decrease in size

c. testes - decrease in size and less firm

d. scrotal sac - pendulous

e. increased bogginess of prostate gland



M. Rectum and anus - male and female


1. History: usual bowel routine, changes in routine, medication use, rectal bleeding, rectal concerns
or pain, family history, self-care behaviors

2. Inspection of perianal areas

a. skin - smooth and uninterrupted
100


b. anal tissues - normally moist and hairless


3. Palpation: rectal tone, presence of stool

4. Alterations

a. hemorrhoids

b. fissures

c. fistulas

d. polyps

e. pain with or without defecation



N. Musculoskeletal


1. History: participation in sports, injuries, surgeries, risk factors for osteoporosis, impact of current
problem on activities of daily living, falls, pain, self-care behaviors

2. Inspection - normal findings

a. gait - client walks with arms swinging freely at sides; coordinated and smooth; rhythmic with
push off and swing through

b. posture and balance

i. upright stance with parallel alignment of hips and shoulders

ii. feet aligned; toes pointing straight ahead

iii. convex curve to thoracic spine

iv. concave curve to lumbar spine

v. can stand still without swaying or tilting


c. extremities - bilateral symmetry in length, circumference, alignment, position and number of
skin folds



3. Palpation

a. joints

b. muscles

c. normal findings: non-tender, no swelling or warmth to touch


4. Range of motion (normal findings) - able to move joints through required range of motion

a. abduction

b. adduction

c. dorsiflexion

d. eversion

e. extension

f. flexion

g. hyperextension

h. inversion

i. plantar flexion

j. pronation

k. supination


5. Muscle strength and symmetry (normal findings) - arm on dominant side generally stronger

6. Alterations
101


a. kyphosis

b. lordosis

c. scoliosis

d. pain



7. Older adult considerations

a. stance less upright with head and neck forward

b. lumbar curvature less pronounced

c. height decreased

d. gait slower to initiate and stop

e. less knee and ankle lifts

f. steps may be shorter and more rapid

g. less coordination and balance

h. muscles atrophy with disuse

i. weaker grip
j. active range of motion may be slower and limited in one or more joints

k. joints appear larger than surrounding tissue; may be stiff



O. Neurological system



1. History: difficulties with memory, communication, sensory data, usual intellectual functioning,
headaches, seizures, dizziness, lightheadedness

2. Mental status - Mini-Mental State Examination (MMSE)

3. Emotional status (normal findings) - affect matches speech

4. Cranial nerve function

5. Level of consciousness (LOC) - normal findings

a. alert

b. orientation to person, place, time, situation

c. responds appropriately to visual, auditory, tactile and painful stimuli

d. able to carry out simple commands
102


e. Glasgow coma scale

f. alterations in LOC



REMEMBER IT
There are a lot of mnemonics to remember the names of the 12
cranial nerves; here's one of the "cleaner" versions: On Old
Olympus Towering Tops A Fin And German Viewed Some Hops

Here's a version to help remember which of the cranial nerves
carry sensory, motor, or both types of impulses (S=sensory,
M=motor, B=both): Some Say Marry Money But My Brother
Says Big Business Makes Money



6. sensory nerve function (normal findings)

a. visual - recognizes objects

b. auditory - identifies sounds

c. tactile - identifies objects through blind touch; perceives pain, hot and cold and vibration; two-point
discrimination

d. olfactory - identifies familiar smells

e. taste - intact

7. Cerebellar function - position and balance

8. Speech and language (normal findings)

a. smooth flowing speech

b. able to formulate words without difficulty

c. varied inflection

d. able to write letters and numbers to dictation

e. vocabulary appropriate to educational level


9. Intellectual (normal findings)

a. memory: immediate recall and remote recall

b. able to abstract

c. demonstrates consistent insight and perception of self


10. Reflexes - newborn assessment

11. Older adult considerations

a. longer response time to sensory stimulation

b. tactile sensation diminishes

c. senile tremor

d. kinesthesia diminishes

e. superficial and deep reflexes may be diminished or absent

When you examine the mouth, you see that the soft palate is moist and pink with whitish spots. Alternation Normal
The client is able to stand on one foot, with eyes shut, for five seconds. Alternation Normal
This 42 year-old client breathes 30 times per minute. Alternation Normal
You examine this client's breast and see a cluster of very tiny dimples near one nipple Alternation Normal
Auscultation reveals bowel sounds in two of the four abdominal quadrants. Alternation Normal
In this 60 year-old man, the left scrotal sac is slightly lower than the right. Alternation Normal
This client can tell you her name, but does not know the day of the week. Alternation Normal
103




X. Client and Family Education

A. Adult learning theory characteristics

1. Self-directed

2. Reservoir of experience

3. Mutual planning and goal setting preferred

4. Internally motivated

5. Established orientation to learning

6. Educator viewed as facilitator of learning

7. Experiential rather than didactic focus

8. Must be immediately applicable to situations


B. Teaching/learning process

1. Data collection - identification of learning needs related to health promotion

2. Communication of identified client needs to RN

3. Reinforce actions for outcomes or goals

4. Review educational offerings

5. Reinforce instructions about healthy behaviors, health risks, and health promotion such as risky
behaviors, breast and/or testicular cancer self-exams


C. Learning styles

1. Vary with individuals

2. Types are

a. visual

b. auditory

c. tactile - learn through touch and "hands on"

d. kinesthetic - learn through movement



D. Teaching strategies

1. Demonstration and return demonstration - individual

2. Programmed instruction - self-paced

3. Role playing - group work

4. Simulation - group work

5. Case study analysis - individual or group work



E. Legal implications

1. American Hospital Association (AHA) issued the Patients' Bill of Rights (1973): guarantees a person's
right to information necessary to give informed consent before treatment begins

2. Patient Care Partnership (2008): describes the rights and responsibilities of individuals who are
hospitalized (replaced the Patients' Bill of Rights)

3. All teaching must be individualized and documented in client's chart

4. Older adult considerations

a. make sure client has glasses or hearing aid, if indicated

b. face the client and use a lower pitched voice

c. supplement oral presentation with print materials
104


d. use large print

e. provide bright lighting

f. some clients have a hard time seeing color; use black ink on white or yellow paper

g. keep sessions short, 15 to 30 minutes, and work with critical information initially

h. repeat, as necessary

i. break down learning into small steps

j. use specific, step-by-step directions and have the client redemonstrate them in the same manner

k. get frequent feedback on client's level of understanding



5. Health Insurance Portability and Accountability Act (HIPAA)

a. signed into law in 1996

b. requires employer-sponsored group health plans, insurance companies, and health maintenance
organizations (HMOs) to

i. limit exclusions for preexisting conditions

ii. prohibit discrimination against employees and dependents based on their health status

iii. guarantee renewability of health coverage to certain employers and individuals

iv. protect many workers who lose health coverage by providing better access to individual health
insurance coverage


c. revised in 2003

i. provides patients with access to their medical records and more control over how their personal
health information is used and disclosed

ii. key provisions

access to medical records

notice of privacy practices

limits on use of personal medical information

prohibition on marketing

stronger state laws

confidential communications

complaints




Points to Remember - OB
Before Birth

Early and regular antepartal (before-birth) care is critical. First trimester health and nutrition directly influences the
development of organs in embryo and fetus.

To identify risks, nurses need both subjective (client's) and objective (the nurse's own) data.

Prescribed medications, over-the-counter drugs, alcohol, street drugs, and tobacco may lead to problems for the fetus
and mother.

Pregnancy diet must include increased calcium, protein, iron and folic acid, which is most critical the first trimester.

If the mother's situation warrants, suggest ways to adapt activity, employment, and travel.

It is helpful if the mother can have the same support person throughout pregnancy, birthing classes, and the labor and
delivery process.

A doula gives prenatal, labor, birth and postpartum support for mothers and families.

Labor

Normal active labor progresses 1.2 centimeters per hour for primiparas and 1.5 centimeters per hour for multiparas.

Maintain safety and medical asepsis through the labor and birth process to reduce risks to mother and fetus/newborn.

Ideally, the same caregivers should stay through all stages of labor.

Reinforce the childbirth preparation techniques practiced by the couple during pregnancy but be flexible since woman
105

will have shorter attention span, increased discomfort, and experience a fluctuation of emotions during labor.

Respect the cultural and religious beliefs of the woman and partner.

Involve the family in the birth process as noted in their birth plan or special requests.

Document ongoing assessments, changes in condition and care.

Pain and anxiety can impede progress of labor.

Safest time for the fetus is to administer analgesics is when the woman is dilated between 4 to 7 centimeters.

Be prepared to assist newborn transition to extrauterine environment.


Points to Remember - OB 2
Postpartum

Reinforce teaching (by demonstration and praise) self assessment and care soon after newborn's birth.

Postpartum physical assessment can be remembered using the acronym: B.U.B.B.L.E. (for breasts, uterus, bowels,
bladder, lochia and episiotomy or C-section incision)

Perform Coombs' tests to detect antibodies after the birth of each Rh positive newborn

direct Coombs' test on newborn using neonatal cord blood

indirect Coombs' test and antibody screen on the mother

Share your findings and plans with the parents; welcome their input.

Respect culture and religious beliefs of the family.

Praise the parents' skills.

Media and pamphlets are useful teaching aids if the parents have a chance to discuss them; be mindful of the level of
education.

Mothers are discharged within 24 to 48 hours; reinforce teaching accordingly.

Home visits and follow-up telephone calls enhance discussions about adaptations, questions and concerns.

Women's health promotion should be emphasized in postpartum period.

The adolescent mother benefits from developmentally appropriate teaching and referral to community resources,
including parenting classes.

Receptiveness to teaching peaks about 3 to 7 days after delivery.

Points to Remember - Growth & Development
General Concepts

Both growth and development normally proceed in a regular fashion from simple to complex and in a cephalocaudal
and proximodistal pattern.

Growth and development are impacted by genetics, environment, health status, nutrition, culture, and family
structures and practices.

Growth should be measured and evaluated at regular intervals throughout childhood; deviations from normal growth
and development should be thoroughly investigated and treated as quickly as possible.

Development occurs through conflict and adaptation.

Children

In the care of children, key concepts are anticipatory guidance and disease prevention.

Major developmental tasks of infancy are: increase in mobility, separation, and establishment of trusting relationships

In both toddlerhood and adolescence, hallmarks are development of independence and further separation.

Children and adolescents have rapid growth patterns, so nurses must stress optimum nutrition and give anticipatory
guidance related to nutrition.

Leading causes of death

Ages 0 to 1 year: developmental and genetic conditions that were present at birth, sudden infant death syndrome
(SIDS), all conditions associated with prematurity and low birth weight.

Ages 1 to 4 years: accidents, developmental and genetic conditions present at birth, cancer

Ages 5 to 14 years: accidents, cancer, homicide

Ages 15 to 24 years: accidents, homicide, suicide


Points to Remember - Growth & Development 2
Older Adults
106


Older adults must adjust to changing physical and cognitive abilities; a majority of older adults have at least one
chronic disease.

When older adults experience cognitive changes, check for possible substance abuse or polypharmacy.

Cognitive impairment can be acute and reversible, or it can be chronic and irreversible.

Many older adults have some impairment in performance of activities of daily living.

Some physiologic changes are a normal part of the aging process and do not signal disease, e.g., decreased cardiac and
respiratory reserves.

Older adults usually need more time to complete psychomotor tasks.

Age is a weak predictor of survival in traumatic injury and critical illness.

Major health problems typically include cardiovascular, cerebrovascular, and respiratory diseases; diabetes; and
cancer.

The older adult will change social roles, and these changes may affect psychological health, leading to depression.

Older adults need the same nutrition as other adults, but need more bulk and fiber, and a more nutrient dense diet
containing fewer calories.

Older adults clear drugs from kidney and liver more slowly; medications have longer half-lives, causing side effects
and toxicity at lower doses (Rule: start low [dose], go slow [increasing the dose]).

Older adults with low protein levels may have increased risks of drug toxicity for drugs that are protein-binding.

Points to Remember - Health Promotion
Data Collection

Check equipment prior to exam for proper functioning.

Take vital signs after the client is at rest for 5 to 10 minutes..

Compare both sides of the body for symmetry.

Collect data for the systems related to the client's major complaint first.

Offer rest periods if client becomes tired.

Note if culture and religious beliefs might play a role in observed differences.

Warm hands and equipment such as stethoscope before touching client.

Tell client what is going to be done before touching client.

Keep in mind that normal variations exist among clients with a range of normalcy for physical findings.

Maintain the client's privacy throughout the process.

Control for environmental factors which may distort findings - lights, sounds.

Consider growth and developmental needs when working with specific age groups.

Integrate health teaching or reinforcement throughout the process.

Cardiovascular

Compare blood pressure in both arms.

Compare blood pressure with client lying, sitting with feet in a dangling position, and standing.


Points to Remember - Health Promotion 2
Lungs

Anemic patients seldom become cyanotic (and are more commonly a dusky-ashen color when hypoxic).

Polycythemic clients may be cyanotic, even when oxygenation is normal.

Cough results from stimulation of irritant receptors, with implications of either acute or chronic etiology.

Cyanosis, either peripheral (hands, feet) or central (circumoral) in origin, is one of the last signs of decreased available
oxygen.

Wheezes indicates narrowing/inflammatory process of lower airways, such as bronchioles.

Stridor is a harsh sound produced near the larynx by a vibration of structures in upper airway with a classic "barky
cough."

Crackles or rales are adventitious sounds, usually heard on inspiration, and can be described as "moist," "dry," "fine,"
and "coarse."

Breasts

Breast tissue shrinks with menopause
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Teach client breast self examination

Abdomen

Remember that tightening of abdominal muscles hinders accuracy of palpation and auscultation; position is dorsal
recumbent for abdominal evaluation

Warm hands before touching client's abdomen.

Note that men breathe abdominally; women breathe costally.

Auscultate all four quadrants for bowel sounds, starting in the lower right quadrant.

Auscultate abdomen between meals if possible.

Auscultate the abdomen before performing percussion or palpation to avoid altering the pattern of bowel sounds

Points to Remember - Health Promotion 3
Musculoskeletal

Older adults walk with smaller steps and need a wider base of support.

Adolescents should be screened for scoliosis.

Neurological

Glasgow coma score

not valid in clients who have used alcohol or other mind-altering drugs.

possibly not valid in clients who are hypoglycemic, in shock, or hypothermic (below 93 F [33.9]).

Reflexes are normally less brisk or even absent in some areas in elderly clients.

Reflex response diminishes in the lower extremities before the upper extremities are affected.

Absent reflexes may indicate a neuropathy or a lower motor neuron disorder, resulting in flaccidity.

Hyperactive reflexes suggest an upper motor neuron disorder, resulting in spasticity.


Reinforcement of Health Care Team Teaching

The teaching-learning process mirrors the nursing process.

Teaching strategies are to be compatible with the client's learning style, age, culture, level of education.

Client teaching should be multi-sensory - tell (auditory), show (visual), have them demonstrate (tactile).

The client's learning style is determined and teaching methods geared to using that style.

The client's understanding is to be validated and documented.

Teaching must be geared to the educational level and interest of the learner - most written materials are written at the
sixth to eighth grade level.

Repeat key information and summarize main points at intervals.

Medical terminology should be stated in lay terms.

Information should be sequenced the way the client will use it.

Be concrete and use the simplest words and the shortest sentences when teaching low literacy clients or any client
under stress.


















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Questions
A nurse is preparing to take a toddler's blood pressure for the first time. Which action should the nurse perform first?
A. permit handling the equipment before putting the cuff in place
B. explain that the blood pressure checks the heart pump
C. explain that the procedure will help the child to get well
D. show a cartoon character with a blood pressure cuff

A practical nurse (PN) is collecting data on a healthy child at the two year check up. Which finding should the nurse report immediately to the registered nurse
(RN)?
A. the growth pattern appears to have slowed
B. the height and weight percentiles vary widely
C. the short term weight changes are uneven
D. the recumbent and standing height are different

A nurse is talking to parents about the side effects of routine immunizations. Which finding should the nurse reinforce about calling the health care provider if
it occurs within 24 to 48 hours after a routine immunization?
A. Some irritability and fussiness
B. Localized tenderness at the injection site
C. Swelling at the injection site
D. Tympanic temperature of 104 F (40 C)

A nurse who works in a public high school is reinforcing information with a class of unwed pregnant students. What is the most important action the nurse
should stress that each girl can take to deliver a healthy child?
A. maintain good nutrition
B. stay in school to keep normal activities
C. keep in contact with the child's father
D. get adequate sleep and frequent rest

During the reinforcement of actions to prevent sudden infant death syndrome (SIDS) with new parents what is the the most important guideline a nurse
should emphasize?
A. place the infant in a supine position for sleep
B. be sure to check the infant hourly during the night
C. follow the recommended immunization schedule
D. do not allow anyone to smoke in the home

A nurse plans to administer liquid medicine to a nine month-old child. Which method is appropriate for the nurse to use?
A. administer the medication with a syringe next to the tongue
B. mix the medication with the infant's formula in the bottle
C. hold the child upright and administer the medicine by spoon
D. allow the infant to drink the liquid from a medicine cup

A nurse measures the head and chest circumferences of a 20 month-old infant. After comparing these measurements, the nurse finds that they are
approximately the same. What action should the nurse take?
A. record these as normal findings
B. listen to breath sounds
C. notify the charge nurse
D. check the anterior fontanel

Prior to giving immunizations, a nurse should check children for possible contraindications which would include which finding?
A. depressed immune system
B. mild cold symptoms
C. low-grade fever
D. chronic asthma

A nurse is preparing to perform parts of a physical examination on an eight month-old who is sitting contentedly on the mother's lap. Which action should the
nurse perform first?
A. examine the skin
B. auscultate the lung sounds
C. measure height and weight
D. examine the external ears

A nurse is discussing the appropriate amount of milk intake with the parents of an 18 month-old child. The nurse should include in the response which
information about the child?
A. can have milk mixed with other foods
B. should have a daily limit of 3 to 4 cups of milk
C. will benefit from fat free cow's milk
D. may drink as much milk as desired

A 14 year-old boy with a history of severe hemophilia A was admitted after a fall while playing basketball. In understanding his behavior and assisting in
planning care for this client, a nurse should recognize that adolescents with hemophilia
A. need to have structured activities
B. often take part in active sports
C. avoid physical risks after bleeding episodes
D. explain any limitations to peers


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A nurse should remember that a toddler's tendency to say "no" to almost everything is an indication of
A. rejection of parents
B. stubborn behavior
C. frustration with adults
D. assertion of control

When the vital signs are taken in children, a nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about
which age (in years)?
A. two
B. four
C. three
D. one


A nurse is reinforcing information about adding table foods with parents of an 11 month-old. Which item should the nurse review as an appropriate finger
food?
A. popcorn
B. sliced bananas cut long wise
C. whole grapes
D. hot dog pieces cut into medallions

A client with heart failure is newly referred to a home health care agency. A nurse identifies that the client has not been following the prescribed diet. It would
be most appropriate for the nurse to take which action at this time?
A. notify the health care provider of the client's failure to follow the prescribed diet
B. recommend a release from home health care related to noncompliance
C. make a referral to Meal-on-Wheels for delivery of one meal three times a week
D. discuss the diet with client to learn the reasons for not following the diet

In reviewing the growth of a 12 month-old child, a nurse expects to find that the infant has which characteristic?
A. increased 10% in height
B. tripled the birth weight
C. two deciduous teeth
D. equal head and chest circumferences

A nurse is planning to give a three year-old child a dose of oral liquid digoxin. Which approach should the nurse plan to use?
A. "Would you like to take your medicine from a spoon or a cup?"
B. "This is your medicine, and you must take it all right now."
C. "Do you want to take this pretty red medicine?"
D. "You will feel better if you take your medicine."

A nurse is checking a two year-old client with a possible diagnosis of congenital heart disease. Which finding is most likely associated with this diagnosis?
A. changes in appetite over the past four to six months
B. weight and height in 10th percentile since birth
C. takes an unusual number of rest periods while playing
D. several otitis media episodes in the last year

While caring for a hospitalized toddler, a nurse reinforces information about the expected developmental changes for this childs age group to the parents.
Which statement by the mother shows that she understands the child's developmental needs?
A. "I understand the need of my child to use new skills."
B. "I intend to keep control over my child."
C. "I will set limits on my childs exploration of the house."
D. "I want to protect my child from any falls."

Which behavior should be of the greatest concern to the nurse when caring for a preschool-aged child?
A. identifies with a family member
B. expresses shame
C. explores the playroom
D. plays imaginatively


110




I. Concepts of Mental Health and Mental Illness

A. Biochemical research

1. Study of the brain and its functioning has helped researchers understand which parts of the brain are involved
in each mental illness

2. Medications are now more effective as a result of a better understanding of neurotransmitters and their
functioning

3. Major neurotransmitters include: norepinephrine, dopamine, serotonin, and gamma-aminobutyric acid (GABA)

4. Neuroimaging through positron emission tomography (PET scan) or the computed tomography (CT scan) and
magnetic resonance imaging (MRI scan) allow researchers and diagnosticians to study the brain without
surgery



B. Genetic research

1. Currently, no type of genetic testing can tell whether a person will develop mental illnesses; not enough is
known about which gene variations contribute to them or the degree to which other factors contribute

2. Familial and genetic factors are part of many major psychiatric illnesses, including bipolar disorder and
schizophrenia


C. Psychological theories

1. Psychoanalytic theory

a. developed by Sigmund Freud

b. introduced concept of the mind as a structure incorporating the id, ego and superego

c. part of each persona's mental functioning is conscious and part unconscious

d. treatment includes helping make the unconscious conscious

e. defense mechanisms are used to defend the ego from conflicts between the id and superego




2. Interpersonal theory

a. originally developed by Harry Stack Sullivan

b. personality develops according to the client's perception of how others view them

c. a healthy personality is the result of healthy relationships

d. Hildegard Peplau, who is considered to be the "mother of psychiatric nursing", was influenced by this theory

i. she wrote Interpersonal Relations in Nursing, which became the foundation for the nurse-client relationship

ii. according to Peplau, the nurse-client relationship is one in which

the client receives unconditional acceptance

the relationship between nurse and client is client-centered

the relationship is developed according to the client's perceived readiness




3. Psychosocial developmental theory

a. developed by Erik Erikson

b. describes eight psychosocial stages of development in the human life cycle

c. development is successful if the person is able to resolve the conflict that arises during each stage

d. if the person does not effectively resolve the conflict, then development is arrested at that stage



4. Cognitive behavioral theory (CBT)

a. focuses on the premise that a person's thoughts control their behavior
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b. if a client is feeling or behaving in an unwanted way, then it is important to identify the thoughts that are causing
these feelings or behaviors

c. the treatment is for the client to replace the current thoughts with ones that produce a more desirable outcome

d. CBT is used to help clients manage symptoms of their illness and live a fuller life


5. Behavioral theory

a. symptoms of mental illness are the result of learned behavior

b. through the use of positive and negative reinforcement unacceptable learned behavior can be replaced by a more
desired behavior

c. symptoms of phobias, sexual dysfunction, and eating disorders are some of the mental illnesses currently treated
using behavioral therapy

d. assertiveness training and desensitization are commonly used behavioral techniques


D. Religious and Spiritual Influences

1. Develop cultural self-awareness - respect the beliefs that are different from those of the nurse

a. Religion - an organized system of beliefs about a higher power

b. Spirituality - beliefs about the essence of being


2. Be familiar with common practices of common religions including value systems, diet, beliefs surrounding death.

a. Catholic

b. Protestant

c. Jewish

d. Muslim

e. Hindu

f. Buddhist

g. Mormon

h. Christian Scientist

i. Jehovah Witness


3. Seek personal spiritual support for clients who are in distress

a. Use of chaplain service

b. Consider HIPAA and client's wishes


4. Recognize that research supports the importance of spiritual support; several studies indicate that prayer
improves health status


E. Cultural Awareness and Cultural Competence

1. Nurse develops cultural self-awareness - respect cultural differences of others

a. Consider culture as different from race or ethnicity alone

b. Determine the cultural beliefs of the client especially related to health practices


2. Be familiar with various cultural practices

a. Folk healing of rural populations

b. Native American practices

c. Integration of Eastern healing or complementary and alternative therapies







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3. Determine any healing practices the client uses, prescribed or unprescribed

a. Use non-judgmental approach

b. Observe for positive or negative interactions of traditional (allopathic) therapy with complementary
alternative therapies (CAT)

c. Document all practices and therapies



F. Grief & Loss

1. Loss

a. a universal phenomenon, occurring across the lifespan

b. types of loss

i. loss of external objects

ii. loss of significant others through death or divorce

iii. loss of environment by relocating, accepting a new job, hospitalization

iv. loss of an aspect of self, which may include a body part (amputation of a limb), physiologic, or psychologic
function

v. perceived loss - felt by the person but intangible to others, e.g., youth

vi. situational loss - the result of an unpredictable event, e.g., natural disaster


c. response to loss depends on

i. personality

ii. culture

iii. previous experience with loss

iv. one's values

v. perceived value of loss

vi. support system




2. Types of grief

a. anticipatory grief: person learns of impending loss and responds with processes of mourning, coping, interaction,
planning, and psychosocial reorganization

b. disenfranchised grief: person experiences a loss that is not or cannot be openly acknowledged, publicly mourned,
or socially supported

c. complicated grief: a result of a sudden loss


3. Mourning: process used to resolve grief

4. Bereavement: a state of grieving

5. Models (or theories) of grief

6. Nursing interventions in grief

a. support client's effective coping mechanisms

b. don't take client's responses personally

c. listen attentively

d. help client with problem-solving and decision-making as indicated

e. encourage the client and/or significant others to express their feelings and concerns

f. utilize therapeutic touch as appropriate

g. assist in discussions of future plans as appropriate



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REMEMBER IT
Tasks of mourning (common to the models of grief): R E A L

Real - accept that the loss is real
Experience the emotions associated with the loss
Adjust or re-adjust to life and activities
Let go and move on with one's own life

II. Therapeutic Interventions

A. Therapeutic relationship

1. Definition: a relationship that is established between a health care professional and a client for the purpose of
assisting the client with problem solving, grief counseling, teaching regarding illness or situation

2. Relationship consists of

a. a nurse who possesses the skills and ability to provide counseling, crisis intervention, health teaching, etc.

b. the client who seeks help for some problem



B. Phases of the nurse-client relationship

C. Five characteristics of nurse-client relationship

1. Mutual definition - the nurse and client define the relationship together

2. Goal direction - purpose, time, and place are specific

3. Specified boundaries - in time, space, content, and confidentiality

4. Therapeutic communication - nurse creates trust and open communication by these interpersonal techniques

5. Nurse helps client toward resolution


D. Types of therapeutic interventions

1. Individual (or one-on-one) therapy

2. Group therapy

3. Family therapy

4. Milieu therapy

5. Occupational therapy



E. The non-compliant client

1. Behavior characteristics - does not cooperate with the treatment plan

a. does not take prescribed medication

b. continues activities restricted by provider of care, such as smoking, drinking, gambling, risk taking behaviors

c. does not follow prescribed activities, such as exercise, adequate rest, healthy diet



2. Nursing interventions

a. explore the reasons for non-compliance

i. lack of understanding - reinforce teaching

ii. lack of family support - involve family and support groups

iii. medication side effects - refer to provider of care

iv. finances and access - refer to Social Services

v. negative attitude toward treatment - encourage expression


b. express genuine concern for client

c. discuss improvement potential


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F. Stress management

1. Stress: a universal phenomenon; requires change or adaptation so that the person can maintain equilibrium

2. Stress can be internal or external

3. Nature of stressor involves

a. intensity

b. scope

c. duration

d. other stressors - their number and nature


4. Categories of stressors - and examples

a. physical - drugs or alcohol

b. psychological - such as adolescent emotional upheaval, or unexpressed anger

c. social - isolation, interpersonal loss

d. cultural - ideal body image

e. microbiologic - infection


5. The greater the stressor as perceived by the client, the greater the stress response

6. Stress response involves both localized and general adaptation

REMEMBER IT
PANIC episode:
Palpitations
Abdominal distress
Nausea
Increased perspiration
Chest pain, chills, choking


7. Factors affecting stress response

a. personal - heredity, gender, race, age, personality, cognitive ability

b. sociocultural - finances, support systems

c. interpersonal - self-esteem, prior coping mechanisms

d. spiritual or belief system

e. environmental - crowding, pollution, climate

f. occupational - work overload, conflict, risk


8. Physiologic indicators of stress (stress response)

9. Emotional and/or behavioral indicators of stress

10. Stress can cause a variety of emotional and physical disorders

11. Stress management strategies



G. Crisis intervention

1. Definition: an acute, temporary state of severe personality disorganization with an extreme state of emotional
turmoil; usual coping mechanisms and resources fail

2. Types

a. acute crisis: client temporarily loses control; panic state

i. emotional reactions are overwhelming
115


ii. decision making and problem solving abilities are inoperative

iii. thinking is scattered

iv. social isolation

v. immobilization (unable to act)


b. exhaustion crisis

i. under emergency conditions

ii. person has lost effective coping

iii. cannot continue to function


c. shock crisis

i. sudden external change

ii. causes release of emotions

iii. overwhelms client



3. (Four) phases of crisis response - average crisis is four to six weeks (may vary widely)

a. vulnerable state

b. precipitating event

i. developmental change - maturational crisis

ii. a life change - situational crisis

iii. loss of loved one or job - situational crisis

iv. environmental disaster or war - adventitious crisis


c. acute crisis

d. reorganization



4. Findings

a. mild to severe anxiety

b. anger

c. crying, social isolation, helplessness

d. impaired cognitive processes; inability to concentrate; confusion

e. insomnia

f. regression

g. nausea and vomiting


5. Treatment - brief supportive interventions focused on the phase of crisis

a. objective: to help the client through the current crisis

b. allow free discharge of emotions

c. enhance client's cognitive processes

d. pharmacologic: trazodone (Desyrel), alprazolam (Xanax)

e. therapies: occupational and recreational


6. Nursing interventions in crisis

a. provide a quiet, restful environment

b. empower the client to solve problems

c. allow the client to express feelings and emotions

d. determine and correct any misperceptions about the crisis the client may have
116


e. help the client to identify support systems and alternative solutions

f. help the client to deal with long term impact of crisis

g. encourage relaxation strategies, e.g., deep breathing, imagery

h. assist the client in the development of new coping skills

i. cognitive behavior therapy

j. administer medications as ordered

k. nursing response to violent situations

i. set consistent limits

ii. inform of consequences

iii. use seclusion and restraints, as indicated

iv. get support and assistance

v. position self for an escape path



H. Suicide Precautions

1. Definition

a. suicide is a self-harming act intended to produce death

b. degrees

i. completed suicide: life ends

ii. attempted suicide: failed self-destructive act

iii. suicide ideation: thoughts of ending one's life

iv. violence can be spontaneous or planned



2. Risk factors for suicide

a. depression/bipolar

b. delusions/hallucinations in psychotic clients - protect from harm

c. hopelessness

d. environmental factors - relationship, social, work and financial loss

e. substance abuse

f. isolation

g. previous suicide attempt

h. unwillingness to seek help


3. Findings - suicide warning signs

a. statements about suicide or violence - verbal or written

b. often exhibit stillness or calmness prior to the act

c. negative feelings, e.g., anger, sadness, hopelessness, negative view of future

d. recent loss of job, loved one, possessions

e. perceived lack of any support system

f. self-mutilation or other destructive behaviors



4. Treatment for suicidal thoughts and behaviors

a. objective - to treat the condition that underlies the suicidal thoughts

b. medications, including antidepressants, antianxiety, and/or antipsychotics

c. Suicide precautions

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5. Nursing care for clients at risk for suicide

a. goal - to assess the client's safety and toto protect client and others

b. establish trusting relationship; use therapeutic communication to encourage negative of feelings, thoughts, plans

c. monitor for verbal or clues such as giving away valuable possessions

d. administer medications as ordered

e. institute suicide precautions, as indicated by data

f. encourage relaxation strategies

g. notify appropriate health care provider


I. Abuse, Maltreatment and Neglect

1. Definitions: any recent act or failure to act that results in death, serious physical or emotional harm, sexual abuse
or exploitation; or an act or failure to act which presents an imminent risk of serious harm

a. types

i. abuse and neglect: child physical abuse, child sexual abuse, child neglect, child psychological abuse

ii. adult maltreatment and neglect: spouse or partner violence (physical or sexual), spouse or partner neglect,
spouse of partner abuse (psychological), adult abuse by nonspouse or nonpartner


b. abuse may be physical, sexual, emotional (or psychological); abandonment of children; substance abuse


2. Etiology

a. biological theories: neurophysiological, biochemical, genetic influences; disorders of the brain

b. psychological theories: psychodynamic theory and learning theory

c. sociocultural theories


3. Findings

a. abusers: blame the victim, are jealous and controlling, demonstrate poor impulse control; low self-esteem;
have unrealistic expectations; are frequently victims of abuse themselves and have a history of past battering

b. person suffering from abuse

i. battered women: low self-esteem, accept the blame; feelings of guilt, anger, fear, shame; isolated from
family and support systems

ii. specific symptoms of abuse: physical (broken bones or dislocations, welts and/or bruises, burns,
inappropriate bald spots; signs of being restrained); sexual (bruising or bleeding in genital or anal area; pain
or itching in genital area; genitourinary infection; evidence of sexual intercourse) and emotional (rocking,
sucking, or mumbling)

iii. symptoms of neglect: malnutrition; extremes in behavior and learning disorders in child; social isolation;
unattended medical problems; unwashed; inappropriately dressed; has attempted suicide


c. cycle of abuse

i. phase I: the tension-building phase

ii. phase II: the acute battering incident

iii. phase III: the "honeymoon" phase (calm, loving, respite)




4. Treatment

a. crisis intervention: remove victim from source of abuse, contact protective services, report to appropriate state
entity

b. family therapy


5. Nursing care

a. ensure privacy

b. limit the number of different health care workers
118


c. provide information about any procedure before beginning

d. offer support

e. stress the importance of safety

f. assist with filing collecting data and filing appropriate reports


III. Therapeutic Communication

A. Overview

1. Consider the developmental level, culture, spiritual and emotional aspects, and physical condition of the
client

2. Focus on actual objective behaviors, not on subjective inferences

3. Focus on description, not on judgment

4. Share information and explore alternatives, instead of offering advice and solutions

5. Focus on how and what and not "why"

6. For confused or disoriented clients, focus on reality orientation

7. Ask open-ended questions and seek information

8. Focus on nursing interventions


B. Therapeutic communication techniques to use

C. Nontherapeutic communication to avoid


D. Cross-cultural Communication

1. Findings of nontherapeutic communication

a. efforts to change the subject - client may not understand what the nurse is saying

b. lack of questions - client may not understand what was said

c. nonverbal cues - blank expression, lack of eye contact


2. Nursing interventions and therapeutic communication

a. use simple sentence structure and gestures while talking

b. use visual aids

c. discuss one topic at a time

i. use the same words when you repeat a topic

ii. go from simple to complex, or familiar to unfamiliar


d. use any words you know in the client's language

e. use a medical interpreter service for verbal communication - avoid using family members as interpreters

f. obtain phrase books or use flash cards

g. ask open-ended questions


3. Cultural interpretations

a. silence

b. (appropriate and therapeutic) touch

c. (culturally-appropriate) eye contact



E. Clients with Hearing Loss

1. Findings of hearing loss

a. speech deterioration

b. indifference
119


c. social withdrawal

d. suspicion

e. tendency to dominate conversation

f. misinterpretation of what is said

g. lack of response to direct questioning


2. Nursing interventions

a. speak slowly and distinctly; do not shout

b. face client directly

c. make sure your face is clearly visible

d. before the discussion, tell client the topic you are going to discuss

e. insure that client has access to hearing aid and that it is functional

f. keep sentences short and simple

g. use written information to enhance spoken word

h. use lower tone of voice



F. Clients with Aphasia

1. Injured cerebral cortex blocks some language-related functions

2. Types of aphasia

a. global aphasia - the most severe form of aphasia where individuals cannot read, write, or understand speech

b. Broca's aphasia ("non-fluent" aphasia) - speech is limited mainly to short utterances of less than four words;
the client may understand speech and be able to read but has limited writing ability

c. Wernicke's aphasia ("fluent" aphasia) - inability to understand the meaning of spoken words and reading and
writing is impaired; able to speak but sentences do not hang together and speech may consist of mostly jargon


3. Nursing interventions

a. face client and establish eye contact

b. avoid completing client's statements

c. use gestures, pictures, and communication boards

d. limit conversation to practical matters

e. use the same words and gestures for objects

f. keep background noise to a minimum and turn off competing sounds, e.g., radio, television

g. do not shout or speak loudly

h. give the client time to understand and respond

i. if client has problems speaking, ask "yes" or "no" questions



120

G. Clients Post-CVA

1. Approach client from side of intact field of vision

2. Remind client to turn head in direction of visual loss to compensate for loss of visual field

3. Explain location of object when placing it near the client

4. Always put client care items in same places

5. Put objects within client's reach and on unaffected side

6. Encourage client to repeat sounds of the alphabet

7. Speak slowly and clearly

8. Use simple sentences with gestures or pictures

9. Reorient client to time, place, and situation

10. Provide familiar objects

11. Minimize distractions

12. Repeat and reinforce instructions


H. Clients with Dementia

1. Be calm and unhurried

2. Keep conversations short and focused

3. Do not ask the client to make decisions

4. Use "yes" or "no" questions

5. Be consistent

6. Avoid distractions

7. Use reality orientation techniques

REMEMBER IT
Communication with individuals with
aphasia or dementia is enhanced if you
remember the K.I.S.S. technique:
Keep It Short and Simple!

The nurse-client relationship is a mutually defined, social relationship. True False

Peplau is considered to be the mother of psychiatric nursing. True False

Grieving over the loss of a loved one lasts for approximately one year. True False

Primitive defense mechanisms are very effective for long-term use. True False

Stress mobilizes the parasympathetic nervous system. True False

Liquid medications are best for clients who are on suicide precautions. True False

A person under stress has pinpoint pupils and feels an urge to urinate. True False

The nurse should write everything down for the client with Wernicke's aphasia. True False

Be sure to look directly at clients before starting to speak. True False

Religious beliefs influence decisions about health. True False




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IV. Mental Disorders

A. Anxiety Disorders

1. Definition: a condition in which a person has excessive fear and anxiety and related behavioral disturbances

a. types: separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, panic
disorder, agoraphobia, generalized anxiety disorder (GAD)

b. depression and substance abuse may occur with an anxiety disorder


2. Etiology

i. not known; may have a genetic link

ii. stress may contribute to the development of GAD


3. Findings

a. main symptom is frequent worry or tension for at least 6 months, even when there is little or no clear
cause; usually related to family, other relationships, work, school, money, health

b. even when aware that worries or fears are stronger than appropriate for the situation, a person with GAD
still has difficulty controlling them

c. other symptoms: problem concentrating; fatigue; irritability; problems falling or staying asleep or restless
sleep; restlessness when awake; upset stomach; sweating; difficulty breathing; muscle tension.



Generalized Anxiety Disorder Panic Disorder




4. Diagnostics

i. physical exam and mental health assessment

ii. laboratory tests to rule out other conditions that may cause similar symptoms


5. Treatment

a. talk therapy

b. medications

i. antidepressants

SSRIs: fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), citalopram (Celexa)

SNRI: venlafaxine (Effexor) is commonly used to treat GAD

bupropion (Wellbutrin)

tricyclic antidepressants: imipramine (Tofranil) is prescribed for panic disorder and GAD

MAOIs: phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan)


ii. anti-anxiety: buspirone (Buspar) for GAD

iii. beta-blockers: propranolol (Inderal)

iv. benzodiazepines: clonazepam (Klonopin) for social phobia and GAD, lorazepam (Ativan) for panic disorder,
alprazolam (Xanax) for panic disorder and GAD


c. stress and relaxation techniques, yoga, acupuncture; kava


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6. Nursing care

a. provide non-demanding environment

b. acknowledge clients feelings

c. do not force contact with feared item or situation

d. provide distracting activities

e. use relaxation techniques

f. identify triggers

g. encourage client to take responsibility for self-care

h. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

ii. management of the illness

medication management

stress management strategies

teach ways to interrupt escalating anxiety


iii. support services, including crisis hotline, support groups, individual psychotherapy




B. Bipolar & Related Disorders

1. Definition: a condition in which a person has episodes of depression and periods of being extremely happy or
being cross and irritable; it includes changes in activity and energy as well as mood

a. types of disorders: bipolar I, bipolar II, cyclothymic

b. cycle: episodes of depression are more common than episodes of mania


2. Etiology: not known; but it occurs more often in relatives of people with bipolar disorder

a. affects men and women equally

b. usually starts between ages 15 and 25

c. common triggers of a manic episode: childbirth, medications (antidepressants or steroids), insomnia,
recreational drug use


3. Findings

a. manic phase may last days to months: easily distracted, little need for sleep, poor judgment, poor temper
control, reckless behavior and lack of control (such as excessive drinking, drug use, sex with many partners,
spending sprees), expansive or irritable mood (racing thought, talking a lot, false beliefs about self or abilities),
very involved in activities

b. depressive episodes are more common than mania and may include: daily low mood or sadness, difficulty
concentrating, remembering or making decisions, eating problems (loss of appetite and weight loss or
overeating and weight gain), fatigue or lack of energy, feeling worthless, hopeless or guilty, loss of pleasure in
activities once enjoyed, loss of self-esteem, thoughts of death or suicide, trouble of getting to sleep or sleeping
too much, pulling away from friends or activities that were once enjoyed


4. Diagnostics: physical exam and mental health assessment


5. Treatment

a. medications

i. mood stabilizers

lithium

anticonvulsants: valproic acid (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), oxcarbazepine
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(Trileptal)


ii. antidepressants (SSRIs): fluoxetine (Prozac), sertraline (Zoloft)

iii. atypical antipsychotics: olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal), ziprasidone
(Geodon), clozapine (Clorazil), lurasidone (Latuda)


b. electroconvulsive therapy (ECT)

c. support programs and talk therapy

d. hospitalization for severe manic or depressive episode


6. Nursing care

a. prevent self-injury and suicide ( Suicide Precautions )

b. mania:

i. offer high protein, high calorie finger foods, supplements for weight loss/malnutrition

ii. set limits on manipulative behavior

iii. positive reinforcement for appropriate behavior

iv. reduce stimuli


c. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

causes of bipolar disorder

cyclic nature of the illness

symptoms of depression and mania


ii. management of the illness

medication management

lithium: symptoms of toxicity, importance of regular blood tests

side effects

adverse effects

importance of not stopping medication

assertive techniques

anger management

electroconvulsive therapy


iii. support services, including crisis hotline, support groups, individual psychotherapy; legal and/or financial
assistance



C. Depressive Disorders

1. Definition: characterized by the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive
changes that significantly affect the individuals capacity to function for weeks or longer; types include disruptive
mood dysregulation, major depressive disorder, persistent depressive disorder (formerly called dysthymia),
premenstrual dysphoric disorder

2. Etiology

a. exact cause is not known; most likely it's due to a combination of genetic, biological, environmental and
psychological factors

b. alcohol or drug abuse, hypothyroidism or chronic pain, medications (steroids), sleeping problems, and
stressful life events are associated with depression


3. Findings

a. agitation, restlessness, and irritability, anger; becoming withdrawn or isolated, fatigue and lack of energy,
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feeling hopeless and helpless, worthless, guilty, self-hate; loss of interest or pleasure in activities that were
once enjoyed; sudden change in appetite, thoughts of death or suicide; trouble concentrating; trouble sleeping
or sleeping too much

b. severe depression can also be accompanied by hallucinations and delusions






4. Diagnostics

i. physical exam and mental health assessment

ii. blood and urine test to rule out other medical conditions with symptoms similar to depression


5. Treatment

a. medications - antidepressants

i. SSRIs: fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft), paroxetine (Paxil), escitalopram (Lexapro)

ii. SNRIs: venlafaxine (Effexor) and duloxetine (Cymbalta)

iii. bupropion (Wellbutrin)

iv. tricyclics, tetracyclics, and MAOIs may also be used


b. talk therapy

i. cognitive behavioral therapy - to teach hot to fight off negative thoughts

ii. psychotherapy - to help to understand the issues that may be behind thoughts and feelings

iii. group therapy - to share with other who have like problems


c. electroconvulsive therapy (ECT)

d. light therapy - to relieve symptoms in the winter time (seasonal affective disorder or SAD)

e. acupuncture, stress and relaxation techniques, massage, meditation, yoga, Tai Chi, Qigong, SAMe

Due to its short half-life (and few drug interactions), Zoloft is the drug of choice for treating depression in the elderly.
Conversely, due to its long half life, PROzac is a better choice for children.


6. Nursing care

a. watch for suicidal behavior in children, teens, young adults ( suicide warning signs and suicide precautions )

b. encourage participation in goal setting and decision-making for own care

c. encourage client to explore and verbalize feelings and perceptions

d. monitor sleep, eating and self-care activities

e. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

ii. management of the illness

medication management
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side effects to report to the health care provider

importance of taking medications regularly

length of time to take effect

diet (specifically for MAOIs)

AVOID concurrent use of natural remedies (St. John's wort and certain antidepressants can lead to
serotonin syndrome)

assertiveness techniques

stress management strategies

way to increase self-esteem

electroconvulsive therapy (ECT)


iii. support services, including suicide hotline number; support groups; legal and financial assistance



D. Feeding & Eating Disorders

1. Definition: characterized by a persistent disturbance of eating or eating-related behavior that results in the
altered consumption or absorption of food and that significantly impairs physical health or psychosocial
functioning

a. types: pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa,
binge-eating disorder

b. serious medical complications can develop over time

i. anorexia - severe malnutrition, low potassium levels, heart problems, confusion

ii. bulimia nervosa - constipation, dehydration, dental cavities, electrolyte imbalances, hemorrhoids,
pancreatitis, swelling of the throat, tears of the esophagus



2. Etiology

a. not known

b. risk factors for anorexia include having an anxiety disorder as a child; having a negative self-image; having
certain social or cultural ideas about health and beauty; trying to be perfect or overly focused on rules


3. Findings

a. anorexia nervosa - severely limiting food intake; cutting food into small pieces and moving around the plate;
refusing to eat around other people; exercising all the time; using diuretics, enemas and laxatives and diet
pills; blotchy or yellow, dry skin covered with fine hair; depression, dry mouth; extreme sensitivity to cold; loss
of bone strength; muscle wasting and loss of body fat

b. bulimia nervosa - eat large amounts of high-calorie foods, usually in secret; forced vomiting; cavities or
gingivitis and enamel of teeth may be worn away or pitted due; excessive exercise; broken blood vessels in the
eyes; dry mouth; using laxatives, enemas or diuretics; small cuts and calluses across the tops of the finger
joints (from forcing oneself to vomit) known as Russells sign



4. Diagnostics

a. anorexia nervosa - laboratory tests to help find the cause of weight loss or to determine damage done by weight
loss including albumin, bone density test, CBC, ECG, electrolytes, kidney function tests, liver function tests, total
protein, thyroid function tests, urinalysis

b. bulimia nervosa - dental exam

c. general

i. physician exam and mental health assessment, including family history

ii. clinician-administered tests, such as Eating Disorder Examination (EDE), Yale-Brown-Cornell Eating Disorder
Scale (YBC-EDS)

iii. self-reports, such as Diagnostic Survey for Eating Disorders (DESD), Eating Attitudes Test (EAT), Eating
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Disorders Questionnaire (EDQ) and many others



5. Treatment

a. anorexia

i. hospitalization may be needed; follow-up with day treatment program

ii. increasing social activity, reducing the amount of physical activity, using schedules for eating (nutritional
rehabilitation)

iii. refeeding programs

iv. medications: antidepressants such as the SSRI fluoxetine (Prozac) (regardless of whether or not the client is
depressed)

v. talk therapy, including cognitive behavioral therapy, group therapy, and family therapy; support groups



b. bulimia

i. a stepped approach, including support groups, cognitive behavioral therapy, and nutritional therapy

ii. medications: antidepressants such as the SSRI fluoxetine (Prozac)

iii. support groups, such as Overeaters Anonymous and American Anorexia/Bulimia Association



6. Nursing care

a. establish adequate/appropriate nutritional intake

b. correct fluid and electrolyte imbalance

c. assist client to develop realistic body image and to improve self-esteem

d. provide support and involve significant others (including family) in treatment program

e. participate in total treatment program with other disciplines

f. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

symptoms of the illness

causes of eating disorder

effects of the illness or condition on the body


ii. management of the illness

principles of nutrition

importance of expressing fears and feelings

alternative coping strategies, relaxation techniques, problem-solving skills

correct administration of prescribed medications

indication for and side effects of medications

when to contact health care provider


iii. support services, such as Overeaters Anonymous, National Association of Anorexia Nervosa and Associated
Disorders (ANAD), the American Anorexia/Bulimia Association, Inc.



E. Neurodevelopmental Disorders

1. Definition: characterized by developmental deficits that produce impairments of personal, social, academic, or
occupational functioning; typically manifested before a child enters grade school

a. types: intellectual disability (intellectual developmental disorder), global developmental delay, language
disorders (including stuttering), autism spectrum disorder, attention-deficit/hyperactivity disorder, learning
disorder, tic disorder

b. requires assessing both cognitive capacity (IQ) and adaptive functioning


2. Etiology
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a. autism spectrum disorder: exact causes are not known

i. linked to abnormal biology and chemistry in the brain

ii. diet, digestive tract changes, mercury poisoning are also considered

iii. can be associated with other disorders of the brain, such as fragile X syndrome, tuberous sclerosis


b. attention deficit hyperactivity disorder (ADHD): not known; probably due to a combination of genetics and
environmental factors


3. Findings

a. autism spectrum disorder

i. difficulties in pretend play, social interactions, verbal and nonverbal communication

ii. overly sensitive in sight, hearing, touch, smell, or taste

iii. have unusual distress when routines are changed, perform repeated body movements, show unusual
attachments to objects


b. attention deficit hyperactivity disorder (ADHD): symptoms fall into 3 groups

i. inattentiveness

ii. hyperactivity

iii. impulsivity




4. Diagnostics

a. autism spectrum disorder

i. complete physical and neurologic exam

ii. hearing evaluation (for delay in language milestones)

iii. blood lead test

iv. genetic testing (for chromosome abnormalities)

v. metabolic testing

vi. screening tests, such as the Checklist for Autism in Toddlers [CHAT] or Autism Screening Questionnaire) and
evaluation of autism (using the Autism Diagnostic Interview-revised (ADI-R); Autism Diagnostic Observation
Schedule (ADOS); Childhood Autism Rating Scale (CARS); Gilliam Autism Rating Scale; pervasive
Developmental Disorders Screening Test-Stage 3


b. attention deficit hyperactivity disorder (ADHD)

i. complete physical and neurologic exam

ii. diagnosis is based on a pattern of the symptoms

iii. many children have at least one other developmental or mental health problem such as a mood, anxiety or
substance use disorder, a learning disability, or a tic disorder



5. Treatment

a. autism spectrum disorder - treatment is most successful when it is geared toward the child's particular needs

i. applied behavior analysis (ABA)

ii. medications - to treat aggression, anxiety, attention problems, extreme compulsions; hyperactivity,
impulsiveness, irritability, mood swings, sleep difficulties, tantrums

risperidone (Risperdal) - an antipsychotic approved to treat children ages 5-16 for irritability and aggression

SSRIs

divalproex (Depakote) - an anticonvulsant also used to treat the manic phase of bipolar disorder

mood stabilizers

stimulants, such as methylphenidate (Ritalin, Concerta)

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iii. diet - some children respond to gluten-free or casein-free diet

iv. various therapies, including occupational therapy, physical therapy, speech-language therapy, vision therapy
and sensory integration therapy

v. support groups


b. attention deficit hyperactivity disorder (ADHD) - partnership between health care provider and client; if client is a
child, then parents and teachers are involved

i. set specific appropriate goals

ii. medication: psychostimulants (stimulants), including methylphenidate(Ritalin, Concerta), amphetamine
(Adderall), dextroamphetamine (Dexedrine), lisdexamfetamine dimesylate (Vyvanse)

iii. various therapies, including talk therapy, behavioral therapy (to teach healthy behaviors and how to manage
disruptive behaviors)

iv. support groups



6. Nursing care

a. consistent daily schedule

b. limit distractions

c. clear and consistent rules for child

d. encourage, praise and reward independent achievement

e. assess the clients mental status

f. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

ii. management of the illness

medication management

side effects

length of time to take effect

what to expect from the medication

explain drug "holiday" (for ADHD)

AVOID over-the-counter medication

importance of not stopping medication

importance of sleep

importance of good nutrition

problem-solving skills


iii. support services, including support groups; legal and financial assistance



F. Obsessive-compulsive and related disorders

1. Definition: an anxiety disorder in which people have unwanted and repeated thoughts, feelings, ideas, sensations
(obsessions), or behaviors that make them feel driven to do something (compulsions)

a. types: obsessive-compulsive disorder (OCD), body dysmorphic disorder, hoarding, trichotillomania disorder
(hair pulling), excoriation disorder (skin-picking)

b. OCD does not usually progress into another disease but there can be long-term complications, such as
excessive hand washing can cause skin breakdown and compulsive hair pulling can lead to hair loss


2. Etiology: not known; however, factors that may play a role include head injury, infections and abnormal brain
function

3. Findings

a. obsessions or compulsions that are not due to medical illness or drug use
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b. obsessions or compulsions cause major distress or interfere with everyday life; not doing the obsessive rituals
can cause great anxiety; the person recognizes the behavior is excessive and unreasonable

c. many people with OCD may have other psychiatric comorbid disorders, including mood and anxiety disorders,
eating disorders, ADHD


4. Diagnostics

a. physical exam and mental health assessment

b. Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to define range and severity of symptoms



5. Treatment

a. medications

i. antidepressants

tricyclic: clomipramine (Anafranil) is used to treat OCD

SSRIs: such as fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil), and
citalopram (Celexa)


ii. antipsychotics: olanzapine (Zyprexa), aripiprazole (Abilify), risperidone (Risperdal)

iii. mood stabilizers: carbamazepine (Tegretol), divalproex (Depakote), lamotrigine (Lamictal)


b. cognitive behavior therapy (exposure and response prevention or ERP)

c. deep brain stimulation (when OCD does not respond to other treatments)


6. Nursing care

a. promote a predictable, structured schedule

b. avoid engaging in power struggles

c. identify triggers to ritualistic behaviors

d. initially allow time for rituals and then begin to limit

e. provide positive reinforcement for non-ritualistic behavior

f. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

ii. management of the illness

medication management, including side effects, length of time to take effect and what to expect

stress management strategies

teach ways to interrupt escalating anxiety


iii. support services, including crisis hotline, support groups, individual psychotherapy; legal and/or financial
assistance



G. Personality disorders

1. Definition: an enduring pattern of inner experience and behavior that deviates markedly from the expectations of
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the individuals culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over
time, and leads to distress or impairment

a. types: general personality, paranoid personality, schizoid personality, schizotypal personality, antisocial
personality, borderline personality, histrionic personality, narcissistic personality, avoidant personality,
dependent personality, obsessive-compulsive personality

b. complications include imprisonment, drug abuse, violence, suicide


2. Etiology: not known

a. may be related to genetic factors and environmental factors, for example, subjected as a child to abuse,
alcoholic parents, etc.

b. more men than women are affected

c. fire-setting and cruelty to animals during childhood are linked to the development of antisocial personality



3. Findings: may be able to act witty and charming; be good at flattery and manipulating other peoples emotions;
break the law repeatedly; disregard the safety of self and others; have problems with substance abuse; lie, steal
and fight often; show no guilt or remorse; are often angry or arrogant

4. Diagnostics: psychological evaluation to assess history and severity of symptoms


5. Treatment: difficult to treat; people usually start treatment when required by court action

a. behavioral treatment

b. talk therapy

c. medication can be used to treat symptoms of anxiety, anger, impulsiveness



6. Nursing care

a. protect client and others from harm

b. provide low environmental stimuli

c. observe behavior

d. set limits and provide structured environment

e. gradually encourage appropriate expression of anger

f. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

ii. management of the illness

medication management, including side effects

relaxation techniques

participation in therapy


iii. support services, including financial and legal assistance



H. Schizophrenia Spectrum & Other Psychotic Disorders

1. Definition: a lifelong condition that makes it hard to think clearly, to tell the difference between what is real and
not real, to have normal emotional responses and to act normally in social situations

a. types: schizophrenia, psychotic disorders, schizotypal (personality) disorder

b. defined by abnormalities in one or more of the following: delusions, hallucinations, disorganized speech

c. complications: having schizophrenia increases the risk of developing problems with drugs or alcohol, physical
illness (due to inactive lifestyle and medication side effects), suicide


2. Etiology: not known; there may be a genetic factor

a. affects about 1% of the world population

b. usually first diagnosed in late teens to early 20s

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3. Findings: symptoms develop slowly over months or years

a. early symptoms: may include irritable or tense feelings, trouble concentrating, trouble sleeping

b. later symptoms: involve thinking, emotions, and behavior, including: bizarre behaviors, hallucinations,
isolation, reduced emotion, problems paying attention, delusions, loose associations



4. Diagnostics

a. physical exam and mental health assessment

b. brain scans (CT or MRI)

c. laboratory tests to rule out other conditions with similar symptoms


5. Treatment

a. hospitalization during acute episodes

b. medications

i. antipsychotics

typical: chlorpromazine (Thorazine), haloperidol (Haldol), perphenazine, fluphenazine

atypical: clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone
(Geodon), aripiprazole (Ability), paliperidone (Invega), lurasidone (Latuda)


ii. antiparkinsonism agents: used to counteract the extrapyramidal side effects (tardive dyskinesia) of many
antipsychotic medications


c. support programs, including family therapy

d. behavioral techniques, such as social skills training, job training


6. Nursing care

a. establish therapeutic relationship - build trust, be honest and dependable

b. avoid touching the client without warning

c. observe for signs of hallucinations but do not reinforce hallucinations - orient client to reality

d. encourage independence in ADLs but intervene as needed

e. give recognition and positive reinforcement for appropriate interactions with others

f. prevent injury to others, self-injury and suicide ( suicide precautions )

g. monitor for side effects of medications

h. assist with setting realistic goals

i. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

ii. management of the illness

medication management

medication side effects

importance of not stopping medications
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when to contact health care provider

relaxation techniques and stress management strategies

skills training, such as social skills training and daily living skills training


iii. support services, including financial and legal assistance; support groups; respite care



I. Substance-related and Addictive Disorders

1. Definition: substance use disorder is a maladaptive pattern of substance use leading to clinical significant
impairment or distress; characterized by addiction, craving, tolerance, withdrawal

a. many different classes of drugs including cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics and
anxiolytics, stimulants

b. often co-occurring mental illness and substance abuse

c. potential complications include bacterial endocarditis, depression, overdose, cancer (mouth and stomach
cancer are associated with alcohol abuse), HIV, memory or concentration problems, problems with the law,
relapse of drug abuse, unsafe sexual practices


2. Etiology: not known; however, genetics, the action of the drug, peer pressure, emotional distress, anxiety,
depression or another mental health problem can contribute to use/abuse

3. Findings

a. stimulants: alertness with increased vigilance, a sense of well-being and euphoria; talkative, flight of ideas,
insomnia, anorexia, tachycardia, hypertension, pupillary dilation

b. opioids: symptoms of mild-to-moderate intoxication include drowsiness, pupillary constriction, slurred speech;
for overdose, respiratory depression, stupor and coma

c. depressants: drowsiness, relaxation, decreased inhibition, incoordination, slurred speech, staggered walk,
respiratory depression

d. specific to chronic alcohol use: anemia, cirrhosis, esophagitis, delirium tremens, hepatomegaly, malabsorption
syndrome, Wernicke-Korsakoff syndrome

e. non-specific: continuing to use drugs even when health, work, or family are being harmed; episodes of
violence/ hostility when confronted about drug use; lack of control over drug use; making excuses to use drugs;
missing work or school or decrease in performance; need for daily or regular drug use to function; neglecting to
eat; not caring for physical appearance; no longer taking part in activities because of drug use; secretive
behavior to hide drug use



4. Diagnostics

a. physical exam and mental health assessment

b. laboratory tests including toxicology screens on blood and urine samples, CBC, electrolytes; liver function tests,
hepatitis viral testing, HIV testing, blood cultures; also ECG, CT scan

c. other tests: naloxone challenge test (for opioid abuse)

d. questionnaires, including Michigan Alcoholism Screening Test (MAST), Cage Questionnaire


5. Treatment

a. begins with recognizing the problem

b. detoxification

i. alcohol

benzodiazepines and antipsychotic medications to treat acute phase

disulfiram (Antabuse) alcohol abuse deterrent

naltrexone (Revia) or nalmefine (Revek) - lower cravings for and less pleasure from drinking


ii. opioids: methadone, clonidine (Catapres) and buprenorphine (Buprenex)

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c. treat malnutrition; treat vitamin and mineral deficiencies (folate, B12, vitamin A, calcium) as needed

d. treat infectious diseases

e. support

counseling

support groups, such as Narcotics Anonymous, Alcoholics Anonymous, Smart Recovery, Lifering Recovery


f. after-care (abstinence)


6. Nursing care

a. during acute withdrawal

i. protect client from harm

ii. monitor vital signs

iii. seizure precautions

iv. consult dietitian

v. participate in total treatment program with other disciplines


b. during abstinence

i. provide emotional support

ii. support development of new coping skills

iii. set limits on manipulative behavior

iv. provide positive feedback for delayed gratification and using adaptive coping strategies


c. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

effects of substance on the body

ways in which use of substance affects life


ii. management of the illness

activities to substitute for substance in times of stress

relaxation techniques

problem-solving skills

essentials of good nutrition, including vitamins supplements


iii. support services, including financial and legal assistance; alcoholics anonymous (or other support group
specific to the abused substance); one-to-one support person



J. Trauma- and Stressor-related Disorders (PTSD)

1. Definition: a type of anxiety disorder in which there has been exposure to a traumatic or stressful event that
involved the threat of injury or death; types include reactive attachment, disinhibited social engagement,
posttraumatic stress (PTSD), acute stress, adjustment

2. Etiology: not known

a. traumatic events, such as an assault, car accidents, domestic abuse, natural disasters, prison stay, rape,
terrorism, war, cause someone to develop PTSD

b. the body keeps releasing the stress hormones and chemicals


3. Findings of PTSD

a. 3 main issues

i. reliving the event, which disturbs day-to-day activity

ii. avoidance

iii. hyperarousal

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b. may also have guilt about the event (survivor guilt)

c. symptoms of anxiety, stress and tension



4. Diagnostics

a. physical exam and mental health assessment

b. blood tests to rule out other illnesses

c. PTSD is diagnosed when someone has symptoms for at least 30 days

d. assessment tools, including the Clinician-Administered PTSD Scale (CAPS); Brief Interview for Posttraumatic
Disorder (BIPD), Acute Stress Disorder Interview (ASDI)


5. Treatment of PTSD

a. cognitive behavioral therapies

b. eye movement desensitization and reprocessing (EMDR)

c. hypnotherapy

d. medications

i. the only FDA-approved medication are SSRIs: sertraline (Zoloft) and paroxetine (Paxil)

ii. "off label" medications: other antidepressants (for example, fluoxetine [Prozac]), mood stabilizers and
anxiolytics (benzodiazepines)



6. Nursing care for PTSD

a. establish trust

b. encourage verbalization about the trauma when ready

c. stay with client during periods of flashbacks and nightmares

d. discuss coping strategies

e. assess for self-destructive ideas or behavior, including suicide warnings

f. assess for maladaptive coping (such as substance abuse)

g. assist health care team to implement client (and family) teaching plan

i. the nature of the illness

ii. management of the illness

medication management, including side effects, length of time to take effect and what to expect from the
medication

stress management

teach ways to interrupt escalating anxiety


iii. support services, including crisis hotline, support groups, individual psychotherapy; legal and/or financial
assistance



K. Other Disorders

1. Disruptive, impulse-control, and conduct disorders
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a. these disorders include conditions involving problems in the self-control of emotions and behaviors

b. this group of disorders includes: oppositional defiant disorder, intermittent explosive disorder, conduct
disorder, antisocial personality disorder, pyromania, kleptomania


2. Dissociative disorders

a. these disorders are characterized by a disruption of and/or discontinuity in the normal integration
consciousness, memory, identify, emotion, perception, body representation, motor control, and behavior

b. this group of disorders includes: dissociative identify disorder, dissociative amnesia,
personalization/derealization disorder


3. Elimination disorders

a. these disorders involve the inappropriate elimination of urine or feces and are usually first diagnosed in
childhood or adolescence

b. this group of disorders includes: enuresis (repeated voiding of urine into inappropriate places) and encopresis
(repeated passage of feces into inappropriate places)


4. Neurocognitive disorders (NCD)

a. this category encompasses the group of disorders in which the primary clinical deficit is in cognitive function,
and that are acquired rather than developmental and represent a decline from a previously attained level of
functioning

b. this group of disorders includes: Alzheimers disease; vascular NCD; NCD with lewy bodies; NCD due to
Parkinsons disease, traumatic brain injury, HIV infection, Huntingtons disease, prion disease

c. formerly referred to as dementia, delirium, amnestic, and other cognitive disorders



5. Sleep-wake disorders

a. individuals with these disorders typically present with sleep-wake complaints of dissatisfaction regarding the
quality, timing, and amount of sleep; resulting daytime distress and impairment are core features

b. this group of disorders includes: insomnia disorder, hypersomnolence disorder, narcolepsy, breathing-related
sleep disorders, circadian rhythm sleep-wake disorders, non-rapid eye movement sleep arousal disorders,
nightmare disorder, rapid eye movement sleep behavior disorder, restless legs syndrome


6. Sexual dysfunctions

a. sexual dysfunctions are a heterogeneous group of disorders that are typically characterized by a clinically
significant disturbance in a persons ability to respond sexually or to experience sexual pleasure; an individual may
have several disturbances at the same time

b. this group of disorders includes: delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual
interest/arousal disorder, premature ejaculation


7. Somatic symptom and related disorders

a. somatic symptoms are associated with significant distress and impairment

b. this group of disorders includes: somatic symptom disorder, illness anxiety disorder, conversion disorder,
factitious disorder


8. Paraphilic disorders

a. a condition in which a person's sexual arousal and gratification depend on fantasizing about and engaging in
sexual behavior that is atypical and extreme

b. this group of disorders includes: voyeuristic disorder, exhibitionistic disorder, frotteuristic disorder, sexual
masochism disorder, sexual sadism disorder, pedophilic disorder, fetishistic disorder, transvestic disorder


9. Gender dysphoria - a condition in which a person feels that there is a mismatch between his/her biological sex and
gender identify

L. Other significant conditions
Note: these conditions are not specified as mental disorders; however, they are clinically significant because they
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affect mental disorders:

1. Abuse and neglect : child physical abuse, child sexual abuse, child neglect, child psychological abuse

2. Relational problems: problems related to family upbringing and primary support group

3. Adult maltreatment and neglect : spouse or partner violence (physical or sexual), spouse or partner neglect,
spouse of partner abuse (psychological), adult abuse by nonspouse or nonpartner

4. Educational and occupational problems

5. Housing and economic problems

6. Other problems related to the social environment, such as living alone, acculturation, social exclusion, rejection,
discrimination

7. Problems related to crime interaction with the legal system: victims of crime, conviction in civil or criminal
proceedings without imprisonment, imprisonment, problems related to release from prison, problems with legal
circumstances


The only FDA-approved type of medications used to treat this disorder are SSRIs.
Post-traumatic stress disorder (PTSD)

Electroconvulsive therapy (ECT) is used to treat a severe form of this disorder.
Depressive disorder

Russells sign is observed with this disorder.
Bulimia nervosa

A person with this disorder may experience drastic changes in mood accompanied by extreme changes
in energy, activity, sleep and behavior.
Bipolar disorder

A drug holidays are sometimes used in the management of this disorder.
Attention deficit hyperactivity disorder (ADHD)

A person with this disorder recognizes their behavior is excessive and unreasonable but cannot stop the
behavior.
Obsessive-compulsive disorder

A person with this disorder experiences hallucinations and delusional thoughts.
Schizophrenia

Malabsorption syndrome and Wernicke-Korsakoff syndrome are associated with this disorder.
(Chronic) Alcoholism

This disorder includes Alzheimers disease, traumatic brain injury, and Huntingtons disease.
Neurocognitive disorders

The child with this disorder has difficulties with social interaction and verbal and nonverbal
communication and also exhibits repetitive behaviors.
Autism spectrum disorder (ASD)

Points to Remember
Coping and Defense Mechanisms

People use coping mechanisms and ego-defense mechanisms to relieve anxiety and stress.

They are usually unconscious; that is, the client is not aware of their use.

Depending on the situation and how often these mechanisms are used, they may be healthy or unhealthy.
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Therapeutic Communication

The three phases of a therapeutic relationship include the initial phase, the working phase, and the termination phase.

Make eye contact, without staring (but be aware of cultural differences regarding eye contact) and be aware of your own body
language - use an open body posture and appear relaxed.

Show empathy, genuine caring, and respect.

Use therapeutic techniques such as open-ended questions, unless the client is cognitively impaired; use "yes" or "no" questions
with the cognitively impaired, severely depressed clients or clients with respiratory distress.

Grief

Since the distinction between grieving and depression can be a matter of degree, look for signs of clinical depression.

Grieving takes time; the amount of time varies with individuals.

The stages of grief are not linear; they may come and go.

Grief follows death; but also follows any loss, e.g., divorce, loss of job, loss of financial status, retirement, loss of limb or other
physical disability.

Be aware of culturally diverse ways of responding to grief, which are important in collecting data about grief reaction and in
respecting the customs and rituals of a cultural group.

Beware of personal reaction to death and over identification with client; when necessary, seek assistance to cope with personal
issues.

Stress Management

Severity of reaction to a stressor depends on how it is interpreted or perceived by the individual and the meaning or significance
given to it.

Physical and emotional stressors trigger the same stress response; however the magnitude of the response may vary.

Duration and intensity of physiologic indicators are directly related to the duration and intensity of the stress.

Prolonged stress decreases the adaptive capacity of the body.

Points to Remember 2
Mental Disorders

Bipolar and related disorders are characterized by mood swings; depressive episodes are more common than mania.

Know the therapeutic lab values for the mood stabilizer, lithium carbonate (Lithane): 0.8 to 1.2 mEq/L; overdose symptoms may
include nausea, vomiting, diarrhea, drowsiness, muscle weakness, tremor, lack of coordination, blurred vision or tinnitus.

Suicide precautions are started when a client verbalizes and/or makes an overt suicidal attempt, including attempts at self-mutilation.

Electroconvulsive therapy (ECT) is a very effective and generally safe treatment for severe depression. The procedure uses a small
amount of electric current to trigger a seizure. Confusion and temporary memory loss is an expected side effect.

Feeding and eating disorders can affect every body system. Clients should be monitored for electrolyte imbalance, anemia,
malnutrition, dehydration, and bone density.

Autism (a neurodevelopmental disorder) affects the brain's normal development of social and communication skills; it affects boys
more often than girls and is typically diagnosed between the ages of 18 months to 2 years of age.

Attention deficit hyperactivity disorder (a neurodevelopmental disorder) symptoms fall into 3 categories: inattentiveness,
hyperactivity, and impulsivity.

Health care workers should take care to be sensitive to cultural differences, since personality disorders are typically based on Western
ideas.

Schizophrenia ranks among the top 10 causes of disability in developed countries; it is treatable but cannot be cured.

Programs that train clients with schizophrenia on the primary activities of daily living (ADLs) have been shown to enhance their social
skills, motivation, and desire to change while decreasing their lethargic and apathetic state.

Long-acting injectable antipsychotic medications (LAIs) or depot formulations are given once every 1 to 4 weeks, which improves
medication compliance.

Delirium tremens is a severe form of alcohol withdrawal, commonly occurring within 72 hours after the last drink; associated findings
may include seizures and severe mental status changes, e.g., agitation, confusion, delirium, hallucinations.

It's important to treat the symptoms of withdrawal as well as any underlying mental disorders and infectious processes.

Complementary and alternative therapies can be used to treat many of the mental disorders. Clients should understand that
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concurrent use of prescribed medications and some complementary and alternative medications may cause adverse or life-
threatening effects.

Treatment of post-traumatic stress disorder includes cognitive behavioral therapies, eye movement desensitization and reprocessing
(EMDR), hypnotherapy and medications.

A nurse is collecting data from a client on admission to a community mental health center. The client discloses that "I have been
thinking about ending my life." The nurse's initial response should be which approach?

A. "Do you want to discuss this with your pastor?"
B. "We will help you deal with those thoughts."
C. "Lets discuss issues of your life that would make you want to end it."
D. "Have you thought about how you would do it?"

An older adult Catholic Latino client with prostate cancer adamantly refuses pain medication because the client believes that
suffering is part of life and that my life is in God's hands. What action should a nurse take in response to this situation?

A. discuss the meaning of the hospitalization with the family
B. present the issue to the care management team
C. report the situation to the health care
D. ask if the client would like to speak with a priest

While a nurse administers medication to a client, the client states "I do not want to take that medicine today." Initially which
response by the nurse would be best? "Is there a reason why you don't want to take your medicine?"

A. "Is there a reason why you don't want to take your medicine?"
B. "Do you understand the consequences of not taking your prescribed medications?"
C. "That's OK. I will come back in a few minutes when you might change your mind."
D. "I will have to call your health care provider and report this."

To enhance a client's response to medication for chest pain from acute angina when the client is at home, a nurse should emphasize
what strategy during reinforcement of prior taught content?

A. limiting alcohol use
B. eating smaller meals
C. learning relaxation techniques
D. avoiding passive smoke

A Native American Chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. An
attending nurse comments to a colleague "I wonder if he has any idea how ridiculous he looks -- he's a grown man!" The nurse's
response is an example of?

A. ethnocentrism
B. discrimination
C. prejudice
D. stereotyping

Which behavior is consistent with the diagnosis of obsessive-compulsive disorder for a client in an inpatient setting?

A. verbalized suspicions about thefts in the agency
B. repetitive, involuntary movements of the hands
C. repeatedly checking that the door is locked
D. preference for daily consistent care givers

A client tells a nurse I am afraid of this planned surgery because I have evil thoughts about a family member. The initial response
by the nurse should be what approach?

A. reinforce recovery statistics
B. call a chaplain
C. listen to the client
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D. accept the feelings





A client with diagnosed Parkinson's disease spends over one hour dressing for scheduled therapies. The most appropriate action by
a nurse should be which of these?

A. demonstrate methods on how to dress more quickly
B. allow the client the time needed to dress
C. ask family members to dress the client
D. encourage the client to dress more quickly.

An older adult Latino client with prostate cancer rates pain as a 6, using a 0 to 10 scale. The client refuses all pain medication other
than ibuprofen (Motrin), which does not relieve the pain. What approach should the nurse take?

A. document the situation in the notes and medication record
B. report the situation to the health care provider
C. ask the client for more information about the refusal
D. talk with the client's family about the situation

A client who has a diagnosis of dementia tends to wander from the assigned room. A nurse can ensure the safety of this client by
which approach?

A. explain the risks of becoming lost to the client
B. repeatedly remind the client of the time and place
C. assign one staff member to check client every 30 minutes
D. attach a wander-guard sensor band to the client's wrist

A nurse states a dislike for African-American clients because "They are all so hostile." The nurse's statement is an example of what
behavior?

A. stereotyping
B. discrimination
C. prejudice
D. racism

A nurse admits a Mexican-American migrant worker after an accident in the fields. To facilitate communication, which of these
actions should a nurse take initially?

A. verify if English is the second language
B. speak through the family members
C. determine the client's ability to speak and understand English
D. request an interpreter

A Latino client, diagnosed with ovarian cancer, refuses both radiation and chemotherapy because they are "hot. The best action for
a nurse to take at this time is to?

A. set aside time to talk to the client about the meaning of hot
B. talk with the client's family about the client's refusal of treatment
C. report the situation to the charge nurse and the health care provider
D. document the situation in the nurses notes as objectively as possible

During postpartum a Hispanic client refuses the hospital food because it is "cold." A nurse should take which action initially?

A. consult with the dietitian as soon as possible
B. send the food to be reheated
C. ask the client what foods are acceptable
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D. encourage the client to eat for strength






A nurse is caring for a client diagnosed with end-stage heart failure. The family members are distressed about the client's impending
death. Which action should the nurse do first?

A. explain the stages of death and dying to the family
B. explore the family's past patterns for dealing with death
C. ask about their religious affiliations and participation
D. recommend an easy-to-read book on grief

A client calls a triage nurse to discuss a recent diagnosis of a panic disorder. Which characteristic identified during the discussion is
most significant for this client?

A. predictable episodes
B. sense of impending doom
C. fear of specific behaviors
D. compulsive behavior

An Hispanic couple confide in a nurse their concern that the staff may give their newborn the "evil eye." The nurse should
communicate to other personnel it is most important for them to have which action?

A. touch the newborn after looking at the child
B. bless the newborn while speaking to the child
C. avoid touching the newborn
D. look only at the parents and not the newborn

A postpartum mother is unwilling to allow a partner to participate in the newborn's care, although the partner is interested in doing
so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is only for mothers" A nurse's best initial
intervention is which action?

A. talk with the partner to provide help in the acceptance of the mothers decision
B. arrange for the parents to attend infant care classes within a few weeks
C. help the mother to express her feelings and concerns about the issue
D. discuss with the mother the sharing of parenting responsibilities

A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the mother sits in a chair.
The mother states, "This is not my baby, and I do not want it." How should the nurse respond?

A. "You seem upset. Tell me what the pregnancy and birth were like for you."
B. "Many women have postpartum blues and need some time to love the baby."
C. "What a beautiful baby! The baby's eyes are just like yours."
D. "This is a common occurrence after birth. Let's talk about how to accept the baby."

A two day-old child with spina bifida and meningomyocele is recovering after an initial surgery. As a nurse accompanies the
grandparents for a first visit since the childs birth, which of these grief responses might the nurse expect of the grandparents?

A. disbelief
B. anger
C. frustration
D. depression


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FOOD GUIDELINES


I. Nutrition and Hydration

A. Food guidelines

1.
Nutritional needs through the life cycle

a. newborns and infants

i. fluid needs - adequate to maintain hydration (approximately 6-8 wet diapers per day)


ii. infants - protein needs approximately 2.2 gm/kg/day

iii. breast milk or formula alone is adequate for the first six months of life; whole milk should be introduced
around age 1 year


b. childhood - gradual increase of all nutrients


c. adults - unchanged except for

i. pre-pregnancy - add 400 ug/day folic acid

ii. pregnancy - add per day: 300 calories, 15 mg iron, 30 g protein, 400 g calcium, and 400 ug folic acid in first
trimester

iii. lactation - add 500 calories, two quarts extra fluid each day

d. age 65 and older - adequate protein to maintain immune and circulatory system



2. Factors affecting dietary patterns

a. health status


b. ability to chew, swallow, and drink

c. culture and religion

d. socioeconomic status

e. personal preference


f. psychological factors, e.g., depression, mania, paranoia

g. non food substances, e.g., alcohol, drugs, pica


3. Energy needs

a. basal metabolism: amount of energy (measured in calories) required to sustain life in a resting individual


b. basal metabolic rate (BMR)

i. influenced by genetic and environmental factors, e.g., gender, age, activity level, body surface area, body fat
percentage, diet

ii. several different formulas can be used to determine BMR

iii. 3500 kcal = 1 pound





Essential nutrients

1. Carbohydrates (CHO)

a. includes sugars, starches and fibers (cellulose)

b. simple sugars (monosaccharides and disaccharides) are most easily metabolized

c. starches are more complex in structure and metabolism

d. most dietary sources are plant-based (except for lactose)


e. excessive carbohydrate calories are stored as fat

f. functions of carbohydrates

i. quickest source of energy (4 kcal/gram)
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ii. main source of fuel for brain, peripheral nerves, WBCs, RBCs, and healing wounds

iii. protein-sparer


g. recommended daily intake: approximately 50 to 60% of total calories (complex carbohydrates are
recommended)


2. Lipids (fats)

a. basic lipids are composed of triglycerides and fatty acids

b. includes saturated fatty acids (animal sources) and unsaturated fatty acids (from vegetables, nuts
and seeds)

c. essential unsaturated fatty acids - linoleic acid is the only essential fatty acid in humans; linolenic
acid and arachidonic acid can be manufactured by the body when linoleic acid is unavailable

d. deficiencies lead to skin, blood and artery problems


e. functions

i. most concentrated source of energy (9 kcal/gram)

ii. body's major form of stored energy

iii. insulation

iv. cell membrane component

v. carries fat-soluble vitamins A, D, E and K


vi. intake should not be more than 30% total caloric intake; should be low in saturated fats



f. recommended dietary intake: total fat intake should not exceed 30% of daily calories with saturated
fats not exceeding 10% of total daily caloric intake



3. Proteins

a. complex organic compounds comprised of amino acids

b. body breaks protein down into 22 amino acids


c. all but eight amino acids are produced by the body

d. "complete protein" food - contains the eight essential amino acids not produced by the body (most meat, fish, poultry
and dairy products)

e. "incomplete protein" food - lacks one or more of the eight amino acids (most vegetables and fruits)

f. incomplete proteins can be combined to yield a complete protein: for example, beans and rice


g. functions of protein

i. secondary energy source (4 kcal/gram) after carbohydrates


ii. essential for cell growth and wound healing

iii. efficiency can affect all of body - organs, tissues, skin, muscles

iv. the body's only source of nitrogen (negative nitrogen balance can occur with infection, burns, fever, starvation, and
injury)


h. recommended protein intake includes 0.8 grams per kilogram body weight each day




4. Vitamins

a. organic substances essential for body growth and metabolism

b. the body cannot synthesize vitamins, which is why regular dietary intake is required

c. types (according to their solvent)

i. water soluble : vitamin C and B-complex vitamins (thiamin, riboflavin, niacin, pantothenic acid, biotin, B6, folate, B12)

cannot be stored in body

daily intake required
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excess is eliminated daily

little risk of toxicity


ii. fat soluble : A, D, E, K
stored in body (primarily in liver and adipose tissues)
absorbed by the body from the intestinal tract
risk of toxicity



d. function: act as coenzymes for chemical reactions required for various body functions, e.g., nerve function, energy and
protein metabolism, normal vision and skin health



5. Minerals

a. inorganic substances essential as catalysts in biochemical reactions

b. form most inorganic material in the body

c. functions

i. catalyst for many body reactions such as regulation of acid-base balance


ii. help cells metabolize, tissues absorb nutrients, and heart muscle respond

iii. minerals work synergistically, i.e., a deficiency or excess of one mineral can disturb the action of other minerals


iv. types - grouped according to amount found in body

major minerals (macrominerals) - calcium, magnesium, sodium, potassium, phosphorus, sulfur, chlorine
(function is known function)

trace minerals (microminerals) - iron, zinc, copper, iodine, manganese, cobalt, and molybdenum; function
unclear

other group of trace minerals (found in even smaller amounts whose function is unclear) - nickel, silicon,
vanadium, cobalt




6. Water

a. accounts for 60 to 70% of total body weight in adults (70 to 75% of total body weight of children)

b. functions

i. temperature regulation

ii. transportation of oxygen and nutrients through the blood


iii. a necessary component of chemical reactions

iv. aids in elimination of waste

v. lubrication of joints


vi. major component of body fluids (mucus and tears)


c. recommended intake: approximately 2 to 3 liters a day



C. Fluid and electrolyte balance

1. Total volume of fluid and amount of electrolytes remain relatively constant in the body

2. Fluid balance and electrolyte balance are interdependent

a. body balances fluid and electrolytes primarily by adjusting output and secondarily by adjusting intake

b. fluid balance is also maintained by osmosis



3. Major electrolytes

a. anions
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i. chloride

most abundant anion in extracellular fluid

helps balance sodium

normal lab value for serum chloride is 95-105 mEq/L


ii. bicarbonate

part of bicarbonate buffer system

limits the drop in pH by combining with an acid to form carbonic acid and a salt

important in acid-base analyses (arterial blood gases [ABG])

normal arterial bicarbonate 22-26 mEq/L, normal venous bicarbonate 24-30 mEq/L


iii. phosphate

participates in cellular energy metabolism

combines with calcium in bone

assists in structure of genetic material

balanced by parathyroid gland, along with calcium

normal serum phosphate level 2.8-4.5 mg/dL






b. cations

i. sodium

most abundant cation in extracellular fluid

regulates cell size via osmosis

needed to maintain water balance, transmit nerve impulses, and contract muscles; used to control blood
pressure and blood volume

regulates acid-base balance by exchanging hydrogen ions for sodium ions in kidney

sodium is regulated by salt intake, aldosterone, and urinary output

normal lab value for serum sodium is 135-145 mEq/L

large changes may occur with minimal clinical findings

low levels of 125 mEq/L or less result in mental confusion, hostility, hallucinations

excess levels may result in hypertension or generalized edema, called anasarca



ii. potassium

most abundant cation of intracellular fluid

potassium pump draws potassium into cell

essential for polarization and repolarization of nerve and muscle fibers

regulates neuromuscular excitability and muscle contraction

regulated by kidneys

normal lab value for serum potassium is 3.5-5 mEq/L

small changes may result in significant clinical findings

high and/or low findings may result in a fast or slow heart rhythm and muscle function with results of
cramping in abdomen or legs



iii. calcium
needed for cardiac contraction, healthy bones and teeth, functioning of nerves and muscles, clotting of blood
vitamin D is needed for calcium absorption
normal values - total calcium 8.5-10.5 mg/dL

hypercalcemia
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causes: hyperparathyroidism, metastasis of cancer, Paget's disease of bone, prolonged immobilization

findings: weakness, paralysis, decreased deep tendon reflexes

hypocalcemia

causes: rickets, vitamin D deficiency, renal failure, pancreatitis, chelation therapy, hypoparathyroidism

findings: muscle tingling, twitching, tetany



iv. magnesium

about half of total body magnesium is found in bone

needed for more than 300 biochemical reactions - involved in normal muscle and nerve function, heart
rhythm, immune system, blood sugar regulation, blood pressure, energy metabolism, protein synthesis, and
bone strength
normal values - 1.5-2.5 mEq/L

hypermagnesemia

causes: chronic renal disease, overuse of magnesium-containing antacids as Maalox and Mylanta, Addison's
disease, uncontrolled diabetes mellitus

findings: lethargy, nausea, vomiting, slurred speech, muscle weakness, paralysis, decreased deep tendon
reflexes, slowing of cardiac conduction

hypomagnesemia

causes: malnutrition, toxemia in pregnancy, malabsorption, alcoholism, diabetic acidosis

findings: mood irritability, cardiac irritability, muscle tingling, twitching, tetany, delirium, convulsions






6. Maintenance of fluid volume

a. osmoreceptor system

i. balances fluid intake volume by the regulation of water output volume

ii. dehydration stimulates osmoreceptors which activate the thirst control center; person feels thirsty and seeks water

iii. also stimulates antidiuretic hormone (ADH) secretion which decreases urinary output by causing the reabsorption of
water in the tubules


b. circulatory system

i. increases in fluid intake increase circulatory volume

ii. this increased volume stimulates the kidney for an increased glomerular filtration rate


iii. end result is an increase in urine output to decrease the initial circulatory volume




c. thirst center

i. located in hypothalamus

ii. stimulated by

increased plasma osmolality

angiotensin II

dry pharyngeal mucous membranes

decreased plasma volume

depleted potassium

psychological factors





7. Maintenance of electrolyte balance

a. aldosterone - hormone (mineralocorticoid)

i. when extracellular fluid sodium decreases or potassium levels increase, then

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ii. adrenal cortex secretes aldosterone, which causes

iii. kidneys to increase active reabsorption of sodium and decreased reabsorption of potassium, which

iv. results in passive water reabsorption along with active sodium reabsorption and increased blood volume


b. parathyroid

i. parathyroid secretes parathyroid hormone (PTH), also called parathormone


ii. stimulates release of calcium from bone

iii. stimulates reabsorption in small intestine and kidney tubules

iv. when serum calcium level is low, PTH secretion increases


v. when serum calcium level rises, PTH secretion falls

vi. high levels of active vitamin D inhibit PTH

vii. low levels of active vitamin D or magnesium stimulate PTH secretion


viii. interaction exists between calcium and phosphorus

when calcium is low, phosphorus is likely to be high

when calcium is high, phosphorus is likely to be low






D. Normal and therapeutic diets

1. Guidelines

a. reference dietary intake (DRI) - average daily nutrient intake for healthy people (replaces the previous recommended
dietary allowance [RDA])

b. ethnic food patterns

c. religious considerations in meal planning

d. personal choice, e.g. vegetarian


e. refer to the 2010 Dietary Guidelines for Americans and MyPlate for information about

a. balancing calories


b. foods to increase, i.e., fruits and vegetables, whole grains, reduced fat milk

c. food to reduce, i.e., sodium and sugary drinks





2. Therapeutic nutrition

a. modification of the nutritional needs based on a disease condition

b. considerations for administering therapeutic diets

i. condition of client

physical

emotional
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mental ability of client to tolerate diet


ii. willingness of client to comply with diet



c. types of therapeutic diets

i. diabetic

goals of nutritional management

providing all essential nutrients

meeting energy needs

achieving and maintaining a reasonable weight

preventing wide daily fluctuations in blood glucose levels

decreasing serum lipid levels


diet individualized according to client's age, build, weight, and activity level

recommended caloric distribution: 50-60% carbohydrates, 20-30% fat, and 10-20% protein

carbohydrate, fat, and protein counting an essential component of diet





ii. Dietary Approaches to Stop Hypertension (DASH) diet

used to help lower blood pressure, but may offer protection against osteoporosis, cancer, stroke, diabetes and
heart disease

encourages sodium reduction and eating a variety of foods rich in nutrients, including potassium, calcium and
magnesium

levels of restriction

standard DASH diet - 2,300 mg sodium/day

lower sodium DASH diet - 1,500 mg sodium/day

DASH diet is low in saturated fat, cholesterol, and total fat


iii. low protein diet

for renal disease such as pyelonephritis, uremia, kidney failure

limit protein less than 40 g/day (0.5 g/kg/day) instead of normal protein intake of 40 to 60 g/day (1g/kg/day)

restricted foods: meats and other foods high in protein such as legumes, fish, dairy


iv. high protein diet

for conditions such as burns, anemia, malabsorption syndromes, ulcerative colitis

include high quality proteins or protein supplements such as Sustagen

promote high protein intake more than 60 g/day (1.5 g/kg/day) instead of normal protein intake of 40 to 60
g/day (1g/kg/day)






REMEMBER IT
Types of Vegetarian Diets

Vegan: refrains from eating animal products
Lacto-ovo vegetarian: consumes eggs and dairy products but
excludes meat, poultry, seafood
Lacto-vegetarian: consumes dairy products, but excludes eggs,
meat, poultry, seafood
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v. low purine diet

prevents uric acid stone; used for clients with gout

lowers levels of purine, the precursor of uric acid

restricts glandular meats, gravies, fowl, anchovies, beer and wine (see gout diet for more details)


vi. low calcium diet

limit to 400 mg per day instead of normal 800 mg

restricts dried fruits and vegetables, shell fish, cheese, nuts


vii. acid ash diet

prevents kidney stone formation

restricts carbonated beverages, dried fruits, banana, figs, chocolate, nuts, olives, pickles


viii. gluten-restricted or gluten-free

used for people with sensitivity to glutens (proteins) in wheat, oats, rye, and barley

may eat rice, corn and millet products


ix. low cholesterol

used for cardiovascular disease, high serum cholesterol levels

normal amount of cholesterol intake - 250 to 300 mg/day

restricts eggs, beef, liver, lobster, ice cream


x. high fiber

used to correct constipation, prevent diverticulitis, lower risk of colon cancer

30 to 40 gram fiber/day recommended

increased intake of fruits, vegetables, bran cereals, whole grains



xi. low residue

used for conditions such as diarrhea, acute diverticulitis

reduce fiber intake: canned fruit, refined carbohydrates, pasta, strained vegetables

foods high in refined carbohydrates are usually low fiber

increased use of ground meat, fish, broiled chicken without skin, white bread



xii. mechanical soft

used with difficulty in chewing, such as poorly fitted dentures or edentulous clients (no teeth)

includes any foods which can be easily broken down by chewing


xiii. puree diet

used with dysphagia or difficulty in chewing

used for tube feedings, small babies

food is blended to smooth consistency


xiv. liquid diets

clear liquid: coffee without cream, tea, popsicles, fruit juices, including apple, cranberry, grape, and carbonated
beverages

full liquid: includes all clear liquids plus milk, cream, ice cream, pudding, yogurt, vegetable juice, creamy peanut
butter



4. Nutritional data collection

a. weight change - over what time frame and amount of weight lost or gained

b. appetite - increased, decreased
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c. food intolerance - result of intolerance such as nausea, vomiting, diarrhea, hives, stomach pain

d. chewing and swallowing

e. indigestion - frequency

f. elimination habits - urinary and bowel

g. eating behaviors - usual meals and amounts

h. nutrient - drug interactions


i. anthropometric measures



5. Feeding tubes

a. indications - inability to ingest, chew, or swallow food (with intact gastrointestinal tract)

b. insertion

i. through nose into stomach or small bowel

nasogastric (NG), nasoduodenal and nasojejunal feeding tubes

used either for short periods or intermittently with relatively low risk

NG tube sizes

adult: 16-18 Fr

pediatric: add 16 to the client's age in years and then divide by 2 (for example: [8 y + 16]/2 = 12 Fr)



ii. endoscopically - better for long-term enteral feeding

gastrostomy tube or PEG tube

jejunostomy tube




c. tube feeding formulas: Vivonex, Isocal, Portagen

d. complications: aspiration, diarrhea, electrolyte or metabolic disturbances



e. nursing care - for gastric-placed tubes

i. keep head of bed raised at least 30 degrees or semi-Fowler's position, to prevent aspiration for 1.5 to 2 hours after
feeding is infused

ii. recheck placement of tube prior to each feeding

iii. placement checks

obtain radiologic (x-ray) confirmation before instilling any feedings or medications or if there are concerns
about other forms of assessment

recommended practice is to aspirate gastric contents and check if pH is acidic (pH should be acidic)

injecting ten mL air into nasogastric tube (NG tube) and listening with stethoscope for rush of air over
stomach is no longer an accepted method to verify placement
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iv. administration of enteral feedings

may be continuous or intermittent

prevent bacterial growth by limiting infusions to hang for less than 8 hours and changing tubing every 24
hours

prevent fluid and electrolyte imbalances by administering at a rate of no more than 300 mL/hour

check gastric residual

every 4 hours if continuous feeding or prior to intermittent feedings

if residual is greater than 50-100 mL (or using facility policy), hold feeding until residual diminishes

reinsert residual into tube to prevent metabolic alkalosis

flush tube with 30 to 60 mL water after feeding




6. Nutritional supplements/liquids

a. used for severe dehydration or diarrhea

b. types

i. infants: Infalyte, Pedialyte, Ricelyte

ii. infant formulas: standard and high-calorie


iii. older children and adults: electrolyte replacement drinks

iv. specialty formulas

used when intolerance to usual milk or milk products

predigested, e.g., Pregestimil, Nutramigen

high-calorie supplements, e.g., Scandishakes, Carnation Instant Breakfast




7. Parenteral nutrition: see Lesson 6: Pharmacological for more information


8. Measures to improve nutritional intake of client

a. frequent small feedings

b. feeding assistance

c. offering preferred foods

d. ethnic foods


II. Mobility/Immobility

A. Prevention of complications of immobility

1. Skin - decubitus ulcers

a. turn client in bed every 2 hours

b. use heel/elbow protectors

c. use alternate pressure mattress or other skin care devices


d. do not massage reddened areas (doing so increases damage to tissues)

e. limit sitting in a chair to 2 to 4 hours or as tolerated with a shift in weight at least every 30 to 60 minutes

f. assess risk with Braden or Norton scales

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2. Musculoskeletal changes, especially contractures

a. perform range of motion exercises to joints on a scheduled basis daily

b. provide foot board, foot cradle or high-topped tennis shoes to prevent foot drop

c. reposition every 2 hours

d. maintain correct body alignment


3. Respiratory - atelectasis, pneumonia

a. instruct client to cough and deep breathe every 2 hours, or more frequently

b. turn at least every 2 hours

c. suction if needed


d. chest physiotherapy

e. incentive spirometry


4. Urinary: renal, calculi, urinary tract infection, glomerulonephritis

a. increase fluid intake (2000 to 3000 mL/day)

b. restrict foods that contribute to renal stone formation



5. Psychosocial

a. provide stimuli to maintain orientation

b. develop and follow mutually agreeable activity schedule with client to maintain mental sharpness




6. Cardiovascular system - decreased cardiac output, clots, emboli

a. orthostatic hypotension

i. instruct client to change position slowly

ii. highest risk is from supine to standing position



b. increased cardiac workload

i. reinforce for client to avoid bearing down (Valsalva maneuver)

ii. minimize coughing


iii. limit sitting in high Fowler's position for more than 1 to 2 hours


c. thrombus/emboli formation

i. apply thigh or knee-high anti-embolic stockings as ordered


ii. monitor use of sequential compression device


iii. turn every 2 hours

iv. monitor anticoagulation therapy, as indicated

v. initiate ambulation or exercise of dorsi and plantar flexion of the foot


vi. limit sitting with feet in a dependent position to 1 to 2 hours



B. Types of exercise

1. Active - client performs exercise independently to retain joint mobility and maintain blood circulation

2. Passive - carried out by the health care provider without assistance from client; purpose is to retain joint mobility and
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blood circulation

3. Resistive - done by the client working against resistance; purpose is to increase muscular strength; enhances bone
integrity

4. Isometric - carried out by the client with no assistance by contracting muscle groups for 10 seconds and then relaxing
muscle group; purpose is to maintain muscular strength when the joint is immobilized

5. Range of motion (ROM) - joint is moved through entire range; purpose is to maintain joint mobility




C. Mechanical aids or assistive devices and interventions

1. Crutches - provides support and assist ambulation for people with weight-bearing restrictions

a. adjust handbars to allow 15 to 30 degrees of elbow flexion

b. keep tips of crutches 8 to 12 inches to side of feet


c. use well fitting shoes with nonslip soles

d. use rubber suction tips on crutches

i. inspect weekly

ii. replace when worn



e. may be used temporarily or permanently

f. prevent axillary damage by avoiding pressure with position of crutch at least one hand's width below axillary bend


g. teach client crutch walking



2. Cane - provides stability when walking and relieves pressure on weight-bearing joints

a. adjust cane with handle at level of greater trochanter, elbow flexed at 30 degree angle


b. have client hold cane close to body

c. have cane held on stronger side

d. client to move cane at same time as the weaker leg




3. Walker - assists in weight bearing and mobility

a. client must be strong enough to pick walker up and move it forward before taking the next step (walkers with wheels
are available for clients who are not strong enough to lift a walker but who can slide it forward)

b. teach client how to sit, stand and turn

c. do not allow client to place hands on walker to stand from sitting position (it is unstable)



4. Gait belt

a. usually a canvas belt, with or without handles, positioned over the client's clothing

b. the gait belt should fit tightly around the waist

c. safety devices for ambulatory clients who may have some balance problems



D. Prosthetic devices - used to replace a missing body part

E. Brace - support for weakened muscles




B. Urinary incontinence: involuntary release of urine

1. Types

a. stress incontinence: sudden increase in intra-abdominal pressure, such as sneezing or coughing, causes urine to leak
from bladder

b. overflow (reflex) incontinence: bladder empties incompletely, so urine dribbles constantly

c. urge incontinence: uncontrolled contraction of the bladder results in leakage of urine before one reaches the
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bathroom

d. functional incontinence: incontinence not due to organic reasons; for instance, altered access to toilet, impaired
mobility or dexterity may prevent the client from reaching the bathroom in time


2. Diagnosis of urinary incontinence

a. history and physical examination


b. urinalysis - determines the presence of blood or infection

c. cystoscopy - determines if abnormalities exist

d. post void residual - measures amount of urine that remains in the bladder after voiding

e. stress test - determines if urine leaks after bladder is stressed when coughing, lifting, bearing down


REMEMBER IT
Remember the reversible causes of urinary incontinence using the
mnemonic D.R.I.P.

Delirium
Restricted mobility (or Retention [urinary])
Infection (or Inflammation or Impaction [fecal])
Pharmaceuticals (or Polyuric states)

3. Treatment

a. pharmacologic

i. antispasmodics and anticholinergics relax and increase capacity of the bladder, e.g. oxybutynin (Ditropan)

ii. alpha-adrenergic agonists - increase urethral resistance


b. Kegel exercises - strengthen weak muscles of the pelvic floor

c. behavioral training - client learns different way to control urge to urinate


d. bladder retraining - scheduled periods to empty bladder throughout the day

e. pessary

f. surgery - repair of weakened or damaged pelvic muscles or urethra



4. Nursing interventions

a. provide appropriate skin care and protective undergarments


b. establish toileting schedule - provide easy access to bathroom and privacy

c. teach client Kegel exercises

i. stop and start urinary stream while voiding

ii. hold contraction of perineal muscles for 10 seconds and relax for 10 seconds

iii. work up to 25 repetitions three times a day


d. prevention of infection

i. cleanse urethral meatus after each void; females to wipe from front to back

ii. acidify urine with vitamin C or increased intake of citrus juices (cranberry, orange)

iii. increase daily intake of fluids to a minimum of 2000 to 3000 mL, unless contraindicated




C. Urinary catheterization

1. Purposes

a. relieve acute urinary retention


b. relieve chronic urinary retention

c. drain urine preoperatively, postoperatively, or post procedure
154


d. determine amount of post void residual

e. accurately measure urine output in the critically ill

f. obtain sterile urine specimen

g. continuous or intermittent bladder irrigation



2. Types of catheters and general guidelines

a. indwelling urethral catheter

i. use a closed drainage system

ii. use sterile technique to insert a urethral catheter


iii. advance catheter almost to bifurcation of catheter, especially in male clients

iv. inflate balloon within guidelines of manufacturer only after urine is draining properly, then slightly withdraw
catheter until slight resistance is met

v. ensure client is not lying on the tubing; secure catheter to client's thigh and allow for some slack to accommodate
movement and to lessen drag

vi. care of indwelling urinary catheter

cleanse the urinary meatus with soap and water during the daily bathing routine and after defecation

do not pull on catheter while cleansing

do not use powder or spray around perineal area

avoid disconnection of the drainage system

keep the drainage bag below the level of the bladder or the insertion site

avoid clamping the drainage tubing unless ordered to do so on a scheduled basis to maintain bladder
tone

catheter is irrigated only with an obstruction, usually following prostate or bladder surgery, if blood
clots anticipated; usually PRN or with standing order





2. suprapubic catheter: achieved via a percutaneous catheter or by way of an incision through the abdominal wall


3. Intermittent self-catheterization

a. used by clients with spina bifida or other neuromuscular deficits


b. can be taught to children as young as 6 years of age

c. teach the client to

i. gather equipment - urethral catheter, water-soluble lubricant, soap, water, urine collection container

ii. wash hands with antibacterial soap

iii. cleanse urethral meatus and surrounding area with soap and water

iv. lubricate tip of catheter with water-soluble lubricant

v. insert catheter until urine flows

vi. withdraw catheter when urine flow stops

vii. clean off residual lubricant from meatus

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viii. dispose of urine

ix. wash hands with antibacterial soap




D. Ostomies

1. Types of bowel ostomies

a. ileostomy - small bowel

i. liquid to semi-formed stool, dependent upon amount of bowel removed

ii. may skew fluid and electrolyte balance, especially potassium, sodium, and bicarbonate

iii. digestive enzymes and alkalinity in stool irritate skin easily


iv. do not give laxatives

v. ileostomy lavage may be done if needed to clear any blockage

vi. usually requires a pouch or appliance


ii. may not require appliance with continent ileal reservoir or Kock pouch procedure

viii. may require scheduled emptying throughout the day

ix. may be used for urinary diversion as in bladder tumor


b. colostomy

i. ascending colon must wear appliance semi-liquid stool

ii. transverse colon must wear appliance semi-formed stool

iii. loop stoma

proximal end functioning stoma; if irrigation needed, this end is used

distal end drains mucous

plastic rod used to keep loop out

usually temporary to rest the distal, large bowel

placement is commonly in transverse colon


iv. double barrel

two stomas

similar to loop but bowel is surgically severed

most likely temporary


v. sigmoid or descending

formed stool

bowel can be regulated so appliance usually not needed

may be irrigated to help regulate evacuation of bowel







2. Nursing assessment and data collection for stoma care

a. color - the stoma will always stay red (due to the rich supply of blood in the lining of the intestine)
156


b. edema - common after surgery for 48 to 72 hours

c. bleeding - some is expected after surgery for 48 to 72 hours

d. drainage consistency and frequency - depends upon stoma location

e. surrounding skin integrity


3. Psychological reaction to ostomy

a. disturbed body image, especially young adults


b. anxiety related to feared rejection

c. ineffective coping related to ostomy care



IV. Rest and Sleep

A. Factors affecting sleep

1. Physical illness

2. Drugs or alcohol

3. Lifestyle


4. Excessive daytime sleep

5. Emotional stress


6. Environment


7. Exercise just before bedtime/fatigue

8. Food intake



B. Sleep disorders

1. Bruxism: tooth grinding during sleep

2. Insomnia: chronic difficulty with sleep patterns

a. initial insomnia: difficulty falling asleep

b. intermittent insomnia: difficulty remaining asleep

c. terminal insomnia: difficulty going back to sleep


3. Narcolepsy: to fall asleep without warning during daytime hours

4. Sleep apnea

a. intermittent periods of not breathing while asleep

b. usually due to problems with upper airway; can be treated with continuous positive airway pressure
(CPAP) during sleep


5. Sleep deprivation: decrease in the amount and/or quality of sleep


6. Somnambulism: sleepwalking, night terrors, or nightmares

7. Depression

a. secondary to disease process

b. can occur with any sleep disorder

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8. Manic behavior - hyperactive behavior with minimal sleep


C. General nursing interventions for promotion of restorative sleep

1. Comfort measures

2. Give prescribed medications: sedatives, hypnotics

3. Assist client to set a sleep routine


4. Encourage daytime activity

5. Eliminate naps

6. Reinforce relaxation techniques


7. Discuss the benefits of environmental control

8. Reinforce limiting alcohol, caffeine, and nicotine in evening

9. Advise client to avoid drinking fluids after 8 to 9 pm to prevent the need to void at night







V. Pain

A. Theories

1. Specificity theory - proposes that pain can be initiated only by painful stimuli

2. Pattern theory - stimulus goes to receptors in the spinal cord, which signals the brain to perceive pain and
muscles to respond


3. Gate control theory - pain impulses can be altered or regulated by gating mechanisms along nerve
pathways; it explains how past and present experiences can influence the perception of pain


B. Variables influencing pain perception

1. Culture and social groups shape attitude towards pain


2. Religious beliefs regarding the reasons for pain

3. Previous experience with pain

4. Age


5. Sex

6. Coping style

7. Family support



C. Types - may be intermittent or constant

1. Acute - pain episode lasting up to six months

2. Chronic - pain lasting longer than six months



REMEMBER IT
Pain Management ABCs

A- Assess the client by asking about the pain
B- Believe the client's pain is real
C- Let the client make pain management choices


D. Therapeutic treatment of pain

1. Pharmacologic interventions - refer to Lesson 6: Pharmacological Therapies

2. Complementary and alternative therapies

a. acupuncture

b. accupressure - pressure put at selected points on the body

c. relaxation techniques - biofeedback, visualization, meditation and hypnosis, which help the client control anxiety,
other emotions, or mild pain

d. electronic stimulation such as transcutaneous electric nerve stimulation (TENS) - electrodes applied over the painful
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area or along nerve pathway

e. distraction - focusing client's attention on something other than mild pain

f. massage - generalized cutaneous stimulation of the body; makes the client more comfortable as a result of the
muscle relaxation

g. ice and heat therapies - effective in some circumstances; ice may decrease prostaglandins which intensify the
sensitivity of pain receptors

h. guided imagery - using one's imagination in a guided manner to achieve a specific positive effect



3. Nursing interventions

a. categorize pain using a pain assessment scale

i. scale of 1 to 10, or absence of pain to worst pain

ii. pain scale using faces, such as the Wong-Baker FACES scale (especially useful with children)

PQRST Format for Assessing Pain

P- What provokes the pain?
Q- What is the quality of the pain?
R- Does the pain radiate? What causes relief?
S- What is the severity?
T- What is the timing?

b. discuss client's coping strategies and factors that produce ineffective coping


c. reinforce client teaching regarding appropriate strategies to deal with different levels of pain




VI. Alternative and Complementary Therapies

A. Herbal therapy

1. Used as dried herbs in capsules or tablets, tinctures, teas, and ointments

2. Use only products standardized with a specific amount of active ingredients

3. Over 600 herbal products, many of which interact with prescribed drugs, particularly cardiac drugs and
antidepressants

4. St. John's wort is the number one herbal product

a. interacts with over 60 percent of all prescription drugs

b. the interaction is to make drugs less effective, including digoxin, cyclosporine, tamoxifen, highly active
antiretroviral therapies (HAART) and combined oral contraceptives




B. Aromatherapy

1. Uses oils produced by plants for inhalation or topical application

2. Different scents are thought to produce different responses in the body

3. Scents of vanilla and green apple are thought to enhance memory and recall




C. Therapeutic massage

1. Manipulates the soft tissue of the body and assists with healing

2. Physiologic effects: primarily improves circulation, oxygenation, perfusion


3. Research findings indicate: muscle relaxation, reduction of some types of pain, sedative effect on nervous system,
increased peristalsis, increased lymphatic circulation

4. Can be relaxing or energizing

5. Is contraindicated for a client with phlebitis, thrombosis, varicose veins, diabetes, pitting edema


159

D. Reflexology

1. Applies pressure to specific areas of the feet and body

2. Uses - relieves stress and muscle tension; promotes relaxation and sleep



E. Hypnosis

1. Used in the treatment of many disorders, including osteoarthritis, rheumatoid arthritis, sciatica, whiplash, chronic pain


2. May also be used to replace traditional surgical anesthesia


F. Chiropractic treatment

1. Effective by manipulating the musculoskeletal system


2. Manipulation to put the vertebrae in proper alignment

3. Used to treat pain at a variety of locations



I. Acupuncture

1. a traditional Chinese therapy using tiny needles placed in the skin to help regulate the flow of (qi) vital energy through
the body; electro stimulation, laser beams or ultrasound waves may be used in place of the needles


2. despite being one of the most widely researched of all CAM/complementary and alternative therapies it remains
unknown how acupuncture works physiologically


J. Acupressure

1. Uses gentle pressure at specific points

2. Used for prevention and relief of muscle tension or pain


Protein is the body's only source of nitrogen. True False
Women who are planning on becoming pregnant need about 200 ug/day of folic acid. True False
Less than 6 to 8 wet diapers a day may be a sign of dehydration in a baby. True False
Glucose is the only fuel used by brain cells. True False
People with insomnia either have difficulty falling asleep or staying asleep. True False
The client using a cane should hold it on his strong side and move the cane at the same time as the weaker leg. True False
Iron is one of the macrominerals found in a healthy human body. True False
Complementary and alternative therapies (CAT) replace the need for pharmacologic interventions. True False
The thirst center is located in the parathyroid gland. True False
A client with gout is prescribed a pureed diet. True False
The flow rate for a nasogastric tube feeding should be no faster than 300 mL/hour. True False
Urinary incontinence is a normal part of aging. True False
A 7 year-old child can be taught to self-catheterize him or herself. True False
The client with a sigmoid colectomy will have semi-liquid stool collect in a colostomy bag. True False
Neuropathic pain is also called musculoskeletal pain. True False

Points to Remember
Nutrition & Fluid Intake

All individuals require the same nutrients, but the amounts vary according to factors such as age, weight, activity level, and health
state.

The energy value of foods is defined in calories; only proteins, fats and carbohydrates provide calories.

Essential amino acids cannot be synthesized; they must be ingested daily.

Weight is maintained when daily food intake equals energy expenditure.
160


Weight loss is a long-term process and patients need long-term support.

Increased fiber in the diet may cause flatulence.

The normal thirst mechanism in the elderly may be diminished and they may need encouragement to drink sufficient water to
prevent dehydration.

The average adult drinks 2 to 3 liters of water per day.

Normal lab values to know:

Sodium: 135 - 145 mEq/L

Potassium: 3.5 - 5.1 mE1/L

Chloride: 98 - 107 mEq/L

Bicarbonate: 22 - 29 mEq/L

Elimination

In constipation, increase fluid to 3000 mL/day (unless contraindicated).

Small frequent loose stools or seepage of stool are often indicative of a fecal impaction.

Use transparent drainage bag initially for assessment of stoma and drainage.

Avoid foods that cause odor, gas, diarrhea, or may block ileostomy.

The majority of residents in nursing homes are incontinent but incontinence is not a normal sequela of aging.

Points to Remember 2
Pain

Allow the client to rate the degree of pain (typically using a 10 point scale) and later to assess (and chart) degree of relief from pain
relief measures.

Self-control methods to manage pain: distraction, massage, guided imagery, relaxation, biofeedback, and hypnosis.

Initiate pain relief before the pain becomes unbearable.

Patient controlled analgesia (PCA) is effective at controlling pain and avoiding the peaks and valleys of nurse-administered narcotics;
clients typically use less pain medication overall than clients receiving nurse-administered narcotics.

Be sure to assess and monitor respiratory rate for client on PCA; naloxone (Narcan) is used to reverse the effects of narcotics.

Mobility

There should be at least two inches between axilla and top of arm piece of crutch to prevent pressure on the brachial plexus.

Prevent deformities and complications such as contractures, thrombophlebitis, and pressure ulcers by regularly turning and
positioning the client in good alignment.

Discontinue range of motion exercises at point of pain.

Use non-skid, rubber tips on crutches and canes to prevent slipping.

A nurse is reinforcing methods to maintain regular bowel movements to an older adult client. The nurse would caution the client to avoid which over-the-
counter item?

A. laxatives
B. vitamin enhanced drinks
C. fiber supplements
D. stool softeners

A nurse is collecting data on a group of clients in a long-term health care facility. Which client is at a highest risk for the development of decubitus ulcers?

A. an obese client who uses a wheelchair throughout the facility
B. an ambulatory older adult who has had type 2 diabetes mellitus for the past 40 years
C. an ambulatory client who had three incontinent diarrhea stools in the past 24
D. a malnourished older adult client who is bedfast

What topic should a nurse reinforce with a client who has been diagnosed with type 2 diabetes mellitus?

A. reduce carbohydrates intake to 25% of total calories
B. continue a regular schedule of meals and snacks
C. maintain previous calorie intake from your age 10 years prior
D. keep a candy bar available for hypoglycemic episodes


161

The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement
of the G-tube?

A. Measure the length of tubing from the insertion site each shift
B. Listen for active bowel sounds in all four quadrants
C. Measure the pH of stomach content aspirate
D. Auscultate the abdomen while instilling 10 mL of air into the G-tube

Which action would be appropriate for a nurse to reinforce about diaper dermatitis to the parents of a nine month-old infant?

A. do not use occlusive ointments on the rash
B. use only cloth diapers that are rinsed in a bleach solution
C. discontinue any new food that was added to the infant's diet just prior to the rash
D. use commercial baby wipes with each diaper change

A nurse is caring for a seven year-old diagnosed with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea
nitrogen and creatinine are both elevated. What dietary modifications are most appropriate at this time?

A. increased potassium and protein
B. decreased carbohydrates and fat
C. decreased sodium and potassium
D. increased sodium and fluids

A nurse is caring for a group of older adult clients who are on complete bed rest. What is the appropriate action by the nurse to prevent skin breakdown?

A. massage their legs twice a shift
B. massage any reddened areas
C. turn every one to two hours
D. apply a sheepskin pad under the torso

A 14 month-old had cleft palate surgical repair several days ago. Which lunch selected by the parents is the best example of an appropriate meal?

A. peanut butter and jelly sandwich, chips, pudding, milk
B. hot dog, carrot sticks, gelatin, milk
C. soup, blenderized soft foods, ice cream, milk
D. baked chicken, applesauce, cookie, milk

A two year-old child is brought to the pediatrician's office with a report of mild diarrhea for two days. Nutritional counseling by the nurse for
reinforcement of information should include which statement?

A. give bananas, apples, rice and toast as tolerated
B. place NPO for 24 hours, then rehydrate with milk and water
C. place the child on clear liquids and gelatin for 24 hours
D. continue with the regular diet and include oral electrolyte replacement drinks


The RN has provided care instructions to the parents of a toddler diagnosed with atopic dermatitis. Which of these actions will the LPN/VN now reinforce
to the parents?

A. Dress the child warmly to avoid chilling
B. Wrap the child's hand in mittens or socks to prevent scratching
C. Clean the affected areas with tepid water and antibacterial soap
D. Keep the child away from other children for the duration of the rash

A mother of a three month-old infant tells a nurse I want to change from formula to whole milk and add cereal and meats to my infants diet. What
should be emphasized as the nurse reinforces information about correct infant nutrition?

A. tap water with fluoride should be used to dilute the milk
B. whole milk is difficult for a younger infant to digest
C. solid foods should be introduced at three to four months
D. supplemental apple juice can be used between feedings

A nurse is making a home visit to a client diagnosed with chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I used to be able to
walk from the house to the mailbox without difficulty. Now, I have to pause to catch my breath halfway through the trip." Which nursing diagnosis would
the nurse expect on the plan of care for this client?

A. self care deficit related to dyspnea
B. impaired mobility related to chronic obstructive pulmonary disease
C. ineffective airway clearance related to increased bronchial secretions
D. activity intolerance related to chronic tissue hypoxia





162

A nurse is discussing dietary intake with an adolescent who has acne. Which of these statements should a nurse include during the discussion?

A. "Decrease fatty foods from your daily diet."
B. "Increase your intake of protein and vitamin A."
C. "Eat a balanced diet for your age group."
D. "Do not drink caffeinated beverages and avoid chocolate"

A client diagnosed with heart failure has been instructed about proper nutrition associated with the disease process. The selection of which lunch items by
the client indicates that the client has learned about sodium restriction?

A. cheese sandwich with a glass of 2% milk
B. sliced turkey sandwich and fresh pineapple
C. cheeseburger and baked potato
D. mushroom pizza and ice cream

Which choice indicates a client understands dietary needs that help prevent digitalis toxicity?

A. small banana
B. medium baked potato
C. average sized naval orange
D. three apricots

Which information should be reinforced and included in a handout on infant feeding that is to be distributed to families visiting the clinic?

A. solid foods are introduced one at a time beginning with cereal
B. cereal is highly recommended to be mixed with formula in a bottle
C. egg white is added early to increase protein intake
D. finely ground meat should be started early to provide iron

During a review of proper nutrition with a client who has a history of emphysema, a clinic nurse should emphasize which of these actions?

A. use oxygen during meals to minimize oxygen deficits
B. cleanse the mouth of dried secretions to reduce the risk of infection
C. perform exercises after respiratory treatments to enhance appetite
D. eat foods high in sodium to increase sputum liquefaction

A client is with hospice at home with the diagnosis of stage 4 heart failure. A home care nurse should encourage the client to rest in which position?

A. left lateral
B. high Fowler's
C. low Fowler's
D. supine

A nurse is reinforcing foot care instructions to a client with a history of arterial insufficiency to the legs. The nurse should identify which client's statement
as incorrect and the need for additional reinforcement?

A. "I cannot go barefoot around my house."
B. "I should ask a family member to inspect my feet daily."
C. "I can only wear cotton socks."
D. "I will trim corns and calluses regularly."

A nurse is reinforcing dietary instructions to the parents of a child diagnosed with cystic fibrosis. The nurse should emphasize that the diet would have
which characteristics?

A. high carbohydrate, low protein, moderate fat
B. high calorie, low fat, low sodium
C. high fat, high sodium, low carbohydrate
D. high protein, high calorie, unrestricted fat

163



I. Pharmacology Terms and Responsibilities

A. Medication nomenclature
Medication nomenclature: some examples
Chemical Name Generic Name Trade
(Brand)
Name
Tall Man
lettering
3,4dihydroxyphenethylamine
hydrochloride
dopamine Intropin DOPamine
4-[2-[4-(4-hydroxyphenyl) butan-2-
ylamino] ethyl]benzene-1,2-diol
dobutamine
hydrochloride
Dobutrex DOBUTamine
1. Chemical name: description of a medication's chemical molecular structure/composition

2. Generic name: description assigned by the U.S. Adopted Name Council; identified by
lowercase letters

3. Trade (brand) name: manufacturer's registered name for a medication that is capitalized
and treated as a proper noun; many different trade names may refer to the same generic
medication


4. TALL MAN lettering

a. one part of a drug's name is written in capital letters (tall man letters) to distinguish it
from the other look-alike and sound-alike drugs, e.g., predniSONE and prednisoLONE

b. used to help prevent medication errors


5. High-alert drugs: medications with a high potential to cause harm if administered
incorrectly to the client




6. Controlled substances

a. medications controlled by the federal Controlled Substances Act (CSA) because they have a
higher risk for abuse

b. controlled substances in the United States - 5 categories

i. Schedule I - category of drugs with high abuse potential and no medical use (generally
unsafe), e.g., heroin, lysergic acid diethylamide (LSD), and marijuana

ii. Schedule II: high risk for abuse or physical or psychological dependency but also have safe
and accepted uses, e.g., morphine, amphetamines, short-acting barbiturates

iii. Schedule III: less potential for abuse or addiction than Schedule II, e.g., paregoric, various
analgesic compounds containing codeine

iv. Schedule IV: medically useful category of drugs with less potential for abuse or addiction
than Schedule II drugs, e.g., chloral hydrate, diazepam, meprobamate, phenobarbital

v. Schedule V: lowest potential for abuse of all categories, medically acceptable uses e.g.,
antidiarrheals and antitussives with opioid derivatives


c. providers must register with the Drug Enforcement Agency (DEA) to prescribe these
medications and include their DEA number on the prescription





164

REMEMBER IT
As a general rule, classes of drugs have the same generic "last" name:
"PRILS" = ACE inhibitors (enalapril, lisinopril)
"SARTANS" = angiotensin receptor blockers (losartan, valsartan)
"TRIPTANS" = treatment of acute migraine headache
"STATINS" = lower LDL cholesterol (simvastatin, rosuvastatin)
"DIPINES" = calcium channel blockers (amlodipine, nifedipine)
"PRAZOLES" = proton pump inhibitors (omeprazole)
"AZOLES" = antifungals (miconazole)


B. Pharmacodynamics (how a medicine changes the body) - it's the mechanism of drug action and
its relationship between drug concentration and responses of the body

1. Used to help predict if the medication will assist the client or will produce a significant change
in the client

2. Replaces a missing substance

3. Destroys or inhibits a pathogen

4. Stimulates, suppresses, or disrupts a process


C. Pharmacokinetics (how the body affects the drug)

1. Consists of four processes: absorption, distribution, biotransformation (metabolism) and
excretion

a. absorption: movement of the drug through blood circulation from the site of administration
to target tissue

i. onset of action: the time between the administration of a medication and the beginning
of its effects


ii. duration: amount of time that a medication exerts its effects, therapeutic and adverse

iii. bioavailability: amount of drug that reaches the target tissue


b. distribution

i. process by which the drug diffuses or is transferred from the intravascular space (blood
stream) to extravascular space (body tissues)

ii. factors affecting distribution

blood flow to the tissue, e.g., vasoconstriction reduces drug distribution and
vasodilation enhances drug distribution

solubility of the drug

binding of the drug to macromolecules in the blood or tissue

ability to cross barriers, e.g., blood-brain barrier, placenta



c. metabolism (biotransformation): chemical conversion or transformation of drugs into
compounds that are easier to eliminate

i. phase I: oxidation, reduction, or hydrolysis by the cytochrome P-450 enzyme system

ii. phase II: conjugation of substance, improves renal excretion

iii. half-life: time it takes the amount of drug administered to decrease to 50% of the peak
drug level



d. excretion: elimination of unchanged drug or metabolite from the body, through renal,
biliary, or pulmonary processes

i. route of excretion depends on the drugs chemical properties

ii. kidneys are responsible for excreting most drugs






2. Factors affecting pharmacokinetics
165


a. client influences

i. body mass index

ii. cultural guidelines

iii. genetic and ethnic factors

iv. pathophysiological impact

v. environmental and immunological factors

vi. developmental (growth and development) factors

vii. nutritional and dietary restrictions


b. drug-related factors

i. dose


ii. timing


iii. route and administration

iv. drug-drug interactions

potentiate

inhibit: decrease or blunt the effectiveness of another medication

incompatible: agent that usually causes harm to the client or causes
complications with the administration of another medication


v. drug-diet interactions

vi. drug metabolism



REMEMBER IT
If you learn drug classifications, it may be easier to
remember specific medications and their indications for
use, adverse effects, and client/family teaching. Refer
to our Drug Classifications guide for more details.



3. Therapeutic range

a. range of concentrations at which a drug or other therapeutic agent is effective with minimal
toxicity to most people

b. common drug examples: acetaminophen, aminophylline, digoxin, lithium, phenytoin,
propranolol, theophylline



4. Peak and trough levels

a. peak: point in time after the administration when a medication exerts its strongest therapeutic
and adverse effects; a serum blood sample is drawn (about 1 hour) after the drug is
administered

b. trough: the lowest drug level that is needed to reach therapeutic range; a serum blood is
drawn (about 30 minutes) before medication administration



5. Drug effects

a. therapeutic: desired primary effect for which drug is given

b. side effect: undesirable or unpleasant client response to pharmacotherapy that tends to be a
nuisance

c. adverse: undesired responses to pharmacotherapy that are harmful to the client or make
administration of the drug very difficult or harmful

d. toxic: dangerous or harmful adverse effect including secondary effect; hypersensitivity, tissue
166

and organ damage

e. cumulative: occurs when drug is administered too frequently or when excretion of the drug is
impaired, may lead to adverse and toxic effects

f. hypersensitivity: immunological response of client; allergy and anaphylaxis

g. tolerance: over time the drug loses its therapeutic effect; requires increased dosing to produce
same effect, not predictive of addiction

h. dependence: disruption of a homeostatic function set-point when an agent is stopped leading
to clinical indicators of withdrawal

i. psychic: predictive of addiction

ii. physical: not predictive of addiction


i. subtherapeutic: not reaching therapeutic effect due to low dosing



D. Administration routes

1. Oral (PO)

a. types

i. capsules, elixir, powder, sprinkles, tablets

ii. timed release tablets or capsules (CR, XR, XL)


b. preferred route of administration

i. less expensive


ii. fewest complications


iii. amenable to home therapy


c. rate of absorption affected by

i. gastric HCl


ii. perfusion to GI tract


iii. rate of gastric emptying


iv. presence of interacting foods or drugs


d. effects on mechanism of action

i. exposes drug to endogenous HCl

ii. time spent in stomach (effects 'absorption;' may alter drug action or effectiveness)

food in stomach: drug spends more time in stomach, delayed absorption

empty stomach: drug is passed out of stomach quickly, faster absorption


iii. food or drug may bind to drug or block absorption

iv. may require injection if action is severely affected


e. first-pass metabolism

i. orally administered drugs primarily absorbed from small intestine

drug enters portal circulation and travels to liver

immediate transformation via liver enzymes


ii. destroys a larger percentage of the active ingredient than injected agents

usually requires larger oral dose versus injected forms








2. Inhaled

a. absorption rate affected by

i. integrity of lung tissue
167


ii. proper administration of drug

iii. perfusion to pulmonary vasculature


b. aerosols

i. information common to aerosol delivery of drugs

goal - to deliver high concentration of drug in the lungs with limited systemic effects

most commonly used in the treatment of asthma, COPD, wheezing

effectiveness of delivery depends on

slow, deep inhalation and

holding breath for 5 to 10 seconds after inhalation

size of particles (most desirable is 1 to 5 microns)

amount of drug reaching lungs and GI system


ii. metered-dose inhaler (MDI)

advantages
less expensive, more portable than nebulizer
delivers high concentration of medication with few side effects

disadvantages

higher risk of dispensing medication into mouth

very young, very old, and weak clients may have difficulty activating device

technique must be correct for medication delivery

canister must be shaken before each use

hand-breathing coordination required

medication remaining in canister can be difficult to determine


technique without spacer: administer one puff using MDI

shake canister for 2 to 5 seconds

hold MDI with thumb under the mouthpiece and the index and middle fingers on
top of the canister

positioning mouthpiece - client has two options

place mouthpiece of MDI in mouth with opening pointing toward the back of
the head; client tightens lips around mouthpiece

position MDI 1 to 2 inches in front of widely opened mouth pointing toward
back of the head; lips should not touch mouthpiece

inhale deeply and exhale completely

tilt head back slightly and simultaneously inhales slowly and deeply through
mouth while depressing canister

continue to inhale slowly for 2 to 5 seconds, then hold the breath for 10 seconds

technique with spacer

insert mouthpiece of MDI into spacer

shake canister for 2 to 5 seconds

insert mouthpiece of spacer device into mouth being careful not to cover
exhalation vents on spacer
168



breathe normally through spacer

depress canister, spraying one puff into spacer

inhale slowly and fully for 5 seconds

hold breath for 10 seconds


rinse mouth after using MDI with or without a spacer

wait 20 to 30 seconds between puffs before administering second puff or
additional medication with MDI

divide the number of doses in the container by the number of doses used per day
to determine how long the MDI will last




iii. nebulizer

advantage - delivery of finer aerosol, less risk of oral medication delivery

disadvantage - not portable; very young, very old, and debilitated clients may have
difficulty setting up equipment

procedure

add medication to nebulizer cup with diluent and attach nebulizer cup to nebulizer

insert mouthpiece of nebulizer into client's mouth; may use face mask if client unable
to follow instructions

instruct client to inhale slowly and deeply, hold breath for a second, then passively
exhale; dyspneic clients may limit breath-holding to every fourth or fifth breath

turn nebulizer on and verify release of mist

tap medication cap toward end of treatment session

reinforce use of breath-holding

check client's heart rate before and during treatment

after finishing treatment

turn nebulizer off

follow agency policy for storing and cleaning tubing and medication cup

provide oral rinse to client

check bilateral breath sounds, peak flow rates, SaO
2
, and heart rate





iv. nasal spray

gently blow nose before administration

shake container

tilt head slightly back

occlude one nostril, insert spray tip into the other nostril

activate spray and gently inhale


v. dry powder

rotacap inhalers

requires high airflow: avoid use with children and older clients and in high humidity

contraindicated for severe asthma exacerbations


3. Topical

a. transdermal medications

i. analgesics

169


ii. antidepressants


iii. hormones


iv. cardiac medications


b. absorption rate affected by

i. skin integrity


ii. tissue perfusion



c. applied locally, but has systemic effects

d. remove previous patch and wash the area to prevent further absorption prior to applying the
next dose

e. use cautiously with older clients due to increased rate of absorption through aging skin



4. Transmucosal: vaginal, buccal, rectal

a. types: vaginal, sublingual (under the tongue), buccal (in the pouch of the cheek), rectal

b. absorption rate affected by

i. length of exposure

ii. perfusion of tissue

iii. integrity of mucosa


c. suppositories - wear gloves for procedure; remove foil wrapper and lubricate the suppository if
necessary

i. rectal suppositories

if used for systemic indication, have client defecate if possible to allow facilitation
of medication

position client on left lateral position and insert just beyond internal sphincter

instruct client to retain the medication for 20 to 30 minutes for stimulation of
defecation and 60 minutes for systemic absorption


ii. vaginal suppositories

position client supine with knees bent, feet flat on bed and close to hips (a
modified lithotomy position)

use application device to insert suppository




5. Intradermal

a. slower absorption rate

b. common sites: inner aspect of forearm, upper chest and upper back

c. administration

i. use tuberculin syringe

calibrated in 0.1 mL and 0.01 mL

needle: 25 to 27 gauge

length: 1/4 to 1/2 inch


ii. dose: 0.1 to 0.01 mL

iii. angle 10 to 15 degrees from the skin to the deposit the medication below the epidermis; a
wheal will form under the skin



6. Subcutaneous (SubQ): implants, injection

a. parenteral administration of medication into the loose tissue between the skin and muscle
(medication must not enter muscle)
170


b. administration

i. needle type
use 5/8 inch needle, greater than 21 gauge

insulin syringes come in many smaller sizes: 5/16 inch or 8 mm and the pen
needles are 1/2 inch (12.7 mm), 5/16 inch (8 mm) and 3/16 inch (5 mm) lengths


ii. inject medication into subcutaneous tissue to avoid muscle

iii. use 45-degree or 90-degree angle

iv. aspiration not required

v. do not massage injection site

vi. rotate injection sites


c. suitable medications for subcutaneous administration

i. isotonic


ii. nonviscous


iii. non-irritating


iv. water-soluble


v. small volumes of medication (0.5 to 1 mL)


d. contraindications

i. shock, cardiac arrest

ii. decreased perfusion to tissue




7. Intramuscular (IM)

a. four common sites: ventrogluteal, dorsogluteal, vastus lateralis, and deltoid

b. absorption affected by the muscle's perfusion, fat content, and degree of vasoconstriction

c. administration


i. verify need to aspirate

ii. inject medication into large muscle; avoid soft tissue other than muscle, especially nerves
and vessels


iii. needle angle: perpendicular (90 degrees) to tissue being injected

iv. children
younger than 18 months: vastus lateralis muscle
older than 18 months: use vastus lateralis, ventrogluteal, deltoid
inject up to 2 mL for children (deltoid should be limited to 0.5-1 mL)
171




v. adults
injection sites: vastus lateralis, ventrogluteal, and deltoid muscles
inject up to 3-5 mL for adults (deltoid: should be limited to 0.5-1 mL)



d. needle length for injections

i. infants 0 to 12 months: 5/8 inch

ii. toddlers and preschoolers: 5/8 up to 1 inch

iii. school-age and adolescent: 5/8 up to 1 inch

iv. adults: 1 to 1 inch

v. older or debilitated adults: 5/8 to 1 inch


e. landmarks for IM injections

i. ventrogluteal muscle

index finger of non-dominant hand on anterosuperior iliac spine (iliac crest, upper,
outer buttocks)

form a V with index finger and middle finger; aim opening of V laterally the middle
finger pointed towards the iliac crest and index finger pointed toward the
anterosuperior iliac spine.
injection site: between index and middle fingers
low potential for injury


ii. vastus lateralis muscle

anterior, lateral aspect of thigh between greater trochanter and knee

use middle third of muscle to inject

low potential for injury


iii. deltoid muscle

locate lower edge of acromion process (protrusion at end of clavicle)

move straight across upper arm to midpoint of the lateral aspect of deltoid
muscle
this line is the base of a triangle pointing toward the elbows
injection site is 1 to 2 inches below acromion process

alternate method: place four fingers across the deltoid muscle placing the top
finger just below the acromion process with injection site just under the third
172

finger

higher potential for injury: radial, brachial, and ulnar nerves and brachial artery lie
under triceps along the humerus
use only for small volume (0.5-1 mL) injections


iv. dorsogluteal muscle: location of sciatic nerve varies between people; avoid using this site
because of high risk of sciatic nerve injury



f. special types of IM injections

i. Z-track method

indication: parenteral medications likely to harm or irritate tissue

technique

after drawing up the appropriate medication amount, add a 0.2 mL airlock, change
the needle to ensure the medication is not tracked into the SQ tissue during needle
insertion
select a large, deep muscle (such as ventrogluteal)

pull skin tightly down or laterally before injection

inject medication and continue to hold tissue in position

allow needle to remain in place for 10 seconds after injection

withdraw medication and quickly release skin so that layers of tissue move over
needle track to "seal" the medication in place



ii. depot injection

intramuscular injection of a drug in an oil suspension that results in a gradual release
of the medication over a period of time (from several days to weeks to months)

administer regular dose of agent first in controlled setting to prevent sustained allergic
reaction

examples: Somatuline Depot (used to treat acromegaly) and Clopixol Depot (used to
treat schizophrenia)
injection techniques, needle angle, landmarks, Z-track method



8. Intravenous (IV)

a. rate of absorption not affected

b. rate of distribution dependent on stable cardiovascular status

c. titration of dose (typically an RN-only action)

i. usually based on therapeutic effect and dosage/kilogram

ii. requires accurate calculations


d.
catheters

i. 26 gauge (smallest) to 14 gauge (largest); 3/4 inch to 1 1/4 inch in length

ii. blood must flow around inserted catheter (but ease of flow and risk of phlebitis increase as
size increases)



e. complications of IV therapy

i. insertion site: air embolism, bleeding, hematoma, site infection

ii. miscalculation of rate or programming error of infusion control device

iii. IV solution: extravasation, infiltration, hypervolemia

iv. catheter

dislodgement, malposition, migration, rupture

occlusion, thrombosis of catheter
173


insertion site infection, sepsis




f. locations for IV therapy

i. peripheral

insertion site: peripheral vein usually in the arm, may be scalp or foot in pediatrics

bedside procedure for insertion and withdrawal

uses

short-term IV therapy

medication: repletion of fluids and electrolytes; nutrition

isotonic infusions, blood products, solutions not to exceed 10%

duration: usually up to 72 hours per site


nursing care

monitor site for edema, redness, induration, drainage, paresthesia, pain,
temperature

assess vital signs, breath sounds, I&O, peripheral edema, nutritional status and
possibly daily weight and compare to baseline data

maintain dry, transparent occlusive dressing

follow agency guidelines for documentation, reusing IV tubing, dressing changes
and types of dressings, insertion site changes




ii. non-tunneled central venous

indications
emergent situations and trauma
lack of suitable peripheral veins
short-term therapy, critical care, surgery


procedure

sterile procedure performed at bedside

place client in Trendelenburg position, with rolled towel between shoulder blades
(potentially contraindicated for clients with respiratory conditions, spinal deformities,
increased intracranial pressure)

subclavian, internal jugular or femoral veins used, with catheter ending in superior
vena cava


size and appearance

can have up to 4 lumens or ports

usually 6 to 8 inches in length


dressing changes require using aseptic technique
174


unused ports must be routinely flushed with heparin solution and clamped

uses

hypertonic solutions

vasoconstricting agents

pressure monitoring

fluid resuscitation


complications : thrombophlebitis, bleeding, infection, extravasation, occlusion


iii. peripherally inserted central catheters (PICC)

smaller, longer (40 to 65 cm catheters) and more flexible than other central line

procedure

sterile procedure performed at bedside

inserted through a peripheral vein in the upper arm, usually either the basilica,
cephalic or brachial vein; catheter ends before superior vena cava

can stay in place for as long as a year if properly maintained

must measure and document external length of PICC with each dressing change

unused ports must be flushed with heparin solution and clamped


iv. tunneled central venous catheters: part of the catheter is encased in subcutaneous tunnel; tissue
granulates onto cuff surrounding catheter creating a barrier and anchor

inserted surgically through the subclavian vein

useful for frequent, long-term IV therapy

typically no dressing is required after cuff heals

types

Broviac

Hickman

Groshong


complications



v. implanted port (vascular access devices (VAD)

surgically implanted

dense septum with reservoir and attached catheter

painful needle insertion: Huber (non-coring) needle must be used to access port

must always confirm needle placement before medication administration

requires flushing after each use; unused port is flushed monthly with heparin solution



175

Comparison of Central Venous Catheters
Non-tunneled Peripherally
Inserted Central
Catheter (PICC)
Tunneled Implanted Port
Insertion
Procedure
sterile (with client in
Trendelenburg position)
bedside sterile surgical surgical
Dressing sterile sterile sterile none required
Insertion
Site
subclavian or internal
jugular ending in superior
vena cava
antecubital fossa or
upper extremity;
ends before
superior vena cava
subclavian upper chest,
upper extremity
Uses hypertonic solutions,
vasoconstricting agents,
pressure monitoring, fluid
resuscitation
suitable for all
infusions, long-term
therapy
frequent long-
term IV
therapy
intermittent, long-
term therapy
Unique
Features
triple lumen catheter used
for monitoring
teach client to
protect arm and
care for insertion
site
types:
Broviac,
Hickman,
Leonard
access: Huber
(non-coring)
needle through
silicone septum
Note: All central venous catheters require Luer-Lok connections and x-ray confirmation of tip placement before
therapy begins.

g. methods of IV administration

i. continuous infusion: risk of fluid volume overload

ii. infusion control device (ICD, pump)

mechanical control of rate and volume

types: syringe (small volume), peristaltic action, and
microchamber

verify volume infused (on time strip of IV bag) without using
pump indicators every hour


iii. IV push

administration by bolus; verify rate of IV push

verify if allowed by scope of practice in Nurse Practice Act and
agency policy


iv. secondary infusion (piggy-back, rider, intermittent)


v. patient-controlled analgesia (PCA) pump

client has limited control of opioid dosing

pump settings prescribed: dosing parameters including basal
rate, bolus dose amount and frequency of boluses

benefits

avoids delay of pain medication

avoids frequent IM injections

greater sense of client control
176

Non-tunneled Peripherally
Inserted Central
Catheter (PICC)
Tunneled Implanted Port

lower incidence of respiratory depression when used with
short-acting opioids






h. IV therapy solutions : used to replace fluids, electrolytes, and nutrients; also rapid administration
of drugs

i. isotonic crystalloid solutions - osmotic pressure similar to plasma; expands extracellular fluid
without changing osmolarity

ii. hypotonic crystalloid solution - exerts less osmotic pressure than plasma; fluids shift into
interstitial spaces and cells, causing cells to swell

iii. hypertonic crystalloid solution - exerts more osmotic pressure than plasma; osmosis pulls
fluids out of the cells, causing them to shrink

iv. hypertonic colloid solutions - also expand intravascular volume plasma but colloids contain
molecules too large to pass through semipermeable membranes


i. additional equipment for IV therapy

i. volumetric device (such as Buretrol)

ii. Luer-Lok: collared slip-lock that fits onto a female catheter hub

iii. filter

place as close to insertion site as possible

can rupture under excessive pressure

various sizes (in microns) depending on solution

removes particulate matter, microorganisms, and air within limits; use only if
indicated



j. role of PN with IV therapy

i. verify state-approved IV skills and IV responsibilities (scope of practice) in Nurse Practice Act

ii. most states allow well-defined IV related tasks only after additional education and training

iii. most states require LPN/VNs to observe IV sites and to report the findings to the RN or health
care provider; observe for

leakage

clean, dry dressing

site: less than 3 days old

infection

warmth

redness

swelling

drainage

tenderness or pain

infiltration

swollen

cool to touch
177


infusion rate slowing or stopping

phlebitis

regional pain and swelling

red streak along vein line

leakage, infiltration, or impaired infusion rate




10. Intrathecal

a. types

i. spinal


ii. epidural: standard drug instillation and liposomal instillation of morphine



b. direct administration of opioids and local anesthetic agents into epidural space or intrathecal
space


c. benefits

i. lower systemic side effects

ii. lower dosing of therapeutic agents


d. dose-dependent effects

i. itching, nausea, vomiting

ii. respiratory depression, urinary retention


e. adverse effects: delayed respiratory depression



11. Intraosseous infusion

a. percutaneous placement of intravenous catheter into a marrow cavity

b. used when peripheral blood vessels are collapsed or inaccessible



12. Ophthalmic

a. preparation

i. wash hands and apply gloves - rinse powdery residue from gloves

ii. instruct client to recline or tilt head back

iii. instruct client to look up






178


b. technique - eye drops
Instilling Eye Drops
1. Wash hands and apply gloves; rinse powdery residue from gloves
2. Instruct client to recline or tilt head back
3. Instruct client to look up
4. Pull lower lid down and to the side
5. Apply drop at lower, outer aspect of eye (lower conjunctival sac)
6. Apply mild pressure to inner canthus for 1 minute to decrease systemic
absorption
7. Instruct client to gently close eyes
8. Wait 2 to 5 minutes before instilling additional eye drop (in same eye)


c. technique - eye ointment

i. apply a thin line of ointment along the edge of the lower lid moving from inner canthus to
outer canthus


ii. instruct the client to gently close the eye and move the eye around



13. Otic

a. ear drops preparation

i. warm medication

ensure tightly sealed medication container

run container under warm water


ii. position client on unaffected side with affected ear facing up

iii. remove ear drainage or cerumen with cotton-tip applicator; avoid pushing cerumen into
ear canal


iv. open ear canal

In a child younger than age 3, pull the lobe down and back

In a child older than 3 years, pull the pinna up and back




b. instillation of drops

i. fill dropper with medication

ii. hold dropper about 1/2 inch above ear canal

iii. gently squeeze bulb on dropper to instill prescribed number of ear drops

iv. instruct client to remain in place for 5 to 10 minutes

v. repeat in other ear if necessary after waiting 5 to 10 minutes


c. if cotton balls are prescribed - place in outermost part of ear canal and remove in 15 minutes


E. Medication delivery

1. Single dosing
179


a. bolus: a single dose administered IV, from a syringe (usually), and at one time (usually an
RN-only task)


b. STAT dose: give prescribed amount of medication immediately

c. one-time dose: prescription is administered only one time

d. loading dose: prescribed amount of medication

i. administered (usually larger than normal) at the beginning of therapy to establish a
therapeutic blood level


ii. administered as single or divided doses

iii. followed by maintenance therapy



2. Intermittent dosing

a. as needed (PRN)

b. IV push: indicates a bolus of medicine in a syringe (usually an RN-only task)

i. therapeutic dose by IV administration given at one time

ii. can be single daily dose or multiple daily doses




c. IV piggy-back

i. small volume IV containing a medication infused over at least 30 minutes

ii. also called a "rider" or "secondary infusion"



3. Continuous dosing

a. subcutaneous implant or pump

b. transdermal infusion system

c. IV infusion

i. continuous IV fluid infusion

ii. titration: drip rate is adjusted to maintain predetermined parameters within an
acceptable range based on amount/client weight/time





F. Nursing responsibilities

1. All medications must have a signed, provider prescription

2. Administer drug as indicated: typically allowed 30 minutes before through 30 minutes after
prescribed time to administer medication

3. Prior to administering a medication

a. know and understand medication incompatibilities

b. verify drug safety in pregnancy and lactation

c. review hepatic and renal function before administration

d. obtain cultures before beginning anti-infective therapies

e. know lab values or other test results prior to administration


4. Individualize pharmacotherapy according to developmental stage or Erickson's Stages of
Development

5. Older adults

a. may retain lipid-soluble drugs longer

b. serum levels of water-soluble drugs may be higher than normal

c. many medications may cause confusion in the elderly


6. Establish baseline data for monitoring medication effectiveness
180


7. Remain up-to-date on information about medications, including evidence-based practice
guidelines

8. Understand concepts, i.e., indications, naming of drugs, related to medication classification

9. Avoid distractions while dispensing and administering medication



10. Five rights of medication administration

a. right dose: check medication label against the administration record
PATIENT SAFETY - Check medication label against the administration record three times
while preparing the medication!
1. When first taking the medication out of the container
2. Just before opening the medication package or pouring the dose
3. Just before replacing the container in the storage area or giving a unit dose to the client

b. right time: check facilities policies, usually 30 minutes before or 30 minutes after the ordered
time


c. right route: Check the medication order that the route is specified

d. right drug

i. proper mixing or dilution

ii. speed of infusion or push

iii. accurate dosage calculations


e. right client

i. check ID bracelet for client name and birth date (depending on facility, include bar code
check of ID bracelet)

ii. have client state full name and birth date

iii. verify information using medication administration report (MAR)



11. Other rights of medication administration include

a. right documentation

i. document immediately after medication is given on MAR or computerized medical record

ii. document if client refuses medication

iii. include drug, time, dose, route, signature


b. right assessment

i. vital signs, ability to swallow, pain

ii. check client data, lab tests, and diagnostic studies before administration


c. right education

i. about the medication - important to stay up-to-date on meds

ii. expectations



d. right evaluation, i.e., response to therapy

e. right to refuse medication

i. nurse should explain any problems associated with not taking a medication

ii. notify health care provider


f. client privacy and client rights



12. Medication errors

a. higher rate of medication errors associated with

i. high-alert drugs


ii. poor communication
181


iii. clients over the age of 60 years

iv. poorly written prescriptions, use of ambiguous abbreviations, and misunderstanding of
prescription's meaning

v. prescribing errors - mistakes made by provider in prescribing drugs involving unsuitable
drug choices, dosing errors, incompatibilities, and contraindications

vi. failure to reconcile client medication list at client hand-offs

vii. most common nursing medication errors
incorrect dose, time, route, and client
multiple routes of administration for single drug on MAR



b. preventing medication errors

i. perform medication reconciliation

reconcile medications at any client hand-off: admission, transfer, discharge,
postoperatively, and at shift change

involves comparing the client's list of medications with the prescriptions

may involve client and family in reconciliation



ii. avoid distractions while dispensing and administering medication

complete check of client's rights: dose, time, route, drug, and client

check client identifiers on each page of MAR

check client data, lab tests, and diagnostic studies before administration

read medication labels three separate times


iii. typical identifiers in acute care setting - follow agency guidelines
check client wristband with name and medical record number
ask client for first and last name; avoid revealing client's name to client


iv. clarify poorly written prescriptions; never attempt to interpret

v. complete client admission assessment
history
allergies
identify the accurate list of client's medications


vi. maintain up-to-date drug information

clarify questions with research or consulting with the pharmacy

refer to agency policy for administration guidelines


vii. report medication errors and problems according to agency policy



13. Client privacy and client rights

a. privacy

i. cover MAR (or reduce screen) except when needed to dispense medication

ii. close door to client's room or pull the privacy curtain to obscure viewing of procedures

iii. request visitors and family members leave the client's room during medication
administration except when allowed by client

iv. avoid discussing client medication except on a "need to know" basis


b. confidentiality

i. avoid sharing information about client's medications except on a "need to know" basis

ii. avoid associating medications or medication related information to client in public areas
182



c. informed consent

i. provide information on medications dispensed before initial dose and during therapy

indications

therapeutic or anticipated effects

adverse effects

risks of accepting or refusing therapy


ii. reinforce client teaching


d. self-determination: client may refuse a dose of a medication or the entire course of therapy
without coercion or threats of retribution



14. Client teaching plan - assist health care team or RN to formulate and implement client teaching
plan

a. do not crush or chew tablets unless directed to do so

b. avoid sharing medication with other people and family members

c. avoid driving and performing hazardous activities until drug effect is well established

d. travel with medication in original containers

e. cutting pills - discuss with health care provider first

i. cost-cutting measure

ii. use commercial pill-cutter

iii. disadvantages
may result in decreased therapeutic effect
serious adverse effects due to rapid release of medication


iv. do not cut capsules, enteric-coated, sustained-release, or extended-release tablets, or
pills intended for transmucosal administration


f. provide drug information

i. name, dose, and indication

ii. administration guidelines

iii. storage


iv. resources for client and family


g. reinforce information about expected effects, side effects and adverse effects

i. side effects may subside after 4 to 6 weeks of therapy

ii. notify provider before stopping therapy due to side or adverse effects

iii. comfort measures for relief of side and adverse effects


h. advise client to contact provider

i. adverse effects or disease process worsens

ii. indications of drug toxicity


i. provide individualized instruction about dosing and administration guidelines

i. avoiding certain foods

ii. preparing drug before administration

iii. dosing schedule and length of therapy

iv. avoiding hazardous activities or driving until the full effects of the medication are well-
183

established


v. taking as directed, even when feeling better

vi. store drugs properly, away from light, heat, and moisture

vii. avoiding over-the-counter (OTC) drugs and herbal remedies without provider discussion


j. discuss need for monitoring and follow-up care


k. notify other providers about drugs on medication profile (complete list of client's drugs)
including

i. herbal supplements - may have adverse effect on prescription drug action

ii. diet pills


iii. over-the-counter drugs

iv. minerals, vitamins, nutritional supplements

v. contraceptive drugs or devices, laxatives, and sleeping aids


l. avoid Internet and international purchase of drugs and dietary supplements

i. some medications may be counterfeit

ii. purity is unreliable

iii. therapeutic equivalents are difficult to determine because

identically-named medications sold in different countries are frequently different
medications (different chemical composition)

identical medications (same chemical composition) sold in different countries will
frequently have different generic and brand names




15. Client safety

a. identify and manage hazards related to pharmacotherapy

b. safety

i. chemical
avoid over-the-counter (OTC), herbal, and other nonprescription remedies
carefully review drug profile when adding or deleting a drug from the list


ii. physical: orthostatic hypotension, stairs, shaving, etc.


c. avoid administering drug with known client...

i. hypersensitivity


ii. pregnancy or lactation

balance of risk versus benefit

some drugs used to preserve life of mother

most drugs are contraindicated due to risk for fetus

pregnancy categories

A: no risk to fetus in the first trimester

B: may or may not show risk in animals, no risk shown in human studies

C: risk shown in animals, insufficient data in pregnant women

D: demonstration of human risk in selected clinical studies

X: clear demonstration of risk to human fetus



iii. hepatic or renal dysfunction


184


II. Total Parenteral Nutrition: Nursing Care of Clients

A. Nutritional support

1. Nutritional deficiency

a. clinical indications for hyperalimentation include clients who

i. cannot use GI tract for absorption of nutrients

ii. require nutritional therapy to maintain or improve nutritional status

iii. have risk factors for malnutrition

body mass index for height and age below average

admission to hospital, nursing home, rehabilitation facility

anorexia, nausea, vomiting from agent, event, or condition

inadequate nutritional intake, increased nutritional loss, or increased
metabolic rate

impaired ability to prepare, obtain, or eat food

substance abuse, older clients

low socioeconomic status, educational deficiencies

dysphagia, infection, multiple chronic illnesses, trauma




b. clinical indicators of malnutrition

i. gold standard: prealbumin below normal (protein deficiency)

ii. other labs: low hemoglobin, transferrin, cholesterol, total lymphocytes

iii. physical findings
gums and teeth in poor repair
reddened and open areas, susceptibility to infection
dull, dry eyes, nails, skin, hair, inadequate muscle bulk





Included on the Institute for Safe Medication Practices (ISMP) List of High-Alert Medications is
all total parenteral nutrition solutions.

2. Hyperalimentation

a. partial parenteral nutrition

i. indications: central line contraindicated, prolonged postoperative ileus

ii. infusion

via large peripheral IV

solutions

isotonic lipid emulsion: may be administered with IV solution

hypertonic amino acid and dextrose solution




b. total parenteral nutrition (TPN)

i. long-term intensive nutritional support for
trauma, major surgery, hypermetabolic state

GI impairment: inflammation, malabsorption, obstruction, side effects of
chemotherapy


ii. hyperalimentation solution used to meet goals of therapy

contains hypertonic dextrose and amino acid solutions
25%-35% dextrose
3%-5% amino acids
10%-20% lipids


infuses via central venous catheter in subclavian or internal jugular vein
185


includes electrolytes, minerals, trace elements, and insulin added by pharmacist

prepared and administered under strict aseptic technique


iii. benefits

individualizes formula according to client needs

protein-sparing action with calories

supplies amino acids for tissue repair and healing

delivers all nutrients with lower risk of fluid overload than nutritional equivalent of
standard IV therapy



c. complications from central venous catheter

d. selected complications from TPN solution

i. infection: solution provides breeding ground for microorganisms

ii. fluid imbalance
hypertonic solution infuses directly into venous circulation
fluid shifts occur due to hyperosmolar nature of solutions


iii. hyperglycemia: most solutions contain insulin or client on sliding scale insulin regardless of
history of diabetes mellitus



B. Nursing care

1. Assist health care team to establish baseline data and check prior to initiating therapy and
periodically thereafter

a. vital signs, SaO
2
, right atrial pressure

b. blood urea nitrogen (BUN), creatinine, liver function tests, pH

c. glucose monitoring (Accu-Chek) minimum once a shift (due to impairment of glucose
metabolism)

i. hyperglycemia: nausea, weakness, thirst, headache, tachypnea

ii. hypoglycemia: diaphoresis, tachycardia, hunger, trembling, confusion


d. fluid volume status: daily weight, I & O, edema, breath sounds

e. nutritional status: skin, serum electrolytes, glucose, cholesterol, triglycerides

f. infection: temperature, WBC, insertion site

g. other: neurologic status

h. refeeding syndrome (first 24 to 48 hours of therapy): bradypnea, lethargy, confusion,
weakness



2. Prevent complications

a. rebound hypoglycemia: withdraw TPN slowly

b. microemboli: use 0.2 m-filter (except with lipid emulsion)

c. injury: check expiration date of solution, verify TPN order and client identity

d. hyperglycemia: verify insulin coverage, check blood glucose frequently

e. acidosis: maintain tight glycemic control, encourage coughing and deep breathing

f. infection

i. avoid contamination from oily skin or tracheostomy

ii. insert catheter with surgical asepsis

iii. refrigerate until 30 minutes before using, discard after 24 hours

iv. sterile dressing change, use aseptic technique, change tubing daily


186


g. fluid shifts, hypervolemia, osmotic diuresis

i. do not increase infusion rate

ii. mantain tight glycemic control: verify provider or agency policy for tracking serum
glucose levels


iii. administer 10% dextrose if TPN infusion is interrupted

iv. carefully control infusion rate, carefully program infusion device

verify volume infused with time strip on TPN container

start infusion slowly; titrate to client response



h. air emboli

i. use Luer-Lok connections

ii. cover site with occlusive dressing

iii. clamp tubing when changing solution or tubing; may need to position client in supine
position or ask client to perform Valsalva maneuver




3. Assist health care team to implement client and family teaching plan for home therapy

a. review purpose and procedure

b. verify written instructions for all procedures, troubleshooting, and complications

i. review procedures and equipment

record keeping

infusing solution

ordering supplies

glucose monitoring


ii. request return demonstration for understanding and competency


c. verify aseptic technique (do not disconnect tubing)

d. verify temperature in refrigerator

e. promptly report

i. fever


ii. breathing difficulties

iii. weight gain, edema, orthopnea

iv. recurring hyperglycemia

v. swelling, redness, or drainage at central venous catheter site




III. Blood Product Administration

A. Administration of blood and blood products

1. Blood products: red blood cells (RBCs)

a. washed RBCs: RBCs washed with sterile saline before administration; removes some
immunoglobulins and proteins

b. packed RBCs: blood cells are separated from plasma and platelets, decreases risk of
fluid overload


c. autologous blood transfusion

d. leukocyte-poor RBCs: removal of most leukocytes, fewer RBCs than packed RBCs


2. Plasma

a. serum albumin


b. immune serum globulin


c. factor concentrates: factors VIII and IX
187


d. fresh frozen plasma: contains coagulation factors

e. cryoprecipitate: clotting factors VII and VIII


3. Other blood components

a. platelets


b. RhoGAM


c. granulocytes






B. Purpose of transfusions and method(s)

1. Restore blood volume

a. provide albumin

i. normal serum albumin


ii. plasma protein fraction



b. increase oncotic pressure

i. serum albumin


ii. packed red blood cells



c. increase fluid volume: whole blood


2. Increase oxygen-carrying capacity

a. increase hematocrit: red blood cells

b. increase hemoglobin: red blood cells


3. Enhance immunologic defense

a. provide immunological factors

i. immune serum globulin


ii. granulocytes



b. prevent Rh-sensitization



4. Enhance hemostasis

a. provide clotting factors

i. cryoprecipitate


ii. fresh frozen plasma



b. provide platelets

i. apheresis packs


ii. random donor packs






C. Risks

1. Allergic reaction

a. most common type of reaction

b. findings: hives and itching

c. may be treated with antihistamines, e.g., diphenhydramine (Benadryl)


2. Febrile reaction

a. a reaction to the white blood cells in the donated blood

b. more common in clients who have had previous transfusions and in multi-para women
188


c. findings: fever within 24 hours of the transfusion, including headache, nausea, chills, or a
general feeling of discomfort

d. may be treated with antipyretic, e.g., acetaminophen (Tylenol)


3. Transfusion-related acute lung injury (TRALI)

a. may occur with any type of transfusion but more common with fresh frozen plasma or
platelets


b. more common in clients who are gravely ill

c. findings: trouble breathing, often within 1 to 2 hours of starting the transfusion but may
begin up to 72 hours post transfusion

d. findings are often under-recognized (which leads to a delay in treatment and an increased
mortality rate)



4. Acute hemolytic reaction

a. rare, but most serious type of transfusion reaction

b. occurs when donor and client blood types do not match

c. usually the result of human error, e.g., mislabeled pre-transfusion specimen, transfusion of
properly labeled blood to the wrong person, clerical errors

d. findings: chills, fever, chest and lower back pain, nausea progressing to hypotension,
bronchospasm, vascular collapse and disseminated intravascular coagulation (DIC)


5. Delayed hemolytic reaction

a. this reaction involves the body slowly attacking the antigens on the transfused blood cells

b. findings

usually none, but may develop fever 4 to 8 days, up to 1 month, after blood
transfusion

lab findings include falling hematocrit and a positive direct antiglobulin (Coombs)
test


c. more common in clients who have had previous transfusions



6. Graft-versus-host disease (GVHD)

a. occurs in severely immunocompromised clients

b. white blood cells in a transfused blood product attack client's tissues

c. more common when a relative or someone with the same tissue type has donated blood

d. findings: within a month of the transfusion, the client may have fever, liver dysfunction, rash,
diarrhea, pancytopenia

e. high mortality rate


7. Non-immune hemolysis

a. lysis of RBCs due to improper storage, handling, or transfusion conditions

b. findings: may include hemoglobinemia and hemoglobinuria


8. Disease acquisition

a. bacterial

i. more common in platelets since they must be stored at room temperature, allowing bacteria
to grow quickly


ii. sepsis


189


b. viral (including Hepatitis B & C, HIV)

c. babesiosis, malaria, Lyme disease, syphilis, Chagas disease, Creutzfeldt-Jakob disease can
be spread by blood product transfusions



9. Hypotension

a. findings: a drop of at least 10 mm Hg in systolic or diastolic arterial blood pressure in the
absence of other findings of transfusion reactions

b. may be associated with use of angiotensin converting enzyme (ACE) inhibitor drugs


10. Post-transfusion purpura (PTP)

a. findings: thrombocytopenia, usually profound

b. typically occurs 7 to 48 days after transfusion


11. Circulatory overload

a. caused by the infusion of blood at a rate too rapid for the client to tolerate

b. findings: dyspnea, orthopnea, tachycardia, sudden anxiety, progresses to pulmonary edema
if transfusion is continued

c. diuretics given after or between transfusions to clients at risk of, or already in, circulatory
overload



D. Nursing care

1. Observe RN prepare and initiate transfusion

a. signed consent required

b. blood products are picked up from the blood bank and must remain refrigerated until ready
for infusion

a. do not store blood in the refrigerator used for food

b. initiate transfusion within 30 minutes of removal from blood bank

c. complete transfusion in 4 hours after removal from blood bank


c. baseline data is established and monitored (following agency policy for frequency and
duration)

i. vital signs, SaO
2
, skin every 15 minutes and 1 hour after completion

ii. breath sounds (crackles especially), dyspnea, jugular vein distention

iii. hemoglobin and hematocrit, urine output; serum potassium, calcium, and creatinine



d. transfusion is given slowly for first 15 to 20 minutes

i. remain at bedside


ii. question client about unusual feelings

iii. monitor vital signs every 5 minutes during first 15 minutes and then as required by
agency policy



e. most reactions...
are due to human error
require symptomatic treatment
mandate notifying the provider and blood bank; follow agency policy
occur within the first 15 minutes of a transfusion



2. Observe RN prevent complications

3. Assist health care team to implement client teaching plan
190


a. reinforce information about contracting infections from blood

b. reinforce information about administration method, monitoring, duration of transfusion,
symptom recognition and reporting




4. Nursing care for transfusion reaction

a. immediately stop transfusion and take vital signs

i. clamp IV tubing and disconnect at hub of catheter

ii. do not allow additional blood to enter client's system, do not flush tubing with saline to clear


b. collaborate with provider for pharmacologic treatment

i. supplemental oxygen

ii. diuretics


iii. antibiotics


iv. antihistamines


v. glucocorticoids



c. monitor hemoglobin and hematocrit

d. complete transfusion reaction form

e. save entire administration set and blood bag, return to blood bank

f. follow agency policy on criteria for transfusion reactions and follow-up nursing actions



IV. Dosage Calculations

A. Ration and proportion

1. Equation description

a. each side of the equation represents the same percentage, fraction or ratio

b. example: 75%

i. equal percentages: 75% = 0.75


ii. equal fractions:



iii. equal ratios: 3 : 4 = 7.5 : 10



c. both sides of the equation represent an equal relationship but are expressed with
different quantities; the two sides match
To figure the calculation, multiply the means (numbers that are closet to each other) by
the extremes (numbers that are the farthest from each other). You are solving X, so X
goes first.


d. use a proportion equation to solve

i. dosage calculations


ii. metric to metric conversion

involves multiples of 10, 100, or 1000

grams : mg : mcg (1 x 1000 x 1000)

1 gram = 1000 mg

1 mg = 1000 mcg

1 gram = 1,000,000 mcg

191



mcg : mg : grams (1 1000 1000)

1 mcg = 0.001 mg

1 mg = 0.001 gram

1 mcg = 0.000001 gram




liters : mL 1 liter = 1000 mL

mL : liters 1 mL = 0.001 liter



e. applicable to other conversions









2. Dosage calculation: solve for x using a proportion problem
Example: The client with heart failure receives furosemide (Lasix) 40 mg by mouth daily. The
pharmacy stocks furosemide 20 mg tablets. How many tablets does the nurse administer for a 40
mg dose?


a. step one: set up proportion problem

i. advantage: proportion problems are easy to set up

ii. both sides of equation must match: display an equal relationship of the factors (mg and
tabs)


iii. first method

one side of the equation is what you have

the pharmacy stocks 20 mg tabs (20 mg per tab)

1 tab = 20 mg


the other side of the equation is what you want

the nurse wants to administer 40 mg; how many tablets does that require?

X number of tabs = 40 mg




iv. second method

make the equation match by placing each factor on opposite sides
one side of the equation is a factor
the other side is the second factor

make the equations match

use what you have as the numerator on opposite sides

use what you want as the denominator on opposite sides
192



the left side of the equation displays the relationship of the factor mg according to


the right side of the equation displays the relationship of the factor tablets according to




v. the answers for the equations in method 1 and 2 are the same: 2 tabs



b. step two: cross multiply and divide


i. (40 mg) 1 tab = (20 mg) x tabs [cross multiply]



ii. 40 = 20x [simplify each side: (40) 1 = 40 and (20) x = 20x]


iii. 20x = 40


iv. solve for x and divide both sides by 20



v. [simplify]



vi. x= number of 20 mg tabs of furosemide (Lasix) equals a 40 mg dose (carefully apply the
desired unit of measure to the solution)




3. Dosage calculation: solve for x using dimensional analysis (DA)

a. Advantage: only one equation used
Example: The client receives 300 mg phenytoin (Dilantin) by mouth daily for seizures. The
pharmacy sends phenytoin 125 mg/5 mL suspension. How many mL of suspension will the
nurse administer?

b. set-up DA equation

i. left side of the equation: what you are solving for (what you want)

x mL of suspension


ii. right side of the equation

available information related to unit of measure on the left side of equation: what
you know aboutmL (what you know or what you have)

what you have written as a fraction
193



place this information on the right side of the equation so the unit of measure from the
left side appears as the denominator on the right side

allows the unit of measure (mL) to be cancelled-out

in the example, the unit of measure on the left side of the equation is mL

in this problem,mLmust then be the numerator on the right side



iii. find the remaining information matching the unit of measure used in the numerator

in the example, this information is the prescription - place this information in the equation
so the mg cancel-out


mg cancel-out



x = 12 mL/day of phenytoin elixir




4. Order: Acetaminophen (Tylenol) elixir 100 mg by mouth every 4 hours as needed for pain.
Available concentration of Tylenol is 80 mg/0.8 mL. How much Tylenol elixir will the nurse
administer?

a. amount desired = 100 mg

b. amount on hand = 80 mg in 0.8 mL

c. (desired) 100 mg/x mL = 80 mL/0.8 mL (have on hand)

d. cross multiply:


100 (0.8) = 80 x


e. solve for x:


x = 100 (0.8)/80

x = 1 mL


f. the nurse would administer 1 mL Tylenol elixir


B. Conversions

1. Metric conversion

a. metric to metric

i. 0.001 kg = 1 gram = 1000 mg = 1,000,000 mcg

ii. 1 mcg = 0.001 mg = 0.000001 gram
194


iii. 1000 mL = 1 liter, 1 mL = 0.001 liter

iv. 1000 mm = 100 cm = 1 meter, 1 mm = 0.1 cm = 0.001 meter


b. metric to other

i. 2.5 cm = 1 inch


ii. 1 kg = 2.2 lbs


iii. 1 gram = 15 grains
1 grain = 60 miligrams


iv. 30 mL = 1 ounce = 2 tablespoons
5 mL = 1 fluid dram (dr)= 1 tsp
2 Tablespoon = 30 mL= 1 oz = 8 drams




2. Temperature conversion

a. Centigrade =


b. Fahrenheit =




C. Weight based dosage calculation
Scenario: The child weighs 68.2 pounds. The nurse must administer amoxicillin (Amoxil) by
mouth at 30 mg/kg/day in divided doses every 6 hours. How much amoxicillin does the nurse
administer each day? How many milligrams of amoxicillin does the nurse administer for each
dose?


1. Step one: convert the weight in pounds to kilograms



2. Step two: how much amoxicillin does the nurse administer each day?

a. insert weight (kg) into dosage equation


b. the nurse administers 930 mg/day


3. Step three: how much amoxicillin does the nurse administer for each dose?

a. calculate doses/day


b. divide total daily dose by the number of doses


c. check your answer

i. total daily dose


ii. dose = prescription






D. Intravenous calculations
195


1. The nurse prepares vancomycin (Vancocin) 500 mg IV in 250 mL of normal saline to infuse
over 2 hours. What is the administration rate in mL/minute?

a. useful equations for calculating administration rate:

b. set up the equation for this problem:


c. administration rate expressed as:



d. determine hourly rate:


e. solve this problem (convert 1 hour to 60 minutes):



2. The prescription is linezolid (Zyvox) 600 mg IV in 300 mL of D5W to infuse over 2 hours. The
IV tubing drip rate = 10 gtts/mL. What drip rate should the nurse use?

a. set up the problem and determine the hourly rate:


b. convert 1 hour to 60 minutes and determine milliliters per minute


c. determine drops/minute:
drip rate of IV tubing = 10 gtts/mL
multiply (units/min) x gtts/mL





3. IV flow rate using DA. The client receives epinephrine (Adrenalin) 0.25 mcg/min IV via infusion
pump. The pharmacy sent epinephrine 0.1 mg in 250 mL of normal saline. What rate in mL/hr will
the nurse use to program the infusion pump?


a. left side of the equation: what is being solved for (what you want)
i. x = mL/hr



b. right side of the equation: what is available (what you have)

i.



ii. first section

since x = mL/hr, the numerator in this section must be mL

the information attached to mL in the example is the epinephrine solution: 1 mg in
250 mL


iii. second section: the example asks for mcg, so mg must be converted to mcg

iv. third section: the example asks for, we have a prescription for


196


need to cancel-out mcg and relate the answer to time

insert prescription into equation: what we have, what is available


v. fourth section: convert minutes to hours

vi. check the equation: all units of measure should cancel-out except for those that solve for x

in the example: x=mL/hr


vii.


mg: cancel-out

mcg: cancel-out

min: cancel-out

remaining units of measure: mL and hr


viii.



ix.



x.





c. standard equation for IV flow rate (using information found in number 3 on epinephrine)

i.



ii. place information about epinephrine above into equation

iii.


the solution was sent in mg, convert mg to mcg



iv.




The nurse will apply mild pressure to the inner canthus of the eye after instilling eye drop medication. True False
Taking a medication sublingually avoids the first-pass effect. True False
Examples of Schedule I medications include morphine and secobarbital (Seconal). True False
The nurse asks the client with emphysema to bear down during insertion of a non-tunneled central venous
catheter (CVC).
True False
An elderly client is more sensitive to the active substance in a transdermal patch than a younger adult. True False
Lactated ringer's (LR) solution is a hypotonic fluid. True False
Clients risk adverse effects if they use herbal supplements along with prescription medications. True False
The nurse infuses 1 liter of 5% dextrose solution over 8 hours at 17 gtts/min; the IV has a drip factor of 15 gtts/mL. True False
The nurse can crush the oral medication disopyramide CR (Norpace CR) and mix it with applesauce. True False
Hypovolemia is a risk for the client receiving whole blood products. True False


Points to Remember
The following are basic critical thinking guidelines for safe drug administration.
Before administration

Assist health care team to gather general baseline data

vital signs, including height and weight

allergies, co-morbidities

laboratory results

hepatic, pulmonary, renal, neurologic, nutritional, and cardiovascular status
197



Identify client factors, including the affect of developmental status, cultural factors, and history of drug
action, safe to use during pregnancy

Determine purpose of therapy

indication for drug

desired therapeutic outcome


Know expected side effects, adverse effects and/or toxic effects and how to prevent or treat adverse
effects

Reconcile medication profile with client, family, nursing staff, provider

Verify prescription and client, including dose, time, calculations, dosing range, dispensing method

After administration

Assist health care team to check client response to therapy and report findings

therapeutic effect

adverse effects or toxicity


Document findings including data requiring action or follow-up nursing care

Document nursing care including care given before and after drug administration

Evaluate care and processes, including any med errors or problems

Reinforce client teaching: assist health care team to implement client teaching plan

What to report

How to administer

Food, substances, activities to avoid

Need for follow-up care and testing

How and when to activate emergency services or contact provider

Points to Remember 2
The following is a list of basic nursing care to prevent or minimize common adverse effects of drug
therapy.

Nausea, vomiting, anorexia

Nursing care: collaborate for antiemetic, eliminate triggers, maintain NPO status

Monitoring: assist health care team to

check fluid and electrolyte balance; bowel sounds and elimination pattern; food intake

track blood pressure; skin and mucous membranes for moisture; urinary output; and serum sodium,
potassium and chloride


Assist health care team to implement client teaching plan:

progress from NPO to clear liquids to small, frequent meals

breathing techniques

avoid triggers


Constipation

Nursing care: provide fluid, fiber, stool softener, encourage ambulation

Monitoring: assist health care team to check bowel sounds, pattern; review diet for fluid, fiber

Assist health care team to implement client teaching plan: increase fluid, fiber; ambulate; establish
bowel habits


Diarrhea

Nursing care: provide hygiene, skin care, close supervision to prevent injury

Monitoring: assist health care team to check bowel pattern, fluid and electrolytes balance, weakness,
198

skin, cultures

Assist health care team to implement client teaching plan: increase fluid intake, wash hands, avoid
irritating foods


Rash, allergy

Nursing care: screen for allergies, previous reactions, provide skin care

Monitoring: assist health care team to check airway, breathing, blood pressure, skin, pruritus, cultures

Assist health care team to implement client teaching plan: report dyspnea, pruritus, hives, worsening
condition


Hypotension, dizziness

Nursing care: maintain supine position, encourage fluids, review med profile; protect client

Monitoring: assist health care team to check vital signs, SaO
2
, EKG, level of consciousness, urinary
output

Assist health care team to implement client teaching plan: remain in bed; ask for help to stand; avoid
alcohol, sedation


Points to Remember 3
The following is a list of adverse effects associated with drug classes or types and associated nursing
care and client teaching

Antihypertensives: orthostatic hypotension, fluid and electrolyte imbalance

Nursing care: assist with activity; eliminate drug interactions, vasodilators, central nervous system
depressants

monitoring: assist health care team to check blood pressure for hypotension if they are taking a diuretic
also, pulse, breath sounds, serum electrolyte levels, edema, dizziness

assist health care team to implement client teaching plan: get help to stand, report dizziness; avoid
alcohol, sedatives, over-the-counter agents, caffeine, change positions slowly. Reinforce client to take
blood pressure and pulse daily.


Anticholinergic agents: dry mouth, constipation, blurred vision

nursing care: provide sips of water and oral care; assist with activity; remove environmental hazards

monitoring: assist health care team to check bowel pattern, vision, oral mucous membranes

assist health care team to implement client teaching plan: frequent oral care, avoid dangerous activity,
ask for help to stand


Anticoagulants and anti-platelet agents: bleeding

nursing care: minimize invasive procedures, shaving; provide gentle oral care; assist with activity

monitoring: assist health care team to check bleeding, coagulation tests, complete blood count,
bruising; remove adverse drug and food affects

assist health care team to implement client teaching plan: avoid dangerous activity, wear MedicAlert
identification, avoid NSAIDs, alcohol, avoid eating food rich in vitamin K


Anticonvulsants: CNS depression, myelosuppression: infection and bleeding

nursing care: assist with activity; protect airway, breathing; minimize invasive procedures

monitoring: assist health care team to check seizure activity, complete blood count with differential,
temperature, regional redness, swelling, or drainage, monitor liver functions tests

assist health care team to implement client teaching plan: wear MedicAlert identification, avoid
dangerous activity, wash hands, avoid crowds, need for follow-up care and testing, avoid alcohol


Antidysrhythmics: new or more dangerous dysrhythmias, changes in blood pressure

nursing care: maintain fluid and electrolytes balance, SaO2 >95%, sinus rhythm; assist with position
changes

monitoring: assist health care team to check pulmonary function test, EKG, blood pressure, pulse,
199

SaO
2
, serum electrolytes, level of consciousness

assist health care team to implement client teaching plan: ask for help to stand; report irregular pulse
and technique for counting pulse, call doctor if the client develops palpitations, weakness, loss of
appetite


Antiinfective agents: renal and hepatic dysfunction

nursing care: obtain cultures before administration, verify administration guidelines, screen for renal
and hepatic dysfunction, allergy, nephrotoxic or hepatotoxic drugs

monitoring: assist health care team to check renal function tests, liver function tests, jaundice, dark
stool or urine, nausea and vomiting

assist health care team implement client teaching plan: report nausea, vomiting, dark stool or urine,
jaundice; need for follow-up care and testing, reinforce take all medications as prescribed, report any
allergic reaction, report sudden weight gain as this may indicate adverse effects on the kidney


Loop, thiazide diuretics: circulatory collapse, myelosuppression, fluid and electrolytes imbalance,
ototoxicity

nursing care: verify infusion guidelines, blood pressure, serum electrolytes, and urinary output before
giving

monitoring: assist health care team to check serum sodium and potassium, breath sounds, edema,
blood pressure, urinary output

assist health care team to implement client teaching plan: report palpitations, weakness, irregular
pulse, decreased urinary output, temperature


Female hormones: thromboembolic disorders, increased risk of breast and endometrial cancer,
hyperglycemia, hypercalcemia, depression, seizures

monitoring: assist health care team to check peripheral perfusion, edema; leg pain, tenderness; serum
calcium, glucose, cytology

assist health care team to implement client teaching plan: report lumps and abnormal bleeding, muscle
twitching


Medications causing confusion in the elderly

200




I. Managing Cardiac Disease

A. Therapeutic classification: antianginal agents

1. Type: nitrates

a. action: arterial, venous, and capillary vasodilation by relaxing vascular smooth muscle

i. decreases myocardial oxygen consumption

ii. decreases preload with venous pooling

iii. decreases afterload by decreasing peripheral vascular resistance


b.
example: nitroglycerin

i. (Nitro-bid) IV (titrate according to blood pressure)

ii. (Nitro-Dur) 1 transdermal patch daily

iii. (Nitrostat) one 0.4 mg sublingual tablet under the tongue; may repeat every 5 minutes up to 3 tablets


c. uses: prophylaxis, treatment, and management of angina, acute myocardial infarction (MI)

d. adverse effects

i. life-threatening: severe hypotension; nitrate tolerance, paradoxical bradycardia, anaphylactoid
reaction, methemoglobinemia

ii. most common: headache, nausea, vomiting, dizziness, reflex tachycardia, postural hypotension


e. contraindications

i. concurrent sildenafil, tadalafil or vardenafil use

ii. hypovolemia, hypotension, idiopathic hypertrophic subarortic stenosis (IHSS), methemoglobinemia, heart
failure, acute myocardial infarction, increased intracranial pressure


f. nursing care

i. assist health care team to establish baseline data and observe during acute angina or IV administration blood
pressure, heart rate, ECG, chest pain

ii. clarify data to report and frequency of report

iii. withdraw treatment gradually to avoid angina

iv. toxicity: central nervous system changes, hypotension, flushing, nausea

v. buccal area must be moist for sublingual absorption

vi. maintain a 6 to 8 hour nitrate-free period every 24 hours after acute episode to avoid tolerance

vii. assist health care team to implement client teaching plan

apply spray under tongue

do not chew tablets

sit down when taking, change positions slowly

report blurred vision or dry mouth, avoid alcohol

keep tablets away from light, moisture, and body heat; change tablets every 6 months

use spray or sublingual tablets for immediate relief; combine medication with rest for acute attack

for acute angina: take 1 tablet (or 1 spray under the tongue) sublingual every 5 minutes up to three
tablets, if not relieved seek emergency treatment

rotate site of ointment or patch; remove ointment or patch and clean skin for daily nitrate-free
period







2. Type: isosorbide dinitrate, mononitrate

a. action: vasodilation by relaxing arterial and venous smooth muscle; decreases preload with venous pooling, peripheral
vascular resistance, and myocardial oxygen consumption
201


b. examples

i.
isosorbide dinitrate (Isordil, Dilatrate-SR): used for both acute attacks and prevention of angina pectoris

sublingual (adults) - acute attack of angina pectoris: 2.5-10 mg every 2 to 3 hours

oral (adults) - prophylaxis of angina pectoris: 10-40 mg by mouth 2 to 3 times per day


ii.
isosorbide mononitrate (Imdur, Monoket): angina prophylaxis: 20 mg by mouth twice a day; maximum 40
mg/day


c. uses: maintenance therapy for angina, coronary artery disease (see also: nitrates: adverse effects, contraindications,
nursing care)


3. Other

a. type: beta-adrenergic blocking agents or "beta blockers" (examples: atenolol [Tenormin], metoprolol [Lopressor])

b. type: calcium channel blocking agents (examples: amlodipine [Norvasc], diltiazem [Cardizem], verapamil [Calan])



B. Therapeutic classification: anticoagulants

1. Type: oral

a. action: interferes with vitamin K dependent clotting factors in the liver resulting in prolonged bleeding time

b.
example: warfarin (Coumadin, Jantoven) 2-10 mg PO/IV for 2 to 4 days; then, adjust dose based on
international normalized ratio (INR)
Black Box Warning - bleeding risk

c. uses: maintenance therapy and prophylaxis to suppress formation of dangerous clots after myocardial infarction,
mechanical heart valve surgery, atrial fibrillation (A fib) and atrial flutter (A flutter), heart failure, deep vein
thrombosis, and pulmonary embolism (PE)

d. adverse effects

i. hemorrhage, peripheral skin necrosis

ii. bone marrow depression, liver dysfunction

iii. anorexia, many drug-drug interactions

iv. high-risk drug with older or incompetent clients


e. contraindications

i. clients at risk for falls, malabsorption syndromes

ii. severe hepatic or renal disease

iii. bleeding disorders and active bleeding

iv. recent invasive procedure to spinal cord


f. nursing care

i. assist health care team to establish baseline data and check

daily international normalized ratio (INR), prothrombin time (PT) and periodic liver function tests (LFTs)

evidence of bleeding, bruising, headache, level of consciousness, and risk of falls (particularly for older adults)


ii. apply prolonged pressure to any puncture wounds to stop bleeding

iii.
antidote : vitamin K

suppresses warfarin activity for 1 to 3 weeks

may need alternate form of anticoagulation


iv. assist health care team to implement client teaching plan

AVOID alcohol, NSAIDs

use electric razor for shaving

seek emergency treatment for falls
202


wear MedicAlert identification

take at same time daily, need for follow-up care and testing

AVOID herbal remedies including echinacea, licorice, green tea, and ginseng

AVOID foods containing vitamin K (decreases effect of warfarin) especially green leafy vegetables,
broccoli, and liver






2. Type: low-molecular weight (LMW) heparin (parenteral)

a. action: blocks action of Factors Xa and IIa without appreciably affecting thrombin or prothrombin

b. examples

i.
dalteparin (Fragmin) 2500- 5000 IU by subcutaneous injection daily
Black Box Warning - epidural/spinal hematoma risk


ii.
enoxaparin (Lovenox) 1 mg/kg or 40 mg by subcutaneous injection daily
Black Box Warning - epidural/spinal hematoma risk


c. uses: prophylaxis against thromboembolic disorders associated with surgery and bedrest

d. adverse effects

i. hemorrhage, thrombocytopenia, angioedema

ii. increased bleeding times and bruising

iii. inflammation at injection site, dyspnea, rash


e. contraindications

i. recent GI bleed or invasive spinal cord procedure

ii. active bleeding, thrombocytopenia , uncontrolled hypertension


f. nursing care

i.
establish baseline data and monitor complete blood count and platelets

ii. does not affect prothrombin time (PT), INR, or activated partial thromboplastin time (aPTT) with therapeutic doses

iii. lower risk of heparin-induced thrombocytopenia than unfractionated heparin

iv. give subcutaneously according to manufacturer's direction

v. client teaching: subcutaneous injection technique




3
.
Type: unfractionated heparin

a. action: inhibits conversion of prothrombin to thrombin thus preventing fibrin formation

b.
example: heparin sodium

c. uses: acute illness to suppress dangerous clot formation; unstable angina, myocardial infarction, cerebral vascular
accident, deep vein thrombosis, pulmonary embolism, atrial fibrillation and atrial flutter, disseminated intravascular
coagulation (DIC)

d. adverse effects

i. life threatening: hemorrhage, severe thrombocytopenia, heparin-induced thrombosis and thrombocytopenia
(HIT/HITT)

ii. other: prolonged clotting time, bleeding, cutaneous necrosis, fever, chills, rash, adrenal insufficiency


e. contraindications

i. IM administration, severe thrombocytopenia, hemorrhage

ii. active bleeding (except DIC), severe hypertension, recent major surgery, recent lumbar puncture or spinal
203

anesthesia

iii. DO NOT give benzyl alcohol-containing forms to neonates, infant, pregnant or breast-feeding clients


f
.
nursing care

i.
assist health care team to establish baseline data and check activated partial thromboplastin time (aPTT),
complete blood count (CBC), and platelets before administration and during therapy

ii. adjust dosage when given with nitroglycerin (NTG) - check aPTT frequently

iii. high-risk therapy for women, older clients, and with renal or hepatic insufficiency

iv.
antidote - protamine sulfate 1-1.5 mg IV/100 units of heparin given; maximum dose: 50mg/dose, rate 5mg/min
Black Box Warning - serious adverse events, appropriate use




C. Therapeutic classification: antiarrhythmic agents

1. Information common to antidysrhythmic agents

a. use

i. eradication of frequent premature ventricular contractions that cause hemodynamic instability or loss of
consciousness

ii. emergency eradication of ventricular dysrhythmias

iii. cardiopulmonary resuscitation

iv. chemical cardioversion of atrial and ventricular dysrhythmias
Antiarrhythmic Classifications
IA IB IC II III IV
Classified by their effects on cardiac conduction tissue



b. adverse effects

i. heart block

ii. most are have dysrhythmogenic potential (capable of causing dysrhythmias)

iii. prolongation of QT interval

iv. increased risk of torsades des pointes


c. assist health care provider to implement client teaching plan

i. count heart rate and pattern of rhythm, i.e., regularity

ii. provide acceptable range for heart rate

iii. report

new onset of irregular rhythm

findings outside of acceptable parameters

worsening heart rate, dizziness, lightheadedness, loss of consciousness, and edema






2. Type: sodium channel blocking agents (Class IA & IB)

a. action: suppresses various phases in myocardial cell action potential by blocking sodium channels; stabilizes
myocardial cell membrane

b. examples

i.
lidocaine (Xylocaine): titrate according to frequency of ventricular ectopy

ii.
quinidine gluconate (generic)
Black Box Warning - mortality
204


iii.
procainamide (generic)
Black Box Warning - positive ANA titer, proarrhythmic effects and blood dyscrasias


c. uses: ventricular dysrhythmias, chemical cardioversion with atrial fib and atrial flutter (except lidocaine)

d. adverse effects

i. life-threatening: ventricular fibrillation, asystole, seizures; thrombocytopenia, neutropenia and hemolytic anemia;
lupus erythematosus and agranulocytosis

ii. other: hypotension, bradycardia, flushing, urticaria, pruritus; central nervous system effects including sedation,
confusion, and seizures (especially lidocaine)


e. contraindications: 2nd or 3rd degree AV block, Torsades de pointes, myasthenia gravis and systemic lupus
erythematosus

f. nursing care

i. assist health care team to establish baseline data and monitor

drug levels

vital signs, ECG, QT interval, neurological status


ii. prevent client injury - associated with many adverse effects

iii. quinidine and procainamide reserved for use after many other therapies have failed

iv. assist health care team to implement client teaching

AVOID citrus juices, antacids, and milk products when taking oral forms

take heart rate daily: report change in rhythm





3. Type: beta-adrenergic blocking agents or beta blockers (Class II)

4. Type: potassium channel blocking agents (Class III)

a. action: slows the outward movement of potassium through myocardial cell membranes and prolongs the action
potential

b.
examples

i.
amiodarone (Cordarone, Nexterone, Pacerone) 200-600 mg by mouth daily; also available IV
Black Box warning - appropriate use, pulmonary toxicity, hepatotoxicity, proarrhythmic effects

ii. sotalol (Betapace) 80-160 mg by mouth every 12 hours


c. uses: ventricular and supraventricular dysrhythmias, chemical cardioversion

d. adverse effects

i. life-threatening: severe bradycardia, AV block, QT prolongation, ventricular arrhythmias, torsades de pointes

ii. most common: malaise/fatigue, ataxia, tremor, hyperkinesia, photosensitivity

iii. other: severe hypotension, cardiogenic shock, cardiac arrest, and ARDS with IV use


e. contraindications

i. cardiogenic shock, severe sinus node dysfunction, 2nd or 3rd degree AV block

ii. bradycardia associated syncope, pregnancy, or breast-feeding

iii. hypersensitivity to iodine


f. nursing care

i. assist health care team to establish baseline data and check vital signs, ECG; hepatic, pulmonary, endocrine,
neurological, and GI function

ii. follow oral and IV administration guidelines - timing and rates of infusion are very important

iii. assist health care team to implement client teaching plan
205


AVOID taking with echinacea

need for follow-up care and testing

protect skin and eyes from UV rays, e.g., wear sunscreen, protective clothing, and sunglasses

count pulse and report changes in rhythm





5. Type: anticholinergic agent

a. action: competes with acetylcholine for muscarinic receptor sites to produce mild vagal excitation

b.
example: atropine 0.5 mg IV every 3 to 5 minutes; maximum 3 mg

c. use: bradycardia associated with increased vagal tone

d. adverse effects

i. life threatening: paradoxical bradycardia with sub-therapeutic dosing; angina, tachycardia

ii. most common: anticholinergic effects, i.e., sedation, dry mouth, blurred vision, urinary retention, constipation,
orthostatic hypotension

iii. other: atropine flush 15 to 20 minutes after injection




6. Type: acetylcholine-sensitive potassium current activator

a. action: shortens duration of action potential, causes hyperpolarization, and slows normal automaticity

b.
example: adenosine (Adenocard, Adenoscan) 6 mg rapid IV bolus

c. use: chemical conversion of supraventricular tachycardia after failure of vagal maneuver

d. adverse effects

i. life threatening: severe bradycardia, ventricular fibrillation, ventricular tachycardia, atrial fibrillation, asystole,
complete heart block

ii. most common: bronchospasm, flushing, dyspnea, chest pressure, nausea. lightheadedness, headache


e. contraindications: 2nd

or 3rd

degree AV block, sick sinus syndrome, cardiac transplant

f. nursing care

i. assist health care team to establish baseline data and monitor continuously during therapy ECG, heart rate, blood
pressure, respiratory rate

ii.
monitor serum electrolytes



Updated clinical practice guidelines indicate that individuals with a systolic blood pressure of 120139 mm Hg or a
diastolic blood pressure of 8089 mm Hg should be considered as "prehypertensive" and will require health-
promoting lifestyle modifications to prevent cardiovascular disease (National Heart Lung and Blood Institute, 2003).


D. Therapeutic classification: antihypertensive agents

1. Information common to antihypertensive agents

a. uses: heart failure, primary and secondary hypertension

b. adverse effects

i. life threatening: orthostatic hypotension, reflex tachycardia, bradycardia

ii. other: dizziness, weakness, sexual dysfunction, nausea, vomiting, diarrhea, anorexia, and constipation


c. contraindications

i. severe deficiencies in serum electrolytes

ii. heart block, pediatrics, hypovolemia


d. nursing care

i. assist health care team to establish baseline data and check before initiating therapy and periodically thereafter:
blood pressure, potassium, fluid and electrolyte balance, renal function
206


ii. older clients more susceptible to toxicity, labile hypotension, and orthostatic hypotension

iii. assist health care team to implement client teaching plan

AVOID over-the-counter drugs

change positions slowly

take medication only as directed, even when feeling well and if blood pressure (BP) is controlled
(indicates that the therapy is effective)

combine with weight loss, smoking cessation, and an active lifestyle for the most effective therapy

reinforce instruction about blood pressure technique for self-monitoring






2. Type: angiotensin-converting enzyme (ACE) inhibitors

a. action: inhibits conversion of angiotensin I to angiotensin II in the lungs preventing vasoconstriction from angiotensin II
and the release of aldosterone

b. examples

i.
enalapril (Vasotec) 10-40 mg twice daily by mouth, initiate therapy at 5 mg
Black Box Warning - pregnancy

ii.
lisinopril (Prinivil, Zestril) 5-40 mg daily by mouth, initiate therapy at 2.5-10 mg
Black Box Warning - pregnancy


c. uses: hypertension and heart failure

d. adverse effects

i. angioedema of head, cough, neck and intestines, severe hypotension, hyperkalemia, renal impairment or failure

ii. hepatotoxicity, neutropenia, agranulocytosis, pancreatitis and Steven-Johnson syndrome


e. contraindications: ACE inhibitor angioedema history, hereditary or idiopathic angioedema, pregnancy

f. nursing care

i.
administer on empty stomach - take 1 hour before and 2 hours after eating

ii.
monitor serum potassium (ACE inhibitors can cause hypokalemia)

iii. assist health care team to implement client teaching plan

contact health care provider if persistent dry cough develops and becomes a problem (more common in
women)

seek emergency care for any indications of angioedema ("does my voice sound funny?")

ACE inhibitors are teratogenic - female client must use contraception when taking





3. Type: angiotensin II-receptor blockers (ARB)

a. action: binds to angiotensin II receptors to block vasoconstriction and release of aldosterone

b. examples

i.
Iosartan (Cozaar) 25-100 mg by mouth daily in 1 to 2 doses
Black Box Warning - pregnancy

ii.
valsartan (Diovan) 80-320 mg by mouth daily
Black Box Warning - pregnancy


c. uses: hypertension and heart failure

d. adverse effects: hyperkalemia

e. nursing care
207


i. relatively few drug-drug interactions

ii. assist health care team to implement client teaching plan

may take with food, avoid salt substitutes containing potassium without provider approval

take medication with a full glass of water





4. Type: calcium channel blocker (CCB)

a. action: block movement of calcium into muscle cell; negative inotropic action (decreases myocardial contractility)

b.
examples

i. amlodipine (Norvasc) 5-10 mg by mouth daily

ii. diltiazem (Cardizem, Cardizem CD, Cardizem LA, Cartia XT, Dilacor XR, Dilt-CD, Diltia XT, Taztia XT, Tiazac)
immediate release dose 30-90 mg by mouth 4 times daily; extended release dose 180-360 mg by mouth daily

iii. verapamil (Calan, Calan SR, Covera-HS, Isoptin SR, Verelan, Verelan PM) immediate release dose: 80-120 mg by
mouth 3 times a day; extended release form:120-480 mg/day 1 to 2 doses divided; IV 2.5-10 mg/kg, may repeat
with 5-10 mg in 15 to 30 minutes


c. uses: hypertension, angina, and dysrhythmias

d. adverse effects: severe hypotension, severe bradycardia, hepatotoxicity and paralytic ileus, heart failure and AV block

e. contraindications

i. severe LV dysfunction, 2nd or 3rd degree heart block, atrial fibrillation or flutter with bypass tract

ii. sick sinus syndrome, severe hypotension and cardiogenic shock


f. nursing care - assist health care team to establish baseline data and check before initiating therapy and periodically
thereafter

i.
BUN and creatinine, liver function tests

ii. monitor heart rate, ECG

iii. assist health care team to implement client teaching plan

AVOID grapefruit and grapefruit juice (may increase medication effects)

AVOID in older clients due to risk of severe constipation

remind clients to change position slowly and report dizziness to health care provider





5. Type: beta-adrenergic blocking agents (antagonists) (aka beta blockers)

a. action: selective (beta-adrenergic receptors) and non-selective (beta- and beta-adrenergic) blockers of the
sympathetic nervous system (SNS) resulting in

i. slower heart rate

ii. decreased vasoconstriction, decreased blood pressure

iii. decreased myocardial oxygen consumption


b. examples

i.
selective blockers

atenolol (Tenormin) 50-100 mg by mouth daily
Black Box Warning - avoid abrupt cessation

metoprolol succinate (Toprol) 25-400 mg by mouth daily; metoprolol tartate (Lopressor) 50-200 mg by mouth twice
a day
Black Box Warning - avoid abrupt cessation


ii.
non-selective blocker: propranolol (Inderal LA, InnoPran XL) 80-240 mg by mouth twice daily; IV 1-3 mg, may
repeat in 2 minutes
208

Black Box Warning - avoid abrupt cessation


c. uses: heart failure, hypertension, heart rate control, angina, and migraine headache prophylaxis

d. adverse effects

i. life-threatening: heart failure, heart block, severe bradycardia, bronchospasm

ii. most common: fatigue, dizziness, constipation, depression, insomnia, weakness, disorientation, nausea, diarrhea,
impotence

iii. other: suppresses clinical indicators of hypoglycemia


e. contraindications

i. cardiogenic shock, sinus bradycardia without pacemaker, sick sinus syndrome without pacemaker

ii. 2nd or 3rd degree AV block without pacemaker, uncompensated heart failure, bronchial asthma


f. nursing care

i. assist health care team to establish baseline data and monitor breath sounds and peripheral perfusion before
initiating therapy and periodically thereafter

ii.
avoid concomitant use of clonidine, thioridazine, and nonsteroidal anti-inflammatory drugs (NSAIDs)

iii. check with provider for administration limits for heart rate and blood pressure

iv. may hide symptoms of hypoglycemia

v. may cause bronchoconstriction and asthma symptoms

vi. taper dose before discontinuing

vii. assist health care team to implement client teaching plan

take pulse or blood pressure before administration

reinforce risk of orthostatic hypotension

take medication at bedtime

do not abruptly discontinue therapy





6. Type: combined alpha- and beta-adrenergic blocking agents

a. action: blocks all SNS receptors and inhibits release of epinephrine (Epi) and norepinephrine (NE) resulting in
decreased vasoconstriction, slower heart rate, and increased renal perfusion

b.
examples

i. carvedilol (Coreg) 6.25-25 mg twice daily by mouth, increase dose in 2 week intervals

ii. labetalol (Normodyne) 400-800 mg 2 to 3 times daily by mouth


c. uses: heart failure, hypertension secondary to renal failure, refractory hypertension

d. adverse effects

i. heart failure, heart block, severe bradycardia, angina exacerbation

ii. asthma, bronchospasm, interstitial pneumonitis

iii. leukopenia, thrombocytopenia, anemia


e. contraindications: severe bradycardia, 2nd or 3rd degree heart block, uncompensated heart failure, cardiogenic shock

f. nursing care

i. assist health care team to establish baseline data and check for bronchospasm, pulmonary edema, and liver failure

ii. taper dose before discontinuing

iii. assist health care team to implement client teaching plan




7. Type: alpha-adrenergic blocking agents

a. action: non-selective blocker of alpha-adrenergic receptors (of SNS)

209

b.
examples: phentolamine mesylate (Regitine)

c. uses: hypertension associated with pheochromocytoma, extravasation of epinephrine and DOPamine
(vasoconstricting agents)

d. adverse effects

i. life-threatening: myocardial infarction, stroke, severe hypotension, arrhythmias, peptic ulceration

ii. other: tachycardia, weakness, dizziness, flushing, orthostatic hypotension, nasal congestion


e. contraindications: coronary artery disease (CAD) and myocardial infarction



8. Type: alpha
1
-blocking agents

a. action: blocks alpha1-receptors of SNS

b.
examples

i. prazosin (Minipress) 3-7 mg by mouth twice daily

ii. terazosin (Hytrin) 1-5 mg by mouth every evening

iii. tamsulosin (Flomax) 0.4 mg by mouth daily


c. uses: hypertension, benign prostatic hypertrophy (BPH)

d. adverse effects: angina, priapism, headache, peripheral edema

e. contraindications: hepatic and renal failure; do not take with erectile dysfunction agents



9. Type: alpha
2
- agonists

a. action: displaces NE and stimulates alpha
2
-receptors of SNS resulting in decreased release of norepinephrine in the
periphery

b.
example: cloNIDine (Catapres, Duracion, Kapvay, Nexiclon XR) 0.1-0.3 mg by mouth twice daily

c. uses: hypertension, chronic pain related to cancer

d. adverse effects

i. life-threatening: severe rebound hypertension, severe hypotension, bradycardia, AV block, syncope, tachycardia

ii. other: dry mouth, drowsiness, dizziness, fatigue, weakness, constipation, sedation, orthostatic hypotension, sexual
dysfunction


e. contraindications

i. cardiovascular disease, severe coronary artery disease, recent myocardial infarction

ii. renal impairment

iii. history of depression or cerebrovascular disease


f. nursing care

i. taper dose before discontinuing

ii. do not discontinue before surgery

iii.
do not administer with monoamine oxidase inhibitors (MAOIs) or beta blockers




10. Type: centrally acting vasodilators

a. action: directly relaxes arteriolar vascular smooth muscle resulting in lowered peripheral vascular resistance and
reflex tachycardia

b.
example: hydrALAZINE (Apresoline) 10-50 mg by mouth daily divided in 4 doses

c. uses: hypertensive crisis, congestive heart failure

d. adverse effects

i. life-threatening: myocardial infarction, neutropenia, blood dyscrasias, lupus erythematosus, peripheral neuritis
210


ii. most common: headache, tachycardia, angina, palpitations

iii. other: nausea, vomiting, diarrhea, rash, flushing


e. contraindications: coronary artery disease, mitral valve rheumatic heart disease, cardiovascular or cerebrovascular
disease and severe renal impairment

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
during therapy complete blood count and antinuclear antibody test (ANA)

ii. reinforce client teaching

report chest pain, severe fatigue, muscle or joint pain

change positions slowly





11. Type: diuretics - especially thiazide and thiazide-like diuretics; to a lesser extent, loop diuretics; used alone or in
combination with other antihypertensive agents


E. Therapeutic classification: anti-lipid agents

1. Information common to anti-lipid agents

a. most affect liver function and require regular liver function tests

b. most effective when combined with low-fat diet, exercise and weight loss

c. instruct clients to avoid alcohol during therapy


2. Type: bile acid sequestrants

a. action: bind with bile acid in small intestine leading to decreased absorption and increased excretion of fat in stool

b.
example: cholestyramine (Prevalite, Questran, Questran Light) 4-8 grams by mouth twice daily

c. uses: in combination with low fat diet to lower serum lipids, primary hypercholesterolemia , and elevated low-
density lipoproteins (LDL)

d. adverse effects

i. fecal impaction, intestinal obstruction

ii. metabolic acidosis, fat-soluble vitamin deficiency

iii. decreased folate levels, osteoporosis


e. contraindications

i. biliary obstruction, constipation

ii. CAD, renal impairment, volume depletion


f. nursing care

i. assist health care team to establish baseline data and to check prior to initiating therapy and at regular intervals
thereafter

listen to bowel sounds before administering medication

monitor for vitamin deficiency


ii. assist health care team to implement client teaching plan

eat a low-cholesterol, low-fat diet

take before meals

take other medications at least 1 hour before or 4 hours after taking cholestyramine

prevent constipation with increased fluids, fiber, and physical activity









211


3. Type: HMG-CoA reductase inhibitors (statins)

a. action: controls final step in cholesterol formation by blocking formation of cellular cholesterol leading to decreased
serum cholesterol and slightly increased high density lipoproteins (HDL)

b. examples

i.
atorvastatin (Lipitor) 10-80 mg by mouth daily

ii.
simvastatin (Zocor) 5-40 mg by mouth daily at bedtime

iii.
rosuvastatin (Crestor) 5-40 mg by mouth daily


c. use in combination with low-fat diet and exercise

d. adverse effects

i. life-threatening: myopathy, rhabdomyolysis, acute renal failure, hepatotoxicity, pancreatitis, angioedema,
leukopenia, thrombocytopenia

ii. most common: pharyngitis, headache, diarrhea, dyspepsia, myalgia, back pain

iii. other: increased risk of rhabdomyolysis when given with niacin


e. contraindications

i. active hepatic disease, elevated liver function tests, pregnancy, breastfeeding

ii. myopathy, hypotension, sepsis or acute infection


f. nursing care

i. assist health care team to establish baseline data and check before beginning therapy and at regular intervals
thereafter:

liver function tests, creatinine, creatinine kinase (CK), lipid panel

muscle pain


ii. administer at bedtime, may take with food to diminish gastrointestinal upset

iii. assist health care team to implement client teaching plan

promptly report muscle pain

monitor for bleeding - check for dark urine and dark stool

maintain regular follow-up care and testing

most effective when combined with lifestyle changes including low-fat diet, weight loss, high-fiber diet, and
exercise





4. Type: fibrates

a. action: decreases synthesis of hepatic LDLs and cholesterol

b.
example: gemfibrozil (Lopid) 600 mg by mouth twice daily

c. uses: hypercholesterolemia and mixed dyslipidemia

d. adverse effects: myositis, myopathy, rhabdomyolysis

e. contraindications: gallbladder disease, hepatic involvement, severe renal impairment

f. nursing care

i.
assist health care team to establish baseline data and check before initiating therapy and at regular intervals
thereafter: serum lipids, liver function tests, complete blood count, creatinine

ii. assess muscle pain




5. Type: niacin

a. action: inhibits release of fatty acid from adipose tissue, improves removal of triglycerides from plasma

b.
example: niacin (Niacor, Niaspan, Slo-Niacin) 1500-3000 mg/day by mouth in 2 to 3 divided doses
212


c. uses: hypercholesterolemia, mixed dyslipidemia and hypertriglyceridemia

d. adverse effects

i. hepatotoxicity, fulminant hepatic necrosis, peptic ulcers, arrhythmias, anaphylaxis

ii. flushing, pruritus, hyperpigmentation, orthostatic hypotension, dyspepsia


e. nursing care

i.
assist health care team to establish baseline data and check prior to beginning therapy and at regular intervals
thereafter serum lipids, uric acid, fasting glucose

ii. assist health care team to implement client teaching plan

take at bedtime to minimize stomach upset

may cause facial flushing





6. Type: LDL absorption inhibitors

a. action: inhibits absorption of lipids from small intestines

b.
example: ezetimibe (Zetia) 10 mg by mouth daily

c. uses: hypercholesterolemia, mixed dyslipidemia, familial hypercholesterolemia

d. adverse effects

i. hypersensitivity reaction, anaphylaxis, angioedema, pancreatitis, hepatitis, cholecystitis, cholelithiasis

ii. avoid giving with cycloSPORINE and gemfibrozil


e. contraindications: liver disease or unexplained increase in liver function tests

f. nursing care

i.
assist health care team to establish baseline data before initiating therapy and check during treatment liver
function, lipid levels; muscle pain, bowel pattern

ii. assist health care team to implement client teaching plan

take with or without food

most effective when combined with low-fat diet and weight loss





7. Omega-3 fatty acids (from fish oil)

a. examples

i. over-the-counter preparations

ii.
Lovaza (465 mg EPA & 375 mg DHA) 4g/day by mouth or divided into 2 doses daily

iii.
Vascazen (680 mg EPA and 110 mb DHA) 1 capsule by mouth 4 times daily


b. use: as adjunct to diet in clients with triglycerides 500 mg/dL



F. Therapeutic classification: antiplatelet agents

1. Type: aspirin (ASA)

a. action: inhibits prostaglandin formation

b.
example: acetylsalicylic acid (Bayer Aspirin) 81-325 mg by mouth daily

c. uses: pain/fever, acute coronary syndrome, myocardial infarction prevention, TIA/thromboembolic stroke, arthritis,
rheumatic fever

d. adverse effects

i. anaphylactic reaction, angioedema, bronchospasm, bleeding, Reye syndrome

ii. GI ulceration/perforation, DIC, pancytopenia, thrombocytopenia, agranulocytosis, aplastic anemia


213

e. contraindications

i. ASA or NSAID-induced asthma or urticaria

ii. GI bleed, coagulation disorder, G6PD deficiency

iii. uncontrolled hypertension, recent surgery or trauma

iv. children younger than age 20 due to risk of Reye's syndrome


f. nursing care

i.
may take with food to decrease GI discomfort

ii. assist health care team to establish baseline data and monitor thereafter for toxicity, i.e., muffled hearing and
tinnitus; bleeding times

iii. assist health care team to implement client teaching plan

AVOID use with feverfew, garlic, ginger, echinacea, ginger, St. John's wort, and ginkgo biloba due to
increased bleeding times

report to provider and discontinue use with persistent ringing or buzzing in the ears, impaired hearing,
dizziness, or bleeding

take with a full glass of water

may chew tablet if taking aspirin 81 mg by mouth






2. Type: adenosine diphosphate inhibitor

a. action: inhibits platelet aggregation by preventing adenosine diphosphate binding to platelet receptor

b.
examples

i. clopidogrel (Plavix) 75 mg by mouth daily
Black Box Warning - diminished efficacy in poor metabolizers

ii. ticlopidine (Ticlid) 250 mg by mouth twice daily with food
Black Box Warning - neutropenia/agranulocytosis


c. uses: thrombotic stroke prevention, stent thrombosis prevention

d. adverse effects

i. intracranial hemorrhage, nephrotic syndrome, hyponatremia, pancytopenia

ii. agranulocytosis, thrombocytopenia, allergic pneumonitis, TTP, serum sickness

iii. diarrhea, nausea, dyspepsia, rash, neutropenia, bleeding


e. contraindications

i. active bleeding, recent trauma or surgery

ii. history of GI disorder or ocular disease


f. nursing care

i.
assist health care team to establish baseline data and check before initiating therapy and periodically during
therapy creatinine, absolute neutrophil count (ANC), complete blood count, platelets

ii. discontinue 7 to 10 days before surgery

iii. assist health care team to implement client teaching plan: avoid taking with acetaminophen, aspirin, and
carisoprodol


3. Type: non-nitrate vasodilator (example: dipyradidamole [Persantine])


G. Positive inotropes

1. Type: cardiac glycoside
214


a. action: slows A-V conduction, improves cardiac output, improves myocardial contractility (increases strength of
contractions) and slows heart rate

b.
example: digoxin (Lanoxin) 0.125-0.25 mg by mouth daily

c. uses: heart failure, ventricular rate control in atrial fibrillation (A fib) and atrial flutter (A flutter), PSVT conversion

d. adverse effects

i. AV block, severe bradycardia, ventricular arrhythmias

ii. thrombocytopenia, delirium, hallucinations

iii. dizziness, headache, diarrhea, nausea/vomiting, visual disturbances


e. contraindications

i. ventricular fibrillation/tachycardia

ii. idiopathic hypertrophic subaortic stenosis (IHSS), unblocked AV accessory pathway, sick sinus syndrome

iii. hypokalemia


f. nursing care

i. assist health care team to establish baseline data and monitor creatinine, electrolytes, heart rate at baseline,
then periodically and serum drug levels

ii. check apical heart rate before administration (hold if apical heart rate is less than 60 beats per minute)

iii. monitor for toxicity

therapeutic range 0.5-2 ng /mL (toxic: greater than 2 ng/mL)

signs and symptoms of toxicity include: altered heart rate or rhythm, visual disturbances or GI
disturbances

antidote for digoxin: digoxin antibodies including digoxin immune fab (DigiFab)


iv. assist health care team to implement client teaching plan

take medication as prescribed

measure heart rate daily before administration

weight daily and report weight gain of more than 2 pounds in 24 hours

report irregular pulse or change in rhythm, heart rate less than 60 beats per minute, signs of
potassium deficiency or digitalis toxicity

AVOID many herbal preparations and dehydration




Therapeutic drug levels are laboratory tests to look for the presence and the amount of specific drugs in the blood.
Some of the cardiac drugs that are commonly checked include digoxin, amitriptyline (Norpace), flecainide
(Tambocor), lidocaine, quinidine, and salicylate.


2. Type: phosphodiesterase inhibitors

a. action: blocks action of phosphodiesterase leading to increased myocardial contractility and vasodilation, increased
myocardial oxygen consumption, and dysrhythmias

b.
example: milrinone (Primacor) 0.375-0.75 mcg/kg/min IV

c. uses: heart failure and cardiac output maintenance post resuscitation stabilization per ACLS guidelines

d. adverse effects

i. ventricular arrhythmias, torsades de pointes, ventricular ectopy, ventricular tachycardia, supraventricular
arrhythmias, hypotension and headache

ii. anaphylactic shock, bronchospasm, severe infusion site reaction


e. contraindications

i. severe aortic and pulmonic valve disease

ii. acute myocardial infarction

215



f. nursing care

i.
assist health care team to establish baseline data and check before initiating therapy and at regular intervals
thereafter BUN/creatine, platelets, blood pressure, and ECG

ii. use infusion pump to administer these agents; change solution and tubing every 24 hours

iii. infuse with normal saline only




H. Therapeutic classification: thrombolytic agents

1. Action: binds with plasminogen to dissolve thrombi (clots) within 4 to 6 hours of occlusion (activates conversion of
plasminogen to plasmin; plasmin breaks down clots)

2. Examples

a.
alteplase (Activase) 15 mg IV for 1 dose then 0.75 mg/kg over 30 minutes, then 0.5 mg/kg over 60 minutes

b.
tenecteplase (TNKase) 30-35mg IV for 1 dose


3. Uses: acute myocardial infarction, acute thrombotic stroke, pulmonary embolism

4. Adverse effects

a. intracranial hemorrhage, stroke

b. severe bleeding, reperfusion arrhythmias

c. anaphylaxis, orolingual edema

d. recurrent pulmonary embolism, cholesterol embolism


5. Contraindications

a. active internal bleeding, intracranial aneurysm, arterial venous malformation, or neoplasm

b. coagulation disorder, severe uncontrolled hypertension, stroke history

c. intracranial hemorrhage, suspected subarachnoid hemorrhage


6. Nursing care

a.
assist health care team to establish baseline data and check during treatment prothrombin time, aPTT or INR

b.
have antidote available: aminocaproic acid (a fibrinolysis inhibitor) for life-threatening hemorrhage

c. AVOID IM or SubQ injections

d. minimize physical manipulation of the client and invasive procedures




I. Therapeutic classification: vasodilators

1. Type: non-nitrate

a. action: coronary artery vasodilation with action similar to papaverine; antiplatelet properties and mild positive
inotrope

b.
example: dipyridamole (Persantine) 50-100 mg orally 4 times daily

c. uses

i. exercise testing

ii. adjunct thromboembolism prevention

iii. angina prophylaxis


d. adverse effects

i. severe hypotension

ii. from IV use: bronchospasm, myocardial ischemia or infarction, arrhythmias and angina exacerbation


e. nursing care
216


i.
assist health care team to establish baseline therapy and check prior to beginning therapy and at regular,
predetermined intervals bleeding time

ii. reinforce client teaching

change positions slowly

AVOID alcohol and over-the-counter drugs, especially aspirin

notify health care provider if unusual bruising or bleeding occurs






2. Type: peptide hormone, synthetic

a. action: inhibits anti-diuretic hormone (ADH) to increase urine output and relax vascular smooth muscle

b.
example: nesiritide (Natrecor) - 0.01 mcg/kg/min IV

c. uses: acutely decompensated congestive heart failure

d. adverse effects

i. life-threatening: severe hypotension, bradycardia, azotemia, renal impairment/ failure, increased mortality

ii. other: elevated creatinine, hypotension, headache, insomnia, nausea, back pain, dizziness, anxiety, angina


e. contraindications

i. cardiogenic shock, systolic blood pressure <90, low cardiac filling pressure

ii. restrictive or obstructive cardiomyopathy, constrictive pericarditis, cardiac tamponade


f. nursing care: monitor blood pressure

3. Type: nitrates (example: nitroglycerin)
4. Type: calcium channel blockers (examples: amlodipine [Norvasc], diltiazem [Cardizem], verapamil [Calan])


J.
Therapeutic classification: vasopressors

1. Type: alpha- and beta-adrenergic agonists, sympathomimetic agents (mimics action of sympathetic nervous system)

a. action: increases heart rate, vasoconstricts peripheral vessels to increase blood pressure, and dilates renal and
splanchnic vessels to improve perfusion via stimulation of sympathetic nervous system; opposite action of alpha- or
beta-blockers

b. examples

i.
example: DOPamine (generic) 1-20 mcg/kg/min IV
Black Box Warning - extravasation

ii.
norepinephrine (Levophed) 2-12 mcg/min IV
Black Box Warning - extravasation

iii.
epINEPHrine (generic) 1 mg IV bolus every 3 to 5 minutes in cardiac arrest


c. uses

i. ACLS for asystole/pulseless electrical activity, V-fib/pulseless V-tach, bradycardia

ii. cardiac output maintenance

iii. adjunct treatment for cardiac arrest

iv. acute hypotension adjunct treatment for shock

v. adjunct treatment for shock

vi. refractory heart failure


d. adverse effects
217


i. life-threatening: pulmonary edema, arrhythmias, severe hypertension, cerebral hemorrhage, extravasation
necrosis, anaphylaxis

ii. most common: tachycardia, headache, nausea, hypertension, vasoconstriction, angina, dyspnea


e. contraindications: pheochromocytoma, peripheral vascular disease, closed angle glaucoma, severe volume
depletion, vascular thrombosis; use cautiously in clients receiving monoamine oxidase inhibitors or other
antidepressants

f. nursing care

i. observe RN establish baseline data and monitor blood pressure and ECG

ii.
antidote for extravasation: phentolamine (Regitine) - an adenergic blocking agent





2. Type: beta-agonist, sympathomimetic agent

a. action: selectively stimulates cardiac beta
1
-adrenergic receptors; primarily increases cardiac output; increases blood
pressure without concomitant increase in heart rate

b.
examples

i.
DOBUTamine (generic) 2-20 mcg/kg IV (do not confuse with DOPamine)

ii. isoproterenol (Isuprel) 2-6 mcg/kg IV


c. uses: cardiac decompensation, cardiac output maintenance, emergent arrhythmias, atropine-resistant bradycardia

d. adverse effects

i. life-threatening: Stokes-Adams seizures, arrhythmias, cardiac arrest, severe hypotension, bronchospasm

ii. most common: nervousness, insomnia, restlessness, headache, minor tremor


e. contraindications: digitalis intoxication tachycardia, angina

f. nursing care

i. observe RN establish baseline data and monitor potassium, blood pressure and ECG

ii. monitor and record blood pressure, heart rate, and rhythm every 15 minutes

iii. control with infusion pump

iv. infuse in central venous catheter




II. Managing Respiratory Conditions

A. Therapeutic classification: bronchodilators

1. Information common to bronchodilators

a. action: direct relaxation of bronchial smooth muscle resulting in increased diameter of airway, eases the work of
breathing

b. nursing care

i. encourage smoking cessation therapy

ii. assist health care team to establish baseline data and check before beginning and throughout therapy

breath sounds, oxygen saturation (SaO
2
), respiratory rate

vital signs and ECG


iii. assist health care team to implement client teaching plan

report worsening findings

AVOID caffeine and over-the-counter drugs

take medication only as directed; do not take extra doses

reinforce use of delivery method - oral, meter-dose inhaler, nebulizer, or aerosolized powder







218



2. Type: adrenergic agonist (sympathomimetic)

a. action

i. stimulates and enhances sympathetic nervous system (SNS) to relax bronchial smooth muscle

ii. may increase rate and depth of respirations

iii. inhibits release of inflammatory mediators (short-term effect)


b. examples

i. short-acting

type: alpha- and beta-adrenergic agonists, non-selective adrenomimetic

epinephrine (Adrenalin) 0.3-0.5 mg (1:1000) SubQ/IM every 20 minutes

terbutaline 2.5-5 mg by mouth three times a day
Black Box Warning - tocolysis use


type: beta-adrenergic agonists, selective adrenomimetic

albuterol (VoSpire ER) 2-4 mg by mouth three to four times a day; extended release 4-8 mg by mouth every
12 hours

metaproterenol (Alupent) 20 mg by mouth three to four times per day or 10-15 mg NEB three to four times
per day

levalbuterol (Xopenex, Xopenex HFA) 0.63-1.25 mg NEB every 6-8 hours or 2 puffs (45 mcg/spray) MDI
every 4 to 6 hours




ii. type: long acting, beta 2-adrenergic agonists

salmeterol (Serevent Diskus) 50 mcg inhaled every 12 hours
Black Box Warning - asthma-related death in pediatric and adolescent use

formoterol (Foradil Aerolizer, Performist) 20 mcg NEB twice daily
Black Box Warning - asthma related death



iii. long acting, beta 2-adrenergic agonist and corticosteroid combination medications formoterol & fluticasone
(Symbicort)

fluticasone/salmeterol inhaled (Advair, Advair HFA) 200/50 mcg (1 puff) inhaled twice daily
Black Box Warning - asthma related death

budesonide/formoterol inhaled (Symbicort) 80/4.5 or 160/4.5 spray MDI 2 puffs twice daily
Black Box Warning - asthma related death





c. uses

i. acute bronchospasm, anaphylaxis

ii. asthma, chronic bronchitis, COPD

iii. prophylaxis for exercise-induced asthma


d. adverse effects

i. desired effect lost when dose exceeds therapeutic level leading to life-threatening adverse effects, including:
paradoxical bronchospasm, asthma exacerbation, asthma related death, anaphylaxis, angioedema, hypokalemia,
arrhythmias, hypertensive crisis
219


ii. most common: adrenal suppression, hyperglycemia, nasopharyngitis, headache, URI symptoms, nasal congestion


e. contraindications: hypertension, cardiovascular disease, diabetes mellitus, hyperthyroidism, seizure disorder, glaucoma,
increased intraocular pressure

f. nursing care

i. assist health care team to establish baseline data and check before and during therapy breath sounds, SaO
2
and vital
signs

ii. available in oral therapy

iii.
small frequent meals to ameliorate nausea, vomiting, anorexia

iv. assist health care team to implement client teaching plan

take before other inhaled medications and 30 to 60 minutes before exercise

report chest pain or palpitations

AVOID caffeinated beverages, dark chocolate, over-the-counter drugs




3. Type: xanthines

a. actions

i. stimulates the sympathetic nervous system: acts directly on bronchial smooth muscle to dilate airways and on
medulla in brainstem to increase rate and depth of respirations

ii. inhibits release of inflammatory mediators in anaphylaxis


b.
examples

i. aminophylline 380-760 mg/day PO/IV every 6 to 8 hours

ii. theophylline (Elixophyllin, Theo-24, Uniphyl) 300-600 mg/day by mouth once to twice daily


c. uses: bronchospasm, asthma, COPD

d. adverse effects

i. life-threatening: seizures, arrhythmias, hypotension, shock

ii. most common: exfoliative dermatitis, nausea, vomiting, headache, insomnia, irritability, restlessness


e. contraindications: seizure disorder, arrhythmias, heart failure, acute pulmonary edema, cor pulmonale, hepatic
impairment, hypothyroidism, febrile, sepsis with multi-organ failure, shock

f. nursing care

i. assist health care team to establish baseline data

ii.
monitor drug levels: theophylline has narrow therapeutic range at 5-15 mcg/mL; toxic levels > 20 mcg/mL

iii. assist health care team to implement client teaching plan: avoid caffeine




4. Type: anticholinergic

a. action

i. blocks muscarinic receptors, acetylcholine release, and stimulation of vagus nerve

ii. results in bronchodilation, diminished secretions, low central nervous system effect (less effect on heart rate)

iii. effects mucociliary clearance minimally

iv. parasympatholytic (reverses effects of), acts like atropine sulfate


b.
examples

i. ipratropium bromide inhaled (Atrovent HFA) 0.5 mg/2.5 mL NEB

ii. tiotropium inhaled (Spiriva HandiHaler) 18 mcg/cap DPI


c. uses

i. COPD

ii. bronchospasm maintenance treatment for asthma

220


d. adverse effects

i. anaphylaxis, angioedema, angel-closure glaucoma

ii. laryngospasm, paradoxical bronchospasm, cough, nervousness


e. contraindications: glaucoma (angle-closure), prostatic hypertrophy, bladder neck obstruction

f. nursing care: assist health care team to implement client teaching plan

i. not for use in acute bronchospasm or as rescue therapy

ii. rinse mouth after treatment

iii. wait several before administering other inhaled medications or as directed by provider




B. Mucolytics and expectorants

1. Mucolytics

a. action: thins respiratory secretions by splitting disulfite bonds in secretions; mobilizes secretions

b.
type: acetylcysteine (generic) 70 mg/kg by mouth every 4 hours for 17 doses; may be given by nebulizer,
intratracheal or nasogastric

c. uses

i. when mucolysis is needed for acute and chronic bronchopulmonary disease, tracheostomy care, pulmonary
complications of cystic fibrosis

ii. diagnostic bronchial studies

iii. acetaminophen overdose


d. adverse effects

i. bronchospasm, hypersensitivity reaction

ii. unpleasant odor during administration, stomatitis


e. contraindications

i. inadequate cough, asthma

ii. upper GI bleed risk


f. nursing care

i. give mucolytics by nebulizer

ii. as antidote for acetaminophen poisoning - direct instillation via nasogastric tube into stomach

iii. most effective when combined with other therapy - encourage ambulation plus coughing and deep breathing





2. Expectorants

a. action: liquefies respiratory secretions by decreasing the surface tension

b.
type: guaifenesin (Diabetic Tussin, Diabetic Tussin Mucus Relief, Kids-Eeze Chest Relief, Little Colds Mucus
Relief, Mucinex, Mucinex for Kids, Mucinex Maximum Strength, Robitussin Chest Congestion, Vicks DayQuil Mucus
Control) 200-400 mg by mouth every 4 hours

c. uses: chest congestions

d. adverse effects

i. nephrolithiasis

ii. rash, vomiting, nausea


e. nursing care

i. identify and resolve etiology of cough

ii. assist health care team to establish baseline data and then monitor appearance and amount of secretions

iii. most effective when combined with adjunct therapy - 8 ounces water with each dose, encourage ambulation,
coughing and deep breathing

iv. assist health care team to implement client teaching plan
221


avoid using combination products for expectorant (guaifenesin found in many over-the-counter combination
products)

avoid dairy products (thickens secretions) and caffeinated beverages (dehydrates to thicken secretions)





C. Antitussive

1. Type: narcotic (opioid)

a. action: cough suppression by depression of cough center in medulla of brainstem, similar to morphine; moderate
histamine releasing action

b.
example - codeine/guaifenesin (Cheratussin AC, Lophen C-NR, Robitussin AC) 10-20 mg by mouth every 4 to
6 hours

c. uses: cough

d. adverse effects

i. CNS and respiratory depression, orthostatic hypotension, bradycardia

ii. syncope, paralytic ileus, seizures

iii. increased ICP, dependency and abuse


e. contraindications: respiratory depression, acute or severe asthma, paralytic ileus

f. nursing care

i. assist health care team to establish baseline data and during therapy - level of consciousness, respiratory rate,
bowel movements, temperature, secretions

ii. provide adjunct therapy to relieve cough, including expectorants, fluid, humidification, lozenges

iii. assist health care team to implement client teaching plan

take only as directed

change positions slowly; ask for help before getting up and avoid dangerous activities until full effects
of treatment are well established

take with food to avoid nausea

drink fluids, increase fiber in diet, ambulate, and establish personal bowel habits to prevent
constipation






2. Type: non-narcotic

a. benzonatate

i. action: cough suppressant without suppression of respiratory center at therapeutic doses; acts like tetracaine
hydrochloride

ii.
example: benzonatate (Tessalon) 100-200 mg orally 3 times daily as needed; max dose is 600 mg/day

iii. uses: cough

iv. adverse effects

sedation, headache, dizziness

pruritus, rash, nausea, dyspepsia

constipation, confusion, hallucinations


v. nursing care

assist health care team to establish baseline data and check appearance and amount of secretions
before starting and periodically during therapy

assist health care team to implement client teaching plan

swallow soft capsules whole (if it dissolves in the mouth may suppress gag reflex)

store capsules in child-resistant container
222


may cause dizziness or drowsiness





b. dextromethorphan

i. action: cough suppression by depressing the medulla; in therapeutic doses comparable to codeine but without
central nervous system depression and analgesia; much less likely to cause constipation, drowsiness, or
gastrointestinal upset

ii.
example: dextromethorphan ( Children's Robitussin Cough Long Acting, Children's Triaminic Long Acting
Cough, Delysm, Robitussin Lingering Cold Long-Acting Cough, Sucrets DM Cough Formula, Vicks DayQuil Cough,
Vicks Formula 44 Costum Care Dry Cough Suppressant) up to 120 mg/day in divided doses

iii. uses: cough

iv. adverse effects

serotonin syndrome, abuse potential

nausea, dizziness, abdominal pain, drowsiness, fatigue

hyperexcitability, especially in children


v. contraindications: monoamine oxidase inhibitor use within 14 days; caution in children younger than 6 years-old

vi. nursing care: assist health care team to implement client teaching plan

humidify air

report cough lasting more than 7 to 10 days

do not crush or chew extended release forms

avoid irritants, should not completely suppress cough

do not overdose dextromethorphan by taking combination product





D. Type: antituberculars

1. Information common to antituberculars

a. actions: destroys or suppresses (bacteriostatic or bactericidal anti-infective agents for treatment of) Mycobacterium
tuberculosis

b.
examples

i. first-line therapy: isoniazid, rifampin (Rifadin), ethambutol (Myambutol), streptomycin (Streptomycin)

ii. second-line therapy: ethionamide (Trecator), pyrazinamide, cycloserine (Seromycin)


c. use: used in combination with other anti-tuberculosis agents; none are used alone to treat TB

d. adverse effects

i. hepatotoxicity, agranulocytosis, aplastic anemia, thrombocytopenia

ii. optic neuritis, peripheral neuropathy, toxic psychosis, paresthesia, nausea, vomiting


e. contraindications

i. acute hepatic disease

ii. severe renal disease and peripheral neuropathy


f. nursing care

i.
assist health care team to establish baseline data and check periodically thereafter creatinine and liver
function tests

ii. review drug-drug interactions for incompatibility

iii. M. tuberculosis eradicated after three negative sputum cultures in a row

iv. assist health care team to implement client teaching plan

report

worsening symptoms, return of fever
223


rash, decreased urine output, edema, weight gain

dyspnea, hallucinations, jaundice

AVOID alcohol, tyramine- and histamine-containing foods

take pyridoxine (vitamin B6) to help prevent or reverse peripheral neuropathy

duration of therapy usually several months; need for long-term care and follow-up testing

continue taking anti-tuberculosis therapy until instructed to stop; continue therapy even when feeling
good






2. First-line therapy

a.
isoniazid (generic) 5 mg/kg up to 900 mg PO/IM daily for 6 to 18 months
Black Box Warning - hepatotoxicity

i. action: bacteriostatic agent that interferes with DNA of M. tuberculosis

ii. use: active and latent tuberculosis infection; combination treatment

iii. adverse effects

agranulocytosis, aplastic anemia, thrombocytopenia

hepatotoxicity, pyridoxine deficiency

paresthesia, optic neuritis


iv. contraindication: acute liver disease

v. nursing care

assist health care team to establish baseline data and periodically check creatinine, liver function tests

administer on empty stomach

assist health care team to implement client teaching plan

report tingling, numbness, or burning of extremities - may indicate toxicity

take pyridoxine (vitamin B6) to help prevent or reverse peripheral neuropathy

AVOID foods with histamine (skipjack tuna, sauerkraut juice, yeast extract) and foods with tyramine (aged
cheese, cured meat, smoked fish)






b.
rifampin (Rifadin) 10 mg/kg PO/IV daily for 4 to 6 months

i. action: inhibits RNA synthesis inM. tuberculosis

ii. adverse effects

hepatitis, thrombocytopenia, leukopenia, hemolytic anemia, agranulocytosis, hemorrhage, DIC, interstitial
nephritis, renal failure

most common: reddish-orange body fluids, elevated ALT, AST


iii. contraindications

IM or SubQ administration

diabetes mellitus, hepatic impairment

porphyria


iv. nursing care

assist health care team to establish baseline data for creatinine, complete blood count, platelets, liver function
tests
224


assist health care team to implement client teaching plan
report bleeding or bruising
do not interrupt prescribed drug regimen

avoid wearing soft contacts - rifampin can cause reddish-orange discoloration of saliva, sweat, tears, feces
and urine





c.
ethambutol (Myambutol) 15-25 mg/kg by mouth daily

i. action: inhibits RNA synthesis

ii. adverse effects: anaphylaxis, hypersensitivity syndrome, erythema multiforme, thrombocytopenia, neutropenia,
leukopenia, irreversible blindness

iii. contraindication: optic neuritis

iv. nursing care

encourage regular eye exams

assist health care team to establish baseline data and check BUN/creatinine, complete blood count, liver
function tests




d.
streptomycin (Streptomycin) 15 mg/kg IM every 24 hours 5 to 7 times weekly
Black Box Warning - appropriate use, neurotoxicity/ototoxicity, neuromuscular blockade


3. Second-line therapy

a.
ethionamide (Trecator-SC) 500-700 mg by mouth daily

i. action: bacteriostatic and bactericidal

ii. use: active tuberculosis

iii. adverse effects

hepatitis, thrombocytopenia, psychosis

peripheral neuritis, optic neuritis, hypothyroidism

dyspepsia, excessive salivation, metallic taste


iv. contraindications: severe hepatic impairment, diabetes mellitus, thyroid disease

v. assist health care team to implement client teaching plan

take pyridoxine (vitamin B6) to help prevent or reverse peripheral neuropathy

take with food to decrease GI upset

not first line treatment



b.
pyrazinamide (generic) 1000-2000 mg by mouth daily for about 2 months; part of a multi-drug regimen - not first-
line treatment

c.
cycloserine (Seromycin) 500-750 mg by mouth daily in divided doses; part of a multi-drug regimen - not first-line
treatment



E. Therapeutic classification: anti-inflammatory agents

1. Glucocorticoids (inhaled)

a. actions

i. inhibits phagocytosis

ii. reduces capillary permeability
225


iii. stabilizes leukocyte membrane

iv. decreases release of inflammatory mediators


b.
examples

i. fluticasone furoate nasal (Veramyst) 27.5 mcg/spray, 1 to 2 inhalations in each nostril daily

ii. fluticasone inhaled (Flovent Diskus, Flovent HFA) 100-500 mcg/spray inhalations twice daily

iii. triamcinolone nasal (Nasacort AQ) 55 mcg/spray, 1 to 2 inhalations in each nostril daily

iv. beclomethasone nasal (Beconase AQ, Qnasl) 80 mcg/spray, 2 inhalations in each nostril daily

v. beclomethasone inhaled (Qvar) 40-320 mcg inhaled twice daily


c. uses

i. allergic rhinitis

ii. maintenance treatment for asthma


d. adverse effects

i. nasal septal perforation, nasal ulcer, nasal/oral candidiasis, increased intraocular pressure, glaucoma, cataracts,
hypercorticism, adrenal suppression

ii. most common: nasal irritation, headache, nausea, lightheadedness, epitaxis


e. contraindications

i. TB infection

ii. measles or varicella exposure

iii. immunosuppression, active respiratory infection


f. nursing care

i. assist health care team to establish baseline data and check periodically thereafter

weight, blood pressure

blood sugar, renal function, gastrointestinal bleeding

wound healing, mental and emotional status


ii. collaborate with dietitian and provider to manage fluid retention, hyperglycemia, and hypokalemia

iii. assist health care team to implement client teaching plan

not rescue therapy - not indicated for acute asthma or allergic attack

therapeutic effect takes 1 to 2 weeks

report infections and fever, worsening findings

blood glucose testing

avoid sick people, wash hands frequently

rinse mouth after treatment to avoid Candida albicans overgrowth (thrush)

if also prescribed a bronchodilator, use this first (to open up and relax airways) and then use steroid
inhaler

reinforce medication delivery method






2. Type: mast cell stabilizer

a. action: inhibits release of histamine and slow reacting substance of anaphylaxis (SRS-A) but without antihistaminic
properties

b.
example: cromolyn nasal (NasalCrom) 1 spray each nostril 3 to 4 times daily

c. uses: allergic rhinitis

d. adverse effects

i. bronchospasm

ii. most common: dry mouth, bitter aftertaste, sneezing, nasal burning

226


e. contraindications: hypersensitivity to drug

f. nursing care

i. therapeutic effects may take up to 1 week

ii. available over-the counter




3. Type: leukotriene-receptor antagonists

a. action: selectively interferes with leukotrienes to inhibit bronchospasm and airway edema

b.
examples

i. zafirlukast (Accolade) 20 mg by mouth twice a day

ii. montelukast (Singular) 10 mg by mouth every evening


c. uses: maintenance treatment for asthma and exercise induced bronchospasm

d. adverse effects

i. angioedema, anaphylaxis, erythema nodosum, aggressive behavior, hallucinations, depression

ii. Churg-Strauss syndrome, hepatic eosinophilic infiltration, hepatotoxicity, suicidality

iii. headache, influenza-like symptoms, abdominal pain, cough


e. contraindication: severe hepatic disease, severe asthma, PKU, tapering systemic steroids

f. nursing care

i. assist health care team to establish baseline data and check during therapy breath sounds, SaO
2
,
respiratory rate

ii. administer 1 hour before or 2 hours after meals

iii. assist health care team to implement client teaching plan

take medication on regular basis (missing a dose may result in a lapse in therapeutic effect)

report flu-like findings, worsening condition, jaundice, dark urine or stool





F. Therapeutic classification: antihistamines

1. Type: first generation antihistamines (for respiratory tract)

a. action: potent H-receptor antagonist (histamine blocking agent) to block the effects of histamine

b.
example: azelastine (Optivar) 137 mcg/spray 1 to 2 sprays each nostril twice daily

c. uses: allergic rhinitis, vasomotor rhinitis

d. adverse effects

i. bitter taste, headache, somnolence, dysesthesia

ii. nasal burning, URI, dry mouth, paroxysmal sneezing

iii. nausea, fatigue, dizziness, epitaxis, cough


e. contraindications: concurrent use of central nervous system depressants

f. nursing care

i. assist health care team to establish baseline data and check during therapy for upper respiratory system
congestion, drowsiness

ii. prime delivery unit before dispensing

iii. assist health care team to implement client teaching plan

AVOID alcohol

AVOID getting nasal spray in eyes

blow nose before instillation - tilt head forward slightly and sniff gently






227


2. Type: second generation antihistamines

a. action: blocks effects of histamine by blocking H
1
receptor and mast cell release of inflammatory mediators

b.
examples

i. loratadine (Alavert, Children's Claritin, Claritin, Claritin RediTabs 12 hour, Claritin RediTabs 24 hour) 10 mg by
mouth daily

ii. fexofenadine (Allegra Allergy 12 hour, Allergra Allergy 24 hour, Children's Allegra Allergy) 180 mg by mouth daily

iii. desloratadine (Clarinex, Clarinex Reditabs) 5 mg by mouth daily

iv. cetirizine (Children's Zyrtec Allergy, Children's Zrytec Hives, PediaCare Childrens 24 hour allergy, Zrytec Allergy)
5-10 mg by mouth daily


c. uses: allergic rhinitis, chronic idiopathic urticaria

d. adverse effects

i. bronchospasm, anaphylactic reaction, hepatotoxicity, cholestasis, seizures, hemolytic anemia, thrombocytopenia,
syncope, severe hypotension

ii. most common: drowsiness, fatigue, abdominal pain, headache, dry mucous membranes


e. contraindications: renal or hepatic impairment, CNA depressant use

f. nursing care

i.
assist health care team to establish baseline data and check during therapy clients creatinine

ii. assist health care team to implement client teaching plan

report unusual findings

may cause drowsiness

provide frequent oral care

AVOID alcohol and central nervous system depressants





G. Therapeutic classification: decongestants

1. Type: sympathomimetic

a. action: stimulate sympathetic nervous system causing vasoconstriction of nasal mucus membranes

b.
examples

i. tetrahydrozoline (Visine) 1 to 2 drops in each eye as needed

ii. oxymetazoline (Afrin, Afrin All Night, Afrin Extra Moisturizing, Afrin Severe Congestion, Afrin Sinus, Dristan
Nasal, Mucinex Nasal Spray, Neo-Synephrine Nighttime Spray, Sudafed OM, Vicks Sinex VapoSpray 12 Hour)
2-3 sprays in each nostril every 10 to 12 hours as needed


c. uses: decongestant for reducing eye redness, nasal congestion

d. adverse effects

i. life-threatening: arrhythmias, angina

ii. others: nasal irritation and dryness, sneezing, rebound congestion, dizziness, elevated blood pressure,
tachycardia, palpitations, restlessness, insomnia


e. contraindications

i. hypertension, cardiovascular disease,hypothyroidism

ii. use within 14 days of MAO inhibitor

iii. diabetes mellitus, prostatic hypertrophy, angle-closure glaucoma


f. nursing care

i. assist health care team to establish baseline data and check at regular intervals thereafter nasal congestion,
breath sounds, respiratory rate, heart rate, blood pressure

ii. administer with client in upright position

iii. assist health care team to implement client teaching plan - do not exceed recommended dose



228



2. Type: oral decongestants

a. action: stimulates alpha-adrenergic receptors in nasal passages resulting in vasoconstriction and shrinkage of swollen
mucus membranes

b.
example: pseudoephedrine hydrochloride (Children's Sudafed, Sudafed 12 Hour, Sudafed 24 Hour, Sudafed
Congestion) 60 mg by mouth every 4 to 6 hours as needed

c. use: nasal congestion

d. adverse effects

i. life-threatening: arrhythmias, hypertension

ii. most common: insomnia, nausea, headache, dizziness, CNS stimulation, anxiety

iii. other: palpitations, tachycardia, BP elevated, tremor, urinary retention


e. contraindications

i. urinary retention, coronary artery disease, prostatic hypertrophy

ii. hypertension, arrhythmias, cardiovascular disease, phenylketonuria (PKU)

iii. diabetes mellitus, angle-closure glaucoma, hyperthyroidism,

iv. within 14 days of MAO inhibitor

v. not recommended for children younger than age 6 years-old


f. nursing care

i. assist health care team to establish baseline data and check periodically during therapy nasal congestion, breath
sounds, respiratory rate, heart rate, blood pressure

ii. assist health care team to implement client teaching plan

avoid other over-the-counter drugs

discontinue if extreme restlessness occurs

do not crush or chew sustained release forms





H. Pharmacological interventions to help clients to stop smoking

1. Type: nicotine

a. action: stimulates nucleus accumbens reward system in the brain to increase extracellular dopamine, endogenous
opioids, and glucocorticoids in the region

b.
examples

i. nicotine gum (Nicorette Gum) 2-4 mg by mouth every 1-2 hours for 6 weeks

ii. nicotine inhaled (Nicotrol Inhaler) 4 mg delivered/cartridge 6-16 cartridges a day

iii. nicotine transdermal (Nicoderm CQ) 14-21 mg patch daily for 6 weeks

iv. nicotine nasal spray (Nicotrol NS) 0.5/spray; 1 spray each nostril 1-5 times a hour for 8 weeks


c. use: smoking cessation

d. adverse effects

i. bronchospasm, nicotine dependence transference, fetal harm risk

ii. most common: insomnia, headache, withdrawal symptoms


e. contraindications

i. severe arrhythmias, worsening or severe angina

ii. acute with in 2 weeks of myocardial infarction


f. nursing care

i. assist health care team to establish baseline data and check periodically breath sounds, frequency of nicotine
use, frequency of urge to smoke, complaints of nicotine withdrawal or nicotine toxicity

ii. nicotine withdrawal: headache, fatigue, drowsiness, irritability, severe cravings
229


iii. nicotine toxicity: gastrointestinal findings, hypotension, dyspnea, weakness, abdominal cramping, blurred vision,
tinnitus; withdraw nicotine therapy immediately

iv. assist health care team to implement client teaching plan

take only as directed

do not smoke when wearing patch

inhaler: puff on mouthpiece

gum: chew slowly for 30 minutes (reinforce it is as potent as cigarettes)

patch: apply daily, rotating sites (reinforce it is as potent as cigarettes)




2.
Type: antidepressants (example: buPROPion [Wellbutrin, Zyban])

3.
Type: antihypertensives (example: cloNIDine [Catapres])



I. Therapeutic classification: therapeutic gases

1.
Type: oxygen

a. action: essential gas for cellular energy production and metabolism

b. uses

i. supplemental oxygen to prevent or correct hypoxia

ii. hyperbaric oxygenation, extracorporeal circulation

iii. ventilatory support for respiratory failure, surgical anesthesia

iv. reduce partial pressure of inert gases, air embolism, decompression sickness


c. adverse effects

i. life-threatening: hypoxic drive in neonates

ii. other:

increased pulmonary capillary permeability

exacerbation of hypoxemia in hypoventilated lungs

atelectasis, irritation of tracheobronchial mucosa, decreased mucociliary transport

mask signs of desaturation from obstruction or hypoventilation



d. nursing care

i. assist health care team to establish baseline data and check at regular intervals respiratory rate, level of
consciousness, breath sounds, SaO
2


ii. humidify supplemental oxygen

iii. avoid 100% oxygen for more than 8 to 12 hours

iv. prevent client injury: avoid open flames and sparks, ground all equipment

v. FiO
2
affected by respiratory rate, tidal volume, inspiratory-expiratory ratio (I:E ratio), inspiratory flow, and
characteristics of delivery system

lowest control
room air

nasal cannula: nasopharynx is reservoir for oxygen; client may breathe from mouth or nose with
patent nares
tracheostomy collar
simple face mask

medium control: Venturi mask, oxygen nebulizer, and nonrebreather mask

high control: endotracheal tube, tracheostomy tube to ventilator

precise control of FiO
2
only achieved with
230

airtight, closed delivery system
separation of inspired gases from expired gases



vi. PaO
2
affected by FiO
2
serum hemoglobin, SaO
2
, efficiency of alveolar gas exchange

vii. assist health care team to implement client teaching plan: cough and deep breathe every hour while awake





2.
Type: carbon dioxide

a. action: by-product of cellular metabolism carried on the bicarbonate ion (HCO
3
-) and transported to the lung where it is
exhaled at the same rate it is produced

b. uses

i. insufflation of internal organs during endoscopic procedures

ii. vasoconstriction of cerebral vessels during cranial surgery

iii. displacement of air surrounding open heart in cardiac surgery




3.
Type: nitric oxide

a. action: cell-signaling molecule that decreases resting vascular tone, prevents platelet aggregation, effector of
macrophage-induced cytotoxicity (stimulates cell destruction by macrophages)

b. uses

i. pulmonary hypertension to vasodilate

ii. diagnostic testing in cardiac catheterization, pulmonary function, and for asthma


c. adverse effects

i. toxicity at levels greater than 50-100 PPM

ii. loss of ciliary action, hypertrophy of pulmonary tissue

iii. surfactant inactivation, methemoglobinemia formation

iv. increased bleeding time, impaired ventricular function due to increased blood flow to left ventricle


d. nursing care: observe RN establish baseline data and monitor

i.
arterial blood gases, methemoglobin levels, occult bleeding

ii. pulmonary artery pressure, cardiac output, breath sounds, pulmonary secretions




4.
Type: helium

a. action: low density, low solubility, and high thermal conductivity making other gases easier to breathe

b. uses

i. diagnostic testing for respiratory obstruction, laser surgery of airway, imaging label, pulmonary function

ii. oxygen dilution in hyperbaric applications




III. Managing neurological conditions

A. Therapeutic classification: anticonvulsants

1. Therapeutic classification: anticonvulsants - overview

a. action: stabilize neuronal membranes to prevent tissue excitability in the cerebral cortex

b. adverse effects

i. life-threatening: ventricular fibrillation, severe hypotension, cardiovascular collapse (IV use)

ii. CNS depression: insomnia, headache, drowsiness, lethargy, fatigue

iii. gastrointestinal upset, anorexia, constipation

231


c.
nursing care

i. assist health care team to establish baseline data and check at regular intervals seizure activity, level of
consciousness

ii. taper dose before discontinuing therapy

iii. assist with ambulation, institute seizure precautions

iv. assist health care team to implement client teaching plan

promptly report

seizure activity, easy bleeding or bruising

loss of balance, rash, jaundice, severe nausea, vomiting

avoid pregnancy

wear MedicAlert identification

need for follow-up care and testing

AVOID over-the-counter drugs

AVOID herbal supplements

change positions slowly, ask for help before getting up








2. Tonic-clonic (grand mal) seizures

a. type: hydantoin

i. action: stabilize neuronal membranes in CNS to limit spread of neuronal excitability

ii.
example: phenytoin
Black Box Warning - cardiovascular risk with rapid infusion

seizure disorder: 100 mg by mouth every 6-8 hours; extended release 300 to 400 mg by mouth daily

status epilepticus: 15-20 mg/kg IV x 1; may give additional 10mg/kg IV x 1 after 20 minutes


iii. uses

status epilepticus

seizure disorder

neurosurgery-associated seizure prophylaxis


iv. adverse effects

life-threatening: ventricular fibrillation, severe hypotension, cardiovascular collapse, AV conduction
abnormalities (IV use)

most common: nausea, vomiting, rash, nystagmus, ataxia, slurred speech

other: dizziness, confusion, paresthesia, blurred vision, somnolence, constipation, headache, insomnia,
gingival hyperplasia, tremor, taste changes, hyperglycemia


v. contraindications

SA block, 2nd or 3rd degree AV block, sinus bradycardia, Adam-Stokes syndrome, hypotension,
cardiovascular disease

renal or hepatic impairment, diabetes mellitus




vii. nursing care

assist health care team to establish baseline data and check periodically thereafter

seizure activity

monitor blood pressure, ECG, respiratory function continuously during and for 20 minutes after IV load

signs and symptoms of depression, behavior changes, suicidality
232


creatinine, complete blood count, folate, liver function tests

assist health care team to establish baseline data and check and report serum levels

therapeutic: 10-20 mcg/mL (total)

toxic: > 20 mcg/mL

timing: 2 to 4 hours after IV load, 24 hours after oral load or just prior to next dose

provide oral care, assist with ambulation

oral administration

avoid giving within 2 to 3 hours of antacids

prompt release forms not suitable for once daily dosing

IV administration - slowly warm IV solution to room temperature



viii. assist health care team to implement client teaching plan

report seizure activity, bleeding, jaundice, dark urine or stool

AVOID alcohol, sedatives, hypnotics, oral contraceptives

AVOID ginkgo biloba

use soft tooth brush; seek regular dental care

avoid hazardous activities without provider approval

do not crush or chew sustained release forms

may take calcium with vitamin D and folic acid



b. type: barbiturates

i. action: interferes with impulse transmission of cerebral cortex leading to central nervous system depression and
unconsciousness

ii.
examples

phenobarbital

seizure disorder: 60 mg by mouth 2 to 3 times per day

status epilepticus: 10-20 mg/kg IV x 1

sedation: 10-40 mg PO/IM/IV three times a day

primidone (Mysoline) 250 mg by mouth 3 times daily


iii. uses

seizure disorder, essential tremor

status epilepticus

sedation


iv. adverse effects

life-threatening: respiratory depression, erythema multiforme, Stevens-Johnson syndrome, angioedema,
megaloblastic anemia, TTP, blood dyscrasias, suicidality

most common: drowsiness, lethargy, hyperactivity (pediatric clients) nausea, vomiting, somnolence

other

porphyria exacerbation, rash, urticaria, pain, swelling, thrombophlebitis, necrosis, hepatitis

physical dependance

toxicity: ataxia, slurred speech, poor judgment, insomnia




233

v. contraindications

porphyria history, severe hepatic impairment

respiratory dysfunction

history of depression, uremia, elderly clients


vi. nursing care

assist health care team to establish baseline data and check periodically thereafter
signs and symptoms of depression, behavior changes, suicidality

liver function tests and drug levels (therapeutic drug level 10-40 mcg/mL; toxic level > 50 mcg/mL)

administration

intravenous

IM injection may not exceed 5 mg at one site

assist health care team to implement client teaching plan
drowsiness may improve over time
AVOID pregnancy, take only as directed
AVOID hazardous activity
AVOID alcohol
provide exposure to sun

take calcium with vitamin D and folic acid




c. type: benzodiazepines

i. very effective anticonvulsant, emergency drug of choice

ii.
example: diazepam (Valium) 5-10 mg IV every 5 to 10 minutes up to 30 mg

iii. adverse effects: respiratory depression


Therapeutic drug levels are laboratory tests to look for the presence and the amount of specific drugs in the blood.
Therapeutic drug levels should be monitored for the following medications used to control seizure activity, e.g.,
phenobarbital, phenytoin, valproic acid and carbamazepine.


3. Petit mal (absence) seizures

a. type: succinimides

i. action: modulates gamma-aminobutryic acid (GABA) to inhibit neuronal pathways

ii.
example: ethosuximide (Zarontin) 250 mg by mouth twice daily

iii. uses: absence seizures

iv. adverse effects

most common: anorexia, dyspepsia, nausea, vomiting, abdominal pain, weight loss

other: lupus erythematosus, paranoid psychosis


v. contraindications: renal or hepatic disease, intermittent porphyria

vi. nursing care: assist health care team to establish baseline data and check during therapy

complete blood count, liver function tests

therapeutic drug levels: 40-100 mcg/mL (toxic level > 150 mcg/mL)

signs and symptoms of depression, behavior changes, suicidality







234



4. Myoclonic

a. type: benzodiazepine

b. type: sulfonamides

i. action: facilitates dopamine and serotonin neuronal transmission

ii.
example: zonisamide (Zonegran) 100-600 mg by mouth divided 1 to 2 doses daily

iii. use: partial seizures

iv. adverse effects

life-threatening: hyperthermia and oligohidrosis in pediatric clients

other: Stevens-Johnson syndrome, toxic epidermal necrolysis, aplastic anemia


v. contraindication: renal failure

vi. nursing care

maintain cool environment

assist health care team to establish baseline data and check BUN/creatinine and complete blood count

assist health care team to implement client teaching plan: avoid dehydration

avoid strenuous activity and heat

drink fluids to avoid kidney stones

avoid alcohol and caffeinated beverages






c. type: valproic acid

i. action: stimulates GABA activity to decrease normal neuronal electrical discharge

ii.
examples

valproic acid (Depakene, Stavzor) 30-60 mg/kg divided 2 to 3 times per day
Black Box Warning - hepatotoxicity

topiramate (Topamax) 200-800 mg by mouth twice daily

tiagabine (Gabitril) 32-56 mg by mouth divided 2 to 4 times per day


iii. use: partial seizures, primary generalized seizures (tonic clonic), Lennox-Gastaut seizures, migraine prophylaxis

iv. adverse effects

life-threatening: hepatotoxicity, pancreatitis, SIADH, hyponatremia, pancytopenia, thrombocytopenia

most common: headache, nausea, vomiting, asthenia, somnolence, dizziness, ataxia, weight and appetite
changes

other: nervousness, emotional lability, insomnia, peripheral edema


v. contraindications
hepatic disease or impairment
urea cycle disorders
infants or young children, pediatric or elderly clients


vi. nursing care

assist health care team to establish baseline data and check at regular intervals liver function tests, platelets,
coagulation studies, ammonia levels

signs and symptoms of depression, behavior changes, suicidality

therapeutic level for valproic acid: 50-100 mcg/mL (epilepsy treatment)

reinforce client teaching

may open capsule and sprinkle granules on soft food
235


AVOID alcohol, over-the-counter drugs, central nervous system depressants





5. Partial (focal) seizures

a. type: benzodiazepines (example: clorazepate [Tranxene SD,Tranxene T-Tab] 7.5 mg by mouth 3 times a day)

b. type: iminostilbene

i.
examples

carbamazepine (Carbatrol, Equetro, Tegretol, Tegretol XR) 800-1200 mg by mouth divided doses 2 to 4
times daily; extended release 400-600 mg ER by mouth twice daily

oxcarbazepine (Trileptal) 600 mg by mouth twice daily; maximum: 2400 mg/day


ii. adverse effects: hyponatremia, leukopenia, thrombocytopenia, pancytopenia, agranulocytosis



c. type: phenytoin

i.
examples

gabapentin (Gralise, Neurontin) 300-1200 mg by mouth three times a day

lamotrigine (Lamictal, Lamictal XR) 250 mg by mouth 2 times daily Black
Box Warning - serious rash


ii. uses

partial seizures, Lennox-Gastaut seizures, primary generalized seizures (tonic clonic)

post-herpetic neuralgia, neuropathic pain, maintenance treatment for bipolar disorder


iii. adverse effects

life-threatening: Stevens-Johnson syndrome, angioedema, DIC

most common: nausea/vomiting, dizziness/vertigo, visual disturbances, somnolence, ataxia, headache





d. type: valproic acid - action: stimulates GABA activity to decrease normal neuronal electrical discharge

e. type: other

i.
example: levetiracetam (Keppra, Keppra XR) 500-1500 mg mg PO/IV every 12 hours; maximum 3000 mg/day

ii. use: adjunct therapy for partial seizures, adjunct treatment in juvenile myoclonic epilepsy

iii. adverse effects

most common: somnolence, asthenia, vomiting, headache, URI symptoms

other: depression, hostility, aggressive behavior


iv. contraindications: renal impairment, psychiatric disorder

v. nursing care

monitor for signs and symptoms of depression, behavior changes, suicidality

avoid abrupt withdrawal

assist health care team to establish baseline data and check during therapy creatinine

assist health care team to implement client teaching plan

avoid pregnancy

report loss of balance, problems with ambulation








236


B. Therapeutic classification: anti-Parkinson's agents

1. Type: dopaminergic

a. dopamine precursor

i. action: crosses blood-brain barrier to form dopamine

ii.
examples

carbidopa/levodopa (Parcopa, Sinemet, Sinemet CR) 10mg/100mg by mouth 3 to 4 times daily;
maximum 200mg/2000mg/day

carbidopa/levodopa/entacapone (Stalevo) 1 tablet by mouth every 3 to 8 hours


iii. use: parkinsonism, idiopathic Parkinson disease

iv. adverse effects

life-threatening: orthostatic hypotension, syncope, severe hypertension, myocardial infarction,
arrhythmias

most common: dyskinesia, nausea/vomiting, hypokinesia/hyperkinesia, diarrhea, dark
saliva/sweat/urine

rhabdomyolysis, depression, suicidal ideation, hallucinations, psychosis, malignant melanoma


v. contraindications: angle-closure glaucoma, melanoma history, undiagnosed skin lesions

vi. nursing care

assist health care team to establish baseline data and check periodically during therapy

increased intraocular pressure if chronic wide angle glaucoma

cardiovascular status if cardiovascular disease history

signs and symptoms of orthostatic hypotension

extrapyramidal side effects

complete blood count, creatinine, liver function tests with extended treatment

assist health care team to implement client teaching plan

report chest pain, palpitations, depression, urinary retention, severe nausea and vomiting, and
involuntary movements

frequent rinsing of mouth, good oral hygiene, and sugarless gum may decrease dry mouth

harmless darkening of saliva, urine, or sweat may occur

sometimes a "wearing-off" effect may occur at end of dosing interval

balance activity and rest, ask for help when getting up

may take with or without food but avoid high protein meals







b. type: dopamine agonists

i. action: acts like replacement therapy to increase dopamine levels but requires functioning neurons capable of
responding

ii.
examples

ropinirole (Requip, Requip XL) 3-6 mg by mouth three times daily; extended release form 6-24 mg by mouth
daily

bromocriptine (Cycloset, Parlodel) 10-30 mg by mouth three times daily

amantadine (Symmetrel) 100 mg by mouth twice daily


iii. use: Parkinson disease, extrapyramidal disorders, neuroleptic malignant disease, hyperprolactinemia, acromegaly

iv. adverse effects

life-threatening: heart failure, arrhythmias, cardiac arrest, psychosis, coma, respiratory failure, pulmonary
edema

most common: nausea, dizziness, insomnia, depression, anxiety, irritability, hallucinations, confusion
237


other: anorexia, dry mouth, constipation


v. contraindications

elderly, depression, psychiatric disorder

heart failure, cardiovascular disease, peripheral edema

angle-closure glaucoma, seizure disorder

renal and hepatic impairment


vi. nursing care

assist health care team to establish baseline data and check at regular intervals during therapy creatinine

AVOID abrupt withdrawal - taper dose to discontinue

assist health care team to implement client teaching plan

wear MedicAlert identification

dermatologic exams

ask for help when getting up, avoid dangerous activities





c. type: monamine oxidase B inhibitor

i. action: blocks breakdown of dopamine and may slow disease progression

ii.
example: selegiline (Eldepyrl) 2.5-10 mg by mouth in 2 doses

iii. use: parkinsonism

iv. adverse effects

life-threatening: hypertensive crisis. arrhythmias. orthostatic hypotension

most common: mental status alterations, hallucinations, extrapyramidal symptoms

other:

dyskinesia, melanoma risk, dizziness, nausea, pain, headache

insomnia, rhinitis, skin disorder, back pain, dyspepsia

hallucinations, confusion, dry mouth

vivid dreams, buccal mucosa irritation, compulsive behaviors



v. contraindications: pheochromocytoma, renal or hepatic impairment, cardiovascular or cerebrovascular disease

vi. nursing care

AVOID abrupt withdrawal

give with breakfast and lunch

AVOID giving with MAOIs, meperidine

reinforce client teaching

report severe headache, severe hypertension, palpitations

AVOID foods with tyramine (aged cheeses, sausage/salami, beer/wine, avocados/bananas/raisins, pickled
herring)

change positions slowly, ask for help getting up





d. type: catechol O-methyl transferase (COMT) inhibitor

i. action: increases availability of dopamine by inhibiting COMT, may allow increased dosing of levodopa

ii.
examples

tolcapone (Tasmar) 100 mg by mouth three times a day
Black Box Warning - hepatotoxicity
238


entacapone (Comtan) 200 mg by mouth with each dose of levo/carbidopa dose; maximum: 1600 mg/day


iii. use: Parkinson's disease adjunct treatment

iv. adverse effects

orthostatic hypotension, dyskinesia, syncope,hallucinations, rhabdomyolysis

most common: nausea/vomiting, hypokinesia/hyperkinesia, diarrhea, urine discoloration


v. contraindication: hepatic impairment, concurrent CNS depressant or alcohol use

vi. nursing care

assist health care team to establish baseline data and check signs and symptoms of orthostatic hypotension,
especially during dose titration

provide assistance for ambulation while initiating therapy

assist health care team to implement client teaching plan

sweat and urine may change color

change positions slowly, ask for help before getting up

AVOID abrupt withdrawal





2. Type: anticholinergic agents

a. action: decreases excess cholinergic effect of dopamine deficiency by competing with acetylcholine (ACh) for
muscarinic receptor sites

b.
examples

i. benztropine (Cogentin) 1-2 mg PO/IM/IV every evening

ii. trihexyphenidyl (Artane) 6-10 mg by mouth daily divided in three doses


c. uses: parkinsonism, extrapyramidal reactions, acute dystonic reactions, idiopathic Parkinson disease

d. adverse effects

i. hyperthermia, heat stroke, neuroleptic malignant syndrome, tardive dyskinesia

ii. most common: xerostomia, blurred vision, dizziness, nausea, anxiety, confusion

iii. other: anticholinergic psychosis, paradoxical bradycardia


e. contraindications: angle-closure glaucoma, elderly, glaucoma, cardiac disease, hypertension, renal or hepatic
impairment

f. nursing care

i. assist the health care team to establish baseline data and monitor gonioscope and intraocular pressure at regular
intervals

ii. assist health care team to implement client teaching plan

AVOID abrupt withdrawal

avoid becoming overheated or dehydrated during hot weather

give with food





C. General anesthetics

1. General

a. action

i. central nervous system depression for invasive procedures and surgery

ii. rapid distribution to brain and spinal cord resulting in rapid onset and short duration of action


b. uses: used in combination with local anesthetics, opioids, anticholinergics, and neuromuscular blockers to achieve
analgesia, unconsciousness, muscle relaxation, and amnesia during surgery

c. types

i. parenteral: short-acting barbiturates methohexital (Brevital)
239

Black Box Warning - appropriate uses, benzodiazepines Midazolam (Versed), opioids Fentanyl, sedative-
hypnotic propofol (Diprivan)

ii.
inhalation: stable gases (nitrous oxide), volatile gases (halothane)


d. adverse effects

i. life-threatening: respiratory depression, cardiorespiratory arrest, circulatory depression, cardiovascular collapse,
arrhythmias, seizures, bronchospasm

ii. most common: hypotension, excitatory phenomena, thrombophlebitis, tachycardia, bradycardia, dyspnea


e. contraindications

i. history of malignant hyperthermia

ii. hepatic or renal failure, severe cardiovascular disease, hypotension, shock

iii. status asthmaticus, increased intracranial pressure, myasthenia gravis


f. nursing care

i. observe RN establish baseline data and monitor - airway, vital signs, SaO
2
, level of consciousness

ii. verify preoperative evaluation of client by anesthesia provider and surgeon

iii. general anesthetics potentiate the effects of one another - used only by specially trained personnel

iv. have emergency equipment and drugs at the bedside

v. observe RN implement client teaching: preoperative instructions

do not eat or drink 6 to 8 hours before the procedure

take medication before procedure as directed by provider - oral drugs can be taken with small sip of
water

arrange chaperone for 24 hours after anesthesia

arrange for transportation home after procedure






2. Parenteral anesthetic agents

a. type: barbiturates

i.
examples

PENTobarbital (Pentothal) 100-500 mg IV

secobarbital (Seconal)


ii. use: in combination with inhalation anesthetics for induction and maintenance of surgical anesthesia (hypnotic and
sedative effects)


b. type: benzodiazepine

i.
example: midazolam (generic) 0.3-0.35 mg/kg IV
Black Box Warning - appropriate use, respiratory depression/arrest risk, individualize IV dose

ii. use: procedural sedation, preoperative sedation, anesthesia induction


c. type: opioids

d. type: propofol

i.
example: propofol (Diprivan) 2-2.5 mg/kg IV

ii. use: anesthesia induction, anesthesia maintenance, monitored anesthesia care induction and maintenance, ICU
sedation

iii. adverse effects

life-threatening: bradycardia, asystole, cardiac arrest, seizures, pulmonary edema

most common: injection site reaction, hypotension, involuntary muscle movements

240


iv. contraindications: hypersensitivity to eggs, soy or soybeans, glycerol; labor & delivery

v. nursing care: observe RN administer immediately after removing from sterile packaging, do not use past expiration
date




3. Inhalation anesthetics

a. type: stable anesthetic gases

i. action: severe central nervous system depression to induce and maintain unconsciousness

ii.
example: nitrous oxide - weak gas, low toxicity, and short acting (with strong analgesic properties)

iii. adverse effects: nausea and vomiting


b. type: volatile gases

i. action: stabilizing effect on postjunctional membrane and acts synergistically with competitive blocking agents

ii.
examples

halothane (Fluothane)

enflurane (Ethrane)

sevoflurane (Ultrane)


iii. uses: induction and maintenance of general anesthesia

iv. adverse effects

life-threatening: hypotension, respiratory depression, malignant hypothermia, hepatotoxicity

other: nausea, vomiting


v. nursing care

observe RN establish baseline data and monitor airway, vital signs

remain at bedside until client maintains airway and spontaneous respirations

collaborate about need for supplemental oxygen and ventilatory support

rapid onset and recovery





4. Perioperative emergency drugs

a. type: hydantoin

i. action: interferes with intracellular release of calcium, slows catabolism in malignant hyperthermia

ii.
example: dantrolene (Dantrium, Revonto) 100 mg by mouth 2 to 4 times daily
Black Box Warning - hepatotoxicity

iii. uses: chronic spasticity, malignant hyperthermia

iv. adverse effects

life-threatening: hepatotoxicity, pleural effusion, heart failure, aplastic anemia, seizures

most common: drowsiness, dizziness, weakness, malaise, fatigue, diarrhea

other:injection site reaction and thrombophlebitis from IV use


v. contraindications: spasticity-dependent posture, balance or function, CNS depressant or alcohol use

vi. nursing care

observe RN establish baseline data and monitor liver function tests

screen clients for client or family history of malignant hyperthermia

reinforce client teaching

report lack of improvement or worsening of findings, abdominal pain, jaundice, dark urine or stool, rash,
itching

take only as directed and do not double dose
241


AVOID alcohol, central nervous system depressants

wear sunscreen






b. type: anticholinergic agent (see Epocrates Online for greater detail)

i. action: blocks action of acetylcholine

ii.
example: atropine (Atropine)

iii. use: reduce respiratory secretions, reduce vagal tone


c. type: opioid antagonist

i. action: competes with opioids for opioid receptors

ii.
example: naloxone (Narcan)

iii. use: to reverse CNS and respiratory depression associated with opioid analgesics


d. type: cholinergic agent; anticholinesterase

i. action: inhibits destruction of acetylcholine

ii.
example: edrophonium chloride (Tensilon)

iii. use: antagonist of curare, diagnostic for myasthenia gravis


e. type: benzodiazepine receptor antagonist

i. action: antagonizes the action of benzodiazepines on the central nervous system

ii.
example: flumazenil (Romazicon) 0.2-0.5 mg IV every minute
Black Box Warning - seizure risk

iii. use: to reverse respiratory and CNS depression of benzodiazepines



D. Therapeutic classification: local anesthetic agents

1. Action: loss of sensation to a region of the body

2.
Examples

a. type: esters - procaine (Novocaine)

b. type: amines

i. bupivacaine (Marcaine)
Black Box Warning - appropriate and obstetrical use

ii. lidocaine (Lidocaine)



3. Uses

a. local, regional, spinal anesthesia

b. status epilepticus, ACLS VF/pulseless VT

c. ventricular arrhythmias, pain related to herpes zoster, post-herpetic neuralgia, cancers and intractable pain


4. Adverse effects

a. life-threatening: CNS toxicity, myocardial depression, convulsions, unconsciousness, anaphylactoid reactions,
respiratory distress, heart block, severe hypotension, bradycardia, ventricular arrhythmias, cardiac arrest

b. most common: nervousness, dizziness, blurred vision, tremor, drowsiness

c. other: nausea/vomiting, chills, pupil constriction


5. Contraindications: hypersensitivity to ester anesthetics

242

6. Nursing care

a. keep emergency equipment at bedside

b. protect client from injury until complete return of sensation and function

c. observe RN provide client teaching

i.
ask for help before trying to get up

ii. effects of local agent and anticipated return of sensation and function





E. Therapeutic classification: cholinergic agents

1. Type: direct-acting cholinergic agonists

a. action: mimics the action of acetylcholine (ACh) by stimulating postsynaptic muscarinic receptors

b.
example: bethanechol (Urecholine) 10-50 mg by mouth 3 to 4 times per day

c. uses: urinary retention, neurogenic bladder, chronic GERD, thymic carcinoma (TCA) adjuvant treatment,
phenothiazine adjuvant treatment

d. adverse effects

i. life-threatening: bronchospasm, hypotension, tachycardia, seizures

ii. most common: abdominal cramps/discomfort/pain, nausea, belching, borborygmi, urinary urgency

iii. other: diarrhea, salivation, headache, hypotension, vasomotor response, malaise, flushing, diaphoresis, miosis,
lacrimation


e. contraindications: bladder neck obstruction, recent bladder or GI surgery, GI obstruction, peptic ulcer disease

f. nursing care

i. catheterization may be ordered to assess postvoid residual

ii. assist health care team to implement client teaching plan

report cramping, bloody diarrhea, flushing

take on empty stomach - 1 hour before or 2 hours after meals

change positions slowly and ask for help when getting up






2. Type: indirect-acting cholinergic agents (anticholinesterase agent, cholinesterase inhibitors)

a. action: reversibly inhibits action of cholinesterase, the enzyme that degrades acetylcholine at the synaptic clef to
increase acetylcholine concentrations and improve neuromuscular impulse transmission

b.
examples

i. treatment

neostigmine bromide (Prostigmin) 45-375 mg/day in divided doses by mouth; IM or IV 0.5-2 mg every 1 to
3 hours

pyridostigmine (Mestinon) 60-180 mg 2 to 4 times daily by mouth; IV: use 1/3 of oral dose

ambenonium chloride (Mytelase) 1-2 grams IV, may repeat in hour; given with atropine IV


ii. diagnosis: edrophonium chloride (Tensilon) 2 mg rapid IV bolus


c. uses

i. diagnosis and treatment of myasthenia gravis, diagnosis of myasthenic crisis

ii. urinary retention prophylaxis and treatment

iii. nondepolarizing neuromuscular blocking agents reversal


d. adverse effects

i. life-threatening: severe cholinergic reaction, arrhythmias, bradycardia, hypotension, respiratory paralysis, seizures,
laryngospasm, bronchospasm

ii. other
243


lacrimation, pupillary constriction, accommodation spasm, diplopia, conjunctival hyperemia, dysarthria,
dysphonia, dysphagia, increased pulmonary secretions, increased GI secretions

reverses therapeutic effect of phenothiazines, antihistamines, and tricyclic antidepressants




e. contraindications

i. peritonitis

ii. bradycardia, hypotension

iii. obstruction of gastrointestinal or genitourinary tract


f. nursing care

i.
assist health care team to establish baseline data and monitor creatinine

monitor for weakness 1 hour after therapy: may indicate cholinergic crisis (overdose of cholinesterase inhibitor)

monitor for weakness 3 hours after therapy: may indicate myasthenia crisis (underdose)


ii. carefully review drug label for correct dosage and concentration

iii. keep atropine, airway, oxygen, and Ambu bag at bedside


Findings of insufficient medication (myasthenic crisis) and excessive medication (cholinergic crisis) can present in
similar ways, including bronchospasm with wheezing, respiratory failure, diaphoresis, and cyanosis. A tensilon test
is used to differentiate between the two; if no improvement is seen after administering edrophonium (Tensilon),
then cholinergic crisis is assumed.



3. Type: centrally-acting cholinesterase inhibitors

a. action: blocks cholinesterase activity at the synaptic cleft resulting in elevated acetylcholine levels

b.
examples

i. rivastigmine (Exelon): 1.5-6 mg by mouth twice daily

ii. galantamine (Razadyne, Razadyne ER): 8-12 mg by mouth twice daily; ER 16-24 mg by mouth

iii. donepezil (Aricept): 5-10 mg by mouth at bedtime
Complementary and Alternative Medicine
Coenzyme Q10, coral calcium, ginkgo biloba, huperzine A, omega-3 fatty acids are being used to help with
symptoms of dementia (Alzheimer's Association).



c. uses: mild-moderate Alzheimer dementia, mild-moderate Parkinson disease dementia, moderate-severe Alzheimer
dementia

d. contraindication: cardiac conduction defects, asthma or chronic obstructive pulmonary disease, GI ulcer risk

e. nursing care

i. assist health care team to establish baseline data and monitor signs and symptoms of GI bleed

ii. fall precautions

iii.
give rivastigmine (Exelon) and galantamine (Razadyne) with food

iv. assist health care team to implement client teaching plan

report excessive salivation, diarrhea, emesis, and frequent urination

apply artificial tears for dry eyes

ask for help before getting up, change positions slowly






244


4. Type: N-methyl-D-aspartate (NMDA) glutamate-receptor antagonist

a. action: blocks NMDA receptors to reduce rate of clinical deterioration

b.
example: memantine (Namenda) 10 mg by mouth twice daily

c. use: moderate-severe Alzheimer's dementia

d. adverse effects: Stevens-Johnson syndrome, headache, dizziness



5. Type: cholinesterase reactivator

a. action: restores response to neuromuscular stimulation by reactivating cholinesterase

b.
example: pralidoxime (2-PAM, Pralidoxime Auto-Injector, Protopam) 1-2 grams IV, then 250 mg IV every 5
minutes until symptoms reverse

c. use

i. treatment of organophosphate insecticide and nerve agent poisoning

ii. treatment of cholinesterase inhibitor overdose




IV. Managing musculoskeletal conditions

A. Therapeutic classification: neuromuscular blocking agents

1. Type: depolarizing

a. action: competes with acetylcholine for acetylcholine-receptor sites resulting in muscle cell depolarization,
initial contraction, and flaccid paralysis

b.
example: succinylcholine (Anectine) 0.3-1.1 mg/kg IV
Black Box Warning - cardiac arrest risk in pediatric clients

c. uses

i. neuromuscular blockade induction and maintenance

ii. rapid sequence intubation


d. adverse effects

i. life-threatening: prolonged paralysis, respiratory depression, apnea, malignant hyperthermia, arrhythmias

ii. most common: postoperative muscle pain, muscle fasciculation, jaw rigidity, elevated intraocular pressure

iii. other: hypersensitivity reaction, anaphylaxis, rhabdomyolysis with hyperkalemia, myoglobinemia


e. contraindications

i. malignant hyperthermia history, myopathy, acute major trauma or burns

ii. acute upper motor neuron injury, angle-closure glaucoma, penetrating eye injury


f. nursing care

i. observe RN establish baseline data and continually monitor vital signs, ECG, airway, ventilation, and SaO
2


ii. observe RN establish baseline data and monitor peripheral nerve stimulation, serum electrolytes

iii. remain at bedside during infusion

keep emergency equipment and drugs at the bedside

maintain oxygenation and ventilation while client is being treated


iv. administer sedation and analgesia to clients while being treated - client is conscious and alert without
sedation

v. fasciculations subside rapidly after initial administration

vi. observe RN implement client teaching plan: etiology of muscle pain, reassurance about drug-induced,
temporary paralysis






245

B. Therapeutic classification: skeletal muscle relaxing agents

1. Type: cyclobenzaprine

a. centrally acting

i. action: acts on central nervous system at the brain stem to relieve muscle spasm without loss of function; similar
in structure to tricyclic antidepressants

ii.
examples

cyclobenzaprine (Amrix, Fexmid, Flexeril) 5-10 mg by mouth 3 times daily

carisoprodol (Soma) 350 mg by mouth 3 times daily and at bedtime


iii. uses: muscle spasm, acute musculoskeletal pain

iv. adverse effects

life-threatening: seizures, cardiac conduction disturbances, arrhythmias, myocardial infarction, stroke,
heat stroke

most common: drowsiness, dry mouth, dizziness fatigue, headache, constipation

other: psychosis, hepatitis

most muscle relaxants are considered high risk drugs in the elderly (based on the Beers Criteria) due
to anticholinergic effects, sedation and weakness


v. contraindications: acute recovery myocardial infarction, cardiac conduction disturbances, arrhythmias, heart
block, heart failure, hyperthyroidism

vi. nursing care

contraindicated with all MAOIs and potassium salts

collaborate with physical therapy and provider for adjunct therapy to decrease need for muscle
relaxants

assist health care team to implement client teaching plan

change positions slowly, ask for help before getting up

AVOID dangerous activity, avoid alcohol and other central nervous system depressants

establish regular bowel habits including fluids, fiber, and physical activity







b. direct acting

i. action: interferes with calcium release in muscle fiber to prevent muscle contraction

ii.
examples

dantrolene (Dantrium) 100 mg by mouth 2 to 4 times daily
Black Box Warning - hepatotoxicity

onabotulinum toxin A (Botox, Botox Cosmetic) IM or injectable dose varies
Black Box Warning - distant spread of toxin effect


iii. uses

chronic spasticity, upper limb spasticity

blepharospasm, primary axillary hyperhidrosis

cervical dystonia, migraine headache prophylaxis


iv. adverse effects
hypersensitivity, anaphylaxis, spread of toxin effect, hepatotoxicity
other: drowsiness, dizziness, weakness, malaise, fatigue, diarrhea


v. contraindications: active hepatic disease

vi. nursing care

assist health care team to establish baseline data and check at regular intervals liver function tests
246


prevent extravasation when administered IV

assist health care team to implement client teaching plan

AVOID alcohol and other central nervous system depressants

report fever, rash, dark urine or stool, jaundice




2. Type: benzodiazepines

a.
example: diazepam (Valium)

b. very effective muscle relaxant, as well as an effective antianxiety agent and anticonvulsant


C. Type: nonsteroidal anti-inflammatory drugs (NSAIDs)

1. information common to NSAIDs

a. action

i. inhibits synthesis of prostaglandins

ii. analgesic, antipyretic, anti-inflammatory agent


b. uses

i. mild to moderate pain of musculoskeletal disorders including osteoarthritis (OA) and rheumatoid arthritis (RA)

ii. pleuritis, pericarditis

iii. primary dysmenorrhea, uterine relaxation


c. adverse effects

i. life-threatening: bleeding, bone marrow depression, fluid retention, hypertension, decreased renal blood flow
(especially in older clients)

ii. most common: irritation and erosion of GI tract resulting in bleeding, nausea

iii. other: headache, fatigue, rash, oral lesions, anaphylaxis


d. contraindications

i. hypertension, renal dysfunction

ii. bleeding disorders, recent trauma or surgery


e. nursing care

i.
assist health care team to establish baseline data and check periodically blood pressure, appearance of
stool, complete blood count, liver function

ii. assist health care team to implement client teaching plan
take only as directed
drink 6 to 8 glasses of water daily
report use of NSAIDs to all providers

AVOID over-the-counter drugs

monitor for bleeding

do not crush or chew sustained release forms

report headache, weight gain, fever, rash, or swelling






2. Sub-type: acetic acid

a.
examples

i. diclofenac sodium (Voltaren, Voltaren XR) 50 mg by mouth 2 to 3 times daily
Black Box Warning - cardiovascular and GI risk

ii. indomethacin 50-200 mg by mouth 2 to 3 times daily
247

Black Box Warning - cardiovascular and GI risk


b. adverse effects: GI bleed, GI ulceration/perforation, myocardial infarction, stroke, hypertension, heart failure

c. contraindications: ASA or NSAID-induced asthma or urticaria

d. nursing care

i.
assist health care team to establish baseline data and check at regular intervals BUN/creatinine, complete
blood count, chemistry profile

ii. monitor ophthalmic exams during long term treatment




3. Sub type: naphthaleneacetic acid derivative

a.
example: nabumetone 1000-2000 mg by mouth daily divided in 1 to 2 doses
Black Box Warning - cardiovascular and GI risk

b. adverse effects: GI bleed, GI ulceration/perforation, myocardial infarction, stroke, hypertension, heart failure



4. Sub type: pyrrolizine carboxylic acid

a.
example: ketorolac (Toradol) 60 mg IM 0r 30 mg IV x 1 dose
Black Box Warning - appropriate use, GI, cardiovascular, renal, bleeding and labor/delivery risk, concomitant
NSAID use, intrathecal/epidural use, hypersensitivity reaction and special populations

b. uses: moderate-severe pain



5. Sub type: oxicams

a.
meloxicam (Mobic) 7.5-15 mg by mouth daily
Black Box Warning - cardiovascular and GI risk


b.
piroxicam (Feldene) 20 mg by mouth daily
Black Box Warning - cardiovascular and GI risk

c. use: osteoarthritis, rheumatoid arthritis, ankylosing spondylitis

d. adverse effects: GI bleed, GI ulceration/perforation, myocardial infarction, stroke, hypertension, heart failure

e.
assist health care team to establish baseline data and check at regular intervals blood count, chemistry profile with
long term treatment, blood pressure



6. Sub type: propionic acids

a.
examples

i. ibuprofen (Advil, Advil Migraine, Caldolor, Children's Advil, Children's Motrin, Infants' Advil, Infants' Motrin, Junior
Strength Advil, Junior Strength Motrin, Midol Liquid Gels, Motrin IB, PediaCare Children's Pain Reliever/Fever
Reducer IB, PediaCare Infants' Pain Reliever/Fever Reducer IB) 300-800 mg by mouth 3 to 4 times daily, not to
exceed 3200 mg in 24 hours
Black Box Warning - cardiovascular and GI risk

ii. naproxen (EC-Naprosyn, Naprosyn) 250-500 mg by mouth every 12 hours, up to 1500 mg in 24 hours
Black Box Warning - cardiovascular and GI risk



b. nursing care
248


i. maximum dose: 3200 mg/day

ii.
give with food




7. Sub-type: COX-2 inhibitor

a. action: selectively inhibits COX-2; inhibits synthesis of prostaglandins; analgesic, antipyretic, anti-inflammatory

b.
example: celecoxib (Celebrex) 200 mg by mouth daily
Black Box Warning - cardiovascular and GI risk

c. uses: osteoarthritis, rheumatoid arthritis,familial adenomatous polyposis, ankylosing spondylitis, dysmenorrhea, acute
pain

d. adverse effects

i. GI bleed, GI ulceration/perforation, myocardial infarction, stroke, thromboembolism, hypertension, heart failure

ii. headache, dyspepsia, upper respiratory infection, diarrhea, abdominal pain, nausea/vomiting


e. contraindications

i. ASA or NSAID-induced asthma or urticaria

ii. aspirin triad, 3rd trimester pregnancy, perioperative use for CABG surgery


f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and periodically thereafter
pain, complete blood count, liver and renal function tests, gastrointestinal upset and bleeding

ii. assist health care team to implement client teaching plan

take with full (6-8 ounces) glass of water or milk and with food

AVOID aspirin and other NSAIDs





8. Sub-type: salicylates, acetylated

a.
aspirin (BAYER Advanced Aspirin Extra Strength, Bayer Advanced Aspirin Regular Strength, Bayer Aspirin, Bayer
Aspirin Extra Strength, Bayer Extra Strength Plus, Bayer Low Dose Aspirin, Ecotrin, Ecotrin Low Strength, St Joseph)
325-600 mg by mouth every 4 hours as needed

b. uses: analgesia, reduction of inflammation, reduction of fever, decreased incidence of transient ischemic attacks and
myocardial infarction

c. adverse effects: tinnitus, GI bleeding, anemia, hemolysis, hepatotoxicity rash

d. contraindications: hypersensitivity to ASA or other salicylates, bleeding disorders or thrombocytopenia; history of GI
bleeding or ulcer disease, chronic alcohol abuse; may increase risk of Reye's syndrome in children with viral infections

e. nursing care

i. may increase anticoagulant effect and bleeding risk with warfarin, heparin, feverfew, garlic, ginger, and ginkgo

ii. give after meals or with food or an antacid to minimize gastric irritation

iii.
monitor creatinine at baseline, serum drug levels




9. Sub-type: salicylates, non-acetylated

a.
example: choline magnesium trisalicylate 1500 mg by mouth twice daily

b. uses: analgesia, reduction of inflammation, reduction of fever

c. adverse effects: tinnitus, GI bleeding, hepatotoxicity, laryngeal edema

d. contraindications: hypersensitivity to ASA or other salicylates, cross-sensitivity with other NSAIDs

249

e. nursing care

i.
monitor creatinine at baseline, serum drug levels

ii. therapeutic drug levels 150-300 mcg/mL; toxic >300 mcg/mL




D. Related anti-inflammatory therapies

1. Type: heavy metal (gold)

a. action: modulates immune response and inhibits inflammation; may suppress phagocytosis and prostaglandin
synthesis

b.
example: gold sodium thiomalate (Myochrysine) 10 mg/week IM for week 1, then 25 mg IM for week 2, then
25-50 mg IM every week
Black Box Warning - appropriate use

c. uses: initial and maintenance treatment for rheumatoid arthritis

d. adverse effects

i. life-threatening: bone marrow depression, nephrotic syndrome; gold bronchitis and pneumonitis

ii. most common: hypersensitivity: flushing, fainting, dizziness

iii. other: Guillain-Barre syndrome, anaphylaxis, nitritoid reaction, aplastic anemia, angioedema, ocular gold
deposits


e. contraindications: severe prior gold toxicity, severe debilitation, systemic lupus erythematosus (SLE), severe
hypertension, blood dyscrasia, rash

f. nursing care

i.
assist health care team to establish baseline data and check periodically urinalysis, complete blood count
with differential, platelets

ii. administration

may give deep IM injection

do not use injectable if darker than pale yellow

client to remain seated or in bed for 30 minutes following injection


iii.
antidote : dimercaprol (British anti-Lewisite or BAL in oil) 2.5-3 mg/kg IM every 6 hours for 8 doses

iv. assist health care team to implement client teaching plan

protect skin from sun with sunscreen or clothing

report rapid improvement in joint edema, pruritus, easy bruising






2. Type: tumor necrosis factor (TNF) (genetically engineered) antagonist

a. action: acts as receptor for TNF to prevent related damage

b.
example: etanercept (Enbrel) 50 mg SubQ weekly
Black Box Warning - serious infection risk and malignancy

c. uses: ankylosing spondylitis, moderate -to-severe chronic psoriasis plaque, psoriatic arthritis, mod-severe rheumatoid
arthritis

d. adverse effects

i. serious infection, sepsis, opportunistic infection, tuberculosis, malignancy

ii. lymphoma, leukemia, HBV reactivation, heart failure

iii. injection site pain, localized erythema, infection, upper respiratory infection


e. contraindications: concurrent live vaccination, active infection, Wegener's granulomatosis on immunosuppressants

250

f. nursing care

i.
assist health care team to establish baseline data and check at regular intervals complete blood count with
differential, hepatitis B surface antigen (HBsAG)

ii. administer a tuberculin skin test prior to start of treatment

iii. administration: rotate sites, reconstitute slowly and gently rotate vial for clear solution

iv. assist health care team to implement client teaching plan

treatment must continue uninterrupted to achieve therapeutic effect

AVOID live vaccines, influenza nasal vaccine, BCG live intravesical

subcutaneous injection technique: rotate injection site by at least 1 inch for each injection in to abdomen,
thigh or upper arm





3. Type: chelating agent

a. action: combines with cystine hydrochloride to prevent stone formation and inhibit collagen formation; related to
penicillin without antimicrobial properties

b.
example: penicillamine (Cuprimine) 250-1000 mg by mouth 4 times daily
Black Box Warning - appropriate use

c. use: cystinuria, severe rheumatoid arthritis, Wilson disease, arsenic poisoning, lead toxicity, primary biliary cirrhosis

d. therapeutic effect may take 3 months to appear

e. adverse effects

i. thrombocytopenia, leukopenia, aplastic anemia

ii. anorexia, epigastric pain, nausea, vomiting, diarrhea

iii. proteinuria, thrombocytopenia, leukopenia


f. contraindications

i. pregnancy, breast feeding

ii. concurrent gold salt, cytotoxic and antimalarial drug use

iii. hypersensitivity to penicillin, renal impairment


g. nursing care

i. assist health care team to establish baseline data and check at regular intervals thereafter

skin/lymph nodes, temperature

liver function tests, creatinine, urinalysis (for protein), complete blood count with differential


ii.
administer on empty stomach 1 hour before or 2 hours after meals; give with pyridoxine 25 mg daily

iii. assist health care team to implement client teaching plan

skin care

take temperature at bedtime

report bleeding, rash, sore throat, fever

take as directed, do not interrupt therapy





E. Therapeutic classification: anti-gout agents

1. Type: uricosuric agent

a. action: inhibits tubular reabsorption of uric acid, increases its excretion, and lowers serum uric acid level

b.
example: probenecid (Benemid) 250-500 mg by mouth twice daily

c. use: prevent recurrence of gouty arthritis, penicillin adjunct

251

d. adverse effects

i. hemolytic anemia, aplastic anemia, hepatic necrosis, anaphylaxis

ii. headache, dizziness, anorexia, nausea

iii. vomiting sore gums, urinary frequency


e. contraindications

i. creatinine clearance <50, acute gout attack

ii. uric acid nephrolithiasis, blood dyscrasias


f. nursing care

i.
assist health care team to establish baseline data and check prior to beginning therapy and at regular
intervals thereafter creatinine, complete blood count

ii. administer lowest effective dose

iii.
collaborate with health care team for purine-restricted diet

iv. assist health care team to implement client teaching plan

do not interrupt therapy

AVOID NSAIDs

drink 3000 mL of fluids each day to keep urine dilute, especially during the night, avoiding caffeinated
beverages






2. Type: colchicine

a. action: inhibits formation of lactic acid in leukocytes resulting in decreased phagocytosis and joint inflammation

b.
example: colchicine (Colcrys) 1.2 mg by mouth x 1 dose, then 0.6 mg by mouth 1 hour later x 1 dose

c. uses: acute gout, gout prophylaxis, familial Mediterranean fever, Behcet's disease, recurrent pericarditis

d. adverse effects

i. life-threatening: myelosuppression, leukopenia, thrombocytopenia, granulocytopenia

ii. other: diarrhea, nausea/vomiting, cramping, abdominal pain, fatigue, headache


e. contraindications: hepatic or renal impairment

f. nursing care

i.
assist health care team to establish baseline date and check before beginning therapy and periodically
thereafter creatinine, complete blood count

ii.
collaborate with health care team for purine-restricted diet

iii. administration: may give with food

iv. assist health care team to implement client teaching plan

report pain, rash, erythema, sore throat, bleeding or bruising

AVOID alcohol and over-the-counter drugs





3. Type: antihyperuricemic agent - xanthine oxidase inhibitor

a. action: reduces endogenous uric acid inhibiting xanthine oxidase (converts hypoxanthine to uric acid in purine
metabolism)

b.
example: allopurinol (Aloprim, Zyloprim) 200-600 mg by mouth daily in 1 to 4 divided doses

c. uses

i. gout prophylaxis

ii. chem0related hyperuricemia
252


iii. recurrent calcium oxalate calculi


d. adverse effects

i. hypersensitivity syndrome, severe skin reactions, exfoliative dermatitis

ii. toxic epidermal necrolysis, Stevens-Johnson syndrome

iii. rash, diarrhea, nausea, gout flare


e. contraindications

i. renal impairment or risk, hepatic impairment

ii. concurrent myelosuppressive agents


f. nursing care

i.
assist health care team to establish baseline data and check before beginning therapy and at regular intervals
thereafter BUN/creatinine, liver function tests

ii. client teaching

promptly report rash, fever

protect eyes from ultraviolet rays

AVOID aspirin and acetaminophen

drink 3000 mL of fluid daily (avoid alcohol and caffeinated beverages)

life threatening reaction may occur 2 to 4 weeks after initiation of therapy - malaise, fever, aching, rash,
deteriorating renal function





4. Type: antihyperuricemic agent - enzyme

a. action: facilitates conversion of uric acid to allantoin

b.
example: rasburicase (Elitek) 0.2 mg/kg IV daily up to 5 days
Black Box Warning - anaphylaxis, hemolysis, methemoglobinemia, uric acid test interference

c. uses: chemo-related hyperuricemia

d. adverse effects

i. hypersensitivity reaction, anaphylaxis, hemolysis

ii. methemoglobinemia, neutropenia, sepsis, pulmonary hemorrhage

iii. fever, headache, anxiety, abdominal pain, constipation


e. contraindications: G6PD deficiency, hemolysis or methemoglobinemia history

f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals during
therapy for pain, hemolysis, anoxia

ii. monitor for signs of allergic reactions

iii. administration: gently rotate vial, do not shake or swirl, should be colorless, dilute in 0.9% NaCl




F. Therapeutic classification: bone resorption inhibitors

1. Type: calcitonin

a. action: opposes action of parathyroid hormone to decrease serum calcium and increase bone density with calcium
deposition

b.
examples

i. calcitonin-salmon (Miacalcin) 100 units SubQ/IM 3 x per week

ii. calcitonin-salmon (Miacalcin Nasal) 200 units/spray 1 spray each nostril daily


c. uses: hypercalcemia, Paget's disease, post-menopausal osteoporosis, hypercalcemia

d. adverse effects
253


i. life-threatening: anaphylaxis, hypersensitivity reaction, bronchospasm, angioedema

ii. other:

nausea/vomiting, injection site reaction, flushing, rash, nocturia, earlobe pruritus, warmth sensation

hypocalcemic tetany (nervousness, irritability, paresthesia, muscle twitching, tetanic spasms)



e. contraindications: elderly patients, prior bisphosphonate use

f. nursing care

i. assist health care team to establish baseline data and check before beginning and at regular intervals during
therapy urine sediment

ii.
keep calcium gluconate immediately available if hypocalcemic tetany develops

iii. assist health care team to implement client teaching plan

subcutaneous injection technique

include weight bearing exercise in daily routine

include calcium and vitamin D rich foods in diet






2. Type: bisphosphonates

a. action: inhibit bone resorption and do not inhibit bone formation and mineralization

b.
examples

i. alendronate (Fosamax) 70 mg by mouth weekly

ii. risedronate (Actonel, Atelvia) 35 mg by mouth weekly

iii. zoledronic acid (Reclast, Zometa) 4 mg IV


c. uses

i. postmenopausal osteoporosis treatment, malignant hypercalcemia

ii. prevention postmenopausal osteoporosis, solid tumor bone metastases

iii. steroid-induced osteoporosis, male osteoporosis, multiple myeloma

iv. Paget bone disease


d. adverse effects

i. dysphagia, esophagitis, esophageal ulcer, erosion, perforation, or stricture

ii. other: gastric/duodenal ulcer, hypocalcemia, abdominal pain and acid regurgitation


e. contraindications

i. pregnancy, breastfeeding

ii. severe renal impairment, hypovolemia or dehydration


f. nursing care

i. assist health care team to establish baseline data and check before beginning and at regular intervals during therapy

bone density

creatinine prior to each does, calcium, electrolytes, magnesium, phosphate, hematocrit & hemoglobin

dental exam prior to treatment


ii. assist health care team to implement client teaching plan

calcium and vitamin D supplements recommended

therapy most effective when combined with weight bearing exercise

take first thing in the morning, 30 minutes before breakfast (or other medications) with 6-8 ounces
plain water; remain upright for at least 30 minutes after administration

if dose is missed, skip dose; do not double dose



254


V. Managing integumentary conditions

A. Therapeutic classification: scabicide, pediculicide

1. Type: chlorinated hydrocarbon

a. action: stimulates nervous system of arthropods to death

b.
example: permethrin topical (Nix, Elimite) 5% cream or 1% lotion

c. uses: scabies, pediculosis capitis or pubis

d. adverse effects: burning, pruritus, erythema, numbness and tingling

e. contraindications: infants, history of hypersensitivity

f. nursing care

i. perform full body scan for nits, lice, or scabies

ii. do not apply to broken skin, avoid application to eyes

iii. cleanse and dry skin before application

iv. assist health care team to implement client teaching plan

wear rubber gloves to administer

treat sexual contacts simultaneously

itching may continue for 4 to 6 weeks after treatment

wash clothing in hot water, dry thoroughly

pediatric use and frequency of treatment
refer to package insert
allow proper time span between applications

remove drug from skin after specified period to prevent toxicity

do not apply to face or mucus membranes; gently and thoroughly cleanse area for accidental
application, rinse very well







B. Therapeutic class: anti-infectives

1. Type: sulfa drugs

a. action: bacteriostatic, competitively inhibits bacterial or fungal dihydropteroate synthase

b.
example: silver sulfadiazine topical (Silvadene) 1 % cream

c. uses: 2nd-3rd degree burns

d. adverse effects: erythema multiforme, neutropenia, leukopenia

e. contraindications: pregnancy, clients younger than 2 months-old, G6PD deficiency

f. nursing care

i.
assist health care team to establish baseline data and periodically monitor thereafter BUN, creatinine,
urinalysis

ii. therapeutic drug levels 8-12 mg/dL; toxic levels > 12mg/dL

iii. application

cover entire surface

cleanse surface before application; remove old ointment before applying new

apply ointment to sterile gauze before applying to surface to prevent contamination of agent






2. Type: antifungal, topical

a. action: interferes with fungal cell permeability

b.
examples
255


i. metronidazole topical (MetroCream, MetroGel, MetroLotion, Noritate) 0.75% cream, gel, lotion

ii. ketoconazole topical (Extina, Nizoral A-D, Nizoral Topical, Xolegel) 2% cream, foam, shampoo

iii. selenium sulfide topical (Selsun, Selsun Blue) 1%, 2.25% shampoo, 2.5 % lotion


c. uses: acne rosacea, tinea corporis, pedis, versicolor, and cruris; seborrheic dermatitis, dandruff/seborrhea

d. adverse effects: skin irritation, hair loss, hair discoloration

e. nursing care

i. inspect surface before administration and at regular intervals during therapy for breaks in the skin or signs of
infection

ii. assist health care team to implement client teaching plan

use sunscreen

avoid alcohol

long-term therapy is usually required

wear gloves to prevent spread of fungus

avoid concurrent use of other over-the-counter agents

report worsening of findings or fever, sore throat, rash





3. Type: antiviral

a. action: interferes with viral DNA replication

b. examples

i.
acyclovir topical 400 mg by mouth three times a day for 7 to 10 days

ii.
penciclovir topical (Denavir) 10 mg/gm cream


c. uses: HSV encephalitis, genital/mucocutaneous HSV prophylaxis,

d. varicella and herpes zoster, herpes zoster ophthalmicus, herpes labialis

e. adverse effects: hallucinations, psychosis, encephalopathy, seizures, coma

f. nursing care

i.
assist health care team to establish baseline data and periodically monitor thereafter creatinine

ii. apply ointment to glove to prevention contamination of drug and spread of infection

iii. cover lesions completely with agent; do not get in eyes

iv. gently cleanse area to remove old agent prior to application of new agent




C. Therapeutic classification: anti-inflammatory agents, topical

1. Type: glucocorticoids

2.
Examples

a. hydrocortisone (Cortaib, Cortizone) 0.5% 1% 2.5% cream lotion ointment

b. triamcinolone (Kenalog, Trianex) 0.025%. 0.1%, 0.5% cream, ointment, 0.025%, 0.1% lotion


3. Nursing care

a. assist health care team to establish baseline data and check skin before beginning and during therapy

b. assist health care team to implement client teaching plan

i.
AVOID over-the-counter drugs

ii. cleanse and dry skin before application

iii. do not apply to wounds or breaks in the skin

iv. initiate therapy as soon as findings appear
256


v. do not apply to broken skin, avoid application to eyes

vi. continue to apply agent until directed to stop; interrupted therapy may result in ineffective therapy





D. Type: anesthetic agents, local anesthetics, topical

1.
Examples: lidocaine (Lidocaine viscous, Numby, Derma Flex)

2. Nursing care: protect client from injury due to impaired cutaneous sensation



VI. Managing gastrointestinal conditions

A. Therapeutic classification: antiemetics

1. Information common to antiemetics

a. action: depresses vomiting center

b. uses: motion sickness, nausea, nausea associated with chemotherapy, postoperative nausea

c. adverse effects

i. tachycardia, hypotension, sedation

ii. dry mouth, dry eyes, blurred vision, constipation, urinary retention


d. contraindications: narrow angle glaucoma, liver disease, intestinal obstruction, depression

e. nursing care

i. assist health care team to establish baseline data and check before initiating therapy and at regular intervals
thereafter fluid and electrolyte balance

ii. provide oral care for dry mouth

iii. verify gag reflex before administration of oral non-pharmacologic measures, e.g., tea, carbonated
beverages, crackers

iv. assist health care team to implement client teaching plan

AVOID alcohol and other central nervous system depressants

do not engage in dangerous activities; be prepared for sedation







2. Type: antihistamines

a. action: decreases vestibular stimulation by competing with histamine for H
1
-receptors

b.
example: dimenhyDRINATE (Dramamine) 50-100 mg by mouth every 4 hours

c. uses: antiemetic

d. adverse effects

i. dizziness, drowsiness, incoordination

ii. headache, epigastric discomfort

iii. dry mucus membranes, paradoxical CNS stimulation


e. nursing care

i. assist health care team to establish baseline data and check at regular intervals during therapy airway, respiratory
rate, level of consciousness

ii. administer IM or IV if vomiting

iii. do not confuse with diphenhydrAMINE (Benadryl)

iv. assist health care team to implement client teaching plan

ask for help before getting up

take 30 minutes before traveling




257

The FDA requires drug manufacturers to use Tall Man lettering for 35 look-alike generic drug names. The
distinguishing letters are capitalized to draw attention to the dissimilarities in their names and to prevent
medication errors. For example: predniSONE and prednisoLONE
Learn more about Tall Man lettering from The Food and Drug Administration (FDA) .


3. Type: anticholinergics

a. action: inhibits acetylcholine (ACh) at receptor sites to decrease secretions and stomach acids, blocks pupillary
accommodation

b.
example: scopolamine (Scopace) 0.3-0.6 mg IM/IV/SubQ as needed, 3 to 4 times daily

c. uses: nausea/vomiting prevention, anesthesia adjunct

d. adverse effects

i. life-threatening: toxic psychosis, tachycardia, seizures, heat stroke, severe hypersensitivity reaction

ii. most common: dry mouth, dry skin drowsiness, blurred vision, mydriasis

iii. other: photophobia, dizziness, flushing, tachycardia, urinary retention


e. contraindications: angle-closure glaucoma, benign prostatic hyperplasia, obstructive GI disease, obstructive uropathy,
acute myocardial infarction

f. nursing care

i.
assist health care team to establish baseline data and during therapy fluid and electrolyte balance

ii. assess for nausea, vomiting, extrapyramidal findings, urinary retention, bowel elimination pattern

iii. safely position client before subcutaneous or IV administration

iv. assist health care team to implement client teaching plan: discontinue drug and report blurred vision, severe
dizziness




4. Type: phenothiazines

a. action: depresses cerebral cortex, hypothalamus, and limbic system with strong alpha-adrenergic, cholinergic,
antipsychotic, and antiemetic properties

b.
examples

i. prochlorperazine maleate (Compazine) 5-10 mg by mouth every 4 to 6 hours
Black Box Warning - dementia-related psychosis

ii.
promethazine 12.5-25 mg PO/IM/IV every 4 to 6 hours
Black Box Warning - respiratory depression, severe tissue injury, gangrene




5. Type: serotonin (5-HT3) receptor antagonist

a. action: blocks peripheral and central serotonin action

b.
example: ondansetron (Zofran, Zofran ODT, Zuplenz) 32 mg IV x 1 dose start 30 minutes before starting
chemotherapy infusion or prior to induction of anesthesia

c. uses: severe nausea/vomiting, non-psychotic anxiety, schizophrenia, allergic conditions, motion sickness, sedation,
prevention of chemo-related nausea and vomiting, prevention of nausea and vomiting postoperatively and for
radiotherapy

d. adverse effects

i. life-threatening: severe hypersensitivity reaction, anaphylaxis, bronchospasm

ii. other: extrapyramidal symptoms, transient blindness, headache, constipation, fatigue, diarrhea


e. nursing care

i.
assist health care team to establish baseline data and check periodically thereafter fluid and electrolyte balance
258


ii. assess for nausea, vomiting, extrapyramidal symptoms

iii. first dose is administered prior to emetogenic chemotherapy

iv. client teaching: immediately report involuntary movement of eyes, face, or limbs





6. Type: combined cholinergic receptor agonist and dopamine receptor antagonist

a. action: enhances gastrointestinal response to acetylcholine resulting in increased peristalsis, relaxation of pyloric
sphincter, and blockage of chemoreceptor zone in brain

b.
example: metoclopramide (Metozolv, Reglan) 1-2 mg/kg IV every 2-3 hours
Black Box Warning - tardive dyskinesia

c. uses: GERD, diabetic gastroparesis, chemo-related nausea and vomiting prevention, postoperative nausea and
vomiting prevention, small bowel intubation, radiologic exam

d. adverse effects

i. extrapyramidal symptoms, acute dystonia, parkinsonism, tardive dyskinesia, neuroleptic malignant syndrome

ii. other: seizures, depression, suicidality, drowsiness, restlessness, fatigue, anxiety, insomnia


e. contraindications: pheochromocytoma, seizure disorder, GI bleed or perforation, GI obstruction

f. nursing care

i. assist health care team to establish baseline data and check at during therapy for nausea, vomiting, extrapyramidal
findings, tardive dyskinesia, mental status

ii. adverse effects more common in older clients

iii. do not confuse with methotrexate or metolazone (Zaroxolyn)





B. Therapeutic classification: antacids

1. Information common to antacids

a. action: neutralize gastric acid (hydrochloric acid)

b. uses: peptic ulcer disease, inflammatory conditions of gastrointestinal tract, concurrent steroid therapy

c. adverse effects

i. most common: inhibits absorption of other drugs

ii. other: constipation, diarrhea, acid rebound, metabolic acidosis, electrolyte excess, fluid retention, heart failure


d. contraindications: electrolyte imbalance, gastroparesis, renal dysfunction

e. nursing care

i.
assist health care team to establish baseline data and check before initiating therapy and periodically
thereafter serum electrolytes, acid-base balance

ii. monitor bowel elimination

iii. must be given 7 times daily to be effective, before and after meals and at bedtime

iv. administer 1 hour before or 2 hours after other drugs and do not give with enteric coated medications

v. assist health care team to implement client teaching plan

time antacids around other medication

chew tablets thoroughly, follow with 8 ounces of water






2. Type: sodium bicarbonate

a.
example: sodium bicarbonate 325 mg-2 g 1 to 4 times daily

b. uses: acute and chronic metabolic acidosis, urinary alkalinization, for antacid
259


c. adverse effects

i. life-threatening: metabolic alkalosis, exacerbation of heart failure, seizures, tetany

ii. most common: flatulence, gastric distention, edema

iii. other: twitching, hypernatremia, injection site pain, extravasation cellulitis


d. contraindications: hypochloremia, alkalosis, renal impairment, congestive heart failure, sodium

e. nursing care

i.
assist health care team to establish baseline data and check at regular intervals during therapy fluid and
electrolyte balance

ii. administration

follow oral administration with 8 ounces of water

if used to treat peptic ulcer, administer 1 to 3 hours after meals and at bedtime





3. Type: calcium carbonate

a.
example: calcium carbonate (Children's Mylanta, Children's Pepto, Maalox Children's Relief, Maalox Regular
Strength, Rolaids Extra Strength Softchews, Tums) 1-3 g by mouth 4 times daily as needed

b. uses: hyperphosphatemia, calcium supplement, osteoporosis, in combination with other antacids

c. adverse effects: constipation

d. contraindications: hypercalcemia, hyperparathyroidism, nephrolithiasis

e.
nursing care: assist health care team to establish baseline data and check serum calcium before and during
therapy



4. Type: magnesium salt

a.
examples

i. magnesium citrate 1.745 g/30 mL 150-300 mL/day divided doses 1-2 times daily

ii. magnesium hydroxide (Little Phillips', Pedia-Lax Chewable Tablets, Phillips' Chewables, Phillips' Concentrated Milk
of Magnesia, Phillips' Milk of Magnesia) 30-60 mL by mouth daily

iii.
magnesium sulfate (magnesium sulfate) 5 g IM, then 5 g IV every 4 hours, up to 40 g daily

iv. uses: acute constipation, bowel prep, ventricular arrhythmias, preeclampsia seizures, tocolysis, hypomagnesemia,
torsades de pointes


b. uses: acute constipation, bowel prep, ventricular arrhythmias, preeclampsia seizures, tocolysis, hypomagnesemia,
torsades de pointes

c. adverse effects

i. life-threatening: cardiovascular collapse, respiratory paralysis, hypothermia

ii. other: nausea, vomiting, anorexia, cramps, depressed reflexes, hypotension


d. contraindications: GI obstruction or bleed, heart block, renal failure, colostomy or ileostomy

e. nursing care

i. assist health care team to establish baseline data and check before initiating and at regular intervals during therapy

pattern of elimination

signs of magnesium toxicity, i.e., thirst, confusion, hyporeflexia

fluid and electrolyte balance

mental status

vital signs


ii.
antidote : keep calcium gluconate at the bedside during IV infusion to reverse respiratory depression or heart
260

block

iii. assist health care team to implement client teaching plan: take only as directed





5. Type: aluminum salt

a.
example: aluminum hydroxide gel (Alternagel, Amphojel) 320-1280 mg by mouth 4 times daily; give 1 to 3 hours
after meals and at bedtime

b. uses: hyperphosphatemia, GI bleeding prophylaxis

c. adverse effects

i. aluminum intoxication, osteomalacia, encephalopathy

ii. constipation, hypophosphatemia, abdominal pain


d. nursing care

i.
assist health care team to establish baseline data and check before starting and periodically during therapy
aluminum, calcium, phosphate if renal impairment

ii. assist health care team to implement client teaching plan

report black tarry stools, abdominal pain

diet: include cheese, corn, lentils, pasta, and prunes and avoid foods containing phosphorus, including dairy
products, eggs, and carbonated beverages






C. Therapeutic classification: antiulcer agents

1. Type: proton pump inhibitors

a. action: suppress the gastric acid pump by inhibiting hydrochloric acid (HCl) secretion by gastric parietal cells

b.
examples

i. omeprazole (Prilosec, Prilosec OTC) 20 mg by mouth daily for 4 to 8 weeks

ii. esomeprazole (Nexium) 20-40 mg by mouth daily for 4 to16 weeks

iii. lansoprazole (Prevacid) 15 mg by mouth daily for 8 weeks

iv. pantoprazole (Protonix) 20 mg by mouth daily for 4 to 8 weeks


c. uses

i. GERD, gastric ulcer, duodenal ulcer, hypersecretory conditions, H. pylori infection

ii. NSAID-associated gastric ulcer prophylaxis


d. adverse effects

i. life-threatening: blood dyscrasias, hepatic impairment, Stevens-Johnson syndrome

ii. other: headache, diarrhea, abdominal pain, nausea/vomiting, dizziness, flatulence, arthralgia


e. nursing care

i.
assist health care team to establish baseline data and check periodically thereafter complete blood count,
liver and renal function tests

ii. assess abdominal pain, regurgitation, heartburn

iii. administer 30 minutes before meals

iv. assess for anemia - client at risk of B12 deficiency

v. increased risk for Clostridium difficile-associated diarrhea

vi. assist health care team to implement client teaching plan

do not chew or crush capsules
261


avoid eating 2 hours before reclining

AVOID smoking, spicy food, caffeinated beverages and alcohol for effective therapy







2. Type: H
2
-receptor antagonists

a. action: reduction in HCl production (by blocking H
2
receptors) and pepsin secretion

b.
examples

i. famotidine (Pepcid) 20-40 mg every evening for 4 to 6 weeks

ii. ranitidine (Zantac) 150 mg by mouth twice daily

iii. cimetidine (Tagamet) 800 mg by mouth at bedtime for 4 to 8 weeks


c. uses

i. active and maintenance treatment for duodenal ulcer, gastric ulcer, GERD, Zollinger-Ellison syndrome, intractable
ulcers

ii. H. pylori infection, active benign and maintenance treatment of gastric ulcers, erosive esophagitis, hypersecretory
conditions

iii. dyspepsia, upper GI prophylaxis bleed


d. adverse effects

i. life-threatening: thrombocytopenia, hepatotoxicity, pneumonia

ii. other: headache, diarrhea, constipation, muscle aches, vertigo, malaise, dizziness, dry mouth, dry skin, rash

iii. cimetidine is a high risk drug in the elderly (based on the Beers Criteria) due to adverse CNS effects


e. nursing care

i.
assist health care team to establish baseline data and check before beginning and periodically during therapy
creatinine

ii. assess abdominal pain and findings indication gastrointestinal bleeding

iii. assist health care team to implement client teaching plan

pain relief may take several days

AVOID smoking, spicy food, caffeinated beverages and alcohol for effective therapy





3. Type: pepsin inhibitor

a. action: forms a viscous substance with HCl that adheres to the gastric mucosa

b.
example: sucralfate (Carafate) 1 gram by mouth before meals and at bedtime

c. uses: short-term therapy and maintenance treatment for duodenal ulcer, aspirin gastric erosion

d. adverse effects: bezoar formation, constipation

e. nursing care

i. assist health care team to establish baseline data and check prior to initiating and at regular intervals during therapy
bowel pattern, abdominal pain, GI bleeding

ii. contains aluminum

iii.
AVOID phosphate supplements

iv. assist health care team to implement client teaching plan

establish regular bowel habits including increased fluids, fiber, and exercise

AVOID smoking

AVOID spicy food, caffeinated beverages and alcohol



262




D. Therapeutic classification: antidiarrheal agents

1. Type: fluid absorbent

a.
example: bismuth subsalicylate (Kaopectate) 30 mL by mouth every 30 to 60 minutes as needed

b. adverse effect: encephalopathy, Reye syndrome, blackened stools and tongue, constipation, tinnitus

c. contraindications

i. pregnancy 3rd trimester, G6PD deficiency

ii. coagulation disorder, influenza, varicella, GI bleed

iii. renal failure


d. nursing care

i. assist health care team to establish baseline data and check bowel pattern

ii. administer 2 to 4 hours after other oral medication

iii. assist health care team to implement client teaching plan

do not exceed dosage recommendation

report diarrhea lasting for more than 48 hours






2. Type: motility suppressant

a. action: slows speed of peristalsis

b.
examples

i. loperamide hydrochloride (Imodium) 2-8 mg by mouth per dose after each loose stool

ii. diphenoxylate/atropine (Lomotil) 1-2 tabs by mouth 2 to 4 times daily as needed


c. adverse effects

i. life-threatening: respiratory depression, ileus, pancreatitis, toxic megacolon, angioedema

ii. other: nausea, vomiting, anorexia, abdominal pain, paresthesia, euphoria


d. contraindications

i. pseudomembranous colitis, toxin-related diarrhea

ii. severe volume depletion, electrolyte imbalance

iii. obstructive jaundice


e. nursing care

i. assist health care team to establish baseline data and check at regular intervals during therapy bowel pattern, fluid
and electrolyte balance

ii. monitor for dehydration in children and older clients

iii. assist health care team to implement client teaching plan

take only as directed

report bloody stool, fever, palpitations, abdominal pain

AVOID potassium salts






E. Therapeutic classification: laxatives

1. Information common to laxatives

a. uses: prevention and short-term treatment of constipation when straining is undesirable or contraindicated;
preoperative bowel evacuation

b. adverse effects

i. dependence
263


ii. diarrhea, cramping, nausea

iii. dehydration, electrolyte imbalance


c. nursing care

i. assist health care team to establish baseline data and check periodically thereafter bowel pattern, fluid and
electrolyte balance

ii. do not administer with intestinal obstruction, abdominal pain or bleeding of unknown origin

iii. most effective when taken with fluid

iv. assist health care team to implement client teaching plan

avoid combining different laxatives simultaneously

establish regular bowel habits including fiber, fluids, ambulation, regular pattern of defecation





2. Type: lubricant

a. action: coats stool and colon to facilitate bowel movement without stimulating the GI tract

b.
example: mineral oil 15-45 mL/day by mouth divided every 8 to 24 hours

c. uses: constipation



3. Type: stool softener

a. action: stool becomes softer by osmotic action without stimulation of GI tract

b.
examples

i. docusate sodium (Colace, Dulolax, Fleet Sof-Lax, Phillips Stool Softener) 100mg by mouth 1 to 2 times daily

ii. glycerin rectal (Colace Suppository for Adults & Children, Fleet Glycerin Suppository, Pedi-Lax Glycerin
Suppository) 1 suppository daily as needed

iii. polyethylene glycol 3350 (Dulolax Balance, GlycoLax, MiraLax) 17 grams by mouth daily


c. uses: constipation

d. adverse effects: electrolyte disorders and laxative dependence with prolonged use

e. contraindications: GI obstruction, known or suspected

f. nursing care

i. check bowel pattern

ii. assist health care team to implement client teaching plan: must be taken with adequate fluids




4. Type: bulk-forming

a. action: increase fluid content and bulk of stool stimulating stretch receptors in bowel and peristalsis resulting in bowel
movement

b.
examples

i. polycarbophil (FiberCon) 2 tabs by mouth 1 to 4 times daily as needed

ii. psyllium (Metamucil) 3.4 g by mouth 1 to 3 times daily as needed

iii. methylcellulose (Citrucel) 1 scoop oral powder 1 to 3 times daily as needed


c. uses: constipation

d. adverse effects: abdominal cramps, nausea, diarrhea

e. contraindications: acute abdomen, appendicitis, fecal impaction

f. nursing care

i. provide adequate fluid

ii. administer other medications one hour before or 2 hours after

iii. assist health care team to implement client teaching plan
264

take immediately after mixing in water
establish regular bowel pattern
do not use with abdominal pain, nausea, vomiting
establish regular bowel pattern and habits including fiber, fluid, and ambulation





5. Type: osmotic

a. action: exert osmotic pull of fluid through intestinal wall to increase fluid in intestinal contents, increase bulk, and
stimulate bowel evacuation

b.
examples

i. lactulose (Kristalose) 15-30 mL/day by mouth 1 to 2 times daily

ii. magnesium citrate 150-300 mL/day by mouth divided in 1 to 2 doses

iii. magnesium hydroxide (Phillips' Milk of Magnesia) 30-60 mL by mouth daily


c. uses: constipation, portal systemic encephalopathy

d. adverse effects

i. serious reaction: hypermagnesemia

ii. common reactions: diarrhea, abdominal pain, dehydration, nausea/vomiting


e. contraindications: renal failure, colostomy or ileostomy, appendicitis, acute abdomen

f. nursing care

i. provide comfort measures and perineal skin care after bowel evacuation

ii. assist health care team to implement client teaching plan

for short-term use only

take oral forms with a full glass of water

after bowel movement, ask for help before getting up





6. Type: chemical irritants

a. action: stimulate nerves of intestinal wall resulting in increased peristalsis and fluid content of stool

b.
examples

i. bisacodyl (Dulcolax, Ex-Lax Ultra-Strength, Fleet Stimulative Laxative) 5-15 mg by mouth daily

ii. sennosides (Senna Soft) 1 tablet by mouth 1 to 2 times daily


c. uses: constipation, bowel prep

d. adverse effects

i. cathartic colon, laxative abuse

ii. other: nausea, abdominal bloating and cramps, flatulence, diarrhea, urine discoloration


e. contraindications: GI obstruction, undiagnosed abdominal pain

f. nursing care

i. give alone and with a full glass of water

ii. administer 1 hour before or 2 hours after antacid

iii. assist health care team to implement client teaching plan

retain suppositories for 30 minutes

AVOID using to establish regular bowel habits







265


F. Therapeutic classification: digestive enzymes

1. Type: pancreatic

a. action: increases absorption of fat, carbohydrate, and protein

b.
example: pancrelipase (Creon, Ku-Zyme, Pancrease, Pangestyme Ultrase, Viokase, Zenpep) 500-2500 lipase
units/kg by mouth with meals and snacks

c. uses: exocrine pancreatic insufficiency

d. adverse effects: fibrosing colonopathy, intestinal obstruction, viral transmission risk

e. contraindications: hypersensitivity to pork protein

f. nursing care

i. report allergic responses, abdominal pain, cramping, hematuria

ii.
assist health care team to collaborate with dietitian and provider for low-fat diet





G. Therapeutic classification: inflammatory bowel disease agents

1. Type: aminosalicylates

a. action: anti-inflammatory action on the colon, splits into 5-acetylsalicylic acid and sulfapyridine

b.
examples

i. sulfasalazine (Azulfidine) 2 g/day by mouth divided in 4 doses

ii. mesalamine (Apriso, Asacol, Liada, Pentasa) 800 mg daily x 3 for 6 weeks


c. uses: rheumatoid arthritis, ulcerative colitis, Crohn's disease

d. adverse effects

i. acute intolerance syndrome, ulcerative colitis exacerbation, neuropathy, interstitial nephritis, renal failure,
hepatotoxicity

ii. other: headache, nausea, eructation, abdominal pain


e. contraindications: hypersensitivity to salicylates, influenza, varicella or febrile viral infections (in clients younger
than 20 years-old)

f. nursing care

i.
assist health care team to establish baseline data and check periodically during therapy BUN/creatinine,
complete blood count if older than 65 years-old

ii. assess elimination pattern, abdominal pain, temperature, urine output

iii.
may impair iron and folic acid absorption

iv. assist health care team to implement client teaching plan

avoid sunlight, protect skin

drink 2000 mL of water daily

report bleeding, rash, fever, sore throat

store in airtight, light-resistant container







2. Type: glucocorticoids

a. action: powerful and effective anti-inflammatory effect on bowel

b.
examples

i. budesonide (Entocort) 9 mg by mouth daily for up to 8 weeks

ii. predniSONE (Sterapred) 5-60 mg by mouth

iii. prednisoLONE (Flo-Pred, Millipred, Orapred, Pediapred, Prelone, Veripred 20) 5-60 mg by mouth daily in 1 to 4
266

doses

iv. hydrocortisone sodium succinate (Solu-Cortef) 100 mg IV every 6 to 8 hours for 24 to 48 hours, taper to oral dose


c. uses

i. mild to moderate Crohn's disease, corticoid-responsive conditions, acute asthma, severe persistent asthma

ii. PCP adjunct treatment, status asthmaticus, shock

iii. acute adrenal insufficiency, acute exacerbation of multiple sclerosis, acute alcoholic hepatitis


d. adverse effects: adrenal insufficiency, Cushing syndrome, anaphylaxis, infection, immunosuppression

e. nursing care

i.
assist health care team to establish baseline data and check periodically during therapy electrolytes, blood
pressure, weight, 2-hour postprandial glucose

ii. taper therapy over two week period before discontinuing


iii. assist health care team to implement client teaching plan

AVOID live vaccines

do not cut, crush, or chew medication

AVOID people who are sick or have
infections





VII. Managing endocrine conditions

A. Therapeutic classification: antidiabetic agents

1. Nursing care - information common to antidiabetic agents

a. oral agents contraindicated in pregnancy

b. assist health care team to establish baseline data and check before starting and at regular intervals during
therapy

i.
renal and hepatic function, blood sugar, serum pH, serum electrolytes

ii. visual acuity

iii. cardiovascular status, including peripheral perfusion


c. assist health care team to implement client teaching plan common to antidiabetic agents

i. need for follow-up care and testing

ii. use and frequency of blood glucose testing

iii. avoid over-the-counter drugs, herbal remedies, and alcohol

iv. beta-adrenergic blockers may mask signs of hypoglycemia

v. keep easily accessible - antidiabetic medication, equipment, high calorie snack

vi. recognition of hypoglycemia, hyperglycemia, and ketoacidosis by client and significant others

vii. monitor compliance with therapy or success of treatment plan with glycosylated hemoglobin (Hgb A1c)

viii. antidiabetic medication requirements may increase during illness or infection; clients with type 2 diabetes
mellitus (formerly called non-insulin dependent diabetes mellitus or NIDDM) may require insulin
periodically

ix. tight glycemic control, i.e., maintaining serum glucose within narrow range, is key to preventing
complications of diabetes mellitus

anti-diabetic medication only 1 part of effective glycemic control

must combine with consistent exercise with consistent diet (weight loss)


x. coordinate antidiabetic agent administration and dietary calories

calorie intake must be coordinated with drug onset, peak action, and duration

client must have calories in the body for onset, peak, and duration of insulin





267



2. Type: insulin

a. action: lowers blood sugar; drives metabolites and ions into cells, stimulates formation of glycogen, protein, and fat;
recombinant DNA replacement insulin made from human insulin

b.
examples, including onset, peak and duration of common insulins
Comparison Actions of Insulin
Type Agent Onset of Action Peak of Action Duration of Action
Rapid-acting Regular (IV)
lispro (Humalog R)
glulisine (Apidra)
aspart (NovoLog)
10-30 minutes
10-15 minutes
30-60 minutes
30-90 minutes
30-60 minutes
3-5 hours
Short-acting regular (Humulin R, Novolin R) 30-60 minutes 2-4 hours 5-7 hours
Intermediate-acting NPH (Humulin-N) 1-2 hours 4-8 hours 10-18 hours
Long-acting glargine (Lantus)
detemir (Levemir)
2-4 hours 8-14 hours 18-24 hours
Very long-acting glargine (Lantus) 1-2 hours No peak 24 hours



c. uses

i. diabetes mellitus type 1 and 2; hyperkalemia

ii. insulin lispro in combination with sulfonylureas in children

iii. ketoacidosis, diabetes mellitus associated with pregnancy


d. adverse effects

i. life-threatening: severe hypoglycemia, hypokalemia, generalized hypersensitivity reaction, anaphylaxis

ii. other; hypoglycemia, injection site reaction, lipodystrophy at injection site, pruritus, rash, weight gain


e. contraindications/cautions: infection, illness or stress, hypokalemia, renal or hepatic impairment

f. nursing care

i. assist health care team to establish baseline data and check blood sugar, anorexia prior to initiating and periodically
during therapy

ii. verify blood sugar before administration

iii. when mixing more than one insulin in a syringe, draw regular insulin first

iv. regular insulin and NPH insulin require 15 gram carbohydrate snack at peak action time

v. allow refrigerated insulin to warm to room temperature before injection by rolling (NOT shaking) between palms of
hands

vi. IV insulin: regular insulin only

small amounts suitable for IV push

use infusion control device to deliver units/hour

prime tubing with 50 mL of insulin solution before infusing (required to coat lumen of tubing)


vii. assist health care team to implement client teaching plan

wear MedicAlert identification

need for follow-up care and testing

blood glucose testing technique and frequency

subcutaneous injection technique; need to rotate injection sites
268


single-use vials of insulin may be stored at room temperature for 30 days - keep away from heat and light





3. Type: oral antidiabetic agents

a.
sub-type: sulfonylureas

i. action: increase insulin secretion by binding to potassium receptors on pancreatic beta cells (beta cells)

ii.
examples

chlorpropamide (generic) 100-500 mg by mouth daily

glyBURIDE (DiaBeta) 1.25-20 mg by mouth daily

glipiZIDE (Glucotrol) 2.5-20 mg by mouth 1 to 2 times daily

glimepiride (Amaryl) 1-4 mg by mouth daily


iii. uses: type 2 diabetes mellitus, as adjunct therapy with diet and exercise

iv. adverse effects
hypoglycemia, blood dyscrasias, hepatitis, hepatic failure
dizziness, asthenia, headache, nausea, photosensitivity

chlorpropamide is a high risk drug in the elderly (based on the Beers Criteria) due to due to a prolonged
half life


v. contraindications

diabetic ketoacidosis, hypersensitivity to sulfonamides

hepatic impairment, adrenal insufficiency, autonomic neuropathy, G6PD deficiency


vi.
nursing care: assist health care team to establish baseline data and check blood sugar, creatinine periodically
thereafter




b.
sub-type:non-sulfonylureas (alpha-glucosidase inhibitor)

i. action: delay glucose absorption by inhibiting an enzyme that breaks down glucose into smaller molecules for
absorption

ii.
examples

metformin (Fortamet, Glucophage, Glumetza, Riomet) 850-1500 mg by mouth twice daily
Black Box Warning - lactic acidosis
repaglinide (Prandin) 0.5-4 mg by mouth before meals

rosiglitazone (Avandia) 4-8 mg by mouth divided 1 to 2 times daily
Black Box Warning - appropriate use/restricted distribution program, congestive heart failure, myocardial
infarction


iii. uses: in combination with insulin and sulfonylureas to treat diabetes type 2

iv. adverse effects

hypoglycemia, blood dyscrasias, hepatitis, hepatic failure

dizziness, asthenia, headache, nausea, photosensitivity


v. contraindications

diabetic ketoacidosis, hypersensitivity to sulfonamides

hepatic impairment, adrenal insufficiency, autonomic neuropathy, G6PD deficiency


vi. nursing care
administer just before meals
much less likely to cause hypoglycemia than sulfonylureas


269




B. Glucose-elevating agents

1. Action: decrease release of insulin and facilitate glycogen breakdown and release from the liver

2.
Examples

a.
glucagon (GlucaGen) 20-25 mg SubQ/IM/IV x 1 dose

b.
diazoxide (Proglycem) 3-8 mg/kg/day by mouth divided every 8 to 12 hours


3. Uses: severe hypoglycemia, diagnostic procedures, beta blocker or calcium channel blocker overdose, anaphylaxis,
hyperinsulinemia-associated hypoglycemia

4. Adverse effects

a. diabetic ketoacidosis, hyperosmolar hyperglycemic state, severe hyperglycemia, heart failure, acute pancreatitis

b. other: sodium and fluid retention, hirsutism, hyperglycemia, glycosuria


5. Nursing care

a. establish baseline data and monitor blood sugar, blood pressure

b. keep insulin at bedside

c. maintain client safety until acute episode is resolved





C. Therapeutic classification: thyroid agents

1. Type: thyroid replacement, synthetic

a. action

i. regulation of protein synthesis

ii. increases rate of caloric turnover to increase cardiac output, renal blood flow, oxygen consumption, and
production of the by-products of metabolism, e.g., carbon dioxide, water and heat


b.
examples

i. levothyroxine (Levothroid, Levoxyl, Synthroid, Tirosint, Unithroid) 50-200 mcg by mouth daily
Black Box Warning - not for obesity/weight loss

ii. liothyronine (Cytomel, Triostat) 25-75 mg by mouth daily
Black Box Warning - not for obesity/weight loss


c. uses: hypothyroidism, myxedema, myxedema coma, nontoxic goiter, thyroid suppression test, adjuvant treatment
for depression

d. adverse effects

i. life-threatening: arrhythmias, cardiopulmonary arrest, myocardial infarction, angina, hypotension, hypertension,
heart failure

ii. most common: tachycardia, headache. irritability, nervousness, tremor, diaphoresis, diarrhea, vomiting,
menstrual irregularities


e. contraindications: myocardial infarction, untreated thyrotoxicosis, uncorrected adrenal insufficiency, cardiovascular
disease, coronary artery disease, diabetes mellitus or insipidus

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating and at regular intervals during
therapy BUN, creatinine

ii. assist health care team to implement client teaching plan

report excitability, insomnia, sweating, heat intolerance

wear MedicAlert identification
270


take in morning as a single dose with full glass (8 ounces) of water on an empty stomach

reinforce need for follow-up care and testing

different brands may not work the same - talk to pharmacists or notify provider if pills look different

AVOID stimulants, caffeinated beverages

AVOID iodine rich foods, e.g., seafood, fish liver oils, iodized salt

take only as directed, do not stop taking drug without notifying provider







2. Type: antithyroid agents

a. sub-type: thioamides

i. action: blocks production of thyroid hormone by inhibiting the conversion of T4 to T3

ii.
examples

propylthiouracil 100-150 mg by mouth divided every 8 hours
Black Box Warning - appropriate use, hepatotoxicity, antithyroid drug use in first trimester pregnancy

methimazole (Tapazole) 5-15 mg by mouth daily


iii. uses: hyperthyroidism

iv. adverse effects

agranulocytosis, leukopenia, thrombocytopenia

aplastic anemia, hepatotoxicity, periarteritis

rash, urticaria, nausea, vomiting, dyspepsia, arthralgia, paresthesia

loss of taste, hair loss, myalgias, headache, edema


v. nursing care

assist health care team to establish baseline data and check periodically during therapy complete
blood count with differential, PT

check for clinical indicators of overdose: muscle hyperexcitability, depression, non-pitting edema ,
intolerance to cold

assist health care team to implement client teaching plan
take at same time daily

AVOID iodine containing foods

do not discontinue taking drug

increase fluids to 3000-4000 mL daily

report bleeding and unusual bruising, fluid gain, edema, dyspnea on exertion, cold intolerance,
depression







b. sub-type: iodine solutions

i. action: blocks thyroid function in high doses by saturating thyroid cells with iodine

ii.
example: potassium iodide (losat, SSKI, ThyroSafe, ThyroShield) 50-250 mg by mouth three times daily

iii. uses: preop thyroidectomy, thyrotoxicosis, cutaneous sporotrichosis, expectorant

iv. adverse effects

life-threatening: arrhythmias, GI bleed, angioedema

other: parotitis, goiter, thyroid adenoma, metallic taste, dyspepsia, urticaria

271


v. contraindications: hyperkalemia, severe volume depletion, Addison's disease, hypothyroidism

vi. nursing care

assist health care team to establish baseline data and check prior to initiating and periodically during
therapy thyroid function

taper dose before discontinuing therapy

assist health care team to implement client teaching plan

may take with food

do not abruptly stop therapy

drink water to thin secretions

need for follow-up care and testing

report bleeding, abdominal pain, iodism

wear MedicAlert identification

AVOID iodine rich foods

AVOID over-the-counter medications including vitamins and herbal supplements without consulting
provider





D. Therapeutic classification: adrenocortical agents

1. Type: glucocorticoids - uses: adrenal insufficiency (Addison's disease), adrenal crisis

2. Type: mineralocorticoids

a. action: increase sodium reabsorption in renal tubules to increase hydrogen and potassium, water retention

b.
example: fludrocortisone acetate (Florinef) 0.1-0.2 mg by mouth daily

c. uses: adrenal insufficiency, orthostatic hypotension

d. adverse effects

i. life-threatening: adrenal insufficiency, steroid psychosis, immunosuppression, peptic ulcer, heart failure,
anaphylaxis

ii. most common: nausea, vomiting, dyspepsia, appetite change

iii. other: edema, headache, dizziness, mood swings, insomnia, anxiety


e. contraindications

i. systemic fungal infection, congestive heart failure, seizure disorder

ii. diabetes mellitus, hypertension, TB infection


f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and periodically
thereafter fluid and electrolytes, 2-hour postprandial glucose

ii. check blood pressure, weight

iii. chest x-ray and ophthalmic exams if prolonged treatment

iv.
collaborate with provider for potassium-rich diet , low-sodium diet

v. assist health care team to implement client teaching plan

report weight gain, peripheral edema, abdominal cramping, nausea, anorexia

do not stop taking this drug abruptly

wear MedicAlert identification








272

E. Therapeutic classification: hypothalamic hormones

1. Type: growth hormone

a.
example: nafarelin (Synarel) 1 to 2 sprays per nostril once or twice daily

b. uses: endometriosis, premature ovulation prevention

c. adverse effects

i. pituitary apoplexy, ovarian cysts, hypersensitivity reaction, bone mineral density decreases

ii. most common: hot flashes, libido changes, vaginal dryness, headache, emotional lability


d. nursing care

i.
assist health care team to establish baseline data pregnancy test, bone mineral density with periodic
pregnancy tests

ii. assist health care team to implement client teaching plan

report rhinitis; signs of puberty, i.e., vaginal bleeding, breast enlargement, after first month of therapy

nasal spray technique

pregnancy category X - client must use contraception throughout treatment







F. Therapeutic classification: anterior pituitary agents

1. Type: adrenocortical hormone

a.
example: menotropin (Pergonal combination therapy with luteinizing hormone, follicle stimulating hormone,
and human chorionic gonadotropin)

i. use: ovulation induction, assisted reproductive technology, spermatogenesis

ii. adverse effects

life-threatening: anaphylactoid reaction, spontaneous abortion, ectopic pregnancy

other: headache, abdominal cramps, ovarian hyperstimulation syndrome, nausea



b.
example: somatotropin (Genotropin, Humatrope, Norditropin, Nutropin, Omnitrope, Saizen, Serostim) 0.04-
0.08 mg/kg/week SubQ

i. use: growth hormone deficiency, HIV-associated cachexia

ii. adverse effects: hypersensitivity, diabetes mellitus, hypothyroidism, intracranial hypertension, pancreatitis,
scoliosis progression





G. Therapeutic classification: posterior pituitary agents

1. Type: synthetic antidiuretic hormone

a. action: increases reabsorption of water in renal tubules to decrease urine formation and increase plasma levels of
factor VIII

b.
examples

i. vasopressin (Pitressin) 5-10 units SubQ/IM 2-4 times daily; 40 units IV/IO x 1 dose ACLS protocol

ii. desmopressin acetate (DDAVP) 0.1-1.2 mg/day by mouth in 2 to 3 doses


c. uses: diabetes insipidus, abdominal distention, abdominal radiographs, renal biopsy, GI hemorrhage, systole/PEA
and VF/pulseless VF ACLS, vasodilatory shock, nocturnal enuresis, hemophilia A, type I von Willebrand disease,
uremic bleeding

d. adverse effects

i. life-threatening: hyponatremia, water intoxication, seizures, anaphylaxis, thrombosis

ii. most common: flushing, headache, rhinitis, nausea, abdominal pain, dizziness, cough, epitaxis


e. contraindication: creatinine clearance < 50, hyponatremia, type IIB von Willebrand disease, coronary artery
disease, hypertension, congestive heart failure
273


f. nursing care

i.
assist health care team to establish baseline data and check periodically creatinine, blood pressure, heart
rate during infusion

ii.
serum blood levels may appear low due to hemodilution

iii. assist health care team to implement client teaching plan

wear MedicAlert identification

AVOID alcohol and over-the-counter drugs

missed doses: take up to 1 hour before next dose, otherwise skip dose, do not double dose






H. Therapeutic classification: parathyroid agents

1. Type: antihypercalcemic agents

a. action: inhibits bone resorption by binding to bone hydroxyapatite to inhibit osteoclast activity

b.
example: risedronate (Actonel, Atelvia) 35 mg by mouth weekly

c. uses: postmenopausal osteoporosis treatment

d. adverse effects

i. dysphagia, esophagitis, esophageal ulcer, erosion, stricture or perforation, gastric/duodenal ulcer, angioedema

ii. diarrhea, influenza-like symptoms, arthralgia, back and abdominal pain


e. contraindications: esophageal stricture, achalasia, inability to remain upright x 30 minutes, hypocalcemia,
creatinine clearance < 30

f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and periodically thereafter
creatinine

ii.
collaborate with dietitian for calcium-rich foods

iii. AVOID antacids, calcium, magnesium or iron salts

iv. assist health care team to implement client teaching plan

take with water after breakfast; do not cut/crush/chew

remain upright for at least 30 minutes after taking

take calcium and vitamin D supplements if daily requirements cannot be attained with diet alone






VIII. Managing renal and urinary tract conditions

A. Therapeutic classification: diuretics

1. Information common to diuretics (except potassium-sparing diuretics)

a. action: increases the rate of urine flow by effecting the renal tubules to excrete sodium; alters renal handling
of other electrolytes, especially potassium

b. uses

i. increase volume of urine, sodium and chloride excretion

ii. heart failure, hypertension, hyperkalemia

iii. rapid fluid excretion, severe edema, pulmonary edema


c. adverse effects

i. life-threatening: severe hypokalemia, severe electrolyte imbalance, metabolic alkalosis,
hypovolemia/dehydration

ii. most common: urinary frequency, dizziness, nausea/vomiting, weakness, muscle cramps


d. contraindications
274


i. anuria, hepatic coma, electrolyte imbalances

ii. hypersensitivity to sulfonamide, diabetes mellitus, acute myocardial infarction


e. nursing care

i.
assist health care team to establish baseline data and check prior to initiating and at regular intervals
during therapy intake, urine output, serum electrolytes especially potassium, blood pressure, cardiac
rhythm, serum glucose and pH

ii. increased risk of digoxin toxicity

iii. assist health care team to implement client teaching plan

may take with food or milk; drink at least 6 to 8 glasses of water daily

AVOID alcohol and over-the-counter drugs

do not stop taking when feeling well

administer in early morning to avoid nocturia

potassium-rich diet (may need to avoid or increase intake)

report irregular heartbeat, low urine output, dizziness, rash, muscle cramps, twitching, weakness








2. Type: loop diuretics, sulfonamide derivative

a. action: blocks sodium-chloride pump in renal tubules preventing reabsorption of sodium and chloride in the ascending
loop of Henle and distal convoluted tubules, and to increase urine and solute excretion

b.
examples

i. furosemide (Lasix) 40-120 mg by mouth divided in 1 to 2 doses daily
Black Box Warning - fluid and electrolyte depletion

ii. bumetanide (Bumex) 0.5-10 mg by mouth divided in 1 to 2 doses daily
Black Box Warning - fluid and electrolyte depletion

iii. torsemide (Demadex) 10-200 mg PO/IV daily


c. adverse effects: azotemia, ECG abnormalities, arrhythmias, thrombosis, ototoxicity

d. contraindication: anuria, hepatic coma, electrolyte imbalances

e. nursing care

i. establish baseline data and monitor hearing, electrolyte depletion

ii. administration: verify serum potassium, blood pressure, and urine output before administration




3. Type: thiazide diuretics, sulfonamides

a. action: chloride pump in renal tubules prevents reabsorption of sodium and chloride in the ascending loop of Henle
and distal tubules resulting in increased excretion of water

b.
examples

i. thiazides

hydrochlorothiazide (Esidrix, Microzide) 12.5- 50 mg by mouth daily

chlorothiazide (Diuril) 500-1000 mg PO/IV 1 to 2 times daily


ii. thiazide-like: chlorthalidone (Hygroton) 50-100 mg by mouth daily


c. uses: hypertension, peripheral edema

d. adverse effects: severe hypokalemia, electrolyte imbalance, arrhythmias, pancreatitis

e. contraindication: anuria, hepatic coma, electrolyte imbalances, hypersensitivity to sulfonamides


275



4. Type: carbonic anhydrase inhibitors

a. action: mild diuretic action by inhibiting the movement of bicarbonate (HCO
3
) resulting in increased loss of sodium and
bicarbonate

b.
example: acetazolamide (Diamox) 250-375 mg Po/IV every other day to daily

c. uses: open-angle, acute angle-closure, and secondary glaucoma, altitude sickness, heart failure, drug-induced edema,
seizure disorder, pseudotumor cerebri, urinary alkalinization

d. adverse effects

i. metabolic acidosis, electrolyte imbalance, anaphylaxis

ii. fatigue, malaise, taste change, anorexia




5. Type: potassium-sparing diuretics

a. action: antagonizes aldosterone to maintain sodium excretion in the distal tubule and retain potassium

b.
examples

i. spironolactone (Aldactone) 25-200 mg by mouth daily
Black Box Warning - tumor risk

ii. triamterene (Dyrenium) 100 mg by mouth 2 times daily
Black Box Warning - hyperkalemia

iii. amiloride (Midamor) 5-10 mg by mouth daily
Black Box Warning - hyperkalemia


c. uses

i. edema, hypertension, primary hyperaldosteronism, diuretic induced hypokalemia, NYHA Class III/IV CHF

ii. lithium-induced polyuria


d. adverse effects: aplastic anemia, hyperkalemia, neutropenia

e. contraindications: hyperkalemia, anuria, renal impairment, creatinine > 1.5, diabetic neuropathy

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter BUN/creatinine, electrolytes, acid-based balance

ii. carefully review medication profile for other drugs associated with hyperkalemia: ACE inhibitors, angiotensin II
receptor blockers, salt substitutes

iii. assist health care team to implement client teaching plan

avoid potassium rich foods

take with food or milk in early morning

AVOID alcohol, over-the-counter drugs

AVOID herbal remedies






6. Type: osmotic diuretics

a. action: pulls large amount of fluid into renal tubules by osmotic pressure

b.
example: mannitol (Osmitrol) 50-100 g IV x 1 dose

c. uses

i. oliguria prevention and treatment, cerebral edema, elevated intraocular pressure and intracranial pressure
276


ii. adjunct treatment for forced diuresis


d. adverse effects

i. life-threatening: seizures, heart failure, cardiovascular collapse, pulmonary edema

ii. most common: headache, nausea, vomiting, polyuria, dizziness, rash, blurred vision

iii. other: osmotic nephrosis, acute renal failure, CNS depression, coma


e. contraindications: anuria, severe pulmonary edema, dehydration, intracranial hemorrhage

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter BUN/creatinine, electrolytes at baseline

ii. check neurologic status and intracranial pressure





B. Managing urinary tract disorders

1. Therapeutic classification: anti-infectives specific for urinary tract

a. information common to urinary tract anti-infectives: obtain urine cultures before initial administration

b. type: antibiotics

i. action: interferes with DNA metabolism of pathogen

ii.
examples
fosfomycin (Monurol) 3 g PO x 1 dose

norfloxacin (Noroxin) 400 mg by mouth twice a day
Black Box Warning - tendinitis/tendon rupture, avoid in myasthenia gravis

sulfonamide combination: trimethoprim/sulfamethoxazole (Bactrim, Septra, Sulfatrim) 160 mg TMP by
mouth every 12 hours

fluoroquinolones: ciprofloxacin (Cipro, Proquin) 250-750 mg by mouth every 12 hours
Black Box Warnings - tendonitis/tendon rupture, avoid in myasthenia gravis


iii. use: urinary tract infection

iv. adverse effects

Stevens-Johnson syndrome, toxic epidermal necrolysis

photosensitivity, fulminant hepatic necrosis

agranulocytosis, aplastic anemia, blood dyscrasias

nausea/vomiting, anorexia, allergic rash, urticaria


v. contraindications
G6PD deficiency, hypersensitivity to sulfonamides
megaloblastic anemia, folate deficiency
clients younger than 2 months-old, pregnancy near-term, breastfeeding


vi. nursing care

assist health care team to establish baseline data and check before starting and at regular intervals
during therapy BUN/creatinine, complete blood count, potassium with renal impairment, concomitant ACE
inhibitor, urinalysis

assist health care team to implement client teaching plan
AVOID caffeine and do not take at same time as dairy products
AVOID exposure to sunlight or tanning beds







277

c. type: urinary acidifiers

i. action: kills pathogens in bladder

ii.
examples

methenamine mandelate (Mandelamine) 1 g by mouth 4 times daily

methenamine hippurate (Hiprex, Urex) 1 g by mouth twice daily


iii. uses: urinary tract infection prophylaxis/suppression

iv. adverse effects: crystalluria, gross hematuria, nausea, dyspepsia, dysuria, rash

v. contraindication: renal dysfunction

vi. nursing care

assist health care team to establish baseline data and check at regular intervals thereafter creatinine, liver
function tests, urinary pH

assist health care team to implement client teaching plan

take with urinary acidifiers, such as cranberry juice

AVOID antacids, sulfonamides, urinary alkalinizers





2. Therapeutic classification: urinary tract antispasmodics

a. action: inhibits action of ACh; anticholinergics, muscarinic receptor antagonist increases bladder capacity and reduces
frequency of bladder contractions

b.
examples

i. tolterodine (Detrol) 4 mg by mouth daily

ii. solifenacin (VESIcare) 5-10 mg by mouth daily

iii. oxybutynin: (Ditropan) 5 mg by mouth 2 to 3 times daily; (Oxytrol) transdermal 3.9/day patch -1 patch twice a week

iv. trospium chloride (Sanctura) 20 mg by mouth twice daily


c. uses: overactive bladder

d. adverse effects

i. life-threatening: anaphylaxis, angioedema, Stevens-Johnson syndrome, rhabdomyolysis, heat stroke

ii. most common: xerostomia, constipation, headache, fatigue


e. contraindications: urinary and gastric retention, uncontrolled angle-closure glaucoma

f. nursing care

i.
assist health care team to establish baseline data and check at regular intervals during therapy creatinine,
urinary pattern, urinary retention

ii. interrupt therapy periodically to determine continued need

iii. assist health care team to implement client teaching plan: avoid hot environments




3. Therapeutic classification: cholinergic agents

a. action: increases bladder tone to increase stimulus for micturition

b.
example: bethanechol (Urecholine) 25-50 mg by mouth three times daily

c. use: urinary retention, neurogenic bladder, GERD, terminal cancer adjuvant treatment, phenothiazine treatment

d. adverse effects

i. life-threatening: bronchospasm, hypotension,tachycardia, seizures

ii. most common: abdominal cramps/discomfort/pain, nausea, belching


e. nursing care: give on empty stomach 1 hour before or 2 hours after meal

278



4. Therapeutic classification: urinary tract analgesic

a. action: direct topical analgesia on urinary tract mucosa

b.
example: phenazopyridine (Azo Standard, Pyridium) 100- 200 mg by mouth 3 times daily for 2 days

c. uses: dysuria

d. adverse effects

i. life-threatening: anaphylactoid reaction

ii. most common: rash, pruritus, nausea, headache, urine discoloration


e. contraindication: glomerulonephritis, severe hepatitis, uremia, renal impairment

f. nursing care

i.
assist health care team to establish baseline data and check prior to beginning and periodically during therapy
creatinine

ii. treat underlying urinary tract infection

iii. assist health care team to implement client teaching plan

urine will be orange-red in color; the dye may stain clothing

tears may be orange-red in color; do not wear contact lenses while using this medication

report jaundice

take with food





5. Treatment of benign prostatic hypertrophy (BPH)

a. therapeutic classification: alpha
1
-adrenergic receptor blockers

i. action: decreases blood pressure; reduces BPH findings; lowers LDL cholesterol, triglycerides and raises HDL
cholesterol

ii.
examples

tamsulosin (Flomax) 0.4 mg by mouth daily; 30 minutes after a meal

terazosin (Hytrin) 1-10 mg by mouth every evening


iii. use: increase force of urine stream


b. therapeutic class: 5-alpha
1
-reductase inhibitor

i. action: inhibits the enzyme responsible for conversion of testosterone to an androgen

ii.
examples

finasteride (Proscar) 5 mg by mouth daily; (Propecia) 1 mg by mouth daily

dutasteride (Duagen) 0.5 mg by mouth daily


iii. use: benign prostatic hypertrophy, hypertension

iv. adverse effects: angioedema, severe skin reactions, high-grade prostate cancer, impotence, decreased libido

v. nursing care

assist health care team to establish baseline data and check periodically thereafter PSA, digital rectal
exam results

administration: swallow capsule whole - do not open/chew/crush capsule

reinforce client teaching: AVOID pregnancy (teratogenic to male fetus); women and children should not
even handle capsules







279

IX. Managing Conditions of the Reproductive Tract

A. Female reproductive system

1. Therapeutic class: female hormones (see also Family Planning for overview of female hormones used in
contraception)

a. type: estrogen

i. action

necessary proper functioning of female reproductive system, development of secondary sexual
characteristics, and endometrial proliferation

stimulates release of pituitary gonadotrophins, inhibits ovulation, promotes calcification of bones


ii.
examples

estradiol (Estrace) 0.5-2 mg by mouth daily
Black Box Warning - endometrial cancer risk, cardiovascular and other risks

estradiol cypionate (Depo-Estradiol) 1-5 mg IM every 3 to 4 weeks
Black Box Warning - endometrial cancer risk, cardiovascular and other risks

conjugated estrogens (Premarin) 0.3-1.25 mg by mouth daily
Black Box Warning - endometrial cancer risk, cardiovascular and other risks

synthetic conjugated estrogens (Cenestin) 0.625-1.25 mg by mouth daily
Black Box Warning - endometrial cancer risk, cardiovascular and other risks

synthetic conjugated estrogens B (Enjuvia) 0.3-1.25 mg by mouth daily
Black Box Warning - endometrial cancer risk, cardiovascular and other risks


iii. uses

moderate-severe vasomotor menopausal symptoms, primary ovarian failure

menopausal vulvovaginal atrophy, hypoestrogenism, dysfunctional uterine bleeding, uremic
bleeding

postmenopausal osteoporosis prevention

palliative treatment for breast and prostrate cancer


iv. adverse effects

thromboembolism, retinal thrombosis, myocardial infarction, stroke, hypertension

other: breast, ovarian and endometrial cancer







vi. contraindications: undiagnosed vaginal bleeding, breast cancer, history of estrogen-dependent cancer or
thromboembolism

vii. nursing care

assist health care team to establish baseline data and check periodically thereafter free T4, T3 if
hypothyroidism

breast exam every 12 months, mammography, blood pressure

action inhibited by grapefruit juice

assist health care team to implement client teaching plan

report fluid retention, leg pain, jaundice, breast lumps, headache, blurred vision

may decrease libido, take only as directed

need for follow-up care and testing: pelvic exam and Pap smear

non-pharmacological comfort measures for the adverse effects of menopause

AVOID herbal supplements: ginseng, green tea, licorice, milk thistle



280



b. type: progesterone

i. action: inhibit secretion of pituitary gonadotrophins preventing the maturation of ovarian follicles, stimulating breast
tissue growth

ii.
example: progesterone micronized (Prometrium) 200-400 mg by mouth daily for 10 to 12 days
Black Box Warning - cardiovascular, breast cancer, and probable dementia

iii. uses: secondary amenorrhea, prevention of postmenopausal endometrial hyperplasia

iv. adverse effects: thromboembolism, hypertension, hepatic adenoma, depression

v. contraindications: hypersensitivity to peanuts, undiagnosed vaginal bleeding, breast and genital organ cancer

vi. nursing care - see previous page for estrogens




2. Therapeutic classification: hormone modulators

a. type: estrogen receptor modulators

i. action: stimulates some and blocks other estrogen receptor sites to elicit some of the positive effects of estrogen
therapy

ii.
examples

raloxifene (Evista) 60 mg by mouth daily
Black Box Warning - venous thromboembolism risk, fatal stroke risk

toremifene (Fareston) 60 mg by mouth daily
Black Box Warning - QT prolongation


iii. uses: postmenopausal osteoporosis prevention and treatment, breast cancer prevention, advanced breast cancer
treatment

iv. adverse effects

life-threatening: hepatotoxicity, ocular toxicity, hypercalcemia, pulmonary embolism

most common: hot flashes, cataracts, dry eyes, sweating, nausea, vaginal discharge

other: dizziness, abnormal visual fields, hypercalcemia


v. contraindications: pregnancy, thromboembolic history, endometrial hyperplasia, severe bradycardia

vi. nursing care

assist health care team to establish baseline data and check at regular intervals potassium,
magnesium, ECG, calcium, complete blood count, liver function tests

assist health care team to implement client teaching plan

report fluid retention, leg pain, jaundice, breast lumps, headache, blurred vision

need for follow-up care and testing







3.
Therapeutic classification: contraceptives

a. type: oral contraceptives

i. action: release of ovum and endometrial proliferation inhibited, increased viscosity of cervical mucus

ii.
examples

desogestrel/ethinyl estradiol (Apri, Azurette, Caziant, Cyclessa, Desogen, Emoquette, Karvia, Mircette, Ortho-
Cept, Reclipsen, Velivet, Viorele)
Black Box Warning - smoking and cardiovascular events

levonorgestrel/ethinyl estradiol (Altavera, Amethia, Amethia Lo, Amethyst, Avaine, Camrese, Camrese Lo,
281

Enpresse, Introvale, Jolessa, Lessina, Levoram LoSeasonique, Lutera, Lybrel, Marlissa, Nordette, Orythia, Partia,
Quasense, Seasonale, Seasonique, Sronyx, Triphasil, Trivora)
Black Box Warning - smoking and cardiovascular events

drospirenone/ethinyl estradiol (Gianvi. Loryna, Ocella, Syeda, Vestura, Yasmin, Yaz, Zarah)
Black Box Warning - smoking and cardiovascular events

norgestrel/ethinyl estradiol (Cryselle, Lo/Ovral-28, Low-Ogestrel, Ogetrel) NOTE: Black Box Warning-smoking
and cardiovascular events

norgestimate/ethinyl estradiol (MonoNEssa, Ortho Tri-Cyclen, Ortho Tri-Cyclen Lo, Ortho-Cyclen, Previfem,
Sprintec, Tri-Previfem, Tri-Sprintec, TriNessa)
Black Box Warning - smoking and cardiovascular events


iii. uses: contraception, moderate dysfunctional uterine bleeding, dysmenorrhea, emergency contraception,
endometriosis

iv. adverse effects: thrombosis/thromboembolism, myocardial infarction, stroke, cerebral hemorrhage, hypertension

v. client teaching

may be monophasic, biphasic or triphasic

monophasic is 28 day cycle

extended cycle or continuous regimes are bi- and triphasic

breakthrough bleeding may occur, especially during first few months after initiating therapy






b.
type: etonogestrel subdermal implant (Implanon, Nexplanon)

i. Restricted Distribution in U.S.

ii. 1 implant subdermally every 3 years

iii. requires surgery


c.
type: levonorgestrel intrauterine device (Minera)

i. inserted into uterus, used for contraception and menorrhagia

ii. effective for 5 years


d.
type: estrogestrel/ethinyl estradiol vaginal (NuvaRing)
Black Box Warning - smoking and cardiovascular events

i. inserted vaginally and left in place for 3 weeks, then remove

ii. insert new ring 1 week later


e.
type: medroxyprogesterone acetate (Depo-Provera)
Black Box Warning - BMD loss

i. effective for 3 months

ii. IM injection

iii. safety conditional for lactation


f.
type: norelgestromin/ethinyl estradiol transdermal (Ortho Erva)
Black Box Warning - smoking and cardiovascular events, venous thromboembolism risk, ethinyl estradiol
pharmacokinetic

i. apply patch firmly to lower abdomen, buttocks, upper outer arm or upper torso

ii. use one patch every week for 3 weeks, off for 1 week


282



4. Therapeutic classification: fertility drugs

a. action: enhance an aspect of follicular development or ovulation

b.
examples

i. type: gonadotrophins-releasing antagonist: cetrorelix (Cetrotide) 0.25 mg SubQ every day until hCG administration

ii. type: chorionic gonadotropin (Novarel, Pregnyl) 5000-10,000 units IM for 1 dose

iii. type: clomiphene (Clomid, Serophene) 50 mg by mouth daily for 5 days

iv. type: follicle stimulators

example: follitropin alfa (Gonal-F, Gonal-F RFF) individualize dose SubQ

example: follitropin beta (Follistim AQ) individualized dose SubQ/IM



c. uses: infertility in males and females, in combination with human chorionic gonadotropin (hCG)

d. adverse effects

i. anaphylactoid reaction, spontaneous abortion, multiple pregnancies

ii. ectopic pregnancy, ovarian hyperstimulation syndrome

iii. hemoperitoneum, adnexal torsion, thromboembolism, pulmonary complications


e. contraindications

i. hypersensitivity to streptomycin and neomycin, primary ovarian failure, pregnancy

ii. uncontrolled thyroid disease or adrenal dysfunction

iii. breast, ovarian or uterine cancer


f. nursing care

i.
assist health care team to establish baseline data and check at regular intervals thereafter estrogen and
estradiol levels, pregnancy

ii. administer with hCG

iii. assist health care team to implement client teaching plan

need for follow-up care and testing

subcutaneous or IM injection technique

record treatment days and days for sexual intercourse on client calendar






5. Therapeutic classification: abortifacients

a. action: cause intense uterine contractions leading to uterine evacuation

b.
examples

i. type: blocks progesterone receptors

dinoprostone vaginal gel or insert (Prepidil, Cervidil) 0.5 gel or 10 mg per vagina

carboprost tromethamine (Hemabate) 250 mcg IM for 1 dose
Black Box Warning - appropriate use


ii. type:mifepristone (Korlym, Mifeprex, RU486) 600mg by mouth for 1 dose (note: restricted distribution in U.S.)
Black Box Warning - serious infection risk, bleeding risk, and patient information

iii. type:levonorgestrel (Next Choice, Plan B One-Step) 1 tablet by mouth every 12 hours for 2 doses


c. uses: 13-20 week pregnancy termination, early pregnancy termination, abortion adjunct, emergency contraception

d. adverse effects

i. life-threatening: severe prolonged vaginal bleeding, severe or fatal infection, sepsis with atypical symptoms

ii. other: abdominal cramping and pain

283


e. contraindications

i. more than 7 weeks gestational age

ii. history of asthma, hypertension, adrenal disease

iii. pelvic inflammatory, cardiac, renal, or pulmonary disease


f. nursing care

i. observe RN establish baseline data and monitor blood pressure, uterine tone, uterine bleeding

ii. confirm gestational age before administration

iii. observe RN implement client teaching plan

do not use abortifacients for birth control

use of delivery method and timing of administration

need for follow-up care and testing

report heavy bleeding, temperature, foul-smelling lochia






B. Male reproductive system

1. Therapeutic classification: hormones

a. type: androgenic anabolic steroid

i. growth and development of male external genitalia and secondary sexual characteristics; increase protein
anabolism and muscle mass

ii.
examples

testosterone (Striant) 30 mg buccally every 12 hours

testosterone cypionate (Depo-Testosterone) 50-400 mg IM once every 2 to 4 weeks

methyltestosterone (Android, Methitest, Testred) 10-200 mg daily in 1 to 4 divided doses


iii. uses: male hypogonadism, advanced breast cancer, hypogonadotropic hypogonadism, male androgen
deficiency, palliative treatment for metastatic breast cancer

iv. adverse effects
virilization for females, BPH, priapism, testicular atrophy, hepatotoxicity
most common: gynecomastia, amenorrhea, menstrual irregularities, male pattern baldness
other: hirsutism, acne, deepened voice, hirsutism, acne, deepened voice


v. contraindications: male breast cancer, prostate cancer, pregnancy, breastfeeding

vi. nursing care

assist health care team to establish baseline data and check periodically thereafter weight, urine
output, blood pressure, hematocrit, hemoglobin, liver function tests, urine/serum calcium levels

hand and wrist X-ray exams every six months for prepubertal males

assist health care team to implement client teaching plan - do not abruptly discontinue therapy






b. type: anabolic steroids

i. action: develop muscle mass without androgenic effects

ii.
example: oxandrolone (Oxandrin) 2.5-20 mg by mouth per day in 2 to 4 divided doses
Black Box Warning - peliosis hepatis, hepatic tumors, lipid changes

iii. uses

adjunct treatment for weight gain, osteoporosis associated bone pain

Turner syndrome short stature, male delayed puberty


284

iv. adverse effects

peliosis hepatis, hepatic necrosis, failure and tumor

most common: acne, hirsutism, deepened voice, menstrual irregularities

other

priapism, gynecomastia, bladder irritability, male pattern baldness

clitoral enlargement, libido changes, impotence



v. contraindications: prostate cancer, male breast cancer, female breast cancer with hypercalcemia, hypercalcemia,
nephrosis

vi. nursing care

assist health care team to establish baseline data and check prior to initiating and at regular intervals
during therapy hematocrit and hemoglobin, liver function tests, lipid panel

establish baseline data and check weight, mental status, blood pressure





2. Therapeutic class: erectile dysfunction agents

a. action: activates or prevents the breakdown of cGMP PDE5 causing smooth muscle relaxation and blood to fill the
corpus cavernosum resulting in an erection

b.
examples

i. sildenafil (Viagra) 50 mg by mouth for 1 dose

ii. tadalafil (Cialis) 5-20 mg by mouth before desired sexual activity

iii. vardenafil (Levitra, Staxyn) 10 mg by mouth 1 hour before sexual activity


c. uses: erectile dysfunction

d. adverse effects

i. life-threatening: anaphylaxis, angina, myocardial ischemia and infarction

ii. most common: hyper or hypotension, syncope, tachycardia, QT prolongation

iii. other: headache, flushing, rhinitis, dyspepsia, sinusitis, flu syndrome, dizziness


e. contraindications

i. prolonged QT interval, moderate to severe hepatic impairment

ii. hereditary fructose intolerance

iii. concurrent nitrate therapy


f. nursing care: review medication profile for nitrates and antihypertensives




X. Managing Hematological Conditions

A. Therapeutic classification: antianemic agents

1. Type: erythropoietin

a. action: stimulates red blood cell (RBC) production in bone marrow

b.
examples

i. epoetin alfa (Epogen, Procrit) 50-100 units/kg SubQ/IV 3 times a week
Black Box Warning - increased mortality and serious cardiovascular events in chronic kidney disease,
increased mortality and/or tumor progression in cancer clients, increased thromboembolic events in post
surgery

ii. darbepoetin alfa (Aranesp) 0.45 mcg/kg SubQ/IV weekly
Black Box Warning - increased mortality and serious cardiovascular events in chronic kidney disease,
increased mortality and/or tumor progression in clients with cancer

285


c. uses: chronic kidney disease-associated anemia, chemo-related anemia

d. adverse effects

i. life-threatening: increased mortality, tumor progression, thromboembolism, myocardial infarction, stroke,
heart failure, hypertension

ii. most common: infection, hypotension, muscle spasm, myalgia

iii. other: diarrhea, nausea/vomiting, upper respiratory infection


e. contraindications: hypersensitivity to albumin, uncontrolled hypertension

f. nursing care

i.
assist health care team to establish ferritin, transferrin saturation at baseline, hemoglobin weekly; blood
pressure

ii. assist health care team to implement client teaching plan

store in refrigerator (but do not freeze), protect from light

do not shake medication

how to self-inject medication








2. Type: iron preparations

a. action: critical element in hemoglobin molecule and establishes its affinity for oxygen

b.
example: ferrous sulfate 750-1500 mg/day by mouth divided in 2 to 4 doses

c. uses: iron deficiency

d. adverse effects: dyspepsia, nausea, vomiting, constipation, diarrhea, dark stools

e. contraindications: primary hemochromatosis, hemolytic anemia, hemosiderosis, PUD, ulcerative colitis

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter - hemoglobin, hematocrit, bilirubin, bowel elimination pattern

ii.
encourage intake of iron-rich foods
Vitamin-rich foods
iron lean red meat, liver; also clams, oysters, sardines
folic acid green leafy vegetables, milk, eggs, liver
vitamin B12 meat, seafood, eggs, cheese
vitamin K dark green leafy vegetables



iii. therapeutic effect may take 2 to 3 weeks, therapy may last 6 to 12 months

iv. administration: best absorption with vitamin C

v. assist health care team to implement client teaching plan

do not crush or chew tablets

stools may be black and sticky

may take with food if gastrointestinal upset is severe

prevent constipation with fluids, ambulation, and fiber

take at least one hour before bedtime, avoid reclining for at least 30 minutes




286

3. Type: folic acid (vitamin B-complex group)

a. action: required for red bone marrow function of red blood cells, white blood cells, platelets

b.
example: folic acid (vitamin B9) 0.4 mg by mouth daily

c. uses: folate-deficient megaloblastic anemia, tropical sprue

d. adverse effects: anorexia, nausea, abdominal pain, flatulence, altered sleep patterns

e. contraindications: undiagnosed anemia

f. nursing care

i.
collaborate with dietitian for folate-rich diet

ii. review medication profile for medications that may interact with folic acid, including phenytoin (Dilantin),
methotrexate (Trexall), nitrofurantoin (Macrodantin)





4. Type: vitamin B 12

a. action: essential for cell growth and division, nerve function, protein and carbohydrate metabolism, red blood cell
development and reproduction

b.
example: cyanocobalamin (vitamin B12) 1000 mcg SubQ/IM every month

c. uses: Schilling test flushing dose, pernicious anemia, vitamin B 12 deficiency

d. adverse effects

i. life-threatening: anaphylaxis, peripheral vascular thrombosis, thrombocytosis, hypokalemia, pulmonary edema,
heart failure

ii. other: headache, nausea, anxiety, ataxia, nervousness


e. contraindications: hereditary optic atrophy

f. nursing care

i.
assist health care team to establish baseline data and check periodically thereafter potassium, platelets

ii. collaborate with dietitian for diet rich in vitamin B12

iii. may be mixed with TPN

iv. assist health care team to implement client teaching plan: may require life-long treatment





B. Therapeutic classification: hemostatic agents (promote blood clotting)

1. Type: heparin antagonist

a. action: binds to heparin and renders it ineffective

b.
example: protamine sulfate 1-1.5 mg IV per 100 units heparin
Black Box Warning - serious adverse events, appropriate use

c. use: heparin reversal

d. adverse effects

i. life-threatening: anaphylaxis, anaphylactoid reaction, bronchospasm, angioedema, circulatory collapse, severe
bradycardia and hypotension

ii. other: dyspnea, flushing, fatigue, nausea


e. contraindication: hypersensitivity to fish

f. nursing care: monitor ECG, blood pressure during infusion





287



2. Type: warfarin antagonist

a. action: promotes hepatic production of several clotting factors

b.
example: phytonadione (Mephyton, vitamin K) 100 mcg by mouth 1 to 2 times daily
Black Box Warning - severe reactions with IV use

c. uses: hypoprothrombinemia, warfarin stabilization

d. adverse effects

i. life-threatening: anticoagulant resistance, hypersensitivity reaction, anaphylaxis

ii. most common: taste changes, flushing, injection site hematoma


e. nursing care - assist health care team to implement client teaching plan

i.
AVOID alcohol and over-the-counter drugs

ii. report bleeding

iii. need for follow-up care and testing

iv. use soft toothbrush, avoid hazardous activity until INR is within normal limits





3. Type: systemic hemostatic agents

a. action: inhibits plasminogen activating substances to stop the endogenous system for dissolving clots

b.
example: aminocaproic acid (Amicar) 4-5 g IV for 1 dose, then 1g/h IV

c. uses: hyperfibrinolysis bleeding, hemophilia A dental bleeding, traumatic, hyphema, hereditary hemorrhagic
telangiectasia, chronic bleeding, missed abortion

d. adverse effects

i. life-threatening: anaphylaxis, coagulation disorder, agranulocytosis, leukopenia

ii. other: thrombocytopenia, thrombosis, rhabdomyolysis, intracranial hypertension

iii. seizures, acute renal failure, nausea, cramps, diarrhea, hypertension


e. contraindications: active intravascular clotting

f.
nursing care: observe RN establish baseline data and monitor creatinine kinase with long-term treatment




C. Therapeutic classification: clotting factors

1. Action: replacement therapy for clotting factor deficiency

2.
Examples

a.
factor VIIa: recombinant coagulation factor VIIa (NovoSeven RT) 90 mcg/kg IV bolus every 2 hours until
hemostasis
Black Box Warning - serious thrombotic events and off-label use

b. factor VII: desmopressin (DDAVP) 0.3 mcg/kg IV for 1 dose

c.
factor IX: coagulation factor IX (BeneFIX) individualized dose


3. Adverse effects

a. life-threatening: anaphylaxis/anaphylactoid reaction, thromboembolism

b. other: headache, dizziness, rash, injection site reaction and pain


4. Contraindications: hypersensitivity to hamsters or latex

5. Nursing care: observe RN assess and monitor blood pressure, heart rate before and during administration

288




D. Therapeutic classification: agents for sickle cell anemia

1. Type: anticancer

a. action: inhibits DNA synthesis

b.
example: hydroxyurea (Droxia, Hydrea) 1-35 5 mg/kg/day by mouth daily
Black Box Warning - appropriate use, serious adverse effects, cardiogenic risk

c. use: sickle cell disease

d. adverse effects

a. life-threatening: myelosuppression, anemia, leukopenia, thrombocytopenia

b. most common: stomatitis, anorexia, nausea/vomiting


e. contraindications: myelosuppression, pregnancy

f. nursing care

i.
observe RN establish baseline data and monitor BUN/creatinine, liver function tests

ii. provide oral care

iii. administration

avoid contact with skin

premedicate with antiemetic


iv. observe RN implement client teaching plan

report fainting, shortness of breath, bleeding, cough

AVOID aspirin, aspirin-like products or NSAIDs

avoid shaving, dangerous activities, and sick people







E. Therapeutic classification: granulocyte colony stimulator

1. Action: stimulates neutrophil production

2.
Example: filgrastim (G-CSF, Neupogen) 5-10 mcg/kg SubQ/IV daily

3. Uses: post-chemo neutropenia, post-bone marrow transplant neutropenia, peripheral blood progenitor cell (PBPC)
mobilization, AIDS neutropenia

4. Adverse effects

a. life-threatening: splenic rupture, ARDS, anaphylaxis, thrombocytopenia

b. bone and musculoskeletal pain, splenomegaly


5. Contraindications: hypersensitivity to Escherichia coli protein

6. Nursing care

a.
assist health care team to establish baseline data and check prior to beginning therapy and during therapy
complete blood count with differential, platelets

b. administration

i. administer no earlier than 24 hours after the administration of cytotoxic chemotherapy

ii. store in refrigerator, do not freeze; allow to warm to room temperature prior to administration


c. assist health care team to implement client teaching plan

i. injection technique

ii. avoid sick people, watch for signs of infection





289

XI. Managing immunological conditions

A. Therapeutic classification: anti-inflammatory agents

1. Type: non-steroidal anti-inflammatory agents

2. Type: steroidal anti-inflammatory agents

a. action: powerful suppression of inflammation by inhibiting the mobilization leukocytes, fibroblasts, and
inflammatory mediators; prevents increased capillary permeability

b. examples

i.
short-acting

hydrocortisone (Cortef) 20-240 mg by mouth daily in 2 to 4 divided doses

hydrocortisone sodium succinate (Solu-CORTEF) 20-240 mg IM/IV divided in 2 to 4 doses


ii.
intermediate-acting: predniSONE (Sterapred, Sterapred DS) 5-60 mg by mouth daily

iii.
long-acting: dexamethasone 0.75-9 mg/kg by mouth daily every 6 to 12 hours


c. uses

i. corticosteroid-responsive conditions, acute asthma, severe persistent asthma

ii. adrenal insufficiency, acute exacerbation multiple sclerosis, prevention for chemo-related nausea and
vomiting

iii. acute alcoholic hepatitis, adjunct treatment for pneumocystis carinii pneumonia (PCP)


d. adverse effects

i. life-threatening: adrenal insufficiency, steroid psychosis, immunosuppression

ii. other: peptic ulcer, heart failure, osteoporosis

iii. most common: nausea, vomiting, dyspepsia, appetite changes, edema





e. contraindications: systemic fungal infection

f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals thereafter

blood pressure, weight

electrolytes, 2 hour postprandial glucose


ii. frequently monitor for signs of infection

iii. assist health care team to implement client teaching plan

take daily therapy in morning

report infection, fever, surgery, anorexia, fatigue, dizziness, joint pain, bleeding

need for follow-up care and testing

do not abruptly discontinue therapy

wear Medic Alert identification, take only as directed

protect skin, avoid sick people, wash hands frequently

injection technique for insulin to control hyperglycemia

AVOID herbal remedies

AVOID over-the-counter drugs





B. Therapeutic classification: antihistamines

1. Type: H-receptor blockers (first generation - associated with drowsiness)

a. action: compete with histamine for receptor sites to decrease allergic response
290


b.
examples

i. brompheniramine (Dimetapp) 12-24 mg by mouth every 12 hours

ii. clemastine (Tavist Allergy) 1-2 mg by mouth 2 to 3 times daily as needed

iii. diphenhydrAMINE (Benadryl) 25-50 mg PO/IM/IV every 4 to 6 hours as needed

iv. promethazine (Phenergan) 6.25-12.5 mg by mouth 3 times per day
Black Box Warning - respiratory depression, severe tissue injury, gangrene


c. uses

i. allergic rhinitis, urticaria, allergy symptoms

ii. moderate to severe allergic reactions, extrapyramidal symptoms, short term treatment for insomnia

iii. motion sickness prevention, sedation, nausea and vomiting


d. adverse effects

i. life-threatening: apnea, respiratory depression, seizures

ii. most common: drowsiness, sedation

iii. other: blurred vision, confusion, dizziness, disorientation, dry mouth, photosensitivity

iv. diphenhydramine is a high risk drug in the elderly (based on the Beers Criteria)


e. contraindications: clients who are comatose, respiratory depression

f. nursing care

i. assist health care team to establish baseline data and check prior to beginning therapy and periodically
thereafter breath sounds and respiratory secretions, temperature, level of consciousness

ii. assist with ambulation

iii. do not confuse diphenhydrAMINE (Benadryl) with dimenhyDRINATE (Dramamine)

iv. assist health care team to implement client teaching plan

may take with food

drink 2000 mL fluids daily

use sunscreen, ask for help when getting up

AVOID alcohol, over-the-counter drugs, central nervous system depressants

do not drive or engage in hazardous activities for 8 hours after taking




2. Type: second generation antihistamines - associated with less drowsiness and anticholinergic effects (examples:
fexofenadine [Allegra], cetirizine [Zyrtec], loratadine [Claritin] - all are sold over-the-counter)

3. Type: mast cell stabilizers (example: cromolyn [Intal inhaler])




C. Therapeutic classification: immune modulators - stimulants

1. Type: interferons

a. action: prevent viral replication in host cells, stimulate production of antiviral proteins, inhibits tumor growth, and
increases aggressiveness of phagocytes

b.
examples

i. interferon beta 1a (Avonex, Rebif)

ii. interferon beta 1b (betaseron, Extavia)

iii. interferon alfacon-1 (Infergen)
BLack Box Warning - fatal/life threatening events, concomitant ribavirin

iv. interferon alfa-2b (Intron A)
BLack Box Warning - fatal/life threatening events

291


c. uses: external condyloma acuminata, hairy cell leukemia, chronic hepatitis B infection, chronic hepatitis C, AIDS-
associated Kaposi sarcoma, follicular non-Hodgkin lymphoma, relapsing forms of multiple sclerosis

d. adverse effects

i. life-threatening: myelosuppression, aplastic anemia, pure red cell aplasia, idiopathic thrombocytopenic purpura,
thrombotic thrombocytopenic purpura

ii. most common: psychosis, aggressive behavior, depression, suicidality

iii. other: influenza-like symptoms, anorexia, pruritus/rash


e. nursing care

i. observe RN establish baseline data and monitor

ECG, ophthalmic exams

complete blood count


ii. avoid contact with skin

iii. clients may become hemodynamically unstable during therapy

iv. different interferons are not interchangeable: each has individual indications, dosing, and administration
guidelines

v. observe RN implement client teaching plan

avoid hazardous activity

report signs of infection

different interferons are not interchangeable - always check refills for correct brand and type of
medicine ordered







2. Type: interleukins (IL)

a. action: stimulates cellular immunity of helper T cells to inhibit tumor growth

b.
examples

i. aldesleukin (Proleukin)
Black Box Warning - appropriate use, capillary leak syndrome, serious infection risk, lethargy

ii. oprelvekin (Neumega)
Black Box Warning - anaphylaxis


c. uses: metastatic renal cell cancer, metastatic melanoma, chemo-related thrombocytopenia prevention

d. adverse effects

i. life-threatening: pulmonary edema, capillary leak syndrome, pleural effusion, atrial and ventricular arrhythmias

ii. most common: dilutional anemia, edema, dyspnea, tachycardia


e. contraindications: heart failure, risk or history

f. nursing care

i.
assist the health care team to establish baseline data for creatinine and monitor throughout therapy complete
blood count with differential, platelets

ii. observe RN implement client teaching plan

report changes in breathing, development of cough

watch for infection, avoid pregnancy

AVOID shaving, aspirin, ibuprofen, alcohol

AVOID pregnancy





292

D. Therapeutic classification: immune modulators, immunosuppressants

1. Information common to immunosuppressive agents

a. action: impair an aspect of the immune system most responsible for or likely to stimulate allograft rejection while
exposing the individual to risks of immunosuppression

b. adverse effects

i. life-threatening: susceptibility to opportunistic infections and malignancies, masks signs of infection, stimulates
latent infection, nephrotoxicity, hepatic dysfunction, hyperglycemia, hyperlipidemia, thrombocytopenia,
arrhythmias, embryotoxic and teratogenic

ii. most common: anorexia, nausea, diarrhea, potentiates the action and adverse effects of other
immunosuppressants


c. contraindications: when risk of immunosuppression outweighs benefit of drug; tolerance

d. nursing care

i. assist health care team to establish baseline data and check prior to beginning therapy and at regular intervals
thereafter

drug levels, renal and liver function tests, complete blood count, immune markers

chest x-ray, tissue biopsy

allograft function

cardiac: blood pressure, ECG

pulmonary: SaO
2
, PaCO
2
, pulmonary function tests

renal: creatinine, creatinine clearance

hepatic: liver function tests, prothrombin time (PT)

search for infection


ii. assist health care team to implement client teaching plan

need for follow-up care and testing, life-long duration of therapy

avoid pregnancy, promptly report signs of infection

follow manufacturer's instructions on mixing and administration, take only as directed, and take until
instructed to stop

hand washing and infection control

reinforce client teaching

avoid sick people, ceiling fans and room fans

wear tight fitting mask on windy days

cook meat, poultry, and fish until well-done

avoid digging in dirt and avoid cat litter boxes, birds and bird cages

restrict fresh fruits and vegetables to items that are easily peeled or washed in soap and water
such as bananas, oranges, apples, carrots, tomatoes, potatoes








2. Type: T- and B-cell suppressants

a. action: suppress antibody production, suppressor and helper T-cells, and release of interleukins

b.
examples

i. cyclosporine modified (Gengraf, Neoral)
Black Box Warning - appropriate use, immunosuppressant, bioequivalence, monitor drug levels, skin
malignancy risk in psoriasis, nephrotoxicity risk hypertension

ii. mycophenolate acid (Myfortic)
Black Box Warning - appropriate use, immunosuppressant, pregnancy
293


iii. sirolimus (Rapamune)
Black Box Warning - appropriate use, immunosuppressant, liver and lung transplantation

iv. tacrolimus (FK506, Hecoria, Prograf)
Black Box Warning - appropriate use, immunosuppressant


c. uses

i. kidney transplant rejection prophylaxis, organ transplant rejection prophylaxis, severe rheumatoid arthritis

ii. severe recalcitrant plaque psoriasis, heart transplant rejection prophylaxis, liver transplant rejection prophylaxis


d. adverse effects: see previous page immunosuppressants

e. nursing care: see previous page immunosuppressants




3. Type: monoclonal antibodies

a. action: impairs the effects of tumor necrosis factor alpha, competes with IL-2 for receptor sites, and impairs
immunological response to antigens

b.
examples

i. muromonab-CD3 (Orthoclone OKT3)
Black Box Warning - appropriate use, anaphylactic/anaphylactoid reaction

ii. basiliximab (Simulect)
Black Box Warning - appropriate use

iii. infliximab (Remicade)
Black Box Warning - serious infection risk, malignancy


c. uses

i. organ transplant rejection prophylaxis, ankylosing spondylitis, Crohn disease

ii. kidney transplant rejection prophylaxis, psoriatic arthritis, rheumatoid arthritis, active moderate to severe ulcerative
colitis


d. adverse effects: serious infection, sepsis, pneumonia, opportunistic infection, tuberculosis, malignancy,
lymphoma,leukemia, fever, chills, myalgia, back pain, headache, fatigue, arthralgia, dizziness, nausea, urticaria

e. nursing care

i.
establish baseline data and monitor HBsAG, signs and symptoms of active HBV, PPD, signs and symptoms of
active TB

ii. observe RN implement client teaching plan

AVOID pregnancy

promptly report signs of infection

need for follow-up care and testing

hand-washing and infection control

wear tight fitting mask on windy days

avoid sick people, ceiling fans and room fans

restrict fresh fruits and vegetables to items that are easily peeled or washed in soap and water such
as bananas, oranges, apples, carrots, tomatoes, potatoes; cook meat, poultry, and fish until well-done

AVOID digging in dirt, cat litter box, birds and bird cages



4. Type: glucocorticoids: used in combination with cyclosporine and other immunosuppressants


294

E. Therapeutic classification: anti-infectives

1. information common to anti-infectives

a. action: interferes with the cellular functioning of the pathogen resulting in impaired proliferation and death without
injuring host

b. uses

i. surgical prophylaxis

ii. treatment of infections from susceptible bacterial pathogens


c. adverse effects

i. life-threatening: hepatotoxic and nephrotoxic especially in older clients

ii. most common: diarrhea, secondary infections especially candidiasis, GI upset including anorexia, nausea,
diarrhea, especially common in children and older clients

iii. other: may render oral contraceptives ineffective


d. contraindications: viral infections

e. nursing care

i. assist health care team to establish baseline data and check prior to starting therapy and at regular intervals
thereafter hydration, temperature, white blood count, clinical indicators of the infection, bowel pattern and
indications of secondary infection

ii.
obtain cultures before initiating therapy

iii. assist health care team to implement client teaching plan

drink fluids, maintain nutrition

take entire course of the medication

continue to take medication when feeling better

barrier contraception may be required during therapy

resistant strains of bacteria and secondary infections may develop if not taken as directed and for
entire length of therapy

report secondary infection: vaginal itching, diarrhea, fever, rash, change in cough or sputum, white
plaques in mouth







2. Type: aminoglycosides

a. action: powerful bactericidal agents associated with many severe adverse effects

b.
examples (dosing adjusted according to blood level of drug and renal function)

i. gentamicin 1- 1.7 mg/kg IM/IV every 8 hours
Black Box Warning - neurotoxicity/ototoxicity, nephrotoxicity, neuromuscular blockade

ii. streptomycin 1-2 g/day IM divided every 6-12 hours
Black Box Warning - appropriate use, neurotoxicity/ototoxicity, neuromuscular blockade


c. uses: bacterial infections, severe PID, active tuberculosis, plague, tularemia

d. adverse effects

i. life-threatening: nephrotoxicity, myelosuppression, neurotoxicity/ototoxicity, neuromuscular blockade

ii. most common: nausea, vomiting, facial paresthesia

iii. other: rash, fever, urticaria


e. contraindications: hypersensitivity to sulfites, impaired vestibular and auditory function, concurrent ototoxic and
neurotoxic medications

f. nursing care

i. assist health care team to establish baseline data and check prior to starting and at regular intervals during therapy
295


signs of original infection

BUN/creatinine, urinalysis

therapeutic drug levels


ii. audiometry for high risk patients

iii. assist health care team to implement client teaching plan: report difficulty breathing, change in urine output or
changes in hearing



3. Type: antimyocbacterials (antituberculars)

4. Type: cephalosporins

a. action: bactericidal and bacteriostatic depending on the agent and dose

b.
examples

i. first generation: cephalexin (Keflex) 1000-4000 mg/ day by mouth divided in doses every 6-12 hours

ii. second generation: cefaclor (Ceclor) 250-500 mg by mouth every 8 hours

iii. third generation: ceftriaxone (Rocephin) 0.5-1 mg IM, IV every 12 hours

iv. fourth generation: cefepime (Maxipime) 0.5-1 gram every 12 hours


c. uses: bacterial infections, endocarditis prophylaxis, uncomplicated gonococcal infections, disseminated gonococcal
infections, gonococcal conjunctivitis, mild-moderate PID, surgical infection prophylaxis, epididymitis, endocarditis
prophylaxis, typhoid fever, febrile neutropenia, mild-moderate and severe UTI

d. adverse effects

i. life-threatening: anaphylaxis, encephalopathy, seizures, leukopenia

ii. other: rash, injection site reaction, diarrhea, hypophosphatemia, elevated ALT & AST, nausea


e. contraindications: hypersensitivity to penicillin, renal impairment

f. nursing care

i. check for signs of infection before initiating and at regular intervals during therapy

ii. assist health care team to implement client teaching plan

report severe diarrhea, headache, dyspnea, dizziness

AVOID alcohol during and 72 hours after therapy (may cause disulfiram-like reaction, including flushing,
headache, nausea, chest pain, dyspnea, blurred vision, seizures)






5. Type: dichloroacetic acid derivative

a.
example: chloramphenicol (Chloromycetin) 50-100 mg/kg/day IV divided every 6 hours
Black Box Warning - appropriate use, blood dyscrasias

b. use: bacterial infections, rickettsial infections, bacterial meningitis

c. adverse effects

i. life-threatening: aplastic anemia, hypoplastic anemia, agranulocytosis

ii. most common: headache, nausea, vomiting, diarrhea


d. contraindications: pregnancy, infancy, mild infection

e. nursing care

i. observe RN establish baseline data and monitor

clinical indicators of infection, secondary infection

therapeutic drug levels
296


creatinine, complete blood count


ii. screen clients for hypersensitivity to other antibiotics




6. Type: fluoroquinolones

a.
examples

i. ciprofloxacin (Cipro, Cipro XR, Proquin XR) 250-750 by mouth every 12 hours
Black Box Warning - tendinitis/tendon rupture, avoid in myasthenia gravis

ii. levofloxacin (Levaquin) 500 mg PO/IV every 24 hours for 7 days
Black Box Warning - tendinitis/tendon rupture, avoid in myasthenia gravis


b. uses: bacterial infections, complicated and uncomplicated UTI, anthrax. typhoid fever, chancroid, acute salmonellosis,
chronic carrier salmonella, acute bacterial exacerbation chronic bronchitis, community-acquired and nosocomial
pneumonia, acute pyelonephritis, acute bacterial sinusitis, non-gonococcal urethritis

c. adverse effects

i. anaphylaxis, hypersensitivity reaction, photosensitivity, C. difficile associated diarrhea

ii. superinfection, increased intracranial pressure, seizures

iii. toxic psychosis, depression, suicidal ideation, QT prolongation


d. contraindications: prolonged QT interval, hypokalemia, myasthenia gravis

e. nursing care

i.
assist health care team to establish baseline data and check at regular intervals during therapy creatinine and
glucose, if diabetic

ii.
administer 1 hour before or 2 hours after meals





7. Type: lincosamides

a.
example: clindamycin (Cleocin) 150-450 mg by mouth every 6 hours
Black Box Warning - C. difficile-associated diarrhea

b. uses: bacterial infections, bacterial vaginosis, mild-moderate PID, endocarditis prophylaxis, babesiosis

c. adverse effects: C. difficile associated diarrhea, thrombocytopenia, anaphylaxis, Stevens-Johnson syndrome

d. contraindications: ulcerative colitis

e. nursing care

i. assist health care team to establish baseline data and check prior to beginning therapy and periodically thereafter
rash, fever, chills, joint pain, bleeding

ii.
BUN, creatinine, liver function tests with prolonged use

iii. administration

do not crush or chew tablets

do not refrigerate oral preparations

give deep IM injection









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8. Type: macrolides

a.
examples

i. clarithromycin (Biaxin) 250-500 mg by mouth every 12 hours for 7 to 14 days

ii. erythromycin base (Ery-Tab, Eryc, PCE) 1000 mg by mouth daily divided every 6 to 12 hours

iii. azithromycin (Zithromax, Zmax) 500 mg by mouth on day one, then 250 mg by mouth every 24 hours for 4 days


b. uses: bacterial infections, acute maxillary sinusitis, acute bacterial exacerbation chronic bronchitis, community-
acquired pneumonia, HIV MAC prophylaxis, H.pylori infections, endocarditis prophylaxis, Legionnaires disease,
intestinal amebiasis, syphilis, gastroparesis

c. adverse effects

i. life-threatening: angioedema, anaphylaxis, cholestatic jaundice, hepatotoxicity, pancreatitis

ii. other: C. difficile associated diarrhea, QT prolongation, nausea, abdominal pain, vaginitis




9. Type: monobactam

a.
example: aztreonam (Azactam) 1-2 g IM/IV every 8 to 12 hours

b. use: serious infections (rarely used)



10. Type: oxazolidinone

a. action: prevents bacterial translation

b.
example: linezolid (Zyvox) 600 mg IV/PO every 12 hours for 14 to 28 days

c. uses: community-acquired or nosocomial pneumonia, VREF infections, complicated and uncomplicated skin/skin
structure infections, moderate severe bacterial infections, urinary tract infections

d. adverse effects: anaphylaxis, hypersensitivity reaction, toxic epidermal necrolysis, seizures, C. difficile associated
diarrhea

e. nursing care

i.
assist health care team to establish baseline data and check before beginning and periodically during therapy
liver function tests, creatinine

ii. assess and monitor for allergic reaction




11. Type: penicillins

a.
examples

i. penicillin G potassium aqueous (Pfizerpen) 1-24 milion units/day IM/IV divided every 4 to 6 hours

ii. penicillin V potassium (250 mg PCN VK=400,000 units PCN) 250-500 mg by mouth 2 to 3 times daily for 10 days

iii. sub-type: aminopenicillin

amoxicillin (Amoxil, Moxatag) 500-875 mg by mouth every 12 hours

ampicillin 250-500 mg by mouth every 6 hours


iv. sub-type: beta-lactamase inhibitors, e.g., amoxicillin with clavulanate (Augmentin, Augmentin ES-600, Augmentin
XR) 500 mg/125-875 mg by mouth every 12 hours



b. uses

i. bacterial infections, meningococcal meningitis, meningococcal septicemia, anthrax, bacterial meningitis

ii. intrapartum GBS prophylaxis, community-acquired pneumonia

iii. group A streptococcal tonsillopharyngitis, rheumatic fever prophylaxis, pneumococcal infection prophylaxis

iv. acute bacterial sinusitis, acute otitis media, H. pylori, endocarditis prophylaxis, anthrax, chlamydial
cervicitis/urethritis

v. dental abscess, early Lyme disease, acute salmonellosis, chronic carrier salmonella, typhoid fever

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c. adverse effects

i. life-threatening: anaphylaxis, immediate or delayed hypersensitivity reaction

ii. other: serum-sickness-like reaction, nausea, vomiting, diarrhea, urticaria


d. contraindications: hypersensitivity to penicillins, aminopenicillins, or cephalosporins, mononucleosis

e. nursing care

i.
assist health care team to establish baseline data and check periodically during therapy creatinine, complete
blood count, liver function tests

ii. female clients taking oral contraceptives should use alternate form of contraception during therapy





12. Type: streptogramins

a.
example: quinupristin/dalfopristin (Synercid) 7.5 mg/kg IV every 8 hours
Black Box Warning - VREF indication

b. use: serious/life-threatening VREF infections, complicated bacterial skin/skin structure infections



13. Type: sulfonamides

a. action: inhibit folic acid synthesis

b.
examples

i. erythromycin/sulfisoxazole (Pediazole) 40-50 mg/kg/day by mouth divided every 6 to 8 hours

ii. trimethoprim/sulfamethoxazole (Septra, Septra DS) 160 mg TMP by mouth every 12 hours


c. uses: bacterial infections, pneumocystis carinii pneumonia prophylaxis and treatment, acute salmonellosis, chronic
carrier salmonella, typhoid fever

d. adverse effects

i. superinfection, C. difficile associated diarrhea, hepatic impairment, hepatitis, fulminant hepatic necrosis

ii. other

QT prolongation, ventricular arrhythmias, torsades de pointes

nausea/vomiting, abdominal pain, anorexia, rash, urticaria, photosensitivity




e. contraindications

i. clients younger than 2 months-old, pregnancy near-term

ii. hypersensitivity to sulfonamides



f. nursing care

i.
assist health care team to establish baseline data and check BUN/creatinine, complete blood count, serum
drug levels

ii. assist health care team to implement client teaching plan

discontinue drug and report rash, hematuria, ringing in ears

drink 2000-3000 mL of fluids daily during therapy









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14. Type: tetracyclines

a.
examples

i. tetracycline (Sumycin) 1-2 g/day by mouth divided 2-4 times a day

ii. doxycycline (Adoxa, Doryx, Monodox, Oracea, Perostat, Vibramycin) 100 mg PO/IV daily

iii. minocycline (Dynacin, Minocin, Solodyn) 100 mg by mouth every 12 hours


b. uses

i. bacterial infections, acne vulgaris, chlamydia infections, primary or secondary syphilis, H. pylori infection

ii. mild-moderate to severe bacterial infections, periodontitis, mild-moderate to severe PID, uncomplicated
gonococcal infections

iii. lymphogranuloma venereum, non-gonococcal urethritis, epididymitis, proctitis, Lyme disease, anthrax, malaria
prophylaxis

iv. chlamydial infection prophylaxis, presumptive cervicitis, Mycobacterium marinum infection


c. adverse effects

i. life-threatening: hepatotoxicity, fetal harm

ii. other: tooth discoloration, oral or vulvovaginal candidiasis, tooth discoloration, oral or vulvovaginal candidiasis,
abdominal and epigastric discomfort, anorexia, flatulence


d. contraindications: pregnancy, avoid conception, clients younger than 8 years-old

e. nursing care

i.
assist health care team to establish baseline data and check before starting and at regular intervals during
therapy liver function tests, complete blood count, BUN/creatinine

ii. assist health care team to implement client teaching plan

use sunscreen

do not take with antacids,salts, milk or calcium products

use barrier protection to avoid pregnancy






15. Type: tricyclic glycopeptide

a.
example: vancomycin (Vancocin) 500-2000 mg/day by mouth every six hours for 10 to 14 days

b. uses: severe bacterial infections, C. difficile associated diarrhea, staphylococcal enterocolitis

c. adverse effects

i. life-threatening: anaphylactic/anaphylactoid reactions, severe hypotension, thrombophlebitis

ii. most common: red-man syndrome, fever, chills, eosinophilia


d. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter hearing, urine output, blood pressure, respiratory rate, ECG

ii.
assist health care team to establish baseline data and check at regular intervals during therapy
BUN/creatinine

iii.
assist health care team to establish baseline data and check at regular intervals during therapy drug peak
and trough

draw blood specimen 1 hour after a 1-hour infusion

draw blood specimen for trough before next dose


iv. assist health care team to implement client teaching plan: take at equal intervals around the clock to maintain
even drug levels



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F. Therapeutic classification: antifungal agents

1. Information common to antifungal agents

a. action: alter fungal cell permeability, prevents replication causing cell death

b. adverse effects

i. hepatotoxicity, renal dysfunction

ii. nausea, dyspepsia, anorexia

iii. rash, headache, dizziness, fever


c. contraindications: renal or hepatic dysfunction

d. nursing care

i.
obtain cultures before initiating therapy

ii.
assist health care team to establish baseline data and check at regular intervals thereafter creatinine, liver
function tests

iii. assist health care team to implement client teaching plan

therapy may last for 6 months

report unusual bruising or bleeding, jaundice

change position slowly, ask for help before getting up

take entire course of therapy, do not stop taking when feeling better






2.
Sub-type: azoles

a. action: fungistatic and fungicidal systemic agent

b.
example: fluconazole (Diflucan) 100 mg PO/IV daily

c. uses: candidiasis (bladder, systemic, vulvovaginal, esophageal, oropharyngeal), cryptococcal meningitis, bone marrow
transplant fungal prophylaxis

d. adverse effects: hepatotoxicity, seizures

e. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter liver function test

ii. IV administration - prevent extravasation

iii. assist health care team to implement client teaching plan

may take with food

shake oral suspension before using

use barrier contraception to avoid pregnancy

report jaundice, nausea, anorexia, fatigue or dark urine or stool





3. Sub-type: amphotericin B, systemic agent

a.
example: amphotericin B deoxycholate (Amphocin) 0.3-1 mg/kg IV daily
Black Box Warning - invasive fungal infection, overdose prevention

b. uses: systemic fungal infections, candida cystitis

c. adverse effects

i. life-threatening: hypokalemia, severe electrolyte imbalance, nephrotoxicity, renal failure

ii. most common: acute infusion reaction, fever, chills
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iii. other: headache, hypotension, injection site pain, epigastric pain, tachypnea


d. contraindications: renal impairment and electrolyte abnormalities

e. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter BUN, creatinine, complete blood count, electrolytes, liver function tests

ii. administer 2000-3000 mL fluid daily

iii. observe RN administer IV treatment

first dose: run a test dose of 1 mg over 30 minutes and monitor client's reaction

change needle after diluting, shake to mix well, then change needle after mixing in IV bag

administer over at least 2 hours

check closely for extravasation





4. Sub-type: nystatin

a.
example: nystatin (Mycostatin) 4-6 mL by mouth 4 times a day

b. uses: oral and intestinal candidiasis

c. adverse effects: nausea/vomiting, diarrhea, abdominal pain

d. nursing care

i. eliminate cause of fungal infection


e. assist health care team to implement client teaching plan

i. long-term therapy may be required

ii. avoid commercial mouthwash during oral therapy





G. Therapeutic classification: antiviral agents

1. Information common to antiviral agents

a. life-threatening adverse effects: heart failure, arrhythmias, cardiac arrest, psychosis, coma

b. contraindications: the elderly, clients diagnosed with depression



2. Sub-type: agents for influenza A and respiratory viruses

a. action: prevents viral replication

b.
examples

i. amantadine (Symmetrel) 100 mg by mouth daily for 3 to 5 days

ii. oseltamivir (Tamiflu) 75 mg by mouth twice daily for 5 days

iii. ribavirin (Copegus, Rebetol, Ribasphere) weight dosed
Black Box Warning - monotherapy not indicated, hemolytic anemia, teratogenic/embryocidal


c. uses

i. influenza A prophylaxis and treatment, extrapyramidal disorders, parkinsonism

ii. uncomplicated influenza B prophylaxis and treatment, chronic hepatitis C


d. adverse effects: hemolytic anemia, neutropenia, thrombocytopenia, aplastic anemia

e. contraindications: pregnancy, male partners of pregnant women, significant or unstable cardiac disease

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter complete blood count with differential, platelets, creatinine, liver function tests, ECG
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ii. initiate therapy as soon as possible after exposure

iii. assist health care team to implement client teaching plan: complete course of therapy to obtain full therapeutic
effect






3. Type: agents for herpes and cytomegalovirus (CMV)

a. action: inhibit viral replication

b.
examples

i. herpes: acyclovir (Zovirax) 400-800 mg by mouth 5 times a day for 5 to 7 days

ii. CMV: ganciclovir (Cytovene) 5 mg/kg IV every 12 hours for 7 to 14 days
Black Box Warning - hematologic toxicities, carcinogen/teratogen, aspermatogenesis, appropriate IV use,
appropriate oral use


c. uses

i. herpes: HSV encephalitis, genital/mucocutaneous HSV in immunocompetent and immunocompromised clients

ii. HSV prophylaxis in immunocompromised clients, HSV keratitis, varicella immunocompetent and
immunocompromised

iii. patients, herpes zoster in immunocompetent and immunocompromised clients, herpes zoster ophthalmicus

iv. CMV: HIV-associated CMV prophylaxis, CMV retinitis in immunocompromised clients


d. adverse effects

i. life-threatening: thrombocytopenia, neutropenia, pancytopenia, sepsis, nephrotoxicity, seizures

ii. other: retinal detachment, hypertension, pancreatitis, GI perforation, impaired fertility, depression, diarrhea, fever,
leukopenia


e. contraindications: ANC< 500/mm
3
or platelets < 25,000/mm
3
, renal disease or severe central nervous system disorders

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter creatinine, complete blood count, platelets

ii. monitor lesions

iii.
give with food

iv. assist health care team to implement client teaching plan

report swollen lymph nodes, fever, bleeding

therapy is not curative

avoid sexual intercourse to prevent spread of virus

need for follow-up care and testing: ophthalmologist, blood tests

complete course of therapy to increase effectiveness and to prevent emergence of resistant strains






4. Agents for HIV and AIDS

a. type: reverse transcriptase inhibitors

i. action: bind directly to HIV reverse transcriptase to prevent transfer of information vital to viral replication and
survival

ii.
examples

delavirdine (Rescriptor) 400 mg by mouth three times a day

nevirapine (Viramune, Viramune XR) 200 mg by mouth two times a day
Black Box warning - hepatotoxicity, skin reactions

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iii. use: HIV infection

iv. adverse effects

life-threatening: severe skin reactions, angioedema, dyspnea

most common: rash, nausea, headache, fatigue, depression, flu syndrome


v. nursing care

assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter liver function test

drug levels decrease with concurrent protease inhibitor therapy

assist health care team to implement client teaching plan

report signs of toxicity: severe nausea, vomiting, maculopapular rash

must be taken at equal intervals around the clock

missed dose: take up to 1 hour before next dose - do not double dose







b. type: protease inhibitors

i. action: block protease activity in the HIV critical for viral maturation

ii.
example: nelfinavir (Viracept) 1250 mg by mouth twice daily

iii. use: HIV infection

iv. adverse effects
life-threatening: seizures, leukopenia, thrombocytopenia, anemia, hepatotoxicity
other: diarrhea, nausea, anorexia, abdominal pain, hyperglycemia


v. contraindications: phenylketonuria (PKU)

vi. nursing care

assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter liver function tests, fasting blood glucose, fasting lipid panel

assist health care team to implement client teaching plan

report diarrhea, nausea, vomiting, rash

give with food






c. type: nucleoside analog antiretroviral agents

i. action: inhibit cell protein synthesis

ii.
examples

abacavir (Ziagen) 300 mg by mouth twice daily
Black Box Warning - hypersensitivity reaction, lactic acidosis/severe hepatomegaly

didanosine (Videx, Videx EC) 200-250 mg by mouth every 12 hours
Black Box Warning - pancreatitis, lactic acidosis/severe hepatomegaly

lamivudine (Epivir, Epivir HBV) 300 mg by mouth daily
Black Box Warning - lactic acidosis/severe hepatomegaly, non-interchangeable forms, hepatitis B exacerbation

zidovudine (Retrovir) 300 mg by mouth twice daily
Black Box Warning - hematologic toxicity, myopathy, lactic acidosis/severe hepatomegaly


iii. uses: HIV infection, prevention of maternal-fetal HIV infection
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iv. adverse effects

life-threatening: lactic acidosis, hepatomegaly with steatosis, hepatotoxicity, severe anemia

most common: headache, malaise, nausea, anorexia

other: asthenia, constipation, abdominal cramps, pain, arthralgia, chills, dyspepsia, insomnia



v. nursing care

assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter creatinine, complete blood count with differential, liver function tests

assist health care team to implement client teaching plan

report fever, flu-like findings, tiredness or weakness, dizziness

carry medication card warning guide at all times






1. Type: combination agents

a.
lamivudine/zidovudine (Combivir) 150/300 1 tablet by mouth twice daily
Black Box Warning - hematologic toxicity, myopathy, lactic acidosis/severe hepatomegaly

b.
abacavir/lamivudine/zidovudine (Trizivir)
Black Box Warning - appropriate use, hypersensitivity reaction, hematologic toxicity, myopathy, lactic
acidosis/severe hepatomegaly, hepatitis B exacerbation

c.
emtricitabine/tenofovir (Truvada) 200/300 1 tablet by mouth daily
Black Box Warning - lactic acidosis/severe hepatomegaly, not approved for HBV infection



2. Type: locally active antiviral agents

a. action: interfere with viral replication and metabolic processes

b.
example: penciclovir (Denavir) 10mg/gm cream apply every 2 hours for 4 days

c. uses: herpes labialis

d. adverse effects: headache, taste change, erythema, pruritus

e. nursing interventions: teach client that these agents are not curative



3. Highly active antiretroviral therapy (HAART)

a. aggressive, combination therapy of at least 3 antiretroviral drugs (a drug "cocktail")

b. suppresses viral replication, allowing body time to rebuild immune system and replenish destroyed CD4 or T cells,
which delays the progression to AIDS and prolongs life




H. Therapeutic classification: antiprotozoal agents

1. Type: antimalarial agents

a. action: inhibit DNA synthesis in susceptible protozoans

b.
examples

i. metronidazole (Flagyl, Flagyl ER) 500 mg by mouth every 6-8 hours for 7 to 14 days

ii. pentamidine (Pentam) 4 mg/kg IV/IM daily for 14 to 21 days
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iii. atovaquone (Mepron) 1500 mg by mouth daily for 21 days



c. uses

i. bacterial infections, trichomoniasis, amebic liver abscess, intestinal amebiasis, perioperative prophylaxis

ii. mild-moderate to severe PID, bacterial vaginosis, giardiasis, C. difficile associated diarrhea, recurrent or
persistent

iii. non-gonococcal urethritis, PCP prophylaxis and treatment, primary and secondary prophylaxis for
toxoplasmosis

iv. toxoplasmosis treatment, mild-moderate babesiosis


d. adverse effects

i. life-threatening-hypersensitivity reaction, angioedema, hepatitis, hepatic failure

ii. other: rash, diarrhea, fever, nausea/vomiting, headache, cough, URI, asthenia, abdominal pain, dyspnea,
insomnia, sweating, influenza-like symptoms


e. contraindications: visual field changes, porphyria

f. nursing care

i.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter BUN/creatinine, glucose, calcium, complete blood count, platelets, liver function tests

ii. assist health care team to implement client teaching plan

medication may cause dizziness or lightheadedness

medication may cause unpleasant metal taste or dry mouth

AVOID alcohol







2. Type: antimalarial agents

a. action: attack various phases of the red blood cell phase of the Plasmodium malariae life cycle

b.
examples

i. chloroquine (Aralen) 500 mg by mouth weekly
Black Box Warning - appropriate use

ii. hydroxychloroquine (Plaquenil) 200-400 mg by mouth weekly
Black Box Warning - prescribing information


c. uses: malaria prophylaxis and treatment, extraintestinal amebiasis, systemic lupus erythematosus (SLE), rheumatoid
arthritis

d. adverse effects

i. life-threatening: seizures, angioedema, bronchospasm, exfoliative dermatitis

ii. most common: dizziness, ataxia, headache, abdominal pain, nausea, vomiting

iii. other: agranulocytosis, thrombocytopenia, aplastic anemia


e. contraindications: retinal or visual field changes, porphyria

f. nursing care

i.
assist health care team to establish baseline data and monitor complete blood count with prolonged treatment

ii. assist RN to check and monitor vision

iii. assist health care team to implement client teaching plan

avoid taking with digoxin

ask for help before getting up
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give with food or milk

AVOID driving and dangerous activities with impaired vision






I. Therapeutic classification: anthelmintics

1. Action: impair metabolic pathways present in invading worm that humans do not have

2.
Examples

a. pyrantel (Pin-X, Pronto Plus Pinworm Treatment, Reese's Pinworm) dose weight specific

b. albendazole (Albenza) 400 mg by mouth twice daily


3. Uses: pinworm, neurocysticerosis, hydatid disease

4. Adverse effects

a. life-threatening: Steven's-Johnson syndrome, renal failure, severe myelosuppression

b. most common: fever, malaise, dizziness, drowsiness

c. other:

i. rash, pruritus, alopecia, fever, headache

ii. abdominal pain, diarrhea, anorexia



5. Contraindications: pregnancy during treatment or 1 month after treatment

6. Nursing care

a.
assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter complete blood count, liver function tests

b. assist health care team to implement client teaching plan

i. report worsening of findings

ii. treat all family members

iii. complete full course of therapy for effectiveness

iv. avoid tub baths; shower at least once daily in the morning

v. sanitize toilet facility; wash bed linens and underwear in hot water

vi. wash hands and scrub under fingernails after voiding or bowel movement






J. Therapeutic classification: antineoplastic agents

1. Information common to anticancer drugs

a. action: disrupt processes related to synthesis of DNA or its precursors

b. adverse effects

i. life-threatening: secondary malignancy, sterility, hemorrhagic cystitis, urinary bladder fibrosis, heart failure,
infection

ii. most common: alopecia, sterility, amenorrhea, nausea, vomiting, diarrhea, stomatitis, anemia, leukopenia,
thrombocytopenia, rash, headache


c. nursing care

i.
observe RN establish baseline and monitor creatinine, complete blood count with differential, platelets,
urinalysis

ii. maintain nutrition, fluid and electrolyte balance

iii. protect client from infection

iv. provide frequent oral care

v. reinforce symptom management, such as nausea, vomiting, stomatitis, fatigue, constipation, diarrhea
307


vi. provide emotional support and therapeutic communication for client and family

vii. assist with hats, wigs, scarves

viii. provide rest, information, calm, soothing environment


ix. administration and handling

only trained RNs administer chemotherapy

dispose of waste safely, handle body fluids safely

empty body waste into toilet without splashing

urine for at least 48 hours and stool for 7 days after last dose

wear non-permeable gloves, gown, goggles for waste, fluids, and linens

prevent extravasation observe RN establish baseline data and monitor infusion site

stop infusion immediately if extravasation is suspected: do not remove IV catheter until antidote given
or confirm with pharmacy


x. reinforce client teaching

report: unusual bruising and bleeding, fever, chills, sore throat, dyspnea, flank pain, swelling

need for follow-up care and testing

avoid pregnancy: use barrier contraception

take as directed and take entire course of therapy

avoid sick people and perform thorough, frequent hand washing

wash fresh fruits and vegetables in soap and water

try to maintain balanced diet: eat highly nutritious food, drink 10-12 glasses of water daily







2. Type: alkylating agents

a. action: non-cell cycle-specific; affects neoplasm cell DNA, RNA, or protein in resting or active state to disrupt
intracellular mechanisms and cause cell death

b.
examples

i.
busulfan (Myleran) 2-8 mg by mouth daily
Black Box Warning - appropriate use, severe bone marrow hypoplasia

ii.
cyclophosphamide - dose may vary

iii.
CARBOplatin (Paraplatin) - dose may vary
Black Box Warning - appropriate use, serious adverse events, anaphylaxis

iv.
CISplatin (Platinol AQ) - dose may vary
Black Box Warning - appropriate use, overdose prevention, dose-related toxicity, ototoxicity, anaphylactoid
reaction


c. uses: mycosis fungoides, rheumatoid arthritis, breast cancer, leukemia, lymphoma, multiple myeloma, ovarian cancer,
retino/neuroblastoma, sarcoma, palliative treatment for chronic myelogenous leukemia (CML), myelofibrosis,
advanced ovarian cancer, metastatic ovarian and testicular cancer, advanced bladder cancer

d. adverse effects

i. life-threatening: nephrotoxicity, acute renal failure, anaphylactoid reaction, myelosuppression

ii. most common: nausea/vomiting, anorexia, elevated BUN & creatinine, hyperuricemia, tinnitus, hearing loss

iii. other: leukopenia, thrombocytopenia, anemia, electrolyte disorders


308


e. contraindications: hypersensitivity to platinum compounds, myelosuppression, renal or hearing impairment

f. nursing care

i. observe RN establish baseline data and monitor

BUN/creatinine, creatinine clearance, calcium, potassium, magnesium, and sodium prior to each dose

complete blood count weekly, liver function tests
neurological exam, audiometry at baseline and prior to each dose


ii. reinforce client teaching

report fever, bleeding, severe nausea, vomiting, diarrhea, edema, ringing in ears

use barrier contraception

ask for help before getting up

encourage clients to obtain head covering early in therapy

take drug as directed and do not stop until directed to do so

AVOID over-the-counter drugs and herbal remedies




3. Type: antimetabolites

a. action: replace normal metabolites to inhibit DNA production in malignant cells; S-phase specific and are most
effective on rapidly dividing cells

b.
example: mercaptopurine (Purinethol) 2.5 mg/kg by mouth daily

c. uses: ALL, Crohn's disease, ulcerative colitis

d. adverse effects

i. myelosuppression, immunosuppression

ii. hepatotoxicity, hepatosplenic T-cell lymphoma

iii. hepatic encephalopathy, ascites, GI ulceration




4. Type: antineoplastic antibiotics

a. action: cytotoxic to rapidly dividing cells and interfere with DNA synthesis

b.
examples

i.
bleomycin (Blenoxane) - dose may vary
Black Box Warning - appropriate use, pulmonary toxicity, idiosyncratic reaction

ii.
DOXOrubicin (Adriamycin) - dose may vary
Black Box Warning - appropriate use, cardiotoxicity, secondary AML or myelodysplastic, hepatic impairment,
myelosuppression

iii.
DAUNOrubicin (Cerubidine) - dose may vary
Black Box Warning - appropriate use, cardiotoxicity, myelosuppression, renal or hepatic impairment


c. uses: malignant pleural effusion, Hodgkin lymphoma, non-Hodgkin lymphoma, squamous cell cancer, testicular
cancer, AML

d. adverse effects

i. life-threatening; myelosuppression, hepatotoxicity, leukopenia, thrombocytopenia, cardiotoxicity, anaphylaxis

ii. other: stomatitis, alopecia, nausea, vomiting, mucositis, tissue necrosis


e. contraindications: impaired cardiac function, hepatic or renal impairment, myelosuppression

f. nursing care: observe RN to take steps to prevent extravasation

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5. Type: cell-protecting agents

a. action: binds to and detoxifies damaging metabolites of chemotherapy

b.
example

i. for cisplatin: amifostine (Ethyol) give 30 min before chemotherapy

ii. for ifosfamide: mesna (Mesnex); total daily dose = 60% total ifosfamide dose


c. adverse effects: anaphylaxis, allergic reaction, headache, injection site reaction, flushing, dizziness

d. contraindications: hypersensitivity to thiol compounds

e. nursing care

i.
observe RN establish baseline data and monitor calcium

ii. check oral mucosa, blood pressure

iii. cutaneous evaluation prior to each dose




6. Type: folic acid derivative

a. action: prevents toxicity by protecting normal cells

b.
example: leucovorin (generic) 200 mg/m
2
IV daily for 5 days

c. uses: rescue for high dose or overdose methotrexate

d. adverse effects: anaphylactoid reactions, seizures, syncope, urticaria, nausea and vomiting

e. contraindications: intrathecal administration, pernicious or megaloblastic anemia, or vitamin B12 deficiency

f. nursing care

i.
observe RN establish baseline data and monitor complete blood count, liver function tests, electrolytes

ii. increase fluid intake

iii. protect from heat and light

iv. reinforce that client should drink 3000 mL of fluid daily





7. Type: hormones and hormone modulators

a. action: block or interfere with hormone receptor sites with hormone-sensitive tumors

b.
examples

i. ACTH-releasing: goserelin (Zoladex) 3.6 mg SubQ every 28 days for 4 doses

ii. androgen: testosterone

iii. anti-estrogen: anastrozole (Arimidex) 1 mg by mouth daily

iv. corticosteroids: dexamethasone (Decadron)

v. estrogen antagonist: tamoxifen (Soltamox) 20-40 mg by mouth daily
Black Box Warning - serious/life-threatening events


c. uses: breast and prostate cancer, endometriosis, dysfunctional uterine bleeding, ovulation induction

d. adverse effects

i. general: thromboembolism, stroke, hypercalcemia

ii. gynecomastia, hot flashes, nausea/vomiting, vaginal discharge and bleeding

iii. peripheral edema, fatigue, headache


310





8. Type: mitotic inhibitors

a. action: cell-cycle specific agents that kill cells at the beginning of cell division and interfere with DNA synthesis; work in
the M phase of the cell cycle

b.
examples

i. paclitaxel (Onxol,Taxol) - dose may vary
Black Box Warning - appropriate use, anaphylaxis/severe hypersensitivity reaction, myelosuppression

ii. vinBLAStine (generic) - dose may vary
Black Box Warning - appropriate use, intrathecal use contraindicated

iii. vinCRIStine (generic) - dose may vary
Black Box Warning - appropriate use, intrathecal use contraindicated


c. uses: breast cancer, non-small cell lung cancer, AIDS-associated Kaposi sarcoma

d.
nursing care: observe RN establish baseline data and monitor bilirubin, complete blood count with differential



9. Type: monoclonal antibodies

a. action: inhibits proliferation of malignant cells by binding to extracellular aspect of human epidermal growth factor
receptor 2 (HER2)

b.
example: trastuzumab (Herceptin) - dose may vary
Black Box Warning - cardiomyopathy, infusion reaction and pulmonary toxicity, embryo-fetal toxicity

c. use: HER2-overexpressing metastatic and adjuvant therapy breast cancer, HER2-overexpressing metastatic gastric
cancer

d. adverse effects

i. life-threatening: severe or fatal ventricular dysfunction, cardiomyopathy, heart failure, thromboembolism, severe or
fatal infusion reaction

ii. other: dyspnea, anaphylaxis, angioedema, ARDS, pain, asthenia, fever/chills, nausea/vomiting, diarrhea,
headache, fatigue


e. contraindications: hypersensitivity to hamster proteins

f. nursing care

i. establish baseline data and monitor fatal infusion reaction: fever, chills, nausea, vomiting, pain, dizziness,
hypotension

ii. reinforce client teaching
may cause teratogenic effects - client must use contraception
AVOID vaccinations
report new onset or worsening of shortness of breath, cough, selling of ankles, face
AVOID crowds or persons with known infections






10. Adjunct therapy: agents used to manage nausea and vomiting

a. therapeutic classification: antiemetics

i. type: serotonin (5HT) receptor blockers

example: granisetron (Granisol, Kytril), ondansetron (Zofran, Zofran ODT, Zuplenz)

nursing care: very effective, often combined with corticosteroids


311

ii. type: benzodiazepine

examples: alprazolam (Xanax), lorazepam (Ativan)

nursing care: effective when combined with corticosteroids



iii. type: dopaminergic blocker

example: metoclopramide (Metozolov, Reglan)

nursing care: especially effective when combined with a corticosteroid, an antihistamine, and a centrally-acting
blocker (haloperidol)



iv. type: combined dopaminergic, a-adrenergic, anticholinergic blocker

example: haloperidol (Haldol)

nursing care: may cause extrapyramidal side effects, drowsiness, reduced blood pressure and increased heart
rate



v. type: phenothiazines

example: prochlorperazine (generic)

nursing care: these types of drugs are not very effective for chemotherapy-induced nausea and vomiting






b. therapeutic class: antihistamines

i. use: to control nausea and vomiting; decrease some of the side effects of other antiemetic drugs, e.g., benzamides,
butyrophenones, phenothiazines

ii.
example: diphenhydramine (Benadryl)



c. therapeutic class: anti-inflammatory agents

i. type: steroids

ii. use: can improve the antiemetic characteristics of other medications, especially serotonin antagonists or Reglan

iii.
examples: corticosteroids such as dexamethasone (Decadron) and methylprednisolone (Medrol)



d. neurokinin-1-receptor antagonists (NK
1
-receptor antagonists)

i. use: in combination with other antiemetic drugs, e.g., serotonin antagonist and a corticosteroid

ii.
example: aprepitant (Emend)



e. cannabinoids

i. uses: best used with chemotherapy drugs that cause minimal nausea and vomiting

ii.
example: dronabinol (Marinol)

iii. nursing care: mild drowsiness, dizziness and euphoria are common side effects



XII. Managing eye conditions

A. Medications used to manage glaucoma

1. Therapeutic classification: cholinergic agents

a. action: constrict the pupil and increase drainage of aqueous humor by stimulating the ciliary muscle to
contract
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b.
examples

i. pilocarpine ophthalmic (Isopto Carpine)

ii. carbachol ophthalmic (Isopto Carbachol)


c. uses: elevated intraocular pressure, open-angle and acute angle-closure glaucoma, mydriasis reversal

d. adverse effects

i. life-threatening: arrhythmias, asthma, hypotension, retinal detachment

ii. other: ocular burning/stinging, blurred vision, ocular discomfort


e. contraindications: acute iritis, pupillary block glaucoma

f. reinforce client teaching: may cause blurred vision, poor vision at night, periorbital discomfort






2. Therapeutic classification: beta-adrenergic agents - used in the management of chronic open-angle glaucoma and other
forms of ocular hypertension

a. action: decreases intraocular pressure by decreasing production of aqueous humor and increasing drainage

b.
example: timolol maleate (Betimol, Istalol, Timoptic, Timoptic-XE)

c. assist health care team to implement client teaching plan: may experience burred vision, burning; may cause
bronchospasm in clients with reactive airway disease



3. Therapeutic classification: carbonic anhydrase inhibitors

a. action: inhibits the enzyme needed to produce aqueous humor leading to decreased production

b.
example: acetaZOLAMIDE (Diamox) 125-250 mg by mouth 2 to 4 times daily

c. nursing care

i. assist health care team to establish baseline data and check at regular intervals BUN/creatinine, complete blood
count, platelets, electrolytes

ii. assist health care team to implement client teaching plan: report taste changes, anorexia, paresthesia, polyuria



Lipid soluble beta blocker eyedrops for glaucoma can be absorbed systemically. If your client states s/he is feeling
"blah" or has no energy, don't assume s/he is depressed. A CNS side effect of these drugs (timolol [Timoptic] and
betaxolol [Betoptic]) is fatigue.


4. Therapeutic class: osmotic agents

a. action: decreases IOP by moving water out of intraocular structures

b.
example: mannitol (Osmitrol)

c. nursing care: establish baseline data and monitor BUN/creatinine, serum electrolytes



5. Therapeutic class: prostaglandin agonists

a. action: increases outflow of aqueous

b.
example: latanoprost (Xalatan)

c. assist health care team to implement client teaching plan: may experience burning, blurred vision, dry eyes, foreign
body sensation



B. Therapeutic classification: anti-infective medications

1. Bacterial agents

a. types
313


i.
aminoglycosides - tobramycin ophthalmic (Tobrex)

ii.
erythromycin ointment

iii.
fluoroquinolones - ciprofloxacin ophthalmic (Ciloxan) & moxifloxacin ophthalmic

iv. quinolones - ofloxacin (Ocuflox)


b. uses: conjunctivitis, corneal ulcers


2.
Antifungal agents: natamycin 5% ophthalmic (Natacyn)

3. Antiviral agents

a.
types: trifluridine (Viroptic), famciclovir (Famvir), valacyclovir (Valtrex) or acyclovir (Zovirax)

b. uses: keratitis (H. simplex, varicella zoster)


4.
Glucocorticoid & bacterial agent: tobramycin and dexamethasone ophthalmic (Tobradex)



C. Therapeutic classification: anti-allergy

1.
decongestant: naphazoline (Naphcon, Vasocon)

2.
antihistamines: ketotifen fumarate ophthalmic solution 0.025% (Zaditen), olopatadine (Patanol), pemirolast
(Alamast)



XIII. Managing Ear Conditions

A. Managing infection: otitis externa

1.
ciprofloxacin 0.3% & dexamethasone 0.1% (Ciprodex)

2.
ciprofloxacin and hydrocortisone (Cipro HC Otic)

3.
hydrocortisone, polymyxin & neosporin (Cortisporin otic solution)

4.
equal parts white vinegar and isopropyl alcohol or other acidifying agents



B. Managing infection: otitis media

1. Therapeutic classification: antibiotics

a. types

i.
aminopenicillin: amoxicillin (Amoxil)

ii.
quinolone: ciprofloxacin otic (Cetraxal)

iii.
fluoroquinolone: ofloxacin (Floxcin Otic)


b. reinforce client teaching

i. take drug around the clock at regular intervals

ii. administration

warm medication (rub container between palms of hand or place in warm water)

gently rub the skin in front of the ear to facilitate drug flow in ear

place cotton ball in affected ear

rinse dropper after each use


iii. not to miss doses
314


iv. completely finish prescription






2. Therapeutic classification: decongestants

a. action: constricts smooth muscle to increase passageways

b. type: sympathomimetic

c.
example: pseudoephedrine (Sudafed)

d. nursing care

i. establish baseline data and monitor heart rate and blood pressure

ii. reinforce client teaching
AVOID taking right before bedtime
withhold medication if restlessness or palpitations or racing heart occur
AVOID other over-the-counter medications and stimulants








C. Adjuvant therapy

1. Managing cerumen (cerumenolytics)

a.
carbamide peroxide (Debrox)

b.
triethanolamine otic (Cerumenex drops)



2. Local anesthetic drops

a.
herbal ear drops containing mullein, garlic, and/or St. John's wort

b.
benzocaine & antipyrine (Auralgan) - pain relief and reduction of inflammation; also facilitates removal of
excessive or impacted cerumen

c.
hydrocortisone, chloroxylenol/pramoxine (Oticin HC Ear Drops)

d.
benzocaine (Pinnacaine Otic Drops)




315



I.Managing pain

A. Information common to analgesics

1. Therapeutic class: analgesics

2. Assist health care team to establish baseline data and check prior to initiating therapy
and at regular intervals thereafter

a. pain

i. objective: pain scale

ii. subjective: characteristics, location, type of pain


b. clinical indicators of pain

i. reluctance to move, ambulate, eat or breathe deeply

ii. restlessness, splinting, muscle tension

iii. higher than normal blood pressure

iv. faster than normal heart rate or respiratory rate
O-L-D-C-A-R-T: a comprehensive assessment of clinical indicators of pain
O = Onset When did it begin?
L = Locations Where is it?
D = Duration How long does it last?
C = Characteristics What are the qualities?
What is the
description?
A = Attributes How did it start? What
caused it?
R = Related findings What is the relationship
with other things such
as eating, position
changes, activity, rest?
T = Therapy & timing What effective and
remedies have been
tried? When does it
occur (time of day;
before or after
something else)? Any
patterns?



c. Documentation (follow agency policy)

time of administration

response to therapy at suitable interval after administration




316


3. Collaborate with provider and RN for comprehensive pain management

a. provide non-pharmacological methods of pain relief such as distraction, positioning, and guided
imagery with pharmacotherapy

b. eliminate factors that decrease pain tolerance: fatigue, boredom, anxiety, stress, anger, fear

c. individualize pain management according to

i. pain history

ii. context of therapy and available resources

iii. client's age, past experiences, values, expectations and physical and mental health


d. administer pharmacotherapy before severe pain develops

e. administer lowest dose of analgesic providing satisfactory pain relief according to client report

f. augment potential analgesic effect with adjunct therapy



4. Avoid alcohol and central nervous system depressants (potentiate analgesic effect)

a. high risk behavior

b. associated with increased risk of adverse effects including liver failure, respiratory depression,
overdose, and death



5. Opioids frequently combined with NSAIDs, acetaminophen or other medications

a. indications: moderate to severe pain, intractable pain syndromes

b. benefit: combination allows lower dose of opioid

c. consider: adverse effects of both agents; to prevent overdose or toxic effects, keep track of total
daily amount of each drug when using combination agents



6. Administration routes

a. oral

i. contraindicated with nausea and vomiting

ii. check response to therapy 30 minutes to 1 hour after administration

iii. slow-release preparations available but may require additional analgesic at initiation of therapy
and for breakthrough pain



b. intramuscular

i. assess response to therapy 30 minutes after administration

ii. avoid with hypothermia and vasoconstriction (placed client at risk for hypotension)



c. subcutaneous

i. check response to therapy 30 to 60 minutes after initiating therapy

ii. well-suited for clients with cancer

iii. requires ambulatory infusion pump (patient controlled analgesia [PCA])

iv. easier to establish steady-state blood level



d. epidural and intrathecal

i. check response to therapy 15 to 45 minutes after initiating therapy

ii. itching can be severe
317


iii. risk of hematoma, infection, meningitis

iv. effective management of severe pain without central nervous system depression

v. agents: preservative-free opioids and local anesthetics via PCA or implantable pump




e. transdermal

i. check response to therapy 1 to 2 hours after initiating therapy; regularly assess for respiratory
depression and skin irritation

ii. difficult to adjust dosage

iii. typical medications: fentanyl and morphine

iv. increased absorption with febrile clients

v. used in chronic and severe pain syndromes

vi. remove old patch and cleanse area before applying new patch; follow agency policy about patch
disposal



f. intravenous

i. check response to therapy 15 to 30 minutes after therapy


ii. delivery method: bolus

immediate, short-term pain management for moderate to severe pain

high risk of CNS depression, especially respiratory depression



iii. delivery method: patient controlled analgesia

can be programmed to deliver medication in small, on-demand doses, a bolus (initial) dose, and an
even flow (basal rate)

typical on-demand dose of morphine sulfate: 0.5-2 mg every 10 minutes

typical basal rate of morphine sulfate: 2-5 mg/hour

client may have concurrent oral pain medications ordered for breakthrough pain

observe RN provide client and family teaching - only client is to activate PCA for on-demand dose


g. other: sublingual, rectal


B. Therapeutic class: opioid analgesics

1. Type: opioid agonists

a. action: stimulate opioid receptors to cause analgesia; vary according to side effects, route of
administration, onset, peak, and duration

b. examples














318


Opioid analgesics
Generic Name &
Equianalgesic
Dose

Trade Name

Combination Products

Comments
fentanyl
100 mcg IM/IV
Duragesic,
Lazanda, Abstral,
Actiq, Fentora,
Onsolis, Subsys
NA Dosing may be nasal, transdermal or transmucosal
IV dosing used for induction and maintenance of
surgical anesthesia
HYDROmorphone
1.5 mg SC/IM/IV;
7.5 mg PO
Dilaudid, Dilaudid
HP, Exalgo
NA 2, 4, & 8 mg PO; 1-4 mg SubQ, IM, IV
morphine
10 mg SC/IM/IV; 30
mg PO
Avinza, Kadian,
MS Contin,
Oramorph SR,
Roxanol
Embeda (naltrexone) Avoid IM or SubQ route as can be painful and
unreliable
HYDROcodone
30 mg PO
NA Hycet, Lorcet, Lorcet Plus, Lortab,
Maxidone, Norco, Vicodin, Vicodin
ES, Vicodin HP, Zamicet, Zydone
(acetaminophen),
Zutripro (chlorpheniramine/
pseudoephedrine),
Hycodan, Tussigon
(homatropine),
Ibudone, Reprexain, Vicoprofen
(ibuprofen),
Rezira (pseudoephedrine),
TussiCaps, Tussionex
PennKinetic (chlorpheniramine)
Most widely prescribed drug in the United States
oxyCODONE
20 mg PO
Oxecta,
OxyContin,
OxyFast,
Roxicodone
Endocet, Magnacet, Percocet,
Primlev, Roxicet, Tylox, Xolox
(acetaminophen),
Percodan (aspirin),
Combunox (ibuprofen)
Tablets should never be dissolved and injected,
may cause local tissue necrosis, pulmonary
granulomas, endocarditis and valvular heart injury
meperidine
75 mg SC/IM/IV;
300 MG PO
Demerol NA May be used for drug-induced rigors or
postanesthesia shivering
considered a high risk drug in the elderly (based on
the Beers Criteria)
tramadol
100 mg by mouth
ConZip, Rybix
ODT, Ryzolt,
Ultram, Ultram ER
Ultracet (acetaminophen) Least likely to cause abuse by patient
codeine
120 mg SC/IM; 180
mg PO
NA Tylenol #3, Tylenol #4
(acetaminophen),
Fiorinal (butalbital, caffeine,
aspirin),
Soma Compound
(aspirin/carisoprodol),
Promethazine/Codeine
Fioricet (butalbital, caffeine,
acetaminophen)
May cause severe toxicity in breastfed infant when
mother takes codeine post birth
NA= not available




319


c. uses: moderate to severe acute and chronic pain, acute myocardial infarction, intraoperative analgesia,
antitussive

d. adverse effects

i. life-threatening: respiratory depression, CNS depression, hypotension, bradycardia, syncope, shock,
cardiac arrest

ii. most common: lightheadedness, dizziness, sedation, nausea/vomiting, sweating, dry mouth,
anorexia, urinary hesitancy/retention


e. contraindications

i. respiratory depression, paralytic ileus

ii. CNS depression, head injury, intracranial pressure increase

iii. asthma, COPD, acute abdomen


f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter respiratory rate, blood pressure, bowel pattern, platelets, level of consciousness,
allergic response

ii. accurately time doses to prevent overdose; reverse effects with antidote naloxone

iii. keep emergency equipment immediately available

iv. counteract adverse effects

nausea: administer antiemetic

pruritus: administer antipruritic or antihistamine

constipation

fluid, fiber, ambulation

stool softeners as monotherapy usually ineffective



v. transition client from IV, IM dosing to oral dosing with equianalgesic doses

vi. assist health care team to implement client teaching plan

ask for help when getting up

report rash, dyspnea, inadequate pain management

prevent constipation with fluid, fiber and ambulation

avoid nausea by taking with food

take only as directed, do not exceed recommended dose

AVOID

alcohol, CNS depressants, antihistamines

herbal remedies including chamomile and kava

driving, making important decisions, and dangerous activity





2. Type: opioid agonist-antagonists

a. action: stimulate some opioid receptors and block other opioid receptors; analgesic effect similar to
morphine

b. examples

i. pentazocine (Talwin) 30 mg IM/IV/SC every 3-4 hours

ii. buprenorphine (Buprenex) 300 mcg IM/IV every 6-8 hours

iii. nalbuphine (Nubain) 10 mg IV/IM/SC every 3 to 6 hours as needed


c. uses: mild to moderate pain, adjunct intraoperative analgesia, labor and delivery

d. adverse effects
320


i. reverses other opioids in system

ii. psychotic episodes with very high doses, severe bradycardia, angioneurotic edema and seizures


e. contraindications

i. physical dependence on opioids

ii. pulmonary impairment, cor pulmonale, biliary surgery or disease, hypothyroidism


f. nursing care: screen clients for previous use of opioids


REMEMBER IT
Switching a client from one opioid analgesic to another should be based on an equianalgesic
conversions to give the client similar pain relief.

For example: 10 mg of a parenteral dose of morphine sulfate is equivalent to 30 mg PO
Another example: conversion ratio of oral morphine to transdermal fentanyl is approximately 2:1 so
60 mg/day of oral morphine sulfate is equianalgesic to 25 micrograms/hour of transdermal fentanyl


3. Type: opioid antagonists

a. action: effectively block the action of opioid receptors

b. example: naloxone 0.4-2 mg IV every 2 to 3 minutes

c. uses: reverse adverse effects of opioids including respiratory depression and overdose, neonatal
respiratory depression

d. adverse effects

i. life-threatening

ventricular fibrillation, cardiac arrest and seizures

initiates acute withdrawal in clients physically dependent


ii. most common: elimination of analgesic effect

iii. other

duration of action is shorter than action of opioids

nausea, vomiting, tachycardia, hypertension, hypotension, tremors, withdrawal symptoms,
diaphoresis



e. contraindications: opioid addiction

f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at
regular intervals thereafter airway, respiratory rate, SaO2,

blood pressure, heart rate and rhythm,
pain intensity

ii. provide information to client

iii. administer with emergency equipment nearby

iv. collaborate with provider and RN for pain management




4. Type: synthetic diphenylheptane derivative

a. action: depresses pain impulse transmission at level of spinal cord

b. example: methadone (Dolophine, Methadose) 15-30 mg by mouth for 1 dose then 5-10 mg
by mouth every 2 to 4 hours PRN
Black Box Warning - incomplete cross-tolerance, respiratory depression, cardiac conduction
effects, opioid addiction treatment

c. use: opioid dependence, severe pain
321


d. adverse effects

i. life-threatening: respiratory depression, hypotension, respiratory arrest, cardiac arrest, QT
prolongation and death

ii. most common: drowsiness, dizziness, headache, nausea, vomiting, anorexia, constipation


e. contraindications: respiratory depression, acute asthma, hypercarbia

f. nursing care: assist health care team to establish baseline data and check prior to initiating therapy
and at regular intervals thereafter

i. establish baseline data and monitor creatinine

ii. signs and symptoms of respiratory depression

iii. assess and monitor pain, vital signs, airway, level of consciousness, pupil reaction to light

iv. opioid intoxication: lack of analgesic effect, clinical indicators of withdrawal

v. assist health care team to implement client teaching plan

report neurologic changes, allergic reactions

avoid CNS depressants, alcohol for 24 hours after administration

change positions slowly, do not drive or engage in dangerous activity





C. Type: non-opioid analgesics

1. Sub-type: NSAIDs

a. action: anti-inflammatory, analgesic, antipyretic, antiplatelet

b. sub-type examples

i. cyclooxygenase-1 inhibitor (COX-1 inhibitor)

ii. cyclooxygenase-2 inhibitor (COX-2 inhibitor)

iii. aspirin



2. Sub-type: acetaminophen

a. action: blocks pain impulses that occur in response to prostaglandin synthesis; antipyretic,
without anti-inflammatory properties

b. example: acetaminophen (Tylenol) 325-1000 mg by mouth/rectally every 4 to 6 hours as
needed, not to exceed 4000 mg daily

c. uses: mild to moderate pain or fever, in combination with opioids

d. adverse effects

i. life-threatening: hepatotoxicity, renal failure, thrombocytopenia

ii. toxicity: nausea, vomiting, abdominal pain, cyanosis, thrombocytopenia, delirium, seizures,
coma


e. contraindications
severe hypovolemia
liver or renal failure, alcoholism


f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at
regular intervals thereafter

pain, nausea, vomiting

serum creatinine, liver function tests

temperature

urinary output
322


vital signs, neurologic status


ii. assist health care team to implement client teaching plan

AVOID alcohol

may crush or cut tablets

do not exceed recommended dose

AVOID over-the-counter medications containing acetaminophen

report nausea, vomiting, abdominal pain






D. Type: anti-migraine headache agents

1. Sub-type: triptan

a. action: cause cranial vasoconstriction and migraine headache relief by binding to serotonin (5-
HT1) receptor sites

b. examples

i. almotriptan (Axert) 6.25-12.5 mg by mouth, maximum of 2 doses in 24 hours

ii. naratriptan (Amerge) 1 mg or 2.5 mg by mouth, may repeat in 4 hours, do not exceed 5 mg
in 24 hours

iii. sumatriptan succinate (Imitrex) 25-100 mg by mouth, may repeat after 2 hours if needed, do
not exceed 200 mg in 24 hours


c. use: treatment but not prevention of acute migraine headache

d. adverse effects

i. life-threatening: hypertension, coronary artery vasospasm, ventricular tachycardia and
fibrillation

ii. most common: dizziness, myalgia, weakness

iii. other: paresthesia, feeling hot, cold, or strange


e. contraindications

coronary artery disease, clients with vascular disease, hypertension

older clients, hepatic or renal dysfunction

concurrent use of ergotamine agents, MAO inhibitor


f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at
regular intervals thereafter pain, blood pressure, ECG

ii. screen clients for cardiovascular or neurovascular history, drugs containing ergotamine

iii. assist health care team to implement client teaching plan

AVOID triggers: foods containing tyramine , sulfites, etc.

report chest pain, worsening of findings, paresthesia

AVOID pregnancy

do not crush tablets

remain in calm environment, away from noise, light






2. Sub-type: ergot derivatives

a. action: constricts vascular smooth muscle in periphery, cranial vasculature and uterus

b. examples

i. ergotamine with caffeine (Cafergot) 1/100 1-2 tabs by mouth every 30 minutes as needed until
323

attack subsides, up to 6 mg
Black Box Warning - peripheral ischemia

ii. dihydroergotamine (DHE 45) 1 mg IM/IV for 1 dose
Black Box Warning - peripheral ischemia

iii. preventative: beta blockers, tricyclic antidepressants, and antiepileptic drugs


c. uses: treatment of migraine headaches

d. adverse effects

i. life-threatening: coronary vasospasm, hypertension, peripheral vascular ischemia

ii. most common: peripheral numbness, myalgia, nausea

iii. other: numbness of fingers/toes, intermittent claudication, photosensitivity, rebound headache
on withdrawal


e. contraindications: vascular, hepatic, renal impairments and hypertension

f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at
regular intervals thereafter

pain and clinical indicators associated with headache, including blurred vision, blood pressure, heart
rate

toxicity: nausea, weakness, intolerance to cold

level of consciousness, blurred vision

serum creatinine at baseline


ii. treat overdose with vasodilators, heparin, and dextran

iii. assist health care team to implement client teaching plan

iv. AVOID alcohol and over-the-counter drugs




3. Type: anticonvulsant

a. example: topiramate (Topamax)

b. uses: migraine prophylaxis



E. Other pain relief agents

1. Type: local anesthetics

a. examples

i. lidocaine topical (Lidoderm)

ii. lidocaine/prilocaine topical (EMLA)


b. nursing care: cream must be applied 1 hour before pain is anticipated as in a procedure



2. Type: herbal remedy

a.
example: capsaicin topical

i. apply 3 to 4 times daily; more effective with consistent use

ii. adverse effects: neurotoxicity, burning, erythema, thermal hyperalgesia

iii. nursing care

wear gloves to apply, rub into skin until cream is transparent

wash hands following application
324


assist health care team to implement client teaching plan






F. Adjunct therapy

1. Type: antihistamines

a. examples: promethazine (Phenergan), hydrOXYzine ( Atarax, Vistaril)

b. use: preoperative medication, sedation, enhance analgesic effect, nausea



2. Type: anticonvulsants

a. examples: gabapentin (Neurontin), carbamazepine (Tegretol)

b. use: neuropathic pain



3. Type: steroids

a. example: dexamethasone, predniSONE (Sterapred, Sterapred DS)

b. use: severe bone pain, nerve compression



4. Type: antihypertensive agent and centrally-acting analgesic: alpha-adrenergic agonist

a. example: cloNIDine (Catapres) - do not confuse with KlonoPIN

b. use: chronic pain syndromes




II. Managing Electrolyte Imbalances

A. Type: sodium

1. Action: the major extracellular cation; important in cell membrane function and action
potential, osmotic pressure, acid-base balance, and extracellular fluid volume; controls fluid
movement

2.
Examples

a. 0.9% NaCl (isotonic or normal saline)

b. 0.45% NaCl (hypotonic saline)

c. 3% NaCl (hypertonic)


3. Uses: hyponatremia, provide osmotic pressure, fluid volume expander, maintain
electroneutrality

4. Nursing care

a. assist health care team to establish baseline data and check prior to initiating therapy and
periodically thereafter

i. serum sodium, pH, and osmolality
Clinical Findings Consistent with
High Levels of Sodium
(Hypernatremia)
Clinical Findings Consistent with
Low Levels Sodium (Hyponatremia)
Serum Na+ level > 145 mEq/L

Thirst, elevated temperature, dry
mucous membranes, oliguria,
hyperreflexia; infants exhibit depressed
fontanelles and irritability
Serum Na+ level < 135 mEq/L

Nausea and vomiting; headache;
confusion; lethargy; fatigue; appetite
loss, restlessness and irritability; muscle
weakness, spasms or cramps; seizures;
decreased consciousness or coma

325


ii. fluid status: breath sounds, edema, weight gain, mucous membranes

iii. neurologic status: confusion, lethargy

iv. avoid fluid overload and administer with caution to older, debilitated, and very young
clients


b. assist health care team to implement client teaching plan

i. read food labels for sodium content

ii. daily weight






B. Type: potassium

1. Action: the major intracellular ion; maintains intracellular fluid volume and action potential of cell
membranes; maintenance of myocardial contractility

2. Example: potassium chloride (Klor-Con)

3. Uses: hypokalemia, concurrent diuretic therapy, ventricular dysrhythmias

4. Adverse effects

a. life-threatening: hyperkalemia, arrhythmias, GI obstruction, bleed, and ulcer/perforation

b. most common: nausea, vomiting, flatulence, abdominal pain/discomfort, diarrhea,
hyperkalemia


5. Contraindications: hyperkalemia, delayed GI transit, esophageal stricture, GI obstruction, renal
failure

6. Nursing care - assist health care team to establish baseline data and check before beginning and at
regular intervals during therapy

a. serum creatinine at baseline, acid base balance, potassium
Clinical Findings Consistent with
High Levels of Potassium (Hyperkalemia)
Clinical Findings Consistent with
Low Levels of Potassium (Hypokalemia)
Serum K+ level > 5 mEq/L

Client may experience irregular heartbeat; nausea;
bradycardia; EKG changes include peaked T wave and
depressed P wave, wide QRS complex
Serum K+ level < 3.5 mEq/L

Muscle weakness, aches and cramps; tetany;
hypotension; constipation; arrhythmias


b. ECG

c. administration

i. slow infusion through central line or large vein

ii. stop infusion with client complaints of pain in IV

iii. infuse slowly through large vein since rapid infusion may cause cardiac standstill


d. assist health care team to implement client teaching plan client teaching

i. take only as directed

ii. take with full glass of water

iii. do not crush or chew tablets

iv. need for follow-up care and testing

v. AVOID over-the-counter drugs and salt substitutes

vi. foods containing potassium include raw salmon, avocado, raisins, banana, spinach,
tomatoes



326



C. Type: calcium

1. Action: neuromuscular function, bone strength and density, enzyme activation, blood clotting

2. Examples

a. calcium chloride, calcium gluconate, calcium citrate

b. calcium carbonate (Maalox, Tums)


3. Uses: osteoporosis, hypocalcemia, hypersecretory (HCl) state, hyperphosphatemia,
hypoparathyroidism, life-threatening arrhythmias, adjunct treatment for hypermagnesemia, calcium
channel blocker overdose, prevention of postmenopausal osteoporosis

4. Adverse effects

a. life-threatening: hypercalcemia, nephrolithiasis, arrhythmias, syncope, extravasation necrosis

b. most common: hypercalciuria, hypomagnesemia, constipation, nausea


5. Contraindications

a. hypercalcemia, hypophosphatemia

b. ventricular fibrillation, digitalis toxicity


6. Nursing care - assist health care team to establish baseline data and check prior to initiating
therapy and at regular intervals thereafter

a. serum calcium, magnesium, phosphorous, and albumin
Clinical Findings Consistent with
High Levels of Calcium (Hypercalcemia)
Clinical Findings Consistent with
Low Levels of Calcium (Hypocalcemia)
Serum calcium level > 10.2 mg/dL

Constipation, anorexia, nausea,
abdominal pain, muscle twitches and
weakness, dementia, irritability
Serum calcium level < 8.2 mg/dL

Seizures; extrapyramidal symptoms;
papilledema; muscle stiffness, myalgias,
spasms; positive Chvostek's and Trousseau's
sign; prolongation of QT interval; diaphoresis


b. assess and monitor bone density, orientation, headache, blood pressure, ECG

c. provide adequate vitamin D

d. seizure precautions for hypocalcemia

e. administration

i. IV: infuse slowly in large vein, stop infusion with client complaints of burning, prevent
extravasation

ii. PO: give 1.5 to 2 hours after meals, avoid giving with enteric-coated tablets


f. prevent constipation with fluid, fiber, and exercise

g. assist health care team to implement client teaching plan client teaching

i. do not change antacids

ii. AVOID dehydration

iii. limit vitamin D intake to 400 units daily

iv. establish regular bowel habits with fluids, fiber, and exercise







327



D. Type: magnesium

1. Action: skeletal muscle contraction, energy production, carbohydrate metabolism activation of B-
complex vitamins, protein synthesis

2. Example: magnesium sulfate

3. Uses: ventricular arrhythmias, preeclampsia seizures, tocolysis, hypomagnesemia, torsades de
pointes

4. Adverse effects

a. life-threatening: cardiovascular collapse, respiratory paralysis, hypothermia, depressed cardiac
function, pulmonary edema

b. other:

i. depressed reflexes, hypotension, flushing, drowsiness

ii. depressed cardiac function, diaphoresis, hypocalcemia, hypophosphatemia, hyperkalemia



5. Contraindications: myocardial damage, heart block, diabetic coma

6. Nursing care - assist health care team to establish baseline data and check prior to initiating
therapy and at regular intervals thereafter

a. serum creatinine at baseline, magnesium, urine output
Clinical Findings Consistent with
High Levels of Magnesium
(Hypermagnesemia)
Clinical Findings Consistent with
Low Levels of Magnesium
(Hypomagnesemia)
Serum magnesium level > 2.1 mEq/L

Uncommon -Usually associated with
increased intake; prolonged PR interval and
widened QRS; hyporeflexia, hypotension,
respiratory depression and cardiac arrest
Serum magnesium level < 1.4 mEq/L

Anorexia, nausea, lethargy, weakness,
tetany, positive Trousseaus or Chvosteks
sign, fasciculations, tremor; usually
accompanies hypokalemia and
hypocalcemia


b. client teaching: foods rich in magnesium include tuna, avocado, spinach, rolled oats, yogurt

c. assess and monitor ECG, deep tendon reflexes, blood pressure; respiratory rate




E. Type: phosphorus

1. Action: vitamin B-complex activation, energy production, cell division; carbohydrate, protein, and
fat metabolism, acid-base balance

2. Uses: hyperparathyroidism, osteomalacia, cirrhosis, hypokalemia, excess IV glucose, respiratory
alkalosis

3. Contraindications: renal failure

4. Nursing care: assist health care team to establish baseline data and check prior to initiating therapy
and at regular intervals thereafter

a. serum phosphorus
Clinical Findings Consistent with
High Levels of Phosphorus
(Hyperphosphatemia)
Clinical Findings Consistent with
Low Levels of Phosphorus
(Hypophosphatemia)
Serum phosphorus level > 4.1 mg/dL

Serum phosphorus level < 2.4 mg/dL

328

Usually asymptomatic; similar to
hypocalcemia
Usually asymptomatic; anorexia, muscle
weakness, osteomalacia


b.
client teaching: foods rich in phosphorus include whole wheat and bran mixes, cottage
cheese or cheddar, corn, broccoli, sunflower seeds, garlic, legumes and nuts




III. Managing Pregnancy

A. Dietary supplements

1. Therapeutic class: vitamins

a. type: folic acid (vitamin B9)

i. action important for normal fetal growth and development, especially neurological
development, prevention of folate-deficient megaloblastic anemia

ii. recommended daily intake: 0.4 mg by mouth every day; may use SubQ or IM due to
oral malabsorption

iii. use: prevention of neural tube defects

iv. nursing care

encourage minimum daily intake in women of childbearing age

increase dietary intake of folic acid , including fresh dark, green leafy vegetables,
orange juice, liver, peanuts, whole grains



b. type: multivitamin, prenatal formula

c. type: vitamin K

i. action: essential ingredient in clotting cascade

ii. example: phytonadione (Mephyton)

iii. use: prevention hemorrhagic disease of newborn






2. Therapeutic class: minerals

a. type: ferrous sulfate

i. recommended daily intake

5 mg ferrous sulfate = 1 mg elemental iron

750-1500 mg divided 2 to 4 times a day by mouth for iron deficiency


ii. use: reduce risk of low-birth-weight infants, increase oxygen-carrying capacity of hemoglobin
and increase the number of erythrocytes

iii. nursing care - assist health care team to establish baseline data and check prior to initiating
therapy and at regular intervals thereafter

assist health care team to implement client teaching plan

stool will be very dark, sticky

take with food to avoid nausea

take with source of vitamin C

increase fiber, fluids, and ambulation to prevent constipation; avoid laxatives and stool softeners





b. type: calcium

i. recommended daily intake

adults 1000 mg by mouth daily (in divided doses for maximum absorption)
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tolerable upper level of 2500 mg daily


ii. use: fetal osteogenesis and tooth formation, blood clotting




B. Agents affecting uterine function

1. Therapeutic class: uterine stimulants

a. type: hormone

i. action: oxytocic; act directly on uterine myofibrils to cause contractions

ii. example: oxytocin (Pitocin)
Black Box Warning - not for elective labor induction

iii. use: increase strength and frequency of uterine contractions, induce labor, incomplete
abortion, postpartum hemorrhage

iv. adverse effects

uterine hypertonicity and tetany, abruptio placentae, seizures, postpartum hemorrhage

fetal distress, bradycardia, arrhythmias, seizures with subsequent brain damage and retinal
hemorrhage


v. contraindications: fetal distress, cephalopelvic disproportion (CPD), total placenta previa,
cord presentation or prolapse

vi. nursing care

requires continuous fetal monitoring

observe RN establish baseline data and monitor

assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter

uterine contractions: frequency, duration, and intensity; associate with fetal response

maternal: blood pressure, heart rate, and SaO
2
, fluid balance, urine output, neurologic status,
vaginal bleeding, and pain

fetal: fetal heart tones (FHT)
administer with infusion control device

immediately stop infusion for
fetal distress or abnormal deceleration patterns and maternal hypotension or hemorrhage
priority: stop oxytocin infusion

position mother on left side, lower head if possible; infuse isotonic fluids, administer
supplemental oxygen

observe RN implement client teaching plan: report sustained uterine contractions or vaginal bleeding,
foul-smelling lochia

assist health care team implement client teaching plan: report sustained uterine contractions or vaginal
bleeding, foul-smelling lochia






b. type: prostaglandins

i. action: stimulation uterine contractions and soften cervix allowing for cervical dilatation and
effacement

ii. example: dinoprostone (Cervidil, Prepidil)

iii. use: induce labor and stimulate initial contractions, oxytocin may be started 30 minutes after
insertion

iv. adverse effects

uterine rupture, bronchospasm
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severe bradycardia and hypertension

fetal acidosis and depression


v. contraindications
fetal distress, vaginal bleeding, placenta previa
cesarean section history, uterine hypertonicity and hyperactivity

suspicion of cephalopelvic disproportion (CPD), oxytocin infusion already infusing, 6 or more previous
term pregnancies


vi. nursing care

observe RN establish baseline data and monitor

assist health care team to establish baseline data and check prior to initiating therapy and at regular intervals
thereafter

maternal vital signs

associated fetal response and fetal heart tones

cervical dilatation and effacement

uterine contractions: frequency, duration, and intensity

provide information

administration

gel-filled syringe: insert applicator in cervical os

suppository: place in posterior fornix of vagina, leave in place for 30 minutes

place rolled-up towel under client hips to prevent escape of gel

provide continuous maternal and fetal monitoring

observe RN implement client teaching plan

assist health care team to implement client teaching plan

remain on bedrest

report vaginal bleeding, sustained contraction, dyspnea





2. Therapeutic class: tocolytics

a. type: electrolytes

i. action: depresses the CNS resulting in less acetylcholine (ACh), inhibited neuromuscular
function, smooth muscle relaxation

ii.
example: magnesium sulfate IV

iii. uses: pre-term labor, anticonvulsant, pregnancy induced hypertension (PIH)

iv. adverse effects

life-threatening: cardiovascular collapse, respiratory paralysis, hypothermia, depressed cardiac function

most common

fetus: transient decrease in variability

depressed reflexes, hypotension, flushing, visual changes, diaphoresis

other

lethargy (may persist for 1 to 2 days after discontinuing therapy)

fewer side effects than beta-adrenergic agonists



v. nursing care - assist health care team to establish baseline data and check prior to initiating
therapy and at regular intervals thereafter

observe RN establish baseline data and monitor

assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter
331

contractions: intensity, duration, frequency
blood pressure, respiratory rate, urine output
seizures, level of consciousness, deep tendon reflexes (DTRs)
serum magnesium - maintain maternal serum magnesium (5.5-7.5 mg/dL)

observe RN establish baseline data and monitor fetal heart tones

do not administer with concurrent calcium channel blocker therapy

antidote : keep calcium gluconate IV at the bedside





b. type: beta-adrenergic agonists

i. example: terbutaline (generic) 0.25 mg SC every 1 to 6 hours
Black Box Warning - tocolysis use

ii. use: inhibit uterine contractions

iii. adverse effects

life-threatening: hypersensitivity, paradoxical bronchospasm, hypertension, QT prolongation, seizures

serious reactions: neonatal hypoglycemia, reactive fetal tachycardia

most common: hyperglycemia

other: nervousness, tremor, headache, tachycardia, palpitations, drowsiness


iv. contraindications: hypertension, arrhythmias, cardiovascular disease, hyperthyroidism

v. nursing care - assist health care team to establish baseline data and check prior to initiating therapy
and at regular intervals thereafter

observe RN establish baseline data and monitor

fetal heart tones, uterine contractions: frequency, duration, and intensity

back pain, bleeding, urine output

provide information

observe RN and assist health care team to implement client teaching plan

report contractions occurring less than every 10 minutes, lower abdominal cramps, rupture of
membranes

report increased pelvic pressure, decreased fetal movement

report chest pain, insomnia





c. type: calcium channel blockers

i. example: NIFEdipine (Procardia)

ii. use: used alone or in combination with terbutaline to relax uterine smooth muscle

iii. life-threatening adverse effects: CHF, pulmonary edema, myocardial infarction, arrhythmias,
severe hypotension

iv. nursing care - assist health care team to establish baseline data and monitor

uterine contractions: frequency, duration, and intensity

maternal back pain, bleeding, urine output

fetal heart tones, fetal movements

provide information


v. assist health care team to implement client teaching plan: report contractions occurring less than
every 10 minutes, lower abdominal cramps, rupture of membranes, increased pelvic pressure,
decreased fetal movement


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C. Agents used with preterm labor

1. Therapeutic class: steroids

a. type: glucocorticoid

i. action: acceleration of maternal and fetal lung maturity

ii. examples

betamethasone (Celestone Soluspan)

dexamethasone


iii. use: preterm labor; to prepare fetus for eminent birth to increase lung maturation

iv. adverse effects

i. increased risk of infection

ii. neonate: lowered cortisol levels, hypoglycemia, sepsis


v. contraindications: systemic fungal disease, heart failure, seizure disorder

vi. nursing care - observe RN establish baseline data and monitor

uterine contractions, fetal movement

fetal movement

temperature and white blood cell



2. Therapeutic class: tocolytics



3. Therapeutic class: antihypertensives

a. type: alpha-adrenergic (centrally acting) vasodilator

i. action: causes selective dilation of arterioles

ii. example: methyldopa (Aldomet) 250-500 mg by mouth daily in divided doses

iii. use: safety and efficacy well-documented for fetus and mother

iv. adverse effects

life-threatening: myocarditis, hemolytic anemia, thrombocytopenia, hepatic necrosis

other

sedation, headache, asthenia, weakness, angina

CHF, orthostatic hypotension, bradycardia



v. nursing care - observe RN establish baseline data and monitor

blood pressure, heart rate, ECG

fetal heart tones and fetal movements

renal and liver function tests, complete blood count

observe RN implement client teaching plan

maintain hydration

do not abruptly discontinue therapy

AVOID over-the-counter medications and hazardous activities

change positions slowly, ask for help before getting up

protect clients (See also: Client protection)




b. type: non-selective beta blocker, such as labetalol (Trandate) 20 mg IV bolus followed by 40-80
mg every 20 minutes up to maximum dose of 300 mg

c. type: direct acting vasodilator, such as hydralazine (Apresoline) 5-10 mg via slow IV injection for
hypertensive crisis; alternatively, may be continuous IV dose


333



D. Diabetes mellitus, gestational and idiopathic

1. Therapeutic class: antidiabetic agent

a. type: insulin

i. lispro, regular, and intermediate acting insulin used in multiple injections

ii. regular insulin used with continuous infusion


b. type: oral hypoglycemic agents (contraindicated in pregnancy)


2. Nursing care

a. anticipate changing insulin needs in pregnancy

i. 1st trimester: insulin dosages may need to be decreased due to enhanced insulin response to
glucose

ii. 2nd and 3rd trimesters: insulin requirements increase


b. maintain blood glucose levels as close to normal as possible




E. Herbal agents

1. Lack of randomized-controlled trials to test safety and efficacy in pregnancy

2. General principles

a. AVOID essential oils

b. AVOID herbs and tonic herbs during first trimester

c. AVOID standardized and highly concentrated forms of herbs

d. AVOID herbal stimulants and laxatives; agents used as abortifacients and to induce
menstruation


3. AVOID: aloe, feverfew, kava, licorice, St. John's Wort and others

4. Use with caution: garlic, ginger, turmeric

5. Sources of vitamins and minerals

a. raspberry leaf: vitamin C and iron

b. oat straw: calcium, magnesium, iron

c. dandelion root: vitamins A and C, beta carotene, potassium



334


F. Pain management in labor and childbirth

1. Information about obstetrical analgesia

a. provide information to client: using anesthetics and analgesics
during labor and childbirth is a balance of risk versus benefit

i. may slow or enhance the progress of labor

ii. may lead to serious adverse effects

maternal: circulatory collapse

fetal distress or sedation



b. use alternative comfort measures alone or in combination
with anesthetic and analgesic agents

c. observe RN assess mother and fetus before initiating pain
management

d. emergency equipment for mother and neonate should
be immediately available

e. client teaching: remain in bed, ask for help before
getting up, empty bladder






Pre-Administration Criteria for Obstetrical Analgesia
Mother
Stable vital signs, SaO2 > 95%

Compliance with cultural considerations

Willingness to receive medication, comply with therapy

No known allergies, co-morbidities, drug dependence, respiratory dysfunction
Fetus
FHT 110-160

Short-term variability present

Deceleration patterns are benign

Acceleration patterns with fetal movement
Labor
Progressing labor with vertex presentation and no complications: station > 0,
cervix > 3-4 cm; established pattern of contractions












335


2. Analgesics used in labor and childbirth

a. type: opioid agonist-antagonist

i. example: nalbuphin (Nubain) 10 mg IV/IM/SubQ every 3 to 6 hours as needed, not to exceed
160 mg/day

ii. adverse effects

sedation, respiratory depression

reverses any opioid in the system


iii. nursing care - observe RN establish baseline data and monitor

pain for type, location, intensity, respiratory rate

frequency, duration, and intensity of uterine contractions

fetal heart tones




b. type: opioid agonists

i. examples

meperidine hydrochloride (Demerol) 50 mg IM every 4 hours

morphine sulfate (Morphine sulfate) 2-10 mg IM, IV every 2 to 4 hours


ii. adverse effects

life-threatening: maternal and fetal respiratory depression, sedation

other:

pruritus, dizziness, nausea, constipation

decreased intensity and frequency of uterine contractions



iii. nursing care

observe RN establish baseline data and monitor
pain for type, location, intensity, respiratory rate
uterine contractions for frequency, duration, and intensity
fetal heart tones

monitor neonate for 4 to 6 hours postpartum for residual respiratory depression

treatment of itching with antihistamine usually increases sedation




c. type: opioid antagonist

i. example: naloxone

ii. use: reverse maternal or neonatal respiratory depression, sedation, and hypotension caused by
opioid agonists and agonist-antagonists

iii. nursing care (neonate): establish baseline data and monitor vital signs frequently for 4
hours in special care area (respiratory depression may recur after naloxone wears off)




3. Anesthesia using local and regional methods

a. local anesthetics

i. action: regional impairment of nerve impulse transmission

ii. examples

procaine (Novocaine)

bupivacaine (Marcaine)
NOTE-Black Box Warning - appropriate use, obstetrical use


iii. uses: local and regional pain management during labor and delivery, alone or in combination
336

with opioid analgesics

iv. adverse effects

life-threatening: CNS toxicity, broad ligament hematoma, perforation of rectum

other: trauma to sciatic nerve


v. contraindications: severe hypovolemia, central nervous system disease, bleeding disorder

vi. nursing care

maternal: observe RN establish baseline data and monitor

blood pressure and heart rate

pain for type, location, intensity; return of sensation

contractions for frequency, duration, and intensity

neonatal: observe RN establish baseline data and monitor fetal heart tones, response to injections

provide information to client about importance of not moving during injection and related transient
discomfort

remain at bedside during injections





b.
nerve block analgesia and anesthesia : affects the uterus, cervix, vagina, and perineum

i. lumbar epidural block

used during first and second stages of labor; onset of action may take
30 minutes

catheter may be left in place for additional injections

major side effect is hypotension

client may exhibit "shiver response" after administration - offer warm
blankets



ii. spinal anesthesia block

first stage for both elective and emergent cesarean births

effects occur within 1 to 2 minutes; generally last 1 to 3 hours

single injection

low spinal anesthesia block may be used for vaginal birth but not suitable for labor

may cause postdural puncture headache

monitor maternal vital signs and fetal heart rate


iii. adverse effects

muscle twitching, dizziness, nausea, itching, shivering, urinary retention

laryngospasm, bronchospasm, respiratory depression, bradycardia, seizures


iv. nursing care

prior to therapy: infuse IV fluids, verify pre-administration criteria; ensure IV access, oxygen, maternal
cooperation, and continuous fetal monitoring

assist client with positioning: either on her side at edge of bed facing middle of bed, pulling knees into
chest, or dangling at bedside with back arched (like a cat)
slowly assist client to labor or childbirth position as directed after injection

establish baseline data and monitor maternal
vital signs every 1 to 2 minutes for 15 minutes, then every 15 minutes
337

pain: including type, location, intensity
contractions: frequency, duration, intensity

establish baseline data and monitor fetal heart tones every 5 minutes for rate, variability, acceleration-
deceleration pattern

client teaching: remain in bed and do not attempt to get up

emergency nursing interventions for maternal hypotension: position in left lateral, increase rate of IV fluids;
apply supplemental oxygen; turn off oxytocin if infusing




c. other anesthesia using local anesthetics

i. pudendal block

injection below pudendal plexus in second stage of labor

low risk of maternal hypotension or fetal depression


ii. local infiltration: injection into soft tissue of perineum, generally given for episiotomy


d. general anesthetics: usually reserved for obstetrical emergencies when fetal demise is expected due to
high risk of fetal depression

i. adverse effects

maternal: postoperative nausea, sedation, high risk of impaired airway

fetal and neonatal: impaired oxygenation, sedation and respiratory depression


ii. contraindications: high-risk fetus

iii. observe RN provide nursing care

maternal

priority to protect airway until gag reflex returns and client is able to maintain airway; and maintain
NPO

monitor vital signs frequently

prevent postpartum hemorrhage

neonatal

establish baseline data and monitor vital signs, especially airway and respirations

provide warmth, quickly dry infant

have emergency equipment immediately available

dedicate one neonatal nurse in delivery area

provide initial maternal-newborn bonding when mother awakens





4. Adjunct therapies for obstetrical pain management

a. therapeutic classes

i. antihistamines

ii. antiemetics

iii. barbiturates


b. uses in labor

i. anxiety, apprehension

ii. antiemetic (except barbiturates)

iii. pregnancy-induced hypertension


c. contraindications: active labor

d. nursing care
338


i. observe RN establish baseline data and monitor maternal

blood pressure, heart rate, respiratory rate and level of consciousness

pain for type, location, intensity

contractions for frequency, duration, and intensity


ii. observe RN establish baseline data and monitor fetal heart tones, response to injections

iii. observe RN provide client teaching - ask for help before getting up




G.
Agent for Rh incompatibility

1. Type: Rh IgG immune globulin

2. Action: suppresses immune response of nonsensitized Rh O (D) negative mothers exposed to Rh O
(D) positive blood from the fetus

3. Examples: human anti-D immune globulin (RhoGAM, HyperRho, WinRho SDF) 1500 IU/300
mcg IV/IM at 28-30 weeks gestation antepartum; 1500 IU IV/IM within 72 hours postpartum
Black Box Warning - intravascular hemolysis with WinRho SDF

4. Use

a. restricted to Rh negative mothers with positive fetus to reduce risk of antenatal sensitization in
mother

i. at 28 weeks gestation with negative antibody screen

ii. within 72 hours of birth if maternalindirectCoombs test and neonataldirectCoombs tests are
negative


b. following amniocentesis, spontaneous or elective abortion, ectopic pregnancy, chorionic villi,
percutaneous umbilical blood sampling, maternal trauma


5. Adverse effects: lethargy, irritation at injection site, fever, myalgia

6. Contraindications: Rh positive client, allergy to blood products

7. Nursing care

observe RN establish baseline data and monitor

verify consent for treatment

considered a blood product - follow agency policy for checking lot number of agent and cross-match

observe RN provide client teaching for Rh negative mothers: drug must be administered within 72
hours after exposure




H. Hemostatic agent - vitamin K1

1. Action: essential component of clotting cascade

2. Example: phytonadione (Mephyton) 1-5 mg IM/IV/SubQ within one hour of birth (IV rate not
to exceed 1 mg/min)
Black Box Warnings - severe reactions, including fatalities, have occurred during and
immediately after IV or IM use

3. Use: prevention of hemorrhagic disease of the newborn



IV. Managing Mental Disorders

A. Information common to psychotropic drugs

1. Consider psychosocial and cultural perspective of client

a. impact on behavior

b. impact on psychotropic drug compliance: unique social stigma about mental illness and
339

psychotropic drugs


2. Make sure client swallows medication to prevent hoarding

3. Assist health care team to establish baseline data and check prior to initiating therapy and
periodically thereafter using standardized rating scales when available

a. negative and positive behavior associated with condition

b. differentiation of psychiatric findings from adverse effects

c. compliance with and adverse effects of therapeutic regimen

d. expected therapeutic effects of psychotropic medication


4. Assist health care team to implement client and family teaching plan

a. take only as directed

b. store away from heat, light, and moisture

c. provide support, encouragement, and community resources

d. provide non-pharmacological strategies to avoid adverse effects; instruct client to take
medication consistently for 4 to 8 weeks before rejecting therapy due to adverse effects

e. identify barriers to compliance, develop collaborative plan to eliminate or minimize

f. psychotropic medication most effective when combined with psychotherapy (counseling)

g. expect drug titration

i. need for follow-up care and testing

ii. use of trial and error with choice of medication and dosing






B. Therapeutic class: antidepressants

1. Information common to antidepressants

a. actions relate primarily to the neurotransmitters norepinephrine (NE), serotonin (5-
hydroxytryptamine or 5-HT) and dopamine to:

i. inhibit the effects of monoamine oxidase

ii. block reuptake of neurotransmitters at the synaptic cleft

iii. regulate receptor sites and neurotransmitter breakdown


b. uses

i. depressive disorders

ii. anxiety disorders (social anxiety disorder, generalized anxiety disorder), obsessive
compulsive disorders, bipolar disorder, childhood enuresis, post-traumatic stress disorder,
diabetic peripheral neuropathic pain and neuropathic pain

iii. off label uses: fibromyalgia, hot flashes, premenstrual symptoms, eating disorders, Tourette
syndrome


c. adverse effects

i. life-threatening: increased suicidal ideation especially in children

ii. most common
anticholinergic effects: dry mouth and eyes, constipation, urinary retention, sedation, insomnia
headache, tremors, fatigue, GI upset
decreased libido and sexual performance, weight gain


iii. other: increased risk of adverse effects in older clients, especially sedation, dizziness,
hallucinations and constipation



340


d. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter affect, weight, suicidal ideation, enjoyment, sleeping pattern, increased energy,
and implementation of daily activities

suicidal ideation , affect, implementation of daily activities

enjoyment, sleeping, energy and weight


ii. assist health care team to implement client teaching plan

report worsening depression, suicidal ideation; seek immediate treatment for well-developed suicide
plans

effective treatment usually consists of taking two or more agents concurrently

take as directed
do not abruptly discontinue therapy
do not stop taking drug when feeling better

AVOID alcohol, over-the-counter drugs

AVOID kava, and S-adenosyl-L-methionine (SAMe)

take drug consistently

initial improvement may not be seen for 4 weeks

many adverse effects will subside with consistent use



iii. strategies for adverse effects

take sedating antidepressants at bedtime

use hard candy, gum, ice chips, and sips of water for dry mouth

increase fluid intake, fiber in diet, and ambulation to prevent constipation

exercise every day




2. Type: selective serotonin reuptake inhibitors (SSRIs)

a. action: inhibits 5HT reuptake in the CNS

b. examples


i. fluoxetine (Prozac, Prozac Weekly, Serafem) 20-80 mg by mouth every morning
Black Box Warning - suicidality

ii. sertraline (Zoloft) 50-200 mg by mouth daily
Black Box Warning - suicidality

iii. citalopram (Celexa) 20-40 mg by mouth daily
Black Box Warning - suicidality


c. uses: depressive disorders, eating disorders, obsessive-compulsive disorders, posttraumatic stress
disorder, anxiety disorders, premenstrual syndrome

d. adverse effects

i. life-threatening: seizures, hemorrhage, dysrhythmias, myocardial infarction, thrombophlebitis

ii. most common

vasomotor instability, palpitation, nasal congestion, dyspnea

sedation, activation, GI activation, constipation

nausea, headache, sexual dysfunction


iii. other

tolerance

suicidality
341


paroxetine increases levels of clozapine, theophylline, warfarin

fluoxetine potentiates tricyclic antidepressants and some antidysrhythmic agents

fluoxetine and sertraline increase levels of benzodiazepines, clozapine, and warfarin



e. contraindications: hepatic or renal dysfunction, mania, concurrent administration of MAO
inhibitors; clients younger than 25 years-old and older than 65 years-old, and females more than 20
weeks pregnant

f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and
periodically thereafter

signs of suicidality, clinical worsening and/or unusual behavior changes

complete blood count, platelets, liver function tests


ii. administration

avoid abrupt withdrawal

may crush tablets


iii. allow 5 weeks between administration of an SSRI and an MAO inhibitors to prevent serotonin
syndrome

iv. assist health care team to implement client teaching plan

report rash, mania, and seizures

use barrier contraception

take weekly doses on same day each week

change positions slowly, ask for help when getting up until adverse effects of drug are well
established





3. Type: phenethylamine

a. action: inhibit reuptake of NE and 5-HT

b. example: venlafaxine (Effexor) 37.5-75 mg by mouth 2 to 3 times daily
NOTE: Black Box Warning - suicidality

c. adverse effects

i. life-threatening: suicidality, worsening depression, mania, withdrawal syndrome

ii. most common: nausea, headache, somnolence, dry mouth, dizziness, insomnia


d. nursing care: taper dose over 2 weeks before discontinuing therapy




4. Type: tricyclic antidepressants (TCAs)

a. action: reduce reuptake of NE and 5HT at the synaptic clef resulting in increased stimulation of
postsynaptic receptors

b. examples

i. imipramine (Tofranil) 150-300 mg by mouth daily
Black Box Warning - suicidality

ii. amitriptyline (Elavil) 50-150 mg by mouth every evening
Black Box Warning - suicidality


c. uses: depressive disorders; also enuresis in children, attention deficit hyperactivity disorder

d. adverse effects
342


i. life-threatening

hypertension, cardiac depression, EKG changes, dysrhythmias

paralytic ileus, hepatitis, hyperthermia, myelosuppression


ii. most common

weakness, fatigue, drowsiness, blurred vision, orthostatic hypotension

constipation, dry mouth, urinary retention, extrapyramidal symptoms


iii. other
overdose: hyperthermia, seizures, delirium, coma
children: higher risk of seizures, cardiotoxicity, agitation, suicide



e. contraindications: recovery phase from MI, narrow-angle glaucoma, seizure disorders, benign
prostatic hypertrophy

f. nursing care

i. assist health care team to establish baseline data and monitor extrapyramidal findings, heart rate,
ECG, blood pressure, ambulation, level of consciousness

ii. assist with ambulation

iii. contraindicated with administration with SSRIs

iv. assist health care team to implement client teaching plan

wear sunscreen and protective clothing in the sun

change positions slowly

AVOID abrupt withdrawal





5. Type: monoamine oxidase inhibitors (MAOI)

a. action: irreversibly inhibits monoamine oxidase (the enzyme responsible for terminating the actions
of serotonin, norepinephrine, and dopamine); results in an increase in the concentration of these
neurotransmitters at the synaptic clef

b. examples

i. phenelzine (Nardil) 45-90 mg by mouth daily in divided doses
Black Box Warning - suicidality

ii. tranylcypromine (Parnate) 10 mg by mouth 3 times daily
Black Box Warning - suicidality


c. uses: depressive disorders in clients who are unresponsive or intolerant of other therapies

d. adverse effects

i. life-threatening: hypertensive crisis, SIADH, intracranial hemorrhage

ii. most common: dizziness, drowsiness, orthostatic hypotension, anorexia

iii. other: blurred vision, dry mouth, constipation, weight gain, change in libido


e. contraindications

i. concurrent administration with TCA or SSRI

ii. hypertension, heart failure, severe hepatic or renal dysfunction, pheochromocytoma severe
cardiac disease, alcoholism



f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals during therapy establish baseline data and monitor

blood pressure, signs of suicidality
343


liver function tests


ii. assist health care team to implement client teaching plan

report

neck stiffness, chest tightness, headache

nausea, vomiting, muscle pain or weakness

rash, changes in urinary patterns, color of urine

palpitations, dizziness, insomnia, change in strength

avoid

caffeine, CNS depressants, OTC cold medicine, cough syrup, drugs for weight loss or allergic rhinitis

foods containing tyramine




A black box warning is the strongest form of warning issued by the Food & Drug Administration (FDA) about a
drug. It's usually the last step before a drug is removed from the market due to the high risk of adverse side
effects.


6. Type: mild reuptake blockers

a. type: aminoketone

i. example: buPROPion hydrochloride (Budeprion, Buproban, Wellbutrin, Zyban) 100 mg by
mouth 3 times daily
Black Box Warnings - suicidality, neuropsychiatric symptoms and suicidality

ii. use: depressive disorders, seasonal affective disorder, smoking cessation, attention deficit
hyperactivity disorder

iii. adverse effects: suicidality, worsening depression, psychiatric disorder exacerbation, behavioral
disturbances

iv. contraindications: MAOI use within 14 days, seizures, bulimia, anorexia

v. nursing care

assist health care team to establish baseline data and check prior to starting therapy and at regular
intervals during therapy appetite, smoking pattern

assist health care team to implement client teaching plan: take nicotine patch or nicotine gum with
the advice of provider; do not exceed dose of buPROPion or nicotine




b. type: triaolopyridine

i. example: trazodone (Oleptro) 50-100 mg daily in 2 to 3 times a day

ii. adverse effects

life-threatening: suicidality, worsening depression, neuroleptic malignant syndrome, orthostatic
hypotension

most common: somnolence, xerostomia, headache, dizziness, nausea/vomiting


iii. contraindications: acute recovery myocardial infarction, CNS depressant and alcohol use

iv. nursing care: assist health care team to implement client teaching plan: avoid abrupt
withdrawal




7. Type: other

a. example: mirtazapine (Remeron) 15-45 mg by mouth every evening
Black Box Warning - suicidality

b. action: blocks reuptake of NE and serotonin increasing the action of NE and serotonin in nerve cells

c. uses: depressive disorders
344


d. adverse effects

i. life-threatening: agranulocytosis, neutropenia, orthostatic hypotension, worsening depression

ii. most common: somnolence, dry mouth, appetite increase, hypercholesterolemia


e. contraindications: MAOI use within 14 days

f. nursing care: assist health care team to implement client teaching plan - client should not cut or
chew oral disintegrating tablet (ODT), avoid abrupt withdrawal



C. Therapeutic class: anxiolytic and hypnotic agents

1. Type: benzodiazepines

a. action: enhances the action of gamma-aminobutyric acid (GABA) in the synaptic clef of limbic
system and reticular activating system; inhibits cell firing

b.
examples

i. anxiolytic agents

alprazolam (Niravam, Xanax) 0.25-0.5 mg by mouth 3 times daily

diazepam (Valium) 2-10 mg by mouth 2 to 4 times daily

lorazepam (Ativan) 2-6 mg by mouth daily in divided doses

midazolam (Versed) 1 mg IV every 2 to 3 minutes; maximum: 2.5 mg/dose

chlordiazepoxide 5-10 mg by mouth, 3 to 4 times daily
Black Box Warnings-appropriate use, respiratory depression/arrest risk, individualize IV
dosage


ii. hypnotic agents

temazepam (Restoril) 7.5-30 mg by mouth at bedtime

flurazepam (Dalmane) 15-30 mg by mouth at bedtime











c. use: see table below
Therapeutic class: anxiolytic agents (benzodiazepines)
Examples Uses Distinguishing Features
alprazolam (Xanax)

diazepam (Valium)

lorazepam (Ativan)
anxiety disorders

hyperexcitability

agitation

skeletal and smooth
muscle relaxation

anticonvulsant
addicting

avoid use as hypnotic

diazepam is drug of choice for
emergency treatment of seizures
midazolam (Versed) perioperative &
conscious sedation

amnesia
short-acting, IV only

used for procedures, surgery
345

chlordiazepoxide
(Librium)
alcohol withdrawal administered in 50 mg doses, up to total
300 mg/24 hours for alcohol withdrawal
temazepam (Restoril)
flurazepam (Dalmane)
sleep induction
(hypnotic)
effect lasts for 6 to 8 hours

chronic use leads to accumulation of
active metabolites
clonazepam (Klonopin) seizure and panic
disorders
tolerance develops to anticonvulsant
effect





d. adverse effects

i. life-threatening: ECG changes, tachycardia, cardiac arrest, laryngospasm, bronchospasm,
myelosuppression

ii. most common

dizziness, drowsiness, confusion, blurred vision, daytime sedation

dose-dependent CNS depression


iii. other

aggravation of sleep-related breathing disorders

amnesia, orthostatic hypotension, nausea, vomiting, hangover (confusion)

older clients: accumulating drug levels with therapeutic doses, half-life may increase 4 times



e. contraindications

i. use with alcohol or other central nervous system depressant

ii. shock, coma, acute narrow-angle glaucoma

iii. psychosis, history of substance abuse, COPD


f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter

degree of anxiety and sedation, mental status, mood, sleep pattern, tolerance, dependency

blood pressure, heart rate, respiratory rate, breath sounds

liver function tests with prolonged treatment, complete blood count

seizure activity if administered as anticonvulsant


ii. older clients - do not abruptly stop therapy (very slowly withdraw drug)

iii. administration

oral: may crush tablets, may take with food or milk

IM: give by deep injection into large muscle (to avoid discomfort)

IV: keep emergency equipment immediately available during IV administration


iv.
antidote : flumazenil (Romazicon) 0.2 mg IV every minute for 1 to 5 doses
Black Box Warning - seizure risk

v. assist health care team to implement client teaching plan client teaching
report palpitations, worsening of findings, trouble breathing, shortness of breath
use contraception while taking benzodiazepines
avoid driving, making important decisions, and dangerous activity
do not abruptly withdraw therapy; taper dose before discontinuing
346


AVOID grapefruit juice, alcohol

AVOID herbal remedies especially kava and SAMe

AVOID antihistamines, sedating antidepressants, and other central nervous system depressants, over-the-
counter drugs




2. Type:
barbiturates


3. Type: nonbenzodiazepine anxiolytic

a. action: inhibits the action of 5HT and dopamine, increases NE levels

b. example: busPIRone (BuSpar) 20-30 mg by mouth daily in 2 to 3 doses

c. use: anti-anxiety with little sedative, anticonvulsant, or muscle relaxing properties

d. adverse effects

i. most common: serotonin syndrome, akathisia, extrapyramidal symptoms, tardive dyskinesia,
dystonia

ii. other

dizziness, drowsiness, nausea, headache

nervousness, fatigue, insomnia, dry mouth, blurred vision



e. contraindications: MAO inhibitor use within 14 days

f. nursing care

i. reinforce that therapeutic effect may take 2 to 3 weeks

ii. avoid drinking large amounts of grapefruit juice




4. Type: pyrazolopyrimidine hypnotics

a. action: interacts with GABA-benzodiazepine receptor
complexes

b. examples

i. zaleplon (Sonata) 5-10 mg by mouth at
bedtime

ii. zolpidem (Ambien, Ambien CR) 10 mg at
bedtime


c. use: insomnia

d. adverse effects

i. life-threatening: suicidal ideation, aggressive behavior, hallucinations

ii. most common: drowsiness, lethargy, daytime sedation

iii. other: chest pain, palpitations


e. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at
regular intervals thereafter mood, affect, sleeping patterns, drowsiness, suicidal ideation, complete
blood count, heart rate and ECG, tolerance and dependency

ii. screen for previous drug dependence

iii. period to induce hypnotic action is limited - prepare client for sleeping before administering
hypnotic
347


iv. assist health care team to implement client teaching plan

to induce sleep
take 30 minutes to one hour before desired hour of sleep
establish bedtime ritual - implement sleep-promoting behavior after taking hypnotic

do not abruptly withdraw therapy after long-term use

AVOID driving, dangerous activity after taking hypnotic agent

AVOID over-the-counter drugs, alcohol, central nervous system depressants, and herbal remedies (may
lead to respiratory depression)





D.
Therapeutic class: antipsychotic agents

1. Action - information common to antipsychotic agents

a. neuroleptic: suppression of psychotic behavior without depressed level of
consciousness

b. postsynaptic dopamine, serotonin, or dopamine receptor blockade of psychotic behavior in the
brain to lower incidence of hallucinations, delusions, and paranoia

c. reticular activating system depression to limit incoming
stimuli


2. Typical (conventional) antipsychotics

a. traditional antipsychotics affect positive aspects of psychotic behavior

b. block non-selective neurotransmitter receptors with high affinity for dopamine-
receptors

c. examples

i.
phenothiazines

chlorpromazine 200-400 mg/day by mouth 3 to 4 times a day
Black Box Warning - dementia-related psychosis

thioridazine start 200-800 mg by mouth 2 to 4 times a day; maximum 800 mg/day
Black Box Warnings - dementia-related psychosis, proarrhythmic effects

trifluoperazine (Stelazine) start 2-5 mg by mouth 2 times a day; maximum 40
mg/day
Black Box Warnings - dementia-related psychosis


ii. butyrophenones: haloperidol (Haldol) start 0.5- 5 mg by mouth 2 to 3 times a day;
maximum 100 mg/day
Black Box Warning - dementia-related psychosis

iii.
thioxanthenes: thiothixene (Navane) start 2-5 mg 2 to 3 times a day; maximum 60
mg/day
Black Box Warnings - dementia-related psychosis





3. Atypical antipsychotic agents

a. newer antipsychotics: lower affinity for dopamine-
receptors

b. lower incidence of extrapyramidal symptoms but some serious adverse
effects

c.
examples: heterocyclic compounds

i. aripiprazole (Abilify) 10-15 mg by mouth daily
348

Black Box Warnings - dementia related psychosis, suicidality

ii. clozapine (Clozaril) 150-300 mg/day
Black Box Warnings - agranulocytosis, seizures, myocarditis, cardiovascular/respiratory
effects and dementia-related psychosis (note: restricted distribution in US)

iii. quetiapine (Seroquel) 150-750 mg/day by mouth divided 2 to 3 doses per day, maximum 800
mg/day
Black Box Warnings - dementia related psychosis, suicidality

iv. olanzapine (Zyprexa) start 5-10 mg/day, maximum 20 mg/day
Black Box Warning - dementia related psychosis

v. ziprasidone (Geodon) start 20 mg by mouth twice a day, maximum 80 mg twice a day (with
food)
Black Box Warnings - dementia related psychosis

vi. paliperidone (Invega): start 6 mg by mouth, maximum 12 mg/day
Black Box Warnings - dementia related psychosis


d. other: prochlorperazine edisylate (Compazine) 10-20 mg IM every 4-6 hours: used to treat
schizophrenia; also used to treat severe nausea and vomiting and prevent nausea/vomiting
postoperatively
NOTE: Black Box Warnings - dementia related psychosis


4. Uses

a. schizophrenia

b. prevention of severe nausea and vomiting

c. bipolar disorder, anxiety disorders, neurodevelopmental disorders (attention deficit-hyperactivity
disorder autism, tic disorder), depressive disorders

d. intractable hiccups

e. chronic pain (in combination with narcotic analgesics)


5. Adverse effects

a. life-threatening

i. hypotension, syncope, extrapyramidal symptoms

ii. myelosuppression, pigment deposits on retina, QT prolongation

iii. impaired thermoregulation, laryngospasm, neuroleptic malignant syndrome, tardive
dyskinesia


b. most common: orthostatic hypotension, sedation, acute dystonia, perioral tremor ("rabbit
syndrome")

c. other: decreased threshold for seizures, weight gain, weakness, photosensitivity, may turn urine
pink or reddish-brown, skin discoloration, bad taste
Selected adverse effects of antipsychotic agents
Neuroleptic
Malignant
Syndrome
Anticholinergic Effects Extrapyramidal Symptoms
hyperpyrexia sedation akathisia (restless leg syndrome)
muscle rigidity dry mouth tardive dyskinesia
altered mental blurred vision pseudoparkinsonism
349

status
elevated
creatinine
phosphokinase
urinary retention, constipation decreased absorption of antipsychotics
seizures,
hypotension,
tachycardia
orthostatic hypotension, dizziness dystonia: torticollis, opisthotonos, oculogyric crisis




6. Contraindications

a. severe hypertension, coronary artery disease, prolonged QT, seizure history

b. hepatic and renal disease, dementia, cerebrovascular disease

c. hypotension, hypovolemia, diabetes, hyperlipidemia, breast cancer

d. clients younger than 25 years-old

e. alcohol or barbiturate withdrawal

f. dementia-related psychosis


7. Nursing care

a. assist health care team to establish baseline data and check prior to initiating therapy and at regular
intervals thereafter

i. mood, affect, orientation, level of consciousness

ii. dizziness, heart rate, blood pressure, ECG, urine output

iii.
serum creatinine, liver function tests, complete blood count


b. provide client safety

i. prepare for sedation

ii. assist with changing positions and ambulation

iii. avoid other medication metabolized using cytochrome P450


c. provide oral care

d. provide, support, encouragement, and community resources

e. administration

i. AVOID contact with skin

ii. may give mixed in juice or carbonated beverage

iii. ensure client swallows medication and does not hoard in mouth or request long-acting injectable
medications (LAIs), also known as depot formulations

iv. increased effect of both drugs with concurrent administration of central nervous system
depressants beta-adrenergic blockers, quinidine, or procainamide


f. neuroleptic malignant syndrome

i. provide cooling and hydration

ii. discontinue all psychotropic medication


g. assist health care team to implement client teaching plan

i. report sore throat, fever, rash, tremors, weakness, and vision changes

ii. wear MedicAlert identification
350


iii. do not abruptly withdraw therapy

iv. do not crush or chew sustained release forms

v. take only as directed, continue to take when feeling good

vi. increase fluids, fiber, and ambulation to prevent constipation

vii. remain supine for 30 minutes after IM injection

viii. AVOID driving, making important decisions, dangerous activity

ix. AVOID hot baths and showers, excessive clothing, hot sun, sunbathing, strenuous exercise

x.
AVOID alcohol, central nervous system depressants, over-the-counter medications

xi. AVOID herbal remedies

xii. AVOID grapefruit juice




E. Therapeutic class: anti-manic agents (mood stabilizers)

1. Type: heavy metal

a. action: alters ion transport across cell membrane in nerves and muscle cells

b.
example: lithium (generic) 900-1200 mg by mouth divided doses 2 to 3 times per day
Black Box Warning - lithium toxicity

c. uses: bipolar disorders, prevention of manic-depressive psychosis

d. adverse effects

i. life -threatening: coma, seizures, ventricular arrhythmias, severe bradycardia

ii. most common: tremor, weight gain, polydipsia, polyuria

iii. acne, hair loss, muscle weakness

iv. drowsiness, impaired coordination


e. contraindications

i. elderly, volume depletion, severe debilitation, alcohol or concurrent CNS depressant use

ii. hepatic or renal disease, cardiac or thyroid disease

iii. Brugada syndrome


f. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at
regular intervals thereafter

weight, edema, sodium intake, urine output, neurologic status

urine for albumin and glucose; serum renal and liver function tests

lithium levels

therapeutic level 0.8-1.2 mEq/L

check Li level after each dosage increase

check Li level every 2 to 3 months or with behavior episode

lithium (Li) toxicity

blood level > 1.5 mEq/L

clinical findings: vomiting, diarrhea, poor coordination, tremors, extreme thirst, tinnitus, dilute
urine

factors that increase lithium levels: dehydration, changes in other medications, fluid and
electrolyte imbalance (especially sodium), NSAIDs, tetracyclines



ii. significant drug-drug interactions
351


iii. AVOID concurrent therapy with diuretics, NSAIDs, cardiac drugs

iv. assist health care team to implement client teaching plan

do not crush or chew capsules

report tremors, impaired coordination, vomiting, diarrhea, dilute urine

use contraception

if dose is missed, take within 2 hours of next dose

AVOID

dehydration, sodium-free diet

driving and dangerous activity

alcohol, over-the-counter drugs, herbal remedies







2. Type: anticonvulsant

a. action: impair abnormal neuronal discharge

b. examples

i. carbamazepine (Carbatrol, Equetro, Tegretol) 800-1200 mg by mouth daily in 2-4 divided doses
Black Box Warnings - serious dermatologic reactions and HLA-B 1502 allele, aplastic
anemia/agranulocytosis

ii. gabapentin (Gralise, Neurontin) 300-1200 mg by mouth three times daily

iii. lamotrigine (Lamictal);200 mg by mouth daily
Black Box Warning - serious rash

iv. topiramate (Topamax)200 mg by mouth twice daily

v. valproic acid (Depakene, Stavzor) 30-60 mg.kg.day by mouth in 2-3 divided doses
Black Box Warnings - hepatotoxicity, teratogen, pancreatitis


c. uses

i. bipolar disorders (mood stabilizer)

ii. seizure disorders, trigeminal neuralgia, migraine prophylaxis



d. adverse effects

i. life-threatening: pancreatitis, SIADH, hyponatremia, pancytopenia, thrombocytopenia

ii. other: headache, nausea/vomiting, asthenia, somnolence, dyspepsia


e. nursing care: reinforce client teaching plan about not abruptly discontinuing therapy



F. Therapeutic class: stimulants

1. Information common to stimulants

a. action: increase release or decrease reuptake of dopamine and NE

b. uses

i. attention deficit hyperactivity disorder in children

ii. appetite control, depression, narcolepsy


c. adverse effects

i. life-threatening: dysrhythmias, tachycardia

ii. most common: palpitations, hyperactivity, insomnia, restlessness

iii. other: children: associated with weight loss and decreased rate of growth; approved for use in
352

children generally older than 6 years-old


d. contraindications

i. glaucoma, concurrent MAO inhibitor

ii. anxiety, Tourette syndrome, children younger than 6 years-old


e. nursing care

i. assist health care team to establish baseline data and check prior to initiating therapy and at
regular intervals thereafter

blood pressure, heart rate, height and weight

mood, affect, aggression, attention span, hyperactivity

sleeping pattern, appetite, tolerance

complete blood count, urinalysis, blood glucose


ii. assist health care team to implement client teaching plan

take at least 6 to 12 hours before bedtime

do not crush, chew, or cut time release tablets

report tremors, insomnia, palpitations, restlessness

take only as directed, do not double dose; taper dose to discontinue

AVOID caffeine, central nervous system stimulants, over-the-counter drugs, alcohol

AVOID guarana, cola nut, and yerba mat






2. Type: piperadine derivative

a. examples: methylphenidate (Concerta, Metadate CD, Metadate ER, Methylin, Methylin ER,
Ritalin, Ritalin LA, Ritalin SR) Adult dose: 5-15 mg by mouth 2 to 3 times per day; Pediatric dose:
0.3-2 mg/kg/day divided 2 to 3 times per day
Black Box Warning - drug dependence

b. use: attention deficit hyperactivity disorder,
narcolepsy

c. adverse effects

i. life-threatening: psychosis, mania, aggressive behavior, MI, stroke, and sudden
death

ii. other: growth suppression, nervousness, insomnia, anorexia, abdominal
pain


d. nursing care - assist health care team to implement client

i. administration: 30 to 45 minutes before meals, last dose before 6
pm




3. Type: methylphenidate derivative (amphetamine)

a.
example: dexmethylphenidate (Focalin) 2.5-10 mg by mouth twice
daily
Black Box Warning - drug dependence

b. adverse effects: abuse dependency, psychosis, amnia, aggressive behavior, Tourette syndrome,
arrhythmias, MI, stroke

c. use: attention deficit hyperactivity disorder

d. nursing care: assist health care team to implement client teaching plan and reinforce that client can
take every 4 hours without regard to meals

353



4. Type: amphetamine

a. action: mimic brain's most important neurotransmitters, dopamine and norepinephrine

b.
example: dextroamphetamine (Dexedrine) start 5 mg by mouth in the morning, maximum 60
mg/day
Black Box Warning

c. use: narcolepsy, attention deficit hyperactivity disorder; also obesity

d. adverse effects

i. life-threatening: MI, hypertension, stroke, sudden death

ii. most common: palpitations, tachycardia, elevated BP


e. contraindications

i. breastfeeding, symptomatic cardiovascular disease, cardiomyopathy

ii. severe arrhythmias, moderate to severe hypertension


f. nursing intervention

i. inexpensive stimulant

ii. high abuse potential, dependency

iii. prolonged duration of action




5. Type: xanthine

a. action: stimulates the SNS

b.
example: caffeine (NoDoz, Vivarin)

V. Antidotes for Medications, Medication Types and/or Poisons
Medication/Medication
Type/Poison
Antidote
acetaminophen N-acetylcysteine (Mucomyst, Acetadote) - most effective
given within 8 hours of ingesting acetaminophen
anticholinergics physostigmine
arsenic, gold, lead, or
mercury
chelation therapy
1) dimercaprol (BAL in Oil)
2) penicillamine (Cuprimine)
3) succimer (Chemet)
benzodiazepines flumazenil (Romazicon)
beta blockers glucagon
calcium channel blockers glucagon, calcium chloride, calcium gluconate
cholinergics atropine, pralidoxime (2-PAM, Protopam)
354

cyanide amyl nitrate/sodium nitrate/sodium thiosulfate
hyperbaric oxygen chamber
digitalis/digoxin digoxin immune fab (DigiFab, Digibind)
ethylene glycol ethanol
fomepizole (Antizol)
heparin protamine sulfate
iron deferoxamine (Desferal)
lead chelation therapy
1) dimercaprol (BAL in Oil)
2) penicillamine (Cuprimine)
3) succimer (Chemet)
magnesium sulfate calcium gluconate
mercury chelation therapy
1) dimercaprol (BAL in Oil)
2) penicillamine (Cuprimine)
3) succimer (Chemet)
methanol fomepizole (Antizol)
ethyl alcohol
organophosphate nerve
agent
atropine
organophosphate or
carbamate insecticide
poisoning
atropine
opioids (codeine, morphine) naloxone
snakes (rattlesnakes,
copperheads, cottonmouths,
coral snake)
Antivenin (Micrurus fulvius)
Crotalidae Polyvalent Immune Fab (CroFab)
spiders (black widow) Antivenin (Latrodectus mactans)
vasopressor extravasation phentolamine mesylate (OraVerse)
warfarin phytonadione (Mephyton, Vitamin K)



VI. Managing Agents of Bioterrorism

A. Pharmacological response to biochemical contamination

1. Antibiotics

a. ciprofloxacin (Cipro)

i. indications
355


anthrax, typhoid fever,

acute salmonellosis, chronic carrier salmonella


ii. administration: 500 mg by mouth every 12 hours for 60 days, or 400 mg IV every 12
hours for 60 days

iii. adverse effects

anaphylaxis, anaphylactic shock, hypersensitivity reaction

severe skin reactions, phototoxicity, seizures, superinfection

C. difficile associated diarrhea



b. penicillin G procaine (See also: type: penicillins)

i. indications

anthrax, rat bite fever, diphtheria adjunct


ii. administration

0.6-1 million units IM daily


iii. adverse effects

hypersensitivity reaction, immediate or delayed

anaphylaxis, serum sickness-like reaction

exfoliative dermatitis, superinfection



c. doxycycline (Adoxa, Doryx, Monodox, Oracea, Periostat, Vibramycin) (See also:
tetracyclines)

i. indications

anthrax, Lyme disease

malaria prophylaxis


ii. administration: 100 mg by mouth every 12 hours for 14-21 days

iii. adverse effects

tooth discoloration, photosensitivity

superinfection, C.difficile associated diarrhea

anaphylaxis, angioedema, lupus erythematosus


iv. contraindications

children younger than 8 years old (may cause permanent discoloration of teeth)

pregnant and lactating women (teratogenic)



d. aminoglycoside antibiotics: streptomycin and gentamicin

i. indication: active tuberculosis, plague, tularemia

ii. adverse effects

nephrotoxicity, Fanconi syndrome, vestibular and auditory ototoxicity

neurotoxicity

neuromuscular blockade, seizures, pseudotumor cerebri


iii. administration

streptomycin: 15mg/kg IM every 24 hours

gentamicin: 1-1.7 mg/kg IM/IV every 8 hours







2. Anti-radiation treatment (chelation therapy)

a. purpose: fluid, electrolyte, and nutrient replacement; rapid administration of drugs
356


b. potassium iodide


3. Anti-chemical treatment

a. atropine

b. reactive skin decontamination lotion (RSDL)

i. removes and neutralizes chemical warfare agents to prevent serious burns and death

ii. administration

packaged as a sponge pad in a pouch

wipe exposed skin with pad





4. Other responses

a. immunizations

b. decontamination

c. activated charcoal (Actidose-Aqua) 25-100 g by mouth for 1 dose within 1 hour of ingestion

i. action: binds and inactivates poisons, toxins and irritants in the GI tract

ii. adverse effects: GI obstruction, fecal impaction, aspiration, bronchiolitis obliterans

iii. cautions

not effective for alkali poisonings, cyanide, ethanol, iron, lithium, methanol, mineral acids, organic
solvents

do not use oral administration in individual who is unconscious or has no gag reflex





B. Biologic agents used as weapons

1. Anthrax

a. exposure to Bacillus anthracis: inhaled, skin, stomach, and intestines; exposed individuals do
not spread infection

b. clinical indicators of anthrax infection

c. treatment

i. decontamination

remove clothing; do not pull anything over the head

decontaminate in area outside of treatment area: using large amounts of water, shower with soap
or wash with soap and running water; flush eyes with running water for 15 minutes


ii. antibiotics

ciprofloxacin (Cipro)

penicillin G procaine

doxycycline (Adoxa, Doryx, Monodox, Oracea, Periostat, Vibramycin)





2. Viral hemorrhagic fever (VHF)

a. causative agents: arenaviruses, filoviruses, bunyaviruses, and flaviviruses

b. disease states: Ebola, Marburg, yellow fever, Argentine hemorrhagic fever

c. the viruses are zoonotic and are totally dependent on their hosts

i. an animal reservoir host, e.g., mouse

ii. arthropod vector, e.g., ticks, mosquitoes


d. clinical indications of VHF

i. initially: high fever, muscle aches, weakness
357


ii. severe disease: subcutaneous and internal bleeding, bleeding from body orifices; shock,
delirium, seizures, and coma


e. treatment: supportive therapy; no effective treatment

f. vaccine: no vaccines except for yellow fever and Argentine hemorrhagic fever




3. Pneumonic plague

a. causative agent Yersinia pestis, carried on rodents and their fleas

i. Y. pestis destroyed by sunlight and dryness, although bacterium can survive for 1 hour after
release

ii. exposed individuals can spread infection


b. clinical indicators of plague

i. rapidly deteriorating pneumonia

ii. fever, chest pain, bloody or watery sputum


c. treatment

i. reduces risk of severe disease if begun within 7 days

ii. isolate exposed individuals

iii. treat with antibiotics (most effective when initiated within 24 hours of first clinical indications
of plague)

streptomycin

gentamicin

doxycycline (Adoxa, Doryx, Monodox, Oracea, Periostat, Vibramycin)

ciprofloxacin (Cipro)



d. vaccine: not available



4. Smallpox

a. causative agent:variola virus

b. types of infections

i. variola major; overall mortality rate at 30%

ii. variola minor; mortality rate less than 1%


c. exposed individuals can spread infection via direct contact or prolonged face to face contact

d. clinical indicators of smallpox disease

i. initially (sometimes contagious): high fever (101 - 104 F [38.3 - 40 C]), malaise, head and body
aches

ii. rash (most contagious): start as small, red spots on the tongue and mouth; the spots become open
sores and, then, spread to the rest of the body becoming pustules that crust and scab-over

iii. individuals are contagious until all scabs have fallen off


e. no specific treatment

f. vaccine

i. most effective: prior to exposure

ii. vaccination

within 3 days of exposure: prevents or greatly decreases severity of illness

within 4 to 7 days: some protection and may decrease severity of illness



358



C. Chemical agents used as weapons

1. Gas

a. mustard gas, nitrogen mustard

i. type of chemical: blister agent or vesicant

damages DNA and causes severe burns on contact; breaks down very slowly

delivered as vapor, oily-textured liquid, or solid in chemical warfare

may smell like garlic, onions, or mustard


ii. exposure via

inhalation, skin exposure, ingestion of contaminated water, contact with liquid

lasts for 1 to 2 days in environment, and from weeks to months in cold climate

common sites: eyes, respiratory tract, and skin


iii. clinical indications of exposure

2 to 24 hours after exposure: redness and itching progressing to yellow blisters

2
nd
and 3
rd
degree burns, scarring

eyes: pain, swelling, and tearing; blindness

respiratory tract: runny nose, sneezing, hoarseness, cough; increased risk of chronic respiratory
disease and lung cancer

GI: abdominal pain, diarrhea, fever, nausea, and vomiting


iv. treatment

no available antidote; rarely fatal

decontaminate in area outside of treatment area: shower with soap or wash with soap and
running water thoroughly; flush eyes with running water for 15 minutes

inhalation: leave area of exposure; get fresh air, provide oxygen, and support breathing




b. nerve gas (Sarin, Soman, VX)

type of chemical: nerve gas

extremely toxic, acts very quickly

irreversible cholinesterase inhibitor

impairs normal functioning of nervous system; can cause seizures, loss of consciousness, and
respiratory failure in minutes

exposure via
inhalation, ingestion, absorption through eyes and skin
can contaminate rescuers by direct contact or off-gassing vapor of contaminated skin or clothing

clinical indications of exposure

immediate: seizures, sweating, copious secretions, respiratory distress, able to talk but not walk or
unconscious, respiratory failure

treatment

decontaminate before transport to treatment facility

flush eyes first for 15 minutes

skin: shower with soap and large amounts of water or 0.5 % solution of sodium hypochlorite
(bleach), or use absorbent powders such as flour or talcum powder

ingestion: do not induce vomiting, administer activated charcoal

supportive measures: maintain airway, assist ventilation, and protect client



antidote
359


atropine adult 2 mg Im/IV every 5-10 minutes

pralidoxime (2-PAM. Protopam) 1-2 g IV for 1 dose then 250 mg IV every 5 minutes until
symptoms reverse





2. Strychnine

a. type of chemical: rat poison

i. white, odorless, bitter powder

ii. very small amount able to cause extremely serious adverse effects

iii. action: impairs functioning of neurotransmitters resulting in severe, painful muscle spasms
without affecting consciousness


b. exposure via

i. injection (mixed with street drugs)

ii. ingestion (food or water contamination)

iii. inhalation (release into air, smoked or snorted in street drugs)


c. clinical indications of strychnine poisoning

i. initially or with low level exposure: apprehension, agitation, painful muscle spasms

ii. later findings or high level exposure: uncontrollable arching of back and neck, rigid
extremities, difficulty breathing, brain death


d. treatment

i. decontaminate in area outside of treatment area

remove clothing; do not pull anything over the head to remove

using large amounts of water, shower with soap or wash with soap and running water

flush eyes with running water for 15 minutes


ii. IV fluid resuscitation

iii. cooling therapy for fever

iv. anticonvulsants, antispasmodic agents and muscle relaxants




3. Ricin

a. no available antidote

b. treatment

i. decontaminate in area outside of treatment area

shower with soap or wash with soap and running water thoroughly

flush eyes with running water for 15 minutes


ii. inhalation

leave area of exposure

get fresh air

provide oxygen and support breathing


iii. ingestion

do not induce vomiting; remain NPO

administer large dose of activated charcoal

aggressive fluid resuscitation and electrolyte repletion

prepare to administer vasopressor therapy





360

D. Radiation used as a weapon

1. Sources

a. nuclear weapon attack

b. accidental radioactive contamination

c. radiation dispersal device (dirty bomb)


2. Contamination via

a. wounds

b. ingestion

c. inhalation



3. Potassium iodide (Iosat, SSKI, ThyroSafe, ThyroShield)

a. thyroid protective agent

i. effective preventative therapy and treatment for thyroid uptake of radioactive iodine

ii. most effective if taken within 3 to 4 hours of exposure; more effective in children than adults

iii. not general (systemic) protection against radiation


b. administration

i. antidote is effective for approximately 24 hours

ii. give as daily, oral (tablets or solution) therapy during exposure to high radiation levels


c. adverse effects

i. arrhythmias, GI bleed, angioedema, parotitis

ii. goiter, thyroid adenoma


d. pregnancy: avoid taking, positive evidence of human fetal risk



361



I. Specimens and Reference Values

A. Blood specimens

1. Most blood specimens are obtained through venipuncture

2. Arterial puncture is used to obtained blood for arterial blood gases

a. special technique and tubes

b. needs direct pressure for a minimum of 5 minutes afterwards


3. Venipuncture and arterial puncture are invasive techniques requiring an order from the health care
provider

4. Sterile technique is required for both procedures

5. Standard precautions are necessary for both

6. Apply pressure to venipuncture site after specimen has been obtained to reduce likelihood of bleeding
for 1 to 2 minutes, especially when there are bleeding precautions, then apply bandage

7. Types of blood test

a. complete blood count (CBC) - Measures the number of red and white blood cells per cubic millimeter
of blood

b. blood chemistry - includes potassium, sodium, chloride and bicarbonate



8. Blood, plasma or serum values - use the "Tables" tab in Epocrates for Lab Values

a. normal plasma values

b. normal blood values


9.
Pediatric considerations

a. communication used with children

i. communicate with children according to their age

ii. explain what is going to happen, how long it will take, and answer questions for toddlers and up

iii. distract child to relieve anxiety


b. family centered care - never ask the caregiver to leave during the procedure; instead, ask how
involved s/he would like to be when drawing blood for labs





B. Urine specimens

1. Types

a. random ( normal adult values )

i. obtained from client voiding naturally, from urinary catheter or diversion bag

ii. used for routine urinalysis


b. clean-voided or midstream (used for culture and sensitivity)

i. used to determine bacterial growth and specific antibiotics that are effective against those
specific bacteria

ii. requires sterile or clean-voided specimen
362


iii. sterile specimen requires urine from urinary catheter

indwelling catheter - clean collection port and, using sterile technique, puncture with
needle attached to syringe to aspirate urine (never collect urine from collection bag)

straight catheter, with urine collected directly into sterile container


iv. females: after appropriate cleansing of urethral meatus, client collects urine after initial stream
in sterile container

v. males: retract foreskin and cleanse glans; client collects urine after initial stream in sterile
container


c. timed

i. used for tests of renal function and urine composition (creatinine clearance, steroids, hormone
levels)

ii. first urine specimen is discarded and for next period of time, all urine is collected and may be
kept on ice or have a special preservative

iii. client may be required to void at specific times

iv. missed specimens or those contaminated with feces or other elements render the test invalid
and test must be restarted and retimed

v. specimen should be refrigerated if it is to be kept for more than one hour

vi. client voids last specimen at end of timed period and total collection is sent to the lab



2. Immediate information on pH, glucose, protein, ketones and blood can be obtained by using
commercial reagent stick

3.
Pediatric considerations

a. offer small child fluid about 30 minutes before needed specimen

b. use terms that child can understand to explain procedure

c. use special collection bags for newborns and infants





C. Other specimens

1. Fecal (stool) specimen - used to determine presence of blood (guaiac test), fat, bacteria or parasites

a. standard precautions are required

b. timed test for fecal fat may be performed (where stool is collected in one container for 48 to 72
hours)


c. stool guaiac test finds hidden (occult) blood

i. client must defecate into clean, dry bedpan to avoid contaminating specimen with urine or water
(only a sample of stool is required)

ii. place small smear on paper card and add a drop or 2 of testing solution; a change in color
363

indicates the presence of blood in the stool

iii. client should not eat red meat, cantaloupe, uncooked broccoli, radishes or horseradish for 3
days prior to the test; client should stop taking vitamin C and NSAIDs prior to the test




2. Sputum specimen - used for microbiologic examination of secretions from the respiratory tract

a. standard precautions are required

b. may be obtained from client expectoration or via suctioning

c. client may gargle with plain water only before specimen collection

d. specimen may be kept in refrigerator if unable to send immediately to lab

e. indications - suspected pneumonia and malignancy

f. tests include a Gram's stain and culture and sensitivity



3. Gastric analysis - measures gastric secretions under fasting conditions

a. standard precautions are required

b. histamine is injected via nasogastric tube and secretions are aspirated

c. indications - suspected gastric ulcer or malignancy

d. client NPO for about 8 hours prior to test and no smoking

e. instruct client to expectorate saliva rather than swallow it

f.
withhold the following drugs for 24 hours prior to test: antacids, anticholinergics, alcohol,
H
2
blockers, reserpine and adrenergic blockers




4. Pleural fluid analysis

a. obtained via thoracentesis (see Respiratory Diagnostic tests on next page)

b. indications - inflammation, infection or malignancy



5. Peritoneal fluid analysis

a. obtained via paracentesis (see Gastrointestinal Diagnostic tests on next page)

b. indications - gross ascites to reduce interstitial fluid



6. Cerebrospinal fluid analysis

a. obtained via lumbar, cisternal or ventricular puncture (See Neurologic Diagnostic tests on next page)

b. indications - inflammation, infection



II. Diagnostic Tests-Common Laboratory Tests

A. Gastrointestinal system

B. Cardiovascular system

C.
Respiratory system

D. Nervous system

E. Musculoskeletal system

F. Integumentary system

G. Endocrine system

H.
Renal system

I.
Reproductive system

J.
Hematologic disorders



364

III. Diagnostic Tests - Other

A. Visualization tests: endoscopy, laparoscopy, arthroscopy

1. Direct inspection of a body part using an instrument with a light

a. endoscope - used for GI tract


b. laparoscope - used for abdominal contents


c. arthroscope - used for joints



2. Performed by inserting the instrument directly into a body opening
or into a body cavity via a surgical incision

3. Fiberoptic instruments may be used to enhance client comfort, to
improve instrument flexibility, and to facilitate visualization

4. May be performed under local or general anesthesia



5. Uses

a. diagnostic - permits inspection and obtaining biopsies

b. therapeutic - remove polyps or foreign bodies, implant radioactive seeds










365

Endoscopy Type Function: Examination of Possible Complications
Otoscopy External auditory canal and middle ear None
Rhinoscopy Nasal cavity None
Laryngoscopy Larynx None
Bronchoscopy Larynx, trachea and bronchi Bronchospasm; bleeding;
laryngospasm
Esophagogastroscopy Esophagus, stomach, and upper duodenum Perforation of esophagus or
stomach; laryngospasm
Colonoscopy Colon Bowel perforation
Proctosigmoidoscopy Lower colon, rectum Bowel perforation
Colposcopy Vagina and cervix with a binocular microscope None
Culdoscopy Vagina and cervix by means of endoscope inserted through
posterior vaginal fornix
None
Hysteroscopy Cervical canal and uterine cavity Perforation of uterus
Cystoscopy Urethra and bladder Dysuria, hematuria, bladder
perforation
Laparoscopy Abdominal and pelvic organs; abdomen filled with CO2 to enhance
vision
Bleeding from puncture site;
shoulder pain
Pelvic endoscopy Abdominal and pelvic organs, using fiber optic light source inserted
via laparoscope
Bleeding from puncture site
Mediastinoscopy Lung Bleeding from puncture site
Thoracoscopy Lung Bleeding from puncture site
Arthroscopy Joint, which may be filled with fluid to enhance visualization Swelling of join; bleeding into
the joint, infection



6. Nursing interventions in general

a. prior to procedure

i. check that consent is signed

ii. reinforce information to the client about the procedure

iii. when it involves the respiratory system, remove dental appliances before procedure

iv. keep client NPO before procedure for 6 to 12 hours

v. if the client is to undergo general anesthesia, give perioperative care


b. after bronchoscopy or laryngoscopy

i. hoarseness is normal for 48 to 72 hours; watch for laryngospasm or bronchospasm within initial 24
hours

ii. monitor client closely until gag and swallowing reflexes return, usually within one to two hours of the
procedure

366


c. post arthroscopy

i. apply pressure dressing and ice to affected joint

ii. caution client to avoid excessive use of joints for 48 to 72 hours

iii. permit weight bearing on knees as directed by health care provider


d. post laparoscopy

i. trapped carbon dioxide gas in the abdominal and pelvic cavities may cause aching shoulder pain for
up to 48 hours after procedure

ii. ambulation helps dissipate gas


e. mild analgesics may relieve most post-procedure discomfort



B. X-rays (Roentgenograms)

1. Noninvasive test in which radiation is passed through a specific body part to display a picture of the
internal aspects of that part


2. Uses

a. determine shape, size and position of organs

b. indicate presence of fluid lines, foreign bodies, infiltrates, abnormal air

c. determine configuration, density and vascular markings of organs

d. determine injury, fracture, degeneration, inflammation, perforations, calculi (stones) or masses

e. types of x-ray

i. chest

ii. musculoskeletal

iii. skull

iv. spine

v. mastoid

vi. sinus

vii. breast

viii. kidneys, ureters, bladder (KUB)

ix. abdominal



3. Nursing interventions

a. reinforce information for client about procedure

b. shield the client's genitals with lead drape

c. check if woman is pregnant; do not x-ray if pregnant (and notify health care provider)

d. for chest x-ray, assist to dress in institution clothing and remove all metal objects, including jewelry
and body piercings

e. consent is not required (these are noninvasive tests)




C. Contrast radiography

1. Visualization of x-ray enhanced by use of a contrast medium

2. Contrast medium may be ingested, injected through a tube or catheter, or given intravenously

3. Contrast medium may be barium, iodine, or air
367


4. Cineradiography: rapid sequence x-rays that film motion

5. Fluoroscopy: projection of x-rays onto screen for continuous observation of motion

6. Barium contrast studies

a. barium swallow

b. upper gastrointestinal and small bowel series

c. barium enema


d. specific nursing interventions

i. before the test

advise a low residue diet or clear liquid diet for two days prior to test

instruct client to be NPO after midnight

reinforce instructions for ingestion of cathartics the day before such as magnesium
citrate, GoLYTELY

give suppository or enema


ii. after the test

encourage drinking of more fluids to aid in elimination of barium since retained barium may
harden and cause an obstruction

examine client's stools for presence of barium - white or clay-colored stools are common for 24
to 72 hours


iii. a mild laxative or cleansing enema may be ordered to help client expel barium





7. Air contrast studies

a. ventriculogram: air injected via direct puncture of lateral cerebral ventricles

b. positive contrast medium may also be injected

c. pneumoencephalogram



8. Iodine-based contrast media

a. intravenous cholangiogram (IVC) - visualizes bile ducts

b. special nursing interventions

i. low residue diet for 1 day prior to test

ii. NPO after midnight




9. Intravenous pyelogram (IVP) - visualization of kidney and urinary system


368

10. Other types of contrast studies

a. arteriographic and venographic studies

b. cerebral arteriography

c. fluorescein arteriography

d. cardiac catheterization

e. digital vascular imaging

f. scintiscan

g. pulmonary arteriography

h. renal arteriography

i. venography

j. lymphangiography

k. myelogram: visualization of the spinal cord using water-soluble or oil agent

l. special nursing interventions

i.
clear liquid breakfast then NPO

ii. client must lie flat for eight to 12 hours after test if oily contrast medium is used

iii. force fluids post-test to replace cerebrospinal fluid

iv.
mild analgesics may be ordered post-test for headache




11. General nursing interventions in all contrast studies

a. check for hypersensitivity to contrast medium

b. observe for allergic reactions post-test

c. force fluids after studies, since contrast is a hypertonic to result in a mild diuresis for 24 to 48 hours
after the test

d. require a signed consent within 24 to 72 hours of procedure in most instances or according to facility
protocol

e. monitor for renal impairment by monitoring BUN and creatinine levels

f. metformin is commonly held before and after exams with contrast to prevent renal failure



D. Ultrasound studies

1. Noninvasive test


2. Uses high frequency sound waves (5,000 to 20,000 Hz) to detect vibrations reflected off soft tissues

3. Vibrations become electrical impulses, displayed on TV screen

4. Transducer placed on client's skin transmits the sound waves

5. Tissues of varying density reflect (echo) the sound differently


6. Uses

a. determine size, shape, position and motion of organs

b. detect masses
369


c. define boundaries between organs

d. determine fetal age and/or abnormalities


e. distinguish between a cyst (fluid-filled cavity) and a tumor (a tissue-filled cavity)

f. types

i. heart

ii. eye

iii. gallbladder

iv. liver

v. spleen

vi. pancreas

vii. renal/bladder

viii. testes

ix. fetal

x. uterus or ovaries

xi. thyroid

xii. abdominal

xiii. peripheral vasculature: doppler ultrasound used to measure peripheral blood pressure and pulses



7. Nursing interventions

a. reinforce information about test to client

b. abdominal, bladder and fetal ultrasound tests require full bladder - have client drink water prior to tests



E. Electrodiagnostic studies

1. Representation of electrical activity in certain organs

2. Electrocardiogram (EKG [or ECG]):

a. records electromechanical activity of myocardium, electrical axis of the heart

i. 12-lead looks at 12 different angles at one moment in time

ii. one lead monitoring system is continuous



b. the EKG records two basic events: depolarization and repolarization

c. the EKG records electrical activity as specific waves

i. P-wave: sinus node generates impulse; atria depolarize
370


ii. PR interval: time for impulse to travel from sinus node through atria to atrioventricular node, the
Bundle of His, the bundle branches and the ventricles; range: 0.12 to 0.2 seconds

iii. QRS complex: ventricle depolarizes and contracts (systole)

iv. T wave: ventricle repolarizes to resting state, ready for next systole

v. ST segment: time between ventricular depolarization and repolarization when the heart muscle
is in diastole or relaxation


d. used to determine presence of ischemic heart disease, cardiac conduction disturbances, cardiac
dysrhythmias



Use this mnemonic device to remember lead placement for a 3-lead EKG: (White) on the right, smoke
(Black) over fire (Red).


3. Exercise stress test

a. records myocardial response to exercise

b. used to determine ischemic heart dysrhythmias or disease and cardiovascular fitness before initiation
of exercise programs

c. exercise level is progressively raised while EKG is monitored

d. blood pressure and blood gases may be measured

e. nonexercise stress test is done after administration of dipyridamole (Persantine), which results in
vasodilation and increased heart rate

f. nursing interventions

i. encourage client to immediately report any findings during and after test for 15 to 30 minutes

ii. client should dress for exercise

bring a change of clothing

wear sturdy, rubber-soled shoes

eat a very light meal or do not eat within 2 to 3 hours of the test





4. Ambulatory electrocardiography (Holter monitor)

a. records myocardial activity continuously for 24 or 48 hours

b. client wears portable device

c. used to detect cardiac rhythm disturbances over time with comparison to client activities

d. correlated with client's activity

i. client keeps detailed diary

ii. diary includes time, activity, feelings - physical and emotional




5. Electrophysiology studies

a. an invasive measure of cardiac electrical activity

b. electrical catheter is inserted into right atrium via a peripheral vein

c. an EKG records each electrical stimulation of heart and how the heart responds

d. used to determine presence and sequelae of cardiac dysrhythmias



6. Event monitors

a. similar to Holter monitors except that there's no continuous recording of the heart's electrical activity

b. symptoms of abnormal hearts rhythms are recorded when they occur - client either starts monitoring or
it starts automatically

c. simultaneous interpretation and instructions


371


7. Electroencephalogram (EEG)

a. records electrical activity at various brain sites without discomfort

b. specific nursing interventions

i. do not stop anticonvulsant medications unless ordered to do so

ii. the night before test, reinforce that adult clients should have 5 hours of sleep (children should have
7 hours)

iii. advise that client will need to wash hair the night before and after the test

iv. instruct to eat a meal prior to the test and to avoid caffeine eight hours prior to test




8. Electromyogram (EMG)

a. records electrical activity in muscle sites with some discomfort

b. nursing: review with client that small needle will be inserted into one or more muscles while client is in
a supine or sitting position (no bleeding or infection should occur afterwards)



9. Electrocochleogram

a. measures auditory function

b. nursing intervention: be aware that client may experience vertigo

c. assure client safety


10. Electronystagmogram: record of electrical activity of eye during spontaneous, positional and calorically-
invoked nystagmus

11. Doppler ultrasound: used to detect deep vein thrombosis

12. General nursing interventions in electrodiagnostic studies

a. reinforce information about the test to client

b. instruct client to remain still during test unless instructed to do otherwise

c. reinforce that client should avoid stimulants 24 to 48 hours before test



F. Radioisotope scans - also called nuclear scans and radionuclide imaging

1. Intravenous injection of a radioactive substance followed by a series of pictures taken by a special
scanning device to detect passage of the substance through the body



2. Types

a. brain scan: used to detect intracranial lesions such as neoplasms, brain abscess, cerebral
hemorrhage, acute infarction and arteriovenous malformation
372


b. cisternography: used to assess cerebrospinal fluid circulation

c. thyroid uptake and scan: used to localize functioning versus non-functioning thyroid tissue

d. ventilation/perfusion scan: used to diagnose pulmonary emboli

e. bone scan: used to diagnose metastatic cancer and traumatic, inflammatory or infectious
musculoskeletal conditions

f. liver scan: used to screen for hepatic metastasis, cirrhosis and hepatitis

g. spleen scan: used to identify splenic infarct, metastasis, tumors, cysts and abscesses

h. renal scan: useful in monitoring rejection of a transplanted kidney and in the detection of tumors,
abscesses, cysts, renal vascular disease and trauma

i. 125

I Fibrinogen Uptake: used to detect the presence of deep vein thrombosis


3. Nursing interventions

a. reinforce information about the test to the client

b. check for allergies, particularly to iodine, shellfish, eggs

c. for renal or thyroid scans, client may excrete radionuclide after the test, so pregnant caregivers
should not handle client's urine for at least 24 hours after the test

d. do not schedule client for more than one radioisotope study on one day

e. lactating mothers must dispose of milk until radioisotope is cleared from the milk

f. know that certain factors may affect results of tests using radioactive iodine

i. dietary intake of iodine

ii. use of antithyroid drugs

iii. drugs containing iodine





G. Tomography and resonance imaging

1. Computerized tomography (CT) scans

a. use an x-ray and a computer to provide accurate images of cross sections of the body

b. a noninvasive procedure using very little radiation that visualizes slices of tissues

c. sharper images than conventional x-rays

d. contraindicated in pregnancy

e. nursing interventions

i. reinforce information about the test to the client

ii. provide mild sedation for selected clients

iii. instruct client to lie very still

iv. administer the radiopaque solution as prescribed

v. advise client to be NPO past midnight

vi. if barium studies were done, do not schedule for a CT scan for at least four days since barium
will obscure film






373

2. Positive emission tomography (PET)

a. uses an intravenous injection of radioactive substance followed by a head scan or other body part
as ordered

b. various shades of color indicate levels of glucose metabolism in the brain

c. nursing interventions - same as CT scan




G. Tomography and resonance imaging

1. Computerized tomography (CT) scans

a. use an x-ray and a computer to provide accurate images of cross sections of the body

b. a noninvasive procedure using very little radiation that visualizes slices of tissues

c. sharper images than conventional x-rays

d. contraindicated in pregnancy

e. nursing interventions

i. reinforce information about the test to the client

ii. provide mild sedation for selected clients

iii. instruct client to lie very still

iv. administer the radiopaque solution as prescribed

v. advise client to be NPO past midnight

vi. if barium studies were done, do not schedule for a CT scan for at least four days since barium
will obscure film





2. Positive emission tomography (PET)

a. uses an intravenous injection of radioactive substance followed by a head scan or other body part
as ordered

b. various shades of color indicate levels of glucose metabolism in the brain

c. nursing interventions - same as CT scan




3. Magnetic resonance imaging (MRI)

a. tomography based on the magnetic behavior of protons in the body tissues

b. used to detect neurologic and musculoskeletal disorders

c. contraindicated in clients with metal implants such as pacemakers, aneurysm clips, metallic orthopedic
devices, extensive tattoos

d. nursing interventions

i. reinforce information about the test to the client

ii. instruct client to lie very still

iii. check prior to procedure if client has claustrophobia; some chambers are enclosed and others
open

iv. loud banging and hammering sounds may annoy or scare some clients; ear plugs or headphones
may be used during the test

v. have client remove all metal, i.e., jewelry, watches, body piercings, hearing aids, removable dental
work, before procedure
374






H. Biopsy

1. Removal of small piece of body tissue for examination by pathologist for benign or malignant cells

2. May be accomplished via needle aspiration, punch biopsy, endoscopy, laparoscopy or surgery

3. May be performed under local or general anesthesia

4. Uses: to differentiate normal from abnormal tissue

5. Types

a. brain

b. thyroid

c. lung

d. pleura

e. lymph node

f. bone marrow

g. muscle

h. nerve

i. synovial

j. bladder, urethra

k. prostate

l. vagina, cervix, uterus, ovaries

m. skin

n. liver

o. breast




6. Nursing interventions

a. reinforce information about the test to the client

b. review client's history for signs of bleeding disorders or use of antiplatelet or anticoagulant agents
within 48 to 72 hours of test

c. instruct that if the clients are awake, they may experience discomfort or pain during biopsy

d. if general anesthesia is used, implement perioperative care
375


e. observe client for signs of bleeding 48 to 72 hours after biopsy and infection at biopsy site for 5 to
10 days

f. administer or advise client that mild analgesics may be prescribed for post-test discomfort




I. Skin

1. Tuberculin skin testing

a. PPD (purified protein derivative) is injected intradermally with a tuberculin syringe until a 6-10 mm
pale wheal is evident

b. indicates whether client has been infected with Mycobacterium tuberculosis or has been in contact
with infected individual

c. site checked at 48 to 72 hours after administration

d. contraindicated in clients with active tuberculosis or previous BCG vaccine

e. positive reaction

i. induration (elevated, red, and hard) of 10 mm in diameter or greater; greater than 5 mm in
diameter if HIV-positive

ii. requires chest x-ray (CXR)



f. negative reaction: no change at site or less than 10 mm redness

g. annual for health care workers, semiannual in high prevalence areas


2. Allergy skin testing

a. antigen is injected intradermally or by scratching the skin

b. site checked in 20 minutes after administration

c. indicates sensitivity to antigens

d. positive reaction: redness, itching, swelling tenderness at site

e. complication: anaphylactic reaction

f. allergy testing can also be accomplished by testing serum (radioallergosorbent test [RAST test])


3. Schick test - determines degree of immunity to diphtheria

a. intradermal injection of toxin in an arm

b. areas examined in 3 to 4 days after administration

c. determines presence of diphtheria antitoxins in the blood

d. positive reaction (indicating no antibodies): redness, swelling and tenderness at site of injection
(should disappear in 3 to 4 days)

e. negative reaction: no reaction


4. Nursing interventions

a. circle the injection site(s)

b. instruct client not to wash circled area(s) or use lotion on site




J. Ear and balance - audiometric tests

1. Screening audiometry

a. 20 dB tone is presented at 500, 1000, and 2000 Hz, and

b. 25 dB tone at 4000 Hz

376



2. Impedance audiometry

a. useful in detecting middle ear disorders

b. evaluates resistance to flow of sound



3. Tympanometry

a. measures compliance of tympanic membrane with variations in air pressure in the external ear
canal

b. determines the amount of negative pressure in the middle ear



4. Romberg test (for balance)

a. for assessment of vestibular function

b. client stands with feet together and eyes closed

c. minimal swaying expected



5. Caloric (oculovestibular reflex) testing

a. tests function of cranial nerve VIII

b. first cold and then warm water is instilled into external ear canal, one ear at a time; performed only
by physicians

c. normal finding

i. cold water - should cause rapid, side-to-side eye movements, i.e., nystagmus; the eyes should
move away from irrigated ear and slowly back

ii. warm water - the eyes should now move towards the warm water then slowly away


d. test can cause nausea or vomiting

e. diminished or absent response occurs with Mnire's disease, brainstem damage



6. Tympanocentesis

a. aspiration of middle ear fluid

b. commonly done during myringotomy

c. fluid is cultured





K. Gastrointestinal tract

1. Esophageal function studies

a. client swallows three thin tubes which pass into stomach

377


b. transducers measure esophageal pressures
Test Description Deviation from Normal
Manometry Normal lower esophageal
sphincter pressure ranges from
10-20 mm Hg
Abnormality of function can
cause dysphagia and
gastroesophageal reflux with
lower pressures
Swallowing
Pattern
Rapid rise and fall in pressure is
normal
Esophageal spasm
Esophageal pH
monitoring
Client swallows fourth tube with
pH monitor; 24-hour test can be
performed at home
Esophageal reflux
Bernstein Test
(also called Acid
Perfusion Test)
Mild hydrochloric acid is instilled
in nasogastric tube, followed by
normal saline (used to reproduce
symptoms of heartburn)
Positive test (or discomfort with
HCl) indicates esophagitis or
esophageal ulcer





2. Paracentesis

a. drains abdominal fluid of client with ascites

b. small incision is made just below umbilicus and trocar is inserted

c. nursing interventions

i. have client void before procedure

ii. sit client with feet firmly on floor

iii. assist with removal of fluid slowly over a period of 30 to 90 minutes to prevent sudden changes
in blood pressure; no more than 500 mL over 30 minutes

iv. monitor client for hypovolemia or electrolyte imbalance

v. observe incision site afterwards for leaking or bleeding

vi. assist with obtaining and labeling specimens





L. Respiratory

1. Pulmonary function tests

a. use a spirometer to record how efficiently lungs exchange oxygen and carbon
dioxide

b. client sits upright, wears nose clip and breathes into mouthpiece


c. uses

i. diagnose lung disease

ii. evaluate the extent of functional disability

iii. evaluate lung function pre-operatively
378


iv. evaluate how lungs respond to bronchodilators


d. nursing interventions

i. reinforce information about the test to the client

ii. instruct client to wear clip on nose during actual testing


e. measurements


Pulmonary
Measurement
Explanation Normal
Range*
Tidal Volume (Vt) Volume of air inhaled and exhaled
during one respiratory cycle
5-10 mL/kg
Inspiratory Reserve Volume (IRV) Maximum air client can inhale after a
normal inspiration
3000 mL
Vital Capacity (VC) Volume of air exhaled after a maximal
inhalation
4800 mL
Residual Volume (RV) Volume of air left in lungs after maximal
exhalation
1200 mL
Functional Residual Capacity (FRC) Volume of air left in lungs after normal
exhalation
2400 mL
Forced Expiratory Volume (FEV) Measures the amount of air that can be
forcibly exhaled in one breath; can be
measured at 1, 2, or 3 seconds
1000 mL
Total Lung Capacity (TLC) Total volume of air in the lungs
following maximum inhalation
6000 mL
*Abnormal Values: values less than 80% of predicted norm


2. Thoracentesis

a. insertion of large bore needle into the pleural space

b. uses

i. to obtain pleural fluid for analysis

ii. to remove pleural fluid

iii. to instill medications


c. nursing interventions

i. position client either sitting upright with arms and shoulders on overbed table, or in a side lying
position

ii. stress that client must stay very still during procedure

iii. explain that client will feel some pressure during needle insertion

iv. check vital signs frequently for initial 4 to 8 hours after the procedure

v. watch for findings of pneumothorax, subcutaneous emphysema or shock

vi. assist with the obtaining and labeling of specimens for analysis in proper sequence





379


3. Pulse oximetry

a. measures oxygen saturation; less accurate than arterial blood gas (ABG)

b. monitors oxyhemoglobin saturation noninvasively

c. technique

i. probe clips to end of finger, toe or earlobe and passes a light through tissue

ii. light is absorbed by photodetector

iii. oximetry calculated from how much light red blood cells absorb

iv. arterial saturation is displayed; normal SaO
2
93%


d. conditions when pulse oximetry reading may be unreliable

i. bright light shining on sensor such as bright room lights

ii. tremor or seizure on extremity where probe is placed

iii. poor perfusion to location where probe is placed

iv. cardiac arrest

v. intravascular dye circulating in the blood stream

vi. abnormal hemoglobin, such as carboxyhemoglobin and methemoglobin, or anemia

vii. dark fingernail polish or artificial fingernails


e. if pulse oximetry shows significant changes, verify its results with arterial blood gas (ABG) analysis

f. values less than 90% need oxygen or other treatment



4. Pilocarpine test (iontophoresis) or sweat test

a. measures sodium and chloride excretion from sweat glands

b. often first test performed for cystic fibrosis (CF) confirmation

c. usually performed on infants

d. pilocarpine is administered to stimulate sweat glands

e. perspiration is analyzed for sodium and chloride content

f. normal findings

i. sodium < 90 mEq/L

ii. chloride < 60 mEq/L (over 60 mEq/L indicates CF)


g. nursing interventions - none



M. Neurological system

1. Lumbar puncture ([LP], spinal tap)


a. needle inserted into the subarachnoid space between L3 and S1 with sterile technique

b. uses

i. measure cerebrospinal fluid (CSF) pressure

ii. obtain CSF for visual and laboratory examination

iii. to inject medications, anesthetic agents, diagnostic agents


c. Contraindicated if client has increased intracranial pressure (ICP)
380


d. Place client in lateral decubitus position (knee-chest); side-lying (also called fetal position)

e. Complications - neurologic deficit of lower extremities; post-puncture headache (report to health
care provider if lasts longer than 48 to 72 hours)

f. CSF findings

g. Nursing interventions

i. reinforce information about the procedure to the client

ii. administer sedative if ordered

iii. assist client to maintain proper position and stillness during procedure

iv. maintain standard precautions

v. label specimens sequentially

vi. provide emotional support as procedure can be painful

vii. post-procedure

keep client flat on back from 4 to 12 hours

give analgesics and ice pack as ordered

perform neurologic checks and vital signs as ordered

encourage fluids unless contraindicated

observe for post-puncture headache, leakage of CSF and assess for tingling
sensation, numbness or pain in lower extremities






2. Intracranial pressure (ICP) monitoring

a. invasive: measuring device is placed


i. in a ventricle

ii. in a subarachnoid space

iii. outside dura mater

iv. within parenchyma


b. devices used: ventricular catheter, subarachnoid bolt, epidural sensor

c. changes in intracranial pressure are converted to an electrical impulse by a transducer and displayed
on a screen or on graph paper

d. measurements include volume-pressure relationships, pressure waves and cerebral perfusion
pressures

e. normal ICP: 10 to 15 mm Hg

f. nursing interventions

i. maintain strict sterile technique

ii. maintain patency of device

iii. observe for CSF leaks or bleeding, signs of infection

iv. monitor pressure and report deviations






381


N. Cardiovascular system

1. Hemodynamic monitoring: invasive cardiac catheter

a. reflects left ventricular end diastolic pressure

b. use of a balloon-tipped, flow-directed catheter to provide continuous monitoring

c. catheter introduced via subclavian vein or by cutdown and passed through right side of heart to
pulmonary artery

d. may be inserted at the bedside or under fluoroscopy


e. complications of hemodynamic monitoring

i. pneumothorax

ii. dysrhythmias

iii. infection, sepsis, thrombophlebitis



2. Intra-arterial pressure - catheter in a major artery and attached to transducer

a. most common site: radial artery

b. usually inserted at bedside

c. also used to obtain arterial blood gas samples and other diagnostic studies

d. complications: clot formation, decreased or absent pulse, hematoma, infection, hemorrhage


3. Cardiac output (CO) = (heart rate x stroke volume) = 4 to 8 L/min

4. Nursing care of client with cardiac catheter - performed by RN



IV. Procedures

A. General nursing interventions for all procedures

1. Reinforce information about the procedure to client and significant others

2. Check for a written consent when indicated by institutional policy, usually with any invasive
procedure

3. Allow time for the client to ask questions, express concerns, fears

4. Implement actions with client to relieve anxiety

5. Involve significant others in procedure as appropriate

6. Assist with procedure according to institutional policy and procedure

7. Provide emotional support before, during, and after procedure

8. Review with client what is going to happen during the procedure

9. Post-procedure, observe for complications specific to the procedure

10. Record all procedures and client's response; if effective or ineffective response, describe

11. Obtain, label, and send all specimens to lab for analysis

12. Document characteristics of all specimens obtained

13. Maintain medical or surgical asepsis as required during procedure

14. Maintain Standard Precautions


382


B. Gastrointestinal intubation

1. Routes

a. nasopharynx: nasogastric, nasointestinal

b. oropharynx - maintains nasal passage for breathing

c. through abdominal wall by incision: gastrostomy, jejunostomy

d. via endoscopy: percutaneous endoscopic gastrostomy (PEG) or jejunostomy (PEJ)



2. Requires an order for insertion

3. Uses

a. diagnostic

b. gastric decompression

c. gastric irrigation

d. feeding




4. Nasogastric and nasointestinal

a. types of tube

i. nasogastric
single lumen: Levine
double lumen: Salem sump - has air vent and injection/aspiration port


ii. nasointestinal

single lumen: Cantor, Harris

double lumen: Miller-Abbott



b. complications of prolonged nasal intubation

i. aspiration risk is higher with nasal tubes

ii. nasal erosion, acute sinusitis, chronic sinus infection

iii. pharyngitis, esophagitis, esophageal sphincter incompetence

iv. gastric ulceration, pulmonary aspiration


c.
nursing interventions in gastric or intestinal intubation



5. Gastrostomy/jejunostomy

a. tube placement is in upper left quadrant of abdomen

b. used for clients who cannot tolerate nasal route or for long term enteral feeding

c. provides more secure and reliable access

d. nursing care

i. cleanse skin around insertion site daily with warm water and mild soap

ii. apply dressing if indicated

iii. observe for complications of infection, blockage

383


e. complications

i. skin breakdown at insertion site

ii. infection

iii. seepage of enteral formula or gastric drainage




C. Ostomy

1. Surgical procedure - creates an opening into the abdominal wall for fecal or urinary elimination
(enterostomy)

2. Portion of intestinal mucosa or ureter brought through abdominal wall creating a stoma through which
feces or urine drains

3. Types

a. bowel: ileostomy (small intestine) or colostomy (large intestine)

b. urinary diversions

i. ileal conduit (ileal loop)

ii. continent urinary diversion

iii. ureterostomy



4. Ileostomy

a. stool is liquid, frequent, highly alkaline, contains digestive enzymes

b. requires constant pouching and frequent emptying


5. Colostomy: thicker, formed stool

a. transverse colon must be pouched at all times - liquid to semi-soft stool

b. sigmoid colon - can be managed by daily irrigation, may be no need for pouch (formed stool)





6. Urinary diversions

a. ileal loop or conduit

i. a segment of the ileum is removed and used as a passage for urine

ii. one end forms a stoma on the abdominal wall, the other is sutured closed

iii. the ureters are implanted into the segment

iv. a pouch is worn on the abdominal wall to collect urine

v. remainder of bowel is re-anastamosed; client has normal bowel movements through anus

vi. urine should be yellowish; may contain mucus shreds with need to irrigate as needed if outlet is
blocked


b. continent urinary diversion

i. reservoir for urine made from parts of small or large bowel

ii. client needs no pouch

iii. reservoir is catheterized at specific times to drain urine


c. ureterostomy

i. one or both ureters are brought through the abdominal wall to form a stoma(s)
384


ii. stomas are pouched to collect urine

iii. usually a temporary measure performed on infants until ileal loop can be done

iv. complications: skin breakdown, infection, necrosis of stoma site



7. Nursing interventions for client with any ostomy

a. pouches to be emptied when they are about 1/3 to 1/2 full

b. if needed, protect skin around ileostomy stoma

c. ostomies threaten body image; do not force client to look at stoma

d. feelings of mutilation, shame, rejection are common

e. clients may feel powerless because they cannot fully control their bodily functions

f. assist client to establish normal elimination routine

g. observe client's tolerance of colostomy irrigation; report immediately if

i. stoma oozes blood when touched

ii. blood is seen in the pouch

iii. bleeding occurs from the stoma

iv. urinary diversion is less than 30 mL/hr in adults (or less than or equal to 1 mL/1 kg/hr in infants or
children)

v. urine smells foul, strong, sweet

vi. blood in urine

vii. urine is very cloudy, unless ileal conduit mucus may make cloudy

viii. client reports burning sensation around base of urinary diversion stoma

ix. client reports back pain above the waist, chills, or fever


h. reinforce teaching of client regarding

i. the types of equipment and their use

ii. how to irrigate the colostomy

iii. prevention of complications

iv. how to avoid constipation

v. that it is vital to drink plenty of fluids (3000 to 4000 mL per day, unless contraindicated)




D. Hemodialysis - cleansing the blood of accumulated waste products

1. Uses

a. short term therapy in acutely ill clients

b. long term use in clients with end-stage renal disease


2. Requirements

a. access to patient's circulation (usually via fistula)

b. access to a dialysis machine and dialyzer with a semipermeable membrane

c. the appropriate solution (dialysate bath)

d. time - 12 hours each week, divided in three equal segments of time

e. place - home (if feasible) or a dialysis center










385

3. Types of access
Access Route for
Hemodialysis
Abbreviation Description
Arteriovenous
Fistula
AVF A section of vein is directly sutured to an artery; it is
usually placed in the non-dominant arm, using the
cephalic vein and radial artery
Arteriovenous
Graft
AVG Connection tube is client's own (autologous) saphenous
vein, or made from polytetrafluoroethylene
Central Venous
Catheter
CVC Catheter inserted by directly cannulating the vein; usual
CVC sites include the femoral, internal jugular, or
subclavian veins





4. Aseptic procedure

a. circulation is accessed

b. unless contraindicated, heparin is administered (see: Lesson 6, Pharmacology)

c. heparinized blood flows through a semipermeable membrane in one direction

d. dialysis solution surrounds the membranes and flows in the opposite direction

e. contents of dialysis solution

i. highly purified water

ii. sodium, potassium, calcium, magnesium, chloride and dextrose

iii. either bicarbonate or acetate, to maintain a proper pH


f. via the process of diffusion, wastes are removed in the form of solutes (metabolic wastes, acid-base
components and electrolytes)

g. solute wastes can then be discarded or added to the blood

h. ultrafiltration removes excess water from the blood

i. after cleansing, the blood returns to the client via the access

j. protamine sulfate may then be given (as blood returns to the body) to counter heparin action


5. Complications related to vascular access in hemodialysis

a. infection

b. catheter clotting

c. central venous thrombosis

d. stenosis or thrombosis

e. ischemia of the affected limb

f. development of an aneurysm


6. Nursing interventions

a. reinforce information about the procedure to the client

b. monitor client parameters per facility policies

c.
reinforce diet and restrictions between hemodialysis treatments

i. protein

ii. sodium

iii. potassium

iv. fluids


d. reinforce adjustment to prescribed medications that may be affected by the process of hemodialysis
386


e. monitor for complications of dialysis related to several conditions

i. arteriosclerotic cardiovascular disease

ii. heart failure

iii. stroke

iv. infection

v. gastric ulcers

vi. hypertension

vii. calcium deficiencies (bone problems such as aseptic necrosis of the hip joint)

viii. anemia, fatigue, SOB

ix. depression, sexual dysfunction, suicide risk




E. Peritoneal dialysis

1. Automated peritoneal dialysis: requires a peritoneal cycling machine for intermittent, continuous or
nightly dialysis

2. Continuous Ambulatory Peritoneal Dialysis (CAPD)

a. a form of intracorporeal dialysis that uses the peritoneum for the semipermeable membrane

b. advantages of CAPD (compared to hemodialysis)

i. more freedom

ii. less physical and psychosocial interference

iii. fewer dietary and fluid restrictions

iv. simple and easy to use

v. provides satisfactory biochemical control of uremia


c. procedure

i. an indwelling catheter is permanently implanted in the peritoneum, usually inserted below or near
umbilicus

ii. for each dialysis exchange: to this catheter, attach a connector and insert it into a sterile plastic
bag of dialysate solution

iii. infuse the solution via gravity for 10 minutes (average 2 liter volume)

iv. the solution now dwells in the peritoneal cavity for a length of time specified, usually 4 to 6
hours, sometimes 8 hours at night

v. at the end of the dwell time, the solution is released and drained into a bag, via gravity

vi. drainage time is approximately 10 to 20 minutes, during which time ultrafiltration occurs

vii. clients average four exchanges per day, including one overnight which allows for uninterrupted
sleep during the night




d. complications of CAPD

i. infection at site

ii. infectious peritonitis

iii. hypoalbuminemia - loss of protein

iv. catheter malfunction

v. communication between the peritoneum and the peritoneal cavity

vi. abnormal drainage

brown - feces from suspected bowel perforation

cloudy - infection possible

bloody or blood tinged - possible perforation


vii. leakage of dialysate
387


viii. hyper- or hypovolemia

ix. bleeding at site or internally

x. obstruction from adhesions


e. nursing interventions

i. reinforce information about the procedure to the client

ii. assist according to institutional procedure

iii. monitor intake and output

iv. observe for signs of complications

v. record characteristics of output dialysate and client responses

vi. review with client

dietary restrictions - usually minimal, many clients on regular diet

parameters to weigh self daily

if infections recur, CAPD will not be feasible long-term

findings of infection

strict aseptic technique required with each exchange

wash hands before and after dialysis exchanges

skipping exchanges raises risk of renal failure

inspect bag before use for leaks, alteration in color, cloudiness


vii. discuss early warning signs of peritonitis

malaise

fever

abdominal tenderness

abdominal pain

cloudy peritoneal fluid




F. Cardiovascular

1. Pacemakers


a. an internal or external battery-powered pulse generator that stimulates the heart via electrodes that
touch myocardium

b. uses

i. hemodynamic and life support

ii. to correct dysrhythmias


c. electrode placement

i. atrial pacing

ii. ventricular pacing

iii. atrioventricular sequential and physiologic pacing


d. types

i. asynchronous (fixed rate): pace at a preset rate, regardless of person's rhythm, least common
388


ii. demand (standby): pace only if intrinsic rate declines below rate set on pacemaker, more
common

iii. synchronous: sensing circuit detects atrial and ventricular activity, more common


e. indications

i. symptomatic bradyarrhythmia

ii. symptomatic tachyarrhythmia

iii. asystole

iv. prophylaxis in persons with high risk of bradycardia

v. diagnosis of dysrhythmias during electrophysiologic testing





f. types of pulse generators

i. temporary pacemakers

transvenous approach (most common) - catheter electrode inserted via peripheral vein and
connected to external pulse generator

transthoracic - used primarily during cardiac surgery or cardiac resuscitation; catheter
electrode is placed directly into heart

permanent pacemakers - transvenous

catheter electrode is passed through right heart and connected to small generator

generator is implanted subcutaneously on chest wall, usually in upper right quadrant in
subclavicular area

lithium-powered battery can last up to ten years




g. complications

i. infection

ii. failure

syncope

hypotension

shortness of breath

pallor


iii. perforation of myocardium

iv. pneumothorax

v. hemothorax

vi. dysrhythmias

vii. thrombosis

viii. hiccups - may indicate perforation of lead through heart muscle or too strong of an impulse


h. nursing interventions

i. reinforce information about the procedure to the client

ii. initiate preoperative care for either general or local anesthesia

iii. postprocedure

initiate post-care

monitor vital signs and ECG as ordered

maintain bed rest as ordered with minimal use of arm or implanted side for 24 to 48 hours to
allow for healing

observe for signs of complications


iv. review with client

pacemaker's set rate
389


how to take pulse (rate and rhythm) in morning before getting out of bed

findings of pacemaker failure, wound infection

activity limitations

hazards: power-generating equipment, arc welding equipment, powerful magnets (including
MRI)

importance of carrying and wearing MedicAlert identification

need for periodic battery replacement

avoidance of contact sports

importance of medical follow-up




2. Automatic implantable cardioverter-defibrillator (AICD)

a. pulse generator implanted in subcutaneous pocket; delivers electrical shock to heart when ventricular
tachycardia or ventricular fibrillation detected


b. used to treat life-threatening ventricular dysrhythmias

c. complications

i. infection

ii. malfunction

iii. battery failure


d. nursing interventions

i. similar to interventions with clients with pacemakers

ii. review with client

signs of defibrillation discharge

wear MedicAlert identification

assure client that no household appliance will affect AICD

shock may be painful





G. Artificial airways

1. Endotracheal tubes

a. polyvinyl tube with inflatable cuff

b. inserted through nose (nasal) or mouth (oral)

c. distal end should be a few centimeters above the carina

d. cuff around tube is filled with air

i. creates a seal in trachea to prevent aspiration

ii. air pressure in cuff is cuff < 25 cm H
2
0; if pressures are higher, client risks pressure necrosis in
the tracheal mucosa


e. size of tube varies with size of child or adult

f. pediatric tubes may not be cuffed

g. when tube is inserted, check for placement
390


i. listen for bilateral breath sounds

ii. look for bilateral chest movement

iii. chest x-ray

iv. measure pulse oximetry


h. nursing interventions

i. reinforce information about the procedure to the client

ii. regularly assess tube placement and security

iii. mark tube length with teeth, or lips if edentulous (toothless)

iv. suction as needed to maintain airway patency

v. provide oral hygiene and care for area around the tube as indicated

vi. observe for skin breakdown around tube site

vii. observe for possible complications

aspiration

oral/nasal pressure sores

accidental extubation

oral, nasal, or pharyngeal damage






2. Tracheostomy

a. surgical opening through the neck into the trachea


b. temporary or permanent

c. indications

i. head and neck surgery

ii. long term airway access; for long-term mechanical ventilation

iii. emergency airway


d. post-op complications

i. tube dislodgement

ii. subcutaneous emphysema

iii. bleeding

iv. infection


e. components of tracheostomy tubes

i. outer cannula - stays in opening in neck

ii. inner cannula - is removed, cleaned, and reinserted at regular intervals - usually every 8 hours;
disposable also available

iii. obturator - used to reinsert intact tracheostomy tube


f. nursing interventions

i. reinforce information about the procedure to the client
391


ii. regularly check tube placement - auscultate for bilateral breath sounds - and security - ties are snug

iii. care for tracheostomy site and inner cannula per facility policies

iv. suction as needed to maintain airway patency (see next page)

v. provide adequate hydration to keep secretions thin

vi. periodically clean inner cannula and stoma site per facility policies

vii. provide regular oral hygiene

viii. change tracheostomy ties when soiled or as ordered

ix. watch for skin irritation/infection at insertion site and around neck, especially the back of the neck
under ties

x. review with client

tracheostomy care - clean technique at home

suctioning procedure - clean technique at home

signs of complications and when to report

how to handle accidental dislodgement/extubation





3. Airway suctioning

a. removing secretions from the upper or lower airway

b. sites for suction

i. nasopharynx, oropharynx, trachea, or bronchi

ii. through endotracheal tube or tracheostomy


c. equipment

i. use bulb syringe to suction nose and mouth of neonates, infants

ii. catheter's outer diameter should be no larger than 1/2 the inner diameter of endotracheal lumen

iii. determining length of catheter

measure from tip of nose to base of ear to sternal notch

infant, young child - insertion tolerance range: 8 to 14 cm

older child, adolescent - insertion tolerance range: 14 to 20 cm



d. procedure

i. sterile procedure is used in institutions (clean procedure is used at homes of clients)

ii. suction when rhonchus is heard

iii. adjust suction control to between 80 to 120 mm Hg

iv. hyperoxygenate client

v. insert suction catheter with suction off until resistance is met, then withdraw catheter an inch or two

vi. apply suction intermittently when withdrawing catheter

vii. rotate catheter during withdrawal

viii. from time of insertion, spend no more than 5 to 10 seconds

ix. re-establish ventilation and oxygenation

x. repeat procedure as indicated

xi. pharyngeal suctioning - less depth, less risk of complications than with tracheal suctioning


e. nursing interventions

i. review information about the procedure to the client

ii. explain that coughing, sneezing or gagging is normal

iii. place client in semi-Fowler's (or higher position if condition allows)

iv. maintain standard precautions
392


v. do not routinely instill saline into airway

vi. if secretions are thick, increase humidity of inspired air

vii. provide client with extra oxygen and extra deep breaths before, during, and after procedure

if client is receiving mechanical ventilation, use ventilator

if client is breathing spontaneously, use manual resuscitation bag


viii. compare client's respiratory status before and after suctioning with inclusion of breath sounds

ix. do not force catheter at any time




H. Oxygen delivery

1. Nasal cannula

a. delivers 25% to 40% oxygen at flow rates of 1 to 6 liters per minute (LPM)

b. higher flow rates can be very uncomfortable and cause nasal bleeding

c. clients with hypoxemia with chronic hypercapnia (as with COPD) require low levels of oxygen
delivery at 1 to 2 LPM

d. nursing interventions

i. review information about the procedure to the client

ii. ensure prongs are in the nares

iii. pad tubing around the tops of ears, as indicated

iv. daily checks for impaired skin integrity at top of ear where tubing lies




2. Simple face mask

a. delivers 50% to 60% oxygen at flow rates of 8 to 12 LPM

b. allows room air to enter mask

c. typically for short-term oxygen therapy or to deliver oxygen in an emergency

d. poorly tolerated, therefore not commonly used




3. Venti-mask (Venturi mask)

a. delivers 24% to 50% oxygen at flow rates of 3 to 15 LPM

b. uses air-entrainment principle to deliver precise concentrations of oxygen

c. interchangeable adaptors used to modify fraction of inspired oxygen (FIO)

d. due to entrainment, provides high rate of total flow

e. ideal for clients with COPD since low flow rates can be set

f. nursing interventions

i. review information about the procedure to the client

ii. keep nasal cannula on stand-by for use during meals

iii. keep air entrapment port for the Venturi adapter open and uncovered to ensure adequate oxygen
delivery

iv. assess for dry mucous membranes; humidity or aerosol can be added




4. Non-rebreather mask

a. mask with added reservoir bag; one-way valve prevents client from exhaling back into the bag

b. oxygen flow rate prevents collapse of bag during inhalation

c. provides highest percentage of O2 available from any mask, from 60% to 100% (depending on client's
ventilatory pattern) at flow rates of 6 to 15 LPM

d. used for sickest clients with deteriorating respiratory status
393


e. nursing interventions

i. review information about the procedure to the client

ii. closely monitor for changes in respiratory effort, rate, and depth

iii. intubation may be needed with increased respiratory effort and deterioration of ABGs

iv. ensure reservoir bag does not completely collapse during peak inspiration

bag should deflate slightly when client inhales and expand when client exhales

if bag collapses at inspiration, increase liter flow to bag


v. ensure pop-off valves on mask are not stuck and work properly




5. Home oxygen therapy - three types

a. compressed oxygen comes in tank or cylinder

b. liquid oxygen in reservoir

c. oxygen concentrator extracts and concentrates oxygen from the air



6. Positive pressure devices

a. continuous positive airway pressure (CPAP)

i. compressor provides air flow to client

ii. baseline of noninvasive positive pressure is maintained throughout inspiration and exhalation

iii. used primarily to treat sleep apnea at home for maintenance of patent upper airway


b. bi-level positive airway pressure (BiPAP)

i. provides a baseline of noninvasive positive pressure throughout inspiration and exhalation

ii. provides positive pressure assist during client's own spontaneous inspiratory effort

iii. used for clients in respiratory failure to rest client and improve oxygenation to avoid intubation




I. Ventilators

1. Purpose

a. support and maintain client ventilation

b. improve ventilation

c. improve oxygenation

d. decrease work of breathing


2. Ventilator control modes - assist and synchronized

a. assist-control

i. preset rate at preset tidal volume

ii. if client initiates breath, machine delivers the preset tidal volume


b. synchronized intermittent mandatory ventilation (SIMV)

i. machine set to deliver a given rate at a preset tidal volume

ii. clients can breathe on their own between machine breaths but will determine own tidal volume

iii. used to gradually decrease machine support of breathing



3. Settings

a. tidal volume: amount of air delivered with each machine breath - usually 800 to 1000 mL

b. rate: number of breaths delivered by the machine in a minute

c. FIO
2
: fraction of inspired oxygen (written as 0.6)

d. %O
2
: percent of oxygen (for example: 60%)

e. an FIO
2
of 0.6 = 60% oxygen


394

4. Sighs: deep breaths (higher volume) delivered periodically by ventilator

5. Positive end expiratory pressure (PEEP)

a. normal physiologic PEEP is equal or less than 5cm H
2
O

b. provides a baseline of positive pressure "throughout exhalation"

c. used to reduce airway collapse and intrapulmonary shunting


6. Nursing interventions

a. reinforce information about the equipment to the client

. monitor and document client's response to mechanical ventilation

c. ensure ventilator is working properly

i. if high pressure alarm - check for tube obstruction

client biting tube

increased secretions

tube slipped into right main stem bronchus

pneumothorax


ii. if low pressure alarm - check for disconnection of tubes


d. provide for adequate nutrition since breathing requires much energy; frequent small amounts of high
carbohydrates

e. monitor pulse oximetry and/or arterial blood gases per facility policies

f. frequent oral care due to drying of mucous membranes




J. Chest physiotherapy

1. Consists of coughing, posterior chest wall percussion, vibration, and postural drainage


2. Designed to improve airway clearance

3. Used for clients with retained tracheobronchial secretions

4. Cough: natural clearing mechanism

5. Chest wall percussion, vibration

a. percussion involves clapping chest with cupped hands

b. vibration is downward vibrating pressure with flat hand; done during exhalation



6. Postural drainage

a. gravitational clearance of airway mucous from various bronchial segments

b. uses ten different body positions
395




7. Percussion and vibration done in each position; simultaneously client coughs or nurse suctions to
remove loosened secretions

8. Nursing interventions

a. review information about the procedure to the client

b. place client in desired position according to lobe being drained

c. percuss each area for at least three minutes

d. encourage client to cough after each area is percussed and vibrated

e. avoid procedure within two hours after a meal




K. Chest drainage

1. Chest tube placement

a. in the pleural space to remove air, fluid, or both

b. anterior and superior chest wall to remove air

c. posterior and inferior chest wall to remove fluid

d. mediastinal tube

i. drains blood or fluid from around heart

ii. no tidaling in mediastinal drainage because tube is not placed in lung cavity



2. Components of chest drainage systems

a. collection chamber

i. collects fluid

ii. monitor and document rate and nature of drainage (initially every 30 minutes in first few hours,
then every 1 to 4 hours)


b. water seal chamber

i. provides a one-way valve so that air leaves and cannot reenter chest

ii. check for bubbling in this chamber - indicates air leak in the lung (a normal finding in initial 48 to
72 hours of therapy for a pneumothorax)

iii. check for tidaling (expected to rise with inspiration, fall with exhalation)


c. suction control chamber

i. negative pressure transmitted to pleural space is determined by the amount of solution in this
chamber, not the setting on the wall suction

ii. expected finding is continuous bubbling in chamber

iii. used to enhance re-expansion of lung quickly

iv. may be stopped to

send client to x-ray department

auscultate breath sounds more accurately

walk client in room or halls


v. types of suction control chambers
396


wet chamber - suction level determined by water level in chamber

dry chamber - suction level determined by mechanical setting or dial on pleurovac





3. Nursing interventions

a. review information about the procedure to the client

b. position the tubing on the bed so that there is straight gravity drainage to the collection device

c. do not allow dependent loops to form in the tubing

d. do not routinely strip or milk the tubing unless prescribed

e. do not routinely clamp the chest tube (it is appropriate to clamp when changing pleurovac)

f. if tube is dislodged, with no air leak

i. apply occlusive dressing - vaseline gauze covered totally with adhesive tape

ii. monitor for respiratory distress

iii. depending on client's condition, tube may or may not need to be replaced

iv. notify care provider promptly


g. if tube is dislodged, and there is an air leak

i. apply non-occlusive dressing to allow air to leave the chest and prevent tension pneumothorax

ii. contact provider for immediate reinsertion of tube


h. tape all connections with adhesive tape

i. assist with tube removal

i. have occlusive dressing ready to apply

ii. remove all equipment with standard precautions in mind


j. know that along with agency policies chest tube dressings are to be occlusive and not changed

k. if a chest tube dressing has drainage, notify care provider promptly - a complication has occurred



L. Urinary drainage

1. Catheterization: insert tube via urethra into bladder for drainage of urine

2. Catheter types

a. intermittent

i. straight single catheter used

ii. catheter withdrawn after bladder is drained

iii. sterile technique used in facilities (clean technique may be used in the home)


b. indwelling

i. double lumen catheter has small balloon, filled with 5 to 10 mL of sterile solution that fixes it in
bladder

ii. used for long term drainage; is attached to a collection system

iii. triple lumen tube may be used for continuous bladder irrigation; these balloons are commonly
filled with 30 mL sterile solution

iv. sterile techniques used


c. condom: applied to penis and attached to collection system


3. Nursing interventions

a. review information about the procedure to the client

b. maintain standard precautions

c. place client in low Fowler's or supine position

d. female: externally rotated thighs with bent knees

e. insert catheter maintaining sterile technique according to facility policies
397


i. insert catheter to full extent for males

ii. insert catheter to three to six inches for females


f. collect urine or attach to collecting system

g. if ordered, send specimen for laboratory analysis

h. measure and record initial urine output

i. record urine color and consistency (clear or cloudy)

j. maintain patency of catheter by avoiding dependent loops during gravity drainage

k. encourage fluids to over 2000 to 3000 mL/day as condition permits

l. provide perineal hygiene at least twice daily

m. care for catheter according to facility policy or as prescribed

n. observe client for signs of urinary inflammation/infection

o. irrigate catheter only as ordered (usually not routinely irrigated)

p. empty collection system as needed when 1/2 to 3/4 full or every shift




M. Wound drain

1. Purpose is to remove wound drainage

2. Types

a. closed drain - called continuous portable suction device

i. drain attached to collection system

ii. uses vacuum to draw drainage into system

iii. example: Jackson-Pratt, Hemovac

iv. specific nursing interventions

maintain patency of drain

empty collection system when 1/3 to 1/2 full or every shift

record amount and characteristics of drainage

drainage sequence expected

first 24 hours - sanguinous

24 to 72 hours - serosanguinous

more than 72 hours - serous




b. open drain

i. removes drainage from wound and deposits it on skin surface

ii. example: Penrose drain

iii. sterile safety pin usually attached to outside end of drain to prevent drain from moving inward

iv. specific nursing interventions

prevent inadvertent removal of drain

protect skin surface from irritating effects of drainage by cleansing skin when dressing
changed

expect large amounts of drainage with frequent dressing changes needed in the initial
24 to 48 hours after surgery

if ordered to advance Penrose drain - pull outward 1 to 2 inches (wear sterile gloves);
a new sterile safety pin may or may not be attached



c. wound vacuum

removes and collects infectious material from wound

computer controlled

requires a seal at wound site with pressure distributing wound packing
398


client may be discharged with device





N. Dressings, compresses, bandages, irrigation

1. Dressings

a. uses

i. protect wound from contamination

ii. promote healing by absorbing drainage and debriding a wound

iii. promote thermal insulation of wound

iv. protect wound from further external injury

v. prevent the spread of microorganisms

vi. control bleeding

vii. comfort



b. types of dressings
Type of
Dressing
Description & Use Advantages & Disadvantages
Gauze Oldest, most common dressing
Comes in woven and nonwoven
forms
May be impregnated with various
products, e.g., antimicrobials
Indications: draining wounds;
necrotic wounds; wounds with
tunnels, tracts, or dead space;
surgical incisions; burns, pressure
ulcers
Advantages:
Wicks away wound exudate
Does not interact with wound
Comes in many sizes, lengths

Disadvantages:
Must be held in place by a
secondary dressing
Fibers may shed or adhere to
wound
Nonadherent
gauze
Similar to gauze with a substance
that hinders sticking (example:
Telfa pad)
Absorbs wound exudate but does
not stick to wound
Transparent
film
Made of polyurethane or
copolymer
Porous adhesive layer that lets
oxygen pass through to and
moisture vapor escape from the
wound

Indications: small, superficial
wounds, e.g., over IV insertion
sites, and stage I or II pressure
ulcers, partial-thickness wounds
Advantages:
Doesn't have to be removed to
examine wound
Impermeable to external fluid and
bacteria
Available in many sizes

Disadvantages:
Fluid retention under dressing may
lead to periwound maceration
Hydrocolloid Dressing contacting would swells
to accumulate exudate

Indications: shallow to moderate
dermal wounds, e.g., venous or
arterial ulcers and decubitus
ulcers
Debrides
Maintains wound humidity
Liquifies necrotic debris
impermeable to contaminants
May stay safely for days

Disadvantages:
Occlusive - does not allow air
399

contact
Hydrogel Dressing impregnated with water
or glycerin-based amorphous gel
(high water content)
Nonadherent

Indications: Used for partial or full
thickness wounds, burns, deep or
necrotic wounds, radiation-
damaged skin
Advantages:
Decreases pain
Maintains humidity
Debrides
Does not stick to wound
Can be used with infected wound

Disadvantages:
Must be covered with another
dressing
Composites Combinations of two or more
different products, featuring a
bacterial barrier, absorptive layer,
foam, hydrocolloid, or hydrogel
Advantages:
Facilitate autolytic debridement
Conformable and easy to apply and
remove
Many sizes and shapes

Disadvantages:
May be contraindicated for stage IV
pressure ulcers
Adhesive borders limit use on
fragile skin
Foam An absorptive dressing consisting
of hydrophilic polyurethane or
film-coated gel

Indications: stages II - IV pressure
ulcers; partial- and full-thickness
wounds with drainage; surgical
wounds
Advantages:
Many sizes, shapes, forms
Conformable
Easy to apply and easy to remove
(nonadherent)

Disadvantages:
Secondary dressing or tape may be
needed to secure in place
Not recommended for nondraining
wounds or dry eschar
May lead to macerating periwound
skin if not changed appropriately
Alginates A polysaccharide from seaweed

Indications: moderately or highly
exudative wounds
Advantages:
Forms gel on wound and moist
environment
Reduces pain
Can be used to pack cavities
Low allergenic

Disadvantages:
Dry wounds or hard eschar
May require secondary dressing
Not recommended in anaerobic
infections





c. nursing interventions

i. review information about the procedure to the client

ii. maintain standard precautions

iii. change dressing as ordered or according to institutional procedure
400


iv. make sure dressing is secure; in some instances to be taped on all four sides

v. document

type and amount of drainage

presence of drains

condition of wound

condition of surrounding skin integrity


vi. observe for signs of infection

yellow-green exudate

foul smell

low-grade temperature

red streak up extremity from wound site


vii. watch moist dressings for growth of yeast

viii. weigh dressing as ordered

ix. review with client

type and purpose of dressing

how to change dressing if change required at home by client or others

signs of wound healing - for example, size decreases

signs of complications, e.g. infection, nonhealing




2. Compresses

a. moistened piece of gauze dressing

b. may be hot or cold

c. uses

i. improve circulation

ii. reduce edema

iii. promote consolidation of pus


d. nursing interventions

i. review information about the procedure with the client

ii. change warm compresses frequently or apply aquathermic pad to maintain temperature

iii. usually used external and on closed intact skin




3. Bandages and binders

a. made of gauze, elastic knit or webbing, muslin or flannel

b. uses

i. provide extra protection or support

ii. create pressure over body part

iii. immobilize body part

iv. support a wound

v. reduce or prevent edema

vi. secure dressings


c. bandage types

i. circular

ii. spiral

iii. spiral reverse
401


iv. figure eight - often used around a joint

v. recurrent


d. binder types

i. abdominal

ii. T-binder

iii. breast


e. nursing interventions

i. review information about the procedure to the client

ii. insure that bandage or binder is not constrictive

check distal pulses if on an extremity

validate needed respiratory effort if chest or abdominal area


iii. tell client to report any discomfort with bandage or binder

iv. replace soiled bandages, or have client wash binders if possible




4. Slings

a. supports arm with muscular sprain or fracture


b. may be commercially made or home made

c. nursing interventions

i. review information about the procedure with the client

ii. support affected extremity while applying sling

iii. place sling outside normal clothing

iv. stress to client that the distal joint is to be higher than the proximal joint for proper use of a sling




5. Irrigation

a. flushing with solution

b. uses

i. to remove foreign matter or exudate

ii. to insure patency of drainage tubing

iii. involves instilling a solution and withdrawing that solution


c. types

i. urinary

ii. wound

iii. nasogastric/gastrostomy/jejunostomy

iv. ostomy

v. ear

vi. vagina (douche)

vii. colonic (enema)

Fleets - small amounts of fluid, usually 120 mL
402


high - large amounts of fluid from 500 to 1000 mL






O. Casts

1. Externally applied structure that holds bone in one position

a. pain should diminish after casting

b. persistent or severe pain after casting may be a medical emergency


2. Uses

a. immobilization

b. prevent bone or muscle deformity

c. support of a weakened limb

d. promote healing

e. permit early weight bearing on affected limb


3. Types of casting materials

a. plaster of paris

i. natural material

ii. indicated in two cases

severely displaced fractures

unstable fracture fragments


iii. when multiple castings are indicated: serial casting

iv. application: takes at least 24 to 48 hours to dry thoroughly

v. advantages

low allergic response

offers rigid protection

easy to apply

inexpensive


vi. disadvantages

long drying time (typically 24 - 48 hours)

weight - plaster casts are heavy

materials may crumble and disintegrate at edges

not waterproof

risk of skin breakdown if handled incorrectly while drying



b. fiberglass

i. synthetic material

ii. indicated in two cases

non-displaced fractures

long term casting


iii. advantages

light weight

easy to apply

moisture-proof

fast: dries in 15 minutes, cures in one hour

colors and patterns help client adjust to immobilization


403

iv. disadvantages

short drying time requires speed and accuracy

more rigid than plaster; may bind if tissues swell

extra rigidity may cause tissue breakdown under the cast

more expensive than plaster castings






4. Types of casts

a. short arm/leg

i. cylindrical cast

ii. allows for flexion or extension of elbow and knee


b. long arm/leg

i. cylindrical cast

ii. does not allow elbow or knee to move


c. spica arm/hip

i. support bar is applied between extremities

ii. permits greater stabilization

iii. for spica arm, be sure a window is cut over epigastrium for patient comfort after eating

iv. for spica hip, extra care is needed to prevent skin breakdown from excretory functions




5. Cast application - various interventions

a. cast must extend to the joint above and below the point of fracture

b. data collection prior to cast application

i. skin: document irritation, laceration, skin breakdown sites

ii. neurovascular status check for color, movement, sensation, temperature

iii. edema or swelling - location and effect on neurologic and vascular function


c. windowing

i. square or diamond hole cut in cast over certain area

ii. indications

observation of surgical incision

observation of skin

relieve pressure over a bony prominence


iii. nursing interventions

cast may crack at window site - weakest part of the cast - report promptly

appropriate padding and/or petaling of open window

advise client not to put objects in window



d. bivalving

i. indications

compartment syndrome: swelling that impairs neurovascular function with loss of pulse,
sensation and movement (a medical emergency)

infection or potential for infection

unrelieved pain after extremity is casted


ii. techniques

lengthwise splitting of the cast with cast saw

apply ace wrap or tape to hold cast together
404


still immobilizes extremity

no weight bearing to any degree after the bivalving



e. petaling

i. edging the cast with soft padding, moleskin, or adhesive tape

ii. indications

prevent irritation or skin breakdown at rough edges of cast

protect cast from perspiration, feces, urine around edges

protect perineal area from skin breakdown




6. Nursing interventions: post cast application

a. plaster of paris casts

i. handle fresh cast carefully for the first 48 hours

indentations may cause pressure points under the cast

handle the cast with open palms of hands, not fingers or fingertips


ii. do not apply pressure to the cast

iii. do not cover the cast - allow to air dry

iv. elevate casted extremity per facility policies or as ordered


b. all casts

i. frequent neurovascular checks

check every 15 minutes the first hour, then every hour for the first 24 hours, then at least
every 4 hours

capillary refill time - arterial circulation

pulse distal to cast if accessible

warmth - temperature

color - circulation, initially tips of digits may be pale and cool from edema

motion checks - neurovascular

client can move toes and fingers of affected limb upon request

if unable to move, a nerve is compressed, suspect compartment syndrome

sensation: numb or tingling may mean nerve compressed


ii. drainage

observe for wound drainage through casted extremity

record size, color, amount; and circle area on cast with felt tipped marker, date, time, and
initial site

check for foul odor of drainage, which may reflect infection


iii. reinforce teaching of clients

keep cast dry and intact, especially plaster casts

avoid placing any objects inside of or through cast

describe indications and therapeutic use of casting for immobilization

properly use assistive devices such as crutches, walker, sling for arm

assess their environment for potential mobility hazards

inspect the cast daily for foul odor, cracks, drainage

sometimes swimming allowed with fiberglass casts and at least one to two hours drying
time afterwards






405


7. Nursing interventions for cast removal with a mechanical saw

a. reinforce information about the procedure to the client

b. inform client that

i. cast removal is painless

ii. client will feel heat and vibration

iii. saw is noisy but will not cut client

iv. tissue under cast will be inspected for signs of inflammation or infection

v. lotion to moisturize skin may be applied if skin is intact

vi. underlying skin may be scaly and dry

vii. a need may exist to perform range of motion exercises for 4 to 6 weeks as prescribed - the longer
time of cast therapy, the more risk of musculoskeletal dysfunction of strength and movement




P.
Traction - pulling force and opposing force applied to injured extremity

1. Longitudinal - when only one force is applied

2. Traction angle - direction of the force in relation to the affected extremity

3. Countertraction - opposing force to the pull of the traction; most often is provided by the
person's body weight

4. Vector force - resultant force produced when two traction forces are applied to a limb

5. Purposes

a. reduce, realign and promote healing of fractured bones - skeletal traction or external
fixation

b. decrease muscle spasms - skin traction

c. immobilize area of body

d. rest inflamed, diseased or painful joint

e. treat or correct deformities

f. reduce and treat dislocations - Bryant's traction

g. prevent the development of contractures

h. expand a joint space during arthroscopy

i. reduce muscle spasms in low back pain or cervical whiplash- pelvic and cervical
traction




Traction Description Use
Bryant's traction Vertical extension with bilateral
traction to legs
Hips kept at 90-degree flexion
Buttocks kept one hand-level off
the bed
Used in infants or children weighing less than 35
to 40 pounds for fractured femur or congenital hip
dysplasia
Buck's traction Simple horizontal traction
Unilateral or bilateral limb traction
Used before repair of fractured hip or for
lumbosacral muscle spasms
Cotrel traction Head halter and pelvic belt pulling
in opposite directions
Preoperative treatment for spinal curvatures
Dunlop's traction Horizontal Buck's
Extension to humerus with vertical
Buck's extension to forearm
Used for supracondylar fractures of the humerus
406

Pelvic Belt Girdle-type belt that fits around
lumbosacral area
Used for low back pain, muscle spasms, and
ruptured nucleus pulposus
Pelvic Sling Hammock-like sling that cradles
pelvis
Used for fractured pelvis
Cervical Halter A strap under the chin Used for degenerative or arthritic conditions of
cervical vertebrae
Russell's Traction Modified Buck's extension with
sling under knees; note risk of
impaired circulation in lower leg
Used for fractures of femur, hip, or knee disorders



6. Types of traction

a. manual traction

i. use of the hands to exert a pulling force

ii. generally used during emergency situations

iii. temporary measure - cannot be maintained for extended periods


b. skin traction

i. pulling force is applied directly to the skin through the use of foam splints, skin traction strips and
tape

ii. temporary measure often to relieve muscle spasms prior to surgery

iii. complications

skin breakdown

detachment of traction device

thrombophlebitis with Russell's


iv. limitation: can apply only 5 to 7 pounds loading force; 2 to 3 pounds with infants



c. skeletal traction

i. traction applied directly to the bone

ii. pins are placed through the affected limbs and attached to a pulling force

iii. can be tolerated for longer periods - up to 4 months

iv. greater weight can be used - 15 to 40 pounds

v. most common types of skeletal traction

balanced suspension

used for displaced, overriding or comminuted fractures

preoperative treatment prior to surgical pinning

external fixation devices


skull tong/halo traction

burr holes drilled into skull and tongs inserted and attached to weights or halo bolts
407

inserted then attached to body cast

tongs used for cervical fractures preoperatively

crushed lower arm and hand or leg and foot injuries

handle / move extremity by frame

monitor for infection - risk is great




vi. complications

infection at pin site

osteomyelitis

skin breakdown

muscle weakness or atrophy





7. Different positions for traction

a. supine

b. perpendicular to the ends of the bed

c. affected limb in proper body alignment

d. head of the bed is flat to low Fowler's unless otherwise ordered


8. Nursing interventions

a. reinforce information about the procedure to the client

b. check neurovascular status of affected area/limb initially every 15 minutes x4, then every 30 minutes
x2, then every hour x4, then at least every 4 hours

i. color

ii. temperature

iii. motion

iv. sensation

v. pulse quality

vi. presence/absence of edema

vii. capillary refill


c. always compare affected limb to unaffected limb for baseline measurement

d. skeletal cervical or halo traction: check cranial nerves III - IX per facility policies

e. skin

i. risk for development of pressure sores

ii. remove Buck's traction boots every 2 to 4 hours to inspect skin integrity

iii. check for any pressure areas every 2 to 4 hours


f. pin assessment: observe for drainage, signs of infection

i. expected drainage clear, yellow, crusty

ii. abnormal - cloudy, yellow-green, thick, foul smell


g. maintain principles of traction

h. administer appropriate medications as prescribed; pain should subside after traction applied

i. beware of multi-system effects from mobility

j. allow time for client to verbalize fear and concerns

k. encourage involvement of family members or peers

l. provide diversional activities that do not increase or strain mobility


408

Care of the client in T-R-A-C-T-I-O-N:

Temperature (extremities, infection)
Ropes hang freely
Alignment
Circulation check (the 5 P's)
Type & location of fracture
Increase fluid intake
Overbed trapeze
No weight(s) on bed or floor


Q. Mobilization devices: orthotic, prosthetic, crutch, cane, walker

1. Orthotic

a. braces designed to prevent deformity, increase efficacy of gait, control alignment and/or promote
ambulation

b. types of orthotic

i. ankle/foot (AFO)

ii. knee/ankle/foot (KAFO)

iii. hip/knee/ankle/foot (HKAFO)

iv. thoracolumbar or sacral (TLSO)



2. Prosthetic: artificial limbs for any extremities

3. Crutches

a. a wooden or metal staff

b. used when no or minimal weight bearing is desired

c. may be temporary or permanent

d. types - both need rubber tips

i. axillary: a padded curved surface at top which fits three to four finger widths under the axilla and
a crossbar forms the handgrip

measure client's height from axilla to client's heel; Crutch pads should be three to four
finger widths under axilla

complication: crutch palsy, i.e., paralysis of elbow and wrist from crutch pressure on
nerves in axilla area


ii. forearm (Lofstrand): an adjustable metal band that fits around the forearm with an adjustable
handgrip




For client to navigate stairs with crutches, remember:
"Up with the Good, Down with the Bad."

To go up stairs, lead with the unaffected or "good" leg, and follow with the affected "bad" leg.

To go down stairs, lead with the affected or "bad" leg, and follow with the unaffected "good" leg.



4. Canes: straight-legged, quad; all need rubber tips

5. Walkers

a. extremely light devices that have four widely placed legs and handgrips on an upper bar; need rubber
tips

b. client moves the walker forward 8 to 12 inches and steps into it, then moves it forward again


6. Wheelchairs: manual, electric

7. Hand-wrist splint - maintains thumb adduction and opposition to fingers

8. Nursing interventions with mobilization devices
409


a. reinforce information about the procedure to the client

b. check the client's physical readiness including muscle strength and range of motion

c. have safety as a priority issue

d. observe client initially for orthostatic hypotension

e. check for environmental risks

f. stand close to client during initial attempts at using mobilization devices

g. provide emotional support

h. resize device as children grow

i. review with the client

i. proper use of device

ii. initial signs of complications - no pain relief, skin irritation

iii. how to climb stairs, maneuver on various surfaces

iv. how to maneuver on and off toilet, chair, tub, shower, car

v. not to look at feet, rather look ahead

vi. how to troubleshoot equipment for

defects

signs of wear - especially rubber tips


vii. wear stable shoes

same heel height as when device fitted

sturdy rubber soles





V. Perioperative Nursing

A. Preoperative period

1. Begins with decision to perform surgery and ends when the client enters the operating room; the
surgery may be inpatient or outpatient

2. Types of surgery

a. purpose

i. diagnostic/exploratory

ii. curative

iii. transplant

iv. palliative

v. cosmetic/reconstructive


b. urgency of surgery

i. elective: performed on basis of client's choice, not essential for health

ii. urgent: necessary to maintain or improve client's health

iii. emergency: must be done immediately to save client's life

usually permit obtained

some instances, as in disaster or war situations, may be done without permit
process



c. seriousness

i. minor: minimally alters body parts, with minimal risk

ii. major: extensively reconstructs or alters body parts; greater risk



3. Medical conditions that increase the risk during and after surgery

a. bleeding disorders
410


b. heart disease

c. diabetes mellitus

d. upper respiratory infection and sinus infection

e. acute or chronic liver disease

f. chronic respiratory disease

g. immunological disorders

h. drug or alcohol abuse



4.
Preanesthetic medications

a. sedatives/hypnotics - calming effect

b. narcotics - to relieve pain, calming effect

c. anticholinergics - to dry secretions, minimizing aspiration

d. tranquilizers and antianxiety agents - to decrease nervousness, promote relaxation

e. H1-receptor antagonists - to prevent nausea and vomiting, e.g., promethazine (Phenergan)

f. proton pump inhibitors - to decrease acid production in stomach

g. possibly an antibiotic - to reduce risk of infection




5. Nursing interventions in order of usual sequence

a. provide psychological support

b. review information about the procedures surrounding the surgery

c. reinforce teaching of client

i. type of surgery to be performed

ii. the importance of deep breathing and coughing

iii. postoperative incision splinting

iv. comfort measures to be used postoperatively


d. check client's identification bracelet; verify verbally, client states their name without prompting

e. check that preoperative permit (informed consent) has been signed and appropriate lab work is
documented

f. have client empty bladder within an hour of the surgery

g. remove any dentures or prostheses

h. remove nail polish and makeup

i. obtain baseline vital signs

j. administer preanesthetic medications as ordered

k. administer prophylactic antibiotics if ordered

l. provide for client safety

m. ensure that right site protocol is used


Signing of the consent forms and post-op teaching should be done before any preoperative
medications have been given.

411


B. Intraoperative period

1. Surgery usually takes place in operating suite

2. Anesthesia, general

a. drug-induced analgesia, amnesia, muscle relaxation, and unconsciousness

b. stages

i. induction: start of anesthetic administration, client becomes drowsy and loses
consciousness

ii. excitement: muscles become tense and almost spasmodic

iii. swallowing and vomiting reflexes remain; may breathe irregularly

iv. surgical anesthesia

muscle relaxation occurs

breathing becomes regular

vital functions and reflexes are depressed

operation begins


v. complete respiratory depression - requires mechanical ventilation


c. types of anesthetic agents

i. inhalation (gas and liquid): nitrous oxide, cyclopropane halothane, enflurane, ether,
methoxyflurane

ii. intravenous agents: methohexital, sodium thiopental

iii. dissociative agents: (no loss of consciousness) ketamine

iv. neuroleptics: fentanyl citrate with droperidol


d. adjuncts to general anesthesia





Anesthesia Adjunct Description Use/Effect
Regional Techniques that render a
specific body area
insensitive to pain
Anesthesia results from nerve block; client
remains conscious
Spinal Anesthetic injected into
subarachnoid space
(lower end of spinal
cord)
Blocks nerve transmission through spinal
nerve roots; client remains conscious
Epidural Anesthesia Local anesthetic injected
into epidural space
Common in obstetrics; client remains
conscious
Peripheral Nerve Blocks Local anesthetic injected
around a peripheral
nerve
Provides anesthesia of area served by that
nerve; client remains conscious
Local anesthesia Topic application or
infiltration of an
anesthetic agent
Provides anesthesia to local area; commonly
used to suture wounds



412


3. Complication of general anesthesia: malignant hyperthermia

a. a hypermetabolic state

b. rapid progressive rise in body temperature (may exceed 102 F [38.9 C])

c. fatal if not treated

d. findings

i. tachycardia

ii. tachypnea

iii. unstable blood pressure

iv. diaphoresis (sweating)

v. muscle rigidity


e. thought to be caused by alteration of calcium-storing properties of muscle-cell membrane

f. familial tendency

g. treatment - dantrolene (Dantrium): a direct skeletal muscle relaxant

h. nursing interventions

i. administer medications as ordered

ii. MedicAlert identification for at-risk clients



4. Nursing interventions during the intraoperative period

a. provide emotional support during anesthesia induction

b. provide for client's physical safety during procedure

c. position the client as ordered by procedure

d.
maintain surgical asepsis

e. monitor for electrical hazards

f. monitor client for effects of heat loss

g. immediately after surgical drapes are removed, apply warm blankets


C. Postoperative period - postanesthesia care unit (PACU)

1. Anesthesia recovery period - may range from a few hours to 23 hours

a. surgical recovery - priority nursing interventions



Care Category
Care Category Interventions
Maintain Patient airway
Monitor Respiratory effort, rate, rhythm, and depth
Stabilize vital signs
Position Position client on side (unless contraindicated) or on back with head to side
Keep side rails up at all times with bed in lowest position (if possible)
Provide For client physical and psychological safety
Oxygen as ordered
Administer pain medication as ordered
Stimulate Ask client to spit out airway (shows gag reflex is back) and to lift head off pillow
Facilitate elimination of residual anesthesia, indicates ability to clear airway
Stimulate client to take a few deep breaths every 5 to 10 minutes
413

Care Category Interventions
Stay Check vital signs every 15 minutes until stable, then every 30 minutes or as ordered
Stay with restless client
Determine if restlessness is due to hypoxia



b. recovery complications and how to react
Complication Reaction 1 Reaction 2 Reaction 3 Reaction 4
Hypothermia* Apply warmed
blankets;
always keep
client covered
Increase temperature of
recovery room
Change method of
assessing
temperature and
compare results

Hemorrhage Check dressing
for intactness
Check any dependent
area of the dressing,
e.g., behind client, and
on bed for drainage,
blood pooling
Check all drainage
tubes and note
color and amount
of drainage
Check for internal
bleeding, looking for
tautness or
distention at
abdomen or incision
site
Hypotension Give IV fluids
as ordered
Monitor heart rate and
blood pressure
Auscultate lungs Elevate legs as
ordered
*Note: shivering may result from certain anesthetics and is not always indicative of hypothermia



c. provide emotional support and reorientation

d. assist with the notification of the family that the surgery is completed and general condition of client

2. Discharge to home

a. discharge criteria includes these "achievements"

i. adequate respiratory function

ii. intact gag reflex

iii. ability to cough and deep breathe; able to lift head off the pillow

iv. stable vital signs

v. return to a normal level of consciousness and muscle strength

vi. ability to ambulate with assistance

vii. ability to retain oral fluids

viii. ability to urinate

ix. ability to repeat an understanding of the care for incision and any drainage tubes

x. flatus and bowel sounds in all 4 quadrants of abdomen


b. verify client's or support person's understanding of

i. prescribed home medications and side effects

ii. care of incision or any drainage apparatus

iii. any other required treatments

iv. findings of infection specific to the surgery

v. activity progression or limitation within the initial 48 to 72 hours, then until follow-up care provider
visit

vi. special dietary restrictions with specific time frames
414


vii. when to contact the care provider about findings or concerns




3. Transfer to medical-surgical unit

a.
Types of pain and acute pain management

i. temporary pain after a body injury

ii. disappears when injury is healed

iii. monitor location, severity, quality, progression and alleviation of pain

iv.
administer pain medications as ordered (information about pain medications can be found in
lesson 6)

v.
provide noninvasive pain relief measures, usually effective for mild to moderate pain, as
ordered

massage

distraction

relaxation

hypnosis


vi. assist with invasive pain relief measures, usually for severe chronic pain, as ordered

acupuncture

nerve blocks



b. Other postoperative care interventions

i. provide for a restful environment - lights low, minimum noise

ii. encourage the client to turn, cough and breathe deeply a minimum of every one to two hours with
use of incentive spirometer

iii. encourage the client to change position every hour

iv. assist the client out of bed as appropriate

v. change dressing as ordered

use sterile technique

observe and record amount, color, odor of drainage on dressing

observe incision for intactness, signs of infection


vi. assist with activities of daily living (ADLs) as appropriate; encourage participation of support
persons of client

vii. ambulate client as ordered (may require physical therapy in some settings)

viii. reinforce teaching of client

to splint incision during coughing or ambulation with pillow or other device such as
special teddy bears after cardiac bypass surgery

incision care

importance of regular progressive activity

prescribed medications and side effects

signs of infection specific to surgical procedure


ix. monitor for complications



4. Complications of surgical procedures

a. hypostatic pneumonia

b. nausea and vomiting

i. caused by anesthetics and analgesics, gastric distention, surgical manipulation, pain, electrolyte
imbalance

ii. interventions
415


limit oral intake

administer antiemetics as ordered

measure drainage and document color, amount and odor of drainage

progress client food intake - begin with clear liquids and progress to full diet as ordered
and tolerated

record intake and output with characteristics of emesis

position client to prevent aspiration of emesis

prevent strain on surgical incision during vomiting


iii. nausea and vomiting increases intraocular and intracranial pressures, and cardiac workload



c. paralytic ileus

i. severely diminished or absent peristalsis

ii. caused by stress response to surgery and anesthesia, trauma or manipulation of abdominal
contents, electrolyte imbalance such as low potassium, anesthetics and pain medications, wound
infections and immobility

iii. occurs to some degree after all abdominal surgeries

iv. bowel sounds should return gradually within 48 to 72 hours after the surgery

v. findings

decreased or absent bowel sounds

abdominal distention with tight, tense abdomen

feeling of fullness, pain of abdomen with activity


vi. interventions

withhold fluids until presence of bowel sounds

provide mouth care to keep membranes moist

encourage ambulation as indicated

nasogastric decompression if ordered


vii. return of peristalsis signaled by presence of bowel sounds, passage of flatus or bowel movement




d. urinary retention - inability to void

i. causes include trauma to the bladder or its nerve supply during surgery, edema around bladder neck;
reflex spasm from drugs; spinal or epidural anesthesia; narcotics that decrease peristalsis of bladder

ii. interventions

encourage ambulation as much as possible

run water so client can hear sound

pour warm water over perineum

warm bath

catheterization if indicated with no results of other actions



e. circulatory complications: thrombosis and embolism

f. fluid and electrolyte imbalance

g. wound complications

i. causes: any factor contributing to poor wound healing, i.e., obesity, malnutrition, chronic steroid use,
diabetes mellitus

ii. dehiscence: complete separation of wound edges

iii. evisceration: more severe - wound edges separate; viscera protrude

position client to minimize strain on incision, usually flat in bed

cover with sterile gauze soaked in sterile saline
416


report immediately once baseline vital signs are taken




D. Radiation therapy: external and internal

1. Utilizes high energy radiation to a specific area

2. Chemical reactions occur which damage the DNA of the cancer cells

3. Used to cure or palliate cancer by decreasing tumor size

4. Different organs have differing degrees of radiosensitivity

a. highly radiosensitive tissues include bone marrow, lymphatic system, testes, ovaries and intestines

b. less radiosensitive are muscle, brain and spinal cord


5. May be used before surgery to shrink tumor

6. Two types: teletherapy, brachytherapy

a. teletherapy: external therapy

i. treatment from a source outside the body

ii. tumor area is marked and other anatomical areas are protected

iii. radiation administered in small doses over time



b. brachytherapy: internal therapy

i. radiation is placed in or directly on the body

ii. intracavity therapy: insertion into a body cavity; used for gynecological cancers: cervical implant

iii. interstitial therapy: insertion of radioactive seeds, needles, or capsules; used in head and neck
lesions, intra-abdominal and intrathoracic lesions

iv. metabolized therapy: radioactive material is ingested, instilled or injected into the body; used for
thyroid, leukemia, bone and intrapleural lesions





7. Radiation safety (More information about radiation safety can be found in Lesson 2)

a. always minimize the client's and health care provider's exposure to radioactivity, whether the therapy is
intracavity, interstitial or metabolized

b. nurse must know

i. type of radiation used

ii. half-life of the isotope

iii. amount of isotope being used

iv. method of delivery (see previous page for types)


c. side effects - severity depends on body location of radiation

i. acute

fatigue

reddened, dry, itchy skin (possible sloughing and oozing)

alopecia (hair falls out) - hair growth returns once therapy ends

altered taste

xerostomia (dry mouth)

esophagitis

anorexia

nausea and vomiting

diarrhea

cystitis

anemia; decreased white and red blood count; decreased platelets
417


pneumonitis

decreased sperm count; sterility


ii. chronic

permanent darkening of skin

permanent taste alteration

dental caries

fibrosis of gastrointestinal tract

malabsorption

radiation nephritis

cataracts

pulmonary and cardiovascular fibrosis




8. Nursing interventions

a. review information about skin care; avoid soaps and lotions; pat dry, no rubbing on site of external
radiation

b. provide frequent mouth care

c. provide small frequent, bland meals

d. avoid extremes of food temperature

e. administer antiemetics and antidiarrheals as ordered

f. monitor for signs of dehydration and skin breakdown

g. provide restful environment - lights low, minimal noise

h. provide emotional support to client and support persons

i. reinforce teaching of client regarding

i. nutritional support strategies

ii. care of site radiated

during treatment, not to wash marked areas off the skin or area between markings

if area must be cleansed, use only tepid water, no soap

not to wear tight clothing in the area

not to expose the area to sunlight

not to shave or scratch the area

not to use creams, lotions or oils on the area

to avoid injury to the area


iii. need to avoid persons with known infections or crowds

iv. how to conserve energy




E. Bone marrow transplant (BMT)

1. Intravenous infusion of bone marrow cells from donor to recipient (client)


2. Used to replace or stimulate non-functioning bone marrow

3. Indications
418


a. leukemia

b. aplastic anemia

c. immunodeficiency disorder


4. Types

a. autologous - client receives own bone marrow cells, harvested before high-dose chemotherapy or
radiation

b. syngeneic - donor and recipient are identical twins

c. allogeneic - donor is not genetically identical to recipient


5. Histocompatibility typing is done to determine a genotype match

6. Marrow is harvested in operating room under general or spinal anesthesia

7. Three stages

a. treatment of chemotherapy or total body irradiation: ensures destruction of malignant cells and
recipient's bone marrow cells

b. infusion of donor's bone marrow cells: injection takes 20 to 30 minutes

c. engraftment

i. usually occurs in one to two weeks

ii. evidenced by presence of bone marrow

iii. blood and immune system should become normal in two to six months after BMT




8. Complications of BMT

a. precautions to take to avoid infection

b. thrombocytopenia

c. anemia

d. micropulmonary emboli

e. bleeding

f. stomatitis

g. nutritional deficiencies

h. disease relapse

i. graft rejection

j. graft versus host disease (GVHD)

i. occurs when donor T lymphocytes introduced into a host who is immunologically incompetent

ii. T lymphocytes proliferate and attack host cells, which they think are foreign

iii. GVHD risk peaks 30 to 50 days after BMT

iv. graded according to degree of organ involvement

v. findings include

dermatitis

hepatitis

enteritis with diarrhea


vi. pharmacological treatment

cyclosporin A: immunosuppressant drug

steroids

anti-thymocyte globulin: an immunosuppressant


vii. prevention

HLA typing: used to determine whether a client has a suitable donor for stem cell
transplant
419

methotrexate or cyclosporin A
irradiate blood products
eliminate T cells from donor's marrow before transplant




9
.
Nursing interventions for BMT

a. reinforce pre-procedure teaching

b
.
post-procedure interventions

i. encourage intake of fluid and high protein, high calorie diet

ii. provide frequent oral hygiene

iii. weigh daily

iv. measure intake and output

v. monitor all mucous membranes, wounds and catheter sites daily

vi. administer total parenteral nutrition (TPN) if ordered
(information about TPN can be found in Lesson 6: Pharmacological and Parenteral Therapies)

vii. maintain isolation as ordered (reverse isolation or laminar air flow room)

viii. sterilize any non-sterile objects before bringing them into the room

ix. administer medications as ordered

x. test urine, stool and emesis for occult blood

xi. report any signs of bleeding immediately

xii. avoid invasive procedures

xiii. maintain a safe environment

xiv. encourage progressive activity as ordered

xv. provide emotional support

xvi. observe for findings of complications



























420

Points to Remember
Specimens

Obtain all specimens using gloves and sterile collection equipment.

Seal all specimen containers tightly, usually placed in a biohazard plastic bag.

Label all specimens with client's name, content, date obtained, and sequence number if more than one
specimen taken.

X-rays and other diagnostic tests

Anticipate a two view minimum.

Joints above and below suspected fracture are included.

Not all fractures show on x-ray; diagnosis may rely on clinical evidence.

Especially in children, x-rays of the unaffected limb may be needed for comparison.

Following a laproscopy, carbon dioxide trapped in the abdomen may cause discomfort and even shoulder
pain.

Be sure to remember to ask client if s/he is allergic to shellfish prior to any test using Iodine-based contrast
media.

Ostomies

A stoma has no feeling, so touching it causes no pain or sensation to the client.

A colostomy may not function for 5 to 7 days after surgery.

Initially ileostomy drainage may be copious and green in color changing to brown once client resumes
normal diet for a few days.

The bowel must be totally healed before attempting irrigation of a colostomy.

Infection, diet or medication may cause spillage between normal colostomy evacuations.

Findings of bowel perforation include sudden rigid, painful abdomen (called 'board-like') with an absence of
bowel sounds and no output from colostomy except small amount of blood.

There will always be some mucus in urinary diversions that involve segments of bowel, such as ileal loop or
continent urinary diversion.

Casts

A cast may be heavy or impair mobility due to its location or type of casting material.

Analgesics given 20 to 30 minutes before casting reduce pain; analgesics such as Valium or Versed may be
given to minimize recall of the reduction process.

A cast should be snug but not restrict circulation.

For proper drying, casts must dry from inside out; covering delays drying.

Cast may smell sour but should never smell foul.

Elevation on two to three pillows and use of ice bags may reduce or minimize swelling.

Report signs of neurovascular impairment immediately (compartment syndrome is a medical emergency).

Traction

Maintain established line of pull and counter traction continuously.

Prevent friction between device and body.

Maintain proper body alignment; use draw sheets to pull clients up in bed.

Effective traction correctly aligns affected bones and body parts.

Pain and spasms should be relieved by traction; if pain or spasms remain at the same level or increase,
further data collection and health care provider notification are needed.

Client does not have to keep other body parts immobile.

Tracheostomies

Clients with new tracheostomy tubes may have bloody secretions for 24 to 48 hours after the procedure or
after a tube change.
421


Tracheostomy obturator should be attached to head of bed in a secure, clear package at all times.

Pediatric tracheostomy tubes do not usually have an inner cannula.

Children have shorter necks so stoma care may be more difficult.

Yeast infections can form under moist tracheostomy dressings and around the neck where ties are found.

Clients with these problems may need more frequent tracheostomy care:

Tracheal stomatitis

Pneumonia

Bronchitis

Short, fat neck

Excessive perspiration

Always have another nurse or family member assist with tracheostomy care to minimize accidental
dislodgement or extubation.

Because the upper airway is functioning minimally, expect more secretions.

Drainage after a tracheostomy tube insertion should be minimal in the initial 24 hours.

Suctioning and chest physiotherapy

Suction no sooner than 2 to 3 hours after client has eaten a meal.

Apply suction for no longer than 10 seconds; apply oxygen prior to and immediately after suctioning.

Be sure to have emesis basin and tissues at hand.

Administer any bronchodilating medications at least 1/2 hour before chest physiotherapy.

Catheterization

Intermittent catheterization at home may be a clean, not sterile, procedure.

Full bladders in clients with high thoracic spinal cord injuries may stimulate hypertensive crisis.



Surgery

Time frames for surgical consents vary among states and facilities.

Primary responsibility for obtaining surgical consent rests with the surgeon.

Informed consent cannot be obtained if the client has an altered level of consciousness, is mentally
incompetent, or is under the influence of mind-altering drugs.

Essential to all preop teaching is discussion of all preop and postop routine procedures, along with a
demonstration/return demonstration by client of postop exercises.

Outpatient surgeries exceed inpatient surgeries in many facilities.

Radiation

Radiation is more effective on local or regional neoplasia while chemotherapy is more systemic in its effects.

Only certified nurses may administer chemotherapeutic agents.

Ionizing radiation will damage both normal and cancerous cells resulting in side effects of the site and
surrounding tissues.

Clients receiving external radiation are not radioactive at any time during or after the procedure.

Clients with internal radiation are not radioactive; the implant or injection is within the body.

If the source of radioactivity is metabolized, the client's secretions and excretions may be radioactive for a
time, based on the half-life of the isotope.

Urinary and bowel excretions - flush toilet twice afterwards

Restrict contact - no contact with children or pregnant women for three to seven days

Wounds

Never touch a wound without wearing gloves.

Remove old dressings with clean gloves by lifting from the center of the dressing, not the edges.
422


First postoperative dressing change is performed by health care provider.

Give analgesic before dressing change, scheduled so that medication peaks during change process.

Follow principles of surgical asepsis

If drains are present, remove dressing one layer at a time to avoid dislodging the drain.

Pressure dressings should not be removed until written order from health care provider.

If dressing must be changed frequently, Montgomery straps will prevent skin breakdown from frequent tape
removal.

Wounds out of the client's field of vision or reach or if a client has motor problems in hands or fingers require
the client to have help in the dressing change.

423



I. Anatomy and Physiology

A. Anatomy

1. Layers

a. pericardium: fibrous sac that encloses the heart


b. epicardium: covers exterior surface of heart muscle

c. myocardium: muscular portion of the heart

d. endocardium: lines cardiac chambers and covers surface of heart valves



2. Chambers of heart


a. right atrium: collecting chamber for incoming systemic venous system (deoxygenated blood)

b. right ventricle: propels blood into pulmonary system

c. left atrium: collects blood from pulmonary venous system (oxygenated blood)

d. left ventricle: largest thick-walled muscle that acts as a high-pressure pump which propels blood into the
systemic circulation responsible for cardiac output





3. Heart valves: membranous openings that allow one way blood flow


a. atrioventricular valves: prevent backflow from ventricles to atria during systole

i. tricuspid - valve between right atrium and right ventricle

ii. mitral bicuspid - valve between left atrium and left ventricle
424




b. semilunar valves prevent backflow from aorta and pulmonary arteries into ventricles during diastole

i. pulmonic - valve between the right ventricle and pulmonary artery

ii. aortic - valve between left ventricle and aorta which leads to central circulation



REMEMBER IT
This might help you to remember the names and location of the heart
valves:

Tiny right side of the heart = Tricuspid valve
Mighty (or Big) left side of the heart = Mitral (or Bicuspid) valve


4. Blood supply to heart

a. arteries - coronary


Cardiovascular: Arteries of the Heart


i. right supplies right ventricle and the back part of the left ventricle

ii. left supplies mostly left ventricle and septum



b. veins

i. coronary sinus - wide venous channel that drains five coronary veins into the right atrium

ii. thebesian - the smallest coronary veins drain some venous blood directly into the right atrium and ventricle
and the left ventricle




5. Conduction system

a. SA (sinoatrial) node - referred to as the pacemaker of the heart; located in the right atrium (intrinsic rate of 100
impulses per minute)


b. junctional tissue - often referred to as the atrioventricular node or AV node (intrinsic rate of 40 - 60 impulses per
minute)


c. bundle branch/Purkinje system - the electrical system located in the septum and into cardiac tissues intrinsic rate
20-40 impulses per minute
425




B. Physiology

1. Function of the heart is the transport of blood which contains oxygen, carbon dioxide, nutrients and waste
products

2. Cardiac cycle - atria and ventricles work in an asynchronous manner


a. systole - the phase of contraction during which the ventricles eject blood

b. diastole - the phase of relaxation during which the ventricles fill with blood; when the heart pumps, myocardial
layer contracts and relaxes


3. Blood flow

a. deoxygenated blood enters the right atrium through the superior and inferior vena cava

b. this blood enters the right ventricle through the tricuspid valve

c. the blood travels through the pulmonic valve to the pulmonary arteries and into the lungs where exchange of
oxygen and carbon dioxide gases occurs.

d. oxygenated blood returns from lungs through the pulmonary veins into the left atrium

e. the blood enters the left ventricle through the mitral (bicuspid) valve

f. finally, the blood, from the left ventricle, goes through the aortic valve into the aorta and into the systemic
circulation to perfuse tissue.




4. The heart itself is supplied with blood by the left and right coronary arteries, which are found at the base of the aorta
above the aortic valve


5. The vascular system is a continuous network of blood vessels

a. the arterial system consists of arteries, arterioles and capillaries and delivers oxygenated blood and nutrients to
tissues

426


b. oxygen, carbon dioxide, nutrients, and metabolic wastes are exchanged at the capillary level

c. the venous system, veins and venules,
return the blood to the heart



C. Hematology

1. Erythrocytes

a. carry oxygen to cells on hemoglobin and move carbon dioxide back to lungs to be expelled through exhalation

b. average life span: 120 days

c. hemoglobin: the oxygen-carrying component of RBCs

d. blood typing

i. persons with type A can receive type A or type O blood

ii. persons with type B can receive type B or type O blood

iii. persons with type O can receive only type O blood, but those with O negative are universal donors

iv. persons with type AB positive are universal recipients






2. Leukocytes (white blood cells) increase with infections or inflammation:
Leukocyte Type Increases in Response to
Neutrophil Granulocyte Infection by bacteria or fungus
Lymphocyte Agranulocyte Viral infection or tumor
Eosinophil Granulocyte Inflammation from allergies
Basophil Granulocyte Inflammation from allergies
Monocyte Agranulocyte Infections - nonspecific



3. Plasma proteins

a. Include albumin and globulins

b. Measuring plasma proteins helps assess nutritional status


4. Platelets

a. Small fragments of cells

b. Life span eight to ten days
427


c. Essential to blood clotting/coagulation

d. Forms the Initial "plug" at the site of injury


II. Heart Infections

A. Pericarditis

1. Definition: inflammation of the pericardial sac



2. Etiology: bacterial or fungal infection, autoimmune disorder, e.g., systemic lupus erythematosus (SLE), or or
inflammatory response after acute myocardial infarction, malignant neoplastic disease

a. there may or may not be pericardial effusion or constrictive pericarditis

b. Dressler's syndrome (also called post myocardial infarction syndrome)

i. a combination of pericarditis, pericardial effusion and constrictive pericarditis; etiology is unclear

ii. occurs several weeks to months after a myocardial infarction





3. Epidemiology

a. may be acute or chronic and may occur at any age

b. severe chest pain is caused by the inflamed pericardium rubbing against the heart

c. pericarditis may occur in up to 15% of persons with a transmural infarction


4. Findings

a. sharp chest pain often relieved by sitting upright and leaning forward and worsened with coughing and lying in
supine position

b. pericardial friction rub Listen

c. dyspnea

d. fever, sweating, chills (with infectious causes)

e. dysrhythmias

f. pulsus paradoxus (fall in systolic BP with inspiration > 10 mm Hg)

g. client cannot lie flat without severe chest pain or dyspnea


5. Diagnostics

a. history and physical exam

b. serum labs

i. increased

white blood cells (with infectious causes)

sedimentation rate (marker for inflammation)


ii. positive

blood cultures if infection

antinuclear antibody (ANA) if due to connective tissue (autoimmune) disease



c. widespread EKG changes in ST segment (most or all leads in 12-lead)

d. echocardiography - to determine pericardial effusion or cardiac tamponade, may show pleural thickening




428


6. Medical management

a. pharmacologic

i. antiinflammatory medications: NSAIDS, corticosteroids to treat inflammation and pain

ii. antibiotics if infectious cause

iii. avoid anticoagulants because they may increase the possibility of cardiac tamponade from bleeding risk


b. oxygen if hypoxia is present

c. surgical

i. emergency pericardiocentesis if cardiac tamponade develops

ii. for recurrent constrictive pericarditis: partial pericardiectomy (pericardial window) or total pericardiectomy



7. Nursing care

a. manage pain and anxiety

i. position for comfort: semi-Fowler's or high-Fowler's position

ii. mild analgesics to keep pain at 0 to 2 (on a scale of 1 to 10)

iii. medications to treat cause



b. collect data about respiratory, cardiovascular, and renal status every 1 to 2 hours in acute phase

c. observe for pericarditis complications

i. dysrhythmias


ii. cardiac tamponade

iii. heart failure



d. maintain a pericardiocentesis tray at the bedside in case of cardiac tamponade

e. client and family teaching - reinforce the cardio five



B. Myocarditis

1. Definition: an inflammatory condition of the myocardium caused by

a. viral infection


b. bacterial infection

c. fungal infection


d. serum sickness


e. rheumatic fever


f. chemical agent


g. complication of a collagen disease, e.g., SLE


2. Etiology

a. usually an acute virus and self-limited, but it may lead to acute or chronic heart failure

b. may be acute or chronic and may occur at any age


3. Findings

a. depends on the type of infection, degree of myocardial damage, capacity of myocardium to recover, and host
resistance


b. may be minor or unnoticed, i.e., fatigue and dyspnea, palpitations, occasional precordial discomfort
manifested as a mild chest soreness and persistent fever

c. history of recent upper respiratory infection with fever, viral pharyngitis, or tonsillitis

d. fatigue and dyspnea
429


e. possible signs of congestive heart failure: peripheral edema, weight gain, crackles in lungs

f. abnormal heart sounds : murmur, S3 or gallop or friction rub Listen

g. tachycardia disproportionate to the degree of fever

h. joint pain or swelling



4. Diagnostic studies

a. EKG for changes and arrhythmias

b. labs

i. increases erythrocyte sedimentation rate (ESR)

ii. increases myocardial enzymes such as:

troponin

creatine kinase (CPK-MB)



c. endomyocardial biopsy (EMB)

d. myocardial imaging




5. Medical management

a. pharmacological

i. antibiotics - if infectious cause

ii. corticosteriods to decrease inflammation

iii. analgesics for pain

iv. cardiovascular medications to treat heart failure-related poor cardiac output (ACE inhibitors, beta blockers,
vasodilators, digoxin)

v. diuretics to treat fluid overload (furosemide)


b. oxygen to maintain oxygen saturation goal


6. Nursing care and data collection

a.
monitor cardiovascular status; notify provider and provide appropriate emergency care if instability or worsening
is evident, including

i. pulse, respirations, blood pressure, oxygen saturation & heart rhythm

ii. daily weights and other signs of fluid overload: orthopnea (inability to breathe when laying flat), peripheral
edema, crackles in lungs

iii. watch for indicators of poor cardiac output, e.g., signs of lightheadedness, activity intolerance, fatigue,
dyspnea with exertion


b. monitor arterial blood gas (ABG) levels as needed to ensure adequate oxygenation

c. reinforce client and family teaching

i. slowly increase activity level as tolerated

ii. monitor and record daily weights; notify provider for weight gain is greater than 3 pounds in 1 to 2 days or
more than 5 pounds in 1 week

iii. avoid pregnancy, alcohol, and competitive sports until approved by provider

iv. stress importance of taking drugs cardiac and antiinfective drugs as ordered

v. for clients who will be taking digoxin, reinforce teaching

check pulse for one full minute before taking the dose, and withhold the drug and call the provider if heart
rate falls below 60 beats/minute

monitor for findings of digitalis toxicity, e.g., anorexia, nausea, vomiting, blurred vision, cardiac arrhythmias




430


C. Endocarditis

1. Definition: an infection of the endocardium, heart valves, or heart valve prosthesis resulting from bacterial or
fungal invasion

a. Infection can lead to growth of valvular vegetations that can break off (embolize) and travel in the blood
stream and lodging in distal areas (lungs, bowel, extremeties).

b. embolization leads to tissue ischemia and necrosis in areas perfused by the blocked blood supply


2. Etiology: infection is most likely to "seed" in damaged or prosthetic heart valves - people with heart murmurs, and
those using illicit IV drugs

a. group B streptococci

b. Staphylococcus aureus

c. fungi



3. Epidemiology

a. with proper treatment, majority of clients recover

b. the prognosis is worse when endocarditis severely damages valves or involves a prosthetic valve



4. Findings

a. cardiac murmurs in 85% to 90% of clients usually a murmur that changes suddenly, or a new murmur that
develops in the presence of a fever

b. fever, chills, nightsweats with no identifiable source of infection "fever of unknown origin"

c. pericardial friction rub

d. malaise, fatigue, anorexia

e. petechiae of the skin, splinter hemorrhage under the nails

f. signs of infarction related to embolization

i. infarction of spleen or abdominal organs: abdominal pain, rigidity, signs of ileus

ii. infarction in kidney:hematuria, pyuria, flank pain, and decreased urine output

iii. infarction in brain: hemiparesis, aphasia, and other neurologic deficits

iv. infarction in lung: cough, pleuritic pain, pleural friction rub, dyspnea and hemoptysis

v. peripheral vascular occlusion: numbness, tingling and cyanosis in an arm, leg, finger, or toe or a blackened
area.




5. Diagnostics

a. health history

b. labs

i. white blood cells (WBC) - elevated

ii. blood cultures - positive for microbe

iii. erythrocyte sedimentation rate (ESR) - elevated


c. transesophageal echocardiogram to detect vegetation on valve- diagnostic for endocarditis

d. EKG to detect arrhythmias


6. Management of endocarditis
431


a. pharmacologic

i. antibiotics - IV antibiotics for 6 weeks or until infection resolves, guided by culture & sensitivity

ii. antipyretics - to control fever


b. oxygen - to prevent tissue hypoxia

c. surgical - valve replacement if valvular damage causes heart failure, or if a prosthetic valve infection does not
respond to antibiotics


7. Nursing care

a. arrange for long-term venous access for IV antibiotics (i.e. peripherally inserted central line) and plan for home IV
therapy at discharge

b. monitor response to antibiotics: fever resolution, WBC return to normal

c. reinforce client and family teaching

i. endocarditis and the need for long-term IV antibiotic therapy

ii. the need for prophylactic antibiotics before dental work and other invasive procedures

iii. to report fever, tachycardia, dyspnea and shortness of breath




D. Rheumatic heart disease (rheumatic endocarditis)

1. Definitions

a. rheumatic heart disease: damage to the heart by one or more episodes of rheumatic fever (which can also
affect joints, skin and brain); pathogen is a group A streptococci

b. rheumatic endocarditis: damage to the heart, particularly the valves, resulting in valve leakage (regurgitation)
and/or stenosis; to compensate, the heart's chambers enlarge (dilate)


2. Epidemiology

a. fairly rare in developed countries; more common in developing countries with malnutrition and crowded living,
in ages 5 to 15


b. prevention: identification and treatment of streptococcal pharyngitis

c. malfunction of valves due to rheumatic damage can lead to heart failure



3. Findings

a. history of streptococcal pharyngitis

i. sudden sore throat, often with tonsillar exudate

ii. swollen, tender lymph nodes at angle of jaw

iii. headache


iv. temperature to 104 F (40 C)



b. polyarthritis manifested by numerous warm and swollen joints (usually elbows, wrists, knees and ankles)

c. high fever with chills, malaise

d. chorea (emotional instability, muscle weakness with quick, uncoordinated jerky movements usually in the
face, feet, and hands)

e. rash- erythema marginatum (ring-like or snake-shaped rash on trunk and extremities)

f. subcutaneous nodules

g. heart problems including shortness of breath and chest pain

h. heart murmurs pericardial friction rub and pericardial rub Listen

i. no lab test confirms rheumatic fever, but some tests support the diagnosis



432


4. Diagnostics

a. antistreptolysin O (ASO) titer - increased

b. erythrocyte sedimentation rate (ESR) - increased

c. throat culture - positive for streptococci

d. white blood cell count - increased


5. Management

a. give antibiotics on schedule to maintain blood levels

b. provide analgesics PRN for pain and inflammation

c. oxygen to prevent tissue hypoxia

d. surgical - commissurotomy, valvuloplasty, prosthetic heart valve


6. Nursing care

a. monitor for cardiac complications, resolution of infection, supportive care.

b. assist the client with chorea in grasping objects; prevent falls

c. encourage family and friends to spend time with client and fight boredom during the long, tedious convalescence

d. reinforce client and family teaching regarding:

i. explanation of all tests and treatments

ii. nutritional needs

iii. hygienic practices

iv. resumption of activities of daily living slowly and scheduling rest periods

v. to report penicillin reactions, e.g., rash, fever, chills

vi. to report findings of streptococcal infection

sudden sore throat

diffuse throat redness and oropharyngeal exudate

swollen and tender cervical lymph glands

pain on swallowing

temperature of 101 - 104 F (38.3 - 40 C)

headache

nausea


vii. the avoidance of crowds and people with respiratory infections

viii. explanation of the necessity of long-term antibiotics

ix. actions to cope with the temporary chorea




III. Valve disorders

A. Mitral stenosis


1. Definition: mitral valve thickens and gets narrower, blocking blood flow from the left atrium to left ventricle


433

2. Epidemiology

a. of clients with mitral stenosis, 2/3 are female

b. most cases of mitral stenosis are caused by rheumatic fever




3. Findings

a. mild - asymptomatic heart murmur

b. moderate to severe stenosis: symptoms of left-sided heart failure due to blood backing up into lungs and poor
cardiac output

i. heart murmur


ii. dyspnea on exertion

iii. orthopnea (dyspnea when supine), recent history of propping up with pillows to sleep or sleeping in recliner

iv. paroxysmal nocturnal dyspnea (PND, sudden waking due to shortness of breath)

v. crackles to severe congestion in the lungs

vi. weakness, fatigue, palpitations

vii. mild weight gain



4. Diagnostics

a. history and physical exam

b. EKG - findings of left atrial enlargement and right ventricle enlargement

c. echocardiogram - reduced mitral valve area

d. chest x-ray- cardiac enlargement (cardiomegaly)

e. cardiac catheterization- coronary arteries normal if no other heart disease



5. Management for symptomatic mitral stenosis - use the DO-ABLE mnemonic

a. D = diuretics - to relieve pulmonary congestion, fluid overload & return to baseline weight

b. O = oxygen - to correct hypoxia

c. A = ACE inhibitors- to reduce preload and afterload, counteracting compensatory hormones

d. B = beta-blockers - to prevent arrhythmias and reduce heart workload

e. L = low sodium diet - to prevent fluid retention

f. E = exercise as tolerated - to monitor response to therapy and return to baseline functional status

g. surgery - mitral valve repair or replacement for severe or recurrent episodes of heart failure


6. Nursing care and data collection

a. CARDIAc LeVeLS assessment for heart failure symptoms and complications

i. C = chest discomfort

ii. A = activity tolerance

iii. R = response to drug therapy

iv. D = depression and anxiety

v. I = increased weight

vi. A = arrhythmias

vii. L = lightheadedness

viii. V = vital sign - changes

ix. L = level of consciousness - decreased

x. S = shortness of breath


b. if client has had valve surgery, watch for hypotension and arrhythmias, administer and titrate anticoagulants,
using PTT for Heparin and INR for warfarin (Coumadin)
434


reinforce client and family teaching

i. reinforce teaching about REAL keys to self-care for heart failure

report findings of heart failure to provider soon after they start: weight gain, worsening dyspnea ,
orthopnea, fatigue

exercise is important - start low & go slow to increase functional capacity, attending to symptoms

adherence to cardiac medications is essential to staying healthy

low sodium diet - 2000 mg per day


ii. if client is on anticoagulants, explain long-term anticoagulation with periodic lab testing of INR for warfarin
(Coumadin), maintain steady Vitamin K level in diet, report signs of bleeding,

iii. reinforce potential need for antibiotics before dental care or invasive procedures




B. Mitral insufficiency (or regurgitation or incompetence)

1. Definition and related terms

a. a damaged mitral valve allows blood from the left ventricle to flow back into the left atrium during ventricular
systole


b. to handle the backflow, the atrium enlarges (as does the left ventricle, in order to make up for its lower cardiac
output)



2. Epidemiology

a. follows birth defects such as transposition of the great arteries


b. in older clients, the mitral annulus may have become calcified

c. cause unknown; may be linked to a degenerative process

d. occurs in 5 to 10% of adults


3. Findings

a. client may be asymptomatic

b. orthopnea, dyspnea, fatigue, weakness, weight loss

c. chest pain and palpitations

d. systolic murmur at the apex; high pitched, blowing murmur; may radiate to axilla

e. jugular vein distention

f. peripheral edema

g. hepatomegaly




4. Diagnostics

a. EKG may show arrhythmias and left atrial enlargement

b. echocardiogram - regurgitant blood flow at mitral valve

c. cardiac catheterization - shows regurgitation of blood from left ventricle to left atrium and increased pressures.
clean coronary arteries if no other cardiac disease.

d. chest x-ray - shows cardiomegaly, pulmonary congestion




435


5. Management

a. DO-ABLE interventions for the management of heart failure

b. surgery - mitral valvuloplasty or valve replacement for severe, recurrent episodes of heart failure



6. Nursing care

a. monitor CARDIAc LeVeLS

b. if client has had valve surgery, watch for hypotension and arrhythmias, administer and reinforce teaching about
long-term anticoagulation

c. reinforce client and family teaching

i. reinforce teaching about REAL keys to self-care for heart failure

ii. if client is on anticoagulants, explain long-term anticoagulation with periodic lab testing of INR for warfarin
(Coumadin), maintain steady Vitamin K level in diet, report signs of bleeding.

iii. explain the potential need for antibiotics before dental care or invasive procedures



The DO-ABLE mnemonic for heart failure interventions:
CARDIAc LeVeLS for Cardiac Assessment
R-E-A-L Keys for Self-Care

The DO-ABLE mnemonic for heart failure interventions:

Diuretics- to relieve pulmonary congestion, fluid overload & return to baseline weight

Oxygen- to correct hypoxia

ACE inhibitors- to reduce preload and afterload, counteracting compensatory hormones

Beta-blockers- to prevent arrhythmias and reduce heart workload

Low sodium diet- to prevent fluid retention

Exercise as tolerated - to monitor response to therapy and return to baseline functional status

Use the CARDIAc LeVeLS mnemonic for cardiac assessment:

Chest discomfort

Activity tolerance

Response to drug therapy

Depression & anxiety

Increased weight

Arrhythmias

c...

Lightheadedness

e...

Vital sign changes

e...

Level of consciousness decreased

Shortness of breath




436

Self-care instructions for heart failure: R-E-A-L keys

Report findings of heart failure to provider - weight gain, worsening dyspnea, orthopnea, fatigue

Exercise is important - start low & go slow to increase functional capacity, attending to symptoms

Adherence to cardiac medications is essential to staying healthy

Low sodium diet - 2000 grams per day


C. Tricuspid stenosis

1. Definition: narrowing of the blood flow through the tricuspid valve between the right atrium and right ventricle

2. Etiology

a. relatively uncommon, results from dilation of the right ventricle and tricuspid valve ring

b. usually associated with lesions of other valves

c. most common in late stages of heart failure from rheumatic or congenital heart disease, IV drug abuse


3. Findings: right heart failure and poor cardiac output when severe

a. dyspnea, fatigue, weakness, syncope

b. peripheral edema, ascites. pulmonary edema unlikely as blood is backing up from right side of heart into
venous system.


c. distended jugular veins


4. Diagnostics

a. echocardiogram - shows tricuspid stenosis

b. EKG - for arrhythmias


5. Management

a. DO-ABLE interventions for the management of heart failure

b. surgery - valve repair or replacement for severe, recurrent episodes of heart failure


6. Nursing care

a. monitor CARDIAc LeVeLS

b. if client has had valve surgery, watch for hypotension and arrhythmias, administer and reinforce teaching
about long-term anticoagulation

c. reinforce client and family teaching

i. reinforce teaching about REAL keys to self-care for heart failure

ii. if client is on anticoagulants, explain long-term anticoagulation with periodic lab testing of INR for warfarin
(Coumadin), maintain steady Vitamin K level in diet, report signs of bleeding.

iii. explain the potential need for antibiotics before dental care or invasive procedures




The DO-ABLE mnemonic for heart failure interventions:
CARDIAc LeVeLS for Cardiac Assessment
R-E-A-L Keys for Self-Care

The DO-ABLE mnemonic for heart failure interventions:

Diuretics- to relieve pulmonary congestion, fluid overload & return to baseline weight

Oxygen- to correct hypoxia

ACE inhibitors- to reduce preload and afterload, counteracting compensatory hormones

Beta-blockers- to prevent arrhythmias and reduce heart workload

Low sodium diet- to prevent fluid retention

Exercise as tolerated - to monitor response to therapy and return to baseline functional status
437


Use the CARDIAc LeVeLS mnemonic for cardiac assessment:

Chest discomfort

Activity tolerance

Response to drug therapy

Depression & anxiety

Increased weight

Arrhythmias

c...

Lightheadedness

e...

Vital sign changes

e...

Level of consciousness decreased

Shortness of breath

Self-care instructions for heart failure: R-E-A-L keys

Report findings of heart failure to provider - weight gain, worsening dyspnea, orthopnea, fatigue

Exercise is important - start low & go slow to increase functional capacity, attending to symptoms

Adherence to cardiac medications is essential to staying healthy

Low sodium diet - 2000 grams per day


D. Tricuspid insufficiency (regurgitation)

1. Definition - tricuspid valve does not close properly during ventricular systole, allowing blood to leak from the right
ventricle back into the right atrium


2. Epidemiology

a. results from dilation of the right ventricle and tricuspid valve ring

b. most common in late stages of heart failure from rheumatic, congenital heart disease, IV drug use


3. Findings: right heart failure and poor cardiac output when severe; asymptomatic in early stages

a. dyspnea, fatigue, weakness and syncope

b. distended jugular veins

c. peripheral edema, ascites. pulmonary edema unlikely as blood is backing up from right side of heart into
venous system



4. Diagnostics - echocardiogram shows abnormal tricuspid valve movement and regurgitation


5. Management

a. DO-ABLE interventions for the management of heart failure

b. surgery - valve repair or replacement for severe, recurrent episodes of heart failure


6. Nursing assessment and intervention

a. monitor CARDIAc LeVeLS

b. if client has had valve surgery, watch for hypotension and arrhythmias, administer and reinforce teaching
about long-term anticoagulation

c. reinforce client and family teaching

i. reinforce teaching about REAL keys to self-care for heart failure
438


ii. if client is on anticoagulants, explain long-term anticoagulation with periodic lab testing of INR for warfarin
(Coumadin), maintain steady Vitamin K level in diet, report signs of bleeding

iii. explain the potential need for antibiotics before dental care or invasive procedures




The DO-ABLE mnemonic for heart failure interventions:
CARDIAc LeVeLS for Cardiac Assessment
R-E-A-L Keys for Self-Care

The DO-ABLE mnemonic for heart failure interventions:

Diuretics- to relieve pulmonary congestion, fluid overload & return to baseline weight

Oxygen- to correct hypoxia

ACE inhibitors- to reduce preload and afterload, counteracting compensatory hormones

Beta-blockers- to prevent arrhythmias and reduce heart workload

Low sodium diet- to prevent fluid retention

Exercise as tolerated - to monitor response to therapy and return to baseline functional status

Use the CARDIAc LeVeLS mnemonic for cardiac assessment:

Chest discomfort

Activity tolerance

Response to drug therapy

Depression & anxiety

Increased weight

Arrhythmias

c...

Lightheadedness

e...

Vital sign changes

e...

Level of consciousness decreased

Shortness of breath

Self-care instructions for heart failure: R-E-A-L keys

Report findings of heart failure to provider - weight gain, worsening dyspnea, orthopnea, fatigue

Exercise is important - start low & go slow to increase functional capacity, attending to symptoms

Adherence to cardiac medications is essential to staying healthy

Low sodium diet - 2000 grams per day


E. Pulmonic stenosis

1. Definition - narrowing of pulmonic valve between right ventricle and pulmonary artery obstructs right ventricular
outflow leading to right ventricular hypertrophy and right heart failure


2. Epidemiology

a.
usually congenital, often occurring with other birth defects such as Tetralogy of Fallot
439



b. rare among the elderly

c. may result from rheumatic fever


3. Findings

a. cyanosis dyspnea, fatigue, syncope, findings of right heart failure

b.
cyanosis, failure to thrive


4. Diagnostics - echocardiogram shows valve abnormalities and increased right heart pressure


5. Management

a. DO-ABLE interventions for the management of heart failure

b. surgery - valve repair or replacement for severe, recurrent episodes of heart failure



6. Nursing care

a. monitor CARDIAc LeVeLS

b. if client has had valve surgery, watch for hypotension and arrhythmias, administer and reinforce teaching
about long-term anticoagulation

c. reinforce client and family teaching

i. reinforce teaching about REAL keys to self-care for heart failure

ii. if client is on anticoagulants, explain long-term anticoagulation with periodic lab testing of INR for warfarin
(Coumadin), maintain steady Vitamin K level in diet, report signs of bleeding

iii. explain the potential need for antibiotics before dental care or invasive procedures





The DO-ABLE mnemonic for heart failure interventions:
CARDIAc LeVeLS for Cardiac Assessment
R-E-A-L Keys for Self-Care

The DO-ABLE mnemonic for heart failure interventions:

Diuretics- to relieve pulmonary congestion, fluid overload & return to baseline weight

Oxygen- to correct hypoxia

ACE inhibitors- to reduce preload and afterload, counteracting compensatory hormones

Beta-blockers- to prevent arrhythmias and reduce heart workload

Low sodium diet- to prevent fluid retention

Exercise as tolerated - to monitor response to therapy and return to baseline functional status


440

Use the CARDIAc LeVeLS mnemonic for cardiac assessment:

Chest discomfort

Activity tolerance

Response to drug therapy

Depression & anxiety

Increased weight

Arrhythmias

c...

Lightheadedness

e...

Vital sign changes

e...

Level of consciousness decreased

Shortness of breath

Self-care instructions for heart failure: R-E-A-L keys

Report findings of heart failure to provider - weight gain, worsening dyspnea, orthopnea, fatigue

Exercise is important - start low & go slow to increase functional capacity, attending to symptoms

Adherence to cardiac medications is essential to staying healthy

Low sodium diet - 2000 grams per day


F. Pulmonic insufficiency (regurgitation)

1. Definition - pulmonary valve fails to close, so that blood flows back into the right ventricle during ventricular
diastole


2. Epidemiology

a. a birth defect, or a result of pulmonary hypertension

b. rarely, result of prolonged use of a pressure-monitoring catheter in the pulmonary artery



3. Findings

a. dyspnea, fatigue, chest pain and syncope

b. peripheral edema may cause discomfort

c. if advanced:jaundice with ascites and peripheral edema

d. possible malnourished appearance


4. Diagnostics - echocardiogram shows abnormal blood or valve movement



5. Management

a. DO-ABLE interventions for the management of heart failure

b. surgery - valve repair or replacement for severe, recurrent episodes of heart failure


6. Nursing care

a. monitoring of CARDIAc LeVeLS

b. if client has had valve surgery, watch for hypotension and arrhythmias, administer and reinforce teaching
about long-term anticoagulation

c. reinforce client and family teaching

i. Instruct about REAL keys to self-care for heart failure

ii. if client is on anticoagulants, explain long-term anticoagulation with periodic lab testing of INR for warfarin
441

(Coumadin), maintain steady Vitamin K level in diet, report signs of bleeding

iii. explain the potential need for antibiotics before dental care or invasive procedures





REMEMBER IT
Treatment for pulmonary edema: M DOG

M= Morphine
D= Diuretics (furosemide)
O= Oxygen
G= Gases (blood gasses)


The DO-ABLE mnemonic for heart failure interventions:
CARDIAc LeVeLS for Cardiac Assessment
R-E-A-L Keys for Self-Care

The DO-ABLE mnemonic for heart failure interventions:

Diuretics- to relieve pulmonary congestion, fluid overload & return to baseline weight

Oxygen- to correct hypoxia

ACE inhibitors- to reduce preload and afterload, counteracting compensatory hormones

Beta-blockers- to prevent arrhythmias and reduce heart workload

Low sodium diet- to prevent fluid retention

Exercise as tolerated - to monitor response to therapy and return to baseline functional status

Use the CARDIAc LeVeLS mnemonic for cardiac assessment:

Chest discomfort

Activity tolerance

Response to drug therapy

Depression & anxiety

Increased weight

Arrhythmias

c...

Lightheadedness

e...

Vital sign changes

e...

Level of consciousness decreased

Shortness of breath

Self-care instructions for heart failure: R-E-A-L keys

Report findings of heart failure to provider soon after they start: weight gain, worsening dyspnea , orthopnea, fatigue

Exercise is important - start low & go slow to increase functional capacity, attending to symptoms

Adherence to cardiac medications is essential to staying healthy

Low sodium diet - 2000 grams per day






442


G. Aortic stenosis

1. Definition: aortic valve becomes narrowed, causing poor cardiac output and increasing left heart pressures.



2. Etiology

a. most significant valvular lesion seen among elderly people; it usually leads to left-sided heart failure, left
ventricular hypertrophy, and cardiomyopathy

b. incidence increases with age

c. occurs in 1% of the population

d. about 80% of these people are male

e. 20% of them die suddenly, around age 60


3. Findings

a. classic triad = dyspnea (especially with exertion), syncope, angina (see assessing clients with cardiovascular
disorders )


b. fatigue


c. palpitations


d. left-sided heart failure may occur with orthopnea, paroxysmal nocturnal dyspnea and crackles in the lungs

e. systolic murmur that radiates into carotid arteries and the apex of the heart

f. EKG - findings of left ventricular hypertrophy



4. Diagnostics: echocardiogram shows small aortic valve area and abnormal blood flow



5. Management

a. DO-ABLE interventions for the management of heart failure

b. nitrates for chest discomfort

c. surgery - valve repair or replacement for severe, recurrent episodes of heart failure, angina or syncope



6. Nursing care

a. monitoring of CARDIAc LeVeLS

b. if client has had valve surgery, watch for hypotension and arrhythmias, administer and reinforce teaching about
long-term anticoagulation

c. reinforce client and family teaching

i. reinforce teaching about REAL keys to self-care for heart failure

ii. if client is on anticoagulants, explain long-term anticoagulation with periodic lab testing of INR for warfarin
(Coumadin), maintain steady Vitamin K level in diet, report signs of bleeding

iii. explain the potential need for antibiotics before dental care or invasive procedures



The DO-ABLE mnemonic for heart failure interventions:
CARDIAc LeVeLS for Cardiac Assessment
R-E-A-L Keys for Self-Care

443

The DO-ABLE mnemonic for heart failure interventions:

Diuretics- to relieve pulmonary congestion, fluid overload & return to baseline weight

Oxygen- to correct hypoxia

ACE inhibitors- to reduce preload and afterload, counteracting compensatory hormones

Beta-blockers- to prevent arrhythmias and reduce heart workload

Low sodium diet- to prevent fluid retention

Exercise as tolerated - to monitor response to therapy and return to baseline functional status

Use the CARDIAc LeVeLS mnemonic for cardiac assessment:

Chest discomfort

Activity tolerance

Response to drug therapy

Depression & anxiety

Increased weight

Arrhythmias

c...

Lightheadedness

e...

Vital sign changes

e...

Level of consciousness decreased

Shortness of breath

Self-care instructions for heart failure: R-E-A-L keys

Report findings of heart failure to provider - weight gain, worsening dyspnea, orthopnea, fatigue

Exercise is important - start low & go slow to increase functional capacity, attending to symptoms

Adherence to cardiac medications is essential to staying healthy

Low sodium diet - 2000 grams per day


H. Aortic insufficiency (regurgitation)

1. Definition

a. blood flows back into the left ventricle during ventricular diastole overloading the ventricle and causing it to
hypertrophy


b. extra blood also overloads the left atrium and, eventually, the pulmonary system



2. Epidemiology

a. by itself, most common among males

b. with mitral valve disease, more common among females

c. may accompany Marfan's syndrome, ankylosing spondylitis, syphilis, essential hypertension or a defect of the
ventricular septum











444


3. Findings


a. uncomfortable awareness of heartbeat

b. palpitations along with a pounding head

c. dyspnea with exertion

d. orthopnea, paroxysmal nocturnal dyspnea, cough

e. fatigue and syncope with exertion or emotion

f. anginal chest pain unrelieved by sublingual nitroglycerin

g. heartbeat that seems to jar the client's entire body

h. client's nailbeds may appear to be pulsating when fingertip is pressed (Quincke's sign)

i. if right ventricle fails, client may show signs of right heart failure with peripheral edema, jugular vein distention
and ascites


j. high pitched diastolic murmur at third or fourth intercostal space - left sternal border

k. pulsus bisferiens: a double-beat pulse (palpated over the carotid or brachial arteries)

l. widened pulse pressure




4. Diagnostics

a. chest x-ray

b. echocardiogram

c. cardiac catherization


5. Management

a. DO-ABLE interventions for the management of heart failure

b. surgery - valve repair or replacement for severe, recurrent episodes of heart failure



6. Nursing care

a. Monitoring of CARDIAc LeVeLS

b. if client has had valve surgery, watch for hypotension and arrhythmias, administer and reinforce teaching about
long-term anticoagulation

c. reinforce client and family teaching

i. reinforce teaching about REAL keys to self-care for heart failure

ii. if client is on anticoagulants, explain long-term anticoagulation with periodic lab testing of INR for warfarin
(Coumadin), maintain steady Vitamin K level in diet, report signs of bleeding.

iii. explain the potential need for antibiotics before dental care or invasive procedures













445

The DO-ABLE mnemonic for heart failure interventions


Diuretics- to relieve pulmonary congestion, fluid overload & return to baseline weight

Oxygen- to correct hypoxia

ACE inhibitors- to reduce preload and afterload, counteracting compensatory hormones

Beta-blockers- to prevent arrhythmias and reduce heart workload

Low sodium diet- to prevent fluid retention

Exercise as tolerated - to monitor response to therapy and return to baseline functional status

Use the CARDIAc LeVeLS mnemonic for cardiac assessment:

Chest discomfort

Activity tolerance

Response to drug therapy

Depression & anxiety

Increased weight

Arrhythmias

c...

Lightheadedness

e...

Vital sign changes

e...

Level of consciousness decreased

Shortness of breath

Self-care instructions for heart failure: R-E-A-L keys

Report findings of heart failure to provider - weight gain, worsening dyspnea, orthopnea, fatigue

Exercise is important - start low & go slow to increase functional capacity, attending to symptoms

Adherence to cardiac medications is essential to staying healthy

Low sodium diet - 2000 grams per day


IV. Disorders of the Heart Muscle

A. Myocardial infarction (MI)

1. Definition: insufficient oxygen supply kills (causes necrosis) myocardial tissue; may be sudden or gradual and
total event may take 3 to 6 hours


2. Etiology: atherosclerotic plaques cause narrowing in arteries (coronary artery disease , CAD); sudden rupture
of unstable plaque causes thrombotic event, suddenly worsening stenosis (acute coronary syndrome) or
occluding coronary blood flow to heart muscle distal to the blockage (myocardial infarction)


3. Epidemiology

a. client history of cardiovascular risk factors: smoking, obesity, diabetes, sedentary lifestyle, hyperlipidemia
446

(high low density lipoprotein (LDL- bad cholesterol), low high density lipoprotein (HDL- good cholesterol),
physical/emotional stress, depression

b. a common killer in North America and Western Europe

c. almost equal for men and women

d. factors affecting mortality

i. mortality about 25%; of the sudden deaths from MI, more than half happen within an hour

ii. number of occluded vessels


iii. previous history of MI


iv. presence of cardiogenic shock


v. advanced age; females have twice the mortality of males





4. Findings

a. classic findings: persistent, crushing substernal chest discomfort

i. pain may radiate to the left arm, jaw, neck and shoulder blades, with a feeling of impending doom

ii. pain may persist for 12 hours or more

iii. some clients report no pain or call it mild indigestion

more likely in older adults or clients with diabetes

clues suggesting "silent" MI (acute or sudden): heart failure, change in mental status, unexplained
abdominal pain, dyspnea, fatigue

women may experience fatigue and/or gastrointestinal symptoms



b. fatigue, nausea, vomiting and shortness of breath

c. sudden death

d. within the first hour clients may experience hypertension

e. others may experience hypotension with signs of shock, especially with large anterior-lateral ST elevation on
EKG ("tombstone" appearance)- poor prognosis- risk of sudden death and complications- EMERGENCY
revascularization needed!



5. Diagnostics

a. history and physical

b. EKG - monitor for ST-segment changes in the 12 lead, arrhythmias

c. serum markers - elevated

i. CK-MB isoenzyme rises 4 to 6 degrees after acute MI (returns to normal in 3 to 4 days)

ii. Troponin rises quickly but remains elevated for two weeks




6. Management for suspected or confirmed acute coronary syndrome/ acute myocardial infarction

a. rapid assessment of symptoms, vital signs and 12-lead EKG

b. immediate administration of M.O.N.A. (morphine, oxygen, nitrates, aspirin)

c. goal is resolution of symptoms as quickly as possible- "Time is muscle"
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d. EMERGENCY coronary angiogram with revascularization if indicated to resupply blood perfusion to heart muscle.
If revascularization is not needed emergently, this will often be done in the near future

i. cardiac catheterization may be performed for percutaneous transluminal coronary angioplasty (PTCA), i.e.,
stent insertion


ii. thrombolytic agents such as tPa (tissue plasminogen activator) - to dissolve the thrombus in the coronary
artery and reperfuse the myocardium (used in centers without angioplasty capabilities)

iii. coronary artery bypass graft surgery


e. cardiac monitoring for arrhythmias

f. supplemental oxygen - to prevent tissue hypoxia

g. induced hypothermia (target temperature of 32 to 34 Celsius) - for cardiac arrest survivors, initiated as soon as
possible after return of spontaneous circulation

h. bed rest during the acute event and with any episodes of physiologic instability - to decrease the workload of the
heart, often with bathroom privileges, activity progressing as tolerated when stable

i. pharmacologic agents - to stabilize the heart and reduce the risk of complications and death

i. antiplatelets and/ or anticoagulants - (i.e. aspirin, heparin) to prevent recurrent thrombosis

ii. nitrates- to decrease pain and decrease preload and afterload while increasing the myocardial oxygen supply

iii. narcotic analgesics for acute episodes of chest discomfort or pulmonary edema - to reduce pain, anxiety, fear,
and decrease the workload of the heart

iv. beta-blockers - to decrease myocardial tissue oxygen consumption and decrease the risk of arrhythmias

v. ACE inhibitors - decrease pressures in heart, reducing the risk of cardiac remodeling that leads to heart failure

vi. diuretics- if pulmonary edema occurs

vii. sedatives - to decrease anxiety and fear and to decrease the workload of the heart

viii. antiarrhythmic - to prevent or control arrhythmias, which are the most common complications after an MI

ix. stool softeners - to decrease the workload of the heart caused by straining, which can cause vagal stimulation
producing bradycardia and arrhythmias


j. pulmonary artery (Swan-Ganz) catheter to monitor pressure in pulmonary artery (measures functioning of left
ventricle)

k. intra-aortic balloon counterpulsation may be used for cardiogenic shock


REMEMBER IT
Therapeutic treatment for Myocardial infarction: "O BATMAN!"

O=Oxygen
B=Beta blocker
A=ASA (aspirin)
T=Thrombolytics (heparin)
M=Morphine
A=ACE (especially for those with heart failure or a lower ejection fraction)
N=Nitroglycerin



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7. Nursing care

a. the cardio-care six plus monitor the following to identify early heart failure, infections and complications

i. temperature


ii. daily weight


iii. intake and output

iv. respiratory rate


v. breath sounds


vi. blood pressure


vii. EKG readings


viii. peripheral pulses

ix. heart sounds especially S3 and gallop Listen



b. monitor for chest discomfort/ recurrent cardiac symptoms, especially findings similar to those that brought the
client into the hospital. For recurrent cardiac symptoms, repeat 12-lead EKG, MONA protocol

c. monitor for cough, tachypnea, and crackles, which may indicate pulmonary edema due to left ventricular failure
Listen


d. as ordered, apply antiembolism stockings and intermittent pneumatic compression devices to prevent venostasis
and thrombophlebitis

e. assistance with range-of-motion exercises as appropriate for clients who are on bedrest

f. reinforce client and family teaching

i. cardio 5 teaching plan

ii. the ICU, CCU or Telemetry units - inform client and family about associated routines and machinery and
communication methods

iii. nitroglycerin use for recurrent cardiac symptoms and when to seek emergency care

iv. advise the client when to report typical or atypical cardiac symptoms or chest discomfort controlled with
nitroglycerin or rest to care provider

v. encourage client to join the cardiac rehab exercise program, if ordered

vi. reinforce education for the gradual resumption of sexual activity when client can walk up 2 flights of stairs
without symptoms - taking nitroglycerin before sex may prevent angina (but reinforce that drugs such as
sildenafil (Viagra) are contraindicated in those taking nitrates- severe hypotension may occur)

vii. reinforce information about postmyocardial infarction syndrome and what to report to care provider

viii. stress that client should modify risky life-style behaviors to reduce likelihood of recurrent MI

x. assist with dietary consultation as indicated




B. Heart failure (HF)

1. Definition and pathophysiology

a. damaged fails to pump enough blood to support the body's functions, leading to poor cardiac output and fluid
overload


b. type of HF depends on which part of the heart is abnormal, and the type of abnormality.

i. the left heart receives blood from the lungs and pumps blood to the body (cardiac output) to perfuse tissue

systolic heart failure: disorder of weakened left ventricule (LV) with reduced ability to contract
characterized by reduced LV ejection fraction of < 40%

diastolic heart failure: left ventricule (LV) is unable to relax properly during diastole, usually due to
hypertrophy; this prevents adequate filling of the LV, reducing stroke volume and is characterized
by normal to high LV ejection fraction > 50%
also called "heart failure with normal ejection fraction"
most common in older adults, clients with a long history of hypertension


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ii. the right heart receives blood from the venous system via the central vena cava, and pumps blood to the
lungs



c. heart muscle damage is called cardiomyopathy, which leads to heart failure syndrome

d. over 5 million Americans have heart failure. It is the most common cause of hospitalization in older adults, and
a common cause of recurrent hospitalization



2. Etiology of heart failure

a. coronary artery disease that causes ischemia and infarction- ischemic cardiomyopathy is most common type
of heart failure


b. infections of the heart (endocarditis, myocarditis)

c. cardiac valvular disorders in moderate to severe stages

d. infiltrative disorders, i.e., amyloidosis, tumors, sarcoidosis

e. collagen-vascular disease: systemic lupus erythematosus, scleroderma

f. arrhythmias that reduce cardiac filling time, i.e., atrial fibrillation

g. disorders that increase cardiac workload: hypertension, anemia, hyperthyroidism

h. cardiac tamponade




3. Findings
Heart Failure symptoms listed in order of earliest to later findings
Right Left
Significant weight gain

Jugular vein distention

Bilateral dependent peripheral edema

Liver engorgement (hepatomegaly with
abdominal pain, anorexia, and nausea)

Ascites
Fatigue and activity intolerance
Cough (often dry initially)
Mild weight gain that leads to early pulmonary symptoms
Shortness of breath/orthopnea
Paroxysmal nocturnal dyspnea
Tachypnea
Crackles
S3 heart sound
Cardiac cachexia and muscle weakness in advanced stage

Acute pulmonary edema:
Frothy sputum (may be blood-tinged)
Restlessness, irritability, hostility, agitation, anxiety
Prominent crackles throughout lung fields
Diaphoresis
Cyanosis


4. Diagnostics - the primary goal is to determine the underlying cause of the heart failure, and to reduce the risk of
complications

a. history and physical exam

b. echocardiogram to look for structural defects, heart movement, blood flow and ejection fraction

c. serum labs: complete blood count (CBC), electrolytes, brain (or B-type) natriuretic peptide (BNP)

d. chest x-ray to determine heart size and pleural effusions

e. EKG for changes, arrhythmias

f. nuclear imaging - to determine myocardial contractility, myocardial perfusion, and acute cell injury, reversible
causes of HF such as ischemia

g. hemodynamic monitoring in cardiogenic shock - arterial blood pressure, pulmonary artery pressure, pulmonary
artery wedge pressure and cardiac output

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5. Management

a. DO-ABLE interventions for the management of heart failure

b. pharmacologic treatments include digitalis, vasodilators, nitrates, antihypertensives, cardiac glycosides, diuretics,
beta blockers, ACE inhibitors, inotropes

c. other treatments: oxygen, intra-aortic balloon counterpulsation, ventricular assist pumping, biventricular pacing

d. surgery: partial left ventriculectomy



6. Nursing care

a. Monitoring of CARDIAc LeVeLS

b. if client has a prosthetic valve or atrial fibrillation administer and titrate anticoagulants, using PTT for Heparin and
INR for warfarin (Coumadin)

c. reinforce client and family teaching

i. reinforce teaching about REAL keys to self-care for heart failure

ii. if client is on anticoagulants, explain long-term anticoagulation with periodic lab testing of INR for warfarin
(Coumadin), maintain steady Vitamin K level in diet, report signs of bleeding



The DO-ABLE mnemonic for heart failure interventions:
CARDIAc LeVeLS for Cardiac Assessment
R-E-A-L Keys for Self-Care

The DO-ABLE mnemonic for heart failure interventions:

Diuretics- to relieve pulmonary congestion, fluid overload & return to baseline weight

Oxygen- to correct hypoxia

ACE inhibitors- to reduce preload and afterload, counteracting compensatory hormones

Beta-blockers- to prevent arrhythmias and reduce heart workload

Low sodium diet- to prevent fluid retention

Exercise as tolerated - to monitor response to therapy and return to baseline functional status

Use the CARDIAc LeVeLS mnemonic for cardiac assessment:

Chest discomfort

Activity tolerance

Response to drug therapy

Depression & anxiety

Increased weight

Arrhythmias

c...

Lightheadedness

e...

Vital sign changes

e...

Level of consciousness decreased

Shortness of breath

Self-care instructions for heart failure: R-E-A-L keys

Report findings of heart failure to provider - weight gain, worsening dyspnea, orthopnea, fatigue

Exercise is important - start low & go slow to increase functional capacity, attending to symptoms

Adherence to cardiac medications is essential to staying healthy

Low sodium diet - 2000 grams per day

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C. Cardiac tamponade

1. Definition: fluid quickly fills pericardial sac and minimizes cardiac output, requiring emergency care to avoid
cardiac arrest



2. Etiology

a. acute pericarditis

b. post-op after cardiac surgery

c. pericardial effusions

d. chest trauma


e. myocardial rupture

f. aortic dissection


g. anticoagulant therapy

h. malignancy





3. Findings: classic triad of signs

a. hypotension with

b. muffled heart sounds with

c. marked jugular vein distention if no hypovolemia

d. in addition,

i. pulsus paradoxus: systolic BP > 10 mm Hg lower on inspiration than expiration

ii. narrowed pulse pressure: difference between systolic and diastolic BP - indicator of poor cardiac output

iii. tachypnea, tachycardia, restlessness, lightheadedness or decreased level of consciousness - this person
requires emergency care!



4. Diagnostics : echocardiogram showing large pericardial effusion with poor heart movement and blood flow

5. Medical management: emergency pericardiocentesis (needle aspiration of pericardial sac)

6. Nursing care

a. continuous monitoring of cardiovascular status

b. bed rest with elevated head of bed 35 to 45 degrees

c. prepare client for pericardiocentesis

d. provide emotional support

e. prepare for surgery if pericardiocentesis is ineffective

f. monitor for complications of procedure

i. pneumothorax


ii. arrhythmias


iii. hypotension




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V. Disorders of the Circulatory System

A. Hypertension

1. Definitions

a. hypertension - systolic blood pressure of 140 mm Hg or greater, diastolic blood pressure of 90 mm Hg or
greater, on at least three separate occasions

i. stage 1: SBP 140-159 mm Hg -or- DBP 90-99 mm Hg

ii. stage 2: SBP > 160 mm Hg -or- DBP > 100 mm Hg


b. pregnancy induced hypertension (PIH) - high blood pressure present before week 20 of gestation

c. accelerated hypertension - a hypertensive crisis when blood pressure rises very rapidly, threatening the
brain






Clinical practice guidelines indicate that individuals with a systolic blood pressure of 120139 mm Hg or a diastolic blood
pressure of 8089 mm Hg should be considered as "prehypertensive" and will require health-promoting lifestyle
modifications to prevent cardiovascular disease (National Heart Lung and Blood Institute, 2003).



2. Etiology and epidemiology

a. primary hypertension - (90-95% of cases) cause unknown, but numerous risk factors

i. family history - immediate family, including mother, father, sister, brother

ii. race - African American, Hispanic, Native American, more susceptible

iii. stress


iv. obesity - 20% more than ideal weight

v. a diet high in sodium or saturated fat

vi. use of tobacco


vii. use of hormonal contraceptives

viii. sedentary life/ lack of exercise

ix. age




b. secondary hypertension is high blood pressure from an identifiable cause such as:

i. renal disease (renal artery stenosis, glomerulonephritis, end-stage kidney disease)

ii. drugs (stimulants such as ephedrine-type decongestants and cocaine, certain immunosuppressants such as
cyclosporine)


iii. Cushing's syndrome (increased levels of cortisol, a stress hormone)

iv. pregnancy- related hormones

v. neurologic disorders (i.e,. brain tumors, traumatic brain injury)

vi. coarctation of the aorta (congenital aortic narrowing)


c. besides hypertension, most individuals have other risk factors for cardiovascular disease (CVD)



3. Findings

a. usually asymptomatic unless end-organ damage is present or hypertensive crisis is occurring

b. findings reflect the effect of hypertension on organ systems

brain: occipital headache, blurred vision, dizziness, TIA or stroke

eyes: retinal arteriole abnormalities

heart: chest pain, palpitations, dyspnea or signs of heart failure; diagnostic tests showing LV hypertrophy,
ischemia or infarction

kidneys: elevated serum creatinine, urine positive for protein
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peripheral vascular: intermittent claudication (leg pain with exercise, relieved by rest), vascular bruits, aneurysm


c. complication: acute hypertensive crisis

findings reflect the effects of sudden blood pressure elevation on organs

brain: hypertensive encephalopathy (often first sign) severe headache, nausea, vomiting, seizures, confusion,
coma, or stroke-like symptoms

eyes: papilledema

heart: rapid development of angina or myocardial infarction, pulmonary edema.

kidneys: new renal insufficiency or renal failure



4. Diagnostics

a. hypertension is diagnosed based on the average of three or more blood pressure readings, two minutes apart, at
each of three or more visits after an initial screening visit ( measuring blood pressure )

b. classification of adult hypertension

c. hypertensive crisis: diagnostic testing to determine end-organ damage



5. Management

a. initial treatment for prehypertension and uncomplicated stage 1 hypertension - lifestyle modifications

i. weight reduction


ii. regular physical activity (goal - 30 minutes total aerobic activity on most days)

iii. DASH eating plan (fruits, vegetables. fat-free or low fat milk products, whole grains, fish, poultry, beans, seeds
& nuts)


iv. limit dietary sodium (avoid high-sodium foods and adding salt or sodium-rich ingredients when preparing
foods)


v. alcohol in moderation

vi. smoking cessation

vii. stress reduction



b. pharmacological - used if life changes fail to decrease the blood pressure to an acceptable level

i. initial therapy - for uncomplicated hypertension, it is recommended to start with a diuretic or beta-adrenergic
blocking agent


ii. oxygen PRN in acute crisis

iii. angiotensin-converting enzyme (ACE) inhibitors are used to treat left-sided heart failure and preferred if client
is diabetic (to protect kidneys)

iv. antilipemics



c. hypertensive crisis: intensive care needed with rapid reduction of blood pressure using IV vasodilators and
prevent and monitor for signs of end-organ damage

d. goals of treatment: blood pressure less than 130/85 mm Hg and control of other cardiovascular risk factors



6. Nursing care - reinforce client and family teaching

a. self-monitoring of blood pressure and how to obtain and use equipment

b. record blood pressure readings for review by care provider during visits

c. a routine or schedule for taking antihypertensive medications

d. avoid over-the-counter medications that can increase BP such as decongestants

e. DASH diet

f. report extremely high blood pressure readings


454

g. healthy heart lifestyle

i. optimize body weight

ii. moderate alcohol intake based on current guidelines

iii. limit dietary sodium, e.g., 2 grams per day

iv. participate in regular and moderately intense aerobic activity (at least 30 minutes total on most days)

v. avoid tobacco and secondary smoke

vi. manage stress and responses to triggers


h. Nursing care for hypertensive crisis

a. monitor for end organ damage

b. monitor urine output; assess level of consciousness

c. monitor BUN, creatinine, arterial blood gases, urinalysis

d. continuous cardiac monitoring

e. record vital signs every 5 to 30 minutes while medications are being titrated


Complementary and Alternative Medicine

Garlic, ginseng dried root, hawthorn, and snakeroot have been used to treat hypertension; however, theres not
enough research to support the efficacy and safety of these herbal therapies.

Supplements:

Coenzyme Q10 (CoQ10) supplements may cause small decreases in blood pressure; low blood levels of CoQ10
have been found in people with hypertension

Omega-3 fatty acids supplements may lower blood pressure

Amino acid L-arginine diet supplements may temporarily lower blood pressure


Alternative systems of care

Traditional Chinese medicine

Avurveda


Note: Licorice and ephedra should not be used by people with hypertension because they can increase blood
pressure.

B. Coronary artery disease (CAD)

1. Definition - fatty deposits in coronary arteries (atheroma or plaque) narrow the artery (by 75% or more) reducing
flow of blood and oxygen to the heart muscle



2. Epidemiology and etiology

a. CAD is epidemic in the western world

b. more than 30% of men age 60 or older show signs of CAD on autopsy

c. most common cause: atherosclerosis

455


d. risk factors

i. gender: white males over age 40; women after natural or surgical menopause

ii. diabetes, poorly controlled

iii. family history of CAD


iv. uncontrolled high blood pressure

v. hyperlipidemia- High LDL (bad cholesterol) and/or triglycerides, low HDL (good cholesterol)

vi. tobacco smoke and second-hand smoke exposure (note: smokers are twice as likely to have a myocardial
infarction and four times as likely to die suddenly - this risk drops sharply within one year after smoking
ceases)


vii. obesity (waist predominance); [added weight increases the risk of diabetes, hypertension and high
cholesterol]


viii. physical inactivity


ix. stressed lifestyle





3. Findings

early stages- asymptomatic

anginal chest discomfort or cardiac symptoms when blockage significantly reduces cardiac blood flow (>
70% narrowing)

characteristic pattern of inadequate blood supply to heart to meet demand

chest discomfort or cardiac symptoms occur with predictable exertion and resolve with rest. Over time,
less activity is required to trigger symptoms

women, people with diabetes and those who are very old often have atypical symptoms such as dyspnea,
lightheadedness, GI complains or pain, discomfort in atypical locations


4. Diagnostics

a. serum labs - all elevated

i. homocysteine levels


ii. C-reactive protein


iii. LDH cholesterol


iv. triglycerides



b. reduced HDL cholesterol

c. Cardiac stress testing shows ST segment changes with exercise or pharmacologically-induced tachycardia

d. Nuclear perfusion scanning shows areas of poor perfusion

e. Cardiac catheterization with coronary angiography ("gold standard" for diagnosis) shows areas of narrowing in
coronary arteries




5. Medical management

a. pharmacological

i. nitrates- coronary artery vasodilators

short-acting nitroglycerin sublingual tablets or spray for relief of acute cardiac symptoms

oral isosorbide or transdermal nitroglycerin to prevent anginal episodes

all nitrates require a nitrate-free period to prevent tolerance- administer during active period of day with break
during sleep


ii. beta-blockers- reduce myocardial oxygen demand by decreasing heart rate and tachycardic response to
stress and exercise

iii. antiplatelet agents (aspirin [81 mg daily]) - reduces platelet aggregation and likelihood of thrombotic event
456


iv. antilipemics- to treat hyperlipidemia; HMG CoA reductase inhibitors ("statin" drugs) stabilize arterial
endothelium, reducing risk of atherosclerotic plaque rupture the cause of most myocardial infarction


b. oxygen during acute anginal events in healthcare settings, to improve myocardial oxygenation

c. well-balanced diet low in fat and cholesterol that includes several daily servings of fruits and vegetables

d. tobacco cessation

e. stress reduction techniques

f. interventional or surgical revascularization for significant coronary lesions

g. coronary angioplasty (PTCA) with stent

h. surgical treatment - coronary artery bypass graft (CABG)


Cardiac Catheterization Coronary Artery Blockage Before & After Vein Graft




6. Nursing care

a. bed rest during acute events, monitor for symptoms as client slowly resumes activity

b. reassure client, explain procedures and tests

c. assess routinely for cardiac symptoms/ chest discomfort

d. when cardiac symptoms/chest discomfort occur, quickly assess pain, vital signs, get 12-lead EKG, MONA
(morphine, oxygen, nitrates, aspirin)

e. keep nitroglycerin available for immediate use

f. post cardiac catheterization and percutaneous transluminal coronary angioplasty/stent

i. maintain heparinization to reduce risk of thrombosis in stent

ii. monitor the client for chest pain, hypotension, coronary artery spasm and bleeding from the catheter site

iii. observe for bleeding, or hematoma at the puncture site

iv. keep the affected leg straight and immobile for 6 to 12 hours

v. check for distal pulses to detect arterial occlusion distal to puncture site

vi. to counter the diuretic effect of the dye, administer IV fluids and make sure client drinks plenty of fluids.
Monitor serum creatinine following procedure

vii. assess potassium level and observe for arrhythmias

viii. observe findings of hypotension, bradycardia, diaphoresis, dizziness; give atropine and lay the client flat


g. reinforce client and family teaching

i. risk-factor modification

teach the risk factors for coronary artery disease (CAD)

encourage client to lose excess weight; review low-fat, low-cholesterol diet, resume activity gradually as
tolerated or encourage participation in cardiac rehabilitation program

encourage smoking cessation- acute coronary events are strong motivation for many clients to successfully
457

quit smoking

teach side effects of drugs for CAD

stress - teach stress reduction techniques


ii. avoid

activities known to cause angina

physical activities for two hours after meals

very cold and very hot weather

alcohol and caffeine drinks

stimulants such as diet pills, nasal decongestants, or any remedy that can raise heart rate or blood
pressure


iii. use

nitroglycerin tablets and carry at all times

1 tablet every 5 minutes up to 3, if no relief call 911


iv. report

new anginal pattern- if it occurs with less activity, or at rest

If multiple doses of nitroglycerin or more frequent use is needed




C. Hyperlipidemia

1. Definition: an elevation of lipids (fats) in the bloodstream, e.g., cholesterol, cholesterol esters (compounds),
phospholipids, triglycerides


2. Etiology: dietary, heredity


3. Pathophysiology: increased lipids and cholesterol leads to atherosclerosis, leading to coronary heart disease


4. Diagnostics

a. total cholesterol - increased

b. LDL - increased


c. HDL - decreased

d. triglycerides - increased



5. Management

a. diet

i. choose healthier fats and eliminate trans fats

ii. limit cholesterol in food


iii. whole grains


iv. eat foods rich in omega-3 fatty acids


b. exercise


c. medications:

i. statins: atorvastatin (Lipitor), rosuvastatin (Crestor), simvastatin (Zocor)

ii. bile acid sequestrants: colestipol (Colestic), cholestyramine (Questran)

iii. niacin



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6. Nursing interventions

a. encourage screening for at risk children with family history

b. teach dietary guidelines or refer to dietician




VI. Cardiac arrhythmias

A. Definition: disturbance in heart rate or rhythm

B. Types of dysrhythmia

1. Supraventricular: sinus, atrial, and junctional (originates outside the ventricles, usually in atria) - immediate
intervention may be required with very fast or slow rates that are symptomatic

a. sinus tachycardia


b. sinus bradycardia


c. sinus arrhythmia


d. premature atrial complexes

e. atrial tachycardia


f. atrial flutter


g. atrial fibrillation - very common, may cause thrombotic stroke due to lack of atrial contraction, requiring
anticoagulation


h. premature junctional complex

i. junctional tachycardia



2. Ventricular: immediate intervention may be required with very fast or slow rates that are symptomatic; very
serious rhythms indicated by emergent care


C. Etiology

1. usually associated with structural heart damage and most common during periods of cardiac insult such as
MI, and post- cardiac surgery

2. sympathetic stimulation increases risk for arrhythmias, i.e., stress, caffeine




D. Findings and priority of management

1. General information: all new or symptomatic arrhythmias require continuous cardiac monitoring, IV access for
medications, vital sign and symptom monitoring for any changes indicating client is not tolerating rhythm

2. Specific findings and management

a. asymptomatic

i. no findings


ii. this means client is tolerating it well and cardiac output is adequate; document and inform provider


b. mild

i. findings: palpitations, fatigue, and client may have a mild reduction in cardiac output

ii. management: check vital signs, inform provider and institute any orders such as oxygen or medications


c. moderate

i. findings: lightheadedness, low blood pressure, chest discomfort, dyspnea or other indicators of poor cardiac
output


ii. bedrest while unstable; 12-lead EKG, oxygen and frequent blood pressure monitoring; call provider
immediately or rapid response team for rapid intervention since this client is at risk of cardiac arrest very
soon!



d. severe

i. findings: client is unresponsive, pulse is absent or very slow or weak, no blood pressure or very low
compared to client's baseline
459


ii. requires emergency care - ABCD's of basic life support; call a code or activate rapid response/emergency
system





REMEMBER IT!
Management of atrial fibrillation: ABCD

A=Anticoagulant
B=Beta blocker to control rate
C=Cardioversion (if beta blocker ineffective or calcium channel blocker to
control rate)
D=Digoxin


E. Nursing care - always treat your client, not just the monitor (the number and degree of findings will often dictate
the treatment)

1. supraventricular arrhythmias - too fast

a. asymptomatic - no nursing interventions indicated

b. symptomatic

i. vagal stimulation


ii. administer medications as ordered (slow rate of administration)

adenosine (Adenocard)

calcium channel blockers

beta blockers


iii. procedures

cardioversion

ablation


iv. provide emotional support

v. reinforce client and family teaching

about medications and side effects

to decrease stimulant use, i.e., caffeine, nicotine

to control reactions to stress

to reduce alcohol intake

about importance of sleep




2. ventricular arrhythmias - ABCDs of basic life support, and then

a. administer medications as ordered

b. continuous cardiac monitoring, with monitored transport with ACLS precautions

c. administer oxygen as ordered

d. provide a restful environment

e. prepare the client for cardioversion or implantable cardioverter defibrillator (ICD) placement if indicated

f. provide emotional support and information for client and family - family often knows what has happened, client
may not, requiring orientation to time, situation and events

g. pain medication/symptom relief measures for CPR-related chest injuries or defibrillator burns, injuries
associated with event

h. reinforce client & family teaching

i. medications and side effects

ii. importance of wearing MedicAlert identification & carrying ICD identification card, family member CPR
training



460


3. atrio-ventricular (AV) conduction disturbances - too slow

a. asymptomatic: no nursing interventions indicated

b. symptomatic

i. administer medications as ordered (atropine to increase HR)

ii. prepare client for pacemaker insertion if indicated

iii. care of the client undergoing a procedure or surgery

iv. provide emotional support

v. provide a restful environment




VII. Other Vascular Disorders

A. Aneurysms

1. Definition - dilation of an artery due to a weakness in the arterial wall

2. Etiology - atherosclerosis

3. Types

a. saccular: outpouching of one wall in a circumscribed area

b. fusiform: involves complete circumference of artery

c. dissecting: accumulation of blood separating the layers of the arterial wall. Active dissection requires
emergency care!


d. pseudoaneurysm: tear of the full thickness of the arterial wall, leading to a collection of blood contained in
the connective tissue



4. Common locations

a. abdominal aorta- the largest artery in the body


i. findings

usually asymptomatic

vague abdominal or back pain- if severe, this may be a sign of active dissection, requiring
emergent care

tenderness & pulsation felt on palpation

hypotension

diminished pulses in lower extremities

most common site: just below renal arteries and above iliac arteries


ii. diagnostics - arteriogram


iii. management - tight control of blood pressure. surgical repair- emergent for dissection


iv. Nursing Interventions

post-op care of the client

after surgery, watch for back pain, a finding of retroperitoneal hemorrhage

monitor for adequate perfusion to extremities and organs

provide comfort measures

provide emotional support to client/family

remind client to avoid prolonged sitting and lifting of heavy objects


461


b. thoracic aorta

i. findings

may be asymptomatic

vague chest pain - may be sudden onset and mimic a dissecting thoracic aneurysm

dyspnea

distended neck veins


ii. diagnostics - arteriography


iii. management -. tight blood pressure control. surgical repair- (emergency for dissection)

iv. Nursing Interventions - provide care for client undergoing surgery or cardiac surgery





B. Arterial occlusive disease

1. Definition: insufficient blood supply in the arteries (usually in legs); may be acute or chronic


2. Types - acute and chronic

a. acute arterial occlusive disease

i. etiology

embolism, thrombosis, and trauma

femoral artery most often affected


ii. findings

pain in affected limb, especially with activity or walking

cyanosis in affected limb

paresthesia in affected limb

if untreated, gangrene


iii. diagnostics - arteriography, doppler studies


iv. management

pharmacologic: anticoagulants (IV heparin with PTT monitoring)

surgical treatment

embolectomy

bypass of affected artery

amputation of limb

percutaneous transluminal coronary angioplasty









462

6 P's of acute arterial occlusion:
Pallor (or mottling)
Pain
Paresthesia (numbness or tingling)
Pallor (cool or cold skin)
Pulselessness (distal to the blockage)
Paralysis (or weakness or muscle spasm)



b. chronic arterial occlusive disease

i. etiology

arteriosclerosis obliterans, aneurysms, hypercoagulability states, tobacco use

slow, progressive arteriosclerotic changes give collateral circulation a chance to form

collateral circulation cannot give tissues enough oxygen; result is hypoperfusion

hypoperfusion leads to ischemia

usually affects legs


ii. findings

intermittent claudication (predictable pain with walking relieved with rest, also called "angina of the legs") -
indicates mild to moderate obstruction

pain at rest indicates severe arterial obstruction

affected limb will show

skin: waxy, hairless, cool, pale, cyanotic

weak or absent pulses

paresthesia

non-healing wounds

in men, impotence


iii. diagnostics

arterial-brachial index - reduced

arteriography


iv. medical management

pharmacologic

anticoagulants - to prevent blood clots

vasodilators

antiplatelet drugs - to prevent platelet aggregation

pentoxifylline (Trental): promotes blood flow by making blood cells more "slippery"


surgical

endarterectomy

femoral-popliteal bypass

sympathectomy

amputation of affected limb for gangrene

laser coronary angioplasty (LTA)

peripheral angioplasty



463



3. Nursing care - both acute and chronic arterial occlusive disease

a. administer medications as ordered

b. monitor peripheral pulses and blanch test

c. provide comfort measures

d. provide foot care

e. post op care of client

f. reinforce client teaching

i. change positions frequently

ii. avoid crossing legs

iii. avoid any constrictive clothing on legs

iv. avoid trauma to lower extremities

v. foot care


vi. place legs in dependent position to increase blood flow




C. Raynaud's phenomenon (arteriospastic disease)

1. Definition

a. episodic vasospasm of the small cutaneous arteries that results in intermittent pallor or cyanosis of the skin -
usually affects the fingers bilaterally, but occasionally affects the toes, nose, or tongue that result in
intermittent pallor or cyanosis of the skin

b. the process involves a severe constriction of cutaneous vessels followed by vessel dilation and then a
reactive hyperemia (blue, white, red). can lead to tissue necrosis when severe.



2. Etiology: unknown

a. may occur by itself with no other disorders, but it is also a component of CREST syndrome, or systemic
scleroderma, which is a progressive severe autoimmune disorder

b. more frequently occurs in women

c. may be triggered by stress, cold or products that cause vasoconstriction such as tobacco, caffeine, and
chocolate



3. Findings : 6 P's of poor perfusion - pain, pallor, pulselessness (poor capillary refill), paraesthesia, paralysis,
poikilothermia (cold)


4. Diagnostics

a. clinical pattern


b. digital plethysmography to look at tissue perfusion

c. peripheral arteriography- to look for specific areas of blockage


5. Management

a. pharmacologic agents - goal is to promote perfusion to affected digits, preventing gangrene and amputation

i. calcium channel blockers: nifedipine (Procardia), diltiazem (Cardizem)

ii. alpha-adrenergic blocking agents

iii. vasodilators


iv. analgesics for pain relief


b. surgery

i. sympathectomy in advanced stages for pain relief
464


ii. amputation of digits showing gangrene


c. modification of lifestyle behaviors (tobacco cessation) and the environment (maintain warm environment)


6. Nursing care

a. administer medications as ordered

b. provide care of the client undergoing surgery

c. reinforce client teaching

i. management of stress


ii. avoidance of tobacco products, caffeine, and chocolate

iii. avoidance of temperature extremes

iv. protection from extreme cold and heat, use gloves

v. medications and side effects





D. Thromboangiitis obliterans (Buerger's disease)

1. Definition: inflammatory disease of the arteries (vasculitis), usually affecting the legs and feet, but sometimes the
hands


2. Etiology

a. rare; affects 10 men for every woman

b. ages 20 to 40 with heavy tobacco use (smoking or chewing)

c. may be related to Raynaud's



3. Findings

a. pain, including intermittent claudication

b. numbness and tingling of toes

c. weak or absent peripheral pulses - remember the 6 P's!

d. ischemic ulcerations may occur

e. can lead to gangrene and amputation


4. Diagnostics - angiography


5. Medical management

a. smoking cessation

b. see nursing interventions for arterial occlusive disease

c. analgesics


d. surgery in late stages, amputation


6. Nursing care

i. administer medications as ordered

ii. monitor peripheral pulses and blanch test

iii. provide comfort measures

iv. advise that dependent positioning of legs can decrease pain

v. help client to develop an exercise program

vi. provide care to the client undergoing surgery

vii. provide foot and wound care
465


viii. reinforce teaching of client regarding how stopping smoking can relieve findings




E. Varicose veins



1. Definition: dilation of superficial veins of the legs and feet

2. Etiology

a. usually found in greater saphenous vein (leg)

b. incompetent valves (incompetence, valvular) in the superficial veins

c. increased pressure in veins causing them to distend

d. risk factors: standing for long periods, pregnancy



3. Findings

a. pain after period of standing

b. foot and ankle swelling at end of day

c. distended leg veins


4. Diagnostics - venography


5. Medical management

a. goal is to reduce pain and halt underlying condition

b. medical: sclerotherapy (injection of sclerosing agent that causes vein thrombosis)

c. surgical: vein ligation (vein stripping)


6. Nursing care

a. provide care to the client undergoing surgery

b. postoperative care

i. application of elastic stocking or bandages

ii. elevation of legs



c. reinforce client teaching regarding

i. not to cross legs


ii. elevate legs as much as possible

iii. avoid anything that impedes venous return

iv. obesity can contribute to the problem- weight loss may help

v. avoid prolonged sitting or standing






466


F. Thrombophlebitis

1. Definition: a thrombus (clot) accompanied by the inflammation of the wall of a superficial blood vessel



2. Etiology

a. trauma


b. intravenous catheters

c. prolonged immobility

d. IV drug use



3. Findings - in an extremity over inflamed site

a. redness


b. swelling


c. tenderness


d. warmth


e. complication: thromboembolism - dislodgement and migration of a thrombus




4. Diagnostics

a. history and physical

b. ultrasonography

c. plethysmography

d. D-dimer



5. Medical management

a. bed rest with elastic stockings

b. elevation of affected extremity

c. anticoagulants - to reduce clot formation

d. analgesics - to control discomfort


6. Nursing care

a. keep affected extremity elevated

b. monitor

i. for findings of pulmonary embolism (sudden chest pain, dyspnea, cyanosis, hemoptysis, shock)

ii. vital signs, including bilateral peripheral pulses

iii. for findings of vascular impairment (pallor, cyanosis, coolness)


c. administer analgesics as ordered

d. reinforce client teaching regarding:
467


i. avoidance of tight or constricting clothing

ii. need to stop cigarette smoking and caffeine use

iii. avoidance of maintaining one position for long periods

iv. activity limitations if on long term anticoagulants



G. Deep venous thrombosis

1. Definition: clot formation in a deep vein (upper or lower extremity)

2. Etiology and risk

a. immobility including during hospitalization, long flights or trips in a vehicle especially if the client is dehydrated

b. sepsis


c. hematological and clotting disorders

d. malignancies


e. heart failure


f. myocardial infarction

g. obesity


h. pregnancy


i. fractures


j. venipuncture


k. surgeries: orthopedic, neurologic, urologic and gynecologic

l. risk of pulmonary embolus


3. Findings : unilateral edema of an extremity, with warmth, tenderness and redness at site

4. Diagnostics - venography, Doppler ultrasound


5. Medical management

a. goal is to eliminate the clot and prevent complications such as pulmonary embolism

b. bed rest


c. anticoagulant therapy - to prevent new clots

d. thrombolytic therapy - to dissolve thrombus

e. compression stockings

f. surgery - thrombectomy



6. Nursing care

a. maintain bed rest

b. follow guidelines for anticoagulation

i. monitor drug therapy (aPTT for heparin, PT/INR for warfarin) and know therapeutic levels

ii. observe for evidence of bleeding, i.e., bruises, nosebleeds, bleeding gums, blood in urine or stool

iii. advise the client to use electric razor and soft-bristled toothbrush


c. administer anticoagulant medications

d. monitor for signs of pulmonary embolus

e. reinforce client teachings regarding:

i. explain long-term anticoagulation with periodic lab testing of INR for warfarin (Coumadin), maintain steady
Vitamin K level in diet, report signs of bleeding.

ii. avoid prolonged immobility
468


iii. maintenance of adequate fluid intake




H. Venous stasis ulcers

1. Definition: chronic skin and subcutaneous ulcers usually found on legs, ankles or feet (often is a chronic
symptom for clients with chronic venous insufficiency)

2. Etiology

a. chronic venous insufficiency

b. incompetent valves (valvular, incompetence) in perforating veins or deep veins cause venous stasis

c. pressure of blood pooling causes capillaries to leak

d. ulcer begins as small, inflamed, tender area

e. any trauma causes tissue to break or it may break spontaneously

f. most common sites: pretibial and medial supramalleolar areas of ankle


3. Findings

a. open skin lesion with irregular border

b. skin around ulcer usually brown and leathery

c. pain in affected area



4. Diagnostics: history and physical exam of site



5. Medical management

a. goal is to correct venous hypertension and both prevent and correct ulceration

b. local wound care, compression as indicated to decrease edema (necessary for wound healing)

c. antibiotics and analgesics as indicated

d. surgery

i. debridement


ii. skin grafting


iii. removal of veins with incompetent valves




6. Nursing care

a. keep client's legs elevated, with feet above level of heart as much as possible

b. apply elastic bandages or compression dressings or stockings as ordered, usually bilateral

c. cleanse and dress ulcer as ordered

d. administer drugs as ordered

e. reinforce client teaching regarding:

i. reporting any findings of inflammation immediately

ii. avoiding trauma to affected limb

iii. providing skin care

iv. applying elastic bandages

v. appropriate nutrition to support healing: protein, vitamins C and E, and zinc



I. Sickle cell anemia (SCA)

1. Definition: one of a group of diseases in which normal adult hemoglobin A (HbA) is partly or completely replaced
by abnormal sickle hemoglobin (HbS)

2. Etiology: autosomal recessive disease; one in 12 African-Americans carries the trait, while one in 375 is affected
with sickle cell disease
469




3. Pathophysiology

a. trigger - RBC shape becomes sickled and clump

b. generalized microvascular occlusion, called vaso-occlusive crisis


4. Findings in vaso-occlusive crisis

a. result from

i. obstruction caused by sickled red blood cells (RBC)

ii. RBC destruction



b. hypoxia


c. organ dysfunction (spleen, liver, kidney) due to ischemia and infarction

d. characterized by painful exacerbations called crises:

vaso-occlusive - painful distal ischemic usually hands and feet

sequestration crisis - pooling of blood in liver and spleen

aplastic crisis - diminished RBC production

hyperhemolytic crisis increased destruction of RBC



5. Diagnostics

a. newborn screening

b. electrophoresis (hemoglobin)



6. Therapeutic management

a. goals are to prevent sickling phenomenon and treat medical emergency sickle cell crisis

b. hydration


c. oxygen


d. pharmacologic

i. analgesics (narcotics during sickle cell crisis)

ii. antibiotics (prophylaxis with penicillin recommended)

iii. folic acid


iv. high dose IV steroids


v. blood and/or exchange transfusions

vi. vaccines, annual influenza immunization



7. Nursing care

i. encourage fluids


ii. accurate I & O


iii. medicate for discomfort as ordered

iv. reinforce teaching for patient and family

how to avoid triggers for sickle cell crisis

findings of infection

increase fluid intake especially in hot weather



8. Concern: sickle cell crisis

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J. B-Thalassemia

1. Definition: inherited blood disorder characterized by deficiencies in rate of production of specific globin chains in
hemoglobin


2. Etiology: autosomal recessive disorder, also known as Cooley's anemia; more often found in persons of a
Mediterranean descent


3. Pathophysiology: abnormal, chronic production and destruction of RBCs resulting in insufficient amounts of
normal circulating hemoglobin


4. Findings

i. severe anemia, pallor

ii. microcytic RBCs

iii. impaired growth

iv. splenomegaly



5. Diagnostics

a. hemoglobin and hematocrit

b. x-rays of involved bones

c. hemoglobin electrophoresis


6. Management

a. splenectomy with prophylactic antibiotics

b. iron chelating agent to counteract hemosiderosis

c. chronic transfusion therapy to maintain hemoglobin of 10 gm/dL

d. referral for genetic counseling or bone marrow transplantation




K. Bleeding disorders

1. Idiopathic thrombocytopenic purpura (ITP)

a. etiology

i. unknown


ii. often occurs one to three weeks after a febrile, viral illness


b. pathophysiology

i. autoimmune disorder


ii. platelets are killed and fewer are made

iii. may be acute and self-limiting; or chronic


c. findings: excessive bruising, petechiae, internal bleeding

d. diagnostics

a. laboratory: platelet count, bleeding time

b. bone marrow aspiration


471


e. management

a. pharmacologic

i. corticosteroids


ii. intravenous immunoglobulins (IVIG)

iii. immunosuppression



b. immunoabsorption apheresis (to filter antibodies from bloodstream)

c. splenectomy for chronic disease


f. Nursing Care

a. monitor for bleeding episodes

b. provide for age appropriate diversional activities

c. reinforce teaching points

i. should not participate in contact sports

ii. should not use aspirin; use acetaminophen (Tylenol) to relieve pain






2. Von Willebrand's disease

a. definition: the clotting protein (called von Willebrand factor) is deficient or defective, affecting both males and
females


b. etiology: the most common congenital (autosomal dominant) bleeding disorder


c. pathophysiology: the body makes too little von Willebrand's factor and factor VIII


d. findings: easy bruising, nosebleeds, heavy menstrual periods, prolonged bleeding times, epistaxis (nosebleed),
blood in stool or urine


e. management

i. usually does not require treatment if findings are mild

ii. avoiding certain medications, including blood-thinning medications, e.g., aspirin and some NSAIDs, clopidogrel
(Plavix), warfarin (Coumadin), and heparin as well as some antidepressants, e.g. citalopram (Celexa),
escitalopram (Lesapro), fluoxetine (Prozac), or sertraline (Zoloft)

iii. replacement of missing clotting factor and/or administration of antidiuretic desmopressin acetate (DDAVP)
following surgery, tooth extraction, or an accident




3. Aplastic anemia

a. definition: a rare condition that occurs when the body stops producing enough new blood cells

b. etiology

i. congenital, e.g., Faconi's anemia

ii. acquired due to exposure to overwhelming infection, e.g., hepatitis, HPV

iii. causative agents such as antineoplastic agents, chemicals, chloramphenicol


c. pathophysiology

i. bone marrow stops making erythrocytes, leukocytes, and platelets.

ii. result:pancytopenia



d. findings: petechiae, bruising, pallor, fatigue, myelosuppression

472

e. diagnostics : bone marrow aspiration


f. management

i. pharmacologic: corticosteroids (to stimulate granulocyte production), antibiotics (for infection), androgens (to
stimulate bone marrow)

ii. removal of causative agent

iii. bone marrow transplant

iv. blood transfusions

v. hemorrhagic precautions



4. Hemophilia

a. definition: group of bleeding disorders in which there is a deficiency of one of the factors necessary for
coagulation of blood

b. etiology: X-linked recessive disorder


c. pathophysiology: missing or defective Factor VIII or Factor IX blood components necessary for blood coagulation


d. findings

i. mild-severe prolonged bleeding; most often in muscles and joints (hemathrosis)

ii. long-term loss of range of motion of affected joints



e. diagnostics

i. history of bleeding episodes

ii. partial thromboplastin time (PTT)

iii. assay procedures for specific factor deficiencies



f. management

i. replacement of missing clotting factor, factor VIII concentrate

ii. desmopressin acetate (DDAVP) - an anitdiuretic that aids blood clotting

iii. prophylactic treatment with clotting factor before surgery and some other procedures

iv. pressure to bleeding site, and ice, rest, elevation, immobilization


g. nursing care

i. prevent bleeding with by avoiding contact sports, falls, other activities that may cause trauma

ii. brushing teeth with soft toothbrush

iii. recognize and control bleeding

iv. support family


v. assess school activities

vi. teaching points

child should wear MedicAlert identification

genetic counseling for parents



473



5. Disseminated intravascular coagulation (DIC)

a. definition: disorder of coagulation characterized by clotting followed by bleeding

b. etiology

i. secondary disorder of coagulation that complicates other disorders

ii. triggered by endothelial damage such as trauma, shock, infections, hypoxia, liver disease



c. pathophysiology

i. the first stage of the coagulation process is abnormally stimulated

ii. clotting mechanism is triggered in circulation, thrombin is generated in greater amounts than the body can
neutralize


iii. rapid conversion of fibrinogen to fibrin with aggregation and destruction of platelets

iv. local and widespread fibrin deposition in blood vessels causes obstruction and necrosis

v. fibrinolytic mechanism causes extensive destruction of clotting factors resulting in increase risk of bleeding



d. findings

i. bleeding, bruising, petechiae

ii. altered serum levels of clotting-related factors (increased PT, PTT, TT, decreased platelets, degraded
fibrinogen)


iii. clotting, hypoxemia, intracranial hemorrhage, progressive organ failure


e. diagnostics : prothrombin time (PT), partial thromboplastin time (PTT) and thrombin time, platelets, fibrin
degradation products, fibrinogen, D-dimer


f. management

i. control of underlying etiology

ii. factor replacement

iii. platelets, fresh frozen plasma (FFP) and red blood cell transfusions

iv. vitamin K


v. oxygen



g. nursing care

i. monitor IV infusions

ii. monitor any severely ill person for this disorder
















474


Points to Remember

Cardiovascular disease is the leading cause of death among Americans, and a primary, coexisting or potential issue for
most adult clients needing medical care.

Current research suggests that cardiovascular changes once consider age-related can now be attributed to lifestyle
and personal habits.

Older adults are less able to physically adapt to stressful physical and emotional conditions, because their hearts do
three things less quickly:

The myocardium contracts less easily

The left ventricle ejects blood less quickly

The heart is slower to conduct the impulse for a heartbeat


BP is an important indicator of cardiovascular status. Accurate BP measurements are essential to appropriate decision-
making and treatment. Keys to measure blood pressure correctly

Give client 5 to 10 minutes to rest before first check and 2 to 3 minutes between BP checks.

Ensure correct positioning for accuracy- arm supported at level of heart.

Measure BP in both arms or remeasure in a few minutes if significantly different from previous readings.

Take blood pressure and pulse while client is lying, sitting, and standing for orthostatic vital signs, watching for BP
drop with pulse rise (indicating fluid volume deficit/dehydration).


The amount of blood pumped from the heart to the body is called cardiac output.

When the atria contract, the atrioventricular (AV) valves (tricuspid and mitral valves) swing open, allowing the blood to
flow down into the ventricles. Any stenosis or insufficiency can lead to signs of heart failure.

Stenosis of valves primarily causes poor cardiac output, followed by fluid overload with worsening stenosis.

Insufficiency or regurgitation primarily causes fluid overload followed by poor cardiac output with worsening
insufficiency.


In all valvular disease, remember that blood backs up from the dysfunctional valve into the lungs if on the left, into the
peripheral venous system if on the right.

All cells in the heart are "automatic" in that they can produce the electrical stimulation for a heart beat and can become
the "pacemaker" for the heart. This is a terrific back up system for the organ responsible for life. However, when
automatic cells take over for the primary conduction system, arrhythmias occur and this may be a problem when they
are too fast or slow, or cause the heart to contract abnormally.

The SA node is the primary pacemaker of the heart, generating "sinus" rhythms.

If the SA node fails to generate an impulse, the AV node takes over at a slower rate.

If the AV node fails, the Bundle of His takes over at an even slower rate.

If the Bundle of His fails, the Purkinje fibers take over at an even slower rate.









475


Points to Remember 2

For all arrhythmias, determine the priority of action based on the patient, not the monitor.

Do the basic life support ABCDs first.

Next, if the client is symptomatic with the arrhythmia (decreased level of consciousness, chest discomfort, dyspnea)
EMERGENCY CARE is needed to prevent cardiac arrest.

If the client is asymptomatic, determine priority based on the risk of cardiovascular instability associated with the
rhythm.


Angina and myocardial infarction are experienced in different ways by different people, particularly those who are very
old, diabetic or women.

Many experiencing typical symptoms of MI or angina may not perceive it as pain, but as a pressure or discomfort.

It is important to use several different descriptors when asking clients about their cardiac symptoms.


Any cardiac symptom suggesting ischemia or infarction requires immediate intervention to assess and treat the cause
and restore blood flow. The goal is to reduce pain level to zero as fast as possible - remember "time is muscle".

Angina and intermittent claudication are both supply/demand imbalances caused by narrowed arteries preventing
adequate tissue perfusion and oxygenation of muscle.

Angina is in the heart, claudication is in the legs.

In both cases, pain at rest indicates severe occlusion and necessitates immediate medical attention.


Many clients with angina or who have experienced a heart attack benefit from a structured cardiac rehabilitation
program.

Because different enzymes are released into the blood at varying periods after a myocardial infarction, it is important to
evaluate enzyme levels in relation to the onset of the physical symptoms, especially chest discomfort.

Clients who are in postoperative recovery, on bed rest, obese, taking hormonal contraceptives or had knee or hip
surgery should be monitored closely for the development of thrombophlebitis.

For a child with altered platelet function or bleeding disorder, do not administer acetylsalicylic acid (aspirin, ASA) or
take rectal temperatures and perform invasive procedures very cautiously.

Children with low WBC may not exhibit common findings of infection, such as purulent drainage. In a febrile client with
granulocytopenia, give antibiotics immediately because this child risks developing rapid and overwhelming sepsis.

Morphine is the pain medication of choice for pain in children with sickle cell disease.

476



I. Respiratory Anatomy & Physiology

A. General Respiratory Anatomy and Physiology

1. The respiratory system is comprised of the upper airway and lower airway structures

2. The upper respiratory system filters, moistens and warms air during inspiration

3. The lower respiratory system is the site of gas exchange, regulating the body's oxygen (PaO2) and carbon
dioxide (PaCO2) levels and acid-base (pH) balance

4. Gas-exchange in the respiratory system occurs in the alveoli and pulmonary capillaries


B. Physiology of Breathing

1. Inspiration: an active process

a. contraction of the intercostal muscles and diaphragm expands the chest

b. intrathoracic pressure decreases, drawing oxygenated air through the upper airway into the lungs


2. Expiration: a passive process

a. relaxation of the intercostal muscles increases intrathoracic pressure

b. carbon dioxide, a waste product of metabolism, is exhaled from the lungs through the upper airway


3. Gas exchange of oxygen and carbon dioxide occurs through diffusion across the alveolar-capillary membrane

4. Neural control of breathing

a. occurs through chemoreceptors in the medulla

b. stimulated by the concentration of hydrogen ions in the blood

c. increased hydrogen levels (acidosis) stimulate increased respiratory rate and volume - "blows off" acid
(CO2)


5. Chemical control of breathing

a. occurs through chemoreceptors in the carotid arteries and aortic arch

b. decreased blood pH and oxygen levels and increased carbon dioxide levels stimulate the respiratory
center in the medulla




6. Acid-base balance - serum pH of 7.4 is necessary for optimal health

a. respiratory system - maintains pH balance through the regulation of CO2 (an acid) by adjusting ventilation rate
and depth and this results in rapid restoration of pH balance

a. correction of respiratory acid-base imbalance

b. compensation in metabolic causes of acid-base imbalance


b. the renal system also maintains a normal pH through the regulation of bicarbonate or HCO3 (a base) ion
excretion and this results in a slower correction of pH imbalance

i. correction of metabolic causes of acid-base imbalance

ii. compensation for respiratory causes of acid-base imbalance.


c. lab normals

i. pH (partial pressure of hydrogen in blood) = 7.35 - 7.45

ii. PaCO2 (partial pressure of carbon dioxide in arterial blood) = 35 - 45 mm Hg (note: these numbers may vary
slightly depending on the resource used)

iii. HCO3 (bicarbonate level) = 22 - 26 mEq/L


d. acid-base lab interpretation
477

pH HCO3 PaCO2 Secondary Response
respiratory acidosis* (< 7.35) (> 26) (> 45) increased renal acid excretion
respiratory alkalosis (> 7.45) (< 22) (< 35) decreased renal acid excretion
metabolic acidosis (< 7.35) (< 22) (< 35) hyperventilate
metabolic alkalosis (> 7.45) (> 26) (> 45) hypoventilate


Remember Acid-Base lab interpretation using - R.O.M.E.
R=Respiratory
O=Opposite
M=Metabolic
E=Equal


C. Upper respiratory structures

1. Nose and sinuses


a. filters, warms and humidifies air

b. first defense against foreign particles

c. inhalation for deep breathing usually occurs through the nose

d. exhalation usually occurs through the mouth


2. Pharynx

a. behind oral and nasal cavities

b. nasopharynx

i. behind nose

ii. soft palate, adenoids and eustachian tube


c. oropharynx

i. from soft palate to base of tongue

ii. palatine tonsils


d. laryngopharynx

i. base of tongue to esophagus

ii. where food and fluids are separated from air

iii. bifurcation of larynx and esophagus



3. Larynx

a. between trachea and pharynx

b. commonly called the voice box
478


c. vocal cords - responsible for voice, airway protection and control of airflow through trachea

d. glottis - opening between vocal cords

e. epiglottis - covers airway during swallowing, protecting against aspiration

f. thyroid cartilage - Adam's apple

g. cricoid cartilage

i. contains vocal cords

ii. the only complete ring in the airway





D. Lower respiratory and other structures

1. Trachea

a. anterior neck in front of esophagus

b. carries air to lungs


2. Mainstem bronchi

a. right and left

b. older adults - right middle lobe is most likely to receive aspirate in people with swallowing difficulty


3. Conducting airways

a. lobar bronchi

i. surrounded by blood vessels, lymphatics, and nerves lined with ciliated, columnar epithelial cells


ii. cilia move mucus or foreign substances up to larger airways


b. bronchioles

i. no cartilage; collapse more easily

ii. no cilia

iii. do not participate in gas exchange




4. Alveolar ducts and alveoli

479


a. lungs contain approximately 300 million alveoli

b. alveoli surrounded by capillary network

c. gas exchange happens at alveolar-capillary membrane (blood takes in O
2
, gives off CO
2
)

d. alveoli are held open by surfactant which decreases surface tension to minimize alveolar collapse


5. Accessory muscles of respiration - use indicates additional effort needed to breathe

a. scalene muscles - elevate first two ribs

b. sternocleidomastoid - raises sternum

c. trapezius and pectoralis - stabilize shoulders

d. abdominal muscles - puts power into cough and used most often with chronic respiratory problems and acute
severe respiratory distress

e. In infants - nasal flaring, sternal or intercostal retractions, grunting Listen

f. older adults - respiratory changes with age include

stiffening and reduced function of respiratory structures

reduced capacity of respiratory defense mechanisms

less effective respiratory control




II. Upper Respiratory System Disorders

A. Rhinitis

1. Definition: inflammation of the mucous membrane of the nose marked especially by rhinorrhea, nasal
congestion and itching, and sneezing

2. Etiology

a. allergic (often called "hay fever") - caused by a exposure to various factors including environmental
allergens i.e. dust, mold, dander, pollen

b. infectious - caused by cold viruses, bacterial infections


3. Findings

a. excessive nasal drainage and congestion, postnasal drip with sore throat

b. allergic causes: nasal itchiness and sneezing, watery eyes

c. viral causes (common cold): sore throat, general malaise, fever, chills, headache

d. bacterial causes: purulent nasal discharge, fever.


4. Diagnostics: history of findings, type and color of drainage

5. Management

a. identify the cause

b. relieve findings using antihistamines, decongestants, NSAIDs if headache

c. bacterial causes: anti-infectives

d. allergic causes: reduction of exposure to allergic causes and desensitization immunizations or treatments

e. viral or bacterial causes:

i. encourage more fluids

ii. rest

iii. salt water gargles, vitamin C, zinc



6. Nursing care

a. administer prescribed medications for relief
480


b. reinforce client teaching

i. environmental reduction of allergens

ii. specific medication instructions

iii. hand washing to avoid the spread of the common cold






B. Sinusitis

1. Definition: inflammation of one or more of the paranasal sinuses


2. Etiology

a. viral or bacterial upper respiratory infection

b. tooth infection

c. allergic rhinitis

d. sniffing aerosols/powders

e. structural defects of the nose

f. underwater swimming


3. Findings

a. frontal headache

b. tenderness over the affected sinus(es), especially when palpated or percussed

c. purulent nasal drainage and congestion

d. nasal obstruction

e. fever

f. malaise

g. tooth pain



4. Diagnostics : x-ray or CT shows fluid in sinuses and mucous membrane swelling

5. Management

a. pharmacologic

i. nasal saline

ii. decongestants

iii. nasal corticosteroids

iv. mucolytics

v. antihistamines

vi. antibiotics

vii. antipyretics

viii. analgesics

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b. surgery to drain and open sinuses

c. antral irrigation (sinus irrigation)

d. functional endoscopic sinus surgery


6. Nursing care

a. reinforce teaching regarding avoiding allergens that may precipitate sinusitis

b. administer prescribed medications

c. encourage fluid intake (non-carbonated, non-alcoholic) of at least six to eight glasses, eight ounces, daily

d. nasal cleaning techniques: hot showers, steam inhalation or nasal irrigation with saline spray followed by nose
blowing

e. nasal irrigation PRN



C. Upper airway obstruction - partial or complete

1. This is a MEDICAL EMERGENCY!

2. Etiology

a. aspiration of food or foreign body

b. laryngeal edema secondary to anaphylactic allergic response

c. trauma


3. Findings

a. stridor (harsh, vibrating sound during inspiration) Listen

b. inability to talk with complete obstruction

c. restlessness

d. accessory muscle use

e. both hands of client around the throat

f. tachycardia

g. skin color changes, i.e. pallor, cyanosis

h. in children, prolonged hypoxemia results in cardiac arrest secondary to inadequate ventilation, oxygen or
circulation


4. Diagnostics: observations at time of occurrence

5. Management: emergency treatment

a. airway clearance techniques

i. conscious victim

infants (less than 1 year): back blows and chest thrusts

younger children: modified Heimlich maneuver ("astride")

older children & adults: Heimlich maneuver

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ii. unconscious victim - begin CPR


b. endotracheal intubation

c. cricothyrotomy (cut cricoid cartilage)

d. tracheotomy/tracheostomy


6. Nursing care: basic life support guidelines for obstructed airway



D. Pharyngitis

1. Definition: inflammation of mucous membranes of pharynx

2. Etiology: viral, bacterial or fungal infections

beta-hemolytic strep accounts for 5-15% of cases and untreated may result in rheumatic heart disease or
glomerulonephritis


3. Findings

a. scratchy throat

b. throat pain, often severe, worsened by swallowing

c. pharynx can appear red and edematous with or without patchy white or yellow exudates


4. Diagnostics: throat cultures and/or rapid strep antigen test

5. Management

a. pharmacologic

i. antimicrobial therapy - penicillins for strep throat (erythromycin if allergic to penicillin)

ii. antifungal therapy such as nystatin for fungal causes

iii. analgesics such as ibuprofen or topical anesthetic sprays or lozenges


b. symptomatic relief

c. prevent secondary complications


6. Nursing care

a. administer prescribed medications

b. encourage increased fluid intake of cool, bland liquids and gelatin; avoid citrus juices and carbonated
beverages

c. reinforce importance of taking all of prescribed antimicrobials to avoid complications of strep infection




E. Tonsillitis and Adenoiditis

1. Definition: inflammation and infection of the tonsils and especially the palatine tonsils

2. Etiology: acute form is usually bacterial; typically viral in association with pharyngitis

3. Findings
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a. sore throat - may be recurrent

b. fever

c. difficulty swallowing

d. enlarged tonsils and adenoids - may be "kissing tonsils" where they are touching

e. foul smelling breath (halitosis)

f. noisy respirations - snoring loudly during sleep if enlarged adenoids

g. recurrent ear infections


4. Diagnostics - positive throat cultures for causative microbes

5. Management

a. anti-infectives, antipyretics, analgesics

b. fluids and rest

c. tonsillectomy and/or adenoidectomy if indicated (recurrent infections)


6. Nursing care

a. administer medication as prescribed

b. provide postoperative care after tonsillectomy/adenoidectomy

i. observe for postoperative complications (hemorrhage, airway obstruction)

ii. provide positioning that allows for comfort and drainage of mouth and pharynx (prone, head turned to
the side)

iii. maintain ice collar for comfort

iv. reinforce client and family education regarding:

findings of hemorrhage - frequent swallowing

use of prescribed mouthwashes and pain medications

semi-liquid diet 48 to 72 hours postoperative






F. Peritonsillar abscess

1. Definition: complication of acute tonsillitis or pharyngitis with spread of tonsillar infection into the surrounding
tissue

2. Etiology: untreated bacterial tonsillar infection

3. Findings

a. inability to swallow saliva with drooling

b. marked tonsillar enlargement, possibly threatening airway

c. "hot potato" or muffled voice

d. high fever and chills

e. increased white blood cell count

f. facial swelling



4. Management

a. intravenous antibiotics

b. drainage of abscess

c. possible emergency tonsillectomy

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5. Nursing care

a. monitor airway patency and resolution of infection

b. administer prescribed medications


Complementary and Alternative Medicine

Herbal remedies for upper respiratory infections

Echinacea (dried root or tea)

Garlic cloves

Horseradish

Slippery elm tea

Alternate systems of care for upper respiratory infections

Ayurveda

Acupuncture

Cupping

Traditional Chinese medicine


G. Vocal cord disorders

1. Laryngitis

a. definition: inflammation of vocal cords and surrounding mucous membranes

b. etiology

i. irritation of the larynx due to chemical, mechanical, infectious or allergic causes

ii. common with upper respiratory infections

iii.
croup and epiglottitis are types of laryngeal inflammation that can lead to airway obstruction
requiring emergency treatment


c. findings

i. hoarse voice

ii. swollen lymph nodes in neck (cervical lymphadenopathy)

iii. fever

iv. larynx blocked by edema, spasm or both


d. management

i. rest voice

ii. treat findings

iii. gargle with warm salt water

iv. remove irritants

v. cool or moist air may bring relief, steamy bathroom, outside in the cool night air, cool air vaporizer



2. Vocal cord paralysis

a. etiology

i. injury, trauma or disease of larynx, laryngeal nerves or vagus nerve

ii. may result as a complication after thyroidectomy surgery or endotracheal intubation

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b. damage to both laryngeal nerves may lead to airway obstruction - emergency treatment needed!

c. findings: hoarse voice, difficulty swallowing

d. diagnostics: laryngoscopy shows abnormal vocal cord movement.

e. management

i. swallowing evaluation to assess for aspiration

ii. voice therapy

iii. surgical treatment - to improve the voice by changing the position of the paralyzed vocal cord





III. Disorders of Lower Respiratory System - Obstructive

A. Chronic obstructive pulmonary disease (COPD)

1. Definition: chronic irreversible airway obstruction with slowed exhalation

a. emphysema - walls of alveoli enlarge and lose elasticity, trapping air and decreasing capacity for vital gas
exchange


b. chronic bronchitis - chronic inflammatory response in the bronchioles of the lung

c. cor pulmonale, with right heart failure, is a late complication of COPD-related pulmonary hypertension


2. Etiology

a. primary cause of COPD - environmental, due to smoking tobacco

b. 3% of emphysema cases - genetic (due to alpha-1 antitrypsin deficiency), occur without tobacco
exposure


3. Findings

a. cough

b. sputum production, purulent with acute infection

c. dyspnea on exertion - may occur with minimal activity or at rest in advanced stages and with acute
exacerbation

d. use of accessory muscles of breathing, particularly with severe COPD or respiratory distress

e. restlessness with respiratory difficulty or distress

f. anxiety

g. barrel chest (increased anterior-posterior diameter)

h. weight loss if breathing difficulty interferes with eating


4. Diagnostics

a. spirometry and other pulmonary function tests

b. chest x-ray

c. sputum examination

d. arterial blood gases: increased PaCO2, decreased PaO2

e. low oxygen saturation levels with higher hematocrit



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5. Management

a.
reduction of risks - tobacco smoking cessation or reduction of exposure to tobacco smoke and other inhaled
environmental irritants


b. pharmacologic treatments

i. inhaled bronchodilators - albuterol (beta-adrenergic), ipratropium (anticholinergic)

ii. inhaled or oral corticosteroids - prednisone (IV during exacerbations), methylprednisolone (Medrol)

iii. expectorants - guaifenesin


c. supplemental oxygen therapy - oxygen is titrated to lowest dose needed to maintain oxygen saturation around
90% with rest, exercise, and sleep

d. pulmonary rehabilitation exercise program

e. airway clearance techniques - effective coughing, chest physiotherapy, postural drainage, vibration

f. surgery - lung volume reduction surgery for emphysema


6. Nursing care

a. reinforce client and family teaching

i. diaphragmatic breathing

ii. pursed-lip breathing

iii. inspiratory muscle training

iv. controlled coughing

v. pacing of daily activities

vi. physical conditioning

vii. small frequent meals with nutritional supplements

viii. avoid temperature and humidity extremes, air pollution, and high altitudes


b. check oxygen saturation at rest and with activity

c. monitor for complications of COPD

i. respiratory insufficiency

ii. respiratory failure

iii. dysrhythmias

iv. pulmonary infections

v. cor pulmonale




B. Asthma

1. Definition: a chronic lung disorder marked by recurrent episodes of bronchospasm-related airway obstruction
triggered by hyperreactivity to various stimuli, producing airway narrowing and tenacious, thick, excess, mucous


a. characterized by remissions and exacerbations
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b. exacerbations - more prevalent during particular seasons, especially with extrinsic and infectious etiologies,
i.e., ragweed season, cold or flu season

c. one of the most common chronic pediatric health problems


2. Etiology

a. extrinsic: asthma associated with inflammation and reactivity in response to a specific environmental
exposure

i. cold air

ii. humidity

iii. allergens such as pollens, molds, dust mites, animal dander

iv. drugs: aspirin & NSAIDs


b. intrinsic: asthmatic inflammation and reactivity in response to physical stimuli

i. respiratory infection

ii. exercise

iii. gastroesophageal reflux-related aspiration

iv. stress





3. Findings

a. with asthma exacerbation

i. (expiratory) wheezing , often audible - wheezing may decease or stop with worsening bronchoconstriction as
airflow becomes severely limited Listen

ii. shortness of breath

iii. cough with sputum production

iv. normal or low oxygen saturation

v. chest tightness

vi. tachycardia

vii. use of accessory respiratory muscles with respiratory distress

viii. high normal PaCO2 and low normal PaO2


b. findings with exposure to trigger

i. shortness of breath

ii. coughing

iii. chest tightness

iv. wheezing with bronchospasm



4. Diagnostics

a. acute phase

i. physical examination and history

ii. serum studies - arterial blood gases

iii. chest x-ray: hyperinflation, flattening of diaphragm

iv. pulmonary function tests: decreased FEV1, prolonged expiratory phase, reduced peak expiratory flow rate


b. chronic phase

i. peak expiratory flow rate monitoring to guide therapy and identify when to seek care.
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ii. allergy testing: skin prick or serum RAST testing, IgE to identify allergic triggers

iii. pulmonary function tests: bronchial reactivity challenge testing with methacholine or specific antigen to
identify severity of airway reactivity

iv. bronchoscopy


c. complications in acute or remission phases

i. hypoxemia - low PaO2

ii. hypercapnia - high PaCO2

iii. recurrence of other respiratory infections

iv. respiratory failure

v. absence of wheezing may be an indication of absence of airflow - emergency respiratory care is needed with
possible intubation



5. Management

a. pharmacologic therapy

i. long-acting control medications

inhaled corticosteroids (ICS) - fluticasone, beclomethasone

long-acting beta agonists (LABA) - salmeterol

leukotriene antagonist - montelukast

anticholinergic inhaler - tiotropium

mast cell stabilizers - cromolyn sodium inhaler


ii. short-acting "rescue" medications

short-acting beta agonists (SABA) as needed - albuterol inhaler or nebulizer

exacerbation: oral (prednisone) or intravenous corticosteroids (methylprednisolone) with tapering dose as
exacerbation resolves



b. peak flow monitoring


c. oxygen for acute management

d. anti-allergy therapy (immunotherapy)


6. Nursing care

a. monitor client's respiratory status (respiratory effort, rate, lung sounds, pulse oximetry)

b. observe for subtle findings of hypoxia (restlessness, other changes in level of consciousness)

c. administer medications as prescribed

d. reinforce client and family teaching

i. use of medications - expected effects, side effects, routine, when to notify health care provider

ii. avoidance of triggers that cause asthmatic episodes

iii. asthma action plan about how to respond to changes in asthma and in emergency situations



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IV. Lower Respiratory System Disorders - Restrictive

A. Interstitial lung disorders

1. Definition: irritants, e.g., toxic drugs, radiation, and industrial substances, cause damaging inflammation of
the alveoli and interstitial tissue of the lungs; as a result, the lungs become scarred, stiff, and non-compliant

2. Common restrictive lung disorders

a. silicosis

b. asbestos

c. black lung disease - also called pneumoconiosis

d. hypersensitive pneumonitis

e. sarcoidosis

f. idiopathic pulmonary fibrosis


3. Findings

a. difficulty inhaling

b. evidences of hypoxia

c. (chronic) cough

d. hemoptysis

e. fatigue

f. anorexia

g. weight loss




4. Diagnostics

a. chest x-ray

b. CT scan

c. biopsy of lung

d. MRI

e. pulmonary function test

f. flexible bronchoscopy with transbronchial lung biopsy


5. Management

a. avoidance of irritants

b. oxygen therapy

c. symptom relief with antitussives, bronchodilators, corticosteroids

d. surgery: lung transplantation


6. Nursing interventions

a. prevent infections

b. pace client's activities to reduce oxygen demands and dyspnea

c. plan for small, frequent meals

d. encourage client to have daily activity within pulmonary tolerance

e. monitor for depression associated with disease and refer as indicated

f. refer client to programs for quitting smoking if indicated



B. Disorders in which lung tissue collapses
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1. Definition: any number of disorders in which the pleural space is abnormally occupied by air or fluid, resulting in
reduced lung capacity


2. Etiology of disorders in which lung tissue collapses

a. pneumothorax: air in the pleural space, causing lung collapse

i. open pneumothorax: air enters the pleural space through a hole in the chest wall, e.g., gunshot wound

ii. closed pneumothorax: air enters the pleural space through a hole in the lung tissue. i.e., after lung
resection

iii. tension pneumothorax: closed pneumothorax with rapid accumulation of air in pleural space, increasing
pressure

high pressure causes mediastinal and tracheal shift away from the affected side, compressing the heart
and preventing adequate cardiac output

results in cardiac tamponade (and possibly pulseless electrical activity) - emergency situation!


iv. all types of pneumothorax - treated with chest tube insertion


b. pleural effusion: fluid (transudate or exudate) in the pleural space; treated with thoracentesis or chest tube

c. hemothorax: blood in pleural space; treated with thoracentesis or chest tube

d. empyema: purulent drainage in pleural space; usually a complication of pneumonia, treated with chest tube
and antibiotics

e. chylothorax: milky white lymphatic fluid in pleural space, treated with thoracentesis or chest tube,
pleurodesis or surgery



3. Findings: worsening respiratory distress

a. asymmetrical chest movement

b. progressive dyspnea

c. diminished or absent lung sounds on affected side

d. low oxygen saturation levels

e. fatigue and activity intolerance

f. tachycardia

g. restlessness, anxiousness

h. chest pain

i. progressive cyanosis


4. Diagnostics

chest x-ray that supports diagnosis

white blood cell count - high in empyema

HCT/HGB - below baseline in hemothorax


5. Management

a. treatment of cause

b. placement of chest drainage device

c. thoracentesis with or without chest drainage device in pleural effusion or hemothorax

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6. Nursing care

a. position client for comfort and to promote ease of breathing

b. monitor respiratory status and effort

c. administer pain medications as ordered

d. maintain/monitor chest tube and closed chest drainage system



C. Neuromuscular diseases that affect breathing

1. GuillainBarr syndrome (see also Lesson 8 C: Neurological - Degenerative Disorders)

a. definition: a group of autoimmune peripheral neuropathies resulting in symmetric and ascending motor
paralysis; an acute condition; potentially fatal if respiratory muscles are affected.

b. etiology: unknown; often follows stimulation of immune system such as after an infection, surgery, trauma,
viral immunization or HIV.

progressive phase of the syndrome lasts from a few days to four weeks

plateau phase

resolution of findings varies


c. findings

i. typically begins with weakness accompanied by tingling sensation in the extremities

ii. ascending paralysis begins in the lower extremities and may affect the entire body

iii. autonomic nervous system involvement may include fluctuations in blood pressure and dysrhythmias,
usually with severe disease

iv. pain - hyperesthesias, paresthesias, muscle aches and cramps

v. when the weakness/paralysis reaches the respiratory muscles the client is unable to maintain an
adequate respiratory effort


d. diagnostics: EMG shows abnormal nerve conduction

e. management

i. supportive care including mechanical ventilation if indicated during acute phase

ii. plasmapheresis or intravenous immunoglobulin





2. Myasthenia gravis (see also Lesson 8 C: Neurological - Degenerative Disorders)

a. definition: autoimmune disorder with fluctuating weakness of skeletal muscle

b. etiology: antibodies attack acetylcholine receptors in the neuromuscular junction

c. findings

i. skeletal muscle weakness with a pattern of fluctuation, and improved strength after rest

ii. muscles most commonly involved are facial muscles including those responsible for chewing and swallowing
and speech - risk for aspiration

iii. proximal muscle weakness in neck, shoulders and hips

iv. exacerbations can be caused by stress, temperature extremes, pregnancy, certain drugs

v. myasthenic crisis can cause respiratory failure and need for emergent care


d. diagnostics

i. EMG

ii. anticholinesterase (Tensilon) test - improved muscle contractility following administration (note: atropine
should be available for emergency use during this test)

492


e. management

i. pharmacologic: anticholinesterases and cholinesterase inhibitors

pyridostigmine (Mestinon)

neostigmine (Prostigmin)

ambenonium (Mytelase)


ii. corticosteroids and other immunosuppressive agents

iii. plasmapheresis

iv. thymectomy (if thymus dysplasia exist)


f. nursing interventions

i. monitor neurologic and respiratory status for disease progression

ii. aspiration precautions if swallowing is affected

iii. schedule periods of rest between activities

iv. discuss potential triggers and reduction or avoidance techniques

v. educate about importance of adherence to medications to promote muscle strength and avoid complications




3. Poliomyelitis

a. definition: viral infection that can affect nerves and can lead to partial or full paralysis

b. etiology - virus spread by person-to-person contact, contact with infected mucus or phlegm from the nose or
mouth, contact with infected feces

c. findings

i. subclinical infection (95% of cases): ranging from no findings to malaise, headache, red throat, slight fever,
vomiting

ii. nonparalytic: back pain, diarrhea, fatigue, headache, irritability, leg pain, moderate fever, muscle stiffness,
neck pain and stiffness, rash

iii. paralytic: fever; abnormal sensations; bloated feeling in abdomen; difficulty breathing, constipation; muscle
pain, contraction or spasms; sensitivity to touch; stiff neck and back

iv. post-polio syndrome: a complication that develops in some people, usually 30 or more years after initial
infection

v. complications may include aspiration pneumonia, cor pulmonale, kidney stones, urinary tract infections,
shock


d. management

i. prevention - vaccination

ii. based on form of disease and findings




4. Amyotrophic lateral sclerosis (ALS; also called Lou Gehrig's Disease)
(see also Lesson 8 C: Neurological - Degenerative Disorders)

a. definition: a disease of the nerve cells in the brain and spinal cord that control voluntary muscle movement

b. etiology: loss of motor neurons responsible for supplying electrical stimulation to the muscles

i. genetic defect in 10% of cases; otherwise cause is unknown

ii. occurs in mid-life affecting men more often than women

iii. chronic, progressive, and irreversible


c. findings
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i. usually begins in upper extremities

ii. progressive neuromuscular weakness, spasticity, inability to communicate or move voluntarily, loss of
involuntary reflexes such as blinking and gag reflex

iii. autonomic, sensory and mental function unchanged

iv. leads to respiratory failure and death within 2 to 6 years


d. ethical issues

i. whether clients want mechanical ventilation or nutritional support

ii. they may want to die before the disease becomes severe


iii. importance of advanced care planning and hospice referral



5. Muscular dystrophies

a. progressive symmetrical wasting of voluntary muscles; no nerve effect

b. as thoracic muscles weaken, breathing becomes harder

c. eventually may not be able to swallow well; may aspirate and lose protective airway reflexes


6. Nursing care common to neuromuscular disorders affecting breathing

a. observe frequently for changes in respiratory status such as respiratory failure and infection

b. regularly check swallowing and client's ability to protect upper airway

c. discuss chances of mechanical ventilation and determine client wishes

d. assist with coughing and secretion clearance as indicated

e. prevent respiratory infection through reduction of risk and immunization (influenza & pneumococcal vaccines)

f. monitor for depression associated with disease, assist with needed referrals

g. administer medications specific to medical condition - strict adherence to schedule

h. assist/provide physical therapy as indicated

i. maintain/promote adequate nutrition



V. Disorders of Lower Respiratory System - Infectious

A. Pneumonia

1. Definition: a lung disease characterized by inflammation and consolidation of lung tissue followed by
resolution


may affect only a region of lung: lobar pneumonia, bronchopneumonia


2. Etiology

a. community-acquired: exposure to infectious organisms outside of hospital

b. hospital-acquired: secondary to infectious organism exposure (i.e. pseudomonas) or risk factors
associated with hospitalization or while in a healthcare facility such as skilled nursing; occurs 48 hours or
more after admission.
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c. aspiration: chemical irritation and inflammation associated with aspiration of food or stomach contents
or normal oral flora.

d. opportunistic: caused by microorganisms that are usually harmless but that can be pathogenic in
individuals with depressed immune function, such as Pneumocystis carinii, Cytomegalovirus, and
Legionnaire's disease

e. risk factors

i. preexisting pulmonary disease

ii. depressed immune function such as HIV, chemotherapy and other immunosuppressant drugs

iii. atelectasis secondary to surgery or immobility

iv. mechanical ventilation or artificial airway

v. advanced age, particularly with chronic illness, frailty

vi. decreased ability to protect airway, swallow safely or cough effectively





3. Findings

a. fever, chills, malaise

b. shortness of breath with decreased oxygen saturation

c. productive cough with purulent sputum

d. pleuritic chest pain

e. crackles in affected lobe(s), egophony, whispered pectoriloquy (indicating consolidation)

f. age-related findings

i. older adults - atypical presentation is common with acute confusion while other findings may be less evident

ii. in infants and young children, lethargy, crankiness and poor appetite may indicate an acute infection such as
pneumonia.



4. Diagnostics

a. chest x-ray

b. laboratory

i. sputum culture, sensitivity and microscopic analysis, Gram stain

ii. arterial blood gases (ABG), if indicated by clinical condition

iii. complete blood count - increased white blood cells



5. Management

a. pharmacologic

i. antimicrobials, depending on pathogen

ii. antipyretic/ analgesic

iii. expectorant


b. IV fluids to prevent dehydration

c. supplemental oxygen, as indicated; respiratory support as needed, may include mechanical ventilation in severe
cases


6. Nursing care

a. monitor respiratory and oxygenation status

b. administer prescribed medications and supplemental oxygen, checking oxygen saturation frequently.

c. monitor WBC levels
495


d. provide positioning that optimizes oxygenation and comfort

e. encourage fluid intake to liquefy secretions

f. space activities to avoid fatigue and hypoxia

g. reinforce teaching of effective coughing, completing course of antimicrobials.



B. Pulmonary tuberculosis (PTB)

1. Definition: a chronic infection caused by an acid-fast bacillus, generally transmitted by inhalation or ingestion of
infected droplets


2. Etiology

a. mycobacterium tuberculosis

b. bacilli lodge in alveoli

c. pulmonary infiltrates

d. can spread throughout body via blood

e. after initial treatment, may lie dormant for years and later reactivate

f. multi-drug resistant PTB is becoming more prevalent

g. TB incidence is rising with increasing homelessness, AIDS, elderly with poor nutrition

h. considered a communicable disease


3. Findings

a. early

i. weakness, fatigue

ii. anorexia, weight loss

iii. chest pain - pleurisy


b. late

i. productive cough with purulent sputum

ii. night sweats




4. Diagnostics

a. laboratory

i. culture for sputum and gastric contents - analysis for the presence of acid-fast bacilli

ii. interferon-gama release assay (IGRA) - blood test to measure immune system response


b. chest x-ray - for presence of active or calcified lesions ("coin" lesions)

c. Mantoux skin test

i. positive if > 10 mm induration in healthy persons (or positive if > 5 mm induration in clients who are
immunosuppressed) - additional tests are needed

ii. false-negative responses - common in people who are immunosuppressed; two-step Mantoux is used for this
496

population (and health care providers)

iii. false positives - may occur for those who have received the BCG vaccine (commonly administered outside
the U.S.)


d. diagnosis of TB requires all of the following: medical history, physical exam, TB skin test or blood test, chest x-
ray and sputum or other culture


5. Management

a. long-term combination antimicrobial therapy with isoniazid (INH) (Hyzyd) or rifampin (Rifadin), with ethambutol
HCL (Etibi) in some cases

b. bed rest until findings subside

c. surgical resection of involved lung if medication not effective

d. high carbohydrate, high protein diet - for energy and healing


6. Nursing care

a. with active infection

i. airborne precautions and client placed in negative airflow room in the hospital

ii. use NIOSH-approved N95 particulate filtering facepiece respirator when providing care; visitors can wear
surgical masks

iii. provide client with surgical mask if transport needed


b. reinforce client teaching

i. proper techniques to prevent spread of infection, including hand washing

ii. report findings of hemorrhage - bloody sputum

iii. not using over-the-counter medications without care provider's approval

iv. not to wear soft contact lenses if taking rifampin (can cause reddish-orange discoloration of saliva, sweat,
tears, urine, skin)

v. importance of taking medications as prescribed

vi. verify with health care provider if vitamin B6 (or B complex) needed (to minimize peripheral neuropathy
associated with antituberculars)





C. Lung abscess

1. Definition: localized collection of purulent fluid in the lung with cavity formation

2. Etiology: usually a complication of pneumonia, TB or aspiration

3. Management

a. broad-spectrum antimicrobial treatment after culture of fluid

b. percutaneous imaging or surgical resection - to drain abscess if the infection does not resolve with
pharmacologic treatment



D. Severe acute respiratory syndrome (SARS)

1. Definition: respiratory illness caused by the coronavirus (called SARS-associated coronavirus)

2. Etiology: infection is spread by close person-to-person contact by direct contact with infectious material
(respiratory secretions or contact with persons or objects infected with infectious droplets)

3. Findings

i. syndrome begins with a fever, overall feeling of discomfort, body aches, and mild respiratory symptoms; dry
cough and dyspnea may develop later

ii. last pandemic occurred in 2003

497


4. Diagnosis: laboratory confirmation of SARS-CoV infection

5. Management

i. hospitalization if radiographically confirmed pneumonia (or acute respiratory distress syndrome) of unknown
etiology

ii. droplet precautions

iii. report to Centers for Disease Control and Prevention (CDC)

iv. supportive care; no specific treatment has been shown to consistently improve the outcome of the ill
persons


6. Nursing care

i. assess temperature and monitor for signs of pneumonia

ii. reinforce client teaching to avoid contact with those suspected of having SARS and to avoid travel to
countries where an outbreak of SARS exists

iii. frequent hand hygiene; persons with suspected disease should wear mask to prevent transmission




VI. Lower Respiratory System Disorders - Miscellaneous

A. Pulmonary embolism

1. Definition: blood clot prevents blood from perfusing the "bed" of arteries that feed the lung, resulting in
pulmonary infarction and decreased cardiac output; emboli can also be composed of air or fat


2. Etiology

a. matter blocks blood from the "bed" of arteries that feed the lung so client is breathing but gases are not
exchanged

b. hypoxemia occurs

c. can be mild or immediately fatal, based on the size and location of matter

d. symptoms develop over a period of minutes and require emergency treatment!

e. types of embolus

i. blood clot - has usually traveled from deep veins in the leg or pelvis

ii. fat - from fractured femur, hip

iii. amniotic fluid - postdelivery

iv. air- from injection of large air bolus through IV or arterial line


f. primary cause is prolonged immobility

g. poor hydration and conditions that impair circulation (atrial fibrillation, heart failure) contribute to clot
development

h. with fat embolism, findings occur about 24 hours after the initial fracture




3. Findings
498


a. abrupt onset of dyspnea - classic finding

b. anxiety, apprehension - feeling of "impending doom"

c. cough - productive or nonproductive

d. tachycardia, tachypnea, low oxygen saturation

e. diaphoresis

f. cyanosis


4. Diagnostics

a. chest CT with contrast (spiral CT)

b. D-dimer - elevated

c. ventilation/perfusion (V/P) scan (also called V/Q scan)

d. arterial blood gases - low PaO2, high PaCO2

e. EKG


5. Management

a. prevention is best treatment - preventive anticoagulants with orthopedic surgeries and when bed-bound

b. oxygen titrated to correct hypoxemia - may need mask or high-flow oxygen

c. pharmacologic

i. anticoagulation - heparin IV or low molecular weight heparin for acute PE; warfarin (Coumadin) chronically to
reduce risk of recurrence

ii. thrombolytics (for large emboli)

iii. pain and anxiety


d. filter surgically placed in vena cava for long term prevention


6. Nursing care

a. watch for changes in respiratory and cardiovascular status

b. administer oxygen and medications as ordered

c. reinforce client teaching regarding anticoagulation usage

d. early ambulation and compression stocking use for immobility



B. Acute respiratory distress syndrome (ARDS); called acute lung injury (ALI) in early stages.

1. Definition: associated with pulmonary injury and characterized by noncardiogenic pulmonary hypoxemia, and
severe respiratory distress

2. Etiology

a. alveolar capillary membrane becomes more permeable to fluids

b. increased extravascular lung fluid

c. pulmonary compliance decreases

d. intrapulmonary shunt increases

e. refractory hypoxemia

f. usually seen after lung injury or massive multi-system organ disease


3. Findings

a. restlessness, anxiety- ill appearance

b. dyspnea, progressing to respiratory distress and failure requiring emergency care!
499


c. tachycardia

d. cyanosis

e. intercostal retractions, accessory muscle use

f. refractory hypoxemia - does not respond to oxygen therapy

g. lung sounds are clear early, later crackles heard throughout Listen

h. interstitial fibrosis develops in some patients who survive ARDS


4. Diagnostics

a. arterial blood gases - hypoxemia despite increasing inspired oxygen level

b. chest x-ray - diffuse infiltrates

c. early respiratory alkalosis; later respiratory acidosis


5. Management

a. optimize oxygenation to maintain saturation > 88% and to correct respiratory acidosis

i. mechanical ventilation

ii. sedation may be required

iii. paralytic agents may be necessary


b. corticosteroids

c. manage primary problem


6. Nursing care

a. plan for frequent client rest periods

b. monitor oxygenation status, arterial blood gases, level of consciousness, central of anxiety

c. observe for changes in vital signs and behavior (confusion and hypertension may indicate cerebral hypoxia)




C. Cor pulmonale

1. Definition

a. right heart failure that develops due to sustained lung resistance in chronic lung disease (i.e. COPD)



2. Etiology

a. increased PVR results from lung disease, particularly chronic hypoxemia

b. hypoxemia constricts pulmonary vascular bed, so increases resistance the right ventricle must pump against

c. often seen with primary pulmonary hypertension


3. Findings

a. fatigue, tachypnea, exertional dyspnea, and cough

b. anginal chest pain - due to right ventricular ischemia or pulmonary artery stretching
500


c. hemoptysis



4. Diagnostics

a. pulmonary artery pressure readings via PA catheter

b. echocardiogram

c. chest radiograph

d. arterial blood gas

e. EKG


5. Management

a. treat hypoxemia with oxygen

b. monitor oxygenation with pulse oximeter

c. bed rest with commode at bedside

d. medications: cardiac glycosides (digitalis), pulmonary artery vasodilators, diuretics

e. possibly restricted fluid intake and diuretics



6. Nursing care

a. monitor oxygenation status

b. pace activities in clients who tire easily

c. provide supportive care

d. monitor skin integrity



D. Respiratory failure

1. Definition: lungs cannot maintain arterial oxygen levels or eliminate carbon dioxide

2. Etiology

a. lung diseases that harden the alveolar-capillary membrane, trap O
2


b. neuromuscular or musculoskeletal disorders

i. respiratory drive dulled or blunted

ii. respiratory muscles weak



3. Findings

a. PaCO
2
> 50 mm Hg

b. PaO
2
< 60 mm Hg

c. clients with chronic lung disease precautions

i. look for drop from baseline function

ii. clients are always hypoxemic and hypercarbic


d. classic presentation: the three "H's" or hypoventilation, hypoxemia, hypercapnia


4. Diagnostics : arterial blood gas, history

5. Management

a. oxygen

b. mechanical ventilation

c. treat underlying cause for respiratory failure
501


d. pharmacologic - bronchodilators, corticosteroids, antibiotics as indicated


6. Nursing care

a. observe for signs of hypoxia and respond to prevent occurrence of respiratory failure

b. administer medications and oxygen as prescribed

c. supportive care for emotions, skin integrity, gastrointestinal function, renal function




Points to Remember

Oxygen is essential for life; therefore a priority nursing action is to keep the airways open and ease breathing effort.

COPD causes poor gas exchange in the lungs, leading to decreased oxygen levels and increased carbon dioxide levels
in the blood and shortness of breath.

Nursing interventions for clients with chronic lung disease should include pacing of activities, because these clients
have little reserve for exertion.

Treatment of COPD consists of cessation of smoking, medications to open the airways and decrease inflammation,
prevention of lung infections, oxygen supplementation, and pulmonary rehabilitation, i.e., using diaphragmatic
breathing and pursed-lip breathing, proper use of respiratory equipment, and occupational or physical therapy.

Clients with asthma must understand the different types of inhalers and when to use each type. For example, some
inhalers are for acute dyspnea ("rescue" or SABA), while other inhalers are for maintenance or prevention (ICS, LABA).

Asthma is not a disease but an inflammatory disorder.

To maximize therapeutic effect of inhalers, the key is technique; teach clients the right technique and observe how
well they use the inhaler.

Clients who have difficulty using inhalers properly (children, confused adults) should use a spacer device.

A pulse oximeter reading is simply one element of an assessment; it is not the whole picture. Arterial blood gases will
give a more complete picture of oxygenation.

Don't rely on the equipment to tell you about changes - always look at the client and determine if there is difficulty
breathing, anxiety, or restlessness. If a client states something is wrong or s/he is going to die, immediately assess
client and act if necessary.

If a client is in respiratory distress, typical orders are to administer oxygen by non-rebreather mask at 10 to 15 liters
per minute until the client's condition improves or stabilizes.








Points to Remember 2

Cyanosis, a late finding, is determined by oxygenation and hemoglobin content. Remember to check nail beds and
mucous membranes for changes; don't forget different skin coloring affects the appearance of anemia.

Anemic clients may be severely hypoxemic and never turn blue - rather, they become dusky, grey, or ashen in color.

Polycythemic clients with high hemoglobin and hematocrit levels may be cyanotic with adequate tissue
502

oxygenation.

The serious public health issue of pulmonary tuberculosis (TB) requires control and reporting of any incidence and
recent contacts that the client had so prophylactic therapy for two to three months can be initiated.

Clients with pulmonary tuberculosis need intensive community follow up to ensure that they continue with long term
pharmacological treatment. Clients who stop therapy too soon are a source for more deadly multi-drug resistant
forms of pulmonary TB.

Smoking cessation is critical to reduce the risk and severity of lung disease.

Second-hand smoke increases the risk of developing asthma or other chronic lung diseases in children.

The best approach to pulmonary embolus is prevention; use compression stockings (TEDS), along with sequential
compression devices (SCDs), range of motion exercises (passive or active), and repositioning, to help prevent clots in
the deep veins.

When caring for a client who just had a chest tube inserted, validate that there's no leak from the lung. Only when
there is no leak should an occlusive dressing be applied.

Gentle tidaling is expected in the water seal chamber of a chest tube; continuous bubbling indicates an air leak and
requires immediate intervention.

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I. Neurologic Anatomy and Physiology

A. Central nervous system (CNS) - coordinates and controls body functions

1. Brain

a. cerebrum

i. hemispheres right and left

ii. frontal lobe - higher intellectual functions, social behavior, personality; Broca's area,
voluntary movement; memory retention

iii. parietal lobe - interprets sensory input (touch, pain, temperature)

iv. temporal lobe - hearing, taste, and smell; Wernicke's area; emotional response

v. occipital lobe - vision


b. diencephalon - thalamus and hypothalamus

c. cerebellum - provide equilibrium and muscle coordination

d. brain stem - midbrain, pons and medulla oblongata; controls basic body functions
(respiratory center) and relays impulses from spinal cord



.
Spinal cord

a. ascending tract - carries sensory impulses to the brain


b. descending tract - carries motor impulses to the brain

c. 31 segments

eight cervical - neck and upper extremities

12 thoracic - thoracic and abdomen

five lumbar - lower extremities

five sacral - lower extremities, urine and bowel control

one coccygeal
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B. Peripheral nervous system - connects the central nervous system to sensory organs (eye, ear)
and other organs, muscles, blood vessels and glands

1. Sensory nervous system - sends information to the CNS from internal organs or from external
stimuli

a. 12 pairs of cranial nerves (see next page for more detail)

b. 31 pairs of spinal nerves - contain both sensory and motor neurons

i. 31 pair - innervate area of skin called dermatome

ii. 8 cervical - neck and upper extremities

iii. 12 thoracic - thoracic area and abdomen

iv. 5 lumbar - lower extremities

v. 5 sacral - lower extremities; urine and bowel control

vi. 1 coccygeal



2. Motor nervous system - carries information from the CNS to organs, muscles, and glands

a. somatic nervous system - controls skeletal muscle and external sensory organs

b. autonomic nervous system - controls involuntary muscles, such as smooth and cardiac
muscle

i. sympathetic - controls activities that increase energy expenditures (speeds up heart
rate, dilate pupils, and relax the bladder) - involved in "fight or flight response"

ii. parasympathetic - controls activities that conserve energy expenditures (inhibiting heart
rate, constricting pupils, contracting the bladder, maintain GI peristalsis)




D. Cranial nerves: 12 pairs of cranial nerves that arise from the brain and brain stem, carrying motor
and or sensory information
Cranial Nerves
I Olfactory VII Facial
505

II Optic VIII Auditory
III Oculomotor IX Glossopharyngeal
IV Trochlear X Vagus
V Trigeminal XI Spinal
VI Abducens XII Hypoglossal

To remember the cranial nerves, remember this sentence:
On Old Olympus Towering Top A Frenchman And German Viewed Some Hops
OR
Oscar Osmond Ought To Try To Find A Girl's Voice Singing High


II. Degenerative Disorders

A. Parkinson's disease

1. Definition: degenerative disorder of the dopamine - producing neurons

a. result: dopamine depletion

b. usually occurs in older adults, males more than females



2. Etiology

a. linked to genetic defect

b. associated with neuroleptics, toxins, structural or vascular lesions in the brain


3. Findings

a. upper extremity resting tremor: pill-rolling; unintentional tremors; both are absent during
sleep
506


b. bradykinesia / akinesia

c. fatigue

d. stiffness and rigidity of muscles - cogwheel rigidity

e. signs are initially unilateral, then bilateral

f. mask-like facial expression, drooling

g. slow, shuffling walk; gradually more difficult

h. difficulty rising from sitting position, postural instability

i. ultimately confined to a wheelchair

j. mind usually stays intact




To remember the classic findings of Parkinson's disease think:
T-R-A-P

T= tremors
R= rigidity
A= akinesia/bradykinesia
P= postural instability


4. Diagnostics

a. based on findings and history of development, response to medications

b. electroencephalogram (EEG)

c. magnetic resonance imaging (MRI)

d. positron emission test (PET)


5. Medical management

a. goals are palliative interventions and care; postpone dependence

b. pharmacologic

i. anticholinergics - extend the effects of levodopa

benzotropine mesylate (Cogentin)

procyclidine (Kemadrin)


ii. antiparkinsonian agents

amantadine HCl (Symmetrel) - reduces rigidity and tremor

dopamine hydrochloridergics: Levodopa (L-Dopa), levodopa-carbidopa (Sinemet)

bromocriptine (Parlodel)

decarboxylase inhibitors


iii. antidepressants for depression

iv. MAO inhibitors: selegiline (Eldepryl)


c. coenzyme Q10

d. physical therapy

e. occupational therapy

f. speech therapy

g. surgery: stereotactic pallidotomy / thalamotomy to decrease tremor


6. Nursing care

a. maintain safety of client

b. prevent effects of immobility

c. foster independence in activities of daily living (ADL)
507


d. help walk with use of sturdy shoes, no leather soles, purposeful steps

e.
promote good nutrition

i. small, frequent meals

ii. soft foods

iii. roughage to decrease constipation


f. administer medications

g. provide emotional support

h. reinforce client and family teaching regarding

i. side effects of drugs

ii. importance of daily exercise




B. Huntington's disease (Huntington's chorea)

1. Definition: progressive atrophy of basal ganglia and some parts of cerebral cortex

2. Etiology: genetic disorder, autosomal dominant

3. Findings: increased involuntary movements, progressive decline in cognition, decline in
speech - findings usually occur in middle age

a. motor

i. chorea

ii. dystonic posture

iii. client gradually becomes bedridden

iv. impaired chewing and swallowing

v. cognitive: less able to organize, plan and sequence behavior

vi. mental: personality changes, depression, even psychosis


b. cognitive: less able to organize, plan and sequence behavior

c. mental: personality changes, depression, even psychosis


4. Diagnostics: history and physical exam, genetic testing

5. Medical management

a. goal - postpone dependence

b. supportive care for findings

c. speech therapy

d. physical therapy

e. genetic counseling

f. pharmacologic agents to manage cognitive findings and decrease chorea


6. Nursing care

a. foster independence in ADLs

b. assist with walking

c. provide good nutrition

d. provide emotional support

e. encourage family members to seek genetic counseling

f. observe for airway and breathing compromise

g. support end of life decisions




C. Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig's disease)

1. Definition: neurological disease in which progressive degeneration of the motor neurons of
508

the anterior horn cells of the spinal cord, brainstem, and motor cortex causes muscle
weakness, disability, and eventually death

2. Etiology

a. onset in later middle age; more men than women

b. death ensues within 2 to 6 years after diagnosis

c. etiology unknown


3. Findings

a. mild clumsiness progressing to total incapacity

b. muscle wasting, atrophy, spasticity

c. usually beginning in head and arms, distal portion first

d. speech disorders

e. mind remains intact

f. no change in sensation or autonomic system

g. death due to respiratory failure or infection of lung or urinary system


4. Diagnostics: history and physical exam, electromyogram (EMG)

5. Medical management

a. goal is to keep functional independence as long as possible

b. no cure

c. management guided by findings

i. muscle relaxants for spasticity, neuroprotector Riluzole (Rilutek) to extend life
expectancy

ii. speech therapy

iii. physical therapy

iv. respiratory care



6. Nursing care

a. provide respiratory care (oxygenation, airway clearance)

b. maintain a safe environment

c. prevent complications of immobility

d. postpone dependence

e. provide good nutrition

f. provide emotional support

g. support discuss end of life decisions and need for hospice




D. Dementia

1. Definition: a loss of brain function that occurs with certain diseases, affecting memory,
thinking, language, judgment, and behavior

2. Etiology: varied, depending on cause

a. Reversible dementia

i. urinary tract infections

ii. low levels of vitamin B
12


iii. medications

iv. hypothyroidism


b. nonreversible (degenerative) dementia

i. Alzheimer's disease - the most common type of dementia
509


ii. Vascular dementia - due to stroke or a series of small strokes

iii. Long-term alcohol abuse

iv. Other medical conditions including Parkinson's disease, multiple sclerosis,
Huntington's disease

v. Infections that can affect the brain, including HIV/AIDS, syphilis, Lyme disease



3. Findings

a. usually first appears as forgetfulness

b. difficulty with many areas of mental function

i. language

ii. memory

iii. perception

iv. emotional behavior or personality

v. higher levels of cognitive function, e.g., ability to think abstractly, perform calculation



4. Diagnostics

a. history of behavior changes

b. physical exam

c. neurological exam, including mental status test, MRI and CT of the head

d.
laboratory tests to rule out reversible causes: B12 levels, blood ammonia levels, blood
gas analysis, cerebrospinal fluid analysis, toxicology screen, blood glucose, liver function
tests, serum calcium, serum electrolytes, thyroid function tests, HIV screen, Syphilis
screen, Lyme titer


5. Medical management

a. treating conditions that can lead to confusion, e.g., anemia, hypoxia, depression, heart
failure, infections, nutritional disorders, thyroid disorders

b. pharmacologic - to control behavior problems caused by a loss of judgment, increased
impulsivity, and confusion

i. Antipsychotics: haloperidol (Haldol), risperidone (Risperdal), olanzapine (Zyprexa)

ii. Mood stabilizers: fluoxetine (Prozac), imipramine (Tofranil), citalopram (Celexa)

iii. Serotonin-affecting drugs: trazodone (Desyrel), buspirone (Buspar)

iv. Stimulants: methylphenidate (Concerta)



6. Nursing care

a. meet client's physical needs

b. promote client's independence

c. establish a routine

d. provide emotional support

e. support and reinforce family teaching regarding home care needs of client




E. Alzheimer's disease

1. Definition: a type of dementia in which there is memory impairment, as well as problems with
language, decision-making ability, judgment, and personality

2. Etiology

a. unknown; thought to include genetic and environmental factors

b. brain changes associated with Alzheimer's disease

i. neurofibrillary tangles - twisted fragments of protein within nerve cells

ii. neuritic plaques - abnormal clusters of dead and dying nerve and brain cells
510


iii. senile plaques - dying nerve cells that accumulate around protein


c. prognosis - incurable and fatal


3. Findings

a. cognitive deficits with memory impairment

b. one or more of the following

i. difficulty naming objects (agnosia)

ii. language disturbance (aphasia)

iii. problems with organization and abstract thinking

iv. difficulty with motor activities (apraxia)


c. noticeable decline in level of functioning

d. cognitive difficulties are not related to other conditions

e. altered sensory perception

i. illusions

ii. hallucinations


f. behaviorial findings

i. wandering - persistent aimless walking

ii. verbal or physical abuse

iii. resisting care

iv. socially inappropriate behavior

v. sundown syndrome (also called sundowning)


g. Alzheimer's disease typically divided into 3 stages (reflected by behavior changes and
physical findings)
Early Stage Middle Stage Final/Terminal Stage
subtle personality changes
difficulty with abstract
thinking

forgetfulness and uncertainty
causes anxiety, irritation,
and withdrawal

difficulty making decisions,
concentrating, and handling
work skills
impaired language, motor
activity and object
recognition

wandering

inability to carry out ADLs
impaired judgment

severe disorientation, with
personality and behavior
changes

may have difficulty
remembering family and
friends

psychotic symptoms such
as hallucinations and
delusions may occur
client loses the ability to
function physically and
mentally

becomes mute,
incontinent, and totally
dependent




4. Diagnostics

a. history of behavior changes

b. physical exam
511


c. neurologic testing, including mental status test, MRI and CT of the head

d.
laboratory tests to rule out other cause of dementia, including B12 levels, blood ammonia
levels, blood chemistry, blood gas analysis, cerebrospinal fluid analysis, toxicology screen,
blood glucose, liver function tests, serum calcium, serum electrolytes, thyroid function tests,
HIV screen, Syphilis screen, Lyme titer


5. Medical management

a. milieu management - structured routine, decreased stimulation

b. managing progressive symptoms and maintenance of functional capacity

c. care for the caregiver

d.
pharmacologic

i. drugs that enhance the action or inhibit the breakdown of acetylcholine in the brain

galantamine (Razadyne)

with meals, twice a day, or every morning (extended release)

encourage fluids

donepezil (Aricept)

given once a day before bed

may be given with or without food

rivastigmine (Exelon)

given with food twice a day

may increase dosage at intervals for maximum effect



ii. memantine (Namenda) - drug that blocks blocks glutamate accumulation and nerve cell
destruction in the brain; for moderate to severe dementia

iii. antidepressants and antipsychotics are used to treat depression and psychotic findings
v. CAT - ginkgo Biloba



6. Nursing care

a. wandering

i. utilize alarms

ii. identify the need the client is trying to meet in wandering

iii. provide safety

iv. use distractions such as offering an activity or food

v. calmly guide the client back


b. abusive behavior

i. maintain a calm and consistent environment

ii. keep the client away from other clients

iii. reduce situations that might cause stress or fear


c. socially inappropriate or disruptive behavior

i. move client to a private area

ii. use positive reinforcement for appropriate behavior

iii. assess the cause of the behavior

iv. avoid the use of restraining devices


d. sundown syndrome

i. use night lights

ii. encourage quiet activities

iii. play soft music

iv. avoid caffeine

512


e. altered thought processes

i. provide quiet, consistent environment

ii. reality orientation in early stages

iii. validation therapy (using supportive behavior and encouraging words to validate the
client's feelings) in later stages

iv. use short sentences and simple words

v. avoid negative confrontation


f. self-care deficits

i. allow plenty of time

ii. encourage as much self-care as possible
iii. memory training / aids
iv. promote a balanced diet


g. risk for injury

i. gait disturbances may necessitate assistive devices

ii. monitor environment to increase safety


h. caregiver role strain

i. establish a therapeutic relationship with caregiver

ii. be supportive and nonjudgmental

iii. refer to support groups and resources
iv. discuss legal issues - living wills, power of attorney, end of life


Find more information regarding Alzheimer's Disease from the National Institute on Aging.


F. Comparing and contrasting delirium, dementia, and depression
Use this chart to better understand the similarities and differences between delirium (an acute
condition), dementia (can be acute or chronic), and depression.
Clinical Feature Delirium Dementia Depression
Onset Sudden/abrupt; depends
on cause; often at
twilight or in darkness
Insidious/slow and often
unrecognized; depends on
cause
Coincides with major life
changes; often abrupt, but
can be gradual
Course Short, diurnal
fluctuations in
symptoms; worse at
night, in darkness, and
on awakening
Long, no diurnal effects;
symptoms progressive yet
relatively stable over time;
may see deficits with
increased stress
Diurnal effects, typically
worse in the morning;
situational fluctuations, but
less than with delirium
Progression Abrupt Slow but uneven Variable; rapid or slow but
even
Duration Hours to less than one
month; seldom longer
Months to years At least 6 weeks; can be
several months to years
Consciousness Reduced Clear Clear
Alertness Fluctuates; lethargic or
hypervigilant
Generally normal Normal
Attention Impaired; fluctuates Generally normal Minimal impairment, but its
distractible
513

Clinical Feature Delirium Dementia Depression
Orientation Generally impaired;
severity varies
Generally normal Selective disorientation
Memory Recent and immediate
impaired
Recent and remote impaired Selective or patchy
impairment; islands of
intact memory; evaluation
often difficult due to low
motivation
Thinking Disorganized, distorted,
fragmented; incoherent
speech, either slow or
accelerated
Difficulty with abstraction;
thoughts impoverished;
judgment impaired; words
difficult to find
Intact but with themes of
hopelessness, helplessness,
or self-depression
Perception Distorted; illusions,
delusions, and
hallucinations; difficulty
distinguishing between
reality and
misconceptions
Misperceptions usually
absent
Intact; delusions and
hallucinations absent except
in severe cases
Psychomotor
behavior
Variable; hypokinetic,
hyperkinetic, and mixed
Normal; may have apraxia Variable; psychomotor
retardation or agitation
Sleep/Wake
cycle
Disturbed; cycle may be
reversed
Fragmented Disturbed; usually early
morning awakening
Associated
features
Variable affective
changes; symptoms of
autonomic hyperarousal;
exaggeration
of personality type;
associated with acute
physical illness
Affect tends to be superficial,
inappropriate, and labile;
attempts to conceal deficits
in intellect; personality
changes, aphasia, agnosia
may be present; lacks insight
Affect depressed; dysphoric
mood; exaggerated and
detailed complaints;
preoccupied with insight
present; verbal elaboration;
somatic complaints, poor
hygiene, and neglect of self
Assessment Distracted from task;
numerous errors
Failings highlighted by
family, frequent near miss
answers; struggles with test;
great effort to find an
appropriate reply; frequent
requests for feedback on
performance
Failings highlighted by
individual, frequentdont
knows; little effort; frequently
gives up; indifferent toward
test: does not care or attempt
to find answer



III. Cerebrovascular Accident (CVA, Stroke, "brain attack")

A. Definition: decreased blood supply to the brain caused by vascular blockage or blood loss

1. Leading cause of disability in US, fourth leading cause of death in US

2. Risk factors

a. hypertension

b. smoking

c. obesity

d. increased blood cholesterol and triglycerides


3. Five classes of stroke - by severity

a. transient ischemic attack (TIA), "angina" of the brain

i. TIA is warning sign of stroke
514


ii. localized ischemic event

iii. produces neurological deficits lasting only minutes or hours

iv. full functional recovery within 48 to 72 hours


b. reversible ischemic neurological deficit (RIND)

i. similar to TIA

ii. symptoms last between 24 hours and three weeks

iii. usual full functional recovery


c. partial, nonprogressing stroke: some neurological deficit, but stabilized

d. progressing stroke (stroke in evolution)

i. deteriorating neurological status

ii. residual neurological deficits


e. completed stroke - neurological deficits permanent




4. Causes

a. ischemic or occlusive stroke (clot) - slower onset

i. results from inadequate blood flow leading to cerebral infarction

ii. caused by cerebral thrombosis or embolism in cerebral blood vessels

iii. most common cause: atherosclerosis



b. hemorrhagic stroke (bleeding) - abrupt onset

i. intracerebral hemorrhagic stroke

blood vessels rupture, bleed into the brain

occurs most often in hypertensive older adults

may also result from anticoagulant therapy


ii. subarachnoid hemorrhage (SAH)

most often caused by rupture of saccular intracranial aneurysms

more than 90% are congenital aneurysms





B. Findings of CVA (depends on location of lesion)
Overview of Findings for CVA
Sensoriperceptual/vision Homonymous hemianopia
Agnosia
Apraxia
Diplopia
Decreased acuity
Sensory loss, i.e., touch, pain, cold
Communication Aphasia: expressive (Broca's), receptive (Wernicke's), or mixed
(global)
Dysarthria
515

Agraphia
Motor Hemiplegia
Hemiparesis
Flaccidity
Spasticity
Behavioral Emotional lability
Loss of social inhibitions
Fear
Anger
Hostility
Elimination Urinary frequency and urgency
Incontinence (bowel and urinary)
Neurological Altered LOC
Seizures
Hyperthermia
Right Left



C. Diagnostics of CVA

1. History and physical exam; provider should evaluate all suspected stroke victims within 10
minutes of arrival to hospital

2. Computerized tomogram (CT) scan within 25 minutes of arrival to hospital (initially without
contrast if hemorrhagic event is suspected)

3. Magnetic resonance imaging (MRI)

4. Doppler echocardiography flow analysis

5. Carotid artery duplex doppler ultrasonography

6. EEG - shows abnormal electrical activity

7. Lumbar puncture - shows if blood is found in the cerebral spinal fluid as a result of a cerebral
bleed (contraindicated with increased intracranial pressure)

8. Cerebral angiography - may be done with or without contrast to show blood flow in cerebral
arteries


D. Medical management: objective is to prevent or minimize the damaging effects of stroke;
dependent on type of CVA

1. Occlusive stroke

a. pharmacologic

i. anticoagulant therapy: heparin, coumadin, lovenox (needs high-alert symbol)

ii. antiplatelet therapy: aspirin, dipyridamole

iii. platelet aggregation inhibitor: clopidogrel (Plavix), ticlopidine HCL (Ticlid)

iv. steroids: dexamethasone

v. calcium channel blockers: nimodipine


b. surgery - if carotid artery is stenotic or partially occluded - carotid endarterectomy or
angioplasty with stenting

516


2. Hemorrhagic stroke

a. pharmacologic

i. antihypertensive agents

ii. systemic steroids: dexamethasone (Decadron)

iii. osmotic diuretics: mannitol

iv. antifibrinolytic agents: aminocaproic acid (Amicar)

v. vasodilators

vi. alpha-blockers and beta-blockers

vii. anticonvulsants


b. surgical excision of aneurysm


3. Common to both types of stroke

a. care based on findings

b. care of the client with elevated ICP

c. physical therapy

d. occupational therapy

e. speech therapy

f. nutrition support



E. Nursing care

1. In acute stage of stroke

a. maintain airway patency (suctioning equipment must be available at the bedside)

b. monitor neurologic and vital signs

c. maintain adequate fluids

d. provide activity as ordered

e. perform passive and/or active range of motion exercises

f. position with head of bed elevated 15 to 30 degrees maintaining head midline

g. maintain proper body alignment

h. administer medications as ordered

i. care of the surgical client if indicated

j. care of client with increased intracranial pressure


2. Long-term care of client with stroke

a. monitor elimination patterns

b. reinforce the use of supportive devices

c. maintain a safe environment

d. prevent the effects of immobility

e.
maintain adequate nutrition in light of feeding and swallowing problems

f. assist with eating and activities of daily living as indicated

g. provide emotional support to client and client support systems

h. provide methods of communication for client with aphasia




IV. Infectious & Inflammatory Disorders

A. Meningitis

1. Definition

a. acute or chronic inflammation of the meninges
517


b. average length of illness - 4 months


2. Etiology

a. bacterial: most commonly meningococcus, H. Influenza, pneumococcus

b. viral

c. fungal

d. parasitic


3. Findings

a. severe headache

b. fever

c. nuchal rigidity (stiff neck)

d. altered LOC - lethargy, drowsiness, irritability, photophobia, hypersensitivity


4. Diagnostics

a. history and physical exam

b. positive Kernig's sign: 90-degree flexion of hip and knee with extension of knee
causes pain


c. positive Brudzinski's sign: flexion of neck causes flexion of hip and knee


d. lumbar puncture

e. CT or MRI with and without contrast





5. Medical management

a. goal is to cure the infection and prevent complications

b.
pharmacologic
518


i. antibiotic therapy depends on type and pathogen

ii. preventive therapy for people exposed to those with meningococcal and H. Influenza
meningitis: rifampin (Rifadin)

iii. H. Influenza vaccine


c. care for fever

d. prevention of increased intracranial pressure, seizures


6. Nursing care

a. care of client with increased ICP

b. seizure precautions

c. administer drugs as ordered

d. provide comfort measures for pain

e. reduce external stimuli

f. isolation if required or indicated



B. Parameningeal infections

1. Definition: localized collection of exudate in brain or spinal cord

2. Etiology: usually caused by bacteria

3. Findings

a. similar to meningitis

b. headache, fever, stiff neck, altered consciousness


4. Diagnostics

a. no lumbar puncture; may cause herniation

b. CT scan


5. Medical management

a. surgical decompression of abscess

b. symptomatic and preventive treatment as with meningitis

c.
pharmacologic: antibiotics


6. Nursing interventions: same as for meningitis



C. Encephalitis

1. Definition: acute inflammatory viral disease of brain tissue

2. Etiology

a. can occur as epidemics or sporadically

b. death rate ranges up to 70%

c. most common pathogen for sporadic encephalitis is herpes simplex

d. may follow a systemic viral illness such as chicken pox


3. Findings

a. adult

i. sudden fever

ii. severe headache

iii. altered level of consciousness, progressing to stupor then coma with seizure activity

iv. nuchal rigidity

v. change in personality

vi. mild flu-like complaints

519


b.
infant

i. vomiting

ii. body stiffness

iii. constant crying that worsens when child picked up

iv. constant full or bulging anterior fontanelle





4. Diagnostics

a. history and physical exam

b. CT scan

c. polymerase chain reaction (PCR) assay


5. Medical management

a. uncomplicated cases require supportive and preventive care

b. bed rest

c. good nutrition

d. fluid balance

e.
herpes simplex calls for antivirals: vidarabine (ViraA), acyclovir (Zoviraz)

f. prevention of increased intracranial pressure

g. mosquito control/use of insect repellant


6. Nursing care

a. comfort measures for fever

b. administer drugs as ordered

c. seizure precautions

d. care of the client with increased ICP

e. when needed, ensure isolation and airborne-droplet precautions

f. reduce stimuli and lighting if photophobic



D. Botulism

1. Definition: acute flaccid paralysis

2. Etiology

a. food poisoning from anaerobic bacillus Clostridium botulism
contaminated food

b. three types: infantile, classic, wound


3. Findings

a. CNS findings usually appear within 12 to 36 hours

b. blurred vision, diplopia, lethargy, vomiting and dysphagia, weakness,
difficulty speaking, life threatening progressive respiratory paralysis


Causative Agent Findings
520

Staphylococci - enterotoxins form
in foods that are held at room
temperature, especially those with
mayonnaise base
Findings appear within 7 hours of ingestion:
-Weakness
-Acute nausea and vomiting
-Intestinal cramps
-Diarrhea
Enteric type:
1) Clostridium perfringens - in
cooled then reheated foods
2) Vibrio parahaemolyticus -
multiplies in uncooked seafood
3) Bacillus cereus - anaerobic
spore; multiplies in food held at
room temperature
Findings appear within 24 hours of ingestion:
-Nausea and vomiting
-Abdominal pain
-Diarrhea
Clostridium botulinum - forms a
toxin in improperly processed food
in anaerobic conditions (especially
in improperly canned or dented
food cans)
Findings appear within 36 hours of ingestion:
-Dry mouth
-Diplopia
-Nausea and vomiting
-Cramps
-Diarrhea precedes dysphagia and dysarthria



4. Management

a. supportive - dependent on body system affected

b. protect ventilation, respiration, and provide nutrition

c. pharmacologic: botulism antitoxin


5. Nursing care

a. observe for and report signs of neuromuscular weakness

b. provide time for test - client will tire easily

c. assess for swallowing difficulties

d. reinforce teaching points

i. rest during recovery

ii. normal bowel elimination may not return for a while; no enemas or cathartics




D
.
Nipah & Hendra Viruses

1. Definition: a paramyxovirus that causes encephalitis in humans and is transmitted from animals

2. Etiology: emerging worldwide infection; potential for use as a biological agent (see Lesson 2: Sa
and Infection Control for other viral agents used as biologic agents)

a. Hendra virus: the cause of a highly fatal respiratory virus disease of horses

b. Nipah virus: transmitted from bats and is zoonotic, causing a highly fatal infection in humans


3. Findings

a. human infections range from asymptomatic to fatal encephalitis

b. initially influenza-like symptoms, e.g., fever, headache, myalgia, vomiting and sore throat

c. some people experience atypical pneumonia and severe respiratory problems

d. encephalitis and seizures occur in severe cases, progressing to coma within 24 to 48 hours



4. Diagnostics
521


a. no standard protocol exists for detection

b. methods used to confirm viral infection

i. history/clinical signs

ii. enzyme-linked immunosorbent assay (ELISA)

iii. laboratory tests to detect antibody (IgG and IgM) in serum, cerebrospinal fluid



5. Management: there is no treatment or vaccine available for either people or animals; ribavirin has been
used with limited effectiveness

6. Nursing care

a. intensive supportive care with treatment of symptoms

b. regular hand washing




V. Autoimmune Disorders of Neurologic System

A. Multiple sclerosis

1. Definition: demyelination of white matter throughout brain and spinal cord


2. Etiology

a. third most common cause of disability in clients ages 15 to 60

b. specific cause unknown

c. increased incidence in temperate to cool climates

d. illness improves and worsens unpredictably

e. severity often associated with stress


3. Findings: depend on location of demyelination with remissions and exacerbations

a. cranial nerve: blurred vision, dysphagia, diplopia, facial weakness and/or numbness

b. motor: weakness, paralysis, spasticity, gait disturbances

c. sensory: paresthesias, decreased proprioception

d. cerebellar: dysarthria, tremor, incoordination, ataxia, vertigo

e. cognitive: decreased short-term memory, difficulty with new information, word-finding
difficulty, short attention span

f. urinary retention or incontinence

g. loss of bowel control

h. sexual dysfunction

i. fatigue





4. Diagnostics

a. history and physical exam

b. lumbar puncture

c. magnetic resonance imagery (MRI)
522


d. computerized tomogram (CT) scan

e. evoked potentials or response - the EEG record of electrical activity at one of several levels in
the CNS by stimulation of an area of the sensory nerve system


5. Medical management

a. goal is to alleviate findings and prevent complications

b.
pharmacologic: adrenocorticotropic hormone (ACTH), beta Interferon (Avonex)

c. treatment during exacerbations

i. interferon: slows the progression of disability

ii. physical therapy

iii. occupational therapy



6. Nursing care

a. maintain functional independence in activities of daily living

b. administer medications as ordered

c. prevent complications of immobility

d. prevent injury from difficulties walking

e. provide emotional support

f. provide counseling for sexual dysfunction

g. reinforce client and family teaching:

i. avoid fatigue and stress

ii. conserve energy

iii. exercise and diet

iv. know drugs and side effects

v. use self-help devices

vi. refer for stress management program




B. Guillain-Barre syndrome

1. Definition: acquired inflammatory disease

2. Etiology

a. causing demyelinization of peripheral nerves

b. precipitating factors include prior viral infection


3. Findings

a. muscle weakness: progressive, ascending, bilateral

b. leading to paralysis

c. loss of superficial and deep tendon reflexes

d. bulbar weakness

e. dysphagia

f. dysarthria

g. respiratory failure

h. sensory signs: paresthesias



4.
Diagnostics

a. history and physical exam

b.
lumbar puncture will show increased protein in CSF

c. electromyogram (EMG)


5. Medical management
523


a. goal is to prevent complications

b. care based on findings: immunoglobulin therapy


6. Nursing care

a. care of client on ventilatory support

b. care of the immobilized client

c. provide a safe environment

d. provide good nutrition and fluid balance

e. provide adequate pain control

f. establish alternate ways to communicate

g. prevent complications of immobility



C. Myasthenia gravis

1. Definition: antibodies destroy acetylcholine receptors where nerves join muscles

2. Etiology

a. two age clusters: women in early adulthood and men in late adulthood

b. progressive; may experience crises


3. Findings

a. fatigue of voluntary muscles, but not muscular atrophy

b. facial

i. ptosis (drooping eyelid) and reduced eye closure

ii. weak smile

iii. diplopia, blurred vision

iv. speech and swallowing disorders

v. weakness of facial muscles


c. signs of restrictive lung disease

d. sensation remains intact


4. Diagnostics

a. history and physical exam

b. edrophonium (Tensilon) test: improved muscle strength indicates positive test for MG

c. single-fiber electromyography

d. serum assay of circulating acetylcholine receptor antibodies



5. Medical management

a. goal is to improve strength and endurance

b.
pharmacologic - medications must be administered on time

i. anticholinesterase agents: pyridostigmine (Mestinon), neostigmine (Prostigmin)

ii. corticosteroid therapy

iii. immunosuppressants: azathioprine (Imuran), cyclosporine


c. thymectomy

d. plasma exchange, plasmaphoresis

e. management of crisis

i. myasthenic crisis usually follows stressor, i.e., infection

ii. signs: sudden inability to swallow, speak, or maintain patent airway

iii. cholinergic crisis may follow over dosage of medication during periods of medication
adjustments
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iv. edrophonium (Tensilon) test results during crisis

positive test signals myasthenic crisis

a negative test indicates cholinergic crisis - treat with atropine


v. ventilatory support may be required



6. Nursing care

a. identify aggravating factors, including:

i. infection

ii. stress

iii. changes in medication regime


b. if client is in crisis - care of the client needing ventilatory support

c. give medications as ordered on time

d. help with activities of daily living and feeding as indicated

e. provide emotional support

f. provide adequate rest periods

g. provide care of the surgical client as indicated

h. reinforce client teaching regarding

i. energy conservation techniques

ii. medications and side effects

iii. signs of impending crisis, both myasthenic and cholinergic

iv. to avoid stressors

v. discuss with health care provider prior to taking any prescription or over the counter
medications




VI. Seizure Disorders

A. Definition

1. Sudden, transient alteration in brain function

2. Disorderly transmission of electrical activity in the brain


B. Etiology

1. cerebral lesions

2. biochemical alteration, such as hypoglycemia

3. cerebral trauma

4. idiopathic

5. acute febrile states (especially in children, infants), hyperthermia

6. cerebral edema



C. Classification of seizure types: partial, simple, complex, generalized

1. Partial seizures

a. characteristics

i. focal motor

ii. seizure activity only in specific parts of the brain

iii. usually client remains conscious


b. types

i. simple partial - no loss of consciousness

with motor findings

with special sensory findings
525


with autonomic findings

with psychic findings

psychomotor


ii. complex partial

psychomotor seizure

impairment of consciousness





2. Generalized seizures - 8 types

a. petit mal - absences - transient loss of consciousness, flickering eyelids, or intermittent jerking
of hands

b. myoclonic

i. sudden, uncontrollable rapid jerking movements of one or more extremities which may
cause a fall

ii. usually occurs in the morning


c. clonic

i. characterized by sudden, symmetric jerking of extremities for several minutes with loss of
consciousness

ii. hyperventilation

iii. face contortion

iv. excessive salivation

v. diaphoresis

vi. tachycardia


d. tonic

i. first, client loses consciousness suddenly and muscles contract (think tense - tonic),
abnormal dystonic posture with deviation of eyes and head to one side

ii. body stiffens in opisthotonos position

iii. jaws clenched

iv. may lose bladder control

v. apnea with cyanosis

vi. pupils dilated and unresponsive

vii. usually lasts less than a minute



e. grand mal: most common type

i. tonic-clonic - tense-flaccid sequence of movement

ii. may be preceded by prodromal period - aura of epigastric discomfort, outcry

iii. lasts 2 to 3 minutes

iv. after tonic-clonic phase, client may be unresponsive for about 4 to 5 minutes (postictal phase)

v. arms, legs go limp after being tense or spastic with loss of bowel and bladder control

vi. breathing returns to normal

vii. afterwards, possible:

disorientation

confusion

headache

fatigue

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f. atonic: sudden loss of postural muscle tone with collapse - totally flaccid

g. unclassified seizures

h. status epilepticus

i. condition where motor, sensory, or psychic seizures follow one another with no intervening
periods of consciousness

ii. medical emergency

iii. failure to treat results in severe hypoxia, hyperthermia, hypoglycemia, acidosis, and death


D.
Diagnostics

1. By the event itself - refer to previous pages

2. History and physical exam

3. Electroencephalogram (EEG)

4. Computerized tomogram (CT) scan


E. Medical management

1. Goal is to control the seizure activity and prevent complications

2. Correct underlying problem

3.
Pharmacologic

a. anticonvulsants for maintenance and prevention

i. phenytoin (Dilantin)

ii. gabapentin (Neurontin)


b. barbiturates: phenobarbitol

c. succinimides

d. benzodiazepines

i. diazepam (Valium)

ii. lorazepam (Ativan)




F. Nursing care

1. Administer medications as ordered

2. Seizure care and precautions

3. Reinforce teaching of client regarding

a. about drugs and side effects

b. to know when a seizure is near - aura

c. techniques to reduce stress

d. seizure care

e. wearing MedicAlert identification




VII. Headache

A. Definition
527


1. Pain located in upper region of the head

2. One of the most common neurologic complaints


B. Classifications


1. Recurrent migraine headache

a. onset in adolescence or early adulthood

b. familial

c. involves unilateral, throbbing pain

d. may be preceded by an aura or prodrome

e. lasts hours to days


2. Cluster headaches

a. sharp or stabbing pain

b. typically eye area

c. lasts minutes, up to 4 hours


3. Recurrent muscular-contraction headache (pressure, tension headache)

a. most common form of headache

b. may be direct result of stress, anxiety, depression, drastic changes in caffeine
consumption


4. Nonrecurrent headaches

a. occur with systemic infections and are usually associated with fever

b. occur as the result of a lesion, after an invasive spinal cord procedure such as a
lumbar puncture, or subarachnoid bleed

c. caused by increased intracranial pressure




C. Findings

1. Vary by type of headache

2. May include throbbing, nausea, vomiting, visual disturbance, photophobia, tenderness, neck
stiffness, and focal neurological signs


528

D. Diagnostics

1. History and physical exam

2. Computing tomogram (CT) scan

3. Magnetic resonance imaging (MRI)

4. Radiological exam of skull and cervical spine

5. Lumbar puncture if inflammation or infection suspected


E. Medical management

1. Goals are to alleviate pain and treat underlying cause

2. Vasoconstriction by pressure, cold or medications

3. Migraine headaches

a. pharmacologic

i. nonnarcotic analgesics: aspirin, acetaminophen (Tylenol), ibuprofen (Motrin)

ii. narcotic analgesics: codeine, meperidine (Demerol)

iii. alpha-adrenergic blocking agentblocker: ergotamine tartrate (Ergostat) without or with
caffeine

iv. steroids: dexamethasone (Decadron)

v. prophylactic treatment with beta-adrenergic blocking agents, serotonin antagonists,
antidepressants, imipramine (Tofranil), sumatriptan (Imitrex)


b. avoid headache-precipitating foods or food additives such as MSG, chocolate, alcohol,
aspartame, tyramine, or milk products


4. Tension headaches

a.
pharmacologic

i. non-narcotic analgesics

ii. muscle relaxants

iii. prophylactically: antidepressants and/or doxepin (Sinequan)


b.
massage, acupuncture, acupressure, relaxation therapy, or other tension reduction
techniques


5. Cluster headaches

a. narcotic analgesics: codeine sulfate

b. administration of 100% oxygen



F. Nursing care

1. Quiet, dark environment

2. Administer drugs as ordered

3. Manage pain with alternative therapies such as massage, cold packs

4. Help client identify precipitating factors

5. Keep NPO until nausea and vomiting subside, if present

6. Reinforce client teaching regarding:

a. drugs and side effects

b. alternatives for pain relief

c. how to avoid trigger factors

d. need to keep a headache diary

e. preventive measures

f. coping strategies for chronic pain




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VIII. Head Trauma

A. Classifications

1. Types

a. closed: non-penetrating with no break in integrity of skull

b. open injury: brain exposed



2. Degree of injury

a. mild: only momentary loss of consciousness with no neurological sequelae

b. moderate: momentary loss of consciousness with a change in neurological function
which is usually not permanent; has higher risk for epidural (arterial) bleed

c. severe: decreased level of consciousness with serious neurological impairment and
sequelae




B. Types of skull fractures

1. Linear: simple break in bone; no displacement of skull

2. Depressed: part of skull is pushed in

3. Basal: at base of skull (think of it as the plate that holds the brain to separate the brain from
the mouth and nose area); may extend into eye orbit or ear; ear or nose may leak CSF

4. Concussion: temporary loss of neurologic function but complete recovery


C. Types of bleeding injuries or hematomas

1. Contusion: bruising on the surface of the brain

2. Intracerebral: bleeding directly in the brain tissue; secondary to invasive skull trauma/open
fracture or hemorrhagic CVA

3. Epidural:

a. lacerated blood vessels (arteries) in the space between the skull and dura mater; often the
middle meningeal artery is involved secondary to a skull fracture or contusion

b. arterial bleeding, the risk of death is greatest

c. client commonly looses consciousness after injury then is lucid; then LOC drops quickly
within the next 24 hours


4. Subdural:

a. lacerated the blood vessels (veins) crossing the subdural space secondary to closed head
injury

b. acute: findings surface in 24 to 72 hours after injury with rapid neurologic deterioration

c. subacute: findings surface 72 hours to 2 weeks after injury with a slower progression of
deterioration

d. chronic: gradual clot formation over time, possibly months with minimal deterioration
530




D. Progression of skull fracture injury

1. Onset: contusions and lacerations of nerve cells

2. Gradual demyelinization of affected nerve fibers results in neuron death

3. Scarring: meninges adhere to injured area of brain


E. Complications

1. Edema

a. increased intracranial pressure

b. results directly from cerebral ischemia, anoxia, and hypercapnia


2. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

a. cerebral edema presses on hypothalamus, which produces excess ADH to skew the
body's sodium and water balance

b. urinary output decreases, BP increases, high urine specific gravity


3. Diabetes Insipidus (DI)

a. DI results when ADH drops and body excretes too much fluid

b. low urine specific gravity with significant increases in urinary output (up to 10 liters of urine
in 24 hours)


4. Stress ulcer

a. head injury activates both the sympathetic and parasympathetic systems

b. stimulation of sympathetic system leads to gastric ischemia

c. stimulation of parasympathetic system leads to increased release of hydrochloric acid

d. steroid therapy may contribute to the development of stress ulcers


5. Seizure disorders

6. Infection

7. Hyperthermia or hypothermia from increased pressure on hypothalamus


F. Findings

1. Degree of neurological damage varies with the type and location of injury

2. Changes in level of consciousness

a. restlessness, irritability initially

b. lethargy, drowsiness follow

c. semicomatose, comatose


3. Headache

4. Nausea, vomiting
531



G.
Diagnostics

1. History and physical exam

2. Computerized tomogram (CT) scan

3. Magnetic resonance imaging (MRI)

4. Electroencephalogram (EEG)


H. Medical management

1. Goals are to reduce intracranial pressure and maintain the nervous system

2. Pharmacologic

a. osmotic diuretics; mannitol (Osmitrol)

b. steroids: dexamethasone (Decadron), hydrocortisone (Solu-CORTEF),
methylprednisolone (Solu-MEDROL)

c. barbiturate coma may be induced


3. Surgical correction of underlying cause

4. Preventive and therapeutic actions for seizures, fever, infection

5. Rehabilitation therapies

a. speech therapy

b. physical therapy

c. occupational therapy

d. behavioral therapy



I. Nursing care

1. Provide care of the client with increased intracranial pressure

2. Maintain seizure care and precautions

3. Provide care of the client on ventilator

4. Provide care of the client undergoing surgery

5. Maintain good nutrition and fluid balance

6. Assist with activities of daily living as indicated

7. Prevent complications of immobility

8. Monitor neurologic status and other vital signs

9. Administer drugs as ordered

10. Provide emotional support

11. Manage pain






532

IX. Peripheral Nerve & Cranial Nerve Disorders

A. Trigeminal neuralgia (tic douloureux, facial neuralgia)

1. Definition: syndrome of paroxysmal facial pain

2. Etiology: unknown

a. affects middle age and older adults; women more than men

b. affects cranial nerve V (trigeminal nerve)

c. involves one side only

d. triggered by harmless events such as a breeze or hot or cold liquids


3. Findings

a. intense facial pain lasting about 1 to 2 minutes

b.
pain follows branches of nerve

c. facial sensitivity


4. Diagnostics: history and physical exam



5. Medical management

a. goals are to relieve and prevent pain

b. anticonvulsants: carbamazepine (Tegretol), phenytoin (Dilantin)

c. surgery

i. nerve block - temporary management of pain

ii. radio-frequency gangliolysis: heat destroys trigeminal ganglion

iii. glycerol gangliolysis: glycerol injected into subarachnoid space around gasserian ganglion

iv. microvascular decompression: move arterial loop away from posterior trigeminal root



6. Nursing interventions

a. help client name triggers and aggravating incidents

b. provide

i. restful environment

ii. good nutrition

iii. care of the client undergoing surgery


c. reinforce client teaching regarding

i. medications and side effects

ii. avoidance of triggering agents

iii. chew on opposite side of mouth

iv. avoidance of drafts

v.
avoidance of very hot or cold foods

vi. importance of oral hygiene and care

vii. avoid exposing face to extreme environmental temperatures




B. Facial nerve paralysis (Bell's palsy)

1. Definition

a.
disorder of cranial nerve VII (facial nerve)
533



b. involves one side only

c. may be related to increased periods of stress


2. Etiology: unknown

a. often occurs during periods of high stress

b. possible herpes simplex virus (HSV) involvement


3. Findings - unilateral

a. ptosis with excess tearing

b. cannot close or blink eye

c. flat nasolabial fold

d. impaired taste

e. lower face paralysis with difficulty eating - impaired swallowing or tongue movement


4. Diagnostics: history and physical exam


5. Medical management

a. goal is to restore cranial nerve function

b.
pharmacologic

i. predniSONE

ii. analgesics

iii. herbs
iv. moistening eye drops (Artificial tears)


c.
local comfort measures: heat, massage and electrical nerve stimulation for muscle tone


6. Nursing care

a. protect the eye from corneal irritation and abrasion

b. provide good nutrition: soft diet, foods easy to chew and swallow

c. administer drugs as ordered

d. reinforce client teaching

i.
chew on opposite side

ii. how to use protective eye wear

iii. effects of steroids

iv. stress management for prevention
v. importance of oral hygiene and care




X. Spinal Cord Injuries

A. Definition: conditions that can affect the spinal cord are usually due to trauma, but may also
be from diseases of the musculoskeletal system (arthritis) or congenital abnormalities (spina
bifida)

1. classification of the injury can be done as

a. complete or incomplete cord injury
534


b. cause of the injury

c. level of the injury


2. types of injuries - if the structures near the spinal cord are injured, surround structures will
be affected, e.g., a bulging disc may place pressure on the spinal cord

a. contusion

b. laceration

c. hemorrhage

d.
transection, complete or incomplete spinal cord injuries

e. damage to blood vessels that supply the spinal cord




B. Etiology: anything inducing trauma to vertebrae or spinal cord, e.g., motor vehicle crash, falls,
sports injuries, stabbings, gunshot wounds, tumors, infection

C. Findings: the degree of findings depend on type of injury, i.e., complete or incomplete
transection of the spinal cord

1. Neurologic

a. spinal shock

b. neurogenic shock (if the injury involves the cervical or upper thoracic vertebrae)

i. altered reflex patterns, i.e., arereflexia, hypo or hyperflexia

ii. sensory changes, i.e., numbness, inability to feel pain or temperature, tingling



2. Cardiovascular - impaired control of the autonomic nervous system (ANS)

a. hypotension

b. dysrhythmias

c. autonomic dysreflexia


3. Respiratory

a. breathing difficulties from paralysis of the breathing muscles and phrenic nerve related
to injury at C3 or above, e.g., hypoventilation, apnea

b. absent or decreased protective mechanisms, i.e., cough


4. Musculoskeletal

a. weakness, incoordination, or paralysis below the level of the injury, i.e., paraplegia or
quadriplegia

b. altered muscle tone, i.e., spasticity, flaccidity, rigidity


5. Other: pain, bowel and bladder dysfunction, e.g., constipation, incontinence, bladder
spasms, and sexual dysfunction



D.
Diagnostics - used to identify the level and extent of injury

1. Radiological exam

2. Computerized Tomography (CT) scan

3. Magnetic Resonance Imaging (MRI
535


4. Somatosensory evoked potential


E. Complications

1. spinal shock
2. Neurogenic shock

2. autonomic dysreflexia

3. osteoporosis

4. pathologic fractures

5. muscle atrophy

6. paralytic or stress ulcers

7. sexual dysfunction

8. stool incontinence and or impaction

9. decubitus ulcers

10. urinary incontinence and or retention

11. permanent paralysis


F. Management

1. Emergency care

a. follow the ABCs of emergency care

b. log roll client to avoid flexing, extending, or rotating spine

c. immobilize spine with c-collar and spine board


2.
Pharmacologic

a. corticosteroids - to decrease spinal cord edema

b. vasopressors - to support blood pressure

c. antispasmotics

d. analgesics

e. stool softeners - to help prevent constipation

f. anticonagulants - to help prevent deep vein thrombosis

g. proton pump inhibitors - to prevent ulcer development


3. Surgery

a. decompression laminectomy

b. spinal fusion

c. insertion of hardware to stabilize and immobilize, e.g. Gardner-Wells tongs



G. Nursing interventions

1. Maintain proper alignment of spine / neck

2. Maintain patent airway

3. Maintain proper fluid / nutrition balance

4. Administer medications as ordered

5. Prevent complications

a. sequential compression device to lower extremities

b. anticoagulant administration

c. maintain skin integrity

d. prevent autonomic dysreflexia


6. Elimination

a. teach self catheterization
536


b. maintain hydration

c. teach bowel retraining programs


7. Mobility

a. passive and/or active range of motion (ROM)

b. reposition every 2 hours

c. maintain skin integrity



Points to Remember

In multiple sclerosis, early changes tend to be in vision and motor sensation; late changes tend to
be in cognition and bowel control.

Peripheral nerves can regenerate, but nerves in the spinal cord cannot regenerate.

During a seizure, turn the client to one side and do not force anything into the client's mouth.

A major problem often associated with a left-sided cerebral vascular accident (CVA) is an alteration
in communication.

Clients with any type of CVAs are at risk for aspiration; these clients must be evaluated for
dysphagia.

The rate, rhythm and depth of a client's respirations are more sensitive indicators of intracranial
pressure than blood pressure and pulse.

When caring for a comatose client, remember that the hearing is the last sense to be lost.

A CVA can result in a loss of memory, emotional lability and a decreased attention span.

Communication difficulties in a client who has had a CVA usually indicate involvement of the
dominant hemisphere, usually left, and is associated with right-sided hemiplegia or hemiparesis.

The client with myasthenia gravis (MG) will have more severe muscle weakness in the evening due
to the fact that muscles weaken with sustained or prolonged activity and regain strength with rest.

Priority when caring for a client having a seizure is protecting the client from injury; side rails should
be padded and suction and oxygen should be available at all times.

Prevent injury and provide diversionary activities activities to clients with Alzheimer's disease who
wander.

Clients with migraine headaches should be reminded to avoid triggers and take medication at the
onset of pain.

Use alternative forms of communication with clients diagnosed with ALS, MG, and stroke.


XI. Senses: Vision

A. Eye structures & function

1. Three layers of the eye: sclera, choroid, and retina

a. sclera (maintains eye shape) - the white part of the eye; protective; supports internal
structures


b. choroid: packed with blood vessels and pigmented to absorb light and prevent blurring
of image;

i. choroid forms iris and lens in front

ii. Schlemm's canal (venous sinus) circles where cornea and iris meet; iris gives eye
537

its color

iii. muscles of iris adjust the pupil

iv. pupil adjusts to:

protect retina

allow enough light to stimulate retina

improve depth perception

respond to sympathetic nervous system


v. ciliary body (smooth muscle) contracts to reduce tension of suspensory ligament on
lens

vi. lens converges light onto retina


c. retina: inner, posterior layer that is photosensitive

i. consists of four layers

pigmented epithelial cell

photoreceptor cells (rods and cones)

bipolar neuron

ganglion neuron


ii. optic disk : retinal area of optic disk contains no photoreceptors (blind spot)

iii. photoreceptor cells: turn light into nerve impulses that go to the optic nerve, cranial
nerve II

rods: located more peripherally - around edges of retina

black, white, gray vision

peripheral vision

cones: located in fovea centralis

three types: red, green, and blue receptors

fine discrimination and color vision








2. Optic nerve, cranial nerve II

a. nerve fibers from median half of each retina cross at chiasm and travel to the opposite sides
of the brain

b. nerve fibers from lateral halves of the retina remain uncrossed


3. Chambers

a. anterior chamber (locus of intraocular pressure [IOP]) and

b. posterior chamber


4. Vitreous body

5. Lens

a. separates the posterior chamber from the vitreous body

b. transparent

c. held in position by suspensory ligaments attached to the ciliary body


6. Accessory structures

a. protective structures: socket, eyelid, eyelashes, eyebrow, conjunctiva

b. lacrimal: secretes and drains fluid that moistens and lubricates the front surface of the eye

c. six oculomotor muscles surround and enter the eyeball
538




B. Eye functions

1. Light reception

a. light passes through the cornea, aqueous humor, lens, and vitreous body to retina

b. the density of the cornea slows the light, and the curvature of the cornea bends it
(refraction)

c. the lens further bends and redirects the light to a point on the retina

d. at this point, light stimulates the photoreceptor cells (rods, cones) which transmit electrical
impulses

e. these impulses travel through the optic nerve to the brain


2. Accommodation

a. process by which the lens changes shape to view an object at close range (or long range)

b. proper vision requires three processes:

i. convergence: image of object falls exactly on fovea centralis retinae of both eyes

ii. focusing of the lens (ciliary body [ciliary muscles] contract or relax)

iii. constriction or relaxation of pupils to regulate light and clarify image on retina


c. when muscles that carry out these three processes are weak or paralyzed, result is
strabismus


3. Binocular vision

a. allows brain to judge distance

b. brain judges

i. difference between two images

ii. the amount of retina taken up by the image

iii. difference between familiar and unfamiliar objects (example: person standing next to
an elephant)

iv. different shades of color


c. both eyes must move together for clear focus (conjugate eye movements)

d. to immobilize one eye, both eyes must be covered




C. Disorders of the eye - overview
Disorder Location Etiology Treatment
Eye trauma Cornea Abrasion Cover the eye to protect and
allow healing, eye drops;
antibiotic and anti-inflammatory
meds
Eye trauma Cornea Laceration Surgery, eye drops: antibiotic,
anti-inflammatory
539

Glaucoma Aqueous
humor
increased
Intraocular pressure
increased
Trabeculectomy; iridotomy, or
iridectomy; eye drops (often
miotics)
Cataract Lens Cloudy ECCE*, phacoemulsion; or
ICCE**
Disorders of
refraction
Lens Loses elasticity, or ciliary
muscles weaken
Corrective lens or various types
of outpatient laser surgery
Retinal
detachment
Retina Retina tears loose from
back of eye; severs
connection with optic
nerve
Laser surgery, cryotherapy,
diathermy, scleral buckle, or
pharmacotherapy
Retinal
degeneration
Retina Rod and cone cells
deteriorate
None
Amblyopia Entire eye Strabismus, cataracts,
disorders of refraction in
children
Glasses (for refractive error);
patch on normal eye; eye drops
* Extracapsular cataract extraction ** Intracapsular cataract extraction




D. Disorders of refraction

1. Myopia (near-sightedness): blurred distance vision, but clear close vision

2. Hyperopia (far-sightedness): blurred close vision, but clear distant vision

3. Presbyopia: in middle age, lens loses elasticity with results of hyperopia

4. Astigmatism: lens refracts light rays to focus on two different points of retina




E. Eye trauma

1. Foreign body: use eversion procedure

2. Corneal abrasion

a. disruption of the cells and loss of superficial epithelium

b. caused by trauma, chemical irritant, foreign body, or lack of moisture

c. severe pain, blurred vision, halo around lights, lacrimation, inability to open eye

d. diagnosis by fluorescein sodium dye

e. abrasions heal within 48 to 72 hours, usually with no scarring or visual deficit

f. treatment includes short-acting analgesic drops, eye rest, antiobiotics or anti-
inflammatories as indicated from cause

g. eye may be patched for client comfort and as a reminder not to rub or touch the eye


3. Corneal laceration
540


a. same causes, findings as abrasions, but lacerations are serious emergencies

b. surgery is generally required

c. follow care for client undergoing eye surgery (See Points to Remember at the end of the
lesson)


4. Penetrating injury

a. do not remove object

b. do not apply pressure of any kind to the eye or the object

c. cover injured eye to protect movement of the object; may use a cup or eye patch

d. cover uninjured eye to avoid sympathetic movement

e. get client to emergency room immediately

f. surgery will be required



5. Chemical irritants

a. flush eye with plenty of water or sterile saline - flush for a minimum of 5 minutes

b. get client to emergency room immediately

c. alkaline substances penetrate the cornea rapidly and must be removed quickly

d. acids coagulate the eye's proteins and often result in relatively superficial, reversible damage


6. Ultraviolet burns

a. often occur from sun exposure or welding flashes (looking at a welding flame without special
glasses during the welding process)

b. irritate epithelium, which swells and scales off (desquamation)

c. care is the same as with lacerations


7. General management of any eye trauma

a. copious irrigation of the affected eye

b. apply bilateral rigid or soft eye patches to rest both eyes by decreased eye movement

c. have clients use tinted glasses for photophobia to reduce eye discomfort from artificial lights or
sunlight

d. assist clients with activities of daily living as needed

e. review with clients to avoid activities which increase intraocular pressure

f.
general pharmacotherapy for eye trauma

i. topical anesthetics

ii. topical anti-inflammatory

iii. topical mydriatic-cycloplegic agents to prevent papillary constriction


Alkaline substances include lye, ammonia, some powdered detergents, drain cleaner, oven
cleaner, and battery fluid. To help remember the pH of alkaline substances, use this rhyme: If
the pH is high... it's alkali.


F. Glaucoma

1. Definition: group of eye conditions that lead to damage to the optic nerve due to increased
intraocular pressure (IOP)
541




2. Types - 4 major types

a. open-angle (chronic) glaucoma

b. angle-closure (acute) glaucoma

c. congenital glaucoma

d. secondary glaucoma





3. Chronic open-angle glaucoma

a. etiology: unknown

i. hereditary link

ii. aqueous humor does not drain adequately, causing intraocular pressure (IOP) to increase

iii. this pressure on optic nerve causes destruction of nerve fibers in retina, with results of
vision loss

iv. most common type: chronic open-angle glaucoma (also called simple, adult primary,
primary open-angle)


b. findings

i. most clients are symptom-free until loss of vision

ii. peripheral vision is affected first

iii. three classic findings

elevated intraocular pressure

visual field loss

cupping of optic disk



c. medical management

i. goals are reduction of intraocular pressure and prevention of visual field defects

ii.
treatment of choice: pharmacotherapy

miotic eye drops (parasympathomimetic agents) - pilocarpine

carbonic anhydrase inhibitors

beta-adrenergic blocking agents

epinephrine eye drops (contraindicated in clients with cardiac conditions)


iii. trabeculectomy or laser trabeculectomy - performed when pharmacological agents not
effective


d. nursing care

i. for pharmacotherapy management

compliance with medical treatment

reinforce client teaching

instilling eye drops

risks related to impaired vision


542


ii. for trabeculectomy by traditional surgery

monitor dressing for excessive bleeding

antiemetics, analgesics, corticosteroids and antibiotics as ordered

assist client with activities of daily living


iii. for trabeculectomy by laser surgery

vision may be blurred for first day or two post-op

eye patch or sunglasses for photophobia

analgesics as ordered


iv. reinforce client teaching regarding:

avoid things that increase intraocular pressure, such as bending, stooping,
straining or lifting (more than 10 pounds)

stress importance of routine eye examinations - once or twice per year






4. Acute closed-angle (shallow, narrow-angle, primary, or congested glaucoma) - iris bulges and
blocks trabecular network

a. etiology

i. a medical emergency, may result in permanent blindness

ii. iris lies near drainage channel (canal of Schlemm) and bulges forward against cornea,
blocking the trabecular network and increasing IOP

iii. affects more women; usually after age 45


b. findings

i. sudden onset of blurred vision, halos or colored rings around white lights, frontal headache,
severe eye pain

ii. followed by progression of findings as pressure increases: profuse lacrimation; mildly
dilated, nonreactive pupil, and nausea/vomiting, cornea appears hazy

iii. findings may come and go, and resolve with rest or sleep


c. medical management

i. goal is to prevent or minimize the damaging effects of acute closed-angle glaucoma

ii.
emergency pharmacologic treatment to decrease intraocular pressure

includes carbonic anhydrase inhibitors - Diamox

miotic eye drops - constricts pupil

intravenous osmotic agents

systemic analgesics


iii. surgery

iridotomy or iridectomy

procedure is usually then repeated on unaffected eye



d. nursing interventions

i. give medications as ordered

ii. advise post-op eyepatch or sunglasses for photophobia

iii. inform that vision will be blurred for 1 to 2 days post surgery

iv. stress importance of routine eye examinations

v. reinforce teaching for the avoidance of activities that increase intraocular pressure




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G. Cataract

1. Definition: clouding of lens - may be unilateral or bilateral; one of the most common eye
disorders

2. Etiology


a. clouding of lens - may be unilateral or bilateral; one of the most common eye disorders

b. first type: senile cataract - result of aging process

c. second type: traumatic

i. develops within a few months after eye trauma

ii. painless but progressive loss of sight in one or both eyes



3. Findings - review the Mayo Clinic's slideshow Vision Problems as You Age (see Links to
Knowledge box below)

4. Diagnostics

a. history

b. physical exam of eyes



5. Management

a. expected outcome: correction of visual field defect

b. treatment - surgical extraction of cloudy lens


i. most commonly done as an outpatient procedure

ii. usually done on one eye at a time

iii. types of cataract extractions

extracapsular cataract extraction (ECCE) - procedure of choice; lens contents
removed and the posterior chamber is left intact

phacoemulsification (ultrasound fragments of the lens contents are suctioned out
of chamber)

intracapsular cataract extraction (ICCE) - rare procedure but may be done with
cataracts due to trauma; lens contents and lens capsule removed



c. intraocular lens implant is usually performed at the time of the extraction

d. peripheral iridectomy is usually performed as part of an ECCE or ICCE


6. Potential complications of surgery

a. hyphema (blood in anterior chamber of the eye)
544


i. may require bed rest, patching, special positioning

ii. observe for increased intraocular pressure - severe eye pain

iii. may prescribe miotics or cycloplegics


b. vitreous prolapse

i. allows vitreous humor to fall forward into wound

ii. may result in pupil block

iii. may lead to retinal detachment

iv. vitrectomy may be performed


c. intraocular infection

i. complaints of throbbing eye pain, drainage

ii. antibiotics (ophthalmic or systemic)



7. Nursing interventions - reinforce client teaching

a. avoiding activities that may cause increased intraocular pressure (IOP)

b. instilling eye drops correctly - wash hands before and after instillation

c. recognizing complications and explaining when to call health care provider

d. understanding of expected findings post-extraction, including

photophobia

feeling that sand is in eye or scratchy feeling for two to three months

pupil may not constrict as readily and be non-circular






H. Retinal detachment

1. Definition: holes or breaks (tears) in the retina

2. Etiology


a. fluid, blood or a mass separates the retina's sensory layer from the pigmented epithelium
(pigment cells)

b. common causes are inflammation, trauma, hemorrhage, and tumors

c. retinal detachment often begins in the periphery and spreads posteriorly


3. Findings

a. arapid separation gives the sense of a "curtain being pulled over the eye" so that clients
have partial vision in affected eye

b. aslow separation may be asymptomatic

c. the ophthalmic exam reveals the detached area as gray bulge, ripple or fold


4. Diagnostics

a. history

b. physical inspection


545


5. Management

a. expected outcome: correction of and/or prevention of further vision loss (vast majority of
retinal detachments are successfully repaired)

b. laser surgery

i. photocoagulation: laser beam is directed through a dilated pupil

ii. the effect is to seal localized breaks or rips in the retina


c. cryotherapy: extreme cold freezes rips in the retina

d. diathermy: heat is applied with ultrasonic probe to repair rips

e. scleral buckle



f.
pharmacotherapy: local or systemic

i. adrenergic-mydriatic agents

ii. cycloplegic agents

iii. antibiotics



6. Nursing interventions

a. maintain the client in proper position for bed or chair rest as ordered

b. apply a post-op rigid/soft eye patch to rest eye (or both eyes)

c. suggest dark lens glasses for photophobia

d. administer medications as ordered

e. prevent activities that increase IOP



I. Visual impairment and blindness

1. Definition: legal blindness is a maximum visual acuity of 20/200 (with optimum correction)
and/or a visual field that is reduced to a range of 20 degrees (normal range=180 degrees)

2. Chief causes: retinal degeneration, glaucoma, cataract, and amblyopia

3. Nursing care

a. speak to client upon entering room

b. incorporate safety measures based on how client accommodates sight loss

c. orient client to new surroundings - placement of furniture, communication methods

d. assist with activities of daily living as required

e. for walking, do not take client's arm to lead - instead, offer client your lower arm, near elbow

f. describe position of items in correlation to the numbers on a clock face - 12, 3, 6, 9




J. Color blindness

1. Definition: an abnormal condition characterized by the inability to clearly distinguish different
colors of the spectrum

2. Etiology

a. usually genetic but may be acquired, as with diseases (Alzheimer's disease, diabetes
mellitus, glaucoma, leukemia, liver disease, chronic alcoholism, macular degeneration,
546

multiple sclerosis, Parkinson's disease), medications (antibiotics, barbiturates,
antitubercular drugs), or chemicals (carbon monoxide, fertilizers, lead)

b. pre-term infants exhibit an increased prevalence of blue color blindness

c. Types: 3 basic variants

i. red-green - most common type of color blindness

ii. blue-yellow (which are seen as white or gray): rare

iii. achromatopsia: total inability to distinguish any color



3. Diagnostics: vision tests (american Optical/Hardy, Rand, and Ritter Pseudoisochromatic test)

4. Treatment: none; focus is on lifestyle changes and using environmental cues


XII. Senses: Hearing

A. Structures of the ear

1. External ear - pinna, mastoid process, external ear canal, tympanic membrane

2. Middle ear

a. tiny, air-filled cavity containing three small bones: incus (anvil), malleus (hammer) and
stapes (stirrup)

b. these bones (ossicles) are connected by joints and supported by muscles

c. ossicles bridge the tympanic membrane and the oval window

d. ossicles magnify small sounds by transmitting them from (small) oval window to
(much larger) tympanic membrane





3. Inner ear

a. contains the sensory receptors for sound and equilibrium

b. connected to nasopharynx by the eustachian tube

c. tube opens during swallowing to equalize inner ear pressure to atmospheric pressure

d. composed of fluid-filled membranous labyrinth in a similarly shaped bony labyrinth

e. membranous labyrinth components include the cochlea and the vestibular apparatus

f. cochlea: a spiral tube

g. within the cochlea is a membranous duct with a triangular cross section:

i. side 1 lies against wall of bony labyrinth

ii. side 2 is made up of Reissner's membrane

iii. side 3 is Organ of Corti (basilar membrane ) which contains the tectorial membrane,
connected by hairs to sound-receptor cells

iv. hairs of receptors convert sound waves to neural impulses

v. impulses travel via the eighth cranial nerve to the brain


h. vestibular apparatus: reflects body position

i. surrounded by perilymph and temporal bone

ii. consists of membranous saccule, utricle, and semicircular canals

iii. in these canals, static and dynamic equilibrium receptors send impulses to the brain
547

regarding body position




B. Outer ear disorders: otitis externa

1. Definition: an infection of the external auditory canal (also called "swimmer's ear")


2. Etiology

most commonly Pseudomonas, also Staphylococcus and Streptococcus

localized trauma (from Q-Tips) or regular swimming or diving decreases the
protective layer of cerumen and creates a environment for bacterial invasion

although seen in all age groups, peak incidence is in children


3. Findings

history of progressive ear pain

pruritus within ear canal

purulent discharge

feeling of fullness or pressure in ear


4. Diagnostics: usually a clinical diagnosis based on history and physical

5. Management

a. preventative: use earplugs when swimming and acidifying drops after swimming

b. gentle cleaning and/or irrigation with a mix of peroxide and warm water (if tympanic
membrane is intact)

c. ear wick

d. analgesics, antipruritics, and antihistamines


6. Nursing interventions

a. teach client the importance of keeping the ear dry

b. teach client how to apply medication to cotton wick and ear canal




C. Middle ear disorders

1. Otitis media

a. definition: infection or inflammation of the middle ear - may be acute (AOM) or chronic

b. etiology

i. usually preceded by a respiratory infection

ii.
bottle feeding increases the risk of ear infection or inflammation

iii.
the second most common diagnosis in sick children in the U.S., after upper
respiratory infections (URI)


c. findings

i. otalgia (ear pain)

ii. otorrhea (discharge from the ear)

iii. fever
548


iv. irritability

v. headache

vi. concurrent (or recent) URI


d. diagnostics

i. laboratory evaluation is usually not necessary for most cases

ii. tympanometry, reflectometry, and/or hearing test

iii. imaging studies for infants or in chronic cases


e. management

i. observation (wait & see approach), over-the-counter pain reliever, applying a warm
moist cloth over the affected ear for uncomplicated AOM with no effusion

ii. chronic cases with effusion: antibiotics, antihistamine-decongestants, steroids, NSAIDs,
mucolytics

iii. in severe cases - surgery (tympanocentesis, myringotomy, TT insertion,
adenoidectomy)

iv.
probiotics (Lactobacillus) and xylitol, herbal ear drops (Calendula officinalis,
Hypericum perfoliatum, Allium sativum), echinacea, chamomilla

v. prevention

vaccinations, e.g., flu vaccine, meningitis, Haemophilus influenzae type B,
Streptococcus pneumoniae

hand washing

limit or eliminate use of pacifiers

elimination of foods that may increase risk of infections, especially wheat,
dairy products, corn, peanuts, or eggs



f. nursing interventions

i. reinforce need to take medications as prescribed

ii. reinforce need for follow up visit for evaluation of effectiveness of treatment

iii. post-op care following surgical intervention


g. complications: tympanic membrane perforation, chronic suppurative otitis media, bacterial
meningitis




2. Otosclerosis

a. definition: a hereditary degenerative disorder that results in conduction deafness

b. etiology: unknown

i. may be familial tendency; more common in women

ii. formation of new bone growth in labyrinth adheres the stapes to the oval window

iii. most frequent cause of middle ear hearing loss in young adults


c. findings

i. (gradual) hearing loss

ii. tinnitus


d. diagnostics: hearing tests

e. management

i. expected outcome: improvement of hearing in the affected ear

ii. medical: use of a hearing aid

iii. surgical: stapedectomy (replacement of stapes with a prosthesis)


f. nursing interventions (postoperative care)
549


i. teach clients to avoid anything that might displace prosthesis, such as coughing, blowing
nose, swimming

ii. limit activity as ordered and as tolerated

iii. give medications as ordered, including antiemetics, analgesics, antibiotics

iv. assess facial nerve function for asymmetry

v. keep external ear area dry

vi. instruct client not to fly for at least six months




D. Inner ear: Mnire's disease

1. Definition: an inner ear disorder where the endolymphatic system dilates and the volume of
endolymph expands

2. Etiology: unknown

a. usually develops between the ages of 40 and 60 years-old

b. acute attack may require hospitalization

c. clients may average two to three attacks per year


3. Findings

a. attacks intermittent

b. three recurrent and progressive findings

i. vertigo with prostrating nausea and vomiting

ii. tinnitus

iii. hearing loss on involved side persists and progresses



4. Diagnostics

a. history

b. direct inspection


5. Management

a. expected outcomes - prevention of hearing loss and control of vertigo

b. medical

i.
pharmacologic - routine

cholinergic blocking agents such as atropine

antihistamines or decongestants


ii.
pharmacolgoic - during remission

diuretics - decrease fluid accumulation

vestibular suppressants, e.g., diazepam (Valium)

adrenergic neuron-blocking agents, e.g., epinephrine


iii.
low salt, low triglyceride diet


c. surgical

decompression of endolymphatic sac: insertion of an endolymphatic subarachnoid shunt

labyrinthectomy: client will lose all hearing in affected ear



6. Nursing interventions - during an acute attack of Mnire's disease

a. keep clients on bed rest in a quiet, dark room

b. avoid unnecessary movement of clients especially of their head

c. give general care to clients with nausea and vomiting

d. restrict salt and water intake as ordered
550


e. have clients avoid tobacco, caffeine

f. institute precautions to prevent clients from falling

g. discuss the need to avoid a high triglyceride diet




E. Hearing loss

1. Definition: an inability to perceive the normal range of sounds audible to an individual with
normal hearing

2. Etiology

a. conductive

i. sound is not conducted efficiently through the outer ear to the middle and inner ear

ii. due to inflammation, obstruction, scarring, allergies, earwax buildup

iii. reduction in sound level or ability to hear faint sounds


b. sensorineural

i. damage to the inner ear (cochlea) or nerve pathways

ii. damage to cranial nerve VIII from aging, head trauma, exposure to loud noise,
medications (such as aspirin, certain antibiotics); also familial tendency


c. mixed


3. Findings

a. decreased hearing

b. tinnitus

c. vertigo



4. Diagnostics

a. otoscopic examination

b. audiometry

c. tests to evaluate hearing, e.g., pure-tone testing, speech testing, auditory brainstem
response


551


5.
Management: depends on type of hearing loss and etiology

a. conductive hearing loss

i. surgery - skin graft for traumatically damaged ear drum; tympanoplasty

ii. removal of ear wax

iii.
antibiotics




b. sensory and neural hearing loss - hearing aids

c.
preventative oral intake of flax oil and omega 3 oil to alleviate accumulation of wax in the
ear

d. speech therapy

e. balance (vestibular) rehabilitation



6. Nursing interventions

a. use other modes of communication when appropriate

b. face client when speaking and do not shout

c.
regular health screenings


d. teach client

i. about workplace noise dangers, noisy toys, recreational noise

ii. preventing falls (due to vertigo)







Points to Remember
Eye

Anything that dilates the pupil obstructs the canal of Schlemm and increases intraocular pressure.

Color blindness, a deficiency in one or more types of cones, is caused by a sex-linked recessive
gene.

Destruction of either the right or left optic nerve tract results in blindness in the respective side of
both eyes.

When mydriatics are instilled, caution clients that vision will be blurred for up to 2 hours; advise
sunglasses for photophobia.

Following eye surgery, reinforce teaching for clients to avoid activities that can increase IOP for 6
weeks

Stooping

Bending from the waist

Heavy lifting - greater than ten pounds
552


Excessive fluid intake

Emotional upsets

Constrictive clothing around neck

Straining with bowel movement or blowing the nose

Reinforce teaching regarding proper administration of eyedrops: to place drop in conjunctival sac
and avoid direct placement on eyeball.

When clients wear eye patches, they lose depth perception; this loss presents a safety risk.

Systemic disorders that can change ocular status include diabetes mellitus, atherosclerosis, Graves'
disease (hyperthyroidism), AIDS, leukemia, lupus erythematosus, rheumatoid arthritis, sickle cell
disease.

Red-green color blindness (where red and green might look the same) is the most common form of
color blindness.

Points to Remember 2
Ear

Changes in barometric pressure will affect persons with ear disorders.

Hearing loss

can be partial or total

can affect one or both ears

can occur in low, medium or high frequencies

American Medical Association formula for hearing loss: hearing is impaired 1.5% for every decibel
that the pure tone average exceeds 25 decibels (dB).

A hearing loss of 22.5% usually affects social functionality and requires a hearing aid.

Noise exposure is the major cause of hearing loss in the United States.

Ask clients how they communicate: lip-reading, sign language, body gestures, or writing.

To gain the client's attention, raise your hand or touch the client's arm.

When talking with hearing impaired clients, speak slowly and face them.

Speak toward the client's good ear.

If the clients wear a hearing aid, allow them to show you how it is inserted and maintained.

Speaking louder to hearing impaired clients does not increase chances of being heard.

Low tones are heard better than high-pitched tones by clients with a hearing impairment.

Communicate the client's hearing loss to other staff members by verbal and written means.

Tell clients taking ototoxic drugs to report any signs of dizziness, loss of balance, tinnitus, or hearing
loss. Ototoxic drugs include:

aminoglycosides

antimyobacterials

thiazides

loop diuretics

antineoplastics


553



I. Anatomy and Physiology

A. Upper gastrointestinal tract

1. Mouth - teeth, tongue, salivary glands

2. Esophagus

3. Stomach


4. Pharynx



B. Lower gastrointestinal tract

1. Small intestine - digests and absorbs, mixes via peristalsis, receives secretions from liver, gallbladder
and pancreas

a. duodenum - joins pylorus of stomach; about 10 inches long

b. jejunum - middle section; about 8 feet long

c. ileum - lower section; about 12 feet long



2. Colon - approximately 6 feet long, absorbs water and sodium

a. cecum ascending - begins at ileocecal valve where appendix is also located, on right lower
abdomen

b. transverse - area of upper abdomen, right and left

c. descending - area of left lower abdomen

d. sigmoid - area of left lower abdomen

e. rectum - last 7 to 8 inches of large intestine; 'S'-shaped



554


C. Accessory digestive organs

1. Liver - largest gland of the body

a. lobes divided into lobules by blood vessels and fibrous material


b. ducts - hepatic duct from liver; cystic duct from gallbladder; common bile duct formed by
hepatic duct and cystic duct and drains into duodenum

c. functions:

i. aids in the metabolism of fats, carbohydrates, and proteins

converts glucose to glycogen for storage in the liver

converts glycogen to glucose and releases into bloodstream

forms glucose from fats or proteins

breaks down fatty acids into ketones

stores fat


ii. synthesizes

triglycerides

phospholipids

cholesterol

choline (B complex factor)

various proteins


iii. converts

amino acid to ammonia

ammonia to urea


iv. other functions

secretes bile, which is important in the emulsifying of fats and is stored in the
gallbladder

detoxifies substances such as drugs, hormones

metabolizes vitamins






2. Pancreas

a. fish-shaped organ extending from duodenal curve to the spleen across upper- abdominal area

555



b. both an endocrine and exocrine gland

i. exocrine: pancreatic cells (acini)
secretory cell clusters secrete enzymes which digest fats, carbohydrates and proteins

enzymes empty into pancreatic duct and then into duodenum along with bile from the
common bile duct


ii. endocrine: Islet of Langerhans

alpha cells secrete glucagon into blood to promote liver glycogenolysis and
gluconeogenesis which ultimately increases blood glucose level

beta cells secrete insulin into blood for glucose control





3. Gallbladder

a. similar in size and shape to a pear


b. made up of smooth muscle and lined with rugae-arranged mucosa

c. only purpose is to store bile

d. empties bile into duodenum when fat is present there



D. Process of digestion

1. Purpose - converts foods into a form which can be absorbed and used by the body

2. Digestive enzymes - substances necessary to break down food into useable form

3. Basic processes

a. absorption - accomplished by active transport via intestinal cells; water and solutes move
through the intestinal mucosa in opposite direction expected in osmosis and diffusion

b. metabolism - consists of the sum of all physical and chemical changes that take place within an
organism

c. catabolism - series of chemical reactions that take place within the cell; breaks down food
molecules to produce energy

d. anabolism - synthesis of compounds from simpler compounds




II. Disorders of Stomach and Colon

A. Pernicious anemia

1. Definition: mucosa and parietal cells of stomach atrophy; stomach fails to produce intrinsic
factor, thus vitamin B12 cannot be properly absorbed

2. Etiology & pathophysiology

a. results in large red blood cells (macrocytic normochromic)
556


b. hydrochloric acid

c. possibly an autoimmune disease

d. often follows gastric resection


3. Findings

a. anemia - findings depend on severity

b. tissue hypoxia - producing fatigue, weakness, dyspnea, pallor, palpitations

c. GI symptoms - sore tongue, anorexia, nausea, vomiting, abdominal pain

d. neurological symptoms - paresthesia in hands and feet, weakness, impaired coordination,
changes in level of consciousness (LOC)

e. complications: GI findings are reversible, but neurological changes are not


4. Complications - GI symptoms are reversible, but neurological changes are irreversible if
treatment is delayed



5.
Diagnostics

a. complete blood count

b. bone-marrow biopsy

c. lack of free hydrochloric acid in stomach

d. Schilling test - to determine whether the body absorbs vitamin B12 normally


6. Management

a.
lifelong monthly vitamin B12 injections (cyanocobalamin)

b.
adequate nutrition

c. blood transfusions as needed


7. Nursing care

a. monitor for impaired gas exchange

b. assist client to manage fatigue

c. monitor for risk of injury from potential decreased level of consciousness and impaired coordination

d. reinforce client teaching regarding:

i. need for lifelong B12

replacement

ii. actions to deal with findings as they interfere with activities of daily living (ADL)




B. Peptic ulcer disease

1. Gastric ulcers

a. definition: an ulceration of the mucous membrane of the esophagus, stomach, or duodenum,
due to action of the acid gastric juice
557



b. etiology and pathophysiology

i. incidence higher if 50 years-old or older

ii. risk factors - use of aspirin, NSAIDs, steroids, caffeine, and alcohol intake; uncontrolled stress;
family history

iii. pathogen - Helicobacter pylori (H. pylori)

iv. most common site - junction of fundus and pylorus


c. findings

i. pain, burning, or gas that worsens with ingestion of food

ii. pain in left upper epigastric area

iii. nausea/vomiting

iv. bleeding; hematemesis





2. Duodenal ulcers

a. definition: an ulcer of the duodenum

b. etiology and risk factors

i. excess production of hydrochloric acid

ii. more rapid gastric emptying

iii. familial tendency

iv. uncontrolled stress response

v. more frequent in people with type O blood

vi. more common in men ages 25 to 50 years-old


c. findings

i. pain, heartburn occur during night or when stomach is empty

ii. pain typically relieved by food intake

iii. melena (tarry stool; black with digested blood)

iv. complications

hemorrhage

assist with iced saline lavage to control bleeding

care provider administers intra-arterial vasopressin

administer intravenous fluids and blood replacement

perforation and peritonitis

severe abdominal pain, increases with movement

sudden board-like abdomen with rupture or when perforation occurs
558


paralytic ileus: absence or decrease in peristalsis with resultant absent bowel sounds

obstruction: scarring may obstruct pylorus





3. Diagnostics for both types

a. endoscopy - esophagogastroduodenoscopy with biopsy

b. gastric analysis

c. upper GI series

d. test stool for occult blood


4. Management for both types

a. before surgical interventions:

i. NPO (nothing by mouth)

ii. nasogastric tube

iii. pharmacologic

antiinfectives: clarithromycin (Biaxin); metronidazole (Flagyl), amoxicillin, tetracycline

H2 receptor antagonists: cimetidine (Tagamet); ranitidine hydrochloride (Zantac);
famotidine (Pepcid); nizatidine (Axid)

anticholinergics: dicyclomine hydrochloride (Bentyl)

antacids: aluminum hydroxide (Amphojel); aluminum-magnesium combinations
(Maalox, Mylanta, Gelusil); calcium carbonate (Tums) - used less frequently

cytoprotective: sucralfate (Carafate)

proton pump inhibitors: omeprazole (Prilosec)

anxiolytics: if stress is a problem

prokinetics: metoclopramide (Reglan)


iv. blood administration


b. surgical intervention

i. vagotomy - eliminates stimulation of gastric cells

ii. pyloroplasty - widening pylorus to improve gastric emptying

iii. subtotal gastrectomy

iv. Billroth I (gastroduodenostomy)

v. Billroth II (gastrojejunostomy)

vi. total gastrectomy


c. postoperative complications

i. dumping syndrome - from rapid emptying of the stomach

tachycardia, palpitations, syncope, diaphoresis, diarrhea, nausea, abdominal distention

more common with Billroth II

subsides after several months

decreases with slow eating, low-carbohydrate, high-protein and fat diet

avoid liquids with meals

if possible, lie down on left side for one to two hours after eating


ii. pernicious anemia secondary to loss of intrinsic factor from removal of part of stomach


559

Complementary and Alternative Medicine
Some evidence supports natural remedies for ulcer prevention and/or management: vitamin
supplements (A, E, K) and licorice.
Other possible therapies for ulcer prevention and/or management (usually associated with stress
reduction):

Ayurvedic medicine: treatment includes dietary and lifestyle changes

Guided imagery, creative visualization, hypnotherapy, meditation and yoga

Homeopathy: use of anacardium, argentum nitricum, and nux vomica

Traditional Chinese medicine, including massage therapy to focus on balancing qi in the stomach,
spleen, and/or liver meridians

Acupuncture

5. Nursing care

a. pain relief

b. monitor for bleeding

c. discuss lifestyle changes: stop smoking, decrease or better control of stress responses

d. reinforce teaching - medications, diet

e. monitor for post-operative complications - infection, bleeding, respiratory complications

f.
maintain patency of nasogastric (NG) tube


g. observe drainage for signs of bleeding (drainage should be dark [not bright] red after initial 24
hours)

h. cimetidine (Tagamet) can cause delirium in the elderly and increases the bioavailability of many
drugs including beta blockers, morphine, and famotidine (Pepcid)

i. give frequent mouth care


To help remember PUD treatment, use this phrase:
"Please Make Tummy Better"

P= Proton pump inhibitor
M= Metronidazole
T= Tetracycline
B= Bismuth subsalicylate


C. Gastroesophageal Reflux Disease (GERD)

1. Definition: a condition in which the gastric contents leak backwards from the stomach into the
esophagus

2. Etiology

a. when muscle fibers (called the lower esophageal sphincter or LES) don't close well, gastric
contents leak back into the esophagus (reflux)

b. reflux causes symptoms and can damage the esophagus

c. risk factors - hiatal hernia, obesity, pregnancy, smoking, scleroderma
560



3. Findings

a. heartburn or burning pain the chest, increased by bending, stooping, lying down, eating;
relieved by antacids

b. nausea after eating

c.
pediatric

i. vomiting or spitting up with meals

ii. failure to thrive

iii. irritable

iv. pallor or cyanosis




Diagnostics

a. history and physical

b. barium swallow

c. esophagogastroduodenoscopy (EGD)

d. esophageal pH

e. esophageal manometry studies

f. scintigraphy - assess gastric emptying

Management

a. depends on severity of findings

b.
more frequent feedings with frequent burping

c.
eat smaller meals and decrease caffeine intake, avoid acidic foods

d. do not lie down 2 hours after eating and sleep with head of bed elevated

e. stop smoking

f.
pharmacologic

i. H2-receptor antagonists, including cimetidine (Tagamet) or famotidine (Pepcid)

ii. proton pump inhibitors, including esomeprazole (Nexium) or pantoprazole (Protonix)

iii. over-the-counter antacids


g. surgery - Nissen fundoplication

Nursing care

a. monitor nutritional status

b. monitor electrolyte levels

c. reinforce teaching points - diet and medication



561

III. Disorders of the Intestines

A. Inflammatory intestinal diseases

1. Ulcerative colitis

a. definition: an inflammatory bowel disease that causes swelling, ulcerations, and loss of
function of the large intestine


b. etiology and pathophysiology

i. begins in rectum and extends to distal colon

ii. abscess and ulcers lead to bleeding and diarrhea

iii. colon cannot absorb because of the scarring, so fluids and electrolytes become
imbalanced

iv. protein is lost in the stools

v. scarring produces narrowing, thickening, and shortening of the colon

vi. remissions and exacerbations are often influenced by periods of higher stress in the
client's life


c. findings

i. bloody diarrhea that ranges from two-three per day to 10 to 20 per day

ii. stools may also contain pus and mucus

iii. abdominal pain - tenderness and cramping

iv. fever, weight loss, anemia, tachycardia, dehydration

v. impaired absorption of fat-soluble vitamins A, D, E, and K

vi. loss of potassium, protein and base or bicarbonate

vii. systemic manifestations

skin lesions - erythema nodosum

joint inflammation

inflammation of the eyes - uveitis

liver disease






d. diagnostics

i. sigmoidoscopy

ii. colonoscopy
562


iii. barium enema

iv. complete blood count (CBC)


e. management

i. before surgery

rest

fluid, electrolyte, and blood replacement

pharmacologic

steroids as anti-inflammatory drugs

immunosuppressives

anti-infectives: sulfasalazine (Azulfidine) primary drug of choice

anticholinergics

antidiarrheals

dietary restrictions - high calorie and high protein


ii. surgical management

total proctocolectomy and ileostomy

ileorectal anastomosis

total proctocolectomy with continent ileostomy (Kock pouch)

total colectomy with ileal pouch (reservoir)



f. complications

increased risk of colon cancer

severe fluid and electrolyte imbalances


g. nursing care

i. assist client to manage

pain

diarrhea


ii. reinforce client teaching regarding:

weight loss

nutrition

coping resources for stress management

knowledge deficits related to long-term care

actions to reduce anxiety



Don't confuse these three!
Ileum = most distal part of the small intestine
Ileus = an obstruction (often in an intestine)
Ilium = part of the hipbone







2. Crohn's disease
563


a. definition: a type of inflammatory bowel disease resulting in swelling and dysfunction of the
intestinal tract, especially the small intestine


b. etiology

i. young people 15 to 30 years old

ii. inflammation involves all layers of bowel wall - transmural

iii. ulceration, fissures, fistula, and abscess formation

iv. bowel wall thickens and narrows, producing strictures

v. slowly progressive


c. findings

i. diarrhea with steatorrhea

ii. abdominal pain - right lower quadrant

iii. fatigue, weight loss, dehydration, fever

iv. systemic manifestations

arthritis, clubbing of fingers

skin inflammations

nephrolithiasis

complications

obstruction from strictures

fistula formation

bowel may perforate and infect: peritonitis





d.
diagnostics - same as ulcerative colitis

e. management

i. rest

ii. nutritional support

iii.
pharmacologic

hyperalimentation

steroids as anti-inflammatories

immunosuppressives

antiinfectives: sulfasalazine (Azulfidine) primary drug of choice

anticholinergics

antidiarrheals

loperamide (Imodium) drug of choice for diarrhea


iv.
diet high in calories and protein, low in roughage and fat

v. balloon dilation of strictures

vi. surgery will not cure Crohn's disease; may limit damage
564


colectomy with ileostomy

subtotal colectomy with ileostomy or ileorectal anastomosis



f. nursing care after surgery

i. monitor

diarrhea

fluid balance and nutrition

skin integrity

coping and self-care activities

sexuality needs


ii. give medications as ordered



B. Diverticular disease

1. Definition: outpouching of the intestinal mucosa


2. Etiology and pathophysiology

a. most common in sigmoid colon

b. constipation, low fiber diet, obesity

c. colon wall thickens with increased pressure in bowel

d. stool and bacteria retained in diverticulum become inflamed and small perforations occur

e. inflammation of surrounding tissue


3. Findings

a. frequently asymptomatic

b. crampy, lower, left abdominal pain

c. alternating constipation and diarrhea

d. low grade fever, chills, anorexia, nausea

e. leukocytosis



4. Diagnostics

a. barium enema

b. complete blood count, urinalysis, stool for occult blood

c. colonoscopy


5. Management

a. diverticulosis (outpouching)

i. high fiber diet

ii. pharmacologic

bulk laxatives

stool softeners
565


anticholinergics



b. diverticulitis (inflammation)

i. NPO for 24 to 48 hours

ii.
rest bowel - low fiber diet in acute phase

iii.
antibiotics

iv. surgery

bowel resection

temporary colostomy




6. Complications

a. abscess formation

b. perforation with peritonitis

c. fistula

d. bowel obstruction

e. hemorrhage


7. Nursing care

i. reinforce the appropriate diet in acute and chronic phases

ii. advise to avoid increased abdominal pressure, e.g., no straining, coughing, lifting more than ten
pounds



C. Constipation

1. Definition: having a bowel movement fewer than three times per week

a. decreased frequency

b. stool is hard, dry, difficult to pass

c. stool is retained in rectum


2. Etiology

a. change in normal bowel habits characterized by

i. decreased frequency

ii. stool is hard, dry, difficult to pass

iii. stool is retained in rectum


b. risk factors

i. insufficient dietary fiber

ii. insufficient fluid intake

iii. medications, especially opiates

iv. lack of activity

v. ignoring urge to defecate

vi. chronic laxative abuse

vii. lack of privacy and/or psychological factors

viii. pregnancy

ix. neuromuscular impairment

x. hypothyroidism


566



3. Findings

a. hard, dry stool

b. abdominal distention

c. decreased frequency of usual stool elimination patterns

d. straining

e. nausea/anorexia

f. palpable mass

g. hemorrhoids

h. fecal impaction with frequent small liquid stools



4. Complications

a. obstruction and/or perforation

b. cardiovascular alterations



5. Diagnostics - history and physical


6. Management

a. cathartics

i. saline or osmotic laxatives - milk of magnesia, magnesium citrate

ii. stimulant laxatives - bisacodyl (Dulcolax)

iii. bulk-forming laxatives - psyllium (Metamucil)

iv. lubricant-emollient - mineral oil

v. stool softeners - docusate sodium (Colace)


b. enemas

i. cleansing - saline, soap solution (volume ordered varies between 500 to 1000 mL)

ii. softening or retention - oil (usually around 100 to 120 mL, packaged in a plastic squeeze bottle
fitted with a 5 centimeter prelubricated rectal tube)

iii. Fleets - a trademark name for a commercially available enema containing 100 mL solution with
16 grams sodium biphosphate and 6 grams of sodium phosphate; packaged in a plastic squeeze
bottle fitted with a 5 centimeter pre-lubricated rectal tube



7. Nursing care

a. reinforce the need for proper nutrition, increased fiber, and increased fluids

b. advise that client obey urge to defecate

c. provide privacy and comfort

d. discuss the need to increase activity


567

Complementary and Alternative Medicine
Complementary and alternative medicines used in the treatment and management of constipation:

Flax seeds or flaxseed oil
Acupuncture
Massage
Reflexology
Aromatherapy

D. Diarrhea

1. Definition: frequent passage of loose stools

2. Etiology

a. fecal impaction - will be frequent, small and liquid

b. ulcerative colitis

c. intestinal infections

d. increased fiber

e. medications, especially antibiotics


3. Findings

a. loose watery or mushy stools

b. complications

i. dehydration

ii. electrolyte imbalance



4.
Diagnostics

a. evaluation and diagnostics depend on cause, duration and severity

b. acute

i.
serum electrolytes

ii.
serum osmolality

iii.
stool specimen for analysis and culture


c. chronic

i. stool specimen for analysis and culture

ii. sigmoidoscopy

iii. biopsy of bowel mucosa to identify inflammation




5. Complications: dehydration, electrolyte imbalance

6. Management

a.
mild diarrhea - oral fluids such as Gatorade, Pedialyte products to replace lost fluid

b.
moderate diarrhea - drugs that decrease motility (Lomotil, Imodium)

c. severe diarrhea - usually from infection, antimicrobials and fluid replacement - treat cause


7. Nursing care

a. monitor for fluid and electrolyte imbalance

b. prevent skin excoriation
568


c. reinforce client teaching regarding:

i.
foods that may affect bowel elimination, e.g., raw fruits or vegetables stimulate peristalsis

ii. not to take antidiarrheals if food poisoning or any infectious process is suspected

iii. if infection, goal is to evacuate bowel of infectious contents


Complementary and Alternative Medicine
Complementary and alternative medicines used in the treatment and management of diarrhea:

Lactase enzymes for lactose intolerance
Herbal treatments, including strong tea of black pepper, chamomile, coriander, rosemary, sandalwood
or thyme
Ginger tea or capsules to reduce intestinal inflammation
Podophyllum tablets

E. Bowel obstruction

1. Definition: a partial or complete blockage of the bowel that results in the failure of the intestinal
contents to pass through


2. Etiology

a. mechanical: adhesions, hernias, neoplasms, volvulus, intussusception

b. nonmechanical: paralytic ileus, occlusion of vascular supply

c. fluid shifts from increased venous pressure with results of hypotension and hypovolemic shock

d. bacteria proliferate


3. Findings

a. abdominal pain

b. distention (more with large bowel obstruction)

c. nausea and vomiting (more with small bowel obstruction) - vomitus will be bile-stained
(yellowish brown) which indicates fluid from small intestine

d. hypoxia

e. metabolic acidosis

f. bowel necrosis from impaired circulation



4.
Diagnostics

a. upper-GI and lower-GI series

b. abdominal x-rays show air in bowel

c. low fluid volume results in increases of white blood cells, hemoglobin and hematocrit, BUN (called
hemoconcentration or dehydration effect)

569


5. Management

a. decompress the abdomen (with nasogastric tube)

b. nasointestinal tube

c. surgical bowel resection


6. Complications

a. perforation and peritonitis

b. shock

c. strangulation of bowel


7. Nursing care

a. manage pain, but avoid morphine or codeine, which slow bowel motion

b. measure abdominal girth every six to eight hours

c. when nasogastric or nasointestinal tubes present, provide oral care every two hours

d. nasogastric tubes: Salem sump (double lumen with air vent), Levin (single lumen without air vent)

e. intestinal or nasointestinal tubes

i. Cantor tube: single lumen, mercury filled weight on tip

ii. Miller-Abbott: double lumen with mercury weighted tip

iii. advance two inches per hour until ordered length is inserted, then tape securely

iv. document amount of tube remaining every shift


f. maintain fluid and electrolyte balance



IV. Disorders of the Liver

A. Hepatitis overview

1. Definition: acute diffuse inflammatory disease of the liver caused by viral, bacterial, or toxic
ingestion

2. Etiology

a. inflammation of liver, enlargement of Kupffer cells, bile stasis

b. regeneration of cells with no residual damage


3. Types: A, B, C, D, E, and others
Hepatitis
Type
Details
A transmitted from infected food, water, milk, shellfish
fecal-oral route of infection common in areas of poor sanitation and
overcrowding
higher incidence in fall and winter
vaccine: Havrix
B transmitted percutaneously or sexually via contact with infected blood
clients may become carriers
vaccine: Recombivax, Engerix B
C transmitted parenterally (post-transfusion hepatitis)
clients may become carriers
CDC recommends testing for all "baby boomers"
570

usually no symptoms for years until cirrhosis develops or liver cancer is
detected
D transmitted percutaneously or sexually via contact with infected blood
coexists with hepatitis B
No effective antiviral therapy for treatment
E transmitted via the oral-fecal route, usually by contaminated water
more common in young adults in developing countries in Africa, Asia
vertical transmission from pregnant woman to fetus
no vaccine; prevention is the most effective approach






B. Hepatitis B

1. Etiology

a. IV drug use

b. health professionals

c. hemodialysis therapy

d. transmission routes

i. exposure to blood or body fluids

ii. history of multiple sex partners



2. Pathophysiology

a. hepatitis B has three distinct antigens

i. HBsAg - surface antigen

ii. HBcAg - core antigen

iii. HBeAg - e antigen


b. damage to the hepatocytes causes inflammation and necrosis

c. liver function decreased in proportion to damage

d. healing takes 3 to 4 months


3. Findings

a. jaundice if liver fails to conjugate bilirubin or excrete it

b. clay-colored stools from lack of urobilinogen

c. urine is dark, tea colored, from urobilinogen excreted in urine rather than stool

d. urine foams when shaken

e. pruritus from bile salts excreted through skin

f. right upper quadrant pain from edema and inflammation of liver

g. anorexia, nausea, vomiting, malaise, weight loss

h. prolonged bleeding from impaired absorption of vitamin K

i. anemia from decreased RBC lifespan


4. Diagnostics : serologic markers of HBV

a. HBsAg - hepatitis B surface antigen
571


b. anti-Hbc - antibodies to B core antigens

c. elevated

i. alanine aminotransferase (ALT; previously SGPT)

ii. bilirubin

iii. aspartate aminotransferase (AST; previously SGOT)

iv. alkaline phosphatase

v. prothrombin time




5. Management of hepatitis : nonspecific and supportive

a.
symptomatic treatment of pain

b.
antiemetics as needed

c. prevention

i. hepatitis B vaccine provides active immunity

ii. hepatitis B immune globulin provides passive immunity

iii. observe standard and enteric precautions

iv. good hand washing


d. rest of liver - no specific drugs given



6. Nursing care

a. fatigue - provide rest periods; may require bed rest initially

b. maintain skin integrity

c. assist client with activity

d.
monitor nutritional needs

i. increase carbohydrates and proteins; decrease fat

ii. avoid alcohol

iii. frequent, small meals - low fat, high carbohydrate


e. explore for any knowledge deficits

f. arrange for home care needs as indicated

g. reinforce infection control actions

i. use disposable utensils and dishes or keep separate from others

ii. frequent good hand washing

iii. do not share razors, toothbrush, eating utensils





572


C. Hepatitis C

1. Definition: viral disease caused by the hepatitis C virus (HCV) that leads to inflammation of the
liver

2. Etiology: transmitted parenterally through dialysis, blood transfusion before July 1992, shared
needles or razors, unprotected sexual contact with someone who has HCV, tattoo or acupuncture
with contaminated instruments

3. Findings

a. often asymptomatic in acute phase

b. often recognized long after exposure

c. often develops into chronic active hepatitis, cirrhosis, and often liver cancer


4.
Diagnostics

a. liver function testing (ALT, AST, ALP, GGT, serum bilirubin) - to identify and monitor liver
damage

b. EIA assay to detect hepatitis C antibody

c. Hepatitis C RNA assay - to measure viral load

d. liver biopsy - to evaluate for chronic hepatitis


5. Management

a. no vaccine available

b. interferon alpha

c.
antiviral medication: ribavirin (Rebetol, Virazole)

d. vaccinations against hepatitis A and B


6. Nursing Interventions

a. promote rest

b. promote adequate nutrition

c. instruct to avoid alcohol and other hepatotoxic agents

d. manage itching and maintain skin integrity




D. Hepatitis D or hepatitis delta virus

1. Definition: inflammation of the liver caused by hepatitis D virus, a defective RNA virus

2. Etiology: bloodborne (same transmission methods as hepatitis B)

i. coexists with hepatitis B (needs hepatitis B to replicate)

ii. may cause either acute or chronic infection


3. treatment and recovery of hepatitis B results in recovery from hepatitis D



E. Hepatitis E

1. Definition: liver disease caused by the hepatitis E virus, which is a non-enveloped, positive-sense,
single-stranded RNA virus

2. Etiology: transmitted mainly through fecal-oral route

a. usually via drinking contaminated drinking water

b. foodborne transmission from infected animals (zoonotic transmission) and through infected
blood products

c. vertical transmission from pregnant woman to fetus

573


3. Findings

a. not clinically different from other types of acute viral hepatitis; usually self-limiting (resolving
in 4 to 6 weeks)

b. can cause fulminant, fatal hepatitis




F. Cirrhosis

1. Definition: irreversible, chronic, progressive degeneration of the liver, with fibrosis and areas of
nodular regeneration


2. Etiology

a. types

i. Laennec's (alcoholic) cirrhosis - related to alcohol abuse

ii. post-necrotic - associated with viral hepatitis or exposure to hepatotoxin

iii. biliary cirrhosis - associated with inflammation or obstruction of gallbladder or bile duct

iv. cardiac cirrhosis - associated with heart failure


b. nodular liver with fibrosis and scar tissue

c. destroys hepatocytes and kills tissue (necrosis)

d. necrosis, nodules, and scar tissue obstruct flow of blood, lymph, and bile

e. impaired bilirubin metabolism



3. Findings

a. weakness, fatigue, weight loss, hepatomegaly

b. right upper quadrant pain

c. jaundice, pruritus, steatorrhea (decreased absorption of fat and fat-soluble vitamins - A, D, E, K)

d. clay-colored stools

e. increased bilirubin in urine, producing dark tea-colored urine

f. impaired aldosterone metabolism results in edema - ascites

g. impaired estrogen metabolism: gynecomastia, menstrual changes, changes in distribution of body
hair, vascular changes - spider angiomas, palmar erythema

h. impaired metabolism of protein, carbohydrate, and fat

i. produces less plasma protein, resulting in edema and ascites

ii. produces less of proteins needed for clotting (fibrinogen and prothrombin)

iii. absorbs less vitamin K, results in prolonged bleeding

iv. liver fails to convert glycogen to glucose, resulting in hypoglycemia and fatigue





4. Diagnostics
574


a.
laboratory

i. liver function studies - elevated ALT, AST, alkaline phosphatase

ii. prothrombin time

iii. complete blood count (CBC)

iv. decreased cholesterol because liver synthesis impaired

v. elevated serum bilirubin and urine bilirubin

vi. elevated ammonia in liver failure with findings of asterixis - flopping hand tremor

vii. endoscopic retrograde cholangiography (ERCP) to examine bile duct


b. CT scan of liver

c. liver biopsy


5. Management

a. steroids for post-necrotic cirrhosis

b. replace B-complex vitamins and fat-soluble vitamins (use a water-based vitamin)

c.
diet

i. increased carbohydrates, vitamins

ii. protein may be restricted, depending on amount of damage and findings

iii. low fat diet

iv. 2000 to 3000 calories daily

v. no alcohol



6. Complications: portal hypertension, ascites, hepatic encephalopathy

7. Nursing care

a. monitor for bleeding

b. provide for alterations in nutrition:

c. provide rest periods; client is usually unable to tolerate strenuous activities

d. discuss any knowledge deficit about cirrhosis and its therapies

e. changes in level of consciousness

i. confusion

ii. lethargy

iii. semi-comatose


f. avoid sedation

g. check for impaired skin integrity, from edema and pruritus

h. monitor fluid balance

i. measure abdominal girth daily

ii. weigh daily

iii. measure intake and output (I & O)




G. Portal hypertension

1. Definition: increased pressure in the portal veins

2. Etiology

a. normal blood flow is altered producing an increased resistance to flow through the liver
575


b. congestion in the portal system dilates veins, especially in esophagus and rectum


3. Findings

a. prominent abdominal-wall veins (caput medusa)

b. hemorrhoids

c. enlarged spleen

d. anemia from increased destruction of RBCs

e. esophageal varices with bleeding - medical emergency


4.
Diagnostics : endoscopy


5. Management

a. sclerotherapy - injection of a sclerosing agent into esophageal varices

b. balloon tamponade

i. Sengstaken-Blakemore tube is inserted into the stomach

ii. gastric balloon is inflated and presses on lower esophagus while allowing suctioning

iii. esophageal balloon places pressure on varices

iv. pressure is released at intervals, as ordered, to prevent necrosis

v. traction for increased pressure added by attaching tube to football helmet

vi. monitor for bleeding and signs of shock

vii. monitor for respiratory distress - aspiration or displacement of tube, have suction available
for client to use PRN

viii. keep head of bed elevated

ix. aspiration is a risk since client cannot swallow saliva with esophageal balloon inflated


c.
pharmacologic

i. vasopressin

constricts veins and decreases portal blood flow

given IV or into superior mesenteric artery

side effects include hypothermia, myocardial ischemia, acute renal failure


ii. nitroglycerin will decrease myocardial effects

iii. beta-adrenergic neuron-blocking agents may decrease risk of recurrent bleeding by
decreasing pressure in portal system

iv. cathartics to remove blood from GI tract and decrease absorption of ammonia - lactulose
most commonly given via NG tube


d. surgical intervention

i. shunt to decrease blood flow to liver and therefore pressure splenorenal shunt

mesocaval shunt

portacaval shunt


ii. transjugular intrahepatic portosystemic shunt (TIPS) - shunt placed between hepatic and
portal vein





6. Nursing care
576


a. monitor for

i. bleeding

ii. infection

iii. impaired skin integrity, especially about nose of NG tube


b. advise to avoid intake of alcohol, irritating or rough food

c. minimize any increased pressure in abdomen

d. if bleeding occurs - administer transfusions, fresh frozen plasma, vitamin K




H. Ascites

1. Definition: accumulation of fluid in the peritoneum

2. Etiology

a. portal hypertension causes increased plasma and lymphatic hydrostatic pressure in portal
system

b. hypoalbuminemia causes decreased colloid osmotic pressure

c. hyperaldosteronism due to liver's inability to metabolize aldosterone causes body to retain
sodium and water


3. Findings

a. abdominal distention, protruding umbilicus, dull sound on percussion of abdomen, fluid wave
on abdomen

b. bulging flank

c. dyspnea


4. Diagnostics

a. abdominal x-ray

b. computerized tomography (CT) scan

c. ultrasound



5. Management

a.
diuretics - spironolactone (Aldactone) - aldosterone antagonist, spares potassium

b.
IV albumin

c. paracentesis to remove fluid

d.
diet - low sodium

e. peritoneal venous shunt - allows drainage of fluid from the peritoneum to superior vena cava


6. Nursing care

a. monitor fluid balance: measure I & O, daily weight, abdominal girth, skin turgor

b. restrict fluids, as ordered

c. monitor for ineffective breathing patterns

d. maintain in a semi-Fowler's position

e. monitor for impaired skin integrity

f. discuss dietary changes

g. monitor for heart failure when IV salt-poor albumin is being given


577


I. Hepatic encephalopathy

1. Definition - CNS dysfunction associated with severe liver disease or failure

2. Etiology

a. impaired ammonia metabolism in liver poisons brain tissue

b. ammonia produced from a breakdown of protein in the body, often from bacterial action on
blood in GI tract


3. Findings

a. changes in level of consciousness from confusion to coma

b. changes to an increased sleep pattern

c. memory loss

d. asterixis - flapping hands tremor

e. impaired handwriting

f. hyperventilation with respiratory alkalosis
g. fetor hepaticus - musty, sweet odor to breath


4.
Diagnostics - serum ammonia level elevated, plus changes in level of consciousness

5. Management

a.
neomycin sulfate (Mycifradin) - inhibits action of intestinal bacteria that produce ammonia

b.
lactulose (Cephulac) - absorbs ammonia and produces evacuation of the bowel, usually
diarrhea

c.
low protein diet to minimize potential breakdown


6. Nursing care

a. maintain client safety

b. provide uninterrupted rest periods

c. provide frequent mouth and skin care, at least every 2 hours

d. monitor breathing patterns

e. reorient as needed

f. administer medications and note results




V. Disorders of Pancreas and Gallbladder

A. Acute pancreatitis

1. Definition: inflammation of the pancreas

2. Etiology

a. alcohol ingestion

b. gall stones

c. drug ingestion

d. viral infections

e. trauma


3. Pathophysiology

i. autodigestion from premature activation of pancreatic enzymes with excess depositing of
578

calcium

ii. proteases and lipases, normally active in small intestine, are activated in the pancreas

iii. phospholipase A digests adipose and parenchymal tissues

iv. elastase digests elastic fibers of blood vessels, to produce bleeding

v. amylase digests carbohydrates

vi. inflammation response occurs from enzyme release


4. Findings

a. severe left upper quadrant abdominal pain, classic "feels like a knife is going through my
body"

b. pain worsens after eating and when lying flat

c. nausea, vomiting

d. fever, agitation, confusion

e. hypovolemia and shock

f. hemorrhage into retroperitoneal space may produce ecchymosis in flank or around
umbilicus

g. tachypnea, pulmonary infiltrates, atelectasis from circulating enzymes

h. complications

i. respiratory problems - atelectasis, pneumonia from the immobility imposed by pain

ii. tetany from decreased calcium levels

iii. abscess or pseudocyst





5.
Diagnostics

a.
laboratory

i. elevated enzymes: serum amylase, serum lipase, and urinary amylase

ii. elevated WBCs, decreased hemoglobin and hematocrit

iii. elevated LDH and AST (SGOT)

iv. hyperglycemia

v. hypocalcemia


b. chest x-ray

c. CT scan

d. ultrasound

e. endoscopic retrograde cholangiopancreatography (ERCP)


6. Management of pancreatitis

a. treat cause

b.
pharmacologic

i. pain relief - meperidine (Demerol)

ii. insulin for hyperglycemia

iii. calcium replacement


c. fluid maintenance to prevent shock

d. decrease stimulation of pancreas

i. NPO and total parenteral nutrition (TPN)
579


ii. NG tube

iii.
anticholinergics

iv.
H2-receptor antagonists


e.
if eating is allowed, provide a diet high in proteins and carbohydrates and low in fat


7. Nursing care

a. manage severe pain

b. monitor alteration in breathing patterns - shallow respirations from severe pain

c. monitor nutritional status - weight gain or loss

d. oral care every two hours when NPO

e. monitor fluid and electrolyte balances

i. low calcium

ii. high glucose

iii. high potassium




B. Cholecystitis

1. Definition - Inflammation of the gallbladder


2. Etiology

a. usually due to gallstones (cholelithiasis)

b. types

i. cholesterol - most common

ii. pigment - unconjugated bilirubin


c. bile drainage is blocked, and infects tissue

d. more common in women, especially those over 40, those who use birth control pills, and
women six to nine months after delivery since high progestin levels during pregnancy inhibit
peristalsis of gallbladder

e. pathophysiology

i. common bile duct is obstructed by a gallstone

ii. bile cannot be excreted, some bile is reabsorbed

iii. remaining bile volume distends and inflames gallbladder

iv. may scar gallbladder, results in less storing of the bile from the liver

v. stones can perforate gallbladder






580

The 6 'F's for gallbladder disease:
Fair (skin and hair)
Fat
Forty (and older)
Fertile (lots of children)
Female
Flatulent

3. Findings

a. colicky pain in right upper quadrant with possible radiation to right shoulder and high back area

b. indigestion after eating fatty foods

c. nausea, vomiting

d. jaundice (if the liver is involved or inflamed or the common duct obstructed)


e. low grade fever


4.
Diagnostics

a. endoscopic retrograde cholangiopancreatography (ERCP)

b. endoscopic retrograde catheterization of the gallbladder (ERCG)

c. ultrasound


5. Management

a. rest

b. low-fat diet

c. removal of stone in common duct by endoscopy

d. to dissolve cholesterol stones

i. chenodeoxycholic acid (Chenodiol) - side effects are diarrhea and hepatotoxicity

ii. ursodiol (Actigall)


e. control pain - meperidine (Demerol) is drug of choice

f.
replace vitamin K if bleeding time is prolonged

g. extracorporeal shock wave lithotripsy

i. client is put in tub of water up to neck area with shock waves applied to client's back in area of
gall bladder

ii. may have hematuria after procedure, but not longer than 24 hours

iii. may have bruise at site of therapy


h. choledocholithotomy - to remove or break up stones

i. laparoscopic laser cholecystectomy

j. cholecystectomy






581

6. Nursing care

a. monitor vital signs for findings of infection

b. medicate for pain, as needed

c. reinforce the need for dietary restriction of fatty foods

Complementary and Alternative Medicine
Complementary and alternative medicines used in the treatment and management of cholecystitis:

Herb goldenseal -active ingredient berbine stimulates secretion of bile and bilirubin and inhibits growth
of pathogens (contraindicated in pregnancy and by nursing mothers)
Points to Remember

The average age at diagnosis for pernicious anemia is 60 years-old; monthly injections are prescribed to
correct the deficiency.

Vitamin B12 deficiency is the number one cause of nutritional dementia and one of the main causes of
peripheral neuropathy in the elderly; it may be a contributing factor in depression (B12 is a cofactor in
the production of serotonin).

A peptic ulcer is a sore in the lining of the stomach or duodenum; treatment may include medications
to block stomach acids or antibiotics.

A client with esophageal varices must be monitored for bleeding, e.g., melena stools, hematemesis,
tachycardia.

The rupture of esophageal varices is life threatening and associated with a high mortality rate.

Ulcerative colitis and crohn's disease are chronic inflammatory intestinal diseases with unknown
etiology.

When assessing a client, frequent liquid stools can be indicative of a fecal impaction or intestinal
obstruction - not diarrhea!

Diverticula are most common in the sigmoid colon.

Clients with diverticulosis are often asymptomatic.

A deficiency in dietary fiber is associated with diverticulitis.

Ascending colostomy drains liquid feces, is difficult to train and requires daily irrigation; descending
colostomy drains solid feces and can be controlled.

Bowel sounds tend to be hyperactive in the early phases of an intestinal obstruction.

Most obstructions occur in the small bowel.

Most large bowel obstructions are caused by cancer.

Onset of cirrhosis is insidious with symptoms such as anorexia, weight loss, malaise, altered bowel
habits, nausea and vomiting.

Management of cirrhosis is directed towards avoiding complications, which is achieved by maintaining
fluid, electrolyte and nutritional balance.

Hepatitis develops in three stages: pre-icteric (pre-jaundice) or prodromal; icteric; and post-icteric
(post-jaundice).

Common symptoms of hepatitis include abdominal pain, dark-colored urine, pale stools and pruritus;
jaundice may occur in some, but not all, cases.

Pancreatitis is often associated with excessive alcohol ingestion.

Pancreatic cancer is an insidious disease that often goes undetected until its later stages; it is the fourth
leading cause of cancer deaths among both men and women.

582




I. Anatomy and Physiology

A. Urinary system

1. Kidney

a. structure

i. cortex (outer layer): glomeruli, proximal and distal tubules


ii. medulla (middle layer): about eight renal pyramids formed by collecting ducts and
tubules

iii. renal pelvis (innermost layer): composed of calyces where papillae move urine into the
ureter by peristalsis

iv. nephron: functional unit that filters, concentrates, reabsorbs, and secretes to produce
urine consists of:

glomerulus: filters fluid wastes out of the blood (plural: glomeruli)

tubules (proximal, Henle's loop, distal): here fluid is made into urine



b. functions

i. fluid and electrolyte balance

ii. acid-base balance: HPO
4
buffer system, NH
3
buffer system

iii. regulates arterial blood pressure: renin, aldosterone

iv. excretes waste products: urea, creatinine

v. supports oxygen delivery: production of erythropoietin



2. Ureters

a. convey urine from each pelvis of the kidneys to the bladder

b. consists of smooth muscle, moves by peristalsis


3. Bladder - stores urine

4. Urethra - conveys urine from bladder for excretion


B. Reproductive system - male

1. Testes: main male sex glands


2. Each testis is encased in a fibrous capsule which has partitions into the inner gland
583


3. Seminiferous tubules form spermatozoa

4. Interstitial cells secrete testosterone

5. Accessory glands

a. seminal vesicles

b. prostate gland

c. bulbourethral glands secrete lubrication prior to ejaculation


6. Ducts

a. epididymis conducts semen from testes to vas deferens

b. vas deferens conduct semen from each epididymis to an ejaculatory duct

c. ejaculatory ducts

d. urethra


7. Scrotum

8. Penis



C. Reproductive system - female

1. Ovaries

a. consist of graafian follicles in which ova develop


b. functions of ovaries:

i. oogenesis

ii. ovulation

iii. secretion of progesterone and estrogen



2. Fallopian tubes - conduct ova from ovaries to uterus

3. Uterus functions in menstruation and pregnancy

4. Vagina

5. Vulva



II. Prostate Disorders

A. Benign prostatic hyperplasia (BPH)

1. Definition - enlargement of the prostate gland

584


2. Etiology

a. occurs as men age in about 50% of men

b. associated with circulating androgens

c. as prostate enlarges, prostatic tissue forms nodules

d. prostate becomes spongy and thick

e. prostatic urethra narrows via compression

f. impedes passage of urine


3. Findings

a. recurrent urinary tract infections (UTIs)

b. early stages often asymptomatic as enlargement occurs

c. changes in micturition - frequency, dribbling

d. difficulty starting or stopping urinary stream




4. Diagnostics

a.
rectal examination

b. laboratory

i. urinalysis

ii. serum creatinine and BUN studies

iii. serum prostate specific antigen (PSA) - elevated


c. endoscopy

d. ultrasound

e. catheter for residual urine


5. Medical management

a. if asymptomatic, check-up annually

b. if symptomatic, treatment may include the following

i. antihypertensives (relax smooth muscles in the prostate and bladder neck but will not
decrease prostate size)

prazosin (Minipress) - decreases urinary urgency, hesitancy, dribbling, retention,
nocturia

doxazosin (Cardura)- decreases urinary urgency, hesitancy, dribbling, retention,
nocturia

terazosin (Hytrin) - decreases urinary urgency, hesitancy, dribbling, retention,
nocturia


ii. hormonal manipulation - finasteride (Proscar), which decreases prostate size and decreases
urinary urgency, hesitancy, dribbling, retention, nocturia

iii. complimentary and alternative therapies (CAT) - Saw palmetto extract

iv. balloon dilation - temporary relief of urinary urgency, hesitancy, dribbling, retention, nocturia

v. surgery, if indicated

transurethral resection of prostate (TURP)

open prostatectomy
585



laser surgery

insertion of prostatic stent




Antihypertensives may cause orthostatic (postural) hypotension. Remember to teach clients to
change "postures" slowly to prevent "postural" hypotension. Men taking medications for erectile
dysfunction are at greater risk.


6. Complications of BPH

a. acute urinary retention

b. involuntary bladder spasms (contractions)

c. hydronephrosis

d. urinary tract infection

e. gross hematuria


7. Nursing care

a. data collection

i. check lower abdomen (suprapubic area) for distention of the bladder

ii. measure post void residual (if needed)

iii. assess for findings of urinary tract infection, hematuria

iv. if beta blockers are used check sitting and standing blood pressures


b. facilitate urinary elimination; provide privacy

c. monitor intake and output

d. maintain catheter patency

e. medicate as prescribed



III. Female Reproductive Disorders

A. Cystocele

1. Definition: bladder herniates into vagina



2. Etiology

a. associated with obstetrical trauma

b. may be due to a congenital defect

c. findings may appear after hysterectomy
586


d. may appear as genitalia atrophy with age


3. Findings

a. in early stages, asymptomatic

b. pelvic pressure

c. changes in urination - frequency, urgency, stress incontinence, inability to empty bladder

d. complications

i. infection

ii. urinary incontinence





Don't be confused by these terms! Cystocele is a hernia (the bladder drops into the vagina), but
endometriosis can lead to cyst formation outside the uterus.


4. Diagnostics

a. pelvic examination

b. urinalysis, urine culture


5. Medical management

a.
in postmenopausal client - possibly estrogen replacement therapy

b. insertion of vaginal pessary to support pelvic organs

c. surgical intervention (if indicated)

i. to restore bladder function

ii. repair of anterior vaginal wall



6. Nursing care

a. data collection

i. history of obstetrical trauma, abdominal surgery, menopause, and estrogen therapy

ii. changes in urination

iii. pain level

iv. bulge from vagina while standing upright

v. bulge from perineum when client bears down


b. provide pain management as ordered

c. control incontinence

d. prevent urinary retention and infections



B. Pelvic inflammatory disease (PID)

1. Definition: infection of the cervix ascending to the fallopian tubes and broad ligaments

2. Etiology

a. increased incidence from reinfection

b. causative agents: Neisseria gonorrhoeae, Chlamydia trachomatis (C. trachomatis), or
Mycoplasma hominis

c. history of multiple sexual partners

d. use of intrauterine device (IUD)

e. history of therapeutic abortion
587


f. douching


3. Findings

a. pelvic pain, sometimes with cervical discharge, may be foul smelling

b. fever

c. cervical motion tenderness

d. irregular bleeding

e. nausea, vomiting, acute abdomen

f. dysuria, frequency

g. chlamydia, gonorrhea, or other STD's


4. Diagnostics

a. endocervical culture

b. CBC with differential

c. laparoscopy to view fallopian tubes

d. culdocentesis


5. Medical management

a.
pharmacologic (may be used in combination therapy)

i. antibiotics (prescription will depend on causative organism): tetracyclines, penicillins,
quinolones, cephalosporins

ii. analgesics


b. potential surgical intervention to drain abscess

c. rest, warm compresses

d. avoid sexual intercourse



6. Complications

a. ectopic pregnancy


b. infertility

c. rupture of abscess

d. sepsis

e. chronic pelvic pain



7. Nursing care

a. data collection

i. history of menses, contraceptive use, sexual habits
588


ii. level of pain

iii. vital signs for hypotension, hypovolemia, and fever

iv. how an STD will impact client socially


b. manage pain

c. restore fluid balance

d. position in bed in semi-Fowler's or higher to facilitate drainage

e. reinforce teaching regarding STD transmission and medication administration



C. Endometriosis

1. Definition: endometrium tissue grows in cysts at various sites throughout the pelvis and/or
abdominal wall


2. Etiology

a. occurs at any age; most commonly 25 to 45 years-old

b. higher incidence in white women than in African American women

c. responds to ovarian hormonal stimulation

i. progestins decrease it

ii. estrogens increase it



3. Findings

a. may be asymptomatic

b. may be present with pelvic pain

c. dyspareunia

d. painful defecation

e. abnormal uterine bleeding

f. persistent infertility

g. hematuria, dysuria and flank pain if bladder is involved

h. complication: infertility

i. dysmenorrhea


4. Diagnostics

a. pelvic examination

b. rectal examination

c. laparoscopy

d. ultrasound, CT Scan, barium studies



5. Medical management

a. pharmacologic
589


i. danazol (Danocrine) - atrophy of ectopic endometrial tissue

ii. leuprolide acetate (Lupron) - reduction of pain and lesions in endometriosis

iii. progestins - decreases endometriosis

iv. oral contraceptives


b. surgical

i. laparoscopic surgery


ii. CO2 laser laparoscopy

iii. laparotomy

iv. presacral neurectomy

v. hysterectomy




6. Complication - infertility

7. Nursing care

a. data collection

i. history of current complaints

ii. pain level

iii. impact of infertility (especially in child-bearing age group)


b. reduce pain

c. increase client's self-esteem

d. discuss lifestyle behaviors that increase risk of recurrence



IV. Genitourinary Disorders

A. Urinary tract infections (UTI)

1. Definition: infections, by various agents, of parts of the urinary system

2. Etiology

a. causative agent enters via urinary meatus

b. women are more susceptible, especially in the perimenopausal phase of life when
estrogen level is dropping

c. can be caused by poor voiding habits, poor toileting habits
590


d. in women, acute infection caused most often by Escherichia coli

e. in men, cause is usually obstructive abnormalities such as BPH


3. Findings

a. spike in temperature to 101 Fahrenheit or higher

b. dysuria, frequency, urgency, nocturia

c. suprapubic pain

d. hematuria

e. complications

i. pyelonephritis

ii. sepsis



4. Diagnostics

a. urine dipstick positive for infection

b. urine microscopy

c. urine culture


5. Medical management

a. antimicrobial therapy

b. uncomplicated infection

i. trimethoprim-sulfamethoxazole (Bactrim)

ii. ofloxacin (Floxin)

iii. nitrofurantoin (Macrodantin)


c. complicated infections

i. oral antimicrobials as ordered

ii. IV antimicrobials may be indicated





6. Complications

a. pyelonephritis

b. sepsis


7. Nursing care

a. data collection

i. history of urinary tract infections (UTIs)

ii. voiding habits, personal hygiene, contraceptive methods

iii. history of vaginal discharge, itching, irritation, dysuria


b. manage pain

i. systemic analgesics

ii. urinary analgesics / antispasmodics


c. reinforce client teaching

i. preventive measures

in the female client, suggest voiding after intercourse

cotton undergarments

wiping from front to back


ii.
nutritional considerations
591


increase water intake to 2000 to 3000 mL per day

avoid coffee, tea, alcohol, and colas (carbonated and noncarbonated)

cranberry juice or vitamin C increase urine acidity





B. Renal calculi

1. Definition: small, hard deposits (made of mineral and acid salts) that form inside the kidneys


2. Etiology

a. hypercalcemia

b. hypercalciuria

c. hyperuricemia

d. chronic dehydration

e. high purine diet (organ meats, yeast, etc.)

f. cystinuria (genetic disorder)

g. chronic infections (proteus vulgaris)

h. chronic obstruction with urinary stasis

i. environmental factors, i.e., living in a warm, humid climate


3. Epidemiology

a. more prevalent in men

b. can be found anywhere in the urinary system

c. peak age of onset is 20 to 30 years of age

d. spontaneous passage occurs in vast majority of clients

e. calculi can lodge and cause obstruction; common sites are: bladder neck; renal pelvix; ureters

f. often recurs in clients with a history of two or more stones



4. Findings

a. pain - site dependent on location of obstruction; can be severe


b. increased hydrostatic pressure

c. renal colic
592


d. urethral colic

e. findings can mimic cystitis

f. with obstruction: when stones (calculi) block urine flow, client will show findings of UTI with fever
and chills

g. gastrointestinal findings

i. nausea, vomiting

ii. diarrhea

iii. abdominal discomfort



5.
Diagnostics

a. intravenous pyelogram (IVP) to determine site and degree of obstruction


b. retrograde or antegrade pyelography

c. analysis of stone material

d.
urinalysis; urine for culture and sensitivity


6. Medical management

a. extracorporeal shock wave lithotripsy (ESWL)


b. percutaneous nephrolithotomy (PCNL)

c. percutaneous stone dissolution (chemolysis)

i. introduce a solvent (depending on the composition of the stone)

ii. give broad-spectrum antimicrobials before, during, and after the procedure to maintain sterile
urine


d. ureteroscopy

e. pyelolithotomy, nephrolithotomy, ureterolithotomy

f. cystolithotomy

g. nephrectomy (surgical removal of a kidney)


7. Complications

a. obstruction from residual stone material (fragments)

b. infection resulting from bacteria or spread of infected stone fragments

c. chronic impairment of renal function (may occur if obstruction persists)

593


8. Nursing care

a. data collection

i. history of UTI's, dietary habits, and family history of stones

ii. pain and location

iii. findings of UTI or obstruction


b. manage pain

c. maintain urine flow by forcing fluids to 3000 mL per day, unless contraindicated

d. monitor for infection

e. reinforce client teaching



C. Acute renal failure

1. Definition: the abrupt loss of kidney function resulting in the retention of urea and other
nitrogenous waste products and in the dysregulation of extracellular volume and electrolytes

2. Etiology

a. onset begins when kidney is injured

b. pathophysiology

i. prerenal - decreased renal blood flow

ii. intrarenal - injury to renal tissue due to toxins, intrarenal ischemia, vascular disorders and
immunologic processes

iii. postrenal - stops or slows urine flow anywhere in the urinary tract


c. stages

i. begins when kidney is injured

ii. oliguric (or anuric) phase: less than 500 mL of output in 24 hours; lasts 3 to 7 days

iii. diuretic phase: 24 hour urine exceeds 500 mL and there is no longer a rise in serum blood
urea nitrogen (BUN) and creatinine levels; lasts 3 to 5 days

iv. recovery phase:

several months to 1 year

more likely to leave scar tissue remnants

functional loss usually not clinically significant




3. Findings
Causes Type of Acute
Renal Failure
Findings/History
Systemic assault, such as
hemorrhage, trauma, burns
Prerenal Hypotension, hypoperfusion, reduced urine output,
shriveled skin, dry mucous membranes
Kidney toxin or injury Intrarenal History of glomerulonephritis; edema; rash; changes in
kidney function (both output and chemistry)
Kidney inflamed or obstructed Postrenal History of urinary obstruction; difficulty voiding; changes in
micturition





4. Diagnostics

a. laboratory

i. urinalysis
594


ii. serum creatinine and BUN - levels rise

iii. urine chemistry evaluation - to distinguish phase and form of renal failure


b. renal ultrasonography


5. Medical management

a. preventive

i. reinforce education regarding use of analgesics, proper hydration, and exposure to
nephrotoxins

ii. monitor intake and output

iii. avoid infection; if present, use only prescribed medications which will be specific to client
needs


b. supportive

i. improve renal perfusion

ii. monitor intake and output

iii. correct and control hyperkalemia, hyperphosphatemia, hypocalcemia

iv. maintain adequate blood pressure

v. maintain nutritional intake



6. Complications

a. systemic infection

b. arrhythmias secondary to hyperkalemia

c. electrolyte imbalances - potassium, phosphate, calcium, sodium

d. GI bleeding due to stress ulcer

e. multiple organ system failure


7. Nursing care

a. data collection

i. history of cardiac disease, malignancy, sepsis or recent infection

ii. exposure to nephrotoxic drugs, including

NSAIDs

antibiotics - especially the aminoglycosides

chemical solvents

contrast media

antineoplastics


iii. urine volume


b. achieve fluid and electrolyte balance

c. prevent infection

d. monitor serum electrolytes - potassium, phosphate, calcium

e. prevent GI bleeding

f. monitor neurologic function

g. maintain adequate nutrition
i. regulate protein intake

ii. offer high-carbohydrate feedings
595


iii. restrict (as needed) foods high in sodium, potassium and phosphorus, especially if on
hemodialysis three times per week

iv. give total parenteral nutrition (TPN) if indicated and ordered

v. regulate fluid intake


h. weight daily



D. Chronic renal failure

1. Definition: a progressive, irreversible deterioration in renal function; body cannot balance
metabolism and fluid or electrolytes, resulting in uremia

2. Etiology

a. hypertension, severe and prolonged

b. diabetes mellitus - uncontrolled

c. glomerulopathy

d. interstitial nephritis

e. polycystic disease (hereditary)

f. obstructive uropathy

g. congenital disorder



3. Findings
System Findings of Chronic Renal Failure
Respiratory Pulmonary edema, pleural effusions, pleural rub
Cardiovascular Hypertension, hyperkalemia with subsequent EKG changes, pericardial effusion, tamponade
Neuromuscular Sleep disorders, headache, lethargy, peripheral neuropathies, seizures, coma
Metabolic-
endocrine
Hyperlipidemia, decreased libido, impotence, amenorrhea, glucose intolerance
Acid-base Water retention, metabolic acidosis, hyperkalemia, hypocalcemia, hypermagnesemia,
hyperphosphatemia
Gastrointestinal Anorexia, nausea, vomiting, gastric, ulcerations and/or hemorrhage
Blood Anemia from decreased or no erythropoietin production, increased bleeding, platelet
defects
Skeletal Renal osteodystrophy, osteomalacia from decreased serum calcium levels
Skin Pruritus, uremic frost, hyperpigmentation, ecchymosis, pallor
Psychosocial Changes in cognition, behavior, personality






4. Diagnostics

a. arterial blood gases
596


b. elevated serum creatinine, phosphorus, potassium, BUN

c. complete blood count - to detect anemia

d. decreased serum levels of bicarbonate, calcium, proteins (albumin)

e. sodium will be either elevated or decreased as it depends on the amount of water retained or lost


5. Medical management

a. control

i. diabetes mellitus

ii. hypertension


b. maintain renal function for as long as possible

c. regulate diet

i. maintain low protein intake

ii. prevent malnutrition

iii. restrict dietary potassium

iv. restrict dietary phosphorus by reducing intake of chicken, milk, legumes, carbonated drinks


d.
treat anemia with epoetin (Erythropoietin)

e. treat acidosis with oral sodium bicarbonate

f. dialysis when necessary - hemodialysis or CAPD


6. Complication: death

7. Nursing care

a. data collection

i. history of chronic disorders

ii. degree of renal impairment

iii. effect on other body systems

iv. how client is responding to illness

v. available support systems


b. maintain

i. fluid and electrolyte balance

ii. adequate nutrition

iii. skin integrity

iv. bowel function

v. safe level of activity


c. determine how much client understands and how well client will comply with support systems
and therapies



V. Sexually Transmitted Diseases (STDs)

A. Overview

1. Definition: a group of diseases resulting from an encounter of a sexual nature with an infected
individual; also referred to as sexually transmitted infections (STIs)
2. Some of the more common STDs
597

Type of Organism STD Causative Agent
Bacterial Chlamydia Chlamydia trachomatis
Gonorrhea Neisseria gonorrhea
Syphilis Treponema pallidum
Viral Genital Herpes (HSV-2) herpes simplex virus
Genital Warts human papilloma virus (HPV
Hepatitis B (HBV) hepatitis virus
HIV/AIDS Human Immunodeficiency Virus (HIV)
Parasitic Pubic lice (crabs) Pediculosis pubis
Scabies* Sarcoptes scabiei
Fungal Yeast infections* Candida albicans
* Some investigators do not classify this infection as a STD.





3. Nursing care

a. data collection

i. presence of lesions and history of lesions

ii. history of other sexually transmitted diseases


b. minimize any fear and anxiety through education

c. discuss with clients ways to cope with altered body image

d. reinforce methods of reducing transmission of STDs

e. discuss disclosure of disease status to sexual partners (sexual partners need treatment also)

f. reinforce need to take all of prescribed medication

g. many STD's are reportable to the CDC



B. Bacterial

1. Chlamydia

a. definition & etiology: the most common sexually transmitted disease in the U.S., caused by the
bacteria Chlamydia trachomatis

b. findings: often called the "silent epidemic" because most people do not know they are
infected

i. women: usually asymptomatic; may experience lower abdominal pain, burning pain with
urination, vaginal discharge

ii. men: usually no symptoms; may have discharge from penis, pain or burning with urination,
inflammation or infection of a duct in the testicles


c. diagnostics: molecular testing of urethral discharge in males or cervical secretions in females
(also known as nucleic acid amplification tests or NAAT) for Chlamydia trachomatis culture
(usually done with test for gonorrhea)
598


i. molecular testing of urethral discharge in males or cervical secretions in females (also
known as nucleic acid amplification tests or NAAT) for Chlamydia trachomatis

ii. usually concurrent testing for gonorrhea


d. management

i. azithromycin (Zithromax); doxycycline (Atridox)

ii. newborns: prophylactic erythromycin eye ointment


e. prognosis: up to 95% cured after one course of antibiotics

i. women: may lead to pelvic inflammatory disease, chronic pelvic pain, ectopic pregnancy,
infertility

ii. men: may develop sexually acquired reactive arthritis, painful swelling of the testicles


f. nursing care

i. all sexually active women should be screened yearly for chlamydia

ii. reinforce options for safe sex practices to sexually active men and women





2. Gonorrhea

a. definition & etiology: one of the most common and oldest known STD; caused by gonococcal
bacteria

b. findings

i. women: usually asymptomatic; may cause itching and burning of the vagina, usually with a
thick yellow-green discharge; bleeding between menstrual periods; need to urinate often; sore
throat; rectal pain and discharge

ii. men: pain or burning during urination; thick, yellow penile discharge, inflammation or
infection of a duct in the testicles, inflammation or infection of the prostate gland; sore throat;
rectal pain and discharge

iii. newborns: irritation of the mucous membranes in the eyes


c. diagnostics: molecular testing for Neisseria gonorrhoeae culture (usually done with test for
chlamydia)

d. management

i. cephalosporins (ceftriaxone [Rocephin])

ii.
newborns: prophylactic erythromycin eye drops or ointment


e. prognosis - up to 99% cured after one course of antibiotics, but complications include meningitis
and perihepatitis, arthritis

i. women: may cause pelvic inflammatory disease, ectopic pregnancy, infertility

ii. men: may develop sexually acquired reactive arthritis, painful swelling of the testicles,
epididymitis

iii. newborns: can cause blindness if untreated


f. nursing care

i. emphasize the need for regular Pap smears and pelvic examinations

ii. listen to and support feelings and concerns about the diagnosis

iii. reinforce options for safe sex practices to sexually active men and women





3. Syphilis
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a. definition & etiology: a chronic STD caused by the spirochete Treponema pallidum; sometimes
called "the great impostor" because it has a variety of findings that can mimic many other
infections

b. findings - 4 distinct stages

i. primary phase: usually starts with a sore (a lesion called a chancre) at the site of infection

ii. secondary phase: 4-10 weeks after the appearance of chancres, may experience flu-like
symptoms (fever, joint pain, muscle aches, headache, sore throat), rash (involving palms and
soles), patchy hair loss


iii. latent (dormant) phase: occurs 1 year or more after first chancre with occasional relapses
back to previous symptoms

iv. tertiary syphilis: 4-20 years after primary phase, may have lesions, cardiovascular findings,
neurological findings


c. diagnostics

i. darkfield microscopy in early stages

ii. blood tests include RPR (rapid plasma reagin), VDRL (venereal disease research laboratory),
FTA-ABS (fluorescent treponemal antibody absorption) or MHA-TP (microhemagglutination
assay for T pallidum)


d. management: penicillin is the drug of choice; tetracyclines (doxycycline [Vibramycin]) or
erythromycin if penicillin allergy

e. prognosis: in the first 2 stages, the majority of individuals are cured with antibiotics; individuals
with tertiary syphilis have a poor prognosis

f. nursing care

i. emphasize the importance of abstaining from sexual activity until the client and all partners are
cured

ii. reinforce need for follow-up testing

iii. listen to and support feelings and concerns about the diagnosis

iv. reinforce options for safe sex practices to sexually active men and women




C. Viral

1. Genital herpes (HSV-2)

a. definition & etiology: an STD usually caused by the herpes simplex viruses type 2 (HSV-2)

b. findings

i. clustered painful vesicles and ulcers on or around the genitals or rectum

ii. mild lymphadenopathy

iii. can be reactivated as a result of stress, infection, pregnancy, sunburn


c. diagnostics: visual inspection during an outbreak; herpes simplex virus culture

d.
management

i. antiviral medications (acyclovir [Zovirax], famciclovir [Famvir], valacyclovir [Valtrex]) can
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shorten and prevent outbreaks

ii. daily suppressive therapy for symptomatic herpes (acyclovir [Zovirax], famciclovir [Famvir],
valacyclovir [Valtrex]) can reduce transmission to partners


e. prognosis: chronic, life-long viral infection

i. recurrent genital sores

ii. psychological distress

iii. pregnant woman with active genital lesions may require C-section

iv. can be fatal to infected fetus and newborn


f. nursing care

i. reinforce information about the disease, including medications to treat an outbreak and
symptomatic relief

avoid tight-fitting clothing

keep blisters or sore clean and dry

local application of ice packs to reduce pain and swelling


ii. listen to and support feelings and concerns about the diagnosis

iii. reinforce options for safe sex practices and how to prevent transmission of disease during
an outbreak





2. Genital warts (also known as condyloma acuminata or venereal warts)

a. definition & etiology: a highly contagious and most common sexually-transmitted disease caused
by a virus (the human papillomavirus [HPV])

b. findings

i. flesh-colored or gray growths found on or around the genitals or rectum

ii. most people report painless bumps, itching and discharge

iii. there may be a history of previous or concurrent STDs


c. diagnostics

i. lesions may be visible only using an enhancing technique called ace to whitening

ii. colposcopy

iii. biopsy

iv. HPV DNA


d. management

i. prevention through HPV vaccination (Gardasil)

ii. treatment using cryotherapy, laser treatment, electrodesiccation (caution - the resulting
smoke plume may be infectious)

iii. medications

topical treatments: podophyllum resin (Pod-Ben-25), podofilox (Condylox),
trichloroacetic acid, 5-fluorouracil (Efudex), imiquimod (Aldara)

interferon alpha-n3 (Alferon N)



e. prognosis: there is no single effective cure or treatment

f. nursing care

i. reinforce information about the disease, including the fact that while cryotherapy and creams
may treat the visible wars, the virus remains in the body forever
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ii. listen to and support feelings and concerns about the diagnosis

iii. reinforce options for safe sex practices and how to prevent transmission of disease during an
outbreak




3. Hepatitis B (HBV)

a. definition & etiology

i. caused by infection with the hepatitis B virus (HBV)

ii. more infectious than HIV or HCV

iii. incubation period (time of exposure to onset of symptoms) is 6 weeks to 6 months

iv. can be self-limited or chronic


b. findings - half of all people infected with hepatitis B virus have no symptoms

i. appetite loss

ii. fatigue

iii. nausea and vomiting

iv. itching all over the body

v. pain over the location of the liver

vi. jaundice

vii. dark-colored urine and pale-colored stools


c. diagnostics: serologic testing

d. management

i. prevention through routine vaccination (hepatitis B immune globulin [HBIG] and hepatitis B
vaccine)

ii. acute HBV: treatment is supportive; no specific therapy is available

iii. chronic: aimed at suppressing HBV replication and remission of liver disease in some persons


e. prognosis: variable; most improve while others can develop chronic HBV infection, cirrhosis, liver
cancer, liver failure and death

f. nursing care

i. reinforce information about the disease, including medications

ii. listen to and support feelings and concerns about the diagnosis

iii. reinforce options for preventing transmission: not to share toothbrushes or razors, cover open
cuts and scratches, clean blood spills with bleach




4. Human Immunodeficiency Virus (HIV)

a. definition and etiology

i. HIV infection can range from a brief acute retroviral syndrome to a multiyear chronic and
clinically latent illness that eventually progresses to a symptomatic, life-threatening
immunodeficiency disease known as AIDS

ii. the disease process progressively depletes CD4 lymphocytes

iii. when CD4 cell count falls below 200 cells/microliter, clients are at risk for developing life-
threatening AIDS-defining opportunistic infections or unusual malignancies, e.g.,
Pneumocystis pneumonia, Toxoplasma gondii encephalitis, disseminated Mycobacterium
avium complex disease, tuberculosis, and bacterial pneumonia

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iv. transmission occurs when bodily fluids (blood, semen, vaginal secretions, and breast milk)
come in contact with a mucous membrane or damaged tissue or are directly injected into the
bloodstream



b. findings

i. disease progression varies greatly and some people may be without symptoms for more than 10
years

ii. it may take up to six months after exposure for someone to test positive on an HIV antibody test

iii. common findings in HIV

lack of energy

weight loss

frequent fevers and sweats

persistent skin rashes or flaky skin

short-term memory loss

mouth, genital, or anal sores (from herpes infections)


iv. common finding in AIDS (when CD4 count is less than 200)

cough and shortness of breath

seizures and lack of coordination

difficult or painful swallowing

mental symptoms such as confusion and forgetfulness

nausea, abdominal cramps, vomiting, severe and persistent diarrhea

severe headaches with neck stiffness

Kaposi's sarcoma

malignant tumor of the endothelium lining the heart, blood vessels, lymphatic
system, and serous cavities

most benign form limited to the skin (particularly the lower extremities)

characterized by diffuse cutaneous lesions


pneumocystis carinii pneumonia (PCP)



c. diagnostics

i. history and physical exam

ii. testing for other STDs, including N. gonorrhoeae, C. trachomatis, HBV

iii. complete blood and platelet counts, blood chemistry profile, lipid profile

iv. CD4 T-lymphocyte analysis and determination of HIV plasma viral load

v. bronchoscopy for pneumocystis carinii pneumonia (PCP)

vi. antibody screening testing using conventional or rapid enzyme immunoassay (EIA) or ELISA,
polymerase chain reaction [PCR])

vii. reactive screening tests must be confirmed by a supplemental antibody test (Western blot [WB]
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and indirect immunofluorescence assay [IFA]) or virologic test (the HIV-1 RNA assay)

viii. polymerase chain reaction (PCR) - confirmatory test

ix. tissue biopsy for Kaposi's


d. management

i. no known cure at present

ii. pharmacologic

antiviral agents: azidothymidine (Zidovudine) - usually in combination therapy

postexposure prophylaxis (PEP) or postexposure chemoprophylaxis for health care
workers (following a sharp injury and exposure to body fluids with high viral load)

pneumocystis: trimethoprim/sulfamethoxazole (Septra), pentamidine (NebuPent)

Kaposi's: vinblastine (Velsar), Vincristine (Oncovin), interferon Alpha-2A (Roferon-A)

highly active antiretroviral therapy (HAART): combination of at least 3 antiretroviral
drugs that attack different parts of HIV or stop the virus from entering blood cells


iii. HIV is a reportable disease to the CDC


e. nursing care

i. initiate standard precautions

wear gloves

use eye/face protection if performing aerosol-generating procedure or contact with
respiratory secretions is anticipated

initiate airborne plus contact precautions if cough, fever or pulmonary infiltrate present
in any lung location in an HIV-infected client or client at high risk for HIV infection

use personal protective equipment when splashing of body fluids may occur


ii. use postural drainage and percussion only when secretions are present and coughing does not
adequately clear lungs

iii. administer oxygen as ordered

iv. provide restful environment

v. monitor for signs of dehydration

vi. maintain diet high in calories and protein, low in residue

vii. encourage fluids

viii. provide supplemental feedings as ordered

ix. administer medications as ordered

x. provide skin care as indicated

xi. weigh client daily

xii. care of the client on mechanical ventilation (see Lesson 7: Safety and Infection Control on Safety
and Procedures - Ventilators)

xiii. assess cognitive impairment (see Lesson 3: Health Promotion and Maintenance for assessment
of the neurological system)

xiv. provide emotional support for client and caregiver

xv. care of the cancer client undergoing chemotherapy (see Lesson 6: Pharmacological and
Parenteral Therapies for information about chemotherapy)

xvi. care of the client on total parenteral nutrition (TPN) (see Lesson 6: Pharmacological and
Parenteral Therapies for information on Total Parenteral Nutrition)

xvii. maintain confidentiality of clients per established regulations
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xviii. reinforce client teaching
avoid persons with known infections or large crowds
practice safe sex
energy-conserving techniques
wear MedicAlert identification
report infections immediately to physician
not to donate blood, serum or semen
not to share toothbrushes, razors, or other items that may draw blood
importance of compliance with medication regimen


Points to Remember

After a urinary catheter is removed, the client may have some burning on urination, frequency and
dribbling but these symptoms should subside within 24 to 48 hours.

Co-trimoxazole (Bactrim) remains the drug of choice to treat urinary tract infections (unless the client is
allergic to sulfa).

After a transurethral resection of the prostate (TURP), tell clients that because the three-way Foley
catheter has a large diameter, they will continuously feel the urge to void for 24 to 48 hours.

After prostatic surgery, it is normal for the client's urine to be blood-tinged and for him to pass medium
to small blood clots and tissue debris for 24 to 48 hours.

Because the prostate gland receives a rich blood supply, it is a priority to observe clients undergoing a
prostatectomy for bleeding and shock.

Chlamydia is the most common sexually transmitted bacterial infection in the U.S. If untreated, it can
cause PID in women and epididymitis in men.

HPV vaccine Gardasil protects against types of HPV that cause most cervical cancers and can help
protect against genital warts in both young men and women.

Be sure to assess the site of the AV fistula of the client receiving hemodialysis for the thrill (it feels like
water running through a thin hose) and bruit (a swishing or swooshing sound heard on auscultation).

Clearly communicate that no blood pressures or blood draws should be taken on the arm with the
fistula.

Recent studies have shown that foods high in calcium, including dairy products, may help prevent
kidney (calcium) stones.

Many STD's are reportable to the CDC.

When CD4 cell count falls below 200, the client is at high risk of developing opportunistic infections.

Common management of HIV infection is the highly active antiretroviral therapy (HAART) regimen.

Adherence prolongs the life of an HIV infective client.


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Unlike the endocrine glands, exocrine glands secrete their products through duct(s) into the body's cavities or onto its surface,
e.g., sweat (from the sweat glands), skin oils (from the sebaceous glands), mucus (from the mucous membranes), and digestive
juices (the pancreas, in its exocrine function).


B. Endocrine glands

1. Pituitary

a. lies in sella turcica above the sphenoid bone


b. consists of two lobes, posterior and anterior, connected to the hypothalamus

i. posterior pituitary: produces antidiuretic hormone (also called vasopressin) and oxytocin

I. Anatomy and Physiology

A. Overview


1. Provides a means of extracellular communication using chemicals (hormones) to communicate between cells and to
regulate body functions

2.
Comprised of hormone-producing glands

a. secrete hormones in very small amounts directly into the bloodstream

b. regulates many physiologic activities

i. reproduction

ii. metabolism

iii. growth and maturation

iv. electrolyte, water, and nutrient balance

v. the balance between behavior and energy


c. regulated by several methods

i. autonomic nervous system

ii. changes in concentrations of specific substances in plasma


iii. (negative) feedback system




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ii. anterior pituitary: produces FSH (follicle-stimulating hormone), LH (luteinizing hormone), ACTH (adrenocorticotropic
hormone, and TSH (thyroid-stimulating hormone) and GH (growth hormone)


c. regulates the other endocrine glands by stimulating target organs

d. controlled by releasing and inhibiting hormones from the hypothalamus



2. Thyroid gland

a. located in the lower neck in front of the trachea

b. two highly vascular lobes

c. regulates the body's metabolic rate

d. secretes two iodine-containing hormones, T3 (triiodothyronine) and T4 (thyroxine), and another hormone, calcitonin, that
prevents calcium from leaving the bone when present in the blood



3. Parathyroid glands

a. four small glands located in the lateral lobes of the thyroid gland

b. control calcium and phosphorus metabolism

c. secrete parathyroid hormone (PTH)



4. Adrenal glands

a. two small glands lying in the retroperitoneal region attached to each kidney


b. functions

i. cortex (outer portion of gland)

regulates electrolyte balance

affects carbohydrate, fat and protein metabolism

influences the development of sexual characteristics

produces the the three types of steroid hormones; glucocorticoids, mineralocorticoids, and androgens


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ii. medulla (inner portion of gland)

stimulation of sympathetic nervous system, responds to stress, produces catecholamines

produces epinephrine and norepinephrine, which are responsible for the flight or flight response



Adrenal gland (cortex) hormones - SSS
S=Sugar (glucocorticoids)
S=Salt (mineralocorticoids)
S=Sex (androgens)


5. Pancreas

a. lies retroperitoneally, with the head of the gland in the duodenal cavity and the tail lying against the spleen


b. insulin, glucagon secretion into the blood - an endocrine function

c. excretion of enzymes and bicarbonate that aid digestion and controls carbohydrate metabolism - an exocrine function


6. Pineal body/gland

a. Located in the middle of the brain


b. secretes melatonin, which may help regulate the wake-sleep cycle



Thymus gland

a. located in the anterior superior mediastinum, extending into the neck

b. the primary central gland of the lymphatic system

c. secretes thymosin, which is needed for the maturation and development of the immune system



Gonads

a. (two) ovaries

i. produce the hormones estrogen and progesterone

ii. produce the protein inhibin, which decreases secretion of follicle-stimulating hormone (FSH)

iii. location: situated in the lower abdomen on each side of the uterus



b. testes

i. responsible for secondary sex characteristics and reproductive function

ii. produce testosterone

iii. location: form within the abdomen but descend into the scrotum

To help remember the glands of the endocrine system, remember: "Herman Probably Pasted The Paper To A Pot Of Tea"
H=Hypothalamus
P=Pituitary
P=Pineal
T=Thyroid
P=Parathyroid
T=Thymus
A=Adrenal
P=Pancreas
O=Ovaries
T=Testes
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II. Disorders of the Anterior Pituitary

A. Hypopituitarism (also known as panhypopituitarism)

1. Definition - diminished secretion of pituitary hormones due to under-activity of the anterior pituitary gland

2. Etiology

a. benign pituitary tumor (or adenoma) - most common cause

b. other causes

i. brain surgery

ii. head trauma

iii. infections of the brain

iv. radiation

v. stroke

vi. subarachnoid hemorrhage



3. Findings - result from hormone deficiency (hypogonadism)

a. (female) hypogonadism

i. amenorrhea

ii. infertility


iii. decreased libido

iv. breast and uterine atrophy

v. loss of axillary and pubic hair


vi. vaginal dryness

vii. delayed physical growth


viii. premature aging

ix. decreased intellectual development

x. increased intracranial pressure


b. (male) hypogonadism

i. decreased libido

ii. erectile dysfunction

iii. small, soft testicles


iv. loss of axillary and pubic hair


c. decreased growth hormone - results in dwarfism (when developed in childhood)

d. hypothyroidism - occurs because pituitary regulates thyroid glands via thyroid stimulating hormone (TSH)

e. hypoadrenalism - occurs because pituitary regulates adrenal glands though production of adrenocorticotropic
hormone (ACTH)

f. syndrome of inappropriate antidiuretic hormone (SIADH): fluid overload and dilutional hyponatremia related to
increased antidiuretic hormone (ADH) levels




4. Diagnostics

a. history and physical exam

b. neuro-ophthalmological exam

c. x-rays of pituitary fossa


d. radioimmunoassays of anterior pituitary hormones

e. imaging tests - computerized tomogram (CT) or magnetic resonance imaging (MRI) scans of brain, pituitary gland

f. laboratory: serum ACTH, cortisol, estradiol, FSH, LH, TSH, T4, testosterone, insulin-like growth factor 1 (IGF-1)


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5. Management

a. goal is to correct hormone deficiency

b. hormone replacement therapy (growth hormones, estrogens/progestins or androgens, thyroid hormones) and
corticosteroid therapy

c. surgical removal of tumor

d. radiation therapy



6. Nursing care

a. discuss need for lifelong hormone replacement therapy

b. discuss findings of inadequate or excessive hormone replacement


c. advise client to wear MedicAlert identification

d. provide emotional support

e. care of the client undergoing surgery

f. provide emotional support

g. reinforce teaching

i. medications and side effects

ii. need for lifelong hormone replacement therapy


iii. the need to wear MedicAlert identification




B. Hyperpituitarism

1. Definition: anterior pituitary secretes too much growth hormone and/or ACTH

a. acromegaly - when growth plates are closed

b. giantism - when growth plates are still open


2. Etiology

a. hyperplasias and carcinomas of the adenohypophysis


b. secretion by non-pituitary tumors

c. certain hypothalamic disorders and carcinoid tumors

d. ACTH overproduction leads adrenal gland to overproduce cortisone (Cushing's disease)



3. Findings: differ according to the oversecreted hormone

a. excess prolactin: typically includes headache, visual disturbances, growth failure; pubertal arrest (with menstrual
abnormalities in girls) during puberty

b. excess adrenocorticotropic hormone: weight gain with concurrent growth failure


c. excess growth hormone

i. mild-to-moderate obesity

ii. gigantism in a child with longitudinal growth acceleration

iii. macrocephaly

iv. coarse facial features

v. cardiovascular disease, i.e., hypertrophy, hypertension

vi. tumors

vii. endocrinopathies, i.e., diabetes, hypogonadism




4. Diagnostics

a. history and physical exam


b. computerized tomogram (CT) scan

c. plasma hormone levels: increased growth hormone and ACTH

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5. Management

a. pituitary microsurgery to remove tumor

b. pituitary radiation

c. gamma knife radiation

d.
pharmacologic: growth hormone suppressant, e.g., bromocriptine (Parlodel); octreotide (Sandostatin)

e. physical changes of acromegaly are irreversible


6. Nursing care

a. encourage client to express feelings about altered body image

b. care of client with hypophysectomy (removal of pituitary gland)

i.
care of the client with increased intracranial pressure

ii. check for signs of diabetes insipidus (removal of a pituitary tumor may injure the posterior pituitary glands and decrease
antidiuretic hormone secretions)


iii. monitor for adrenal insufficiency


c. reinforce client teaching - since treatment usually produces hypopituitarism, lifelong hormone replacement therapy is
required



III. Disorders of the Posterior Pituitary

A. Diabetes insipidus

1. Posterior pituitary gland makes too little antidiuretic hormone (ADH). Body loses too much water in the urine; plasma
osmolality and sodium levels increase.


2. Etiology

a. central DI - most common form, usually caused by damage to the hypothalamus or pituitary gland as a result of

i. head injury

ii. infection


iii. loss of blood supply to the gland

iv. surgery

v. tumor



b. nephrogenic DI - defect in tubular reabsorption of water back into the bloodstream; runs in families



3. Findings

a. excessive thirst (polydipsia)

b. polyuria - as much as 20 liters per day with specific gravity below 1.006

c. nocturia

d. signs of dehydration

e. constipation


4. Diagnostics

a. water deprivation tests: inability to concentrate urine; also differentiates between primary DI and nephrogenic DI

b. osmotic stimulation

c. computerized tomogram (CT) or magnetic resonance imaging (MRI) scans




5. Management

a.
pharmacologic

i. hormonal agents

desmopressin (DDAVP) - drug of choice

vasopressin (Pitressin) - antidiuretic hormone

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ii. nonhormonal agents

chlorpropamide (Chloronase)

carbamazepine (Tegretol)

diuretics, e.g., hydrochlorothiazide (HCTZ) and amiloride (Midamor)



b. IV fluid replacement therapy


c. surgical removal of tumor

d. if nephrogenic DI is caused by medication (for example, lithium), medication must be discontinued or damage may be
permanent


6. Nursing care

a.
monitor for findings of dehydration; measure urine; specific gravity


b. measure intake and output

c. weigh client daily

d. monitor for changes in vital signs and neurological status

e. monitor electrolytes

f. reinforce client teaching regarding

i. importance of recording intake and output

ii. need to wear MedicAlert identification


iii.
avoidance of food and drinks with diuretic effects

iv. maintain intake of adequate fluids and to report findings of dehydration (dry skin, thirst)




B. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) - continuous secretion of ADH with water intoxication

1. Etiology: can be divided into 4 main categories

a. nervous system disorders, e.g., acute psychosis, brain abscess and tumors, delirium tremens, encephalitis

b. neoplasia

c. pulmonary diseases, e.g., COPD, acute respiratory failure, asthma, pneumonia, pneumothorax

d. drug-induced, e.g., barbiturates, haloperidol, halothane, opiates (morphine), MAOIs, tricyclic antidepressants



2. Findings

a. changes in level of consciousness

b. changes in mental status

c. tachycardia

d. hyponatremia

e. weight gain


f. urine specific gravity - will be greater than 1.030

g. hypertension


3.
Management

a. loop diuretics, e.g., furosemide (along with hypertonic sodium solution)


b. CAREFUL IV administration of 3% hypertonic sodium for hyponatremia (too rapid infusion can cause permanent
neurologic deficits)

c. osmotic diuretics, e.g., urea, mannitol (Osmitrol)

d. vasopressin receptor antagonists (aquaretics), e.g., conivaptan (Vaprisol), tolvaptan (Samsca)

e. chemotherapy



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4. Nursing care

a. monitor intake and output


b. monitor vital signs

c. check for signs of fluid overload and hyponatremia

d. daily weights


e. monitor electrolytes

f. restrict water intake as ordered




IV. Disorders of the Thyroid Gland

A. Hypothyroidism

1. Definitions

a. hypothyroidism: a condition in which the thyroid gland does not make enough thyroid hormone; an underactive
thyroid

b. myxedema crisis/coma: a loss of brain function as a result of severe, longstanding hypothyroidism; usually
precipitated by a secondary insult (hypothermia, infection, or another systemic condition, or drug therapy)


2. Etiology

a. thyroiditis (most common), including autoimmune thyroiditis (also called Hashimoto's thyroiditis) and atrophic
thyroiditis

b. other

i. medications, e.g., such as lithium, amiodarone, interferon alpha

ii. congenital hypothyroidism

iii. radiation treatment to the neck or brain to treat different cancers

iv. radioactive iodine (used to treat an overactive thyroid)

v. surgical removal of all or part of the thyroid gland




3. Findings

a. early

i. constipation


ii. increased sensitivity to cold

iii. fatigue

iv. heavier menstrual periods

v. joint or muscle pain

vi. paleness or dry skin

vii. sadness or depression

viii. thin, brittle hair or fingernails

ix. weight gain


b. late - if left untreated

i. decreased taste and smell

ii. hoarseness

iii. puffy face, hands, feet

iv. slow speech


v. thickening of skin

vi. thinning of eyebrows





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4. Diagnostics

a. history and physical exam

b.
laboratory

i. TSH - increased

ii. serum T3 and T4 - decreased

iii. complete blood count - anemia

iv. cholesterol and triglycerides - elevated

v. serum glucose - hypoglycemia



c. decreased basal metabolic rate (BMR)



5. Management

a. pharmacologic: synthetic thyroid hormone: levothyroxine sodium (Levothroid, Synthroid); liothyronine sodium (Cytomel)

b. myxedema crisis/coma

i. mechanical ventilation

ii. treatment of associated infection

iii. correct hypothermia with passive rewarming

iv. IV thyroid hormone replacement



6. Nursing care

a. give thyroid replacement in the morning on an empty stomach

b. watch client for signs of myxedema


c. provide restful, warm environment

d. explain need for continued follow-up to monitor thyroid hormone status

e.
provide increased roughage and fluids to prevent constipation


f. monitor for overdose of thyroid medications: tachycardia, insomnia, restlessness

g. monitor for extremes of vital signs



B. Hyperthyroidism (Graves' disease)

1. Definitions

a. hyperthyroidism: overactive thyroid makes too much thyroid hormone

b. thyrotoxic crisis (thyroid storm): rare but potentially fatal complication of hyperthyroidism; precipitated by factors such
as stress, infection, pregnancy


2. Etiology: considered autoimmune response

a. Graves' disease - accounts for most cases of hyperthyroidism

b. too much iodine

c. thyroiditis

d. noncancerous growths of the thyroid gland, due to viral infections or other causes

e. overdosage of thyroid hormone



614


3. Findings

a. difficulty concentrating

b. fatigue

c. hyperphagia, weight loss, diarrhea

d. goiter or thyroid nodules

e. heat intolerance

f. exophthalmos

g. tachycardia

h. palpitations


i. restlessness

j. thin, brittle hair, pliable nails ("plummer's" nails)

k. irregular menstrual periods in women


l. insomnia

4. Diagnostics

a. history and physical exam: palpable thyroid enlargement (goiter)


b.
laboratory

i. serum T3 and T4 levels - elevated


ii. radioactive iodine uptake - elevated


iii. presence of thyroid autoantibodies

iv. TSH levels - decreased


5. Management
a. expected outcomes: to reduce the excess hormone secretion and to prevent complications
b. pharmacologic

i. sodium 131I (radioactive iodine)

ii. methimazole (Tapazole)

iii. antithyroid agents, e.g., propylthiouracil (PTU)

iv. beta-adrenergic blocking agents, e.g., propranolol (Inderal)
c. surgical - thyroidectomy (partial or total removal of thyroid gland)
d. diet high in calories, protein, carbohydrates


6. Nursing care

a. monitor vital signs, especially blood pressure and heart rate


b. provide quiet, restful, cool environment

c. monitor diet therapy, increase caloric intake

d. provide extra fluids

e. provide emotional support

f. administer antithyroid medications as ordered - also, acetaminophen to reduce fever; sedatives, if ordered

g. supplemental oxygen to meet increased metabolic demands

h. daily weight

i. reinforce client teaching

i. antithyroid and/or iodine preparation medications and side effects

ii. stress avoidance measures


iii. energy conservation measures
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iv. avoiding stimulants


j. care of the post-thyroidectomy/post-sub thyroidectomy client

i. maintain airway and breathing

ii. monitor for excessive swelling about the neck

iii. avoid Fowler's position (due to strain on incision)


iv. promptly report changes in voice or findings of hypocalcemia




V. Disorders of the Parathyroid Gland

A. Hypoparathyroidism

1. Definition: parathyroid produces too little parathormone (paraphyroid hormone), resulting in hypocalcemia

2. Etiology

a. most often results from injury to parathyroid glands


b. other causes include low blood magnesium levels, metabolic alkalosis


3. Findings

a. neuromuscular

i. irritability

ii. personality changes


iii. muscular weakness or cramping

iv. numbness of fingers

v. tetany

vi. carpopedal spasms

vii. laryngospasm

viii. seizures


b. dry, scaly skin

c. hair loss


d. abdominal cramping




4. Diagnostics

a. positive Chvostek's sign- facial muscle spasm at touch of cheek area in front of ear

b. positive Trousseau's sign- carpal spasm occurs when the upper arm is compressed (by a blood pressure cuff, for at least 1
minute)

c. ECG - abnormal heart rhythms


d. laboratory

i. serum calcium - decreased

ii. serum phosphate - increased

iii. magnesium - low

iv. PTH levels - low


v. urine - calcium levels



5. Management

a.
calcium replacement therapy - ideal serum calcium level 8.6mg/dL

b.
vitamin D preparations - facilitate uptake of calcium

c.
calcium-rich, low phosphorous diet


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6. Nursing care

a. monitor carefully for signs of tetany and hypocalcemia

b. place airway, suction, and tracheotomy tray at bedside

c. provide seizure precautions as indicated

d. monitor vital signs

e. prepare for administration of IV calcium gluconate or calcium chloride (given if client demonstrates signs of tetany, positive
Chvostek's or Trousseau's signs)

f. provide a quiet environment with low lights

g. reinforce client teaching

i. increase vitamin D intake and increase calcium in diet

ii. decrease phosphorus intake - restrict intake of fish, eggs, cheese, cereals

iii. encourage client to wear MedicAlert identification




B. Hyperparathyroidism

1. Definition - parathyroid secretes too much parathyroid hormone (PTH); results in increased serum calcium (hypercalcemia)

2. Etiology

a. primary hyperparathyroidism: enlargement of one or more of the parathyroid glands; usually no known cause


b. secondary hyperparathyroidism: the body produces extra parathyroid hormone because calcium levels are too low

c. tertiary hyperparathyroidism: the parathyroid glands continue to produce too much parathyroid hormone even though
the calcium levels are back to normal (usually occurs with kidney disease)


3. Findings

a. gastrointestinal: constipation, nausea, vomiting, anorexia

b. skeletal: bone pain, demineralization, deformities, pathological fractures

c. kidney stones - due to increased calcium levels

d. blurred vision (due to cataracts)

e. muscle weakness and fatigue

f. depression



Symptoms of hyperparathyroidism can be remembered as: "moans, groans, stones, and bones... with psychic overtones."


4. Diagnostics

a. history and physical exam

b.
laboratory

i. serum calcium - elevated


ii. serum phosphate level - decreased


c. x-rays and dual-energy radiographic absorptiometry reveal bone demineralization

d. imaging studies (CT & MRI) and ultrasound of the neck


5. Management

a. drink more fluids (to prevent kidney stones from forming), exercising, avoiding thiazide-type diuretics

b. surgery - removal of parathyroid glands (parathyroidectomy) - recommended for people under age 50

c. for tertiary hyperparathyroidism (caused by kidney failure) - treat with extra calcium and vitamin D, avoiding phosphate in
the diet, dialysis/kidney transplant, parathyroid surgery


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6. Nursing care

a. provide care of the client undergoing parathyroidectomy

i. observe for signs of hypocalcemia, including tingling and numbness

ii. notify care provider if calcium level drops

iii. monitor for laryngeal damage - change in voice pattern and hoarseness


iv. monitor renal involvement, i.e., strain urine for stones, evaluate low back pain, check for hematuria


b. reinforce for the client to consume diet rich in calcium

c. encourage mobility (immobility increases demineralization of bones)

d. increase fluid intake (to dilute calcium levels in blood and urine)


e. encourage client to wear MedicAlert identification



VI. Disorders of the Adrenal Gland

A. Addison's disease

1. Definition

a. gradual destruction of the adrenal cortex, resulting in decreased production of cortisol and often aldosterone

b. a rare and chronic disease; also called primary adrenal insufficiency


2. Etiology: destruction of the adrenal cortex, due to

a. autoimmune disease

b. infections, e.g., tuberculosis, HIV, or fungal infections

c. hemorrhage

d. tumors


e. use of anticoagulants


3. Findings

a. acute adrenal insufficiency (Addisonian crisis)

i. severe headache or back pain

ii. severe generalized muscle weakness

iii. diarrhea or constipation


iv. confusion

v. lethargy

vi. severe hypotension

vii. circulatory collapse


b. adrenal insufficiency

i. vague complaints or findings

ii. fatigue

iii. muscle weakness

iv. vague abdominal complaints: anorexia, nausea, vomiting


v. personality changes

vi. skin pigmentation darkens





4. Diagnostics

a. history and physical

b.
laboratory

i. ACTH stimulation test - low cortisol levels
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ii. electrolytes - low blood levels of sodium and high levels of potassium

iii. serum glucose - low

iv. 24-hour urine collection - decreased levels of free cortisol



5. Management

a. chronic insufficiency

i.
glucocorticoid replacement therapy: hydrocortisone (Cortef)

ii.
mineralocorticoid replacement therapy: fludrocortisone acetate (Florinef)

iii.
diet high in protein, carbohydrates, and sodium


b. Addisonian crisis

i. emergency management of circulatory collapse

ii. intravenous hydrocortisone



6. Nursing care

a. manipulate the environment to reduce stressors

b. preserve the client's energy by assisting with activities of daily living as indicated

c. monitor electrolytes and report abnormal results

d. measure intake and output

e. monitor vital signs


f. monitor weight

g. reinforce client teaching

i. diet

add more sodium to the diet

AVOID extra potassium (avoid salt substitutes)

have a quick sugar source available

increase fluid intake (3000 mL/day)


ii. need for lifelong hormone-replacement therapy (corticosteroids)


iii. wearing MedicAlert identification

iv.
how to avoid, minimize, or manage stress




B. Cushing syndrome

1. Definition: adrenal cortex secretes too much glucocorticoid (cortisol)

2. Etiology

a. long term treatment with corticosteroid medications, e.g., prednisone and prednisolone

b. over-production of cortisol, due to

i. Cushing's disease: pituitary gland makes too much ACTH, which causes the adrenal glands to produce cortisol (often
due to a tumor of the pituitary gland)

ii. tumor of the pituitary gland


iii. tumor elsewhere in the body that produces cortisol or ACTH (such as pancreas, lungs, thyroid)



3. Findings

a. upper body obesity with thin arms and legs

b. round, red, full face (moon face)

c. slow growth rate in children

d. skin changes - acne, striae (purple marks) on skin of abdomen, thighs, breasts, easy bruising
619


e. muscle/bone changes - backache, bone pain or tenderness, buffalo hump, rib/spine fractures

f. women with have excess hair growth on face, neck, chest, abdomen, thighs

g. men may be impotent, decreased libido

h. other - personality/behavior changes, fatigue


4.
Diagnostics

a. history and physical exam


b.
laboratory - 3 standard case detection tests

i. 24-hour urinary free cortisol (UFC)


ii. late-night salivary cortisol

iii. 1-mg overnight dexamethasone suppression test

iv. laboratory findings

levels of cortisol, sodium, and glucose - increased

potassium - decreased


v. other tests: bone density, abdominal CT, pituitary MRI




5. Management: treatment depends on the cause

a. Cushing syndrome caused by corticosteroid use - slowly decrease medication under medical supervision


b. Cushing syndrome caused by pituitary tumor or tumor that releases ACTH - remove tumor (transsphenoidal surgery),
radiation therapy following surgery and hydrocortisone (cortisol) replacement therapy

c. Cushing syndrome due to adrenal tumor or other tumors - remove tumor (adrenalectomy); if tumor cannot be removed,
medication to block the release of cortisol

d. pharmacologic - agents that inhibit steroidogenesis, e.g., metyrapone (Metopirone), mitotane (Lysodren), ketoconazole
(Nizoral)

e.
diet including sufficient calcium and vitamin D


6. Nursing care

a. monitor for findings of hypokalemia, hypernatremia

b. explain the need for lifelong treatment

c. need for MedicAlert identification

d. encourage client to stay away from other persons with infections

e.
do not discontinue steroid medications abruptly ( care of client taking steroids )


When reading the stem of the question, give special attention to words such as: BEST, MOST, LEAST, FIRST, PRIORITY, INITIAL.


C. Pheochromocytoma

1. Definition: adrenal medulla secretes too much epinephrine and norepinephrine (catecholamines), causing excessive
stimulation of the sympathetic nervous system

2. Etiology: usually a benign tumor of the adrenal medulla

3. Findings

a. abdominal pain, chest pain

b. irritability, nervousness

c. severe stress response


d. pallor

e. palpitations

f. tachycardia
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g. severe headache

h. diaphoresis

i. weight loss

j. other: hand tremor, hypertension, difficulty sleeping


4.
Diagnostics

a. adrenal biopsy


b. abdominal computerized tomogram (CT) & magnetic resonance scans

c. metaiodobenzylguanidine (MIBG) scintiscan

d. laboratory

i. 24-hour urine collection - increased urinary catecholamines

ii. glucose





5. Management

a. surgical removal of the tumor - scheduled only after client has been normotensive for at least one week


b.
pharmacologic

i. antihypertensive agents as needed pre-op

ii. antidysrhythmic agents as needed pre-operatively: nitroprusside (Nitropress)


iii. alpha-adrenergic blocking agents - postoperatively: phenoxybenzamine (Dibenzyline)

iv. beta adrenergic blocking agent (beta blockers): propranolol (Inderal), nadolol (Corgard)

v. tyrosine inhibitors: alpha methyl-para-tyrosine (decreases circulating catecholamines)


c. post op diet - high in calories, vitamins, and minerals



6. Nursing care

a. monitor vital signs, especially blood pressure


b. keep phentolamine (Regitine) available for treatment of hypertensive crisis

c. monitor urine for glucose

d. promote rest and nonstressful environment


e. never palpate the abdomen of a client with a pheochromocytoma


f.
if bilateral adrenalectomy performed, lifelong steroid therapy required

g. reinforce client teaching

i. medications and side effects

ii. need for lifelong follow-up

iii. regular blood pressure checks

iv. decreasing caffeine intake


v. diet




VII. Disorders of the Pancreas

A. Diabetes mellitus (DM)

1. Definition - a condition in which the pancreas produces too little insulin, or cells stop responding to insulin; results in
hyperglycemia

2. Etiology

a. type 1 diabetes mellitus

i. genetic

ii. autoimmune response
621


iii. severe insulin deficiency - beta cells stop insulin production


b. type 2 diabetes mellitus

i. obesity is major risk factor

ii. relative lack of insulin or resistance to the action of insulin

iii. insulin is sufficient for protein and fat metabolism but not carbohydrate metabolism





3. Diagnostics

a. history and physical exam

b. laboratory

i. fasting blood sugar - elevated serum glucose levels


ii. oral glucose tolerance test (GTT)

iii. glycosylated hemoglobin test (also known as Hemoglobin A1c or HbA1c)



4. Findings

a. hyperglycemia


b. the 3 "polys" of diabetes mellitus

i. polydipsia (increased thirst)


ii. polyuria (increased urine production)

iii. polyphagia (increased hunger)


c. fatigue

d. weight loss (in type 1 diabetes mellitus only)

e. blurred vision

f. vaginal infections

g. slow wound healing


Although it's extremely oversimplified, think of the relationship between insulin and glucose as a see-saw. When one is higher,
the other tends to be lower.


5. Management

a.
diet therapy and weight loss - eat foods high in nutrition and low in fat and calories

b. exercise

i. lower glucose levels and improve circulation

ii. decreases total cholesterol and triglycerides


c. insulin

i. used in type 1 DM and type 2 DM (when better glycemic control is needed)

ii. types of insulin - rapid-acting, short-acting, intermediate-acting, long-acting (and very long-acting)

iii. preparations

vials and prefilled syringes
622


cartridges (used in pen-like devices)

insulin pumps - deliver rapid-acting insulin continuously throughout the day



d. other medications for type 1 DM

i. hypertensive medications, including angiotensin-converting enzyme (ACE) inhibitors or angiotensin II
receptor blockers (ARBs)


ii. cholesterol-lowering drugs (the statins)

iii. pramlintide (Symlin) - injectable medication prior to eating that slows the movement of food through
the stomach and curbs the rise in blood sugar


e.
oral antidiabetic medications - sulfonylureas, meglitinides, biguanides, thiazolidinediones and alpha-
glucosidase inhibitors

i. prescribed for clients with type 2 DM

ii. therapy can be a single oral agent or a combination of oral agents if adequate blood glucose control is
not attained


f. investigational treatments - pancreas transplant, islet cell transplant, stem cell transplant



6. Complications

a. hypoglycemia (insulin shock)

i. blood sugar falls below 50 mg/dL

ii. caused by too much insulin, too little food, or excessive physical activity

iii. may result from delayed meals, exercise, or vomiting


iv. rapid onset


v. findings of insulin shock

diaphoresis; cold, clammy skin

anxiety, tremor, slurred speech

weakness

nausea

mental confusion, personality changes, altered level of consciousness

headache



vi. management of hypoglycemia

if client is conscious, give at least 15-20 grams of carbohydrates, such as 4 ounces of juice
or regular soda, 2 tablespoons of raisins, 4 or 5 saltine crackers, 4 teaspoons sugar, 1
tablespoon honey or corn syrup

if unconscious: give 1 mg glucagon IM or SubQ




b. diabetic ketoacidosis (DKA) - an acute complication

i. results from severe insulin deficiency

ii. findings

blood sugar levels greater than 350 mg/dL

elevated ketone levels - cause sweet odor to breath (may also have odor of someone drinking
623

alcohol)

metabolic acidosis - Kussmaul's respirations, flushed appearance

thirst

polyuria

drowsiness

anorexia, vomiting

may lead to shock and coma

usual causes:
undiagnosed diabetes mellitus
inadequacy of prescribed therapy for diabetes mellitus; missed dose of insulin
physical stress such as surgery, illness, or trauma in person with diabetes mellitus
caused by increased gluconeogenesis from amino acids and glycogenolysis in the liver

management:

correct fluid depletion - IV fluids

correct electrolyte depletion - especially potassium

correct metabolic acidosis - (regular) insulin IV



Complementary and Alternative Medicine

Herbal remedies for diabetes

green tea

garlic some research supports its use for lowering blood sugar levels

fenugreek a medicinal plant that is considered a carminative, demulcent, expectorant, laxative
and stomachic; seed extracts have been reported to lower blood glucose levels

Flaxseed oil may help reduce cholesterol and triglyceride levels in some people with diabetes

Vitamins & minerals

magnesium supplements may improve insulin sensitivity

chromium (found in wheat germ; beef; liver; eggs; chicken; apples; spinach; brewers yeast)
important in the metabolism of fats and carbohydrates; also important in the metabolism of
insulin


c. hyperosmolar hyperglycemic state (formerly called: hyperglycemic hyperosmolar nonketotic coma [HHNC])

i. rare, but with a high mortality rate

ii. gradual onset

iii. findings

severe hyperglycemia; usually > 600 mg/dL

pH usually > 7.4

ketones - negative

(profound) dehydration

altered level of consciousness


iv. usually precipitated by physical stress such as an infection

v. non-diabetics - can be due to tube feedings without supplemental water, or too rapid rate of parenteral
nutrition


d. other chronic complications

i. diabetic triopathy
624


retinopathy: chronic and progressive impairment of the retinal circulation that eventually
causes hemorrhage

nephropathy: progressive decrease in kidney function

neuropathy: general deterioration of the nervous system throughout the body with
complications leading to development of nonhealing ulcers of the feet


ii. macrovascular complications

coronary artery disease

peripheral vascular disease



7. Nursing care

a. give medications as ordered

b. watch for signs of hyperglycemia or hypoglycemia

c. guide client for self-monitoring of blood glucose

d. assist client with meal planning

e. support client emotionally

f. reinforce client teaching

i. importance of daily consistency in diet, medication and exercise

ii. need to eat more before strenuous exercise


iii. self blood-glucose monitoring


iv. methods of insulin administration

v. medications and side effects

vi.
not to cross legs and need for special foot care

vii. early reporting of findings of ketoacidosis, local allergic reactions, complications


viii. need to carry extra rapid-absorbing carbohydrate on person at all times

ix. need to wear MedicAlert identification

x. need for regular eye exams

























625

Points to Remember
Endocrine System

The endocrine system controls maturation, development, growth, and regulation within the body; the functions of the endocrine
and nervous systems are interrelated.

Endocrine disorders may be caused by

hyper- or hyposecretion of hormones

hyporesponsiveness of hormone receptors

inflammation of glands

tumors
Pancreas

In the pancreas, the beta cells in the islets of Langerhans make insulin.

Clients with type 1 diabetes typically test blood sugar 4 times a day (before meals and at bedtime); those using an insulin pump
may test more frequently.

Treatment for type 2 diabetes typically includes oral antidiabetic agents.

Hypoglycemia, allergic reactions, lipodystrophy, and Somogyi effect are problems associated with insulin therapy.

Exercise increases the body's metabolic rate that results in a decrease in blood sugar and an increase in insulin sensitivity.

Illness can disrupt metabolic control and raise blood sugar, which results in an increased need for insulin.

Glycated hemoglobin (HbA1c) provides a good estimate of how well diabetes has been managed in the past 2 to 3 months. A
HbA1c of 6% or less is normal; diabetics should try to keep their HbA1c below 7%.

Diabetes is the leading cause of heart disease, stroke, adult blindness and nontraumatic lower limb amputations.

The highest incidence of diabetes is among Native Americans.

Target blood glucose levels before a meal is between 90 to 130 mg/dL; 1 to 2 hours after a meal it should be less than 180 mg/dL.

Diabetic ketoacidosis (DKA) occurs more commonly in type 1 diabetes whereas hyperosmolar hyperglycemic nonketotic
syndrome (HHNS) occurs most often in clients with type 2 diabetes.

Points to Remember 2
Thyroid Gland

The thyroid gland secretes thyroxine and triiodothyronine.

Following neck surgery, potentially life-threatening complications such as laryngeal edema and tracheal obstruction can occur;
monitor for respiratory distress.

Following thyroid surgery, many clients suffer transient hypocalcemia from hypofunction or removal of the parathyroids; monitor
for signs of tetany for up to three days after surgery.
Parathyroid Gland

The parathyroid glands secrete parathyroid hormone.

Chvostek's sign and Trousseau's sign are tests for neuromuscular irritability; a positive test, i.e., hyperirritability, for either of
these indicates hypocalcemia or hypomagnesemia.

Positive Chvostek's sign: contraction of facial muscle occurs when light tap is given over facial nerve in front of ear.

Positive Trousseau's sign: carpal spasm occurs when the upper arm is compressed (by a blood pressure cuff, for at least 1
minute).
Adrenal Gland

The adrenal medulla produces epinephrine and norepinephrine; the adrenal cortex secretes mineralocorticoids, glucocorticoids,
adrenal androgens, and estrogen.

In primary disease, e.g., primary Addison's disease and primary Cushing's syndrome, destruction of the adrenal glands usually
results from an autoimmune process.

A client with Addison's disease may have hyperpigmentation of the skin; don't confuse this with jaundice.
Pituitary Gland

The pituitary gland secretes oxytocin and antidiuretic hormone.

Diabetes insipidus is a pituitary disorder.

626



I. Anatomy and Physiology

A. Bone

1. Functions

a. supports and protects structures of the body

b. anchors muscles

c. some bones contain hematopoietic tissue which forms blood cells - pelvic, femur, sternum

d. participates in the regulation of calcium and phosphorus


2. Joints

a. bursa - enclosed cavity containing a gliding joint


b. synovium - lining of joints which secretes lubricating fluid that nourishes and protects

c. classification of joints - synarthrosis, amphiarthrosis, diarthrosis


3. Cartilage - connective tissue covering the ends of bones

4. Types of bones

a. long - legs, arms

i. external structure - diaphysis, epiphysis, periosteum

ii. internal structure of bone - medullary cavity; cancellous bone; red marrow


b. short - ankles, wrists

c. flat - shoulder blades

d. irregular - face, vertebrae




Short Bones Long Bone





627


B. Fascia - surrounds and divides muscles

C. Muscles - produce movement of the body

1. striated (skeletal) - controlled by voluntary (cerebrospinal) nervous system

2. smooth (visceral) - controlled by autonomic nervous system

3. cardiac - controlled by autonomic nervous system


D. Tendons - fibrous tissue between muscles and bones

E. Ligaments - fibrous tissue between bones and cartilage; supports muscles and fascia

II. Trauma: Contusions, Strains, Sprains

A. Contusions (bruise)

1. Definition: a fall or blow breaks the capillaries but not the skin

2. Pathophysiology: extravasation (bleeding) under skin

3. Findings: ecchymosis (bruising) and pain when the contusion is palpated

4. Management

a. for first 24 to 48 hours, apply ice for 15 minutes, three or more times a day to decrease
swelling

b. then apply heat if necessary

c. wrap to compress

d. observe closely for extension or enlargement of bruise if client is at risk for bleeding due to
thrombocytopenia or other coagulation disorder

e. observe for changes in mental status if the bruise is related to head injury

f. report any evidence that the integrity of surrounding structures is jeopardized by the bruise
when injury occurs near a structure (such as the eye) - the swelling can jeopardize the
structure


5. Resolution: should heal within 7 to 10 days

6. Color changes from a blackish-blue to a greenish-yellow after 3 to 5 days



B. Strains

1. Definition - lesser injury of the muscle attachment to the bone


2. Etiology - caused by overstretching, overexertion, or misuse of the muscle

a. chronic strain

i. long-term overstretching of muscle/tendon

ii. repeated use of the muscle beyond physiologic limits


b. acute strain: recent injury to muscle or tendon; classified by degree

i. first degree strain: mild; gradual onset; feels stiff, sore locally

findings of acute first-degree strain

tenderness to palpation
628


muscle spasm

no loss of range of motion

little or no edema or ecchymosis

management of acute first-degree strain

comfort measures

apply ice

rest, possibly immobilize for short term, elevate

oral analgesics






ii. second degree strain: moderate stretching, sudden onset, with acute pain that eventually leaves area
tender

findings of acute second-degree strain

extreme muscle spasm

passive motion increases pain

edema develops early; ecchymosis later

management of acute second-degree strain

keep limb elevated

apply ice for the first 24 to 48 hours, then moist heat

limit mobility

muscle relaxants, analgesics, NSAIDs

physical therapy after acute phase



iii. third-degree strain: severe stretching with tear; sudden; snapping or burning sensation

findings
muscle spasm
joint tenderness
edema (may be extreme)
client cannot move muscle voluntarily
delayed ecchymosis

management of third-degree strain

keep limb raised

apply ice for 24 to 48 hours, then moist heat

either immobilize or limit mobility of the limb

medication - muscle relaxants, analgesics, NSAIDs

physical therapy after acute phase



C. Sprains

1. Definition - greater than strain; injury to ligament structures by stretching, exertion or trauma

2. Classification/finding/management

a. first degree sprain

i. minimal tearing of ligament fibers
629



ii. localized edema or hematoma

iii. no loss of function

iv. no weakening of joint structure - joint integrity remains intact

v. mild discomfort at location of injury

vi. pain increases with palpation or weight bearing

vii. management

compress with ace bandage to limit swelling

keep limb raised to decrease edema

apply ice 24 to 48 hours following injury

analgesics for discomfort

isometric exercises (muscle tightening activities) to increase circulation and
resolve hematoma





b. second degree sprain

i. up to half of the ligamentous fibers torn


ii. increased edema and possible hematoma

iii. decreased active range of motion

iv. increased pain

v. mild weakening of the joint and loss of function

vi.
management

protectively dress/splint the joint, immobilize it

raise the limb to decrease edema

for 24 to 48 hours, alternate

ice
to produce vasoconstriction to decrease swelling
to reduce transmission of nerve impulses and conduction velocity to decrease pain
630

moist heat to reduce swelling and provide comfort
analgesics for discomfort

physical therapy to increase circulation and maintain nutrition to the cartilage after
acute phase



c. third degree sprain

i. complete rupture of the ligamentous attachment


ii. severe edema with hematoma

iii. usually, severe pain

iv. dramatic decrease in active range of motion

v. loss of joint integrity and function

vi. management

casting / immobilization

surgery to restore integrity of joint

see second degree management


Nursing Care for sprains and strains: RICE
R= Rest
I= Ice
C= Compression
E= Elevation


D. Fractures

1. Definition: fracture is any alteration in the continuity of a bone

2. Fracture dislocation: a fracture in which the joint is dislocated in that position, fracture will not
heal completely

3. Classifications

a. by completeness

i. complete (bone broken in two or more pieces)

ii. incomplete (bone broken but still in one piece)


b. by wound

i. closed or simple; does not break skin

ii. open or compound or complex
bone fragments break through skin
injures soft tissue and often infects tissue
subdivided by degree of soft tissue injury




631


c. by fracture line

i. longitudinal - linear fracture

ii. oblique - produced by a twisting force, and requires traction to heal properly.

iii. spiral - results from twisting force, may accompany damage to soft tissue, and requires traction
or internal fixation.

iv. transverse - caused by angulation, common in pathological fractures, and generally stable after
reduction.



d. by type of fracture

i. avulsion fractures

bone fragments and soft tissue are pulled away from the bone

results from a direct force on the bone


ii. comminuted fractures

produced by high energy forces

results in two or more bone fragments

splinters the fragments

injures soft tissue severely


iii. compression fractures

often seen in the lumbar spine

may be pathological (a disease weakens the bone)


iv. greenstick fracture

results in an incomplete fracture

caused by

compression forces

angulation forces

cortex of the bone bends to one side and buckles on the other; cortex stays intact on the side
subject to tension forces and fractures on the opposing side

requires reduction or completion of the fracture line through the cortex



v. impacted fractures (telescoped)

direct force breaks bone and telescopes the fragment with the smaller diameter into
the fragment with the larger diameter
632


fracture fragments move in unison

rapid union occurs


vi. stress fracture

incomplete fracture

result of repetitive trauma to region

two types:

fatigue - from repeated trauma

insufficiency - pathological fracture




4. Pathophysiology

a. predisposing factors - biologic

i. bone density

ii. client's age


b. extrinsic factors

i. force - direct or indirect

ii. rate of loading (how fast the force strikes)


c. intrinsic factors - bone capabilities

d. pathological fractures

i. bone is weakened by disease, such as a malignancy

ii. fractures occur in response to minimal or no applied stress

iii. classification by cause

general: developmental, nutritional, hormonally controlled

local: neoplasm, infection, cystic lesion



e. behavioral factors - high-risk activities, e.g., football, ballet


5. Treatment and management

a. closed reduction

i. purposes: realign bone fragments for healing, minimal deformity, minimal pain.

ii. pre- and postreduction x-rays are essential to determine successful reduction of fracture


b. immobilization

i. purposes

relieve pain

keep bone fragments from moving


ii. methods - cast, traction, splints, braces, and external fixation


iii. traction

manual: applied by pulling on the extremity - may be used during cast application
633


skin: applied by pulling force through the client's skin - used to relax the muscle
spasm

skeletal: applied directly through pins inserted into the client's bone - used to align
fracture


iv. open reduction (see Orthopedic Surgery section for hip and knee replacement)



6.
Stages of bone healing

a. hematoma formation

b. fibrocartilage/granulation tissue formation

c. callus formation

d. ossification

e. consolidation/remodeling


7. Evidence of healed fracture

a. radiographic

i. presence of external callus or cortical bone across the fracture site

ii. fracture line may remain long after healing


b. clinical

i. pieces of bone no longer move at fracture site

ii. no tenderness over fracture site

iii. weight bearing is pain free



8. Complications

a. immediate complications of the injury

i. shock (hemorrhagic, hypovolemic) - especially with pelvic and femur fractures

ii. fat embolism

occurs after the initial 24 hours from the injury

more common with pelvic and femur fractures


iii. compartment syndrome - a medical emergency

nerves and blood vessels are compressed causing muscle and nerve damage

decreased sensation, paleness, and weakness

treated with longitudinal incision to relieve pressure or loosening of tight cast or
wrap


iv. deep venous thrombosis (DVT) - change in skin color, swelling, increased warmth or pain in
lower limb

v. pulmonary embolism - a complication of DVT

vi. hemorrhage

vii. wound infection (tissue and bone)



b. delayed complications

i. joint stiffness

ii. posttraumatic arthritis (osteoarthritis, type II)

iii. reflex sympathetic dystrophy

painful dysfunction and disuse syndrome

characterized by abnormal pain and swelling of the extremity

634


iv. myositis ossificans

formation of hypertrophic bone near bone and muscles

forms in response to trauma

hypertrophic bone is removed when bone is mature


v. malunion

fracture healing is not stopped but slowed

prevention of malunion
reduce and immobilize properly
be sure clients understand their limits on activity and position



vi. delayed union

fracture does not heal

more common with multiple fracture fragments

no evidence of fracture healing four to six months after the fracture


vii. loss of adequate reduction

viii. refracture


9. Nursing interventions for fractures

a. risk for peripheral neurovascular deficit

i. check neurovascular status distal to an injury
skin color - color should match other body areas

skin temperature - temperature should feel warm to touch and match other body
areas

movement - there should be no increase in discomfort with active or passive
movement distal to the injury
sensation - no report of numbness, tingling, or loss of sensation distal to the injury
circulation - capillary refill and pulse amplitude should match other body areas

pain - increasing pain distal to the injury, especially with passive motion, is a critical
sign of compartment syndrome


ii. raise limb above level of heart (except with compartment syndrome) - keep extremity level

iii. apply cold to minimize edema
The 5 P's of circulation checks:

P=Pain
P=Paresthesia
P=Paralysis
P=Pulse
P=Pallor (Paleness)


b. manage pain

i. assess level of pain (using a pain scale of 1 to 10 or faces for children, cognitively impaired
clients, or clients who speak a different language)

ii. administer prescribed pain medications

iii. maintain appropriate traction if applied

iv. non-medical interventions include repositioning client, padding bony prominences

v.
teach relaxation techniques, i.e., visual imagery, music therapy


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c. risk for impaired skin integrity

i. causes

open fractures

soft tissue injuries

pressure areas

immobility


ii. additional factors

age - elderly more at risk

general condition of client

preexisting conditions - obesity, diabetes mellitus, malnutrition


iii. nursing interventions

mobilize the client as soon as possible

turn the client often

pad bony prominences

position the client properly

use orthopedic devices to limit skin impairment - order specialized be if client is at high
risk

do not massage reddened areas or bony prominences since this increases capillary
fragility for breakdown




d. impaired gas exchange

i. most often accompanies chest trauma

ii. risks of fat embolism and deep venous thrombosis

iii. nursing interventions

mobilize as soon as possible

frequent and effective use of incentive spirometer

maintain good hydration




e. risk for infection

i. related to

open fractures

surgical intervention

superficial/deep wounds


ii. watch for findings of infection, i.e., elevated temperature, redness or drainage from surgery site

iii. provide proper wound care

iv. give antibiotic therapy as indicated



f. skeletal traction care

i. daily pin care; clear crusty drainage is normal

ii. inspect traction apparatus every 8 hours for alignment and proper function

iii. ensure weights are always hanging freely and not obstructed by other objects


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g. reinforce client teaching

i. how fractures heal

ii. why the fracture is being immobilized

iii. how to bear weight and how much (if permitted)

iv. how to use assistive devices to walk

v. cast care - see Lesson 7 (Procedures) for more details on cast care

keep cast dry

may blow cool air into the cast with a hair dryer at cool setting for itching

report swelling, discoloration of digits, pain during motion, burning and tingling under
the cast



10. Fractures: factors that affect healing
Enhanced Healing Hinders Healing
Fracture is near good supply of blood Poor blood supply to one or more bone fragments
(mid-shaft fractures have less blood supply)
Minimal damage to soft tissue Severe damage to soft tissue
Anatomic reduction Separation of fragments
Fragments in good position to heal Traction pulls fragments apart
Immobilization Improper fixation lets bones move or rotate
Weight can be borne on long bones Pre-existing factors: obesity, diabetes mellitus, use of steroids

Severe comminution

Bone loss

Infection




E. Repetitive use injuries

1. Definition: injuries that result from repeated twisting and turning of the affected joint

2. Common injuries: carpal tunnel syndrome, bursitis, and epicondylitis

a. carpal tunnel syndrome

i. occurs when the carpal tunnel in the wrist narrows from repetitive irritation then
compresses and irritates the median nerve

ii. numbness and tingling of the thumb, index finger, and middle finger of the affected hand
develops


b. bursitis

i. affects bursae in the shoulder, hip, leg, and elbow - often associated with athletic endeavors
such as pitching in baseball and playing tennis

ii. manifestations include tenderness and pain with joint movement


c. epicondylitis

i. involves inflammation of a tendon where it inserts into the bone

ii. manifestations include point tenderness and pain radiating down the affected extremity


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3. Nursing interventions

a. rest and immobilization of the involved joint is supported by the nurse

b. ice therapy may be used to decrease pain and inflammation

c. NSAIDs are often administered for pain and inflammation

d. in the case of surgery, nursing care focuses on recognition and prevention of postoperative
complications as well as support of rehabilitation



III. Degenerative disorders

A. Definition

1. Slowly progressive disorders of articular cartilage and subchondral bone

2. Findings do not affect joints symmetrically, i.e., both knees not necessarily affected

3. Worsen progressively

4. Eventually incapacitate, despite treatment



B. Osteoarthritis (OA)

1. Definition - degeneration of the articular cartilage and formation of new bone in the
subchondral margins of the joint

a. primarily involves weight-bearing joints

b. non-inflammatory disorder

c. localized with no systemic effects

d. results in an abnormal distribution of stress on the joint




2. Types

a. primary osteoarthritis

b. secondary arthritis


3. Incidence

a. most common form of arthritis

b. OA affects twice as many women as men

c. more common in Caucasians


4. Pathophysiology

a. stage one - micro-fracture of the articular surface

i. articular cartilage is worn away

ii. condyles of bones rub together: joint swells and is painful

iii. cartilage loses cushioning effect: joint friction develops

iv. prostaglandins may accelerate the degenerative changes


b. stage two - bone condensation

i. erosion of cartilage
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ii. cartilage may be digested by an enzyme in the synovial fluid


c. stage three - bone remodeling

i. matrix synthesis and cellular proliferation fail

ii. eventually the full thickness of articular cartilage is lost

iii. bone beneath cartilage hypertrophy and osteophytes form at joint margins

iv. result: joint degenerates with minimal function



5. Findings

a. joint stiffness following periods of rest

b. pain in a movable joint, typically worse with action, relieved by rest

c. paresthesia in affected extremity

d. joint enlargement - bones grow abnormally; spurs form and synovitis sets in

i. Heberden's nodes


ii. Bouchard's nodes


e. joint deformities

f. tenderness on palpation

i. may involve widely separated areas of the joint

ii. mild synovitis may be felt - positive bulge sign may be found


g. pain on passive movement

h. limitation in active range of motion because

i. joint surfaces no longer fit

ii. muscle spasms and contracts

iii. joints are blocked by osteophyte, loose bodies

iv. crepitation, crunching when joints are moved

v. eventual ankylosis


i. gait

i. abnormal antalgic gait

ii. shortened stance

iii. widened base of support

iv. shortened step length



6.
Diagnostics

a.
lab tests to rule out autoimmune disorders

i. sedimentation rate: used to measure inflammation in the body

0-15 milliliters per hour for males

0-20 milliliters per hour for females

higher for elderly clients

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ii. rheumatoid factor

a lab test that is ordered when symptoms indicate that RA may be present

a positive test may also be seen in lupus, endocarditis, tuberculosis, cancer,
sarcoidosis, syphilis, viral infection or disease of liver, lung or kidneys


iii. C-reactive protein (CRP): increases with inflammation, appears in higher amounts when there
is swelling in the body


b.
other lab tests

i. complete blood count (CBC): analyze before NSAID therapy to determine if within normal limits

ii. kidney and liver status

analyze before starting NSAID therapy especially in older clients

repeat every six months


iii. test for TB with purified protein derivative (PPD)

analyze before starting steroids

clients testing positive for tuberculosis must receive INH at same time as steroid


iv. antinuclear antigen (ANA) titer

a positive test may indicate an autoimmune disease

may be lower in the elderly

does not necessarily prove a connective tissue disease



c. synovial fluid analysis distinguishes osteoarthritis from rheumatoid arthritis

d. radiographs

i. taken in standing, weight-bearing condition

ii. shows the prime sign of OA: joint space narrowing

iii. x-ray does not necessarily reflect severity of disease

iv. joint loses space asymmetrically because cartilage narrows from production of osteophytes or
bone spurs

v. later stages may show bony ankylosis, spontaneous fusion


e. bone scans

i. radionuclide imaging

ii. shows skeletal distribution of osteoarthritis

iii. monitors complications of joint replacement surgery


f. MRI scans show the extent of joint destruction

g. computerized tomogram (CT) scans show cortical and cancellous bone density


7. Management - conservative treatment

a. education

i. exercise patterns

ii. relaxation techniques

iii. nutritional assessment

iv. counseling about maintaining a normal weight



b.
nutrition - weight reduction
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c. activity and rest

i. preservation of joint motion through a balance of

rest (protection)

activity (rehabilitation)


ii. individualized activity rehabilitation program

iii. physical or occupational therapist may be helpful

iv. passive range of motion exercises

v. active stretching


d. pharmacologic

i. aspirin - most often recommended
advantages: relatively safe and inexpensive
disadvantage: high dosages result in GI findings and may lead to ulcers


ii. nonsteroidal anti-inflammatory medications (NSAIDs)

reduce pain and inflammation

inhibit prostaglandin formation

may cause GI bleeding, gastric ulcers, diarrhea


iii. adrenocorticosteroid injections into affected joint

iv. corticosteroid injections

v. hyaluronic acid injections

vi. mild narcotic pain relievers



e. non-pharmacologic

i. assistive devices

canes

walkers


ii. protection from further injury by splinting or bracing

iii. transcutaneous electrical nerve stimulation (TENS) - for pain relief
Complementary and Alternative Medicine

Herbal remedies used to treat osteoarthritis

ginger concentrate

capsaicin (topical)

Mind-body interventions, including guided imagery, therapeutic massage, biofeedback,
hypnosis, Tai Chi, Qigong and yoga

Supplements

glucosamine sulfate (improvement may take as long as 3 months)

SAMe

chondroitin sulfate

gamma-linolenic acid (primrose oil)


Folk remedies
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static magnet therapy

copper bracelets

mud baths

Alternative systems of care

acupuncture

acupressure

Ayurveda

traditional Chinese medicine





f. surgical management

i. arthroscopy - examination and treatment with use of a narrow tube inserted into the body

ii. arthroplasty (joint replacement)

iii. osteotomy


8. Nursing care

a. determine the client's level of functioning - mobility, ability to perform daily tasks

b. reinforce teaching regarding

i. pain medications

ii. the use of assistive devices, e.g., splints, orthotics

iii. prescribed heat therapies

iv. posture and body mechanics

v. weight reduction (ensure client has adequate resources on the topic)

vi. referral to support agencies

vii. exercise - type, frequency, when to stop an activity; balance activity and rest


c. home care considerations

i. safety measures

no scatter rugs

well-fitted, supportive shoes

use a night light

handrail(s) for stairs and grab rails for bathtub, toilet area


ii. assistive devices

canes, walkers

elevated toilet seats

faucets with one lever that require no turning

lever-type door handles




C. Charcot joints (also called neuropathic joint disease)

1. Definition: multi-causal degeneration and deformation of joint; usually the ankle

2. Etiology

a. diabetes mellitus leading to foot neuropathy

b. syringomyelia results in charcot's joint of the shoulder

c. tertiary syphilis
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d. peripheral neuropathies

e. spina bifida with myelomeningocele

f. leprosy

g. multiple sclerosis

h. long term intraarticular steroid injections


3. Findings

a. inspection: foot is everted, widened, and shorter than normal

b. examination

i. joint instability

ii. soft tissue swelling

iii. pain secondary to inflammation



4. Diagnostics

a. laboratory analysis of synovial fluid

i. fluid is noninflammatory

ii. low protein content

iii. no hemorrhage noted


b. radiographs

i. chronic destructive arthritis of the foot

ii. severe destruction of the articular cartilage, subchondral sclerosis

iii. fragments of bone and cartilage in joint




5. Management

a. conservative treatment

i. protection from overuse/abuse

ii. braces and splints


b. surgical management - arthrodesis (joint fusion): treatment of choice for unstable joints


6. Nursing interventions

a. expected outcome: preserve the joint

b. education can prevent further injury

c. protection of the joint

i. braces

ii. orthopedic shoes


d. prolonged immobilization

i. 8 to 12 weeks to decrease swelling

ii. leads to minimal joint deformity and a functional painless foot




D. Chondromalacia patellae (also called patellofemoral arthralgia)

1. Definition: progressive, degenerative softening of the bone; follows a knee injury

2. Etiology

a. lateral subluxation of the patella (kneecap)

b. direct or repetitive trauma to the patella produces chondral fracture
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c. underdevelopment of the quadriceps muscles


3. Findings

a. pain with flexed knee activities (poorly localized)

b. mild swelling

c. occasional episodes of buckling of the affected knee

d. minimal joint effusion

e. evidence of "squinting kneecaps"

i. knee caps point inward

ii. accompanied by bowlegs or knock-knees

iii. loose or tight kneecaps can occur


f. atrophy of quadricep muscles

g. inverted 'J' tracking of the patella in the final 30 of extension

h. excessive quadriceps angle

i. positive apprehension sign: pain with pressure on the medial patellar

j. crepitation upon range of motion



4. Diagnostics

a. radiographs

i. anterior posterior (AP) and lateral views are not helpful

ii. sunrise views with the knee in 30, 60 and 90 of flexion - shows the patella free from other
surrounding bones


b. bone scans

c. MRI Scans

d. arthroscopy (see Orthopedic Surgery )


5. Conservative management

a. progressive resistive exercises

i. quadriceps setting - isometric

ii. hamstrings - isotonic


b. pharmacologic: NSAIDs

c. non-pharmacologic intervention: application of ice or moist heat

d. activity restriction


6. Surgical management

a. indicated if findings remain after six months of conservative treatment

b. arthroscopy (see Orthopedic Surgery section that follows)

c. arthrotomy

i. realignment of proximal and/or distal soft tissue

ii. tibial tubercle elevation

iii. patellectomy



7. Nursing interventions (see previous Osteoarthritis section)



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IV. Inflammatory Disorders

A. Rheumatoid arthritis (RA)

1. Definition - chronic systemic inflammatory disease of the connective tissue


a. starts in feet and hands, gradually destroys these peripheral joints

b. affects diarthrodial joints

c. bilateral involvement

d. incidence

i. strikes between the ages of 20 and 50 years of age

ii. 2 to 3 times more common in women than in men, regardless of race



2. Etiology

a. cause is not fully understood

b. autoimmune disorder

c. genetic tendency; but may involve bacteria or viruses

d. may affect the connective tissue of the lungs, heart, kidneys, or skin


3. Pathophysiology

a. synovitis immune complexes initiate inflammatory response

b. IgB antibodies are formed

c. rheumatoid factor (RF)

i. pannus formation

ii. destruction of subchondral bone

iii. present in 85% - 90% of all cases

iv. worsens the inflammatory response - can go on indefinitely

v. irreversible - will lead to ankylosis of joint





4. Findings

a. general findings

i. fatigue

ii. loss of appetite and weight

iii. enlarged lymph glands


b. in early RA joints will be

i. painful, stiff

ii. warm, red, swollen at capsules and soft tissues

iii. incapable of full range of motion


c. in late RA, joints will show

i. bony ankylosis
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ii. destruction of joint - reactive hyperplasia

iii. adhesions

iv. inflammation and effusion that will be

symmetrical

polyarticular



d. rheumatic nodules

i. in 20% of cases

ii. firm, oval, non-tender masses under the skin

iii. presence indicates poor prognosis


e. findings of Raynaud's syndrome - fingers, nose or toes may feel numb or cool in response to cold
temperatures

f. deformities

i. ulnar deviation


ii. deformed hand and fingers, including swan-neck of the fingers and Boutonnire deformities


g. neurological examination

i. foot drop

ii. evidence of spinal cord compression - findings of neurological deficits below the level of
damage



5.
Diagnostics

a. history and physical

b.
laboratory analysis

i. elevated ESR

ii. decreased RBC

iii. positive C-reactive protein

iv. positive antinuclear antibody in 20% of cases

v. positive rheumatoid factor (RF)


c. radiographic studies

i. bony erosion

ii. decreased joint spaces

iii. fusion of joint


d. aspiration of synovial fluid; analysis shows

i. cloudy appearance

ii. more white blood cells than normal


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6. Management

a. adequate rest

b. ice for joint inflammation

c. heat for joint stiffness

d. splinting - resting, correction or fixation

e. surgical interventions - joint replacement surgery

f. pharmacological

i. aspirin - high doses (in the 1000 mg range)

ii. NSAIDs

Motrin, Naprosyn

misoprostol (Cytotec), a synthetic prostaglandin that may be given to counteract the
gastric complication associated with chronic NSAID use


iii. cytotoxic agents - since they are immunosuppressive, the nurse should observe for signs of
suppressed immunity

iv. glucocorticoid steroids - observe for Cushing syndrome signs, especially hyperglycemia

v. hydroxychloroquine sulfate (Plaquenil)

vi. sulfasalazine (Azulfidine)

vii.
immunosuppressive agents, e.g., azathioprine (Imuran), cyclophosphamide (Cytoxan,
Procytox), methotrexate (Rheumatrex)


viii. leflunomide (Arava)

ix. biological response modifiers (BRMs), e.g., etanercept (Enbrel), infliximab (Remicade),
adalimumab (Humira)

x. anakinra (Kineret)


g.
nutrition therapy

i. weight reduction

ii. calcium supplements


h. psychological support

i.
complimentary & alternative therapy (CAT)

i. acupuncture - can reduce fatigue

ii. relaxation techniques - reduce pain

iii. omega-3 fatty acids - decrease inflammation

iv. herbal therapies (ginger, curcumin) - reduce inflammation



7. Nursing interventions

a. psychological support

b. care of clients taking corticosteroids

c. promote self-care/independence

d. administer medications as prescribed

e. encourage balance of exercise and rest

f. promote use of assistive devices


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B. Systemic lupus erythematosus (SLE)

1. Definition: chronic, systemic, inflammatory disease of the collagen tissues


2. Etiology unknown

a. majority of cases reported are women

b. African Americans, Hispanics, Asians, and Native Americans are 2 to 3 times as likely as
Caucasians to have lupus

c. antigen stimulates antibodies, which form soluble immune complexes, deposited in tissues;
number of T suppressor cells dwindles

d. immune complex inflames tissue; inflammation creates findings/complaints

i. the intensity and location of the inflammation reflects findings and organs involved

ii. clients with central nervous system or renal involvement have poorer prognosis




3. Findings - SLE is present if client has four or more of the following

a. arthritis: characterized by swelling, tenderness and effusion; involving two or more peripheral
joints

b. malar rash: characteristic butterfly rash over cheeks and nose

c. discoid lupus skin lesions

d. photosensitivity

e. oral ulcers

f. serositis: pleuritis

g. renal disorder: persistent proteinuria

h. neurologic disorder: seizures or psychosis in the absence of drugs or pathology

i. hematologic disorder: hemolytic anemia with reticulocytosis or leukopenia

j. immunologic disorder: positive LE (lupus erythematosus) cell preparation or anti-DNA or anti-Sm
(Smith antigen) or false positive serologic test for syphilis

k. antinuclear antibody: abnormal titer of antinuclear antibody by immunofluorescence or
equivalent assay

l. positive LE cell reaction


4. Management

a. goals are to control system involvement, findings, and induce remission

b. prevent adverse effects of therapy

c. recognize flare-ups promptly to get treatment

d. pharmacologic

i. salicylates

ii. nonsteroidal anti-inflammatory agents (NSAIDs)

iii. corticosteroids
648


iv. antimalarial agents (to decrease inflammation)

v. immunosuppressive agents



5. Nursing interventions

a. pain management strategies

b. strategies to combat weight loss

c. provide emotional support

d.
care of clients taking corticosteriods


e. advise client about skin protection, i.e., avoid sun, use sunblock, cover skin with clothing (since
sunblocks are sometimes ineffective to protect skin)



C. Gout

1. Definition - monoarticular asymmetrical arthritis characterized by hyperuricemia


2. Etiology

a. primarily affects men

b. peak incidence 40 to 60 years of age

c. familial tendency

d. abnormal purine metabolism or excessive purine intake results in formation of uric acid
crystals which are deposited in the joints and connective tissue

e. deposits are most often found in the metatarsophalangeal joint of the great toe



3. Findings

a. tight, reddened skin over the inflamed joint - big toe most common, most often unilateral

b. elevated temperature

c. severe pain in the affected joint

d. edema of the involved area

e. hyperuricemia

f. acute attacks commonly begin at night and last three to five days

g. gout attacks may also follow trauma, diuretics, increased alcohol consumption, a high purine diet,
stress (both psychological and physical) or suddenly stopping maintenance medications

h. warning signs of flare-up include the exacerbation of previous findings or the development of a
new one

i. systemic manifestations may include fever, renal disease, tophus

j. complications include cellulitis, renal calculi if fluids aren't forced


4.
Diagnostics

a. increased urinary uric acid following a purine restricted diet

b. hyperuricemia


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When you are studying, organize or "chunk" the material into different logical groups of content. By
developing these conceptual structures, the material should be easier to recall.


5. Management

a. goals are to control findings and prevent attacks

b.
pharmacologic

i. NSAIDs

ii. colchicine (Colsalide) - increases uric acid excretion through kidneys

iii. antihyperuricemic agents such as allopurinol (Lopurin) or probenecid (Benemid) to prevent
flare-ups by decreasing uric acid production


c. heat or cold therapy

d.
dietary

i. avoid purine foods such as meats, organ meats, shellfish, sardines, anchovies, yeast, and
alcoholic beverages

ii. control weight

iii. drink more fluids and less alcohol



6. Nursing interventions

a. apply pain management strategies

b. elevate the client's affected limb; provide bed rest and immobilize joint

c. avoid pressure of bed clothing on affected joint

d. reinforce dietary management and weight control

e. administer anti-gout medications as ordered

f. increase fluid intake to prevent renal calculi (kidney stones)

g. observe for cellulitis of foot and ankle - edema, redness, pain to touch



D. Fibromyalgia

1. Definition - a common rheumatic syndrome of musculoskeletal pain, stiffness, and tenderness

2. Findings

a. chronic achy muscle pain, local or systemic

b. tenderness at trigger points

c. fatigue, sleep deprivation, headaches, and irritable bowel

d. pain and fatigue aggravated by exertion


3. Management

a. heat

b. massage

c. stretching and low-impact aerobic exercises

d. sleep improvement (amitriptyline has been found to promote sleep and relieve findings)

e.
alternative therapies, Reiki, acupuncture


4. Nursing interventions

a. reinforce teaching about the disorder assuring the client that it is a real disorder and not
psychosomatic as it is often erroneously portrayed
650


b. support prescribed therapy

c. reinforce teaching about safety in mobility




V. Metabolic Bone Disorders

A. Osteomalacia

1. Definition - delayed mineralization that results in a softer and weaker bone

2. Pathophysiology - similar to rickets

a. bones have too little calcium and phosphorus

b. vitamin D deficiency; possibly inadequate exposure to sunlight

i. less serum calcium than normal

ii. more parathyroid hormone

iii. more renal phosphorus clearance



3. Findings

a. accurate client history includes:

i. generalized muscle and skeletal pain in hips

ii. similar pain in low back


b. data collection

i. gait

client reluctant to walk

wide stance

waddling gait


ii. muscle weakness

iii. bones

deformities of weight-bearing bones

scoliotic or kyphotic deformities of the spine

bones break easily






4. Diagnostics

a. radiographic findings

i. generalized demineralization

ii. pseudo fractures

iii. bending deformities


b. laboratory studies

i. decreased serum calcium

ii. decreased serum phosphorus

iii. alkaline phosphatase level is moderately elevated



5. Management

a. pharmacologic

i. calcium gluconate

ii. vitamin D daily until signs of healing take place


b. diet high in protein
651


c. ultraviolet radiation therapy


6. Nursing interventions

a. reinforce teaching about dietary vitamin D intake

b. remind client of importance of sun exposure to gain vitamin D


Carefully read each multiple-choice question to looking for key concepts that are familiar to you. Try
rephrasing the question, but do NOT read anything into it.


B. Osteoporosis

1. Definition

a. multifactorial disease results in

i. reduced bone mass

ii. loss of bone strength

iii. increased likelihood of fracture


b. types

i. type I osteoporosis (estrogen related)

ii. type II osteoporosis (related to old age)





2. Etiology and epidemiology

a. most common metabolic disease of bone

i. affects an estimated 25 million Americans

ii. contributor of 50% of all adult fractures


b. onset is insidious

c. women affected twice as often as men

d. skeletal changes result from the aging process

e. bone loss due to

i. immobilization

ii. lack of gravitational stress


f.
risk factors related to osteoporotic fractures

i. low bone density

ii. history of scoliosis

iii. neurological impairment following
CVA
Parkinson's disease
decreased vision from macular degeneration, complications of diabetes, etc.




652

3. Findings

a. client history

i. acute fracture

ii. prior history of a traumatic fracture; no trauma

iii. history of falls


b. pain

i. greater when active, less while resting

ii. early in disease, pain in mid to low thoracic spine


c. anxiety

i. about further falls/fractures

ii. about ability to perform ADLs


d. kyphosis - also known as 'dowager's hump'; may reflect multiple spinal fractures

e. loss of height

i. two or more inches

ii. usually precedes diagnosis of osteoporosis




4. Diagnostics

a.
blood tests

i. complete blood counts

ii. serum levels

calcium

phosphate

alkaline phosphatase



b. x-rays

i. help identify fractures and kyphosis of spine

ii. less useful in the detection of pre-fracture osteoporosis

iii. detect osteoporosis only after 20% bone mineral content is lost


c. bone densitometry

i. best means of measuring risk for fracture

ii. quantitative computerized tomogram (CT) measures pure vertebral trabecular bone

iii. dual energy X-ray absorptiometry (DXA, previously DEXA) - technique of choice

assesses cortical and trabecular bone in spine and hip

T score of -2.5 or greater indicates high risk for advanced osteoporosis

single photon absorptiometry measures cortical bone in long bones
653







5. Management

a. exercise

i. restorative - aims to increase bone density, decrease risk for fracture

ii. within the client's tolerance

iii. must be maintained throughout life


b.
nutrition

i. calcium and vitamin D

ii. deficiencies increase risk of fracture

iii. sedentary older adults may need supplements


c.
pharmacologic

i. supplemental calcium

ii. anti-resorptive agents

do not increase bone mass - rather prevent further bone loss

estrogen therapy

calcitonin (Osteocalcin)
peptide hormone
powerful inhibitor of osteoclastic bone resorption
modestly increases bone mass in osteoporosis

not shown to decrease osteoporotic fractures


iii. bisphosphonates

inhibit bone resorption

sustained use associated with osteomalacia and Paget's disease

alendronate (Fosamax)
100 to 500 times more potent than etidronate
non-hormonal agent
highly selective inhibitor
not associated with detrimental effects of mineralization
expensive per-day cost

Actonel (Boniva)

decreases the activity of cells that cause bone loss

taken once per month on empty stomach

expensive with no generic version

zoledronic acid (Zometa): an IV medication infused once per year that can reduce risk of
654

fractures but may impact kidney function


iv. bone-forming agents

sodium fluoride (Fluoritab)

androgens
taken long-term, increases bone mass in osteoporotic women
however, androgens virilize and elevate cholesterol levels




d. surgical intervention - treats vertebral compression

i. vertebroplasty

ii. kyphoplasty



6. Nursing intervention: reinforce teaching about prevention of osteoporosis and its damage

a. reinforce medication teaching - Fosamax

i. take early in the morning with eight ounces of water only as first item ingested

ii. sit or stand for thirty minutes after taking

iii. do not take calcium or vitamins within 30 minutes of Fosamax


b. discourage risk-related behaviors

c. reinforce positive behaviors and lifestyles

d. reduce risk of falling

i. reinforce proper lifting techniques

ii. encourage proper footwear

iii. have client install safety equipment in home

iv. reduce clutter, no scatter rugs

Watch a short video about osteoporosis


C. Paget's disease (osteitis deformans)

1. Definition: a slowly progressing resorption and irregular remodeling of bone

2. Etiology

a. bone resorbed; new bone poorly developed, weak, easily fractured

b. mainly affects major bones: skull, femur, tibia, pelvis, and vertebrae

c. cause unknown

d. possible viral implications

e. family tendency - noted in siblings


3. Findings

a. asymptomatic initially

b. musculoskeletal

i. deformity of long bones

ii. pain and point tenderness of affected limbs

iii. pathologic fractures


c. fatigue


4. Diagnostics

a. radiographs
655


i. bowing of long bones

ii. thickened areas of bone

iii. pathological fractures

iv. sclerotic changes


b. laboratory analysis

i. increased alkaline phosphatase means osteoblasts more active

ii. increased urinary hydroxyproline means osteoblasts more active

iii. serum calcium level will be normal




5. Management

a. only treat if symptomatic

b. conservative intervention - medications

i. NSAIDs
ii. bisphosphonates - alendronate (Fosamax): slows bone resorption

ii. calcitonin (Osteocalcin)

slows bone resorption

allows normal lamellar bone development


iii. plicamycin (Mithracin)

chemotherapeutic agent

used only when Paget's disease bone is damaging to the nerves and non-responsive
to other treatments



c. surgery

i. reduce pathological fractures

ii. correct secondary deformity

iii. relieve neurologic impairment

iv. complications common

nonunion

malunion




6. Nursing interventions

a. observe for side effects of medications

b. emphasize safety and fracture prevention

c. provide pain management

d. support exercise programs

e. reinforce teaching on use of orthotic devices and pain management

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VI. Orthopedic Surgery

A. Total hip replacement

1. Indications for surgery

a. osteoarthritis

b. rheumatoid arthritis

c. femoral neck fractures

d. avascular necrosis of femoral head caused by steroids

e. failure of previous prosthesis


2. Surgical modalities

a. total hip replacement (hip arthroplasty): replacement of both articular surfaces of the hip
joint, the acetabular socket, and the femoral head and neck

i. acetabular socket is screwed into pelvis

ii. femoral shaft may be either cemented into femur or may have a special coating that
promotes bone growth around the prosthesis


b. hemiarthroplasty of the hip is the replacement of one of the articular surfaces, usually the
femoral head and neck



Step 1 Step 2 Final




3. Nursing interventions and postoperative care

a. common postoperative complications

b. wound drainage

i. first 24 hours - expect up to 500 mL

ii. by 48 hours - drainage should be minimal (and wound drain is removed)


c. clients may require transfusions (autologous is preferred) due to blood loss during surgery

d. pain management - PCA for the first 48 hours, advancing to non-narcotic oral analgesics by the
4th or 5th postoperative day

e. monitor for signs of deep venous thrombosis and pulmonary embolism

f. monitor neurovascular status of affected limb: color, temperature, presence of pulses

g. positioning client

i. prevent adduction of hip: abduction device - used during the first postoperative week while the
client is in bed or sitting in a chair

ii. logroll client onto unaffected side, with legs abducted, to provide care and assess skin

iii. prevent flexion of the hip with the use of a fracture bedpan


h. apply anti embolism stockings (and sequential compression devices if ordered)
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i. reinforce client teaching regarding:

i. use of assistive devices - crutches, walker, raised toilet seat

ii. avoiding weight bearing on affected extremity, use of overhead trapeze, pivot turning, and toe-
touch

iii. methods to prevent dislocation

do not flex the operative hip beyond 90 degrees

do not cross the legs at the knees or the ankles


iv. can resume sexual activity when suture line heals; avoid flexion of hip by assuming dependent
position during sexual activity for at least 3 to 6 months




B. Total knee replacement

1. Indications for surgery

a. osteoarthritis


b. rheumatoid arthritis

c. trauma


2. Surgical modalities

a. metal or acrylic prosthesis, hinged or semiconstrained

b. choice of prosthesis depends on the strength of surrounding ligaments to provide joint
stability


3. Postoperative complications


4. Nursing interventions (knee replacement)

a. for first 24 to 48 hrs, apply ice to the knee to control bleeding and edema

b. wound drainage

i. in the first 8 hours post-op - expect up to 200 mL

ii. by 48 hours - minimal drainage expected (and wound drain removed)


c. transfusions - rarely required

d. within 24 hours - aggressive physical therapy started to promote knee flexion

e. anticipate the use of a continuous passive motion (CPM) device

i. implement the prescribed amount of flexion and extension, measured in degrees, and
increases are specific in amounts as client tolerates more motion

ii. when the CPM machine is not in use, apply knee immobilizer


f. keep leg elevated when the client is out of bed, sitting in a chair

g. on first post-op day, anticipate that client may begin to use crutches or walker

h. pain management - patient controlled analgesia (PCA) for the first 48 to 72 hours
postoperatively; by fifth post-op day, non-narcotic oral analgesia
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i. monitor limb's neurovascular status, color, temperature, and pulses

j. monitor for findings of deep vein thrombosis or pulmonary embolism; apply anti
embolism stocking


For client to navigate stairs with crutches, remember:
"Up with the Good, Down with the Bad."

To go up stairs, lead with the unaffected or "good" leg, and follow with the affected "bad" leg.

To go down stairs, lead with the affected or "bad" leg, and follow with the unaffected "good" leg.


C. Amputation

1. Definition - removal of an entire or part of an extremity

2. Purpose: relieve findings; improve function; save or improve quality of life

3. Lower extremity indications

a. progressive peripheral vascular disease (often secondary to type 2 diabetes mellitus)

b. gangrene - from lack of arterial circulation

c. trauma such as crushing injuries, burns, or frostbite

d. congenital deformities

e. malignant tumor


4. Upper extremity indications

a. trauma

b. malignant tumor

c. infection

d. congenital malformations


5. Levels of amputation

a. now termed "retained limb"

b. amputate to most distal point that will heal successfully

c. determined by circulation and functional status



6. Types of prosthesis

a. hydraulic

b. pneumatic

c. biofeedback - controlled

d. myoelectrically controlled

e. synchronized


7. Potential postoperative complications

a. hemorrhage

b. infection

c. skin breakdown

d. contractures


8. Nursing interventions

a. provide pain management - usually relieved with narcotic analgesics
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b. observe for a need to evacuate accumulated fluid or hematoma

c. relieve muscle spasms by heat or changing extremity position

d. deal with phantom limb pain

i. may occur any time up to three months post amputation

ii. most common with above-knee amputation (AKA)

iii. relieved with

stump desensitization by kneading massage

transcutaneous electrical nerve stimulation (TENS)

distraction

beta-adrenergic blocking agents for burning, dull pain

adjunct medications such as anticonvulsants, which will decrease sharp and
cramping pain

ultrasound therapy, massage, biofeedback




e. other client issues

i. wound healing

aseptic dressing change technique

compression dressing (or cast) to control edema


ii. altered body image

may take months to resolve

convey acceptance and respect for individual

foster independence: encourage client to look at, feel, and eventually care for limb


iii. grief

many clients go through a mourning process, shock, anger, and depression, before
acceptance is reached

caregivers should support and listen actively


iv. restoring physical mobility

early rehabilitation

muscle strengthening exercises

prosthetic preparation


v. preventing contractures

below the knee amputation (BKA) - client should lie supine with the affected leg
extended for 20 to 30 minutes, 3 to 4 times per day

above the knee amputation (AKA) - client should be prone with the affected leg fully
extended for 20 to 30 minutes, 3 to 4 times per day



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D. Arthroscopy

1. Definition - endoscopic procedure that allows direct visualization of the joint, most often
performed on knees and shoulders

2. Indications

a. torn medial and lateral meniscus

b. chondromalacia patellae

c. synovitis

d. torn cruciate ligament

e. subluxation patella

f. intra-articular soft tissue mass

g. pyarthrosis


3. Surgical procedure - most often outpatient surgery

4. Postoperative care

a. compression dressing to control edema along with elevation

b. ice may be applied

c. oral narcotic or non-narcotic analgesics for pain management

d. weight bearing depends on the procedure


5. Postoperative complications are rare

a. infection

b. thrombophlebitis

c. stiffness


Screws are placed into the bone above and below the fracture, and a device is attached to the screws from
outside the skin, where it may be adjusted to realign the bone.


E. External fixator

1. Definition: a device for holding complex, unstable fractures in place; pins or screws are placed
into the bone on both sides of the fracture and these are secured externally by clamps and rods


2. Indication: the device stabilizes fracture with soft tissue or crush injury

3. Procedure: fracture aligned and immobilized by pins of Kirschner wires inserted in the bone and
attached to a rigid frame outside the body

4. Nursing interventions

a. monitor neurovascular status every two hours for initial 24 to 48 hours

b. elevate extremity to reduce edema

c. check pin insertion sites for infection: erythema, cloudy yellow drainage and increased warmth

d. pin care and cleaning every shift as ordered
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e. be aware that clear yellowish crust requires removal from pin insertion site

f. reinforce isometric and active exercises as prescribed

g. assist with non-weight bearing ambulation which depends on soft tissue injury

h. reinforce discharge teaching regarding

i. ambulation with assistive device (crutches, walker)

ii. care of pin site - cleanse daily

iii. movement of extremity is done by grasping the rigid frame, not the extremity




Points to Remember

After hip replacements, pulmonary embolism, often a fat embolus, may occur even without thrombosis
in foot or leg.

Clients, after hip replacement, should sit in a straight, high chair; use a raised toilet seat; and never
cross their legs or ankles.

In hip or knee replacement, clients will need assistive devices for walking until muscle tone strengthens
and they can walk without pain.

After an amputation, the home must be assessed for any modifications needed to ensure safety.

The management of soft tissue injury can be remembered by the acronym R.I.C.E.:

Rest

Ice

Compression

Elevation

Some clients will need transportation to continue rehabilitation out of the home.

Amputee support groups can be helpful for clients.

After arthroscopy, outpatient rehab may be prescribed depending on procedure; health care provider
may prescribe knee immobilizer.

Prepare client preoperatively (if possible) about external fixator device to reduce anxiety; device looks
clumsy, but client should be reassured that discomfort is minimal.

After a femoral-head prosthesis, caution client not to force hip into more than 90 degree of flexion, into
adduction or internal rotation.

Caution clients with a new prosthesis not to use any substances such as lotions, powders etc. unless
prescribed by the health care provider.

Osteoporosis cannot be detected by conventional x-ray until more than 30% of bone calcium is lost.

Foods high in calcium include milk, yogurt, turnip greens, cottage cheese, sardines, and spinach.

When collecting musculoskeletal data on a client with Paget's disease, note the size and shape of the
skull; the skulls of these clients will be soft, thick and enlarged.

Clients at high risk for acute osteomyelitis are: elderly, diabetics, and those with peripheral vascular
disease.

Immuno-suppressed clients should avoid contact with persons who have infections and locations where
there are crowds.

Steroids may mask the signs of infections, so clients should promptly report a slight change in
temperature.

Photosensitive clients should avoid the sun, limit outdoor activities during peak sun hours, wear sun
block, or use clothing and hats to avoid sun exposure.

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I. Oncology

A. General Information

1. Definitions

a. cancer is a term used for diseases in which abnormal cells divide without control and are
able to invade other tissues

b. cancer types

i. lymphoma and myeloma: cancers that begin in the cells of the immune system

ii. carcinoma: cancer that begins in the skin or in tissues that line or cover internal organs

iii. leukemia: cancer that starts in blood-forming tissue, e.g., bone marrow, and causes
large numbers of abnormal blood cells to be produced and enter the blood

iv. sarcoma: cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other
connective or supportive tissue

v. central nervous system cancers: cancers that begin in the tissues of the brain and spinal
cord


c. types of tumors

i. benign: refers to a tumor or growth that is not cancerous

ii. malignant: the uncontrolled growth of abnormal cells in the body, i.e., cancerous cells,
which are spread through metastasis


d. metastatic cancer: cancer that has spread from the place where it first started (primary site
or site of origin) to another place in the body (the secondary site)

i. almost any cancer can form metastatic tumors

ii. most common sites of cancer metastasis: lungs, bones, liver






e. staging: describes and classifies extent or severity of cancer (most, but not all, cancers are staged this
way)
Cancer
Staging
Extent of Malignancy
T based on the size of the original (primary) tumor and whether or not it has grown
into nearby tissues
N whether or not the cancer has spread to the nearby lymph nodes
M whether or not the cancer has spread to distant areas of the body
Developed by the American Joint Committee on Cancer










663

f. grading: describes the degree of malignancy according to the type of tumor cell

a. indicates the degree of cell undifferentiation

b. cancers with more abnormal-looking cells tend to grow and spread faster
Cancer Grading Degree of Malignancy
stage 0 carcinoma in situ
stage I localized with tumor limited to the
tissue of origin
stage II limited spread
stage III extensive local and regional spreading
stage IV distant metastasis
Most cancers are graded using a number from 1 to 3 or 4; the lower the number, the more the cancer cells look like
normal tissue.




2. Etiology

a. generally unknown but may be caused by interacting factors

b. familial risk for certain cancers: lung, stomach, breast, colon, rectum and uterus

c. theories include predisposing factors:

i. constant irritation

ii. history of cancer

iii. environmental carcinogens

iv. radiation

v. persistent stress in general or to one body function


d. cancer is the second most common cause of death in the U.S.; it is the leading cause of death
worldwide

a. leading causes of cancer death among men: lung, prostate, colorectal, liver

b. leading causes of cancer death among women: lung, breast, colorectal (see risk factors for
developing breast cancer )



3. Warning signs: The seven warning signs of cancer (see below) and cancer screening
recommendations
Seven Warning Signs of Cancer
C Change in bowel or bladder habits
A A sore that does not heal
U Unusual bleeding or discharge from any part of the body
T Thickening or a lump in the breast or elsewhere
664

I Indigestion or difficulty swallowing
O Obvious change in a wart or mole
N Nagging cough or hoarseness
National Cancer Institute, U.S. National Institutes of Health




4. Diagnostics

a. history and physical exam - depends on location of tumor

b. radiographic studies, e.g., chest x-ray, mammogram

c. biopsy: obtaining tissue for histological examination

i. needle biopsy: aspiration of cells

ii. incisional biopsy: removal of a wedge of suspected tissue from a larger mass

iii. excisional biopsy: complete removal of entire lesion or mass

iv. staging biopsy: multiple needle or incisional biopsies of suspected metastasis

v. vacuum-assisted biopsy: vacuum-assisted tissue biopsy (ex: Mammotome breast biopsy)


d. cytological studies, e.g., Papanicolaou's (Pap) smear

e. proctoscopic examination, including guaiac for occult blood

f. liver function studies

g. imaging - using computerized tomography (CT scan), magnetic resonance imaging (MRI)

h. tumor markers - identifying biochemicals made and released by tumor cells, e.g., prostate-specific
antigen (PSA), carcinoembryonic antigen, alpha-fetoprotein


5. Treatment - based on stage and grade of tumor, treatment objective is to remove all traces of the
cancerous tissue

a. surgery - specific to site and type of malignancy

b.
chemotherapy - use of chemical agents in the treatment or control of the disease (adjuvant
therapy)

c. radiation therapy - destroys cancer cells, with minimal exposure of normal cells to the damaging
effects of radiation (adjuvant therapy)

i. external beam radiation (the source of the radiation is external to the client)

ii. brachytherapy: the radiation source comes into direct, continuous contact with tumor tissues
for a specific time (the source of the radiation is within the client)

unsealed radiation source - administration is by oral or intravenous route or by
installation into a body cavity

sealed radiation source - solid implant is implanted with the tumor target tissues



d. biologic therapy - typically used along with conventional cancer treatments (adjuvant therapy)

i. immunotherapy - helps repair, stimulate or enhance the body's natural ability to fight cancer,
including cancer vaccines, interferon, and interleukin 2 treatments

ii. targeted therapy - non-chemotherapy drugs used to target cancer cells

iii. monoclonal antibodies: artificially produced antibodies that act against a particular antigen,
including trastuzumab (Herceptin), etanercept (Enbrel), infliximab (Remicade), abciximab
(Reopro)
665


iv. tyrosine kinase: inhibits growth of cancer cells, such gefitinib (Iressa) for lung cancer, lapatinib
(Tykerb) for breast cancer, and sunitinib (Sutent) for renal cell carcinoma


e. bone marrow transplantation

f. stem cell transplantation


6. Nursing care

a. assist RN to monitor for effectiveness of all medications

b. monitor vital signs

c. assist RN to monitor for post-operative surgical complications

d. monitor intake and output

e. monitor diagnostic tests and laboratory values, e.g., white blood cell and platelet counts

f. monitor for fever, sore throat, unusual bleeding, or findings of infection

i. common sites of infection: skin, respiratory and gastrointestinal tracts

ii. ensure frequent and thorough hand hygiene by client, family, staff


g. monitor side effects of chemotherapy

i. fatigue

ii. alopecia

iii. nutrition

iv. nausea and vomiting

v. mucositis

vi. signs of anaphylactic reaction



h. monitor side effects of radiation therapy and treat as indicated

i.
follow radiation safety protocol for implanted, sealed radiation source

ii. local skin changes

gently wash irradiated area with warm water (with or without mild soap); use hand, not
washcloth

take care not to remove skin markings


iii. alopecia

iv. fatigue - most common side effect of radiation (see side effects of chemotherapy on previous
page)

v. altered sense of taste (see side effects of chemotherapy on previous page)


i. monitor for complications of bone marrow transplantation (see also Infection Precautions for Bone
Marrow Transplant Recipients )
CANCER Interventions:

C=Comfort
A=Altered body image
N=Nutrition
C=Chemotherapy
E=Evaluate response to medications
R=Respite for caretakers




B. Cancer Pain Management
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1. Causes of cancer pain

a. bone destruction

b. obstruction of an organ

c. compression of peripheral nerves

d. infiltration or distention of tissue

e. inflammation

f. necrosis

g. psychological factors, e.g., fear, anxiety


2. Use a variety of pain relief measures (see Lesson 5: Basic Care and Comfort for information
regarding non-pharmacologic pain relief measures)

3. The World Health Organization has developed a 3-tiered approach for treating cancer pain

a.
begin with nonopioids (aspirin, paracetamol) if pain occurs

b.
if pain persists or increases, administer mild opioids (codeine) for mild to moderate pain,
along with adjuvant medications to calm fears and anxiety

c.
strong opioids (morphine) should be administered if pain is still not relieved, along with
adjuvant medications to calm fears and anxiety


4. Nursing care, related to pain

a. assess client's pain; pain is what the client describes - do NOT under-medicate the cancer
client who is in pain!

b. monitor effectiveness of medication

c. monitor for side effects of medication, e.g., respiratory depression related to narcotic
administration

d.
provide nonpharmacological techniques for pain relief, e.g., guided imagery, biofeedback,
massage, heat-cold applications, relaxation techniques




II. Pediatric Oncology

A. Overview

1. Cardinal Findings

a. Unusual mass

b. Pallor

c. Sudden tendency to bruise

d. Rapid, unexplained weight loss

e. Change in vision or eye

f. Recurrent fever

g. Persistent headache, often with vomiting

h. Change in balance or gait


2. Childhood cancers can occur suddenly, without early symptoms

3. Childhood cancers usually arise from noninherited mutations in genes of
growing cells

4. There are 12 major types of childhood cancers; leukemias and cancers of the
brain and central nervous system account for more than half of the new cases
667


5. Childhood cancer is highly curable

6. For all age children, the goal is to prevent fear and misunderstanding


Age appropriate diversional activities:
Toddler washable soft toys, appropriate cartoons, action toys (wagon, push toys)
Pre-
school
appropriate cartoons, washable stuffed doll, coloring books and crayons, action toys
Kindergar
ten
appropriate cartoons or video games, coloring book and crayons, washable stuffed toys
School
age
appropriate cartoons or video games, coloring book and crayons, school work when
appropriate, computer, beads for creating jewelry
Middle
School
computer or cell phone, appropriate video games, school work when appropriate
High
School
computer or cell phone, appropriate video games, school work when appropriate


B. Leukemias

1. Definition: cancer of while blood cells


2. Etiology

a. unrestricted proliferation of immature leukocytes crowd the bone marrow and
flood the bloodstream; this interferes with production of red blood cells and
platelets, resulting in anemia and bleeding problems and increased risk of
infection

b. account for 25% of all childhood cancers

c. types: most common is acute (rapidly developing); also chronic (slow
developing)

i. acute (rapidly developing) - most common

acute lymphocytic leukemia (ALL) - usually found in children ages 2
to 8 years

acute myelogenous leukemia (AML)


ii. chronic (slow developing)


d. risks: associated with having received prior radiation or chemotherapy for
other types of cancer, genetic disorders (Down syndrome, Kleinfelter
syndrome, Fanconi's anemia); genetic link

e. symptoms caused by infiltration and replacement of any tissue of the body
668

with non-functional leukemia cells

f. highly vascular organs such as spleen and liver are most severely affected


3. Findings: acute or insidious onset depending on type

a. anemia, thrombocytopenia, infection, bleeding

b. lymphadenopathy, hepatosplenomegaly, bone or joint pain

c. meningeal irritation, i.e., irritable, lethargic, stiff neck


4. Diagnostics

a. history and physical findings

b. peripheral blood smear

c. bone marrow aspiration

d. lumbar puncture


5. Management

a. combination chemotherapy to achieve a remission; intrathecal administration
of methotrexate

b. radiation with central nervous system involvement

c. bone marrow transplant


6. Nursing care

a. prepare child and family for diagnostic procedures

b. relieve discomfort

c. monitor for infection, hemorrhage and anemia

d. assist health care team in managing problems of drug side effects, i.e., nausea
and vomiting, anorexia, mucosal ulceration, neuropathy, alopecia, moon face

e.
provide nutritional snacks

f. facilitate access to needed services - financial or home care

g. reinforce teaching plan

i.
bone marrow aspiration precautions

ii. encourage parents to ask questions when unsure

iii. school work for child when appropriate




Children, particularly toddlers and pre-schoolers, tend to have bruises as a result of play. Any unusual
bruising -on the back or neck, large or dark bruises- needs to be checked out. It could be the first sign
of leukemia or it could possibly due to child abuse. If you are unsure, be sure that another nurse
checks the child with you.


C. Hodgkin's disease (Hodgkin's lymphoma)

1. Definition: malignancy of the lymph tissue found in the lymph nodes, spleen, liver, and bone
marrow

2. Etiology

a. neoplasm of lymphatic system

b. characterized by giant, multinucleated cells (Reed-Sternberg cells)

3. Findings
669


a. characterized by painless enlargement of lymph nodes, particularly in supraclavicular area

b. anorexia, weight loss, malaise; painless; night sweats

c. fever


4.
Diagnostics

a. lymphangiography

b.
labs: complete blood count (CBC), erythrocyte sedimentation rate, urinalysis, kidney
function tests, protein levels, liver function tests

c. bone marrow biopsy

d. CT scan of the chest, abdomen, pelvis

e. chest x-ray

f. PET scan


5. Management

a. chemotherapy and radiation

b. treatment based on staging of disease (stages I-IV) and age of client

c. transfusion of blood products (platelets for low platelet counts or packed cells for anemia)

d. antibiotics


6. Nursing care

a. assist with preparation for diagnostic procedures

b. reinforce explanation of side effects of treatment

c. provide age appropriate diversional activities

d. reinforce teaching points

i. long term treatment plan

ii. multidisciplinary approach

iii. encourage to ask questions when unsure

iv. school work for child when appropriate



7. Possible Complications

a. prognosis: most curable form of cancer

b. long term complications of chemotherapy or radiation therapy




D. Brain tumors

1. Definition: solid tumors of the nervous system

2. Etiology

a. types: medulloblastoma, astrocytoma, ependymoma, glioblastoma

b. most common solid tumor in children

c. location extremely important


3. Findings

a. headache

b. vomiting

c. ataxia

d. seizures
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e. visual changes, slurred speech, behavioral changes

f. bulging fontanel in infants


4. Diagnostics

a. history and physical, neurological exam

b. MRI scan and CT scan of the brain

c. bone scan

d. myelogram

e. lumbar puncture


5. Management

a. surgery

b. radiation

c. chemotherapy

d.
steroids, anti-seizure medication

e. ventriculoperitoneal shunt

f. possibly bone marrow transplantation


6. Nursing care

a. monitor neurologic checks and other neurologic sign changes

b. monitor vital signs

c. assist with preparation of child and family for diagnostic and operative procedures (possible
shaving of head)

d. positioning considerations depend on procedure done

e. monitor dressing and intracranial pressure (ICP), if appropriate

f. begin feeding when ordered

g. medicate for discomfort as indicated

h. reinforce teaching points

i. child's post operative appearance

ii. refer for needed resources, including rehabilitation

iii. explain the procedure to the child based on developmental level, e.g., dolls for illustration
of positioning, and procedure; drawings for older children



7. Complications

a. prognosis: varies greatly

b. late effects may include cognitive delay, seizures, growth abnormalities, hormone
deficiencies, vision and hearing problems

c. children who had brain tumors are more likely to develop a second cancer, including a second
brain tumor




E. Neuroblastoma

1. Definition: malignant tumor the develops from nerve tissue

2. Etiology: unknown
a. accounts for almost all cases of cancer under age 1 year
671


b. most common extracranial solid tumor of childhood

c. most neuroblastomas begin in the abdomen (in the adrenal gland or next to the spinal cord) or
in the chest - can spread to the bones, bone marrow, liver, lymph nodes, skin and around the
eyes

d. often has metastasized by the time it is diagnosed


3. Findings: first symptoms are usually fever, malaise and pain; other findings are tumor-dependent

a. enlarged abdomen - from tumor or excess fluid

b. periorbital edema, cyanosis - cancer spread to eye(s)

c. bone pain or tenderness - cancer spread to bones

d. dyspnea or chronic cough - cancer spread to lungs/chest

e. flushed red skin

f. tachycardia

g. profuse sweating


4. Diagnostics

a. physical exam - examination of abdomen may reveal a lump, swollen lymph nodes

b. bone scan, x-rays

c. CT and MRI scan of chest and abdomen

d. biopsy

e.
labs: complete blood count (anemia), coagulation studies (ESR), hormone tests (especially
epinephrine and other catecholamines), 24-hour urine (for catecholamines, homovanillic acid
and vanillylmandelic acid)


5. Management: depends on tumor location, metastasis and client's age

a. ranges from observation only in certain types of neuroblastoma to aggressive therapy with
surgery, radiation therapy, chemotherapy, and stem-cell transplantation for older children

b. retinoid therapy, tumor vaccines and immunotherapy (using monoclonal antibodies)


6. Nursing care: support family and reinforce client teaching

7. Complications

a. prognosis: varies greatly

b. metastasis and associated damage and loss of function of involved organ(s)

c. children treated for neuroblastoma may be at risk for getting a second, different cancer in the
future




F. Osteosarcoma

1. Definition: malignant bone tumor that usually develops during a period of rapid growth
(adolescence, young adulthood)

2. Etiology: unknown
672


a. usually affects teens and people in their 20s

b. originates from bone-forming mesenchyme

c. location - most common in distal femur, also in the tibia or humerus

d. may be a genetic link (gene associated with retinoblastoma)


3. Findings: localized pain, limp, decrease in physical activity

4.
Diagnostics

a. history, physical assessment

b. bone scans, x-ray

c. chest x-ray, CT scan of the chest - for suspected metastasis to chest


5. Management

a. surgery - limb salvage with prosthetic bone replacement or amputation

b. chemotherapy before and/or after surgery


6. Nursing care

a. client and family support following amputation

b.
reinforce client and family teaching about stump care


7. Complications

a. prognosis: long-term survival is good if cancer has not spread to lungs

b. limb removal

c. metastasis

d. side effects of chemotherapy




G. Ewing sarcoma

1. Definition: a rare malignant bone tumor affecting children

2. Etiology: unknown

a. arises not from osteoid tissue but in bone marrow spaces

b. most common in shaft of femur, tibia, humerus, scapula

c. more common in males and Caucasian children

d. can occur any time but usually develops during puberty


3. Findings

a. few symptoms

b. localized pain, decrease in physical activity

c. pathologic fracture at site of the tumor


4. Diagnostics

a. biopsy, MRI, x-ray of tumor

b. bone scan

c. chest x-ray, CT of chest


5. Management

a. intensive radiation therapy of the malignant bone

b. combined with chemotherapy

i. cyclophosphamide (Cytoxan)
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ii. doxorubicin (Adriamycin)

iii. etoposide (Vepesid)

iv. ifosfamide (Ifex)

v. vincristine


c. after course of chemotherapy and possibly radiation, tumors may be removed surgically;
amputation may be the only choice


6. Nursing care

a. assist child and family with effects of chemotherapy

b. reinforce information provided by health care team


7. Complications

a. treatments have many complications and should be discussed on individual basis

b. amputation has short- and long-term side effects




H. Wilms' tumor (nephroblastoma)

1. Definition: a rare type of kidney cancer that affects children

2. Etiology

a. causes a tumor on one or both kidneys (more common on left kidney)

b. most often affects children under age 5 years

c. risks: certain genetic conditions or birth defects (hypospadias, undescended testicles, aniridia);
family history; female; African American

d. tumor encapsulated for extended period


3. Findings

a. abdominal mass and swelling

b. characteristically firm, non-tender

c. constipation

d. malaise

e. high blood pressure

f. increased growth on one side of body



4.
Diagnostics

a. abdominal ultrasound, x-ray

b. intravenous pyelogram

c. bone scans

d.
labs: blood urea nitrogen, complete blood count (may show anemia), creatinine and
creatinine clearance, urinalysis
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e. do NOT prod or push on child's belly


5. Management

a. surgery - simple nephrectomy, partial nephrectomy, radical nephrectomy

b. combination chemotherapy and radiation therapy


6. Nursing care

a. use care during bathing and handling to avoid injury to tumor site

b. support family

c. treat effects of radiation and chemotherapy - nausea and vomiting, loss of appetite, mouth
sores, fatigue, loss of hair, weakened immune system

d. reinforce teaching


7. Complications

a. prognosis: 90% cure rate if tumor has not spread

b. hypertension

c. kidney damage




I. Rhabdomyosarcoma

1. Definition: a malignant tumor of the muscles attached to bones; the most common soft tissue
tumor in children

2. Etiology: unknown

a. soft tissue neoplasm

b. grows from undifferentiated mesenchymal cells of skeletal muscle

c. location: most common in head and neck, the urogenital tract, arms or legs

d. may be a genetic factor

e. highly malignant; often metastasized when diagnosed


3. Findings

a. non-tender, firm mass

b. related to site of tumor and compression of adjacent organs

c. symptoms often vague, similar to otitis media or "runny nose"


4. Diagnostics

a. history and physical exam

b. imaging tests, x-rays, CT scan, MRI scan, bone scan, ultrasound

c. biopsy


5. Management: depends on the site and type of rhabdomyosarcoma

a. surgery

b. high-dose irradiation of the primary tumor

c. combination chemotherapy

d. surgical resection





6. Nursing care

a. pain management, including administration of pain medication, positioning, age-appropriate
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diversional activities

b. facilitate participation in family support group and counseling


7. Complications

a. prognosis: usually good

b. complications from chemotherapy

c. metastasis




J. Retinoblastoma

1. Definition: a rare, cancerous tumor of the retina

2. Etiology

a. caused by a mutation in a gene controlling cell division

b. may have a genetic link

c. generally affects children under the age of 6 years


3. Findings

a. may affect one or both eyes

b. differing iris colors in each eye

c. leukocoria ("cat's eye reflex") - unusual whiteness noticeable in photographs taken with a flash

d. strabismus, poor vision, double vision

e. eye pain and redness


4. Diagnostics

a. ophthalmoscopic exam under general anesthesia,

b. MRI and CT scan of the head

c. head and eye echoencephalogram (ultrasound of the eye)


5. Management: treatment depends on stage of tumor with grading

a. laser surgery or cryotherapy - small tumors

b. radiation therapy - local tumor or larger tumors

c. chemotherapy - if tumor has spread beyond the eye(s)

d. enucleation


6. Nursing care

a. involve parents in care and reinforce teachings about diagnostic procedures

b. facilitate genetic counseling for parents

c. multi-disciplinary support for child following enucleation of an eye

d. reinforce teaching points: care for prosthetic eye


7. Complications

a. prognosis: if the cancer has not spread beyond the eye, almost all clients can be cured

b. blindness






III. Circulatory System Oncology

A. Non-Hodgkin's lymphoma (NHL)
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1. Definition: cancer of the lymphocytes found in lymphoid tissue, which includes lymph nodes,
spleen, and other organs of the immune system

2. Etiology: unknown

a. both B lymphocytes and T lymphocytes can develop into lymphoma cells (B-cell
lymphomas are more common in the U.S.)

b. risk factors: adults with weakened immune systems or who have had an organ transplant

c. types: based on how fast it spreads and by protein (B lymphocytes) and/or genetic
markers (T lymphocytes)

d. slightly more common in women


3. Findings: many are dependent upon the location of the cancer (chest, abdomen, brain)

a. painless, enlarged lymph nodes in cervical or axillary region

b. night sweats, fever

c. itching

d. weight loss


4. Diagnostics

a. physical exam - enlarged lymph nodes

b. biopsy of suspected tissue (usually lymph node)

c. bone marrow biopsy

d.
labs: complete blood count, protein levels, liver function, kidney function and uric acid
level


5. Management: depends on type of lymphoma, stage of the cancer, age and overall health of
client, symptoms

a. chemotherapy - main type of treatment

b. radiation - for disease confined to one body area

c. radioimmunotherapy may be used

d. bone marrow transplant (using client's stem cells) - when chemotherapy is ineffective or
lymphoma returns

e.
immunologic therapy: rituximab (Rituxan)


6. Nursing care - see Oncology Overview for more specifics

a. facilitate participation in support group and/or counseling

b. reinforce client teaching about oral care, preventing infections during chemotherapy; diet


7. Complications

a. prognosis: dependent on 5 factors - client's age, stage of lymphoma, organs affected
outside the lymph system, ability to perform ADLs, serum level of lactate dehydrogenase
(which goes up with amount of lymphoma in the body)

b. autoimmune hemolytic anemia

c. infection

d. side effects of chemotherapy drugs






IV. Respiratory System Oncology

A. Cancer of the larynx
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1. Etiology

a. most tumors of the larynx are squamous cell carcinoma

b. more common among men, age 50 to 65 years-old

c. risk factors include cigarette smoking and alcohol consumption


2. Findings

a. persistent sore throat

b. dyspnea

c. dysphagia

d. increasing persistent hoarseness

e. weight loss

f. enlarged cervical lymph nodes

g. neck pain/lump in neck (late)


3. Diagnostics

a. physical exam - may detect lump on outside aspect of neck

b. other tests: biopsy, chest x-ray, CT scan of chest, head and/or neck, MRI of head or neck


4. Management

a. either surgery or radiation therapy alone - when tumor is small

b. chemotherapy, along with radiation - when tumor is larger or has spread to lymph nodes

c. surgery: removal of all or part of larynx (laryngectomy)

d. brachytherapy


5. Nursing care - see Oncology Overview for more specifics

a. facilitate clients with laryngectomies to participate in support groups

b. support established method of communication after surgery

c. maintain airway; have suction equipment at bedside

d. observe for signs of hemorrhage or infection

e. reinforce teaching about tracheostomy and stoma care

f. assist with period of grieving

g. assist with nutritional support


6. Complications

a. prognosis: throat cancers can be cured in 90% of clients if detected early

b. possible airway obstruction

c. difficulty swallowing

d. disfigurement of the neck or face

e. loss of voice and speaking ability

f. metastasis









B. Lung cancer
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1. Etiology

a.
types of lung cancer


i. squamous cell carcinoma

ii. small-cell (oat cell) carcinoma

iii. adenocarcinoma

iv. large cell carcinoma


b. prognosis is generally poor

c. largely preventable if smokers stop and nonsmokers avoid second hand smoke


2. Findings

a. hoarse voice

b. changes in breathing

c. persistent cough or change in cough

d. blood-streaked or bloody sputum

e. chest pain or tightness in chest wall

f. recurring pneumonia, pleural effusion

g. weight loss


3. Diagnostics

a. imaging tests including x-ray, CT scan

b.
cytological sputum analysis, carcinoembryonic antigen (CEA) test, complete blood count,
liver and kidney function tests

c. bronchoscopy

d. biopsy



4. Management

a. nonsurgical

i. chemotherapy

ii. radiation therapy

iii. laser therapy to de-bulk tumor

iv. thoracentesis and pleurodesis


b. surgical: thoracotomy

i. wedge resection - part of a lobe

ii. segmental resection- part of a lobe

iii. lobectomy - one or more lobes

iv. pneumonectomy - entire right or left lung



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5. Nursing care - see Oncology Overview for more specifics

a. assist with chest drainage system

b. provide routine post operative care

i. monitor respiratory status frequently

ii. review effective cough techniques

iii. reinforce physical therapy exercises

iv. administer pain control


c. optimize oxygenation

d. provide opportunities for the client to talk about cancer; as needed, refer to support groups

e. reinforce client teaching based on treatment plan and prognosis

f. optimize nutritional status



V. Neurological System Oncology

A. Brain Tumors

1. Definition: growth of tissue within skull

i. may be cancerous or benign

ii. classified according to tissue type

iii. may be primary or metastatic


2. Findings

a. increased intracranial pressure

b. depend on size and location of tumor

i. frontal lobe: personality changes, focal seizures, visual disturbances, hemiparesis,
aphasia

ii. occipital lobe: focal seizures, visual hallucinations

iii. temporal lobe: seizures, headache

iv. parietal lobe: seizures, visual losses

v. cerebellum: coordination or walking/mobility difficulties





3.
Diagnostics

a. history and physical exam

b. computerized tomogram (CT) scan

c. magnetic resonance imaging (MRI)





4. Management
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a. goals are to remove the tumor and minimize harm to the nervous system

b. depends on location and size of tumor

c. treatment for increased intracranial pressure

i. surgery

ii. craniotomy to remove tumor

iii. stereotactic laser surgery

iv. radiation therapy for malignancy


d.
pharmacologic: chemotherapy (for malignant tumors)


5. Nursing care - see Oncology Overview for more specifics

a.
care of the client with increased intracranial pressure

b. care of the client undergoing surgery

c.
seizure precautions and seizure care

d. good nutrition and fluid balance

e. provide emotional support



VI. Gastrointestinal

A. Colon cancer

1. Definition: the development of malignant cells in the epithelium of the large intestine

2. Etiology

a. may develop from adenomatous polyps


b. risk factors: low residue diet, high-fat diet, refined foods, age over 50 years, history of
polyps of the colon and/or rectum, family history, inflammatory bowel disease, exposure
to carcinogens


3. Pathophysiology

a. adenocarcinoma is the most common type

b. most common locations are sigmoid rectum and ascending colon

c. often metastasizes to the liver

d. classification (staging) systems: TNM or Modified Duke
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i. TNM judges the size of primary tumor (T), evidence of regional extension or nodes (N),
and evidence of metastases (M)

ii. Modified Duke Staging System places clients into one of four categories depending on
tissue involvement and metastasis (Stages A, B, C, or D)



4. Findings

a. rectal bleeding

b. change in bowel habits - constipation, diarrhea

c. change in shape of stool

d. anorexia and weight loss

e. abdominal pain, palpable mass





5. Diagnostics

a. colonoscopy

b. sigmoidoscopy

c. digital examination

d.
stool for occult blood, carcinoembryonic antigen (CEA)

e. barium enema

f. CT scan


6. Complications - obstruction, perforation of the bowel wall by the tumor, metastasis

7. Management

a. radiation

b.
chemotherapy

c. local excision and fulguration (small, localized polypoid lesions)

d. treatment of choice is surgery - bowel resection, colostomy

i. right hemicolectomy - involves ascending colon

ii. left hemicolectomy - involves descending colon

iii. abdominal-perineal resection: removal of sigmoid colon and rectum with formation of a
colostomy






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8. Nursing care - see Oncology Overview for more specifics

a. manage pain

b. monitor for complications

i. wound infection

ii. atelectasis

iii. thrombophlebitis


c. maintain fluid and electrolyte balance

d. reinforce teaching about ostomy care



B. Liver Cancer (hepatocellular carcinoma)

1. Definition: cancer of the liver

2. Etiology

a. the cause of liver cancer is usually scarring of the liver (cirrhosis), due to alcohol abuse,
hepatitis B or C virus infection, autoimmune diseases of the liver, hemochromatosis

b. occurs more often in men

c. usually seen in people older than age 50


3. Findings

a. abdominal pain or tenderness (upper right quadrant)

b. easy bruising or bleeding

c. enlarged abdomen

d. fatigue

e. jaundice


4. Diagnostics

a. abdominal CT scan, ultrasound, MRI

b. liver biopsy

c. laparoscopy

d. chest x-ray - to determine if the liver tumor is primary or has metastasized from a primary
tumor in the lungs

e.
liver enzymes, serum alpha fetoprotein, serum bilirubin


5. Management

a. surgery or liver transplant - best for treating small or slow-growing tumors

b. chemotherapy

c. radiation treatments

d.
sorafenib tosylate (Nexavar): blocks tumor growth

e. prevention: childhood vaccination against hepatitis B

f.
immunosuppressive drugs - following liver transplant

i. tacrolimus (Hecoria, Prograf)

ii. cyclosporine (Neoral, Gengraf)

iii. sirolimus (Rapamune)

iv. mycophenolate mofetil (MMF) (Cellcept)
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v. corticosteroids

vi. azathioprine (Imuran)

vii. muromonab CD3 or OKT3 (Orthoclone)

viii. thymoglobulin (Anti-Thymocyte Globulin)

ix. IL-2 Receptor Antagonist Antibodies



6. Nursing care - see Oncology Overview for more specifics

a. facilitate participation in support groups

b. facilitate discussion of end-of-life wishes and efforts to improve quality of life

c. care for end stage liver disease (ESLD)

i. monitor labs - fluid and electrolyte imbalances, platelet counts, serum ammonia

ii. low protein diet

iii. assist with ambulation, range of motion due to muscle weakness, stiffness

iv. monitor for bleeding, stool for occult blood, H & H

v. monitor breathing and elevate head of bed

vi. monitor I & O

vii. monitor for encephalopathy - neuro signs

viii. monitor for indications of renal failure

ix. monitor skin for breakdown and apply lotion - pruritus is common

x. administer diuretics for ascites and care for client undergoing paracentesis

xi. monitor and treat nausea and vomiting

xii. prevent or manage constipation

xiii. assist with pain management



7. Complications

a. poor prognosis

b. gastrointestinal bleeding, liver failure, metastasis to other parts of the body




C. Pancreatic Cancer

1. Definition: cancer of the pancreas

2. Etiology: unknown

a. more common in people with diabetes, chronic pancreatitis, smokers

b. may be genetic link


3. Findings

a. dark urine and clay-colored stools

b. fatigue and weakness

c. jaundice

d. loss of appetite and weight loss

e. nausea and vomiting

f. abdominal pain or discomfort (right upper quadrant)




4. Diagnostics
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a. CT and MRI of the abdomen

b. endoscopic retrograde cholangiopancreatography (ERCP)

c. endoscopic ultrasound

d. pancreatic biopsy

e.
labs: complete blood count, liver function tests, serum bilirubin, carcinoembryonic
antigen (CEA) test


5. Management

a. surgery - pancreaticoduodenectomy (Whipple procedure)

i. may be done but usually cancer is so advanced that surgery is often not successful

ii. involves removing the head of the pancreas, gallbladder, part of the duodenum, the
pylorus, the lymph nodes near the head of the pancreas


b. radiation therapy or chemotherapy - when the tumor has not spread out of the pancreas but
cannot be removed


6. Nursing care - see Oncology Overview for more specifics

a. pain management

b. palliative care

c. assist with managing complications of Whipple procedure - delayed gastric emptying and
other digestive difficulties


7. Complications

a. very poor prognosis

b. common complications: blood clots, depression, infection, liver problems, pain, weight loss




VII. Genitourinary System Oncology

A. Bladder cancer (urothelial cancer)

1. Definition: cancer that starts in the bladder (from the transitional cells lining the bladder)

2. Etiology: unknown

a. classified on the way the tumor grows

i. papillary tumors: wart-like appearance and are attached to a stalk

ii. nonpapillary (sessile) tumors: flat, less common, more invasive and worst prognosis


b. possible causes: cigarette smoking, chemical exposure (at work), chemotherapy, radiation
treatment, chronic bladder infection or irritation


3. Findings

a. abdominal pain

b. blood in the urine

c. bone pain or tenderness (due to metastasis)

d. urination - painful, frequency, urgency, incontinence

e. weight loss






4. Diagnostics
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a. abdominal and/or pelvic CT, MRI

b. bladder biopsy

c. cystoscopy

d. intravenous pyelogram

e.
urinalysis and urine cytology


5. Management

a. stage 0 and I

i. surgery to remove the tumor without removing the bladder - usually a transurethral
resection of the bladder (TURB)

ii. chemotherapy

iii. immunotherapy: usually the Bacille Calmette-Guerin vaccine (BCG) or interferon given
directly into the bladder using a foley catheter


b. stage II and III

i. surgery to remove part of or entire bladder

cystectomy - remove bladder

ileal conduit, continent urinary reservoir, or orthotopic neobladder surgery
may be performed to help drain urine after the bladder is removed


ii. chemotherapy and radiation therapy either before (to shrink tumor) and/or after
surgery


c. stage IV

i. no surgery

ii. chemotherapy may be considered - inserting agents doxorubicin HCl (Adriamycin PFS),
valrubicin (Valstar) and epirubicin (Ellence)

iii. palliative care


d. laser-ablation therapy


6. Nursing care - see Oncology Overview for more specifics

a. palliative care

b. facilitate participation in support groups and counseling

c. support change in body image following urinary diversion surgery

d. support clients with changes to their sexuality


7. Complications
prognosis depends on the stage of cancer
anemia
urinary incontinence
urethral stricture





B. Cancer of the kidneys

1. Definition: a type of kidney cancer that starts in the lining of the kidney tubules

2. Etiology

a. renal cell carcinoma - most common type of kidney cancer

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b. risk factors: smoking, hypertension, obesity, family history, chronic kidney failure and/or
dialysis, high calorie diet, Von Hippel-Lindau disease

c. more common in men, detected between the ages of 50 and 70 years


3. Findings: unknown

a. may be asymptomatic

b. abdominal, back, flank pain

c. hematuria

d. varicocele (swelling of the veins around a testicle)

e. weight loss

f. sometimes excessive hair growth in females


4. Diagnostics: no blood or urine tests to directly detect the presence of tumors

a. kidney ultrasound, MRI or CT scan

b. renal arteriography

c. intravenous pyelogram (IVP)

d.
labs: complete blood count, liver function tests, urinalysis

e. tests used to determine metastasis: abdominal CT, MRI; bone scan; chest x-ray, PET scan


5. Management

a. surgery: partial or radical nephrectomy (radical nephrectomy includes removal of kidney and
adrenal gland)

b. tumor ablation - cryoablation (freezing malignant cells) or microwave ablation (extreme heat)

c. arterial embolization - to shrink tumor

d. hormone treatments

e. chemotherapy

f.
immunotherapy

i. multikinase inhibitors: sorafenib (Nexavar), sunitinib (Sutent), temsirolimus (Torisel)

ii. angiogenesis inhibitor: bevacizumab (Avastin)


g. radiation therapy usually does not work for kidney cancer


6. Nursing care - see Oncology Overview for more specifics

a. encourage participation in support groups and counseling

b. assess remaining kidney function

c. reinforce client teaching about healthy lifestyle choices (exercise, well-balanced diet high in
fiber and low in animal fat, quit smoking)

d. palliative care (if indicated)


7. Complications

a. prognosis depends on tumor stage and grade

b. hypertension

c. hypercalcemia

d. high red blood cell count

e. liver problems

f. metastasis (kidney cancer spreads easily)


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C. Female oncology

1. Cervical cancer

a. three types dysplasia

i. dysplasia

ii. carcinoma in situ

iii. invasive carcinoma


b. etiology and epidemiology

a. the most common age group is 35 to 55 years of age

b. higher incidence in African American women

c. higher incidence among low socioeconomic populations

d. risk factors include

i. multiple sexual partners

ii. human papillomavirus (HPV)

iii. history of STDs

iv. sexual activity at an early age



c. prevention: HPV vaccine Gardasil - a series of 3 injections over 6 months to be completed
before becoming sexually active



d. findings

i. usually asymptomatic in early stages

ii. postcoital bleeding, irregular vaginal bleeding

iii. spotting between periods

iv. spotting after menopause

v. evidence of discharge

vi. pain with radiation to buttocks and legs

vii. anemia

viii. weight loss

ix. fever


e. diagnostics

i.
Papanicolaou test (Pap smear)

ii. staging laparotomy
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iii. metastatic evaluation

intravenous urography (also called intravenous pyelography or IVP)

cystoscopy

sigmoidoscopy



f. management

i.
radiotherapy

used in any stage

internal - radium via applicator

external - via linear accelerator or cobalt


ii. surgery

hysterectomy

not commonly recommended for women of childbearing age

if carcinoma in situ or invasive carcinoma, combine with radiotherapy

complication: impairment of the bladder function is most commonly found

pelvic exenteration (removal of all organs in the pelvis - bladder, uterus, ovaries, colon, etc.)

conization


iii.
chemotherapy - used in addition to surgery or radiation when indicated


g. nursing care - see Oncology Overview for more specifics

i. collect data

history of pap smears, sexual history and past STDs

presence of vaginal bleeding, discharge, weight loss, leg pain, flank pain

client's understanding of the disease


ii. reduce anxiety

iii. enhance body image


h. complications - include metastasis to

i. lungs

ii. mediastinum

iii. bones

iv. liver with subsequent spread to rectum and bladder



2. Endometrial cancer

a. definition: cancer that starts in the endometrium, the lining of the uterus

b. etiology: unknown

i. the most common type of uterine cancer

ii. may be related to increased levels of estrogen
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iii. most cases occur between the ages of 60 and 70 years old

iv. risk factors: estrogen replacement therapy without the use of progesterone, history of
endometrial polyps, infertility or never being pregnant, use of tamoxifen (for breast cancer),
menopause after age 50


c. findings

i. abnormal bleeding from vagina, i.e., bleeding between periods, spotting after menopause

ii. extremely long, heavy, or frequent episodes of vaginal bleeding after age 40

iii. thin white or clear vaginal discharge after menopause


d. diagnostics

i. endometrial aspiration or biopsy

ii. dilation and curettage (D & C)

iii. pap smear


e. management

i. surgery - (abdominal) hysterectomy

ii. radiation therapy and chemotherapy


f. nursing care - see Oncology Overview for more specifics

i. post operative care: pain control, and assess for increased bleeding (hemorrhage)

ii. facilitate participation in support group

iii. reinforce client teaching about frequent pelvic examinations and screening tests, e.g., Pap
smear



Look Good... Feel Better is dedicated to improving the self-esteem and quality of life of people
undergoing treatment for cancer.


3. Breast cancer

a. definition: cancer that starts in the tissues of the breast types of breast cancer

b. etiology

i. in women, may begin in lining of milk duct or the lobes

ii.
higher risk if family history

iii. risk may increase with the use of hormones

iv. types

invasive (infiltrating): spreading outside the membrane that lines a duct or lobule,
invading the surrounding tissues

noninvasive (in situ) - includes ductal carcinoma in situ (DCIS), lobular carcinoma in
situ (LCIS)



c. findings

i. painless, firm lump - most often immoveable

ii. painless thickening in a breast

iii. enlargement of axillary nodes or supraclavicular nodes

iv. nipple discharge

v. scaliness or retraction of nipple (seen more in Paget's disease)

vi. pain, ulceration, edema, orange-peel skin (usually late finding)


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d. diagnostics

i. mammography



ii. biopsy or aspiration (stereotactic biopsy, Mammotome or vacuum-assisted biopsy, ultrasound-
guided biopsy, ductal lavage)


iii.
labs: tumor marker tests, including carcinoembryonic antigen (CEA) test, CA15.3, TRU-QUANT,
CA125

iv. tests to determine metastases (bone scan, MRI, CT scan)


e. management

i. surgical approach (will depend on the results from the lymph node biopsies and tumor staging) -
from most conservative to radical

lumpectomy - tumor removal and small amount of normal tissue around it

partial mastectomy - removal of part of breast with cancer and some surrounding tissue

total mastectomy - removal of whole breast

modified radical mastectomy - removal of whole breast, many of the lymph nodes, the
lining over the chest muscles

radical mastectomy - removal of whole breast, all of the lymph nodes, chest wall muscles


ii. radiation therapy


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iii.
chemotherapy

cyclophosphamide (Cytoxan)

methotrexate (Mexate)

doxorubicin HCL (Adriamycin)

paclitaxel (Taxol)


iv. endocrine therapy

bone marrow transplant

oophorectomy

adrenalectomy


v.
hormone therapy

tamoxifen (Nolvadex): for premenopausal women with positive nodes or stage 1 with
negative nodes

aromasin (Exemestane) or evista (Raloxifene): for post menopausal women

use of other hormones in advanced disease

estrogens (DES) or ethinyl estradiol (Estinyl) to suppress FSH and LH

progestins may decrease estrogen receptors

androgens may suppress FSH and estrogen production

aminoglutethimide blocks estrogen by blocking adrenal steroids

corticosteroids from the adrenal glands suppress secretion of estrogen and
progesterone




f. complications of breast cancer

i. metastases

ii. bone pain, neurologic changes, weight loss, anemia

iii. shortness of breath, cough, pleuritic pain, nonspecific chest discomfort


g. nursing care - see Oncology Overview for more specifics

i. reinforce client teaching

ii. support client and assist with determining coping ability, social support

iii. assess for lymphedema and nerve damage following a radical or modified radical mastectomy
(when lymph nodes are removed)



D. Male oncology

1. Breast cancer in males

a. cancer resembles the types found in women

b. a greater incidence in men in their 60's

c. accounts for about 1% of all breast cancer cases

d. prognosis is poor because men delay seeking diagnosis and treatment

e. gynecomastia is often an associated factor
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2. Prostate cancer

a. definition: malignant neoplasm, usually adenocarcinoma, of prostate gland

b. etiology and epidemiology

i. more prevalent in African American men

ii. most appear on the peripheral zone of the gland

iii. most are palpable on rectal examination

iv. spreads via the lymphatics, the bloodstream or by local extension

v. specific etiology unknown; familial history increases risk


c. findings

i. usually asymptomatic in early stages

ii. obstruction of urinary flow that may result in urinary urgency, hesitancy, dribbling, retention,
nocturia, infection, hematuria

iii. pain in an area represents the location of the metastases

lumbosacral

hips

lower legs


iv. rectal discomfort

v. weight loss

vi. anemia

vii. edema of the lower extremities


d.
diagnostics

i. digital rectal examination

ii. needle biopsy of the gland

iii. transrectal ultrasonography

iv. descending urography

v.
serologic markers

prostate specific antigen (PSA)

prostatic acid phosphatase


vi. metastatic evaluations

chest x-ray

intravenous urography (also called intravenous pyelography or IVP)

CT scan of specific areas or entire body

MRI



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e. management

i. conservative approach

usually no treatment for men over 70 due to the prostate cancer's slow progression

analgesics to manage pain - both non-narcotic and narcotic

short course of radiotherapy (site-specific)

administration of IV strontium chloride 89 (beta emitter agent)

placement of suprapubic catheter for obstructed outflow through urinary tract



ii. surgical approach

radical prostatectomy

laparoscopic dissection of pelvic lymph node

cryosurgery

transurethral resection of prostate (TURP)


iii. curative approach

external beam radiation

interstitial radiation - the direct implantation of radioactive substances into the
prostate either permanently (seeding) or briefly (high dose rate); also called
brachytherapy, seed implantation


iv. palliative approach

hormone manipulation

estrogen therapy diethylstilbestrol (DES)

luteinizing hormone-releasing hormone (LHRH)

bilateral orchiectomy (removal of the testes)

use of anti-androgen drugs

flutamide (Eulexin) - blocks the effect of testosterone

drugs are often used in combination therapy




f. nursing care - see Oncology Overview for more specifics

i. data collection

presence of urinary urgency, hesitancy, dribbling, retention, nocturia, infection,
hematuria

presence of palpable lymph nodes

presence of flank pain, weight loss, rectal pain

presence of bladder distention


ii. control pain to acceptable levels

iii. reduce anxiety in clients and family members by facilitating referrals made by health care team
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iv. discuss potential changes re: sexual functioning, energy levels


g. complications

i. of the cancer - bone metastases

ii. of hormone manipulation

nausea and vomiting

gynecomastia

sexual dysfunction

hot flashes




VIII. Endocrine System Oncology

A. Thyroid cancer

1. Etiology

a. radiation exposure increases risk for thyroid malignancies

b. thyroid malignancy is rare in the U.S. (benign thyroid disease is relatively common)

c. most thyroid tumors are benign

d. most common types: papillary and follicular

e. greater likelihood of malignancy in clients older than age 60 years and younger than 30
years-old


2. Findings: painless, palpable, solitary nodule on thyroid gland

3. Diagnostics

a. history and physical (palpation of nodule)

b. fine needle aspiration biopsy (FNAB)

c. ultrasound of the thyroid, thyroid scan

d. laryngoscopy

e.
serum thyroid-stimulating hormone (low), calcitonin


4. Management

a. surgical excision - total or subtotal thyroidectomy

b. postoperative radioiodine scanning and ablation

c. RapidArc radiotherapy: a fast and precise form of radiation therapy

d. possibly chemotherapy

e.
medications

i. thyroid hormone replacement therapy - usually T4 (Synthroid) or triiodothyronine (T3,
Cytomel)

ii. recombinant human TSH (Thyrogen) - in remnant ablation



5. Nursing care - see Oncology Overview for more specifics

a. support clients undergoing radioisotope treatment

b. post-operative care: relieve pain, observe for indications of tracheal obstruction,
swelling, bleeding or laryngeal spasm


6. Complications

a. injury to the larynx and hoarseness after thyroid surgery

b. low calcium levels from accidental removal of parathyroid glands
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c. metastasis





IX. Integumentary System Oncology

A. Melanoma

1. Definition: malignant tumors that originate in the pigment-producing melanocytes in the
basal layer of the epidermis


2. Etiology

a. fair skin, blue or green eyes, or red or blond hair

b. live in sunny climates or at high altitudes

c. have had one or more blistering sunburns during childhood

d. use tanning devices

e. genetic predisposition


3. Findings - identification of potentially malignant pigmented lesions

a. A for asymmetry

b. B for border irregularity

c. C for color multiplicity

d. D for diameter greater than 1/4 inch

e. E for evolution (change) in size and/or shape


4. Diagnostics

a. epiluminescence microscopy (magnification and polarized light to enhance detection)

b. biopsy

c. sentinel lymph node biopsy - to predict progression of disease




5. Management - almost always curable if recognized and treated early

a. excision of the tumor (stage 1)

b. Mohs micrographic surgery - layers of tissue are removed until margins of skin are cancer-free

c. regional lymph node dissection

d. adjuvant treatment

i. radiation therapy

ii. immunotherapy/biochemotherapy, including interferon injections, tumor necrosis factor,
lymphokines, and vaccines

iii. gene therapy

iv. chemical peeling

v. laser therapy

vi. regional limb profusion (chemotherapy limited to an extremity) or chemotherapy

vii. photodynamic therapy

696


e.
peginterferon alfa-2b (Sylatron): used to treat stage III melanoma
Black Box Warning - can cause or aggravate fatal or life-threatening neuropsychiatric,
autoimmune, ischemic, and infectious disorders; genotoxic


6. Nursing care - see Oncology Overview for more specifics

a. with radiation therapy, reinforce information about common side effects such as nausea,
vomiting, diarrhea, hair loss, malaise

b. reduce anxiety

c. anticipate need for analgesics

d. reinforce patient and family teaching teaching

i. how to recognize early signs of melanoma

ii. location of common sites of melanoma - back, legs, between toes, face, feet, scalp, fingernails
and backs of hands

iii. avoid exposure to sun - wear long sleeves, hats and use sunblock


e.
help control the odor of a wound with odor-masking substances such as oil of cloves or
balsam of Peru



B. Nonmelanoma skin cancers - account for more than 90% of skin cancers

1. Basal cell carcinoma (BCC)


a. definition: abnormal, uncontrolled growths or lesions from the skin's basal cells (the deepest
layer of the epidermis)

b. etiology

i. usually caused by a combination of cumulative UV exposure and intense, occasional UV
exposure

ii. almost never metastasizes

iii. most common form of skin cancer


c. finding: look like open sores, red patches, pink growths, shiny bumps, or scars

d. management

i. surgery: Mohs micrographic surgery, excisional surgery, curettage and electrodesiccation,
cryosurgery, photodynamic therapy, laser surgery

ii. radiation

iii.
topical medications

imiquimod (Aldara) - for superficial BCC; works by stimulating the immune
system

5-Fluorouracil (5-FU) - for superficial BCC

vismodegib (Erivedge) - for more advanced BCC
Black Box Warning - embryotoxic and teratogenic


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e. nursing care

i. reinforce teaching about skin cancer prevention and identification

ii. supportive care for disfigurement





2. Squamous cell carcinoma

a. definition: uncontrolled growth of abnormal cells arising in the squamous cells (upper layers of
the epidermis)


b. etiology

i. second most common form of skin cancer

ii. mainly caused by cumulative UV exposure over the course of a lifetime

iii. can be disfiguring and may be deadly if allowed to grow


c. findings

i. look like scaly red patches, open sores, elevated growths with central depression, or warts; may
crust or bleed

ii. usually occurs on any area exposed to sun but may occur on mucous membranes and genitals


d. management

i. surgery: Mohs micrographic surgery, excisional surgery, curettage and electrodesiccation,
cryosurgery, photodynamic therapy, laser surgery

ii. radiation

iii.
topical medications: 5-Fluorouracil (5-FU)


e. nursing care

i. reinforce teaching about skin cancer prevention and identification

ii. supportive care for disfigurement



3. Actinic keratosis (also called solar keratoses): scaly or crusty growths (lesions) caused by damage
from UV light; the most common pre-cancer

4. Dysplastic nevi (atypical moles): unusual benign moles that resemble melanoma








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Points to Remember

Only certified (registered) nurses may administer chemotherapeutic agents.

Clients undergoing chemotherapy should avoid crowds and persons with infections and to report signs
of infection.

Radiation has local effects related to site irradiated; chemotherapy is more systemic.

Biological therapies (interferons, interleukins, colony-stimulating factors, monoclonal antibodies,
vaccines, gene therapy, and nonspecific immunomodulating agents) use the body's immune system to
fight cancer or to lessen the side effects that may be caused by some cancer treatments.

Although clients receiving internal radiation are not radioactive, the implant or injection is radioactive;
treat waste products and body fluids as radioactive.

Although clients with cancer may experience pain at any time during their disease, pain is usually a late
symptom of cancer.

Be sure to test client for tuberculosis (TB) before cancer treatment using monoclonal antibodies,
especially infliximab (Remicade), since they will allow TB to fulminate.

Melanoma is the most dangerous form of skin cancer and the leading cause of death from skin disease.

Lung cancer is the leading cause of cancer deaths in both men and women (exception - the leading
cause of cancer deaths in Hispanic women is breast cancer).

Most Pancreatic cancer has a very poor prognosis since it's often advanced when first discovered.

The cause of liver cancer is cirrhosis, which may occurs with hepatitis B or C. Individuals should be
vaccinated for HBV. The Centers for Disease Control and Prevention recommends that all baby boomers
are tested for HCV.

Administration of HPV vaccine Gardasil is recommended for the prevention of cervical cancer.

Points to Remember - Pediatric

There are 12 major types of childhood cancers; leukemias and cancers of the brain and central nervous
system account for more than half of the new cases.

Children typically have longer treatment plans than adults due to their increased metabolic rate and
rate of cell turnover.

Cure rate is improving for most types of pediatric malignancies.

During nursing assessment of a child with Wilm's tumor, do NOT palpate the abdomen

Neuroblastoma is a cancer that actually begins in utero.

An active child who suddenly becomes lethargic and exhibits symptoms of childhood cancer, e.g.,
weight loss, pain, and fever, should be evaluated by a health care provider.

Acute leukemia can advance very quickly; a child with anemia and bruising should be evaluated for
leukemia.

Osteosarcoma is more common than Ewing's sarcoma but both are tumors of the bone.

Pediatric oncologic emergencies include: acute tumor lysis syndrome, superior vena cava syndrome,
septic shock.

Pediatric cancer is a highly charged emotional arena. Be calm and collected in dealing with both parents
and patients

All cancer victims and their families need support and encouragement. Families with children who have
cancers can be especially affected. Other children in the family may need as much or more attention
and support than the parents.

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I. Cardiac Arrest

A. Adult/child/infant cardiopulmonary resuscitation (CPR)

1. Assessment

a. shake gently and shout "are you okay?"

b. check victim's pulse (for at least 5 seconds, but no more than 10 seconds)

i. adult or older child check carotid

ii. child check carotid (or femoral)

iii. infant check brachial or femoral


c. if victim is breathing and has a pulse, position in a recovery position

d. if victim has a pulse but is not breathing

i. adult: give 1 breath every 5 to 6 seconds (approximately 10 to 12 breaths/minute) and
recheck pulse every 2 minutes

ii. child and infant: give 1 breath every 3 to 5 seconds (approximately 12 to 20
breaths/minute) and recheck pulse every 2 minutes


e. If victim is unresponsive:

i. for adults or child with out-of-hospital sudden collapse: first call the emergency response
system

ii. for infants and children: provide 2 minutes of CPR before activating the emergency
response system

iii. call for a defibrillator (AED)





2. Chest compressions

a. begin chest compressions if pulse is absent or in child/infant if heart rate is less than 60 with signs
of poor perfusion

b. be sure client is on a firm surface and lying face up

c. hand position

i. adult/older child center of chest between nipples; two hands with heel of one hand and the
other hand on top

ii. child center of chest between nipples; one hand or two hands with use of the heel(s) of the
hands


iii. infant just below the nipple line; one rescuer uses two fingers or two rescuers use two thumbs
encircling hands around chest
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d. compression depth

i. adults: at least 2 inches (5 cm)

ii. child: at least 1/3 anterior-posterior diameter of chest or about 2 inches (5 cm)

iii. infant: at least 1/3 anterior-posterior diameter of chest or about 1.5 inches (4 cm)


e. compression ratio: at least 100 compressions per minute for all ages

f. push hard and push fast, allowing chest to recoil between compressions

g. minimize interruptions in chest compression keep at 10 seconds or less


3. Open the airway

a. head tilt-chin lift


i. place one hand on victim's forehead and push with your palm to tilt the head back

ii. place the fingers of your other hand under the bony part of the victim's lower jaw

iii. lift the jaw to bring chin forward


b. jaw thrust (if trauma is evident or spinal injury suspected)


4. Deliver 2 breaths using barrier devices, such as a face mask with 1-way valve

a. deliver air over 1 second to make the victim's chest rise

b. avoid excessive ventilation

c. advanced airway considerations (laryngeal mask airway, esophageal-tracheal combitube or
endotracheal tube)

i. give breaths at a rate of 1 breath every 6 to 8 seconds (approximating 8-10 breaths/minute)
when an advanced airway is in place during 2-person CPR for victims of all ages

ii. asynchronous with chest compressions

iii. there should be no pause in chest compressions for delivery of breaths


d. keep dentures in the mouth if they are secure; remove if loose in mouth


B. Additional Information about CPR

1. Compressions - ventilation ratios until advanced airway is placed

a. adult 30:2 (30 compressions to 2 breaths) for both one or two rescuers

b. child or infant

i. one rescuer 30:2 (30 compressions to 2 breaths)

ii. two rescuers 15:2 (15 compressions to 2 breaths)


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2. Check pulse about every 2 minutes

3. Definition of ages (for health care provider)

a. adult: adolescent and older child (health care provider)

b. child: 1 year to onset of puberty (about 12 to 14 years old)

c. infant: under 1 year


4. Apply monitor or defibrillator when available

5. Continue until ACLS providers take over or the client starts to move



C. Automated External Defibrillator (AED)

1. Power "ON" the AED

2. Attach the pads to the victim's bare chest

a. only adult pads can be used on adults; children/infant pads OR adult pads can be used on
children

b. for victims with lots of chest hair, it may be necessary to either shave area first or use pad to
tear off hair

c. place one AED pad on the victim's upper right chest (directly below the collarbone) and the
other pad to the side of the left nipple, with the top edge of the pad a few inches below the
armpit; for children, can also place one pad on the chest and the other pad on the victim's
back


3. Be sure no one touches the victim while the AED analyzes heart rhythm

4. AED will prompt when shock is advised; if no shock is needed, immediately resume CPR starting
with chest compressions

5. After 5 cycles or about 2 minutes of CPR, the AED will prompt and re-analyze rhythm


D. Differences for lay persons

1. Lay rescuers do not need to assess for pulse or signs of circulation for an unresponsive victim

2. The American Heart Association supports the use of compression-only CPR (no mouth-to-mouth)


E. Conscious choking

1. Age one year and older - use Heimlich maneuver; continue to perform a new abdominal thrust
until the obstruction is removed

2. Infants - alternate between delivering 5 back blows and 5 chest thrusts until obstruction is
removed or infant loses consciousness


F. Unconscious choking

1. If it is known that a person was choking and is now unresponsive - activate the EMS system, lower
the client to the ground and begin with compressions (don't check for a pulse)

2. If the rescuer does not know there is an airway obstruction - begin CPR

3. Open the victim's mouth wide and look for the object before giving breaths; remove object only if
able to remove without further pushing down airway


II. Shock

A. Overview

1. Definition: a clinical syndrome marked by inadequate tissue perfusion and oxygenation of
cells, tissues and organs

2. Requirements for homeostatic regulation (if one or more of these components malfunctions
shock may follow)
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a. adequate cardiac output

b. uncompromised vascular system

c. adequate blood volume

d. ability of tissue to extract and use oxygen



B. Major categories or types of shock

1. Cardiogenic (pump failure or heart failure)

2. Obstructive (mechanical interference with ventricular filling or ventricular emptying)

3. Distributive (vasogenic)

a. septic

b. anaphylactic


4. Hypovolemic (intravascular volume loss)


C. Three stages of shock

1. Compensatory (reversible, initial, "warm")

2. Progressive stage

3. Irreversible stage



D. Findings - Stage I (Compensatory, Reversible, Initial, "Warm")

1. Findings depend on type of shock

a. hypovolemic and cardiogenic shock: decreased cardiac output and perfusion

b. anaphylactic, septic, and neurogenic shock: blood vessels dilate, causing the blood to remain
in the blood vessels instead of returning to the heart, which triggers anaerobic metabolism
and development of lactic acidosis; blood pressure drops


2. Compensatory mechanisms (neural, chemical, and hormonal) act to maintain perfusion

a. neural compensation

i. baroreceptors in carotid sinus aortic arch activate sympathetic nervous system (SNS), which
contracts blood vessels so that skin cools

ii. SNS releases epinephrine and norepinephrine, which stimulates heart (tachycardia) and
blood flow to kidneys and gastrointestinal system is reduced, pupils dilate


b. hormonal compensation

i. decreased blood flow to kidneys releases angiotensin, which constricts vessels and
increases blood pressure

ii. angiotensin II stimulates the secretion of aldosterone; aldosterone causes kidneys to retain
sodium which increases serum osmolality, which in turn stimulates antidiuretic hormone
(ADH)

iii. ADH causes water retention

iv. increased sodium and water retention results in increased BP, decreased urine volume
and increased urine specific gravity

v. anterior pituitary is stimulated to secrete adrenocorticotropic hormone (ACTH); ACTH acts
on adrenal cortex to increase secretion of glucocorticoids, which increases serum glucose


c. chemical compensation

i. decreased pulmonary blood flow causes hypoxemia

ii. hypoxemia is sensed by chemoreceptors that increase rate and depth of respirations,
which results in respiratory alkalosis


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3. Clinical findings at this stage are vague because of compensatory mechanisms

a. subjective findings include chest pain, lethargy, somnolence, restlessness, anxiousness,
dyspnea, diaphoresis, thirst, muscle weakness, nausea and constipation

b. objective physical assessment findings

i. hypoxia, tachypnea progressing to 40 breaths/minute, hypocarbia, wheezing

ii. skin

may be pale, mottled or dusky in color, cool, diaphoretic, warm, flushed with
fever (distributive shock)

rash (anaphylactic and septic shock)


iii. angioedema (anaphylactic shock)

iv. blood pressure - may be within the expected reference range during the initial stage (but
can increase during the progressive stage and then drop to 50 to 60 mm Hg)

v. tachycardia - increasing to 140 beats/minute (pulse is weak, thready or bounding with
distributive shock)

vi. decreased urine output




E. Findings - Stage 2 (Progressive)

1. Compensatory mechanisms can no longer maintain perfusion and organ functions deteriorate

a. severe hypoperfusion

b. massive cell death

c. organs begin to fail

d. severe lactic acidosis and metabolic acidosis


2. Findings of progressive stage of shock

a. neurologic

i. altered mental status, depressed level of consciousness due to decreased blood flow to the
brain

ii. cerebral edema and irreversible brain cell damage may occur, leading to coma


b. respiratory

i. decreased pulmonary blood flow alters the exchange of oxygen and carbon dioxide
between the alveoli and capillaries

ii. decreased oxygen levels and increased carbon dioxide levels, leading to respiratory
acidosis, tachypnea with hypoventilation and adventitious lung sounds (crackles and
wheezes)


c. cardiovascular

i. decreased cardiac output and decreased BP with systolic below 90 mm Hg

ii. narrowing pulse pressure

iii. tachycardia and irregular pulse; faint peripheral pulses

iv. jugular venous distention


d. gastrointestinal (GI)

i. blood shunted from the GI track and liver to the heart and brain causes organs to become
ischemic, resulting in ischemia of the gastric mucosa

ii. liver fails as shock progresses, leading to hypoglycemia


e. renal/elimination
705


i. hypoperfusion leads to decreased urine output, oliguria, which may result in acute renal
failure

ii. dilute urine osmolality

iii. absent bowel sounds


f. integumentary

i. skin color changes - ashen and cyanotic

ii. due to vasoconstriction, the skin will be cool and moist


g. unless this stage of shock is treated rapidly, the client's prognosis is poor



F. Findings - Stage 3 (Refractory)

1. Death from multi-organ dysfunction syndrome (MODS)

2. Findings of refractory stage of shock

a. cardiac failure

b. respiratory failure

c. renal shutdown

d. liver dysfunction

e. loss of consciousness



Types of shock are classified according to etiology: CHANS

Cardiogenic - caused by inability of the heart to pump blood effectively (due to heart attack or heart
failure)

Hypovolemic - caused by inadequate blood volume (due to bleeding or dehydration)

Anaphylactic - caused by allergic reaction

Neurogenic - caused by damage to nervous system (due to extreme emotional upset due to personal
tragedy or disaster)

Septic - caused by systemic infection

G. Diagnostics

1. Bedside data collection used to assess client's condition and identify etiology of shock

2. Complete blood count

a. hemoglobin & hematocrit - to identify hypovolemic shock

b. white blood cells - to rule out septic shock

c. platelet count - may be low due to coagulopathy related to sepsis

d. CBC can help exclude anemia


3. Brain natriuretic peptide (BNP) - an indicator of congestive heart failure and as an independent
prognostic indicator of survival

4. Arterial blood gases (ABGs) - as shock progresses, this can measure metabolic acidosis

5. Electrolytes and glucose - to determine the progression of shock (as shock progresses, sodium
levels decrease, potassium levels increase, and glucose levels decrease)

6. BUN and creatinine - check for decreased renal perfusion

7. Blood cultures - to determine the causative agent in septic shock

8. Creatine Kinase-MB (CK-MB) and troponin - to determine cardiogenic shock

9. X-ray's, CT, and MRI - to determine the extent of the injury and locate site of internal
hemorrhage
706


10. Invasive hemodynamic monitoring (Swan-Ganz catheterization) - to exclude volume depletion,
obstructive shock and septic shock


H. Management - objective is to correct underlying cause and prevent progression

1. Many treatments listed are used for all shock syndromes, e.g., vasopressors, positive inotropic
support, oxygen therapy (intubation), fluid replacement

2. Cardiogenic shock - early revascularization in patients with myocardial infarction and
intervention in clients with structural heart disease

a.
pharmacologic treatments

i. positive inotropic agents - increase myocardial contractility and improve systolic ejection

ii. vasodilators - improve heart's pumping action by reducing its workload

iii. vasopressors - increase peripheral vascular resistance and elevate blood pressure

iv. diuretics and digoxin (Lanoxin) - may be given if the client shows heart failure

v. antidysrhythmic agents - may be given to regulate the client's heart rhythm


b. oxygen therapy - titrated based on ABG analysis and respiratory effort

c. supportive treatments - to assist with blood circulation

i. intra-aortic balloon pump (counterpulsation)

ii. left and right ventricular assist pumping



3.
Hypovolemic shock - rapid fluid replacement therapy to replace lost volume

a. crystalloids

b. colloids (not for sepsis or burn)

c. hemoglobin-based oxygen carriers, e.g. PolyHeme, Hemopure, Hemolink

d. blood and blood products

i. whole blood (autotransfusion an option if they go to surgery/chest tube)

ii. packed red blood cells - increase the oxygen carrying capacity of blood

iii. platelets

iv. fresh frozen plasma - to expand blood volume

v. cryoprecipitate - treats clients with clotting factor deficiencies




4.
Anaphylactic shock

a. epinephrine (adrenalin) given SubQ or IV - to restore arterial blood pressure and promote
vasodilatation

b. antihistamines, e.g., diphenhydramine (Benadryl) - to reverse the effects of histamine

c. corticosteroids - prevent a delayed reaction from the antigen

d. albuterol (Proventil) - to reverse bronchospasm

e. aminophylline (Theophylline)


5. Neurogenic - depends on causative agent

a. IV fluids are ordered to reverse the peripheral vasodilation

b. If cause is severe pain, appropriate analgesic should be ordered

c. minimize spinal cord trauma with stabilization of the vertebral column

707



6. Septic shock

a. fluid replacement

b.
anti-infective agents based on culture results

c.
improve cardiac output with positive inotropes and vasopressors



I.
Nursing interventions for shock: the cardio-care six except

1. Do not elevate or lower head: maintain complete bed rest in
flat position or with legs slightly raised to increase venous
return (modified trendelenburg)

2. Bed rest

3. Turn patient every two hours as tolerated

4. Monitor the client's body temperature - prevent shivering
and keep client warm

5. Assess vital signs every 15 to 30 minutes

6. Monitor for restlessness, confusion or mental status
changes- this indicates cerebral perfusion

7. Monitor for bowel sounds and abdominal distension/pain

8. Assess for sudden, sharp chest pains, dyspnea or cyanosis

9. Administer parenteral therapy, medications

10. Monitor mean hemodynamic indicators as ordered

11. Blood plasma expanders or packed cells if hematocrit and
hemoglobin low



III. Trauma Care

A. Airway with simultaneous cervical spine immobilization

1. Head to neutral position, but do not force if encounter resistance

2. Cervical spine immobilization using rigid cervical collar (trauma clients are always presumed
to have cervical spine injury)

3. Must use jaw thrust - do not use head-tilt chin-lift!


B. Breathing

1. Look, listen and feel for respirations

a. Assess for spontaneous breathing, rise and fall of the chest, rate and pattern of breathing,
use of accessory muscles

b. assess skin color

c. assess integrity of soft tissues and bony structures of the chest wall


2. Auscultate the lungs bilaterally

3. Follow BLS procedures

4. Use advanced airway device, e.g., endotracheal tube, with traumatized airway, emesis

5. Inspect for tracheal deviation and jugular venous distention



708

Emergency trauma assessment: ABCDEFGHI
Primary Assessment = A, B, C, D & E
Secondary Assessment = F, G, H & I

A= Airway (with simultaneous cervical spine protection
B= Breathing
C= Circulation
D= Disability ((neurological status)
E= Examine/expose
F= Full set of vital signs/focused adjuncts
G= Give comfort
H= History and Head-to-toe assessment
I= Inspect the posterior surfaces


C. Circulation

1. Assess pulses

a. palpate a central pulse (carotid, femoral, or brachial in infants under one year of age)

b. assess for strength (normal, weak, or strong) and rate (normal, slow, or fast)


2. Blood pressure

a. assess using pulse - if a client has a palpable radial pulse, systolic blood pressure is estimated
to be at least 80 mm Hg; a palpable femoral pulse is estimated at 70 mm Hg; if only the carotid
pulse can be palpated the BP is estimated at 60 mm Hg

b. taking a formal blood pressure can be deferred until later


3. Inspect for any obvious signs of uncontrolled external bleeding (apply direct pressure and elevate
area with gross hemorrhage)

4. If pulses are absent, life support measures should be initiated - prepare and assist with an
emergency thoracotomy (only in facilities with the resources to manage postthoracotomy clients)

5. After initial assessment, start two large-bore IVs

a. administer warmed isotonic crystalloid solution at a rate appropriate for the client's condition

b. interosseous needles may be used for access in the sternum, legs, arms or pelvis if the client's
injuries wound not interfere with the procedure



D. Disability/neurological status

1. Assess pupils for size, shape, equality, and reaction to light

2. Determine the presence of lateralizing signs - unilateral deterioration in motor movements, along
with unequal pupils and other symptoms help locate the area of injury in the brain

3. Ability to move extremities, check for sensation

4. Ability to move against resistance

5. Score on Glasgow Coma Scale - a quick way to measure the client's level of consciousness (even
though it is not a measure of total neurological function); initial and serial scores provide the
trauma team with a good indication as to client outcomes.


E. Expose/examine

1. Undress client carefully and quickly so injuries can be determined

2. Inspect for injuries or deformities


For the initial assessment - use the AVPU mnemonic:

A=Alert - Speak to the client; a client who is alert and responsive is considered "A" (for "alert")
709

V=Verbal - The client who responds to verbal stimuli is considered "V" (for "verbal")
P=Pain - Apply a painful stimulus; a client who does not respond to a verbal stimuli but does respond to
a painful stimulus is considered "P" (for "pain")
U=Unresponsive - The client who does not respond to a painful stimulus is considered "U"
(unresponsive)


F. Full set of vital signs/focused adjuncts

1. Full set of vital signs - pulse, respiratory rate and blood pressure

i. pulse - greater than 120 bpm is of concern

ii. respiratory rate - greater than 30 breaths per minute is of concern

iii. blood pressure - less than 100 mm Hg systolic is of concern


2. Maintain warmth - warm blankets, warming lights

3. Focused adjuncts

a. ECG, pulse oximeter

b. insert an indwelling catheter and nasogastric tube if needed

c. facilitate radiographic and diagnostic studies (such as chest x-rays; CT scan of head, abdomen,
and chest; cervical spine x-rays; diagnostic peritoneal lavage if needed)

d.
blood typing, complete blood count, electrolytes

e.
administer tetanus booster



G. Give Comfort

1. Talk and touch the the client

2. Pharmacological and nonpharmacological pain management as needed by (conscious or
unconscious) client

a. unmanaged pain can cause increased heart rate and increased force of cardiac contraction,
peripheral vasoconstriction and pallor, tachypnea, muscle tension, nausea/vomiting, increase
in blood pressure and myocardial oxygen consumption

b. interventions

i. remove any pain producing objects, e.g., shattered glass

ii. administer prescribed medication and monitor for side effects of the medication, including
respiratory depression, hypotension, nausea/vomiting, bradycardia, and hallucinations

iii.
consider alternative methods, e.g., therapeutic touch, positioning/splinting,
application of heat/cold, distraction, relaxation exercises, guided imagery, humor



3. Family presence

a. assess the families desires and needs, support the families involvement

b. assign a health care professional to provide explanations about the procedures and to be with
the family

c. utilize resources if needed such as social worker or chaplin



H. History and head-to-toe full assessment

1. How did injury occur - mechanism of injury

a. knowledge of mechanism of injury and specific injury patterns

b. type of motor vehicle, impact of injury, length of time since injury

c. Injuries sustained - ask pre-hospital personnel about client's general condition, level of
710

consciousness, and apparent injuries


2. Measure vital signs

3. If the client is responsive, ask questions to evaluate the client's condition, pain, location,
duration, intensity

4. Obtain medical history, including age, any premedical conditions, allergies, last tetanus shot,
previous hospitalization/surgeries, use of drugs/alcohol, date of last menstrual period, current
medications

5. Head to toe - full body system assessment

a. general appearance - note body position, guarding, stiffness, or flaccidity of muscles

b. note any unusual odors, such as gasoline, chemicals, vomit, alcohol, urine/feces

c. head and face

i. eyes - visual acuity (hold up fingers), inspect for periorbital ecchymosis (racoon eyes),
perform PEARLA

ii. ears - inspect ecchymosis behind the ear (battle's sign - late sign of head injury), note any
unusual drainage

iii. nose - inspect any unusual drainage such as blood or clear fluid (may be cerebrospinal fluid
if clear - do NOT insert a gastric tube through the nose)

iv. neck - inspect for any trauma, position of trachea, palpate for subcutaneous emphysema


d. chest

a. observe breathing, rate, depth, and use of accessory muscles

b. auscultate lungs and heart tones

c. palpate sternum and ribs for bony crepitus and deformities


e. abdomen

i. inspect for lacerations, abrasions, contusions, puncture wounds, impaled objects,
ecchymosis, edema

ii. auscultate for bowel sounds and palpate gently for rigidity, guarding, masses and areas of
tenderness


f. pelvis/perineum

i. inspect for lacerations, abrasions, contusions, avulsions, puncture wounds, impaled objects,
ecchymosis and edema

ii. palpate for instability and tenderness over the iliac crests and symphysis pubis

iii. inspect for blood at the urethral meatus, inspect penis for priapism (with proper personnel
to examine the rectal area in males to determine anal sphincter tone)


g. extremities - inspect color, assess skin temperature and moistness, palpate pulses (comparing
one side with the other)

h. soft tissue injuries - inspect for bleeding, lacerations, abrasions, contusions, avulsions,
puncture wounds, impaled objects, edema, angulation, deformity or open wounds

i. bony injuries - note crepitus, palpate for deformity and areas of tenderness

j. motor function - inspect for spontaneous movement of extremities, determine strength and
range of motion of all 4 extremities

k. sensation - determine client's ability to sense touch in all extremities



I. Inspect posterior surfaces

1. maintain cervical spine protection, support extremities with suspected injuries, log roll on the
711

uninjured side

2. inspect back, flanks, buttocks, posterior thighs, palpate vertebral column, and all posterior
surfaces for deformity and tenderness


Complications of a trauma client: TRAUMATIC

T=Tissue perfusion problems
R=Respiratory problems
A=Anxiety
U=Unstable clotting factors
M=Malnutrition
A=Altered body image
T=Thromboembolism
I=Infection
C=Coping problems

Points to Remember - CPR
CPR

Compressions - Airway - Breathing ("C-A-B")

The healthcare provider should not delay activating the EMS but check the victim for two things
simultaneously: response and breathing.

The current emphasis is on establishing good chest compressions with 30 compressions preceding the 2
ventilations.

Start compressions within 10 seconds of recognizing cardiac arrest.

Push hard and fast on the chest, without interruption, at a rate of at least 100 compressions a minute, allowing
complete chest recoil after each compression.
For adults, compress the chest at least 2 inches using 2 hands.
For children, compress the chest approximately 2 inches using 1 or 2 hands.
For infants, compress the chest approximately 1.5 inches using 2 fingers or the thumbs of both hands.

For the adult victim, give 30 compressions and 2 breaths (30:2 ratio) with either 1 or 2 rescuers.

For the child or infant victim, give 30 compressions and 2 breaths (30:2 ratio) when there is 1 rescuer; with 2
rescuers, infant and child CPR becomes 15 compressions and 2 breaths (15:2 ratio).

Minimize interruptions in compressions to less than 10 seconds.

Give effective breaths that make the chest rise and avoid excessive ventilation.

Individuals with ventricular fibrillation or pulseless ventricular tachycardia should receive chest compressions until
a defibrillator is ready; defibrillation should then be performed immediately.

There are 4 universal steps for using any AED

POWER ON the AED

ATTACH the AED pads

ANALYZE the rhythm

SHOCK if advised






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Points to Remember - Shock & Trauma
Shock

Types of shock are classified according to etiology: CHANS (Cardiogenic, Hypovolemic, Anaphylactic, Neurogenic
and Septic shock).

In shock, the first hour of treatment is most critical; early detection is key.

There are different ways to categorize shock; basically shock presents three potential problems:

Not enough fluid in the blood vessels.

Fluid has moved outside the vessels, so cannot be pumped to the organs.

Heart cannot pump fluid that is present in the vascular space.

The major problem in shock is tissue hypoxia.
Trauma

The initial assessment of the trauma client is the most important step.

If client has head injury, the most important data collection is level of consciousness, next is pupil
response to light; changes in vitals signs are very late signs.

With trauma clients, assume spine is injured until proven otherwise; while the airway is being opened, the
cervical spine should be immobilized.

When treating a trauma client, a quick check of the ABCs is the priority. After you know the client is
breathing and has a pulse, vital signs can wait while any bleeding is stopped and other interventions (such
as starting IVs) are started.

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I. Pediatric Cardiovascular

A. Congenital heart defects - general information

1. Definition: problems with the heart's structure that are present at birth, which affects the
normal flow of blood through the heart

2. Etiology: usually not known but associated with the following maternal factors

a. infection

b. alcoholism

c. age over 40 years

d. (type 1) diabetes mellitus

e. genetics, chromosomal changes


3. General findings of congenital heart defects

a. child small for age

b. physiological failure to thrive

c. exercise intolerance

d. dyspnea while feeding

e. squatting position

f. clubbing of fingers


4. Physical consequences of cardiac problems

a. increased workload

b. pulmonary hypertension

c. decreased systemic output

d. cyanotic defects

e. can lead to hypoxemia and polycythemia

f. concern - formation of thrombus with embolus





B. Acyanotic defect - infant or child is "pink" but may become cyanotic

1. Pathology: hole in the heart's internal wall

a. blood flows from heart's arterial (left) to venous (right) side or a "left to right shunt" within the
heart itself

b. size of defect will determine severity of condition








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2.


Common types
Increased Pulmonary Blood Flow
1. Atrial Septal
Defect (ASD)
Asymptomatic or mild heart failure (HF):Increased flow of oxygenated
blood into the right heart (systolic murmur)
2. Ventricular
Septal Defect
(VSD)
HF to a degree that depends on the size of defect; murmur: increased
blood volume pumped into the lungs (CHF, bacterial endocarditis)
3. Patent Ductus
Arteriosus (PDA)
Asymptomatic during infancy; mild HF; machinery-like murmur; increased
pulse pressure; dyspnea; bounding rapid pulse on exertion
Decreased Pulmonary Blood Flow
1. Coarctation of
aorta
Increased blood pressure (BP) in head and arms, lower BP in feet & legs;
cooler temperature in both legs; mild HF; occasional increased BP in older
children who complain of headache, dizziness and fainting
Narrowing at the aortic value: children exercise intolerance, chest pain &
dizziness
Narrowing at pulmonary artery: asymptomatic or mild cyanosis-increased
symptoms with greater narrowing
2. Aortic Stenosis
3. Pulmonary
stenosis



Aortic Stenosis Coarctation of aorta

PDA VSD












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ASD



C. Cyanotic defect: infant or child is "blue"

1. Pathology

a. unoxygenated blood mixes with oxygenated, via a "right to left shunt"


b. decreases oxygenation to the entire system

c. results far more severe than acyanotic

d. thrombus formation is always a concern


2. Types
Types with Decreased Pulmonary Blood
Flow
Findings
Tetralogy of Fallot (TOF), VSD,
pulmonic stenosis, overriding aorta,
right ventricular hypertrophy,
tricuspid atresia
Cyanosis, depending on degree of obstruction or of
blood flow from right ventricle; murmur; failure to
thrive clubbing; exertion causes dyspnea and
cyanosis, systolic murmur
Type with Mixed Blood Flow Findings
Transposition of the Great Vessels
(TOGV)
Cyanosis, depending on type and size of associated
defects; cardiomegaly





D. Heart failure

1. Pathology - occurs in infants with severe heart defects

2. Findings

a. cyanosis, pallor

b. rapid respirations, increased respiratory infection
716


c. tachycardia, edema, fatigue

d. feeding difficulties, failure to gain sufficient or adequate weight or "poor weight gain"



E.
Diagnostics

1. EKG: noninvasive, painless, infants and young children may require mild sedation

2. Cardiac catheterization

a. presence of diaper rash may postpone procedure

b. preparation depends on level of growth and development

c. child may have difficulty complying with keeping insertion point in correct position post
procedure



F. General care guidelines for congenital heart defects

1. Provide emotional, physiological, and psychological interventions

2. Assist the child and family to adjust to special needs

3. Reinforce goals

a. child will maintain adequate oxygenation and physiological stability

b. child will attain adequate, growth and development


4. Nursing interventions

a.
recognize finding of heart failure early

b. monitor height, weight, vital signs, pulses, pulse oximeter, intake and output

c. medications

i. digoxin (Lanoxin)

ii. furosemide (Lasix) or chlorothiazide (Diuril)

iii. recognize and treat pain appropriately: pharmacological and nonpharmacological
interventions for age


d. maintain a safe environment

e. conserve child's energy

f. maintain proper nutrition with small, frequent, feedings

g. support and discuss treatment with parents

h. positioning - slanting position with head elevated, older babies in infant seats, occasional
knee-chest (as ordered by care provider)


Cyanotic defects - the 4 T's:

T=Tetralogy of fallot
T=Truncus arteriosus
T=Transportation of the great vessels
T=Tricuspid atresia


II. Pediatric Respiratory

A. Respiratory infections

1. General concepts

a. etiology

i. bacterial, viral

ii. often influenced by age, season, preexisting disorder, living conditions

717


b. findings: increased respiratory and heart rate, fever, nausea and vomiting, nasal discharge
and blockage, thick mucus production, coughing, abnormal lung sounds listen

c. management

i. treatment goals

child exhibits respiratory stability, able to clear secretions, and remains
comfortable with a patent airway

spread of infection to others prevented

child able to ingest adequate fluids and maintain hydration


ii. pharmacologic: possible anti-inflammatory drugs, anti-mucolytic drugs, antipyretics,
bronchodilators, oxygen as needed

iii. chest physiotherapy

iv. nutrition and fluids


d. nursing interventions

i. support prescribed therapies

ii. reinforce child and family teaching regarding:

nutritional needs

importance of fluids

requirements for follow-up care

hand hygiene







B. Upper respiratory tract infections (URI)

1. Etiology: often acute viral nasopharyngitis, or the "common cold"

2. Pathophysiology

a. organism invades mucous membranes

b. edema, vasodilation and mucus production

c. usually self-limiting


3. Findings

a. nasal congestion

b. sneezing

c. nasal discharge

d. low grade fever

e. cough

f. irritability


4. Management

a. pharmacologic: antipyretics, decongestants (oral or nasal), analgesics

b. cool mist humidifier

c. adequate fluids

d. rest


5. Nursing interventions

a. with infants, suction nares routinely with bulb syringe (infants are nasal breathers)

b. reinforce the need for good handwashing
718


c. stress the importance of maintaining fluid balance




C. Tonsillitis

1. Etiology: bacterial, viral (in association with pharyngitis)

2. Pathophysiology

a. dysphagia and difficulty breathing due to infection and inflammation of the tonsils

b. palatine tonsils usually visible during oral exam

c. pharyngeal tonsils are also known as the adenoids


3. Findings

a. "kissing tonsils"

b. sore throat

c. halitosis

d. mouth breathing (evidenced by child snoring at night)

e. fever


4. Diagnostics: history, physical exam, throat culture

5. Management

a. supportive: antibiotics, fluids, rest, antipyretics, analgesics

b. surgery: tonsillectomy (and adenoidectomy) is scheduled

i. with repeated (7 or more) episodes of tonsillitis in one year

ii. if the child has trouble breathing

iii. due to presence of abscesses or growths on the tonsils


c. adenoidectomy may be done with tonsillectomy, if adenoiditis is present


6. Nursing care - post op tonsillectomy

a. assess for frequent swallowing - bleeding may be the cause

b. assess any vomitus

c. place child on side

d. medicate for pain as needed

e. avoid offering fluids with red or brown color or acidic fluids

f. offer soft foods; avoid highly seasoned food

g. reinforce teaching

i. child needs quiet activity

ii. monitor for bleeding, such as indicated by frequent swallowing

iii. antipyretics and analgesics (but no aspirin due to Reyes syndrome)

iv. complete recovery takes 1 to 2 weeks; but no school for at least 7 to 10 days and no
exercise or swimming for 3 weeks








D. Croup syndromes (including laryngitis, tracheitis, epiglottitis)

1. Definition: several airway-blocking infections; common in children

a. findings of croup:
719


i. inspiratory stridor

ii. harsh/brassy cough, barking cough

iii. hoarse voice

iv. respiratory distress


b. types (by primary area affected):

i. subglottal area: acute spasmodic croup, laryngitis, laryngotracheobronchitis (LTB), tracheitis

ii. supraglottal area: epiglottitis



2. Etiology

a. usually viral

b. occasionally bacterial (tracheitis, epiglottitis)

c. younger children with "true croup" (spasmodic croup)

d. older children with tracheitis and epiglottitis


3. Pathophysiology: mucosa inflamed and airway narrowed (due to edema)

4. Findings

a. classic: "barky" harsh cough, stridor, hoarseness, fever, purulent secretions, dyspnea if severe
listen to stridor

b. bacterial: child looks "sicker"

c. epiglottitis manifests the 4 "D's"

i. drooling

ii. dysphagia (difficulty swallowing)

iii. dysphonia (hoarse voice)

iv. distressed inspiratory efforts with chin thrust used to open airway




5. Management

a. viral

i. cool air/mist; fluids

ii. if inpatient, nebulized epinephrine and inhaled steroids

iii. antipyretics


b. bacterial: same as above plus antibiotics, possible intubation

c. concerns: if epiglottitis is suspected, epiglottis should never be visualized using a tongue depressor since it
could precipitate obstruction due to airway spasm

d. epiglottitis is a medical emergency; tracheotomy may be necessary


6. Nursing interventions

a. reinforce teaching to family and child signs of impending airway obstruction

b. promptly report

i. increased pulse

ii. changes in respirations

iii. retractions

iv. increased restlessness


c. maintain fluid balance, since increased respiratory rate results in water loss

E. Bronchiolitis
720


1. Definition: acute infection at the bronchiolar level

2. Etiology

a. viral - respiratory syncytial virus (RSV) most common

b. occasionally bacterial


3. Pathophysiology

a. virus spreads via direct contact

b. enters body via nose or eye

c. leads to edema, mucous accumulation and cellular debris which obstruct bronchioles

d. can progress to atelectasis


4. Findings

a. usually mild upper respiratory infection (initially associated with lower airway infection)

b. sneezing

c. productive cough

d. low-grade fever

e. nasal discharge

f. abnormal lung sounds


5.
Diagnostics

a. history and physical

b. chest x-ray

c. nasal fluid cultures and blood gases


6. Management - depends on severity

a. mild: fluids, humidification, rest

b. severe (pharmacologic): antiviral medications, IV fluids, possibly bronchodilators, steroids
and mechanical ventilation; maintain droplet and possibly contact precautions

c. prophylaxis: respiratory syncytial virus immune globulin in high risk infants


7. Nursing interventions

a. maintain fluid balance

b. monitor for acute respiratory distress

c. reinforce any (droplet/contact) precautions, including hand washing




F. Respiratory distress syndrome (RDS)

1. Definition - disease is mainly caused by a lack of a slippery, protective substance called surfactant,
which helps the lungs inflate with air and keeps the air sacs from collapsing (also called hyaline
membrane disease)

2. Etiology

a. premature infants - usually from surfactant deficiency

b. newborns - birth lack of oxygen (asphyxia), multiple gestations, diabetic mother

c. older children - trauma, drowning



3. Pathophysiology

a. decrease in amount and/or quality of pulmonary surfactant
721


b. in older children, surfactant may be washed out by drowning or fluid aspiration


4. Findings

a. tachypnea with increased respiratory effort

b. paradoxic "seesaw" respirations

c. nasal flaring

d. substernal or intercostal retractions

e. expiratory grunt, possible apnea
Listen

f. cyanosis

g. hypoxia


5.
Diagnostics

a. physical exam

b. laboratory: serum arterial blood gases, glucose, calcium

c. chest x-ray confirmation


6. Management

a. oxygen therapy (possible mechanical ventilation)

b. possible medications: surfactant, prophylactic antibiotics


7. Nursing interventions

a. reinforce child and family teaching

b. assist with activities of daily living for age

c. administer medications as prescribed

d. monitor for changes in respiratory status

e. monitor for apnea




G. Apnea

1. Definition: cessation of breathing for over 20 seconds

2. Etiology

a. prematurity

b. foreign-body aspiration, drowning, or trauma

c. incorrect positioning

d. gastroesophageal reflux

e. infections

f. seizure

g. hypoglycemia


3. Pathophysiology is dependent on type of apnea

a. central: absence of respiratory effort and air movement

b. obstructive: respiratory effort but no air movement

c. mixed: first central, then obstructive


4. Findings

a. depend on type (see above)
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b. color changes, hypotonia


5. DIagnostics: variety of laboratory tests, chest x-ray, electroencephalogram (EEG), EKG,
pneumocardiogram, upper GI series

6. Management


a. home apnea monitoring

b. basic life support (BLS) training to family

c. medications based on type and underlying condition




H. Respiratory failure

1. Definition - inability to maintain adequate oxygenation

2. Findings

a. restlessness, mood changes

b. changes in level of consciousness

i. lethargy

ii. drowsiness

iii. decreased play activity


c. increasing rates of respiration and pulse

d. dyspnea at rest


3. Management

a. observation and physical exams

b. correct hypoxemia, maintain ventilation and deliver oxygen


4. Nursing interventions

a. monitor oxygenation status, pulse oximeter

b. administer oxygen as needed

c. monitor ventilator care, if indicated

d. assist with medication administration




I. Aspiration of Foreign Body

1. Etiology

a. child aspirates solids, liquids, vegetative matter into air passages

b. most common in older infants and children up to three years of age


2. Pathophysiology: most substances become lodged in bronchi

3. Findings: sudden coughing, gagging, wheezing, cyanosis, dyspnea, and stridor


4.
Diagnostics

a. chest x-ray
723


b. fluoroscopy

c. bronchoscopy

d. history


5. Management: direct laryngoscopy or bronchoscopy to remove object, then supportive therapy

6. Nursing interventions

a. have supportive actions toward caregivers of child

b. assist with pre and post procedure care as indicated




J. Asthma/Reactive Airway Disease

1. Definition: a chronic lung disorder marked by recurrent episodes of bronchospasm-related airway
obstruction triggered by hyperreactivity to various stimuli, producing airway narrowing and
tenacious, thick, excess, mucous

2. Etiology


a. genetic predisposition

b. triggers are: allergens, infection, stress, exercise, medical conditions, medications

c. types: intrinsic, extrinsic, occupational


3. Pathophysiology

a. trigger leads to an immediate phase reaction (cell activated, with mast cell, eosinophils and
histamine released with other mediators of inflammation)

b. resulting in bronchoconstriction with additional granulocyte response with more inflammatory
presence

c. later phase reaction (additional inflammation and hyperresponsiveness)

d. bronchospasm and obstruction cause most symptoms

e. one of the most common chronic pediatric health problems


4. Findings

a. classic: hacking cough, wheeze on expirations, dyspnea Listen

b. cough: may be nonproductive at first; later productive with mucus

c. change in level of consciousness: restlessness, irritability, decreased play activity in younger
children


5. Diagnostics

a. physical exam and history

b. pulmonary function tests (PFT), chest x-ray

c. Mantoux skin testing

d. complete blood count with differential

e. allergy testing



6. Management
724


a. goals: normal growth and development, patent airway, good control

b. preventive: allergen control and avoidance

c. use of peak flow meter

d. medications

i. long term control (preventer) medications: to achieve and maintain control of inflammation;
also called controllers

corticosteroids - anti-inflammatory

cromolyn sodium - nonsteroidal anti-inflammatory

nedocromil - anti-allergic and anti-inflammatory

long acting beta adrenergics (Albuterol) used for acute exacerbations

methylxanthines (theophylline) bronchodilator

leukotriene modifiers (Zileuton) - mediator of inflammation


ii. quick relief (rescue) medications to treat acute symptoms and exacerbations

short acting beta adrenergics

anticholinergics

systemic corticosteroids


iii. acute management

pharmacologic

bronchodilators

steroids (inhaled, IV and/or oral)

oxygen

IV fluids

possibility of intubation




7. Nursing Interventions

a. monitor child for respiratory distress and/or need for nebulizer treatments

b. place semi- to high-Fowler's position

c. stay with child if at all possible - have parent stay during acute phase of illness

d. monitor fluid volume status

e. teaching points

i. child and family must comply with medications and treatments

ii. correct use of metered-dose inhaler (MDI) with a spacer

iii. risks include overuse of bronchodilators

iv. teach parents and child about peak flow meter usage for self-evaluation




8. Complications

a. exercise-induced bronchospasm: acute and reversible, usually stop in 20 to 30 minutes

b. status asthmaticus: an emergency situation


More information about asthma can be found in Lesson 8B - Respiratory.


K. Cystic fibrosis (CF)

1. Definition: an inherited disease that causes the body to produce abnormally thick and sticky
725

mucus

2. Etiology


a. due to an inherited autosomal recessive trait

b. thick, sticky mucus builds up in the lungs and digestive tract (particularly the pancreas)


3. Pathophysiology

a. mucous glands produce a thick mucoprotein that accumulates instead of a thin freely flowing
secretion

b. results in life-threatening lung infections and serious digestion problems

c. affects respiratory, gastrointestinal and (male) reproductive systems; also may affect the
sweat glands


4. Findings

a. gastrointestinal

i. meconium ileus

ii. steatorrhea

iii. prolapse of rectum

iv. failure to grow


b. respiratory

i. thick tenacious mucus causes patchy atelectasis cough

ii. barrel-shaped chest

iii. clubbing of fingers and toes




5.
Diagnostics

a. laboratory tests

i. sweat chloride test - standard diagnostic test for CF (high levels of sodium and chloride in the
patient's sweat is a sign of the disease)

ii. immunoreactive trypsinogen (IRT) test - standard newborn screening test for CF (high level of
IRT suggests possible CF and requires further testing)

iii. stool analysis


b. lung function tests

c. chest x-ray or CT scan - patchy atelectasis

d. possibly also upper GI and small bowel series


6. Management

a. chest physiotherapy

b. pharmacologic

i. bronchodilators

ii. antibiotics (for Pseudomonas aeruginosa, Burkholderia cepacia, and Staphylococcus aureus)
726


iii. DNase enzyme replacement therapy - decreases viscosity of mucus, making it easier to cough
up


c.
high protein, high caloric diet for older children and adults; vitamin supplements, especially A,
D, E, and K should be added

d. yearly flu vaccine and pneumococcal polysaccharide vaccine (PPV)


7. Nursing interventions - family teaching

a. clearing or bringing up mucus or secretion should be done 1 to 4 times each day

b. drink plenty of fluids

c. avoid smoke, dust, dirt, fumes, household chemicals, mold and mildew

d. exercise 2 to 3 times each week, especially swimming, jogging or cycling; avoid contact or
endurance sports



III. Pediatric Neurology

A. Increased intracranial pressure (ICP)

1. Etiology

a. aneurysm rupture and subarachnoid hemorrhage

b. brain tumor

c. head injury

d. subdural hematoma

e. infection, including encephalitis, meningitis

f. hydrocephalus

g. status epilepticus


2. Pathophysiology: swelling caused by irritation or bleeding into brain tissue

3. Findings

a. infant: bulging fontanels, widened cranial sutures, high-pitched crying, irritable

b. child: headache, nausea, vomiting, lethargy, diplopia, seizures



4.
Diagnostics : computerized tomography, magnetic resonance imaging

5. Management

a. pharmacologic: osmotic diuretics, antihypertensives, anti-seizure

b. maintain airway - oxygen and even mechanical ventilation may be needed

c. minimize external stimuli


6. Nursing care

a. assess and monitor level of consciousness, pupillary reaction, vital signs
727


b. cluster care to allow periods of rest

c. may not bathe child if ICP is unstable

d. raise head of bed; keep infant seat or toddler in secured car seat in the bed

e. support family





B. Hydrocephalus

1. Definition - excess amounts of cerebro-spinal fluid (CSF) within the brain due to blockage of
drainage of CSF


2. Etiology: congenital, acquired, or idiopathic

3. Pathophysiology: depends on type

a. communicating: impaired absorption of CSF within the subarachnoid space

b. non-communicating: obstruction of the flow of CSF through the ventricular system


4. Findings: increased intracranial pressure (ICP)

a. infant

i. bulging fontanels, increased head circumference

ii. "setting sun" eyes, pupils slow to constrict to light

iii. eats poorly

iv. high-pitched cry

v. variable pulse, changes in respirations


b. older child

i. headaches

ii. dizziness

iii. vomiting

iv. diplopia

v. ataxia

vi. decreased play activity



5. Diagnostics : computerized tomography, magnetic resonance imaging (sedation may be
required)

6. Management

a. surgical placement of shunt in neonates, infants, and older children

b. measure head circumference - more frequent in acute phase
728




7. Nursing care

a. monitor neurological and vital signs

b. observe for abdominal distention for possible catheter complications, including obstruction

c. monitor fluid volume status

d. monitor head circumference

e. keep diaper off perineal dressing




C. Neural tube defects (NTDs)

1. Anencephaly

a. most serious

b. both cerebral hemispheres are absent

c. condition is incompatible with life (beyond a few days)


2. Spina bifida (SB): incomplete closure of vertebrae and neural tube


a. etiology: unknown


b. pathophysiology

i. spina bifida occulta: defect not visible externally

ii. spina bifida cystica: visible defect with an external sack-like protrusion

meningocele: encases meninges and spinal fluid but no nerves; no neurological
deficit

meningomyelocele: contains meninges, spinal fluid, and nerves; varying
neurological deficit



c. findings vary widely according to degree of spinal defect

d. diagnostics

i. physical exam

ii. MRI; ultrasound; CT- myelography

iii.
complete blood count (white blood cells)

729


e. management

i. initial care

protect sac from rupturing or drying out

moist sterile non-adherent dressing

fluids - on demand

positioning - side-lying, usually bed is flat

early surgical closure of lesion


ii. long term

protect skin integrity

maintain bladder and bowel function

support musculoskeletal integrity


iii. complications

hydrocephalus after surgical repair; may require shunt

meningitis

urinary tract infection

pneumonia






D. Cerebral palsy (CP)

1. Definition: disorders characterized by early onset and impaired movement and posture; non-
progressive - missed developmental milestones

2. Etiology

a. disorders characterized by early onset and impaired movement and posture; non-progressive

b. cause: abnormality in extrapyramidal or pyramidal motor system (cortex, basal ganglia,
cerebellum)

c. can occur prenatally, perinatally, or postnatally

d. may be accompanied by perceptual problems, language deficits and intellectual involvement


3. Pathophysiology

a. classifications: athetoid, spastic, ataxic, mixed

b. associated defects: mental retardation and cognitive impairment, hearing or visual losses,
attention deficit disorder (ADD)

c. high metabolic rate, leading to increased calorie expenditure


4. Findings

a. primary disturbances: abnormal muscle tone and coordination

b. spastic movement in one or more extremity

c. athetoid movements

d. primitive reflexes persist

e. disturbances in gait, abnormal posture

f. impairments in speech and swallowing


5.
Diagnostics : physical exam, EEG, computerized tomography

6. Management

a. physiological: nutrition, musculoskeletal, respiratory, integumentary
730


b. cognitive: evaluation with supportive actions for development to maximum potential


7. Nursing care

a. range of motion exercises

b. incorporate play into treatment




E. Down syndrome (trisomy 21)

1. Etiology: extra group G chromosome, chromosome 21, associated with late maternal age

2. Pathophysiology: depends on which region of chromosome 21 was altered

a. distinctive facial features

b. heart defects

c. mental retardation (varies from severe retardation to low average intelligence)

d. dermatologic changes

e. incomplete embryogenesis


3. Findings

a. facial features

i. brachycephalic

ii. flat occiput

iii. protruding tongue

v. high-arch palate


b. body features

i. short, broad hands with simian crease

ii. short, broad neck

iii. dry skin

iv. large space between great toe and second toe



4. Management

a. supportive: specific to body system affected

b. promotion of developmental progress

c. cognitive - evaluate with support for maximum development


Simian Crease Palpebral Slant Macroglossia





F. Reye's syndrome - toxic encephalopathy

1. Etiology: seen in children under age 18 after an acute viral infection, associated with increased
use of aspirin

2. Pathophysiology: acute noninflammatory encephalopathy and hepatopathy
731


3. Findings

a. related to cerebral edema and fatty changes in liver

b. viral upper respiratory infection

c. fever

d. severe nausea and vomiting

e. profoundly impaired consciousness

f. coma


4. Diagnostics

a. history and physical

b.
ammonia levels

c.
liver biopsy


5. Management

a. supportive: dependent on body system affected

b. aspirin and other products with salicylates should not be used for any reason in treating
children with viral infections such as influenza or varicella disease


6. Nursing care

a. monitor neurologic and vital signs

b. monitor fluid volume status



IV. Pediatric Endocrinology

A. Hypothyroidism

1. Definition: deficiency of thyroid hormone (TH); a more common childhood endocrine
disorder

2. Etiology

a. congenital or acquired deficiency in thyroid hormones

b. thyroid irradiation


3. Pathophysiology

a. absent or underdeveloped thyroid glands

b. decreased triiodothyronine (T
3
) or thyroxine (T
4
)


4. Diagnostics

a. history and physical

b. increased TSH

c. decreased serum T
3
and T
4


d. anemia

e. decreased basal metabolic rate (BMR)

f. increased cholesterol and triglycerides

g. hypoglycemia


5. Findings: insidious at the onset, depend on extent of dysfunction and age of child at onset

a. lethargy, constipation, feeding problems

b. dry skin, weight gain, puffy eyes, sparse hair

c. intolerance to cold
732


d. slowed growth, developmental delay and/or retardation if T
4
low at birth and thyroid
replacement not started

e. if findings develop after 2 to 3 years of age, when brain has grown, less risk of mental
retardation


6. Management

a.
lifelong hormone replacement - levothyroxine (levothyroid)

b. rest

c. protect client from cold until metabolism is stabilized


7. Nursing interventions

a. allow rest periods or cluster care

b. assist with monitoring response to hormone replacement therapy

c. reinforce teaching to caregivers

i. not to change brands of medication or from generic to brand name

ii. have child take in morning on an empty stomach for 6 to 8 ounces of water

iii. report findings of hypo- or hyper-thyroidism






B. Hyperthyroidism & Graves disease

1. Definition: hypersecretion of thyroid hormones, causing increased BMR, toxic nodular goiter, or
hyperactivity of thyroid gland


2. Etiology: autoimmune response to thyroid-stimulating hormone (TSH) receptors

a. possible genetic component

b. Graves disease is the most common cause of hyperthyroidism in pediatric clients


3. Diagnostics

a. history and physical

b. palpable thyroid enlargement (goiter)

c.
laboratory

i. serum T3and T4 levels - elevated

ii. radioactive iodine uptake - elevated

iii. presence of thyroid antibodies

iv. TSH levels - decreased



733

4. Findings

a. increased BMR, appetite, nervousness, heart rate, palpitations

b. gradual weight loss despite voracious appetite

c. lowered tolerance to heat

d. exophthalmos or hyperthyroid stare (infrequent blinking)

e. myopathy

f. personality changes, poor school performance, mood instability

g. linear growth and bone age accelerated

h. insomnia

i. increased blood pressure


5. Management

a. antithyroid therapy

b. surgery - subtotal or total thyroidectomy


6. Nursing interventions

a. observe behavior before and after medication administration

b. listen to voice quality after surgery

c. quiet, non-stimulating environment

d. administer moisturizing eye drops for child with exophthalmos


7. Concern - thyrotoxicosis or "thyroid storm" from sudden release of hormone

a. mortality risk is nearly 100%

b. findings

i. acute onset of severe irritability

ii. vomiting

iii. diarrhea

iv. hyperthermia

v. severe hypertension

vi. tachycardia

vii. prostration, absolute exhaustion


c. treatment

i. propranolol (Inderal) - to diminish clinical findings

ii. potassium iodine (Thyro-Block) - to destroy thyroid tissue

iii. antithyroid drugs

iv. treatment cooling blanket - to bring down temperature more quickly





C. "Precocious puberty"

1. Definition: unusually early activation of maturation process that is considered normal later in life;
manifestations of sexual development before age nine in boys or age eight in girls

2. Etiology: brain lesions, inflammatory disorders, idiopathic, adrenal disorders

3. Pathophysiology

a. premature activation of hypothalamic-pituitary-gonadal axis

b. early increased release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH)
734


c. early acceleration of linear growth with early closure of growth plates

d. ultimate height less than if puberty had been normal


4. Findings - occurs most often in girls

a. development of breasts in prepubertal females

b. early development of sexual hair

c. isolated menses

d. development of secondary sex characteristics


5. Management

a. directed toward specific cause

b. hypothalamic-pituitary origin: luteinizing hormone-releasing hormone (LHRH) monthly
injections


6. Nursing interventions

a. provide support and guidance to parents and child

b. child may be embarrassed

c. assign nurse that is the same sex as child

d. early identification of affected child


7. Teaching points

a. long-term problem

b. after puberty, child will be the same as peers




D. Diabetes mellitus - type 1

1. Definition: deficiency of hormone insulin; most common endocrine disorder of childhood


2. Etiology: genetic, autoimmune response; usually with trigger factors of virus, bacterium or
possible chemical irritant

3. Pathophysiology:

a. trigger directs islet cell antibodies against cell surfaces

b. antibodies destroy the insulin-secreting beta cells

c. less insulin means glucose is blocked from intracellular space, hence from blood

d. when glucose level exceeds kidney's threshold (about 180 mg/dL), result is hyperglycemia

e. kidney then "spills" glucose into urine, producing osmotic diuresis

f. starved for glucose, body instead breaks down fats, producing ketones


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4. Findings

a. hyperglycemia:

i. the three "polys" of diabetes: polydipsia, polyuria, polyphagia

ii. additional findings: fatigue, hunger, weight loss, enuresis, weakness, dehydration



5. Diagnostics

a. oral glucose tolerance test

b. glycosylated hemoglobin (HbA1c) reflects average blood glucose levels for past 2 to 3 months

c. fasting blood glucose

d. urine tests for presence of ketones and/or glucose



6. Management

a.
pharmacologic

i. insulin injections

ii. insulin pump


b.
diet - aimed at maintaining stable body weight for age

c. activity

d.
laboratory: blood glucose monitoring, Hgb A
1C



7. Complications:

a. DKA (diabetic ketoacidosis) or extreme hyperglycemia (blood sugar greater than 350 mg/dL)

i. etiology: not enough insulin

ii. findings

fruity breath

sudden decreased level of consciousness, lethargy, drowsiness

nausea/vomiting, abdominal pain

increased urine output

Kussmaul's breathing


iii. management

regular insulin, drips initially, and then subcutaneous - short or intermediate acting

frequent monitoring of blood glucose

frequent monitoring of electrolytes, fluid balance, and neuro checks



b. hypoglycemia:

i. etiology: most common occurrence of insulin therapy and bursts of physical activity, without
additional food, or with missed meals

ii. findings

nervousness, irritability - note: in children with sudden drops in glucose, they may
initially have lethargy or drowsiness

fatigue

pallor

sweating

palpitations

hunger

loss of coordination
736


seizures

coma


iii. management:

by mouth: 10 to 15 mg of simple carbohydrate, four ounces of regular soda, juice, or
milk

followed by complex carbohydrate such as slice of bread, crackers, cheese, or
peanut butter to prevent rebound hypoglycemia

occasionally glucagon injection is prescribed




8. Nursing care

a. assess child frequently of neurologic and vital signs

b. blood glucose levels

c. administer insulin as ordered

d. support child's family



V. Pediatric Gastrointestinal

A. Dehydration

1. Occurs when total output of fluid exceeds total intake

2. Compared to adults, children

a. are less able to concentrate urine

b. have immature kidney and immune-regulatory systems, especially during infancy

c. have a higher metabolic rate

d. have more body surface in relation to body mass

e. need more fluid and lose more urine per kilogram of body weight because more of body
weight is fluid


3. Types of dehydration (serum sodium determines type)

a. isotonic: occurs in conditions in which electrolyte and water deficits occur in balanced
proportions

b. hypotonic: occurs in conditions in which electrolyte deficit exceeds the water deficit

c. hypertonic: occurs in conditions in which water loss exceeds electrolyte loss


4. Findings
Level of Dehydration Mild Moderate Severe
Fluid loss 3-5 percent 6 to 10 percent Greater than 10
percent
Mucous
membranes
Normal Very Dry Parched
Urine output Decreased Oliguria Marked oliguria
Turgor Decreased Poor Very Poor
Pulse Normal Increased Rapid, thready
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Blood pressure Normal Normal or
decreased
Orthostatic
Color Pale Gray Mottled
Capillary filling
time
Greater than 2
seconds
2 to 3 seconds More than 4 seconds



5. Pathophysiology

a. decreased fluids and electrolytes from extracellular fluid (ECF)

b. leads to eventual loss of fluid from intracellular fluid (ICF)

c. cellular dysfunction, shock


6. Complications

a. fluid losses: monitor urine output, in children 1 mL/kg/hour, and specific gravity

b. electrolyte losses: monitor sodium, potassium, chloride, calcium

c. acid-base disturbance: metabolic acidosis





B. Vomiting

1. Definition: forceful ejection of gastric contents through the mouth

2. Etiology: infection, obstruction, allergy, psychological causes, motion sickness, neurologic lesions,
food poisoning

3. Pathophysiology

a. cause stimulates emetic center of brain

b. mechanism of vomiting involves autonomic nervous system:

i. salivation, sweating

ii. pallor, increased heart rate

iii. contraction of stomach and duodenum


c. types of vomiting: regurgitation, forceful, projectile


4. Management

a. detect and treat the underlying cause

b. prevent dehydration, electrolyte loss and acid-base disturbance

c. anti-emetic medications


5. Nursing care

a. assess vomitus

b. assess child for dehydration

c.
keep child NPO

d. position child to avoid aspiration when vomiting

e. assist child to rinse mouth after vomiting

f. be aware of developmental stages - toddlers and preschoolers may become very upset when
vomiting because they are incapable of understanding and they "don't know what to do"



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C. Tracheoesophageal fistula (TEF) and esophageal atresia (EA)

1. Definition: failure of esophagus to develop as a continuous passage and a failure of the trachea
and esophagus to separate into distinct structures


2. Etiology: congenital, idiopathic, VATER syndrome (combination of vertebral, anorectal, and renal
abnormalities in addition to TEF)

3. Findings - in infants

a. coughing

b. cyanosis with feeds

c. increased oral secretions

d. depend on type of defect


4.
Diagnostics : history, abdominal x-rays

5. Management

a. preop: airway patency, NPO, IV therapy, positioning

b. prevention of aspiration pneumonia

c. surgery


6. Nursing care

a. position head of crib elevated 30 degrees

b. tube feedings begun when tolerated; care for gastrostomy tube




D. Pyloric stenosis

1. Etiology

a. unknown cause

b. hypertrophy, hyperplasia of circular muscles of pylorus



2. Pathophysiology

a. trigger irritates mucoid lining of pylorus; edema
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b. narrowed pylorus resists passing of fluid; chyme

c. pylorus then enlarges and contracts with more force to attempt gastric emptying

d. slowly pylorus constricts, and resistance persists until next cycle


3. Findings

a. usually begins at 2 to 4 weeks of age

b. progressive, projectile, nonbilious vomiting after eating

c. metabolic alkalosis - with severe persistent vomiting

d. movable, palpable, firm, olive-shaped mass in right upper abdominal quadrant

e. irritability, crying, hunger

f. takes feedings eagerly


4.
Diagnostics : history, abdominal x-ray, upper GI, ultrasound

5. Management - surgery (pyloromyotomy)

a. preop: IV fluids to prevent shock, may order thickened feedings with caution

b. postop: small, frequent feedings initially with Pedialyte, gradually increasing in include milk


6. Nursing care

a. pre-op: document vomiting episodes and stools; position child flat or slightly elevated

b. post-op: monitor for vomiting


7. Concerns: fluid and electrolyte imbalances, threats to airway, inadequate nutrition



E. Constipation

1. Definition: infrequent passage of firm or hard stools

2. Etiology

a. triggered by diet, medication, dehydration, emotions, neurogenic , or lack of regular daily
activity

b. structural disorders (Hirschsprung's disease) - has ribbon-like stools

c. systemic disorders such as hypothyroidism


3. Findings

a. abdominal pain and cramping

b. palpable, movable fecal mass

c. malaise, anorexia, nausea


4. Diagnostics : history, abdominal x-rays, rectal exam, palpation and percussion

5. Management

a. prevention - higher fiber diet, fluids, regular exercise, regular toileting habits

b.
pharmacologic: stool softeners, enemas, laxatives

c. counseling in emotions involved


6. Nursing care

a.
provide dietary modifications that promote bowel elimination appropriate for age

b. assess and record pattern of bowel elimination



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F. Diarrhea

1. Etiology

a. intestinal infections (bacterial, viral, parasitic); colon disease

b. food intolerance; food poisoning; overfeeding; malabsorption

c. medications

d. stress


2. Pathophysiology:

a. causative factor - irritates mucosal lining

b. damages microvilli, increases secretion and decreases absorption

c. abnormal intestinal water and electrolyte transport

d. increased intestinal water permeability with dehydration in younger children

e. can be acute or chronic


3. Findings

a. dehydration (mild, moderate, severe)

b. increased stooling

c. increased heart and respiratory rate

d. dry, hot skin

e. dry mucous membranes

f. decreased urine, decreased tearing or sunken anterior fontanel in infants


4. Management

a. goals are to restore fluid and electrolyte balance and return bowel to normal functioning

b. fluids: oral rehydration with electrolyte solutions as Pedialyte or parenteral rehydration

c. medications: antibiotics, antidiarrheals (based on cause)

d. education - if associated with food poisoning



When assessing diarrhea or constipation, remember the acronym ACCT:
A= amount
C= color
C= consistency
T= time (duration)


G. Celiac disease (gluten-sensitive enteropathy or celiac sprue)

1. Definition: a chronic condition, triggered by consumption of the protein gluten, that damages the
small intestine and interferes with the absorption of nutrients

2. Etiology: absorption problem with genetic predisposition, possibly immune abnormality

a. runs in families and has a genetic basis

b. gluten is found in the grain of wheat, barley, rye, and oats

c. becoming more frequent in middle age and elderly populations


3. Pathophysiology: inability to absorb the gliadin portion of gluten (results in the gliadin triggering
an immune response that damages the intestinal mucosa)

a. increasing levels of glutamine in the intestine - toxic to mucosal cells

b. atrophy of villi and decreased absorptive surface

c. malabsorption of fats, carbohydrates, vitamins and electrolytes

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4. Findings (most often appears between ages of 1 and 5 years)

a. stools - large, bulky, and frothy

b. abdominal distention

c. failure to thrive

d. vomiting

e. muscle wasting (atrophy of buttocks)

f. anorexia

g. abdominal pain


5.
Diagnostics :

a. history (findings occur 3 to 6 months after infant begins eating grains)

b. serum anti-gliadin antibody (AGA)

c. jejunal biopsy


6. Management

a. diet: gluten-free - no wheat, barley, rye, or oat products - with vitamin supplements; may
eat rice, corn, and millet products

b. Celiac crisis: IV fluids, steroids, electrolyte replacement


7. Nursing care

a. monitor tolerance of new diet and weight gain

b. record episodes of diarrhea




H. Intussusception

1. Definition: the slipping of a length of intestine into an adjacent portion, usually producing an
obstruction

2. Etiology: unknown; one of the most frequent causes of intestinal obstruction between ages of 3
months and 5 years


3. Pathophysiology

a. trigger - bowel "telescopes" inside itself causing obstruction

b. pressure on bowel leads to bleeding

c. possible mesenteric ischemia

d. edema and possible bowel necrosis, perforation, peritonitis, or shock

e. may affect small or large intestine

f. most common site: ileocecal valve area

4. Findings
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a. sudden acute abdominal pain

b. vomiting (green/yellow)

c. currant jelly stools

d. sausage-shaped abdominal mass over site affected

e. lethargy

f. high fever



5. Diagnostics : barium enema, abdominal x-ray, rectal exam reveals mucus and blood


6. Management

a. priority goals are to restore bowel to normal position and function as quickly as possible, and
stabilize fluids

b. non-surgical approach, sometimes with barium

c. surgery


7. Nursing care

a. monitor fluid status

b. assess pain

c. monitor for barium excretion and passage of brown stool (indicates intussusception has
resolved)




I. Hirschsprung's disease

1. Definition and etiology: congenital aganglionic megacolon

2. Pathophysiology

a. absence of autonomic (parasympathetic) ganglion cells, usually at rectum and part of large
intestine

b. intestine does not propel stool

c. stool builds up; colon dilates, constipation results with risk of intestinal rupture


3. Findings

a. newborn: failure to pass stool first 24 hours of life; reluctance to ingest fluids; bile-stained
vomitus; distended abdomen; "ribbon-like" stools that are flat, wide, and wavy

b. later: failure to thrive, distended abdomen, constipation, signs of fecal impaction


4. Diagnostics : history and physical exam, radiographic barium enema, rectal biopsy, anorectal
manometry
5. Management
743


a. surgical correction: remove aganglionic portion

b. temporary ostomy for 3 to 6 months, then reanastomose



6. Nursing care

a. monitor fluid status

b. assess pain

c. monitor for barium excretion and passage of brown stool that indicates intussusception has
resolved

d. reinforce teaching about colostomy care



Associate Hirschsprung's with a girl ("her") who wears "ribbons" in her hair - to recall that "ribbon-like"
stools are a classic finding of this disease.


J. Appendicitis

1. Definition: inflammation of vermiform appendix (blind sac at end of cecum)

2. Etiology:

a. virus, impacted fecal material, parasites, foreign body

b. most common in children school age or older



3. Findings

a. colicky abdominal pain

i. generalized but usually descends to lower right quadrant

ii. most intense pain at McBurney's point


b. nausea, vomiting, anorexia

c. possible fever and chills

d. decreased bowel sounds

e. guarding of abdomen

f. rebound tenderness

g. dull pain around umbilicus


4.
Diagnostics
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a. physical exam

b. laboratory: complete blood count - WBC elevated

c.
urinalysis - to rule out UTI, urinary incontinence, or pregnancy

d. MRI


5. Management

a. surgical removal of appendix

i. by laparoscopy if not ruptured

ii. by lower abdominal incision


b. pharmacologic: antibiotics, analgesics, IV fluids


6. Nursing care

a. monitor IV fluids

b. diet advanced gradually as tolerated and as prescribed, when bowel sounds return

c. do not give enemas or cathartics or use heating pad if suspected appendicitis

d. if appendix ruptures, postoperative incision may be open and packed, which will require more
intense dressing changes




VI. Pediatric Genitourinary

A. Urinary tract infection

1. Definition

a. bacteria in urine and inflammatory response

b. may involve any structure in urinary system: kidney (pyelonephritis), ureters, bladder
(cystitis) or urethra

c. findings will point to location

d. peak age: toddler to preschool age


2. Etiology

a. bacterial (E coli in most cases)

b. structural (such as a malformed kidney) or functional (such as VUR) defect of the urinary
system

c. extrinsic, e.g., Foley catheter, medications

d. improper perineal hygiene

e. irritants, e.g., use of bubble baths or strong soaps, tight-fitting nylon underwear, caffeine


3. Pathophysiology

a. organism usually ascends through urethra to bladder

b. with a structural defect, urine flows back from ureters into kidney


4. Findings often depend on age

a. under 2 years: often nonspecific resembling GI disturbance

i. failure to thrive, feeding problems, nausea and vomiting, anorexia

ii. dysuria, persistent diaper rash, abdominal distention


b. over 2 years:

i. enuresis, daytime incontinence in toilet-trained child, foul smelling urine

ii. frequency and urgency, dysuria
745


iii. possible pyelonephritis: similar signs but with fever, back pain, and lethargy



5.
Diagnostics

a. laboratory: urine culture, CBC

b. x-rays (such as a voiding cystourethrogram), ultrasound


6. Management

a.
pharmacologic: antimicrobials, antipyretics, analgesics

b. fluids - oral, or IV if dehydration is severe


7. Nursing care

a. careful history

b. check diaper every half-hour

c. provide adequate or increased fluid intake

d. monitor for irritability

e. reinforce teaching points

i. hygiene: wipe front-to-back for girls

ii. do not delay urination

iii. if child is maintained on daily low dose antibiotics, giving dose at bedtime allows
medications to remain in bladder overnight






B. Enuresis (nocturnal or "bed wetting')

1. Definition: intentional or involuntary passage of urine , when the child is beyond the age when
bladder control should be normally acquired (occur twice a week for 3 months age is older than 5
years); nocturnal, or "bed wetting" during sleep, very common - More common in boys

2. Etiology and findings: in most instances there is no organic basis for persistent enuresis

a. primary: never dry at night or during sleep, and due to CNS or psychological reasons

b. secondary: child has been toilet trained and becomes incontinent again; findings (as with UTI)
due to infection, medications, trauma


3.
Diagnostics : history, urine tests, serum culture

4. Management

a. primary

i. have the child participate in activities for urination control

ii. limit fluid in evening before bedtime

iii. have child void before bedtime

iv. imagery, behavioral conditioning

v.
pharmacologic

tricyclic antidepressant; imipramine

desmopressin (DDAVP)



b. secondary: treat underlying cause


5. Nursing care

a. reinforce that parents should not punish child if enuresis occurs

b. reinforce teaching plan


746



C. Vesicoureteral reflux (VUR)

1. Definition: retrograde flow of bladder urine into the ureters

2. Etiology

a. primary (congenital anomaly)

b. secondary (acquired, usually associated with urinary tract infection)


3. Pathophysiology

a. bladder reflux

b. residual urine from ureters remains in bladder until next void

c. increases chance for and perpetuates infection

d. vesicoureteral reflux grading system: grade I - V


4. Findings: UTI with chronic signs and recurrences

5.
Diagnostics

a. radiographic studies

b. voiding cystourethrogram

c. urine culture


6. Management

a.
medications: low-dose antibiotics for grades I - IV include

b. surgery for severe cases (grades IV or V)


7. Nursing care

a. adequate or increased fluid intake

b. usual post-op care if child has surgery

c. monitor I & O

d. reinforce teaching - all children in family should be screened for possible reflux




D. Acute glomerulonephritis (AGN)

1. Definition: immune complex disease that occurs after a streptococcal infection (Beta-hemolytic
streptococci)

2. Etiology

a. acute bacterial infection associated with strep infections of pharyngitis and impetigo

b. underlying systemic disorder


3. Pathophysiology

a. infection, usually Group A beta-hemolytic Streptococcus, provokes immune complex response

b. onset appears after latent period of about 10 to 15 days


4. Findings

a. oliguria

b. edema (periorbital and peripheral)

c. hematuria ("smoky" or "tea-colored" urine)

d. mild hypertension

e. lethargy

f. moderate proteinuria
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g. loss of appetite


5.
Diagnostics

a.
laboratory

i. urine testing

ii. serum studies - antibody, complement, C-reactive protein, erythrocyte sedimentation rate,
WBC

iii. throat culture


b. history of antecedent strep infection


6. Management

a. no specific treatments - recovery spontaneous and uneventful in most cases

b. supportive with careful regulation of fluid balance; I & O, daily weights

c.
pharmacologic: antihypertensives, if needed

d. possible diuretic nutrition - low in sodium, protein, potassium


7. Nursing care

a. monitor vital signs, fluid balance, and behavior

b. assess child's appearance; check for signs of edema

c. possible institution of seizure precautions if indicated

d. possible fluid restriction

e. provide frequent rest periods




E. Chronic nephrosis or nephrotic syndrome

1. Massive proteinuria, hypoalbuminemia, hyperlipemia and edema

2. Etiology: not fully understood

3. Pathophysiology

a. glomerular alteration and increased permeability to plasma proteins, especially albumin

b. plasma protein losses; increased presence in urine, decrease plasma volume, colloidal osmotic
pressure in capillaries decreases

c. hydrostatic pressure is greater than colloidal osmotic pressure resulting in fluid accumulation
in interstitial spaces and body cavities

d. shift in plasma fluid leads to hypovolemia

e. hypovolemia - triggers kidneys to produce renin and angiotensin, which stimulates the release
of aldosterone and increases the reabsorption of water and sodium

f. aldosterone increases

g. decreased blood pressure also causes release of ADH leading to increase in water absorption


4. Findings

a. progressive weight gain

b. puffiness of face

c. generalized edema (insidious)

d. periorbital edema

e. loss of appetite

f. oliguria
748


g. lethargy

h. pallor


5.
Diagnostics

a. history and physical

b.
laboratory

i. urine tests - massive proteinuria

ii. BUN and creatinine - elevated

iii. antistreptolysin O (ASLO) titer - to detect group A beta-hemolytic streptococci infection



6. Management: mainly supportive

a.
diet - limit sodium, but high potassium and protein

b.
medications: corticosteroids, immunosuppressants, diuretics


7. Nursing care

a. monitor vital signs

b. monitor intake and output; assess volume and character of urine

c. monitor weight

d. restrict fluid intake

e. seizure precautions if appropriate

f. activity should increase as protein in the urine decreases

g. place child in semi-Fowler's or Fowler's position to treat periorbital edema




F. Wilms' tumor

1. Definition: rare type of kidney cancer; a nephroblastoma


2. Etiology

a. probably arises from malignant undifferentiated cluster of cells

b. can occur on both kidneys, but usually affects just one

c. highest survival rate of all pediatric malignancies

d. the most common malignant tumor of the kidneys in children

e. occurs around ages 3 to 4


3. Pathophysiology - cells regenerate an abdominal structure; impaired renal function

4. Findings

a. abdominal mass or swelling - firm, nontender

b. fatigue, malaise

c. respiratory findings if metastasis

749


5. Diagnostics

a. chest x-ray

b. unilateral abdominal x-rays

c.
laboratory tests, including complete blood count


6. Management

a. surgical removal

b. radiation and possible chemotherapy

c. antibiotics: actinomycin D


7. Nursing interventions

a. pre-op: post signs on bed "do not palpate abdomen"

b. post-op: assess BP, pulmonary status and remaining kidney function - strict intake and output

c. teaching points

i. support family

ii. child should avoid contact sports

iii. findings of infection





G. Cryptorchidism

1. Definition: failure of one or both testes to descend normally through inguinal canal into scrotum

2. Etiology and pathophysiology

a. abnormal testes, or

b. decrease in the hormonal stimulation necessary for descent


3. Management

a. wait up to one year for descent

b. medications (hCG) to assist in descent

c. surgery (orchiopexy)




H. Hypospadias

1. Definition: urethral meatus below normal placement on glans penis or any where along ventral
(underside) surface of penile shaft

2. Etiology: idiopathic - related to genetics, environment, hormonal influences

3. Pathophysiology: incomplete development in utero

4. Management: surgical correction (with urinary catheter and stents postop)

5. Concerns: stenosis, chordee, body image and self esteem



I. Ambiguous genitalia

1. Etiology: abnormalities in chromosomes, embryogenesis, or hormones

2. Pathophysiology: interruption in normal development around seven to eight weeks gestation,
when normally male begins differentiating from female

3. Diagnosis

a. history and physical exam

b. tests to determine gender, e.g., endoscopy, ultrasound, radiographic contrast; genetics lab
test; laparotomy; biopsy

750


4. Management: surgery

5. Concerns: body image and self esteem, family support



J. Bladder exstrophy

1. Definition: a congenital malformation of the bladder in which the normally internal mucosa of the
organ lies exposed on the abdominal wall

2. Etiology: congenital - associated with genital abnormalities

3. Pathophysiology

a. failure of abdominal wall and underlying structures, including the ventral wall of the bladder,
to fuse in utero

b. bladder develops outside

c. the earlier in gestation, the more severe the defect

d. defect almost always associated with epispadias (urethra opens upon the upper surface of the
penis)

e. often associated with other birth defects


4. Management: surgeries

a. two surgeries - one to repair the bladder and another to attach the pelvic bones to each other;
may need third surgery to repair any bowel defect

b. treatment objectives

i. preservation of renal function

ii. attainment of urinary control

iii. adequate reconstructive repair

iv. preservation of optimum sexual function


c. pre-op: prevent organs from drying out, fluids, infection control

d. post-op: antibiotics, compression bandage and/or lower body cast or sling (4-6 weeks), bed
rest




VII. Pediatric Musculoskeletal System

A. Children's musculoskeletal differences

1. Bones are more pliable and porous; bend, buckle, absorb shock

2. Tendons and ligaments are more flexible

3. Bones produce callus that speeds healing

4. Thicker periosteum, so stronger and more active osteogenesis

5. Skull is pliable during infancy; anterior fontanel fuses at 18 months; posterior fontanel fuses
at two months

6. Skeletal maturation completes when epiphysis fuses with diaphysis (usually 18 to 21 years of
age)




B. Immobilization in children

1. Affects multiple systems

a. muscular, GI, GU, pulmonary, cardiovascular, integumentary

b. psychologic, behavioral, economic


2. Affects normal growth and development
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3. Pathologic changes mostly occur from

a. decreased muscle strength and mass, decreased metabolism

b. possible bone demineralization

c. decreased range of motion and decreased joint


4. Concerns

a. hydration

b. dietary modification

c. activity as condition permits

d. self care as condition permits




C. Fractures in children

1. Definition: break or disruption in bone continuity

2. Etiology: usually due to mobility and immature motor and cognitive skills, trauma, osteogenic
diseases, birth injuries, child abuse, automobile accidents

3. Pathophysiology

a. fractures are seldom complete breaks (bone is so flexible)

b. many types: greenstick, spiral, oblique, transverse, comminuted, pathologic.

c. classification: simple (closed) or compound (open); complete or incomplete

d. pediatric risks

i. external hemorrhage creates risk of critical blood loss

ii. break at epiphyseal plate (growth plate between epiphysis and metaphysis)



4. Findings: swelling, pain, bruising, edema, muscle rigidity, diminished functional use of affected
part, muscle spasm in limb of fractured bone

5. Diagnostics : x-rays, various laboratory tests

6. Management: cast or traction to realign, possible surgery

7. Concerns: bone healing and alignment, neurovascular status, pain, bone growth, compartment
syndrome



D. Clubfoot

1. Etiology: congenital malformation of one or both feet


2. Findings: plantar-flexed foot/feet, with inverted heel and adducted forefoot.

3. Management: often monitored until preschool age, since it may correct itself - if not, then
surgery
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E. Genu varum (bowleg) and genus valgum (knock knee)

1. Etiology: congenital

2. Findings
most common talipes equinovarus-foot downward and inward

a. bowlegs (genu varum) common in infants and toddlers

b. knock knees common in preschool age and older.


3. Management: most resolve spontaneously - pathologic forms may require night splints, manual
manipulation, casting or surgery
Treatment- a. correction b. maintenance of correction c. follow-up observation



F. Hip dysplasia

1. Definition: developmental dysplasia of the hips (DDH), or dislocation

2. Etiology: three basic causes

a. physiologic - maternal hormone secretion and positioning intrauterine

b. mechanical - breech presentation, oligohydramnios, large infant

c. genetics


3. Pathophysiology: head of femur is improperly seated in acetabulum of hip

4. Clinical manifestation

a. limited abduction

b. short femur on affected side (Galeazzi's sign)

c. asymmetry of gluteal skin folds

d. Ortolani's sign or Ortolani's maneuver

e. waddling gait (bilateral dislocations)

f. for children already walking, increased laxity of hip


5.
Diagnostics

a. physical exam and screening at birth

b. radiographic studies


6. Management

a. surgery

b. immobilization of joint - Pavlik harness, spica cast, traction (such as Bryant's)


7. Concerns: non-compliance, impaired skin integrity, avascular necrosis from improper positioning
of harness






G. Scoliosis
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1. Definition: "lateral" curvature of the of spine and rotation of vertebral bones

2. Etiology

a. idiopathic

b. associated with neuromuscular disorders or trauma (paralytic)

c. congenital

d. most commonly found during adolescent growth spurt and mandated screenings


3. Pathophysiology

a. dependent on type (idiopathic, congenital, paralytic)

b. curved spine deforms rib - body develops compensatory curve to maintain posture and
balance


4. Findings

a. visible curve (either C or S shaped curves)

b. "rib hump," or asymmetric rib cage

c. legs are different lengths

d. waist angles uneven


5.
Diagnostics : visual screening with specific body movements, radiographic studies

6. Management

a. initially, exercise and bracing to hold curve - Milwaukee brace (rarely used) or Boston brace (a
thoracolumbosacral orthosis [TLSO] or custom-molded plastic-shell jacket)

b. if curve progresses, surgery


7. Concerns

a. body image and self esteem, pain and discomfort

b. compliance with exercises and bracing; impaired skin integrity, threat to airway clearance


Findings 1 Findings 2 Spinal Fusion





H. Juvenile Idiopathic Arthritis (formerly known as juvenile rheumatoid arthritis [JRA])

1. Definition: inflammation of joints

2. Etiology: autoimmune with probable genetic predisposition

3. Pathophysiology

a. trigger inflames synovium

b. effusion of the joint and increased fluid

c. erosion and fibrosis of the articular cartilage

d. further deterioration occurs with bone erosion, and

e. decrease in joint's range of motion and function

754


4. Findings

a. may have sudden inability to walk on one leg

b. intermittent joint pain, stiffness, swelling

c. decreased range of motion, morning stiffness


5. Diagnostics

a. history and physical examination

b.
laboratory testing - no definitive serologic tests

i. ESR and CRP (sign of rheumatic fever) - increased

ii. anemia

iii. leukocytosis (in early stages)

iv. human leucocyte antigen (HLA) testing


c. x-rays - widening of joint spaces followed by gradual fusion and articular destruction



6. Management

a. goals

i. preserve joint function

ii. prevent physical deformities

iii. relieve findings

iv. maintain growth and development


b.
pharmacologic

i. nonsteroidal anti-inflammatory drugs (NSAIDs)

ii. slow acting antirheumatic drugs (SAARDs)

iii. corticosteroids, e.g., methotrexate

iv. cytotoxic agents


c. other

i. physical, occupational, whirlpool, and/or heat therapy

ii. ultrasound; electrical stimulation

iii. balancing rest and activity

iv. splinting surgery for joint replacement



7. Nursing care

a. compliance with therapy

b. prevent contractures

c. monitor pain and discomfort - possible application of moist heat

d. assess for altered growth and development due to deceased activity, decreased ability to perform
ADLs



I. Osgood-Schlatter disease

1. Definition: a benign, self-limiting knee condition associated with pain and edema of the tibial
tubercle; one of the most common causes of knee pain in the adolescent

2. Etiology

a.
idiopathic - possibly due to repetitive stress from sports related activity plus overuse of
755

immature muscles and tendons


b. usually self-
limiting


3. Findings

a. knee pain or tenderness

b. edema of tibial tubercle

c. exacerbated by running and jumping


4. Diagnostics : physical exam, history, radiographic studies

5. Management

a. avoid activities that aggravate condition

b. use elastic bandage on affected knee or joint

c. rest, ice, NSAIDs




J. Legg-Calve-Perthes disease (osteochondritis)

1. Definition: aseptic necrosis of femoral head


2. Etiology: unknown - possible growth disorder

3. Pathophysiology

a. disturbance in blood supply


b. ischemic aseptic necrosis of femoral head, usually self-limiting


4. Findings

a. insidious onset

b. intermittent painful limp on one side


c. increased pain after extended period of activity


d. decreased range of motion


5.
Diagnostics : history, radiographic studies, bone scan, MRI

6. Management

a. bed rest


b. non weight-bearing; range of motion, as tolerated


c. containment devices such as braces, casts, traction

d. possible surgery


7. Nursing care: mostly outpatient activities


Points to Remember
Pediatric Cardiovascular

Common types of acyanotic defects with increased pulmonary blood flow include atrial septal defect,
ventricular septal defect and patent ductus arteriosus; those with decreased pulmonary blood flow
include coarctation of the aorta, aortic stenosis and pulmonary stenosis.

In cyanotic heart disorders, such as tetralogy of fallow, tricuspid atresia and transposition of the great
vessels, major concerns are polycythemia or increased hemoglobin and hematocrit, which can lead to
thrombus formation.

Acquired cardiac disorders include bacterial endocarditis, acute rheumatic fever, hyperlipidemia,
Kawasaki disease, and cardiomyopathy.
756


Pediatric Respiratory

Children's airways are smaller, more flexible and shorter than adult's and are therefore more prone to
obstruction than adults

Acrocyanosis is a common finding in a newborn.

Stridor usually indicates an upper airway concern, while wheezing indicates a lower airway disorder.

Signs of increased breathing work are tachypnea, retractions, abnormal positioning, shortness of breath
and fatigue.

Asthma is not a disease but an inflammatory disorder.

Epiglottitis, acute tracheitis, and status asthmaticus are acute medical emergencies.

Never attempt to directly visualize epiglottis with tongue depressor on child with any of the croup
syndromes (laryngitis, tracheitis, epiglottitis) because it can trigger laryngospasm.

The best way to stop the spread of respiratory syncytial virus (RSV) is meticulous hand washing; the
virus is transmitted by direct contact with fomites.

Cystic fibrosis in an inherited disease that affect the respiratory, gastrointestinal and (male)
reproductive systems; it may also affect the sweat glands.

Children with cystic fibrosis should eat a high protein, high calorie diet and take vitamin supplements
(especially A, D, E, and K).
Points to Remember 2
Pediatric Neurology

A positive Babinski reflex is normal in children until one year of age; thereafter, this and other abnormal
posturing is an ominous sign.

Acute bacterial meningitis is a medical emergency requiring swift intervention.

The care of the unconscious child focuses on respiratory management, neurological assessment,
monitoring intake and output, providing appropriate medications and evaluating outcomes.

Children with congenital neurological disabilities will often develop complications in other body
systems.

Cerebral palsy is a neuromuscular disorder and is characterized by problems with perception, language,
and/or intellectual function.

With increased intracranial pressure, the head of the bed should be elevated approximately 15 to 30
with the child's head maintained in midline alignment.

The most common complications of shunting systems used to treat hydrocephalus are bacterial
infection and obstruction.

Pediatric Endocrine

Untreated infant hypothyroidism will lead to mental retardation.

A major concern of precocious puberty is rapid bone growth, which can result in early fusion and short
stature.

The vast majority of children with new-onset diabetes mellitus type 1 will experience a "honeymoon"
period when their bodies secrete insulin and their need for exogenous insulin decreases.









757

Pediatric Musculoskeletal

Children with structural defects/disorders require regular follow-up evaluation until they reach skeletal
maturity.

Children under one year of age generally do not experience fractures.

Since many musculoskeletal disorders begin with trauma, it is important to assess ABC (airway,
breathing and circulation) first.

There are usually no symptoms of scoliosis. Most cases are discovered during mandated school
screenings (usually in 5th or 6th grades).

Points to Remember 3

Pediatric Genitourinary

One gram of diaper weight equals one milliliter of urine.

Children with urine output less than one milliliter/kilogram/hour should be closely monitored for
possible renal failure.

Acute renal failure should be suspected in a child with decreased urine output, edema and/or lethargy,
and who is dehydrated, recovering from surgery or in shock.

In a child with ambiguous genitalia, the criterion for choice of gender and rearing is typically not genetic
sex, but the infant's anatomy

Pediatric Gastrointestinal

Whenever a newborn coughs, chokes, and turns blue with feeding, suspect tracheoesophageal fistula
(note the 3 C's - cough, choke, and cyanosis.)

Any newborn failing to pass meconium stool within the first 24 hours of life and who is prone to
constipation or or has decreased stool frequency in the first month of life, should be evaluated for
Hirschsprung's disease.

Dehydrated infants and children face greater morbidity risk than adults because children differ in body
composition and metabolic rate, and their fluid-regulation systems have not matured.

758



I. Overview of normal, uncomplicated pregnancy and vaginal labor and delivery

A.
Physiological changes and related normal discomforts of pregnancy

B. Stages and phases of labor and delivery

1. First stage of labor - onset of regular contractions to complete dilation

a. latent phase I

b. active phase II

c. transition phase III


2. Second stage of labor - complete dilation to birth of newborn

3. Third stage of labor - delivery of newborn to the delivery of the placenta

4. Fourth stage of labor - return to homeostasis (usually defined as the initial hour or two
postpartum)



See lesson 3 for more information about uncomplicated pregnancy, labor and delivery


II. Cesarean Birth

A. Definition: surgical incision into the uterus and abdominal wall to deliver the fetus

1. Incision types image


a. abdominal - low transverse through the skin and abdominal muscles in any Cesarean

b. uterine

i. low transverse - more common with less bleeding or infection risk and faster healing

ii. classical - less common with greater risk for bleeding, infection or less toned uterus



2. Vaginal birth after cesarean (VBAC)

a. possible but usually not recommended

b. weakened uterine muscle as a result from a prior classical incision or more than one low
transverse incision

c. risk for uterine atony with hemorrhage postpartum




B. Indications

1. Fetal distress

2. Abnormal delivery presentation, i.e., breech, shoulder, face

3. Prolapsed cord

4. Placental complications, i.e., placenta previa

5. Twin or multiple fetuses

759

6. Maternal exhaustion



C. Data collection

1. Note maternal risk factors

2. Observe for dystocia, maternal factors precluding safe vaginal delivery for mother and/or fetus,
and rescue of fetus for non-reassuring heart rate or heart rate incompatible with labor

3. Review of physical preparation of the woman for surgical delivery

4. Emotional and psychological preparation of the woman for surgical delivery

5. Review of preparatory measures for surgical intervention

6. Prompt notification of health care provider in emergency situations involving maternal or fetal
emergencies


D. Nursing interventions

1. If repeat cesarean, review client understanding of preparation, operative procedure and
postoperative care

2. If maternal conditions deteriorate or fetal status become incompatible with labor, immediate
emergency procedures are instituted

3. Assist with notification of medical personnel, anesthesia, pediatric providers

4. Institute procedures to maintain organ perfusion with particular emphasis on uterine perfusion

5. Assist with skin preparation, shaving, Foley catheter, electrodes, SEDS, preoperative medication as
ordered

6. Provide nursing presence at bedside to alleviate anxiety, fear and to explain emergency interventions

7. Accompany client to surgical suite and maintain continuity of care

8. Assist with preparations for neonatal stabilization

9. Monitor postoperatively until stable


III. Complications During Pregnancy

A. Gestational Hypertension (GH) (formerly called pregnancy-induced hypertension
[PIH])

1. Begins after 20 weeks gestation

2. Second leading cause of maternal death in the U.S.

3. Leading cause of fetal complications, e.g., low birth weight, premature birth,
and stillbirth




760

4. Types of gestational hypertension

a. transient hypertension

i. elevation of blood pressure for first time at the time of birth resolves by 12
weeks after birth

ii. no proteinuria


b. preeclampsia

i. systolic readings > 30 mm Hg and diastolic readings > 15 mm Hg above baseline
blood pressure, or blood pressure > 140/90; readings taken at least twice, 4 to
6 hours apart

ii. mild proteinuria: 1+ or 2+ on urine dipstick


c. eclampsia

i. extremely high blood pressure

ii. 4+ proteinuria

iii. generalized edema

iv. 4+ patellar reflexes

v. tonic-clonic seizures (lasting less than 3 to 4 minutes)


d. HELLP syndrome

i. HELLP: acronym for Hemolysis,Elevate Liver enzymes, and Low Platelets

ii. serious complication of preeclampsia

characterized by rapidly deteriorating liver function (elevated liver
enzymes) and thrombocytopenia (low platelet count)

right upper quadrant pain is common in women - due to liver
ischemia





B. Diabetes in pregnancy

1. Definition: a condition that appears midway through the 2nd trimester and
disappears after birth of the baby

a. predisposing factors

i. obesity - with a BMI of 30 or over

ii. family history of type 2 diabetes

iii. older mothers (age 35 and over)

iv. high blood pressure

v. Hispanic, African American, Native American, South or East Asian or of
Pacific island descent


b. goal - euglycemia (normoglycemia)

c. risks for mother/pregnancy

i. stillbirth

ii. birth canal injury, i.e., lacerations of the vaginal tract, fractured pelvis, due
to large fetus

iii. surgical delivery


d. risks for the fetus/newborn

i. macrosomia

ii. birth trauma/injury, i.e., fractured clavicle, brain injury
761


iii. neonatal hypoglycemia

iv. congenital anomalies
Respiratory Distress Syndrome




2. Findings

a. glucose challenge test (GCT) at 24 to 28 weeks; if GCT > 140 mg/dL
proceed to a 3-hour oral glucose tolerance test (GTT)

b. if GTT positive, dietary controls initiated

c. if dietary controls fail to keep fasting blood sugar (FBS) 105 mg/dL,
insulin therapy is initiated

d. observe for glycosuria, ketonuria, polydypsia, polyphagia, polyuria

e. monitor for excessive weight gain or excessive weight loss

f. fetal growth is estimated serially with sonograms

g. fetal non-stress test weekly starting at 36 weeks

h. biophysical profile (BPP) weekly starting at 36 weeks

i. daily fetal movement counts

j. client's understanding of findings of hyperinsulinism and ketoacidosis


3. Management

a. maintain euglycemia throughout pregnancy

b. mother proceeds to term (37 weeks or more) with reassuring fetal
condition

c. delivery of infant without morbidity or mortality


4. Nursing interventions

a. monitor blood sugar and report abnormalities

b. reinforce education of woman regarding:

i. increased risk for genitourinary infections, dystocia, hydramnios,
cesarean birth

ii. diet, glucose screening and insulin administration

iii. treatment for hyperglycemia, hyperinsulinemia and recognize signs of
ketoacidosis


c. most women with gestational diabetes mellitus (GDM) will return to normal
glucose levels after childbirth

d. women with GDM are at greater risk for GDM in future pregnancies

e. women with GDM are at greater risk of developing glucose intolerance later in life



C. Anemia in pregnancy

1. Definition: a condition of pregnancy characterized by a reduction in the
concentration of hemoglobin in the blood

2. Etiology

a. physiologic - due to hemodilution; normal adaptation during
pregnancy

b. pathologic - oxygen-carrying capacity of the blood is deficient

i. nutritional deficiency of iron, folic acid, or vitamin B12
762


ii. malignancy, chronic malnutrition, exposure to toxins, or chronic
disease, e.g., sickle cell



3. Findings of anemia

a.
laboratory values

i. first trimester: Hgb < 11g/dL or HCT < 35%

ii. second trimester: Hgb < 10.5 g/dL or HCT < 35%

iii. third trimester: Hgb < 10 g/dL or HCT < 33%


b. reports of listlessness, fatigue

c. pallor

d. slow capillary refill

e. poor weight gain

f. infection, bleeding

g. fetus - small for gestational age (SGA), intrauterine growth retardation



4. Management

a.
diet - prevent iron deficiency with elemental iron supplementation

b.
pharmacologic - prevent iron deficiency with elemental iron
supplementation

c. monitor for hemorrhagic findings

d. monitor fetal growth


5. Nursing interventions

a. reinforce teaching regarding:

i. nutritional instructions - iron rich diet, increase vitamin C and folic acid

ii. oral iron supplement

iii. parenteral iron (Imferon) if necessary

iv. need to take oral supplements with orange juice for absorption and
between meals

v. include roughage and 8 glasses of water to prevent constipation


b. discuss the need to alternate activities with rest



D. Hyperemesis gravidarum

1. Definition

a. vomiting causing weight loss of 5% or more of pre-pregnancy weight
with dehydration, ketosis, acetonuria & electrolyte imbalances

b. results in electrolyte, nutritional and metabolic imbalances


2. Etiology - unknown; suspected cause elevated estrogen and human
chorionic gonadotropin (hCG) levels

3. Data collection

a. monitor amount of vomiting, retching, nausea, weight loss, signs of
starvation, dehydration status

b. observe for ketoacidosis (from loss of intestinal juices), hypokalemia,
tachycardia, fever, hypovolemia, and oliguria
763


c. observe for mental confusion, ataxia, jaundice


4. Management

a. sedatives and/or antiemetics - to stop the vomiting

b. Re-establish normal fluid and electrolyte balance

c. dietary counseling

d. goal: improve maternal and fetal health status


5. Nursing interventions

a. monitor intake and output and weight status

b. begin oral feedings slowly with frequent small meals and fluids

c. encourage verbalization of client's feelings




E. Rh Sensitization in Pregnancy

1. Etiology

a. sensitization occurs when incompatible blood component of infant's
blood stimulates antigen-antibody reaction in mother

b. seen in Rh negative clients with Rh positive infant

c. other blood incompatibilities may also occur, e.g., ABO incompatibility


2. Data collection

a. during pregnancy

i. assist the RN to identify maternal history of blood transfusions,
previous pregnancies, previous spontaneous and induced abortions,
and blood type and Rh of father

ii. Rh titers are repeated periodically if incompatibility is suspected

iii. amniocentesis is used to determine and monitor disease process of
erythroblastosis fetalis in the fetus and percutaneous umbilical
cord blood sampling (PUBS)


b.
postpartum - newborn

i. blood type and Rh factor

ii. direct Coomb's

iii. complete blood count

iv. bilirubin level



3. Nursing interventions

a. Rh(D) Immune Globulin or RhIG (RhoGAM) administered at 28
weeks, after abortion, ectopic pregnancy, amniocentesis, version of
breech or in any situation in which maternal and fetal blood may
interface

b. administer RhoGam with negative indirect Coomb's


764



IV. Complications During Labor and Delivery

A. Dystocia

1. Definition: painful, difficult, prolonged labor and birth resulting in
failure to efface, and/or descend within an expected time frame

a. contractions may be either hypotonic or hypertonic

b. may result in maternal dehydration, infection, fetal injury, or
death


2. Classifications

a. abnormalities of the power (contractions)

b. abnormalities of the passage (birth canal)

c. abnormalities of the passenger (fetus)


3. Data collection

a. monitor uterine contraction frequency, intensity, duration

b. monitor effacement, dilation and descent

c. check uterine resting tone for hypertonus

d. monitor fetal heart rate for non-reassuring pattern

e. check fetal presenting part for molding, asyncliticism

f. monitor maternal coping skills

g. monitor for amniotic fluid loss and time in labor




4. Management

a. establish and treat cause of dystocia for vaginal delivery

b. prepare for cesarean birth if appropriate

c. fetal monitoring

d. pharmacologic

i. interventions for pain relief

ii. oxytocin (Pitocin)

iii. IV fluids

iv. prophylactic antibiotics



5. Nursing interventions

a. monitor uterine activity for frequency, intensity and duration

b. provide rest and comfort measures, e.g., back rubs and position changes

c. assist with ambulation in active phase

d. monitor intake and output

e. provide adequate physical and emotional support for pain

f. prepare for neonatal resuscitation if necessary









765

B. Emergency birth

1. Definitions

a. birth of the newborn in the absence of expected health care provider and/or
midwife
b. precipitous
labor


c. precipitous birth


2. Data collection

a. assess contractions for excessively strong (tetanic-like) frequency
(tachysystole), or excessively long contractions

b. review history for previous precipitous labor

c. primigravida - cervical dilatation greater than 5 centimeters/hour

d. multigravida - cervical dilatation greater than 10 centimeters/hour

e. rapid fetal descent

f. increased bloody show, initiation of and strong expulsive efforts


3. Management

a. safe conduct of birth with minimal maternal soft tissue trauma

b. safe conduct of birth with minimal fetal trauma

c. preparation for neonatal resuscitation and stabilization

d. anticipation of postpartum hemorrhage


4. Nursing interventions

a. constant nursing attendance at bedside and monitor mother and fetal
heart rate (FHR)

b. immediate notification of appropriate health care provider

c. preparation for emergency delivery (supplies and personnel)

d. delivery of newborn by most qualified personnel

e. neonatal resuscitation prepared




C. Prolapsed cord

1. Displacement of the umbilical cord in front of presenting part


2. Data collection

a. note characteristic, color and nature of amniotic fluid when
membranes rupture

b. observe for decreased fetal heart rate

c. observe for umbilical cord if fetal bradycardia occurs
766


d. monitor for moderate to variable decelerations of fetal heart rate



3. Management

a. goal - maintain placental perfusion

b. expeditious delivery


4. Intervention

a. vaginal examination and dislodge presenting part to relieve cord pressure

b. Trendelenberg, knee-chest position, or elevation of hips on pillows to
minimize cord compression

c. start IV fluids

d. initiate intrauterine resuscitation:

i. oxygen therapy

ii. fluid bolus

iii. placental perfusion maintained


e. do not manipulate or replace cord back into vaginal canal

f. notify of health care provider immediately

g. prepare for newborn resuscitation

h. prepare for most expeditious birth - vaginal or cesarean

i. provide for physical and emotional needs of parents in a calm
environment



D. Postpartum hemorrhage

1. Definitions

a. blood loss more than 500 mL in vaginal delivery; more than 1000 mL in
cesarean delivery

b. hematocrit change of 10% or greater

c. classifications:

i. early (within 24 hours)

ii. late (after 24 hours)


d. most common causes: uterine atony, multiparity



2. Data collection

a. observe for predisposing risk factors

b. observe for intrapartum events that increase potential for postpartum
hemorrhage

i. prolonged labor

ii. cesarean birth

iii. oxytocin induction of labor

iv. uterine infection

v. over-distention of the uterus


c. palpate uterine fundus; check that it is midline; if deviated most likely
bladder is full

d. observe amount of lochia rubra, consistency and presence of clots
767


e. palpate bladder fullness (full bladder impedes contraction of uterus)

f. monitor pain relief

g. observe vital signs and for findings of hypovolemia



3. Management

a. maintain normal vital signs

b. control maternal hemorrhage

c. maintain hemodynamics


4. Nursing interventions

a. support cardiac output

b. massage uterine fundus and expel clots under supervision of RN, if
bleeding

c. facilitate bladder emptying

d. do pad count or number and amount of saturation and/or weigh pads

e. hydrate with intravenous fluids

f. administer oxygen to provide organ perfusion as needed

g. monitor oxytocins as ordered

h. reinforce purpose of interventions and self-care actions



E. Fetal distress

1. Alterations of fetal heart rate

a. acceleration of fetal heart rate (FHR)

i. transient tachycardia may occur with fetal activity

ii. abrupt increase of 15 or more beats, lasting 15 seconds or more,
with a return to baseline in less than 2 minutes from onset


b. FHR variability

i. absent or minimal variability

ii. may be caused by fetal central nervous system depression

iii. associated with narcotics and barbiturates, fetal hypoxia, acidosis,
immaturity



c. tachycardia

i. FHR above 160 beats/minute, lasting over 10 minutes

ii. may be caused by maternal fever or dehydration and drugs such as
atropine, hydroxyzine (Vistaril), tocolytics, e.g.,ritodrine (Yutopar),
or terbutaline (Brethine)



d. bradycardia

i. FHR below 110 beats/minute lasting over 10 minutes

ii. may be caused by fetal hypoxia as a result of anesthetics, maternal
hypotension, prolonged umbilical cord compression, or analgesics






768


2. Meconium in the amniotic fluid indicates fetal distress

a. normal color of amniotic fluid is clear

b. greenish or brown color of fluid may indicate fetal meconium

Type 1: Early Type 2: Late Type 3: Variable
Fetal head compression Uteroplacental insufficiency Umbilical cord compression
FHR Decreases with onset of contractions
and mirrors the pattern of the
contraction
Returns to baseline as the contraction
ends
Decreases with the onset of
contractions
Deceleration persists beyond
completion of contraction
Decreases at any point during or
between contractions
Decelerations may be jagged V or
U shaped
Range
of FHR
Drop
Within normal limits of 120-160
beats/minute
Rarely below 100 beats/minute
Within normal limits of 120-160
beats/minute
Sometimes below 100 beats/minute
Large, extends below normal
Usually late in labor
Mild are reassuring
Shape Uniform Uniform Not uniform
Concern Innocuous
Reassuring
Ominous
Nonreassuring
Moderate to severe
Ominous
Nonreassuring
Nursing
Actions
Observe Turn to left side
Give oxygen by mask
Summon health care provider
Turn to left side
Give oxygen by mask
Summon health care provider
















769

Points to Remember

During pregnancy

Maternal understanding of various disease processes and recommended therapies may provide
impetus for self-care.

Nutrition

Fetal problems from anemia of mother include growth retardation with associated morbidity and
mortality.

Daily logs of dietary intake may help the client focus on positive improvement.

Pica is the craving by, pregnant client, for non-food substances from low serum iron levels.

Failure to correct nutritional imbalances in pregnancy can result in:

fetal complications - intrauterine growth retardation, central nervous system malformations
and fetal death

maternal complications - severe dehydration, metabolic alkalosis, ketosis, cardiac
dysrhythmias and death for the woman.

Cardiovascular

Normal pregnancy cardiovascular changes increase the heart's workload.

Cardiac output maximizes at approximately 28 weeks; is increased during labor and is at its highest
during first hour postpartum.

Failure to detect blood incompatibility with the fetus can result in red blood cell hemolysis and severe
morbidity or mortality; RhoGAM should be administered to all sensitized client's within 72 hours
following delivery, miscarriage, or abortion.

Cardiac disease in pregnancy can deteriorate rapidly.

Client must verbalize understanding of cardiac findings indicating complications.

Class II to IV cardiac clients should have induction, regional anesthesia and should not push during
birth; legs should never be higher than the heart and should be monitored intensively following
delivery.

Class II to IV cardiac clients should labor side-lying, in semi-Fowler's position to facilitate cardiac
emptying; pulse oximetry should be used to monitor tissue perfusion; and cardiac monitoring should be
maintained.

Anemia in pregnancy is associated with complications of abortion, infection, pregnancy induced
hypertension, preterm labor and heart failure.

Endocrine

If the maternal pancreas is unable to increase insulin production sufficiently, gestational diabetes
mellitus results.

Euglycemia is the most important factor in avoiding maternal/fetal complications.

Maternal hyperglycemia results in glucose crossing the placenta and the fetus manufacturing insulin.

Insulin in the fetus acts as a growth hormone producing a large-size, macrosomic infant.

Newborns of diabetic mothers may incur birth injury, hyperbilirubinemia, hypoglycemia, and neurologic
damage.

Maternal insulin needs are dramatically reduced following delivery.


770


Points to Remember 2
Labor and Delivery

Vaginal birth is the birth method of choice and interventions should be directed at accomplishing that
goal

Prolonged labor at any stage should be evaluated for fetal, pelvic or uterine dysfunction.

Pain and anxiety can impede the laboring progress.

Maintenance of a calm, soothing environment is necessary.

Efficient and effective gathering of supplies and personnel is imperative.

Maintain eye contact and verbal contact with woman to provide support.

Assist mother to birth as slowly as possible to prevent maternal/newborn trauma.

Be prepared to assist with the newborn transition to extrauterine environment.

Inform and support mother in any emergency.

Prepare for expeditious birth - usually cesarean.

Cesarean birth is utilized to rescue the infant when fetal, pelvic or uterine dysfunction cannot be
overcome.

Surgical interventions have associated complications of increased infection, increased postoperative
hemorrhage, increased morbidity and potential of increased mortality.

Surgical delivery (C-section) of the newborn reduces mechanical compression of the chest. It may
potentiate respiratory difficulties in the newborn such as transient tachypnea of the newborn.

Severe postpartum hemorrhage may result in organ failure, disseminated intravascular coagulation
(DIC), and/or mortality.

Estimation of bleeding is critical.

Uterine massage is the first line of defense against excessive hemorrhage.

Oxytocins are used to contract the uterus during the laboring process and after delivery.

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I. Anatomy & Physiology

A. Anatomy

1. Skin

a. largest organ in the body

b. 2 layers

i. dermis - connective tissue layer under the epidermis containing nerve endings, sensory
receptors, capillaries and elastic fibers

ii. epidermis - contains keratin cells (a fibrous protein), basal cells, and melanocytes
(produce the pigment melanin)



2. Follicles and glands

3. Hair and nails



B. Physiology

1. Protection

2. Temperature regulation

3. Sensory reception

4. Biochemical synthesis

5. Absorption


C. Skin Condition Factors

1. Age

2. Hydration and nutrition

3. Soap, laundry detergents, and topical products

4. Medications

5. Infectious processes (viral, bacterial, fungal)

6. Mechanical forces (tearing, friction, shearing) & vascular damage

7. Tape and adhesive products

8. Allergy

9. IV infiltration

10. Temperature

11. Bodily secretions: urine, stool, ostomy drainage, fistula




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Pediatric Differences

Newborns skin is thinner, more easily hurt by endotoxins and tearing forces

Childs body absorbs more of topical products

Harder to regulate body temperature
Browse the RxList Image Collection Gallery for pictures of many different skin disorders and diseases.


II. Wounds

A. Assessment

1. Acute or chronic: etiology of pressure, shearing, trauma

2. Measurements: depth, size, location, "tunneling", open, closed

3. Staging: partial or full thickness, complex (involving muscle, bone)

4. Types of wounds: abrasions, lacerations, contusions, punctures, avulsions, burns, ulcers


B. Factors impacting wound healing

1. Perfusion, oxygenation

2. Nutritional deficiencies

3. Infection

4. Underlying systemic condition

5.
Topical products and type of dressing used

6. Pressure over bony prominences leading to skin breakdown and ulceration, especially in
elderly bedridden clients

7. Medications


C. Principles of successful wound management

1. Remove or eliminate causative factors

2. Provide appropriate systemic support: fluids, nutrition

3. Apply appropriate topical products - encourage moist wound healing and process of occlusion


D. Evaluation of successful wound healing

1. Type: primary, secondary or tertiary wound closure

2. Measurement: decreasing size, viable tissue, decreased exudate, color


E. Modes of caring for skin disorders

1. Non-surgical: skin care products, nutrition, healthy lifestyle

2. Surgical: debridement, skin grafts and flaps





III. Noninfectious Skin Disorders

A. Atopic dermatitis (eczema)
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1. Definition: hypersensitivity reaction (similar to an allergy) in the skin, which leads to long-
term inflammation of the skin

2. Etiology

a. genetic tendency, multifactorial with family history of allergies or asthma

b. exacerbated by stress and certain foods


3. Pathophysiology: trigger- increased histamine release with inflammatory response, e.g.,
itching and findings of exacerbation

4. Findings

a. dry skin, itching, erythema

b. skin coloring changes and erythema around blisters

c. lichenification (thickened or leather-like areas) due to long-term irritation and scratching

d. macule, papule, pustule and even vesicles possible

e. acute weeping areas with excoriated red plaques



5. Diagnostics

a. family history

b. physical exam

c. skin biopsy

d. allergy skin testing


6. Management

a. goals: control itching, moisturize, remove irritants and allergens, and prevent secondary
problems (infections)

b. wet compresses, occlusive dressings, mild detergents

c.
pharmacologic

i. antihistamines

ii. topical immunomodulators (TIMs), including tacrolimus (Protopic) and pimecrolimus
(Elidel)

iii. barrier repair creams containing ceramides

iv. immunopsuppressants, including cyclosporine, methotrexate, mycophenolate mofetil

v. antibiotics (for skin infections)



7. Nursing care

a. remove allergens

b. keep child's fingernails short
c. clothe lightly to decrease sweating

d. apply emollient preparation immediately after bathing

e. provide rest periods
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f.
reinforce information about appropriate dietary modifications





B. Seborrheic dermatitis

1. Definition

a. recurrent inflammatory reaction of skin that causes flaky, white to yellowish scales to form on
oily areas such as the scalp or external ear canal

b. called "cradle cap" in infants; also commonly known as dandruff


2. Etiology: probable dysfunction of sebaceous glands and irritation from a yeast called malassezia

3. Findings: usually non-pruritic oily scales on scalp, forehead and eyebrows or behind ears

4. Management

a. massage baby's scalp gently with fingers or soft brush and daily shampooing with mild baby
shampoo, hydrating creams or mineral oils

b. over-the-counter dandruff or medicated shampoos; prescription shampoos or lotions for
severe cases


5. Reinforce with parents about cleaning scalp and shampooing hair



C. Diaper dermatitis ("diaper rash")

1. Definition: inflammatory skin disorder caused directly or indirectly by wearing of diapers

2. Etiology


a. ammonia in urine, fecal enzymes, detergents, moisture, heat

b. can lead to secondary fungal infection (especially candida albicans)


3. Pathophysiology

a. prolonged and repetitive contact with irritant (especially urine ammonia, which is formed by
urea breakdown from fecal bacteria); inflammation

b. excoriation, with macules or papules and erosion

c. concern: secondary infection


4. Findings: red, excoriated macules and papules; maceration

5. Diagnostics

a. usually diagnosed by appearance alone

b. skin lesion KOH exam



6. Management

a. cleaning and frequent diaper changes

b. pharmacologic

i. skin protectants and moisture barriers

ii. topical antifungals, including nystatin, miconazole, clotrimazole
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iii. steroids


c. if diarrhea, treat underlying cause

d. preventative action - apply coating of a water-barrier substance (such as A&D Ointment) over
the anal area at the first sign of loose, diarrheal stools to prevent excoriation of the diaper
area




D. Contact dermatitis

1. Definition: inflammatory reaction of the skin to chemical substances natural or synthetic

2. Etiology: multiple factors and irritants foods, solutions, allergens, plants

3. Findings: irritant and allergic types

a. irritant: causes dry, inflamed, pruritic lesions where irritant touched

b. allergic: blisters after weeping, pruritic, lesions


4. Management


a.
topical applications: anti-inflammatory and antipruritic

b. cold compresses

c. supportive care, i.e., prevent further exposure to offending substance if possible




E. Acne vulgaris

1. Definition: common skin condition in which pores become clogged and inflamed

2. Etiology: multifactorial (heredity, hormones, emotions)

3. Pathophysiology

a. puberty: increased androgens; involves hair follicle and sebaceous gland complex

b. increased sebaceous glands secrete more sebum

c. pores become plugged and dilated

d. fatty acids are oxidized on skin and form blackheads

e. internal fatty acids form whiteheads

f. rupture causes local inflammation, sometimes with pustules


4. Findings: whiteheads (closed comedones), blackheads (open comedones), papules, pustules,
nodules, red and excoriated skin


5. Management

a. general - good cleansing of skin, nutrition, and no squeezing or picking at lesions

b.
pharmacologic
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i. topical applications: vitamin A, benzoyl peroxide, antibiotics

ii.
oral antibiotics

iii. oral birth control pills

iv.
isotretinoin (generic only - formerly available as Accutane)

v. photodynamic therapy, dermabrasion, or chemical skin peels



6. Nursing care

i. reinforce importance of compliance with treatment program

ii. extremely important to assess sexual activity, especially in teenage girls, since isotretinoin and
vitamin A products (such as retinol) are teratogenic (Category X drug)



Because isotretinoin is teratogenic, it is sold only under a special program approved by the Food and
Drug Administration called iPLEDGE . Providers and pharmacies must be registered in this program.


IV. Infectious Skin Disorders

A. Impetigo contagiosa

1. Definition: bacterial infection of skin

2. Etiology: staphylococcus aureus, group A beta-hemolytic streptococcus; methicillin-resistant
staph aureus is becoming a common cause

3. Pathophysiology: starts in area of broken skin - highly contagious for seven to ten days

4. Findings

a. primary: pustules or vesicles

b. secondary: honey-colored crusts, superficial erosion, easily bleeds, pruritic

c. tends to heal without scarring unless secondary infection


5. Diagnostics: typically based on appearance of the skin lesion; skin culture

6. Management

a. careful removal of crusts or debris with warm soapy solution

b.
short fingernails

c.
pharmacologic

i. topical antibiotics for early small lesions

ii. systemic antibiotics - treatment of choice



7. Concerns: highly contagious, therefore good hand washing needed and no sharing of towels
or eating utensils




B. Cellulitis

1. Definition: infection of dermis and/or subcutaneous tissue
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2. Etiology: streptococcal bacteria, e.g., Streptococcus group A or Streptococcus pyogenes;
Staphylococcus aureus; Haemophilus influenza

3. Pathophysiology

a. starts in area of broken skin

b. highly contagious for days

c. can occur on any part of the body


4. Findings

a. affected area: red, edematous, tender, occasional discoloration

b. enlarged lymph nodes; fever, malaise, headache; "streaking" frequently seen



5.
Diagnostics

a.
complete blood count, blood cultures, possible skin culture

b. computerized tomography


6. Management

a.
oral or parenteral antibiotics

b. warm moist compresses

c. possible incision and drainage

d. monitor size of area by marking and dating red area


7. Concerns: secondary infection, alteration in skin integrity



C. Herpes simplex

1. Definition: oral herpes, cold sore, fever blister

2. Etiology: HSV-1 or HSV-2; cytomegalovirus (CMV); Epstein Barr (infectious mononucleosis);
varicella-zoster virus

3. Pathophysiology: virus infects body fluids, which then come in contact with breaks in the skin or
mucous membranes

a. HSV-1 affects areas above the waist; "cold sore"

b. HSV-2: affects areas below the waist; genital herpes

c. virus dormant within nerve cells; then reactivated by fever, stress, trauma, sun exposure,
menstruation


4. Findings

a. often depend on location in body

b. prodromal period common

c. vesicles, pain, pruritus, paresthesia, increased skin sensitivity at site
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5.
Diagnostics

a. history and physical exam

b.
smears and tissue cultures


6. Management (when symptomatic)

a. fluids

b.
possible antiviral medication: acyclovir

c.
antibiotics - if secondary infection

d.
analgesics


7. Concerns

i. highly contagious

ii. secondary infection

iii. pain

iv. alteration in body image

v. HSV can be deadly to the fetus if untreated

vi. HSV-2 is sexually transmitted - this includes oral sexual activities



See lesson 8E - Genitourinary for more information about genital herpes and sexually transmitted
infections


D. Moniliasis candidiasis (thrush)

1. Definition: oral candidiasis characterized by white adherent patches on the tongue, palate, and
inner aspects of the cheeks

2. Etiology: fungus, candida albicans

3. Pathophysiology: acquired via birthing process, antibiotics, inhaled steroids

4. Findings

a. white plaques on tongue, gums or buccal mucosa

b. possible ulcerations in oral mucosa

c. itching



5. Management
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a.
oral antifungals - either swish and swallow administration after feeding or topical
application

b.
vaginal suppository or creams - antifungal medications

c. education on mouth rinsing after inhaled steroid


6. Concern: may spread to groin, buttocks



E. Tinea (ringworm)

1. Definition: superficial fungal infection that lives on, not in, the skin

2. Etiology: dermatophytes


3. Pathophysiology

a. transmitted person to person, animal contact, contact with contaminated fomites (nonliving
"host")

b. associated with poor hygiene, friction from tight clothing


4. Findings (refer to table below)

5. Management (refer to table below)
Type of Tinea Location Findings Management
Capitis Hair, scalp Scaly circular patches, "blood dot,"
alopecia, red area, pruritus, fever
Antifungals, shampoos
Corporis Body Erythematous, scaling patches, round
or oval
Local therapy with antifungal creams or
powders
Cruris ("jock
itch")
Perineum Similar to corporis; pink papules;
pruritus in genital folds
Local therapy with antifungal creams or
powders
Pedis
("athlete's
foot")
Feet or
ankles
Lesions, pruritus, maceration between
toes, burning sensation
Local therapy with antifungal spray or
lotion, possibly Burow's solution



6. Nursing care

a. reinforce good hygiene practices

b. reinforce that client should not share clothing or hair brushes

c. reinforce not to overuse over-the-counter products, especially for feet




F. Pediculosis capitis (head lice)

1. Definition: lice infestation
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2. Etiology: parasitic insects (lice) belonging to the family Pediculidae

3. Pathophysiology

a. these lice live only on humans

b. transmitted by direct and indirect contact

c. types of lice include: scalp (pediculus capitis); body (pediculosis corporis); pubic area
(pediculosis pubis); eyebrows and eyelashes (pediculosis palpebrarum)

d. all types pierce skin and suck blood, with females laying eggs (nits) at the base of hair shaft


4. Findings

a. nits (tiny silvery or grayish-white specks) and pruritis

b. with corporis, papular rose-colored dermatitis



5. Management

a. topical shampoos or body ointments with ant-infectives

b. cut nails short to minimize scratching

c. teach client to prevent recurrence and spread: wash clothes and bedding in hot water, no
sharing of clothes, hats, scarves, or hair brushes; vacuum carpets and upholstered furniture;
boil combs and brushes in water

d. repeat therapy in 8 to 10 days after initial treatment to kill remaining hatched nits


6. Concerns

a. compliance and recurrence

b. lindane (Kwell) shampoo is neurotoxic in children under the age of five years

c. lice are highly contagious; in hospital, infested client requires contact isolation - for
information on isolation see Lesson 2: Safety and Infection Control

d. do not leave topical application on longer than directed - neurotoxicity can occur with any age
group




G. Scabies (itch mite)

1. Definition: contagious infestation of the skin with mites

2. Etiology: mite (Sarcoptes scabiei)

3. Pathophysiology

a. female mite burrows into epidermis, lays eggs
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b. mites, eggs and excrement all cause intense pruritus (due to histamine release)


4. Findings

a. pruritus, burrows (fine, grayish brown threadlike lines)

b. intense itching, especially at night

c. papule like eczema in infants


5. Diagnostics : visualization, scrapings with microscopic exam

6. Management

a.
pharmacologic

i. scabicide topical medications or creams; treatment of choice is over-the-counter topical
medication permethrin (Elimite)

ii. anti-steroidal creams for itching may be included

iii. systemic anti-infectives for persistent secondary infections


b. wash clothes and bedding in hot water

c. all persons and pets in close contact with affected person will need treatment




V. Temperature-Related Disorders

A. Cold-related - frostbite

1. Definition of frostbite: localized cold injury - tissue damage when ice crystals form in tissue

2. Findings

a. blanching, decreased sensation, mottled

b. second degree (cold after rewarming): blisters and possible bulla

c. third degree: cyanosis, mottling- then red with swelling, local necrosis, hemorrhagic
vesicles

d. fourth degree: complete necrosis, gangrene, loss of body part



3. Management

a. cover area immediately but do not massage area

b. rewarm affected part gradually by immersing in 100 to 108 Fahrenheit water

c.
give analgesics and sedatives for severe pain during rewarming

d. possible surgical intervention - escharotomy





B. Cold-related - hypothermia

1. Definition: cooling of the body's core temperature to injurious levels (below 95 degrees
Fahrenheit or 35 degrees Celsius)

2. Findings: cooling of the body's core temperature to injurious levels (below 35 degrees Celsius)

3. Management - 3 categories of rewarming

a. for mild hypothermia - passive external rewarming (PER): client is placed in warm environment
782

and covered with insulation

b. active external rewarming: heat is applied to skin over trunk of body only

c. active core rewarming (most effective way to rapidly increase core temperature)

i. warmed, humidified air

ii. peritoneal dialysis

iii. heated irrigation

iv. diathermy: ultrasound and low-frequency microwave radiation

v. extracorporeal - most rapid means of rewarming








C. Heat-related - sunburn

1. Definition: dermatitis due to overexposure to the sun

2. Etiology: overexposure to ultraviolet light waves, including UVA (minor burning) and UVB
(tanning, burning, harmful effects)


3. Factors influencing degree of burn

a. genetic makeup and skin type

b. season of year, altitude, time of day

c. window or glass, light reflected by snow or water

d. medications, underlying conditions, topical products


4. Prevention

a. avoid sun exposure to the skin and eyes

b. wear clothing over extremities and eyewear such as sunglasses with UV protection

c. apply topical sunscreens and blocks liberally - use higher numbers, greater than SPF 30

d. no direct sun between 10 am and 3 pm


5. Management: based on findings and severity (see following for treatment of thermal injuries)



D. Heat-related - thermal Injuries (burns)

1. Definition: injuries to skin resulting from extreme heat sources

a. partial thickness: first and second degree burns

b. full thickness: third and fourth degree burns

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2. Etiology: thermal (most common in children), chemical, electrical, secondary to irradiation

a. hot water scalding more common in toddlers

b. flame-related burns more common in older children


3. Pathophysiology

a. severity affected by location, concurrent inhalation injury, trauma, underlying condition, age

b. anatomy and physiology of burns

i. depth

amount of local tissue destroyed or damaged

related to length of exposure and temperature


ii. types (first, second, third, and fourth degree)

iii. severity - determined by total body surface area (TBSA) and thickness


c. extent of burn determines responses: local or systemic

i. local response

cellular damage and fluid movements - edema

fluid leaks into interstitial spaces, fluid lost to air

fluid is lost to circulating volume (the "oliguric" phase)

burn damages tissue


ii. multi-systemic response and potential complications

cardiovascular: dehydration; "burn shock"

pulmonary: respiratory distress, possible post-inhalation injury, ARDS, aspiration
pneumonia, pulmonary edema

gastrointestinal: ischemia - decreased bowel sounds, possible ileus, Curling's
ulcer

renal: decreased fluids, increasing BUN and creatinine

metabolic: increased basal metabolic rate, vital signs

neuroendocrine: increased ADH and aldosterone

central nervous system: possible encephalopathy, seizures, coma, altered level of
consciousness

integumentary: burned, infection, scar tissue formation and poor healing

anemia: associated with major burns





4. Findings

a. superficial (first degree) burn: localized pain, dry surface, blanches with pressure, redness,
possible blister

b. partial thickness (second degree) burn: open wound, very painful, denuded skin; blistered, moist

c. full thickness (third degree) burn

i. tough, leathery, dull dry, with variable pain (often severe).

ii. color: brown, tan, black, or red depending on severity

iii. may be life threatening; may affect many body systems, as with Curling's ulcer


d. full thickness (fourth degree) burn

i. wound dull and dry

ii. ligaments, tendons, bone may be exposed



5. Management: initial priority is to stop the burning process
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a. superficial:

i. cleanse with solutions

ii. debride loose debris or necrotic tissue

iii. add antimicrobial ointment

iv. dressing (fine mesh or occlusive)

v. prophylaxis tetanus

vi. mild analgesic


b. care of full thickness burn

i. maintain ABCs: airway, breathing, circulation, safety

ii. weigh client and provide fluids and electrolytes; use Parkland formula (Rule of 9s) for burn
management

iii. remove constrictive clothing or jewelry

iv. cover the burn: prevent infection, heat loss, and further deterioration

v.
provide sufficient nutrition and calories to prevent negative nitrogen balance and meet
body demands

vi.
pharmacologic

provide adequate pain control

antibiotic therapy

tetanus prophylaxis




6. Nursing interventions

a. use aseptic technique

b. pre-medicate for pain before any dressing change

c. assist with debridement: surgical, enzymatic, hydrotherapy

d. cleanse wounds with mild solutions as ordered, then cover with antimicrobial

e. assist with skin grafts care (temporary, permanent): allograft and autografts

f. care for donor site, usually covered with xeroform dressing - (nursing staff do not change this
dressing)

g. reinforce teaching regarding long term: Jobst pressure stockings and body wraps, support
surfaces, range-of-motion activities


7. Concerns in burn cases

a. acute: airway status, pain, shock, infection, fluids

i. initial 48 to 72 hours - fluid loss

ii. after initial 48 to 72 hours - fluid overload


b. long-term: nutrition, pain control, contractures, wound healing, keloid formation, psychological,
body image and self esteem

Burn Injuries - Children

Thinner skin, so tissue damage is more severe

Fluid volume changes faster than cardiovascular system can respond

Relatively large surface area increases risk for losses of fluid and heat
785


Increased risk for dehydration and acidosis due to: diarrhea, insensible fluid loss, and
because child's body requires higher proportion of water than adult's

Immature immune system increases risk of infection

Long term: scars mature more slowly and keloids may develop


E. Heat-related - hyperthermia

1. Definition: exposure to air temperatures over 85 F and humidity above 50%

a. heat cramps: involuntary spasm of the large muscles of the body; least severe type of
hyperthermia; common in athletes

b. heat exhaustion: findings of hyperthermia are more systemic; commonly affects firefighters,
construction or factory workers, as well as those who wear heavy clothing in a hot, humid
environment

c. heat stroke: least common but most life-threatening; the body's cooling system fails


2. Findings

a. heat cramps

i. painful muscle spasms; may include abdominal cramps

ii. face is red, flushed and sweaty

iii. oral temperature can be 98.6 - 100 F


b. heat exhaustion

i. cool, moist, pale, ashen skin, headache, nausea, dizziness, weakness, and exhaustion

ii. oral temperature will be above 100 F


c. heat stroke

i. The skin will be red but without perspiration, changes in consciousness, rapid weak pulse,
and rapid, shallow breathing

ii. body temperature may rise to 106 F (41 C) or higher



3. Management

a. heat cramps

i. lightly stretch the muscle and gently massage the area

ii. fluids, such as cool water or commercial sports drink

iii. move to cool shady area

iv. avoid salt tablets and salt water since they can contribute to fluid volume overload

v. can resume activity when cramps subside


b. heat exhaustion

i. get the person out of the heat and loosen any tight clothing

ii. apply cool, wet cloths, such as towels or sheets to the back of the neck, the groin, and the
armpits; spraying the person with water and fanning may also help

iii. if the person is conscious, give small amounts of cool water to drink; give about 4 ounces
of water every 15 minutes (refrain from drinking fluids too quickly)


c. heat stroke

i. call 911 or rapid response number if the person is refusing water, vomiting, experiencing
changes in consciousness - their condition is worsening

ii. keep the person lying down and place cool packs on the wrists, ankles, groin, armpits to
cool the large blood vessels


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4. Nursing interventions

a. hyperthermia related to heat exposure----Intervene to remove patient from heat source and
begin cool down procedures including hydration

b. fluid volume depleted related to excessive perspiration and insensible water loss from
tachypnea - replace fluids with cool drinks in small amounts

c. altered state of consciousness related to potential hypovolemic shock - activate the EMS, place
in side-lying position if vomiting, assess ABC's


Points to Remember
Temperature-related Disorders

Never rub or massage an area affected by frostbite; massaging the ice crystals under the skin can cause
irreparable damage to underlying tissues.

Thermal injuries can be caused by heat, chemicals, electricity, and also secondary to radiation.

People at risk for heat-related emergencies are those who work or exercise outdoors, elderly people,
young children, and people with health problems.

Acute concerns in burn cases include airway status, pain, shock, infection and fluids.

Keloids are overgrowths of scar tissue that follow skin injuries. Dark-skinned individuals tend to form
keloids more readily than lighter skinned individuals.

Noninfectious Skin Disorders

Atopic dermatitis (eczema) is a recurring, non-infectious, inflammatory skin condition with no known
cause. It is most common in infants, but most children outgrow it.

Seborrheic dermatitis, is also known as "cradle cap" or dandruff.

The goal is to prevent diaper dermatitis, or diaper rash, from occurring by using preventative measure,
e.g., frequent diaper changes and good skin care.

Contact dermatitis can be caused by foods, solutions, allergens, plants.

Since isotretinoin is a known teratogenic, it is sold only under a special program approved by the FDA
called iPLEDGE. Female clients using this medication for severe acne vulgaris must have negative
pregnancy tests before and during treatment and must use 2 effective forms of birth control.

Infectious Skin Disorders

Herpes simplex 1 affects areas above the waist (for example, "cold sores" of the lip); herpes simplex 2
affects areas below the waist (for example, genital herpes)

Moniliasis candidiasis (or "thrush") is an opportunistic fungal infection that can be acquired at birth or
can develop as a result of taking antibiotics, using inhaled steroids; it is also one of several AIDS defining
illnesses.

Tinea does have a circular appearance but it is caused by a fungal infection, not worms (as the name
"ringworm" might suggest).

Pediculosis Capitis (head lice) are transmitted through close contact or, for example, sharing combs or
hats with someone who has head lice; they do not jump and cannot fly.

Wounds

Determine tetanus immunization status for anyone with a wound injury.

Prognosis for wound healing depends on a variety of factors, including the type of wound, the
underlying injury, and the basic health of the client, including presence of any chronic diseases,
nutritional status, age, and if the person smokes.

TEST 1

Which finding should a nurse recognize as an outcome from iron deficiency anemia?

A. reduced hemoglobin saturation
B. cerebral edema
C. tissue hypoxia
D. decreased cardiac output
When the hemoglobin falls sufficiently to produce client complaints, the findings are directly attributable to tissue hypoxia.
Decreased cardiac output, cerebral edema and reduced hemoglobin saturation are not events caused by iron deficiency
anemia.

Test-taking Tips: The key words in this question are iron deficiency anemia and clinical findings. Notice that two
options can be immediately eliminated because they refer to other systems of the body than the content of this question.
When left with two options that both could be correct, compare the options and read carefully that one option indicates a
reduced hemoglobin saturation, not a reduced hemoglobin. Now ask: which would be the worst outcome for the client? In
this case that would be the correct response, tissue hypoxia.
A nurse collects data on a client with diabetes mellitus type 1. Which client complaint calls for immediate nursing action?

A. intense thirst and hunger
B. reduced lower leg sensation and tingling
C. diaphoresis and shakiness
D. fatigue and some depression

Diaphoresis, shakiness, nervousness, and irritability are signs of hypoglycemia which warrant immediate attention. Clients
diagnosed with diabetes mellitus type 1 have a lack of insulin production and require exogenous insulin.

Test-taking Tips: The key words in this question are diabetes mellitus type 1 and complaint calls for immediate nursing
action. Diabetes mellitus type 1 has primary focuses of hyperglycemia and hypoglycemia. The only option that focuses on
this content is the correct response. It is also the odd option in that it refers to a more systemic effect. The nonspecific way
in which this question asks about diabetes mellitus type 1 suggests that the more general answer is most likely correct.

An 18 year-old client is admitted to intensive care from the emergency room after a diving accident. The injury to the spinal cord is
suspected to be at the level of the second cervical vertebrae (C-2). A nurse should have as the priority to collect data related to which
focus?

A. respiratory function
B. response to stimuli
C. bladder control
D. muscle weakness
Spinal injury at the C-2 level results in quadriplegia. While the client will experience all of the problems identified, respiratory
function is a priority.
While collecting data on a one month-old infant in the emergency room, which finding should a nurse report to the registered nurse
(RN) immediately?

A. inspiratory grunt
B. irregular breathing rate
C. increased heart rate with crying
D. abdominal respirations

Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant. The other options are expected
findings of newborns.

Test-taking Tips: The word immediately implies an emergency. Inspiratory problems are typically a first priority in any
situation. Pay attention to the age of the child and ask: what would and would not be normal at that stage of life? Three
options are all normal, while the correct response is not.





TEST 2

A client has just been admitted with a diagnosis of end-stage cirrhosis. When helping to plan care, a nurse should identify which
nursing diagnosis as most important?

A. fluid volume excess
B. ineffective individual coping
C. risk for injury
D. altered nutrition: less than body requirements

The client with end-stage cirrhosis is at great risk for injury or hemorrhage due to impaired coagulation and fragile varices,
especially in the esophagus.

Test-taking Tips: The key words in this question are end-stage cirrhosis and priority nursing diagnosis. Ask: which of
the options is a priority? Remember, especially if guessing, that safety is the first priority. Also realize that three options
address client issues that are not mentioned in the stem.

A client reporting severe shortness of breath is diagnosed with acute heart failure. A nurse checks the pulse oximetry for a reading of
80%. The client's color has changed to gray and the client expectorates large amounts of pink frothy sputum. The first intervention of
the nurse should be to take which action?

A. call the registered nurse (RN) immediately
B. place on continuous pulse oximetry
C. position in a high-Fowler's
D. administer the ordered prn oxygen

The client is in frank pulmonary edema. All responses are correct actions by the nurse. The most important action is to
deliver supplemental oxygen to the client, since the primary problem is oxygenation and not obstructed airway.

Test-taking Tips: The key words in this question are severe shortness of breath, acute heart failure," pulse oximetry of
80%, and nurses first action. When all options are possibilities, ask: what this client needs most or first? A client with a
pulse oximetry would need immediate oxygen. The answer to this question should lead to the correct response as the first
action."

A nursing history for a newborn suspected of having pyloric stenosis would most likely reveal which findings?

A. absence of gastrointestinal peristalsis with vomiting
B. mild emesis progressing to projectile vomiting
C. cyanosis and vomiting immediately after feedings
D. frequent vomiting of bile-stained liquid in between feedings

Mild regurgitation or emesis that progresses to projectile vomiting is a pattern of vomiting associated with pyloric stenosis.

Test-taking Tips: The key words in this question are pyloric stenosis of a newborn and history. Eliminate one option
since this is an expected finding with a lack of peristalsis, which is not the problem in the stem. The problem in the question
relates to a valve problem. Eliminate another option as it is a late finding of hypoxia and does not support such a finding. If
deciding between the last two options go with what sounds more reasonable. For future reference, associate the word
projectile with the words pyloric stenosis or increased intracranial pressure since these are the only two situations in
which projectile vomiting happens.

A nurse is participating in a team conference for a newborn with tracheoesophageal fistula (TEF). Which nursing diagnoses on the
newborns plan of care should the nurse give the most attention to?

A. altered nutrition
B. ineffective airway clearance
C. risk for dehydration
D. risk for injury

The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal
segment is connected to the trachea or primary bronchus by a short fistula at or near the bifurcation. Thus, a priority is to
maintain an open airway and prevent aspiration. The other nursing diagnoses should then be addressed.





TEST 3

A client diagnosed with infective endocarditis has been on medication for four days. The client stops into the community clinic to
discuss with a nurse the findings below. Which finding must be reported immediately to the clients health care provider?

A. fever of 103 degrees Fahrenheit
B. fatigue over two days
C. diffuse rash of flat, red spots
D. nausea and vomiting

Persistent, prolonged fever being present after the initial 72 hours of therapy for infection indicates a subtherapeutic dose or
an incorrect, ineffective antibiotic. The antibiotic in these situations need to be changed. The incorrect responses may be
found with this problem. However, the rash exhibits as tiny reddish spots that resemble freckles that may appear on the skin
and in the whites of the eyes. Small streaks of red (called splinter hemorrhages) may appear under the fingernails.

A nurse is caring for a client diagnosed with a subarachnoid hemorrhage after the client fell in the home. The computerized tomogram
shows that the bleeding has stopped. Which aspect of the client's plan of care is most important for the nurse to enforce?

A. Unrestrict spontaneous client movement
B. Restrict visitors to the immediate family
C. Keep the door to the room closed
D. Arouse the client as needed for care

Maintaining a quiet environment will assist in reduction of the risk for a rebleed. All of the options are part of the plan of care.
However, the correct response most directly maintains a quiet in-room environment. With minimal visitors noise will be less
in the room.

Test-taking Tips: Two options focus on restricted stimuli more than the other two options. Note that the correct response is
more directly associated with the client stimulus than just closing the door.

A nurse is performing a neurological assessment on a client who has been diagnosed with a right-brain cerebral vascular accident
(CVA). Which of these findings, if observed by the nurse on the day after admission, would warrant immediate attention?

A. difficulty speaking or answering questions
B. altered feeling on the left fingertips
C. increased sleepiness with fatigue
D. emotional liability when family is present

A further decrease in the level of consciousness such as increased sleepiness or lethargy would be indicative of a further
progression of the CVA.

Test-taking Tips: This is a priority question where all answers could be considered correct. Notice that three options would
not require as immediate attention as the correct response, the change or decrease in level of consciousness. Also note
that the question focuses on a finding that is observed a day after the CVA. The other three options could be expected
residual effects from the CVA.

During a discussion with parents about the concerns of their child diagnosed with sickle cell disease, a nurse should reinforce that their
child should take which course of action?

A. avoid overheating
B. maintain normal activity
C. delay the routine immunizations
D. be cautious of addiction

Fluid loss with resultant sudden dehydration caused from overheating can trigger a sickle cell crisis. Normal activity is
expected and not a priority issue.

Test-taking Tips: The key concept in this question is the life style of a child with sickle cell disease. Two options can be
eliminated immediately because they address content that is not addressed in the stem of the question. Notice that two
options address dehydration and activity. Ask: in sickle cell, what could lead to a serious problem or be a cause for sickle
cell crisis, normal activity or overheating (dehydration)?






TEST 4

A client diagnosed with chronic heart failure should be reminded to contact the home health nurse if which problem occurs?

A. a decrease in appetite over two to three days
B. an appearance of non-pitting ankle edema in the evening
C. a weight gain of two pounds or more in a 48 hour period
D. urinating four to five times each day

It is critical for clients with cardiac problems to report and be treated for these findings: rapid weight gain (from retention of
excessive fluid), decreased urinary output over 24 hours, worsening nocturnal orthopnea, pitting ankle edema especially in
the morning, increases in fatigue, and other findings of chronic heart failure. Identification of these findings early results in
avoidance of hospitalization. Voiding four to five times per day is normal. If the decreased appetite is persistent it should be
reported. Ankle edema in heart failure is usually "pitting" edema of the feet then upward to the ankles.

Test-taking Tips: If guessing, narrow the choices down to the two options that are similar but dissimilar. Two options are
associated with weight gain but differ in the area affected, one general and the other specific. Since the question is more of
a general question, the more general answer is most likely the best guess.

An older adult client with type 2 diabetes mellitus should be instructed to contact the outpatient clinic immediately if which findings
are present?

A. an open wound on the heel with minimal discomfort
B. nausea with two episodes of vomiting
C. sustained insomnia and daytime fatigue
D. persistent dryness and itching of the perineal area

When findings of infection occur in their feet, older clients who have either type of diabetes and/or arterial vascular disease
should seek health care quickly and continue treatment until the infection is resolved. Without treatment, serious infection,
gangrene, limb loss, and death may result. Sensations may be diminished in the feet and legs in these clients. Even though
perineal area complaints would need to have further evaluation, the problem is not a priority. Insomnia is not a manifestation
of diabetes mellitus type 2. If vomiting is persistent or causes other problems it should be reported, but as persistence of
vomiting is not specified, it cannot be assumed.

The nurse is caring for a client who had a chest tube inserted three days ago during a right lower lobectomy. The nurse notes constant
bubbling in the water-seal chamber and but finds no air leaks after inspecting the chest, dressing and tubing. What action should the
nurse take next?

A. Turn off the suction and empty the drainage collection chambers
B. Ensure the suction chamber is full of water
C. Ask the registered nurse (RN) to confirm the finding
D. Continue the assessment because this is a normal expected finding

Continuous bubbling in the water seal chamber is abnormal and suggests there is a break or leak in the system. In this
situation, the problem is not in the suction or collection chambers. The LPN has collected the necessary data and should
ask the RN to assess the chest tube.

A nurse participates in planning care for a two month-old child in bilateral leg casts for congenital clubfoot. Which issue should the
nurse reinforce as a priority nursing goal after the initial cast application?

A. infant will experience no pain
B. mobility will be enhanced
C. muscle spasms will be relieved
D. tissue perfusion will be maintained

Immediately after a cast application, the chief goal is to maintain circulation and tissue perfusion under the cast. Permanent
tissue damage can occur within a few hours if perfusion is not maintained.

Test-taking Tips: The key word in this question is priority." Ask: which option would have the worst outcome for the client:
pain, muscle spasms, lack of mobility, or a lack of tissue perfusion? Two options can be eliminated immediately. Notice the
fact that one option specifies that the infant will experience no pain, which is not a realistic goal. This leaves the correct
response as the priority goal.





TEST 5

A nurse is caring for a client awaiting transfer to the intensive care unit during a hypertensive crisis. The priority intervention should be
for the nurse to take which action at this time?

A. auscultate breath sounds
B. check bilateral pupil responses
C. palpate pedal pulses bilaterally
D. monitor heart rate for irregularity

The organ most susceptible to damage in hypertensive crisis is the brain due to rupture of the cerebral blood vessels.
Neurologic status with associated assessments must be closely monitored.

A client diagnosed with pneumonia affecting two-thirds of the right lung denies shortness of breath. What is the best position for a
nurse to recommend?

A. sitting at a 90 degree angle
B. dyspnea position
C. left side-lying to back rotation
D. sitting in a chair as tolerated

Gravity will draw the most blood flow to the dependent portion of the lung, the left lung, with an outcome of the best gas
exchange. Ventilation is minimally affected in the dependent lung in this position. This position also allows for the drainage
of the infection from the affected lung with a promotion of coughing. Since the client is not dyspneic, neither the sitting nor
dyspneic positions such as tripod are indicated. Standing may be useful in recovery, but does not enhance circulation nor
gas exchange in the left lung.

A nurse is caring for a client after being diagnosed with a myocardial infarction (MI) in a direct observation unit. It is noted that the
hourly urinary output has dropped significantly. What observation should the nurse expect to make more frequently?

A. blood pressure
B. respiratory rate
C. heart rate
D. body temperature

Following an MI, a significant decline in urine output indicates decreased cardiac output. This will be best observed by heart
rate changes.

With a drop in urine output, there is no expected change in body temperature. A compensatory rise in heart rate as well as
respiratory rate is the initial finding of acute heart failure which is a complication of MIs. The later finding in this instance is a
drop in the systolic blood pressure.

Test-taking Tips: The key words in this question are myocardial infarction and hourly urinary output has dropped
significantly. Notice that the correct response is the only heart answer. One option is a vascular answer. Associate that
heart rate influences cardiac output or blood pressure. So heart rate would be first monitored more frequently to identify
early changes. Associate cardiac with heart and output with urine output. Thus, cardiac output influences urinary
output. If cardiac output is low, urine output may be low

An older adult nursing home resident has a tympanic temperature of 100.6 degrees Fahrenheit. This is a sudden change in an
otherwise healthy client. Which data should a nurse collect more information about first?

A. appetite changes
B. level of alertness
C. breath sounds
D. urine output

Assessing level of consciousness (alert vs. lethargic vs. unresponsive) will help the health care provider determine the
severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.

Test-taking Tips: Ultimately data collection should be done on all of the answer options. However, the question is asking
what to collect first?" Ask: what usually happens to mental status in older adult clients who have an infection? If guessing,
narrow the choices to two options, pulmonary and neurological issues. Beware that at this point a reflex guess might be
made and lean towards pulmonary because of a thinking - ABCs. Make sure to read the entire question, however. One
option refers to lung sounds, not specifically to the lungs themselves. Changes in mental status are a priority over breath
sounds for initial data collection. In addition, there is no data in the stem to suggest abnormal breath sounds.


TEST 6


A child with a congenital heart defect visits the clinic several weeks before a planned surgery. A nurse should give priority attention to
collecting data related to what issue?

A. nutrition
B. infection prevention
C. oxygenation
D. developmental delays

All of the above are important in the treatment of a child with congenital heart defects. However, persistent hypoxemia
results in acidosis which further decreases pulmonary blood flow.

Test-taking Tips: The key here is to pay attention to the words congenital heart defect and priority." Ask: which of the
options is most closely related to the hearts function? Although all the options could be correct, the question being asked is
to prioritize items during data collection and this hints to focus on respiratory function.

A nurse walks into a client's room and finds the client lying still and silently on the floor. The nurse should first take what action?

A. open the client's airway
B. find out if anyone saw the client fall
C. call for help by activation of emergency button in room
D. establish that the client is unresponsive

The first step in basic life support is to establish unresponsiveness. Calling for help and opening the airway are actions that
should follow establishing unresponsiveness. Getting a history of the fall should follow after the clinical situation has been
resolved and stabilized.

Test-taking Tips: The key here is to remember that when asked about what to do first, data collection is usually the best
initial action. The correct response is the only data collection answer. The other options are actions or interventions.

A nurse auscultates bibasilar inspiratory crackles in a newly admitted older adult client with a diagnosis of heart disease. Which other
finding is most likely to be observed at this time?

A. chest pain
B. peripheral edema
C. lethargy
D. nail clubbing
When crackles are heard bibasilarly, acute heart failure is suspected. This is often accompanied by peripheral edema
secondary to fluid overload caused by ineffective cardiac pumping. Chest pain can occur with heart failure but is not as
indicative as peripheral edema. Nail clubbing is associated with chronic lung conditions such as COPD or anemia.
Lethargy, a finding of hypoxia, can occur with heart failure but is not as indicative as peripheral edema.

Test-taking Tips: The key words in this question are heart disease and bibasilar inspiratory crackles. Notice that two
options are not heart answers. This is a specific heart disease question and requires a specific answer associated with
heart failure. Another option does not relate to heart failure and the correct response does.
A nurse is caring for a client diagnosed with cirrhosis of the liver and ascites. When discussing care of the client with the unlicensed
assistive personnel (UAP), the nurse should emphasize which client activity?

A. Alternate ambulation and bed rest with legs elevated
B. Activity as tolerated and remain in semi-Fowler's position in bed
C. Remain on bed rest in a semi-Fowler's position
D. Ambulate and sit in chair as tolerated

Encourage alternating periods of ambulation and bed rest with legs elevated to mobilize edema and ascites. Encourage and
assist the client with gradually increasing periods of ambulation.

Test-taking Tips: The key to this question is to notice that ascites, edema about the abdomen, is the content and must be
considered when carefully reading the answer options. Notice that two options focus on a semi-Fowlers position. Ask: how
would this position affect ascites? Fluid is affected by gravity, so in this position, the fluid may have more of a tendency to
accumulate. Notice that the correct response focuses on the clients legs being elevated when sitting. It also addresses
alternating ambulation and bed rest. The other option is too general of a response for such a specific question.

TEST 7

For a six year-old child hospitalized with findings of moderate edema, gross hematuria and mild hypertension associated with the
diagnosis of acute glomerulonephritis (AGN), which nursing intervention would be appropriate?

A. relieve boredom through physical activity
B. institute seizure precautions
C. weigh the child twice per shift
D. encourage the child to eat protein-rich foods

The severity of the acute phase of AGN is variable and unpredictable. Therefore, a child with edema, hypertension, and
gross hematuria may be subject to complications. Anticipatory preparation such as seizure precautions is needed. The
other options are incorrect actions.

Test-taking Tips: Read these answer options carefully as they relate to the content of AGN, hypertension, and edema,
all of which are specified in the stem question. Notice that only the correct response can be associated with this content. If
guessing, ask which option deals with the worst consequence.

A nurse is collecting data about a four year-old diagnosed with possible rheumatic fever. Which finding should the nurse suspect is
related to this diagnosis?

A. episode of a fungal skin infection last week
B. diagnosis of chickenpox six months ago
C. treatment for ear infection two months ago
D. exposure to strep throat in daycare last month

Evidence supports a strong relationship between infection with Group A beta-hemolytic streptococci and subsequent
rheumatic fever (usually within two to six weeks). Therefore, the history of playmates recovering from strep throat would
indicate that the child diagnosed with rheumatic fever most likely also had strep throat. Sometimes, such an infection in
children has no clinical findings.

A nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible
myocardial infarction. The next action the nurse should take is which intervention?

A. check the client for responsiveness, airway, breathing and circulation
B. notify the "code" team and provider
C. prepare for immediate defibrillation
D. begin cardiopulmonary resuscitation

The nurse must first check the client to determine the appropriate next step. The level of consciousness and then the ABCs
are in order to be done.

Test-taking Tips: Remember, gathering more information always precedes intervention. Notice the word check in the
correct response, it is a data gathering word. A nurse might perform any or all of the other options depending on what is
found during the data collection.

A nurse enters the room as a three year-old in the bed begins to have a generalized seizure. Which intervention should the nurse
perform first?

A. clear the room of any hazards
B. place the child in a side-lying position
C. give the prescribed anticonvulsant
D. minimally restrain the child's extremities

Protecting the airway is the top priority in a seizure. Side-lying positions minimize aspiration. Option 1 is too general to be
the best answer.

Test-taking Tips: Notice that the only answer that has the child in it is the correct response. If guessing, chose the client
centered option.







TEST 8

While caring for a client with infective endocarditis of the triscuspid valves, which finding suggests a complication?

A. spike in temperature
B. pronounced wheezes
C. pain on deep inspiration
D. sudden dyspnea

Vegetation from the infected heart valves on the right side of the heart often leads to the complication of pulmonary
embolism (PE) in the client with infective endocarditis. A significant piece of evidence is sudden dyspnea. The breath
sounds associated most with PE are diminished or absent, not pronounced. Pain on inspiration is associated with pleurisy.
A spike in temperature is more commonly from bacterial pneumonia, urinary tract infection, or otitis media. Vegetation from
the infected heart valves on the left side of the heart would lead to the complication of cerebral infarction or finding of a
stroke.

Test-taking Tips: The key words in this question are infective endocarditis and complication. Notice that two options
suggest a complication. Ask: which complication is worse, elevated temperature or sudden dyspnea? Also notice that two
options are similar but dissimilar answers in that they both deal with respiratory problems. If guessing, narrow the options
and ask: is difficulty breathing a worse complication than pain with breathing? Another hint is the word sudden in the
correct response. Anything sudden typically indicates a complication.

An older adult client was admitted with a diagnosis of a cerebral vascular accident (CVA). Over the past several hours since admission,
a nurse notes increasing lethargy. Which finding should the nurse report immediately to the registered nurse (RN)?

A. sonorous breathing
B. slurred speech
C. muscle weakness
D. bowel incontinence

Changes in speech patterns and level of consciousness can be indicators of continuous intercranial bleeding. Sonorous
breathing is not indicative of a CVA complication. Muscle weakness, usually unilateral, is expected and bladder or bowel
incontinence occurs in some cases.

A home health nurse visits a client to provide wound care and finds the client lethargic and confused. The partner states the client fell
down the stairs about two hours ago. The nurse should take what action?

A. reassure the client's partner that the findings are transient
B. place a call to the client's health care provider for instructions
C. call an ambulance to take the client to the emergency room for evaluation
D. instruct the client's partner to call the health care provider if condition becomes worse

This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care
nurses must prioritize interventions based on assessment findings that are in the client's best interest.

Test-taking Tips: The content of this question is about a client who recently fell and is showing signs of a possible severe
head injury - lethargic and confused. Notice three options delay further evaluation to make them incorrect. Only the correct
response provides immediate attention to an emergency situation.

A client is admitted with a tentative diagnosis of heart failure. For which assessment should a nurse be most certain to observe and
document?

A. loss of appetite
B. pedal edema
C. decreased urine output
D. inspiratory crackles
All responses are manifestations of heart failure. The most important observation listed is inspiratory crackles, a finding
which reflects fluid buildup in the lungs.






TEST 9

A preschooler is admitted for the treatment of chronic lead poisoning. A nurse recognizes that the most serious effect associated with
chronic lead poisoning is which finding?

A. moderate anemia
B. central nervous system damage
C. renal tubule damage
D. growth impairment

The most serious consequences of chronic lead poisoning occur in the central nervous system. Neural cells are destroyed
by the toxic effects of the lead with outcomes of many problems with the intellect that ranges from mild deficits to mental
retardation and even death. Anemia can occur if GI bleeding is a result of lead poisoning. Lead intoxication may impair
kidney function. Stunted growth can occur from lead intoxication. However, none of these consequences are as serious as
nervous system damage.

Test-taking Tips: Notice that although all of the answers have some connection to chronic lead poisoning, the question
being asked is to prioritize the most serious problem. That would eliminate two options immediately. Ask: which is more
serious, brain damage or impaired kidney function? Brain damage is going to impact the body more than kidney failure,
especially in the acute phases.

A client is admitted to the hospital with a diagnosis of deep vein thrombosis (DVT). During the admission process, the client complains
of sudden shortness of breath. The SaO2 is 87. The priority focus of the nurse at this time should be which area?

A. skin color
B. breath sounds
C. peripheral pulses
D. heart rate

Breath sounds are a critical focus at this point. The nurse should be alert to crackles which may highly suggest a pulmonary
embolism. Pulmonary embolism exhibits the classic finding of sudden onset of difficulty breathing.

Following a diagnosis of acute glomerulonephritis (AGN) in their six year-old child, the parents remark that they are unclear as to how
the child caught the disease. A nurse should respond based on which understanding of the disease?

A. the disease is easily transmissible in schools and children's camps
B. it is not "caught" but is a response to a previous B-hemolytic strep infection
C. AGN is a streptococcal infection involving the kidney tubules
D. the illness is usually associated with chronic respiratory infections

AGN is generally accepted as an immune-complex disease in relation to an antecedent Group A beta-hemolytic
streptococcal infection. It is considered to be a noninfectious renal disease.

Test-taking Tips: The key words in this question are AGN and how disease is caught. Read the answer options closely
and notice that the key words from the stem are found in two options. Study these two options closely and notice that
caught and infection both appear in the correct response.


A nurse is caring for a two month-old infant diagnosed with a congenital heart defect. Which approach should a nurse implement?

A. add strained cereal to the diet at least once a day
B. maintain intravenous fluids at the ordered rate
C. dilute the formula to reduced calorie intake
D. provide smaller feedings every three hours

Infants with congenital heart defects are at increased risk to develop heart failure. Infants with heart failure have an
increased metabolic rate and require additional calories to grow. However, at the same time, rest and conservation of
energy for feedings is important. Feedings should be smaller and every three hours rather than the usual four hour
schedule for normal infants.







TEST 10

A nurse is reinforcing home care to the parents of a child with rheumatic fever. The nurse should make it a priority to emphasize which
topic?

A. clumsiness and behavior changes should be reported
B. home schooling is preferred to classroom instruction
C. most play activities will be restricted indefinitely
D. the child may remain a strep carrier for years

A major manifestation of rheumatic fever that reflects central nervous system involvement is chorea. Early findings of
chorea include behavior changes and clumsiness. Chorea is characterized by sudden, aimless, irregular movements of the
extremities, involuntary facial grimaces, speech disturbances, emotional lability, and muscle weakness. Chorea is transitory
and all manifestations eventually disappear.

Test-taking Tips: The timeframes in two options give a clue that they are incorrect (the terms "for years" and "indefinitely").

A nurse should reinforce the teaching of a client diagnosed with Raynaud's phenomenon that it is most important to take which
action?

A. reduce stress
B. keep feet dry
C. stop smoking
D. avoid caffeine

The most important teaching for this client is to stop smoking, since the nicotine causes direct arterial vasoconstriction. All
alternate options are appropriate in Raynaud's phenomenon, but are not as important as smoking cessation.

Test-taking Tips: All four options could be correct. The question being asked is to decide on the most important teaching
about Raynauds. Notice that three options are similar in that they are all decrease answers but are dissimilar. When
guessing among 3 similar but dissimilar responses, further narrow down the options to the two that are the most similar and
those would be two options because they both include substances put into the body. Then look at the verbs -- to stop
versus avoid. Ask which of these might be most effective to maintain the system and minimize the phenomenon.

A nurse is working in a high risk antepartal clinic. A 40 year-old woman in the first trimester gives a thorough health history. Which
collected data should receive the priority attention of the nurse?

A. she reports recent use of over-the-counter sinus remedies
B. her husband was treated for tuberculosis as a child
C. her father and brother are insulin dependent diabetics
D. she has taken 800 mcg of folic acid daily for the past year

Over-the-counter drugs are a possible danger in early pregnancy. A report by the client that she has taken medications
should be followed up immediately with the registered nurse (RN). Recall that in the first trimester fetal formation occurs and
medications can alter this.

Following an acute asthma episode a client has low pitched wheezes present on the final half of exhalation. One hour later the client
has high pitched wheezes extending throughout exhalation. Which is the client's greatest need at this time?

A. airway suctioning
B. supplemental ordered prn oxygen
C. an ordered prn corticosteroid
D. an ordered prn bronchodilator

During an acute asthmatic episode, the client's greatest need is bronchodilation, which can be accomplished by
bronchodilators and then corticosteroids. The client does not give evidence of a need for suctioning. Without achievement of
bronchodilation first, any supplemental oxygen will not be optimally beneficial to the client.

Test taking Tips: Eliminate one option since there is no data in the stem to suggest a problem with mucus. If guessing,
select the two options that are similar but dissimilar. Two options focus on prn orders. The question being asked is about
the greatest need for a client with high-pitched wheezes throughout exhalation. Association is to be made with high pitched
wheezing and bronchial constriction. The fact that bronchodilation would be the first action to take makes it the most
important action out of those described.

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